Transiting from pathy-based to people-centered holistic healthcare

1. Opportunity of in adversity

The COVID-19 pandemic has disrupted lives of peoples’ all over the world posing an unprecedented public health emergency. The confidence in health care systems globally, has been shaken. The current standard care for clinical management of COVID-19 has limitations especially when addressing immunological and mental health problems. The test of any knowledge is not just philosophy but its ability to transform and solve real life problems. The approaches and solutions are bound to be different across knowledge systems. It is not scientific or ethical to ignore a plausible solution merely because its logic is different from a dominant knowledge system. Ignoring potential of AYUSH in the management of COVID-19 seem to be biased due to western biomedicine prejudice. However, recent trends emerging from clinical studies in different cities supported by the Ministry of AYUSH (MoA) indicate that Ayurveda and Yoga interventions can contribute to prevention as well as in improving recovery time and rate in management of COVID-19. While adhering to standards of quality, effectiveness, and safety, it is reasonable, ethical, and fair to integrate cost effective AYUSH measures for management of COVID-19. The adversity created by COVID-19 pandemic is opening an opportunity for long overdue reforms in healthcare system. It may be prudent to break disciplinary silos and transit from pathy-based system to people-centered holistic health care.

The Honorable Prime Minister's vision for a ‘New India’ subsumes Healthy India where its own culture, tradition and knowledge systems can make it a role model. The western biomedicine commonly known as allopathy remains the most preferred system. A vast conceptual framework and canvas of Ayurveda, Yoga especially a concept of Swasthya goes much beyond typical notion of ‘medicine’. Recognizing the value of ancient insights in facilitating modern discoveries can help in reimagining integrative health care system for Atma Nirbhar Bharat [1]. India is being presented with a unique opportunity to create a new, globally relevant model of integrative health sciences through reforms in medical education health research, clinical practice and public health.

In the past Bhore Committee (1946) adhered to Macaulay's strategy and sidelined Indian systems of medicine (ISM) giving western biomedicine a monopoly. However, several nationalist scholars including Sir Ram Nath Chopra (1948), KN Udupa (1958), H R Nagendra (2016) and Dr Vijay Bhatkar (2019) have highlighted the need for evidence-based integration of ISM into the healthcare system. The 12th Five Year Plan (2012–2017) followed by National Health Policy (NHP) 2017, National Education Policy (NEP) - 2020 and the National Digital Health Mission (2020) have strongly advocated the need for harnessing the potential of AYUSH systems by integrating them with mainstream healthcare.

2. National needs

The basic healthcare needs of the Indian people are i) Family Medicine ii) Primary Care iii) Disease Prevention and iv) Promotion of Public Health. To meet these needs, every Indian medical doctor needs relevant knowledge and skills drawn from Ayurveda, Yoga, and western biomedicine. To meet the Sustainable Development Goals, India needs Integrative Health System (IHS) to ensure equitable and universal healthcare. As a first step we must define ‘integration’ in the Indian context. Integration is not mere colocation, bridge courses or mixed pathy practice. The integrative healthcare system in India needs to be pivoted on her own culture, values, and ethos.

Modern scientific advances in biotechnology, diagnosis, and surgery should not be perceived as the monopoly of western biomedicine. The abilities of Ayurveda and Yoga in disease prevention, health promotion, managing psychosomatic and chronic conditions as well as improving immunity and mental health needs to be properly recognized. Then they can be adopted. A true integration should involve a spirit of mutual respect and willingness to learn from different knowledge systems they western or eastern. People of India need affordable people-centered holistic healthcare. People of India need to be empowered to take care of their own health. To meet their needs healthcare reforms are required primarily in Medical Education, Health Research, Clinical Practice and Public Health.

3. Medical education

As suggested by NEP 2020 “health care education needs to be re-envisioned so that the duration, structure, and design of the educational programs match the national priorities and actual needs of people. Basic medical education must be integrative meaning thereby that all students of allopathic system must understand basics of AYUSH and vice versa”. Currently, India has two distinct streams opted by most medical graduates one representing biomedicine leading to Bachelor of Medicine, Bachelor of Surgery (MBBS) and the other representing AYUSH doctors. The two systems offer courses with the same duration; also, their curricula have major overlaps, especially in pre-clinical and para-clinical subjects. The Indian basic medical graduate program should be able to respect our knowledge heritage, recognize national priorities and understand the actual needs of people. India needs more emphasis on determinants of health and primary health care, family and community medicine, disease prevention and promotion of public health. India needs to focus more on disease prevention and health promotion by strengthening primary care and family medicine.

The first step of reforms in health care system must be at the undergraduate level basic medical education. We must learn from various experiences that other countries have carried out for transforming medical education. Abraham Flexner's historical report (1910) that transformed medical education and practice in the United States and Canada remains an historic landmark. The global standards in medical education prescribed by the World Forum on Medical Education (WFME) also advise that the interface with complementary medicine should begin at undergraduate level. The Foundation for Advancement of International Medical Education and Research (FAIMER) advocates improving global health by improving health professionals' education focusing on local needs. The World Health Organization (WHO) in 2002, advised its member states to develop policies for respective traditional and complementary and alternative medical (T&CM) systems. Many American and European medical universities have adopted integrative medicine in their curricula. China presents the best example as to how traditional medicine can be integrated in basic medical education. Over this background, the visionary NHP 2017 and the bold medical education reforms recommended by the NEP 2020 can make the Indian healthcare system more inclusive and stronger.

4. Health research

Health research is an important area that should not continue to remain in silos. The Indian structure of health research involves seven different funding agencies: the Department for Health Research (DHR), the Indian Council of Medical Research (ICMR), and the five research councils under the MoA. Several other departments and councils of science and technology also support biomedical research. Each of these entities has different research goals, without much synergy. The priorities may not be aligned to national strengths and overall societal needs. High quality transdisciplinary research on ISM must not be restricted to AYUSH, but should be promoted at all levels. The mandate of DHR needs to be expanded to cut across all medical systems; it should become the national nodal point for integrative health research. Most importantly, the epistemological nuances must be considered for conceptualization, planning, methodology and execution of high impact research programs. Health research should be locally need based, nationally relevant and globally significant well aligned to the mandate of India's National Research Foundation. Learnings from innovative national network research programs such as Golden Triangle Project, New Millennium Technology Leadership Initiative, Ayurveda Biology and AyuGenomics. Strengthening research culture and capacity building among young students and faculty members must be top priority. High quality transdisciplinary research on basic concepts of Ayurveda, Yoga and other AYUSH systems can open global leadership opportunity for India.

5. Clinical practice

Various studies on health seeking behavior suggest preferences for plural systems of medicine mostly driven by people themselves. Medical doctors should be the guardians of health, not just therapist prescribing drugs. Various policies have suggested that strengths of ISM should be used for prevention and treatment, the practitioners may not get actively engaged in integration. The global trend of integrative medicine has not caught required momentum in India. The integration at clinical level needs awareness, training, and cross talk between modern medical clinicians and practitioners of traditional systems. This situation needs reforms in medical education, and regulations. Clinical protocols are required to be developed based on clinical experiences, and scientific evidence and best practices. Traditional knowledge of nutrition, dietary practices also remains valuable as also the lifestyle, behavioral interventions, and mind-body medicine approaches.

Clinical integration should not be limited to co-location and co-posting but it should be driven by formal training and consideration of basic clinical needs. Already, integrative models and protocols have been developed, validated and practiced at few clinics in India.

6. Public health

The COVID-19 pandemic has highlighted need for of family and community centric healthcare. The world has realized the value of home-based prevention; equally the limitations of curative services. India needs to focus on strengthening basic determinants such as nutrition, lifestyle, genetics, environment as well as social determinates such as sanitation, hygiene, water, education. The burden on secondary and tertiary care can be reduced by strengthening the foundation of people's health using a participatory approach. AYUSH systems can play an important role in this process. India's triple burden of disease involving communicable diseases, non-communicable diseases and lifestyle disorders requires healthcare providers to possess diverse skill sets and to follow holistic healthcare models. The nation needs a new implementation framework for the National Health Mission to bring administrative, functional, and structural coordination across different systems of medicine. India needs promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life cycle. Providing a level playing field to plural systems is a complex task. However, this can be implemented in phases jointly by the MOA and MHFW. India requires to develop an integrative model for equitable and universal healthcare based on its own inherent strengths.

7. One Nation – One Health System

A person-centered system of holistic healthcare, based on India's own culture and ethos, developed by optimally integrating strengths from modern science, biomedicine and AYUSH systems would be in the best interest of the peoples of India. The concept ‘One Nation - One Health System’ needs to be seriously considered by dissolving the ‘pathy’ based silos. Advances in science and biotechnology, strengths of ISM and advantages of biomedicine could be integrated in a framework of person-centered holistic healthcare. One Health System should not be misconstrued as an attempt to monopolize any particular system or a threat of losing any one's identity. One Health System implies evidence-based integration making the best available knowledge systems work in the best interest of people. This concept can meet the actual needs of people while at the same time maintaining global standards, priorities, and societal needs. Starting from integrative basic medical education, this approach could encourage transdisciplinary research, person-centered clinical practice and promotion of public health. Such approach could transform India's public health system, enabling it to achieve her national priorities, and fulfil the actual needs of the peoples of India.