6. AYUSH Report_Chapter 1 by Nikunj Tyagi

1 Status of Integration

Status of Integration Health Seeking Behaviour and Medical Pluralism

Congruence of Traditional and Modern Medicne

Status of Adjuvant Use of Ayurveda and Unani Medicine

Brain-storming to Decide Priorities for Part-II

Special Survey on Adjuvant Use of Ayurveda and Unani Medicine

Experiences with Integration – Physicians’ Observations

A Corporate Sector Initiative with Integrative Medicine

Contemporary Ayurveda and Ethical Marketing of Ayurvedic Drugs

The History of Ethical Marketing of Ayurvedic Drugs

PI’s Interview of HDC Professionals

Annexures:

Annexure-I: Roadmap for Mainstreaming of AYUSH under NRHM - Joint letter of Secretary, Department of Health and Secretary, Department of AYUSH to all States

Annexure-II: Joint Letter of Secretary, Health and Secretary, AYUSH to States

Annexure-III: Minutes of the Meeting on Approach to Part II of the Status Report held on 9th December 2011at 2.30 pm in the CCRUM Conference Hall, Janakpuri, New Delhi

Annexure-IV: Questionnaire to Investigate the extent of Adjuvant AYUSH Therapy with Patient Responses

Annexure-V: List of Experts/Faculty/Practitioners who commented on Survey outcomes on the Adjuvant use of AYUSH

Annexure-VI: List of leading Pharmaceutical Companies engaged in manufacturing Ayurvedic Medicines

2 Status of Indian Medicine and Folk Healing

1 Status of Integration

Health Seeking Behaviour and Medical Pluralism Medical pluralism accepts, even recognizes the existence of more than one system of medicine. Each medical system is based on different principles, and most policy makers that allow medical pluralism feel that the choice to utilize different systems exclusively, successively or simultaneously has to be left to people to decide. As a result many people visit a variety of practitioners and follow a range of options, until there is improvement in the condition. In many societies a continuing process of negotiation goes on as patients seek therapies and etiologies that support their understanding of a particular illness. In this process, the use of traditional medicine is reported from almost every country, but in varying degrees. While, there is growing acceptance that different kinds of traditional medicine are effective for the treatment of specific conditions, the extent of such use has been studied and reported upon rather sporadically. These are based on limited surveys or derived from government data. Innumerable studies have, however confirmed that a high percentage of the population of developing countries relies on home remedies as the first alternative. Increasingly these are also referred to as Local Health Traditions (LHT). In India, hardly any episode of cough and cold, diarrhoea, constipation or flatulence goes without resorting to drinking herbal decoctions, spiced teas, milk with turmeric or pepper, lemon juice with ginger or by seasoning the food with fenugreek seeds or asafetida. Such practises run across all regions in the developing countries but the source of knowledge and the combinations

used differ from place to place. While considerable reliance is placed on household knowledge, the practice of buying packaged single herbs over the counter has also taken root in cities. One of the main reasons for the revival of interest in traditional medicine has been a growing interest in promoting good health by using different forms of self-care. The assumption is that “natural means healthy and safe”. Another reason why patients turn to Traditional Medicine (TM) is for treating chronic and debilitating diseases for which there is no established cure in modern medicine. In addition, factors like rapid urbanization and demographic ageing have seen a huge increase in non-communicable diseases such as heart disease, cancer, diabetes, and mental disorders. Consumption of unhealthy food, neglect of physical exercise, environmental factors like air and water pollution, ecological changes and congestion have led to medical conditions which were quite rare in the past. Auto-immune responses and chronic allergies are increasingly being treated by traditional medicine but the surveys do not bring out a picture which is dependable enough to trigger policy intervention if called for. Hundreds of home remedies including tribal and folk practices have been observed, compiled and published. Over 3000 such practices have been observed and recorded in the publications of the Central Councils for Research in Ayurveda and Unani Medicine which were described in detail in Part-I of the Status Report under the chapter on Medicinal Plants. The main source of knowledge

Status of Integration 3

continues to be based on family practices. The concern is how these time-honoured home and community level practices would continue to be used in the years to come despite having been the first line of treatment for generations. Years ago World Health Organization (WHO) recognized the need to understand the behaviour of health seekers by systematically collecting data on the subject. Characteristics like delay in seeking care, concomitant use of different systems and doctor swapping were found to be widespread. It was recognized that the prescription practices of health providers and the status of referrals between systems needed to be studied. WHO advised that studies were needed to understand the more influential factors like the education of users or patterns of use supported by a cost analysis of user habits. Such behaviour defines the social position of health and provides a better understanding of how the majority of users tend to respond. With this background the PI made an effort to locate the outcome of surveys on the use of traditional medicine conducted at global, regional and local levels. The findings point to the paucity of representative data on the subject which calls for undertaking repetitive surveys on a wider scale so that the findings lead to policy intervention where called for. Global Perspectives on Traditional Healthcare Based on the widespread use of traditional health care systems WHO identified three types of approaches to health system management. These were called as the Integrative health system, the Inclusive health

system and a Tolerant health system. In the Integrative system, traditional medicine was officially recognized and incorporated into the provision of health care. As yet, only China, the Democratic People’s Republic of Korea, and Vietnam seem to have established integrative systems. The Inclusive system recognized traditional medicine, but it had not been fully integrated into the overall provision of health care. Countries which operate an inclusive system include the USA, United Kingdom, the UAE, Japan, Australia, Germany, Canada, India, Sri Lanka, Norway, Indonesia, Nigeria and Mali. In countries following a Tolerant system, the national health care system is based entirely on allopathic medicine, but some traditional medicine practices are tolerated by law.1 In response to the global challenges posed by the widespread use of traditional medicine, WHO developed WHO Traditional Medicine Strategy: 2002-2005 with four major objectives: (i) Framing a policy; (ii) Ensuring safety, efficacy and quality; (iii) Enhancing access and (iv) Building a professional approach into the behaviour and responsiveness of traditional medicine practitioners to remove the hubris that surrounds their treatment practices. Systematic answers to the “why”, “how long”, “risks”, “benefits” and “side effects” were sought to be answered with a view to enhancing patient confidence. India has addressed many of these requirements as it already had a policy in place right from 2002. The Indian Systems of Medicine viz., Ayurveda, Unani, Siddha and Homoeopathy and allied therapies like Yoga and Naturopathy. All have support systems for conducting research, providing structured education, registration of practitioners and

1. WHO Traditional Medicine Strategy, 2002-2005 (document WHO/EDM/TRM/2002.1). Geneva, World Health Organization, 2002.

4 Status of Indian Medicine and Folk Healing

licensing of the manufacture of drugs. But where India lacks, say in comparison to China, has been the negligible quantum of high quality published research which addresses quality, safety and efficacy issues in a convincing manner. Second, much of the claims about usage of and dependence on traditional medicine are based on surveys which are open-ended and generally restricted to localized studies. First, there is a need to understand the trends that are developing across the country and to have a policy response to them. When different lobbies are at work to embrace or decry the traditional systems, there is need for conducting continuous independent surveys to show what is actually happening on the ground. Second, strategies that are put in place require acceptance and amalgamation down the line among health workers and cannot remain confined to the issue of administrative orders alone. In the case of India, physical integration is being promoted in a big way but there is a sharp divide at an intellectual level which influences the way well-intentioned policies unfold. Many more initiatives are needed if health systems are to achieve the mainstreaming of traditional medicine in the way that Government policy envisages. And key to that is the need to confront the barriers that exist by systematically finding ways to convince antagonists about the rationale behind the policy. But even before that is done, there is a need to have convincing data to justify the claims in terms that are understood – something that has eluded the traditional medicine sector for decades – ever since the subject of establishing its efficacy first began.

Significant Findings of Surveys on the Use of Traditional Medicine International Examples of Early Surveys The results of a few published country surveys and findings of unbiased international organizations show widespread use of traditional medicine for specific disease conditions: •

A survey of the WHO’s Roll Back Malaria programme (1998) showed that in Ghana, Mali, Nigeria and Zambia, around 60 percent of all febrile cases in children, presumably caused by malaria, were treated at home with herbal medicine.2

•

Information compiled by UNAIDS revealed that approximately two thirds of the HIV/AIDS patients in a variety of developing countries sought symptomatic relief to manage opportunistic infections by using traditional medicine.

•

In Brazil, a study reported that 89 percent of patients diagnosed with cancer used traditional medicine products to treat their condition.3

Traditional Medicine Systems in India India has the largest network of independent traditional medicine dispensaries and hospitals supported by a network of registered practitioners, research institutions and licensed pharmacies. Ayurveda, Unani, Siddha and Homoeopathy are legally recognized systems of medicine and have been integrated into the national health delivery system. Of these,

2. Brieger W.R. et al. Roll Back Malaria, Pre-testing of needs assessment procedures – IDO local government, Oyo State Nigeria. Unpublished draft, 1998. 3. The World Medicines Situation 2011 – Traditional Medicines: Global Situation, Issues and Challenges; WHO 2011.

Status of Integration 5

Ayurveda and Homeopathy are the most popular. Yoga has been adopted as a part of the exercise regimen of many schools and offices and has become a way of life for thousands of people who practise it by joining classes or as a part of their daily regimen. Yoga is also used as supportive therapy to assist in the recovery and rehabilitation of patients, especially after surgery or long periods of immobilization. Taken together Ayurveda, Yoga, Unani, Siddha, Homeopathy and Naturopathy are referred to as the AYUSH systems, particularly in Government terminology. National Surveys on the Utilization of ISM/AYUSH4 in India NSSO Survey The survey done by National Sample Survey Organization (NSSO) on ‘Morbidity and Utilization of Medical Services’ in 1986-87 indicated that of the selected sick persons who availed of treatment, 96 percent were treated by the allopathic system. The survey also revealed that about 14 percent of sick persons (18.5 percent in rural and 11 percent in urban areas) did not avail of any treatment. The reasons given for not availing of any treatment were that the ailment was not considered serious (81 percent) and another 10 percent was on account of financial reasons. It was felt that those who did not avail of any treatment (because the ailment was not considered serious enough) might have used home remedies or visited traditional healers. That was not studied in the survey.5

CCRAS Survey-I: The Central Council for Research in Ayurveda and Siddha conducted a survey in 12 states across the country during 1987 covering various aspects of health related behaviour over different periods. The information was gathered from various sources, viz. Ayurvedic colleges, Ayurvedic physicians, Siddha hospitals, dispensaries, clinics, private physicians, local healers and NGOs. A number of episodes related to the use of traditional medicine to treat malaria, filariasis, chikungunya were recorded from the experience of physicians.6 The findings showed that out of the total population studied by all the Mobile Clinical Research Units, over 71 percent of the population had received Ayurvedic treatment, 25 percent Allopathic treatment and around 2 percent were shown as “others”, meaning folk medicine, just over 1 percent with Homoeopathy and negligible percent age with Siddha medicine. For conducting this survey, the CCRAS had documented the reported medical practices on prevention and management of vector-borne and infectious diseases using the resources of 17 institutes across different states of the country. This picture may be reliable up to a point but gives a skewed finding because the survey was restricted to specific cohorts of the population only. NCAER Survey A National Council of Applied Economic Research (NCAER) survey conducted during the year 1993 revealed that about eight percent

4. ISM refers to Ayurveda, Unani, Siddha, Homoeopathy, Naturopathy Yoga and the use of home remedies based on oral knowledge. AYUSH specifically refers to the expanded from of the acronym – Ayurveda, Yoga, Unani, Siddha and Homoepathy. Now Sowa-Rigpa has also been added. 5. Morbidity and Utilization of Medical Services (42nd round), National Sample Survey Organization, New Delhi 1986-87. 6. Published report on “Study of Health Statistics under Mobile Clinical Research Program”, 1987, CCRAS, New Delhi.

6 Status of Indian Medicine and Folk Healing

of illness episodes were treated by indigenous systems of medicine and homeopathy. This survey, however, covered a higher proportion of urban respondents compared to those living in villages. The sampling fraction ranged from 0.1 coming from small villages to 1.0 in big cities.7 The result appears to have a bias in underestimating the proportion availing of traditional systems, because sick persons living in relatively small and inaccessible villages are known to depend more on indigenous systems when allopathic doctors are not available. The survey did not cover this huge section of the population. NFHS-2 National Family Health Survey-2 (NFHS-2) 1998-99, collected information on the utilization of Indian Systems of Medicine & Homoeopathy (ISM&H) for treating reproductive health problems. It was found that among the women who had reproductive health problems over 7.5 percent had taken the advice of a private vaid/hakim/ homeopath/traditional healer. The NFHS also collected information on the treatment of diarrhoea and reported that about five percent of those who availed of treatment used home remedies/herbal medicine.8 Those availing of ISM&H services in the government system had not been specifically reported upon in this survey. Therefore once again the survey had a bias and a complete picture cannot be derived therefrom.

ICMR Survey Based on a survey “Utilization of Indigenous Systems of Medicine & Homoeopathy in India” (2001-02) covering 35 districts in 19 states, a total of 45,000 patients from 33,666 households were surveyed by the Institute for Research in Medical Statistics at the request of the erstwhile Department of ISM&H. It was found that 14 percent of the patients had used AYUSH and the reasons given for using traditional medicine was that there was “no side effect” and “low cost of treatment.”9 NHSRC Survey A study on the Role of AYUSH and Local Health Traditions under National Rural Health Mission (NRHM) was undertaken in 18 states across India during 2008-2009. The impact of mainstreaming AYUSH as a part of the NRHM programme was studied in the surveys.10 Institutional level OPD (Out Patient Department) attendance data showed that the standalone11 AYUSH facilities were better utilized than the co-located12 ones, in most states. The high utilization of AYUSH services and Local Health Tradition (LHT) in certain states like Tamil Nadu and Kerala appeared to refute an argument which is frequently made that people resort to traditional medicine therapies due to non-availability and the expensive nature of modern treatment. Tamil Nadu and Kerala have comparatively the best functioning public systems of free health care and high utilization of Allopathic public and private services.

7. Household Survey of Health Care Utilization and Expenditure, National Council of Applied Economic Research, New Delhi, 1993. 8. National Family Health Survey-2, International Institute for Population Sciences, Mumbai; 1998-99. 9. Padam Singh*, R.J. Yadav & Arvind Pandey,Utilization of indigenous systems of medicine & homoeopathy in India,Institute for Research in Medical Statistics (ICMR), New Delhi, India, Indian J Med Res 122, August 2005, pp 137-142 10. Ritu Priya and Shweta A.S. Status and role of AYUSH and Local Health Traditions under the National Rural Health Mission – Report of a study, National Health Systems Resource Centre (NHSRC), National Rural Health Mission, Ministry of Health & Family Welfare, Government of India, New Delhi, 2010. 11. Stand-alone AYUSH institutions are either hospitals or dispensaries. 12. Co-located AYUSH facilities refers to District Hospital (DH), Community Health Centre (CHC) & Primary Health Centre (PHC).

Status of Integration 7

Among the North Eastern states, Tripura showed high attendance at the stand-alone and at the co-located dispensaries, followed by Manipur, which had a good turnover in the stand-alone facilities at a state level. Nagaland also had good attendance at the stand-alone and co-located facilities In the Non-High Focus states, the number of patients attending the OPDs in Kerala, Tamil Nadu and Delhi was very high compared to the other states. Therefore, the report concludes that the community had a ‘felt need’ for services other than offered by the modern system and that pluralistic health seeking behaviour reflects the inherent strengths and limitations of various systems. Regional and Local Surveys Jammu Study A group of doctors from Jammu conducted a survey during August-November, 2005 which indicated the popularity of cross-pathy practices among both qualified allopathic and Ayurvedic practitioners in urban tertiary healthcare settings. In the tertiary care allopathic hospitals, NSAIDS (non-steroidalanti-inflammatory drugs), antibiotics, multivitamins, and drugs for acid-pepticdisease (APD) constituted the bulk of the allopathic prescriptions. However, Ayurvedic liver tonics, analgesic ointments and drugs for dysfunctional-uterine-bleeding were also being prescribed for these conditions and such Ayurvedic drugs were available as over the counter (OTC) drugs13. WHO-CCRAS Study in Safdarjung Hospital A study “Feasibility of integrating Ayurveda

with modern system of medicine in a tertiary care hospital for management of osteoarthritis (Knee) - An Operational Study” was undertaken in 2007 in collaboration with the WHO (India country office) conducted by CCRAS in collaboration with the Department of Orthopedics, Safdarjung Hospital, New Delhi. The study covered 252 patients of osteoarthritis of the knee, who had been referred (over a duration of one year) by 30 physicians from the Department of Orthopedics. The study established functional linkages between the Ayurvedic and Orthopedics departments which led to sustained communication and increase in cross referrals. A considerable shift in attitude was observed. Referred patients, most of whom had never used Ayurvedic medicine were convinced about the benefits of Ayurvedic approaches and 70 percent of them even recommended Ayurvedic treatment to other patients. The project was able to send a positive message to others patients attending the Safdarjung Hospital which was evident from 180 patients who turned up for Ayurvedic treatment of on their own volition without being referred by the Orthopedics Department. It was evident from the study that continued communication and a joint approach would strengthen integration. Developing a rational cross referral system would improve access to Ayurveda.14 Vellore Study Regarding the utilization of AYUSH/LHT for HIV/AIDS, the pattern of health seeking behaviour across the country revealed that Ayurveda is the most widely used system throughout India, although Siddha is more prevalent in the state of Tamil Nadu. Although

13. Verma U, Sharma R, Gupta P, Gupta S, Kapoor B. Allopathic vs. ayurvedic practices in tertiary care institutes of urban North India. Indian J Pharmacol 2007. 14. Sulochana Bhatt, Vikas Gupta, Srikanth, N.; Feasibility of Integrating Ayurveda with Modern System of Medicine in a Tertiary Care Hospital for management of Osteoarthritis (Knee) – an operational study; Technical Repot, CCRAS, 2007.

8 Status of Indian Medicine and Folk Healing

there is insufficient literature on the rate of utilization by people with HIV, the practice is reportedly widespread, especially in areas with poor access to health care generally and ART specifically.15 Safdarjung Hospital Study 2008-09 A self - administered pilot survey entitled “Awareness and attitude of allopathic practitioners about the integration of Ayurveda in a tertiary care hospital - A cross sectional study” was conducted on allopathic practitioners in Safdarjung Hospital, Delhi. From the analysis of 202 responses from practitioners, it was evident that all the allopathic practitioners were aware of the basic principles and strengths of Ayurveda and they felt that integration was capable of strengthening the existing health care system. But communication barriers between practitioners of the two medical systems, lack of research, poor dissemination of research findings and lack of uniformity in the implementation of policy were found to be the main obstacles in bringing about functional integration.16 IIPS Study on Urban Preferences The International Institute for Population Sciences (IIPS), Mumbai (2003) studied the dynamics of medical pluralism in urban Mumbai covering 400 households. In this study a hierarchical selection of systems was noticed within the continuum of pluralism.

A majority of the woman clients in the study opted for ISM treatment and subsequently allopathy and many continued to believe in a similar ordering, even after receiving “effective relief” from ISM. Nevertheless though placed lower in the order, for many, ISM was a trusted option. This was indicative of a small but distinct niche for ISM in the overall gamut of pluralist medical system choices.17 Planning Department Study (Government of Delhi) According to an Evaluation Study report on Ayurvedic dispensaries undertaken in 2006, it was found that patients were aware about Ayurvedic dispensaries. According to the field survey, about 84 percent of the patients who had received Ayurvedic treatment had reported progressing satisfactorily after the fourth or subsequent visits. About 87 percent of the patients under Ayurvedic treatment expressed overall satisfaction with the prescriptions and medicines given by the doctors.18 Delhi Survey A survey of Ayurvedic institutions in Delhi showed that rickshaw pullers and other working class people turned to Ayurveda for several chronic ailments, such as skin diseases, gastrointestinal disorders, liver diseases, arthritis, gynecological problems and some acute ailments. The main problem pointed out was the dearth of supply of medicine to AYUSH hospitals and dispensaries.19

15. Chamat A.M. et al; Knowledge, Reliefs and Health Care Practices relating to treatment of HIV in Vellore, India, AIDS Patient Care STDS, 2009 Jun; 23(6): 477-84. 16. Research Paper under publication in an International Journal. 17. Papiya G. Macundar and Sumit Mazumdar. Traditional Medicine in Contemporary India: Medical Pluralism by Urban Females. Paper presented at 2nd Indian Anthropological Congress, Human Development: Evaluation and Vision, organized by Indian National Confederation and Academy of Anthropologistics (INCAA), University of Pune, Pune, February,2007. 18. Evaluation study report on Ayurvedic dispensaries of Delhi Government Planning Department (Evaluation Unit) Delhi Secretariat, Government of NCT of Delhi. 19. Sujatha V. What could ‘integrative’ medicine mean? Social science perspectives on contemporary Ayurveda; J Ayurveda Integr Med. 2011 Jul-Sep; 2(3): 115–123.

Status of Integration 9

Tribal and Folk Medicine Surveys Jaipur Study on Rural/Tribal Healthcare Choices A report on reproductive health care practices in a village in Rajasthan described women’s perceptions and experiences (1999). It showed how perceptions of illness and health seeking behaviour are interlinked with the outreach of health facilities, experiences encountered in hospitals, age at the time of marriage, beliefs about allopathic, Unani and spiritual remedies, household composition, fertility, Quranic education, economic and working conditions. Fieldwork showed that mere provision of health services was not enough. It had to be reinforced by proper attitudes and beliefs, and positive experiences.20 Some relatively well-off women among the tribal women of Rajasthan talked about taking the help of indigenous medicine (ISM) practitioners in coping with certain conditions. The reason cited for not using modern health facilities was primarily the inaccessibility of doctors. It was observed that patients do not generally pay much attention to routine problems during ante-natal, natal and post-natal periods, which they regard as in-built in the process of child bearing and child rearing. In the case of reproductive health problems and general health problems like fever and malaria, at the first stage some treatment is administered at home, followed by a visit to the bhopa (the local faith healer) and a herbalist in that order. Most of the women living in remote areas

did not bother about treatment for Sexually Transmitted Diseases (STDs) and regarded them as their fate. Some expressed inability to undergo treatment owing to the high costs involved. Others went to unqualified doctors for treatment. Only at a couple of places, mention was made of Lodh (Simplicos racemosa), an Ayurvedic medicine, claimed to be effective in curing gynaecological disorders.21 CCRAS Survey-II on Local Health Traditions and Folk Medicine In addition to the recognized system, folk medicine also plays a role in medical care in some parts of the country. During the study period over two percent of the population was found to have used folk medicine. Among the population studied, Joginder Nagar (HP) had the highest number of people, i.e. 14 percent that had used folk medicine, followed by Bangalore (over nine percent) and Kolkota (Calcutta) (over seven percent). People living in Varanasi (UP), Nagpur (Maharashtra), Vijayawada (AP), Bhubaneswar (Orissa) and Patiala (Punjab) were not reported as relying on the use of folk medicine.22 Ethnobiology Survey An All India coordinated Research project on Ethno-biology was carried out by the Department of Environment, Government of India. It concluded that the tribal communities use over 9,000 species of plants. Folk practitioners are by no means confined only to the treatment of coughs and colds or simple ailments.23

20. Unnithan-Kumar, Maya, 1999, Households, Kinship and Access to Reproductive Health Care among Rural Muslim Women in Jaipur, Economic and Political Weekly, Vol. 34, No. 10-11, March 6-12/3-19, pp.621-630. 21. Lakhwinder P Singh & S. D. Gupta; Health Seeking Behaviour and Healthcare Services in Rajasthan, India: A Tribal Community’s Perspective, IIHMR Working Paper No. 1. 22. An Appraisal of Tribal-Folk Medicines, CCRAS, Department of AYUSH, Ministry of Health and Family Welfare, Government of India, 1999. 23. Balsubramanian A.V. The relevance of a vibrant tradition, The Hindu folio, pp. 6-8, October, 2000.

10 Status of Indian Medicine and Folk Healing

CCRAS Survey-III The Central Council for Research in Ayurvedic Sciences (CCRAS) documented Ethnomedical practices, use of medicinal plants besides studying living conditions of tribal areas across the country covering the TransHimalayan region, the North-Eastern region as well as the Southern parts of the country including Andaman & Nicobar Islands. The Council utilized 18 Survey of Units, Mobile Clinic Research Units to conduct the survey and the authenticity of the information was cross-checked by examining patients who had received treatment. The specimens of plants/ part(s) which are used were preserved in the herbariums/museum as specimens. Around 5000 Folklore/Ethno-medical claims used by tribal people were documented. The tribal people were found to treat a wide range of conditions from common cold, cough, fever, vomiting, skin diseases, digestive problems, reproductive and child health problems to wounds etc. The use of herbs for contraception was also found to be prevalent.24 Bone Setting as a Part of LHT Traditional bone setting practices remain popular in many parts of India. Around 6000 traditional bone setting Vaidyas (practitioners) are reported to be using this skill throughout rural areas predominantly. Puttur kattu is a traditional way of bone setting said to have been â&#x20AC;&#x153;inventedâ&#x20AC;? by K. Kesava Raju in 1881. Now, the fourth generation of his family is practising bone setting at Puttur, Andhra Pradesh, giving services to around 200-300 patients a day. A study was undertaken to analyze the techniques of diagnosis, style

of management, the formulation of the medicine, the plants used and the method of application. Fifty four percent of the patients were observed to have come to the Puttur Traditional Bone Setter (TBS) on the advice of other patients. It was observed that educated people were increasingly patronizing this approach to bone setting and 23 percent patients had taken discharge from a modern hospital voluntarily to receive Puttur kattu treatment. Eighty percent patients believed that this therapy along with home remedies would hasten the healing process. Forty-four percent patients opted for this therapy due to fear of pain having to wear a heavy plaster bandage, having to undergo months of immobilization or surgery and even amputation. Seventyone percent patients who were followed were satisfied with the treatment provided by the Putter bone setter and had suffered few complications.25 Tamil Nadu study In a survey conducted in Tamil Nadu, it was found that people differentiate between professional systems like Ayurveda, Siddha, Homeopathy and Biomedicine. But, when they talk of traditional medicine, they distinguish between kaatu (forest) marundhu (medicine), kadai sarakku marundhu (dry medicine from the indigenous drugstore used by Siddha/Ayurveda practitioners) and aaspathiri marundhu (hospital medicine consisting of tablets and injections). A project was undertaken by the Government of Tamil Nadu around the year 2000 to address maternal anemia through the use of Ayurvedic preparations. Over a period of

24. CCRAS Research an Overview, Central Council for Research in Ayurveda & Siddha, Department of AYUSH, Ministry of Health and Family Welfare, Government of India, pp.63-68, 2002. 25. Panda AK. Puttur kattu (bandage) - A traditional bone setting practice in South India, J Ayu Int Med, Vol. 2 (4), 174-178.

Status of Integrationâ&#x20AC;&#x192; 11

one year, a team of Ayurvedic and Siddha experts designed a package of lehyams and churnams; they were then produced by TAMPCOL (Tamil Nadu Medicinal Plant Farms and Herbal Medicine Corporation Ltd.) to be delivered to rural women through the ANMs. The ANMs were also given a kit of 50 Ayurvedic medicaments for common ailments that were well received by health seekers in rural areas. This programme has had a significant impact on maternal nutrition in Tamil Nadu.26 Karnataka Village Study Another research study (2007) identified a system of “forced pluralism” in which they found “spiritual” and traditional healers, shopkeepers selling tonics and tablets, traditional birth attendants and RMPs (Rural Medical Practitioners) all being accessed by the public. The lack of qualified health providers had led to “forced pluralism”, a practice that was found to be “unethical and dangerous”. In the survey conducted in rural Karnataka, 548 providers working in the 60 villages of Karnataka were interviewed covering a population of about 82,000 people. This included 35 spiritual healers, 133 traditional healers, 178 traditional birth attendants, 47 RMPs, one qualified Ayurvedic doctor, 152 provision stores and two medical shops. Although there are a few private specialists in the larger towns, the rural reality of Koppal showed domination by “informal providers”.27 NSSO Survey 2011 – ongoing India is a vast country having wide diversity in eco-climatic conditions inhabited by people

distinguished by race, religion, cultural beliefs as well as social and economic disparity. There are as many as 400 ethnic groups including tribal people. There is a wide variation in the availability of health infrastructure which includes doctors, health staff and access to drugs. Comparatively speaking very little information is available on the utilization of AYUSH Systems and other local health traditions in India as the studies undertaken are not representative of utilization patterns across education and wealth quintiles and across regions. NSSO has for the first time included some questions in their consumer expenditure schedule for the 68th annual round on socio-economic surveys by collecting information for Department of AYUSH. NSSO collected information from about one lakh households nationwide both in rural and urban areas. The survey commenced from July, 2011 and was conducted in subrounds until June, 2012. The survey results are expected to become available in 2013. The survey result will give an authenticated base level assessment from a representative section of households about the usage and acceptability of AYUSH systems in the country. Department of AYUSH will be able to use the survey results for preparing a road map for the provision of AYUSH services. Conclusion and Recommendations The available surveys show that the interest in traditional medicine has always been there but the samples have been too localized to provide a reliable assessment of health seeking behaviour cutting across regions, urban and rural areas and the education and economic status of users. The countrywide NSSO survey will provide a reliable cross-sectional picture

26. Sujatha V; Pluralism in Indian Medicine: Medical lore as a genre of medical knowledge; contributions to Indian Sociology 2007; 41; 169. 27. Sen G., Iyer A, George A. Systematic Hierarchies and systemic gender and health inquities in Koppal district. Econ Polit Wkly, 2007 Feb. 24; 42(8): 682-90.

12 Status of Indian Medicine and Folk Healing

in 2013 but this would need to be repeated continually. While evidence shows that when people search for a cure they try whatever systems might be available, it is also clear that they are at a loss to know what worked and what did not and which course of treatment to opt for in case of recurrence. This needs to be addressed so that patients get guidance and counseling in an unbiased way which will only happen if efforts are made to collect

enough data to substantiate claims. Unless surveys bring out how large this multi-system health-seeking behaviour actually is, it will not trigger a reaction from those responsible for guiding patients or addressing their concerns. Frequent, well-designed surveys are also needed because the extent of use of traditional systems for certain conditions will decide whether a larger group of people feel encouraged to seek such treatment.

Status of Integrationâ&#x20AC;&#x192; 13

Congruence of Traditional and Modern Medicine WHO Views on the use of Traditional Medicine For several years the World Health Organization (WHO) has emphasized the need for harmonization between the traditional and the dominant medical system of medicine used in each country. The term “harmonization” implies a serene process in which “traditional” and “modern” systems blend together. In reality, this process is extremely complex and influenced by powerful commercial interests, barriers, and a degree of mistrust. A Consultation Meeting on harmonizing Traditional and Modern Medicine approaches was held at Beijing, China in 199928 to evaluate the contemporary role of traditional medicine in maintaining health; develop a scientific approach to policy-making in traditional medicine; and also to assess how traditional medicine can be harmonized with modern medicine. Thereafter the WHO draft Regional Strategy for Traditional Medicine (Western Pacific 2011–2020) recommended the inclusion of traditional medicine in the national health system; the promotion of safe and effective use of traditional medicine; and the protection and sustainable use of natural resources. It recognized that there was a need to strengthen cooperation in generating and sharing traditional medicine knowledge and skills. In India several high level policy documents have repeatedly articulated and emphasized

the need for integration sometimes referring to it as mainstreaming the AYUSH systems into the delivery of health services. However, both at a national level and the State level there remains a paucity of guidelines and strategies to promote meaningful integration of traditional medicine systems, drugs and therapies into the overall health care system. National Policy and NRHM Strategies on Integration of Traditional Medicine One of the stated goals of the National Policy on Indian Systems of Medicine & Homoeopathy, 2002 was the “integration of ISM&H in health care delivery system and national programme to ensure optimal use of the vast infrastructure of hospitals, dispensaries and physicians.”29 The 11th Plan document (2007-2012) recommended “mainstreaming of AYUSH systems to actively supplement the efforts of the allopathic system”. The process of colocation of AYUSH services by posting AYUSH doctors within the primary health care system was a new initiative introduced as a part of the National Rural Health Mission (NRHM). Prior to 2005 the operation of the AYUSH systems was in fact completely separate from the organization and management of the medical and public health services run by the Central and State Governments. The Department of AYUSH at the Centre and its equivalent in the States worked in a vertical fashion and except for a few Ayurvedic and Unani specialists offering consultation services in a handful of Central Government and State

28. A Report of the Consultation Meeting on Traditional and Modern Medicine: Harmonizing the two Approaches, 22-26 November 1999, Beijing, China, World Health Organization, Western Pacific Region, 2000. 29. Dept. of AYUSH, National Policy on Indian Systems of Medicine & Homoeopathjy, 2002.

14 Status of Indian Medicine and Folk Healing

hospitals, the facilities, doctors, drug supply and therapeutics operated in completely separate water-tight compartments.

The guidelines for Indian Public Health Standards (IPHS) for CHCs, which have been disseminated to the states, are being updated so as to adequately address the parameters applicable to the AYUSH component also. Once the guidelines are received, priority should be given for upgradation of AYUSH facilities to those standards.

While constructing new PHCs according to Indian Public Health Standards, adequate space should be provided for locating the AYUSH dispensary within the same premises.

Physical Integration under NRHM At a policy level physical integration was first conceived under NRHM and two joint letters signed by the Union Secretaries for Health & Family Welfare and AYUSH spoke of unification of the services for the first time. Union Secretaries Integration

write

Policies

The first letter dated August, 2005 is titled “Roadmap for Mainstreaming of AYUSH under NRHM” Annexure-I. The letter refers to “total functional integration” of AYUSH to be brought about at the primary health care level. The letter spells out physical and functional approaches to be fulfilled by the States. The main instructions included the following: 1.

All Primacy Health Centres (PHCs) ought to have an AYUSH doctor. If space permits, the AYUSH dispensary may be relocated in the existing building of the PHC. In places where the AYUSH infrastructure is good, the feasibility of shifting the PHC to the same building be examined. Although there could be constraints in the availability of space, at least 10 percent of the PHCs with adequate space could accommodate AYUSH dispensaries. Action to shift the AYUSH dispensaries to such PHCs may be taken on priority during the first year of the mission period. Where relocation of AYUSH practitioners is not feasible due to lack of AYUSH dispensaries, qualified AYUSH practitioners may be hired on contractual basis and funds for which would be provided from NRHM budget.

The letter underscored the need for “enthusiastic participation of the states” which was imperative for the success of the NRHM. The second letter (Annexure-II) dated August, 2006 requested the states to “take urgent measures” for mainstreaming AYUSH, plan and implement integration of NRHM – AYUSH schemes supported by an Action Plan to make AYUSH services widely available in rural areas. Recommendations of the Steering Committee (February, 2012) on Health for the 12th Five-year Plan The Steering Committee made a number of recommendations and those pertaining to integration aspects: Human Resource Development 1. Doctors and Nursing Staff of the Allopathic system need to be introduced to the positive aspects of the AYUSH systems through “short orientation modules” on AYUSH. 2. Efforts should be initiated for the develop ment of cross-referral understanding between all systems, based on the strengths of respective systems.

Status of Integration 15

3. At the post-graduate levels, “crossdisciplinary learning” between allopathy and AYUSH systems ought to be promoted. For this purpose coordinated efforts need to be made. Two suggestions were: a. Modifications in respective syllabi b. AYUSH chairs to be established in medical colleges On Practice and Promotion of AYUSH 1. Standards need to be established for the primary, secondary and tertiary level AYUSH facilities similar to Indian Public Health Standard (IPHS). 2. Standard Treatment Guidelines and Model Drug Lists need to be developed for community health workers. 3. AYUSH services of an appropriate standard should be provided at all primary, secondary and tertiary care institutions under the MOHFW, State Health Departments and other Ministries like Railways, Labour, and Home Affairs. 4. National health outcomes incorporate inputs collected AYUSH colleges.

must from

5. AYUSH - based lifestyle guidelines should be considered for RCH, Adolescent Health, Geriatric Care, Mental Health, Non-Communicable Diseases, Anemia, Nutrition and Health Promotion by establishing “Joint behavioural change plans”. 6. “Bridge courses” and “appropriate modifications in regulations” should

be considered so as to facilitate the prescription of essential allopathic medicines by AYUSH practitioners. On Fostering Mutual Respect The Steering Committee recognized that it would take time for these recommendations to fructify but expressed anxiety over what was seen as a communication gap which existed between the AYUSH practitioners and those from modern medicine. The Committee pointed out that they do not communicate for want of a ‘bridge language’. The report showed how the poor quality of clinical research and an over reliance on converting Ayurvedic concepts into western medical concepts had led to “near antipathy” among the ASU and allopathic doctors. On the Reported Level of Integration The Steering Committee’s Report gave an assessment of the level of integration of AYUSH healthcare institutions under NRHM which is reproduced below: Facility

Total Units

Number (%age) of co-located AYUSH facilities

Primary Health Centers

23391

8366 (35.77%)

Community Health Centers

4510

2945 (65.3%)

604

424 (70.2%)

District Hospitals

Report of the National Health Systems Research Centre30 (NHSRC) A study conducted called “Mainstreaming AYUSH and Revitalising Local Health Traditions under NRHM - a Health Systems Perspective”

30. National Health Systems Research Centre (NHSRC) has been set up as an autonomous registered society under the National Rural Health Mission to provide technical support and capacity building for strengthening the Public Health System in India.

16 Status of Indian Medicine and Folk Healing

aimed at providing a broad understanding of the functioning of AYUSH and LHT services in the country. The report recommended orientation of the ASHAs31, ANMs32, the Rogi Kalyan Samitis33 and the Village Health Committees34 to focus on the stocking and dispensation of AYUSH medicine and to encourage the use of local health traditions to promote healthcare. The NHSRC study covered 18 states. The main findings were as follows:

Grading for Quality of AYUSH Facilities across States Sl. No.

State

Standalone

High Focus States 1.

Jammu & Kashmir

Fair

Uttarakhand Good Poor

Orissa

Good Fair

Bihar

Fair

Co-location not started at the time of survey

Jharkhand

Fair

Co-location not started at the time of survey

Level of Utilization of AYUSH Services State and institutional level OPD (Out Patient Department) attendance data showed that the stand-alone services were better utilized than the co-located ones in most states.

Co-located

Very poor

High Focus North East States

Quality of AYUSH Services

Assam

Poor

The quality of AYUSH services was assessed on a set of parameters covering infrastructure, human resources, supplies, record-keeping and other inputs. The quality of infrastructure, availability of human resources, supply of medicines, and record maintenance was found to be unsatisfactory.

Manipur

Fair

Nagaland

Poor

Sikkim

Fair

10. Tripura

Fair

Poor

Among the stand-alone facilities, in eight states they were graded ‘fair’, in 2 ‘good’ and in 3 ‘very good’. Among the co-located, seven were graded ‘poor’, six ‘fair’ and two ‘good’. Thus, the quality of services was found to be better in the stand-alone than the co-located ones, the gradient across States being similar.

Non-High Focus States 11. Andhra Pradesh

Fair

12. Haryana

Fair

Poor

13. Punjab

Fair

Co-location not started at the time of survey

14. West Bengal Fair

Fair

31. ASHA (Accredited Social Health Activist) is a health worker who acts as a mobilizer, facilitator and a link between existing health facilities and member of the community. 32. ANM (Auxiliary Nurse Midwife) and ASHA have been integrated in various ways. She will provide guidance to ASHA in ciase she encounters problem. 33. Rogi Kalyan Samiti (Patient Welfare Committee) is a simple yet effective management structure which acts as a group of trustees for the hospitals to manage the affairs of the hospital. It consists of members from local Panchayati Raj Institutions (PRIs), NGOs, local elected representatives and officials from Government sector who are responsible for proper functioning and management of the hospital/ Community Health Centre. 34. Village Health Committees (VHCs) are the first step towards community orientation of health care services and for making health as a people’s movement. The elected member of PRI of the village is the Chairperson and other members include the ASHA Sahyogini, the Anganwadi Worker, the ANM, and a representative from an NGO.

Status of Integration 17

15. Karnataka

Fair

Poor

16. Tamil Nadu

Very Good Good

17. Kerala

Very No co-location Good

18. Delhi

Good Good

The report underscored that the criteria for the grading had been “minimalist” and “relative” and the scores attained could not be treated as desirable standards of quality. The objective of the composite matrix was to provide a comparative rather than an absolute analysis. PI’s Findings on Status of Integration during Field Visits The Principal Investigator used these policy prescriptions, recommendations and survey findings when she visited different states and more particularly while holding discussions with the State Health Secretaries and Directors in charge of Ayurveda and Unani medicine in the states of Odisha, Uttar Pradesh, Andhra Pradesh, Himachal Pradesh and Jammu & Kashmir. Since the states of Maharashtra, Rajasthan, Karnataka, Kerala, Tamil Nadu, Chattisgarh and Delhi had been covered by her when Part-I of the Report was written, those states were not re-visited a second time. In the case of Bihar, Uttarakhand and West Bengal the material was collected through questionnaires. Utilization of available AYUSH Doctors The presence of the District AYUSH Officer who has operated for long years prior to NRHM started, has gone unnoticed in the wide gamut of activities undertaken under the Mission. This functionary is now uncertain about his role and the PI found that he preferred to manage the stand-alone facilities and to take a back seat on NRHM matters.

18 Status of Indian Medicine and Folk Healing

During discussion with the District AYUSH Officers, it was clear that most of them only had an idea of the stand-alone facilities and treated the AYUSH inputs into the NRHM co-located PHCs as an independent stream to be supervised by the District health hierarchy. The latter however had little knowledge or experience of functionaries of the AYUSH systems and their areas of strength. Under the NRHM set-up, the posting of AYUSH doctors is being done by the District Health Office (Civil Surgeon in some states). The District AYUSH Officer is in fact not officially entitled on the basis of most State Government orders to check the work or output of the AYUSH doctors recruited under NRHM. In some states even copies of orders posting the AYUSH doctors are not endorsed to the Director AYUSH/Ayurveda or the District AYUSH Officer, so making his role as the senior supervisory face of AYUSH superfluous. The contractual doctor’s first priority is naturally to gain the acceptance of the M.O./incharge of the PHC to whom he reports. Such appointees under NRHM are respectful but indifferent to the District Ayurveda Officer’s role and ignorant about the AYUSH work being done outside the PHC of posting. Status of Cross Referrals in Co-located Facilities In the PHC’s and Community Health Centres visited by the PI in five States (Odisha, Uttar Pradesh, Andhra Pradesh, Himachal Pradesh and Jammu & Kashmir), cross-referrals were not being practised even marginally. It was apparent that the contractual recruits in the co-located facilities were working on their own and when drugs were not available the number of patients dwindled down to hardly 2-3 persons in a day whereas the OPD on the allopathic side was running into 50-60 patients per doctor where the attendance of the allopathic physician was regular. The

allopathic doctors were not making referrals to the AYUSH practitioner sitting next door, except very occasionally. Guidelines and standard operating practices need to be laid down for making referrals as ultimately the patient loses out on the benefits of integration. PHC Doctors Expectations from AYUSH Doctors On a positive note, the PI found a palpable change in the attitude of the allopathic Medical Officers in the Primary Health Centres (PHCs) visited by her. There was tolerance and friendliness towards the AYUSH doctor and the “incharges”(allopathic) welcomed the presence of an additional hand and someone keen to cooperate and accept a supportive role. But, although the presence of the AYUSH doctor had been accepted it had not translated into becoming an advantage for patients. Suggestions on how this ought to be managed have been made in the report after looking at the experience of AYUSH doctors working in different settings. Reporting Systems for AYUSH The PI found that generally District and Regional Officers collect the data from the PHCs and feed it to the District CMO. The output of the stand-alone AYUSH dispensaries is collected separately by functionaries who do not report to be District Health Officer or Civil Surgeon but report to the Director of Indian Medicine/AYUSH of the state. The AYUSH data collected from the PHCs was found to be quite haphazard, and although figures were being collected, they were not being translated into strategies to improve the situation when shortcomings were glaring. The supervisory officers were not in the habit of analyzing data and asking questions particularly relating to unexplained swings in OPD and IPD figuresmonth to month.

Unless the data is scrutinized and correctives are introduced, the mere collection of data becomes meaningless. In order to project a higher number of patients it is quite possible that an exaggerated version is being conveyed because there is a persistent fear among the contractual doctors that their jobs may be rendered redundant for want of evidence of utilization of the AYUSH services. Therefore, there is a need to measure OPD attendance in a meaningful way. One way might be to only collect OPD attendance data when drugs are available as no patients are going to attend the OPD in the absence of getting medicine. Low attendance makes the AYUSH hierarchy feel threatened, and therefore there is a need to link the attendance of patients with the availability of AYUSH drugs in the co-located facilities. Utilization of AYUSH Doctors under NRHM Several PHCs and CHCs are using AYUSH doctors to perform duties as the in-charges of the facility and to conduct deliveries. These doctors are regularly put on night duty which amounts to being on emergency duty. Therefore, guidelines must visualize all the situations likely to occur but these require amplification with special reference to 3 and 4 below. 1.

When the AYUSH doctor functions in a PHC under the M.O. in-charge and AYUSH drugs are available. (Instructions are available)

When AYUSH drugs are not available and the AYUSH doctor works below the M.O. incharge. (Instructions are available)

When AYUSH drugs are not available and the AYUSH doctors is the In-charge. (Instructions are available but are very broad and general)

Status of Integration 19

When the AYUSH doctor is placed on night duty which amounts to being on emergency duty when IV fluids, injections and life saving drugs might need to be administered. There are no instructions on this. In States like Odisha and J&K, doctors repeatedly requested for legal protection for undertaking such work.

Since, the situations at (3) and (4) above are quite frequent in the more remote PHCs, the fact that AYUSH work will take a back seat has to be recognized. It is necessary that under NRHM, there is an organized way of having a monthly meeting of the Director of AYUSH/ Ayurveda ISM with the district CMOs and the District Programme Manager of NRHM where the rational use of the AYUSH personnel can be discussed. Second, the availability of AYUSH doctors and medicines at the PHC level need to be overseen as otherwise the AYUSH component will get ignored if too much time goes in only doing modern medicine work. Since AYUSH work has a direct relationship with drug availability this needs to be overseen regularly at the State level.

in rural areas as they are all covered in the list of drugs for primary health care. Relevance of Findings related to the sector AYUSH made by the 5th CRM The CRM comprises several experts appointed by the Ministry of Health & Family Welfare to report on NRHM’s progress in the States and districts. The CRM’s findings on AYUSH deserve to be given objective consideration. Unless there is a quarterly meeting at the level of the State Health Secretary specifically to address these issues, it is unlikely that the officers of the Ayurveda/ISM Directorate would have the wherewithal (and often the confidence) to be able to correct the deficiencies which are several. •

One criticism reported in the Fifth CRM was that AYUSH doctors’ posts have been utilized for positioning allopathic doctors. This can only be corrected with the intervention of the State Health Secretary. It defeats the purpose of introducing AYUSH under NRHM if the states have the flexibility to cannibalize those posts to make up for normal deficiencies.

•

It has been also pointed out that work of the AYUSH doctors goes unnoticed. This leads to a lack of ownership and will ultimately lead to the co-location strategy falling into disuse. This needs correction keeping in mind suggestions made in the preceding section.

•

Non-availability and inadequacy of AYUSH drugs was rampant in almost all PHCs. This points to the need to revitalize the State pharmacies as drug supply arrangements made from outside the States are proving to be insufficient and unreliable.

National List of Essential Medicines (NLEM) In the list of essential medicines there are three categories: Primary (P), Secondary (S) and Tertiary (T). There are 348 drugs listed in NLEM 2011. Of these 1.

181 fall under the category of P, S and T;

106 medicines fall under the category of S and T and

61 drugs are categorized as T only.

The pharmacology of the 181 drugs which fall under the category of P, S and T should be taught to AYUSH doctors through inclusion in the curriculum. In turn these drugs can be permitted to be used for primary care treatment

20 Status of Indian Medicine and Folk Healing

•

working as “in charges” of health facilities need to be spelt out. There is little clarity about the extent to which AYUSH doctors can attend to medical emergencies which are expected to be available in all 24x7 government health facilities.

The MIS for AYUSH stand-alone and co-located ought to be incorporated into the overall Health MIS that is prepared for the District and the State as a whole.

Conclusions and Recommendations From the foregoing discussion, it is apparent that the co-location strategy has not stabilised sufficiently to the point that patients are benefiting significantly. Therefore : 1.

The utilisation of state and district AYUSH manpower (non-NRHM) needs to be considered for supervision of AYUSH work at the co-located facilities .

Standard guidelines are needed on making referrals intra the co-located facilities to facilitate patients.

The expectations from AYUSH doctors

Reporting systems for AYUSH when drugs are/ are not available needs fine tuning. This is because there was shortage of AYUSH drugs in almost all the facilities visited by the PI which was also the finding of the surveys conducted by NHSRC and by the 5th CRM undertaken in November 2011.

The recommendations of the 5th CRM relating to the AYUSH component of the NRHM program are very relevant and correctives need to be made as advised.

Status of Integration 21

Status of Adjuvant Use of Ayurveda and Unani Medicine Introduction India is the only country in the world which officially recognizes multiple systems of medicine. These include Allopathy and the Indian systems of medicine viz: Ayurveda, Unani, Siddha, Homeopathy and the supportive therapies of Yoga and Naturopathy. Another system Sow Rigpa35 also known as Amchi medicine got official recognition from the Government of India in 2009. The fact that patients use different systems of medicine simultaneously is well known but the advantages, disadvantages, benefits and risks of combined use, particularly along with modern medicine have not been studied. Brain-storming to decide priorities for Part-II A meeting of Ayurveda and Unani technical experts from Uttar Pradesh, Jammu & Kashmir, Orissa, and Himachal Pradesh was organized under the aegis of the Unani Research Council (CCRUM) on 9th December, 2011 (Annexure-III). The meeting was attended by both the Director Generals of the Research Councils for Ayurveda and Unani systems of medicine. The experts agreed that the majority of the patients use more than one system of medicine simultaneously, especially for chronic conditions, most often without informing their treating physician. The use of traditional systems of medicine as adjuvant therapy was reported to occur

more frequently in the case of lifestyle and chronic conditions like diabetes mellitus, hypertension, lipid disorders, joint diseases, skin ailments, allergies and auto-immune diseases which call for a longer, sometimes even lifelong treatment. While discussing the reasons for using the traditional medicine as adjuvants, the main reasons for such adjuvant use included the belief that Ayurvedic/Unani medicine being derived from natural resources is safe and can do no harm. The physicians that came for the meeting all agreed that patients explored options for Ayurvedic and Unani treatment to avoid surgical intervention. They also believed that the dosage of allopathic medicines (and the cost) could be reduced by concurrently taking Ayurvedic/Unani medicine. Some patients opted for traditional medicine because they were apprehensive about the use of injectable medicines,knowing that Ayurvedic/Unani treatment would be non-invasive. Special survey on Adjuvant use of Ayurveda and Unani medicine Decision to mount a Survey on Adjuvant use of AYUSH medication At the meeting held in December, 2011, it was decided to conduct a survey using a standard questionnaire to be administered to patients at selected hospitals, as proposed by the CCRAS and CCRUM, respectively36. Data was collected from approximately 2000

35. “Sowa-Rigpa” commonly known as ‘Amchi’ is one of the oldest surviving system of medicine in the world, popular in the Himalayan region of India. In India this system is practiced in Sikkim, Arunachal Pradesh, Darjeeling (West Bengal), Lahoul and Spiti (Himachal Pradesh) and Ladakh region of Jammu & Kashmir. 36. Ayurveda Regional Research Institute, Jammu; Ayurveda Regional Research Institute, Patna; National Veterinary– Ayurveda Research Institute and Hospital, Lucknow; BHU Varanasi, Ayurveda Regional Research Institute, Mandi, and National Research Institute of Ayurvedic Drug Development, Bhubaneshwar. The Unani (Regional Research Institute of Unani Medicine, New Delhi; Central Research Institute of Unani Medicine, Hyderabad; Central Research Institute of Unani Medicine, Lucknow & Regional Research Institute of Unani Medicine, Srinagar).

22 Status of Indian Medicine and Folk Healing

patients (200 patients each from six Ayurveda and four Unani hospitals). A comprehensive questionnaire was developed by the PI in consultation with experts of both systems (Ayurveda and Unani) to collect information (Annexure-IV). The data collected during the survey was analyzed by a statistician provided by the CCRUM. The slides below show the findings of the survey. The purpose of the

survey was to ascertain the health-seeking behaviour of large number of patients and to understand their reasons for availing of Ayurveda and Unani medicine for different conditions. The areas where adjuvant therapy was preferred included musculo-skeletal disorders, respiratory conditions and lifestyle disorders. The findings are summarized in the charts that follow:

Summary of the survey outcomes Relating to Adjuvant Treatment

Status of Integrationâ&#x20AC;&#x192; 23

Experiences with Integration-Physiciansâ&#x20AC;&#x2122; Observations A workshop was organized by the PI on 19th July 2012 at the CCRUM Headquarters, New Delhi where practitioners selected by the Directors General of CCRAS & CCRUM attended (Annexure-V) to discuss the findings of the survey and issues related to the adjuvant use of AYUSH drugs. After hearing the outcome of the survey and the Ayurveda as well as Unani experts, the opinion expressed by the physicians was that such adjuvant use of Ayurvedic and Unani drugs reduces side effects, increases bioavailability, reduces the dose required, including the expenses on treatment, improves quality of life, and helps in swifter recovery. The doctors shared their experiences on prescribing Ayurveda/Unani drugs as adjuvant to allopathic treatment but added certain precautions that needed to be taken, along with the need for patient counseling. Some of the highlights of the discussions are summarized in the boxes which present the views of individual practitioners. In addition there are boxes which capture the views of some modern medicine doctors who were asked to give their views independently. The interviews show how integration is unfolding and how practitioners are in any case factoring in what patients are opting for. Doctors that diagnose and treat a variety of patients in different settings have formulated their own responses and the examples bring out the ground realities. The descriptions relate to a wide range of health facilities and encompass the views of AYUSH doctors working in city based dispensaries and hospitals, the Government Ayurvedic & Unani Tibbia college at Karol Bagh, New Delhi, the Government Ayurveda College at Lucknow and at the Integrative Medicine, Department

24â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing

at Medanta one of the leading private hospital conglomerates in the country. Independent of this meeting, during a detailed discussion that the PI had with the faculty of Hakim Ajmal Khan Tibbiya College, Aligarh, she was informed that the majority of the patients suffering from Herpes, tuberculosis, skin allergies, ulcers and other chronic / lifestyle disorders like arthritis, asthma, sinusitis, hypertension, dyslipidemia, diabetes mellitus, were taking Unani medicine in addition to allopathic medicine. Using Ayurveda and Unani medicine as Adjuvant Therapy: Main Findings of physicians The detailed interviews show that many physicians accept the adjuvant use of Ayurvedic and Unani medicine and have developed their own approach to what patients are seeking. The responses range from a high level of confidence to those who advise caution. In the ESI outpatients department it appears to be common practice to prescribe Ayurvedic drugs as adjuvant therapy during the intensive phase of the treatment of tuberculosis under the DOTS regime. The administration of Ayurvedic drugs used in combination with chemotherapeutic drugs was found to promote healing, improve vitality and increase the ability to combat the side-effects of strong drugs. It was reported that blood sugar levels could improve in the case of diabetic patients and the dosage of allopathic medicine can be tapered off. In the case of Unani medicine the PI was told that adjuvant therapy using these drugs could reduce the unwanted effects of strong medicine used in the long-term treatment of HIV/AIDS, epilepsy, diabetes, typhoid fever, urinary tract infection and psychotic disorders. The use of such drugs alongside chemo and radiation therapy and in the treatment of Ischemic

heart disease was also referred to. A modern medicine doctor who had treated a very large number of filariasis cases went so far as to suggest that lead hospitals should use medicine from more than one system and patient care protocols should be upgraded and much more research should be supported in collaboration with national laboratories. There were also notes of caution which inter alia included the need to maintain a time gap of at least one hour to avoid the possibility of drug interaction when using allopathy and Ayurveda drugs. It was admitted that there is not much knowledge about various drug interactions with the joint use of allopathic and Ayurvedic medicine. Another word of caution was that Ayurveda is not a panacea for all major and minor health related ailments. However Ayurvedic practice has an independent role in health restoration and promotion and there are conditions where Ayurveda â&#x20AC;&#x153;potentiates the action of modern medicine and reduces the harmful effects of strong drugs.â&#x20AC;? The actual advice of each physician ,reduced into writing makes interesting reading because it represents the extent of use of Ayurvedic and Unani medicine as adjuvant therapy which calls for policy responses and strategies to be put in place which cream off the best advice possible keeping in mind the need for patients to receive safe and effective treatment. Views of an eminent Allopathic Physician37 India has a rich tradition of different systems of medicines like Ayurveda and herbal medicines. Unfortunately in our systems of education of these systems and the allopathic systems of medicine we

were taught not to prescribe the medicines of the different systems at the same time. We went to the extent of saying that such administration of medicines would harm the patient. It is now time to review this policy today. Certain countries are using medicines of the different systems together. Even in USA and UK many traditional medicines are used by allopathic practitioners to decrease the side effects of powerful allopathic medicines. The use of ginger to decrease the nausea inducing property of powerful anticancer drugs is one such example. In India the movement for such treatment has started at the grass roots level. The different reviewers of the National Rural Health Mission has reported that allopathic doctors and Ayurvedic doctors have been administering with success both synthetic allopathic drugs and herbal preparations. In their book, published last year Ritu Priya and A.S. Shweta listed the conditions at the primary health care level where a medicine form the allopathic system of medicine and a locally available plant were used together. These are digestive disorders, arthritis, asthma, diabetes, piles and allergic disorders. The herbal remedies have been listed: lemon juice with salt for diarrhoeas, karela and methi for diabetes, beetroot and dates for anemia, castor for constipation, pepper with salt and honey for cough and cold and tulsi to raise immunity. It is very exciting that this trend is coming from the field. Academicians and researchers of the different systems of medicine need to discuss this exciting development and

37. Professor Ranjit Roy Chaudhury, National Professor of Pharmacology (National Academy of Medical Sciences) and Advisor Health, Government of National Capital Territory of Delhi.

Status of Integrationâ&#x20AC;&#x192; 25

prepare Standard Treatment Guidelines for specific conditions. With so many systems of medicine available in our country if proper use of the systems and the medicines is made, no person in the country should be without health care –anywhere and for a lifetime. Views of a Delhi Municipal Corporation Ayurveda doctor38 Patients should be properly counseled regarding the adjuvant use of traditional medicine drugs and possible consequences. Allopathy and Ayurveda drugs should be consumed with a time gap of at least one hour to avoid the possibility of drug interaction. Patient counseling is very important particularly in the case of lifestyle related/chronic non-communicable diseases like Hypertension, Diabetes, Respiratory disorders, Hypothyroidism. Most of these diseases can be managed without complications, if the patient follows preventive approaches described in Ayurveda. AU doctors should accept the responsibility for counseling because modern medicine doctors do not have the time to counsel patients. At best they refer patients to a dietician. Most patients attending AU clinics are taking conventional medicine, and in some cases vice versa too. Knowledge exchange among the treating physicians is required so that they become conversant with the differences in treatment and choice of drugs. They would be in a better position to discuss signs and symptoms that patients notice instead of brushing aside what the patient wishes to discuss.

Experience of an Ayurveda physician39 from the Employees State Insurance Corporation (ESIC) on the use of Ayurveda as an adjuvant in the treatment of Pulmonary Tuberculosis. Patients attending ESI OPDs and taking DOTS regime opt for Ayurveda as adjuvant therapy in the following conditions: Chronic complaints – Persistent cough, general weakness, loss of weight, loss of appetite, feverishness, Possible side effects of ATT – Burning sensation in the hands and feet, gastrointestinal upset, Jaundice, drowsiness, ringing in the ears, loss of hearing, impaired vision, joint pains Following are the list of the drugs available in the ESI Ayurveda units and which are generally prescribed for the above conditions: 1. Chyavanprash – to promote general status of the patient / immunity 2. Brahma rasayan – to build up strength and immunity 3. Vasavaleh – in persistent coughs, expectoration of sputum with blood, fever 4. Agasthya haritaki – Soothens the respiratory tract, gastric upset, 5. Swarnavasant malti ras – in fever, burning sensation, loss of weight, and to promote immunity 6. Rajamriganka ras – afflictions of tuberculosis

7. Sitopaladi/Talisadi churna – loss of appetite, hoarseness of voice, burning sensation in palms and soles, fever, cough

38. Dr. Sathya N Dornala, Senior Medical Officer, East Delhi Municipal Corporation. 39. Dr. G.Prabhakar Rao, Chief Medical Officer (NFSG), ESI Dispensary, Nand Nagri, New Delhi.

26 Status of Indian Medicine and Folk Healing

Respiratory

8. Eladi vati – Anorexia, nausea, loss of taste, indigestion, clears tongue, 9. Hepatoprotectives like Liv.52, Livomyn, Amlycure, etc., to pacify the hepatotoxicity of ATT drugs 10. Drakshasav – Increases appetite, promotes good sleep, acts as a liver tonic. Patients usually opt for these adjuvant therapies/drugs during the intensive phase of the DOTS regime. All patients are strongly advised to continue the DOTS regime along with Ayurvedic medicine. No adverse effects have been reported by the patients using Ayurveda as adjunct to ATT while they do report improved well-being. The administration of Ayurvedic drugs used in combination with chemotherapeutic drugs not only promotes healing, but also improves vitality and increases the ability to combat the side effects of strong drugs. This approach can bring a new dimension into the health care, and promote an integrated approach which would greatly benefit certain patients. Experience of a Faculty member40 from the Ayurvedic & Unani Tibbia College, New Delhi on the use of Ayurvedic drugs as adjuvant therapy There are issues connected with the adjuvant use of Ayurvedic drugs. At the outset, it is good if a patient selects a single system for treatment. We still do not know much about various drug interactions with the joint use of allopathic and Ayurvedic medicine.

In the acute phase of an ailment it should be managed by using allopathic medicine and when the severity is minimized Ayurvedic drugs may be started to build up the tissues and to check the recurrence of the disease. Many allopathic practitioners are convinced by this idea but the problem is that they are ignorant of the mode of action of Ayurvedic medicine. Increasing interaction between disciplines would give some answers but this approach has not been developed in any measure. The strength of the Ayurvedic system should become better known: •

Fistula-in-ano can be effectively treated in the OPD without involving hospital stay. It is a very cost-effective treatment and the ICMR has also standardized the thread that is used in the treatment.

•

Irritable Bowel Syndrome is very common in urban areas and some Ayurvedic medicinal plants are very useful in managing the condition e.g. the use of Bael (Eagle marmelos).

•

Kutaja (Hollarrhena antidysentrica), Dadima (Punica granatum) and Patta Ajowan added to the food diet along with butter milk and cumin seed is a panacea for many conditions.

•

In cases of Primary complex in children where ATT may prove toxic, Ayurvedic medicines such as Svarna Vasanta Malati Rasa along with the extract of Rudanti gives marvelous results.

•

Panchakarma therapy in Ayurveda is a detoxification therapy and it can be used along with allopathic medicine.

40. Dr. Praveen Choudhary, Associate Professor, Department of Shalya, Ayurvedic & Unani Tibbia College, Karol Bagh, New Delhi.

Status of Integration 27

Experience of an Ayurvedic Medical Officer41 of Municipal Corporation of Delhi on the adjuvant use of Ayurvedic drugs in the treatment of Madhumeha (Diabetes mellitus) Ayurveda classifies two kinds of diabetic patients: Lean & thin Diabetic Patients: Such patients are usually suffering from Type I Diabetes and are on Insulin. Even after taking more than 40 units of Insulin the blood sugar is not controlled. In such patients, immunomodulator drugs and drugs which promote secretion of insulin are used. For example Ashvagandha, Fenugreek, Gudmar and classical gold preparations Basant Kusumakara Rasa are beneficial for such patients. However, the drugs need to be withdrawn for a few days after being administered for 15 days. The patient is administered both allopathic and Ayurveda drugs for at least one month and the blood sugar (Both Fasting and Post-prandial) is monitored every week. The patient has to follow a strict dietary and life style regimen as advised by the Ayurvedic physician according to his constitution. The blood sugar level improves within a month and gradually the dosage of allopathic medicines can be tapered off. Within a period of three months, minimum/ or no Allopathic drugs need to be given. Patent Ayurvedic Hypoglycemics e.g. Hyponidd/ Amree Plus/ Madhusar are generally prescribed. Strong and Overweight Diabetic patients: Patients generally belong to the Type II Diabetes NIDDM category. Such patients

are usually on 2-3 hypoglycemic drugs and encounter side effects of hypoglycemics, most common being stomach upsets. Such patients are administered patent Ayurvedic hypoglycemics along with allopathic drugs initially for a period of one month. Chandraprabha Vati, a classical medicine for genito-urinary problems has a good effect on the majority of hypoglycemic patients. Blood Sugar (Both Fasting and Post-prandial) is examined every week. Carminative and digestive Ayurvedic preparations like Lasunadi Vati etc. are prescribed along with such drugs. After one month, the blood sugar generally tends to improve or becomes stable. One of the allopathic hypoglycemics is then withdrawn. For the next month again the same protocol is followed and generally within three months all the Allopathic hypoglycemics can be withdrawn and the patient can lead a near normal life with natural Ayurvedic drugs. However, for the next three months, the blood sugar level is closely monitored to check any further need for allopathic hypoglycemics. Adjuvants for combating side effects of allopathic drugs: Of all the side effects of allopathic hypoglycemic drugs, the most troublesome is that of stomach upsets. For this the patient is given carminative and digestive preparations e.g. Lasunadi Vati, Praval Panchamrita Rasa, Bilva Churna, Hingwashtaka Churna. But again such drugs have to be selected by an expert according to the constitution of the patient. Ayurvedic drugs if used by qualified professionals can definitely help Diabetics to lead a normal Life.

41. Dr. Mamta Ralhan, Senior Medical Officer, North Delhi Municipal Corporation.

28â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing

Views of an Unani expert42 from the A&U Tibbia College, New Delhi There is a long road ahead for Traditional Medicine to become a mainstream line of treatment. Despite its enormous success, western biomedicine can discourage patients as many diseases, especially chronic ones, are not cured or even ameliorated adequately; the treatment can result in serious adverse reactions and these are well –known and documented. Unani drugs can be used as adjuvant therapy to reduce the unwanted effects of strong treatment. These cases include: •

Long - term allopathic treatment for HIV / AIDS, Tuberculosis, Epilepsy, Diabetes, Typhoid fever, Urinaray Tract Infection, Psychotic disorders e.g. Depression, Anxiety and Schizophrenia.

•

The use of Immuno-suppressant drugs

•

Alongside Chemo - and Radiation Therapy

•

In Ischemic treatment

Heart

Disease

Unani Adjuvants: •

To Combat Hepatotoxicity: Single Herbs: Kasni (Cichorium intybus), Karafs (Apium graveolens), Kasoos (Cuscuta reflexa), Sunbul-ut-teeb (Nardostachys jatamansi), Darchini (Cinnamomum zeylanicum), Qust shirin (Saussurea lappa), Hab-e-Balsan (Commiphora opobalsum), Mujaith (Rubia cordifolia), Giloy (Tinospora cordifolia); Compound Formulations: Majoon Ddabidulward, Habb-e-Kabid Naushadri, Dawa-ulKurkum, Sharbat Deenar.

•

For Resolution of the TB Inflammation and Healing of the Lesion: Single Herbs: Tabasheer (Bambusa arundinacea), Zaffran (Crocus sativus), Mastagi (Pistacia lentiscus); Unani Compound Formulations: Dawa-ul-Kurkum, Sharbat Bazoori Mautadil, Dayaqooza

•

For Modulation of Immunity: Single Herbs: Zafran (Crocus sativus), Mushk (Moschus moschiferus), Marwareed, Silajeet, Amla (Emblica officinalis), Giloy (Tinospora cordifolia), Asgand (withania somnifera); Compound Formulations: Khamira marwareed, Khamira abresham, Khamira Gauzaban Sheera Unnab Wala, Dawa-ul-Misk.

•

Removal of toxins from the body: Single Herbs: Zaffran (Crocus sativus), Sunbulut-teeb (Nardostychus jatamansi), Gulab (Rosa damascene). Dana illaichi khurd (Eletaria cardomum). Compound Formulations: Dawa-ul-Kurkum, Majoon Dabidulward, Mufarah Shaiqurrais, Sharbat Bazoori Mautadil.

•

For Improvement of Bio-availability of Primary Treatment: Fifil siyah (Piper nigrum), Kafoor (Commiphora camphor).

(IHD)

1. Anti Tubercular Treatment - ATT comprises Isoniazide, Rifampicin, Pyrazinamide, Ethambutol and Streptomycin. The toxic effects of Isoniazide are peripheral neuritis and a variety of neurological manifestations e.g. paraesthesia, numbness and mental disturbance due to pyridoxine deficiency and hepatitis caused by damage to liver cells. Rifampicin, Pyrazinamide are also known to cause hepatitis and other symptoms like nausea, vomiting, abdominal cramps accompanied by diarrhoea. Use of pyrazinamide causes arthralgia, and flushes. Streptomycin is associated with ototoxicity and nephrotoxicity.

42. Prof. Rais-ur-Rahman, Head, PG Department of Moalejat, A & U Tibbia College, Karol Bagh, New Delhi

Status of Integration 29

2. Anti Epileptic Treatment - The major drawback of antiepileptic drugs is their sedative action. Long term administration produce behavioural abnormalities, diminution of intelligence, impairment of learning and memory, mental confusion due to neurotoxicity. Unani adjuvants : Single Herbs: Asgandh (Withania somnifera), Asarun (Valeriana wallachi), Badam Shirin (Prunus amygdalus), Jadwar (Delphinium denudatum), Ooud Salib (Aquilria agollocha), Brahmi (Bacopa monniera), Ustokhuddus (Lavendula stoechas). Compound Formulations: Habe-sara, Majoon zabeeb, Khamira gauzaban ooud salib wala, Majoon brahmi, Majoon falasfa. 3. Anti HIV Treatment - Since none of the currently available regimens in modern medicine can eradicate HIV from the body of the patient, the goal of therapy is to inhibit viral replication so that the patient can attain and maintain effective immune response towards potential microbial pathogens. Unani adjuvants can be used to enhance immunity and prevent/reduce potential toxicity of the antiviral drugs in such failing conditions. Unani Adjuvants - To Enhance and modulate Immunity: Khamira Marwareed, Khamira abresham, Khamira gauzaban, Dawa-ul-misk. To Reduce Toxicity: Majoon dabidulward, Dawa-ul-kurkum, Jawarish zarooni, Sharbat bazoori. To enhance the strength of vital organs: Mufrah azam, Dawa-ul-misk, Yaqootiyat, Khamira sandal. 4. Cancer Treatment - The anticancer drugs are one of the most toxic drugs used in therapy. Hence, Unani adjuvants can reduce toxicity, modulate immunity and enhance vitality during prolonged periods of therapy.

Unani adjuvants: Anti-carinogenic and Radioprotective; Tulsi (Ocium sanctum); To Combat Toxicity: Sharbat Bazoori, Jawarish Zarooni, Dawa-ul-Kurkum, Majoon Dabidulward. To Restore Normal Uric Acid Level: Hyperuricaemia occurring as a consequence of rapid destruction of tumour masse and degradation of large amount of purines can be reduced by: Majoon suranjan, Hab-e-suranjan, Majoon azraqi, Qurs mufasil, Hab-e-azraqi, Habe-asgandh, Sharbat bazoori. Immunity modulation: Khamira marwareed, Khamira abresham, Khamira gauzaban. Enhancement of Power of the Vital Organs: Mufrah azam, Dawa-ul-misk, Yaqootiyat, Khamira sandal. Views of an Allopathic physician43 As an allopathic physician I have been fortunate enough to get an exposure to Ayurveda. Earlier, I was of the opinion that Ayurveda was a very primitive practice, without much data and trials in its support in an era of modern analytical medicine, having no known pharmacokinetics, mechanism of action or knowledge of adverse effects. But after getting exposure I realized that in many disease conditions it works in a much better way with least adverse effects and high efficacy. I personally feel that the negative propaganda is due to there being little research work on modern parameters and low promotion efforts and awareness building among the public. These factors have led Ayurveda to be side-lined when the treatment is cheaper and very effective in various conditions like auto- immune disorders. In the allopathic system the use of immunosuppressants is the mainstay of treatment which is full of side effects. In

43. Dr. Y.C. Sharma, MBBS; MD (Medicine), State Ayurvedic College, Lucknow, U.P.

30â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing

Ayurveda the control of symptoms is better with least side effects. To give an example, in patients with psoriasis long term remission is possible by using Ayurveda which controls the disease with least possible side efforts. Panchkarma is very effective in the treatment of arthritis and is a mode of rehabilitation. Keeping this mind I recommend, public awareness programmes be undertaken on a large scale using posters and wall paintings which clearly mention the general features and cardinal manifestations of those diseases in which Ayurveda works better. In my view Ayurveda works better when dealing with certain conditions. They are: •

Psoriasis and other auto-immune skin disorders

•

Liver disorders (Non-acute condition)

•

Urolithiasis (renal stone)

•

Arthirtis (Joints pain) (Non-infective origin)

•

IBS (Irritable Bowel Syndrome)

•

Early Type II Diabetes

•

Mental problems like depression (except acute and severe conditions)

•

Sexual problem—Like PME (pre mature ejaculation), loss of libido.

There are certain conditions where Ayurveda is effective when used in combination with Allopathy. They are: •

Auto-immune disorders-with moderate to severe conditions, to start with a combination of the two is better. This gives a promising response with regression of the probabilities of complication.

•

Moderate to severe Diabetes of both types

•

Liver disorders – acute conditions

•

Hypothyroidism management

•

Drug induced hepatotoxicity (like steroids, anti-tubercular drug, some pain killers

•

In respiratory & allergic conditionsAsthma for long term management

•

Headache & eyes problems, specially migraine

•

Hypertension and heart diseases-

for

long

term

Note: In my opinion Ayurveda may not be the first choice in acute and infective conditions but it is a good choice in chronic conditions and as maintenance therapy. Lastly, in my opinion, Ayurveda is a lifestyle modification not only a drug therapy. Adopting Ayurveda from the very beginning will markedly reduce morbidity or mortality. Views of prominent Ayurveda Faculty members44 The claims that Ayurved is a panacea for all major and minor health related ailments are over exaggerated. But that should not be understood to mean that Ayurvedic practices cannot have an independent role in health restoration or promotion. At the same time there are conditions where Ayurveda can be used to potentiate the action of modern medicine or reduce the harmful effects of strong medicine. The following are the areas where Ayurveda can be more effective and can be applied for better results:

44. Prof. Y.K.Sharma, HOD, Kayachikitsa, Ayurvedic College, Paprola. HP & Prof. Eena Sharma, HOD, Stri roga Prasuti, Ayurvedic College, Paprola. HP

Status of Integration 31

Kayachikitsa or Internal Medicine i. Non ulcer dyspepsia. ii. Constipation. iii. Irritable bowel syndrome. iv. Chronic amoebiasis. v. Chronic bronchitis. vi. Prevention of episode of asthma. vii. Infective hepatitis. viii. Chronic refractory urinary tract infections. ix. Benign Prostate Hyperplasia. x. Small renal stones. xi. Osteopenia. xii. Dyslipidaemias. xiii. Obesity. xiv. Viral infections. xv. Immunocompromised state or recurrent infections. xvi. Rheumatic pains. xvii. Insomnias. xviii. Parkinsonism. xix. Vascular headache.

Panchkarma i. Residual paralysis. ii. Muscle contractures. iii. Bellâ&#x20AC;&#x2122;s palsy. iv. Muscular dystrophies. v. Chronic arthritis. vi. Migraine. vii. Sciatica. viii. Psoriasis. ix. Chronic skin disorders. x. Low back ache. xi. Chronic asthma. xii. Chronic degenerative and neuromuscular disorders.

Bal-roga or Pediatrics i. Growth failure and failure to gain weight. ii. Recurrent respiratory tract infections. iii. Loss of appetite and eating disorders.

Prasuti Tantra/Stree Roga (Obstetrics and Gynecology) i. Dysfunctional uterine bleeding ii. Non specific Leucorrhoea iii. Intrauterine growth retardation. iv. Pregnancy vomiting of morning sickness. v. Pregnancy related constipation. vi. Pregnancy anemia. vii. Dysmenorrhoea. viii. Menopausal syndrome. ix. Preparation of birth canal in last trimester of pregnancy.

Twak roga or Dermatology. i. Eczemas. ii. Psoriasis. iii. Chronic atrophic dermatitis. iv. Chronic xerotic disorders. v. Chronic skin allergies. vi. Chronic warts and papillomas. vii. Chronic hypertrophic skin disorders.

Swasthvritta or Preventive medicines i. Diet instructions as per seasons or diseases. ii. Dincharya, Ritucharya.Anti aging Rasayanas

Shalya or General Surgery i. Piles ii. Fistulas. iii. Fissures. iv. Warts. v. Non-healing wounds.

Shalakaya or ENT & Opthalmology i. Dry eye syndrome ii. Myopia of growing age. iii. Chronic tonsillitis. iv. Chronic pus discharge from ears. v. Computer eye syndrome. vi. Allergic conjunctivitis

Aasthi-Sandhi or Orthopedics i. Delayed bone healing. ii. Osteoporosis. iii. Tennis elbow. iv. Frozen shoulder.

Evidence based Integrative Medicine benefits Lymphatic Filariasis in rural India45-Views of a Modern Medicine Physician The Institute of Applied Dermatology in Kasaragod, Kerala (IAD), has championed integration of Biomedicine, herbals from Ayurvedic medicine and Yoga. The

integrative Medicine protocol is patient led and home based care is combined with allopathy and ayurveda drugs. The Institute successfully treated over 3300 patients of Lymphatic Filariasis (elephantiasis), one of the most common and disabling diseases in India; and other common chronic skin diseases.

45. Dr. S.R. Narahari, MBBS, DVD; MD (Modern Medicine- dermatology),Director, Institute of Applied Dermatology, Kasaragod, Kerala 671121.

32â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing

Integrative Medicine evolved by studying patients who were simultaneously treated with biomedicine and ayurveda. These treatment protocols are low cost technology, accessible to most people as an outpatient regimen and safe. It is easily administered at Community Health Centre level by providing a brief training to patients and care givers in the family. With more than seven million poor persons to be treated in rural India there is little chance that Government facilities would be able to handle the need for modern surgical treatments for elephantiasis. IAD’s Integrative Medicine, pivoted on allopathy, has shown to be effective in two outreach southern Indian districts. International scientific bodies have acknowledged this medical advancement in a positive way at congresses and in their publications. We propose that multi health system teams should be taught and developed in academic medical centers and should lead hospitals to simultaneously use medicines from more than one system of medicine. Centers with experience of an evidence based integrative patient care protocol should be upgraded as training centers and provide post graduate diploma courses. Research into patient care protocols should be supported through grants and collaboration with national laboratories. Integrating Ayurveda into Mental Health The current status of mental health care under CCRAS is described below. The infrastructure available in the State of Kerala is described in the box that follows.

An Advanced Centre for Ayurveda in Mental Health and Neuro-Sciences has been functioning as a unit of the Central Council for Research in Ayurvedic Sciences (CCRAS) in the National Institute of Mental Health & Neurosciences at Bengaluru since 1971. This Ayurveda research institute has mainly worked in areas of Generalized Anxiety Disorder, Mental Retardation, Cognitive Deficit and Schizophrenia. The extent to which integration between the two approaches has taken place can be summarized as: • Sensitizing modern counter parts about the potential of Ayurveda in mental health. • Providing patient care through appropriate cross-referrals. • Interdisciplinary research involving Ayurveda, Psychiatry and allied sciences. The draft Mental Healthcare Bill 2012 prepared by the Department of Health& Family Welfare recognizes AYUSH doctors with specified qualifications (Manasrogviseshagna) among the professionals to be included under the proposed law. The registration of AYUSH professionals working in the field of mental health is to be done by the State Mental Health Authority. Ayurvedic psychiatry in Kerala46 Most of the professionals working in the field of mental health in Kerala are unaware that there is such a thing as Ayurvedic psychiatry as a small but growing field of specialization within Ayurveda. There is one government Ayurveda Mental Hospital all over India.

46. Dr. Claudia Lang, Post-doctorate Research Scholar at the Institute of Social and Cultural Anthropology, LudwigMaximilians-University Munich, Germany.

Status of Integration 33

Moreover there are three Ayurveda colleges in India which offer postgraduate courses in Ayurvedic psychiatry since the last decade, one of them being in Kerala. Apart from that, there are a few Ayurvedic doctors not trained, but who have specialized in mental disorders and working in different places in Kerala. The Government Ayurveda Research Institute of Mental Diseases or Government Ayurveda is situated in Malappuram district. It has a daily outpatient facility and general wards and provides pay wards for fifty inpatients. Patients are from different social and religious backgrounds and come from nearby villages and towns as well as from other parts of Kerala, and even from other states. In the same town, the government-aided Vaidyaratnam P.S. Varier Ayurveda College has been offering a three-year postgraduate course in ‘Knowledge of the mind and of mental disorders’ (Mano Vigyan avum Mano Rogam) or simply ‘Ayurvedic psychiatry’ as part of the Department of General Medicine (Kaya Cikitsa) since 2000. The outpatient treatment of mental health (Mano Vigyan) is continuing from 1997. The postgraduate course in psychiatry offers six seats every year for the diploma in Manasik Svasthya Vigyan (knowledge of mental health), or simply D.P.M. (Diploma of Psychiatric Medicine). Psychiatric training entails both Ayurvedic and Western theories of the mind, psychology and mental health, etiology, and treatment of mental disorders. Apart from the Ayurveda College in

34 Status of Indian Medicine and Folk Healing

Kottakkal, there are two other Colleges offering a psychiatry (Manas Roga) postgraduate qualification. One is in Hassan, SDM College of Ayurveda & Hospital, Hassan, Karnataka, offering 6 seats; the other is the Faculty of Ayurveda Institute Of Medical Science Banaras Hindu University Varanasi, Uttar Pradesh offering one seat per year. Kottakkal Ayurveda College offers free outpatient services for manasika ro-gam (mental disease) on a daily basis. Most of the patients are referred by general Ayurvedic doctors. Integrating Ayurveda into Public Mental Health in Kerala As common mental disorders such as depression are expected to become a major public health concern in the coming decades, the WHO and global health researchers are calling for scaling up services for mental disorders in the lowerand middle-income countries. While Ayurveda has been integrated into general public health schemes in India (NRHM) it does not play a significant role in the public mental health care either in Kerala or elsewhere in India. In a paper called “Mental Health Policy for Kerala State” (2000), the Kerala State Mental Health Authority (KSMHA) has plans “to start full-fledged psychiatric departments in all Ayurveda Colleges and psychiatric units in all Ayurvedic District Hospitals with minimum five beds. However, the KSMHA is not proposing to integrate Ayurvedic mental health care into the general mental health programs.

A Corporate sector Initiative with Integrative Medicine

that the modern medicine physician has little knowledge about the principles and benefits of Ayurveda/AYUSH.

MEDANTA’s Experience with Integration The PI came to know that the MedantaMedicity, Gurgoan, Haryana had incorporated Ayurvedic treatment alongside allopathic treatment in multi speciality and super speciality settings. She therefore interviewed an Ayurvedic physician at Medanta47 and the outcome is given below: PI’s questions to Ayurvedic Physician at Medanta PI: I would like to have your views on how you feel the Indian systems of medicine can be integrated in a more organized way down to the patient’s level so as to make better use of the systems. It is understood that Medanta has been offering integrated services of allopathy and Ayurvedic medicine for some years. Please describe what led to this initiative and generally what the experience has been – both relating to the receptivity of allopathic doctors and patients’ attitudes. Also please describe with the help of selected allopathic doctors what the initial reaction was to such integration. Since the PI has found scepticism and near antagonism among modern medicine professionals whenever the subject of integration came up at a policy level. How was this overcome at Medanta? What would you recommend by way of essential steps/guidelines that would reduce “rubbishing” by some modern medicine doctors? What strategies would work the best? Please suggest a set of guidelines to encourage cross referrals in the full knowledge

Response of the Ayurvedic Physician on the history of establishing the “Department of Integrative Medicine” at Medanta: GHPL the parent company of Medanta-The Medicity, headed by Dr.Naresh Trehan, had from its very inception intended to create an institution which integrates medical systems, for better clinical outcomes, reduce harmful patient interventions and cost effective medication. With this intention, GHPL named it the “Institute of Integrative Medicine and Holistic Therapies”. Later, this was renamed as Medicity, and subsequently as Medanta. In late 2006, I was engaged as a senior consultant to understand and develop the concept of Integrative Medicine (IM). I had been commissioned by Dr.Trehan to conduct a study of available data in India and elsewhere and analytically conclude on the plausibility of IM in India. The report titled “Towards integration of Medical Systems” was submitted to Dr. Trehan in April 2007 and I strongly supported the feasibility of such a project citing developments and advances across the globe. Following this a core group was constituted to formulate Integrative Medicine polices for Medanta consisting of Dr. .Trehan himself as the lead and myself as the coordinator. The other members of the team were Dr.PM Bhargava and Dr.Sanjay Mittal. The discussions aimed at seamless integration of holistic traditional therapies and modern bio-medicine, to create a new technologically advanced medical system having a holistic approach. It also decided

47. Dr. Geetha Krishnan, M.D. (Ayurveda), Senior Consultant and Coordinator, Integrative Medicine, Department of Integrative Medicine, Medanta - The Medicity, Sector-38, Gurgaon.

Status of Integration 35

Though several medical systems (all systems legally valid in India under AYUSH sector) came into consideration for integration, it was decided to initiate and experience the learning curve with one system, before venturing into others. Ayurveda was selected as the first system to be included and Yoga was defined as a technique of Ayurvedic medicine. Co-locating the Department within a common area for outpatient, therapeutic and inpatient services was one of the initial decisions.

would be evolutionary progressing from parallel practice, to Integrative medicine. We drew a patient centric path consisting of mutual discussions and collaborations between the physicians of both the systems, with reference to an individual patient. The decision of treatment relied on the confidence of the doctors of the respective medical systems. Another strategy consisted of a multi-system approach where both systems of medicine were administered concurrently, but under the guidance of one doctor as primary treating physician. We also considered inter-system protocols to cater for integrated management.

Operational guidelines on the delivery of service/offering options to the patients took more time and required a debate. Parallel practice, which is characterized by independent health care practitioners working in a common setting where each practitioner performs his job within his/ her formally-defined scope of practice had generally constituted the scope of integrative medicine in India. (e.g. CGHS dispensaries, Safdarjung, Moolchand and Holy Family Hospitals). Integrative medicine that Medanta aspired for and went beyond this approach.

Medanta established the “Department of Integrative Medicine” as a full-fledged clinical unit on 2nd October 2010. The OPD, IPD and Panchakarma facilities with appropriate manpower became operational from May 2011. At present, the patients get Integrative Medicine services, through a “cafeteria approach”, where in they select the Ayurvedic services by themselves or based on information made available by word of mouth or in-house display of information. The other route was by referrals made by collaborating doctors.

to establish the Department of Integrative Medicine to develop and institute the processes.

Medanta sought to mould itself as Boon, Verhoef, O’Hara, Findlay and Majid has defined48 An interdisciplinary team approach was built through a process of consensus building, mutual respect, and a shared vision of health. It offered care that permits each practitioner and the patient to contribute their particular knowledge and skills within the context of a shared, synergistically charged plan for care. As there was no history to follow the footsteps of, we understood that the process

The conglomerate called Medanta runs the largest private medical facility in Asia having 22 super specialties, 1250 inpatient beds, 300 simultaneous outpatient consultancy facilities and more than 5000 outpatients are catered to daily. It was decided that the Ayurveda OPD consultancy fee should be equal to that of other super specialty fees charged for neurology, oncology or cardiology consultation. Housing the Panchakarma rooms within the hospital on the lines of

48. Boon H, Verhoef M, O’Hara D, Findlay B, Majid N: Integrative health care: Arriving at a working definition. Alternative Therapies in Health and Medicine, 2004.

36 Status of Indian Medicine and Folk Healing

the therapeutic areas such as dialysis and endoscopy was another challenge. Access to all available resources of the institution were placed at par. An unbiased approach was ensured across all supportive services including administration, HR, pharmacy, nursing, HIS, IT, house-keeping, billing, laboratory, radiology, statistics and research departments. Evidence based enhancement in support facilities was provided on an evidence based criterion and not on financial results. Growing patient numbers, acceptance, efficiency and effectiveness of the integrative modalities were the key points taken into account. Interdepartmental presentations, discussions and interactions were encouraged and facilitated to improve communication and educate other departments with encouraging results. Even the billing program for Panchakarma was reinvented and suitably modified so that the bills reflected the time spent on each Panchakarma therapy. Personally I encountered few issues of egoistic reactions from biomedicine colleagues. Such episodes were few and short lived and largely from junior colleagues who had not yet understood the role the department had to play within the hospital. Generally, I have found that professionally well-established colleagues accept and embrace the integrative concept much faster and more easily. PI: Please indicate your own professional experience of interaction with modern medicine doctors at Medanta Ayurvedic Physician at Medanta: A clinical trial on integrated management of Parkinson’s disease was vehemently opposed by a very senior colleague, because there was no evidence available at the Institutional

Review Board meeting. Nor did a pharmacotherapy based approach exist. Though the project moved out of this shadow during the next review, once sufficient evidence of the supportive strength of Ayurveda was available, the doubting senior colleague turned to be one of the most fervent supporters of the integrative approach. He happens to be one of the doctors who frequently refers cases to Ayurveda. Joint disorders and GI tract disorders including liver disorders are well known to be managed through Ayurveda. Trials of integrative approaches were initially opposed by both the specialties, citing lack of evidence and lack of understanding of the medication. Separate but continuous interactions supported by research papers were discussed which finally led to simple collaborative work openings. The Department of Respiratory medicine and Sleep medicine, Division of Chest services and minimally invasive thoracic surgery, Institute of Cardio thoracic surgery, Division of Critical care, Institute of Bone and Joint Disorders, Institute of Neurosciences and the Institute of Preventive and Positive Health have been the most communicative, interactive and receptive to the concept of Integrated Medicine. In all these departments scepticism was minimal and collaborative programs could be built with considerable ease. In my opinion, the first step for eliciting positive approach from a biomedicine practitioner would be to educate him. It had been my experience that when more information is exchanged and more experience are observed it makes them receptive. The second criteria, is of course “evidence”. Creating data bases of clinical practice outcomes which the doctors know are

Status of Integration 37

authentic supported by all details, makes integration a much easier task. Experience is the third criteria, to open-up the mind sets of biomedicine practitioners to support integration. It is essential that they are allowed to meet and interact with the other system practitioners and patients. Including integrative techniques in their curriculum would be most appropriate. Again, I would like to state that the more experienced and successful the biomedical practitioners, the more open they are to integrative approaches. PI: How do you communicate with the patient, and how is the patient’s decision mediated or corrected in an ethical manner? Ayurvedic Physician at Medanta: A. Referrals: Treatment is independently administered by the Ayurvedic team. But the choice of making a referral rests on the allopathic practitioner. Decision to accept rests with the patients/patient relatives. Examples include: (i) Nonsurgical cases of lumbar disc prolapse which are referred for completely independent Ayurvedic management. (ii) Patients with post thoracotomy surgical pain–post VATS/CABG are referred to Ayurveda for completely independent management. (iii) Patients with chronic prostatic hypertrophy and having pain in the perineum are referred for pain management by Urosurgery department. B. Complementary care: Here the treatment is decided by physicians of both the systems in consultation with each other and modified based on discussions between the attending physicians of the two systems, supported by clinical outcomes observed during reviews. The choice for referral and

38 Status of Indian Medicine and Folk Healing

acceptance depends on mutual discussion between the respective physicians. Decision to accept rests with the patients/patient relatives. These cases include (i) Patients of insomnia do a specific Yoga regimen as a part of the Cognitive Behavioural Therapy program for sleep disorders. (ii) Patients undergoing radiation therapy for head and neck cancer are being referred for concurrent Ayurvedic medication and Yoga for better acceptance of radiotherapy. (iii) Parkinson’s disease patients are being referred for concurrent complementary management along with allopathic drug based therapy. C. Protocol based: Here integration is a part of a fixed protocol. All patients with a particular clinical condition undergo the predetermined integrated protocol. The choice of the protocol rests with the allopathic/Ayurvedic physician, citing valid reasons. The patient has the right to reject the integrative protocol. This is used for managing specific conditions where patients have undergone elective minimally invasive thoracic surgery. Yoga-Pranayama and Prakruti analysis pre-surgically and Yoga – Pranayama, post-surgically as part of the fixed protocol. Conclusions and Recommendations The findings from of the preceding interviews given by a range of practitioners are indicative of what can and should be done for the better integration of Ayurveda and other traditional systems into mainstream medical practice while keeping the systems separate. •

There is firstly, a need to set up a group of experts taking the cue from the Medanta example and looking to what is happening on the ground in terms of

patient preferences, to evolve a workable system that respects the patient’s choice but also guides him before he opts for integration. Without well-considered guidelines which addresses disease conditions and reactions, integration will continue to be practised without the benefit of expert advice. The group of experts need to be selected with care and it might be better to include some of the people from the allopathic side that have already been exposed to integration as otherwise much time will go in generalities. Experienced biomedical practitioners need to listen to the findings of practitioners from both the modern and Ayurvedic systems. The Committee should be headed by a medical person (like a leading pharmacologist) who preferably has been exposed to both systems. •

•

Secondly, as pointed out by Kishor Partwardhan in an occasional article at Medical education in India: Time to encourage cross-talk between different streams49 there is no official provision for cross-talk between the professionals belonging to different streams during the medical education, research or practice. This has in fact given rise “to mutual misgivings” among healthcare professionals regarding the strengths and weaknesses of each other’s work. Thirdly, more research is needed to establish the advantages or the possible hazards of adjuvant use of different medical systems. However since it will

not be practical to stop such practice which is patient driven, there is a need to introduce ASU modules in the MBBS curriculum which give an overview of commonly practiced ASU interventions. Essential information regarding herbdrug/food-drug/drug-drug interactions related to commonly used herbs/drugs/ dietary compounds ought to be a part of the module. •

The Department of AYUSH may also set up a group of experts from ASU, pharmacology, clinical research and community medicine to prepare a module containing essential information in the form of an e-book. This should also include the links and addresses of important organizations and institutions that can facilitate the acquisition of further information on the issues addressed. The module may be introduced either during the final MBBS or during the period of internship. At the same time, CCIM should come up with norms making it essential for part-time biomedicine experts to be recruited in ASU colleges to cover the biomedicine portion of the syllabus.

•

As a long-term measure, a 10-year integrated MBBS/MD/Ph.D in integrative medicine might be introduced, wherein the essentials of all major streams of healthcare systems can be incorporated alongwith a research project. This would encourage more researchers to involve themselves with the ASU systems.

49. Dr. Kishor Patwardhan, Assistant Professor, Department of Kriya Sharir, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University. Writes in his blog: http://www.kishorpatwardhan.blogspot.in/2012/09/ medical-education-in-india-time-to.html.

Status of Integration 39

Contemporary Ayurveda and Ethical Marketing of Ayurvedic Drugs Introduction Ethical Marketing is a phrase which was associated with having to keep track of the effect of using new drugs by maintaining data on drug reactions. Today it is increasingly associated with the marketing of Ayurvedic Proprietary Medicine (APMs) which targets modern medicine practitioners. It is promoted through the collection and presentation of data in ways that modern medicine doctors are accustomed to, supported by research and publications. The approach was tried by various drug manufacturers and while some gave up, the efforts which have been made by the Himalaya Drug Company (HDC) merit special mention for the reasons given. The History of Ethical Marketing of Ayurvedic Drugs During the 1950s and until the 1980s Ms. Alarsin had successfully promoted its products to both allopathic as well as Ayurvedic doctors. In the early 1970s Zandu adopted this approach and more than a fifth of the Company’s sales used to come from prescriptions by allopathic doctors. Ms Baidyanath and Charak started the strategy several decades ago which continues even today for selected brands. M/s Ajanta Pharma also entered the market of herbal APM products and at one point half their sale revenues came from ethical marketing. In the 1990s Dabur India Limited (DIL) introduced capsules and creams to be used as adjuvant therapy for diabetes, acne and

skin infections. Another small firm namely Bioved produced a single product which contained four Ayurvedic herbs that met the standards prescribed by the American Society of Rheumatology and could be prescribed by allopathic practitioners. Other Pharma firms which took this route, albeit briefly, include M/s Candilla, Torrent, Wockhardt, IPCA Labs, Raptakos Brett and Ranbaxy. Under the umbrella CSIR’s NMITLI project described in Part-I of the Status Report (chapter on Research) four products were developed, after years of research. Safety and efficacy data was also established but the drugs have still not found a significant market. Many of the firms discontinued manufacture of Ayurvedic drugs as they saw better prospects in the market for modern pharmaceuticals where the regulations are well set and the risks and vagaries involved are few.50 To a large extent Himalaya Drug Company has done much to contribute to research and development which has lead to use of Ayurvedic drugs by a wider clientele including modern medicine doctors. Several other manufacturers continue to work on similar lines and prominent names are given at Annexure-VI. Himalaya Drug Company’s Initiative in promoting Integrated Medicine Globally, the concept of integrated medicine (combining modern medicine with traditional) is gaining popularity. Himalaya Drug Company (HDC) has seized the opportunity and contemporized it. It is well known that in Ayurveda, the Vaidya prescribes drugs based

50. The preparation of this chapter was done in consultation with Dr. DB Anantha Narayana, Retired Director, Regulatory Affairs, Unilever research, Bengaluru.

40 Status of Indian Medicine and Folk Healing

on the condition of a patient and treatment varies from patient to patient. It is against the concept of Ayurveda to prescribe one drug for the same symptoms in different patients. And that is why questions are always raised about the sustainability of HDC’s approach. Yet no one disagrees that Himalaya’s innovations are backed by dedicated research and scientific validation of data. The company continues to grow and presently has a presence in 70 countries which include Russia and the CIS countries, the Middle East, the US and Latin America. This is far higher than the turnover of other pharmaceutical companies in the Ayurveda drugs sector. HDC’s flagship brand Liv-52, a hepato-protective drug, is among the top 15 drugs sold in India with an annual sale of over Rs 137 crore according to data of IMS Health (India), which tracks drug sales through distributors. HDC’s role has to be recognized for taking the initiative even in the absence of Ayurvedic Proprietary Medicine (APM) products having to prove safety and efficacy. On its own initiative HDC conducted clinical trials to prove the efficacy of the products which was the only way they could influence modern medicine doctors. It was a deliberate choice which was followed up with tenacity. HDC’s research has been published in different international journals. The first article on HDC’s product ‘Serpina” was published in 1949 in British Heart Journal and in 1953 in the New England Journal of Medicine. The other Journals where HDC research papers have been published are - Japanese Heart Journal; Australian Journal of Medical Herbalism; Asian Medical Journal; European Journal of Integrative Medicine; American Journal of Pharmacology & Toxicology; European Journal of Pharmacology; European Journal of Clinical Pharmacology; Journal of Czech Physicians; World Journal

of Gastroenterology; Antiviral Research; Yugoslavia Physiology and Pharmacology Acta; British Heart Journal; Asian Journal of Obstetrics and Gynaecological Practice; Phytotherapy Research and Phytomedicine. Some important research papers published by HDC are listed below: 1.

Effect of Liv.52, an herbal preparation, on absorption and metabolism of ethanol in humans. European Journal of Clinical Pharmacology (1991).

Influence of Abana on experimental atherogenesis in hypercholesterolaemic rabbits. Japanese Heart Journal (1993).

Evaluation of Geriforte, an herbal geriatric tonic, on antioxidant defence system in Wistar rats. Annals of the New York Academy of Sciences (1994).

Radioprotective effect of Abana, a polyherbal drug following total body irradiation. The British Journal of Radiology (2004).

The efficacy of Liv-52 on liver cirrhotic patients: A randomized, doubleblind, placebo-controlled approach. Phytomedicine (2005). Urban & Fischer, Germany

Clinical evaluation of a herbal formulation in Liver disorders. Australian Journal of Medical Herbalism, (2009).

Himalaya can therefore be considered a pioneer and a leader despite apprehensions about the loss of the holistic approach of Ayurveda. This should explain the reason for devoting a special segment to contemporary Ayurveda; also why the PI used HDC’s experience to corroborate what she had observed during her field visits because no other company appeared to be so aware of

Status of Integration 41

the trends which were easily discernible in the clinics of private practitioners. The strategies used by HDC have been summarised from an in depth interview conducted by the PI with the senior professional managers at HDC. The full interview appears later in the chapter but the main strategies which were employed to influence and involve modern medicine doctors in using Ayurvedic drugs are recounted below.

•

Referring to the Ayurvedic practitioners, HDC found that they needed to be convinced about using contemporary Ayurvedic medicine. In the case of allopathic practitioners, the challenge was of convincing them to agree to write the name of an Ayurvedic product.

•

HDC also recounted the efforts they had made to convince the Ayurvedic fraternity about the concept of contemporary Ayurvedic drugs by conducting campaigns in around 192 Ayurvedic colleges. In addition blood donation camps; quiz and presentation contests as well as regular CMEs were conducted with a view to engaging the students and faculty.

•

Ayurvedic drugs for hypertension and diabetes were promoted with relevant scientific/clinical data relating to the extent of reduction of blood pressure and blood sugar levels when used alone and along with allopathic medication. Information on drug interaction was also provided. The doctors were guided about the dosage schedule when used alone and in combination with allopathic treatment. Likewise they were advised about reduction of allopathic drugs when APM’s were introduced.

•

On the subject of the competence of modern medicine doctors’ in using Ayurvedic drugs, HDC argues that most Ayurvedic drugs are available over the counter, and as such they do not fall under the category of “prescription drugs”, under Drugs and Cosmetics Act, 1940. It is HDC’s view that an allopathic doctor is as qualified a person as any other to recommend an Ayurvedic over-the-counter drug when such a drug can be obtained by an ordinary citizen without a doctor’s

Strategies Employed by HDC to contemporize Ayurveda •

HDC began educating modern medicine physicians about the constitution of the drugs, their therapeutic actions, indications for use, limitations, and role in clinical practice.

•

According to HDC the main reason for acceptance of contemporary Ayurveda was because scientific and empirical data was presented while talking to the doctors.

•

The company took note of the fact that allopathic doctors needed to be sure of what they were prescribing. Having no knowledge of Ayurveda, it was only the data on clinical trials which confirmed the efficacy and safety of the drugs. This in turn determined whether there was willingness to place reliance on the drug. HDC found that once modern medicine doctors saw the data on the treatment of patients supported by publications in good journals they were prepared to listen. It also made a difference whether the doctors that had been engaged in the trials had a good standing in the profession. Added to this the design of the study was also important and was an important factor in deciding about acceptance.

42 Status of Indian Medicine and Folk Healing

prescription. Stocking and sale of OTC products does not require a prescription or a special license and hence nothing stops the modern medicine doctor from recommending the drugs on personal satisfaction. •

According to HDC there is definite scope for both allopathic and Ayurvedic medicines to be used together, if used judiciously. The company is of the view that it is only by encouraging the concept of contemporary Ayurveda that the world will accept the Ayurvedic system of medicine. For this it has to be presented in a scientific and contemporary manner. While conventional medicine will always play an important role in healthcare, HDC feels that through a process of evolution a new model of integrated healthcare is developing and doctors are working together to provide such treatment to patients. That opportunity needs to be responded to.

The full interview with the CEO of HDC and the Corporate Head (Legal) follows. PI’s Interview of HDC Professionals51 PI: A description of Himalaya’s experiences in modernising, globalising and integrating Ayurveda in health care may be described. HDC reply For more than 80 years, Himalaya has focused on contemporizing Ayurveda. The efforts have focused on developing products rooted in Ayurveda, but validated by modern scientific research to ensure that over time, this ancient system of medicine becomes an integral part of mainstream medicine. For this to happen, Ayurveda needs to gain

acceptance amongst the larger medical fraternity, which means, practitioners of allopathic medicine must think of it as a credible system of medicine. Way back in 1934, Himalaya developed the world’s first natural antihypertensive drug, Serpina. Derived from the plant Rawolfia serpentina, the drug had similar properties as the allopathic drug reserpine, but it came without the serious side effects associated with reserpine. This success proved that well-researched herbal medicine could offer better treatment options to patients, thus improving their quality of life. After more than eight decades, we are now witnessing the growing acceptance for traditional medicines amongst the medical fraternity. There are several reasons behind this paradigm shift: 1. Conventional medicine is unable to provide the best solutions to several ailments. 2. Side effects of allopathic medicines sometimes outweigh the benefits. Several blockbuster drugs have had to be pulled off shelves because of their dangerous side effects. 3. Increased focus on health management and preventive care – where herbal medicines are seen to play a vital role 4. Rise of traditional systems of medicine like TCM and Ayurveda, with governments trying to promote medical pluralism and medial tourism. 5. Rising cost of healthcare – and the need to explore alternative, affordable treatments. 6. Growing mindsets within the medical

51. Mr. Philipe Haydon, CEO – The Himalaya Drug Company and Julie Buragohain, Head-Corporate Legal, The Himalaya Drug Company

Status of Integration 43

community that integrated healthcare may be the preferred approach to offer holistic, treatment options. Interestingly, this transformation is happening on a global scale. For instance, in Russia, Himalaya’s Liv.52, a hepatoprotective, is prescribed as an adjuvant in the treatment of TB in government hospitals. Also, Himalaya’s product Cystone, for kidney stones, is the leading drug for this condition in Russia. In 2010, Himalaya was the only Indian company to be invited to present research papers at the International Congress on Complementary Medicine Research (ICCMR), held in Tromso, Norway. Majority of the doctors that attended this conference were from the allopathic stream of medicine, reflective of the changing mindset of the medical community. We are also seeing more doctors prescribe Himalaya products for chronic conditions and lifestyle disorders like arthritis or management of blood sugar. Allergies, respiratory ailments are other conditions being treated, and doctors are prescribing herbal formulations as the first line of treatment. Speaking the language of modern science can go a long way in building credibility for traditional systems of medicine. The main reason behind the acceptance of contemporary Ayurveda is the scientific and empirical data Himalaya presents when talking to doctors. Himalaya’s Liv.52 has over 260 clinical trials backing it. While conventional medicine will always play an important role in healthcare, what we are experiencing is the evolution of a new model of integrated healthcare, where various disciplines work together to provide the best treatment to patients.

44 Status of Indian Medicine and Folk Healing

PI’s General findings about allopathic practitioners and use of Ayurvedic Medicine. PI: Allopathic doctors rely wholly on the use of their own systems of diagnosis and treatment, but increasingly they have also begun prescribing Ayurvedic products which generally fall in the Ayurvedic proprietary medicine category. These products are usually carrying western sounding names. It appears that the practitioners have been exposed to marketing from pharmaceutical companies who have told them the benefits of the Ayurvedic drugs whether used as adjuvant therapy or as standalone drugs. Since a significant number of the practitioners seem to be relying on these products which carry the label of Ayurvedic medicine, an understanding of the trends which have developed among allopathic practitioners may be given. The extent to which a climate for medical pluralism exists may be commented upon based on the HDC’s experience. HDC reply India houses about five lakh allopathic practitioners practicing various specialties including general medicine. Majority of these doctors use their own system for diagnosis and use a combination of allopathic and Ayurvedic Proprietary Medicines (APMs) for treatment. The usage of APMs is very high in the following therapeutic categories: -

Liver diseases;

Immunomodulators recurrent infections;

Non-surgical management of urinary disorders including renal calculi;

Irregular menstruation and other problems associated with women’s

preventing

health such osteoporosis etc;

menopause,

General health maintenance – stress, obesity etc; Sexual disorders, infertility;

Long-term relief from arthritis;

GI disturbance in infants, children as well as adults;

Skin ailments – mainly in chronic conditions;

Non-surgical haemorrhoids.

management

It is very important for an allopath to be sure of what he is prescribing as he is not proficient in the field of Ayurveda. What helps him to make a right decision is the clinical documentation i.e., data on clinical trials conducted proving the efficacy and safety of these APMs. Allopathic doctors are extremely particular about proof of efficacy as well as safety that must conform to international guidelines for medical products. Apart from this, the doctor makes a decision based on previous feedback received from earlier experience. As far as regional differences in this trend are concerned, it goes back to the roots and culture of the land. For example in Kerala, Ayurveda has a very strong presence and in some parts of the State, Ayurvedic products are prescribed as the first line of therapy. In UP, which is a very strong market for Ayurvedic practice, there seems to be hardly any difference in the choice of medicine between allopathy and APMs. Allopathic doctors prescribe either or both forms of medicine, based on the condition of and suitability for an individual patient. Cost of medication is also an important criterion in UP when it comes to the choice of medicine prescribed.

The most important points that support the rise of medical pluralism are two facts: 1. The primary intention of every doctor is to heal the patient. In the face of having to provide a solution to treat chronic/difficult problems, the source of the healing agent (medicine) assumes lesser importance. 2. Deep down, every doctor is an Indian at heart and is well aware of the Indian Systems of Medicine. A well - researched herbal product is used quite easily once concerns about safety and efficacy have been addressed. Once modern medicine doctors have seen the data and tried it on some patients and if the drugs are manufactured by reputed firms or if the studies have been published in good journals, or the doctors associated with the studies have a good standing and the design of studies are of acceptable standard the products may be used by modern medicine doctors. With the Ayurvedic practitioners, the challenge is to convince them to use an APM (contemporary Ayurveda medicine). With the allopathic practitioners, the challenge is of convincing them to write the name of an Ayurvedic product. Himalaya has addressed this through scientific validation studies carefully evaluated, scientifically researched and well documented. We maintain a scientific temperament in our promotion efforts which is acceptable to practitioners from both streams. PI’s general findings about Senior Ayurvedic practitioners/Vaidyas PI: Institutionally qualified Ayurvedic practitioners belonging to the older age group working in the private sector mostly running small clinics were found to be using Ayurvedic

Status of Integration 45

single drugs (where Sanskrit/Hindi classical names are used on the label) as the first line of treatment. Diagnostic tests, x-rays and modern methods like ultra-sound and CT scan are seldom recommended by the older Ayurvedic private practitioners. If the patient gets relief, the practitioner prescribes Ayurvedic patent proprietary medicines for the next week or so for improving metabolism and debility after illness. Some older practitioners also rely on classical formulations procured from a range of pharmacies generally from South India dispensed in smaller doses from their clinics. The charges for medicine are around Rs 70100 for three days. The “consultation” is said to be free. HDC may provide their findings in relation to these observations. HDC reply Institutionally qualified Ayurvedic practitioners belonging to the older age group rely mainly on the Ayurvedic single herbs and the Ayurvedic formulations prepared locally by a known person/or prepared at an attached manufacturing unit. They try to establish the ‘Prakriti’ (constitution) of the individual and prescribe a suitable medication to treat that particular individual. Their reliance on allopathic medication is low. They may also suggest change in diet, lifestyle ‘Pathya’ to relieve the patients’ condition along with the medication. They may even suggest a series of therapeutic procedures as supportive treatment to go with medication. They are more traditional in their approach mainly treating chronic diseases like arthritis, skin diseases, asthma and sinusitis. They dispense the medicines themselves and usually the secrecy of the ingredients is maintained. They rely on APMs only in those conditions where they are not proficient in manufacturing the drugs or if a patient asks them to provide medication which

46 Status of Indian Medicine and Folk Healing

is easily administrable- usually for long travel or absence from home. Otherwise such practitioners usually ask to see the patient on a fortnightly basis to evaluate his condition before prescribing the next round of medicine. Himalaya seems to have good prescription support from the Ayurvedic practitioners of the older school as the products of HDC suit their requirements in specific therapeutic areas like arthritis, for Benign Prostrate Hypertrophy (BPH) and as Immunomodulators. HDC’s single herbs marketed as “Pureherbs” is another important category of products prescribed by senior ayurvedic practitioners. Since the quality of the single herbs is assured, it is well known that the ingredients would be pure and dependable. HDC uses HPTLC finger print testing which helps in identification, determination and validation of active compounds in each herb. Liquid Chromatography Mass Spectometry (LCMS) is another technique followed by HDC to identify the total marker profile with greater accuracy and specificity. PI’s observations about younger institutionally qualified BAMS graduates on cross – prescription practices: PI: This group of doctors was found to be using allopathic drugs, administering injections and antibiotics even as demanded by the patient. They also relied on APMs side–byside. Classical formulations in the form of arishthas, asavas and grihtas were not used much though they were stocked. They justified using injections and life saving allopathic drugs saying their training covered such practice. They appeared very confident about prescribing and dispensing medicines of both systems freely. It would appear that the trend is moving towards the use of allopathy

supplemented somewhat with easy-to-use Ayurvedic patent proprietary products-usually APMs, not single drugs or classical medicine. HDC is asked to provide their perceptions in relation to the above findings. HDC reply Younger institutionally qualified BAMS graduates are quite proficient in the allopathic (conventional) system of medicine. The reason being that a compulsory allopathic curriculum is taught to them during their BAMS course and also because they are attached to an allopathic medical college during their internship or during post graduation. The majority of such practitioners use laboratory investigations to arrive at a diagnosis. They usually use a combination of allopathic and APMs in practice. Their prescriptions are honoured and dispensed by the nearby medical store. Their practice profile would mainly includes acute diseases and rarely covers chronic diseases. HDC is a favourite among the younger generation Ayurvedic practitioners as the products and packaging can be easily prescribed and dispensed. Certain specific therapeutic products like Liv.52 group – for liver disorders, Himcocid – for hyperacidity, dermaceuticals – for common dermatological ailments are routinely prescribed by these doctors. In an effort to familiarize the concept of APMs among the Ayurvedic Medical College students, HDC has been conducting Ayurvedic Medical College Campaigns in around 192 ayurvedic colleges in India. Apart from this, activities like – blood donation camps, quiz and presentation contests and regular CMEs delivered by eminent speakers are also promoted.

Medical pluralism must be encouraged by imparting basic training to doctors relating to the Indian system of medicine. Whether to use or not to use must be left for the practitioner. PI’s question on practitioners’ use of Single herbs & Ayurvedic proprietary medicine (APM) PI: All practitioners using Ayurvedic Medicine were found to be using single drugs which are generally dispensed as capsules. These single drugs are apparently water-soluble and devoid of alcohol. The practitioner generally dispenses a three-day supply to the patient. It is not apparent whether he has received training on the dosage as the drugs have been reduced from their rough form (as in churnas) and also whether the dosage by age, sex and weight is uniformly to known them. The general picture of what is happening and whether this is a matter for concern may be commented upon. HDC reply Every single herb is a complex mixture of herbal actives and would act in balance to provide the desired therapeutic benefits. When a physician of Ayurveda prescribes a single herb drug, he is well aware that the drug he has prescribed would take a few days to show its action which is dependent upon multiple factors such as prakriti of the person, the pathya that is followed, the nature and strength of the medicine used, age, sex and other details of the patient. HDC offers a range of 27 single herbs to address various conditions. We clearly communicate in our scientific communication to the doctors that the minimum duration of therapy is three months. (Based on the condition, prakriti and requirement).

Status of Integration 47

In order to popularize the contemporary ayurvedic system among the medical college students, HDC has deputed a sales team of 150 medical representatives (M.R.), who meet allopathic medical college students, interns and postgraduates and promote HDC range of products. This is an immense financial investment on the part of HDC, as these MRs are given no targets and their sole responsibility is to promote contemporary Ayurveda and familiarize the young doctors with the product. PI’s question on how physicians of both allopathy and Ayurveda are educated about drug interaction due to cross-pathy prescriptions or adjuvant use of medicines from both streams PI: More specifically it may be indicated as to how the pharmaceutical agents are keeping the physicians informed of the constitution of the drugs and informing them about suitable dosage for different age groups. Do the product inserts and labelling carry information in different languages? Is there a concern about using drugs to reduce hypertension and blood sugar levels being taken in parallel along with treatment? What do’s and don’ts are needed for physician and patient counselling when it is well known that practitioners of the two streams–allopathic and Ayurvedic do not mingle or discuss things and hardly join the same CMEs?

have been launched in India long after most doctors have completed their education. The new information on these drugs is obviously provided by Pharma companies through their medical representatives. It is mandatory for the companies to mention both the Sanskrit name along with the botanical names (universal) of the constituents of the products. All labels and promoted literature from HDC features the Sanskrit and the botanical name of the important herbs present in the APMs. APMs for hypertension and diabetes are being promoted with all the relevant scientific/clinical data. This includes extent of reduction of blood pressure/ sugar levels when used alone and with the corresponding allopathic medication along with information on drug interaction. Adequate education of the doctors has to be carried out to guide them on the dosage schedule when used alone and in combination with allopathic treatment. It is also essential for the pharmaceutical companies to inform the doctors on the dosage reduction of the allopathic products when APMs are added, whenever necessary. At HDC, we promote, a polyherbal antihypertensive drug to doctors of both the streams of medicine. We communicate the following: -

Mode of Action of Abana

Reduction of dosage of beta blockers and diuretics when prescribed with Abana

Comparative trials with Propranalol, a beta blocker

HDC reply It is the sole responsibility of the pharmaceutical company to educate the physicians on the constitution of the products they manufacture, their therapeutic actions, limitations, indications and role in clinical practice. This holds true for both ayurvedic as well as allopathic companies. The logic is clear, a large number of breakthrough drugs

48 Status of Indian Medicine and Folk Healing

We also promote two products for the management of type II diabetes. The efficacy and safety of the products has been proven by a Meta analysis study also. While promoting the drugs we communicate that:

The drugs can be prescribed as monotherapy and also as an adjuvant to Oral Hypoglycemic Agents (OHAs) and insulin.

Alloveda – Published by HDC with IJCP group of publishers to promote the knowledge of Ayurveda among the allopathic doctors

Reduction in Hb A1c52 are indicators of reduction in glycemic levels used both as monotherapy and as an adjuvant

Pediritz – Aimed at bringing out the latest in pediatric arena

Perinatology – A journal dedicated to perinatal and neonatal care – aimed at gynaecologists, paediatricians and neonatologists

Himalaya Infoline – to propagate the latest happenings in the medical field among Ayurvedic medical college students.

Dosage when prescribed alone and also as an adjuvant is clearly spelt out.

Dosage reduction required in OHA and insulin when prescribed along with the Ayurvedic drug.

HDC also conducts a series of CMEs titled – Doctor Meet Programs with renowned physicians as speakers to help the Doctors to understand HDC products. These meets are attended by both Ayurvedic practitioners and allopathic practitioners. In an effort to familiarize the doctors on the latest developments in various therapeutic categories, and also on our product range and the outcome of clinical trials, HDC publishes several journals and newsletters as follows: -

Probe – Aimed at top practitioners – successfully published from last 50 years

Capsule – Aimed at General physicians to update them on recent developments in various medical fields and also on our products – also completed 50 years

Livline – Aimed at promoting knowledge, research and information on liver health

We also carry out High Visibility Campaigns through our pharmaceutical medical representatives. These campaigns are carried out at Doctor chambers and through medical associations. Inputs used are as follows: -

Patient information leaflets – 12 regional languages, 25 disease areas, reach out to almost 2 cr population every year

Patient information posters - 12 regional languages, 15 disease areas, reach out to almost 2 cr population every year

Patient group meets o

Jagriti – An initiative by HDC for enhancing the importance of healthcare among women of various strata

IDEA – An Initiative on Diabetes Education and Awareness among working professionals.

52. HbA1c – Glycosylated haemoglobin. It is a lab-test shows the average level of blood sugar (glucose) over the period of 3 months.

Status of Integration 49

PI: HDC may comment on policies and strategies which can enhance the acceptance of Ayurvedic medicine and improve knowledge about its efficacy.

confusion and scares doctors. News items, like the one below, creates a negative impact.

HDC reply The choice to prescribe an APM should ideally be left to the doctor. The doctor should be free to prescribe the APM if he is satisfied with the quality, safety and efficacy of the product that he is prescribing. Longterm market standing, clinical trial reports, personal, previous experience with the product should be the basis on which the doctor should be deciding on the medicine and not on which stream the drug is from. In today’s world there is a definite scope for both allopathic and Ayurvedic medicines, if used judiciously. Encouraging companies that are working in the field of contemporary Ayurveda is the only way the world will accept this system of medicine. For this it has to be presented in a scientific and contemporary manner. HDC feels that the idea that ‘herbal/ ayurvedic” medicine should be left exactly the way it has always been, is redundant. If the management of blood pressure in the allopathic school of medicine which is only a few hundred years old can dramatically shift from bloodletting to countless new molecules why can’t there be modernization of a 5000 years old science? PI: HDC may comment on legal issues and prevailing court orders and HDC’s experiences with both. HDC reply The biggest problem is with regard to various sporadic news reports that creates

50 Status of Indian Medicine and Folk Healing

As we are aware Ayurvedic Drugs DO NOT require a prescription for sale. However, the above news article wrongly mentions that in UP, on orders of the Hon’ble Supreme Court, Cheif Health Secretary Sanjay Aggarwal has written to all District Officers and CMOs to take strict action against the Allopathic doctors prescribing Ayurvedic Drugs. Similarly, the report erroneously mentions that the Ayurvedic, Unani and Homeopathy doctors have been completely banned from using allopathic drugs. This is an example of irresponsible news reporting that hampers our reputation. In other words, through this news article, it would imply that the doctor’s driver can buy Liv 52 but if the doctor himself prescribes Liv. 52, he goes to jail! We would appreciate it if news articles were published with better insight on matters at hand. Such news is a clear case of misinterpretation of the Honourable Supreme Court orders. The correct stand is that it is completely legal to obtain Ayurvedic Drugs since Ayurvedic Drugs are non prescription drugs and they do not require prescription for sale or for purchase. The reasoning behind this judgement was

that so far as Allopathic drugs which were sold across the counter for common ailments were concerned, no deep knowledge in regard to these drugs was necessary, even for practitioners of other systems of medicines like Ayurvedic or Unani, etc, and it was open for them to prescribe and administer those Allopathic medicines which were sold across the counter for common ailments. In this case, the Court did not treat different systems of medicines as being water-tight compartments with no overlapping. As you may be aware, Ayurvedic drugs are available over the counter, as they do not fall under the category of â&#x20AC;&#x153;prescription drugsâ&#x20AC;?, under Drugs and Cosmetics Act, 1940. . Thus, the allopathic doctors would be fully entitled to prescribe such drugs of which they have sufficient knowledge from the literature relating to those drugs available in the allopathic medical literature including various medical journals of allopathic medicines. If a drug, even if it is of Ayurvedic origin, has been tested and clinical trials have been performed on that drug by allopathic doctors and the reports of those trials are contained in medical journals covering allopathic medicine, it would clearly demonstrate that such drugs have become a part of modern Allopathic Medical Practice. It would therefore be totally incongruous for anybody to contest that merely because the origin of a drug was in an ancient system of medicine; it is not legally permissible for Allopathic Doctors to prescribe that drug. It would only be logical to further conclude that, an allopathic doctor is as much qualified person to prescribe an Ayurvedic over-the-counter drug which otherwise

could be obtained by an ordinary citizen who is a layman in the field of medicine, by mere asking at the counter of a medicine store or from any general store, since stocking and sale of these OTC products does not require any special license under the Drugs and Pharmacy Act. A non-allopathic doctor is restrained from administering allopathic medicine because of the serious side effects the allopathic medicines have; whereas an Ayurvedic Medicine does not have such adverse side effects. It is for this reason that most of the Ayurvedic medicines are not scheduled drugs and are available to patients directly without any prescription. Hence, it would be erroneous and draconian to contend that a drug, which could be prescribed by a patient himself, cannot be prescribed by an allopathic doctor who is well qualified because such an understanding would be adverse to public health and against public interest. Conclusion and Recommendations Since it is evident that the market has already determined an important way in which Ayurveda is being practised, it is time to take note of these developments. It is quite apparent that the adoption of Ayurvedic drugs depends to a significant extent on the acceptability by the doctors of the dominant medical system. Therefore the route followed by HDC, and some others needs to be taken note of together with what is happening among the younger generation of practitioners who are the products of Ayurvedic colleges. If integration is already being practised through the adjuvant use of the drugs in addition to traditional practice, a lesson has to be taken

Status of Integrationâ&#x20AC;&#x192; 51

from the experience. Whereas it is apparent that real integration has not taken place in most government health facilities, it has steadily become a reality within a significant group of modern medicine practitioners. It is therefore necessary to learn from this integration and use the experience to advantage.

52â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing

When an expert group is set up to look into aspects of practical integration, it would be useful to take note of the strategies that have been used by the private sector. Ultimately everything seems to depend on the quality of clinical research that is conducted and the respect attached to publications in good journals.

Annexure-I Roadmap for Mainstreaming of AYUSH under NRHM-Joint letter of Secretary, Department of Health and Secretary, Department of AYUSH to all States

Status of Integrationâ&#x20AC;&#x192; 53

54â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing

12th August 2005

Status of Integrationâ&#x20AC;&#x192; 55

Annexure-II Joint Letter of Secretary, Health and Secretary, AYUSH to States

56â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing

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Annexure-III Minutes of the Meeting on Approach to Part II of the Status Report held on 9th December 2011at 2.30 pm in the CCRUM Conference Hall, Janakpuri, New Delhi List of Officers/Experts attended the Meeting 1.

Smt. Shailaja Chandra, Principal Investigator Former Secretary, Ministry of Health & Family Welfare, Department of AYUSH and Former Chief Secretary, Government of Delhi E-mail:shailajachandra1@gmail.com

Prof. S. Shakir Jamil, Director General CCRUM, New Delhi E-mail:unanimedicine@gmail.com

Dr. Ramesh Babu Devalla, Director General CCRAS, New Delhi E-mail:dg-ccras@nic.in

Dr. Shoeb Qasmi, Director, Directorate of Unani Services 9th Floor, Indra Bhawan, Lucknow (Uttar Pradesh) Phone:0552-2288515 Mobile: 09935372566

Dr. Kabir Dar, Director, Indian Systems of Medicine & Homoeopathy Srinagar (Jammu & Kashmir) E-mail:drkabir@rediffmail.com, dismjk@gmail.com Mobile: 0941206656

Dr. Khalid M. Siddiqui, Asstt. Director (Unani) CCRUM, New Delhi

Mr. Mehr-e-Alam Khan, Consultant (Portal) CCRUM, New Delhi E-mail:mehrealamkhan@gmail.com Mobile:09810606784

Researchers/Practitioners of Unani Medicine from different States 1.

Dr. Arsheed Iqbal, Research Officer (Unani) RRIUM, Hazratbal, Srinagar (Jammu & Kashmir) E-mail:iarsheed@yahoo.com Mobile:08941907838/ 09419078302

Dr. Maqbool Ahmad, Assistant Director (Unani) CRIUM, Lucknow (Uttar Pradesh) Mobile: 09415547368

Dr. Mohammad Haroon, Private Unani Practitioner Village: Mustafabad ,Near Jwalapur,Distt. Haridwar (Uttarakhand) E-mail:haroonalig1@gmail.com Mobile:09716478542

58â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing

Researchers/Practitioners of Ayurveda from different States 1.

Dr. Ramji Singh, Assistant Director (Ay.)/In-charge Central Research Institute (Ayurveda) Lucknow (Uttar Pradesh) E-mail:vari.lucknow@gmail.com Mobile:09415890486

Dr. Om Raj Sharma, Assistant direct (Ay.) Ayurvedic Regional Research Institute (ARRI) Mandi (Himachal Pradesh) E-mail:dr.omsharma.mandi@gmail.com Mobile:09418073962

Dr. Sarada Ota, RO (Ayu) CCRAS, New Delhi E-mail:sarada_ota@yahoo.com, Mobile: 9810425662

Dr. Banamali Das, Research Officer (Ay.) National Research Institute of Ayurvedic Drug Development (NRIADD) Bhubaneswar (Odisha) E-mail:banamali.d@gmail.com Mobile. 09439956684

The Principal Investigator thanked the DG CCRUM and DG CCRAS for supporting her efforts by convening the meeting and inviting key officers/ practitioners to give their views at the meeting. She explained the objective of Part II of the project she was researching after giving the background of the project and the work done so far. The PI clarified that the generic recommendations already covered all states and in Part II she was adopting a different approach. A.

Department of AYUSH had already written to 15 states in the North, East and North-Eastern parts of the country asking them to support the PI in her work. The Principal Investigator had subsequently requested the selected states to draw up a plan which covered the following: (i) Giving her access to policy initiatives that the state has taken to popularize ISM/ Ayurveda/ Unani Medicine, particularly initiatives which would be worth sharing with other states. (ii) An itinerary to visit selected institutions or practitioners in the Government or private sector where unique work which is accessed by the public in large numbers could be observed. (iii) To gather an understanding of the conditions in which medicinal plants are sourced and folk healing is being practiced.

The PI indicated that the list of practitioners/institutions/clinics would be shared with the State Government so it is desirable that the selection is made giving justification for the same. It was agreed that this would be done by 31st December 2011 and mailed to the PI care of: â&#x20AC;˘

Dr MAH Jamali who was assisting the PI. The address was Room 502, Central Council for Research in Unani Medicine, 61-65, Institutional Area, Janakpuri, New Delhi110058.

Status of Integrationâ&#x20AC;&#x192; 59

•

To avoid back references, it would be necessary as far as possible for the officers attending the meeting to provide a joint programme as PI would be covering the State in one visit.

Similar efforts would need to be made to identify tribal folk healers and collectors /traders of the medicinal plants in the State of Jammu & Kashmir, Uttarakhand and Himachal Pradesh. A descriptive account of the ground situation can be included in the Report by the PI.

It was also indicated that there are many Unani and Ayurvedic practitioners who are being accessed by patients who are already undergoing allopathic treatment. Occasionally this was done as a part of overall hospital treatment in an organized way as reported briefly by the PI in Part I of her Report. Often adjuvant treatment is given by the Unani/Ayurvedic practitioners at the request of the patients themselves who inform the practitioner about the allopathic treatment and medication being taken. Documentation about a crosssection of typical cross consultation would help clarify the extent of this approach seen as a part of patients’ choice. It was clarified by the PI that this was entirely different from the concept of cross prescription which was not allowed. Rather it related to an important area which was cross-consultation by the patient who was seeking adjuvant therapy, a practice which is widely used but has never been documented. It was decided that representatives that attend the meeting would prepare documentation on this subject so that the Report reflects patients’ attitudes and related factors. Through Part II of the project this aspect can be covered in greater detail which would give an idea of public preferences and ground realities. DG CCRAS said a proforma could be devised and Dr Sarada Ota of CCRAS undertook to provide a simple format.

It was decided that the PI would have letters prepared for each identified state and these would be sent to the offices of DGs of CCRAS and CCRUM for onward transmission to the concerned officers for follow-up. A copy of the letter sent already to the states was attached and hard copies would be sent on receiving a fax number.

In addition to the above they would also take care of the liaison with the state governments to collect documentation on policies, strategies and initiatives which had been initiated which would fall in the area of “best practices” and which should be included in the Project Report for the knowledge of other states.

Shailaja Chandra Principal Investigator 19th December, 2011

60 Status of Indian Medicine and Folk Healing

Annexure-IV Questionnaire to Investigate the extent of Adjuvant AYUSH Therapy with Patient Responses Specified Target Study (1000/5C/09.102012/45 Days) Centre……… Objectives: 1. To investigate the extent of adjuvant use of Ayurvedic medicine. (Used in addition to allopathic treatment) 2. To analyze patients’ reasons for seeking Ayurvedic treatment as an adjuvant therapy for treating different diseases/conditions. 1.

Name of the Patient: ____________________ Age/Sex:________________________

Marital Status:

i) Married [ ] ii) Unmarried [ ]

Social Status:

i) BPL [ ] ii) APL [ ] iii) Average [ ]

Education Status: i) Illiterate [ ] ii) Up to Primary [ ] iii) High School [ ]

iv) College and above [ ]

Disease: _____________________________________________________________

Duration of Illness: ____________________________________________________

Diagnosis of Allopathic doctor/Hospital

Patient’s Reasons for seeking adjuvant Ayurvedic/Unani treatment/therapy: •

Allopathic drugs have side effects and Indian Medicine (Ayurvedic system of natural.)

•

To avoid surgical procedures eg stone, etc.

•

To improve quality of life and mitigate symptoms.

•

To get second opinion

•

Allopathic system of medicine does not suit to patient.

•

Dosage of allopathic medicine can be reduced by taking Ayurvedic medicine.

•

To avoid expensive diagnostic procedures.

•

To avoid injections as a mode of drug administration.

•

To avoid hospitalization Attending Officer Date: .................

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Annexure-V List of Experts/Faculty/Practitioners who commented on Survey outcomes on the Adjuvant use of AYUSH DG, CCRAS and CCRUM also attended the workshop and participated in the discussions. Unani Experts 1.

Hakim MS Usmani Formerly Senior Faculty & Senior Physician A&U Tibbia College, Karol Bagh, New Delhi

Hakim AJ Khan Formerly Senior Faculty & Senior Physician A &U Tibbia College, Karol Bagh, New Delhi

Hakim Raisur Rahman Professor A &U Tibbia College, Karol Bagh, New Delhi

Hakim Anwar Ahmad Formerly Senior Faculty & Senior Physician A &U Tibbia College, Karol Bagh, New Delhi

Ayurveda Experts 1.

Dr. HC Gupta Associate Professor (Deptt. of Kayachikitsa) A &U Tibbia College, Karol Bagh, New Delhi

Dr. Praveen Choudhary Associate Professor (Deptt. of Shalya) A &U Tibbia College, Karol Bagh, New Delhi

Dr. Prabhakar Rao CMO ESI Dispensary, Nand Nagri, New Delhi

Dr. Mamta Ralhan SMO BRD Ayurvedic Clinic Rajouri Garden, New Delhi

Dr. Sathyanarayan Dornala SMO MCD Ayurvedic Dispensary Krishna Nagar, New Delhi

62â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing

Annexure-VI List of leading Pharmaceutical Companies engaged in manufacturing Ayurvedic Medicines S. No. PHARMA 1. Dey’s pharma 2. 3. 4. 5. 6. 7. 8.

Albert David Merrind pvt Ltd (Wolkhardt) Ind swift Pvt Ltd Vouge Pharma Panacea Biotec Elan Pharma TTK Healthcare

9. 10. 11. 12. 13. 14. 15. 16.

Teresa Healthcare (Lincoln Pharma Anglo-French Drugs Concept Pharma Meyer pharma Venus Pharma Xebac Drugs Indoco Remedies Ind-Swift Ltd

17. 18.

Psychotropics India Ltd (PIL) National Chemical & Pharmaceuticals Work Pvt Ltd Serum Institute of India Ltd Prithvi Wedge Healthcare Lupin Herbals Universal Medicaments Pvt Ltd Apex laboratories. Chennai.

19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

Emmessar Biotech, Mumbai. Franco-Indian pharmaceuticals, pvt. ltd. mumbai. ADFAC Laboratories Pvt. Ltd. Hyderabad. Raptakos, Brett&co. Ltd Mumbai. ATRIMED Pharma,Bangalore. Carpo Labs.Bangalore. Phyotonova, Mumbai. Alembic Ranbaxy Laboraties Cipla Bestochem Centaur Pharmaceuticals pvt ltd Mumbai

Main Products I-tone eye drops, Herbodil cough syrup, Cap Trasina, Livina Syrup Cap&Syurp Adliv, Siotone Syrup, Siocare Immu mod Cap Arthrill, Cap Cirroliv Vogliv Syrup, Cap Chargin Tab Thank OD Elagesic liniment, Enzyplex Syrup, Honeykool Syrup Tefroliv Forte syrup & Tablets, Delivera cream, Lactone Granules, Cap Lukare, Syrup Utrinorm, Tab Virilex, Tab Mustong UT-Tone syrup Hepax Syrup Cap Ajar Kidicof cough syrup, Lycoprost Septiloc lotion Arthobak Apispur syrup Cap Anaproct, Cap Distone, Livasa Syrup, Krisma syrup, Cap Krisma Plus, Cap Gasgon, Cap Arthril Forte, Benprest-8, Syrup Cirrholiv, Cap Vigrovit Forte Biligaurd Syrup, Tab Menovit Cap Volken Cap Simrose Efive IQmem Syurp, Karnim Capsules Cap Clearliv, Cap Diazen, Cap Immunit, CapTriglize, Syurp Femigard Gold, Bestlin ointment. Cap Supportt Joint. Syurp Stimuliv &Tablet. Cap Hispo, Cap Pilogaurd, CapSedia, CapDer-9, Cap RegMen, Cap Cindi, Cap Neurotip, Cap Rapokostat &Vaginal Gel. Cap Aclear & gel Cap. Vathapy. *** Branch of Charak Pharma Cap & Syrup NewLivfit Eatease, Olesan Gel X-pain balm, Paincid oil Bestogesic oil, Glowsun syrup Syrup Kofarest, Syrup Livosil-H

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