STATUS OF INDIAN MEDICINE AND FOLK HEALING With a focus on integration of AYUSH medical systems in health care delivery Part II
Shailaja Chandra
Former Secretary, Government of India Ministry of Health & Family Welfare Department of AYUSH and Former Chief Secretary, Government of Delhi
Under the aegis of Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) Ministry of Health & Family Welfare Government of India FEBRUARY 2013
Front cover: Collage of medical manuscripts in Sanskrit, Tamil and Arabic Back cover: Holy basil (Ocimum sanctum)
Intellectual property rights of this report rest with Department of AYUSH, Ministry of Health & Family Welfare, Government of India and Shailaja Chandra, former Secretary, Government of India and former Chief Secretary, Delhi
Printed at: India Offset Press A-1, Mayapuri Industrial Area, Phase-I New Delhi – 110 064 (India)
ii  Status of Indian Medicine and Folk Healing
Contents Acknowledgements
vii
Officers, Experts and Stakeholders Consulted
xi
Abbreviations and Acronyms
xxi
Executive Summary
xxvii
Summary of Major Findings and Recommendations
xxxv
Chapter 1: Status of Integration
3 – 63
Health Seeking Behaviour and Medical Pluralism
3
Congruence of Traditional and Modern Medicine
14
Status of Adjuvant Use of Ayurveda and Unani Medicine
22
Contemporary Ayurveda and Ethical Marketing of Ayurvedic Drugs
40
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
53
Annexure-II: Joint Letter of Secretary, Health and Secretary, AYUSH to States
56
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
58
Annexure-IV: Questionnaire to Investigate the extent of Adjuvant AYUSH Therapy with Patient Responses
61
Annexure-V: List of Experts/Faculty/Practitioners who commented on Survey outcomes on the Adjuvant use of AYUSH
62
Annexure-VI: List of leading Pharmaceutical Companies engaged in manufacturing Ayurvedic Medicines
63
Chapter 2: AYUSH in Selected States - Findings from Field Visits
67 – 140
Odisha
67
Uttar Pradesh
75
Andhra Pradesh
91
Himachal Pradesh
102
Jammu & Kashmir
111
States Consulted (Bihar, Uttarakhand, West Bengal)
118
Contents iii
Annexures:
Annexure-I: List of Officers who attended the meeting chaired by the Commissioner-cum-Secretary, Health and Family Welfare, Government of Odisha at the request of the PI
121
Annexure-II: List of Faculty members the PI met at AK Tibbiya College, AMU, Aligarh
122
Annexure-III: Treatment of choice in Ayurveda and Unani for Common Disease Conditions
123
Annexure-IV: Letter of the PI to Principal Secretary, Andhra Pradesh
128
Annexure-V: List of Faculty and Staff PI met at the Rajiv Gandhi Government PG Ayurvedic College and Hospital, Paprola
130
Annexure-VI: Letter sent to the Health Secretaries of West Bengal, Uttarakhand, Bihar and Madhya Pradesh
131
Annexure-VII: Questionnaire sent to the Health Secretaries of States
132
Annexure-VIII: Anubandh for AYUSH doctors in Uttarakhand
135
Chapter 3: Postgraduate Education in Ayurveda – Filling the Gaps
143 – 149
Chapter 4: Building Credibility for Panchakarma
153 – 160
Chapter 5: A Study of Selected State Pharmacies
163 – 175
Annexures:
Annexure-I: Grant in Aid released to States/UTs under the Centrally Sponsored Scheme for Quality Control of ASU&H drugs from 2000-01 to 2011-12 (in Rs. lakhs)
173
Annexure-II: Questionnaire for Preparing Status Report on Government Ayurvedic Pharmacies
174
Chapter 6: Regulatory Framework for ASU Drugs
179 – 201
Annexures:
Annexure-I: Letter of Secretary, UP to all the CMOs regarding harassment faced by the ISM practitioners in the State
194
Annexure-II: Court order on the issue of Inter-disciplinary Cross-practice in UP
195
Annexure-III: Ministry of Health & Family Welfare’s notification regarding practice of Gynaecology & Obstetrics and Diagnostic Ultrasonography by ISM Graduates
197
Annexure-IV: Himachal Government’s circular allowing ISM practitioners to use modern medicine
198
Annexure-V: Directorate of ISM, J&K Circular regarding “Prescription of Allopathic Medicine by AYUSH Doctors”
199
Annexure-VI: Proposal of J&K Department of ISM to notify the use of essential allopathic medicine by AYUSH doctors
200
iv Status of Indian Medicine and Folk Healing
Chapter 7: Guru-Shishya Parampara – A Critique of the Rashtriya Ayurveda Vidyapeeth
205 – 222
Annexures:
Annexure-IA: Recommendations of the Review Committee of Department of ISM, Government of India which had reviewed the performance of RAV
213
Annexure-IB: Recommendations of the International Management Institute, New Delhi on the future growth options for Rashtriya Ayurveda Vidyapeetha (RAV), New Delhi
215
Annexure-II: Details of Gurus and Shishyas associated with RAV since the time of inception
217
Annexure-III: Covering letter of the PI with Questionnaire issued to MRAV/CRAV alumni/Shishyas
218
Annexure-IV: List of Gurus and Shishyas who responded/ did not respond
220
Chapter 8: National Institute of Indian Medical Heritage (NIIMH) – A Historical Overview and Major Contributions
225 – 231
Annexure:
Annexure-I: Research Activities Reported in NIIMH Bulletin/Journal, 1963-2009 Chapter 9: Folk Healing Practices of the North East
230 235 – 265
Annexures:
Annexure-I: Letter of the PI to the Director of North East Institute of Folk Healing
263
Annexure-II: Questionnaire on the Practice of Traditional Medicine and Folk Healing in the North Eastern States
265
Chapter 10: Ayurvedic Veterinary Products – Status and Future Prospects
269 – 273
Chapter 11: Initiatives with a Difference
277 – 279
Chapter 12: Transformation Needed
283 – 286
Contents v
Acknowledgements When Part I of this report was written I had acknowledged the contribution of scores of people who had helped me in big ways and small. What follows are a few repetitions but many more additions. Under the Presidentship of the Honourable Minister for Health and Family Welfare, Shri Ghulam Nabi Azad as the President of CCRUM I continued to receive whole-hearted support from the Department of AYUSH and the Research Councils particularly from Unani Medicine and Ayurvedic Sciences. Headed by the Union Secretary (AYUSH), Shri Anil Kumar the Department’s officers gave me access to data and information without which it would not have been possible to have delved down to the root of so many subjects. The Secretary was always accessible whenever I requested to meet him and shared his thoughts with candour. I am grateful to stalwarts like Prof. Valiathan, Prof. Ranjit Roy Chaudhury, Prof. RH Singh who gave me the benefit of their valuable advice which has been acknowledged in the report. I must also mention the part played by Dr. SP Aggarwal, the former Director General Health Services, Ministry of Health & Family Welfare who grounded his remarks in down-to-earth wisdom on what was possible and practical. Shri Bala Prasad (then the only Joint Secretary in the Department), put me in touch with the right persons which facilitated my work greatly. In particular Dr. DC Katoch was one person who provided information by return e-mail within minutes. Of greatest value were the official letters of introduction sent to the State Governments which enabled me to observe and record the ground realities. The Director-General of CCRUM Professor Shakir Jamil continued to extend the support of the whole institution and enabled me to hold two joint meetings of the two Research Councils for Unani and Ayurvedic medicine where numerous experts, faculty members and practitioners of both systems gave me the benefit of their advice. Dr. KM Siddiqui, Deputy Director in CCRUM did the behind the scenes work for the meetings and also drew up and time-tuned the travel itineraries for my visits to different States. Without this, it would have been difficult to have synchronised meetings with so many people at so many places. He also provided me the services of a statistician Shri Zameer Ahmad who assisted me in assembling the statistical portions of the report. Dr. Ramesh Babu Devalla, the Director General of CCRAS continued to extend invaluable support, chiefly by finding the right person at each juncture who could give the technical support that I needed. Because of this I was able to get useful base papers prepared by Dr. N Srikanth, Dr. Sarada Ota and Dr. Pradeep Dua - all from CCRAS who helped me to assemble the facts for three chapters. The role of several officers from the National Institutes under the Department of AYUSH must also be placed on record. Among these I recall Dr. V V Prasad, Director, Rashtriya Ayurved Vidyapeeth because of his brevity with words but capacity to deliver on promises.
Acknowledgements  vii
Dr. Ajay Kumar Sharma, the Director of the National Institute of Ayurveda was good enough to assign four faculty members to help me to get a study on selected State pharmacies done, when I was about to abandon the idea. Shri Otem Dai, the Director of the North-Eastern Institute of Folk Medicine went out of his way to help me to prepare the chapter on folk medicine in the North-East with enthusiasm. He assigned a resourceful Senior Research Officer Shri Hemen Hazarika to coordinate the work. The work was organized despite many parts of the North-East being affected by torrential rain and floods and the Internet system remaining out of commission for several weeks at a stretch. Before the work relating to the interface of AYUSH and NRHM was undertaken, I had requested Dr. Ritu Priya, Professor, Center of Social Medicine & Community Health, Jawaharlal Nehru University (JNU), former Advisor, Public Health Planning (NHSRC) to help unravel her own report on 18 States. Dr. Priya gave me the benefit of briefing me through her experience and introduced me to Dr. Shweta also an Ayurvedic doctor who walked me through the report with enthusiasm. A very special mention needs to be made of the Principal Secretaries in charge of AYUSH Shri K Ratna Kishore in Andhra Pradesh, Shri J P Sharma in U.P., Shri Ashok Shekhar in Rajasthan, Shri Ali Raja Rizvi in Himachal Pradesh, Smt Anu Garg in Odisha and Shri M K Dwivedi in Jammu and Kashmir, all of whom went out of their way to make my visits to their States as meaningful as possible. In Andhra Pradesh Dr. Srivasuki held charge as the Commissioner AYUSH and accompanied me during most of my visits to the facilities in Hyderabad. The State Directors of Ayurveda/Unani/ ISM who gave me immense support in different ways include Dr. KR Kohli from Maharashtra, Dr. Raksha Goswami, Director Ayurveda and Dr. Shoeb Qasmi, Director (Unani)-both from Uttar Pradesh, Dr. PS Draik from Himachal Pradesh and Dr. Kabir Dar from Jammu & Kashmir. All of them wanted to see the project succeed in the interest of the systems and used their personal contacts and initiative to pack in as much as possible, including gracious hospitality . Several other State officials from the departments of Ayurveda and Unani medicine looked after me and their resourcefulness must be acknowledged. Among these I will always remember Dr. Narendra Hota, the State Research Officer for AYUSH in Odisha, Dr. Ramanna, Regional Deputy Director, AYUSH in Andhra Pradesh along with Dr. Satya Prasad, the Principal of BRKR Ayurvedic College, Hyderabad for arranging the visits with enthusiasm and imagination. I also recall with warmth the tremendous support given by Dr. A.A. Hashmi, Deputy Director Unani in Uttar Pradesh. Dr. Nuzhat Manzoor and Dr. Shabeer Ahmed Gaffari from J&K accompanied me to innumerable health facilities with meticulous planning. Although the programme included several scheduled meetings and the distances to be covered to different districts were long, they took care of every detail so that I could spend limited time fruitfully. Likewise, Dr. Om Raj Sharma, Research Officer of CCRAS at Mandi accompanied me during my entire visit to Himachal Pradesh and his personal contacts and friendly approach provided me with rare insights. Thanks must be given to numerous people who helped me at the back end without whose help this report could never have been completed. To start with, I am grateful to Dr. Sathyanarayana Dornala who coordinated the amalgamation of the chapters using his dexterity with computer
viii  Status of Indian Medicine and Folk Healing
applications and knowledge of people, places and happenings to make useful suggestions. That most of the work could be done on e-mail across the country and also across continents and oceans (when I was overseas) reflects his quick understanding. I was assisted throughout by a young BAMS graduate Dr. Anubha Yadav who despite her youth and relative inexperience made up through her quick comprehension, willingness to learn despite being buffeted with constant instructions. That she could measure up to the most exacting standards which I laid down and also maintain enormous documentation systematically, speaks volumes for her potential. She is a gem of a girl. Behind the scenes, Shri Dilawar Singh, Administrative Officer at CCRUM, his assistant Shri Arya, Accountant maintained all my accounts and rid me of so many tedious but essential responsibilities. Shri Humayun, the ever-helpful PA to the DG asssisted me in innumerable ways, always smiling and never putting off anything he could accomplish even to the next minute! A rare virtue. I also acknowledge the support of Shri Ajay Nirwal who looks after the office of the Chairman of the Delhi Public Library - a position I hold in an honorary capacity. In the end, I depended on Shri Mehr-e-Alam Khan, Consultant (Portal) at CCRUM, who enabled me to turn sheaves of unruly paper into an organized report despite his several pressing commitments. If editorial mistakes remain, I am at fault. I hope the report will be found useful and will be disseminated to the State Governments along with copies of Part-I of the Report. The findings and recommendations given in the Report are my own and do not reflect the views of the Department of AYUSH. This has been an exciting learning experience for me and one that I will always treasure. My grateful thanks to all those who made it possible. Shailaja Chandra Principal Investigator and Former Secretary, Government of India & Former Chief Secretary, Delhi
Acknowledgements  ix
Officers, Experts and Stakeholders Consulted Department of AYUSH, Ministry of Health & Family Welfare, Government of India 1. 2. 3. 4.
Shri Anil Kumar Secretary Shri Bala Prasad Joint Secretary Dr. Dinesh Katoch Joint Advisor (Ayurveda) Dr. Manoj Nesari Joint Advisor (Ayurveda)
ASU Research Councils Central Council for Research in Unani Medicine: Headquarters, New Delhi: 1. Prof. Syed Shakir Jamil Director General 2. Dr. Khalid M Siddiqui Deputy Director 3. Mr. Mehr-e-Alam Khan Consultant & formerly Research Officer (Publication) 4. Dr. Abdul Raheem Assistant Director (Unani) RRIUM, Bhadrak (Odisha): 1. Dr. L Samiullah
Deputy Director (Unani)
2.
Dr. Subhan Allah Khan
Assistant Director (Bio-chemistry)
CRIUM, Lucknow: 1. Dr. Maqbool Ahmed Assistant Director (Unani) RRIUM, Aligarh: 1. Dr. Latafat Ali Khan Deputy Director (Unani)
CRIUM, Hyderabad: 1.
Dr. Ataullah Sharief
Director Incharge
2.
Dr. MA Waheed
Deputy Director
3.
Dr. Mushtaq Ahmad
Ex-Director
4.
Dr. MA Wajid
Assistant Director
5.
Dr. S Mazhur-ul-Haq
Assistant Director (Pathology)
6.
Dr. Alokananda Chakraborty Assistant Director (Physiology)
RRIUM, Srinagar (J&K): 1. Dr. Arsheed Iqbal Research Officer (Unani) Central Council for Research in Ayurvedic Sciences: Headquarters, New Delhi: 1.
Dr. Ramesh Babu Devalla
Director General
2.
Dr. N Srikanth
Assistant Director (Ayurveda)
3.
Dr. Sarada Ota
Research Officer (Ayurveda)
4.
Dr. Pradeep Dua
Research Officer (Ayurveda)
CRI(Ayurveda), Lucknow: 1.
Dr. Ramji Singh
Assistant Director (Ayurveda)
ARRI, Mandi: 1.
Dr. SK Sharma
Assistant Director (Ayurveda)
Officers, Experts and Stakeholders Consulted  xi
2.
Dr. Om Raj Sharma
Research Officer (Ayurveda)
ARRI, Jammu: 1.
Dr. Krishna Kumari
Assistant Director (Ayurveda)
National Research Institute of Ayurvedic Drug Development (NRIADD), Odisha: 1. 2.
Dr. Banamali Das Research Officer (Ayurveda), Scientist-II Dr. MV Acharya Assistant Director
National Institute of Indian Medical Heritage (NIIMH), Hyderabad: 1. 2. 3. 4. 5. 6.
Dr. Ala Narayana Director Dr. K Bharathi Research Officer (Ayurveda) Dr. GP Prasad Research Officer (Ayurveda) Dr. V Sridevi Research Officer (Ayurveda) Dr. B Venkateshwarlu Research Officer (Ayurveda) Dr. T Saket Ram Research Officer (Ayurveda)
AYUSH National Institutes 1. 2. 3.
Prof. V V Prasad Director Rashtriya Ayurveda Vidyapeeth, New Delhi Prof. Ajay Kumar Sharma Director National Institute of Ayurveda (NIA) Jaipur Dr. K Shankar Rao* Associate Professor & HOD Department of Rasa Shashtra & Bhaisajya Kalpana National Institute of Ayurveda (NIA) Jaipur
xii  Status of Indian Medicine and Folk Healing
4.
Dr. V Nageswar Rao* Associate Professor Department of Rasa Shashtra & Bhaisajya Kalpana National Institute of Ayurveda (NIA) Jaipur 5. Dr. Parimi Suresh* Assistant Professor Department of Rasa Shashtra & Bhaisajya Kalpana National Institute of Ayurveda (NIA) Jaipur 6. Dr. Sanjay Kumar* Lecturer Department of Rasa Shashtra & Bhaisajya Kalpana National Institute of Ayurveda (NIA) Jaipur 7. Dr. Otem Dai* Director North East Institute of Folk Medicine (NEIFM), Pasighat 10. Shri Hemen Hazarika* Senior Research Fellow North East Institute of Folk Medicine (NEIFM), Pasighat 11. Shri K Jeyaprakash* Senior Research Fellow North East Institute of Folk Medicine (NEIFM), Pasighat State Health Ministers, Chief Secretaries, Principal Secretaries, Commissioners, Directors and Others Odisha: 1. Smt Anu Garg Commissioner-cum-Secretary Department of Health and Family Welfare 2. Dr. BK Mishra Special Secretary Department of Health and Family Welfare 3. Shri Pramod Meherda Managing Director NRHM, Odisha
4. 5.
Dr. Upendra Kumar Sahu Director of Health Services Shri Padmalochan Behera Director Indian Medicine & Homeopathy Joint Secretary Department of Health and Family Welfare 6. Dr. PK Das Director of Medical Education & Training Uttar Pradesh: 1. Shri JP Sharma Principal Secretary Medical Education & AYUSH 2. Sh. SK Saxena Special Secretary Medical Education 3. Shri Sanjay Agarwal* Principal Secretary (NRHM) 4. Dr. Saudan Singh Director General Medical Education 5. Dr. Mohammad Sikander Hyat Siddiqui* Director (Unani) 6. Dr. RR Choudhary Director (Ayurveda) 7. Dr. Raksha Goswami Ex-Director (Ayurveda) 8. Dr. M Shoeb Qasmi Ex-Director of Unani Services 9. Dr. AA Hashmi Deputy Director (Unani Services) Andhra Pradesh: 1. Shri KR Kishore Principal Secretary Health & Family Welfare 2. Dr. KP Srivasuki IFS Commissioner ( AYUSH) 3. Dr. KV Ramanna Regional Deputy Director of Ayurveda 4. Dr. K Vishnu Prasad Director (Medical Education)
Himachal Pradesh: 1.
Shri Ali Raja Rizvi
Principal Secretary (Health & Ayurveda)
2. 3. 4.
Shri PS Draik Director (Ayurveda) Shri Rameshwar Sharma Additional Director (Ayurveda) Dr. RakeshPandit Ex-OSD, Directorate Ayurveda
Jammu & Kashmir: 1.
Shri Sham Lal Sharma
Health Minister
2.
Shri Madhav Lal
Chief Secretary
3.
Shri MK Dwivedi
Secretary of Government of Jammu & Kashmir
Health & Medical Education Department
4.
Shri Syed Iftikhar
Special Secretary
Health & Medical Education Department
5.
Dr. Yashpal Sharma
Mission Director
NRHM
6.
Dr. Saleem-ur-Rehman
Director Health Services
Kashmir
7.
Dr. Abdul Kabir Dar
Director, Indian Systems of Medicine & Homoeopathy
8.
Mr. KA Quasba
Joint Director
Agriculture
9.
Mr. Pran Dullo
Joint Director
Floriculture
10. Dr. KS Manhas
Dy. Director
ISM, Jammu
Officers, Experts and Stakeholders Consulted  xiii
11. Dr. Abdul Lateef
Assistant Director
ISM Unani
12. Dr. Rakesh Kumar Raina
Assistant Director (Ayurveda)
ISM
Bihar 1. Shri Vyasji* Principal Secretary Department of Health and Family Welfare 2. Shri Amarjeet Sinha* Ex-Principal Secretary Department of Health and Family Welfare Uttarakhand: 1. Dr. Ranbeer Singh* Principal Secretary 2. Dr. Pooja Bhardwaj* Director General (AYUSH) West Bengal: 1. Shri Sanjay Mitra* Principal Secretary Madhya Pradesh: 1. Shri Tanvir Krishnan* Principal Secretary 2. Shri Sudesh Kumar* Ex-Principal Secretary Maharashtra: 1. Dr. KR Kohli* Director (Ayurveda) Rajasthan: 1. Shri Ashok Shekhar* Principal Secretary (AYUSH) 2. Dr. Ujwal Rathore* Director (Ayurveda) Karnataka: 1. Shri GN Sreekantiah* Director (AYUSH)
xiv  Status of Indian Medicine and Folk Healing
Arunachal Pradesh: 1. Shri K Tayeng* Secretary Department of Health & Family Welfare Assam: 1. Shri JC Goswami* Commissioner & Secretary Department of Health & Family Welfare 2. Shri AB Mohammad Younis* Commissioner Department of Health & Family Welfare Manipur: 1. Shri K Moses Chalai* Commissioner Health & Family Welfare Meghalaya: 1. Shri DP Wahlang* Commissioner-cum-Secretary(Health) Department of Health & Family Welfare 2. Dr. A Das* Director of Health Services Nagaland: 1. Shri Menukhol John* Commissioner & Secretary (Family Welfare) Department of Health & Family Welfare 2. Shri T Limsong* Secretary (Family Welfare) Department of Health & Family Welfare Government of Nagaland North Eastern Council, Shillong: 1. Shri PS Thangkhiew* Planning Advisor North Eastern Council Government of Shillong Sikkim: 1. Shri K Bhandari* Secretary Department of Health & Family Welfare
Tripura: 2. Shri SK Roy* Principal Secretary Department of Health & Family Welfare Academics and Experts consulted 1. 2. 3. 4. 5. 6. 7.
Prof. MS Valiathan National Research Professor Manipal University, Manipal Prof. Ranjit Roy Chaudhury National Professor of Pharmacology (National Academy of Medical Science) And Advisor Health Government of National Capital Territory of Delhi Prof. Ram Harsh Singh Life time Distinguished Professor Faculty of Ayurveda Banaras Hindu University Dr. LS Chauhan Director National Centre for Disease Control Ministry of Health and Family Welfare Government of India Prof. Bhushan Patwardhan Professor Interdisciplinary School of Health Sciences University of Pune, Pune Mr. Darshan Shankar Chairman Foundation for Re-vitalization of Local Health Tradition (FRLHT) Bengaluru Dr. Ritu Priya Professor Center of Social Medicine & Community Health Jawaharlal Nehru University (JNU) Former Advisor Public Health Planning National Health Systems Resource Center (NHSRC), Delhi
8.
Dr. Rama Jaysundar Additional Professor Department of NMR All India Institute of Medical Sciences, New Delhi 9. Dr. SR Narahari MBBS, DVD; MD (Dermatology) Director, Institute of Applied Dermatology Kasaragod, Kerala 10. Dr. Madhulika Banerjee Associate Professor Department of Political Sciences Delhi University 11. Dr. Kishor Patwardhan Assistant Professor Department of KriyaSharir Faculty of Ayurveda Institute of Medical Sciences Banaras Hindu University 12. Dr. Shweta AS Ex-Consultant (AYUSH) Public Health Planning National Health Systems Resource Center (NHSRC), Delhi ASU Pharmaceutical Sector 1.
Dr. DBA Narayana
Chairman
Indian Pharmacopoeia Commissions Crude Dry & Herbal Product Committee
2.
Dr. Philipe Haydon
CEO
The Himalaya Drug Company
3.
Ms. Julie Buragohain
Head-Corporate Legal
The Himalaya Drug Company
4.
Dr. JLN Sastry
Head Healthcare Research
Dabur Research and Development Centre, Ghaziabad
Officers, Experts and Stakeholders Consulted  xv
5.
Brigadier VAM Hussain
Ex-Managing Director
IMPCL
6.
Dr. Amit Agarwal
M/s Natural Remedies Ltd. Group of Industries
Bengaluru
Heads of Educational Institutions Faculty Members, Research Officers and Medical Officers Odisha 1. Dr. BB Behera Deputy Director Homoeopathy Department of Indian Medicine & Homeopathy 2. Dr. Gaurav Giri Drugs Inspector (Ayurveda) Department of Indian Medicine & Homoeopathy 3. Shri RN Sethy Establishment Officer Department of Indian Medicine & Homoeopathy 4. Shri Adait Kumar Pradhan State Programme Manager National Rural Health Mission 5. Dr. Rama Krushna Mishra Inspector Ayurveda Cuttak Circle, Odisha 6. Dr. Surendra Kumar Mishra I/C Inspector of Ayurvedic Eastern Circle Bhubaneshwar 7. Prof. (Dr.) Kamadev Das Principal Gopalbandhu Ayurveda Mahavidyalaya Puri, Odisha 8. Dr. LK Nanda Former Principal Dr. ACHMC&HC Bhubaneshwar
xvi  Status of Indian Medicine and Folk Healing
9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
Dr. NP Naik Deputy Superintendent Government Ayurvedic Hospital Bhubaneswar Dr. Narendra Hota State Research Officer Directorate of AYUSH State Government Dr. RN Acharya Scientific Officer Drug Testing Laboratory (ISM) Bhubaneshwar Dr. Kamal Khan In-charge Government Unani Dispensary District Bhadrak, Odisha Dr. Satyabrata Mohapatra Ayurvedic Medical Officer Odisha Dr. Subrat Mohanty Ayurvedic Medical Officer Odisha Dr. Md. Okar Shamce Unani Medical Officer Government Unani Dispensary Cuttak Dr. Safiqur Rehman Medical Officer (Unani) Dobal, District Bhadrak, Odisha Dr. Ashok Kumar Sitha In-charge PHC, Satasankh, Odisha Dr. RN Mishra In-charge Medical Officer CHC, Dharamshala, Jajpur, Odisha Dr. JJ Mishra Gynaecologist CHC, Badachana, Odisha Dr. Manoranjan Mohapatra Consultant AYUSH Odisha Dr. Soumya Devi AYUSH Doctor
22. 23.
PHC, Satasankh Odisha Dr. Anita Behera AYUSH Doctor CHC, Dharamshala, Jajpur, Odisha Dr. Rehanuddin Khan AYUSH Doctor (Unani) City Hospital, Cuttak
Uttar Pradesh 1. Prof. Saood Ali Khan Principal and Chief Medical Superintendent AK Tibbiya College 2. Prof. Shagufta Aleem Dean Faculty of Unani Medicine AK Tibbiya College, AMU, Aligarh 3. Prof. Mukhtar Husain Hakim Department of Moalijat AK Tibbiya College, AMU, Aligarh 4. Prof. Abdul Mannan Department of Moalijat AK Tibbiya College, AMU, Aligarh 5. Prof. MMH Siddiqui Department of Elaj Bit Tadbir (Regimental Therapy) AK Tibbiya College, AMU, Aligarh 6. Dr. Misbahuddin Siddiqui Associate Professor Department of Moalijat AK Tibbiya College, AMU, Aligarh 7. Dr. Younus Siddiqui Associate Professor Department of Moalijat AK Tibbiya College, AMU, Aligarh 8. Dr. Sanjeev Rastogi Associate Professor Department of Panchakarma State Ayurvedic College& Hospital University of Lucknow, Uttar Pradesh 9. Dr. Tafseer Ali Assistant Professor and Deputy Medical Superintendent AK Tibbiya College & Hospital, AMU Aligarh
10. 11. 12. 13.
Prof. M Wasi Akhtar Department of Moalijat AK Tibbiya College, AMU, Aligarh Dr. YC Sharma Lecturer (Medicine) State Ayurvedic College Lucknow, Uttar Pradesh Dr. Arvind Srivastava Lecturer State Ayurvedic College, Uttar Pradesh Dr. Mohd Belal Guest Faculty Department of Amaraze Jild AK Tibbiya College, AMU, Aligarh
Andhra Pradesh 1.
Dr. N Satya Prasad
Principal
Dr. BRKR Government Ayurvedic College
Hyderabad
2.
Dr. Syed Arifuddin
Principal
Government Nizamia Tibbi College
Hyderabad
3.
Dr. Mir Yousuf Ali
Professor & HOD
Department of Ilmul Advia
Government Nizamia Tibbi College
Hyderabad
Himachal Pradesh 1.
Dr. SK Sharma
Sr. Medical Superintendent
Regional Ayurvedic Hospital
State Government of Shimla
2.
Prof. Sanjeev Sharma
Medical Superintendent
Rajiv Gandhi Government PG Ayurvedic College (RGGPGAC&H)
Himachal Pradesh
3.
Prof. YK Sharma
Head
Department of Kayachikitsa
Officers, Experts and Stakeholders Consulted  xvii
4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Rajiv Gandhi Government PG Ayurvedic College (RGGPGAC&H) Himachal Pradesh Prof. Eena Sharma Head Striroga avam Prasuti Tantra Rajiv Gandhi Government PG Ayurvedic College (RGGPGAC&H) Himachal Pradesh Dr. Ramesh Arya Head & Professor Department of Shalya RGGPGAC&H Himachal Pradesh Dr. Sanjeev Awasthi Reader & Head Department of Shalakya RGGPGAC&H, Himachal Pradesh Dr. Baldev Awasthi District Ayurvedic Officer Kullu Dr. Vidyasagar Gupta District Ayurvedic Officer Mandi Dr. Bhagat Ram Sharma District Ayurvedic Officer Kangra Dr. Hemraj Sharma District Ayurvedic Officer Solan Dr. Uttam Chand Chandel District Ayurvedic Officer Bilaspur Dr. Subhash Rana In-charge ISM Herbal Garden Jogindernagar, Himachal Pradesh Dr. Sushil Nag Ayurvedic Medical Officer, Casualty RGGPGAC&H Himachal Pradesh Dr. Thakur Singh Bhatt Ayurvedic Medical Officer, Casualty RGGPGAC&H Himachal Pradesh
xviii  Status of Indian Medicine and Folk Healing
15. 16.
Dr. Virender Kaul Ayurvedic Medical Officer, Casualty RGGPGAC&H Himachal Pradesh Dr. Vikram Rana Ayurvedic Medical Officer, Casualty RGGPGAC&H Himachal Pradesh
Jammu & Kashmir 1. Dr. Mohammad Iqbal Principal KTC, Srinagar 2. Dr. Khurshid Ahmad Bhakshi Principal IAMS, Srinagar 3. Dr. Mohammad Iqbal Medical Superintendent Jawahar Lal Nehru Memorial Hospital Rainawari, Srinagar 4. Dr. Mohammad Maqbool Medical Superintendent District Hospital, Pulwama 5. Smt Geeta Garg Professor Jammu Institute of Ayurveda Research Jammu & Kashmir 6. Dr. Mohammad Ayuoob Ganie District Medical Officer District Hospital, Pulwama 7. Dr. Syed Ashaq Hussain District Medical Officer Srinagar 8. Dr. Syed Ashiq Hussain ADMO, Srinagar 9. Dr. Saif-ul-Abrar In-charge, AYUSH Unit Jawahar Lal Nehru Memorial Hospital Rainawari, Srinagar 10. Dr. Mushtaq Ahmad Parry In-charge, AYUSH Unit Government Medical College & Hospital Srinagar 11. Dr. Bilal Ahmad Wani Unani Doctor In-charge PHC, Gulmarg
12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.
Dr. Asif Khan Block Medical Officer and In-charge CHC, Tanmarg Dr. Shabeer Ahmed Gaffari Medical Officer Directorate of ISM, J&K Dr. Nuzhat Manzoor Technical Officer J&K State Medicinal Plant Board Dr. AS Shawl Sr. Scientist (Ex-HOD) Indian Institute of Integrative Medicine (IIIM), Jammu Dr. Nazir Ahmed Ahanger Unani Doctor Government Unani Hospital Shaltang, Srinagar Dr. Irfan Bandey Unani Doctor Government Unani Hospital Shaltang, Srinagar Dr. Musaddaq Ahmed Unani Doctor Government Unani Hospital Shaltang, Srinagar Dr. Roohi Tabbasum Ayurvedic Doctor Government Unani Hospital Shaltang, Srinagar Dr. Shaheen Mir Ayurvedic Doctor Government Unani Hospital Shaltang, Srinagar Dr. Bilal Ahmed Ayurvedic Doctor Government Unani Hospital Shaltang, Srinagar Dr. Taseer Unani Doctor Jawahar Lal Nehru Memorial Hospital Rainawari, Srinagar Dr. Shahnawaz Unani Doctor Jawahar Lal Nehru Memorial Hospital Rainawari, Srinagar
24. 25. 26.
Dr. Mushtaq Ahmad Aga Unani Doctor Government Medical College & Hospital Srinagar Dr. Irfana Latief Unani Doctor Government Medical College & Hospital Srinagar Dr. Arshad Hussain Thoker Unani Doctor District Hospital, Pulwama
Delhi 1. Prof. Raisur Rahman Department of Moalejat Ayurvedic & Unani Tibbia College & Hospital Karol Bagh, New Delhi 2. Dr. HC Gupta Associate Professor Department of Kayachikitsa Ayurvedic & Unani Tibbia College & Hospital Karol Bagh, New Delhi 3. Dr. Praveen Choudhary Associate Professor Department of Shalya Ayurvedic & Unani Tibbia College & Hospital Karol Bagh, New Delhi 4. Dr. Prabhakar Rao Chief Medical Officer Employees State Insurance Corporation (ESIC Dispensary) Nand Nagri, New Delhi 5. Dr. Sathyanarayana Dornala Panchakarma Specialist Swami Vivekanand Ayurvedic Panchakarma Hospital Dilshad Garden East Delhi Municipal Corporation 6. Dr. Mamta Ralhan Senior Medical Officer Municipal Corporation of Delhi Rajouri Garden New Delhi
Officers, Experts and Stakeholders Consulted  xix
Private Practitioners 1. 2.
Dr. G Geetha Krishnan Senior Consultant Ayurveda Co-ordinator Integrative Medicine Department of Integrative Medicine Medanta the Medicity, Gurgaon Dr. Gopal Dutt Sharma Principal Vaidya Yagya Dutt Sharma Ayurved Mahavidyalaya Khurja, Uttar Pradesh 3. Hakim MS Usmani Formerly Senior Faculty Ayurvedic &Unani Tibbia College & Hospital Karol Bagh, New Delhi 4. Hakim AJ Khan Formerly Senior Faculty Ayurvedic & Unani Tibbia College & Hospital Karol Bagh, New Delhi 5. Hakim Anwar Ahmad Formerly Senior Faculty Ayurvedic & Unani Tibbia College & Hospital Karol Bagh, New Delhi 6. Dr. Tom Paul Angamali, Ernakulum 7. Dr. Rakesh Kapoor Traditional Healer Himachal Pradesh 8. Dr. Ashwini Sharma Ayurvedic Practitioner Himachal Pradesh 9. Dr. Manik Soni Ayurvedic Practitioner Himachal Pradesh 10. Dr. Mohammad Haroon Unani Practitioner Uttarakhand
11. 12. 13. 14. 15. 16. 17.
Dr. M Sadique Unani Practitioner District Bhadrak Odisha Dr. Niyametullah Siddique Unani Practitioner District Bhadrak Odisha Dr. Mazharuddin Private Practitioner Nimasahi, Cuttak Vaidya Kripa Ram Traditional Healer Arki Village, Himachal Pradesh Vaidya Ram Kumar Bindal Ayurvedic Practitioner Solan Hakim Zafar Khan Unani Practitioner Sambal District, Uttar Pradesh Shri Sabir Ali Ansari Bone Setter (Unani) Uttar Pradesh
Others 1. 2.
Ms. Reecha Das 5th year B.A.L.L.B The West Bengal National University of Jurisdical Science Kolkata Dr. Claudia Lang* Postdoctural Researcher of Cultural Anthropology Institute of Social and Cultural Anthropology Ludwig-Maximilians-University Munich Germany
Technical Staff: 1. Shri Zameer Ahmad Investigator, CRIUM Lucknow
Note: * Those with whom the PI corresponded through mail or phone.
xx  Status of Indian Medicine and Folk Healing
Abbreviations and Acronyms ADHD
Attention Disorder
ADMA
Deficit
Hyperactive
BAMS
Bachelor of Ayurvedic Medicine & Surgery
Ayurvedic Drug Manufacturers' Association
BD
Bis Die (two times in a day)
BHU
Benaras Hindu University
ADMO
Assistant District Medical Officer
BMO
Block Medical Officer
AIDS
Acquired Immuno Syndrome
BPH
Benign Prostatic Hypertrophy
BPL
Below Poverty Line
AIIA
All India Institute of Ayurveda
BUMS
AIIMS
All India Institute of Medical Sciences
Bachelor of Unani Medicine & Surgery
CABG
Coronary Artery Bypass Graft
AIIPMR
All India Institute of Physical Medicine and Rehabilitation
CAM
Complementary and Alternative Medicine
AIW
Artificial Insemination Workers
CCIM
AMO
Ayush Medical Officer
Central Council Medicine
AMU
Aligarh Muslim University
CCMB
ANM
Auxiliary Nurse Midwife
Centre for Cellular Molecular Biology
AP
Andhra Pradesh
CCRAS
APD
Acid Peptic Disease
Central Council for Research in Ayurvedic Sciences
APL
Above Poverty line
CCRUM
APM
Ayurvedic Proprietary Medicine
Central Council for Research in Unani Medicine
ARRI
Ayurveda Institute
CD
Compact Disc
CEO
Chief Executive Officer
CGHS
Central Scheme
Deficiency
Regional
Research
of
Government
Indian and
Health
ART
Anti Retroviral Therapy
ASC
Altered State of Consciousness
ASHA
Accredited Social Health Activist
CH
Community Health
ASIIA
A Science Initiative in Ayurveda
CHC
Community Health Centre
ASU*
Ayurveda, Siddha, Unani
CMC
Christian Medical College
ASUDCC
Ayurveda, Siddha & Unani Drugs Consultative Committee
CME
Continuing Medical Education
CMO
Chief Medical Officer
ASUDTAB Ayurveda, Siddha & Unani Drugs Technical Advisory Board
CRAV
Certificate of Rashtriya Ayurveda Vidyapeeth
ATT
Anti-tuberculosis Treatment
CRIUM
AVP
Ayurvedic Veterinary Products/ Ayurvedic Veterinary Practice
Central Research Institute of Unani Medicine
CRM
Common Review Mission
AVS
Arya Vaidya Sala
CSIR
AYUSH*
Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy
Council of Scientific & Industrial Research
CSRP
Centre for Scientific Research in Panchakarma
Abbreviations and Acronyms  xxi
FMRI
Functional Magnetic Resonance Imaging
Clinical Trials Registry of India
FPG
Fasting Plasma Glucose
CV
Curriculum Vitae
FRLHT
D&C Act
Drugs & Cosmetics Act
Foundation for Revitalization of Local Health Traditions
DAO
District Ayurveda Officer
FSSAI
DCA
Drugs & Cosmetics Act
Food Safety & Authority of India
DCAR
Drugs & Cosmetics Act Rules
GAU
Gujarat Ayurved University
DCGI
Drugs Controller General of India
GB
Governing Body
GCP
Good Clinical Practices
DDA
Delhi Development Authority
GDP
Gross Domestic Product
DG
Director General
GHPL
Good Health Plan Ltd.
DGHS
Director-General Services
GIT
Gastro-Intestinal Tract
GMP
Good Manufacturing Practices
CSS
Centrally Sponsored Scheme
CT
Computerized Tomography
CTRI
of
Health
Standards
DH
District Hospital
GOI
Government of India
DHS
Directorate of Health Services
GP
General Practitioner
DIL
Dabur India Limited
HCCA
DIMH
Department of Indian Medicine & Homoeopathy
Homoeopathic Central Council Act
HDC
Himalaya Drug Company
DM
Diabetes Mellitus
HIV
Human Immunodeficiency Virus
DMET
Director of Medical Education & Training
HOD
Head of Department
HP
Himachal Pradesh
DMRA
Drugs and Magic Remedies Act
HPTLC
DNB
Diplomate of National Board
High Performance Thin Layer Chromatography
DOTS
Directly Observed Treatment – Shortcourse chemotherapy
HS
Hora Somni (at bed time)
IAD
Institute of Applied Dermatology
DPR
Detailed Project Report
I-AIM
DS
Double Strength
Institute of Ayurveda Integrative Medicine
DTL
Drug Testing Laboratory
IAS
Indian Administrative Service
DUB
Dysfunctional Uterine Bleeding
IBS
Irritable Bowel Syndrome
EAG
Empowered Action Group
ICCMR
ECG
Electro Cardiography
EEG
Electroencephalography
International Congress on Complementary Medicine Research
EFC
Expenditure Finance Committee
ICMR
ELISA
Enzyme Linked Immunosorbent Assay
Indian Council Research
ICU
Intensive Care Unit
ENT
Ear, Nose, Throat
IDEA
ESIC
Employees State Corporation
Initiative on Diabetes Education and Awareness
IEC
FMCG
Fast Moving Consumer Goods
Information, Education Communication
xxii Status of Indian Medicine and Folk Healing
Insurance
of
and
Medical
and
J-AIM
Journal of Ayurveda Integrative medicine
Indian Forest Service
JAMA
Indira Gandhi National Open University
Journal of American Medical Association
J&K
Jammu & Kashmir
IHD
Ischaemic Heart Disease
JNU
Jawaharlal Nehru University
IIHM
Indian Institute of History of Medicine
KHADC
Khasi Hills Autonomous District Council
IIHMR
Indian Institute of Management Research
KIMS
Kalinga Institute Sciences
IIIM
Indian Institute of Integrative Medicine
LCMS
Liquid Chromatography Mass Spectrometry
IIPS
International Institute Population Sciences
LHT
Local Health Traditions
MBBS
Bachelor of Medicine Bachelor of Surgery
IEEE
Institute of Electrical Electronic Engineers
IFS IGNOU
and
Health
of
of
and
Medical
and
IISc
Indian Institute of Science
IIT
Indian Institute of Technology
MCI
Medical Council of India
IJAR
International Journal of Ayurveda Research
MD
Doctor of Medicine
MDT
Multi Drug Therapy
IJCP
International Journal of Clinical Practice
MIS
Management System
IM
Integrative Medicine
MLA
Member of Legislative Assembly
IMA
Indian Medical Association
MLC
Member of Legislative Council
IMCC
Indian Council
MMP
Modern Medicine Practice
MO
Medical Officer
IMI
International Institute
MoHFW
Ministry of Health & Family Welfare
IMNCI
Integrated Management of Neonatal and Childhood Illness
MR
Medical Representative
IMPCL
Indian Medicines Pharmaceutical Corporation Ltd.
MRAV
Member of Rashtriya Ayurveda Vidyapeeth
IMS
Institute of Medical Sciences
MSR
Minimum Requirements
INCAA
Indian National Confederation and Academy of Anthoropologists
NAAC
National Assessment Accreditation Council
IPCA
Indian Pharmaceutical Combine Association
NABH
National Accreditation Board for Hospitals & Health Care Providers
IPD
In Patient Department
NBE
National Board of Examinations
IPHS
Indian Public Health Standards
NBRC
National Brain Research Centre
ISM&H*
Indian Systems of Medicine & Homoeopathy
NCAER
National Council of Applied Economic Research
IT
Information Technology
Medicine
Central
Management
Information
Standard and
Abbreviations and Acronyms  xxiii
National Centre for Complementary and Alternative Medicine
OD
Omne die (once a day)
OHA
Oral Hypoglycemic Agents
OPD
Out Patient Department
NCD
Non-Communicable Diseases
OSD
Officer on Special Duty
NCE
New Chemical Entities
OTC
Over the Counter
NCHRH
National Council for Human Resources in Health
PA
Personal Assistant
NCT
National Capital Territory
PNDT Act
Pre Natal Diagnostic Techniques Act
NE
North East
PCIM
NEIFM
North East Institute of Folk Medicine
Pharmacopoeia Commission for Indian Medicine
PCOD
Poly Cystic Ovarian Disease
NFHS
National Family Health Survey
PCT
Participating Countries Treaty
NGO
Non-Government Organization
PEPC
NHSRC
National Health Research Centre
Performance Expectations Patient Counselling
PEPSU
NIA
National Institute of Ayurveda
Patiala and East Punjab States Union
NIDDM
Non Insulin Dependent Diabetes Mellitus
PG
Post Graduation
PGI
Post Graduate Institute
NIH
National Institutes of Health
PHC
Primary Health Centre
NIHFW
National Institute of Health and Family Welfare
PhD
Doctor of Philosophy
NIIMH
National Institute Medical Heritage
PHFI
Public Health Foundation of India
PHSC
Public Health Sub Centre
NLEM
National List Medicines
PI
Principal Investigator
PIL
Public Interest Litigation
NMBG
Nehru Memorial Garden
PIP
Project Implementation Plan
PLIM
NMITLI
New Millennium Indian Technology Leadership Initiative
Pharmacopoeial Laboratory for Indian Medicine
PME
Pre-mature Ejaculation
NMPB
National Medicinal Plants Board
PPG
Post Prandial Glucose
NMR
Nuclear Magnetic Resonance
PPM
Patent & Proprietary Medicine
NRHM
National Rural Health Mission
PRI
Panchayati Raj Institutions
NRI
Non Resident Indian
PSA
Principal Scientific Adviser
NRIADD
National Research Institute of Ayurvedic Drug Development
PSC
Public Service Commission
PSU
Public Sector Undertaking
NSAIDS
Non Steroidal Anti Inflammatory Drugs
QCI
Quality Control of India
RAV
Rashtriya Ayurveda Vidyapeeth
NSG
National Security Guards
RCH
Reproductive & Child Health
NSSO
National Sample Organization
R&D
Research and Development
NCCAM
NUD
Systems
of
of
Non Ulcer Dyspepsia
xxiv  Status of Indian Medicine and Folk Healing
Indian Essential
Botanical
Survey
&
RGGPGAC Rajiv Gandhi Government Post Graduate Ayurveda College
TDS
Ter die sumendus (three times a day)
TID
Ter in die (three times a day)
TM
Traditional Medicine
Regional Research Institute of Unani Medicine
UAE
United Arab Emirates
UGC
University Grants Commission
SAB
Skill Attendant at Birth
UNAIDS
SC
Sub Centre
United Nations Programme on AIDS
SMPB
State Medicinal Plants Board
UP
Uttar Pradesh
SOP
Standard Operating Procedures/ Practices
US
United States
USA
United States of America
SPECT
Single Photon Emission Computerized Tomography
USG
Ultra Sonography
UT
Union Territory
SPM
State Programme Manager
UTI
Urinary Tract Infection
SRF
Senior Research Fellow
VAP
Veterinary Ayurvedic Products
STD
Sexually Transmitted Diseases
VATS
Video-Assisted Thoracic Surgery
VD
Veterinary Doctor
VHC
Village Health Committee
VLI
Veterinary Livestock Inspectors
VLW
Village Level Workers
WHO
World Health Organization
RMP
Rural Medical Practitioners
RO
Research Officer
ROTP
Re-Orientation Programme
RRIUM
Training
TAMPCOL Tamil Nadu Medicinal Plant Farms and Herbal Medicines Corporation Ltd. TB
Tuberculosis
TBS
Traditional Bone Setter
TCM
Traditional Complementary Medicine/Traditional Chinese Medicine
* Explanatory Note on the alternate use of ASU, AU, AYUSH and ISM&H in Parts I and II of the Report. •
In Part I the term ASU was used because that report dealt with specific aspects of the Ayurvedic, Siddha and Unani systems of medicine in relation to research, education, practice and drug manufacture. The acronym ASU referred to the three systems and was also used to distinguish them from Homoeopathy, Naturopathy and Yoga.
•
In Part II there is practically no mention of the Siddha system. This is because the PI has based most of the findings upon observations and interviews held in States where the Siddha system is not being practised. Hence when referring to the medical systems, the term AU has been used.
•
The acronym AYUSH has been used mainly in the context of integration of health delivery envisaged by NRHM. The term AYUSH has therefore been used in a generic sense as used in Government parlance and refers to its role in service delivery.
•
The term ISM has been used occasionally in keeping with this nomenclature which continues to be used in States like Jammu & Kashmir.
Abbreviations and Acronyms xxv
Executive Summary Summary of Chapters Part I of the Status Report had covered generic issues relating to the status of Research, Education, Practice, Medicinal Plants and Drugs which influence the functioning of the Ayurveda, Siddha and Unani systems of medicine. The focus of the Report was on the benefits that the public had received through the systems. Part II of the Status Report focuses on the health seeking behavior of consumers, the prevailing government policy on the integration of several legally recognized medical systems and the widespread use of Ayurveda and Unani medicine as adjuvant therapy. The focus is on the status of integration of these medical systems into health care delivery. The Report describes the PI’s field visits to five States in the country, what she observed and visible gaps that need to be filled. There are separate chapters on the status of postgraduate education, AYUSH State pharmacies and the regulatory framework and legal status of cross practice by AYUSH practitioners. Part II also contains a critique on significant initiatives which have been taken through the Rashtriya Ayurveda Vidyapeeth, the National Institute of Indian Medical Heritage as well as the Status of Folk Healing practices in the North-East. The use of Ayurveda in the veterinary sector has also been covered in an independent chapter. A few promising initiatives which bring hope of greater recognition have been touched upon. Finally, the transformation needed by focussing on a priorities which can bring rich returns forms the concluding chapter of the Report.
Chapter I. Status of Integration Health Seeking Behaviour and Medical Pluralism This Chapter starts with the status of health seeking behaviour and medical pluralism, and gives an account of what is known through surveys and reports which describe public preferences in different settings. It shows how dispersed and sporadic these efforts have been which call for regular, continuous surveys which can provide an objective analysis of consumer preferences including the adjuvant use of Ayurveda, Unani and Siddha systems to support allopathic treatment. Congruence of Traditional and Modern Medicine This Chapter gives an account of the efforts made by the World Health Organization which had recommended harmonization of traditional medicine into the dominant medical systems of each country. The Chapter highlights the policy prescriptions of the National Rural Health Mission and the Department of AYUSH on mainstreaming AYUSH into the delivery of health services. The degree to which the recommendations have been implemented by various states has been commented upon with particular reference to the functioning of co-located facilities and the utilization of contractual doctors appointed under NRHM.
Executive Summary  xxvii
Status of Adjuvant Use of Ayurveda and Unani Medicine Brainstorming to Decide Priorities for Part II The first subchapter contains details of a brainstorming which was organized by the PI under the aegis of the Central Council for Research in Unani Medicine (CCRUM) and supported by the Central Council for Research in Ayurvedic Sciences (CCRAS) to decide upon the priorities for Part II of the Status Report. The subchapter recounts the outcome of the meeting with Ayurvedic and Unani experts who described their experiences with the adjuvant use of Ayurveda and Unani medicine in different settings – both government and in the private sector. Special Survey on Adjuvant use of Ayurveda & Unani Medicine The second subchapter describes how the suggestions made at the meeting were taken forward by organizing a special survey comprising of 1000 patients from each system who availed of treatment in five different hospitals of the Ayurvedic and Unani systems of medicine located in different parts of the country. The organization of the survey, including the methodology used and the findings have been presented along with patient preferences while resorting to the use of Ayurvedic and Unani medicine as adjuvant therapy. The cross-section of patients by gender and economic status have been described and their responses to the questionnaires have been analyzed separately for each system. Experiences with Integration–Physicians’ Observations The third subchapter deals with the responses and viewpoints expressed by a variety of physicians working in different settings like hospitals, dispensaries of the Municipal Corporation of Delhi, the ESI Corporation, the Ayurvedic & Unani Tibbia College, Delhi and a leading Ayurvedic college in Himachal Pradesh. The understanding of a modern medical specialist who had been exposed to Ayurvedic therapeutics has also been recounted. Each response brings out the physicians’ experience and advice in the form of written communications. A Corporate Sector Initiative with Integrative Medicine The fourth subchapter presents the outcome of an extensive interview with an Ayurvedic doctor responsible for providing integrated medical treatment in the super speciality corporate hospital conglomerate called Medanta, at Gurgaon. In this interview, a new way of integration has been described through an interview with the Senior Consultant (Ayurveda) and Coordinator in the Department of Integrative Medicine. The interview brings out the manner in which patient preferences have been taken into account. Also, how the initial negative reactions which were encountered from modern medicine specialists were overcome. Contemporary Ayurveda and Ethical Marketing of Ayurvedic Drugs This Chapter gives an overview of efforts made by the private sector to widen the use of Ayurvedic drugs.The growth in sales of Ayurvedic products with a focus on the modern medicine practitioners has been referred to. Interviews with key professionals working in the Himalaya Drug Company (HDC) have been presented, which gives an idea of how their strategies have successfully broken down barriers to integration which are seen elsewhere.
xxviii Status of Indian Medicine and Folk Healing
Interview with HDC Professionals A detailed interview with professionals working in HDC has been given while summarizing the strategies that appear to have made the difference.
Chapter II. AYUSH in Selected States – Findings from Field Visits In this chapter the PI's observations during her visits to the States of Odisha, Uttar Pradesh, Andhra Pradesh, Himachal Pradesh and Jammu & Kashmir have been recounted. The text is supported by photographs which display interesting facets of the therapeutic work being carried out in different kinds of facilities along with a record of official meetings with the Principal Secretaries and senior officers of the AYUSH Departments in the States. The focus in this chapter is on the status of integration and benefits that the public seem to be receiving from the policy of mainstreaming AYUSH. There is also a brief account of States that could not be visited but which were consulted on the basis of a questionnaire.
Chapter III. Postgraduate Education in Ayurveda–Filling the Gaps This chapter shows the views of a leading exponent of Ayurveda and his criticism that postgraduate medical education in Ayurveda has not been developed adequately, which is impacting on the future of education, research, and practice. The status of postgraduate education has been given together with suggestions for dealing with the situation in the short term.
Chapter IV. Building Credibility for Panchakarma This chapter recounts the manner in which Panchakarma treatments are being provided in different facilities with special reference to the major factors that need attention in administering the procedures. It brings out the need for research studies which establish the effectiveness and efficacy of Panchakarma therapies, viewing how Panchakarma works. It shows why a beginning needs to be made by first establishing the effectiveness of the therapies arguing that if this is not done, the status of Panchakarma will be confined to mere claims and a promising opportunity would be lost. The route that needs to be followed has also been described in consultation with experts.
Chapter V. A Study of Selected State Pharmacies The State pharmacies had been established mainly to ensure continuous supply of ASU medicines to the government health facilities (hospitals and dispensaries). Keeping this background in view, the report takes note of what was happening in different States and in view of the persistent and the large-scale shortage of Ayurvedic and Unani drugs which was apparent everywhere, she commissioned a quick survey which would give an indication of the scope for improving the capacity utilization of the State pharmacies and the feasibility of attempting to upgrade them. The chapter recounts details of a survey conducted in different States where four faculty members from the Department of Rasa Shastra and Bhaisajya Kalpana of the National Institute of Ayurveda visited the State pharmacies and gave their findings. Suggestions have been made for better capacity utilization and for considering the establishment of more joint sector projects which could bring much-needed efficiency and increased output from the State pharmacies.
Executive Summary xxix
Chapter VI. Regulatory Framework for ASU Drugs Major Milestones Crossed In this chapter, the focus is on two aspects which relate to drug licensing and quality control aspects of production of AYUSH drugs. First, the major modifications and amendments that have been made in the Drugs and Cosmetics Act, 1940 and the accompanying rules and regulations in respect of Ayurvedic, Unani and Siddha drugs have been tabled at one place. Thereafter, the efforts made to promote quality control and to address safety concerns have been recounted also showing how in the absence of guidelines on research protocols the position still remains grey. The manufacture and sale of most drugs has been continuing based on their common usage for thousands of years. While this is legally permissible, such an approach has militated against conducting research which could identify how and to what extent the drugs and therapies are effective. The chapter also gives the position in respect of new categories of drugs which have been introduced through recent measures. Improving Quality Control and Enforcement - Current Developments and Future Prospects The five subcommittees set up under the ASUDTAB and their terms of reference have been summarized in this subchapter. For the first time, safety studies and evidence of effectiveness studies are proposed. The status picture has been referred to and the progress as was given to the PI has been recounted. Legal Status of Cross Practice The third subchapter gives an overview of judgements which have been pronounced on the issue of cross practice by AYUSH practitioners, the orders issued by the State governments and the new thinking that is going on in the State of Maharashtra. There is a reference to whatever documentation could be collected from different State governments showing that there continues to be wide variation between the approach followed by different States. This chapter needs to be read in conjunction with Chapter II - AYUSH in Selected States – Findings from Field Visits.
Chapter VII. Guru-Shishya Parampara–A critique of the Rashtriya Ayurveda Vidyapeeth In this chapter, the current status of the Rashtriya Ayurveda Vidyapeeth, a unique institution under the Department of AYUSH has been described, based upon the findings of a survey which was administered as a part of the project through questionnaires sent to the Gurus and the Shishyas. Whether the selection of the Gurus and Shishyas has been done objectively and whether the experiment is leading to positive outcomes by way of imbibing practical skills has been commented upon, based upon the responses received. Since there were two earlier committees which had given reports on this institution, the extent to which their recommendations have been given effect to has also been commented upon.
xxx Status of Indian Medicine and Folk Healing
Chapter VIII. National Institute of Indian Medical Heritage–A Historical Overview and Major Contributions This Chapter describes a unique institution focusing on the history of medicine under the Central Council for Research in Ayurvedic Sciences. The status gives a historical account of how one of the oldest institutions for studying the history of medicine was established. The endeavour emanated from the advice of eminent medical historians and others from the renowned Johns Hopkins University in Baltimore USA. The manner in which the institution has been working primarily in the area of documenting the result of historical research has been brought out along with a summary of publications in different fields. The current work in hand has also been described along with efforts made to provide access to information and documentation through the Internet.
Chapter IX. Folk Healing Practices of the North East In this Chapter, the folk healing practices of eight States in the North East, namely Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura, have been recounted. The report is based upon field surveys conducted by academic and teaching institutions selected by the North East Institute for Folk Medicine (NEIFM) under the Department of AYUSH. The current use of folk healing practices has been described along with efforts that have been made to document the knowledge and also to enroll the healers. Photographs capture the healing practices, therapies and drugs quite explicitly.
Chapter X. Ayurvedic Veterinary Products–Status and Future Prospects Based upon a background paper prepared by a well-known pharmacist and supplemented with published data, the chapter gives an overview of the veterinary sector and the role that Ayurvedic medicine presently plays within that. The Chapter brings out the scope for the development and propagation of Ayurvedic veterinary medicine and highlights the roles that need to be played by the AYUSH Drugs Sector and the Department of Animal Husbandry, Ministry of Agriculture jointly. The chapter describes how there is not only commercial scope but an immense opportunity for Ayurveda to fill the growing search for antimicrobials, which do not lead to multi-drug resistance and more importantly do not require the use of synthetic additives which are known to have harmful effects upon the quality of milk, poultry, eggs and meat.
Chapter XI. Initiatives with a Difference This chapter describes two specific initiatives that are being pursued through the scheme titled “A Science Initiative in Ayurveda (ASIIA)" and the "Vaidya-Scientist Fellow Programme". These two initiatives were selected because for the first time there is a movement away from a fortyyear focus on drug discovery, drug development and standardization to understanding the fundamental concepts of Ayurveda, seen through the lens of pure science. The two initiatives recounted in the chapter carry a hope that a completely new way of understanding Ayurveda might emerge and may also help bridge the chasm between pure science and Ayurvedic concepts.
Executive Summary xxxi
Chapter XII. Transformation Needed In this chapter, five suggestions have been made which it is felt could bring about much needed transformation and also build credibility for AYUSH. Studying Integration in China While several delegations have visited countries like China as well as the US and South America, there is a need to send a delegation of selected health systems managers to visit China to observe how integration takes place at various levels in the health facilities and to prepare a roadmap which would be of relevance to the primary and secondary health sectors in India. Promoting Research under the Aegis of NCCAM Designing and pursuing meaningful grant proposals A suggestion has been made on the need to undertake a search of projects funded by the National Centre for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH) in the US to analyze the subject areas and the conditions under which researchers from other countries have availed of research grants. The need for involvement of ICMR to be able to prepare an acceptable standard of research proposals has been emphasized. It has also been suggested that under the existing protocols that are available for conducting collaborative research with foreign research institutions a few projects that fall within the contours of the standing policy administered by the Ministry of Health and the Ministry of External Affairs need to be taken up. Promoting High Quality Research and Publications The chapter alludes to the main weakness of the AYUSH system which is the lack of high quality published research. It bring out immense scope for collaborative research to be undertaken and the need for proactively encouraging institutions and researchers outside the government system by facilitating collaborative projects in allopathic and other institutions which are amenable to integrated treatment. Acting Against Exaggerated Advertisements that make Medical Claims This is one area where no deterrent action has been initiated. With the large-scale use of the Internet unacceptable claims are being spread through websites and social network sites. The fact that institutions and individuals are making claims which are prohibited by law has been brought out. Suggestions have been made as to how this can be tackled so that at least the public has an avenue and an opportunity to check on the reliability of what they read about. Specifically suggestions have been made to establish a toll-free number to provide information and for involving the Press Council of India when misleading advertisements appear in the print media.
xxxii  Status of Indian Medicine and Folk Healing
Uniform Policy on Reimbursement of AYUSH Treatment A recent case of an injured NSG commando who was paralysed and received Ayurvedic treatment but could not get reimbursement for the expenses incurred has been described. A case has been made for following a uniform policy by treating cases of rehabilitation of government employees who suffer injury while performing duty as an exclusive category to become entitled to receive Ayurvedic treatment in any facility which gives such treatment. The need for the Department of AYUSH to convince all Ministries and Departments to reimburse medical expenses on AYUSH treatment of employees in respect of specific conditions has also been brought out.
Executive Summary  xxxiii
Summary of Major Findings and Recommendations I. Status of Integration Health Seeking Behaviour and Medical Pluralism Need for Independent Surveys on the Utilization patterns of the AYUSH Systems Many claims about the large-scale use of traditional medicine are based on surveys which are open-ended and generally restricted to localized studies. (The Report has given a broad idea of various studies and their findings show large variation depending on the settings and sample size.) There is therefore a need to understand the dimension and circumstances under which traditional medical therapies and drugs are being opted for by different communities both in urban as well as rural settings. Such findings if based on a representative sample can form the basis for the overall management of AYUSH services within the health system. This is also needed because several pressure groups alternately embrace or decry the traditional systems, which calls for an objective and professional approach to analyzing what is actually happening in terms of consumer preference and utilization. The NSSO survey results may be the first nationwide survey, the results of which would be available only in June 2013. While this is a good step the recommendation is to repeat the surveys at regular intervals. Congruence of Traditional and Modern Medicine The concept of mainstreaming AYUSH and encouraging integration of different medical
systems was given a big thrust from 2005 onwards after the NRHM programme was introduced. In pursuance of Government policy the two Departments of the Ministry– Department of Health and the Department of AYUSH made a joint effort to promote integration. Their policy letters to all State Governments underscore the need for convergence. In physical terms that means positioning of AYUSH manpower where much has been achieved; but in terms of convergence from the patients’ point of view much more could be achieved. The recommendations highlight the barriers which need to be removed if the public is to benefit from the policy of integration. Need to Convince Government Professionals about AYUSH Systems
Health
The AYUSH alternative does not appear to have permeated into the work culture of the medical fraternity in most government health facilities. Despite policy level instructions and the physical posting of contractual AYUSH doctors, the State heath machinery under the State Directors of Health Services and the NRHM hierarchy–particularly those responsible for the supervision of the primary and secondary health infrastructure (PHCs, CHCs and the district hospitals)–require special orientation to overcome barriers which are still deep-rooted. Some government doctors from the modern medicine stream have yet to overcome suspicion about the traditional medicine systems. Senior health administrators need to implement government policy which has expressly provided AYUSH services in government facilities. This should not be difficult as the extra support that has become available through the posting of
Summary of Major Findings and Recommendations xxxv
AYUSH doctors has been accepted by them and even welcomed. Formulation of Standard Responses and Guidelines Both at the national level and the state level, there remains a paucity of guidelines and operating practices to promote integration of AYUSH medical systems (drugs and therapies) into the health care system. A group of experts needs to prepare such guidelines which should include standard responses to guide and counsel patients that wish to use different systems in tandem. Determining the Relationship between NRHM and non-NRHM AYUSH doctors For several decades long before NRHM started, the AYUSH infrastructure was already widespread in many States. After NRHM came into existence, there is a need to spell out the extent to which AYUSH stand-alone facilities should work independent of the AYUSH initiatives under NRHM. The NRHM set-up at the state level does not appear to have sufficient expertise to supervise the AYUSH systems and AYUSH work done in the PHCs and CHCs. Mere physical location of contractual doctors will not achieve the desired results. Since it will be cost-ineffective to establish another supervisory set-up only for the AYUSH component of NRHM, the existing State AYUSH Department's staff ought to be used for supervision. (The advantages of doing this have been covered in the Report in the sections describing the field visits.) Need to Facilitate Referrals for AYUSH Treatment There is a need to have guidelines and standard operating practices laid down for making referrals for specialized treatment. Ultimately, the patient loses out on the benefits
xxxvi  Status of Indian Medicine and Folk Healing
of integration when doctors – particularly the modern medicine doctors show ignorance when patients seek advice on trying AYUSH therapies in parallel. For certain medical conditions cross-reference can be made if the patient so demands, and three examples are for availing of panchakarma treatment in government facilities, for undergoing Ksharasutra procedures for piles and fistula and for the treatment of liver and skin diseases. Need for Standard Promotional Literature on AYUSH Standard literature on the availability of AYUSH treatment as well as for preventive health needs to be supplied by all co-located facilities and district hospitals indicating where more information can be accessed. Signage at the Government health facilities needs to be designed professionally and given to the State Governments to get translated into regional languages as the present efforts were found to be haphazard and perfunctory at many places. Measuring the Contribution of Contractual AYUSH Doctors Although the physical presence of the AYUSH doctor has been accepted in the co-located facilities as an additional hand, his presence has yet to become an advantage for patients. The output of the AYUSH doctor needs to be measured by a different set of yardsticks when AYUSH drugs are available and when there is insufficient or no supply of AYUSH drugs as both situations exist. There is also a need to measure the output of AYUSH doctors separately for doing AYUSH work and doing modern medicine work. (The Report has shown how the mechanical collection of data provides little information about the progress of mainstreaming AYUSH.)
Need for Supervision of AYUSH Drug Supply Since AYUSH work has a direct relationship with drug availability, the supply made to the PHCs/CHCs needs to be overseen regularly from the State level. When not even the names of the medicines are known to the supervisory level NRHM staff, it is necessary to involve the Director ISM of the State and the District AYUSH officers in supervising the AYUSH component of NRHM. A monthly meeting of the Director of AYUSH/Ayurveda/ISM with the District CMOs and the District Programme Manager of NRHM would be useful as the contractual AYUSH doctors have been engaged primarily for performing AYUSH related functions. They are increasingly being treated as additional hands to supplement or substitute the work of the regular PHC doctors, which was never the consideration when hundreds of AYUSH doctors were appointed to mainstream AYUSH services under NRHM. Need for Training AYUSH Doctors Appointed under NRHM to Use Emergency Medicine Having said this, it must also be recognized that several PHCs and CHCs are using AYUSH doctors to perform duties as the sole “in charge” of the facility. This has the approval of the State Health Departments. These contractual AYUSH doctors are regularly put on night duty as the single doctor on duty which amounts to being on emergency duty. The instructions must visualize all the situations that are likely to arise at night, with a view to safeguard patient safety. The AYUSH doctors are anyhow prescribing allopathic drugs available in the dispensary. There is a need to orient all NRHM contractual AYUSH doctors about the administration of all drugs, including injections and parenterals which are stocked in the PHC/CHC. (The training possibly does not take care of emergency
situations when life-saving measures may require to be taken.) Patients are not expected to know the difference in competencies of single doctors on duty. In the National List of Essential Medicines (NLEM) notified for government facilities there are three categories of drugs: Primary (P), Secondary (S) and Tertiary (T). Under NLEM 2011 there are 348 drugs listed. Of these : • 181 fall under the category of P, S and T to be used by all facilities; • 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 all AYUSH doctors recruited under NRHM as they are functioning as the single doctors in charge of the PHC. Eventually this knowledge should be imparted by making appropriate additions to the curriculum. Observations of Fifth CRM (Common Review Mission) related to AYUSH i. The Fifth CRM had reported that AYUSH doctors’ posts have been utilized for positioning allopathic doctors. ii. It has been also pointed out that work of the AYUSH doctors goes unnoticed. iii. Non-availability and inadequacy of AYUSH drugs was found rampant in almost all PHCs. iv. The MIS for AYUSH stand-alone and co-located facilities ought to be incorporated into the overall Health MIS that is prepared for the District and the State as a whole.
Summary of Major Findings and Recommendations xxxvii
Status of Adjuvant Use of Ayurveda and Unani Medicine India is the only country in the world which officially recognizes multiple systems of medicine. The fact that patients use different systems of medicine simultaneously is well known but the advantages, disadvantages, risks and benefits of combined use do not appear to have been studied in depth. In preparing Part II, the experience relating to the adjuvant use of AYUSH along with modern medicine was studied through a survey of 2000 patients to get an idea of what was happening. Consultations were also held with a cross-section of practitioners both in the government and private sector working in a wide range of facilities. Based on the results of these initiatives the following recommendations have been made: Need for Clarity on Adjuvant Use of AYUSH Medication A Task Force should be set up to address the ground realities relating to patients’ combined use of modern medicine and AYUSH drugs and therapies. Only the Government can set up an expert group which can examine whether cases of adverse drug reaction or contraindications call for a cautionary to be issued. The group should have on it pharmacologists who have been working with the AYUSH sector as well as practitioners from Ayurveda and Unani medicine, who can describe the constituents of the drugs. A beginning should be made in respect of conditions where the combined use of drugs from different systems is widely prevalent. A well-considered approach on the adjuvant use of AYUSH drugs particularly in sensitive areas such as lowering blood sugar and hypertension is needed. The expert group needs to draw up a list of precautions, do’s and don’ts about the adjuvant use of AYUSH drugs.
xxxviii Status of Indian Medicine and Folk Healing
In due course it would be necessary to design guidelines for the secondary and tertiary level hospitals too as that would help patients that have long-term medical problems and who resort to adjuvant therapy for a variety of reasons. The example of the Medanta conglomerate which has provided integrated treatment to over 2000 patients in multi-specialty settings can work as a model, to start with. A detailed report on the strategies followed at Medanta has been given in the main chapter while describing the corporate initiative. Need for Guidelines for Patient Counseling Guidelines need to be drawn in consultation with experts from all drug based AYUSH systems to guide patients about the benefits and strengths available under each system of medicine. This initiative will save the patient from a lot of confusion, loss of time and unnecessary expenditure on the basis of lay recommendations. For example, a patient suffering from Piles (hemorrhoids) or Fistula-in-ano may be ignorant about a noninvasive Ayurvedic treatment procedure called Ksharasutra. Similarly, there have been ample instances wherein patients slated for surgery for Chronic Tonsillitis, Uterine fibroids, PCOD, sinus-related interventions, Urinary calculus, have benefited by opting for AYUSH treatment. Unani medicine is being accessed for the treatment of Vitiligo and Siddha treatment is well known in the South for the treatment of Psoriasis. Information on treatment options available under AYUSH in respect of specific diseases should be published with the names of the places where such treatment is available in the public sector facilities. When allopathic drugs are used alongside for other conditions like diabetes, hypertension, thyroid etc. which cannot be stopped while ASU treatment is in progress, the guidelines should indicate the precautions to be taken including the timings of drug use.
Need for Basic Information on ASU Services to Be Also Given to non-AYUSH Doctors in Government Health Facilities Modern medicine doctors in the Government health facilities also need to be provided with standard literature so that patients can gain basic information about options available without the doctor himself having to get involved. They need only have a list of government facilities in each district of the State where the related AYUSH treatment is available and provide this information to the patient if requested. This would enable the patient to select an appropriate treatment option based upon his special circumstances. This should include the need to seek advice on adjuvant use of drugs from different systems. Need for Interaction Between Modern medicine & AYUSH Doctors in the Interest of Patient Care Presently, there is no forum for regular interaction between the medical professionals belonging to different streams during the course of medical education or during practice. This has in fact given rise to “mutual misgivings” regarding the strengths and weaknesses of the alternatives available. Since it is impractical to stop a 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 herb-drug/food-drug/ drug-drug interactions related to commonly used herbs/drugs/dietary compounds ought to be a part of the module.The module may be introduced either during the final MBBS or during the period of internship. As a long-term measure, a 10-year integrated MBBS/MD/PhD in integrative medicine needs to be introduced, wherein the essentials of all major healthcare systems can be incorporated. If this is linked with openings for research, it would generate much greater interest in the AYUSH systems.
Need for Sensitization of Para-medical Staff Apart from the doctors, the nursing and pharmacy staff working at the primary and secondary hospitals also need to be exposed to the strengths of the AYUSH systems. The introduction of short orientation modules on AYUSH in the nursing and pharmacy courses needs to be facilitated by Department of AYUSH by holding discussions with the Nursing and Pharmacy Councils and degree/ diploma granting bodies. This should be done through the Para-medical Services Division in the Ministry of Health to see that the strategy is followed systematically. Interaction within the AYUSH Systems The research staff of the Councils work in isolation and there is virtually no interaction intra-the systems which militates against taking up joint projects and co-authorship. All ASU research staff and physicians need to be encouraged through a policy directive issued by the Department of AYUSH to the Research Councils to participate in seminars, workshops and conferences organized on a common subject by a sister Council. This would provide a forum to share knowledge and experience. In all such conferences, there should be proper representation from the relevant research staff from the other system up to at least 25 percent of the total participation. Likewise at least 10percent of the participants in scientific seminars and conferences should be from the research division of private sector companies from among those who have already published papers in good journals. More specifically: i.
A joint ICMR-AYUSH decision making body with representation of all research councils should be constituted for promoting interdisciplinary research. This was dealt with extensively in the Chapter on Research in Part I of the Status Report. Summary of Major Findings and Recommendations xxxix
ii.
Both CCRAS and CCRUM have units running through the length and breadth of the country but there is virtually no interface between the research personnel intra-AYUSH. The senior research staff working in different units of CCRAS and CCRUM are quite often unable to provide guidance to pursue rigorous research. Ideally, there should be a common platform where the outcomes of research studies in similar areas are discussed and repetitive projects discouraged.
iii.
An effort to cross-reference common medicinal plants in the Ayurvedic and Unani Pharmacopoeias could serve as a bridge between the two systems. Independent advice of a group of scientists involved in pharmacopoeial work needs to be taken.
iv.
v.
vi.
Posting postgraduate doctors from the Ayurvedic and Unani systems jointly on hospital duty needs to be attempted so that they can learn from each other and a better working relationship grows. The younger research and clinical staff would welcome this strategy but the official system will resist the move, which calls for intervention at a central level. It appears that the research officers of the Councils have been permitted to publish the outcomes of their research in national and international journals. It was reported that most papers are only going into the in-house journals which have no “impact” factor. There should be an editorial policy and an editorial Board set up with experts having a track record of publishing. An emphasis on publication in national and international journals should receive encouragement and recognition because most of the research staff do not appear to be interested in publishing. There are several repetitive functions
xl Status of Indian Medicine and Folk Healing
which are undertaken by both the Councils. These areas relate to statistical functions, maintenance of herbal gardens and publishing work. It would make for greater efficiency if such facilities and staff are operated in common and the satellite centres of the Ayurveda, Siddha and Unani Research Councils, made accessible to all research staff as a matter of policy. In the absence of this, too many small units are operating on a tiny scale, which is very inefficient. Suggestions of the Steering Committee on AYUSH The Steering Committee on Health/ AYUSH set up for preparing the 12th Plan had made several useful recommendations which need to be implemented. These are indicated below : i.
Cross-disciplinary learning between Allopathic and AYUSH systems at postgraduate levels should be encouraged.
ii. AYUSH chairs should be established in medical colleges, which would provide the necessary technical expertise to jointly take up research, teaching and patient care. Once cross-disciplinary education is allowed, there would be a new class of professionals who would be able to leverage the strengths of each system to develop the most appropriate and effective treatment regimes. iii. Department of AYUSH should develop standards for facilities at primary, secondary and tertiary levels, standard treatment guidelines and model drugs list for the community health workers. iv. All primary, secondary and tertiary care institutions under the MOHFW, state health departments and other Ministries should have facilities to provide AYUSH services of appropriate standard.
Contemporary Ayurveda and Ethical Marketing of Ayurvedic Drugs Recognizing Private Sector Initiatives It is evident that the market has already decided how Ayurvedic drugs can become acceptable to a new clientele. The sale of Ayurvedic drugs has expanded with doctors of the dominant medical system willing to prescribe the same for their patients. The phenomenon has to be taken note of as it is a great step forwards towards integration of medical systems for public benefit. This is despite the reservations that many modern medicine doctors still harbour which is what makes it noteworthy. The strategies employed by Himalaya Drug Company (HDC) one of the leading Ayurvedic drug manufacturers in bringing about integration have led to a worldwide understanding of the strength of Ayurvedic Medicine. HDC's strategies include: i.
Collection and presentation of scientific and empirical data while talking to modern medicine doctors.
ii.
Documentation of the data collected during clinical trials to prove the efficacy and safety of the drugs.
iii.
Selecting a convincing research design and publishing outcomes in good journals
iv.
Providing information on the adjuvant use of Ayurvedic drugs supported by scientific/medical data.
v.
Providing information about dosage of the drugs when used alone and in combination with allopathic treatment.
It is necessary to learn from such strategies
as modern medicine doctors have to be convinced and the resistance will not break down until special efforts are made to allay their fears which are understandable.
II. AYUSH in Selected States–Findings from Field Visits**1 Odisha Suggestions for better coordination i.
Under NRHM the integration and mainstreaming of AYUSH was a part of government policy and has been accepted right from the year 2006. It is necessary that awareness about the availability of AYUSH doctors and medicines is built up. At all places visited it was clear that the two year delay in supply of medicine had lowered public expectations.
ii.
Unless there is full understanding about government policy at the level of senior health administrators (medical and public health) the fruit of deploying AYUSH health manpower will not be realized.
iii.
Considering the volume of the work and the time taken in follow-up, there is a need to assign a competent senior officer with direct access to the Secretary of the Health Department to oversee the integration aspects at the NRHM facilities and to give a sense of ownership to the concept of pluralistic medical and health care. Most persons in the AYUSH hierarchy do not appear to be able to demand sufficient attention to glaring gaps in implementation. Unless a solution is found locally, the tendency for working in strictly divided compartments
**1 There may be repetition in respect of some recommendations made after the State visits. The recommendations have not been clubbed at one place only to give a State-specific picture for further use. However, the general recommendations made for one State are generally applicable to all States.
Summary of Major Findings and Recommendations  xli
responsibility is first accepted at the top. Joint sensitization along with the AYUSH doctors needs to be organized where a list of nearby facilities, names of persons to be contacted and phone numbers are made available to patients.
will continue and the public for whom all this is being done will not benefit. Only the PHCs will get additional hands to help with day-to-day work which was not the aim of the NRHM strategy. iv.
The Department of AYUSH Manual and joint instructions issued by the Union Secretaries for Health and AYUSH on mainstreaming AYUSH had emphasized that an important aspect of NRHM was “to know about the strengths of the AYUSH systems” and to promote “a culture of cross-referrals”. Therefore apart from the infrastructural aspects, the coordination and healthcare delivery aspects in government facilities require to be monitored under the fulltime guidance of a Director for Indian Systems of Medicine/ AYUSH. Apparently the position had been vacant for some time.
v.
Better signage is necessary at the CHCs and PHCs particularly indicating how the public can benefit from the AYUSH systems and the specific areas where the systems have strength. There is a need to have standard instructions available for the guidance of patients. Likewise, there is a need for basic operational guidelines to be given to the contractual AYUSH doctors so that there is uniformity in following a regimen for the usual conditions (even as treatments may vary at times depending on the “constitution” or “prakriti” of different patients).
vi.
The treating allopathic doctors need to be made capable of advising the patient where to go (within the government facilities), in cases a patient asks for information on AYUSH facilities. This will not happen unless there is complete understanding at the highest levels of the health hierarchy and the
xlii Status of Indian Medicine and Folk Healing
vii. There was a suggestion made by AYUSH officials in Odisha that there should be an Advisory Board or Standing Committee which can give regular inputs to the Health Department about gaps that exist and how better coordination can be built up. This was mentioned by the PI during the meeting with the Odisha Health Secretary. Ideally, the Advisory Committee should be headed by a serving officer of the Department of Health who can translate the suggestions into practical strategies and obtain the orders of the Secretary quickly. viii. The engagement of part-time allopathic lecturers to impart modern medical education on specific subjects should be followed through soon. As this requirement to take classes has been given officially to the modern medicine doctors, it needs to be implemented without excuses. If honorarium and transportation charges are not being paid, it is unlikely that any member of the allopathic faculty would agree to give lectures in an Ayurvedic institution. The prescribed rate for outside lecturers appears to be Rs. 450 per lecture but even so the modern medicine doctors were not attending as required. Perhaps an arrangement could be worked out with the Kalinga Institute of Medical Sciences (KIMS) or some other professional institute which is qualified to undertake the responsibility on a continuous basis. ix.
Several positions of medical officers both
to which they belong. However, it is for policymakers to take an overall view because if the organization is not headed by a sufficiently articulate and resourceful officer, it would not be possible to infuse any dynamism into AYUSH service delivery.
Unani and Ayurveda appeared to be lying vacant. This needs to be reviewed. x.
An awareness programme needs to be built up on the State television channels where doctors and administrators with good communication skills speak about how the integration of the systems under NRHM can benefit the patients.
In States like Himachal Pradesh, Kerala, Karnataka, Gujarat, Rajasthan, Jammu & Kashmir and Odisha, there is a common Principal Secretary in charge of all aspects including Health, medical education and AYUSH. However, in the States of Maharashtra, Uttar Pradesh, Jharkhand and some others, AYUSH is combined under the Principal Secretary (Medical Education), and NRHM is handled by another Principal Secretary who is in charge of policy matters, the national programmes, government hospitals and rural health facilities.
That is one more reason to position a supervisory officer of a sufficiently high level as the Commissioner for AYUSH in Uttar Pradesh as functional linkages need to be established between the regular AYUSH and the NRHM AYUSH infrastructure and related matters like drug procurement and supply.
iii.
There is a critical need for improving and expanding the utilization of the Lucknow State pharmacy which is preparing Ayurvedic and Unani medicines and has a huge infrastructure available. If more medicines are supplied directly by the State pharmacy it would improve the availability of drugs round the year. Between Lucknow and Pilibhit pharmacies, a substantial part of the requirements of all Government facilities can be met. This would require enhancement of raw material supply and budgets for operational activities.
Uttar Pradesh i.
The State being very large, it is well known that there is huge diversity within regions, districts and communities. At the organizational level, it was apparent that with the absence of a senior unifying force to look after both Ayurveda and Unani systems, the hierarchy of each medical system was working independent of the other and with little collaboration.
ii.
There is a need to have a focal point which can act as a bridge between the professional people belonging to both the systems, to be able to plan, make overall recommendations and follow them up with the Health Department. A position of Commissioner (AYUSH) which could be filled from the Indian Administrative Service (IAS) or from the Indian Forest Service (IFS) (as was the prevailing practice in Andhra Pradesh) would provide much-needed leadership. The Andhra Pradesh example of having a generalist officer as the Commissioner would work better as the gaps to be filled are purely organizational and administrative in nature and not technical. This would avoid an intersystem tussle too. It is possible that there would be both criticism and resistance against such a move as all technical officers understandably have aspirations to reach the top of the organization
Summary of Major Findings and Recommendations  xliii
iv.
As far as traditional skills like bone setting are concerned, the practice is very popular and widely acknowledged as being the mainstay in rural areas. Even in a Government Medical College in Kerala, and in a few well-appointed nursing homes in that State, the practice of bone setting is being resorted to routinely and happens to be the first preference of numerous patients. Even educated patients interviewed by the PI in Kerala had told her that when bone setting is done by a skilled person, it reduces immobility and the attendant problems of shortening and stiffness of the limb, which accompany conventional fracture treatment. More importantly, surgery can be avoided if the patient has other health problems. It is necessary in a large State like Uttar Pradesh to make systematic efforts to get the AYUSH medical colleges to consider mainstreaming of such skills (not the bone setters) into Ayurvedic and Unani practice as Kerala has done.
v.
At the time the PI visited the State, the colocation of AYUSH doctors under NRHM was still to take off. Eventually, the State would be recruiting a very large number of doctors when the NRHM policy and strategies on AYUSH are adopted fully. An understanding needs to be reached on how integration is to be brought about between modern medicine and AYUSH doctors working in the same facility. There is a need to address the issue of the use of modern medicine by AYUSH doctors, which is not permitted in UP (Chapter on legal issues has brought this out).
Andhra Pradesh i.
The State has a post of Commissioner of AYUSH where an IAS officer is generally
xliv  Status of Indian Medicine and Folk Healing
posted. When the PI visited the State an Indian Forest Service Officer (IFS) was looking after the work of Commissioner of AYUSH. It is understood that this arrangement has since been made into a regular one. IFS officers already have a strong knowledge of plants and can get into AYUSH-related issues quite easily, particularly those relating to medicinal plants and drugs. IAS officers at the level of Commissioner get transferred frequently and the initiatives taken often loose momentum with each transfer. An IFS officer is more likely to stay for a longer duration. The position of Commissioner (AYUSH) seems to be unique to Andhra Pradesh and Tamil Nadu States. Having the position of Commissioner (AYUSH) helps because it provides leadership and continuity within the AYUSH sector. A senior generalist officer can apply strong negotiating skills to get the attention of the State Health Secretary and the health hierarchy including the modern medicine doctors. In Andhra Pradesh, the posting of a Commissioner appears to have helped to raise the level of acceptance of AYUSH and is a good model for other States to follow. ii.
The PI had requested for a brainstorming with modern medicine doctors also present to discuss approaches to integration which was not in much evidence in the facilities visited. However, during discussion there was opposition to any concept like integration beyond physical co-location. This negates the government policy on integration of AYUSH under NRHM. Unless it is understood and accepted by key people like the Directors of Health Services and Medical Education, the message may not translate into implementation.
The Department of AYUSH should get a suitable organization in the Health Sector like NIHFW, PHFI or NHSRC to partner with an AYUSH institution to hold sensitization programmes for senior State level medical functionaries. State institutions can also be enrolled to undertake similar exposure-cumorientation programmes as acceptance of the policy of integration at higher professional levels, is low.
explanation about the properties of the herbs along with service of a fresh decoction made on the spot would help propagate the benefits available from specific medicinal plants.
There seems to be immense scope for teaming up with universities and colleges to organize lectures and hands-on display on the cultivation and use of medicinal plants especially for those pursuing general courses on botany, pharmacology and Ayurvedic Dravyaguna.
The Institute offers an excellent location for meetings of the State Medicinal Plant Boards. Even if the temperate climate available at Joginder Nagar is unique only to Himachal Pradesh and other mountain States, it should be possible to engage stakeholders from Uttrakhand, Sikkim and some North-Eastern States in an exchange of experiences. This would facilitate interaction between cultivators, collectors and tribal people and  give greater visibility to the Institute. The Department of AYUSH/ NMPB should consider setting up a group of experts both from the field of botany, medicinal plant cultivation as well as tourism to use the potential of this institution to benefit a wider group of stakeholders. The NMPB should designate this as a resource centre too.
iii.
Pharmacy, Joginder Nagar
There is considerable scope for upgrading this pharmacy but what is needed even more is vibrant leadership. According to the figures given to the PI, the annual production capacity was 300 quintals. Both in terms of land availability and the proximity to the Joginder Nagar herbal garden, and the Ayurvedic Pharmacy College
Himachal Pradesh i.
The network of government-run Ayurvedic hospitals and health centres are actively engaged in providing Ayurvedic treatment but paucity of medicine and irregularity in the supply of drugs was found to be a recurring problem everywhere. This was taking away from the dedicated contribution of many District Ayurveda Officers as also from the continuity of treatment. There is every need to step up internal production in the State pharmacies to cater to the growing demand for AYUSH drugs instead of depending so much on purchased drugs which do not seem to be ordered or to reach in time.
ii.
Herbal Garden, Joginder Nagar (HP Government)
Since the specimens available in the garden as well as stocked in the herbarium are so plentiful, it would be worthwhile to place this institute on the tourist map of Himachal Pradesh as has been recommended in the case of Jammu & Kashmir also. The display of exotic medicinal plants, their properties, followed by a live demonstration of how decoctions are prepared could become an interesting and educative visit for tourists from other states. An
Summary of Major Findings and Recommendations  xlv
located next door, there is potential for increasing production. Human resources, plant material and space are readily available. With more investment and better coordination it would be possible to expand production.
With planned investment and professionally supervised production and supply it would be possible for the State pharmacy to meet 80percent of the basic drug requirement of the state dispensaries. Owing to problems of leakage, seepage, fungus which are common in hilly places, it is unlikely that medicines procured from other States would remain in good condition even if the vagaries of tendering and supply can be overcome. It would be far better to augment the supply from within the State and to see that at least 30 highquality medicines produced by the State pharmacies are collected by the District Ayurveda Officers every quarter. Steady availability of medicines would give a huge impetus to the propagation of Ayurveda for which there is high public demand as well as support at a policy level.
to come. Two Medical Colleges one each for Kashmir and Jammu division are under construction which may in due course take care of this problem to some extent.
The AYUSH doctors appointed under NRHM had not received in-service training in respect of their own system without which it would be difficult for them to become conversant with what is expected of them. The NHSRC report2 has pointed out that the NRHM appointees are only doing allopathic work which should be restricted.
ii.
Awareness & Publicity:
During the PI’s visit to the State, it was pointed out that there was huge expenditure on propagating general health benefits under NRHM but no funds had been made available for conducting training or issuing advertisements for the propagation and promotion of AYUSH systems. The Director (ISM) felt that a separate budget provision was needed to conduct seminars at the tehsil/block/ district levels and for publishing best practices and the beneficial effects of Ayurvedic and Unani systems for preventive and promotive healthcare.
Jammu & Kashmir i.
Medical Manpower Needs
iii.
Referrals
The state does not have any government college for Ayurveda and Unani medicine in the public sector, there being only three private colleges in the State, one in Jammu division and two in Kashmir division. Without educational institutions, the production of doctors for manning public sector facilities would become a problem in the years
While the receptivity at higher levels including at the level of the Secretary and Special Secretary for Health, the DHS and the Director NRHM was comparatively high compared to what the PI found in any other State, this had not permeated to the health facility level. Steps need to be taken to overcome the resistance of allopathic doctors to writing
2
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.
xlvi Status of Indian Medicine and Folk Healing
even a simple referral which does not constitute a recommendation to use any particular therapy but atleast facilitates a patient to go to an AU facility within the same complex instead of starting from scratch. iv.
Supervision and Reporting systems
The Director (ISM) and his hierarchy of AYUSH doctors do not have any role to play in the NRHM organizational structure and reporting systems. It has to be recognized that only the AYUSH doctors can suggest correctives when it comes to the AYUSH component of work done by the contractual AYUSH doctors recruited under NRHM. Hence, the Director (ISM) ought to be given official legitimacy and authority to check on the AYUSH work done in the public health facilities under NRHM, and his advice should be heard when the AYUSH activities under NRMH are reviewed.
v.
Practice of Modern Medicine by AYUSH (NRHM) Appointees
The tendency to do only allopathic work as backup support for the Primary Health Centres seems to be growing. The objective of positioning AYUSH doctors will not be met, particularly if the supply of drugs also remains nonexistent. Therefore, there is every need to strengthen coordination and reporting systems in which the Director (ISM) has a specific role to play in the State Health Society and the district AYUSH officers in the ISM Department coordinate and report on the AYUSH component of the work being done by the contractual appointees in the co-located facilities. Otherwise the contractual doctors will increasingly be used only as “additional hands”. That could not help the cause
of popularizing AYUSH in the State. vi.
Harmonization and integration
There is a need to sensitize the modern medicine doctors as well as the paramedics about the strengths of the AYUSH systems. Unless this is done, the tendency to look upon the introduction of AYUSH merely as a symbolic strategy will persist. The patients would ultimately lose out and the money being spent on so many contractual AYUSH doctors would not benefit the patients.
vii. Shalimar Garden and Herbal Garden at Nehru Memorial Botanical Garden (NMBG), Chasmashahi
The ancient Hammam (Turkish bath) which had been excavated at the Shalimar Gardens in Srinagar is being restored so that visitors and tourists could see the traditional Baths in their original form. It might be useful to link this with Unani concepts if research supports it, as the baths will be visited by thousands tourists once the restoration is done.
There is immense scope to develop herbal tourism and to heighten interest among visitors and tourists in the preparation and use of fresh decoctions. It appears that funds that have been given by the ISM Department to the Directorate of Horticulture under Medicinal Plants Mission had not been utilized. This was brought to the notice of the Secretary Health.
viii. PHC Gulmarg
If the single doctor on night duty is expected to attend to the administration of parenterals and to use emergency life-saving drugs, he should be trained for this and his competence should be tested also as the public cannot
Summary of Major Findings and Recommendations xlvii
distinguish between AYUSH doctors.
allopathic
and
ix.
Legal Empowerment Needed for AYUSH Doctors to Practice Modern Medicine
Since the AYUSH doctors are being regularly placed as the single doctor on night duty at the PHC, the health system should be clear whether such doctors should be administering injections and using life saving drugs and IV fluids. If that is the expectation, the doctors require hands-on training in hospital settings and the State should then notify the AYUSH doctors as competent to practise modern medicine under the D&C Act, 1940 which would give the doctors protection against court cases also. If they are not to perform certain functions it should be clear as to which staff member is authorized to perform the functions particular on night duty. As per Supreme Court directives, everything depends on what the State notifies.
The availability of treatment facilities needs to be notified along with timings and possible payments to be made by paying patients. This is because some skin conditions like vitiligo carry immense stigma and people are in search of treatment. People who use the internet would feel encouraged if all loose ends could be tied up before coming to a new city for treatment.
Arya Vaidya Shala (AVS) Kottakal attracts a large number of patients from India and many other countries too. Most of the clientele coming from outside Kerala come through the Internet. AVS although it is relatively far away from the airport and quite inaccessible manages to give full confidence to visiting patients from abroad and from within India. The strategies they have used ought to be studied and utilized to make things simpler for outstation patients.
ii.
Details about Unani treatment, herbs and other ingredients used in the treatment should be listed with full details and links on the website. The website can be developed using the IT services of a specialized institute like National Institute of Indian Medical Heritage (also located at Hyderabad) so that interested users can see the ingredients used in Unani drugs and their properties.
iii.
The CRIUM can become a flagship Institute for the treatment of skin diseases, but the physicians should be trained in handling questions, and ideally the treating physician should not be changed mid-stream during treatment.
Central institutions visited by the PI Central Research Institute of Unani Medicine (CRIUM), Hyderabad i.
The Institute is doing useful work particularly in the area of treating cases of vitiligo. However, for people coming from all over the country it may not be possible to stay at the Institute’s hospital continuously. It is necessary to build awareness about the facilities available for vitiligo treatment and patient care. The website should answer questions on the probable duration of treatment and of intermittent stay in Hyderabad. Paying guest/hotel arrangements need to be identified and listed on the website to give guidance and confidence to outstation patients who can then make their own arrangements.
xlviii  Status of Indian Medicine and Folk Healing
Ayurveda Regional Research Institute (ARRI), Mandi (HP) The PI was shown a good location where a new building is to come up but being on a steep
hillside, it is questionable how many people would take the trouble of reaching the spot which would need four-wheeled transportation for the most part. It was observed that the annual OPD of this Institute even when it is located in the heart of the marketplace at Mandi was just over 18,000 persons. The subjects selected for research studies are far fewer. The number would reduce substantially by moving to another location higher up on a hillside seen from the point of view of getting sufficient patients. This needs to be looked into. Regional Research Institute of Unani Medicine (RRIUM), Bhabrak (Odisha) The new building is well located and impressive but a dispute about a piece of land required to be sorted out with the State revenue authorities to avoid infructuous expenditure on a very large building, which from present indications was not going to be occupied in the near future because of a tussle with local users. The local RRIUM officers need to be supported by the CCRUM Headquarters. Herbal Garden at the Central Research Institute of Unani Medicine (CRIUM), Lucknow i.
ii.
There was no flexibility available with the in charge of the Institute for investment in gardening equipment, or for promoting water conservation and nets for preventing destruction of plants by monkeys. There appears to be a need to devolve greater financial authority on the local officers and to leave it to audit to check on the prudence of incurring expenditure. Centralizing all authority curbs initiative and the utility to the public remains a question mark. There also appears to be a need to involve students of both Ayurveda and Unani to visit the herbal garden and to play a more pro-active role in the
management of the garden to increase their understanding of the properties of various plants. iii.
Keeping this herbal garden as another small unit of CCRUM with no sustainable linkages with botanists, faculty members both from Unani and Ayurvedic side and university faculty and students, produces limited benefit. Such units need to be judged by their linkages and outreach performance and not merely by day-today, routine activities. The benchmarks need revision as the research output was not evident.
III. Postgraduate Education in Ayurveda–Filling the Gaps Undoubtedly the Central Sector scheme for the development of AYUSH Institutions which provided Grant-in-aid for infrastructural development of AYUSH Colleges has made a substantial difference to some institutions. But the overall production of postgraduates to pursue initiatives related to teaching, research and speciality treatment remains grossly insufficient. The extent of the problem has been recounted in detail in the chapter. The recommendations inter-alia include the following suggestions: Manpower Study A manpower Needs Assessment Study needs to be undertaken to take stock of the gaps that remains after making a notional assessment of the annual out turn of postgraduates and their placement. Since the gap is already very large and is likely to grow, some emergent measures need to be taken to augment the number of seats available for post-graduation. That in turn would depend upon the availability of teachers to take PG classes. Therefore short-term and medium-
Summary of Major Findings and Recommendations  xlix
term plan for expanding PG education needs to be evolved. Increasing PG Seats in Under-represented Speciality Areas There are about 2421 Ayurvedic hospitals and about 15017 Ayurvedic dispensaries throughout the country (as on 1.4.2012). If at least one postgraduate is considered essential for each clinical branch of Ayurveda (Kaya Chikitsa, Bal Roga, Shalya, Shalakya and Prasuti), hundreds of postgraduates would be needed in each discipline to meet the health care needs within hospital settings as well as provide private practitioners who also draw a huge clientele. Increasing PG seats is a necessity if specialization is to be promoted. Purely as a short-term measure, it may be considered whether qualified experts from the Research Councils for Ayurveda (as well as Unani and Siddha systems, if they face a similar paucity of teachers and postgraduates) could be inducted to take on teaching responsibilities for postgraduates with the approval of affiliating Universities. If that is allowed, the identified research institutes of CCRAS (also CCRUM if required) could register students for MD and PhD degrees after obtaining affiliation from the nearest university. A twinning programme could be arranged with the faculty of nearby Ayurveda colleges so that the CCRAS research units can conduct PG education and research together. The CCRAS scientists could be authorized to guide selected MDs and PhDs in addition to their core research work which would be beneficial for both, as it would bring much needed dynamism and productivity into the research institutes. The research staff of the Council could be given short-term reorientation and training to equip them to undertake teaching.
l  Status of Indian Medicine and Folk Healing
Minimum Standard Requirements (MSR) of Ayurveda Colleges & Attached Hospitals Regulation, 2012 Need for Accreditation System for AYUSH Colleges It is recommended that an accreditation system for AYUSH colleges may be considered to evaluate the adherence to standards instead of a once-in-five-years inspection. Regular evaluation needs to be undertaken by an accreditation agency as was envisaged for the National Council for Human Resources in Health (NCHRH) as the general feeling is that most institutions would not take matters seriously, knowing that there would be no oversight for several years. Engagement of Retired Faculty The introduction of video-taped interviews should be introduced before engaging retired faculty members after the age of 65 years (which has been made permissible under the new regulations.) This is necessary because some of the older faculty members are unable to keep the interest of the students alive and it is better not to re-appoint them mechanically, regardless of competence and teaching ability. Revamping the Syllabus and Curriculum The structural changes will only have an impact when the syllabus and curriculum also undergoes a change and keeps pace with contemporary demands. In order to make the postgraduates more research oriented, they need to be encouraged and recognized if they publish in high impact journals. They also need to improve their language and internet skills. This had been dealt with in detail in Part I of Status Report. It is essential that research techniques and computer skills, which are essential tools to gain entry into the field of high quality
publication, are taught to the students as soon as possible. These aspects need to be included in the syllabus, and qualified parttime teachers need to be engaged for giving this exposure on a continuous basis. Some of the funding that is made available under the Central scheme should be earmarked for giving exposure training in research institutions like AIIMS, PGI Chandigarh, the GB Pant Hospital at Delhi, the CMC Vellore among others. Even by sending batches of two or three students to a research institute in the medical field to observe and learn from the rigours of independent research, the present tendency to gloss over the need for conducting scientific research with rigour may be better understood. Such initiatives would need to be taken centrally by having a steering committee with members from ICMR and the Directors of AIIMS, PGI Chandigarh among others. The Committee’s role would be to design research exposure programme for AYUSH doctors so that they get sufficient knowledge of how independent research is conducted.
IV. Building Credibility for Panchakarma Years ago, only skilled people performed Panchakarma therapies which form the backbone of Ayurvedic therpeutics. Nowadays the procedures are practised lasting for vastly differing length of time. Owing to the absence of standardization of Panchakarma procedures, patients face a dilemma about whether the procedures were executed fully. Specific protocols for each procedure have been recounted in the ancient texts but unless there is oversight the tendency to cut corners does arise. Despite Panchakarma’s immense potential both as a direct as well as a supportive therapy, it is not widely accepted as effective and trustworthy. The main recommendation is therefore to do everything possible to
position Panchakarma at par with Chinese Accupuncture which has a proper licensing procedure. The following suggestions may be considered: Effectiveness Studies There is a need to build substantial evidence to show the benefits of Panchakarma as a therapeutic intervention. Several observational studies are required to justify what today are mere claims. The efficacy of Rasayana (rejuvenation) drugs need scientific endorsement and by simultaneously setting up two similar groups of patients - one which undergoes Panchakarma and another which does not, outcomes can be evaluated in comparative terms. Unless such evidence is documented following an acceptable protocol and the co-researchers on the team are from related disciplines, the outcomes, even if they are very positive and claims about effectiveness may not be trusted. Evaluation Studies on Patient Responses There are no prescribed end points in terms of primary and secondary outcomes. As such there is a need to atleast evaluate the patient’s perception of his expectations and experiences which would help identify the gaps between the “perceived” and the “practised” standard of Panchakarma procedures at different facilities. Evaluation of Panchakarma
Functional
aspects
of
Research has shown that trainees (who generally administer the procedures) tend to offer procedural explanations to the patients but owing to their limited experience and over enthusiasm, there is a possibility of over-projection of expected benefits. The non-involvement of senior consultants in the process of explaining the processes to the patients has been viewed as a deficiency.
Summary of Major Findings and Recommendations li
Hence the following recommendations are made:
by all State Government Ayurvedic Hospitals that provide Panchakarma treatment.
i.
The delay caused by “waiting for turn” should be reduced without compromising on the quality of services. The Model followed by AVS Kottakal and some other centers should become the benchmark for the duration of procedures as well as essential equipment and consumables that would need to be used. AVS Kottakal has checklists for each procedure which can be seen by the patient also.
ii.
Privacy for women should be assured as it affects their receptivity to undergoing treatment.
It is also necessary to encourage reputed Panchakarma centres in the private sector to acquire accreditation as there is a low level of hygiene and general upkeep in many facilities. Accreditation will provide minimum benchmarks for hygiene and give users more confidence about the facility. Department of AYUSH could also give a bridge loan to reputed private facilities to get NABH accreditation on the condition that they treat an agreed number of referred cases sent by the Government facilities.
iii.
iv.
Patients need to feel comfortable during the process of preparation and during the actual treatment. Uncertainty leads to stress which impacts negatively on the outcomes. Cancelling or refusing Panchakarma services due to breakdown of equipment or absenteeism of staff should be monitored to bring in more professionalism. A thorough recordkeeping of the equipment and regular supply of all consumables is necessary to improve efficiency.
Standard Operating Procedures Accreditation for Panchakarma Centres
and
Standard Operating Procedures (SOPs) for Panchakarma needs to be introduced for all centres whether in the government or private sector. The National Accreditation Board for Hospitals and Healthcare Providers (NABH) has brought AYUSH hospitals and wellness centres under its ambit. It has issued detailed guidelines on services to be maintained by AYUSH hospitals aspiring for certification. There is a need to introduce a Central Scheme to support the acquisition of NABH Certification
lii Status of Indian Medicine and Folk Healing
Need of Guidelines for Ayurvedic Panchakarma Massage Parlours There has been a phenomenal increase in the demand for specific Panchakarma procedures to enhance beauty and provide relaxation. Most five star hotels and high-end tourist resorts provide some form of Panchakarma limited to massage and Shirodhara. Since the name of Ayurveda is being used, there should be a requirement for such procedures to be performed only by qualified staff. Care has to be taken that the fair name of Ayurveda or Panchakarma does not fall into disrepute. By involving the Tourism Departments of the states through the Ministry of Tourism it would possible to bring uniformity in the services provided, when the service is claimed to be a part of Ayurveda. If they are merely offering massage services, it needs no intervention. However, the use of the term Ayurvedic massage or Panchakarma should have attendant requirements that have to be fulfilled on the lines of the green leaf strategy of Kerala State. Establishing a ‘Centre for Scientific Research in Panchakarma In the long term there is a need to plan for a Centre where the related validation
studies can be undertaken or alternatively to fund research which can be undertaken in leading medical research institutes which can permit the use of their equipment to test the change in markers and physical parameters of the patient after undergoing different procedures. A group of scientists from Ayurveda as well as related modern medicine research fields including biophysicists needs to be set up to agree on measurement devices and markers that can evaluate different parameters to establish the efficacy of each intervention separately. That is a long-term measure. In the short-term since most of the subprocedures of Panchakarma seem to be a part of physical medicine as seen from a contemporary perspective, a Panchakarma unit should be started at the All India Institute of Physical Medicine and Rehabilitation (AIIPMR), Mumbai. Collaborative studies can be undertaken with AIIPMR which would be a simple way of determining the effectiveness of Panchakarma procedures. There is likely to be no resistance as that Institute is generally interested in pursuing procedures that help the rehabilitation of physically challenged patients. There is no doubt that Panchakarma has a strength in the areas of restoration and rehabilitation. AIIPMR receives the kind of patients that would benefit from such treatment. The Institute comes under the Ministry of Health/Directorate General of Health Services.
Manesar, Haryana (Deemed University under Department of Biotechnology, Government of India) if Department of AYUSH approaches them and also funds the project. ICMR should be involved in identifying the most appropriate scientific centres run by different agencies.
Research Study on Shirodhara - A Model to Follow
Need for a policy on the revival of State Pharmacies
A study which has been referred to in the main chapter had described the efficacy of Shirodhara when it is undertaken in a standardized reproducible manner. This study can be a model for similar studies to be undertaken on the efficacy of Shirodhara once a centre is established. Studies could also be undertaken in collaboration with the National Brain Research Centre (NBRC),
A policy on the revival of State pharmacies needs to be made as the provisioning of drugs has to go hand-in-hand with the appointment of hundreds of contractual doctors under NRHM. Even if funding for drugs is provided for the NRHM facilities, efforts would need to be made to compress the time taken for the drugs to actually reach the facilities. The procurement process is ridden with
Promotion of Panchakarma on the lines of Chinese Acupuncture Despite its popularity, Panchkarma is underutilized at a global level as compared to Acupressure and Acupuncture. Clinics for such procedures are available in abundance, particularly in the US. Chinese acupuncture is available with full certification of therapists and technicians. In the US such staff is not only of Chinese origin but can belong to any nationality. There is a need to gain similar foothold for Panchakarma services by offering courses for students in the US, leading to the grant of a licence. Initially such courses can be started with the approval of any US State authority which is prepared to allow such courses to be run in that State. Ayurveda and Panchakarma do not need endorsement from the US. However that is one of the most effective ways of marketing authentic and effective Panchakarma services. The recommendation should be seen in that spirit. V.
A Study of Selected State Pharmacies
Summary of Major Findings and Recommendations  liii
procedural problems. If the ultimate goal is to see that AYUSH is mainstreamed, out-of-theway measures would need to be taken to run the State pharmacies in a cost-effective and efficient way. It must be recognized that total reliance on budgetary support and supplies made under NRHM or Department of AYUSH would never be able to meet the requirements of the hospitals and stand-alone facilities, which are completely a State responsibility. Recommendations Based on the Outcome of a Visit to six Randomly-selected State Pharmacies i.
All State pharmacies should be able to prepare and supply at least 30percent of the demand of medicines required by the government-run hospitals and dispensaries to avoid large scale shortage of drugs which exists at most facilities. Instead of giving small grants to the States as a part of an overall scheme, central funding should be related to improvement in production in specific identified pharmacies.
ii.
Quality control is an important aspect of GMP. State Government Pharmacies should adopt proper quality control processes. This needs to be reviewed periodically by engaging an independent agency before funds are released for specific pharmacies (and not in bulk) so that improvements can be evaluated.
iii.
The utilization and upkeep of equipment needs to be monitored by the State AYUSH Department. Compliance certificates should be obtained annually from each pharmacy and periodic external checks should be instituted to verify the status.
iv.
Pest control procedures should be prescribed and a certificate of compliance obtained annually.
liv  Status of Indian Medicine and Folk Healing
v.
Waste disposal guidelines should be issued and a compliance certificate obtained annually.
vi.
The staff strength should be suggested by Department of AYUSH on normative lines and should be related to capacity utilization and production.
vii. Plentiful space that is available at most State pharmacies should be utilized properly. The demand and supply of drugs needs to be planned properly at the State level and a fixed percentage of the drugs required to be supplied only by the State pharmacies. viii. The revival of such pharmacies may require changing the terms of engagement of the staff, and moving to a higher standard of financial management and production. This would also require that rules applicable to industrial units would need to apply as working only during government working hours is inefficient. State pharmacies working on commercial lines are functioning quite successfully if the examples of TAMPCOL in Tamil Nadu and Oushadi in Kerala are considered. In the interest of using the capacity nearer home so that the uncertainties of transportation and storage are minimized, there is a need to follow the examples of Tamil Nadu and Kerala. Even if a couple of States set up a joint sector undertaking, it would be a great beginning.
VI. Regulatory Framework for ASU Drugs Recommendations Related to AYUSH Drugs Quality Control i.
The new clientele of AYUSH drug users is becoming increasingly discerning and conscious about safety and quality. For
They are not only prescribing allopathic medicines but are being trained to handle different situations that arise in health settings. Their posting as the sole in-charge necessitates them to be conversant with the use of emergency measures. But in that case the States have to use the provision of the D&C Act, 1940 to make appropriate notifications to support such practice. Such notifications cannot then be confined solely to Government appointees. They would apply to all ISM/AYUSH doctors that have graduated after the recognized degree course. The example of States like Maharashtra would then need to be followed to give legal cover to the AYUSH doctors. The most balanced approach would be to allow ASU doctors to practise modern medicine to the extent that is needed at the primary health centre level, while accepting that would need to include immediate response to emergencies, acute illnesses, besides routine illnesses. The contractual AYUSH doctors should be trained to handle such situations through posting in government hospitals before being posted as the sole in-charges of PHCs/ CHCs.
this, the regulatory and enforcement authorities have to show zero tolerance for indifferent quality. The number of statutory and ordinary samples collected and the findings and follow-up action taken needs constant review at the State level. ii.
At least one percent of the drugs in the market should be obtained as survey samples (not statutory samples), tested and the outcomes of laboratory testing publicized. The work of the State licensing and enforcement authorities needs to be monitored constantly. This is a very weak link.
iii.
The position of Drugs Controller General for AYUSH needs to be created with the full complement of supporting staff.
iv.
Most of the State governments appoint Drug Inspectors (Ayurveda) (Unani) from among Ayurvedic Medical Officers except in States like Delhi and Kerala. Sometimes a member of a college teaching facility is given the responsibility. There ought to be separate qualifications prescribed in the recruitment rules along with previous experience of regulatory work for engagement of AYUSH drug inspectors. This should be adopted on an all India basis which will strengthen quality control.
v.
ii.
As far as private practitioners are concerned, the State should notify that ASU doctors using modern medicine need to avail of a training which equips them to handle emergency situations excluding surgery. Against the payment of a fee which the States should prescribe, medical colleges and hospitals may accredited for conducting such training confined to stabilizing the patient who needs emergency intervention, before he can be referred to an appropriate facility.
iii.
A certificate of having acquired this training should be issued by a State
Branding of Ayurvedic drugs should not be banned as this prevents investment in R&D and marketing of classical medicines. This was explained at length in Part-I of the Report under the chapter on Drugs.
Recommendations related to Practice of Modern Medicine i.
It is evident that Ayurvedic doctors are managing several health facilities as the sole in-charges of PHCs and CHCs.
Summary of Major Findings and Recommendations  lv
Board and the display of the certificate made mandatory. Side by side, a list of interventions and drugs that must not be used by ASU practitioners should be listed to remove all ambiguity.
i.
RAV needs to reinvent itself while continuing with its core activities. If this institution is to grow, a person who is conversant with the higher education sector and preferably one who has served as a Vice-Chancellor or a similar position is needed to provide leadership as Chairman of the Governing Body.
ii.
The status of this unique institution has been described based upon the findings of a survey which was administered as a part of this study. The extent to which a selection of the Gurus and Shishyas has been done objectively and whether the experiment is leading to positive outcomes by way of imbibing practical skills has been commented upon, based upon the responses received. The efforts made by the Institution were found to have led to some positive outcomes though these are limited to one aspect of practical exposure only. Since there were two earlier committees which had given reports on this institution, the extent to which their recommendations have been given effect to have been referred to.
RAV can also be made as a functional body to regulate and conduct courses on AYUSH paramedical education (Diploma of two years) or a oneyear certificate course including ASU Pharmacy education, ASU Nursing, Panchakarma technicians’ course. RAV could also organize or run basic Ayurveda Education for Allopaths and selected visitors from abroad. RAV can enter into Memoranda of Understanding with State colleges and State pharmacies to impart AYUSH paramedical education and take on the role of the certifying authority until an independent Council is established to regulate standards.
iii.
RAV’s terms of reference, aims and objectives need to be augmented so that the Institute organizes study tours and exposure visits for the college going children of NRIs who are looking for avenues to learn about their roots combined with an exposure to Indian culture which includes Indian Medicine.
Recommendations for Upgrading the Institute for Formal Teaching
VIII. National Institute of Indian Medical Heritage (NIIMH)—A Historical Overview and Major Contributions
iv.
Unless the State notifies that the AYUSH doctors can practice modern medicine under the Drugs & Cosmetics Act, 1940, the mere issue of executive instructions could be violative of the Supreme Court's orders and hence the States should be alerted about the need for issuing appropriate notifications.
VII. Guru-Shishya Parampara—A Critique of the Rashtriya Ayurveda Vidyapeeth
Besides conducting the Guru-Shishya courses which are basically to improve exposure and learn skills, there is a need for RAV to move into more structured education also. The suggestions made by two earlier Committees set up by the Government (Reports have been annexed) do not appear to have been acted upon fully.
lvi Status of Indian Medicine and Folk Healing
This is a unique institution under the Central Council of Research in Ayurvedic Sciences. It is one of the earliest institutions set up for studying the history of medicine emanating from the advice of eminent medical historians and others from the renowned Johns Hopkins
University in Baltimore USA. The institution has been working primarily in the area of documenting the result of historical research and is now focusing on providing easy access to all the information and documentation that has been collected. Recommendations Visibility i.
for
Giving
Greater
The Institute should hold an Annual Conference in which academics who are working in the History of Medicine field are invited along with publishers who specialize in this area. Linkages should be established with international scholars who are proficient in Ayurveda and Unani medicine or are studying Sanskrit/Arabic/Persian manuscripts so that they know what the Institute can do for them.
ii.
The Institute should set up on Advisory Committee with representation from different stakeholders, from multidisciplinary backgrounds like history of medicine, anthropology, political science and also from the world renowned Johns Hopkins University, USA so that new ideas are generated and the institute becomes a gateway for scholars and students of the History of Indian Medicine.
iii.
NIIMH should maintain a database of AYUSH PG/PhD theses, copies of good AYUSH journals, including other traditional systems and establish reading halls so that research can be undertaken in comfortable, wellequipped surroundings.
iv.
The Institute should be permitted to accept registration fees for seminars and conferences and the funds can be permitted to be used for hiring good facilities for conferencing, boarding
and lodging of out-station participants. However all such functions should be outsourced to a suitable agency as the Institute has no in-house capacity to handle this.
IX. Folk Healing Practices of the North East The folk healing practices of eight States in the North East namely Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura have been recounted based upon field surveys conducted by academic and teaching institutions in the North-East. Recommendations for Giving Certification to Folk Healing i.
The efforts which are being made to conserve and revive folklore in the North East and to give it validation and recognition are good initiatives seen on a broad plane. But there is a need to understand the dynamics of accepting the responsibility for the selection of healers considered fit for “certification�. The aim of such certification needs to be spelt out. If it is to give legitimacy the question of how the standards for inclusion were selected and the credibility of the certifying agency would need to be prescribed. There is also a need for clarity about entitlements which accrue as a result of certification. Sooner or later the aspirations of those who have received certification will grow and demands for parity or some other recognition will start. At that time the basis for selection of healers may arise which should be anticipated from now so that the process is clearly understood.
ii.
The efforts to understand and document the folk healing practices are very good. However, it is necessary to have an
Summary of Major Findings and Recommendations  lvii
overall idea of where this would lead. The Ministry of Environment & Forests and the Ministry of Tribal Affairs have had considerable experience of dealing with allied subjects of rights, entitlements and protection of sui generis knowledge. The NEIFM needs to become a nucleus around which past endeavours in the area of folk healing can be collated at one place for the North East region. The Institute should start by building networks and accessing studies and reports which were undertaken elsewhere. iii.
iv.
With the increase in deforestation, forest fires and overexploitation of medicinal plants, there is also a need to sensitize the people about the need to preserve the forest and promote herbal gardens. NEIFM should shoulder this responsibility by networking with an organization in each State which can implement approved strategies. Scientific validation, reverse pharmacological and observational studies are required to understand the healing properties of plants outside the codified systems focusing on those plants which are being used extensively by the healers but are outside the ASU formularies. The outcomes need to be published in botanical journals.
The State-specific recommendations are not being repeated as they are by and large, common.
X. Ayurvedic Veterinary Products – Status and Future Prospects The scope for the development and propagation of Ayurvedic veterinary medicine has been brought out and the opportunity that is available for selectively moving from chemical additives to safer alternatives
lviii  Status of Indian Medicine and Folk Healing
has been described. This is with a view to benefiting the public as consumers of milk, poultry, eggs and meat. Need to Prepare an Ayurvedic Veterinary Pharmacopoeia There is a need to prepare and publish a separate Ayurvedic Veterinary Pharmacopoeia covering the Ayurvedic veterinary products. A separate veterinary Pharmacopoeia has been published in the case of synthetic drugs and pharmaceuticals (Published by Indian Pharmacopoeia Commission). It is understood that the newly formed Pharmacopoeia Commission for Indian Medicines (PCIM) has formed a Veterinary Ayurvedic Committee to initiate this work. However, the availability of resources and other facilities needs to be looked into so that the work is expedited. Separate Wing for ASU Veterinary Sector There is a need to initiate inter-ministerial dialogue/cooperation between the Department of AYUSH, Ministry of Health and Family Welfare and the Department of Animal Husbandry, Ministry of Agriculture and the Veterinary Council relating to the use of Ayurvedic medicine for Veterinary use. Within the Department of AYUSH there should be one technical officer who can focus on specific needs of the veterinary sector and facilitate processing the approval of new regulations needed for this sector. He should visit the factories making Ayurvedic Veterinary medicine to understand the processes etc. Presence on the ASUDTAB The AYUSH veterinary sector should be given greater representation on the ASUDTAB. There are several government notifications which have been issued keeping only the human application of ASU medicines in mind. There is a need to either exempt ASU veterinary medicines from the purview of such notifications or to look
into their applicability for the veterinary sector. Ideally, animal- specific standards need to be prescribed for quality control as well as other aspects like labeling.
can use cheaper alternatives as substitutes. However, unless the regulations envisage and encourage this, the cost-effectiveness issue will not be overcome.
Training Veterinary Manpower about Ayurvedic Medicine for Animals
The Ayurvedic veterinary sector is still small but it has a huge potential given the interest in natural products and the large population of animals and poultry that can be treated for some conditions without resorting to the use of chemical drugs. Greater encouragement to R&D and awareness building through participation in Animal Husbandry camps and schemes would popularize the use of Ayurvedic veterinary products.
The number of veterinary doctors being limited, they generally attend to serious and complicated cases only. A vast majority of the common metabolic disorders (which are generally self limiting and non-life threatening) are attended to by VLIs, VLW’s and AIW’s. Most of the licensed Ayurvedic drugs are meant for common metabolic disorders. The State Departments of Animal Husbandry need to be sensitized about the availability of Ayurvedic products and to start including them in the inventory of stores. There is a need to encourage the paramedical veterinary manpower to understand the benefits of traditional veterinary medicine. Companies engaged in the manufacture of Ayurvedic veterinary products should be encouraged to impart know-how and training to the para workers and to livestock and poultry farmers. This requires official acceptance by the DGHS/NCDC/Department of Animal Husbandry. This further requires the AYUSH sector to assemble these players and oversee that the process starts. Prioritizing ASU Veterinary Sector Ayurvedic veterinary medicines are generally sold based on their relatively lower cost compared to modern medicine. While the Ayurvedic products were once cheaper, since the main ingredients being used are medicinal plants which are becoming costly, the Ayurvedic veterinary medicine is losing out on its major usp–its comparatively lower cost. There is a need to encourage research and simplify regulations so that manufacturers
Need to Create Balya-Poshak/Positive Health Promoter Drug Category There are a large number of animal feed supplements of both synthetic as well as herbal origin. Such herbal feed supplements are often a combination of vitamins and nutrients mixed with herbal powders and/or extracts. This requires that a new category is introduced with separate requirements for animal use. To overcome the apprehension that the Ayurvedic Drug Licensing Authorities may object to the combination of herbal ingredients with synthetic ingredients like vitamins and nutrients there is a need to arrive at an understanding and to declare what is expected. The Food Safety and Standards Authority of India (FSSAI) have apparently yet to prepare guidelines for licensing veterinary products. Therefore, there is a need for Department of AYUSH to take a view on responsibilities for laying standards and for monitoring this sector.
XI. Initiatives with a Difference It is expected that the two initiatives described in the Report viz. the Science Initiative in
Summary of Major Findings and Recommendations lix
Ayurveda (ASIIA) and the Vaidya-Scientist Fellow Program would open up a new approach to the study of Ayurveda. A wider public should be made aware of such initiatives in order to create hope that if past efforts have not yielded substantial results, one can anticipate better outcomes from such new initiatives which are on the anvil.
XII. Transformation Needed Studying Integration in China Sending Delegation to Study Success of TCM in China An important goal of NRHM and the overall health policy has been to mainstream AYUSH into healthcare delivery. China achieved integration of modern medicine and Traditional Chinese Medicine (TCM) decades ago. Although several delegations have visited China, there is a need to send a cross-section of health system managers namely a Medical Superintendent of a Central Government hospital, and selected State Directors General and Directors of Health Services to visit China to understand how integration of TCM at different levels of health care delivery has taken place. Time needs to be spent on specifically observing how integration takes place at the patient’s level, instead of making general visits to institutions which have been made several times. A team comprising one modern medicine Doctor, an AYUSH physician and a hospital administrator may be asked to prepare a paper on the integration that was observed, particularly how cross referrals were managed after initial registration of the patients. This needs to be studied keeping in mind specific medical conditions so that the operating procedures that are followed when modern medicine and TCM are used together are clear.
lx  Status of Indian Medicine and Folk Healing
Promoting Research under the Aegis of NCCAM Designing and Pursuing Meaningful Grant Proposals It would be useful to select a team of AYUSH doctors who are already publishing papers (the Benaras Hindu University, Department of Ayurveda has several such faculty members) to conduct an up-to-date search of Complementary and Alternative Medicine (CAM) projects that have been funded by the National Centre for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH) in the US in the last five years. The subject areas and conditions under which research grants have been given to researchers from different countries and institutions need to be gleaned. With the help of ICMR the effort should be to get good research proposals accepted by NCCAM. Also to facilitate foreign researchers interested in conducting research in India to undertake collaborative research. Protocols are already available in the Department of Health and the Ministry of External Affairs and ICMR to approve such collaborative projects. This is necessary to get global recognition. Promoting High Quality Research and Publications It is important to give continuous support to journals because they bring credibility to the research work that is being done which will help raise acceptance of the systems and also the standard of further research and published work. Part I of the Status Report had already indicated the paucity of published research emanating from the AYUSH sector. Apart from the fact that the Research Councils have been unsuccessful in publishing papers of real significance in high-quality journals, even the universities and colleges have not been able to make any impact on the canvas of publications on Complementary and Alternative Medicine. The publication of good journals from India provides a platform and
therefore such journals need to be encouraged and supported with financial support to make them viable. No journal can be published without proper editorial and research staff engaged on a full-time basis and funding has to keep that in mind. Guidelines on Research Proposals The system for screening and approving requests for publication of journals should be independent of any bureaucratic or departmental approvals. Once a high level committee of well respected experts is set up, it should be left to the Committee to finalize the grants within the budeget provided which should be generous. Acting Against Exaggerated Advertisements that make Medical Claims The Drugs and Magic Remedies (Objectionable Advertisements) Act (DMRA), 1954 and the rules thereunder were enacted way back when the production of pharmaceuticals was very small. Under this Act, advertisements related to childbirth, women’s diseases, menstrual disorders, infertility and impotency, treatment of severe infections and certain other diseases like cancer, rheumatism, diabetes, and hypertension are prohibited. The AYUSH sector has unfortunately become notorious for publishing exaggerated claims and cures including the above areas. The labelling provisions make unacceptable claims and many educated patients turn away from using even simple medicine because of such claims. Starting Toll-free Helpline A mechanism should be introduced whereby the departments of AYUSH at the State level warn the public through newspaper advertisements and on television that there are centres as well as manufacturers of medicines that make claims about curing intractable diseases like Cancer and HIV/AIDS and
diabetes. The public should be asked to seek advice from an All-India toll-free number (to be set up by Department of AYUSH) to guide the caller. Standard responses should be available on the monitor for helpline staff to give guidance. These should be prepared by experts but converted into commonly used languages-English and Hindi. A model for this is already available in the Call Centre initiative taken by the Ministry of Health’s Call Centre run by the Jansankhya Sthirata Kosh for reproductive and child health. Cancellation of Licence All Ayurvedic and AYUSH hospitals that advertise claims of curing certain intractable diseases should be sent a notice that the hospitals/ nursing home licence would be cancelled if such claims are made. State governments need to be given a doable set of guidelines as to how they should deal with these situations and at least a couple of cases in a year should be followed up; which can stand as examples for other States to follow with tenacity. Uniform Policy on Reimbursement of AYUSH Treatment The Department of AYUSH should take steps to convince all Ministries and Departments to reimburse medical expenses on AYUSH treatment taken by employees and dependents suffering from specific conditions in recognized facilities. AYUSH treatment should be permissible in any AYUSH facility in the case of an employee requiring rehabilitation after undergoing an accident or injury suffered in the course of performing duty. In the case of non-duty related conditions and in the case of other employees of Central Government and their families, specific package deals should be recognized upto a specified amount to be undertaken in hospitals recognized by Department of AYUSH.
Summary of Major Findings and Recommendations lxi
1 Status of Integration
Status of Integration Health Seeking Behaviour and Medical Pluralism
3
Congruence of Traditional and Modern Medicne
14
Status of Adjuvant Use of Ayurveda and Unani Medicine
22
Brain-storming to Decide Priorities for Part-II
22
Special Survey on Adjuvant Use of Ayurveda and Unani Medicine
22
Experiences with Integration – Physicians’ Observations
24
A Corporate Sector Initiative with Integrative Medicine
35
Contemporary Ayurveda and Ethical Marketing of Ayurvedic Drugs
40
The History of Ethical Marketing of Ayurvedic Drugs
40
PI’s Interview of HDC Professionals
43
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
53
Annexure-II: Joint Letter of Secretary, Health and Secretary, AYUSH to States
56
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
58
Annexure-IV: Questionnaire to Investigate the extent of Adjuvant AYUSH Therapy with Patient Responses
61
Annexure-V: List of Experts/Faculty/Practitioners who commented on Survey outcomes on the Adjuvant use of AYUSH
62
Annexure-VI: List of leading Pharmaceutical Companies engaged in manufacturing Ayurvedic Medicines
63
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 “invented� 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 Integration  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 Integration  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.
3.
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.
4.
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
on
Policies
of
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.
2.
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
2.
Uttarakhand Good Poor
3.
Orissa
Good Fair
4.
Bihar
Fair
Co-location not started at the time of survey
5.
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
6.
Assam
NA
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.
7.
Manipur
NA
Fair
8.
Nagaland
NA
Poor
9.
Sikkim
NA
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
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)
2.
When AYUSH drugs are not available and the AYUSH doctor works below the M.O. incharge. (Instructions are available)
3.
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
4.
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;
2.
106 medicines fall under the category of S and T and
3.
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 .
2.
Standard guidelines are needed on making referrals intra the co-located facilities to facilitate patients.
3.
The expectations from AYUSH doctors
4.
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.
5.
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 Integration  23
Experiences with Integration-Physicians’ 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
24  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 “potentiates the action of modern medicine and reduces the harmful effects of strong drugs.� 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 Integration  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.
28  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.
30  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. Bell’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.
32  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).
2.
Influence of Abana on experimental atherogenesis in hypercholesterolaemic rabbits. Japanese Heart Journal (1993).
3.
Evaluation of Geriforte, an herbal geriatric tonic, on antioxidant defence system in Wistar rats. Annals of the New York Academy of Sciences (1994).
4.
Radioprotective effect of Abana, a polyherbal drug following total body irradiation. The British Journal of Radiology (2004).
5.
The efficacy of Liv-52 on liver cirrhotic patients: A randomized, doubleblind, placebo-controlled approach. Phytomedicine (2005). Urban & Fischer, Germany
6.
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
in
preventing
health such osteoporosis etc;
as
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
of
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
o
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 “prescription drugs�, 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 Integration  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.
52  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 Integration  53
54  Status of Indian Medicine and Folk Healing
12th August 2005
Status of Integration  55
Annexure-II Joint Letter of Secretary, Health and Secretary, AYUSH to States
56  Status of Indian Medicine and Folk Healing
Status of Integration  57
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
2.
Prof. S. Shakir Jamil, Director General CCRUM, New Delhi E-mail:unanimedicine@gmail.com
3.
Dr. Ramesh Babu Devalla, Director General CCRAS, New Delhi E-mail:dg-ccras@nic.in
4.
Dr. Shoeb Qasmi, Director, Directorate of Unani Services 9th Floor, Indra Bhawan, Lucknow (Uttar Pradesh) Phone:0552-2288515 Mobile: 09935372566
5.
Dr. Kabir Dar, Director, Indian Systems of Medicine & Homoeopathy Srinagar (Jammu & Kashmir) E-mail:drkabir@rediffmail.com, dismjk@gmail.com Mobile: 0941206656
6.
Dr. Khalid M. Siddiqui, Asstt. Director (Unani) CCRUM, New Delhi
7.
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
2.
Dr. Maqbool Ahmad, Assistant Director (Unani) CRIUM, Lucknow (Uttar Pradesh) Mobile: 09415547368
3.
Dr. Mohammad Haroon, Private Unani Practitioner Village: Mustafabad ,Near Jwalapur,Distt. Haridwar (Uttarakhand) E-mail:haroonalig1@gmail.com Mobile:09716478542
58  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
2.
Dr. Om Raj Sharma, Assistant direct (Ay.) Ayurvedic Regional Research Institute (ARRI) Mandi (Himachal Pradesh) E-mail:dr.omsharma.mandi@gmail.com Mobile:09418073962
3.
Dr. Sarada Ota, RO (Ayu) CCRAS, New Delhi E-mail:sarada_ota@yahoo.com, Mobile: 9810425662
4.
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.
B.
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: •
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 Integration  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.
C.
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.
D.
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.
E.
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.
F.
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:________________________
2.
Marital Status:
i) Married [ ] ii) Unmarried [ ]
3.
Social Status:
i) BPL [ ] ii) APL [ ] iii) Average [ ]
4.
Education Status: i) Illiterate [ ] ii) Up to Primary [ ] iii) High School [ ]
iv) College and above [ ]
5.
Disease: _____________________________________________________________
6.
Duration of Illness: ____________________________________________________
7.
Diagnosis of Allopathic doctor/Hospital
8.
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: .................
Status of Integration 61
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
2.
Hakim AJ Khan Formerly Senior Faculty & Senior Physician A &U Tibbia College, Karol Bagh, New Delhi
3.
Hakim Raisur Rahman Professor A &U Tibbia College, Karol Bagh, New Delhi
4.
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
2.
Dr. Praveen Choudhary Associate Professor (Deptt. of Shalya) A &U Tibbia College, Karol Bagh, New Delhi
3.
Dr. Prabhakar Rao CMO ESI Dispensary, Nand Nagri, New Delhi
4.
Dr. Mamta Ralhan SMO BRD Ayurvedic Clinic Rajouri Garden, New Delhi
5.
Dr. Sathyanarayan Dornala SMO MCD Ayurvedic Dispensary Krishna Nagar, New Delhi
62  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
Status of Integration 63
2 AYUSH in Selected States-Findings from Field Visits
AYUSH in Selected States-Findings from Field Visits Odisha
67
Uttar Pradesh
75
Andhra Pradesh
91
Himachal Pradesh
102
Jammu & Kashmir
111
States Consulted (Bihar, Uttarakhand, West Bengal)
118
Annexures:
Annexure-I: List of Officers who attended meeting chaired by the Commissioner-cum-Secretary, Health and Family Welfare, Government of Odisha at the request of the PI
121
Annexure-II: List of Faculty members the PI met at AK Tibbiya College, AMU, Aligarh
122
Annexure-III: Treatment of choice in Ayurveda and Unani for Common Disease Conditions
123
Annexure-IV: Letter of the PI to Principal Secretary, Andhra Pradesh
128
Annexure-V: List of Faculty and Staff PI met at the Rajiv Gandhi Government PG Ayurvedic College and Hospital, Paprola
130
Annexure-VI: Letter sent to the Health Secretaries of West Bengal, Uttarakhand, Bihar and Madhya Pradesh
131
Annexure-VII: Questionnaire sent to the Health Secretaries of States
132
Annexure-VIII: Anubandh for AYUSH doctors in Uttarakhand
135
66  Status of Indian Medicine and Folk Healing
2 AYUSH in Selected States-Findings from Field Visits Introduction When Part I of the Status Report on Indian Medicine (August 2011) was written, the PI had given an account of her observations based on her visits to the States of Maharashtra, Gujarat, Rajasthan, Karnataka, Kerala, Tamil Nadu, Chattisgarh and Delhi. In this Report (Part II), the PI visited the States of Odisha, Uttar Pradesh, Andhra Pradesh, Himachal Pradesh and Jammu and Kashmir. The PI also tried to collect information relating to AYUSH infrastructure, pharmacies, drug supply, patients guidelines through letters sent to the States of West Bengal, Uttrakhand, Bihar and Madhya Pradesh- using a detailed questionnaire. The findings have been given under each State and have not been presented collectively. However they are available in the Summary of Major Recommendation. Odisha (25-28 March 2012) The State government has established a wide network of facilities for providing AYUSH services. There are three Government Ayurveda colleges and five Ayurveda hospitals besides three pharmacies, a drug testing laboratory and nine medicinal plant gardens including those maintained by the government colleges. There are 619 Ayurveda and nine Unani dispensaries. All 30 districts are served by a network of Ayurvedic dispensaries. The Unani dispensaries are concentrated in a few districts only. One thousand two hundred and thirty four Ayurvedic doctors and four Unani doctors have
been recruited under NRHM, and the majority of them have completed the induction training including preparation for Skill Attendant at Birth (SAB), Integrated Management of Neonatal and Childhood Illness (IMNCI), routine immunization, the management of Tuberculosis, Malaria and leprosy cases as well as implementation of the school health programme. Over 40,000 ASHAs have completed training on mainstreaming of AYUSH. The drug kits provided to the ASHAs contain Punarnavadi Mandoor, an Ayurvedic drug which works as an iron supplement. One of the points which was repeatedly brought out was that the AYUSH doctors that are working in co-located facilities are practising modern medicine wherever no MBBS doctor is available. When AYUSH doctors function as the single doctor at a health facility they have no option but to practise modern medicine; but this is not legally protected by the issue of a State notification as done in some other States. It was also pointed out that a separate OPD for AYUSH doctors is still not available in some State hospitals and hence the strategy of making AYUSH services available across the board is working only in patches. AYUSH Vacancies: in the standalone dispensaries, only 474 Government Ayurvedic doctors were in position as against 619 sanctioned posts. All nine Unani doctors were in position as sanctioned. In the co-located facilities, against the sanctioned strength of 796 Ayurveda doctors, 670 had been posted, leaving a vacancy of 126 doctors. There was
AYUSH in Selected States  67
a shortfall of four Unani doctors against posts sanctioned for the co-located facilities. Observations from the PI’s visit to selected Ayurveda and Unani health facilities The PI visited a range of facilities in the Bhadrak, Cuttack, Jajpur and Puri districts of the State accompanied by Dr. Narendra Prasad Hota, the State Research Officer (Ayurveda). For a part of the visit she was accompanied by Dr. Samiullah Deputy Director in charge at the Regional Research Institute of Unani Medicine (RRIUM) at Bhadrak and Dr. Subhan Ali Khan, the Deputy Director (Biochemistry) from the Institute. It was evident from a range of conversations the PI had with numerous stakeholders that Odisha State was interested in the propagation of Ayurveda (especially) and local people needed no introduction to the system. However, mainstreaming and integration of AYUSH had not gathered momentum, and there was a need for intensive awareness building, starting with the doctors and health workers posted in the CHCs and PHCs. Additionally no AYUSH drugs were available in most facilities the PI visited. Public faith cannot be sustained only on the basis of physical co-location of the doctors.
that his experience and BUMS qualification were not being used in the government system even when there was an opportunity to do so –only because of his age. It was evident that he had a good clientele and people were coming to him because he had earned a reputation for providing useful treatment.
Dr. Samiullah and Dr. Subhan Ullah Khan - both Deputy Directors at Regional Research Institute of Unani Medicine (RRIUM) with Dr. Siddiqui (private Unani practitioner)
Places visited Bhadrak The first stop was at village Mulla Sahi in Dhamnagar Block of Bhadrak District. The PI was encouraged by the officials of the CCRUM who were accompanying her to meet Dr.M.Siddiqui, a private practitioner who had done BUMS, and also his father Dr. Niyametullah Siddiqui. There were several patients at the clinic and they had come for treatment for filariasis, joint pain, hypertension and depression. Since the practitioner was 42 years old and he had not been appointed on contract as an NRHM doctor he felt frustrated
68 Status of Indian Medicine and Folk Healing
Dr. Siddiqui showing his patients
The same boy with Filariasis at Dr. Siddiqui’s clinic
was being run almost in a shack), was well positioned on the main road. It seemed to be well frequented despite the fact that medicines had not been supplied for several months.
View of patients at the village clinic of Dr. Siddiqui
Dobal, District Bhadrak The PI met Dr. Shafiqur Rehman, the Unani Medical Officer working at the Government Unani dispensary at Dobal. The dispensary was running in a rented house without a signboard, unsuitable for delivery of health care services. A Unani Medical Officer, his assistant and a part-time sweeper-cum-watchman were present but showed two year old medicines, which had not been replenished in between. Some medicine bottles were lying open and exposed to moisture. It was understood that new premises had since been located and there was a plan to move the dispensary. This needs to be done at the earliest as the Unani set-up will get a bad name because of the shabby condition of the existing dispensary.
Dr. Kamal Khan who was in charge appeared to be a popular doctor. The OPD attendance figures showed that there was an eager clientele despite the fact that the doctor was simply writing prescriptions. The patients appealed to the PI to do something to see that medicines were supplied on a regular basis.
Dr. Kamal Khan, Unani physician at the dispensary
The PI also visited the Regional Research Institute of Unani Medicine(RRIUM) at Bhadrak town and was shown around by Dr. M. Samiullah, the Deputy Director in charge. The PI interviewed a few patients and listened to the presentation that the doctors had prepared. Some of the younger research officers appeared to be interested in publishing papers which was a good sign.
Outside Government Unani Dispensary, Bhadrak
In contrast, the Government Unani dispensary at Bhadrak, which the PI visited (although it
View of the RRIUM , Bhadrak
AYUSH in Selected States  69
average but it was apparent that there was little coordination with the rest of the doctors. Her room had been changed four times since she joined which had affected her sense of belonging. This did not seem to be intentional but it was clear that her presence was not given much importance.
Display board showing the priority areas of research at RRIUM, Bhadrak
The premises were not in a good condition but the PI was shown a new building that had come up on the main road some distance away. The new building is well located and impressive but a dispute about a piece of land needed to be sorted out with the State revenue authorities. From indications given during the visit it appeared as though the building was not going to be occupied in the near future because of a tussle with local users about a thoroughfare running along the building.
At Jajpur, the PI also visited the CHC at Badachana and at the time of the visit a male gynaecologist Dr. J.J. Mishra was present. The AYUSH doctor was on leave. There was no separate OPD for the AYUSH doctor. Dr. Mishra said that the AYUSH doctor was regular in attendance but virtually no patients came for any Ayurvedic health service and was dismissive about the situation while praising the AYUSH doctor for being “always punctual”. Later, the PI met various Unani and Ayurvedic practitioners who came to see her at the Circuit House in Cuttack with whom she interacted on the manner in which data was being collected.
View of the New building for Regional Research Institute of Unani Medicine, Bhadrak
Jajpur The PI visited the CHC Dharmashala at Jajpur where the in-charge Medical Officer Dr. R.N. Mishra - a surgical specialist met her. The contractual AYUSH doctor Dr.Anita Bahera was present. The CHC has 16 indoor beds but there were no patients admitted at that time. The AYUSH doctor showed an OPD attendance of about 15 patients on an
70 Status of Indian Medicine and Folk Healing
Dr. Rama Krushna Mishra, Inspector of Ayurveda I/c, Cuttak Circle; Dr. Satyabrata Mohapatra, Ayurvedic Medical Officer; and Dr. Subrat Mohanty, Ayurvedic Medical Officer
During discussion with Dr. Ramakrishna Mishra, the Inspector of Ayurveda in charge of Cuttack Circle, it was apparent that he was only collecting figures and did not question unexplained changes. While collecting the
data on the Unani dispensary at Kendrapara it was indicated that the number of patients who had been treated in 2009 and 2010 were in the range of 11,000 in the year. In 2011 the figure came down to just 3000. The inspection report only stated that the medicine position was inadequate but did not highlight that the non-availability of medicines had affected the OPD so adversely.
and reported to the Health Department, which ought to have the data scrutinized for aberrations. The present reporting systems appear to be perfunctory with a lot of contradictions creeping in from time to time. Mangalpur The visit to the PHC was made at 8:20 AM. No staff member, doctor or health worker including the AYUSH doctor were present. Since it is a main road PHC, this kind of absenteeism would be making a poor impression on the local people who would per force have to travel to some other place to obtain medical services. Satasankha
Dr. Md. Okar shamce, Unani Medical Officer, Govt. Unani Dispensary, Balia, Cuttak; Dr. Rehanuddin Khan, AYUSH Doctor (Unani), City Hospital, Cuttak; and Dr. Mazharuddin, Private practitioner, Nimasahi, Cuttak
A glance at the quarterly progress reports showed that the details of patients was being recorded haphazardly although the names of the doctors, their mobile numbers, whether an exclusive AYUSH OPD was being maintained, names of the diseases treated and total number of new and old cases were all being collected laboriously. Unless the reports are scrutinized, such reporting leads to mechanical data collection. There is every need to train the officials who are collecting data to look for “highs and lows” and comment upon any huge difference in figures. In case this is not done the data would continue to be collected but would serve little purpose. Since it is now a policy decision to mainstream and integrate AYUSH under NRHM, it is necessary that various aspects which have been spelt out in detail in the Manual issued by the Government of India are overseen
The PI visited the PHC (New) at 8:40 AM when there were already about 15 patients in the queue waiting to see Dr.Ashok Kumar Sitha who had already disposed off quite a few patients by then. He was attending to the patients single-handedly and appeared to be in great demand.
View of the PHC, Satasankha
Dr. Ashok Kumar Sitha (Allopathic doctor with large number of patients)
AYUSH in Selected States 71
In another room the AYUSH doctor Dr. Soumya Devi set by herself but there was no patient waiting to meet her. The daily OPD register showed that she had very few patients, never exceeding a handful of patients in a day
feel that they are being forced to go to the Ayurvedic doctor simply because of pressure of work. Unless clear guidelines and standard operating practices are issued patients will not receive the benefits that two doctors working in unison could provide. Puri The visit to the Gopabandhu Ayurveda Mahavidyalaya, at Puri gave a good impression of a well-organized, clean and neat hospital.
Empty Co-located AYUSH facility
Dr. Soumya Devi, AYUSH doctor sitting alone
There was no evidence of any kind of interaction or of cross referrals being made. The PI asked Dr. Sitha whether some of the patients could not be screened by the AYUSH doctor while they were waiting in the queue and there could not be greater understanding about where Ayurvedic treatment might be useful whether as a stand-alone therapy or as an adjuvant. His response was that he occasionally sent people with joint pain to the Ayurvedic doctor. It was apparent that a busy doctor would have little time to think of anything except his immediate patient load. There is therefore a need for rationalizing the integration in a way that the public does not
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Various procedures in progress at the Gopabandhu Ayurved Mahavidyalaya, Puri
The PI met the faculty in a meeting chaired by the Principal Professor Kamadev Das. He along with the faculty indicated that the health department of the Government of Odisha had approved that selected lectures should be taken by allopathic faculty members but this was implemented more as an exception than the rule. This affects the knowledge, competency of the doctors needs to be addressed conclusively by the Health Department. Unless the deployment of teachers of modern medicine is overseen, it is highly unlikely that the Principal of the college would alone be able to insist on their taking classes regularly.
the facilities visited, little understanding about what the AYUSH doctor was expected to do when posted as the in- charge of a health facility and an absence of guidelines on crossreferrals between systems. At the meeting there was little receptivity for the concept of functional integration, better counseling, or the issue of standard protocols from the allopathic experts present at the meeting. They were against any kind of integration and misgivings about the absence of published research and evidence of efficacy of AYUSH treatment were all brought up at the meeting despite knowledge of the NRHM policy on integration at the primary level.
PI’s meeting with Principal and Faculty at Gopabandhu Ayurved Mahavidyalaya, Puri
Meeting with State Health Secretary, Odisha The list of those who attended the meeting is at (Annexure-I). A meeting was chaired by the Commissionercum-Secretary Smt. Anu Garg when the PI presented the findings of her visit. Among others the meeting was attended by the Managing Director of the NRHM programme, the Director of Health Services and the Director of Medical Education &Training. The PI discussed her findings from the visit and chiefly that there appeared to be an absence of integration and patients did not appear to be getting the full benefit of the AYUSH infrastructure created under NRHM. She pointed to the need for a higher level understanding about the missing links which included the absence of AYUSH drugs at all
One issue that was brought up in the meeting was the prevalence of interminable court cases often accompanied by court stays on administrative decisions. Such stays prevented the authorities from executing the procurement of drugs in a timely fashion. Court cases had also adversely affected many aspects of the running of the health sector including recruitment and promotions. Almost everyone accepted that this was the reality, and hence there was no assurance that things might improve the stay orders from the courts were reported to have disrupted on-going executive processes. Among all the States visited, this phenomenon seemed to be a major obstacle to only in Odisha State. Conclusion and Recommendations based on PI’s findings and State inputs 1.
Under NRHM since the integration and mainstreaming of AYUSH was a part of government policy and had been accepted right from the Year 2006, it is necessary that more awareness about the availability of AYUSH doctors and medicines is built up.
2.
At all places visited it was clear that the
AYUSH in Selected States 73
two-year delay in the supply of medicines had lowered public expectations from the systems. Concerns about court cases are genuine but a mechanism to improve procurement systems needs to be put in place with higher level intervention. 3.
4.
5.
One of the recommendations relating to integration issued by the Government of India was to consider bringing the standalone dispensaries of AYUSH under the umbrella of NRHM. Whether that is done or not, unless there is integration at the level of senior health administrators the fruit of deploying the AYUSH manpower will not be realized. Greater orientation for the senior medical administrators working in the modern systems of medicine is needed as they must be proactive in providing leadership to the concept of integration. The overall situation calls for a competent senior officer with adequate access to the Secretary of the Health Department to be given the responsibility for overseeing the integration aspects at the NRHM facilities; also to give a sense of ownership to the concept of pluralistic medical and health care. Unfortunately no one in the AYUSH hierarchy seems to have the status to be assertive. Unless a solution is found the tendency for working in strictly divided compartments will continue and even grow. The Government of India Manual had emphasized that one of the important aspects of NRHM was to know about the strengths of the AYUSH systems and to promote “a culture of crossreferrals”. Therefore, apart from the infrastructural aspects, the coordination
74 Status of Indian Medicine and Folk Healing
and healthcare delivery aspects of the Manual need to be implemented under the full-time guidance of a Director for Indian Systems of Medicine. Apparently, the position had been vacant for some time. In addition, there is a need to position at least a Joint Director level officer to monitor whether the CHCs and PHCs are doing what the Manual has prescribed instead of leaving it to the officials to simply collect numerical data. 6.
Better signage is necessary at the CHCs and PHCs particularly indicating how the public can benefit from the AYUSH systems and the specific areas where the systems have a strength. There is every need to have standard instructions for guidance of patients. Likewise, there is a need for operating practices being given to the AYUSH doctors so that there is some uniformity in following a regimen despite the fact that treatments may vary somewhat depending on the “constitution “ or “prakriti “ of the patient.
7.
There is also a need for counseling patients that the allopathic and AYUSH doctors work are equipped to make referrals to one another or even to a higher level facility. In the case of chronic problems, many patients may get relief from AYUSH treatment but they should have the confidence that they can seek advice from any available doctor on options available. This will not happen unless it starts with ownership and understanding at the highest levels of the professional health hierarchy.
8.
There was a suggestion that there should
be an Advisory Board or Standing Committee which can give regular inputs to the Health Department about gaps that continue to exist and how better coordination and awareness could be built up. This was mentioned by the PI during the meeting with the Secretary that, ideally, the Advisory committee should be headed by a serving officer of the Department of Health who can translate the suggestions into practical strategies. 9.
The possibility of paying the part-time allopathic lecturers who have to impart education on specific subjects should be followed through soon. As the responsibility to take classes has been given officially it needs to be taken to its logical conclusion. If honorarium and transportation charges are not being paid it is unlikely that any member of the allopathic faculty would agree to give lectures in an Ayurvedic institution. The prescribed rate for outside lecturers appears to be Rs. 450 per lecture but whether this is sufficient for those who come from a distance needs to be checked. Perhaps an arrangement could be outsourced to the Kalinga Institute of Medical Sciences (KIMS) which might be open to entering into a partnership model.
10. Several positions of medical officers both Unani and Ayurveda appeared to be lying vacant. At least contractual appointments should be made. 11. An awareness programme needs to be built up on the State television channels where doctors and administrators with good communication skills can use the
Government of India instructions to speak about how the integration of the systems under NRHM can benefit the patients. Uttar Pradesh (28-29 April and 2-3 May 2012) Visit of the PI to AYUSH facilities in the State of Uttar Pradesh Being a large state, the visit was undertaken in two parts as suggested by the Central Council for Research in Unani Medicine (CCRUM) and the Central Council for Research in Ayurvedic Sciences (CCRAS). In the first lap of the visit, the PI was accompanied by Dr. Pradeep Dua and Dr. Raheem, both Research Officers who had been deputed by the Ayurveda and Unani Research Councils. Findings from Field visits (28-29 April 2012 by road) The first visit was to the interiors of Western Uttar Pradesh namely to Sambhal, Aligarh and Khurja. CCRUM had suggested a visit to a renowned practitioner of the traditional Unani system in the town of Sambhal. Hakim Zafar said he was the 131st descendant of a family of Hakims and lived in the same building as his forefathers (although his personal lifestyle was quite modern). The Hakim only used pulse diagnosis to decide treatment. He prescribed freshly prepared decoctions using a combination of crude herbs besides prescribing do’s and don’ts. The drugs were dispensed from an attached outlet managed by his staff who looked at the pictures he had ticked off on the illustrated prescription slip. Accordingly small newspaper packets were made using ingredients which had been ticked by the Hakim.
AYUSH in Selected States 75
Hakim Zafar disposed of nearly 40 patients standing in two queues running along the left and right corridors outside his consultation room. At a time the Hakim was looking at two different patients sitting to his left and right as the idea was to save every second of his time.
The staff of Hakim Zafar preparing decoction packets for dispensing to individual patients
The style of management entailed no interaction with the patient except pleasantries. The Hakim held the pulse for a few seconds and proceeded to tell the patient his or her symptoms and to tick mark the prescription sheets where the list of single ingredients and medicines had been printed with illustrations of the items. If the patient mentioned a specific complaint the Hakim did not respond, but told the patient he may also be suffering from certain other general conditions like headache, stomach ache, pain in the legs etc. He did not ask for the veil to be raised to see the condition of some women patients. The disposal of all patients was extremely rapid not more than a minute for each patients, and the thumbnail pictures show the kind of people that accessed him. Two things were apparent from the visit to Hakim Zafar: 1.
The registration of patients showed that on average day 200 to 300 people were disposed of in a matter of a few hours unassisted by any case sheets. People made a beeline to see the Hakim prompted by the belief that he had healing powers. The Hakim’s sons had graduated with a BUMS degree or acquired other professional qualifications but they were not connected with the diagnosis and treatment of patients. They seemed more interested in the manufacture of medicine and starting a new educational institution for Unani Medicine. This spells that this kind of traditional healing as a family vocation is on the wane.
2.
While there did not seem to be any great thought given to the selection
Silk cocoons used in Unani decoctions
The patients included both middle class and poor patients who had come from both rural and urban areas well as from nearby States like Punjab, Haryana and Delhi. The visit was an eye opener for the reason that a large number of patients of all age groups, communities and both sexes were visiting the Hakim continuously for hours together. The PI was permitted by him to observe how he was attending to patients. In around one hour,
76  Status of Indian Medicine and Folk Healing
Hakim Zafar examining a stream of patients in his clinic at Sambhal, Uttar Pradesh
of single herbs which were being dispensed in dry form for being boiled down to a decoction (by the patient), the ingredients were such that would have health building properties. This kind of approach was also found to be adopted by the Government Unani College in Lucknow which dates back to 1902, by the AK Tibbiya College in AMU Aligarh, by the Government Nizamia Tibbia College in Hyderabad and seems to be long respected tradition. Therefore the practice of using a combination of dried herbs to be boiled into a decoction continues to be a strong Unani tradition, which is treated with respect by common people from all communities. What was remarkable was the tremendous faith that people seemed to have in the healing properties of the Hakim and his drugs. No questions were asked by any of the patients regarding the possible improvement of their condition or lack of it, what exactly was being
prescribed and why. It would appear that people had received relief from the use of the decoctions and have implicit faith in the properties of the drugs. Visit to the AK Tibbiya College under the Aligarh Muslim University The PI visited different wards of the hospital after having a meeting with the Dean, the Principal and several faculty members. The list of doctors she met are at (AnnexureII). Since a description of the Departments, OPD and IPD of the AK Tibbiya hospital had already been described in Part-I of the project report in the chapter on Medical Practice, only those aspects directly connected with the visit are highlighted here. The large number of patients attending the OPD and the care given to the indoor patients was indicative of the commitment of the doctors and the quality of treatment offered.
AYUSH in Selected States  77
Patients outside the AK Tibbiya College Hospital
After going around the hospital and viewing the work done, the PI used the opportunity to engage the faculty members to discuss the utilization of different single herbs for the treatment of specific conditions, to understand areas of similarity and dissimilarity between the approaches of Ayurveda and Unani. A meeting was organized where discussions took place between Dr. Pradeep Dua, Research Officer of Ayurveda and the senior faculty from the A.K. Tibbiya College and Hospital.
Patient of Jaundice at the Hospital
Patient of Herpes at the Hopital
Discussions with faculty at AK Tibbiya College. Picture shows PI and Dr. Pradeep Dua (Ayurvedic Research Officer) talking to faculty members
Decoctions were being prepared in all the hospital wards and each patients had his earmarked mug in attached pantry.
Faculty members at AK Tibbiya College expressing their views on the use of common ingredients used in the Unani system of medicine
Picture of pantry and individual mugs for supplying fresh decoctions
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Regional Research Institute of Unani Medicine is also functioning at Aligarh and conducting collaborative research with AK Tibbiya College, Aligarh in the field of Ilmul Advia and Moalejat.
Vaidya Yagya Dutt Sharma Ayurved Mahavidyalaya, Khurja
PI with Deputy Director, Dr. Latafat Ali Khan and Dr. Soofia Abbas,a staff member at RRIUM, CCRUM
View of the Vaidya Yagya Dutt Sharma Ayurved Mahavidyalay and attached hospital
Unani system of Medicine: Dr. Pradeep Dua - An Ayurvedic doctor’s perspective
The college and hospital have a good building. The PI could only reach the hospital late in the evening when the OPD was closed. The hospital was spacious and fairly affluent patients were occupying the private rooms.
Commonalities and Dissimilarities within Ayurveda and Unani Medicine Dr. Pradeep Dua, was asked to give his assessment on points of similarity and difference with a focus on the use of single drugs. According to Dr. Dua: “The prescription pattern of the Unani practitioners appeared to be similar to the practice adopted by the Ayurvedic practitioners. Majority of the herbs prescribed by the Unani experts seemed to be similar as in Ayurveda. However, a noticeable difference could be observed in indications for which the drugs were used (given at Annexure-III). The Unani system of medicine advocates the use of certain medicinal plants for specific indications and these are different from those followed in the Ayurvedic system for the same conditions. Also, certain ingredients like Silk (Bombyx mori)-‘Abresham’ are widely used in Unani practice but are never used by Ayurvedic practitioners. The Silk cocoon (Abresham muqriz) is used in simple herbal formulations for the management of hyperlipidemia, atherosclerosis, and hypertension.”
Dr. Gopal Dutt Sharma with a Female patient of Rhematoid Arthritis at the private rooms of college hospital
Vd. Gopal Dutt Sharma’s son is an allopathic doctor and under that umbrella, surgical procedures were being carried out. The PI was told about a particular patient who “had not been accepted by any allopathic hospital” and was to undergo a hysterectomy operation the next morning at his Ayurvedic hospital. The operation was to be conducted by an Ayurvedic doctor, a faculty member from the Department of Ayurvedic surgery. There appeared to be no doubt in his mind or that of Dr. Gopal Dutt Sharma or the surgeon about the legal right of the Ayurvedic Surgeon who had been AYUSH in Selected States 79
trained in surgery to perform surgeries like hysterectomies despite the prevailing law in Uttar Pradesh which forbids such surgeries being undertaken by Ayurvedic doctors. Visit to Lucknow (2-3 May 2012 by air) The PI was accompanied throughout this visit by Dr. Raksha Goswami, Director Ayurveda; Dr. AA Hashmi, Deputy Director (Unani Services) and Dr. Arvind Srivastava, Lecturer, Ayurvedic College. Dr. MS Qasmi, Director (Unani) also accompanied her to some places. In UP, there are eight Government Ayurvedic & seven private Ayurvedic Colleges besides 2106 hospitals (340 out door dispensaries, 1625 four-bedded, 70 fifteen-bedded and 71 twenty five-bedded hospitals). 2186 Ayurvedic Medical Officers were reported as working in the above hospitals. During this visit to Lucknow, the PI visited the State Takmil-ut-Tib College and Hospital which was established in 1902. Although the college has moved to its new premises which are modern and spacious, the hospital continued to function from the old hospital. That is good because the public has grown accustomed to this facility, which has existed for over 110 years and which is located in a very congested area of the city accessed by a large number of patients from all communities.
Women waiting at the registration counters
Three things were apparent at this hospital: 1.
The patients were from different communities and the lines at the registration counters were long.
2.
There was a long line of patients waiting to collect their Joshandas (decoctions) which was freely supplied for different conditions. These decoctions were in high demand but each patient could fill one bottle full only.
3.
The two medical conditions for which patients seemed to be coming to the hospital were skin diseases and women’s gynaecological problems.
Patients waiting for consultation
Plaque of 1902 at the entrance to the Takmil-ut-Tib College and Hospital
80  Status of Indian Medicine and Folk Healing
Patient consulting Hakim Hussain Ahmed Azmi
Herbal garden at the Regional Research Institute of Unani Medicine (RRIUM), CCRUM, Kursi Road, Tedipuliya Lucknow The PI visited the herbal garden and although there was considerable enthusiasm over the visit, the positive and negatives that were evident need to be noted.
Ingredients for Joshanda Humma1
The premises are well maintained and the research staff was enthusiastic and committed. The herbal garden was well located and there was sufficient land to manage better growth and display of medicinal plants. However there was no flexibility available with the in charge of the Institute for investment in gardening equipment, promoting water conservation, or spreading nets to prevent destruction of plants by monkeys. There is a need to devolve greater financial authority on the local officers and to leave it to audit to check on the prudence of incurring expenditure. Centralizing all authority curbs initiative and the utility from an overall point of view remains a question mark.
Ingredients for Joshanda Mussaffi2
There also appears to be a need to involve students of both Ayurveda and Unani to visit the herbal garden and to play a more substantive role in the management of the garden to increase their understanding of the properties of various plants. Several useful lateral linkages can be established but this requires a degree of confidence and capability. There is a need for commitment to use the herbal garden for hands-on study of medicinal plants regardless of the professional discipline of the student. Keeping this herbal garden as to a small unit of CCRUM with no sustainable linkages with botanists, faculty members both from Unani and Ayurvedic side
Patient filling bottle with Joshanda (Decoction)
1. Ingredients are Althaea officinalis, Malva sylvestris, Glycirrhiza glabra, Caccinia glauca, Zizyphus sativa, Tinospora cordifolia, Swertia chirata, Cordia obliqua 2. Ingredients are Sphaeranthus indicus, Tephrosia purpurea, Swertia chirata, Zizyphus sativa, Rosa damascene, Azadirachta indica
AYUSH in Selected States  81
and university faculty and students has very limited benefit. Such units need to be judged by their linkages and outreach performance and not merely by day-to-day, routine activities. The tendency to vertically subdivide facilities like herbal gardens, laboratories and investigation facilities between Unani and Ayurveda research facilities restricts the benefits of cross-fertilization of ideas. Greater cohesion will benefit stake-holders much more, and the recommendation of the Steering Committee for the 12th Plan to have a common governance structure for CCRAS and CCRUM is needed without which the benefits derived from so many units all over the country would remain of limited value.
College principal with the faculty members
The Panchakarma unit was highly subscribed to, despite the standard of lighting and cleanliness being in need of much maintainance.
State Ayurvedic College, Lucknow The PI visited this college which was first established in 1948 at the King George’s Medical College campus from where it has been moved to the King’s English Hospital. A five-year degree course was started in 1959 and postgraduate classes were started in 1971. Today apart from PG, graduation and diploma courses the college also runs Nursing and Pharmacy courses. The college has a library with over 13,000 books and a seating capacity of nearly 80 readers at a time.
State Ayurvedic College & Hospital Name board
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Entrance to the Hospital Panchakarma unit in great demand
Ayurvedic surgeon performing Ksharsutra procedure at the State Ayurvedic Hospital, Lucknow
Besides Panchakarma, other outdoor and indoor therapies were also being provided. Recently a new ward and OPD complex had been established for paediatrics, gynaecology and obstetrics with facilities for ECG, USG and X-ray. The attached 20-bed King’s English Hospital has modern facilities and functions completely in tandem with the Ayurvedic hospital. The integration seen at this complex was among the best examples of both systems working together and could be one model to go by in hospital settings. Visit to the Lavanya Cancer Centre at Chinhut near Lucknow
Ayurvedic medicine store at the Lavanya
The treatment includes chanting of hymns, fumigation, pacifying various Zodiac signs, Crystal and Gem therapy based on medical astrology. Drugs containing purified mercury, gold, silver, copper and minerals are being administered to the patients along with Panchkarma Therapy. Leech therapies, various Bastis, Agnikarma (Cauterization with silver rods) are also being undertaken. The Lavanya Centre claims to have an Intensive Care Unit (ICU), Ventilators with an operation theatre to “provide assistance for early recovery in Cancer cases.” The PI did not visit these units.
View of Lavanya Ayurvedic Cancer Center
CCRAS had recommended a visit to the Lavanya Ayurveda claims to be engaged in treating patients of diseases like Cancer, AIDS, Hepatitis-B and C, Asthma and Diabetes for the last 15 years. The centre claims that “a very large number of Cancer patients have shown their faith in the treatment provided to them and subjective as well as objective relief is invariably reported.”
The medical claims that were being made through brochures, presentations and as gathered from the website of the Lavanya Centre lacked scientific evidence. It was evident that families looking after terminally ill patients came to the centre in the hope of prolonging the life of the patient, where different styles of faith healing were used along with the drugs and therapies aimed at improving the quality of life of the patient. The medical capabilities and claims do not appear to have been
AYUSH in Selected States 83
investigated either by the Central Council for Research in Ayurveda which recommended the PI’s visit or by the state AYUSH officers. The visit of the PI, accompanied by officers of the State Government gave immense credibility and legitimacy to the centre which from the PI’s point of view was avoidable.
the PI that if they were given sufficient raw material and funds, the pharmacy had enough capacity to provide drugs to all the AYUSH facilities throughout the State. The PI found that the stocking of the medicines was organised and the variety of products and the size of the inventory was impressive.
State Ayurvedic & Unani Pharmacy The PI visited the State pharmacy at Lucknow which once had a huge capacity for manufacturing Ayurvedic and Unani medicines. The staff at the pharmacy appeared proud of the work they were doing which followed the traditional methods of making Ayurvedic and Unani drugs. The pharmacy in charge as well as the Director Ayurveda Dr. Raksha Goswami proudly informed
Raw drugs Store
Preparing Asavarishta Entrance of the pharmacy
Work area of the pharmacy
84 Status of Indian Medicine and Folk Healing
Mechanised pulveriser for Tamra bhasma
Making churna
Station for keeping finished products
Sorting Ingredients
Station for keeping Ayurvedic finished products
Furnace for preparing decoction
Station for keeping Unani finished products
Wooden container for preserving Ashokarishta
This is one pharmacy which could become a showpiece for people who wish to know how classical Ayurvedic and Unani drugs are prepared and the buildings and premises which are extensive can be made to look impressive with a little maintenance and upkeep. The pharmacy staff were enthusiastic and no one made any complaints on any score.
AYUSH in Selected States  85
Visit to the bone setter Sabir Ali Ansari at Unnow This visit can be better described through photographs. Sabir Ali owns a semi-pucca building in an interior part of a village in situated some 60 kms from Lucknow by road.
Bone setter Sabir Ali Ansari’s name board
Bone-setter’s daughter who assists him with the preparation of pastes and bandaging
The day that the PI visited the bone setter there were about 40 patients who were being treated by him, a large number of them as “in patients”. The facilities provided were rudimentary - each patient was given a Takht or wooden slab to sleep on. Belongings were either hooked on to nails or strung across the ropes attached to the mosquito nets. A family member would cook the food for each patient, sitting next to his “takht”. Altogether it was a vibrant community life.
86 Status of Indian Medicine and Folk Healing
Pictures showing “indoor patient facilities” in and around the Sabir Ali’s bone setting facility
The patients were not destitute or even from the very poor. Asked what was being paid, one of the patients who had remained an “inpatient’ stated that he had paid Rs.18,000 for a four month stay including treatment. Food was arranged by the patient. It was noticeable that there were quite a few small children who had suffered fractures or dislocation and the parents had brought the child with great confidence that the treatment would be successful.
been ground into a paste. The bone setter’s daughter showed the herbs which were easily recognised by the AYUSH doctors that were accompanying the PI. Sabir Ali showed the PI a vast array of bamboo splints which had been chiselled and kept in stock for different kinds of fractures. The bone setter seemed familiar with reading X-rays brought by his patients and went about his task with great confidence.
Bone setter showing an array of bamboo splints
Sabir Ali and his daughter relaying the splints
It was interesting that the Central Council of Research in Unani Medicine had suggested that the PI visit this bone setter. The State Government officials too were well aware of this local healer and his work and confirmed that people from all over the district and even the region came to him. However when asked whether the improvements (or absence thereof) could be observed and documented, there was no interest either from the research staff of the CCRUM or the State Government Unani Officers. This aspect deserves the attention of the two research councils who should have examined the efficacy of such treatment in a variety of settings. Sabir Ali showed the PI how he changed the bandage and repositioned the splints every third day. The injured area was covered with an application of herbs which had
All the patients whom the PI spoke to said that they had come to Sabir Ali to avoid surgery and being immobilized in a hospital or at home. Since the bone setter advised constant movement, assisted by a family member, the patients felt more confident of early recovery. The biggest benefit from the point of view of the patients was non-dependency on a government hospital which they felt was impersonal; also recovery through traditional bone-setting was known to be quicker with no adverse outcomes. The PI suggested that the case sheets of the patients and the documentation available, including the X-rays , pre- and post-recovery if studied might confirm whether the recovery had been satisfactory in a large cross-section of cases – not with the purpose of checking the competency of the bone setter but more to understand whether such skills indeed had a place in fracture management.
AYUSH in Selected States 87
The bone-setting practice is very popular in Kerala and at one point the PI had observed a large number of patients waiting for fracture treatment at the Government Ayurvedic College in Thiruvanantapuram for fracture treatment. The same style of fracture management was being used routinely in many parts of the North-East also. There appears to be every reason to study these skills and to use them to selectively equip ASU students to manage fractures, if patients are benefitting from this kind of management. For most people a fracture signifies either complete immobility or encasement of a limb into an uncomfortable cast leading to all kinds of after-effects like shortening, bending, and shrinkage of the limb besides acute discomfort. Bone setting skills need to be mainstreamed into Ayurvedic practice, and since patients seem to be benefitting, the public is likely to be benefited if regular check-ups are done to see the progress of healing. A group of experts should be able to decide on the inclusion of such skills in the ASU syllabus. Meeting with Shri J P Sharma, Principal Secretary, Medical Education and AYUSH in the Secretariat, Lucknow. The PI shared her findings and observations with those present at the meeting chaired by the Secretary. The meeting was attended by the following: 1.
Shri JP Sharma, Principal Secretary, Medical Education, UP
2.
Shri SK Saxena, Special Secretary, Medical Education, UP
3.
Dr. Saudan Singh, Director General, Medical education, UP
4.
Dr. Raksha Goswami, Director Ayurveda Services, UP
5.
Prof. MS Qasmi, Director Unani services, UP
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6.
Dr. AA Hashmi, Deputy Director Unani Services, UP
The Principal Secretary looking after AYUSH was unconnected with NRHM and was not dealing with co-location plans. The allopathic doctors who had been requested to attend to enable a discussion on how best patients could be benefited through better guidelines and counselling on providing integrated access to allopathy and ASU treatment were openly critical of ASU doctors and questioned their competence. It seemed that the development of Ayurveda and Unani medicine was not a matter of importance for senior health professionals. Later in August 2012, the PI spoke to the Principal Secretary in charge of NRHM Shri Sanjay Aggarwal who informed her of a change of policy and that the programme to post contractual doctors under NRHM has started. He added that he was in regular touch with Department of AYUSH, Government of India and assured the PI that AYUSH was well cared for. The PI requested him for a copy of the policy guidelines and budget provisions which had been introduced recently but the documents were not sent. It is understood that recruitment of contractual doctors under NRHM is in progress. According to the briefing given to the PI, the absence of a DG for AYUSH was the reason behind the fact that there was delay in rolling out the AYUSH component of NRHM. It would appear that structurally AYUSH officers, professional staff and colleges report to the Principal Secretary (Medical Education). However, NRHM is entirely under the Principal Secretary (Health) of the State and operates under the Mission Director. The co-location of AYUSH doctors may take time judging from the progress noted during the visit. Considering the large population involved, there is every need for focused attention to the provision of services as envisaged.
reorganization of the structure and systems would be necessary. At the organizational level, it was apparent that with the absence of a senior unifying force to look after both Ayurveda and Unani systems, the hierarchy of each system was working independent of the other without any functional collaboration. Therefore, there is a need to have a focal point which can act as a bridge between the professional people belonging to both the systems, to be able to plan, make overall recommendations and follow them up with the State Government. A position of Commissioner AYUSH which could be filled from the Indian Administrative Service (IAS) or from the Indian Forest service (as is the case in Andhra Pradesh) would provide muchneeded leadership. Officials of both the Directors – Ayurveda and Unani systems would like the position of Director General to be created but the Andhra Pradesh example of having a generalist officer might work better as the gaps to be filled are organizational and administrative not technical.
Meeting chaired by Sh. J.P.Sharma, Principal Secretary, Medical Education UP. Picture shows those present at the meeting listed in the write-up
In Maharashtra State also, AYUSH comes under the Medical Education Department and not the Health Department. But since the Director (Ayurveda) is able to make his presence felt, the system is operating efficiently. In a large State like UP, there is every need for AYUSH to be under one umbrella both for the standalone component which is quite large, and the NRHM component to bring some organizational strength to the management of the sector. Conclusions and Recommendations 1.
Since the State is very large and there is huge diversity within regions, districts and communities, if Ayurveda and Unani systems are to gain primacy,
In States like Himachal Pradesh, Kerala, Karnataka, Gujarat, Rajasthan, Jammu and Kashmir, and Odisha, there is a common Principal Secretary in charge of all aspects including Health, Medical Education and AYUSH. However in the States of Maharashtra, Uttar Pradesh, and some others, AYUSH is combined under the Principal Secretary (Medical Education) while NRHM is handled by another Principal Secretary and the Mission Director. The PI found that in such a situation, the interface between the established AYUSH hierarchy and the NRHM AYUSH doctors is virtually non-existent. The advantages of sector
AYUSH in Selected States  89
start with, there should be an effort to see whether the healing is satisfactory and to consider mainstreaming such skills into Ayurvedic practice with proper protocols.
knowledge and technical background are lost.
In Maharashtra, the system is functioning because the Director (Ayurveda) is a very senior academic expert who has worked with WHO’s Regional Office and has had a lot of exposure. He has the negotiating ability which was found to be missing among the Directors for Ayurveda and Unani systems working in Lucknow. Therefore it is recommended that there should be a common supervisory officer of a sufficiently high level to act as a Commissioner for AYUSH in Uttar Pradesh who can see that functional linkages are established between the regular AYUSH infrastructure and the NRHM AYUSH infrastructure being provided to co-located facilities. This would be cost-effective and will give a spurt to the propagation of Ayurveda and Unani systems.
2.
There is a great need for improving and expanding the utilization of the Lucknow State pharmacy which is preparing Ayurvedic and Unani medicines. If more drugs are supplied directly by the State pharmacy it would improve the availability of drugs round the year which is the only way that patients would care to take advantage of the systems. Between Lucknow and Pilibhit pharmacies, at least 50percent of the requirements of all facilities can be met.
3.
As far as traditional skills like bone setting up concerned, the practice is very popular even in a Government Medical College in Kerala and it needs to be investigated further, particularly when numerous people are taking advantage of such facilities. At least to
90 Status of Indian Medicine and Folk Healing
4.
There is a need for much greater understanding about what is hoped to be achieved by co-locating AYUSH doctors under NRHM. Uttar Pradesh state would eventually be recruiting a very large number of doctors if they adopt the NRHM policy and strategies. There is every need to evolve an understanding of how integration is to be brought about between doctors providing services in the same facility. There is a need to address the issue of the use of modern medicine which is not permitted in UP as the chapter on legal issues has shown.
5.
Reporting systems about treatment given under AYUSH need to be able to capture the patient’s health seeking behaviour. The work being done in Ayurvedic and Unani colleges should also be taken into account as there is considerable specialization in the State and university owned hospitals including those attached to medical colleges. There is a need to also evolve guidelines on adjuvant use of AYUSH therapies for certain chronic diseases as there is considerable experience available with the Benares Hindu University (BHU) and the Aligarh Muslim University’s Tibiya College.
6.
As far as the Central Government institutions are concerned, whether it is the Regional Research Institute or the herbal gardens under the CCRUM, there is every need for basic facilities like laboratories, medicinal plant gardens
and statistical support systems to be shared. The vertical division between the institutions of the two systems only means that they lose out on interaction, interdependence and distance themselves from familiar initiatives taken elsewhere, instead of learning from them. As was recommended by the Steering Committee that met for the 12th Plan there is a need for a common structure to be evolved to derive best advantage from the outcome of research.
Incharge doctor sitting extreme left at the PHC Kottakota, Poothlapatthu Mandal, AP with AYUSH woman doctor
Andhra Pradesh (8-12 May 2012) The Principal Secretary (Health), Government of Andhra Pradesh had asked the PI to complete a visit to Rayalseema region and then to give her observations in a meeting to be chaired by him at Hyderabad. Accordingly, the PI undertook visits to Naravari Palli, Chandragiri (tehsil) of Chittoor district, to see the status of co-location of facilities at Government Ayurvedic dispensaries. This was followed by a visit to the P. Kottakota, Poothala Pattu (tehsil), again in Chittoor district to see another Government Ayurvedic dispensary co-located under NRHM. There was one Ayurvedic graduate woman doctor working there and an MD in Biochemistry was the incharge at the facility.
Outside the PHC, Naravaripalli, Chandragiri Mandal, AP with Ayurveda co-located facility
Picture of scanty Ayurvedic drugs available at PHC
Chart of Ayurvedic lifestyle displayed at the PHC
AYUSH in Selected States  91
The co-location work had not gathered momentum judging from the conversations the PI had with the Regional Director of Ayurveda, Dr. Ramanna who accompanied her throughout. While efforts had been made to display pictures of medicinal plants and various charts showing the properties of easily available herbs used as home remedies, there were hardly any medicines or patients in the facilities. The registers also showed that the public was not accessing Ayurvedic treatment as envisaged in the NRHM approach to mainstreaming AYUSH.
Chart on different diseases displayed at PHC
Chart on Ayurveda drugs displayed at PHC
The PI found that reporting systems were quite diffused and the Regional Director although he was enthusiastic and supervised a dedicated network of AYUSH doctors under him, was not in a position to make the co-located facilities more vibrant. During discussion, the PI was not able to derive a meaningful idea of whether the data relating to co-located facilities revealed anything about patients’ acceptance of the provision of AYUSH services.
92 Status of Indian Medicine and Folk Healing
On its own Andhra Pradesh has good coverage with almost as many AYUSH primary level facilities (above sub-centre level) as are available for modern medicine. The State has a post of Commissioner of AYUSH where an IAS officer is generally posted. When the PI visited the State an Indian Forest Service(IFS) Officer was looking after the work of Commissioner of AYUSH. It is understood that this arrangement has since been made into a regular one. There is a clear advantage in posting a senior officer dedicated to the overall management of AYUSH at the State level. The PI was told that the alternative of posting IFS officers to head the AYUSH structure in fact works well. This is because IFS officers already have a strong knowledge of plants and can get into AYUSH-related issues quite easily–particularly those relating to medicinal plants and drugs. IAS officers get transferred frequently and new initiatives taken lose momentum with each transfer. An IFS officer is likely to stay for a longer duration and would welcome the opportunity to work in a health-related area. However, the availability
of a position of Commissioner AYUSH seems unique to Andhra Pradesh and Tamil Nadu States. Even a State like UP has only a Director (AYUSH) and a Director (Unani) for the whole State. Maharashtra, Gujarat, Karnataka and Chhattisgarh States all have a position of Director (Ayurveda) and J&K has a Director (ISM). Although a person at that level provides leadership and continuity of administration within the AYUSH sector, the officer usually lacks the visibility, weight and negotiating ability to get the attention of the State Health Secretary and the Health hierarchy. Therefore a position of Commissioner does help to raise the level and is a good model to follow. The State Medicinal Plant Board was doing well and the Commissioner for AYUSH Dr. Srivasuki, IFS was deeply interested in the development of AYUSH. However, no links between growing plants and linking cultivation to improving raw drug supply to the single State Pharmacy had been established. The Vth Common Review Mission of Ministry of Health & Family Welfare had also found
that convergence and co-ordination were lacking at all levels in the AYUSH sector in Andhra Pradesh. The PI found that approach to AYUSH was enthusiastic at the college level but ownership at the facility level was weak. There was a universal shortage of drugs and the AYUSH doctors did not appear to have much work. The allopathy-AYUSH interaction within the co-located facilities was friendly but there was no system of referrals or of giving guidance to patients. There appeared to be no system for evaluating the output of the AYUSH doctors as an integral part of the Health System. Sri Srinivasa Ayurveda Pharmacy, Tirupati The PI visited the Sri Srinivasa Ayurvedic Pharmacy attached to the Tirupati Ayurvedic Hospital which was managed efficiently. The Ayurvedic Medicine dispensed in the 240bed SV Ayurvedic Hospital at Tirupati was being supplied by this Pharmacy. It presented an excellent example of which an inhouse pharmacy can achieve in a cost-effective way.
Photographs of the Sri Srinivasa Ayurveda Pharmacy
AYUSH in Selected States  93
Photograph showing display of samples dry herbs with their basic info at the Sri Srinivasa Ayurveda Pharmacy, Tirupati
Sri Venkateshawara Ayurvedic College & Hospital, Tirupati This institution is run by the Tirumala Tirupati Devasthanams, an autonomous quasi Government organization setup under the Andhra Pradesh State Charitable, Hindu Religious Institutions and Endowment Act (1987) of the Government of Andhra
Pradesh. Since 2011, the attached hospital has an increased bed strength of 210 beds and provides specialty Ayurvedic treatment, free of cost to poor patients. The hospital presents one of the best examples of a wellrun Ayurvedic hospital. The PI found the functioning efficient and the patient load was indicative of the useful work being done at the facility. The Panchakarma and Ksharasutra techniques of Ayurveda were very popular and people seemed to have come from all parts of Andhra Pradesh and adjoining States for undergoing these two procedures. Specialized Ayurvedic therapies were also being performed on children affected by cerebral palsy, Attention Deficit Hyperactive Disorder (ADHD), Autism and mental retardation. The out-patients department of the hospital has an average load of 350 patients daily and medicines worth Rs 50-/ per patient were being supplied free of cost for 15 days at a time. All
Photographs of the Inpatient services at the SV Ayurvedic College Hospital, Tirupati
94  Status of Indian Medicine and Folk Healing
the Bio-chemical, radiological investigations, Panchakarma therapies, ano-rectal operative procedures, medicines and diet were being provided to all in-patients without levying any user charges. About Rs.100/- is spent on each in-patient every day (excluding diet). Some details are captured below to give an idea of the work undertaken and costs incurred in a well-run facility because it presents an efficient model which gives an idea of the budgets necessary to maintain efficient hospital services. The annual budget for drugs is around what is presently spent on AYUSH drugs by the entire State. Data sheet on S.V.Ayurvedic College Hospital from April 2011 to March 2012 Out-patients In-patients
Admissions Surgeries
- 1, 09, 571 - 39,170 (Bed occupancy days = No of beds occupied by patients on every day x 365) - 2,378 (Number of patients admitted) - 120 (Ano-rectal surgeries) - 27,990
Panchakarma therapies Bed distribution among various specializations 1. Panchakarma - 42 (Upgraded to PG Dept) 2. Shalya - 42 (Upgraded to PG Dept) 3. Kaumarabhritya - 42 (Upgraded to PG Dept) 4. Kayachikitsa - 36 5. Shalakya - 12 6. Prasuti sthree - 12 roga 7. Hospital Unit 24 Total 210 Annual Budget for drugs purchase in the financial year 2011-12
:
Drugs supplied from Sri Srinivasa Ayurveda Pharmacy, Narasingha Puram (Chandragiri)
:
Rs.1,00,13,322/-
Rs. 58,51,300/-
Drugs purchased from outside companies through call of annual tenders
:
Rs. 27, 22, 489/-
Cost of Surgical items, lab chemicals, kits, X-ray films etc.
:
Rs. 78, 422/-
Cost of stationary items
:
Rs. 1,02, 175/-
Miscellaneous expenditure
:
Rs. 63, 519/-
Total budget utilised in financial year 2011-12
:
Rs. 88,17,905/-
Total budget of the Hospital including salaries to staff (excluding clinical teaching staff that are paid from College budget).
:
Rs.2,69,15,000/-
Number of medicines manufactured in SSA Pharmacy which are being supplied to Hospital
:
85 Nos
Number of medicines purchased from outside pharmacies by calling tenders
:
90 Nos
The AYUSH systems (ASU) require a continuous supply of drugs without which patients loose interest. A facility wise norms need to be drawn up for supply of drugs which should be adjusted periodically depending on patient load at each facility. A model like the Tirupati Hospital should be followed at least in all Government hospital facilities which would attract many more patients. The hospital also serves as a model of time management and could be studied as a good working example. Meeting with Principal Secretary (Health) Andhra Pradesh A meeting was chaired by Shri Ratna Kishore, Principal Secretary, Government of Andhra Pradesh attended by Dr. Srivasuki, IFS, Commissioner, AYUSH; Dr. K. Vishnu Prasad, Director, Medical Education; Dr. N.Satya
AYUSH in Selected States  95
Prasad, Principal, Dr. B.R.K.R. Government Ayurvedic College, Hyderabad and the Principal, Government Nizamia Tibbia College, Hyderabad. The PI gave her observations on the status of AYUSH in co-located facilities and her impressions of visits to rural PHCs in Rayalseema region and at the Tirupati Hospital. During the discussion she raised points relating to integration and mainstreaming of AUYSH which had been sent in advance to the Secretary. The main point which she had made in her letter before her visit was that there was a universal need for more organized integration at the primary health care level. The availability of doctors and drugs was not uniform and counseling on the use of ISM needed to permeate to the patient’s level. Integration if built upon operational guidelines and protocols could provide useful information to the patients instead of leaving the patient to try permutations and combinations on the basis of limited knowledge. In her letter she had requested the Principal Secretary for the presence of clinicians (both allopathic and having an Ayurveda/Unani background) to provide a forum for a frank discussion so that the PI could benefit from a brain-storming keeping in mind the ground realities. The letter is at (Annexure-IV).
In the meeting under the Secretary’s Chairmanship, it was apparent that the idea of integration hed not received much consideration although the Principal Secretary was personally appreciative of its need. By contrast the senior allopathic doctors were not geared up to accept the concept of integration. The mind-set of the higher level health professionals in charge of administering health services showed that the concept of cross-referrals was considered unworkable and unacceptable. The policies enunciated in the joint letters of the Health and AYUSH Secretaries regarding mainstreaming and integration had apparently not percolated except for physically positioning the contractual AYUSH doctors. There was an apparent need for the concepts and strategies for integration to be adopted across the government health doctors. That would not come only through the issue of instructions. In Andhra Pradesh as in other States visited by the PI, there was no understanding about how integration could be strengthened not just in physical terms but in a way that the services enabled the patient to derive the best advantage from the facilities provided. There is every need for devising a central set of guidelines and operational systems so that patients derive greater benefit
Photographs showing PI’s Meeting with Principal Secretary, Health AP and other Officials
96 Status of Indian Medicine and Folk Healing
from co-location. Leaving it to patients to decide is an easy way out but it is the responsibility of the architects of the mainstreaming policy to also lay down the strategies for efficient management of the patients.
This was followed by a visit to the attached
Dr. B.R.K.R. Government Ayurvedic Medical College, S.R. Nagar, Hyderabad
the oldest Ayurvedic Institutions in India and
The PI met the Principal and faculty members and went around the in-patient facilities.
Government Ayurvedic Hospital. The level of interest being taken by the faculty and students was good and the institute gave a favourable impression. She was told that it was one of several renowned Ayurveda experts like Dr. I. Sanjeev Rao, Dr. HS Kasture, Dr. VS Chauhan etc.,were products of this college.
View of the Dr. BRKR Government Ayurvedic College, Hyderbad with Commissioner (AYUSH), College Principal, the faculty and students
Photographs showing the entrance of the Government Ayurvedic Hospital, SR Nagar, Hyderbad where PG education is imparted
AYUSH in Selected States  97
Dr. Srivasuki, IFS, Commissioner (AYUSH) chairing the meeting with the faculty in the Principal’s chamber at the Dr. BRKR Government Ayurvedic College, Hyderbad
Later, a meeting was held with Dr. Srivasuki, Commissioner, Department of AYUSH and Dr. N. Satya Prasad, Principal, Dr. B.R.K.R. Government Ayurvedic College, Hyderabad and faculty members of the hospital. Government Nizamia Tibbia College, Charminar, Hyderabad The PI also visited Government Nizamia Tibbia College, Charminar in the old city of Hyderabad where she interacted with the faculty and ascertained about possibilities for better coordination intra the Unani and Ayurveda faculties aimed at learning from each other’s experiences in handling certain diseases. The faculty opined that interaction would give a lot of boost to move ahead with research and better management of diseases. The PI went around the hospital and observed a large cross-section of patients admitted in the Hospital and the treatment and procedures followed. The hospital was supported by modern medicine doctors, a surgeon,
98 Status of Indian Medicine and Folk Healing
an anesthetist, a dental surgeon and an Obstetrics or Gynecology specialist to support the teaching of traditional Unani Medicine. A large number of young girls (aged between 5 and 12) had been admitted for the treatment of vitiligo and had been left to hospital care by their parents which showed faith in the security and safety that the institution provided. The unique feature of this hospital is its location in the old city where facilities for both Unani and Ayurveda treatment is provided.
Outside view of the Govt Nizamia Tibbia College, Charminar, Hyderabad
Central Research Institute of Unani Medicine (CRIUM) at Hyderabad
Meeting with the faculty at Govt Nizamia Tibbia College Hospital and Commissioner AYUSH in the chair at the right
The PI visited the Central Research Institute of Unani Medicine at Hyderabad. The Institute was established in 1971. The Government of Andhra Pradesh had provided 5 acres of land for the institute. It has emerged as a centre for the treatment of several diseases and has treated over 100,000 patients of vitiligo alone. Over 2,000 new vitiligo cases are registered each year and the patients come from various parts of the country and even from abroad.
View of the CRIUM (A major centre of the CCRUM), Hyderbad
Patients at the Paediatric ward at Government Niazamia Tibbia College Hospital, Charminar, Hyderbad
The PI enquired about any examples of interaction between Ayurveda and Unani experts. She was told about an AYUSH Seminar which was conducted at Hyderabad which had given a good boost to AYUSH doctors of different streams as many of them presented papers on their research work before a combined audience.
View of the Herbal garden at CRIUM
The Institute is developing a clinical trial site as per WHO Guidelines with funding from the Department of Science and Technology and Department of AYUSH. The researchers are being given advanced training in research techniques particularly in the field of clinical research methodology to upgrade the quality of research being carried out at the Institute.
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Patients undergoing treatment for Vitiligo and other skin conditions at CRIUM, Hyderbad
The general up-keep of the Institute and the patient load gives the impression of an institute of professional standing and the high patient demand is evident. Considering the expertise that has been developed this Institute ought to become a focal national point for treatment of Vitiligo and certain other conditions.
Dr. MA Waheed examining a vitiligo patient
100  Status of Indian Medicine and Folk Healing
For people coming from all over the country it may not be possible to stay at the Institute’s hospital continuously. It is necessary to build awareness about the facilities, the level
that the treating Hakim changed with each visit. Curious and educated patients will not accept such an approach for treating chronic conditions. Suggestions for Reorganization made by AYUSH doctors from Andhra Pradesh
From L to R : Dr. M.A. Waheed, Deputy Director(Unani); Dr. M. Ataullah Sharief, Director Incharge; Dr. S. Mazhar-ul Haq, Research Officer Pathology; Dr. M.A. Wajid, Assistant Director; Dr. Alokananda Chakraborty, Research Officer Physiology at CRIUM, Hyderabad
of research work and patient care and to start a website which answers questions on the probable duration of treatment and of intermittent stay. Paying guest/hotel arrangements need to be identified and listed on the website to give confidence to out-station patients and to facilitate them. The availability of treatment facilities needs to be notified along with timings and payments through the website. Details of Unani treatment, herbs and other ingredients used should also be available on the website which should be developed using the IT services of a specialized institute like National Institute of Indian Medical Heritage (also located at Hyderabad) so that users can also avail of links that describe Unani drugs and their properties. This is because some skin conditions like vitiligo carry immense stigma and people would go anywhere in search of treatment. People who are internet savvy would feel encouraged if all loose ends could be tied up before coming to a new city for treatment. The CRIUM, Hyderbad has the potential to become a flagship Institute for skin diseases, but the physicians should be trained in handling questions and ideally the treating physician should not be changed mid-stream. The PI was told by some patients who had gone from Delhi for treatment
In Andhra Pradesh almost all AYUSH dispensaries have been co-located with the PHCs but the attendance of patients is very poor. The AYUSH supervisory officers find it very difficult to maintain supervision over the dispensaries which have been co-located with the rural PHCs. Better road connectivity to nearby towns has given people more choice than before. It is common to share autos which provide comparatively speedy transportation to the district headquarters or towns at an affordable cost. Government ambulances are functioning on a 24 X 7 basis quite effectively. The penetration of mobile phones even in rural areas makes it possible to summon ambulances in the event of an emergency. This has reduced interest and dependency on AYUSH in rural areas. This requires reorganization of the AYUSH staff bearing in mind patient preferences in rural areas. In urban areas the spread of education has brought about a shift in people’s healthseeking behaviour. There is now a growing demand for AYUSH services in urban areas with a heightened awareness about the sideeffects of modern drugs whereas in rural areas people show marked preference for modern medicine. There is a misconceived opinion among the majority of policy makers (politicians and senior bureaucrats as well as the media) that AYUSH systems do not fit into the current lifestyles of people and their utility is minimal. This opinion has gained ground mainly because no thought has been given to prioritization of core areas of strength within AYUSH. Instead of expanding AYUSH facilities in rural areas it is necessary to establish Ayurvedic speciality centres in urban areas where treatment can be provided for identified diseases and conditions. The possibility of receiving treatment at speciality centres would create a lot of interest and would prevent the need to visit quacks. The AYUSH dispensaries functioning in rural areas co-located or standalone need to be linked with the proposed specialty centres which can be established in municipal towns. The following suggestions are made for better utilisation of strength of AYUSH systems:
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• Five-bed Speciality Ayurvedic Centres should be set up at the municipal level with a Panchakarma/Kaya Chikitsa (Internal Medicine) Specialist, an Ayurvedic surgeon and an Ayurvedic Gynecologist. • A Fifteen-bed Specialty Centre should be established at the District Headquarters or at any large township in every district. A Specialty centre should be dedicated to diseases affecting the nerves, for dermatology for specialized intervention for diabetic foot and non-healing wounds , also for mental health conditions. The centres should be located either in teaching hospitals or in the District Hospital or a Government Allopathic hospital.
Research in Ayurvedic Sciences, Department of AYUSH). It is located on the first floor of a building in the heart of the marketplace and the discussions with the in charge of the Institute showed that people from the district as well as neighbouring districts visited the OPD for Ayurvedic consultation and treatment. The institute runs a general as well as a geriatric OPD and offers treatment for “flu like illnesses” and also supplies free medicines.
Conclusion and Recommendation The suggestions made by AYUSH doctors in Andhra Pradesh regarding reorganisation of the AYUSH manpower in the state needs to be discussed and the view taken. The suggestions have weight but they are state specific. Himachal Pradesh (16-19 May 2012) The State gives a picture of strong commitment to the development and utilization of Ayurveda. While the Unani system has a very small presence in the State, public faith in the Ayurvedic system seems to be strong and growing. The PI found that the network of government-run Ayurvedic hospitals, health centres and private practitioners all have a dedicated clientele but paucity of medicine and irregularity in supply are recurring problems which are affecting the continuity of treatment adversely. There is every need to step up internal production of drugs in the state pharmacies to cater to the growing needs, instead of depending on commercial purchase or government supplies which do not seem to reach in time.
View of the Ayurveda Regional Research Institute, Mandi
This Institute like many others under the Research Councils of Ayurveda follows the principle of widening the OPD clientele base to be able to locate patients that can fit into research projects. The PI found that in the process everyone received general treatment and the division between research and clinical practice was blurred.
The places visited by the PI are described as per the itinerary followed. Mandi The PI visited the Ayurvedic Regional Research Institute, Mandi, (under Central Council for
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Dr. Om Raj Sharma, Research Officer attending to patients at Ayurveda Regional Research Institute, Mandi
So far the institute has conducted clinical research on rheumatoid arthritis, malaria, malnutrition, acid peptic diseases, iron deficiency anemia, hypertension, skin diseases, jaundice, obesity, piles, leucoderma, gout, irritable bowel syndrome (IBS), hypertension and type II diabetes mellitus using Ayurvedic medicine. That is obviously too diverse a range for any meaningful research to be done and the outcomes would be based on a very small sampling of patients. The Institute had organized a “National Campaign Programme in Ayurveda 2010-2011� in collaboration with the Department of AYUSH, and the State Government and provided treatment for Ano-rectal disorders, Geriatric Care, Anemia, Mother and child health, in five districts of the State. In all 5,965 patients were examined and treated during the campaign. The feasibility of introducing Ayurveda as a part of the National Reproductive and Child Health Programme was also investigated in two blocks of Kangra and Mandi districts in collaboration with R.G.G.P.G. College at Paprola. The PI was shown a picturesque location where a new building is to come up but being on a steep hillside, it is questionable how many people would take the trouble of reaching the spot which would need four-wheeled transportation for the most part. It was observed that the annual OPD of this Institute even when it is located in the heart of the marketplace was just over 18,000 persons. The number might reduce substantially by moving to what appears to be a scenic location but not very practical from the point of view of getting sufficient patients from where research subjects would need to be identified. This needs re-consideration. More importantly the research needs to be linked to publications and unless there is independent assessment of outcomes,
the results cannot be taken at face value.
Ayurvedic Health Centre,Urla Mandi
Dispensing room at the Ayurvedic Health Centre, Urla Mandi
State facilities visited The PI interacted with Dr. Vidyasagar Gupta, District Ayurveda Officer, Mandi who informed the PI that 166 Ayurvedic Health Centers were functioning in the remote areas of the district. There were 18 co-located facilities under NRHM but modern medicine doctors were available only at five of these facilities and the rest were being managed by Ayurvedic doctors only. Joginder Nagar Herbal Garden A visit to the herbal garden and herbarium at Joginder Nagar presented a rich display of medicinal plants with an interesting range of both live specimens and dry herbs. Located
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on a 24 acre plot just off the main road, the Herbal Garden sells germplasm/planting materials and undertakes experimental cultivation. Several exposure visits and training camps have been held for the benefit of farmers, students, research scholars, NGOs and departmental officers.
The general upkeep of the nursery as well as the preparation of planting material was being done professionally. According to the version of the in-charge of the Institute Dr. Subhash Rana, around 2500 people including farmers had benefited during one year. This number could increase if the Institute widens its network.
Entrance view of the Joginder Nagar Herbal Garden
Dr. Subhash Rana, Incharge of the Joginder Nagar Herbal Garden
Display of plants at the Joginder Nagar Herbal Garden
Museum at the Joginder Nagar Herbal Garden
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With little investment, the institute could easily become a hub for the display of good cultivation practices for medicinal plants. Since the specimens available in the garden as well as the herbarium are so plentiful, it would be worthwhile to place this institute on the tourist map of Himachal Pradesh as has been recommended by the PI in the case of Jammu and Kashmir also. The display of exotic medicinal plants, their properties, followed by a live demonstration of how decoctions are prepared could all be combined to become an interesting and educative visit for tourists. An explanation about the properties of the herbs followed by serving a freshly made decoction would help propagate the benefits available. The Institute seems to have immense scope for partnering with universities and colleges to be able to have lectures and hands on display of the cultivation of medicinal plants for those pursuing courses on botany, pharmacology and Ayurvedic Dravyaguna. The Institute also offers an excellent location for meetings
of State Medicinal Plant Boards. Even if the temperate climate available at Joginder Nagar is unique only to Himachal Pradesh and other mountain states, it should be possible to engage stakeholders from Uttarakhand, Sikkim and the North-Eastern States in an exchange of experiences. This would facilitate interaction between cultivators, collectors and tribal people, and  give greater visibility to the Institute. The Department of AYUSH/ NMPB should consider setting up a group of experts both from the academic field of botany, medicinal plant cultivation as well as tourism to use the potential of this institution to benefit a wider group of stakeholders and build awareness about the potential of plantbased decoctions (fresh and dry). Joginder Nagar Pharmacy The PI held discussions with the Manager of the pharmacy on methods of procurement of raw material, processing, manufacturing and supply of various formulations. The pharmacy which was established in 1953 has over 5000 square meters of covered space. As against 93 sanctioned positions of pharmacy staff, only 44 were in position. The cost of medicines prepared in 2011-12 was about Rs 1.5 crore and the total expenditure on raw material was around Rs 80 lakh. Many among the pharmacy staff complained about outdated equipment which was in poor condition, so exposing them to risk. There is considerable scope for upgrading this pharmacy but what is essentially needed is more vibrant leadership. According to the figures given to the PI, the annual production capacity was 300 quintals but both in terms of land availability, proximity to the Joginder Nagar herbal garden, and the Ayurvedic Pharmacy College located next door, there is immense potential for increasing production. Human resources, plant material and space being
readily available, with greater investment and co-ordination the pharmacy can expand production and provide sustained support to hundreds of Ayurveda dispensaries. In Himachal Praesh the Ayurvedic dispensaries are widely used by the local population living in dispersed hamlets and villages. Owing to problems of leakage, seepage and fungus, which are common in hilly places, it is unlikely that supply of medicines procured from other States would remain in good condition for long. It would be far better to augment the supply from within the State and to see that at least 30 high-quality medicines produced by the State pharmacies are collected by the District Ayurveda Officers every quarter. Steady availability of at least basic medicine would give a huge spurt to the propagation of Ayurveda. Almost universally, every District Ayurveda Officer and the patients that the PI interacted with showed a strong preference for medicines manufactured at the government pharmacies, and there was a persistent complaint that the supply of Ayurvedic drugs was irregular. The PI also visited the College of Ayurvedic Pharmaceutical sciences at Joginder Nagar. Classes were in active progress at the college which the PI visited without any notice. The students (predominantly girls) showed interest in what was being taught.
Entrance to the Joginder Nagar College for Pharmaceutical Sciences
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Picture shows inpatient ward at the RGGPGA Hospital Picture shows that girl students dominate at the Pharmacy College
Rajiv Gandhi Government PG Ayurvedic College and Hospital, (RGGPGAC&H) Paprola, Kangra The PI visited the hospital and met the acting Principal Dr. YK Sharma, Dr. Eena Sharma, Dr. Sanjeev Sharma and the District Ayurveda Officer. She went around the hospital wards and observed the medical conditions for which patients were admitted. Strategies to help people quit smoking seemed a priority for the Institute as many hill people are heavy smokers and suffer from respiratory diseases.
View of the Rajiv Gandhi Post Graduate Ayurvedic College & Hospital (above), Dr. YK Sharma and Faculty members (below)
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Although Dr.Y.K. Sharma spoke about the faith of local people in Ayurvedic treatment, the general approach of the faculty gave the impression of greater focus on teaching and practising allopathic medicine as compared to other colleges visited by the PI. Particularly in the area of gynaecology and obstetrics, it was argued that the hospital as well as the faculty was entitled to perform surgeries and use modern medicine based on a letter issued by the Ministry of Health and Family Welfare. (Annexure-V) Apart from the R.G.G.P.G. Ayurvedic College, Paprola the following activities were also reported for promoting different aspects of Ayurveda: I.
Zonal Centre of Excellence for Geriatrics, Paprola had received Rs. 5 crore from the Department of AYUSH, Government of India for establishing a 20-bed stateof-the-art hospital to cater to geriatric patients.
II.
A pilot project on Anaemia-free Himachal Pradesh was started under NRHM.
III.
155 Ayurvedic medical officers had been appointed at various PHC/CHCs under NRHM.
IV.
Kwathshalas have been set up at various hospitals to provide fresh decoctions to patients.
V.
Panchkarma treatment centers had been expanded from six to sixteen and Kshar Sutra Centres increased from two to nine.
VI.
Fifty-seven training camps had been organized to train farmers in medicinal plant cultivation.
District visits The PI was able to hold discussions with seven out of 12 District Ayurvedic Officers during the course of her tour to those districts. Some of the observations are described below. Kullu The PI held discussions with Dr. Baldev Awasthi, District Ayurvedic Officer (DAO), Kullu. He was very knowledgeable about the dispensaries under his charge and had all details at his fingertips. It was clear that he was undertaking regular tours. However asked whether the dispensaries were having sufficient stock of Ayurvedic medicine he indicated that drug supply was irregular and that affected patient attendance adversely.
doctors and the other half have modern medicine doctors. The PI was informed that in all the remote facilities it was only the Ayurvedic doctors who performed all the functions as In-charges. Pancharukhi The PI met Dr. Ashwini Sharma, a leading Ayurvedic private practitioner, and he explained how he had developed his practice over the last 25 years. He received a daily patient load of nearly 200 patients. The PI observed that he relied on Himalaya Drug Company’s single drugs which were available on his table while also dispensing Ayurvedic medicines in syrup form from a small compounding section within the clinic.
Co-location: Regarding the status of colocation, there were five co-located facilities under NRHM and 63 Ayurvedic health centres (standalone facilities). The PI was not shown any co-located facility. However, it appears that in all the five co-located NRHM facilities there are no allopathic doctors and an Ayurvedic doctor functions as the in-charge of the facility. Kangra Kangra district has 227 Ayurvedic health centres dispensaries and just 10 co-located facilities under NRHM. Half the co-located facilities (five) are manned by Ayurvedic
Dr. Ashwini Sharma at his clinic attending to patients (above) and packaged single drugs displayed on his table (below)
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Private practitioner Dr. Ashwini Sharma’s crowded clinic
At the time that the PI visited his clinic there were numerous patients waiting for consultation. Dr. Ashwini said he charged Rs.70/- for a three-day supply of medicines but did not ask for consultation fee. The PI found that the patients were from different economic backgrounds. Patients with high fever were also lying on the benches awaiting consultation. This was unusual as in most States (except in South India), the tendency is to start on a course of modern medicine as soon as there is any fever. Dr. Ashwini Sharma seemed to be relying substantially on Ayurvedic medicine which seemed to have high acceptance among the patients.
Dr. Manik Soni at his clinic inside his residence
Hamirpur The PI visited the District Ayurvedic Hospital and held discussions about various facilities and services like panchakarma, Ksharasutra which were being provided at the hospital. She took a round of the indoor wards and asked the admitted patients about the treatment being provided to them. They appeared satisfied.
Nagrota Bagwan This place is in Kangra District where the PI visited the residence-cum-clinic of Dr. Manik Soni and Dr. (Mrs.) Soni, private practitioners who were products of the Ayurveda College at Paprola. The clinic stocked a wide range of both Ayurvedic and allopathic medicines and the husband-wife couple saw patients anytime of the day or night. According to Dr. Soni, patients just rang the bell and when required he would provide emergency treatment for acute conditions, at night. This included administration of intravenous fluid and injections and life-saving drugs.
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View of the District Ayurvedic Hospital, Hamirpur
She was informed that Hamirpur had 69 Ayurvedic Health Centres. There are only two co-located facilities under NRHM one of which was manned by an Ayurvedic doctor exclusively. Bilaspur
projects and programmes undertaken by the hospital and the general response of the public. She took a round of the indoor wards, the kwathashala and the panchakarma and ksharasutra units. The annual OPD (from 1.4.2011 to 31.3.2012) had provided treatment to 45,000 patients.
The PI met Dr. Uttam Chand Chandel, the District Ayurveda Officer who told her that except for shortage of drugs the Ayurvedic system had great public support in the State. There were 65 Ayurvedic dispensaries/centres but just two co-located facilities, both manned exclusively by Ayurvedic doctors. Shimla The PI had a useful meeting with Shri Ali Raza Rizvi, Principal Secretary, Health & Ayurveda Government of Himachal Pradesh who chaired the meeting. The Director of Ayurveda Shri P.S. Draik, Shri Rameshwer Sharma, Additional Director and Dr. Rakesh Pandit, OSD, Directorate of Ayurveda and Dr. Om Raj Sharma, Assistant Director, ARRI, Mandi were present at the meeting. Shri Ali Raza Rizvi, Principal Secretary was aware that Ayurvedic Doctors were manning the PHCs in remote areas and that most of the allopathic doctors recruited under NRHM (42 out of 155) were posted in Shimla District. It was evident that integration of health services from the patient’s point of view had not taken place even when Himachal was one State where public faith and acceptance of Ayurveda was comparatively high.
View of Ayurveda Regional Research Institute, Shimla
Medical store at Shimla Regional Ayurvedic Hospital
Regional Ayurvedic Hospital, Shimla The PI visited the hospital and viewed various facilities offered at the hospital. She held discussions with Dr. SK Sharma, Medical Superintendent, the District Ayurveda Officer and other medical officers about various
Dr. Asha Sharma attending to a patient at Shimla Regional Ayurvedic Hospital
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various facilities available. He informed that Ayurvedic doctors provided health services in institutions where allopathic physicians were not available. The data showed that there were 76 Ayurvedic facilities and three Colocated NRHM facilities where three modern medicine doctors were available.
Kwathasala at Shimla Regional Ayuvredic Hospital
Quatha containers at Kwathasala, Shimla Regional Ayuvrvedic Hospital
The PI also met Vaidya Kripa Ram, a traditional healer from Arki village who displayed many varieties of medicinal herbs for treating chronic diseases. The healer was prepared his own decoctions and supplied them, and was being awarded respect by the regular doctors.
Gleaming, new OPD hall at Solan Ayurvedic Hospital
Interaction with private practitioners The PI also interacted with Vaidya Ram Kumar Bindal, a popular Ayurvedic practitioner who shared his experience of 40 years practice. He mentioned that he had maintained documentary evidence of his patients and also ran an Ayurvedic Pharmacy. The claim to have cured cancer and other intractable diseases was made with great confidence.
Vaidya Kripa Ram – a local healer
Solan The PI visited the District Ayurvedic Hospital and held discussions with Dr. Hemraj Sharma, District Ayurveda Officer about
110 Status of Indian Medicine and Folk Healing
View of a private Ayurvedic Clinic at Solan
the State pharmacy and the herbal garden at Joginder Nagar needs to be exploited. The suggestions made by AYUSH doctors in Himachal Pradesh regarding reorganisation of the AYUSH manpower in the state needs to be discussed and the view taken. The suggestions have weight but they are state specific. Jammu & Kashmir (2-5 September 2012) Vaidya Ram Kumar Bindal, traditional Ayurvedic practitioner along with Dr. Hem Raj Sharma, District Ayurvedic Officer
Suggestions for Reorganization made by AYUSH doctors from Himachal Pradesh The state governments should give regular AYUSH doctors (non-contractual) the responsibility for both coordination and monitoring medical and health activities at the block and below block level and their output should be a part of the NRHM reporting systems in specific terms. The AYUSH Doctor (non-NRHM) can then use his/her special education and training to additionally spread AYUSH concepts of preventive health in the community and can supervise the use of AYUSH drugs, planting and utilization of medicinal plants for which he has full knowledge. Such a move would provide the services of a senior person to coordinate between stakeholders. The district functionaries in charge of RCH, tuberculosis and Nutrition would have the advantage of better inputs from a medical functionary with 10-20 years service, who can be easily oriented to report on location specific features of each programme. The strategy will require a policy decision through the NRHM hierarchy and would require the AYUSH doctors (non-NRHM) to get assimilated into the NRHM reporting systems and organizational hierarchy. Such doctors (as opposed to the NRHM contractual doctors) have several years of experience and know the district and the talukas intimately.
Conclusion and Recommendations The State has a natural advantage as the faith in and the use of Ayurveda is very strong and widely respected. The State Government has invested funds and time into expanding the infrastructure. However, there was a universal paucity of drugs for which the potential of
The State of Jammu and Kashmir has established one 25-bed Ayurvedic Hospital at Jammu and one ten-bed Ayurveda/Unani facility attached to 17 district hospitals. The Regional Research Institute of Unani Medicine under CCRUM and the Regional Research Institute of Ayurvedic Medicine also have attached hospitals. There are 485 standalone AYUSH dispensaries, and co-location has been done at 396 PHC’s using 438 doctors appointed under NRHM. During 2010-11 over 20 lakh patients received treatment in the standalone dispensaries and other AYUSH facilities excluding the number of patients treated in the co-located facilities under NRHM. Over 1000 patients received indoor treatment during the year. It was reported that 90 percent of the co-located PHCs have AYUSH doctors who had received induction training under NRHM. The State does not have a single government college for Ayurveda and Unani medicine in the public sector, there being only three private colleges in the State, one in Jammu Division and two in Kashmir Division. Without any educational institution in the public sector, research and specialization may not develop. Two private Medical Colleges one each for Kashmir and Jammu Division are under construction which will fill the gap of doctors to some extent. The PI was accompanied for most of the visit by Dr. Kabir Dar, the Director (ISM) of the State. During the PI’s visit to the State, it was
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lamented out that there was huge expenditure on propagating general health benefits under NRHM but no money had been made available for conducting training or issuing advertisements for the propagation and promotion of AYUSH systems. Hence awareness about how the systems could benefit the public was poor. The Director (ISM) felt that a separate budget provision was needed to conduct seminars at the block/tehsil/district levels and for publishing best practices and the beneficial effects of Ayurvedic and Unani systems for preventive and promotive healthcare. Besides, intraAYUSH (Unani to Ayurveda and vice-versa) cross-referrals need to be encouraged for which there is a need for better understanding among the Ayurveda and Unani doctors. Overall, the number of facilities was quite extensive. There were 485 standalone facilities which compared favourably with the provision of public sector allopathic facilities excluding sub-centres. There was one Government AYUSH doctor for every 16,000 people (compared to one Allopathic doctor for 12,000 people. Ayurveda and Unani are the dominant systems in Jammu & Kashmir although the Amchi system is also prevalent. Over 90 percent of the PHCs have been colocated and AYUSH doctors are available but it was reported that in remote, rural and underserved areas only the AYUSH doctor were managing the facilities. The general perception was that the quality of AYUSH services was better in the standalone facilities as compared to the co-located facilities. As a result of this and as has been pointed out by the report done by NHSRC3, in the absence of drug supply it is the AYUSH doctors who have been mainstreamed and not the system. The findings of the report and the PI’s
observations point to give wider orientation to the contractual AYUSH doctors which goes beyond the national programmes as they are doing general allopathic practice most of the time. Presently there are no guidelines or restrictions on what they can and cannot do. Pharmacies and Drugs Supply A State pharmacy has not been commissioned and drugs are being purchased using the State budget allocation which is not being released regularly. Sometimes drugs are purchased as part of the centrally sponsored scheme under the Department of AYUSH, Government of India. No supplies had been received through NRHM during the last three years. The stock position of drugs was reported to be unsatisfactory. Practice of modern medicine by AU doctors It was pointed out that the responsibilities to be fulfilled by Ayurvedic/Unani doctors functioning as single in-charges of the Primary Health Centres, had not been issued. These doctors were conducting deliveries/postpartum procedures and were attending to emergencies according to their own competence. They were being put on night duty/emergency roster duty regularly. The PI was told that a proposal to notify the use of essential allopathic medicine by AYUSH doctors was under active consideration of the health department and had been submitted by the Directorate of Indian systems of medicine for consideration. The introduction of regimental therapy like cupping, leeching and panchakarma procedures in the regular AYUSH facilities had increased the demand for OPD services and this has resulted in a growing interest among the public about the benefits of these systems.
3. 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.
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Ayurvedic Panchakarma had been introduced in many facilities and the quality of tables and other equipment was very good. Referrals: a system of referrals did not seem to exist at any of the places visited by the PI. while it was claimed that a large number of cases were being referred by allopathic doctors but when even one document was asked to be seen, it was evident that such referrals were being made orally only. This is not in keeping with the guidelines issued for mainstreaming and steps need to be taken to overcome the resistance of allopathic doctors to writing simple referrals. Supervision and Reporting systems The Director (ISM) and his hierarchy of AYUSH doctors do not have any role to play in the NRHM organizational structure and reporting systems. Only AYUSH doctors can oversee and suggest correctives when it comes to the work of the AYUSH doctors recruited under NRHM. Unless the Director (ISM) has an official position, he has no authority to check the AYUSH work being done in the public health institutions. The tendency to do only allopathic work as backup support for NRHM and public health activities is growing and the objective of positioning AYUSH doctors will not be met, particularly if the supply of drugs also remains non-existent. Therefore, there is every need to strengthen coordination and reporting systems and the Director (ISM) has a specific role to play in the State Health Society. Ideally, all the district officers ought to coordinate and report on the AYUSH component of the work being done in the co-located facilities. Harmonization and integration There is every need to sensitize the AYUSH contractual doctors and paramedics about their primary responsibility towards giving AYUSH treatment. Eventually, the patient will lose out and the money being spent on recruiting so
many contractual AYUSH doctors would be used only as a back-up to give relief to modern medicine doctors from getting posted in difficult places or having to undertake night duties. This needs to be corrected as without supervision by senior AYUSH doctors who have the technical knowledge of what ought to be done, the contractual AYUSH doctor will only work as an appendage or helpfill the gaps in the availability of regular modern medicine doctors. The latter may be welcomed by the contractual AYUSH doctors but would be short-circuiting the intention behind the policy of integration. Tour Highlights Srinagar The PI visited the AYUSH centre located at the Government Medical College and the attached SHMS Hospital and the Jawaharlal Nehru Memorial Hospital, Srinagar.
Patients waiting at registration counter of the hospital
The PI was accompanied by Dr. Kabir Dar, Director (ISM) who had established an excellent rapport with all the allopathic doctors, including the Director, Health Services, Mission Director, NRHM, Principal, Govt. Medical College, and the Medical Superintendents of SMHS Hospital and JLNH, Srinagar. Good work was being done in the AYUSH setup and there was an air of involvement and professionalism. It was evident that given proper leadership there is a climate of mutual respect and acceptance of different systems could be built up. This kind of cooperation was not evident in any other State. AYUSH in Selected States  113
Gulmarg The PI also visited the Primary Health Centre at Gulmarg. It was manned entirely by an AYUSH doctor.
View of the PHC, Gulmarg manned only by AYUSH doctor under NRHM
parts of the country wherever regular allopathic doctors are hesitant or unwilling to get posted. Therefore the reality must be confronted. In case the AYUSH doctor is expected to attend to the administration of parenterals and to use emergency life-saving drugs, he should be trained and his competence should be overseen by a method of proctoring. It was evident that because the allopathic facilities at the sub-divisional headquarters at Tanmarg are located within a half hour drive, there is a complacency that real emergencies can be sent there. In that case it begs the question whether at all there is a need to maintain such a huge infrastructure if it is not being used. AYUSH doctors must therefore know the extent to which they are expected to use the modern medicine drugs and therapies, and the first priority ought to be towards providing AYUSH services and not only in stepping in to fulfill gaps created by the absence of the modern medicine doctor. Shalimar Garden and Herbal garden at Nehru Memorial Botanical Garden (NMBG) Chasmashahie
Director of ISM Dr. Kabir Dar speaking to NRHM AYUSH doctor working as I/C of PHC, Gulmarg
There were about five other persons present in a large PHC which had facilities for investigation as well as X-ray which were not being used. All beds were empty. The PI asked the Ayush doctor what work he did. It was admitted that no AYUSH medicine had been made available and since he functioned as the In-Charge of the PHC he had to perform all duties. He said he was confident about prescribing and administering IV fluids but when asked to demonstrate, he asked the AYUSH pharmacists to do the demonstration who in turn had to depend on the ward boy. There is nothing exceptional about this situation. This is often the case in many other
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In the evening the PI was taken to see an ancient Hammam (Turkish bath) which had been excavated during Mughal era at the Shalimar gardens in Srinagar. This was being restored so that visitors and tourists could see the traditional Bath in their original form. Herbal garden at Nehru Memorial Botanical Garden (NMBG) Chasmeshahi The PI was shown a herbal garden which was a part of the botanical garden. It was a good initiative to sensitize visitors about medicinal plants but stopped short of becoming a bridge to actually enable people to know how to use medicinal plants as home remedies. Since it was simply an ornamental garden, the purpose was served in a very limited kind of way. The PI suggested that there was immense scope to do
things differently, to heighten interest among visitors and tourists. It appears that funds that have been given by the ISM Department to the Directorate of Horticulture under Medicinal Plant Mission had not been used. Pulwama The PI was taken to visit the AYUSH standalone facility at Ratnipora Pulwama. The facility was very well attended and work was in progress even after working hours were nearly over.
Medical store at the District hospital
The PI was also taken to the AYUSH unit at the allopathic facility where also the interface with the allopathic doctor and the ISM doctors was quite collaborative. All facilities were neat and clean and Ayurvedic treatment was also being provided along with Unani treatment. There was no evidence of segregation of the two systems as is generally apparent elsewhere in the country. AYUSH Centre at District Hospital, Pulwama
Display board showing facilities available at co-located AYUSH centre at District Hospital, Pulwama
Call on the State Health Minister The PI called on Shri Sham Lal Sharma, Health Minister of J& K, which was very useful because he had a deep interest in the development of Indian Medicine and more importantly besides being Health Minister was also in charge of both Floriculture and Horticulture. This gave a rare opportunity to bring together the strengths of the three departments and in particular the Health Minister agreed that the strategy of promoting health tourism with special reference to the use of medicinal plants was something that the State was well positioned to undertake and which he would be taking up in due course of time. Meeting with Chief Secretary and State Health Secretary
Patient availing facility of wet cupping at AYUSH District Hsopital, Pulwama
The PI appreciates that the State’s Chief Secretary Shri Madhav Lal (IAS) gave time to listen to all the developments that were brought to his notice. The State Health Secretary Shri MK Dwivedi was also present. The point
AYUSH in Selected States 115
about non-availability of medicines and the fact that the contractual AYUSH doctors were being mainly used as backup support for doing the normal functions related to NRHM and public health was discussed and the Chief Secretary gave instructions on the subject. The PI told them that although the level of participation and integration of departments like tourism, horticulture were excellent initiatives, perhaps a focus on medical tourism including a display of high altitude plants, their healing properties, a demonstration of the preparation of decoctions and a visit to an AYUSH facility would give both foreign and Indian visitors a better idea of how these systems work.
Director (ISM), Dr. Kabir Das had built up good connections with the allopathic doctors at the helm of affairs. They had an open mind to integration and did not show the overt distaste for any talk of integration which was observed in other states. They were willing to find ways of making it easier for patients to avail of services and the atmosphere at higher levels for from being hostile was friendly and receptive. The presence of officials from the Departments of General Health Services, Agriculture, Floriculture and Integrated Medical Research far from being symbolic showed their conversance with the AYUSH sector and its interface with other Departments. Their contribution was very positive. Those present included:
Directors from health sector and related departments at Srinagar
The Director (ISM) had taken the trouble of organizing a meeting with all stakeholders from the AYUSH and related sectors. The interactions turned out to be participatory and supportive of AYUSH. It was clear that the
116  Status of Indian Medicine and Folk Healing
1.
Mr. Syed Iftikhar, Special Secretary, Health & Medical Education, J&K Government.
2.
Dr. Yashpal Sharma, Mission Director, NRHM, J&K
3.
Dr. Saleem-ur-Rehman, Director, Health Services, Kashmir
4.
Dr. Abdul Kabir Dar, Director, Indian Systems of Medicine, J&K
5.
Dr. AS Shawl, Sr. Scientist (Ex-HOD) Indian Iinstitute of Integrative Medicine (IIIM).
6.
Mr. KA Qasba, Agriculture
Joint
Director,
7.
Mr. Pran Floriculture
Joint
Director,
8.
Smt. Geeta Garg, Professor, Jammu Institute of Ayurveda Research
9.
Dr. Krishana Kumari, Assistant Director, ARRI Jammu
Dullo,
10. Dr. Mohammad Iqbal, Principal, KTC Srinagar 11. Dr. Khurshid Ahmad Bhakshi, Principal, IAMS Srinagar 12. Dr. KS Manhas, Dy. Director, ISM, Jammu
13. Dr. Abdul Lateef, Director(Unani), ISM
Assistant
14. Dr. Rakesh Kumar Raina, Assistant Director(Ayurveda), ISM 15. Mr. Munish Dutta, Assistant Director, ISM, Planning 16. Dr. Syed Srinagar
Ashiq
Hussain,
ADMO,
Visit to 50-bed Government Unani Hospital This is the first ever referral hospital providing Unani treatment and has taken several years to be completed and started. Located on the National Highway at Shalteng Srinagar, the OPD facilities have been started by internal arrangement of staff pending sanction of staff. Among other facilities this hospital provides the good facilities to patients through regimenal therapies of Unani Medicine like: Cupping (Wet & Dry), Hammam (Steam Bath), Massage, Leeching, and Ayurvedic Panchkarma procedures. Intra-AYUSH cross-referral is very much available in the hospital which can become a model for other institutions. There was excellent display of the medicines available in stock so that the general public had an idea of availability, date of manufacture and date of expiry of the medicines. This was a commendable initiative.
Day care facility for Regimenal therapy
Hammam (steam bath) procedure at the hospital
Conclusions & Recommendation The extensive use of AYUSH doctors to man PHCs in remote areas should be overseen. If they have to primarily provide modern medical services their training to do so would need to be upgraded. There is a need to give a role to the Director (ISM) and his district Officers to supervise the availability of AYUSH drugs in co-located PHCs and to guide the AYUSH doctors about this primary aspect of their work. The State has unique opportunity to capitalize on its strength as a high altitude State with huge tourist potential by organizing a live demonstrations of the strengths of medicinal plants by for visitors and tourists.
The only Government Unani Hospital
The linkages established with Floriculture and Tourism Departments need to be taken forward with greater enthusiasm. Finally, the
AYUSH in Selected States  117
supply of AYUSH drugs must be overseen regularly as otherwise the goals set out under NRHM will not be achieved. States Consulted The PI wrote letters and sent a questionnaires to the States of Bihar, Uttarakhand, West Bengal and Madhya Pradesh to elicit information on specific aspects of AYUSH in those States. The letter and the questionnaire are at AnnexureVI and Annexure-VII, respectively.
Ayurvedic/Unani doctors appointed under NRHM. Role and responsibilities guidelines had been issued by the State including on expected performance from Ayurvedic/Unani doctors positioned in co-located facilities. No response was given on whether guidelines for patient counselling on the usefulness of Ayurveda/Unani treatment for specific conditions had been issued.
Bihar
No guidelines had been issued on the combined use of allopathic and Ayurvedic medicine.
Infrastructure
Government and private practice
There were five graduate level governments colleges, three private colleges and one postgraduate college. There was one graduate level Unani college under the government and three private colleges. There were 69 Ayurvedic and 30 Unani dispensaries. Under NRHM 1384 (704 Ayurvedic, 252 Unani and 428 Homoepathic) + 426 (50% Ayurvedic, 20% Unani and 30%Homoeopathic) functional facilities were being run on co-located basis. The annual IPD figures were not provided. Seven hundred and seventy-two Ayurvedic and 252 Unani doctors have been appointed under NRHM.
There was no Government notification regarding the use of allopathic medicines by Ayurvedic/Unani doctors.
Pharmacies and Drug supply The major supply of drugs was through the State Pharmacy, purchase made by the State Government and supplies from the Department of AYUSH. The stock position of AYUSH Drugs was stated to be unsatisfactory. The reasons for the state pharmacy being unable to produce more drugs was started to be due to shortcomings of infrastructure, manpower and funding. Instructions have been issued to the DHs/ MOs Incharge of CHCs & PHCs relating to
118  Status of Indian Medicine and Folk Healing
No response was given as to whether the State was providing allopathic drugs to Ayurvedic/ Unani dispensaries run by the Government. Also, no notification or instructions had been issued relating to Medical practice by Ayurvedic/Unani practitioners using modern medicine under the Drugs and Cosmetics Act, 1940. However, instructions had been issued on the responsibilities to be fulfilled by Ayurvedic/ Unani doctors functioning as single Incharges in CHCs & PHCs so far as National programmes are concerned: The reply given by the State stated that more grass root level awareness about Ayurvedic, Unani and Homeopathy medicines and the involvement of AYUSH Government and private doctors in the National health delivery system and implementation of different scheme is required. The use of local herbal medicinal products and traditional knowledge regarding prevention and promotion of health needs to be publicised.
Uttarakhand Infrastructure There are two government and three private Ayurvedic colleges with attached hospitals functioning in the State. There are 546 government Ayurvedic and Unani dispensaries and 183 functional facilities co-located under NRHM. One hundred and fifty-four doctors have been appointed for the PHCs and 29 for the CHCs making a total of 183 doctors. The annual OPD (2010-11) was 44,86,461 and the annual IPD (2010-11) was 51587. There was a growth in OPD attendance as well as bed occupancy over the previous year. Pharmacies & Drug supply It was reported that the drug supply from the State pharmacy was poor but the stock position of drugs was reported as satisfactory because of supplies received by Government of India agencies. The reason given for the State pharmacy being unable to increase production was shortage of skilled persons and shortage of funds. Instructions had been issued to the DHs/ MOs in-charge of CHCs and PHCs relating to Ayurvedic/Unani Doctors appointed under NRHM through an “Anubandh” (Annexure-VIII). No guidelines had been issued relating to patient counselling on the usefulness of Ayurveda/Unani treatment for specific conditions. No guidelines had been issued regarding the use of Ayurvedic and Allopathic treatment in combination either. Government and private practice No notification has been issued regarding the use of essential allopathic medicines by Ayurvedic/Unani doctors under the national programmes. No supply of allopathic drugs was being made to Ayurvedic/Unani
dispensaries run by the Government. No guidelines had been issued regarding medical practice by Ayurvedic/Unani practitioners under the drugs and Cosmetics Act, 1940. Regarding instructions issued on the responsibilities to be fulfilled by Ayurvedic/ Unani doctors functioning as single in-charge in CHCs and PHCs as far as the National Programmes were concerned, reference was made to the Anubandh signed by the doctor (Annexure-VIII). The State Government recommended that the public can be benefited through Ayurveda both in urban and rural areas particularly for rejuvenation but there was a need to counsel them about specific diseases. West Bengal Infrastructure There State has three government and one private Ayurvedic college and one private Unani college with attached hospitals. There are 295 state Ayurvedic dispensaries, 200 Gram Panchayat Ayurvedic dispensaries and four Unani dispensaries. There are no colocated facilities under NRHM. The annual OPD in 2010–11 of the AYUSH facilities was 7,11,429. The State reported 20 percent increase in patient attendance compared to the previous year. The annual IPD in 2010-11 was 28,137 (Bed days) with a 10 percent increase in patient-bed occupancy compared to the previous year. Pharmacies & Drug supply The State pharmacy supplied 40 percent of the required medicines and the remaining drugs were purchased from IMPCL using the Grants-in-aid provided by Government
AYUSH in Selected States 119
of India, Department of AYUSH. The stock position of drugs was stated to be satisfactory. The reason given for the State pharmacy being unable to increase production was stated to be on account of the pharmacy staff which had been resolved. Modern Medicine Practice, Performance Levels and Patient Counselling There being no co-located facilities and no appointments made under NRHM, no instructions had been issued. Asked whether there were any guidelines issued for patient counselling on the usefulness of Ayurveda and Unani treatment, the response was that standard operational guidelines existed, but these were not sent to the PI. It was also stated that there were standard operational guidelines in force regarding the combined use of Ayurvedic and allopathic medicines but no such document was sent. The response stated that there was no notification relating to the use of essential allopathic medicines by Ayurvedic/Unani doctors under the national
120  Status of Indian Medicine and Folk Healing
programmes and nor was there any supply of allopathic drugs to Ayurvedic/Unani dispensaries run by the Government. No instructions had been issued regarding modern medical practice by Ayurvedic/Unani practitioners under the Drugs and Cosmetics Act, 1940 and no instructions had been issued relating to the responsibilities of Ayurvedic/ Unani doctors functioning as single in-charges in CHCs and PHCs. However, the State Government had constituted a Committee to review the matter of allowing AYUSH doctors to prescribe life-saving allopathic drugs during emergency. The State AYUSH Department made the following suggestions: All district hospitals should have Ayurvedic/ Unani wings for which proposals had been included in AYUSH Project Implementation Plan (PIP) 2011-12 & 2012-13 sent to Government of India. The State reported that integration under NRHM was essential to promote pluralism in the interest of improving public health services.
Annexure-I List of Officers who attended meeting chaired by the Commissioner-cum-Secretary, Health & Family Welfare, Government of Odisha at the request of the PI 1.
Anu Garg
Commissioner-cum-Secretary to Govt. of Health & F.W. Department
2.
Pramod Meherda
M.D., NRHM (O)
3.
Dr. Upendra Kumar Sahu
DHS (O)
4.
Padmalochan Behera
DIMH (O), Joint Secretary to Govt. of Health & F.W. Department
5.
Dr. PK Das
DMET (O)
6.
Dr. BK Mishra
Special Secretary to Govt. of Health & F.W. Dept.
7.
PK Mallick
Conservator, State Medicinal Plant Board, Odisha
8.
Dr. MV Acharya
Scientist, National Research Institute of Ay. Drug Development
9.
Dr. RN Acharya
Scientific Officer, DTL (ISM), BBSR
10. Dr. Surendra Kumar Mishra I/c Inspector of Ay. Eastern Circle, Bhubaneswar 11. Dr. LK Nanda
Former Principal Dr.ACHMC&HC, Bhubaneswar
12. Dr. NP Naik
Dy.Supdt., Govt.Ayurvedic Hospital, Bhubaneswar
13. Dr. Subham Allakhan
R.R.I.U.M., Bhadrak
14. Dr. L Samiulla
Dy. Director, R.R.I.U.M. Bhadrak
15. Dr. Manoranjan Mohapatra Consultant AYUSH, Odisha 16. Adait Kumar Pradhan
SPM, NRHM (O)
17. Dr. Balakrishna Panda
Joint (Director) Technical
18. RN Sethy
Establishment Officer, DIMH (O)
19. Dr. Gaurav Giri
Drugs Inspector (Ay.), DIMH (O)
20. Dr. BB Behera
Dy. Director Homoeopathy, DIMH (O)
21. TD Hansda
Accounts Officer, DIMH (O)
22. Dr. NP Hota
A.M.O.-cum-R.O., DIMH (O)
AYUSH in Selected States  121
Annexure-II List of Faculty Members the PI met at AK Tibbiya College, AMU, Aligarh 1.
Prof. Saood Ali Khan, Principal and Chief Medical Superintendent
2.
Prof. Shagufta Aleem, Dean, Unani Medicine
3.
Prof. Mukhtar Husain Hakim, Prof. and Consultant Department of Moalijat
4.
Prof. Abdul Mannan, Prof. and Consultant Department of Moalijat
5.
Prof. MMH Siddiqui, Prof. and Consultant, Department. of Elaj Bit Tadbir (Regimental Therapy)
6.
Dr. Misbahuddin Siddiqui, Associate Prof. and Consultant, Department of Moalijat
7.
Dr. Tafseer Ali, Assistant Prof. and Deputy Medical Superintendent, A.K. Tibbiya College & Hospital
8.
Dr. M Wasi Akhtar, Assistant Prof., Department of Moalijat
9.
Dr. Mohd Belal, Guest Facility, Department of Amaraze jild
10. Dr. Younus Siddiqui, Associate Prof. and Consultant, Department of Moalijat Other Expert present at the meeting: Dr. Latafat Ali Khan, Deputy Director, RRIUM, Aligarh
122  Status of Indian Medicine and Folk Healing
Annexure-III Treatment of choice in Ayurveda and Unani for Common Disease Conditions* S. No. 1
Clinical condition Jaundice
Ayurvedic Drug of Choice
Botanical Name
Unani Drug of Choice
Kutaki
Picrorhiza kurroa Royle ex Benth.
Nausadar
Punarnava
Boerhavia repens L. var. diffusa (L.) Hook.f. syn. Boerhaavia diffusa L.
Makoya
Solanum nigrum L.
Bhumyamalki
Phyllanthus amarus Schmach. & Thonn.syn. Phyllanthus fraternus G. L. Web.
Kasni
Cichorium intybus L.
—
Kutaki
Picrorhiza kurroa Royle ex Benth.
Arogyavardhini Vati
—
Majoon-edabidulvarda 2
Cough with expectoration
Karkatshringi
Pistacia integerrima Stewart
Vasa
Justicia adhatoda L. Sapistan syn. Adhatoda zeylanica Medik.
Talishaadi Churna Kantakari
3
4
*
Inflammation of Joints
Fever
Botanical Name
—
Kakrasingi
Pistacia integerrima Stewart Cordia dichotoma Forst. f. syn. C. obliqua Willd.
Adusa/Vasa
Solanum virginianum L. Katan syn. Solanum surratense Burm.f.
—
Justicia adhatoda L. syn. Adhatoda zeylanica Medik. —
Amaltas
Cassia fistula L.
Banafsha
Viola pilosa Blume
Guggulu
Commiphora wightii (Arn.) Bhandari
Suranjaan
Colchicum luteum L.
Suranjaan
Colchicum luteum L.
Guggulu
Commiphora wightii (Arn.) Bhandari
Kulanjan
Alpinia galanga (L.) Swartz
Guduchi
Tinospora cordifolia (Willd.) Hook. f. & Thomson
Karanjava
Caesalpinia bonduc (L.) Roxb. emend. Dandy & Exell
Sudarshan
Crinum asiaticum L.
Giloy
Tinospora cordifolia (Willd.) Hook. f. & Thomson
The list was compiled by Dr. Pradeep Dua, Research Officer (Ayurveda), Central Council for Research in Ayurvedic Sciences, New Delhi who accompanied the PI.
AYUSH in Selected States 123
S. No.
Clinical condition
Ayurvedic Drug of Choice Chirayata
5
Hyperacidity
Botanical Name
Swertia chirayita (Roxb. ex Flem.) Kars. syn. S.chirata (Wall.) Clarke
Unani Drug of Choice Khaksi
Sisymbrium irio L.
Afsanteen
Artemisia absinthium L.
Amla
Phyllanthus emblica L.syn. Emblica officinalis Gaertn.
Muletthi
Glycyrrhiza glabra L.
Amla
Phyllanthus emblica Papita L.syn. Emblica officinalis Gaertn.
7
Hypertension
Diabetes Mellitus
Carica papaya L.
Shatavar
Asparagus racemosus Willd.
Muletthi
Glycyrrhiza glabra L.
Tabasheer 6
Botanical Name
—
Sarpagandha
Rauwolfia serpentina (L.) Benth. ex Kurz
Sarpagandha
Rauwolfia serpentina (L.) Benth. ex Kurz
Ashwagandha
Withania somnifera (L.) Dunal
Asrol
Rauwolfia serpentina (L.) Benth. ex Kurz
Punarnava
Boerhavia repens L. var. diffusa (L.) Hook.f. syn. B. diffusa L.
Tukhm-e-hayat
Arjuna
Terminalia arjuna (Roxb. ex DC.) Wight & Arn.
Arjuna
Terminalia arjuna (Roxb. ex DC.) Wight & Arn.
Badi Elaichi
Elettaria cardamomum (L.) Maton
—
Jamun guthli
Syzygium cumini (L.) Skeels
Jamun guthli
Syzygium cumini (L.) Skeels
Karela
Momordica charantia L.
Karela
Momordica charantia L.
Gudmaar
Gymnema sylvestre (Retz.) R. Br. ex Schult.
Gudmaar
Gymnema sylvestre (Retz.) R. Br. ex Schult.
Methi
Trigonella foenumgraecum L.
Methi
Trigonella foenum-graecum L.
Kalaunji
Nigella sativa L.
Kalaunji
Nigella sativa L.
Sadabahaar
Catharanthus roseus (L.) G. Don
Sadabahaar
Catharanthus roseus (L.) G. Don
Vijaysaara
Pterocarpus marsupium Vijaysaara Roxb.
124 Status of Indian Medicine and Folk Healing
Pterocarpus marsupium Roxb.
S. No.
Clinical condition
Ayurvedic Drug of Choice
Botanical Name
Paneer doda
Withania coagulans (Stocks) Dunal
Shilajeet 8
Diarrhoea
—
Unani Drug of Choice
Tukhm-e-hayat Withania / Paneer doda coagulans (Stocks) Dunal Shilajeet
—
Bel
Aegle marmelos (L.) Correa
Bel
Aegle marmelos (L.) Correa
Kutaja
Holarrhena pubescens (Buch.-Ham.) Wall. ex G. Don syn. Holarrhena antidysenterica Wall. ex A. DC.
Atees
Aconitum heterophyllum Wall. ex Royle
Jaharmohra
Wrightia tinctoria (Roxb.) R. Br.
Marodaphali
Helicteres isora L.
Jeera Triphala
10
Eczema
Cardiotonic
—
indrajau
Gizzard
9
Botanical Name
— Cuminum cyminum L. —
Haridra
Curcuma longa L.
Chirayata
Swertia chirayita (Roxb. ex Flem.) Kars. syn. Swertia chirata (Wall.) Clarke
Chirayata
Swertia chirayita (Roxb. ex Flem.) Kars.syn. Swertia chirata (Wall.) Clarke
Shahtara
Fumaria indica (Haussk.) Pugsley syn. F. vaillantii Loisel.
Neem
Azadirachta indica A. Juss.
Sarfonka
Tephrosia purpurea (L.) Pers.
Neem
Azadirachta indica A. Juss.
Mehandi
Lawsonia inermis L.
Kalaunji
Nigella sativa L.
Jaitoon oil
Olea europea L.
Amla
Phyllanthus emblica L.syn. Emblica officinalis Gaertn.
Amla
Phyllanthus emblica L. syn.Emblica officinalis Gaertn.
Arjuna
Terminalia arjuna (Roxb. Arjuna ex DC.) Wight & Arn.
Mukta
—
Marvareed/ Mukta
Terminalia arjuna (Roxb. ex DC.) Wight & Arn. —
Abresham
Bombyx mori
Ghulab
Rosa centifolia L.
AYUSH in Selected States 125
S. No.
Clinical condition
Ayurvedic Drug of Choice
Botanical Name
Unani Drug of Choice Kewara
Pandanus odoratissimus Roxb.
Turanja
Citrus limon (L.) Burm.f.
Gajvan
Onosma bracteatum Wall.
Tukhm-e-raina 11
Leucorrhoea
Mocharasa
Bombax ceiba L.
Lauha bhasma
13
14
15
16
Menstrual Regulator
Constipation
Hemostatic
Bronchial Asthma
Chronic Sinusitis
—
Zaafran
Crocus sativus L.
Mocharasa
Bombax ceiba L.
Marvareed
—
Kadali svarasa
Musa sapientum
Majoon-edabidulvarda
—
Kanchanaara
Bauhinia variegata
Sharbat-efaulaad
—
Ark Makoya 12
Botanical Name
Ashok
Saraca asoca (Roxb.) de Ashok Wilde
Solanum nigrum L. Saraca asoca (Roxb.) de Wilde
Hansaraj
Adiantum philippense L. syn. A. lunulatum Burm.f.
Sanay
Cassia senna L.syn. Cassia angustifolia Vahl
Sanay
Cassia senna L.syn.Cassia angustifolia Vahl
Eranda
Ricinus communis
Banafsha
Viola pilosa Blume
Ghulab
Rosa centifolia L.
Nilofar
Nymphaea alba L.
Lodhra
Cissempelos pereira
Kehroba
—
Doorva
Cynodon dactylon
Habis
—
Muletthi
Glycyrrhiza glabra L.
Geru
—
Sangejarahat
—
Barahsingi kushta
—
Kusht-emarjaan (corals)
—
Karkatshringi
Pistacia integerrima Stewart
Vasa
Justicia adhatoda L. syn. Adhatoda zeylanica Medik.
Kantakari
Solanum virginianum L. syn. Solanum surratense Burm.f.
Banafsha
Viola pilosa Blume
Haridra
Curcuma longa L.
Lakshmivilasa Rasa 126 Status of Indian Medicine and Folk Healing
Khamira gajvaan
Onosma bracteatum Wall.
S. No.
Clinical condition
Ayurvedic Drug of Choice
Botanical Name
Unani Drug of Choice
Botanical Name
Sitopaladi Churna Shadbindu Taila 17
Urinary Calculus
Varuna
Craeteva nurvalla
Kulthi
Kulattha
Dolichos biflorus
Hajrul yahood
—
Pashanbheda
Berginia ciliata
Majoon Sange Saremaahi
—
Bhutta ka resha
Vigna unguiculata (L.) Walp. syn. Dolichos unguiculatus L.; D. biflorus L.
Zeamays L.
AYUSH in Selected States 127
Annexure-IV Letter of the PI to Principal Secretary, Andhra Pradesh* Subject: Report on the Status of Indian Systems of Medicine with Special Reference to the Benefits the Systems has given the Public. Principal Investigator: Shailaja Chandra. Dear Shri Kishore, Background: This refers to earlier correspondence from the Department of AYUSH which is attached for ready reference. There has been some delay in visiting Andhra Pradesh which I hope to make good now. Part I of the report titled “Status of Indian Medicine and Folk Healing -- with special reference to Benefits that the Systems have given to the Public” was published and has been with the Government last September. If you have not received a copy, I will bring it with me and in the meantime it can be seen on the internet at http://reporttraditionalindianmedicine.blogspot.in/ I have now started work on Part II of the Report. Generic points which apply to all Ayurvedic and Unani institutions and programmes have been covered in detail in Part I and these will not be repeated in Part II as they are applicable to all such activities, subject to Government’s acceptance of the recommendations. Visit to Andhra Pradesh to observe Medical Pluralism: During the forthcoming state visit to AP, I wish to observe the ground realities relating to the utilisation of AYUSH treatment at the District hospital, the CHCs and PHCs to enable me to suggest how we can deepen the existing pluralistic health policy framework to make it more robust and functional. No other country in the world gives legal recognition to so many systems of health care. Today the NRHM through its stated policy of integrating AYUSH already has an operational framework for implementing pluralistic health strategies. Trends in Health Seeking Behaviour of Patients: The general behaviour of the public shows that pluralistic preferences in health behaviour are widespread but more so in some states. For different needs people go to different systems and at different stages of the progression of a medical condition. For emergencies, practically everyone relies on allopathy. But when there are acute conditions like diarrhoeal symptoms patients first try home remedies and then Ayurvedic/Unani medicine to avoid taking “strong” drugs. For chronic problems, including old-age related conditions people tend to rely on a combination of systems. Patients also try and reduce hypertension or blood sugar levels by taking ISM drugs side-by-side with allopathic drugs. They hope thereby to also reduce the intake of allopathic drugs. Absence of Integration at the Operational Level: When to combine the systems and how to do it is purely a personal decision. Educational, research and health service institutions and practitioners have always operated in separate compartments leaving the patient to decide. True integration if built upon operational guidelines, case studies and protocols giving useful * This is the typical template used in the letters sent to the State Governments.
128 Status of Indian Medicine and Folk Healing
information to the patient would be more meaningful instead of leaving the patient to try permutations and combinations on the basis of limited knowledge. While physical integration has begun with the co-location of health facilities and practitioners from different systems under NRHM, presently there is no system of counselling or of following protocols either for the doctors or the patients. Meeting with the Principal Health Secretary: As the Health Secretary of the state, I would feel privileged to have your views on how you feel the Indian systems of medicine can be integrated in a more organised way down to the patient's level so as to make better use of the systems. If you could kindly chair a meeting it would help me to get the responses of clinicians –both allopathic and having Ayurvedic/ Unani background. It would be more like a brain-storming viewing the realities in the context of patient behaviour and the need to have broad operating guidelines to deal with such pluralistic demands. Advice of Private Practitioners at Brainstorming meeting: It is not necessary that we restrict the discussion only to government facilities and doctors. The presence of private practitioners might also be useful- particularly covering areas where patients tend to use both the allopathic and Ayurvedic/Unani systems simultaneously. Arthritis, bronchial asthma, skin related conditions, liver disorders, women’s and children's problems, infertility treatment are some of the areasbesides diabetes and hypertension.
AYUSH in Selected States  129
Annexure-V List of Faculty & Staff PI met at the Rajiv Gandhi Government PG Ayurvedic College and Hospital, Paprola Dr. Yoginder Sharma Prof. & Head Department of Kayachikitsa Dr. Bhagat Ram Sharma District Ayurvedic Officer, Kangra at Dharamshala Dr. Ramesh Arya Prof. & Head Department of Shalya Dr. Eena Sharma Prof. & Head Department of Stri & Prasooti Tantra Dr. Sanjeev Sharma Prof. & Head Department of Asthi Sandhi Rog Dr. Sanjeev Awasthi Reader & Head Department of Shalakya Dr. Sushil Nag AMO, Casualty Dr. Thakur Singh Bhatt AMO, Casualty Dr. Virendra Kaul AMO, Casualty Dr. Vikram Rana AMO, Casualty
130  Status of Indian Medicine and Folk Healing
Annexure-VI Letter sent to the Health Secretaries of West Bengal, Uttarakhand, Bihar and Madhya Pradesh Dear Health Secretary/Secretary in charge of Ayurveda and Unani Medicine Subject: Status of Indian Medicine and Folk Healing with a focus on benefits that these systems have given the public. As you are aware, a project titled “Status of Indian Medicine and Folk healing with a focus on Benefits that the Systems have given the public” is being pursued by me as commissioned by the Ministry of Health and Family Welfare, Department of AYUSH. In this regard, a letter had been written to you by the Joint Secretary in the Department and the copy is attached for ready reference. When the first part of the project was undertaken, I had visited several states and sent detailed questionnaires relating to education, consumer preferences and the concerns of Industry to the colleges where Ayurveda, Unani and Siddha medicine are being taught; likewise questionnaires relating to consumer preference were got filled in as a survey. T he Associations representing the Ayurvedic, Unani and Siddha drugs industry were also contacted and responses obtained through the Association (ADMA.) The result of all these efforts as well as other research done by me has been published as Part I of the report. The Report is available on-line at http://reporttraditionalindianmedicine.blogspot.in In order to do the above work, I had toured a large number of states but because of the need to submit my generic findings and recommendations before the 12th plan was finalised, it was not possible for me to visit all the states. As I undertake Part II of the project, I have begun visiting different states but the focus this time is different. The attached questionnaire seeks to collect information relevant to what is being covered in Part IIand I would be grateful if the questionnaire could please be got filled up and sent back to me for amalgamation in the Report. I request you to entrust this task to a resourceful and knowledgeable officer so that the picture of your state is reflected fully. With regards, Yours sincerely, Shailaja Chandra, (Principal Investigator) Former Secretary Department of Ayush, Ministry of Health and Family Welfare, Government of India.
AYUSH in Selected States 131
Annexure-VII Questionnaire sent to the Health Secretaries of States Information required by Project Investigator Smt Shailaja Chandra (IAS Retd) for the project titled Status of Indian Medicine and Folk Healing with a focus on benefits that these systems have given the public. Background: A project titled “Status of Indian Medicine and Folk healing with a focus on Benefits that the Systems have given the public” has been assigned to by me by the Ministry of Health and Family Welfare, Department of AYUSH. When the first part of the project was undertaken, the Principal Investigator (the undersigned) had visited several states and sent detailed questionnaires relating to education, consumer preferences and the concerns of Industry to the colleges where Ayurveda, Unani and Siddha medicine are being taught; likewise questionnaires relating to consumer preference were got filled in as a survey. The Associations representing the Ayurvedic, Unani and Siddha drugs industry were also contacted and responses obtained through the Association (ADMA.) The result of all these efforts as well as other research undertaken has been published as Part I of the report which is available on-line at http://reporttraditionalindianmedicine.blogspot.in/ Part II of the project addresses concerns which were not covered in Part I. It is requested that information pertaining to your state may please be supplied within 15 days of receipt of this communication. If no response is received the information cannot be included in the Report and hence it may be sent within time.( All information is such as would be readily available with regional and district AYUSH officers. 1. Infrastructure: Please give the number of Ayurvedic/ Unani institutions engaged in education, service delivery and other activities as follows: (a)
colleges, graduate and postgraduate __________________________________
(b)
hospitals __________________________________
(c)
health centres and dispensaries __________________________________
(d)
functional facilities that are co-located under NRHM _______________________________
(e)
annual OPD of all Ayurveda/Unani facilities in the state for last year (2010-2011)
_____________________________________________________________________________
(f)
Whether there has been growth in patient attendance compared to the previous year.
_____________________________________________________________________________
(g)
Annual IPD of all Ayurveda/Unani facilities in the State for the last year (2010 – 2011)
_____________________________________________________________________________
(h)
Whether there has been growth in patient bed occupancy compared to the previous year. (Yes/No) ____________________________________________________________________
132 Status of Indian Medicine and Folk Healing
2. Pharmacies, Drugs Supply and Patient Guidelines 1.
What percentage of drugs required for patients uses are being supplied by the state pharmacy? Are the remaining drugs coming from state purchase or are they supplied under NRHM or by Government of India, Department of AYUSH?
_____________________________________________________________________________
_____________________________________________________________________________
2.
Is the stock position of drugs satisfactory?
_____________________________________________________________________________
_____________________________________________________________________________
3.
What are the reasons, if any, for the state pharmacies being unable to produce the majority of drugs needed for government facilities?
_____________________________________________________________________________
_____________________________________________________________________________
4.
What instructions have been issued to the district hospitals/medical officers in charge of CHCs and PHCs relating to the Ayurvedic/Unani practitioner appointed under NRHM? What is the AU doctor’s job responsibilities which have been issued in writing?
_____________________________________________________________________________
_____________________________________________________________________________
5.
How many Ayurvedic/Unani doctors have been appointed under NRHM and are functioning from co-located hospital/primary health care facilities?
_____________________________________________________________________________
_____________________________________________________________________________
6.
Are there any guidelines, operating practices or instructions issued by the state relating to the expected performance from the Ayurveda/Unani doctors positioned in co-located facilities?
_____________________________________________________________________________
_____________________________________________________________________________
7.
Have any guidelines been issued for patient counselling on the usefulness of Ayurveda/ Unani treatment for specific conditions?
_____________________________________________________________________________
_____________________________________________________________________________
8.
Have any guidelines been issued about combined use of both Ayurvedic and allopathic treatment by the patients?
_____________________________________________________________________________
_____________________________________________________________________________
AYUSH in Selected States  133
3. Government and private practice: (a)
Is there a government notification indicating that the Ayurvedic/Unani doctors can use essential, life-saving drugs and administer allopathic medicines to treat acute conditions in the event of there being no other doctor available. A copy of the orders may be made available Yes. No.
(b)
Is the state supplying allopathic medicines and life-saving drugs to Ayurvedic/Unani dispensaries run by the state government? Yes. No.
(c)
Are there any instructions/orders about medical practice by Ayurvedic/Unani practitioners issued under the Drugs and Cosmetics Act, 1940? Yes. No.
If yes, specify (with the copy of the order.)
(d)
Please supply instructions issued on the responsibilities to be fulfilled by Ayurvedic/Unani doctors who are functioning as Single in-charges in PHCs and CHCs in so far as National Programmes are concerned.
4. Any other information: The present project deals with how the public can be benefited through Ayurveda and Unani medicine. It is generally found that patients access traditional medicine systems on their own— usually on word-of-mouth recommendations. Patients do not have an idea of the do’s and don’ts concerning the use of different systems together, at the same time. Under the Drugs and Cosmetics Act 1940 as well as under the policy of integration under NRHM, the effort has been to promote medical pluralism. Some states have taken steps to inform and educate the public and such best practices need to be shared with other states. Comments and advice in this regard would be appreciated.
_____________________________________________________________________________
_____________________________________________________________________________
134 Status of Indian Medicine and Folk Healing
Annexure-VIII Anubandh for AYUSH Doctors in Uttarakhand vuqcU/k i= ¼,u-vkj-,p-,e-½ lafonk fpfdRld vk;qosZfnd@gksE;ksiSfFkd eSa Mk0 &&&&&&&&&&&&&& iq=@ iq=h Jh &&&&&&&&&&&&&& fuoklh &&&&&&&&&&&&&& ,u-vkj-,p-,e- ds vUrxZr vk;qosZfnd@gksE;ksiSfFkd foHkkx lkeqnkf;d@izkFkfed@vfrfjDr izkFkfed LokLF; dsUnª &&&&&&&& tuin &&&&&&&&&& mRrjk[ka.M esa lafonk fpfdRld ds in ij fnukaad &&&&&&&&& ls ,d o"kZ vFkok ;kstuk lapkfyr gksus rd tks Hkh igys ?kfVr gks ds fy, foHkkx }kjk fu/kkZfjr fuEu lsok "krksZ dks Lohdkj djrk@djrh gWw& 1-
;g fd izFke i{k ¼foHkkx½ }kjk ubZ fu;qfDr ds le; mDr lsok dk ykHk fn;s tkus gsrq eSa dHkh fdlh izdkj dk nkok ugha d:Wxk@d:WxhA
2-
;g fd izFke i{k ¼foHkkx½ ij fu/kkZfjr ekuns; vfrfjDr egaxkbZ HkRrk] edku fdjk;k HkRrk ,o vU; fdlh Hkh izdkj ds HkRrs gsrq dksbZ nkok izLrqr ugha d:Wxk@d:WxhA
3-
;g fd foHkkx fdlh Hkh izdkj dh nq?kZVuk gksus ij ftEesnkj ugha gksxkA
4-
;g fd foHkkx ls fdlh Hkh le; dk;Z lUrks"ktud u ik;s tkus ij lafonk esa j[ks x;s vk;qosZfnd@ gksE;ksiSfFkd fpfdRld dks lsok ls fudkys tkus dk vf/kdkj eq>s ekU; gksxkA
5-
;g fd izFke i{k foHkkx }kjk fn’kk funsZ’kks dk ikyu ’kklukns’k la[;k office order No. 532chi.2-2002/261/2002, dated 26th July, 2002 ds vk/kkj ij ikyu djus dsk eSa viuh lgefr nsrk gWw@nsrh gWwA mDr ’kklukns’k ds Øe ls eSa HkyhHkakfr ifjfpr gWw fd eq>sa fuEu dk;Z lEikfnr djus gSA a)
Cykd esa rSukr leLr vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlkf/kdkjh] lkeqnkf;d LokLF; dsUnz@ izkFkfed LokLF; dsUnz dh ekfld cSBd esa Hkkx ysuk lqfuf’pr d:Wxk@d:Waxh ftlls fd foHkkxks esa csgrj LkeUo; LFkkfir gks ldsA
b)
Tkuin Lrjh; vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlkf/kdkjh eq[; fpfdRlkf/kdkjh ds dk;kZy; esa izR;sd ekg esa gksus okyh ekfld cSBd esa Hkkx ysuk lqfuf’pr djsaxsA
c)
jktdh; vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlky; vkj-lh-,p dk;Zdze dh ekfld izxfr eq[; fpfdRlkf/kdkjh@lkeqnkf;d LokLF; dsUnz ds fpfdRlkf/kdkjh@Cykd Lrjh; fpfdRlkf/kdkjh }kjk miyC/k djk;s x;s fu/kkZfjr izk:Ik ij lkeqnkf;d LokLF; dsUnz ds fpfdRlkf/kdkjh@ Cykd Lrjh; fpfdRlkf/kdkjh dks miyC/k djkuk lqfu’pr djuk eq[; fpfdRlkf/kdkjh ds Lrj ij ekfld izxfr ds ladyu esa foHkkxokj miyfC/k vyx ls fn[kk;h tk;sxhA eq[; fpfdRlkfèkdkjh vuqJo.k gsrq iz;ksx esa yk;s tkus okys izk:Ik ,oa jftLVj vkfn vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlkf/kdkjh dks miyC/k djk;saxs rFkk Hkfo"; esa mudh fujarj miyC/krk Hkh lqfuf’pr djsaxsA
d)
jktdh; vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlky; muds {ks= esa fdlh Hkh izdkj dh egkekjh dh lwpuk lkeqnkfk;d LokLF; dsUnz ds fpfdRlkf/kdkjh@Cykd Lrjh; fpfdRlkf/kdkjh dks
AYUSH in Selected States 135
rRdky miyC/k djkuk lqfuf’pr djsaxs ,oa mldh jksdFkke rFkk fu;=.k gsrq iw.kZ lg;ksx iznku djsaxsA e)
jktdh; LokLF; ,oa ifjokj dY;k.k foHkkx }kjk leLr vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlkfèkdkfj;ksa dk jk"Vªh; dk;ZØeksa gsrq lans’khdj.k djuk lqfuf’pr fd;k tk;sxk rFkk leLr vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlkf/kdkfj;ksa tuin rFkk jkT; Lrjh; izf’k{k.k dk;ZØeksa esa ,ykSisfFkd fpfdRlkf/kdkfj;ksa ds lkFk izfrHkkx djsaxsA
f)
vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlkf/kdkjh ckg~; jksxh foHkkx ds ykHkkfFkZ;ksa dks jk"Vªh; dk;ZØeksa ds lapkyu gsrq izkIr fn’kk funsZ’kks ds vuq:Ik lqfo/kk;s miyC/k djkuk lqfuf’pr djsaxsA
g)
eq[; fpfdRlkf/kdkjh jk"Vªh; dk;ZØeksa ds lapkyu esa vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlkfèkdkfj;ksa ds izHkkoh izfrHkkx gsrq dk;ZØe lEcU/kh lkexzh dh le; ls miyC/krk lqfuf’pr djsaxsA
h)
iztuu ,oa cky LokLF; dk;ZØe esa Cykd Lrjh;@lkeqnkf;d LokLF; dsUnz@izkFkfed LokLF; dsUnz }kjk fu/kkZfjr izkFkfed ikB’kkyk ds cPpks dk Ldwy gSYFk izksxzke ds vUrxZr fu;fer fpfdRld LokLF; izf’k{k.k djkuk lqfuf’pr djsaxs ,oa bldh lwpuk Cykd Lrjh; lkeqnkf;d LokLF; dsUnz@izkFkfed LokLF; dsUnz ds izHkkjh fpfdRlkf/kdkjh ;g ifjHkkf"kr dj nsaxs fd dkSu ls Ldwy ij fdl fpfdRlkf/kdkjh dk Ik;Zos{k.k jgsxkA
i)
vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlkf/kdkjh vks-ih-Mh- ds vUrxZr mipkj izkIr jksfx;ks esa ls oSDlhu ls jksdFkke dh tkus okyh chekfj;ksa rFkk ethyl ,oa VsVul ls ihfMr cPpksa dh igpku dj bldh lwpuk Cykd Lrjh; lkeqnkf;d LokLF; dsUnz@izkFkfed LokLF; dsUnz dks miyC/k djkuk lqfuf’pr djsaxsA
j)
vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRld jktdh; fpfdRlky;ksa esa mfpr O;oLFkk gksus dh n’kk esa ifjokj dY;k.k f’kfojksa dk vk;kstu djuk lqfuf’pr djsaxs ,oa fpfdRlky;ks esa mfpr O;oLFkk miyC/k u gksus dh n’kk esa {ks= esa vk;ksftr gksus okys ifjokj dY;k.k f’fojksa esa viuk ,oa fpfdRlky;ksa ds deZpkfj;ksa dks iw.kZ ;ksxnku nsuk lqfuf’pr djsaxsA egkfuns’kd LokLF; }kjk funs’kd vk;qosZfnd ls fopkj&foe’kZ djrs gq, ,sls fpfdRlky;ksa dks bafxr djrs gq, lqn`< fd;k tk;sxk tgkW ifjokj dY;kx f’kfoj Hkfo"; esa yxk;s tk ldrs gSA bldk foRr isk"k.k Hkkjr ljdkj dh ;kstukvksa vFkok ckg~; O;kolkf;d ;kstukvksa esa fd;s tkus gsrq egkfuns’kd iz;kl djsaxsA
k)
Cykd Lrjh; lkeqnkf;d LokLF; dsUnz@izkFkfed LokLF; dsUnz }kjk fu/kkZfjr vk;qosZfnd ,oa gksE;ksiSfFkd jktdh; fpfdRlky;ksa esa Vhdkdj.k f’kfojksa esa vk;kstu dh O;oLFkk lqfuf’pr djsaxsA izfrj{k.k dk;Z gsrq oSDlhu rFkk vU; lkeku dh vkiwfrZ dh O;oLFkk Cykd Lrjh; lkeqnkf;d LokLF; dsUnz@izkFkfed LokLF; dsUnz }kjk dh tk;sxhA
l)
Cykd Lrjh; lkeqnkf;d LokLF; dsUnz@izkFkfed LokLF; dsUnz }kjk p;fur vk;qosZfnd ,oa gksE;ksiSfFkd jktdh; fpfdRlky;ksa esa vkj-lh-,p- dSEi ,oa vkj-lh-,p vkmVjhp ls’ku vk;ksftr fd;s tk;saxs ftlds fy;s iw.kZ O;oLFkk Cykd Lrjh; lkeqnkf;d LokLF; dsUnz@izkFkfed LokLF; dsUnz ds }kjk dh tk;sxh ,oa bu vkj-lh-,p dSEi }kjk vkj-lh-,p vkmVjhp ls’ku esa vk;qosZfnd ,oa gksE;kiSfFkd fpfdRlkf/kdkjh rFkk deZpkjh iw.kZ lg;ksx nsuk lqfuf’pr djsaxsA
136 Status of Indian Medicine and Folk Healing
m)
vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlkf/kdkjh jk"Vªh; dk;zZØeksa gsrq izkIr fn’kk&funsZ’kksa ds vuqlkj lkefxz;ksa dk forj.k ykHkkfFkZ;ksa dks djuk lqfuf’pr djsaxs ftldh O;oLFkk Cykd Lrjh; lkeqnkf;d LokLF; dsUnz@izkFkfed LokLF; dsUnz }kjk dh tk;sxhA d ik= nEifr;ksa dks fujks/k forj.kA [k ik= efgykvksa dh tkWp ds mijkUr vksjy fiYl dk forj.kA Xk xHkZorh efgykvksa ,oa f’k’kqvksa dks vk;ju rFkk QkWfyd ,flM dk forj.kA ?k 3 o"kZ ds de vk;q ds cPpksa dks foVkfeu&, dh [kqjkd A M nLr jksx ls ihfMr cPpksa dks vks-vkj-,l dk forj.k A Pk xzh"e ,oa o"kkZ _rq esa tulk/kkj.k dks ikuh ls ?kfVr gksus okyh chekfj;ksa ls cpko gsrq Dyksjhu dh xksfy;ksa dk forj.kA N jk"Vªh; dk;Zdzeksa ds O;ikid izpkj&izlkj gsrq vkbZ-bZ-lh- lkexzh dk forj.kA
n)
vU; jk"Vªh; dk;ZØe (i)
eysfj;k%&leLr jktdh; vk;qosZfnd ,oa gksE;kiSfFkd fpfdRlky; Toj mipkj dsUnz ,Q-Vh-Mh- dk dk;Z djsaxsA Toj ls xzflr jksfx;ksa dh jDr ifVVdk rsS;kj dj lkeqnkf;d LokLF; dsUnzksa dks miyC/k djkuk lqfuf’pr djsaxs ,oa ,sls jksfx;ksa dks DyksjksDohu nok ls mipkj djsaxsA
(ii)
dq"B jksx %&leLr jktdh; vk;qosZfnd ,oa gksE;ksisfFkd fpfdRlky; ckg~; jksxh foHkkx esa tkWaps x;s Ropk ,oa gYds jax ds nzO; ,oa xkBksa okys jksfx;ksa dks lkeqnkf;d LokLF; dsUnz@izkFkfed LokLF; dsUnz esa dq"B jksx dh tkWp ,oa mipkj gsrq Hkstuk lqfuf’pr djsaxsA lkeqnkf;d LokLF; dsUnz ds fpfdRlkf/kdkjh@Cykd Lrjh; fpfdRlkf/kdkjh ds fn’kk funsZ’k vuqlkj dq"B jksx ls xzflr jksfx;ksa dks ,e-Mh-Vh miyC/k djkuk lqfuf’pr djasxsA
(iii) {k;jksx%&leLr
jktdh; vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlky; okg~; foHkkx esa tkWps x;s lEHkkfor {k; jksx ls xzflr jksfx;ksa dks lkeqnkf;d LokLF; dsUnz@izkFkfed LokLF; dsUnz lEHkkfor djuk lqfuf’pr djsaxs ,oa lkeqnkf;d LokLF; dsUnz ds fpfdRlkf/kdkjh@ Cykd Lrjh; fpfdRlkf/kdkjh ds fn’kk funsZ’k vuqlkj {k; jksx ls xzflr jksfx;ksa dks {k; jksx mipkj miyC/k djkuk lqfuf’pr djsaxsA
(iv) ,p-vkbZ-oh-@,Ml%
leLr jktdh; vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlky; ckg~; foHkkx esa tkWps@ns[ks x;s lEHkkfor ,p-vkbZ-oh-@,Ml@,l-Vh-Mh- jksx ls xzflr jksfx;ksa ds y{k.k ds vk/kkj ij flUMªksfed VªhVesaV mipkj lqfuf’pr djsaxs ,oa ifjokj LokLF; tkx:drk i[kokMk vfHk;ku esa iw.kZ lg;ksx iznku djsaxsA
(v)
vU/krk fuokj.k dk;ZØe% leLr jktdh; vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlky; ckg~; jksxh foHkkx esa tkWaps x;s o`) jksfx;ksa esa lEHkkfor eksfr;kfoUn ls xzflr jksfx;ksa dk lkeqnkf;d dsUnz@izkFkfed LokLF; dsUnz@us= f’kfojksa esa tkWp ,oa mipkj gsrq Hkstuk lqfuf’pr djsaxsA
AYUSH in Selected States 137
buds vfrfjDr leLr jktdh; vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlk vf/kdkjh LokLF; ,oa ifjokj dY;k.k }kjk pyk;s tk jgs vfHk;ku ¼iYl iksfy;ksa bR;kfn½ esa iw.kZ lg;ksx nsuk lqfuf’pr djsaxsA
(vi) izfrj{k.k%
leLr jktdh; vk;qosZfnd ,oa gksE;ksiSfFkd fpfdRlkf/kdkfj;ksa dks LokLF; ,oa ifjokj dY;k.k egkfuns’kky; }kjk lapkfyr jk"Vªh; dk;ZØeksa ds rgr izf’k{k.k dk;ZØeksa esa izf’k{k.k iznku fd;k tk;sxk fofHkUu dk;Zdzeksa esa vk;qoZsfnd fpfdRlkf/kdkfj;ksa ds lkFk lkeatL; LFkkfir djrs gq, egkfuns’kd ¼LokLF;½ dk;ZØe fØ;kUo;u gsrq okafNr ykftfLVd liksVZ lgk;d lkexzh lqfuf’pr djsaxsaA
mijksDr O;oLFkk ds fujUrj vuqJo.k gsrq jkT; Lrj ij egkfuns’kd ¼LokLF;½ ds v/khu ,d leUo; lSy xfBr fd;k tkrk gS ftlesa vij funs’kd LokLF; izHkkjh jk"Vªh; dk;ZØe rFkk funs’kd vk;qosZfnd }kjk ukfer uksMy vf/kdkjh ,d ekg ds vUnj la;qDr izf’k{k.k ,oa vU; fo"k;ksa ij viuh O;k[;k izLrqr djsaxsA ;g lSy bl O;oLFkk ds lQy lapkyu gsrq bldh fujUrj leh{kk djds lfpo fpfdRlk ,oa LokLFk; dks voxr djk;saxsaA 6-
;g fd izFke i{k foHkkx }kjk vko’;drkuqlkj mRrjk[k.M {ks= esa dgh ij Hkh fu;qfDr@LFkkukUrfjr djus ij eq>s dksbZ vkifRr ugha gksxhA
gLrk{kj ftyk vk;qosfnd@gksE;kiSfFkd vf/kdkjh
vkosnd ds gLrk{kj ,oa uke@irk
xokgksa ds uke@irk ,oa gLrk{kj 1 2 TRANSLATION OF “ANUBANDH” I Dr.______________________ s/o / d/o Shri________________________ R/o________________ _____________________________ have been appointed at the Community/Primary/Other Primary Health Centre________________________________Uttarakhand in Department of Ayurveda/Homoeopathy under NRHM on the post of contractual doctor from date__________till one year or till the completion of programme whichever is earlier. I accept the following terms and conditions laid by the Department: 1.
that I will not claim for the benefit of this service whenever the Department holds new appointments.
2.
that I will not claim for HRA/DA/any other allowances other than the renumeration fixed by the Department.
3.
that the Department will not be responsible for any kind of mis-happening during contractual period.
4.
that in case of non-satisfactory service, my service shall be liable to be cancelled.
138 Status of Indian Medicine and Folk Healing
5.
that I extend my consent for the acceptance of instructions issued by the office order no. 532-chi. 2-2002/261/2002 dated 26th July, 2002. I am well versed with the following terms and conditions under the above mentioned order: a) To attend the monthly meeting of all Ayurvedic/ Homoeopathic doctors at CHC/PHC to ensure better coordination among all Departments. b) To attend the monthly meeting of all Ayurvedic/ Homoeopathic doctors at District Level. c) To submit monthly progress of RCH programme in the desired format to the CHC/ PHC. d) To immediately inform the Medical Officer Incharge or Block level Medical Officer of Community Health Centre (CHC) in case of an epidemic and extend full support to prevent and control it. e) To participate alongwith their allopathic counterparts in the dissemination of messages under National Health Programmes (Under Dept. of Health & Family Welfare) f) To provide services according to the instructions issued for the delivery of National Programmes for the benefit of OPD patients. g) Chief Medical Officers would ensure timely availability of material to the Ayurvedic and Homoeopathic Medical Officers for their effective contribution in conduction of National Health Programmes. h) To ensure regular medical health training to the children of primary schools allotted by the Chief Medical Officer under School Health Programme {Reproductive Child Health (RCH) programme through block level/CHC/Primary Health Centre (PHC)}. i) To inform block level CHC/PHC about the number of children affected by measles, tetanus and other diseases falling under vaccination programme in the OPD. j) To organize family welfare camps at State Government Hospitals/Dispensaries where all the facilities are available and in case of inadequate facilities, will extend full support to arrange family welfare camps in other places. Further, in discussion with the competent authorities, some dispensaries may be selected for upgradation. The financial support will be arranged by the Director General, Health through various schemes under Government of India. k) To organize immunization camps in Ayurvedic and Homoeopathic state dispensaries selected by block level CHC/PHC. The vaccines and other necessary requirements will be fulfilled by the CHC/PHC. l) To extend full cooperation in RCH camps and RCH outreach session organized by the block level CHC or PHC in selected Ayurvedic and Homoeopathic state dispensaries. m) Ayurvedic and Homoeopathic MO’s would ensure distribution of material to the real beneficiaries according to the provisions under the National Programmes. i) Distribution of “Nirodh” to couples
AYUSH in Selected States 139
ii) Distribution of oral pills to the women after check-up iii) Distribution of Iron and Folic Acid to pregnant ladies and children. iv) Distribution of ORS to diarrhea infected children v) Distribution of Vitamin-A supplement to children under the age of 3 years. vi) Distribution of chlorine tablets for prevention of water borne diseases during summer and rainy season. vii) Distribution of IEC materials for widespread promotion of National Programmes n)
Other National Programmes: 1) Malaria: All state Ayurvedic & Homoeopathic dispensaries would work for fever treatment depots (FTD) and send blood samples of fever affected patients to the CHC and treat the patients with chloroquine. 2) Leprosy: To send all the patients found with light coloured patches or nodules to the CHC or PHC for examination of leprosy and further treatment and make sure that all affected patients are given MDT according to the instructions of MOs of CHCs 3) Tuberculosis: To send all the suspected cases of TB to the CHC or PHC and ensure that affected patients receive treatment according to the instructions of the doctor. 4) HIV or AIDS: To provide symptomatic treatment to the suspected cases of HIV or AIDS or STD at OPD level and extend full cooperation in family health awareness week campaign. 5) Blindness Eradication Programme: To send all the elderly patients with suspected cataract to the CHC or PHC for examination and treatment. 6) Training Programmes: To ensure that desired logistic support is provided for training programmes organized by the Health and Family Welfare Department. For this, a coordination cell comprising of a Nodal Officer (nominated by Deputy Director, Health and Director, Ayurveda) would submit their report within one month after completion of the Training Programme.
6.
that I wont have any objection in my being posted /transferred anywhere in Uttarakhand.
Signatures District Ayurveda/Homoeopathy Officer
Name, Address & Signatures of Witness: 1. 2.
140â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
Signature of Applicant and Name & Address
3 Postgraduate Education in Ayurveda-Filling the Gaps
Postgraduate Education in Ayurveda-Filling the Gaps Introduction
143
Needs of Postgraduate Education
143
Existing Infrastructure
144
Existing status of AYUSH manpower (Teachers/Specialists)
144
Minimum Standard Requirements (MSR) 2012
145
Substance of Representations Against the MSR 2012
146
Conclusions and Recommendations
148
142â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
3 Postgraduate Education in AyurvedaFilling the Gaps Introduction A Panel discussion1 to comment on Part-I of the Report titled ‘Status of Indian Medicine and Folk Healing’ was held on 19th March 2012 at India International Centre, New Delhi to capture insights from a diverse range of experts connected with the subjects covered in the Report. Each expert commented on the findings and recommendations made in the Report (Part-I) and suggested subjects which needed to be addressed when Part II of the Report was written. Needs of Postgraduate Education Professor R.H. Singh spoke on the Education Chapter and while commenting on several matters (he elaborated at length) on the issue of postgraduate education in Ayurveda. His talk is available at http://over2shailaja.wordpress. com/2012/04/04/panel-discussion-at-iicon-status-of-indian-medicine-folk-healing/. An excerpt from his address is recapitulated below: “I agree that most of the things that this report (Part I) says are needed to improve the syllabus and curriculum. But it is also necessary if you make the syllabus and the curriculum to consider where the teachers who will impart education are. There is an acute shortage of teachers in all AYUSH colleges. We have
more than 300 colleges for these three systems and we produce only 1500 PGs every year. And to become a teacher, the minimum qualification is a PG degree. From where are we going to get these teachers? This is the main reason why half of the AYUSH colleges in the country have been banned from taking admissions during the last two years. We are going down and down and not up and up. What is the reason? What should be done? This report does not reflect on it. Let me say that in our case we produce 10,000 graduates and only 1500 PGs. So we are in a real bad state as far as education is concerned. And this report has not reflected on this. This is a very important thing which should have been addressed. It can be said now because I was told that another volume of the report is going to come.” Later writing in the Journal AYU Professor Singh reiterated the same view while commenting on the Status Report on Indian Medicine (Part I).2 Status Report on PG Education with a focus on Ayurveda Since Part I of the Report had not examined PG education, the subject is being covered here. The focus is on availability of post graduates to fill manpower gaps in the areas of teaching, specialized practice and research. The PI in her interaction with faculty members
1. Names of the panelists: i. Prof. Bhushan Patwardhan, Vice Chancellor, Symbiosis International University, Pune; ii. Prof. Ram Harsh Singh, Life Time Distinguished Professor, Faculty of Ayurveda, IMS, BHU, Varanasi; iii. Mr. Darshan Shankar, Chairman, Foundation for the Re-vitalisation of Local Health Traditions (FRLHT), Bengaluru; iv. Dr. DBA Narayanan, Chairman of the Indian Pharmacopoeia Commission’s Crude Drug & Herbal Products Committee; and v. Dr. Madhulika Banerjee, Department of Political Science, University of Delhi, Delhi. 2. Singh RH. Beyond a bureaucratic status report on Indian medicine and folk healing. AYU 2012;33:7-9.
Postgraduate Education in Ayurveda 143
working across a wide range of colleges was told that Ayurvedic education suffered from inherent structural contradictions which had led to a situation in which graduates from Ayurvedic colleges were uncertain about their future prospects – whether to opt for higher education, research, practice or lateral job openings. Part I of the Status Report had concentrated on the contents of the curriculum and the syllabus. Accordingly for addressing the specific issue of PG education the PI took the assistance of two experts.3 The latest Gazette of India on Ayurveda education states, “The aims of the Postgraduate degree courses shall be to provide orientation of specialities and super specialities of Ayurveda and to produce experts and specialists who can be competent and efficient teachers, physicians, surgeons, obstetricians and gynecologists, pharmaceutical experts, researchers and profound scholars in various fields of specialization of Ayurveda”. Patwardhan et al. have demonstrated serious flaws in a large nationwide survey of undergraduates, postgraduates and teachers of Ayurvedic medical colleges. It has been shown that at the end of the course the students remain ill-equipped to handle both simple emergencies at the primary health care level or handling specialized Ayurvedic procedures like panchakarma. Access to the latest scientific literature is virtually absent from the libraries, and the potential of the internet lies untapped. Without a foundation of knowledge acquisition and processing retrieval systems, students in this system feel uneasy outside their academic institutions.4
Existing infrastructure AYUSH in India 2012 (published by the Department of AYUSH, Government of India) reports the establishment of 508 AYUSH colleges in India (conducting undergraduate AYUSH courses) with an admission capacity of 25586 students. It is reported that 21 percent of the colleges account for around 17 percent of the total intake capacity and fall in the Government sector. Of these, half provide Ayurveda education while around 36 percent teach Homoeopathy. Around 12 percent of the colleges with an admission capacity of 11 percent pertain to Unani, Siddha and Naturopathy education. The State of Maharashtra leads over other States and has the maximum number of Ayurveda colleges. The States of Uttar Pradesh and Tamil Nadu have the maximum number of Unani (26.8 percent) and Naturopathy (28.6 percent) colleges, respectively. There are no AYUSH colleges in the North-Eastern States except Assam. Union Territories like Andaman & Nicobar Islands, Dadra & Nagar Haveli, Daman & Diu, Lakshadweep and Puducherry have no AYUSH College. Incidentally the areas representing the highest density of AYUSH colleges also have the largest number of modern health care facilities too (Karnataka and Maharashtra). Existing Status of AYUSH manpower (Teachers/Specialists) Apart from the skewed distribution of institutions, AYUSH colleges throughout India have been facing a huge manpower shortage in terms of availability and quality of teachers.
3. This chapter was prepared with inputs from Dr. Sanjeev Rastogi, Associate Professor and Head, Deptartment of Panchakarma, State Ayurvedic College & Hospital, Lucknow, Uttar Pradesh. Prof. RH Singh, Distinguished Professor, Faculty of Ayurveda, IMS, BHU, Varanasi was also consulted. 4. Kishor Patwardhan, Sangeeta Gehlot, Girish Singh, and H. C. S. Rathore, “The Ayurveda Education in India: How Well Are the Graduates Exposed to Basic Clinical Skills?,” Evidence-Based Complementary and Alternative Medicine, vol. 2011, Article ID 197391, 6 pages, 2011. doi:10.1093/ecam/nep113
144 Status of Indian Medicine and Folk Healing
Many Ayurveda institutions had been facing a bar imposed by the regulatory body i.e. the Central Council of Indian Medicine (CCIM) and later also by the Central Government, mainly due to an acute deficit of faculty. In 2011, the CCIM reduced the PG admission seats by over 50 percent at three apex institutions of Ayurveda namely BHU, Varanasi; GAU, Jamnagar; and NIA, Jaipur. Similar curtailment was done at several other institutions engaged in postgraduate Ayurveda education. This was due to the non-availability of teachers for imparting postgraduate education. The minimum qualification to become a faculty member is a postgraduate degree in the respective subject. The Ayurveda education sector has around 1488 postgraduate seats which are filled on an annual basis. The highest share goes to the Departments of Kaya Chikitsa, Rasa Shashtra, Dravyaguna and Shalya which account for half the total PG admission capacity. Several other subjects which are essential components of the undergraduate curriculum are underrepresented at the PG level. Due to lack of qualified teachers, the teaching of several
subjects remains incomplete which naturally reflects on the competence of the graduates. The paucity of postgraduate doctors also affects research and clinical practice. There are about 2421 Ayurvedic hospitals and about 15017 Ayurvedic dispensaries throughout the country (as on 1.4.2012). If just one post graduate is considered essential for each clinical branch of Ayurveda (Kaya Chikitsa, Bal Roga, Shalya, Shalakya and Prasuti), over 2000 postgraduates would be needed to meet specialized health care needs within Ayurvedic hospital settings. The admission capacity for Post Graduation does not cater to the need for specialization for patients who now expect a higher level of disease specific knowledge and therapeutic competence. Minimum Standard Requirements (MSR) 2012 The Government issued minimum standard requirement for Ayurveda Colleges on 19th July, 2012. The position prevailing until then and the changes effected are summarized in the chart below:
Comparative Position of MSR over two years5 S/No.
MSR
2012-13 32 / for 50 students 39 / for 60 students 45 / for 80 students 52 / for 100 students + No provision of part time teachers
2013 â&#x20AC;&#x201C; 14 onwards (New gazette)
1.
Teaching staff against number of students
30 / for up to 60 students 45 / for up to 100 students + 8 part time teachers of Modern medicine + One part time Yoga teacher
2.
Student bed ratio
1:2
1:1
3.
Bed occupancy per year (IPD) on average
50%
40%
4.
Student OPD patients ratio per day on average of the year
5.
Higher faculty (Professor 50 % of higher faculty & Reader) should be available in the concerned subject.
1: 2
Having either Professor or Reader made optional in all departments except in Kaya Chikitsa.
5. Inputs provided by Dr. Sathya N. Dornala, Senior Medical Officer, East Delhi Municipal Corporation.
Postgraduate Education in Ayurvedaâ&#x20AC;&#x192; 145
S/No.
MSR
2012-13
2013 â&#x20AC;&#x201C; 14 onwards (New gazette)
6.
Faculty promotions
Post-graduation in the concerned subject is essential for promotion as Reader or Professor.
Condition of post-graduation in concerned subject for promotion has been removed, allowing for post graduate in any allied subject. (Allowed for five years only)
7.
Age of superannuation
65 years
70 years
8.
College visitation
Once in a year
Once in five years
9.
Biometric attendance for Mandatory the staff
Desirable
10.
Minimum area to start a new ayurvedic college
Three acres for 60 students Five acres for 100 students
Ten acres
Reacting to the 2012 regulations, some Associations made representations to the PI both through e-mail and by post. Since the Department of AYUSH also received the same representations and the subject pertains to ongoing Government policy, the PI has only commented generally based on perceptions gathered during discussions with faculty members and PG students in different college settings. Substance of Representations against the MSR 2012 1. Minimum requirement of teaching faculty Representation from Associations Reduction in the total number of teaching staff requirement for the colleges with an intake capacity of 60 students/year the number from 35 to 30, which had earlier also been reduced from 43 to 35 in the last gazette which will affect teaching. For those colleges with an intake capacity of 61 to 100 students, the number has been reduced from 57 to 45. Only 90 percent teachers are required to run the college. Such reduction will lower standards. Comment: The reduction appears to be realistic keeping in mind what is actually
146â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
happening in a majority of the colleges and the existing paucity of teachers. But it needs a review after undertaking a manpower study which looks at projected needs over the next 10 years. 2. Student bed ratio, bed occupancy and minimum number of patients Representation by the faculty and students Reduction in Student bed ratio from 1:2 to 1:1 and bed occupancy from 50 percent to 40 percent, and minimum number of patients required has been reduced to 24. This will lower the standard of teaching. Comment: The PI never found more than 2025 indoor patients in any hospital that she visited except those where specialty treatment was offered say for skin diseases in the Unani hospital at Hyderabad. Reducing the requirements is therefore quite realistic. 3. Frequency of College Visitation Representation by the faculty and students Reduction in the frequency of college visitation by the CCIM from once in a year to once in five years will lead to violation of all standards in the absence of regular monitoring.
Comment: The measure will at least reduce the threat of visitations and resorting to appeasement measures which had become notorious. However an accreditation system would have been better which would have devised ways of insisting on adherence to standards on a regular basis. It is recommended that this may be considered even now with random inspections undertaken by an accreditation agency as was envisaged to be set up for the National Council for Human Resources in Health (NCHRH). 4. Minimum area to start a new Ayurvedic college Representation by the faculty and students The total area required to start a new college is reduced to three acres from previous 10 acres, which is too small for a Professional College. Comment: The reduction is realistic looking at the non-availability of land at most places. 5. Biometric system for attendance of employees Representation by the faculty and students Relaxation in Biometric attendance tracking devices being made ‘optional’, which was ‘mandatory’ in earlier modification, will give rise to absenteeism. Comment: Biometric checking of attendance does not apply very much in college setting and therefore making it optional should be left to individual colleges to decide. 6. Age of superannuation of teachers Representation by the faculty and students Age for retirement increased from 65 to 70 years which will affect quality of teaching. Comment: The PI found that several faculty
members were in good health and spirits after 65 and until 70 years and even later. And age alone should not be a factor for exclusion. However, older faculty members generally had set ways and were unaware of contemporary developments, research methodology, the use of the internet or the importance of publications in peer reviewed journals. Many of them did not inspire much confidence in being able to mould young minds to acquire skills that are invaluable in today’s world. Hence, the engagement should have been made subject to an interview/vedio presentation before an independent observer so that older persons do not continue mechanically regardless of performance. 7. Minimum requirement for senior faculty Representation by the faculty and students Relaxation in the requirement of senior faculty from having both Professor and Reader in each department to the option of having either a Professor or Reader for all subjects (except Kaya Chikitsa) would further lower standards. Comment: This step may help the colleges until the outturn of postgraduates improves. 8. Promotion of teachers of allied subjects as Reader or Professor Representation by the faculty and students The condition of concerned subject postgraduate has been removed for promotion and Lecturer or Readers from allied subjects can get promoted as Readers or Professors. The specialty divisions are meant for the betterment of concerned academical subjects. If it is diluted by a provision of an alternate, the authorities who run the colleges will definitely go for easily available options, rather than trying for the concerned specialty faculty.
Postgraduate Education in Ayurveda 147
Comment: Specialization in the concerned subject at the post-graduation level has been removed which will increase promotion avenues for Lecturers or Readers from allied departments/subject areas who can now get promoted as Readers or Professors. Were this not done, the career prospects of a large number of faculty members would have remained dismal, affecting their morale adversely. This will also improve teacher availability. However if they lack knowledge of the particular speciality, it should be made incumbent on each such teacher to demonstrate competence before a Board as otherwise they may not make the effort needed to acquire knowledge about a new subject area. Even if the lectures were video-taped it would prevent a routine approach to teaching. Short-term measures to increase/ strengthen availability of PG faculty It was suggested to the PI that the simplest way to counter the faculty deficit in Ayurveda might be to increase the number of postgraduate seats by focusing upon the subjects and areas which are underrepresented. Even so, several other related factors would also need attention and the outturn of postgraduates would take time. Purely as an interim and emergent measure the use of expertise available in the CCRAS research units and centers spread throughout the country was suggested to be utilized by affiliating the centers to Regional universities. If that is allowed, the identified research institutes of CCRAS could register students for MD and Ph. D. degrees after necessary affiliation with the nearest university. A twinning programme could be arranged with the faculty of nearby Ayurvedic colleges so that the CCRAS research units can conduct PG education and research together. The CCRAS scientists could be authorized to guide selected MDs and PhDs
148â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
in addition to their core research programme, which would be beneficial for both as it would bring much needed dynamism and productivity into the research institutes. The research staff of the Council could be given short term reorientation and training to equip them to undertake teaching. This suggestion was made for tackling the acute shortage of postgraduate teachers instead of just waiting for things to fall into place in the fullness of time. It is apparent that the intake of postgraduates in the Ayurvedic colleges is not in keeping with the needs of postgraduate education or the need to promote specialized Ayurvedic treatment and research. The lowering of standards, which has been introduced under the new MSR, is actually a response to the fact that the earlier standards were not achievable, given the shortage of teachers. One of the measures introduced, which was to allow teachers to continue up to the age of 70 years, is an answer to this situation but as brought out in the text above may not necessarily lead to acceptable standards of teaching across the wide range of colleges in the country. Need for Need Assessment Study To overcome this, a study needs to take stock of the gaps that remains after making a notional assessment of where the yearly out turn of postgraduates is likely to find placement. Since the gap is already big and likely to grow, some emergent measures need to be taken to augment the number of seats available for post-graduation. That in turn would depend upon the availability of teachers. Conclusions and Recommendations It is too early to comment on the changes that will be brought as a result of the Minimum Standard Regulations 2012 in but it will definitely ease the pressure to fulfill impractical
standards which had been prescribed for ASU colleges. Thereby the tendency to indulge in cover-ups may reduce. The effect of the new regulations may not have an impact on the number of seats available for postgraduates and for which there is a need to conduct a proper manpower study and to find ways of augmenting the supply of postgraduates. Only then will it be possible
to raise the standard of the colleges and to ensure that the level of specialization in clinical care and research improves. The suggestion to use the research staff from the Councils who possess the requisite qualifications to take classes in coordination with the relevant University may be considered as a stop-gap arrangement for five years till the outturn of postgraduates improves.
Postgraduate Education in Ayurvedaâ&#x20AC;&#x192; 149
4 Building Credibility for Panchakarma
Building Credibility for Panchakarma Introduction
153
Application of Panchakarma
154
Bringing Credibility to Panchakarma
154
Lack of Evidence
155
Findings of a Survey on Panchakarma
155
Accreditation for Panchakarma Centres
156
Need of Guidelines for Ayurvedic Panchakarma Massage Parlours
156
Establishing a ‘Centre for Scientific Research in Panchakarma (CSRP)’
156
Example of a Research Study on Shirodhara
157
List of Instruments/Equipment required for research in Panchakarma
157
Conclusions and Recommendations
158
152 Status of Indian Medicine and Folk Healing
4 Building Credibility for Panchakarma
Introduction Panchakarma is one of the most trusted and widely used therapies practised in Ayurvedic hospitals and clinics all over India. It is considered a radical therapy, which reduces the chances of recurrence of disease. It is reported to be particularly beneficial for the maintenance of good health which accounts for the growing interest evinced by some sections of the public who are prepared to travel long distances to avail of authentic Panchakarma. The therapy comprises of five applications (pancha means five, and karma means therapeutic procedure) aimed at cleaning the disease-causing factors and hence rendering the body comparatively cleansed and ready to absorb different kinds of medication. They are Vamana (therapeutic emesis), Virechana (therapeutic purgation), Vasti (therapeutic enema), Nasya karma (nasal errhines) and Rakta mokshan (bloodletting). Tracing its origin to the classical textual triad of Ayurveda (Charaka, Sushruta and Vagbhata), Panchakarma has a history of many thousand years of uninterrupted practice. Being a part of samsodhana (correction through elimination) type of Ayurvedic therapeutics, it is considered superior to samsaman (correction through rebalance) therapy, because it aims at
eradicating the disease and minimizing the chances of recurrence.1 The main reason for which healthy patients visit AVS Kottakal and similar centres mainly in the South is to undergo seasonal detoxification of the body. In order to popularize Panchakarma, there is an increasing need to build substantial evidence to show its benefits. Several observational studies are required to collect evidence which justifies what today are just claims. The efficacy of Rasayana (rejuvenation) drugs need scientific endorsement. Unless evidence on the outcomes is documented, it would not be possible to rely only on claims or to motivate people to accept this therapy as treatment for medical conditions. Despite its popularity within the country, Panchkarma is underutilized at a global level as compared to Acupressure and Acupuncture therapies, which are available in abundance, particularly in the US. Only a few Panchakarma procedures that focus on de-stressing or relaxation, through whole body oil massage or a stream of medicated oil poured on the head (Shirodhara) have gained prominence. Panchakarma is not being practised like Chinese acupuncture, which is available with full certification of therapists and technicians not only of Chinese origin but belonging to different nationalities too.
1. This chapter was prepared with inputs from Dr. Sanjeev Rastogi, Associate Professor and Head, Department of Panchakarma, State Ayurvedic College & Hospital, Lucknow, Uttar Pradesh. Prof. R.H. Singh, Distinguished Professor, Faculty of Ayurveda, IMS, BHU, Varanasi was also consulted.
Building Credibility for Panchakarmaâ&#x20AC;&#x192; 153
Application of Panchakarma Panchakarma is considered of particular importance in Ayurveda because it is considered a radical therapy, which nullifies the chances of recurrence of diseases. Panchakarma is beneficial for2 1.
Preventive, Promotive health purposes,
2.
Management of various systemic diseases viz., joint disorders, musculoskeletal, dermatological, neurological, psychiatric, geriatric, gynaecological disorders, respiratory disorders, etc.,
3.
The regimen is also widely prescribed in chronic incurable diseases for improving the quality of life.
Panchakarma has several sub-procedures3 which are generally being used for the following conditions: 1.
Preterm infants - Regular Snehana with til oil
2.
Rheumatoid Arthritis - Ruksha Udvartana, Saindhava Baluka Sweda, Vamana, Virachana, Vasti.
3.
Osteoarthritis - Patra pinda Sweda, Jaanu Vasti, Naadi Sweda
4.
Low back pain - Kanji Dhaara, Kati Vasti, Naadi Sweda
5.
Cervical spondylosis Greeva Vasti,
6.
Spondilytis - Patrapinda Sarwanga sweda
-
Shirodhara, Sweda,
7.
Hemiplegia - Sarwanga Sweda , Pinda Sweda, Vasti
8.
HypertensionShirodhara
9.
Anxiety- Shirodhara
10. DepressionShirodhara
Sarwanga
Nasya,
Sweda
,
Dhumapana,
11. Psoriasis – Vamana, Virechana Bringing Credibility to Panchakarma Years ago only skilled people performed the therapies under the supervision of an expert. This has changed and now the technicians use a range of practices of different duration, using herbs, steam and massage in differing proportion. Owing to the absence of standardization of Panchakarma procedures, patients face a dilemma about what to expect. While specific protocols for each procedure have been recounted in the ancient texts, the management is quite subjective and at times haphazard. This limits the use of these procedures to a limited segment of societythose who are unaware of the details of the therapies but who have innate faith in its goodness. Lack of Standard Operating Procedures (SOPs) is the biggest gap that prevents further growth and dissemination of the benefits of Panchakarma and remarks like “Dirty”, “Unhygienic” and “Inefficiently managed” are often heard, except when practised at selected centres. Recognizing the utilization and potential of Panchakarma, the Central Council for Research in Ayurvedic Sciences (CCRAS)
2. Guidelines on Basic Training and Safety in Panchakarma, CCRAS, New Delhi, 2008. 3. Snehana ( oil application), Swedana (steam application) and regional adaptations of these procedures to suit local site and disease like: Kati Vasti (hot medicated oil irrigation upon low back), Greeva Vasti (hot medicated oil irrigation upon back of neck) , Janu Vasti (hot medicated oil application upon knee joints) and Patrapinda Sweda (heat application through a bolus of herbs roasted in medicated oil). Shirodhara is another allied procedure where a medicated liquid preparation (oil or decoction) is poured upon forehead in the form of a regulated stream.
154 Status of Indian Medicine and Folk Healing
drafted guidelines for basic training and safety in administering Panchakarma. These guidelines were finalized in a national workshop after inviting subject experts and incorporating their suggestions.4 These guidelines remain available but are hardly applied in the Panchakarma clinics either in the public or private sector. Lack of Evidence There is scanty evidence proving the effectiveness and safety of Panchakarma while treating various clinical conditions. Its effectiveness has been poorly evaluated. Both in terms of primary and secondary outcomes and treatment endpoints, there are no prescribed procedural standards. In a literary search made at PubMed and Google Scholar, besides individual case reports, case series, and some pilot trials, it was not possible to locate studies that identified patient perceptions about the effects of Panchakarma therapy.
procedural explanations to the patients but owing to their limited experience and over enthusiasm, there is a possibility of over-projection of expected benefits. •
The non-involvement of senior consultants in the process of explaining the processes to the patients was seen as a deficiency.
•
The delay caused by the “waiting for turn” syndrome was a major component of the total time consumed, leading to a poor resource-patient ratio at some centres.
•
The scope of reducing the patient’s hospital stay without compromising on the services had not been addressed.
•
There was gross inadequacy of privacy for women which ultimately affected their receptivity to undergoing treatment. It was found that if patients do not feel comfortable during the process of preparation or during the actual treatment they remain under stress which impacts outcomes negatively on outcomes.
•
An evaluation of the patient’s perception of his experiences and expectations would help identify the gaps that lie between the “perceived” and the “practised” standard of Panchakarma procedures.
•
Cancelling or refusing Panchakarma services due to breakdown of equipment or its non-availability affects the professional reputation of the Panchakarma centres. A thorough record-keeping of the equipment and the regular supply of all consumables are both necessary to improve efficacy.
Findings of a Survey on Panchakarma A questionnaire based survey was conducted at the State Ayurvedic College and Hospital, Lucknow, Uttar Pradesh to identify the perceived efficacy, safety and standard of service delivery of Panchakarma.5 This hospital is one of the largest secondary care Ayurvedic hospitals in the northern region of India. The hospital has a fully functional Panchakarma unit with approximately 22,000–26,000 treatment enrollments in a year. The findings of this report points to many gaps that need to be filled: •
Trainees (who are the ones who generally administer the procedures) tend to offer
4. Guidelines on Basic Training and Safety in Panchakarma, CCRAS, New Delhi, 2008. 5. Sanjeev Rastogi. Effectiveness, safety, and standard of service delivery: A patient-based survey at a Panchakarma therapy unit in a secondary care Ayurvedic hospital. J Ayurveda Integr Med 2011; 2:197-204.
Building Credibility for Panchakarma 155
Panchakarma Protocols at AVS Kottakal The PI found that the AVS Kottakal Branch Hospital at Karkardooma, Delhi follows a check-list which is pasted on the door of each Panchakarma cubicle which ensures that individual procedures are taken up in sequence and continue like clock-work. This calls for laying down Standard Operating Procedures (SOPs) and introducing an accreditation system for each clinic whether in the government or private sector. Accreditation for Panchakarma Centres The National Accreditation Board for Hospitals and Healthcare Providers (NABH) has brought AYUSH hospitals and wellness centers under its ambit. It has issued detailed guidelines on services to be maintained by AYUSH hospitals aspiring for certification. There is a need to introduce a Central Scheme to support the acquisition of NABH Certification by State Government Ayurvedic Hospitals. The condition of the Panchakarma units in the Government hospitals in most places is poor. The PI found a low level of hygiene and general upkeep in most government-run facilities in almost all States. With the exception of a few privately-run nursing homes, the standards even in private clinics were rudimentary Despite all these shortcomings, Panchakarma units are doing brisk business in many hospitals and centres and have a substantial turnover of patients. Seeing the large number of waiting patients, it is necessary to lay down basic conditions that must be fulfilled to receive accreditation. Need of Guidelines for Ayurvedic Panchakarma Massage Parlours There has been a phenomenal increase in the demand for specific Panchakarma
156â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
procedures to enhance beauty and provide relaxation. Most five star hotels and highend tourist resorts provide Panchakarma limited to massage and Shirodhara. Since the name of Ayurveda is being used, there should be a requirement for such procedures to be performed only by qualified staff. Panchakarma which calls for massaging, fomentation, steam bath, etc. need to follow certain precautions, keeping in mind factors such as age, time of day, etc. If Panchakarma is followed by swimming or preceded by a full meal it may have some associated risks. The association of the name of Ayurveda or Panchakarma will fall into disrepute if care is not taken. Hence there is a need to involve the Tourism Departments of the states through the Ministry of Tourism to bringing uniformity in the use of massages and other techniques which purport to be a part of Ayurveda. If they are merely offering massage services, it needs no intervention but the use of the term Ayurvedic massage or Panchakarma should have some attendant requirements that need not have to be fulfilled. Establishing a â&#x20AC;&#x2DC;Centre for Scientific Research in Panchakarma (CSRP)â&#x20AC;&#x2122; While commendable efforts have been made to research different aspects of Panchakarma, unfortunately, according to many Ayurveda teachers that the PI interacted with, the research has been poorly designed, poorly executed and the main focus has been on subjective clinical observation. The statistical tools employed to evaluate such studies are generally inappropriate. A fundamental reason for this is that research is being done primarily by postgraduate students as a part of their dissertation. A separate centre for quality research in specialized fields is required where the scientific validation of various Panchakarma procedures can be undertaken
based on the clinical application of different procedures for specific indications. Such a research centre needs to be equipped with a team which includes Panchakarma experts as well as experts from biochemistry, physiology and radiology. A Panchakarma research centre would generate data on a range of benefits that are observed scientifically which alone can justify the claims about Panchakarma. Example of a Research Study on Shirodhara “Ayurveda definitely has new ideas for health promotion and prevention of diseases,” says Kazuo Uebaba, Associate Superintendent of the International Traditional Medicine Research Center of Toyama prefecture, International Health Comple, Japan. His study is titled `Usage of Modern Technology for the Scientific Study of Ayurveda’ on Shirodhara (oil dripping treatment on the forehead). According to him, Shirodhara is one of the characteristic healing techniques in Ayurveda prescribed for headache, insomnia, anxiety, neurosis, hypertension and several kinds of psychosis. Dr. Kazuo and his team6 developed a healing robot to conduct Shirodhara in a standardized manner. “The healing robot will conduct Shirodhara in a computerized reproducible manner. This helps in studying the mechanism of the treatment. It was found that physiological changes during Shirodhara were related to psychological experiences such as anxiety and Altered State of Consciousness (ASC) or
anxiolysis. This was assessed by a psychometric method. The study also discussed the clinical utility and validity of Shirodhara. Factors such as oil flow rate, oil temperature, dripping speed, dripping pattern and kind of oil and its effect on the treatment of stress, headache, insomnia, eye disease and facial wrinkles were also studied. All patients tolerated the treatment well without any adverse events. Such studies can be undertaken in India in collaboration with the National Brain Research Centre (NBRC), Manesar, Haryana (Deemed University under Department of Biotechnology, Govt. of India)7 among other tertiary level Institutions. List of Instruments/Equipment required for research in Panchakarma The PI had requested Dr. Sanjeev Rastogi8 and Dr. Rama Jayasundar9 to prepare a list of equipments that would be needed to conduct tests and evaluation. Professor R.H. Singh, Distinguished Professor, Department of Kayachikitsa, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi while appreciating the lists provided by the two experts, suggested the necessity of using investigative equipment for two different purposes: 1.
Therapeutic equipment to assess the efficacy of different treatment procedures such as standard Droni, Shiridhara equipment, Nasya equipment, standard Vasti instrument, standard Vaman chair, standard Shirovasti set, etc.
6. Uebaba K, Xu FH, Tagawa M, Asakura R, Itou T, Tatsuse T, Taguchi Y, Ogawa H, Shimabayashi M, Hisajima T. Using a healing robot for the scientific study of shirodhara. Altered states of consciousness and decreased anxiety through Indian dripping oil treatments. IEEE Eng Med Biol Mag. 2005 Mar-Apr;24(2):69-78. 7. Inputs provided by Dr. Sathya N. Dornala, Ph.D. (Panchakarma), Senior Medical Officer, East Delhi Municipal Corporation, New Delhi. 8. Associate Professor, Department of Panchakarma, State Ayurvedic College, Lucknow 9. Associate Professor, Department of Nuclear Magnetic Resonance (NMR), AIIMS, New Delhi
Building Credibility for Panchakarma 157
2.
Equipment to assess the mechanism of the effect of different procedures to see how they act.
He drew a distinction between efficacy studies and studies on the mechanism of action. He felt that sophisticated procedures and equipment were required for the mechanism of action studies and advised that the current focus should be on efficacy studies which would demonstrate prima facie the therapeutic effect of the treatment which may help to standardize the procedures. For this, simpler devices could be fabricated by individual investigators and therapists. In view of this he felt that we may not need an isotopic tracer studies or even the detailed molecular studies straightaway. In view of this the exhaustive lists of equipment suggested by Dr.Sanjeev Rastogi and Dr. Rama Jayasunder have not been referred in this chapter but the material is available with the PI. Conclusion and Recommendations Effectiveness Studies There is a need to build up substantial evidence to show the benefits of Panchakarma as a therapeutic intervention. Several observational studies are required to collect evidence which justifies what today are mere claims. The efficacy of Rasayana (rejuvenation) drugs need scientific endorsement and by simultaneously setting up two similar groups of patients - one which undergoes Panchakarma and another which does not, outcomes can be registered in comparative terms. Unless such evidence is documented following a strict protocol and the research has independent co-researchers on the team, the outcomes even if they are very positive may not be trusted. Evaluation Studies on Patient Responses There
is
scanty
evidence
proving
158 Status of Indian Medicine and Folk Healing
the
effectiveness and safety of Panchakarma while treating various clinical conditions. Both in terms of primary and secondary outcomes and treatment endpoints, there are no prescribed process standards. Therefore there is a need to also evaluate the patient’s perception of his experiences and expectations which would help identify the gaps between the “perceived” and the “practised” standard of Panchakarma procedures at different facilities. Establishing a ‘Centre for Scientific Research in Panchakarma In the long term there is a need to plan for a Centre where the related validation studies can be undertaken or alternatively to fund research which can be undertaken in leading medical research institutes which can permit the use of their equipment to test the change in markers and physical parameters of the patient as a sequel to undergoing different procedures. A group of scientists from Ayurveda as well as related modern medicine research fields including biophysicists needs to be set up to agree on measurement devices and markers that can evaluate different parameters to establish the efficacy of each intervention separately. Most of the Sub procedures of Panchakarma seem to be a part of physical medicine as seen from a contemporary perspective. As a quick measure, a Panchakarma unit should be started at the All India Institute of Physical Medicine and Rehabilitation (AIIPMR), Mumbai or collaborative studies can be undertaken with AIIPMR which would be a simple way of determining the effectiveness of Panchakarma procedures. There is likely to be no resistance as that Institute is generally interested in any procedure that helps rehabilitation of patients. There is no doubt that Panchakarma has a strength in the areas of restoration and rehabilitation. AIIPMR receives the kind
each procedure which can be seen by the patient also. Alternately the CCRAS guidelines should be officially notified for adoption after being examined for general application.
of patients that would benefit from such treatment. The Institute comes under the Ministry of Health/Directorate General of Health Services. Research Study on Shirodhara shows the way A study which has been referred to in the main Chapter had described the efficacy of Shirodhara when it is undertaken in a standardized reproducible manner, which helps in studying the mechanism of treatment. This study can be a model for similar studies to be undertaken on the efficacy of Shirodhara. Studies can also be undertaken in collaboration with the National Brain Research Centre (NBRC), Manesar, Haryana (Deemed University under Department of Biotechnology, Government of India) if Department of AYUSH approaches them and also funds the project. Evaluation of Panchakarma
Functional
aspects
of
Research has shown that trainees (who are the ones who generally undertake the procedures) tend to offer procedural explanations to the patients but owing to their limited experience and over enthusiasm, there a possibility of over-projection of expected benefits. The non-involvement of senior consultants in the process of explaining the processes to the patients has been viewed as a deficiency. Hence the following recommendations are made: i.
The delay caused by “waiting for turn” should be reduced without compromising on the quality of services. The model followed by AVS Kottakal and some other centers could become the benchmark for the duration of procedures as well as essential equipment and consumables that would need to be used. AVS Kottakal has checklists for
ii.
Privacy for women should be assured as it affects their receptivity to undergoing treatment.
iii.
Patients need to feel comfortable during the process of preparation and during the actual treatment. Uncertainty leads to stress which impacts negatively on the outcomes.
iv.
Cancelling or refusing Panchakarma services due to breakdown of equipment or absenteeism of staff should be monitored to bring in more professionalism. A thorough recordkeeping of the equipment and regular supply of all consumables is necessary to improve efficiency.
Standard Operating Procedures Accreditation for Panchakarma Centres
and
Standard Operating Procedures (SOPs) for Panchakarma needs to be introduced for all centers whether in the government or private sector. The National Accreditation Board for Hospitals and Healthcare Providers (NABH) has brought AYUSH hospitals and wellness centers under its ambit. It has issued detailed guidelines on services to be maintained by AYUSH hospitals aspiring for certification. There is a need to introduce a Central Scheme to support the acquisition of NABH Certification by all State Government Ayurvedic Hospitals which provide Panchakarma treatment. It is also necessary to encourage reputed Panchakarma centres in the private sector to acquire accreditation as there is a low level of hygiene and general upkeep in many facilities. With the exception of a few privately
Building Credibility for Panchakarma 159
run nursing homes, the standards are rudimentary. Hence accreditation will provide minimum benchmarks for hygiene and give users the confidence about the standards and services offered at the facility. Department of AYUSH could also give a bridge loan to selected private facilities to get NABH accreditation on the condition that they treat an agreed number of referred cases sent by Government facilities. Need of Guidelines for Ayurvedic Panchakarma Massage Parlours There has been a phenomenal increase in the demand for specific Panchakarma procedures to enhance beauty and provide relaxation. Most five star hotels and high-end tourist resorts provide some form of Panchakarma limited to massage and Shirodhara. Since the name of Ayurveda is being used, there should be a requirement for such procedures to be performed only by qualified staff. Care has to be taken that the fair name of Ayurveda or Panchakarma does not fall into disrepute. By involving the Tourism Departments of the states through the Ministry of Tourism it would be possible to bring uniformity in the services provided, when the service is claimed to be a part of Ayurveda. If they are
160â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
merely offering massage services, it needs no intervention. However, the use of the term Ayurvedic massage or Panchakarma should have attendant requirements that have to be fulfilled on the lines of the green leaf strategy of Kerala State. Promotion of Panchakarma on the lines of Chinese Acupuncture Despite its popularity, Panchkarma is underutilized at a global level as compared to Acupressure and Acupuncture. Clinics for such procedures are available in abundance, particularly in the US. Chinese acupuncture is also available with full certification of therapists and technicians. In the US such staff is not only of Chinese origin but can belong to any nationality. There is a need to gain a similar foothold for Panchakarma services by offering courses for students in the US, leading to the grant of a licence. Initially, such courses can be started with the approval of any US State authority which is prepared to allow such courses to be run in that State. Ayurveda and Panchakarma do not need endorsement from the US. However that is one of the most effective ways of marketing authentic and effective Panchakarma services. The recommendation should be seen in that spirit.
5 A Study of Selected State Pharmacies
A Study of Selected State Pharmacies Background
163
A Study of State Pharmacies by Faculty of National Institute of Ayurveda, Jaipur
165
General Findings
170
Conclusions and Recommendations
170
Annexures
Annexure-I: Grant in Aid released to States/UTs under the Centrally Sponsored Scheme for Quality Control of ASU&H drugs from 2000-01 to 2011-12 (in Rs. lakhs)
173
Annexure-II: Questionnaire for Preparing Status Report on Government Ayurvedic pharmacies
174
162â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
5 A Study of Selected State Pharmacies Background A panel discussion1 was held on 19 March 2012 in order to elicit expert views on Part-I of the Status Report on Indian Medicine and Folk Healing. One of the panelists Dr. Madhulika Banerjee, Associate Professor of Political Science in Delhi University spoke about the role of State pharmacies in making quality medicines available to Government health facilities. She had this to say: “In the Government sector, huge network of State pharmacies had once been at the forefront in providing Ayurvedic and Unani medicines to people. The pharmacies have actually let down the system in a big way. We all gun for industries, and there is no question about that the industry has taken advantage to a great extent. The industry has taken Ayurveda in directions which are problematic, but that’s a different issue. But Ayurvedic and Unani pharmacies run by the State were meant to produce good quality medicines for the common person - a person who is not a consumer. Regarding reference, the last time State Pharmacies were ever referred to in any Government. Report was by the Udupa Committee Report. As for the questionnaires used in the Udupa Committee’s Annexure, it is amazing how much the subject continues to be
relevant. We need a thorough understanding, investigation and analysis of what we did with the State Pharmacies. The Department was quite taken aback when I said we were talking about what the industry should do and what research should do. What happens to the pharmacy? Why are the pharmacies not brought into the picture? Don’t we need to see why they are not doing what they were doing? Or are they doing something valuable which we are not assessing properly?” The present status of State Pharmacies is as follows: A Centrally Sponsored Scheme for Quality Control was started in the year 20002001 (9th Plan) to support strengthening of State Drug Testing Laboratories and Pharmacies. Revisions were made to the scheme to include many more important aspects of quality control. During the 10th and 11th Plans, grant in aid for State Pharmacies was confined to giving balance instalments for the strengthening of the Pharmacies but no new Pharmacy was supported in the 11th Plan. As a result, 46 State ASU&H Pharmacies received funding for infrastructure development. The funding released may be seen in Annexure-I. The lump-sum provisions may have helped some pharmacies but that too only partially.
1. Name of the panelists: i. Prof. Bhushan Patwardhan, Vice Chancellor, Symbiosis International University, Pune; ii. Prof. Ram Harsh Singh, Life Time Distinguished Professor, Faculty of Ayurveda, IMS, BHU, Varanasi; iii. Mr. Darshan Shankar, Chairman, Foundation for the Re-vitalisation of Local Health Traditions (FRLHT), Bengaluru; iv. Dr. DBA Narayanan, Chairman of the Indian Pharmacopoeia Commission’s Crude Drug & Herbal Products Committee and v. Dr. Madhulika Banerjee, Department of Political Science, University of Delhi, Delhi. http:// over2shailaja.wordpress.com/2012/04/04/panel-discussion-at-iic-on-status-of-indian-medicine-folk-healing/.
A Study of Selected State Pharmacies 163
Certainly not enough to expand production capacity and make large-scale improvements in terms of renovation and modernization. During her visits to the States of Odisha, Uttar Pradesh, Andhra Pradesh, Himachal Pradesh and Jammu & Kashmir, the PI found that shortage in the supply of medicines and the indifferent quality of some drugs procured from private and public sector companies was a universal complaint. All the officials recounted that several years ago, the supply from the State Pharmacies was excellent and people were very appreciative of the quality of medicine. But now the supply from the state pharmacies had dwindled down considerably. It was lamented that problems of delay in transit, leakage, fungus existed and had not been addressed. The lone public sector unit under the Department of AYUSH is located at Almora (Uttarakhand) and is called Indian Medicines Pharmaceutical Corporation Ltd. (IMPCL). In the State Sector TAMPCOL in Tamil Nadu and Oushadi (in Kerala are also well-known manufacturers. The PI did not examine these commerciallyrun enterprises as a part of her study. However they were doing brisk business and there were no complaints of shortages in those State. The PI felt that it would be useful to have a quick random survey done of a few Staterun departmental pharmacies to understand their working and the general picture that the situation presents. It was not possible for the PI to have an all India survey conducted due to constraints of time. The exercise undertaken was not intended to be either an inspection or a fault finding mission – simply a glimpse of the work undertaken by a cross-section of State pharmacies. Since such a study required knowledge of how Ayurveda pharmacies are expected to be organized and run, the PI had, after
164 Status of Indian Medicine and Folk Healing
visiting two pharmacies herself, decided to commission a study using a group of subject experts who could provide an objective and analytical picture. Accordingly the PI visited two pharmacies – the Uttar Pradesh State Pharmacy at Lucknow and the pharmacy attached to the SV Ayurvedic College Hospital at Tirupati. The outcomes of her visits have been mentioned in the reports covering field visits and are not being repeated here. This Chapter highlights the findings of the group of experts that visited eight State pharmacies using a questionnaire that was prepared by National Institute of Ayurveda (NIA), Jaipur in consultation with the PI. The PI contacted Prof. Ajay Kumar Sharma, the Director of the National Institute of Ayurveda at Jaipur. He selected the faculty members who would conduct the study. The PI then requested selected State Health Secretaries or Directors in charge of AYUSH in the States of Rajasthan, Karnataka, Uttar Pradesh, and Andhra Pradesh to permit the visits. All the officers were cooperative and the state authorities agreed that it was important to have such a study conducted. The documents/investigation sheets have not been reproduced in this report for the sake of brevity. What follows is a summary of the findings of the team from NIA that visited various pharmacies examining aspects like the suitability of the location, the space available, pest control measures, power supply, negative press reports, if any, waste disposal systems, availability of manpower, quality control systems, the production of drugs at each facility, supply of raw material, storage, packing, equipment and its upkeep. To a certain extent the picture of fund availability has also been discussed. Ascertaining about adverse press reports was a way of identifying whether the subject of drug production was noteworthy or not.
Study of State Pharmacies by Faculty of National Institute of Ayurveda, Jaipur Professor Ajay Kumar Sharma, Director, National Institute of Ayurveda, Jaipur deputed the following faculty members to pay visits to selected State Pharmacies in four States. Four faculty members from the Department of Rasa Shashtra and Bhaisajya Kalpana, who visited different Pharmacies and used the questionnaire provided (Annexure-II) were as follows:
Highlights Location of the Pharmacies The Hyderabad and Jodhpur Pharmacies were difficult to reach. The remaining pharmacies were well connected by local transport. Availability of Space All the eight pharmacies had a large amount of space but except at Ajmer, Bharatpur and Lucknow, the space was not being utilized efficiently.
1.
Dr. K Shankar Rao, Associate Professor & Head
Power Supply
2.
Dr. V Nageswar Professor
3.
Dr. Parimi Suresh, Assistant Professor; and
Except for Ajmer Pharmacy, shortage of electricity was not reported by the Pharmacies.
4.
Rao,
Associate
Dr. Sanjay Kumar, Lecturer
The team visited the following 8 pharmacies: 1.
Government Indian Medicine Pharmacy (Ayurveda), Kattedan, Hyderabad, Andhra Pradesh.
2.
Government Central Bangalore, Karnataka
Pharmacy,
3.
Government Ayurvedic Jodhpur, Rajasthan
Pharmacy,
4.
Rajkiya Ayurvedic Udaipur, Rajasthan
5.
Government Ayurvedic Ajmer, Rajasthan
Pharmacy,
6.
Government Ayurvedic Bharatpur, Rajasthan
Pharmacy,
7.
State Ayurvedic & Unani Pharmacy, Lucknow, Uttar Pradesh
8.
Lalit Hari Government Ayurvedic Pharmacy, Pilibhit, Uttar Pradesh.
Rodent/Insect Menace All the eight pharmacies were prone to rodent menace and insect infestation but no measures were being employed to prevent and control this. Recommendation: Pest control procedures should be laid down and a certificate of compliance obtained annually. Negative Press Reports •
Jodhpur: The local newspapers had published reports about insect infestation in some material.
•
Hyderabad: The Ex-Incharge’s pension was blocked on account of irregularities in the purchase of a generator.
•
Udaipur: Certain pharmacy in charge officials were facing Departmental enquiries.
Rasayanshala,
No such reports had appeared in the press in respect of other pharmacies visited.
A Study of Selected State Pharmacies 165
Waste Disposal In none of the pharmacies had any waste disposal systems been installed. In Lucknow, a big ditch was being used for waste disposal. Recommendation: Waste disposal guidelines should be issued and compliance sought annually. Availability of Manpower 1)
Hyderabad: There was shortage of technical staff. No labour union existed and the labour presently working in the pharmacy consisted of very senior persons who did not evince much interest. The office staff however was found to be working sincerely.
2)
Bangalore: There was a shortage of unskilled attendants (25 posts were vacant).
3)
Jodhpur: There did not appear to be any shortage of workers. However, punctuality was not being observed.
4)
Udaipur: No technical and skilled labours were available in the pharmacy. The Incharge and Assistant In-charge of the pharmacy were graduates and had been working as Medical Officers since long. They did not possess the technical knowledge required for supervising pharmacy work.
5)
6)
7)
Ajmer: There was a need to fill the vacant posts. Out of a total of 51 posts, 12 were lying vacant. Additional personnel like machine operators, electricians, a store keeper and pharmacists were needed. Bharatpur: The total sanctioned posts were 27, out of which 17 were for labourers. Recruitment to fill the vacant posts of labourers needed to be undertaken. There was a need for an additional post of Machine Operator. Lucknow: It is a big campus and
166â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
production is on a large scale. The workers were not in uniform. 8)
Pilibhit: There was a shortage of unskilled attendants.
Recommendation: The staff strength should be suggested on normative lines and should be related to capacity utilization and production. A normative list issued by Department of AYUSH would enable the Pharmacies to argue for specific manpower support. Quality Control in the Pharmacies 1.
Hyderabad: Earlier, the Drug Testing Laboratory was attached to the pharmacy but at present it is located at the Erragadda College. The raw material and finished goods were being tested at the new location.
2.
Bangalore: The Quality Control Department is in an adjacent building in the same compound. All the materials including raw materials, finished goods and inspection samples collected from private pharmacies are being tested here. The requisite equipment was available.
3.
Jodhpur: A Quality Control Department did not exist. The raw materials were being supplied in response to tenders called at Ajmer, and the material was expected to be inspected by external morphology only. No information about finished goods could be collected.
4.
Udaipur: No Quality Control Lab was linked to the pharmacy.
5.
Ajmer: The State Drug Testing Laboratory (DTL) operates from the same building, but did not appear to be functioning satisfactorily. There is a requirement to test raw materials and finished products which was not being undertaken.
6.
Bharatpur: A Drug Testing Laboratory was not available.
7.
Lucknow: A Drug Testing Laboratory is attached to the pharmacy but was not functioning satisfactorily. There were certain vacant posts and skilled persons were not available.
8.
prepare 89 formulations and gradually it was reduced to 29. At present the number of formulations has been further reduced to just 12. The majority of the formulations are in powder form and the quantity produced is small. 5)
Ajmer: Presently this unit is preparing 15 Ayurvedic formulations which include various forms like Vati, Rasa, Choorna, Lepa, Arka, Dhoop. Inaddition, the unit is also preparing 18 Unani formulations.
6)
Bharatpur: Only 12 Ayurvedic products are being manufactured in this unit. The dosage forms include Bhasma, Pisthi, Taila, Vati, Choornaand Malham.
7)
Lucknow: Fifty Ayurvedic and 42 Unani formulations were being manufactured.
8)
Pilibhit: Forty Ayurvedic Products were being manufactured.
Pilibhit: The Quality Control Lab was not attached to the pharmacy and tests were being conducted in the State Ayurvedic College nearby.
Recommendation: Quality control is an important aspect of the GMP requirements. State Government Pharmacies should adopt proper quality control processes. This needs to be reviewed periodically before funds are released for various schemes related to capacity building. Production Capacity and Utilization 1)
2)
3)
4)
Hyderabad: A total of 44 formulations had been allotted to be prepared which included 6-7 different dosage forms, out of which 13 were in powder form, 13-14 in tablet forms, four were medicated oils, and four were bhasmas. In addition three ointments and two local applications were also being prepared. Bangalore: Eighty Ayurvedic products and 58 Unani products were being manufactured. The formulation of a variety of dosage forms: powders, guggulu, oils and ghee, asavaristhas and lehyas was being undertaken. Jodhpur: Only 13 products were being manufactured in this unit. Apart from the medicines produced in these units, certain drugs were also purchased from private pharmaceuticals to meet the requirements of the dispensaries. Udaipur: Earlier the pharmacy used to
Raw Material availability 1.
Hyderabad: Separate committees exist for Selection, Tender and Purchase. E-tenders were being issued on an AllIndia basis depending upon the annual requirement. No extra local purchases were being made.
2.
Bangalore: E-tendering was being undertaken. There was no shortage of raw materials and no order was left pending for want of raw material.
3.
Jodhpur: E-tendering was being done at the main pharmacy at Ajmer. After passing the tender, the material was being supplied directly to the pharmacy. Occasionally, a shortage of material had been experienced.
4.
Udaipur, Ajmer and Bharatpur: Centralized open tender system was executed by the Directorateâ&#x20AC;&#x2122;s Office at Ajmer. From the previous year
A Study of Selected State Pharmaciesâ&#x20AC;&#x192; 167
e-tendering had been adopted. The raw materials were being purchased and supplied to the pharmacies as per the budget provision. No extra local purchases were being made generally. It was reported that a shortage of raw materials was faced occasionally. 5.
Lucknow and Pilibhit: There is central tendering system operated from the Directorate’s office.
Storage of products
raw
material
and
working order. This needs the creation of a post of “Machine Operator”. Recommendation: The utilization and upkeep of equipment need to be monitored by the AYUSH/ISM Directorate or a designated official should give an independent audit report to avoid underutilization. Dispensaries and Hospitals 1.
Hyderabad: They claim to be meeting up to 75-80 percent of the target but the dispensaries complain about non-supply and irregular supply of medicine.
2.
Bangalore: It was said that 60 percent of the target was met and the supply was regular. Wooden boxes are used and a private organisation has been entrusted with distribution to the respective dispensaries.
3.
Jodhpur: The pharmacy indicated that it was achieving 100 percent of the target. The material was supplied twice a year through a private transporter and the finished products were being supplied to the zones and the respective dispensaries or collected by them.
4.
Udaipur: The pharmacy was meeting up to 75-80 percent of the target. Occasionally, dispensaries complained about the non-supply of medicines in time. Wooden boxes were packed and supplied to various dispensaries and hospitals. These were seen lying in the pharmacy even after the manufacturing process had been completed.
5.
Ajmer: The material is supplied twice in a year through a private transporter. The supply is regular and the pharmacy said it was achieving up to 60 percent of the target.
6.
Bharatpur: The material was being supplied twice in a year through a private
finished
In all the pharmacies, there was an absence of proper storage as per the GMP guidelines. Items were being stored in gunny and plastic bags. Some materials were stored in galvanized iron drums and cartons. In Ajmer and Bharatpur, although the storage place was sufficient, it was not being used optimally. Packaging aspects In all the pharmacies, the packing was being done manually in plastic bags and plastic containers. Availability of equipment 1)
Hyderabad, Udaipur and Lucknow: Brand new equipment was lying idle. Even after installation, due to certain problems like payment of bills and non-availability of skilled persons the equipment remained unutilized. If these problems are corrected, the production likely to improve.
2)
Bangalore, Ajmer and Pilibhit: They were having enough capacity to meet the requirements.
3)
Jodhpur: Certain machinery was lying idle ever since it was purchased.
4)
Bharatpur: Even though most of machinery was available, it was not in
168 Status of Indian Medicine and Folk Healing
purchase of raw materials was Rs.2.0 lakh under plan and Rs.166 lakh under non-plan head. Out of these, one lakh was utilized under plan and Rs.99 lakh was utilized under Non-plan head. The rates of raw material was decided through competitive tender, hence less budget was utilized.
transporter. The supply was regular and the pharmacy was achieving up to 80 percent of the target. 7.
Lucknow: They achieved 100 percent of the target. Medicines were supplied to hospital/ dispensaries twice a year.
8.
Pilibhit: They achieved 100 percent of the target and the supply was made once in a year.
Recommendation: All State pharmacies should be able to prepare and supply at least 50 percent of the demand of medicines required by the general hospitals and dispensaries. The targets given should be reviewed as at all places people seemed to prefer medicines which were formulated inhouse over commercially procured medicine. The capacity of all State pharmacies and their turnover required to be augmented to ensure timely and dependable supply to government AYUSH facilities. Fund Availability for meeting production requirements2 1)
2)
Hyderabad: The funds allotted for purchase of raw material was Rs.37 lakh for the financial year 2011-12. The allotted fund was not utilized for the said purchase due to shortage of manpower, non-availability of requisite machinery for manufacturing and lack of proper transportation for finished product. Bangalore: During the financial year 2011-12, the total fund sanctioned under plan was Rs.70 lakh and for nonplan expenditure was Rs.359 lakh. Out of this, Rs.66 lakh was utilized under plan and Rs.285 lakh was utilized under non-plan heads. The budget allotted for
3)
Jodhpur: Total fund allotted for purchase of raw materials was Rs.20 lakh during the financial year 2011-12 which was fully utilized. As per delegation of power, the Incharge has the power to purchase raw materials locally to the tune of Rs.30,000/- per annum.
4)
Udaipur: The total fund sanctioned for the financial year 2011-12 was Rs.104 lakh, out of which the budget allotted for purchase of raw material was Rs.40 lakh. Out of which a sum of Rs.15 lakh was utilized.
5)
Ajmer: The total sanctioned budget for financial year 2011-12 was Rs.131 lakh, out of which budget sanctioned for purchase of raw material was Rs.76 lakh. Raw materials were purchased for Rs.68 lakh. As per delegation of financial power, the Incharge has power to spend Rs.25,000/- per annum.
6)
Bharatpur: The total sanctioned budget for the financial year 2011-12 was Rs.104 lakh, out of which budget allotted for purchase of raw material was Rs.7.0 lakh. A sum of Rs.6.5 lakh was utilized for purchase of raw material. As per terms of delegation of authority, the Incharge had the power to spend from Rs.25,000/- to 30,000/- per annum.
2. The data is as collected by the research team. This has however not been counter-checked with the States. The data has been included only to give an idea of the level of funding and production of different kinds of drugs.
A Study of Selected State Pharmaciesâ&#x20AC;&#x192; 169
7)
Lucknow: The total sanctioned budget for the financial year 2011-12 was Rs.561 lakh, out of which budget for raw material was Rs.131 lakh which was fully utilized.
8)
Pilibhit: Total sanctioned budget was Rs.58 lakh out of which Rs.16 lakh was for purchase of raw material which was fully utilized.
Recommendation: Funding should be related to cost of production and improvement in production should be encouraged and incentivised. Local purchase for identified items should be allowed as all requirements cannot be catered for fully. Scope for setting up joint sector production units to improve efficiency The Hyderabad, Udaipur, Ajmer, Bharatpur and Lucknow Pharmacies were not interested in any joint sector arrangement. 1.
2.
3.
Bangalore: The State Government has released Rs. 5-10 crore for the construction of Pharmacy. Another Rs. 10 crore would be given by Department of AYUSH, GOI on 50-50 percent sharing basis. Jodhpur: It was learnt that the pharmacy (all units) might be handed over to a private company. The authenticity of this could not be checked. Pilibhit: It was indicated that this was subject to the jurisdiction of the State Government.
General Findings The general picture that emerges although it is quite different from pharmacy to pharmacy and from State to State shows that production of Ayurvedic and Unani medicine
170 Status of Indian Medicine and Folk Healing
is in progress, and a range of products are being manufactured within the capacity of the infrastructure available to each unit. None of the pharmacies, except in Lucknow and Pilibhit presented a picture of efficiency or of being one of the key players in the area of supplying medicines to the State hospitals and pharmacies. The position seems to have deteriorated over the years although there was capacity available in terms of space and in some places even in terms of equipment. The availability of raw material seems to be totally dependent upon the State tendering process and although at all places the Incharges claimed that they had adequate powers it is unlikely that they could actually make local purchases to fill emergent gaps like payment for gas supply or other essential consumables. The redeeming feature was that electricity supply was not reported to be a big problem and most places were well connected by local transport. Some of the negative challenges that came out of the study, which might be indicative of what probably prevails in most State pharmacies, are indicated below. •
Although there was plentiful space available at most of the pharmacies it was not being utilized properly.
•
The prevention and control of rodents and insects spoiling the raw drugs as well as the manufactured products is not a stated requirement.
•
There appears to be a universal shortage of technical staff and labour.
•
Arrangements for quality control seem to lack focus and from the reports it would appear that the GMP requirements are hardly being met by the State pharmacies at many places.
Conclusions and Recommendations Although the production capacity used to be quite large some years ago, it has diminished considerably and cannot be augmented unless coordinated action is taken to provide technical staff, labour and raw material. All these aspects are perhaps being addressed in routine or not at all. There is every need for the State AYUSH Departments to augment production and supply from the State pharmacies as opposed to making purchase of finished goods from outside because all the field visits had shown that even in the States where primacy has been given to Indian medicine (Himachal Pradesh, Odisha and Uttar Pradesh), the demand and supply of drugs from the State Pharmacies was irregular and insufficient. The PI discussed the reasons for the decline of State pharmacies with some State Directors of Ayurveda. She was told that the State pharmacies became dormant or defunct because they were established at a time when the government instructions were extremely rigid but over time these could not be followed because there was a need for extensive documentation for which there was little capacity. Over the years it became difficult to extract work from the pharmacy staff who were not bound by shift duties round-theclock but were engaged only to work during normal office hours. Whenever power supply was a problem, most of the time was spent in idle gossip. The revival of such pharmacies would require changing the terms of engagement of the staff, moving to a corporate culture in terms of financial management and production. This would also require that the industrial production laws would have to apply.
State pharmacies working on commercial lines are functioning quite successfully if the examples of Tamcol in Tamil Nadu and Oushadi in Kerala are considered. In the interest of using the capacity nearer home so that the uncertainties of transportation and storage are minimized, there is a great need to follow such examples. Even if a couple of states set up a joint sector undertaking or a State run corporation, it would be a great beginning. This would require tremendous persuasion and the preparation of a MOUs and legal documents if such projects are to be taken forward. The level of interest among individual States is poor and there is no willingness to give up making purchase of medicines from outside despite vagaries of supply. The Directors of Ayurveda had pointed out that state governments are not investing in the purchase of AYUSH drugs. They depend on the provisions made under NRHM or allocations made by the Department of AYUSH. A policy on the revival of state pharmacies needs to be made as the provisioning of drugs has to go hand-in-hand with the appointment of hundreds of contractual doctors under NRHM. Even if funding is continued for the NRHM facilities, efforts would need to be made to maintain supplies to the AYUSH dispensaries and hospitals and also to compress the time taken for the drugs to actually reach the facilities. The procurement process is ridden with procedural problems. If the ultimate goal is to see that AYUSH is mainstreamed, some imaginative measures would need to be taken to run the state pharmacies in a cost-effective and efficient way. It may be worthwhile to start by establishing a new society with an independent Governing Body or to set up new ventures while using
A Study of Selected State Pharmaciesâ&#x20AC;&#x192; 171
the old infrastructure. Each state could empower the Governing body to take local decisions on procurement of raw material and processing. The infrastructure could be placed under control of the new setup and the staff could be given the choice to join the new setup or measures may have to be taken to redeploy them within the government. It must be recognised that total reliance on budgetary support and supplies made under NRHM or by Department of AYUSH, Government of India would never be able to meet the requirements of the hospitals and stand-alone facilities. This is completely a state responsibility. Unless there is a continuous supply of at least 50 products made by the State Pharmacies, Ayurveda and Unani systems will fall into
172â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
disuse in the government sector. Some drastic measures are needed because there has been a virtual absence of drugs in several States visited by the PI among the Eastern and Northern States. Funding for state pharmacies should be revived in the 12th plan. It is necessary to give the money to specific pharmacies by name and to relate further funding to increase in production capacity and fulfilment of targets. It is not as though all the pharmacies have closed down. With some injection of leadership, supervision and funds, things can improve. But it is a subject which needs special attention because on it depends the success of the Ayush initiatives at the facility level.
Annexure-I Grant in Aid released to States/UTs under the Centrally Sponsored Scheme for Quality Control of ASU&H drugs from 2000-01 to 2011-12 (in Rs. lakhs) S. No.
State/UT
1
Andhra Pradesh
2
Drug Testing AYUSH Strengthening Reimbursement Support to GMP compliant ASU of Drug Laboratory Pharmacies of Enforcement Units Testing Fee Mechanism
Total Grant Released
150.00
670.00
36.94
2. 00
-
858.94
Arunachal Pradesh
95.00
100.00
36.40
2.00
-
233.40
3
Assam
93.50
95.00
32.27
2.00
0.60
223.37
4
Bihar
150.00
90.70
29.00
2.00
-
271.70
5
Chhatisgarh
137.60
179.49
29.00
2.00
-
348.09
6
Delhi
95.00
-
29.00
2.00
-
126.00
7
Chandigarh
Â
-
29.00
2.00
-
31.00
8
Gujarat
150.00
598.72
29.00
2.00
18.71
798.43
9
Haryana
100.00
200.00
29.00
4.00
4.21
337.21
10
Himachal Pradesh
100.00
378.05
37.06
4.00
1.97
521.08
11
Jammu & Kashmir
100.00
100.00
30.00
2.00
-
232.00
12
Jharkhand
100.00
150.00
37.06
2.00
-
289.06
13
Karnataka
120.00
185.00
29.00
2.00
37.80
373.80
14
Kerala
150.00
365.00
36.78
2.00
65.79
619.57
15
Madhya Pradesh
115.69
380.00
39.90
2.00
-
537.59
16
Maharashtra
79.04
52.65
38.52
2.00
26.07
198.28
17
Lakshadweep
-
-
29.00
2.00
-
31.00
18
Meghalaya
88.62
-
29.00
2.00
-
119.62
19
Mizoram
175.00
-
34.00
4.00
-
213.00
20
Nagaland
175.00
200.00
34.00
4.00
-
413.00
21
Orissa
100.00
584.47
37.89
2.00
5.00
729.36
22
Punjab
150.00
95.00
34.25
2.00
-
281.25
23
Rajasthan
141.19
779.24
44.46
4.00
20.88
989.77
24
Sikkim
150.00
-
29.00
2.00
-
181.00
25
Tamil Nadu
232.04
600.00
29.00
2.00
-
863.04
26
Tripura
134.63
100.00
35.78
2.00
-
272.41
27
Uttar Pradesh
130.33
534.76
29.00
2.00
-
696.09
28
Uttaranchal
150.00
499.77
36.34
2.00
-
688.11
29
West Bengal
140.00
350.00
29.00
4.00
3.99
526.99
30
Pondicherry
-
-
29.00
2.00
-
31.00
3502.64
7287.85
987.65
72.00
185.02
12035.16
Total
A Study of Selected State Pharmaciesâ&#x20AC;&#x192; 173
Annexure-II Questionnaire for Preparing Status Report on Government Ayurvedic Pharmacies 1)
Name of Pharmacy & address:
2)
Date upto which license has been issued:
3)
Date on which GMP approved :
4)
Sanctioned posts and staff details with qualifications.
5)
Posts (enclose separate list)
6)
What is the installed capacity of the pharmacy product-wise.
7)
Is the capacity fully utilized? If not, why? Give details of : •
Staff shortages
•
Raw material shortage
•
Equipment not in working order.
•
State whether budget is the problem or management capability.
8)
Funding agency (AYUSH/State Govt.)Indicate quantum of grants received in last 3 years:
9)
Total sanctioned budget last year:
10) Total utilized budget last year: 11) Is there sufficient infrastructure for expansion of manufacturing capacity by volume and by adding more terms? 12) Budget allotted for Raw material(last year) and utilization: 13) If budget for raw material was not utilized give reasons including non-availability of certain items. 14) Procedure for raw material purchase: 15) Any delay in raw material purchase: 16) Is any formulations pending for want of Ingredients: 17) Are you satisfied with the storage facilities for Raw material/finished goods: 18) No. of items (classical/proprietary) prepared: 19) Has packing of finished medicines and supply in properly packed condition been satisfactory? Were any complaints received from state hospitals and dispensaries? 20) What percentage of the needs of state hospitals /dispensaries is met from your Pharmacy? 21) Is there any pharmacy development committee? What were its major recommendations? 22) Was there delay caused by administrative procedures. Give examples: 23) Does the in charge have financial/administrative powers? Give details of such delegated authority.
174 Status of Indian Medicine and Folk Healing
24) Last yearâ&#x20AC;&#x2122;s Target item-wise: 25) Whether target was achieved: 26) If not, give details (enclose separate sheet) 27) Any labour/union problems/scams/ enquiries under process? 28) Is there shortage of Power supply? Is there scope to justify a generator?: 29) List of equipment which are not in working order and reasons for non-repair/nonreplacement. 30) Whether Drug Testing Lab attached with Pharmacy or not: 31) List of dispensaries where you are supplying products and comparison with the demand placed: 32) Whether supply of products was regular/irregular with reasons: 33) Has there been any thinking or discussion on the possibility of converting the pharmacy into a corporation or starting a joint sector company with IMPCL or any other state public sector company? 34) Any other suggestion?
(Signature of Pharmacy I/C)
A Study of Selected State Pharmaciesâ&#x20AC;&#x192; 175
6 Regulatory Framework for ASU Drugs
Regulatory Framework for ASU Drugs Major Milestones Crossed
180
Improving Quality Control and Enforcement - Current developments and future prospects
182
Legal Status of Cross Practice
184
Annexures :
Annexure-I: Letter of Secretary, UP to all the CMOs regarding harassment faced by the ISM practitioners in the State
194
Annexure-II: Court order on the issue of Inter-disciplinary Cross-practice in UP
195
Annexure-III: Ministry of Health & Family Welfare’s notification regarding practice of Gynaecology & Obstetrics and Diagnostic Ultrasonography by ISM Graduates
197
Annexure-IV: Himachal Government’s circular allowing ISM practitioners to use modern medicines
198
Annexure-V: Directorate of ISM, J&K Circular regarding “Prescription of Allopathic Medicine by AYUSH Doctors”
199
Annexure-VI:Proposal of J&K Department of ISM to notify the use of essential allopathic medicine by AYUSH doctors
200
178 Status of Indian Medicine and Folk Healing
6 Regulatory Framework for ASU Drugs Introduction Post Independence, when India had to confront new challenges of manufacturing quality pharmaceuticals within in the country, the Drugs Act 1940 was enacted. It was only in 1964 that Cosmetics was brought under the purview of the Act. In 1964, the Drugs & Cosmetics Act (DCA) was further amended to insert definitions for Ayurveda, Siddha, and Unani(ASU) drugs. In 1982, a Schedule of Authoritative books was notified with a view to giving legal recognition to “AnubhutiYog” (experience-based ASU medicine) and also for defining “Patent & Proprietary” (P&P) ASU Medicine. Chapter IV of Drugs and Cosmetics Rules (DCAR) lays down regulations for synthetic compound-based drugs (generally referred as allopathic drugs) while Chapter IVA of DCAR provide regulations for ASU drugs. It would appear that the latter provisions began to be implemented only in 1983 when the Ayurveda, Siddha and Unani Drugs Technical Advisory Board (ASUDTAB) was first constituted to advise the Central and State Governments on technical matters arising out of Chapter IVA. Broadly speaking, Chapter IVA provides that licenses can be obtained from the licensing authorities under the State Governments. The only difference between “patent proprietary medicine” and “classical medicine” is the requirement to strictly adhere to the classical texts in the case of classical medicine. This stipulation was in the wisdom of the Parliament, based on a history of safe usage
over thousands of years since the formulations had undergone years of examination by the Vaidyas and needed no further proof to be licensed for manufacture. However, in the case of P&P ASU drugs, the formulations could be “tweaked” to make them different and special. But a specific license had to be obtained for deviating from the classical text while ensuring that the ingredients in any case were the same as listed in the ancient texts; also the processing methods were similar to those in the authoritative texts. Thereby alterations promoted by private sector manufacturers also received legal recognition. Challenges that beset ASU Drug Manufacture and Sale Lack of enforcement to check the quality of ingredients used as well as gaps in the fulfilment of the procedures as prescribed in the classical texts remain major shortcomings. Since no sale licence is required, shops can stock medicine, oils and a diverse range of formulations and these products can be obtained over the counter without any prescription. This leaves everything in the hands of manufacturers and not all among them show due diligence. Although there are some 9000 licensed units in the country just 10 manufacturers account for almost 85 percent of the sales. The regulations for maintaining safety and quality control apply to all manufacturers but these are often ignored because of the knowledge that State enforcement is weak.
Regulatory Framework for ASU Drugs 179
Major Milestones Crossed Major Milestones relating to ASU drugs Several major initiatives have been taken by the Department of AYUSH, Government of India and are being listed below as they represent a commitment to improving the quality of ASU
drugs. It is important to note that many of these amendments and initiatives have been undertaken at the behest of industry, and most of them are on the lines of measures applicable to the pharmaceuticals industry, but modified to fit the ASU drugs sector.
Schedule of Regulatory Milestones Crossed S.No. 1. 2.
Steps/Initiatives Provision of exemption in the labelling and packing provisions was made with an amendment in the Drugs & Cosmetics Rules, whereby ASU drugs could be labelled as per the requirements of the country to which they were exported. This was for facilitating export. Good Manufacturing Practices (GMP) notification was introduced to strengthen quality control of ASU medicines, both by the drug manufacturers and licensing authorities. GMP provisions prescribe the requirements of infrastructure, hygiene, man power, and related aspects to maintain quality control. (2000)
3.
In order to improve the quality of production and testing facilities for ASU&H drugs in the public sector, a Centrally Sponsored Scheme (CSS) was implemented to strengthen State Pharmacies and Drug Testing Laboratories. (2001)
4.
Standards for the manufacture, sale or distribution of ASU drugs were prescribed through an amendment in the Drugs & Cosmetics Rule 168. (2002)
5.
Regulatory provisions for recognition of laboratories for testing ASU drugs and raw materials were made under the Drugs & Cosmetics Rules. Notification was made for laying down the qualifications of the State Licensing Authorities for ASU drugs. Essential Drug lists of Ayurveda, Siddha and Unani were published to facilitate standardized supply of medicines to government dispensaries and hospitals. (2003)
6. 7. 8.
Joint inspections were initiated by the representatives of Central Government and State Licensing Authorities for granting recognition to the Drug Testing Laboratories under the Drugs & Cosmetics Rules. (2004)
9.
Standard requirements of space and technical manpower were prescribed prior to grant of approval for carrying out testing of ASU drugs. Use of excipients was permitted with specific conditions and permissible limits to improve the quality and shelf life of ASU drugs. Many of them are currently manufactured on an industrial scale and distributed across the country. Rule 169. Administrative orders were issued to the State Governments and Drug manufacturers for arranging for batch to batch testing of heavy metals in export-oriented ASU herbal ASU medicines. (This was subsequent to an article published in the Journal of American Medical Association (JAMA) about the presence of heavy metal contents in Ayurveda products, and concerns raised on the safety of herbal ASU medicines). (2005)
10. 11.
12.
Pharmacopoeia Laboratory for Indian Medicine (PLIM) was notified under the Drugs & Cosmetics Rules to function as Central Drugs Laboratory. PLIM is the Appellate Laboratory for the purpose of testing ASU drugs. (2006)
13.
A Technical Committee was set up to examine applications seeking Central Governmentâ&#x20AC;&#x2122;s permission for conducting clinical trials on ASU medicines. (This remained a temporary measure only. The committee did not continue and its working was objected to by several firms). Pharmacopoeial standards of multi-ingredient Ayurvedic formulations were developed and published for the first time, in the Ayurvedic Pharmacopeia of India. (2007)
14.
180â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
15.
16. 17. 18.
19.
20. 21. 22.
23. 24.
25. 26. 27. 28.
29. 30. 31. 32. 33. 34.
Drugs & Cosmetics Rules were amended to provide for maintenance of records of raw materials used by licensed ASU drug manufacturing units in preceding financial year. (This was to get manufacturers to provide annual data on consumption of raw herbs and materials with a view to generate data on utilization as well as demand and supply aspects to maintain sustainability). Framework for issue of WHO-GMP certification of ASU drugs was finalized. Administrative orders were issued prescribing permissible limits of heavy metals, aflatoxins, pesticide residues and microbial load in Ayurvedic drugs. Administrative orders issued banning the use of misleading prefixes and suffixes in classical and patent ASU medicines. Later certain exemptions were also issued. (This order in effect prevented branding of classical medicine which the PI feels has impacted adversely on R&D and the “look and feel” of classical medicine.) (See Part I, Chapter on Drugs for a detailed critique on branded drugs). (2008) Guidelines for manufacturing of Mineral and Herbo-mineral formulations notified vide amendment in Schedule ‘T’ of Drugs & Cosmetics Act. (Supplementary GMP requirements were introduced specifically for the manufacturers of metallic preparations of ASU drugs that need to undergo purification as per the authoritative texts. This was an additional measure to ensure safety and quality of ASU drugs). Voluntary quality certification scheme for AYUSH products was started in collaboration with Quality Council of India (QCI). (2009) Shelf life/date of expiry for ASU medicines notified under Drugs & Cosmetics Rule 161 (B). (This was a long standing demand from consumers and was advised by Consumers Affairs Ministry as providing information on the durability of products has become a consumer right). Guidelines for issue of manufacturing license to various types of Patent & Proprietary (P&P) ASU drugs notified listing documents required in support of efficacy and safety. (This broadened the scope of and permitted P&P drugs to use extracts based on ethanol and solvents. A new category called ASU Cosmetics and Supplements was introduced) List of poisonous substances used in ASU systems of medicine was amended through Schedule E-1 of Drugs & Cosmetics Act. Pharmacopoeia Commission for Indian Medicine (PCIM) was set up to accelerate the pharmacopoeia work of ASU drugs. (The Pharmacopoeia Commission is run by scientists who lay down standards for ASU medicines and related aspects, on lines similar to Indian Pharmacopoeia Commission for Allopathic drugs). (2010) Research Councils were directed to register all clinical trials on ASU & H drugs under Clinical Trial Registry of India (CTRI). Ayurveda, Siddha and Unani Drugs Technical Board (ASUDTAB) was reconstituted. (2011) Notification of draft rules regarding the mandatory mention of botanical names and plant parts on the labels of ASU medicines. Good Clinical Practice (GCP) guidelines for ASU drugs were approved by Department of AYUSH. Initiatives in the Pipeline Provision of Retail Sale license for ASU drugs containing poisonous raw materials (as per Schedule E-1) has been initiated on the recommendation of Ayurveda, Siddha, Unani Drugs Technical Advisory Board (ASUDTAB). (This move was proposed many times in the past) Legal ban on misleading use of prefix or suffix in ASU medicines has been initiated. This prevents the branding of classical medicine. (The PI feels that branding ought in fact to be encouraged. See part I of the Status Report-Chapter on Drugs). Regulatory provision introduced for mandatory compliance to GCP to conduct clinical trials on ASU drugs. Notification of model laboratory practices for testing of ASU drugs initiated. Review of shelf life of ASU drugs initiated to rectify ambiguities between the formularies and the legal provisions. Amendment of the lists of authoritative texts of Ayurveda, Siddha and Unani listed under the First Schedule of the Drugs & Cosmetics Act undertaken. (2012)
*(Remarks in parentheses are the PI’s views and do not constitute an official point of view).
Regulatory Framework for ASU Drugs 181
Improving Quality Control and Enforcement - Current developments and future prospects Regulations that Relate to Safety and Efficacy of ASU Medicine With the resurgence of interest in Ayurveda and Indian systems of medicine, there is an increasing need to refer to not just the profile of the ingredients but to satisfy the consumer about the safety and efficacy of the drugs. On the one hand the D&C Act 1940 does not prescribe the need for any safety studies or clinical studies in respect of ASU drugs; on the other nothing can be taken for granted simply because it claims to follow what has been stipulated. The manner in which laboratory testing can be refined and modernised has been dealt in detail in Part I in the Chapter on Drugs. Introduction of New Categories under the D&C Act Particular reference needs to be made to the sixth amendment to the Drugs and Cosmetics Rules issued in 2010 elaborating guidelines for issue of licence of different kinds of ASU products. Categories intended to promote good health, paediatric formulations, cosmetic and toilet preparations, as well as extracts were mentioned as separate categories for the first time. Although it was specified that the conditions relating to safety studies and experience or evidence of effectiveness would need to be as specified, such requirements do not appear to have been spelt out. In the case of cosmetic and toiletry preparations, it was specified that safety studies were to be undertaken in case the formulation contained any of the ingredients mentioned in schedule E (1). (Poisonous substances) In respect of extracts of medicinal plants (dry or wet) no requirement for safety studies or for
182â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
experience/evidence of effectiveness studies have been laid down but in the case of new indications other than those mentioned in the list of books and if the extracts are other than hydro/hydro-alcohol-based, acute chronic, mutagenicity and teratogenicity studies have been asked to be conducted. It has also been indicated that the standard protocol should include the concepts of Anupan, Prakriti and Tridoshas as published by the Central Research Councils. Strengthening the Regulatory Mechanisms for Enforcement The Mashelkar Committee (2003) and the Ayurveda, Siddha, Unani Drugs Consultative Committee (ASUDCC) chaired by the Drugs Controller General of India (DCGI) while recommending the need to strengthen the regulatory mechanism at central and state levels suggested the creation of a Central Drug Controller for AYUSH. With this the Central Government would assume a significant role in enforcing the regulatory provisions prescribed under Drugs and Cosmetic Act 1940 and the rules there under. Accordingly, the Department moved a proposal in 2010 to set up a Central Drug Controller for ASU & H Drugs. The EFC chaired by the Secretary (Expenditure) is reported to have approved the proposal. Thereafter the Department of Expenditure was approached for creation of posts and infrastructure. The Department of Expenditure has sought clarifications and it is understood that the matter remains under process. Guidelines for Clinical Research Considerable cloudiness covers the requirement to follow protocols for clinical trials as well as the level of trials needed for ASU drugs. For the first time the ICMR issued AYUSH specific ethical guidelines for biomedical research in human
subjects in the year 2000 and revised them in 2006. The guidelines suggest the composition of an institutional Ethics committee but there is little specificity about when exactly Phase-I, Phase-II and Phase-III trials are needed. Also the ICMR committee perhaps did not recognize that for ASU drugs with long usage, Phase I to III studies which apply primarily to Synthetic New Chemical Entities (NCE’S) may not be required. The categorization of ASU drugs into different categories as given in the ICMR guidelines does not synchronize with the way ASU drugs are listed in the pharmacopoeias or used in practice. The result has been that the ICMR guidelines have generally remained on paper. ASU research as well as practice has been guided by the protocols drawn up by the Scientific Advisory Committees of the Government Research Councils or as Sub Committees under ‘Ayurveda Siddha Unani Drugs Technical Advisory Board (ASUDTAB)’
undertaken by private manufacturers. There, therefore exists no final position on what is needed for ASU drugs clinical research. A number of papers based on clinical trials carried out by companies like Himalaya and Dabur have been published in leading international journals. Hence the adoption of acceptable standards can be learnt from the way the private companies have successfully published their research in high impact journals including international publications. Some details are given in the Chapter on Cotemporary Ayurveda. It is interesting to note that five sub-committees had been set up under the ASUDTAB with different terms of reference. The five subcommittees and their terms of reference can be summarized as under: Terms of references
1. Subcommittee to examine Schedule “Z’ and other relevant notification
Introduction of Schedule ‘Z’ in Drugs & Cosmetics Rules 1945 – related to requirement & guidelines for permission to manufacture ASU drugs for sale or to undertake clinical trials
2. Subcommittee to evaluate the proposed Retail Sale License for ASU drugs
Introduction of Retail sale license for ASU medicines containing Schedule E (I) drugs (poisonous substance) of the Drugs & Cosmetics Rules 1945
3. Subcommittee to review the Model Laboratory Practices for testing of ASU drugs
Amendments in Drugs & Cosmetics Rules, 1945, for introduction of Schedule-T-1 related with “Good Laboratory Practices & Requirements of premises &equipments for testing of ASU Drugs”
4. Subcommittee to amend Frame the Amendment of the list of authoritative books in the First First Schedule of Drugs & Schedule of Drugs & Cosmetic Act, 1940 with details of writer, Cosmetics Act, 1940 for the publisher, year of publication etc. list of Authoritative ASU books 5. Subcommittee to examine shelf life of ASU Medicines
Review of shelf life of Siddha and Ayurvedic drugs mentioned in respective formularies and under Rule 161-B, 2 (ii) of the Drugs & Cosmetics Rules to harmonize the shelf life of drugs to rectify ambiguities between Formularies and legal provisions.
The template which has been used for the preparation of the proposed Schedule Z has been modelled on Schedule Y for allopathic drugs. For the first time safety studies and evidence of effectiveness studies are proposed to be specified and exactly when and in what circumstances Phase I, Phase II and Phase III are needed have been planned to be included.
The qualifications, training and experience of clinical investigators, the responsibilities of the sponsor and investigator, a requirement to report unexpected serious adverse events, informed consent, responsibilities of the ethics committee, maximum dosage levels, measurement of drug activity, therapeutic confirmatory trials and post marketing trials are some of the features which
Regulatory Framework for ASU Drugs 183
have been included in the template. Despite efforts the PI could not get an authentic account of the progress made. Conclusion and Recommendations It is apparent that for the first time an effort is being made to have evidence of safety and efficacy and to fulfill meet requirements that are considered necessary to protect the consumer and keep him informed. While the steps initiated are laudable it has also to be seen how far the sub-committees will modify or augment the template. The final adoption of the rules would probably take several months more. It is hoped that in the process wide consultations would be held with all stakeholders before new measures are put in place. In order to get a counter view, the meetings should be notified for stakeholders to attend as observers who can then give their suggestions in writing. Alternately the meetings should be video-taped and put on the internet. Ultimately, the aim is for ASU medicines to reach a larger clientele, which is becoming increasingly discerning and conscious about safety and quality. The position of Drugs Controller for AYUSH needs to be created with the full complement
of supporting staff at the earliest. At least one percent of the drugs in the market should be subjected to intense scrutiny and the outcomes publicized and if serious shortcomings are found, licences should be suspended and cases should be prosecuted. The work of the State licensing and enforcement authorities needs to be monitored constantly. This is a very weak link despite all the legal changes. Most of the state governments appoint the Drug Inspectors (Ayurveda) from the available list of Ayurvedic medical officers except in states like Delhi and Kerala. There ought to be a separate recruitment rules and standards or specialization prescribed for the drug inspectors who look after ASU medicine. This should be adopted on an all India basis which will strengthen the reputation for quality of Ayurvedic drugs. Clinical research needs to be promoted by giving generous grants to encourage more people to take an interest in this area. There should be much greater encouragement given to publishing papers in high impact journals. Regular support should given to the few journals that have set up independent editorial boards and are trying to maintain high standards.
Legal Status of Cross Practice Practice of Modern Medicine by ASU Doctors Medical practice being on the concurrent list of the Constitution, both Central as well as State Governments can pass laws on the subject. Ordinarily if the State law conflicts with the Central Law, the Central Law will prevail. The following major Central and State laws have been passed over the years: -
The Medical Council Act, 1956 which regulates modern system of medicine (MCI Act).
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-
The Indian Medicine Central Council Act, 1970 which regulates the Indian systems of medicine including Ayurveda, Siddha and Unani systems of medicine (IMCC Act).
-
The Homeopathic Central Council Act, 1971 which regulates practice of homeopathic medicine (HCCA Act).
-
The Drugs & Cosmetics Act, 1940 and Rules there under with a special Chapter IV A for ASU drugs.
Most State Governments have also passed laws in respect of ASU medical practitioners. All such laws have schedules attached which list the qualifications and degrees/ diplomas which would entitle practitioners to practice a particular branch of medicine. The Medical Council Act, 1956 lists the degrees and diplomas which are recognized for practicing allopathic medicine. Likewise the Medical Councils at the State level specify the maintenance of the State medical registers, set the standards for observance of medical ethics and enumerate what constitutes medical practice and malpractice. Recognition to medical colleges of Ayurveda, Siddha and Unani medicine is however granted only by the Central Government on the recommendations of the Central Council for Indian Medicine CCIM which includes Ayurveda, Siddha and Unani Medicine. A major issue that the Courts have had to deal with is that of cross practice. Can an Ayurvedic practitioner prescribe allopathic drugs? The most relevant case on this issue is that of Mukhtiar Chand and Ors v State of Punjab.1 In Mukhtiar Chand v State of Punjab, the primary question before the Supreme Court was “who may prescribe allopathic medicine?” This case raises questions of general importance and practical significance; questions relating not only to the right to practice the medical profession but also to the right to life that includes the health and wellbeing of a person. The controversy in this case was triggered by the issuance of a notification by some State Governments under clause (iii) of Rule 2(ee) of the Drugs and Cosmetics Rules, 1945, which defines a “Registered Medical Practitioner.”
Under such notifications the Vaidyas/Hakims claimed the right to prescribe allopathic drugs covered by the Drugs and Cosmetics Act, 1940 (D&C Act). Furthermore, Vaidyas/Hakims who had obtained degrees in integrated courses claimed the right to practice the allopathic system of medicine. It is necessary to understand what Rule 2(ee) means in the context of cross practice. This provision defines “registered medical practitioner” as a person: i)
Holding a qualification granted by an authority specified or notified under Section 3 of the Indian Medical Degree Act, 1916, or specified in the Schedules to the Medical Council Act, 1956; or
ii)
Registered or eligible for registration in Medical Register of a State meant for the registration of persons practicing the modern scientific system of medicine (excluding the homeopathic system of medicine); or
iii)
Registered in a Medical Register (other than a register for the registration of homeopathic practitioner) of a State, who although not falling within subclause (i) or sub-clause(ii) is declared by a general or special order made by the State Government in this behalf as a person practising the modern scientific system of medicine for the purposed of the Act.
In the Mukhtiar Chand v State of Punjab case, non-allopathic doctors sought to reinforce their right to prescribe allopathic medicine on the strength of notifications issued and under (iii) above and to restrain interference with this right. Similar issues also arose in various other high courts. Finally all the cases reached the Supreme Court. The Apex Court observed
1. (1998) 7SCC 579
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that Rule 2(ee) only defines the expression ‘registered medical practitioners’ and does not provide as to who can be registered. Therefore, the Court read the notification in consonance with laws regulating and permitting medical practice and held that the benefit of Rule 2(ee) and the notifications issued would be available in those States where the privileges to practice modern medicine (such as in Maharashtra) is conferred upon by the State law for the time being in force, applicable to medical practitioners of Indian medicine registered in the State. The Supreme Court also held that the right to prescribe drugs in a concomitant right to practise a system of medicine. In another Apex Court decision, Subhasis Bakshi v West Bengal Medical Council & Ors2 the Court reiterated that State Governments were at liberty to decide the qualifications that would permit prescription of allopathic and other medicines in the State. The other issue before the court was whether the right to issue prescriptions or certificates could be treated as a part of this right. The Court relying on the Mukhtiar Chand case held that the right to prescribe drugs and the right to issue certificates is a concomitant to the right to practise medicine. This case dealt with a situation where the West Bengal Government had allowed certain diploma holders to practise modern medicine to a limited extent in rural areas. However, in the PoonamVerma vs. Ashwin Patel3, the Supreme Court made an offquoted observation: “A person who does not have the knowledge of a particular system of medicine but practices in that system is a quack and a mere pretender to medical knowledge or skill, or to put it differently, a charlatan.” 2. (2003) 9 SCC 329 3. (1996) 4 SCC 332 4. AIR 2003 Karnataka 388
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In this case, a registered Homoeopathy doctor prescribed Allopathic medicines to PoonamVerma’s husband. His defence was that he had received instructions in modern system of medicine (Allopathy), and after the completion of his course, he had worked as Chief Medical Officer at a well-known allopathic clinic. The Court went on to observe that no person can practise a system of medicine unless he is registered either under the Central Indian Medical Register or the State Register to practise that system of medicine; and only such persons as are eligible for registration and possess recognized degrees as specified under the concerned Central and State Acts may so practice. The mere fact that during the course of study some aspects of other systems of medicine were studied does not qualify such practitioners to indulge in the use of other systems. In the PoonamVerma case, the Court held that the doctor was registered only to practise Homoeopathy. He was under a statutory duty not to use other systems of medicine. He trespassed into a prohibited field and was liable to be prosecuted under Section 15(3) of the Indian Medical Council Act, 1956. His conduct also amounted to actionable negligence for injury caused to his patient by prescribing allopathic drugs. While the above cases dealt with the situation where ISM practitioners were practising Allopathy, an equally important issue that needs to be addressed is whether allopathic doctors can prescribe and practise Ayurveda and other forms of Indian medicine. Interestingly, in the case of Akhtar Hussain Delvi (Dr.) vs. State of Karnataka4 a registered
Allopathic medical practitioner sought the right to prescribe drugs and medicine of Ayurvedic origin, which had been accepted by professionals practising Allopathic medicine pursuant to clinical and other tests. The High Court observed that under the Indian Medicine Central Council Act, 1970 only those who possess the medical qualifications specified in Second, Third or Fourth Schedule of the Act or are enrolled in the State Register of Indian Medicine have the right to practise Indian medicine. The Petitioner had neither acquired such a qualification nor passed the qualifying examination under the concerned State Act, and was therefore, not entitled to prescribe Ayurvedic medicine. This runs counter to the present practice (which is increasing of late) whereby modern medicine doctors prescribe Ayurvedic medicine once they are convinced by data based on clinical trials, the knowledge of which is imparted by medical representatives hired by drug manufacturers, exactly as is done by modern pharmaceutical companies. The Court cases and judgements have not set the controversy at rest because enforcement is weak and there is unsureness about Court judgements and intermittent executive orders. Occasionally, the associations of modern medicine doctors urge for action against those who resort to modern medical practice but this peters off. The numerical strength and clout of the non Allopathic AYUSH doctors is quite substantial and they have the sympathy of policy makers (political and bureaucratic). Different States have been taking different stands and also changing them from time to time, which leaves a big difference between the de facto and the de jure position. Maharashtra State seems to have taken the lead in trying to bring the subject into sharper focus something no other state has done until now.
State-wise Policies on Cross-pathy practice Maharashtra The State Government of Maharashtra has recently declared that the Maharashtra Medical Practitioners Act, 1961 will be amended to include that Ayurveda, Homeopathy and Unani practitioners would soon be able to legally prescribe allopathic medicines in Maharashtra provided they complete a one-year course in pharmacology. The government also plans to allow them to practise Allopathy after passing a one-year course. This decision by the Maharashtra Government has caused unrest among the Allopathic doctors in the State who argue that they spend five years acquiring an MBBS degree which enables them to practise and prescribe Allopathic medicine and it would not be right to allow Ayurvedic doctors to practise and prescribe Allopathic medicine after a mere one-year course. The Indian Medical Association (IMA) is planning to challenge the decision taken by the Maharashtra Government in the courts. It would be interesting to see how the court addresses this issue, especially after various decisions have been announced that reflect a view that a medical practitioner needs to be trained in a particular system of medicine in order to practice that system. The question that would need an answer is whether a oneyear course in pharmacology is sufficient to suggest that a person is trained in that medical system. The official version recounted to the PI by the Director Ayurveda of Maharashtra State Dr. K.R. Kohli, himself an Ayurvedic doctor is recapitulated below. The responses answer the itemized issues raised by the PI. Cross-Pathy Practice to be allowed after undergoing the related Pharmacology Courses. 1. What triggered the initiative In Maharashtra, Ayurvedic doctors registered
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in Schedule A, B & A-1 appended to the Maharashtra Medical Practitioners Act of 1961 have been declared as eligible to practise the modern system of medicine to the extent of the training they received in the system by a Notification dated 25th November 1992. Similarly, Unani Doctors registered under Schedule D of the Maharashtra Medical Practitioners Act of 1961 have been permitted to practise modern system of medicine to the extent of training they received in the system. There was a continuous demand from Homoeopathic doctors in the State to allow them the practice of modern system since last more than 20 years. Moreover several surveys have indicated a very poor doctor population ratio in Maharashtra which is approximately 1:1213 which is much lower than many other States. The fact remains that most of the rural population and slums in the cities and metros is being catered by primarily Homoeopathic and Ayurvedic doctors. Most of these doctors practising in rural areas as of today also practice modern system of medicine irrespective of the legal propriety of doing so. Many times such doctors have also been taken to the consumer courts. During almost every Assembly session, questions were being raised by the several MLAs and MLCs about not allowing Allopathic practice by doctors of the Indian Systems of Medicine -specially when adequate number of Allopathic doctors were on one hand not available and on the other most of them do not want to serve in the rural areas. It was during the last Monsoon Session (2012) that the Hon’ble Minister of Medical Education & Drugs announced that an Ordinance would be issued to allow Practitioners of other systems to practise the stream in which they undergo Certificate Course of Respective Pharmacology, which is planned to be
188 Status of Indian Medicine and Folk Healing
conducted by the Maharashtra University of Health Sciences. 2. Important milestones in Decision Making In the year 2009, the Government had set up a Committee under the chairmanship of Vaidya Kuldip Raj Kohli with representatives from Director Medical Education & Research, Maharashtra University of Health Sciences and a few prominent Homoeopathy Doctors. This committee studied various State and Central Acts, various judgements including the Mukhtiar Chand v/s State of Punjab of Supreme Court of India, Poonam Verma v/s Ashwin Patel of Supreme Court of India, the report submitted by the Committee headed by Director of Medical Education & Research Dr. Ganeriwal in 1997, the opinion given by the then Advocate General Shri C J Sawant in 1997, the opinion given by the then Advocate General Sh. Gulam Vahanvati in 2001 and the opinion of the National Law School given on the Poonam Verma Case referred by Department of AYUSH in 2006. This Committee recommended that the pharmacology of Modern Medicine should be taught to Homoeopathic doctors and then relevant changes may be made in the Bombay Homoeopathic Act, Indian Drug & Cosmetic Act and a notification be issued on similar grounds as was issued for Ayurvedic &Unani Doctors in the state of Maharashtra. Very recently also, an opinion was sought from Advocate General Shri Ravi Kadam who in his opinion dated Aug 25, 2010 stated that ‘Central Council pf Homoeopathy Act, 1973 protects the privileges provided by the State Acts.’ This provision enables the State Government to provide the privilege of using allopathic medicines to Homoeopathic doctors. He had suggested that to enable such doctors to practise Allopathy they need to have a Comprehensive training for Homoeopathic
doctors and the course be called “Certificate in Clinical pharmacology”. Now that several opinions had been sought, the Health Minister of Maharashtra replied on the floor of the House that a Certificate Course in Pharmacology of all disciplines of Medicines, i.e., Modern Medicine/Ayurved/ Homoeopathy/Unani would be started for doctors of other streams to allow cross pathy practice and that parallelly necessary amendments in the relevant State Acts would be made to facilitate the practice of the newly learnt subject. To work out the details of this scheme, a Committee has been setup to devise syllabus, duration of the courses, the fee structure and other related issues. The Committee is headed by Director Ayurved with Director Medical Education and the Vice Chancellor of Maharashtra University of Health Sciences as members besides a few members of the respective Councils. 3. The Expected Outcome, Risks & Benefits of the Initiative The outcome of this will be that doors will be open for all doctors of Modern Medicine/ Ayurved/Unani/Homoeopathy to learn other streams of medicine and this will create a mutual respect amongst all systems of medicine. But primarily, the goal would be to enable the population living in rural areas and the urban slums to have access to welltrained doctors which would reduce the risk of complications that could have arisen because of indiscriminate use of modern medicine without the doctor having knowledge of that discipline. The medical manpower available in the State has to be utilized optimally for achieving the targets of several national
programmes. The doctor population ratio will greatly improve as there are around 60000 Homoeopaths and 58000 Ayurvedic doctors in the State. Risks: Maharashtra Medical Council has already declared that they will oppose the move. Present Status: Maharashtra Government has sought legal opinion from the Law and Judicial Department of the State and also from the Advocate General. The matter was reported to be under active consideration (October 2012). Uttar Pradesh In Uttar Pradesh, the stated policy does not allow ISM practitioners to practise Allopathy. The case that is often relied upon is that of Mehboob Alam v State of Uttar Pradesh and Ors5, which was heard in the Allahabad High Court. In this case, a Unani practitioner was prescribing Allopathic medicines and it was held by the court that he was not eligible to do so as his qualifications did not match those which are listed in the First Schedule of Indian Medical Council Act and neither was he enrolled on the State Medical Register under the same Act. This case clearly stated that doctors holding a qualification in Indian Medicine and registered with the Indian Medicine Board cannot prescribe Allopathic drugs and registered doctors must confine themselves to the branch in which they were qualified. During 2012 in a legislative assembly meeting of Uttar Pradesh, the Parliamentary Affairs Minister Mohammad Azam Khan said “The government cannot allow Bachelor of Ayurvedic Medicine and Surgery (BAMS)
5. AIR 2001 ALL 371
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doctors to do the work of MBBS doctors and provide Allopathic treatment. It’s not possible. If such a thing is done, there will be no need for MBBS studies.” He was reported in media reports to have been replying to an adjournment notice given by some Congress members who asked the government to grant permission to BAMS doctors to provide Allopathic treatment like MBBS doctors.6 The National Integrated Medical Association of Uttar Pradesh, however, advocates the integration of modern scientific medicine and traditional medicine like Ayurveda, Siddha and Unani. Sh. Jagjit Singh, Secretary, Government of Uttar Pradesh had written a letter dated 24.2.2003 (Annexure-I) to all the Chief Medical Officers of UP by which Ayurvedic/ Unani Medical Practitioners registered with UP Indian Council Board had been authorised to prescribe Allopathic drugs. He had referred to Section 29 (1) and Section 29 (2) of the UP Indian Medicine Act, 1939 and had also directed all the CMOs restraining them from taking any coercive steps against Ayurvedic/Unani Doctors. It stated that the Supreme Court has directed prosecutions of unregistered doctors and not registered practitioners in Indian Medicine prescribing Allopathic medicines. But in view of Dr. Mehboob Alam v/s State of UP writ petition no. 5896 of 2000, the Allahabad Court said that this Government order dated 24.2.2003 has become nonest and must not be acted upon. In an order dated 6.7.2004 it stated that “Any inter-disciplinary transgression is prohibited.”(Annexure-II) Tamil Nadu The Siddha system of medicine originated in
Tamil Nadu and is almost entirely confined to that State. There have been several instances when the Madras High Court has addressed the issue of cross practice among practitioners. One of the important cases that the Madras High Court dealt with is that of Dr. Abdul Janeer v Jaleed Ahmed Siddiqui.7 In this case, the Madras High Court restrained ISM practitioners from practising the Allopathic system. Passing the order, Justice K K Sasidharan had held that the police could take action against those who practise the modern system without possessing the qualification. Following this order, the State police started a widespread crackdown on ISM practitioners for practising Allopathy. Perturbed by the police action, the Siddha practitioners and others are reported to have approached the High Court, and Justice FM Ibrahim ruled that the registered practitioners in Siddha, Ayurveda, Homoeopathy and Unani were eligible to practice surgery, obstetrics and gynaecology, anaesthesiology, ENT, ophthalmology, etc. and said penal action against such practitioners should be dropped immediately. After the order was announced, the State government wrote to the State police that institutionally qualified and registered practitioners of Ayurveda, Siddha and Unani could practise their respective systems with modern scientific medicines including surgery, gynaecology & obstetrics, anaesthesiology, ENT, ophthalmology, etc. based on their training and teaching in the course. This was based on Section 17 (3) B of the Indian Medicine Central Council Act, 1970. Later, the Tamil Nadu branch of the Indian Medical Association (IMA) appealed against
6. No permission to Ayurvedic doctors in UP to practice allopathy http://post.jagran.com/no-permission-toayurvedic -doctors-in-up-to-practise-allopathy-1340165346 7. AIR 2010 MAD 178
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the verdict before the High Court and the case is still pending with the court. Punjab Besides the Mukhtiar Chand case, in the Gurvinder Kaur8 case, the Punjab State Consumer Disputes Redressal Commission observed that a BAMS doctor cannot prescribe Allopathic drugs. It is said that BAMS doctors were not qualified to treat patients like Gurvinder Kaur and by doing so they had committed an act of grave negligence. Punjab follows the principle that a practitioner needs to be registered in a particular medical register of the State in order to practise that particular system of medicine. However, the Punjab Government announced that it would set up “five super speciality Ayurveda Centres, besides recruiting 200 Ayurvedic doctors, in its endeavour to promote the Ayurvedic system of medication and treatment”. This was announced at a function organized by the All-India Integrated Medical Association (AIIMA), in association with Punjab Ayurvedic Medical Services Association.9 Himachal Pradesh Reliance was placed on a circular issued by the Government of India, Ministry of Health and Family Welfare dated 1 September 2011 in which the practice of gynaecology and obstetrics and the use of diagnostics and ultrasonography had been clarified to all States and UTs. The letter states that those who had qualifications included in the second scheduled to the IMCC Act, 1970 were competent to pursue modern technological innovations for example radiology, ultrasonography,
ECG in their clinical practice on the basis of their teaching and training as notified by the CCIM on 6.1.2009. It was emphasized that this should not violate the provisions of the Prenatal Diagnostic Techniques (Prohibition of Sex Selection Act, 1994) and the Medical Termination of Pregnancy Act, 1971. (Annexure-III). This circular makes no mention of conducting hysterectomy operations or of delivering babies by C-Section which was apparently being taught and performed at the RGGPG Ayurvedic College, Paprola in Himachal Pradesh. On a practical note it must be recognized that the hospital is located in hilly terrain and once people bring patients, there is no nearby place where they can be asked to go especially at night. Medical interventions were, therefore, being carried out within the competence of the treating doctor which included performing operations. The State authorities were aware of this which amounts to giving tacit approval although not stated specifically in a Government order. The PI was separately provided with a circular dated 26th of September 1980 issued by the Government of Himachal Pradesh according to which the Vaids and Hakims could use modern medicine drugs. It stated that all the Vaids and Hakims registered under Himachal Pradesh Ayurvedic and Unani Practitioners Act, 1968 can prescribe modern medicine drugs in Himachal Pradesh for the purpose of Drugs and Cosmetics Act (Annexure-IV). It was stated during discussions that this notification had never been rescinded or modified. There was also a claim that the government was supplying a few essential modern medicine drugs to the Ayurvedic dispensaries as a
8. (2008) 2 PLR 791 9. http://www.tribuneindia.com/2010/20100920/region.htm
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matter of course but this was not corroborated by others. The position was therefore far from clear at the operational level. No one was in a position to clarify the position with finality. Jammu and Kashmir The Jammu & Kashmir State reported that instructions had been issued from time to time instructing the AYUSH Medical Officers “to stick to their own pathy and no cross practice is allowed” (Annexure-V). No guidelines have been issued related to operating practices by the doctors appointed under the NRHM, nor any instructions given on what was expected by way of performance by such doctors. Likewise no guidelines had been issued relating to the combined use of Ayurveda/ Unani/Allopathic treatment on a patient. The Director ISM of J&K reported that a proposal to notify the use of essential Allopathic medicines by the AYUSH doctors was, however, under active consideration of the Health Department and had been submitted by the Directorate of Indian Systems of Medicine (Annexure-VI). However, at present no life saving Allopathic drugs are being supplied to the Ayurvedic dispensaries. On the subject of responsibilities to be fulfilled by Ayurvedic/Unani doctors functioning as single In-charges posted in the CHCs & PHCs no specific instructions were shown to the PI. However, these doctors were conducting deliveries/ postpartum and attending to emergencies at some PHCs. They were also being put on night duty/ emergency roster duty regularly particularly where modern medicine doctors were not available. Need to confront the Legal Dilemma Most State Governments declare a commitment to the development of the Indian
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systems of medicine which, apart from being an effort to preserve cultural heritage, also provides an alternative system of medical care in addition to the Allopathic system. However the dominance of the Allopathic system is all pervasive seen in the national context. The AYUSH systems tend to imitate the dominant system in structure and management. Ayurvedic manufacturers also tend to imitate the Allopathic presentation of treatment by using modern packaging and labelling which make them acceptable to the modern medicine doctors as well as to educated patients who opt for self-medication. The old practice of holistic treatment has been overtaken by “Contemporary Ayurveda”. Over the last 80 years, the Himalaya Drug Company (HDC) has focused on contemporarizing Ayurveda. The company had opted for 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”. Allopathic doctors routinely prescribe Ayurvedic drugs for liver related diseases and some other conditions. The question that arises is whether Allopathic doctors practising the modern system of medicines are entitled to prescribe drugs which might have originated in Ayurveda? The pre-clinical and clinical trials for new Ayurvedic drug formulations have been prescribed by the Department of AYUSH with the intention of providing appropriate evaluation methods for new formulations based on traditional systems of medicine. The problem with conducting clinical trials is that a large amount of capital is required which only major drug manufacturers can afford. Most Ayurvedic doctors feel clinical trials will probably kill the industry and circumscribe the practice of traditional medicine. The dilemmas that confront the sector are immense. The
Department of AYUSH should consider putting out an official approach on its website as even officers working in the department refer to a variety of interpretations but these are mostly self-referential. Conclusions and Recommendations The legal position of ASU practitioners practicing modern medicine needs to be confronted because it is evident that Ayurvedic doctors are maintaining the health facilities as the sole in-charges of PHCs and CHCs. They are not only prescribing Allopathic medicine but are expected to handle all the situations that arise in a health setting. The use of modern interventions and drugs including injectibles and parenterals has not been addressed upfront. If that is permitted and encouraged then the States have to use the provisions of the D&C Act to make appropriate notifications to support the practice which cannot then be confined solely to Government appointees. It would have to apply to all ISM/ AYUSH doctors that have graduated after a five-anda-half year degree course. The most balanced approach would be to allow ASU doctors to
practise modern medicine to the extent that is needed at the primary health centre level, while accepting that would need to include immediate response to emergencies, acute illnesses and routine illnesses. But they require to be trained thoroughly to handle such situations both in the public and private sector facilities. As far as private practitioners are concerned, the State should notify that ASU doctors using modern medicine need to avail of a training which equips them to handle certain non-invasive/non-surgical medical needs. Medical Colleges and hospitals may be given accreditation for conducting training and for levying a charge on each private doctor. The colleges should provide training free of cost to Government doctors. A certificate of having acquired this training to provide limited medical care to patients should be issued by a State Board and the display of the certificate made mandatory. Side by side, a list of interventions and drugs that must not be used by ASU practitioners should be listed to remove all ambiguity on the matter.
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Annexure-I
Letter of Secretary, UP to all the CMOs regarding harassment faced by the ISM practitioners in the State
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Annexure-II Court order on the issue of Inter-disciplinary Cross-practice in UP
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Annexure-III Ministry of Health & Family Welfareâ&#x20AC;&#x2122;s notification regarding practice of Gynaecology & Obstetrics and Diagnostic Ultrasonography by ISM Graduates
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Annexure-IV Himachal Governmentâ&#x20AC;&#x2122;s circular allowing ISM practitioners to use modern medicine
198â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
Annexure-V Directorate of ISM, J&K Circular regarding “Prescription of Allopathic Medicine by AYUSH Doctors”
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Annexure-VI Proposal of J&K Department of ISM to notify the use of essential allopathic medicine by AYUSH doctors
200â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
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7 Guru-Shishya Parampara
Guru-Shishya Parampara A Critique of the Rashtriya Ayurveda Vidyapeeth, New Delhi (National Academy of Ayurveda) Introduction
205
Survey on Perceptions of Gurus and Shishyas
207
Conclusions and Recommendations
211
Annexures Annexure-IA: Recommendations of the Review Committee of 213 Department of ISM, Government of India which had reviewed the performance of RAV Annexure-IB: Recommendations of the International Management Institute, New Delhi on the future growth options for Rashtriya Ayurveda Vidyapeetha (RAV), New Delhi
215
Annexure-II: Details of Gurus and Shishyas associated with RAV since the time of inception
217
Annexure-III: Covering letter of the PI with Questionnaire issued to MRAV/CRAV alumni/Shishyas
218
Annexure-IV: List of Gurus and Shishyas who responded/did not respond
220
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7 Guru-Shishya Parampara A Critique of the Rashtriya Ayurveda Vidyapeeth, New Delhi (National Academy of Ayurveda) Introduction Rashtriya Ayurveda Vidyapeeth (RAV) was established in 1988 with the broad objective of promoting knowledge about Ayurveda. The allied goals included a focus on continuing education, raising the standards of Ayurveda education by introducing new methods of teaching and to provide a platform for recognizing talent and merit among scholars. The Vidyapeeth started a unique course which was a revival of the Gurukula system of informal education of India i.e., Guru Shishya Parampara. All the classical texts of Ayurveda viz., Charaka Samhita, Sushruta Samhita, Ashtanga Hridaya which were the result of such informal education. This approach is absent from the teaching imparted in the modern educational institutions where courses are naturally circumscribed by the curriculum and syllabus. The basic idea behind the RAV courses was therefore to provide an in-depth knowledge to young scholars who were already proficient in the Ayurveda texts so that the tradition of Ayurvedic education and skill
learning continues. Basis for the Selection of Gurus and shishyas Initially the identification and recommendation of Gurus for both the courses CRAV1 and MRAV2 was being done by a Search Committee comprising of experts nominated by the Governing Body or the President of the Governing Body of RAV. In the last 12 years besides conducting a search through the Committee, the CVs received by the institute have also been considered. The Gurus are finally selected after ensuring that training facilities are available where they work. During the last four years advertisements have been issued on an all India basis inviting applications from eligible Vaidyas. The Committee scrutinizes the bio-data of the Vaidyas and scholars and selects the Guru. The selection is made after physical verification of the clinic/hospital and the patient load and facilities available. Initially for 2-3 years the Gurus used to select their students but from 2002 the selection of Shisyas is also made on all India basis by inviting application from registered Ayurvedic practitioners. The
1. Chikitsak Guru Shishya Parampara - One-year/Six monthâ&#x20AC;&#x2122;s course of Certificate of Rashtriya Ayurveda Vidyapeeth (CRAV) includes Learning of Ayurvedic Clinical Practices. 2. Acharya Guru Shishya Parampara - One-year Course of Member of Rashtriya Ayurveda Vidyapeeth (MRAV) includes Learning of Texts of Ayurveda.
Guru-Shishya Paramparaâ&#x20AC;&#x192; 205
selection of Shishyas is based on merit and they are allocated to Gurus on the basis of the position in the entrance test and speciality selected. Evaluation method adopted by RAV The Shihsyas are expected to prepare patient case sheets on a daily basis and submit the same to RAV as a monthly record, followed by a quarterly follow-up report on the patients. Internal assessment tests are conducted by the Gurus and these are sent to the RAV for scrutiny. Each student has to submit a ‘Monograph’ on a particular disease/disorder, and the history of cases he treated during the training period. Students are allowed to appear in the final examination only on submission of all documents. The monograph as well as performance in the examination are assessed by a Board of Examiners appointed by the Governing Body. Viva-voce is also conducted by the Board in which students are judged on the basis of their performance in the written exam as well as assignments submitted. Duration of the membership of the Governing Body (GB) of RAV and names of the members The tenure of the Governing Body and Standing Finance Committee is for 5 years. The tenure of last Governing Body expired on 19th January, 2011 and a new Body is yet to be reconstituted by Department of AYUSH. The tenure of the SFC is co-terminus with that of GB. However, the Department takes necessary decisions on finance and policy matters, as and when required, in the absence of a Governing Body meeting. A list of Governing Body members for the last term can be viewed at http://ravdelhi.nic.in/ index1.asp?linkid=348&langid=1
206 Status of Indian Medicine and Folk Healing
External evaluation of the functioning of RAV The performance of the RAV has been evaluated twice by two separate Committees. A Committee appointed by the Department of AYUSH had conducted review in 2001 and another was done by an independent agency, International Management Institute (IMI), New Delhi in 2011. The outcomes in the form of recommendations enclosed at Annexure-IA & B. Details of Gurus and Shishyas since inception The chronological lists given at Annexure-II. Scientific papers published by RAV – Standards prescribed Every year RAV holds a national seminar, on a health problem, research outcomes and the experiences of Vaidyas intended to keep Ayurvedic practitioners updated. The papers which are received are scrutinized and selected by a Committee usually consisting of a member of Governing Body, a technical officer of the department and two experts from the Ayurveda Research Council. The Committee examines the papers and selects them (about 50) for publication. When the papers are placed before the selection Committee, the names of the authors are removed to generate unbiased assessments. Out of the papers selected, a few (20-22) cover the experiences of vaidyas which are presented at a two-day Seminar. List of Seminars and workshops held so far are available at: http://ravdelhi.nic.in/ index1.asp?linkid=350&langid=1 Benchmarks for Continuing Medical Education (CME) programmes RAV is the Nodal Office to monitor and implement a scheme run by the Department of AYUSH whereby grants are released
to selected AYUSH institutions for running CME programs. The selection of institutions is done by the Department of AYUSH, where after the grantee institutions conduct separate CMEs for teachers, doctors, paramedics, heads of institutions according to the prescribed guidelines. Details of CMEs organized during the 11th Plan period are available at http://ravdelhi.nic.in/index1. asp?linkid=347&langid=1 Survey on Perceptions of Gurus & Shishyas The Principal Investigator sought detailed information about the achievements of the Institute in different areas. A questionnaire was issued with instructions that the respondents (both Gurus & Shikshyas) send their responses directly to the PI. Methodology: Two different questionnaires were evolved by the PI and sent to all the Gurus nominated for MRAV, CRAV courses as well as Shishyas who had completed the courses. The questionnaires focused on the utility of the courses and suggestions, if any, for the improvement in future. The questionnaires are at Annexure-III. The questionnaires were sent to 36 Gurus and 94 Shishyas. In response, 31 Gurus and 42 Shishyas sent their responses (Annexure-IV). Response received from the Gurus On being asked to give reasons for agreeing to be a Guru, maximum percentage said they agreed so as to pass on experiences to the next generation. Other reasons mentioned were propagation of Ayurveda; their interest in teaching and because they were proud to be a part of RAV’s Guru-Shishya tradition; remaining said they agreed to be a Guru on the request of the institution. As for the benefits of training under Guru - Shishya
training program in addition to the regular course, maximum percentage opined that practical training was the main benefit of the programme. Some felt that the students get an opportunity to discuss ideas with Senior Physicians which is the best way to transfer advanced knowledge to students. Other reasons included:- inadequate exposure given in most Ayurvedic Colleges; Self-confidence of Shishya increases; Students get individual attention and learn skills needed for private practice. The remaining respondents opined that it led to in-depth understanding of the basic concepts of Ayurveda. When asked about the relevance of Guru-Shishya type of training in today’s context, maximum percentage of respondents expressed that it was relevant to have a practical understanding of the subject. Other points were that such training increased the Shishya’s confidence in Ayurvedic practice because superficial knowledge is given in regular colleges; the transfer of personal experience from seniors to juniors in a “1 to 1” situation is the best way to study; the lack of good full-time teachers in most colleges were the other reasons given. That the training helped overcome difficulties in managing “new” ailments was also response. There was a feeling that such training allowed young students to remain free from stereotyped examination pressure permitting free discussions with the teachers which added to knowledge and understanding. Maximum respondents expressed satisfaction with the existing RAV system. Regarding students performance after the course, most of the Gurus said that their Shishyas started their own clinic and had begun diagnosing patients on the basis of Ayurveda; the remaining students got selected in MD and still others were engaged in teaching or as physicians in Ayurveda hospitals.
Guru-Shishya Parampara 207
Main findings of the Survey on the perceptions of Gurus
208â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
Responses received from the Shishyas On being asked to give reasons for joining the course, maximum respondents expressed the reason for joining course as “out of interest in Ayurvedic chikitsa karma”, and other reasons expressed were “to know the subject in depth”, “to gain higher qualification” and the least was “to do research work”. Most of the respondents were aware of the course through the Newspaper advertisement, and the remaining said they came to know through friends, seniors, teachers, the website and ex-students. The lowest number came to know through the college. Reasons expressed for selecting a particular Guru in order of decreasing priority were “Guru being renowned in his field” ; “due to interest in the subject” ; “Guru being nearest to my place” ; “By chance got selected under the Guru” and “ Guru’s Institute is having good exposure to patients” . Many expressed their expectation before joining the course as “To gain clinical
exposure”; others said “To be well-acquainted with the subject”; and some others as “to increase professional skills.” Some also said it was to get an added qualification, stipend or to do research work or to obtain a certificate which would be helpful for joining Government service. The maximum number of respondents said their reasons for joining the course as well as for working with the selected Guru had been fulfilled and agreed that the course improved their knowledge. All of them are apparentlyemployed by the Government or are in private practice or pursuing post graduation. Many respondents suggested that the certificate should be recognized and preference should be given in gaining entry to MD or the PSC exams; also that there should be a common syllabus for each subject. Some felt that the duration of the course should be increased. Research work should also be done as a part of the training and the stipend should be increased.
Main Findings of the survey on the perceptions of the Shishyas
Guru-Shishya Parampara 209
Summary of Suggestions given by the Shishyas
210â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
Conclusion and Recommendations It would appear from the responses received and the PIâ&#x20AC;&#x2122;s conversations with a crosssection of knowledgeable people working in the Ayurveda Sector that RAV is doing commendable work. However, the suggestions made by certain Committees (Reports annexed) do not appear to have been acted upon. The suggestion that a Diplomate of a National Board of Ayurveda may be instituted should have been taken forward. The other option of seeking affiliation with different Universities also has not received much attention. The alternative goal suggested was to aim for deemed university status, which too was abandoned. The PI sought the reasons and she found the goals to be achievable if proper guidance was given. Mainly there are two reasons for little followup: RAV does not have the exposure or experience that is required to understand the concept of running DNB type of training programs. Whatever efforts were made were being planned on the basis of the experience of the allopathic health sector. Because that itself got into a controversy, a good model seems to have been abandoned by RAV. The advantage of introducing DNB would be that students pass a rigourous examination to get placement into higher-level hospitals and facilities which are doing continuous work with patients. That exposure had been equated with undergoing regular postgraduate education because ultimately an examination has to be passed. The concept is good and needs to be revived regardless of the controversy that continues on the side of allopathy. The second architectural issue is that the President of the Governing Body is usually a non-institutionally qualified vaidya who is held in high regard. However such a person would have competence to provide
a direction to the Guru-Shishya strategy that RAV has been promoting but may not be able to give a direction to opening channels with universities and hospitals. The advantage of RAV trying to upgrade its status in the field of education already forms a part of the recommendations of earlier committees. But for those recommendations to become a reality, it requires a different level of exposure and orientation to mould the concepts to suit prevailing conditions. If this institution is to grow, a person who is conversant with the higher education sector and preferably one who has served as a Vice Chancellor or a similar position is needed to provide leadership for such new areas. RAV can also be made the functional body to regulate and accredit paramedical education (Diploma of two years) in Ayurvedic Pharmacy, Ayurveda Nursing, Panchakarma technicianâ&#x20AC;&#x2122;s practical training as well as Ayurveda Education for modern medicine doctors. This is the right time to think about the regulation of para medical education in AYUSH systems on an all India basis. RAV can enter into MoUs with state colleges and state pharmacies to impart education while acting as a Board to give certification until regular Councils for standard setting are established under law. In addition to ongoing work, the Governing Body could authorize the aims and objectives of RAV to be expanded to provide practical knowledge about Ayurveda to visiting students from any discipline. The Institute could then arrange lecture/ tours to different places where Ayurveda is popular. A number of Universities abroad are looking for summer visits for their undergraduates which give them an exposure to other countries and their approaches to service delivery. This would be a good way of marketing Ayurveda. A number of second generation children of NRIs have an interest in different aspects of
Guru-Shishya Paramparaâ&#x20AC;&#x192; 211
Indian culture and the practice of Ayurveda is one of the most interesting- particularly when a range of approaches are presented accompanied by explanations. It would give NRI parents great confidence if the tours are managed by a reputable Government Institute and the students are shown something specific (AUS practice) as well as general (Culture) of India. In each city where a study tour is planned RAV would find former shishyas who could attend to local liaison and co-ordination issues with the State Culture and Tourism departments and the travel agency. The Institute should work with a good travel agency to draw up a plan which gives students an exposure to how Ayurveda and other systems are being managed in different places in India. The Institute could identify around 10 places which represent a crosssection of good work being done e.g. the Gujarat Ayurvedic University, AVS Kottakal, the Choudhary Brahm Prakash Hospital at Kheda Dabur, the State Siddha Medical College and the TAMCOL manufacturing facility, the Himalaya Drug Company’s research facility, one or two good units of CCRAS which could form part of the exposure-cum-lecture series. If the concept is approved by RAV's Governing Body, the Institute should give its credentials on a website and offer to run exposure visits in coordination with the state tourism corporations which can take care of board and lodging and the logistics of travel. In this way, RAV need not burden itself with logistics. This suggestion is being made as it would give primacy to the Indian systems of medicine and would satisfy the needs of a niche clientele which has the means to pay for such study
212 Status of Indian Medicine and Folk Healing
tours. It would however give recognition to India’s special strengths. A full-time officer should be engaged on contractual basis to exclusively manage this work under the Director RAV. A steering committee should be set up to oversee the programme and other details so that all questions are anticipated and responded to on the website. The Science Counsellor in the Indian Embassy in the US to start with and other missions abroad in due course should be requested through the Embassies to identify institutions and colleges which would like to avail of such exposure tours. Since such an initiative would only function during the summer break no more than two batches need to be covered over two months each year. The objective would be to engage groups of students of Indian origin to understand how widespread the use of Indian medicine is and also see something of the country. It is too niche an area to attract general tourists except as an add on option. But it would be of interest to students of Indian origin and would be encouraged by the University/ college who would get funded for this activity. A part of the funding would naturally come to RAV to defray the costs. The budgeting would have to be done so that all aspects of travel, transportation as well as board and lodging are factored in. RAV should not be bound to run the study tour unless the threshold of applicants is sufficient enough to justify the organizational work. In due course if RAV builds up experience it would be able to develop a range of packages for different kinds of visitors interested in Ayurveda. The bottom line is that RAV needs to reinvent itself while continuing with its core activities.
Annexure-IA Recommendations of the Review Committee of Department of ISM, Government of India which had reviewed the performance of RAV. (vide an order Ref. No. V.26012/2/99 – N.I.Desk, dated 16-5-2000 and extended its terms up to 6-1-2001 by another order of even number, dated 9-10-2000) The committee after careful scrutiny and evaluation of work done in RAV recommended the following also: •
The Vaidyas possessing special treatment skills like Agnikarma, Raktamokshana, Kshara Sutra, Panchakarma, bone setting, Marma Chikitsa, Dentistry, Visha Chikitsa etc. are to be preferred for appointment as Chikitsak Gurus, to preserve such procedures prevalent in India which are vanishing gradually.
•
Teacher and student both are expected to devote their maximum time (at least 8 hours per day) in achieving the goals and to produce concrete results. The philosophy behind this is to preserve the knowledge possessed by traditional and eminent Vaidyas which was earlier vanishing out with the Guru because of lack of transfer to the new generation and to prepare the scholars having eminent knowledge of texts of Ayurveda, so that they can become good teachers.
•
The committee feels that while selecting Shishyas preference may be given to teachers for MRAV course and physicians working in dispensaries and hospitals for CRAV course on leave/deputation basis.
•
The committee advised that the topics of all theses may be circulated to all P.G. Colleges and Institutions for their information and utilization. The material available may also be scrutinized for publication.
•
The committee recommends that persons possessing MRAV or CRAV qualification after undergoing training for two years and one year respectively under the tutelage of Gurus should be given preference/weightage for academic posts especially in promotion to the posts of Reader or Professor or in recruitment to the post of Lecturer, so that the knowledge gained by them can be disseminated to other students of Ayurveda.
•
In order to establish linkage and coordination with the premier institutions of Ayurveda, representatives of faculty of Ayurveda, I.M.S., B.H.U., Varanasi, National Institute of Ayurveda, Jaipur and Director, CCRAS may also be nominated on the Governing Body of the Vidyapeeth as ex-officio members.
•
Keeping in view the aspirations of a large number of Ayurvedic graduates and to meet the requirement of specialists in teaching and research institutions, the Committee recommend that the Vidyapeeth may start Diploma of National Board in Ayurveda (DNB (Ay.) courses in clinical subjects like Kayachikitsa, Shalya, Shalakya, Prasuti Tantra and Bala Roga on the pattern of DNB courses run by National Board of Examinations. A selected number of hospitals in Ayurveda may be accredited by the RAV, where the students can take clinical training to pass DNB courses in Ayurveda. A separate committee may be constituted by the
Guru-Shishya Parampara 213
Government to prepare comprehensive proposal/project report on rules and regulations, syllabus etc. for the DNB (Ay.) course. •
It has been seen that most of the products of RAV i.e. MRAV and CRAV passed Vaidyas gained specialized knowledge but their services are not fruitfully utilized for advancement of Ayurveda. The Committee, therefore, recommends that the MRAV holders have been doing literary work on a particular Samhita/Commentary; hence the MRAV course may be recognized as equivalent to M.Phil. Degree (in Ayurveda).
•
The CRAV holders appear to have gained good clinical knowledge under the tutelage of eminent Vaidyas so the course of CRAV may be recognized as Post Graduate Diploma in Ayurvedic Clinical Practices.
•
Vidyapeeth has been functioning under Plan Scheme of the Department of Indian Systems of Medicine and Homeopathy for about a decade. The growth of the Vidyapeeth in terms of staff is limited though sizeable work has been done under the scheme. The status of the Vidyapeeth needs to be strengthened and established permanently in terms of its standing for a long period in furtherance of Ayurvedic education and health management. Hence, the Committee recommends that required portion of the Grant-in-aid under Plan may be transferred to Non-Plan grant to Vidyapeeth.
214 Status of Indian Medicine and Folk Healing
Annexure-IB Recommendations of the International Management Institute, New Delhi on the future growth options for Rashtriya Ayurveda Vidyapeetha (RAV), New Delhi (2010-11) The key recommendations of Consultancy work are: 1.
RAV needs to immediately upgrade its current manpower and infrastructure keeping in mind the constant pressure on the existing employees and the proposed growth targets.
2.
The demand for recognition of RAV programs by a University or other relevant statutory Body is legitimate.
3.
RAV is doing useful work for the revival of traditional system of Ayurveda to enter into era of medicinal pluralism and integrated preventive health care as envisaged in the policy statement of WHO. It has been estimated by WHO that “ by 2010 more than two-thirds of the world would have tried some form of alternative medicine. Four in five developing nations already rely on traditional system of health care” (Mint. Sep. 29, 2010). If the system is not revived with full vigour, it will languish and so will its practitioners and researchers.
4.
The Secretary, AYUSH has suggested that there is need for scaling up of activity of training being conducted now along with new activities like training of teachers. Doctors, paramedical staff etc. on the lines of National Institute for Health and Family Welfare (NIHFW). RAV should put serious efforts in reviving its MRAV (2years) course. To facilitate such large scale training, RAV should have its own campus, buildings and infrastructure with necessary divisions and man-power so that it can be upgraded as a National Institute of Training in Ayurveda.
5.
We have given our recommendations regarding setting up of a campus of RAV. Effort should be made to acquire a plot measuring 5 acres or less through allotment or purchase from DDA. A competent architect should prepare the campus plan that could finally fit into the requirement of Deemed University. The Campus buildings with good landscaping should be eco-friendly and the various divisions/faculties/departments as recommended in this report should be established with a provision for further expansion. The campus should be conceptualized as an interdisciplinary, or a multiversity educational venture. DPR (detailed project report) for this purpose should be prepared along with implementation of other recommendations.
6.
In order to ensure proper training at national level and ensuring its effectiveness, there is a need to establish regional centers. There can be 4-5 regional centers, each manned with a technical officer and one administrative staff to oversee the functioning of training centers in the region.
7.
As a long term solution RAV should aim at acquiring a Deemed University status under De novo category. We have dealt with the subject of University status of RAV in details and it is possible by the end of 12th plan, provided the campus building gets ready in a year’s time.
Guru-Shishya Parampara 215
8.
Pending the grant of Deemed University status, RAV can affiliate its programs either with a State Ayurvedic University or Guru Gobind Singh Indraprastha University, Delhi, a State University or with Indira Gandhi National Open University (IGNOU)-a Central University. Affiliation of IGNOU would be more appropriate because the IGNOU procedures for affiliation are not time consuming.
9.
RAV should also explore the possibility of upgrading itself to acquire a status like National Board of Examinations (NBE), to seek equivalence of its Diploma with DNB. RAV may start courses as equivalent to those of National Board of Examinations for postgraduate training in recognized Ayurveda hospitals with same duration of training and methods of evaluation. It is possible to have this in place provided conditions as mentioned in the report are fulfilled. Ayurvedic hospital can be roped in to help RAV to move in this direction.
10. CCIM may be approached for due recognition for its courses. Simultaneously the Department of AYUSH may send letter to all States governments and other recruitment agencies for considering the courses of RAV under desirable qualifications for appointment to teachers, medical officers or other personnel. As far as recognition by CCIM is concerned, it is a must, before or after affiliation with a University. 11. In due course of time RAV should strive for Deemed university status with various departments of AYUSH and allied sciences for carrying out all kinds of training courses besides inter-disciplinary research.
216â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
Annexure –II Details of Gurus and Shishyas associated with RAV since the time of inception
Year
MRAV Course No. of Gurus
CRAV Course
No. of Shishyas
No. of Gurus
No. of Shishyas
1994 - 95
8
8
-
-
1995 – 96
4
6
-
-
1996 – 97
4
5
-
-
1997 – 98
5
6
-
-
1998 – 99
5
12
-
-
1999 – 2000
9
9
8
15
2000 – 01
4
5
7
11
2001 – 02
5
7
5
21
2002 – 03
1
1
6
18
2003 – 04
1
2
6
18
2004 - 05
2
4
4
4
2005 – 06
2
5
12
25
2006 - 07
1
1
11
31
2007 – 08
-
-
13
24
2008 – 09
-
-
16
19
2009 – 10
-
-
16
23
2010 – 11
-
-
76
228
2011 - 12
-
-
24
31
51
71
204
468
Total
Guru-Shishya Parampara 217
Annexure - III Covering letter of the PI with Questionnaire issued to MRAV/CRAV alumni/Shishyas RAV Questionnaire Preamble Project: Status of Indian Medicine & Folk healing with a focus on the benefits the systems have given the public. The Department of AYUSH, Ministry of Health and Family Welfare, has supported the above project titled “The Status of Indian Medicine & Folk healing in India” with a focus on the benefits the systems have given the public to be undertaken by Smt. Shailaja Chandra (IAS Retd.,) former Secretary (1999-2002) in the Department of AYUSH, GOI and former Chief Secretary Government of NCT of Delhi. The project is being executed in collaboration with and with the support of the Research Councils of AYUSH namely CCRAS and CCRUM. As the Project Investigator (PI) Smt Chandra has already given Part I of the Report to the Government and is now pursuing work on Part II. The PI is required to give a comprehensive report on the current status of the Indian systems (in this case Ayurveda) with special reference to whether the developmental efforts are translating into improved public benefit. The Rashtriya Ayurved Vidyapeeth (RAV)is one of the institutions engaged in improving the competencies and skills of the practitioners in the Guru-Shishya parampara. The enclosed questionnaires seek to find out your views on the experiences gained at RAV. This questionnaire is being sent through the Director of RAV but it is requested that responses may be sent by name directly to the PI at the address given below. The responses will be tabulated but no names would be revealed in the Report or otherwise. However the number of Gurus and Shishyas who were contacted and who did/did not respond will be given in the Report. Kindly have the questionnaire as applicable filled up and sent so as to reach the PI no later than 31st July 2012. (Shailaja Chandra) Principal Investigator, Room 502, CCRUM, Central Council of Research in Unani Medicine, 61-65 Institutional Area, Opposite D Block, Janakpuri. New Delhi 110058
218 Status of Indian Medicine and Folk Healing
Questionnaire for MRAV/CRAV alumni/Shishyas 1.
Name:
2.
Qualifications:
3.
Have you completed your course? If yes, when?
4.
The name of your Guru and the subject of MRAV/CRAV:
5.
Reasons for joining the MRAV/CRAV course:
6.
How did you come to know about the course?
7.
Reasons for selecting a particular Guru:
8.
What had you expected before joining the course?
9.
Whether the reasons for joining the course were fulfilled? i)
Joining the course
ii) Working under the selected Guru 10. If expectations were not fulfilled, the reasons therefor: 11. If you were satisfied with the course what you learnt from the Guru, the reasons therefor: 12. Whether the course improved your knowledge of course you had completed or are still pursuing ? 13. Explain in a few words, what the impact of the course had on the patient can/education or research aspects of the work you do. 14. Are you doing any job/practice now ? If so has the course helped/is helping. 15. Your suggestions to improve the course: Address with contact numbers & e-mail:
Signature
Questionnaire for RAV Gurus (Past/Present): 1.
Name
2.
Qualifications, year of passing, Institution/University
3.
How long have you been a Guru under the RAV Programme
4.
Reasons for agreeing to be a Guru
5.
Benefits training under the guru-shishya program in addition to the regular course.
6.
Relevance of guru-shishya type of training in the to days context.
7.
Are you satisfied with the existing system of CRAV training or MRAV
8.
Have you assessed the impact of your training on patient care through your students?
9.
After the course, how are your students are performing? Give examples please.
10. Your suggestions for improving the course 11. Any other comments. Address with contact numbers & e-mail:
Signature
Guru-Shishya Paramparaâ&#x20AC;&#x192; 219
Annexure-IV List of Gurus and Shishyas who responded/did not respond List of Gurus who responded
30. Vd. Ved Vrat Sharma
1.
Vaidya Suresh Chaturvedi
31. Prof. C. P. Shukla
2.
Dr. Premwati Tewari
List of Gurus who did not respond
3.
Vd. Jagdish Prasad Sharma
4.
Dr. N.P. Parameswaran Namboothiri
5.
Vd. Mahesh Dutt Sharma Shastri
6.
Dr. P. Madhavankutty Varier
7.
Prof. Ram Harsh Singh
8.
Dr. Ganjam Krishna Prasad
9.
Vd. Devendra Kumar Shah
10. Dr. Sudhakar M.Sathye
1.
Dr. Surya Prakash Sharma received after last date)
2.
Vd. Dayaram Awasthi (Reply received after last date)
3.
Vd. Maa Anantanand Tirth
4.
Dr. S.K. Dixit
5.
Dr. C. Suresh Kumar
6.
Acharya H.S.Kasture
11. Dr. Mukul Patel
List of Shishyas who responded
12. Vaidya Ashwani Kumar Sharma
1.
Dr. Nishan Deep Singh
13. Vaidya B.P. Gupta
2.
Dr.Sarvpreet Singh
14. Vd. Ravindra Vatsyayan
3.
Dr. Hetal Karkar d.
15. Dr. S.K. Balian
4.
Dr. Lalit Nagar
16. Dr. Surya Prakash Sharma
5.
Dr. Naveen Mahajan
17. Vaidya Rameshwarlal Sharma
6.
Dr. Ashwin Kumar K.G.
18. Dr. Raghuraj Chaturvedi
7.
Dr. Preeti Pahwa
19. Dr. K.V.S. Rao
8.
Dr. Nutan Deelip Chopda
20. Dr. Madhusudan Deshpande
9.
Dr. Kranti Kambhampati
21. Dr. A. V. Aravindakshan
10. Vd. Kshama Gupta
22. Dr. M.V.Vijayakumaran
11. Dr. Dinesh L. Borad
23. Dr. K. Chidambaram
12. Dr. Umesh Bajirao Kale
24. Dr. L. Sucharitha
13. Dr. Swapan Das
25. Dr. G. Purushothamacharyulu
14. Dr. Sujitha S.
26. Dr.Narendra Narayandas Gujarathi
15. Dr. Mamta Jain
27. Dr. Satya Prakash Gupta
16. Dr. Arjun P. S.
28. Dr. Dhanraj V. Gahukar
17. Dr. Vanita Thakur
29. Dr. Raman Singh
18. Vd. Himanshu Jitubhai Joshi
220â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
(Reply
19. Dr. Bhavana Ramesh Bhosale
5.
Dr. Vaishali Bhardwaj
20. Dr. Gaurav Verma
6.
Dr. Uday Narayan Singh
21. Dr. Majida Hyder Ali
7.
Dr. N. Raja Shekhar
22. Dr. Priyada K.
8.
Dr. Teneti Sambasiva Rao
23. Dr. Raghvendra Singh
9.
Dr. Kumud Tiwari
24. Dr. Shubhada I. Hegde
10. Dr. Seema Saxena
25. Dr. Mani Bhushan Kumar
11. Dr. Anita Khetabhai Patel
26. Dr. Naveen Kumar Chauhan
12. Dr. Nalawade Pallavi
27. Dr. Sunil Jagadishbhai Suthar
13. Dr. Mayank Umakant Shah
28. Dr. Abhishek Kumar Ojha
14. Dr. Amit Kumar
29. Dr. Chandra Prakash Verma
15. Dr. Jasir Ahammed. N.
30. Dr. Ajay Kumar Singh
16. Dr. Roy S. Devi
31. Dr. Jaiprakash Bholanath Ram
17. Dr. Sumi Jain
32. Dr. Vishnu Harit
18. Dr. Lipika Kulshrestha
33. Dr. Mohan Lal
19. Dr. Mahesh Kumar
34. Dr. N. Venugopal
20. Vd. Angel K. Vachhani
35. Dr. Achyut Kumar Tripathi
21. Vd. Prakruti Y. Vyas
36. Dr. Narendra Prasad Hota
22. Dr. R. Soumya
37. Dr. Shaliesh Nath Saxena
23. Dr. Bharti
38. Dr. Rangnath Mishra
24. Dr. Shruti
39. Dr. Chandrika S. V.
25. Dr. Gauraw Singh Baghel
40. Dr. Patel Tanuja
26. Vd. Aher Snehal Bhagarant
41. Dr. Kedar Nath Upadhyay
27. Vd. Syed Farhatunnisa A.
42. Dr. Manjeet Kaur
28. Dr. Praveena P. Nair
List of Shishyas3 who did not respond
29. Dr. Mukesh Rawat 30. Dr. Kshitij Sharma
1.
Dr. Vandana P. Raval (Reply received after last date)
2.
Dr. Jagannath Upadhyaya
32. Dr. Bharat Bhushan
3.
Dr. Kailash Chaubey
33. Dr. Dinesh Sharma
4.
Dr. Pratibha Sharma
34. Dr. Iqbal khan Goury
31. Dr. Mamta Thakur
3. All the Shishyas were reminded repeatedly and the messages were transmitted through the RAV also. The response from Shishyas was not encouraging.
Guru-Shishya Paramparaâ&#x20AC;&#x192; 221
35. Dr. Sweta Kumari Shaw
43. Dr. Sumer Singh
36. Dr. Varinder Singh
44. Dr. Sanjay B. Thatere
37. Dr. Divya T. Namboothiri 38. Dr. Anurag Saxena 39. Dr. Geeta A. Odak 40. Dr. Meghna Punde
45. Dr. (Mrs.) Seema Joshi 46. Dr. Ashok Kumar Dixit 47. Dr. Darshna M. Rawal 48. Dr. (Mrs.) Alankruta R. Dave 49. Dr. Santosh Kumar Singh
41. Dr. Umesh Chandra Mishra
50. Dr. Lakshman Singh
42. Dr. Meenakshi Singh
51. Dr. Sanjay Raghabaji Talmale
222â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
8 National Institute of Indian Medical Heritage (NIIMH) - A Historical Overview and Major Contributions
National Institute of Indian Medical Heritage (NIIMH) A Historical Overview and Major Contributions Historical Overview
225
Contribution of the Institute
226
Current Priorities
227
Collection and Digitization of Medical Manuscripts from South India, Maharashtra and Madhya Pradesh
227
Ayurvedic Encyclopedia
227
Research database on Ayurveda and Siddha AYUSH Research Web Portal (http://ayushportal.ap.nic.in/)
228
Health aspects of Panchatantra and selected Unani Translation
229
WHO Collaborative Study
229
Medico-Historical Library and Museum
229
Conclusions and Recommendations
229
Annexure
Annexure-I: Research Activities Reported in NIIMH Bulletin/Journal, 1963-2009
224â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
230
8 National Institute of Indian Medical Heritage (NIIMH) - A Historical Overview and Major Contributions Historical Overview The PI visited the National Institute of Indian Medical Heritage (NIIMH), Hyderabad which is a unique institute with potential to become a hub for academic interaction on the history of medicine. The Institute has its origins in a recommendation made by Professor Henry E. Sigerist (1891-1957), Director of Johns Hopkins Institute of History of Medicine, Baltimore, USA. A recommendation to open an Institute of History of Medicine1 was made to a Committee, headed by Sir Joseph W. Bhore. Based on this recommendation, a special committee headed by Dr. A.L. Mudaliar, the then Vice Chancellor of Madras University was established to identify suitable premises to house the new institute. Dr. Mudaliar and Major General S.L. Bhatia, the Surgeon General of the composite State of Madras recommended that a Department of History of Medicine be opened in the Andhra Medical College, Visakhapatnam. At that time, no college in India had a History of Medicine Department. After the formation of Andhra State, the Department started functioning from Visakhapatnam which was later transferred to Hyderabad in 1957 as the State capital already had many Ayurveda
and Unani Colleges as well as libraries and museums. In 1958, a postgraduate diploma in History of Medicine was instituted. In 1962, the department shifted to the newly constructed building of the Osmania Medical College and was handed over to the Indian Council of Medical Research (ICMR). In 1969 it was renamed as the Institute of History of Medicine. In 1970, the Institute was transferred to the Central Council for Research in Indian Medicine and Homeopathy (CCRIM&H). In 2009, the institute was again renamed as the National Institute of Indian Medical Heritage. Prof. Sigerist saw India as a country in transition moving from heavy dependence on indigenous medicine practitioners to greater reliance on scientific medicine. According to him an understanding of the evolution of medicine would enable medical graduates to integrate better with the emerging social and economic structure of Indian society. While recognizing that the “history of medicine is both history and medicine”2 Sigerist said that the Institute should “investigate the medical heritage of the country dispassionately and critically, not in order to prove a point”. He was perhaps hinting at the need to avoid
1. Report of the Health Survey and Development Committee (Vol. III, Appendices) p. 204-213. Simla: Government of India Press. (1946) 2. Government of India. (1946). Report of the Health Survey and Development Committee (Vol. III, Appendices) p. 209. Simla: Government of India Press.
National Institute of Indian Medical Heritage (NIIMH) 225
using history for political ends and noted that the institute should “reconstruct and envisage the medical past of India from the perspective of history, in relation to and as part of the general civilization of the various periods”3. His aim was to preserve and exploit what was of use in the indigenous systems while refuting claims that were not justified4. He therefore recommended that a critical study of medical folklore should be undertaken to provide evidence of the sustenance of tradition. He stressed the need to investigate books, folklore and other sources of information keeping in mind the interaction that India had with other cultures and expected the Institute to study the efficacy of reported treatments not directly, but by pointing out to pharmacologists and clinicians what needed to be tested. He felt that such initiatives would enrich the medical education curriculum by bringing in a historical perspective. Dr. D.V.Subba Reddy is generally recognized as the pioneer in the study of Indian medical heritage5. He joined the Visakhapatnam Medical College in 1931 and when Andhra Pradesh state was formed in 1956 he became the first Chair in the History of Medicine at the Andhra Medical College. He is credited with establishing the medico-historical library which forms the core of NIIMH’s current collection. These include medical classics from around the world, books on the history of medicine, and books on the history of culture, literature and science. His second major contribution was the setting up of a museum,
which continues to be developed at NIIMH. Himself a prolific researcher he produced more than 125 articles, 19 monographs and books on Indian systems of medicine and Indian medical heritage6. He was among those who believed in pursuing a rigorous scientific approach and emphasized the view that “the medical historian must find out what the health conditions were in a given society at a given time”7. This broad mandate provides the rationale for the work the National Institute of Indian Medical Heritage has undertaken over the years. The PI had visited the Institute on 10th May, 2012 during her visit to Andhra Pradesh and met the Director and his officers.
Interaction with Director and other Research Officers of the NIIMH, Hyderabad
Contribution of the Institute The current activities include: 1.
Collection of old medical manuscripts and rare books on indigenous medicine systems, in different languages.
2.
Translation and publication of selected manuscripts.
3. Government of India. (1946). Report of the Health Survey and Development Committee (Vol. III, Appendices) p. 210. Simla: Government of India Press. 4. Government of India. (1946). Report of the Health Survey and Development Committee (Vol. III, Appendices) p. 211. Simla: Government of India Press. 5. Dr. D.V.Subba Reddy Memorial Lectures: Souvenir, P-3. Hyderabad: Indian Institute of History of Medicine. (1992) 6. Dr. D.V.Subba Reddy Memorial Lectures: Souvenir, P -5. Hyderabad: Indian Institute of History of Medicine. (1992) 7. Dr.D.V.Subba Reddy Memorial Lectures: Souvenir, P -32. Hyderabad: Indian Institute of History of Medicine. (1992)
226 Status of Indian Medicine and Folk Healing
3.
Collection of medical information from non-medical sources like ancient literature, archaeological and epigraphical sources, and accounts written by foreign travelers to India.
3.
4.
Studying the historical development of concepts of disease and drugs in the indigenous systems of medicine.
Collection and Digitization of Medical Manuscripts from South India, Maharashtra and Madhya Pradesh
5.
Preparation of biographies of physicians and authors and creating a commentary of classical medical literature, during different periods.
6.
7.
8.
Writing the history of medicine, focusing on geographical areas, specific time periods, and specific themes. Disseminating information, holding exhibitions and seminars, providing referral services and guidance to research scholars. Collecting the oral history and material from hereditary physicians and traditional medical practitioners in and around Hyderabad.
The Institute has been publishing a Bulletin/ Journal since the seventies now renamed as the “Journal of Indian Medical Heritage”. 39 volumes of the journal (1971-2009) contain 711 articles which present an interesting record of years of research activities. The outcome of the research is summarized in the table (Annexure-I). Current Priorities The recent priorities of the institute include: 1.
Collection and Digitization of Medical Manuscripts from South India, Maharashtra and Madhya Pradesh.
2.
Preparation Encyclopedia.
of
an
Ayurvedic
Creating a Research database on Ayurveda, Siddha, other traditional medicines and related sciences and an Ayush Research Web Portal (http:// ayushportal.ap.nic.in/).
The NIIMH has digitized 2568 manuscripts (801 palm leaf and 1767 paper manuscripts), 691 rare books and 407 rare journals. Thus, in all, 3666 items have been digitized during the three years of the project (Table 2). Table 2: Manuscripts, books and journals digitized, NIIMH, June 2011 Subject Ayurveda
Manuscripts Rare books Total 1502
Siddha
559
Unani
506
Naturopathy Sub-total
1 2568
Rare Journals Total
571 2073 46
605 506
74
75
691 3259 407 3666
Ayurvedic Encyclopedia The project will provide the scientific, academic and lay users an authentic ready reference for the correct usage of Ayurvedic technical terms. The translation of Ayurvedic terminology would have authentic references, etymology, definitions, synonyms, and literal and applied meanings. The encyclopedia has been planned to be printed in English and Hindi supported by a digital version. This would be a word lookup tool developed inhouse which would be useful for searching different texts.
National Institute of Indian Medical Heritage (NIIMH) 227
Centre, Hyderabad, an electronic database was developed which comprises four volumes of research databases available online. Research Database Volume I, cover page, NIIMH
Samhita Look-up tool and Ayurveda Encyclopedia, NIIMH
E-book version of Caraka Samhita, Sushruta Samhita, Nibandha Sangraha and Nyaya Chandrika commentaries have already been released and e-books on Vagbhata, Madhava Nidana, and 24 Nighantus are under finalization. The CDs are reported to be in great demand. The Unani books are yet to be included as e-versions. The encyclopedia and the e-books would mainly be of use to the researcher, but they can be converted into interesting products for the general public. Research database on Ayurveda and Siddha AYUSH Research Web Portal (http://ayushportal.ap.nic.in/) This project began in February 2008. Academic and research institutions of Ayurveda and Siddha, medical colleges, universities, pharmaceutical industries, agricultural universities, research scholars, and others were approached to provide research abstracts available with them in a prescribed format. With technical assistance from the National Informatics
228â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
An Online Ayush Research Portal has been launched where it is possible to search of research data by user. Selected institutes can also upload research data. The table below indicates the status as of September, 2011. A brief overview of data upload on the online AYUSH Research Portal Disease related
September 2011
Standard Treatment Guidelines
78
Preventive & Promotive health care
227
Pre-clinical & Clinical
3085
Literary & fundamental
355
Drug standardization
83
Local health traditions
71
Drug Monographs
2891
Ayurvedic Formulary of India
2193
References from classical texts
32
Plant monographs
304 9319
Other than Disease related Literary, basic & fundamental research
1711
Drug research
1693
Health aspects of Panchatantra and selected Unani Translation Panchatantra is a non-medical text which contains some information on health. It dates back to 300-200 BCE, and is believed to have been composed by Vishnusharma. A research study is in progress covering five texts among around 50 editioins. Translations of the Persian manuscript Ilajul-Atfal, by Syed Fazl Ali Shifae Khan (1836) are also being prepared, and this work is important as it focuses on paediatrics at a time when this specialty did not exist. Another text called Ain-ul-Hayat (Spring of Life), by Mohammad Ibn Yousuf Harvi (1532) is a manuscript in Arabic on Geriatrics. The work of translating it into English and identifying the specific formulations claimed to delay aging and counter diseases of old people, is also in progress. WHO Collaborative Study Evidence-based Ayurvedic remedies/therapies identified through research work: This study aims at presenting evidence on the efficacy of Ayurvedic Drugs/practices as identified by the Research Councils and National Institutes. From an initial selection of 1000 short-listed studies an expert Committee has included 106 papers which are being scrutinized according to prescribed parameters to decide finally about their inclusion. Medico-Historical Library and Museum A specialized library devoted to the history of medicine was one of the early objectives of NIIMH. Over the years, a medico-historical library with 9194 books, 282 medical manuscripts (170 Ayurvedic, 106 Unani and six
Siddha manuscripts) has been established. Of these, 444 of the books are classified as “rare books”. The focus is on medicine as reflected both in medical literature as well as found in works on art and sculpture, archeology, epigraphy, history of science and in world medicine. The library is open to historians and research scholars. Early and first editions of rare books (like the A. F. Rudolf Hoernle edition of The Bower Manuscript, 1893-1912, and Richard Quain’s The Anatomy of the Arteries of the Human Body 1844) which are of immense medico-historical value are also available. There is also a small Medico-Historical Museum which displays exhibits like photographs, paintings, charts, models, postal stamps of medico-historical importance, and antique clinical apparatus. Some important palm leaf and paper manuscripts are also on display. In all there are 840 exhibits.
Conclusions and Recommendations For all the work that the institute is doing in a comparatively rudimentary set up, there exists little knowledge about its presence and output. The Institute should hold annual seminars in which academics active in the history of medicine field should be invited along with publishers who specialize in this area. Linkages should be established with international scholars who are proficient in Ayurveda and Unani medicine so that they begin to use the resources. The Institute should set up on Advisory Committee with representation from different stakeholders, particularly from scholars of public healthfrom institutions like Johns Hopkins USA and European institutions so that new ideas are generated and the institute becomes a gateway for scholars and students of the history of Indian Medicine.
National Institute of Indian Medical Heritage (NIIMH) 229
Annexure-I Research Activities Reported in NIIMH Bulletin/Journal, 1963-2009 Sl. No.
Name of Project
196365
197180
198190
19912000
200109
Total
Ayurveda 1
Search for, and editing and publication of rare medical manuscripts/books
11
27
6
6
4
54
2
Biographical studies and articles on authors/compilers, redactors/ commentators, phywsicians of classical treatises
1
19
–
6
14
40
3
Translation of selected passages from ancient medical classics
12
8
–
–
1
21
4
Study and collection of medical information from archaeological and epigraphical sources and archival records
–
3
–
–
–
3
5
Collection/ compilation of medical information from non-medical literature (Vedas, Puranas etc.)
4
4
1
5
15
29
6
Medico-historical papers on drugs/ diseases
–
5
–
5
14
24
7
Projects on writing the history of medicine (area wise, period wise and theme wise)
–
7
3
5
5
20
8
Compilation of travelers’ accounts of the development of medical science
7
4
–
1
–
12
9
History of Ayurveda
–
1
1
3
–
5
10
General articles on Ayurveda
–
12
10
3
1
26
11
Lists of medical works
10
1
4
2
–
17
45
91
25
36
54
251
20
14
4
5
–
43
Ayurveda total
Unani 1
Search and collection of information, editing and publication of rare medical manuscripts/ books.
2
Biographical studies and preparation of articles on authors/ compilers, redactors/ commentators and physicians of classical treatises.
1
14
2
3
–
20
3
Translation of selected passages from ancient medical classics.
6
6
5
2
1
20
4
History of Unani medicine area wise, period wise and theme wise.
–
5
3
–
–
8
230 Status of Indian Medicine and Folk Healing
Sl. No.
Name of Project
196365
197180
198190
19912000
200109
Total
5
Drafting/Publication of MedicoHistorical paper on drug/disease
–
–
–
–
2
2
6
Lists of medical works
9
1
–
–
–
10
36
40
14
10
3
103
Unani total
Others 1
Siddha
–
16
–
–
3
19
2
Homeopathy & Naturopathy
–
8
–
–
–
8
3
Modern Medicine
4
11
1
1
–
17
4
Early European medical writers
8
2
–
–
–
10
5
Book reviews
–
11
4
16
1
32
6
Compilation of bibliographic indexes
6
5
2
3
1
17
99
184
46
66
62
457
National Institute of Indian Medical Heritage (NIIMH) 231
9 Folk Healing Practices of the North East
Folk Healing Practices of the North East Introduction
235
Basic facts about the North Eastern Institute of Folk Medicine (NEIFM), Pasighat
236
Arunachal Pradesh
236
Assam
241
Manipur
245
Meghalaya
248
Mizoram
252
Nagaland
254
Sikkim
255
Tripura
259
Conclusions and Recommendations
261
Annexures: Annexure-I: Letter of the PI to the Director of North East Institute of Folk Healing
263
Annexure-II: Questionnaire on the Practice of Traditional Medicine and Folk Healing in the North Eastern States
265
234â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
9 Folk Healing Practices of the North East Introduction
gather and compile the data by using NEIFMâ&#x20AC;&#x2122;s collaborating institutions:
The North East region of India comprises the States of Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura. The region is endowed with rich biodiversity and an uninterrupted heritage of using traditional folk medicine which is prevalent even today. Local knowledge about the medicinal properties of plants and other living and inert matter is extensive.
1.
North Eastern Institute of Science and Technology, Jorhat
2.
Department of Botany, University, Guwahati
3.
Department of Environmental Sciences, Mizoram University, Aizawl
4.
Regional Research Gangtok, Sikkim
On the recommendations of the Steering Committee on AYUSH for the 11th Plan set up by the Planning Commission, an initiative for establishing the North Eastern Institute of Folk Medicine (NEIFM) was approved by the Government to come up at Pasighat in Arunachal Pradesh. The decision was taken in February 2008 and an initial budget of Rs.38 crore was assigned.
5.
Department of Life Sciences, Manipur University, Imphal
6.
Tripura University, Agartala
7.
Martin Luther Shillong
Christian
University,
8.
Department of Botany, University, Nagaland
Nagaland
The State Government allotted 40 acres of land located on the banks of the Siang River (which is known as Tsangpo in Tibet and Brahmaputra in India) where the river leaves the mountains and enters the plains.
The data and information was collected, compiled and edited by Shri Hemen Hazarika, SRF assisted by Shri K Jayaprakash, SRF both at NEIFM. The final report is based on details provided by the collaborating institutes and was modified by the PI to focus only on folk medicine. Several discussions were held with Shri Otem Dai and Mr.Hazarika when the reports were prepared. Since different institutions were involved in collecting the data it has not been possible to present the picture of each State in a uniform manner.
The PI requested Shri Otem Dai, Director, NEIFM, for assistance for preparing a chapter on tribal and folk healing in the North Eastern States. A background note and a questionnaire were provided for his guidance (Annexure-I and II). Despite facing constraints of staff and infrastructure, the Institute readily agreed to
Guwahati
Institute
(Ay)
Suryamaninagar,
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 235
Basic facts about the North Eastern Institute of Folk Medicine (NEIFM), Pasighat
have been created. An additional 159 posts have still to be created.
The North Eastern Institute of Folk Medicine (NEIFM) is a National Institute, functioning as an autonomous registered society under the Department of AYUSH, Ministry of Health & Family Welfare, Government of India. The Union Minister (H & FW) is the President of the Governing Body of the Institute. The Director of the Institute is expected to be assisted by various committees with domain experts from the North Eastern Region and other parts of the country, once the Institute takes shape.
Tribal Folk Healing in North East India
The aims and objectives of the NEIFM are to survey, document and validate folk medicine practices, remedies and therapies prevalent in the region, with a view to revitalizing, promoting and harnessing local health traditions. The institute is required to create an interface between traditional/folk medicine practitioners and research institutions to undertake a thorough study based on an understanding of folk medicine. The Institute will also help upgrade the skills of traditional/ folk medicine practitioners, while protecting their intellectual property rights. Depending on the feasibility, the benefits of these traditions are planned to be integrated into the mainstream healthcare system, for being used by the public at the primary healthcare level. The main building consists of three floors housing the administrative and research divisions supported by a 50 bedded hospital to be manned by Allopathic and Ayurvedic experts along with folk healers. A thematic garden of medicinal plants and herbs is also being developed on the campus. A threeroom Guest House is also planned. So far only the positions of Director, 2 Senior Research Fellows and administrative staff
236 Status of Indian Medicine and Folk Healing
ARUNACHAL PRADESH Introduction Arunachal Pradesh is called the “Land of the Rising Sun” The State has 16 districts which are inhabited by 27 tribes and 110 subtribes who live in villages and mostly prefer traditional folk medicine to take care of their daily health needs. Amongst the North Eastern States, Arunachal Pradesh has a rich tradition of folk medicine. Owing to its earlier inaccessibility and remoteness, there has been little outside influence and local traditions are preserved well. The State introduced the non-allopathic system of health care treatment in 1980 by opening 10 Homoeopathy dispensaries which continue to function. In 1991, 73 Homoeopathy Medical Officers and 20 Ayurvedic Medical Officers were posted under a Centrally Sponsored Scheme. Under this, 52 Specialty Clinics for Homoeopathy and nine for Ayurveda were also established. Under NRHM, the Government of Arunachal Pradesh has employed another 35 Ayurveda doctors, 54 Homeopathy doctors and one Unani doctor. The Regional Research Institute for Ayurveda at Itanagar has a 10-bed Ayurveda Hospital with Panchakarma and other facilities. The North Eastern Institute of Folk Medicine (NEIFM) at Pasighat operates an OPD with an Ayurveda doctor. The services of the Tibetan system of medicine locally called Gso-Rig-Pa have been provided at specific locations by his Holiness the Dalai Lama.
The acceptance of Ayurveda is reported to be good and is gaining popularity. Presently, 20 Ayurvedic Medical Officers are covering most districts. One Medical Officer (Unani) has been posted under the NRHM. Local health traditions are widely used. Government-run non-Allopathic Institutions: There is no Ayurvedic/UnaniCollegein the State, but non-Allopathic treatment is available in the State Hospital at Naharlagun, the General Hospital, Pasighat, the District Hospitals, CHCs, PHCs and many dispensaries. There are a number of local traditional healers using local healing practices such as bone setting. The Department of Health has started enrolling these traditional healers after they produce supporting documents from the local administrator. Today there are nine traditional healers that have been enrolled. In the survey conducted in 2012, six districts of Arunachal Pradesh were covered, cutting across different ethnic groups. The Government-run Ayurvedic and Allopathic Institutions were visited and informal interviews/discussions were held with the folk healers and villagers, the Gaon Burahs (Village Heads), the head of a family or aged knowledgeable persons, in order to collect primary information on the utilization pattern of local health traditions, the prevailing customs as well as local beliefs. A rapid assessment was carried out in East Siang District. Besides meeting herbalists and local experts to elicit first hand information, the practitioners who were treating different ailments were also consulted. These healers and herbalists were convinced about the importance of documenting the available knowledge on folk medicine. But tactful handling and persuasion was needed as the folk practitioners were
generally reticent and not keen to divulge the identity of the plants used or the method of preparing the medicine. There was a strong belief that the medicinal effect of some herbs was greatly enhanced through incantation. This boosted the faith of the patient as well as the practitioner. Status of Ayurveda and Unani: The status of Ayurveda has been growing in popularity in the State over the last 10-15 years. The reasons for this are as follows: 1)
There appeared to be a growing disenchantment with Allopathic medicine due to side effects, high cost of medicine and tests, non-availability of doctors and out-of-pocket expenses incurred by the patients
2)
Under NRHM, the Indian Systems of Medicine were being propagated and Ayurveda doctors were being posted in selected CHCs/PHCs and hospitals.
3)
The indigenous tribal population of Arunachal Pradesh had only experienced allopathic treatment and had only recently come to know about other systems of medicine like Ayurveda and Homoeopathy to which they had an open mind. There is a sizeable population of (non-tribal) people from neighbouring States who are already familiar with Ayurveda and Homoeopathy.
4)
The Central Government Institutions and to some extent the State Government are providing Ayurveda services and medicines free of cost, which has contributed to the growing popularity of these systems.
Status of Medical and Health Services: Owing to its mountainous terrain, poor transportation facilities and poor communication network,
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 237
even in major towns, only 20 percent of the deliveries take place in hospitals and clinics and only 43 percent of the children receive full immunization. Diarrhoea is prevalent among the children. A high mortality rate has been recorded in the under five years’ age group due to the lack of medical facilities in rural areas. Most villages are not connected by road and have no access to telecommunication either. This makes the situation very difficult as the Primary Health Sub Centres (PHSC) are also located far from most villages. Status of the tribal and folk healing in Arunachal Pradesh: In addition to the local indigenous folk healers, there are many other folk healers who come from Assam, Nepal, West Bengal and Bihar who too are very popular. Traditional healers do not fall in a single category as each one has a field of expertise. Traditionally, folk healing is practised by herbalists, faith healers, traditional birth attendants, bone setters, snake bite doctors and ethno-veterinary practitioners. Although they are not recognized, they use their spiritual powers to cure common ailments, and local people have faith in this approach. Herbalists: Empirical knowledge plays an important role, which helps the herbalist to
diagnose certain illness with certainty and prescribe healing herbs accordingly. Magic also plays an important role and it is the belief of common people that everyone cannot become a good herbalist because it requires the use of spiritual powers in conjunction. Faith Healers: They use the power of prayer for treating the patient. While undertaking diagnosis and treatment many faith healers resort to the use of prayer in candlelight or by using water as a medium. Traditional Birth Attendants: They serve the communities located in isolated and remote areas where there are no medical facilities available. Traditional Bone Setters: There are different kinds of bone setters who attend to various types of bone fracture and dislocations, sprains, congenital disorders like club-foot, as well as hereditary disorders like arthritis. The North Eastern Institute of Folk Healing (NEIFM) in collaboration with Indira Gandhi National Open University (IGNOU) started a pilot scheme for giving certification of “Prior Learning” for traditional healers in the North East states. The details of the healers of Arunachal Pradesh are given below.
Table 1:List of the Some Traditional Healers from Districts of Arunachal Pradesh Sl. No.
Name of the healers
Address
District
1
ShriTasenZirdo
S/O: Late TaloZirdoVill: Zirdo village Circle: New Daring PO &PS: New Daring Dist: West Siang , Along
West Siang
2
ShriPromtaTamei
Vill: Loiliang, Circle: TezuDist: Lohit (M) 8974643531
Lohit
3
Shri Chowmikita Namchoom Vill: Pangkhawa PO: KhremDist: Lohit
Lohit
4
ShriTemkenMingki
Vill: Meka, PO: Roing (M) 9863770546 Dist: Lower Dibang Valley
Lower Dibang Valley
5
ShriAndaloKeche
Vill: Mayu; Roing. Dist: Lower Dibang Valley (M) Lower Dibang 9612269585 Valley
238 Status of Indian Medicine and Folk Healing
6
ShriTaiyumTadoNirjuli
Short Cut, Nirjuli, Near NERIST Campus Type I Colony,District : Papum pare
Papum pare District
7
Mr. TasungJamoh
Yagrung, Pasighat (M) 09862703302
East Siang
8
Smt. YanungJamoh Lego
GTC Pasighat,080145234485
East Siang
9
Mr. TalutSiram
Pangivillages,P.O. Pangin 094024041807
East Siang
10 Mr. Tazom Mize
VillRiga,P: O: Boleng 09402657508
East Siang
11 Mr. TasorMuang
Po;Ps; Vill: Panging Tarak,Boleng 09436220322 East Siang
12 ShriTalungTaamuk
Vill: Rew , 09402617625
East Siang
13 Mr.Arakang
Vill: KomkarMariang
Upper Siang
14 Mr.AttiMekik
Vill: Adipasi P;O; Marriyang 09612543956/9402657498
Upper Siang
15 Mr.TagumTaki
Vil: Takilalung, P:O: yagrung 07308998263
East Siang
16 Mr.Boluperme
Vill : Kongkul, P;O; Mebo 09615982139
East Siang
17 BekpaTyeng
Lower Dibang valley retired principal (M) 08822106544/09706971877
Lower Dibang Valley
18 Mr. Darin Perme
VillNgopok P;O; Mebo 9402649922
East Siang
19 Mr. TayiGommeng
Rani Village P;O: Pasighat 9402461271
East Siang
Currently, there are three folk healers serving in the NEIFM, Pasighat OPD where approximately 15-18 patients come daily for treatment. The
patient records are maintained by the health assistants along with the names, address, treatment provided and photographs.
Table 2: Folkhealer serving in the NEIFM OPD: Sl. No.
Name
Address
Treatment offering
1
Mr. Tasung Jamoh YagrungBasti, Common ailment, bone Pasighat, Contact setting, Paralysis, poisonous No.09862703302 bites etc
2
Mr. Anand Jamoh
Yagrung, Sibut, Pasighat Contact no. 09862172644
Common ailments, Jaundice, Bonesetting, mother and child care, paralysis,piles, and fistula
3
Mrs.Yalak Jamoh
Yagrung, Pasighat
Common ailments, mother and child care, skin care.
Photographs
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 239
Result of Regional Survey: A rapid assessment of the traditional health practices was carried out in 24 villages in East Siang Districts where it was found that the herbal healers attended to around 29 conditions by using home remedies (Table-3). The folk healers were asked to document one complete remedy for each common problem like Bone fracture, Diarrhoea, a gynaecological problem or for pimples and black spots on the face, constipation with burning sensation, white patches on the skin, eye pain, tooth ache, common jaundice, Hepatitis-B, urinary bladder infection, cuts and wounds, gastric ulcer, Diabetes, Piles, Sinus, Headache, Ring worm, fever, snake bites (Table-4).
Table 3: Result of the rapid assessment of 24 villages as provided by folk healers S.No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Village name Boleng headquarters Boleng Riga Panging Sissen Yembuk Pangin Mirku Mirbuk Napit Sibut Yagrung Pasighat CT Mebo Mebo village Upper Ngyopok Borghuli Seram Niglog Ruksin Oyan camp Sille Rani 10th mile
Population 2651 4985 3887 4784 237 51 82 655 1126 121 813 778 21965 12980 1370 1538 915 915 1094 794 442 751 1212 751
Table 4:List of diseases where relief was claimed Healer and his plant remedies
Healer treating a patient
240â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
S. Disease No.
S. Disease No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
16 Joint pain
Diarrhoea Malaria Jaundice Gastric problems Sinus Piles Conjunctivitis Anaemia Tonsil Asthma Common cold Cough Tooth ache Headache Fever
17 Menstruation problem 18 Skin problem 19 Bone fracture 20 Cut and wounds 21 Stomach ache 22 Snake bite 23 Hair fall 24 Pimples 25 Mouth ulcer 26 Cancer 27 Dandruff 28 Spondilitis 29 Back ache
Photo gallery of interviews with the healers and patients
Patients in line at NEIFM OPD
Healer with a patient
Healer shows the plants used for treating patients
Investigators document the knowledge of a birth attendant
Conclusion: Traditional healing practices are the oldest form of treatment which have been used by indigenous people for centuries. Such traditional practices believe that energy is present in all matter and the knowledge about plants is established through trial and error. This has led to innovations along the way, and the experience is passed on to succeeding generations. This traditional knowledge gradually becomes a part of the oral knowledge of a particular community. Arunachal Pradesh has a treasure house of traditional knowledge which is used by 110 sub-tribes. Efforts which are being made to conserve and revive the folklore and give it validation and recognition are good initiatives but the documentation has to be done
continuously by adding new findings. The goal of certifying the healers and the criteria used for inclusion and exclusion require policy endorsement as the approach may lead to raising aspirations and expectations which should be factored into the strategy. ASSAM Introduction Assam is situated in the North-East region of India â&#x20AC;&#x201C; bordering all seven States of Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Tripura and West Bengal and two countries viz. Bangladesh and Bhutan.
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 241
Proportion of Rural and Urban Population
than in the rest of India. The status of Ayurveda and Homoeopathy facilities is given below. There is no Unani hospital or Unani Health Centre in Assam in the Government sector.
Eighty-six percent of the total population lives in rural areas, which is a higher proportion
Table 5: Status of Ayurveda & Homoeopathy S. No.
Name
Ayurvedic
Homoeopathic
1
Colleges
1 (Adm.Cap.50 for UG & 12 for PG)
3 (Adm. Capacity 50+50+50=150)
2
Hospitals
1 (150 bedded)
3 (50+50+50=150 bedded)
3
Dispensaries (attached with SD,PHC,CHC,CH)
358 (under State Health Service) + 287 (under NRHM)
75 (under State Health Service) + 50 (under NRHM)
4
Registered Practitioners
697
1129 Part-A 1874 Part-B
5
Registered Pharmacists
120
Nil
6
Licensed Pharmacies (Whole sale/Retail sale)
22
680
7
Medicine Manufacturing Lab/ Pharmacy
51
1
Table 6: AYUSH Human resources in Assam S. No.
Post
No. of staff
1
Deputy Director of Health services (A)
1
2
Deputy Director of Health services (H)
1
3
Zonal Officer (A)
3
4
Medical Officer (A)
358 + 287 (under NRHM)
5
Medical Officer (H)
75+ 50 (under NRHM)
6
Pharmacist (A)
20
Total
795
Source: www.nrhm assam.in A-Ayurveda H-Homoeopathy
Table 7:Beds available for non-allopathic treatment Name
Ayurveda
Homeopathy
Total
Hospitals
1 (150 bedded)
3 (50+50+50=150 bedded)
4
Source: www.nrhm assam.in
242â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
Status of tribal and folk healing in the state of Assam Assam has a large number of ethno-linguistic tribes, mainly Chakma, Dimasa, Garo, Hajang, Hmar, Khasi, Jaintia, Khanti, some Kuki tribes, Lakher, Barmans in Chachar, Boro, Borokachari, Deori, Hojai, Kachari, Sonwal, Lalung, Mech, Miri and Rabha. The traditional healers among them give treatment for minor diseases like, fever, cough, skin disease, hair falling, body pain, stomach problem, abdominal pain, gastric ailments, eye itching, constipation and teeth problems. Diseases like diabetes, TB, dysentery, cholera, piles, malaria, swelling of liver, bone fracture
and jaundice are also treated. The knowledge is passed from generation to generation through orally because there is no written script. The local people primarily depend on the local traditional healers for their basic health problems. The healers rarely keep written records about the patients but occasionally it is done. In some rural villages of Assam midwives offer their services at the time of delivery and also attend to pregnancy related problems. But they do not maintain any records.
Traditional & Folk Healing Practices in Assam
A plant raw drug
An animal raw drug
A picture of traditional practitioner (Mr.Singheswar Shyam-Jorhat)
Picture of medicine bottles
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 243
Records maintained by Mr. Singheswar Shyam, Jorhat
Practitioners of Folk medicine in Jorhat, Assam S. No.
Name of the Healer
Photo
Age (years)
Address
1
Mr. Puna Das
39
Village:- Bogoriguri P.O.- Holmora, Dist.- Jorhat
2
Mr.Bhadaswer Bordoloi
48
V:- GowalGaon P.O:- Garumora P.S.:- Pulibor D:- Jorhat
3
Mr.Phutul Bezbora
37
V:- CharingiaBezgaon P.O. :- Tilikiaam Pin:- 785006 D:- Jorhat S:- Assam
4
Mr. N. C. Borah
50
V :- Titaborbibizan P.O:- Titabor D:- Jorhat S:- Assam
Interviews with healers and patients
244â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
MANIPUR Introduction The State is divided into nine districts, four in the valley and five covering the hill areastogether having a population of 23 lakh.
therapists, 52 Homoeopathy physicians and six Unani physicians working in the nine districts. Under NRHM, two Ayurvedic and 14 Homoeophathy physicians have been additionally posted. The position of AYUSH doctors working in Health Centres in Manipur is given in the table below:
Government-run non-AYUSH facilities There are 12 Ayurvedic physicians, 12 Yoga Table 8: AYUSH doctors working in Health Centres in Manipur S. No.
Name of the health centre District/Town
No of Doctors Ayurveda
No of Doctors Yoga
No of Doctors Homoeophaty
No of Doctors Unani
1
Imphal West
2
1
6
2
Imphal East
3
2
8
3
Thoubal
1
3
7
4
Bishnupur
1
5
Churachandpur
2
2
4
1
6
Tamenglong
1
1
3
2
7
Senapati
1
2
10
8
Ukhrul
1
1
4
9
Chandel
2
5
1
5
Table 9: Community Health Centres in Manipur under NRHM (AYUSH) A-Ayurveda, H-Homeopathy S. No.
Name of the health centre District/Town/
No of No of Doctors No of MO Doctors Homeophaty (Allopathy)
No of Health workers
No. of Beds For in-patient services
1
Imphal West
0
H-2
2
3
10
2
Imphal East
0
H-3
3
1
10
3
Thoubal
A-1
H-2
3
1
10
4
Bishnupur
A-0
H-2
2
2
10
5
Churachandpur
H-1
1
1
10
6
Tamenglong
H-1
1
1
10
7
Senapati
H-2
2
1
10
8
Ukhrul
1
0
10
9
Chandel
1
0
10
A-1 H-1
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 245
Table 10: No of patients who visited AYUSH Government Health Care Facilities during 2010-11 AYUSH Systems
Hospitals (incl. CHCs)
Dispensaries
IPD
OPD
Ayurveda
-
8014
-
Unani
-
-
Siddha
-
PHCs
Total IPD
OPD
35801
-
43815
-
9800
-
9800
-
-
-
-
-
323
37502
2913
122884
-
163299
Yoga
-
485
-
3116
-
3601
Naturopathy
-
9537
-
27128
-
36665
Amchi
-
-
-
-
-
-
323
55538
2913
198729
323
257180
Homoeopathy
Total ISM & H
Table 11: Diseases for which Patients visited the Government AYUSH facilities during the year 2010-11 as Out-Patients (OPD) S. No.
Ayurveda Name of the disease
Unani
Homoeopathy
No. of the Name of No. of the Name of No. of the Patients Visited the disease Patients Visited the disease Patients Visited
1
G.I. system
10738
1214
30604
2
Intestinal infections
7196
1112
26535
3
Respiratory diseases
7635
1012
25527
4
Hypertension
6899
981
19501
5
Skin
5655
1567
19466
6
Urinary system
3185
1115
18399
7
Female diseases
1204
992
10347
8
Viral diseases
843
1024
934
9
Musculo skeletal cases
214
304
931
10
Others
246
479
11055
There are two Teaching Institutes namely Regional Institute of Medical Sciences (RIMS) and Jawaharlal Nehru Institute of Medical Sciences (JANIMS) and an Integrated 50bedded AYUSH Hospital, at Imphal(West) and a 10-bed AYUSH Hospital (Homoeo) at the
246â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
JANIMS Hospital Complex, Imphal (East). Status of Folk healing practices in Manipur The
traditional
Manipuri
Maiba-Maibi
treatment is prevalent in the State and is
one of the oldest traditions. Maiba (male healer) Maibi (female healer) treat patients by prescribing medicine which they prepare out of locally available plants, animal products and inorganic minerals like ores and crystals. The Maiba and Maibi read the pulse of patient to diagnose the ailment. Generally, the right hand of the male patient and left hand of the female patient are held while reading the pulse and the index, middle and ring fingers are used for pulse examination. The system of traditional Maiba-Maibi healing practice is widely accepted by Manipuri people for the treatment of white patches, jaundice, paralysis, kidney stone, measles, diabetes, white discharge, liver pain, stomach ulcer, cough,boil, snake bite,dog bite, bone fracture, mental disorder and allergies. In rural and the hilly areas of Manipur where modern doctors are not available, the traditional Maiba and Maibi are the only
experts available. The Maibis also deal with deliveries. There are five types of treatment which are practiced as a part of the traditional healing practices of Manipur: a)
Treatments by psychotherapy: Performing rituals like chanting of hymns and making offerings to the Gods.
b)
Treatment using (Pukshuba) and Shuba)
c)
Treatment using physical exercise
d)
Treatment using diet and food
e)
Treatment using plant remedies, animal products and minerals
massage therapy reflexology (Mari
It was claimed that 80 percent of the population of Manipur depend on traditional medicine in the rural areas, where Allopathic facilities are not available.
Table 12: Some Traditional Folk Healers of Manipur Sl. No. Name of the healers
Address
Photograph
1
MS. CHEI CHIN
CHEI CHIN. L Female/45 yr Community/ Tribe: Zou District:: Churachandpur Mob: 8974103265
2
MR. LAISHRAM IBATOMBI SINGH
LAISHRAM IBATOMBI SINGH Male/81 yr Community/Tribe: Meitei Address: Lamlai Bazar District:: Imphal East Mob: 9612705597
3
MR. OINAM NINGTHEM OINAM NINGTHEM SINGH Male/63 yr SINGH Community/Tribe: Meitei District: Imphal West Address: LangolLairembiLeikai Mob: 9612558587
4
MR. ATHOKPAM RAJENDRO SINGH
ATHOKPAM RAJENDRO SINGH Male/61 yr Community/Tribe: Meitei District: Top MakhaLeikai, Porompat Road, BPO-k.k.Khong, Imphal East
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 247
Traditional & Folk Healing Practices in Manipur
Growth commonly known as Lairenshajiktreated by traditional healers
Healer demonstrates about the properties of folk medicine
The healer with his patient
Herbal medicine prepared by women
MEGHALAYA Introduction Meghalaya, the â&#x20AC;&#x153;Abode of Cloudsâ&#x20AC;? has seven districts and three ethnic groups viz.; Khasi, Jaintia and Garos. They have distinct beliefs, customs, traditions and culture and are mostly dependent on agriculture and other farming activities for their livelihood. The people have a rich indigenous traditional knowledge of health care which they practice in both rural and urban areas. These practices are passed on from generation to generation by word of mouth. Since a large number of villages do not have access to formal health care services, folk healing remains popular and traditional healers play a pivotal role in providing health care. They include bone setters, traditional birth attendants, herbal healers, veterinarians, healers who treat
248â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
poisonous bites and those that specialize in ailments of the eyes, skin, mental disorders, liver, dysentery etc. However, inspite of being widespread and popular, the practice of traditional healing is slowly diminishing due to over exploitation of medicinal plants, deforestation and lack of documentation. A survey was conducted covering around 10 percent of the villages in each block comprising both accessible (60%) and inaccessible (40%) villages. Since most of the healers as well as the villagers were illiterate, information was collected based on a semistructured questionnaire and by conducting interviews, group discussions and home visits. These meetings revealed a keenness to promote traditional medicine. In each village the interviews start with the village headman (traditionally known as Sordar) so as to get an idea of the population of the villages, number
of traditional healers popular with the villagers and the availability of regular CHC/PHC/SC facilities. Status of Medical and Public Health The general state of health in Meghalaya has improved in recent years. Although the mountainous tribal regions are often inaccessible and the tribal people are often wary of modern medical treatment, yet there
has been a change of attitude. The health department has taken steps to improve the general conditions and at present there are seven government hospitals established in the major cities of the state. Three of them are in Shillong, and the remaining four are at Tura, Nongstoin, Williamnagar and Jowai. Quite a few private hospitals have come up in recent years mostly in and around Shillong. The following table shows the number of medical institutions in Meghalaya.
Table 13: District wise number of Hospitals, Dispensaries, PHCs, CHCs, 2008-09: Districts
Hospitals
Dispensaries
PHCs
CHCs
East Khasi Hills
4
4
24
6
West Khasi Hills
1
-
17
5
RiBhoi
1
2
8
3
Jaintia Hills
1
1
17
5
West Garo hills
1
3
18
6
East garo hills
1
1
17
2
South Garo Hills
-
1
7
2
Source: Statistical Handbook Meghalaya 2010-11
In addition the non-allopathic systems of health services have also been integrated. The National Rural Health Mission (NRHM) had asked for the revitalization of local health traditions and mainstreaming of AYUSH (Ayurveda, Yoga, Unani, Siddha, Homoeopathy) to strengthen the public health services. The non-allopathic doctors (Homoeopathy and Ayurveda) are being posted in different district hospitals, CHCs and PHCs. Currently, there are 54 AYUSH doctors in the state health department. Of these, 19 are permanent employees from the state and 35 are on contract under NRHM. The contract doctors are placed in three CHCs and 32 PHCs. During the last four years an AYUSH (Ayurvedic & Homeopathic Wing) has been set up in all seven Districts. Besides, 10 AYUSH doctors (Ayurvedic & Homoeopathic)
have been appointed on contractual basis in 10 PHCs in the State. However traditional healers continue to be sought after by the people. They are called “Nongaidawaikynbat” in the Jaintia Hills and as “Uwaaidawaikynbat” in the Garo hills or just “Kaviraj”. All tribes have a large number of traditional healers and this work is respected locally. A traditional healer named Dr. John Kharduit provides treatment for burn injuries, broken bones, paralysis, arthritis, diabetes, blood pressure, rheumatism, severe spinal injuries and other complicated cases even after people lose faith in other system of treatment. He owns a six bedded nursing home known as “John’s Herbal Nursing Home” at Thangsning. He has a swimming pool and the tank is used as a healing remedy for treating patients suffering from spinal injuries.
Folk Healing Practices of the North East 249
In 2011, nine well-known traditional healers of Khasi, Jaintia and Garo Hills were awarded honorary doctorates for public health
service by Martin Luther Christian University, Meghalaya.
Table 14: List of nine renowned herbal practitioners S. No.
Name of Healer
District
1
Dr. Boss Myrthong
Nongstoin, West Khasi Hills
2
Ms AlkaKharsati
Shillong, East Khasi Hills
3
Mr. KristonThabah
Pynursla, East Khasi Hills
4
Mr. CarehomePakyntein
Jowai, Jaintia Hills
5
Dr. Vidyanish
Tura, Garo Hills
6
Dr. Bentinck
Tura, Garo Hills
7
Mr. Vincent Kharbuli
Shillong, East Khasi Hills
8
Mr. RiangkhroLaloo
Jowai, Jaintia Hills
9
Mr. John Wesley Kharduit
Thangsning, East Khasi Hills
Table 15: List of herbal practitioners owning hospitals S. No.
Name of Healers
Hospital
Location
No. of beds
1
John Kharduit
John’s Herbal Nursing Home
Thangsning, East Khasi Hills
6
2
Delas Rani
Samaritan Herbal KhasiHospital
Mawryngkneng,EastKhasiHills
10
3
Dr. Vidyanish
Sam A’chikSikman
Tura, West Garo Hills
6
Of these the Sam A’chikSikman hospital is not registered with the Government of Meghalaya. Although traditional folk healing is wide spread, it is slowly reducing in importance due to a variety of reasons. The Khasi Hills Autonomous
District
Council
(KHADC)
had passed a Bill on the 2nd March, 2011 with a view to codify, protect and promote Khasi Traditional Medicine according to the social customs, traditional knowledge and Khasipractices. Approximately, 462 healers from Khasi and Jaintia Hills attended the program which aimed at sensitizing the district healers about the Bill and related aspects. A survey was conducted in both
250 Status of Indian Medicine and Folk Healing
accessible and inaccessible villages in three administrative blocks. A total of 39 villages were surveyed covering a population of 16597 comprising of 3521 households. There are 129 local health practitioners and 71 birth attendants practicing in the villages according to information gathered from the village headman/Sordar. It was also found that most of the people living in villages are more likely to consult traditional healers than an allopathic doctor. This is so because of the shortage of man power in the CHCs/PHCs and SCs; secondly the people are more likely to trust village elders who have knowledge of the age-old traditional practices and have been looking after the health of the village for long years. There were only 9 herbal gardens
in all the surveyed villages which shows a need to encourage more gardens to ensure availability of medicinal plants. Of the 129 traditional healers who were identified, 43 were male and 28 female 40 of the healers owned a clinic in the village. The source of income of the traditional healers was not entirely dependent on their practice as they also pursued other activities like farming, teaching, business or working as labourers. Most traditional healers practiced only on a part time basis while a few renowned healers devoted full time to healing. The medicine used by the traditional healers consists mainly of herbs obtained from the nearby forest, or from herbal gardens or village markets. Some medicinal plants are sourced from other districts of the state. It was found that 31 healers maintained documentation which included the patientâ&#x20AC;&#x2122;s name, village, and disease treated etc.
Fig. 2: A traditional healer in his clinic and registers maintained by him for keeping patient records.
Generally however traditional healers were not aware about of the importance of documentation but have recently begun keeping records. Data was collected through a household survey in order to get an idea of the most dominant diseases in the villages. From a total of 160 responses collected, it was observed that the most widespread ailments related to fever, cough, cold, headache, chest problem (104); gastro intestinal problem(82) and malaria(50) while the rest were of occasional nature only.
Table 16: Prioritization of diseases by the local people S. No.
Names of Diseases
Pynursla (50)
Mawkyrwat (40)
Rongram (70)
1.
Gastro intestinal
36
34
12
2.
Fever, cough, cold, headache, chest problem
47
37
20
3.
Diabetes
1
1
0
4.
Rheumatism
1
2
0
5.
Malaria
12
9
29
6.
Boil
1
1
0
7.
Jaundice
0
0
3
8.
Blood pressure, stroke
2
2
0
9.
Eye infection
3
0
0
10.
Skin disease
4
2
3
11.
Injuries
0
2
0
12
Arthritis
4
0
0
NB: Number in parenthesis is the number of respondents who participated in the household survey.
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 251
The preparation of medicine is mostly home based. After collection, the medicinal plants are washed and ground into a paste. (Fig 3A). After preparation the medicines are stored in small plastic packets or in an air tight container (Fig 3C and Fig 3D). Most of the medications are prepared fresh by grinding into a paste or boiled in water to be taken orally or applied externally. On the other hand, the parts of rare medicinal plants i.e. the seeds, bark, roots, etc. are dried, ground to a powder and stored in air tight containers.
of the face, hands and legs accompanied by weakness of the body determine the diagnosis. Since the poison affects the heart, proper treatment has to be given immediately. The healers prepare a herbal paste and apply it to the area of the bite at least once a day for a week or depending on the condition. Birth attendants The traditional birth attendants do not use any herbs and this was seen in all the three blocks where surveys were conducted. The highest number of birth attendant was reported from Mawkyrwat, West Khasi Hills. Conclusion
Fig. 3: Preparation of medicines by the traditional healer: A: Grinding of medicinal plants, B: Grinding stone used by traditional healers, C &D: Storing of medicinal plants.
Bone setters The bone setters mainly treat fractures and dislocation of bones and cartilages caused by accidents or on account of bone TB. The treatment is based on whether the symptoms are simple or complicated. If they are complicated or multiple, they refer the patient to the hospitals after giving first-aid. The diagnosis is based on the degree of swelling, the type of wound and extent of difficulty in movement. Treatment consists of wrapping a bandage around the affected area after applying selected herbs and giving a herbal formulation to the patient.
Traditional health practitioners play a pivotal role in providing health care services especially in rural areas where there is an acute paucity of health care facilities. With increase in deforestation, forest fires and overexploitation of medicinal plants, there is a need to sensitize people about preserving the forest and promoting herbal gardens. MIZORAM Introduction Mizoram is a land of rolling hills, valleys, rivers and lakes. There are eight districts inhabited by different tribes. The Lushais are the most dominant tribe besides a few others like Paihte, Lakher, Chakma and Riangs. While making the survey village elders, women and the local people of different areas were consulted.
Snake bite treatment
Status of Tribal and folk healing in the State
In the case of snake bites, symptoms like the bite mark, redness of the eyes, swelling
It was found that that about 99 percent of the interior rural population rely on herbal
252â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
medicine and about 98 percent of raw drugs are harvested from the wild. In urban areas it was found that some people still prefer natural drugs to synthetic or allopathic medicine. Some practitioners are offering treatment as a part of family tradition with knowledge handed down from generation to generation. Some of them have acquired basic knowledge about traditional medicine and have begun using it for commercial purposes, but that is not widespread. Non-Government Medical Hospitals/ Institutions & bed strength in Mizoram There are10 non-Allopathic doctors (AYUSH
Doctors) posted at each district allopathic hospital including those recruited under NHRM. At present there are 21 AYUSH doctors in all including those recruited under NRHM (Ayurveda-2, Homeopathic-19).There are seven 10-bed AYUSH hospitals located in seven districts (excluding Aizawl). A State Drug Testing Laboratory was constructed in 2006 to test medicinal plants and to ensure better quality control. Currently, there are four scientific officers and 2 Laboratory Analysts working there. An AYUSH wing is co-located in five CHCs, namely atThenzawl, Chawngte,Tlabung, Saitual and at Khawzawl.
Traditional and folk Healing Practices in Mizoram
Traditional Healer giving treatment to a patient
Drying medicinal plants for future use
Grounded and mixed in medicinal plants
Processing of Cinnamon for medical use
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 253
NAGALAND Introduction Nagaland has a population of 19.81 lakh with 11 districts. Status of Indian medicine in the State: There are 85 Ayurvedic dispensaries in the State. There are nine AYUSH doctors in the State of Nagaland. Out of these, two are appointed by the Government of Nagaland, one in Naga Hospital Authority, Kohima, and the second at the Dimapur civil Hospital. The remaining seven doctors have been appointed on contractual basis under the NRHM and are posted in different health facilities. Traditional Naga medicinal practitioners have been treating patients with the available resources. Even today, these local practitioners
are trusted for being able to treat many conditions. Such knowledge is passed on from parents to the children, but in some cases, the practitioners die without transmitting their knowledge to anyone. The knowledge remains a guarded secret and is therefore confined to the family in most cases. During the survey, the folk practitioners were selected meticulously, based on their experience and as recommended by local people. After making a comparison of the medicinal plants used by the healers, it was found that there are some similarities between the healers of two communities as far as the selection of plant species is concerned as well as the utilization pattern and the treatment given for various diseases / disorders. The communities are still totally dependent on wild plants.
Table 17: Details of the healers consulted Community Name of the Healers Age Sex Angami
Ao
Experts of the field
Occupation
Mr.Apu
40
M
All kinds of sickness.
Government servant
Mr.Apa
29
M
All kinds of sickness.
Healer
Mr.Aku
72
M
Gastric and Kidney stone
Healer
Mrs.Tanusuo
77
F
Nerve problems and bone fracture
Healer
Mr.Katuka
72
M
Bone fracture
Healer
Mrs.Bino
42
F
Women related problems and Bone Traditional fracture weaver healer
Mr.Nungshiba
32
M
Sickness and poisoned
Healer
Mr.Asungba
55
M
All kinds of sickness
Healer
Mr.N.lmti
71
M
Stomach Disorder
Advocate Healer
Mr.Chollen
62
M
Paralysis, sinus, appendix, piles and Healer cancer
Mr.Akanglemba
78
M
Bone fracture
254â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
Healer
Folk Healers
districts viz. East, West North and South. There are three climatic zones i.e. Cultivation Zone (8.9%), Forest Zone (46.00%) and Alpine Zone (39.00%).
SIKKIM Introduction The Himalayan State of Sikkim joined the Indian Union in 1975 and is the smallest mountain state. The population of the State is about six lakh. The State is divided into four
Efforts to provide regular AYUSH services are the result of the NRHM initiatives. The present status is given in the tables below.
Table 18: Strength of AYUSH manpower posted under NRHM in the State of Sikkim Designation
Numbers Homoeopathy
Doctors
04 (NRHM) 01 (State contract)
Paramedics AYUSH
05 (NRHM)
Total
Ayurveda 02 (NRHM)
Amchi 02 (NRHM) 01 (State regular)
Total 10 5 15
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 255
Table 19: System-wise AYUSH facilities co-located in the State S. No.
Location
System
1.
District Hospital, Singtam, East Sikkim
Homoeopathy and Ayurveda
2.
District Hospital, Namchi, South Sikkim
Homoeopathy
3.
District Hospital, Gyalshing, West Sikkim
Homoeopathy and Amchi
4.
District Hospital, Mangan, North Sikkim
Amchi
5.
Jorthang CHC, South Sikkim
Homoeopathy
6.
STNM Hospital, Gangtok
Ayurveda and Amchi
Only OPD services are being provided.
Status of Folk healers of Sikkim Lepcha, Bhutia and Nepalese, three ethnic groups of Sikkim have been practicing traditional medicine for years. 29 Traditional Healers are registered with the State Medicinal Plant Board of the Government of Sikkim. More than 100 Folk healers have been practising their traditional system at different places in the State. The tantrik forms of religion and medicine are believed to have been popularized by Guru Pamasambhava or commonly known as Guru Rimpoche. He is considered to be the master of healing. In his tantrik form as the Medical Buddha he is supposed to be able to heal mental depression and psychological problems. Illnesses are treated along with worship and devotion. The folk healers believe that unless a medicine has been empowered by special benediction, it will have little effect. The folk healers collect the herbs at an auspicious time because they believe this to better efficacy. A publication titled Traditional Herbal Healers of Sikkim has been published as a Monograph by the State Medicinal Plants Board and the Forest, Environment & Wild life Management Department of the Government of Sikkim. This publication contains information based on personal experiences and describes the practical aspects of Traditional Folk healing along with uses and preparation of different drugs.
256 Status of Indian Medicine and Folk Healing
An association of traditional healers called “Sikkim Paramparik Chikitsak Welfare Sangh” exists and 29 Folk / Traditional healers have been given registration by the State Medicinal Plants Board (SMPB). In addition, there are more than 100 Folk healers who have been practising in different places in the four districts. Lepcha medical practice: Lepchas constitute about 13 percent of the total population of the State, and they inhabit the Dzongue reserve of North Sikkim district. Among the Lepchas, the concept of health and illness is guided entirely by a belief in the supernatural. The Lepchas mainly follow the Mahayana sect of Buddhism. They have their own script, and distinct costume, language, and culture. The use of medicinal plants is described in the Lepcha epics called Namthar, Tengyur, and Domang. They acknowledge certain semi-divine guardian spirits known as “Lungzee,” who are not gods but worthy of respect. These could include a huge tree, a cluster of trees, a cave or a special hillock or some other natural object. It is believed that if these items are ignored or any disrespect is shown to them by defiling or polluting them, it might invite suffering on the entire village or a particular individual who may suffer from serious illness or even die. According to the Lepchas, the world is governed by good and
evil spirits. All natural calamities including bad harvests, drought, hailstorms, and similar natural events are believed to be the action of evil spirits. On the other hand, good health and vitality, a good harvest, and prosperity are attributed to the action of good spirits. Traditionally, only the Bong things (male Lepcha priests) and Muns (the female Lepcha priestesses) are called during sickness or at a funeral ceremonies. The Muns, however, perform rituals connected with supernatural forces in which the Lamas play no role. Pougorip/Totola (Oroxylumindicum) is a medicinal plant used in Ayurveda as an ingredient of Dashamula. It also plays an important role in Lepcha medical treatment. The Lepchas believe that since it is not even touched by bees, it has the purity and chastity of a virgin and the plant is used as a liver tonic and as an anti diabetic medicine. The fruit of the plant is shaped like a huge sword. The seeds from inside the fruit are flagellated like paper silk, and are used on auspicious occasions and at ceremonies. Chi (millet beer) also plays a very important role in Lepcha culture and is used to drink to good health. Bhutia medicinal practice The Bhutias place great emphasis on coercive rites to exorcise and destroy demons. Like the Lepchas, the practice of religion is in the hands of trained specialists called paus, neyjums, and lamas, paus being male and neyjums female. During the process of curing, a pau enters into a state of trance, communicates with spirits to discover why they have afflicted the patient. Another approach to diagnosis is by divination using a plateful of rice. The pau shakes the plate until the symbol of the evil spirit appears in the rice. The pau performs “Phuphi” by offering money, eggs, and clothes which have been circulated thrice time over the
patient’s head to be offered to the malignant spirit. Only the clothes are brought back from the ritual and it is believed that patients will be cured within three days of performing the ritual. All Sikkimese settlements are adorned with prayer flags, or Dacho, which are believed to carry good fortune from every direction. Nepali medical practice Nepalese believe that supernatural forces play a part in the creation of illness. Dami and Jhakries are performed during the puja to treat physical and mental disease. Folk uses of herbs such as Oroxylum indicum for hypertension, Fraxinus floribunda for gout, Panax pseudoginseng for longevity, Ephedra gerardiana for asthma, Elsholtzia blanda, Mahonia nepalensis for eye infection and eczema, and Urtica parviflora as an invigorating agents after child-birth are in use and are considered to be of medicinal value. Rhizome of Budo-Vokati (Stible rivlaris) is considered to be good for lumbago. It is crushed and taken as a decoction after boiling in water or chewed like betel nut for relief of body ache. Flowers of Pandanus nepalensis are said to have aphrodisiac properties which also induce sleep. These are found at altitudes up to 1700 m and are used to adorn the hair to win lovers. The plant’s roots taken with milk are said to prevent abortion; the flowers are said to remove headache and weakness, and the seeds are believed to cure broken hearts. The healing practices of these three ethnic groups are a mixture of personalistic and naturalistic theories of illness. According to prevalent beliefs, illnesses may be linked to transgressions of a moral or spiritual nature which involve inappropriate behaviour, violation of social norms, or a breach of religious taboos. Naturalistic theories view illness as a disharmony between the person and the environment. Perception of illness is
Folk Healing Practices of the North East 257
highly culture related. During the survey, data on 44 medicinal plants was collected. Most of the plants were being used for rheumatoid arthritis, gout, gonorrhea, fever, viral flu, asthma, cough and cold and indigestion. A total of 48 folk healers were identified in four districts of Sikkim. Their age, sex, educational qualifications, sources of knowledge, types of practices, experience and use of traditional knowledge were all noted. Only four (8.32%) of the folk healers were young i.e. in the age range (20–40) years, and 17 (47.92%) were over the age of 60. The study showed that most folk healers 39 (81.25%) were male while nine (18.75%) were female. About half 25 (52.08%) were illiterate and only five (10.41%) had education beyond matriculation. Twenty-seven (56.25%) healers had acquired their knowledge from their parents, and 11 (22.91%) had acquired it from their Guru. Only four (8.34%) learned herbal medicine by reading books and manuscripts. Bone setting is the dominant traditional skill. Only two healers were found to practice veterinary medicine and one treated snake bites. Most [34 (70.84%)] of the folk healers belonged to the Nepali community and only four folk healers belonged to the Lepcha community. Most of the Nepali folk healers practised in accordance with Ayurvedic principles of treatment, and 12 (25.00%) practised Tibetan medicine. No one knew about Siddha, Unani, or Yoga practice. The majority (68.75%) of folk healers were practising their traditional folk healing running into the third generation. The socioeconomic standard of these folk healers was also studied. It was found that most folk healers (48%) had a monthly income in the range Rs.1000–3000, while only eight percent folk healers earned over Rs. 9000 per month. Most importantly, 80 percent of
258 Status of Indian Medicine and Folk Healing
the folk healers were ready to find alternative means of earning and wanted to leave their traditional vocation. Also they were not happy with their profession. An attempt was made to know how knowledge was being exchanged within the people. It was found that 28(58.33%) folk healers had not transferred their knowledge to anybody, even after the age of 50, but 15(31.25%) folk healers had instructed their sons and daughters. The health traditions of Sikkim’s population are linked with the ancient philosophical systems that make a connection between the cosmic and terrestrial, between the outer and inner environment, and between the external and internal body. The people of Sikkim access folk medicine easily at little or no cost. It is considered an effective and acceptable method of treatment. It would be difficult to alter the faith in traditional medicine and even if allopathic drugs were available, people would need to overcome the fear of modern medicine which is considered strong and chemical-based, needing a doctor’s prescription, and also generating side effects. Examples of Folk Medicine Practitioners in Sikkim Mr Chintamoni Dabani of Chengay Lakha, East Sikkim is a traditional folk healer aged about 60 years has been practicing herbal medicine for 40 years having acquired his knowledge from his father. He treats ailments such as fever, jaundice, gastritis, wounds, burns, female disorders, and infertility. The manner of treating a case of fever was observed and is recounted below: A patient came to the healer's house having suffered from fever and headache for two days. The healer checked the patient’s pulse and advised him to take a decoction of
Swertiachirayata stem and leaves three to four times daily for three days. The patient was normal after three days without any other medicine. There are 31 medicinal plants which are used frequently in traditional healing practices in Sikkim. Folk traditions are gradually declining as the new generation of young people are not volunteering to learn these healing practices as a profession. The NGOs working for traditional medicine are trying to establish an association of folk healers for the preservation and promotion of their age old traditions. But because of a significant shift in the socio-economic status of people folk medicine practices are on the wane. Scientific validation, reverse pharmacological and observational studies are required to understand their healing properties. TRIPURA Introduction Tripura has diverse ethno-linguistic groups, but the culture is quite composite. The
dominant eithnic groups are Manipuri, Tripuris, Jamatia, Reang, Noatia, Koloi, Murasing, Chakma, Halam, Garo, Kuki, Mizo, Mog, Munda, Orang, Santhal, and Uchoi. These groups mainly reside in remote forest areas and generally use traditional medicine. The healer’s knowledge is passed on from generation to generation through oral tradition because there is no written script. Much of the traditional knowledge has remained confined to the local healers. Status of AYUSH facilities There is only one Ayurvedic Hospital (10 bedded, five for male and five for female) situated in the State Capital Agartala. There are 88 Ayurvedic OPD centres co-located along with all PHCs. (i)
Presently, there are two medical colleges run by the Government of Tripura and four Ayurvedic hospitals are proposed to be established. A Panchakarma Therapy Centre is being operated at Sepahijala Wild Life Sanctuary run by the Tripura Forest Department.
Table 20: Table of AYUSH Facilities in Tripura 1
Status of co-locatedAYUSH Health facilities
Total Numbers
1.1 District Hospital
2
1.2 Community Health Centers
12
1.3 Primary Health Centers
79
1.4 Sub-divisional Hospital
11
2
Status of AYUSH Facilities (Stream-wise)
2.1
No. of Hospitals
No. of Beds
2.2 Ayurvedic
1
10
2.3 Homeopathy
1
20
2.4 Unani
0
0
3
Hospitals
Dispensaries
No. of Dispensaries
3.1 Ayurvedic
36
3.2 Homeopathy
77
Total
113
Folk Healing Practices of the North East 259
4
Regular M.O, AYUSH On Contract Basis under NRHM under State Health Department
Status of Manpower
4.1 Medical Officers
In position
In position
4.2 Ayurveda
53
49
4.3 Homeopathy
50
75
103
124
Total
Status of AYUSH paramedical manpower Regular AYUSH Pharmacists under State Health Department
Contractual Pharmacists under NRHM
5.1 Ayurveda
34
19
5.2 Homeopathy
59
8
93
27
5
Status of Manpower
Total
Table 21: List of ailments generally treated by local traditional healers of Tripura Major ailments treated by the folk healers Bone fracture Arthritis Leprosy Jaundice Kidney stone Gonorrhea Heart disease Bronchitis Asthma Epilepsy Elephantiasis Bronchitis Paralyses Hepatitis Diphtheria Diabetes Typhoid
Minor ailments treated by the folk heallers Fever Cold and cough Skin disease Diarrhea Dysentery Boil and burns Stomach disorder Tooth ache Gastritis Allergy Cuts and wounds Others. ( minor child ailments)
*In some cases, the folk healer also treats snakebites but it does not always give satisfactorily results.
Medication System: The medication system practised by the healers in Tripura is centuries old. The healers recommend different kinds of medicine for a variety of diseases. There is no scientific documentation of the traditional formulations and nor is any written record maintained. The medicine given to the patient may be in capsule form or powdery material or tied to the body with a piece of newspaper
260 Status of Indian Medicine and Folk Healing
or leaves. It may also be administered in the form of a paste, liquid or syrup. This is provided in an ordinary bottle along with instructions for use. The local villagers depend upon the traditional healers and reported that they were satisfied with the medication. There are around 95 Midwives/Dais who offer their services at the time of delivery and attend to pregnancy related problems.
Traditional & Folk Healing Practices in Tripura
Local traditional healers in Tripura
Raw drugs
Field investigators interviewing
local traditional healers
recognition will start. At that time the basis for selection of healers may arise which should be anticipated from now so that the process is clearly understood.
Conclusion and recommendations •
The efforts which are being made to conserve and revive folklore in the North East and to give it validation and recognition are good initiatives seen on a broad plane. But there is a need to understand the dynamics of accepting the responsibility for the selection of healers considered fit for “certification”. The aim of such certification needs to be spelt out. If it is to give legitimacy the question of how the standards for inclusion were selected and the credibility of the certifying agency would need to be prescribed. There is also a need for clarity about entitlements which accrue as a result of certification. Sooner or later the aspirations of those who have received certification will grow and demands for parity or some other
•
The efforts to understand and document the folk healing practices are very good. However, it is necessary to have an overall idea of where this would lead. The Ministry of Environment & Forests and the Ministry of Tribal Affairs have had considerable experience of dealing with allied subjects of rights, entitlements and protection of sui generis knowledge. The NEIFM needs to become a nucleus around which past endeavours in the area of folk healing can be collated at one place for the North East region. The Institute should start by building networks and accessing studies and reports which were undertaken elsewhere.
Folk Healing Practices of the North East 261
â&#x20AC;˘
With the increase in deforestation, forest fires and overexploitation of medicinal plants, there is also a need to sensitize the people about the need to preserve the forest and promote herbal gardens. NEIFM should shoulder this responsibility by networking with an organization in each State which can implement approved strategies.
262â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
â&#x20AC;˘
Scientific validation, reverse pharmacological and observational studies are required to understand the healing properties of plants outside the codified systems focusing on those plants which are being used extensively by the healers but are outside the ASU formularies. The outcomes need to be published in botanical journals.
Annexure-I Letter of the PI to the Director of North East Institute of Folk Healing Project: Status of Indian Medicine & Folk Healing with a focus on the benefits the systems have given the public Background Note for the Director This relates to the status of traditional and folk medicine as practised in the seven North Eastern States. It will not be possible for me as the Principal Investigator of the above project to personally visit all the North Eastern States and do justice to their traditional healing practices. Unlike the other States there are reportedly no institutions offering education or significant treatment under the Ayurvedic and Unani medicine systems in a structured way which happens to be the focus of my study. There is also no report of private practice covering these two systems. (My study does not include Homoeopathy). On the other hand, there are a wide variety of tribal and folk healing practices which are very much in use even today. The local knowledge about the medicinal properties of plants and other living and inert matter is understood to be extensive. While it is not my purpose to conduct an ethnographic study of such practices I need to capture the status of such medical treatment practices which are used frequently and on which there is considerable local dependency. It would be necessary to give a picture as the folk practices prevail in each state and to refer to the diseases, healing practices, preventive measures in use at a local level and the extent to which people rely on these options in different situations-acute care, ante-natal care and conditions affecting the skin, allergies, musculo-skeletal problems, digestive problems and psychiatric disorders, to name a few. As the Director of the Folk Medicine Institute, I request for your support in identifying the status of traditional healing practices in the seven NE States; also to enable me to extend an opportunity to knowledgeable and locally respected healers and practitioners of traditional and folk medicine to state what they wish to on any aspect of relevance to my study. Through you I would like to identify a few competent officers or research staff who can collect the information as sought in the attached questionnaire on a state-wise basis. In case the Folk Medicine Institute can do this I would request for an estimate of costs involved. This would require visits, writing letters, follow-up on the â&#x20AC;&#x2DC;phone and even convening a meeting to assemble the final Chapter on the North East. I can visit Pasighat or Shillong, the Headquarters of the NE Council (if you feel the involvement of the NE Council would be useful) once the draft is ready. I request you to help plan this out and to accept leadership to have this done. The questionnaire is self-explanatory but the purpose is to provide a status picture of what is widely known in the State but little known elsewhere. I do not need to do primary research but photographs with captions would be needed to show the places and practitioners visited. Part I of the Status Report has already covered aspects relating to Research, Education, Practice,
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 263
Medicinal Plants and Drugs. I will not be repeating the generic recommendations in Part II of the Report but focusing on patient care as provided by traditional and folk practitioners. Kindly facilitate me to do this. The time available is short. Please advise me how we can compress the time in a meaningful way by farming out the responsibility to different research staff engaged for a few days. With regards,
Dr. Otem Dai Director, North East Institute of Folk Medicine, Pasighat
264â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
Shailaja Chandra Principal Investigator Former Secretary AYUSH, Govt.of India and Former Chief Secretary ,Govt. of Delhi Mob. 09810501172 Tel. 011-24101261 Fax-011-24673220
Annexure-II Questionnaire on the Practice of Traditional Medicine and Folk Healing in the North Eastern States Background 1.
Give the Population of the State, number of districts and their population. A general picture of the status of medical and public health in the state (hospitals, CHCs, PHCs and dispensaries in each district may be provided. Within the health sector please describe the status of Ayurveda and Unani medicine or any other traditional system of healing established by the State.
2.
(i) In case there exists any college, hospital, community health centre, Primary health centre or dispensary run by the Government where non-allopathic medical treatment is available, either in separate or co-located facilities, please mention the town/district and describe the facility. (ii) Please give details of the strength of non-allopathic doctors posted in such facilities under the NRHM or as a State initiative. (iii) Please give the number of beds available for non-allopathic treatment in case inpatient services are available.
3. What is the status of tribal and folk healing in the districts in the State? After giving a Stateand district-wise picture, please explain whether the practitioners are offering treatment as a part of family tradition or because of any specific skill acquired recently. Please give an idea of how these traditional healers work including details and pictures of the treatment of patients coming for different ailments. A picture of the practitioner, the men, women and children going to him for treatment may be provided; also pictures of the medication given (fresh or dry herbs/powders/decoctions and ointments) may be provided along with the corresponding list of conditions (e.g. skin, digestive or respiratory conditions). Even if this medication is given in a newspaper or an ordinary bottle it may be shown. 4. An approximate idea of the daily OPD (out-patients) examined by the healer may be given. Also an idea of whether records are maintained by the healer or by the patient. 5. A small interview with the healer and the patients would be useful. Bone setters, traditional midwives/dais and snake bite experts may be included. 6
In case there is any mention in anthropological studies or any other published work specific to the State/districts it may be referred to in full and photocopies of the relevant pages supplied for inclusion in the Report.
Folk Healing Practices of the North Eastâ&#x20AC;&#x192; 265
10 Ayurvedic Veterinary Products (AVP) â&#x20AC;&#x201C; Status and Future Prospects
Ayurvedic Veterinary Products (AVP) â&#x20AC;&#x201C; Status and Future Prospects General Overview of Veterinary Sector
269
Ayurveda and Animal Health
270
Current Regulatory Status
270
Conclusions and Recommendations
272
268â&#x20AC;&#x192; Status of Indian Medicine and Folk Healing
10 Ayurvedic Veterinary Products (AVP) – Status and Future Prospects1 decades.
General Overview of Veterinary Sector Animal health care is of great importance as it forms a vital part of the food chain. Concerns about food safety has grown after the use of chemicals, hormones and anti-biotics in rearing animals and poultry became widely known. As residues of antibiotics/chemical drugs remain a part of the food chain, their use is being discouraged in Europe and several other countries.
•
The composition of the livestock population has also undergone significant transformation. Within cattle, there has been a marked shift from work animals towards milch animals. As a result, the number of crossbred cows has increased from three million to around 10 million.
•
India is currently the largest producer of milk in the world. It produces 110 million tones of milk annually. The per capita availability of milk increased from 112 gm per day to about 250 gm per day. However, the yield of Indian breeds is still far below the world average and nowhere near the yield of cows in developed countries.
•
Apart from being an important contributor to the national income, animal husbandry is one of the ways of reducing poverty and unemployment in rural areas. A large majority of livestock owning households comprise of small and marginal farmers and landless households – poorest sections of society. Overall, the distribution of livestock is much more equitable than that of land. The bottom 60 percent of rural households own 65 percent of all milch animals. Therefore, the health of
Since India is one of the biggest consumers of milk and milk products, there is a growing concern about the nutrition and medication given to milch animals. Veterinary products play a big role in animal and poultry rearing. India’s share livestock
of
world
population
of
•
The population of different livestock species as per the 18th livestock census 20072 places India at first rank for having the largest buffalo population, second in respect of cattle and goats, and third in respect of sheep. India has the fifth largest poultry population in the world.
•
The contribution of the livestock sector to agriculture is about 22 percent which contributed four to six percent of the National GDP during the last two
1. The preparation of this chapter was done in consultation of Dr. DB Anantanarayan, Advisor, M/s Natural Remedies Ltd. The figures quoted in the chapter were supplied by Dr. Amit Agarwal from M/s Natural Remedies Ltd. Group of Industries, and is based on market research carried out by them along with data available in public domain. 2. Department of Animal Husbandry Dairying and Fisheries, Government of India.
Ayurvedic Veterinary Products (AVP) 269
livestock becomes very important being a source of sustenance and livelihood. Market size and segments of the total veterinary sector3 The total Animal Health market is valued at around Rs. 2500 crore and is growing annually by eight to 10 percent. •
Of this fifty-three percent (Rs. 1325 crore) caters to the health and well being of cattle.
•
Thirty-seven percent (Rs. 925 crore) caters to the poultry segment.
•
Five percent (Rs. 125 crore) worth of products are used for domestic pets.
•
Five percent (Rs. 125 crore) is for the well-being of “other animals” (Aqua / equine).
Veterinary health products can be categorized into therapeutics, food additives and bio security products. •
Therapeutics have a market size of Rs. 1025 crore (41percent)
•
Food additives have a market size of Rs 750 crore (30 percent)
•
Bio-security products have a market size of Rs.725 crore (29 percent)
Ayurveda and Animal Health In ancient India, the use of animals in agriculture, transportation, food and on the battle field was widespread. As such veterinary science was well developed. Ayurveda has many branches like Gauayurveda, Hastyayurveda, Ashvayurveda, Mrig-Ayurveda, Vriksha-ayurveda, etc. These Ayurvedic sciences were later enriched with literature and practices followed from the
17th century onwards. There is a need and an opportunity to revive veterinary Ayurveda. In the Schedule 1 of Drugs and Cosmetics Act, more than 50 official books are listed but none of them are specific to veterinary Ayurveda. Several veterinary specific dosage forms are yet to be included in the Ayurvedic Formulary of India. Ayurvedic veterinary drug industry The Ayurvedic veterinary drug industry in India has been contributing to the treatment of both common ailments as well as newly emerging diseases. There are more than 80 Ayurvedic veterinary drug producing companies functioning at present. The total size of the industry is estimated at Rs. 400 crore, growing annually by 22 to 25 percent. Thus, out of the total animal health market of Rs. 2500 crore, the Ayurvedic Veterinary Products (AVPs) constitute 16 percent of the total animal health market. This sub-sector primarily consists of the following categories: 1.
Digestives
2.
Liver support agents
3.
Lactation promoters
4.
Nutritives/Tonics
5.
Anti bloating agents
6.
Anti stress agents
7.
Anti diarrheal agents
8.
Uterine tonic/ecbolic agents
Current regulatory status In India, though exact data about non-human use of antibiotics is not available but it is well known that antibiotics are used widely to
3. The data was sought to be confirmed through official channels but no response was given despite reminders.
270 Status of Indian Medicine and Folk Healing
prevent and treat animal infections. Nontherapeutic usage of antibiotics has been especially common in poultry production. The Prevention of Food Adulteration Rules, 1995-part XVIII: Antibiotic and other Pharmacologically Active Substances, regulates the use of antibiotics and other pharmacologically active substances. Enforcement is carried out by authorized Central and State Government organizations. The Departments for Animal Husbandry at the Centre and in the State Governments oversee all aspects relating to the regulation of veterinary education, practice and drug manufacture. However, currently either there are no effective regulations regarding the use of antibiotics in livestock or there is very weak compliance of the regulations as there is little importance given to this issue. As a part of the National Policy on Anti-microbial use, it was inter alia recommended that alternative medicine should also be practiced. The committee under the Chairmanship of Director-General of Health Services (DGHS) has formulated the National Policy on Antimicrobial use4, and it is understood that there is also a committee under the Council for Scientific and Industrial Research (CSIR).Inputs about the possibilities for the use of Ayurvedic or alternative medicine could not be found. Inputs from the AYUSH sector are needed because the Department of Animal Husbandry, Ministry of Agriculture, is not in a position to directly make any recommendations about Ayurvedic medicine. It is necessary that the AYUSH sector focuses on developing evidence-based substitutes for antibiotics, which are widely used for disease prevention and growth promotion in milch animals and poultry. This can help reduce extra-human use of antibiotics. It can also
contain anti-microbial resistance which is a big source of concern. In the Inter-sectoral Committee proposed under the National Policy on Anti-microbial use, there is need for identifying a nodal person to represent the interests of AYUSH, Health and Animal Husbandary so that guidelines for use of antibiotics in livestock and replacing them in a phased manner with alternative medicine including herbal drugs can be evolved. Licencing Products
Requirements
for
Veterinary
Veterinary Ayurvedic Products (VAPs) are regulated under the Drugs and Cosmetics Act, 1940 – 1945 and Rules thereunder. Two categories of pre-market licenses have to be obtained before introducing VAPs in the market. These are “Classical Ayurvedic Formulations” and “Patent & Proprietary Ayurvedic Products”. Classical Ayurvedic Formulations are prepared as per the formula & procedures given in ancient literature and Ayurvedic Patent & Proprietary medicines are new combinations of products made using herbs which are recognized and accepted in the official books. The Sub-Committee for Veterinary Ayurvedic Formulations of the Ayurvedic Pharmacopoeia Committee has identified 22 such books which should be included in the schedule to the Act. These products require to be licensed by the Licensing Authority or the Director of Ayurveda depending on the policy of each state. There is need to distinguish between VAPs which are primarily feed supplements and those which are medicines as the standards are different. The PI was told that there were inconsistencies and varying interpretations relating to excise,
4. Inputs from Dr. LS Chauhan, Director, National Centre for Disease Control (NCDC), New Delhi.
Ayurvedic Veterinary Products (AVP) 271
sales tax and other levies and much greater clarity is needed. Currently, the VAP industry adopts the same quality parameters prescribed for raw herbs, extracts, minerals mentioned in The Ayurvedic Pharmacopoeia of India or The Ayurvedic Formulary of India. Conclusions and Recommendations Need to prepare an Ayurvedic Veterinary Pharmacopoeia There is a need to prepare and publish a separate Ayurvedic Veterinary Pharmacopoeia covering the VAPs. A separate Veterinary Pharmacopoeia has been published in the case of synthetic drugs and pharmaceuticals (Published by Indian Pharmacopoeia Commission). It is understood that the newly formed Pharmacopoeia Commission for Indian Medicines (PCIM) has formed a Veterinary Ayurvedic Committee to initiate this work. However, the availability of resources and of lab facilities need to be looked into so that the work is expedited. Separate section for ASU veterinary sector There is a need to initiate inter-ministerial dialogue/cooperation between the Department of AYUSH, Ministry of Health and Family Welfare and the Department of Animal Husbandry, Ministry of Agriculture. Within the Department of AYUSH, there should be at least a Director level officer who can understand the specific needs of the veterinary sector and facilitate the approval of regulations apart from suggesting modifications as necessitated by experience. The ASU veterinary sector should be given representation on the
ASUDTAB. There are several government notifications which have been issued keeping only the human application of ASU medicines in mind. There is a need to either exempt ASU veterinary medicines from the purview of such notifications or to look into their applicability for the veterinary sector. Training veterinary manpower on Practice of AVPs Veterinary health care is in the hands of veterinary doctors (VDs), veterinary livestock inspectors (VLIs), artificial insemination workers (AIWs) and village level workers (VLWs). All been estimated, there are around 25,000 qualified vets and 80,000 (VLIs, VLW’s and AIW’s) engaged in the veterinary sector5. The number of veterinary doctors being limited, they generally attend to serious and complicated cases only. A vast majority of the common metabolic disorders (which are generally self limiting and non-life threatening) are attended to by VLIs, VLW’s and AIW’s. Most of the licensed Ayurvedic drugs are meant for common metabolic disorders. There is a need to encourage the paramedical veterinary manpower to understand the benefits of traditional veterinary medicine. Companies engaged in the manufacture of Ayurvedic veterinary products should be encouraged to impart know-how and training to the para-medical workers. Prioritizing ASU veterinary sector Ayurvedic Veterinary medicines are sold based at a relatively lower cost compared to modern medicine. While the traditional
5. (a) Rajendra Singh, Pratap Singh Birthal, B S Rathore, 1998, “Review of animal health services in India”, The Indian Journal of Animal Sciences, 68(5). (b) Ghotge, Nitya, and Sagari. Ramdas, 2002. “Women and Livestock: Creating Space and Opportunities.” LEISA Magazine 18 (4) (December): 16–17.
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products are cheaper, the main ingredients being medicinal plants are becoming more and more expensive. As a result, Ayurvedic veterinary medicine is losing its major edge over Allopathic drugs, which was the cost consideration. There is a need to encourage research and simplify regulations so that manufacturers can use cheaper alternatives as substitutes. However, unless the regulations focus on the advantages of using non-synthetic alternatives, the opportunity will be lost. The Ayurvedic veterinary sector is yet small but it has a huge potential given the interest in natural products and the large global population of animals and poultry that can be treated for at least some conditions without resorting to the use of chemicals. Greater encouragement to R&D and awareness building through Animal Husbandry camps and schemes would also provide an impetus but bridges need to be built to create an interest and an understanding. Need to create balya-poshak/positive health promoter category outside the drug category There are a large number of animal feed supplements of both synthetic as well as herbal origin. These products are in line with the Ayurvedic philosophy that it is better to maintain health and prevent disease rather
than treat diseases at a later date. From a brief interaction with some stakeholders the PI got the impression that manufacturers as a group are reluctant to approach the authorities for including such products under the “balya-poshak/positive health promoter” category as this category has been created as a sub-section of patent and proprietary “medicines” used for human health promotion only. When the main cause of veterinary diseases is improper nutrition, traditional Ayurvedic enhancers and drugs can play a significant role in enhancing animal health provided suitable regulations are put in place to encourage Ayurveda Balya-Poshak products in the veterinary category. A meeting with Ayurvedic Veterinary drug producers is therefore called for to give a direction to this. There is also an apprehension that the Ayurvedic Drug Licensing Authorities may object to combining herbal ingredients with synthetic ingredients like vitamins and nutrients. The Food Safety and Standards Authority of India (FSSAI) has apparently not prepared any guidelines as yet for licensing veterinary products. There is a need to take a view on the responsibility for laying standards and for monitoring in this area.
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11 Initiatives with a Difference
Initiatives with a Difference A Science Initiative in Ayurvedic Biology
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Vaidya-Scientist Fellow Program
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Conclusions and Recommendations
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11 Initiatives with a Difference Initiatives of a new kind are being taken in different research institutes in India and abroad, which are a harbinger of things to come. It is a welcome sign that instead of again focusing on discovering new molecules, drug development and standardisation which have all been pursued for more than four decades there is now a paradigm shift towards understanding the fundamental concepts of Ayurveda, seen through the lens of pure science. It is beyond the scope of this report to capture the status of all those projects. But two approaches merit special mention because they carry a hope that the change may augur a completely new way of understanding Ayurveda. The new emphasis on Ayurvedic biology and on bridging the chasm between pure science and Ayurvedic concepts are just two initiatives that the PI has included in this report to give an idea of the direction in which things seem to be moving. A Science Initiative in Ayurvedic Biology Enormous research work on Ayurveda had been done throughout the 20th century in Indian Universities, National Laboratories and in the private sector. But the work was largely focused on drugs and standardization. Much less attention was paid to holding trials to determine the efficacy and effectiveness of traditional medicine even after liberalization of research guidelines by the WHO. The study
of the concepts and procedures of Ayurveda by adopting the rigorous approach required of basic sciences (such as biology and immunology) had received little attention. There was indeed no platform for basic scientists and Ayurvedic physicians to interact, and both were impoverished in the bargain. This problem was recognized by the Indian Academy of Sciences in 2006 when the academy published a Vision Document “Towards Ayurvedic Biology”.1 Its importance was noted by the office of the Principal Scientific Adviser (PSA) to the Government of India who approved a scheme “A Science Initiative in Ayurveda (ASIIA)” to support a limited number of collaborative projects between institutions of science and Ayurveda. Seven projects were approved under ASIIA in which several top institutions2 of science and Ayurveda were involved like IISc, CCMB, BHU, IIT/Kharagpur, AVS/Kottakal and FRLHT to build a joint culture of collaborative research between scientists and Ayurvedic experts and with the aim of publishing high quality research papers. The first round of projects approved for research address questions such as do Vata/ Pitta/Kapha Prakritis have a genomic basis? Do Rasayanas accelerate the repair of DNA chain breaks? What are the metabolic and immunological correlates of Panchakarma?
1. http://www.ias.ac.in/academy/dvdocs/ayurvis.pdf 2. Indian Institute of Science (IISc); Centre for Cellular and Molecular Biology(CCMB); Banaras Hindu University(BHU); Indian Institute of Technology (IIT), Kharagpur; Arya Vaidya Sala (AVS), Kottakal; Foundation for Revitalisation of Local Health Traditions (FRLHT).
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Would the microstructure of a mercury derived Bhasma hold the key to its acclaimed “nontoxicity”. The results of few studies have been published in reputed international reputed journals.3, 4
iv.
Nature News mentions Professor Lakhotia’s paper on the effects of Amalaki Rasayana on Drosophila5 from an ASIIA project. The progress made by ASIIA was appreciated by the Department of Science and Technology and it was decided to take over the scheme under a “Task Force in Ayurvedic Biology”6 set up under the chairmanship of Dr. MS Valiathan, National Research Professor, Manipal University. The approach excludes herbal drugs research and safety and efficacy trials and focuses instead on basic research applied to the concepts and procedures of Ayurveda.
The Task Force is responsible for setting priorities, identifying research areas and developing proposals for the smooth implementation of the ASIIA projects.
Objectives of the Task Force on Ayurvedic Biology i.
Development of a basic understanding of the concepts, procedures, and products of Ayurveda in terms of modern sciences such as biology, immunology and chemistry.
ii.
To develop infrastructure facilities, Centres of excellence, and major research facilities in this area.
iii.
To promote human resource development in this area by offering fellowships, training opportunities, and providing support to scientific meetings and workshops.
To promote collaborative research with institutions abroad which are active in pursuing studies on traditional medicine and may have shared interest in Ayurvedic Biology.
As Dr. M S Valiathan erstwhile Director and Professor of Cardiac Surgery at the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruanantapuram put it, “the merit of the initiatives under ASIIA is that they have paved the way for the emergence of a new discipline called Ayurvedic Biology, which is rigorous like other branches of biology but is based on cues from Ayurveda. This has evoked much interest among pure biologists who have shown keenness to pursue leads from the published work of Lakhotia, Subba Rao and others. Valuable papers are in the pipeline and more may be expected to get published in the next 4 to 5 years and establish the new branch of biology on a firm footing’’. Vaidya-Scientist Fellow Program Vaidya-Scientist is a new academic fellowship programme for teachers/researchers of Ayurveda who have demonstrated high levels of scholarship, innovation and strong research potential. Vaidya-Scientists are
3. Bhavana Prasher et al., Whole genome expression and biochemical correlates of extreme constitutional types defined in Ayurveda. Journal of Translational Medicine 2008, 6:48. http://www.translational-medicine.com/ content/6/1/48 4. Shilpi Agarwal et al., EGLN1involvement in high-altitude adaptation revealed through genetic analysis of extreme constitution types defined in Ayurveda. http://www.pnas.org/content/107/44/18961.full. pdf+html?sid=49371cad-8f01-4ea0-955b-7bee0758af0d 5. Dwivedi V, Anandan EM, Mony RS, Muraleedharan TS, Valiathan MS, Mutsuddi M, Lakhotia SC. (2012) In Vivo Effects Of Traditional Ayurvedic Formulations in Drosophila melanogaster Model Relate with Therapeutic Applications. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0037113 6. http://www.dst.gov.in/whats_new/whats_new12/AYURVEDIC%20BIOLOGY.pdf
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seen as agents of change and ambassadors of Ayurveda in order to create a bridge between “Shastra” and “Science”. Dr. Ashok Vaidya pioneered this concept, on the lines of ‘Ayurvidya’ proposed by Lokmanya Tilak7. The mission of the programme is to develop high quality human resources in the Ayurveda sector, focusing on under-graduate and postgraduate education and is being hosted by the Institute of Ayurveda and Integrative Medicine (I-AIM), (a unit of FRLHT, Bengaluru), with support from the Department of AYUSH, Government of India. The Indian Academy of Sciences Journal, Current Science8, published an article on the Vaidya-Scientist concept giving the programme further impetus. The programme is designed to create a new cadre of young Vaidyas who are strongly rooted in the Shastra but also fully understand the relationship
between the systemic theories of Shastra and the structural theories of science.9 These Vaidya-Scientists are expected to become agents of change by becoming masters of contemporary approaches to transdisciplinary Ayurvedic research. Fellows will be mentored by eminent scholars and the list includes Vaidya Vilas Nanal, Prof. RH Singh, Dr. GG Gangadharan, Dr. Tanuja Nesari, Dr. Ashok Vaidya, Dr. Rama Vaidya, Prof Bhushan Patwardhan, Dr. Madan Thangavelu, Prof Alex Hankey, among others. Conclusion and recommendations It is expected that these initiatives will usher in a new approach to the study of Ayurveda and something tangible will emerge which can give the primacy and respect that the system needs for acceptance by a wider scientific community.
7. Patwardhan B, Ghooi R. Dr. Ashok DB Vaidya. J Ayurveda Integr Med 2011;2:209-10 8. Bhushan Patwardhan et al,. Vaidya-Scientits: catalysing Ayurveda renaissance. Current Science Vol.100, No.4, 25 Feb 2011. http://cs-test.ias.ac.in/cs/Volumes/100/04/0476.pdf 9. Singh RH. Perspectives in innovation in the AYUSH sector. J Ayurveda Integr Med 2011;2:52-4. http://www.jaim. in/text.asp?2011/2/2/52/82516
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12 Transformation Needed
Transformation Needed Observing Integration of Health Services in China
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Promoting Research under the Aegis of NCCAM
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Promoting High Quality Research and Publications
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Acting Against Exaggerated Advertisements that Make Medical Claims
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Uniform Policy on Reimbursement of AYUSH Treatment
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12 Transformation Needed Observing Integration of Health Services in China One of the important goals of NRHM and the overall health policy has been to mainstream AYUSH services into overall healthcare delivery. China achieved integration of modern medicine and traditional Chinese medicine decades ago. Although several delegations have visited China, this aspect has not been amplified in terms of managerial inputs. There is therefore a need to send a cross-section of health system managers namely a Medical Superintendent of a Central Government hospital, and selected State Directors General and Directors of Health Services to visit China to understand how integration of TCM at different levels of health care delivery have taken place. Time needs to be spent on specifically viewing how integration has been provided for at the patientâ&#x20AC;&#x2122;s level, instead of making a general visit. A team comprising one modern medicine Doctor, an AYUSH physician and a hospital administrator may be asked to prepare a paper on how cross referrals are managed in China after initial registration in the outpatient department. This needs to be studied keeping in mind specific medical conditions so that the operating procedures that are followed when modern medicine and TCM are used together are clear. Promoting Research under the Aegis of NCCAM It would be useful to select a team of AYUSH doctors who are already publishing papers
(the Banaras Hindu University, Department of Ayurveda has several such faculty members) to conduct an up-to-date search of Complementary and Alternative Medicine (CAM) projects that have been funded by the National Centre for Complementary and Alternative medicine (NCCAM) of the National Institutes of Health (NIH), USA. As a sequel to this exercise the subject areas, countries and institutions that have been awarded research projects needs to be gleaned. With the help of ICMR the effort should be to get good research proposals accepted by NCCAM; also to suggest avenues for foreign medical researchers interested in conducting collaborative research in India. This is permissible under the protocols that are already available in the Department of Health and the Ministry of External Affairs. ICMR is the Secretariat for doing such research and the requirements are well known to ICMR. A number of AYUSH doctors say they do not need any endorsement from Foreign institutions and this mindset must be changed as world recognition depends on the platform used for research and publications. Promoting High Quality Research and Publications In the last seven years several efforts have been made to assist the process of integration but the picture is not as satisfactory as one might have expected, given the sustained interest in promoting the AYUSH systems at a policy level. The fundamental weakness of the AYUSH system is the lack of high quality published research and the tendency to make exaggerated claims. This has to
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be confronted if any significant change is expected. A promising beginning has already been made by a few good journals which are helping to publish and disseminate research findings. Quality journals have begun to be published which are being accessed internationally. These include International Journal of Ayurvedic Research (IJAR), an official publication of Department of AYUSH, Government of India; AYU journal of Gujarat Ayurveda University, Jamnagar; Journal of Ayurveda and Integrative medicine (J-AIM) of Institute of Ayurveda & Integrative Medicine, Bengaluru; Ancient Science of Life of The Ayurvedic Trust, Coimbatore. Even so, one of the leading initiatives has met with some avoidable impediments1. Recently at the initiative of the Department of AYUSH and WHO a publication called “Standardization of Terminologies of AYUSH systems” has been completed which should help adoption of standard terminology. The portal of the National Institute of Medical Heritage has begun to upload the details of research undertaken by the Research Councils of Ayurveda, Unani and Siddha medicine after putting the research papers through a fresh review. These steps create ground for increasing knowledge and understanding of the Indian systems of medicine but continuous efforts are needed not only to publish but to examine the impact factor critically. In Part I of the Status Report, several suggestions had been made after bringing out what has been achieved by various research bodies
working under the Government of India. As recommended by the Steering Committee set up for the 12th plan, all the AYUSH Research councils need to function in close co-ordination with ICMR instead of working in independent silos. The need for publication in high impact journals should be emphasised and funding linked to such quality research chiefly in the areas of clinical research. There is little chance that the research done will improve incrementally unless high standards are set and outcomes monitored by a multidisciplinary group of research experts that are familiar with standards expected by quality journals. ICMR can be a route to understand the processes to be followed. However it may be worthwhile to identify people from the private sector or from different Universities to join the effort. A search committee should identify such experts. Acting Against Exaggerated Advertisements that make Medical Claims Despite some laudable initiatives taken by the private sector the bulk of small manufacturers are ignoring the codes on advertising medical cures. Countrywide there are instances of advertisements of therapies and medication under the AYUSH systems which are defying the Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954. Claiming to have a cure for scheduled intractable diseases and conditions is expressly forbidden by law and is a punishable offence. This is one area where no visible deterrent action has been initiated. With the large-scale use of the
1. Numerous people mentioned to the PI that the publication of a journal called “International Journal of Ayurveda Research (IJAR) had been announced in 2008. Funds were released for the first year and the Journal became the first Ayurvedic journal to be indexed with Pubmed. However in the subsequent years the funding was restricted to almost half of what was needed for one online version. It appears the Journal has not made any further headway because the editors are unable to manage the editorial work within the budget provided. At the time when the work came to a halt, there were apparently around 300 papers being processed. It is important to give continuous support to good journals because they bring credibility to the research work that is being done which will help raise the credibility and acceptance for the systems and also promote further research and published work.
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Internet, claims for curing cancer and other diseases are being spread through websites and social network sites. For several years the subject has come up for discussion both in the Department of AYUSH and with the state governments. No overt action which has resulted in effective enforcement of the law appears to have been taken. The public needs to be forewarned about such advertisements and claims because no such cures for certain diseases have been discovered by any system of medicine. If AYUSH drugs require a different list then it requires a change of law. It is the function of state Drugs Controllers to inform the public and to set up a system for monitoring misleading and exaggerated claims. But because AYUSH is seen as “separate “ and the AYUSH Drugs personnel are not in charge of administering the law which generally comes under the Health Departments, this has become “no man’s land”. As a result the public often gets duped. A mechanism should be introduced whereby the Departments of AYUSH at the state level warn the public periodically through newspaper advertisements and on television that there are centres as well as manufacturers of medicine that make claims about curing intractable diseases like Cancer and HIV/ AIDS. This is a public safety hazard. The public should be asked to seek advice from an All-India toll-free number to check about the credibility of the claims made when in doubt. Far from detracting from the value of AYUSH treatment and medication, the public would recognize that there is a reliable way of checking on exaggerated and false claims. Standard responses should be available on the monitor for help-line staff to give guidance. These should be prepared by experts but converted into commonly used English and Hindi. All Ayurvedic and AYUSH hospitals, centres
and individual issuing advertisements about curing certain intractable diseases should be given a written warning and a report about the publication of misleading advertisements taken up with the Press Council of India. The State governments need to be given guidelines which are legally sound on how they should deal with such advertisements. Uniform Policy on Reimbursement of AYUSH Treatment Background In the aftermath of the terrorist attack in Mumbai a peculiar case came to light of the Shourya Chakra awardee PV Mahesh, an NSG commando who killed a terrorist but was hit by a grenade that left three shrapnel in his head. As a result he was in coma for 6 months and his right side was paralysed. Later he is reported to have availed of Ayurvedic Panchakarma treatment from a private Ayurvedic hospital situated 300 Kms from his village in Kerala. This reportedly resulted in speedy recovery according to the patient’s own claim. He was however refused reimbursement of the expenses as the Army authorities did not recognise the Ayurvedic system of medicine. A PIL was filed in the Delhi High Court seeking directions to the Armed Forces to frame a policy for medical treatment/reimbursement to officers/employees who wish to avail of Ayurvedic or other alternate systems of medicine keeping in view that such treatment is provided in Government hospitals across the country free of cost or at negligible cost. Further the Central Government had framed a policy in 2002 called the National Policy on Indian Systems of Medicine & Homeopathy 2002 emphasising that medical reimbursement should be provided to employees availing Ayurvedic treatment.
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The Delhi High Court directed the Army authorities to consider framing a policy in light of the National Policy on Indian Systems of Medicine & Homeopathy 2002. The latest position of the particular case is not known and is beyond the scope of this report. Recommendations The Department of AYUSH needs to convince all Ministries and Departments to reimburse medical expenses on AYUSH treatment of employees if availed of for specific conditions and in recognized facilities. A list of such facilities should be drawn up at least in the cities which have CGHS cover which cater to large populations of Central government servants. The rest of the employees are covered by the CSMA Rules. AYUSH treatment should be permissible in any recognised AYUSH facility for which a list needs to be available in all CGHS centres, and clinics. However in the case of an employee requiring rehabilitation after undergoing an accident or injury suffered in the course of performing duty, there should be an understanding that he can avail of Ayurvedic treatment in any facility as per his convenience at rates accepted for recognised
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facilities. This would facilitate such patients who are paralysed or incapacitated to select facilities which are conveniently placed. In the case of other employees of central government, package deals should be recognized upto a specified amount to be undertaken in hospitals recognized by Department of AYUSH. This is already being done but perhaps needs to be reviewed annually so that more facilities can be recognised. While the Armed Forces will no doubt have their own policies for serving soldiers including officers and other ranks, cases requiring rehabilitation particularly on becoming paralysed or incapacitated because of an injury suffered on duty, need to be treated differently. Permission to avail of Ayurvedic treatment should be given liberally for paraplegics, hemiplegics and those who suffer from chronic musculoskeletal problems which are the result of injuries that occured while on duty. In these circumstances Ayurvedic treatment should not be denied to any soldier or uniformed employee who desires to avail of such treatment for rehabilitation. The cost involved would be too small to even try and compute limits on expenditure.