So this is the kind of faith-based medicine that NITI Aayog wants “integrated” with real medicine. Some Rajya Sabha members recently clamoured for funds greater than the ₹1686 crore budgeted for AYUSH this fiscal to be made available for it, even though this is already much higher than what was allocated to it in 2016-17. Some strange claims were made in the House – that weren’t contested nor were fact-checked by the media. The word “scientific” was thrown around a lot without anyone seeming to understand that science is not a love-in event meant for crank ideologies to mingle with and defile rationality at. RK Selvaraj, for instance, claimed that “ancient Siddha system was helpful in curing many incurable diseases“. Does that proposition not contradict itself? How can a disease that is incurable be cured? He also claimed that Siddha “was so advanced that it had records of diseases like AIDS“. The timeline for emergence of HIV and the earliest documented incidence of AIDS in human beings dates back to the early 20th century. Viplove Thakur wants “traditional medicine doctors [to be] treated on a par with Allopathy doctors.” Facepalm. He also said that the government should take measures to standardize traditional medicine and develop them in a scientific manner. Anything that passed muster with science would just be… scientific medicine? Welcome to the club! Although Jairam Ramesh probably didn’t get the memo, he was probably right when he said that “there should be strict provisions for penalising quacks practising traditional medicine system.”
All this comes at a time when globally, governments and citizens are getting wiser, beginning to understand what “science” in the context of medicine means. France recently announced that it will stop reimbursing patients for homeopathy from 2021 in order to wean them away from it. France’s National Authority for Health (HAS) concluded at the end of June that there was no benefit to the medicine, saying it had “not scientifically demonstrated sufficient effectiveness to justify a reimbursement”. Germany is also seeking to carry out similar reforms in its healthcare system. The universal healthcare system in the UK, NHS, has decided to stop funding homeopathy, and this decision has been upheld by a British High Court. Australia has done it best. Its federal government has recently withdrawn rebate support to private health insurance from a large number of “natural therapies” that include naturopathy and homeopathy, as a part of comprehensive healthcare reforms. Australia’s Department of Health says that “there is no clear evidence demonstrating the efficacy of the excluded natural therapies” and that “changing coverage for the excluded natural therapies will ensure taxpayer funds are spent appropriately and are not directed to therapies that do not demonstrate evidence of clinical efficacy“. In fact, the op-ed cited earlier itself says, “...it is unclear how evidence-based medicine should be applied to integrative medicine when the field stresses individual treatments and is willing at times of low risk to use unproven treatments.” In India, however, we have elected representatives demanding that more be spent on pseudoscience because “tradition”, while the leading “think tank” of the country bats for mixing pseudoscience with science.
Yes, there are real issues with the Indian healthcare system. First thing, the number of doctors in India is grossly inadequate, and this problem is especially pronounced in rural areas. Rural patients have to migrate to urban areas to access decent healthcare services. As a result, urban healthcare facilities are often overburdened. Lack of proper infrastructure in the majority of state-funded healthcare facilities only compounds the problem. The state spends less than 2% of its GDP on health. Also, the state provides health insurance support only for secondary and tertiary healthcare, and its infrastructural investment in primary healthcare still remains meagre. This only ends up benefitting the private players. All this means that for primary health issues, poor people, especially the rural poor, still have to bear out-of-pocket expenses, and as a result, largely avoid primary healthcare. Trained doctors and paramedics are typically reluctant to go to the rural areas, again because of lack of infrastructure in public hospitals, in addition to lack of basic amenities in rural spaces, salaries that are deemed inadequate, and connectivity issues. As India is said to still live in its villages, the barometer of the country’s health ought to be its rural health. By that yardstick, India is pretty sick.
This shortfall in healthcare professionals is sought to be made up for by bringing in AYUSH practitioners, who as we have seen, are ill-equipped to handle primary health. They are being used to make up the numbers. This report (there is a lot of cringeworthy stuff in this one, but let’s ignore that for now) claims that “India has already achieved the World Health Organization recommended doctor to population ratio of 1:1,000 the “Golden Finishing Line” in the year 2018 by most conservative estimates” even though it concedes that “after considering attrition, it gives a doctor (modern medicine) and population ratio of 0.77:1,000 as per current population estimate of 1.33 billion“. Compare that to doc-pop ratios in Australia (3.374:1000), Brazil (1.852:1000) and Germany (4.125:1000). “Even Pakistan”, a proud Indian might fretfully murmur, “has a ratio of 0.806:1000.” The report goes on to say that “by 2024, the doctor–population ratio is expected to be around 1.03 per 1000 population” in India. So why have we been massaging numbers just to cross the “Golden Finishing Line”? This is not all.
It’s not just about mechanically churning out doctors like we have been doing with engineers for the last decade or so. Let us go back to the Reuters investigative report on the state of medical education in India. It reveals many systemic flaws. We learn that many private medical colleges in India are established by businessmen and politicians who have no experience operating medical or educational institutions. We are also aware of the “capitation fee” culture in medical admissions in India, resulting from a government-backed surge in private medical schools which, to boost revenue, frequently charge under-the-table fees for admission. As Dr. Anand Rai, who was key to exposing the Vyapam scam in MP, said, “The next generation of doctors is being taught to cheat and deceive before they even enter the classroom.” Proliferation of for-profit and poorly regulated medical schools mean that once they do enter the classrooms, they are trained poorly. In the words of former health secretary Sujatha Rao, “The market has been flooded with doctors so poorly trained they are little better than quacks.” So even if we do end up reaching the “Golden Finishing Line” by 2024, how much of that will be of the quality necessary to nurse India to health?
So yes, there are a lot of issues. But, injecting AYUSH into the system is not so much the solution as an acknowledgement of policy failure. Pseudomedicine cannot be a substitute for, or even ‘complementary’ to, scientific medicine. The focus should be on slowly phasing out state funding to AYUSH and AYUSH institutions. The feasibility of retraining the current AYUSH practitioners so they can serve as paramedics should be considered. That doesn’t mean a ‘bridge course’. It means comprehensive training that helps the trainee effectively unlearn the nonsense they have wasted time on earlier, and then learn medically relevant stuff.
The whip must be cracked on errant private medical colleges, and comprehensive audit, both internal and external, of their admission procedure and teaching outcomes must be done and shared in the public domain. Even though RTI has now become compromised, private medical colleges must be brought under its purview. Greater investment needs to be made in rural primary health infrastructure, both at central and state levels. The pay structure for doctors and paramedics needs reforms, and incentives should be given to doctors to serve in rural areas. There should also be a rotation policy that will allow doctors to come back to urban areas after having served in rural areas for some time. Also, there is a need for starting a system of triage across hospitals, especially urban ones, in emergency cases to help separate those which need urgent and dedicated medical attention from those where first aid may suffice. Far from promoting AYUSH, the government ought to dismantle the AYUSH Ministry and instead spend a share of the funds thus freed up on spreading awareness against quackery and pseudomedicine. This is of crucial importance in a country full of health fraudsters and charlatans who go around promising miracle cures and end up causing enormous harm to people.
What about us hapless citizens? Article 51A(h) needs dusting up. We need to understand that everything that has to do with our health has been and can only be explained by biochemistry, molecular biology, genetics, neurology, etc, all of which are strictly scientific disciplines. Bodily humour, miasms, and bloodletting are no longer relevant to healthcare. What the 1999 op-ed linked to earlier said must be kept in mind, that in most countries CAM is practiced more by non-doctors than doctors. In this context, it is also important to know that something like homeopathy can be practiced even by those who don’t have a license in many countries. Healthcare modalities that emerged in ancient times might be admirable from a historical perspective and must be studied in detail, but they have nothing to do with modern science. It must not be forgotten that AYUSH needs to use modern technology and science to even be marginally relevant. You can’t boast of your “tradition” and then quietly go back to modern technology to be seen as doing medicine. You cannot have your cake and eat it too. We, as citizens, along with civil society, need to do our best to spread awareness about good health habits, which includes boycotting CAM.
It must be remembered that mere tradition and celebrity endorsements don’t lend any scientific validity to pseudomedicine. In fact, any celebrity who promotes magic pills and miracle cures must be penalized under provisions of the Consumer Protection Bill, passed recently by the Lok Sabha, once it becomes an Act. Also, licensed medical practitioners who clandestinely promote pseudomedicine for ideological reasons must be reported and disciplined. We ought to demand that the government provide support for primary healthcare to the poor, in addition to secondary and tertiary healthcare. It is important to raise our voices against initiatives like that of NITI Aayog to lower the standards of medical care by introducing IM.
IM will be nothing other than an attempt by quackery to infiltrate the medical sphere, seeking the same status as the latter without having to submit itself to scientific rigor. We must also strive to arrange for providing psychological and social support to those who suffer the side-effects of chemotherapy. In addition, we could sensitize people about the difficulties faced by overworked and underpaid medical staff in understaffed and underfunded hospitals, help them understand that doctors are humans, that only humans can be doctors and that humans can make mistakes. It’s a tragedy that in a country of more than 1.3 billion, quacks and charlatans are worshipped as demigods despite being criminals while doctors, who save lives, are beaten up viciously for their unintentional mistakes. We can’t allow pseudoscience to make us that stupid collectively.
Readers Can Access Part I and Part II Here.