Is ayurveda the key to universal healthcare in India?

Making traditional medicine mainstream

Since coming to power in May 2014 the Bharatiya Janata Party government led by Modi has focused on making traditional forms of medicine mainstream. The government has established the Ministry of Ayurveda, Yoga, Unani, Siddha, and Homeopathy (AYUSH) under the independent charge of minister of state Shripad Yesso Naik.

The National AYUSH Mission was launched in September 2014 to complement allopathic medicine, especially in remote rural areas with poor access to conventional health facilities. It focuses on building infrastructure such as hospitals and dispensaries; promoting AYUSH facilities at primary health centres, community health centres, and district hospitals; and improving the quality of remedies.

Ayurveda is also gaining popularity in towns and cities, with many new ayurvedic therapy centres and clinics opening. Some people seek ayurvedic treatment as their first option, others use it as their last option or alongside allopathy, and for some people it is the only option.

“Unlike allopathic medicine, traditional medicine is less technology and infrastructure intensive and therefore relies on knowledge and human capital for its implementation,” G Geetha Krishnan, head of the integrative medicine department at Medanta Medicity, a privately owned multispecialty medical institute in Gurgaon, Haryana, told The BMJ.

But does it work?

Some secondary and tertiary allopathic hospitals, such as Medanta Medicity, are setting up ayurvedic consultation centres. Medanta offers integrated care in areas including chronic pain management and stroke rehabilitation.

Medanta currently has two randomised controlled trials under way to test whether ayurveda has clinical benefit for the management of mucositis during radiation therapy for head and neck cancer and for the management of side effects and quality of life in patients with breast cancer undergoing chemoradiotherapy. Each trial has 60 patients and will be completed by the end of 2016.

Some ayurvedic practices may benefit patients. A 2011 double blind, randomised, placebo controlled pilot study of 43 patients found that an ayurvedic herbal compound was just as effective at treating rheumatoid arthritis symptoms as methotrexate but with fewer adverse events.5 6

“The government needs to support research to consolidate the evidence from ayurveda, which has a large pharmacopoeia. Especially there is a need to evaluate existing clinical practices of promising ayurvedic formulations and enhancing their clinical potential,” SR Narahari, chairman and director of the Institute of Applied Dermatology, Kasaragod, Kerala, told The BMJ. “Positive outcomes of combining biomedicine with complementary and alternative medical systems, such as ayurveda, in the morbidity control of lymphatic filariasis, a tropical disease affecting millions of poor in India, have been recognised even in the allopathic sector.”

A non-randomised interventional study on community level morbidity control of lymphoedema in two districts of southern India where lymphatic filariasis is endemic showed that self care and treatments that integrate ayurveda are possible in village settings.7 A total of 730 of 1008 patients completed three and half months’ follow-up and showed a statistically significant reduction in the volume of their lower limbs (up to the mid thigh). Cellulitis episodes reduced from 40% to 12.8%.

Challenges in building an evidence base

Patients and clinicians have a growing interest in knowing the efficacy and safety of traditional therapies. But, as Linda A Lee, director at Johns Hopkins Integrative Medicine and Digestive Center in Lutherville, Maryland, United States, told The BMJ, “Study of these types of therapies is challenging using the paradigm of the double blind randomised placebo controlled trial, which is what is used to evaluate the efficacy of pharmacological agents.

“For many types of traditional therapies, it remains to be established what is the best placebo. For therapies such as massage and acupuncture, for example, it is not always possible to blind practitioners and patients to the therapies. In contrast to pharmacological studies, there is often a lack of sufficient industry or national support to conduct large clinical trials.”

Anil Kumar Ganeriwala, joint secretary of the Ministry of AYUSH, told The BMJ, “AYUSH Research Councils, which have 81 research centres across the country, are collaborating with other institutes on clinical trials of the safety and efficacy of drugs so as to meet the US and European Union regulations.” Private research centres are also researching ayurveda.

Critics argue that some ayurvedic remedies have no proved curative properties but may work as placebos. Ram Vishwakarma, director of the Indian Institute of Integrative Medicine in Jammu, warned, “There is no shortcut in bringing the treatment modalities of ayurveda to patients without addressing evidence based preclinical and clinical studies, safety, quality control, and GMPs [good manufacturing practices].”

He told The BMJ, “New drug discovery from medicinal plants has a rich history from aspirin to quinine to artemisinin. Therefore there is a great need for continuous research and development on ayurveda and its plants and concepts.”

Ayurvedic therapies can pose safety risks if taken unsupervised and used incorrectly, especially drugs that have metallic ingredients or herbal products that are contaminated, not of standard quality, or admixed with synthetic drugs. “Due to lack of awareness and lack of scientific data, potential interactions affecting bioavailability of drugs taken concomitantly may cause concerns.” DBA Narayana, member of the Indian Pharmacopoeia Commission’s scientific committee and chairman of its herbs and herbal products committee, told The BMJ.

Serious conditions

Johns Hopkins Medicine, an integrated global health enterprise with its own medical school and hospitals, has a caution on its website: “While Ayurveda can have positive effects when used as a complementary therapy in combination with standard, conventional medical care, it should not replace standard, conventional medical care, especially when treating serious conditions.”8

Lee said, “Studies in the US suggest that most people who are interested in using traditional therapies wish to do so in conjunction with, rather than in lieu of, their conventional therapy. Patients choose to use these therapies for myriad and sometimes complex reasons. For example, some cancer patients wish to use these traditional therapies not to treat their cancer directly but to manage symptoms or common side effects, such as fatigue, insomnia, nausea, neuropathy, or digestive symptoms.”

In India the private sector provides 80% of outpatient care and 60% of inpatient care, resulting in huge out-of-pocket expenses.9 Traditional treatments are generally not covered by private health insurance, except for some social insurance programmes and the Central Government Health Scheme.

“For a common cold or temporary stomach upset, ayurvedic medicines may cost about Rs50-100. For a major ailment requiring continuous medication for a couple of months, it may cost about Rs500 a month. Three week long inpatient therapy for a debilitating disease may cost about Rs75 000-150 000,” said TS Muraleedharan, chief of technical services at the charitable institution Arya Vaidya Sala in Kottakal, Kerala.

Self help health management

Darshan Shankar, vice chancellor of the Transdisciplinary University (Institute of Transdisciplinary Health Sciences and Technology) in Bangalore, suggests setting up a fourth tier of self help health management that is not institutionally driven like primary, secondary, and tertiary healthcare but where the providers are millions of households. “The traditional Indian medicine system has many simple and cost effective solutions for common ailments, prevention, and wellness,” he told The BMJ.

Health activists argue that a more patient centred approach to healthcare is needed if universal healthcare in India is to become a reality. “Allopathic treatments have provided longevity, and ayurveda can add quality to this prolonged life. The government needs to implement a policy framework whereby integration of traditional medicine systems with allopathy is validated,” Shailaja Chandra, former AYUSH secretary in the health ministry, told The BMJ.