Opinion How AYUSH and modern medicine can work together

In a competitive model, the two systems of medicine exhibit rivalry. While individual practitioners can always do as they please, in this scenario, name-calling will also occur at the systems or professional association level.

Professional associations/councils will take a stand against each other and initiate litigation. Both systems will compete to get the patients to their system by pointing out their strengths and other systems’ weaknesses. These could be related to effectiveness, side-effects of their products and extraneous factors like nationalism or commercialism. In short, “all is fair in a war”.

In the “coexistence” model, each recognises the legitimacy of the other systems and opts for clear boundaries to ensure that they coexist without encroaching on others’ domain or realm. Most modern practitioners would let patients decide whether they want to take AYUSH treatment. They would advise the patients to continue the medicines or accept responsibility for their discontinuation. If AYUSH is effective, then the medicine dose will automatically be reduced.

Ayurveda and homoeopathy practitioners usually ask that the patients stop their modern medicines if they want to initiate their therapy. In this model, these practitioners could be co-located at a facility, with each therapy having a separate system. However, there is no mutual referral. In short, the principle is “live and let live.”

The “cooperation” mode is the ideal integrative medicine model where the two streams acknowledge what is good in the other system and work jointly as a team to deliver the best possible care to the patient. This has the potential to improve the preventive and promotive component in modern medicine which is much too medicine-focused.

I see four sets of challenges before this. The first is the trust deficit between the two groups. There have been many instances of patients who were well or ill-controlled on one therapy, switched to the alternative treatment, and end up worsening or improving their disease. Most of these are anecdotal evidence and can be quoted to justify whatever point of view one holds. This is worsened by claims of effective cure for diabetes or cancer by AYUSH proponents without adequate evidence to support it.

The technical challenge is that AYUSH is a heterogenous group and each of these therapeutic disciplines must be dealt with separately and would need a different decision. Increasing evidence available on the effectiveness of yoga for the management and prevention of different health conditions has resulted in its growing acceptance among modern medicine practitioners.

For non-pharmacological aspects, it might be easy to integrate once the evidence is generated. It is the prescription of medicines (ayurveda/homoeopathy) which will remain a bone of contention. Can a dosha-based management, proposed by ayurveda, work with the standard management protocols that are being pushed in modern medicine?

In terms of operational challenges, for a team-based approach to work, the team members must know their own limitations and acknowledge others’ strengths in that area. Modern medicine practitioners have no idea of the AYUSH streams and cannot make an informed decision in this regard. They will have to accept at face value what AYUSH practitioners are saying, which is difficult given the trust deficit. Patients themselves are not informed enough to take these decisions and leaving it to them to decide is not appropriate.

However, the most challenging aspect of this integration would be its regulation. Many modern practitioners prescribe some ayurvedic pills without understanding their method of action. This is not acceptable and in conformity, AYUSH practitioners also should not practise modern medicine. While this appears reasonable, its enforcement is currently very weak. These areas fall under the jurisdiction of respective professional councils. Unfortunately, councils have failed to inspire confidence in seeking professional accountability. If something goes wrong with the patient, who will be held accountable?

So how do we move forward? The first step is to get better evidence for AYUSH treatments. Only this can bridge the trust deficit. Also, use this opportunity to weed out ineffective treatments in AYUSH. If evidence is available, it might be possible to build composite standard treatment guidelines that combine the best of the two streams. However, the evidence benchmark applicable to modern medicine must apply equally to AYUSH therapies. This has been one of the major fault lines in this debate. I believe that if we look at the evidence without being influenced by extraneous considerations, we could arrive at a consensus for certain chronic conditions. These could be a good starting point for a larger discourse.

Will it help if we teach these subjects to the other streams? Ayurveda courses teach some modern medicine concepts. Should MBBS students also be taught all AYUSH subjects? The MBBS curriculum as such is quite heavy with never-ending pressure to put greater emphasis on certain subjects. Adding AYUSH subjects to MBBS will worsen the situation. One way is to not have exams in these subjects or make them optional. However, there is a good possibility that they will not be read at all, and the objective would not be served. I do not recommend this course.

A good regulatory framework that establishes rules/guidelines for collaboration, communication, and referral between practitioners of different modalities, ensuring coordinated and safe care for patients with clear articulation of accountability is much needed. It would need to define acceptable interventions and modality of its determination. Other regulatory issues would be related to insurance payouts, compensations, quality of medicinal products and medicines. This could be within the health technology assessment framework already available in India. The bottom line is that our approach must be evidence-based. While some of the issues can be addressed and evaluated in pilot projects, it will not work without a strong regulatory framework.

The writer is professor of community medicine at the All-India Institute of Medical Sciences, New Delhi. Views are personal