A clear reading of the Ayurveda surgery move

In 2014, while speaking at the inauguration of a hospital in Mumbai, Prime Minister Narendra Modi extolled the virtues of India’s medical heritage. “How else would Shiva have grafted an elephant head on Ganesha after having beheaded the boy,” he asked to thunderous applause from an audience of senior doctors and very important persons. Shiva as a surgeon is of course mythology. But we know about Sushruta and his surgical dexterity at a time when the world had not yet woken up to the art and the science of surgery. There are detailed descriptions in the Sushruta Samhita, the ancient Sanskrit text on medicine and surgery, of procedures such as rhinoplasty where the nose is reconstructed with tissue from the cheek. It was thousands of years later that modern plastic surgeons described this procedure.

Response to notification

Last week, on November 20, a Gazette of India notification by the Central Council of Indian Medicine — a statutory body under the Indian Medicine Central Council Act, and “which regulates the Indian Medical systems of Ayurveda, Siddha, Sowa-Rigpa and Unani Medicine” — identifying surgical procedures that can be performed by post-graduate Ayurvedic doctors in Shalya (surgery) has stirred up a hornet’s nest.

Also read | Nod for Ayurveda PGs to perform surgeries

Many of the reactions are on predictable lines. The Indian Medical Association (IMA) has written a curious self-flagellating letter to the Prime Minister. Allopathic surgeon colleagues are outraged. Social media and WhatsApp groups are abuzz with alarmist responses. Some have portrayed doomsday scenarios, ‘where our children will be operated’ by half-baked ‘Ayurvedic doctors’ in the future.

After 1947, what the state did

What is the overexcitement about? It is useful to go back a bit into history to understand the imbroglio better. After Independence, the Indian state was faced with the difficult task of accommodating both the ascendant modern medicine brought in by the British and India’s traditional systems of medicine, notably Ayurveda. There were two options. One was to take the best from all systems and integrate them into one cohesive science. This was possible but not easy as the systems have certain incompatible differences of approach.

Faced with this vexing question, the state attempted everything. It patronised and encouraged formal medical education in modern medicine as well as in other traditional systems. For a brief period there actually existed ‘integrated’ courses, wherein both Ayurveda and Modern medicine were taught to students. But these withered away partly due to opposition from purists in Ayurveda who were outraged by the ‘dilution’ of their science.

Also read | West Bengal doctors’ body opposes move to permit surgery by Ayurveda students

Thus, the degree in Ayurvedic medicine became largely an Ayurveda course. However, it was necessary out of a practical career compulsion to teach the basics of modern medicine to these graduates. They had to survive in the medical market, which by that time was the dominant form of health care in India. Most Ayurvedic graduates entered general practice. More importantly, several of them went on to work in rural and under-served areas. Some set up nursing homes. In rural Maharashtra, several nursing homes were run by integrated graduates. In Chiplun in the Konkan, for instance, the only nursing homes offering emergency obstetric and surgical services were run by non-allopathic graduates. In health care, availability is often more important than quality, specialisation and such extravagant ideas.

Handling an identity crisis

As modern medicine made rapid strides, Ayurvedic graduates experienced an identity crisis. Many of them had joined the course not for the love of Ayurveda but to get a degree with the honorific ‘Dr.’ which gave them upward mobility, social status and even value in the marriage market. They could not but practise allopathy which most of them do. And became an important cog in the modern medicine machine. Thus, they became resident doctors, intensive care duty doctors and operation theatre assistant surgeons. They picked up skills, were diligent and unlike their counterparts in MBBS, were not constantly distracted by thoughts of post graduation and entrance exams.

Also read | Yoga, Ayurveda India’s ‘gift’ to global health: Minister

In an instance from a hospital, the Ayurvedic surgical assistant employed there closes the abdomen better than new trainees. In Mumbai, there is an instance of a homoeopathic graduate manning and training others on the extracorporeal membrane oxygenation, or ECMO, a complex heart lung machine in the largest unit used for critically-ill COVID-19 patients. In Maharashtra, the ‘108’ emergency response ambulance service is manned by non-MBBS doctors. During COVID-19, a large number of the quarantine centres were manned by these doctors. Incidentally, they work for less pay which allows hospitals to control costs and even make profits. All this is not a rationalisation but an explanation which we ought to know.

Now to the idea of Ayurvedic surgeons. In an effort to develop postgraduate programmes, Ayurveda medical colleges developed one in “Shalya’ or “surgery”. This is awkward as unlike the vast pharmacopeia, there is really nothing called Ayurvedic surgery. A procedure called ‘Kshar Sutra’ used for anal fistula was described in Ayurveda texts and has been incorporated in modern medicine. In fact the Indian Council of Medical Research conducted a trial on this many years ago. To my knowledge, “Kshar Sutra” is the only substantive contribution.

Also read | WHO to set up centre for traditional medicine in India, PM says matter of pride

Most Ayurvedic medical colleges run hospitals. In some areas, theirs is the only viable and equipped hospital. I am aware, for example, of the phenomenal work done by a surgeon in an Ayurvedic hospital in South Konkan who served the community for many years and at very low cost. Even today, even when there are several MS qualified surgeons, there is hardly a patient in this area who agrees for surgery unless they have his opinion. The Mumbai Municipal Corporation has appointed Ayurvedic surgeons to many of their hospitals, but I have not seen them perform any surgery.

Procedures and complexities

The controversial notification, issued on November 20 — called the Indian Medicine Central Council (Post Graduate Ayurveda Education) Amendment Regulations, 2020 — by the Central Council of Indian Medicine authorises an MS (Ayurved) Shalya Tantra, or General Surgery postgraduate degree holder on completion of his course to perform 58 surgical procedures. Some of the procedures in the list are rather complicated. For example, I would not even trust a modern surgical postgraduate to perform a removal of the gallbladder called cholecystectomy independently unless they have assisted or been taken through at least 100 odd procedures. For Ayurvedic surgeons to do it is an obvious overkill. It has been listed as “PittashmariNirharan-chhedan” in the notification.

A silver lining

But there are ways to look at the move beyond just outrage and alarmist social media tropes. Ayurveda graduates including surgeons are a large workforce in search of an identity. India needs them. If they are creatively and properly trained, they can play important roles in our health-care system. In fact as we have seen in certain situations, they already do. On site or ambulance care of trauma victims is in a shambles in India. It is effectively delivered by trained paramedics in many countries. Given the right training, pay and identity, Ayurvedic surgeons can be trained to strengthen this service and save hundreds of lives.

AYUSH, or Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy, is a priority area for the present government. The revival of Indian medicine fits well into a certain narrative. Be that as it may, the IMA in its opposition to such moves needs to be precise and constructive. Currently, its response is like faux chest thumping of a guild of insecure professionals. A former office-bearer of the IMA has been active on social media during the COVID-19 pandemic invoking Rahu Ketu in the war against the novel coronavirus. If the IMA is defending science, it needs to publicly oppose such opportunism also. Pseudoscience is not a preserve of Indian medicine.

If the noise is a turf war between an overambitious Ayurveda establishment on the one hand and modern medicine with a siege mentality on the other, it is a superfluous distraction which will hopefully die down. But if it is a pointer to an urgently needed and serious discussion about utilising India’s large workforce of non-MBBS doctors to improve access to decent health care for our ordinary citizens, then it is well worth our time.

Dr. Sanjay Nagral is a surgeon and writer from Mumbai

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Printable version | Jan 24, 2021 11:48:18 AM | https://www.thehindu.com/opinion/lead/a-clear-reading-of-the-ayurveda-surgery-move/article33187896.ece

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