The Indian Council of Medical Research (ICMR) under the Union Health Ministry and the Union Ministry of Ayush have agreed to enhance cooperation in health research in the field of integrated medicine. This move will help Ayush departments at the All India Institute of Medical Sciences (AIIMS) evolve into departments of integrated medicine. Will such an integrated system of medicine work? Ennapadam S. Krishnamoorthy and Cyriac Abby Philips discuss the question in a conversation moderated by Zubeda Hamid. Edited excerpts:
What do you think about the Ayush Ministry’s move to open inpatient and outpatient departments at Central government hospitals?
Ennapadam S. Krishnamoorthy: It looks like two kinds of collaborations have been talked about: one for practice at AIIMS and the other for research. This is a step in the right direction because it will enhance the treatments that we can offer under one roof. It will help build harmonised protocols for clinical care research, and this is especially important for non-communicable diseases, where our medical treatment options can be limited. Ayurveda and yoga are the mind-body medicine of India. We have a duty to take them to the world. That is what integrative medicine is all about.
Cyriac Abby Philips: Integrative medicine does not feature in any scientifically progressive society in the world because it is like mixing something that works with something that does not and then giving undue credit to things that do not work. Ayurveda and homeopathy are pseudo-scientific practices. There is no evidence for their use for any disease condition as preventives or treatments. When you cannot enable your people to afford good healthcare, you mix things to mislead them. It is proposed only in places where, like in India, you have a huge gap to bridge in the actual [provision of] healthcare to the masses.
Dr. Philips, you had previously said that sometimes, alternative medicine, which could be laced with modern drugs or heavy metals, has caused injuries to the body. What is the prevalence of the use of alternative medicine? Does the sale of these medicines need to be regulated?
Cyriac Abby Philips: About 50% of people use complementary/alternative medicine, and more than 70% have used it at some point during their lifetime. This is because it is promoted and advertised. There are no evidence-based benefits, and people can get it over the counter. Because we lack data on safety and efficacy, a lot of people develop side effects and experience adverse events, the most common being liver injury. This is mostly because of adulteration or contamination or direct toxicity of particular herbs in the product. We have no pharmacovigilance happening here.
Ennapadam S. Krishnamoorthy: Complementary/alternative medicine is not restricted to India. It is a global phenomenon. It is not just internal; there is a whole range of procedures. There are concerns about erroneous products that can damage the body, and a lot of these are provided over the counter. But again, the nutraceutical industry is larger than the pharmaceutical industry globally. I believe there is room for sensible use and practice. I agree it has to be regulated. I also believe that all formulations should be treated equally in terms of standards.
Do we need standardisation of formulations, randomised control trials (RCTs) and peer-reviewed studies of traditional medicine?
Ennapadam S. Krishnamoorthy: Quality control is vital. There has to be standardisation of formulations, whichever domain they come from. Also, RCTs are not the gold standard for everything. They are the gold standard for drug formulations, and I believe that all internal drug formulations must be subject to RCTs. But in the domain that I work with, i.e., autism and dementia and other chronic diseases, it is virtually impossible to run an RCT for many non-pharmacological therapies. I don’t believe that everything in modern medicine is fantastic and everything in traditional medicine is not great.
Cyriac Abby Philips: We must look at standardising a formulation only when we identify it as being potentially useful for patients. When it comes to Ayurveda or homeopathy or any integrated practice, whether internal or external, none of them have conclusively proven to be of benefit. So, why standardise a formulation or a practice which has no benefits to start with? But then there is a lot of health misinformation around, because of which we are forced to educate people on how this can impact them negatively. So yes, standardisation is important, so we can reduce the health burden. And regarding RCTs, they are the gold standard for actual diagnosis or a particular intervention that can improve a condition. Alternative/complementary medicine runs away from RCTs because they know that it is not going to be good for them.
Many patients use traditional systems of medicine, many others use modern medicine alongside traditional systems of medicine. One of the approaches of Ayurveda, for instance, is to focus on a unique cure as per an individual’s circumstances. Naturopathy focuses on non-invasive treatments. In a world where popping a pill is the norm for any ailment, alongside a growing mistrust of the pharma industry, is there a reason why some people gravitate towards these particular approaches?
Cyriac Abby Philips: People think that modern medicine is all about prescribing pills. Proponents of complementary/alternative medicine also indoctrinate patients about modern medicine being just [about] pill-pushers. This is wrong. A lot of guidelines promote preventive medicine as one of the biggest aspects of treatment, where there are no pills prescribed, you have properly studied and effective lifestyle changes, and a lot of other external varieties of treatment. The most important aspect is to make people understand the right healthcare choices for them, which have the least risk when done within that particular evidence-based margin. With alternative medicine, you don’t have a proper safety net or a benefit net. People must understand that integrative medicine is a business. Data show that it increases the cost of care and does not improve the patient’s clinical outcomes.
Ennapadam S. Krishnamoorthy: Modern medicine is a business too. I’m a doctor of modern medicine and I prescribe medicines to my patients all the time. But I also offer them integrated healthcare approaches to help them get better. In the domains that I am familiar with, the non-pharmacological therapy trials that get published are very much about things that happen in traditional healthcare practices. So, I don’t believe that no research happens. There’s even a journal of integrative medicine that is peer-reviewed. We should not assume that we know everything and our patients know nothing. A good integrative medicine practitioner helps patients make and practice safe choices. Ayurveda is an ancient system of medicine. Nothing lasts for centuries if it does not work. The Ayush market in India has grown, which means that the consumer is choosing it. We can’t ignore that.
So, why do patients gravitate towards complementary/alternative medicine?
Ennapadam S. Krishnamoorthy: I think there are five barriers to healthcare: awareness, access, acceptability, affordability, and accountability. A person with chronic disease gravitates because they have already tried a number of things. Take mental health. If I have been on different types of medications for years and it’s not having an impact on me — 10-20% of people are pharmacotherapy non-responders — isn’t it natural that I will start turning towards other things that may help?
It’s also acceptability: often, medical consultations are very short, you have not had a proper conversation about your health. Rightly or wrongly, that’s better facilitated in other settings, which people gravitate towards.
Cyriac Abby Philips: From a science-based practitioner’s perspective, there is not enough communication happening. I agree with Professor ESK: it’s not just about sending [patients] to the pharmacy, there has to be a human connection and compassion. Once there is a gap between the patient and the doctor, that gap is filled by alternative medicine. With good communication, and evidence-based and compassionate care, a lot of alternative medicine practices can die down. Important, informed decisions from patients come only when doctors put patients first and discuss evidence-based options first and then go towards non-evidence-based options. I don’t think integrative medicine has any major role to play now other than being a cost burden. But I hope this will change.
Ennapadam S. Krishnamoorthy: I believe that many systems of medicine have a role to play in keeping human beings well. Modern medicine is extremely important. But there is a wealth of wisdom and ancient traditions which can be incorporated sensibly and safely for the well-being of man.
Ennapadam S. Krishnamoorthy is founder of Buddhi Clinic, Chennai; Cyriac Abby Philips is senior consultant and clinical scientist in Hepatology, The Liver Institute, Rajagiri Hospital