Doctors Protest: Improving public health- Is 'mixopathy' the right way?

Getting into a medical stream:

In India, a degree in MBBS is mandatory in order to be a professional medical practitioner. This essentially involves a six-year-long education and training in various branches of modern medicine after the secondary school education in chemistry, physics, and biological sciences. In present times, with commercialisation of health-care and medicine, a career as a medical practitioner is perceived to be lucrative and therefore it is coming to be exceedingly competitive to acquire a degree in MBBS. To put it in perspective, in 2020 alone more than 13 lakh students from all over India appeared for NEET (a common entrance test for MBBS) while the total number of seats available is a meager 80,000 - enabling as low as 6% of students to enroll in MBBS. One rather interesting observation is that most of the students who make it to this 6% turn out to be from affluent families who could afford intensive coaching for NEET and other such competitive exams during or after their secondary education.

Gap between allopathy and alternative medicine:

A small fraction of the above students who do not make the cut opt for undergraduate courses in alternative medicines (AYUSH). These are students from relatively modest backgrounds who, in many cases, couldn't have afforded expensive and intensive coaching. They settle with the choices they are left with in despair. In an undergraduate course in BAMS, students learn ancient traditional interpretations (in contrast to modern scientific understanding) of human anatomy, physiology, pathology and diagnostic procedures from classic references written in Sanskrit. The oldest known references in Ayurveda (probably written around 800BC to 400 AD) are the Charaka Samhitha and Sushrutha Samhitha. It cannot be denied that traditional medicines which are empirical in origin made their contribution during times when the scientific understanding of biology was out of sight. Also, since they are integrated with indigenous cultural practices people tend to trust them easily. It is worth mentioning the case of the Chinese system of medicine which is also considered to be one of the oldest in the world. Chinese medicine, unlike Ayurveda, has been fully integrated with modern medicine and the traditional practitioners (barefoot doctors) were given training by the experts in modern medicine for six months to one year. However, in India there have not been enough attempts to modernise Ayurveda. Widespread conservatism in academia and among policy-makers treat Ayurvedic practices as sacrosanct. Since ancient practices are considered holy (as in Vedic tradition) it stands impervious to any kind of questioning and scientific trials. The other important reason for the cleft between allopathy and traditional Indian medicine is the perception of allopathic doctors to this kind of medicine as quackery.

The new amendment

The number of practicing MBBS doctors to population ratio in India is below the WHO recommended level. The scarcity of specialist and super-specialist medical professionals has also been very alarming and this became more apparent during the COVID-19 crisis. The government is often criticised for not taking appropriate measures to balance this situation. Probably with an intention to cover-up this lack or to exaggerate the ancient texts, a strange notification was recently issued by the CCIM (Central Council of Indian Medicine) about the surgical procedures in modern medicine that are allowed to be performed by a postgraduate Ayurvedic doctor. This is absurd for the following reasons:

1) Modern surgeries come under therapeutic practices of allopathy and may not necessarily align with ayurvedic medicine. Ancient surgical practices cannot be considered equivalent to modern surgical techniques.

2) Performing a surgery is a highly complex skill that is part of a long and comprehensive understanding of modern medical science, and therefore cannot be treated as an easily acquired vocational skills.

3) Apart from surgical routines, a sound knowledge in modern anatomy, pathology, microbiology, pharmacology, and anesthesia are essential and these cannot be overlooked.

The ministry of AYUSH defends its decision saying that its practitioners have been performing surgeries since ages and only modern scientific terminology is being used at present to facilitate effective communication among various stakeholders. But the very use of this modern scientific terminology has serious concerns and has every chance to confuse the layman who might not think of checking the degrees of a doctor before getting operated on for a disease. The ministry also responded to the concerns raised saying that it is deeply committed to maintaining the authenticity of Indian systems of medicine (as it always does), and is against any mixing with modern medicine contrary to the earlier indications apparent from a scheme which was announced last year (Scheme for Integrated Health Research) which aims to integrate AYUSH with modern medicine. First, to make things clear, there is a gross disconnect among the various schools of medicines and any ad hoc attempts to integrate them will be proved dangerous if not done in a scrupulous manner. A better way is to integrate them sequentially - and speciality branches of surgery (general surgery, Gastroenteric surgery, Ophthalmology, ENT, Dentistry) are definitely not a good entry point. Every person regardless of his or her socio-economic status or literacy status or regional preference should have the right to get quality medical and surgical care.

In this context, the apprehensions of the Indian Medical Association (IMA) and other medical doctors seem justified. But the leadership of IMA should also remember the moral obligations they have and clear their stand on privatisation of medical education which led hundreds of medical students to join MBBS courses just because they have the money to do so. Even the post-graduate medical education degree which requires much more mental faculty has been made available for a price! The association has also in the past not done enough (in the public interest) to counter detrimental practices of private medical institutions for obtaining a license to run the college. It's high time that the IMA introspects its crucial role in society and stands for the greater good.

An insight on the existing system and probable solutions:

Governments often defend the decision to integrate and recruit AYUSH doctors at the village-level by saying that specialist doctors trained in modern medicine lack interest to serve in rural areas. This is also a flawed argument for three reasons. First is the lack of specialist doctors in proportion to MBBS doctors produced. Second, the failure of successive governments to provide basic amenities to the professionals who desire to work in rural areas. Third, the lack of confidence in the new professionals to serve independently in rural areas.

A medical professional, either allopathic or alternative, not only has personal needs such as desiring a decent education and atmosphere for their children, but also need amenities such as functional space and operation theaters, latest equipment, supportive staff from anesthetists to assistant surgeons, nursing staff, and cleaning staff. More than half of the Primary Health Centers in India which are supposed to be the first point of contact between people and the health system are ill-funded and ill-equipped. Most of the recruitments made are either contract-based (temporary) or politically-influenced if permanent. The need for qualified medical practitioners in rural areas is arguably true but this should not be the reason for providing unskilled workforce to rural populations and jeopardising their safety.

Some of the above concerns can be addressed by giving special training to the MBBS graduates who are already in the stream of modern medicine and are ready to serve in rural areas voluntarily in a discipline called family medicine. This training programme prepares them in a holistic manner to practice confidently in rural and urban areas, where there's a need to provide health care across a range of specialisations (Obstetrics, emergency medicine, anesthesia, etc). It is worth mentioning the example of People's Polyclinics in erstwhile Andhra Pradesh which were successful in giving training to a number of MBBS doctors in basic procedures in all areas of medical specialisation informally for three years so that they can provide some level of medical care to patients that is otherwise only provided by specialty doctors. They also trained village health volunteers to provide first aid in remote and rural areas.

To conclude, focus on the promotion of health and prevention of diseases at the primary level requires minimal finances and alleviates the need for specialist doctors in the long term. This should be the center of all policy interventions to achieve the goal 'health for all'. Provision of secondary and tertiary level surgical interventions that need greater resources in terms of material, finances, skills and training can be made accessible and affordable over a period of time with meticulous planning. The meager public health spending in India (<1.5% of its GDP) has to be increased significantly and the efforts of the government should be directed towards reducing the high out-of-pocket expenditure to the general public which most of the time even throws them below the poverty line. Only then can we ensure the provision of quality medical services to each and every person.