Covid-19: Government’s tacit approval of traditional medicine treatments alarms India’s doctorsBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4319 (Published 12 November 2020) Cite this as: BMJ 2020;371:m4319
When traditional health practitioner Nirmal Awasthi tested positive for covid-19, he turned to the therapy he has been prescribing to his community for months: ayurveda.
“I consumed kadha, a herbal decoction made of tulsi, pepper, ginger, and a few other herbs boiled in water twice a day. For the joint pain, I had moringa and ashwagandha powder. I was fine within a week,” he told The BMJ.
As the founder of the Traditional Healers Association of Chattisgarh, Awasthi has ramped up production of herbal medicines in the past few months. He sells the medicines at just under 100 rupees (£1; €1.1; $1.4) per 100 g and distributes them at government run primary healthcare centres and door-to-door across villages and towns in the state, to non-profit organisations and government agencies. He isn’t the only one.
On 6 October, the Ministry of Ayush (ayurveda, yoga and naturopathy, unani, siddha, and homoeopathy) released a set of guidelines for traditional practitioners.1 Treatments from traditional medical systems are being steadily adopted for covid-19 across informal and formal healthcare centres.2 It fits into the Indian government’s larger scheme of a “one nation, one health system” policy,3 planned for 2030, which will integrate modern and traditional systems of medicine. In September, parliament passed three bills to boost research and practice of alternative medicine.4
This comes as India records the second highest covid-19 case count in the world, with over eight million cases reported. As healthcare facilities are overwhelmed, a panicked public are growing reliant on alternative or traditional healing therapies where conventional medicine is lacking in resources and reach.
Lack of transparency
The ayush guidelines are based on “knowledge from ayurveda classics and experience from clinical practices, empirical evidence and biological plausibility, and emerging trends of ongoing clinical studies,” according to a statement by the ministry.
No details or results from ongoing clinical trials5 by research and tertiary care centres or private centres affiliated with the ayush ministry are, however, available publicly. The trials are registered in the clinical trial registry of India but there are no details of the protocols or how many people are enrolled.
R Meenakumari, director of the National Institute of Siddha, told The BMJ they have had four clinical trials underway since March 2020 to test the efficacy of kabasura kudineer. Tanuja Manoj Nesari, director of the All India Institute of Ayurveda, says its 500 doctors have remained free of covid-10 infection despite being on the front line “because they were consuming the ayurveda preventive kit daily,” which has also been provided to 80 000 police in Delhi over a period of two months. She claims the initiative has brought down the incidence of the infection though, again, no study results have been made available.
Doctors and public health experts across the country have voiced their concerns about the government increasingly legitimising the use of alternative medicines during the pandemic without a body of evidence.
A few days after the health ministry released its ayush protocol for covid-19, the Indian Medical Association (IMA) challenged Health Minister Harsh Vardhan on the claims6 stating in a letter that he would be “inflicting fraud on the nation and gullible patients by calling placebos as drugs” if the approval continued. IMA president and orthopaedic surgeon Rajan Sharma said, “We had to make a statement, because if a layperson takes the government’s guidelines as the gospel truth, their symptoms will be neglected as they go from mild to moderate to severe.
“Were all the ministers who were infected with covid-19 taking herbal medicines? If they were, why did they get covid-19?” Sharma said, adding, “If ayush has been proven to cure covid-19 there should be nothing stopping ministers from handing over control to the ayush ministry. Why did so many of them go to allopathic hospitals for treatment? We can’t have two sets of principles—one for the general public and one for the ruling party.”
Traditional medicines are widely available without prescription in India. The market is flooded with “immunity boosters” and doctors are warning against the side effects of overconsuming over-the-counter drugs.
Joyeeta Basu, an allopathic physician based in Gurugram, north India, told The BMJ, “I have been seeing many patients with gastritis and an upset stomach, who’ve consumed too much kadha, especially in the summer. Many of these powders have too much ginger and peppercorn and are very strong.”
“Ashwagandha, a plant, can irritate gastric tissues. It can also cause blood pressure to drop and thyroid levels to rise. The moment we stopped patients taking it, their levels went back to normal. A patient who was on the homeopathic drug arsenicum album for six months had his platelet count drop. It went back up four weeks after he stopped taking it.” Homeopath Abhijit Indraprastha told The BMJ that there is no evidence that arsenicum album works as a preventive for covid-19, even though the ayush ministry said in March that it does, leading many Indians to consume it daily.
“We don’t really have documented side effects of ayurveda and homeopathy. It’s now, during the pandemic, that people are taking it so often and we are seeing the side effects,” said Basu.
There are rising cases of self-medication and patients mixing different medicines. Anant Bhan, a public health researcher at Yenepoya University, in the state of Karnataka, says, “ Because of the claims being made of ayush medicines, people are layering therapies, mixing them with allopathy, and this is worrying because we don’t know how these different systems interact with each other in the body.”
The boom in consumption has alarmed even the regulatory bodies of alternative medicines, such as the All India Institute of Ayurveda, who have started cracking down on companies pushing products without a licence. In June, yoga and ayurveda guru Baba Ramdev claimed that his ayurvedic medicine Coronil could cure people of covid-19. The ayush ministry stopped his company from selling it as a cure but later allowed it to be sold as an “immunity booster.”
Despite unproven claims, traditional medicine fills a serious healthcare gap in India. Studies have found informal providers account for 68% of the total provider population in rural India, especially in areas with poor access to hospitals. It is also relatively cheaper than conventional medical treatment.
Hariramamurthi G, head of the Centre for Local Health Traditions and Policy, who works with a network of healers, said there are at least one or two healers per village that serve 600 000 villages. “Coronavirus cannot be managed unless we engage communities. How can we handle such a pandemic, especially in rural areas of India, where there is a total lack of public and private health facilities and personnel?” he said.
But a shortage of medical professionals doesn’t mean scientific scrutiny should be sacrificed, say doctors. A Times of India investigation on 17 October7 revealed many private hospitals were using ayush doctors in intensive care units to make up for staff shortages.
What worries R V Asokan, secretary general of the IMA, about the ayush covid-19 guidelines is the lack of transparency in what has been made a national protocol. “For example, the entire discussion on hydroxychloroquine has been in the public domain. So, our demands are that the ayush protocol should be similarly evidence based, it should be repeatable in other centres across the world, it should be a double blind controlled study, and the strength of the evidence should be in the public domain.
“In my opinion, what is happening is pseudo-nationalism masquerading as protocol, which is wrong. It is a dangerous trend and can cost lives.”
Commissioned, not peer reviewed
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.