This article is written by Raslin Saluja, from KIIT School of Law, Bhubaneswar. This article analyses the Central Government’s notification to allow formal training of surgeries to Ayurvedic doctors and postgraduate students.
The Central Government of India sanctioned through an official gazette notification on November 19, 2020, to the Central Council of Indian Medicine (CCIM, statutory body of the Ministry of AYUSH) and brought an amendment to the Indian Medicine Central Council (Post Graduate Ayurveda Education) Regulations, 2016 to introduce formal training of surgeries for Ayurvedic doctors and postgraduate (PG) students. The Act has now been renamed to Indian Medicine Central Council (Post Graduate Ayurveda Education) Amendment Regulations, 2020.
The amendment states that the curriculum of these students will now also incorporate training to perform two streams of surgery under the title of MS (Ayurveda) shalya tantra (general surgery) and MS (Ayurveda) shalakya tantra (diseases of ear, nose, throat, ENT, eye, head, oro-dentistry) specializations and removal of benign tumours and cataract operations. It has listed 58 surgical procedures that can be performed by Ayurveda PG students pursuing the shalya and shalakya courses.
The decision to integrate Ayurveda into modern medicine comes from the Centre’s aim at having a ‘One Nation and One Health System’ policy by integrating various systems of medicines including Allopathy, Ayurveda, Siddha, Unani in medical practice, education, public health and research, for providing holistic care to the patients in India. This is inspired by the Chinese healthcare system, which strives to balance between modern and traditional Chinese medicine.
Another reason behind it is to address the persistent shortage of manpower in the healthcare system. As per a statement made by the Government in Parliament, there is only one allopathic doctor for 1,445 students. This is as opposed to the World Health Organization’s (WHO) norm of 1 doctor for every 1,000 people. Too many allopathic doctors are not willing to serve in rural areas and therefore there is a need to cater to them.
The need to integrate modern medicine with the traditional systems of AYUSH has also been mentioned in the recently released National Education Policy (NEP). The Government plans to have a “One Nation, One Health System” policy by 2030 which would integrate all the modern and traditional systems of medicine in practice, education and research. In furtherance of that, NITI Aayog has set up committees that will propose a framework for the integrative health system of Indian traditional systems with modern medical systems. The Government even aims to set up an exclusive drug control department to facilitate and enhance the research and development, monitor quality control and standardise the manufacturing of medicinal products of Ayurveda and other traditional Indian treatment systems. Thus a patient will be treated with the most suitable and appropriate method depending upon their condition irrespective of the medicinal system. The Union health minister even stated that they want to build the brand of India and make its global presence. They want to take the traditional medicine market in India and make it up to the quality standards according to international specifications.
Ancient Indian surgeons
Currently, as per the 2016 Regulations, the postgraduate students of Ayurveda specialize in Shalya Tantra, Prasuti evam Stree Roga (Obstetrics and Gynecology) and Shalakya Tantra. This means that they are already trained to perform many of these surgeries. The new notification only legalizes and clarifies what exact procedures these doctors are allowed to perform, which were already being performed for 20 years by the Ayurvedic practitioners.
The practice of surgery is not new to Ayurveda. Those supporting this move refer to Sushruta, the ancient Indian sage from 500 BC who is known as the father of surgery. The ancient text of Sushruta Samhita boasts in great detail the description of instruments and procedures that are followed even today.
Criticism and opposition
There have been repeated warnings from the Lancet that even though Sushruta Samhita talks about heart surgery and cracks, the measures described in the treatise are hypothetical. It suggested the Indian Health Ministry save its patients from incompetent doctors who have not learnt the basics of intricate surgery and that the mixing of the Ayurveda system of medicine with allopathy would be a medical blasphemy.
However, despite these apprehensions, the amendment was introduced which faced huge criticism from the doctors countrywide. To that end, the Indian Medical Association (IMA) reflected its opposition and demanded the withdrawal of the notification by publishing a statement against it.
The IMA president in various reports stated that the National Eligibility cum Entrance Test (NEET) appeared by lakhs of students will lose its importance. Education will be reduced to mediocrity which cannot be tolerated. It will create a double system. The patients might not be clear on who their doctors are, what course of medicine they are following and how qualified the doctors are to perform such surgeries. The doctors were worried that it would mislead the patients as the surgeries listed are performed by super-speciality surgeons. The IMA urged the CCIM to develop its own surgical disciplines from ancient texts and not claim surgical disciplines of modern medicine as its own. Moreover, these subjects are not taught at the Bachelor of Ayurvedic Medicine and Surgery (BAMS) level, hence allowing Ayurveda doctors to perform them with half knowledge would be risky. Even at the postgraduate level, Ayurvedic surgical training is a 3-year course.
The doctors see this integrative system as a khichdi medical system that will produce doctors in a hybrid system. IMA in its statement stated that the integration is “corrupting modern medicine by mixing with other systems and poaching the disciplines of modern medicine through the back door”.
Allopathic doctors see promise in Ayurvedic treatments and medicines as a supplement to modern medicine but are agitated, raising concerns for this practice of unguided mixopathy/crosspathy. Allopathy practitioners are terming it as encroaching upon the jurisdiction and nomenclature of modern medicine. They are concerned whether the Ayurvedic medical colleges and hospitals in their setting will be able to provide the same standards and quality of training as allopathic institutions. They are questioning the ability of the Ayurvedic doctors to perform critical procedures.
The AYUSH Ministry clarified that the notification was issued to streamline the provisions of the Postgraduate Ayurveda Education regulations by adding clarity and definition to it. The 2016 notification had stipulated that students will be undergoing training of investigative procedures, techniques and surgical performance of procedures and management in their respective speciality and the relevant syllabus was also issued for the PG course by CCIM. It stated that there has not been any policy shift and Shalya and Shalakya have been independent departments of Ayurveda colleges. The postgraduate Ayurveda students will be restricted in their training and practice of 58 types of surgical procedures and not practise surgeries beyond what has been mentioned in the list. The notification stated that there is no mixing of modern medicine with the ancient Indian Ayurvedic system as the CCIM is committed to maintaining the authenticity of Indian systems of medicine.
The associations were not satisfied with the clarification. In response to the notification, the IMA doctors even demonstrated a protest in 10,000 different public spots across the country on December 8, 2020, and threatened to close all non-emergency medical services on December 11, 2020, from 6 am to 6 pm, if their demands were not met. Doctors were wearing black ribbons to show support to IMA’s decision from all the medical institutes across the country.
The Maharashtra Medical Council published its circular on December 15, 2020, and stated that any person who obtains qualification from another system of medicine would not be allowed to practice the modern system of medicine. They have practised healing in scientific forms and do not associate with anyone professionally who violates this principle.
The doctors believe that modern medicine has evolved over years through evidence-based research and caters to serve the patients safely and effectively. This decision by the Ministry undermines all progress and can threaten human life and health.
Moving to Supreme Court
After projecting their opposition, the IMA decided to move to the Supreme Court against CCIM and filed public interest litigation (PIL) on December 19, 2020, urging the court to set aside/ quash the amendment introduced to the regulations to the PG Ayurveda Surgery and declare that the council does not have the powers to include modern medicine in the syllabus.
The plea stated that the concerned Regulations are subordinate legislation and are contrary to the specific legislative policy of the Medical Council Act, 1956 and Medicine Council Act, 1970. Thereby, the CCIM, whose powers are restricted to the system of Indian medicine, has transgressed its boundaries by introducing such enactment. It stated that the Regulations are arbitrary, ultra vires, illegal, unconstitutional and unreasonable in law, affecting the constitutional and fundamental rights of citizens to receive effective and safe treatment. Further, it causes prejudices to the rights of the millions of medical doctors across the country who have toiled hard over the years to attain the required exposure and qualifications for performing surgeries under the modern scientific system of medicine.
It also referred to the previous judgment of the Supreme Court in the case of Dr Mukhtiar Chand & Ors. v. The state of Punjab (1998) where similar attempts were made by the CCIM but were set aside by the Court stating that the persons who are registered on Central or State Registers of Indian Medicine under the 1970 Act are prohibited from practising Modern Medicine and this prohibition is also statutorily provided in Section 15(2)(b). It also cited the judgment of the Kerala High Court in the case of the National Integrated Medical Association v. State of Kerala & Ors. (2006), wherein the Court set aside the permission taken by the CCIM to allow persons holding qualifications under the system of Indian Medicine to also practice Modern Medicine. In both these cases, it was held that the CCIM does not have any power or jurisdiction to permit any persons possessing qualifications under the system of Indian Medicine to practice Modern Medicine.
Academic and research output
In research terms, few treatments of Ayurveda have been found successful by randomized controlled trials (RCTs). The equivalent outcome has been found in trials comparing conventional anti-diabetes treatment with the Ayurvedic system. Similarly, even in comparison to treatment in Rheumatoid Arthritis, Ayurveda has shown the same result with fewer adverse effects. Another RCT found that there was no difference between outcomes of treatment of diarrhoea-predominant IBS with Ayurvedic formulation and placebo. Even in cases of Covid-19, a study revealed that a combined application of both the treatments got the RT-PCR negative results in an average of 7.85 days as against 12.19 days for those on allopathic medicines.
Further, there has been increasing recognition and popularity of Ayurveda in the western world health care context. Ayurveda is said to focus on a person’s bio-psycho-spiritual unity and equilibrium and apply a human-centric approach to medicine based upon an individual’s connection with the surroundings and the way they perceive or “narrate” their own complex individual existence in sickness and in health. To that end, even the World Health Organisation (WHO) urges everyone to preserve, protect and safeguard these practices. It is supported by various clinical effectiveness tests and has a growing demand in the West which is inclining towards a more traditional-mind-shape approach to the multidimensional needs of the triad of disease-illness-sickness.
Many organizations and institutions have been working relentlessly outside India for the propagation of Ayurveda. Even the Department of AYUSH has been receiving requests from several Non-Governmental Organisations based in Europe and the USA (which are merging in the International Alliance of Ayurvedic Professional Associations—IAAPA) to have a mutual exchange of dialogue to develop a cooperative mechanism that can be implemented to ensure quality and professionalism in training, research, and practice of Ayurveda. The AYUSH Ministry has signed a memorandum of understanding (MOUs) with 25 countries. As for Italy, its medical Act already recognizes Ayurvedic and the other non-conventional medicines (since 2002) by the Italian National Federation of Councils of MDs and Dentists (FNOMCeO).
Many are of the view that there is no such thing as traditional or alternative or holistic medicine. The only distinction should be based on whether a medicine works or not. If we are to only logically reason from the point of view of the beneficial stakeholders i.e patients, then the practise should be such that the medicines that work are available to all practitioners and their patients. The antagonism between these sciences can only be ended by making them complementary in all respects. To make this concept successful, a similar level of scrutiny, quality standards, norms and requirements are expected from the practitioners; their qualifications need to be developed for all sorts of medicinal education and practice. Also, all the concepts of various branches of alternative medicine can be combined seamlessly along with integrating different treatments into modern medicine courses to produce doctors who are free to use the medicines that work and discard those which don’t.
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