December 2020

Integrative Medicine: Global Perspective Gundu HR Rao and Pratiksha G Gandhi Emeritus Professor, Lilehei Heart Institute, University of Minnesota, USA Chair Person, IPC Heart Care Center, Mumbai, India *Corresponding author: Gundu HR Rao, Professor, Laboratory Medicine and Pathology, Anesthesiology, Lillehei Heart Institute, University of Minnesota, USA, Tel: 952 594 5248; E-mail: gundurao9@gmail.com Rec date: Mar 15, 2014, Acc date: Mar 27, 2014, Pub date: Mar 29, 2014 Copyright: © 2014 Gundu HR, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Integrative medicine is an approach to care, which can be easily incorporated by all medical specialties and professional disciplines including, Indian Traditional Health Systems, and by all other health care systems worldwide. Its use will not only improve health care for patients, but also enhance the cost effectiveness of health care delivery for providers and payers and facilitate the development of universal health care for all. A practical strategy, integrative medicine puts the patient at the center (patient centric) and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health. Important elements of an integrative approach to health care include, engaging the patient as an informed and empowered partner and personalizing the care to best address the individual’s unique conditions, needs and circumstances. This approach is totally lacking in the modern allopathic system worldwide. The integrative approach emphasizes prevention, health maintenance and early intervention, and utilizes all appropriate, evidenced-based and personalized therapeutic approaches, to achieve optimal health and wellbeing across one’s lifespan. Although this is the basic strategy of all Indian traditional health systems, they lack evidence-based or observation-based clinical data, to support the benefits of such an approach. Global Alliance of Traditional Health Systems, a new platform that promotes integrative approach, is developing strategies to collect and collate observation-based clinical data on the safety and efficacy of Traditional Indian System of Medicine. In this presentation, we review some aspects of “Global Perspective” on this subject and suggest ways to develop and promote this method of healthcare delivery. Introduction South Asians have the highest incidence of coronary artery disease (CAD), compared to any other ethnic group in the  world [1-3]. In addition, they also have a high incidence of cardio-metabolic disorders such as hypertension, central  abdominal obesity, type- 2 diabetes (T2D), vascular disorders and stroke [1-4]. Currently we have 65 million type-2 diabetics in the country and an equal number of pre- diabetics [4]. To create awareness develop educational and preventive programs, I started a society, South Asian Society on Atherosclerosis and Thrombosis (SASAT) in the USA in 1993. Since then we have organized over 15 international conferences in India and published several books and scholarly articles on the subject. To promote the concept and practice of Integrative and Alternate Medicine, we are working with AYUSH, IPC Heart Care Center, Mumbai, as well as we are starting two new platforms, a dedicated institution, Institute of Preventive Medicine (IPM), and a professional society, International Society for Prevention of Atherosclerosis and Thrombosis (IPSAT). During SASAT-2010 conference in Bangalore, we organized a Round Table Discussion on the subject of “How to Provide Affordable Health Care to All”. The experts who were present in these discussions felt an immediate need for the creation of a novel platform that provides accessible, acceptable and affordable health care for all. Since the modern medicine as we know today, cannot be provided to all levels of the community, it was felt desirable to bring all the Indian traditional therapies on a common platform. In view of these observations, it was decided to launch a platform called, Global Alliance of Traditional Health Systems (GATHS: www.GATHS.org), to standardize and promote traditional therapies. We also launched a sister platform called, Mind Body Spirit Society of India, to complement the Integrative Medicine. This concept was presented at the 4th World Ayurveda Conference (December 2010) in Bangalore. Bringing traditional methods of therapies as an alternative or complementary medicine is called “integrative medicine” in other countries [5-7]. In India and other developing countries, these traditional therapies are the mainstream therapeutic modalities available. Integrative medicine by and large, is an approach to health care that can be easily incorporated by all medical specialties and professional disciplines, and by all health care systems. If the integrated platform could be developed well, its use will not only improve health care for patients, but also will enhance the cost effectiveness of health care delivery for providers as well as payers. Since in a country like India, less than 10% of the individuals are covered by health insurance, we will have to find a novel way to empower people to take charge of their own health care. Integrative approach to health care should include engaging the patient as an informed and empowered partner and personalizing the care to best address the individual’s unique conditions, needs and circumstances. To develop such a system, we need to bring in multiple stakeholders and develop the needed infrastructure, at the level of the community health centers. In view of this need, we have launched an alliance of traditional healers (Global Alliance of Traditional Health Systems: GATHS), so that we can develop a well-harmonized, accessible, acceptable, and affordable health care to all. By bringing traditional therapeutic specialties like Yoga, Ayurveda, Unani, Siddha, Naturopathy and Homeopathy and the science of spiritual healing modalities, we can address the full range of physical, emotional, mental, social, spiritual aspects, which affect a person’s health. By treating the whole person (holistic approach), both the patient’s immediate needs as well as the effects of the long-term and complex interplay between a range of biological, behavioral, psychosocial influences can be addressed. This process enhances the ability of individuals to not only get well, but most importantly, to stay well. The integrative approach emphasizes prevention, health maintenance and early intervention, and utilizes all appropriate, evidenced-based

Note from the Prof. Dr. K. Kanakavalli, Director General, Central Council for Research in Siddha, Arumbakkam, Chennai. Question 1. Are the Siddha practitioners in a position to prescribe their standard treatment protocols that are already validated in the Siddha stream, at the Health and Wellness Centres to address all the standard tasks (maternal health, non-communicable disease, and so on). AYUSH practitioners posted at Health and Wellness Centres would also be required to attend to central government and state government disease control programmes, besides any other preventative programmes as per requirement. Answer 1. Yes, the Siddha Practitioners based on the training imparted during the Bachelor of Siddha Medicine and Surgery (B.S.M.S) curriculum and experience gained during the Compulsory Rotatory Residential Internship (CRRI) will certainly be able to handle the Standard Treatment Protocols available in the Health and Wellness Centres. In Tamilnadu, the Health and Wellness Centres are under the administrative control of Directorate of Indian Medicine and Homoeopathy (DIM &H), Govt. of Tamil Nadu. We now learn that standard treatment protocols were prepared but yet to be provided to Siddha consultants working in HWC. The exact number of HWC’s functioning as on date would also be available with DIM& H. Central Council for Research in Siddha (CCRS), an autonomous organization functioning under the Ministry of AYUSH is an apex body for research in Siddha system of Medicine. CCRS is constantly working towards developing Standard Treatment Guidelines (STG) for various diseases. Some of the works done by CCRS is as follows : a. Standard Treatment Guidelines (STG)s in respect of Siddha for malaria, dengue fever, Influenza, hepatitis, Encephalitis, Prevention & Treatment of Substance Abuse, Including Narcotic Drug Abuse and Nutritional need of children, pregnant & lactating women and geriatric population have been prepared. b. STG in respect to external therapies in Siddha have been published as Siddha Protocols and OUTcomes (SPROUT) for Siddha External Therapies. c. Recently, the Ministry of AYUSH has published Siddha Treatment Guidelines for Covid -19 d. An Intra Mural Research (IMR) project entitled “Development of Siddha Treatment Guidelines for Non-communicable Diseases (DSTGNCD)” have been completed which addresses Siddha treatment guidelines for Heart diseases, hypertension, obesity, hyperlipidemia, diabetes, cancer, arthritis, anemia, mental disorder, urolithiasis and polycystic ovarian diseases have been completed. e. Standard Treatment Guidelines (STG) for Skin diseases – Psoriasis & Ring worm infection, orthopaedic disorders such as lumbar spondylosis & osteo arthritis and Neurologic ailments – Hemiplegia & Migraine have been prepared. Question 2: At this first point of contact, there will be patients needing emergency attention, that will require some immediate curative steps to be taken. Some very real-world instances were cited in the Note circulated, example, a  aemorrhaging appendicitis, respiratory distress turning into viral pneumonia, a case of infant encephalitis, or the onset of a thrombotic stroke. Do the AYUSH doctors feel equipped to handle suchlike emergency cases. What manner of additional exposure / training would they require in order to begin handling suchlike cases? Answer 2. Siddha doctors definitely require training to handle Emergency cases as cited in the real-world scenarios. Moreover, they need to be taught to diagnose these emergency conditions including differential diagnosis. For example, they need to interpret an Echocardiogram (ECG). Additionally, life saving techniques like Cardiopulmonary resuscitation (CPR), should be taught and hands on training must be provided too. In toto, they must be equipped with the skillset needed o save lives. In the long run, it is better to equip the undergraduate students itself on “Emergency Diagnosis and Management”. During Compulsory Rotatory Residential Internship (CRRI), at least 3 months of posting in Emergency handling exposure is warranted.

Response from Dr. Mukta Sraj on mandate of HWCs and ability of Ayurveda Practitioners 1. The purpose of Health and Wellness Centers, as envisaged by Govt. of India is envisaged to deliver a comprehensive range of services which will address the primary health care needs of the entire population within the jurisdiction of each HWC, while expanding access, universality and equity within the community being served. 2. There is a pronounced emphasis on health promotion and prevention, designed to retain the focus on keeping people healthy by engaging and empowering individuals and communities to be responsible for choosing health seeking life style and regulated daily regimen which will together minimise exposure to the risk of developing chronic diseases and other morbidities. 3. A. Within this scheme of things, GoI envisages that primary health care needs include: • meeting people’s health needs throughout their lives; • addressing the broader determinants of health, such as clean drinking water and say, sanitation through multisectoral policy and action; and • empowering individuals, families and communities to take responsibility for their own health. 3. B. Primary and secondary prevention: • Vaccination and post-exposure prophylaxis of children, adults and the elderly; • Provision of complete information on the medical and health risks typically associated with behavioural and lifestyle management and what measures would be relevant and appropriate to reduce risks at the individual and population levels; • Inclusion of disease prevention programmes at primary and specialized health care levels, with access to preventive services (ex. counselling); • Nutritional and food supplementation; and • Dental hygiene education and oral health services. • Population-based screening programmes for early detection of diseases; • Provision of maternal and child health programmes, including screening and prevention of congenital malformations; and • Provision of chemo-prophylactic agents to control risk factors (e.g., hypertension) 3. C. Health promotion • Policies and interventions to address intake of tobacco and alcohol, the dangers of physical inactivity, and the benefits of regular, healthy diet (e.g., FCTC , DPAS, alcohol strategy and NCD best-buys) • Dietary and nutritional intervention would also appropriately tackle malnutrition, defined as a condition that arises from eating a diet in which certain nutrients are lacking, or are in excess (too high an intake), or in the wrong proportions • Intersectoral policies and health services interventions to address mental health and substance abuse • Strategies to promote sexual and reproductive health, including through health education and increased access to sexual and reproductive health, and family planning services, while cautioning about risky behaviour • Strategies to tackle domestic violence, including public awareness campaigns; treatment and protection of victims; and linkage with law enforcement and social services. The MoHFW also states that – the principle being “time to care” to be no more than 30 minutes. 3. D. Expanded services includes 1. Care in pregnancy and child-birth. 2. Neonatal and infant health care services 3. Childhood and adolescent health care services. 4. Family planning, Contraceptive services and other Reproductive Health Care services 5. Management of Communicable diseases including National Health Programmes 6. Management of Common Communicable Diseases and Outpatient care for acute simple illnesses and minor ailments. 7. Screening, Prevention, Control and Management of Non-Communicable diseases 8. Care for Common Ophthalmic and ENT problems 9. Basic Oral health care 10. Elderly and Palliative health care services 11. Emergency Medical Services 12. Screening and Basic management of Mental health ailments INPUTS from DR. MUKTA SRAJ (Ayurveda) 1. An AYUSH practitioner can take care of, and handle all the tasks and activities at the HWC except for the Emergency Care, which encompasses roughly 5-10% mortality in rural areas. 2. AYUSH practitioners can run a HWC single handedly tbecause their primary focus is expected to remain as health care promotion and prevention provided that they are also trained in basic life saving skills, so that they can contribute towards minimizing the mortality. 3. AYUSH practitioners could be trained in the diagnosis and treatment of the emergency care. Methods and medicines do exist BUT the major drawback is 1. No research on emergency Ayurvedic medicines 2. No research on Ayurvedic methods of Emergency handling 4. I have spoken to a few doctors both Ayurvedic private doctors and Allopathic doctors working as MO – 1. Many BAMS students have commenced working in private hospitals and have begun to handle emergencies as soon as they complete their internship. Today there are a fair number of young Ayurvedic students with knowledge of equipments and methods used in emergencies 2. Many MO’s placed in the field, across rural India, shared with me that they have barely encountered any emergency healthcare that that cannot be sent to CHC 5. The maximum part of the HWC include the Preventive and promotive health , and that is the USP of AYUSH. Role for Ministry of AYUSH 1. To help the teachers and practicing doctors to test the emergency methods they have 2. Then proceed further: these knowledgeable emergency care, AYUSH practitioners can train the students during their Graduate level education AS PART OF THE CURRICULUM. 3. Since this will benefit the next generation, for now, AYUSH practitioners in HWCs would need training in basic life saving skills before appointment.  

There is an indication that the Working Group of the Mahamana Declarations-2020 is concluding that Ayush practitioners are not fully equipped to be the first point of care at the Health and Wellness Centers (HWCs) of the Union government’s Ayushman Bharat programme. Well-trained Ayush practitioners could become a reliable workforce to address acute illness-related healthcare needs of people living in remote rural villages. The 2018 GOI Scheme on Health and Wellness Centres, stated Ayush practitioners, are slated to be posted as the only doctor of primary contact across the 1.5 lakh HWCs. It is here a Special Interest Group of the Mahamana Declarations examines the extent to which the Ayush practitioners are equipped and ready to handle this responsibility. Meenakshi Datta Ghosh, member Mahamana Declarations, former secretary, Government of India and Chair Vertical 4 during an interaction, wherein Dr. K K Aggarwal, Co-Chair and former president, Indian Medical Association, drew attention to what would potentially happen on a regular basis at any given HWC. “Incoming persons could require routine attention and treatment as in dengue or malaria; urgent and priority attention, as in a caesarean, or paediatric encephalitis; and emergency attention, as in a road accident, onset of a thrombotic stroke, need for immediate drainage of sepsis, and so on. At these HWCs unless there is clinical competence to perform life-saving emergency and critical care to save lives during the most important Golden Hour, we could be in for adverse outcomes,” pointed out Dr Aggarwal The Ayurveda and Siddha representatives at that meeting uniformly responded that they have no significant training to handle emergency care. They expressed a serious lack of confidence till such time as they are given comprehensive, targeted and differentiated training on lifesaving technologies and related, feasible interventions. They do not feel clinically competent to handle emergency care. They expressed that archaic curriculum across Ayush medicine has ensured inadequate exposure to a cross-section of medical conditions, which is needed to acquire clinical proficiency. This infirmity needs to be addressed upfront. It would transform their image as well as capabilities, said Ghosh. Ayush practitioners were confident that preventive and promotive medicine is their forte, and hence routine handling of maternal-infant care, and non-communicable diseases is no problem at all. Ghosh added that the changing role of the Ayush practitioner is also an issue. Today, no more than 18 per cent Ayush practitioners function from rural India, while 82 per cent are functioning from urban areas. Among these, a majority are seen to be practising allopathic medicine. At the rural HWCs, they will be called upon to implement central and state government health schemes of which they now have only a vague idea. The younger Ayush practitioners find that remuneration and living conditions in rural areas are a problem. Recently vacancies announced for Haryana and Madhya Pradesh saw a gap of Rs. 40,000/ per month between allopathy and Ayush salaries, she added. The Mahamana Declaration on Ayush is a platform with nine verticals, coming together in a Working Group once every six weeks, to take stock of the tasks covered. One Working Group meeting convened online, by Bejon Misra, advisor-consultant IMS, BHU, recently was chaired by Prof. YB Tripathi, Faculty of Ayurveda, Institute of Medical Sciences, BHU, Varanasi. The nine verticals address standard setting among the different streams of Ayush, regulatory oversight, value of bringing scientific rigor, leadership, and so on.