Combining complementary medicine with western medicine - can we gain something?

This is a text from 2005, written for a conference where this study was presented. Read also the appendix "Facts about Ayurveda". Presentation with photos is found here.

ABSTRACT

At the Sambhavna Clinic in Bhopal in India, Ayurvedic medicine is used together with Allopathic (western) medicine to care for the victims of the Carbide gas catastrophe in 1984. The patients and the doctors appreciate this possibility. Use of active and expensive western medicines can be decreased. The small studies that are conducted show positive results. 

Ayurvedic medicine has many components that are difficult to accept for western educated physicians. There are elements that we can recognise and accept, like patient-centredness, the patient’s role and the importance of lifestyle.

There is a discussion of whether we overlook important methods of helping patients when we say no to complementary methods. These methods might be of use for those patients with unclear symptoms where allopathic medicine offers no help. If it is cheaper than western methods, it can, in addition, contribute to keeping control over health care expenditures.

BACKGROUND

Health care for gas victims in Bhopal

It was during the night of Dec 2-3 1984 that 43 tonnes of methyl isocyanates (MIC) were released as an aerosol cloud, spreading over 520,000 inhabitants of Bhopal, India (1). It is plausible that at least 8,000 people died, of whom 3,000 were under 15 years of age. More than 100,000 suffered permanent injuries to the lungs, eyes, neurological system and other areas. The medical, social and economic rehabilitation has many shortcomings.

Compared to other towns of India, there are a large number of health care institutions in Bhopal, most opening since the gas disaster. However, the number of beds is large while primary health care is poorly developed. After the disaster, the town was invaded by private doctors, qualified as well as un-qualified. New government hospitals were built, but some of them did not begin to function until more than 10 years had passed. The Bhopal Memorial Hospital and Research Centre (BMHRC) is a super-specialised hospital, with eight outreach centres, financed by Union Carbide. They are obliged to provide free care to the gas victims for only eight years.

Health care at the government hospitals should be free for the survivors. However, it is not uncommon that they have to buy the medicines outside the facility. This is also true for the tuberculosis hospital.

The Indian Council of Medical Research (ICMR) provided three working manuals from 1986-1989, with advice that is mainly still up-to-date today (2, 3, 4). However, these manuals were never spread to the doctors in Bhopal. Also, no resources were allocated for the recommended physiotherapy, psychotherapy or health education. In 1990, patients were prescribed irrational or unnecessary medicines, which were sometimes hazardous, at government hospitals (5). The therapies prescribed in 1994 seemed to be aimed at giving temporary symptomatic relief rather than long-term amelioration of a chronic disease process (6). The victims sometimes spent more money on medicines than on food (7).

METHODS

The author has followed the development of the work at the Sambhavna Clinic since starting her yearly visits. The material produced by Sambhavna has been studied. During recent visits, the staff has been interviewed.

RESULTS

Sambhavna Clinic for gas victims

Sambhavna – The Bhopal People’s Health and Documentation Clinic – started in 1996 with a staff of 12. Today it has grown to 38 people (of whom two ar fulltime allopathic and two are Ayurvedic doctors) plus volunteers. A new building was inaugurated in April 2005. A community health unit has opened in the area where the groundwater was polluted. Up to April 2005, nearly 14,000 patients have been registered.

The main funds for Sambhavna are raised in the UK by Bhopal Medical Appeal (www.bhopal.org). In the USA funds are collected by the Pesticide Action Network, North America. The work is directed by six national trustees. An International Advisory Group provides long-term support.

The clinic offers help to those who can prove that they were affected by the Carbide gases in 1984. If they have lost their documents, health workers will check with their neighbours to see whether a person was indeed a victim of the disaster. The clinic also provides treatment for children born prior to December 1986 to exposed parent/s and to people exposed to contaminated groundwater.

Today, the following services are offered:

·        Clinical services to gas-affected survivors: Allopathic internal medicine, gynaecology and psychiatry; ayurvedic treatment including herbs, steam baths, yoga and massage; a dispensary, with Ayurvedic drugs and allopathic “essential drugs”; and a laboratory, for haematology, biochemistry, microscopy, cytology, ECG and spirometria.

·        Administrative support: Registration, personal identity documents for every patient, a record system, patient-owned health booklets; computerised patient data and data analysis; an economy department; a library and documentation centre.

·        Community work: General health education, health information for women, and finding and supporting tuberculosis patients in gas-affected areas; health education and support to inhabitants in water-polluted areas; verbal autopsy.

·        Studies: Surveys on different subjects, in gas-affected areas; small studies on effects on patients of different treatments.

The staff members are devoted to their work. Different quality assurance studies are always going on, at a level that is not always common in Indian health care. However, this means a lot of documentation is required and it is regarded as a burden by the staff. The management of the clinic is democratic. All decisions are made at the weekly meetings for all staff. The salaries are roughly the same for all the staff. To attract doctors, it has been necessary to offer them a slghtly higher salary. 

The complaints from the patients are partly particular to gas victims, and partly the same as in primary health care in any country. Respiratory problems are common and treated with bronchodilators, steroid inhalations, oxygen therapy, antibiotics, ayurvedic medicines and yoga. The increasing rate of diabetes, hypertension and heart diseases all over the world also leave an impression on the patient stock. Backache, joint ache also among young people, headache, gynaecological problems like white discharge and irregular menstruation are common, as well as mental problems like somatisation disorders, anxiety, insomnia and depression. Milder symptoms are mixed with serious diseases. Now and then a new tuberculosis or cancer is detected, also in patients who were taken care of at other health care facilities.

Investigations and diagnoses are made at the clinic. However, for x-rays, ultrasonography, mammography etc, the patients must be referred to other private hospitals, as the equipment at the governmental hospitals is often out of order. This means extra expenditure.

The workload is big, especially for the doctors. An internal physician may have up to 60 patients per day, of whom 10 are new. Many of them are quick visits, to get medicines for the coming fortnight. Since the start, it has been difficult to recruit allopathic doctors.

What is Ayurveda?

Ayurveda is the traditional natural healing system of India, several thousand years old. The treatment ranges from diet, herbs, yoga and massage, to lifestyle counselling and meditation (7, 8). Some say it is the cradle of medicine – even Jung took inspiration from Ayurveda. The goal of Ayurveda is to influence health, wealth and the next life. Food, sleep and sex are important ingredients to achieve positive influences.

The education for an Ayurvedic doctor is 5 years, including 2 years of “allopathic” medicine (the functions of the body), plus 6 months compulsory internship at an Ayurvedic hospital. Scientific research on the effects of Ayurvedic treatment is undertaken and published.

In Ayurvedic medicine, there are conceptual differences from allopathic (western) medicine:

·        Ayurveda is inseparable from the spiritual roots from which it sprang.

·        We are part of nature, of the universe, made of the same stuff as the stars.

·        Disease and illness are caused by an imbalance in the three humours. The process of re-balancing takes as long a time as it does to get ill.

·        Individuals are treated, not diseases. Every person is treated on the basis of his or her constitution.

·        It is the individual, not the doctor, who has the power to preserve or gain his/her own health. The doctor shows the path.

Ayurveda and Yoga at Sambhavna

Dr Deshpande, an Ayurvedic doctor, finds it more difficult to help this group of patients, compared to where he worked before. Even if they get better, they often get relapses.

Although Ayurvedic medicine cannot be separated from the philosophy behind it, it is not necessary for the patients to understand the philosophy. However, lifestyle changes depend on understanding of the philosophy. At Sambhavna, the patients are advised on medicines, diet and yoga. There is no difference between the Muslim and the Hindu patients’ acceptance of the treatments.

Yoga is offered to patients with physical and mental problems. The methods most used are postures (asans), cleansing (shodhan kriya) and breathing exercises (pranayam). Mental relaxation is sometimes also used. Some of the postures and breathing exercises are similar to those used by physiotherapists in the west.

Yoga can help with problems of the respiratory tract, the neuromuscular system, women’s reproductive system and insomnia. Prolapse is a common problem because of early marriage and many pregnancies, and yoga is a good treatment. As the women spend 30 minutes in the yoga room, they get time to talk about their misery.

Yoga has been seen to be effective (on the basis of hard data) for respiratory diseases, menstrual problems, hypertension and diabetes. For diabetes, postures of 3-5 minutes are used. For respiratory problems, in addition to breathing exercises, internal cleansing of the body is also used (rinsing of nose and stomach). Some patients have been able to quit inhalation treatment and keep good spirometria values.

For ayurvedic treatment, the patients can either choose themselves, or be referred by the other doctors.  Of the new patients, only 5 – 10 % take Ayurvedic treatment. Around 70% of the total number of patients prefer the allopathic doctors, while 30% want to see the ayurvedic doctor.

Dr. Qaiser, the internal medical specialist, often refers patients with chronic arthralgia, gastrointestinal problems, cough and chronic breathlessness for ayurveda and yoga. If there is exacerbation, the patient gets allopathic treatment. Hypertension and diabetes are treated with ayurvedic methods. Patients with very high blood sugar who refuse injections can manage on ayurvedic treatment plus allopathic antidiabetics.

It is the impression of the gynaecologist Dr. Devinda Kaur that women prefer ayurvedic medicines to allopathic. For women with non-serious symptoms, like young girls with menstrual problems, short-time bleeding problems, constipation and joint pains, she prefers to send them for ayurvedic treatment. Obese patients with menstrual irregularities are recommended yoga.

Many symptoms are often treated successfully with ayurveda: constipation, diarrhoea, loss of appetite, tiredness, tingling, an irritating cough, sternal burning, urinary problems, skin diseases, common colds, etc are often successfully treated with ayurveda. Massage for joint pains can reduce the need for pain-killers. Some of the herbal medicines are antioxidants. At Sambhavna, metals are not used.

The allopathic doctors consider ayurveda to be very helpful for the patients, with no side-effects. It gives the doctors a chance to prescribe fewer medicines, thus causing fewer side-effects. Continuous ayurvedic treatment may reduce the need for allopathic medicines. Ayurvedic treatment is also considerably cheaper than the allopathic medicines. But like every treatment, it has its limitations. Ayurveda is less effective for diabetes, hypertension, malaria, acute respiratory infection and severe bronchospasms. Women patients often have difficulty in leaving home for yoga instruction and also in finding space at home to do the exercises.

A patient, who is probably also common elsewhere, who is lamenting and complaining of “pains everywhere”, without real findings, might be sent first to yoga, then to the psychiatrist, and thereafter get treatment with placebo-like vitamins, iron and calcium.

DISCUSSION

The ancient Ayurveda medical system of India rests on a totally different paradigm from that of allopathic (western) medicine. However, there are elements that we can recognise as useful when meeting patients with “illness” and no diagnosis, and that are familiar from modern techniques for lifestyle changes.

Traditional western medicine relies on prescribing medicines (10). This is obvious in prevention. Risk factors like moderately elevated blood pressure or blood sugar are considered to be diseases and are treated with pills. Yet when we look at the benefits to the individual, this can be called into question. The number needed to treat (NNT) for one person not to fall ill is usually very large.

Other lifestyle-related conditions, like backache, over-weight, insomnia, tiredness, etc tend to be treated with pills rather than with lifestyle changes. It is easier for the patient and the doctor to try to solve the problem with a pill. However, this is often not successful.

In the last few years, the scientific evidence for lifestyle’s importance for common diseases has grown fast. We know that physical activity is essential for both prevention and treatment of diseases, and that there is hardly any condition where physical activity should not be encouraged. A proper diet seems to have a protective effect on cardiovascular diseases, diabetes and overweight. The need to cut down on tobacco and alcohol use is well known. Today, it is necessary to learn to cope with stress that contributes to a lot of diseases and symptoms.

To make people change habits is a long process. The paternalistic way, ordering patients to “do this and that”, is mostly ineffective in the western culture. Proschaska et al (11) have shown how a person goes through many steps before a change is undertaken and maintained. For the health care staff, it is necessary to know on which step the patient is, to know how to support him or her. Techniques like the “Motivating Interview” are developed and spread in primary health care. This technique stresses the patient’s own responsibility for his/her life.

There are also many patients, where allopathic medicine is powerless. We do not find any proper diagnoses, and whatever treatment we try, it does not help. Using pills only increases the risk of side-effects. The reasons for the ailments of those patients may be many: diseases that we are not yet (or will never be) able to diagnose, results of chronic stress caused by today’s situation or experiences earlier in life, exogenic or environmental factors, etc. Health care personnel often feel that these patients require another kind of care, sometimes time, sometimes social or economic support.

Looking into Ayurveda, it is obvious that it is difficult for us western people to accept the concept behind the treatments. There is a fundamental difference between the three major monotheistic religions and Hinduism that is also reflected in culture. (According to Hinduism, everything is God, whereas the monotheistic religions say “God created everything”.) But there are elements that we can recognise and accept:

·        Individuals are treated, not diseases. Every person is treated on the basis of his or her constitution.

·        It is the individual, not the doctor, who has the power to preserve or gain his/her own health. The doctor shows the path.

·        Self-knowledge and self-love are basic questions.

·        Good living habits will reduce or eliminate the possibility of ailments occurring.

Antonovsky (12) has pointed out the importance of “health factors” as essential for a person to experience well-being, irrespective of what diseases he/her might suffer from. In western medicine, we concentrate on biochemical “disease-factors” and on treatments that are biologically evidence-based. We have reduced the patient’s role in managing his/her own well-being. 

In the western paradigm, do we miss important methods of helping patients? Would it be better to concentrate on health factors, supporting the well-being factors for each patient, instead of only looking into the disease-factors? Should complementary treatments, experienced as positive by the patients, be integrated into the health care system? In that case, should these treatments that are not evidence-based, be paid for by the insurance system?

In the future, it will be necessary to gain better control over health care expenditure in western countries. As the oil crisis influences the economy, we will have to reduce expenditures. Can complementary methods that are often cheaper than western medicines, replace some of the methods used today, at least for some of the patients?

Appendix 

Facts about Ayurveda  

References

1. Eckerman I. The Bhopal Saga – Causes and Consequences of the World’s Largest Industrial Disaster. Hyderabad, India: Universities Press (India) Ltd, 2004.
2. Working Manual 1 on the Health Problems of Bhopal Gas Victims. Assessment & Management. New Delhi: Indian Council of Medical Research, April 1986.
3. Bhopal disaster. Manual of Mental Health Care for Medical Officers. Bangalore: ICMR Centre for Advanced Research on Community Mental Health, 1987.
4. The Health Problems of Bhopal Gas Victims. Assessment &Management. Working Manual 2. New Delhi: Indian Council of Medical Research and DST Centre for Visceral Mechanism, December 1989.
5. The Bhopal Gas Tragedy 1984 – ? A report from the Sambhavna Trust, Bhopal, India. Bhopal: Bhopal People’s Health and Documentation Clinic, 1998.  
6. Bhatia R, Tognoni G. Pharmaceutical use in the victims of the carbide gas exposure. International Perspectives in Public Health 1996; pp 11-12: 14-22.
7. Atreya. Practical Ayurveda. Secrets for Physical, Sexual & Spiritual Health. Mumbai, India: Jaico Publishing House, 2004.
8. Interview with Ms Anne-Marie Johansson, International Co-ordinator, Agastyaa Heritage Ayurvedic Centre, Kovalam, Kerala.
9. Eckerman I. The Health Situation of Women and Children in Bhopal. International Perspectives in Public Health 1996; pp11-12: 29-36
10. Eckerman I. The Consultation to Promote Health : The Most Important Tool in Preventive Work. [In Swedish.] Nacka, Sweden: Population Health Unit in Nacka, 2004.
11. Proschaska JO, DiClemente CC, Norcross JC. In Search of How People Change. Applications to Addictive Behaviors. American Psychologist, 1992;47: pp1102-1114.
12. Antonovsky, A. Unraveling The Mystery of Health - How People Manage Stress
    and Stay Well. London: Jossey-Bass Publishers, 1988.