Spoonful of Sugar

Since November 2014, the alternative treatment industry in India has been bolstered by the establishment of a dedicated ministry called the ministry of ayurveda, yoga & naturopathy, unani, siddha and homeopathy, or AYUSH. Upgraded from its status as a department, the AYUSH ministry now operates parallel to the ministry of health and family welfare, which focusses primarily on evidence-based modern medicine. In the past four years, the AYUSH ministry’s budget has more than doubled to Rs 1,428.7 crore in 2017-2018. With such serious money under its belt, plans for the industry’s scale and growth have been ramped up.

In 2017, the union minister of state for AYUSH, Shripad Yesso Naik, a Bachelor of Arts graduate with no scientific training, announced that the centre had approved proposals to set up 100 AYUSH hospitals across the country. This would include a major Ayurveda centre, called the All India Institute of Ayurveda—dreamed up as an equivalent of AIIMS in Delhi, India’s premier government teaching hospital. In addition, Naik spoke of plans to set up an Institute of Naturopathy in Pune, at a cost of Rs 1,000 crore. The government also approved postings for 4,000 AYUSH practitioners in primary health centres across the country. This year, there was an even more aggressive push to commemorate days promoting alt-med—as alternative treatment systems are popularly referred to—in the Indian public health system. The Homoeopathy Day in April, Yoga Day in June and National Ayurveda Day in November are all fallouts of this policy push.

Urban citizens, who rely on private medical care and often choose to combine a range of modern and traditional therapies, remain largely unaffected by this push on the health front. However, a majority of the rural population, a larger segment compared to the urban demographic, either cannot afford private care or do not have access to different therapy options. Even if they do have access, many do not possess the capacity to evaluate the efficacy of different treatments. Recent schemes, such as the Ayushman Bharat—a health insurance that promises to “cover over 10 crore poor and vulnerable families”—ensure that alt-med becomes the primary source of treatment for certain segments of the population.

Most forms of alt-med possess little or no scientific basis. In the case of Ayurveda, a relatively demonstrative form of alt-med, research frequently lacks experimental rigour and the few treatments that display effectiveness require a robust case-by-case analysis. However, homoeopathy is the one branch of alt-med that suffers from a glaring lack of scientific credibility since none of its treatments have ever been systematically proven.

Homoeopathy was founded in Germany in 1796 by the physician Samuel Hahnemann. It became a popular form of treatment at a time when a large number of disease mechanisms were still unknown. Today, it is prevalent in societies with a culture of traditional therapies, such as India and China. Its popularity tends to spread on the basis of anecdotes—everyone has a family member or an acquaintance who vouches for its miraculous properties. Its proponents claim it cures diseases ranging from cancers and infections to metabolic syndromes, such as type-2 diabetes.

Homoeopathy is said to work on the understanding that “like cures like”—a substance that may cause harm in large doses can cure causal symptoms when taken in miniscule doses. The lowest amount of the homoeopathic drug or “remedy” is mixed with large volumes of water or alcohol and poured over sugar pills. The upper limit of this prescribed dilution yields a ratio of 1:10,00,00,00,00,000. This means a batch of 1,00,00,00,000 litres will contain about 1 millilitre of the remedy. Another principle of homoeopathy is the untenable idea that water molecules hold a “memory” of the properties of substances they come in contact with—an idea that forms the basis of using such low doses of remedies.

A hallmark of evidence-based research is robust statistical efficacy in a large cohort of several categories. These divisions include age and gender, with further sub-classifications based on pre-existing conditions, such as diseases or pregnancy. The scientific method ensures that results are replicable over repeated trials and the methodology covers experimental biases. The gold standard of this process is the randomised double-blind trial. Two or more groups are administered either the tester drug or a placebo. The contents of the drug are not disclosed to the drug receiver and the clinician. On all occasions, homoeopathy has consistently shown to be no more effective than a placebo.

The basis of modern pharmacology is determining the right dosage, based on the weight, gender and age of the individual. This is loosely termed as the therapeutic window—the range within which a drug dose is considered safe, with minimal side effects. For instance, a 120 milligram dose of paracetamol will affect a child weighing eight or nine kilograms, but will be ineffective on a 70-kilogram adult. Since the homoeopathic dilution doesn’t even come close to any drug’s therapeutic window, its relative efficacy can only be explained as a placebo effect. (In which a patient’s condition improves based on the expectation that the drug they have taken will be helpful.) Homoeopathy’s prescription for major diseases can cause complications due to non-treatment or even be fatal.

Homoeopathy is considered cost effective in the short-term because of its lack of active ingredients. However, its dosage pattern suggests long-term administration. A study was conducted on the long-term cost comparison between homoeopathic treatment and modern medicine on about 44,000 patients in Germany. It suggested that even though the cost for modern medicine was higher in the short term, in the longer term, homeopathic treatment was more expensive than modern medicine.

Set up in 1978, the Central Council for Research in Homoeopathy—now under AYUSH—claims to have successfully concluded several studies of 159 disorders, including endocrinal, gastrointestinal, geriatric, neurological and infectious diseases. The council incurred an expenditure of Rs 106 crore for these investigations in 2017-2018 alone. Modern medicine practitioners fear that this increased budget for the AYUSH council does not bode well for the main health ministry. The health ministry may have to contend with an increasing number of untreated patients or patients with sustained complications, in secondary care, after being attended by AYUSH practitioners in the primary centres.

Further, this increased push for alt-med, at a public health policy level, comes at a time when international public health systems, such as the UK’s National Health Service, have distanced themselves from homoeopathy. In 2010, the UK’s House of Commons published an extensive report concluding that homoeopathy works no better than a placebo treatment. Medical scientists from countries such as France and Australia have also reached an expert consensus on homoeopathy’s ineffectiveness.

Another fundamental flaw of alt-med is that some of its systems—Ayurveda, Unani and naturopathy—are based on an ancient understanding of disease mechanisms. They prescribe treatments to illnesses that modern medicine can only manage, but not cure completely.

Ayurveda was considered a progressive medicinal system until a few centuries ago. However, its incomplete understanding of molecular biology, such as genetics and epigenetics, and the refusal to accept biomedical research advancements has set it back. For instance, Ayurveda recommends the use of bitter gourd, a gustatory opponent of sugar, as an anti-diabetic. Modern medicine, for instance, has now established that type 2 diabetes isn’t caused by consuming excessive sugar, but by a combination of genetics and lifestyle. (Of course, diet, obesity and physical fitness do play an exacerbating role.) Studies conducted on the bitter gourd by herbal drug researchers were largely published in low repute journals and held all the characteristics of questionable herbal studies—low sample size, low effect and disputable statistics.

This year, AYUSH and its statutory bodies have also promoted substandard and ill-researched Ayurvedic anti-diabetic drugs, namely BGR-34 and IME-9. Both these drugs have recorded major side-effects, such as increasing the patients’ blood glucose to dangerously high levels. Additionally, the monthly cost of these drugs was found to be more than the widely prescribed anti-diabetic drug, metformin.

Overstating its efficacy and making elaborate claims is a hallmark of alt-med, and its practitioners and science journalists are equally to blame. Lately, instances of irresponsible journalism, such as a Times of India report on cow urine as a cure for cancer, have played a major part in transforming public opinion on treatments that have no scientific rationale.

During the recent Nipah epidemic in India, when research on the anti-viral drug was still underway in animal models, several videos surfaced on YouTube claiming homoeopathy had discovered the vaccine. There is no evidence of any vaccine for Nipah in the entire canon of homoeopathic literature. Such wild claims perpetuate false ideas of the drug development process.

Alt-med has also been unable to match high-paced modern medical research. Evidence-based medicine can conduct experiments with elegant miniscule details—from imaging live calcium ions in brain cells, deleting-adding a specific gene in animals to change functionality or behaviour, to creating drugs that target specific ion channels. The argument that modern science does not understand the mode of action of ancient drugs and has a long way to catch up is fallacious and dangerous.

In addition, India’s heavily privatised health-care system has generated mistrust in patients due to some medical practitioners placing profits over community health. This mistrust has carried over to modern medicine and is amplified by conspiracy theories and misinformation. One of the biggest hoaxes of modern medicine revolves around pharmaceutical industries withholding an inexpensive and natural cancer cure, for profiteering or exclusively for the global elite. A large number of websites and blogs, selling superfoods claiming to kill cancer cells in a few hours, thrive on such conspiracy theories.

Advocating a complete ban on alt-med is not an optimal solution as it impacts the livelihood of practitioners and the democratic choices of patients. Rather, the industry should be rigorously regulated for safety and efficacy, with emphasis on increased public awareness. (Especially when its effects are not always benign—mercury and lead has been found in certain Ayurveda and Siddha medicines.) It can remain privately available to those who wish to pursue it. From a policy perspective, one can certainly question its dependence on public funds for research and practice, particularly when there is not a shred of scientific evidence to prove that treatments such as homoeopathy work.

The sole reliance on ancient Indian heritage for scientific wisdom is illogical. Celebrating ancient arts and culture, to bolster national pride, is arguably less dangerous for human survival, than holding medicine to standards set in antiquity. Dependence on ancient texts for medicine and science in the twenty-first century, and enshrining that as part of a public health policy, is not only a disservice to the citizens but also to ancient scientists who would have, in all likelihood, desired its progression.