Doctors of modern medicine and AYUSH practitioners in Kerala are up in arms after the Kerala Assembly passed the Kerala Public Health Bill 2021. The Bill was passed in the House on March 21 and awaits the Governors’ assent. It has been the subject of debates between practitioners of AYUSH and of modern medicine ever since it was first tabled in 2021. The Bill was sent to a select committee which heard various stakeholders, including AYUSH practitioners. The revised Bill was submitted on March 20 and passed the following day without discussion. However, some of the issues raised by both parties still remain. The Indian Medical Association (IMA) and doctors of modern medicine oppose the inclusion of AYUSH practitioners in the Bill, while AYUSH practitioners are demanding additional powers and role in decision making, on par with their counterparts in modern medicine, within the Bill.
The Kerala Public Public Health Bill is expected to “enhance administration of public health in the state,” and entrusts authorities at the state, district, and local level with the “prevention and control of emerging diseases, outbreaks of communicable diseases, and prevalence of non-communicable diseases.” Once it becomes law, the Bill will supersede the Madras Public Health Act, 1939, and the Travancore-Cochin Public Health Act, 1955, which are in place in the state right now.
The Bill, in its draft form that was tabled on October 4, 2021, invited the displeasure of AYUSH practitioners as it excluded them from administrative and decision making capacities.
> Scope of the definition of "Registered Medical Practitioners (RMPs)": The draft Bill allowed only “RMPs of modern medicine” to declare a person as free from any communicable disease. AYUSH practitioners across the state came together under AYUSH Aikyavedi, in order to lobby for their inclusion in the Bill. The definition of RMPs was expanded after select committee consultations to include qualified practitioners of Indian systems of medicine and homoeopathy. The IMA has raised strong objections to this change as, according to them, AYUSH systems of medicine lack the testing methodology and practices required to confirm that a person is disease-free.
> Public Health Authorities (PHA) vs Public Health Committees (PHC): The draft Bill proposed PHAs at state, district, and local levels headed by modern medicine practitioners. Following the lobbying by AYUSH Aikyavedi, they were changed to PHCs at all three levels that include representatives from Indian systems of medicine and homoeopathy. Now, AYUSH practitioners are further demanding that the Secretary or any IAS-level officer from the AYUSH Department be added to the committee, as the Health Secretary, who represents modern medicine, has been included in it.
TNM spoke to representatives of the IMA and practitioners of AYUSH systems of medicine to know more about the contested clauses in the Bill.
The Kerala chapter of IMA has issued a statement saying that they will approach the Governor, Chief Minister, and Health Minister regarding the contested clauses and explore the possibility of legal action. “While the [draft] Public Health Bill is conducive to radical improvement in Kerala’s health sector, the IMA is worried that the inclusion of officials from the AYUSH department, who have no connection with public health, in the committees will be a huge setback,” a statement issued by IMA read. “The inclusion of AYUSH department officials in the state committee and other committees, in contrast to the provisions of the draft Bill, is not acceptable. Although the Public Health Bill has introduced strong guidelines, including penal clauses to maintain clean food, drinking water, and pollution-free environment and is not confined to the health sector, the inclusion of unscientific branches of medicine in the committees may cause Kerala to take a step back,” it said.
Stating that a Public Health Act is a long pending demand of the IMA and other experts working in the field, state IMA president Dr Sulphi N said that while this was a comprehensive law in the draft form, a few provisions have caused apprehensions. “Inclusion of alternative medicine practitioners is not in place anywhere in the world. Public health is a concept of modern medicine, and if alternative medical practitioners are included in the Bill, it will become an anomaly. Though they are included along with other departments like agriculture, water, sanitation, etc, alternative medicine has no role in public health. In the event of any epidemic like Nipah or COVID-19, modern medicine takes the lead. While several powers are given to public health committees in the Bill, our only apprehension is the inclusion of alternative medicine practitioners,” he said.
The IMA statement said, “The certification process for very serious notifiable diseases like Nipah, COVID-19, and SARS should follow rules that reflect international standards and involve only modern medical science.”
Dr GS Vijayakrishnan, president, IMA Thiruvananthapuram and former state president of Kerala Government Medical Officers’ Association (KGMOA), said the Bill proposes a change in the certification process for communicable diseases. “Earlier, only a modern medicine doctor could issue the certificate, but now a medical practitioner of any system of medicine can do the same. This becomes a problem while handling epidemics or major public health issues. For instance, modern medicine deals with COVID-19 with drugs and vaccinations, while several other systems of medicine reject vaccinations. When such a conflict arises within different systems of medicines, it becomes a threat to public health itself,” he said.
Dr Ram Mohan, an Ayurveda practitioner and the state secretary of Ayurveda Medical Association of India (AMAI), was of the opinion that the Public Health Bill opens up a forum for all systems of medicine to cooperate to facilitate better public health. “When a communicable disease spreads, allopathy (modern medicine) will be needed to address the crisis first, as it is more technologically advanced. But as we saw in the case of both the Chikungunya epidemic and the COVID-19 pandemic in the state, AYUSH was able to make considerable contributions in treating long term health effects that resulted from both diseases,” he said. He further emphasised, “Each system should try to help the other, instead of seeing this as a competition. Cooperation between the systems is possible, and the Public Health Bill opens up such possibilities. What we need is a multi-system centric public health approach.”
Besides this, AYUSH Aikyavedi also objected to the proposal for Public Health Authorities at the state, district, and local levels in the original Bill. The final Bill that was passed in the Assembly hence proposed Public Health Committees at all three levels, with its members including a representative each from Indian systems of medicine and homoeopathy.
“The earlier Travancore-Cochin Public Health Act required the state to have health authorities. Now, it has been changed to health committees, which will have nominees from various departments, including from agriculture, veterinary, and AYUSH,” Dr Vijayakrishnan said.
He further added that while all the alternate medicine practitioners are legally accredited, modern medicine is what conducts research and employs evidence-based medicines during public health crises. “We are not opposing any medicinal system, but our biggest concern is about the state of public health when such conflicts arise. Our only aim is to ensure that there are no public health issues in the event of epidemics or calamities, due to the tug-of-war between different systems of medicines,” he said.
Dr Arif Hussain Theruvath, science communicator and an ex-homoeopath, said that though the expansion of PHAs to PHCs is an inclusive action as it now includes representatives from different medicinal systems, their presence is perceived counterproductive by those who practise modern, evidence-based medicine. “This is in view of their [AYUSH] allegiance to pseudoscientific practices and dependence on lobbying rather than on Scientific methods to incorporate AYUSH practices in treatment protocols,” he said.
“As other pandemics and new epidemics are likely to break out, treatment and testing methods must be based on scientific surveillance and testing systems for public health as a whole,” the IMA statement said.
Dr Arif Hussain called the Bill “an opportunity for AYUSH practitioners to become accountable. They have to come up with empirical data and prove their usefulness. As of now, they are not able to produce evidence as the systems are solely based on testimonials and anecdotes. The Bill gives AYUSH an opportunity to establish itself by complying with scientific methods and statistical evaluation.”
When asked for his comment on the allegation that Ayurveda and other Indian systems are not evidence-based, Dr Ram Mohan said, “Ayurveda has been effectively practised for over 4000 years now. Is that not sufficient evidence?” He also said that the public view it as a credible system of medicine, as evidenced by the steady number of patients he receives every day. He further added, “The IMA says that Ayurveda needs to be subjected to randomised control trials (RCT) like modern medicine. But Ayurveda is not a system that can be studied through RCT in the same way that modern medicine is. It is personalised for each patient based on their age, gender, humor, physical environment, and other factors.”
Dr Ram Mohan countered the allegation that AYUSH practitioners cannot certify persons as disease-free due to the lack of scientific tests in such systems by saying that they too depend on laboratory tests and facilities like x-rays in diagnosis. He said that the aim of all medicine practitioners in the state should be to cooperate with each other to better contribute to public health.
Dr Abhil Mohan, treasurer of AYUSH Aikyavedi and general secretary of Siddha Medical Association of India said, “When the draft Bill came, we sought changes in some clauses. While many of them were addressed, the final Bill is still not satisfactory. The Public Health Bill is a crucial one. Neither the 1939 Act or the one in 1955 included AYUSH practitioners as such a department was not there back then. When a Bill is introduced in this day and age, both modern medicine and Indian systems of medicine should be given equal importance. That was our main demand.”
The draft Bill spoke of Public Health Authorities, which was changed to Public Health Committees as per the demands of multiple stakeholders. He said that while the Bill contains provisions for committees, they are headed by doctors of modern medicine. “We also need a secretary-level IAS officer as a representative from the AYUSH side. The Health Department Secretary has been included as the vice chairman of the state-level committee. Similarly, AYUSH Secretary must be included, and similar to the Director of Health Services, Director of Ayurveda Medical Education should be included in the committee. There are secretaries from other departments, including agriculture, but not from AYUSH. This is a huge neglect,” he said and added that they will approach the government with detailed demands for amendments in the Bill.
Regarding the IMA statement and AYUSH’s contributions to public health, he said, “AYUSH has been included in multiple hospitals and Primary Health Centres (PHCs) in other states, and also in several National and state level policies. In Kerala alone, this system is not followed. IMA is taking an extreme stance in this regard, which is not new. They have been opposing us for long. They say that we did not contribute during the pandemic, but all of us saw that the governments – both Union and state – were promoting both vaccines and AYUSH medicines simultaneously. There were clear protocols for each systems of medicine. There were multiple study reports also. They cannot deny our contributions.”
Besides courting controversy over the initial exclusion and later inclusion of AYUSH practitioners in the Bill, experts also believe that the Bill doesn’t address all the public health concerns that face Kerala today. The Bill is silent on mental health as a component of public health. An article in The Wire suggested that the one-health approach to public health suggested in the Bill, which focuses on “improving the social determinants of health such as clean water and environment, sanitation and waste management,” doesn’t fully address Kerala’s specific public health requirements. TNM discussed with experts what more the Bill could have incorporated to present a holistic public health approach.
Dr Vijayakrishnan called the one-health approach a welcome move, stating that public health needs to encompass everything – living and non-living – within its scope as each influences the other. “We don’t live in isolation. We have seen communicable diseases being contracted from animals. The Bill also incorporates food safety into the scope of public health, which is a good thing.” Dr Arif Hussain added, “Through this Bill, public health will be radically enhanced by developing policies rooted in evidence-based medicine. Its implementation will involve public participation through a decentralised approach, so as to abate any upcoming public health challenge, without leaving a chance to err.”
However, Dr Arif Hussain pointed out some of the shortcomings of the Bill. “There are three failures that I see. One is that there is no clear reference about funding and data privacy; there is no clarity on slaughter waste and solid waste management; and lack of non-obstante clauses (upholding enforceability of a particular provision of law over another provision that is contradictory to it). Further, though there is a part that deals with communicable diseases (CD) elaborately, non-communicable diseases (NCD) are still left half attended. International treatment guidelines are to be followed not just in CDs, but also in NCDs, to limit adverse events and attain the public health goals more effectively.”