Medical Pluralism in India

Introduction

The Indian medical system has traditionally included the medicine systems known as AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy and Naturopathy) and the folk sector of Indian medicine that encompasses spiritual and tribal healing methods (Albert, Nongrum, Webb, Porter, & Kharkonger, 2015; Ravishankar & Shukla, 2007). However, when the British colonized India in the 1600’s, biomedicine was introduced (Alavi, 2008; Arnold, 1996). Currently in much of India, biomedical and traditional medicine systems have begun to coexist with each other, resulting in medical pluralism throughout the country (Roy & Ali, 2001). The concept of medical pluralism refers to the simultaneous existence of more than one medical system in a single society, in which each system may be based upon different principles, beliefs, and world views (Roy & Ali, 2001). Examples of medical pluralism can be found in various other countries and cultures, including China, Uganda, and Africa.

Since the introduction of biomedicine in India, traditional AYUSH medical systems have developed into professional systems that work alongside biomedical practices (Priya, 2013). The AYUSH systems are now accessed individually or in conjunction with biomedical techniques (National Health Portal [NHP], 2015). However, folk and tribal practitioners have remained unprofessionalized and rest on a separate level of the blended medical system (Priya, 2013; Roy & Ali, 2001). In India, medical pluralism offers both benefits and disadvantages to those seeking healthcare. Blending of the various medical systems has allowed people to move between different health systems depending on their beliefs, to choose alternative health methods if initial interventions do not work, and to have increased access to educated health professionals in both biomedicine and traditional medicine (Priya, 2013; Roy & Ali, 2001). Alternatively, medical pluralism has resulted in power differentials between the various medical systems, a mistrust of newly instituted systems due to lack of knowledge and acceptance, social inequalities, and inadequate education and communication between medical professionals (Albert et al., 2015; Broom, Doron, & Tovey, 2009; Nisula, 2006; Roy & Ali, 2001).

Although India’s medical system was once based upon traditional AYUSH and folk medicine practices, the introduction of biomedicine has created a pluralistic medical system that has resulted in both advantages and challenges in the management and accessibility of India’s current medical system. This webpage will examine the topic of medical pluralism in India by further exploring the history and practices of India’s traditional medical systems (AYUSH and folk medicine), the introduction and integration of biomedicine into India’s healthcare system, the current coexistence of traditional and biomedical techniques in India, and the benefits and challenges of the medical pluralism that exists in India today.

Traditional Indian Medical Systems

India has many diverse traditional medical systems in place today. While some are common and well-known, others are found in only specific regions of the country. The five main systems are referred to as AYUSH, meaning Ayurveda, Yoga, Unani, Siddha, and Homeopathy and Naturopathy (Albert et al., 2015; National Health Portal [NHP], 2015; Ravishankar & Shukla, 2007). There has been a steady increase of interest in the AYUSH medical systems in India due to the growing problem of non-communicable diseases, specifically diabetes, cardiovascular disease, and cancer (NHP, 2015). The main goal of India’s traditional medical systems is holistic health – health that encompasses the spiritual, emotional, physical, and mental aspects of a person. Aside from AYUSH, some ethnic villages continue to practice folk or tribal medicine, which is far less commercialized and codified than AYUSH (National Center for Biological Sciences [NCBS], n.d.).

History of Traditional Medicine

Evidence of traditional medicine practices in India dates back thousands of years (NCBS, n.d.). Excavations of anthropological sites suggest that medical interventions such as dentistry and trepanation (drilling a hole in the skull to improve brain pulsations and overall well-being) were being performed as early as 700 BCE (NCBS, n.d.). Anthropologists and historians have also identified the significance of certain medicinal plants and trees in Indian society in regards to health and well-being (NCBS, n.d.). Furthermore, research suggests that traditional Indian culture valued the importance of cleanliness and water sanitation, indicating an advanced understanding of health management (NCBS, n.d.).

According to Mackenize and Rakel (2006), traditional Ayurvedic medicine evolved from the Vedas, the oldest scriptures of Hinduism, which can traced back to 5000 BCE. Traditional Indian medical systems were further developed by ancient Rishis (saints), which resulted in the creation of Siddha and early forms of Yoga (NHP, 2015). Unani originated from Hippocrates, a Greek philosopher, during the eighth century AD (NHP, 2015). Homeopathy and Naturopathy was developed in Germany, and caught on in India because it fit well with the holistic values and beliefs of other traditional medical systems already in place (NHP, 2015). Lastly, folk and tribal medicine has been passed down through families and communities in Indian culture for centuries (NCBS, n.d.). The historical context of India’s traditional medical systems has informed the existence of AYUSH and folk/tribal medicine in the country today.

Ayurveda

Ayurveda is one of the most developed, utilized, and researched forms of traditional medicine in India (NHP, 2015). The term Ayurveda originates from the Sanskrit words Aya, meaning life, and Vedic, meaning “human science and knowledge” (Rajasekharan, Vinod Kumar, Shanavaskhan, Pushpangadan, & Binu, n.d.). The main focus of Ayurveda is balance, and it is believed that when imbalance occurs, disease follows (Rajasekharan et al., n.d.). Thus, maintaining balanced natural bodily cycles, including sleep, wake, meditation, and work, is thought to be crucial to health (NHP, 2015). According to Ayurvedic professionals, suppressing natural urges may also lead to illness (Pathak, Raut, & Vaidya, 2008). For example, suppressing the sneezing reflex leads to shoulder pain, and suppressing the urge to defecate or pass gas leads to diverticular disease and reverse peristalsis (Pathak et al., 2008).

This medical system has many complex and thorough divisions, components, and features. In general, Ayurveda is divided into eight distinct sections:

• “Kāyacikitsā: general medicine, medicine of the body
• Kaumāra-bhṛtya: the treatment of children, paediatrics
• Śalyatantra: surgical techniques and the extraction of foreign objects
• Śālākyatantra: treatment of ailments affecting ears, eyes, nose, mouth, etc. (“ENT”)
• Bhūtavidyā: pacification of possessing spirits, and the people whose minds are affected by such possession
• Agadatantra: toxicology
• Rasāyanatantra: rejuvenation and tonics for increasing lifespan, intellect and strength
• Vājīkaraṇatantra: aphrodisiacs and treatments for increasing the volume and viability of semen and sexual pleasure” (Rajasekharan et al., n.d., para. 7).

Ayurveda can further be divided into Swasthavritta Athuravritta (NHP, 2015). Swasthavritta refers to the promotion of health and prevention of disease, while Athuravritta refers to disease management and treatment (NHP, 2015). Ayurvedic principles incorporate five key elements that make up bodily substances: earth, air, fire, water, and ether (NHP, 2015). These elements are further divided into three energies, called Doshas, that are responsible for the body’s physiological functions: Vata, Pitta, and Kapha (NHP, 2015). Some theories suggest that all three of these energies must be in balance in order for health to occur, while other theories argue that all people have a different ratio of Doshas, which create their personalities (NHP, 2015).

In terms of diagnosing and treating disease, Ayurveda describes eight ways to identify illness: pulse, urine, stool, tongue, speech, touch, vision, and appearance (NHP, 2015). Classical forms of Ayurvedic treatment included many types of surgical interventions. Alternatively, contemporary Ayurveda stresses maintaining the health of peoples’ metabolic, digestive, and excretory systems in order to avoid more intensive and complicated forms of interventions (NHP, 2015). Treatment may include methods of purification or cleansing from toxins (vomiting, purgation, nasal inhalations, medicated retention enemata, and bloodletting or cupping), palliative treatment (diet control, fasting, exposure to sun rays or wind, exercise, yoga, and medications), appropriate diet and activity, avoiding causes or situations that lead to disease or disease aggravation, and medications (NHP, 2015; Ravishankar & Shukla, 2007). The main treatment goals are based upon Hindu beliefs that value holistic physical, mental, emotional, and spiritual health.

Ayurvedic medicine has been highly professionalized since the Indian government began regulating traditional medicines. Today, there are hundreds of schools that offer various levels of education and certification in Ayurvedic medicine (NHP, 2015). For example, the National Institute of Ayurveda offers doctorate, masters, and bachelor’s degrees, as well as diplomas and certificates in this type of traditional medicine (National Institute of Ayurveda, 2016).

Yoga

Yoga is a form of meditation that focuses on harmony between the mind, body, and spirit (NHP, 2015). According to the National Health Portal (2015), the aim of Yoga is self-realization and to overcome all types of suffering. Yoga is derived from the Sanskrit word Yuj, meaning “to join” or “to unite” (NHP, 2015). Yoga has many different forms, schools, and goals. The most popular types are Hatha and Raja Yoga (Lau, 2000). In the last few decades, Yoga has seen a global emergence of popularity due to its holistic healing capabilities and its positive effect on body appearance and muscle tone (NHP, 2015). Furthermore, Yoga principles have advanced over time, and the concept of energy channels that flow through the body during the practice of Yoga has been developed (NHP, 2015). Many scientific research studies have found that Yoga is an effective complementary tool for asthma, stress and pain management, physical injuries, and heart disease (NHP, 2015).

Unani

One of the greatest scholars of Unani, Ibn-e-Sina has defined Unani medicine as “the science in which we learn various states of body in health and when not in health and the means by which health is likely to be lost and when lost, is likely to be restored” (NHP, 2015, para. 1). Unani is a comprehensive medical system with fundamentals based on scientific principles and holistic concepts of healing (NHP, 2015). Much like Ayurveda, Unani principles include the presence of elements in the body. However, unlike Ayurveda, Unani describes four elements: earth, fire, air and water (NHP, 2015). A high importance is placed on sustaining an adequate and nutritious diet (NHP, 2015).

Unani medicine states that the body receives nourishment for organs from four humours: blood, phlegm, black bile, and yellow bile (Ravishankar & Shukla, 2007). Each of these humours have their own characteristics, and the mixture of the humours in a person’s body creates his or her temperament (Ravishankar & Shukla, 2007). Similarly to biomedicine, diagnosis and treatment using Unani medicine depends on the disease characteristics (NHP, 2015). Following the diagnosis of an illness, management of the disease is determined on the basis of etiology using a specific model:

• Izalae Sabab: removal of the cause
• Tadeele Akhlat: normalizing and balancing the humours
• Tadeele Aza: regulating the tissues/organs (Unani Medical College and Hospital, 2012).

Forms of treatment using Unani include aromatherapy, surgery, pharmacotherapy, and cupping therapy, which is a process where blood is drawn through small incisions into a container using a vacuum (Unani Medical College and Hospital, 2012). In India, there are over 40 accredited medical schools that teach Unani medicine (NHP, 2015).

Siddha

Siddha is a form of traditional Indian medicine that is mainly practiced in the southern provinces of the country (NHP, 2015). The term Siddha comes from the Tamil word Siddhi, meaning “perfection” (NHP, 2015). According to the Siddha medical system, bodily functions, both physical and mental, are a result of seven elements:

1. Ooneer/ Plasma: responsible for growth and development;
2. Cheneer/Blood: responsible for sustaining tissues and maintaining the mind;
3. Oon/Muscle: responsible for body shape and tone;
4. Koluppu/Kozhuppu/Fatty Tissue: responsible for protecting joints;
5. Elumbu/Bone: responsible for movement and physical structure;
6. Elumbu Majjai/Bone Marrow: responsible for the formation of blood cells;
7. Sukkilam/Semen: responsible for reproduction (NHP, 2015).

Similar to other forms of traditional Indian medicine, Siddha medicine states that health is based on balance and equilibrium; therefore, disequilibrium of body elements is seen to cause disease, and treatment is focused on regaining balance (NHP, 2015). Diagnosis is performed through analyzing and examining the body’s pulse, eyes, voice, touch, colour, tongue, stool, and urine (NHP, 2015; Ravishankar & Shukla, 2007). Treatment of illness is achieved through many avenues, however the use of medications is common. Medications utilized by Unani practitioners are classified as being either herbal, inorganic, or made of animal products, and are further classified by internal or external (oral or topical) use (NHP, 2015). In general, within Unani medicine, prevention of illness is held with much more importance than treatment (NHP, 2015).

Homeopathy & Naturopathy

The word Homeopathy means “similar and suffering” (NHP, 2015). Fittingly, the medical system of homeopathy is based on the Law of Similar (NHP, 2015). Based on this law, disease and illness is treated by something that creates the same symptoms that the disease causes (NHP, 2015). For example, both onions and hay fever cause people to have watery eyes and a runny nose; thus, the homeopathic treatment of hay fever is a preparation made of onion (Homeopathy Plus, 2014). (Other examples of the Homeopathic Law of Similars can be found at this website: http://homeopathyplus.com/tutorial-1-the-law-of-similars/.) Homeopathy is often used as a stand-alone treatment method or as an adjunct to other types of treatment systems (NHP, 2015). Homeopathy is a recognized medical system in India through the Homeopathy Central Council Act, which was established in 1973 (NHP, 2015).

Naturopathy is essentially the art and science of living a healthy and fulfilled life (NHP, 2015). It is a drug-less medical system that believes that nature is the greatest and most effective method of healing (NHP, 2015). The only medicine used by naturopathic doctors is food (NHP, 2015). Using Naturopathic treatment involves healing all aspects of the body at the same time, since disease affects the entire body and not merely one specific body system or organ (NHP, 2015). Various non-invasive treatments are used, which include: diet and fasting therapies, mud therapy, hydrotherapy, massage, acupressure, air therapy, magnets, steam, and physiotherapy (NHP, 2015). According to the Ministry of AYUSH (2010), there are 12 accredited institutions in India offering degrees that allow people to become certified in the science of Naturopathy.

Folk & Tribal Medicine

While the main traditional medical systems of India fall under the category of AYUSH, many local ethnic health traditions are passed on through families and communities, creating an informal folk and tribal medical system (NCBS, n.d.). This form of medicine is most often used by locals who cannot afford the increasingly expensive biomedical and AYUSH treatments (NCBS, n.d.). Folk medicine typically involves simple interventions including diet changes and the treatment of minor illnesses. Complex treatments such as bone setting, midwifery, and bloodletting also exist; however, complex treatments are much less prevalent than the former interventions (NCBS, n.d.).

Tribal medicine can be divided into two categories: folk healers and faith healers. Folk healers are either specialized herbalists, bone-setters, snakebite healers, or traditional birth attendants (Priya, 2013). Faith healers include shamans and mystics, and they perform healing using chants, rituals, and medicines made of herbs and animal products (Priya, 2013). For example, in northeastern India, the Dimasa Kacharis people believe that spirits cause disease; therefore, a shaman is consulted if a person becomes ill (Roy & Ali, 2001). Shamans identify the spirit causing the illness using magical techniques (Roy & Ali, 2001). After the spirit has been identified, shamans recommend or carry out individualized interventions to please the spirit (for example, sacrificing live stock) and ward off the disease (Roy & Ali, 2001).

Traditional Indian Medicine Today

In populated areas and city centres, traditional healing methods have been demoted to a secondary role behind biomedical techniques and treatments in India (NCBS, n.d.). Regardless of this fact, some sources state that up to 80% of India’s population use some form of traditional medicine (Dargan et al., 2008; National Center for Complementary and Integrative Medicine, 2015). Furthermore, some types of traditional medicine, particularly Yoga and Homeopathy, are becoming more popular (NHP, 2015). Globally there has been a growing interest in alternative forms of medicine due to the increasing aversion to surgical and pharmacological biomedical treatments (NHP, 2015). As complementary forms of medicine become more widespread, the development of simplified versions of traditional medicine that appeal to mainstream ideals is occurring (NCBS, n.d.).

The government of India recognizes AYUSH as official forms of medicine with distinct practices, principles, and treatments (NCBS, n.d.). In order to achieve focused development of AYUSH medical systems, the Union Ministry of Health and Family Welfare, a division of the Indian government, created the Department of AYUSH, formerly known as the Department of Indian Medicine and Homeopathy (NHP, 2015). The Indian government also set up the Traditional Knowledge Digital Library in 2001 as a source of over 200,000 interpretations, documents and information in regards to AYUSH and traditional folk Indian medicine (Press Information Bureau, 2010). While folk and tribal techniques have remained as an unprofessionalized sector of Indian traditional medicine, the AYUSH techniques have begun to become highly professionalized, with certified education programs for the training of AYUSH professionals (NHP, 2015).

Biomedicine in India

Unlike many of India’s traditional medical systems, biomedicine is a more recent addition to India’s healthcare system. Also referred to as Western medicine, biomedicine can be defined as, “the form of medicine that developed out of the scientific tradition in 18th century Europe” (Wiley & Allen, 2013, p. 10). It is a medical system that views disease as having a unique biological cause, originating within the body. Possible causes include but are not limited to: a microorganism, a deficiency, a malignancy, or the failure of an organ. Biomedicine is widely accepted and well developed; it has a set of diagnostic criteria for disease states that can be applied across cultures (Wiley & Allen, 2013). In basic terms, biomedicine aims to identify the causes of patients’ health issues and fix the problems through medical interventions. These medical interventions range from medications and pharmaceuticals, to complex surgical techniques. The introduction of Western medicine into Indian culture was the result of colonization by the British Empire, a factor that ultimately led to the creation of a medically pluralistic healthcare system.

History of Biomedicine in India

The British arrived in India at the beginning of the 1600’s, and India was under the colonial rule of Britain from the 1740’s to the 1940’s (Alavi, 2008; Arnold, 1996). During this time, the British greatly influenced India’s medical system by introducing the concept of biomedicine, which was based on the British peoples’ own beliefs and experiences of disease and illness (Alavi, 2008; Bhattacharyat, 2011)

Early Introduction of Biomedicine

In the early days of biomedicine in India, doctors were not only involved with direct medical practice, but were also engaged in building the economy (Bhattacharyat, 2011). Doctors often went with traders to factories and military outposts; therefore, biomedicine in India began in the military and in larger cities (Arnold, 1996; Bhattacharyat, 2011). Biomedical professionals set up general hospitals and medication dispensaries to meet the needs of all Indian and European patients (Bhattacharyat, 2011). Similarly, missionaries in India promoted European medical ideas while learning from local practitioners. Therefore, terms and images taken from the colonial language of medicine and disease began to infiltrate Indian culture and the expression of medicine (Medicine in India Today, n.d.).

During the early years of British colonization, new industries were being established. This resulted in an increasing number of injuries such as lacerated wounds, fractured bones, and serious limb damage (Bhattacharyat, 2011). There soon became an increased need for biomedical professionals’ expertise. Bhattacharyat (2011) articulates that Indian patients had thus far been treated solely within their domestic settings, but they began to be placed within hospital settings for medical help and treatment. As well, many Indian practitioners were impressed by European surgery and teaching. They updated their own traditional practices by adapting these modern methods and integrating them into their care (Medicine in India Today, n.d.). This led to movement away from individualized medicine by traditional healers, and began a push towards the mass production of pharmaceuticals (Bhattacharyat, 2011). Campaigns aimed at prevention (bubonic plague prevention, smallpox vaccinations, and sanitary practice) began as India became more involved with biomedicine and as efforts were made not only to treat and cure diseases, but also to prevent them (Arnold, 1996).

Historic Integration of Medical Systems

What was regarded as traditional knowledge in Indian practice was considered mere information to the British, and was seldom taken seriously (Bhattacharyat, 2011). Most British officials and physicians believed traditional systems of medicine would die out due to the perceived superiority of biomedicine (Medicine in India Today, n.d.). Beginning in the 1830’s, the British government no longer tolerated Indian medicine, and only those trained in biomedicine could be registered as doctors (Bhattacharyat, 2011). Still, traditional practices continued, as not all of India converted to biomedicine. There were many more traditional practitioners than biomedical ones in the 1920’s and 1930’s, mainly due to the inability of biomedicine to reach the large populations living in India’s remote areas (Bhattacharyat, 2011). Additionally, shipping medical supplies from Britain was expensive and difficult, so local medical practices continued. Traditional medicine was a cheap and practical healthcare system for the local people. Arnold (1996) proposed that the desire for a familiar medical system, Indians’ beliefs that traditional ways of understanding disease and health were more effective, and the fact that traditional medicine was cheaper were all factors that lead to the continuation of traditional approaches.

Yet, biomedicine remained a growing part of India’s healthcare system. Overall, the introduction of biomedicine produced fairly good treatment outcomes as a result of its correct anatomical understanding (Bhattacharyat, 2011). These positive outcomes were seen particularly in cases suffering from abscesses, tumours, bone fractures, and lacerated wounds (Bhattacharyat, 2011). The historical introduction of biomedicine into the Indian culture generated the pluralistic medical system that is in place today.

Modern Biomedicine in India

The role of biomedicine in modern India is different than the historical role it played in the country. Before long, biomedical practices became increasingly accepted, and integrative medicine started to develop (Bhattacharyat, 2011).

Shift in Favour of Biomedicine

In 1946, a health report for India noted a very high death rate, high infant mortality rate, and low life expectancy since the British rule and the introduction of biomedicine (Arnold, 1996). However, these reported problems were said to be due to unhealthy living environments and poor provision of healthcare rather than the introduction of biomedicine (Arnold, 1996). This report illuminated some key points for the future of biomedicine in India. Firstly, there became a need for an increased number of biomedical physicians in order to meet the population’s needs (Arnold, 1996). Secondly, it was apparent that the majority of people did not view biomedicine as inappropriate or unaffordable; they just needed more of it (Arnold, 1996). Finally, Arnold (1996) stated that the majority of people began to not even consider India’s traditional medical systems as an alternative.

The ramifications of these factors contributed to the shift towards favouring biomedicine in India. An example of this is seen largely in Mysore, South India. Results of a study carried out by Nisula (2006) suggest that for the majority of people in Mysore, biomedical treatment is an obvious choice of treatment. It is a form of therapy that is often taken for granted, and selected without question by most individuals (Nisula, 2006). When the preference for biomedical services in Mysore is compared with the preference for traditional services, the results are in favor of biomedicine; traditional methods are usually utilized because of the perceived failure of biomedical techniques (Nisula, 2006).

Current Challenges to Biomedical Practice

Although biomedicine in India is favored and widespread today, India’s current public healthcare system is patchy (Dhawan, 2015). Underfunded and overcrowded hospitals and clinics are the norm, and inadequate rural coverage seems all too common. This is due in part to the growing incidence of age and lifestyle-related chronic diseases resulting from urbanization, sedentary lifestyles, changing diets, and rising obesity levels, (Dhawan, 2015). Despite an increasing need for adequate healthcare and health promotion, India has one of the world’s highest numbers of diabetes sufferers (more than 65 million individuals) (Dhawan, 2015). In a recent report from the Health Care Outlook for India 2015, Dhawan (2015) stated that currently India has only one hospital bed for every 1,050 patients, and has a shortage of qualified medical professionals (Dhawan, 2015). India has a ratio of 0.7 doctors and 1.5 nurses per every 1,000, people; there is also an acute shortage of paramedic and administrative professionals (Dhawan, 2015). The situation is aggravated by the fact that medical professionals are concentrated in urban areas, which contain only 30 percent of India’s total population (Dhawan, 2015). Many patients desiring to access biomedical interventions, especially those living in rural and semi-urban areas, are still receiving services from unqualified practitioners (Dhawan, 2015).

Based on these current issues with biomedicine, Dhawan (2015) has made some suggestions for the future of biomedicine. These suggestions include: establishing more medical colleges to provide the required number of healthcare professionals, investing in preventive and social medicine by increasing health education and health promotion, and implementing measures for increased access to biomedical healthcare in rural areas (Dhawan, 2015).

Historically, the role of biomedicine in India revolved around suppression and forceful implementation of Western healthcare ideas. However, biomedicine in India is now portrayed as a complementary system to the traditional practices; it is a system that brings adequate benefits for public health and extensive physiological knowledge. The biomedical knowledge that is available can greatly contribute to the overall health of the Indian population.

Coexistence of Indian Medical Systems

After an investigation of the various medical systems in India, it is important to examine how these medical systems currently coexist to meet India’s healthcare needs. The Indian government has been promoting the integration of Indian traditional medical systems with biomedicine to create a healthcare delivery system in which people have access to varying services (Nisula, 2006). The government has recently made a movement to institutionalize the concept of medical plurality within India’s national health system (NHP, 2015; Sujatha & Abraham, 2012). They are planning on doing this by funding positions for qualified non-biomedical, traditional health practitioners and advocating for an increase in the use of the folk and tribal sector of medicine (Sujatha & Abraham, 2012). Thus, in much of India, blending has occurred between the various medicine systems as biomedical and traditional systems have begun to coexist and supplement each other (Nisula, 2006; Roy & Ali, 2001).

As the medical systems have begun to coexist, they have developed into a hierarchy. Folk practitioners that are not formally educated (considered to be non-experts), rest lowest on the hierarchy of medical systems (Priya, 2013). However, the growth of the AYUSH systems have mirrored that of biomedicine, with practitioners completing college and professional education programs (Priya, 2013). With the increased education, AYUSH systems have developed into parallel systems that exist alongside biomedicine (Priya, 2013). AYUSH systems have also begun to integrate biomedical components and interventions – such as biomedical technology and pharmaceuticals – into their previously non-biomedical health systems (Nisula, 2006). Thus, biomedicine and AYUSH stand side-by-side on the hierarchy of medical systems, with folk and tribal practitioners resting lower on the hierarchy (Prasad, 2007; Priya, 2013). Those with more formal education are more employed and utilized by Indian citizens (Priya, 2013). Yet, in some Indian cities, it has been found that biomedicine dominates AYUSH in terms of healthcare utilization and numbers of hospitals, clinics, and pharmacies (Nisula, 2006).

Benefits of Medical Pluralism – Medical Systems Complementing Each Other

The growth of the traditional and biomedical systems alongside each other has provided an abundance of options for Indian citizens seeking healthcare (Nisula, 2006). Indian citizens may move between the different medical systems and interventions based on the type of illness they experience and what interventions they believe to be most effective (Roy & Ali, 2001). Most studies that have examined the utilization of the medical systems have found that people tend to try home remedies and self medication first, and then seek biomedical assistance if these home remedies fail (Nisula, 2006; Roy & Ali, 2001). Traditional AYUSH techniques would then only be accessed if both home remedies and biomedical interventions fail (Nisula, 2006). However, other areas of India have reported utilizing folk healers and AYUSH practitioners for initial treatment, and accessing biomedical practitioners solely as a last resort (Priya, 2013). Regardless of which type of healthcare people choose to access, the pluralistic medical system allows people to choose the interventions that best meet their health needs and beliefs. It additionally allows them to utilize alternative systems if their initial treatment choice does not seem to be effective (Roy & Ali, 2001).

Some areas of India have chosen to further improve peoples’ treatment options by offering both biomedicine and AYUSH options in the same locations (Priya, 2013). Some hospitals and health centres contain both practitioners trained in traditional medicine and those trained in biomedicine, to facilitate easier access to peoples’ desired medical interventions (Priya, 2013). Furthermore, some biomedical practitioners accept the interventions provided by practitioners of traditional medicine. These biomedical clinicians prescribe traditional medications or home remedies to their patients and/or refer their patients to AYUSH practitioners or folk healers if they believe that the other medical systems may benefit their patients (Priya, 2013). The practitioners that do this may be better able to serve and assist their patients, since they understand the advantages of the other medical systems and are more able to assess their patients’ needs and determine the most appropriate treatment options to meet these needs. If more practitioners chose to prescribe or refer patients to alternative treatments, the medical systems would be better able to complement each other and partnerships could be created between professionals at various levels of the healthcare system.

Due to the differences between the various medical systems, utilization of the different systems simultaneously allows the different interventions to support each other and promote improved healing. Biomedical techniques often focus primarily on the medical and physical aspects of peoples’ health, while traditional methods tend to be more holistic, encompassing the psychological, spiritual, and physical dimensions of health (NHP, 2015; Ravishankar & Shukla, 2007). When used simultaneously, biomedical and traditional health methods promote healing of both the body and mind, while still allowing people to access their preferred treatment methods (Ravishankar & Shukla, 2007). Thus, it could be said that biomedicine and traditional medicine can be used beneficially as adjuncts, or complementary medicines, to each other (Patwardhan, 2013).

Challenges and Conflicts Between Medical Systems

While the pluralistic medical system of India does produce multiple benefits to society and healthcare delivery, various conflicts have arisen between the different medical systems. Some biomedical health professionals and traditional medicine experts are beginning to feel confused and threatened by the clashing of different medical approaches (Dhawan, 2015). Conflicts arise from the lack of knowledge or acceptance of certain types of medicine by citizens, social inequalities, and lack of education and communication between different medical professionals.

Lack of Knowledge, Trust, and Acceptance

Much of India is promoting and investing in the pluralistic approach to healthcare that encourages the simultaneous existence of biomedicine alongside traditional medicine systems (Albert et al., 2015). However, in order to promote medical pluralism, acceptance and trust of the various systems by Indian citizens must occur (Albert et al., 2015). It has been found that some areas of India acknowledge and accept biomedicine and tribal/folk medicine, yet are unaware of or do not accept AYUSH systems (Albert et al., 2015). Still other areas of India rely primarily upon folk and AYUSH systems and do not accept biomedicine (Roy & Ali, 2001). In these areas, people tend to not accept biomedicine if the biomedical concepts conflict with their cultural perceptions about health, if certain diseases treated by biomedicine are not believed to be true illnesses, or if certain diseases are believed to be caused by culturally specific factors and not treatable by modern medical interventions (Roy & Ali, 2001). In order to reduce the lack of trust and acceptance that some citizens have of the different medical systems, people must be informed and educated on the reasons and benefits of specific interventions. Once people have true knowledge of the different systems, they can then make informed decisions based on their cultural and health beliefs and preferences.

Additionally, the efficacy of traditional methods are sometimes argued by those looking from a Western or biomedical perspective (Broom et al., 2009). AYUSH traditional systems have been undisputed in the past, recognized as being worthy of the creation of

medical degrees in order to register professionals (Chandra, 2016). At the recent International Conference on the Frontiers of Yoga, the Indian Prime Minister stated that it is essential to “apply the techniques and methods of modern science [to traditional AYUSH medicine], to test and validate results, assure quality, and explain benefits” (Chandra, 2016, para. 1). This is a crucial concept, as traditional medicine currently has an absence of any specific tools of measurement or validation. Therefore, traditional medical claims require proof of safety and effectiveness that are judged by the same standards of research set out for modern biomedicine (Chandra, 2016). In order for some individuals in India to begin considering and believing in the benefits traditional medicine, the practices need to be judged by the same biomedical standards that the world already accepts (Chandra, 2016). When people begin to see proof of effectiveness of both traditional medicine and biomedicine, the acceptance of medical pluralism in India may increase.

Social Inequalities

Social inequalities caused by medical pluralism in India stem from peoples’ abilities to access different types of medical care and the underlying patriarchal structure of the Indian culture (Broom et al., 2009). People are less likely to choose biomedical interventions if they have low socioeconomic status and lack the social status and funds required to pay for treatment (Broom et al., 2009; Prasad, 2007). Also, those that live far from urban areas, where most biomedical centres are located, often are faced with challenges in accessing biomedical care. Those in remote regions typically resort to the traditional healing methods that are more prevalent in remote areas (Broom et al., 2009).

Furthermore, due to the patriarchal structure of Indian culture, families are less likely to access biomedical interventions for women, especially if the treatment is costly (Broom et al., 2009). Traditional methods are often used for those seen as being lower priority, including women and older adults, while biomedical interventions may be reserved for those of higher priority (men and youth) (Broom et al., 2009). This creates social inequality in the Indian society, as fewer women and older adults are able to receive the treatment that they may desperately require. Also, it has been found that when people rely on traditional methods first, as is often the case for women and older adults, if biomedical intervention is later sought out, it may be too late for biomedical practitioners to control the disease or illness; by the time these people present for biomedical treatment, their diseases have progressed beyond the state where treatment is effective (Broom et al., 2009).

For older adults, India has begun to put various interventions in place in order to facilitate access to traditional AYUSH medicine (Helpage India, 2012). While this does not improve their access to biomedicine, interventions such as AYUSH clinics in rural areas and mobile AYUSH clinics have improved older adults’ access to at least some form of medical assistance (Helpage India, 2012). As well, it has been found that many older adults prefer utilizing traditional medicine over biomedicine, as they have grown up using traditional medicine for most of their lives (Helpage India, 2012).

Lack of Education and Communication Between Medical Professionals

Lack of education and communication between medical professionals is another challenge occurring in India’s current medical system. This not only results in reduced utilization of the full potential of the pluralistic medical system, but also in safety concerns for patients. As integration has occurred between the various medical systems, some of the AYUSH educational institutions have begun to incorporate biomedical teaching into their curriculum (Nisula, 2006). However, much of this biomedical teaching is being completed by AYUSH practitioners who do not have extensive knowledge of biomedical subjects (Nisula, 2006; Patwardhan, 2013). In addition, very few biomedical institutions are incorporating teaching about traditional Indian medical systems into their curriculums (Patwardhan, 2013). This has resulted in AYUSH practitioners gaining incorrect or fragmented knowledge of biomedicine, and biomedical practitioners having little awareness of the knowledge and practice domains of AYUSH clinicians (Patwardhan, 2013). With little education, and minimal communication between the different medical practitioners, it is difficult to build mutual trust and respect between healthcare professionals (Patwardhan, 2013). Lack of trust and respect then leads to individual practitioners not acknowledging the potential benefits of alternative treatment methods that could better assist their patients.

Education and communication between different medical practitioners is also critical in order to maintain patient safety (Patwardhan, 2013). If patients access biomedical and traditional medical interventions simultaneously and practitioners are unaware of the treatments provided by the other medical systems, herb-drug, food-drug, and drug-drug interactions may be overlooked (Patwardhan, 2013). This creates safety risks for patients, as medication interactions can greatly impair peoples’ health. Thus, it may be beneficial to introduce education on traditional Indian medical practices into biomedical curriculum and to have biomedical experts complete the education for students in AYUSH education programs (Patwardhan, 2013). This would ensure that all trained medical practitioners are aware of the available treatments offered by other practitioners and informed of the potential safety risks for patients accessing interventions from multiple medical systems.

Conclusion

Despite the current challenges and conflicts between the different medical systems that exist in India, the integration of biomedicine with traditional medicine has produced an opportunity for people to access diverse types of medical interventions to meet their individual health needs. The AYUSH and folk healing practices that existed traditionally in India have been able to expand in knowledge and adapt to meet the changing health needs of India’s population. While the initial introduction of biomedicine involved the forceful integration of Western ideas into the Indian culture, biomedicine has now become a system that brings extensive physiological knowledge and benefits for the health of India’s citizens. The coexistence of traditional and biomedical health systems in India is being promoted by the Indian government and population, and medical pluralism has become a growing reality in the country (Nisula, 2006; Sujatha & Abraham, 2012).

Medical pluralism brings various advantages to the health of the Indian population. With the blending of traditional medicine and biomedicine, a diverse array of healthcare knowledge and techniques have become available in the country. Indian citizens are provided with healthcare options, and in some cases, are even able to access various types of medical interventions simultaneously (Nisula, 2010; Priya, 2013). The concurrent use of different health interventions allows people to receive healthcare that meets their holistic health needs, addressing their physical, psychological, social, and spiritual health.

However, there also appear to be some changes that could be implemented in order to strengthen the pluralistic medical system of India. Indian citizens require education regarding the services and background knowledge offered by the different medical systems. Only with an understanding of the healthcare options available to them, can citizens make informed decisions about their treatment. As well, India is currently advocating for traditional medical techniques to be tested for validity by the scientific method (Chandra, 2016). The completion of scientific testing on the various traditional healthcare options in India will further provide information and legitimate rationales for the use, or exclusion, of traditional treatments. Additionally, in order for the distinct medical systems to effectively meet India’s health needs, collaboration between biomedical and traditional medicine practitioners is essential. This collaboration requires professionals to be educated upon the knowledge foundations and interventions of the different medical systems. It also requires professionals of different medical systems to work in partnership with each other, understanding and accepting the potential benefits that other systems may offer for their patients. If these interventions could be initiated in India, the country’s pluralistic medical system would have the opportunity to flourish, with a wealth of both traditional and biomedical knowledge, and professionals at all levels of the healthcare system working together to meet the immense health needs of India’s population.

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