Indigenous Medical Practitioners to Curb Coronavirus Disease-2019 Crisis in India: A Pragmatic Proposal?

Sir: The government of India has long ago established an objective, relevant, and cost-effective health care in the country, and committed four-pronged principles of primary health care consisting of equitable distribution, community participation, intersectoral coordination, and use of appropriate technology for the improvement of its quality. The "Health for All" (HFA) initiative brewed this concept of primary health care, and some of its prime attributes were essentiality, universal accessibility, acceptability, affordability, availability, proximity, comprehensiveness, continuity, appropriateness, adaptability, and coordination. However, poor health awareness, affordability, accountability, accessibility, direly inadequate human resources, and inappropriate application and execution of the government's existing policies are the top-tier hurdles in India's health care system. The health care system in India comprises (1) national health programs, (2) public health sectors, (3) private sectors, (4) voluntary health agencies, and (5) indigenous systems of medicine. All References don't seem to support this statement.[1-3] The socioeconomically backward section of the community cannot afford access to private hospitals/clinics. Hence, they have only two options left where affordability is not the determining factor: either visiting the government/public health sectors or going to indigenous medical practitioners ("quacks"), especially those practicing allopathic medicine or sometimes "mixopathy" without any certified and validated training. The question of why poor people choose untrained/unqualified and non-certified indigenous practitioners over free public health services arises. There are several explanations:[4] (1) affordability of treatment; (2) unpleasant experiences from public facilities; (3) "dignified treatment;" (4) "detailed checkups and flexibility;" and (5) personal preference of "quacks" over certified doctors. This preference might be stemming from round-the-clock availability and empathetic behavior towards the patients and his/her caregivers. In addition, the "quacks" offer drugs at low cost. The flexibility, approachability, availability, and proximity are the essential characteristics that earn the broader acceptance of people in socioeconomic deprivation, marginalization, and discrimination.[5-7] At a glimpse at the conditions, one may get surprised that these are nothing but the specific attributes motioned in the strategic brochure of the HFA initiative; then, where do the discrepancies lie? The discrepancies lie in the fact that the HFA initiative, besides the promises described above, which appear to get fulfilled by the indigenous medical practitioners or quacks, also promised "quality-assured" essential health care; they also assured usage of appropriate technology for detecting, diagnosing, and treating pathologies. The HFA initiative dreamt of scientific, evidence-based health care alongside providing continuous health awareness to make the community health-conscious. In addition, quite conceivably, these are the lacunae, which quacks can never plug. Moreover, without any knowledge of this, the community will continue to suffer.[5-7] Indeed, instances such as death due to mistreatment, using the same syringe for multiple patients leading to the spread of human immunodeficiency virus, or conducting illegal transplants are not even rare. Quite expectedly, the ubiquitous practice of uncertified and untrained quacks in India will lead us toward the ice age. Whatever drugs they prescribe and the treatment they offer is not evidence-based. Unsurprisingly, evidence is age-old and umpteen that these rampant "quack" practices will lead to a wholly broken healthcare delivery system in India. Unfortunately, we have not been great achievers even after incessant search for definitive curative therapy against this critical disease. The administrative authorities have little clue about the natural history of disease and are formulating short-lasting guidelines, often proved to be compelling and ever-changing. When even the certified infectious disease specialists and other specialists find it difficult to contain and combat COVID-19, how can the administrative authorities even think indigenous medical practitioners can stand up to this pandemic? Where are we heading? Towards containment of the pandemic or concealment of the government's failures? The burning question remains. COVID-19 and indigenous medical practitioners/quacks - the unlucky 13 and the current scenario: They do not know or follow any established evidence-based guidelines for treating COVID-19 cases. Quacks are self-proclaimed "Omni-specialists." They treat everyone with the same approach. They already have the habit of indiscriminate use of dexamethasone for various purposes, which may lead to the re-emergence of outbreaks of infectious diseases like mucormycosis, uncontrolled diabetes, Cushing's, and adrenal insufficiencies. They are treating with oral drug favipiravir without evidence and improper dosing schedules. Indigenous medical practitioners, expectedly, neither know "antimicrobial stewardship" nor follow any antimicrobial prescription guidelines. Using antibiotics indiscriminately will undoubtedly raise the antimicrobial resistance and their unmonitored usage-related toxicities. The mixopathy practitioners are prescribing herbal, homeopathic, and allopathic medicines together. Neither they, nor anyone in the world knows the interactions, actions, and consequences. Usually, indigenous medical practitioners also keep arrangements for a few beds for the temporary admission of some patients on a required basis. They do not know what to monitor, how to assess the severity of illness and exactly when to refer the patient to higher centers. It is often too late when they finally take the "credit" of referring a COVID-19 case to a dedicated hospital. Moreover, sometimes, there lie some unholy nexus/rackets underneath, which in turn enforce referral and admission of patients who do not need admission and nonreferral of those cases require hospital admission. They give essential health care services to people in distress at difficult times. It is a work worthy of salutation, but they seldom make people aware of the disease spreading. They never uphold the importance of contagious disease appropriate social behaviors. They do not know how to observe "COVID-19 appropriate behaviors"; thus, they are getting more affected themselves and infecting communities at large scale. They rarely give a legit prescription and an entire strip of tablets; hence when the patient becomes critical and reaches the emergency department, nobody has any clue what medication the patient had already consumed. In the name of low-cost service, if this continues frantically, it will only lead to the deliberate exploitation of vulnerable groups. Managing uncontrolled diabetes mellitus, especially at times of pandemic, has become challenging even in countries with the best in-house medical facilities. Improper oral anti-hyperglycemic choice, improper dosing patterns, improper monitoring of blood glucose and other organ functions, and overwhelming "therapeutic inertia" will lead to what is called resistant hyperglycemia or "difficult to control" hyperglycemia and further end-organ damage. Indigenous medical practitioners often blame modern medicine for the deaths of patients at these crucial times, without any evidence, and try to sell unverified products with highly questionable safety and efficacy profile to people at large. For what? Profit or service? Training of quacks to "replace" qualified and certified frontline doctors is the new notion buzzing around many places in India. Not going into in-depth criticism, it can be perceived that training of 3-6 months can never "replace" the knowledge and attitude practiced throughout a minimum of six years or even more by a certified doctor. Regarding affordability, the quacks practice may be low-cost but certainly not cost-effective. There is, unfortunately, no "free time" left to "train and use" techniques that authorities are daydreaming about. If it was really to be done, it should have been done as a part of "epidemic preparedness" long before COVID-19 struck the country or at least in the "free-time" offered by the pandemic between waves. Some of these practitioners are promoters of "anti-vaccine propaganda." Since, as previously mentioned, the community, especially those with lower socioeconomic status, trust them blindly, such "anti-vaccination propaganda" will lead to unnecessary and pitiful prolongation of the pandemic. If quacks find loopholes to get into the system because of ill-conceived government policies, it would only aggravate the conditions. Moreover, whatever utility they are providing should be provided by the country's primary healthcare. Instead, the government has inclined towards unqualified health professionals. Adding to the fact that only 20% of those who practice medicine in India are certified is a nightmare. The government needs to tighten the rules, bring this burning issue under the spotlight and bring separate legislation. Ultimately, quackery is itself a socioeconomic disease, affecting the health and morals of the country in its roots. We must be cautious of not aggravating an epidemic of quackery while already combating one. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.