Public Health and the Politics of Knowledge: The Role of Traditional Medicine in the Management of COVID-19 in Two South Indian States

Abstract

Public health discourse about COVID-19 pandemic has mostly been framed around biomedical interventions, although there is evidence of the effective use of traditional medicine (TM) to manage the pandemic by some Asian countries such as China, Thailand, Vietnam and India. This article aims to place on record the policy of medical pluralism in the two South Indian states of Tamil Nadu and Kerala in their respective deployment of Siddha and Ayurveda in the management of COVID-19. Based on interviews with physicians of TM and health administrators, press reports, social media posts and published research, this article reconstructs the crucial yet undocumented process of incorporating TM in the biomedicine-based health bureaucracy in Tamil Nadu and Kerala to deal with infectious fevers such as dengue and chikungunya in the past and COVID-19 in the present. It is our argument that those methods of TM which are safe and in long recent use could provide low-cost and accessible means of prevention and early treatment of infectious fevers. They have to be identified and subjected to further investigation as innovations in social medicine brought forth by the state and its officials and are different from the highly expensive projects of the corporate pharmaceutical sector.

Keywords

Traditional medicine for COVID-19 medical pluralism and COVID-19 traditional medicine in public health Ayurveda and Siddha public health in Tamil Nadu public health in Kerala South Asian medical knowledge

Introduction

The crisis created by the COVID-19 pandemic has given a boost to pluralism in health systems in Asia, Africa and Latin America, bringing traditional medical practices into public health, but it has also given rise to a fair share of controversies. Asia, Africa and Latin America are regions endowed with rich biodiversity and, in contrast to the temperate regions of the world, they also possess time-tested knowledge of TM for the treatment of infectious fevers. Herbal formulations from TM pharmacopeia have been used by the people as preventives and adjuvants for COVID-19 in Africa (Orisakwe et al., 2020), Latin America (Frazer, 2020; Lugo-Morin, 2021), China, Korea (Jang et al., 2021) and India (Kotecha, 2021) and have also been subject to further research. In China, traditional Chinese medicine (TCM) drugs, methods of fumigation and aqueous herbal decoctions were brought into the treatment protocol at Wuhan during the COVID-19 crisis (Nature Plants, 2020) with some good results (Zhao et al., 2021).

Interestingly, however, the overwhelming popular support for home remedies and traditional drug formulations in these regions of the world and the permissiveness of their governments in bringing them into COVID-19 management have only been met with scepticism and strong opposition on the part of the biomedical fraternity.

Debates about the inclusion of Ayurveda and Siddha¹ (which are the traditional medicines [TMs] officially integrated in the Indian health services under a separate ministry known as the Ministry of AYUSH)² in COVID-19 management in India have followed a similar trajectory. Professional biomedical associations and a large part of the English language media objected to the involvement of TM in COVID-19 care on the grounds that they are not proven through randomised controlled trials (henceforth, RCTs).³ Yet they flourished during the pandemic because of government policy, publicity received in the regional language media, and widespread social and community support, and this is also testified by the steep rise in the sales of herbal medicines and decoctions in India during this period (Sujatha, 2021b).

Infectious Fevers in South Asian Medicine

Infectious fevers are not new to Asia, and for centuries both canonised and folk streams of medicines have developed therapeutic strategies to deal with fevers of different kinds, including environmentally induced epidemics. One question which is raised frequently is: How could ancient systems of medicine have remedies for fevers caused by new germs? Such statements emerge from the faulty belief that the germ theory of disease is the only medical explanation for fevers. Ayurveda and Siddha, like most Asian medicines, understand the pathology of fevers in systemic terms and have much to offer in terms of modulating host factors—a vital aspect relating to infectious diseases (Pinto, 2021)—and are different from the biomedical theory of invading microorganisms.

Environment and Host-Based Approach

In the major classical texts of Ayurveda, there are references to epidemic diseases (janapada udhvamsa). The Caraka Samhita (a text from 300 bce) explains how a population with individuals of different physical and mental characteristics (constitution, dietary practices, strength, habits, age and so on) could possibly suffer from the same condition due to the degradation of air, water, environment and time in succession and affect the entire population. General health measures to be advocated in the community such as avoiding physical contact and moving to safer locations are also discussed.

Importantly, that nasal passages are the points of contact for the causative agent is specially mentioned in this context. Contagious fever is a type in the group of fevers identified by the Sushruta Samhita as Agantu jvara,⁴ and Butabhisanga jvara is a sub-type which is caused by microorganisms. Authors like Gananath Sen have explained that due to the influence of place and time and multiple etiological factors, present-day manifestation may not exactly match with the descriptions in the classical Ayurvedic texts (Puthiyedath et al., 2020), but it is possible to identify therapeutic protocols for a cluster of symptoms. A host mechanism and environment-based approach to infectious fevers are also fundamental to Siddha medicine, and fever is listed the first among the ailments in the compendiums of later Siddha texts. Fevers have been classified into 64 types based on differing clinical criteria with details of incubation, stages of progression, symptoms in phases of development of the disease and specific interventions for various stages.

Germs are secondary to the Siddha theory of pathology as they are not activated all the time. Their actions depend on the temperature variations due to the seasons and the bodily predisposition of the exposed person. The latter are the proximate and particular causes for the onset of fever to which Siddha texts direct their attention. A Siddha doctor, Dr JS explained in an interview during 2020 that:

Fevers can be addressed irrespective of the kinds of microorganisms involved based on the affected bodily parameters and functions. Hence the efficacy of Siddha medicines for COVID-19 has to be tested not for reducing the viral load, but their action on the reduction in Lactate Dehydrogenase (LDH) Isoenzymes.

In the following sections we shall see how the Siddha doctors correlated the WHO definition of symptoms with the Siddha classification of diseases to identify dengue, SARS-CoV-1 and COVID-19. Host-based approaches may thus be able to address infections by enhancing general immunity (Prakash et al., 2021).

Siddha texts like Kudineer Nooru (literally, ‘hundred types of decoctions’) by the renowned Siddha physician Theraiyar of the fourteenth–fifteenth century contain clear instructions for the preparation of 100 herbal decoctions, of which 48 are meant for various fevers. Apart from single herb decoctions, fever pills were also prepared by renowned physicians well into the twentieth century. In 1802, the garrison surgeon from Ganjam, G. Dunbar wrote about intermittent fevers being successfully treated by a locally acquired substitute for the imported Peruvian bark which he called the ‘Hindustanee Fever Pill’. The pharmacopeia of Siddha medicine prepared by Dr Shanmugavelu (1973) published by the Industrial Labour Welfare Association in Coimbatore gives a protocol for dengue and influenza, which consists of five medicines to be administered in the prescribed doses along with ginger juice and honey.

The Siddha physicians explained how they are able to correlate epidemic fevers such as bird flu and COVID-19 with the textual classification of fevers based on functional, seasonal and pathological characteristics—including fevers which biomedicine regards as new from the viewpoint of the microorganisms involved. For instance, the WHO-listed symptoms (NHP 2015) for dengue were correlated with the symptoms mentioned in Siddha texts such as Agastiyar Sura Nool 300⁵ (Agastiyar fever text of 300 verses). Based on the symptoms—severe headache, nausea, vomiting, rash and pain behind the eyes and the incubation period for the fever—it was identified as a variety of pitta suram, which is one of the ailments caused by the derangement of pitta (roughly translated as bile) and is said to be mediated by blood, showing a correlation to the vector-borne character of dengue. Pitta suram causes mild shivering and intermittent fever, though the appetite need not be affected as much as it would be in the case of what is known as Kabasuram, under which COVID-19 has been classified. COVID-19 symptoms such as mild fever, lack of appetite, diminished sense of smell, cough, cold and breathing difficulty match with the Siddha classification of Kabasuram. Also, it fits well with the Siddha theory that Kabasuram is the most frequent type of fever in the spring season. Besides, Kabasuram is associated with long incubation, mild fever and final stages of delirium, leading to death on the 14th day. The Siddha physicians interviewed also suggested that recovery in the case of Kabasuram is likely to be delayed.

The use of the TM knowledge of the region in the management of COVID-19 by the state government in two South Indian states, Tamil Nadu and Kerala, is of interest to public health specialists and social sciences alike, because it represents a valuable case of adapting embedded and qualitative TM knowledge to the vast bureaucratic healthcare delivery system. Although this process is by no means new in India and has been unfolding for over a century with a rich body of historical, anthropological and sociological writing on every aspect of medical pluralism, the deployment of traditional knowledge in the management of epidemic fevers including COVID-19 has not received due attention. Despite being a massive governmental intervention, it does not seem to have come in the radar of the global public health discourse. The academic literature on COVID-19 management is profuse with protocols and genome sequencing studies based on the expertise of laboratory sciences removed from real-life situations of the pandemic. The demand for hard evidence from the lab is said to have slowed down preventive responses from bureaucrats and medical officials to the pandemic based on soft evidence (Bhaduri & Knorringa, 2020).

This article seeks to throw light on the efforts of two well-performing South Indian states to bring institutionally qualified practitioners of TM to manage the pandemic, though in a marginal role.

Materials and Methods

Tamil Nadu and Kerala

Although AYUSH protocols for COVID-19 were introduced throughout the country by the Government of India in May 2020, we have chosen Kerala and Tamil Nadu as the case studies because they are among the Indian regions to have a hoary and distinguished history of TM extending into recent times and embedded in the regional health culture. Most importantly, these regions represent a coherent strategy on the part of the state government to harness TM practices in public health delivery to address dengue, chikungunya and SARS in the past decade and presently in the management of COVID-19. Moreover, the internal variation between the state policy of Tamil Nadu and that of Kerala on the role of TM practices in the COVID-19 strategy is illustrative of different models of integrating TM in pandemic management.

There are around 1.2 million allopathy doctors and 0.8 million AYUSH doctors in India according to figures from 2020, of which 443,704 are registered Ayurveda practitioners and 9,125 are Siddha practitioners (Ministry of AYUSH, 2021). The latter are mostly based in Tamil Nadu and Kerala. These are the states with leading performance in health status among the Indian states. They are endowed with a well-functioning health infrastructure in terms of the proportion of beds and biomedical doctors to the population. As of December 2018, of the 1,154,686 allopathy doctors in the country, Tamil Nadu had 133,918 (7,233 in government services) and Kerala had 59,353 (5,239 in government services; CBHI, 2019). Kerala has a total of 25,142 Ayurveda practitioners and 2,275 Siddha practitioners, whereas Tamil Nadu has 4,357 Ayurveda practitioners and 6,844 Siddha practitioners (CBHI, 2019). Tamil Nadu has a small proportion of Siddha doctors in the government services, about 650 in total,⁶ and Siddha medicine had been assigned a marginal role in the Tamil Nadu health services before 2010–2011. Kerala, on the other hand, has an impressive cadre of around 1,500 Ayurvedic physicians in its government centres, and the rest are in the flourishing private sector. The profound influence of Ayurveda and indigenous traditions in the health culture of Kerala is well documented by anthropologists. But its contribution in improving health status tends to be ignored in the writings on the ‘Kerala model’ of development (Payyappallimana, 2011).

In this article, Tamil Nadu represents a case of the proactive role of the state in the promotion of a classical polyherbal formulation from the pharmacopeia of Siddha medicine for preventive and therapeutic use for mild and moderate cases of COVID-19 without co-morbidities. Kerala represents a case in which Ayurveda-based protocols for COVID-19 were restricted by the government for use only as preventives and for the post-recovery phase. Although the TM protocols were created, publicly announced, implemented and widely followed by the people in these two states, there is little documentation of the process or their effect on the population.

This article builds up the material on this important public health experiment in using TM, based on interviews, newspaper reports, online news portals, government orders and reports, analysis of published research and the study of selected portions of Siddha and Ayurvedic texts and compendiums on fever. In particular, the Tamil Nadu case draws upon in-depth interviews, both physical and telephonic, conducted by the first author, with 10 institutionally qualified Siddha doctors located in Chennai, New Delhi, Tambaram, Tirupathur, Palayamkottai and Pondicherry between April and December 2020, of which 5 were from the government sector and the others from the private sector, apart from 1 retired health secretary of the Tamil Nadu government. Data on medicinal supplies was obtained on email request from IMPCOPS and TAMPCOL in December 2020. The Kerala case is based on interviews conducted by the second author with 10 Ayurveda physicians located in the districts of Thiruvananthapuram, Kollam, Ernakulam, Thrissur, Palakkad and Kannur, of which 3 were Ayurveda researchers, while the rest were clinical practitioners. Three of the ten in the sample were from government services, including members of the COVID-19 taskforce for Ayurveda in Kerala, and the data was collected between August 2020 and August 2021. Archives from Arya Vaidya Sala (AVS) Kottakkal (an old, renowned and the largest Ayurveda institution in the state), print and visual media reports during the said period and social media posts on Ayurveda for COVID-19 were also relied upon.

Tamil Nadu: The Bureaucratisation of Health Culture

When the state has to endorse and adopt a health practice from tradition in order to deal with a public health threat like dengue or COVID-19, several factors come into play. Since 2006, Tamil Nadu has seen several minor and major outbreaks of epidemic fevers such as swine flu (H1N1), chikungunya and dengue. The Tamil Nadu government’s experience in tackling epidemic fevers with Siddha medicine is more than a decade old. Official acceptance of Siddha herbal preparations to address epidemic fevers started around the swine flu outbreak in 2006, followed by the chikungunya outbreak during 2007–2008. The Siddha experts consulted by the then Commissioner of Indian medicine suggested the well-known herbal formulation Nilavembu Kudineer (NK), which has been in use at the Government College of Indian Medicine since 1964 and also registered in Siddha Formulary of India.

Nilavembu Kudineer for Dengue

NK is a polyherbal formula containing eight ingredients, of which the main ingredient is Nilavembu (Andrographis paniculata), a herb known as the ‘king of bitters’, widely used in the Asian system of medicines. There are thousands of publications on Nilavembu across Asia, and in Siddha medicine, it is always administered with other catalysts which modulate its effects on the body, as it is a highly potent drug.

The antipyretic effects of the Nilavembu plant are clearly mentioned in the Siddha texts, and it is also common knowledge among Siddha doctors today. However, its specific action with regards to dengue is of interest because dengue was defined as pitta suram, and Nilavembu’s potency for addressing derangement of pitta is established and confirmed by its bitter taste. Taste is an indicator of pharmacological action in Siddha and Ayurveda.

There are other Siddha medicines probably with greater efficacy, but NK was found to be appropriate for mass production and distribution in the public health delivery system, as it contains only herbal ingredients. According to the Siddha physicians interviewed, safety was the foremost concern while selecting a formulation. Second, watery herbal decoctions are the preferred form of medication for fever in Siddha because they also rehydrate the body dried up by the fever. Lastly, the Siddha physicians preferred to choose a compound formulation from the Siddha Formulary in order to retain the exclusivity and reputation of Siddha and avoided common formulations that Siddha shared with Ayurveda.

The real breakthrough for NK came during the dengue outbreak of 2011 when the cases showed a rising trend since 2010. The then chief minister (CM) of Tamil Nadu (TN), Ms Jayalalitha, not only issued a government order for the distribution of NK but also made a public appeal to consume NK for prevention and management. This step was taken only after the CM confirmed that there was research publication on the ingredients contained in NK and its safety was well established. Two key publications were said to have been provided to her: one published in 2011 in Asian Pacific Journal of Tropical Medicine, confirming the anti-pyretic, anti-inflammatory and analgesic properties of Nilavembu Churnam based on in vivo study on mice (Anbarasu et al., 2011). Another study published in 2012 in a Springer nature journal BMC Complementary and Alternative Medicine was based on in vitro study of methanolic extracts for anti-dengue activity of six medicinal plants used in Malaysian folk medicine, of which Andrographis paniculata was one and found to be efficacious (Tang et al., 2012).

An informant goes to say that the Tamil Nadu CM first asked for a cup of NK and consumed it. Considering its bitter taste, it was thought that Nilavembu will never be approved for mass distribution by the CM. Later in the day, she approved it for public distribution and passed the order. The CM testing the medicine on herself before approving it was seen as a highly responsible act. She also added the juice of papaya leaves to the dengue protocol for improving the platelets.

The CM’s proclamation gave a big boost to the Siddha physicians, and NK was distributed to school children in government schools. NK camps were conducted by religious organisations, companies and trusts of various kinds, apart from being made freely available in government hospitals. The NK powder was also a product in high demand in the indigenous drug stores. MLAs and district collectors took the initiative to organise NK camps to contain the spread of dengue in their constituencies.

Despite this open social acceptance and the popularity that the NK camps received in visual and print media in Tamil, there are very few systematic studies evaluating its effects on the population. The year 2012 was a year with a very high number of cases at 15,770 and mortality at 71 for Tamil Nadu (Chandran & Azeez, 2015), which came down to 2,531 cases and 5 deaths in 2016. But 2017 was again a bad year, with 23,294 cases and 65 deaths, which came down to 8,527 cases and 5 deaths in 2019. The response to dengue was multi-pronged, of which NK was one part, and it is difficult to arrive at any statement from population data in the absence of proper documentation. There, however, seems to have been a feedback system within the health department and many committees convened to deal with the epidemic, which were convinced about its utility as a preventive and curative for mild cases of dengue. The biomedical doctors stuck with a huge patient load of dengue cases did not object to the use of NK.

During the devastating floods in Chennai city in Tamil Nadu during November–December 2015, the distribution of NK among the flood victims facing the possibility of epidemic outbreaks after waterlogging is noted by the Director of the Community Medicine Institute of the Madras Medical College. He found NK to have dual role, both in prevention as an immune enhancer and in treatment along with regular allopathic drugs. He further went on to show that follow-up reports proved the effectiveness of the control measures in preventing and limiting the epidemic following a major disaster. ‘Even in the laboratory-confirmed cases raise in infections were limited, not in epidemic proportions expected after such severe floods’ (Selvavinayagam, 2016). In 2018, a clinical evaluation of an ethanolic extract of NK was conducted to examine its mode of action by the International Centre for Genetic Engineering and Biotechnology, New Delhi (Jain et al., 2020), which found that ‘NK controls fever in a comprehensive manner through its healing effects of temperature regulation, inflammation control and body pain relief. It acts in a way to boost immunity’ (Jain et al., 2020).

The COVID-19 Crisis and Kabasura Kudineer

We mentioned earlier that based on triangular analysis of symptoms from WHO definitions, Siddha texts and clinical evidence, COVID-19 was identified as a kind of Kabasuram by Siddha research scientists in the Central Council for Research in Siddha (CCRS). Accordingly, Kabasura Kudineer (KSK), another polyherbal preparation containing 15 herbs, was also adopted for public distribution.

KSK had been used previously for the treatment of swine flu in 2009. During the 2009 outbreak, there were greater proportions of patients reporting diarrhoea and vomiting, along with the previously known symptoms such as fever, cough and body ache (Thillaivannan et al., 2015). The 2009 strain of the virus had become resistant to the conventional biomedical treatment for the same, consisting of oseltamivir and zanamivir, which also produced adverse reactions and bronchospasm. Hence, KSK was recommended as safe for long-term use. Due to prior experience, the Tamil Nadu government released the Siddha protocol for COVID-19 on 24 April 2020 and started the distribution of KSK packets for 0.1 million families in the containment zones in Chennai under the Arogyam scheme (TNM, 2020), and it was promoted only as an immunity booster along with other precautions.

In the months after April 2020, huge amounts of KSK in the form of powder in packets of 60 ml each (per day dosage is 30 ml twice) were brought into the public domain and distributed as powder to be added to water and boiled or as hot, ready-made Kudineer in flasks and vessels in containment zones where people could not access a stove. Police personnel, health staff and doctors were given KSK as part of their protection (Padmanabhan, 2020).

Utilisation of Existing Institutional Infrastructure

The Tamil Nadu state government clinics source KSK from the government’s own enterprise, TAMPCOL and from the cooperative store in Chennai—IMPCOPS. The upscaling of production of KSK had been massive to reach 25,000 packets a day only in Chennai city, while another report says that 6 million people in Trichy town received KSK free of cost from government hospitals (PIB, 2020). To facilitate decentralised mass production and the trouble of transporting KSK from Siddha clinics, the Tamil Nadu government roped in Amma canteens (subsidised food outlets for weaker sections started by the government, approx. 700 in number throughout the state, employing women workers from marginalised sections of the society), run by women’s self-help groups into the task of preparing KSK after some training. Each canteen was equipped to prepare 2,000 doses per day, which were then carried by the city corporation trucks to containment zones and distributed free of cost to vulnerable sections (Karthik, 2020).

The Tamil Nadu government instructed that all government health facilities, allopathic or otherwise, will supply KSK as a preventive. CCRS released a protocol consisting of KSK and other compounds from the Siddha Formulary, adding fumigation of the house with neem leaves to the protocol. The widespread popularity of KSK provided the impetus to exclusive Siddha COVID-19 care centres which were set up by private Siddha doctors as well as government Siddha officers. About 10–12 centres in many towns came up and were dealing with COVID-19 positive mild and moderate cases and by 7 August 2020, 5,725 people had recovered from 11 centres throughout Tamil Nadu (PTI, 2020).

Subsequently, it was reported that about 75,000 patients had been successfully treated by Siddha in Tamil Nadu, and exclusive Siddha treatment centres were announced for every district in the state, citing the good results also obtained in Kerala, which was using Ayurveda⁷ at the local level. Furthermore, a 100-bedded Siddha care hospital with amenities to make herbal preparations in the premises was inaugurated in Pudukkottai town by the Tamil Nadu health minister in the end of July 2020.⁸ Around 120 metric tonnes of KSK and NK had also been used in public distribution.⁹

The special government COVID-19 centre in Tirupattur town admitted patients on a voluntary basis and provided holistic Siddha regimen based on natural substances, including bath accessories, cooking in earthen pot, millet and special rice varieties, herbal teas, massages and medicines for seven days. All this luxurious spa-like treatment was offered free of cost in the facility set up by the government. About 124 people were monitored, of which 2 turned positive. The Siddha doctor in charge of this centre had won the award for the best doctor in the district in 2020 (Narayanan, 2020) and was running the centre with great zeal with much encouragement from the district collector.

KSK also had legal endorsement from the Madras High Court, which in its response to a habeas corpus petition filed in favour of a dubious man who was arrested for claiming miraculous Siddha cure for COVID-19, also made general observations on the lack of support for Siddha and Unani medicines from the Central government, which allocated more resources for Ayurveda, and instructed the Central government to promote KSK throughout the country (Legal Correspondent, 2020).

Clinical Efficacy

It is to be noted that in the management of COVID-19, patients with comorbidities, pregnant women and severe cases were not allowed for Siddha treatment, and therefore the trials involved only mild and moderate cases of COVID-19.

Six studies have been listed in the Clinical Trials Registry of India (CTRI) for KSK since March 2020, of which four are randomised controlled studies. These controlled trials are either comparing KSK with conventional biomedical intervention—zinc and vitamin C—or testing groups receiving KSK, NK and decaffeinated tea (Natarajan et al., 2020). It is important to mention that all but one of the foregoing trials had been hosted by government institutions with the support of the government agency of CCRS, and the medicines were sourced from government providers and virtually involved very little expenditure. A double-blind, placebo-controlled clinical trial of KSK and NK along with standard biomedical treatment carried out at the Government Institute of Medical Sciences in Noida, Uttar Pradesh, an allopathic hospital has confirmed the efficacy of KSK and NK over the placebo (Srivastava et al., 2021).

Kerala: Ayurveda at the Margins of Public Health

Ayurveda and Infectious Fevers in Kerala

Kerala has a long history of the utilisation of Ayurveda and indigenous medical practices to tackle epidemic fevers. In 1903, during a serious outbreak of Cholera in the region, AVS Kottakkal addressed the problem by developing an Ayurvedic product, Vishuchikari pills and Vishuchikari Dravakam, which were amenable for public distribution (Joseph et al., 2015). During this period, AVS also made mass training efforts among physicians through the publication of a book titled Vishuchika (correlated to cholera) in 1906.

In the past two decades, Kerala has witnessed epidemics of certain new fevers, such as dengue, leptospirosis and chikungunya, which were otherwise unknown to the region. Chikungunya and H1N1 (bird flu) have been regularly reported from 2006 and 2009, respectively. In the past decades, most viral fevers were diagnosed clinically and not extensively through lab tests; antigen and RT-PCR tests have become common only during the COVID-19 pandemic. Thus, the differential diagnostic data is not readily available for the past years (Government of Kerala, 2011). Apart from this, there have been more severe viral outbreaks as well. There were two outbreaks of Nipah virus infection in 2018 and 2019. In Kerala, the mortality in 2018 was 17, but in 2019 it was contained without any fatality.

Ayurveda in the Public Health Scenario in Kerala

Ayurveda and home remedies have been widely used during the outbreaks of chikungunya, dengue and so on, though it has been difficult to delineate and quantify its effects amid several strategies employed and their limited documentation. During the chikungunya outbreak in 2006–2007, the Ayurveda community conducted medical camps in different parts of the state and in Lakshadweep. A broad-based formulation for fumigation in Ayurveda known as Aparajita Dhuma Churna, manufactured by the Government of Kerala’s unit, Oushadhi Pharmaceuticals, was distributed widely. There are few clinical management documentations using Ayurveda, as clinical treatment involves extensive personalised care adapted to disease stages and patient characteristics. According to Ansary (2010), a clinical study on 164 patients with chikungunya with Ayurvedic treatment showed that around 40 patients who had acute conditions with symptoms such as fever, lack of appetite and arthralgia responded positively within 2 weeks of management, and 68 patients with chronic complications after 6 months to 1 year following the fever responded positively in 45 days of Ayurvedic treatment. The authors find that there are antiviral and immunomodulatory effects in Ayurvedic management which can prevent joints and skin-related complications. Ayurvedic management has been widely used for post-recovery pains in chikungunya and managed as Sandhigata vata (vata affecting joints) as a systemic manifestation with a multimodal approach. This is based on the Ayurvedic systemic understanding that an externally caused disease type (agantu) becomes systemic (nija) in five–seven days.

Following a series of such effective engagements by the Ayurveda community during these outbreaks, the 12th Plan document (Government of Kerala, 2011) for the period 2012–2017 acknowledged that Ayurveda programmes in identified hotspots with interventions of respective medical system strategies had brought down the incidence. It also recommended that a comprehensive state Act—The Kerala State Public Health Act—be created, with cadres drawn from all the disciplines of the ‘healing’ sciences (Ayurveda, homoeopathy and allopathy), as well as those from nursing and dentistry. However, when the protocols for the management of infectious diseases were released by the Directorate of Health Services, no mention of the AYUSH sector was found. Such omissions have become glaring in the protocols issued during the COVID-19 pandemic as well.

Policies and Strategies in the Use of Ayurveda for COVID-19 in Kerala

Unlike the Tamil Nadu experience which is based on mass application of specific formulations like KSK, the Kerala Ayurveda community (in both public and private sectors) followed a stage-wise, personalised management protocol for COVID-19 administered through Ayurveda institutions and individual physicians.

The Kerala COVID-19 response AYUSH taskforce was formed by the government in early days of the pandemic which came out with a comprehensive plan by experts on 2 April 2020. The strategy was towards capacity building and skill development of Ayurveda practitioners and health workers to manage the infection through pharmacological interventions in terms of preventive herbal decoctions, as well as non-pharmacological interventions pertaining to diet, hygiene and daily regimen. An essential drug list and a systematic protocol for management of COVID-19 were prepared. The basic units at the delivery end such as the AyurRaksha Clinics and all dispensaries were to be utilised for this purpose and were linked to the Local Self Government Departments (LSGD). Thus, Ayurveda in Kerala was playing a role in the preventive interventions which would bring down the number of cases which could have progressed to an advanced stage of disease.

Moreover, the Government of Kerala launched multimodal programmes such as Amritham, designed for giving preventive medicines to those in quarantine, Sukhayushyam, envisaging physical, psychological and emotional support to the old-age population, and Swasthyam, to strengthen the individual protection against COVID-19 among those below the age of 60. An online portal called Niramaya connecting all government Ayurveda facilities in the state and providing online consultations in Ayurveda was also set up. Punarjani is a convalescent care programme introduced for people in the post-recovery phase. Apart from government institutions, private colleges, hospitals and large organisations such as the Ayurveda Medical Association of India are also active parts of the government campaign across the state. At the local level, the government Ayurveda dispensaries along with people’s representatives, Health Management Committee members, Accredited Social Health Activists (ASHA), Anganwadi workers, Kudumbashree unit members, local Ayurveda doctors and students formed the ‘Ayurshield’ taskforce. Like the biomedical services in Kerala, Ayurvedic healthcare was also tied closely to local self-governance structure, maximising community participation and monitoring.

The manufacturing unit of the Kerala government’s Ayurveda company, Oushadhi, came out with the health promotion kit with Ayush Kadha and other classical formulations. This became quite popular with a high degree of community percolation. The Confederation of Indian Industry (CII), in association with Ayurvedic Medicine Manufacturers Organisation of India (AMMOI), Ayurveda Hospital Management Association (AHMA) and Ayurveda Medical Association of India (AMAI), launched immunity clinics across the state. According to a news release, ‘More than 6,000 Ayurveda medical shops and 1,500 Ayurveda clinics have consented to set up these chain of immunity clinics where treatment will be provided thrice a week’ (Business Line, 2020).

Challenges

Despite these grassroots-level initiatives, there was hesitancy on the part of the Kerala government in involving TM on an equal footing in the overall COVID-19 management strategy. On 23 March 2020, the Government of Kerala came out with a directive that beds from all AYUSH hospitals needed to be made available for allopathic services by discharging the Ayurvedic patients with immediate effect and referring the emergency patients to a nearby ‘medical institution’ (Government of Kerala, 2020), which also stated that no patients with fever or respiratory infection should be treated at AYUSH centres. But the public demand for AYUSH medicines was so high that the government subsequently allowed the Ayurvedic medicine outlets to open during the lockdown period (Payyappallimana, 2020).

Ayurveda doctors were appointed to serve in the COVID First Line Treatment Centers (CFLTCs) in a supportive role to allopaths, which led to challenges in the running of the routine services of AYUSH dispensaries. The Ayurveda Medical Association of India in Kerala approached the Kerala High Court for amending the government circular preventing curative care by AYUSH for COVID-19 in the state (The Hindu, 2020). The Kerala High Court, however, issued a ruling in August 2020 that Ayurveda can only be followed for prophylaxis and not for curative care, strengthening the position of the government.

Even during the exponential increase of patients in the second wave of the pandemic in 2021, Ayurveda doctors were appointed only in a supportive role to allopaths. The Kerala Ayurveda Government Officer Federation (KAGOF) continued to demand that they should be allowed to administer Bheshajam, the protocol developed by AYUSH for the treatment of asymptomatic and mildly symptomatic patients (The New Indian Express, 2021), but there was no major change in the government’s policy except that now those in CFLTCs could also avail Ayurveda medicines.

In a response to a question in the Kerala Legislative Assembly on 4 August 2021, the health minister highlighted the benefits of the Amritham programme—of the 101,218 participants of the programme between 21 May and 4 July 2020, only 0.34% got COVID-19 positive as against 1.67% in general population. She emphasised the remarkable prophylactic benefit of Ayurveda preventive package without any reported adverse effects. Among the participants who got infected, none of them advanced to severe stages. She added that from November 2020, Ayurveda physicians had been permitted to treat ‘non-critical’ (category A) COVID-19 patients; however, she reiterated the position that there is no plan to include Ayurveda experts in the state COVID-19 taskforce.

There were some controversies generated by constant confrontations between associations. The practice of Dhooma Sandhya (fumigation at dusk) carried out in households by the Alappuzha Municipality (Mathrubhumi, 2021) in May 2021 was heavily criticised by the Kerala Sastra Sahitya Parishad (KSSP), a left leaning people’s science and literary movement in Kerala, as an unscientific public act. Ayurveda Medical Association of India strongly responded to this and presented a study (Namboodiri, 2020) with Aparajitha Dhuma, citing that such practices have proven antimicrobial efficacy and they are understood as a disinfectant and help in creating aseptic condition, calming fever patients and cleansing the atmosphere. Medicinal fumigation was earlier extensively used during the chikungunya and dengue epidemics throughout Kerala, also as a vector control measure through Oushadhi, the state government Ayurveda manufacturing facility which distributed the powder across the state through its 1,200 dispensaries and 650 retail outlets.

On 14 January 2021, the Centre for Public Policy Research, a think tank in Kerala, published a report, A Comparative Study of COVID-19 Outbreak in the Hubei Province of China and the Indian State of Kerala, which criticised the Kerala government for not adequately integrating TM at various levels as the Chinese government successfully did. The authors quoted,

A white paper on China’s fight against COVID-19 released by the Information Office of the Chinese State Council [similar to India’s Union Cabinet] on June 7, 2020 stated that TCM has been used in treating 92 percent of all confirmed COVID-19 cases across China. In Hubei, the province hit hardest by COVID-19, more than ninety percent of confirmed cases had received TCM treatment. (CPPR, 2021)

The denial of equal opportunity for Ayurveda in Kerala has been the subject of active discussions on social media and primetime TV debates in the past 18 months.

On the research front, though a large number of clinical trials were registered on CTRI for Ayurveda and Siddha, yet Kerala as the heartland of Ayurveda did not register even a single study till mid-2021.

Discussion

Three major observations are foregrounded as the key highlights of the article: First, the traditional South Asian medicines with a host-based medical episteme could address epidemic fevers without a theory of microorganisms; second, the identification and deployment of safe, accessible and time-tested TM formulations for epidemic fevers could be considered as frugal innovations in preventive care and early intervention in public health matters; and third, while political ideologies do play a role in public health as reflected in the difference between the approaches of the governments of Tamil Nadu and Kerala, they may also be seen as representing more than one viable way of integrating TM in public health.

Tamil Nadu and Kerala were among the worst affected by the spread of COVID-19 pandemic, but they also have well-functioning health infrastructure compared to the other states in India. We saw how they also chose to employ the qualified Ayurvedic and Siddha physicians in various capacities in their fight against the pandemic, though in a subordinate role under the command of biomedical physicians. The introduction of TM in the management strategy was made possible by the decisions taken by senior officers in the administrative services, such as the health secretary and district collector to come out with a viable remedy in the moment of crisis. While it is supplied free of cost in government health centres and hospitals, ISO-certified KSK brands cost about ₹140 for 100 g in the market and work out to be ₹10 a day (US$0.13).

About the outcome or effectiveness of the interventions, we have to mention that the mortality in the first wave of 2020 in both the states was not very high; Kerala especially received accolades world over for its exemplary containment strategy. In the second wave of 2021 which came like a Tsunami after both the states went through heavily crowded political campaigns for state assembly elections during March–April 2021, there was great damage. In the second wave, Tamil Nadu tried to restart the KSK campaign after the case load rapidly increased. In any case, the mortality rates in Tamil Nadu and Kerala were far below the national and international levels. Until late March 2021, Kerala’s case fatality rate (CFR) hovered at 0.32%, while in Tamil Nadu, it was 0.52% (Shankar, 2021).

There could be several factors responsible for lower mortality by international comparisons, but the point of this article is to bring on record the fact that TM was also actively deployed in the management of COVID-19 in these two states.

Unlike Tamil Nadu where the state actively promoted Siddha, in Kerala, Ayurveda is deeply embedded in community health practices and has played a crucial role through private consultations, while the state measures permitted the use of Ayurveda mostly as prophylactics and rejuvenation after recovery from COVID-19. The Siddha professional community in Tamil Nadu could arrive at a consensus on the classification of infectious fevers treating chikungunya as vatajvara, dengue as pitta jvara and COVID-19 as kapha jvara and identify specific herbal preparations (Kudineers) suitable for mass production and distribution. In Kerala, on the other hand, the Ayurvedic approach was based on stage-wise personalised management in the clinic and was accessed largely through online consultations with Ayurveda practitioners.

In Tamil Nadu, the government’s position was strengthened by the publicised remarks of the Madras High Court, recommending KSK for pan-India distribution, whereas the Kerala High Court supported the Kerala government stance and did not give relief to Ayurvedic petitions for participation in the treatment of COVID-19. Nevertheless, Ayurveda in Kerala could be brought in the service of COVID-19 more through the channels of the private sector. Thus, evidence and narratives from the two South Indian states suggest that there could be different modalities of integration and co-location of TM in public health.

Conclusion

This article aims to show that some remedies from TMs could be brought into health management through an integrative approach in dealing with serious public health threats like pandemics. This may help the cause of social medicine in which cost-effective and socially acceptable methods of prevention and early intervention could be adopted, and the exclusive reliance on time-consuming and expensive pharmaceutical interventions like vaccines is reduced. Some of these methods have also been cleared through in situ clinical trials as reflected in the emergence of refereed publications in Siddha and Ayurveda. The inclusion of TM in the management of COVID-19 is an exceedingly important public health experiment in medical pluralism, and this could well be an innovation in public health management. It is high time that such interventions are brought on record, systematically evaluated and adopted using new methodologies of validation for integrative approaches.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Notes

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