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 Table of Contents  
DISCUSSIONS
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 143-151

Enabling use of Homoeopathy in India's preparedness for pandemic/epidemic situation like COVID-19


Central Council for Research in Homoeopathy, New Delhi, India

Date of Submission28-Apr-2020
Date of Acceptance29-Apr-2020
Date of Web Publication29-May-2020

Correspondence Address:
Dr. Harleen Kaur
Central Council for Research in Homoeopathy, 61-65, Institutional Area, Opp. ‘D’ Block, Janak Puri, New Delhi - 110 058
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrh.ijrh_42_20

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  Abstract 


India reported its first positive case of COVID-19 on 30th January 2020. The alerts, the checks and the quarantines soon followed. As of 28th April 2020, India had crossed the 20,000 mark of positive cases and seen over 900 deaths. The nation is adapting and preparing fast for this rapidly spreading COVID outbreak, and new advisories superseding the previous ones as per the evolving needs are being issued by the concerned authorities on almost daily or weekly basis. The unprecedented spread of this pandemic was unforeseen, and therefore, many nations, including India, were caught off guard, and understandably so. The preparedness, policies for emergency measures in health delivery, and laws related to curfews and lockdowns had to be brought into action without much time for anticipatory planning. However, among all these arrangements, and preparedness of our nation toward the outbreak of COVID-19, the role of AYUSH has so far been minimal. The situation, however, is opening up, of late, with latest advisories and notifications roping in AYUSH professionals and students as COVID warriors for providing health support, as also for taking up evidence-based trials in selected COVID-positive cases, after due ethical and official approvals. The article reflects on why enabling the use of Homoeopathy in India's preparedness for pandemic/epidemic situations like COVID-19 is important and how this can be achieved.

Keywords: Arsenic album, AYUSH, COVID-19, Homoeopathy, India's preparedness for pandemics or epidemic, Novel Corona Virus


How to cite this article:
Azis SP, Kaur H. Enabling use of Homoeopathy in India's preparedness for pandemic/epidemic situation like COVID-19. Indian J Res Homoeopathy 2020;14:143-51

How to cite this URL:
Azis SP, Kaur H. Enabling use of Homoeopathy in India's preparedness for pandemic/epidemic situation like COVID-19. Indian J Res Homoeopathy [serial online] 2020 [cited 2020 Jul 10];14:143-51. Available from: http://www.ijrh.org/text.asp?2020/14/2/143/285292




  Introduction Top


India reported its first positive case of COVID-19 on 30th January 2020.[1] The alerts, the checks and the quarantines soon followed. Advisories began to be issued, and so did guidelines on prevention and control of COVID-19. In the next 3 months, local spread among those with a history of international travel and their immediate contacts was reported, as India entered its second phase of the pandemic. As of 28th April 2020, India had crossed the 20,000 mark of positive cases and seen over 900 deaths.[2]

On 29th March 2020, the Government of India identified its COVID Taskforce which is leading the fight against the Novel Corona Virus, and guiding the frontrunners, the COVID warriors, with their well thought out directions.[3] Further, the Ministry of Health and Family Welfare released a 6-component Preliminary Stakeholder Engagement Plan (SEP) on March 27th 2020, within the framework of India COVID-19 Emergency Response and Health Systems Preparedness Project.[4] This project aims to respond to, and mitigate the COVID-19's threat and strengthen national systems for public health preparedness in India. These six components are: emergency COVID-19 Response; Strengthening National and State Health Systems to Support Prevention and Preparedness; Strengthening Pandemic Research and Multi-sector, National Institutions and Platforms for One Health; Community Engagement and Risk Communication; Implementation Management and Monitoring and Evaluation and Contingent Emergency Response Component. This is a 4-year project which is being prepared under the World Bank's Environment and Social Framework.

The SEP outlines the ways in which the project team will communicate with stakeholders and includes a mechanism by which people can raise concerns, provide feedback, or make complaints about the project and any activities related to the project. The involvement of the local population is essential to the success of the project to ensure smooth collaboration between project staff and local communities and to minimise and mitigate environmental and social risks related to the proposed project activities. In the context of infectious diseases, broad, culturally appropriate and adapted awareness-raising activities are particularly important to properly sensitise the communities to the risks related to infectious diseases.

The nation is adapting and preparing fast for the fast-spreading COVID outbreak, and new advisories superseding the previous ones as per the evolving needs are being issued by the concerned authorities on almost daily or weekly basis. The unprecedented spread of this pandemic was unforeseen, and therefore, many nations, including India, were caught off guard, and understandably so. The preparedness, policies for emergency measures in health-care delivery and laws related to curfews and lockdowns had to be brought into action without much time for anticipatory planning. The Indian Prime Minister, Mr. Narendra Modi, has globally been hailed for timely measures to curb the spread of the disease.[5] In fact, the lockdown in Stage II of the spread was one of the exemplary steps by India.

India continues to issue most directions related to the COVID-19 in due course, amid the dynamically changing situation. However, among all these arrangements and preparedness of our nation towards the outbreak of COVID-19 that all the AYUSH practitioners have been keenly following, the role of AYUSH remains largely minimal, that too in a country that is an ideal, imitable model worldwide for offering alternative systems of medicine just on the same shelf as standard medicine, much to the consternation of the AYUSH sector.


  Ayush Advisory for the Prevention of Covid-19 and Homoeoprophylaxis Top


An advisory issued by the Ministry of AYUSH in the initial stage of this outbreak in India talked of the role of AYUSH modalities in enhancing the immunity of a person to fight Coronavirus, and suggested some remedies that could be taken by the people while following other general measures of prevention such as maintaining social distancing, frequent handwashing, etc., as prescribed by the World Health Organisation (WHO).[6] Homoeopathic medicine: Arsenic album in the 30th potency, one dose in an empty stomach, to be taken every day for 3 days, followed by a repeat after a month was a part of this advisory. This was widely circulated and many state governments, through their AYUSH departments, eventually issued guidelines to distribute Arsenic album 30 for prevention in all State Primary Healthcare Centres. But how far this could be, in turn, implemented is still a matter of evaluation. However, 7 states of India – Kerala, Manipur,[7] Goa, Karnataka, Madhya Pradesh,[8] Rajasthan and Gujarat –have distributed preventive medicine Arsenic album 30 to its people who use Homoeopathy for routine ailments, as well as to those who showed up at homoeopathy units only for this purpose.

A case in point is a mass-scale distribution among the local population of homoeopathic medicine Arsenic album 30, in Pathanamthitta district of Kerala, which had 17 COVID-19 positive cases.[9] A population of 6, 35, 912 (53%) has been administered the medicine as per information gathered from the District Medical Officer, Homoeopathy, Pathanamthitta as on 28th April 2020. In Ranni taluk, alone, which had 5 Covid positive cases,[10] with a population of 1.98 lakhs,[11] at least 40,000 people have been administered Arsenic album 30. The cases were reported in the taluk on 8th March 2020 and the homoeoprophylaxis drive was initiated on 14th March 2020. No new cases were reported from the taluk as on today and this raises positive contention towards favouring the use of Arsenicum album 30. More reports on this are awaited after data is analysed once the prophylaxis programme is concluded in the district.

Further, as a part of corporate social responsibility, Mr. Rajiv Bajaj, Managing Director of a corporate firm, Bajaj Auto, in a homoeopathy centre run by him in Pune, called Prana, has enabled distribution of 67,000 vials of homoeopathic medicine, Camphor 1M, for prevention. Each vial is enough for a family of 4–5 people. Mr. Bajaj distributed this medicine among his employees and close friends, and also inspired the Police Commissioner of Pune city, Dr. K. Venkatesham, who administered this homoeopathy medicine to 15,000 police personnel in in his jurisdiction in Pune and Pimpri-Chinchwad. Moreover, till date, none among them has been affected by coronavirus.[12]

Many Homoeopaths in their own capacity through social media advocated different medicines like Camphor, Influenzinum, etc. Although such distributions and outcomes need deeper analysis for the protection effect caused (or not) by the drug, they make for a few typical examples of effective implementation drive. Furthermore, such examples help in negating the immediate adverse news reports that followed the issuance of Advisory by Ministry of AYUSH for prevention, questioning the recommendation of Arsenic album, or any other homoeopathic medicine as preventive, even after it being a safe, harmless, age-old, homoeopathic medicine, prepared as per homoeopathic pharmacopoeial standards and approved by Central Drugs Standard Control Organisation, with no proven side effects. Any positive lead in this regard could be a preliminary stepping stone to equip India for its further strategy of having homoeopathy on the planning chart during epidemic outbreaks.[13] China did so by adopting its Traditional Chinese Medicine (TCM) for treatment purpose, and their evidence basis so generated is helping other countries adopt the TCM in COVID-19 treatment protocol.[14]

It has been realised that it is still not brought to the notice of many stakeholders that using homoeopathy for prevention in the form of homeoprophylaxis (pre-exposure prophylaxis) is, in fact, evidence-based.[15],[16],[17],[18],[19],[20],[21],[22] This approach involves the use of highly-diluted and succussed (potentised) homoeopathic medicine prepared from different sources, including plants, animals, minerals, bacteria and viruses. Potentised pathogens or disease products known as nosodes or biotherapies prepared as per homoeopathic pharmacopeial standards have been reported to be effective in controlling epidemic diseases, but it is a focus of strong debate calling in for more research.[15],[18],[22] Homoeoprophylaxis has historically been used in epidemics since 1798 for the prevention of vaccine-preventable and non-preventable diseases.[23],[24],[25],[26] This approach combines knowledge from homoeopathy, immunology and epidemiology, resulting in a possible alternative in epidemic settings. It is noteworthy to mention the Cuban success story of using highly diluted bacteria for leptospirosis epidemic control.[22]

In the on-going pandemic, as scientists around the world speed up clinical trials to find a cure or vaccine for the coronavirus, the Cuban government began distributing a homoeopathic remedy to the elderly and other vulnerable people to 'prevent' the spread of COVID-19 where the homoeopathic compound preparation PrevengHo-Vir cleared by the Cuban Drug Regulatory Authority is being administered.[27] In India, such nosode trials may be brought under the framework of monitored emergency use of unregistered and experimental interventions (MEURI) during such outbreaks, and of the research laboratories under Central Council for Research in Homoeopathy (CCRH) and selected GMP-certified homoeopathic drug manufacturers may be upgraded to at least Biosafety level 3 to handle highly virulent strains of microbes used to prepare such nosodes, when such a need arises. Had this been a reality today, the development of nosode from COVID-19 in India would not have been this big a challenge as it is today.

Nevertheless, as regards treatment of COVID-19 cases is concerned, AYUSH, as a whole, has so far been kept for solely prophylaxis purposes. In that too, due to nationwide lockdown (which was necessary as a policy to prevent mass transmission), this could not be done at mass-level. The fact remains that the eagerness among homoeopaths to serve is driven both by their clinical experience in treating other viral influenza-like illnesses earlier, and by the acceptance in public health system, that the AYUSH professionals have so far enjoyed, provided both by the central and state governments. In fact, it seems it was a little unsettling for the AYUSH sector to eventually understand that their role in the COVID-19 fight so far could neither be of treatment (not even as an adjunct), nor contributory (in the form of taskforce). However, gradual strategies emerged for the inclusion of AYUSH human resources, which began with their capacity building for their involvement at quarantine or isolation centres, clearance for AYUSH-intervention based researches and then counting AYUSH services as essential medical services in further notifications.[28]


  Use of Homoeopathic Medicine as an Epidemic Treatment Response Top


To seize the opportunity of conducting quality research during the current COVID-19 epidemic, establishing a national coalition of stakeholders across various health initiatives is what is urgently needed. A multi-disciplinary team would be the key to success; it should consist of members who have expertise in COVID-19, AYUSH (Homoeopathy), clinical research methodology, as well as ethics and regulations, and those who are patients' representatives. Additional research investment, in terms of resources and personnel, will enable the immediate systematic collection of data on outcomes that could later be shared across centres in a coordinated manner. Only such data are expected to provide an insight as to how Homoeopathic interventions impact prognosis. Besides, they will also help identify the more promising homoeopathic intervention that should be prioritised for further assessment in controlled trials within the duration of the epidemic. A trial design in the middle of an epidemic should be practical yet reliable, aiming to quickly generate interpretable efficacy and short-term safety results. Later on, based on preliminary conclusions, rigorous controlled trials are to be conducted in a transparent manner, which would help in clearly determining the worthiness of homoeopathic interventions in such pandemic/epidemic situations.

There should be continuous evaluation of the outcomes of implementing Homoeopathic treatment in such epidemics to strengthen the evidence base of such interventions for the greater sake of public health and for the adaptability of such integrated models at international levels. Amid ambiguities about the nature of the SARS-CoV2 with reported cases of reinfections,[29] care should be taken in ensuring post-discharge quarantine and compulsory follow-up testing after homoeopathic interventions. This should be compared with a control comprising patients not under homoeopathic intervention to interpret the superiority/inferiority or equivalence of the intervention, as suggested in a study by Wang et al.[30] Medical professionals should diagnose and treat patients according to up-to-date guidelines and ensure adherence of citizens to all local public health measures. A customised homoeopathic medicinal intervention protocol[31] for the prevention and treatment of diseases with similar symptoms of COVID-19 and its mutants has been proposed. The homoeopathic interventions are to be carried out adhering to the standard safety measures and isolation/quarantine protocols for COVID-19 and homoeopathic treatment to be provided as an adjuvant. The bright side of this dark, cloudy picture is that COVID-19 has brought many issues which remained under the carpet for long. First and foremost is the role of AYUSH systems, which remained dormant in public health issues for long. Although the human resources of AYUSH have been utilised for the national programmes without active use of AYUSH interventions. One such example is the government's programme called Rashtriya Bal Swasthya Karyakram, aiming at early identification and early intervention for children from birth to 18 years to cover 4 'D's viz. Defects at birth, Deficiencies, Diseases, Development delays including disability.[32] Some interventions have been allowed on a pilot basis in the 'National Programme for Prevention and Control Of Cancer, Diabetes, Cardiovascular Diseases and Stroke'.[33] However, there has never been a programme independently taken over by these conventionally established systems for the larger public use in eventualities. The possible reason is that these are not well-researched, which, in turn, is due to lack of the research opportunities provided to them in these programmes, or elsewhere.

Hence, it would not be inappropriate to say that the doors for these systems are still not fully opened, and therefore, a cohesive model of coexistence is essential. Fortunately, this is being fast recognised in the wake of COVID-19. India, can lead by example in dealing with a public health emergency, if the potentials of AYUSH systems are adequately harnessed and put to use for the benefit of masses. It could then, well be in the position of being the global leader in offering a whole range of health choices to its patients. The entire Traditional and Complementary Medicine (T&CM) sector in the world is looking up to India to showcase emergency-handling by way of integration. In fact, this was actually the motive when India incorporated AYUSH in its Health Policy of 2017.


  Adapting to the Concept of Integrated Medicine in Epidemics Top


Many countries now recognise the need to develop a cohesive and integrative approach to a health care system that allows governments, health care practitioners and most importantly, those who use health care services, to access T&CM in a safe, respectful, cost-efficient and effective manner. A global strategy to foster its appropriate integration, regulation and supervision is being encouraged by the WHO to its member countries to develop a proactive policy towards this important and often vibrant and expanding part of health care.[34] T&CM lacks both a robust research tradition and an adequate research infrastructure and therefore fails to attract experienced researchers. There is a need to enhance financial and human resources in this sector when both are available. Opinions that often contradict the existing evidence seem to dominate complementary and alternative medicine, and this highlights the necessity of bringing opinion in-line with the evidence. The best way to achieve this is through rigorous research and the broad dissemination of its findings.[35]

India's National Health Policy (NHP),[36] 2017, primarily aims to inform, clarify, strengthen and prioritise the role of the Government in shaping health systems in all its dimensions, including the prevention of diseases and promotion of good health through cross-sectoral actions. NHP talks extensively, and inclusively, of AYUSH systems and their role in shaping a healthier nation. The progressive policy clearly mentions that the patients who so choose and when appropriate would have access to AYUSH care providers based on documented and validated local, home and community-based practices. These systems, inter alia, would also have government support in research and supervision to develop and enrich their contribution to meeting the national health goals and objectives through integrative practices. Promotion of healthy living and prevention strategies from AYUSH systems and Yoga at the workplace, in the schools and in the community would also be an important form of health promotion that has a special appeal and acceptability in the Indian context. Mainstreaming AYUSH services in all three dimensions of healthcare– primary, secondary and tertiary in organising health-care services is one of the seven key policy shifts proposed in the policy. Rechristening the public health facilities as 'Health and Wellness Centres', the NHP talks of access to assured AYUSH health-care services. Prioritising the utilisation of AYUSH personnel in urban health care is another recommendation in the policy.

While focussing on mainstreaming of AYUSH services, the policy clearly states, 'For persons who so choose, this policy ensures access to AYUSH remedies through co-location in public facilities.' The policy further supports the integration of AYUSH systems at the level of knowledge systems, by validating processes of health care promotion and cure. It further talks of putting the digital tools to good use for generation and sharing the information about AYUSH services and AYUSH practitioners with the public.

Further, talking particularly about Homoeopathy, it is worthy of notice that the Homoeopathy framework in India is substantially significant to offer a considerable role in the public health setups, in general, and in health emergencies, in particular. This applies both to infrastructure and skilled resources (homoeopathic practitioners). The total number of homoeopathy practitioners in India is 2,84,471, which is 37% of the total number of AYUSH practitioners (7,73,668). Among AYUSH colleges, homoeopathy colleges are second highest in number: that is, 35.8%, (195 out of 544), and so also in annual student intake, 42.3% (13,658 of 32,256 combined). India is producing, on an average, 13,658 homoeopathic graduates every year through 195 academic institutes. One can only imagine the task force that is being generated every year in the homoeopathy sector, in addition to the existing count of 0.28 million. Further, the total number of homoeopathic wellness centres in India, combining the state and central government sectors, has seen consistent growth of about 28% from 5910 wellness centres in 2007 to 7544 in 2017.[37]

Today, when there are no vaccines or medicines approved yet for the novel coronavirus infection,[38] and also none in sight near future,[39] it is time to see what else can be possibly done to control the crisis. Although >80 clinical trials have been launched to test standard treatments of coronavirus, including some drug repurposing or repositioning for COVID-19.[40] Drug repositioning for other neglected diseases is an essential and universal strategy in the development of new drugs due to: lower costs and reduced time to reach the market because some clinical trial steps might not be required, especially concerning phases I and II; existing pharmaceutical supply chains are available for formulation and distribution; the possibility of combinations with other drugs in treatments that are more effective than monotherapy; may facilitate the discovery of new mechanisms of action for old drugs and new classes of medicines.[41],[42]

A search done on 12th March 2020, at the clinicaltrials.gov database (a resource from the US National Library of Medicine), contains clinical studies conducted by 209 countries with the descriptor (coronavirus) identified 24 clinical trials, that have already started with the repositioning of >20 medicines for COVID-19 treatment, in which 19 studies were at clinical phases 2, 3, or 4. The pharmaceutical interventions found for COVID-19 treatment include human immunoglobulin, interferons, chloroquine, hydroxychloroquine, different anti-viral agents and TCM.

Repositioning trials for COVID-19 using TCM combination with lopinavir ritonavir, alpha-interferon via aerosol, Xiyanping or lopinavir-ritonavir interferon inhalation, TCM plus interferon inhalation are ongoing.[43] This was possible in China because their guideline to health-care professionals encouraged to offer integrative Chinese–Western Medicine treatments for COVID-19 patients, regardless of their disease status and clinical classification, as soon as possible to achieve the best clinical outcome.[44] Although drug repurposing has some limitations, repositioning clinical trials may represent an attractive strategy.

Government of India, in adopting such an integrative treatment approach, as envisaged in 2017 health policy will surely come out with better clinical outcomes. Although homoeopathic system is minuscule in China and that too only in Hong Kong, but has a major stay in India and will prove to be effective integration with modern medicine as being well tolerated, safe and without any drug-drug interaction. This strategy can best be adopted in the Indian scenario for understanding the efficacy of AYUSH interventions, especially Homoeopathy in the treatment of COVID-19. This makes it an easy intervention to administer in the wake of an epidemic by a trained homoeopathic doctor. The AYUSH practitioners are demanding opportunities to treat active Corona cases in full-fledged COVID-19 treatment facilities as per the clinical stage of the disease.[45] In fact, instances from other countries (China, Iran, Italy) treating COVID-19 cases through homoeopathy and other alternative systems are reported or published in a scientific journal.[14],[46],[47]

The Ebola experience demonstrated the feasibility of rigorously evaluating therapeutic measures during an epidemic. An expert panel constituted by WHO in 2014 reached a consensus that it is ethical to offer unproven interventions with as yet unknown efficacy and adverse effects, as potential treatment or prevention. Moreover, ethical criteria must guide the provision of such interventions. These include transparency about all aspects of care, informed consent, freedom of choice, confidentiality, respect for the person, preservation of dignity and involvement of the community. The group explored how the use of such interventions can be evaluated scientifically to ensure timely and accurate information about the safety and efficacy of these investigational interventions. There was unanimous agreement that there is a moral duty to also evaluate these interventions (for treatment or prevention) in the best possible clinical trials under the circumstances to definitively prove their safety and efficacy or provide evidence to stop their utilisation. The ongoing evaluation should guide future interventions.[48] This is the commendable strategy endorsed by China in the use of TCM interventions. Emergencies, such as the outbreak of disease pandemics, create an imbalance between capacity and resources to meet the needs of the survivors or the people whose lives are threatened during that period. In the case of an outbreak of infectious diseases, MEURI could be approved says ICMR ethical guidelines[49] and the Declaration of Helsinki.[50]

Rescue medicines and supportive treatment should be accessible at all times with prompt sharing of data on safety and efficacy, which would be beneficial to reduce delay for other researchers to take up more rigorous studies. While proposing to use Homoeopathy for preventive and treatment purposes in epidemics, we are not dealing with unregistered or experimental interventions except with regard to nosode development. Homoeopathy has shown potential benefit in treating various diseases of epidemic proportions such as Swine flu,[51] Infuenza-like illnesses,[52],[53],[54] Acute encephalitis syndrome,[55] hemorrhagic dengue fever,[56] diarrhoeal disorders[57],[58] and Chikungunya[59] with already existing and approved drugs.


  The Way Ahead Top


There is no denying that Government of India realises the core strengths of AYUSH systems such as holistic treatment, lesser side effects, safer and gentler healing and economic viability, thereby optimising the use of all available health modalities for maximising treatment options available to its people. Besides NHP 2017, a 2018 report by the Planning Commission of Government of India also clearly envisioned enhancing access to AYUSH services by providing its co-location in at least 50% of primary health centres, 70% of community health centres and 100% of district hospitals by 2022–2023, as the way forward in public healthcare.[60]

Now, in a public health emergency that we are witnessing globally, it is about time to 'walk the talk' of our own policies we have so proudly endorsed – to embrace the 'integrated model' that is required today, more than ever. We need to make ways to see how we can use, and while doing so, validate the use of AYUSH systems in the treatment of COVID-19, especially Homoeopathy, given its historical evidence in successful epidemic management and published evidence, as cited before. Moreover, it seems as the virus is invading the country further, despite our best possible efforts, India too is changing its approach in the combat plan, and becoming more 'accommodating' of using AYUSH disciplines.

The efforts of the Ministry of AYUSH in mobilising organised, scientific work to promote the use of AYUSH in this situation are noteworthy. The ministry has issued a notification on 31st March 2020, calling on AYUSH practitioners and institutions to submit their inputs, which will be reviewed by a task force committee consisting of representatives from the Department of Biotechnology, Council of Scientific and Industrial Research and AYUSH practitioners. More than 3400 proposals have been received.[61] Further, the ministry is also readying its AYUSH resources for their role as COVID warriors by offering online sensitisation training, which are being imparted mandatorily to those employed in public health services, and to private AYUSH professionals, and students through volunteer entries on their website.[62]

Further, in a chart of COVID taskforce uploaded by the Ministry of Health and Family Welfare on its website on 6th April 2020, the role of AYUSH doctors is recognised in 'Field Supervision', and at 'Isolation facility', while AYUSH students have been called upon for 'Field Surveillance'.[63] Considering that AYUSH practitioners together make 43.5% of the total practitioners in India (773,668), vis-à-vis conventional medicine practitioners which are 56.5% (numbering 1,005,106), involving AYUSH forces in the fight against COVID-19 is a step in the right direction. This would give a fair chance to the AYUSH sector to rise up to the occasion of serving their nation, which they were feeling deprived of, as well as makeup for the deficit that the country might face, should the situation worsen.

Acknowledgement

The authors acknowledge Dr. Anil Khurana, Director General Incharge, CCRH for his guidance in improving the content value of this article.

Financial support and sponsorship

Nil.

Conflicts of interest

None declared.

 
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