India – Drivers of the transformation

• If you are looking for a chemist in Kerala, you are often confronted with a choice: 'English chemists' or 'Indian chemists'. In the former, you will find medicines that have been developed by scientists and tested for effectiveness. In the latter, you can buy home-mixed tinctures and traditional remedies that are barely regulated.

This dual pharmacy system would be a curiosity if it weren't indicative of a larger problem: in India's rural areas in particular, people are losing their health - and a lot of money - to charlatans because they can't find proper medical care. More than 75 per cent of India's healthcare infrastructure is concentrated in the big cities, where only 27 per cent of the population lives. The remaining 73 percent of India's population has no access to basic healthcare. Many of them turn to witchdoctors and over-the-counter remedies that promise relief. The alternative medicine industry behind this is booming, subsidised by the government to the tune of millions and even given its own ministry. And this in a country that has enshrined in its constitution the pursuit of a 'scientific spirit'. We can only speculate how many people are crushed between deprivation and disinformation.

One person who has tackled this problem is Dr Cyriac Abby Philips, a
hepatologist from Kerala. By day, he treats patients as a liver specialist in a clinic in the port city of Kochi; by night, he sits at his desk in his apartment overlooking the city, fighting the madness of the internet. A bit like Batman, but with clinical trials and peer reviews. On Twitter, YouTube and the like, Philips is known as 'TheLiverDoc', has hundreds of thousands of followers, a growing audience - and powerful enemies who threaten him, sabotage his studies, sue him and try to prevent him from publishing. But, says Philips, he is only writing about the state of research.

It all started in 2017 when Philips was working with patients who had developed jaundice and hepatitis for no apparent reason. He was able to rule out common triggers such as alcohol abuse, contaminated water or reactions to medication. He then realised that many of his patients were taking herbal supplements, mostly Ayurvedic remedies, which are supposed to boost the immune system and help against diabetes and high blood pressure. Liver disease often correlates with the use of Ayurvedic products. „I searched the literature for studies, but found little, especially no data from India,“ says Philips. So, together with colleagues, he started a study in 2018 and found a connection between severe liver damage and the use of Ayurvedic medicines in 94 of the 1440 patients studied. In 33 people, the liver damage could be clearly traced back to traditional medicine through a meticulous process of exclusion - the highly concentrated plant tinctures had caused the patients to ingest large amounts of heavy metals such as arsenic and mercury. 20 percent of them eventually died from the damage caused by the herbal preparations. „I myself was surprised by the drastic nature of the results,“ says Philips.

It is no secret among hepatologists that some herbal compounds can
cause severe liver damage: in 2020, seven cases of severe jaundice were attributed to dietary supplements containing highly concentrated turmeric in Italy alone; in 2022, the root extract also triggered hepatitis in 10 patients in the USA, and one patient even died. The plant is completely safe when used as a spice in curry or tea. But artificially increasing the body's ability to absorb the active ingredient can cause liver damage - just one example of the many problems health professionals around the world have with poorly tested, supposedly harmless herbal remedies.

Philips' first study was widely acclaimed by his peers, published in prestigious journals in India and the US, and won the 'National Paper of the Year Award 2018' from the Indian Society of Gastroenterology. But he wanted to share his findings not only with other doctors, but also with his patients - and those who should not become patients. „So I started publishing my findings in a simplified form,“ says Philips. He started writing about the problems with traditional remedies on Facebook and WhatsApp - and struck a chord.

His posts were forwarded thousands of times, and most people were outraged by the scientific devaluation of traditional medicine. Philips receives warnings and hate mail, mainly because he has a Christian name and is therefore accused of 'Hinduphobia'.

A few weeks later he received an invitation from the Ministry of AYUSH, which is responsible for education and research into Ayurveda, yoga and other traditional natural remedies. The ministry has been working alongside the health ministry since November 2014 and currently has a budget of around 400 million euros, which it uses to promote health programmes, particularly in rural areas, as well as research and education on alternative healing methods. The revival of Ayurveda is one of the flagship policies of Narendra Modi's Hindu nationalist government. Among other things, the ministry made headlines in 2017 for urging pregnant women to avoid eggs, meat and 'lust' without any scientific basis.

After his criticism of Ayurvedic practices became public, the AYUSH ministry asked him for an interview, Philips says, but only in private and without consulting other health experts. „It was clear that they were not interested in education and public health, but in deflecting bad publicity from the industry.“

Philips declined the invitation. Instead, he initiated further studies investigating the effect of Ayurvedic herbs on patients with severe liver disease, demonstrating the devastating effect on patients with chronic liver disease. He also published individual cases of young, healthy people who died after taking Ayurvedic diet pills and children whose livers were irreversibly damaged.

Philips is receiving support online from people who want to protect their health. In India, where the state healthcare system is chronically overstretched and cases of contaminated or ineffective medicines continue to alarm patients, the liver specialist's warnings are more bad news - but news that is backed up by sources. Philips writes in a way that is easy to understand for non-specialists, but also provocative and without regard to religious sentiment: about the ineffectiveness of turmeric (recommended by the AYUSH ministry to cure Covid 19), about homeopathy (whose influence is so widespread that tinctures were distributed to schoolchildren in Kerala at the height of the pandemic), about cow urine cures (praised by the AYUSH ministry as a basis for cancer drugs).

Since 2019, the Liverdoc has also been publishing on Twitter, where he reaches 230,000 people, and he has 25,000 subscribers on YouTube who listen to him regularly. His research and public statements are also increasingly picked up by local newspapers and TV stations, reaching people outside the digital sphere. His audience continues to grow - and so do his detractors. Philip's scientific articles are retracted under pressure from tincture producers, a laboratory working for him is attacked by a mob, large companies such as the Himalaya Wellness Corporation sue the doctor for around one million euros in damages for defamation, and his Twitter account is briefly blocked. In February 2022, he is reprimanded by the Ministry of AYUSH for criticising the medicinal use of turmeric, and the Kerala State Medical Council orders him to exercise restraint. Philip's research threatens a powerful industry: The annual turnover of Ayurvedic medicine production in India has risen from three billion dollars in 2014 to 18.2 billion dollars in 2022, according to the AYUSH ministry.

The day after the interview for this article, Cyriac Abby Philips and his family receive death threats as a yoga guru (and Ayurveda businessman) defames Philips' revelations as anti-national and anti-religious and urges his followers to strike back.

„I have often been told: 'If you don't like it here, why don't you go to Pakistan? I always say that they also treat everything with turmeric,“ says Philips. He reacts to the pressure with sarcasm. He doesn't want to think about the threat to himself and his family, he says. „I see patients in the clinic every day. If someone brings a knife, what can I do?“ In a country like India, where social reformers like Narendra Dabholkar and journalists like Gauri Lankesh have been gunned down in the streets in recent years for their work against superstition and in favour of science-based progress, Philip's perseverance oscillates between naivety and deadly courage.

It sounds like a heroic story, but Philip doesn't want to be a hero. „It makes me sad that today it is considered courageous to publish your research,“ says Philips. He wants to be a good doctor in a country that honours science and its scientists. Nothing more and nothing less. It is a vision that keeps him awake night after night, producing countless social media posts, videos and podcasts explaining his work and defending it against anti-science trolls. And this vision is so strong that, despite the opposition, he is now expanding his commitment rather than retreating.

In 2022, Philips learned by chance from his domestic helper that she had been taking medication for diabetes and high blood pressure for about four months with no improvement. Out of curiosity, he had the generics sold at a certified pharmacy tested and found that one in four of the drugs were of very poor quality. „After this random sample, I began to wonder how many ineffective drugs were out there,“ says Philips.

Together with some 40 biomedical scientists, mathematicians, researchers, lawyers and doctors, he founded a new network, the Mission for Ethics and Science in Healthcare. Their aim is to conduct studies by asking the public for donations to test the effectiveness of 72 widely used generic drugs: These include medicines for fever and diabetes, high blood pressure and high cholesterol. The network needs to raise around €30,000 to carry out these tests and publish the results.

If successful, this would be a unique initiative in India. Poor quality medicines have been a problem in India for decades, with scandals such as the one in 2022 and 2023 when hundreds of children in Gambia, Uzbekistan and Cameroon died from a contaminated cough syrup produced in India. Experts have long called for independent testing of medicines, with the results made public. The drug tests being carried out by the Mission for Ethics and Science in Healthcare would be a first step in this direction. The network, which has so far been registered as a non-profit organisation, is due to launch a project in June 2024 that will initiate a public debate on the quality of medicines outside the field of naturopathy.

Philips and his fellow activists cannot solve the problems of the Indian healthcare system - inequality of access to medicines and treatments, the growing influence of non-scientific healers and wellness companies. Their aim is to fly the flag of rationality in an ideologically charged public discourse. What drives Philips? „Yesterday a man came into my practice who had read about my work on Facebook,“ he says. The man had travelled many hundreds of kilometres from the interior of the country to have his liver disease treated not by healers, but by the 'LiverDoc'. Now he can help him, says Philip. Patients like this show him that, despite all the opposition, his work is bearing fruit. „We can push back the disinformation by speaking out against it.“

––––––––

To Series: India – A country on the move