Healing India’s Traditional Healers

India has an estimated 2.5 million medical “quacks.” Can they be trained to do no harm?

On a balmy Sunday morning in the sleepy town of Suri, sixty people wearing grey lab coats met in a blue-walled room. Armed with pens and paper — the latter ranging from notebooks to scraps of old newspaper — the students were ready to learn and willing to scribble their notes anywhere.

They were far from their villages in Birbhum district, located in the Indian state of West Bengal. Suri, the district’s capital, is lined with palm trees and shops selling fresh coconuts and bubbling chai.

One of the eager students, 41-year-old Aditya Bandopadhyay, has been practicing medicine for more than twenty years in his village Salbadra, about 40 miles from Suri. But like most in the room, he has no medical degree. In fact, he has no formal medical education whatsoever; the only training he received was from a homeopath a long time ago.

Even still, he has diagnosed and treated ailments in his community for the last two decades, from colds to broken bones. He sees about thirty patients a day, and charges 10 rupees (US$0.15) per consultation.

Bandopadhyay is one of India’s estimated 2.5 million traditional healers — or, more derisively, “quacks” — who practice medicine without any formal training.

Though the quacks are completely unregulated and punishable under the Indian Medical Council Act of 1956, they fill a void for the country’s vast rural population, which has long suffered from a severe shortage of doctors willing to leave major cities.

Though 68 percent of Indians live in rural areas, less than a fifth of the country’s doctors practice in these areas. Moreover, the country spends only one percent of its GDP on health — which has a disproportionate effect on medical access in remote villages like Salbadra, where Bandhopadhyay operates.

“As much as the medical council would like to ban these quacks — if that’s what you want to call them — the truth is, medical graduates are never going to go into these areas,” said Manoj Mohanan, assistant professor of public policy and global health at Duke University.

“So we have a conundrum. These rural health workers provide continuative care that will almost never happen with medical graduates, [since] the quality of infrastructure is so poor and a doctor can never have a proper life.”

While many quacks are well-respected in the communities they serve, others have misdiagnosed and mistreated their patients. In northern India they’ve been blamed for the high incidence of Hepatitis C infection because of their reuse of dirty syringes, while others have been taken to court for claiming to cure patients of HIV.

Mohanan led a recent study that found that children in rural India regularly receive wrong treatments for diarrhea and pneumonia — the two leading killers of children in the country. For instance, medical practitioners frequently prescribe unnecessary antibiotics rather than simple oral rehydration salts for diarrhea. Of the 340 medical practitioners in the study, 80 percent had no formal qualification.

“There are so many horror stories,” said Mohanan. “They’re actually performing surgeries and getting away with it. That level of harm needs to be avoided.”

Several groups in West Bengal — and elsewhere in India — are now working to change the status quo.

Since last April, Bandopadhyay has been attending a nine-month training program that turning quacks into “rural healthcare providers.” The program, which is run by a West Bengal-based NGO called the Liver Foundation, has trained about 2,500 people since its inception in 2007.

The premise of the program, which runs on Sunday and Tuesday mornings, is to reduce the harm quacks have been inflicting. It aims to equip people like Bandopadhyay with the skills to diagnose and treat common illnesses — and importantly, when to refer villagers to real doctors.

On this humid Sunday morning, students are busy scribbling notes as Dr. Kajal Chatterjee explains how to identify measles cases and what to do if they come across a child with the disease.

“This group of people see patients in their own way and that’s wrong,” said Chatterjee, who works at the local hospital. “But they’re the sole hope at night if someone is sick. Love them or hate them, we can’t ignore them. They can become a very useful force in the healthcare delivery system.”

When Bandopadhyay graduates, he will be given a new title: Rural Healthcare Provider. That means he and his colleagues will no longer be able to call themselves doctors. They’ll also have to stop prescribing most Schedule H and Schedule X medicines, like Diltiazem to treat hypertension and Dextroamphetamine for Attention Deficit Hyperactivity Disorder. These are drugs that only real doctors are allowed to prescribe and which are not available over the counter.

In exchange, they gain knowledge to help their patients. “I had no knowledge of the human body before the training program,” said Bandopadhyay. “I’ve realized that I’ve been wrongly diagnosing patients and wrongly judging the dose they need. I used to use antibiotics to treat a fever but I know that paracetamol can be used.”

“People in my village used to call me a doctor but now I tell them I’m not a doctor,” he added.

But of course, there’s still nothing stopping practitioners from overprescribing antibiotics or prescribing Schedule H and X drugs. Abhijit Chowdhury, who runs the program, admits that despite the training, practitioners continue to carry on unlawfully prescribing drugs.

“We keep telling them it’s a legal violation but we’ve failed to convince them,” he said. “The issue is that basically there is almost no drug that a person without a medical degree can’t prescribe. It’s happening all the time. But what do you do?”

The issue of unnecessary and overprescribing of antibiotics is not just confined to quacks. A study led by Jishnu Das, an economist at the World Bank, found that qualified doctors were also more likely than not to prescribe unnecessary antibiotics to treat diarrhea, asthma and unstable angina (i.e., when your heart doesn’t get enough blood flow and oxygen). Such a finding challenges the common perception that quacks are purely to blame for India’s growing antibiotic resistance problem.

But why sign up for a training program that would essentially demote you and and prevent you from pretending you are more qualified than you really are?

For 40-year-old Radha Binod Das, removing the prefix “Dr” from his name was daunting at first. But he said that his patients actually want him to complete the training.

From 7am-7pm for the last two decades, he’s treated patients in a small village called Santosh Pur. He’s seen a range of ailments over the years, like coughs, diabetes, fevers, and more serious cases that he’s reluctant to share.

“Before this training, I was prescribing the wrong medicine,” he said. “Now I’m learning how to correctly diagnosis people, give them a proper dosage, and also recognize danger signs so I can refer patients to a doctor. My confidence level is rising — and I’m seeing that my patient number is increasing because word spreads about the training program.”

The Liver Foundation developed a curriculum that reflected local health problems. It has undergone myriad changes over the years to reflect emerging health challenges, such as the rise in non-communicable diseases.

“The one thing that has stayed consistent throughout the years is that we tell these providers they are not doctors,” said Chowdhury. “We keep telling them that.”

The students receive 60 rupees (US$1) towards their transport cost for each training they attend. Many travel by local bus for more than two hours each way. On the days they do attend they sacrifice their day’s earning — but according to many students, it’s a sacrifice worth making.

“They love to get trained, nobody has even given it to them before,” said Chowdhury. “It doesn’t impact their income because in the end local people know they’ve been trained and we’ve found that their overall volume of clientele increases.”

At the end of the nine months, students must sit a two-day exam which is a mix of theory and practical questions, including a range of case scenarios. But unlike most exams, there’s no “pass” or “fail.” Even if a student gets just one question correct, the Liver Foundation has realized that he or she will still continue practicing.

So rather the exam is seen as an opportunity to evaluate to what degree the students have benefited. (Chowdhury said that about 20 percent of students don’t benefit at all from the training, while 40 percent perform very well.)

Similarly, the students don’t receive a certificate or anything that acknowledges their participation in the program. They instead rely on word of mouth, which for many is more valuable than something they can hang on the wall.

In 2012, Chowdhury, who is also a professor of hepatology at the Institute of Post Graduate Medical Education and Research in Kolkata, approached World Bank economist Jishnu Das to help assess the impact of the training program.

“Chowdhury had no idea whether the training was helping or hurting,” said Das.

The results of the randomized controlled trial — which compared the quality of care by rural medical practitioners trained by the Liver Foundation with those who haven’t completed any training — are not yet publicly available, but Das and Mohanan were startled. “I’m really impressed with the training,” said Mohanan.

But not all are convinced. Ikram Khan, chief executive officer of the Rural Health Care Foundation, which provides cheap medical care to the rural poor, says a major issue is the lack of regulation.

“Tomorrow if you put ‘Dr’ in front of your name, you can start practicing and no one will do anything,” said Khan. “These people are completely driven by money. That is why they prescribe a lot of medicines — and is one of the biggest reasons why we have antibiotic resistance. Regulation is completely absent and monitoring is simply impossible.”

The Indian Medical Association (IMA), the lead body representing doctors across the country, is similarly outraged. In fact, the West Bengal branch of the association is challenging the legality of the program.

“The training program is against the law,” said secretary general of the IMA, Dr K.K Aggarwal. “It is wrong. These quacks are the reason we have antibiotic resistance in the India — they are injurious to the community. It requires five-and-half years of studying to become a doctor, not a few weeks.”

Chowdhury from the Liver Foundation believes the training is only the first step. “Once you bring them to the surface, you can also regulate them,” he said. We can punish them. They are being told what not to do.”

Khan reluctantly agrees that when it comes to rural healthcare, perfect cannot be the enemy of good. “It’s better to train them than to pretend they don’t exist,” he said. “The government has no option. In the end I think this training will lead to a big revolution in healthcare in India.”

Looking ahead, Chowdhury hopes that West Bengal will serve as a model for the rest of India — particularly in the states of Bihar, Uttar Pradesh and Madhya Pradesh, which rely heavily on quacks. He also hopes that eventually the government will make the training mandatory.

To start, the West Bengal government approved the program for statewide scale-up last November. The Liver Foundation will hand over the reins in April and the government will begin a six-month, once a week training, that will aim to train 7,000 of the state’s 100,000 rural practitioners every year.

“The Liver Foundation is happy we showed the way,” said Chowdhury. “There is a tremendous amount of unnecessary paranoia in the mindset of the medical profession that this group of people is going to pose as competitors to them. They’re not; they’re complementary.”

But the program is of course not a panacea to India’s deep-rooted health issues. There is a desperate need not only for more doctors, but for doctors to somehow be enticed to serve rural areas.

The country is also grappling with the rise in non-communicable diseases, which is projected to cause 70 percent of deaths in India by 2020.

Back in Suri, the Sunday morning training session is over and students have gathered around their motorbikes, sipping chai, ready for the long journey home where they have patients waiting to see them.

“Patients now expect me to give them a correct diagnosis,” Bandopadhyay said, as he got on his motorbike and drove into the distance.

Photographs by Chiara Goia for The Development Set. The Development Set is made possible by funding from the Bill & Melinda Gates Foundation. We retain editorial independence. // The Creative Commons license applies only to the text of this article. All rights are reserved in the images. If you’d like to reproduce the text for noncommercial purposes, please contact us.