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Sunday, September 27, 2020

Renaissance in Ayurveda

After decades of neglect, the ancient Indian healing and cure system is poised to take its place in the healthcare mainstream.

New Delhi | June 19, 2020 9:36:26 pm
The need to transform Ayurveda was recognised about 150 years ago. Progress was made but probably not enough to sustain its development.

Written by Arvind Chopra

After years of wilderness in post-independence India, Ayurveda is now poised to truly and actively participate in the health and medical care system. Thanks to the efforts of the Narendra Modi government, Ayurveda is now on a fast track of progress and transformation into a modern vibrant health and medical system. While preserving its core strengths, it is using modern science to unravel clinical evidence. Along with its powerful individual holistic approach, the system is advocating several general means, including Yoga, to improve people’s health.

Ayurveda is also involved in the fight against COVID-19. The government has announced innovative clinical drug trials to evaluate the safe and effective use of selected and standardised Ayurvedic medicines in the prophylaxis and treatment of COVID-19. This is probably the first of its kind and magnitude, where modern medicine physicians will work alongside vaidyas to manage this dreadful infectious disease. The Ministry of AYUSH has also released an advisory for general public on the use of several well-known Ayurveda formulations to improve the immune system and health in the fight against COVID-19. There is no medicine nor any vaccine available for COVID-19 — there is very little evidence for modern drugs like hydroxychloroquin and azithromycin that are being used to prevent and treat COVID-19. Hence, it is appropriate that India investigate the therapeutic potential of Ayurveda in treating COVID-19.

The need to transform Ayurveda was recognised about 150 years ago. Progress was made but probably not enough to sustain its development. There were several challenges, but none of them were more overwhelming than what was created by the dominance of the modern medicinal system. The Ministry of AYUSH was formed in 2014, which has set up an efficient network of communications and doable operations involving the Centre and various stakeholders and beneficiaries at the grass roots. It oversees over 4.8 lakh Ayurveda physicians, 256 Ayurvedic medical colleges, over 2,400 Ayurveda hospitals and several hundred Ayurveda pharmacies and is engaged in fields such as education and research, conservation and preservation of medicinal plants etc.

The framework for health and medical care system in India was designed by the Sir Joseph Bhore Committee in 1945. But the government conferred recognition in a legal framework to the four main non-Allopathic medicinal systems including Ayurveda only in the 1970s. An independent department was established in 1995, which was renamed as AYUSH (Ayurveda, Unani, Siddha and Homeopathy) in 2003. A decade later, it was upgraded to an independent ministry. In 2005, AYUSH was included in the agenda of the National Rural Health Mission. In 2017, the ministry inaugurated its flagship institution, the All India Institute of Ayurveda, Delhi. Meanwhile, a Traditional Knowledge Digital Library (TKDL) was established, which contains a large repository of over three lakh formulations from the Ayurveda and Unani systems. Importantly, the contents of TKDL are in a patent compatible format and all patent claims can now be easily checked and authenticated.

There has been an unprecedented resurgence of interest in Ayurveda in the past three decades or so. Swami Ramdev turned practising yoga into a mass movement. His Ayurveda venture, Patanjali, started in 2006, has been a huge commercial success. Concurrently, Indians rediscovered the virtues of naturopathy and popular centres mushroomed all over India. India had become the world capital of diabetes and many Indians embraced naturopathy to lose body weight, control blood sugar and lower blood pressure. Naturopathy is a spin-off of Ayurveda.

Why did the revival of Ayurveda take so long despite efforts starting at the turn of the 18th century? We need to understand the reasons so that Ayurveda is not thrown again into a deep pit in a rush to “modernise” it.

The clinical effectiveness and safety of Ayurveda is best endorsed by its record of centuries of healing people. Generations of physicians have transmitted their knowledge and practice through word of mouth. However, the British Raj considered Ayurveda unscientific, mystical and a religious belief and was keen on destroying the system.

In 1835, the teaching of Ayurveda was suspended in the Calcutta Medical College. The national uprising and social reforms infused a new strength in Ayurveda. And the orientalist turn in the Raj indirectly benefited Ayurveda. It compelled its opponents to revisit Ayurveda and recognise the science within it.

In the War years, Ayurvedic physicians had organised themselves into a professional organisation, started publishing journals and were participating in the freedom struggle. But modern medicine, which enjoyed state patronage, was threatening to engulf the system. It was suggested that Ayurveda be integrated with modern medicine. It was argued that a “united system may be more perfect than the disjointed individual sciences” and “while we should absorb the pathology of the ‘seed of disease’ from Allopathy, we must give the ‘pathology of the soul’ in disease to modern medicine”. But this was seen as a threat to the core identity of Ayurveda and several orthodox physicians opposed it. Anyway, modern medicine was too engrossed into making fantastic discoveries and seemed in no mood to reconcile with Ayurveda.

The graduates of the Madras Ayurvedic College (established 1909) were up in arms against the British government’s decision to recognise and register the LIM (Licentiate in Indian Medicine) doctors from the Government Indian Medical School Madras (established 1924). The LIM diploma was launched earlier in Calcutta Medical College in 1851 to meet the growing demand for doctors. LIM contained elements from both modern and traditional medicine and required a relatively shorter period of training. Many believed it to be a kind of check on Ayurveda. LIM doctors were useful in independent India but the diploma was soon abolished following the Bhore Committee recommendations in favour of modern medicine.

Modern medicine was born in the background of the growing threat of deadly infections that killed millions of people. Fuelled by the community needs and expectations and funded by hefty investments, it made rapid progress in the 20th century. Several cures for infections were unleashed and life expectancy of humans increased. As is true with a victorious army, all else was conquered including the ethnic medicinal systems. The new world order dominated by the Americans and Europeans made sure that modern medicine was crowned as a global mainstream medicinal system. It is prudent to add there was a global appeal to preserve and promote the legacy of ethnic medicinal systems. One shining example was the Chinese traditional medicinal system. The Chinese allotted sufficient space to modern medicine but did not vacate the whole space.

Undoubtedly, there was no political and social support for Ayurveda in free India for several decades. The doyens of Ayurveda failed to propel the collective growth of the system in the early post-independence era. There were, of course, islands of excellence in the old Ayurveda institutions in Kolkata, Benares, Haridwar, Indore, Pune, Mumbai. And post 1960s, there was a spurt in the growth of well-planned medical colleges and universities, especially in Gujarat and Kerala. But all this was not enough to arrest the lethargy that had crept into the system.

There were some early interventions towards preparing a validated inventory of medicinal plants and Ayurveda pharmacopeia. Ram Nath Chopra (1882-1973), a distinguished and much decorated modern medicine physician, reignited the call for a practical integration of both Indian and Western medicinal systems. Directors of the Indian Council of Medical Research such as V Ramalinga Swamy and G V Satyavati, were supportive of his efforts.

A large force of young Ayurvedic physicians have been disillusioned by the failings and the tottering of the system. For several decades, a career in modern medicine or engineering remained the top honour. Often the rejected and the dejected accepted Ayurveda. This was despite the huge demand for doctors in India, which has not been met by the modern medicine system. However, the glow of modern medicine was blinding that Ayurvedic physicians were compelled to learn the quick-fix remedies and tricks of modern medicine. All this diluted the practice and discredited the system. Unscrupulous elements who sold herbal medicines contaminated with modern medicines like steroids and pain-killers dealt a blow to the credibility and confidence in the system.

The inadequacies of Ayurveda in treating acute infections and other emergencies including surgery, and lack of meaningful research in therapeutics continue to torment young Ayurveda physicians. Ayurveda has an outstanding record in treating lifestyle disorders and non-communicable diseases. Ayurveda therapeutics is complex and there are too many dos and don’ts. Medicines are slow to act and heal. It is difficult if not impossible to predict response or prognosis. There are no good pain-killers. But would Ayurveda have survived over 5,000 years if the vaidyas did not know how to treat human pain?

Ayurveda is not a uniform practise. Two vaidyas may disagree on the treatment. What is good in the North does not seem to be good in the South? To some extent there is a rationale for such disparity. Medicinal plants are substantially influenced by the geography, climate and local agriculture practices. The individual constitution is a fundamental aspect of clinical assessment. Seasonal variations are important in Ayurveda. Interestingly, all this does not seem to matter much in modern medicine wherein diseases are classified and treated as per prior set criteria, one-size-fits-all.

Ironically, in this post-independence gloom in Ayurveda, the herbal pharmaceutical industry took firm roots and flourished. Its growth was backed up by a robust Ayurveda pharmacopeia. The law and regulations were lax. The industry claimed that its manufacturing practices were consistent with the classic Ayurveda texts. It publicised all kinds of medicinal claims based on absent or insufficient science. With very little knowledge of Ayurveda (and despite legal professional restrictions), even many modern physicians prescribed herbal drugs for difficult to treat diseases. Gradually, Ayurvedic medicines began to follow the pathway of modern medicine. Another hype was let lose — that Ayurveda drugs did not have any side effect. This led to further obsession for drugs in the community and ailments requiring lifestyle correction were instead treated with poly-pharmacy. It is prudent to add that Ayurveda ought to teach the community the basic principles of Ayurveda management. Also, the community ought to realise that Ayurveda is essentially a holistic science and goes much beyond drugs to treat and heal.

Over the last few decades, there has been an increase in the global interest in Ayurveda. To a large extent this has been a result of the public’s disenchantment with modern medicines. This was perceived as a marketing opportunity by the Ayurveda pharma industry. Exports of drugs increased but Ayurveda as a system was not promoted. Several pseudo Ayurvedists set shop in Europe and the US. In 2006, this writer, was in London to attend a meeting of the European Union Medicinal Agency to seek greater recognition for Ayurveda. After the meeting, I was escorted to an Ayurveda college housed in a small residential building on Harley Street. Anybody and everybody could join this college and practise Ayurveda. A counter in its reception area sold a brand of tea, which was claimed to be compatible with the “prakriti” (a body constituent trait in Ayurveda) of the individual. Obviously, this is not the best way to project Ayurveda to the world.

Several countries do not officially recognise Ayurveda and have restrictions on the use of Ayurvedic medicines. In some countries, including the US, Ayurvedic drugs follow an abbreviated less stringent regulatory pathway for “food and diet supplements” and are sold over the counter not as medicines but as health products.

To make matters worse, there was a huge cacophony regarding poor quality and toxic contamination (often minerals) of Ayurvedic medicines in the US. In 2004, a leading American journal (JAMA) reported heavy metal (arsenic, mercury, lead) content in some of the Ayurveda drugs sold in the US, way beyond the allowed safety limits. This led to a world-wide condemnation and plenty of soul searching in India. The government made testing of heavy metals in herbal drugs compulsory and the industry was asked to follow WHO standards. But the damage was done. Nobody really explained that hundreds of Ayurveda herbal formulations contained metals and minerals that had therapeutic properties. Since times immemorial, vaidyas have painstakingly detoxified these metals in elaborate Ayurveda formulation processes before clinical use.

Another aspect that has worked against Ayurveda is its neglect of research. The discovery of newer drugs and overall growth and development of modern medicine has been largely supported and financed by the pharmaceutical industry in the US and Europe. There has been a robust nexus between the industry and the academia. Huge funding and scientific collaborations have played a major role in fulfilling the aspirations of the modern medicine physician and scientist. The modern pharma has also continuously deliberated with the community and participated in public health campaigns. All this while, the pharma industry was regulated by stringent laws and punitive actions.

There is another vital aspect that has been neglected by the mandarins of modern medicine in India. Let me illustrate this. I graduated from a premier medical institute in 1977. Nobody taught me even the basics of Ayurveda. Much later, I learnt about Ayurveda when I joined a research programme to validate Ayurveda medicines. It is unfortunate, if not outrageous, that modern Indian physicians are not sensitised to Ayurveda. There are several fallacies and shortcomings in modern medicine which could be met with by Ayurveda. Integrative approach, even if not truly integrative, is the answer. Let us introduce Ayurveda teaching in modern medicine colleges.

During the last five decades or so, research in Ayurveda was mainly confined to hundreds of drug trials using modern medicine methods. Often it was found that standardisation of formulation and quality of methods and data in the study was substandard. Also studies to describe the kinetics of the drug in human body and its biological actions were neglected. Research findings were rarely published in peer-reviewed medical journals. However, it needs to said that while such studies are important, it is difficult, if not impossible, to deliver Ayurveda treatment in a capsule form.

Another very interesting research development in Ayurveda was the conceptual framework of “reverse pharmacology”, which was championed by Ashok Vaidya in Mumbai. Under this framework, taking advantage of centuries old safe-use, clinical drug trials could be carried out before comprehensive evaluation of pharmacology and mechanism of action. In the conventional model, the pharmacological research precedes clinical validation by several years and the entire process may take 15-20 years and cost billions of dollars before a successful drug is launched in the community. A well-planned “reverse pharmacology” study can drastically reduce all of this. An excellent example of this was demonstrated by the NMITLI (New Millennium Indian Technology Leadership Initiative) programme, a flagship scheme of the Atal Bihari Vajpayee government.

The primary objective of NMITLI was to obtain leadership position for India in domains where the country had a distinct advantage and potential to deliver on a global stage. Ayurveda was one such domain. Several target medical disorders were researched but remarkable success was achieved in the case of arthritis. An Ayurvedic medicine demonstrated efficacy equivalent to modern medicine in the treatment of osteoarthritis (OA) knees in a final drug trial of 24 weeks. No pain killers were required. It showed better X-Ray improvement and was safe. OA is a common “wear and tear” disorder of knees and spine. Several laboratory research studies were carried out in parallel to clinical screening of potential herbal formulations. The report was published in Rheumatology (a British journal) and won the coveted clinical research excellence award from the European Society of Integrative Medicine in 2011. NMITLI arthritis project was a team effort of several premier medical and research institutions. But sadly, the arthritis drug is still on the shelf in CSIR.

In this roller coaster journey since independence, there has been one bright exception, the state of Kerala, where Ayurveda continues to occupy a unique position in the health and medical care sector. Several renowned vaidyas, including the legendary P S Warier family, played a pivotal role. Kottakkal Arya Vaidyasala is a world renowned Ayurveda centre. Preserving the legacy, Ayurveda was permitted to imbibe some relevant research methods of modern science. Several medical disorders like filariasis and rheumatoid arthritis which were declared difficult to treat by modern medicine were successfully managed using Ayurveda. The vaidya in Kerala remains a very much respected and sought-after doctor. India needs to embrace the Kerala model in Ayurveda.

Though deeply rooted in antiquity and Hindu civilisation, Ayurveda has carried forward some of the finest traditions in healing and cure the world has ever seen. It has undergone some transformation to suit modern India, but more is required. The national spirit is in its favour and it now enjoys unprecedented state patronage. A renaissance has begun. Ayurveda should aim for its rightful place along with modern medicine as a mainstream medicinal system.

(The writer is director and chief rheumatologist, Centre for Rheumatic Diseases, Pune)

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