Ayurveda The Alter Native?

Before you unthinkingly pop those two ­Ashwagandha pills from the bottle you plucked off the neighbouring chemist’s front desk at the last minute, along with your zinc-fortified B-complex, consider the macro picture again. Never before has medical science been so beset by a life-upending situation; never did it have to expend all its wiles in rallying so vigorously from the baseline. Of the entire landmass on our big blue planet, only a handful of Pacific islands, we’re told, have been Covid-free so far. The rest, like surfers, are still trying to stay upright while navigating the crests and troughs of the ­pandemic. Yet, unlike that helpless situation we were in a year ago, an immune response is only two vaccine doses away. Can that stop transmission? Nobody’s yet pressed the button on that buzzer round poser. Nevertheless, that’s a crucial one: will immunity passports be the next gate passes to a safer world?

Therein lies an elusive piece in the entire Covid jigsaw puzzle, and a term that’s everywhere—immunity. It crops up in most attempts to explain the greys that cover the canvas. For the moment, all that tends to subsume into the main battle tank against Covid—the vaccine. Plenty of vaccine platforms still in investigation, potentially improved ones, all trying various routes, besides the 10 or so already market-ready. India’s pharmaceutical heft places it smack in the middle of all this. But what about that other front back home that Covid has spurred into activity: the arcane realm of traditional medicine? Especially Ayurveda? A name that swims into soft focus for most Indians, swaddled in images of grandma remedies, ideas of a pure past and pure being, and the secret magic of nature—brought on by seventies TV advertisements for herbal toothpaste, if nothing else? Why’s there suddenly so much foam and lather around that name in Covid season?

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Well, last April, the Ministry of Ayush (‘Ayurveda, Yoga and Naturopathy, Unani, Siddha, Homoeopathy’) had strode boldly into the fog, permitting practitioners of alternative medicine to conduct clinical trials for a Covid application. Since then, over 200 clinical trials have been initiated—outside allopathy—in hospitals and research centres across India. Many were Ayush-led—sponsored by research councils under the ministry—and Ayurveda was the chief focus. In fact, a review in July 2020 slotted about 60 per cent of all Covid-related trials on the Clinical Trial Registry of India in that category! So clearly, the scene was in ferment.

Yet, it was yoga guru Baba Ramdev who took the spotlight last month with claims about ‘Coronil’—a brand developed by his firm Patanjali as a panacea for all things Covid. At the launch, where Ramdev was flanked by Union health minister Harsh Vardhan and transport minister Nitin Gadkari, it was billed as “the first evidence-based medicine for COVID-19”. Plenty of questions have been raised, primarily about how robust the clinical study was. Even WHO—whose global certification protocol was alluded to during the launch—hastened to clarify that it had not reviewed nor certified any traditional medicine for Covid. The Indian Medical Association (IMA), meanwhile, pulled no punches, calling it a laughing stock. Patanjali shot back with its published research findings, principally in the Elsevier-­owned science journal Phytomedicine. (Patanjali hasn’t responded to Outlook’s emailed questions.) Last heard, Patanjali had thrown an open challenge to the IMA for a discussion on “the science behind Coronil”, and the latter picked up the gauntlet.

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Of course, the fundamental disputes between Ayurveda and allopathy are hardly new. Any attempt to find crossover points between the former’s concepts of bodily humours and modern medicine’s underpinnings in germ theory and its newfangled diagnostic tools would currently seem futile. If the idea that disease originates in the imbalance between vata, pitta and kapha can indeed be translated into modern terms, we are still searching for an interpreter. Nor is this because the West is unfamiliar with bodily humours—Ayurveda broadly shares that conceptual ground with the ancient Greeks. Recent decades have seen tentative attempts to bridge the gap—recall the Golden Triangle project from circa 2005, which brought together the Council for Scientific and Industrial Research (CSIR), the Indian Council of Medical Research (ICMR) and the Ayush department in a joint quest to try and scientifically validate classical Ayurvedic products and promote collaborative research. Those were also the days of the storied global battle for haldi. The US patent office had granted a patent for the wound-healing properties of turmeric—the news, after the first pang of incredulity, brought a public appreciation of how modern scientific knowledge, while dissing traditional systems, may actually be coveting their old secrets. And, yes, a sense of the vast markets that potentially loomed out there. Anyway, India fought and got that patent revoked. The episode also spurred, in the early noughties, the ring-fencing of India’s traditional medicinal knowledge from biopiracy via the Traditional Knowledge Digital Library (TKDL). So far, TKDL has documented about 2.9 lakh medicinal formulations from classical Indian texts in five international languages.

Several noted researchers who have straddled both worlds—Dr M.S. Valiathan, Dr Subhash Chandra Lakhotia and Prof T.R. Raju, to name a few—fear that the recent controversy will only be damaging to Indian systems of medicine. Ayurveda, its serious practitioners reckon, has been witnessing a genuine renaissance of sorts thanks to efforts over the past couple of decades. Some of it was aimed at getting rid of the old accusation that its methods did not speak in scientific terms—even if the ancient treatises were highly systematised documents of knowledge, its modern practitioners couldn’t translate the core concepts into acceptably ‘scientific’ terms as understood today; and where their healing worked, they couldn’t always say why. This goes to the heart of the ­conundrum. Ayurveda, in its holistic study of a patient, individualises treatment. Two patients with the same ailment may not walk away from the same vaidyan with the same set of herbal curatives. That speaks of an inherently more dynamic approach to healing than modern, ‘evidence-based’ allopathic solutions that tend to universalise—everyone gets the same Covid vaccine, or headache pill. How could ­compatibility be striven for? The taint of ‘irrationality’ in the modern world seemed difficult to get rid of.

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The Delhi-based freelance photojournalist, forced to be out on his work even during a pandemic, saw his fears coming true back in April 2020—he had possibly got near an infected person at one of the events he covered. Luckily, he had only mild symptoms—cough, and loss of taste and smell. “People suggested I get admitted at LNJP, but other journalist friends told me the hospital was overwhelmed with patients,” says Barolia. He was keen to explore the Ayurvedic option, and soon heard of the state-run Chaudhary Brahm Prakash Ayurved Charak Sansthan in north Delhi. A lot of Covid patients were admitted there, but Barolia returned ­impressed with its facilities. Treatment was simple. “Mostly, saline gargles and milk with turmeric at night, kadha, ­ashwagandha and giloy,” says Barolia. Once he developed fever, and the doctor gave him paracetamol—the rest was “soothing” Ayurveda. “I was admitted on April 26 and turned asymptomatic on May 9. As per the protocol then, I was sent for a 16-day home isolation, and completely recovered on May 27,” says Barolia. “I think I took the best decision. It felt like I was treated at home.”

Not everyone thought so; some ventured boldly into this epistemological gap. A decade ago, the Arya Vaidya Pharmacy in Coimbatore measured the efficacy of Ayurveda treatment on rheumatoid arthritis in a pilot study co-funded by the US National Institutes of Health. That award-winning research paper, billed as the first-ever, double-blind, randomised, placebo-controlled study comparing Ayurveda to the anti-rheumatic drug Methotrexate demonstrated, as its investigators put it, that it was possible to test individualised Ayurvedic versus allopathic treatment—in ways acceptable to both. Reverse pharmacology has been the other route to unlock the mysteries of traditional medicine. A few months ago, the Department of Biotechnology reported that its animal studies on the effect of Ayurvedic oral interventions on Covid were in the final stages. These included formulations such as Ashwagandha, a Guduch-Pippali combination, Mulethi and Ayush-64, a polyherbal compound.

Neurophysicist Prof T.R. Raju, who is also a visiting professor at SVYASA Yoga University, Bangalore, says a lot of genuine good work has been happening in both Ayurveda and Yoga, but they get overshadowed by the “red herrings” that draw more attention. As Dr P. Rammanohar, director of Amrita Advanced Ayurveda Research Centre, says of ­Ayurveda, “The system has itself never claimed any cure for Covid” (see column by Shyama Rajagopal).

But the field is indeed in a creative ferment, with or without having won converts universally. Here’s a random snapshot. At AIIMS Delhi, a year-long study on the prophylactic effect of Ayurveda and Yoga on 452 healthcare workers will be completed in a couple of weeks. The All India Institute of Ayurveda, an autonomous organisation under the Ayush ministry, tested an Ayurvedic treatment on 80,000 Delhi Police personnel—the volunteers took 250 mg tablets of Samshamani Vati, applied Anu taila drops in their nostrils once a day and gargled warm water mixed with rock salt and turmeric, besides practising Yoga, including Pranayama, for eight weeks. “The results are encouraging,” says Ayush secretary Vaidya Rajesh Kotecha (see interview). Last April, the Medanta Hospital in Delhi initiated a year-long study to assess the effectiveness of giloy and pipli, in addition to the standard-of-care in Covid patients. And JIPMER Pondicherry has registered a clinical trial on the practice of Yoga and Naturopathy on 200 healthcare workers—it aims to find out if practising Nadi Shodhan Pranayama and Panchakosha meditation can help with psychological parameters, sleep quality and coping abilities.

Other Indian systems of medicine too have registered clinical trials—for instance, Siddha medicines such as Kabasura Kudineer and Brahmananda Bairavam with honey or ginger juice are being evaluated. Add to this about 50 clinical trials involving Homoeopathic medicine—another distant galaxy shrouded in grey for modern science.

Does this mean traditional medicine has shrugged off concerns over its scientific rationale? Not yet, not till robust results arrive. And several difficulties attend to that. The nature of the above examples should suffice. One appraisal of 58 early trials, published in the Journal of Research in ­Ayurvedic Sciences, put it in a nutshell: most trials registered between March and June 2020 had been designed for asymptomatic, mild or moderate cases of Covid; only two included severe cases. Only three were double-blind (meaning neither the candidate nor the evaluator knew which group receives treatment) and placebo-­controlled trials, and there were no open-label trials where the evaluator was not aware of the arm to which the patient has been assigned—endpoint blinding method, as it is called. These, considered the gold standard in modern medical trials, are not often easy to replicate in ­Ayurveda: even WHO has acknowledged that double-­blinding becomes difficult with many traditional medicines simply because the strong aromas cannot be replicated in a placebo, and the patient or evaluator cannot be fooled.

So that’s a cul-de-sac vis-à-vis Covid, despite the fact that some Ayurvedic treatments have indeed been scientifically validated over the years—like Kshaarasootra, an ancient ­procedure for anal fistula prescribed in classical texts. Back in the early 1990s, a multicentric, randomised controlled trial by ICMR concluded that the long-term outcome with ­Kshaarasootra surpassed that of surgery, offering an effective and safe alternative treatment. That’s the only way to go. Prof Lakhotia, who has investigated Ayurvedic rasayanas in animal models of Polyglutamine (PolyQ)-­related genetic diseases and Alzheimer’s disorder, says any claim not based on good lab practices and reproducible results is damaging—in any discipline. Covid, he says, has spurred such claims not only in Ayurveda, but in other healthcare disciplines as well. “An unbelievably large number and varieties of products are now being advertised either to kill viruses or protect from Covid,” says Lakhotia.

The allopathic world saw enough of that hurly-burly. Recall the scramble to repurpose drugs when the pandemic broke out last year. Many early ­candidates that looked promising as cures or prophylactics—the antimalarial hydroxychloroquine (HCQ), for one—were ­conclusively proven to have no effect in treating Covid. Speaking to Outlook last July, when the pandemic was shifting gears and the need for drugs that worked was desperate, Dr S.P. Kalantri, director-professor of the ­Mahatma Gandhi Institute of Medical Sciences at Sevagram, rued the fact that Indian allopathy too had missed an opportunity to launch its own well-designed, large, randomised ­controlled trials—on the lines of the RECOVERY trial in the UK—despite the 550-odd medical schools and hospitals across the country. Instead, several repurposed drugs were being commonly prescribed without much evidence of efficacy, but based on anecdotal evidence. “People like stories, not solid hard data or numbers,” Kalantri had said then.

Today, nobody talks about HCQ anymore, he points out. “And the reason is that trial after trial has shown it doesn’t work,” he says. Even a negative trial is, thus, valuable. “The problem right now in India is that hundreds of clinical trials have been conducted, but all very small in size and poorly designed. At the end of the day, you don’t get a clear answer,” he says. The rare exception, he says, was ICMR’s clinical trial on convalescent plasma. “I give full marks to ICMR for having the courage to publish a negative trial that says, well, convalescent plasma doesn’t work in Covid patients.”

Despite the task seeming like having to cut a path through a mountain, there’s no denying the great interest in what traditional medicine can yield—even WHO has announced plans for an International Centre for Traditional Medicine in India. COVID-19, a sly killer that poses special difficulties in treatment terms, has also sharpened the urgency—even if the market could muddy the science. Ayurveda alone is a Rs 30,000 crore industry which, we’re told, has only grown in this past year when people have been seeking out herbal remedies to an unknown scourge. Think only of the ‘immunity-boosters’ suddenly all around you, many aggressively promoted by Ayush. We have the contradiction right there. ‘Immunity’ products have mushroomed, but many experts point to the problematic nature of that terminology, especially the easy generalisations it enables. For, no one has really studied the effect of Ayurvedic medicine on the individual immune system to date, says Dr Valiathan, whose translations of Ayurvedic texts have been a bridge between the ancient discipline and modern medicine. “I don’t know any such proper study on Ayurveda and its impact on immune functions,” he tells Outlook. As he explains it, Ayurvedic physicians have their own way of assessing bodily resistance and protection. “That may not be what we call immune function in modern medicine. A joint research is needed to understand the effect of Ayurveda on the immune system.”

Virologist T. Jacob John, who has had long years of experience in polio and HIV eradication, reckons terms such as ‘immunity’ aren’t well understood. “You cannot induce immunity to a specific agent by any drug or anything else other than that very infection, or its vaccine, which is a component of the microbe,” says John. “When people talk about boosting immunity, it’s just a figment of the imagination.” Instead, he points to Ayurvedic techniques such as nasyam, to which he was introduced as a child, as those meriting deeper study. A method of cleansing the nasal passage by sucking warm salt water through the nostrils, nasyam has been shown to be beneficial for respiratory tract infections due to the chloride ions. “I was taught nasyam and I taught it to my children and grandchildren, essentially as a treatment for sinusitis,” says John, adding that it helped him avoid antibiotics.

But the market has its own logic, separate from the hard logic of science. Prof Madhulika Banerjee of Delhi University, who has authored a book on the commerce of Ayurveda, points to how a bulk of that market takes on the form of FMCG (fast moving consumer goods). That approach has made many formulations more accessible to people, even as cosmetics. To that extent, it’s been a masterstroke. But Banerjee reckons there’s a downside to packaging herbs like ashwagandha, neem and tulsi as standalone drugs without the vaidyan in the frame. “We forget that the knowledge system of the vaidyan is complex, accounting for the patient’s ­constitution, the correct proportions of herbs tailored for that, and the diet that would best suit the composition of the medicines,” Banerjee tells Outlook. Mass-marketing isolated products, she feels, runs the risk of “deligitimising the knowledge of the vaidyan” and promoting self-medication, which can be risky, as with any medicine. (It’s a myth that herbal medicines don’t have side-effects.)

But considering the traditional vaidyan gives us the picture of a world caught in transition, even before the Covid-led churn. For, the fact is traditional vaidyans are struggling to find legal endorsement for their practice—unless equipped wth a formal degree. A court order that came in October 2020, in the midst of the Covid debates, handed a victory, paradoxically, to the Ayurveda Medical Association of India (AMAI). This was a 20-year legal battle fought within the discipline, between the older practitioners who had learnt from their masters, often within the ­household, and those who were graduating formally from the Ayurveda colleges. “Traditional vaidyans were conferred B-class registration in 1953 and then in the Central Council of Indigenous Medicine Act, 1970, when there was a shortage of qualified hands,” says journalist Shyama Rajagopal, who extensively researches health. “As the number of Ayurveda colleges increased, and a number of qualified professionals with a BAMS degree came into the system, AMAI argued there was no need to provide registration to ‘unqualified’ practitioners.” AMAI joined the case in 2001, when a section of traditional practitioners (parambarya vaidyar) went to court seeking recognition. When the Kerala High Court first banned ‘traditional’ practice in a 2003 verdict, a group of vaidyars knocked on the Supreme Court doors seeking the right to their livelihood. The SC, in 2017, upheld the Kerala division bench ruling, saying medical practice should be governed by the rule of law. A few more twists in the tale, and the October ruling delivered a coup de grace.

Kerala, perhaps India’s strongest seat of Ayurveda, was the crucible in which the discipline’s inner structure was being remoulded. Kerala had an estimated 70,000 traditional—­formally ‘unqualified’—practitioners when the case started in 2001. By the time the case reached the SC, there were nearly two lakh! Sadath Dinakar, general secretary, AMAI, says that leap in numbers itself proves they were mostly “quacks”. The progeny of all traditional Ayurveda houses have now armed themselves with proper degrees, he says. The overall numbers are interesting—India has about 7.88 lakh Ayurveda, Unani and Homoeopathy doctors (allopathic doctors number about 12 lakh). Modern Ayurveda practitioners, Banerjee says, strive to grow out of the stereotypical imagery of rishis in front of a mortar and pestle—to disprove that “things haven’t moved at all”. Even, we could add, to dispel the taint of quackery. But this flux, this transition from traditional, intuitive healing methods to essentially being in conversation with another, largely incompatible system is where Ayurveda is right now.

If a traditional vaidyan looked at the patient’s whole being, a modern allopath may sometimes not even see a patient—­relying instead of microscopic, granular data from the lab, like ESR reports. Holism versus atomism. How can integration happen, how shall the twain meet, if at all? It’s a profound question for our times.