Recently I completed twenty years of my academic career as an Ayurveda teacher and that makes me record my reflections on some crucial aspects of Ayurveda education, practice, and research in this post. The content is India-centric, obviously.
How did we deal with the Covid-19 situation?
1. Promoting unscrupulous self-medication
Let me begin with how Ayurveda fraternity has dealt with Covid-19. Having an introspection on this topic might give us some idea as to how should we proceed further. Ayurveda sector saw a great opportunity in this pandemic and the way how this opportunity was exploited needs to be analyzed. To me, personally, the performance of Ayurveda sector looks disappointing because we somehow encouraged self-medication among the public by advocating preparations like Ayush Kadha and by distributing some spices and herbs for free. We failed to send across the message that unscrupulous use of any medicines could be harmful. Several case reports have emerged suggesting the gastrointestinal and other adverse events possibly associated with Ayurveda herbal interventions.
People often argue that they have been using many herbs and spices in kitchen on a daily basis and hence, what is wrong if they consume them to prevent Covid-19? Well, basically what we often don’t understand is that ‘using spices in kitchen’ is different from consuming them in the form of concentrated decoctions. Spices used in small quantities are particularly safer, but the same cannot be said if they are used in larger quantities and in higher concentrations, too frequently for months together. Hence, we need to know that unsupervised use of even familiar herbs can be harmful as has been suggested in many studies.
Another point is that we have not educated the general public in the matters concerned with the identification of the correct herb, though we encouraged their consumption. Guduchi also known as Giloy and Cinnamon, commonly called Dalchini, could be taken as two examples where a correct identification of the herb matters a lot. Tinospora cordifolia is the actual Giloy which is generally safe whereas Tinospora crispa is reported to possess toxic effects on liver and kidneys. The point to be noted is that lay public cannot possibly distinguish between the two species because both look very very similar.
Cinnamon is another spice that is extensively used. But many of us don’t know that it comes in two varieties: Cinnamon xylanicum and Cassia cinnamon. Both look similar but the former is the safer variety. Often Cassia cinnamon is used as an adulterant, which contains a molecule called coumarin in large concentrations, which is known to possess toxic effects on kidneys. Hence, self-medication of any herb for a long duration needs to be actively discouraged.
2. Poor documentation of Covid-19 cases treated with Ayurveda interventions
Almost every Ayurveda physician came up with his/her own formulations as a purported cure for Covid-19. Many lab reports suggesting clinical improvement because of Ayurveda interventions were shared on different social media platforms, but most of them did not make into good case reports or case series. Thousands of Covid-19 cases being treated by Ayurveda physicians could have made a good data that would have allowed for further evaluation. Even though the Ministry of Ayush came up with an online case registry, the cases registered on the portal are not sufficient for anyone to interpret the results.
3. Poor standards of clinical trials
Many clinical trials came up for Covid-19, and a few even got published. However, most of these trials lacked good study designs. For instance, to prove the efficacy of a new intervention in mild to moderate cases of Covid-19, where the spontaneous recovery itself is more than 95%, one needs a large sample size and a robust study design. In most of these trials the Ayush interventions were either given as add-on therapy along with conventional protocol, or, when given as independent intervention, they were administered in mild to moderate cases only. The clinical outcomes observed too varied widely which make the actual interpretation of the results, a difficult task. Even the Governmental agencies widely publicized a few formulations unnecessarily that were tested either in small samples with not so good study designs, or were tested in mild to moderate disease which normally does not require any specific intervention at all, and drew flak from the scientific community for doing so.
4. Immune Boosting: A futile approach
Scientifically speaking, “immune boosting” is a vague and potentially misleading term. During the pandemic every other pharmacy came up with its own patent and proprietary formulation that supposedly boosted immunity.
On many platforms, experts were heard saying that Ayush sector is contributing to economy by promoting the exports of certain herbs and by citing an increased market share of some of the Ayush formulations. Common public definitely was made to believe that Ayush interventions were safer, of much preventive value and were effective in treating the disease. In fact, the preventive role of Ayush interventions is very difficult to prove, that too with small samples. Prevention studies need log-term follow up, however, no good study from Ayush stream could convince the scientific community for its preventive role. Even the purported efficacy of certain medicinal plants and formulations in preventing the disease were studied in comparison with hydroxychloroquine or similar drugs that have been now removed from most of the preventive protocols.
How differently this could have been handled?
After delving with this, “How differently we could have approached the Covid-19 situation?” is the question that naturally comes up. Ayush sector could have been visualized as a crucial healthcare-related workforce. Instead of making them (especially PG students) engage with online classes and tons of webinars, they could have been roped-in to manage various tasks such as telephonic triaging, tele-consultations, monitoring of home-quarantined patients and referral services. Though some Ayush hospitals were converted into Covid-Care Centers, most of these facilities looked after only mild to moderate cases, which even without any specific interventions, would have been resolved without complications. Those who developed complications were promptly referred to higher centers, thus making the data look like Covid-19 cases in Ayush hospitals had good clinical outcome. “Not a single death” was actually achieved in many Ayush hospitals this way. This is where a collaboration was required, in fact, between Ayush and conventional healthcare professionals. In most of the situations, this coordination was lacking, one of the reasons being a lack of connectedness between Ayush and ICMR protocols. The two protocols did not establish a dialogue by prompting “at which stage a case can be managed by Ayush professionals and at what stage it needs referral”.
Moreover, the Ayush workforce could have been used to address the needs of Non-Covid patients. During the periods of restrictions, the non-Covid patients suffered the most because of various factors including a lack of transportation facilities, conversion of many hospitals into Covid-Care Centers and limited functioning of many hospitals and clinics. Ayush sector could have used this opportunity to the fullest extent and could have contributed in taking care of Non-Covid patients. Succumbing to pressure of Covid-19 and an imaginary expectation to showcase our strength in Covid-19 exposed the sector to public scrutiny.
Engaging with the voices that call all Ayush systems ‘Pseudoscience’
During the pandemic, due to some greedy pharma companies that started making tall claims about their poorly tested formulations, and because of the involvement of Yoga Guru Baba Ramdev, a huge debate on the contribution of Ayush sector started amidst the pandemic. Ayush Vs Evidence Based Medicine (popularly but incorrectly known also as Allopathy) became a hot topic for debate on many television channels, bringing the issue literally into every drawing room of TV-viewing Indian households. It went on to become a chosen topic of discussion on social media too. Amidst all this, a few hard-core scientists with background in different branches of biomedical sciences started a social media campaign calling all Ayush systems to be pseudoscience. Most of these experts are doing this in a mission mode with an attitude of activism. In my view, what this small group of rationalists is propagating will soon assume the shape of a social movement influencing the huge chunk of common people who use social media. Dr. Cyriac Abby Philips, a hepatologist by profession is one of the popular names who is leading this movement.
These anti-pseudo-science activists mainly carry out a few very interesting activities.
1. They conduct chemical analysis of many Ayush formulations and demonstrate that many of these products contain high doses of unwarranted constituents such as antibiotics, corticosteroids, heavy metals etc.
2. They publicize the unscientific and outdated content present in the textbooks of Ayush graduate programs.
3. They propagate the various clinical case reports where adverse events are reported after exposure to Ayush interventions. Often these cases are of liver failure, kidney failure etc.
4. They keep publishing such case reports in scholarly biomedical journals
5. Exposing the poor quality of clinical trials and other published literature also is another activity this group is engaged with.
They do this most of the time with evidence such as lab reports and other investigation reports. This movement is aimed at sensitizing the public about evidence-based medicine and publicizing how Ayush interventions lack good evidence.
The activities of this mostly unorganized group have received severe criticism from Ayush sector: from practitioners, pharma industry, teachers and also from the policymakers. Many representations have been made before different government officials against the group’s activities and they have been targeted personally on many social media platforms.
This activity in my opinion is very crucial and needs support from at least those who believe in rational Ayurveda. This would make Ayush academicians and policymakers think seriously about the current education system. How much of irrelevant and impractical content is taught in Ayush curricula is a matter of serious concern and needs serious deliberation. Such a deliberation does not happen when only Ayush experts sit together for carrying out curricular reforms but will happen when there is external criticism by biomedical experts who call Ayush streams “Pseudoscience”. Present academia has made Ayurveda a pseudo-science by teaching the young minds that “whatever is written in ancient texts is the ultimate truth and can’t be challenged or changed”. This assumption makes Ayurveda non falsifiable and hence a non-science. “Is there any point in teaching a vibrant science in a manner how artforms are taught?”- is a question that needs thoughtful consideration.
Evidence Generation: Do or Die situation
One cannot deny the fact that thousands of patients throng on a daily basis in many Ayush hospitals. Obviously many get benefited of these interventions. However, this popularity has not yet been translated into documented and publishable evidence. There are no good published systematic reviews and meta-analyses on Ayush modalities. These are known as the highest form of evidence where results of a number of independent clinical trials are synthesized and analyzed. Even the individual clinical trials published are mostly weak in their designs, either with small sample sizes or lack meaningful and implementable results. Let us admit this fact: there is no reliable (highest level of) evidence whatsoever to show that Ayurveda interventions work independently and to show that they are either equally or more efficacious than conventional medicine or conventional surgeries. This makes one think as to why should anyone consider Ayurveda given the uncertainty of the outcome, possible development of adverse events and uncertainty about cost-effectiveness. Procedures such as Panchakarma are often beyond the reach of common man in certain settings.
This situation coupled with mass media and social media trials are going to take Ayurveda away from educated and rationalist, scientifically thinking class in the coming years – is what I can foresee. Often irresponsible and hyperbolic statements by so-called stakeholders of Ayurveda especially the ones from the pharma industry and also sometimes by politicians are going to damage the sector. The rationalist movement calling out Ayurveda as Pseudoscience is likely to have a major role in forming public opinion against Ayurveda.
The one and only way to make Ayurveda a real science, is to present evidence before the scientific community that Ayurveda works beyond any doubt. To do this we need to plan accordingly. Absence of uniform protocols either for diagnosis or for intervention make Ayurveda practice too subjective. An objective evaluation of this is very difficult in the standard format of double blind randomized controlled trials. Studies have shown that the inter-rater variability among physicians while diagnosing different Ayurveda clinical parameters is huge. Even the preliminary parameters such as Prakriti, Agni, Ama, Oja etc have not yet seen their universally acceptable standard formats. Most of the tools that have been shown to be promising to assess these parameters are still not there in the public domain. This makes the evidence-building evidence a Herculean task.
Observational Studies: Possibilities
What one can do practically is to go for longitudinal observational studies in multiple centers. It is wrong to assume that observational studies should by default be inferior to randomized clinical trials. When assessing the effectiveness of multi-component interventions, observational studies would be the ideal ones to carry out. This needs meticulous planning. Each patient needs to be diagnosed properly based both on modern medical parameters as well as on Ayurveda parameters. Physicians/ surgeons looking at these patients too must be from both sides, i.e., Ayurveda and conventional medicine streams. Initially around twenty different clinical conditions involving different organ systems can be identified where physicians feel Ayurveda has definite role as a potential treatment option. A large sample with long term follow up in a multi-centric design will go a long way in establishing the usefulness of Ayurveda. I visualize a period of at least 10 years for such a study to come up with conclusive results. It maybe pertinent to mention that the causal relationship between smoking and lung cancer was revealed through a huge observational study that lasted for about 40 years!
The conflict between Education and Practice:
We never teach our graduates the patent and proprietary formulations. However, as they set up their clinical practice, they start prescribing these formulations. Most of these are not backed up by good trials and even pre-clinical and toxicity studies. Thousands of pharmacies have developed their own formulations and the companies that manufacture primarily classical formulations has reduced to bare minimum. This speaks in volumes about how the sector is being commercialized.
The standards of education are really poor in most of the institutions because the curricula still contain a lot of material that is outdated. Students spend their precious time in memorizing this stuff and in preparing for PG eligibility test. This could be a best example to show how human resources can be wasted massively.
An increase in the number of new Ayurveda colleges is continuing indiscriminately and students studying in many of the poorly equipped colleges end up being individuals with no clinical expertise but with an Ayurveda degree. Lack of good teaching staff, lack of good patient input, lack of good infrastructure etc are the lacunae known to exist in these colleges. Maintaining and approving only a manageable number of colleges is very essential to ensure all students get good clinical exposure.
Introducing basic sciences in Ayurveda curricula would be the single most important intervention that I would suggest. This suggestion is based on my experiences in Banaras Hindu University. In BHU, Ayurveda Post Graduate students are formally trained in basic sciences such as Physiology, Biochemistry, Pathology, Pharmacology and Microbiology by the experts in these respective fields. These papers are officially the parts of their PG training, irrespective of one’s specialty. This happens nowhere else. This basic-science training makes them develop critical thinking and analytical skills. Instead of simply learning the Rasa, Guna, Virya and Vipaka of a medicinal plant, they also know their chemical composition and the biological basis of their effects in the body. This makes them alert and vigilant vaidyas.
Of course, the present Ayurveda curricula contain some information pertaining to basic sciences. However, in most of the colleges, there are no experts who can teach these subjects in such a depth which is required. Introducing more subjects such as molecular biology and genetics would add further value to Ayurveda programs.
Ps.: An abridged version of this post has been published as an Op-Ed in "The Hindu" available at: https://www.thehindu.com/opinion/op-ed/making-ayurveda-a-real-science/article37614617.ece
