Interview with Dr. P. Rammanohar, Research Director, Amrita School of Ayurveda

From the onset of COVID-19 pandemic, the Indian Government has pushed Ayurveda as an immunity booster. But, is that all Ayurveda has to offer? Dr. P. Rammanohar, Research Director, Amrita School of Ayurveda talks to THIP Media explaining the process of collecting scientific evidence for Ayurveda and its relevance and efficacy in times of a pandemic, especially in India.

How do you define Ayurveda? Can it be called a medicinal field in scientific terms or is it just a guideline of preventive healthcare? Does it have any relevance in today’s world?

Ayurveda is more than a medical system; it is a way of life as the word indicates – knowledge of life. Preventive health care especially with a focus on nurturing positive states of health is a strength of Ayurveda. But this does not mean that Ayurveda does not have any role in curative medicine. However, it may not fully pass the tests of the prevalent reductionistic scientific paradigm as the tenets of Ayurveda are rooted in an epistemological approach that models the human being in a more complex way.

Having said that, I would like to also point out that the so-called scientific studies from a reductionistic paradigm are also applicable to a certain extent to understand and validate Ayurvedic practices.

To illustrate my point, let us take an Ayurvedic formulation with many herbs as ingredients. The typical pharmacological approach would be to identify the so-called ‘active components’ followed by explorations of specific ligand-receptor interactions in the body and the resultant impact on the molecular mechanism of the disease process. However, Ayurveda formulations seem to act in a more complex manner. The multitude of chemical components in a particular formulation orchestrate in a synergistic manner and could be modulating multiple molecular targets in the body and modifying the response to the disease in an individualistic manner. A very simple example is the case of curcumin, which is an active component of turmeric. This particular compound has poor bioavailability but another compound piperine found in pepper has the ability to enhance the bioavailability by 2000%. Thus, the efficacy of curcumin in Turmeric depends on the addition of pepper. When there are many ingredients in a formulation, it becomes even more difficult and challenging to understand the complex ways in which various molecules interact with each other.

Thus, science in its reductionistic framework has limitations in comprehending the rationale behind Ayurveda. The emergent field of Network Pharmacology or Polypharmacology could be applied to better understand the complex mechanisms underlying the therapeutic action of Ayurvedic formulations. The research field of systems biology has greatly advanced and, as a result, the concept of network pharmacology has been developed. This advancement, in turn, has shifted the paradigm from a ‘one-target, one-drug’ mode to a ‘network-target, multiple-component-therapeutics’ mode. Network pharmacology is more effective for establishing a “compound-protein/gene-disease” network and revealing the regulation principles of small molecules in a high-throughput manner.

In recent times, Prof. M.S. Valiathan came up with the A Science Initiative in Ayurveda project with support of the Prime Minister’s Office and Department of Science and Technology, Government of India. A series of interdisciplinary studies were conducted by collaboration of eminent scientists and scientific institutions with Ayurveda experts and institutions. All these studies have produced encouraging outcomes pointing to the need for further studies.
The relevance of Ayurveda today lies in its ability to address unmet needs and gaps in the present health care system. World over, people are seeking complementary and alternative health care for many health care challenges faced by them. A careful study of what happens at the point of care will enable us to understand exactly where systems like Ayurveda are contributing and can contribute to better human health. In my opinion, Ayurveda can bring a new paradigm for understanding health and disease, an integrative model of health which is person centred, prevention oriented and focuses more on salutogenesis rather than pathogenesis.

Multiple active compounds working with each other, can be a thing. But the fact is, for a process that we claim is thousand years old and is inherent to our culture, we haven’t been able to have a research, validation and documentation of even half the compounds. Where have we gone wrong?

It was the great poet Kalidasa who made this pithy remark –Being ancient or contemporary, old or new is not the criteria for credibility, those with noble intent investigate with an open mind and take a decision based on facts.
Antiquity, by itself, has not been a criterion for credibility in our tradition. The Charaka Samhita says that only those who investigate before initiating action will succeed. The authoritative teachings (aptopadesa) had to be verified through direct investigation (pratyaksa) and inferential interpretation of the findings (anumana).

Vagbhata, the author of a celebrated Ayurvedic text says that facts are facts whether Brahma utters, or his son utters it. He even goes on to say that we cannot accept an improperly formulated statement even if it comes from a Rishi.

As they say, if something survives long, it has to withstand the test of time. Sooner or later, it will go through the process of rigorous scrutiny.
Now, coming to where we have gone wrong. We have gone wrong in at least two areas. First of all, we have not promoted research in Ayurveda in any significant manner. For that matter, in India, the focus is on clinical medicine rather than medical research even in the field of modern medicine. All the research happens in the west and we borrow the knowledge in toto most of the time.

The budget allocated for AYUSH systems in India is just about 4-5% of the overall budget in the health sector and out of this, a fraction is spent on research.

Thus, the very question is paradoxical. Without adequate investment for research in Ayurveda, we raise the question as to why there is no research and validation.

The second wrong thing that has happened is in terms of the methodology adopted for research. As hinted earlier, whatever little research has happened in the field of Ayurveda has been an attempt to force fit the system into the framework of the epistemology of modern medicine, forgetting the very fact that Ayurveda exists because it offers an alternative view of the human being in health and disease.

Carefully conducted research has always generated compelling insights on Ayurveda and Prof. Valiathan’s science initiative is an example as pointed out. I was myself involved in an NIH, USA funded clinical trial to evaluate the role of Ayurveda in rheumatoid arthritis, in which, Arya Vaidya Pharmacy, the institution where I worked earlier cooperated with University of California, Los Angeles with the participation of an eminent rheumatologist, Dr. Daniel Furst. This study was innovative with respect to modification of the Randomised Controlled Trial study design, which allowed for individualized multi modal Ayurvedic treatment to be administered to the patients. This study that won the Excellence in Integrative Medicine Research Award from European Society of Integrative Medicine was recommended by Dr. Edzard Ernst, an otherwise vehement critic of Complementary and Alternative Medicine (CAM) as a blueprint for future studies on CAM.

Though it was a pilot study, the outcomes clearly indicated that complete Ayurvedic intervention was equal in effect to Methotrexate, a standard drug of choice for rheumatoid arthritis. To summarize the tradition has not prioritized the importance of anything ancient just on the basis of face value and is open to investigation.

We need to invest in research, in collaboration and development of methodologies that are appropriate and sensitive to the epistemological premises of Ayurveda. It would be unfair to dismiss Ayurveda even before examining it in a comprehensive and fair manner.

A lot of Ayurveda is practiced by individual Vaidyas whose medicinal composition varies. For a medicinal practice that is built on the belief that the physiological baseline is different for every individual and hence the treatment procedure, is it even possible to generalize this practice, set common standards of medicines and take it to a global scale?

Variability has to be considered from two angles. One is the variability in the medicinal preparations and the other is in the prescription patterns of clinicians. In Ayurveda, natural plant, animal and mineral sources are used to prepare medicines. Depending on soil conditions, the climate, the stage of growth and such other factors, the chemical composition of the drug sources can vary.

Another reason is the use of substitutes when the recommended sources are not available. Sometimes there is adulteration. There is a need to enforce good practices from harvesting of drug sources to manufacturing of medicines, its packaging, storage and distribution to ensure that quality standards are met. When these guidelines and protocols are not complied with, then there can be batch to batch variations in the chemical composition of these medicines beyond acceptable limits and even sometimes contamination. Enforcement of protocols for manufacturing Ayurvedic medicines to meet quality standards is the solution to this challenge.

The next challenge is variability in the treatment prescriptions given by Ayurveda physicians. Two physicians may not arrive at the same prescription for the same patient. Moreover, there may be regional variations in prescribing practices. This could happen due to variability in diagnosis as well as variations in the choice of treatment even when there is convergence in diagnosis.

We need to understand this variability in clinical practice in the proper perspective. Even in modern medicine, we do find variation amongst physicians in both diagnosis and choice of treatments. This is in spite of the existence of common standards and treatment guidelines. Such variations cannot be completely eliminated in clinical practice. Having said that, we cannot also justify a chaotic situation where every physician prescribes to his or her whim and fancy.

In Ayurveda, setting rigid guidelines for clinical practice recommending one or a set of medicines for a particular disease is not possible. Indeed, Ayurveda advocates a person-centered approach that takes into consideration multiple variables. However, Ayurvedic texts have formulated algorithms and treatment guidelines even with provision to assess and accommodate new diseases and modified treatment protocols.

Definitely Ayurvedic approaches to treatment can be standardized in the form of broad treatment algorithms that are flexible enough to permit individualization at the point of care. This requires research initiatives, development of consensus statements, constant updating of the treatment algorithms based on feedback from clinical practice. By strengthening clinical practice-based research, it should be definitely possible to formulate well defined treatment guidelines in Ayurveda.

A lot of researches has happened about phytochemicals of different plants and herbs. We know garlic, gooseberry, turmeric etc are healthy and how. But we don’t hear much about how much of a certain thing (say, Garlic) is good for whom under what condition. Where is the research around the dosage, side effects, application condition etc.?

Ayurvedic texts have elaborated the properties of different herbs on the basis of the principles of Ayurvedic pharmacology. It is a dictum in Ayurveda that there is no substance in the world that is absolutely safe or without any benefits. All substances have merits (guna) and demerits (dosa) and risks and benefits have to be taken into consideration. We cannot say that garlic, turmeric and so on are unconditionally safe. Ayurvedic texts have contraindicated the use of garlic in specific situations. The indications and contraindications of garlic are very well detailed in Ayurvedic texts. That garlic can be harmful in people with bleeding tendency is noted in the earliest textbooks of Ayurveda. So also, other herbs.

There are detailed descriptions in Ayurvedic texts regarding the properties and actions of herbs, methods of processing, methods of combining as well as dosage. So, there are already guidelines advising where, in whom and how to use these herbs codified in the classical texts.

However, Ayurvedic texts explain the systemic properties of the plants rather than the phytochemicals present. It is a wrong understanding that complete understanding of the phytochemistry is even possible. Plants contain hundreds of phytochemicals and a complete chemical profiling of a plant is almost impossible. New compounds in plants are still being discovered.

For example, Curcumin is not the only compound in turmeric although the two are now considered to be almost synonymous. Ar-turmerone is another compound that has been found to have very interesting pharmacological activity. In fact there is a whole set of non-curcuminoid compounds in turmeric.

Two approaches are possible here. We can try to identify some of the ‘active compounds’ and understand their properties and actions. But this cannot be ascribed to the plant as a whole. It is much more difficult to understand how different chemical constituents in a single plant work together when used in a crude form. Ayurveda offers a model of pharmacology where the focus is on understanding such systemic properties rather than properties of fractionated compounds.There are advantages and disadvantages in both approaches. An integrative approach that combines insights from Ayurveda and modern phytochemistry would help us to get a more comprehensive understanding.

The COVID pandemic could have been a time to test the efficacy of Ayurveda, research more about it and build on the learnings. So while modern medicine will experiment with a flu drug or malaria drug as ‘cure’, Ayurveda is being presented as an ‘immunity building’ measure. Is there a limitation for the Ayurveda Vaidyas to actually treat COVID-19 patients?

If Ayurveda has been presented as an immunity building measure, it is not because there is no possibility for Ayurveda to manage COVID-19 patients. It is mainly because Ayurveda has not been included in the public health response to the COVID-19 pandemic and Ayurvedic physicians were not authorized to treat COVID-19 patients.

The situation has changed in some states and not only are Ayurvedic physicians treating COVID-19 patients in some places in the country, some Ayurvedic hospitals have also been designated as COVID Care Centers.
The experience with Ayurveda in both clinical practice and in hospitalized care has given ample indication that Ayurveda can care for COVID-19 patients. Successful management of even oxygen dependent COVID-19 patients have been reported by physicians.

However, many states have still not granted permission for AYUSH practitioners to treat patients though there is permission to provide preventive care. COVID-19 is not such a deadly disease that every other person who contracts the virus will fall dead on the floor. In fact, compared to the more deadly Nipah virus, SARS-CoV-2 is comparatively mild, though highly contagious. Between 95% to 98% recover without any specific treatment. Only supportive care is needed. There is no question of curing a COVID-19 patient unless the person is in the highly critical category. And in my opinion, Ayurveda is a more patient friendly, cost effective and holistic approach to provide care for COVID-19 patients.

We can always adopt an integrative approach in patients who may need intensive and critical care.

Lakhs of rupees are being spent by patients in allopathic hospitals for COVID-19 care. There is clearly a disparity in the treatment of the rich and the poor. Many patients have died waiting to get a bed in a hospital. Integrating Ayurveda for care of COVID-19 patients will ease the burden on Allopathic hospitals and will also give patients a cost-effective option.

In Delhi, the experience at the Chaudhary Brahmaprakash Ayurveda Chikitsa Sansthan and All India Institute of Ayurveda clearly demonstrates that Ayurveda can give supportive care for a large number of COVID-19 patients.
A cure for COVID-19 is an altogether different matter. As Dr. Bhushan Patwardhan remarked, COVID-19 has brought Ayurveda and Allopathy on a level playing ground. Research has to happen in both systems and that may take time. Modern medicine is hunting for a magical antiviral drug or a vaccine. Ayurveda can hunt for a new herbal formulation that has anti-viral and immunomodulatory properties that can help to mitigate the severity of the disease and facilitate quick recovery.

And while the medicines are being brewed in the research laboratories, lakhs of patients who are falling sick cannot be ignored. Ayurveda can offer good supportive care for COVID-19 patients based on its principles of management of epidemic fevers.

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