Hitāhitam sukham duhkham āyustasya hitāhitam
mānam ca tacca yatroktam āyurvedaḥ sa ucyate
“That is said to be Ayurveda which measures the beneficial and harmful, the happy and unhappy, the wholesome and unwholesome factors of life and the lifespan.” Caraka Samhita I/41
Although certainly not for the first time in its history, Ayurveda has again arrived at another crossroads–one requiring a re-clarification of purpose. Ayurvedic physicians, who today live in a world surrounded by influences from many spheres, need to refocus their vision of what is the true role of Ayurveda in the modern world. The historical roots of Ayurvedic medicine need to be revisited, more closely studied, respected, and absorbed while simultaneously more effective educational methods need to be developed and expanded. Far from these two goals, the current global Ayurvedic diaspora more and more disassociated from Vedic tradition has resulted in the debauchment of Ayurveda. Even within India modern science is influencing Ayurveda both for the better and for the worse. If we cannot ourselves define, articulate and preserve what is unique to our medical tradition, the tools and technology of our medicine will eventually be at best subsumed into biomedicine and at worst surrendered to the illegitimate and unqualified modern-day “Ayurvedic practitioner”. In either scenario the sacred underlying wisdom will be lost.
Although there are many potential bridges of collaboration between Ayurvedic medicine and biomedicine, I think we need to ask ourselves, do we wish to be technicians like Western physicians have more or less become, or scholar-physicians which is our original and true dharma?
Ayurvedic medicine has always been based largely on scholarship and a literary tradition, with the requirement to study essential classical texts, absorb them into one’s mind, quote them, debate them, penetrate them. The foundations of Ayurvedic medicine are based on principles (tridosha, saptadhatu, agni, ojas, and more) that require both a philological and philosophical approach to the body of knowledge. Traditionally, a physician-in-training was required to have command of the Sanskrit language, the principles of logic, grammar, and the natural sciences to study texts as the Bhela, Caraka and Susruta samhitas and the various other works.
In India, the concept of the priest-physician was largely developed during the Vedic period (approximately 2700 to 500 BC) when Ayurvedic knowledge was coded in hymns and poems and transmitted in an oral tradition. With the advent of the Classical period of Ayurveda and the appearance of the first written compendiums the scholar-physician model appeared and knowledge began to spread throughout the vast subcontinent. Even more importantly, an organic and meditative approach to this knowledge was developed and encouraged.
This era was considered to be a ‘renaissance’ not only in medical thought but in human development as well, so great were the developments of the six philosophical schools which arose contemporaneously in the first 500 years of the AD period of history Today’s modern era has eroded the ideal of the Scholar-Physician to some degree in India, however along with modern clinical Ayurvedic medical practice it has survived relatively intact. Evidence of this is in the burgeoning number of Ph.D. (Ayu) candidates and scholarly publications which appear each year. In the West, however, where the development of Ayurvedic medicine is still in an embryonic stage, there is much confusion about what direction we should go.
Adding to this dilemma is the lack of proper formal education of Western Ayurvedic physicians, the appearance of a growing number of dreadfully unqualified “Ayurvedic Practitioners” and “Clinical Ayurvedic Specialists” and the muddled legal landscape regarding Ayurvedic practice throughout the world. Charaka denounced these quacks in no uncertain terms and warns the public:
“One may survive the fall of a thunderbolt on one’s head but one cannot escape the fatal effects of treatment prescribed by an ignorant physician”. (CS, Sutrasthanam I/128-132)
Later in the same section he further condemns “those who putting on the garb of the physician, thus trick their patients just as the bird-catcher in the forest tricks the birds into his net by camouflaging himself; such outcasts from the science of healing both theoretical and practical, of time and of measure, are to be shunned, for they are the messengers of death on earth. The discriminating patient should avoid these unlettered laureates, who put on the airs of physicians for the sake of a living; they are serpents who have gorged on air”. (CS, Sutrasthanam XXIX/10-12).
Should Ayurvedic authorities quietly accept these charlatans bearing artificial sham titles invented by self-serving so-called “schools” of Ayurveda? Are we as Ayurvedic physicians to practice within the existing healthcare system or seek to establish ourselves outside of it? Do we embrace the research methodologies of the 21st Century, with its randomized, placebo-controlled, double-blinded studies and p-values, or following our tradition and duty of the scholar-physician, do we find our own paradigm for scientific advancement?
These are among the many questions we face as we stand at this crossroad.
Our Critical Crossroad: The Path of the Scholar-Physician vs. The Path of the Highly–trained Technician
The modern biomedical world has seen vast changes in the last one hundred years, as vast institutions of hospitals, merging hospital chains, health maintenance organizations (HMO’s), pharmaceutical companies, insurance providers, and government research institutions have centralized the world’s financial and intellectual resources and largely usurped the power once in the hands of doctors.
Today, medical doctors have largely had their role reduced to that of a high-trained technician. This is unfortunately not an exaggeration if we stop and consider for a moment. Physicians have lost control over the very sources of their information, over their fee structure, over their ability to make unbiased decisions regarding medical care. Even aside from the imposing economic and political changes, the advancement of medical science data in Western biomedicine has been largely “outsourced” to the disciplines of genetics, information sciences, physical and organic chemistry, biology, pharmacology, and physiology–which are separate professions and distinct and separate areas of study.
Doctors rely largely on information gained from expensive technological machinery, while being pressured by the insurance industry which demands reductionist and ‘definitive’ molecular diagnoses, leaving little room then for physician judgments based on knowledge and experience.
The insurance industry largely determines physician fees, what services will be covered, and for how long. If a person has high cholesterol and we know that the ‘definitive cause’ is activity of an enzyme called 3-hydroxy-3-methyl-glutaryl-CoenzymeA reductase (HMG-CoA-reductase), then we need only give HMG-CoA-reductase inhibitors to solve the problem. Despite the fact that those inhibitors are ineffective in large numbers of people and cause severe adverse effects in relatively large numbers of patients, insurance companies pay for it so physicians continue to prescribe it.
The same can be said for dyspepsia, or amlapitta, a condition seen more and more commonly in modern Western society. Biomedicine has identified the cause to be excessive stomach acid production by the parietal cells. So pharmaceutical companies first developed histamine H2-receptor antagonists (i.e. tagamet, zantac) and shortly thereafter proton pump inhibitors (i.e.prilosec, nexium, etc.). These chemicals are often ineffective and they ALL have well-known adverse effects including hypotension, cardiac arrhythmias, impotence, diarrhea, headache, and decreased calcium absorption. Yet insurance companies pay for them so physicians continue to prescribe them by the hundreds of thousands annually. But insurance companies will not pay for any of the more natural interventions which often effectively eliminate the problem at its root such as panchakarma detoxification procedures, yoga asana training, meditation, or herbal medicines.
Most people interested in genuine health-care careers are drawn to Ayurvedic medicine as a clear alternative to the current biomedical establishment, in the hope of maintaining a degree of intellectual and clinical independence in the day to-day practice of medicine. Most Ayurvedic physicians in India are still independent providers, mostly in small offices with relatively low overheads or work in Ayurvedic hospitals or medical clinics.
Even in India many Ayurvedic physicians, however, are becoming misguided by the lack of a clear vision on the direction of Ayurveda in the 21st Century. The situation in the West is even more alarming. This is principally due to the fact that there are very few Ayurvedic physicians in the United States or Europe with the legal status to practice the full spectrum of medicine. In these places, Ayurvedic “therapists” or “practitioners” are wrestling with their role as primary(?) or secondary health-care providers, independent of or part of the biomedical system.
Modern medicine has also lost the integrity of the physician-patient relationship to a large extent. HMO’s and insurance companies often dictate the choice of physicians or specialists for patients, determine fees, treatments, frequency of visits, and duration of treatment! What’s more, physicians have also relinquished control of their materia medica to pharmaceutical companies, who pressure physicians to prescribe their proprietary medications for obscene profit. Physicians who are pressured avoid similar medicines of competitors and certainly ‘unproven’ treatments such as herbal medicines. Enormous legal institutions such as the FDA (Food and Drug Administration), AMA (American Medical Association), NIH (National Institutes of Health), and the HMO/insurance establishment have reduced the physician to a highly paid employee of a medical mega-structure. Sadly, doctors are unable to control even their own information sources in their own medical schools.
What Can Be Done?
There is great pressure on the Ayurvedic medical tradition to follow the existing paradigm, to reject intuition and instinct, to bow to scientific method, to accept the unqualified “practitioners” infiltrating its ranks, to enter and integrate into the biomedical world. Should that happen, the intrinsic strengths of Ayurvedic medicine could be in danger of further deterioration, because much of what makes Ayurveda strong could not easily survive in this environment. Ayurveda has always depended on certain fundamental requisites:
1. Complete and comprehensive training and knowledge before advising even a sip of water
2. Individualization of treatment based on physician judgment
3. Preservation of traditional diagnostic methods and flexible
4. Freedom to employ the full spectrum of Ayurvedic treatment modalities
5. Physician control of medicines and preparations
6. Time, attention and care given to patients determined by physicians and patients
7. Patients free to find and choose their own Ayurvedic physician
8. Commitment to continuing basic and clinical research
While it is important for new graduates to be encouraged to intern with established health care providers in private offices, it is also important for us in the West to develop clinical environments that are conducive to the practice of the full spectrum Ayurvedic medicine (i.e. rasashastra, kshar sutra, vamana chikitsa, raktamokshana, agni danda, etc). This must also include Ayurvedic medical research. This may mean we need to eventually develop authentic Ayurvedic patient in-care facilities, including hospitals where herbal medicines, panchakarma, and the full spectrum of Ayurveda are used.
Ayurvedic medicine is based on study of philosophy and nature, mind and body–the cornerstones of clinical practice. Vaidyas are also encouraged to have a broad knowledge of the natural sciences and humanities. The modern trends in medical studies have moved away from philosophical approaches and the humanities in deference to total immersion in the hard sciences. This trend is also beginning to influence the training of Ayurvedic medical doctors in India, where studies in the surviving original metrical sutras of the rishis have been diminished in the curriculum or, in some institutions, already abandoned.
In conclusion, the scholar-physician embodies and lives the knowledge that is taught to him/her, and in this way continues to penetrate it and preserve it. The knowledge base of Ayurveda belongs to each individual physician, not to some centralized knowledge source based on data from studies and large institutions. Each physician’s experience is potentially innovative and creative, but authentic and complete education is a pre-requisite. The knowledge base is stored in the historical and modern Ayurvedic medical literature, and includes natural philosophy and the clinical case studies of generations of physicians. In order for Ayurveda to have a healthy future, we need to recognize the roots of our philosophy and practice, and create environments where we can both cultivate the strengths of our tradition and interact with other medical providers and systems from a position of strength and knowledge. This will require training for present-day Ayurvedic students in such subjects as Ayurvedic medical history, Sanskrit, classical texts such as the Caraka and Susruta samhitas, and the preserved case histories of past physicians. Then we need to put this knowledge into practice by connecting ourselves with the ongoing lineage of Ayurvedic medical practice, one which has been building through the contributions of generous teachers and scholars for many generations.