Quo vadis, Ayurveda?

1. Introduction

Currently, Ayurveda is at the cross roads [1]. On the one hand there is the pull of loyalty to the classical concepts & teachings which have the weight of centuries behind them and the authority of great personages of yore like Charaka, Sushrutha & Vagh Bhata [2]. On the other, there is the clarion call for modernization prompted by the popular clamour for a system based on modern medicine. What is one to do? Should we be unwavering in our loyalty to Ayurveda and refuse to change with the times? Or should we jettison Ayurveda altogether and climb on the bandwagon of so-called Modern Medicine with all its attendant problems?

This paper is an attempt to find answers to these difficult questions, based on data collected from a cross section of Ayurvedic scholars at different levels and some Practitioners. It is by no means the last word on the subject but is merely an effort to kindle thoughts on the subject of Integration.

2. SWOC analysis

2.1. Strengths of Ayurveda

• 1.It is an ancient system based on centuries of experiential evidence in identifying & treating diseases. It is indigenous, conceived & nurtured in our own land and enjoys the goodwill of majority of our people. This is an asset which should not be lost sight of [3].
• 2.It is holistic medicine targeting the restoration of complete health & not merely the treatment of a disease. Its focus is on Health and its preservation by preventive & promotive measures and encouraging a healthy lifestyle in tune with circadian rhythm and seasonal variations.
• 3.It is personalized, even individualized taking into consideration the Dosha(s) predominant in a person and modifying the therapeutic measures accordingly [4].
• 4.It has an important role in chronic diseases like arthritis, backache, paralysis & general weakness.
• 5.It can be home-based care to a large extent, which has proven advantages over institutional care.
• 6.Dietary advice is part & parcel of Ayurvedic armamentarium as Ayurveda recognizes the stellar role of diet in health & disease [5].
• 7.It can be easily combined with Yoga &/or Meditation wherever necessary. Ayurveda, Yoga & Meditation if combined mutually reinforce each other as excellent adjuvants [6].
• 8.If practiced properly, Ayurveda has less side effects of therapy compared to other systems of medicine.
• 9.With appropriate measures, it can be made affordable to the majority of the population.
• 10.Well into the 19th century, 75% of the drugs in British Pharmacopoeia were indigenous to India [2].

2.2. Weaknesses

2.2.1. Physicians

• 1.Mindset of the Ayurvedic Practitioners is the biggest hurdle to integration with modern medicine. While many of them pay only lip service to Ayurveda (see 2 below), some senior Practitioners and teachers have a rigid mindset and truly believe that Ayurveda is complete & comprehensive in all respects and can handle all diseases. They do not accept the germ theory of modern medicine and all other valuable contributions of recent scientific advances. They hold the venerable works of Charaka, Sushruta & Vagh Bhata as the final word in Medical Practice and do not brook any questioning or criticism of the theories enunciated therein. They give these texts the same hallowed place as our scriptures, something beyond the scope of scientific questioning [2]. This mindset goes against the teaching of Charaka who had explicitly stated that “the entire world is a teacher for the wise” [2].
• 2.Most Ayurvedic Doctors of today practice, often very successfully, Allopathic medicine [7]. It is also true that most of them aspired to become MBBS Doctors & could not get the opportunity for one reason or the other. From the beginning they view Ayurveda as second rate & inferior to modern medicine and this continues well & long into their practice. Even while studying in an Ayurvedic College, they spend their evenings learning Allopathy informally. Obviously their loyalty & contribution to Ayurveda leaves much to be desired.
• 3.There is no co-ordination of Ayurvedic practice in different parts of the country, even within a city. They all seem to function in silos not knowing what others are doing. (Cf. co-ordination & regular professional meetings of Allopathic Doctors at various for & various levels (district, state, regional & national.)
• 4.It is unfortunate that Ayurveda is falling an easy prey to the tempting but unhealthy trend in modern medicine and is getting over medicalized. The focus is on the disease & not the patient whereby the chief characteristic of Ayurveda i.e., emphasis on the patient as an individual with a disease is being lost sight of.
• 5.Doctor-Patient relationship, the sheet-anchor of Ayurveda is taking a hit under the influence of Allopathic practitioners. It appears that all the strong points of Ayurveda are yielding place to the temptation of aping the ills of modern medicine.
• 6.Ethics, again greatly emphasized in Ayurveda is being given the go by for commercial considerations. Excessive dependence on lab results, lack of evidence based practice, blatant use of allopathic drugs and over medication are some examples.

2.2.2. Education & training

• 1.At the moment, in India, there are 495 Ayurvedic Colleges including 64 Govt & 377 Private [8]. Their standards vary widely due to a number of reasons. One cannot say with any degree of confidence that any & every graduate form any of these colleges will meet the minimum requisite standards. It is a far cry to expect them to emerge from these colleges with the competence & confidence to treat patients.
• 2.In almost all these colleges, there is no scientific leadership to encourage the students to question what they are learning and subject it to scientific scrutiny. There is no encouragement of research &/or experimentation [9].
• 3.None of the textbooks in use have been standardized. The same text is interpreted differently in different colleges & treatment centers and even different teachers [9]. Just to cite an example, most modern medicine textbooks from Physiology to Internal Medicine have undergone as many as twenty editions in the last fifty years. The same cannot be said for ayurvedic text books.

2.2.3. Research & Development

• 1.Teaching institutions have not laid sufficient emphasis on R&D, which is a sine qua non for any scientific discipline in the modern era [9,11].
• 2.Ayurveda has enunciated so many theories to understand health & disease. There is no concerted effort to test these theories by modern scientific methods. Often, the excuse is given is that Ayurveda is a totally different system and cannot be subjected to modern scientific methods but has to be tested by a different yardstick. This argument is specious and will not pass muster with enlightened public [7, 9, 11].

• 3, Seeking evidence for effectiveness of any modality of Ayurvedic treatment is still not standard practice [7, 9].

• 4.Epidemiological studies of the incidence, prevalence & other aspects of diseases as per Ayurveda are a must for making any kind of progress.

2.2.4. Treatment

• 1.Ayurvedic treatment is often prolonged & is therefore compared unfavourably with modern medicine where most treatment schedules are of a much shorter duration [9,11].
• 2.Treatment of emergencies is the well-known Achilles Heel of Ayurveda. But a standard protocol for recognizing such emergencies which are acknowledged to be beyond the capability of Ayurveda & which need referral elsewhere has not been developed [9,11].
• 3.In day to day practice, patients approach Ayurvedic physician only for certain chronic conditions. There is no awareness of the potential of Ayurveda [11].
• 4.Reputed good Ayurvedic Hospitals are few & far between, though recently some efforts have been made by the Government to start some Institutes of excellence in Ayurveda.

2.2.5. Drugs

• 1.Regulation of Ayurvedic drugs is very unsatisfactory at the moment and has many issues. For example, license to manufacture an Ayurvedic formulation is granted by the State Govt, but once manufactured, it can be sold in many other states. The States where they are sold have poor control over the quality of drugs. The Drug Inspectors have to refer the matter to the authorities in the State where it was manufactured. This is a very unsatisfactory system due to conflicting interests. Similarly, the same formulation manufactured by different Ayurvedic Companies has quantitative & qualitative differences. The Ayurvedic Pharmacopoea of India needs to provide standards like Indian Pharmacopoea.
• 2.Standardisation and quality control of drugs sold in the market by different companies & in different states is lacking.
• 3.Formulations with multiple components are a complex problem for standardization & quality control [9].
• 4.Chemopharmacodynamics of Ayurvedic drugs need to be studied urgently & more extensively [9].
• 5.For a detailed account of the problems listed in this section, please refer to the seminal work on the subject, “The Truth Pill” written by Thakur DS & Reddy PT [10].

2.3. Opportunities

2.3.1. In relation to allopathy

• 1.Accept Integration as the future for both systems. Ayurveda has major problems in providing appropriate treatment in surgical emergencies. This is also true of many medical emergencies like snake bite, acute cardiac failure and so on. Similarly, Modern Medicine has no curative treatment for the predominant lifestyle diseases like diabetes & hypertension. In many chronic neurological conditions, Modern Medicine is of questionable value while Ayurveda can confer benefit to the patient especially by appropriate physiotherapy. Measures to boost the General Immunity is another area where Ayurveda has a positive effect, though more concrete evidence is required. From the foregoing, it is obvious that Ayurveda & Modern Medicine have to have a symbiotic & not antagonistic relationship, if they have to remain relevant. For this, both sides have to accept Integration as the only option in the future.
• 2.Learn from the history & evolution of Allopathy, how it changed rapidly in the last two hundred years from traditional to modern medicine. Even 200 years ago allopathy had a very poor concept of diseases and very primitive armamentarium of drugs but they have not hesitated to change their concepts and armamentarium in the light of emerging scientific evidence.
• 3.Since both systems have weaknesses, there is a golden opportunity to play roles complimentary to each other.
• 4.Avoid the well-known & well-documented pitfalls of Modern Medicine like over-investigation, over-treatment, unnecessary procedures and unaffordable cost.
• 5.Join hands with Allopathy on Public Health Initiatives. Public Health has always had a vital role in promotion of health and prevention of diseases. This is going to be increasingly so in the coming years with the alarming rise of lifestyle diseases. To this add the problem of recurrent pandemics/epidemics like Covid19. In all these areas, where Public Health initiatives have a salutary role, Ayurveda can profit by joining hands with its personnel & resources and contribute to the well being of society.
• 6.Take on such clinical & public health problems which have not been adequately addressed by the Allopathic system [12].

2.3.2. Draw on your strengths

• 1.Lifestyle Modification is an area which has been emphasized by Ayurveda since ancient times. Its time has now arrived with Modern Medicine acknowledging the important role of lifestyle in the current undeclared pandemic of Non-Communicable Diseases (NCD). Ayurveda should claim its rightful place in all public health initiatives advocating lifestyle modification. The emphasis on correct eating and appropriate exercise in Ayurveda is most valuable [6].
• 2.The great strength of Ayurveda is treating the person who has the disease rather than the disease in isolation. This concept, a very welcome one, wherein the treatment is customized to the individual is finding more & more acceptance among patients and is to the advantage of Ayurveda [4].
• 3.The recent COVID19 pandemic which was a challenge for the entire medical profession & humanity as a whole, was able to show the benefits of the Ayurvedic approach. Lessons learnt therein can be used as a template for the future & Ayurveda should be ready with contingency plans for such future epidemics which won't be long in coming [11].
• 4.With their personal rapport with patients, Ayurvedic Physicians can play an important role in primary care of Psychiatric illness, including identification of the problem, initial diagnosis & management with the backup of qualified Psychiatrists who are in short supply and therefore overworked. Even the common garden Insomnia may have effective solutions in Ayurveda [13]. Senile Dementia & Alzheimer's Disease are also fertile areas of further research [14].
• 5.Panchakarma is a modality of treatment with great potential. The indications should be explored & expanded. Many of the patients under Allopathic treatment can benefit from Panchakarma, especially during convalescence & rehabilitation [15].

2.3.3. Research opportunities

“Ayurveda owes its call not to selfish goals or worldly pleasure, but to compassion for fellow beings. In seeking to know my legacy, you have but seen the leaves of a universal tree, too vast for your eyes. May your sight grow and your quest never end” [16].

This is one area where Ayurveda is sitting on a goldmine. There is so much to be done & so few to do it. The following are a few selected areas to indicate some of the topics where Ayurvedic Research is urgently called for.

• 1Interdisciplinary approach, use of modern technology including opportunities with Telemedicine & Artificial Intelligence is the obvious way forward and Ayurvedic Physicians must grab these both hands.
• 2.The core concepts of Ayurveda like Tridosha theory, Naadi Parikshan, Hetu theory and so on need to be questioned, reinvestigated by modern scientific methods, put through the crucible of scientific rigour and the results accepted whatever they may be. There should be no hesitation in challenging age-old theories just because they are age-old. Science does not accept such arguments as these are not “our” methods, these need no validation, these are too sacrosanct to be questioned and so on. Just like other laws of science like the law of gravity, Ohm's law can be verified/proved anywhere on earth, it should be possible to verify Ayurvedic principles by anyone, anywhere. Modern medicine made its remarkable progress only because it had an open liberal mind and was ready to dispassionately throw out old methods and systems proved useless by scientific methods. It continues to do so and evolve even today. It will gladly embrace any Ayurvedic remedy or principle or modality of treatment proved by science.
• 3.Modern medicine claims to be evidence based. To a large extent, this is true. Like any other method, this too has limitations. With all these limitations, it is still the most acceptable system and should be adopted by Ayurveda [17,18]. Scientific validation of not only Ayurvedic drugs but also well-known home remedies like ginger, garlic is the need of the hour.
• 4.Rasayana(Rejuvenation to enhance lifespan) and Vajikarana (Enhancement of sexual potency) are two modalities of Ayurvedic therapy which have been dealt with in detail by both Charaka & Vagbhata. Modern medicine has evinced keen interest in both these areas. There is ample scope for research in these two areas.[19]
• 5.Chemopharmacodynamics of Ayurvedic preparations is a fascinating area for research. Results in this type of research will open the eyes & ears of everyone and probably pave the way to new drugs and formulations, especially antibiotics and cancericidal drugs [19].
• 6.With the basic understanding in Ayurveda from time immemorial that no plant on earth is without medicinal value, there is tremendous research scope in Ayurveda to look for new drugs [19].
• 7.Standardisation and Quality Control of Ayurvedic methods & medications has barely begun. There is tremendous scope for research in these areas [12].

D. Challenges in Popularisation of Ayurveda: In public imagination, there is more of misunderstanding of this system of medicine than of understanding. And the Ayurvedic Practitioners are responsible for this state of affairs. Therefore, there must be concerted efforts to educate the public about the strengths, potential and scope of Ayurveda as also what one can expect and what one cannot expect from Ayurveda. A very important subset of the population is the younger generation viz., students from VIII to XII standard who are at an impressionable age and who have absolutely no idea of Ayurveda. Similarly, Allopathic Medical students should have some exposure to Ayurveda during their student days so that they can overcome their prejudice and antipathy to this system of Medicine.

2.4. Challenges

Challenges are many. Important ones are listed below. However, this is not an exhaustive list.

2.4.1. Issues requiring steps against some ingrained and established problems

• 1.First & foremost is the mindset of the Ayurvedic Physician himself. He has to be open minded, receptive to new ideas, capable of accepting the scientific method as the way forward. If he is rigid in his attitude and thinks that Ayurveda has the answers to all medical problems and nothing can be changed in the old order that will be the end of the road. Curiosity, the rock bed of science and inquisitiveness about the old teachings and newer advances are the sine qua non of progress. Integration with Modern Medicine can be very beneficial [20].
• 2.The second challenge is the silos attitude both within Ayurveda and in relationship with modern medicine. Differences in individual practices, reluctance to share information with others, differences at individual, district and state levels and absence of a robust platform to come together within Ayurveda and similar such platforms to share knowledge with Allopathy are some of the challenges we face in overcoming the silos attitude.
• 3.Unscrupulous elements have already started exploiting Ayurveda, making unscientific claims and swindling gullible public. This erodes the credibility of Ayurveda and brings a bad name to the whole system. This has to be addressed by a Watchdog mechanism created for this purpose.
• 4.Aping Allopathy, the evil of commercialization is rapidly catching up in Ayurveda. Medicines & procedures are recommended without proper indications with a commercial motive. Unless the profession appoints an apex body to standardize treatment guidelines and implement them after arriving at a consensus, this challenge will remain unaddressed and burgeon into a monstrous evil [21].
• 5.Stagnation seems to be another problem faced by Ayurveda. Newer methods of diagnosis, search for new drugs and an effort to reach out to the public at large are urgently required to inject some fresh blood into the system. It is no exaggeration to say newer diagnostic and therapeutic method in ayurveda have not kept pace with other scientific branches.
• 6.Malpractice, prevalent in Allopathy, is already creeping into Ayurveda and needs to be curbed by appropriate measures before it is too late. As mentioned elsewhere, these range from unauthorized practice of allopathy, use of unnecessary medication and lack of emphasis on non-pharmacological aspects of treatment.
• 7.Global (Multi National) Pharmaceutical giants do not tolerate competition and are already taking measures to run down Ayurveda as a system as also specific formulations as dangerous. It is well known & documented that they stop at nothing, cannot be called to accountability by the different Governments and will do anything to protect their market. They are powerful antagonists and will need a well-planned, well supported system to take countermeasures.
• 8.Ayurvedic texts badly need standardization. About a hundred years ago, there was a similar confusion in modern medicine about anatomical nomenclature and a convention sat to decide on universally acceptable names for structures, processes and so on, so that all could speak the same language. This is urgently required in Ayurveda as it appears that the same term in anatomy, physiology or pharmacology means different things to different people. Conversely, same thing is called by different names by different people [9].
• 9.Modern Lifestyle is a tremendous attraction for the present & future generations because of the ease & convenience of fast foods & the irresistible call of a life free from physical exertion. All these come with a price tag of hypertension, diabetes and their inevitable consequences. And added to this package is Stress which aggravates other problems. Ayurveda has to fight against this by advocating a healthy lifestyle which is unpleasant & unwelcome advice. Allopathy faces the same problem and the two systems can come together to fight this menace.
• 10.Already afoot are subtle (and sometimes overt) measures to run down Ayurveda. These have to be identified and countermeasures taken to alleviate the misgivings in the public mind.

Funding

As with all other endeavours, this is always a major challenge. [22] Though there is a silver lining in the form of ongoing and gradually increasing Government support, this should not be taken for granted. To be sustainable, the Government has to be convinced that the funds allotted are being utilized well, fully and in time. Otherwise, it will soon dry up. It is high time Ayurvedic institutions looked for other avenues like private sector and their CSR funds. A lot of detailed homework will be required before they can be convinced to support the effort.

In the field of Research & Development, the Government has already taken a major step in establishing a world-class research establishment among several other measures. There should be many more such across the country, say one in each state, with a central professional body to guide them in areas of research. Without ongoing robust and continuous research, it is impossible to counter the other challenges enumerated in the preceding paragraphs.

We also need funding to establish good Ayurvedic referral hospitals which can treat a large number of patients on a regular basis. These will automatically evolve into research setups also. At the moment we do not have Institutes in Ayurveda of a national stat.

2.4.2. Research & Development

• 1.Though a lot of research is going on in Ayurveda, there needs to be more engagement with the community at large so that their areas of immediate concern are addressed and research will have direct impact on the community and bring benefit to the sufferers (Grassroots approach and not ivory tower.) [23]
• 2.Depending on epidemiology and peculiarities of different geographic regions in the country, research may have to customized to be of use in that area.
• 3.Research Institutions established as suggested above should encourage & attract researchers who are genuinely interested and who are already involved in research in their area of work. Research institutions can become white elephants if not nurtured on merit, monitored on progress and oriented to benefit society at large.
• 4.Getting volunteers for clinical trial is always a big challenge. Ways & means of attracting them without compromising on ethical guidelines have to be worked and standardized.
• 5.A vital area of immediate effort is to establish modern methods and systems of research and also to evolve standard guidelines for treatment of at least common conditions, so that the patient is assured of a certain standard of care regardless of where & by whom he/she is being treated.

2.4.2.1. Challenges needing urgent attention

• 1.A protocol to guide practitioners regarding the management of common medical & surgical emergencies. In this protocol, the capabilities & limitation of Ayurveda in dealing with different emergencies should be brought out without any bias or prejudice. The only criterion should be the maximum & timely relief for the patient.
• 2.Fast acting drugs are a felt need in Ayurveda. While patients get relief in a few minutes from Asprin or Paracetamol or sublingual nitrates, there are no such preparations in Ayurveda. A few proven fast acting remedies will add to credibility & acceptability of Ayurveda.
• 3.Standardisation of drug formulations, treatment protocols and undergraduate/postgraduate curricula across the country is also an urgent challenge.
• 4.Publicity & Marketing is yet another area crying for attention. It needs a dynamic push like Yoga got a few years ago. The scope & potential of this branch of medicine is not fully known to most of the public. On the other hand, there is a lot of misinformation afloat creating confusion and eroding credibility. Apart from general public, special attention should be given to publicity among school students from VIII to XII standards as they are not only the future patrons but also the future practitioners.
• 5.Modern Medicine practitioners and Medical students have a lot of misunderstandings and misgivings about Ayurveda. Ways and means of clearing these is another urgent challenge [24].

3. Discussion

The strengths, weaknesses, opportunities and challenges presented by Ayurveda as perceived by a group of practitioners and researchers have been enumerated above. Obviously this is not an exhaustive list and has many shortcomings. Also, space did not permit a detailed discussion of many of the points listed. Some of them need further elaboration and brainstorming. But the basic thrust of this paper is to emphasise the importance of integration of Ayurveda & Modern Medicine. Some contemplation of these points will make it amply clear that the weaknesses of Ayurveda are the strengths of Allopathy and vice versa. Hence the need for a symbiotic relationship between the two systems and not an antagonistic or apathetic one. It is heartening to note that many Modern Medicine practitioners are beginning to see the benefits of Ayurveda [24].

Each one of the points listed above merit detailed discussion and brainstorming. Broadly speaking, the analysis above shows that the weaknesses of Ayurveda, like poor scientific leadership, lack of emphasis on Research, non-availability of standardised & updated textbooks, paucity of epidemiological study of disease and absence of credible protocol for surgical (& some medical) emergencies are the strengths of Modern Medicine. Similarly, Strengths of Ayurveda like treating the patient as a person with a disease, having a better rapport with the patient, diet & lifestyle advice as part and parcel of treatment and paying attention to the psychological aspects are the weaknesses of Modern Medicine as practiced today.

The pressure on Ayurveda to get into the main stream of modern science and technology is much greater than on Modern Medicine to adapt Ayurveda (R56). It is therefore for urgent consideration to seize the opportunities, capitalize on strengths, acknowledge the weaknesses and face the challenges from the individual all the way up to the national & international levels.

A lot of commendable work is already going on in this direction, too numerous to be enumerated. But a lot more need to be done. And prioritization is very important to understand the order in which the challenges have to be taken up. National Task Forces apart, everyone connected with Ayurveda must get involved to achieve tangible results. And such an effort needs to be well-coordinated so that duplication and waste are avoided.

As already brought about, the mindset of practitioners on both sides of the divide is the biggest psychological impediment and will require a nuanced approach to get all on board.

4. Conclusion

Integration of Ayurveda and Modern Medicine is inevitable and vital to preserve the best in each field for the ultimate benefit of the patient who is the undisputed center of the physician's universe regardless of their differences in their approach & methods. Proceeding from this, there is a tremendous amount of hard work ahead of all the stakeholders. Starting with the mindset and going up to all areas indicated above, urgent well-coordinated efforts at multiple levels is the need of the hour. Will Ayurveda take up the challenge and do the necessary course correction? Quo vadis, Ayurveda?

Funding Sources

None.

Author contribution

The author was solely responsible for conceptualization, drafting and revising the manuscript.

Declaration of generative AI

None used.

Conflict of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.