Nobel prize, Traditional Chinese Medicine and Lessons for Ayurveda?

Recent days have sprung surprises of sorts for traditional medicine. Extraction of an antimalarial drug using an herb used in Traditional Chinese Medicine (TCM) has been awarded the Nobel Prize for medicine. While closer home, there has been a trail blazing paper on Ayurveda about prakṛti published in Scientific Reports, a journal from the Nature Group.

The Nobel Prize for Medicine this year brought traditional medicine, specifically Chinese Medicine into the limelight. China's Tu Youyou received the coveted award for extracting an anti-malarial drug from a herb mentioned in a traditional text of Chinese Medicine. This text which is dated circa 4^th Century CE mentions the Sweet wormwood (Artemesia annua) to be a treatment for fever.[1]

The award of the Nobel Prize to Youyou has been considered as a triumph for traditional medicine by many. Nobel committee member Hans Forssberg reiterated that: “It's very important that we are not giving a prize to traditional medicine, the award was only for scientific work that had been inspired by it.” This is an acknowledgment that the award was for a scientific work inspired by traditional medicine. This by itself is a testimony to the fact that ancient medical systems can inspire scientific work and are worthy of scientific investigation.

But that doesn’t seem to be the crux of the matter. There are others who lament that the initiative shown by China in the development of Chinese medicine has not been shown by India for Ayurveda. To such naysayers, there is enough evidence on the contrary. One may recall the case of Reserpine, an alkaloid of Rauwolfia serpentina, indicated for insanity in the Suśrutasaṃhitā. Reserpine, isolated during the middle of the 20^th Century, represented a highly important clinical advance in the treatment of schizophrenia. Till then, the pharmacological tools against the disease were limited to chlorpromazine that was introduced into practice two years before Reserpine. Though it did not bring a Nobel Prize in the name of Ayurveda, it made history as a drug that heralded the beginning of the psychopharmacological era.[2] But, we as Ayurveda practitioners need to ask ourselves whether recognition by those who don’t appreciate the fundamentals of Ayurveda is all that we seek. Secondly, we have to ask ourselves whether such an approach which denies the soul of Ayurveda will be effective in the long run.

We need a nuanced approach in drawing our conclusions from the Nobel Prize winning discovery. This significant discovery will prove to be a life saver to numerous malaria patients in the future. The discovery involves successfully isolating an active principle from Artemisia annua. Many such discoveries have happened with Ayurveda providing leads. The leads have led to interesting alkaloids being isolated from many medicinal plants. A few plants which formed sources for interesting alkaloids include Commiphora wightii, Terminalia arjuna, Curcuma longa, and Coleus forskholii. All these alkaloids showed immense promise but could not be translated into effective drugs for human use on a large scale.[3] But Youyou's discovery is significant because Artemisinin-based combination therapy (ACT) is currently considered as the best available treatment for the potentially deadly malaria. Nearly 200 million individuals are affected by Malaria every year. Artemisinin is now routinely used in all Malaria-ridden parts of the world. In combination therapy, artemisinin can reduce mortality by more than 20% overall and by more than 30% in children. This means that more than 100,000 lives are saved annually in malaria ridden areas like Africa.

Artemisinin is not without its problems. It is important to understand that Artemisinin is not recommended to be administered alone. It is administered as part of a combination therapy - Artemisinin Combination Therapy (ACT). The WHO recommends five different variants of ACT. The artemisinin compound reduces the main parasite load within three days of treatment. The partner drug in the combination then eliminates the residual parasites. In those patients who are infected with artemisinin resistant strains, the artemisinin compound cannot kill all the parasites within three days but if a partner drug effective in that geographical region is added, the combination still works in the long term.[4]

Five countries of the Greater Mekong sub region (GMS): Cambodia, the Lao People's Democratic Republic, Myanmar, Thailand and Vietnam have confirmed artemisinin resistant strains of malarial parasites. In the Cambodia-Thailand border, Plasmodium falciparum has become resistant to all antimalarial medicines. It is a real risk that multi drug resistance may emerge in other regions as well.

The discovery of artemisinin from the wormwood plant represents the conventional scientific method of drug discovery, which is inspired by the reductionist framework of modern pharmacology. The single target single molecule equation is the basis of such an approach. Traditional medicine becomes merely the source for the first clues, the leads for drug development. Through phytochemical screening, the active ingredient is identified, isolated and separated to develop a new drug. Such an approach has its advantages and shortcomings, its successes and failures. It is a method for assimilating the empirically established practices of traditional medicine into the framework of modern scientific medicine. This is in stark contrast with the philosophy of traditional systems such as TCM and Ayurveda, which use the principle of combining different herbs to produce synergistic effects.

For the above reasons, we can hear voices of protest emerging from the community of TCM physicians. Rather than being excited about the Nobel Prize for Youyou, TCM practitioners are apprehensive that this may encourage new research on TCM that will sideline the classical holistic approach of TCM. The foundational concepts of TCM are not well understood or accepted by modern scientists as credible. The notion of the life force “qi”; the idea of illness as imbalance of the five elements; the Ying-Yang theory are all brushed aside as pseudo science and to be not amenable to scientific investigation.

It can be further emphasized that complex herbal mixtures are used in TCM. In contrast, Youyou chemically extracted the active ingredient of a single plant in isolation. It is the opinion of many senior and successful TCM practitioners that the Nobel Prize celebrates westernized Chinese medicine. They also feel that such an approach will end up doing more harm than good for authentic traditional medical practice. The China Daily dismissed the view that the Nobel Prize winning research of Youyou was a victory for TCM. It argued that such westernized reforms that conveniently ignore traditional theories will strip TCM of its unique holistic approach to healing.

Medical systems such as TCM and Ayurveda advocate a complex method of developing drugs which works in a diametrically opposite way compared with biomedicine. A drug is developed by combining multiple herbal and non-herbal ingredients together to create what we call in modern parlance as a molecular cocktail. Therefore, what traditional medicine can help to develop is the science of molecular combinatorics, of combining multiple ingredients to make a complete and balanced formulation. It is also pertinent to recall here that Artemisinin also works better in combination rather than isolation.

On the other hand, we also need to take note of an interesting paper published in Scientific Reports from the Nature Group titled “Genome Wide Analysis Correlates with Ayurveda Prakriti”. This paper is the first attempt to classify the prakṛtis using genome-wide Single Nucleotide Polymorphism (SNP) markers and to provide a scientific basis for prakṛti classification.[5]

Out of the total screened, 262 individuals with single prakṛti dominance were selected. Out of this, 94 were vāta-dominant, 75 were pitta-dominant and 93 were kapha-dominant were studied. DNA isolated from their blood samples was subjected to genome-wide analysis using about one million genetic markers (SNPs). Data obtained from this analysis was subjected to statistical analyses that led to the identification of 52 SNPs that are unique to the three prakṛtis (vāta, pitta and kapha) and can differentiate them. The authors have concluded that the concept of prakṛti as elaborated in Ayurveda has a genetic basis. As a result, the study opens a new dimension for personalized medicine. We find this approach, which while trying to evaluate Ayurvedic concepts in the light of science doesn’t deny the soul of Ayurveda, to be a welcome shift.

Tu Youyou's discovery demonstrates what can be harvested from traditional medicine using conventional methods of drug research within the prevalent scientific paradigm. On the other hand the study on prakṛti and genomics demonstrates how investigation into the theoretical foundations of Ayurveda can bring about a conceptual shift in our understanding of older systems of medicine.

A Nobel Prize need not necessarily be a pointer to the right direction for the development of medical systems such as TCM and Ayurveda. Using different conceptual and theoretical frameworks can lead to paradigm shifts in our thinking. It may also lead to a better appreciation of traditional or alternative or complementary medicine.