Brhat | Integrative Medicine: The Confusion Compounded

I refer to the recent article The Mixing of Āyurveda and Allopathy: Holistic or Dangerous? by Dr. Gopal Pingali on Brhat, in two parts. The subtitle reads, for Part 1, as “The mixing of allopathy and Āyurveda (MBBS-BAMS) into a single curriculum spells disaster for both“ and for Part Two as “Āyurveda and Allopathy work for health and disease, but the differing underlying paradigms prevent an indiscriminate mixing”. The primary error that the article makes is that it conflates the integration of two disparate curricula with the integration of two disparate medical/health systems. Dr. Pingali is indiscriminate in how his arguments in favour or against either or both premises are mixed up, and in the process, does justice to neither (referred to as ‘mixed theses’ going forward). The subtitle of part one is sensationalist and unrepresentative of the contents, while that of part two is a truism— who would indulge in ‘indiscriminate’ mixing? Furthermore, the article does not attempt to define what constitutes integrated medicine or integrative medicine, the status of integrative medicine globally, or how one may approach the subject of bringing together the seemingly disparate systems of medicine. Ultimately, it ends up confounding multiple strands of thinking and confusing the reader.

It is appropriate for this author to acknowledge ab initio that he is not in favour of the indiscriminate mixing of Āyurveda and Allopathy into a unified undergraduate curriculum, though it should be selectively considered at the post-graduate level and beyond, and he has clearly opined as much in earlier writings[1]. However, this author is a strong advocate of integrative care, wherein clinicians from different systems of medicine collaborate in real time or otherwise to provide personalized care at a whole-person level.

The key arguments that Dr. Pingali poses in his two-part article are below, in the order stated, with my comments in italics:

1. “There are significant challenges in designing a combined curriculum and securing international recognition for such degrees….However, is such a combination feasible or even desirable?” The answer, in a single word, is no. The primary reason for such an arrangement is the incommensurability of paradigms, and the most unfortunate consequence is the injustice it inflicts upon both systems.”

Securing international recognition for a degree cannot be the basis for the validity of a combined curriculum or that of an Indian degree. An MBBS/MD degree holder from India must still clear additional qualifying examinations in most foreign countries before being permitted to practice. We need to concern ourselves with what is good for India and Indians. Furthermore, feasibility and desirability are two different points of contention, and Dr. Pingali summarily concludes with a vocal ‘no’ to both, attributing it to ‘incommensurability of paradigms’. It appears, from his summary rejection, that Dr. Pingali’s erroneous presumption is that an integrative approach necessarily implies a single doctor prescribing a unified package of Āyurveda and Allopathy-based medicines or care at the same time for the same medical objective. However, the following alternative scenarios are worth due consideration: two doctors (from the same or different systems of medicine) may prescribe, for a given patient, medications for two different medical objectives (say, hypertension and joint pain) or for a primary and (not directly related) subsidiary objective (say, hypertension and constipation/sleep). It could also be a particular disease at different stages or levels of severity: preventive, chronic, acute-on-chronic, emergency, rehabilitation, survivorship, or end-of-life-care, managed by clinicians from one or more medical systems. It could be symptomatic relief for an acute condition, followed by the reversal of the root cause of a disease. It could be conservative management (Āyurveda) or more invasive management (Allopathy), depending on the unique patient-disease combination. A high-impact use case for integrative care (Āyurveda and Allopathy) is in primary health settings for patients being triaged in order to make a decision on referral to a higher centre or management with symptom alleviation. At higher levels of care, each system can deliver care based on patient preference and evidence-based clinical pathways. What integrative care can offer shall differ in each case.

While it is true that the paradigms are starkly different, they share a common stage—the human body and its physical and physiological responses to different stimuli. What an integrative medical education is intended to foster is an integrative mindset: primarily, the ability to understand where a clinician from another system of medicine is coming from, and, secondly, to be abreast of relevant foundational concepts and knowledge of another medical system of relevance. The integrative mindset shall enable doctors to engage with each other more effectively to arrive at a consensus on what is in a patient’s best interests at a whole-person level, in the short term and in the longer term. Neither system has all the answers; together, they perhaps serve patients better. In fact, a term such as ‘co-managed care’ bridges the (erroneously) perceived chasm of integration.

On the matter of an integrated curriculum, therefore, at an undergraduate level for anatomy, physiology, pharmacology, biochemistry, and other foundational subjects, there canand must be a shared core curriculum. Further, MBBS graduates shall be enriched with an orientation capsule of the fundamentals of Āyurveda, including cikitsā concepts, pancakarma basics, and Āyurvedic nutrition and dietetics relevant to their practice. Both sides should learn key safety aspects, including inclusion-exclusion criteria for management in their respective systems, and referral criteria to refer patients to the other. This shall lead to responsible and ethical patient management. Beyond some overlap in the curricula, the two systems need not unify at the undergraduate level, i.e., it does not make sense and will be nearly impossible to conceive an integrated MBBS-BAMS course that does not compromise either system of medicine, both training and practice. Such integration is not just unnecessary but fallacious. However, at the post-graduate, specialty, and super-specialty level, an integrative approach to education becomes much more feasible (as in the scenarios enumerated above), and targeted curriculum design can be achieved, particularly in non-surgical, clinical specialties. This would be a pragmatic approach to integration.

2. “Drug interactions present a complex issue; in poly-drug therapy involving both systems, there is scant research, necessitating a fresh start.”

This statement is incongruously placed in the middle of a larger statement as a cornerstone of the thesis against integration. The erroneous presumption referred to in the previous paragraph applies to this point as well. Further, the author conveniently ignores the huge prevalence of polydrug therapy prevalent in Allopathy as a standalone system, and the fact that the real-world impact of drug-drug interaction electronic alert systems on clinical outcomes and evidence for direct improvement in reduced hospitalizations or mortality remains limited [2]. Polypharmacy and drug-drug interaction (allopathy-allopathy, Āyurveda-Āyurveda, allopathy-Āyurveda) is a reality that should not be ignored and must be systematically studied, and safeguards must proactively be instituted. However, that cannot be the basis for summary rejection of an integrative approach without evaluating systematic means to mitigate the risk of drug-drug interaction.

3. “Āyurveda: A Note”

The tenor of the passage is intended to be factual, with partial and selective enumeration of a few characteristic features. It acknowledges “Despite differing guiding principles, Āyurveda as a medical system engages deeply with physiology, anatomy, and observational studies of diseases”. However, it does a disservice to Āyurveda by making imprecise, broad-brush statements. One example in this section is: “Contemporary Āyurveda, however, adopts a systems approach, suggesting that a pure chemical may not be effective unless combined with other known and unknown substances”. It is not clear what this is trying to convey: is it that a systems approach and combination of chemicals are inconsistent with each other? Additionally, it is inaccurate: Āyurveda’s systems approach does not preclude the possibility of a pure chemical (such as Gandhaka Rasāyana, Sphaṭika Bhasma, etc.) or single herb-based products (such as Āmalakī Rasāyana, Citraka Rasāyana) being used in therapeutic intervention. The different anupāna or media used for consuming the medicine (such as hot water, honey, milk, butter milk, etc.) differ according to disease state, place, and time, and are intended to enhance palatability, bioavailability, absorption, and the ultimate therapeutic effect. However, the anupāna is not considered to be an integral part of the medicine itself.

4. “Dharampal, the British Records, and Colonial Consciousness”

This section concludes with “The well-established and highly effective Indian inoculation practice remains a blip in the history of Indian medicine and the consciousness of most Indians.”

While this section and comment are well-intentioned and seek to reinstate the relevance and validity of Indian medicine, they have nothing to do with the main (mixed) thesis of the article.

5. Traditional and Modern Sciences: The Work of René Guénon

The philosophy of science is a complex topic with many dimensions of enquiry. The unfortunate generalization in this section is that, it attempts to distinguish between the ‘profane’ and the ‘sacred’ sciences, with contrasting dyads such as ‘temporary hypotheses’ versus ‘intuitive metaphysical truths’, ‘theory-ladenness (sic) of observation’ versus ‘experimental investigations strictly within the confines of higher knowledge’, and so on, positing two ostensibly watertight compartments. It does a gross disservice to the evolved knowledge system that is Āyurveda, which is built not only on divine revelation but keen observation of nature and its constituent entities in toto, and their dynamic interaction at microcosmic, macrocosmic levels, including from an energy perspective. The author’s claim that “traditional sciences represent the undeniable outcomes of intuitive metaphysical truths” is a broad-brush statement. The gargantuan, refined corpus of observation and experience of the human condition in physical-mental-spiritual dimensions cast into a highly structured knowledge framework that underlies all vedas, including Āyurveda, should not be ignored. Revealed knowledge and knowledge from systematic observation and trial (upaśaya-anupaśaya) coexist in the vase of Āyurveda.

Āyurveda, by its very nature, is integrative, wherein an allopathic drug can be studied as a dravya and allopathic procedures such as surgeries, transplants, etc., and diagnostics may be understood as specialized sub-branches of Āyurveda. Āyurveda originally had eight specialties, viz, Kāya Cikitsa (Internal Medicine), Śalya Tantra (Surgery), Ślākya Tantra (ENT/Ophthalmology), Kaumāra Bhṛtya (Pediatrics), Agada Tantra (Toxicology), Prasūti Tantra & Strī Roga (Obstetrics and Gynecology), Bhūtavidyā/Graha Cikitsa (Psychiatry/Spiritual Healing), Rasāyana (Geriatrics/Rejuvenation), and Vājīkarana (Aphrodisiacs/Fertility).

Today, there are a total of 22 specialties in which MD(Ayurveda) or Ayurveda Vachaspati (15) and MS (Ayurveda) or Ayurveda Dhanvantri (7) degrees are awarded.

NIMHANS, Bengaluru, has a full-fledged Department of Integrative Medicine. It offers doctoral programs in neurophysiology and post-doctoral fellowships in multiple areas to MD(Ayurveda) doctors. Furthermore, it offers a full MD(Ayurveda) program[3]. Medvarsity from the Apollo Hospitals group has recently launched a 1-year Fellowship in Integrative Oncology open to Āyurveda and Allopathy doctors[4].

6. Science versus Metaphysics

This is a completely unnecessary battle in the context of Āyurveda. Let us consider a general definition of science[5] as “Knowledge or a system of knowledge covering general truths or the operation of general laws especially as obtained and tested through scientific method (involving the recognition and formulation of a problem, the collection of data through observation and experiment, and the formulation and testing of hypotheses)”. Āyurveda fulfills this definition based on its system of knowledge and the nature of intervention.

In this context, it is also pertinent to share what conventional modern pharmaceutical science has achieved, or more precisely, not achieved, as delineated in the following graphic from an article[6] in Nature, 2015.

Schork, N. Personalized medicine: Time for one-person trials. Nature 520, 609–611 (2015). — Schork, N. Personalized medicine:
Time for one-person trials.
Nature 520, 609–611 (2015).

This article calls for ‘one-person’ trials questioning the scientific validity of the prevalent, gold-standard ‘double-blind randomized clinical trial’ (DBRCT) research methodology, which has led to gross ineffectiveness and increased risk associated with modern pharmaceutical drugs, since it primarily measures symptom reduction and not disease reversal. A singular definition of what constitutes science in medicine reflects territorial protection rather than the merit of scientific/logical argument.

To add insult to injury, applying a standard of ‘science’ to Āyurveda, which is intrinsically not amenable to this methodology since it is a ‘bundle therapy’ of personalized diet-lifestyle-medicine (one or more medicines, and each medicine potentially being polyherbal in origin) and therapy (external and internal, deep system cleansing) regimen. Āyurveda clearly distinguishes between the two generic clinical outcomes as roga śamana (disease-symptom alleviation) and roga nivṛtti (disease reversal on a sustained basis), the latter being defined as reversal of the aetiopathogenesis at the systemic level. Building evidence for the latter is more complex than the mere suppression/reduction of symptoms. The Western-imposed definition of DBRCT, sweetly swallowed by many Indians, imposes a framework on Āyurveda that is intrinsically impossible to comply with. Assessing a passage in Sanskrit using the rules of English grammar is not only futile but foolish.

Āyurveda requires its own robust research frameworks, and in the next three years, the efforts of many committed Āyurveda researchers will bear fruit with the presentation of credible evidence to the world.

Rather than impute metaphysical attributes to Āyurveda, it would be more appropriate to recognize Āyurveda as a rational, systematic, personalized approach to disease reversal and sustained wellbeing. Āyurveda is a science in its classical sense, and it also transcends the definition by virtue of its philosophical and metaphysical view of life and nature, a foundational tenet of most Indian systems of knowledge. There is no contradiction.

Note: Read Part Two Here.