Brhat | Integrative Medicine: The Confusion Compounded

7. The Incommensurability of Paradigms
Note: Read Part One Here

This section concludes with “These factors likely contribute to the critique of Āyurveda as a non-falsifiable belief system rather than as a knowledge system open to 'scientific' inquiry”. This sweeping statement is untenable. The fact that conceptually rich frameworks remained within the scope of scientific enquiry—rather than outside it—while the technological and methodological capacity to test them decisively emerged much later, is evident across multiple fields. For example, in medicine, the germ theory of disease was initially considered speculative and had to compete with the empirically entrenched miasma theory from the times of ancient Greece. However, this was only until mid-19th-century advances in microbiology allowed germ theory to gain decisive empirical support. It is pertinent to note that Āyurveda had spoken of sūkṣmajīvāṇu/krimi as parasites, worms, and microbes (microorganisms) that cause disease, encompassing both visible and invisible pathogens affecting the body internally and externally, over two millennia ago. Similarly, for most of the 20th century, peptic ulcers were attributed only to stress and acid, until endoscopy, better culture techniques, and trials established H.pylori infection to underly most peptic ulcer disease — retroactively validating a theory that earlier medicine lacked the tools and conceptual framework to prove through experiment. Again, it is pertinent to note that firstly, Āyurveda śāstras have attributed disease to different types of krimis as early as the Caraka Saṃhitā[7] (300 BCE) and śleṣmaja krimi (corelatable to H.pylori; originating from ajīrṇa–pūti–klinna–saṅkīrṇa bhojana), causing pariṇma śla (closely mirroring peptic ulcer disease). These examples illustrate that not only was Āyurveda two millennia ahead of other medical systems of the world, but Āyurveda-based hypotheses are testable, though not necessarily with a flawed, externally imposed DBRCT test methodology.

Furthermore, in the case of Āyurveda, while tridoṣas and triguṇas may not be directly measurable, but there are other mensurable parameters that are accessible and amenable to modern experimentation and observation. In fact, at centers of excellence in Āyurveda cikitsā, the scientific process can be seen applied in the treatment of every patient, including structured approach to patient intake, diagnoses, plan of care, provision of care, and comprehensive capture of general, disease-specific and safety biomarkers, imaging reports, international outcome scales, physician’s outcome scales, functional health reports and patient-reported-outcomes.

Dr. Pingali further states:

“Āyurvedic texts delineate three sources of knowledge: pratyakṣa (direct perception), anumāna (inference), and āptopadeśa (the teachings of an āpta or authority). Concerning the latter, the highest authority is the Veda, which, in most Indian schools, is regarded as apauruṣeya (non-human origin). As a result, the foundational principles (ontology) and methodologies for acquiring knowledge (epistemology) differ markedly between Āyurveda and modern medicine. While the first two sources of knowledge are generally uncontroversial, the third source (āptopadeśa) and the fundamental ontology (consciousness as primary; mind-matter as secondary) are not derived from empirical observation but are viewed as revealed knowledge. In other words, only a qualified authority or an āpta can impart the theory of tridoṣa, its characteristics, the causal links, and the existence of metaphysical entities such as the soul and the mind. Nonetheless, direct observation and logic must be employed when diagnosing and developing a treatment protocol for a patient.”

The definition/interpretation of āptopadeśa by Dr. Pingali is restrictive. In addition to what he has said, āgama pramāṇa or sāstrā is also considered to be āptopadeśa, not to mention and include aitihya. Āgama is defined as sāstrā or science preached by the āpta that can be validated or proved with the help of pratyakṣa pramāṇa, and that which is universally applicable; it gives the true meaning or essence of the science. To assess the authenticity of any sāstrā, 18 criteria for the examination of texts are described.

As regards epistemology, in addition to the three pramāṇas mentioned above, it includes a fourth one: yukti (rational, logical, judicious integration of information from the preceding three pramāṇas). This is an extremely systematic process and has been superficially treated with a reductionistic statement that “direct observation and logic must be employed when diagnosing and developing a treatment protocol for a patient”.

Āptopadeśa pramāna with the help of pratyakṣa, anumāna and yukti, can be applied in the examination and treatment of diseases with 15 criteria enumerated: Roga- disease condition, Prakopana- vitiation of dośa, Yoni- etiology of (prakopana) vitiation of dośa, Utthāna- onset of disease, Ātmānam- cardinal signs and symptoms of dośa, Adhiṣṭhāna- site of occurrence of disease, Vedana- sign and symptoms, Saṃsthāna- location of the origin of vitiation like stomach (āmaśaya), intestine (pakvaśaya), other internal organs (avayava viśeṣaa) or micro-channels of the body (sūkṣma srotas), śabda, sparṣa, rūpa, rasa, gandha- the function and pathology of senses, Upadrava- complications, Vṛddhi, sthāna, kṣaya- the increased, balanced or decreased state of doṣa, Udarka- prognosis, Nāma- nomenclature of disease, Pravṛtti- indicated treatment, Nivṛtti-contraindicated treatment.

Further, Dr. Pingali says that, “Therefore, studying Āyurveda as an independent discipline, detached from the broader Saṃskṛta corpus encompassing mind and spirituality, undermines a more holistic understanding of Indian medicine”.

Dr. Pingali will be happy to realise that students of Āyurveda are indeed taught the foundational siddhāntās, including the metaphysical principles on which Āyurveda is based. Padārtha Vijñāna, Vaidyakīya Subhāṣita Sāhitya, Patañjala Sūtra, Raghuvamṣa, and the Ṣad Darśanas are introduced as foundational learning material for every BAMS student.

In short, Dr. Pingali is selective in reference and ignores the vast body of published texts on Āyurveda, wherein systematic clinical assessment, diagnostic process, and systematic determination of a personalized medical/health management plan are outlined. Also, the large number of research publications is overlooked. To summarily dismiss Āyurveda as a non-falsifiable belief system does a gross injustice to Āyurveda śāstras and to contemporary practice. Even in the case of the tridoṣas, defining prakṛti types with explicit phenotypic and physiological profiles and then testing associations prospectively is possible. Further, in the case of testing treatment efficacy and safety, controlled experiments can be, and are being conducted for homogenous clusters with a cluster-specific intervention. It is just that the treatment intervention is not a single chemical entity/molecule but a cikitsā package. In the next three to five years, robust evidence is likely to emerge for Āyurveda as a treatment of choice for select medical conditions. What constitutes robust evidence may, however, undergo some change.

Āyurveda cikitsālayas have been accredited not only by NABH, QAI, and ISO but also audited under the USA’s JCI standard. Dr. Pingali, in restrictively attributing metaphysical character to Āyurveda, displays a lack of exposure to the real, contemporary world of precision Āyurveda cikitsā that not only abides by āptopadeśa but is also consistent with (and in many cases ahead of) contemporary medical care standards.

8. Ontology, Epistemology, and Consciousness in Western and Indian Philosophies

This section is mostly irrelevant to the topic at hand. Furthermore, it makes several questionable assertions, which may be ignored since any relevance is tangential.

9. Yoga

Once again, this section is mostly irrelevant to the topic at hand, although Yoga and Āyurveda are sister disciplines that both draw their conceptual origins from Sāṃkhya Darśana. In the last paragraph of this section, by bringing in concepts such as multi-life and rebirth, the author seeks to place Āyurveda above conventional testing/evaluation as a sacred, metaphysical science — which it is not.

. Surgery and Anaesthesia: Challenging Questions

This section is meandering and at times, self-contradictory. It begins with the thesis that contemporary surgery requires “training, apprenticeship, accreditation, and advancements in areas such as antimicrobials, diagnostics, imaging, and anaesthesia” and simultaneously avers “it is noteworthy that, on numerous occasions, non-qualified personnel in the operating theatre can perform remarkably well—sometimes even surpassing qualified surgeons—in both open and minimally invasive techniques”.

It suggests that Āyurvedic surgeons may be capable of the ‘how’ of surgery but not the ‘when’ and ‘when-not’. It would have been more accurate to say that Āyurvedic surgeons are not likely to be capable of all three without adequate training being provided.

The NCISM (National Council of Indian Systems of Medicine) has notified the restricted list of surgical and para-surgical procedures[8] that qualified MS(Shalya Tantra) post-graduate Āyurvedic doctors are licensed to perform. Health being a state subject, there are different regimes in place permitting Āyurvedic doctors to do more or less than what an Allopathic surgeon is licensed to do. Āyurveda scores over allopathy in treating ano-rectal and urological disorders, non-healing wounds of different types, conservative pain management, etc. This is in addition to specific Āyurveda para-surgical procedures in eye care (Śālākya Tantra), and women’s health (Strī Roga evam Prasūti Tantra).

Further, on one hand, Dr. Pingali says that there is ‘no harm in training Āyurvedic doctors in surgical skills and BHU offers PG surgical courses’, and on the other hand, states ‘however, very few patients would approach an Āyurvedic surgeon today for their operative needs’. A majority of Āyurveda colleges with PG programs include śalyatantra in their programs, with a large number of Āyurvedic surgeons being successful in Āyurvedic surgical practice across India.

This author concurs with Dr. Pingali that modern surgery has advanced to a level that Āyurveda should not try to duplicate without adequate training, privileges, and access to necessary equipment/ therapeutic inputs. Patient safety is of paramount importance and must not be compromised. Āyurvedic doctors have enough of an open field in healthcare without attempting to duplicate the ill effects of what is being well done by their peers in allopathic surgery. Āyurvedic surgical practice should focus on areas of relative advantage, yet utilising modern technological advances to enhance the safety and efficacy of the core Āyurveda service. This is not mixopathy.

11. Integration, Symbiosis, Assimilation, or Absorption: How do the Twain Meet?

This section is based on a 2017 paper ‘Āyurveda for Revitalising Healthcare in India’ by P. L. T. Girija, T. M Mukundan, and M. D Srinivas. While a review of this 138-page paper is not within the scope of this article, the principal suggestions/ observations made in this paper are as follows:

Budgetary provisions for Āyurveda should be made 1% of GDP by 2025.
Promote healthy interaction between BAMS and MBBS students
Government hospitals and primary health care centers should ideally incorporate all branches of Āyurveda alongside their counterparts in modern Western medicine.
Improvements to be made in the Āyurveda syllabus and curriculum.
“The National Health Policy of 2017 scarcely acknowledges Āyurveda, oblivious to the significant manpower and resources within the Āyurvedic system…”.

Suggestion 1 is ideal but impractical and unlikely to happen. As it is, MoAyush is unable to fully spend its annual budget, with actual expenditure falling short of both the initial Budget Estimates (BE) and the Revised Estimates (RE) over the last several years. No one can disagree with the next 3 suggestions. Observation 5 is incorrect: the NHP 2017 is a fine document enunciating a clear, pluralistic health framework with Ayush’s complementary role in preventive, promotive, curative, palliative, and rehabilitative healthcare services by synergistically leveraging the role and reach of Ayush systems of medicine [9]. It is another matter that the vision has not been adequately translated into programs on the ground.

This section does not address the elephant in the room: what is the true nature of integration, if at all that is possible? Integrative medicine considers interventions from one or more systems of medicine in case of multimorbidity, depending on the stage of the disease, referral for differential diagnosis, adjuvant care, precision Āyurveda therapies (leveraging modern technology), functional health (sleep, bowels, state of mind, vitality, appetite, digestion, etc.), rehabilitation (cancer, neurodegenerative, cardiac, pulmonary, etc.) convalescent care, geriatric care etc. All use cases are aligned with the highest principles of patient-centric care. While Western medicine (USA specifically) presupposes a central and primary role for Allopathy, and only a secondary, supportive role for complementary systems of medicine, it is high time that an India-specific definition of integrative medicine is articulated, wherein Allopathy and Āyurveda play primary-secondary roles interchangeably depending on the patient-disease context.

12. Concluding Remarks of Dr. Pingali

Dr. Pingali supports the recitation of the Cāraka Śapatha, correctly calling out the colonial mindset that opposes this practice in lieu of the Hippocratic Oath, although both are deemed non-binding and inadequate in today’s complex medical field. An oath must be differentiated from a code of conduct, but this debate is peripheral to the issue.

His asseveration that “Knowledge is an attribute of the ātman, and it is always a first-person account… the tridoṣa of Āyurveda is to be understood only through the first-person, which is what nyāya enables us to do” is incorrect. Āyurveda does not restrict understanding of tridoṣa only to a first-person account. It explicitly integrates external observation (sparśana, darśana, praśna), physiological signs, and inference from patterns, over time.

He continues, “Āyurveda ought not to be evaluated through the lens of modern medicine, nor does it require validation from Western sources”. There should be absolutely no objection to demanding robust evidence from Āyurveda — and whether such evidence is Western or not is immaterial. What should matter is whether the evidence is derived from a systematic experimental study that is statistically significant and reproducible.

Dr. Pingali concludes, “The current BAMS curriculum requires significant improvements; however, the proposal to merge BAMS and MBBS into a single program is untenable and would result in considerable injustice to both fields. There is an urgent need to bring together genuinely concerned experts in Indian philosophy, Āyurveda, and modern medicine to forge a better path forward. National pride about Indian heritage without understanding the philosophical foundations of Indian civilization is certainly not the solution”.

No sensible person would encourage a rash integration of two distinct medical systems and their educational curriculum. This has nothing to do with national pride or ‘philosophical foundations of Indian civilisation’ but a pragmatic assessment of what afflicts Indian healthcare and indeed health systems across the world. Unfortunately, it appears that Dr. Pingali has opined on Āyurveda without understanding first-hand the scope or capacity of Āyurveda to effectively treat a range of complex medical conditions or of its clear potential to fill critical gaps in Indian healthcare. This has led to an untenable 48% out-of-pocket expenditure, notwithstanding ABPMJAY, particularly in primal, primary prevention, in rehabilitative/ promotive care, and in secondary prevention of complex NCDs compounded by multimorbidity. While Dr. Pingali has his heart in the right place, his understanding of Āyurveda and the potential to appropriately integrate medicine is not right, leading to ambiguous and often erroneous commentary.

To conclude, it would be wise for Indian policy makers to commit to responsible, ethical, integrative medicine wherein clinicians from one or more systems collaborate and work together, under one roof or through a referral process, to render medical care from whichever system that is best suited to the patient's unique health status (rogi-roga avasthā). A seamless, protocol-based collaboration; not mixopathy. India can take the lead globally in this regard, leading to a more affordable and viable healthcare system (for individuals, families, the state, and the nation) across the patient's life cycle that is accessible to every Indian. Appropriate and judicious integrative healthcare is not an option; it is an imperative for India. This does not imply that medical education must be integrated across the board. In fact, this author does not support this step at an undergraduate level and has suggested a pragmatic, staged approach to integrated curriculum design. It can and should progressively be considered for select medical specialties/sub-specialties at the post-graduate level.

Medical practice must be integrative in intent and should not be held hostage to viewpoints emanating from incomplete understanding. A clear articulation of what constitutes an Indian definition of integrative medicine is necessary and urgent. Work in this direction is currently underway.