Tuesday, September 1, 2015

Notes on Ayurveda in Nepal and India

Observing an ayurveda session in New Delhi, India (Sept. 2012)
by Gideon Lasco, MD

LEH, JAMMU AND KASHMIR - The first step in anthropology is a step back. A dinner conversation becomes a form of ethnographic data-gathering when you cease participating in it solely, but also begin to observe. Sometimes, the problem in “stepping back” is being unable to step in again, and anthropologists are often observers of their own lives, more than those of others. On the other hand, whenever I am traveling, I find the anthropologist's perspective very useful. I am reminded of a friend of mine who is a hiker and a birdwatcher; she says that since the mountains are full of birds, she has no problems in joining my hiking trips; she can also do “incidental birdwatching”, as long as I don't mind her occasional stops.

Perhaps, traveling is much an enabler of anthropology as mountains are of birdwatching, only that I should also slow down a bit. Then, incidental anthropology can contribute as much to my understanding as a deliberate one.

This is how it has been in our field trip, where my classmates and I went to New Delhi to learn about Ayurveda. There were only three days scheduled for the actual “exposure” to Ayurveda, which consisted of meeting with private and public institutions of Ayurvedic medicine. However, I spent three weeks in India and Nepal, and my encounters with Indians of all walks of life broadened my perspective about Ayurveda.

The first South Asian city I visited was Kathmandu. I arranged for a meeting with the Fiipino community there, which mainly consisted of wives of Nepalese men. After exchanging pleasantries and receiving the plea for daing (dried fish) which they sorely miss, I had the chance to ask them about life in Hindi culture. They introduced some realities to me about Hindu culture, particularly the caste system. As daughters-in-law, their sorry role is to cook the food for the entire clan, because servants, being of a different caste, are forbidden to prepare or cook their masters' food. t is also very interesting how the women bring their own beliefs with them. In advising us to visit the Hindi temple called Pashupatinaph where cremations are routinely done, she warned us not to look at the priests, which had a powerful gaze that is sure to cause usog.

What do they do when a member of the family gets sick? Just like in the Philippines, Western medicine is at hand. When I asked about Ayurveda, one of them responded:
Yung Ayurveda, para 'yang kung sa atin, yung mga albularyo, pero sa kanila, big-time. May sarili silang ospital...pero meron din namang mga dyan lang sa tabi-tabi. Effective din daw pero kami, dun kami nagpapatingin sa doktor na parang sa atin lang... (Ayurveda, it's like what we have – the traditional healers – but to them, it's 'big time'. They have their own hospital, though there are also those that you can just find in the corner. They say it's effective but for us, we jus consult the regular doctor, just like in our [country])

Another adds:
Ayurveda kung tawagin, para yun sa mga sakit na hindi mapagaling ng mga doktor, yung mga malala na. Mas maganda daw ang pakiramdam. (What they call Ayerveda...it's for those who have illnesses that couldn't be treated by doctors, those which are already severe. They say that the feeling is good.) 

After our conversation, I tried to look at how the caste system has affected Ayurveda, but I was not able to get specifics. Many writers have written about the caste system as a “historical inequity” but apparently, in Ayurveda this was never a problem. Perhaps this is because this particular health system has co-evolved with Hindu society throughout the centuries.

In Kathmandu, there are several big hospitals, including a heart center, but you could also see Ayurvedic hospitals, clinics, and “chemists”, not to mention occasional advertisements for Tibetean medicine. It would become a foreshadowing of what I would see in India: medical pluralism.

***

ARRIVING IN New Delhi, I saw many more of the 'chemists'. Some sell exclusively  Western pharmaceuticals – at much cheaper prices (I bought two rounds of Azithromycin treatment, at P10/tablet). Other chemists sold both Western and Ayurvedic products, while still others focused primarily on Ayurveda.

After Taj Mahal and the inevitable gems and carpets that were peddled to us, we reached the highlight of our trip: visits to private and public institutions of Ayurveda.

On our first day, we went to a private Ayurvedic hospital – the Delhi branch of a chain of hospitals that from Kottakal, in Kerala. Our host was a scion of the Varier faimily, whose patriarch P. S. Varier established the first Ayurvedic hospital in 1902.

His office was just like any other MD in the Philippines: Framed diplomas, bookshelves full of medical textbooks, elegant interior design. He also wore a white coat, and  a stethoscope hung prominently on a rack beside his table. Perhaps the only thing that would not be found on a Filipino physician's office was a portrait of Dhavantari, the “god of Ayurveda”.

The way he talked was very physician-like: affable, congenial, and knowledgeable. He deftly answered the question of Dr. Gueco, a nephrologist, about side effects, invoking pharmacologic concepts of lethal dose and therapeutic index. Hand-in-hand with his knowledge of Western medicine was his eloquent exposition of Ayurveda, from its history, its eight specialties, and so on.

His manner and conduct; his personality, and his office – very Western, and yet, avowedly Ayurvedic, symbolizes and shows how Ayurvedic medicine try to achieve a “double legitimacy” of their heath care system but applying (or borrowing) scientific (i.e. biomedical) methods of validation. My classmates (and myself) were visibly impressed by this kind of proficiency and fluency in the language of medicine.


The next day, our meeting with the AYUSH Council (Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homeopathy Council) affirms what I observed in the private hospital: there is a conscious effort to present Ayurveda as professionalized and modern (i.e. Western). There is no mention of the Hindu religion, nor of the mantras that are required to make the therapy a success – a requisite act in traditional Ayurvedic practice. Instead, 14 successful randomized clinical trials on medicinal plants were presented, together with the curriculum for Ayurvedic medicine that is identical to that of Western medicine, including lessons in anatomy and physiology (side by side with “Ayurvedic literature”).

We see, thus, that the medical pluralism of India, elements that fortify the position of the dominant health system (i.e. biomedicine) are borrowed by the other health systems to strengthen their own validity and credibility. The less flattering (at least to the eyes of observers) aspects of Ayurveda, like the prayers, and the side effects of therapy using metals, were glossed over.

Moreover, there is an awareness that whatever Ayurveda is, it must fit within the larger picture of health care in India and elsewhere. Instead of being packaged as a health system that can take care of everything, its exponents highlight its strengths in focused areas, such as chronic illnesses, specifically psoriasis and rheumatism, as well as preventive care, and palliative care. The AYUSH people are very careful not to make claims of Ayurveda as superior to other healing systems. It is as if there is an unspoken armistice of Western medicine, that it will be tolerated as long as long it does not encroach on Western medicine itself:
Patients are free to choose what treatment they want. If they choose Ayurveda, okay. If they choose Western medicine, it's okay also. We do not impose Ayurved. It's up to them. And if we think that Western medicine is better, for instance for emergencies, we also tell them.
Another often-highlighted aspect of Ayurveda is  its “safety” i.e. “no side effects” and “it is all natural” is an attribute of Ayurveda that is oft-mentioned, by laypersons and professionals alike.

In Ladakh, in the Indian province of Jammu and Kashmir, I met several Indians,  from various cities, and I had the chance to  ask them what they think about Ayurveda. An Indian couple, from Mumbai, spoke highly of it. Another couple, from Assam, had a son who was a medical student, and said that they preferred Western medicine, citing its proven safety. But even they acknowledge that Ayurveda has its strengths, like “those hopeless cases”. Moreover, they have personal experiences of illnesses. As an affluent man from Delhi told me:
For our chidren's coughs and colds, sometimes we use Ayurvedic medicines, sometimes, we buy from the chemist. The irony is, I suspect that even we don't give them anything, they'll still get well! 

What emerges from our India experience is the existence of parallel, but co-adaptive professional sectors of medicine, folk and popular sectors that employ elements of both, and patients taking their pick from various “choices”, using their own experiences as guide. “Doctor shopping” becomes more interesting in a world where various developed and respectable health care systems exist; it becomes “health care system shopping” instead.

Observing the reactions of my classmates, and reflecting on my own, two things impressed us: one, the exotic-ness, and its Western-ness of it. Perhaps, in the future of Indian health care, Ayurveda will be indistinguishable from Western medicine, Ayurveda being so Westernized, and Western medicine adopting some of the best practices of Ayurveda.

As for religion, Western medicine was once closely linked with Christianity, but it has since distanced itself from it. I would venture to speculate that as Ayurveda becomes more “scientific”, and as it draws more legitimacy from clinical studies and experimental methods, it, too, will do away with its “excess baggage of Hinduism” whenever convenient; even as Hinduist Ayurveda will continue to appeal to its traditional Indian clientele.

Based on what I have seen and learned in India, then, the success of Ayurveda can be explained in terms of the following characteristics of it, all of which contribute to the claims of legitimacy and validity of Ayurveda:

1. Longevity – The fact that Ayurveda has been around for so long is used to support its claim as a legitimate health care system. It is true that Ayurveda has its origins from the first millennium before Christ, and has been in continuous use since then. However, the idea of an unchanging, timeless system of medicine needs to be challenged. Islamic influence in India, which brought the unani system of medicine, has also influenced Ayurveda, beginning in the 1100s and reaching its zenith during the Mughal empire (1556-1758). Moreover, following the introduction of Western medicine in the 19th century, Ayurveda has gone through a series of adaptations that continue to the present, absorbing the best of Western medicine and developing its own strengths.

2. Claims to divinity – Closely related to longevity is claims to divinity that Ayurveda espouses. Dhavantari, the mythical founder of Ayurveda, is also known as the physician to the gods. The images of Dhavantari in clinics and wards show that this mystical connection is still honored; a large statue of the god adorns the lobby of AYUSH compound in New Delhi. I had the impression that this is something that was not highlighted to us by the people we met, probably since we were outsiders to Hindu culture. But its presence is evident in many places and instances. The revered founder of the Arya Vaidya Sala private institution, in his official biography, is acclaimed not only for his pioneering work in Ayurveda, but there is a short paragraph at the end telling of his commitment to a Hindu dance troupe.
The complexity of India makes it difficult to predict whether the relationship of Ayurveda with Hinduism will continue to be embraced by its exponents in the future. With Ayurveda increasingly validated by science, perhaps there would a wider latitude for it to become more “secularized”. 
On the other hand, by over-embracing the biomedical divorce of science and religion, Ayurveda might undermine the very reason for its appeal in the first place: its holistic approach to health, seeing its spiritual and emotional dimension alongside the physical. Given this, I would wager that Dhavantari's statue in the AYUSH building will still be there when the next batches of medical anthropology students go on their Indian field trip

3. Efficacy – Efficacy is crucial to any medical system, and this can be measured either as perceived by the people, or by an external mechanism for validation, such as the scientific method. Importantly, the latter method feeds into people's perceptions as well, making it very influential, especially in cultures where “blind faith in science” - as Hawking's philosophical perambulations have been described - is prevalent. In my interviews with people, most of them say that Ayurveda works for them, and they cited their personal experiences.

The scientific case for the efficacy of Ayurveda is more complicated, and perhaps this is a project that will take decades to resolve. A PubMed search would reveal mixed results of conclusive and inconclusive studies, although there is a growing consensus that Ayurveda has benefit in particular illnesses, such as rheumatoid arthritis, chronic illnesses, and palliative care. Moreover, herbs and therapies such as yoga and meditation that have long been part of Ayurvedic therapeutics are increasingly validated by Western studies.

The open-ness of Ayurvedic institutions to having its therapies examined under the microscope of biomedicine will ultimately be for its good, allowing it to have both the “double legitimacy” of sacred texts and scientific research, and the reflexivity that will allow self-improvement.

4. Safety –  Doctors and patients of Ayurveda agree that one of the remarkable strengths of Ayurveda is the fact that it has “no side effects”. This reasoning comes from the fact that since Ayurveda draws its remedies mainly from plants and natural products, there is none of the “harmful chemicals” that go with Western pharmaceuticals. This discourse is not unique to India; we see this being played across various cultures where Western medicine and traditional systems of healing are compared and contrasted. In the Philippines, we see this in the “cough remedy wars” being waged between manufacturers of lagundi and manufacturers of conventional cough syrups.

Many critics of Ayurveda have pointed out that its use of heavy metals as therapy is problematic, and the toxicity as a result of such therapies is becoming a  growing albeit poorly-documented problem that is spreading globally as Ayurveda becomes global. As a 2008 report concludes:
A significant proportion of Ayurvedic medicines contain heavy metals and there are numerous reports of heavy metal, in particular lead, poisoning related to use of these products. In patients, both adults and children, presenting with unexplained anaemia, or unexplained gastrointestinal or neurological symptoms, heavy metal poisoning should be considered in the differential diagnosis.  


The doctors we interviewed counter that these side effects are no different from side effects from biomedicine: they are inevitable in the wider scale, but avoidable if proper techniques are followed.

This issue is hard to adjudicate, given the limited number of studies that deal with toxicity from Ayurvedic therapies, and the qualification of what constitutes “good Ayurvedic practice”. What is important to note, however, is the fact that Ayurveda's perceived safety contributes to its popularity.

5. Holism – The approach of Ayurveda to health is no support the body, strengthen the immune system; not to kill the germs. The massages are said to be “very relaxing” and “very comforting”. Perhaps, the function of Ayurveda as a provider of comfort is no different from the hilot sa panganganak, who provides much comfort (ginhawa) to the women after childbirth, something that Western medicine does not have.

6. Adaptability – This is not an external feature of Ayurveda, but as we mentioned earlier, it is a striking asset without which, in all likelihood, Ayurveda would not have survived. Perhaps, this feature is the one that enabled it to achieve longevity and receive validity from both the scientific and the sacred.

In my interviews with traditional healers in the Philippines, I was also able to observe much adaptation, with some healers using cellphones, X-rays, and other technologies; while others take on emergent diseases using their own techniques, and in this way, cancer, dengue fever, and HIV/AIDS falls under the scope of their practice. What is remarkable in India, however, that  this adaptation is done in an organized, not individual scale.

The degree program for Ayurvedic medicine, however, is styled “Bachelor of Ayurveda, Medicine, and Surgery”. Established in 1940, its holders are entitled to practice not just Ayurveda, but also modern medicine. This indicates that early on, the degree of integration has been fairly high in India, which can explain why Ayurveda has attained a degree of sophistication that cannot be said of other traditional medical systems around the world, with the exception of Chinese and Korean medicine, as well as, to a certain extent, homeopathy.

***

In this short piece, I related my experiences and insights on Ayurveda in India. But what of yoga, siddha, unani, and homeopathy? We did not have time to explore these other systems of healing, but surely, they add to the richness and diversity of health care in India. Scratching the surface of it, I am no different from Alexander the Great, who was, as an important part of the Ayurvedic history narrative goes, “very much impressed”.

India
September 2012

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