India: A Second Opinion

Extended Interview

Working with researchers from the UCLA School of Medicine, Dr. Ram Manohar has begun a project that applies modern scientific rigor to the traditions of Ayurveda. With the study, Manohar hopes to demystify Ayurvedic practices while, at the same time, legitimizing them by Western medical standards. Although a study like this might have the opposite effect, Manohar is confident about the power of Ayurveda. Manohar and the researchers have chosen to examine the treatment of rheumatoid arthritis, to compare the effects of Ayurvedic treatment with the Western drug methotrexate.

“Rheumatoid arthritis is … a kind of autoimmune disease with an inflammatory response. There is an inflammatory reaction in the joints, the major joints of the body, and in the process of inflammation, the synoviam, the capsules, they’re all visibly damaged, so it leads to crippling pain,” Manohar explains. “In Western medicine there are different approaches. A new concept is the management of rheumatoid arthritis with a new class of drugs called DMARDs -- Disease Modifying Anti-Rheumatic Drugs. So these are drugs that actually claim to do something that will reverse the disease process, or at least put the disease into remission. One important medicine in this category is methotrexate, the drug we have kind of chosen as the active control for our study.

"Our study has basically three arms: one arm in which the patient gets both genuine Ayurvedic and genuine allopathic treatment, that is methotrexate in this case, the best that each side can do. The next group will get genuine allopathic treatment, that is, real methotrexate, but then the Ayurvedic component would be the placebo. And then the third treatment would get genuine Ayurvedic treatment but placebo methotrexate. This way, we ensure that every subject that is recruited to the study will get some form of treatment or the other, which is very important for a (painful) condition like rheumatoid arthritis. To be without treatment for rheumatoid arthritis for nine months would be extremely unethical."

And how does one create a placebo for Ayurveda?

“This has been one of the most challenging aspects of the whole study. It’s not just enough that we make a look-alike thing. We have to look also into other components of the medication, like flavor, taste, consistency. Ayurvedic dosage of those forms is extremely varied. And on top of all this, we need to make sure that what we design is also inert, or it cannot be a placebo.”

What if, when the results come back in a few months, they show that the placebo worked, that people believed Ayurveda was going to work, so it worked? Is that OK?

“Yes, of course. In Ayurveda, we do not deny the placebo effect. We feel it is something every physician uses in healing. We feel it’s absolutely stupid to eliminate the placebo effect. For research, it might have meaning to measure, but it’s very much a part of the healing process, which is something that is inescapable, even with an allopathic practitioner.”

Why is the AVP open to putting itself to the test like this?

“Our manager, Krishna Kumar, he has a very broad perspective. On the one hand, he is a very strong promoter of these rituals and traditions. On the other hand, he also has an open mind to promote scientific inquiry. I think it’s a deep conviction that all these traditions work. He has been seeing it right from childhood, and he feels that bringing science would only add credibility.”

Extended Interviews

As the director of research for the Arya Vaidya Pharmacy (AVP) in Coimbatore, India, Dr. Ram Manohar has dedicated himself to the promotion and use of traditional medicines. He trained at both the Ayurveda College in Coimbatore and at the ALN Rao Memorial Ayurvedaic Medical College in Karnataka, and worked as a senior fellow with the Foundation for Revitalization of Local Health Traditions in Bangalore. In this interview with T.R. Reid, he discusses the essential differences between Ayurveda and Western medicine, Ayurveda's unique approach to healing, and the dilemmas facing traditional Indian medicine during the process of modernization.

T.R. Reid: If you were talking to someone who knew nothing about Ayurveda and they said, "How is it different from Western medicine?" how would you explain it?

Dr. Ram Manohar: I think Ayurveda and Western medicine originated in entirely different cultural paradigms, which nurtured radically different world views. So, the basic difference lies in the epistemology, the very approach to knowledge-building. I would say the most primary thing is that Ayurveda looks at the human personality as composite of the body, mind and self. This is very central to the approach of Ayurveda. The human personality is considered as a dynamic manifestation of interactions between the mind, body and the self, whereas Western medicine seems to be more focused on the body. And the mind is just an epiphenomenon of reactions that take place in the body, and the self is almost a nonexistent entity.

Whereas in Ayurveda, the mind is given much greater importance than the body. The body is the shadow of the mind, as far as an Ayurvedic physician is concerned. So, this makes radical differences in the way an Ayurvedic physician approaches a patient and tries to understand disease and health.

Q: Western medicine generally relies on established scientific authority. What is the source of authority in Ayurveda?

A: In Ayurveda also we have mechanism for kind of validating knowledge. So, just like in modern science, there is this concept of scientific authority. Ayurveda believes that knowledge is generated out of experience through a process of validation. And this validation takes place through two things. There is a validation by authority, by individuals who have the training and the background to validate knowledge, plus the tools of validation.

But the ultimate process, it's a process of self-discovery. Because the texts say that it’s the experience of the seeker that is the ultimate authority to distinguish what is right and what is wrong. In that way, Ayurveda has always been a dynamic knowledge system. It’s not imposing a set of predefined beliefs on the seeker of knowledge, but it’s rather opening up a path of inquiry. The texts are very clear in this regard.

And so, Ayurvedic writings, Ayurvedic traditions have continuously evolved over a period of 2,000 to 3,000 years. The theories have undergone modifications. New formulations have been discovered. New diseases have been described. Treatment modalities have been improvised. Ayurveda has been a growing body of knowledge. … in that way it is very much similar to the modern scientific enterprise. But still there are epistemological differences.

Q: Can you briefly describe some of the belief system that forms the basis of Ayurveda?

A: Basically, the traditional view holds that the universe represents a duality at the level of the material manifestation. This is called in Ayurveda Agni and Soma. This loosely translates as energy and matter, Agni representing energy and Soma representing matter.

The Ayurvedic text explains that the entire material manifestation is pervaded by this duality of Agni and Soma, Agni eating Soma to grow, and Soma attacking Agni to preserve itself. So, there’s a perpetual transformation of matter and energy.

And this has been identified to occur in five phases. It’s a cyclic transformation -- energy getting transformed from matter, or Agni becoming Soma, and Soma, again, becoming Agni. This takes place through five phases, and those five phases are what we list under the five great elements. They are not actually elements in the way modern science or modern chemistry understands. They are actually processes representing the perpetual transformation of matter and energy.

So now when we come to the Tridosha Siddhanta, this understanding was translated into the biological context. And then they discovered that any life form is involved in this dynamic operation, that it is preserving itself in a material form. And even as it preserves its material aspect, it continuously transforms matter into energy to exhibit the basic characteristics of life. So they realize that to live means to strike a balance in this process.

Q: Can you explain a little more about the three doshas -- Pitta, Kapha and Vata -- which, in combination, make up the constitution of each individual?

A: Central to this theory of Tridosha is the Ayurvedic understanding of constitution. Because we look at each system as perpetually engaged in the acquisition, transformation and expenditure of this matter and energy complex. So we say there are tendencies. Certain systems tend to conserve matter more than they expend. Certain systems tend to convert matter more than they expend or preserve. And certain systems overspend. The constitutions that tend to spend more energy we call Vata. Pitta is a situation where there’s nothing preserved, not fully utilized. That is a Pitta constitution. Then we have a Kapha constitution, which tends to conserve more. So we say Kapha constitution people live longer because their energy expenditure cycle is much slower, whereas a Vata constitution person gets exhausted much faster.

This is the background in which health and disease manifest. So we have to first understand what the constitution of an individual is.

Q: So it is genetic make-up, in a way?

A: Yes. And that’s central to whether we need to customize our treatment. Personalized medicine is one of the fundamental approaches that Ayurveda adopts. Because we say, “Without the stage, there cannot be the action.” And the constitution creates the stage. So each individual has his own unique way of handling the matter/energy transformations.

So we have to first balance the constitution of an individual. Even a healthy individual needs to balance his constitution to remain healthy. It is in that backdrop that we adopt a treatment also.

The very word dosha also means "fault." It only shows that your system is going to collapse at some point. The very factors that keep it going will eventually collapse, even if you follow the best regimen that any medical system can advise. Eventually, it’s the doshas that kill you. It’s the doshas that create you; the same doshas kill you.

Western medicine has seen that common disease process. But it has ignored the differences on how the individual persons respond to those disease processes. The response is different in two ways. One is in how the body tries to rectify that breakdown. It varies between individuals.

Secondly, the impact of the same disease process also varies from individual to individual. Two people with the same coronary artery disease might get affected in two different ways. Two persons with diabetes, the same disease process, but the way their organ systems respond to it may be entirely varied.

So Ayurveda looks at these variabilities and how the person responds to the disease process. Which is why the entire focus has been on personalized medicine. Western medicine does not nurture the body’s own healing powers to handle the disease process. It provides help from outside. Whereas Ayurveda believes in providing help from within, activating the body’s own healing processes to combat disease.

Q: So once an individual’s constitution is understood, how, then, how does the healing take place?

A: We say that healing occurs through three basic forces. One is the self-generated mechanism, in which the healing process can be generated by the individual through a psychological process. This is not something that can always be predicted, but it is a major force in healing.

The healing process can also be initiated through external factors -- even the mere presence of a physician sometimes evokes a healing response. We recognize that. We say that that should also be accounted for.

And the third thing is the most reliable approach, which is based on drugs. There, the physician is under full control. The other two processes, you cannot control. You cannot predict, because it may or may not happen.

But we say healing is a complex phenomenon. And drugs play a role only in the backdrop of this self-generated healing energy, plus the healing process getting activated through various external factors. We cannot standardize the other two mechanisms -- that is, the psychological component from both within and outside. It is only the drugs that we can standardize. So that is what Ayurveda employs as a reliable tool. But the Ayurvedic physician really draws upon the support of the other two mechanisms also for healing to really take place.

Q: Hasn’t the process of standardization become a bit problematic, though, both in the dispensing of drugs and in the training of physicians?

A: Yes, because in the traditional context, the physician and the patient were in complete control. One person’s formula couldn’t be used in a widespread way for others. In training, a young student basically sat and wrote out these prescriptions. And by writing out these prescriptions for the master, the student began to appreciate the logic through which these formulations are made.

And most of the formulations are very simple to make. In those days, most of the herbs were found in the courtyards of the patient’s home itself. So, because the patient was an interested person, he would make sure that best herbs were collected and would make the medicine and consume it himself.

Similarly, the physician has his own home pharmacy. There was not this kind of centralized distribution of medications. So it is in modern times now that the control of manufacturing medicines has shifted, first from the patient to the physician, now from the physician to a third party.

Q: How is the introduction of third-party manufacturing working here?

A: It’s not. That is the biggest challenge that India faces in the process of modernization: the movement of the pharmacy from the patient to the physician initially, and then from the physician to a pharmaceutical establishment. And in the process, learning is affected. An Ayurvedic physician is supposed to know everything about what goes into a medication, but now the pharmaceutical industry discovers the medicine. The physician used to be very much part of the process of drug discovery. But now the Ayurvedic pharmaceutical industry has become confused because of this shift to a third-party manufacturer and the introduction of Western parameters.

So, apart from classical formulations, a new group of patented and proprietary medications began to emerge in the market. This was an attempt to mimic Western medicine -- one medicine for one disease. So what has happened now is the modern Ayurvedic physician has no control over the medicines that he prescribes. He has no way to assure quality control. And that learning process is also completely damaged.

The biggest tragedy that has happened is where Ayurvedic text talks about tens of thousands of formulations, which can be carefully customized for the specific needs of individuals. Today, we have to treat with just about 400 pre-made formulations.

Q: In talking about the healing process, you mentioned the psychological component, which sounds very similar to the Western concept of the “placebo effect.”

A: Yes, it is. If the patient can evoke his own healing response or it can be evoked through some external factor, without actually the administration of a drug, that is very well recognized in Ayurveda. Ayurveda believes in using that tool and using that in addition to the drug.

So it becomes sometimes confusing for an Ayurvedic physician when he’s confronted with a scientific question as to how did your medicine work? Was it the medicine, or was it a placebo effect? And we would say it’s always a combination of both.

I rather believe that healing has to be initiated from the mind of the patient. And we use all techniques as much as we can, including religious. Because the aim of the Ayurvedic physician is only to heal. What is the purpose if we prove that we are doing scientific medicine, and the patient doesn’t get well? The whole idea is use whatever tools are available to initiate the healing process.

Q: In the face of the UCLA study (see sidebar), are you optimistic that Ayurveda will continue to thrive?

A: Ayurveda has definitely been designed traditionally to face this challenge of external skepticism and the demand for scientific evidence. So it will be the ultimate test. And the thing is, Ayurveda must pass that test. And I think we have this wonderful opportunity to make that a reality. One of the biggest medical traditions that human civilization has produced is now on the verge of being put to the acid test of analysis, of scientific analysis. And if it comes through, then I think that will be the real victory that Ayurveda gains. That will be the victory of tradition.