Questions over science swirl, but AYUSH stands firm-TheHindu
RUKMINI SHRINIVASAN Updated: April 26, 2015 03:51 IST
There is still no credible evidence of the effectiveness of homeopathy or ayurveda, say detractors. But every system has its own philosophy and can’t be judged by the same criteria, say supporters. Meanwhile, all five alternative medicines that fall under the AYUSH Ministry continue to thrive in India.
There is no credible evidence yet of the effectiveness of either homeopathic or ayurvedic medicines and treatments, a range of medical experts have told The Hindu. Yet, both schools of medicine form an integral part of India’s public health system, and their importance looks all set to grow.
Across the public health spectrum in India, from common colds to HIV, alternative medicines and treatments have official sanction. Created in 1995 as the Department of Indian Systems of Medicine and Homoeopathy under the Ministry of Health, the re-named Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy or AYUSH became a full-fledged ministry in May 2014, when the Narendra Modi-led BJP government took oath. As of March 2015, India has just over nine lakh allopathic doctors and nearly eight lakh AYUSH practitioners, over 90 per cent of whom are either homeopaths or ayurveds. The Ministry has a Rs. 1,200 crore budget for this year.
Worrying evidence
However, the scientific evidence on homeopathy and ayurveda is worrying. Two major systematic reviews — one published by medical journal Lancet in 2005, and the other published in early 2015 by Australia’s National Health and Medical Research Council — found no evidence of homeopathy being any more effective at treating disease than a placebo. The UK House of Lords Committee on Science and Technology, in a comprehensive review of alternative medicine in 2000, found that “in the case of homeopathy, although it is covered by a separate Act of Parliament, we were not able to find any totally convincing evidence of its efficacy”, and “there is at present no credible evidence base to support the value of any of the therapies that we list in our Group 3”, a category that included ayurveda.
India has never conducted any systematic review of any of the systems of medicine under AYUSH. For homeopathy, several double blind placebo-controlled trials or Randomised Control Trials (RCTs) — clinical trials in which a drug’s effectiveness is tested against a placebo — have been conducted in India, but the standards were not acceptable to the Lancet or the Australian review. Dr. R. K. Manchanda, Director General of the Central Council for Research in Homeopathy (CCRH), the AYUSH Ministry’s nodal homeopathic research arm, has conducted many such trials himself, which he candidly told The Hindu were found wanting by the Australian review and their results dismissed.
In the case of ayurveda, there is extensive research, but few RCTs. “I can count the number of RCTs on the fingers of one hand,” Dr. Bhushan Patwardhan, Professor and Director of the Interdisciplinary School of Health Sciences, Pune University, told The Hindu. As a result, there has been no proper review of the trials. The first such review is now underway at the University.
How they work
There is one significant difference between homeopathy and ayurveda. While the science of how ayurveda works is not questioned, the very basis of homeopathy — highly diluting a substance in alcohol or distilled water, stirring a fixed number of times in precise directions, striking a pestle against a mortar certain times, for instance — has been dismissed as scientifically impossible. The way ayurveda works, on the other hand, is well established within the theories of science. “How it works is not very different from modern medicine,” said Dr. T. Sundararaman, Professor and Dean of the School of Health Systems Studies at the Tata Institute of Social Sciences, Mumbai. “Most modern medicine is derived from active ingredients of roots or plants that are used in ayurveda,” said Dr. Dinesh Katoch, Joint Adviser in the AYUSH Ministry. But because of this, say experts, there is no reason why ayurveda should not be subject to the same tests as modern medicine.
Among the ayurvedic and homeopathic academic fraternities, there is much debate over the lack of RCT-derived evidence of effectiveness. Among ayurveds, who have had less of a bad rap internationally than homeopaths, there is introspection. “The ancient texts were written a long time ago, and the environment has changed a lot since. It is fair to wonder whether those treatments would work in the modern era,” said Dr. Patwardhan. “Ayurveda primarily focuses on prevention and creating a healthy person. Unfortunately, as our society has become increasingly medicalised, there are perverse incentives against investing in preventive healthcare”.
“Maybe AYUSH will be more acceptable as preventive health than as drugs,” he suggested. Among homeopaths, meanwhile, there are questions about whether to do more RCTs at all. “We are doing research, both observational studies and RCTs. But the question is whether a scrutiny of homeopathy through RCTs is really required?” said practitioners.
Both schools stress that their medicine treats the individual and not the disease, and are affected by context and temperament. But few public health experts agree that this can be the way going forward. “They cannot hide behind mysticism. All medicine is for individuals. Since trials involve a group of individuals, they account for individual idiosyncrasies,” said Dr. Samiran Nundy, noted gastroenterologist at Delhi’s Sir Ganga Ram Hospital and editor-in-chief of the journal, Current Medicine Research and Practice. Dr. Sundararaman agreed: “Everything cannot rest on the claims of practitioners.”
Allopathy’s failure
None of this exculpates modern medicine either. “A lot of unnecessary and irrational treatments go on in modern medicine too. Just look at digestives, most vitamin supplements and cough expectorants, for example,” said Dr. Sundararaman.
The Hindu spoke to dozens of people seeking treatment who talked of the opacity of allopathic treatments, the high prices charged, the lack of accountability, and the apathy.
Bhim Singh (50) is seated in the waiting room of a government-run homeopathy centre in Noida. He is there for a dermatological condition. He rues the thousands he has spent on allopathic treatments, and the terrible side-effects of the medicines. “Even when I went back to complain about the side effects, the doctor would not take more than 10 seconds. Here at least they ask you about you, your job, lifestyle,” he said. Ultimately, said Dr. Sundararaman, it isn’t always clear what cures a disease — pharmacology, the withdrawal of other harmful medicines, lifestyle changes, physical confidence, or even just rest.
Whether the government should continue with its AYUSH programme in its present form, with little to no evidence to back any of it, is an open question, however. As of today, ayurvedic and homeopathic treatments for HIV/ AIDS and cancer, homeopathic prophylactics against swine flu, and a range of other drugs and treatments for serious diseases have official sanction.
Until now, no health body, Indian or international, has expressly suggested that India curtail or amend its AYUSH programme. “The [Australian] NHMRC Statement on Homeopathy advises that homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence of safety and effectiveness,” a spokesman for the Council told The Hindu, but added that questions on what India should do were for the Indian government to answer.
The World Health Organization did not respond to requests for comments from The Hindu, but the organisation’s 2006-11 Country Cooperation Strategy with India included a supplement on traditional medicine, which recommended both more research and greater mainstreaming of AYUSH. Their 2007-12 document does not mention AYUSH separately. In India, the Indian Medical Association has objected to AYUSH doctors performing allopathic treatments, but not to AYUSH itself.
What’s ahead
The AYUSH Ministry is aware of the questions swirling around, but is unlikely to make any major changes. “For the thousands of years that ayurveda has been practised, nobody asked for evidence. Now, because the medicines are being exported, these questions are being asked,” Shripad Yesso Naik, Union Minister for AYUSH, told The Hindu. “We are still going to do the research, and not just for medicines that will be exported,” he added.
The draft National Health Policy 2015 suggests greater integration of AYUSH with modern medicine, a type of “cross-pathy” that the Indian Medical Association has strongly opposed.
“India has always had a pluralistic health system. Every system has its own philosophy and even its own testing criteria. It will not be appropriate to apply the same parameters to different sciences,” said Dr. Katoch. The Ministry will, however, continue to carry out research.
AYUSH: The six systems
Ayurveda
Ayurveda (“science if life”) is a system of Indian traditional medicine with roots in the ancient Hindu texts, particularly the Atharva Veda, and later the Charaka Samhita and the Sushruta Samhita. Ayurveda believes that all living beings comprise five elements, whose permutations and combinations determine three types of humours — Vata, Pitta and Kapha. A key principle of ayurveda is balance; an imbalance of the doshas is believed to result in disease. Treatments follow one of two possible approaches: Vipreeta, in which medicines and diet are meant to “antagonise” the disease, and Vipreetarthkari, in which medicines, diet and activity are targeted to exert effects similar to the disease process. Most medicines and treatments are derived from herbs.
Yoga
Yoga (“to join” or “to unite”) is a physical and spiritual discipline that has its roots in the Indian sub-continent and has been recorded in the Upanishads and later in the Yoga Sutras of Patanjali. The practice of yoga is meant to lead to a stage of higher consciousness and is also described as “soul therapy”. Japa Yoga, Karma Yoga, Gyana Yoga, Bhakti Yoga are spiritual, while Raja Yoga, more popularly known as Ashtanga Yoga, involves eight steps, including the pranayama or breathing exercises. Some forms of yoga and their modern practice focus mostly on asanas. Practitioners say yoga can cure diseases, and the government runs the Central Council for Research in Yoga and Naturopathy. Early indications from an on-going five-year study at Harvard indicate that yoga helps with chronic stress.
Homeopathy
Homeopathy is of European origin and dates back to the end of the 18th century, to the work of German physician Samuel Hahnemann. Homeopathy is premised on the belief that highly diluting a substance in alcohol or distilled water increases its potency, a principle that is almost universally disputed in scientific communities. Remedies involve dilutions on a logarithmic scale, and grinding of insoluble compounds with a mortar and pestle according to prescribed motions. Diagnosis involves detailed consultations, including questions about the individual’s personal life. Medicines are either small pills, made of an inert compound with drops of the dilute solution added, or powders.
Unani
Introduced by Arabs and Persians to India in the 12th century and with a rich literature, Unani medicine remains popular in parts of South and Central Asia. Freedom fighter and physician Hakim Ajmal Khan was among its champions in India. Unani shares many common principles with ayurveda, including the belief in the four humours. The human body is believed to be made up of elements whose permutations and combinations determine temperament. Medicines have herbal, animal and mineral origins.
Siddha
An ancient form of traditional medicine, Siddha originated in Tamil Nadu through the work of “siddhars” or scientist-saints. Siddha sharedmany principles with ayurveda, including the belief in humours, elements and imbalance.Diagnosis involves a key checklist of eight signs and symptoms. Drugs are herb-based and treatments are both internal and external. Siddha’s chemistry around its drugs is complex. Research, teaching and practise is largely restricted to Tamil Nadu.
Naturopathy
Naturopathy is an umbrella term for a range of alternative treatments derived from natural products. Naturopaths believe that, except for accidents, the cause of all disease is the accumulation of “morbid matter” in the body, and treatment means the removal of this matter. Therapies include special diets, mud packs, acupuncture, acupressure and magnet therapy. Prayer is an important part of treatment. Naturopathy schools exist across the world.
