Ayurveda At A Crossroads: Critical Questions For Today’s Ayurveda Community

Hitāhitam sukham duhkham āyustasya hitāhitam
mānam ca tacca yatroktam āyurvedaḥ sa ucyate

“That is said to be Ayurveda which measures the beneficial and harmful, the happy and unhappy, the wholesome and unwholesome factors of life and the lifespan.” Caraka Samhita I/41

Although certainly not for the first time in its history, Ayurveda has again arrived at another crossroads–one requiring a re-clarification of purpose. Ayurvedic physicians, who today live in a world surrounded by influences from many spheres, need to refocus their vision of what is the true role of Ayurveda in the modern world. The historical roots of Ayurvedic medicine need to be revisited, more closely studied, respected, and absorbed while simultaneously more effective educational methods need to be developed and expanded. Far from these two goals, the current global Ayurvedic diaspora more and more disassociated from Vedic tradition has resulted in the debauchment of Ayurveda. Even within India modern science is influencing Ayurveda both for the better and for the worse. If we cannot ourselves define, articulate and preserve what is unique to our medical tradition, the tools and technology of our medicine will eventually be at best subsumed into biomedicine and at worst surrendered to the illegitimate and unqualified modern-day “Ayurvedic practitioner”. In either scenario the sacred underlying wisdom will be lost.

Although there are many potential bridges of collaboration between Ayurvedic medicine and biomedicine, I think we need to ask ourselves, do we wish to be technicians like Western physicians have more or less become, or scholar-physicians which is our original and true dharma?

The Scholar-Physician

Ayurvedic medicine has always been based largely on scholarship and a literary tradition, with the requirement to study essential classical texts, absorb them into one’s mind, quote them, debate them, penetrate them. The foundations of Ayurvedic medicine are based on principles (tridosha, saptadhatu, agni, ojas, and more) that require both a philological and philosophical approach to the body of knowledge. Traditionally, a physician-in-training was required to have command of the Sanskrit language, the principles of logic, grammar, and the natural sciences to study texts as the Bhela, Caraka and Susruta samhitas and the various other works.

In India, the concept of the priest-physician was largely developed during the Vedic period (approximately 2700 to 500 BC) when Ayurvedic knowledge was coded in hymns and poems and transmitted in an oral tradition. With the advent of the Classical period of Ayurveda and the appearance of the first written compendiums the scholar-physician model appeared and knowledge began to spread throughout the vast subcontinent. Even more importantly, an organic and meditative approach to this knowledge was developed and encouraged.

This era was considered to be a ‘renaissance’ not only in medical thought but in human development as well, so great were the developments of the six philosophical schools which arose contemporaneously in the first 500 years of the AD period of history Today’s modern era has eroded the ideal of the Scholar-Physician to some degree in India, however along with modern clinical Ayurvedic medical practice it has survived relatively intact. Evidence of this is in the burgeoning number of Ph.D. (Ayu) candidates and scholarly publications which appear each year. In the West, however, where the development of Ayurvedic medicine is still in an embryonic stage, there is much confusion about what direction we should go.

Adding to this dilemma is the lack of proper formal education of Western Ayurvedic physicians, the appearance of a growing number of dreadfully unqualified “Ayurvedic Practitioners” and “Clinical Ayurvedic Specialists” and the muddled legal landscape regarding Ayurvedic practice throughout the world. Charaka denounced these quacks in no uncertain terms and warns the public:

“One may survive the fall of a thunderbolt on one’s head but one cannot escape the fatal effects of treatment prescribed by an ignorant physician”. (CS, Sutrasthanam I/128-132)

Later in the same section he further condemns “those who putting on the garb of the physician, thus trick their patients just as the bird-catcher in the forest tricks the birds into his net by camouflaging himself; such outcasts from the science of healing both theoretical and practical, of time and of measure, are to be shunned, for they are the messengers of death on earth. The discriminating patient should avoid these unlettered laureates, who put on the airs of physicians for the sake of a living; they are serpents who have gorged on air”. (CS, Sutrasthanam XXIX/10-12).

Should Ayurvedic authorities quietly accept these charlatans bearing artificial sham titles invented by self-serving so-called “schools” of Ayurveda? Are we as Ayurvedic physicians to practice within the existing healthcare system or seek to establish ourselves outside of it? Do we embrace the research methodologies of the 21st Century, with its randomized, placebo-controlled, double-blinded studies and p-values, or following our tradition and duty of the scholar-physician, do we find our own paradigm for scientific advancement?

These are among the many questions we face as we stand at this crossroad.

Our Critical Crossroad: The Path of the Scholar-Physician vs. The Path of the Highly–trained Technician

The modern biomedical world has seen vast changes in the last one hundred years, as vast institutions of hospitals, merging hospital chains, health maintenance organizations (HMO’s), pharmaceutical companies, insurance providers, and government research institutions have centralized the world’s financial and intellectual resources and largely usurped the power once in the hands of doctors.

Today, medical doctors have largely had their role reduced to that of a high-trained technician. This is unfortunately not an exaggeration if we stop and consider for a moment. Physicians have lost control over the very sources of their information, over their fee structure, over their ability to make unbiased decisions regarding medical care. Even aside from the imposing economic and political changes, the advancement of medical science data in Western biomedicine has been largely “outsourced” to the disciplines of genetics, information sciences, physical and organic chemistry, biology, pharmacology, and physiology–which are separate professions and distinct and separate areas of study.

Doctors rely largely on information gained from expensive technological machinery, while being pressured by the insurance industry which demands reductionist and ‘definitive’ molecular diagnoses, leaving little room then for physician judgments based on knowledge and experience.

The insurance industry largely determines physician fees, what services will be covered, and for how long. If a person has high cholesterol and we know that the ‘definitive cause’ is activity of an enzyme called 3-hydroxy-3-methyl-glutaryl-CoenzymeA reductase (HMG-CoA-reductase), then we need only give HMG-CoA-reductase inhibitors to solve the problem. Despite the fact that those inhibitors are ineffective in large numbers of people and cause severe adverse effects in relatively large numbers of patients, insurance companies pay for it so physicians continue to prescribe it.

The same can be said for dyspepsia, or amlapitta, a condition seen more and more commonly in modern Western society. Biomedicine has identified the cause to be excessive stomach acid production by the parietal cells. So pharmaceutical companies first developed histamine H2-receptor antagonists (i.e. tagamet, zantac) and shortly thereafter proton pump inhibitors (i.e.prilosec, nexium, etc.). These chemicals are often ineffective and they ALL have well-known adverse effects including hypotension, cardiac arrhythmias, impotence, diarrhea, headache, and decreased calcium absorption. Yet insurance companies pay for them so physicians continue to prescribe them by the hundreds of thousands annually. But insurance companies will not pay for any of the more natural interventions which often effectively eliminate the problem at its root such as panchakarma detoxification procedures, yoga asana training, meditation, or herbal medicines.

Most people interested in genuine health-care careers are drawn to Ayurvedic medicine as a clear alternative to the current biomedical establishment, in the hope of maintaining a degree of intellectual and clinical independence in the day to-day practice of medicine. Most Ayurvedic physicians in India are still independent providers, mostly in small offices with relatively low overheads or work in Ayurvedic hospitals or medical clinics.

Even in India many Ayurvedic physicians, however, are becoming misguided by the lack of a clear vision on the direction of Ayurveda in the 21st Century. The situation in the West is even more alarming. This is principally due to the fact that there are very few Ayurvedic physicians in the United States or Europe with the legal status to practice the full spectrum of medicine. In these places, Ayurvedic “therapists” or “practitioners” are wrestling with their role as primary(?) or secondary health-care providers, independent of or part of the biomedical system.

Modern medicine has also lost the integrity of the physician-patient relationship to a large extent. HMO’s and insurance companies often dictate the choice of physicians or specialists for patients, determine fees, treatments, frequency of visits, and duration of treatment! What’s more, physicians have also relinquished control of their materia medica to pharmaceutical companies, who pressure physicians to prescribe their proprietary medications for obscene profit. Physicians who are pressured avoid similar medicines of competitors and certainly ‘unproven’ treatments such as herbal medicines. Enormous legal institutions such as the FDA (Food and Drug Administration), AMA (American Medical Association), NIH (National Institutes of Health), and the HMO/insurance establishment have reduced the physician to a highly paid employee of a medical mega-structure. Sadly, doctors are unable to control even their own information sources in their own medical schools.

What Can Be Done?

There is great pressure on the Ayurvedic medical tradition to follow the existing paradigm, to reject intuition and instinct, to bow to scientific method, to accept the unqualified “practitioners” infiltrating its ranks, to enter and integrate into the biomedical world. Should that happen, the intrinsic strengths of Ayurvedic medicine could be in danger of further deterioration, because much of what makes Ayurveda strong could not easily survive in this environment. Ayurveda has always depended on certain fundamental requisites:

  1. Complete and comprehensive training and knowledge before advising even a sip of water
  2. Individualization of treatment based on physician judgment
  3. Preservation of traditional diagnostic methods and flexible
  4. Freedom to employ the full spectrum of Ayurvedic treatment modalities
  5. Physician control of medicines and preparations
  6. Time, attention and care given to patients determined by physicians and patients
  7. Patients free to find and choose their own Ayurvedic physician
  8. Commitment to continuing basic and clinical research

While it is important for new graduates to be encouraged to intern with established health care providers in private offices, it is also important for us in the West to develop clinical environments that are conducive to the practice of the full spectrum Ayurvedic medicine (i.e. rasashastra, kshar sutra, vamana chikitsa, raktamokshana, agni danda, etc). This must also include Ayurvedic medical research. This may mean we need to eventually develop authentic Ayurvedic patient in-care facilities, including hospitals where herbal medicines, panchakarma, and the full spectrum of Ayurveda are used.

Ayurvedic medicine is based on study of philosophy and nature, mind and body–the cornerstones of clinical practice. Vaidyas are also encouraged to have a broad knowledge of the natural sciences and humanities. The modern trends in medical studies have moved away from philosophical approaches and the humanities in deference to total immersion in the hard sciences. This trend is also beginning to influence the training of Ayurvedic medical doctors in India, where studies in the surviving original metrical sutras of the rishis have been diminished in the curriculum or, in some institutions, already abandoned.

Conclusion

In conclusion, the scholar-physician embodies and lives the knowledge that is taught to him/her, and in this way continues to penetrate it and preserve it. The knowledge base of Ayurveda belongs to each individual physician, not to some centralized knowledge source based on data from studies and large institutions. Each physician’s experience is potentially innovative and creative, but authentic and complete education is a pre-requisite. The knowledge base is stored in the historical and modern Ayurvedic medical literature, and includes natural philosophy and the clinical case studies of generations of physicians. In order for Ayurveda to have a healthy future, we need to recognize the roots of our philosophy and practice, and create environments where we can both cultivate the strengths of our tradition and interact with other medical providers and systems from a position of strength and knowledge. This will require training for present-day Ayurvedic students in such subjects as Ayurvedic medical history, Sanskrit, classical texts such as the Caraka and Susruta samhitas, and the preserved case histories of past physicians. Then we need to put this knowledge into practice by connecting ourselves with the ongoing lineage of Ayurvedic medical practice, one which has been building through the contributions of generous teachers and scholars for many generations.

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Scott Gerson, M.D., Ph.D. (Ayu) is one of the world’s leading clinical physicians and researchers in Ayurvedic Medicine. He is the medical director of The Gerson Institute of Ayurvedic Medicine (est. 1982). Dr. Gerson is an Associate Professor at Tilak Ayurved Mahavidyalaya, Department of Kayachikitsa (Internal Medicine), where he earned his M.Phil. and Ph.D. in Ayurveda, and a Clinical Assistant Professor, Dept. of Community and Preventive Medicine, New York Medical College.

3 comments

  1. I think this article highlights several important points that the modern and ‘American Ayurveda’ seeks to ignore. I have addressed the same and a call for a more integral Ayurveda that also doesn’t shun surgery which is an integral aspect of Ayurveda as also it’s contribution to world medicine and techniques, as well as the modern system of pasteurising diagnosis down to the dimunitive tri-dosha model which fails, as well as dosha-stereotypes, not considering all variables.

    The average western student of Ayurveda is also ignorant of the study of the shad darshanas etc. which compliment Ayurvedic science, as also facets such as agni-karma, raktamoksha, rasashatra etc. as Dr. Gerson has noted.

    I have been criticised by even some of my western ‘peers’ and also teachers and colleagues relative to my stance for making Ayurveda ‘too complicated’, but it’s what is seen in the shastras, which we cannot deny. We can’t simply approach Ayurveda from the quasi or New-Age angle and introduce modalities such as Pranic-Healing, Reiki, Chakra-balancing and such nor explain the effects of yajnas, homas, pujas etc. as mere ‘magical spiritual’ effects, since the shastras actually give a more rational approach to these and where they were employed, a deeper understanding according to a rational and scientific basis was given, as also in the Nyaya-Vaisheshika systems that have to compliment Mimamsa, Samkhya, Yoga and Vedanta; of even Vedanta in the West, the over-simplified version of Shankaracharya’s elaborate system (which people forget is also also the basis of the Bhakti traditions in India as well as the expanded Kashmiri Saivite and Tantric traditions and tattvas he explained) – reducing Shankara and his Advaita down to a few statements such as “All is One” and “The world is an illusion” taken in the literal context the Western world with it’s Christocentric bias does well and thus equating “Jesus says” and “The Bible says so, so be quiet” with these (misconstrued) Vedantic statements taken out of context let alone translation, reducing even the science of debate down (of which a careful reading of the classics will provide the depth and scope of such in ancient times and that such wasn’t based on some ‘Acharya’s’ words, but debated and had to be substantiated as per the pramanas).

    The points Dr. Gerson has raised are all very important for the future of Ayurveda!

  2. This comment epitomizes the whole problem and I couldn’t have made the point any more starkly if I tried. So thank you David. It simply is not acceptable that kind and well-meaning but woefully unqualified acolytes such as yourself represent Ayurveda “to the best of their ability”. I do not know you but would hazzard a guess that you’re one of the many “Ayurvedic practitioners” who probably attended one of the California, New Mexico, Brazil, etc “schools”. My “attack” is not against you or your colleagues personally. I wish only to point out the elephant in the room that Ayurveda is a medical science requiring a special kind of medical education which is not available in the U.S. or even anywhere outside of India. I lament this fact but its true. Its not enough to learn and master basic or even advanced principles. Learning true Ayurveda involves a much different aspect of education. An example from first weeks of Ayurvedic college: we’re taught only when you understand the true meaning of vyahritis will you be able to know the true significance of the mahabhutas. Nidhidyasanam type of meditations are given to students for this: maha iti brahma brahmana vava sarve veda mahiyante (Taitt. Up. 1.5.3). Compare this to what U.S. students are given. Sorry for such a long answer–I want you to understand.

  3. It is sad that Dr. Gerson chooses to attack those who have chosen to delve deeply in to Ayurveda and serve people in a fair and helpful way to the best of their ability, building communities of Ayurvedic knowledge and passing on these teachings. I think he could have made his point without so much attack on other members of the Ayurveda community. But then again, his Ayurvedic community is actually quite small, since so many people don’t qualify.
    I hope that Dr. Gerson can save Ayurveda from the destructive forces and people that surround it.

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