In the Bonesetter's Waiting Room

by Aarathi Prasad

  ‘They come from different forest regions,’ he explained as I surveyed them. ‘Our researchers make trips into the forests four times a year. The teams are made up of botanists as well as Ayurvedic plant specialists. They stay for fifteen days, collecting plants needed for Ayurvedic formulations, doing surveys of the forest peoples – recording their folklore with respect to the plants. In this way we sometimes come across plants not used in Ayurveda, some not even known to us, medicinally. There was one we came across, for example, a Zamina – this is a South American plant …’

  ‘And it was growing in a Karnataka forest?’ I asked.

  ‘It must have been brought in colonial times – yes, it had grown there and thrived and we discovered that the local forest people harvested the fruit – for nutrition, but they also say that it is a cure for infertility. So we record plants and information like this.’

  ‘And what do you do with the specimens when they are brought back?’ I was curious to know whether they would be analysed chemically to look for active ingredients that could be tested as a treatment for infertility. Thinking back to how people who habitually use plants as medicine used to venerate them, I also wondered whether Dr Venkateshwarlu had a sense of what the forest people thought about sharing the secrets of their herbs.

  ‘The tribes and locals do worry that knowledge will be misused. But they are sharing their knowledge, you have to give them financial compensation and we acknowledge them in our publications. The knowledge will also be sent to the Forest Department. When the team return they do chemical analysis of the specimens here in our labs.’

  A few days after meeting Dr Venkateshwarlu I was invited to visit the Foundation for the Revitalisation of Health Traditions. I had been told that this research centre housed a very large database of plant-based products used in Ayurveda, Siddha and Unani medicines. But, more significantly from my point of view, it was also affiliated with a recently built hospital, in which patients had access to facilities that integrated both traditional and Western medicines. It was a little way out of Bangalore’s city centre, part of the still rural but rapidly expanding developments towards the new airport and close to my home. As I set out with Amreesh, a twenty-two-year-old taxi-driver from my village, we talked about hospitals and healthcare I asked if he’d ever gone to an AYUSH doctor when he was ill. ‘No,’ he said, sounding a little confused. ‘I go to the clinic. Everyone goes to the clinics. There are about twenty in the town.’

  ‘Twenty? In such a small town? Do you mean private clinics, or government?’ I asked.

  ‘Private. There are different clinics for different problems and they charge different prices, so we go where we can afford. My wife had our baby at the government hospital, though. She went there because some family recommended a doctor working there. She had to have a caesarean and he was very good.’

  I asked him why she needed a caesarean. ‘The baby was big. Three kilos.’ That was under seven pounds. I told him that three kilos was not a particularly big baby – or at least it wouldn’t be considered so in the West. ‘Well, it’s not that big, but my wife was very small,’ Amreesh explained. ‘She was only sixteen. After the delivery, though, the hospital was terrible. She had to stay for a week – the sheets were dirty, the ward was dirty. Every time she needed the staff to do something they asked for money, tips. We don’t want to go back there again.’

  What Amreesh told me reflected many conversations I’d had in and around Indian cities – with everyone from manual labourers in tattered saris to auto-rickshaw drivers to security guards to people eking out a living in slums. When they got ill, it was the pharmacies, hospitals or clinics of the mainstream that would be the first port of call. Though the state hospital system was woefully underfunded, there were schemes to help people living below the poverty line, so that they could at least access ‘Western’ healthcare, however poor its quality. For those with a slightly higher income, there was a plethora of private clinics to suit different pockets.

  I began to get the impression that the World Health Organisation’s assertion that seventy per cent of the population accessed traditional treatments as primary care might really be reflecting usage by India’s majority rural population. Put off by remoteness, poor salaries and lack of access to the modern facilities that middle-class medical students would be accustomed to, rural communities tend not to easily attract or keep MBBS (Bachelor of Medicine, Bachelor of Surgery) qualified doctors, instead being often better served by AYUSH practitioners. AYUSH institutions across the country have approximately 62,000 hospital beds and more than 785,000 health workers. One conventionally qualified doctor might serve up to 10,000 people in rural areas, so it comes as no surprise that the majority are thought to use AYUSH or medicinal plants to help meet their general healthcare needs.

  Traditional medicine is, on the other hand, seen as a desirable add-on to Western medicine among the growing numbers of India’s wealthy. The popularity of Eastern medicine in the West may also have led to ‘reorientalism’ – a resurgence of indigenous practices in their country of origin. The use of Ayurveda-based beauty products in expensive Western spas and retreats was being echoed among the well-off on Ayurveda’s home turf, who are increasingly buying into a new glamour of India’s ancient prescriptions. As one doctor I talked to put it, ‘We do see more interest in Ayurveda when there’s interest from the West.’

  But at the other end of the spectrum, the reverse was true: I had heard from health workers that poorer Indians preferred to visit Western healthcare clinics. In a rapidly technologising nation that had recently launched its own mission to Mars, there appeared to be a move by those with little to leave the old behind. And, even though, as Dr Venkateshwarlu had told me, Ayurveda and its practitioners can be found all over India, I had heard from Ayurvedic doctors in Bangalore that it was not so easy to make a living from it, unless you were already a well-established vaidya to whom patients came by recommendation.

  As Amreesh drove through Bangalore, I wondered what this meant for the thousands of students graduating annually from India’s AYUSH colleges. Throughout the city, along wide main roads or in warrens of homes and shops of the old towns, the footprint of both the modern and the traditional was evident. There were makeshift signs on roadside walls displaying public health messages: Touch spreads love, not disease; Donate your eyes. I saw vans parked on the side of the city’s traffic-clogged arteries, disguised as tents under reams of exotic fabric and offering Ayurvedic treatments for sexual dysfunction and all manner of illnesses. Medical advertisements were everywhere – from large private hospital chain and IVF clinic billboards to tiny haemorrhoid and fistula clinics to alternative signs hand-painted directly onto walls, like the one that read German dispensary homoeopath for old inherited diseases.

  Fairly soon after we passed that sign, we found our turn-off and headed down a bougainvillaea-lined track that opened out into lush green fields, either side of which were the buildings of the Foundation for the Revitalisation of Health Traditions and the 100-bed research hospital belonging to the Institute of Ayurveda and Integrative Medicine.

  The foundation had been established as a non-profit public trust in 1991 by Sam Pitroda, an electronics entrepreneur and technology advisor to former prime ministers Rajiv Gandhi and Manmohan Singh; and Darshan Shankar, an educational theoretician engaged with traditional knowledge systems. The scale of their achievement is impressive, and between them, hold both the Padma Bhushan and the Padma Shri, two of India’s most esteemed civilian awards for distinguished service to their country.

  Over the years, their campaign to revitalise the practice of Indian health traditions has become widely respected for its standards of clinical practice and for its work in community health, as well as its significant contributions to medicinal plant conservation, the study of medicines derived from natural sources and products developed from them. The research hospital next door was started with the aim of reinvigorating India’s medical heritage in practice,
as a route to introducing a new type of healthcare that embraces India’s main medical traditions – both ancient and modern.

  Because Amreesh had been late picking me up that morning, by the time I arrived I was at least an hour late for my meeting with Dr Darshan Shankar. His building had been constructed in the traditional style of the Bangalore region, which would have been a common sight before air-conditioned condominiums and concrete-block housing began their ubiquitous spread. The environmentally friendly unrendered brick facade under high, pitched ceilings gave way to a cool, semi-open courtyard, filled with medicinal herbs and trees, from which a staircase led to the director’s first-floor office. I knocked, and after apologising for my timekeeping, rapidly became absorbed in a discussion around the foundation’s database, a mammoth collection of information on materia medica across India’s systems: Ayurveda, folk, Unani, Siddha and the Tibetan Swa Rigpa. Darshan described how their database covered usage of plant-based medicines across an astounding 2,400 years from 1500 BCE.

  ‘From my perspective,’ Darshan said, ‘we can see from the database that folk, Unani, Siddha, Swa Rigpa – they are all “expressions” of Ayurveda. Their theoretical forms are similar – and the materials even more so. If you query the database, for example, for plants used in Unani, you will find four hundred to five hundred indigenous Indian species – meaning that Unani probably absorbed India’s materia medica, rather than bringing with it a whole other set of medicinal plants. When you look at the ingredients in some of its formulations, you see it’s the same as an Ayurvedic treatment of another name. There has been a great amount of assimilation [into Ayurveda] – Buddhist, Jain, Islamic and colonial influences.’

  Darshan pointed out that many of the oldest medical systems incorporate a strong practical element, but what sets Ayurveda apart is that it had a pre-existing, robust body of theory as well, cementing its status in India. ‘Ayurveda is so important in India, other systems will find a way of talking through its language and materials.’

  ‘What about the “other” using the language of biomedicine: modern science?’ I asked. I was curious about how much integration – scientific, theoretical and clinical – had already occurred and what Darshan’s vision was for the future.

  ‘You know, I had a cardiac condition six months ago. My family decided I should be opened up. So I went to an allopathic [conventional] doctor. He said to me, “I know what job you do – don’t mix up all these types of medicines. Leave it to us.” He said Ayurveda can do nothing. But now, post-surgery I am using a combination of allopathy and Ayurveda. OK, allopathic drugs can control cholesterol levels. But why do I have high cholesterol? We need also to look at the causes of that. Allopathy – biomedicine – is interested in maintaining problems within their limits, but the best of Ayurveda is telling me cardiovascular disease is a metabolic disorder. The mind is also a very important thing – I am also doing yoga for other reasons. Sooner or later, I will drop the allopathy.’

  I was surprised that Darshan had had heart surgery so recently. He came across as being very healthy. He was slim, he looked well and he was full of enthusiasm and energy.

  ‘Pluralistic choices have set the stage for people to ask questions and take different options when no one system has the answers,’ he continued, ‘but educational and healthcare institutes have not caught up. Forty to seventy per cent of people are exercising that choice, the World Health Organisation report on the use of traditional medicines shows that. I’m not talking about practitioners, but for the public – sometimes they are well informed, sometimes they are not. So sometimes there will be good outcomes, sometimes not. In a nutshell, today, for whatever political and sociological reasons, Western knowledge systems are dominant in all parts of the world. So you have a system prevailing in Asia, Africa, Europe, America – everywhere – where Western traditions dominate. Its strength is that Western science has incredible knowledge of detail – the fundamental units of the physical world, but you don’t have a picture of the whole.’

  I was interested (though, with my geneticist’s hat on, unconvinced) to hear from Darshan that in 2003, an Indian scientist, Professor Bhushan Patwardan classified a random population based on an Ayurvedic schematic and he showed that the three doshas (bodily constitutions) corresponded with specific genotypes (genetic compositions). ‘For us,’ Darshan told me, ‘this has opened the doorway to pharmacogenomics [the role of genetics in drug response] – it is known now as Ayugenomics. But Ayurveda doesn’t need to do research in the same way as modern science. We are not testing a drug, we are testing a system of diagnosis and treatment.

  ‘Such testing has been going on at least since the 1970s, when there was a study on the management of rheumatoid arthritis in Coimbatore, in Tamil Nadu. Ayurveda is known to be efficient in the management of this disease. The musician Ravi Shankar had participated in the study when the condition meant he could no longer play the sitar and in a few months he was cured. But the 1970s trials designed by World Health Organisation scientists aimed only to assess one narrow measure of success: to decide whether the Ayurvedic treatment did or did not work. The Ayurvedic doctor in Coimbatore said that he would have used fifty measures. The trial was abandoned as unworkable, but in 2011 the University of California, Los Angeles came back to repeat the study, testing Ayurvedic management against the best allopathic drug, methotrexate, in a well-designed study. They found that outcomes were the same under both systems, but there were fewer side effects with Ayurveda. So there is now a framework available to counter reductionist designs of conventional clinical trials. We don’t test only one parameter.

  ‘See, it costs millions of US dollars to do biomedical research,’ said Darshan. ‘But Ayurveda has survived for centuries and was created by a long history, not by science. There are 5,000 medical manuscripts in Siddha, there are 100,000 in Ayurveda, covering aspects of medicine and surgery. It’s highly, highly sophisticated. What Ayurveda needs to progress is to use modern tools. So the way we are working now is like this – the theory will be Ayurveda, the tools will be modern. And traditional theory must also grow in parallel otherwise it will lose its autonomy. If Ayurveda wants to come out of its marginalisation, today I have no option but to talk to the dominant medical system. In the future, in this age, we should be able to use modern methods to detect kapha, vāta and pitta doshas on a cellular level.’

  I left to talk to some of Dr Shankar’s research scientists, visit their botanical gardens and investigate the thriving integrated medicine hospital across the way. I thought, on the short walk over, about the point Darshan had made and what this would mean for the future of Ayurveda in India. In order to compete with the dominant ‘allopathic’ system, as he believes it is necessary to do, India’s traditional systems require a different level of understanding and the development of new characteristics. While knowledge of its foundations will remain necessary, new applications of Ayurvedic medicine must see what changes are occurring on a cellular level, just as scientific medicine is doing. I was also very clear on what he thought the benefits of integration were.

  ‘It is important to revitalise traditional medicine because of the marginalisation of traditional knowledge,’ he had told me, ‘for three reasons – because depressed traditional communities will get visibility; because patients will benefit; and because the frontiers of knowledge will expand.’ Dr Shankar’s thoughts reminded me rather of Hendrik van Rheede’s comments over 300 years earlier. The demise of Ayurveda has been a concern for centuries, but it has always survived.

  As I walked around the hospital guided by Dr Dhrudev Vyas, head of its operations and new initiatives, it felt like the realisation of a dream that had been sketched out multiple times since India’s colonisation and after its independence. The hospital seemed strangely unlike a hospital: there was an air of calm and orderliness and a distinct absence of the ominous smells of antiseptic and disease normally so all-pervasive. Wards were comfortable and spotless. The doctors were a mix of allopat
hic-trained and Ayurvedic and there were also pharmacists, physiotherapists, surgeons, acupuncturists, radiologists, yoga experts and biomedical scientists to process patient samples. The nurses’ stations, above which were signboards listing patients’ rooms by the Ayurvedic diets their occupants had been prescribed, were manned by conventionally trained nurses and auxiliaries, sharply dressed in shirts and trousers.

  On ward rounds, doctors both observed patients (by eye, for external clues and through biomedical measurements) and talked at length to them. Through questioning, they assessed the various dimensions important in Ayurveda for understanding what, for any particular patient, was normal or pathological function. Part of this was looking at the doshas (bodily constitution): – there might be an excess of pitta (bile, or heat), for example, but the patient’s background – factors like their genetics, geographic origins and history of infectious disease – could mean that this make-up was unexceptional for that individual. One person’s medicine could be another’s poison.

  Dosages, too, were very much tailored to the individual. Dispelling the popular perception that Ayurveda is slow to work, doctors at the hospital told me it simply takes time to optimise each patient’s treatments because each regimen is personalised. Doctors also ascertain which of the patient’s disease-causing imbalances might be be related to diet, activity and even the way they think. Without imbalances, they say, no disease can manifest. Equally, correcting a disease is not enough – success is achieved not when the problem the patient initially presents with has gone, rather, when all functions – sleep, appetite, digestion, metabolism – return to harmony.