Ancient Indian medicine offerings to the greying modern world: Stenting the stumble blocks

The Prime Minister of India has expressed in his “Mann Ki Baat” that people across the world are paying special attention to Ayurveda and Yoga and the need to introspect on our own strengths and our glorious tradition and our knowledge base could be supplemented through evidence-based research that could ensure a global acceptance for Ayurveda and our traditional systems of Medicine. The potential of Ayurveda and other traditional systems of medicine are worth exploring, in the contemporary way of evidence based research, when the world is undergoing a shift from infectious diseases to chronic and non-communicable diseases. This has necessitated closer look at modern medicine and its ability to support health promotion, prevention and rehabilitation. While modern medicine has contributed much in management for many non-communicable diseases, it is time to integrate medical systems which encourage healthy life style. Ancient Indian medical system- Ayurveda, in its broader sense provide solutions which are complementary to modern medicine. There are many avenues where the outlook of Indian Traditional Systems of Medicine vary widely from the contemporary biomedicine due to the difference in philosophical underpinnings of both systems, which challenge its potential for global impact and offer potential solutions to overcome these stumbling blocks to the global reach and acceptance and use of Indian medicine systems. We believe India has the potential to develop and showcase research paradigms relevant to integrative health system for the global health community. Modern medicine emphasizes on research evidence based patient care, wherein evidence is generated through clinical studies, often using randomization and control group. On the other hand, Ayurveda is a science based on long term, generational, practice and practitioner based evidence. Ayurveda interventions are logically customized for a patient centred care, based on the specific characteristics of each individual, his or her environment. Research in personalized medicine is bringing it to closer individual and to ideological thinking of Ayurveda. Still, evidence generation is a question of importance for Ayurveda. Many Ayush interventions, for example Ayurveda and Yoga, have utilized both practitioner and patient-based approaches and have adopted methodologies of randomized control trials for conduct, assessment, and evaluation[1,2,3]. Age and ageing process are the strongest risk factors for several diseases. With increasing life span in countries such as Sweden and India, more interest is laid on ensuring a healthy life span[4]. Hence therapeutic and prophylactic interventions and other factors that either delay/ prevent spectrum of diseases associated with mortality and disability are important. Recently, gero-scientists have recommended a focus on optimization of physiological function throughout life span[5]. Instead of focusing solely on absence of pathology, a novel understanding of health defines it in a positive sense, as a compendium of organizational and dynamic features that maintain physiological functions[6]. However, use of modern medicine(MM) in elderly often results in poly-pharmacy as multi-morbidity is common in them and MM treats individual disease rather than viewing multi-morbidity as a multisystem expression of advanced stage of ageing[7]. Therefore use of Integrative Medicine (IM) based on a holistic view and systems biology may be more desirable for healthy ageing[8]. In this regard, ancient science and holistic approaches to health are attracting much research attention[6,9]. Many complex interventions characterized by a holistic view, are not adequately assessed by gold-standard Randomized Controlled Trial (RCT) methodology[10,11]. Traditional and Complementary Medicine (T&CM) systems often utilize complex interventions that focus on health promotion from a whole systems/holistic perspective (WHO 2019). Despite high potential for preventive and therapeutic options, global acceptance of TCM/CAM systems is relatively low owing to lack of sufficient data on safety, quality and efficacy[12]. The resultant apprehension about T&CM systems among MM practitioners/researchers is rooted into challenges with understanding of the methods for evaluation of these systems. The differences in therapeutic approaches and epistemologies call for improved or newer research methodologies for TCM. New research methods can be better evolved by embracing diversity – by breaking silos between disciplines, approaches, Eastern and Western philosophies and ideas of health and wellness by way of cross pollination and cross talks between stakeholders in these research field[8]. A classical example to demonstrate an integrative medicine (IM) approach using Ayurveda with MM is Type 2 Diabetes Mellitus (DM)[13]. It is now known that glucose homeostasis is a tightly regulated physiological process that involves networking between multiple organs and cellular crosstalk. Hence a holistic approach that can target multiple organ systems involved in glucose homeostasis and pathophysiology of diabetes is now proposed[14]. Increasing use of Ayurveda for chronic conditions is reported from many parts of the world including from Sweden[15,16]. Beyond the Indian sub-continent, Ayurveda has also increasingly come into use in a global context[17] and is one of the largest expressions of CAM globally[18]. In the Swedish context, as well as the Euro-American context in general, Ayurveda falls under the broad umbrella of CAM. In Sweden, licensed health care practitioners are not legally permitted to practice CAM as professional vocation. Generally, natural remedies and medicines (including Ayurvedic ones) are the largest category of CAM-treatments used in Sweden, further warranting research into these[19,20]. Ayurveda has a holistic approach and emphasis on restoring homeostasis. It prescribes daily (Dincharya) and seasonal (Ritucharya) regimens for health[21]. Notably, Ayurveda has a branch termed Rasayana that describes lifestyle, diet, and other interventions with properties to enhance growth, retard ageing, and modulate immunity[22]. The interest in the Rasayana concept of Ayurveda, that incorporates rejuvenation and regeneration, is emerging as a priority area. Ayurveda has been one of the three main systems of medicine that existed at the beginning of the first millennium AD. Ayurveda suffered minor setbacks during the colonial rule, owing predominantly to the wider acceptance of MM that enjoyed state support, and the growth and development of Ayurveda suffered for many decades and its tradition of science gradually became ritualistic. Nevertheless, Ayurveda was given due consideration in the post independence era, wherein promotion and propagation of Ayurveda has been taken up as a mandate by many committees constituted during that time, and later on Ayurveda has been integrated into the national health system in India to a small extent but challenges due to positioning as inferior to MM exists[23]. The concepts of evidence in Ayurveda described as Pratyaksha, Anuman, Apta and Yukti that could be understood respectively as experimental evidence, logic and causality, experiential wisdom and tactical analysis[24]. Although Ayurveda has its own method of evidence, the conventional understanding of EBM is based on Western biomedical standards that includes systematic drug discovery, development with RCTs, and statistical analysis to show that the prescribed drug prevails over a standard/placebo[8]. However, it is noteworthy that Ayurveda has a holistic approach based on thousands of years of experience and is a unique system that considers body, mind, and spirit. Ayurvedic therapeutics is not restricted to the mere use of drugs and include an entire armamentarium of interventions that ranges from therapeutic interventions to behavioural and spiritual aspects. The dietary and lifestyle interventions that cater to the physical, mental and spiritual aspects of the whole human being forms the bedrock of Ayurvedic therapeutics. Thus Ayurveda attempts to treat the root cause—by introducing change in the environment within a milieu intérieur, as described by Claude Bernard[25]. Some experts have questioned the validity of models based on reductionist EBM approaches to holistic systems like Ayurveda[26,27]. The critique of EBM applies to most complex interventions even within conventional Indian and Swedish healthcare, including psychosocial interventions. Therefore, diversity in research approaches for the evaluation of complex and holistic interventions will carry broad benefit for medical science. One of the main problems with RCTs as the golden standard for EBM includes their reliance on single diagnoses – the complexity of ill-health often found among the elderly is not a suitable target for RCT assessment. Therefore, external validity of RCT methodology is often low, and a particular shortcoming when it comes to research among the elderly[28]. However, there are no appropriate existing models to replace EBM in this context, and this is a great challenge for holistic systems such as Ayurveda. One of the major barriers to the acceptance and appropriate use of Ayurveda has been lack of ‘evidence in contemporary viewpoint’[29]. Given the limitations with use of dominant research methods, several alternative approaches are floated. However concentrated effort at evolving practical guidance on methods for appropriate research in Ayurveda and IM as to stand the tests of scientific rigor while not compromising the fundamental principles of Ayurveda are desperately needed[30,31]. It is high time, scientists develop and test methods for research in these systems and an international consensus is built on methods for integrative medicine. As the PM has repeatedly underscored in his Mann Ki Baat, evidence based research is pivotal to address the challenges caused by the limited visibility in terms of evidence, to guide Ayurveda and Yoga practice. TM systems that remained ignored from the mainstream research in India and there is a wide gap to be filed. With the increased support to TM systems in India, unlike ever before, it would be apt for India to steer this knowledge development and offer the best of ancient treasures to the world in the spirit of Vasudhaiva Kutumbakam. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.