Observations and Reflections on some Emerging Trends.
A V Balasubramanian
Abstract.
In India a large number of medical systems coexist. While several are officially supported and recognized, many others also flourish with public patronage. At present, no single system of healthcare is able to provide comprehensive and effective solution to all the health needs of our people both on grounds of efficacy and performance as well as due to economic, social-cultural and historic factors. In practice, there are a large number of attempts made at “Integration” of multiple systems which represents a whole spectrum of partnerships that are attempted by the individual care seekers and/or the experts with varying degrees of intuitional recognition and support. This article provides a bird’s eye view of some of these efforts ranging from those that are initiated by the patient and / or by the experts / practitioners in various ways. There are also community based efforts which by pass the “Traditional/Modern” binary. A cross-cutting theme here is the issue of methodology of science and accepted norms for testing and validation of knowledge and practices. These efforts have great significance not only in terms of pragmatic considerations of access and outreach of medical services, but also with respect to the methodology and epistemology of knowledge systems. Some of these efforts involve the end user namely the “Patient” in a central and critical way, and these are relatively free of the “Hangover of Methodologies” and do not concede any high ground or special status to any expert. There are no pre-existing models or templates for such efforts .The Indian society has eclectic traditions and we have a genius for synthesis. We can provide the most fertile ground to nurture such efforts which may have consequences that are far reaching and way beyond this specific domain of knowledge / practice as well as our geographic reach.
A. What is Integration?
The word - "Integration" is used in this article in a very broad sense and may represent use of multiple systems in a variety of ways such as -
A combination of any two or more systems - in an extreme situation this may be considered as a - "Merger"
A partnership in which two or more systems are used together - this may be simultaneously or - "In succession" (such as Allopathy during an earlier acute/infective stage and traditional medicine as a long term follow up) or in some cases, diagnostic methods may be used to assess the incidence/severity of a condition (such as through an x-ray or a blood test for sugar....) and again to track and monitor the progress in terms of treatment.
There may also be a partnership in the sense that particular systems are used exclusively or in preference for specific diseases/conditions.
B. Integration at Various Levels
In terms of the individual/agency that is initiating or trying out such integration, it may be again at varied levels At the level of a nation/state or province , it may be at the level of an institution that provides care . Choices may be made by practitioners of any system and this may be attempted at the level of the individual - the patient/care seeker or a member of the family or guardian for the care seeker.
C. Scope of this article
In India, a very large number of medical systems prevail and several of them are officially recognized and supported. Here I plan to limit myself to understanding and examining partnerships that exist between two specific systems namely - Allopathy/modern medicine on the one hand and Ayurveda on the other. Who represents or - "Speaks” for a knowledge system? It would appear in the context of modern knowledge that it is the - "Professional/Practitioner” who is qualified in domains such as - medicine, architecture....etc. However, in the case of traditional knowledge, the social organization of the knowledge system and its practice is substantially different. Here, even in theory there is a - "Continuum between the lay person...folk practitioner...specialist" and knowledge is generated, innovations take place and practitioners abound it appears in all levels. Hence, there is a need to keep this in mind when we talk about the combined use of modern and traditional systems.
D. Testing, Validation and Utilisation – Varying Approaches and Reflections on Challenges and Limitations.
The issue of methodology in terms of answering the question - "How does knowledge get generated, accepted and validated" assumes a great importance. This is because on this issue modern science has traditionally claimed a moral high ground and it is generally assumed implicitly or suggested explicitly that the - "Method" adopted by modern science is universal and has a validity that cuts across various domains of knowledge and types of knowledge. It has been sometimes said that there is no need to look at knowledge as - "Modern or Traditional or Old or New" and any knowledge is valid knowledge if it can withstand the scrutiny of scientific method. Since this has a bearing on the question of “Integration”, we will start with an overview of various approaches to – “Testing and Validation”.
1. Types of Testing and Validation Efforts
There is indeed a multiplicity of approaches including the following –
a. Modern approaches to testing making use of modern/scientific methodology – of this there are several examples, and in a sense, this appears to be the major effort in our modern science and technology institutions, whenever they take up work relating to traditional knowledge..
b. Approaches to testing and validation that start with and rely on what may be considered as parameters or factors from traditional knowledge systems. These are relatively less in number.
c. There are also emerging new approaches and once such instance is a – “Community based assessment” which manages to bypass the traditional/modern binary.
2. Challenges and Limitations with Respect to Efforts for – “Testing and Validation”
Is it always possible to take up testing and validation of traditional knowledge using modern scientific parameters?. We see the following possibilities –
a. In some cases, testing may be simple.
b. In some cases, testing may not be simple since the two different approaches namely – traditional and modern may suggest measurements of factors/phenomena, that may be “Overlapping” but not identical.
c. In other cases, the two different approaches may be – “Non commensurate”.
E. Integrated Use of Traditional and Modern Approaches: Efforts By The Patients/Care Seekers
1. Elements of the approach: Several patients I have been involved in attempts to integrate inputs and solutions from different medical systems in order to take care of immediate health problems. Patients seem to have clear perceptions about the relative strengths of modern medicine and alternative systems. The table below summarizes what emerged as the general approach of most patients.
Modern medicine versus alternative systems – Patients’ perceptions of each system’s strengths
Modern medicine | Alternative systems |
|---|---|
Surgery | Chronic conditions |
Acute conditions | Organic |
Emergency situations | Complex situations affecting many physiological systems |
Infectious and communicable diseases | Requiring many areas or systems |
Problems in specific areas of the body | Psychosomatic conditions |
Purely physical problems | Those with strong emotional components |
Analgesicaction for immediate relief | Support for long term relief – “Getting to the root of the problem” |
2. Strengths of such efforts at Integration
In this light, and as a result of current efforts at integration, we note the following specific strengths of Ayurveda, and its contemporary use in integrative practice:
Practical benefits experienced by the patient
Modern medicine as a primary line of treatment, with secondary inputs from alternate systems as regards food, improved immunity, and other system capacities, make a fine complementary pairing
Traditional medicine as the main line of treatment for chronic disease, with modern medicine for acute emergencies, surgical procedures, communicable diseases, etc., also form another fine complementary pairing.
Either pairing is now frequently used to take care of several contingencies, e.g., minimizing the side effects of modern cancer treatments.
Both have led to mutual respect between practitioners and both have paved the way for a better understanding of each other’s’ strengths.
The patient becomes an active participant in his own healing process.
3. Weaknesses of such Efforts
While it is significant that efforts at integration are in progress at the ground level, it cannot be denied that they suffer from a number of limitations due to their being ad hoc and without centralized leadership or direction. Some of the weaknesses are as follows:
One or more experts (sometimes all!) being in the dark about the overall plan! This leads to poor design
Lack of fall-back arrangements for emergencies, when traditional medicine is tried as the main line of treatment
Practitioners of modern medicine (even open-minded ones) being ill-equipped or unable to give patients advice on complementary therapies – what, where and how.
The worldview of many patients still being entrenched in the traditional medicine paradigm which may get projected to the modern treatment with dangerous consequences, e.g., stop taking medicine when symptoms disappear/deep suspicion of long drawn out medication for palliative treatments of chronic conditions
This also applies in reverse to the modern medicine paradigm which may get projected on to traditional treatments with dangerous consequences, e.g., deep suspicion of slow response to medication for deep treatments of chronic conditions, so stop taking medicine before symptoms are minimized or disappear
Modern practitioners advising patients on traditional therapies without inputs and expertise of traditional scholars – leading to results that are at best limited and sometimes negative.
There is also a dangers of “Over dosage” due to combined use of several systems without a nuanced understanding of how they work or produce effects.
There is also a common belief that alternative therapies and traditional medicine such as herbal remedies have no side effects and are entirely safe to use. There is certainly a measure of truth in this to the extent that their standard drugs used in common treatments are indeed free of “side effects,” but only when used by expert practitioners or knowledgeable persons. But this does not mean that any traditional remedy or approach can be picked up and used by anyone at all with the assurance that “even if it does no good it cannot cause any harm.” Even traditional approaches to healing can cause problems if they are not properly employed.
F. Documentation and Assessment of Local Health Traditions (DALHT): A Different take on Integration
The approach involves the community in a key and central manner. In the community, the users of the knowledge (patients) as well as the folk practitioners provide the primary inputs and share experiences. The formally qualified practitioners of traditional medicine in the community (Ayurveda, Siddha, etc) comment on the practices in terms of soundness, completeness and safety. Modern medical practitioners, community health experts and modern drug research experts are also consulted. In a large number of practices, it is found that the modern researchers (Allopath, Drug researchers etc) have not tested or studied the local knowledge and practices. In such cases, the assessment process notes that on this topic - “Modern medical scientific research is data deficient”. The assessment makes a decision about the utilization and propagation of ITK based on the available evidence and reflections and refinement from the other participants. The critical difference between this approach and the – “Normal Scientific assessment”, is that the utilization and propagation of ITK is not put on hold or halted due to the lack of “modern scientific research” In most cases Allopathy has not – “Looked into / studied” the efficacy of the herb or treatment. In such cases the Allopathy input is labeled as – “Data deficient”. What the community is telling the Allopath is as and when you take up research or studies keep me informed. In the meanwhile, I am not going to be waiting for a – “Green Signal” from you. Absence of evidence for efficacy…… Is NOT the same thing as……. Evidence for absence of efficacy!!
G. Integrated Use Of Traditional And Modern Approaches: Efforts By The Experts With Institutional Support
This is perhaps the most promising of the recent trends. As I see it, its origins can be traced to what started as – “Referrals”.
1. Starting with – “Referrals”
The starting point for this approach is – “Referrals” of patients across systems, which perhaps progressed through the following stages –
a. Allopathy/Ayurveda experts taking note of the fact that patients are involved in mutual referrals and observing it without being critical if not overtly encouraging.
b. Allopathy/Ayurveda experts initiating such referrals with some hesitation and over a period of time with greater assurance as they developed mutual respect (however grudging) and with a nuanced understanding of what kind of referrals were effective or “Worked” (such as specific diseases or types/stages of diseases).
c. A recent interesting effort is a formal document put out by the CCRAS (Central Council for Research in Ayurvedic Sciences) about cross referrals.
d. Towards integration at the level of treatment.
While what we have to say about 1 and 2 is mostly anecdotal there is more to report in terms of documented efforts with respect to 3 and 4 above.
2. Dealing with Specific Conditions
In terms of integrating modern and Ayurveda approaches for the treatment of specific conditions, one of the most interesting and systematic efforts is what has been in progress at the Department of Integrative Dermatology at the Institute of Applied Dermatology at Kasaragod in Kerala. This effort is a multidisciplinary effort that has been pioneered by Dr. S.R.Narahari and has been in progress for well over 20 years. In the year 2016, the journal Current Science produced a special issue on – “Integrative medicine” (Volume 111, Issue 02) dated 25th July 2016 for which Dr. Narahari and his collaborators Dr. Terence Rayon (From England) and Dr.G.M.Aggithaya were invited to be guest editors. The issue contains a series of articles wherein this team has described their approaches, challenges and results with respect to integrative care specifically in the area of Dermatology . The efforts of this team have some outstanding features which are indeed pioneering and addressed various challenges in the area of – “Integrative medicine”. As per Dr. Narahari himself, the basic approach and methodology of their work has been spelt out in great detail in their earlier publication . Some of the interesting features are -
a. Dermatology treatment protocols have been developed for patients with long standing skin diseases.
b. A team of Doctors from modern dermatology, Ayurveda, Yoga therapy and homeopathy studied recruited patients to develop mutual orientations on each therapeutic system.
c. The conclusion from this review is reproduced here - “Conclusion: It is evident that integration at the therapeutic level is possible, although the pathological basis is interpreted differently. Irrespective of background understanding of the given disease, a mutually oriented multisystem therapeutic team was able to effectively use medicines from more than one system of medicine and to develop guidelines for their prescription and a patient care algorithm.”
The same issue of the journal Current Science also carries interesting articles about integrated care with respect to Leprosy as well as the reflections of the team on how the scientific horizon of such efforts may be expanded.
H. Conclusion and The Way Forward
1. Seeing with Two Eyes
I would like to suggest that in solving medical problems, seeing from the perspective of two different medical systems may be compared to the physiology of “seeing with two eyes.” When one looks at an object with two eyes, what the right eye sees is a little different from what the left eye sees. However, there is no need for resolving this difference at the level of answering the question – “Which is the correct view?” There turn out to be clear advantages in seeing with two eyes:
a. Improved resolution at edges, increased contrast, better ability to read when the print is small or illumination is poor.
b. Information obtained about depth of field gaining “perspective”.
c. The difference in the information provided by two eyes is thus information of a different logical type.
Hence approaches using more than one medical system have interesting advantages and should be taken forward wherever feasible.
2. The Framework for Integration – What is the Viewpoint and the Overall Objective?
Whenever “Integration” is attempted, at one level it can be seen that the overall objective is to provide better care for the patient and address the health issues. However, at the foundations of this concern we can also see that there are viewpoints and values that may be guiding, determining, limiting or enabling choices that have been made and strategies that are being adopted. The following list is given by Dr. Narahari and his team in terms of their approach and methodology to “ Integration”.
a. The authors considered the – “Framework of biomedical diagnosis” to be critical and central.
b. The integration is driven by the concern that modern medicine which can take care of acute conditions faces a critical gap with respect to – “Chronic” conditions and Ayurveda can fulfill this need.
c. Ayurveda and integration are valuable in our context because resources are limited and this especially so in rural areas.
While there is nothing that we can fault with any of the above. It is clear that if we start out with other priorities, preferences and values, the approach and outcome would be different.
This also leaves us with a few questions such as –
Are these solutions recommended/suitable only in a society/ situation which is severely limited by the resources available?
Are we taking the view that for the poorer sections of the society solutions drawn from Ayurveda and integrative medicine are all that we can offer/afford while the more prosperous amongst us can afford modern medicine?
Is Ayurveda/ integrative medicine a “Stop Gap” arrangement that we live with till such time that we can offer modern medicine to all our people?
These questions are very similar to the questions raised in the early days of – “Rural technology/ appropriate technology” wherein various kinds of solutions (such as low cost housing with eco-friendly material….) were being offered to rural areas. Such questions will remain and have to be answered even as we make efforts at integration.
3. Reversing the Gaze.
One way of looking at this is to see if integration would have a different approach and results if it is lead, driven and motivated by Ayurvedic Physicians. While a lot has been said and written about how modernity/modern medicine looks at and evaluates traditional medicine based on which it accepts/rejects ideas, techniques and materials, the reverse is not widely or prominently seen.
How do Ayurvedic physicians look at, assess/evaluate modern medicine based on which they accept or reject its offerings. However, there are a few trends that we can take note of.
Use of spectacles and other devices: In some cases there is widespread use of specific pieces of technology/devices that have found widespread acceptance. The use of spectacles for correction of vision is one such case.
Modern diagnostic methods: There is increasing and widespread use of modern diagnostic methods which may be employed as a guide for treatment and also to track improvement.
Assessment of New Foods: In terms of assessment of properties of new foods (in the sense of something not know and described in the Ayurvedic texts) there have been efforts made by Vaidyas to attempt a detailed and rigorous categorization based on Ayurvedic principles. For example, one such analysis about custard has been carried out by Vd. Ramesh Nanal who has drawn conclusions about its actions on Doshas, Dhatus, Malas, action on diseases, contraindications, etc. Similar analyses have also been carried out with respect to other substances such as – tomato, tobacco, etc. In more recent years as a result of increased interest and use of Ayurveda in the West, Vaidyas have also written and discussed about properties of herbs and foods that are "New" in the sense that they do not find a mention in Ayurvedic texts or tradition.
Vaccination and Public Health : There has been widespread and increasing use of vaccination as a measure of public health and it’s acceptance may be considered as widespread. There have been critics of vaccination on – “Ethical/Moral grounds” – such as those voiced by Mahatma Gandhi about which there has been a mention in the diaries of Shri. Mahadev Desai. However, it appears that currently the Ayurvedic community does not object to this on technical/scientific grounds.
It appears to this author that there have been various individual approaches and responses but something in the nature of a more systematic or larger approach involving an entire community of physician or strong institutional support is yet to emerge.
I. Towards Strengthening New Efforts.
Some of these new efforts involve the end user – patient, farmer, consumer…….it does not critically depend on any kind of expert and cuts across varied domains.. It is free of any hangover from methodologies. It does not concede any “epistemic ground” to any expert. It is capable of horizontal spread and acceptance through new age media. The limitation of some of these efforts is that experts who could play a supportive role may not be a part of the scheme. Allocation of public funds and resources still requires/is dependent on validation of the formal kind involving modern experts.. Can we transform these kinds of initiatives to a more powerful and effective level? We need to nurture them with a different approach. It must involve both traditional and modern experts in a partnership with some sense of equality. The end user / consumer of the knowledge / technology generated must also be a partner in this effort with an equal – “Epistemic status” and these efforts must be nurtured patiently with substantial investments in terms of time and resources. There are no pre-existing models or templates.The Indian society has eclectic traditions and we have a genius for synthesis. We can provide the most fertile ground to nurture such efforts.
Selected References:
Balasubramanian AV, Devi N. Is there an Indian way of doing Science? In: Balasubramanian AV, editor. Traditional Knowledge Systems of India and Sri Lanka. Chennai: Centre for Indian Knowledge Systems; 2006. p. 183-92.
Documentation and rapid assessment of local health traditions – a strategy for mainstreaming local health traditions for primary health care in India by G.Hariramamurthi .Chapter 3, pages 27 – 59 in the book – “Testing and validation of indigenous knowledge: the COMPAS experience from Southern India (editors) A.V.Balasubramanian, K.Vijayalakshmi, Shylaja. R. Rao and R. Abarna Thooyavathy (Centre for Indian Knowledge Systems, Chennai). March 2011.
WHO Global Atlas of Traditional, Complementary and Alternative Medicine. Text volume by Bodeker G, et al and Map volume by Ong CK, et al. Kobe, Japan: World Health Organisation; 2005.
Ayurveda and conventional medicine: Cross referral approach for selected disease conditions (Editor N. Srikanth). Central Council for Research in Ayurvedic Sciences (New Delhi) 2021.
Ayurvedeeya Drushtikon se gunkarmadi ka nischaya by Vaidya Ramesh Nanal. Ayurvedeeya Mahasammelan Patrika. February 1989. 17 – 19.
Note: A full version of this paper is available here.
A V Balasubramanian is the Founder-Director of the Centre for Indian Knowledge Systems (CIKS), Chennai, and can be reached at ciksbalu@gmail.com. His brief bio sketch is available at https://www.ppstindiagroup.in/a-v-balasubramanian-s-bio
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