Why knowing Ayurveda’s limitations and improving clinical exposure are important while teaching traditional medicine

There is urgent need to update Ayurveda curriculum while also evolving it on its fundamental principles

By Taran Deol
Published: Wednesday 22 March 2023
Ayurveda is rarely the primary line of treatment for most people, who by default turn to modern medicine for their ailments. Photo for representation: iStock
Ayurveda is rarely the primary line of treatment for most people, who by default turn to modern medicine for their ailments. Photo for representation: iStock Ayurveda is rarely the primary line of treatment for most people, who by default turn to modern medicine for their ailments. Photo for representation: iStock

AYUSH (Ayurveda, Siddha, Unani, Naturopathy, Homeopathy and Sowa Rigpa) practitioners found their way into mainstream healthcare over a decade ago when the government of India attempted to fill the lacunae of insufficient healthcare workers by integrating these alternative systems of medicine in what was then referred to as the National Rural Health Mission. 

While the role of AYUSH practitioners in providing primary healthcare has often been advocated for, students of this traditional system of medicine are unhappy with some facets of their education. 

“Our curriculum does not explain exactly how Ayurveda applies to public health. We should be able to explain whether this is a complete system of medicine which can treat all types of diseases or whether it should be complementary to modern medicine. I am still not clear,” Lochan Acharya, a postgraduate student of Ayurveda at the Government Ayurveda College in Kerala’s Tripunithura, told Down to Earth (DTE). 

The Indian Medicine Central Council Act, 1970 was the first legislation to regulate Ayurveda education by setting minimum standards for institutes and maintaining a register of practitioners.

Under this act, the Central Council of Indian Medicine (CCIM) was constituted for monitoring purposes. The act was revised several times, first in 2002, when concerns about mushrooming of sub-standard colleges were raised. 

“According to the procedure in vogue, an intending society or trust can obtain the permission of the state government and consent of the affiliating university and start a college. After that, they approached the Central Council of Indian Medicine to permit them to run the course for a fixed number of seats,” A Raja, the then Union Minister of Health and Family Welfare had told Lok Sabha in 2002

There is no legal provision that makes it obligatory to obtain prior approval from the central government or the Central Council. This has led to the proliferation of sub-standard colleges, Raja added. Amendments to the act were recommended “with a view to permitting only those new colleges, which would comply with guidelines laid down in this regard,” he argued. 

While the law has since evolved several times, with the latest version including sundry requirements an institute must meet before being allowed to function, it hasn’t necessarily translated into an improvement in the quality of education.

The mushrooming of sub-standard colleges cited by Raja has only been on the rise. In the 1940s, there were only 35 Ayurveda colleges in the country. As of May 2022, this has multiplied to 453 colleges, government data showed. Of these, 352 are private institutes. 

Many argue that private colleges form the fulcrum of poor-quality education. Inspectors assessing whether the minimum standard requirements of Ayurveda colleges and attached hospitals are being met cite insufficient faculty who are poorly paid, fake patient data, bribing examiners and exploiting teachers as some of the pitfalls in how private institutes are functioning. 

However, it would be inaccurate to paint all private institutes with the same brush. The true quality of education can only be assessed on a case-by-case basis, Rammanohar, the research director at Kerala’s Amrita School of Ayurveda, told DTE

The National Commission for Indian System of Medicine Act, 2020 was introduced to address the lacunae in providing quality education, repealing the 1970 Act since the CCIM “had failed in its responsibility and not cooperated with the Central Government to safeguard the standards of education and practice of Indian Medicine,” a legislative note argued

Since the setting up of a National Commission (NCISM) was proving to be a tedious and time-consuming task, the 1970 Act was not immediately repealed. In fact, its 2020 amendment was aimed at reconstituting the CCIM. By June 2021, NCISM had been set up, officially making the 1970 Act redundant.

Owing to transitory powers, the rules and regulations made under the old Act will remain in force till new ones under the NCISM Act are notified. 

For updating the minimum standards and requirements for colleges and teaching hospitals, the NCISM released a document on February 25, 2023 to garner public opinion for a month, which will be finalised as a gazette notification three months thereafter.

At present, the Indian Medicine Central Council (Minimum Standard Requirements of Ayurveda Colleges and attached Hospitals) Regulations, 2016 remain in effect. 

A lacking clinical exposure

These regulations outline a standard that colleges and teaching hospitals must adhere to.

For instance, under the minimum requirement of beds, bed occupancy and Out-Patient Department (OPD) attendance for teaching hospitals, an institute must have a student-to-bed ratio of 1:1, student-to-OPD attendance of 1:2 and In-Patient Department (IPD) bed occupancy of 40 per cent. 

This is critical in dictating the quality and diversity of clinical exposure students of Ayurveda receive. However, not all institutes are able to meet these requirements, with many of them running the show on very limited resources. 

The disparity in the quality of clinical exposure depends on where the college is located — peripheral or in the city — whether it is linked with a modern medicine hospital and what kind of funding they have.

Compounding this further, Ayurveda is rarely the primary line of treatment for most people, who by default turn to modern medicine for their ailments. 

While renowned institutes like Banaras Hindu University (BHU), National Institute of Ayurveda in Jaipur, Gujarat Ayurveda University in Jamnagar and Government College of Ayurveda in Kerala, are able to provide students with robust clinical exposure, they constitute a minority.

“There are good examples on the micro level, but the macro picture is not satisfactory,” Rammanohar said. 

Aanchal Sharma, who completed both her undergraduate and postgraduate education in Ayurveda from BHU, believes clinical approach and exposure are important, particularly for Ayurveda.

“Some Ayurveda practitioners are very strict in following what is written in the ancient texts. But we need to upgrade our knowledge with the technology available today. To implement this in reality, we need clinical exposure, to identify what to upgrade and how to provide a more feasible treatment for people today. This is a big reason why our clinical impact is not as strong as it can be,” she said. 

Recalling how he was sceptical about the subject when he had first begun his education, Rammanohar said: “I was completely lost when I first started learning because, like most of my peers, I come from a science background.”

A lot of students go through the crisis of thinking Ayurveda is unscientific because of how it is taught, he added. “As opposed to coming in the latter half of the undergraduate degree, I believe clinical exposure should begin right away; to see these theories be implemented in practice helps students understand the concept better,” Rammanohar said. 

The current teaching method of Ayurveda mirrors the one for modern medicine; from theory to practice. This needs to be reversed, Manohar believes, to retain good talent, which is slowly losing faith in the system because they do not see Ayurveda be implemented.  

The need to update Ayurveda syllabus 

There is a need to update the Ayurveda curriculum by gauging how to optimally include modern medicine while also evolving Ayurveda based on its fundamental principles. The latter half of this updating exercise can be crucial and may potentially hold answers to the questions students like Acharya raise about the role of Ayurveda in public health.

The Bachelor of Ayurvedic Medicine and Surgery (BAMS) course mirrors the Bachelor of Medicine and Bachelor of Surgery (MBBS) course — lasting five years and six months, including a year-long internship.

The 19 subjects range from Charak Samhita (an ancient Ayurvedic text, taught in two parts), Prasuti evam Striroga (Obstetrics & Gynaecology), Bal Roga (Paediatrics), to Kriya Sharir (Physiology), Rachana Sharir (Anatomy) and Rasashastra evam Bhaishajya Kalpana (Pharmaceutical Science). 

However, traditionally, Ayurveda had only eight specialisations. The teachings are largely based on a handful of key texts —the Charaka Samhita covers the principles of internal medicine and is believed to be documented around 500 CE. 

The Sushruta Samhita covers surgery; the Ashtanga Hridaya is a summary of the Charaka Samhita and Sushruta Samhita; and the Sharngadhara Samhita is a more recent text (1300 CE) on the principles of pharmaceutics physiology and clinical methods. 

“Almost no Ayurvedic text is available in its original form. Knowledge has evolved over a period of time, with several changes and redactions to these texts,” Kishor Patwardhan, professor of Ayurveda physiology in the Ayurveda faculty at the Institute of Medical Sciences, explained. 

These texts were originally written in Sanskrit, which is considered to be a hurdle for students. “Translating Ayurvedic terminology into English is a bit challenging and contextualisation is often lost in translation. Good science should always be translatable, language shouldn’t be a barrier,” Patwardhan said. 

On this, GL Krishna — an Ayurveda physician, Homi Bhabha fellow and visiting scholar at Indian Institute of Science, Bengaluru — argues the language hurdle is often exaggerated.

“A diligent study of the first year Sanskrit course alongside making use of the good translations that are available can easily mitigate this problem,” he wrote in a 2017 editorial for Swarajya magazine.

Several academics describe Ayurveda as a free-flowing river characterised by self updation and continuous evolution.

Rammanohar classifies and teaches the curriculum as three key domains — where the texts themselves are debating about a theory, principles which are well-established through practice, and intuitive concepts, which cannot be scientifically proven currently. 

This is where some of the bigger, more pressing concerns of Ayurveda lie. Its primary texts have been used to impart knowledge for 3,500 years.

What began as an oral tradition in the gurukul system was formalised only in the 20th century when regulatory councils were set up to streamline the traditional system of medicine and its education system. 

However, the text is often preached as the gospel truth and the attitude of teaching is extremely defensive. “So naturally, questioning, rational thinking, and scientific temper are not encouraged in most institutions,” Patwardhan told DTE. This is among the system’s most serious pitfalls. 

In a confessionary essay published in the Indian Journal of Medical Ethics in July 2022, Patwardhan narrates his two-decade-long experience as a professor re-interpreting Ayurvedic texts through “recent advances in the field of medical physiology” to prove obsolete concepts, which at best “apparently (reduced) cognitive dissonance among students.” 

As example, he lists the formation of blood, which as per Ayurvedic texts takes place in the liver, spleen and even stomach. And this is how it is taught in class as well. 

In reality, we know blood is formed in the bone marrow thanks to advances in modern medicine and technology. Such a dissonance exists because at the time when this text was written, the concept of blood cells was not known. The onus is often on students to interpret the knowledge correctly. 

There exists a sect of academics who have reservations about this ‘obsolete’ argument. Among them is Sanjeev Rastogi, director of the Rashtreeya Ayurveda Vidhyapith, an autonomous organisation under the AYUSH ministry. 

“Some fundamental principles of Ayurveda are termed obsolete because we don’t understand the mechanism. If I am not able to understand, it’s a function of my limitation, not the subject’s,” he said, narrating incidents of some of his patients who have responded to certain Ayurvedic therapies of which he doesn’t fully understand the function of. 

While Rastogi admits there are parts of the Ayurveda syllabus which make little sense, to write off entire concepts as obsolete without properly experimenting and testing these theories is premature. This argument brings us to an interesting crossroads.

The Ayurveda stream has regularly been accused of resisting evidence, which has been tested scientifically and documented properly for the claims it makes. “This is the most common criticism the system faces,” Rastogi explains, who is also the editor of the Annals of Ayurvedic Medicines under the Association of Ayurvedic Physicians of India, a University Grants Commission (UGC) listed journal with over a decade-long publishing history. 

On an average, 80 per cent of the papers they receive are rejected for two key reasons; either the submitted paper is very poor in quality and substance, or the authors have failed to address comments raised by the reviewers. 

“Scientific writing does not take precedence in Ayurveda colleges. It is largely absent from the syllabus. Those who are publishing their work are doing so out of their own interest. This is a big gap which needs to be bridged for Ayurveda students,” Rastogi said. 

Acharya has similar complaints. As a postgraduate student, he has to submit a thesis in order to formally complete his degree. For this, students like him conduct randomised clinical trials (RCT) — considered to be the gold standard of scientific research — to prove their hypothesis.

However, in the absence of appropriate control to maintain randomisation, the assessment is often subjective and vague. 

“There is hardly any research that concludes anything negative about Ayurveda. This is evidence of a reporting bias and lack of integrity. Our research standard is low because we are not provided with appropriate training,” he said. 

However, implementing the RCT method may not be appropriate for Ayurveda, which advocates for individualised treatment. In such a situation, there is a desperate need to build a consensus on what constitutes the most accurate method to build credible evidence for Ayurveda theories. 

While acknowledging an improvement on this front in the past few decades, an editorial published last year in the International Journal of Ayurveda Research — a quarterly journal of the Delhi-based All India Institute of Ayurveda (AIIA), an autonomous organisation under the Ministry of AYUSH — argues “Ayurveda still needs to establish a culture of scientific publication to achieve widespread acceptance as a medical system.” 

To include or not to include modern medicine

While some academics argue there is a need to shift away from the modern medicine teaching method when approaching Ayurveda, the confluence of the two is a bit more complex. 

Disciplines like anatomy, physiology, pathology and the detailed pharmacology of herbs are not a part of the original Ayurveda texts. These contemporary components have been declared critical for two key reasons — to help bridge the gap in learning since most students come from the science stream after completing class 12 and to understand the limitations of the treatments Ayurveda can offer. 

Practitioners of traditional medicine must know what illnesses they can treat and, more importantly, what they cannot treat and therefore must refer to the appropriate specialist.

“This is impossible without having an understanding of modern medicine. Students must be able to recognise not only what the illness is but whether it is treatable with Ayurveda. It is not essential that every patient coming to an Ayurveda hospital must require Ayurveda treatment,” Rastogi said. 

Other academics like Rammanohar worry about what kind, and how much, of modern medicine knowledge is included because too much emphasis on modern medicine makes students want to practise that system.

While academics agree there is a need to teach modern medicine to students of Ayurveda, who is conducting classes on these contemporary subjects? Until the turn of the century, Ayurveda institutes employed faculty specialising in modern medicine who were equipped with handling such subjects, Rastogi said. 

“However, their posts were gradually, effectively abolished with hardly any new recruitments for the past 15-20 years in most institutes,” Rastogi added.

As per the 2016 minimum standard requirement regulations, an Ayurveda college must have an eight-member strong faculty of modern medicine on a part-time basis.

In reality, colleges often bypass this requirement, forcing Ayurveda practitioners to teach modern medicine subjects, naturally causing a decline in the quality of education, Patwardhan explained. 

The situation is variable across the country with some institutions, particularly the reputable ones, retaining some functionaries of modern medicine.

Such fissures in the Ayurveda education system plague the future of many aspiring students and practitioners. To address some of them, the Ministry of AYUSH launched the National AYUSH Mission (NAM), which includes targeted attention towards strengthening educational systems. 

First introduced in 2014, the centrally sponsored scheme has been expanded till 2026. Some states have also taken steps to improve the quality of Ayurveda education by strengthening medical colleges and research institutes.

For instance, the Kerala government introduced an AYUSH policy in 2016, under which one of the aims is to elevate AYUSH colleges to “premium quality” and promote academic and clinical research through a centralised facility. 

Under the Kerala government’s 13th five-year plan (2017-2022), the working group report on AYUSH noted: “All government and aided colleges are to be upgraded to the level of model colleges.” “Stringent steps should be taken to maintain the quality of education in the private sector,” it added.

The Uttarakhand government made similar observations in its AYUSH policy released in 2018 and outlined steps to upgrade medical education institutes and implement a robust regulatory framework to ensure standardised quality education. 

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This article was supported by Health Systems Transformation Platform as a part of HSTP – Health Journalism Fellowship 2022.

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