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A modern incarnation of Ayurveda: hybrid practice at Naradevi Hospital.

Introduction

Ayurveda, the venerable South Asian medical tradition, takes on a stunning variety of forms in contemporary Kathmandu. From tantric jharpuke vaidyas blowing mantras to rasa sastra alchemists concocting potent rejuvenating formulas, to pharmacists dispensing Indian commercial products and even to white-coated, stethoscope-wearing doctors ordering blood tests and prescribing herbs in the form of capsules and syrups, the myriad forms of Ayurveda resemble the half-cultivated, half-wild tangle of growth at the Godawari botanical gardens. And, like such a forest-garden, some of the members are heirloom varieties, established in their soil for generations, and some newer cultivars, including hybrids that have crossed with foreign varieties.

Trying to comprehend this diversity was one goal of my Fulbright research, conducted over the course of 10 months from September 2008 to June 2009. This paper's focus is on the institutional incarnation of Ayurveda as practiced at the Outpatient Department of Naradevi Ayurveda Hospital. Having witnessed the extent to which the practice at Naradevi is influenced by Western biomedicine, I turn my attention here to analyzing that hybrid practice. I examine, in turn, the diagnostic methods used and the medicines prescribed at Naradevi, paying special attention to the types of language used there. Discussion of the different kinds of Ayurvedic drugs leads to an analysis of drug company rhetoric, which sheds light on the priorities and orientations of one brand of modern Ayurveda. Positing an epistemological divide between Ayurvedic alchemy and scientific chemistry, I locate the basis of one Naradevi doctor's claims for legitimacy on the scientific side. I end with an exhortation to Ayurvedic students and professionals to stay rooted in the rich legacy of that tradition, even while moving forward with the project of integration.

Methodological Issues

On a number of occasions during winter 2008-9, I observed at Naradevi Ayurveda Hospital's Outpatient Department (OPD) as part of my Fulbright student research. Typically I would come in after the clinical day had begun, and take a seat around the table where Doctor D.B. Roka and his interns were sitting and examining patients, or along the wall where patients were lined up, awaiting their turn. The scene in the examination room was busy: in addition to the doctor, the two interns and myself, there was a steady stream of patients moving through, so that at any given time there were some being examined, some finishing up their consultations and picking up their prescriptions, and some waiting to be seen. Although at first I felt awkward taking up space in such a setting, it soon became clear enough that my presence was at most a curiosity.

Surprisingly to my American sensibility, privacy is mostly a non-issue in medical settings in Nepal, and at times the OPD room could get downright theatrical. After a couple of visits I grew comfortable enough to jump into medical conversations or re-iterate to an elderly patient a point the busy doctor had made hurriedly, following the lead in this case of my fellow researcher, Dinesh Nepal (1).

I should emphasize here, at the start, that, although this work falls partly under the auspices of anthropology, I am not trained as a social scientist per se. Indeed, not only did I find myself unprepared to take quantitative data at Naradevi, but the prospect of compiling statistics left me cold. Rather, my interest is in Ayurveda as a flexible and often fuzzy conceptual apparatus and in the various ways that apparatus is put to work; in the forms that Ayurveda takes and the motivations behind those forms; in the content of the tradition and the myriad ways that content is interpreted. My work is informed by my background in the humanities and in Ayurvedic studies, which I pursued for one year with Dr. Vasant Lad at his Ayurvedic Institute in New Mexico, USA. Some of the points that follow might benefit from numerical support, but I am confident that my main contentions and observations stand independent of any such statistics.

Definitions

Before I delve into the body of this paper, a few definitions should be addressed: specifically, such potentially confusing or contentious terms as 'traditional,' 'biomedicine,' and even 'Ayurveda' itself. By traditional, I refer to those theories and practices within Ayurveda that have been handed down through a largely oral guru-disciple lineage. Generally these are the same theories and practices referred to in Ayurveda's Sanskrit texts, and include the doctrines of the panca mahabhuta and tridosa, samprapti, and (on the practical side) astavidha pariksa, methods of sodhanam and samanam, as well as more recent but now canonical practices such as the use of alchemical compounds for healing purposes. In naming a few of the vast body of techniques and understandings that make up part of the great Ayurvedic tradition, I do not mean to imply that traditional practices are static and inflexible, for Ayurveda is a body of living traditions, deeply-rooted, but constantly growing and even sending out new shoots and hybridizing with foreign species of medical understandings. Still, as a category of practice, 'traditional' stands in contrast to 'modern,' i.e. those practices and understandings that are more heavily influenced by 'biomedicine,' the globally dominant medical paradigm also called Western medicine or allopathy (2). It should be understood that many practitioners (perhaps most) fall somewhere towards the middle of the spectrum running from traditional to modern. Finally, by 'Ayurveda' I refer to the vast living body of theory and practice that can be traced back at least to the Caraka Samhita, and that finds multitudinous expression all over Southasia and (these days) beyond (3).

Diagnosis at Naradevi OPD

Once I began my observations at Naradevi OPD, it did not take long for first impressions to form. The operative clinical model there is definitely modern, that is, it closely follows the biomedical one. The speed of consultations was one immediate indicator: given high patient volume and limited physician (wo)manpower, each patient is dealt with quickly. Thus there is little time for detailed patient histories or indeed anything but those tests directly pertinent to diagnosis: basic biomedical parameters such as blood pressure are ascertained on the spot, and more specific testing (blood, urine, stool, X-rays, etc.) are ordered and, upon the patient's return, the results examined. Indeed, at first I was so caught up trying to follow the intricacies of the dozens of cases in front of me that I almost missed what soon emerged as the obvious point: that these patients' cases were being talked about in biomedical language, in English. This held true both for the patients' symptoms and for the diagnoses. The tests being done also reflected the influence of biomedicine in this ostensibly Ayurvedic examination room: every physician's and intern's neck was adorned with a stethoscope (worn on top of their white coats), whereas l only ever saw pulse being examined to determine simple heart rate. In traditional Ayurveda, it should be remembered, pulse examination is one of the prime means of diagnosis; the vaidya examines the pulse not just for rate but for such diverse factors as gati and bala, and often checks the status of particular organs through specific positions of the radial pulse (e.g., under the left middle finger for the stomach pulse). Equally surprising is that I never once saw a tongue examined. Certain traditional methods of diagnosis were, however, in evidence. It was routine practice for the doctor and interns to question the patient about his/her bowels and urine, if not actually to examine it. (I did not get to watch tailam bindu pariksa, in which the physician places a drop of sesame oil in a glass of the patient's urine and watches the movement of the oil, in action). Nevertheless, these examination techniques were put in the service of a largely biomedical diagnostic paradigm. Every patient's diagnosis was recorded in the clinic's log book, and the disease names I saw again and again are revealing not just of the health issues prevalent in the Kathmandu Valley, but also of the biomedically-leaning priorities of the Naradevi staff: COPD (chronic obstructive pulmonary disease), APD (acid peptic disorder, one of the incarnations of the ubiquitous disorder known in Nepali as "gastric"), and acute viral hepatitis top the list. Virtually the only times I saw a Sanskrit, Ayurvedic disease name listed were when it had a precise biomedical correspondent. In this case, "tamak swaas" might be written in lieu of "bronchial asthma."

I did on occasion observe an explicitly Ayurvedic diagnosis take place. One patient was complaining of aches and pains that were non-local and seemed to migrate around his body. The intern dealing with the man, unable to pinpoint any biomedical disease, recognized that the man's complaints fit under the Ayurvedic heading of a vata disorder. Thus a diagnosis, albeit a vague diagnosis, was possible: vata vyadhi, read the entry in the log book (4). His treatment consisted of aswagandha curna, a recognized vata-samak (wind-pacifying) herb. The incident demonstrated that traditional Ayurvedic understandings are not completely forgotten at Naradevi OPD, but that they are largely overlooked in favor of biomedical ones. Like an old, rusty tool, they lie in wait for the moment when they may be found useful again.

Treatment at Naradevi OPD

The vata case has brought up treatment for the first time here. As in many of the traditional ausadhalayas ('abodes of medicine,' i.e. traditional vaidyas' clinics) I visited, treatment consists largely of medicine, along with dietary restriction so that the patient's diet does not ruin the work (ausadhi ko kam bigarnu) of the medicine. This is in sharp contrast to both the more Western (tourist)-oriented Ayurvedic treatment centers in the Valley and to the ways I have seen Ayurveda practiced in America, where pancakarma treatments, sirodhara, and lifestyle counseling form a large part of the picture. The difference between the ausadhalayas and Naradevi lies both in the kinds of medicine used and in the stated reasons for using them. In the most traditional ausadhalayas, such as that of Banepa vaidya Keshab Kavi Baidya, the great majority of medicines dispensed are "shastric" medicine, i.e. hand-rolled pills, powders, medicated ghee or oil, decoctions, or some other type of medicine formulated from herbs, animal products, minerals and/or metals according to a recipe given in one of a number of Sanskrit texts, such as the Rasa Sar Sangraha or the Bhavaprakash. Occasionally Keshab-ji will modify such a formula or compose his own based on the principles of dravyaguna vijnana, traditional Ayurvedic pharmacology, and on his own clinical experience. Such an innovation may be to address a modern need (such as the need for an effective AIDS treatment) or to better address an age-old problem (such as impotence, for which I watched Keshab-ji compose a formula for a client). These medicines are the standard canon from which vaidyas have drawn for centuries, and I would argue that innovations of the kind Keshab Baidya makes fall within the bounds of tradition which is, I want to emphasize, a living tradition.

At Naradevi the situation is markedly different, both in what is given and in the justification cited for why a given remedy is appropriate. At the OPD, treatment does typically involve herbs that are traditionally used in Ayurveda. These are given as (in order of increasing new-fangledness) powder, capsule, or in a "patent medicine" formulation. In addition, one or more pharmacological drugs is often given alongside the herbs, with the latter being prescribed for a few weeks or a month or more while the former is often used for short-term (1-2 week) treatment. A single patient might well receive a pharmacological drug (e.g. Metranidazole), an herb in capsule form (e.g. Neem or Aswagandha caps), an Ayurvedic patent medicine in syrup or capsule form (e.g. Livotrit, Dermatone), and an herbal powder. The latter may consist of a single herb, as in guduci curna (Nepali gurjo ko dhulo), a mixture of two or more herbs to be purchased separately but taken together, or a classical Ayurvedic herbal formula, pre-mixed (such as Avipattikar Curna, Triphala Curna, or Hingwashtak Curna). Oxidized, powdered mineral substances (bhasmas) may also be given as part of an herbal mixture, although the clinic seems to use only two or three out of the dozens of classical mineral preparations.

Complicating the Medicine Chest

Clearly Metronidazole is biomedical, while Avipattikar is Ayurvedic. One is an import, the other the traditional local product. But the other types of medicine, herbs in capsule form and particularly the packaged "patent" medicines, blur the line between biomedicine and Ayurveda. Single herbs in capsule form are essentially a wolf in sheep's clothing (or a sheep in wolf's clothing). Their substance is Ayurvedic, while their packaging and research-based marketing reflect the need to appeal to the Western values and biases that are increasingly dominant in Kathmandu. The patent medicines are more complicated. Generally these are combinations of ten or more herbs, sometimes with minerals added as well. The herbs and minerals themselves are substances that have been part of the Ayurvedic materia medica for centuries or millennia, but the particular combinations of them are novel and, in fact, patented. They have pharmaceutical-sounding names like "Allerin," "Rhumasyl" and "Liv.52 DS." Their form is decidedly modern in terms of appearance and even taste. This last feature is especially surprising, given the importance Ayurveda attributes to taste as an indicator of therapeutic action: even a liver tonic formula whose medicinal constituents are bitter herbs may come as a syrup not only artificially colored and flavored but heavily sweetened. These products' form and advertising, more than their actual formulation, are revealing: they appeal to two legitimating frameworks simultaneously. On the one hand, their advertisements (or the marketing representatives who flood the OPD after clinical hours making their product pitches) may tout the presence of a particular, well-known herb such as Kutki (Neopicrorrhiza scrophularia) that is featured in the product. Presumably, an Ayurvedically trained physician will trust to a medicine that contains herbs he knows and esteems. This, then, is an appeal to tradition. On the other hand, almost everything else about these patent medicines--their packaging and marketing--reflects the apparent need to appeal to the biomedical paradigm for recognition and legitimacy.

Re-packaging Ayurveda

Consider the advertisement, posing as an informational bulletin, for the Himalaya company's product Liv.52. The poster warns, "The liver, the largest metabolic gland in the body, may face continuous onslaughts from."

Viral Infection (hepatitis virus)

Alcohol

Toxins (pesticides, cigarette smoke, industrial affluents)

Drugs (paracetamol, antitubercular agents, antibiotics, antiamoebic drugs, oral contraceptive pills)

These four enemies are arranged around a liver on four sides with arrows representing their "onslaught." Driving home the militaristic imagery that is so common in biomedical discourse is the ad's closing warning: "If you experience these symptoms [lists symptoms], your liver needs protection ..." (emphasis added).

The advertisement under consideration uses English-language biomedical terminology and the dominant biomedical metaphor for disease, that of attack and defense. For Himalaya Drug Company, Ayurveda is (literally) valuable but needs to be clothed in layers of biomedical speak in order to be marketable. Ayurveda's distinctive voice, suspicious, incredible or confusing to many ears, is muffled in favor of the prestigious, global voice of biomedical science. Interestingly, the advertising strategy here seeks both to valorize Ayurveda as a remedy for the ills of modern society (5), including the toxic nature of pharmacological drugs, and to submit Ayurveda to the legitimating processes of western science, e.g. clinical research studies.

Very much along the lines of this advertisement, Dr. Roka does not hesitate to critique certain aspects of biomedical practice and to tout Ayurvedic medicines (patent and otherwise) as solutions. For example, one morning a patient came in with jaundice and a fever. She had been taking paracetamol for the fever, but Dr. Roka told her to stop, saying that the drug was toxic to the liver and contributing to her jaundice. He prescribed, amongst others, Chiraito tablets; chiraito is a classic bitter herb used for both reducing fever and, indeed, 'protecting the liver.' It is interesting to hear how Dr. Roka himself conceptualizes this style of practice. A senior physician at Naradevi and professor of Kaya Cikitsa (internal medicine), Dr. D. B. Roka is an advocate of what he calls "integrated medicine." For him, being a doctor is coterminous with being able to treat all disorders, and both biomedical and Ayurvedic treatments are useful and indeed complementary means to this end. On one occasion he explained that be uses "allopathy to save the life, Ayurveda to prolong the life," but on another he told me that he considered everything he was doing to be part of Ayurveda, since Ayurveda is simply 'knowledge of life.' This is indeed one definition of Ayurveda, and one that has roots in the classics (6). The logic here construes Ayurveda not as a particular set of theories, practices, and beliefs regarding life and health but rather as a large-size frame in which all knowledge of medicine is contained. It is also arguable, however, that in the modern context, amidst tremendous pluralism (not to mention post-modernism), such a definition is so broad as to lose all meaning; under Dr. Roka's operational definition, presumably, a Japanese shaman or indeed any type of healer or doctor could qualify as an Ayurvedic vaidya. It is at least clear that Dr. Roka, like many good doctors, is a pragmatist, ever ready to use whatever tool or technique he believes will be most effective in a given case.

Sources of Legitimacy

Despite definitional confusion, there are elements of Ayurveda that tend to act as litmus tests, dividing traditional from modern practitioners along a rather neat line. In particular, the branch of Ayurveda called rasa sastra (Vedic alchemy) accomplishes this division by putting forward as medicine substances which a scientifically trained practitioner would view with skepticism, if not outright horror, as toxic. If you think in traditional Ayurvedic terms, they are (as Banepa vaidya Bishunath Karmacarya put it to me, "amrt" (nectar). There seems to be little room for compromise on this score: for a vaidya steeped in tradition, properly prepared mercury is a divine substance capable of inducing radical cures and rejuvenation. For anyone coming from biomedical training, mercury is poison (7). Thus it is significant that at Naradevi, rasadis, the class of traditional drugs containing mercury, appear to be avoided altogether. When asked about this omission--for classically these are considered among the most potent medicines--Dr. Roka replied that standards in the purification and processing of these drugs are lacking (8), and that, if not properly processed, rasadis are dangerous. The caveat about "not properly processed" struck me as a way of hedging: it seemed he was fundamentally distrustful of these substances but did not want to take a stand against them. Meanwhile, the point about unreliability may be true, given the likelihood of Ayurvedic drug companies' switch to mechanization cutting comers off the laborious, time-consuming processes outlined in the texts of rasa sastra (alchemy), for the sake of cost-efficiency.

There is an epistemological divide between Indian alchemy and western chemistry. It seems that Dr. Roka, though he may try and straddle the gap, ends up on the side of modern science. For when appealing to science for legitimacy, it is too risky to use or advocate the use of mercury-containing drugs, regardless of whether they have been processed in the traditional manner. Dr. Roka uses the dubiousness of their production as an excuse, bur this is after all something of a red herring, since these medicines have never been produced according to modern scientific standards--at least not until recently. Ironically, companies like Dabur now advertise the fact that their production methods are automated, high-tech; in other words, presumably closer to Dr. Roka's standards than has ever been possible before.

In this somewhat extended analysis of the kinds of medicine used at Naradevi, I hope the significance of the kind of language used to talk about those medicines has not been lost. For the dominant influence of biomedicine at Naradevi OPD is equally in evidence in the language used as in the drugs themselves. Even when discussing Ayurvedic herbs, their usage is generally justified by classifying their actions with pseudo-biomedical terminology. Guduci, a widely renowned herb considered both bitter and strengthening (an unusual combination in Ayurveda, if not in Western Herbalism), is hailed as an "immunomodulator (9)." Never mind that this term itself is vague (in what way is the immune system being modulated?) and would likely be regarded with skepticism by many biomedical doctors, at least in the medically less pluralistic West. In the context of the Naradevi OPD, the terra "immunomodulator" becomes salient because it provides a connection to biomedical physiology (however vague), and thereby stakes a claim for the kind of legitimacy that the biomedical paradigm can bestow.

Conclusions

I have tried to show that, in his practice at the Naradevi OPD, Dr. Roka is invested in both biomedical and Ayurvedic paradigms, but that the weight is not equally distributed between the two. At the end of the clinical day, Dr. Roka is aligned with the modern; consciously or not, he seems to buy into the narrative of Western science as final arbiter of legitimacy, of the Real. Though a highly respected clinician and favorite teacher of many students at the Ayurveda.

College with which Naradevi is associated, Dr. Roka strikes me as one of many clinicians and educators poised to subsume traditional Ayurveda into the dominating framework of biomedicine. I hope that I am not alone in seeing the violence that occurs when one epistemologically-distinct system is subjected to the out-of-context, limiting definitions of another. Modern practitioners, no matter how effective their clinical work, need to be aware of the postcolonial dynamic that can rear its head so easily in an East-meets-West endeavor such as the effort to integrate biomedicine and Ayurveda. Of course, there is little doubt that, in an increasingly global world, integrative medicine will emerge as a more and more important player. The question is, "how is integration to proceed?" It is essential for the health of Ayurveda itself that all its practitioners keep at least one foot firmly rooted in tradition, so that a true, balanced integration is possible.

Notes

(1.) Although we ended up taking our interest in Ayurveda in different directions, Dinesh-ji was an invaluable help during the initial stages of my work, and I owe him thanks for his generosity and friendship.

(2.) I avoid "allopathy" in this context, since this terra simply refers to the principle of treating with opposites. Since Ayurveda generally adheres to this principle, it would not be useful to try and distinguish biomedicine on these grounds.

(3.) Defining Ayurveda more closely can be treacherous, since internal definitions may no longer seem adequate, while modern attempts to pinpoint Ayurveda as specifically Indian (or Southasian) medicine add their own cartload of nationalist baggage to the picture.

(4.) Ayurvedic language can be much more specific than simply naming the dosa involved in a disorder: an example of a more specific diagnosis might be sama majja gata vata, vata mixed with ama and afflicting the tissue known as majja (bone marrow, sometimes understood to include nerve tissue).

(5.) See Jean Langford's Fluent Bodies for more along these lines.

(6.) The Caraka Samhita defines Ayurveda by the following sutra: hitahitam sukham dukham ayus tasya hitahitam /manam ta tacca yatroktam ayurveda sa ucyate. In other words, Ayurveda is about what is conducive and what is not conducive to a happy, healthy life.

(7.) Actually, there may be room for reconciliation here: the mercury used in Ayurveda is almost always reacted with sulphur to form kajjali or rasa sindur, black and red sulphide of mercury, respectively. It seems that these substances have negligible toxicity, since they are basically nonreactive. Their rejuvenative capacity might then be due to their exerting a catalytic effect on the tissues, without actually participating in any reactions. Nevertheless, up to the present, western science has consistently condemned any and all forms of mercury as toxic.

(8.) Dr. Roka laughed when I asked about the shastric injunctions for testing the purity of bhasmas (mineral drugs, including such controversial substances as naga, lead), which demand that (amongst other empirical tests) the powdered substance be fine enough to enter into the fingerprints as well as to float on the surface of water. In this day and age, nothing less than scientific analysis is sufficient, he told me.

(9.) I would contend that the traditional Ayurvedic analysis of Guduci as rasayana, vajikarana, medhya, jwarahara and tridosaham is more specific and much more useful than this one-word, pseudo-biomedical classification.
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Title Annotation:RESEARCH NOTE
Author:Edwards, Jonathan Hadas
Publication:Contributions to Nepalese Studies
Article Type:Report
Geographic Code:9NEPA
Date:Jul 1, 2009
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