From Witchcraft to Allopathy
Uninterrupted Journey of Medical Science
Witchcraft, Ayurveda, homeopathy and allopathy evolved over time and exist today. While witchcraft was based on the belief that evil spirits inflict disease, Ayurveda in India and Yin-Yang in China introduced the concept that the cause of disease is physical and not supernatural, which led to a search for physical remedies from plants, animals and soil. Homeopathy recognised that drugs assist the body to cure itself. Given the complexity of the biological system and disease processes, none of the medical disciplines can fully meet the expectations of the patient and therefore, have managed to survive until now. The dismal state of healthcare system in India, coupled with strong feudal culture, also caters to the survival of both rational and irrational medical disciplines and practices.
DAYA R VARMA
I Background
T
II Introduction
In no other area of knowledge are myth and reality, rationality and irrationality so intertwined, each claiming to be superior to the other, as in medicine. Because people expect from medicine both what is possible and what is not, there is always a stream of people who are eager to be preyed upon. Both the clientele and the healers have mushroomed in the era of the religious right. So we have Sai Baba, Ajmeri Baba and Pandit Maharaj offering cures for all your problems. Numerous ‘Matajis’ are blessing and hugging you so you can attain Nirvana easily in return for a “voluntary” contribution. The craft and “Art of Living Foundation” of Sri Sri Ravi Shankar advises from his modest 60 acres ashram near Bangalore about everything that is good for him and you. Sophisticated “healers” like Deepak Chopra can combine everything that is good into a single package for your consumption in exchange for your money. What makes all this possible? It is the desire of the people to be cured regardless of the nature and pathology of the disease. It is easier to exploit the limits of medicine than its merits. So we have practitioners of Ayurveda, homeopathy, acupuncture, naturopathy, alternative medicine and so on. All these professionals may or may not have something to offer; however, unlike an ethical practitioner of medical science who may simply tell the patient that she or he has no more than few days or months to live, the unethical ones claim no limit to their art.
Medicine and other branches of biology deal with a highly complex system; it is not surprising then that biology does not achieve the same precision, as do the physical sciences. In one sense, however, biology itself may be considered to be the most complex part of physics and chemistry. In the final analysis, fundamental particles in some complex combination and interaction with each other create living organisms, which can be as tiny as a virus or as big as an elephant. The distinguished British crystallographer J D Bernal in his celebrated work, The Origin of Life, published in 1967, writes: “My provisional definition of life: Life is a partial, continuous, progressive, multiform and conditionally interactive, self-realisation of the potentialities of atomic electron states (italics in original), should be sufficient to show that all life has some material structure in common, in the form of enzymes, nucleic acids and essentially reproducing organs or molecules.”
We do not hear of different disciplines within physics and chemistry, only subspecialties, because there is not much money to be made by doing so. Biology is different. Intelligent design as opposed to evolution is needed to shackle people in religious orthodoxy. Money can be made by good as well as bad medicine. Yet all branches of science have a similar history. Until 1845, chemists believed that organic compounds were produced under the influence of a “vital force” and could not be made artificially. Even the synthesis of urea (an organic compound) by Wohler in 1828 could not dispel the vital force theory because he used ammonium cyanate which was, until then, only obtained from animals. Only when Kolbe synthesised acetic acid in 1845 from its elements could the vital force theory be discarded. But there is no doubt that it was discarded. There is no branch of chemistry now that is based on vital force theory. Medicine, somehow, is different.
How did the system of medicine evolve, where does it stand at this point in time and why are there so many systems of medicine but only one system of physics and chemistry? (For convenience and lack of competence in the area, I leave out the Sangh parivar’s astrology and palmistry from this list.)
III Origin of Medical Science as Witchcraft
All systems of knowledge, rational or irrational, speculate on the causes of an event and a method to appropriately use the event to their advantage. Medicine is no exception. Disease is as ancient as human kind; so is the human desire to be rid of the disease. The early humans had little knowledge of science but were witness to natural blessings and havocs of one kind or another. While fruits and fish were blessings, disease was a curse. Naturally they believed that illness is a curse of an evil spirit, which can be termed the “devil”. So they came up with an explanation for the disease. In a way this process was revolutionary because it is based on enquiry, the fact that the answer was wrong is a different matter. We come up with a wrong answer to the right question all the time. Because our ancestors speculated that the disease was caused by the devil, the treatment naturally was to satiate the evil spirit. This was the origin of witchcraft. In its own way this is a complete system linking theory with practice. There is a cause and there is a cure. The approach is scientific even if its foundation is faulty. While the theoretical basis of witchcraft was, to a great extent, similar all over the world, the methods of appeasing the devil differed from society to society depending upon other prevailing social practices and available natural products and methods. So the first stage of medicine was the science of witchcraft. It lasted for the longest time and still exists. Counterirritants and inflicting pain to treat the sick are common practices of witchcraft; some of them might even be effective. Nonetheless, it is very likely that widespread belief in witchcraft and superstition delayed the development of rational medicine. Reflecting on Dr Morton’s successful demonstration of the anaesthesia induced by ether at the Massachusetts General Hospital in 1846, Green commented: “So long as witches were being burned in Salem, anaesthesia could not be discovered 20 miles away in Boston”. There are many anecdotal tales in India of how the sick were forced to undergo witchcraft instead of being taken to a hospital.
IV Materialist Theory of Disease
Ayurveda, Yang-Yin and Egyptian-Greek Physicians
As time passed and human knowledge increased, the “curse of the devil spirit” as the cause of disease came under scrutiny. It did not make sense when it was realised that disease is physical so the cause must be physical. This was the second and the most important phase in the evolution of medicine. It is not surprising that this breakthrough came from two of the oldest living civilisations – India and China. Indian scientists of that time came up with a new theory of disease. According to them, the cause of disease was not the curse of evil spirits but an imbalance between three systems (‘Tridoshas’), termed ‘Bayu’, ‘Pitta’ and ‘Kapha’ (respiratory, circulatory and digestive system in the broadest sense). China came up with the theory of interaction between two opposites – Yang and Yin, similar to the dialectical concept of unity of opposites. These were the milestones in the progress of medical science. The contributions of Egyptian and Greek physicians were in specific areas and related to the description of diseases and possible cures and toxicity of drugs. These concepts were developed to a high level of detail by Hippocrates (468-377 BC).
Just as Darwin (1809-1882), a thousand years later, provided a biological basis for evolution in his celebrated treatise The Origin of Species (1859), Ayurveda presented a physical as opposed to a mythical basis of disease. So did the theory of Yin-Yang. And just as the spiritual basis of disease led to witchcraft, the theory of the physical basis of disease led to the exploration of physical means of alleviation of disease. Thus began the search for remedies from plants, animals and soil. It is beyond the scope of this short note to deal with different reasons for the selection of different remedies in Ayurveda or the Chinese medical system but the approach, even if intuitive, was scientific and based on some empirical data. It might be worth speculating that experimentation was a way of life for our ancient ancestors, which is not the case in an era of abundant supply (if one can afford it) of ready-to-use goods requiring only the reading labels, if at all.
Not only did Ayurveda recognise the physical basis of disease, it also ventured into devising a method for identifying the nature of the diseases that is a method of diagnosis. Aside from the obvious clinical picture presented by the patient and the patient’s description of the ailment, Ayurveda recognised that there exists pulsation at the wrist and that these pulsations can vary from one disease to the other. Thus a circle was completed. What causes a disease, how a disease can be diagnosed and how it can be cured. Between 300-400 BC, Greek and Egyptian physicians also developed a materialistic view of medicine; their description of the symptoms of disease has stood the test of time and the Hippocratic oath is still held to be the ultimate test of medical ethics. Since Greek and Egyptian medicine became a continuum of modern medicine, it did not germinate into a separate disciple like Ayurveda. I should hasten to say that is not only the story of Ayurveda; due to the stagnation of Arab and Iranian society they got stuck with Hikmat, Hakeem and Yunani (original Greek, since Yunan is Arabic for Greece) medicine.
Ayurveda also solved some problems of surgery. However, surgery is simply a measure of craftsmanship, which relies on joining or removing parts of the body; its advance is based on first and foremost on the discovery of anaesthetics by American scientists in mid-19th century and development of fine sophisticated tools ever since; useful and lifesaving as surgery can be, it is a subspecialty and I do not intend to deal with it in any larger context.
Achievements of Ayurveda
The principal achievement of Ayurveda, as stated above, is to provide a materialist approach to disease. In addition, it attempted to identify remedies, mainly from vegetation – this is also a scientific approach. During the evolutionary process,
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humans, animals and vegetation have been in constant interaction with the environment and in turn, changing the environment. It is not surprising that they contain both poisons and remedies. Chemicals that are endogenous to the body (or structurally similar chemicals synthesised in the laboratory) produce their biological effects by stimulating or inhibiting specific receptors on or inside cells. The human (and animal) body also has receptors for morphine, cannabinoids (active ingredient of marijuana or ganja) and other substances as well. It also possesses enzymes to destroy almost any other foreign substance; these are not naturally present in the body (although like substances might exist such as endogenous opioids) and yet the body is prepared to receive them. This fact simply denotes a common history and hence interaction between humans and the rest of living and non-living matter during evolution. Therefore, there is always a probability that plants, animals, metals and other matter in nature can cure or kill. The knowledge of which of these can do what must have required a mammoth amount of experimentation just as a lot of trial and error must underlie the identification of edible and nonedible foods. Therefore, the claim of Ayurveda to be knowledgeable about the therapeutic value of their prescriptions is not unsound. Such claims can be with or without merit and this is true for modern drugs as well. It is still worth noting that the culture of faith in natural as opposed to synthetic drugs is not specific to India. For example, the sale of herbal drug St John’s wort for the treatment of depression reached nearly US $ 6 billion in Europe in 1998.
Limits of Ayurveda
Somehow the mythical aspects of Indian history are such that we are weak on dates but clear about other details. For example, Anand Patwardhan in his documentary ‘Ram ke Naam’ on the Babri mosque episode has one of the characters reveal that he knows exactly where Lord Rama was born, but is not at all sure when he was born. Likewise, we know Charaka is the founder of Ayurveda; but when exactly he elaborated (Veda) the science of life (Ayu), we are not very sure. Ayurveda is said to be pre-Vedic, 5,000-6,000 years old or even older.
A major limit of Ayurveda is ingrained in its very origin. The world population 6,000-7,000 years ago (approximate origin of Ayurveda) is estimated to be perhaps 100 million. Greater India’s population could have been 20 million scattered sparsely. Longevity was short, may be less than 30 years since it was still less than 40 years at the time of independence in 1947. Ayurveda developed in the context of illnesses prevalent in India thousands of years ago. Many diseases have made their way with increase in population. For example, asthma, which affects one in every 10 children in western society, did not even exist a few hundred years ago. Louis Pasteur, one of the most celebrated contributors to modern medicine and the founder of the discipline of bacteriology, estimated that the summer air of Paris in late 19th century could contain as many as 10,000 microbes per cubic metre, which was not the case in the countryside. Consequently, Ayurvedic or Chinese physicians could not have visualised the medical needs of today. On the other hand, diseases share symptoms, which are fewer than diseases, and a variety of diseases can produce similar or identical symptoms (e g, pain either localised or general, diarrhoea or constipation, emaciation, fever, loss of consciousness, etc). All infections produce fever. Cancer, tuberculosis, AIDS and many others cause emaciation. Since Ayurveda claims to envision unity of life and mind, one can endlessly argue that it was a complete system then and is a complete system now as claimed by Choprapathy.
There is no one single originator of allopathy, physics, chemistry and mathematics. These sciences started as nascent knowledge and can almost never reach a state of perfection and end. In contrast, Ayurveda and homeopathy, like religion, are the brainchild of single geniuses. Could there have been a genius 6,000 years ago who could have supplied the correct and final answer to all ailments like the prophets have done?
Experimentations or trials that led to the discovery of a remedy thousands of years ago had limitations. Ayurvedic medicines are often mixtures of many substances, and many properties are attributed to each medicinal substance; consequently scientific verification of virtues attributed to Ayurvedic medicine are difficult even today. As a matter of fact, pharmacological research in postindependent India paid great emphasis in research on indigenous medicine with dismal success.
Medical science like any other branch needs continuous revision, experimentation and each new advance poses new questions requiring new tools for both investigation and the discovery of solutions. In this sense, Ayurveda ceased to be a living science long time ago and several factors contributed to this state of affairs.
First, the advance of Ayurveda was hindered by the brahiminical culture, which exerted adverse effects not only on medicine, but also on other scientific pursuits. One characteristics of brahiminical culture is that knowledge must only be transferred to deserving select pupils and not to the general public. The Dronacharya – Eklavya tale in the Mahabharata, best exemplifies this. Dronacharya, the legendary teacher of archery not only refused to teach the bright sudra (low caste) boy Eklavya but also had him gift his severed right thumb once he excelled Arjuna, the favourite of his ‘guru’. Unfortunately this despicable act is touted as the ultimate in teacher-pupil relationship. Buddhism tried to break it and started more accessible learning institutions but it was then routed from India, partly by force and partly because it was not mystical enough. The ‘guru-shishya’ (teacher-pupil) culture is ingrained in every science and art form. It even influenced Muslim practitioners of Yunani medicine (essentially similar to Ayurveda with the exception of the source of remedies) and classical musicians. This is the single most-binding constraint placed on Ayurveda, which prevented its evolution. If one traces the profile of Ayurveda practitioners, almost all of them, until recently at least, were caste Hindus.
The second deterrent to the advance of Ayurveda was the culture of secrecy in knowledge transfer. An Ayurvedic practitioner almost never wishes to divulge the full secrets of his prescription. If feeling the pulse can tell more than heart rate and rhythm, this special knowledge is by and large non-transferable. Any knowledge that is not transferable is doomed; it cannot evolve into a living science. The schools of Ayurvedic (or Indian) medicine, which started after independence are a mixture of Ayurvedic and modern medicine; usually, though not necessarily, they neither produce a competent Ayurvedic nor an allopathic practitioner because they are based on an erroneous foundation that there can be diverse systems of a single discipline, in this case medicine. China has a different approach. Chinese schools train students in modern medicine, who also want to appropriate traditional knowledge that has merit and not everything that is traditional.
The third factor that led to the ossification of Ayurveda, which is also true for other intellectual and scientific pursuits in India, is the stagnation of Indian society by the long persistence of a feudal mindset. I do not know why feudalism survived for so long in India and why with all their culture and development, India and China were not the first to start the industrial revolution. Nonetheless, feudalism is a shackle against science. All branches of science grew with the turmoil and success of the industrial revolution in the west, an important aspect of which was the weakening of the hold of the church. It is, therefore, not surprising that England, France and Germany became the centres of modern medicine. One can hazard a conjecture, which can neither be proved nor disproved, that had India accomplished the industrial revolution, Ayurveda itself would have annihilated itself giving birth to what we call modern medical science. It would then have been like slavery giving birth to feudalism and feudalism to capitalism instead of all of them surviving in bits and pieces simultaneously.
Finally, Ayurvedic practitioners tend to specialise in treating diseases that are vague or non-existent such as purifying blood, increasing libido, freshening mind (‘mastishk’), increasing strength (‘shakti’), etc. In these cases the drug almost always works. Administering drugs without justifiable reason is also common in allopathy. Since a patient with real or vague complaints cannot be satisfied with an advice against drug usage (which might be the correct advice), physicians are tempted to give something.
Can the Efficacy of Ayurvedic Medicines Be Established?
A pharmacological dictum is that therapeutic, toxic and placebo effects are properties of many drugs but toxic and placebo effects are common to all drugs. So there cannot be a drug without toxicity. A drug is good if it produces toxicity in quantities much greater than that required to produce therapeutic effect. Given this definition, the safest drug known so far is penicillin; but even small doses of penicillin can kill if the subject is allergic to it, which has been caused by unintended contact with the drug. We only know of a substance as a drug because it can produce a therapeutic effect without producing unacceptable toxic effect and this, obviously, depends upon the dose. The higher the dose, the greater is the probability of producing unacceptable toxicity. The nature of Ayurvedic formulations are such that quantities required to treat the disease are often too bulky to cause toxicity; by the same token, they might be ineffective even if they do contain therapeutic potential.
If the efficacy of an Ayurvedic medicine can be scientifically established, it gets incorporated in modern medicine, which will increase its medicinal value and may even deter establishments like Divya Yog Pharmacy run by Ramdev from adulterating their recipes. However, an evaluation of the therapeutic efficacy of drugs is a complex process, which is costly and often imperfect. The efficacy of drugs can only be fully appreciated when it goes into general use and not when it is tested in a selected population during what is called Phase 1, 2 and 3 Clinical trials. Take for example the case of the selective cyclooxygenase (COX) inhibitor rofecoxib (Merck: trade name Vioxx). COX is an enzyme, which generates prostaglandins, which contribute to inflammatory conditions like arthritis. There are two subtypes of COX; COX 1 is always active, but COX 2 is activated during inflammation.
Aspirin blocks both COX 1 and COX 2. Because COX 1 also produces prostaglandins of I and E series, which protect the stomach lining, aspirin suppresses inflammation but causes gastric irritation by inhibiting I and E series of prostaglandins. It was theorised that if COX 2 can be selectively blocked, we have a drug that can treat inflammation without harming the stomach. Such drugs were made during the last 10 years, with clinical trials, etc, costing over 200 million US dollars, each; Vioxx is one such drug. The drug was approved for general use. Only when the drug went into the retail market, were several cases of fatal heart attack noted. The drug has now been withdrawn. This is just one example illustrating that the evaluation of drug efficacy is not simple.
I am not sure if an ethically acceptable and effective system for drug evaluation has yet been developed. India is emerging as an ideal place for clinical trials because the expertise and the subjects are available in abundance at a reduced cost, but this does not mean India will be contributing to the development of safe effective drugs.
Until 1962, allopathic drugs could be introduced as long as they were deemed safe during toxicity studies in animals. It is only later that efficacy became a requirement for introducing new drugs in the market. Regulations governing introduction of new drugs differ from country to country, the US being most restrictive so that thalidomide (a totally unnecessary drug for what it was then used, that is, sedation), which caused thousands of malformations; its use was not permitted in the US. The story of thalidomide and DES (abundantly used in the US) also show that toxicity cannot be always reliably established. DES (diethylstilbestrol, a synthetic substitute for normally occurring female hormone estrogen) was synthesised in 1938 and approved for use during pregnancy in 1947 and indeed, used by approximately 10 million women as a safeguard against miscarriage; wives of returning soldiers, eager to have a family, were the main victims. Serious adverse effects of DES on the daughters, mothers and sons only became apparent years later. Thalidomide causes birth defects only in primates so tests in rats and mice could never have predicted this dangerous potential.
Even within the limitations stated in the above paragraph, the formulations of Ayurvedic medicine are such that it makes their evaluation quite difficult. One can start with the assumption that well known Ayurvedic medicines, which have been used over time, are as safe within limits as allopathic medicines. In fact, sometimes Ayurvedic as well as homeopathic medicines become toxic because the practitioner adulterates them with allopathic drugs, commonly steroids and antibiotics. Therapeutic efficacy of Ayurvedic drugs could be evaluated if a rigorous protocol of its usage and effects are recorded and the outcome statistically analysed; this is quite different from the technique of evaluating new drugs.
There is a Sambhavana Clinic adjacent to now defunct Union Carbide pesticide plant in Bhopal. It provides free medical care to victims of the gas disaster of 1984. It operates in the most cost-effective way. Nobody is paid high salary and there are enough motivated doctors willing to work. The clinic uses allopathic as well as Ayurvedic medicines plus Yoga supplementation in the treatment of some conditions like diabetes and respiratory insufficiency. They have initiated a system that they call evidence-based medicine. For example, the patient’s lung function and oxygen saturation are measured using modern tools before and during therapy with an Ayurvedic medicine with or
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without Yoga supplementation. Proper records are maintained and the efficacy is evaluated after a sufficient number of patients have been treated according to a specific protocol. A negative conclusion leads to the rejection and a positive conclusion leads to the continuation of the specific treatment. Perhaps if evidencebased medicine shows promise for a particular Ayurvedic medication, it can be reevaluated for its biochemical effects and mechanism of action using available modern technology.
The evaluation of Ayurvedic drugs according to the current protocol used to evaluate new drugs by the pharmaceutical industry is impractical and costly. Indeed, the high cost of evaluation is an advantage to big pharmaceuticals because it has practically eliminated small entrepreneurs and individual scientists as discoverers of new drugs from the beginning to the end.
V Homeopathy
Thousands of years after Ayurveda and Yin-Yang, Samuel Hahnemann (1755-1843) came up with the theory that like treats like. The additional aspect of this was that instead of treating a specific ailment such as pneumonia, you treat the entire body for which you can administer symptom-simulating drugs in the tiniest amount, almost 10 to the power minus 20 (10-20) or even minus 33 (10-30). Is homeopathy an advance or a regression in the evolution of medical science? In my opinion, it certainly is not an advance. The term “like” is too vague to scrutinise the concept of like treats like. Penicillin can cure infection in any part of the body caused by gram-positive bacteria but on its own it produces no effect even at doses 10 or 20 times greater than that needed to cure. In some cases it is possible to simulate symptoms by drugs. For example you can cause convulsions by a drug that may grossly resemble epilepsy, although here also the similarity is very superficial. Drugs cannot simulate the symptoms of the majority of diseases and many diseases have no symptoms whatsoever until very late, if at all. One can die of heart attack within minutes without ever having known that there was something wrong. Lung cancer is usually symptomfree until close to death because the lungs have no pain fibers. Ordinarily, high blood pressure produces no symptoms, and if it does the symptom may just be headache, blurred vision or erectile dysfunction. Which symptom to simulate and at what stage of the disease a homeopath should intervene are difficult issues for homeopathy. In order for symptoms to become apparent, the disease has to progress to some extent; often enough it may have progressed so far that treatment is not possible. Moreover, the potency of the drug advised in homeopathy is like throwing a single dose in the Pacific Ocean, hoping that some molecules will be present in water samples near both San Francisco and Hong Kong. The noted British pharmacologist A J Clark and the author of the 1923 book Applied Pharmacology wrote: “From 1829 onwards he (Hahnemann) recommended the administration of all drugs to the thirtieth potency, which corresponds to a concentration of 1 part in 1060 parts. This works out to a concentration of 1 molecule of drug in a sphere with a circumference equal to the orbit of Neptune.” Surprisingly, homeopathy which has far less scientific basis than Ayurvedic or Chinese system of medicine has a bigger clientele than Ayurveda, second only to allopathy.
Notwithstanding these basic limits, homeopathy implies that drugs do not cure; they only boost the ability of the body to deal with the illness. This is true and is also a recognised principle of modern drug therapy.
VI Modern Medicine
Modern medicine is not a conceptual advance over Ayurveda. It incorporates all systems of medicine, is in continuum with them and has advanced over all of them to the most rational stage possible. The use of vaccines to boost body defences against potential diseases has some superficial similarity to homeopathy; quantitatively, vaccines weigh much less than all other medications, yet they are far more than homeopathic dosages. How does then modern medicine differ from all other forms of medicine? Suffice to say that modern medicine, like all other branches of science, is based on constant enquiry and renovation determined by careful experimentation and observation. Take for example the case of tuberculosis. Modern medicine considered tuberculosis to be a constitutional disease, giving rise to the term “consumption” only about 100 years ago and the only treatment was going to sanatoria. As soon as it was recognised that the disease is caused by Mycobacterirum tubercule, the old theory was discarded. In fact, new textbooks of internal medicine and pharmacology do not even mention many medications that were dealt in great detail not too long ago. There is not a single professor of pharmacology today who can even score 10 per cent if he/ she was administered question papers used to examine first or second year medical students till the dawn of the 20th century.
The essence of medical science is to discard what cannot be proved to merit for which it has been used or prescribed; this is done from laboratory study using animals or tissues to clinical trials and re-evaluations once the drug is in general use. This is not to say that modern medicine evolved without going through prejudice and scepticism. Some of them are as horrendous as church’s indignation against Galileo (1564-1642), though short of proclaiming execution. Sterilisation during surgery and childbirth is perhaps the greatest advance in medical science. Nothing has saved more lives and nothing has decreased puerperal sepsis and neonatal mortality as much as washing hands and boiling surgical instruments. And yet, when the Hungarian-Austrian physician Ignaz Semmelweis (1818-1865) proposed in 1846 that surgeons should wash their hands before handling wounds or births, he was ridiculed; surgeons argued that washing hands before surgery will waste precious time. Louis Pasteur suggested in 1865 that organisms in the air might cause sepsis. This led British surgeon Joseph Lister to start using antiseptics and he announced the marvelous outcome in 1867; this contribution, too was greeted with reasonable scepticism. However, once the value of sterilisation got recognised, it became a norm and old thinking was totally discarded.
The essence of medical science is not that it uses synthetic as opposed to natural drugs. Indeed, almost all medications used by the allopath until the end of 19th century were derived from plants or metals. Many remained popular even till quite late, many are still used and many are being added. Take for example the use of arsenic for the treatment of syphilis. It was the only medication available until the discovery of penicillin soon after the second world war. Mercury was the most effective diuretic and used to rid body of fluid accumulation such as in heart failure until other useful diuretics were discovered as late as 1960s. Aspirin is derived from willow bark and one of the oldest drugs second only to morphine and has stood the test of time. Indeed new uses of aspirin such as to reduce the risk of heart attack and cerebral thrombosis or for the treatment of some types of cancer were the result of both understanding of how it works and what underlies these diseases. It was said of morphine (active ingredient of opium) that if you are allowed to keep only one drug it must be morphine and one of the pioneer of research on opium alkaloids wrote in 1680: “Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium”.
Andean natives chewed coca (Erythoxylon coca) leaves (source of cocaine) for stimulatory action and cocaine emerged as the first local anesthetic in late 19th century. The recognition of the effects of cocaine by Sigmund Freud in late 19th century and of the Indian plant Rauwolfia serpentina (source of reserpine) in early 20th century on mood ushered the era of psychopharmacology, which led to discovery of many drugs and the closure of inhuman mental hospitals by 1960s. Vitamins, which are essential for life but cannot be made by human body, are solely derived from foods. Many naturally occurring drugs such as quinine for malaria, emetine for amebiasis, digitalis for heart failure, quinidine for heart irregularities, ergot for migraine, caffeine and ephedrine for asthma, vinca alkaloids for cancer, atropine for reducing secretions and intestinal spasm, colchicines for gout and so on are still in use. Lithium, the lightest of the alkali metals, which cannot be synthesised, proved invaluable in the treatment of manic-depressive illness. Indeed, medical science is eager to appropriate any natural substance or practice with proven value in its armamentarium. In Cuba, doctors engage patients with Alzheimer in intellectual activities such as chess to retard the progression of the disease. In many hospitals pets (birds, dogs) are brought to cheer the patients, which is hoped to reinforce their will to fight the disease. The realisation that plants may be a better source of useful drugs than previously thought has led some of the big pharmaceutical industries to purchase vast areas of forests in Brazil and other tropical regions in the hope of finding something better than they can generate in laboratory. In short, source of drug (herbs, plants, metal, living organism) does not distinguish Ayurveda from allopathy; what distinguishes the two is that one is based on evidence and the other on tradition with unproven or half-proven value.
Here I present the merit of one important drug of plant origin for the treatment of one the most prevalent and debilitating diseases, namely, malaria. It is not quinine, which was used to treat fever in Latin America by Jesuits, nearly 400 years ago, and is still a valuable drug. Approximately 300-500 million people suffer from malaria worldwide, mainly in Africa and south Asia and more than 1-2 million die annually; the main victims are children. With the use of DDT in early 1950s, it appeared that malaria would disappear like bubonic plague. By that time, emergence of bacterial resistance against antibiotics was not fully recognised and therefore, no one suspected that mosquitoes will develop resistance against DDT (which turned out to be an environmental hazard) and malarial parasite will become resistant to quinine (the age old remedy) and chloroquine (discovered after cinchona plantations, the source of quinine, in south-east Asia came under Japanese occupation during second world war); however, both happened. The search for an effective antimalarial against resistant strains, surprisingly led to recognition of the value of artemisinin, which is derived from the Chinese medicinal herb quinghao (Artemisia annua); Chinese have used it for more than 2,000 years and introduced it in a big way to treat the North Vietnamese troops during the Vietnam war. At this point in time, nothing seems superior to artemisinin in the treatment of malaria resistant to common medications and pharmaceutical industries are trying to grow the plant elsewhere.
The greatest discoveries of immense therapeutic significance by the modern medicine are sulfa drugs (by German scientist Domagk), penicillin (by British scientist Fleming) and streptomycin (by American scientist Waksman); all three won Nobel Prizes. While sulfa drugs are synthetic, penicillin (still the most commonly used antibiotic) and streptomycin (rarely used now) are produced by microorganisms, all natural sources, and not synthesised in a laboratory. Until very recently the source of insulin was beef and pork pancreas (now replaced by human insulin produced using recombinant DNA technology).
Indeed, the major contributions of modern medical science are not in the area of drug discovery but rather in the area of diagnostics and the pathology of diseases, neither of which are a solace to the patient who needs cure more than diagnosis. They now even have dogs trained to detect early lung cancer by smelling its distinct odor. More patients are saved in hospitals by supportive therapy that is maintaining fluid balance, respiration and blood pressure than by spectacular drugs. With the exception of few poisons (cyanide, morphine, methanol and war gases), treatment of drug overdose or poisoning does not require antidote, even if antidotes exist, but rather supportive therapy. Indeed, the World Health Organisation (WHO) list of essential drugs is very small and can easily be made much smaller. A lot of hype surrounds gene therapy and stem cell research; whether or not they would offer anything needs to be seen; it should, however, be recognised that modern medical research pays greater attention to diseases of the few and of developed countries than to diseases which afflict the majority in developing countries.
If India can address the issue of diarrhoea, which relates to sanitation and water supply and not drugs, and malaria and tuberculosis, which need both prevention and drugs, it has solved major health problems.
VII Why Do Different Systems of Medicine Persist?
The reason for the survival of Ayurveda, homeopathy and Choprapathy are not the same as the reasons for the persistence of bullock carts in the era of trucks, trains and airplanes. No one residing in south Delhi or Marine Drive aspires to own bullock carts in place of luxury automobiles but there are still too many there who would opt for homeopathy (first choice) or even Ayurveda (second choice). Conversely every one saddled with bullock carts would readily exchange it, if only he could, with a truck and would rather be in Escort or Jaslok hospital than consuming medicines from Divya Yog Pharmacy of Baba Ramdev.
The first and foremost of factor leading to the survival of different medical disciplines is the limits of medical science.
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Economic and Political Weekly August 19, 2006
Modern medicine or allopathic medicine cannot cure all existing diseases or even safely relieve all unpleasant symptoms. Diseases are a part of biology; some treatable some not. Some were untreatable before but have become treatable now. For example, there was no cure for tuberculosis when Kamla Nehru (the wife of Jawaharlal Nehru) had it but the discovery of effective antitubercular drugs has made it possible to cure tuberculosis. On the other hand, many common ailments like essential hypertension and diabetes can be controlled but cannot be cured even now. Cancer, AIDS, heart failure are other areas where complete breakthrough has not been achieved despite much effort. However, limitation of medical science is not acceptable to the patient who will, naturally and justifiably, search for cure. They are likely to try anything and there would always be an Ayurvedic practitioner or homeopath that will promise a cure. Many a time these practitioners of other types of medicine will impose strict dietetic or other routines on the patient, which are hard to abide by and failure to abide by these rather than the medicine can be held responsible for the failure of the prescribed treatment.
Unlike many consumer goods, which arrive from major centres, treatment must be available in proximity of the sick especially during acute serious illnesses. In a place like India, where public healthcare is in disarray in favour of fancy modern private profitmaking hospitals in major cities, the marginalised population has little to choose between an allopathic and Ayurvedic doctor. An Ayurvedic practitioner is always available and usually develops better rapport with the patient and patient’s family and charges less than an allopathic doctor.
An unintended offshoot of the vibrant environment movement is reinforcement of the mythical greatness of the past; sometimes it tends to become anti-science and anti-progress. Since ignorance and religion cater to ultra-nationalism, age-old traditions find a favourable climate for assertion or reassertion. It is true everywhere including in India and China. However, religion has a weak base in China and not encouraged by the state. So the Chinese take a philosophical view of Yang-Yin and experiment with traditional method of treatment such as acupuncture before adopting them as a part of healthcare system. India with strong religious influence gave Ayurveda a mythical status; many hold that the system is fully developed and correct forever and needs reinforcement and not change. Some political figures even consider that patriotism requires promoting Ayurveda. The recent attack on Brinda Karat for exposing the malpractices of Ramdev pharmacy is, in addition to gut anti-communism and anti-women, also an expression of the love of heritage. There are other reasons for popularity of Ayurveda; its medicines are made by nature and not humans (apparently not part of nature); formulation is bulky with active ingredients, if any, in rather smaller quantity to do any harm. Ayurvedic medicines have usually unpleasant taste, which is traditionally associated with effective medicine. Moreover, some Ayurvedic or Yunani medicines are effective and they help the survival of the useless lot.
Finally, biological systems have an inbuilt method of correcting abnormal episodes. Indeed, Darwin would have had nothing to write if species did not have the natural ability to deal with adversity and evolve. Humans cannot grow severed finger like reptiles do but there exists a mechanism of repair, fighting infections, preventing infection, correcting changes in blood pressure, suppressing cancer, etc. It is a common knowledge that people recover from episodes of fever without taking medication and often without even knowing the cause of the fever. No epidemic kills every body; some survive, why? Childhood asthma has increased dramatically in the west, perhaps because of industrial pollution; however, many of these children completely recover, as they grow older. Given this situation, a great majority of common diseases can be cured by any drug, provided the drug itself does not cause toxicity. So the physician of any branch of medicine has a good chance of satisfying a good percentage of her/his patients. That is a part of the reason why a number of practitioners without training in any type of medicine can carry on with their business in India successfully. This is also part of the reason why placebos are used as some form of control in drug evaluations because all medications have placebo effect and that many only have placebo effects.
Most importantly, survival of spurious disciplines of medicine is rooted in the total disarray in public healthcare system in India. The modern medical healthcare system was introduced in India in late 19th century during the British colonial rule. This system comprised of primary health centres located sparsely in villages, a large size hospital in district headquarters and even bigger ones in major cities; a number of medical schools attached to major hospitals were also started. Some research was done and the crowning point of this was the discovery of the malarial parasite and its transmission by mosquitoes. The healthcare system stipulated referral from primary to secondary to tertiary healthcare centres. Hospitals were free. The principle is sound and has reached near perfection in Cuba, where healthcare is not only universal but health centres treat the patients as well as maintain vital statistics and ensure prevention of diseases and its complications as best as is physically possible. The opposite happened in India. While India increased number of medical schools and started formal schools of indigenous medicine, it allowed a total collapse of free healthcare system in favour of highly modern, profit-making hospitals in major cities like Delhi, Mumbai, Hyderabad, Bangalore, etc, which cater to the 150-200 million rich and even attract foreigners. The public healthcare system provides practically nothing so that nearly 85 per cent of healthcare is provided by money-making institutions (hospitals and nursing homes) to the 15 per cent of the population; 85 per cent of the population relies on dismal services. A sound healthcare system has implications far beyond health and beyond the scope of this note. Suffice it to say that nothing makes poor feel helpless, marginalised and victims of loan sharks more than sickness in the family, especially of the children.
Finally a sound healthcare system is not contingent upon role of multinationals, WTO and TRIPS. Even a capitalist country like Canada can do it; so why not India? Nothing is more crucial than a free universal healthcare system to the vast majority of India’s marginalised population. Yet, it is surprising that this issue does not constitute a major platform of political parties including the left parties. In any case, this deterioration in public healthcare is an important reason for survival of all systems of medicine including witchcraft and unethical medical practices both indigenous and modern.
EPWEmail: daya.varma@mcgill.ca
Note
1 The central idea of this article comes from a brief comment made by Narendra P Gupta some time in the mid-1950s when I was a student at King George’s Medical College, Lucknow, and he was a professor – both of us were associated with the Communist Party of India.
