In the Bonesetter's Waiting Room

by Aarathi Prasad

  What Anna was saying reminded me of something van Rheede had written in the Hortus Malabaricus: that, even in 1678, the use of Indian plants ‘whose curative virtues were proclaimed by indigenous physicians as having been famous for extreme antiquity was rapidly approaching its end’.

  A further reason for the demise of the Ashtavaidya’s work – which would have been a problem even when van Rheede was searching for collaborators in seventeenth-century India – had also emerged from Anna’s research. The traditional education of the old Indian medical scholar-practitioners was exclusive, sometimes dependent on royal patronage and extremely long and demanding. Generally, such instruction was given only to men who were members of an existing practitioner’s family or of a high caste. A wealthy sponsor would also be vital in order to support what could be fifteen years of rigorous one-to-one apprenticeship. Students would receive training in not only healing practices (study of the medical texts, diagnosis and preparation or medicine formulations) but also logic, astrology and additional periods of meditation and memorisation and recitation of classical texts.

  This unwieldy system persisted until the nineteenth century, when a European-style fixed curriculum was introduced, with specialist subject teachers, a set training period and qualifying exams. Successful candidates would receive a medical certificate and a licence permitting practice. Ayurvedic and other traditional medical colleges in India still operate with a standardised syllabus that includes Western disciplines – anatomy, physiology, biochemistry – ostensibly so that the old and new can interact with ease. Although this streamlined system has turned out large numbers of traditional medical physicians and widened the availability of their services, the inclusion of Western practices is considered by many to have undermined the philosophy behind Ayurvedic medicine.

  Still, things have been worse. In 1822 the British Raj outlawed the integrative approach pioneered by de Orta and colonial India’s various fledgling medical institutions would teach only the separate disciplines, rather than pushing for the pluralism which had been so effective.

  Unsurprisingly, under the British, European medicine was to supplant all others. The English politician Thomas Babington Macaulay was the architect of this change. An uncompromising modernist and the son of a missionary, he considered the ‘pagan’ Indian systems of medicine to be both backward and slowing the progress of Anglicisation. Despite the protests of British Orientalists, he decreed that Ayurveda as a system of medicine was to end. At the new Calcutta Medical College, only one system was to be taught as medicine.

  IT IS UNDERSTOOD that much of Vedic medical anatomical knowledge arose as a result of animal sacrifice, rather than opening the human body. Far pre-dating that, such information was gathered from hunting and butchering. India’s 20,000-year-old Mesolithic art repeatedly portrays so called ‘X-ray’ animal images on the walls of rock shelters: complex drawings of boar and cattle showing organs in place. Later came the substantive surgical works of Sushruta, whose texts include a systematic method for the dissection of the human cadaver. But by the nineteenth century, human dissection was not performed as part of the training of Ayurvedic doctors.

  ALTHOUGH THERE WERE ARABIC translations of the Sushruta Samhita, made in the eighth century, the work was not readable in English until 1907. Macaulay read neither Arabic, nor Sanskrit. This must have contributed to his conclusions as outlined in his ‘minute on education’, where he described India’s offerings as including ‘medical doctrines which would disgrace an English farrier, astronomy which would move laughter in girls at an English boarding school …’ And so, in 1836, Macaulay famously ordered a fifty-gun salute at the new College to celebrate what was publicised as the first post-mortem dissection of a human body performed by an Indian. Despite the circus, and political and practical challenges, practitioners of Ayurveda and other Indian medical systems didn’t give up the fight. Encouraged by the growing strength of nationalist voices towards the 1940s, and in response to the hostility of the colonial policy toward Indian medicine, traditional therapists joined forces and specialised colleges of ‘indigenous medicine’ were established.

  I had a very personal interest in wanting to understand the story of Indian medicine because of my grandfather’s involvement in both Ayurveda and post-independence health policy, and an academic one in wishing to understand whether Ayurvedic theory and modern science could really be happy bedfellows. After nearly seventy years of independence, and twenty years after the establishment of the government department for Indian systems of medicine for which my grandfather had striven, I was keen to find out where the long struggle between autonomy and integration stood in the twenty-first century.

  I arranged to meet an old friend in Bangalore who had trained as an Ayurvedic doctor at a college affiliated to the medical university of Chennai. Anusha had grown up in a house obliquely opposite mine in the Caribbean, before moving to the States in the late 1980s and then to India. There she became fluent in Hindi and learnt Tamil and scholarly Sanskrit so that she could work with ancient Ayurvedic texts. On returning to the States she’d researched complementary and integrative medical therapies with colleagues at Boston University School of Medicine and at the Harvard School of Public Health, which had pointed her towards her main area of interest: Ayurvedic research and development.

  Before we met in India, Anusha mentioned that she had been working as a consultant for L’Oréal India in Bangalore. I was curious about what a French cosmetics company would be doing with Indian medicinal herbs. I discovered that, in April 2013, it had opened a research facility in Bangalore’s fashionable Whitefield neighbourhood, attracted by the city’s reputation for bioinformatics (analysing and storing biological data) and phytochemistry (chemical analysis of the substances derived from plants). In the words of Laurent Attal, the company’s executive vice-president of research and innovation, ‘This Research and Innovation centre is a tribute to India’s scientific excellence. It is designed to become a laboratory of innovation for Indian beauty and a source of inspiration for the rest of the world.’

  L’Oréal India’s initial bridge products between traditional beauty routines and modern technology had included rudimentary fusions with familiar Indian beauty regimes – Garnier Shampoo plus Oil; Maybelline Colossal Kajal – but their interest in working with Ayurvedic specialists was part of a three-year investment programme costing approximately £110 million, designed to uncover the secrets of plants used in Ayurveda that might turn up leads to improved cosmetics. It looked like L’Oréal was working on a hunch that the next anti-ageing revelation might well be found in the ancient herbs used by Ayurvedic healers.

  L’Oréal aside, Anusha’s academic interest was in the medicinal rather than cosmetic, researching the safety and efficacy of traditional Ayurvedic formulations. In fact, they are on the world’s radar just as much as Indianised mascara and maquillage. The market for Ayurvedic products has been growing steadily at ten to twelve per cent annually and now boasts a Rs8–10,000 crore (£8–10 million) turnover combining both domestic and exports. In addition, although it is difficult to put an exact figure on what proportion of the medical tourism industry (worth about £2.5 billion) is attributable to Ayurveda, there are signs that it is significant, probably particularly in Kerala, where traditional Ayurvedic spas have long been a major attraction for foreign tourists.

  Though her clear commitment to Ayurveda, its holistic philosophy and its efficacy was understandable, much of Anusha’s recent work had involved investigation of concerns regarding the safety of traditional medicines that had been surfacing in medical literature from several countries, particularly Italy and the USA. In the United States and in Europe, herbal products don’t necessarily have to be classified as medicines: they can be marketed as cosmetic or food products. This means that, in general, consumers regard them as harmless and regulators do not ask for proof of safety or efficacy. This lack of knowledge surrounding traditional herbal medicines, combined with an explosion in
their use, demanded further investigation, and I was interested that Anusha’s response was based on modern Western science, informed by an understanding of Indian tradition.

  She explained this to me when we met over a cappuccino in one of Bangalore’s many Coffee Day franchises, where we were joined by her husband and her clever, funny toddler, who was alternating her requests for cake between Tamil and English.

  ‘There are some products that are not good products,’ Anusha explained. ‘That doesn’t mean the Ayurvedic formula is harmful, but that the product could be adulterated. Ayurvedic medicines can be herbal, metal, mineral or a combination of those. The problems have come from heavy metal poisoning – lead, mercury, or arsenic. Even in chawanprash [a popular, particularly tasty dietary supplement containing honey, ghee, berries and spices and sold all over the world], there can be a lot of variation between companies depending on how and where they source the ingredients.

  ‘The dosage that ends up in a product can become too high for several reasons. A supplier might gather a crop from a polluted waterway or next to a busy road, for example, or store it incorrectly. So now Indian producers are being regulated – herbal plants should be grown and harvested in controlled conditions. But the regulation still only covers products for export, not those for the Indian market. The other issue is how an Ayurvedic medicine or formulation is prepared. We know that the heavy metals which are used in Ayurveda can have severe effects, but this should not happen if they are formulated properly. When their use is described in the ancient texts, it’s only after extensive processing during which they undergo a physical or chemical change that makes them safe to ingest. In this way, a toxic material like mercury can be converted into a medicine.’

  By processing, Anusha was referring to how raw medicinal substances used in Ayurveda are first modified, for example by heating until red hot and dipping into a specified series of liquids; or by subjecting them to high pressures. It may sound a little like alchemy, but because what she was describing involved physical manipulation of materials, it is not unreasonable, scientifically, to suppose that those materials were themselves undergoing physical changes. How the original practitioners millennia ago thought these manipulations affected the efficacy of the medicines is hard to know, but using the language of modern science, Anu says that these processes of rapid cooling and varying pressures are techniques that would have altered the crystal structure of the metals. And whether a metal has the capacity to cause poisoning depends on these changes; its molecular configuration could determine how much of the potential poison is locked into the medicine or else is freely available to cause harm to the patient.

  In her writings on this subject she concludes that even though Ayurvedic medicines containing heavy metals have been used for hundreds of years, their mode of action – pharmaco-kinetics and pharmaco-dynamics – are still largely a mystery that demands study both by people who are knowledgeable about traditional pharmaceuticals as well as by experts in modern chemical analysis.

  This use of modern scientific language and calls for the study of the indigenous within the framework of the modern has long been controversial – both on the ground, from traditional vaidyas, and from above.

  In 1947 the government-commissioned Chopra Committee reported on whether the indigenous medical systems of India could or should be integrated. The report concluded that the ‘synthesis of Indian and western medicines is not only possible but practicable, though it will be time-consuming and not easy’, and recommended that ‘immediate steps should be taken in this direction’. Perversely, the government’s response was that the theory and principles between systems were too different for integration to be practical. Modern scientific medicine was to be the basis for development in the new India, although the policy makers did concede that traditional medicine might also have a place alongside it.

  Such duality was nothing new. By 1947, when my grandfather served as secretary to the Chopra Committee, he had been working towards integration of a sort for at least fifteen years. But it would be another fifty before the government of India would create a department for traditional medicines under its Ministry of Health.

  At the time of independence, the general view was that neither the Western nor the indigenous systems were perfect, but that each had its own special merits and limitations. I heard similar sentiments repeatedly on my travels through India nearly seven decades later: that the ‘valuable facts’ provided by Western medicine – the precise details gathered from scientific instruments and verifiable empirical measurements – were offset by its ‘poor … knowledge of general principles’.

  Anusha’s husband Pari, an Ayurvedic doctor from Tamil Nadu who was studying towards a qualification in public health, told me how this use of modern scientific tools to deconstruct and study ancient methodologies still makes doctors trained in indigenous systems targets for criticism today. ‘When you do studies like Anu’s, people can either look at it like you’re trying to make Ayurveda better, or that you are trying to bring the field into disrepute. But imagine if such analytical studies had been done two hundred years ago – Ayurveda could have been the mainstream now.’

  Anusha had arranged for me to visit the nearby National Ayurveda Dietetics Research Institute at the Government Central Pharmacy of the Department of AYUSH, which covers the practice of Ayurveda, Yoga, Siddha, Unani, Homoeopathy and Naturopathy. I was to meet its director, Dr G. Venkateshwarlu, and his scientific officers. Anusha had told me that a great deal of government-funded research and analysis was conducted there.

  On a corner off a busy Jayanagar main road, the 1970s facade of the government Ayurveda research building hid a wonderful courtyard garden filled with trees, shrubs and herbs. Along the seedling-lined corridors bordering the medicinal garden were laboratories and classrooms and we found Dr Venkateshwarlu’s office on the second floor, at the level of the larger trees’ branches. His office was large, with around twenty chairs arranged in rows. As he greeted us kindly, I noticed two large notice boards near the door which detailed the institute’s aims and projects. Falling under the Indian government’s Central Council for Research in Ayurveda and Siddha (medicine), the signboards detailed a résumé of the institute’s achievements from its inception in the 1970s. I was particularly interested to see that its work on Ayurvedic formulations or rituals was framed in the language of modern pharmaceutical or laboratory research. The sign included details of a clinical trials unit (‘194,657 patients treated to date’); a drug standardisation research unit, working on single drugs and compound formulations; a survey of medicinal plants (‘26,943 specimens collected in medicobotanical surveys in eighteen districts of Karnataka’); and an ongoing clinical research programme (‘Rasayana [a therapy for boosting energy levels, immunity and general health], obesity, dysmenorrhoea [period pain], and quality of life for cancer patients’). I also noticed from staff biographies that several had come from laboratory or academic research backgrounds: genetics, botany and neuroscience, for example. It was not what I had expected to see in an institution dedicated to Ayurveda and Siddha medicines.

  I asked Dr Venkateshwarlu why it was important to the government that this kind of research should happen. ‘In India, Ayurveda, has become alternative. The government is taking steps to mainstream this as a primary system; to move it from a traditional science to a medical science,’ he began. ‘The other Indian medical systems vary by place and traditions, but there are government Ayurvedic doctors throughout the country. Ayurveda can work really well with non-communicable diseases. In the West also, where communicable diseases are no problem, the issue more and more is non-communicable.’

  ‘You mean things like obesity and diabetes?’

  ‘Yes, and for malnutrition – eating the wrong foods – sometimes it’s a matter of education. In India there are many people who don’t eat vegetables,’ Dr Venkateshwarlu continued.

  ‘They don’t eat vegetables?’ I was taken slightly by surprise. ‘In Indi
a?’

  ‘Well, they cook vegetables, then they might dip chapatti in the sauce, but result is they will eat things that make them feel full rather than balanced meals – high starch, fibre, but no nutrients. In pregnancy also, for example, to keep the baby small so labour will be less painful, women will restrict protein intake. We run health camps that regularly go out to rural areas to educate people about good nutrition.

  ‘The origin of the [Indian] diet is medicinal. You know Vasco da Gama came, the Britishers came – they all came to take the spice, which was for taste, but also medicinal. Across India, people have adapted regimes … traditional practices, regional, therapeutic diets. But dietetics is a neglected area in Ayurveda. The thing about recipes described in the scriptures is that it is not mentioned how much to take, only what to eat. Food generally, there is no dose, just satisfaction. There is no scientific validation for Ayurvedic diets [dietetics], so the government set up this research with the Central Food Research Institute and Institute for Nutrition.’

  Dr Venkateshwarlu also described how they might tackle the problem of malnutrition, or other conditions such as gastric problems. He told me that after an extensive study of the active components of an Ayurvedic formulation for a disease, the idea was to come up with a dietary supplement. They might take wheat flour and enrich it with Ayurvedic ingredients. They were also using recipes described in the scriptures, supplementing staples like rice with them and dehydrating the results for use as a powder that would keep its shelf life and potency. ‘We’ve already developed an antibiotic food formulation and a gastric formulation,’ he said.

  Unlike some of the commercially available formulations that Anusha had been concerned about, the sources of the National Ayurveda Dietetics Research Institute’s plants – in their medical formulations as well as in their medicobotanical gardens – were evident. Opposite the noticeboard listing the 26,943 specimens from the institute’s surveys over the years, the wall to the right of Dr Venkateshwarlu’s desk served as a gallery for photographs of all manner of leaves, fruits, herbs and trees, labelled with their names in Latin and English transliterations from the Sanskrit.