Happy that our article is accepted in “Journal of Ayurveda”. Posting here, with kind permission of the Editor, in the interest of Global Common Good.
🟢Answering a critical question: Are Ayurvedic medicines against COVID-19 placebos?🟢
Deep Narayan Pandey
The first cases of the novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome–related coronavirus 2 (SARS-COV-2) was reported by China in December 2019.1-3 The pandemic has spread globally with more than 45.42 million confirmed cases and 1.18 million deaths as of 01 November, 2020. In India there are 8.13 million cases and 0.12 million deaths during the same period. Despite worldwide research efforts, and more than 65,862 research publications in Scopus database, there is still no known, clinically-proven and evidence-based medicine or vaccination against COVID-19 in any system of healthcare. Widespread failure of so called mainstream conventional medicine is evident globally now. Thus, available drugs from all systems of medicine, including Ayurveda, must be explored and employed against COVID-19. Like other systems of medicine large efforts are underway on pre-clinical and clinical research in Ayurveda. A great deal of progress has been made.
Interestingly claim made by some sections of conventional medical practitioners that Ayurvedic drugs were no better than placebos4 is erroneous, flawed and motivated. Indeed, what may turn out to be placebo is the standard protocol being promoted by modern medicine (also called biomedicine, conventional medicine, mainstream medicine, orthodox medicine, Western medicine or allopathy) against COVID-19 in India. These medical practitioners continue to use drugs such as hydroxychloroquine for COVID-19, even though there is neither any evidence for their efficacy, nor they are safe for patients. Drawing on the Ayurveda classics, contemporary scientific studies, and experiential knowledge, here we provide an analysis of COVID-19 and Ayurveda. We hope this will help further employ Ayurveda to serve the humanity in times of pandemic.
- Ayurveda perspective on COVID-19
In Ayurveda classics, there is an elaborate description of causation and management of epidemic (Janapadodhwamsa).5-7 Clinical profiling of COVID-19 is necessary to provide both preventive and therapeutic insights. Research efforts have now established clinical profile, although there is no unanimity as yet. One of the most important efforts by a team of Vaidyas and physicians from bio-medical system suggests that the disease should be considered as vātakaphadominant sannipātajvara of āgantu origin with pittānubandha.8 This study also described the asymptomatic, presymptomatic, mild, moderate, severe and critical stages of COVID-19 along with differences in clinical presentations on the basis of nidāna, doṣa, dūṣya, nidānapañcaka and ṣaṭkriyākāla.8 Many studies have arrived at similar conclusions.9-12 Another important study by the team of Vaidyas and scientists from the National Institute of Ayurveda have suggested that COVID-19 has analogy with the Rajayakshma with suboptimal immune response.13
On the scope for Ayurveda against COVID-19, in one of the earliest publications on the subject, a plan for graded response, depending on the stage of infection among individuals, in a population was proposed. This pragmatic strategy classified people into 4 groups—unexposed asymptomatic, exposed asymptomatic and quarantined, with mild COVID-19 symptoms, and with moderate to severe COVID-19 symptoms—and accordingly provided a management regime.12 It has also been argued that the supremacy conferred on biomedicine, notwithstanding the fact that it does not have a proven cure, required that Ayurveda interventions must be allowed on similar principles. Despite having a large potential, and despite having kept India reasonably healthy for 5000 years, if Indian people fail to extensively employ the world’s longest surviving healthcare system to treat COVID-19, it will be a great loss to humanity.12 There are reasonable number of publications that provide enough guidance and evidence that Ayurveda may indeed be helpful in the treatment of COVID-19 patients. These publications include both prophylaxis and therapeutic interventions. On prophylactic or preventive aspects, scientific evidence based on long-term research indicates that Ayurveda rasayanas and other Indian medicines can be a potential candidate for management of COVID-19 cases.14-19 A protocol along with supporting evidence has been presented on prophylaxis which also analyses and supports the guidelines issued by Ministry of AYUSH, Government of India.18 Potential usefulness of Ayurvedic and Unani herbs against COVID-19 has also been described.20-22 The evidence of known case of a COVID-19 positive patient treated entirely with Ayurveda is also available.10 Thus, there is every reason that Ayurveda must continue to be employed for the treatment of COVID-19.
- On the fear of self-medication
A fear has been raised that promoting Ayurveda may increase self-medication and thus hamper public health efforts. Such claims are common and require careful examination. It has been recently contended that any claims on the part of traditional healthcare systems such as Ayurveda may promote self-medication, particularly among those with symptoms of acute respiratory illness, fever cough, or shortness of breath, and therefore, exacerbate the risk of spread of infections. This may hamper public health efforts to contain transmission, and thus may be detrimental to screening, quarantine and surveillance, as well as a hindrance to promote research and practice of integrative medicine.23 These are valid assumptions, but discriminatory against Ayurveda. Condemnation that self-medication is entirely a problem of traditional medicine constitutes an epistemic injustice in itself. Self-medication is not just the problem of Ayurveda. Indeed, deep concerns have been raised that an endorsement by the highest scientific body of India as well as the political leadership in USA created an overly optimistic belief of the effectiveness of hydroxychloroquine among masses 24. Consequently, due to self-medication, markets in the USA went into short supply of both hydroxychloroquine and chloroquine. India is no exception to this dangerous self-medication of by the public.24 Indeed, in times of COVID-19 pandemic, self-medication with conventional medicine is a global challenge.25 Accordingly, blaming Ayurveda alone and ignoring the widespread self-medication in conventional medicine is flawed. Determined efforts in educating the population at large about this menace of self-medication may prove useful instead of the blame game.
- Are Ayurveda medicines no more than placebos and conventional medical guidelines unequivocally evidence-based?
As noted in the beginning, a surprising statement was recently made by some organizations from the conventional bio-medical establishment that Ayurvedic drugs are merely placebo.26 It is worthwhile and ethical to ask a counter question: Which of the 65,862 papers published on COVID-19 till 01 November 2020 have supplied the evidence used to support the prevailing standard medical guidelines and practices followed in India for the management of COVID-19?27 Indeed, it would be in larger public interest that organizations making erroneous and flawed statements against Ayurveda remain humble. One finds that the prevailing guidelines and practices that have been promoted over the course of pandemic by conventional medical establishment do not have any support in published science. To our knowledge, no meta-analysis of clinical trials provides any evidence whatsoever that one can quote unequivocally in favour of standard COVID-19 protocol. Indeed, the evidence for contrary is now large. For example, results of a systematic review and meta-analysis of 53 randomized trials in COVID-19 and other diseases find that Hydroxychloroquine (HCQ) is associated with a high total risk of adverse effects compared with the placebo or no intervention in the overall population.28 Furthermore, SOLIDARITY Therapeutics Trial, coordinated by the World Health Organization, indicate that Remdesivir, Hydroxychloroquine, Lopinavir and Interferon regimens appeared to have little or no effect on hospitalized COVID-19, as indicated by overall mortality, initiation of ventilation and duration of hospital stay.29
Indeed, reviewing all the studies is beyond the scope here, but suffice it to say that there are a large number of robust studies providing evidence that several guidelines and practice of standard care are indeed not based on reasonable scientific evidence.30-34 Results of a recent meta-analysis suggest that Hydroxychloroquine alone did not reduce mortality in hospitalized COVID-19 patients, and further, the combination of hydroxychloroquine and azithromycin significantly increased mortality.35 Furthermore, another meta-analysis showed no benefit on viral clearance, although a significant increase in death was observed with hydroxychloroquine in patients with COVID-19, compared to the control.36 Hydroxychloroquine actually is no different than standard of care alone in patients admitted to hospital with mainly persistent mild to moderate COVID-19. In addition, treatment resulted in higher adverse events in hydroxychloroquine recipients than in non-recipients.37 Hydroxychloroquine has failed even as prophylaxis. After high-risk or moderate-risk exposure to COVID-19, hydroxychloroquine did not prevent illness compatible with COVID-19 or confirmed infection when used as postexposure prophylaxis within 4 days after exposure.38 So, in the interest of global common good, it is always desirable to respect science, avoid promoting pseudoscientific treatments in the COVID-19 Pandemic, be modest to accept and let every system of healthcare serve the humanity.
This officially endowed supremacy to conventional medicine, regardless of the fact that it does not have a proven cure, demonstrates the epistemic injustice against Ayurveda. It is a common knowledge that Ayurveda originated in India several thousand years ago and continues to serve the humanity. This injustice against Ayurveda, and aggressive promotion of conventional biomedical system, may be disastrous in the long-term. This epistemic injustice requires to be corrected forthwith.39
- Studies in Ayurveda and COVID-19
While there are a large number of studies on various medicinal herbs and formulations that have been published, yet clinical studies are currently limited because clinical trials in Ayurveda did not receive required facilitation from the early days of pandemic. There are large number of clinical trials registered in the Clinical Trials Registry of India,40 and it is expected that outcome of these researches would become available in public domain soon. However, a few studies that have already appeared provide useful insights on the usefulness of Ayurveda and integrative approach.
First known case of a COVID-19 positive patient treated entirely with Ayurveda10 should have actually encouraged the healthcare policy makers to quickly use Ayurveda to bring the COVID-19 pandemic under control in India, as they seemed to have demonstrated it in China with TCM.10 Another case report on the outcomes of Ayurvedic care in a COVID-19 patient with hypoxia may provide useful guidance.41 The report provides for the first time, the successful outcomes of Ayurvedic intervention in a COVID-19 patient with severe hypoxia requiring supportive oxygen therapy. This provides hope that Ayurveda care may be useful as first-line cost-effective and efficacious option for COVID-19 patients presenting with hypoxia in an integrative setup. Since the patient had high risk for progression to severe disease condition because of many co-morbidities, the favourable outcomes with Ayurvedic treatment is significant.41 Another useful prospective clinical study of an Ayurveda regimen in COVID 19 patients has recently appeared.42 In this study, 112 patients were screened as per inclusion criteria, 11 failed the screening, and finally 101 patients were recruited in the trial. Two patients complained about difficulty in swallowing the tablets and were discontinued on Day 3. Ultimately, among those 99 patients that completed the study, 60 patients received Ayurveda regime as add on, and 39 patients received only standard care. Study found that the median day of admission from the onset of symptoms was 6th (range 1st to 12th) in treatment group; while it was 5th day (range 1st to 16th) in control group. Patients with co-morbidities such as Diabetes and Hypertension were 90.04%. Asthma and Hypothyroidism were observed as other co-morbidities among the rest. The patients suffering from breathlessness fell from 53% to 16 % to 1.6% on day 1, 3 and 7 respectively in the treatment group. In the control group the percentage fell from 46% to 38% to 28% only. Ageusia reduced from 75% to 25% to 3.3% in the treatment group. In the control group it dropped from 46% to 36 % to 26%. Overall, prompt clinical improvement in breathlessness was seen with the add-on Ayurveda regimen. The duration of hospital stay was also reduced. Thus, insights from this study demonstrate the potential of Ayurvedic therapy in treating COVID-19 patients.
Even the widely promoted non-pharmaceutical interventions against COVID-19 including quarantine, cordon sanitaire, and social distancing and healthy lifestyles have their origin in Ayurveda.43-45 These are erroneously thought to date back to 14th-century Europe.46,47 In reality, these originated in India back in 5th century BC. In a city now known as Varanasi, a legendary teacher and king of Kashi, Lord Dhanvantari explained to a class of his students about how infectious diseases spread, and what needs to be done to contain social spread of infections. The renowned scholar of Ayurveda and surgery, Sushruta, was one of the students in the class. He compiled one of the most ancient scientific treatise of surgery and science of life known to humanity. This treatise now known as Sushruta Samhita made Sushruta the father of Surgery. About the infectious diseases, Sushruta notes: Contact with the body of the infected person, breathing in the air containing the exhaled air of patient, eating, sleeping and sitting together, using cloths, garlands and cosmetics used by an infected person – all these actions transmit diseases such as skin-infections, fever due to infections, pulmonary tuberculosis, ophthalmia or conjunctivitis, and other contagious diseases from one person to the other (Su.Ni.5.33-34). Consequently, complete avoidance of these actions is necessary to prevent the transmission of infectious diseases in community.
- Way forward
Scientific advancements occur only when the knowledge produced by a scientific enterprise is robust, irrefutable and unequivocal.48 This applies equally to both Ayurveda and conventional medicine. This is important to understand that every health care system existing and practiced in the world has a primary motive of providing optimal health care to their followers. A health care system having an uninterrupted history of its practice and knowledge transference for over five millennium, itself speaks about the potential utility it may possess. There can be epistemological differences of looking at the same phenomena which are understandable on the basis of historical evolution of the knowledge, but a knowledge cannot be refuted simply for the reason that it is not understandable by the people who believe in another set of philosophy. It is now high time that perpetual animosities between vaidyas and allopaths should end for the common good of the humanity. The solutions to resolve the COVID-19 pandemic are complex, multifaceted and recalcitrant and therefore require evidence-based decision-making on multiple fronts. A way forward would be to acknowledge that scientific research has strengthened evidence-base, yet if Ayurveda was non-scientific, it wouldn’t have survived 5000 years. Denial of this evidence, as well as evidence from the contemporary studies, is indeed a form of pseudoscience. We must draw on all systems of knowledge rather than be enslaved by western medicine that currently lacks both evidence and directions.
Conflict of interest: None.
Acknowledgements: I am grateful to Prof. Dr. Sanjeev Rastogi, Department of Kaya Chikitsa, State Ayurvedic College and Hospital, Lucknow; Prof. Dr. Pawan Kumar Godatwar, Department of Roga Nidana, National Institute of Ayurveda, Jaipur; and Neha Pandey Prakash, Yajurvid Pharma, Jaipur for their insightful suggestions. The views expressed here are personal and driven by the Principle of Global Common Good. They do not in any way represent the views of the institution or service to which author belongs.
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