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Ayurvedic theory conceptualizes the human body in terms of pancha mahabhutas (five elements), three doshas (biological forces that maintain and regulate the body), its seven dhatus (tissues), malas (waste products), and its agni (the fiery energy that fuels digestion and metabolism) and describes the impact of these substances and energies on the body’s srotas (metabolic pathways) and on the functioning of its organs. Ayurveda also posits that all the various forms of matter that exist in the universe are made up of the same five elements that constitute the body. In substances that body ingests, such as foods and herbs, these elements are said to manifest in the substance’s rasa (taste), gunas (qualities), virya (potency), and vipaka (the taste that arises after digestion and metabolism). Information explained under the Basic concepts of Ayurveda were compiled from Charaka Samhita and Ashtanaga Hrudaya. [4–5]
Ayurveda explains that life comprises sarira (the physical body), indriya (the senses), sattva (the mind), and atma (the soul or conscious elements). This understanding of life is rooted in the laws of nature. According to Ayurveda, one of the most important principles that govern natural phenomena is the connection between the macrocosm and the microcosm. This principle holds that human life is a microcosm that exists in a state of constant interplay with the cosmos (the macrocosm).
Ayurveda proposes that the interdependence of the individual human being and all matter in the external universe stems from the precept that everything in nature consists of the same five elements, or pancha mahabhutas (five basic elements): air, fire, earth, ether, and water.In Ayurvedic terms, health is defined as a state in which both the quantities and the qualities of these five basic elements are in perfect balance. Panchamahabootas are considered as basic building block of the universe. The concept of panchamahabootas helps to understand physiology, pathology and pharmacokinetics.These are the minutest elements which constitute living and nonliving matters. Any living body is an outcome of the interplay of the panchamahaboota in a specific manner.According to panchamahaboota theory,manifestation of the entire physical universe including human body is made possible by the combined attributes of Panachamahabootas which are listed below.
Aakasha (Space): Akashamahaboota is the first expression of consciousness and is the space without which matter cannot exist. The main sense attribute to Akasha mahaboot is Sound. Nonresistance is its chief property. It is present in hollow cavities within body and empty areas of cosmos, transmit sound, non resistant to anything, frictionless or smooth,subtle, soft and abundant. Any diet, food or herbs with the similar properties will increase Akashamahaboota in the body.
Vayu (Air): Vayumahabootas evolved from Aakashamahabootas. The main sense attribute to Vayu mahabootas is Touch. As it evolves from Aakasha mahaboota, it also inherits attribute of sound. Mobility is its chief property.Properties of Vayumahaboota include light,dry, subtle, mobile, transparent, and rough. It is responsible for movement and dryness in the body. Any diet exercise and food which has simialr properties will increase Vayumahaboota in the body.
Agni (Heat): Agnimahabootas evolved from Vayumahaboota. The main sense attribute to Agni mahabootas is Vision. It also inherits sense attributes of Sound and Touch from Akasha and Vayu mahabootas. Hot is its chief property. Properties of Agniumahaboota include hot, sharp, intense, dry and light. Any food,exercise, herbs with the similar property will increase Agnimahaboota.
Aapa (Water): Aapa mahaboota evolved from Agni mahaboota. The main sense attribute to Aapa mahaboot is Taste. It also inherits sense attributes of Sound Touch and Vision from Akasha Vayu and Agni mahabootas. Liquidity is the chief property. Properties of Aapmahaboota include moist, cohesive, sticky, cool, soft and oily. Any food and herbs with the similar property will in increase Aap mahaboota.
Prithvi (Earth): Pritvi mahaboota evolved from Aapa mahaboota. The main sense attribute to Pritvi mahaboot is Smell. It also inherits sense attributes of Sound Touch Vision and Taste from Akasha Vayu Agni and Aapa mahabootas. Roughness is the chief property.Properties of Prithvi mahaboota include solid,dense, stable, heavy, hard, dull and slow. Any food, exercise and herbs which have similar property will increase Pritvi mahaboota.
There are two kinds of doshas: somatic( vata , pitta , and kapha ) and psychological ( rajas and tamas ). The somatic and psychological doshas constitute an axis that facilitates the seamless integration of cross-talk between the mind and the body’s neurological, endocrine,and immunological systems. Whenever one of these doshas undergoes changes, the others become deranged. Each one has certain, gunas (qualities) and karmas (functions) and needs to be present in the body in a specific pramana (quantity) to bring health.
The central concept of Ayurvedic Medicine is the tridoshic theory. This theory proposes that there are three doshas, or biological energies, that govern all of the body’s biomotor,metabolic, and physiological activities. Doshas determine longevity at the cellular level and maintain homeostasis in the body. Every living species contains a unique combination of all three doshas ( vata , pitta , and kapha ). While all the five elements (air, fire, earth, ether, and water) are present in each of these dynamic physiological forces, the two elements that dominate its makeup define its nature. For example, the vata dosha is dominated by akasha (ether) and vayu (air); pitta dosha, by tejas (fire) and aap (water);and kapha doshas, by aap and prithvi (earth).
These three innate physiologic forces govern the entire life process from conception and growth through decay and death. While the doshas pervade the entire body, there are particular organs/body parts where they primarily reside. For example, vata is located mainly in the large intestine, pelvic region,thighs, ears, bones and the organ of touch(skin); pitta in the small intestine, stomach,blood, eyes, skin, sweat glands, lymph, and body nourishing fluid; and kapha in the chest,larynx, head, pharynx or esophagus or pancreas,all joints, the stomach, body nourishing fluid,body fat, nose, and tongue.
Vata governs all types of movement in the body and thereby governs all life functions. Its specific functions include controlling respiration and speech, maintaining co-ordination between body and mind, excreting waste products from the body, transporting body elements,and regulating intestinal movements. Pitta controls all types of digestions, metabolism,and transformational actions in the body.Its particular functions include maintenance of body temperature, softness of the body and luster of the skin, visual acuity, taste,appetite, thirst, intellect, and courage. Kapha is responsible for anabolism and the stability and strength of the body. This general role encompasses maintaining stability of joints,unctuousness of body, and the ability of mind and body to tolerate stress.
Each dosha has its own characteristics,anatomic, physiologic, and psychologic properties. Vata is dry, light, cold, rough, subtle,and mobile. Pitta is oily, sharp, hot, light,spreading, liquid, pungent, and fleshy smelling.Kapha is wet, cold, heavy, dull, sticky, soft,dense, and static.
Each of the doshas is divided into five types. The five types of vata are:
Prana vata: Situated in the head; moves around in the chest and larynx. It is represented by the functional units of the respiratory center and governs the sensory and motor organs,mind, intellect, and consciousness. Prana vata also regulates inhalation, swallowing, sneezing,and expectoration.
Udana vata: Situated in the chest. It moves around in the nose, umbilicus, throat,and trachea. It maintains the act of speech and governs energy, enthusiasm, color of the skin/complexion, and memory.
Vyana vata: Situated in the heart. It moves all over the body. It controls walking, flexion,extension of limbs, blinking, and yawning.
Samana vata: Situated near digestive fire(stomach and small intestine). It moves around the abdominal cavity. It controls digestion and absorption and assimilation of nutrients.
Apana vata: Situated in the anal canal. It moves around in the area of urinary bladder,genitals, thighs, and pelvis. It controls excretion of urine and feces, ejaculation of semen, the flow of menstrual fluids, and delivery of infants.
The five types of pitta are:
Pachaka pitta: Situated in stomach and large intestine. It governs digestion and assimilation of food and nourishes the other types of pitta.
Ranjaka pitta: Situated in liver, spleen,stomach, and small intestine. It governs the synthesis of hemoglobin and imparts red color to the blood.
Sadhaka pitta: Situated in the heart. It helps individuals to achieve their desires by maintaining mental activity and intellect.
Alochaka pitta: Situated in the eyes. It is responsible for vision.
Bharajaka pitta: Situated in the skin; it maintains a healthy, lustrous complexion.
The five types of kapha are:
Avalambaka kapha: Situated in the chest;it nourishes other types of kapha.
Kledaka kapha: Situated in the stomach; it is represented mainly by mucus secretion in the gastrointestinal tract, and it helps moisten food.
Bodhaka kapha: Situated in the tongue;enhances sense of taste.
Tarpaka kapha: Situated in the head. It nourishes all the sensory organs.
Shleshaka kapha: Situated in the joints. It helps in maintain joint stability.
During different seasons of the year, the doshas undergo certain changes. For example,at the end of summer, vata tends to become aggravated, increasing beyond the level required to maintain the proper balance of the doshas.This typically happens to pitta during autumn,and to kapha during spring. Failure to harmonize dietary and lifestyle practices with the seasons,as well as improper eating habits and an unhealthy lifestyle, may also lead to aggravation of the doshas and eventually manifest as symptoms of disease. Please see below for the factors that cause each of the doshas to increase.
Vata Excessive consumption of bitter,astringent, and pungent tastes; overconsumption of cold, dry, and light food; intake of food at improper time, intake of less nutritive food, and fasting; suppression of natural urges; late bedtimes; loud conversations; excessive physical exercise; overexposure to erratic motion due to traveling in a vehicle for long time; rainy weather.
Pitta Excessive consumption of salty,pungent, and sour tastes; overconsumption of alcoholic beverages and hot, spicy, oily fried foods; excessive sorrow, fear, anger, leading to reduced intake of food and lack of sleep;overexposure to the sun and fire.
Kapha Excessive intake of sweet, sour and salty tastes; overconsumption of oily,cold, heavy, sweet, and sticky food; sedentary lifestyles and sleep during day time; excessive intake of meat, heavy, or unctuous food, and milk; overeating.
If a dosha that has increased due to these factors continues to accumulate, the aggravation progresses to a more severe state, known as provocation. Doshas can also decrease to a point below their optimal level. The following section outlines the signs and symptoms of increased (aggravated), provoked (agitated),and decreased (depleted) doshas.
Increased vata Emaciation, black discoloration of skin, craving for heat, tremors, flatulence, constipation, loss of power of body and organs, sleeplessness, talkativeness, dizziness,sorrow, hoarseness of voice, and dry skin.
Provoked vata Prolapse of organ, ptosis,dilatation of organs, throbbing pain, numbness,tiredness, pain, cutting pain, retention due to obstruction, body ache, muscle contractions,rounding of an organ, shivering, dehydration,abnormal movements in limbs, dryness,sponginess, atrophy, pulsation, feeling of covering, rigidity, astringent taste in the mouth,and appearance of blue or crimson discoloration of skin.
Decreased vata Slow movements, slow,diminished speech, laziness, diminished functioning of sense organs, unconsciousness,and disease due to increased kapha.
Increased pitta Yellow coloration of skin, feces, urine, and eyes; increased appetite,thirst, anger, affection for cold; reduced sleep;unconsciousness; loss of power; and weakness of organs.
Provoked pitta Burning sensation, redness,rise in body temperature, suppuration, sweating,discharge, secretion, gangrene, coma, sour and pungent taste in the mouth, discoloration of skin except in white or black skin.
Decreased pitta Reduced body temperature,diminished digestive power, and loss of luster of skin.
Increased kapha Anorexia, excessive salivation, laziness, heaviness, pallor, reduced body temperature, tiredness, cough, breathlessness,excessive sleep, dullness, drowsiness, weakness in joints.
Provoked kapha Unctuousness of body and stools, hardness, thickening, obstruction,wetness, heaviness, edema, itching, indigestion,coldness, excessive sleep, salty or sweet taste in mouth, pallor, chronicity of diseases.
Decreased kapha Dizziness, feeling of emptiness in stomach, palpitations, weakness in joints, dryness of skin, burning sensation,excessive thirst, weakness and reduced sleep.
Thorough understanding of each dosha’s primary locations, functions, and the symptoms associated with its increase and decrease is crucial for understanding the causes and effects of diseases.
Health and disease are a direct reflection of the balance/imbalance of the doshas in the body and mind. Proper diet, exercise, and a harmonious lifestyle promote balance among the doshas. Restoring and maintaining the proper balance of the three doshas with respect to their quantity (pramana), quality (guna), and functions (karmas) leads to health.
In Ayurvedic Medicine, constitutional phenotypes, or psychobiological tendencies,are referred to as prakriti. This term equates to the innate balance of the combination of mental and physical qualities that is unique to each individual. This distinctive constellation of qualities is determined at conception and correlates with the patterns of gene expression that shape the individual’s physical, psychological and emotional, and structural characteristics; physiological functioning; metabolic tendencies; personality;and disease susceptibility (immunity). An individual’s prakriti reflects his or her baseline characteristics. It determines an individual’s capacity for transformation at the physical,mental, and emotional levels and influences how that individual interacts with external and internal stimuli, all of which affect the aging process [6] . The idea that there is a delicate balance between biophysiological forces(doshas) and constitution (prakriti) is central to Ayurveda’s understanding of health and disease. Ayurvedic theory ascribes prakriti to the preponderance doshas at the time of an individual’s conception, while also factoring in external influences such as the environment inside the mother’s womb and the dietary and lifestyle habits of both parents. As described in classical Ayurvedic texts, these features of prakriti point to its genetic origin and to its dependence on the interplay between innate characteristics and external factors.
There are seven types of prakriti: vata , pitta , kapha , vata-pitta , pitta-kapha , vata kapha , and sama .
Three Basic Types of Prakriti: Characteristic Features
Vata prakriti Dry, rough skin and nails;cracks in soles of the feet and palms; production of cracking noise in joints during movement;thin or emaciated body; prominence of tendons and veins; irregular teeth; loss of hair and beard; dry, rough hair with split ends; dry eyes.
Pitta prakriti Medium build; feeling of excessive heat; early appearance of grey hair and wrinkles, baldness; numerous black moles;foul body odor; coppery color of nails, whites of eyes, tongue, palate, limbs, palms, and soles of feet; enthusiasm; bloodshot eyes.
Kapha prakriti Large, compact physique;soft, smooth, unctuous skin; big eyes with plenty of eyelashes; whitish tinge in the eye; curly dark hair; prominent forehead, chest; and arms.
Mixed Prakritis The mixed prakritis combine the characteristic features of the different doshas that govern them. While the vata-pitta, pitta-kapha, and vata-kapha prakritis combine the characteristics of two doshas, the sama prakriti possesses the features of all three doshas in equal proportions.
The Importance of Understanding Prakriti Effective Ayurvedic treatment requires a firm grasp of the patient’s prakriti, including its susceptibility to certain diseases. For example, a person with kapha prakriti is particularly vulnerable to kapha-type diseases,such as ailments of the respiratory tract.Hence the clinician should advise this person to consistently avoid any factors that can aggravate kapha.
Factors Responsible for Determining Prakriti These include the following: The quality of sperm and ovum; the season when conception occurred; diet and lifestyle of mother and father at the time of conception; lifestyle and diet of the mother during the pregnancy;nature of the elements that constitute the fetus.
Researchers continue to evaluate whether the various prakritis can be grouped according to anthropometric measurements and biochemical variables like serum cholesterol, blood sugar,and blood types [7] . Studies have also looked into variations in whole genome expression among the different prakriti types.
The Psychic Components of Prakriti An individual’s prakriti encompasses not only the body’s physical aspects but also the characteristics of his or her mind. Ayurveda proposes that three fundamental attributes (gunas) exist in everything in the universe, including our body and mind: sattva (purity), rajas (motion/action),and tamas (inertia). Rajas and tamas represent opposing influences on the mind that, like the doshas, can cause disturbances when they are present in excess. Sattva is the state of perfect balance. The gunas that predominate at the time of an individual’s conception determine the nature of his or her manas (mind).
Dhatus are seven basic tissues in the body: rasa (plasma/lymph), rakta (blood), mamsa (muscle), meda (adipose tissue), asthi (bone,or osseous tissue), majja (bone marrow/nerve tissue), and shukra (reproductive tissue). The term dhatu means “that which assists the body or which serves as building block of the body”.These seven dhatus and several updhatus (secondary tissues) make up the physical bulk of the body and occur in particular proportions in various organs of the body. Any changes in these proportions and in their proper equilibrium can lead to disease. As long as the production and nourishment of the seven dhatus proceeds normally, health is maintained.
The following list describes the main functions of each dhatu:
Rasa (plasma/lymph) — nourishes all the other tissues.
Rakta (blood) — gives vital energy to all bodily functions.
Mamsa (muscle tissue) — covers all the other tissues.
Meda (adipose tissue) — lubricates all the tissues.
Asthi (bone tissue) — supports the body.
Majja (bone marrow/nerve tissue) — f ills bones.
Shukra (reproductive tissue) — reproduction.
The following section lists the signs and symptoms that arise in each of the seven dhatus when there is an increase or a decrease in that dhatu.
Rasa Dhatu
Increase: Discomfort in chest area, and excessive salivation.
Decrease: Chest pain, tremors, numbness,excessive thirst, dryness of body, tiredness,drowsiness, intolerance to sound.
Rakta Dhatu
Increase: Skin rash, splenomegaly, abscesses,dermatitis. Gout, excessive bleeding, tumors,thickening of gums, jaundice, discoloration of skin, loss of digestive power, unconsciousness, redness of eyes, skin, and urine, craving for blood, enlarged veins.
Decrease: Liking for sour and cold food,varicose veins, dry skin, loss of luster of skin.
Mamsa Dhatu
Increase: Cervical tumors; enlarged cervical and other lymph glands; enlarged thyroid and abdomen; hypertrophy of cervical muscles, thighs, neck, lips, phallus, arms;buttocks appear big and muscular.
Decrease: Emaciation of buttocks, neck,abdomen, lips, chest, calves; dryness and pain in the organs; drowsiness; joint pains; weakness of organs; varicosity of blood vessels.
Meda Dhatu
Increase: Mental confusion, breathlessness on little exercise, flabby buttocks, breasts, abdomen and back, oily skin, cough, breathlessness, foul body odor.
Decrease: Joint pain, drowsiness, weakness,emaciation, reduced abdomen, numbness in lower back, splenomegaly, numbness of joints.Dryness of body, affection for oil, and flesh.
Asti Dhatu
Increase: Excessive bone growth and extra teeth.
Decrease: Loss of body hair, scalp hair,beard nails, loss of teeth, tiredness, weakness of joints, pain in bones, breaking of teeth and nails, dryness of body.
Majja Dhatu
Increase: Heaviness of eyes and body, nonhealing ulcers over joints.
Decrease: Weak, light bones, disease of bone due to aggravated vata, reduced semen,joint pains, and numbness.
Shukra Dhatu
Increase: Formation of stones of semen,excess semen, increased sexual desire.
Decrease: Weakness, dryness of mouth,paleness, tiredness, lethargy, impotency,absence of ejaculation of semen, pain in testes and penis, reduced sexual power, premature scanty, blood-stained ejaculation of semen.
Rasa dhatu is formed directly from ahara rasa (the nutrient portion of food obtained from the digestive process). The rasa dhatwagni (the metabolic fire within that tissue) further processes the rasa tissue, producing the plasma and lymph that circulate throughout body as well as components of its successor tissue, rakta dhatu . The metabolic fire within those components ( rakta dhatwagni ) then complete the transformation of rasa into blood. The formation of the other tissues proceeds step-by step from the initial creation of rasa (the first tissue) to the production of rakta (the second one) and continues on until the last one (shukra) is generated.
During the formation of dhatus, upadhatus(secondary tissues) and malas (waste products) are produced. Table 1–2 shows the secondary tissues and waste products associated with the various dhatus.
Doshas imbalances are usually reflected in the dhatus that they govern, where they can lead to dosha-specific diseases. For example,pitta diseases typically involve the blood; vata diseases, the bone; and kapha diseases, the plasma. That said, a doshas can enter into any tissue and cause various diseases.
The ultimate essence of all the dhatus is known as ojas . As the body’s source of biological strength, vitality, and immunity,ojas determines a person’s vigor and resistance against disease. The word ojas means “shining,bright, or full of luster”. While it is present throughout the body, its main seat is the heart.In terms of its qualities, ojas is described as white with yellowish and reddish tinge, cold,oily, soft, smooth, steady, sweet, heavy, viscid,and clear.
Ayurvedic texts refer to two kinds of ojas:
Para ojas — Located in the heart it consists of eight drops. Its loss leads immediately to death.
Apara ojas — Circulates all over the body. Its volume is approximately that of a fist (10～15 mL).
All the activities of all cells, tissues, and organs depend on ojas. If ojas is diminished or absent, the tissue won’t function properly.Increased ojas makes a person happier, stronger, and more energetic.
Table 1–2 Upadhatus and Malas Produced during Dhatu Formation
Disorders of Ojas Injury, overexertion,and psychological disturbances such as anger,sorrow, fear, and worry can all lead to disorders of ojas. These include the following:
Ojo visramsa — Displacement of Ojas from its own site. Symptoms include pain, dull complexion, dislocation of joints, inactivity, and disturbance of doshas.
Ojo-vyapat — Ojas is disturbed by one or more doshas. Symptoms include emaciation,wasting, weak digestive power, exhaustion,edema of vata type, splitting pain, excessive sleep, drowsiness, dizziness, and fainting.
Ojo-kshaya — Decrease of Ojus. Weakness,exhaustion, dull complexion, dryness of skin,weak digestive fire, fear, disorders of sensory and motor system, impaired thinking, blindness,wasting of muscles, fainting, delusions, delirium,and loss of consciousness sometimes leading to death.
The word mala means “dirty” or “unclean”and refers to excretable products of the body.The body produces two kinds of malas: ahara malas (food wastes) and dhatu malas (tissue wastes). Ahara malas comprise purisha (feces), muthra (urine), and sweda (sweat). According to Ayurveda, these waste products help maintain health as long as they are properly eliminated and normal in their quantity, qualities, and functions. Malas play a vital physiological role—their extreme depletion may lead to death. The signs and symptoms of imbalances in the malas are listed below:
Signs and symptoms of increased feces Flatulence, heaviness and pain sides of chest and abdomen.
Signs and symptoms of decreased feces Pain in cardiac region and back, intestinal pain, shifting pain due to vata in the sides of chest,backache.
Signs and symptoms of increased urine Pricking pain in urinary bladder, feeling of incomplete excretion of urine, increased urine output, frequency of micturition, flatulence.
Signs and symptoms of decreased urine Painful micturition, discoloration of urine,excessive thirst, dryness of mouth, pricking pain in urinary bladder, decreased urine output,blood in the urine.
Signs and symptoms of increased sweat Excessive sweating, bad smell to skin, itching.
Signs and symptoms of decreased sweat Loss of body hair; numbness, dry cracked skin;abnormal sensation; decreased or absent sweating.
Agni (digestive fire) is the force responsible for digesting, absorbing and assimilating everything that the body takes in. It resides chiefly in the kostha (gastrointestinal tract) and dhatus (tissues). Any imbalance in the function of agni can leads to disease. Agni has a profound influence on the individual’s lifespan and health span. In addition to digestion and metabolism, it controls sensory perceptions,intellectual functions, and the transformation and assimilation of mental and emotional impressions. Agni fuels the production of various types of enzymes in the gastrointestinal tract and in the liver and in the tissues. The 13 different types of agni that govern digestion of food and metabolism at different levels fall into the following 3 categories:
Jatharagni — This is the primary digestive fire located in the stomach ( amashaya ) and duodenum ( grahani ) of the small intestine.
Bhutagni — These five types of agni correlate with the pancha mahabhutas (five elements). Their role is to metabolize and transform external heterogenous mahabhutas into internal homogeneous ones.
Dhatvagni — The seven dhatvagni reside in the body’s tissues. They help in assimilation and transformation of nutrient materials after processing in the liver ( bhutagnipaka ).
Weak agni undermines digestive functions,resulting in malabsorption and the accumulation of ama (digestive and metabolic toxins). Due to its central role in the body’s digestive and metabolic functions, disturbances of agni are considered the most critical factor in the development of disease. One of the core treatment principles in Ayurveda is to restore and to strengthen the patient’s agni.
When the doshas are in a state of equilibrium, agni functions normally. When there is imbalance in the functioning of doshas,the functioning of agni is impaired. These states are described below:
Vishamagni — This state stems from excess vata. It is characterized by erratic digestion that ranges from slow to normal and may also include symptoms such as abdominal distension,colicky pain, constipation, heaviness, and gurgling sounds in the intestinal tract. This type is seen in individuals with Vata-predominant body constitution.
Tikshnagni — The predominance of the pitta dosha fuels extremely sharp and strong agni that can quickly digest large frequent meals. This type of digestion may be followed by a burning sensation in the abdomen and the palate, parched lips, and a feeling of heat.This type is seen in individuals with Pittapredominant body constitution.
Mandagni — This state of agni is mainly due to influence of kapha. Agni in this state is very sluggish and sometimes unable to digest and metabolize even a small quantity of food.It also leads to heaviness in the abdomen and head, coughing, dyspnea, salivation, vomiting, and weakness of the body. This type is seen in individuals with Kapha-predominant body constitution.
Samagni — This term describes balanced agni that can properly digest a normal diet.
Before starting the treatment of any disease,all the effort should be made to balance the agni.The concept of agni and its role in digestion,metabolism, and assimilation is fundamental to the theory and practice of Ayurveda.
Ama is the undigested, toxic, foulsmelling, viscid, sticky substance formed as result of weak digestive fire such as weak jatharagni or dhatvagni. Ama is considered as the root cause of the diseases. The undigested food is not easily absorbed and remains in the gastrointestinal tract where it stagnates and acts like a poison.
There are many factors that can cause weak digestive fire: quantity of food — excessive food intake; quality of food — intake of excessive fluids and dry, heavy, cold, contaminated food;improper administration of panchakarma (detoxification therapies); suppression of natural urges; abnormal season (aberration in the seasons).
Srotas are channels of circulation, where nutrients and other essential materials and energies are assimilated, transformed, and transported to and from the body’s organs and tissues. Within these hollow structures, body elements are produced, nourished, transformed into other body elements and catabolized, and metabolic wastes are carried out of the cells for elimination by the body’s excretory organs.The structure and functions of the srotas are deemed normal as long as the doshas, agni, and the dhatus are functioning normally. When damaged or impaired, however, srotas serve as a base for the production of a lesion or manifestation of disease. This typically occurs when a vitiated dosha spreads throughout the network of channels and comes into contact with a defective srotas. The disturbed dosha may then settle there, creating the conditions for the development of a disease. The various causes of defective srotas include the following:
Kulaja (heredity) — the cause of an impairment that’s linked to the genetic makeup of a person’s mother or father.
Jataja (teratogenicity) — improper diet and lifestyle of a pregnant women that produces a defect in the system.
Aharaja (dietary causes) — irregularities in diet and daily regimen that cause imbalances in the doshas, dhatus, or other aspects of a person’s constitution, setting the stage for disease.
Agantuja (external causes) — factors such as excessive heat or cold or toxins that produce imbalances in the doshas or dhatus or other aspects of the person’s constitution, leading to diseases.
Shesha doshaja (remnant causes) —improper management of an existing disease that causes relapse of that diseases or new diseases.
The classical Ayurvedic text, the Charaka Samhita , describes the body’s major systems in terms of 13 srotas: Pranavaha srotas (respiratory system), Annavaha srotas (digestive system up to small intestine), Udakavaha srotas (water metabolism system), Rasavaha srotas (body nourishing fluid system), Rakthavaha srotas (cardiovascular system), Mamsavaha srotas (muscular system), Medovaha srotas (fatty tissue system), Asthivaha srotas (bony tissue and skeletal system), Majjavaha srotas (bone marrow/nervous system), Sukravaha srotas (reproductive system), Mutravaha srotas (urinary system), Purishavaha srotas (defecation system), and Swedavaha srotas (perspiratory system).
In another foundational Ayurvedic text written later, the revered physician Sushruta delineated 11 srotas, excluding the asthi vaha srotas and majja vaha srotas and introducing a system called the artava vaha srotas (channels for transporting nutrients to the female reproductive tissues).
Ayurveda also recognizes two other srotas: Manovaha srotas (system of mind), Stanyavaha srotas (lactation system).
According to Ayurveda, mind is considered as the controller of the sense faculties. Ayurveda explains that mind plays a major role in the knowledge of happiness and unhappiness etc.and it is Atindriya-Trans-sensual. It has been considered as the controller of sense faculties.Mind is part of a person, consisting of thoughts,feelings and the function of willing.
There are three qulaities of Mind explained in Ayurveda: Satva-state of balance, harmony and stability; Raja-Incharge of activity; Tamasleads to inertia.
Satva Guna makes mind more conscious.Our eternal Self could be discovered by pure Satva.
Raja and Tamas cause disharmony,agitation and delusion in mind. Raja makes the difference in perception of the mind as it perceives false ideas of the external world and makes the impression like real. This may temporarily cause happiness for some time but lose the inner peace in longer run. Desires and emotional upsets are caused by Raja. Rajas is in charge of activity of mind. Ignorance comes from Tamas. Adequate balance of these three Guna is very much essential as Satva makes balance in the energy of Raja, while stability with Tamas. According to Ayurveda, brain and heart are the seat or location of mind.
Peace of mind, sensory satisfaction and positive mind play a major role in healthy life.Disturbances in the balance of quality of mind cause various dosorders in the functioning of mind which can lead to various psychological and physiological disorders. According to Ayurveda, body, and mind are connected.
Ayurveda defines health as a state in which an individual sustains the balance between the 3 doshas, the 7 dhatus, the 3 malas, and the 13 agnis that is ideal for his or her constitution.In this state, the person experiences total biological equilibrium along with sensorial,mental and emotional, and spiritual well being. Ayurvedic teachings help individuals achieve this healthy balance by providing comprehensive guidance on lifestyle, diet,exercise, and personal and social behavior, as well as detailing daily, nightly, and seasonal routines that are specifically designed for their unique constitution. Ayurveda also promotes health through the use of various types of rejuvenating ( rasayana ) herbs and therapies and detoxification therapies (panchakarma).
These treatment approaches are based on a holistic understanding of the various factors that cause imbalances of the doshas, dhatus,and malas. According to Ayurveda, the primary cause of all disease is a lack of harmony between the individual and his or her environment.Thus malfunctions of kala (time), such as unseasonable weather, and improper use of budhi (the intellect) or indriyartha (objects of five sense organs) can be considered causes of disease.
The Ayurvedic approach to diagnosis is a two-fold process: examination of the patient and examination of the disease. Examination of patient helps the clinician determine and understand the prognosis of the disease and to decide how to manage it. This part of the diagnostic process entails an assessment of 10 aspects of the patient: constitution, imbalance,quality of tissues, compactness of the body,anthropometric data (e.g., weight, height,etc.), adaptability, mental stamina, digestive power, physical strength, age and rate of aging.This assessment provides the clinician with a general picture of the patient’s constitution and the status of his or her health and vitality. The second part of the diagnostic process is carried out in order to identify the patient’s present disease. This threefold process includes the following: patient interview (to determine the chief complaint and obtain a health history),general examination (observation of the patient’s pulse, tongue, voice, skin, eyes, urine, stool,general appearance, etc.), systematic examination of the whole body, including the channels.
Ayurveda’s approach to restoring the balance of doshas, dhatus, malas, and agnis draws on the principle of samanya and vishesha (similarity and dissimilarity). According to this principle, materials that are similar to various constituents of the body strengthen those constituents and dissimilar materials deplete them. Based on this principle, Ayurveda recommends dietary, lifestyle, behavioral,and psychological interventions with qualities that are either similar or different from the qualities of the patient’s dosha, dhatus, or other constituents, depending on whether they are depleted or present in excess. The entire approach is individualized to restore balance to the body and mind of each patient.
Ayurvedic Medicine encompasses three main categories of interventions: daivavyapashraya (divine therapy), yukthivyapashraya (rational therapy), and sattvavajaya (psychotherapy).Divine therapy includes chanting, offering oblations and prayers, and wearing stones with special properties. Psychotherapy aims to support the mind, and rational therapy strives to restore balance by recommending strategies based on tridoshic theory and on the state of the patient’s agni and other indications of his or her health status. The rational therapy comprises two parts: samshodhana (purificatory therapy) and samshamana (curative treatment). The purificatory therapy aims to clean the channels of the body to facilitate absorption of nutrients and herbs. It is practiced in two forms: external purification such as oleation, fomentation,and massage to liquefy the impurities and push them to gross channels from where they get easily excreted using internal purificatory therapies; internal purifications (panchakarma),which consists of vamana (emesis), virechana (purgation), anuvasana vasti (oil enema), asthapana vasti (decoction enema), and nasya (nasal cleansing). When a disease is present,purificatory therapy is followed by specific curative treatment. This typically consists of herbs and diet and lifestyle practices that are appropriate for the patient’s constitution and the state of his or her dosha, dhatus, malas, and agni.
The classical texts of Ayurveda contain detailed explanations of how to achieve its twin goals of protecting the health of healthy persons and managing disease in persons suffering from disease. In addition to recommending daily and seasonal routines, practices that promote physical and emotional balance, and a code of proper conduct, these texts stress the importance of traya upastamba — the three pillars of health.
Ayurveda identifies three supportive pillars/values for the maintenance of life and health: Ahara (food), Nidra (sleep), and Brahmacharya (positive lifestyle).
The adequate growth and maintenance of body depend on a healthy and balanced diet. Ayurveda provides detailed advice about wholesome food and describes a wide variety of foods and drinks and methods of preparation,as well as a code of discipline that should be followed while eating, and factors that need to be considered when cooking food.
In Ayurveda, ingredients used for food and drinks have been classified into the following 12 groups: Sukadhanya (corn with bristles), Samidhanya (pulses), Mamsa (meat), Saka (vegetables), Phala (fruits), Harita (vegetables eaten raw), Madya (wines), Ambu (water), Gorasa (milk and milk products), Iksuvikara (products of sugarcane), Kritanna (cooked food preparations), and Aharayogin (other supplies used for cooking food such as oil, spices, salts).
According to Ayurvedic wisdom, one’s diet should be easily digestible, simple, small in quantity, and sattvik (balanced). One must always give thought to agni (digestive power) before consuming food. When taking food,one should fill half of the stomach with solid food, one fourth with liquids, and leave the rest of the stomach empty. This will promote easy digestion of food. One must consume food containing different rasas (tastes) so that all the doshas will be balanced. One must pay attention to the quality and quantity of the food. The proper choices may vary from person to person.When planning and eating meals, individuals must also consider the potential effects on their constitution of the combination of foods, the method of preparing and eating the food, and their emotional state during the meal.
The following factors play a significant role in determining the makeup of a balanced diet: Matra (quantity), Kala (time of the day or season), Kriya (mode of preparation or cooking), Bhumi (habitat or place or climate), Deha (constitution of person who will consume the diet), and Desa (body and environment).
Ayurvedic Medicine also considers the issues surrounding dietary incompatibility. It advises against eating foods that present any of the following issues: combinations of foods with biological qualities that conflict with one another, foods that are incompatible with your constitution, foods that are incompatible with the place or time of consumption.
All of the factors outlined above can be used to determine the wholesomeness or unwholesomeness of various foods. In addition,Ayurveda identifies eight other factors that should be considered: Prakriti (nature of food articles), Karana (method of processing), Samyoga (combinations), Rasi (quantity), Desa (habitat or climate), Kala (time), Upyoga samstha (rules for governing intake of food),and Upyokta (wholesomeness of the individual who is taking food).
Other important considerations include the impact on processing/cooking food. The qualities of food may be transformed in ways that can either enhance or degrade the food’s wholesomeness by activities such as diluting, applying heat, cleaning, churning, storing,maturing, and flavoring.
Ayurveda also lays out 10 rules for governing the intake of food: One should eat warm food. One should consume unctuous food. One should take food in the proper quantity. One should wait to consume a meal until the previous meal is digested. One should avoid food with contradictory properties. One should eat in the proper place and use the appropriate utensils. One should not eat too hurriedly. One should not eat too slowly. One should avoid talking or laughing while eating and focus solely on the food. One should take food in the prescribed manner, with due regard for oneself.
Individuals are also advised to give thought to the effects that various foods may have their constitution in terms of their weight.For instance, foods classified as brahmana samanya have properties like heaviness,unctuousness, and coldness that can lead to increase in tissue and body weight. Foods called langana samanya , on the other hand, tend to reduce tissue and body weight.
Other properties such as taste can have a profound impact on an individual’s dosha,dhatus, malas and agni. Ayurveda delineates a total of six tastes. Table 1–3 shows the effects of the six taste on the three doshas.
Table1–3 The Effects of the 6 Tastes on the 3 Doshas
Proper sleep endows the individual with happiness, nourishment, strength, vitality,knowledge, and longevity. Improper sleep,untimely sleep, and excessive sleep cause various imbalances in the body. Ayurveda has described in detail the mechanisms of sleep and its qualities. It advises against sleep during the daytime in a season other than summer.Sleeping during the daytime in all seasons is recommended for only those people who are exhausted by singing; study; alcoholic drinks;sexual acts; elimination therapy; carrying heavy loads; walking long distances; suffering from wasting diseases, thirst, diarrhea, colic pain, dyspnea, hiccups, or psychosis; and for those who are very old or very young, weak, or emaciated, as well as for those injured by a fall or an assault; exhausted by a long journey in a vehicle or by anger, grief, or fear; and for those who are accustomed to daytime sleep.
Ayurveda teaches that living a long and healthy life requires practicing restraint in regard to sex and worldly pleasures.
Classical literature in Ayurveda also includes extensive discussion on the two other aspects of good conduct that promote health and happiness: Sadvritta (mental and social health), Swasthavrtta (healthy lifestyle).
Ayurveda proposes that swasthavritta (a healthy regimen) is the key to a balanced life.This regimen spans three categories of routines.The ancient Ayurvedic literature gives detailed instructions on how each of these should be conducted: Dinacharya (daily routine), Ratricharya (night routine), and Ritucharya (seasonal routine).
Ayurvedic instructions for a balanced daily routine are as follows: One should get up from bed before sunrise. He or she should attend to natural calls and should wash his face, hands,and excretory orifices properly with clean water. The individual should clean the mouth and teeth. The teeth should be cleaned with the help of fresh wooden stick with astringent,bitter or pungent taste (top portion is crushed) without damaging gums. After this, one should clean his tongue using tongue cleaner made of gold, copper, or silver, which should be about 10～15 cm long. Eyes should be cleaned with cold water. After drying the eyes, one must apply anajana (collyrium) to promote good vision. One should use nasal drops (anu tailam can be used) daily to protect the sensory organs and organs above the shoulder. Gargling with oil or decoction is beneficial for the strength of jaws and teeth and to protect the sensory organs. One must also put the oil drops in the ears to prevent the diseases due to vitiated vata and to protect the ears. One who applies oil on his head regularly won’t suffer from headache,baldness, early greying of hair, and hair loss. It also helps to protect all the sensory organs. One must apply oil all over the body and massage the body to protect the body and to have healthy skin and happiness. One must engage in daily exercise to achieve body stability and physical and biological strength. One must pay attention to his own strength to decide on the intensity of the exercise. After exercise, one should take a bath. A bath should be taken twice a day and an attempt should be made to clean all of the body. Beard and nails should be cut thrice a fortnight. One should wear clean cloths and use natural perfumes and garlands. One should wear gems and ornaments to have a charming effect and happiness. One should use footwear while walking to protect the feet from attacks of reptiles, thorns, etc. One should eat in proper quantity, paying attention to agni. (The previous section includes detailed explanations about food.) One should engage in smoking the cigars that are made up of plant powders.It helps create a feeling of lightness in the chest and head and promotes the liquification of kapha.
The regimen of life in different seasons is described in this section of the text. This regimen will help the body to overcome the seasonal challenges and prevent the diseases that occur due to seasonal changes. According to the time factor, the whole year is divided into two parts: uttarayana, or adanakala (northward movement of sun and its act of dehydration),which bring about three seasons (late winter,spring, and summer), and dakshinayana , or visargakala (southward movement of sun) and its act of hydration that give rise to the other three seasons (rainy season, autumn, and early winter). The changes in the body that happen during these times influence the doshas, dhatus, agni, and malas. The practices explained in this section of the text mainly aim to preserve the equilibrium of these biological energies.
Conduct during night is explained in this section. Ayurveda explains different types of sleep and measures to induce good sleep. Proper sleep endows the individual with happiness,nourishment, strength, virility, knowledge, and longevity. Improper sleep causes emaciation,weakness, ignorance, and even early death.Ayurveda recommends avoiding day sleep, and advises that only certain people can indulge in day sleep (please refer the previous section about sleep). Certain measures are explained to induce good sleep. Massage; bath; intake of soup of domestic marshy, aquatic animals, rice with curd,milk, unctuous substances, and alcohol; smell of fragrance; calming the mind; application of soothing ointment to the eyes, head and face;and a comfortable bed and home will help induce good sleep. Food should be taken as early as possible during night. One shouldn’t go to sleep immediately after a meal at night. Food should be light and easily digestible. Intake of curd during night is prohibited; it may affect digestion and metabolism.
The traditional health systems that are officially recognized in India include Ayurveda,Yoga, Unani, Siddha, Homeopathy, and so on,which are represented by the acronym AYUSH.(Since Homeopathy is not indigenous to India,the acronym AYUSH in reference to the present article does not include Homeopathy.) AYUSH systems have been absorbed into the national healthcare delivery system in India and are integral parts of it. However, the mainstream healthcare system remains conventional biomedicine, known also as Western medicine,biomedicine, or allopathy. Although, all AYUSH systems run parallel to Western Medicine in terms of education and practice,some steps toward integration have been taken of late [8] .
Prior to Indian independence, vaidyas (Ayurveda practitioners) were largely unsanctioned by official governing boards,with the exception of a few provincial boards that recognized specific qualifications. Once Western Medicine received official recognition from the colonial rulers, and as its acceptance grew, Ayurveda had to reinvent itself in order to maintain its relevance. The home-based Ayurvedic pharmacies were slowly converted into bulk drug manufacturing units, and commercial production of formulations started.Even after independence it took more than 20 years to formally integrate Ayurveda, Unani,and Siddha into the national healthcare system.More than seven expert committees were formed by the government and were asked to furnish their reports. The committees’ reports represented different priorities and points of view. The important committees and their recommendations have been summarized in Table 1–4 [9] .
The four non-allopathic systems of medicine — Ayurveda, Unani, Siddha, and Homeopathy — were legally recognized in the 1970s. Before the enactment of Indian Medicine Central Council (IMCC) Act, 1970,several state governments had passed various legislation establishing the requirements for Ayurvedic degrees and regulating the practice of indigenous medicine. The earliest statute appears to be the Board of Indian Systems of Medicine Act, 1947, of Mysore State, followed by the East Punjab Ayurvedic and Unani Practitioners Act, 1949. Chennai, Maharashtra,Hyderabad, the Andhra area, enacted their own legislation. The Andhra Ayurvedic &Homeopathic Medical Practitioners Registration Act,1956, was specifically introduced to regulate and recognize practitioners in the Andhra area. In 1964, a special chapter,Chapter IV A, was included under the Drugs &Cosmetics Act 1940 [10] .
At present, the education and practice of the Ayurveda, Siddha, and Unani (ASU) systems of medicine is regulated by the Central Council of Indian Medicine (CCIM), a statutory organization established by a central enactment. The medicine system (popular in the Himalayan region), was included in the regulations of CCIM in 2011. The Central Council of Homeopathy (CCH) oversees the education and practice of Homeopathy. Yoga and Naturopathy are also taught throughout the country by different institutions; however,there is no central registry maintained for registration of the practitioners of these systems [10] .
The Central Government established an independent Department for the Indian Systems of Medicine & Homeopathy in 1995. The Department of ISM & H was renamed AYUSH in 2003. The status of this department was upgraded to that of an independent ministry in 2014. Among AYUSH systems, Ayurveda currently dominates the healthcare scenario in terms of the number of educational institutions,practitioners, hospitals, pharmacies, and dispensaries [8] .
Under the IMCC Act, 1970, the Central Council of Indian Medicine (CCIM) was established to ensure a standard and uniform ASU medical education system. It adopted the same framework as that of the Medical Council of India (MCI) under the MCI Act,1956. A system for membership and election to the General Body and the Executive Body of the CCIM was also introduced. In the list of changes that aimed to bring the standards for traditional medical systems up to par with those for Western Medicine, the CCIM recommended the requirements for MBBS/BAMS/BSMS and BUMS degrees include five and a half years of training [10] .
Table 1–4 Summary of Major Recommendations of Seven Expert Committees Concerning the Education and Practice of Ayurveda and Other Indigenous Systems of Medicine (ISM)
Recently, the National Commission for Indian System of Medicine (NCISM) Act 2020) has come into effect from 11 th day of June 2021, replacing the provisions of Indian Medicine Central Council (IMCC) Act 1970 (48 of 1970). It proposes to introduce a paradigm shift in regulation of ASU education in INDIA.Functionally, it is set to take over the role of CCIM. One of the important features is a new regulatory hierarchy comprising a commission,an advisory council, and various autonomous boards with a mandate to operate within specified domains. It proposed the establishment of two boards: one charged with ensuring ethics in education and practice and overseeing regulation of the registration process, and another responsible for assessing and rating of educational institutions. Another prominent feature is the replacement of the current norm of “elections” with a transparent merit based “selection” process. This new selection process would apply to key positions on the Commission and its constituent boards. It also has replaced the current input-based regulatory mechanism with an outcome-based one. Other significant provisions include the following:the inclusion of experts in fields such as botany,pharmacology, management, economics, and law in the framework of the Commission;introduction of a national entrance examination to ensure a transparent merit-based admission process; the development of an examination to certify the competency of graduates to practice professionally and to enter postgraduate programs; and ongoing collaboration with the NMC to ensure interaction between all branches of healthcare delivery [11] .
One of the important features of this bill is the introduction of a new regulatory hierarchy comprising a commission, an advisory council, and various autonomous boards with a mandate to operate within specified domains. The bill proposes the establishment of two boards: one charged with ensuring ethics in education and practice and overseeing regulation of the registration process, and another responsible for assessing and rating educational institutions. Another prominent feature of the draft is a proposal to replace the current norm of “elections” with a transparent merit-based “selection” process.This new selection process would apply to key positions on the Commission and its constituent boards. The draft also calls for replacing the current input-based regulatory mechanism with an outcome-based one. Other significant provisions of the draft include the following:the inclusion of experts in fields such as botany,pharmacology, management, economics, and law in the framework of the Commission;introduction of a national entrance examination to ensure a transparent merit-based admission process; the development of an examination to certify the competency of graduates to practice professionally and to enter postgraduate programs; and ongoing collaboration with the NMC to ensure interaction between all branches of healthcare delivery [11] .
According to the 2017 data, there are 11 national institutes operating under various AYUSH councils. [12] .
The following is an abridged list of officially recognized degree programs for Ayurvedic physicians:
Graduate-Level Programs These programs,which comprise five and a half years of coursework leading to a Bachelor of Ayurveda Medicine and Surgery, are currently operating throughout the country under IMCC Act, 1970.
Postgraduate-Level Programs Thes three-year programs provide advanced training in various specialties. Currently available postgraduate programs for Ayurvedic physicians span 22 fields of specialization.
Postgraduate Diploma Programs Thes two-year programs span 16 specialty fields.
Table 1–5 lists the courses taught to students training to become Ayurvedic physicians during the first four and half years of a graduate-level program [13] .
Table 1–5 Subjects Taught to Graduate Students of Ayurveda during their First 4.5 Years of Professional Training
The following table (Table 1–6) provides a statistical breakdown of the population of registered practitioners across the four categories of AYUSH systems as of January 2017 [14] .
Table1–6 The Number of Registered Practitioners of AYUSH Systems in India
The Ayurvedic, Unani, and Siddha systems vary considerably in their approach to education and practice. Ayurveda is practiced countrywide, and there are several approaches that derive from either regional/traditional custom or university based training. For instance, the use of panchakarma procedures and botanical preparations is popular in southern India,whereas rasa shastra-based practice is more popular in the northern states. Public trust also differs widely across regions. The Unani system is more dominant in the pradeshes of Uttar Pradesh, Bihar, Andhra Pradesh, Maharashtra,Delhi. The practice of Siddha Medicine is mostly confined to the state of Tamilnadu [10] .
The Central Council for Research in Ayurveda (CCRA) was set up as an advisory body in 1962, and the Central Council for Research in Indian Medicine and Homeopathy(CCRIM&H) was established in 1969. The Central Council for Research in Ayurveda and Siddha (CCRAS), an apex body charged with formulating, coordinating, and developing research in Ayurveda and Siddha along scientific lines, was established in March,1978. The purpose of its efforts was to validate Ayurvedic knowledge in “scientific terms”. In 2011, the CCRAS was renamed the Central Council for Research in Ayurvedic Sciences. The Council has been executing its research programs across a network of 30 peripheral institutes/centers/units and has assigned responsibility for oversight of these programs to its headquarters.The Council relies on more than 700 officers and staff, as well as on collaborative studies with various universities, hospitals, and institutes to conduct its research. CCRAS programs span a wide variety of research areas, including Clinical Research, Fundamental Research,Pharmacology (Pre-clinical Safety/Toxicity and Biological Activity Studies), Medicinal Plants(Medico-Ethno Botanical Surveys, Cultivation,Pharmacognosy), Drug Standardization, and Literature Reviews, and Documentation [15] .
While the efforts to systematize the development and propagation of Ayurvedic,Unani, and Siddha Medicine gained momentum through the creation of an independent department, the first ISM health policy was announced only in 2002. It spoke of mainstreaming the AYUSH sector across all aspects of education, research, and practice.
In order to promote the medicinal plants sector, the Government of India set up the National Medicinal Plants Board (NMPB) on November 24, 2000. Currently the board is located in the Ministry of AYUSH (Ayurveda,Yoga & Naturopathy, Unani, Siddha, and Homeopathy), Government of India. The primary mandate of NMPB is to develop an appropriate mechanism for coordination between various ministries/departments/organizations in India and to implement support policies/programs for overall (conservation,cultivation, trade, and export) growth of medicinal plants sector at both the central/state and international levels [16] .
To meet increasing demand for medicinal plants, the NMBP focuses on in-situ and exsitu conservation and on augmenting local medicinal plants and aromatic species of medical significance. The NMPB also promotes research and development, capacity building through training, and raising awareness through promotional activities like creation of home/school herb gardens. NMPB also supports programs for quality assurance and standardization through development of Good Agricultural and Collection Practices (GACPs);development of monographs laying down standards of quality, safety and efficacy; and development of agro-techniques and credible institutional mechanism for certification of quality of raw drugs, seeds, and planting material. The NMPB’s overall aim is to develop the medicinal plants sector through strong collaboration between various ministries/departments/organizations charged with implementing policies/programs that address that sector’s concerns [16] .
Traditional Knowledge Digital Library(TKDL) is an initiative to prevent misappropriation of India’s traditional medicinal knowledge at International Patent Offices. In 2005, the TKDL expert group estimated that about 2,000 inappropriate patents related to Indian systems of medicine were being granted every year at the international level. Because India’s traditional medicinal knowledge is documented in languages such as Sanskrit, Hindi, Arabic,Urdu, and Tamil, it is neither accessible nor comprehensible to patent examiners in international patent offices [17] .
With the help of information technology tools and the innovative Traditional Knowledge Resource Classification (TKRC) system, the Traditional Knowledge Digital Library has been able to translate about 0.29 million medicinal formulations documented in the ancient texts of Ayurveda, Siddha, Unani, and Yoga into five international languages (i.e., English,Japanese, French, German, and Spanish).The TKRC has organized traditional Indian medicinal knowledge into approximately 25,000 subgroups for Ayurveda, Unani, Siddha,and Yoga. Under A61K 36/00, the TKRC has enabled incorporation of about 200 subgroups into International Patent Classification, far surpassing the limited number of subgroups on medicinal plants available under A61K 35/00 and thus enhancing the quality of searches and examination of previously filed patent applications in the area of traditional knowledge. TKDL has also been able to establish international specifications and standards for setting up TK databases. The Committee adopted these standards in 2003 in the fifth session of the Intergovernmental Committee (IGC) of World Intellectual Property Organization (WIPO) on Intellectual Property and Genetic Resources, Traditional Knowledge,and Expression of folklore [17] .
Poorly designed study protocols have attracted a lot of criticism when it comes to clinical trials pertaining to Ayurveda. To overcome these constraints, the department of AYUSH created a set of Good Clinical Practice guidelines in 2013 that span every stage of the clinical trial process from the design, conduct,termination, audit, and analysis of the trial to clinical study reports and the documentation of the trial’s participants. The guidelines describe in detail the most essential scientific and ethical steps a researcher needs to follow while conducting a clinical trial [18] .
In 2014, the department of AYUSH published a manual entitled Good Manufacturing Practice (GMP) Guidelines that was based on the requirements for ASU drug manufacturing units laid down by the Drugs and Cosmetics Rule 157, 1945. GMP guidelines comprise a series of general principles that ASU pharmaceutical establishments must be observed during manufacturing. These guidelines ensure that raw materials used in the manufacture of drugs are authentic, meet prescribed quality requirements, and are free from contamination;that the manufacturing process conforms to the prescribed standards; that adequate quality control measures are adopted; and that the drug released for sale is of acceptable quality [19] .
In the era of globalization, concerns are being raised regarding the clinical safety of contemporary ASU formulations. There is a prevailing misconception that all drugs of natural origin are safe. Other false assumptions include the belief that natural medicines ensure both safety and efficacy and that there is a little or no chance of drug interactions. Contrary to these beliefs, an increasing number of published case reports document potentially adverse effects associated with AYUSH interventions.To tackle this issue, the Ministry of AYUSH has initiated the Pharmacovigilance Program for ASU & H drugs [20] .
The All India Institute of Ayurveda, New Delhi, is the National Pharmacovigilance Coordination Center (NPvCC) for implementation of the pharmacovigilance program for ASU &H Drugs. The NPvCC receives input in terms of suspected ADRs from the Intermediary Pharmacovigilance Centers (IPvCs). The National Pharmacovigilance Coordination Center undertakes the pharmacovigilance activities under the guidance and technical support of Indian Pharmacopoeia Commission( t h e W H O C o l l a b o r a t i n g C e n t r e f o r Pharmacovigilance), and the relevant program officers at WHO Country Office-India. If required, the National Pharmacovigilance Co-ordination Center, in consultation with the Pharmacopoeial Commission of Indian Medicine and Homeopathy (PCIM&H),conducts the Causality Assessment of the signals received from the Intermediary Pharmacovigilance Centers and then reports confirmed cases of Adverse Drug Reactions and misleading advertisements to the Ministry of AYUSH to enable suitable action [20] .
The Central Council for Research in Ayurvedic Science has initiated Tribal Health Care Research Program (THCRP) in 14 states through 15 institutes that operate under it. This program aims to study the living conditions of tribal peoples, collecting health statistics on tribal populations and studying their dietary habits,the nature and frequency of prevalent diseases,and the use of common medicinal plants in the area. It also strives to provide medical aid at the doorsteps of tribal peoples while also propagating knowledge of the Ayurvedic concept of Pathyapathya (wholesome and unwholesome food), including hygiene habits and dietary practices. It also collects information pertaining to LHTs/folk medicines/traditional practices prevalent in the area. This study has been implemented under TSP (Tribal Sub Plan) and,as of 2018, has covered approximately 842,959 people from 1,003 villages [21] .
The Swasthya Rakshan Program was initiated through Central Council for Research in Ayurvedic Sciences (CCRAS), the Central Council for Research in Unani Medicine(CCRUM), the Central Council for Research in Homeopathy (CCRH), and the Central Council for Research in Siddha (CCRS) in selected districts/villages. The program aims to organize Swasthya Rakshan outpatient departments,Swasthya Parikshan camps (Health camps), and health/hygiene awareness programs and to raise awareness of the importance of cleanliness of domestic surroundings and environment. It also documents the demographics, dietary habits,hygiene conditions, seasons, lifestyle, and incidence/prevalence of disease associated with each district [22] .
Initiated under the Scheduled Castes Sub Plan (SCSP), this program provides door-to-door healthcare services in areas with officially recognized castes pockets [22] .
This program has been undertaken by the Ministry of AYUSH and Ministry of Health and Family Welfare to promote prevention of noncommunicable diseases in three identified districts of three pradeshes: Bhilwara (Rajasthan),Surendra agar (Gujrat), and Gaya (Bihar) [22] .
This initiative of the Department of Health and Family Welfare and Ministry of AYUSH aims to strengthen healthcare facilities in remote areas [22] .
The Ministry of AYUSH has recently developed a comprehensive web portal for Standardized Terminologies and National Morbidity Codes of Ayurveda, Siddha, and Unani Systems of Medicine and WHO-ICD-10 and ICD-11. This aims at pan-India implementation of ASU National Morbidity Codes for reporting morbidity and treatment outcomes along with ICD-10/11 (Dual Coding System) and is expected to serve as reference repository of A-S-U terminologies and Morbidity Codes for further development of ASU international terminologies and ICD-11 Morbidity Codes [23] .
A standardized prakriti assessment scale has been launched by the Ministry of AYUSH in April 2018. It has been developed by conducting one year study by 8 peripheral centers of CCRAS.It aims at solving the problem of assessment of prakriti at Oot Patient Department level, which helps to prescribe medicine, diet, and lifestyle to maintain one’s health.
A comprehensive IT platform has recently been developed to effectively manage all functions of healthcare delivery systems and patient care in AYUSH facilities. The Ministry of AYUSH has created AYUSH GRID to bring all the IT projects under one umbrella. The platform integrates all IT projects that are dedicated exclusively to the improvement and facilitation of AYUSH healthcare delivery across India [24] .
This plan has been implemented under Schemes for Public Health initiatives scheme of AYUSH. Its main objective is to spread awareness among public about remedies available in AYUSH system of medicine. This scheme has 5 components focusing on spread of knowledge in public.
A voluntary product certi fi cation scheme for selected AYUSH products aimed at enhancing consumer confidence has been initiated by the ministry of AYUSH. The Quality Council of India (QCI) is the partner institute in this initiative. It offers two levels of certification: AYUSH Standard Mark,which is based on compliance to the domestic regulatory requirements, and AYUSH Premium Mark, which is based on GMP requirements,WHO Guidelines, and product requirements with flexibility to certify against any overseas regulation provided these are stricter than the former criteria.
Due to emerging demands for natural medicine and the process of globalization, a few initiatives in the AYUSH sector have been made through electronic means. Use of such information technology can add dimensions to the domain and scope for modernization of the AYUSH sector for its better accessibility to the stakeholders. All major classical textbooks have been made available in digital format for free use by National Institute of Indian Medical Heritage, Hyderabad, an institution that is governed by CCRAS.
This acronym stands for E-Channel for Herbs, Aromatic, Raw Material, and Knowledge and is a platform for enabling information exchange between various stakeholders involved in the medicinal plants sector. E-Charak has been jointly developed by the National Medicinal Plants Board (NMPB) and the Center for Development of Advanced Computing (CDAC) [25] .
This initiative is aimed at preparing a skilled workforce in the AYUSH sector. Under this initiative, the All India Institute of Ayurveda has developed curricula for different courses leading to different levels of certification, such as AYUSH Sports Therapist.
Until recently there were virtually no good peer-reviewed journals dedicated exclusively to publishing AYUSH research. This gap has now been filled by several journals that are indexed in standard databases such as PubMed and Scopus. According to Scopus data, approximately 6,321 articles have been published to date that contain the keyword“Ayurveda”. Of those, 4,274 came out in the last decade alone. Most of the articles on Ayurveda that have been published appeared in the Journal of Ayurveda and Integrative Medicine ( J-AIM ) . Bulletin of the Indian Institute of History of Medicine and the Journal of Ethnopharmacology are the oldest publications among the top five journals [26] .
Not surprisingly, most of the articles on indigenous Indian Medicine that are being published and indexed, are authored by the Indian researchers. Out of the approximately 6,300 published, 4,417— around 70% of the total number — originated in India. The next largest number of articles (705) came from the U.S,followed by the UK with 193, while Germany,the sole European contributor, published 138 articles. Researchers from Japan, Australia, Sri Lanka, and Canada have published 91, 86, 75,and 71 papers respectively [26] .
The majority of the articles published(3,141) fell under the category of medicine.Around 2,873 dealt with pharmacology and pharmaceutics; 975 related to biochemistry,genetics, and molecular biology; and 521 of the articles published fell under the category of agriculture and biological sciences. While researchers in chemistry and the social sciences contributed 269 and 251 papers, respectively,those in the allied health professions and nursing categories published only 179 and 157,respectively [26] .
The quality of research in Ayurveda has long been a concern. The fundamental difficulty of testing the effectiveness of Ayurvedic interventions is rooted in the complexities of Ayurvedic diagnosis and treatment. Of late,however, a few models for conducting clinical trials without compromising the Ayurvedic approach to disease have been proposed that look promising. The problem of poor quality research also appears to stem from the failure of college and university level courses in Ayurveda to sufficiently stress the importance of following standard research protocols. The same training deficiencies are reflected in the scarcity of high-quality Ayurvedic research publications. These challenges must be tackled so that Ayurvedic research can become more visible and earn wider respect from the mainstream scientific community [27] .
A 2009 nationwide survey of students and teachers from more than 30 colleges of Ayurveda raised concerns about the field’s lack of high-quality educational standards. The study suggested the curriculums of Bachelor of Ayurvedic Medicine and Surgery (BAMS) programs failed to deliver the skills that practitioners need. Participants complained that college syllabi lacked sufficient information on certain relevant topics such as intellectual property rights, standardization of medicinal products, toxicity of medicinal products,healthcare management, and cultivation of medicinal plants. The study also suggested that the Ayurvedic academicians were not following the accepted standard methods of research and documentation, and that the educational institutions should be urged to do more to shore up the evidence base for Ayurveda. In addition,survey respondents noted that Ayurveda graduates need more exposure to basic clinical skills in order to be able to deal effectively with the challenges of primary healthcare delivery.Since that time, the Central Council of Indian Medicine has introduced a series of curricular reforms designed to address these deficiencies.To determine their success, a critical evaluation of the present situation is now required [28–29] .
Exhaustive field work conducted by Shailaja Chandra, the former Secretary of the Department of AYUSH, resulted in the 2011 and 2013 publication of a two-volume report titled “Status of Indian Medicine and Folk Healing, with a Focus on Benefits the Systems Have Given to the Public”. Since the report’s publication, many changes have been implemented that warrant re-evaluation of the situation described in the report [9] . A major concern raised by all these reports was that the mushrooming growth of substandard colleges was diluting the rigor of Ayurvedic medical training. Other concerns included the presence of corruption in the educational system, which manifested in the emergence of many colleges whose resources existed only on paper, and the failure of AYUSH faculty to provide undergraduates with a strong foundation in the biomedical sciences and insufficient hands-on training in clinical settings [10] .
Teaching/learning methods in Ayurveda have received negligible attention in the contemporary literature on Ayurvedic education.While serious research in this area has been minimal, a few promising studies have been published recently. One study that looked at various integrative approaches to teaching and another on problem-based learning modules pointed to the potential benefits of implementing these innovative methods in Ayurvedic educational programs [30] .
Based on the requirements, NCISM have now implemented the outcome based education model to the graduation level Ayurvedic program.
The historical and cultural diversity of various countries is a key source of the wide disparities among them in regard to the evolution and adoption of traditional indigenous medical systems such as Ayurveda.Differences in economic conditions, religious beliefs, government healthcare policies, and scholarly opinions also help account for these disparities. The current status of Ayurveda in countries outside India is reflected in its increasing visibility in forms ranging from Ayurvedic cooking methods and massage therapies, panchakarma centers, Ayurvedic spas, and yoga retreats to products such as nutrition supplements, herbal remedies, and aphrodisiacs. While these traditional Indian wellness applications have been enthusiastically embraced in many Western countries, most Westerners have yet to realize the value of Ayurveda as a medical system whose scope encompasses the prevention, treatment, and management of a plethora of diseases. In the US,Ayurveda is, at best, relegated to the category of complementary and traditional medicine; yet unlike many better known alternative medical systems such as chiropractic and acupuncture,Ayurveda is ineligible for health insurance coverage. Another potential barrier to its official recognition as a healthcare discipline in the West, is the presence of heavy metals in some traditional Ayurvedic remedies. While the therapeutic use of heavy metals has been extensively documented in Ayurvedic texts,these formulations violate the stringent drugmanufacturing norms that prevail in most Western countries. Due to the risk of toxicity from heavy metals like mercury, arsenic, and lead, the US, Britain, and the EU have banned the importation and sale of these preparations [31] .
The Ministry of AYUSH has set up information centers in more than 30 countries to disseminate authentic knowledge of AYUSH systems. The Ministry has also signed a number of memorandums of understanding (MoUs) with various countries to encourage productive communication and cooperation among ISM stakeholders.
WHO has played a key role in spreading Ayurvedic knowledge worldwide. Along the same lines, it has recognized Morarji Desai National Institute of Yoga (MDNIY) and Institute for Post Graduate Teaching & Research in Ayurveda (IPGTRA) as its Collaborative Centers in Traditional Medicine. As an initiative to standardize its terminology according to contemporary needs, a Project Collaboration Agreement (PCA) has been signed between the Ministry of AYUSH and the WHO, Geneva, for developing WHO Terminologies for Ayurveda,Unani, and Siddha.
Various associations and organizations in different countries, led primarily by eminent Indian scholars, have been involved in the development of Ayurveda abroad. They are mainly offering Ayurvedic treatments and training. To gain an overview of the status of Ayurveda globally, the countries can be broadly classified into four groups:
Ayurveda is indigenous to India and enjoys a strong foothold in other member states of the South Asia Association for Regional Cooperation(SAARC). Because SAARC countries recognize Ayurveda as an independent medical system,they regulate its trade and practice standards through various Acts and statutes.
Other Asian Countries Ayurveda and Traditional Chinese Medicine are recognized in many other Asia countries. While each of these countries has its own traditional medical system, Ayurveda still plays a major role in delivery of primary healthcare services.
Developed Countries This group includes America, Europe and Australia, where Ayurveda is widely practiced as a form of wellness therapy, with no official recognition or regulation. The medicines are sold more often as food supplements and cosmetics, without the intervention of any Ayurveda practitioner, often as over-the-counter (OTC) products. There are many educational institutions that offer Ayurveda courses in these countries, some with and some without accreditation and recognition.
Europe and Other Countries Approximately 70%～80% of Ayurvedic drugs are banned from import into the EU. Per the EU Directive for Traditional Herbal Medicines (2005 only those drugs being sold as OTC products with a minimum of 15 years of documented use within the EU can be marketed there). The directive restricts the sale of newly developed Ayurveda drugs and all drugs that use animal products such as milk products and honey, including formulations containing metals and minerals along with herbal components. The opinion expressed in the directive deems these drugs a potential threat to public health as well as to the reputation of the healthcare system. Despite these concerns about the safety of traditional medicines, the majority of medical tourists who visit India are Europeans with various chronic disorders seeking treatment with Ayurvedic therapies and medicines [31] .
Other Countries A large number of consumers of Ayurveda treatment and services reside in Africa, Latin America, Russia, and other Commonwealth of Independent States(CIS). Ayurveda is recognized as an alternative system of medicine in these regions, andvarious Ayurvedic services are popular there.
Australia The evolution of Ayurveda inAustralia dates back to 1970s when the FirstInternational Congress on Traditional AsianMedicine, known as ICTAM, was organized.This event initiated a dialogue betweenstakeholders in various traditional medicinesystems around the globe. It was followedby the establishment of the InternationalAssociation for the Study of Traditional AsianMedicine (ASTAM) by the Australian AyurvedaAssociation. Currently, the Australian Instituteof Higher and Further Research (AIHFR) runsa nationally recognized program that leads to anadvanced diploma in Ayurveda. The programdelivers all the theoretical lectures online andrequires a minimum of 400 hours of supervisedclinical training.
Europe In Europe, the European Institutefor Ayurveda Medicine (EIFAM) provides a12-month foundation course on AyurvedicMedicine for healthcare professionals, as wellas a collaborative program with the EuropeanUniversity Viadrina that leads to a master’sdegree in complementary medicine. Theinstitute is also involved in Ayurvedic researchand development and is working towarda vision of integrative medicine. Anotherleading contributor to the advancement ofAyurveda is the European Ayurveda Association(EUAA), a network of organizations,hospitals, educational institutions, therapists,manufacturers, and suppliers and distributorsof Ayurvedic products that extends across16 countries in the European EconomicArea (EEA). The group is actively involvedin issues of major interest to the Ayurvediccommunity such as freedom of choice inmedicine, health insurance reimbursement, the quality of Ayurvedic products and services and patient safety. It works in collaboration with European government health authorities, health insurance companies, professional associations, universities, training institutes, the Ministry of AYUSH, and the Ministry of Health and Family Welfare, Government of India.
The Rosenberg European Academy of Ayurveda (REAA), a nonprofit organization funded by students’ tuitions and patients’ treatment fees and donations, runs various treatment and training centers in Germany, Switzerland, and Austria. It offers a number of courses for Ayurveda enthusiasts, including Ayurveda seminars for beginners, further training for doctors, Ayurveda as complementary medicine, and postgraduate studies in Ayurvedic nutrition, massage, and marma therapy. It also provides training for alternative practitioners, Ayurveda and yoga health coaches (IHKs),and Ayurvedic nutritionists, health consultants, cooks, and medical phytotherapists [32] . In addition, the academy is partnering with Middlesex University, the School of Health and Education (London, UK), and Charité University Medical Center Berlin (Master module) in a program that leads to the first recognized Master of Science degree in Ayurveda. The four-year university course is divided into three parts and features a flexible curriculum that meets the needs of graduate students. It includes clinical internships in India and Europe and home studies.
United States In the US, Ayurveda is gaining ground through the efforts of the National Ayurvedic Medical Association (NAMA), a renowned organization dedicated to the growth of Ayurveda in the West. Founded in 2000, its primary goal is to support Ayurvedic education and professional practices. The Standards Committee surveys the Ayurvedic education system and is involved in setting standards for Ayurvedic professionals. There are currently around 30 NAMA-recognized schools of Ayurveda operating in various regions of the country. The organization strives to serve as an official spokesperson for and representative of the Ayurvedic profession in the United States. Its efforts are oriented toward regulating education, ethics, professional competency and licensing, and research. Along with establishing recognition and acceptance of the Ayurvedic profession and forging connections with government agencies, policymakers,and numerous Ayurvedic organizations, and businesses, NAMA hosts yearly conferences that consistently attract a broad swath of the Ayurvedic community [33] .
Russia Although there is no legal recognition of the Ayurvedic profession in Russia, the government and the public have acknowledged Ayurveda as a healing system. A large medical center in Moscow called NAAMI that included a team of vaidyas from India on its staff in the late 1990s has been successful in generating awareness of Ayurveda. NAAMI has also signed an MOU with the Indian government, agreeing to dedicate government aid from India to promote the development of Ayurveda in Russia. In addition, upcoming translations of works by Charaka, Sushruta, and Vagbhata will soon enable Russians to read the classics of Ayurveda in their native language.
Japan Ayurveda in its present form, has a history of 30 years in Japan, where its traditions are perpetuated by respected institutions,including the Society of Ayurveda, founded by Osaka Medical School; the Japan School of Ayurveda (Tokyo); and the Institute of Traditional Oriental Medicine (Tokyo).
Balanced and sustainable growth needs to happen at the level of more standardized education, clinical practice, research and pharmacy levels. Since few decades, there has been tremendous growth in Ayurveda happening globally. But, there is an urgent need for strategic planning to address certain challenges. Healthcare policy decisions in India are largely opinion-based and often fail to consider regional differences in culture, socialeconomic conditions, population characteristics,healthcare-seeking behavior, literacy levels, and other relevant factors. This “one-size-fits-all”approach falls short in the context of Ayurveda.This fact becomes obvious when one compares the model of Ayurvedic education that prevails in southern India with the one that predominates in the northern states. While many institutions in northern states, including Banaras Hindu University in Uttar Pradesh, have adopted an integrative model of Ayurvedic training, those located in southern states like Kerala have largely opted for a “classics-oriented” approach.Thus, the goal of promoting uniformity in training may be unrealistic [34] . Furthermore,advocates of these different approaches lack sufficient evidence to categorically state that either model (integrative or “pure” Ayurveda) is superior to the other.
Most importantly, there is almost no research on Ayurvedic educational policy happening in India. Unlike most nations,India has yet to found either government or university-based institutes dedicated to research on medical education policy. As a result of this research gap, huge disparities in training between different streams of healthcare professionals persist. A wellthought-out strategy is clearly needed to address this problem. Data from well-designed educational surveys and experiments is essential to policymakers’ ability to craft informed decisions. To date, only a handful of published papers that provide such data are available on the research databases such as PubMed. The establishment of an institution focused on medical education policy research and equipped with a mandate to guide the development of evidence-based policies in close collaboration with the Ministry of Health and Family Welfare and the Ministry of AYUSH would go a long way toward resolving these issues.
Ultimately, the advancement of Ayurvedic Medicine both within and beyond India will require a multi-pronged effort to align it with modern science. Pharmacoepidemiological studies documenting its safety and effectiveness and new clinical processes, research protocols,and whole system treatment regimens are needed. Much remains to be done. Yet as a knowledge system that pioneered a holistic,personalized approach to medicine that has thrived for thousands of years, Ayurveda promises to play an innovative, dynamic, and highly valued role in the continued evolution of integrative healthcare.
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