Navigating the Ayurveda-Allopathy Surgery Debate – What is the way forward?

Introduction

The Ministry of AYUSH’s recent amendment allowing Ayurveda surgeons to autonomously perform 58 Allopathic surgical procedures has had a mixed reaction. While some have condemned this move on the basis of ‘khichdification’, others have defended the amendment and the CCIM’s move on grounds that it provides greater surgical care accessibility, particularly to rural and poor populations. The scope for the integration of Ayurveda and Allopathic surgery certainly presents exciting possibilities. However, some fundamental questions remain – What would be the frame of such an integration? Where would one draw the line between integration and appropriation? Is there even the space for such an inter-disciplinary dialogue to take place in a frame of mutual respect? Respectfully? This article attempts to critically look at both the possibilities and challenges associated with such an endeavour.

A Brief Historical Background

The Master of Surgery degree in Ayurveda was introduced for the first time in 1963 in the Post-Graduate Institute of Indian Medicine, in the Banaras Hindu University. The MS Shalya Tantra course is 3 years long, and includes intense surgical training together with relevant in-house and ex-situ postings. While there are uniquely Ayurvedic aspects to the syllabus (as of 2021) - 7 management protocols for wounds and ulcers (Sapta upakrama), the Kshara Sutra (caustic alkali therapy) etc. – a majority of the syllabus, at least in practice, is constituted by Allopathic surgery. Ayurveda MS Shalya Tantra scholars have been trained for many years in Allopathic surgical management of several conditions including pyloric stenosis, tumours, stones, hernias, cysts, ulcers, fistulas, haemorrhoids etc. Some of the textbooks studied, such as S. Das’s Textbook of Operative Surgery, are the same as those used in the General Surgery MD discipline of Allopathy. Some of the major Ayurveda hospitals already perform more than 1000 surgeries a year. However, all surgeries performed by qualified Ayurveda doctors thus far, have almost always required the presence and supervision of an Allopathic surgeon and anaesthetist where required.

Two Key Questions

Two key questions are thrown up here. Why is Allopathic surgery such a large part of the Ayurveda syllabus? Second, why has this question been raised only now? This question could have been asked at any time during the last 58 years, and interestingly has not been raised at this scale even once, not even when the syllabus first came out.

Why is Allopathic surgery such a large part of the Ayurveda syllabus?  

Surgery has always been an integral part of Ayurveda, right from the time of Sushruta, 3000 years ago. The Sushruta Samhita is the oldest textbook on surgery in the world. The surgical prowess of ancient pan-Indian surgeons, as demonstrated in the Sushruta Samhita was undoubtedly an astounding feat 3000 years ago, and one that established that Indian surgery at that time was widely researched and practised. In fact, aspects of the theory and practice of the surgical frames evolved then, continue in Ayurveda teaching colleges and hospitals to this day. However, in today’s times, when medical systems across the world have developed very particular identities and niches and do no look kindly upon unnegotiated attempts to homogenize/blur boundaries, using Sushruta and the Sushruta Samhita as a justification for Ayurveda surgeons to perform Allopathic surgery does not acknowledge the very significant advances Allopathic surgery has made in the last two centuries or examine carefully whether a 3000 year-old Indian surgical tradition is comparable to/reconcilable with contemporary Allopathic surgery.

The large-scale inclusion of Allopathic procedures and techniques into the Ayurveda syllabus has been justified by some, as facilitating better access to surgery particularly amongst rural populations and increasing the overall reach of surgical care to health-seekers. During the course of my 5.5-year under-graduation and 3 year Masters Degree in Ayurveda, I witnessed a large number of health seekers successfully avail of surgical facilities on a daily basis in my institute, and must therefore agree with the argument that allowing Ayurveda surgeons to perform surgery will most certainly improve surgery accessibility for health-seekers.

While this may be true, some uncomfortable questions remain. Does Allopathic surgery have theoretical and philosophical compatibility with Ayurveda? Have the operable diseases found mention in Ayurvedic texts, and is there any special mention of their surgical remedies? Do these surgical remedies possess any similarity to the corresponding Allopathic surgical remedies? If yes, have the similarities and differences between them been documented and comparatively evaluated? These questions, unfortunately, still remain largely unanswered.

The scope for such documentation and comparative evaluation is enormous. Let me present one example from my own experience. Our hospital regularly carries out Kshara Sutra (medicated alkali) procedures for haemorrhoids and fistula-in-ano cases. One of these surgeries, that we, as interns were allowed to observe, was carried out in a man who had approached Ayurveda as a last option after four previous surgeries at different hospitals, were followed by fistula recurrences. He was posted for surgery, and it went smoothly with no complications. Importantly, the surgery was a wonderful example of Ayurveda-Allopathy surgery integration. While the operation theatre, instruments used, and the spinal anaesthesia administered etc. were Allopathic, the primary surgical technique employed – Kshara Sutra – was Ayurvedic. The post-surgical wound management involved a combination of Ayurvedic and Allopathic medication. Such a surgery, therefore, required the expertise of both Allopathic and Ayurvedic surgeons, during surgery as well as during the post-operative care period. At the time of writing this article, my colleagues tell me, that he still comes for regular six month follow-ups, 5 years after the surgery, and that there has been no recurrence so far. This example is one of many instances where Ayurveda and Allopathy surgery were successfully integrated to provide maximal patient benefit.

Documentation of such cases is the need of the hour. More importantly, developing spaces for interdisciplinary discussions on surgical care are vital – spaces where concerned disciplines share successes, failures, questions, and discuss if and where integration can maximize patient care. Such discourse will not only give birth to more informed medical practitioners and surgeons, but also pave the way for sensitive integration if and where possible/needed.

However, the paucity of comparative studies and interdisciplinary collaboration, has led to the amendment being viewed as an attempt by Ayurveds to appropriate entirely, practices and techniques of another system, in the cause of the ‘greater common good’. This is the IMA’s biggest objection to the amendment - the issue of misappropriation.

Interestingly, even a cursory search of popular online health-care platforms such as Practo show that several Allopathic anorectal surgeons claim to be experts in Kshara Sutra. This is a reverse example of the same kind of misappropriation discussed above.  In view of these and other concerns raised, the current discourses on ‘khichdification’ are welcome.

Why this debate now?

The second question - why has this issue arisen at this scale only now, 58 years after Ayurveda surgeons began incorporating Allopathic surgery? As discussed earlier, until the amendment, most Ayurveda surgeries involved the supervision and certification of an Allopathic surgeon - this entailed the signature of the supervising Allopathic surgeon(s) (and anaesthetist where present), on the case file of the patient. However, irrespective of the presence of the Allopathic surgeon, many Ayurveda surgeons found that they were more than capable of independently performing many general and some specialized surgeries on their own. Several hospitals possess and have published remarkable surgical results, even in cases that were written off by Allopathic surgeons. The only effective change (in practice) through the current amendment, is the elimination of the presence and signature of the supervising Allopathic surgeon. Do the issues being raised now, then, actually pertain to ‘mixopathy/khichdification’? If yes, why have several Allopathic physicians who have happily supervised countless Ayurveda surgeries over the last 58 years not raised their voices at this scale even once? Is the IMA’s problem with Ayurveda surgeons performing Allopathic surgeries at all? Or is it with the sudden autonomy that has been granted to Ayurveda surgeons? The sudden outrage at this time certainly seems to indicate the latter.

A possible way ahead

Today we are seeing a growing emphasis on interdisciplinary collaborations across the world. From nano-technology and systems pharmacology to machine learning, we are reaping the benefits of such successful interactions between various disciplines. In this context, the surgery debate has unfortunately become only about territory, boundary and misappropriation. While the lines between misappropriation and integration need to be very clearly delineated, it seems essential that at the same time, equal and mutually respectful space/fora for interdisciplinary dialogue between the two systems, are created.

These spaces will facilitate further discourse regarding past integration experiments/forays, as well as future possibilities, allowing for informed formalization of integrative approaches. Peer-reviewed publication of such integrative surgeries will further serve to validate them. It is also vital to keep in mind a third and often-overlooked stakeholder – the health seeker. Keeping health seekers informed regarding the outcomes of such collaboration will go a long way toward making them aware of such possibilities and enriched outcomes.  Such systematic and long-term interaction and collaboration seems to be the only sustainable way of going ahead.