II. INDIA

In this article, India refers to the entire Asian subcontinent south of Afghanistan and the Himalayan range, including the modern nations of India, Pakistan, Bangladesh, and Nepal (often referred to as the "Indic" region) as well as the island nation Sri Lanka. In the third millennium b.c.e. there flourished a civilization in and around the Indus Valley known as the Harrapan city culture. Gradually, from the second millennium, the subcontinent was infiltrated by Indo-European tribes from Central Asia. These people formed the classical culture that survives to modern times with many transformations. In the eighth century, Muslim invasions began in the north, culminating in the powerful Mogul empire of the fourteenth and fifteenth centuries. Historic India is the home of two of the world's major religions, Hinduism and Buddhism, as well as of Jainism, and host to Islam, now the majority religion in Pakistan and Bangladesh, as well as to ancient Christian and Jewish communities in the south. From the interaction of Hinduism and Islam grew another religion in India, the Sikh faith. In the sixteenth century, India's cultural and religious influence extended into China and Tibet, as well as to the lands of Southeast Asia.

The origins of medicine in India stretch back to antiquity. The urban architecture of the earliest civilization, in the cities of the Indus Valley, demonstrates knowledge of sanitary techniques. One of the Vedas, the sacred lore of the early Indo-Europeans (ca. 1500–1000 b.c.e.), contains chants to ward off disease, and lists of herbal medicines. The ancient texts extolled by the bhesaj, persons skilled in the medicinal uses of herbs. Priest-physicians prescribed prayers and fasts, as well as herbal medicines. Out of this text, the Atharvaveda, and other systems of philosophical speculations developed a system of medicine based upon a theory of bodily humors and a therapeutic regimen of herbs and plants. The term "Ayurveda," meaning knowledge of vitality and long life, designated this classical Indian medicine that is widely practiced in India today. Ayurvedic medicine developed in the fifth century b.c.e.; its earliest classical treatise, Carakasamhita, can be dated to the first century c.e. The oldest known Sanskrit medical manuscripts, discovered in a Buddhist monastery in China and dating from about 450 c.e., reveal a developed medical system, mentioning elixirs for long life (including garlic), eye lotions, enemas, aphrodisiacs, and ways of caring for sick children. The text mentions Indian physicians of renown, including the most famous, Sushruta (second century c.e.). After the adoption of Buddhism by King Ashoka (273–232 b.c.e.), Buddhist monks, who were not bound by the rigorous Hindu laws of purity and pollution, were free to mingle with common people and to invite them into their monasteries, thus bringing their medical skills to the needy and hospitality to the sick. They also seem to have brought Ayurvedic medicine to Tibet and China. Monks of the Jain tradition, which arose about the same time as the Buddhist tradition, also contributed to the development of the medical system. Early medical speculations and observations about the body, mind, and illness were consistent with tenets of all three major religions.

There appears to have been a flowering of medicine during the first millennium c.e. (Jolly; Winternitz). In the course of time, six classic texts of Ayurveda were recognized. Two of these, Sushrutasamhita and Carakasamhita, are named after the most famous physicians of the tradition, Sushruta and Caraka (first century c.e.); it is suggested that the word "caraka," which also means "one who moves about," refers to the itinerant Buddhist monks; Sushruta was a physician to a Buddhist king. The other four—Ashtangahridaya, attributed to the physician Vagbhatta; Madhavanidana; Sarangadharasamhita; and Bhavaprakasha—date from the eighth, ninth, thirteenth, and sixteenth centuries, respectively. The latter two reveal the influence of Arabic medicine, and the last mentions phirangi roga, the disease of the Franks (the Portuguese who came to India in 1498), probably syphilis. The use of opium as a therapeutic agent is prescribed in these later texts.

Assumptions of Ayurveda

Ayurveda is deeply rooted in the great religious and philosophical traditions of India, whose visions of human nature and the universe informed medicine and, in turn, were enriched by the concepts formed in medical practice (Dasgupta). Ayurvedic constructs of the self and the body, concerns central to the medical enterprise, grew in tandem with the faith traditions. Ayurvedic physiology and pathophysiology rest on a doctrine of humors (doshas) and bodily substances (dhatus). The principal humors are wind (vata), bile (pitta), and phlegm (kapha), representing movement, heat, and moisture in the body, respectively. The primary body substance, dhatu, is "organic sap" (rasa) derived from food, transformed in various ways as it moves through the body, stored in various reservoirs, and excreted as waste. Sap is first transformed into blood, then into flesh, fat, bone, marrow, and semen, the last being the purest product of the transformation.

Health is a state of balance of bodily humors and substances (dhatusamya); illness is disequilibrium. The body is affected by external factors, such as food and climate, as well as internal influences, such as anger and jealousy; social experiences, such as praise or scorn, also affect bodily states. Each of these may cause disease or restore health. This interactive universe of substances blurs the boundaries between inside and outside, and makes for a constant flux. The body is in dynamic relationship with the cosmos, whose elements of wind, fire, and water are reflected in the body; similarly, the body is seen as a reflection of the mythic cosmogony, in which the primordial person arises from chaos and is differentiated into multiple forms. Breath (prana) is the supreme force that unites bodily parts and becomes the definition of life (jiva): "People say of a dead person, that his limbs have become unstrung," say the Upanishads (ancient religious discourses). Ayurvedic medicine visualizes the sick person as in a state of fragmentation; his or her bodily components must be taken apart, cleansed, and put together again (Desai, 1989). Breath also becomes equated with the narcissistic and metaphysical components: ahamkara and atman. Ahamkara, "I-ness," literally the saying of the word "I," is the perishable self; and atman, cognate with the Greek atmos, is visualized as a self beyond death, without properties, pure consciousness, and transcendental. Although Hindu, Buddhist, and Jain traditions have differing notions of the self, they share common beliefs about the transience of the perishable body, often a source of pain, and the consubstantiality of the body with the universe.

The theory of gunas (literally "strands" or "qualities") is an aspect of samkhya and an important foundation of Hindu ethics. Inherent and substantial, sattva (goodness), rajas (vitality), and tamas (inertia) are found in all material substances in various combinations and determine the over-all constitutional disposition of persons, foods, activities, bodily substances, and so forth. Physically sattva is cool and light; rajas, hot and active; and tamas, heavy and dull. Psychologically they are calmness, passion, and lethargy or stupidity, respectively. In character they are purity or virtue, happiness or sorrow, and darkness or evil, respectively. Contemplation, meditation, silence, devotion, and fasting promote goodness; love, battle, attachment, pleasure seeking, and emotionality enhance vitality; sloth, sleep, and idleness increase inertia. In the hierarchy of values, the sattva categories tend to reign supreme and become less material and closer to the idea of sat (truth or essence); in Ayurvedic discourses they are understood to be the same as the mind or the self. The ethical aim, therefore, is to transform physical and mental dispositions from inertia to activity to goodness. Such transformations are promoted by ingestion of foods and performance of activities that are conducive to the higher strand. Therapeutic aims are also to transform the self and the body to higher levels of functions: from imbalance to equipoise, from idleness to activity, from agitation or pleasure seeking to calmness and contemplation.

The Physician

An Ayurvedic physician, called a vaidya, is one of the quartet (the physician, the drugs, the attendant, and the patient) responsible for amelioration of diseases. Although esteemed for their powers to bring about health and disease-free states ("the cause of virtue"), physicians were regarded with mixed feelings in ancient India; anxiety concerning disease and death was displaced onto them. Physicians contracted impurity from their handling of body products, lesions, and corpses, and through their "democratic practice of mingling with the common people" (Chattopadhyaya). Religious texts enjoined people not to receive food from physicians and to avoid them at religious ceremonies. Taboos concerning touching caused palpation to fall into disuse as a diagnostic tool.

The Ayurvedic texts demand that a physician excel in theoretical knowledge, have extensive practical experience, be dextrous, and observe the rules of cleanliness. A physician began his education as an apprentice, teacher and pupil choosing each other. A good teacher was free from conceit, greed, and envy; the student was calm, friendly, and without physical defects. The physician must be compassionate, virtuous, of high lineage, devoted to learning, rational, and always ready to act. The Carakasamhita regards the profession as suitable to the upper castes: Brahmins (for the welfare of all living beings), Kshatriyas (for their own protection), and Vaishyas (for livelihood). The Sushrutasamhita also permits the Shudras, the lowest caste, to be physicians. Later the vaidyas became a caste, an occupational division, and the profession passed from father to son. In modern India, physicians, Ayurvedic or otherwise, may be from any caste.

Carakasamhita contains an extensive ethical treatise in the form of an initiation oath to be sworn by one entering the practice of medicine. Among its injunctions are these:

Day and night, however you may be engaged, you shall strive for the relief of the patient with all your heart and soul. You shall not desert or injure your patient even for the sake of your life or your living.

You shall be modest in your dress and appearance and speak words that are gentle, pure, righteous, pleasing, worthy, true, wholesome, and moderate.

When entering a patient's house, you shall be accompanied by a man who is known to the patient and who has his permission to enter. Having entered, your speech, mind, intellect, and senses shall be entirely devoted to no other thought than that of being helpful to the patient, and of things concerning him only. The peculiar customs of the patient's household shall not be made public.

Though possessed of knowledge, you should not boast very much about it. Most people are offended by the boastfulness of even those who are otherwise good and knowledgeable.

There is no limit at all to which knowledge of Ayurveda can be acquired, so you should apply yourself to it with all diligence. The entire world is the teacher of the intelligent and the foe of the unintelligent. Hence, knowing this well, you should listen and act according to the words of instruction of even an unfriendly person when they are worthy and such as to bring fame and long life to you, and are capable of giving you strength and prosperity. (Menon and Haberman, 1970, pp. 295–296)

Sushrutasamhita describes procedures that include an ingenious method of making a new nose when the original has been cut off (a form of humiliation that was a common punishment for criminals and unfaithful wives). The text also contains directions for dissection of the cadaver. However, dissection for purposes of teaching and study was not normally practiced. The objection to dissection was based on the deep-seated Indian taboo on contact with dead matter of any kind. The doctrine of ahimsa (nonviolence), which was taught by Buddhism and Jainism, did not prevent dissection of a dead body, provided the body was not deliberately killed for that purpose; but ahimsa did act as a check on vivisection of any creature.

Care of animals such as cows, horses, elephants, and even birds formed an integral part of the prevailing religious beliefs. Mention is made in the literature of hospitals for sick and wounded birds. Although ancient Indian physicians were taught the care and treatment of animals, there were also veterinarians who cared only for animals.

Quacks and charlatans were unequivocally condemned. They were known by their loose tongues, superficial knowledge, pretense, and arrogance. When the patient worsened, they abandoned him. The fate of their patients was worse than death; one can survive a thunderbolt, says Carakasamhita, but not the medicine prescribed by quacks. A physician, on the other hand, was to hold his tongue, not enter into needless debates, and apply himself continuously to new learning. He was to avoid women who belong to others, not to enter the house of a patient without the presence of a person known to the family, to maintain confidentiality, and never to mention a patient's approaching death.

Modern Indian physicians, especially those trained in Western medicine under the British, took the Hippocratic oath. The Indian Medical Council promulgated its code of ethics in 1970. The code directs physicians to serve humanity without regard to religion or race, social or political affiliation. A physician must provide pro bono services, maintain confidentiality, and hold teachers in esteem with a sense of gratitude. An adulterous relationship with a patient or with a patient's family member is considered a breach of ethical principles (Medical Council of India).

The Origin of Life

The origin of life is a major concern of the authors of traditional medical texts. An embryo is formed through the union of the woman and the man when both have appropriate humoral dispositions and appropriate nourishment. The life principle is thought either to enter at the moment of conception or to be a latent property of the seeds; the latter is comparable to fire in the rays of the sun becoming manifest on passing through a lens, or the combining of male and female germinal substances. At other times the moment of quickening or the descent of the fetus in the womb is seen as a moment of independent life or viability. Defective germinal substances, "unnatural" coitus, failure of nourishment or inappropriate nourishment, and weakness or disturbance in humors explain the unexpected, such as multiple pregnancies and infertility. Initially the fetus is visualized as genderless and becomes male or female in the third to fourth month of pregnancy. Among the rites of passage, samskaras, there is one that is performed at this stage of pregnancy to promote the development of a male child.

Having a male child is a Hindu religious obligation, for the performance of funerary rites by a son secures passage to the land of the forefathers. In this rite of passage, the son symbolically reconstitutes the body of the dead father and reunites him with his lineage. Therefore, a man must have a son; if necessary, he must take another wife to beget a son, invite his younger brother or a Brahmin of good conduct to impregnate his wife (a custom called niyoga), choose another willing woman, or otherwise adopt, procure, or purchase a son. The epic Mahābhārata provides examples of niyoga—the birth of the father of Pandavas, the protagonists, and of the Kauravas, the antagonists of the epic—and of in vitro fertilization—the development of embryos in pots, as in the case of the Kauravas. The birth of the last liberated sage of the Jain tradition, Mahavira, provides an example of embryo transfer from one womb to another, as does the birth of an older sibling of Lord Krishna (Desai, 1988). In light of these traditions, modern forms of surrogacy or new technologies present few problems.

Contraception and abortion also have precedents in Indian tradition. The medical texts dwell upon ways of enhancing the possibilities of conception through manipulation of a number of variables; the same variables can be manipulated to retard the chances of conception. In practice, sexual congress outside the Hindu religious Law was not prohibited for men, but women were scorned if found lacking in virtue—especially widows, who were forbidden to remarry—and means had to be sought to prevent unwanted pregnancies. Bhavaprakasha, a sixteenth-century medical text, provides a list of oral contraceptives. Modern methods of contraception have been introduced in India, and a massive family-planning campaign includes male and female sterilization. Research work on antipregnancy vaccine and depot preparations (large doses suspended in oil so that they are slowly released over a long period of time) of hormones is ongoing.

Medical texts, especially the Sushrutasamhita, describe various forms of arrested fetal development, fetal death, stillbirth, and obstructed deliveries, and the treatments for them that consist of induction of labor and/or destruction of the fetus. The text cautions against hasty action and requires royal permission to induce abortion and extraction of the fetus in case of danger to maternal life. Although early religious texts consider abortion to be a sin, equal to the killing of a Brahmin, by the seventeenth century Ayurvedic physicians were advising the use of an herb, administered vaginally, for the induction of labor, "a useful remedy for pregnant women in poor health, widows, and women of liberal morals" (as quoted from Vaidya Jeevanamin Chandrashekar, p. 45).

In colonial India abortions were governed by English law; in 1972 the government of India legalized abortion, mainly to prevent illegal abortions and to give further impetus to family planning. Abortions in the first trimester, and under special conditions in the second trimester, are available on demand. More recently, RU-486, "the morning after" pill, has been introduced in India on an experimental basis.

Amniocentesis has become extremely popular in India. Overwhelming preference for boys, permissive abortion laws, and the crushing burden of dowries have led parents to seek to ascertain the sex of the fetus, so that a female can be aborted. A vigorous debate, both for and against using the new technology for sex selection, has ensued, one camp arguing in effect that feticide is better than infanticide and the other decrying the culture's age-old cruelties against women (Desai, 1991).

Disease, Death, and the Laws of Karma

Karma is the operative principle of Hindu ethics and has come to mean that every action has a consequence: "As you sow, so shall you reap." Karma has explanatory power for questions like "Why me?" and encourages action for future rewards. The cycle of birth, death, and rebirth, as well as that of health and disease, is governed by the laws of karma. The laws of karma also have dominated Buddhist and Jain ethics.

The ancient physicians classified the etiology of diseases into three categories. External or invasive diseases were caused by foreign bodies, war injuries, possession, or infestation. Internal diseases were disturbances of humors brought about by lapses in discretion, which included faulty diets, overexertion, sloth, sexual indulgence, and mental disturbances. The third category was reserved for the workings of karma, fruits of action from past deeds or previous lives. Some disease states were also seen as the workings of time, as in aging. The unseen hand of karma was invoked in all diseases, a schema that brought ordinary actions like dietary habits and seasonal observances under the umbrella of ethics. Mental illnesses also arose from these etiologies: possession by spirits, disturbances in humors, and lapses in discretion. Like other conditions that defy easy explanations, epidemics and natural disasters were thought to be caused by the collective misdeeds of a population or of a ruler. Physicians of the era of Caraka and Sushruta paid homage to the principle of karma but argued that passivity on part of a physician who assumed predetermination of disease or death made the whole medical enterprise meaningless. Human effort was always a factor in the workings of karma, and the human body was the object of physicians, who held alleviation of diseases and restoration of health as their primary objectives.

On the other hand, there were incurable diseases. It was prudent of physicians to be wary of heroic efforts to prevent the inevitable, which not only brought loss of income but social censure and ignominy as well. If the physician knew that a case was hopeless, he was to do no more than sustain the nutrition of a dying patient. Thus, prolonging life with artificial means is not always acceptable. Those who have led a full life must, like ripened fruits, fall from the tree; untimely death of the young is another matter. Yet, death is not the opposite of life; it is simply the other end, the opposite of birth. Those who are born must die.

Debates in the West on the issues of aging, the care of the terminally ill, and euthanasia have prompted a reexamination of medical ethics in the East. Not surprisingly the Hindu, the Jain, and the Buddhist views converge and have a place for a "willed death" or, more correctly, "hastened death" (Young; Desai, 1991; Bilimoria, 1992; Fujii, 1991). Shrinivas Tilak (1989), after examining Hindu and Buddhist texts, concluded that aging represents points in a life cycle, indicating both growth and maturity as well as eventual decline and loss; at the end point it is an indicator of ultimate dissolution of life. Hindu texts bemoan the inevitability of death, and the Buddhist texts point to pain and unhappiness as inherent in life. In the face of approaching or inevitable death or debilitating and painfully long suffering, traditional ethics provides "permission to leave" voluntarily. Also, the anxiety occasioned by the uncertain timing of death is to be mastered by death that is willed; choosing the moment of death is permitted to ascetics or otherwise superior and elevated souls. Each of the three traditions provides for taking a vow to gradually refrain from taking food and water (and medications, when relevant); thus one ultimately starves to death. The early discourses do not regard this as suicide, which is a death brought upon oneself in a state of desperation and imbalance, and therefore belongs to a different category. The three traditions, which uphold ahimsa as central to the view of sanctity of all life, find little difficulty with death that is hastened by starvation. A telling episode in the life of Mahatma Gandhi illustrates this debate (Parekh). A calf that had no hope of surviving and was suffering was put to death with Gandhi's consent. Gandhi rejected the view that killing was never justified and always represented violence. He said that there is violence when the intention is to cause pain; otherwise it is simply an act of killing. When confronted by his critics, especially the Jain merchants of Gujarat, with the problem of euthanasia, Gandhi gave the following response:

1. The disease from which the patient is suffering should be incurable.
2. All concerned have despaired of the life of the patient.
3. The case should be beyond all help or service.
4. It should be impossible for the patient in question to express his or her wish.
5. So long as even one of these conditions remains unfulfilled, the taking of life from the point of view of ahimsa cannot be justified.

Although Gandhi believed that he had arrived at his position independently, he was building on the position advanced by ancient medical authorities.

Other Systems of Medicine

Yoga philosophy and the related tantra have enriched the Indian medical system on the periphery. In classical yoga thought, the Yogasutra of Pantanjali, the aim is to bring the mind to focus by inhibiting its waywardness, through successive disciplines of body and thought and by regulation of body functions. Thus body and mind are yoked and come into correct conjunction. Later elaborations have included arduous physical practices and other forms of meditation. Modern relaxation techniques and biofeedback, popular in the West, owe their origin to the discipline of yoga.

Yogic thought visualizes the body in concentric layers, proceeding from the less important outside to the vital inside, from gross to subtle, from hard to soft, and from more material to less material. The body is penetrable and its boundaries permeable; only the innermost self, which must be realized through yoga, is an adamantine core of permanent joy and bliss.

Other forms of yoga, especially the kundalini yoga, advance a concept in which the spine is a vertical axis along which are chakras (wheels or lotuses), centers of energy and impulses. The lower chakras represent vegetative functions(e.g., genitoexcretory, digestive, circulatory, and respiratory); the higher ones, centers of thought and emotion. In this dualism, kundalini, the spiritual aspect of a person, lies dormant in the lowest chakra at the base of the spine; it must be awakened through yogic exercises and made to travel up the spine, activating other chakras on the way and finally uniting with the highest chakra, where the principle of consciousness resides. The regulation of breath is critically important in these exercises, for the breath is the source of energy and must travel through the chakras into the various nerves or channels (nadis). The left-handed form, tantra, is a fringe discipline emphasizing esoteric sexual practices. The feminine powers are invoked and sought for the purpose of incorporating them in the self of the practitioner. The way to accomplish this is literally to reverse the flow of sexual fluids from men to women. Ultimately the enriched semen will be forced up the spinal axis to repose in the head as a collection of the most vital and purified energy.

Another Indian medical system is the siddha tradition, practiced mainly in southern India. Based on the Ayurvedic principles, it favors the Greek pharmacopoeia, especially the metallic oxides. The use of astrology in diagnosis and treatment, including the wearing of precious and semiprecious stones, is quite common in India. There is also a rich tradition of folk medicine, including exorcists, bonesetters, snakebite curers, and those who use mantras for cure.

The Yunani or Arabic system of medicine was brought to India by the Muslim invaders. Accepted by the rulers, it began to displace the older Ayurvedic practice to the periphery but also interacted with it. Its humoral thinking, based on Galenic principles, was congenial to Ayurveda. The examination of the radial pulse became a central feature of Ayurvedic diagnosis, and whereas the Ayurvedic pathophysiology had until then been exclusively humoral, the liver and blood were now implicated in folk pathophysiology. Muslim rulers patronized the system and founded publicly funded hospitals and dispensaries. Hakims, the practitioners of Arabic medicine, enriched the Ayurvedic herbal apothecary with their metallic oxides. They often specialized in the treatment of male sexual dysfunctions. This system is especially patronized by the Muslim population of the subcontinent.

"Allopathy" is the term by which modern Western medicine is known in India. European missionaries, especially from Portugal and France, brought it in the fifteenth century, and the British introduced the system in the delivery of care of their own personnel, later founding hospitals and medical schools in the major Indian cities. Allopathy pushed Ayurveda and Yunani to the periphery of medical practice. Today in India all systems are patronized, allopathy more in the cosmopolitan areas and the indigenous systems more in the rural. Patients often move from one to the other, depending on their own explanatory system or the success or failure of one or the other. The indigenous systems are more often chosen for the treatment of chronic conditions, which by definition have failed to be cured by modern methods. Although antibiotics have changed the epidemiology of acute conditions, they are seen as heavy and harmful with many side effects, in contrast to the gentler herbal preparations. Preparations for internal use have to meet the test of culturally constructed theory of inputs and fluxes. The most significant impact of modern antibiotics has been on maternal and infant morbidity and mortality.

In the 1990s most hospitals are staffed by practitioners of allopathic medicine. There are over 100 allopathic medical schools, over 500,000 hospital beds, and over 300,000 licensed medical practitioners. About 100 Ayurvedic colleges exist, and over 250,000 practitioners, but they have only 20,000 hospital beds. Research in Ayurvedic and Yunani medicine has been organized under central institutes.

Surgery, for which ancient India was famous, has passed into the domain of modern Western medicine. With anesthesia, asepsis, and blood transfusion, modern surgical practice has totally excluded the traditional forms. Organ transplants are becoming common, since traditional beliefs about construction of the body from discrete parts allows for removal and replacement. However, extreme poverty has created a widespread and unregulated market in which poor people offer corneas and kidneys for sale to the wealthy.

A fragmented, either commercialized or bureaucratic system of care that is neither easily accessible nor affordable is the major ethical problem of India. Emigration of physicians and nurses to the West has not helped. Multinational drug cartels and fly-by-night Indian drug firms with little regulation in manufacture or prescription form a lethal combination with diagnoses made by divination or without examination. The cultivation of public health and prevention points a way out of the current problems.

prakash n. desai (1995)

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