Do Prakriti and Doshas Really Exist?: Decoding Ashtanga Hridayam

In last article, I tried to explain why our current treatment paradigms might be flawed and why it is important to understand and embrace the principles enshrined in Ashtanga Hridayam. In this article I will briefly touch upon the Ayurvedic Concepts of Prakriti and Doshas, understand in detail how clinical trials are inaccurate instruments to confirm and validate any evidence for Ayurveda and explain how modern medical genetics provides authoritative evidences proving accuracy of Ayurveda.

(This is a very crude attempt from my end to read and interpret Ashtanga Hridayam, and explain it’s principles in treating diseases. I am a medical doctor training in Allopathy, and I am deeply passionate about human biology. I will be explaining Astanga Hridayam using layman’s language with a perspective of an allopathy practitioner.)

Prakriti And Doshas

Ancient India, like many other places in the world, has been a birthplace of extremely advanced civilizations. Vedic culture refers to a culture whose practices are documented in a set of ancient books called the Vedas. The origins of Vedic culture are believed to date back to the early Indus Valley Civilization, which flourished between 3300 BC and 1300 BC in the northwestern region of the Indian subcontinent. The Vedas are a collection of hymns, prayers, and rituals that were orally transmitted from generation to generation and eventually written down in Sanskrit between 1500 BC and 500 BC.

The Vedas consist of four main texts: the Rigveda, the Yajurveda, the Samaveda, and the Atharvaveda. Ayurveda is an ancient system of medicine described in Atharvaveda. Ayurveda has been practiced in India for over 5,000 years. One of the central concepts in Ayurveda is the idea of Prakriti, which refers to an individual’s unique constitution. Prakriti of an individual is a function of that person’s unique genetic makeup and how those genes express in life. Understanding a person’s Prakriti is essential for effective diagnosis and treatment in Ayurveda.(1)

According to Ayurvedic principles, matter is thought to be composed of five Mahabhutas (basic elements) that have the properties of space (Akasha), air (Vayu), fire (Tejas), water (Jala) and earth (Prithivi). These combine to form three Doshas, known as Vata, Pitta and Kapha. The Doshas can be imagined as “energies” that govern various aspects of the human body. Vata is formed from the lighter elements with properties of space (Akasha) and air (Vayu). Pitta is formed from the elements with properties of fire (Tejas) and water (Jala). Kapha is formed from the heavier elements with properties of water (Jala) and earth (Prithvi). Vata predominantly regulates movement and communication, including blood flow, contraction of the heart, breathing, movement of food through the digestive tract and communication of cells through nerve impulses. Pitta is primarily responsible for digestion, metabolism, and transformation, including energy exchange, appetite and endocrine functions. Kapha drives structure and cohesion of the body, including strength, stability, fluid balance and weight. It is important to note that while each Dosha has its own predominant functions, they all colloborate together and influence each individual function. They are all inter-dependent.

Each individual has a unique ratio of Vata, Pitta and Kapha. No combination of proportions is perfect- each individual has his/her unique levels of these doshas that is perfect for him/her. And that unique combination of doshas represents that person’s prakriti. And any deviation from this unique combination is known as Vikriti. Vikriti is the genesis of all diseases. This system of classifying and analyzing Prakriti and correcting Vikriti is the key principle behind Ayurvedic medicine.(2)

Evidence Based Medicine- Do Evidences Make Sense?

Ayurveda is not considered mainstream medicine today. Many consider it to be dubious. One of the biggest questions raised is “where is the evidence that Ayurveda works?” Modern medicine relies on clinical trials and biostatistics to analyze strength of evidence confirming efficacy and safety of any treatment strategy for a particular disease. In allopathy, one disease can have one medicine that works for most patients. And this can be tested by conducting clinical trials and analyzing the results using biostatistics (I will soon explain that such evidence is flawed when you are treating a patient). However, in case of Ayurveda, treatment of a disease will vary depending on each patient’s unique Prakriti, presenting symptoms, dietary patterns, daily habits and imbalance in the doshas. Ayurveda will not only prescribe a medicine (aushada) but also will advocate on certain behaviors (viharana) and dietary regimes (ahara). These interventions will also be adjusted according to age, mental state (satva, rajas and thamas- three states of mind), the season (climate and other environmental factors), etc. Each individual gets his/her own unique personalized treatment for the same disease. And for the same individual, for the same same disease, treatment strategy may change in Ayurveda depending on time of the year and mental state. (3) (7)

Modern western medicine draws its inferences from clinical trial data analyzed using biostatistics. While it might be factually incorrect to simply say that these interpretations are simply based on law of averages, but they do rely heavily upon theory of probability. In simple terms, all what they can say is what is the chance that a drug will work when used in given population for treating a particular disease.

While clinical trials might say that a medicine is 95% effective, it just means that if that medicine is given in 100 patients, it “might work” in 95 patients. Even in those 95 patients some patients may have extremely good response and some patient may experience below average response. Designing clinical trials itself is not perfect. It based on assumptions which are not quite true. For example, when you have two armed study, the assumption is that patients in both the groups are similar. The ground reality, however, is that no two patients are same- forget about two groups of patients being similar! (4)

But, to be fair, probability does work when you consider large numbers. So, when someone is treating a large set of patients using western medicine, often, the results mimic the data from clinical trials.

Clinical trials and biostatistical methods become quickly impractical when two people with the same condition need entirely different therapies. Consider this non-medical example. Imagine two students with low grades in school. One is not able to sleep properly at night due to stress, while the other one is not at all interested in studying. The approach for improving grades in one student will definitely not work for the other. If we only focused improving sleep and did an experiment to give sleep-enhancing supplements on a population of randomly chosen students without considering interest levels, we will draw absolutely inaccurate conclusions from that trial. In any disease that an individual suffers, there are too many factors and processes unique to that particular individual that modify the disease process for that individual. And these factors cannot be accounted for in any clinical trial.(5) (3)

In Ayurveda, treatments are formulated in a holistic and individualized manner after assessing the current state of imbalance in the doshas in the patient. There will be several factors that lead to imbalance in the doshas in an individual and together they are unique to each patient. There is no way you can have a test group and control group matched for all these factors, thus making it logically impossible to conduct clinical trials evaluating Ayurveda. The gold standard double-blind clinical trials just don’t make sense to assess therapies that involve critical lifestyle changes along with herbal formulations. For example, how do we fool an Ayurvedic therapist into prescribing fake meditation at some times and real meditation at other times? And how do you fool the patients and make them “fake” meditate? (5) (3)

In short, the methods of clinical trials and biostatistics cannot be applied to evaluate Ayurveda. It’s like trying to use a microscope to evaluate how planets are moving in the sky.

Towards Personalized Medicine- Where Are We?

Modern medicine is now slowly accepting that each person is unique, and there cannot be a single medicine that works optimally in all patients for treating a disease. For example, it is now known that aspirin does not work similarly in all patients. The inhibitory effect of aspirin on platelets differ according to prakriti of each individual patient. It has been conclusively proven that Vata-Pitta Prakriti individuals show best response to lower doses of aspirin compared to individuals with other prakriti types.(6)

The science of genetics tells us that each person has a set of genes unique to him/her. It is like a signature. Each gene is like a software code, and several such codes work together to make us who we are. With the current advancements in the field of genetics, it now possible to read these genomic signatures for each individual. For a long time, it was believed that one day we will decode functions of every gene and we will know results of various combinations of genes- and from that day onwards we would be able to define which medicine will be the best to treat a disease in a particular person depending on his/her genetic signature.

Unfortunately, it is more complicated than that.  

Genotype refers to an individual’s genetic makeup, while phenotype refers to their observable physical traits and characteristics. Phenotype is a result of genes expressing in response to individual’s environment. Today scientists are finding real hard time interpreting genetic signatures because of a phenomenon called genotype-phenotype mismatch. The same genetic variations do not always result in same observable changes in the phenotypes of all individuals. For example, a defect in a gene in X chromosome will cause Fabry Disease in several patients. But the same defect in the same gene might not cause any disease in few other patients. (12) This is extremely intriguing, and directly challenges the whole promise of genomics driven personalized medicine. And the reason for this phenomenon is simple- genes don’t work in a closed system. Our body is an open system. It interacts with its environment. The mood of the person based on his/her interactions with fellow human beings, the age of that person, the room temperature, the fragrance, the sound, the climatic conditions- everything and anything surrounding that person interacts with his/her genes and depending on these interactions few genes over-clock and few genes slow down or stop functioning. This makes it difficult to isolate the effects of individual genetic variations on phenotype. This is a problem that can’t be solved even using AI. We just don’t know enough.  

Ayurveda tries solving the same problem of personalization using a remarkably different approach. Rather than trying to decode all the genes and their combinations in an individual (for which one would need extremely costly technologies like SANGER, NGS etc), Ayurveda approaches the problem by simply focusing on phenotypes. As I earlier explained, an individual’s phenotype refers to his/her observable physical traits and characteristics. Ayurveda, in principle, starts by recognizing that each individual is unique. This uniqueness is measured in terms various proportions of doshas in each individual. (7)

As explained earlier, each individual has a unique combination of Vata, Pitta, and Kapha energies. This uniqueness is called Prakriti. In the language of western medicine, we can loosely refer to it as phenotype. Prakriti is believed to be stable throughout an individual’s life with variations happening depending on interactions with others and the environment. (7)

Using the concept of Prakriti, Ayurveda circumvents the challenge of genotype-phenotype mismatch faced by Allopathy. For example, two individuals may have the same genetic variation that increases the risk of a certain disease, but their overall health outcomes may be different due to differences in the interactions between their individual prakriti and environment and lifestyle. One individual may have a strong Vata imbalance due to a stressful lifestyle and lack of sleep, while the other may have a strong Kapha imbalance due to a sedentary lifestyle and poor diet. (7) (8)

Medical Genetics Behind Prakriti and Doshas

In recent years, advances in genomics and bioinformatics have led to a growing interest in understanding the genetic basis of prakriti and its potential implications for personalized medicine. Recent studies have explored the genetic basis of prakriti and its potential implications for personalized medicine.(9) One such study is the “Genome-wide Analysis Correlates Ayurveda Prakriti (GACAP) study” conducted by Periyasamy Govindaraj et al. in 2015. The GACAP study used a genome-wide association study (GWAS) approach to identify genetic variations associated with prakriti in a cohort of 341 individuals. The study identified several genetic variations associated with prakriti, including variations in genes involved in inflammation, metabolism, and neurotransmitter signaling.(10)

Importantly, this study indicated that in any individual, all genes can be grouped into three clusters- each cluster representing one Dosha. This is a remarkable finding, since it simply means that Ayurveda simplifies interpretation of an individual’s genetic make- up without requiring to take any tissue sample or expensive gadgets, while bypassing the fallacies due to genotype-phenotype mismatch.(10)

The study also found that individuals with different prakriti types had different patterns of gene expression and methylation. This again suggests that analyzing prakriti might be more meaningful than analyzing someone’s genes.(10)

Another study conducted by Prasher et al. in 2017 used whole-genome sequencing to explore the genetic basis of prakriti in a cohort of 82 individuals. Similar to the earlier study, this study found that individuals with different prakriti types had different patterns of gene expression and DNA methylation, suggesting that prakriti may be associated with epigenetic modifications that modulate gene expression. Individuals from the three doshas exhibited striking differences with respect to biochemical and hematological parameters and at genome wide expression levels. Biochemical profiles like liver function tests, lipid profiles, and hematological parameters like haemoglobin exhibited differences between the three Prakriti types. (11)   

Ayurveda Is Far Beyond Just Treating Any Disease

Ayurveda was not developed in isolation. It was developed to fully harmonize with other Vedic sciences and practices like Yogasana, Pranayama etc. The ancient Indian sciences are deeply interconnected and interdependent. Ayurveda deeply incorporates various aspects of Vedic culture, including the concepts of Gotra and Varna and various others. Gotra is a term used in Vedic culture to denote lineage or ancestry. It refers to the clan or family of an individual, which is determined by their patrilineal ancestry. Varna, on the other hand, is a system of social stratification that divides society into four major categories or varnas based on their occupation, lineage, and temperament.

Ayurveda recognizes the importance of lineage and ancestry in determining an individual’s physical and mental characteristics. The concept of gotra is believed to play a role in determining an individual’s Prakriti. In Ayurveda, it is believed that individuals belonging to the same Gotra are likely to share similar physical and mental characteristics due to their shared ancestry. This understanding of Gotra can help Ayurvedic practitioners in determining an individual’s Prakriti and providing personalized treatment plans based on their unique constitution.

During the Vedic era, the society was classified into four Varnas- Brahmins (priests and scholars), Kshatriyas (warriors and rulers), Vaishyas (merchants and traders), and Shudras (laborers and service providers). The concept of varna played a vital role in Ayurveda, as an individual’s occupation and lifestyle can have an impact on their physical and mental health.  According to Ayurveda, an individual’s occupation and lifestyle can influence their Prakriti and susceptibility to certain diseases.

Today, it is quite dangerous socially to talk about Varnas and Gotras. These terms have been tainted and abused. Today, use of these terms would suggest racist and divisive mentality. But, one you understand the science behind these systems, you will realize that they were never developed to create any form social divide. They have simply been misinterpreted by modern media since several decades now using general public’s availability bias and confirmation bias.

This post does not intend to explain the science behind Gotra and Varna systems. Varna system is actually a method of genetic technique called “in-breeding” which is coupled with environment enhancement to super-specialize a phenotype. Gotra system acts as a safety valve to prevent genetic diseases while implementing these genetic “in-breeding” methodologies in masses. I know it won’t make much sense to most readers just by reading previous two sentences. I have a written in detail about the science behind Gotra system HERE. Please do read.

Gotra and Varna are just two of the several Vedic systems that are tied to Ayurveda. There are several others, which are completely out of scope for this post.

Challenges With Ayurveda

It is truly unfortunate that the science of Ayurveda is heading towards an imminent collapse.

Modern medicine is a multi-billion-dollar industry. The amount of revenue generated by western medicine can’t be ignored. That revenue feeds into further investment and growth in western medicine. Discovery of new profitable medicines drives medical research. There is no such level of funding for Ayurveda. Most don’t even consider it as a valid way of treating diseases. Lack of funding and interest is a good recipe to kill any science.

Western allopathy tends to standardize treatment for every disease with few guidance on how treatment paradigms might change with factors such as age or pregnancy etc. It’s easy to learn and implement. Medical negligence can be easily traced back and errors can be identified. In this era where doctors are under constant fear of getting sued/attacked by patients, it is very important to have a way to prove that treatment was in accordance with some documented acceptable standard. And these standards are so rule based that even artificial Intelligence algorithms are now being trained to replace/augment doctors in most cases to mitigate human-led error.

To perfectly learn and use Ayurveda, it takes several decades of dedication and practice with very high levels of intellect and uncompromising ethics. It’s like music. It’s easy to quantify musical notes in terms of frequencies and amplitudes and make rules. But real music is an art that combines emotions and imaginations beyond those rules for musical notes. It is almost impossible to say if an Ayurvedic doctor dispensed the right medicine to a patient, because the treatment would depend on patient’s condition and Dosha imbalance and dietary habits and environmental conditions at the time when the patient came to the doctor. Based on simple pulse examination, a trained Ayurveda expert can diagnose and give accurate medicines. But, there is no way to check if what he did was correct.  So, one will have to simply trust the Ayurvedic doctor 100% blindly. It was this exact reason why in ancient times, only few select individuals were allowed to learn and practice Ayurveda.

The other issue is that the ancient Vedic practices which integrate with Ayurveda have today nearly disappeared in oblivion. They were necessary for Ayurveda to be completely effective. The tags of pseudoscience and superstition have killed many of these ancient sciences. In such scenario, the question arises- is Ayurveda still completely relevant?

When I was in high school, I had ZERO maturity to know what I want to do in future. I didn’t even think about Ayurveda vs western medicine when I chose to do MBBS. Today, in India, Ayurveda is usually pursued by students who don’t get MBBS or BDS or engineering (in general). Most start using allopathic methods immediately after they graduate. Several institutes teaching Ayurveda struggle with funding and find it difficult to maintain quality.  Pay grade of professors teaching Ayurveda are too low.

Given these facts, how does one trust a doctor practicing Ayurveda? Nevertheless, the fact remains that Ayurveda is a deep science and is comprehensive medical system that holistically treats any disease.

The Way Forward

As seekers of science, we must not give up.

Humanity, as a population, is moving towards a massive health crisis. This is truly evident with sudden explosion of chronic diseases such as diabetes, hypertension, cardiovascular diseases, cancer etc. They are all rising in epidemic proportions. Western medicine has phenomenally increased our knowledge about human biology. We know in depth about millions of molecular pathways and how to manipulate them. Unfortunately, the same approach of exploring the depth leads to myopic approaches for treating diseases. Western medicine is extremely efficient for tackling urgent life- threatening situations but fails miserably to tackle chronic diseases. Approach towards disease and health has to be holistic. Ayurveda uses a simplistic, yet comprehensive and holistic approach considering the fact that all systems and processes are interlinked, and that their interplay is unique in each individual. Ayurveda is not just about curing diseases; it is also a way of life that serves to prevent diseases and promote happiness.

What if there is a better way?

Maybe- there is a way to integrate the “narrow and deep” approach of modern medicine with the holistic approach of Ayurveda. Maybe, we can learn to use modern medicines to bring back lost balance of Doshas in any disease. After all, the herbs used in Ayurveda have pharmacological actions just like any medicine in allopathy. Is it possible to find out laboratory markers to measure each of the doshas and identify Prakriti of each patient? We need to slowly start understanding which molecular pathways are associated predominantly with which doshas. If this approach succeeds then we would be able to identify Dosha imbalance in any patient and start using allopathic medicines optimally along with Ayurvedic methodologies to correct the imbalance.

Science should be science and it should be based on facts and not on what popular media projects; nor should it be based on what is economically profitable. There is a growing segment of young intellectuals in India who are trying to revive this dying science of Ayurveda. I am trying in my own small way towards the same. This article is a small attempt in that direction.

During my research on this topic I came across a brilliant research paper written by Prashar et al. that gives enormous insights into genetic basis of Doshas. The link to that article is HERE. If you get access to the full text, it’s a beautiful reading.

References

1. Patwardhan B. Bridging Ayurveda with evidence-based scientific approaches in medicine. EPMA J. 2014;5(1):19.

2. Sharma H. Ayurveda: Science of life, genetics, and epigenetics. Ayu. 2016;37(2):87-91.

3. Pilapitiya S, Siribaddana S. Issues in clinical trials in complementary and alternative medicine (CAM). Curr Opin Pharmacol. 2013;13(2):311-2.

4. Sanson-Fisher RW, Bonevski B, Green LW, D’Este C. Limitations of the randomized controlled trial in evaluating population-based health interventions. Am J Prev Med. 2007;33(2):155-61.

5. Raha S. Foundational principles of classical Ayurveda research. J Ayurveda Integr Med. 2013;4(4):198-205.

6. Bhalerao S, Deshpande T, Thatte U. Prakriti (Ayurvedic concept of constitution) and variations in platelet aggregation. BMC Complement Altern Med. 2012;12:248.

7. Prasher B, Gibson G, Mukerji M. Genomic insights into ayurvedic and western approaches to personalized medicine. J Genet. 2016;95(1):209-28.

8. Sharma H, Keith Wallace R. Ayurveda and Epigenetics. Medicina (Kaunas). 2020;56(12).

9. Wallace RK. Ayurgenomics and Modern Medicine. Medicina (Kaunas). 2020;56(12).

10. Govindaraj P, Nizamuddin S, Sharath A, Jyothi V, Rotti H, Raval R, et al. Genome-wide analysis correlates Ayurveda Prakriti. Sci Rep. 2015;5:15786.

11. Prasher B, Negi S, Aggarwal S, Mandal AK, Sethi TP, Deshmukh SR, et al. Whole genome expression and biochemical correlates of extreme constitutional types defined in Ayurveda. J Transl Med. 2008;6:48.

12. Ries M, Gal A. Genotype-phenotype correlation in Fabry disease. In: Mehta A, Beck M, Sunder-Plassmann G, editors. Fabry Disease: Perspectives from 5 Years of FOS. Oxford2006.