Criticism has been raised by the Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy (AYUSH) against a paper claiming to link the Ayurvedic herb Tinospora cordifolia (TC) — also known as giloy — to liver disease.
While the paper, published in the Journal of Clinical and Experimental Hepatology — a peer-reviewed journal of the Indian National Association for the study of the liver — has been widely publicised in the media, the Ministry of AYUSH has deemed it “completely misleading”. The study observes a number of patients presenting what they describe as herbal-induced liver injury, specifically acute hepatitis following a recent exposure to ingestion/consumption of a distinctive formulation containing TC.
TC is considered in Ayurvedic practice as an immunity booster and is available in pre-prepared dried tablet form. Commonly, the twigs of the plant are prepared in a tea in which the twigs are boiled. Critically, such a use of the plant makes estimates regarding the actual amount of the active ingredients difficult to establish.
This forms the basis of the criticism from the Ministry of AYUSH. They note in a statement that “the study has many flaws in it. It is unclear that what dose the patients had taken or whether they took this herb with other medicines. The study has not taken into account the past or present medical records of the patients…it was also noticed that the authors of the study have not analysed the contents of the herb that was consumed by the patients. It becomes the responsibility of the authors to ascertain that the herb consumed by the patients is TC and not any other herb.”
The paper suggests that “the mechanism for unmasking of latent chronic autoimmune liver disease may be explained by the immune stimulant effects of T. cordifolia, which could have exacerbated an underlying pre-existing heightened immune response to self-antigens expressed by the liver.”
However, their arrival at this conclusion is debatable at best. A key concern is the very low number of study participants. At six individuals, this number risks evidence being circumstantial at best with further issues in the study design adding to this. Each individual presents with a differing comorbid condition, with some having hypothyroidism, some diabetes, and another beta-thalassemia minor.
In addition, as the Ministry of AYUSH points out, the amount of TC varies greatly between individuals. Some participants had been taking the TC in a tea for up to seven months, others had only been taking the medication for a few weeks.
Case five of the study is particularly demonstrative of the fact that the paper may be jumping to conclusions based on limited evidence. The individual had a trans-jugular liver biopsy performed which “showed lymphoplasmacytic infiltrate mixed with plasma cells and eosinophils, moderate interface hepatitis, fibrosis and altered architecture suggestive of an auto-immune cirrhosis.”
This individual only began taking TC three weeks prior to the hospitalisation with liver injury and, over that period of time, only boiled a single twig two to three times a week. Six to nine consumptions of a dose far lower than the three to four twigs consumed by other participants resulting in such aggravated damage to the liver would suggest that TC is a potent and dangerous toxin.
This narrative is questioned when the paper goes on to state that “four (all women) had features of chronic liver disease with autoimmune features on liver biopsy.” The implication of this is that these individuals all had long-standing liver issues long before the often short period of time they began taking TC. To claim that the damage was caused by the herb alone is simply wrong.
The paper gives an explanation that the herb may have played a role in exacerbating symptoms and, as the majority of individuals enrolled in the study had preexisting conditions, this may be the case. However, with such a small sample study this cannot be finalised.
The danger in the criticisms from the Ministry of AYUSH is the positioning of their point of view beyond scientific reproach. Given the precedent of unproven and often dangerous treatments being put forward by Ayurvedic practitioners, it is abundantly clear that neither side is above scientific criticism.
During the first wave of the COVID-19 pandemic in India criticism was abundant of the Centre’s push for Ayurvedic treatment. The opening paragraph of a report for Science by Priyanka Pulla published – headlined “‘A fraud on the nation’: critics blast Indian government’s promotion of traditional medicine for COVID-19” – read “the Indian health ministry has begun to recommend traditional remedies to tackle the country’s COVID-19 outbreak…triggering sharp criticism from the Indian Medical Association (IMA), a group of more than one-quarter of a million modern medicine practitioners.”
Ayurveda is promoted as a system worthy of merit due to its ancient background. However, it must be acknowledged that this system was developed over hundreds of years — through criticism leading to knowledge of what works and what doesn’t. As Health Issues India noted in a previous op-ed
“Charaka Samhita, Sushruta Samhita and Ashtanga Hridaya of Vagbhata (~400 BC–200 AD) are some of the main classics, which give detailed descriptions of over 700 herbs and 6,000 formulations. Madhav Nidan written later at around 800 AD provides over 5,000 signs and symptoms.
“The practice was created and refined over a period of time spanning more than a thousand years. The practice has a long history that is constantly evolving. As a living practice there is no need to define the 21st century as the period of time in which this practice stops and begins to look only backwards.”
Likewise, studies that have been put forward which make bold claims made on insubstantial evidence must be criticised and validated. Allopathy and Ayurveda often find themselves at odds with one another when the systems might often work in tandem. For example, a course of medication for a cardiac condition may be further enhanced with a suggestion of the practice of yoga, which may improve overall cardiac health.
The claims made in the study may have merit, and it may be the case that the herbs used may exacerbate prior symptoms of liver disease. However, these claims need further research, rather than the outright dismissal levied by the Ministry of AYUSH. Defiance against all criticism will not push forward medical practice. Evidence will.