A year ago, a Sunrise Review Application (Application) was submitted to the Colorado Department of Regulatory Affairs (DORA), proposing the licensing of Ayurvedic “doctors” and other Ayurvedic practitioners in that state. Per Colorado law, DORA reviewed the Application and, last month, issued its Sunrise Review recommending that the state not regulate Ayurvedic “professionals”, but this does not prevent a licensing bill from being introduced, or from passing, in the Colorado legislature. (The deadline for bill introduction is in January, 2020.) Based on information submitted in the Application, it appears that this effort may be the beginning of a national campaign to legitimize Ayurvedic practice via licensing. With this, we start a new chapter in the rich history of Legislative Alchemy, that is, the deliberate incorporation of pseudoscience into the American healthcare system via legislation in lieu of evidence.
We’ll return to this effort in a moment, but first, let’s take a brief look at Ayurveda, a prescientific belief system that originated, and is still practiced extensively, in India. Ayurvedic practitioners believe that all people are made up of five basic elements (space, air, fire, water, and earth) that combine into three “life forces” or “energies”, called “doshas”. These doshas (vata, pitta, and kapha), control different bodily functions. Each person is, according to this belief system, a unique mixture of these doshas, although one usually dominates. Whether you get sick, and the illnesses you develop, depend on the balance of your doshas.
The vata dosha is thought to be the most powerful, controlling basic bodily functions, such as cell division, as well as one’s mind, breathing, blood flow, heart function, and elimination. Things like “eating again too soon after a meal, fear, grief, and staying up too late” can disrupt one’s vata dosha. If vata dosha is your main dosha, Ayurvedic practice predicts you are more susceptible to developing conditions like “anxiety, asthma, heart disease, skin problems, and rheumatoid arthritis”.
According to Wikipedia,
Treatments include herbal remedies, oils, enemas, bloodletting, diets, meditation, yoga, and, of course, “detoxification”, called “Panchakarma”, the “benefits” of which were described in a previous SBM post:
Panchakarma will remove the excess doshas and correct imbalances in them as well as eliminate the harmful ama out of your system through the body’s own organs and channels of elimination (colon, sweat glands, lungs, bladder, urinary tract, stomach, intestines, etc). Panchakarma purifies the tissues at a very deep level. It involves daily massages and oil baths, herbal enemas, nasal administrations. It is a very pleasurable experience. Ayurveda recommends Panchakarma as a seasonal treatment for maintaining mental and physical hygiene and balance.
Personally, I had not thought herbal enemas would be “very pleasurable” but, then again, I’ve not tried one.
There is, of course, no evidence that these doshas exist, and the dangers of basing diagnosis and treatment on a fantasy-based system of human functioning should be obvious. For example, the “Ayurvedic Practitioner Certification Exam Detailed Reference Guide” (2019 Ed.) lists as possible causes of psychosis demons, the influence of snakes, spirits, divine intervention, celestial musicians, and possession.
Even according to the CAM-friendly National Center for Complementary and Integrative Medicine, regrettably ignoring the fact that the whole system is based on magical thinking, says that while there is very limited evidence that some Ayurvedic herbal remedies might possibly be effective for a few conditions, “there is little scientific evidence” of its value for other health issues.
There are, however, a number of well-recognized dangers of Ayurveda, one of the most worrying of which is the use of metals like gold, mercury, copper, and silver in its remedies, a subject we’ve addressed here on SBM and noted by the NCCIH:
A 2015 published survey of people who use Ayurvedic preparations showed that 40 percent had elevated blood levels of lead and some had elevated blood levels of mercury. About one in four of the supplements tested had high levels of lead and almost half of them had high levels of mercury.
There is also a danger of arsenic poisoning. This is in addition to the usual risk of taking any herbal remedy, which, due to lack of effective regulation, may be contaminated or suffer from other quality issues.
Sunrise Review Application
With that background, let’s turn to the Sunrise Review Application and DORA’s recommendation against licensing Ayurvedic practitioners.
First, we learn from the Application that Ayurvedic practitioners have taken a page from the chiropractic, naturopathic, and Traditional Chinese Medicine/acupuncture (TCM) playbook and set up a system of organizations that, on their face, mimic those of the medical profession, but are actually designed to incorporate and perpetuate their pseudoscientific belief systems and, via self-regulation, shield them from outside scrutiny. These are the
- National Ayurvedic Medical Association, an private association of Ayurvedic “doctors” and other Ayurvedic practitioners with “more than 800 Ayurvedic professional members in the United States.”
- National Ayurvedic Medical Association Certification Board, a private association which establishes the number of hours of instruction needed to complete training for the three levels of practice for which they seek licensure in Colorado: Ayurvedic Doctor, Ayurvedic Practitioner and Ayurvedic Health Counselor, and administers the “rigorous” exams required for certification. (You can find the study guide for the “rigorous” Practitioner certification exam here. For clarity, I will use “Practitioner” when referring to that specific level of practice and “practitioner” or “provider” to refer to those who practice Ayurveda in general, whatever their level.)
- National Ayurvedic Medical Association Accreditation Council, a private organization, which is gearing up to apply for recognition from the U.S. Department of Education as the accrediting agency for Ayurvedic schools in the U.S. If successful, their students will be eligible for taxpayer-funded student loans and their educational institutions eligible for federal research money.
Although no specific licensing bill is proposed, it is apparent that the Application contemplates that the state, as in the case of chiropractic, naturopathic and TCM licensing, would default to these private organizations, created and run by Ayurvedic practitioners, to control the education, training, examination, and continuing education requirements for Ayurvedic practitioners, thereby ensuring that science and protection of the public’s health will not intrude.
Second, the Application makes no apologies for the fantastical practices of Ayurveda (which it sets out in some detail) nor does it pretend that there is any evidence to support their effectiveness or safety. (In fact, the Application admits to some of their dangers, a point we’ll return to shortly.) Rather, the case for licensing is based on familiar logical fallacies we frequently see trotted out in the promotion of pseudoscientific practitioners. One, CAM is “popular”, based on the logical fallacy which
tells us that if something is popular, it must be good/true/valid, but this is not so, especially in a society where clever marketing, social and political weight, and money can buy popularity.
Two, an appeal to authority, in this case invoking the World Health Organization which “recognizes Ayurveda as a form of traditional and complementary medicine” in its “Traditional Medicine Strategy” and “encourages Member States to consider [Traditional and Complementary Medicine] as an important part of the health system,” a move that has been widely criticized as “antithetical to the [WHO’s] commitment to evidence-based medicine, a desertion of duty to uphold the highest scientific standards”, and which the WHO itself says is not an endorsement of T&CM.
Third, in spite of its basis in pseudoscience and the lack of evidence of safety and effectiveness, the Application seeks an extremely broad scope of practice. Ayurvedic “doctors” and Ayurvedic Practitioners need have only 6 college credits in anatomy and physiology plus, respectively, 3,000-4,500 hours of education and training in Ayurveda and 300 patient encounters, or 1,500-2,500 hours and 150 patients encounters, to be eligible for “certification”. How these hours are calculated is not explained. Of course, much of this time is spent learning nonsensical concepts such as:
Changes in vikṛti due to changes in agni, guṇas resulting in digestive disorders, appetite and elimination changes
Attributes (guṇas) that cause the doṣas to accumulate and become aggravated
Diet (āhāra) and lifestyle (vihāra); how diet, climate, season and age impact the prakṛti and subsequently contribute to doṣa vikṛti and cause of disease
What constitutes excess, deficient and the imbalance of doṣas within their own site
Theory of similar and dissimilar and balancing the doṣa vikṛti through a proper daily routine, seasonal routine and basic six tastes (rasa) for a person of each constitutional type
And so on.
Yet, for both “doctors” and Practitioners, the Application does not propose any limitation on the scope of practice. It includes diagnosis, treatment, and management “from the Ayurvedic perspective” of any disease or condition in any patient of any age, unsupervised by any other health care professional. The Ayurvedic Health Counselor, with 600-1,000 hours of education and 50 patient encounters, offers “health promotion and disease prevention” using “principles of Ayurvedic medicine”, including assessment of the patient’s Ayurvedic constitution and the imbalance and state of his or her doshas. They refer patients to Ayurvedic “doctors” or Practitioners when the patient’s “disease state” requires diagnosis and treatment, but also practice unsupervised.
Fourth, the Application claims that licensure would “ensure that Ayurveda recommendations be given in coordination and cooperation with the client/patient’s licensed healthcare team” although no actual requirement for “coordination and coordination” is proposed. Presumably to shore up this notion, and perhaps to allay any fears that Ayurvedic providers might harm patients because they don’t know what they’re doing, the Application makes some extraordinary claims for Ayurvedic providers’ proficiency in “Western” medicine. According to the Application, Ayurvedic “doctors”
have a working knowledge of Western medical pathology, pharmacology, diagnostic reports, and treatments, in order to interface with the Western medical community and modify the Ayurvedic management of cases accordingly, as needed.
have a working knowledge of Western medical diagnostic and treatment terminology and practices, sufficient to enable them to correlate those terms and diagnosis into Ayurvedic understanding and practice.
As well, they have
an informed awareness of public health and epidemiology . . . from the Western and Ayurvedic perspectives.
Ayurvedic Practitioners “must be able to refer a patient for assessment and possible treatment by a medical practitioner” and “have knowledge of red flag symptoms that require immediate referral” and (in a statement of breathtaking hubris) “must understand how other health care professionals can complement the care being provided by the Ayurvedic Practitioner”.
Even Ayurvedic Health Counselors “have the knowledge of symptoms that require referral to a licensed medical professional”.
In my opinion, these claims are both disingenuous and dangerous. Ayurvedic providers are educated and trained (such as it is) wholly outside the mainstream American medical educational and training system and fully accept prescientific beliefs as a substitute for “Western” science-based medicine. Yet, they are somehow able to both put aside their fantastical notions about predetermined disease susceptibilities based on inborn doshas and their imbalances and magically transform themselves into competent “Western” medical diagnosticians. Not only that, they can take these two irreconcilable systems and combine them in their management of patients, much like NASA and astrologists work together to combine “Western” astronomy, physics, and chemistry with the predetermined fates ascribed to one’s “sign” into one successful space program. (Actually, they don’t.)
Judge for yourself just how credible this claim could be by examining the curricula of the school ranked number one by universities.com for “Best Colleges with Ayurvedic Medicine/Ayurvedic Degrees in the United States”, Southern California University of Health Sciences, a school that also offers chiropractic, acupuncture, and oriental medicine degrees.
Upon completing the one-year program conferring the Ayurvedic Wellness Educator Certificate, consisting of online and weekend courses, recorded lectures, and working in the school clinic, a student can enroll in the Ayurvedic Practitioner Certificate program. This program lasts one year as well, and also consists of online and weekend courses and recorded lectures. The “Clinical Internship” is four weeks long, for 15 hours per week, or a total of 60 hours. The description says nothing about learning or employing “Western” medicine.
Fifth, the Application admits that Ayurvedic remedies include dangerous metals, such as lead, and dangerous herbs, such as Ashwagandha, which can affect adrenal hormones, citing medical literature exposing these risks. It promises that licensing will solve these issues with vague assurances of compulsory adherence to best practices and practitioner competency and training. At best, this might work to exclude therapies once the harm is discovered, but it does nothing to address the problem of using unproven therapies whose harms are not yet known because testing for safety is considered unnecessary. (The Colorado Citizens for Science in Medicine filed Comments with DORA opposing licensing and listed even more dangers for DORA’s consideration.)
In fact, the one remedial step Ayurvedic organizations have taken does not appear to be working. According to the Application, in 2008, several organizations agreed practitioners should stop using any product to which lead, mercury, or arsenic (but not copper, silver, gold or herbs) have been intentionally added “until modern Western science have proven the safety of such products” underscoring that Ayurvedic practitioners do not consider it their job to evaluate the safety of their therapies. (Leave that task to “modern Western science”.) Yet, several of the harms reported in the medical literature occurred after that date.
Sixth, and finally, the Application fully admits that one goal of licensing is increased prestige:
Regulation gives a measure of authenticity, professionalism, credentialing, integrating and complimenting other healthcare modalities. . . Regulation also achieves an enhanced status in the eyes of the public, which equates Ayurvedic professionals with professionals licensed in other fields.
In other words, the public will be completely fooled.
They may also seek coverage under health insurance plans. Indeed, at least theoretically, insurers would be required to cover their services under Section 2706 of the Affordable Care Act. (Although that has not been the financial boon anticipated by CAM providers.)
DORA recommends a “no”
Fortunately, as noted, DORA recommended against regulation, via licensing, of Ayurvedic “professionals”, although, as also noted, this does not prevent the legislature from passing a bill doing just that. Now, a normal person might think: “Of course they didn’t recommend licensing! Ayurveda is total nonsense!” Unfortunately, being nonsense-based does not legally preclude licensing or registration (another form of regulation, with its attendant imprimatur of legitimacy) in Colorado, which also regulates chiropractors and naturopathic “doctors” or, more accurately, allows them to self-regulate.
Instead, DORA considered the criteria mandated by law, the first of which asks whether the practice of Ayurveda “clearly harms or endangers the health, safety, or welfare of the public”. In other words, the more dangerous you are, the more likely you are to be awarded the honor of being licensed and, as the Ayurvedic providers put it, achieving an “enhanced status in the eyes of the public”. Based on the information it had, DORA concluded that “Ayurvedic professionals are not causing widespread harm to consumers who utilize their services” and that most examples of consumer harm were “product-related, not practice-related” ignoring the fact that many of these products were supplied by Ayurvedic practitioners (although some were in India).
The second criterion is whether the public needs and can benefit from initial and continuing professional competence through, for example, educational and examination requirements. DORA decided it wasn’t necessary to address this one, as there was insufficient evidence to conclude the unregulated practice of Ayurveda harms the public. (Again, apparently, the fact that this education and examination would be fantasy-based is not a consideration in the eyes of the law, had DORA chosen to address this criteria.)
In fact, its decision on the first criterion pretty much allowed DORA to skip consideration of all the remaining criteria. The agency did note that Colorado’s Natural Health Consumer Protection Act or, as I prefer to call it, the Quack Full Employment Act, permits the practice of Ayurveda, which, in DORA’s view, provides some pubic protection. Indeed, lack of licensing doesn’t seem to be stopping anyone: There are about 70 Ayurvedic practitioners currently plying their trade in the state.
While this is the first attempt in recent years at licensing Ayurvedic practitioners, a bill was filed in New Hampshire back in 1999 to license Ayurvedic “physicians”, who would be allowed to diagnose and treat any patient, regardless of age, disease, or condition. They could employ physical and orificial examinations, pulse analysis, X-rays, electrocardiograms, ultrasound, phlebotomy, clinical laboratory tests and examinations, and physiological function tests, do minor office surgery, prescribe according to a formulary, prescribe barrier contraceptives, and practice “natural” childbirth. They would have been self-regulated by their own Ayurvedic Board of Examiners. Fortunately, the bill was defeated.
The Indian Medical Association, whose members see first-hand what the widespread practice of Ayurveda looks like, were faced with the prospect of licensing Ayurvedic practitioners in their country. They opposed licensing, saying:
The government is giving sanction to quackery. If those doctors make mistakes and people pay with their lives, who is going to be held accountable?
Exactly. State legislatures in the U.S. should heed their warning.