Ojas and Vyadhikshamatava- Ayurvedic Perspectives of Immunity and its modulation in Clinical Arena

Introduction

The Darwinian thought of Survival of the fittest is being realized in the present times and only those who have strong armours called ‘Immunity’ can win over the deadly viruses and their toxic effects on the body. Immunity is the buzz word in public health circles in these prevalent times of Corona virus pandemic. All the public health efforts are being oriented towards optimizing the immune response of the body cells to neutralize the virus and its toxins, so that disease does not manifest itself or body tissues are not affected by the deleterious effects caused by infection control response of the body. In order to understand the perspective of Immunity, one needs to understand the origin of the word and the context in which it is used. The word ‘Immunity’ is derived from the French word ‘Immunite’ which means privilege, inviolability. In Latin, it is originated from ‘Immunitatem’ meaning ‘exemption’ from a service or charge, exempt free [1]. Merriam Webster defines Immunity as a condition of being able to resist a particular disease caused by micro-organism and the effects of microbial pathogenic products [2]. In common parlance it is known as disease resistance. The current medical literature defines immunity as the capability of multicellular organisms to resist harmful micro-organism [3]. The conventional bio-medical system of medicine looks upon immunity as host response to neutralize the microbes and their toxins, viruses, cancer cells by specialized cells in the body. With the emergence of auto- immune disorders, immune-pathologies, allergies and non- communicable, Immune responses has manifested in the form of double edged sword, its under and over expression can actually harm the body constituents which may lead to many serious disorders some of which are very hard to treat and sometimes even lethal. From this brief introduction of this power word “Immunity” one can infer that it is defensive response of the body towards a physical, chemical, biological or psychological agent which is liable to disrupt the homeostatic Balance. This view brings ‘Immunity’ very close to the concept of “Dhatu Samyata” “Arogya” or health in Ayurvedic perspective. In Ayurvedic perspective, in the context of the origin of Ayurveda, Acharya Charaka has explained in a lucid manner that, Ayurveda originated to enhance the disease resistance of the humans who were afflicted with various illnesses affecting their higher pursuits [4]. ‘Ayurveda’ therefore conceived with prime aim of establishing ‘Arogya’ and ‘Dhatu Samya in ailing humanity’ [5]. This makes Ayurveda the first science of enhancing disease resistance by various approaches which are elaborated in the volumes of classical treatises. This is what is expressed as the primal objective of this great knowledge system: continuous health maintenance and health preservation (swasthysya swasthavruttanuvrutti) [6]. over and above the disease eradication. Because diseases only manifests in an milieu which is afflicted with vitiated Dosha Dhatu, Mala and Srotas. This approach prompts Ayurveda to promote various life style and therapeutic measures which help in creating a internal environment in which diseases and disorders do not occur and state of health remains preserved. These measures are referred to as Ajata Vikaranama anutpattikar bhava’ [6].

This preventive and promotive aspect of health care is the essence of Immunity in Ayurveda.

In contemporary era, ‘Ojas’ or ‘Vyadhi Kshmatava’ are the two famous connotations or correlations of Immunity in ‘Ayurveda’ as many of the available review studies on Immunity from Ayurvedic perspective elaborate these two fundamental concepts. This essay is purported to explore the concept of Immunity as a basic tenet of Oja/Ojas and Vyadhi Kshmatava (disease resistance) with the available current scientific literature and to establish Ayurvedic perspectives and practices of immune- enhancement. In this study various aspects of Ojas as immunity, its origin in the body, signs of its manifestation in the body, its pathological states and the different types of Bala or Ojas and their therapeutic and clinical perspective will be discussed in the light of current research evidence.

Material and Methods

Charaka Samhita, Sushruta Samhita, Ashtanga Hrudaya with their commentaries, online Ayurveda research portals, Dhara, AYUSH portal and other research portals like Google scholar, scopus were searched for the references of Ojas, Bala, Vyadhi Kshamatava. Chapters from different Sthana of the samhita where references about Ojas or Bala or Vyadhi Kshmatava is found were included in the study. The online database, PubMed, PubMed Central and IndMed were searched for citations for keywords “Ojas” and “Vyadhi Kshmatava” Immunity and Ayurveda, Immunno therapeutics, Immnopathology was searched. Review papers, experimental papers in English, revealing the key words cited above were included in the review [7]. The studies based on Immunochemistry, Immunological tests were excluded. Studies in languages other than English, and whose abstracts were unavailable were excluded from the review. After applying the inclusion and exclusion criteria and removing the duplicates, a total of 41 studies were selected for the final review. The important papers which were studied in details are tabulated as below:

Defining ‘Ojas’ in Ayurveda Swasnajna

In Samskrita dictionary, Shabda Kalpa Druma, synonyms of ‘Ojas’ are Bala and Aarjavam. All the major treatises of Ayurveda acknowledge the Ojas as Bala of the body which can be defined as the sum total of the structural and functional integrity of the body constituents to maintain and restore the state of health or wellbeing.

तत्र रसादीनां शुक्रांतानां धातूनां यत परं तेजस्तत खल्वोजस्त्द्देव बलमित्युच्यते (सु.सू. 15/19) It is the protective shield which protects the body from various physical, environmental, biological and psychological stressors. Charak Samhita and Ashtanga Hrudya also define Ojas as quintessence of the seven formative substances of the body.

यच्छरीरसंस्नेहः प्राणा यत्र प्रतिष्ठिताः (च.सू. 30/11), धातुप्रसाद संज्ञकानीति अत्यर्थशुद्धेनैव (च. सू. 28/ 4, चक्र. टी.) Acharya Charaka referred to ‘Ojas’ as first shareer Dhatu which decides the further development of the human frame in the mother’s womb, making ‘Ojas’ as the primal formative structural and functional element of the body which gets manifested after the fertilization and Jeevopkramana [8]. It is the first deciding factor which decides the continuance of in-utero life in the Kalala roopa Garbha. Sushruta Samhita [9] and Ashtanga Hrudya [10] also emphasize that it is from the ‘Ojas’ that different entities of Sharira emerge and sustain without which body cannot survive. All the material manifestations of the body upon which survival depends emerge from Ojas. From the point of view of importance, Ojas is classified as Para Oja with its seat in Hrudya, the Pranayatanam. It is the first site where the Ojas manifested during the inception of life and decides the future course of the in-utero life. The other form is the Apara Ojas which can be seen as the circulating primodial Dhatu elements which after the Dhatu Parinama will convert into the local (स्थायी) Dhatu. Hence, the Para Ojas is the Pranaytana [8, 11] and essential for the survival while Apara Ojas is the circulating Ojas which gets depleted on daily basis depending upon the supply and demand of the individual and requires to be replenished. In Chraka samhita, the physician who knows the management of Pranayatana is termed as Pranabhisara Vaidya. This highlights the importance which is given to the Ojas as it is seen as one of the important factor in the treatment of the disorders. To sum up, one may infer that Ojas is the quintessence of life processes in the body which help to maintain the structure and function of the body components by preventing it get afflicted from the various intrinsic and extrinsic stressors and pathogens. It is compared with the Ghee and Honey. Their formation depends upon the quality of the formative substances i.e. Milk and flower nectar and the series of processes through these essences come into existence. Any diminution in quality of the formative substances or any disruption in the process of formation may lead to malformation of Ojas or Bala termed as Ama, progenitor of all the disorders. This highlights the importance of Ojas in health and Ama in emergence of disease. On the basis of the origin the Bala is defined to be of three types:

Assessment of Ojas in Individuals

Till date there is no single, clinical, laboratory or radiological parameter which can predict the immunity or disease resistance of an organism. Laboratory tests which are currently available only assist in the clinical correlation of a diseased state with some under activity or hyperactivity of immune cells. As we have seen, Immunity is a holistic integrative function of different components of the body, therefore, it would be inapt to see immunity solely from the lens of different immune markers available in the immunoassays. From, Ayurvedic perspective it is difficult to assess Ojas quantitatively in an individual though its quantitative aspect is discussed in classical treatises. As

described in the outset, Ojas is a factor which is present in every component of the body (सर्वदेह व्यापिन: सावयवस्तेन) regulating their structural and functional integrity. Therefore, it is important to assess functioning of Ojas or Dhatu Samya in the body from the integrative features of health i.e. Arogya Lakshana as mentioned in Charaka Samhita [12]:

• Rugapshamanam: Absence of any discomfort, pain or distress.
• Swar varna Yoga: Healthy structural appearance and speech.
• Shareer Upchaya: Optimum Growth
• Bala vruddhi: Optimum, Physical, Mental and Psychological strength and agility.
• Abhyavararya Abhilasha: Interest in food.
• Ruchiraahra Kaale: Appetite
• Kaale Samyagjarnanam: Time bound digestion of food.
• Nidra Laabho Yatha Kaale: Good sleep at appropriate time
• Vaikaarika Svapana Adarshanam: No bad dreams and thoughts
• Sukhena Cha Pratibodhanam: No difficulty in awakening after sleep
• Vaata Mutra Purish Retas Artava mukti: Proper efflux of urine, feces, semen and menstruation
• Sarvakaare Mano Buddhi Indriyanam Avyapatti: No sensory, intellectual and Psychological distress.

Acharya Sushruta further summarizes the lakshana of Ojas or Bala in the following features:

तत्र बलेन स्थिरोपचितमांसता सर्वचेष्टास्वप्रतिघातः स्वर वर्ण प्रसादो बाह्यानामाभ्यांतराणां च करणानामात्मकार्यप्रतिपत्तिर्भ वति।। (सु, सू. 15/20) [13]

The markers of immunes strength are elucidated as appropriate growth and development of the organs and organ systems, unhindered or organized physical, mental and vocal activities, healthy voice and appearance of the person, organized distress free functioning of all the sensory, motor and cognitive apparatus of the body. These two can be used for the assessment of the functions of Ojas or Bala. If an individual functioning levels deviates from these, it indicates towards the presence of Ama or emergence of a diseases which requires to be corrected by taking appropriate therapeutic measures of Diet, Behaviour and Conduct. Hence we can use this explicit Ayurvedic quality of life criteria or Health criteria which include almost every detail of the body and mind function to assess the Vyadhi Kshamatav, resistance to disease. The more the additive score an individual scores on this scale, the better would be his level of functioning, from which one can easily predict the status of his or her Ojas or Bala.

Ayurveda focuses directly on maintaining and retaining the state of health and to avoid the emergence of diseases in this context Immunity is also defined as Vyadhi Kshamatva the term which is elaborated by Acharya Chakrapaani as: “व्याधिक्षमत्व: - व्याधिबल विरोधित्वं व्याध्युत्पाद प्रतिबंधकत्वमिति”, this is possible only when Dhatu and Srotasa are able to defy the pathogenetic forces by virtue of their structural and functional integrity which is an expression of Ojas. Hence, Ojas and Vyadhi Kshamatva are the two sides of the same coin, while the former is more health centric term latter is a disease centric term. The common thread joining the two is the exemption from the disease in terms of homeostasis and recovery from an illness.

Ojas or Bala assessment is an important aspect of Ayurvedic diagnostics as mentioned in Charaka Samhita which is done with the purpose of determining the distress bearing capacity of an individual and resilience towards the homeostatic disturbing factors. This is also important to decide the strength of the therapeutic intervention required for a particular person as mentioned in Charaka Vimana Sthana: This is a 10 factor assessment [14]:

• Prakruti: (Physico-psychological temperament)
• Vikruti: ( Nature of the disorder with reference to Dosha, Dushya, Hetu, Lakshana, Bala, Desha, Kala)
• Saara: (Dhatu level structural and functional integrity)
• Samhanana: (Over all structural integrity of the body)
• Pramana: (Body Dimensions)
• Satmaya: (Dietary and lifestyle patterns)
• Satwa: (Psycho-congitive and Behavioral Predispositions)
• Aaahar Shakti: ( Quantitiative Dietetics)
• Vyayama Shakti: (Exercise or Physical stress tolerance)
• Vaya: (Age related strength and agility) On the basis of which we can determine the health assets of an individual and ability to cope with the disease or not. In this context, Acharya defined Prashasta Purusha lakshana (healthy person) as:

सममांस प्रमाणस्तुसम संहननो नरः । दृढेंद्रिय विकाराणां न बलेनाभिभूयते ।। क्षुत्पिपासातपसहः शीत व्यायामसंसहः। समपक्ता समजरः सममांसचयो मतः ।। (च. सू. 21/18-19) [15]

This represents a model of healthy and immune person who can bear all the physical, mental, environmental including pathogenic stress. These individuals show an optimum immune response without any distress to other tissues of the body.

Acharya Charaka in the context of Vyadhi Kshmatava clarified that bodies which have a disturbed structural and functional organization of Dhaatu, Obese, very lean and asthenic, weak, those who indulge in diets incompatible to their body structure, those who eat very less, those who are psychologically labile and prone to stress are unable to resist disease or becomes diseased easily.

शरीराणिचातिस्थूलान्यतिकृशान्यनिविष्टमांसशोणितस्थीनि दुर्बलान्यसात्मयाहारोपचितान्यल्पाहाराण्यल्पसत्वानि च भवन्त्यव्याधिसहानि (च. सू. 728/7, चक्र. पाणि) [16]

This reference is very helpful in designing the personalized treatment protocols of immune enhancement in different individuals with different risk factor of the immuno deficiency.

Therefore, before administering any immune-enhancing or strengthening treatment, it is imperative to understand who needs what, where is the locus of the diminution, which Dhatu sarta is affected by the diseases . In order to understand the dynamics Ojas with respect to health and disease it is important to understand its formation in the body.

Ojas formation in the body

Ojas is referred to as ‘Parma saara of Dhatus’, which themselves are product of Aahara (nutrition) as rightly pointed out by Sushruta Samhita, “ प्राणिनां पुनर्मूलाहारो बलवर्णौजसां च” (सु सू, 46/3) [16]. In all living being, life depends upon Aahara (Food and nutrition) and its maintenance and sustenance depends upon the derivates of Ojas which are manifested as Bala (Strength and agility) and Varna (Shape and complexion).It is important to understand the mechanism of the transformation of food to Ojas and various other factors which aid in this process. As elaborated in Charaka Samhita:

“विधिमशितं पीतं लीढं खदितं जन्तोर्हितमन्तरग्निसन्धु क्षितबलेन यथास्वेनोष्मणा सम्यगविपच्यमानं कालवद अव्स्थित सर्व धातुपाकमनुपहतसर्व धातुष्ममारुत स्रोतः केवलं शरीरमुपचयबलवर्णसुखायुषा योजयति शरीर धातूनउर्जयति च, धातवो हि धात्वाहारः प्रकृतिमनुवर्तन्ते” (च. सू. 28/3) [17]

People across the globe eat different varieties of food, all these foods when digested by the action of Jathargni, the Panch Mahabhuta from different foods depending upon their constitution of food, are released and then assimilated by the action of Bhutagni and Dhatwagni into different types of the Dhatu. This whole transformation process takes place in Srotasa (Annavaha, Dhatuvaha, Updhatu vaha and Malavaha) which should be healthy, non-vitiated by any Dosha or Mala. Vayu which transports the products of one Paka to the successive Paka state in different srotasa must be in physiological state (Prakruta) and importantly the transforming agent state i.e. Agni at all the levels Jathragni, Bhutagni and Dhatwagni must be in the state of normalcy. This process of bio transformation process is time dependent process. The product of Aahara so formed is called Ojas which help in the nourishment of the body increase its strength, agility, maintain proper structure and function of the body components leading to total health. If any of the above mentioned factors is vitiated or disorganized the process of formation of ‘Ojas’ is hampered and the product which so formed remains under- transformed (incompletely metabolized) leading to the formation of ‘Ama’ an opposite of Ojas. Unlike Ojas it leads to the decrease in the strength, agility, and cause structural and functional disorders of the components of body leading to the disease and disorders. Hence, the Prasada (quintessence) of Dhatu paka is Ojas or immunity while the under-processed product of Dhatu paka is Ama which provide the inflammatory milieu for the infections, inflammations and auto-immune disorders to flourish in the body:

$$ S r o t a s \quad \boxed {A a h a r a + A g n i} \quad v a y u \longrightarrow \quad O j a s / A m a. $$ It is Samayoga of all the above factors i.e. Aahara, Agni, Srotas, Vayu, Kala to help the body generate Ojas. Diseases are caused due to Vishamayoga (Heena, Mithya, Ati) of these factors. Hence, it is important to conserve this Samyoga to promote health and prevent disease. In maintaining this Samyoga, Agni plays an important role as it solely can neutralize the ills of the other factors and if it is in a good state it can lead to the formation of Ojas. As rightly pointed in Grahni Dosha Chikitsa by Acharya Charaka:

आयुवर्णो बलं स्वास्थ्यमुत्साहोपचयौ प्रभा । ओजस्तेजोग्न्यः प्राणाश्चोक्ता देहाग्निहेतुकाः।। यद्न्नं देहधात्वोजो बलवर्णादि पोषकम। तत्राग्निहेतुराहारान्न ह्यपक्वाद्र्सादयः।। (च. चि. 15/3-5) [18]

This highlights the importance of Agni in Ojas formation and it undermines the importance of Dravya i.e. Aahara or Aushadha in the Ojas formation when the transforming agent is not in right condition. This sutra highlights that overuse of a lot of commercial products for improving immunity or Ojas without any consideration for the condition of Agni in the individual, is the mismanagement of immunity related disorder. This is an important practice pearl hidden in the classical text. Hence it is important to maintain an optimum state of Agni in the body to enhance the immunity.

In modern immunology practice, the higher emphasis is given on various macronutrients, probiotics, vitamins for immunomodulation considering their individual effects on different types of immune cells like arginine is essential for the generation of nitric oxide by macrophages and the micronutrients Vitamin A and Zinc regulate cell division and so are prescribed as essential for the successful proliferative response within the immune system. However, new studies are emerging which are cautioning against the excessive and irrational use of these immune-modulators as these can impair immune system in long run. Modern day immunology also contends that food itself can be an antigenic stimulus for the immune response on the body and Gut Associated Lymphoid tissue associated with the Payer’s patches in small intestines can help in moderating the immune response by signaling mechanism between Gut and systemic immune system [19]. This validates the Ayurvedic conceptual framework of Agni modulation described above and regulation of Ojas. Therefore maintaining a Gut health by choice of right kind of foods qualitatively and quantitatively with proper care of Agni can lead to holistic health. As food and agni can create a milieu for healthy immune responses independent upon extrinsic medications. Optimal Agni is a surety to proper digestion, absorption and assimilation of the nutrients to generate an optimal immune response in the form of immunoglobulins, antibodies and other immuno molecules required.

Genetic and Epigenetic Basis of Ojas

Only healthy parents can give birth to the healthy offspring, healthy gametogenesis is also affected by the immune status of the potential parents. It is therefore important to enhance Kalaja and Yuktikruta Bala of the potential parents for production of healthy gametes leading to Shreyashi Praja or Healthy Progeny. Significance of healthy gametes by process of Shodhna was so profound in the earlier eras, that a chapter named as “Shukra Shonit Shuddhi” was dedicated to this process to eradicate Shukra dosha, Artava Dosha and Yoni Vyapad to increase the chances of conception, continuation of pregnancy till the healthy parturition, as a part of pre-natal care. We know that fertilization and placental formation involve immune responses. Hence it can be said that an optimal immunity affects the pregnancy and human reproduction also [25].

Practice Aspect: Genetic and Epigenetic Basis of Ojas

With various environmental, cultural and lifestyle transitions, there is an alarming increase in the fetal malformations, recurrent pregnancy loss, reproductive wastage, neural tube defects, and chromosomal abnormalities. According to an estimate, an approximate of 21,400 children with Down syndrome, 9000 with beta- thalassaemia and 5200 with sickle cell disease are born in India every year [29]. A defective Sahaja Bala or Ojas can be attributed to this raise in number. Ayurveda can play a major role in optimizing the reproductive outcomes by manipulating the Ojas or Sahaja Bala. Ayurveda offers a complete range of Ojas enhancing therapeutic modalities form pregnancy planning to parturition and maximize the healthy reproductive outcomes in terms of Shreyasi Praja (Optimum reproductive outcome). It includes the selection of the mate on various attributes which are desirable in one’s progeny, eliminative therapy (shodhan chikitsa) to cleanse the body and promotion of healthy gamete formation in both the potential parents, which is followed by Samsarjan Krama (Dietary Therapy). Only then mating for pregnancy is allowed. Rajaswala Charya, Ritumati Charya are two lifestyle disciplining approaches which help in optimizing the Dhatu samya and help in Beeja and Kshetra Shuddhi for enhancing Beeja Kshetra Sampata. Planned pregnancy at right time i.e. Garbhaadhaana samskar is also an important imunity modulator. Once the woman conceives, there are many factors enlisted as Garbhopghaatkar Bhava to be avoided by the pregnant woman. From critical appraisal of all these Bhava it is observed that all these factors cause damage to the vital link between mother and fetus and decrease the Ojas in the conceptus leading to the abortion. If pregnancy continued the conceptus may have some kind of structural or functional compromise. Garbhini charya is meant to enhance the Ojas in both the Garbha and Garbhini. As marked by Acharya Sushruta, “ह्रद्यं द्रव मधुरप्रायं स्निग्धं दीपनीयं संस्कृतं च भोजनं भोज्येत,सामान्यमेतदाप्रसवात” (सु. शा. 10/3) [30]. Hrudya here implies Ojasya dravya. A view of the Garbhini Pricharya which is mostly based on milk, butter, ghee, indicates that it is to enrich nutritional resources of the mother for the healthy fetal development. As milk has all the properties of Ojas it directly increases the Ojas of Garbha and Garbhini. A well complied Garbhini paricharya leads to the enhanced disease resistance in the offspring without much pregnancy related complications for the mother. In this continuum of care, Prasava Paricharya and Sutika Paricharya and Dhatri paricharya is entailed to enhance the Ojas of the offspring and enhance the resistance of the mother towards the intra-natal and post-natal complications when her body is already depleted by the burden of pregnancy. This regulated dietary and lifestyle intervention to optimize the fetal nutrition forms the basis of increasing the Sahaj Bala of the fetus and ensuring fetal health, the first step towards the Immunity enhancement. Therefore, pregnant women should be targeted with this Immunity enhancement approach of Ayurved during peri-conceptional and ante natal care period.

Garbh-Garbhini Samskara to produce healthy generations which will decrease the overall burden of various diseases, by increasing the Sahaja Bala of the fetus and Yuktikruta Bala of the mother. This can also go a long way to reduce the Infant and maternal mortality rate by reducing the stress of reproduction.

Disorders of Ojas or Bala Ojo Dosha

As described in Shushruta Ojas or disease resistance is disrupted by Injury, trauma, Generalized debility or depletion caused by various disorders or malnutrition, metabolic disorders, psychological affliction of grief, anxiety and worry, hard physical stress and lack of food all cause the disorders of Ojas. As Ojas which has seat in the heart gets depleted in levels and due to the excessive agni but no substrate to metabolize it gets diminished from the body [31].

In the context of Rasyana, Acharya Charka beautifully explained the etiology of Oja Kshaya which are attributed to Gramya Aahara (Organized and settled life, urbanized) or life style indiscretions with various psychological afflictions lead to the weakening of Dhatus and srotas carrying these dhatus which finally converge to cause Ojas Kshaya and manifesting into Lakshana of Dhatu Vaishmaya or different disorders [32]. Charaka Samhita in the context of Oja Kshaya enumerated excessive exertion or athletic activity coupled with Anashana (lack of food), Worry or mental stress, Dry, light and nutrient deficient diets in very less quantity (Strict dieting), environmental factors (Dry tropical climate with high temperature exposure), Phobia or anxiety, depression, excessive alchoholism, late night shifts or lack of sleep, excessive drainage of body fluids in the form of Kapha, Rakta, Feces, Urine, enteral secretions, age related degeneration in immune function and infections and worm infestations are some of the common causes of Oja Kshaya which require a therapeutic interventions.

Current medical research literature defines immunodeficiency disorders as diseases caused by one or more defects of the immune system, leading to increased susceptibility to infections. It is a group of heterogeneous disorders with immune system abnormalities characterized by various combinations of recurrent infections, auto- immunity, lympho-proliferations, granulomatous processes, atopy and malignancy. Most of the primary immunodeficiency are genetic in nature (Beeja Dushti Janya). Secondary immune deficiency are caused by Age factors, pre-maturity and age related changes, medications like immunosuppresants, corticosteroids, Procedures like use of anesthesia, splnectomy, infections like HIV, AIDS, temporary during infections, metabolic disorders like Diabetes, uremia, Protein losing conditions like Nephrotic syndrome, Protein losing enteropathy, Alcholic cirrhosis, Hereditary conditions like chromosomal abnormalities. Miscellaneous like SLE, Burns, malignancies and radiation therapy [30]. Therefore, Ojo Kshaya is requires some kind of Ojo therapeuctic modality for the re-establishment of the equilibrium.

Behavioural Medicine and Ojas

Acharya Sushruta described four disease mitigation approaches referred to as: Samshodhana (Eliminative therapies), Samshamana ( Health establishing medical approaches), Aahara (Therapeutic and restorative Dietetics) and Aachara (Health Behavioural). Behavioral approach includes the physical, mental and cognitive behaviors which are conducive to one’s own health and other’s too. Behavioral and cognitive states are elucidated to have modulate the equilibrium of Dosha, Dhatu and Mala. As Acharaya Sushruta described defined sensory-mental and cognitive dimension of health: प्रसन्नात्मेंद्रिय मनः स्वस्थ इत्यभिधीयते. In terms of Ojas, Acharya Charaka enlisted psycho-behavioral factors as Ojasya viz. To avoid mental stressors and to engage meaningfully in activities enhancing mental peace as well as wisdom [39]. Based on this, Achara Rasayana (Behavioral Rejuvenation) and Sadvruta ( Health promoting behaviors) have been highlighted in the classical treatise. The ultimate goal of the above two is to modulate the immunity by decreasing the exposure of an individual to the immuno-stressor agent, physical, mental and cognitive. Idea of behavioral rejuvenation is based on to promote the psychological attributes which decrease the cognitive fallacies pertaining to health related decision making (Prajnapradha) and to promote making healthy choices. As all our behaviors affect our health therefore, these psychological attributes affect our thoughts which brings about changes in physical behavior. Physical behaviors directly affect Tridosha, Dhatu, Agni leading to formation of Ojas. Benefits of Acharaya Rasayana by Acharya Charka can be summarized as: All the behavioural and psychological elements of Achara Rasyana brings the same transformation in the body frame as is the brought about by regular use of Rasayana medicine [40]. Acharya Sushruta also highlighted the importance of Behavioural elements in promoting health, rational eating (भोजनं जीर्णे), timely attention towards the eliminatory reflexes (वेगानां चाविधारणं), non-attached attitudes towards life (ब्रह्मचर्य ),non-voilence (अहिंसा), avoidance of the risky behaviors (साहसानां च वर्जनम). These elements help in enhancing resistance against various intrinsic as well as extrinsic disorders and keep the body resilient against the stress of the disease. Therefore, Achara Rasayana and Sadvrutta affect two folds, it decreases the hetu Bala on one hand and Vyadhi Kshamatava on the other hand. This also represents the patient compliance and readiness to maintain the health equilibrium. Ayurveda emphasize. Achara Rasayana and Sadvrutta is represented as the preventive and promotive approach which enhance the Bala and help individuals to avoid Prajna apradh janya vyadhi. All the behavioural elements of Dincharya, Ritu charya, Garbhini Paricharya, Rajaswala Paricharya, Sutika Paricharya, Dhatri Paricharya comes under the purview of Sadvrutta to enhance the healing process and to avoid the onset of diseases (Vikaranam anutpatti). In prevalent times, the measures of social distancing, personal and respiratory hygiene are the hygiene practices mentioned in classical texts to avoid emergence of many infectious diseases.

प्रसंगाद्गात्रसंस्पर्शान्निश्वासात सहभोजनात। सहशय्यासनाच्चापि वस्त्र्माल्यानुलेपनात।। औपसर्गिकरोगाश्च संक्रामन्ति नरान्नरम।। (सु. नि.) Similarly, Acharya Charaka has mentioned many personal hygiene measures with their beneficial effects on health:

• द्वौ कालावुपस् पृशेत- Taking shower twice a day, morning and evening.
• मलायनेष्वभीक्ष्णं पादयोश्च वैमल्यादध्यात – Hand and foot hygiene
• त्रिः पक्षस्य केशश्म्श्रुलोमनखात – Hair hygiene
• नित्यमनुपहत वासाः – Clothing Hygiene
• सुमनाः सुगंधि – Use of natural product based toiletries, hygiene and perfumed products for stimulation of the brain and mind
• मूर्धश्रोत्रघ्राणपादतैल नित्य: - Oiling of the apertures of the body with head and scalp and feet to enhance the strength and to control the entry of dust, fomites deeper into the body. Hence, the physical, mental, social and moral conduct of an individual can lead to better health outcomes. Every rasayana and shodhana therapy requires a lot patient compliance and disciplining which can only be achieved by Sadvrutta.

Discussion

The modern approach to immunity and Immunology is very complex and comprise of a complex computational biology approach of proteomics, transcriptomics and bioinformatics [22]. However, Ayurveda adopts a simplistic model of Ojas (Vyadhi Kshamatav or Bala) as the homeostatic model of immunity which is based on the idea that immunity is built upon the structural and functional components we inherit genetically from the parents. In post-natal life, it is sustained and maintained by the diet, life style and psychological attributes which create a milieu (epigenetic environment) in which healthy body components and constituents are formed. A well coordinated function of these body components and constituents makes body disease resistant and resilient making recovery from a disorder easy. Bala or Ojas reflects the Swabhavoparamvada principle:

जायन्ते हेतुवैषम्याद्विषमा देह धातवः। हेतुसातम्यात समास्तेषां स्वभावोपरमः सदा।। (च.सू. 16/27) [41]

This principle also emphasize the creation of Dhatu Satmya by adopting health promotion of factors which leads to the disruption of the chain reaction of pathogenesis leading to recovery or disease mitigation. This principle is the model of Immunity and forms the premise of every therapeutic approach in Ayurvedic management of a disease. This generic approach is applied in every disease in contrast to the highly specific approach of conventional immunology which focus upon the activities of particular immune cells in different diseases and disorders and target treatment either on the suppression or proliferation of these cells without considering the effects other systems.

Sahaja, Kalaja and Yukti Kruta Bala should be enhanced. Sahaja as described above the congenital or innate immune strength which can be enhanced by Garbhadhana Vidhi, Garbhini Paricharya. Kalaja is also innate immunity which manifest temporally as the disease resistance in Visarga Kala, Yuvana awastha is superior to that of the Adana Kala or Vruddha Awastha. This disease resistance can further be enhanced by following Dincharya, Ritucharya, Ahara Vidhi Palana, Ritu Shodhana, Rasayana and Vajikarana Upyoga to counter the day to day Dosha Dhatu Mala vitiation and to replenish the day to day wear and tear caused by the Dhatu Parinama. This approach of immune strengthening is referred to as Ajatanaama vikaranama Anutpattikara Bhava. Third is clinically very important and transcend between Kalaja and Yuktikruta and it includes special diets, drugs, physical activity aimed to address particular vitiation in the body and increasing the immunity as per the samprapti of the Ojas Kshaya. Many therapeutics are based on the Yuktikruta Bala like use of Raja Yapana Basti, Mamsa Prayoga, Vaya sthapana Basti, Guda Sarpi, Agastya Rasayana, Kamsa Haritaki, Kashyapokta Rasayana Kalpa, Shilajatwadi Kalpa etc. are the examples of Yukrti Kruta Bala. The purpose of Yukti Kruta Bala is to enhance the adaptive immune response and it is usually began after the eliminative therapy and associated with a lot of life disciplining and Achara Rasayana. This represents the planned and focused approach targeting a particular pathogenetic phenomenon or Kshaya or Vruddhi state. Neutralizing the etio-pathogenetic factors with the salutogenic factors is the essence of immune-enhancement through Ayurveda, which is sequential and systematic as described above.

From our review of articles on various research portals, 15 articles can be found by key word ‘Ojas’ at Dhara platform most of the articles contends that Ojas is the vital energy and Prana shakti, immunity and disease resistance. Guduchi, Ashwagandha, Trifala and Amalaki are the most widely studied Ayurvedic herbs and herbal compounds studied extensively for their roles in immunomodulation. There is paucity of clinical and experimental studies on the immune-modulator role of commonly prescribed herbal formulation and rationale behind their use. Most of the articles which were reviewed were review articles, one clinical study on 400 children and one animal study which showed some evidence of the immune-modulation by the use of Ayurvedic herbs. Panchkarma therapies are widely used in the management of auto-immune diseases like rheumatoid arthritis, SLE, psoriasis and immune deficiency disorders but there are no studies available to review the role of Panchkarma in these clinical disorders related to the immunity. There are many review studies on the role of Rasayana therapy on the immunity disorders and attribute the effect of Rasayana therapy to anti-oxidant activity of the drugs. For establishing the role of Ayurveda as an evidence based therapeutic modality for immune-strengthening it is therefore necessary to fill the gaps and document the role of various therapeutic modalities in immune enhancement in terms of the improvement in status of Health related quality of life parameters like the signs of Dhatu Samya described above and not only the molecular demonstration of immunomodulation and anti-oxidant activity. Health related quality of life parameters are multidimensional indicators related to physical, mental, emotional and social functioning which goes beyond the direct measure of health and focuses on the quality of life consequences of health status and are determinants of the immune status. There are three measures on which HRQOL is based Global health measures, measures of well being and participation measures [42]. This highlights that immune cell assays and antigen antibody titers are just one aspect of the immune disorders and cannot substitute the total health. In present day, immunology also patient reported health related outcomes are recommended to be used for the assessment of effectiveness of therapy [43]. It is emphasized that Immunity is a long term outcome of our dietary and lifestyle activities which must be optimized by health promotion and preservation approaches of Ayurveda. The assessment of effectiveness of Ayurvedic modalities must be done on the basis of these parameters vis a vis disease free period following an Ayurvedic intervention, which is still a missing part in the whole picture.

Conclusion

To conclude, immunity or disease resistance represents an internal milieu which is an integrative product of a healthy genetic inheritance, diet, life style and ageing. Mere use of one or two Rasayana dravya without considering the above factors which also determines immunity is a reductionist approach like conventional biomedical science. Immunity and disease resistance is a continuous process which requires compliance to the healthy life style approaches of Ayurveda mentioned in Dincharya, RituCharya, Aharavidhi, Sadvruta, Garbhadhana vidhi, Rajaswala Paricharya, Prasav paricharya, Sutika Paricharya, Jatottar Karma, Shodhana, Rasayana and Vrushya prayoga, which helps in the generation of better quality components and constituents of the body inherently disease resistant. It also helps in the replenishment of the degeneration caused by day to day wear and tear. As long standing morbidities decrease the tissue resilience and capacity to heal, following the above helps in clearing the breeding ground of the pathogens and stressors which further help in the immunity to express optimally. It may be due to the same reason that Rasayana is given primacy to the disorder management in Charaka Samhita emphasizing the role of immunity enhancement treatment over the disease mitigation treatment.

Therefore, diets, foods and actions which promote this functional and structural integrity are classified as Urjaskara or Ojasya Dravya. This area of Ayurveda is a promising area for research and practice if rationally applied. Therefore, immunity is an individual health asset which dwells upon idea of maintaining health and well being, Ayurveda principles of healthy living can be used to strengthen this health asset and can make India a world leader in the management of double burden of diseases especially with this approach.