The Āyurvedic Understanding of COVID-19: Prevention and Treatment Approach by Scott Gerson, M.D., Ph.D. (Ayu)
Note: Parts of this article contains advanced Āyurvedic terms and concepts that are beyond the scope the article to fully explain. An attempt is made to at least define these terms and, despite being a potential distraction, their inclusion was deemed necessary to the subject. Also, nothing in this article should be deemed as medical advice for the treatment of any disease or condition. For this reason, specific formulations and dosages have purposely been omitted. Always consult with your physician for personal guidance regarding any treatment.
By now everyone knows that the COVID-19 pandemic began in December 2019 in Wuhan China and rapidly extended to become a global health and economic emergency. Its etiological agent (nidana) is the coronavirus SARS-CoV-2. COVID-19 presents a wide spectrum of clinical manifestations, which ranges from an asymptomatic infection to a severe pneumonia accompanied by multisystemic failure that can lead to death. The immune response to SARS-CoV-2 is known to involve all the components of the immune system that together appear responsible for viral elimination and recovery from the infection. However, these very same immune responses are implicated in the disease's progression from a mild infection to a more severe and lethal process. This wide clinical spectrum of COVID-19 is a consequence of the correspondingly variable spectrum of the immune responses to the virus. The critical point where progression of the disease (in the conventional medical paradigm) is triggered appears to center on loss of the immune regulation between controlled protective and uncontrolled destructive responses due to an over-exuberant production of various cytokines (pro-inflammatory chemicals). As logical as this sounds, as you will see the Āyurvedic paradigm understands this critical point of progression to be very different.
It has been observed that clinical presentations of patients are different--with the lower respiratory, upper respiratory, gastrointestinal, hematological, and nervous systems being variably affected in patients. Based on the clustering of these and other symptoms (lakshanas) COVID-19 infection can be interpreted based on an Āyurvedic understanding of the pathogenesis with reference to imbalance of tridoṣa. The Āyurvedic assessment of many but not all disease is based on imbalances in the tridoṣic configuration (vāta, pitta, and kapha). It appears that COVID-19 is one of the conditions that can be understood in this way.
Knowledge of specific patterns of doṣic imbalance is already furthering the Āyurvedic understanding of COVID-19 immunopathogenesis and is helping to design more effective therapeutic and prophylactic strategies.
Disease Progression as per Conventional Medical Model
Following exposure, the incubation period of the SARS-CoV-2 virus is 10-14 days. Symptoms can appear as early as 4 days in some people and the majority will develop symptoms of the illness by day 12. In rare cases (<5%) symptoms can be delayed for up to 24 days after exposure.
Observations made by Āyurvedic physicians (including myself) reveal a wide spectrum of symptom presentation. Even according to the Centers for Disease Control (CDC), the symptoms present at the onset of COVID-19 are highly variable. That being said, once the disease reaches its full-blown stage (bheda avasthā) the three cardinal symptoms are fever, dry cough, and shortness of breath.
Here are the six clusters identified by researchers at Kings College in London:
Mild-to-Moderate “Flu-like” with no fever: Headache, loss of smell, muscle pains, cough, sore throat, chest pain, no fever
Mild-to-Moderate “Flu-like” with fever: Headache, loss of smell, cough, sore throat, hoarseness, fever, loss of appetite
Mild-to-Moderate with Gastrointestinal features: Headache, loss of smell, loss of appetite, diarrhea, sore throat, chest pain, no cough
Severe, with fatigue: Headache, loss of smell, cough, fever, hoarseness, chest pain, fatigue
Severe, with confusion: Headache, loss of smell, loss of appetite, cough, fever, hoarseness, sore throat, chest pain, fatigue, confusion, muscle pain
Severe, with abdominal and respiratory pain: Headache, loss of smell, loss of appetite, cough, fever, hoarseness, sore throat, chest pain, fatigue, confusion, muscle pain, shortness of breath, diarrhea, abdominal pain.
COVID-19 as per the Āyurvedic Medical Model
To begin with some general background, in India today there are approximately 430,000 registered Āyurvedic physicians. There are approximately 2800 Ayurveda hospitals. There are about 15,000 Ayurveda dispensaries. There are approximately 7800 Āyurvedic licensed manufacturing pharmacies. All these resources are intensely focused on finding solutions to the current pandemic. [Press Information Bureau, Government of India. Available at: http://ayush.Gov.In/sites/default/files/16%20licensed_ pharmacies%202018.pdf.]
The Āyurvedic perspective of COVID-19 is very different. Being a modern disease, COVID-19 does not have an exactly matching disease described in the ancient literature. However, it can nonetheless be understood in Āyurvedic terms, albeit not perfectly.
Fever, being the most frequently occurring symptom in the syndrome of COVID-19 (91-99% of patients), allows us to consider it without question as a type of jvara (fever). Here is the mythological origin of fever as described by Caraka, Nidanasthana 1, 35:
“Jvara (fever) is the outcome of the wrath of Maheshvara. It leads to the death of all living beings. It afflicts the mind, body, and senses with misery (jvarayati=to bring misery). It destroys intelligence, strength, complexion, joy, and enthusiasm. It produces exhaustion, depletion, improper digestion, and unconsciousness. No other disease is so threatening, complicated, and difficult to cure as jvara. It is the king of all diseases.”
A very sobering description. COVID-19 is a type of jvara (fever). It is usually only a moderately high fever. It is equally clear that this disease fits several other sub-categories. It meets the requirements for being both janapadodhvaṃsa (epidemic; affecting large numbers of human settlements) and āgantuja (caused by an exogenous agent). So far so good. COVID-19 also fits neatly into three other sub-categories of agantuja diseases known as bhutābhiṣaṅgajvara (fever caused by invasion of pathogens), visakrimijanya (caused by a virulent pathogen) and saṅkrāmika (contagious). There is no debate.
The imprecision and messiness start when it comes to considering which of the three doṣas are vitiated (deranged) in COVID-19 because it is observed to vary. Being an agantuja disease, it is initially caused by exposure to an exogenous pathogen (SARS-CoV-2 virus). When an etiological factor comes into contact with the body, a disease process tries to initiate. Simultaneously, the body tries to resist disease. The capacity of the body or mind to prevent the development of a disease or cure itself from an already established disease is called Vyadhikshamatva, (literally, “resistance to disease;” immunity). With exposure to the SARS-CoV-2 virus, most infected individuals (>80%) will either remain asymptomatic or develop a mild form of the disease. The disease progresses clinically to more severe forms only when the doṣic imbalance is initiated. Based on observed signs and symptoms that individuals develop, it is clear that there is a significant variation in doṣic imbalance in different people.
Over the course of human history, its been observed that some individuals do not develop disease even after being exposed to the relevant etiological factors, while others do in fact become afflicted. The reason is that in those individuals, there is a sufficiently strong resistive capacity. The simile used to illustrate this principle is that when a seed is sown in unfertile soil, it cannot grow and is ultimately destroyed. Vyadhikshamatva (immunity) depends upon the maintenance of the equilibrium of the three doṣas and the quality and function of the tissues and srotamsi (channels of the mind and body).
In the case of COVID-19, most individuals manifest a dominance of vāta and kapha vitiation with a lesser but ubiquitous degree of pitta disruption. The good news is that at the stage where COVID-19 becomes anubandya (i.e. symptoms correspond to doṣic imbalances), it can be effectively managed by classical doṣic-specific interventions. For example, if there is a dry cough (kasa), a dominance of vāta can be inferred and the appropriate vātāhara vāta-pacifying measures implemented..
The pathogenesis of kasa in COVID-19 is also due to paraspara avarana (mutual partial obstruction) between prana vāta and udana vāta—two of the five subdoṣas (doṣa prakara) of vāta, which regulate inhalation and exhalation, respectively. Avarana, although lucidly explained in the ancient texts, is one of the least understood concepts in modern Ayurveda. Avarana means obstruction, which can be total or partial, and it is one of the important root mechanisms of disease—particularly those involving vāta doṣa. In all avaranas, there are two components: the avrutta (which gets obstructed) and the avraka (which is doing the obstructing). Often the symptoms manifested are observed by disturbed function of both the obstructing factor as well as the obstructed but the more severe symptoms are usually those relating to the avraka factor. Obstructions can be caused by doṣas, subdoṣas (doṣa prakara), ama, or mala. The most severe type of avarna is a paraspara avarana involving two vāta subdoṣas—which is the case with COVID-19. Here are the classic symptoms of these mutual obstructions of vāta subdoṣas:
Udanavraka prāna vāta (udana blocking prāna): Loss of the will, memory, effort, ojas (immunity), strength and complexion. Labored breathing, especially exhalation, diminished voice. There may be even the death of the patient.
Prānavraka udana vāta (prāna blocking udana): Loss of positive spirit, inspiration (in both senses of the word), diminished senses (i.e. smell and taste), dyspnea, stiffness of the head, rhinitis, heart diseases & dryness of the mouth, in severe degree--death.
Vāta avarana (obstruction) is different than vāta dosa-yukta, or association with another doṣa without obstruction. COVID-19 also has this feature as a vāta-kapha yukta. If the normally dry “covid cough” is associated with phlegm and fatigue, a strong component of kapha is present (associated). The degree of involvement of these two doṣas is reflected in the consistency and appearance of the phlegm - whether it is clear and thick or yellowish and thin, with the former indicating a predominance of kapha and the latter, vāta. If there is high grade fever covid fever is generally low-to-moderate), then a state of vāta-pitta-kapha yukta, also known as sannipata vyadi (disease involving all three doṣas) can be inferred.
But to complicate matters, the relative degree of doṣic manifestation (doṣavikalpa) varies not only at initial presentation, but also throughout the clinical course of the disease. This is especially true for the pitta doṣa component. In addition, the course of the disease, with respect to doṣic imbalance, is definitely affected by the presence of co-morbidities which is also a known risk factor for earlier and more severe complications (upadravas).
What all this means is that the best approximation of the doṣic effects of COVID-19 is to say that it is vātakaphapradhāna pittānubandha—meaning a disease with mainly (pradhāna) dominance of vāta and kapha doṣa with association (anubandha) of varying degrees of pitta doṣa. The Āyurvedic classification of COVID-19 is summarized in Table 1.
Table 1. Āyurvedic clinical assessment of COVID-19
Type of Disease
Impact of Disease
Disease Nomenclature
Saṅkrāmika (Contagious, Communicable)
Janapadodhvaṃsa (Epidemic; affects large number of human settlements)
Jvara (Fever)
Early: Āgantu jvara (Fever of exogenous origin)
Late: Anubandya vyadhi (disease caused by doṣic imbalances which manifest predictable symptoms and signs, and which are pacified by specific doṣic treatments in the stage of mild disease)
Bhutābhiṣaṅgajvara (Fever caused by invasion of pathogens)
Specific Etiology
Doṣavaiṣamya (Nature of doṣa imbalance)
Viṣakṛmijanya (Caused by virulent pathogen)
Sannipāta Vyadhi (Derangement of all three doṣas)
Doṣavikalpa (Specificity of doṣa imbalance)
Vātakaphapradhāna Pittānubandha (Dominance of Vāta and Kapha with association of Pitta)
Dūṣya (Body elements affected)
Rasa (In early stage), Rakta (In late stage)
Srotas (Affected body channels)
Prāṇavaha (Cough and Dyspnea), Udakavaha, Annavaha, Rasavaha (Fever), Raktavaha (complications. i.e. coagulapathies)
Avarana (Obstruction)
Rogamārga (Disease Pathways)
In early stage: udana avraka prāna (udana vāta obstructing prāna vāta)
In late stage: prāna-udana paraspara avarana (reciprocal obstruction)
In early stage: Abhyantara; Inner pathway; curable
In late stage: Madhyama; Middle pathway; difficult to cure/incurable
Upadrava (Complications)
Vyadhisvabhava (Nature of Disease)
Śvāskṛcchratā (Shortness of breath; ARDS), Hypoxia, Marmopaghāta (Damage to vital organs), Coagulapathy, Multi-organ system failure
Āśukārī (Acute); Ojokṣaya (diminished ojas; diminished immunity)
Sukhasādhyatā (Favourable Prognosis)
Kṛcchrasādhyatā (Difficulty to manage)
Alpaliṅgatva (Mild Symptoms), Dvirogamārgatva (Affects only inner disease pathway), Balam (Immunity), Yauvanam (Younger age)
Madhyaliṅgatva (Moderate Symptoms), Śvāsakṛcchratā (Shortness of breath), Bahyagatatva (Involvement of external disease pathway)
Asādhyatā (Bad Prognosis)
Vibaddhadoṣatva (Doṣas in mutual opposition), Pūrṇalingatva (Full range of symptoms), Agnināśa (Digestive and metabolic crisis), Vārdhakya (Old age), Rogasaṅkara (Co-morbidities), Marmagatatva (Harm of vital organs)
Āyurvedic Prevention and Treatment Approaches for COVID-19
With respect to COVID-19 status and treatment, people can be separated into four clear categories as shown below.
1. Unexposed-Asymptomatic
This includes people who currently do not have any SARS-Cov-2 related symptoms. These ostensibly healthy people may be the most suitable for strengthening innate immunity and general health so that infection-related pathogenesis can be avoided or greatly minimized. Preventive interventions here can include both pharmacological as well as non-pharmacological strategies.
Among the non-pharmacological interventions, carefully individualized Panchakarma treatments followed by an appropriate diet (containing abundant plant-derived flavonoids) and rasayanas (strengthening and tissue nourishing herbal medicines) is the preeminent strategy. Other preventive interventions should include healthy lifestyles, adequate physical activity, sufficient sleep, sadvritta, and avoidance of infected persons. With respect to this last measure, building immunity requires time. There may be some apparently healthy asymptomatic carriers who could transmit the virus to other people. Hence, physical and social distancing for all would be essential to avoid transmission.
The aushadis (specific medicines) and rasayanas (general medicines/immune tonics) which are appropriate for this population include: Amalaki (Emblica officinalis), Shilajit, Guggulu preparations (Commiphora mukul), Tulsi, Ashwagandha (Withania somnifera), Chyavanprash, Brahma Rasayana, Kantkaryavaleha, Vasa ghrita, Amrit Bhallataka, Vidaryadi Ghritam, I will mention here one particular traditional Āyurvedic preparation is currently being used in an “off-label” manner. It is an herbomineral gold-containing preparation known as swarna (gold) prashana which is traditionally given to young children with honey, ghee, and several other herbal extracts for one month to promote growth and memory enhancement. It was first mentioned in the Kashyapa Samhita (c. 500BCE), a text dealing primarily with pediatrics. Swarna prashama is being used in parts of India as a prophylactic medicine for COVID-19.
2. Exposed-Asymptomatic (quarantined)
This group comprises of people without symptoms, but at risk due to a positive Covid antibody test or contact history. They need to be quarantined conscientiously. Specific prophylaxis for this group should not include Panchakarma but may include Sanjeevani vati, Chitrakadi vati and combinations of Guduchi (Tinospora cordifolia), Shunthi (Zingiber officinale) and Haridra (Curcuma longa). This choice of medicines is aimed at maintenance of agni as well as āma pachana (“cooking” and removal of āma) in order to prevent avarana (obstruction) and the progression of the disease past its initial sanchaya-prakopa-prasara stage.
Sanjivani vati deserves special mention. It is a compound herbal medicine widely used against communicable diseases, fever due to infection and sannipataja jvara, common cold, cough, and indigestion. Used properly, it possibly strengthens and rejuvenates the immune system. However, it contains vatsanabha (Aconitum ferox root) and bhallataka (Semecarpus anacardium fruit)—both potentially toxic materials. The former contains aconitine—a sodium channel agonist which can cause diarrhea, muscle weakness and cardiac arrhythmia if used improperly. Aconitine can interact with voltage-dependent Na+ channels and suppress the conformational change of Na+ channels from the active state to the inactive state so that the membrane remains depolarized. Therefore, it needs to be taken under close medical supervision.
Other Āyurvedic herbs which are useful for this population include Zingiber officinale, Ocimum
Sanctum, Glycyrrhiza glabra, Adhatoda vasica, Andrographis paniculata, Swertia chirata, Moringa oleifera, Terminalia chebula, and Trikatu. These herbs are recommended due to their broad-spectrum antiviral activity and in two cases protease inhibitor activity (Ocimum sanctum and Terminalia chebula). The diet should be the same as for unexposed, asymptomatic individuals. Full elucidation of the principles of Āyurvedic dietary recommendations is beyond the scope of this article but as mentioned above, flavonoids (specifically myrietin and quercitin among others) and polyphenol-containing foods in general should be included (strawberries, blueberries, grapes, cranberries, spinach, most nuts, mango, black tea, green tea, nettles, purslane, fenugreek seeds, honey, swiss chard, and garlic are a few good sources)
3. Mild COVID-19 Symptoms
These are people who have tested positive for SARS-CoV-2 and who are having mild symptoms. These patients must be strictly isolated and monitored for any progression of the disease, while at the same time receiving adequate therapy to curtail the symptoms and balance the vitiated doshas which are the root causes of disease progression.
Formulations like Lakshmi Vilas Rasa (used if Kapha doṣa is prominent), Kumar Kalyan Ras, Suvarna vasant malti ras, Pippali rasayana, Sanjeevani vati, Abhrak bhasma (mica), Gojihvaadi Kashaya (main ingredient-Onosma brachteatum), Vyaghri Haritaki aveleha (jam--good for children too), Kantakari Avaleha, Sudarshan churna (good for children), Dashmoola kwath, Sitopaladi churna, Talishadi churna (main ingredient-Himalayan fir leaf), and Yastimadhu may be the most suitable drugs to be used at this stage. Several of these medicines are rasāushadhis (metal and mineral containing medicines) which are more potent and faster acting. However they are only to be taken without exception under strict medical supervision.
Patients whose condition deteriorate (increased hypoxia, difficulty breathing, weakness) may require immediate hospitalization or admission to an ICU.
The key criterion for choosing rasāushadhis in category 3 as noted above is the urgency for initiation of therapeutic actions. Rasāushadis are shown to have greater bioavailability and absorption through sublingual and oral route due to the nano size of their particles. Regarding both herbal and herbomineral formulations, the wide range and permutations of natural substances contained in them, although summarily dismissed in conventional medicine circles, constitutes a nearly inexhaustible source of medicines for preventing and treating disease. Everyday more information is arising through the multidisciplinary approach of ethnobotany and omics science (genomics, proteomics, metabolomics).
4. Moderate to Severe Covid-19 Symptoms
There is no Āyurvedic treatment recommended for individuals who fall into this group. Instead, these patients should be hospitalized at a facility providing secondary and tertiary care.
The pathogenesis of highly pathogenic human coronavirus is still not completely understood. Both an excessive inflammatory response due to “cytokine storm” and viral evasion of cellular immune responses play important roles in disease severity. About 80% of documented COVID-19 cases worldwide are either asymptomatic or present with mild symptoms requiring only primary medical care. Of the other 20% of cases 15% require urgent medical attention and supplemental oxygen at secondary health care services hospitalization under the care of specialists (e.g. pulmonologist, infectious disease physician, cardiologist, etc). The remaining 5% are critical cases requiring ventilation at a tertiary care hospital equipped with an ICU.
In those 5% of cases requiring intensive care, the disease progression is quite variable and can progress from symptoms of lower or upper respiratory tract infection to Acute Respiratory Distress Syndrome (ARDS) in 2 to 10 days. ARDS often is followed by un-correctable hypotensive shock, multi-organ failure and in too many cases death.
For this reason, it is unacceptable and dangerous to treat any COVID-19 patient past the stage of mild symptoms (Stage 3) with Āyurvedic intervention. Once a person progresses to the stage of moderate symptoms (Stage 4), hospitalization is urgently required where supplemental oxygen and, if necessary, PEEP or mechanical ventilation are available. Often a person’s severe degree of hypoxia does not correlate with the patient’s relatively mild symptomatic distress.
Let us not forget also that there are co-morbidities and risk factors that make people more susceptible. People of advanced age, those with diabetes, hypertension and cardiovascular disease, males, anorexia and those who present without fever are more susceptible. Reduced peripheral capillary oxygen saturation below 92% is also a risk indicator in what appear to be apparently mild cases.
Conclusion
Āyurveda has a holistic and systemic understanding of the pathological evolution of COVID-19 which prominently includes its root cause as a doṣic imbalance. Based on its understanding of COVID-19 as a vātakaphapradhāna pittānubandha disease, it offers a pragmatic strategy for preventing, or at least mitigating, the disease and improving patients’ recovery from its milder stages. In that regard, Ayurveda recognizes the importance of preemptive biopurification via Panchakarma for unexposed asymptomatic individuals, regulating intestinal function and maintaining energetic (doṣic) balance. In addition, the judicious use of special herbal and herbomineral medicines and formulations which contain arrays of bioactive compounds contribute to prevention and recovery from the various manifestations of SARS-CoV-2 infection.
Table 2. Proposed Ayurveda interventions for COVID-19 by Stage
Stage
Exposure/Symptom Level
Proposed Intervention
I
Unexposed
Asymptomatic
Common health-promoting approaches of Ayurveda: adequate sleep, healthy diet, drinking water from a copper vessel (tamra jalapana), daily nasal irrigation (nasya), physical activity, good conduct (sadvritta), observing suppressible and non-suppressible urges, and avoidance of disease- causing factors (carelessness in daily living, contact with infected persons, mental stress, excessive cold and exposure to pollutants)
Panchakarma:
Full program (purva-, pradhana- and paschat-karma) adjusted to individual prakriti (constitution) and ritu (season) and including: sarve abhyanga (full-body oil massage), snehana (internal oleation), virechana (laxative procedure), specialized nasya herbalized nasal oils), dhoomapana (medicated smoke), gandusha (oil pulling), kevala (herbal gargle), vamana (physician-supervised vomiting), shirodhara, shirobasti, anuvasana and niruha basti (oil- and decoction-based enemata), lepa (herbalized body paste), others.
Aushadi/Rasayanas (Medicines/Immune Tonics):
Amalaki (Emblica officinalis), Shilajit, Guggulu preparations (Commiphora mukul), Ashwagandha (Withania somnifera), Chyavanprash, Brahma Rasayana, Kantkaryavaleha, Vasa ghrita, Amrit Bhallataka, Vidaryadi Ghritam, Sanjeevani vati, Swarna prashana.
II
Exposed
Asymptomatic
(Quarantined)
Same health-promoting approaches as for Stage I.
Panchakarma: Not Applicable
Aushadi/Rasayanas (Medicines/Immune Tonics):
Sanjeevani vati, Chitrakatdi vati, Chyavanprasha, Brahma Rasayana, and decoction of a combination of herbs, Guduchi (Tinospora cordifolia), Ashwagandha (Withania somnifera),Ginger (Zingiber officinale),Turmeric (Curcuma longa), Tulsi (Ocimum sanctum),Licorice (Glycyrrhiza glabra),Vasaka (Adhatoda vasica),Kalamegh (Andrographis paniculate),(Kiratatikta (Swertia chirata), Shigru (Moringa oleifera),Triphala and Trikatu.
III
Mild COVID-19 Symptoms (dry cough, smell and taste disturbance, fatigue, fever >100.4°F, shortness of breath, muscle aches, headache, sore throat), oxygen sat >92%.
Same health-promoting approaches as for Stage I & II
Panchakarma: Not Applicable
Aushadi/Rasayanas (Medicines/Immune Tonics):
Pippali rasayan, Go Jihvadi Quath, Kantakari, Avaleha, Chitrakadi vati, Vyaghri haritaki, Dashamul kwath, Sitopaladi, Talishadi, Yashtimadhu Pippali rasayan, Laghu Vasant Malati, Sanjeevani vati, Tribhuvan Keerti rasa, Brihata Vata Chintamni rasa, Mrityunjaya rasa, Makardhvaja
IV
Moderate to Severe
COVID-19 Symptoms
Hospitalization in a tertiary-care facility required. ICU may be required at any time.
Panchakarma: Not Applicable
Aushadi/Rasayanas (Medicines/Immune Tonics): Not Applicable
Āyurvedic interventions are to be implemented in addition to conventional advisories by government authorities including universal mask usage, frequent handwashing with soap and water and/or alcohol-based sanitizer for 20 s, and physical distancing.
Personalized formulations and dosage are to be prescribed by an experienced Āyurvedic physician with comprehensive knowledge of Āyurvedic principles and extensive experience in treating vulnerable patient populations--children, immunocompromised, pregnant, and the elderly.