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Tradi&onalMedicine

ShamsuzzohaB.Syed,MDMPHDPH(Cantab)StephenA.Haering,MDMPH

JohnsHopkinsBloombergSchoolofPublicHealthDecember2007

Preparedaspartofaneduca&onalprojectoftheGlobalHealthEduca&onConsor&um

andcollabora&ngpartners

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Learningobjec&ves

1.  Ar&culatedefini&onsoftradi&onalmedicine(TM)2.  EnumeratethelevelofglobaluseofTM3.  DiscussreasonsforthepopularityofTM4.  Ar&culateaclassifica&onofTM5.  Discusssafety,efficacy,andqualityissues6.  Discusspolicy&regulatoryframeworkissues7.  DiscusssomecasestudiesontheuseofTM8.  Discusspossiblefuturedevelopments

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Moduleoutline

•  Defini&ons•  LevelofglobalTMusage•  ReasonsforTMpopularity•  Classifica&onofTM•  Safety,Efficacy,andQuality

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Moduleoutline(con&nued)

•  Ra&onalUseofTM•  Policyandregulatoryframeworks•  CasestudyontheuseofTMinruralBangladesh– Tradi&onalhealersandseverementalillness– Genera&ngevidenceoninformalcare

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Defini&ons:Whatistradi&onalmedicine?

TheWorldHealthOrganiza&onstates:“Tradi&onalmedicinereferstohealthprac&ces,approaches,knowledgeandbeliefsincorpora&ngplant,animalandmineralbasedmedicines,spiritualtherapies,manualtechniquesandexercises,appliedsingularlyorincombina&ontotreat,diagnoseandpreventillnessesormaintainwell‐being.”

See Notes

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Defini&ons:Tencoreterms

1.  Tradi&onalmedicine(TM)2.  Complementary/

alterna&vemedicine(CAM)

3.  Herbalmedicines4.  Herbs5.  Herbalmaterials

6.  Herbalprepara&ons7.  Finishedherbal

products8.  Tradi&onaluseofherbal

medicines9.  Therapeu&cac&vity10. Ac&veingredient

See Notes

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LevelofglobalTMusage

•  GlobalTMusageiswidespreadandgrowing•  Highusageinvariouspartsofthedevelopingworld:

–  InAfricaupto80%useTM–  InChina,40%ofdeliveredhealthcareisTM–  InIndia,65%ofthepopula&oninruralareasusetradi&onalmedicinetohelpmeettheirprimaryhealthcareneeds

–  InmanyotherAsiancountriesTMwidelyused•  60‐70%ofallopathicdoctorsinJapanprescribeTM

–  La&nAmericaalsoreportshighlevelsofTMusage•  71%inChile;40%inColumbia

Use of TM is high in many countries in the developing world. Data presented in slides from: 1.  WHO Traditional Medicine Strategy 2002-2005. Geneva. 2002. Publication number WHO/EDM/TRM/

2002.1. Available at: http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf 2. WHO Report by the Secretariat on Traditional Medicine. Executive Board 111th Session. December 2002. Publication number EB111/9. Available at: http://www.who.int/gb/ebwha/pdf_files/EB111/eeb1119.pdf

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Figure source: WHO Traditional Medicine Strategy 2002-2005. Geneva. 2002.

Publication number WHO/EDM/TRM/2002.1. Available at: http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf

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•  Usageinthedevelopedworldisalsohighandincreasing•  Percentagesofpopula&onswhohaveusedCAMatleastonce:

–  Australia46%;Canada70%;USA48%;Belgium31%;andFrance49%•  IntheUK40%ofallGPsoffersomeformofCAMreferraloraccess•  IntheUSAonestudyconcludedthatuseofatleast1of16alterna&ve

therapiesduringthepreviousyearwas42%in1997–visitstoCAMprovidersnowexceedsbyfarthenumberofvisitstoallprimarycarephysiciansintheUS

•  AjointNIH/CDCstudyof2004provideddetailedinforma&ononCAMusageintheUSA

See Notes

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Figure source: WHO Traditional Medicine Strategy 2002-2005. Geneva. 2002.

Publication number WHO/EDM/TRM/2002.1. Available at: http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf

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ReasonsforTMpopularity:Developingcountries

•  Availability.•  Accessissues.•  Affordability.•  ConfidenceintheabilityofTMtomanagedebilita&ng/incurablediseases.

•  Familiaritywithprac&&oners.•  Integra&onwithcommunitybeliefsystems.

•  Availability data in Africa – in Tanzania, Uganda and Zambia, researchers have found a ratio of TM practitioners to population of 1:200-1:400 (this contrast with the availability of allopathic practitioners, where the ratio is typically 1:20,000 or less.

•  USAID data indicates that traditional practitioners outnumber allopathic practitioners by 100 to 1. •  Allopathic practitioners in Africa are often located primarily in cities or other urban areas. •  TM is often the only affordable source of health care – especially for the poorest patients. Traditional

practitioners can often be paid in kind and/or according to the wealth of the client. •  Often, the principals of TM are embedded within the community and traditional practitioners are well

known and respected in their communities

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ReasonsforTMpopularity:Developedcountries

•  Concernregardingadverseeffectsofchemicals•  Ques&oningtheassump&onsofallopathicmedicine•  Increasedaccesstohealthinforma&on•  Changingvaluesandreducedtoleranceofpaternalism•  Chronicdiseasesrequireholis&capproach•  PerceivedlowrisksofTM•  Consumersa&sfac&onwiththelevelofinter‐personalcareprovided

The fact that CAM usage is high and increasing in developing countries indicates that cost and tradition are not the only reasons for the use of traditional medicine. Many inter-related factors are contributing to the high levels of CAM use – some of these factors are mentioned in the slide.

Health systems in many developing countries are struggling to maintain continuity of care for the populations they serve – this fragmentation of care is occurring at the same time as high levels of chronic diseases that necessitate such continuity. CAM has been reported to provide a high level of quality in terms of inter-personal care. This can be postulated as one of the reasons for the popularity of CAM.

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Classifica&onofTM/CAM

Any attempt to classify traditional medicine is hazardous, as the field is continuously emerging and many traditional practitioners resist formalized classification. A good starting point is provided by the WHO, as outlined in the table in the slide. One should note, however, the absence of multiple traditional healing practices in Africa and South America. Each slide that follows will provide some brief information on the therapies mentioned in the WHO table. Table source: WHO Traditional Medicine Strategy 2002-2005. Geneva. 2002. Publication number WHO/EDM/TRM/2002.1. Available at: http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf

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Classifica&onofTM/CAM:ChineseMedicine

“Tradi&onalChinesemedicine(TCM)isanancientmedicalsystemthattakesadeepunderstandingofthelawsandpanernsofnatureandappliesthemtothehumanbody.TCMisnot"NewAge,"norisitapatchworkofdifferenthealingmodali&es.TCMisacompletemedicalsystemthathasbeenprac&cedformorethanfivethousandyears.”(Tradi&onalChineseMedicine–WorldFounda&on)

See Notes

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Classifica&onofTM/CAM:Ayurveda

“LifeinAyurvedaisconceivedastheunionofbody,senses,mindandsoul.Thelivingmanisaconglomera&onofthreehumours(Vata,Pi(a&Kapha),sevenbasic&ssues(Rasa,Rakta,Mansa,Meda,Asthi,Majja&Shukra)andthewasteproductsofthebodysuchasfaeces,urineandsweat.Thusthetotalbodymatrixcomprisesofthehumours,the&ssuesandthewasteproductsofthebody.Thegrowthanddecayofthisbodymatrixanditscons&tuentsrevolvearoundfoodwhichgetsprocessedintohumours,&ssuesandwastes.Inges&on,diges&on,absorp&on,assimila&onandmetabolismoffoodhaveaninterplayinhealthanddiseasewhicharesignificantlyaffectedbypsychologicalmechanismsaswellasbybio‐fire(Agni).”(Source–AYUSH,MinistryofHealth&FamilyWelfare,India)

See Notes

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Classifica&onofTM/CAMUnani

•  OriginatedinGreece,basedonteachingsofHippocratesandGalen.•  DevelopedintoanelaborateMedicalSystembytheArabs(Rhazes,Avicenna,Al‐

Zahravi,Ibne‐Nafisandothers).•  Unanitreatmentisbasedonnaturaldiagnosismethods.•  Mainlydependentonthetemperament(Mizaj)ofthepa&ent,hereditarycondi&onand

effects,differentcomplaints,signsandsymptomsofthebody,externalobserva&on,examina&onofthepulse(Nubz),urineandstooletc.

•  UniqueandspecialtreatmentmethodslikeDietotherapy(Ilaj‐bil‐Ghiza),Clima&ctherapy(Ilaj‐bil‐Hawa),Regimentaltherapy(Ilaj‐bit‐Tadbir),makeitaremarkableandpopularsystem.(Source–AYUSH)

The Department of Ayerveda, Yoga & Naturoptahy, Unani, Siddha and Homeopathy (AYUSH) of the Ministry of Health and Family Welfare of India has a section on Unani at: http://indianmedicine.nic.in/unani.asp

The American Institute of Unani Medicine provides a wide range of further information on Unani at http://www.unani.com

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Classifica&onofTM/CAM:Naturopathy

“Naturopathyisasystemofhealingsciences&mula&ngthebody’sinherentpowertoregainhealthwiththehelpoffivegreatelementsofnature–Earth,Water,Air,FireandEther.Naturopathyisacallto"ReturntoNature"andtoresorttosimplewayoflivinginharmonywiththeself,societyandenvironment.Naturopathyprovidesnotonlyasimpleprac&calapproachtothemanagementofdiseases,butafirmtheore&calbasiswhichisapplicabletoalltheholis&cmedicalcareandbygivinganen&ontothefounda&onsofhealth.”

(Source‐AYUSH)

The Department of Ayurveda, Yoga & Naturoptahy, Unani, Siddha and Homeopathy (AYUSH) of the Ministry of Health and Family Welfare of India has a section on Naturopathy at: http://indianmedicine.nic.in/naturopathy.asp

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Classifica&onofTM/CAM:Osteopathy

“Developed130yearsagobyphysicianA.T.S&ll,osteopathicmedicineisoneofthefastestgrowinghealthcareprofessionsintheU.S.andbringsauniquephilosophytotradi&onalmedicine.Withastrongemphasisontheinter‐rela&onshipofthebody'snerves,muscles,bonesandorgans,doctorsofosteopathicmedicine,orD.O.s,applythephilosophyoftrea&ngthewholepersontothepreven&on,diagnosisandtreatmentofillness,diseaseandinjury.”

(AmericanOsteopathicAssocia&on)

The American Osteopathic Association website provides a wealth of information: http://www.osteopathic.org/index.cfm

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Classifica&onofTM/CAM:Homeopathy

•  Homeopathyseekstos&mulatethebody'sdefensemechanismsandprocessessoastopreventortreatillness.

•  Treatmentinvolvesgivingverysmalldosesofsubstancescalledremediesthat,accordingtohomeopathy,wouldproducethesameorsimilarsymptomsofillnessinhealthypeopleiftheyweregiveninlargerdoses.

•  Treatmentinhomeopathyisindividualized(tailoredtoeachperson).Homeopathicprac&&onersselectremediesaccordingtoatotalpictureofthepa&ent,includingnotonlysymptomsbutlifestyle,emo&onalandmentalstates,andotherfactors.(Source–Na&onalCenterforComplementaryandAlterna&veMedicine,Na&onalIns&tutesofHealth,UnitedStates).

See Notes

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Classifica&onofTM/CAM:Chiroprac&c

•  Focusesondisordersofthemusculoskeletalsystemandthenervoussystem,andeffectsofthesedisordersongeneralhealth.

•  Chiroprac&ccareisusedmostotentotreatneuromusculoskeletalcomplaints,includingbutnotlimitedtobackpain,neckpain,paininthejointsofthearmsorlegs,andheadaches.

•  Chiropractorsorchiroprac&cphysicians–prac&ceadrug‐free,hands‐onapproachtohealthcare.

•  Chiropractorshavebroaddiagnos&cskillsandarealsotrainedtorecommendtherapeu&candrehabilita&veexercises,aswellastoprovidenutri&onal,dietaryandlifestylecounselling.(Source–AmericanChiroprac&cAssocia&on)

The American Chiropractic Association provides a large amount of information at: http://www.amerchiro.org/index.cfm

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Classifica&onofTM/CAM:Therapeu&ctechniques

•  Manytherapiesandtherapeu&ctechniquesarecommontomorethanoneTMsystem.

•  Theseinclude:– Herbalmedicines– Acupunctureandacupressure– Manualtherapies–  Spiritualtherapies–  Exercises

Source: WHO Traditional Medicine Strategy 2002-2005. Geneva. 2002. Publication number WHO/EDM/TRM/2002.1. Available at: http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf

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Classifica&onofTM/CAMAnalterna&veNIHclassifica&on

•  Fourdomains:1.  Mind‐BodyMedicine2.  BiologicallyBasedPrac&ces3.  Manipula&veandBody‐BasedPrac&ces4.  EnergyMedicine

•  Biofieldtherapies•  Bioelectromagne&c‐basedtherapies

•  Wholemedicalsystems,cutacrossallfourdomains.

See Notes

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Keyissues:Safety‐efficacyandquality

TheWHOar&culates6challengesinconsideringtheseissues:1.  Lackofresearchmethodology2.  Inadequateevidence‐baseforTM/CAMtherapiesandproducts3.  Lackofinterna&onalandna&onalstandardsforensuringsafety,efficacy,

andqualitycontrol4.  Lackofadequateregula&onandregistra&onofherbalmedicines5.  Lackofregistra&onofTM/CAMproviders6.  Inadequatesupportforresearch

Source: WHO Traditional Medicine Strategy 2002-2005. Geneva. 2002. Publication number WHO/EDM/TRM/2002.1. Available at: http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf A discussion of these issues is found on page 21 of the report.

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•  Scien&ficevidencefromrandomizedclinicaltrialsisstrongformanyusesofacupuncture,someherbalmedicinesandsomemanualtherapies.

•  Furtherresearchisneededtoascertainefficacyandsafetyofseveralotherprac&cesandmedicinalplants.

•  Unregulatedorinappropriateuseoftradi&onalmedicinesandprac&cescanhavenega&veordangerouseffects.

•  Forinstance,theherb“MaHuang”(Ephedra)istradi&onallyusedinChinatotreatrespiratoryconges&on.IntheUnitedStates,theherbwasmarketedasadietaryaid,whoseoverdosageledtoatleastadozendeaths,heartanacksandstrokes.(Source–WHO)

Source: WHO Traditional Medicine fact sheet available at http://www.who.int/mediacentre/factsheets/fs134/en

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Keyissues:Safety‐efficacyandquality•  TheevidencebaseforTMisexpanding

•  NowabletosearchPubMedwithafocusonTM:

–  Asearchon“safety”retrieves7,034ar&cles–  Asearchon“efficacy”retrieves19,884ar&cles–  Asearchon“quality”retrieves15,572ar&cles(NumbersasofDecember2007)

•  However,thereiss&llanurgentneedtoexpandthispoolofglobalknowledge

•  Researchmethodologiesalsoneedtoadapttotheuniqueanributesof

tradi&onalmedicineNCCAM and the National Library of Medicine (NLM) have partnered to create CAM on PubMed, a subset of NLM's PubMed. This is available at http://nccam.nih.gov/camonpubmed

The Cochrane Complementary Medicine Field was established in 1996 to produce, maintain and disseminate systematic reviews on TM/CAM topics.

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Keyissues:Safety‐efficacyandquality•  TheWHOhasiden&fiedglobal&na&onalkeyneedsinensuringthe

safety,efficacyandqualityofTM/CAM

•  Atthegloballevel,thereare3keyneeds:

1.  Accesstoexis&ngknowledgeofTM/CAMthroughexchangeofaccurateinforma&onandnetworking

2.  SharedresultsofresearchintouseofTM/CAMfortrea&ngcommondiseasesandhealthcondi&ons

3.  Evidence‐baseonsafety,efficacyandqualityofTM/CAMproductsandtherapies

Source: WHO Traditional Medicine Strategy 2002-2005. Geneva. 2002. Publication number WHO/EDM/TRM/2002.1. Available at:

http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf

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•  Atthena&onallevelthereare5keyneeds:1.  Regula&on&registra&onofherbalmedicines2.  Safetymonitoringforherbalmedicines&otherTM/CAM3.  SupportforclinicalresearchintouseofTM/CAMfortrea&ng

country’scommonhealthproblems4.  Na&onalstandard,technicalguidelinesandmethodology,for

evalua&ngsafety,efficacyandquality5.  Na&onalpharmacopoeiaandmonographsofmedicinal

plants


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Ra&onaleuseofTM

TheWHOadvocatesthera&onaleuseofTM.Fivekeyneedsatthena&onallevelarehighlighted:1.  TrainingguidelinesformostcommonlyusedTM/CAMtherapies2.  Strengthened&increasedorganiza&onofTM/CAMproviders3.  Strengthenedcoopera&onbetweenTM/CAMmedicine&allopathic

medicineprac&&oners4.  Reliableinforma&onforconsumersonproperuseofTM/CAMtherapies

andproducts

5.  Improvedcommunica&onbetweenallopathicmedicineprac&&oners&theirpa&entsconcerninguseofTM/CAM


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Ra&onaleuseofTM

Importantprogressinaddressingneedsiden&fiedonslide28include:

•  TMtrainingishighlydevelopedindevelopingcountriese.g.Africancountries,ChinaandIndia

•  Anemptsarebeingmadetodefinethetrainingneedsforhealthprac&&onersindevelopedcountries

•  TM/CAMprovidersarebecomingincreasinglyorganizedthroughouttheworld–theinternetisrevolu&onizingorganiza&onalcapacityacrossborders

•  Coopera&onbetweenTMandallopathicprac&&onersisslowlyincreasing

•  Informa&ononTMisincreasinglyavailable

See Notes

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Ra&onaleuseofTMWHOMonographsonselectedmedicinalplantsisanexampleofhowscien&ficinforma&onispercola&ngtheprac&ceofTM.TheMonographsinclude:–  Botanicalfeaturesofthemedicinalplants–  Theplantsmajorchemicalcons&tuents–  Instruc&onsonqualitycontrolofplantderivedherbs–  Pharmacology–  Posology–  Contraindica&ons

–  Adversereac&ons

The monographs are mentioned on page 33 of the WHO Traditional Medicine Strategy 2002-2005. Geneva. 2002. Publication number WHO/EDM/TRM/2002.1. Available at: http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf The monographs are a “key reference for national health authorities, scientists and pharmaceutical companies and are also used by lay persons to guide them in rational use of herbal medicines.” Posology = study of the dosages of medicines and drugs.

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Policy&regulatoryframeworks

TheWHOar&culates5challengesinthisarea:1.  Lackofofficialrecogni&onofTM/CAMandTM/CAMproviders

2.  TM/CAMnotintegratedintona&onalhealthcaresystems

3.  Lackofregulatoryandlegalmechanisms4.  Equitabledistribu&onofbenefitsofindigenousTMknowledgeand

products

5.  Inadequatealloca&onofresourcesforTM/CAMdevelopmentandcapacitybuilding


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WHO defines nine key elements of a national TM/CAM policy: 1.  Definition of TM/CAM 2.  Definition of government’s role in developing TM/CAM 3.  Provision for safety and quality assurance of TM/CAM therapies

and products 4.  Provision for creation or expansion of legislation relating to TM/

CAM providers & regulation of herbal medicines 5.  Provision of education & training of TM/CAM providers

(Continued)


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WHO key elements of a national TM/CAM policy (cont.):

6. Provision for promotion of proper use of TM/CAM 7. Provision for capacity building of TM/CAM human

resources, including allocation of financial resources 8. Provision for coverage by state health insurance 9. Consideration of intellectual property issues


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Policy&regulatoryframeworksChina–AnintegratedapproachtoTM

•  Na&onalpolicyonTMispartofthe1949cons&tu&on•  ExistenceofStateAdministra&onofTradi&onalandComplementaryMedicine

(TCM)•  Herbalindustryregulated,pharmacopeiaincludesherbs&essen&aldrugslist

includesherbalmedicines•  HighlevelofhumanTMresources•  PublichospitalsincludeTMprac&ce•  HealthinsurancecoversTM•  Highlevelofresearchcapacity

•  IntegratedTM/Allopathiceduca&onatuniversi&esNumerical data on TM capacity in China: 600 manufacturers of herbal medicines; 340, 000 herbal farmers: Human TM resources (525,000 TCM doctors, 10,000 TCM/AM doctors, 83,000 TCM pharmacists, 72,000 TCM

associate doctors) Hospital resources (2,500 TCM hospitals, 39 TCM/AM hospitals, 35,000 total beds, 127 TM hospitals for

minority groups). 170 national and state TM research institutions. Educational resources (30 TCM universities, 3 TM colleges for minority groups, 51 medical technology schools

of TCM). Source: WHO Traditional Medicine Strategy 2002-2005. Geneva. 2002. Publication number WHO/EDM/TRM/2002.1. Available at: http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf

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CasestudyontheuseofTMTradi&onalmedicineandmentalillnessinBangladesh

•  Theprevalenceofaseverementalillnesssuchasschizophreniais1%acrosstheglobe–thistranslatesto1.5millionBangladeshiswithschizophrenia

•  Tradi&onalmedicineisotentheonlytreatmentavailableforseverementalillnessinruralBangladesh

•  Anarrayoftradi&onalprac&&onersofferservicesinruralBangladesh

•  PabnaHospitalistheonlyhospitaldedicatedtothecareofthosewithseverementalillness

The case studies are real, from personal experience in Pabna Mental Hospital, Bangladesh. The names of the cases are fictitious.

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•  MehrunNessaisa24yearoldladywhoanendstheoutpa&entcenteratPabnaHospitalinchains

•  Shehasbeen“disturbed”and“possessed”formanyyearsaccordingtotherela&vesthataccompanyher

•  Shehasbeenseenbynumeroustradi&onalprac&&onersandhasreceivedvariousformsoftreatment,otenatgreatfinancialcosttothefamily

•  Takingafullhistoryrevealsthelatesttreatmentshereceivedwasthepouringofhotoilintoherears–MehrunNessaisnowdeafaswellascon&nuingtobeaffectedbyauditoryhallucina&ons

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•  SajeedaKhatumisa18yearoldgirlwhohasrecentlybeenwithdrawnfromherfamilyandfriends,andhasbeenac&nginabizarrefashion

•  Herfathertookhertoatradi&onalprac&&onerwhoimmediatelyrecognizedshewasaffectedbyseverementalillness

•  Thetradi&onalprac&&onerandherfatherarewithSajeedaattheoutpa&entcentreatPabna

•  Followinganassessmentbythephysician,atreatmentplanisdiscussedwithSajeeda’sfamilyandtradi&onalprac&&oner

•  Thetradi&onalprac&&onerhaspreviouslysupportedthecareofpa&entsaffectedbyschizophreniainthecommunity,andisconfidenthewillbeabletosupportSajeeda

andherfamily

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•  Thetwocasestudiesdemonstratemarkedvaria&onintheprac&ceoftradi&onalmedicineinruralBangladesh

•  Tradi&onalprac&&onerscanprovideaninvaluableresourcefortherecogni&onofseverementalillness

•  Tradi&onalprac&&onerscanpoten&allybepartofintegratedcarepathwayswithallopathicprac&&oners,asillustratedbythecaseofSajeedaKhatum

•  Dangeroustradi&onalprac&cesareprevalentinruralBangladesh–theseprac&cesneedtobechallengedusingcommunitybasedapproaches

To learn more about traditional medicine in Bangladesh see the entry in Banglapedia at http://banglapedia.search.com.bd/HT/T_0207.htm

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•  Researchisrequiredtounderstandtheprac&ceofTMinruralBangladesh•  SuchresearchisbeingconductedinBangladeshbyFutureHealthSystems:

Innova&onsforEquity•  Thisresearchconsor&umisconduc&nghealthsystemsresearchin6

countries•  TheresearchinBangladeshaimstounderstandhowinformalruralhealth

caresystemsworkandinteractwiththeformalhealthcaresystems&localgovernance

•  Gainingsuchanunderstandingisthefirststeptowardsstrategizinginterven&onsthatensuresafeandhighqualityintegra&onoftradi&onal&allopathicmedicine

See Notes

Quiz•  Now we invite you to take the module quiz and test your

recent learning. •  This module quiz includes ten questions to test whether

you have internalized the key concepts presented in the module. The last question focuses on the case study

•  Note your letter answers (A,B,etc.) on a piece of paper. After completing the quiz you can check the following slides for the correct answers and additional feedback.

•  After the quiz a short summary is provided for this module presentation

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1. Which component is not included in The World Health Organization definition of traditional medicine?

A Plant, animal and mineral based medicines. B Spiritual therapies C Allopathic medicines D Manual therapies E Exercises

2. Which of the following countries uses the term complementary and alternative medicine when referring to traditional medicine?

A Tanzania B Bangladesh C United Kingdom D Botswana E Bhutan

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3. Which of the following statements is not true on the level of usage of traditional medicine in the developing world? A In Africa up to 80% use TM B In China, 40% of delivered health care is TM C In India, 65% of the population in rural areas use traditional medicine to

help meet their primary health care needs. D Traditional medicine is used by only a minority in Bangladesh. E In Chile 71% of the population report having used traditional medicine.

4. Which of the following statements is not true on the level of usage of traditional medicine/CAM in the developed world?

A In the USA, about half of the population have used CAM at least once. B In France, about half of the population have used CAM at least once. C In Canada, 70% of the population have used CAM at least once. D In the UK the formal health care system does not encourage use of CAM. E In Belgium, about a third of the population have used CAM at least once.

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5. Which of the following systems of traditional medicine are not mentioned in the WHO classification system?

A Chinese Medicine B Ayurveda C Unani D Homeopathy E African indigenous medicine

6. The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health groups CAM practices into four domains. Which of the following is not one of the NIH domains?

A Mind-Body Medicine B Biologically Based Practices C Homeopathy D Manipulative and Body-Based Practices E Energy Medicine

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7. The WHO has identified five key needs at national level to ensure the safety, efficacy and quality of TM/CAM. Which of the following is not one of the five key needs that have been identified?

A Regulation & registration of herbal medicines.. B Safety monitoring for herbal medicines & other TM/CAM. C Increased funding for ensuring safety, efficacy and quality of TM/CAM. D Support for clinical research into use of TM/CAM for treating country’s

common health problems E National standard, technical guidelines and methodology, for evaluating

safety, efficacy and quality

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8. The WHO has articulated five key needs at the national level for the rationale use of TM. Which of the following is not one of the five key needs that have been identified?

A A national salary and remuneration scale for those practising TM/CAM B Strengthened & increased organization of TM/CAM providers C Strengthened cooperation between TM/CAM medicine & allopathic

medicine practitioners D Reliable information for consumers on proper use of TM/CAM therapies

and products E Improved communication between allopathic medicine practitioners & their

patients concerning use of TM/CAM.

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9. The WHO defines key elements of a national TM/CAM policy. Which of the following is not one of the key elements?

A Definition of TM/CAM. B Definition of government’s role in developing TM/CAM. C Provision for creation or expansion of legislation relating to TM/CAM

providers & regulation of herbal medicines. D Defining a desired population to practitioner ratio for each of the types of

TM practised in the country E Provision of education & training of TM/CAM providers

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10. Reflect on the case study from Bangladesh. Which of the following statements, in your opinion, is true?

A The practice of pouring of hot oil in Mehrun Nessa’s ears should not be challenged as it is part of a traditional practice

B Traditional practitioners can never be integrated into the care of patients with severe mental illness.

C Traditional medicine needs to be understood prior to strategizing interventions to integrate TM and allopathic medicine

D The opinion of the community should be ignored as global medical knowledge increases

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And now, check out the correct answers

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1. Which component is not included in The World Health Organization definition of traditional medicine?

A Plant, animal and mineral based medicines. Incorrect -- Traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being. B Spiritual therapies Incorrect -- Traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being. C Allopathic medicines -- Correct -- This is not included in the WHO definition if traditional medicine as this is the type of medicine prescribed by allopathic physicians. The WHO definition of traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being. D Manual therapies Incorrect -- Traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being. E Exercises Incorrect -- Traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being.

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2. Which of the following countries uses the term complementary and alternative medicine when referring to traditional medicine?

A Tanzania Incorrect -- The terms "complementary medicine" or "alternative medicine" are used inter-changeably with traditional medicine in some countries. They refer to a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system. The term is often used in the United Kingdom and other developed countries. B Bangladesh -- Incorrect -- The terms "complementary medicine" or "alternative medicine" are used inter-changeably with traditional medicine in some countries. They refer to a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system. The term is often used in the United Kingdom and other developed countries. C United Kingdom Correct -- The terms "complementary medicine" or "alternative medicine" are used inter-changeably with traditional medicine in some countries. They refer to a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system. The term is often used in the United Kingdom and other developed countries. D Botswana -- Incorrect -- The terms "complementary medicine" or "alternative medicine" are used inter-changeably with traditional medicine in some countries. They refer to a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system. The term is often used in the United Kingdom and other developed countries. E Bhutan -- Incorrect -- The terms "complementary medicine" or "alternative medicine" are used inter-changeably with traditional medicine in some countries. They refer to a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system. The term is often used in the United Kingdom and other developed countries.

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3. Which of the following statements is not true on the level of usage of traditional medicine in the developing world? A In Africa up to 80% use TM -- Incorrect -- This statement is true. B In China, 40% of delivered health care is TM -- Incorrect -- This statement

is true. C In India, 65% of the population in rural areas use traditional medicine to

help meet their primary health care needs. -- Incorrect -- statement is true. D Traditional medicine is used by only a minority in Bangladesh. --

Correct -- This statement is not true. TM is widely used in Bangladesh – exact latest data on the level of use is currently being explored by researchers.

E In Chile 71% of the population report having used traditional medicine. Incorrect -- This statement is true.

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4. Which of the following statements is not true on the level of usage of traditional medicine/CAM in the developed world?

A In the USA, about half of the population have used CAM at least once. -- Incorrect]. -- This statement is true.

B In France, about half of the population have used CAM at least once. Incorrect]. -- This statement is true.

C In Canada, 70% of the population have used CAM at least once. Incorrect. -- This statement is true.

D In the UK the formal health care system does not encourage the use of CAM. -- Correct -- This statement is not true. In the UK 40% of all General Practioners offer some form of CAM referral or access.

E In Belgium, about a third of the population have used CAM at least once. Incorrect. -- This statement is true.

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5. Which of the following systems of traditional medicine are not mentioned in the WHO classification system?

A Chinese Medicine -- Incorrect -- The WHO Traditional Medicine Strategy 2002-2005, displays a Table on the commonly used TM/CAM therapies and therapeutic techniques. Chinese medicine is included in this table. B Ayurveda Incorrect -- The WHO Traditional Medicine Strategy 2002-2005, displays a Table on the commonly used TM/CAM therapies and therapeutic techniques. Ayurveda is included in this table. C Unani -- Incorrect -- The WHO Traditional Medicine Strategy 2002-2005, displays a Table on the commonly used TM/CAM therapies and therapeutic techniques. Unani is included in this table. D Homeopathy -- Incorrect -- The WHO Traditional Medicine Strategy 2002-2005, displays a Table on the commonly used TM/CAM therapies and therapeutic techniques. Homeoptahy is included in this table. E African indigenous medicine -- Correct -- The WHO Traditional Medicine Strategy 2002-2005, displays a Table on the commonly used TM/CAM therapies and therapeutic techniques. Surprisingly, African indigenous medicine is not included in this table.

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6. The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health groups CAM practices into four domains. Which of the following is not one of the NIH domains?

A Mind-Body Medicine -- Incorrect. -- This is one of the four NCCAM domains. B Biologically Based Practices -- Incorrect. -- This is one of the four NCCAM domains. C Homeopathy -- Correct -- This is not one of the four NCCAM domains. Homeopathy is considered a whole medical system, which cuts across all four domains. Whole medical systems are built upon complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. Examples of whole medical systems that have developed in Western cultures include homeopathic medicine, a whole medical system that originated in Europe. Homeopathy seeks to stimulate the body's ability to heal itself by giving very small doses of highly diluted substances that in larger doses would produce illness or symptoms (an approach called "like cures like"). D Manipulative and Body-Based Practices -- Incorrect. -- This is one of the four

NCCAM domains. E Energy Medicine -- Incorrect. -- This is one of the four NCCAM domains.

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7. The WHO has identified five key needs at national level to ensure the safety, efficacy and quality of TM/CAM. Which of the following is not one of the five key needs that have been identified?

A Regulation & registration of herbal medicines. -- Incorrect -- This is one of the five key needs identified by the WHO.

B Safety monitoring for herbal medicines & other TM/CAM. -- Incorrect -- This is one of the five key needs identified by the WHO.

C Increased funding for ensuring safety, efficacy and quality of TM/CAM. -- Correct -- Although increased funding is certainly needed, this is not one of the five key needs identified by the WHO. D Support for clinical research into use of TM/CAM for treating country’s common

health problems. -- Incorrect -- This is one of five key needs identified by the WHO. E National standard, technical guidelines and methodology, for evaluating safety,

efficacy and quality. -- Incorrect -- This is one of five key needs identified by the WHO.

56

8. The WHO has articulated five key needs at the national level for the rationale use of TM. Which of the following is not one of the five key needs that have been identified?

A A national salary and remuneration scale for those practising TM/CAM -- Correct -- This is not one of the five key needs identified by the WHO for the rationale use of TM. B Strengthened & increased organization of TM/CAM providers. Incorrect

This is one of the five key needs identified by the WHO for the rationale use of TM.

C Strengthened cooperation between TM/CAM medicine & allopathic medicine practitioners. -- Incorrect -- This is one of the five key needs identified by the WHO for the rationale use of TM.

D Reliable information for consumers on proper use of TM/CAM therapies and products. -- Incorrect -- This is one of the five key needs identified by the WHO for the rationale use of TM.

E Improved communication between allopathic medicine practitioners & their patients concerning use of TM/CAM -- Incorrect -- This is one of the five key needs identified by the WHO for the rationale use of TM.

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9. The WHO defines key elements of a national TM/CAM policy. Which of the following is not one of the key elements?

A Definition of TM/CAM. -- Incorrect -- This is one of the key elements of a national TM/CAM policy defined by the WHO.

B Definition of government’s role in developing TM/CAM. -- Incorrect -- This is one of the key elements of a national TM/CAM policy defined by the WHO.

C Provision for creation or expansion of legislation relating to TM/CAM providers & regulation of herbal medicines. -- Incorrect -- This is one of the key elements of a national TM/CAM policy defined by the WHO.

D Defining a desired population to practitioner ratio for each of the types of TM practised in the country. -- Correct -- This is not one of the key elements of a national TM/CAM policy defined by the WHO. E Provision of education & training of TM/CAM providers. -- Incorrect -- This is

one of the key elements of a national TM/CAM policy defined by the WHO.

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10. Reflect on the case study from Bangladesh. Which of the following statements, in your opinion, is true?

A The practice of pouring of hot oil in Mehrun Nessa’s ears should not be challenged as it is part of a traditional practice. -- Incorrect -- This is a harmful practice that infringes on the human rights of Mehrun Nessa.

B Traditional practitioners can never be integrated into the care of patients with severe mental illness. -- Incorrect -- The supportive role provided by traditional practitioners can be invaluable in the integrated care in the community for persons affected by severe mental illness.

C Traditional medicine needs to be understood prior to strategizing interventions to integrate TM and allopathic medicine. -- Correct -- There is an urgent need to gain an understanding of TM in Bangladesh. Research conducted by Future Health Systems: Innovations for Equity is contributing to this increased understanding in rural Bangaldesh.

D The opinion of the community should be ignored as global medical knowledge increases, -- Incorrect -- Community ideas, concerns, and expectations related to health and health care need to be understood when designing health systems for the future.

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Summary

•  Tradi&onalmedicineisanintegralpartofthehealthseekingbehaviorofpeoplethroughouttheglobe

•  GaininganunderstandingofTM/CAMisessen&alfordesigninginclusivehealthsystems

•  Materialpresentedinthismodulewillallowpar&cipantstoappreciatethecomplexityofthisareaofwork

•  Resourcesprovidedinthismodulecanguidepar&cipantsintheiraddi&onallearninginTM/CAM

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GeneralReferences

1. WHO Traditional Medicine Strategy 2002-2005. Geneva. 2002 Publication number WHO/EDM/TRM/2002.1. Available at: http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf 2. WHO Report by the Secretariat on Traditional Medicine. Executive Board 111th Session. December 2002. Publication number EB111/9. Available at: http://www.who.int/gb/ebwha/pdf_files/EB111/eeb1119.pdf 3. House of Lords Report on complementary and alternative medicine. Great Britain Parliament House of Lords Select Committee on Science and Technology. Author: Lord Walton of Detchant (chairman, Sub-committee I). House of Lords papers 123 1999-00. Publisher: TSO (The Stationery Office). 4. Complementary medicine: information pack for primary care groups. Department of Health of the United Kingdom. June 2000. Available at: http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=6166&Rendition=Web This document aims to provide primary care groups (PCGs) with a reference source on forms of complementary and alternative medicine (CAM). It begins by defining terms and giving an overview of current CAM provision in primary care. The main body of the document deals with six individual therapies, namely acupuncture, aromatherapy, chiropractic, homeopathy, hypnotherapy, and osteopathy. In each case information is provided on conditions which are likely to benefit from treatment, practitioner qualifications, and registering bodies. The document cites numerous references. 5. The roots of ancient medicine: an historical outline. Subbarayappa BV. J Biosci. 2001 Jun;26(2):135-43. Full text available at: http://www.ncbi.nlm.nih.gov/entrez/utils/fref.fcgi?PrId=3169&itool=AbstractPlus-def&uid=11426049&db=pubmed&url=http://www.ias.ac.in/jbiosci/jun2001/135.pdf This article provides an excellent historical perspective on the development of different systems of medicine. It covers: Egyptian medicine; Greek medicine; Greco-Arabic medicine; Chinese medicine; Indian medicine; Ayurveda; Unani; and Siddha.

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Books

6. Traditional medicine. Edited by Biswapati Mukherjee and Amerendra Patra. Published by International Science Publisher, New York. 1993. ISBN 1881570320. Web Links

7. World Health Organization, Traditional Medicine. http://www.who.int/topics/traditional_medicine/en/ This page provides links to descriptions of activities, reports, news and events, as well as contacts and cooperating partners in the various WHO programmes and offices working on this topic. Also shown are links to related web sites and topics.

8. The Department of Health of the United Kingdom, Complementary and Alternative Medicine. http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Complementaryandalternativemedicine/index.htm This page provides information on Complementary and Alternative Medicine, including British policy, summary documents on different types of complementary medicine, links with primary care, as well as the regulation of the field.

Credits

Thisslideshowwaspreparedaspartofaneduca&onalprojectoftheGlobalHealthEduca&onConsor&umandthefollowing

collabora&ngpartners:‐ShamsuzzohaB.Syed‐StephenA.Haering

SponsorsThe Global Health Education Consortium gratefully acknowledges the

support provided for developing these teaching modules from:

Margaret Kendrick Blodgett Foundation The Josiah Macy, Jr. Foundation

Arnold P. Gold Foundation

This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0

United States License.

NOTE:Slide5Definitions:WhatisTraditionalMedicine?TheWHOquoteontraditionalmedicinespresentedontheslidecanbeaccessedat:http://www.who.int/mediacentre/factsheets/fs134/en/TheWHOTraditionalMedicineStrategyPaperstatesthefollowinginansweringthequestionof“Whatistraditionalmedicine?”“TraditionalmedicineisacomprehensivetermusedtoreferbothtoTMsystemssuchastraditionalChinesemedicine,IndianayurvedaandArabicunanimedicine,andtovariousformsofindigenousmedicine.TMtherapiesincludemedicationtherapies–iftheyinvolveuseofherbalmedicines,animalpartsand/orminerals–andnon‐medicationtherapies–iftheyarecarriedoutprimarilywithouttheuseofmedication,asinthecaseofacupuncture,manualtherapiesandspiritualtherapies.Incountrieswherethedominanthealthcaresystemisbasedonallopathicmedicine,orwhereTMhasnotbeenincorporatedintothenationalhealthcaresystem,TMisoftentermed‘complimentary’,‘alternative’or‘non‐conventional’medicine.”Thesamepaperalsostates:“TherearemanyTMsystems,includingtraditionalChinesemedicine,IndianayurvedaandArabicunanimedicine.AvarietyofindigenousTMsystemshavealsobeendevelopedthroughouthistorybyAsian,African,Arabic,NativeAmerican,Oceanic,CentralandSouthAmericanandothercultures.Influencedbyfactorssuchashistory,personalattitudesandphilosophy,theirpracticemayvarygreatlyfromcountrytocountryandfromregiontoregion.Needlesstosay,theirtheoryandapplicationoftendiffersignificantlyfromthoseofallopathicmedicine.”TraditionalmedicinewillbereferredtoasTMwithinslidesinthismodule.ReturntoSlide5==============================NOTE:Slide6Definitions:10CoreTermsImportantdefinitionsarepresentedbelow‐sourceWorldHealthOrganizationavailableathttp://www.who.int/medicines/areas/traditional/definitions/en/index.htmlTraditionalmedicinereferstohealthpractices,approaches,knowledgeandbeliefsincorporatingplant,animalandmineralbasedmedicines,spiritualtherapies,manualtechniquesandexercises,appliedsingularlyorincombinationtotreat,diagnoseandpreventillnessesormaintainwell‐being.Traditionalmedicineisthesumtotaloftheknowledge,skills,andpracticesbasedonthetheories,beliefs,andexperiencesindigenoustodifferentcultures,whetherexplicableornot,usedinthemaintenanceofhealthaswellasintheprevention,diagnosis,improvementortreatmentofphysicalandmentalillness.Theterms"complementarymedicine"or"alternativemedicine"areusedinter‐changeablywithtraditionalmedicineinsomecountries.Theyrefertoabroadsetofhealthcarepracticesthatarenotpartofthatcountry'sowntraditionandarenotintegratedintothedominanthealthcaresystem.

TheCochraneCollaborationdefinescomplementaryandalternativemedicine(CAM)asabroaddomainofhealingresourcesthatencompassesallhealthsystems,modalities,andpracticesandtheiraccompanyingtheoriesandbeliefs,otherthanthoseintrinsictothepoliticallydominanthealthsystemsofaparticularsocietyorcultureinagivenhistoricalperiod.TheNationalInstituteofHealthintheUSstatesthatCAMisagroupofdiversemedicalandhealthcaresystems,practices,andproductsthatarenotpresentlyconsideredtobepartofconventionalmedicine.ConventionalmedicineismedicineaspracticedbyholdersofM.D.(medicaldoctor)orD.O.(doctorofosteopathy)degreesandbytheiralliedhealthprofessionals,suchasphysicaltherapists,psychologists,andregisterednurses.SomehealthcareproviderspracticebothCAMandconventionalmedicine.ThelistofwhatisconsideredtobeCAMchangescontinually,asthosetherapiesthatareproventobesafeandeffectivebecomeadoptedintoconventionalhealthcareandasnewapproachestohealthcareemerge.Herbalmedicinesincludeherbs,herbalmaterials,herbalpreparationsandfinishedherbalproductsthatcontainasactiveingredientspartsofplants,orotherplantmaterials,orcombinations.Herbs:crudeplantmaterialsuchasleaves,flowers,fruit,seed,stems,wood,bark,roots,rhizomesorotherplantparts,whichmaybeentire,fragmentedorpowdered.Herbalmaterials:inadditiontoherbs,freshjuices,gums,fixedoils,essentialoils,resinsanddrypowdersofherbs.Insomecountries,thesematerialsmaybeprocessedbyvariouslocalprocedures,suchassteaming,roasting,orstir‐bakingwithhoney,alcoholicbeveragesorothermaterials.Herbalpreparations:thebasisforfinishedherbalproductsandmayincludecomminutedorpowderedherbalmaterials,orextracts,tincturesandfattyoilsofherbalmaterials.Theyareproducedbyextraction,fractionation,purification,concentration,orotherphysicalorbiologicalprocesses.Theyalsoincludepreparationsmadebysteepingorheatingherbalmaterialsinalcoholicbeveragesand/orhoney,orinothermaterials.Finishedherbalproducts:herbalpreparationsmadefromoneormoreherbs.Ifmorethanoneherbisused,thetermmixtureherbalproductcanalsobeused.Finishedherbalproductsandmixtureherbalproductsmaycontainexcipientsinadditiontotheactiveingredients.However,finishedproductsormixtureproductstowhichchemicallydefinedactivesubstanceshavebeenadded,includingsyntheticcompoundsand/orisolatedconstituentsfromherbalmaterials,arenotconsideredtobeherbal.Traditionaluseofherbalmedicinesreferstothelonghistoricaluseofthesemedicines.Theiruseiswellestablishedandwidelyacknowledgedtobesafeandeffective,andmaybeacceptedbynationalauthorities.Therapeuticactivityreferstothesuccessfulprevention,diagnosisandtreatmentofphysicalandmentalillnesses;improvementofsymptomsofillnesses;aswellasbeneficialalterationorregulationofthephysicalandmentalstatusofthebody.Activeingredientsrefertoingredientsofherbalmedicineswiththerapeuticactivity.Inherbalmedicineswheretheactiveingredientshavebeenidentified,thepreparationofthesemedicinesshouldbestandardizedtocontainadefinedamountoftheactiveingredients,ifadequateanalyticalmethodsare

available.Incaseswhereitisnotpossibletoidentifytheactiveingredients,thewholeherbalmedicinemaybeconsideredasoneactiveingredient.ReturntoSlide6==============================NOTE:Slide9LevelofGlobalTMUsageSourceofUSstudyof1997–EisenbergDM,DavisRB,EttnerSL,etal.TrendsinalternativemedicineuseintheUnitedStates,1990‐1997:resultsofafollow‐upnationalsurvey.JAMA.1998;280(18):1569‐1575.ThemostcomprehensiveandreliablefindingstodateonAmericans'useofCAMwerereleasedinMay2004bytheNationalCenterforComplementaryandAlternativeMedicine(NCCAM)andtheNationalCenterforHealthStatistics(NCHS,partoftheCentersforDiseaseControlandPrevention).Asurveywascompletedby31,044adultsaged18yearsorolderfromtheU.S.civiliannoninstitutionalizedpopulation.ThesurveyincludedquestionsonvarioustypesofCAMtherapiescommonlyusedintheUnitedStates.Detailscanbefoundat:http://nccam.nih.gov/news/camsurvey_fs1.htmThestudyfoundthatintheUnitedStates,36%ofadultsusedsomeformofCAM.WhenmegavitamintherapyandprayerspecificallyforhealthreasonsareincludedinthedefinitionofCAM,thatnumberrisesto62%.PerhapsmostimportantlythesurveyfoundthatmostpeopleuseCAMalongwithconventionalmedicineratherthaninplaceofconventionalmedicine.CAMTherapiesIncludedinthesurvey:Acupuncture*;Ayurveda*;Biofeedback*;Chelationtherapy*;Chiropracticcare*;Deepbreathingexercises;Diet‐basedtherapies(Vegetariandiet,Macrobioticdiet,Atkinsdiet,Pritikindiet,Ornishdiet,Zonediet);Energyhealingtherapy*;Folkmedicine*;Guidedimagery;Homeopathictreatment;Hypnosis*;Massage*;Meditation;Megavitamintherapy;Naturalproducts(nonvitaminandnonmineral,suchasherbsandotherproductsfromplants,enzymes,etc.);Naturopathy*;Prayerforhealthreasons(Prayedforownhealth,Otherseverprayedforyourhealth,Participateinprayergroup,Healingritualforself);Progressiverelaxation;Qigong;Reiki*;Taichi;Yoga.Anasterisk(*)indicatesapractitioner‐basedtherapy.ReturntoSlide9==============================NOTE:Slide14ClassificationsofTM/CAMChineseMedicineTheWorldFoundationforTraditionalChineseMedicineisanexcellentresourcetogainanunderstandingofTCM.ThewebsitefortheFoundationis:http://www.tcmworld.org/TheFoundationwebsiteexplains:“AttheheartofTCMisthetenetthattherootcauseofillnesses,nottheirsymptoms,mustbetreated.Inmodern‐dayterms,TCMisholisticinitsapproach;itviewseveryaspectofaperson—body,mind,spirit,andemotions—aspartofonecompletecircleratherthanlooselyconnectedpiecestobetreatedindividually.”Further,thewebsiteprovidesanintroductiontosomeofthekeytermsandconceptsintraditionalChinesemedicine.

AsectionofthewebsiteexplainsthemajorTCMtreatmentmodalitieshttp://www.tcmworld.org/what_is_tcm/:“OftenWesternCAMpractitionersandtheirpatientsorclientsderivetheirunderstandingofTCMfromacupuncture.However,acupunctureisonlyoneofthemajortreatmentmodalitiesofthiscomprehensivemedicalsystembasedontheunderstandingofQiorvitalenergy.Thesemajortreatmentmodalitiesare:Qigong:anenergypractice,generallyencompassingsimplemovementsandpostures.SomeQigongsystemsalsoemphasizebreathingtechniques.HerbalTherapy:theuseofherbalcombinationsorformulastostrengthenandsupportorgansystemfunctionAcupuncture:theinsertionofneedlesinacupointstohelpQiflowsmoothly.Acupressure:theuseofspecifichandtechniquestohelpQiflowsmoothly.FoodsforHealing:theprescriptionofcertainfoodsforhealingbasedontheirenergyessencesorenergysignatures,notnutritionalvalue.ChinesePsychology:theunderstandingofemotionsandtheirrelationshiptotheinternalorgansystemsandtheirinfluenceonhealth.”Anotherpaperresourceisareviewarticletitled,TraditionalChinesemedicineandKampo:areviewfromthedistantpastforthefuture.TheauthorsareYuF,TakahashiT,MoriyaJ,KawauraK,YamakawaJ,KusakaK,ItohT,MorimotoS,YamaguchiN,KandaT.DepartmentofGeneralMedicine,KanazawaMedicalUniversity,Ishikawa,Japan.JIntMedRes.2006May‐Jun;34(3):231‐9.Theabstractisreproducedbelow:“TraditionalChinesemedicine(TCM)isacompletesystemofhealingthatdevelopedinChinaabout3000yearsago,andincludesherbalmedicine,acupuncture,moxibustionandmassage,etc.InrecentdecadestheuseofTCMhasbecomemorepopularinChinaandthroughouttheworld.TraditionalJapanesemedicinehasbeenusedfor1500yearsandincludesKampo‐yaku(herbalmedicine),acupunctureandacupressure.KampoisnowwidelypractisedinJapanandisfullyintegratedintothemodernhealth‐caresystem.KampoisbasedonTCMbuthasbeenadaptedtoJapaneseculture.InthispaperwereviewthehistoryandcharacteristicsofTCMandtraditionalJapanesemedicine,i.e.theselectionoftraditionalChineseherbalmedicinetreatmentsbasedondifferentialdiagnosis,andtreatmentformulationsspecificforthe'Sho'(thepatient'ssymptomsatagivenmoment)ofJapaneseKampo‐‐andlookattheprospectsfortheseformsofmedicine.”ReturntoSlide14==============================NOTE:Slide15ClassificationofTM/CAMAyurverdaTheDepartmentofAyurveda,Yoga&Naturoptahy,Unani,SiddhaandHomeopathy(AYUSH)ofthe

MinistryofHealthandFamilyWelfareofIndiahasanexcellentwebsitecoveringIndianmedicine:http://indianmedicine.nic.in/index.aspThesectiononAyurvedacanbefoundat:http://indianmedicine.nic.in/ayurveda.aspAnexplanationofthebodymatrixinAyurvedaisexplainedintheslide–thisisatthecoreofAyurveda.FurtherdetailsonmultipledimensionsofAyurvedaareprovidedatthewebsite.Theseinclude:(1)“Panchamahabhutas”(2)HealthandsicknessconceptsinAyurveda,(3)DiagnosisinAyurveda(4)TreatmenttypesinAyurveda(5)PreventiveTreatment&theconceptsofAetio‐Pathogenesis(6)DietandAyurvedictreatment.Anotherpaperresourceisareviewarticletitled,“Utilizationofayurvedainhealthcare:anapproachforprevention,healthpromotion,andtreatmentofdisease.Part1‐ayurveda,thescienceoflife.”TheauthorsareSharmaH,ChandolaHM,SinghG,BasishtG.TheOhioStateUniversityCenterforIntegrativeMedicine,CollegeofMedicine,TheOhioStateUniversity,Columbus,Ohio,UnitedStates.JAlternComplementMed.2007Nov;13(9):1011‐20.Theabstractisreproducedbelow:“AyurvedaisanaturalhealthcaresystemthatoriginatedinIndiamorethan5000yearsago.Itsmainobjectiveistoachieveoptimalhealthandwell‐beingthroughacomprehensiveapproachthataddressesmind,body,behavior,andenvironment.Ayurvedaemphasizespreventionandhealthpromotion,andprovidestreatmentfordisease.Itconsidersthedevelopmentofconsciousnesstobeessentialforoptimalhealthandmeditationasthemaintechniqueforachievingthis.Treatmentofdiseaseishighlyindividualizedanddependsonthepsychophysiologicconstitutionofthepatient.Therearedifferentdietaryandlifestylerecommendationsforeachseasonoftheyear.Commonspicesareutilizedintreatment,aswellasherbsandherbalmixtures,andspecialpreparationsknownasRasayanasareusedforrejuvenation,promotionoflongevity,andslowingoftheagingprocess.AgroupofpurificationproceduresknownasPanchakarmaremovestoxinsfromthephysiology.WhereasWesternallopathicmedicineisexcellentinhandlingacutemedicalcrises,AyurvedademonstratesanabilitytomanagechronicdisordersthatWesternmedicinehasbeenunableto.ItmaybeprojectedfromAyurveda'scomprehensiveapproach,emphasisonprevention,andabilitytomanagechronicdisordersthatitswidespreadusewouldimprovethehealthstatusoftheworld'spopulation.”ReturntoSlide15==============================NOTE:Slide19ClassificationsofTM/CAMHomeopathyTheNationalCenterforComplementaryandAlternativeMedicineattheNationalInstitutesofHealthprovidesalargeamountofinformationonhomeopathyat:http://nccam.nih.gov/health/homeopathySubjectscoveredinclude:(1)Whatishomeopathy?;(2)Whatisthehistoryofthediscoveryanduseofhomeopathy?(3)Whatkindoftrainingdohomeopathicpractitionersreceive?(4)Whatdohomeopathicpractitionersdointreatingpatients?(5)Whatarehomeopathicremedies?(6)HowdoestheU.S.FoodandDrugAdministration(FDA)regulatehomeopathicremedies?(7)Haveanysideeffectsorcomplicationsbeenreportedfromtheuseofhomeopathy?(8)Whathasscientificresearchfoundoutaboutwhetherhomeopathyworks?(9)Aretherescientificcontroversiesassociatedwithhomeopathy?

(10)IsNCCAMfundingresearchonhomeopathy?Also,furtherinformationsourcesandreferencesareprovided.Anotherpaperresourceisanarticletitled,“Wheredoeshomeopathyfitinpharmacypractice?.TheauthorsareJohnsonT,BoonHfromtheUniversityofToronto,LeslieDanFacultyofPharmacy,ON,Canada.AmJPharmEduc.2007Feb15;71(1):7.Fulltextavailableat:http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17429507Theabstractisreproducedbelow:“Homeopathyhasbeenthecauseofmuchdebateinthescientificliteraturewithrespecttotheplausibilityandefficacyofhomeopathicpreparationsandpractice.Nonetheless,manyconsumers,pharmacists,physicians,andotherhealthcareproviderscontinuetouseorpracticehomeopathicmedicineandadvocateitssafetyandefficacy.Asdrugexperts,pharmacistsareexpectedtobeabletocounseltheirpatientsonhowtosafelyandeffectivelyusemedications,whichtechnicallyincludeshomeopathicproducts.Yetmanypharmacistsfeelthatthehomeopathicsystemofmedicineisbasedonunscientifictheoriesthatlacksupportingevidence.Sinceconsumerscontinuetousehomeopathicproducts,itisnecessaryforpharmaciststohaveabasicknowledgeofhomeopathyandtobeabletocounselpatientsaboutitsgeneraluse,thecurrentstateoftheevidenceanditsuseinconjunctionwithothermedications.ReturntoSlide19==============================NOTE:Slide22ClassificationofTM/CAMAnAlternativeNIHClassificationTheNationalCenterforComplementaryandAlternativeMedicineattheNationalInstitutesofHealthgroupsCAMpracticesintofourdomains,recognizingtherecanbesomeoverlap.Theextractsbelowareavailableat:http://nccam.nih.gov/health/whatiscam1.Mind‐BodyMedicine–Mind‐bodymedicineusesavarietyoftechniquesdesignedtoenhancethemind'scapacitytoaffectbodilyfunctionandsymptoms.SometechniquesthatwereconsideredCAMinthepasthavebecomemainstream(forexample,patientsupportgroupsandcognitive‐behavioraltherapy).Othermind‐bodytechniquesarestillconsideredCAM,includingmeditation,prayer,mentalhealing,andtherapiesthatusecreativeoutletssuchasart,music,ordance.2.BiologicallyBasedPractices–BiologicallybasedpracticesinCAMusesubstancesfoundinnature,suchasherbs,foods,andvitamins.Someexamplesincludedietarysupplements,herbalproducts,andtheuseofotherso‐callednaturalbutasyetscientificallyunproventherapies(forexample,usingsharkcartilagetotreatcancer).3.ManipulativeandBody‐BasedPractices–Manipulativeandbody‐basedpracticesinCAMarebasedonmanipulation(theapplicationofcontrolledforcetoajoint,movingitbeyondthenormalrangeofmotioninanefforttoaidinrestoringhealth).Manipulationmaybeperformedasapartofothertherapiesorwholemedicalsystems,includingchiropracticmedicine,massage,andnaturopathy.and/or

movementofoneormorepartsofthebody.4.EnergyMedicine–Energytherapiesinvolvetheuseofenergyfields.Theyareoftwotypes:a)Biofieldtherapiesareintendedtoaffectenergyfieldsthatpurportedlysurroundandpenetratethehumanbody.Theexistenceofsuchfieldshasnotyetbeenscientificallyproven.Someformsofenergytherapymanipulatebiofieldsbyapplyingpressureand/ormanipulatingthebodybyplacingthehandsin,orthrough,thesefields.b)Bioelectromagnetic‐basedtherapiesinvolvetheunconventionaluseofelectromagneticfields,suchaspulsedfields,magneticfields,oralternating‐currentordirect‐currentfields.Inaddition,NCCAMstudiesCAMwholemedicalsystems,whichcutacrossalldomains.Wholemedicalsystemsarebuiltuponcompletesystemsoftheoryandpractice.Often,thesesystemshaveevolvedapartfromandearlierthantheconventionalmedicalapproachusedintheUnitedStates.ExamplesofwholemedicalsystemsthathavedevelopedinWesternculturesincludehomeopathicmedicine,awholemedicalsystemthatoriginatedinEurope.Homeopathyseekstostimulatethebody'sabilitytohealitselfbygivingverysmalldosesofhighlydilutedsubstancesthatinlargerdoseswouldproduceillnessorsymptoms(anapproachcalled"likecureslike").Naturopathicmedicine,awholemedicalsystemthatalsooriginatedinEurope,aimstosupportthebody'sabilitytohealitselfthroughtheuseofdietaryandlifestylechangestogetherwithCAMtherapiessuchasherbs,massage,andjointmanipulation.Examplesofsystemsthathavedevelopedinnon‐WesternculturesincludeTraditionalChineseMedicine,awholemedicalsystemthatoriginatedinChina.Itisbasedontheconceptthatdiseaseresultsfromdisruptionintheflowofqiandimbalanceintheforcesofyinandyang.Practicessuchasherbs,meditation,massage,andacupunctureseektoaidhealingbyrestoringtheyin‐yangbalanceandtheflowofqi.Anotherexampleofasystemthatdevelopedinnon‐WesternculturesisAyurveda,awholemedicalsystemthatoriginatedinIndia.Itaimstointegratethebody,mind,andspirittopreventandtreatdisease.Therapiesusedincludeherbs,massage,andyoga.ReturntoSlide22==============================NOTE:Slide29RationaleUseofTMPaperresource:Whatshouldstudentslearnaboutcomplementaryandalternativemedicine?GasterB,UnterbornJN,ScottRB,SchneeweissR.UniversityofWashingtonSchoolofMedicine,Seattle,Washington98105,USA.AcadMed.2007Oct;82(10):934‐[email protected]:Withthousandsofcomplementaryandalternativemedicine(CAM)treatmentscurrentlybeingusedintheUnitedStatestoday,itischallengingtodesignaconcisebodyofCAMcontentwhichwillfitintoalreadyoverlyfullcurriculaforhealthcarestudents.Thepurposeofthisarticleistooutlinekeyprincipleswhich15NationalCenterforComplementaryandAlternativeMedicine‐fundededucationprogramsfoundusefulwhendevelopingCAMcourse‐workandselectingCAMcontent.Threekeyguidingprinciplesarediscussed:teachfoundationalCAMcompetenciestogivestudentsaframeworkforlearningaboutCAM;choosespecificcontentonthebasisofevidence,demographicsandcondition(whatconditionsaremostappropriateforCAMtherapies?);andfinally,providestudentswithskillsfor

futurelearning,includingwheretofindreliableinformationaboutCAMandhowtosearchthescientificliteratureandassesstheresultsofCAMresearch.Mostoftheprogramsdevelopedevidence‐basedguidestohelpstudentsfindreliableCAMresources.Thecumulativeexperiencesofthe15programshavebeencompiled,andanannotatedtableoutliningthemosthighlyrecommendedresourcesaboutCAMispresented.AssociationsoftraditionalpractitionersexistinthemajorityofAfricancountriesandmanyAfricancountrieshaveestablishedTMresearchinstitutions.AnexampleofanorganizationofTM/CAMproviders:TheEuropeanHerbal&TraditionalMedicinePractitionersAssociation(EHPA).Website:http://www.ehpa.eu/“TheEHTPAwasfoundedin1993whenitbecameclearthatwiththedevelopmentoftheEuropeanUnion,thelegislativeframeworkunderwhichherbalmedicinewaspractisedwaslikelytoundergoradicalchange.ThemainprofessionalherbalpractitionerassociationsintheUKformedaUKnationalorganisationcalledtheBritishHerbalPractitionersAssociation(BHPA).InEurope,theBHPAaffiliatedwithIrishandDanishherbalassociationstoformtheEuropeanHerbal&TraditionalMedicinePractitionersAssociation(EHTPA).Inlate1994,thebasisofherbalpracticeintheUKwasthreatenedbythesuddenannouncementbytheMedicinesControlAgency(nowtheMedicinesandHealthcareproductsRegulatoryAgency)thatexistingEuropeanmedicineslegislationhadsweptawayallthosestatutesintheMedicinesAct1968thatgaveBritishherbalpractitionerstheirlegalrighttoobtainherbalmedicines.TheEHTPAfounditselfthrownheadlongintothecampaigntorescuetherightofUKpractitionerstoobtainherbalmedicineswithouttheneedforfullmedicineslicences.Thishighlysuccessfulcampaigndidmuchtocreatefirmbondsbetweenitsmemberorganisations.Todayourworkfocusesonthedevelopmentofstandardsoftrainingandeducation,accreditationoftraininginstitutions,strengtheningtheidentityoftheprofessionandworkingcloselywithkeystakeholdersonspecificprojects.Forexample,weareakeystakeholder,workingcloselywiththeDepartmentofHealth,indevelopingthepathtowardsstatutoryregulationofherbalpractitionersintheUK.WeworkwiththeMHRAonreviewingthestandardsofsafetyandqualityofunlicensedherbalremediesandwiththerestoftheherbalsectoronimplementingtheDirectiveofTraditionalHerbalMedicinalProducts."ReturntoSlide29==============================NOTE:Slide39CaseStudyontheuseofTM,TraditionalMedicineandMentalIllnessinBangladeshDetailsontheactivitiesofFutureHealthSystems:InnovationsforEquitycanbefoundathttp://www.futurehealthsystems.org/index.htmTheworkbeingcarriedoutinBangladeshisdescribedinapaperpresentedatForum10oftheGlobalForumforHealthResearch.Linkagesbetweenevidenceandpolicy:researchprioritiesforfuturehealthsystems.SyedSB,HyderAA,BloomG,FHS:InnovationsforEquity(theme3group).Availableat:http://www.globalforumhealth.org/filesupld/forum10/F10_finaldocuments/posters/Syed_Shamsuzzoha

.pdfThepaperemphasizestheimportanceofconsideringtheinterfacebetweenevidencegenerationanddecisionmaking.AsectionofthepaperontheworkinBangladeshisreproducedbelow:“AsignificantproportionofthepoorinBangladeshuseinformalhealthcareprovidersastheirfirstlineofcare.ThegeneralobjectiveoftheworkistounderstandthisinformalcaresystemanditsinteractionwiththeformalhealthsystemandlocalgovernanceinChakaria,aruralareaofBangladesh.Theprojectaimstoanswerresearchquestionsfocusedonthe:roleofinformalhealthcaresysteminthehealthstatusofthepoorinruralBangladesh;therelationshipbetweeninformalandformalhealthsectors;healthcareutilizationpatternsandtheirdeterminants;utilizationcostsofformalandinformalhealthcareservices;servicequalityprovidedbyinformalhealthcareproviders;andtheroleofelectedlocalgovernmentrepresentativesinhealthissues,particularlyinrelationtothepoor.Studyfindingswillthenbeusedtodevelop,implement,andevaluateappropriateinterventionstoimprovethehealthofthepoorbetween2007and2010.Theproposedworkincorporatesevidence‐policyinterfaceconsiderationsinanumberofways.Asstatedabove,thepoorinBangladeshdependontheinformalsector;thechosensubjectareaaswellastheresearchapproachisfirmlyembeddedwithinadevelopmentcontext.Theinter‐relationshipoftheinformalhealthsectorwithindividualandcommunityvulnerabilitiesandcapabilitiescanbeelucidatedfromtheproposedresearch.Theeffectsofhealthshocksoncare‐seekingfromeithertheformalorinformalhealthsectorcanalsobeexplicatedbytheproposedwork.Theproposedresearchisoperationalinnatureandisactionfocused.FindingswillhelpdesignfutureinterventionsforworkingwiththeinformalhealthsectorinBangladesh–thustheprocessofinfluencingpolicymakingwithresearchfindingscanbeexploredprospectively.Costsandqualityofcareareintegraltotheresearchproposal,whichcreatesafurther‘realworld’focusoftheresearch.Considerationofhowtheinformalhealthsectorcanbeincorporatedintothehealthsystemrepresentsaninnovativeapproachtofuturehealthsystemdevelopment.Projectfindingsonkeyinformalhealthprovidersmaysignificantlyaffectpolicymaking.Thisdecisionmakingprocess,embeddedinapoliticalcontext,canbeexamined.Forexample,acohortofvillage“doctors”(non‐MDs)wasaresultofgovernmentsponsoredtrainingschemesinthepast.Studyfindingsontheircurrentrolemayinfluencedecision‐makinginrelationtotheseinformalhealthproviders.Findingsfromalllocalelectedrepresentatives(162electedmembersof18unioncouncils)willprovidevaluableinformationonlocaldecisionmakerperspectivesonthehealthsector.Whilemultiplelevelsofpolicymakingarerecognizedintheliterature,themorelocallevelsareoftenignored–thisworkattemptstofillthiskeyknowledgegap.Inaddition,awidearrayoflocalstakeholdersisincludedwithintheresearchproposal.Manyofthesestakeholders,forexampletraditionalhealers,arenon‐intuitivestakeholdersinformalhealthsystemdevelopment.”FurtherdetailsontheworkinBangladeshcanalsobefoundinarecentpublication.Exploringhealthsystemsresearchanditsinfluenceonpolicyprocessesinlowincomecountries.HyderAA,BloomG,LeachM,SyedSB,PetersDH,FHS:InnovationsforEquity.BMCPublicHealth2007Oct31;7(1):309.Fulltextavailableat:http://www.ncbi.nlm.nih.gov/entrez/utils/fref.fcgi?PrId=3196&itool=Citation‐def&uid=17974000&db=pubmed&url=http://www.biomedcentral.com/1471‐2458/7/309ReturntoSlide39

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