HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Related articles in AJPH Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fink, S. Search for Related Content PubMed PubMed Citation Articles by Fink, S. Related Collections Global Health Health Administration Health Care Facilities/Services Government

Sheri Fink, MD, PhD

Sheri Fink has worked in the Balkans, the northern Caucasus region, Central Asia, and southern Africa with International Medical Corps, a nongovernmental organization that provides medical aid to populations in crisis. Her writing on health, medicine, and science has been published in Discover magazine, MAMM magazine, several newspapers, and numerous scientific journals. Her book on a Bosnian war hospital will be published by PublicAffairs in spring 2003.

Correspondence: Requests for reprints should be sent to Sheri Fink (e-mail: sherifink{at}aol.com).

	ABSTRACT

TOP ABSTRACT INTRODUCTION CURRENT CHALLENGES T/CAM AND HIV POTENTIAL OF T/CAM TO... THE CHALLENGES AHEAD References

 

Affordable, available, and ever more popular at home and abroad, "alternative" healers are finally getting positive attention from Western practitioners. This rapprochement has enormous implications for public health worldwide.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION CURRENT CHALLENGES T/CAM AND HIV POTENTIAL OF T/CAM TO... THE CHALLENGES AHEAD References

 

Left: A Nigerian man wears a necklace of herbal remedies.

WHEN TED LEON, MD, TRAVELED to Madagascar with a nongovernmental organization to study the occurrence of malaria in the wake of a devastating cyclone, his long-time interest in traditional medicine led him to write an extra question into his survey instrument. He wanted nurses to determine what proportion of febrile patients seeking treatment at a government clinic had already tried traditional medicines or seen a traditional healer. The answer—only 1%—astounded Leon, who knew that a far greater percentage of the population was thought to use these services. In some African countries, up to 90% of the population relies on traditional medicine for basic health care needs, for reasons ranging from trust in traditional healers to poor access to official health care systems.¹

In an effort to sort out the discrepancy, Leon began to ask patients what they had done when they were suffering with fever. One after another, they described trying herbs and visiting traditional healers. When Leon asked why they hadn’t mentioned this to the nurses who had surveyed them, they often answered that they were ashamed to tell doctors and nurses in the government-run clinic about their involvement with traditional medicine. They feared that the medical professionals, who tend not to respect traditional healers, would provide lower-quality care if they knew.

"It’s very similar to the US in that regard," says Leon, who presented his malaria study results at the May 2002 Global Health Council meeting, "Global Health in Times of Crisis," in Washington, DC. "If you go to the doctor here, not that many people are willing to say, ‘I’ve already seen my herbalist and my magnet therapist about this.’ You’re afraid it’s going to bias the caregiver’s opinion of you."

Indeed, in the United States, where the number of visits to complementary–alternative medicine providers such as acupuncturists outstrips the number of visits to primary care physicians, less than 40% of complementary–alternative therapies used are disclosed to physicians, according to a random household telephone survey of over 2000 respondents published in the Journal of the American Medical Association in 1998.² The same study estimated that in 1997, out-of-pocket expenditure in the United States relating to alternative therapies—defined as interventions neither taught widely in medical schools nor generally available in US hospitals—was $27 billion, and that about 42% of the US population had used at least 1 of a list of 16 alternative therapies, up from 33.8% in 1990. The United Nations Conference on Trade and Development Secretariat has estimated that the worldwide market for herbal remedies based on traditional knowledge stands at $60 billion.³

While people in the developed world increasingly turn to alternative therapies for problems related to aging and chronic diseases, the majority of those in the developing world rely on traditional medicine for basic health care. Ironically, the widespread use of complementary and alternative medicine in both the developed and developing world contrasts with its lack of integration into the health care systems of most countries.

To address this disconnect, the World Health Organization (WHO) recently released its first global strategy on traditional, complementary, and alternative medicine (T/CAM). Besides reviewing the practice of T/CAM worldwide, the 74-page strategy document released in May 2002 outlines steps that governments may take over the next 3 years to improve the safety, efficacy, and availability of these practices.⁴ "Our purpose is to try to promote the safe and effective use of traditional medicine, through policy, research and guidelines," says Dr Xiaorui Zhang, acting team coordinator for traditional medicine in the WHO’s Department of Essential Drugs and Medicines Policy in Geneva and 1 of 3 drafters of the new strategy. Developed in consultation with representatives from UN member states and from nongovernmental and international organizations and foundations, the strategy has provoked a variety of responses from practitioners and others involved in T/CAM. However, there is agreement that issues related to T/CAM deserve greater recognition from those funding and supporting public health worldwide.

	CURRENT CHALLENGES

TOP ABSTRACT INTRODUCTION CURRENT CHALLENGES T/CAM AND HIV POTENTIAL OF T/CAM TO... THE CHALLENGES AHEAD References

 
One of the major problems cited by those involved with T/CAM is the lack of coordination between T/CAM healers and "official" health care systems and practitioners. Reports in US and UK medical journals document potentially harmful interactions between herbal medicines and drugs prescribed by allopathic physicians. For example, ginseng, one of the most popular herbal products sold in the United States, may cause dangerous levels of blood thinning in people using the prescription medication warfarin. Likewise, Saint John’s wort, another popular product used by many for its antidepressant properties, reduces blood levels of the anti-HIV medication indinavir below the level required to block replication of the AIDS virus.⁴

Below: A New Guinean woman rests after giving birth; nearby, her baby is cradled by the midwife.

The gap between traditional and allopathic medicine in developing countries is often even wider. Animosity toward traditional medicine dates back to colonial times, when healers—powerful leaders in their communities—were forbidden by law from practicing. Many continue to work underground and in secrecy, which struck Leon during his work in Madagascar. "It became clear to me there were 2 systems integrated only by the patient," he says. "Perhaps the best analogy is like having a wife and mistress. There’s not a lot of interaction between the two. The patient zips back and forth between the traditional healer and the medical doctor."

A group of Ugandan men cut and pound local herbs into traditional remedies against skin disease, typhoid, and AIDS.

This lack of interaction is a source of both dangers and lost opportunities. One example involves children with cerebral malaria, who often present with seizures and are rushed to traditional healers. According to Leon, while those healers cannot provide anything as effective as quinine, still a life-saving drug in Madagascar, they do not refer such patients to physicians. On the other hand, certain chronic or psychological conditions may be more conducive to treatment with traditional than allopathic medicine, but allopathic physicians will not refer patients to traditional healers and often do not even know who they are.

In a variety of countries, nongovernmental organizations have initiated programs that encourage traditional healers and health center personnel to work together. Several have focused their efforts on traditional birth attendants (TBAs). "In developing countries, particularly in Bangladesh, our experience is still that given the fact that trained doctors are really not available in the rural areas, most of the births are being conducted by the traditional healers," says Shahnewaz Khan, MD, MSc, assistant country director for Concern Worldwide in Bangladesh. "It’s true, they’re not as skilled as the trained medical practitioners are. But in areas where there aren’t trained doctors, they’re the only ones supporting the services."

TBAs are frequently elderly women with no formal education or medical training whose mothers and grandmothers have coaxed the births of generations of children and who often accept deferred payment or payment in kind. Their services are readily available in rural Bangladesh, where people have trouble accessing governmental health care centers for reasons of distance, cost, or ethnic differences with staff members. These TBAs, however, like the traditional healers in Madagascar, have long been shunned by the official system. "The government didn’t really recognize them," Khan says. TBAs couldn’t refer patients to the government health facilities, which led to devastating consequences—including maternal and child deaths—when they were faced with problem births they were not trained to handle.

Concern Worldwide now supports a program whereby medical doctors and paramedics from the official system train and monitor TBAs. Although the training has involved discouraging such traditional practices as putting animal excrement on the umbilical cord—a cause of neonatal tetanus—Khan says that most TBAs have been open to the supervision. "They now have recognition and encouragement," he says.

Most importantly, the program has resulted in a decrease in maternal mortality, says Khan. Soon after the program began, Concern Worldwide staff members saw the potential for TBAs to promote good health beyond good births. "They [TBAs] give the care along the whole chain, not just the delivery," says Khan. "They prepare the family for the pregnancy, support the delivery. Then for these 70% of mothers, they’re the first caregivers of the newborns. They’re the first contact with any health system." TBAs now receive additional skills training in prevention and management of diarrhea, malnutrition, and respiratory infections. In the future, they will learn about HIV prevention and treatment.

	T/CAM AND HIV

TOP ABSTRACT INTRODUCTION CURRENT CHALLENGES T/CAM AND HIV POTENTIAL OF T/CAM TO... THE CHALLENGES AHEAD References

 
With an overwhelming lack of access to life-extending antiretroviral medications (ARVs) and drugs to prevent and treat the opportunistic infections that accompany the immunodeficiency of AIDS, traditional medicine is often the only option in many parts of Africa and developing countries in Asia. UNAIDS, the Joint United Nations Program on HIV/AIDS, recently reviewed collaboration with traditional medicine practitioners in AIDS prevention and care in sub-Saharan Africa in 9 African countries.⁵ "Most poor children don’t have access to effective antibiotics to treat pneumonia, let alone access to ARVs, not to mention support services for the monitoring and management which would go on for the lifetime of the individual," says nurse and midwife Breda Gahan, who is the overseas health program advisor for Concern Worldwide. "We have to take advantage of any existing indigenous leaders and systems that are in place." In Uganda, she says, Concern Worldwide staff found that traditional healers were providing psychological and palliative treatment for people with HIV/AIDS, using 147 medicinal plants to treat 29 disease symptoms.

In a study conducted by the local Ugandan organization THETA, 154 HIV-positive patients with herpes zoster were treated by indigenous traditional healers administering herbal treatment at the Mulango Hospital of Makarere University; they were compared with 55 patients receiving symptomatic treatment or acyclovir at The AIDS Support Organization clinic.⁶ Both groups had similar rates of resolution of their zoster attacks, but zoster-associated pain resolved faster among patients of the traditional healers. "It’s totally possible that if we were to explore systematically the thousands of plants that are being used in a completely incongruous way by healers for HIV/AIDS, we could find some very useful medicines," says Jaco Homsy, MD, MPH, the lead author of the study, who currently serves as an advisor to THETA and to the Doctors Without Borders Access to Essential Medicines Campaign. The problem, he says, is a serious lack of willingness among major donors to fund research on traditional medicine, knowledge "based on oral traditions . . . that [are] quickly disappearing."

Both Homsy and Gahan believe that traditional healers have a role to play in AIDS prevention too. "Most [traditional healers] haven’t been informed about the benefits of nevirapine, which is one of the easier treatments to prescribe and take to reduce HIV transmission from mother to child," Gahan says. "They could be great advocates of getting that message out." For the past several years, THETA has brought together hundreds of traditional healers and allopathic doctors, who serve a population of many millions in 9 districts of Uganda, to share knowledge and methods of AIDS prevention and treatment on an intensive, long-term basis. "Some healers became really involved in counseling and wanted to go deeper, blending a mix of their practice and HIV information," Homsy says. "They just took over the work in their community about prevention, information, care and support," building schools and forming support groups for people infected with HIV.

Two Taiwanese men mix and measure herbal medicines in a traditional Chinese pharmacy.

	POTENTIAL OF T/CAM TO IMPROVE PUBLIC HEALTH

TOP ABSTRACT INTRODUCTION CURRENT CHALLENGES T/CAM AND HIV POTENTIAL OF T/CAM TO... THE CHALLENGES AHEAD References

 
Although traditional healers often evaluate the effectiveness of their treatments in fundamentally different ways than Western scientists, many traditional medicines and practices have been demonstrated to be medically effective when studied by scientific methods. In a recent example with potential for wide public health benefits, the Chinese herbal remedy Artemisia annua has been found effective at treating resistant malaria.^4,7 Indeed, about 25% of modern medicines are descended from plants first used traditionally.⁷ Acupuncture has been shown to relieve pain and nausea, and randomized controlled trials have demonstrated the effectiveness of hypnosis and relaxation techniques in alleviating anxiety, panic disorders, and insomnia.⁴

Sandra Land, regional advisor on local health services for the Pan-American Health Organization, provided input on the WHO traditional medicine strategy, contributing information about studies of indigenous medical practices in the Americas. She cites the example of Peru, where the social security system allows conventional medical doctors to refer patients for treatment at alternative–complementary clinics. A study of 339 patients over 1 year, undertaken with Peru’s National Program in Complementary Medicine, found that traditional treatments were more efficacious and cost-effective for such pathologies as moderate osteoarthritis, back pain, anxiety disorders, light or intermittent asthma, peptic ulcer disease, and tension migraines.

	THE CHALLENGES AHEAD

TOP ABSTRACT INTRODUCTION CURRENT CHALLENGES T/CAM AND HIV POTENTIAL OF T/CAM TO... THE CHALLENGES AHEAD References

 
The WHO’s strategy document refers to its own effort as "daunting." Not only does it aim to increase the number of countries implementing national T/CAM policies—something the WHO has advocated since the mid-1980s—but it also aims to address issues ranging from the safety of T/CAM to the regulation and registration of herbal medications. All of those interviewed for this article agree that the strategy’s goals are ambitious. "A lot of things get tried—eradicate smallpox, reduce malaria, decrease AIDS," says Dr Ted Leon. "This will be at least as challenging, because it’s so in the dark. You won’t be able to say, ‘Well, let’s make a roster of all traditional doctors.’ Easier said than done. ‘Test them.’ Easier said than done. ‘Certify them.’ Easier said than done." The difficulties will be compounded, he says, by the antipathy toward traditional medicine of many national governments.

Left: A faith healer with eyes closed places both hands on the head of a seated man in Mexico.

Dr Zhang of the WHO admits that only 25 of 191 WHO member states have a national policy on traditional medicine, and very few fully integrate T/CAM into the national health care system, as her native China does. However, she believes that increased use of T/CAM will be a useful source of pressure. "Governments have to face the demands," she says.

Even if governments can be persuaded to take a more active role in promoting, regulating, researching, and increasing access to T/CAM, opposition to some aspects of the WHO strategy might come from another corner—traditional practitioners. "Who would make the decisions on what’s effective or not?" asked Don Warne, MD, MPH, who comes from a family of Lakota Native American traditional healers and has trained in native medicine. Warne, also a board-certified family medicine and acupuncture practitioner who works for the National Institutes of Health to develop diabetes interventions in Native American populations, points out that any evaluation of effectiveness would have to take into consideration more than the physical dimension. "In traditional healing, the focus is not based on the disease process, but based on the needs, which could include physical as well as spiritual, emotional, and psychological needs. There is no way to quantify that," he says.

Below: A medicine man in Kerala, India.

He calls the idea of governmental regulation of traditional healers "paternalistic" and says that, of the many Native American traditional healers he knows, he cannot think of one who would welcome such intervention. "Even if it meant more recognition, outside regulation is not what they’d want," he says. "For a lot of traditional medicine, the healing practice and religious practice are inseparable. We don’t need the government coming in and saying whether or not practices are useful, safe or effective because we’ve done it for thousands of years."

There are many other challenges and potential controversies ahead, from ensuring adequate funding for research into T/CAM to weighing the benefits of recording and preserving indigenous knowledge vs the intellectual-property risks this entails. "Nothing’s perfect," says Zhang. "This is the first step in the strategy. After 4 years we will review it and make something else for the next 4 or 5 [years]."

	Footnotes

 
Peer Reviewed

Accepted for publication July 17, 2002.

	References

TOP ABSTRACT INTRODUCTION CURRENT CHALLENGES T/CAM AND HIV POTENTIAL OF T/CAM TO... THE CHALLENGES AHEAD References

 
World Health Organization. Promoting the Role of Traditional Medicine in Health Systems: A Strategy for the African Region 2001–2010. Harare, Zimbabwe: World Health Organization; 2000. Document AFR/RC50/Doc.9/R.

Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA. 1998,280:1569–1575.[Abstract/Free Full Text]

Systems and National Experiences for Protecting Traditional Knowledge, Innovations and Practices. Background Note by the UNCTAD Secretariat. Geneva, Switzerland: United Nations Conference on Trade and Development; 2000. Document TD/B/COM.1/EM.13/2.

WHO Traditional Medicine Strategy, 2002–2005. Geneva, Switzerland: World Health Organization; 2002. Document WHO/EDM/TRM/2002.1. Available at: http://www.who.int/medicines/organization/trm/orgtrmmain.shtml. Accessed June 5, 2002.

Collaboration With Traditional Healers in AIDS Prevention and Care in Sub-Saharan Africa: A Comparative Case Study Using UNAIDS Best Practice Criteria. Geneva, Switzerland: UNAIDS; 1999.

Homsy J, Katabira E, Kabatesi D, et al. Evaluating herbal medicine for the management of Herpes zoster in human immunodeficiency virus-infected patients in Kampala, Uganda. J Altern Complement Med. 1999;5:553–565.[Medline]

WHO launches the first global strategy on traditional and alternative medicine [press release]. Geneva, Switzerland: World Health Organization; May 16, 2002.

Related articles in AJPH:

Putting the "Public" Back Into Public Health

Mary E. Northridge
AJPH 2002 92: 1710-1711. [Extract] [Full Text]  

This article has been cited by other articles:

				J. C. Belliard and J. Ramirez-Johnson Medical Pluralism in the Life of a Mexican Immigrant Woman Hispanic Journal of Behavioral Sciences, August 1, 2005; 27(3): 267 - 285. [Abstract] [PDF]

				B. T. Shaikh and J. Hatcher Complementary and Alternative Medicine in Pakistan: Prospects and Limitations Evid. Based Complement. Altern. Med., June 1, 2005; 2(2): 139 - 142. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Related articles in AJPH Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fink, S. Search for Related Content PubMed PubMed Citation Articles by Fink, S. Related Collections Global Health Health Administration Health Care Facilities/Services Government