T
Key points:
WHO Traditional Medicine
Strategy 2002–2005
raditional, complementary and alternative
medicine attract the full spectrum of
reactions — from uncritical enthusiasm to
uninformed scepticism. Yet use of traditional
medicine (TM) remains widespread in
developing countries, while use of complementary
and alternative medicine (CAM) is
increasing rapidly in developed countries.
In many parts of the world, policy-makers,
health professionals and the public are
wrestling with questions about the safety,
efficacy, quality, availability, preservation
and further development of this type of
health care.
It is therefore timely for WHO to define its
role in TM/CAM by developing a strategy to
address issues of policy, safety, efficacy,
quality, access and rational use of traditional,
complementary and alternative
medicine.
What is traditional medicine?
“Traditional medicine” is a comprehensive
term used to refer both to TM systems such
as traditional Chinese medicine, Indian
ayurveda and Arabic unani medicine, and to
various forms of indigenous medicine. TM
therapies include medication therapies —
if they involve use of herbal medicines,a
animal parts and/or minerals — and nonmedication
therapies — if they are carried
out primarily without the use of medication,
as in the case of acupuncture, manual
therapies and spiritual
therapies. In
countries where
the dominant
health care system
is based on allopathic
medicine, or where TM has not been
incorporated into the national health care
system, TM is often termed “complementary”,
“alternative” or “non-conventional”
medicine.b
Widespread and growing use
TM is widely used and of rapidly growing
health system and economic importance. In
Africa up to 80% of the population uses TM
to help meet their health care needs. In Asia
and Latin America, populations continue to
use TM as a result of historical circumstances
and cultural beliefs. In China, TM
accounts for around 40% of all health care
delivered.
Meanwhile, in many developed countries,
CAM is becoming more and more popular.
The percentage of the population which has
a Herbal medicines include herbs, herbal materials, herbal preparations and finished herbal products, that contain as
active ingredients parts of plants, or other plant materials, or combinations thereof.
b Accordingly, in this document, “traditional medicine” is used when referring to Africa, Latin America, South-East Asia, and/or
the Western Pacific, whereas “complementary and alternative medicine” is used when referring to Europe and/or North
America (and Australia). When referring in a general sense to all of these regions, the comprehensive TM/CAM is used.
Key points: WHO Traditional Medicine Strategy 2002–2005
WHO Traditional Medicine Strategy 2002–2005
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used CAM at least once is 48% in Australia,
70% in Canada, 42% in USA, 38% in Belgium
and 75% in France.
In many parts of the world expenditure
on TM/CAM is not only significant, but
growing rapidly. In Malaysia, an estimated
US$ 500 million is spent annually on this
type of health care, compared to about
US$ 300 million on allopathic medicine. In
the USA, total 1997 out-of-pocket CAM
expenditure was estimated at US$ 2700
million. In Australia, Canada and the United
Kingdom, annual CAM expenditure is
estimated at US$ 80 million, US$ 2400
million and US$ 2300 million respectively.
Why such broad use?
Accessible and affordable
in developing countries
In developing countries, broad use of TM is
often attributable to its accessibility and
affordability. In Uganda, for instance, the
ratio of TM practitionersc to population is
between 1:200 and 1:400. This contrasts
starkly with the availability of allopathic
practitioners, for which the ratio is typically
1:20 000 or less. Moreover, distribution of
such personnel may be uneven, with most
being found in cities or other
urban areas, and therefore
difficult for rural
populations to access.
TM is sometimes also
the only affordable
source of health care —
especially for the world’s poorest patients. In
Ghana, Kenya and Mali, research has shown
that a course of pyrimethamine/sulfadoxine
antimalarials can cost several dollars. Yet
per capita out-of-pocket health expenditure
in Ghana and Kenya amounts to only
around US$ 6 per year. Conversely, herbal
medicines for treating malaria are considerably
cheaper and may sometimes even be
paid for in kind and/or according to the
“wealth” of the client.
TM is also highly popular in many developing
countries because it is firmly embedded
within wider belief systems.
An alternative approach to health care
in developed countries
In many developed countries popular use
of CAM is fuelled by concern about the
adverse effects of chemical drugs, questioning
of the approaches and assumptions of
allopathic medicine, and greater public
access to health information.
At the same time, longer life expectancy has
brought with it increased risks of developing
chronic, debilitating diseases such as
heart disease, cancer, diabetes and mental
disorders. For many patients, CAM appears
to offer gentler means of managing such
diseases than does allopathic medicine.
Uncritical enthusiasm versus
uninformed scepticism
Many TM/CAM providers seek continued —
or increased — recognition and support for
their field. At the same time many allopathic
medicine professionals, even those
in countries with a strong history of TM,
express strong reservations and often frank
disbelief about the purported benefits of
TM/CAM. Regulators wrestle with questions
of safety and efficacy of traditional herbal
medicines, while many industry groups and
consumers resist any health policy developments
that could limit access to TM/CAM
therapies. Reports of powerful immunostimulant
effects for some traditional
medicines raise hope among HIV-infected
c TM practitioners are generally understood to be traditional healers, bone setters, herbalists, etc. TM providers include
both TM practitioners and allopathic medicine professionals such as doctors, dentists and nurses who provide TM/CAM
therapies to their patients — e.g. many medical doctors also use acupuncture to treat their patients.
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individuals, but others worry that the use of
such “cures” will mislead people living with
HIV/AIDS and delay treatment with “proven”
therapies.
So together with growing use of TM/CAM,
demand has grown for evidence on the
safety, efficacy and quality of TM/CAM
products and practices. Interestingly, much
of the scientific literature for TM/CAM uses
methodologies comparable to those used to
support many modern surgical procedures:
individual case reports and patient series,
with no control or even comparison group.
Nevertheless, scientific
evidence from randomized
clinical trials is
strong for many uses
of acupuncture, for
some herbal medicines,
and for some of the manual
therapies.
In general, however, increased use of TM/CAM
has not been accompanied by an increase
in the quantity, quality and accessibility of
clinical evidence to support TM/CAM claims.
Challenges in developing
TM/CAM potential
To maximize the potential of TM/CAM as a
source of health care, a number of issues
must first be tackled. They relate to: policy;
safety, efficacy and quality; access; and
rational use.
Policy: basis of sound action in TM/CAM
Relatively few countries have developed a
policy on TM and/or CAM — only 25 of
WHO’s 191 Member States. Yet such a
policy provides a sound basis for defining
the role of TM/CAM in national health care
delivery, ensuring that the necessary
regulatory and legal mechanisms are
created for promoting and maintaining
good practice, that access is equitable, and
that the authenticity, safety and efficacy
of therapies are assured. It can also help to
ensure sufficient provision of financial
resources for research, education and
training.
In fact, many developed countries are now
seeing that CAM issues concerning safety
and quality, licensing of providers and
standards of training, and priorities for
research, can best be tackled within a
national policy framework. The need for a
national policy is most urgent, however, in
those developing countries where TM has
not yet been integrated into the national
health care system, even though much of
their population depends on TM for health
care.
An increased number of national policies
would have the added benefit of facilitating
work on global issues such as development
and implementation of internationally
accepted norms and standards for research
into safety and efficacy of TM/CAM,
sustainable use of medicinal plants, and
protection and equitable use of the knowledge
of indigenous and traditional medicine.
Safety, efficacy and quality:
crucial to extending TM/CAM care
TM/CAM practices have developed within
different cultures in different regions. So
there has been no parallel development of
standards and methods — either national or
international — for evaluating them.
Evaluation of TM/CAM products is also
problematic. This is especially true of herbal
medicines, the effectiveness and quality of
which can be influenced by numerous
factors. Unsurprisingly, research into
TM/CAM has been inadequate, resulting in
paucity of data and inadequate development
of methodology. This in turn has
slowed development of regulation and
legislation for TM/CAM.
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National surveillance systems to monitor
and evaluate adverse events are also rare.
So although many TM/CAM therapies have
promising potential, and are increasingly
used, many of them are untested and their
use not monitored. As a result, knowledge
of their potential side-effects is limited. This
makes identification of the safest and most
effective therapies, and promotion of their
rational use more difficult. If TM/CAM is
to be promoted as a source of health
care, efforts to promote its rational use,
and identification of the safest and most
effective therapies will be crucial.
Access: making TM/CAM available
and affordable
Although many populations in developing
countries are reported as depending heavily
on TM to help meet their health care needs,
precise data are lacking. Quantitative
research to ascertain levels of existing
access (both financial and geographic), and
qualitative research to clarify constraints to
extending such access, are called for. The
focus should be on treatments for those
diseases which represent the greatest
burden for poor populations.
Also, if access is to be increased substantially,
the natural resource base upon which
certain products and therapies depends
must be protected. Raw materials for herbal
medicines, for instance, are sometimes
over-harvested from wild plant populations.
Another major challenge concerns intellectual
property and patent rights. The economic
benefits that can accrue from large-scale
application of TM knowledge can be substantial.
Questions about how best these
benefits can be shared between innovators
and the holders of TM knowledge have not
yet been resolved though.
Rational use: ensuring appropriateness
and cost-effectiveness
Rational use of TM/CAM has many aspects,
including: qualification and licensing of
providers; proper use of products of assured
quality; good communication between TM/
CAM providers, allopathic practitioners and
patients; and provision of scientific information
and guidance for the public.
Challenges in education and training are
at least twofold. Firstly, ensuring that the
knowledge, qualifications and training of
TM/CAM providers are adequate. Secondly,
using training to ensure that TM/CAM
providers and allopathic practitioners
understand and appreciate the complementarity
of the types of health care they
offer.
Proper use of products of assured quality
could also do much to reduce risks associated
with TM/CAM products such as herbal
medicines. However, regulation and registration
of herbal medicines are not well
developed in most countries, and the
quality of herbal products sold is generally
not guaranteed.
More work is also needed to raise awareness
of when use of TM/CAM is appropriate (and
cost-effective) and when it is not advised,
and why care should be taken when using
TM/CAM products.
The current role of WHO
WHO’s mission in essential drugs and
medicines policy is to help save lives and
improve health by closing
the huge gap between
the potential that
essential drugs have
to offer and the reality
that for millions of
people — particularly the
poor and disadvantaged — medicines
are unavailable, unaffordable, unsafe or
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improperly used. It does this by carrying out
a number of core functions: articulating
policy and advocacy positions; working in
partnership; producing guidelines and
practical tools; developing norms and
standards; stimulating strategic and operational
research; developing human resources;
and managing information.
In terms of TM/CAM, WHO carries out these
functions by:
➤ Facilitating integration of TM/CAM into
national health care systems
by helping Member States to develop
their own national policies on TM/CAM.
➤ Producing guidelines for TM/CAM
by developing and providing international
standards, technical guidelines
and methodologies for research into
TM/CAM therapies and products, and
for use during manufacture of TM/CAM
products.
➤ Stimulating strategic research into
TM/CAM
by providing support for clinical research
projects on the safety and efficacy of
TM/CAM, particularly with reference to
diseases such as malaria and HIV/AIDS.
➤ Advocating the rational use of TM/CAM
by promoting evidence-based use of
TM/CAM.
➤ Managing information on TM/CAM
by acting as a clearing-house to facilitate
information exchange on TM/CAM.
But the challenges described earlier demand
that WHO activities in this area be extended
and increased.
Framework for action
The WHO Traditional Medicines Strategy
2002–2005 reviews the status of TM/CAM
globally, and outlines WHO’s own role and
activities in TM/CAM. But more importantly
it provides a framework for action for WHO
and its partners, aimed at
enabling TM/CAM to
play a far greater
role in reducing
excess mortality
and morbidity,
especially among
impoverished
populations. The strategy
incorporates four objectives:
1. Policy — Integrate TM/CAM with
national health care systems, as
appropriate, by developing and implementing
national TM/CAM policies and
programmes.
2. Safety, efficacy and quality — Promote
the safety, efficacy and quality of TM/
CAM by expanding the knowledgebase
on TM/CAM, and by providing
guidance on regulatory and quality
assurance standards.
3. Access — Increase the availability and
affordability of TM/CAM, as appropriate,
with an emphasis on access for poor
populations.
4. Rational use — Promote therapeutically
sound use of appropriate TM/CAM by
providers and consumers.
Implementation of the strategy will initially
focus on the first two objectives. Achieving
the safety, efficacy and quality objective
will provide the necessary foundation for
achieving the access and rational use
objectives.
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Strategy implementation
Maximizing the potential that TM/CAM
offers for improving health status worldwide
is a daunting task, covering a diverse
range of activities and demanding many
types of expertise. Fortunately, WHO has
established a global TM/CAM network,
members of which include national health
authorities, experts of WHO Collaborating
Centres and research institutes, as well as
other UN agencies and nongovernmental
organizations working on TM/CAM issues,
and whose assistance WHO can call upon.
Many organizations have contributed to
development of the WHO Traditional
Medicine Strategy 2002–2005, and many of
them have agreed to be our partners in its
implementation.
Use of critical indicators will facilitate
monitoring of country progress under each
of the strategy objectives