A case for integrated medicine

Print edition : August 04, 2001

THE word integrative medicine has been coined by the Americans (it is integrated medicine in the United Kingdom) to refer to a system in which conventional (allopathic) medicine and the good elements of complementary medicine (such as Indian systems of medicine) are integrated. In the past, the practitioners of the two systems have remained bitter critics of each other. Now the wind is blowing in favour of integration. If we examine three editorials published in the British Medical Journal, which is of international repute, the attitudinal change becomes apparent.

The first editorial published in 1980 on complementary medicine titled, "The Flight From Science", suggested that some aspects of chiropractic ought to be as extinct as divination of the future by the examination of birds' entrails; acupuncturists' beliefs were described as irrational. In contrast, the second editorial, published in 1999 alongside a specially commissioned series of articles on complementary medicine, entitled "A New Dawn", stated that complementary medicine is not unproved. The article continued: "Increasing evidence shows the effectiveness of some treatments in some conditions."

The third editorial, published in 2000 with a front-page legend "Integrated Medicine - orthodox meets alternative", defines integrative or integrated medicine as a system of medicine that is practised in a way that selectively integrates elements of complementary and alternative medical systems into comprehensive treatment plans alongside solidly orthodox methods of diagnosis and treatment. It aims to combine the advantages of the conventional and the complementary systems.

It has been increasingly recognised that allopathic medicine has become more disease-specific and ignores the person as a whole. As for complementary medicine, it deals with health and healing. It views a patient as a whole person with mind and spirit as well as body and includes these dimensions into treatment. How has this attitudinal change been brought about? Is it because of the rising cost of conventional medicine that people are opting more and more for complementary medicine?

There has been a phenomenal increase in the demand for complementary medicine in recent years. In the United States, expenditure on complementary medicine rose between 1990 and 1997 from $13 billion to $38 billion a year and twice as many consultations were with the practitioners of complementary medicine as with mainstream family doctors.

This trend was also apparent in Australia. Within the U.K. a recent survey showed that in Southampton (population 2,00,000) around �4 million was spent in a year on complementary medicine outside the National Health Service (NHS). The World Health Organisation (WHO) estimates that in the coming two decades the world market for complementary medicine will reach $5 trillion. Who can ignore such a tremendous increase in public demand for complementary medicine?

In the U.S., the National Institutes of Health (NIH) established a National Centre for Complementary and Alternative Medicine (NCCAM). The centre's mission is "to explore complementary and alternative healing practices in the context of rigorous science; to educate and train CAM (complementary and alternative medicine) researchers; and to disseminate authoritative information to the public and professionals. This centre had funds of $68.3 million for the fiscal year 2000.

In England, there was a combined meeting of the NCCAM and the Royal College of Physicians to formulate integration between the two systems. The Select Committee of the House of Lords on Science and Technology not only acknowledged that 40 per cent of general practice in U.K. provided some complementary medicine services but also evolved guidelines for its improvement. It categorised complementary medicine as follows:

Group 1: Professionally organised alternative therapies: acupuncture, chiropractic, herbal medicine, homoeopathy and osteopathy

Group 2: Complementary therapies: Alexander Technique, aromatherapy, Bach and other flower extracts, body work therapies including massage, counselling, stress therapy, hypnotherapy, meditation, reflexology, shiatsu, healing, Maharishi ayurvedic medicine, nutritional medicine and yoga

Group 3: Alternative disciplines

3 (a) Long-established and traditional systems of health care: anthroposophical medicine, ayurvedic medicine, Chinese herbal medicine, eastern medicine (Tibb), naturopathy and traditional Chinese medicine

3 (b) Other alternative disciplines: crystal therapy, dowsing, iridology, kinesiology and radionics.

The Government of India objected to this categorisation and sent a team of ayurvedic experts to seek to have ayurvedic medicine included in the first category. To educate medical practitioners and medical students about complementary medicine, a conference was organised in 1995 by the NIH, which recommended that complementary and alternative medicine should be included in nursing and medical education.

Two years later, a survey of all 125 U.S. medical schools found that 75 of them offered some form of education on complementary and alternative therapy. Teaching includes elective modules, core curriculum lectures and problem-based learning at the undergraduate and residency level. Reputed universities such as Harvard and Stanford offer continuing post-graduate education courses, and the Universities of Maryland and Arizona offer research and clinical fellowships. The Association of American Medical Colleges has issued guidelines on including alternative and complementary therapies in the curriculum for residents.

The NIH recently issued a funding initiative in order to support the development of teaching on complementary and alternative therapies in medical, dental and nursing education. It also supports career development and training programmes at several of its research centres in the U.S. In the U.K., two centres - Southampton and Glasgow - have emerged as advance centres for teaching complementary medicine and they have prepared teaching modules for undergraduate students. The aim of these teaching modules is to sensitise medical graduates regarding complementary medicine.

In the field of research, many good trials have been completed. Specific examples of such reviews include the use of Hypericum Perforatum (St. John's Wort) in depression. It has been found equal to any allopathic anti-depressant. Gingko biloba has been found to delay cognitive decline in patients with Alzheimer's disease; Serenoa repens (saw palmetto) relieves symptoms associated with benign prostatic hyperplasia; and glucosamine and chondroitin sulphate help in osteoarthritis. The NCCAM now supports randomised controlled trials on many dietary supplements. More and more research trials have been initiated in recent years.

The integration of complementary medicine with conventional medicine was started mostly in China in the early 1950s in order to deal with a massive health problem. A survey in Thailand showed that 60 per cent of the people use multiple healing systems, including modern Western medicine, Chinese medicine and religious healing. A survey in two village clinics in China's Zheijang province showed that children with upper respiratory tract infections were being prescribed an average of four separate drugs, always a combination of Western and Chinese medicine. The Department of Traditional Chinese Medicine treats 20 per cent of the outpatients. Integration is seen also in South Korea.

In India the two systems have been developed in a parallel model. They are governed by the Indian Medicine Central Council Act, 1970. In most of the Central Government Health Scheme (CGHS) dispensaries there exists a counter for complementary medicine. This department is no doubt under the Health Ministry but is looked after by an officer at the level of Secretary to the Government of India. In recent years great stress has been laid on improving education, standardising drugs, enhancing the availability of raw materials, research and development, information, education, communication and larger involvement of this type of medicine in the national system for delivering health care. The Central Council of Indian Systems of Medicine oversees research institutes, which evaluate treatment. The government is adding 10 traditional medicines into its family welfare programmes, funded by the World Bank and the Central government. These medicines relate to anaemia, oedema during pregnancy, postpartum problems such as pains, uterine and abdominal complications, difficulties with lactation, nutritional deficiencies, and childhood diarrhoea.

We live in an era of evidence-based medicine. In complementary medicine also, evidence is being established through good scientific trials. The number of randomised trials of complementary medicine has approximately doubled every five years.

St. John's Wort has been found to be as effective as any allopathic tricyclic antidepressant but has fewer side effects. Twenty-seven drug trials have been published on this drug. Another drug, Sawpalmetto (Serenoa repens), has been found in 18 trials to relieve symptoms of benign prostate hyperplasia. Acupuncture has been found to be effective for pain and nausea but not in helping smokers to quit. The British Medical Journal has published a report supporting the use of acupuncture for pain and nausea. In the U.S., the NIH has issued a consensus statement supporting the use of hypnosis for pain related to cancer and the use of acupuncture for pain and nausea. Acupuncture, hypnosis and relaxation techniques have been included in guidelines on the management of pain associated with cancer that have been published in the U.S. National Comprehen-sive Cancer Network.

Gingko biloba has been found to delay mental deterioration in Alzheimer's disease and is now being tried for prevention of dementia in elderly people. More and more clinical trials have been initiated in complementary medicine.

In Germany, a centre for research into complementary medicine has provided a series of important systemic reviews on complementary medicine. In the U.S., research units have been established in the University of Maryland, Columbia University in New York, Harvard University in Massachusetts and Memorial Sloan-Kettering Cancer Centre in New York. All these centres are not any less renowned than the All India Institute of Medical Sciences (AIIMS). Regulations for the proper use of complementary medicine have been prepared in these countries.

India has a rich heritage of indigenous systems of medicine. Ancient Hindu texts speak of many a medical marvel. Shusruta, for instance, is credited with having done brain and plastic surgeries 3,000 years ago. With such a background, we should not feel shy of talking of the integration of Indian systems of medicine with the conventional

A response from Dr. C.P. Thakur, Union Minister of Health and Family Welfare, to the article "Mixing medicines", published in the July 6, 2001 issue of Frontline.

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