Expanding the Beneficial Use of Complementary and Alternative Medicine and Traditional Medicine
Despite the uncertainty about the clinical efficacy and cost-effectiveness of certain CAM and TM practices, expansion of their use in instances in which moderate evidence of their efficacy and good evidence of their safety exists could yield health, social, and economic benefits. A number of surveys show that local pharmacies are the primary source of treatment for many ailments, especially in rural areas where government or private clinics are less accessible. In these situations, improving the quality of TM might serve as an effective substitute for allowing the unregulated use of conventional medical treatments. Training traditional healers is substantially less expensive than training doctors or nurses. A study of 52 traditional healers interviewed as part of a survey in Kenya estimated that the average out-of-pocket (cash) costs of training to be a traditional healer were K Sh 418 (US$40 in 1981) (Mwabu, Ainsworth, and Nyamete 1993).
Traditional healers can also be recruited into a more broadly based system for delivering public health; for example, with additional training, traditional healers can serve as primary health care workers (Hoff 1997) and provide advice on such matters as sexually transmitted diseases and oral rehydration therapy (Nations and de Souza 1997; Nations and others 1988; Ndubani and Hojer 1999). In addition, permitting access to CAM and TM within the context of the conventional health care system would facilitate access to multiple health services at one location.
Comprehensive policy on CAM and TM is lacking in most countries, including the United States. According to the 1994 Dietary Supplement, Health, and Education Act, the U.S. Food and Drug Administration cannot require proof that dietary supplements and herbal products are safe and effective before they are sold, although it is charged with requiring good manufacturing practices. The quality of herbal products is not regulated, and herbal products typically differ from source to source and from batch to batch in terms of their component ingredients and respective amounts and in terms of whether they contain contaminants. In the United States, no single entity is responsible for all aspects of CAM and TM control, education, information, and research, and no national, voluntary system of self-regulation exists. National nongovernmental organizations, such as the Accreditation Commission for Acupuncture and Oriental Medicine, the American Board of Medical Acupuncture, the Council of Chiropractic Education, the Council of Homeopathic Education, and the Commission on Massage Therapy Accreditation, accredit education in some CAM and TM fields, but such accreditation bodies do not exist in many developing countries. Nearly all countries lack rigorous research training programs in CAM and TM.
A common misperception is that in the developing world CAM and TM is used primarily by poorer, uneducated populations, while in industrial countries it is used more by affluent and better-educated segments of the population (Eisenberg and others 1998). In both settings, relatively little evidence supports this view. Many investigators have failed to critically assess the use of CAM and TM by minority and immigrant populations in Western nations. In Africa, nearly 85 percent of the population uses TM, often as the only way to obtain primary health care, and wealthier people in developing countries often use TM (WHO 2002). Investments in improving the quality and consistency of TM could reduce the cost of health care delivery, especially for chronic conditions such arthritic pain and AIDS, where TM interventions may improve patients' sense of well-being, appetite, and energy. At the same time, in the absence of resources to extend the public health infrastructure, a network of certified CAM and TM providers could provide the infrastructure for delivering other care, such as immunizations and maternal-child health programs.
Recognizing the redistributive nature of investment in TM is important. Indigenous people will seek the help of traditional healers because of proximity, familiarity, and trust. Investments in TM could therefore be used strategically to increase access to conventional preventive and therapeutic care. Including the traditional healer as part of the health care team may thus be an important strategy both to attract patients and to upgrade the skills and training of traditional healers.
How equity is affected by the proportions in which different condition-specific interventions are combined and how other interventions (regulations, tax policy, managerial changes) are likely to affect equity need to be studied. Given that the majority of indigenous populations in developing countries use TM for their primary health care, the availability, safety, and affordability of TM, including herbal medicines, should be ensured as a matter of equity. One way to do this is by supporting local production of safe and effective herbals such as artemisia at affordable prices. In addition, rigorous research on TM should be supported. WHO is currently conducting collaborative studies on herbal treatments for HIV/AIDS, malaria, sickle cell anemia, and diabetes. Ineffective or unsafe herbal products identified by such studies should be removed from use, while those with proven efficacy and safety should be made available for therapeutic use.
