Travel has always been a great source of insight and an impetus for progress. More important than the places we see, the people we meet and the experiences we have, the true value of travel is the way all these things help change the way we see ourselves and our home. As an emergency physician who has worked in many settings in our multicultural society, my approach to clinical care was shaped by a life of travel. Among other things, it helped me to really listen to my patients and connect with them in a way that transcends culture and background. Perhaps the most important milestone in my career was a two-year break from medicine that I spent learning about traditional healing while backpacking around the world.
That experience led me to step away from the ER to set up a practice in pain management in Ottawa that combines conventional and alternative medical treatments, an approach called integrative medicine. I also developed and teach a course on this subject to medical students, which encourages them to consider how other ways of thinking about and practising medicine can improve modern health care. The Canadian health care system is focused primarily on treating established diseases with drugs and surgery. In Canada, natural health products, acupuncture, chiropractic, massage, mind-body techniques and many other tools commonly used in the field of rehabilitation are considered Complementary and Alternative Medicine (CAM) therapies.
Although CAM therapies can be very helpful, often patients must learn about them on their own. Most primary care and specialist physicians don’t know much about them and some even sternly warn their patients against them. While some patients have access to CAM therapies through their insurers or in some hospital-based programs, they unfortunately remain a very small part of the health care system.
At a time when most of the health care debate in Canada is about providing more health care, it may be worthwhile to stop and take a look around the world. There may be lessons we can learn about how to make things better by providing different health care.
One of the most important forces shaping integrative medicine in Europe is history. Before aspirin, which was developed by Bayer AG in 1897, plants and botanical extracts were first-line drugs used and taught in the medical schools of Europe. Centuries of tradition continue to influence health care in most European countries, leading to widespread use of herbal medicine by the population. In Germany, many standardized herbal preparations are dispensed by prescription only, and their quality and manufacturing standards are generally very high. Many more positive clinical trials are published in European medical journals than in American ones, a fact that was statistically demonstrated in a recent study of publication bias.
Another important difference is the remarkable role of acupuncture in the practice of medicine around the world. It has been in use in China for millennia, and the oldest text documenting its use is the Yellow Emperor’s Classic of Medicine, which is believed to have been written in the first century BCE. First described by a French priest in 1671, acupuncture has been prominent for much longer in Europe than in North America. In Germany, it is typically performed by licensed medical doctors. They are required to undergo in-depth training by the German Acupuncture Association, which was established in 1937 and has over 10,000 member physicians.
There is an interesting duality in Europe. The global pharmaceutical industry is based in Basel, Switzerland and its powerful interests are in favour of stricter regulation of herbs, vitamins and other natural health products. At the same time, strong support from an enlightened public has led many national governments to include manual medicine treatments and other CAM therapies in their health care plans. This means that people can see licensed practitioners without having to pay out-of-pocket. It will be interesting to see how this situation evolves in an era of cost-cutting and economic turmoil in the eurozone.
A number of factors have influenced the development of integrative medicine in Central and South America. The most obvious is the rich diversity of plants that have been used as medicines by shamans and medicine men and women for thousands of years. The Mayans in the Yucatan peninsula, the Incas in pre-Columbian Peru and the tribal healers scattered throughout the Amazon rainforest have all used hundreds of plants. Today, much of the population cannot afford high-tech medicine or expensive drugs even for a few weeks, much less for years as needed to treat chronic diseases, so the medicine of choice for most people is food and herbs. In Mexico the leaves of a cactus are boiled and eaten to treat diabetes; these nopales have demonstrated hypoglycemic effects in clinical trials. Chanca piedra is Spanish for “stone-breaker,” and this plant was shown to facilitate passage of kidney stones in Brazilian trials.
The upper- and middle-class minority in many of these countries once dismissed these traditional remedies as quaint native practices. They proudly insisted that the only real medicine was western medicine, and colleagues have reported that many didn’t feel as if they got proper treatment unless it included an injection. This is changing. CAM therapies are becoming more popular and more and more well-to-do patients are asking their doctors for non-drug solutions to their problems.
In fact, some people in Latin America choose not to use pharmaceutical drugs on political grounds. I have been told by patients that they associate drugs with the colonial powers that become wealthy on the backs of their people, and that refusing them is an act of resistance. I first came across this sentiment in Argentina, where there are many fans of Che Guevara, the doctor who joined Castro and became a socialist hero in the Latin world. Then I heard it again in Bolivia, Venezuela, Ecuador and Colombia, where large popular movements have also risen against global capitalism.
Cuba provides another interesting example of how politics can affect health care. Cuba’s special relationship with the Soviet regime has been a double-edged sword. When the Soviet Union collapsed in the 1990s, Cuba lost its trading lifeline to the outside world, including access to pharmaceutical drugs. In reaction, the government made health care independence a national priority and went back to basics. Its comprehensive strategy includes having herbal medicines in every community clinic and retraining physicians in traditional medicine as taught by doctors flown in from China. These days Cuban doctors are actually exported to other countries in exchange for oil and other resources, making them legendary throughout the developing world. One hospital in Cuba is especially worth mentioning. The Centro Internacional de Restauracion Neurologica (CIREN) is a rehabilitation centre in Havana that treats patients with chronic neurologic problems from Cuba and around the world. It has intensive programs for adults and children with a wide range of problems at many levels of disability. These combine occupational therapy, physiotherapy and manual therapies with acupuncture, ozone therapy, specialized diets and regular consultations with holistic medical doctors. Many patients excitedly told me how they had improved more during their one-month treatment at CIREN than in the entire previous year in their home countries.
Both India and China have health care systems that are rapidly modernizing in the presence of traditional healing systems that are thousands of years old. Over the years, I have met and spoken with many integrative physicians from different parts of Asia. However, my personal experience is limited to India, where I spent several months studying ayurveda in a university-based program in Pune, about two hours south of Mumbai.
Hundreds of universities throughout India offer five-year post-secondary programs in ayurvedic medicine. While this degree does not carry the same prestige as an allopathic medical degree, graduates are respected doctors, called vaidyas. They tend to work independently, but I trained in a hospital-based ayurvedic clinic where patients underwent intensive centuries-old panchakarma treatment regimens. Many were referred by their medical and surgical specialists for a variety of conditions. I saw lots of back pain and osteoarthritis, cancer and cardiovascular disease, and was impressed by the benefits the patients reported.
Ayurvedic treatment is truly patient-centred because it is tailored to an individual’s constitutional imbalance or dosha. This medicine, whose 500-page Sanskrit scriptures have been memorized for three thousand years, is not just a part of the health care system but it is also part of people’s daily lives. Morning yoga is held in public spaces. Spices are added to meals based on their medicinal properties. Cold drinks are never consumed with meals because they interfere with digestion. Sauna therapies never heat the head. Medicinal plants are added to massage oils to enhance treatment. Colonic treatments are always given using oils and never water. And breathing exercises are commonly taught and used to alter someone’s mood or mental state.
In China there is even more integration of traditional medicine in allopathic health care. The communist revolution in China emphasized the importance of their traditional medicine as a gift to mankind. As a result, there are acupuncture clinics in many hospitals – and on most street corners. Prestigious schools of Traditional Chinese Medicine are dotted throughout the country, and a sophisticated infrastructure distributes plant and animal medicinal ingredients widely. Tai Chi is a common practice, although medical qigong is banned because of its spiritual implications.
A growing number of peer-reviewed journal publications are coming from China, including in integrative medicine. As Chinese researchers’ ability to conduct rigorous clinical trials improves over time, we should expect to see a lot more fascinating research coming from that part of the world.
Seeing how integrative medicine has emerged around the world is fascinating and allows us to see how truly limited our perspective can be here at home. Alternative approaches to medicine might have developed in other countries because of cross-fertilization between neighbouring countries or because of people’s inability to pay for drugs and surgery. They may be influenced by tradition, culture and even politics. Whatever the reasons, these different approaches may have something important to teach us about how we do things here in Canada.
It is important for us to learn from our neighbours in other parts of the world. Health care is a basic human need, and even a fundamental human right. Many forward-thinking clinicians and researchers are waking up to the fact that “complementary” or ‘“alternative” medicine is no different from any other medicine. We should learn more about other forms of treatment, access them, evaluate them to find out how to best use them, and make them part of our health care system in Canada.