The recent 72nd World Health Assembly – the May 2019 edition of WHO’s annual global health gathering in Geneva – offered unusually powerful windows into the advances of traditional, complementary and integrative medicine (TCIM) internationally. A WHO progress report detailed the expanding regulatory context for traditional medicine practice. Exemplar nations participated in a TCIM briefing session (all presentations available publicly). In parallel, the approval of a separate WHO initiative, long in development, to include Traditional Chinese Medicine (TCM) codes in the 11th version of WHO’s international classification of diseases (ICD-11) received major push back.
The centerpiece in May was the issuance of the WHO Global Report on Traditional and Complementary Medicine 2019 that effectively provides a mid-way status report on the influential WHO Traditional Medicine Strategy 2014-2023. A 2018 survey that paralleled another from 2012 reported these changes related to TCIM among member states:
The initiative, backed by former WHO Secretary General Margaret Chan during her 2006 t0 2017 term, is led by Zhang Qi, MD, a Chinese medical doctor (3rd from L) who heads the WHO TCIM effort. The report included substantial input from representatives of all of the 6 WHO regions. A slide presentation from the Geneva rollout is online here.
Representing the Americas on the project were Daniel Gallego-Perez, MD, Dr.PH (cand.) (R) and Ricardo Fabrega, MD, both from the Pan America Health Organization (PAHO). While the comparative data were not reported for 2012, the number of the 35 nations in the Americas with each of the forms of recognition of traditional and complementary medicine were found to be: national or state laws (15); national programs (13); expert advisory committee (12); and research institute (9). Particularly in the last 3 years, PAHO has had a robust organizing initiative. I contacted Gallego-Perez, the PAHO consultant and report contributor, for his comments:
I think the report represents a very important step towards better understanding several facets of the TCIM phenomenon at a global scale, particularly, through the institutional lens (since the report mainly relies on official responses from governments). Hopefully, the report would help in continuing making the case for the need of including TCIM in the global public health agenda, and particularly, within the current thrust toward achieving Universal Health Coverage. It also provides some insights about the kinds of gaps and needs that should be addressed in order to facilitate the advancement of the processes for integrating/articulating TCIM within healthcare systems and services. And, in my opinion, the report provides some evidence about the importance of the role that the WHO has played to mobilize member states, particularly, through providing guidance and an action framework with the two versions of the WHO strategy on T&CM, and other related instruments that have been developed.
Nation-by-nation descriptions of developments provide a fascinating rapid sampler of the international TCIM movement, from Micronesia to Bhutan, Switzerland to Turkey. Synopses from such nations as Australia and China are multi-page whereas others such as Germany and Kuwait are quite brief.
In the latter category is that from the United States, for which the descriptor is but a half-page. The (dis)credit for this faulty account goes straight to the US government which has neither backed the WHO traditional medicine initiative nor participated except peripherally. The US didn’t participate, for instance, in the 2018 survey. The paltry listing fails to mention the Veterans Administration’s “whole health initiative” with its extensive use of complementary and integrative approaches. Nor does it reference recent inclusion in pain guidance from agencies such a FDA and CDC that have included non-pharmacologic approaches. No one appears to have been at the helm to conscientiously report developments.
Meantime, certainly the most significant systemic development for traditional medicine is the WHO decision to include Traditional Chinese Medicine (TCM) terms as Chapter 26 in the new ICD-11. As Nature reports:
“… seventy per cent of money spent on health care globally is reimbursed or allocated on the basis of ICD information – now TCM will be part of that system.”
Through a series of meetings over the past decade, interested parties from Japan, Korea, China with strong traditions have fought over just what terms would be included. Chapter 26 of the new code will include hundreds of new TCM items. Nature cites a website at Five Branches University, an accredited USA TCM institution, that celebrates the move as a major arrival:
For the first time in history, ICD codes will include terminology such as Spleen Qi Deficiency or Liver Qi Stagnation.
The action has been received negatively in some quarters. Here is CNN, citing a higher authority: “Scientific American magazine called the move ‘an egregious lapse in evidence-based thinking and practice.'” Writers on the impact in India expressed concerns for extinction of wildlife because of animal elements in some TCM products. Known integrative medicine antagonists lambasted it as a “triumph of the integration of quackery with real medicine.” CNN turned to Arthur Grollman, MD, a professor of pharmacological science and medicine at Stony Brook University in New York:
[Incluson in ICD-11] will confer legitimacy on unproven therapies and add considerably to the costs of health care. Widespread consumption of Chinese herbals of unknown efficacy and potential toxicity will jeopardize the health of unsuspecting consumers worldwide.”
The relatively even-handed account in Nature provide useful context. The writer describes the strategic role of TCM in China’s Belt-and-Road initiative for global economic expansion that includes implanting TCM. The effort is paying off with of TCM products from China already climbing steadily to nearly $300-million annually. Nature again gives Grollman a platform, as a mouthpiece for those “steeped in Western medicine” who find “the continued spread of traditional treatments worrisome”. The potential for TCM to be less expensive my lead to “replacing proven Western medicines with traditional substitutes, where there is a cost advantage.” Grollman is quoted this way:
“The thing [TCM advocates] want is to make it sound official and be recognized by the insurance companies. Because it’s relatively low cost, insurance companies will accept it.”
Despite the calls for an evidence-base or evidence-informed practice, politics is never far from decision processes for all kinds of medicines. The fact that the most powerful ascending nation on the planet is a major advocate for traditional medicines – particularly of the Chinese variety – will continue to have significant influence on whether these approaches are utilized, save money, and/or as the case may be, cause the harms Grollman fears. It’s a rare twist for traditional and complementary medicine to such a decision process err on the side of inclusion.