Integrating Complementary and Alternative Medicine Into Conventional Health Care System in Developing Countries

Abstract

Complementary and alternative medicine has been a part of human life and practices since the beginning of time. The role of complementary and alternative medicine for the health of humans is undisputed particularly in light of its role in health promotion and well-being. This article discusses ways through which complementary and alternative medicine can be promoted and sustained as an integrated element of health care in developing countries. We specifically present the exemplary of Amchi traditional doctors of Northern Himalayas.

Background

Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. ¹ CAM has been linked inextricably to human existence since the beginning of time. Studies have documented that about half the population of many industrialized countries now use CAM, and the proportion is as high as 80% in many developing countries. ² An estimated 29% of US adults used at least one CAM therapy in the past year. In other countries, the intermittent use of complementary and alternative medicine has been reported in high proportions: Australia, 48% ³ ; France, 49%; Germany, 46%; the Netherlands, 20% ⁴ ; Canada, 70%; and considerable use exists in many developing countries (China, 40%; Chile, 71%; Colombia, 40%; and up to 80% in African countries).² CAM, including among others ayurveda, siddha, Chinese, chiropractic, manual therapy or manipulation, phytotherapy or herbal medicine, ^4,5 have been and still remain the leading sources of accessible health care delivery in developing countries. The cultural system of medicine of South East Asia, Yoga of ayurveda—once limited to saints—has now gained worldwide interest. ⁶ This is largely due to the effort of countries and communities with a felt need to restore it. With the passage of time, CAM has been challenged and overshadowed by giving high priority to conventional medicine. In Nepal, the ayurvedic system of medicine was a state system of medicine in the period of the reign of the Amshu Vama (605-620 AD), ⁷ but now it is largely ignored by conventional practices because of lack of attention to it. The 700 Ayurvedic government health centers in Nepal are largely ill staffed and underutilized. ⁸ This article discusses ways through which CAM can be promoted and sustained as an integrated element of health care in developing countries. We specifically present the exemplary of Amchi traditional doctors of Northern Himalayas. Amchi henceforth is used in 2 senses: the healing art and the practitioner.

Amchi literally means “superior of all,” and it is also known as Sowa Rigpa (knowledge of healing). ⁹ It is mainly practiced by people living in the trans-Himalayan region. A few decades back, they were the only health service providers available to the people of these areas. Even today Amchi is widely believed and used in the upper mountain regions of Nepal. It provides services to thousands of people where conventional medicine is still inaccessible. This practice historically resembles Tibetan medicine. Also, the Amchi system of medicine resembles, in some broad aspects, the ayurvedic system but has its own characteristics. It makes use of minerals, hot water springs, puncturing of veins, branding, and herbs. It is widely believed that Buddha himself developed this system of medicine 2500 years ago. Trying to understand sickness and its relation to the environment, Amchi combines science, art, philosophy, and religion. They treat the sick physically, emotionally, and spiritually. They deliver mainly preventive health care, such as education on clinginess, good diet, and healthy behaviors. ⁹ They use different herbs, animal products, manual therapies, and formulations in their practice. Lower plant species such as lichens are also used in preparing medicine by Amchi. For curing chronic fever and poisoning, lichens were mixed with other ingredients to prepare a medicine. The details about the Amchi practice of medicine is described elsewhere. ¹⁰

Amchi diagnose using techniques similar to conventional medicine like examining tongue and urine analysis. In addition, Buddhist rituals are practiced and mantras are also chanted during these activities. Many Amchi practice Buddhist astrology and astronomy as well. ¹¹ Use of different herbs is a major part of Amchi treatment, which is favored by the abundant availability of medicinal plants in high altitude. An earlier study conducted to assess the medicinal plants used in complementary and alternative medicine in Nepal found 121 medicinal plant species, of which 49 were vascular plants and 2 were from fungal families encompassing 92 genera. These 121 species were employed to treat a total of 116 ailments. ¹² Historically, Nepal, being a place where Hindu and Buddhist ideologies were mingled, provided the perfect backdrop for Amchi to grow and expand in the past.

In rural communities along the trans-Himalayan region, Amchi are placed in the highest order in society. They are highly respected for their novel work. Amchi do not charge for treatment, but instead they are helped by the villagers in farm work such as in ploughing and during autumn harvest. Occasionally, the villagers collect grains during the harvest and offer it to the Amchi family. Still in many places in Himalayas such as Dolpo in Nepal and Ladakh in India, Amchi are taken as wise men with knowledge of spiritual healing, which increases the acceptability of the services they offer. Amchi knowledge has been passed down to son or daughter through generations. This is known as the RGYUTPA lineage, which is the terminology used by communities in Ladakh, India. ¹³ New Amchi take the final examination orally in front of senior Amchi from neighboring villages. In every village, there are usually 1 or sometimes 2 Amchi families.

Amchi’s practice of sowarigpa is rapidly disappearing. ¹⁴ The herbs grown on the lap of Himalayas are overextracted. Thousands of tons are collected annually and are sold to Chinese and Indian markets each year. Herbs that cure life are going into antiwrinkle creams. Jatamasi, known scientifically as Nardostachys grandiflora, and Kutki, Picrorhiza kurrooa, have been traded heavily between Tibet and the lower valleys of Nepal, and their trade to international markets has increased. ¹⁵ The demand for herbs in Chinese and ayurvedic medicine is increasing each year. ^15,16 This has increased the price of herbs, and Amchi cannot afford to buy them. So Amchi have to cut down either their philanthropy or have to charge the patients they treat. Also, Amchi are facing hard conditions for their livelihood. In this situation, they can turn to other professions and might migrate to other places for work. New generations have shown lack of interest in coming forward to adopt Amchi as a profession. Amchi practice largely based on their knowledge about the herbs, animal products, their different formulations, and manual techniques. Older Amchi cannot transfer their knowledge to young as only a few Amchi have disciples. An earlier study revealed that despite Amchis’ willingness to transfer their knowledge system to the next generation, 64% did not have any disciple or student; this clearly indicates a decline in interest among the young generation to adopt Amchi as a profession. ¹⁰

The World Health Organization called on member states to develop and integrate CAM as part of their current health system. ¹⁷ However, to effectively integrate CAM into a conventional health care system, the integration should begin at the community level through integration of practitioners and allopathic health care professionals. ¹⁸ Some of the early field-based studies by the World Health Organization in Ghana, Mexico, and Bangladesh to evaluate the effectiveness of CAM practitioners as primary health care workers have been shown to be effective. ¹⁹ This made the ground for integrating complementary and alternative medicine providers to primary health care. In the point of view of developing countries’ inadequate human resources for health, the existing CAM practitioner can be added to the existing pool of human resources for conventional medicine. The health workforce in Nepal is unevenly distributed, with a shortage of doctors in rural areas, ²⁰ for instance. However, this should be guided by strategies that promote rational integration from grassroots level. Moreover, a regulatory body can be built to oversee the quality of CAM products such as medicines and other therapies and the training and licensing of CAM practitioners. ²¹

While China and India have recognized the practices, in Bhutan and Mongolia Tibetan healing is the part of the national health care system, Nepal still is far behind in recognizing Amchi as part of primary health care. ²² Though CAM has been mentioned in the National Health Policy, Amchi is still unrecognizable. Looking at the approaches taken by India, China, and Bhutan to consider Amchi as a part of the National Health Care system, Nepal can learn how to integrate such a system as part of its own health care system. In this window of opportunity, the role of medical schools and research is paramount. One example is, how the people in the upper mountain region of Nepal started a school to train Amchi doctors who would serve as doctors to the people in need in remote mountains and hills in the Himalayas. ²³

There are many self-organized community-based efforts to promote complementary and alternative medicine in Nepal. Despite the lack of support from the government, the Himalayan Amchi Association was established in 1998 and has been promoting Amchi practice of CAM in Nepal including the establishment of an Amchi medical school in Kathmandu. ²⁴ The Himalayan Amchi Association provides training and other forms of medical education, putting effort to benefit rural communities with efficient health care delivery. They work toward cultivation, conservation, and sustainable utilization of medicinal plants and also promote research on these medical practices. ²⁵ Another example is Lo Kunphen School established in Lo Monthang in the Mustang district in 2000. This school runs a 10-month course in Tibetan medicine, and several clinics and medicine producing units in Mustang of Nepal. In India, Lhasa of Tibet, and other places, there are similar courses in Amchi, such as Amchi Durapa diploma (3-year course), Kuchapa degree with 1 year of in-house training (bachelor degree), and Smarampa degree (3-year master’s degree). Also there is an award, Smarampa Chewa degree, which is awarded to Amchi who have worked proficiently for at least 20 years.

The Amchi practices need to be scientifically validated, and only proven practices should be brought to the practice. It is believed that when given to patients they do not show any side effects. ²⁶ However, as found in other folk medicine, it is likely that Amchi may also have some cons. More research is needed to document different aspects of Amchi, which helps to develop a clear integration plan with conventional medicine. In a place where there is a shortage of conventional health care practitioners, Amchi can play an important role for improving human health. They may be trained for providing family planning devices, instructing people to prepare oral rehydration solutions from sugar and salt; identifying danger signs of acute respiratory infections; diarrhea; danger signs in mothers and children during pregnancy, delivery, and postpartum period; and health promotion on noncommunicable diseases together with their own healing system. Amchi could also be important agents for referral to the conventional health care system. They can practice their own rituals at first and can also refer to the conventional health facility for further diagnosis and treatment if needed. Such practices where traditional providers deliver services to rural people need to be promoted. To ensure that conventional medicine is properly understood and utilized within the pluralistic context, the identification and training of Amchi who may specialize in diagnosis or referral demonstrates promise. ²⁷

Sometimes ignorance might be the reason for delayed response to restoration. Because the community does not know the importance and seriousness of the issue related to preservation of Amchi, they are less likely to initiate actions for its restoration. In this light, the national governments need to plan training programs such as academic as well as nonacademic degrees in Amchi and awareness programs on the importance of Amchi so that people would know their systems of medicine and be motivated to use it. The government needs to look at management issues of Amchi, with more budgets and stringent plans and strategies. The Amchi health facilities need to be formally established, integrated, and streamlined within the national health system. More research needed so that evidence about the role of Amchi can be brought to the public, policy makers, and program planners.

Conclusion

Amchi is the most popular CAM in the Himalayan region. The system is based on holistic Buddhist philosophy and traditions in which the sick are treated physically, emotionally, and spiritually. Despite being the dominant healing system for the people in the trans-Himalayan region, little is explored about it scientifically. Very little is documented about the possibility of integrating Amchi with conventional medicine. In a country like Nepal where there is a large shortage of conventional health professionals, opportunities have to be explored through rational integration of Amchi in the conventional medicine.