PAHO/HSP/HSO/018-00 Original: English

Pan American Health Organization (PAHO) World Health Organization (WHO)

Report

Working Group PAHO/WHO Traditional, Complementary and Alternative Medicines and Therapies

Washington, D.C. November 15-16, 1999

Division of Health Systems and Services Development, PAHO Team Department of Essential Drugs and Medicine Policies, WHO

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TABLE OF CONTENTS

1. INTRODUCTION ...... 1

2. DEFINITIONS ...... 1

3. UTILIZATION AND SITUATION IN DIFFERENT COUNTRIES ...... 2

3.1 COMPLEMENTARY AND ALTERNATIVE THERAPIES ...... 2 3.2 UTILIZATION AND SITUATION IN DIFFERENT COUNTRIES...... 3 4. CHALLENGES AND ISSUES ...... 3

5. RECOMENDATIONS ...... 4

6. PROPOSED ACTIVITIES ...... 5

6.1 MEDICINE ...... 5 6.2 INTEGRATION OF COMPLEMENTARY AND ALTERNATIVE MEDICINES AND THERAPIES INTO THE NATIONAL HEALTH SYSTEMS AND PROMOTION OF INDIGENOUS HEALTH SYSTEMS ...... 5 6.3 EXCHANGE OF GENERAL AND EVIDENCED BASED INFORMATION...... 5 ANNEXES ......

I. AGENDA ...... 1 II. PARTICIPANT LIST...... 2 III. WORKSHOP ON ...... 3 IV. PROJECT 2000: "FRAMEWORKS FOR THE INTEGRATION OF INDIGENOUS MEDICINE AND THERAPIES INTO PRIMARY HEALTH CARE"...... 4 TABLES: UTILIZATION AND SITUATION IN DIFFERENT COUNTRIES...... V. COMPLEMENTARY AND ALTERNATIVE THERAPIES ...... 5 VI. INDIGENOUS MEDICINE ...... 7

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1. Introduction

In the last two decades complementary and alternative medicines and their therapies became a very important aspect of health delivery in many developing countries. During the 90's the utilization of such therapies by of European, North and Latin American population has been growing rapidly.

Traditional/indigenous medicine in the Region of the Americas has been practiced for centuries. The knowledge and practices of indigenous health systems cover the needs of the communities to some extent. However, the search for complementary services and the development and strengthening of strategies designed to establish national health systems that respond to the characteristics of the beneficiary population are valid approaches to improve the health of both indigenous and non-indigenous populations.

With this in mind, the PAHO Division of Health Systems and Services Development decided to create a working group in collaboration with WHO-HQ to develop the following objectives:

! Formulate recommendations to PAHO in the development of the technical cooperation in complementary and alternative therapies (CAMT). ! Identify sources of technical and financial support for Latin America and the Caribbean. ! Develop mechanisms of coordination in the areas of complementary and and traditional/indigenous medicines and therapies within PAHO different Programs

2. Definitions

Traditional Medicine and Therapies

It is a medical knowledge that came long before the development and spread of Western medicine and it reflects a country's culture, history and beliefs. It is often passed on orally from generation to generation.

Major Systems in Traditional/Indigenous Medicine ! Traditional Chinese traditional medicine Ayurvedic medicine Indigenous medicine

! Non Traditional

Therapies ! Medication therapies Medical plants & Mineral materials

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Animal materials Diet & nutrition

! Non medication therapies Manual therapy Traditional exercises (Qigong, Taiji, and Yoga) Physical, mental, spiritual and mind-body therapies

Complementary/Alternative Medicine

It refers to the medicine that does not play a major role within the national health care systems. In most counties where Western medicine assumes full responsibility for national health care, most forms of traditional medicine and other therapies are considered to be complementary or alternative systems of medicine.

3. Utilization and situation in different countries

The demand for alternative and complementary therapies is growing in many countries, but the trends are different. While in developed countries the trend of using alternative therapies is because of the search for better health care, in developing countries this demand has to do with economic issues or because, as in the case of the indigenous medicine, it is the only available source of health care.

3.1 Traditional/Complementary and Alternative Medicine and Therapies

The utilization of TRM/CAMT by the population in the developed counties is currently estimated as follows:

Country % population Country % population utilizing utilizing Australia 60 United Kingdom 90 Belgium 40 U.S.A 40 France 49 Singapore 45

For Latin America, in , 71% of the population accepts CAMT. In Colombia 40% of the population used CAMT. No data are available for other countries in Latin America.

Situation analysis in Latin America

To make an assessment of the situation a questionnaire was submitted to the Member Countries, 15 countries responded (see table in annex # 5). The results can be summarized as follows:

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! 11 out of 15 do have norms, policies and regulations in relation to at least one of the CAMT disciplines. ! 8 out of 15 countries do have a national program based at the Ministry of Health. ! 9 out of 15 countries do have an academic program in CAMT. ! The most common disciplines are herbal medicine, homeopathy, acupuncture, Ayurvedic medicine & chiropractic.

3.2 Indigenous medicine

In the World Health Organization estimate, and in many developing countries, approximately 80% of the rural population, indigenous as well as non- rely on traditional medicine for their basic health care. This situation results from the limited access to Western medicine as well personal preferences.

In Bolivia where 50,5% of the population is indigenous, the proportion of the population with access to Western medicine ranges from 11 to 70%. There is strong preference for traditional medicine. For example in southern Cochabamba, over 55% of the population opt for traditional medicine.

Situation analysis in Latin America

To make an assessment of the situation, available data on international resolutions i.e. ILO Convention 1691, PAHO Resolution CD37.R52, and information from 17 countries were reviewed (see table in annex # 5) The results can be summarized as follows:

! 9 out of 17 countries have ratified ILO Convention 169. ! All 17 countries as PAHO Member Countries have ratified Resolution CD37.R5 ! 9 out of 17 countries have laws and resolutions related to indigenous medicine ! 11 out of 17 countries do have a governmental technical unit in charge of indigenous issues including indigenous medicine. ! 4 out of 17 have a training program in indigenous medicine ! 7 out of 17 have a research program in indigenous medicine

4. Challenges and Issues

! Various forms of traditional medicine have developed in the context of different cultures and history in geographic regions without a parallel development of international standards and effective methods for evaluating traditional medicine.

1 ILO Convention, 1989, Article 25, 2. Health services shall, to the extent possible, be community-based. These services shall be planned and administered in co-operation with the peoples concerned and take into account their economic, geographic, social and cultural conditions as well as their traditional preventive care, healing practices and medicines 2 Resolution PAHO-CD37R5, 19932. 2.d. To promote the transformation of health systems and support the development of alternative models of care, including traditional medicine and research into quality and safety, for indigenous populations.

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! The quantity and quality of research data on safety and efficacy are insufficient to evaluate the potential of traditional medicine, to contribute to the health care of countries. ! Inadequate regulation/registration for herbal products and other traditional therapies is common. ! Indigenous and non-indigenous groups express concerns about the use of cultural knowledge and property by different groups and pharmaceutical companies without adequate protection for communities. ! There is also a call for the documentation, biodiversity protection, and cultivation of endangered species of plants known to have medicinal value to assure sustainability of natural resources. ! An urgent need exists to generate a climate of international awareness of the health, environment, and economic importance of preserving and strengthening the role of traditional health systems in developing countries and among indigenous peoples. ! Decrease in the number of male and female birth attendants and healers as well as the high percentage of the elderly among them, are resulting in progressive disappearance of certain indigenous therapies and concern for the transmission of traditional knowledge to future generations. ! There continues to be a lack of respect for cultural diversity and a lack of knowledge of traditional/indigenous medicine and culture. ! Although there has been a great deal of attention to CAMT in recent years, there is a lack of coordination among institutions and sectors interested in the subject of traditional, complementary and alternative medicine.

5. Recommendations

Participants of the PAHO/WHO Working Group on Traditional, Complementary and Alternative Medicines and Therapies emphasized the need to respect the integrity of the social, cultural, and spiritual values and practices of indigenous peoples. This includes the full indigenous participation in the national processes to overcome current problems of deficient coverage, lack of access, poor acceptance and low health impact in the health systems and services for indigenous peoples.

! Based on the challenges and issues identified, three priority areas of work were proposed:

! Herbal medicines ! Integration of complementary and alternative medicines and therapies into the national health systems and promotion of indigenous health systems. ! Exchange of information, general and evidence based CAMT

! In order to facilitate the implementation of activities in each of the priority areas the following were proposed:

! To identify focal points to facilitate coordination within PAHO Programs (HS) and HSE) in the areas of complementary and alternative medicine and traditional/indigenous medicines and therapies ! To strengthen collaboration between WHO-HQ and PAHO

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! To enhance coordination between PAHO and the WHO Collaborating Centers in traditional medicine, especially those in the Region of the Americas i.e. The University of Illinois at Chicago (UIC), The National Center of Complementary and Alternative Medicine of the National Institutes of Health (NCCAM-NIH)

6. Proposed activities 2000-2001

6.1 Herbal Medicine

! Workshop on medicinal plants in 2000 (Annex #3)

Contact person: Dr. Rosario D'Alessio, HSP/HSO

6.2 Integration of complementary and alternative medicines and therapies into the national health systems and promotion of indigenous health systems

Indigenous medicine and therapies

! Formulate and implement project 2000: "Frameworks for the promotion of the indigenous medicine and therapies in primary health care" (Annex #4).

Contact person: Dr. Sandra Land, HSP/HSO

Complementary and alternative medicine and therapies (non-indigenous, non-herbal medicines and therapies)

! 2001 Workshop on integration of complementary and alternative medicine and therapies into national health systems

Contact person: Dr. Juan Carlos Silva, HSP/HSO

6.3 Exchange of general and evidenced based information

Herbal medicine

! Translate WHO document about the regulatory situation of herbal medicine from English into Spanish. ! Update information about regulatory situation of herbal medicine within AMRO Member states ! Gather and disseminate general and evidenced based information

Contact person: Dr. Rosario D'Alessio, HSP/HSO

Indigenous medicine and therapies

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! Disseminate English and Spanish version of the inventory on traditional medicine ! Gather and disseminate general and evidenced based information

Contact person: Dr. Sandra Land, HSP/HSO

Complementary and alternative medicine and therapies (non-indigenous, non-herbal medicines and therapies)

! Finalize survey on legal status of complementary and alternative medicine and therapies ! Gather and disseminate general and evidenced based information

Contact person: Dr. Juan Carlos Silva, HSP/HSO

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ANNEX I

TRADITIONAL, COMPLEMENTARY AND ALTERNATIVE MEDICINES

AND THERAPIES

PAHO/WHO Working Group November 15 &16, 1999 PAHO Headquarters - Room 209

OBJECTIVES:

1. Formulate recommendations to PAHO in the development of the technical cooperation in Traditional, Complementary and Alternative Medicines and Therapies. 2. Identify sources of technical and financial support for Latin America and the Caribbean. 3. Develop mechanisms of coordination in the areas of Complementary and Alternative Medicine and Traditional/Indigenous medicine and therapies among PAHO different Programs

AGENDA

Review the background information and activities on traditional medicine by Xiaorui Zhang, WHO/HQ/EDM/TRM

Exchange information on the utilization of CAM in Latin America and the Caribbean JC Silva and The Group

Review of the Health of the Indigenous Peoples Initiative Sandra Land and Rocío Rojas

Development of Recommendations for PAHO The Group

Development of the 2000-2001 Plan of Action The Group

Review of the background information on the University of Illinois at Chicago, PAHO/WHO Collaborating Center for Traditional Medicine Harry Fong

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ANNEX II

Participant list

Rosario D'Alessio, PAHO Rocío Rojas, PAHO Advisor in Pharmaceutical Services Consultant Pan American Health Organization Health of the Indigenous People Initiative 525 23rd Street, NW - Washington, D.C. Pan American Health Organization 20037-2895 525 23rd Street, NW - Washington, D.C. Phone: (202) 974-3214 - Fax (202) 974-3610 20037-2895 E-mail: [email protected] Phone: (202) 974-3827 - Fax (202) 974-3641 E-mail: [email protected] Harry Fong, University of Illinois at Chicago Professor of Pharmacology - Associate Director Juan Carlos Silva, PAHO Program for Collaborative Research in the Regional Advisor in Prevention of Blindness Pharmaceutical Sciences Pan American Health Organization PAHO/WHO Collaborating Center for Cra. 13 no 32-76 Piso 5to Ed. Urano - Santafé Traditional Medicine de Bogotá College of Pharmacy, 833 S. Wood St. Phone: (571) 336-7100 - Fax (571) 336-7306 Chicago, IL 60612, USA E-mail: [email protected] Phone: (312) 996-5972 - Fax (312) 413-5894 E-mail: [email protected] Xiaorui Zhang, WHO Sandra Land, PAHO Acting Coordinator - Traditional Medicine, Regional Nursing Advisor - Focal Point Essential Drugs and Other Medicines Program Health of the Indigenous People Initiative World Health Organization Pan American Health Organization 20 Avenue Appia 1211 Geneva 27, 525 23rd Street, NW - Washington, D.C. Switzerland 20037-2895 Phone: 0041.22-791.3639 - Fax: 0041.22- Phone: (202) 974-3214 - Fax (202) 974-3641 791.0746 E-mail: [email protected] E-mail: [email protected]

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ANNEX III

Workshop on Medicinal Plants

Participants:

Ministry of Health Regulatory Units

Purpose:

To discuss about: ! Establishing national policy, regulations and registration of herbal medicines. ! Issues on utilization of herbal products, evaluation of safety and , commercialization- market and market control regulation, insurance scheme coverage ! Academic/training programs and research programs ! Requirements for herbal product registration

Other issues: ! Medicinal plants protection – Biodiversity -Conservation ! Intellectual property rights

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ANNEX IV Project 2000: "Frameworks for the promotion of the indigenous medicine and therapies in primary health care"

Project duration: 12 months Objectives ! Systematize information in 3-5 countries on specific indigenous health systems i.e., medicine, , Aymara medicine, Nahuat medicine, Miskito medicine, Amazon medicine. ! Developing frameworks and guidelines for the promotion of the indigenous medicine and therapies in primary health care. Proposed Activities ! Analysis situation in areas such as policy, regulations, certification, recognition, networks for referrals, safety and efficacy of the use. ! Regional workshop ! National workshops on development of framework(s) for promoting indigenous medicine in primary health care as models ! Preparation of frameworks and guidelines

Expected Results ! Frameworks and guidelines on policy, training, the proper use ! Case studies on indigenous medicine in primary health care ! Harmonization between the modern and indigenous health systems Timetable Months Activities 1-3 Identification of institutions, project sites, presentation of protocol in 3-5 countries 3-6 Diagnosis/situation analysis based upon protocol

6-8 Review of documents/analyses developed 8 Regional workshop for exchange of experiences 8-10 National workshops 10-12 Preparation of frameworks and guidelines for dissemination

Partners

! WHO - HQ - Traditional Medicine Program ! The University of Illinois at Chicago (UIC) ! The National Center of Complementary and Alternative Medicine of the National Institute of Health (NCCAM-NIH)

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Complementary and Alternative Medicine in Selected Latin American Countries

Country Governmental Policy, Regulations, and Governmental Academic % of Social Non-MD Interest Norms Technical Unit programs utilization insurance practice

Bolivia Yes Ministerial Resolution 0231 No Institute of No Related to Alternative Traditional (Ayurvedic) and Traditional Medicine Medicine (Ayurvedic) Brazil Chiropractic College Ayurvedic

Canada Yes Chiropractic Institute of Chiropractic Yes Acupuncture Chinese Medicine and Acupuncture Colombia Yes Yes Technical Juan Corpas 40% Yes 02927 Related to Committee School of Resolution Ministerial Resolution Herbal 0806 1998 Homeopathy, Acupuncture, Medicine Neural therapy, Therapy with filters, Touching therapies Chile Yes Yes Homeopathy Traditional and Homeopathy 71% ISAPRES (MD) Yes Alternative Medical Society (acceptance) (chiropractors) Medicine Unit (2 Years Diploma) Costa Yes Herbal medicine Acceptance Rica Cuba Yes Yes National Traditional and 9-97 Ministerial Resolution Commission Natural for Traditional Medicine and Natural University Medicine Hospital Development

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Complementary and Alternative Medicine in Selected Latin American Countries

Ecuador Yes Yes (Chiropractors) (Acupuncture and Homeopathy)

EUA Yes Acupuncture, NCCAM-NIH Several 40% Yes Chiropractic, and (Chiropractic) Homeopathy Guatemala Yes Herbal medicine Advisory Board on Phytotherapeutic Products Jamaica Yes

Mexico Yes Yes Homeophatic (Homeopathy (Homeopathy, Traditional , Chiropractic Chiropractic) Medicine ) National Academy

Nicaragua Yes Yes Ministry of URACCAN General Law of Health Leon University Medicaments and Department of Pharmacy Medicinal Plants (Herbal medicine) Panama Herbal medicine Peru Yes Traditional Medicine National Institute (Herbal Medicine)

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ANNEX VI

Indigenous Medicine in the Americas Country Policy, Regulation and Norms Governmental Technical Academic Programs Unit Training Research Argentina National Constitution - Art. 75-17 National Institute of Law No 23.302 Indigenous Affairs Decree No 1269-96 Resolution No 83-94 Convention 169 (*) Resolution CD37.R5 (1) Bolivia Traditional Medicine Practice Ministry of Sustainable UMSA Biochemistry and Regulation No. 198771-1984 Development and Planning. Pharmacy School Resolution 198771 -84- Vice-Ministry of Indigenous Ethnobotanic Area of the Official Establishment of the Affairs and First Nations National Museum of History Bolivian Society of Traditional Medicine (SOBOMETRA) Convention 169 (*) Resolution CD37.R5 (1) Brazil FUNASA's policy on integral National Health Foundation indigenous health care proposes (FUNASA) the respect for the sociocultural characteristics and traditional health systems of indigenous people. Resolution CD37.R5 (1) Canada Resolution CD37.R5 (1) Colombia Convention 169 (*) Secretariat of Indigenous Resolution CD37.R5 (1) Affairs Chile Resolution CD37.R5 (1) Technical Unit of Traditional Medicine and other Alternative Medicines Costa Rica Convention 169 (*) Resolution CD37.R5 (1)

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Indigenous Medicine in the Americas Country Policy, Regulation and Norms Governmental Technical Academic Programs Unit Training Research Ecuador Ministerial Resolution to create National Division of Traditional Birth Attendants Central University the Division of Indigenous Health Indigenous Health Training Program Andina University National, among other areas, to Andina University promote the development of Central University traditional medicine. Convention 169 (*) Resolution CD37.R5 (1) Guatemala Peace Agreements Folkloric Studies Center of the Convention 169 (*) San Marcos University Resolution CD37.R5 (1) Inter-ethnic Research Institute

Honduras Convention 169 (*) Department of Ethnic Department of Ethnic Affairs National University of Resolution CD37.R5 (1) Affairs Honduras Mexico Convention 169 (*) Traditional Medicine Area, National Indigenist Institute Botanical Garden of the Social Resolution CD37.R5 (1) Subdivision of Social Security Mexican Institute Welfare National Indigenist Institute National Indigenist Institute Nicaragua Department of Popular and URACCAN Traditional Medicine of the Leon University Ministry of Health Resolution CD37.R5 (1) Panama Resolution CD37.R5 (1) Paraguay Constitution-Article 62 National Indigenist Institute Law 904-81 (INDI) Convention 169 (*) National Division of Rural Resolution CD37.R5 (1) Affairs and Indigenous Health

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Indigenous Medicine in the Americas Country Policy, Regulation and Norms Governmental Technical Academic Programs Unit Training Research Peru Ministerial Decree to create the Traditional Medicine TAKIWASI Bartolomé de las Casas Center, rural and Peripheral Urban Institute Cuzco Service (SERUMS) gives special importance to research studies and the promotion of indigenous medicine. Convention 169 (*) Resolution CD37.R5 (1) USA Self-Determination Act Indian Health Service Resolution CD37.R5 (1) Venezuela In 1995 Venezuela created the Civil Society of Central Endemic Diseases (CENASAI) and Health Care of Indigenous Peoples (ATSAI) supported by the Bolivar State Governation Resolution CD37.R5 (1)

(*) ILO Convention, 1989, Article 25, 2. Health services shall, to the extent possible, be community-based. These services shall be planned and administered in co-operation with the peoples concerned and take into account their economic, geographic, social and cultural conditions as well as their traditional preventive care, healing practices and medicines.

(1) Resolution PAHO-CD37R5, 19932. 2.d. To promote the transformation of health systems and support the development of alternative models of care, including traditional medicine and research into quality and safety, for indigenous populations.

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