The Social Demand for a Medicine Focused on the Person: The Contribution of CAM to Healthcare and Healthgenesis.

The Non Conventional Medicines have a greater social impact and the demand for such treatments of more than 10 million Italian citizens (male and female) of all ages and social classes and of thousands of Italian families reveals an interest proving that there is a trend reversal, involving also other sectors of the medical and scientific world, which shifts the focus from the symptom to an idea of more general and comprehensive well-being of the person. Over the last few years the scientific debate on Non Conventional Medicines and their integration with the academic or dominant medicine in our western society has favored and legitimated an increase in the demand and has activated a cultural transformation process involving the life styles. The focus is therefore shifted to the self-healing capacities, to the reawakening of the individual potentialities, which support and amplify the benefits of the treatments and the citizens start pretending to be accurately informed in order to choose freely their own health program.

Introduction

The definition of CAM, relative to statements of NCCAM and WHO, points out that ‘unconventional’, although the most common expression used in Italy, would seem to place these treatment methods in contrast with academic medicine, considered as conventional. In the English-speaking world the term CAM (Complementary and Alternative Medicine) is used, and it is crucial to underline the complementary nature of different possible diagnostic and therapeutic approaches that fit here in order to emphasize the integration which is currently in the health system and the possibility of the practical use of all the information provided by the patient. Concepts like healthcare strictly connected with that of healthgenesis are introduced together with data concerning CAM in the western world thus focusing on the present situation of Non Conventional Medicines/CAM in Italy. ‘Medicine Focused On The Person’ results from the need of every patient and client. The importance of being treated with dignity and respect is every person's right, improving patient's experience of care, reducing inequalities, being well aware of the ‘health social gradient’ with regards to sustainable balance and pharmacoeconomy in order to encourage change in the thought processes of Health Policy, particularly towards those developing national health care strategies. The term ‘Medicine Focused On The Person’ in terms of sustainability clearly includes, the sense of Integrative Medicine as a synergistic and harmonious blend of conventional and complementary medicine, within a safe environment but looks open to future developments. The results of numerous surveys on health care quality carried out in the USA, in Europe and more recently in Italy show that, if a patient is asked to assess the quality of the medical treatments, his/her priorities are: humanization, tailoring of the treatments, the need of attention from Public Institutions and adequate information in a comfortable environment for a free choice of the individual health program. The focus on the patient in the choice of the individual health programs leads to a different social view of the healthcare quality and of the attention given by the Institutions to the social need for the humanization of the welfare system starting from Medicine or better from the social demand for a Person-Focused Medicine.

Person-focused Medicine

The Person-focused Medicine provides a psychophysical balance to the individual, and this is the stepping-stone of any sustainable social balance for current and future societies. Non Conventional Medicines represent a development of medical knowledge and practice. The evolution of the medical doctrine in the end of the 19th century led to great undeniable medical progresses; on the other hand the methodological and epistemological approaches of NCM/CAM are useful to meet the 21st century requirements.

Complementary and Alternative Medicine

As is known, CAM is a widely used term, but it has no commonly accepted definition. The definition of CAM is recent. It has been developed at a 1997 conference of the United States Office for Alternative Medicine of the National Institutes of Health [now National Center for Complementary and Alternative Medicine, NCCAM (appendix)] and subsequently adopted by the Cochrane Collaboration and the Ministerial Advisory Committee on Complementary and Alternative Medicine. The definition is: ‘Complementary and alternative medicine (CAM) is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being.’

The World Health Organization defines it as follows: ‘Complementary and alternative medicine (CAM) refers to a broad set of health care practices that are not part of a country's own tradition and not integrated into the dominant health care system. Other terms sometimes used to describe these health care practices include “natural medicine”, “non-conventional medicine” and “holistic medicine”.’ The World Health Organization in ‘General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine (Geneva, 2000) states the following definitions of Traditional Medicine ‘Traditional Medicine has a long history. It is the sum total of the knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health, as well as in the prevention, diagnosis, improvement or treatment of physical and mental illnesses. The terms complementary/alternative/non-conventional medicine are used interchangeably with traditional medicine in some countries.’

Traditional Medicine (TRM)

Traditional medicine is the sum total of the knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.

Complementary/Alternative Medicine

The terms ‘complementary medicine’ or ‘alternative medicine’ are used inter-changeably with traditional medicine in some countries. They refer to a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system.

Herbal Medicines Include

Herbs including crude plant material such as leaves, flowers, fruit, seed, stems, wood, bark, roots, rhizomes or other plant parts, which may be entire, fragmented or powdered.

Herbal materials including, in addition to herbs, fresh juices, gums, fixed oils, essential oils, resins and dry powders of herbs. In some countries, these materials may be processed by various local procedures, such as steaming, roasting or stir baking with honey, alcoholic beverages or other materials.

Herbal preparations are the basis for finished herbal products and may include comminuted or powdered herbal materials, or extracts, tinctures and fatty oils of herbal materials. Extraction, fractionation, purification, concentration or other physical or biological processes produce them. They also include preparations made by steeping or heating herbal materials in alcoholic beverages and/or honey, or in other materials.

Finished herbal products consisting of herbal preparations made from one or more herbs. If more than one herb is used, the term mixture herbal product can also be used. Finished herbal products and mixture herbal products may contain excipients in addition to the active ingredients. However, finished products or mixture products to which chemically defined active substances have been added, including synthetic compounds and/or isolated constituents from herbal materials, are not considered to be herbal.

Traditional Use of Herbal Medicines

Herbal medicines include herbs, herbal materials, herbal preparations and finished herbal products that contain as active ingredients parts of plants, or other plant materials or combinations. Traditional use of herbal medicines refers to the long historical use of these medicines. Their use is well established and widely acknowledged to be safe and effective, and may be accepted by national authorities.

Therapeutic Activity

Therapeutic activity refers to the successful prevention, diagnosis and treatment of physical and mental illnesses; improvement of symptoms of illnesses; as well as beneficial alteration or regulation of the physical and mental status of the body.

Active Ingredients

Active ingredients refer to ingredients of herbal medicines with therapeutic activity. In herbal medicines where the active ingredients have been identified, the preparation of these medicines should be standardized to contain a defined amount of the active ingredients, if adequate analytical methods are available. In cases where it is not possible to identify the active ingredients, the whole herbal medicine may be considered as one active ingredient.

World Health Organization

WHO made a number of policy recommendations concerning practitioners of TM/CAM. Among these were that national governments should: establish registration and licensing of providers; recognize the role of TM/CAM providers in providing health care; optimize and upgrade the skills of TM/CAM providers; develop training guidelines for the most commonly used TM/CAM therapies; strengthen and increase the organization of TM/CAM providers; strengthen cooperation between TM/CAM providers and other health care providers. The most widespread Non Conventional Medicines in Europe share a holistic view of man and of the world, take into account the complexity of the natural phenomena, the study of the man-environment relationships and of the mind-body interactions, the meaning of man's spiritual integrity and the potential active role of the patient in his/her recovery and in the preservation of good health. A modern professional ethics, which aims at achieving a satisfying doctor–patient relationship, should develop from a renewed listening capacity to a renewed understanding capacity. This implies that the focus on the microscopic and tiniest aspects is to be shifted and the view extended to the natural and social environment in which man lives and falls ill. That is why an integrative medicine based on a true confidence is required.

The Consortium of Academic Health Centers for Integrative Medicine

In the year 2000 The Consortium of Academic Health Centers for Integrative Medicine, (CAHCIM) was founded in the USA in order to promote CAM research and training. It gathers more than 30 universities. The Consortium developed and adopted on May 2004 and edited on May 2005 the following Definition of Integrative Medicine: ‘Integrative Medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.’ The World Health Organization, with resolution no. WHA56 31 dated May 28, 2003, invites the Member States to formulate and implement policies and national regulations on NCM, and to give special attention to personnel training. The best position statement on the practice of CAM at European level was produced by the Council of Europe in a resolution in 1999 Resolution 1206.

The Council of Europe

The membership of the Council of Europe embraces all European countries including the EU 27. On November 4, 1999 the Council of Europe published the Resolution no. 1206 on non-conventional medicine. In it the Council stated that: various forms of medicine should not compete with one another; it is possible for them to exist side by side and complement one another; alternative or complementary forms of medicine could be practiced by doctors of conventional medicine as well as by well-trained practitioners of non-conventional medicine; a patient could consult one or the other, either upon referral by family doctor or of his/her free will; ethical principals should prevail; Member States should model their approach of their neighbors’ experiments and, whenever possible, co-ordinate their position with regard to these medicines.

The European Union

The free movement and establishment of persons within the EU is a cornerstone of the Treaty of Rome, but the diversity of national policies on healthcare severely limits its applicability to practitioners of CAM because Article 152 of the Amsterdam Treaty states: ‘Community action in the field of public health shall fully respect the responsibilities of the Member States for the organisation and delivery of health services and medical care.’ European Parliament (1997), Council of Europe (1999) and World Health Organization (2003) stated that policies and regulations on CAM should be formulated and implemented. Directive 2005/36/EU (appendix) on the recognition of professional qualifications: mutual recognition of qualifications after completion of basic medical training or specialist medical training. No mutual recognition of other medical qualifications. New medical specialties can be included if common to at least two-fifths of the Member States. In EU we have no legislation in CAM area also if CAM in medical practice is a growing remarkably widespread phenomenon in the EU. This situation causes self-regulation by establishing training standards and accrediting training courses. National statutory/legal regulation is still patchy in spite of resolutions by EP, Council of Europe and WHO.

The European Community and CAM

There is a growing demand among the European citizens CAM: the clinical effectiveness of CAM is, in many cases, at least as high as the effectiveness of conventional medicine, as showed by several long-term studies involving many thousands of patients; CAM is not only effective but also very safe, and that, therefore, CAM can help to reduce the enormous burden of mortality and morbidity caused by the adverse effects of conventional prescription drugs. In the ‘Seventh Framework Programme of the European Community for Research, Technological Development and Demonstration Activities’ (2007–13) among the provisional activities in the chapter ‘Optimizing the delivery of health care to European citizens’, CAM are included as follows: ‘Translating clinical outcome into clinical practice: to create the knowledge bases for clinical decision-making and to address the translation of outcomes of clinical research into clinical practice, especially addressing patient safety and the better use of medicines (including some aspects of pharmacovigilance and scientifically tested complementary and alternative medicines) as well as the specificities of children, women and the elderly population.’ NCM/CAM empowers the patient taking responsibility for its own health; it promotes the individual's health awareness making her/him less dependent of the present health care system (social security).

Analyses of Cost

Studies indicate that NCM/CAM is cost effective since it contributes to and restores a sustainable health (certainly in the long run and taking into consideration the positive social fringe effects). Integrated Health Care offers the better of two worlds, i.e. conventional medicine and NCM/CAM. A system of Integrated Health Care will contribute to a healthier health economy, since NCM/CAM deals with (potential) health problems in an earlier stage and will thus prevent high-cost interventions in more advanced pathology.

Italian Situation

In 2002 the Italian National Federation of MDs’ and Dentists’ Colleges (FNOMCeO) with the so-called Terni Resolution, entitled ‘Guidelines on Non Conventional Medicines and Practices’, assigned to nine disciplines the medical status: Acupuncture, Traditional Chinese Medicine, Homeopathy, Homotoxicology, Ayurvedic Medicine, Anthroposophic Medicine, Phytotherapy, Osteopathy and Chiropractic. Government and Parliament had been invited to pass a law that acknowledges and rules the practice of NCM. Such law has not yet passed. Similar resolution has been issued on 2003 by the Italian Federation of Veterinarians (FNOVI). On the other hand the Italian Supreme Court of Justice [(Suprema Corte di Cassazione, Statement no. 1735/21.05.2003 (appendix)] stated that those CAM must be practised only by MDs.

Perspective towards the Future

The educational and therapeutic task of Complementary Medicines is to teach modern medicine how to take advantage of their contribution in an integrated way, including humanization of medical practices. The time has come now for a deep reflection involving all the society levels as it is the society itself, the patients’ and citizens’ associations, as well as the individual citizens (male and female) who demand that the integrity and wholeness of each human being is restored and respected with regards to the diagnostic-therapeutic access. This is the first contribution of Non Conventional Medicines to a medicine focusing on the human being in its wholeness, integrity and full dignity for a suitable and free choice of the individual health program. Health is no longer conceived as absence of illness but it corresponds to the psychophysical well-being claimed by the World Health Organization.

Appendix

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EU Use of Complementary and Alternative Medicine (1)
40–70% of the European population has used some form of CAM (data from WHO)
10–20% of the EU-15 population has seen a CAM doctor/practitioner within the previous year
30–50% of the EU-15 population has used CAM as self-support (OTC medicines) within the previous year

Most Commonly used CAM Therapies in Medical Practice in Europe (1)
Homeopathy, Acupuncture/Traditional Chinese Medicine, Herbal medicine (Phytotherapy), Anthroposophic Medicine, Natural medicine (Naturopathy), Chiropractic/Osteopathy

Doctors Interested in CAM or Referring for CAM Treatments (1)
UK: 83% of GPs refer for CAM treatments, 66% have significant interest in CAM, 20–40% provide CAM treatment (chiropractic, acupuncture, homeopathy)
Germany: 70% of GPs support CAM and 10% of all working medical doctors hold an additional CAM qualification (number increased by 125% in 8 years), 5000 hospital doctors with CAM qualifications (mainly chiropractic and naturopathy)

Doctors Practising CAM (1)
More than 130 000 doctors in the EU have taken training courses in a particular CAM therapy, of whom: 60 000 in acupuncture; 40 000 in homeopathy; 30 000 in other CAM therapies, such as anthroposophic medicine, natural medicine

CAM in EU Hospitals (1)
In several EU countries CAM doctors work in mainstream hospitals (mainly at outpatients departments) especially acupuncture, but also homeopathy, anthroposophic medicine and natural medicine. As a comparison: in the USA more than one in four hospitals currently offer any kind of CAM therapy

CAM at EU Universities (1)
Professorial CAM chairs
Germany: University of Witten/Herdecke, University of Duisburg/Essen, Technical University of Munich (Centre for Complementary Medicine Research)
United Kingdom: University of Exeter, University of Southampton
Switzerland: University of Bern, University of Zürich

CAM Familiarization Courses in the Under-graduate Curriculum at Medical EU Faculties (1)
Available: EU-15: 40%; CEE: 20%
Compulsory: EU-15: 13%; CEE: none
Examination: EU-15: 31%; CEE: none

EU Doctors Practising CAM (1)
In almost all countries doctors are allowed to practise any CAM therapy, even without any substantial training. Some national medical associations deny doctors the right to practise CAM because it ‘is not evidence-based medicine’. Risk of being struck off the register (Slovenia, Sweden)

CAM Training Courses for EU Medical Doctors (1)
Postgraduate training courses given mostly at private teaching centers and, in some countries, also at universities (e.g. France, Germany, Latvia, Poland, Spain)
Professional CAM doctors’ associations (ECH, ICMART, IVAA) have established training standards and accredited training courses that comply with the standards

CAM and National Medical Associations (1)
In some EU countries doctors can obtain specific additional qualifications in CAM issued by the national medical associations (Austria, Germany, Latvia, Romania). In other countries the national medical associations are in favor of statutory regulation of CAM for physicians (France, Greece, Italy, Spain)

Healthcare Regulation Systems in Europe (1)
All-regulated monopolistic system: only authorized/licensed personnel are legally allowed to provide medical treatment (Portugal, Spain, France, Belgium, Italy, Austria, Czech Republic, Slovakia, Slovenia, Hungary, Poland, Lithuania, Latvia, Estonia, Romania, Bulgaria, Greece)
Semi-regulated system: anyone is allowed to provide medical treatment, with some restrictions (some medical procedures and the treatment of certain diseases are reserved for medical doctors) (Eire, UK, Netherlands, Germany, Denmark, Sweden, Finland8)

Legally Recognized CAM Therapies (1)
Chiropractic: Belgium, Cyprus, Denmark, Finland, Hungary, Italy, Malta, Portugal, Sweden, United Kingdom
Osteopathy: Belgium, Finland, France [MDs only], Hungary, Malta, Portugal, United Kingdom
Acupuncture: Belgium, Hungary [MDs only], Malta, Portugal
Homeopathy: Belgium, Bulgaria [MDs only], Hungary [MDs only], Portugal

Recent Regulatory Action to Regulate CAM Practitioners (1)
Belgium (2003), Catalonia (Spain) 2007, Denmark (2006), Ireland (2006-07), Netherlands (1993) Norway (2006), Portugal (2006), Sweden (2006), United Kingdom (1993, 2000, 2007)
Between 25 and 40% of European MDs prescribe occasionally homeopathic and anthroposophical medicines
Between 6 and 8% of European MDs regularly prescribe homeopathic and anthroposophical medicines

Italian Population and Non Conventional Medicine/CAM
ISTAT (1996–99): 9 million = 15.5%
DOXA (2003): 23% population
ISPO (2003) il 65% familiar with the term NCM and know them
FORMAT (2003) il 31.7% used NCM at least once; il 23.4% use NCM regularly
CENSIS about 50% consider NCM useful; more than 70% ask for a reimbursement by National Health System; 65% ask more control by health national authorities
Menniti-Ippolito et al. (Annali Ist. Sup. Sanità 2004) 3 year follow-up of 52 332 families, (140 011 people), use of NCM by Italian population: 15.6% (Homeopathy 8.2%, Manual therapies 7.0%, Phytotherapy 4.8%, Acupuncture 2.9%, other NCM 1.3%)
EURISPES (Rapporto Italia 2006) 11 million use Homeopathic Medicine