Accessible and affordable in developing countries
In some developing countries TM is much more widely available than allopathic medicine. In Tanzania, Uganda and Zambia, researchers have found a ratio of TM practitionersf to population of 1:200 - 1:400. This contrasts starkly with the availability of allopathic practitioners, where the ratio is typically 1:20 000 or less.19,20 A 1991 survey by the US Agency for International Development found that, in sub-Saharan Africa, traditional practitioners outnumber allopathic practitioners by 100 to 1.21 Moreover, allopathic practitioners are located primarily in cities or other urban areas. So for many rural populations TM is the only available source of health care. Surveys conducted by the WHO Roll Back Malaria Programme in 1998 showed that in Ghana, Mali, Nigeria and Zambia, more than 60% of children with high fever are treated at home with herbal medicines.22,23,24,25 One of the key reasons cited for this was the ready accessibility of herbal medicines in rural areas. (See also Figure 5.)
f TM practitioners are generally understood to be traditional healers, bone setters, herbalists, etc. TM providers include both traditional medicine practitioners and allopathic medicine professionals such as doctors, dentists and nurses who provide TM/CAM therapies to their patients. E.g. many medical doctors also use acupuncture to treat their patients.
Figure 5. Malaria treatment in Ghana with herbal medicines is considerably cheaper than other forms of health care
Source: adapted from Ahorlu C et al., 1997.26
TM is also sometimes the only affordable source of health care - especially for the poorest patients. In Ghana, Kenya and Mali, research has shown that a course of pyrimethamine/sulfadoxine antimalarials can cost several dollars. Yet total out-of-pocket health expenditure in Ghana and Kenya is only around US$ 6 per capita per year. In other words, some populations simply cannot afford chemical drugs.27 On the other hand, herbal medicines may be not only relatively cheap but payable in kind and/or according to the "wealth" of the client. Similarly in Salvador, the fee for treating a child for diarrhoea as an out-patient Global review at a public hospital - including consultation fee and medication - can be as high as US$ 50. Treatment by a TM practitioner may be no more than US$ 5 or payable in kind.28
Greater accessibility to TM practitioners - and confidence in their ability to manage debilitating, incurable disease - probably explain why most Africans living with HIV/AIDS use traditional herbal medicines to obtain symptomatic relief and to manage opportunistic infections. Frequently, TM practitioners are well known in their communities for their expertise in health care and prevention of many sexually-transmitted diseases.g At the same time, TM is often embedded in wider belief systems and continues to be an integral and important part of many people's lives. UNAIDS is therefore advocating collaboration with TM practitioners in AIDS prevention and care in sub-Saharan Africa.29,30
"It was argued at [a] UNAIDS-sponsored meeting in Kampala [in June 2000] that traditional medicine is in a real sense carrying the burden of clinical care for the AIDS epidemic in Africa. This trend has been largely overlooked by health ministries and international agencies."31
g Researchers in some countries have noted that some other illnesses and conditions not classified as sexually transmitted in biomedical nosology may be locally regarded as such by traditional healers and their clients.
TM is also commonly used in developing countries in Asia. The Indian Government has reported that for 65% of its population, TM is the only available source of health care. In some Asian countries, governments are actively promoting TM. The Ministry of Health of the Lao People's Democratic Republic, is encouraging use of TM, including broad distribution among communities of the report, Medicines in Your Garden. In Thailand, the Ministry of Health is working to enhance people's awareness and greater use of medicinal plants for primary health care. This has included publication of the Manual of Medical Plants for Primary Health Care.
An alternative or complementary approach to health care in developed countries
In many developed countries, increased use of CAM indicates that factors other than tradition and cost are at work. Concern about the adverse effects of chemical drugs, questioning of the approaches and assumptions of allopathic medicine, greater public access to health information, changing values and reduced tolerance of paternalism are just some of them.16,32
"Traditional medicine is based on the needs of individuals. Different people may receive different treatments even if, according to modern medicine, they suffer from the same disease. Traditional medicine is based on a belief that each individual has his or her own constitution and social circumstances which result in different reactions to "causes of disease" and treatment."6
At the same time, longer life expectancy has brought with it an increased risk of developing chronic, debilitating diseases such as heart disease, cancer, diabetes and mental disorders.27 Although allopathic treatments and technologies are abundant, some patients have found that these have not provided a satisfactory solution. Treatments and technologies have not been sufficiently effective or have caused adverse effects. A national survey in the USA showed that the majority of CAM users do not in fact perceive CAM as "alternative to" but rather as "complementary to" allopathic medicine.33
A recent survey showed that 78% of patients living with HIV/AIDS in the USA use some form of CAM (Figure 6).34,35,36
Figure 6 Use of CAM by patients living with HIV/AIDS in the USA
Sources: Anderson W et al., 1993; Mason F, 1995; Ostrow MJ et al., 1997.34,35,36
In developed country surveys of health-seeking behaviour and consumer satisfaction, a high degree of appreciation of the quality of care offered by CAM providers has been noted. The perceived relatively low risks associated with the use of procedural-based therapies of TM may also contribute to their popularity. In an analysis of data on malpractice for 1990 - 1996 in the USA, claims against chiropractors, massage therapists and acupuncturists were generally found to occur less frequently, and usually involved less severe injury, than claims against medical doctors. In a worldwide literature search, only 193 adverse events following acupuncture (including relatively minor events such as bruising and dizziness) were identified for a 15-year period.38
"It is imperative to acknowledge and affirm the essential role of conventional medicine with its capability to respond competently in the care of acute disease and trauma, its technical innovations in diagnosis and treatment and the escalating clinical applications of basic science discoveries. However, it is in the areas of comprehensive care and the management of chronic disease conditions that the more reductionistic, mechanistic, and organ-specific approach of conventional medicine can be lacking."37