Mainstreaming Traditional Medicine in Public Health Discourse

ARVIND CHOPRA, MDARVIND CHOPRA, MD

DIRECTOR & RHEUMATOLOGIST, DIRECTOR & RHEUMATOLOGIST,

CENTER FOR RHEUMATIC DISEASES, PUNECENTER FOR RHEUMATIC DISEASES, PUNE

COCO--ORDINATOR, WHO ILAR COPCORDORDINATOR, WHO ILAR COPCORD

CHAIRMAN, ICMR TASK FORCECHAIRMAN, ICMR TASK FORCE MUSCULOSKELETAL DISORDERSMUSCULOSKELETAL DISORDERSCOCO--ORDINATOR, THE BONE AND JOINT DECADE INDIAORDINATOR, THE BONE AND JOINT DECADE INDIA

Website: rheumatologyindia.org

RIS-ICMR-EC-UCLAN CONFERENCE 2011, DELHI EQUITY AND ACCESS TO MEDICINE

2011, DELHI

DISCLOSUREDISCLOSURENONE RELEVANT TO THIS NONE RELEVANT TO THIS

PRESENTATIONPRESENTATION

Source: WHO, EXECUTIVE BOARD EB120/36 ,120th Session 14 December 2006; Provisional agenda item 4.13

Contribution of traditional medicine to public health

•• Traditional medicine Traditional medicine represents the represents the sum total of the sum total of the knowledge, skills andandpractices based on the theories, beliefs based on the theories, beliefs and experiences and experiences indigenous to different cultures, where explicable or not, used , where explicable or not, used in the in the maintenance of healthmaintenance of health, as well as , as well as in the in the preventionprevention,, diagnosisdiagnosis,,improvementimprovement oror treatmenttreatment of physical of physical and mental illnesses. and mental illnesses.

Bodekar & Kronenberg. A Public Health Agenda for Traditional , Complementary and Alternative Medicine American Journal of Public Health 2002, 92:10, 1582

Research and policy developments in TM have Research and policy developments in TM have tended to tended to neglect the wider public health neglect the wider public health dimensionsdimensionsPublic Health policy and research agenda in Public Health policy and research agenda in TMTM must consider social, cultural, political, and must consider social, cultural, political, and economic contextseconomic contextsAffordability, availability and cultural familiarity are Affordability, availability and cultural familiarity are the key attractions of TM for the communitythe key attractions of TM for the communityDistinguish between qualified practitioners and Distinguish between qualified practitioners and practices to achieve incorporation of TM into practices to achieve incorporation of TM into naitnal health care programs and systemsnaitnal health care programs and systems

Bodeker G, Kronenberg F. A Public Health Agenda for Complementary, Alternative and Traditional (indigenous) Medicine. American Journal of Public Health 2002, 92(10):1582-1591.

The construction of a broad The construction of a broad public health agenda public health agenda for T/CAM for T/CAM is in order. is in order.

Such agenda should evolve with an awareness of Such agenda should evolve with an awareness of social, cultural, and political dimensions and social, cultural, and political dimensions and should address should address

Values (equity, ethics), Values (equity, ethics), sustainabilitysustainability

RegulationRegulationFinancingFinancingknowledge generation, knowledge generation, knowledge management,knowledge management,capacity building capacity building

research environmentresearch environment

WHO TRADITIONAL MEDICINES STRATEGYWHO TRADITIONAL MEDICINES STRATEGY(2002(2002--2005)2005)Focus onFocus on

PolicyPolicysafety, efficacy, and qualitysafety, efficacy, and qualityAccessAccessRational useRational useFOR ACTION TO MAXIMIZE THE FOR ACTION TO MAXIMIZE THE POTENTIAL ROLE OF TM/CAM IN PUBLIC POTENTIAL ROLE OF TM/CAM IN PUBLIC HEALTHHEALTH

Within each of these areas, CHALLENGES Within each of these areas, CHALLENGES FOR ACTION ARE IDENTIFIEDFOR ACTION ARE IDENTIFIED

Bodekar and Kronenberg. A Public Health Agenda for Traditional, Complementary and Alternative Medicine Am J Public Health 2002,92:1583

A vast informal A vast informal Silent Health Care Sector Silent Health Care Sector exists in all countries.exists in all countries.No comprehensive picture of this sector No comprehensive picture of this sector exists as yet in any countryexists as yet in any countryTo identify, we need to studyTo identify, we need to study

Trends and demographicsTrends and demographicsQuality of services Quality of services Any model for integration or partnership Any model for integration or partnership between TM and Modern Medicine for effective between TM and Modern Medicine for effective and affordable health careand affordable health care

G Bodekar, P Kronenberg. A Public Health Agenda for Traditional G Bodekar, P Kronenberg. A Public Health Agenda for Traditional ,,Complementary and Alternative Medicine. Complementary and Alternative Medicine. American Journal of Public Health American Journal of Public Health –– 2002, 92:10, 15892002, 92:10, 1589

EQUITY:EQUITY:Industrialized Countries: CAM assocaited with Industrialized Countries: CAM assocaited with the rich & educatedthe rich & educated

For ethnic minorities, TM may be the first port of callFor ethnic minorities, TM may be the first port of call

Separate but unequal care systemSeparate but unequal care system

Equity perspective differs in developed Equity perspective differs in developed and developing countries. The million and developing countries. The million dollar question is to keep medicine dollar question is to keep medicine affordableaffordable andand accessibleaccessible

Why do we need to generate modern science evidence based

Ayurveda?Prescription drug usePrescription drug useNewer drugsNewer drugsNewer interNewer inter--medicinal system medical medicinal system medical care management strategies care management strategies To Position visTo Position vis--àà--vis other systemsvis other systemsGlobal use Global use

Who needs it?

SIR RAM NATH CHOPRA (1882-1973)

Sowed the seeds of self reliance and triggered the movement of scientific research on traditional ‘Indian medicine’ (V Ramalingaswami & GV Satyavati 1982)Chaired several Committeee on Indigenous Chaired several Committeee on Indigenous Systems of Medicine in 1920sSystems of Medicine in 1920s--1940s1940sRecommended integration of Indian and Western Recommended integration of Indian and Western Systems which still remains a far crySystems which still remains a far cry

……WE ARE 70-80 YEARS LATE

• Chopra A, Lavin P,Patwardhan B, Chitre D.

Randomized double blind trial of an Ayurvedic plant derived formulation for treatment of rheumatoid arthritis. J Rheumatology 2000;  27: 1365‐1372

• Chopra A, Lavin P, Patwardhan B, Chitre D.

A 32 – Week Randomized, Placebo‐Controlled clinical evaluation of RA‐11, an Ayurvedic drug on Osteoarthritis of the knees. J Clinical Rheumatology 2004; 10:236‐245

2000‐2003• Chopra A.

Ayurvedic medicine and arthritis. Rheum Dis Clinics N America 2000; 26: 133‐144

• Chopra A, Patil J, Doiphode V, Patwardhan B.Exploring Ancient Ayurveda for Rheumatology: Traditional Therapy, Modern Relevance and Challenges. APLAR J Rheumatology 2001; 4: 190‐199

• Chopra A, Doiphode V. Ayurvedic Medicine: Core Concept, Therapeutic Principles, and Current Relevance. Med Clinics N America 2002; 86: 75‐89

• Ayurvedic medicine (Web site: Physicians Information and Education Resource (PIER), American College of Physicians (ACP)http://www. pier.acponline.org

1995‐2000

2003 (IRACON ORATION)• Chopra Arvind

Rheumatology: Made in India (Camps, COPCORD, HLA, Ayurveda, HAQ, WOMAC and Drug Trials)J Indian Rheum Assoc 2004;12:43‐53

2003-2008 (NMITLI, A GOI CSIR PROJECT)• A controlled drug trial to evaluate Ayurvedic derived Shunthi-Guduchi based standard

formulations in the treatment of Osteoarthritis (OA) Knees: A Government of India NMITLI ARTHRITIS PROJECT Ann Rheumatic Dis 2006; 65: 226-227 (Abstract).

• Comparing Ayurvedic (Indian) Herbal drugs and HCQS (hydroxychloroquin sulfate) in the Treatment of Rheumatoid Arthritis (RA): A Randomized, Double Blind, Multi-centric Exploratory Drug Trial of 24 Weeks Duration Arthritis & Rheum 2007; 56 (9): 394-395) (Abstract)

• A 24 Week RDB Multicentric Trial To Demonstrate Equivalence Between Individual Drugs For Symptomatic Treatment of OA knees: Ayurvedic (Indian Asian) , Glucosamine and Celecoxib Arthritis & Rheum 2008; 58 (12): 4032 (Abstract)

• A Randomized Controlled Exploratory Evaluation Of Standardized Ayurvedic Formulations In Symptomatic Osteoarthritis Knees: A Government Of India NMITLI Project Evidence-Based Complementary and Alternative Medicine (eCAM) 2011; doi: 10.1155/2011/724291 .

2009‐2010• Ayurveda Modern medicine interface: A critical appraisal of studies of Ayurvedic medicines to treat 

Osteoarthritis and Rheumatoid arthritis. J Ayurveda Integrative  Med (J‐AIM) 2010;  V1 (3): 190‐198

• Efficacy and safety of Ayurvedic medicines: Recommending equivalence trial design and proposing safety index.International J Ayurveda Res (IJAR) 2010; V1 (3): 175‐180

NMITLI ARTHRITIS PROJECT 2002-2007 (New millennium Indian Technology Leadership Initiative,

A Project of CSIR , GOI )

DR ARVIND CHOPRA, MDPRINCIPAL INVESTIGATOR & CO-ORDINATOR

Director & Chief Rheumatologist, CENTER FOR RHEUMATIC DISEASES (CRD), PUNE

Website: www.rheumatologyindia.org

Optimization studies, Final formulation, Stability, Doses, Labeling &

Clinical Trial Material

1414

NMITLI ARTHRITIS PROJECT

Best Medicinal Plants Short listed & Procured

NBRIBotanical,

Morphological & Other tests

ISHSPreparation of Test materials

I I I M (RRL)Chemistry

Profile,fingerprinting

PRE-CLINICAL – PHARMACOLOGY CHEMISTRY, MANUFACTURING, CONTROLS

IRSHA /ARI / ISHS

Clinical Studies-Exploratory, Dosing & Final CRD, KEM, SPARC, AIIMS, NIMS

Overlap of Activities, Concurrent development,

EVALUATION & COLLATION

2 0 0 2 TO

2 0 0 7

A Randomized Controlled Exploratory Evaluation Of Standardized Ayurvedic Formulations In Symptomatic Osteoarthritis Knees: A Government Of India NMITLI Project.Evidence-Based Complementary andAlternative Medicine (eCAM) 2011; doi: 10.1155/2011/724291 .

1515

Randomized Double Blind EXPLORATORY (N=245)Placebo & Active Control, 7 Arm, 16 week Multicenter

Randomized Single Blind DOSING (N=96)4 Arm, 6 weeks, Single Center

Randomized Double Blind EQUIVALENCE TRIAL (N=440) Active Control (Glucosamine, Celecoxib)

4 arm, 24 weeks Multicenter

2002

2007

NMITLI DRUG TRIALS: OA KNEES

EXTENTION PHASE Follow up (N=100) Maintain Double Blind with Active Comparator Cross Over (for safety)

3 Arm (One Ayurvedic Drug), 24 WEEKS Single center

CONCEPT TO PRODUCT

A 24 week RDB multi-centric trial to demonstrate

equivalence between individual drugs for

symptomatic treatment of OA knees: Ayurvedic

(Indian Asian), Glucosamine and Celecoxib NEW MILLENIUM INDIAN TECHNOLOGY LEADERSHIP INITIATIVE (NMINEW MILLENIUM INDIAN TECHNOLOGY LEADERSHIP INITIATIVE (NMITLI)TLI)

PRESENTATION ON BEHALF OF THE NMITLI ARTHRITIS GROUP PRESENTATION ON BEHALF OF THE NMITLI ARTHRITIS GROUP

ARVIND CHOPRA, MDARVIND CHOPRA, MDPRINCIPLE INVESTIGATOR & CLINICAL COPRINCIPLE INVESTIGATOR & CLINICAL CO--ORDINATORORDINATOR

DIRECTOR & CHIEF RHEUMATOLOGIST, DIRECTOR & CHIEF RHEUMATOLOGIST, CENTER FOR RHEUMATIC DISEASES (CRD), PUNECENTER FOR RHEUMATIC DISEASES (CRD), PUNE

((www.rheumtologyindia.orgwww.rheumtologyindia.org ))

COCO--ORDINATED BYORDINATED BYCOUNCIL OF SCIENTIFIC & INDUSTRIAL RESEARCH (CSIR), COUNCIL OF SCIENTIFIC & INDUSTRIAL RESEARCH (CSIR),

GOVERNMENT OF INDIAGOVERNMENT OF INDIAPresented in the Annual Meeting of the American College of RheumPresented in the Annual Meeting of the American College of Rheumatologyatology

20082008

1919

NMITLI OA STAGE III/1NMITLI OA STAGE III/1

OA-01 Vs CELECOXIB DIFFERENCE IN THE DIFFERENCE IN THE MEAN CHANGE (BASELINE TO COMPLETIONMEAN CHANGE (BASELINE TO COMPLETION--PER PROTOCOL ANALYSIS ): TRIAL OF EQUIVALENCEPER PROTOCOL ANALYSIS ): TRIAL OF EQUIVALENCE

Variable OA-01 Celecoxib Difference in mean change

95% CI TARGET

Equivalence Range

PainVAS

(0-10cm)

-2.36 -2.03 -0.33 -1.02, 0.36 ± 1.5cm

W_Pain

(0-20)

-2.87 -2.39 -0.48 -1.48, 0.52 ± 2.5

W_Diff

(0-68)

-8.85 -7.94 -0.91 -4.29, 2.47 ± 8.5

20

NMITLI OA STAGE III/1 NUMBER OF PATIENTS WITH ADVERSE EVENTS (AE)-

NUMBER (Percent) (N=418)

AE OA-01(n=103)

OA-03(n=102)

CXB(n=105)

GLU(n=108)

EPIGASTRIC BURNING/ PAIN

9 (8.7) 11 (10.7) 12 (11.4) 4 (3.7)

NAUSEA / VOMITTING

3 (2.9) 3 (2.9) 3 (2.8) 2 (1.9)

DIARRHOEA 0 0 1 (0.9) 1 (0.9)

CONSTIPATION 1 (0.9) 3 (2.9) 4 (3.8) 4 (3.7)

ORAL ULCERS 1 (0.9) 1(0.9) 1 (0.95) 1 (0.8)

SKIN RASH & ITCHING

1 (0.96) 1 (0.97) 2 (1.9) 1 (0.8)

Abnormal SGPT 4 (3.8) 3 (2.9) 0 0

ACR 2008ACR 2008 2121

NMITLI OA STAGE III/1 URINARY CTX – II MEAN CHANGE (95% CONFIDENCE INTERVAL) FROM BASELINE TO COMPLETION: (N=233)

TREATMENTGROUP

N MEAN(geometric)

95% CI

OA-01 61 1.63 1.04, 2.54

OA-03 59 1.20 0.83, 1.75

CELECOXIB 57 0.99 0.65, 1.51

GLUCOSAMINE 56 1.08 0.74, 1.57

EXPLANT OA HUMAN CARTILAGE MODELGLYCOSAMINOGLYCANSRelease (chondroitin sulfate)

AGGRECANRelease

Nitrous Oxide Release

Short term Long Term

C Decrease* - - -

C+G No effect Decrease* Decrease DecreaseCelecoxib Decrease* - - -

Glucosamine Decrease* - Decrease -

An Ayurvedic formulation inhibits damage of cartilage matrix from Osteoarthritis Knees (Phytother Res 2008; 22) Venil Sumantran*, Kulkarni A*, Chandwaskar R*, Boddul S*, Koppikar SJ*, Patwardhan B**, Chopra A***, Wagh UV* *Interactive Research School of Health Affairs (IRSHA), PUNE **ISHS, University of Pune***Center for Rheumatic Diseases, Pune

*Significant compared to untreated cartilage, p<0.05

CAN AYURVEDA BE DELIVERED IN A CAPSULE ?

• None of the Ayurvedic drug trials mentioned have tried to evaluate the relavance, if any, of the fundamental Dosha & other crirtical Ayurvedic measures and attributes to the therapeutic outcome.

• Customized Ayurvedic holistic approach is difficult to validate. This approach has a tremendous commonsense appeal

•Pragmatic Drug trials or ‘Black Box’ Design trials may provide more true to life answers

•PRAGMATIC VERSUS EXPLANATORY

Single drug Vs ‘black box’ care

Disease centric Vs holistic

Disease specific drug Vs designer drug

•General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine. WHO, Geneva. WHO/EDM/TRM/2000.•MacPherson. Pragmatic Clinical Trials. Comp Ther Med 2004; 12: 136- 140•Gagnier JJ et al. Reporting Randomized Controlled Trials of Herbal Interventions: An Elaborated CONSORT Statement. Ann Intern Med 2006; 144: 364-367

How do we build in ‘Safety’ performance into the ‘Efficacy

Success Equation’?Other important issues:Other important issues:

Quality of lifeQuality of lifeToleranceToleranceComplianceComplianceSatisfactionSatisfaction

Sarmukaddam, Tillu and Chopra. Efficacy and safety of Ayurvedic medicines: Recommending equivalence trial design and proposing safety index. International J Ayurveda Res (IJAR) 2010; V1 (3): 175‐180

PROTOCOLTo determine clinical research

methods best suited for validating Ayurvedic medicines

Dr Arvind Chopra, MD Dr Arvind Chopra, MD (Rheumatologist)(Rheumatologist)Dr Sanjeev Sarmukaddam, PhD Dr Sanjeev Sarmukaddam, PhD (Bio(Bio--Statistician)Statistician)

Dr Girish Tillu, MD Dr Girish Tillu, MD (Ayurvedic Physician)(Ayurvedic Physician)

Center for Rheumatic Diseases, Center for Rheumatic Diseases, PunePune

www.rheumatologyindia.orgwww.rheumatologyindia.org

AYURVEDA and BIO-MEDICINE INTERFACE

DR ARVIND CHOPRA, MD

Director & Chief Rheumatologist,

CENTER FOR RHEUMATIC DISEASES (CRD),

PUNE

Website: www.rheumatologyindia.org

WORLD AYURVEDA CONGRESS BANGALORE 2010

AYURVEDA, MODERN MEDICINE & RESEARCH (in a socioeconomically challenged scenario)

MY RECOMMENDATIONObservational Longitudinal Data Bases OF Observational Longitudinal Data Bases OF Ayurvedic InterventionsAyurvedic InterventionsCompare WHOLE SYSTEM PACKAGE To Compare WHOLE SYSTEM PACKAGE To Standard of Care Modern Medicine In Standard of Care Modern Medicine In Difficult To Treat Disorders; Long Term StudiesFocus OnFocus On CLINICAL ENDPOINTSIDENTIFY SUBSETS WITH IDENTIFY SUBSETS WITH BEST RESPONSEHIGHLIGHT SAFETY ADVANTAGEEvaluate COMBO (AyurMod) Strategy Evaluate COMBO (AyurMod) Strategy Move towards Global use Move towards Global use

AYURVEDA, MODERN MEDICINE & RESEARCH (in a socioeconomically challenged scenario)

MY RECOMMENDATIONBUT TO BEGIN WITHBUT TO BEGIN WITH………………………………………………..In India, Ayurveda Should Be Provided a level In India, Ayurveda Should Be Provided a level Ground With Modern MedicineGround With Modern MedicineNational Health Policy, Community Health & National Health Policy, Community Health & Medical Research Medical Research Expose Modern Medicine Students and Doctors Expose Modern Medicine Students and Doctors to Ayurvedato AyurvedaVaidya Scientist Program (FRLHT/ IIM, Bangalore Vaidya Scientist Program (FRLHT/ IIM, Bangalore

INTERFACE & INTEGRATION SHOULD BE IN PLACE & BE VISIBLE IN ALL MAJOR MEDICAL INSTITUTIONS

Dina Czeresnia. The concept of health and the difference between prevention and promotion Cad. Saude Publica, 1999, 15(4) : 701 -707

Epidemiological conceptsEpidemiological concepts are the basis of are the basis of preventive public health discoursepreventive public health discourseHealth promotion Health promotion projects knowledge from projects knowledge from epidemiological risk studies.epidemiological risk studies.Formal aim of Formal aim of risk analysis risk analysis is to infer causality, is to infer causality, to assess the probability of disease events in to assess the probability of disease events in individuals and or populations exposed to given individuals and or populations exposed to given factorsfactorsMay delete important aspects of the respective May delete important aspects of the respective phenomena.phenomena.Limits of risk estimates must be properly Limits of risk estimates must be properly understood; donunderstood; don’’t ignore outlierst ignore outliers

Our medical curriculum is highly skewed away from the community and our young doctors of today are poorly equipped to tackle community “aches and pains”.

Several perceptions and attitudes were recorded by COPCORD which were then put together on a common platform to counsel and treat patients (and research). Every doctor working with the community should have some grounding in the community KAP (knowledge, attitude and practices).

Doctors ought to have grass root knowledge about the “way” and “quality” of life in the community before they begin to preach on ‘WHAT IS RIGHT AND WHAT IS WRONG’.

COPCORD Bhigwan survey recorded high use of oral tobacco in healthy and cases with rheumatic pain. Despite our loud condemnation of tobacco its use (tobacco)remains rampant. This is despite the fact of an enviable prolonged (1996 till date) rapport with the community

The villagers were aware of ‘oral tobacco and oral cancer’ but that did not deter its use. They believe that the use of tobacco is traditional and that it helps them in various ways. Nothing attracts the community more than tobacco (it is relatively cheap) to find solace, peace and freedom (though transient) from fatigue, pain and boredom of the routine. The bowels move smoothly with quick complete evacuation.

I believe that our rhetoric (condemning tobacco) will only work if we can provide the villagers with an equally soothing alternative.

Why do people use TM?• improve their health and well-being• relieve symptoms associated with chronic, even terminal,

illnesses or the side effects of conventional treatments for them

• holistic health philosophy • transformational experience • greater control over one’s own health

TM practitioners try to treat – physical and biochemical manifestations of illness– nutritional, emotional, social, and spiritual context in which the illness

arises

The overwhelming majority of patients using TM/CAM approaches do so to complement conventional care rather than as an alternative to conventional care

TM & INDIAN LIFE• From birth to death

• Preventive, promotive and curative• Kitchen is the pharmacy in every Indian

home• Extensive use of SPICES, turmeric, black

pepper, sunthi, honey, ghee, methi seeds, castor oil, churan, ajawan,amla,chawan prash, and many many more……….

• YOGA AND MEDITATION• Dictated by geography, culture and local

traditions

SH SWAMI RAMDEV JI MAHARAJ

DURING THE LAST DECADE OR SO, THIS YOGA GURU HAS SPREAD

THE CULTURE OF YOGIC EXERCISES, BREATHING AND MEDITATION

INTO ALMOST EVERY INDIAN HOME THROUGH EXTREMELY POPULAR

TV SHOWS AND CAMPS.

THIS is UNPRECEDENTED. A REMARKABLE EXAMPLE of TRADITIONAL MEDICINE for PUBLIC HEALTH

SAVE ME

Tissue Culture Studies in Boswellia serrata Roxb. : In Vitro Production of Potent Anti-Inflammatory

Metabolite ‘Boswellic Acid’

GuideDr. T. D. Nikam

Co-GuideDr. Arvind Chopra

A Ph.D Dissertation (University of Pune) By Ravi P Ghorpade

Isolated Inoculated 28 days

Maintained in a glass house with low light intensity (191.1 µmol m-2s-1); high humidity (90%) and temperature (26 ±2 0C)

In vitro germinatedzygotic embryo

EmbryoGreenfruits

Resulting seedlings were transferred to natural field conditions with max light intensity (765.7 µmol m-2s-1);temperature (21 – 28 0C) and humidity (65 – 80%)

Plantlets were transferred to small pot sand soil (1:1)

Forest tree

In vitro Embryo Germination for Conservation of Boswellia serrata .

Ghorpade et al., 2010 Physiol Mol Biol Plant 16(2):159-165

Maria-Costanze Torri, and Julie Laplante. Enhancing innovation between scientific and indigenous knowledge : pioneer NGO’s in India Journal of Ethnobiology and Ethnomedicine 2009, 5:29, 1

• Identify innovation capacity, management practices and institutions developed by communities & local actors based on traditional knowledge

• Integration of local and scientific knowledge to anchor practices

• Enhanced social capital at village and network level

• Revitalization of perceived traditions• Caution: transformation into health commodities with

new elites

• Model: FRLHT (I-AIM), Bangalore

Bodekar & Kronenberg.A Public Health Agenda for Traditional , Complementary and Alternative Medicine. Am J Public Health – 2002, 92:10, 1589

RESEARCH DOMAIN• Randomized Controlled Clinical Trials (RCT)

Is this the best way forward for TM?• Ethnographic, epidemiological (survey & cohort) and

observational data (public health domain)• Epistemological Studies: CHALLENGE FOR TM/CAM• Diseases for which current conventional treatment regimens

are unsatisfactory

• Prevention of disease is a cornerstone of many TM– diet and nutrition– traditional forms of exercise ( e.g Yoga, tai chi)– stress reduction

Comparative evaluations and newer treatment paradigms– TM and Conventional Medicine

• TRADITIONAL MEDICINE• ?TRADITIONAL HEALTH PRACTICES • COMPLEMENTARY & ALTERNATIVE MEDICINE

• ETHNIC MEDICINE /?NON CONVENTIONAL MEDICINE/ ?NON 

ORTHODOX MEDICINE/ ?NON MAINSTREAM MEDICINE

IT IS A COMPLEX SUBJECT…..BUT WE MUST BEGIN..WHAT IS THE TARGET ?

WHOM ARE WE TARGETTING?

WHAT IS THE EXPECTED OUTCOME??? 

WILL THERE BE A FOLLOW UP?

THINK  LOCAL  ACT GLOBAL AN AUDIT /WHITE PAPER  

Ref: Vincent M B Silenzio. What is the role of Complementary and Alternative Medicine in Public Health. Am J Public Health, 2002, 92:10, 1562

• Determine the extent of TM in a society• Determine efficacy and effectiveness• Acknowledge the diversity and tapestry of care

resources for public health– Lead to a broad conceptualization and reconstruction of

public health care system• Acknowledge cultural issues• Adopt less reductionist approach to preserve

the habitat or milieu interior of TM• RECKON BIODIVERSITY, ECOSYSTEMS, ECONOMICS

& EQUITY

TM AS A COMPONENT OF PUBLIC HEALTH

interface

inte

grat

e

WHOWHO’’s Goal in Medicines Goal in Medicine

To help save the livesTo help save the lives

Improve health by Improve health by

Ensuring Quality, Efficacy, Safety and Rational use of Ensuring Quality, Efficacy, Safety and Rational use of

medicines ( including TM)medicines ( including TM)

Promoting Equitable and Sustainable Access to Essential Promoting Equitable and Sustainable Access to Essential

Medicines (especially the poor)Medicines (especially the poor)

The interface between TM, public health and The interface between TM, public health and

biodiversity/ ecosystems involves a number of biodiversity/ ecosystems involves a number of

relevant and contemporary issuesrelevant and contemporary issues

ZP, 2005

Traditional Medicine IS AN

IMPORTANT PUBLIC HEALTH ISSUE

THANK YOU THANK YOU DR ARVIND CHOPRA, MDDR ARVIND CHOPRA, MD

Please visit our Website:Please visit our Website:www.rheumatologyindia.orgwww.rheumatologyindia.org