Considering traditional and folklore medicine in regional health systems

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Sir,

We read with great interest the article of Gerber and colleagues entitled “Use of complementary and alternative medicine among midlife Arab women living in Qatar” published in the Eastern Mediterranean Health Journal (1). They assessed the prevalence of the use of complementary and alternative medicine (CAM) in Qatar through a cross-sectional study in 2011–2012 (1). A high prevalence of CAM use among inhabitants of the Eastern Mediterranean region, as reported by the authors, is a common finding in our Region. It should be emphasized that it is part of the culture in the region to use CAM, at least for common disorders and this is usually learned in families. The use of nutritional interventions (based on folk or traditional medicine) as a complement to other treatments is quite common and may have been underestimated in Gerber and colleagues’ study (2). For instance, it is part of the culture to abstain from certain foods during a common cold and this may have arisen through interaction of science and culture over the centuries. Furthermore, this region has endemic cultivars of many special medicinal plants. The easy access to these herbal remedies, together with the above-mentioned cultural background, have resulted in their higher usage even in more complicated chronic conditions, for example in patients with chronic kidney failure on haemodialysis (3).

With regard to the data in the study, there seems to be some missing data. In Table 4, the percentages in somatic and psychological symptoms sum to less than 100% and the total number of patients is not equal to those mentioned in the table (739 and 716, respectively) (1).

Nonetheless, health policy-makers should consider seriously the findings of this study. The high prevalence of use of CAM, which we believe may be an underestimation, warrants a more active role of health systems in standardization as well as scientific promotion of CAM. While the proper use of CAM could be health promoting even in chronic noncommunicable diseases (4–7), improper use could be perilous. As an example, in a recent series of severe drug-induced liver disease, the role of herbal remedies has been prominent (8,9).

The suggestion of WHO for Member States in developing countries to integrate CAM into their health systems and promote research into and practice of national traditional medicine where appropriate is a timely proposal (6,10).

Regarding health inequities, limitations and challenges (11), the Islamic Republic of Iran started to follow the above-mentioned recommendations in its national health system many years ago and boosted the process after of announcement of new “General Health Polices” by the supreme Leader of the Islamic Republic of Iran (10,12). An integrated approach in education, therapeutics and research focusing on standardization of CAM practice has been the basis for these activities. The importance of efficacy and safety should never be forgotten in any part of practising medicine, even in CAM.

Mehdi Pasalar^1,2 and Kamran Bagheri Lankarani¹

¹Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to Mehdi Pasalar: This email address is being protected from spambots. You need JavaScript enabled to view it.).

²Essence of Parsiyan Wisdom Institute, Traditional Medicine and Medicinal Plant Incubator, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran.

References

1. Gerber LM, Mamtani R, Chiu YL, Bener A, Murphy M, Cheema S, et al. Use of complementary and alternative medicine among midlife Arab women living in Qatar. East Mediterr Health J. 2014 Sep;20(9):554–60. PMID:25343468
2. 2. Pasalar M, Zarshenas MM, Lankarani KB. Good Digestion is a key element for healthy hearts: an appealing concept from Avicenna’s viewpoint. Med Hypothesis Discov Innov Interdisciplinary J. 2014;1(1):15–7.
3. 3. Roozbeh J, Hashempur MH, Heydari M. Use of herbal remedies among patients undergoing hemodialysis. Iran J Kidney Dis. 2013 Nov;7(6):492–5. PMID:24241097
4. 4. Pasalar M, Lankarani KB, Mehrabani D, Tolide-ie HR, Naseri M. The Effect of Descureania Sophia L. and Prunus Domestica L. in Prevention of Constipation among Iranian Hajj Pilgrims, Saudi Arabia. Res J Pharm Biol Chem Sci. 2013 April-June 2013;4(2):1195-204.
5. 5. Freeman MP, Fava M, Lake J, Trivedi MH, Wisner KL, Mischoulon D. Complementary and alternative medicine in major depressive disorder: the American Psychiatric Association Task Force report. J Clin Psychiatry. 2010 Jun;71(6):669–81. PMID:20573326
6. WHO traditional medicine strategy: 2014–2023. Geneva: World Health Organization; 2013. 76 p.
7. Ansari M, Farzin D, Mosalaei A, Omidvari S, Ahmadloo N, Mohammadianpanah M. Efficacy of topical alpha ointment (containing natural henna) compared to topical hydrocortisone (1%) in the healing of radiation-induced dermatitis in patients with breast cancer: a randomized controlled clinical trial. Iran J Med Sci. 2013 Dec;38(4):293–300. PMID:24293782
8. Teschke R, Wolff A, Frenzel C, Schulze J. Review article: Herbal hepatotoxicity–an update on traditional Chinese medicine preparations. Aliment Pharmacol Ther. 2014 Jul;40(1):32–50. PMID:24844799
9. Chalasani NP, Hayashi PH, Bonkovsky HL, Navarro VJ, Lee WM, Fontana RJ; Practice Parameters Committee of the American College of Gastroenterology. ACG Clinical Guideline: the diagnosis and management of idiosyncratic drug-induced liver injury. Am J Gastroenterol. 2014 Jul;109(7):950–66, quiz 967. PMID:24935270
10. Pasalar M. Promotion of traditional Persian medicine; a neglected necessity. Arch Iran Med. 2014 Aug;17(8):593. PMID:25208355
11. Lankanari KB; Kamran Bagheri Lankanari. The experiences of the Islamic Republic of Iran on tackling health inequities. Glob Health Promot. 2009; Suppl 1:52–3. PMID:19477834
12. Lankarani KB, Alavian SM, Peymani P. Health in the Islamic Republic of Iran, challenges and progresses. Med J Islam Repub Iran. 2013 Feb;27(1):42–9. PMID:23479501

Author response

We are appreciative of the comments received as a Letter to the Editor in reference to our article “Use of complementary and alternative medicine among midlife Arab women living in Qatar” published in the Eastern Mediterranean Health Journal, 2014, 20(9):554–560.

The purpose of our cross-sectional study was to investigate the use of complementary and alternative medicine (CAM) and the correlates of its use among women in their midlife years who were attending primary care centres in Qatar. As mentioned, our study findings cannot be generalized to all women living in Qatar. That being said, we agree that the use of CAM, especially nutritional and herbal remedies, is common in the Eastern Mediterranean region and may be considered as part of the culture.

Furthermore, there are no missing data in Table 4 as alluded to in the Letter to the Editor.  Table 4 presents the use of CAM for women reporting vasomotor, somatic, and psychological symptoms.  The first row presents the use of any type of CAM for women with each type of symptom.  These percentages range from 38.1% use of any form of CAM for women with psychological symptoms to 41.7% among women with vasomotor symptoms.  The total number of women in the rows below “Any type” consists of women who use the specific methods of CAM and these numbers sum to over 100% of “Any type” since women often use more than one method.

We agree that CAM should be used where appropriate and that patient safety should never be compromised. Additionally, both health care providers and patients need to be informed regarding the benefits and limitations of CAM use. We agree that policy-makers should pay heed to these studies and formulate national guidelines for the use of CAM in conventional health care settings when appropriate.

Linda M. Gerber,1 Ravinder Mamtani,2 Ya-Lin Chiu,1 Abdulbari Bener,3 Madhuvanti Murphy,4 Sohaila Cheema2 and Mohamud Verjee2

¹Weill Cornell Medical College, New York, United States of America (Correspondence to L.M. Gerber: This email address is being protected from spambots. You need JavaScript enabled to view it.).

²Weill Cornell Medical College in Qatar, Doha, Qatar.

³Hamad Medical Corporation, Doha, Qatar.

⁴The University of the West Indies, St Michael, Barbados.