by Hwee-Ling Koh
National University of Singapore
The World Health Organisation (WHO) defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” . This definition has remained unchanged since 7 April 1948. In this era of evidence based medicine, precision medicine and personalized medicine, how does one strive to achieve optimal health as defined by WHO? The key may be “Integrative Medicine”.
According to the Academic Consortium for Integrative Medicine and Health , integrative medicine and health 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 and lifestyle approaches, healthcare professionals and disciplines to achieve optimal health and healing. Founded in 2002, the Consortium comprises major medical schools and health systems in the United States of America, Canada and Mexico that are dedicated to the advancement of integrative medicine and health. Box 1 shows the key characteristics of Integrative Medicine.
In other words, using all appropriate evidence-based methods to help the body heal itself is the cornerstone of Integrative Medicine. The patient is treated as a whole entity and the approach is very individualized. Health promotion and wellness are emphasized as it is important to prevent a disease condition before it develops.
In the National Health Statistics Reports , combined data from 88,962 adults aged 18 and over collected as part of the 2002, 2007 and 2012 National Health Interview Survey were analyzed. The various complementary health approaches that were reportedly used in 2012 are shown in Table 1.
The top 3 most commonly used complementary health approaches are the non-vitamin, non-mineral natural products (which include herbs and probiotics), deep breathing exercises and finally yoga, Tai Chi (also known as Tai Ji) and Qi Gong. Other approaches that are gaining popularity in recent years but are not listed in Table 1 include mindfulness, art therapy, music therapy and pet therapy etc.
It is interesting to note the new evidence-based clinical practice guideline from the American College of Physicians (ACP) . Given that most patients with acute or subacute low back pain improve over time regardless of treatment, the ACP recommends that clinicians and patients should select non pharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If drug treatment is desired, nonsteroidal anti-inflammatory (NSAIDs) drugs or skeletal muscle relaxants (moderate-quality evidence) should be considered. For patients with chronic low back pain, clinicians and patients should initially select non pharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), Tai Chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). This is testament to the usefulness of some of these approaches and may pave the way for other clinical guidelines involving non pharmacologic treatment of other conditions in future.
Of the complementary health approaches listed in Table 1, natural products (which include herbal medicine), Tai Chi, Qi Gong and acupuncture are related to Traditional Chinese Medicine (TCM) or Chinese Medicine (both terms will be used interchangeably in this paper). TCM or Chinese Medicine is an ancient holistic system of health and healing emphasizing harmony and balance, through moderation and prevention. It is a complete system of health care with its unique theories of anatomy, health and treatment involving the concepts of Yin and Yang (pairs of opposites), 5 elements (metal, wood, water, fire and earth), qi (vital energy) and meridians (specific pathways in the body through which qi flows). When there is a smooth flow of qi and Yin and Yang are balanced, the person is in the pink of health. When there is obstruction to the flow of qi or an imbalance of the Yin and Yang, pain or other problems will arise. Chinese Medicine employs various methods as shown in Box 2. Some of these methods include Chinese herbal medicine, acupuncture and cupping. The therapeutic goals of TCM are to restore normal balance of Yin and Yang, smoothen the flow of qi and to stimulate the body’s innate healing ability. It is very individualized for a person, identifying and treating the underlying root causes.
Healthy living and healthy eating are important aspects of Chinese Medicine as the philosophy of TCM is its emphasis on prevention rather than cures. The practitioner treats the human body as a holistic entity, which is closely inter-related with nature. During consultation, the practitioner examines the patient, listens, smells, asks questions, takes the pulse, looks at the tongue and makes use of other diagnostic tools to help in the diagnosis. Through syndrome differentiation, the practitioner will then decide on the necessary treatment modalities. The ancient Yellow Emperor Internal Classic (Huang Di Nei Jing) long advocates the importance of healthy living, healthy eating and prevention of diseases. In Chinese Medicine, Yang Sheng (Health and Healing) is the promotion of health and longevity through good maintenance of physical health and good management and nurture of emotions.
Scientific evidence for Chinese Medicine
In this era of evidence based medicine, research is increasingly being carried out on Chinese Medicine. In this section, notable scientific evidence is presented. For Chinese herbal medicine, the work carried out by pharmaceutical scientist Youyou Tu and her team on the isolation and identification of the antimalarial compound artemisinin from a Chinese herb Artemisia annua resulted in the award of a Nobel Prize in Physiology or Medicine 2015 to Youyou Tu . Artemisinin and its derivatives are used clinically for the treatment of malaria . Another example is arsenic trioxide. It was identified from TCM and is now used as a United States Food and Drug Administration (FDA) approved drug for Acute Promyelocytic Leukemia (APL) . One of the most commonly used Chinese herbal medicine is the highly regarded Chinese ginseng root. It is recommended as a tonic for invigoration and fortification in times of fatigue and debility or declining capacity for work and concentration as well as for use during convalescence . Panax ginseng and other closely related herbs have been reviewed . A photograph of American ginseng (Panax quinquefolius), San qi (Panax notoginseng) and Chinese/Korean ginseng (Panax ginseng) is shown in Figure 1. Besides single herbs, Chinese formulae have also been studied scientifically. In particular, Professor Yung-Chi Cheng and his team studied PHY906 which is based on the formula Huang Qin Tang for treating gastrointestinal problems e.g. diarrhoea, cramps, nausea, vomiting. They found that it can improve chemotherapeutic efficacy of anticancer drugs and reduce chemotherapeutic side effects e.g. nausea and vomiting .
Other TCM methods e.g. acupuncture and Tai Chi have also been shown to be useful. Acupuncture has been found to be useful for many purposes including pain relief, prevent vomiting and reduce nausea due to chemotherapy, and may improve immune response amongst others . Likewise, Tai Chi has been found to have many health benefits including improving cognition and memory, treating and preventing mental disorders and preventing falls just to name a few [12,13]. It was also found to be cost effective in optimizing spending to prevent falls and maximize health gains in people with Parkinson’s disease .
It is exciting and rewarding to see the scientific basis behind the various practices that are very much a way of life for many people. More resources are needed to study the various modalities to assess their safety and efficacy.
The six B’s of Integrative Medicine
Of all the different complementary health approaches, some commonalities can be seen. Table 2 lists the six B’s linking various Integrative Medicine modalities. They are listed from top to bottom of the human body for ease of remembering and are not in order of importance, except for number 6 (Behaviour) which is not associated with any specific part of the body, to incorporate the other commonalities.
One can choose any approach or combination of approaches which may be suitable for oneself, that is, it is very flexible and individualized.
The goals of medicine encompass the relief of pain and suffering, the promotion of health and prevention of disease, avoidance of premature death and pursuit of peaceful death and the cure of disease when possible and the care of those who cannot be cured . Hence, the different methods to reduce suffering and promote health, prevent and cure diseases differ in their approaches to help the patient achieve optimal health and quality of life. Regardless of the specific name, what that works for an individual is considered good medicine. Harnessing the benefits of both Chinese and Western approaches to health and healing, as well as Integrative Medicine in general, may be part of the global solution to curb escalating healthcare costs, improve quality of life of patients and ameliorate the socio-economic impact of rising prevalence of non-communicable diseases. This is in line with the WHO’s goals set out in the WHO Traditional Medicine Strategy 2014-2023, namely, in harnessing the potential contribution of Traditional and Complementary Medicine to health, wellness, people centred health care and universal health coverage, as well as in promoting safe and effective use of Traditional and Complementary Medicine through the regulation, research and integration of such products, practices and practitioners into the health system, as appropriate.
More importantly, the individual is empowered to actively participate in his or her own health maintenance and healing in a lifelong manner. Should we be more open-minded, considerate and educated about the different approaches that are available, and keep the communication lines between patients and healthcare professionals open? Afterall, the common goals for all stakeholders are safe, efficacious, sustainable, accessible and affordable healthcare, and to achieve optimal health and quality of life.
- Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of WHO, no. 2, p. 100) and entered into force on 7 April 1948.
- Academic Consortium for Integrative Medicine & Health https://www.imconsortium.org/ Accessed 12 February 2017.
- Clarke TC, Black LI, Stussman BA, Barnes PM, Nahin RL. Trends in the Use of Complementary Health Approaches Among Adults: United States, 2002–2012. National Health Statistics Reports, no. 79, 10 Feb 2015, https://www.cdc.gov/nchs/data/nhsr/nhsr079.pdf
- Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Feb 14. doi: 10.7326/M16-2367. [Epub ahead of print]
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The author declares no conflict of interest and wishes to thank all the teachers and gurus of Integrative Medicine, as well as the patients and users of complementary health approaches for the generous sharing of their experiences.
About the Author
Associate Professor Hwee-Ling Koh obtained a BSc (Pharmacy)(Hons) and MSc (Pharmacy) from the National University of Singapore, as well as a PhD from the University of Cambridge (United Kingdom). She is a registered pharmacist with the Singapore Pharmacy Council. Her research areas include Traditional Chinese Medicine, quality control and safety of botanicals and drug discovery from medicinal plants. She is a technical/expert assessor with the Singapore Accreditation Council-Singapore Laboratory Accreditation Scheme (SAC-SINGLAS) and serves on various committees: Agri-Food and Veterinary Authority (AVA) Advisory Committee on Evaluation of Health Claims; Complementary Health Products Advisory Committee (Health Sciences Authority, Singapore); United States Pharmacopoeia Expert Panels: Adulteration of Dietary Supplements with Drugs and Drug Analogs Expert Panel, and Herbal Medicine Compendium, East Asia Expert Panel. She has published 3 books, namely, “A guide to medicinal plants: an illustrated, scientific and medicinal approach”, “Ginseng and ginseng products 101- what are you buying?” and “Medicinal plants and malaria: applications, trends and prospects”.