traditional and modern medicine: harmonizing the two approaches

TRADITIONAL AND MODERN MEDICINEHARMONIZING THE TWO APPROACHES

WORLD HEALTH ORGANIZATIONWestern Pacific Region

2000

A Report of the Consultation Meetingon Traditional and Modern Medicine:Harmonizing the Two Approaches,

22-26 November 1999, Beijing, China

© World Health Organization 2000

This document is issued by the World Health Organization -Regional Office for the Western Pacific (WHO/WPRO) for general

distribution. All rights are reserved. Subject to due acknowledgement toWHO/WPRO, this document may, however, be freely reviewed,

abstracted, reproduced or translated, in part or in whole, provided thatsuch is not done for or in conjunction with commercial purposes and

provided that, if it is intended to translate or reproduce the entire work, orsubstantial portions thereof, prior application is made to the Publications

Unit, WHO/WPRO, Manila, Philippines.

The views expressed in this Report are those of the participants in theConsultation Meeting on Traditional and Modern Medicine: Harmonizingthe Two Approaches, 22-26 November 1999, Beijing, China, and do not

necessarily reflect the policy of the World Health Organization.

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CONTENTS

page

Summary 1

1. Introduction 4

1.1 Objectives of the meeting 51.2 Participants 51.3 Organization 6

2. Proceedings 72.1 Opening ceremony 72.2 Purpose of the meeting, procedures 8

and outcomes2.3 Presentations 82.4 Group activities 92.5 Plenary sessions 92.6 Closing session 9

3. Traditional medicine 113.1 Background and characteristics 113.2 Changes in trends of usage 133.3 Consumers, government and 14

other stakeholders

4. Traditional and modern medicine 164.1 Integration of traditional medicine 16

with modern medicine4.2 The need for harmonization of 17

traditional and modern medicine

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5. Evidence and traditional medicine 19

5.1 Acquisition of traditional medical 19knowledge

5.2. Evidence–based health care practice 20

6. Evidence of practice of traditional medicine 23

6.1 Basic science research in acupuncture 236.2 Clinical research on acupuncture 246.3 Basic science research in 25

herbal medicine6.4 Clinical research in herbal medicine 27

7. Harmonizing traditional and modern 32medicine: Conclusions andrecommendations

7.1 Towards harmonization of 32traditional and modern medicine

7.2 Operational recommendations 42

ANNEXES:

Annex 1- List of Participants 47

Annex 2- Opening Speech of Dr Shigeru Omi, 59WHO Regional Directorfor the Western Pacific

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TRADITIONAL AND MODERN MEDICINE: HARMONIZING THE TWO APPROACHES

SUMMARYThe major aims of the meeting held in Beijing China, from 22

to 26 November 1999 were to evaluate the contemporary role oftraditional medicine in maintaining health, to develop a scientificapproach to policy–making in traditional medicine, and, ultimately,to assess how traditional medicine can be harmonized with modernmedicine. The meeting also provided a forum for identifying researchrequirements in traditional medicine.

The meeting was attended by 24 temporary advisers, threeconsultants, one secretariat staff from the WHO Regional Officefor the Western Pacific, and 19 observers.

Participants presented review papers on past research, barriersto the acceptance of traditional medicine, research methodology andevidence–based medicine. Participants were divided into sub–groupsto deal with acupuncture, herbal medicine and socio–economicaspects relevant to harmonization.

In the course of these discussions, the meeting concluded thatthere were challenges to the harmonization of traditional and modernmedicine. Better access to information, facilitating appropriateclinical trials, improving rigour in clinical trials, improving educationand collaboration of practitioners and researchers, and respectingtraditional practices in research, were all identified as importantsteps towards achieving harmonization.

The group concluded that WHO should continue to encouragegovernments to adopt policies to promote rational and safe use oftraditional medicine. WHO and its Member States should supportthe harmonization and appropriate integration of traditional medicinewith modern medicine.

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The group believed that evidence–based research could be anessential step towards the harmonization. In addition to detailedrecommendations on steps for harmonizing the two approaches, themeeting also provided the following recommendations:

(1) WHO should continue to encourage governments toadopt policies to promote rational and safe use oftraditional medicine.

(2) WHO and its Member States should support theharmonization and appropriate integration of traditionalmedicine with modern medicine.

(3) Findings of well–designed and well–performed researchshould be disseminated as widely as possible. Thisshould include the preparation and dissemination inEnglish and native languages of rigorous systematicreviews based on the research literature from variouscountries.

(4) WHO should develop appropriate mechanisms toimprove dissemination of information on researchactivities. It should assist in updating the availabledatabases on traditional medicine, preparing a documentillustrative of the evidence–based approach to clinicalresearch in traditional medicine, and forming networks.

(5) WHO should continue to co-ordinate critical dataanalysis on traditional remedies.

(6) Relevant governments and professional agencies shouldensure appropriate adverse event reporting andrecording mechanisms are in place.

(7) WHO should support training in research methodologiesas well as in traditional medicine.

(8) WHO and its Member States should advocate, supportand encourage conducting of high quality research.

(9) Research that establishes the value of traditionalmedicine in promoting health and wellness beyondtreating diseases should be encouraged.

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(10) Clinical trials of widely used and established traditionalremedies should be encouraged and undertaken priorto obtaining the results of extensive ‘pre–clinical’ basicresearch.

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1. INTRODUCTIONTraditional medicine is the ancient and culture–bound medical

practice which existed in human societies before the application ofmodern science to health. The practice of traditional medicine varieswidely, in keeping with the societal and cultural heritage of differentcountries. Every human community responds to the challenge ofmaintaining health and treating diseases by developing a medicalsystem. Thus, traditional medicine has been practised to some degreein all cultures.

After the introduction of modern medicine into the Region,traditional medicine was usually rejected by the formal medicalservice system. Recently, however, attitudes towards traditionalmedicine have changed. Traditional medicine is now widely used inthe Region and practised side by side with modern medicine in mostcountries. Many traditional remedies and therapies have transcendedtheir original culture and become “complementary/alternative”medicine in other countries.

Modern medicine developed very quickly and made majorcontributions to disease control in the past century. Interestingly,despite a rapid growth in knowledge and techniques in modernmedicine, the end of the last century also saw a dramatically increasedinterest in traditional medicine. The increasing public demand forits use has led to considerable interest among policy–makers, healthadministrators and medical doctors on the possibilities of bringingtraditional and modern medicine together.

The practice of traditional medicine is mainly based onconventional use and personal experience. The value of traditionalmedicine (as well as many modern medical treatments) has not beenfully tested by using modern scientific means. Extensive accountsof use and experiences from generation to generation provide some

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evidence of the effectiveness of traditional medicine. However,scientific research is needed to provide additional evidence of itssafety and effectiveness.

To evaluate the role of traditional medicine in maintaining health,to develop a scientific approach to policy–making in traditionalmedicine, and, ultimately, to focus on how traditional medicine canbe harmonized with modern medicine, WHO Regional Office forthe Western Pacific organized the consultation meeting on how toharmonize the two approaches, from 22 to 26 November 1999 inBeijing, People’s Republic of China.

1.1 Objectives of the meeting

The objectives of the meeting were to:

(1) review the outcome of recent scientific research ontraditional medicine and to confirm its value inmaintaining health;

(2) identify the scientific basis for evaluating the efficacyof traditional medicine;

(3) discuss how to promote a dialogue of understandingbetween traditional and modern medicine;

(4) identify research requirements and research prioritiesfor better understanding of the value of traditionalmedicine in the Region; and

(5) propose sound research methodologies for objective (4).

1.2 Participants

The consultation group on the harmonization of traditional andmodern medicine was composed of 24 temporary advisers, 3consultants, 1 secretariat staff from the WHO Regional Office forthe Western Pacific and 19 observers. The list of participants isattached as Annex 1.

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1.3 Organization

Professor Il Moo Chang and Professor Cao Xiaoding wereelected as Chairman and Vice–Chairperson of the ConsultationGroup. Drs Charles Vincent, K.C. Tang, and Leonila Dans werethe Rapporteurs.

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2. PROCEEDINGS

2.1 Opening ceremony

Dr Shigeru Omi, WHO Regional Director for the WesternPacific, opened the meeting with the emphasis on WHO’scommitment to foster a better understanding of traditional medicine.He reported on the high usage rate of traditional medicine in theRegion and the increasing interest in traditional medicine fromMember States during recent years. He indicated that WHOsupported the efforts to bring traditional medicine into mainstreamgeneral health service. However, WHO could only endorse therapiessupported by solid scientific evidence. Dr Omi reminded theparticipants that they were facing many threats to human healthand the outcomes of the meeting would lay the foundation fortraditional and modern medicine to work together to meet everincreasing challenges of the new century.

Dr Zhu Qing–shen, Vice–Minister of Health and Director–General of State Administration of Traditional Chinese Medicine(SATCM), of People’s Republic of China, welcomed the attendeesand described the important role traditional medicine plays inmaintaining the health of the people of China.

Dr Margaret Chan, Director of Health of Hong Kong, China;Dr P.Y. Lam, Deputy Director of Health and several staff fromDepartment of Health, Hong Kong, China; a delegate from Georgia;Professor Zheng Shou–Zhan, President of Beijing University ofTraditional Medicine, and some senior staff from the StateAdministration of Traditional Chinese Medicine also attended theopening ceremony.

Dr S. Omi’s speech is attached as Annex 2.

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2.2 Purpose of the meeting, procedures and outcomes

Dr Chen Ken, Medical Officer of Traditional Medicine, WHORegional Office for the Western Pacific and responsible officer forthe meeting, gave a brief introduction to the objectives, process,and proposed methods of work of the workshop.

The purpose of this meeting was to:

• review previous scientific research on traditionalmedicine;

• discuss appropriate evidence for better acceptance oftraditional medicine; and

• identify research requirements, research priorities andappropriate research methods which could be adoptedfor creating additional evidence on the usefulness oftraditional medicine.

It is expected that the conclusions and recommendations of theconsultation meeting will be followed up by WHO and its MemberStates to ensure the proper use of traditional medicine by harmonizingtraditional and modern medicine.

2.3 Presentations

Papers on specific themes relevant to the conference wereprepared by the consultants, temporary advisers and the secretariatand were distributed among all participants. The consultation groupagreed to receive verbal summaries of these papers during the plenarysession. Twenty verbal presentations were made by the authors ofthe papers and the topics included:

• WHO’s involvement in traditional medicine;

• acupuncture – research on its mechanisms;

• acupuncture – clinical trials and clinical effectiveness;

• medicinal plants and herbal medicines – experimentalresearch;

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• quality of medicinal plants;

• clinical trials in herbal medicine;

• evidence–based health care practice;

• issues of evidence in traditional medicine;

• Growth of traditional medicine; and

• Clinical research methodologies.

These papers and presentations provided background materialfor subsequent discussions by sub–groups.

2.4 Group activities

The consultation group was divided into five sub–groups witheach group focusing on one of the following: clinical research inacupuncture, clinical research in herbalism, basic science researchin acupuncture, basic science research in herbalism, and socio–economic factors involved in harmonizing traditional and modernmedicine. Following two days of small group discussions, the twosub–groups discussing herbal research were merged into one, andthe two sub–groups discussing acupuncture research were mergedinto one on the final day of group discussions.

2.5 Plenary sessions

After lengthy periods of discussion, the groups reported to theconsultation group. Interactions between groups continued until finalrecommendations were agreed upon.

2.6 Closing session

On behalf of all participants, Dr Acuin acknowledged the effortand support of the WHO Regional Office for the Western Pacific inholding the Consultation Meeting, and thanked the ChineseGovernment for hosting the meeting in Beijing.

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Dr Il–Moo Chang, chairman of the meeting, thanked alltemporary advisers, three short term consultants and the observersfor their active participation and continued efforts in achieving thetasks assigned to the meeting. Dr Chang congratulated the groupfor the success of the meeting.

Due to another commitment, Dr S. Omi, WHO Regional Directorfor the Western Pacific was not able to attend the closing session.However, Dr Omi gave his response to recommendations of themeeting by a fax message. Dr Omi indicated the importance ofidentifying priorities for the future. He agreed that there was a needto collate what was happening in research on traditional medicineas well as a need to focus on research that would establish the valueof traditional medicine for treating diseases and promoting healthand wellness.

Dr Chen Ken thanked all participants for their contribution torender the meeting a successful, fruitful and productive one, andthanked WHO for its support of the traditional medicine programme.He expressed his thanks to the Chinese Government, the Ministryof Health and the State Administration of Traditional ChineseMedicine for their support of the meeting. He thanked the Chairman,the Vice–Chairperson, the chairmen of the group discussions andthe Rapporteurs, the consultants and the colleagues from WHO aswell as from the Institute of Chinese Materia Medica, a WHOcollaborating centre for traditional medicine, for their support.

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3. TRADITIONAL MEDICINE

3.1 Background and characteristics

Traditional medicine is the ancient and culture–bound medicalpractice which existed before the application of modern science tohealth. The practice of traditional medicine varies widely, in keepingwith the societal and cultural heritage of different countries. Everyhuman community has responded to the challenge of maintaininghealth and treating diseases by developing a medical system. Thus,traditional medicine has been practised to some degree in all cultures.

A workshop on development of national policy on traditionalmedicine organized by WHO Regional Office for the Western Pacificin October 1999 defined traditional medicine as the sum total ofknowledge, skills and practices of holistic healthcare, which isrecognized and accepted by the community for its role in themaintenance of health and the treatment of diseases. Traditionalmedicine, based on the theory, beliefs and experiences indigenous todifferent cultures, was developed and handed down from generationto generation1.

In some countries, remedies used by traditional medicine havere–emerged. Such techniques are usually known as “alternative” or“complementary” medicine, which as a form of medicine has evolvedrecently as a reaction to high technology medicine2.

A traditional medicine practitioner is a person who is recognizedby the community where he or she lives as someone competent toprovide health care by using plant, animal and mineral substancesand other methods based on social, cultural and religious practices.Traditional medicine practitioners are also recognized as experts oncommunity attitudes and beliefs related to physical, mental and social

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well–being and the causes of disease and disability. Traditionalmedicine practitioners include traditional healers, traditional birthattendants, herbalists and bone–setters.

There are many traditional systems of medicine. However, manytraditional systems of medicine have some common characteristics.

• Traditional medicine is based on a belief that health isa state of balance between several opposing aspects inthe human body. Illness occurs when an individual fallsout of balance, physically or mentally. The “causes” ofimbalance could be change of weather, intake of certainfood; external factors, such as magical or supernaturalpowers; mental stimulation and societal reasons.Traditional medicine tries to restore the balance usingdifferent therapies.

• Traditional medicine is based on the needs ofindividuals. Different people may receive differenttreatments even if they suffer from the same disease.Traditional medicine is based on a belief that eachindividual has his or her own constitution and socialcircumstances which result in different reactions to“causes of disease” and treatment.

• Traditional medicine applies a holistic approach. Itconsiders a person in his or her totality within anecological context and usually will not only look afterthe sick part of the body. Besides giving treatment,traditional practitioners usually provide advice onlifestyles and healthy behaviour.

• Traditional medicine precedes modern medicine. Mosttraditional remedies have not been evaluated by soundscientific methods. This means that, at this stage,traditional medicine is not easily understood by modernmedicine. However, traditional remedies have been“field–tested” by tens of thousands of people forhundreds of years.

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• Traditional medicine covers a wide scope and itspractices vary widely from country to country. In theRegion, the main therapeutic techniques are medicinalplants and acupuncture.

3.2 Changes in trends of usage

Traditional medicine exists in most countries and areas in theWestern Pacific Region and makes a significant contribution to thehealth of the people of the Region. Interest in traditional medicinehas increased over the last decade and seems likely to continue.People now are more prepared to look for alternative approaches tomaintain their health.

There are no solid data on the extent of usage of traditionalmedicine in the Region. However, data from several countries andareas in the Region show that around 40% to 60% of the populationof these countries and areas use traditional medicine. For example,traditional medicine accounts for around 40% of all health caredelivered in China and in Hong Kong, approximately 60% of thepopulation has consulted traditional medicine practitioners at onetime or another.3

The use of traditional/complementary medicine in industrializedcountries has increased significantly. Studies conducted in the USshow that complementary therapy usage increased from 34% in 1990to 42% in 1997.4 In Australia, research has indicated that 48.5% ofthe population used at least one non–medically prescribed alternativemedicine in 1993. The estimated national expenditure on alternativemedicines and alternative practitioners is close to A$1 000 millionper annum, of which A$621 million is spent on alternative medicines.5An Australian government report in 1996 estimated that there wereat least 2.8 million traditional Chinese medicine consultations in1996, representing an annual turnover of A$84 million within thehealth economy. This growth was also reflected in a four–foldincrease in the importation of Chinese herbal medicines since 1992.6

Clearly, traditional medicine is widely used by the public, andin some countries its use has increased dramatically. Increaseddemands from public lead to increased interest and involvement of

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the academic and scientific community. Concurrently, more andmore governments from countries and areas within the Region haveshown their interest and willingness to promote the proper use oftraditional medicine.

3.3 Consumers, government and other stakeholders

Based on the growing interest in traditional medicine shown byconsumers, scientists and regulators, three important challengespresent themselves.

• The public and the users of traditional medicine requestsafe, quality–controlled and effective remedies.

• Medical scientists request more scientifically soundevidence before comfortably accepting many traditionalmedicine practices. Many health professionals havedoubts about the usefulness of traditional medicine. Inmany cases, they require more scientifically–basedevidence if they are to trust its safety and effectiveness.Meanwhile, the involvement of the academic andscientific community provides the opportunity to createmore evidence by means of modern science.

• Governments need to establish and update mechanismsfor the regulation of traditional medicine and itspractitioners and, in doing so, require morescientifically–based evidence to support decision–making. As traditional systems of medicine becomebetter documented, and more scientifically credible,usage is only likely to increase further.

Consumers, of course, have many different reasons for usingtraditional medicine, and may not require the same level of evidenceof practice that is espoused by medical scientists. Consumers mayhave confidence in, for example, oriental herbal medicine becauseof its existence in public hospitals and medical infrastructure inChina, Republic of Korea, and Japan, instituted by centuries of use,scholarly writings and a formal tertiary education system.Consumers may also be prepared to try an herbal formula that hasbeen used and documented in classical medical literature for many

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centuries and may be less convinced by a clinical trial of a new drug– having been applied only to a well–defined sample group.Consumers’ awareness of these factors may generate more confidencein terms of ‘evidence behind practice’ than any singlemethodologically rigorous clinical trial. However, to the scientistit’s the latter, and not the former, that represents the stronger evidence.

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4. TRADITIONAL MEDICINE ANDMODERN MEDICINE

Traditional and modern systems of medicine were developed bydifferent philosophies in different cultural backgrounds. They lookat health, diseases and causes of diseases in different ways. Thesedifferences bring different approaches to health and diseases.However, both systems deal with the same subject – human being.The old and modern arts of healing should exist together.

4.1 Integration of traditional medicine with modernmedicine

The integration of traditional medicine with modern medicinemay have three different meanings.

First, it may mean incorporation of traditional medicine intothe general health service system. The government recognizes thepractice of traditional medicine and the use of traditional medicineis incorporated into the mainstream of health service system. In theRegion, traditional medicine has been an integral part of formalhealth service system in several countries, albeit in different forms.

Second, it may mean integration of the practice of traditionalmedicine with that of modern medicine. In fact, many medicaldoctors who have adequate knowledge of traditional medicine havetried to incorporate remedies used by traditional medicine into theirdaily work. In some places, traditional and modern medicine arepractised side by side. Studies have also shown that many patientsuse both traditional and modern medicine.

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Third, it may mean the integration of traditional and modernmedicine as two branches of medical science. Although traditionaland modern medicines have developed in different cultural contextsand are at different stages of scientific development, they have manysimilarities. Efforts have been made to synthesize the two branches,in order to form a new branch of medical science, incorporatingelements of both. However, at this stage this would appear to be adifficult task.

4.2 The need for harmonization of traditional and modernmedicine

Increased cross–cultural communication has resulted in theexposure of many indigenous forms of traditional medicine to new,more modern, medical environments. Various responses may andhave occurred to the presence of differing approaches to health care.These range from complete rejection of TM by modern medicalpractitioners and of modern medicine by TM practitioners, to aparallel existence with little communication over patient care, or toultimately forced understanding, subsuming and integration of onemodel by the other. None of these approaches is ideal preciselybecause none confers adequate respect on the practices of the other.This results in a weak utilization and exploration of the benefitspresented by each model.

Harmonization of traditional and modern medicine emphasizesthe importance of respectful co–existence. Within the model ofharmonization, there is the requirement to develop and hold a goodunderstanding of the other approaches to health care. Modernmedicine practitioners and researchers are required to achieveadequate education and awareness of the practice, principles andcontext of traditional medicine. Similarly, TM practitioners need tobe significantly more aware of the nature of practice and strengthsof modern medical approaches. The purpose of this broadereducation base is not simply to yield a better understanding ofdiffering practices, but primarily to promote the best care for patientsby intelligently selecting the most facilitating route to health andwellness.

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Surveys and other sources of evidence indicate that traditionalmedical practices are frequently utilized in the management of chronicdiseases.7 It is particularly for this category of illness that TM hasdeveloped a reputation. It is also in this area of treatment that modernmedicine is considered the weaker. An approach to harmonizingactivities between modern and traditional medicine will promote aclearer understanding of the strengths and weaknesses of each, andencourage the provision of the best therapeutic option for patients.The alternative to this is poor health care practice and bad medicine,most especially as the quantifiable scientific evidence of effectiveTM practices mounts.

Collecting evidence based on research is, therefore, regardedan essential step, although, of course, much more is involved inharmonization.

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5. EVIDENCE AND TRADITIONALMEDICINE

5.1 Acquisition of traditional medical knowledge

“In order to evaluate the efficacy of ginseng, find two peopleand let one eat ginseng and run, and the other run without eatingginseng. The one that did not eat ginseng will develop shortness ofbreath sooner.” Bencao Tujing, Atlas of Materia Medica, 1061AD.

Traditional medicine practitioners have developed uniquemethods of diagnosis and treatment that are specific to their particularcultures. Some of these approaches based on complex theoreticalframeworks can be traced back as far as 3 500 years.

Although there is evidence from the Song dynasty in China thatcomparative trials were used to illustrate treatment effects, they werenot applied in a rigorous systematic manner to advance the state ofknowledge. For the most part, it was assumed that knowledge oftraditional medicine was reinforced through clinical experience andtransferred either verbally or by cataloguing accumulated experiencein reference texts.

Clinical experience is an excellent way to learn about medicine.However, development of new medical knowledge relies on treatmentsafety, costs, and systematic research. Given today’s interest intraditional and complementary medicine, information on safety,efficacy and costs is being requested by patients, governments,traditional practitioners and practitioners of modern medicine.

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5.2. Evidence–based health care practice

The practice of evidence–based medicine (EBM) involves “theconscientious, explicit, and judicious use of current best evidence inmaking decisions about the care of individual patients.”8 When itwas originally proposed in 1992, EBM was defined as a newparadigm for medical practice: “Evidence–based medicine de–emphasizes intuition, unsystematic clinical experience andpathophysiologic rationale as sufficient grounds for clinical decisionmaking and stresses the examination of evidence from clinicalresearch.”9

Although evidence–based medicine emphasizes the use of therandomized controlled trial (RCT) for the evaluation of therapeuticeffectiveness whenever possible, the practice of EBM does not relyexclusively on the randomized controlled trial. Evidence to supportclinical practice can come from any number of systematic researchdesigns; however, these different types of research designs do notall lead to the same level of evidence. The rules of EBM privilegecertain kinds of evidence as having more weight. The latest levels ofevidence provided by the Cochrane collaboration include:

Level I. Strong evidence from at least one systematic reviewof well–designed RCTs.

Level II. Strong evidence from at least one RCT.

Level III. Well–designed trials without randomization.

Level IV. Non–experimental evidence.

Level V. Expert opinion.

Level VI. Someone told me.

There are several other ways to level the evidence proposed bydifferent institutions.

EBM is the use of best evidence integrated with individualclinical expertise in making a medical decision. One can not standwithout the other. Without the clinical expertise, external evidencemight not be applied appropriately to individual patients. Withoutthe use of evidence, clinical expertise alone might be biased and

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out–of–date. In clinical guideline development process, actualrecommendations come from different levels of evidence. Strongrecommendations come from strong evidence (i.e. from well–designed randomized controlled trials). However, in most situationswhen there is a lack of good evidence, the panel usually considersother factors such as cost, availability of health personnel, laboratoryand medical interventions, practical considerations, targetpopulation, etc. to decide on the best recommendations. Therefore,the role of traditional medicine in areas where western medicine isnot readily available or affordable has to be emphasized. Even ifthere might be a lack of good evidence (and this is also true ofwestern medicine), use of traditional medicine interventions mightstill be part of most clinical practice guideline recommendations.

The following methodology is proposed for creating evidencebased recommendations (EBRs). This framework provides a seriesof validated steps to ensure the development and acceptance ofobjective, users–friendly, evidence–based recommendations forclinical practise.

The six–steps to EBR development are described below.10

Step 1: Project definition and team formation:

• specification of questions to be addressed andselection of team,

• focused questions on the management of a specificdisease or condition;

Step 2: Perform a formal literature search:

• electronic search, where possible,

• retrieval of local publications, including translationof primary sources by persons trained in traditionalmedicine and clinical epidemiology;

Step 3: Create systematic overviews:

• evaluation of literature discovered, based onobjective criteria;

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Step 4: Estimate expected benefits, harms and costs:

• evaluation of important sources of information fromobservational and historical databases which mayreveal important information with respect totoxicity, costs and culturally–based patientpreferences;

Step 5: Judge relative value of expected benefits, harms andcosts:

• relative importance of benefits and harms to thepatient and payer; and

Step 6: Develop EBRs based on levels of evidence.

Evidence–based medicine is not a methodological researchframework; it is a research transfer framework . Although evidence–based medicine de–emphasizes the sharing of unsystematic clinicalexperience, it does not invalidate clinical experience as a method ofgaining knowledge. Using the EBM framework, however, a cliniciancan transfer his or her knowledge to other practitioners; theknowledge must be presented in a transparent fashion so that therecipient can appraise the knowledge to determine the level ofevidence it represents.

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6. EVIDENCE OF PRACTICE INTRADITIONAL MEDICINE

These notes reflect consensus views developed in groups inresponse to papers submitted to the meeting. The groups consistedof representatives from various Member States with backgroundsin both traditional medicine and modern medicine.

6.1 Basic science research in acupuncture

The group recognized that although acupuncture researchinitially concentrated on analgesia and neurological models, recentlyit had broadened to other areas of physiological systems includingendocrine, immunological and metabolic.

Two perspectives could be discerned in the research:

• traditional theory and clinical evidence is used to providethe basis for modern experiments in neurophysiology,and

• basic scientists are attempting to describe traditionalideas of meridians, point location, etc. in scientific terms.

The principal areas of this research were described in papers byProfessors Cao Xiaoding, Kyuya Kogure and Liu Jungling. Thegroup recognized, however, that much of the important originalscientific work on acupuncture was not yet available in English.

Most of the research work on mechanisms of action was carriedout on acute pain management, and it was not clear whether thiswas relevant to effects of acupuncture on chronic pain, which mayhave different underlying mechanisms, nor whether similar

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mechanisms could be applied to other therapeutic applications ofacupuncture. The issue underscored the importance of integratingclinical science and basic research in future acupuncture studies.

6.2 Clinical research on acupuncture

The starting point of the group’s discussion centred on theawareness of the enormous historical and cultural significance oftraditional acupuncture, as well as the importance of clinicalexperience and observation in this area. However, the focus ofdiscussion was on the modern methods of treatment evaluation.

A number of English language reports of clinical trials areavailable.11,12 In the last few years, activities of the Cochrane Centrefor Systematic Reviews have been extended to include reviews ofcomplementary/traditional medicine. Reviews of the clinical trialliterature on acupuncture for low back pain, asthma, nausea andvomiting and smoking cessation are also available. Reviews are inprogress for the acupuncture treatment of chronic headache.

The findings from all these reviews are similar, in that clinicaltrials have been too few, too small, and inadequately controlled.There have been doubts about the adequacy of treatment, problemswith the definition of placebos and a variety of other methodologicalproblems. Overall, methodological details have been lacking in manystudy reports. While progress has been made in defining anappropriate methodology for acupuncture evaluation, this has notyet translated into trials of a high standard that can provide definitiveresults. Hence, the results from most reviews are fundamentallyinconclusive. Clearly, if research is to be continued, much largertrials of considerably better quality need to be conducted. Most ofresearch literature remains in Chinese, and, therefore, not easilyaccessible to those carrying out the systematic reviews. Conversely,the English language studies and reviews are not easily accessedwithin China.

The conclusions reached from the clinical trial perspectivecontrast strongly with those reached by clinicians and researchersworking from within a traditional medicine framework. From withintraditional medicine, the result of literally hundreds of years of clinical

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experience, and thousands of case series suggest that acupuncturecan be effective for a wide range of clinical conditions.

The modern clinical trial and the traditional medicineperspectives can be usefully encompassed with the evidence–basedmedicine framework described above. There is a need toacknowledge the evidence base within traditional medicine, whilealso recognizing the importance of clarifying the extent andlimitations of traditional practice through methodologically soundresearch. However, the design of studies needs to incorporatetraditional medicine perspectives, including differences in diagnosticapproaches that guide treatment.

6.3. Basic science research in herbal medicine

A wealth of information exists in the literature regarding plantsand plant formulas used in traditional medicine. The Western PacificRegion is a particularly rich source of such information. Historicaldata has also been the starting point for basic science research thathas led to the discovery of active components. Using highly advancedresearch techniques a number of compounds have been discoveredover the years and successfully brought into clinical use.

The collection of data on herbal use is an ongoing process. InChina, over 100 000 herbal preparations have been recorded thatare still in clinical use. Researchers in Fiji, Malaysia, Samoa andTonga have recently published monographs on medicinal plants withinformation on taxonomy, traditional use, chemical constituents, etc.Also, an extensive Korean database exists of over 12 000 prescriptiontitles with respective formulas, 12 000 natural constituents withdrawings of chemical structure and analytical data, photo images ofstandard herbal materials and original medicinal whole plants withtaxonomical verification and a dictionary of disease classificationin terms of TCM and modern medicine. All participants voiced theneed for a comprehensive regional database that would allow easyaccess and exchange of information.

Quality control of herbal products will have a significant impacton the overall effectiveness of herbal medicines. To this end, Chinahas introduced new legislation requiring approval for new raw

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materials and traditional herbal formulas to be classified as drugs.New drug approvals require documentation of identification,cultivation, physical and chemical characteristics, pharmacology,standards of clinical use, stability, and preparation methods alongwith three reference samples. To date over 1000 new drugapplications have been approved. Recent legislation in Malaysiarequiring the registration of herbal products has lead to the licensingof 4778 (28.9%) out of 16 518 products. Many (71.1%) failed tosatisfy strict regulatory requirements as to their quality, safety andefficacy. 13 Research activities currently include evaluation of activeherbal constituents for efficacy, bioavailability and toxicity. In Japan,80% of practising physicians have experience using herbal formulas.Japan now produces 210 Kampo herbal formulas according to strictquality controls, 147 of which are covered by health insurance. Itwas the consensus of the group that quality control measures shouldcontinue to be promoted.

Phytochemical and pre–clinical research are the areas of researchin which the active components of herbal remedies are isolated, theirstructures identified and biological activities analyzed formechanisms of action, toxicity, etc. Recently in the Republic ofKorea, acubin was isolated from Plantago asiatica, a traditionalmedicinal plant that has been used for hepatitis B. Derivativessynthesized from the lead compound, higenamine, isolated fromAconitum tuber, have shown activity as an anti–platelet aggregatingagent. Extensive research has been performed in Japan on about 30Kampo formulas on a pre–clinical or basic science level. Oneexample of this research is the work on the immunostimulatingactivity of Juzen–Taiho–To (JTT). JTT consists of ten differentcomponent herbs. It has been shown to influence the immune systemby enhancing the T–cell dependent antibody response, phagocytosis,anti–complementary activity and mitogenic activity against spleenB cells in mice. The biological activity was identified to originatefrom three different types of polysaccharides having differentactivities. These three different types of polysaccharides wereseparated into 22 unique active pectic polysaccharides. AlthoughJTT consists of ten component herbs, the correspondingcarbohydrate–lignan complex fractions from each component herbdid not demonstrate immunity enhancing activity. However, when

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at least five certain herbs were combined, the activity was observed.The series of experiments strongly suggests the presence of asynergistic effect in this Kampo preparation. Examples of otherareas of Kampo medicine that are currently being investigated includethe anti–dementia actions on the nervous system, treatment of liverdiseases, allergic reactions, anti–influenza, anti–atherosclerosisactivity, suppression of chronic inflammatory airway disease andanti–pyretic activity.

6.4 Clinical research in herbal medicine

The range and number of human clinical trials of traditionalherbal medicines performed in China, Republic of Korea, Japanand other countries are extensive. For the purposes of this summarya sub–group of participants reviewed and graded a limited numberof studies submitted to the group by participants to provide a snapshotof research activity in this area. The focus of activity of this groupwas on oriental herbal medicine.

The following six major aspects of clinical trial design wereutilized to objectively evaluate the studies at hand:

• the use of explicit, objective entry criteria;

• appropriate use of a control group;

• random allocation of patients to control and interventiongroups;

• appropriate levels of blinding;

• complete follow–up and reporting on all patientsrecruited into the trial; and

• the selection of unambiguous and clinically meaningful,patient–based end points.

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Two additional criteria were considered important by the groupif traditional medicine were to be assessed appropriately:

• the use of a traditional diagnostic framework in guidingtreatment; and

• tailoring the treatment to trial subjects where possible.

These clinical trial criteria were used to grade clinical trialsaccording to the strength of evidence they represent. The trialsreviewed are summarized below and presented in Table 1. Thequality of evidence represented by each trial was rated according tothe guidelines in section 5.2.

Summary of studies

Gastroenterology

One well–performed randomized controlled trial has beenrecently published in English on irritable bowel syndrome. Thistrial was considered to represent level II evidence.

Hepatology

A randomized, prospective unblinded Japanese study of atraditional herbal formula demonstrated reduced cumulativeincidence of hepatocellular carcinoma and increased survival ofpatients with cirrhosis. This trial was considered to represent levelII evidence.

A retrospective study also demonstrated that long–termadministration of a licorice root derivative was effective in reducingthe cumulative incidence of liver cancer in chronic hepatitis Cpatients. This trial was considered to represent level IV evidence.

Reproductive endocrinology

An unblinded, randomized controlled comparison of herbalmedicine with conventional medicine in polycystic ovary diseasedemonstrated positive outcomes along a number of parametersalthough there were concerns about methodological standards. Thistrial was considered to represent level II evidence.

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A small randomized controlled trial on intrauterine growthretardation demonstrated a positive outcome on birth weight andplacental villi but exhibited similar methodological problems. Thistrial was considered to represent level II evidence.

Dermatology

Two studies of traditional herbal medicine demonstratedeffectiveness over placebo in both children and adults with refractoryatopic eczema. Both studies were deemed level II evidence.

Psychiatry

A randomized, placebo–controlled blinded trial demonstratedthe benefit of a traditional herbal formula in the treatment of vasculardementia. Although there were some limitations in design this studywas credible overall. The trial was considered to represent level IIevidence (see Table 1).

Reviews

In addition, one systematic review and one meta–analysis wereavailable for discussion.

Acute ischaemic or hemorrhagic stroke

A review and meta–analysis performed on 15 clinical trials of aState approved traditional Chinese herbal medicine, conductedbetween 1992–1996, revealed variable methodological quality(unpublished). Only one of the clinical trials reported single blindprocedure, none double blind. All claimed a positive outcome.However, the review identified significant problems with the trialmethodology.

Acute respiratory infections

A systematic review of clinical trials of Chinese herbal medicinesin acute respiratory infections concluded that the inadequate methodsof most studies made it difficult to interpret the results withconfidence.14

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Table 1: Summative table of human clinical trials reviewed

Disease Reference Trial Results Level ofcharacte- evidence

ristics

Hepatocellular Cancer, 1995, Randomized, Reduced cumula- IIcarcinoma 76(5):743-749 unblinded, tive incidence of

controlled hepatocellularcarcinoma,increasedsurvival

Hepatocellular Cancer, 1997, Retrospective, Reduced cumula- IVcarcinoma 79(8):1494-1500 historical tive incidence of

controls hepatocellularcarcinoma

Eczema Lancet , 1992, Double–blind, Reduced skin II340:13-17 crossover, damage

placebo–controlled,adults

Eczema British Journal Double–blind, Reduced skin IIof Dermatology crossover, damage1992, placebo–126:179-84 controlled,

children

Vascular Journal of Double–blind, Improvement IIdementia Traditional randomized, in global ratings,

Medicine, 1994, placebo– psychiatric11:246-255 controlled, symptoms,

multi–centre and activities ofdaily living

Irritable JAMA, 1998, Double–blind, Positive IIbowel 280 randomized, improvementsyndrome (18):1585-89 placebo– in bowel

controlled, symptom

follow–ups measures

Conclusions

Overall, the herbal trial reports represent some good preliminaryevidence of the efficacy of herbal medicine in a number of clinicaldisorders including, but not limited to, those reported above. Thereis further evidence in numerous other clinical areas. The process of

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acquiring quantifiable clinical trial evidence on traditional orientalherbal medicine is clearly underway.

However, whilst some good quality research has been reported,there is a relative paucity of good clinical trials and systematicreviews of the practice of traditional (oriental) herbal medicine, andmost remain published in non–English journals. Whilst the outcomesof the trials largely support the efficacy of herbal medicine, manyare compromised by methodological flaws. The clinical trialspublished in English are few. There is a significant volume of clinicaltrials in the Chinese herbal literature, although methodologicalproblems have been a major concern which weaken the credibilityof the outcomes.

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7. HARMONIZING TRADITIONALAND MODERN MEDICINE:CONCLUSIONS AND RECOMMENDATIONS

The meeting participants recognized that a large proportion ofthe population in the Region use traditional medicine as a primarymeans of care. Traditional medicine will continue to exist as aseparated medical system for some time. It was noted that manyusers of traditional remedies also use modern medicine at the sametime. Many medical doctors apply both traditional and modernmedicine. Harmonization of traditional and modern medicine will,therefore, ensure that the two approaches work effectively side byside properly.

7.1 Towards harmonization of traditional and modernmedicine

By the end of the conference, the consultation group identifieda number of issues that were important in the harmonization oftraditional and modern medicine. The group recommended severalsteps which would contribute to the goal of harmonizing the twosystems of medicine.

7.1.1 Promoting an evidence–based approach

An evidence–based approach is important in harmonizingtraditional and modern medicine and minimizing bias. There is aneed to acknowledge the evidence base within traditional medicine;traditional medicine should recognize the importance to clarify the

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extent and limitations of traditional practice throughmethodologically sound research. Importantly, the consultationgroup did not see any major problems with applying the principlesof evidence–based medicine (including the randomized controlledtrial) to TM research and practice. This is a process that will onlyassist in increasing the credibility of TM practices. To this end,researchers should endeavor to utilize rigorous features in clinicaltrial design as described in sections 5 and 6. All suitable andappropriate study designs should be encouraged for the purpose ofacquiring useful information on the efficacy and safety of traditionalpractices and medicines. This would include drawing on studydesigns such as case series, retrospective studies, cohort and case–control studies, and involvement of traditional healers indocumentation of treatment outcomes.

Research should establish the value of traditional medicine innot only treating disease, but also in promoting health and wellness.This could include research on the use of combinations of therapy(for example, acupuncture with dietary changes and/or herbalmedicine).

The concept of an holistic approach to treating patients isimportant and paramount in traditional medicine. Hence, outcomemeasures in clinical trials need to be relevant to the whole health ofpatients. A strong emphasis was placed on the need to develop andvalidate the reliable, clinically meaningful, multi–dimensionaloutcome measures that related to quality of life.

Whenever possible, researchers should endeavor to utilizerigorous features in clinical trial design, including;

• the use of explicit, objective entry criteria;

• appropriate use of a control group;

• random allocation of patients to control and interventiongroups;

• appropriate levels of blinding;

• complete follow–up and reporting on all patientsrecruited into the trial; and

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• the selection of unambiguous and clinically meaningful,patient–based end points.

A more conducive environment for research on traditionalmedicine needs to be set up. This includes looking into the legalstatus and training practitioners, education of researchers, fundingand utilization of research findings.

In undertaking clinical research, the Declaration of Helsinkiand other guidelines relevant to ethical issues in health researchshould be followed.

7.1.2 Encouraging a mutual respect

Lack of adequate education by modern medical practitioners inthe TM approaches to diagnosis and treatment, and the lack ofadequate education in designing methodologically sound researchby traditional medicine practitioners represent significant barriersto the harmonization of traditional and modern medicine. In thepast, non–TM trained researchers conducted poor quality clinicalresearch due to the inappropriate application of TM techniques.Similarly, poor quality research resulted from TM practitionersfailing to recognize the well–established importance of rigorousapproaches to performing clinical trials. Improved relevant educationis required on both sides.

While performing rigorous research on TM, it must beemphasized that TM principles of practice should be strictly adheredto. It is important that traditional medical theory is not ignored inthe context of a good trial design. In some cases, whilst a modernmedical diagnosis may be required for the purposes of screeningand including patients for a clinical trial, the trial should be designedto permit a traditional diagnostic and therapeutic approach topractice. Practice is particularly individualized in TM and a researchdesign that moves too far from TM practice would no longer achieveits purpose in evaluating TM. The importance of collaborationbetween TM practitioners and clinical researchers is apparent.Trialists and researchers need to develop expertise in both traditionalmedicine and research methodology, and they need to ensure thatresearch methodologies are appropriate to the practice of traditional

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medicine. Furthermore, developing interpretations of traditionalmedicine in terms of modern medical theory is also important. Thiscan provide credibility to the traditional medical diagnostic andtheoretical concepts without undermining its practice base.

Harmonization through mutual respect of practices will occurif a wide range of well–performed clinical trials proceed. Barriersto the performance of worthy clinical trials should be minimized.For example, it has been proposed that since herbal medicines areavailable in the public arena and the government has not sought torestrict their usage, a clinical evaluation of the products should beencouraged. For the purpose of a clinical trial, safety evaluationbeyond the recorded history of use of the medicinal agents shouldnot generally be required. In fact, the clinical trial itself providessafety information. Regulation and restriction, if required, shouldoccur as a matter of public risk minimization measure, not to obstructevaluation of publicly available products. This will provide anevaluation of effectiveness and assist the government not only todefine a regulatory position, but also to clarify the potential role ofthe therapeutic agents concerned. This issue is of relevance to clinicalresearchers, government regulators and institutional ethicscommittees.

7.1.3 Disseminating information

Poor dissemination of research literature related to the practiceof TM presents a major barrier to researchers worldwide. Somehigh quality basic science and clinical research on many forms oftraditional medicine exist only in Japanese, Korean or Chineselanguage journals and are relatively inaccessible. Hence, thereremains a need to translate, collate and disseminate the relevantresearch findings of the last two decades. In addition, TM researchersneed to reach a broad readership and raise the level of awareness.WHO, researchers, professional associations, research institutes andother agencies should consider mechanisms to improvecommunication and information sharing. These include furthernetworking, newsletters, expert meetings, conferences and othermechanisms.

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Due to the vast array of TM practices, geographical separationand cultural diversity, communication, even in the same tongue,presents a barrier to harmonization. The development of a “modern”language for TM may lead to better understanding of its theory andpractice by the public, policy–makers and the medical society. Acommon language will contribute to further cooperation amongstresearchers.

The general public will also benefit from information on thesafety and effectiveness of traditional medicine and the outcome ofscientific research explained in simple language easily understood.

7.1.4 Research on herbal medicine

The basic science areas of herbal medicine provides a means ofassuring the quality and safety of herbal remedies. It may also leadto the discovery of clinically important drugs.

There is a need to change the order in which basic scienceresearch is performed in the discovery of new drugs in the practiceof traditional herbal medicine. Historically, basic science researchin herbal medicine begins with the selection of plants based onwidespread use and folklore. This is followed by intensive laboratorywork leading to the development of bioassays, isolation techniquesand characterization of active constituents, determination of themechanism of action and a battery of toxicology testing. Promisingagents are then moved into clinical trials. Although many extremelyuseful drugs have been discovered using this method, the vastmajority of plants that undergo this method of evaluation do notyield clinically useful drugs. Applying two new strategies thatembrace the principles of evidence–based medicine may dramaticallyincrease this success rate.

The first strategy is to categorize plants and traditional medicineformulas according to an Evidence Rated Research Scale. Byutilizing this style of categorizing plants and herbal formulas,researchers will have a common language in which to assess thebody of knowledge available for each plant or formula.

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Evidence Rated Research Scale consists of the following:

1. Single plant or herbal formula that has extensive positiveclinical efficacy, proven safety, known mechanism ofaction, structurally identified active compounds andstrict quality control which fully supports its use in thegeneral population

2. Single plant or herbal formula that has extensive pre–clinical in vitro and/or in vivo positive research resultsalong with basic science research on safety, mechanismof action, structurally identified active compounds andstrict quality control which supports its use in the generalpopulation but has not been clinically verified.

3. Single plant or herbal formula used and broadlyaccepted as efficacious based on a long history of usethat has been tested for quality control and safety.Clinical efficacy has not been verified by randomizedcontrolled trials.

4. Single plant or herbal formula used and broadlyaccepted as efficacious based on a widespread and longhistory of use. Clinical efficacy has not been verifiedby randomized controlled trials.

5. Single plant or herbal formula used locally or only rarelyfound in the literature.

The second strategy involves shifting the initial focus of TMherbal research from that of basic science to clinical outcomes.According to this approach, high quality clinical trials would initiallybe performed using plants or herbal formula believed to beefficacious. Those TM herbal remedies confirmed to be effectivewould then undergo rigorous scientific investigation. By applyinga Post–clinical Basic Science Research Approach, the basic researchscientists will conduct their investigations starting with clinicallyproven effective material which may enhance and expedite thediscovery new clinically effective agents and research tools. Theformat of the Post–clinical Basic Science Research Approach is asfollows:

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(1) Each interested regional country identifies andprioritizes diseases that warrant research.

(2) Single plants or herbal formulas used to treat thosediseases might then be chosen for a variety of reasons(most notably, clinical experience) although preferencemight also be given to plants appearing high on theEvidence Rated Research Scale.

(3) Safety and toxicity studies should be carried out (unlessalready documented). A long history of human use isacceptable evidence of basic safety under this scheme.

(4) High quality, evidence–based clinical trials should thenbe designed and performed.

(5) Plants or formulas that are shown to be positive inclinical trials will then undergo rigorous basic scienceresearch including:

• isolation and structure elucidation of the activecompound(s);

• dosage, bioavailability and advanced safety studies;

• pharmacokinetics and mechanism of actionidentification;

• activity enhancing chemical modification studies;

• other types biological activity studies; and

• quality control studies to standardizephytopharmacological equivalents.15

Thus, by combining the knowledge and use of traditionalmedicine to obtain clinically useful evidence in which to focus theresources of modern medicine’s basic science research, the healthof the people utilizing both systems may be improved.

During the process of evaluating traditional herbal remedies,the responsibility of TM practitioners will be to facilitate theappropriate evaluation of effectiveness, while other medical researchtechniques provide the capacity and approaches to determine howthe therapeutic agents work. This order of activity differs from

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conventional synthetic or semi–synthetic pharmaceutical researchfor new therapeutic chemical constituents, where the latter has hadno marketplace exposure or history of human usage in therapy. Thisis an important distinction: TM therapeutics have a long history ofhuman usage and previously accepted marketplace exposure. Thisdistinction should motivate traditional medicine practitioners andrelevant industry sectors to collaborate to raise adequate fundingand to develop and fulfill meaningful research plans.

An awareness of the principles of TM practice is important inbasic science research. The synergism of activity of the herbsdemonstrated by the Japanese studies reported in section 6.3, whereindividual herbs failed to show activity demonstrated by the wholeformula, highlights the importance of adopting traditional approachesto the utilization of traditional medicines. Attention in research shouldbe paid to the synergistic behaviour of whole formulations in contrastto actions and safety of single bioactive agents.

In accordance with the UN Convention on Biologic Diversityheld in Rio de Janeiro in 1992, researchers in the development ofherbal remedies must recognize the importance of the conservationof diverse plant species.

7.1.5 Research on acupuncture

There is a need to standardize animal models in basicacupuncture research by considering standardized models from otherfields. The animal models used in acupuncture research need to beunderstandable, reproducible, and exchangeable. Animal researchmust correlate as closely as possible to clinical reality.

Acupuncture researchers need to document the morphologicaland physiological connection to internal organs through the use oftechnologically advanced modalities such as functional magneticresonance imagine (MRI) and positron emission tomography (PET)scans. This could lead to better understanding of the importance ofacupoints and meridians, including the awareness of micro–anatomy,connective tissue and metabolic aspects. In view of the costsassociated with these technologies, it was suggested that ways to

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co–ordinate and facilitate the use of these resources must be promotedby governmental bodies.

Acupuncture research presents some unique methodologicalchallenges that can cause problems with respect to the maintenanceof blinding and thus may open trials of acupuncture to bias. Theacupuncture researcher must consider the appropriate selection ofsham procedures in order to address these issues. Some points toconsider include:

• Sham needling presents difficulties related to choice ofposition, stimulation, duration and technique. Patientexpectations and experience with acupuncture can resultin failures in blinding.

• Mock TENS is difficult to undertake because the patientcan perceive the active stimulation.

• Minimal acupuncture may have a mild effect and canbe distinguished from true acupuncture by the subject.

• Placebo acupuncture, with a retractable blunt needle,demonstrates promise but has not yet been adequatelyevaluated in clinical trials.

• Alternative treatment, such as physiotherapy, may giveindication of effectiveness over ‘standard care’.

Researchers need to be very explicit when describingexperimental trials so that all the steps of design and procedures arefully explained in order to allow other researchers to repeat the sameexperiment and grade the level of evidence.

7.1.6 Other perspectives on acceptance

Traditional medicine is rooted in respective cultures andtraditions, so there are many issues and perspectives that need to beexamined aside from the basic science and clinical aspects. Like allother systems of health care, the development of traditional medicineis not solely driven by science but equally by policy, and economicand socio–behavioral factors. These factors can act as a bridgebetween research and action.

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Research on traditional medicine beyond the basic science andclinical perspective should be conducted. Other scientists such associal scientists, health economists and epidemiologists need to bepart of multi–disciplinary teams conducting research in traditionalmedicine.

There is a need to understand the health and health care seekingbehaviour of the users and non–users in the following areas:

• pathways to seeking care – issues such as delay ofseeking care, concomitant use, doctor shopping andswitching from one medical system to another;

• patterns of use – issues such as user characteristics,medical conditions for which traditional medicine aresought, extent and frequency of use, payments, factorsassociated with use and non–use and effects of educationand policy on use and non–use;

• provider behaviour – issues such as providercharacteristics, prescribing behaviour and referrals; and

• policy studies – cost analysis and issues such as effectsof education and policy on patterns of use.

Research in the context of the above will provide useful evidenceto policy–makers in dealing with traditional medicine.

Business involvement in TM is a global concern. It is possiblethat profit motivation could override safety, efficacy and healthconcerns. Issues of professionalism, ethics and marketing areimportant areas for future research. Some examples include:

• impact of TM on health care expenditures (e.g.insurance coverage);

• investment in product development by business/commercial sector (their concerns, marketing behaviour,and interest in private investment in TM)

Governments should actively promote the rational use oftraditional medicine that have been scientifically validated. To doso, they need a national policy for approving those drugs andtechniques that are safe and effective for specified clinical indications.

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The adoption of such policy will help to overcome some of the legalbarriers against the use of traditional medicine.

7.2 Operational recommendations

There are clear challenges to the harmonization of traditionaland modern medicine. Better access to information, facilitatingappropriate clinical trials, improving rigour in clinical trials,improving education and collaboration of practitioners andresearchers, and respecting traditional practices in research are allimportant steps towards achieving harmonization.

It is recognized that the idea for harmonizing traditional andmodern medicine will not occur immediately. To accumulate evidencebased on research can be regarded as the first step. However, muchmore is involved in harmonization of traditional and modernmedicine. The group also believes that a number of simple actionscan be taken to initiate the efforts for harmonization. In addition tothe suggestions and recommendations mentioned above, the groupmade the following operational recommendations to establish aframework to begin the process.

(1) WHO should continue to encourage governments toadopt policies to promote the rational and safe use oftraditional medicine.

(2) WHO and its Member States should support theharmonization and appropriate integration of traditionalmedicine with modern medicine.

(3) WHO should collaborate with research institutes andresearchers engaged in research on traditional medicineto disseminate their findings as widely as possible,including publication of their results in broadlycirculated English language journals. Furthermore,professional associations, journals, research institutesand other agencies should endeavour to make availablein English the reports of research studies presentlyavailable only in Chinese, Japanese and Koreanliteratures. This should include the preparation anddissemination in English and native languages such as

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Chinese, reviews of research conducted in othercountries. The successful dissemination of the outcomesof well–designed and well–performed research willassist traditional and modern medicine practitioners tomake informed decisions about the most effectivetherapy for patients.

(4) Appropriate mechanisms to improve dissemination ofand access to information resulting from researchactivities should be developed:

• WHO should assist in updating available databaseson traditional medicines and utilization of thosedatabases by researchers and other interested users;

• WHO should consider commissioning thepreparation of a document which could be availablein English and native languages, to illustrate theuse of the evidence–based approach to research intraditional medicine; and

• WHO should undertake activities (formingnetworks, organizing meetings and conferences, andusing electronic media) for informationdissemination.

(5) WHO should continue to co–ordinate data analysis onimportant traditional remedies. Researchers who haveexpertise in trial evaluation and traditional medicineshould be mobilized to evaluate research paperspublished in the last five to ten years according to thelevels of EBM. This could then form the frameworkfor a scientifically–evaluated traditional medicine.

(6) As part of acquiring clinical evidence, relevantgovernments or professional agencies should ensure thatappropriate adverse event reporting and recordingmechanisms are in place. Regular summary findingsshould be disseminated by the relevant government orprofessional agency to interested parties.

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(7) WHO should support the training of people withknowledge of traditional medicine to acquire skills inresearch methodologies including clinical epidemiology.Furthermore, WHO should encourage and support thetraining of clinical trialists to acquire training in thetheory and fundamentals of traditional medicine.

(8) WHO and its Member States should advocate, supportand encourage the conducting of high quality researchin traditional medicine, including clinical research, basicsciences, policy issues (legal and educational), andsocial, behavioural and economic issues. ResearchGuidelines for Evaluating the Safety and Efficacy ofHerbal Medicine and Guidelines for Clinical Researchon Acupuncture, prepared and published by WHORegional Office for the Western Pacific, providevaluable guidance on principle and methodology fordesigning, conducting and evaluating basic scientificand clinical research in traditional medicine.

(9) WHO should encourage research to establish the valueof traditional medicine in promoting health and wellnessbeyond treating diseases.

(10) WHO and its Member States should advocate that,provided adequate evidence of safety (such as historyof human use) is available, clinical trials of widely usedand established traditional remedies may be undertakenprior to obtaining the results of extensive ‘pre–clinical’basic sciences research.

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REFERENCES

1 Report of the Workshop on Development of National Policy onTraditional Medicine, Beijing, China, 11 to 15 October, WHORegional Office for the Western Pacific.

2 Eighth General Programme of Work covering the period 1990-1995.Geneva, WHO, 1987:149.

3 Report of technical briefing on traditional medicine, Forty-ninthRegional Committee Meeting, World Health Organization RegionalOffice for the Western Pacific, Manila, 1998 (WPR/RC49/TechnicalBriefing).

4 Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, VanRompay M, Kessler RC. Trends in alternative medicine use in theUnited States, 1990-1997: results of a follow-up national survey.JAMA 1998;280(18):1569-75

5 Maclennan, et al. Prevalence and cost of alternative medicine inAustralia. Lancet, 1996; 347:569-573.

6 Bensoussan, A., Myers S.P. Towards a safer choice, the practice oftraditional Chinese medicine in Australia. Sydney: University ofWestern Sydney, November 1996

7 Op cit, Ref. 6

8 Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB andRichardson WS. Evidence–based medicine: what it is and what it isn’tBMJ 1996;312:71-2.

9 Evidence-Based Medicine Working Group, Anonymous. Evidence-based medicine. A new approach to teaching the practice of medicine.Evidence-Based Medicine Working Group. JAMA 1992;268:2420-5.

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10 Browman GS, Levine MN, Mohide AE, Hayward RSA, PritchardKI, Gafni A and Laupacis A. The practice guidelines developmentcycle: A conceptual tool for practice guidelines development andimplementation. Journal of Clinical Oncology 995;13(2):502-512.

11 Richardson PH and Vincent CA. Acupuncture for the treatment ofpain: a review of evaluative research. Pain 1986;24(1):15-40.

12 Ter Riet G, Kleijnen J and Knipschild P. A meta-analysis of studiesinto the effect of acupuncture on addiction. Br J Gen Pract1990;40(338):379-82.

13 Guidelines for the Appropriate Use of Herbal Medicines. WorldHealth Organization Regional Office for the Western Pacific, Manila,1998 (ISBN 92 9061 124 3).

14 Liu C, Douglas RM. Chinese herbal medicines in the treatment ofacute respiratory infections: a review of randomized and controlledclinical trials. Med J Aust 1998;169 (11-12):579-82

15 Guidelines for the Appropriate Use of Herbal Medicines. WorldHealth Organization Regional Office for the Western Pacific, Manila,1998 (ISBN 92 9061 124 3).


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ANNEX 1

LIST OF TEMPORARY ADVISERS, CONSULTANTS,OBSERVERS AND SECRETARIAT

1. TEMPORARY ADVISERS

Professor William AalbersbergProfessor of Natural Products ChemistryUniversity of South PacificSuva, FijiTel. no.: (679) 312952FAX: (679) 300373E-mail: [email protected]

Dr Cecilia AcuinProgramme Officer of Population CouncilSouth East Asia-Philippines OfficeMonteverde Mansions Unit 2A385 Xavier Street, GreenhillsSan Juan, Metro ManilaPhilippinesTel. no.: 632-722-6886FAX: 632-721-1286E-mail: [email protected]

Professor Cao XiaodingProfessor of NeurobiologyInstitute of Acupuncture ResearchShanghai Medical UniversityNo. 138 Yi Xue Yuan RoadShanghai 200032,People’s Republic of ChinaTel. no.: 86-21-64041900 ext. 2397FAX: 86-21-64174579E-mail: [email protected]


48

Professor Chan Kit LamDirectorCenter for Drug ResearchUniversiti Sains Malaysia11800 Penang, MalaysiaTel. no.: 604-6583444FAX: 604-6568669E-mail: [email protected]

Professor Il-Moo ChangDirectorNatural Products Research InstituteSeoul National University#28, Yungun-dong, Jongro-kuSeoul 110-460Republic of KoreaTel. no.: (82-2) 740 8921FAX: (82-2) 745 1015

Dr Hwan-Young ChePresidentAssociation of Korean Oriental Medicine965-1 Chegi-dongDongdaemun-kuSeoul 130-060Republic of KoreaTel. no.: 82-2-959-7344FAX: 82-2-959-7347

Dr Leonila DansAssociate ProfessorDepartment of PediatricsUniversity of the Philippines ManilaCollege of MedicineManila, PhilippinesTel. no.: (632) 721-1875; (632) 722-1897FAX: (632) 526-6085E-mail: [email protected]


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Dr Tim EwerGeneral Practitioner and Physician in Complementaryand Nutritional MedicinePomona Road, Ruby BayNelson, New ZealandTel. no.: (64) 3 540 2705FAX: (64) 3 540 2621E-mail: [email protected]

Professor Ka Kit Paul HuiDirectorDepartment of MedicineCenter for East-West MedicineUniversity of CaliforniaBox 951736, B-551, Factor BuildingLos Angeles, California 90095-1736United States of AmericaTel. no.: (310) 998-9118; (310) 453-7679; (310) 206-1876FAX: (310) 829-9318; (310) 206-0370E-mail: [email protected]: http://www.medsch.ucla.edu/som/medicine/cewm

Dr Kyuya KogureDirectorChosei Kai HospitalFoundation for Brain Function and DiseasesInstitute of Neuropathology1216 Nakase, FukayaSaitama 366-0001 JapanTel. no.: (81) 485-87-1262FAX: (81)-485-87-1263E-mail: [email protected]


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Professor Lai ShilongDirector and ProfessorTraining Center for Design, Measurementand Evaluation in Clinical ResearchGuangzhou University of TraditionalChinese Medicine12 Jichang Road, Guangzhou 510405People’s Republic of ChinaTel. no.: 8620-863 64466FAX: 8620 863 64466E-mail: [email protected]

Professor Tai Hing LamProfessorDepartment of Community MedicineUniversity of Hong Kong7 Sassoon Road, Hong KongTel. no.: (852) 2819 9287FAX: (852) 2855-9528E-mail: [email protected]

Dr Lee Tat LeangHeadDepartment of AnaesthesiaNational University of SingaporeLower Kent Ridge Road, Singapore 119074Tel. no.: (65) 772 4200FAX: (65) 777 5702E-mail: [email protected]

Professor Liu Bao-yanDeputy Director-GeneralDepartment of Science,Technology and HealthState Administration of TraditionalChinese Medicine (SATCM)No. 13 Baijiazhuang DongliChaoyang DistrictBeijing 100026, People’s Republic of ChinaTel. no.: 86-010-65911264; 11269; 23571FAX: 86-010-65911268


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Professor Lu Wei-boProfessor of Internal MedicineChina Academy of Traditional Chinese MedicineStanding Committee MemberChinese Association of Integration ofTraditional Chinese and Western MedicineXiyuan Hospital 4-6-202Haidian District, Beijing 100091People’s Republic of ChinaTel. no.: 86-10-62883714FAX: 86-10-62883714

Professor Ikuro MaruyamaProfessorDepartment of Laboratory andMolecular MedicineKagoshima University School of MedicineKagoshima, JapanTel. no.: 81-99-275-5437FAX: 81-99-275-2629E-mail: [email protected]

Professor Shen ZhixiangDirector-GeneralDepartment of International CooperationState Administration of Traditional ChineseMedicine (SATCM)No. 13 Baijiazhuang DongliChaoyang District, Beijing 100026People’s Republic of ChinaTel. no.: 86-010-65911264; 11269; 23571FAX: 86-010-65911268

Professor Min-kyu ShinDirectorKorea Institute of Oriental Medicine129-11 Chungdam-dongChungarm BuildingKangnam-ku, Seoul 135-100Republic of KoreaTel. no.: +82-2-3442-6514FAX: +82-2-3442-0220


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Dr Kwok-Cho TangSenior LecturerDepartment of Public Health and Community MedicineUniversity of SydneyEdward Fong BuildingSydney, Australia 2006Tel. no.: 612-9351-7601FAX: 612-9351 5205E-mail: [email protected]

Professor Le The TrungPermanent MemberExecutive CommitteeTraditional Medicine Association of Viet NamNational Institute of BurnsMinistry of HealthTan Trieu-Thanh Tri, Ha NoiViet NamTel. no.: 844-8462433FAX: 844-8460947

Dr Charles VincentReader in PsychologyDepartment of Psychology(1-19 Torrington Place)University College LondonGower StreetLondon WC1E 6BT, United KingdomTel. no.: +44 171-504-5948FAX: +44 171 391 1714E-mail: [email protected]

Professor Hiroshi WatanabeDirector and ProfessorInstitute of Natural MedicineToyama Medical and Pharmaceutical UniversityToyama 930-0194, JapanTel. no.: 81-76-469-5702FAX: 81-76-434-5056E-mail: [email protected]


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Professor Haruki YamadaProfessor and Executive Director for ResearchOriental Medicine Research CenterThe Kitasato Institute5-9-1 Shirokane, Minato-kuTokyo 108-8642, JapanTel. no.: +81-03-3444-6161 (ext. 2143)FAX: +81-03-3445-1351E-mail: [email protected]

Professor Jin YuShanghai Medical University419 Fang Xie RoadShanghai 200011People’s Republic of ChinaTel. no.: 63770161-322; 63674734FAX: 0086-21-63770768E-mail: [email protected]

2. CONSULTANTS

Dr Alan BensoussanSenior LecturerFaculty of HealthUniversity of Western SydneyHead, Research Unit for Complementary MedicineCampbelltown, NSW 2560, AustraliaTel. no.: 612-0772-6363FAX: 612-9773-0998E-mail: [email protected]

Dr Gordon S. DoigAssistant ProfessorDivision of Critical Care MedicineDepartment of MedicineUniversity of Western OntarioLondon Health Sciences Centre Research Institute375 South St., London, OntarioCanada N6A 4G5Tel. no.: 519-685-8500FAX: 519-432-7367E-mail: [email protected]


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Dr David D. McPhersonThe Doctor’s Inn of Health and HealingIntegrative Medical Center5411 Hwy. 50Delavan, Wisconsin 53115United States of AmericaTel. no.: 262-740-1100FAX: 262-740-1290E-mail: [email protected]

3. OBSERVERS

Professor Ding GuanghongInstitute of Biomedical EngineeringDepartment of Mechanics and Engineering ScienceFudan University220 Handan Rd.Shanghai, People’s Republic of ChinaTel. no.: 0086-21-65642744FAX: 0086-21-65119204E-mail: [email protected]

Dr Anne FungMedical OfficerTraditional Chinese Medicine DivisionDepartment of HealthWu Chung House32nd Floor213 Queen’s Road EastWanchai, Hong KongTel. no.: 852-21265132|FAX: 852-21239566E-mail: [email protected]

Professor Fei LunFudan University220 Handan Rd.Shanghai, People’s Republic of ChinaTel. no.: 0086-21-65119204FAX: 0086-21-65119204E-mail: [email protected]


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Professor Huang LuqiDeputy-Head of WHO Collaborating Centrefor Traditional MedicineInstitute of Chinese Materia MedicaChina Academy of Traditional Chinese MedicineBeijing, People’s Republic of ChinaTel. no.: 4013996FAX: 4013996

Professor Huang YipingVice-Head of WHO Collaborating Centrefor Traditional MedicineInstitute of Chinese Materia MedicaChina Academy of Traditional Chinese MedicineBeijing, People’s Republic of ChinaTel. no.: 64032658FAX: 4013996E-mail: [email protected]

Dr Seok-Beom KimAssistant ProfessorDepartment of Preventive Medicineand Public HealthYeungnam UniversityCollege of Medicine317-1, Daemyung 5 Dong, Nam GuTaegu 705-717, Republic of KoreaTel. no.: 82-53-620-4374FAX: 82-53-653-2061E-mail: [email protected]

Ms Lin HongWHO Collaborating Centre for Traditional MedicineShanghai University of Traditional Chinese Medicine530 Lingling RoadShanghai 200032,People’s Republic of ChinaTel. no.: 0086-21-64186532FAX: 0086-21-64178290E-mail: [email protected]


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Professor Niu JianzhaoVice-PresidentBeijing University of Chinese Medicine11, Beisanhuan East RoadBeijing University of Chinese MedicineBeijing, People’s Republic of China 100029Tel. no.: (8610) 6428-6716; (8610) 64213841FAX: (8610) 64220867E-mail: [email protected]

Mr Shang LiDirectorInternational Communication DepartmentShanghai University of TraditionalChinese Medicine530 Lingling RoadShanghai 200032, People’s Republic of ChinaTel. no.: 0086-21-64186532FAX: 0086-21-64178290E-mail: [email protected]

Professor Xiang PingHead of WHO Collaborating Centre for Traditional MedicineNanjing University of Traditional Chinese Medicine282 Hanzhong RoadNanjing 210029,People’s Republic of ChinaTel. no.: 0086 25 6798078; 6798079FAX: 0086 25 6798078; 6798079E-mail: [email protected]

Professor Yao NailiHead of WHO Collaborating Centre for Traditional MedicineInstitute of Clinical Research and InformationChina Academy of Traditional Chinese MedicineNo. 18 Beixincang, Dongzhimen NeiBeijing 100700,People’s Republic of ChinaTel. no.: 8610-64016387FAX: 8610-6401638


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Professor Zhu BingDeputy DirectorInstitute of AcupunctureChina Academy of Traditional Chinese MedicineDongzhimen NeiBeijing 100700, People’s Republic of ChinaTel. no.: 0086 10 64014411-2789FAX: 0086 10 64013968

Dr Dong-wuk ChoDirectorManagement and Planning teamPrincipal Research ScientistKorea Institute of Oriental MedicineKangnam-ku, Chungdam-dong, 129-11Seoul, 135-100Republic of Korea

Professor Liu JunlingProfessorInstitute of AcupunctureChina Academy of Traditional Chinese MedicineNo. 18, BeixinchangDonzhimen Nei,Beijing 100700,People’s Republic of ChinaTel. no.: (010) 64014411-2765

Professor Jin ZhigaoProfessorInstitute of AcupunctureChina Academy of Traditional Chinese MedicineNo. 18, Beixinchang, Donzhimen Nei,Beijing 100700People’s Republic of ChinaTel. no.: (010) 64014411-2760


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Professor Chen ZhengqiuProfessorInstitute of AcupunctureChina Academy of Traditional Chinese MedicineNo. 18, Beixinchang, Donzhimen Nei,Beijing 100700, People’s Republic of ChinaTel. no.: (010) 60414411-2933E-mail: [email protected]

Professor Liu ZhishunDirector of Acupuncture DepartmentGuang An Men HospitalChina Academy of Traditional Chinese MedicineNo. 5 Bei Xian Ge Street, Xuan Wu DistrictBeijing, People’s Republic of China

Dr Weiguo HuDirector of Department of JingluoDiagnosis and AcupressureDeputy Director of PolyclinicInstitute of Acupuncture-MoxibustionChina Academy of Traditional Chinese MedicineNo. 18 Beixincang, Dongzhimen NeiBeijing 100700, People’s Republic of China

Ms Yao XinProject Manager of WHO Collaborating Centrefor Traditional MedicineNanjing University of Traditional Chinese Medicine282 Hanzhong Road, Nanjing 210029People’s Republic of China

4. SECRETARIAT

Dr Chen Ken (Responsible Officer)Medical OfficerTraditional MedicineWHO Western Pacific Regional OfficeU.N. Avenue, ErmitaManila, PhilippinesTel. no.: (63 2) 528-9948FAX: (63 2) 521-1036E-mail: [email protected]

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ANNEX 2

OPENING SPEECH BY DR SHIGERU OMI,REGIONAL DIRECTOR,

WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC,AT THE CONSULTATION MEETING ON TRADITIONAL

AND MODERN MEDICINE:HARMONIZING THE TWO APPROACHES,22-26 NOVEMBER 1999, BEIJING, CHINA

Honourable Vice Minister of Health, China, Dr Zhu Qing-Shen,

Honourable Director of Health of Hong Kong, China,Dr Margaret Chan,

Distinguished participants, Ladies and Gentlemen,

I am very pleased to welcome all of you to this ConsultationMeeting on Traditional and Modern Medicine: Harmonizing the TwoApproaches. On behalf of the World Health Organization, I wouldlike to express my sincere appreciation to the Government of Chinafor hosting this very important meeting in your beautiful capital.

WHO has had a traditional medicine programme for the last 20years. It was developed in conjunction with the goal of health forall and the adoption of the primary health care approach. WHOrecognizes that a large percentage of the population of the WesternPacific Region still uses traditional medicine to treat disease andmaintain health. Figures show that around 50% of the population insome countries in the Region is using traditional medicine for differentreasons. This is also the case elsewhere in the world. For example,studies show that use of traditional or complementary medicine inthe U.S.A. has increased from 33.8% of the population in 1990 to42.1% in 1997. It seems probable that interest in traditional medicinewill continue to increase in the future.

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We support Member States in their efforts to bring the properuse of traditional medicine into the mainstream of general healthservice systems. WHO’s involvement in traditional medicine isfocused on our joint efforts with Member States for national policydevelopment, regulation of traditional medicine, use of traditionalmedicine in supporting primary health care, research and informationexchange. WHO supports only a few specific remedies andtechniques used by traditional medicine, such as use of artemisininand acupuncture. For example, use of artemisinin in some countriesas a first line anti-malaria drug is supported by WHO. In the caseof acupuncture, in June 1997, a provisional list of 43 diseases anddisorders that lend themselves to acupuncture treatment was drawnup by a WHO Interregional Seminar on Acupuncture, Moxibustionand Acupuncture Anaesthesia held in Beijing, China. However, theselection of those diseases and disorders was based on clinicalexperience and not necessarily on controlled clinical research.

A number of resolutions adopted by the World Health Assemblyand the Regional Committee for the Western Pacific have urgedMember States to undertake research on traditional medicine and toimprove cooperation between traditional and modern medicine,especially as regards the use of scientifically proven, safe andeffective traditional remedies. However, lack of scientifically-basedevidence limits our involvement in supporting the use of specifictraditional remedies.

We believe that we need to keep an open mind on traditionalmedicine. However, we would like to endorse a therapy with solidscientific evidence.

Long historical use of many forms of traditional medicine andexperiences passed from generation to generation have demonstratedthe effectiveness of traditional remedies. However, scientific researchis needed to provide additional evidence of its safety and effectiveness.Scientific research will serve as the basis of our endorsement of theuse of traditional remedies and techniques.

The major tasks of this consultation meeting are, first, to reviewthe outcome of previous research on traditional medicine and,second, to identify research priorities and sound research methods.By identifying a research strategy, we will be able to focus on the

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kinds of evidence we need in different areas of traditional medicine.

This meeting is very timely. We are about to welcome a newcentury and a new millennium. Looking back over this century, it isclear that modern medicine developed very quickly in the last 100years. However, if we look back over the whole millennium,traditional medicine represented main stream of health care to dealwith the health problems of human beings. Although modernmedicine has enabled us to make great advances, particularly indisease control, many threats to human health remain. Some ofthese are new threats, such as lifestyle-related diseases includingdrug abuse and depression. I believe that traditional medicine hasan important role to play in helping us to meet these challenges.

We have to prepare ourselves to meet the challenge of the nextcentury. That is why the WHO Regional Office for the WesternPacific is holding this meeting. We expect that the outcome of thismeeting will lay the foundation for traditional and modern medicineto work together to meet ever increasing challenge in the newmillennium.

With these few words, I wish you a successful and fruitfulmeeting. Thank you.

traditional and modern medicine: harmonizing the two approaches

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