Collaboration Culture in Medicine

“Integrative Medicine (IM) selects best practice of public health and biomedicine.” It is increasingly felt that IM would complement modern medicine by providing cost effective treatment. IM combines latest scientific advances with profound insight of ancient healing systems. Complementary and alternative systems of medicine (CAM) are playing vital role in public health by the virtue of their acceptance by people with or without government backing. However, experts are divided on its utility to meet the global challenge of providing affordable and quality health care.[1–3] Ryan's article in this issue (Symposium of Integrative Dermatology page no. 132-141) analyses their arguments. He highlights the benefits of IM and CAM to the public health program particularly to manage large number of common diseases affecting rural populations. Quoting his association with the Institute of Applied Dermatology (IAD) Kasaragod, Kerala, he disapproves the undue concern on safety of IM. He improves the Hippocratic phrase as “Do (k) no (w) harm” to remind the enthusiasts on adverse events and toxicities of allopathy and dangers of indiscriminate use of CAM.

Protocols of IM evolved from the clinical observations in patients who simultaneously used biomedicine and CAM.[4] In India, patients practiced it themselves long before doctors realized it has value. This was encouraged by over-the-counter availability of many CAM drugs. Indian media regularly carry columns of reputed ayurveda doctors on CAM utility for various chronic ailments. This is supported by literature on comparable biomedical diagnosis in general health media. Furthermore, the government issues licenses to sell CAM and allopathy from one and the same pharmacy. Ryan writes that collaboration between various approaches in medical practice within and outside of allopathy existed long since. These approaches although governed by different philosophies benefited patients. He illustrates it referring to the works of William Osler and Garrod and his own experiences through his associations with Krebs and Richard doll. Ryan feels it is foolish to make judgments by comparing the approaches of “these knights of medicine.”

Ryan appeals to us to make use of any approach to treatment if it is proved of efficacious. He advises not to ignore the advantages of IM such as low-cost technology, accessibility to most people, and safety over the disease itself. Having seen himself the benefits of CAM in Asia and Africa, he became a strong advocate of IM. He practiced what he preached. Ryan's Oxford department of dermatology conducted several studies on wound healing with herbals. He invited Dr. Gerard Bodeker, a strong proponent of CAM in Europe and South East Asia to establish Gifts of Health in Oxford. Later, as Secretary General of International Foundation for Dermatology, he began a new program “Skin care for all.”[5] He collaborated with groups across continents to gather support for community dermatology to manage common and neglected diseases[6] involving skin. He hypothesized the combined use of locally available ancient systems such as ayurveda and yoga.[7] This led to the development a self-care integrative treatment for lymphatic filariasis, a disease affecting over 20 million poor in India.[8,9] In India, there is a decade of spending on CAM research by scientists, modern doctors; Golden triangle partnership (with science, ayurveda, and allopathy) schemes of government[4] and presence of multispecialty doctors and advanced centers for reverse pharmacology.”[10] (See ‘Evidence Based Integrative Dermatology’ in this issue page no. 127-131) But there are not many IM protocols in India. What prevented expansion of IM to new diseases? The focus of researchers and funding agencies has been on laboratory studies of CAM. There has been little attempt toward collaboration with clinicians of various systems of medicine. There is a lacuna in qualitative and quality studies to validate ayurveda in spite of opportunities offered by the Indian Government.[4] Valiathan blamed it on the teaching and learning culture in medical colleges.[11] Twentieth century Indian doctors adopted ayurveda and allopathy by the transfer of knowledge not understanding the philosophy and method of experimentation behind their development.

The major knowledge base of allopathy and CAM is derived from the same human observation of natural events. Significant differences arose from the interpretations placed on the observations.[12] A modern botanist argues that plants should be classified by their genetic relationship. The ayurvedist classified medical plants on the basis of utility. Combining traditional ayurveda with modern medicine, investigators at IAD worked together to discover where the two knowledge systems complimented each other. IM has the advantage of awareness of at least some of the medium-and long-term side effects. Ayurveda literature has already recorded these long-term events and cycles albeit in a different language culture.[13] Therefore, it is pragmatic to have the scientifically trained and practicing modern doctor, pharmaceutical scientist, and CAM doctors working together. The key to the success is in following each other's method and information, while reviewing their conclusion before prescribing IM. Mutual orientation in patient care of a given disease in allopathy and ayurveda by a multisystem doctors team is probably the first step toward developing an IM treatment protocol.[4] This will lead to the construction of a vikruthi table[4] of comparable biomedical terminology such as the IAD team's vikruthi table for lichen planus. The words are not synonymous in medical systems, but they can be compared by examining the patients together (See “Evidence Based Integrative Dermatology” in this issue page no. 127-131). This collaboration requires understanding epistemology of concerned systems and the influence of culture on the language used to describe.[14]

IAD's experiences exposed new challenges in integrative dermatology. Several procedures used in IM and CAM such as oil massage (udwarthana[9] or IMLD-2) are meant to achieve absorption of oil. Fifty to seventy milliliters of herbal oil are absorbed per IM treatment procedure in lymphedema patients. Vehicles used in topical preparations of CAM are water, ghee, etc.,[15–17] They are proved not effective by pharmaceutical research. Manufacturing and dispensing methods of CAM might lead to loss of its active ingredients.[18] Currently available information and ICT tools are not sufficient to assess the possible interactions of CAM with modern drugs. It would be wise to split the botanicals of each compound preparation of CAM and later to do a systematic search[19] to get leads on active ingredients and drug interactions. However, the active ingredient of the whole compound in vivo may not be the same as in vitro molecules identified in this manner. Furthermore, animal experimentation for toxicity and efficacy trials need to define three doshas, namely vatha, pitta, and kapha, in the experimental animal used.[20] In the pre-patent era, the Indian pharmaceutical industry developed “process technology” to manufacture almost every drug invented in Europe and America. This helped to reduce the cost of modern drugs on the Indian market and retained the same efficacy. Ayurveda drug manufactures should collaborate with clinicians, academia, and modern pharmaceuticals industry to develop processes to improve manufacturing and dispensing of CAM drugs. This should aim at enhancing the clinical potential of traditional drugs. Such drugs with enhanced efficacy would reduce the time required to respond to the treatment and save the herbal raw materials. The demand for CAM usage has increased worldwide. The herbal sources are depleted especially by deforestation or use of roots when leaves will do. Furthermore, they are often replaced by counterfeit preparations. India has no preparedness for post-patent era. Our new drug development capability is not sufficient to provide affordable treatment for a majority of poor. IM will come to the rescue of our patients if hostility among practitioners of Allopathy and CAM is addressed with objectivity. Clinicians, academia, and industry should develop collaboration culture to enhance the clinical potential of IM protocols for common diseases. IM should have the evidence of using proven outcome measures of biomedicine. It should selectively incorporate elements of ayurveda and other CAM based on diagnosis of allopathy. Such collaborations should begin a new era of marketing thousands of drugs in untapped CAM pharmacopeias[21] with their enhanced clinical potential and clearly defined indications for their use.