|Year : 2013 | Volume
| Issue : 2 | Page : 132-141
|Integrative medicine selects best practice from public health and biomedicine
Terence J Ryan
Department of Dermatology, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ, United Kingdom
|Date of Web Publication||5-Mar-2013|
Terence J Ryan
Brook House, Brook St, Gt Bedwyn, SN8 3LZ
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The meaning of terms Integrated and Integrative are described variously by an amalgam of latest scientific advances with ancient healing systems, of complementary medicine and biomedicine, and sexually transmitted infections and HIV/AIDS. It means seamless good quality care between hospital and primary care. They provoke approval mostly from patients and disapproval mostly from advocates of science and evidence-based medicine. The Institute of Applied Dermatology in Kasaragod, Kerala, India has championed a mix of Biomedicine, Yoga and herbals from Ayurvedic medicine, partly based on publications from the Department of Dermatology of the University of Oxford. In Oxford dermatology, acceptance of value of integrative medicine (IM) is demonstrated, especially in wound healing and the skin's blood supply. This has long featured in the university's research program. A variety of approaches to the practice of medicine are illustrated with reference to Osler, Garrod, and Doll. IM is believed to underlie contemporarily best practice. Particular emphasis is given to the control of heat, pain, redness, and swelling, all manifestations of inflammation, and the importance of emotion as a stimulus or inhibitor carried by neural pathways. These may explain some unbelievable Asian practices and one of the many roles of Yoga. The concept of Integrative is expanded to include care of the earth and nutrition, the hazards of climate change, Gardens for Health, do (k) no (w) harm as a key to good practice.
Keywords: Agriculture, alternative medicine, Ayurveda, complementary, Institute of Applied Dermatology, integrative medicine, lymphatic filariasis, medical pluralism, Osler, public health, traditional medicine
|How to cite this article:|
Ryan TJ. Integrative medicine selects best practice from public health and biomedicine. Indian J Dermatol 2013;58:132-41
| Introduction|| |
Integrative medicine (IM) is popular and Google's 21 million examples are mostly extolling its practice but there is also substantial disapproval.
"Integrated care is what we all want" says Fiona Godlee, the editor of the British Medical Journal (BMJ). 
But what is it that we all want? Clearly, the term integrated (known in America as integrative and adopted for this article) can be interpreted in many ways. Godlee is writing about seamless good quality care between hospital and primary care in response to a success story in North West London, in which she says was hard won against every kind of obstacle; meaning "opposition from everyone." "Gateways to Integration" is the title used by WHO/UNAIDS writing about HIV/AIDS  as being too much of a vertical program and advocating more integration with other sexually transmitted infections.
"Integr ated Medicine (IM) couples the scientific body of knowledge of Biomedicine with the most profound insights of ancient healing systems, providing thereby the best ways to ensure good health, to live longer and ensure maximum rates of recovery from illness."
Dr. S. Jalaja,  a former Secretary of the Department of AYUSH, Ministry of Health and Family Welfare Government of India, used integrated when writing the approval of the work of the Institute of Applied Dermatology (IAD) in a preface to a Project Evaluation Report that followed the work of the IAD in 2011. She invokes evidence-based medicine (EBM) as its essential feature.
"Although India has a rich tradition of ancient healing systems like Ayurveda, unfortunately an integrated approach to medical care has not received much attention in this country. IM could receive world-wide acceptance only when its efficacy can be successfully tested through evidence based approach."
At one time, the best way to classify Medical Practice was from whence it originated; Greece, Persia, China, India, or even with the development of Man from darkest Africa. Galenic and Modern Medicine are such terms.
There are many kinds of medicine. Some would take a simplistic view and say there is good and bad. But today like Jalaja above, evidence based is deemed a determinant of good.
In this article, I will give a personal view based on experience, some of it in the Department of Dermatology in Oxford but recently with Saravu Narahari at the IAD in Kerala managing elephantiasis with a mixture of Yoga and Ayurvedic Medicine, taking those practices which can be integrated with allopathic physiology theory that Vaqas and Ryan  identified when advising the Global Alliance for the Elimination of Lymphatic Filariasis on morbidity control. At the IAD best practice for a severely disabling condition has astonished those who have struggled to control elephantiasis, not just because it is easy to see the change in the affected limb, but because careful measurement borrowed from allopathy has provided the evidence so much wanted to demonstrate in an evidence-based way that traditional therapy can be effective. This is just one example from my experience that justifies the term Integrative. It can be used to build the case for IM that from some of the Medical Profession gets a vitriolic press such as "IM is the most insulting, misleading, and nonsensical rebranding yet."  IM allows you to find optimal health by understanding your individual needs for achieving balance and harmony.
Wikipedia under the search heading of alternative medicine describes very well the controversies that revolve around this topic. Leading scientific organizations, Nobel prize winners, and Heads of State and their Governments are at times supportive but also strong critics abound. The criticism of The Prince of Wales's Foundation for Integrated Medicine has been anything but courteous and questionably rich in wisdom.  The Royal London Homeopathic Hospital has quite recently changed its name to the Royal London Hospital for Integrated Medicine and not with everyone's approval.
| The Controversy in Oxford|| |
The Oxford School of Medicine, from which I have shown interest in IM, is currently rated in several aspects as number one in the world because it is backed by such a huge volume of successful recently produced scientific knowledge. It was not always so and there have been high points of discovery and teaching followed by prolonged low points with little discovery and little pride in its teaching. The 17 th century was a high point at Oxford with Harvey discovering the circulation, Boyle showing interest in gases, Locke performing the first blood transfusion, and others getting together to form the Royal Society to which only the leaders of science can be elected, and whose members include those who provide the kind of opposition to which Fiona Godlee refers.
In the UK, and especially at the Royal Society and recently at Oxford's Bodleian library, we celebrate Medical Firsts.  These are discoveries by one's own country without paying too much attention that many thousands of years ago in India and China some of what they had discovered was already known. The 18 th and 19 th centuries in Oxford were not so well endowed with brilliant innovators but the 20 th century has seen huge advances with a vast increase in available therapies and some great teachers such as William Osler.  Osler, who promoted Best practice, was critical of adverse side effects delaying healing, but was aware of other systems of medicine's ability to speed recovery. The long corridor of the John Radcliffe Hospital in Oxford has a splendid oil painting of Dr. John Grosvenor (1742-1823) who strongly supported one alternative medicine, that of massage and whose "rubber nurses" put it into practice for more than 100 years just prior to Osler's arrival in Oxford, from Johns Hopkins in 1905. 
The Department of Dermatology in Oxford during the closing years of the 20 th century added to its interests, complementary and alternative medicine (CAM), focusing on blood supply, lymphatic drainage, and wound healing. CAM was the term applied to practices that differed from mainstream scientific or later EBM. As a result of studying the blood supply of the skin earlier in my career,  I became a founder member of the British Microcirculation Society and a treasurer of the European Microcirculation Society. I was President of a World Congress of Microcirculation in 1984. During this conference, Rui Xui Rian  and her team from the Institute of Microcirculation Peking University Beijing demonstrated benefits of Chinese Traditional Medicine. During the Chinese Cultural Revolution, she had noted that in an epidemic of meningococcal meningitis, infants died with vasoconstricted skin induced by allopathic ephedrine, while infants survived with pink skin due to a vasodilatory effect of an herbal remedy. Such benefits were soon observed by us on overseas visits while also observing unbelievable effects of mind over body in frequently held Asian festivals [Figure 1].  There is still much that stretches credulity to the limits. I too have seen things that are unbelievable. Early in my career, I watched, examined, and photographed a religious-based performance of body piercing in which swords were passed through cheek or from one side of the neck to another and inserted 4 inches into the abdomen while dancing in praise of Allah. There was no pain, minimal bleeding, and no scarring, even after years of repeating the procedure. If recounted, then it is unbelievable and not possible.
|Figure 1: Stretching credulity to the limits! Body piercing without pain, bleeding or scarring in spite of being performed frequently. Scientific advances in analysis of brain function is providing explanations of ancient customs|
Click here to view
In the Department of Dermatology in Oxford, sometimes a scientific discovery came first but more often an observation on CAM utilization, indicating its value, was followed much later by studies that lead to an explanation of effectiveness. George Cherry, heading the unit's wound healing interventions, made contact with Vietnam and China, while Gerard Bodeker in the Department as Chairman of the newly founded Global Initiatives for Traditional Systems (GIFTS) of Health, promoted research into Oxford's population and dermatological use of CAM. It resulted in the WHO's two volume WHO Global, Atlas of Traditional, Complimentary, and Alternative Medicine and many other publications. Lack of access to Modern Medicine influences its uptake. During the Vietnam War and for sometime afterwards, it was not possible to purchase allopathic medicine. The Vietnamese had to rely on their own herbals. The Department of Dermatology in Oxford had contact with the National Burns Institute in Hanoi where they were successfully treating severe burns, from napalm and flame, using frog skin and/or a local common weed. We in Oxford decided that this experience should be measured, the in vitro effects of the plant should be examined and the results published by the Vietnamese once they became proficient in English and publication technology. Others had demonstrated that frog skin healed burns. The frog habitually uses its skin as a barrier in a torrid environment of bacteria and toxins. It had developed in its sebum effective wound healing chemicals to manage trauma from its environment. We discovered that in vitro the weed they were using had much in its favor accelerating collagen contraction, hastening epithelial migration, and having anti-bacterial properties.  We have not proved that in burn patients it is working in the same way as in vitro, but it would be foolish to ignore these laboratory studies because of lack of evidence from measurement in the human subject, when one so frequently observes good responses in the field using traditional therapy.
Studies with Bodeker and earlier on Leprosy, brought myself and the editor of this symposium, Narahari, together to regenerate in Kerala one of the best examples of IM, using body movement, massage, and washing with herbal solutions to speed the recovery from lymphedema. ,
| Evidence and Science|| |
We have asked repeatedly, is IM the same as EBM and is it or is it not Science based? These are Questions asked by millions of Google's followers of the IM approach. The Medical School at Oxford University, obeys General Medical Council objectives by teaching both EBM and traditional medicine to its medical students so that they are aware of the issues surrounding the practice of other systems of medicine. Many such students take this topic as a "special study module." One such student was Vaqas of Vaqas and Ryan, a fourth-year medical student. His article, with his supervisor, stimulated Narahari who had named the Institute he headed the IAD; a term much used to indicate putting into practice the observations suggesting the effectiveness and safety of years of utilization of Traditional Medicine and from much more recent research. In a letter to the Lancet from Sri Lanka in answer to an editorial declaring that ignoring basic science was catastrophic,  the author Jayasinghe S wrote.
"The real conceit is to believe that health issues are mainly solved by basic scientists and health professionals. The truth, though unpalatable to some, is that health related problems are mostly the result of the social and physical environment during our life course, and medical care accounts for only five years of the 30 years gained in life expectancy during the 20 th century."
| A Historical Perspective on Discussions in Oxford|| |
In Oxford, I am the curator of the house in which William Osler, George Pickering, and Richard Doll once lived. I have been fortunate to argue about IM over the lunch table at Green College (Now Green Templeton College) with leaders of great science such as the Noble Prize winner Hans Krebs of the Krebs cycle and of the Guru of EBM David Sacket during their appointments in Oxford. The discussion was not only about aspects of skin care but also about famous predecessors who were significant scientists as well as supporters or opponents of what we now describe as IM They began often with a historical perspective, comparing William Osler to Sir Archibald Garrod who succeeded him. Immediately, the point is made that bad medicine is often ignorant and unscientific and good medicine many believe is rigorously scientific and is evidence based. The founders of the Royal Society, which is regarded as a Mecca for Science, were advocates of the scientific approach to medicine. But it is important that Scientific bodies should not be too arrogant or self-righteous. Recently, a series of lectures at Green Templeton College on CAM received the strong opposition of a kind mentioned above by the Editor of the BMJ, from a current Fellow of the Royal Society in London, campaigning against IM  on the grounds that it was encouraging beliefs in medicine that were bad for the reputation of the College. I found myself a spokesman for the College arguing that CAM had value. It is a view not dissimilar to that provided in the 2011 Harveian Oration at the Royal College of Physicians, given by Sir Michael Rawlings.  As Chairman of The National Institute for Health and Clinical Excellence, UK, an organization that reviews therapy and advises the Government on effectiveness, he was supportive of CAM research, and he is aware of the social priorities of the day.
Richard Horton, the editor of the Lancet, writes:  "Part of the disquiet about modern science may be that it is too often silent about the lives of the people it purports to serve." Writing about the 18 th century views of Rouseau, Horton suggests that our practice of medicine should allow our emotions to improve our reason and scientists should take more seriously the origins of inequality, one of which is the cost of health provision. Since our emotions are now known to influence almost all the brain's activities and the neurological pathways of almost all our thoughts and functions pass through our emotions center,  there is backing for Rousseau's suggestion, and an emotional response to the cost of EBM and science is discussed later in this article. It was an influence on the article by Vaqas and Ryan. 
During the 20 th century, Oxford Medicine has been headed by the Knights of Medicine who were Regius Professors of Medicine, such as Sir William Osler, Sir Archibald Garrod, Sir Richard Doll and their approaches to practice were governed by very different philosophies.
Osler, the great physician and perhaps in his younger days a significant laboratory scientist was one of the first to see the cause of malaria in red cells under the microscope. He did contribute to the identification of the platelet. Diseases, such as hereditary hemorrhagic telangiectasia are named after him. He largely introduced teaching medical students by the bedside and unlike the medical profession of today; he did read the early writings on medicine, creating over many years the largest collection of medical books bequeathed to McGill University, Montreal, Canada. His textbooks were the leading teaching texts in medicine for almost half a century.  Osler was not a great prescriber because in his life, compared to today, there was little that was effective and safe to prescribe.
" To you the silent workers of the ranks, in villages and country districts, in the slums of our large cities, in the mining camps and factory towns, in the homes of the rich, and in the hovels of the poor, to you is given the harder task of illustrating with your lives the Hippocratic standards of learning, of sagacity, of humanity and of probity." 
Garrod, who followed him, the author of "Inborn Errors of Metabolism"  pointed out that Mendelian Laws can be applied to humans, disease could be due to a single chemical agent and many see him as the greater scientist for having done so, equating that with good medicine and the origin of the genetic approach which so dominates modern medicine. He wrote "Scientific method is not the same as the scientific spirit. The scientific Spirit does not rest content with applying that which is already known, but is a restless spirit, ever pressing forward towards the regions of the unknown." Several Oxford Scientists have compared Osler and Garrod. They praise Garrod for his Science because he was the first to describe that enzymes are determined by genes. They downgrade Osler for not being a scientist. In my view, they have lost the argument that Garrod was more important since it is realized now that how the genes express themselves is much determined by the environment and by human behavior and our emotions. All of which concerned Osler.
Richard Doll's approach was "Epidemiology offers the simplest, the best and most direct way of elucidating causes of disease that are amenable to public health manipulation." Shortly before he died Richard Doll advised Narahari and me on a statistical analysis of IM.  Repeatedly, writers about these giants in medicine have found it necessary to state who was the better doctor or scientist. It is argued that Osler practiced good medicine but Garrod was the greater scientist.  Richard Doll placed the epidemiological approach in a leading position in Medicine. It is a foolish business arguing who is best.
| Best Practice|| |
Good medicine has and will continue to benefit from all these approaches; laboratory, clinical, and epidemiological. Critics of IM fail to note.
1. To be a good medical practitioner, one should know that up to 80% of the world's population subscribes to Traditional and CAM. For best practice and patient first practice, patient belief must be known. It is the Cultural Competence now expected for all health practitioners. 
2. Access to medicine is limited by distance and cost. IM, inclusive of self-help, breathing, appropriate posture and body movement as well as preparing Gardens for Health is locally and sustainably available at low cost.
3. Lower levels of evidence and the often stated "lack of evidence is not evidence of ineffectiveness" are helpful perspectives in managing diseases of poverty.
4. Skin care, aimed at preventing failure of skin function and covering not just dermatology's classic curriculum but wound healing, lymphedema, burns and the neglected tropical diseases, provides many examples of effectiveness. It should be better understood and taught. A full understanding of interventions such as washing or body movement as contributions to health can be both scientific and a deserving priority in the management of disease.
5. Science can provide a rational basis for why some IM is effective, but its reductionist approach fragments holistic regimens whose parts often have little effect by them. It is foolish behavior to oppose traditional and CAM outright and thus to neglect its capacity to benefit.
6. Like allopathy, other systems of medicine can be both beneficial and harmful. All systems should be monitored for efficacy, cost, and side effects. Such monitoring should be part of the curriculum of all schools. The life-threatening side effects and huge cost of some effective modern allopathic medicines are as potentially dangerous as some of the ineffectiveness. 
However, side effects of IM receive so much more criticism.
| Reasoning from the Neural Sciences and from a Study of the Transduction of Biochemical Signals by Mechanical Forces|| |
Osler's power to make people feel better, the placebo effect of much medicine and the power of much traditional medicine by invocation of the spiritual may depend on the emotions. Trust, hope, and absence of fear may act through the neural pathways that use emotion to enhance or reduce inflammation. The reassuring effects of prolonged empathic counseling or the consequences of being touched in a massage session work through the brain to control inflammation. The calor, dolor, rubor, and tumor (heat, pain, redness, and swelling) which have been described since the early practice of medicine, each indicate a feature of inflammation that can be enhanced or diminished by neural influences and provide explanation for the Asian practices of body piercing and perhaps too the Stigmatists of the Catholic Church whose pain swelling and bleeding are such a powerful demonstrations of an emotional response to thoughts about Christ.  Much of my belief is based on physiological studies in animals. I would not oppose aroma therapy, having read articles on the release of endorphins by grooming in animals  or the work of Francis et al.  on the effect of touch in the brain and its relationship with taste and olfactory areas.
Primates spend a lot of time in grooming. McGlone  is investigating why grooming behaviour makes us feel good. Imaging is used to look inside the brain to see response to stroking, as speed and force vary. Grooming releases endorphins. Grooming activity is rewarding and it is good for you, influencing mood. Touch is an important experience for developing brains and ultimately social well-being. There may be a relationship between tactile history and depression. McGlone is fascinated by why scratching and itching should be so rewarding! I am interested in how Manual lymphatic Drainage not only stimulates the lymphatic system but also carries with it enhancement of well-being and a very well-satisfied patient. Indian Manual Lymph Drainage adopted from ayurvedic procedures to IM protocol of IAD is massaging the limbs with and without oil. 
Furthermore, studies of Yoga which demonstrate that the way one breaths modulates the autonomic nervous system , and support the emphasis on breathing in the management of lymphedema. One accepts that everything that works well in healthy people or has an effect in a laboratory animal may not work in the diseased human, but it would be foolish to ignore the possibility of its effect when healing is observed in those patients using it and has now been so well demondtrated by Narahari , and his team in Kerala. I hold the belief that treatment by IM of the huge hypertrophy that features in those with chronic lymphedema acts through lowering of tissue tension when edema is reduced and invokes its effect through the way cells respond to mechanical forces and the control of the grip and stick effects of proteases. This is a control of inflammatory responses of great complexity and inclusive of neural influences. This is based on in vitro studies and in animal work and in some healthy humans and may never be conclusively analyzed in the diseased patient.
| What Then is Bad Medicine? Is it Unaffordable and Unavailable Locally?|| |
On my bookshelves I have several books that describe some of its features. One of them is called "Bad Science" by Ben Goldacre.  He discusses the "Placebo effect," "Is mainstream medicine evil?," "Why clever people believe stupid things," "Bad Statistics," and "How the media promote the misunderstanding of science." He finds much to criticize in both allopathy and CAM.
If one preaches, or still worse, practices that which is not mainstream or evidence based there are senior scientific bodies, such as the Royal Society and General Medical Councils that will place an embargo on what one has to say or do. I and my colleagues in India, have attended meetings in the UK and in India where intentions to speak about some of our best practices have been barred by the Chairman on the grounds that it is "alternate" and consequently must be rated as unacceptable bad science, even though the purport of our commentary was evidence of a great benefit to patients. Against CAM or IM, the critics include many learned scientists and more worryingly their pupils who tend to be interested in CAM are less critical of their science teachers. As the Editor of the BMJ quotes "sceptical, suspicious, unwilling, and obstructive clinical colleagues seem to have been the main opposition."
When the House of Lords of the UK produced a survey of CAM, it left out any system for which there was no evidence. Immediately on publication of "The House of Lords, Select Committee on Science and Technology, Complementary and Alternative Medicine Session 1999-2000 6th Report, London The Stationary Office,"  Asian Systems of Medicine were judged by the uncritical Medical Practitioner as being bad medicine because the Lords had stated there was no evidence. It must be suggested that they had not looked hard for the evidence in India. They ignored the fact that even the Guru of EBM, David Sackett,  stated repeatedly that lack of evidence of effectiveness is not worthy of ineffectiveness. While he was Visiting Professor in Oxford, an early meeting was arranged with Ryan and Bodeker to discuss some of the problems arising in a study of Traditional medicine used in wound healing. We found Sackett was not a member of the opposition! But his beliefs in Evidence were often used against us. We argued that Randomized Controlled Trials (RCTs) were too expensive and too complex for use where traditional medicine was most prevalent. In response he said, correctly, there was no excuse for not trying. And that excuses for opting out of EBM should be always under review.
I find it fascinating to read the history of medical practice in India. Looking at the gravestones of St. Stephen's Church in Ootacamund in the Nilgiris where my family had a Cinchona plantation in the middle of the 19 th century. The tomb stones illustrate that there were at that time many infant siblings dying before the age of 2 years and adults before 40 years mostly through the powerful inflammatory effects of bacteria. The British brought their own medicines from the British Isles but one can read that British mothers often turned secretly to their Indian child minders for their herbal remedies for good reason that they were safer.  Reading Dickson  I have found the strongest opposition member to allopathy of the year 1850 namely Samuel Dickson who at the age 24 years was an army surgeon to H M 30 th Foot of the British Army in Madras, India, in 1828 when cholera was prevalent. One learns that the therapy consisted of repetitive bleeding, purges, and calomel. He correctly believed that much harm was done by these and wrote disparagingly of allopathic Medicine. In 1850, he wrote of Alternate medicine and of nature's capacity to heal given time as an explanation of some of the successes attributed to the prescription of all medicine, both good and bad.  There was little good and safe medicine to prescribe in those days. Even 50 years later, William Osler, whom most would describe as a good doctor, was clearly not a generous prescriber of the medicines available to him. In his time, the British Medical Association published in 1909 a book on "Secret Remedies,"  a diatribe on unsafe medicines of which there were very many. Osler's celebrated wisdom made him a reluctant prescriber of medicine but a great counselor and certainly an assuager of inflammation by the induction of equanimity.
The highest levels of EBM such as the double-blind randomized controlled trial exclude much that would destroy the evidence. Importantly, the exclusions include the most vulnerable, the infants, the pregnant, and the very old. EBM feels very uncomfortable when having to work with multiple causation and the possibility of confounding. It works best with the single bullet of maximal simplicity and purity. It does not enjoy working with a mix of approaches. In reality, medical practitioners have to deal with confounders every day! The odor and taste of a good French wine is due to the complexity of its herbal constituents and its alcoholic content is of less interest to the connoisseur. The isolation of single active principals might select ethyl alcohol, thus providing an agent which is fully understood by the chemist, but not contributing to taste and odor. It is highly toxic. Much of medical practice is like cherishing a good wine, with a long history of the care of its body, shared with ones most supportive community over a nutritious meal. Any adverse reaction is due to the ethyl alcohol, made less harmless in a complex environment. The cinchona derivative quinine grown by my forefathers in Ooty is still less likely to induce resistance than chloroquine. There are plenty examples of synergism in which the contents of a plant either act together to magnify an effect or have an active principle of which the side effects in which the side effects,in for example the liver, are protected by another active principle within the plant. The "opposition" when discounting the possibility of a good effect from a therapy, like homeopathy, note but give little credit to the prolonged time given to the patient by the homeopath, an hour of questioning, listening, and counseling that ensures concordance of high degree which alone may be therapeutic.
August A Thomen  wrote "Doctors don't believe it." Decades later we ask "Is it evidence based?" Was the ceremonial body piercings describes above any more unbelievable than the rapid shape change secured by IM in a patient with gross elephantiasis? [Figure 2].
|Figure 2: Stretching credulity to the limits! Rapid resolution of very considerable hypertrophy of the tissues. Integrating modern physiological concepts held by biomedicine helps with the integration of some ancient Ayurvedic practices|
Click here to view
| The Price of Therapy and the Cost to the Patient|| |
A main concern is cost. Allopathic medicine is often extremely expensive since the pharmaceuticals have to recruit the costs of production and marketing. The poor, who globally dominate rural and suburban environments, must be protected from being ruined by such expense or by ineffective remedies, for which they pay generously in the hope of cure. One can add to the meaning of Integrative, the mixing of low cost to alleviate high cost. Returning to the philosophy of Rouseau  that scientists should take more seriously the origins of inequality, one of which is the cost of health provision, IM should have this in its sights at all times. They should use emotions to moderate whatever they feed through the brain. It should not be Brain Washing, it must do no harm, but it must use the advantages of the placebo effect, prolonged and wise counseling, and it should be accessible locally and therefore also affordable. Participation has become a key word and this is also one of the defining moderators of the emotions, of feeling good, happy, and dignified.
Much of the highest cost is determined by the pharmaceutical industry and much of low cost is self-help low technology such as washing. Today, there is a pharmaceutical industry making available thousands of mostly well-tested medicines with well-defined dosage but resulting in a large admission to hospital from adverse side effects. A reason for giving many of these a bad press is not just lack of effectiveness nor cost. It is the way drugs are marketed to fund the maker and seller. Thus, it is possible to treat macular degeneration and delay subsequent blindness with drugs named Aventis or Lucentis. The latter is many times more expensive. The manufacturers of both are marketing the more expensive drug as safer. However, several studies have not found Aventis to have significant adverse effects and there is currently much discussion and litigation concerning the marketing language encouraging purchase of the very expensive drug. Two agents are purchasable which differ in price by many thousands of pounds. The industry makes both but markets the most expensive. In fact, they are the same agent. One further problem is counterfeit medicine or the selling of goods in the market place which if not counterfeit completely lack safety advice. When looking for the best in medicine, the practitioner of IM provides counseling that protects the patient from dangerous purchases.
There is a question of access. Snake bite is a good example. Most persons are bitten far away from the best therapy of the most dangerous snakes which is the inoculation of antiserum. There are hundreds of species of snakes and a bite from the majority is not life-threatening. It is only recently that tourniquets, incision, sucking the bite, and a severely jostling ride to visit the resource of antiserum have been proven, evidence based, to be harmful.  Reassurance and immobilization to delay lymphatic drainage of the poison is best practice. Using a mobile phone to photograph the snake and communicate with an antiserum center to establish availability of the correct antiserum is increasingly possible.
I worry how attractive EBM is to resource givers and how readily they give huge amounts of money for trials requiring huge numbers of participants. Lower levels of evidence that are very much cheaper do provide some useful information but tend not to be funded. The scientific approach now receives astonishing levels of funding for studies such as tying a knot in a mouse's tail to show that this "environmental" intervention activates thousands of genes. They will continue to receive similar resources for studying the role of these genes while those who want money simply to untie the knot in the mouse's tail to reverse the process will receive not one dollar!
When first working with Narahari, I welcomed the term "integrative medicine," while following up the in vitro, animal studies and experiments on healthy humans in which I had been involved during my career. The article by Vaqas and Ryan  could not refer to any studies of breathing, because none exist in diseased humans. Those who oppose CAM would quickly find this to be a good reason for increasing their opposition. It seemed that the term IM could better apply to a combination of Yoga and Ayurveda when combined with theory based on observations of in vitro, animal, and healthy human studies. In addition, there are the following reasons I find IM a valuable intervention. Primarily, it is locally available and affordable since it is of huge concern that many people worldwide do not have access to any therapy that will improve their condition. This may because in some seasons when weather is bad there can be no access and when the weather is good, there is a need to grow a year's food supply in a few months and it is difficult to justify traveling to get the necessary help. In the case of the use of herbals, it must be identified correctly, the numbers using it should be counted, and the benefit they have had from using it correctly is valuable information for those attempting to provide a service. There is a need to know what these large numbers of participants were using in order to assess interactions.
One of the most common and disabling diseases in India is elephantiasis. A few surgeons of India have offered therapy. Mostly, it has been debulking but now skilled anastomosis of lymphatics to the venous system is on offer. This is expensive and the time in hospital can be many weeks. With more than seven million persons to treat, the opportunity for such therapy is limited. IM has been offered as an alternative. Based on Yoga, and with herbals integrated with some allopathic principles it was not greeted by the scientific body with enthusiasm until it was shown to be effective in practice. 
The study of the morbidity control of elephantiasis has identified that Yoga and Herbals are not expensive. They are locally available at low cost and sustainably. There is proof of effectiveness. How it comes about and what science underlies this success has still to be explored.
Bandages are a significant cost and so the IAD in Kerala seeks donations but also looks at ways to reduce cost. Perhaps, for example, Yoga, massage, and herbals are sufficient therapy for some patients, and a possibility that is worth research is to identify those for whom bandaging is not essential. It would be an example of IM in which the biomedical contribution is proved to be the least value, but the most expensive.
In IM, the approach should be to take from Allopathy all that has been discovered about how the body works and what has gone wrong in disease. In the case of lymphedema, it was from failure of lymph flow, in part because of a failure to breathe effectively, from overload from the venous system and from inflammation due to bacterial entry through the skin. It was necessary to take from Indian systems of medicine self-help from Yoga and Ayurvedic practice, the availability of herbals which reduced inflammation of the skin and in addition a system of heating the skin all of which combine to diminish elephantiasis. I hypothesized that  lymph flow would be encouraged by the breathing practices of Yoga which empty the great veins in the thorax. Stimulation of the nervous control of lymphatic contractility was another possible effect. Yoga movements and massage would encourage peripheral lymphatic flow and reduce venous overload. The Herbals would reduce inflammation of the skin and might be antibiotic. Steaming would heat the skin to body temperature and have an effect on tissue viscosity making it more amenable to massage and providing a more optimal temperature for proteases to act on reducing the hypertrophied tissue. 
| Integrating Agricultural Practice with the Provision of Nutrition Gardens for Health|| |
A feature of CAM and hence of IM compared to allopathy is that it is more concerned with what one eats and with health promotion and not just with disease. Recently, great emphasis has been placed on Gardens for Health. Man has long grown enough food. Indian Systems of Medicine would encourage this. In Allopathic/biomedical practice, it is a lower priority. In Africa with no written traditions adding nutrition seems a new idea. The practice of IM in, for instance, one medical center in Rwanda has meant adding to the staff of a health center an agricultural expert to grow demonstration gardens, enhance the attractiveness of the center with herbals, and to teach the patients attending with a wide range of illnesses, how improved food intake can restore health. In India, Ayurveda, Siddha, and Unani systems of Medicine all recognize how one is the food one eats. Vanya Orr in Ootacamund teaches children and farmers to value and restore the earth also linked to health centers.  At the IAD, diet is a part of therapy.
| The Future Practice of Medicine|| |
It is likely that older wisdom will be incorporated into modern practice and the preaching of holisms and equanimity such as that of Osler will join with the science of Garrod and the epidemiology of Doll. "Do (k) no (w) harm!" has to be kept on top of the list of objectives. Attention to the environment and the best agricultural practices will have added improved control of waste, and care of the earth as well as the body. The hazards of climate and the ancient and new infective organisms that do us so much harm will be managed by improving our responses to cause and consequences and a better understanding of calor, dolor, rubor, and tumor inclusive of the ancient well ingrained responses to flight and fright and immunosurveillance that are so readily affected by our emotions. This is IM. It is far more complex with more synergism and less easily given an evidence base that science would happily partner. But it has a great capacity to benefit far greater numbers at far lower cost and fewer adverse reactions than much of the biomedical advances in the last 50 years.
Finally to return to the opening theme and the title that "IM selects best practice from public health and biomedicine," Integration applies to a continuum of care from self help, through primary care, to tertiary hospital care. It is the integration within a curriculum as in the WHO Collaborating Centre in Tanzania for Dermatology, Sexually Transmitted Infections (STI) and Leprosy the Regional Dermatology Training Centre Tanzania (RDTC) of the International Foundation of Dermatology. As Chairman; of the International Society's Task Force for Skin Care for All: Community Dermatology, I am charged with taking care to where its ownership is integrated. It is the property of Dermatologists, of those who manage sexually transmitted infections, but also wound healers, burns managers, and lymphedema therapists. It includes several neglected tropical diseases requiring skin care Viz. leprosy leishmaniasis, lymphatic filariasis, onchocerciasis, buruli ulcer, yaws, and so on. RDTC at first, in Africa, did not focus its teaching on Dermatologists but on Allied Health Professionals, inclusive of the largest Health Care profession which is Nursing. An integrated approach requires care from head to foot so should ignore neither the psychiatrist nor the podiatrist. It is active from the womb to the tomb so learns from the specialist in neonatology and gerontology. For the future it must be patient centered while teaching self-help and its public health approach to disease. It must be collaboration with Traditional Midwives and Traditional Health Practitioners (THPs) who greatly outnumber the Allopathic Physician and Nurse. The greatest epidemics, such HIV/AIDS or obesity and diabetes, will not be controlled without all meanings of integration being activated without opposition. A not dissimilar debate has been that concerning the distribution of condoms in Africa requiring that all systems of medicine are educated and helpful about their effect on prevalence of sexually transmitted infections. Thus, there is still a strong lobby to discourage support of the effective, cheap, and safest components of CAM. It is often said that 80% of the developed world use CAM and 80% of those living in the developing world go first to THP. Therefore, Dermatology should be practiced as an informed patient centered Global Resource as integrative dermatology. While scientists, religious leaders, or philosophers may have differences of opinion, an agreed approach to health for all should lead to the removal of as many barriers as possible.
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[Figure 1], [Figure 2]
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||Community level morbidity control of lymphoedema using self care and integrative treatment in two lymphatic filariasis endemic districts of South India: a non randomized interventional study
| ||S. R. Narahari,K. S. Bose,M. G. Aggithaya,G. K. Swamy,T. J. Ryan,B. Unnikrishnan,R. G. Washington,B. P. S. Rao,S. Rajagopala,K. Manjula,U. Vandana,T. A. Sreemol,M. Rojith,S. Y. Salimani,M. Shefuvan |
| ||Transactions of the Royal Society of Tropical Medicine and Hygiene. 2013; 107(9): 566 |
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