The World Health Organization’s (WHO) recently announced International Classification of Traditional Medicine (ICTM) could bring greater respect and more widespread recognition to traditional medicine* systems across the world. However, some parties are claiming that it also represents a failure by WHO to achieve greater global inclusiveness and that it could result in oversimplification of the complex nature of the world’s many unique traditional medicine systems.

With the goal of easing and encouraging the use of traditional medicine in clinical, epidemiological, and statistical settings, WHO’s ICTM will provide a harmonized traditional medicine evidence base with stated terminologies and classifications for diagnoses and interventions.¹ In a recent press release, WHO said the ICTM is in part a response to traditional medicine classification and terminology tools remaining sparse while worldwide usage of traditional medicine increases.

“Currently, the data collection practices for [traditional medicine] are frequently not integrated within national or international health information systems,” said M. Meri Robinson Nicol, PhD, a technical officer in WHO’s Department of Health Statistics and Informatics (e-mail, February 15, 2011). Dr. Robinson said that this lack of integration hinders quality data collection on many aspects of traditional medicine interventions, which in turn means that insurance and billing procedures for traditional medicine are not always integrated into general service procedures. “This is an issue, as TM should be included in international health statistics,” she added.

Joining other significant activities, such as the 1978 Alma Alta Declaration and the recent 2008 Beijing Declaration,² the ICTM further illustrates WHO’s efforts in aiding traditional medicine’s globalization and integration into worldwide healthcare. The classification will initially include information on practices and customs in China, Japan, and the Republic of Korea. These countries are part of WHO’s Western Pacific Region, which produced its own International Standard Terminologies on Traditional Medicine in 2008.³ The ICTM is currently being drafted and WHO hopes for it to be completed in time for approval voting at the May 2014 World Health General Assembly.

WHO expects the ICTM to produce data that can be used to evaluate objectively traditional medicine’s benefits, safety, use, spending, and trends; as well as to enable the study of traditional medicine’s role in disease prevention and treatment. Additionally, according to WHO, one accepted classification system will allow all countries throughout the world to base their monitoring of traditional medicine on the same set of data.

According to Dr. Robinson, WHO and various partners will begin creating the ICTM by recording all traditional medicine terminology in ontology software (e.g., Protégé) “to precisely describe the content of each term, which will allow for the most appropriate knowledge representation and possible multilingual equivalents.” This record will be organized into a modular structure that groups certain practices, such as East Asian/Chinesebased traditional medicine, homeopathy, and Ayurveda.

As a next step, the team will link from the ICTM to the current WHO International Classification of Diseases (ICD), using a common terminology base when possible, such as infectious disease names and common signs and symptoms. As when drafting and revising other WHO International Classifications, WHO and its ICTM partners will use an interactive, web-based platform called iCAT, (International Collaborative Authoring Tool). “This system is set up to accommodate for the parameters, or characteristics of traditional medicine identified by selected and national experts as critical for the description and identification of TM diagnoses and TM interventions,” said Dr. Robinson. Traditional medicine experts will be able to input diagnostic and intervention information from around the world. “This, in turn, allows for broader-based input, as it is not required that each expert personally attend each meeting, and experts may continue to work between meetings to make proposal[s] for the initial draft content,” said Dr. Robinson.

ICTM’s Potential Impact

“The ICTM may have wide impact on both traditional and allopathic practitioners, as well as hospital administrators, insurance companies, and policy makers,” said Ryan Abbott, director of research and project management for Nova Worldwide Consulting and a former member of WHO’s traditional medicine team (e-mail, January 8, 2011). Abbott noted that this impact will likely be greater in countries such as the United States where no comparable domestic classifications exist, as opposed to some Asian countries that already have standardized, domestic versions of traditional medicine disease classifications.

“The ICTM may have a legitimizing effect for traditional healthcare practitioners and practices that are still looked down upon by allopathic providers,” Abbott continued. “This initiative potentially represents an important step toward greater integration of traditional and allopathic medicine.”

ICTM will join similar WHO classifications, such as the ICD,⁴ which are meant to provide a consensual, meaningful, and useful classification framework and language for governments, healthcare providers, and consumers.⁵ The ICD, for example, is used to “classify diseases and other health problems recorded on many types of health and vital records, including death certificates and health records.”⁶ These informational records are stored and retrieved for clinical, epidemiological, and quality uses, and are also used by countries around the world to form their mortality and morbidity statistics.

Additional impacts of the ICTM, according to Abbott, might include greater insurance reimbursement for traditional providers and services and the creation of a more scientific approach to traditional medicine by having answers to such questions as how many patients have particular traditional diseases, which receive a certain therapy, what are their outcomes, etc. “It may also help generate data on drug-herb interactions, which is an area where data is sorely lacking,” he continued. “Better data in this area may help patients avoid adverse effects, and may also improve conventional reluctance on the part of physicians to combine [conventional pharmaceutical] drugs and herbs.”

While the potential positive effects of the ICTM are broad, the potential for challenges and negative effects exist as well. “Traditional medical practices tend to be characterized by a highly individualized approach to treatment, which may be difficult to reduce into simple or standardized terms,” said Abbott. Regional Director of WHO’s Western Pacific Region, Shin Young-Soo, MD, PhD, reflected this sentiment in a recent speech at an ICTM meeting held in Manila, Philippines, saying the task “poses a formidable challenge.”³

Dr. Robinson of WHO recognizes that the ICTM framework is—like the ICD—based on the idea that each diagnosis must have a title, that there will be certain signs and symptoms associated with this, such as criteria for diagnosis, body parts, systems, or functions that might be affected, risk factors, and more. “Within this framework, we can expand as necessary to include the intricacies of each healthcare system, and ensure adequate representation of each,” she said.

Additional integration challenges and disadvantages, according to Abbott, include the difficulty inherent in translating traditional medical concepts into terminology with which the mainstream medical community can understand and work, and the possibility that integrated traditional medicine will face some of the same problems as mainstream medicine, such as the modern role of billing and insurance that some consider to be a constraint on clinical practice and physician autonomy. Others are concerned about the effect that an ICTM might have on the intellectual property rights of the people who originated such traditional medicine practices. As voiced in an article on one of India’s leading intellectual property blogs, WHO’s next step should be creating an international benefit-sharing protocol.

WHO Globally Inclusive?

Some are claiming that WHO has done too little to communicate this initiative with all involved parties. After discussing the ICTM with colleagues in Asia and Africa, Gerry Bodeker, EdD, found that “no one in the field knows much about it.” Bodeker is a senior clinical lecturer in public health at Oxford University, chair of the Oxford-based Global Initiative For Traditional Systems (GIFTS) of Health, and co-editor of the 2005 WHO Global Atlas of Traditional, Complementary and Alternative Medicine.

“WHO, as a UN agency made up of member states, is more appropriately expected to consult with member states about core initiatives that will affect states—rather than take a lead on its own,” he said. “None of the African, South Asian, and [South East] Asian policymakers or researchers with whom I discussed this had heard anything from WHO about it” (e-mail, January 21, 2011).

In response to claims that WHO did not adequately reach out to appropriate parties, Dr. Robinson said: “WHO did contact a wide variety of Member States to gauge interest in developing an [ICTM]. A great number of national representatives attended both the WHO Congress (Nov, 2008) and the WHO Working Group Meeting (May 2009) to discuss the priorities and feasibility of each.”

The US National Center for Complementary and Alternative Medicine (NCCAM), a WHO traditional medicine collaborating center, was contacted by WHO in regards to the ICTM. “NCCAM has been aware of this project and we have discussed various aspects of it with WHO representatives,” said NCCAM’s Deputy Director Jack Killen, MD (e-mail, February 28, 2011). “We have offered input and advice to WHO on plans for the project. We have not participated in two meetings which have taken place to date.” According to Dr. Killen, because the preliminary version of the ICTM focuses on traditional medicine in China, Japan, and South Korea, it will likely have little effect on CAM practice, research, or policy in the United States. If successful, however, it could have an impact on terminology and related aspects of clinical research design, he noted.

A further concern Bodeker pointed out is that the ICTM’s initial East Asian focus might result in the extension of such a framework to all traditional medicine systems, many of which are based on different concepts. The parties with whom he discussed the ICTM expressed “a wish for broad-based inter-regional consultation on (a) the desirability for an [international classification] in the first place; (b) appropriate region and tradition-based approaches to classification; (c) partnerships with experts already working in the field outside East Asia.”

According to Dr. Robinson, the selection of practices that originated in China, Japan, and Korea “was based on the facts that these practices were both widely around the world, and that there was a significant amount of Member State interest and support for this area of work. If there is interest in and support for other TM systems, such as has been expressed for Ayurveda, Traditional Mongolian Medicine, and others, we would be happy to work on these in the future, as well.”

—Lindsay Stafford

References

1. WHO to define information standards for traditional medicine [press release]. World Health Organization: Geneva, Switzerland. December 7, 2010. Available at: www.who.int/mediacentre/news/notes/2010/trad_medicine_20101207/en/. Accessed December 29, 2010.
2. Stafford L. WHO Congress passes Beijing Declaration on Traditional Medicine. HerbalGram. 2009;83:24-25. American Botanical Council. Available at: http:// cms.herbalgram.org/herbalgram/issue83/article3449.html.
3. Normile D. WHO Shines a Light on Traditional Medicine. Science Insider. December 6, 2010. Available at: www.news.sciencemag.org/scienceinsider/2010/12/who-shines-a-light-on-traditional.html. Accessed December 29, 2010.
4. The WHO Family of International Classifications. World Health Organization website. Available at: www.who.int/classifications/en/. Accessed December 29, 2010.
5. International Classification of Diseases (ICD). World Health Organization website. Available at: www.who.int/classifications/icd/en/. Accessed January 4, 2011.
6. Coming Soon: International Classification of Traditional Medicine by WHO. Spicy IP. December 11, 2010. Available at: http://spicyipindia.blogspot.com/2010/12/coming-soon-international.html. Accessed March 4, 2011.

*Traditional medicine refers to the practice of historical and indigenous systems of medicine and is distinguished from modern conventional, mainstream, orthodox, standard-practice, or sometimes, “allopathic” medicine, which is sometimes referred to erroneously within the conventional medical profession as “traditional medicine.”