Applying the 6 Principles to LMICs

 In Opinions Editorials

Kimani McDonald
Safiya McCarter, ND
Molly Niedermeyer, ND, LM

Student Scholarship – Honorable Mention Research Review

Naturopathic Medicine & the Global Burden of NCDs

As an international student, with living and working experience in Jamaica, Tanzania, Ethiopia, Nicaragua, and the United States, I am acutely aware of the grave disparities that exist across the world in the nature of disease burden, as well as provision and access to health care. In contrast to just 5 short years ago when infectious diseases dominated global health agendas, non-communicable diseases (NCDs) – mainly cardiovascular disease, cancer, chronic lung diseases, and diabetes – are now the world’s top killers. Affecting more than 36 million people annually, NCDs have reached veritable epidemic proportions globally, and there is a significant equity issue. According to the World Health Organization (WHO), nearly 80% of NCD deaths occur in low- and middle-income countries (LMICs).1 Although the development of chronic disease is heavily influenced by individual risk factors, vulnerability to NCDs are more attributable to factors found in the living and working conditions of these countries and related macroeconomic forces and policies, ie, the social determinants of health.2

Thus, clinical and community health-level interventions alone will not have the power to stem the tide of social malaise underlying the new burden of disease. This year the United Nations Development Program rolled out the Sustainable Development Goals – a universal call to action to end poverty and ensure that all people enjoy peace and prosperity.3 I believe that naturopathic medicine responds to this call to action by addressing individual, community, and social determinants of health for NCDs in LMICs inherently through its 6 principles of practice.

Using the 6 Principles of Practice to Address NCDs

1| Vis Medicatrix Naturae (The Healing Power of Nature)

The utilization of health services for treating and preventing disease is a major social determinant of NCD status.2 For many cultures around the world, spiritual beliefs play a significant role in how people choose to use health services. For example, one of the main reasons that women in Ethiopia choose to give birth at home is that the priest must be present to bless the spirit of the baby before it enters the world, and priests are not allowed inside hospital birth rooms.

The naturopathic principle Vis medicatrix naturae honors the concept of a vital life force that sustains life and directs healing. By acknowledging that the Vis (called by a variety of names in different cultures, such as God, Spirit, or Ancestors) is the undercurrent of healing and can be fed by spiritual leaders and practices, naturopathic medicine aligns with the beliefs of many traditional societies. This approach addresses one of the core components of overall peace and well-being – spiritual health – which is often overlooked in conventional medical care. In this way, naturopathic medicine allows for a degree of mutual cultural understanding and respect that increases the likelihood that people will seek out naturopathic primary care services and, by effect, improve chronic disease outcomes.

2| Tolle Causam (Identify and Treat the Cause)

In naturopathic medicine, the approach to clinical diagnosis of a patient is to look beyond the symptoms to identify the underlying cause of disease. The fact that the global burden of NCDs disproportionately lies in LMICs suggests that an underlying cause rests in economic instability, inequity, and power dynamics within global markets. The very foundations of health – healthy food, clean water and air, adequate sleep, community, emotional well-being – can be threatened for people in LMICs, leading to a cumulative impact of disparities in environmental exposure, biological vulnerability, and social vulnerability.4

While it may be unrealistic for naturopathic doctors to address the multi-symptomatic phenomena of poverty and power distribution, our practice of getting to the root cause of disease gives us a comparative advantage to serve as a collective voice for health policies and practices that are closer in reach. For example, food and beverage marketing has been identified as a significant environmental contributor to childhood obesity and type 2 diabetes rates, due to the heavy influence to consume energy-dense, nutrient-poor food and beverages.5,6 LMICs are frequently prey for such aggressive marketing campaigns, the effects of which we see in the disproportionately high incidence and prevalence of NCDs. A host of possibilities exist for naturopathic doctors to treat some of the real causes of NCD development in LMICs. For instance, we can insist on times for regular exercise and provision of healthy food choices within schools and public spaces by becoming involved in country-specific public health policies. In the current global context, identifying and treating the cause of chronic disease requires this ambitious role of naturopathic doctors as activists and voices for change at the global health level.

3| Primum Non Nocere (First Do No Harm)

The preference and norm of using natural medicine is woven into the very fabric of many traditional cultures of LMICs. In Jamaica, for example, it is commonplace for individuals that identify with the Rastafarian faith (“Rastas”) to self-treat both mild and severe illnesses at home with a wide variety of herbs. In Ethiopia, up to 80% of the population is rural and use traditional medicine healers as their first line of health care.7 This trend has its basis in cultural and philosophical tradition, but is also attributable to natural medicine being the only medicine people can afford. In Jamaica, the majority of Rastas are of low socioeconomic status, and despite a history of being proponents of a healthy lifestyle, with changing tides of socioeconomics in Jamaica, Rastas are now progressing to serious complications of chronic diseases without being seen by a doctor.

Based on the principle Primum non nocere, naturopathic medicine uses various natural therapies to address disease until higher-force interventions are shown to be necessary. This approach provides cost-effective, culturally-informed treatment solutions for NCDs in LMICs. Furthermore, based on the global prevalence of natural medicine use, the International Congress for Integrative Health and Medicine has declared a call to action for all governments, and for the WHO and professional organizations to prioritize research, regulation, and implementation of the WHO Traditional Medicine Strategy.8 Naturopathic doctors are trained in both conventional standards of primary care as well as evidence-informed natural approaches, which makes naturopathic medicine poised to help lead this global priority of science-based, regulated natural medicine in every country.

4| Docere (Doctor as Teacher)

The most effective treatment for NCDs lies in behavior change, which is dependent on empowering patients with knowledge, confidence, and skills to adopt healthy practices.8 In my experience living in LMICs, people often perceive themselves as victims of broken economic and social systems, and generally have fewer opportunities to embody agency and practice leadership. This perception of victimization is often reflected in the clinical encounter where patients lack the impetus for behavioral change and look for easy handouts, particularly when they are desperate for free or affordable alleviation of their condition.

Katherine Raymer, MD, ND, specializes in mental health at the Bastyr University’s Center for Natural Health in Seattle, WA. In the words of Dr Raymer, shared with me and fellow students in a class at Bastyr, “The most effective teachers and doctors are those who not only are committed to sharing information, but also have an attentive ear and the capacity to learn from others. A team approach is the most effective way to empower people to set and attain their goals.”

The naturopathic principle Docere embodies the approach in which the doctor becomes a teacher charged with the role of empowering a patient to be the expert and leader of their own health journey. In this way, people not only take responsibility for their individual health – a necessary step for behavioral change for NCDs – but also become community leaders that influence the health of their entire community.

Ethiopia’s Health Extension Program is a prime example of the effect of empowerment and leadership on community health outcomes. This program first educates and employs female health workers, who return to their communities to teach basic healthcare practices to people in their homes, such as using an outdoor latrine and washing hands with ashes when soap is not available. Once a family adopts these healthy practices, they graduate as “Model Families” and are celebrated and rewarded at a community graduation ceremony. Model Families are then tasked to train other families to do the same, causing a rippling effect of empowerment, responsibility and health in the community.

By embodying the role of education and empowerment, naturopathic medicine stands as an appropriate medical specialty for global and community health issues related to NCDs in LMICs.

5| Tolle Totum (Treat the Whole Person)

On the basis that social determinants of disease contribute the greatest to NCD status, a multifactorial approach that treats all the dimensions of a person is necessary for effective treatment. Take this case example: Maria, a 48-year-old female patient, is diagnosed at the Natural Doctors International clinic in Ometepe, Nicaragua, with pre-hypertension and pre-type 2 diabetes. Her treatment plan includes adopting a low-glycemic index diet, decreasing sugar and salt intake, increasing intake of fresh fruits and vegetables, and using in-office stress reduction techniques to prevent the progression of her conditions.

Naturopathic medicine is superior in honoring the many dimensions of a person, particularly mental and spiritual health; however, the principle Tolle totum extends even further. If patients are not also considered within the context of their environment, we are missing a key aspect of Tolle totum. Even when armed with lifestyle-change recommendations, Maria will still return to the same environment that precipitated her health conditions in the first place. This will likely prevent her from successfully implementing the recommended changes: the local market is 3 miles away by foot and offers very limited fresh fruit and vegetable options that are more expensive, Maria experiences incredible stress in her abusive relationship, and she has no one with whom to leave her children so that she can exercise. “It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change.”9

Naturopathic medicine acknowledges that medicine does not work in the vacuum of the human body and that lifestyle change happens within the context of community. Addressing NCDs globally requires this holistic perspective that naturopathic medicine embodies.

6| Praevenire (Prevention)

Because NCDs have their basis in social determinants of health and preventable risk factors, the biomedical model has been grossly ineffective at addressing the epidemic. In the 2 decades leading to 2030, the cost of NCDs will exceed US $30 trillion, representing 48% of the global per-capita gross domestic product (GDP) in 2010. And the burden of NCDs will increasingly affect LMICs.10,11

Tackling risk factors such as physical inactivity and unhealthy diet in the adolescent population is a more effective solution and has become the priority of WHO’s NCD efforts.11 Praevenire (prevention) is both a fundamental principle and a specialty of naturopathic medical training that emphasizes identification of key risk factors, early detection of signs and symptoms, and early intervention to prevent progression to diagnostic criteria. By focusing on overall health and disease prevention, naturopathic doctors are vanguards of a new medical revolution who will not only save lives but, by extension, hold the key to the economic survival of LMICs.

Conclusion

We are now at the dawn of a new international global agenda where Sustainable Development Goals are to “ensure healthy lives and promote well-being for all at all ages,” such that we expand our focus from surviving to thriving.3 This new era in global health is ripe for naturopathic medicine. Using its 6 principles of practice, naturopathic medicine can bring people closer to their indigenous practices while also influencing  health-seeking behavior through culturally-informed care; identify and build on cultural social assets; prevent chronic disease, allowing for economic savings for LMICs; provide a fuller understanding of the multi-dimensional determinants of health; and stand in a privileged position to serve as advocates for the public health reforms required to truly address the global NCD epidemic.

References:

  1. World Health Organization. Preventing Chronic Diseases: a vital investment. 2005. WHO Web site. http://www.who.int/chp/chronic_disease_report/full_report.pdf. Accessed September 1, 2016.
  2. World Health Organization. Social Determinants of Health: Sectoral Briefing Series 5. 2013. Available at: http://apps.who.int/iris/bitstream/10665/91591/1/9789241506199_eng.pdf?ua=1.  Accessed September 1, 2016.
  3. United Nations. Sustainable Development Goals. Available at: http://www.un.org/sustainabledevelopment/health/. Accessed October 28, 2016.
  4. Morello-Frosch R. The Science of ‘Riskscapes’: Understanding the Cumulative Impacts of Environmental and Social Stressors. [Powerpoint presentation] Available at: http://csdh.ucsf.edu/sites/csdh.ucsf.edu/files/wysiwyg/RMF%204%2017.pdf. Accessed November 1, 2016.
  5. Roberto CA, Baik J, Harris JL, Brownell KD. Influence of licensed characters on children’s taste and snack preferences. Pediatrics. 2010;126(1):88-93.
  6. Kraak VI, Gootman JA, McGinnis JM, eds. Food Marketing to Children and Youth: Threat or Opportunity? Washington, DC: National Academies Press; 2006.
  7. Kassaye KD, Amberbir A, Getachew B, Mussema A historical overview of traditional medicine practices and policy in Ethiopia. Ethiopian Journal of Health Development. 2006;20(2):127-134.
  8. Stuttgart Integrative Health and Medicine Declaration. Endorsed by the International Congress for Integrative Health & Medicine, June 9-11, 2016. Change.org web site. https://www.change.org/p/stuttgart-integrative-health-medicine-declaration. Accessed October 28, 2016.
  9. Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, DC: National Academies Press; 2000.
  10. Dobbs R, Sawers C, Thompson F, et al. How the world could better fight obesity. November, 2014. McKinsey & Company web site. http://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/how-the-world-could-better-fight-obesity. Accessed February 18, 2016.
  11. Bloom DE, Cafiero ET, Jané-Llopis E, et al. The Global Economic Burden of Non-communicable Diseases. September, 2011. Harvard School of Public Health. Available at: http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf. Accessed September 1, 2016.
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Kimani McDonald is an international student from Jamaica who is currently in her 4th year (of 5) of the naturopathic medicine program at Bastyr University in Seattle, WA. After completing 2 years of high school in Tanzania, an undergraduate degree in International Public Health at Stanford University, and 1 year of medical school at the University of the West Indies in Jamaica, she finally found her home in naturopathic medicine at Bastyr. Alongside being a full-time student, yoga teacher, wife and mom of 2 beautiful boys, Kimani’s big mission is to spread naturopathic medicine all across the globe.

 

Safiya McCarter, ND, is a naturopathic physician licensed to practice medicine in the state of Washington. In addition to her private medical practice, she serves as adjunct faculty at Bastyr University in the School of Naturopathic Medicine and Department of Midwifery. She also serves as the ND Alumni Admissions Advisor and Co-Chair of the Multicultural Mentorship Group, an initiative of the Bastyr University Center for Social Justice and Diversity.

 

Molly Niedermeyer, ND, LM, graduated in 1984 from John Bastyr College of Naturopathic Medicine with a doctorate degree, and completed her midwifery degree in 1985. She is currently in private practice at Emerald City Naturopathic Clinic in Seattle, WA. From 1985-1991 she was a distinguished faculty member at Bastyr College, serving as Dean of Naturopathic Medicine and Chair of the Midwifery Department. From 1987-1993 she was on the Board of the Midwives Association of Washington State (MAWS), and served as Treasurer for WANP. She continues to teach as a guest instructor at Bastyr University, and publicly lectures and writes articles.

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