Roberta Pellizzoli [*] and Giulia Dario [°]

In 1978, the World Health Organization (WHO), in the Declaration of Alma Ata on primary health care, appealed to the international community to support the inclusion of complementary medicine and traditional therapies of scientifically-proven effectiveness in national health systems, on the basis that they can reduce the consumption of conventional pharmaceuticals and thus costs of public health systems. Moreover, not only can traditional medicines reduce patients’ adverse responses to conventional drugs, but their production and use is a way to contribute to the development of local economies and to the sustainability of health services. Thirty years later, on the anniversary of the Declaration of Alma Ata, this International Workshop has been the occasion to share and discuss experiences of integrating complementary and traditional medicine (CTM) and to reassert the importance of these practices.
Tuscany is a pioneer in Italy and a leader in Europe in the integration of CTM in its regional public health system, so choosing Florence for this occasion was significant. Moreover, the Tuscany Region has established an active partnership with the UN in the framework of the ART Initiative, supporting projects to adapt and transfer this methodology in several countries through ART’s IDEASS programme[1].

At international level, ART IDEASS is promoting methodologies aimed at including traditional medicine in national health systems. Several technology-transfer actions have been implemented with the support of the health services of the Tuscany Region. In particular, ART IDEASS is promoting the methodologies adopted by the National Department of Natural and Traditional Medicine of the Cuban Ministry of Health, which has generated great international interest. Building on this ongoing collaboration, the workshop’s strategic aim was to inform representatives of Ministries of Health of these innovative primary health practices, stimulate a broad exchange of experiences and generate new demands for adopting this approach.
Two hundred twenty people participated, representing Health Ministries, public and private institutions and experiences, NGOs and decentralized cooperation actors from Afghanistan, Albania, Austria, Bolivia, Chile, Cuba, Dominican Republic, El Salvador, Ecuador, France, Gabon, Germany, Guatemala, India, Iran, Italy, Lebanon, Mali, Morocco, Mozambique, Serbia, Sri Lanka, South Africa, Syria, Switzerland and Venezuela.

The first session focused on analysing the response that complementary and traditional medicine has generated in public health systems. Precious Matsoso, from the WHO Secretariat on Public Health, Innovation and Intellectual Property, stressed the need for a common language between conventional and traditional medicine that could facilitate understanding and the need to develop appropriate methods and approaches of research, so that the safety and efficacy of herbal products can be controlled. After a seminal lecture from Edgar Morin (see the section “Critical concepts” of this issue for the full script), Nila Heredia of the Executive Secretariat for the Andean Health Organism called for a change in the dominant paradigm of conventional medicine towards a more holistic approach that defines health not just as lack of illness, but rather as wellbeing in the biological, spiritual and social sphere of every human being. A key concept, in her presentation, was that of interculturality, understood as the process of creating “another” knowledge, “another” political practice, “another” society, to create a balance between all human beings and the environment in which they live and to achieve health for all. In this respect, interculturality is not only a tool for reducing costs and commercializing traditional medicines but is important for the articulation of different - conventional and traditional - forms of knowledge and practices that should not be hierarchically organized.

The second session dealt with the main aspects of a national strategy for the inclusion of CTM in public health systems and Elio Rossi, for the Tuscany Network of Complementary Medicine, discussed the concrete steps and the role of key actors needed for putting in place such a strategy. Marta Pérez Viñas, director of the Centre for the Traditional Medicine of the Health Ministry in Cuba, provided a concrete example of how this strategy can be designed and implemented, presenting the articulated experience of Cuba, where a plan to use CTM for helping victims of natural disasters has been recently developed.

Other experiences of integration of CTM in the public health systems were presented in the third and fourth sessions, where speakers from Sri Lanka, South Africa, Afghanistan, Mali, Ecuador, Bolivia, Venezuela, Chile, Guatemala, Dominican Republic, Serbia, Mozambique, Albania, Iran and Morocco discussed projects, problems and prospects in their own countries.

The fifth session highlighted “Specific topics related to the implementation of a national strategy for the inclusion of CTM in public health systems”. Rita Cassisi, from UNIFEM Mexico, stressed the relevance of the production of medical plants not only for local economic development but also to empower women: women, she underlined, have an in-depth knowledge of the environment in which they live, including a specific knowledge of the indigenous plants and of their use in medicine that should be recognized and enhanced. Lourdes Acosta, from the Centre for Traditional and Natural Medicine of the Health Ministry of Cuba, focused on her country's experience of training human resources to use natural medicine in addressing epidemic diseases. According to her, a key factor for a successful strategy of integrating CTM is having university- level training in using traditional medicine and techniques. In Cuban universities, in fact, students can choose to qualify in Natural and Traditional Medicine. These skills have been successfully used to address epidemic diseases such as hemorrhagic dengue fever or hepatitis A with homeopathy, acupuncture or flower therapy.

Another major challenge relates to the need of exchanging experiences and practices in South-South cooperation networks, together with an increased role of research institutes and Universities as Dr. Precious Matsoso (WHO) stressed in an interview:

Interview with Precious Matsoso, Director, WHO Secretariat on Public Health, Innovation and Intellectual Property:
Q: The presentations have underlined the relevance of different forms of knowledge that are being created in different ways and different places as well as the relevance of multiculturality and of a multidisciplinary approach: can you comment on this? A: Integrating different approaches is key in the WHO strategy that intends health as �complete� health in all sectors of life. Social determinants of health have to be addressed to respond adequately to challenges and requirements and a multisectoral approach has to be seen as an opportunity to deal with these social determinants. It is important to advance knowledge through innovative means and the research and development agenda have to respond to these challenges. Q: What might be a possible role for North-South networks between Universities in developing an approach to teaching that support different forms of knowledge? A: There is a need for the formal establishment of North-North, North-South, South-South partnerships for joint projects and activities and for sharing knowledge. Within this process stakeholders have to be identified and agencies such as WHO, WTO, UNDP, UNOPS must play a primary role. A primary role must be also played by research institutes and the academia in producing, sharing and disseminating knowledge. Q: Which are the challenges for WHO within this context? A: I would speak of opportunities rather than challenges: it is important, both for rich and poor countries, to start integrating knowledge on traditional medicine from the very beginning of the university curriculum, so that undergraduate students know how practices have evolved in various countries. As for poor countries it is important to protect people from malpractice and unethical behaviour, promoting good practices just like we do with conventional medicine.

The important role of universities in disseminating knowledge on CTM was also emphasized by Nila Heredia who, referring to case of Bolivia, highlighted how the election of an indigenous President, Evo Morales, has been the starting point for a new and progressive approach towards the strengthening of intercultural practices. The Bolivian section of the Andean Health Organism, in fact, is leading several projects aimed at including intercultural education in the Faculties of Medicine and at organizing courses for the non-graduated staff working in the health sector. While recognizing that there are some aspects in the Bolivian intercultural experiences that need to be improved, Heredia argued that exchanging strategies and practices is crucial for the improvement of the health sector. The experiences of Bolivia and of other countries demonstrated how important it is to find spaces for the exchange of accumulated knowledge and to expand networks and partnerships at all levels. The last session was intended as a space for open discussion and for advancing proposals to build concrete cooperation prospects for the inclusion of CTM in public health systems. The draft of the final declaration was discussed, and countries interested in receiving cooperation on CTM issues presented their requests. The Final Declaration stresses that health systems must be adapted and responsive to an intercultural approach to health and disease: within this approach, complementary and traditional medicine is an important tool for empowering and enriching the capacity of public health systems and improving quality of life. It was underlined that CTM can make health systems more comprehensive and preserve cultural diversity, thus contributing to human development. Importantly, this Declaration gave birth to the “International network for the integration of complementary and traditional medicines in public health systems” and proposed the establishment of a Cooperation Programme to support its activities[2] .
The 2008 World Health Report underlined the direct link between income and health, but also stressed how economic growth is not enough: on the contrary it can exacerbate levels of inequality. From that perspective, cooperation around health issues continues to be crucial but with a renewed focus on primary health care, so as to guarantee increased access for the poor. Certainly CTM is a very important tool to be used in this process, and the workshop’s Final Declaration is the starting point for further research and increased commitment.