A few weeks ago, a young woman named Chloe Thomas contacted me in response to the placebo series. She has a fascinating real-life cautionary tale in global health: what the clash between Lao traditional medicine and globalized Western medicine means for a man with a potentially operable brain tumor. No easy answers, stories like these are important in illustrating the sticky points and pitfalls of cross-cultural health care.
Last year when traveling through Southeast Asia I was deeply inspired by the beauty of the people of Laos yet frustrated by their lack of access to basic health services. Small and landlocked, Laos routinely places among the lowest in many health and development indicators. I returned, college idealism in hand, dedicated to help in anyway I could. I found a volunteer opportunity with a NGO in the capital, Vientiane. The NGO’s work attempted to preserve Lao traditional medicine for both its cultural heritage and importance as the sole access to healthcare of any kind for most rural and impoverished populations.
I know many of you reading this may share my initial skepticism, traditional medicine as hokum, an almost ignorant naiveté. But approximately 60- 80% of the global population is dependent on medicinal plants to fulfill primary healthcare needs, and in Africa and Asia, this figure may be upward of 80%. This widespread use is most often attributed to confidence in efficacy, accessibility, and affordability. (For those needing further persuasion, information and/or definitions see the WHO’s Traditional Medicine Strategy.) Furthermore, the use of medicinal plants employed by these various cultures is often the first step in the discovery of bioactive compounds that lead to novel drugs — think artemisinin.
As a medical school aspirant I was eager to explore the evidence-based efficacy of traditional medicinal plants and their potential health benefits, as well as understand different cultural perspectives in medicine. Armed with only a BA and having no experience in either the aid world or ethnomedicine, I was aware I needed to reach out to those more capable of undertaking research and inducing change. Promoting the safety and standardization of plants currently being used was, and should be, a priority. I hungrily began reading, researching, and contacting those in the field.
The first few months proved a crash course in aid politics, grant writing and how to tactfully navigate through the Lao bureaucracy. It was also during this time my Director (whom I will henceforth call Mr. Smith) slowly revealed himself as a self-proclaimed master in Lao traditional medicine (though seemingly without formal, or even informal training). I was not too concerned with this, as over 70% of Laotians routinely use traditional medicine. However, when he continued to talk about his ability in the same sentence with flying monks and talking turtles, and then spoke of his life goal of being able cure the sick by simply walking past them, it became clear that this religious conviction and personal ambition would pose a great challenge to any objective approach I made.
Several weeks later, I checked my email to find an attachment from my Director of the medical record of a mid-twenty year-old, complete with a CT scan noting a mass in the right posterior fossa. The clinical impression relayed to me by Mr. Smith (obtained from the patient) was that this was a brain tumor, which without surgery would give the patient only months to live. Although Mr. Smith admitted that he was told the patient would have a good prognosis with an operation, he insisted that he another local traditional medicine practitioner, they could cure him using solely traditional medicine, and that he wanted me to document the progress.
Most likely the patient sought my boss’s care because they could not afford the operation. If this was the case, I was uncomfortable sitting by idly and watching this vulnerable person be used as a human subject to substantiate an experimental treatment. Human lives should be more precious than tools to validate one person’s conviction or to further their ambitions.
What’s worse still is that if the patient had opted for surgery (assuming he could find the means) and it was unsuccessful, Mr. Smith would no longer accept the patient, citing that the traditional medicine treatment would no longer be effective, almost as if it was out of personal vengeance. Choosing to respect one form of treatment should not mean having to reject the other.
Echoing the South African controversy surrounding traditional treatment for AIDS (involving the now deceased Health Minister Manto Tshabalala-Msimang), a myriad of emotions ran through me, bafflement, hostility, frustration. After a heavily emotional argument in which I pressed that we should at least advocate for funds for the operation if money was the sole determinant in the patient’s choice, my Director accused me of not believing in traditional medicine or his ability to cure.
I am not a doctor and still remain unsure about the accuracy of the diagnosis or the validity of the medical team’s consultation. But, I do realize what I was presented with was irresponsible and potentially fatal. While some plants have shown promise in cancer treatments, too many unknowns still remain for me to allow myself to participate in such a high stakes gamble.
No doubt there has been and will continue to be cases such as this. The ethical implications remain thorny, and literature scant (see here for one of the few articles I have found). With the growing use and recognition of the benefits of traditional medicine systems, there is also a growing need for safety, efficacy, quality and rational use. In fact, nationalization of Lao Traditional Medicine is a goal of the Government, and this would undoubtedly necessitate regulation, standardize treatments and hopefully create a governing body to whom malfeasance can be reported. Professionalization among traditional medicine practitioners would also enable a body of educated primary health care providers in the most rural and remote regions. Unfortunately, discerning the tangible from the intangible in these often religiously contextualized treatments will prove harder still.
It’s a sad reality not every person can afford the care they may desperately need. While I will respect this particular patient’s decision, I will only do so if presented with clear and accurate information on his choice, I will not be involved in a situation in which a patient is mislead by the desire of one person’s goal of attaining supernatural ability. My dilemma left me wondering–when do we admit the most realistic options for medical treatment? What’s the middle ground between Western medicine and traditional systems? Can the two ever co-exist in harmony while still respecting the benefits and fundamental beliefs in both systems? Or are there too many differences, areas of profound misunderstanding that make them perpetually destined for conflict. Perhaps my dilemma was just an example of this.
Apart from this instance, most of my experiences working with traditional medicine were positive, forcing me to revaluate my own perception and views of healthcare and medicine. It was challenging finding the delicate balance between science and religion, and acknowledging that my Western train of thought is just one among many world-views. Though I remain without clear resolve on many of the ethical issues that have arisen with the growing use of traditional medicine and alternative treatments, I hope that with more education will come more clarity. However, what I will take into my medical education is the importance of mutual understanding and respect when treating patients humanely and effectively across cultural chasms, for no matter where I work, there is no doubt that I will continue to work with patients whose healing beliefs greatly differ from my own.
Ms Thomas is originally from California, and a graduate from UC Berkeley (2008) in Molecular and Cell Biology. She is currently in the process of applying for medical school in the United States.
 R. Alves et al., “Biodiversity, traditional medicine and public health: where do they meet?” Journal of Ethnobiology and Ethnomedicine (2007), 3:14