The global healthcare system is gradually shifting towards a more inclusive system of healthcare delivery, in order to improve the quality of life (QOL) of its clientele. The emergence of COVID-19 has further cemented the call for an integrative approach to healthcare delivery, as some countries such as India and China have adopted a combination of natural and conventional healthcare therapies in handling the pandemic. The use of natural therapies has seen a general surge globally, with Ghana being no exception. Since the declaration of COVID-19 as a pandemic by the World Health Organization (WHO), Ghanaians have adopted a wide array of natural therapies in a bid to fight the disease. This phenomenon further calls for an integrative approach to medical care in our primary healthcare system.
Many conventional medical professionals have their reservations about the activities of Naturopathic Practitioners in Ghana. Conventional practitioners are particularly skeptical about the educational and professional training of Naturopaths; why is this so?
Definition of Naturopathic Medicine
Naturopathic Medicine is a distinct area of primary health care delivery which combines the traditions of natural healing with the rigors of modern science. Naturopathic physicians/doctors (NDs) are trained as primary care providers who diagnose, treat and manage patients who have acute and chronic conditions, while addressing disease and dysfunction at all levels of the body, mind and spirit. NDs concentrate on whole patient wellness, through health promotion and disease prevention, attempting to find the underlying cause of the patient’s condition. NDs care for patients of all ages and genders. They provide individualized, evidence-informed therapies, applying the least harmful and most effective approaches to help facilitate the body’s inherent ability to restore and maintain optimal health.
A resurgence of interest in naturopathic medicine in North America in the 1970s resulted in rapid growth and maturation of the naturopathic profession to where it is today. As of 2019, there were seven accredited institutions of higher learning offering naturopathic degrees across North America.
In Ghana at the moment, the Nyarkotey College of Holistic Medicine is the only tertiary institution providing rigorous science-based Naturopathic training based on the World Naturopathic Federation (WNF), Canada, recommendations. Currently, the college has presented Ghana’s first ever Higher National Diploma and Bachelors in Health Technology in Naturopathy and Holistic Health Sciences for program accreditation under The Commission for Technical Vocational Education and Training (CTVET).
Modern Naturopathic Medical students at Nyarkotey College of Holistic Medicine
In 2016, Professor Agyeman Badu Akosa, former Director-General of the Ghana Health Service, advocated for a national health dialogue on the proliferation of health experts without identifiable sources, educating people through the mass media. Prof Akosa was speaking to the Ghana News Agency in Accra on the sidelines of the 67th New Year School and Conference on the theme: “Promoting Universal Health for Sustainable Development in Ghana: Is the Information, Communication and Technology the Game Changer.” He was concerned that some of these people speak with so much authority such that Ghanaians believe them; these are “naturopathies, naturopathic practitioners, computer doctors, people who can say they can melt fibroids.” He was worried that these “naturopaths” were preying on the ill health and sensitivity of the people of Ghana.
“I want us to begin to talk about the health of Ghanaians. Who should be doing these things? Which of these people are going against any standard practice? So that in the end, I say the patients who should be at the center of the healthcare industry should benefit sincerely from knowledge that is generated in health,” he added.
The rate at which these “Naturopaths” just get up and begin to prescribe diets for people and the wrong misconceptions attached to why women get fibroids were some of his worries in the healthcare sector at the time.
Prof Akosa noted: “And I think it is time, let’s sit down and let’s debate. Who is an herbal practitioner? Who is a naturopath? What knowledge do they acquire before they get that? You can go and bring a family health guide and read and come and stand on television and speak to people as if you are an authority. Is not done anywhere. And it should not be allowed in Ghana,” he said.
Prof Akosa said because Ghana has got a high number of radio stations, anybody could go to any radio station and be given a platform, because he is paying for airtime to speak his mind on health issues to the people; stating that whether the message has negative health implications or not, nobody cares.
“People are using computers to make diagnoses, people are writing 19 drug prescriptions. Is that what we should be doing in our healthcare system industry? And because people are on radio, people assume that they have the authority and the right to do what they are doing. “I’m saying let’s all sit down, and let’s talk health,” he said.
He further said: “We should be learning from those who have done things properly! Best practice not just any anything”
Prof. Akosa’s observation in the herbal and Naturopathic community is topic that needs to be given optimum importance in Ghana as a nation, in order to help improve the QOL of Ghanaians. Indeed, many people under the guise of naturopathy are doing many things which completely either detour or frolic from the scope of practice of Naturopathy. Many are those who have no knowledge on Naturopathy, but hide under the umbrella of natural medicine and act as Naturopathic Practitioners.
Indeed, there are many different types of Naturopathic practices, of which Ghanaians are not aware. It is really time to sit down as a country to standardize the profession of Herbal and Naturopathic medicine, as has been done in India, South Africa, North America and many other western countries. Once we are able to standardize the herbal and Naturopathic system of healthcare, a more integrative approach to healthcare delivery can be practiced and sustained, so as to reap the benefits of both conventional and naturopathic medicine, and further improve the relationship and confidence level between Mainstream and Naturopathic practitioners.
The burden of lifestyle diseases in Ghana
Modern Naturopaths are vested in Lifestyle Medicine and can contribute to the fight against lifestyle diseases in Ghana.
Due to the ongoing epidemiological transition of disease burden from infectious to more lifestyle related diseases globally, incidence rates of non-communicable diseases have been on the rise in recent time. The Ghana Health Service (GHS, 2021) has indicated that this phenomenon has not left Ghana behind, as high rates of some non-communicable and lifestyle diseases such as hypertension and diabetes among the public, including children, within the Accra Metro space have been recorded since the local outbreak of COVID-19. The acting Director of the Non-Communicable Disease (NCD) Directorate of the GHS, Dr. Efua Commeh, indicated that 11,046 cases of hypertension were recorded in 2019, while 9,248 were recorded in 2020, with more than 9,250 cases recorded already this year.
Dr. Commeh further indicated that the cases of diabetes were equally alarming, with 4,201 cases recorded in 2019, rising to 4,385 in 2020 and 3,231 already this year. Dr. Commeh blamed the health situation of people on their lifestyle, and added that the conditions as recorded at the health facilities were only a tip of the iceberg. All these lifestyle changes, she said, were risk factors which included the lack of physical exercise, late night eating, alcohol, tobacco use among others.
An earlier article also published in 2020 by the Daily Graphic as reported on increased risk of stroke due to uncontrolled high blood pressure. This was asserted by the Director of Health Promotion Division of the Ghana Health Service, Dr Dacosta Aboagye, who also believed that lifestyle factors such as high blood pressure, smoking, diabetes, high blood cholesterol levels, heavy drinking, and intake of high salt and high fat diet and lack of exercise are the major challenge.
Interestingly, all these lifestyle diseases could be dealt with using lifestyle medicine which is incorporated and taught in Naturopathic Medical Schools. Hence, well trained Naturopaths could play an integral role in the primary healthcare system if they are well incorporated, standardized and acknowledged. What Ghana needs at this point in time is to formulate national policies on standards in naturopathic education and practices.
Naturopathy and Public health are analogous, as evidenced by empirical data (Obu & Aggrey-Bluwey, 2021). Naturopaths could also play an integral role in health promotion, since they have a large following, with a significant percentage of the population receiving their primary healthcare from Naturopaths. The codified principles that guide naturopathic communities could be applied in our healthcare to help educate the public, if we sit down as a nation to debate on the practice of Naturopathy to remove the unscrupulous predators from the profession.
Integrative Medicine to bridge the gap in healthcare
The Current State of TCM: What is Integrative Medicine?
The Academic Consortium for Integrative Medicine & Health, (2015) defines integrative healthcare as an avenue of medicine and health that “reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare, and disciplines to achieve optimal health and healing.”
Naturopathic doctors in integrative systems are the alternative approach. Gaver and Vaartnou, (2015) explained that the term ‘integrative care’ is, in the current healthcare climate, simply an ideal. “It is an idealized system for streamlining patient care; where the strengths of each profession, both naturopathic and conventional, are realized, and patients are directed to the appropriate practitioner for care”. The healthcare system in Ghana is becoming pluralist, with government setting up herbal departments in some hospitals. This, however, is just one aspect of the integration process and Naturopathy is a much wider discipline as compared to herbal medicine. What Ghana needs is holistic integration. Thus, while these operations are headed in a positive direction, they still have a long way to go before fully operating under the umbrella of true integrative care.
With Naturopathy currently take a center stage in the Ghanaian healthcare system, there is the need for extensive changes and modifications to aid the integrative healthcare model. This is the kind of healthcare community we would like the system to operate within. Notwithstanding, we are aware that we still have a long way to go to achieve this reality in our healthcare system.
“As a naturopathic physician and a researcher, I know there is the other aspect of healthcare that mainstream medicine is not aware of. I also know that, medicine is not about competition” (Obu, 2020) and Naturopathy and Mainstream can coexist. Nonetheless, Naturopathy has its own limitations as it cannot address some medical and surgical emergencies. Besides, naturopathic modalities are not magic bullet therapies.
The challenge with Naturopathic practices in Ghana is that sometimes, practitioners attend to patients who have exhausted conventional modalities and still show no improvement in their health. These patients later turn to naturopathic alternatives because they are not getting better. Hence, when they meet the practitioner, they tend to place all their hopes in them, even to the extent of asking practitioners to give them hope or promise them a concrete cure for their long-standing ailments. Unfortunately, by the time most of these qualified practitioners work with these types of patients, they are frustrated and have spent both time and money without receiving any apparent benefits.
Gaver and Vaartnou, (2015) believes that the beauty of an integrative care model is the potential to streamline patients to the appropriate medical model. They talk of the synergistic approach and note: “In many cases, a synergy can exist when both the conventional and naturopathic approaches are applied to a patient’s case. For this to happen, however, the two professions have to understand the strengths and weaknesses of both approaches. It is vital that we as physicians recognize the following: when one approach is better suited over the other, understand how the two professions can work in tandem, and most importantly trust the treatment plan of the other doctor. Essentially, we must keep an open mind for true integrative care to become a reality”.
Indeed, the hierarchy of healing or what we often called the therapeutic order, admonishes practitioners to resort to either pharmaceuticals or surgery as the last resort. This means that Naturopathy is not in conflict with mainstream medicine as propagated by some practitioners who receive substandard naturopathic training, mostly via an apprentice system, in Ghana.
Interestingly, the College of Naturopathic Physicians of British Columbia, (2015) explained that the two professions have come a long way in working alongside each other, and naturopathic doctors have gained grounds and respect as medical practitioners, with the scope of practice continuing to evolve. There are four primary objectives for scope of practice for British Columbia naturopathic doctors. With these goals in mind, the British Columbia Naturopathic Association (BCNA) works tirelessly to expand the scope of naturopathic practice. These goals include prescribing rights, laboratory and diagnostic access, specialist referral, and hospital privileges.
In 2009, the first of these pillars was realized, with naturopathic doctors gaining prescribing privileges. Naturopathic doctors have the ability to order laboratory testing; however, patients are required to pay for each test. In addition to prescribing privileges, naturopathic doctors incorporate various modalities into patient treatment plans. These may include acupuncture, manual therapies (osseous manipulation, electrotherapy), injection therapies (neural therapy, prolotherapy), botanical medicine, use of nutraceuticals, and medical nutrition. Naturopathic doctors receive extensive training in these modalities and are able to make clinical judgments as to when one is indicated over another. A vital aspect of naturopathic education is a thorough understanding of how these many modalities interact with each other when they are best implemented according to (Gaver & Vaartnou, 2015).
In North America, The Council on Naturopathic Medical Education (CNME) is the accrediting body for Doctor of Naturopathic Medicine programs. Graduates of CNME accredited naturopathic medical programs receive a Naturopathic Doctoral designation (ND) and are eligible to take the entry to practice examination. Online or distance programs are not accredited to train NDs.
In South Africa, The Allied Health Professions Council of South Africa (AHPCSA) is a statutory health body established with the Allied Health Professions Act, 63 of 1982 (the Act) in order to control all allied or complementary health professions, including Naturopathy, Homeopathy, Aromatherapy, Ayurveda, Chinese Medicine, Acupuncture. Chiropractic, Osteopathy, Phytotherapy, Reflexology, Therapeutic Aromatherapy, Therapeutic Massage Therapy, Therapeutic Reflexology and Unani-Tibb. The educational requirement is five years.
In South Africa, persons with qualifications from private providers of education and training that do not have the South African Qualifications Authority (SAQA) registration and Council for Higher Education (CHE) accreditation will not be considered for registration. Students of The Allied Health Professions Council of South Africa (AHPCSA) regulated professions are required by law to be registered with the AHPCSA whilst studying or face a penalty after graduating and then requesting registration as a practitioner/therapist. Graduates that do not register within six months of graduating will be required to undergo a competency assessment, at their own cost, to ensure that skills have not been lost due to a delay in registering.
In Nigeria, Naturopathy is considered a second-class profession and an alternative form of medical practice which is regulated by their Medical and Dental Council.
In Congo DR, naturopathy was regulated under the 1950 traditional/natural medicine legislation (Dunn et al.,2021).
In British Columbia, naturopathic medicine was added to the Health Professions Act in 1996. Since then, the profession became a self–regulating one, providing support to patients while ensuring public safety by setting stringent guidelines for education and training.
The scope of practice is still growing and they continue to be self–regulated under the College of Naturopathic Physicians of British Columbia (CNPBC). The greater the scope of naturopathic practice, the more equipped naturopathic physicians are to utilize the extensive training to manage cases as primary care practitioners (PCP). Increasing the scope of practice of naturopathic doctors further facilitates the creation of an integrative care system. The B.C. government has repeatedly highlighted the need for additional primary care practitioners (Shaw, 2015). Shaw, (2015) further explains that there are incentives for newly graduated doctors to work in rural communities; however, many city–dwellers also lack primary care practitioners. One report by Agpforme.ca reported that Health Ministers in British Columbia have called for support to tackle the shortfalls of the current healthcare system and continue to focus on the “GP for Me” program, which aims to ensure British Columbia residents have primary care practitioners. This kind of problem also exists in Ghana, especially in our rural healthcare delivery where medical Doctors fail to take up positions in these areas. Trained Naturopathic doctors could help address this shortfall in the healthcare delivery system.
In jurisdictions where there is law on Naturopathic practice, Naturopathic doctors are currently licensed as primary care practitioners who specialize in natural medicine. Some have limited scope of practice, whilst others have wider scope of practice. Hence scope of practice is jurisdictional.
We believe that if standards are initiated in Naturopathy in Ghana, with a well-defined national scope of practice, naturopathic physicians can, under an integrative model, support conventional efforts in our current burden healthcare system.
Most Naturopathic students at Nyarkotey College of Holistic Medicine understand the collaborative nature of the healthcare profession and have learned to respect the authority of the Medical practitioner and educate the patient on their options. Every Naturopathic Medical Student is well vexed in the biomedical sciences as well as the Natural Medicine coupled with their mandatory clinical training.
They understand the ethics of their profession and why not to fight the medical profession as we both play integral roles in healthcare delivery. Every Naturopathic Medical student knows his or her limitations, unless the student is not from Nyarkotey College of Holistic Medicine. Besides, these students are all part of the Association of Naturopathic Physicians Ghana, the peak body of Naturopathic profession in Ghana and anyone dealing with members of this association should be assured that he or she is dealing with a well-trained Naturopath. The Association of Naturopathic Physicians Ghana is a full member of World Naturopathic Federation (WNF), Canada, the global umbrella body of the Naturopathic profession. The Nyarkotey College of Holistic Medicine is also and Educational Member of the World Naturopathic Federation (WNF). Hence, any patient who comes to see any Naturopathic Practitioner from the association goes through an initial intake, which involves a full health history and a physical exam. Depending on the chief concern, this can take anywhere from 30 to 90 minutes. Patients frequently seek out a naturopathic doctor because they want the assurance, they are living a healthy life; this is where the naturopathic doctor does well.
The strength of the naturopathic approach is that naturopathic doctors, take inventory of many facets of a patient’s lifestyle. These include social history, family history, dietary habits, environmental stressors, emotional state, current medical treatments, and a review of systems. They do this because we believe it is necessary to treat the whole person, not just the individual symptom or system. This, in turn, provides us with valuable information to create targeted treatment protocols and work with the patient to treat the root cause of their ailment. In other cases, where the patient simply wants lifestyle support, gathering this degree of information facilitates preventing disease later on.
Gaver & Vaartnou, (2015) explained the difficulty in not bridging the gap in healthcare. They indicated: “In the current system, where the ideal integrative model does not yet fully exist, there are several hurdles for patients who seek alternative care. If their GP is not open to complementary care from other health professionals, it potentially isolates that patient”. In fact, sometimes patients have a fear of telling the Medical doctor that they are using a particular alternative care product. Some doctors do not want to hear about herbal medicines. Yet as humans, we are a product of herbalism. We would lose our human species without nature. Even the air we breathe is a form of Naturopathy.
There are also some Naturopaths who also advise their clients against conventional medicine. This attitude between Naturopaths and the Medical community do not improve patients’ quality of life.
Interestingly, the Ghana Health Service Patient Charter admonishes Medical Persons to provide alternative treatment advise to patients if it would improve the patient’s quality of life. So why can’t the patients feel free to explore other options? Why must their healthcare be managed by one avenue of medicine or, in some cases, an individual?
Gaver & Vaartnou, (2015) agrees: “I believe they should feel free to seek out additional care and utilize the strengths of other healthcare practitioners. The same goes for my profession: there are times when I have witnessed naturopathic doctors taking patients off of medications and instead recommending supplements in their place without regard for our MD counterpart’s treatment plan. There needs to be a better way for our two professions to interact. Improving the relationship between our two professions will facilitate better patient experiences, and ideally, more positive patient outcomes”.
Interestingly, we have personally encountered many people who claim to be Naturopaths and are against the modern style of Naturopathy, practiced by Naturopathic Doctors such as Dr. Raphael Nyarkotey Obu. They don’t understand the need to promote modern Naturopathic Medicine. They claim this style of Naturopathy deviates from the original naturopathy. They don’t understand why we shouldn’t critique conventional medicine and be more lenient. As a matter of fact, many Naturopaths have benefitted immensely from mainstream medicine. The truth is we cannot downplay the significance of mainstream medicine. Collaboration is key.
In fact, the 2002 Romanow Report demonstrated the need and desire of Canadians for a more comprehensive healthcare system. The report recommends a collaborative system where individuals receive care from a multitude of healthcare services delivered in a seamless fashion, as opposed to receiving isolated care from many healthcare practitioners. In his report, Romanow discusses the need for an integrative approach that works on prevention, promotion, primary care, community, and mental health. This extensive report was a huge step for the naturopathic profession; in discussing the shortfalls of the current healthcare system, it created a niche for naturopathic doctors to exist in an integrative care model. It highlighted the importance of healthcare practitioners working together under an integrative model to streamline patient care.
The current healthcare system in Ghana needs a revamp. We believe that the Romanow report needs to be relooked at to shift the direction for our conservative current healthcare system.
Romanow argues the need to re–evaluate key determinants of health. If we as healthcare professionals hope to empower patients to live healthier lives, reduce the burden to healthcare, and improve patient experience, naturopathic and allopathic physicians need to start working together.
Van & Vaartnou, (2015) detailed some areas integration already exist. They explained: “We do have a few areas where this integration has been easier; for example, in the oncology world, medical and naturopathic doctors work alongside each other at the Cancer Treatment Centers of America (CTCA), and there are a number of local naturopathic doctors who work with Inspire Health. Chronic care is another area where naturopathic doctors excel, and in several integrative clinics in the Vancouver area, naturopathic and medical doctors co-manage cases. Naturopathic doctors have the luxury of longer patient visits, which lends well to these types of cases”.
Stumpf et al., (2008) agrees that the integrative model demonstrates positivism. The problem is implementation as there are consequences. Stumpf et al., (2008) further believe that the first thing to tackle is a clear definition of the model. This definition must clearly define the types of practitioners involved and their specific roles. It may be necessary to differentiate the naturopathic doctor from other alternative healthcare practitioners who lack the extensive science–based clinical education.
Gaver & Vaartnou, (2015) finally note: “In addition, a major barrier is the potential for mismanagement. Without a clear definition of physician roles, there is the potential for patients to fall through the cracks. For example, monitoring a patient on a specific drug begs the question of who is the initial prescriber and which physician is ultimately responsible for following that patient’s progress. For this to work, naturopathic and medical doctors must recognize and respect each other’s judgment. On the flip side, the integrative model, in a world of specialists, has the potential to ensure a sole physician monitors a patient’s diverse care. In the current system, a GP has limited time with each patient to oversee cases managed by multiple physicians. In addition to the potential for mismanagement of an integrative system, is the significant barrier of a naturopathic doctor’s fee for service. Naturopathic doctors are able to spend significantly more time per patient visit because they are paid privately. While every naturopathic doctor employs a different fee schedule, ultimately, our services are more accessible to individuals who can afford to pay. If we hope to provide equal access to patients, this aspect would need to be addressed”.
They further hold the view that, “While our two professions have made great strides in working together, there is still a long way to go. As each profession continues to recognize the strengths of the other and how these strengths can best benefit a patient’s case, patients will be more effectively and efficiently cared for. A true integrative model is the ideal, and we are a way from making it a reality. However, with an open mind and a willingness to take a few small steps in the short term, I believe it can be realized in the future”.
The challenge we experience in Ghana is that students studying in Ghanaian medical, nursing, midwifery and allied health schools have little exposure or not at all to naturopathy as well as complementary alternative medicines. The Nyarkotey College of Holistic Medicine sought to present a naturopathic practitioner’s perspective on integrative medicine and to bridge the gap with the training and promotion of modern Naturopathy in Ghana. We also sought to educate the public that naturopathy is not in crossroad with mainstream. Our challenge is differentiating those hiding under the generic umbrella of natural medicine to paint a wrong picture about the profession. Natural medicine and naturopathic medicine are different, hence, the challenge is to differentiate the naturopathic doctor from other alternative healthcare practitioners who lack the extensive science–based clinical education. we entreat the public that, if they are looking for a qualified Naturopathic doctors or Naturopaths, or in case they are confused about Naturopathic Medicine, The Nyarkotey College of Holistic Medicine can be contacted. We therefore believe that the two professions can live in harmony to improve quality of life. We conclude with a Biblical verse in Isaiah 11 : 6-9:
“The wolf shall dwell with the lamb, and the leopard shall lie down with the young goat, and the calf and the lion and the fattened calf together; and a little child shall lead them. The infant will play by the cobra’s den, and the toddler will reach into the viper’s nest. They will neither harm nor destroy on all My holy mountain, for the earth will be full of the knowledge of the LORD as the sea is full of water.”
The Bible says that the wolf will lie down with the lamb. In other words, the wolf (the lamb’s natural predator) will no longer be an enemy of the lamb. There is finally peace between the two creatures, as well as all the creatures mentioned in these verses.
The writers are healthcare policy researchers with Nyarkotey College of Holistic Medicine, Tema, C 7 and University of Education, Winneba. E- mail: [email protected]
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