By Prof. Raphael Nyarkotey Obu
The term Naturopathy includes Naturopathy and Naturopathic Medicine (WNF, 2021). According to the World Naturopathic Federation (2021), direct risks associated with naturopathic care have been reported very infrequently and the vast majority are minor. Empirical evidence suggests that these risks mostly originate from some unlicensed and rogue practitioners.
In Ghana for instance, unlicensed and medically untrained practitioners appear to have a higher risk profile. Naturopathy and other Complementary and Alternative Medicine Practitioners are currently under the jurisdiction of the Traditional Medicine Practice Council (TMPC) of the Ministry of Health, based on Ministerial directives. The challenge, however, has to do with standardization of the practice. 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, who find themselves “educating”the general public through the mass media. He was worried that these “naturopaths” were preying on the ill health and sensitivity of the people of Ghana.
What is Naturopathy?
Naturopathy or Naturopathic Medicine is defined by two core philosophies and seven principles and naturopathic practice that are guided by distinct naturopathic theories of twelve. Naturopathy was formalized as a distinct system of medicine at the end of the 19th century in Germany, and at the beginning of the 20th century in North America, which later became the home of modern Naturopathy as professionalization, education and standardization started.
The World Naturopathic Federation (WNF, 2021) Health Technology Assessment book on Naturopathy has also defined Naturopathy as a system of healthcare with a deep history of traditional philosophies and practices and with medically trained practitioners who utilize a breadth of natural treatment modalities and practices in the provision of person-centered healthcare.
Naturopathic practice is complex and multi-modal and incorporates core naturopathic therapies, modalities and practices including applied nutrition, clinical nutrition, herbal medicine, lifestyle modification, mind-body medicine, counselling, naturopathic physical medicine, hydrotherapy, and other therapies based on jurisdictional regulations and naturopathic education. Naturopathic diagnoses categorize the symptoms, conditions and/or disease-state using biomedical terminology and diagnosis criteria along with traditional naturopathic diagnostic concepts.
Naturopathy is a traditional system of medicine originating in Europe and it is part of Traditional and Complementary Medicine (T&CM) around the world. Two key practitioners exist in the profession: Naturopaths and Naturopathic Doctors. These practitioners treat patients throughout the span of their life. Naturopathic care focuses on prevention and chronic conditions, but also in the treatment of patients with acute conditions and those in palliative care.
Standardization is Needed
Ghana is currently being recognized as a key player in the global Naturopathic community, by the World Naturopathic Federation (WNF) in their latest book on Naturopathy, due to the hard work of Nyarkotey College of Holistic Medicine and Technology in modern Naturopathic Medicine. In line of this, I believe it is prudent, the Traditional Medicine Practice Council of the Ministry of Health takes the necessary steps to standardize the profession of Alternative Medicine in Ghana. Naturopathy and other alternative Medicine Practices in Ghana are imported and hence, the World Health Organization (WHO) benchmarks for training should be adopted to streamline the practice. In the situation where standardization is not adopted and enforced, many unqualified practitioners are empowered, and this poses huge risk to the patients.
In Ghana, practitioners arrogate to themselves titles they do not qualify to use. A case is co-option of the term “naturopath” and Naturopathic doctor, which occurs in jurisdictions without occupational licensing and exposes the public to increased risks. Analysis of media reports concerning the risks of naturopathic care suggests that reports have often been critical without justification to the merits of the situation being discussed or containing objective analysis.
Naturopathic practice, when performed by a professional and qualified naturopathic practitioner, is safe and patient safety and highly dependent on the educational standards and regulatory settings within jurisdictions.
The World Naturopathic Federation (WNF), in its recent Naturopathy book, is of the view that to fully appreciate and appraise the relative merits of any practice and the provision of any health intervention, decision-makers need to be mindful that a range of potential risks may be associated with its use. All forms of health care have some form of risk that must be considered when comparing to potential benefits and determining appropriate use. Preventable risks are minimized when adequate clinical, regulatory and policy frameworks are put in place.
Naturopathy/naturopathic medicine is no exception, with regulation of its practice being an effective tool in minimizing risks.
Panesar et al.,(2016) and Nabhan et al.,(2012) are of the view that the main types of risks associated with naturopathic practice are similar to those from any other health profession which employs a broad scope of practice and results primarily from tools of trade and the primary-care context within which they work. However, in jurisdictions with no regulatory oversight, misrepresentation of naturopathic care by non-naturopaths also presents a risk to the public. Although the focus of naturopathic practice on lower risk interventions means that naturopathic practice can be considered a relatively safe and low-risk practice, some harms may occasionally occur in the Ghanaian jurisdiction where standardization is problematic with inadequate schools to train such practitioners.
Wardle et al., (2014) viewed risk as direct, indirect or non-health risks. They hold the view that direct risks are directly associated with the provision of health care and have been reported very infrequently in naturopathy/naturopathic medicine practice. Examples of direct risks relevant to naturopathy/naturopathic medicine are potential hepatoxicity or interactions from use of botanical medicines and burns from treatments involving the application of heat. As a therapeutically eclectic profession with a broad primary health care scope of practice, each therapeutic modality or practice used by naturopaths/naturopathic doctors has its own inherent associated risks. For Hayward et al.,(2005), indirect risks are those risks not caused by medical intervention or errors of planning or execution, often termed as acts of omission.
Indirect risks include opportunity costs caused by monopolization of care resulting in underuse or rejection of other effective health services and quality issues such as delayed diagnosis, failure to provide indicated treatments, or employing sub-therapeutic doses of medicines. Non-health risks are also possible and are defined as risks of using health services that harm the patient or consumer in ways not related to health, most commonly manifesting as economic harm as the result of healthcare costs or financial exploitation of patients.
There can be no standardization policy without education. The WHO benchmark for Naturopathy and other complementary medicine practitioners’ education should be adopted in Ghana to help sanitize the profession. The WHO recommends a minimum of 1,500 hours for Naturopaths and maximum of 4,500 for Naturopathic Doctors’ education. This requirement is used by accredited Naturopathic Medical Schools globally and supported by the World Naturopathic Federation(WNF), Canada.
Naturopathic Medical Knowledge
The full breadth of naturopathic knowledge covered in naturopathic educational programs as recommended by the WHO benchmark includes: 1) Naturopathic history, philosophies, principles, and theories. 2) Naturopathic medical knowledge, including basic sciences, clinical sciences, laboratory and diagnostic testing, naturopathic assessment, and naturopathic diagnosis. 3) Naturopathic modalities, practices, and treatments. 4) Supervised clinical practice. 5) Ethics and business practices. 6) Research.
In the advanced countries, some of the risks of naturopathic practice have resulted from dishonest practitioners practicing out of their scope, which in most cases have been dealt with by their naturopathic regulatory authorities but have occasionally extended to the broader court system. For example, in Ghana, the case of Joseph Nkunim is a typical one. In United States v Dr. Mazi 3:21-mj-71156 MAG, a California-based naturopathic doctor is the first person in the United States to face charges of offering fake “homeoprophylaxis immunization” coronavirus vaccines and falsifying COVID-19 vaccination cards saying that the purchasers of the pellets had received doses of the Moderna vaccine and also spreading misinformation concerning the vaccine.
In United States v. Feingold, 416 F. Supp. 627 (EDNY 1976,USA courts affirmed the conviction of an Arizona naturopathic physician for unlawful distribution of narcotic (opioid) medications, which naturopathic physicians in that State were specifically prohibited from doing. Another case in point is the United States v Livdahl, 459 F. Supp. 2d 1255, (S.D. Fla. 2005). In this case, USA courts affirmed the conviction of another Arizona naturopath selling unapproved botulinum toxin type A, misrepresenting the product as an FDA-approved drug. Even in jurisdictions where naturopathic practice is permitted, a few practitioners have been found by relevant courts to be placing the public at risk practicing outside their scope of practice, by virtue of representing themselves as medical specialists where they did not possess training – for example in the Australian case of Malaguti v. Orchard QDC 242, where a regulatory appeal prohibiting a naturopath identifying as a medical oncologist without specialist qualifications was upheld.
Further, Judgment of the regional court in Bonn (landgericht bonn) 9 0 234/14 of 19 June 2015, also dealt with practitioners for unprofessional conduct and professional misconduct. In this case, the German courts have found naturopaths liable on occasion for failing to warn patients of potential secondary harms caused by treatments; for example, blistering that may form on the skin in moxibustion. In the USA case Bailey v Arkansas No. CR 97-1442, an insanity acquittee with conditional release based on taking prescribed medications had relapsed, resulting in legal action after ceasing such medication based on advice from a naturopathic physician, with the courts highlighting the act as professional misconduct, though no action was taken as the practitioner was not within the jurisdiction of the case. Courts have also dealt with criminal offences by naturopaths. An Australian naturopath (Wilson case) was found guilty of multiple counts of sexual assault and rape on patients. Complainants had initially failed to take action due to fraudulent representations as to the medical nature of the sexual act. Michael Morris Wilson, 53, formerly of suburban Armadale, raped and sexually assaulted women who came to see him with problems ranging from endometriosis to ingrown leg hairs. Wilson will spend up to 16 years in jail for sexually assaulting 13 patients over almost two decades.
Medical Doctors practicing under the disguise of Naturopathy
It is also interesting to note that in some jurisdictions, medical doctors who have already been deregistered in their profession and rebrand as naturopath/naturopathic doctors can be prosecuted. This was the judicial reasoning in the Australian case of Health Care Complaints Commission v Bao-Queen Nguyen Phuoc NSWCATOD 81. This case provides an illustrative example of the courts having to take specific action prohibiting an individual practicing as a naturopath, after they had been de-registered as a conventional medical practitioner for misconduct and had attempted to resume medical practice under the guise of providing naturopathic services. Although this does not present evidence of harm from naturopathic practice, it does place the public seeking naturopathic care at risk, if they cannot be assured that their choice of naturopath/naturopathic doctor is suitably qualified. Although these risks are real, they may be readily ameliorated through proactive regulatory and legislative mechanisms that ensure minimum standards of naturopathic practice and education.
In a Slovenia case, Pravnik: Revija za Pravno Teorijo in Prakso, 2018. 135(11-12): p. 823-858, the courts recognized the development of naturopathic practice standards as reducing the impact of inappropriate practice in that country. In Ghana, naturopathic practice is increasing even more rapidly than legislative and regulatory tools. Á Vivanco Martínez (2009) asserts that in Chile, for example, it has been held by the courts that naturopathic treatment is a valid option for those rejecting other treatments (e.g. cancer treatments), as well as complement those treatments, but that such treatments must abide by similar codes of conduct as conventional medical practice.
Unlicensed Versus Licensed Naturopathic Practitioners
Patient safety is highly dependent on the regulatory settings within jurisdictions, and the level of training and accountability of practitioners. This is a concern in naturopathic practice, especially in jurisdictions without regulation, as unregulated practitioners appear to have higher risk profiles.
In conclusion, just as appropriate regulations are necessary to minimize the risks of naturopathic practice, inappropriate regulations may increase risks of naturopathic practices. It is my hope that, the Traditional Medicine Practice Council would develop appropriate regulatory arrangements for naturopathic and other alternative medicine practice standards. This is likely to improve safety and reduce the number of cases involving naturopaths and other alternative medicine practitioners in court systems to avert liabilities.
The author is an honorary Professor, Naturopathic Researcher, Chartered Management Consultant(Canada) and a final semester LLB student. He is also the President of Nyarkotey College of Holistic Medicine & Technology; African Naturopathic Foundation & Association of Naturopathic Physicians Ghana. E-mail: [email protected]