Speech by AMA Federal President, Dr Kerryn Phelps to the International Holistic Health Conference - Australian Integrative Medicine Association (AIMA), Noosa : Doctors, healing, and the role of complementary medicine

Doctors, healing, and the role of complementary medicine

Good evening. It is an honour for me to speak at this conference and an added pleasure to be here in Noosa.

Two years ago I opened a speech to the Natural and Complementary Healthcare Summit in Canberra with the words "I come in peace."

I'm afraid the closest I can come to that tonight is "I come in goodwill."

Two years ago I said the community expects and deserves evidence that alternative or natural therapies work.

They need evidence of the right doses for particular indications, information on contra-indications, and evidence of possible adverse effects.

If the evidence is there, complementary medicines and therapies will be appropriately embraced by the medical profession...for the benefit of patients and the wider community.

Since the time of that speech much has been done to improve the image and credibility of many aspects of complementary medicine.

The demand for products and therapies has risen. The focus has gradually shifted to embrace research and the clinical evidence paradigm.

But much more needs to be done in the areas of training, education, quality safety, and efficacy. More on that later.

The reality is that recent events have hit the complementary medicine sector like a sledgehammer.

All of a sudden, the complementary medicine industry is under threat and the need for evidence has never been greater.

But to the need for evidence you must now add the need for proof of quality, safety, efficacy...and the rebuilding of trust.

The Pan fiasco has been to the complementary medicine industry what HIH was to the insurance industry.

It will affect the whole industry, not just one manufacturer.

It has hammered a number of innocent bystanders including many retailers who face the prospect of going out of business.

But rather than the Pan fiasco being seen as 'the end' - as it has by some - I believe it presents more opportunities and challenges than the threat of doom and destruction.

Arguably there is no better time to move to provide the evidence of quality and safety, the safeguards and the trust that will restore people's faith and belief in evidence-based complementary medicine.

And there are many sceptics...a lot more since Pan.

Among them are a great number of doctors.

But, along with quite a few of my medical colleagues - some of you here today - I can see a place for complementary medicine to work alongside and within orthodox medicine to provide better health outcomes for Australians.

Under my presidency, the AMA has moved to embrace complementary medicine as an important component of integrated, quality health care.

I established the first ever AMA Complementary Medicine Committee and charged it with the task of consulting with experts in complementary medicine to develop a contemporary position statement which will set the tone of future AMA policy in this important area of health care.

We have always stressed that the principles of quality, safety, and efficacy are as essential with complementary medicine as they are with mainstream medicine.

However, where things presently stand, the evidence clearly tells us that complementary medicine faces a crisis of confidence in the wake of the Pan Pharmaceuticals' scandal.

The Therapeutic Goods Administration - the TGA - has suspended Pan's licence to manufacture all medicines for six months because of what they describe as serious concerns about the quality and safety of Pan products.

The TGA has also recalled all batches of products manufactured by Pan for the Australian market since 1 May 2002, and cancelled Pan's approval to supply its range of products for export.

These actions follow audits of the company's manufacturing premises.

These audits revealed widespread and serious deficiencies and failures in the company's manufacturing and quality control procedures, including the alleged systematic and deliberate manipulation of quality control test data.

The actions of Pan Pharmaceuticals have put the credibility of the entire complementary medicine industry and movement at stake.

The damage has been magnified and extended by the media coverage.

The misdemeanours of a few people regarding some products have dragged down the whole sector. Public confidence in the sector is low.

It is vitally important that those of us concerned about the role of complementary medicine do not try to sweep the significance of this under the carpet.

It is equally important that we publicly support those products, treatments and therapies that are proven to be effective.

In measuring our response, we need to recognise that this is a crisis created by people who the complementary medicine industry had embraced and honoured.

Just last year the former CEO (and still majority owner) of Pan was awarded the Complementary Healthcare Council's prestigious Lady Cilento Award in recognition of his - and I quote - "exceptional contribution over many years to the advancement and professionalism" of the health and nutrition industry.

In retrospect, you could say the contribution has indeed been exceptional, but you'd have to question the 'advancement' bit.

Let's take a brief look at Pan's transgressions, always keeping in the front of our minds that we seek to promote an agenda of quality health care.

From 16 January this year, the Australian Adverse Drug Reaction Reporting System started receiving alarming reports of adverse - and highly variable - reactions to a popular travel sickness pill whose active ingredient had been popularly used for 50 years with no negative reports.

Consumers were reporting that they would take one Travacalm pill and be fine, but the next one would cause reactions ranging from hallucinations to extreme illness.

The TGA's laboratory staff undertook urgent sample testing of the medication.

They found a wide disparity of active chemical composition between different tablets. Testing found dosages varied from 0 to 700 per cent of that listed on the label.

When confronted by the TGA with these results, the marketers of this over-the-counter medication, Key Pharmaceuticals, responded that this was an isolated incident, but agreed to a voluntary recall of the product.

Concerned at the disparity between its own lab results and what it was being told, however, the TGA determined to conduct a special audit of the plant of the manufacturer, Pan Pharmaceuticals. A very "special" audit indeed.

Pan founder Jim Selim claimed early in the crisis that Pan had been audited 25 times in 29 years and never had any problems.

We now know that all previous TGA audits were conducted after several days' prior warning. A bit like the inspections of Woomera Detention Centre.

This says something about the effectiveness of the risk management approach the TGA adopted in the early 1990s. On this occasion, though, three TGA auditors arrived unannounced at Pan's Moorebank factory on 30 January.

When the TGA auditors asked for access to a computer, they were apparently first told that the person with the password was not available.

When that person became available, the computer records were found to have been re-formatted and the relevant information deleted.

The auditors found "critical deficiencies" in the manufacturing process of a very wide range of products - complementary, over the counter, and, finally, at least one prescription medication manufactured by Pan.

The 'critical deficiencies included:

• batch records were unsatisfactory;

• critical steps were being missed in milling and blending ingredients; and

• examination of computer records suggested further "manipulation of data".

The TGA's Chief Medical Adviser, Dr John McEwan, explained on the Sunday Program that TGA audits are generally undertaken in a circumstance of trust.

He said audits are generally conducted every 18 months to two years.

It is that audit certification that allows pharmaceuticals to move throughout the world, in effect.

Dr McEwan justifies that audits have been done on an announced basis in part because they need the cooperation of the staff, for example, to observe production runs of tablets, to have access to computers, or to get old batch records.

Fair enough, provided that cooperation is forthcoming, and that the forewarning is not simply used as an opportunity to clean up for the once-every-18-months audits.

Pan was first 'nabbed' for Travacalm - which is not a complementary medicine - but it was enough to set off a chain of events still hitting the industry today...and will for some time, because Pan was the largest single manufacturer of complementary medicines in Australia.

The initial recall was just the tip of the iceberg. The TGA then went to work on all of Pan's production - with a very large proportion of complementary medicines.

Much was found wanting.

Because of Pan's failures, the entire complementary and self-medication industry is now under scrutiny.

You have to wonder how they let this happen.

Jim Selim's track record in business is now a matter of public record. This track record was well-known by many in the complementary industry and it raises a number of crucial questions.

Why did they still do business with his company? Was it because Pan was the only manufacturer who could supply certain products?

Or was it because they were the cheapest supplier? Was quality sacrificed to save a few bucks in the name of competition? Why didn't all of Pan's customers conduct consistent and frequent independent post-manufacturing quality checks of their own to ensure standards?

Why didn't they see this coming? But I suppose hindsight is a wonderful thing.

Looking back in history, the Pan situation has some eerie parallels to the early legislative moves to regulate the quality of both foods and medicines in the United States early last century.

One morning in 1906, President Theodore Roosevelt was eating his favourite breakfast of sausages, and reading a report of a new novel, called The Jungle, by Upton Sinclair, an American writer and activist.

While it was a novel, this book was clearly based on the factual situation in the meat slaughtering and packing district of Chicago, and it became a runaway best seller.

Among the scenes described in the book were depictions that could be said to bear an uncanny resemblance to reports of practices on the Pan production line.

There were accounts of meat that had tumbled out on the floor, in the dirt and sawdust, and shovelled back into the vats, and sent out to become the public's breakfast.

Looking warily at his own breakfast sausages, Teddy Roosevelt quickly moved to ensure that the Congress enacted the Food and Drugs Act...to keep an eye on quality and safety and efficacy of food and drugs.... including sausage meat.

The US Food and Drug Administration carries this attribution on its website today:

"The turning point in US public and political opinion in the USA came earlier that year when Upton Sinclair published his novel, The Jungle, aimed, as he later said, at people's hearts but hitting their stomachs instead.

His few pages describing filthy conditions in Chicago's packing plants, widely reported and confirmed by governmental inquiry, cut meat sales in half, angered President Roosevelt, and pushed a meat inspection bill aimed at protecting the domestic market through the Congress.

The 1906 law forbade interstate and foreign commerce in adulterated and misbranded food and drugs.

Offending products could be seized and condemned; offending persons could be fined and jailed.

Drugs had either to abide by standards of purity and quality set forth in the United States Pharmacopoeia and the National Formulary - works prepared by committees of physicians and pharmacists - or meet individual standards chosen by their manufacturers and stated on their labels...

An effort failed to place in the law...food standards, as defined by the agricultural chemists...but the law prohibited the adulteration of food by the removal of valuable constituents, the substitution of ingredients so as to reduce quality, the addition of deleterious ingredients, and the use of spoiled animal and vegetable products.

Making false or misleading label statements regarding a food or a drug constituted misbranding.

The presence and quantity of alcohol or certain narcotic drugs had to be stated on proprietary labels.

The law sought to protect the consumer from being deceived or harmed, mainly by following a favourite assumption that the average man was prudent enough to plot his own course and would avoid risks if labelling made him aware of them."

All this goes to show, at the turn of the 20^th century, the importance of regulation and registration and legislation and vigilance and, in Roosevelt's case, personal experience in bringing about change and reform and progress...and acceptance.

There are changes afoot that will impact on the complementary medicine industry in Australia.

You may be aware of moves that would effectively abolish the TGA and replace it with a Trans-Tasman Therapeutic Goods Agency.

Australia is unique in the world in the extent to which we seek to regulate complementary medicines.

Where other countries do this - including New Zealand - it is usually through food standards regulations, rather than medicines.

The AMA supports the Australian approach, as I dare say most of you do.

And yet it clearly failed in the case of Pan.

Yes, the problem had been detected, but how long had it been going on? We have no way of knowing.

We need to ask why it happened, and prevent it happening again.

Do our "risk management" regimes simply need to be better managed?

The obvious first step is to examine the role of the TGA - not just in the Pan case, but generally.

The TGA is funded by industry under the rules of full cost recovery. Allow me to quote briefly from the TGA's 2002 Annual Report:

From 1 July 1998, the TGA has been required by the Government to fully recover its operating costs for all activities that fall within the scope of the Therapeutic Goods Act 1989, including regulation of industry and the TGA's public health responsibilities.

The TGA achieves cost recovery in several ways:

• by charging fees for the evaluation of applications to include products in the Australian Register of Therapeutic Goods - the ARTG - or to amend details of products currently in the Register;
• by charging fees for issuing manufacturing licences and for undertaking inspections and audits of manufacturing premises;
• and by levying annual charges for products which are included in the Register.

The TGA has one main effectiveness measure:

• the number of products on the ARTG requiring recall or cancellation for safety-related reasons as a result of post market surveillance
.

I for one can't wait to see the TGA's 2003 report. I suspect it will not be so rosy in its reporting on the TGA's one main effectiveness measure!

To the general public, this situation of the TGA being entirely dependent on the pharmaceutical industry for its source of revenue must pose questions about whether the TGA's decision-making process can ever be influenced - even subtly or unconsciously - by this dependence on the industry for all of its revenue...although it is a compulsory contribution.

I know that other industry regulators also operate on a basis of full cost recovery from the industry they regulate, and apparently do so without allowing those industries to influence decisions, even subtly or subconsciously.

This can be important, for example, in deciding whether (and how) to have spot audits, or to apply sanctions.

The National Industrial Chemicals Notification and Assessment Scheme, or NICNAS, for example, has been effectively imposing greater controls on the industrial chemicals and cosmetics industries, including post-marketing surveillance.

NICNAS is part of the Office of Chemical Safety, which, like the TGA, is part of the Commonwealth Department of Health and Ageing.

Perhaps we need a community debate on the level of cost recovery and industry funding that is appropriate for our industry watchdogs.

Good public policy dictates that at least some of the TGA's resources must surely come from the public purse.

Otherwise the sceptics out there may question the transparency and accountability of the decision-making process.

Other questions arise. Can we make the TGA stronger and more effective in other ways?

Does the TGA need a stronger legislative base?

The Government has promised to look into this, although it is not included in the terms of reference of the expert committee inquiring into the role of complementary medicine in the health system.

It does appear that the "teeth" supporting the TGA's legislative base does need to be considered.

Allow me to make a few observations in this regard.

The sledgehammer with which the TGA hit Pan on 28 April suggests that perhaps the TGA doesn't lack clout in possible sanctions - at least once they have identified an apparently intractable problem and choose to act on it.

But why haven't we seen the TGA sledgehammer more regularly?

The question must be about the TGA's ability, or willingness, to act earlier, with more measured sanctions.

If we are to believe the claims made on the Sunday Program:

• Pan whistleblowers had tried to alert the TGA over a decade to the breaches of good manufacturing practice on the production line
• and the TGA was not prepared to act to seriously investigate the allegations until forced to by the severe adverse reactions to Travacalm in January this year.

A big question mark still remains over the timing of the TGA action.

Surely among the lessons we learn from this are that the audit process needs to be consistent, and needs to be applied to the end product, as well as the process.

The fact that the reports of the adverse reactions to Travacalm led to the downslide that became the Pan fiasco is a testament to the effectiveness of the Australian Adverse Drug Reaction Reporting System.

While reporting of adverse reactions is voluntary, Australia and New Zealand claim the highest reporting rate per capita in the world.

I guess you could regard that as either a good or bad thing.

Anyone - health professional or member of the general public - can report an adverse reaction on the TGA website.

The TGA must implement marketplace surveillance as part of their routine auditing process.

Announced audits are no deterrent to people who wish to flout the rules in any way at any time in any walk of life or in any industry.

If you add random, unannounced product checks in the marketplace by a rigorous regulator, you narrow the odds against such offences succeeding or continuing.

What is most vital is that community confidence be restored.

Industry self-regulation and self-assessment is surely off the agenda for the time being.

At this point, the community does not trust the industry to self-regulate. The community does not like product recalls. They destroy trust.

The Government's expert committee announced by parliamentary Secretary Trish Worth has a huge job ahead of it.

They must work to restore consumer faith in evidence-based complementary medicines and suggest quality safeguards to prevent another Pan-style recall. The problem is, the composition of the committee does tend to suggest an under-representation from the complementary medicine sector.

Complementary medicines and therapies that are of high quality and are known to work should not be dragged down by the Pan scandal.

The AMA has offered its support to the Government and to the expert committee in order to seek to ensure that the manufacturers and wholesalers of complementary medicines regain the respect of the community.

The AMA welcomes the inclusion in the expert committee's terms of reference consideration of the need for a program of information, education and training of both health care practitioners and consumers in the use of complementary medicines.

Since long before the Pan scandal broke, we have been working with the Pharmaceutical Society of Australia and the Pharmacy Guild to develop a joint submission for a program of information, education and training in the use of complementary medicines.

On a personal note, I am not a blow-in to this debate.

Almost a decade ago I visited the Integrative Medicine Department at the University of California in San Francisco.

It was there that I saw the value in an integrated approach to the practice of medicine and the art and science of healing.

In the last five years, a number of Australian university medical schools have introduced aspects of Complementary Medicine into their undergraduate courses.

The depth of such curriculum coverage appears to vary but most medical schools have appropriately adopted an evidence-based approach to the subject matter.

In pharmacy it also appears that many universities have introduced some coverage, mainly on herbal medicines.

It appears that new graduates will increasingly have had some exposure to an evidence-based approach to complementary medicine, although more uniform and adequate coverage would require the agreement of standards in this area.

A number of university postgraduate courses are also being offered which are relevant to doctors and pharmacists.

What is currently lacking is ready access to a comprehensive set of information on complementary medicines for health professionals, such as doctors and pharmacists, that will provide a base that may be updated through continuing education.

Pharmacists and doctors also require:

• the skills to evaluate the evidence on complementary medicine;

• an understanding of their roles in providing evidence based information/advice;

• an ability to access more detailed information when the need arises.

• an ability to explain the regulatory framework developed by the TGA and the role it plays in certifying safety and efficacy.

The public has concerns that many prevailing views of complementary medicines are based on the idea of "natural" products being "safe" - no questions asked.

This is an impression that has been encouraged and exploited by commercial players in the complementary medicine field.

To get an even playing field for consumers, it is important that the public gains greater awareness of:

• the fact that complementary medicines are manufactured chemicals in many respects, just like pharmaceutical products

• the need to continue to assess the evidence for safety and efficacy of complementary medicines in a range of clinical circumstances, such as pregnancy, childhood, diabetes, and so on.

• the potential for interactions between complementary medicines; and pharmaceuticals; as well as

• the role of the TGA in listing and registering products.

Patient outcomes depend on doctors and pharmacists providing evidence-based information about complementary medicines.

This information must be communicated more clearly and, in an ideal world, there would be greater communication between doctors and pharmacists and natural therapists.

It is essential that patients continue to seek appropriate medical care and do not jeopardise the management plan prescribed for medical conditions.

In terms of sales, more than fifty per cent do not occur in a pharmacy. They take place in outlets such as health food shops and supermarkets where there is no professional advice or source of information.

It is also important for us all to be aware that only about a half (57%) of people using complementary medicines currently inform their medical practitioner of their usage.

This may be partly based on a fear that their doctor will not approve of their use. And as a result, GPs tend to underestimate the extent of use by their patients.

This is something that must change.

And the key to that change - from an alternative medicine perspective - is evidence.

This should not just be the preserve of doctors. It should be demanded by practitioners of complementary therapies.

Safety and standardisation should become hallmarks of the industry.

There must be proof that the medicines and therapies work and are safe.

Is the patient - the consumer - getting the desired outcomes and value for money? Are health outcomes improving?

The claims, for example, in the Catalyst program on ABC TV on 8 May 2003 need to be responded to.

Catalyst claims that research from a number of Australian universities shows quality problems affecting many more manufactures of herbal medicines, with up to 50 per cent of products having significant dose variations and up to 10 per cent having no active compounds at all.

These problems are not confined to Pan Pharmaceuticals' products and they've been ongoing for more than five years.

This is another issue that the TGA and the industry itself needs to address.

We need to counter the common belief out there that anything herbal is safe. This is artifice. Funnel web spider venom is "natural" but hardly what you could call safe.

Although I am concentrating on examples relating to nutritional supplements and herbal products this evening, the expectation of safety and efficacy is of course far broader than these products.

We have seen the evolution of the acceptance of modalities such as acupuncture, hypnosis and meditation through clinical research so that we have a deeper understanding of the conditions helped for example by acupuncture, and the conditions it has not been shown to help.

Once so-called "alternative medicine" it is now simply "good medicine" in the right application.

On the other hand, unsubstantiated claims such as an electric mat can "cure multiple sclerosis" or that HIV can be diagnosed by the sound of your voice on the phone, payable by credit card, are irresponsible and indefensible.

In the area of herbal medicine, one of the most worrying stories to emerge over the last ten years is aristolochia.

Throughout the 1990s, the use of this herb was associated with a spate of adverse outcomes in Belgium, Spain, Taiwan and the United Kingdom.

It is now known that this herb can cause renal failure and cancer.

There is a danger that aristolochia may still be contaminating some herbal preparations on sale today in Australia, despite its banning last year by the TGA. We can only know if herbal raw materials are stringently tested.

Another issue is efficacy of treatments.

A case in point is the use of herbs in treating menopausal symptoms.

As Associate Professor John Eden wrote in the Medical Journal of Australia in a groundbreaking article in 2001:

"...phytoestrogens are largely safe; however they have little if any beneficial effect on bone metabolism. If there is an effect on menopausal systems it is mild and not much better than a placebo."

Similarly, negative results have been found in trials of evening primrose oil and wild yam cream.

The Chinese Medical Association has been critical of these trials on the basis that they didn't test the herbs in the right conditions or in the right way.

The Association's concerns to accurately reflect the therapeutic treatment in a trial are legitimate.

However, the Association must go beyond criticism of the trials - they must work more closely with the researchers to get it right.

To get evidence. And then abide by the results.

If there is clearer, more available evidence available it will assist complementary medicine practitioners and GPs to come together in constructive dialogue.

While awareness and interest in complementary medicine has grown, there has also been increasing concern that outcomes for patients in varying clinical circumstances should be critically evaluated.

Medical practitioners and consumers should have information about potential benefits, potential adverse effects, and pharmaceutical /herb interactions.

Increasingly, scientific evidence is becoming available from research studies designed to assess the effectiveness of complementary medicine.

This evidence is gradually being incorporated into the Cochrane Collaboration - an international evidence-sharing mechanism on health issues.

Attention is also being given by researchers to developing creative research designs that will have valid controls and that are sensitive to the nature and, in some cases, the context of the treatments being tested.

Increasingly it will be possible for judgements to be based on evidence of the three pillars: safety, quality and efficacy.

As such research emerges, it will be possible for us to take an evidence-based approach to the use of all complementary medicines and therapies and therapeutic claims, and to advise patients on this basis.

The National Health and Medical Research Council, as the principal source of medical research funds in Australia, has a very poor record of supporting research into complementary medicines.

The NHMRC has an obligation to commit more resources into establishing a robust evidence base which can guide industry, practitioners, regulators and consumers in the use of complementary medicines.

An evidence-based approach also paves the way for more constructive relationships between medical practitioners and complementary therapists.

I know that the President of AIMA, Professor Marc Cohen, has a particular interest here.

There needs to be a more coordinated and extensive system of reporting of adverse events in relation to complementary medicines.

This is something that will clearly emerge from the Government's expert review.

There are also situations that give rise to concern - particularly where, for example, patients may forgo a medical diagnosis and best practice treatment in an unfounded belief that a complementary practitioner has the skills to manage a medical condition which is beyond the scope of their training and experience.

This is of even greater concern where the patient is a child or otherwise unable to make an informed choice of their own.

We must find ways of informing and empowering consumers while respecting their right of choice over health care treatments.

There are also very real medico-legal ramifications of the therapist-client relationship in complementary medicine.

As you all know, medical indemnity is a huge problem for medical practitioners.

It is also a problem for nurses and hospitals.

And, if it isn't already, it will become a growing problem for complementary medicine practitioners.

I firmly believe that issues of legal liability will hit the complementary medicine industry hard. So please prepare yourselves. Risk management will be the key.

In the current environment, I should note problems with product liability for suppliers, importers and manufacturers.

We need to establish what constitutes a duty of care for medical practitioners in relation to complementary medicine.

For complementary therapists, the issue of respecting the boundaries of competency will, I believe, become crucial.

There are moves towards the regulation of practitioners at a State/Territory level.

It is crucial that there is an accreditation process based on scientific evidence about particular therapies and recognition of individual therapists on the basis of external accreditation of teaching programs.

While the AMA does not oppose these moves, our position is definite that non-medical complementary therapists cannot - and should not - claim expertise in medical diagnosis and treatment.

The resolution passed by the Federal Council of the AMA in relation to registration is:

That recognition of health disciplines through the processes of State or Federal registration should be dependent upon their fulfilling the following criteria:

1. the discipline is supported by accepted scientific evidence of safety and efficacy;
2. registrants complete an approved course of training at an accredited institution.

While the Federal AMA does not have a formal position on the regulation of particular groups of complementary therapists, it considers there is no case for establishing State/Territory based regulation for any discipline that lacks an accepted scientific evidence base.

Additionally there are still concerns about the lack of quality controls over the importation and use of raw herbs, which is another State/Territory responsibility.

In the case of dispensing of restricted herbs, we have suggested that additional procedures be put in place, such as those akin to "authority prescribing" for the medical profession.

It may be that the ability to prescribe such herbs should be limited to particular classes of therapists.

In closing, I remain hopeful of an ever-improving relationship between so-called 'orthodox' medicine and so-called 'alternative' or 'complementary' medicine.

The Pan situation should not detract any of us from this objective.

I have been pursuing this goal for some considerable time.

There is nothing to be achieved through continuing the past adversarial approach between the orthodox and complementary advocates.

It is a time to build bridges - and all bridges must be built on trust and understanding...and scientific evidence.

This now extends to trust between the consumer/patient and the manufacturer/supplier.

A good starting point is being clear about what we have in common - best practice, health outcomes and patient welfare.

The key now is to look at Pan and think not 'threat', but 'opportunity'.

There is no doubt that the complementary medicine industry has gained the public's attention - even if it has been for all the wrong reasons.

Turn this attention to advantage. Enter the debate and contest the arguments.

It is time to think positively and act proactively. There is no place for complacency. There is no place for an attitude of 'let's put our heads down until it blows over'.

It won't blow over.

The complementary medicine sector needs to get rid of the bad eggs and do what ever it takes to ensure quality and reliability.

There is a place for complementary medicines and therapies in our community. It is time to prove it. The days of innocence are over.

Thank you.