Gastroenterologists throughout the world have long recognized the high prevalence of irritable bowel syndrome (IBS) among their patient populations and the challenges that the assessment and management of this disorder pose. However, a quick scan of the literature would suggest that IBS is a predominantly Western disorder and that studies of diagnostic and therapeutic approaches to IBS are the almost exclusive preserve of clinician-investigators in Europe and North America. To “set the record straight” and, in doing so, to identify and attempt to address the additional challenges that IBS, as a truly global entity, presents, the Rome Foundation and the World Gastroenterology Organisation jointly organized an international symposium on “IBS—The Global Perspective” in Milwaukee, Wisconsin, on April 6 and 7, 2011. For WGO, this symposium represented a logical extension of its earlier activities in this area, the IBS Global Guideline (http://www.worldgastroenterology.org/irritable-bowel-syndrome.html), the WGO IBS Task Force and symposium presented at Gastro 2009 in London and the various activities and publications related to World Digestive Health Day 2009 (http://www.worldgastroenterology.org/wdhd-2009.html). The symposium set out to address two related issues:
- To begin to draw a global picture of IBS. Although IBS and all functional gastrointestinal disorders (FGIDs) seem to have high prevalence rates throughout the world, many questions remain unanswered. Firstly, the world map of IBS still shows many blank spaces where prevalence data either do not exist or are fragmentary. Secondly, the potential for those interested in IBS around the world to learn from cultural and ethnic group similarities and differences relating to such factors as prevalence, genetics, environmental factors, symptom reporting, gender distribution, pathophysiology, diagnostic workup, management, treatment approaches, patient adherence to treatments, and clinical outcome, remains largely untapped.
- To address the importance of the development of cross-cultural clinical and research competencies. Cross-cultural clinical competence relates to the ability of health care providers to function optimally in the multicultural background of patients in many medical practices. Patterns of migration across and between continents now expose clinicians to a more diverse patient population drawn from different linguistic, ethnic, and cultural backgrounds. Yet, as medical students and trainees, we receive little or no instruction in the clinical approach to such patients when they present with a disorder, such as IBS, which is so encumbered by psychosocial dimensions. Cross-cultural research competence relates to the skills required to conduct research involving population subgroups of differing cultural and ethnic backgrounds.
The symposium was codirected by Ami Sperber and Eamonn Quigley who were joined in the planning committee by Richard Hunt, Kok Ann Gwee, and Carolina Olano, representing WGO, Douglas Drossman, Max Schmulson, and Lin Chang, representing the Rome Foundation, and Nancy Norton, representing the International Foundation for Functional Gastrointestinal Disorders.
As the program evolved it became clear that the two themes, a global look at IBS and multicultural competence were overlapping and closely intertwined. For example, in addressing the conduct of international clinical trials one has to confront the complexities of translating common symptoms; a word or phrase that we may take for granted as indicating or representing a specific symptom in English may simply not exist in other languages!
The scene was set by a thought-provoking key-note address by Byron Good from Harvard University in his discussion of "how symptoms mediate culture and biology." He introduced us to hermeneutics, the science of interpretation, and explored how language and culture interact to influence the interpretation of illness and the expression of symptoms. His concept of symptoms, accordingly, was not as a simple reflection of bodily processes, but as mediators between body, person, and cultural forms. This concept has special relevance for IBS where biomarkers are notable for their absence and the approach to the patient is based on symptoms alone. The relationships between culture and health were explored in further detail by Jon Stretzler and vividly illustrated by the differences in attitudes and therapeutic approaches to pain between the United States and the rest of the world: Americans, who constitute only 4.6% of the world population, consume 80% of the global opioid supply! Paul Brodwin brought these concepts to bear on IBS and functional gastrointestinal disorders through his exploration of explanatory models of illness and emphasized how divergent the physician expert's and the patient's models may be. In doing so, he made it abundantly clear how important an understanding of a given patient's explanatory model may be and suggested how this may be approached.
The specific implications of differences in clinical presentation, range of potential differential diagnoses, and available diagnostic armamentarium were explored by colleagues from Asia, Eastern Europe, and Latin America, thus providing a more global picture of the clinical approach to IBS. Pathophysiology was also explored from a global perspective in individual presentations on genetics and ethnicity, the microbiota, food-related symptoms, and the impact of psychopathology and stress. For many of these areas, data remain preliminary but comparative studies of candidate genetic markers or putative microbial signatures between, and within, different populations may well yield important insights. In a provocative review of the role of genetics in IBS, Nicholas Talley suggested that the available data on IBS prevalence, which is quite similar world-wide, would argue against a major contribution to its pathophysiology from ethnicity, genetics or even rates of exposure to infection!
How does the care of the patient differ in various cultural and geographical settings? If culture and ethnicity do not influence IBS prevalence, they certainly exert a profound impact on the care of the patient with IBS. Not only is the physician-patient interaction impacted by cultural and religious factors but access to health care per se may be precluded by these self same customs and beliefs and exacerbated by language barriers, as well as the influence of local healers and complicated by the use of folk remedies and other complementary and alternative practices. On a larger scale, multinational trials in IBS pose additional challenges which begin with the development and validation of study instruments such as questionnaires and are further complicated by variations between countries in the ethics of clinical research and approaches to subject recruitment. While the challenges and some of the ethical dilemmas posed by epidemiological and multinational clinical trials, in particular, were highlighted some success stories were also presented and some useful guidance for future international studies emerged. Once a new therapy has been developed, it must gain regulatory approval before it can reach the patient: presentations by representatives from the United States, European, and Japanese regulatory agencies highlighted the different approaches taken in these major jurisdictions, a source of much anxiety for clinician-investigators and pharmaceutical companies alike.
Like all good meetings, this symposium generated vigorous discussion and, in truth, generated as many questions for future study as it provided answers. In the formal presentations and in break-out workshops, the critical importance of cultural competency to the modern gastroenterologist caring for IBS patients was made abundantly clear; in parallel, the potential for truly international studies of IBS to shine new light on this fascinating but perplexing disorder become evident. There is much to be done and both Rome Foundation and WGO are committed in promoting a global approach to the study of IBS.