WGO – Rome Foundation Joint Symposium Summary IBS—The Global Perspective Eamonn M. M. Quigley, MD,* Ami D. Sperber, MD, MSPH,w and Douglas A. Drossman, MDz G astroenterologists 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 (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: 1. 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, diag- nostic workup, management, treatment approaches, patient adherence to treatments, and clinical outcome, remains largely untapped. 2. 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 explora- tion 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 explana- tory 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, From the *Department of Medicine, National University of Ireland, Cork University Hospital, Cork, Ireland; wDepartment of Medi- cine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; and zUniversity of North Carolina at Chapel Hill, Chapel Hill, NC. Reprints: Eamonn M.M. Quigley MD, Dept. of Medicine, National Univ. of Ireland, Cork, University Hospital, Cork, Ireland (e-mail: e.quigley@ucc.ie). Copyright r 2011 by Lippincott Williams & Wilkins WGO NEWS