Essentials of Complementary and Alternative Medicine (June 1999)

Part III
). Many patients find that the more they incorporate these activities into their lives, 
the less difficulty they have in managing chronic disease no matter what the cultural orientation (
38
, 
38a
 and 
39
).
S
PIRITUALITY
There is a surge of interest in the role of religion and spirituality in medical practice, research, and education (
39a
). The concept of “holism” often takes on the 
language of spirituality, in which patients seek a greater meaning in their suffering than is offered in conventional medicine (
39b
). Most CAM systems address 
spirituality and the meaning of suffering directly. Often they have their own special concepts and terms for how healing relates to the inner and outer forces of the 
spirit. Tibetan medicine (
Chapter 14
) and Native American medicine (
Chapter 13
) illustrate this most clearly. In anthroposophically-extended medicine, physicians 
receive conventional training and then get special instruction aimed at developing intuitive and spiritual sensitivity.
H
EALING
When a specific cause is the dominant factor in an illness, it makes sense to direct a therapy toward that factor and then attempt to minimize the side effects of 
therapy. If a patient has an upper respiratory tract infection (URI) that develops into bacterial meningitis, for example, the healing action of the body has been 
overwhelmed by the cause, and the only hope of recovery is to eliminate the bacteria with high-dose antibiotics. However, if the URI becomes a chronic sinus 
problem, in which the efforts of the body are the dominant factor in the illness complex, a drug must act on the person to enhance (by stimulation or support) those 
self-healing efforts. Approaches for stimulating the immune system (e.g., acupuncture or herbs) or supporting auto-regulatory mechanisms (e.g., rest, fluids, dietary 
changes, relaxation and imagery) may be preferred. Most CAM systems aim to enhance the body's healing efforts but may not address a known cause. This 
characteristic of CAM is attractive to patients (
40
).
A
DVERSE
 E
FFECTS OF
 C
ONVENTIONAL
 T
HERAPIES
Patients are also concerned about the side effects of conventional medicine. Approximately 10% of hospitalizations are due to iatrogenic factors (
41
), and properly 
delivered conventional treatments are the sixth leading cause of death in the West (
42
). There is a perception among patients that orthodox treatments are too harsh, 
especially when used over long periods for chronic disease (
43
) and that CAM treatments are safer. Some interest in CAM is based on the myth that “natural” is 
somehow inherently safer than conventional medicine–an idea that is certainly not true (
44
, 
45
). Another misconception is that avoiding “harsh” orthodox treatments 
will result in better quality of life. This is also not necessarily true. For example, Cassileth showed that patients who underwent chemotherapy compared with those 
who underwent a dietary and life style treatment for cancer actually had slightly better quality of life scores (
46
).
C
OSTS

Concern over the escalating costs of conventional health care is another reason for the interest in CAM. Control of health care costs by improving efficiency in 
delivery and management of health care services has reached a maximum, and costs are expected to double in the next 10 years (
47
). Many developing countries are 
realizing that access to and affordability of conventional medicine are impossible for their population and that lower-cost, “traditional” medical approaches need to be 
developed (
47a
). Approaches that attempt to induce auto-regulation and self-healing and that rely on life style and self-care approaches may reduce such costs (
39
, 
48
).
T
HE
 D
EMOCRATIZATION OF
 M
EDICINE
Several other social factors also influence the increasing interest in CAM. These include the rising prevalence of chronic disease with aging; increased access to 
health information in the media and over the Internet; and a declining faith that scientific breakthroughs will have relevant benefits for personal health; (
49
). An 
especially salient factor has been the “democratization” and “consumerization” of medical decision making (
12
, 
50
). The explosion of readily available information for 
the consumer and the ability to experience diverse cultures around the world have accelerated this process. Increasingly, patients wish to be active participants in 
their health care decisions. This participation includes evaluating information about treatment options, accessing products and practices that enable them to explore 
those options, and engaging in activities that may help them remain healthy (
5a
).
CAM AND STANDARDS OF EVIDENCE
New standards may be needed for the examination of both unconventional and conventional medicine (
51
, 
54
). Historically, medical science has benefited from the 
development of new methodologies, such as blinding and randomization which are first applied to unorthodox practices before being adopted as standards for all 
medicine (
51
, 
52
 and 
53
).
Humans seem to have an infinite capacity to fool themselves and are constantly making spurious claims of truth, postulating unfounded explanations, and ignoring or 
denying the reality of observations they cannot explain or do not like. Science is one of the most powerful tools for mitigating this self-delusionary capacity. However, 
the complexity of disease and the powerful healing capacity of the body often make it difficult to apply science to clinical medicine, especially when evaluating chronic 
disease (
55
, 
56
). K. B. Thomas demonstrated that nearly 80% of those who seek out medical care get better no matter what hand-waving or pill-popping is provided 
(
57
). This is called the “80 Percent Rule,” meaning that data collected on novel therapies delivered in an enthusiastic clinical environment typically yield positive 
outcomes in 70 to 80% of patients (
58
).
N
ONSPECIFIC
 E
FFECTS
Oftentimes our most accepted treatments are shown to be nonspecific in nature (
59
, 
60
 and 
60a
) or even harmful (
61
) when finally studied rigorously. Their apparent 
effectiveness in practice is due to a variety of factors unrelated to the treatment, such as the ability of the body to heal (often enhanced by expectation), statistical 
regression to the mean (a measurement problem), and self-delusion (sometimes called bias) (
58
). It is not surprising that for the majority of physicians and patients, 
many therapies, both orthodox and unorthodox, seem to work. The methods of clinical research–especially blinding and the randomized controlled trial–have emerged 
as powerful approaches for better identifying to what extent the outcome can be attributed to the treatment. These methods must be used rigorously, however, if we 
wish to examine both the social and statistical forces that shape our perception of reality. As sophistication in clinical trials methods improves in order to better control 
for these nonspecific effects, however, the rigorous evaluation of chronic disease prevention and treatment approaches become more difficult and expensive (
62
).
M
ETHODS FOR
 E
XAMINING
 C
HRONIC
 D
ISEASE
 T
REATMENTS
For these and a variety of other ethical, economic, and scientific reasons, it is very unlikely that all CAM (or conventional) therapies can be examined using large, 
rigorous, randomized trials (see 
Chapter 4
). There are now sophisticated scientific methods for applying basic-science information to clinical practice and highly 
effective approaches for the management of trauma and acute and infectious diseases. Current methods for examining chronic disease or practices that have no 
explanatory model in Western terms, however, are not adequately informed by science. CAM offers the opportunity to test new approaches for examining these areas 
as their presence in medicine increases. For example, the development of observational and outcome research methods is being explored in CAM as a new approach 
for obtaining acceptable evidence for the use of low-risk therapies for treatment of chronic disease (
63
, 
64
 and 
65
).
S
YNERGISTIC
 E
FFECTS
Most research on plant products is done to identify single active chemicals for drug development. Many herbal products, however, contain multiple chemical agents 
that may operate synergistically, producing effects with low amounts of multiple agents and lower risk for adverse effects. Standardization and quality production of 
herbals (necessary for producing safe and reliable products) may allow us to develop low-cost therapies with reduced risk over pharmaceuticals (
16
, 
18
).
C
ONSCIOUSNESS
Another frontier area with potentially profound implications for science and medicine is the area of consciousness and its relationship to statistical events and 
biological outcomes. For example, extensive research has documented that intention can have an influence on chance events (
75a
, 
76
 and 
76a
) and living systems 
(
77
, 
78
). Traditional and indigenous healing practices from around the world universally assume that this is true and claim to use these “forces” in practices such as 
shamanism, spiritual healing, and prayer. Science now has the experimental methodology, sophisticated technology, and statistical expertise to examine this question 
precisely. If changes in consciousness do have significant effects, what potential might this have for diagnosis and treatment (
79
, 
80
)? What implications would this 
have for our methods of experimentation and the notion of “objectivity?” Research on unorthodox medical practices allows us to begin serious scientific investigation 
of such areas.
A
NOMALOUS
 F
INDINGS
The unconventional basic-science assumptions that underlie some CAM practices provide opportunities to explore some of the deepest and most difficult enigmas of 
modern biology and medicine. Acupuncture, for example, was largely ignored in the United States until brought to national attention by a prominent reporter traveling 
with President Nixon in 1972. This led to basic science research and the discovery of its pain-relieving mechanisms (
66
). Another current enigma is whether 
biologically active nonmolecular information can be stored and transmitted through water or over wires, as claimed in homeopathy and electrodermal diagnosis (
40
, 
67
, 
68
, 
69
, 
70
, 
71
 and 
72
). Most scientists are unaware of the research in this area and claim that the concept is impossible. If some version of this claim were true, 
however, its potential implications for biology, pharmacology, and medical care are enormous. Data from clinical research on homeopathy do not support the expected 
assumption that homeopathy operates entirely like placebo (
73
, 
74
 and 
75
). Basic research on homeopathy can help examine the accumulating anomalous 
observations and experiments in this area (
40
).
CENTRAL MODELS OF ETIOLOGY AND TREATMENT IN MEDICINE
What can we make of the diversity of CAM approaches? Are they an unrelated, socially defined, and shifting group of disparate practices, or do they have common 
concepts and central themes that tie them together and to conventional medicine? If so, how are these approaches similar to and different from modern Western 
medicine? Historically and cross-culturally, different medical systems have exhibited different understandings of disease causation and of factors relevant to etiology. 
Alongside this diversity are different approaches to identifying etiological factors and to addressing them in clinical practice. These diverse perspectives can be 
classified into (a) those that focus on a specific cause, and (b) those that emphasize complex systems of causative or antecedent factors. Alongside these two central 
perspectives on disease etiology, most major medical systems emphasize one of three approaches in the treatment of disease. These are (a) a hygiene-oriented or 
health-promotion approach, (b) approaches that induce or stimulate endogenous healing responses, and (c) approaches that oppose, interfere with, or eliminate 
disease causes and biological responses to those causes.
Figure 1
 illustrates these different models of etiology and approaches to treatment. The “specific cause model” (1, 
Figure 1
) attempts to identify the most prominent 
linear etiological pathway of the headache. This usually leads to a therapy that interferes with that pathway directly (opposition approach—a, 
Figure 1
). Thus, in a 
patient who presents with a headache, an understanding of the pathophysiology of the headache is traced to vasospasm, and medication or biofeedback is provided 
to interfere with that pathway. Treatment is offered for only those aspects of the illness that cross a predefined diagnostic threshold. The “systems model” (2, 
Figure 1
) 

attempts to identify the web of etiological influences that contribute to the headache and their relationships to other covert problems or risks. Intervention targets the 
most prominent of these factors on multiple levels. Thus, a chronic headache patient who has other less prominent problems (fatigue, borderline blood pressure, 
insomnia, etc.) is treated with lifestyle changes and behavioral therapy addressing diet, exercise, relaxation skills, and drug or medication abuse (hygiene 
approach—b, 
Figure 1
). The “wholistic model” (3, 
Figure 1
) examines the patient's reactions to etiological agents and influences. Treatment approaches focus on 
improving resistance, restoring homeostatic “balance,” or stimulating self-healing processes in the patient (induction approach—c, 
Figure 1
). Thus, the headache 
patient may be given acupuncture to restore the balance of  chi, a vasospastic agent (e.g., caffeine or belladonna alkaloids) to adjust autonomic reactivity, or a 
specifically selected homeopathic drug to restore auto-regulatory processes.
Figure 1. Models of disease treatment.
The Use and “Specialization” of Central Models in Medicine
The specific cause model, the systems model, and the wholistic models of etiology (and their frequently corresponding treatment approaches) allow us to better 
understand the relationship between various medical traditions. They help explain how quite varied interventions can produce restorative effects on similar diseases 
and how single interventions may affect a variety of conditions. In addition, they allow us to examine how different medical traditions have “specialized” in developing 
theories and interventions based around one or more aspects of agent/host interactions. All major medical systems use all three of these approaches when needed. 
Figure 1 illustrates how these common concepts of etiology and treatment can be used to “map” a particular medical system's emphasis. Conventional medicine 
frequently waits until a disease has crossed a certain diagnostic threshold before intervention is attempted. The treatment usually assumes a linear cause—effect 
pathway and uses a treatment designed to interfere with that specific pathway (combination 1.a in 
Figure 1
). Many CAM (and some conventional) systems use the 
hygiene approach which intervenes prior to the diagnostic threshold and assumes that general multi-level support across systems is needed (combination 2.b in 
Figure 1
). Many CAM systems assume complex etiologies may or may not wait until the diagnostic threshold is crossed. Finally, interventions may be aimed at 
altering the host response to multiple etiologies in a way that reestablishes homeostasis (combination 3.c in 
Figure 1
).
While most major medical systems use all these etiological models and treatment approaches, some medical systems have developed approaches that emphasize 
particular levels as primary and have developed them extensively. In Native American and many indigenous medical systems, for example, the spiritual nature of the 
disease/healing complex is often emphasized. In these cultures, access to and interaction with patterns and forces in the spirit realms is considered a central focus for 
healing practices. Spirits are removed or opposed to stop a pathological process. In acupuncture and homeopathy, the “energetic” nature of disease/healing systems 
is emphasized. Patterns of “energy” assessed through history and physical examination are stimulated and balanced to induce a restorative response. In Ayurvedic 
medicine, the emphasis is on approaching illness through “consciousness,” and entry into “pure consciousness” is the core of meditative and cleansing practices that 
support healing. Naturopathy, nutritional biotherapy, and orthomolecular medicine all contain elements that have their roots in the Greek “hygiene” approach, which 
used diet, plant remedies, baths, tonics, and other supplements as the central focus of intervention. Modern Western medicine addresses illness on the “naturalistic” 
level typically uses approaches that block a path in the disease/healing process or by removing a specific causal agent.
These central approaches are also used in conventional medicine today as since antiquity. If a person has an infection one is given an  anti-biotic, a drug designed to 
kill the infecting agent. If one has inflammation and pain in the joints one is given an  anti-inflammatory or analgesic (literally “against sensation”). These are examples 
of the “interference/opposition” approach as used in modern medicine. This approach has evolved tremendously over the last 50 years and is a very sophisticated 
component of modern medical treatment. This approach works well when a cause is simple, easily identified and dominates the disease/healing complex. Vaccination 
and allergy desensitization shots are examples of the “induction/stimulation” approach in modern medicine. Some drug treatments use the “induction” principle, too, 
such as Ritalin (a stimulant) for hyperactive (overstimulated) children and vaccines to induce resistance to disease. For the most part, modern drug therapy looks for 
chemicals that will stop or interfere with physiological processes involved in an illness and then try to manage the side effects separately. It is much easier to use the 
interference approach when a specific cause is known, which is one reason it is currently the dominant method. Finally, life style, diet, exercise, and other health 
promotion and support approaches were considered outside of mainstream medicine until the last 20 years or so, but have now become more accepted and widely 
used in modern medicine. These are examples of the “hygiene” approach that overlap conventional and complementary medicine.
THE INTEGRATION OF CAM AND CONVENTIONAL MEDICINE
If we, as health care practitioners, scientists, and educators, do not begin to examine more closely the social and scientific forces that shape medicine, then we are 
destined to relive much of the divisiveness that has characterized the past and current relationship between mainstream and nonmainstream medical care (
81
). To 
adopt CAM without developing quality standards for its practices, products, and research threatens to return us to a time in medicine when therapeutic confusion 
prevailed. Modern conventional medicine excels specifically in the provision of quality-controlled health care and the use of cutting-edge scientific findings. CAM must 
adopt similar standards. Conventional medicine is also the world's leader in the management of infectious, traumatic, and surgical diseases; in the study of pathology; 
and in biotechnology and drug development. All medical practices, conventional and unconventional alike, have the ethical obligation to retain these strengths for the 
benefit of patients (
82
).
At the same time, important characteristics of CAM are at risk of being lost in its “integration” with conventional care. The most important of these is an emphasis on 
self-healing as the lead approach for both improving wellness and treating disease. All of the major CAM systems approach illness by first trying to support and induce 
the self-healing processes of the patient. If this can stimulate recovery, then the likelihood of adverse effects and the need for high-impact/high-cost interventions are 
reduced. It is precisely this orientation toward self-healing and health promotion–what Antonovsky has termed salutogenesis as opposed to pathogenesis (
84
)–that 
makes CAM approaches to chronic disease especially attractive.
The rush to embrace a new integration of alternative and conventional medicine should be approached with great caution. Alternative medicine, like conventional 
medicine, has pros and cons, promotes bad ideas and good ones, and offers both benefits and risks. Without critical assessment of what should be integrated and 
what should not, we risk developing a health care system that costs more, is less safe, and fails to address the management of chronic disease in a publicly 
responsible manner. We must examine carefully the potential risks and benefits of CAM before we head into a new, but not necessarily better, health care world.
The Potential Risks of Integration
The potential risks of integration are easily identifiable, yet much resistance to their amelioration remains among CAM practitioners. These risks include issues related 
to quality of care, quality of products used in treatment, and quality of scientific research underlying CAM therapies.
Q
UALITY OF
 C
ARE
The formal components of medical doctor licensure are usually not required of various CAM providers. These requirements include the content and length of time of 
training, testing, and certification; a defined scope of practice; review and audit; and professional liability with regulatory protection and statutory authorization 
complete with codified disciplinary action (
85
). All 50 states provide licensure requirements for chiropractic, but only about half do so for acupuncture and massage 

therapy, and much fewer do for homeopathy and naturopathy. Many of these practitioners operate largely unmonitored (
27
) (see 
Chapter 2
).