Alternative Systems of Medical Practice
Jennifer Jacobs, M.D.--Cochair
John C. Reed, M.D.--Cochair
Michael Balick, Ph.D.
Gerald Bodeker, Ed.D.
Carlo Calabrese, N.D., M.P.H.
Edward Chapman, M.D.
Deepak Chopra, M.D.
Effie Chow, Ph.D.
Patricia Culliton, M.A., Dipl.Ac.
Peter Hindebergh, M.D.
Tori Hudson, N.D.
Fredi Kronenberg, Ph.D.
Nancy Lonsdorf, M.D.
Robert S. McCaleb
Kevin McNamee, D.C., L.Ac.
John C. Reed, M.D., Lead Author
Claire Cassidy, Ph.D.
John C. Reed, M.D.
Traditional Oriental Medicine
Effie Chow, Ph.D.
John C. Reed, M.D.
John C. Reed, M.D.
Nancy Lonsdorf, M.D.
Jennifer Jacobs, M.D.
Brian Berman, M.D.
Anthroposophically Extended Medicine
Paul Scharff, M.D.
Tori Hudson, N.D.
Charles Moss, M.D.
Community-Based Health Care Practices
Claire Cassidy, Ph.D.
Rayna Green, Ph.D.
Clara Sue Kidwell, Ph.D.
In the United States many people think of
mainstream biomedicine as the world's standard health care
system, assuming it is used by most people most of the time._
Actually, careful estimates reveal that worldwide only 10 to 30
percent of human health care is delivered by the conventional,
biomedically oriented health care system. The remaining 70 to 90
percent of health care sought out by people includes everything
from self-care according to folk principles to care rendered in
an organized health care system based on an alternative tradition
of practice (Dean, 1981; Hufford, 1992).
Such strikingly high usage of alternative
health care systems also is reflected in a number of recent
surveys. For example, a nationwide telephone survey of 1,539
people, conducted in 1990, indicated that up to one in three
Americans used alternative therapies (Eisenberg et al., 1993).
Another telephone survey conducted in 1992 in the States of
Maryland and Pennsylvania reported that someone in 33 percent of
1,165 households consulted chiropractors, 25 percent, massage
therapists; and 16 percent, spiritual healers (Kirby, 1992). One
biomedical clinic survey of 660 cancer patients showed that 54
percent used alternative medical care along with conventional
care, and 8 percent used strictly alternative care (Cassileth et
al., 1984). In addition, a survey of 628 cancer patients found
the utilization rate of folk treatments for cancer to be 70
percent (Hufford, 1992). Finally, an acupuncture clinic survey of
180 general-care patients showed that 70 percent sought other
alternative professional or community-based health care in
addition to biomedical and acupuncture care (Cassidy, 1994).
Given the immense political and economic
investment this country has made in its "mainstream"
medicine, these statistics are quite surprising. However, to
better understand why alternative systems of medicine not only
survive but thrive, it is worthwhile to first examine how people
typically go about choosing their health care.
Studies show that most people go through a
"hierarchy of resort" when seeking health care
assistance (Romanuicci-Ross, 1969). That is, when ill, they
usually begin by trying simple home remedies, often consulting
friends and family about what to do. Only if the condition
persists and worsens do people typically seek help from health
The hierarchy of health care specialists
includes the popular, community-based, and professionalized
(Hufford, 1988; Kleinman, 1980). All are similar in that they aim
to help people stay or get well and use manipulation (from laying
on of hands to surgery), chemical substances (foods and drugs),
or psychospiritual approaches (e.g., talking, suggesting,
praying, drumming) as therapeutic techniques. They differ,
however, in factors such as how much training they require of
practitioners, how intensely they scrutinize and theorize about
their own methods, how widely their practice is spread, and to
whom they primarily aim their care.
Popular health care is what most people
practice and receive at home, such as drinking hot honey and
lemonade to relieve a sore throat. People get information about
popular health care primarily from family or friends; it can be
centuries old or relatively new to that family or social circle.
People also learn about popular medicine from magazines,
television, and other informal sources. In the United States,
popular medicine often uses the words but not necessarily the
underlying thinking of biomedicine.
Community-based health care refers to the
nonprofessionalized yet specialized health care practices of both
rural and urban people. The term community-based is used to avoid
the stereotypes associated with the terms folk and tribal.
Information in such systems is commonly passed on orally (through
workshops, apprenticeships, and so on) and through informal and
popular media sources. Some community-based practices have
ancient roots (such as rootwork among African-Americans,
powwowing among European-Americans, curanderismo among
Hispanic-Americans, and religious pilgrimage and psychic healing
traditions), while others have developed relatively recently,
such as the various 12-step programs (e.g., Alcoholics
Anonymous), popular weight loss programs, and various health and
natural foods dietary practices. In contrast to popular and
professionalized systems, these community-based systems
characteristically focus on community health care or on the
individual as part of the community. They also usually fuse
concepts of medicine and religion or spirituality in such a way
that all care is explained as being influenced by a "higher
Professionalized health care is
characteristically urban and complexly organized. It is the most
intellectualized and formalized type of health care. Certain of
these have been called the "Great Tradition" medical
care systems. Examples of such professionalized health care
systems include conventional Western biomedicine, Asian-Indian
Ayurveda, traditional oriental medicine, and traditional Persian
medicine (Unani), all of which have evolved over time within
major urban cultures. Other systems such as chiropractic
medicine, osteopathic medicine, anthroposophically extended
medicine, environmental medicine, and homeopathic medicine have
been the result of the formalization and expansion of the
teachings of a specific creative founder within the Western
rational and intellectual culture. Each of these major formal
systems of medical practice has the following general
characteristics: (1) a theory of health and disease; (2) an
educational scheme to teach its concepts; (3) a delivery system
involving practitioners who usually practice in offices, clinics,
or hospitals; (4) a material support system to produce its
medicines and therapeutic devices; (5) a legal and economic
mandate to regulate its practice; (6) a set of cultural
expectations on the role of the medical system; and (7) a means
to confer "professional" status on the approved
Two major types of illnesses are recognized in
most of these systems, though one or the other is usually
emphasized: the naturalistic illness (which results from an
accident, infection, intoxication, malformation, aging,
environmental stress, etc.) and the personalistic illness (which
is the result of malfunction in relationships between people). A
third category of illness is increasingly proposed: the energetic
illness, which is the result of abnormalities in the flow of
Studies show that people are quite astute at
knowing what sorts of conditions to take to what sorts of
practitioners. The practitioners at the top of the hierarchy,
those that are the most "socially foreign" (i.e., hard
to reach from the point of view of the patient), are consulted
last and usually only when the condition is unresponsive, very
serious, or chronically debilitating. For example, rural Mexicans
go to the curandero or curandera for "folk" illnesses,
to the nun or nurse for mild biomedical conditions, and to the
biomedical physician for the most serious conditions (Young,
1981). Likewise, in urban America many people consult a
registered nurse, pharmacist, or health food salesperson before
taking their concerns to the medical doctor. One-third of the
users of unconventional therapy are estimated to use it for
"nonserious" conditions, health promotion, or disease
prevention. However, in the case of more serious health problems,
the medical doctor is not the most socially foreign type of
practitioner in the United States, because M.D.s and D.O.s
(doctors of osteopathy) are abundant. People consulting
alternative practitioners for an identified health problem are
much more likely to have first consulted a medical doctor
(Eisenberg et al., 1993). This point suggests that many of the
alternative practitioners are rendering care to people with
conditions either unresponsive to or unsatisfactorily treated by
standard biomedical care.
Of the types of health care listed above, only
the professionalized practitioners have received much, if any,
scientific study regarding the causes of illness and the
explanations and results of treatment. Indeed, community-based
practices have been virtually ignored by conventional medicine on
the assumption that these superstitious ways are dying out. On
the other hand, popular and community-based systems have been
studied primarily by social scientists, historians, and
folklorists. These researchers, though not primarily concerned
with clinical results or health outcomes, have provided most of
the clinical material currently available. Health educators have
made use of such studies in designing culturally sensitive
outreach programs (see the "Diet and Nutrition"
In recent years, the professionalized
biomedical health care system has initiated a number of programs
in an attempt to influence popular health practices on the basis
of sound epidemiological concerns, addressing such issues as
smoking and health, diet and cardiovascular disease, sexual
behavior and human immunodeficiency virus (HIV), and healthy
childbirth practices. The comparative clinical effectiveness of
indigenous community-based health care practices remains,
however, a fruitful field for further research.
The remainder of this chapter comprises three
major sections, the first of which describes several examples of
professionalized alternative health care systems. The following
section focuses on community-based practices. Except for the
epidemiological issues addressed in the "Diet and
Nutrition" chapter, popular practices are not discussed in
this document, because the emphasis is on health care delivered
by the community of alternative medicine practitioners rather
than by laypeople. The last major section addresses the barriers,
key issues, and overall priorities for research in alternative
systems of medical practice.
Professionalized Health Systems
This section includes discussions of
representative health systems whose practitioner base and
standards of practice are such that outcomes research may lead to
generalizable conclusions applicable to the improvement of the
Nation's health care delivery system. These systems are
* traditional oriental medicine,
* Ayurvedic medicine,
* homeopathic medicine,
* anthroposophically extended medicine,
* naturopathic medicine, and
* environmental medicine.
Traditional oriental medicine and Ayurvedic
medicine are professionalized health systems that are enjoying
popularity beyond the ethnic Asian community and are building
practitioner bases, educational systems, and popular awareness in
North America. Likewise, acupuncture, both as a treatment method
and as a formal professional medical system, has an established
formal educational base, extensive legal sanction for a variety
of practitioners, and a broad base of public support and
acceptance in the United States.
Homeopathic medicine has maintained a sound
educational base for both professional practitioner training and
popular self-help support and has the only officially established
"alternative" drug production system regulated by the
Food and Drug Administration (FDA). Naturopathy has a base in two
formally accredited naturopathic medical schools in the United
States and legal recognition of practitioners in a number of
States. Anthroposophically extended medicine, while limited in
availability in the United States, has a track record of
thoughtful research and drug development in Europe that
exemplifies the possibilities for "scientific
alternatives" in our own health care system. Environmental
medicine is a modern specialty area within biomedicine that has
developed in ecological theory of health and disease.
Discussion of these professionalized systems is
intended as an overview only. The serious student or researcher
will find an extensive global database for future research. Each
of the following subsections ends with a discussion of current
research issues and recommendations for future research.
Traditional Oriental Medicine
Overview. Traditional oriental medicine is a
sophisticated set of many systematic techniques and methods. Many
of these methods are widely known in the United States, including
acupuncture, herbal medicines, acupressure, qigong, and oriental
massage techniques. Traditional oriental medicine is rooted in
Chinese culture and has spread, with variations, throughout other
Asian countries, particularly Japan, Korea, and Vietnam. As a
professionalized health system, it has a range of applications
from health promotion to the treatment of illness.
The fundamental concepts of oriental medicine
are embedded in the philosophical and metaphysical worldviews of
Taoism, Confucianism, and Buddhism, which began evolving and
spreading throughout East Asia 2,500 years ago. Whereas the
religions and philosophies of the Western world developed around
the theme of separation of mind, body, and spirit, the Eastern
philosophies undergirding oriental medicine consider the whole
person and nature to be systematically interrelated.
Chinese medicine developed concurrently with
Chinese culture out of its shamanic, tribal origins in the
pre-Christian era. By the beginning of the Han Dynasty (200
B.C.E.) the Chinese had acquired and documented formidable
medical experience. The first mention of the Shen Nung
pharmacopoeia dates from the first century A.D. (Unschuld, 1986).
Anatomic dissections and surgeries were practiced during the
earlier eras, although in later centuries the Confucian belief in
the sacredness of the human body prevented further developments
in surgery and anatomic research. The early Chinese State
distinguished various sorts of doctors, including medical
physicians, surgeons, dietitians, veterinary surgeons, and
community-based health officers. By the close of the Han era (220
A.D.), the Chinese had a clear idea of preventive medicine and
first aid, knew pathology and dietetics, and had devised
breathing practices to promote longevity. After Buddhist
influences were assimilated, particularly a tolerance for judging
medical practices by their results and not by their theories, the
characteristic qualities and components of Chinese medicine had
developed by 500 A.D. These qualities and components were
expanded during periods of cultural intellectual growth that
paralleled the Middle Ages and the Renaissance in Western Europe
During the colonial periods of encounter with
Western culture, the systems of oriental medicine became
fragmented. As Western medical science followed the spread of
Western social and political power throughout East Asia, some
traditional methods were relegated to folk and quasi-religious
practitioners. However, since 1949, traditional Chinese medicine
has enjoyed a Government-sponsored renaissance in the People's
Republic of China (PRC) (Hiller and Jewel, 1983; Unschuld, 1992).
Today, both traditional-and Western-oriented medical training,
research, and institutional practice are available throughout
mainland China (Quinn, 1972). In addition, traditional practices
survive in various degrees in other East Asian countries (Sonoda,
The most striking characteristic of oriental
medicine is its emphasis on diagnosing disturbances of qi
(pronounced "chee"), or vital energy, in health and
disease (Unschuld, 1985; Wiseman et al., 1985). There are many
aspects of healthy balance and function in oriental medicine, and
these aspects are described qualitatively or metaphorically as
"disharmonies" among forms of vital energy. The concept
of yin and yang harmony is a basic description of the interaction
between the active and passive, stimulating and nurturing,
masculine and feminine, and "heavenly" and
"earthly" qualities that characterize living things.
Imbalances of yin and yang can manifest within the functions of
internal organs in their generation of metabolic energy, can
propagate along energetically active channels represented on the
body as the acupuncture meridians, and can undergo
transformations of expression according to the system of
"five phases." Each phase of energy has a
characteristic quality of material expression represented by the
elemental natures of fire, earth, metal, water, and wood. The
Chinese systematically incorporated into their theories new
discoveries of environmental and infectious influences on healthy
qi and incorporated the emotional, psychological, and personality
aspects of illness into the five-phase system.
Diagnosis in oriental medicine involves the
classical procedures of observation, listening, questioning, and
palpation, including feeling the quality of the pulses and the
sensitivity of various body parts. The well-trained physician is
taught to use all procedures together in evaluating the patient
and to search for details of habit, lifestyle, nutritional
indulgence, and specific mediating circumstances. Physical and
emotional aspects of health are assumed to be interrelated; for
example, fullness of the lungs is said to produce dreams of
sorrow and weeping. A range of traditional therapies is
prescribed to correct physical symptoms, restore energetic
balance, and redirect and normalize the patient's qi.
The professionalization of oriental medicine
has taken diverse paths in both East Asia and the United States.
Currently, the model in the PRC, which was established after the
1949 revolution, involves the organized training of practitioners
in schools of traditional Chinese medicine. The curriculum of
these schools includes acupuncture, oriental massage, herbal
medicine, and pharmacology, though the theoretical style of
making a diagnosis and designing a treatment plan is the one
traditionally associated with herbal medicine (Flaws, 1993). The
graduates of these colleges are generally certified in one of the
four specialty areas at a training level roughly equivalent to
that of the Western bachelor's degree (Flaws, 1993). In contrast,
in Japan there is a distinct profession of acupuncture, and the
herbs used in traditional herbal medicine products (kampo) are
prescribed by medically trained physicians or pharmacists (Birch,
In the United States the professional
practitioner base for oriental medicine is organized around
acupuncture and oriental massage. There are about 6,500
acupuncturist practitioners in the United States. The American
Oriental Body Work Therapy Association has approximately 1,600
members representing practitioners of tuina, shiatsu, and related
techniques (Flaws, 1993). Many American schools of acupuncture
are evolving into "colleges of oriental medicine" by
adding courses in oriental massage, herbal medicine, and dietary
interventions. They are also offering diplomas and master's or
doctor's degrees in oriental medicine. Although graduates of
these programs are exposed to herbal medicine pharmacology, only
the States of California and Nevada include a specific section
evaluating knowledge of herbal medicine in the state
acupuncturist licensing examination. The legal sanctioning of
oriental medical practice is most extensive in New Mexico, where
the acupuncturists have established an exclusive profession of
oriental medicine. Their legal scope of practice is currently
similar to that of primary care M.D.s and D.O.s, and their State
statute restricts other licensed New Mexico health professionals'
ability to advertise or bill for oriental medicine or acupuncture
services (New Mexico Association of Acupuncture and Oriental
As with any new profession in the United
States, the issues of appropriate formal training, State-by-State
legal scope of practice, official title and privileges of
practitioners, and professional monopoly on health practices are
currently controversial, even among the community of oriental
medicine advocates. Furthermore, the position of oriental
medicine practices and practitioners within the broader U.S.
health care system continues to be a subject of heated political,
economic, and intellectual debate (Birch, 1993; Flaws, 1993;
National Council Against Health Fraud, 1991; New Mexico
Association of Acupuncture and Oriental Medicine, 1993).
The treatment modalities most associated with
traditional oriental medicine and used regularly by practitioners
include acupuncture, moxibustion, acupressure, remedial massage,
cupping, qigong, herbal medicine, and nutritional and dietary
interventions. These are discussed below. Acupressure, massage,
and qigong are also discussed in the "Manual Healing
Acupuncture. It is important to remember that
acupuncture was but one branch among several therapies. It
involves the direct manipulation of the network of energetic
meridians, which are believed to connect not only with the
surface or structural body parts but also to influence the deeper
internal organs. The needle is inserted at appropriately chosen
energetic points to disperse or activate the qi by a variety of
technical manipulations. Western-style research showing that
acupuncture could relieve pain and cause surgical analgesia
through the release of pain-inhibiting chemicals (endorphins) in
the nervous system led to the first theories of how acupuncture
might work in terms of a biomedical science model (Han, 1987).
This model does not, however, account for the many different ways
acupuncture is used clinically to improve or correct ailing body
functions. Because acupuncture has attracted major interest in
the United States, an expanded section on acupuncture is included
in this chapter.
Moxibustion. Moxibustion using Artemisia
vulgaris (a plant of the composite, or daisy, family) evolved in
early times in northern China. In this cold, mountainous region,
the effect of heating the body on the energetically active points
was a logical development. Moxibustion is thought to have
preceded the use of needles. The crushed leaves, or moxa, of
vulgaris may be used in loose or cigar form. In theory, the
burning from the moxa releases a radiant heat that penetrates
deeply and is used to affect the balance and flow of qi.
Acupressure. The energy points and channels can
be treated with direct physical pressure by the fingertips or
hands of the therapist. Simple points may be used for first aid
or symptomatic relief or entire systems of manual therapy (e.g.,
shiatsu, jin shin jyutsu) may be used to effect the overall
well-being of the body.
Remedial massage. The techniques of remedial
massage (an-mo and tuina) are described in medical texts of the
Han period. Later, in the Tang dynasty, massage was taught in
special institutes. An-mo tonifies the system using pressing and
rubbing hand motions, while tuina soothes and sedates using
thrusting and rolling hand motions. Both systems employ a complex
series of hand movements called the eight kua on specific body
areas to produce the desired effects.
Cupping. Cupping is a technique of applying
suction over selected points or zones in the body. A vacuum is
created by warming the air in a jar of bamboo or glass and
overturning it onto the body to disperse areas of local
congestion. This therapy is used in the treatment of arthritis,
bronchitis, and sprains, among other ailments.
Qigong. Qigong is the art and science of using
breath, movement, and meditation to cleanse, strengthen, and
circulate the vital life energy and blood._ Three basic
principles are observed in the performance of the exercises:
relaxation and repose; association of breathing with attention;
and the interaction of movement and rest. Tai chi and other
practices of oriental physical culture emphasize maintaining
internal and external balance while encountering one's
environment. Certain of the qigong exercises, particularly the
gou lin form, have been used for immune stimulation and self-help
in cancer patients (Sancier, 1991, 1993). These personal
practices are the "internal" qigong type. Certain
qigong "masters" are considered to be "energetic
healers," who via "external" qigong use some of
their own energy to strengthen the vitality of others who have
Herbal medicine. There is a complex series of
practices regarding the preparation and administering of herbs in
Chinese medicine (Unschuld, 1986). The traditional materia medica
in China included approximately 3,200 herbs and 300 mineral and
animal extracts (Bensky and Gamble, 1986). Herbal prescriptions
cover the entire range of medical ailments, including pain,
hormone disturbances, breathing disorders, infections, and
chronic debilitating illnesses. Medications are classified
according to their energetic qualities (e.g., heating, cooling,
moisturizing, drying) and prescribed for their action on
corresponding organ dysfunction, energy disorders, disturbed
internal energy, blockage of the meridians, or seasonal physical
demands. One unique aspect of traditional prescribing is the use
of complex mixtures containing many ingredients. Such
prescriptions are systemically compounded to have several
effects: to principally affect the disease or disharmony, to
balance out any potential side effects of the principal therapy,
and to direct the therapy to a specific area or a physical
process in the body. (See the "Herbal Medicine" chapter
for details on specific Chinese herbs and how they are used).
Nutrition and dietetics. Dietary interventions
are also individualized on the basis of the physical
characteristics of both the patient's constitution and the
patient's illness disturbance. Foods are characterized according
to their energetic qualities (e.g., tonifying, dispersing,
heating, cooling, moistening, drying). Emphasis is given to
eating in harmony with seasonal shifts and life activities.
Research base. Although extensive research has
been done in China through the institutions of traditional
Chinese medicine, much of this clinical research has been
empirical, that is, reports of observed results of various
treatments. Many of these reports have been difficult to
translate into Western languages and into the standard formulas
or analysis typical for Western biomedical research. Because of
the interest in applying acupuncture for pain and for chronic
conditions, much research has focused on these two areas.
However, clinical practice experience in the Asian countries
suggests there is a role for complementary use of traditional
therapies with a myriad of modern Western "scientific"
medical interventions (Sun, 1988; Unschuld, 1992; Wong et al.,
Only in the past quarter-century have
biomedical scientists in China been characterizing and
identifying the active agents in much of the traditional medical
formulary (Hsu et al., 1982, 1985). However, extensive research
has been published detailing the pharmacology and toxicity of
many traditional oriental herbs (Bensky and Gamble, 1986; Hsu et
al., 1982, 1985; Ng et al., 1991). How many clinical trials of
traditional oriental herbal medicine have been conducted and what
extent and validity the findings have are unclear. Few references
to published studies appear in the databases available in the
West. Although some individual studies appear quite promising,
only preliminary conclusions can be drawn about the field until
more complete literature searches are conducted. (See the
"Herbal Medicine" chapter for a more complete
discussion of the status of herbal medicine research in China.)
Tsutani conducted an extensive search to find
the number of clinical trials of herbal medicine in China
(Tsutani, 1993). Of 148 studies retrieved from computerized
databases, 39 were double blind, used random allocation, or were
randomized controlled clinical trials. He conducted a combined
computerized and manual search of the Japanese literature and
retrieved references to 59 controlled studies on the use of kampo
(Japanese traditional herbal medicine). An additional unpublished
search by Birch of computer-indexed herbal medicine studies
published in the period 1978-92 located 23 studies in English and
44 in other languages (Chinese 37, Japanese 5, German 1, French
1). In general, the methodological quality of these studies was
poor, and they had multiple study design problems, including poor
experimental design, lack of randomization, unclear entry
criteria and end points, and lack of consideration of the
traditional uses of the herbs (Birch, 1993).
Research in the medical effects of qigong has
been a subject of interest in the PRC in recent years and was the
topic of six international conferences between 1986 and 1991.
Patients who practice internal qigong exercises combining
meditation and gentle body movement were shown to have better
results in therapy for hypertension, cancer, and coronary artery
disease (Sancier, 1991, 1993). Qigong exercise also was shown to
affect the blood chemistry of individuals practicing it. In
addition, studies on external qigong have included measurements
of the effect of qi emitted by master practitioners on cell
cultures, germination rate of seeds, and electroencephalographic
measurements of human recipients (Sancier and Hu, 1991).
Measurements of emissions from external qigong
practitioners suggested that infrasonic energy was present in
frequency ranges from 8 to 12.5 hertz (lower than the human ear
can hear) and in intensities measurably different than
background-noise level (Sancier and Hu, 1991). These suggestive
findings parallel certain studies done in the West on mind-body
interactions and nonlocal or "energetic" healing. (See
the "Manual Healing Methods" and "Mind-Body
Interventions" chapters.) Unfortunately, these Chinese
studies are available only in abstract or conference proceedings
formats in English. It is not known whether the complete papers
are published in the Chinese literature with supporting data that
would allow a methodological evaluation of the quality of the
Future research opportunities. Although many
diseases may be helped by the modalities of traditional oriental
medicine, documenting its benefit in conditions of greatest
concern to the United States should have research priority:
cancer, acquired immune deficiency syndrome (AIDS),
cardiovascular diseases, neuromuscular disabilities, chronic
fatigue syndrome, psychosomatic problems, alcohol and drug
addictions, and chronic pain.
Clinical research into the nondrug modalities
of traditional oriental medicine includes opportunities for
investigating manual healing therapies, bioelectricity and
magnetic physical interventions, and the use of body-mind
interactions for health purposes. Issues and criteria for such
future research are discussed in other chapters of this report.
The use of traditional oriental herbal
medicines and formulas in China and Japan has been studied for
therapeutic value in the following areas: chronic hepatitis;
rheumatoid arthritis; hypertension; atopic eczema; various
immunologic disorders, including AIDS; and certain cancers
(Hirayama et al., 1989; Sheehan and Atherton, 1992; Smith, 1987;
Sun, 1988; Tao et al., 1989; Wong et al., 1991; Xu et al., 1989;
Zhao et al., 1993). It would be useful to repeat these studies in
the United States using high-quality research criteria. Research
into the application of traditional oriental products could be
roughly organized in three levels: first, publication of
appropriate safety studies; second, pharmacological studies
characterizing the contents, action, and components of single
herbs and herbal formulas; and third, controlled clinical trials
for specified conditions. The expense of this research endeavor
can be lessened if World Health Organization proposals (see the
"Herbal Medicine" chapter and app. C) allowing the
documentation of traditional use are adopted by U.S. regulatory
authorities (McCaleb, 1993). Given the large-scale use of
over-the-counter herbal products as "food supplements"
in the U.S. market, studies involving postmarketing surveillance
of the use, clinical results, and complications of currently
available products also would be appropriate (Ng et al., 1991).
Examples of creative basic research would
include viewing the pH balance of body fluids as a representation
of yin-yang balance, noting changes in organ and tissue receptor
sites following treatment with herbal preparations, and
investigating various neurological responses to massage and
acupressure interventions. There is a major opportunity for
cataloging and translating research done in China, Japan, and
Korea in order to stimulate further development of the field in
the United States.
Outcomes research can also address the
application of traditional oriental medicine as a system. Such
research would involve comparing (a) the overall health
improvement and cost of care of a population working with a
program of mixed interventions prescribed by practitioners of
traditional oriental medicines with (b) the health indices of a
control group using conventional care.
Overview. Acupuncture involves stimulating
specific anatomic points in the body for therapeutic purposes.
Puncturing the skin with a needle is the usual method of
application, but practitioners may also use heat, pressure,
friction, suction, or impulses of electromagnetic energy to
stimulate the points. Acupuncture was an evolving part of the
medical practices of the Chinese people and is described in two
surviving historical texts: the well-known medical treatise Huang
Ti Nei Ching Su WLn (The Yellow Emperor's Classic of Internal
Medicine), and Shi Ji (Book of History), both dating to the
period 200-100 B.C.E.
Over the centuries, acupuncture spread
throughout the medical practices of the Asiatic peoples around
the Pacific Rim. However, it has been practiced as a medical art
in Western Europe for several hundred years, having been brought
home by the traders, diplomats, and missionary priests who
encountered it during their travels in the Orient. By the late
19th century, acupuncture was known and used on the east coast of
the United States. Sir William Osler's American medical textbook,
which was first published in 1892 and was updated periodically
through 1947, recommended acupuncture for treating lumbago or
lower back pain (Lytle, 1993). Acupuncture also reached the
United States on the west coast as an ethnic practice among Asian
immigrants in the 19th and 20th centuries.
George Soulie de Morant, a French diplomat in
China at the turn of the century, became an accomplished
acupuncturist. On his return to France he began systematically
introducing the full range of acupuncture to the French and
European medical community. He published significant texts in
1934, 1939, 1941, and 1955 that represent a landmark effort to
expand Western biomedical explanations of the physiology of
health and disease to include the classical and empirical
observations of Chinese acupuncture. His influence did much to
establish acupuncture as an accepted clinical art in Europe
In the past 40 years acupuncture has become a
well-known and reasonably available treatment in both developed
and developing countries. Since the reopening of relations
between the United States and the PRC, acupuncture has attracted
increased attention from the American public and governmental
agencies (Chen, 1973). With the emergence of traditional Chinese
medicine as an organized system of practice in the PRC, formal
training programs in acupuncture and oriental medicine have
expanded throughout the world. Schools and training programs of
acupuncture in the United States incorporate varying degrees of
traditional Chinese medicine as well as European acupuncture
approaches and elements of the traditional and modern practice
traditions from Japan, Korea, and Vietnam.
Because the traditional view of health and
illness in oriental medicine is related to a proper balance of
qi, or energy, in the body, acupuncture is used to regulate or
correct the flow of qi to restore health. Acupuncture treatment
points are chosen on the basis of diagnosis of a medical problem
by history and physical exam using one or more models of how the
body operates in health and disease. The model, or
"tradition," that is used to guide treatment may vary
according to the cultural background and education of the
practitioner as well as the nature of the patient's problem.
Acupuncture prescriptions can be simple or sophisticated. A
series of 10 or more treatments is usually prescribed for a
chronic illness or physical rehabilitation. On the other hand,
one to four treatments may suffice for minor injuries, a
self-limited illness, or a seasonal "tune up."
Modern theories of acupuncture are based on
laboratory research conducted in the past 40 years. Acupuncture
points have been found to have certain electrical properties, and
stimulation of these points has been shown to alter the chemical
neurotransmitters in the body. Many of the therapeutic effects of
acupuncture can be clearly related to the mechanism of
neurotransmitter release via peripheral nerve stimulation. This
mechanism is associated with changes in the balance of the
natural physiological chemicals in the body, which can be used
for a therapeutic effect (Pomeranz, 1986). Other therapeutic
effects may be related to mechanical stimulation or alteration of
the natural electrical currents or electromagnetic fields in the
Although the physiological effects of
acupuncture stimulation in experimental animals have been well
documented, the use of acupuncture treatments for clinical
illness in humans has remained controversial within much of the
mainstream medical community in the United States. Some
controversy comes from the "foreignness" of traditional
Chinese interpretations of medical illness, and some may be due
to an unfamiliarity with the existing global research base. In
1973 the commissioner of the FDA announced that devices used in
acupuncture, including the specialized needles, electrical
stimulators, and associated paraphernalia, would be considered
investigational on the basis of the perception at that time that
"the safety and effectiveness of acupuncture devices [had]
not yet been established by adequate scientific studies to
support the many and varied uses for which such devices are being
promoted including uses for analgesia and anesthesia"
(Lytle, 1993). This designation is still official FDA policy.
In the subsequent 20 years, however,
acupuncture has become an increasingly established health care
practice in the United States. Furthermore, there are currently
more than 40 schools and colleges of acupuncture and oriental
medicine in the United States, 20 of which are either approved or
in candidacy status with the National Accreditation Commission
for Schools and Colleges of Acupuncture and Oriental Medicine.
There are licensure or registration statutes in 28 States for the
practitioner graduates of these programs. There are an estimated
6,500 acupuncturist practitioners in the United States, of whom
3,300 have taken the examination of the National Commission for
the Certification of Acupuncturists. In addition to these
practitioners, naturopathic and chiropractic physicians also can
legally incorporate acupuncture in their practice in a limited
number of States.
Besides the "alternative" medical
practitioners who are trained in acupuncture, an estimated 3,000
conventionally trained physicians (M.D.s and D.O.s) have taken
courses to incorporate acupuncture as a treatment modality in
their medical practices. Such courses have been affiliated with
the UCLA School of Medicine, the New York University School of
Medicine and Dentistry, and St. Louis University Medical School
(Helms, 1993). Proficiency certification examination for
physician acupuncturists has been offered for a number of years
in Canada by the Acupuncture Foundation of Canada, and similar
examinations are currently in development in the United States,
Australia, and New Zealand (Williams, 1994). The gradual
acceptance of acupuncture therapeutics based on clinical practice
experience in American medicine is reflected by the incorporation
of descriptions of this discipline into most current textbooks of
physical medicine and pain management (Chapman and Gunn, 1990;
Lee and Liao, 1990). Moreover, a recent review estimated that
patient visits for acupuncture to physician and nonphysician
practitioners are occurring at a rate of 9 to 12 million per year
in the United States (Lytle, 1993). Thus, the continued FDA
"experimental" designation, which is echoed by the
reference committee of the American Medical Association (AMA), is
considered by many to be obsolete in the face of the large-scale
use of acupuncture by legally sanctioned practitioners in the
United States as well as in many other countries' health care
Research base. Acupuncture is one of the most
thoroughly researched and documented of the so-called alternative
medical practices. A series of controlled studies on the
treatment of a variety of conditions has shown compelling, though
not statistically conclusive, evidence for the efficacy of
acupuncture. These conditions are osteoarthritis (Dickens and
Lewith, 1989), chemotherapy-induced nausea (J. Dundee et al.,
1989), asthma (Fung and Chow, 1986), back pain (Gunn and
Milbrandt, 1980), painful menstrual cycles (Helms, 1987), bladder
instability (Phillip et al., 1988), and migraine headaches
(Vincent, 1990). Moreover, in spite of the unenviable challenge
of serving as the "alternative" therapy of "last
resort," acupuncture studies have shown positive results in
managing chronic pain (Patel et al., 1989) and drug addiction
(Bullock et al., 1989; Smith, 1988), two areas where conventional
Western medicine has generally failed. Indeed, the criminal
justice systems in New York City and Portland, OR, have mandated
acupuncture as part of their detoxification and probation
programs for drug abusers.
In addition, basic science research in animal
models suggests that neurological pathways are the mechanism by
which acupuncture relieves pain (Pomeranz, 1986). There also is
work showing acupuncture effects in treating veterinary medical
problems, such as bacteria-induced diarrhea in pigs (Hwang and
Jenkins, 1988). A broad range of applications in human medicine
also has been explored.
The risk and safety issues in acupuncture also
have been thoroughly investigated (Lytle, 1993). In a recent
review of 3,255 acupuncture citations in the world scientific
literature, the conditions of study in 365 Western and 344
Chinese clinical research papers were tabulated (American
Foundation of Medical Acupuncture, 1993). The number of studies
per topic was as follows: surgical applications, 77; pain
(chronic and acute pain of all types), 222; neurological
disorders, 62; organic illness (e.g., heart, lungs), 200; women's
reproductive disorders, 43; mental illness, 29; addiction
therapy, 54; and acupuncture treatment complications, 11. The
diversity of clinical applications and supporting basic
physiology studies points to acupuncture having a therapeutic
effect that exceeds a purely placebo or culturally dependent
Acupuncture research involves tailoring the
study design and question to one of several levels of clinical
investigation. At the most basic level, one can study the effect
of stimulating a specific acupuncture point on a specific
physiological response. For example, Dundee and colleagues
conducted a series of investigations involving more than 500
patients for a 5-year period, evaluating the effect on nausea of
stimulating the acupuncture point PC-6 (neiguan). These studies
involved manual needling, electrical stimulation on the needle,
acupressure, and noninvasive electrical stimulation. Control
groups included patients with no treatment as well as patients
who were needled at a sham point (a point unrelated to the
accepted treatment meridian). The patients being investigated
were undergoing minor gynecologic operations under general
anesthesia. Results of the active acupuncture treatments showed
better response than was shown by controls or by those who
received sham acupuncture treatments. Indeed, needle acupuncture
gave slightly better results than the then-standard antinausea
drugs (R. Dundee et al., 1989).
Moreover, the effect of acupuncture in the
treatment of specific clinical conditions has been measured. For
example, Helms (1987) studied 43 women suffering from
dysmenorrhea (painful menstrual periods); the patients were
divided into four groups: real acupuncture, sham acupuncture,
standard controls (no intervention), and visitation controls
(visits to the treating physician). The patients were free to
take their previously used pain medications during the 3-month
treatment period and a followup period. Ninety-one percent of the
real acupuncture treatment group showed improvement, whereas only
36 percent of the sham acupuncture group showed improvement. Only
18 percent of the standard control group and 10 percent of the
visitation control group showed improvement. In addition, there
was a 41-percent decrease in use of pain medication in the real
acupuncture group, versus no change in the others (Helms, 1987).
Furthermore, the improvement noted in the real acupuncture
treatment group persisted beyond the end of the active treatment
Although acupuncture effects on pain problems
can be considered purely subjective phenomena, acupuncture
treatments also can be studied in terms of their effect on
altering patient behavior and use of medical care. Bullock et al.
(1989) studied 80 severe alcoholics through the Hennipen County,
MN, alcohol detoxification program. These patients all had a
history of repeated hospital admissions for alcoholism, or were
severe recidivists. They were divided into two groups, a
treatment group receiving acupuncture at specific ear acupuncture
points and a control group treated with sham acupuncture points
on the ear. The patients were treated for 45 days from the date
of their last acute alcoholism hospital admission.
Six months after the treatment program the
control (sham) group had nearly twice as many drinking episodes
and admissions to detox centers as the treatment groups (Bullock
et al., 1989). These types of results have caught the attention
of public agencies and criminal justice systems across the
country who are concerned with the cost of managing the social
impact of people with severe drug abuse behavior.
Promising early evidence suggests that
acupuncture can be cost-effective in conventional medical
practice settings as well. In France, for example, statistics
from the insurance syndicate show that physicians whose practice
is at least 50 percent acupuncture cost the system considerably
less for laboratory examinations, hospitalizations, and
medication prescriptions than their non-acupuncture-practicing
colleagues (Helms, 1993). In the United States, a pilot study on
followup of chronic pain patients receiving acupuncture in a
managed-care setting demonstrated a reduction of clinic visits,
physical therapy visits, telephone consultations, and
prescription costs in the 6 months following a short course of
acupuncture therapy (Erickson, 1992).
In Denmark a study was made involving the 58
patients on a county health system's waiting list for elective
knee replacement surgery. Forty-eight of these patients were
considered candidates for a controlled trial of acupuncture
therapy, and two-thirds (32) participated in the study. The
subgroup treated with acupuncture initially showed improvement in
both objective and subjective measures of knee function and a
50-percent reduction in nonsteroidal anti-inflammatory drug
(NSAID) use after six treatments when this group was compared
with its own baseline findings and with the untreated subgroup.
The untreated patients were then treated with acupuncture and
also showed improvement. Five of these were called for their
elective surgery, and the remaining 17 continued in long-term
followup for 49 weeks with monthly acupuncture treatments for
maintenance. At the 1-year followup point, NSAID use in the group
as a whole was still 20 percent less than the baseline
measurements, and 22 percent (seven) of the study group had
responded so well that they no longer desired knee replacement
surgery. These seven patients constituted 12 percent of the
original elective surgery waiting list (Christensen et al.,
1992). Taken as a whole, these results suggest that wider use of
acupuncture in the United States might reduce health care costs
significantly as well as improve outcomes of selected conditions.
Future research opportunities. Basic research
is needed to examine the effects of acupuncture beyond the pain
management field. This extended basic research in acupuncture
should address the broad range of clinically observed effects of
acupuncture treatments, including improved physical health,
improved emotional stability and cognitive functioning, and
overall improvement in quality of life. State-of-the-art
techniques for monitoring and detecting changes in body
physiology (e.g., electroencephalography, brain mapping,
single-photon emission tomography scans, positron emission
tomography scans, and electromyographic mapping) could be used.
Such techniques are useful in evaluating medical conditions in
which patients do not show gross changes in standard biochemical
Basic research in the bioelectromagnetic effect
of acupuncture on the physical and energetic phenomena of the
human body might present another modern correlation to the
traditional concept of qi. (See the "Bioelectromagnetics
Applications in Medicine" and "Manual Healing
Methods" chapters.) The alterations by acupuncture of the
neuropeptide chemicals involved in the digestive and immune
responses also could be studied. This biochemical research would
parallel the existing studies on pain relief with acupuncture.
Another promising area is research into disorders of the
autonomic nervous system and their alteration or correction by
Acupuncture's traditionally reported effects on
improving the well-being of the whole person should be
investigated using established psychological and behavioral
health measures as well as standardized measurements of health
status and quality of life. Since acupuncture is a procedural
therapy involving an intentional interaction between the
practitioner and the patient, acupuncture research is an
appropriate area in which to investigate the interpersonal and
transpersonal aspects of mind-body healing. (See the
"Mind-Body Interventions" chapter.)
Acupuncture research in clinical medicine is
entering a challenging period. With a broad base of research and
practice supporting the safety and promising results of
acupuncture in many clinical conditions, studies now need to be
done to firmly establish the efficacy of acupuncture in
comparison with other medical interventions for relevant health
problems. There are three appropriate questions for clinical
studies of acupuncture: (1) Is acupuncture efficacious for the
condition under study in comparison with conventional or other
alternative treatments? (2) Is acupuncture more than a placebo
intervention for the specific conditions being studied? (3) Is
the mechanism of acupuncture more than that of a nonspecific
irritant stimulation? That is, does it matter where you stick the
needle? These levels of research, done as controlled clinical
trials, are necessary to answer treatment efficacy questions that
are equivalent to those being studied in Phase III drug treatment
trials. These initial studies should assist in correcting the
"experimental" designations imposed by the FDA and the
AMA on the practice of acupuncture.
Key issues. Because of the entrenched
skepticism in American medicine regarding acupuncture, an
extremely high standard of biostatistical and clinical expertise
will be required for these acupuncture clinical trials.
Unfortunately, as an operator-dependent procedure--a type of
procedure that has individualized treatment
protocols--acupuncture can be studied in a full-scale, blinded,
randomized, placebo-controlled fashion in only a limited number
of clinical conditions. Suggested areas for such
placebo-controlled acupuncture research studies include treatment
of acute low back pain, chronic osteoarthritis of the knee,
cancer chemotherapy-induced nausea and vomiting, and pain related
to dental procedures. Issues for which existing studies have been
criticized, such as sample bias, inadequate statistical power,
lack of appropriate controls, practitioner incompetence, and
inappropriate treatment design, must be addressed to ensure that
the data generated in new clinical trials are of the highest
possible quality (ter Riet et al., 1990).
Furthermore, the drug model of biomedical
research is appropriate for only a limited range of acupuncture
investigations. For most clinical applications, acupuncture
research trials will have to compare clinical effectiveness, that
is, compare the outcome of courses of acupuncture treatment with
clinical outcomes in non-acupuncture-treated or conventionally
treated patients. (See the "Research Methodologies"
chapter.) The priority areas for these acupuncture research
studies should be based on considerations of public health
importance, the inadequacy of current treatment methods owing to
excessive side effects or cost, and the existing promising data
in the global acupuncture research base. Attention to specificity
of the diagnostic, therapeutic, and outcome criteria is necessary
to allow compelling conclusions to be drawn about the
effectiveness of acupuncture in disorders such as chronic
headaches, urinary system dysfunction, respiratory disorders,
allergies, neurological and orthopedic problems, and substance
Since acupuncture treatments for many of these
health problems are individually designed and directed at
improving the function of the whole person, specific research
methods must be involved that will not only document alterations
in a specific disease process but also validate the improved
quality-of-life outcomes reported by patients who have been
treated by experienced acupuncture practitioners.
Overview. Ayurveda is the traditional, natural
system of medicine of India, which has been practiced for more
than 5,000 years. Ayurveda provides an integrated approach to the
prevention and treatment of illness through lifestyle
interventions and a wide range of natural therapies. The term
Ayurveda has its origins in the Sanskrit roots ayus, which means
"life," and veda, which means "knowledge."
Ayurvedic theory states that all imbalance and
disease in the body begin with imbalance or stress in the
awareness, or consciousness, of the individual. This mental
stress leads to unhealthy lifestyles, which further promote ill
health. Therefore, mental techniques such as meditation are
considered essential to the promotion of healing and to
Ayurveda describes all physical manifestations
of disease as due to the imbalance of three basic physiological
principles in the body, called doshas, which are believed to
govern all bodily functions. Evaluation of these three
doshas--vata, pitta, and kapha--is accomplished primarily by
feeling the patient's pulse at the radial artery, which is a
detailed and systematic technique called nadi vigyan. This
evaluation determines the types of herbs prescribed, and it
guides the physician in the application of all other ayurvedic
Specific lifestyle interventions are a major
preventive and therapeutic approach in Ayurveda as well. Each
patient is prescribed an individualized dietary, eating,
sleeping, and exercise program depending on his or her
constitutional type and the nature of the underlying dosha
imbalance at the source of the illness. The Ayurvedic
practitioner uses a variety of precise body postures, all derived
from the age-old discipline of yoga; breathing exercises; and
meditative techniques. These postures are used to create an
individualized self-care program to improve both physical health
and personal consciousness. In addition, herbal preparations are
added to the patient's diet for preventive and rejuvenative
purposes as well as for the treatment of specific disorders.
In addition to mental factors, lifestyle, and
dosha imbalance, Ayurveda identifies a fourth major factor in
disease: the accumulation of metabolic byproducts and toxins in
the body tissues. Ayurvedic physical therapy, called panchakarma,
consists of physical applications, including herbalized oil
massage, herbalized heat treatments, and elimination therapies
(e.g., therapies to improve bowel movements), which promote
internal cleansing and removal of such toxic metabolic wastes.
Certain of the agents used in panchakarma therapy are proposed to
have free-radical scavenging, or antioxidant, effects (Fields et
al., 1990). Free radicals are naturally occurring atoms or
molecules that are highly reactive with anything they come into
contact with. A recently developed theory suggests that free
radicals play important roles in causing a wide range of
degenerative and chronic disorders, including cancer and aging.
Thus, substances with antioxidant properties may be effective in
preventing, or even treating, myriad conditions. (See the
"Diet and Nutrition" chapter for more information on
free radicals and antioxidants.)
Ayurveda emphasizes the interdependence of the
health of the individual and the quality of societal life.
Therefore, measures to ensure the collective health of society,
such as pollution control, community hygiene, the collective
practice of meditation programs, and appropriate living
conditions, are supported.
There are currently approximately 10 Ayurveda
clinics in North America, including one hospital-based clinic,
which together have served an estimated 25,000 patients since
1985 (Lonsdorf, 1993). More than 200 physicians have received
training as Ayurvedic practitioners through the American
Association of Ayurvedic Medicine, have received continuing
medical education credit for Ayurvedic training programs, and
have incorporated Ayurveda into their clinical practices as an
adjunct to modern medicine (Lonsdorf, 1993). A modern
revitalization of Ayurveda now being practiced in the United
States and internationally is known as Maharishi Ayurveda. This
approach utilizes a full range of physical and mental therapies
from the Ayurvedic tradition.
In India, Ayurvedic practitioners receive
State-recognized and-institutionalized training along with their
physician counterparts in the Indian state-supported systems for
conventional Western biomedicine and homeopathic medicine. A
number of these Indian-trained Ayurvedic physicians practice or
teach Ayurveda in the United States.
Research base. There have been extensive
studies of the physiological effects of meditative techniques and
yoga postures in both the Indian medical literature and the
Western psychological literature (Funderburk, 1977; Murphy,
1992a; Murphy and Donovan, 1988). For example, students in hatha
yoga classes showed improvement in fitness measures, including
flexibility, strength, equilibrium, and stamina (Jharote, 1973).
In addition, effects of yogic postures and
breathing on finger blood flow showed consistent changes with
various breathing practices, changes that were more pronounced in
trained yogic practitioners (Gopal et al., 1973). Changes in
endocrine hormone measurements also have been associated with
certain Ayurvedic practices (Glaser et al., 1992; Udupa et al.,
1971). Measurement of metabolic rate, oxygen exchange, lung
capacity, and red and white blood cell counts have been found to
be associated with general yogic training and in some cases with
specific asanas (posture) (Gopal et al., 1974). Similar basic
research on meditative practices has led to the development in
Western medicine of biofeedback and relaxation training (see the
"Mind-Body Interventions" chapter).
Yogic and meditative practices also have been
studied as specific interventions for disease states such as
asthma and hypertension (Bhole, 1967; Patel, 1973). A recent
pilot study performed in Holland followed a group of patients who
used a combination of Ayurvedic therapies. The study documented
improvements with Ayurvedic therapies in 79 percent of patients
who were studied for a 3-month treatment period with a number of
chronic disease conditions, including rheumatoid arthritis,
asthma, chronic bronchitis, eczema, psoriasis, hypertension,
constipation, headaches, chronic sinusitis, and
non-insulin-dependent diabetes mellitus (Janssen, 1989).
In addition, published studies have documented
reductions in cardiovascular disease risk factors, including
blood pressure, cholesterol, and reaction to stress, in
individuals practicing Ayurvedic methods (Schneider et al., 1992)
and have shown improvement in overall health care utilization
measures among meditators (Orme-Johnson, 1988).
The "technology" of meditative
practices has been subjected to studies showing physiological
changes of heart rate, blood pressure, brain cortex activity,
metabolism, respiration, muscle tension, lactate level, skin
resistance, salivation, and pain and stress responses
(improvement), and both negative and positive behavioral effects
Further laboratory and clinical studies on
Ayurvedic herbal preparations and other therapies have shown them
to have a wide range of potentially beneficial effects for the
prevention and treatment of certain cancers, including breast,
lung, and colon cancers (Sharma et al., 1990). They have also
been shown effective in the treatment of mental health (Alexander
et al., 1989b) and infectious disease (Thyagarajan et al., 1988),
in health promotion (Schneider et al., 1990), and in treatment of
aging (Alexander et al., 1989a; Glaser et al., 1992). Mechanisms
underlying these effects are believed to include free-radical
scavenging effects (Fields et al., 1990), immune system
modulation, brain neurotransmitter modulation, and hormonal
effects (Glaser et al., 1992). The National Cancer Institute
(NCI) has included Ayurvedic compounds on its list of potential
chemopreventive agents and has recently funded a series of in
vitro studies on the cancer-preventive properties of two
Ayurvedic herbal compounds, maharadis amrit kalash 4 and 5 (MAK-4
and MAK-5). In preliminary studies, NCI researchers have
demonstrated that MAK-4 and MAK-5 significantly inhibited cancer
cell growth in both human tumor and rat tracheal epithelial cell
systems (Arnold et al., 1991).
Future research opportunities and priorities.
Because of the potential of ayurvedic therapies for treating
conditions for which modern medicine has few, if any, effective
treatments, this area is a fertile one for research
opportunities. For example, when NCI researchers began testing
MAK-4 and MAK-5 for effects against tumor cell growth, they also
found that similar compounds such as ferulic acid, catechin,
bioflavonoids, retinoic acid (vitamin A), ascorbyl palmitate, and
glycyrrhetinic acid also showed chemopreventive activity (Arnold
et al., 1991).
Known scientific data on the intrinsic rhythms
and laterality (right side vs. left side) patterns in the
autonomic nervous system can provide a model for understanding
how stress disrupts healthy physical function. Certain meditative
and yogic practices have been proposed as noninvasive
"technologies" to self-regulate the neural matrices
that couple mind and metabolism in the body (Shannahoff-Khalsa,
1991). Translation of the traditional concepts of yogic medicine
into the language of modern medicine could stimulate creative
research in the neurophysiology of stress and adaptation.
The following are the research opportunities as
well as the priorities for investigations in this area of
1. Performing a critical review of world
literature to identify potentially useful Ayurvedic therapies for
2. Conducting long-term health care utilization
and cost effectiveness studies on individuals who use Ayurvedic
therapies, lifestyle programs, and meditation regularly for
3. Studying the effectiveness of Ayurvedic
therapies and lifestyle for the prevention and treatment of
diseases such as cardiovascular disease, cancer, AIDS,
osteoporosis, autoimmune disorders, Alzheimer's, and aging.
4. Assessing the cost and treatment
effectiveness of Ayurvedic therapies in the treatment of specific
functional or chronic disorders such as chronic fatigue syndrome,
premenstrual syndrome, chronic pain, functional bowel and
digestive problems, insomnia, allergies, and neuromuscular
5. Identifying the mechanisms underlying
therapeutic effects of herbal therapies, diet, Ayurvedic physical
therapies such as panchakarma, meditation, yogic practices, and
other treatment modalities.
6. Studying the effects of the collective
practice of meditation on community health indices and health
care costs in cities, the Nation, and other social groups.
The term homeopathy is derived from the Greek
words homeo (similar) and pathos (suffering from disease). The
first basic principles of homeopathy were formulated by the
German physician Samuel Hahnemann in the late 1700s. Curious
about why quinine could cure malaria, Hahnemann ingested quinine
bark and experienced alternating bouts of chills, fever, and
weakness, the classic symptoms of malaria. From this experience
he derived the principle of similars, or "like cures
like": that is, a substance that can cause certain symptoms
when given to a healthy person can cure those same symptoms in
someone who is sick.
Hahnemann spent the rest of his life
extensively testing, or "proving," many common herbal
and medicinal substances to find out what symptoms they could
cause. He also began treating sick people, prescribing the
medicine that most closely matched the symptoms of their illness.
The information from this experimentation has been carefully
recorded and makes up the homeopathic materia medica, a listing
of medicines and their indications for use. According to the
Homeopathic Pharmacopoeia of the United States, homeopathic
medicines, or remedies, are made from naturally occurring plant,
animal, and mineral substances.
By the end of the 19th century, homeopathy was
widely practiced in the United States, when there were 22
homeopathic medical schools, more than 100 homeopathic hospitals,
and an estimated 15 percent of physicians practicing homeopathy.
The practice of homeopathy (along with other types of alternative
medicine) declined dramatically in the United States following
the publication of the Flexner Report in 1910, which established
guidelines for the funding of medical schools. These guidelines
favored AMA-approved institutions and virtually crippled
competing schools of medicine. In the past 15 years, however,
there has been a resurgence of interest in homeopathy in this
country. It is estimated that approximately 3,000 physicians and
other health care practitioners currently use homeopathy, and a
recent survey showed that 1 percent of the general population, or
approximately 2.5 million people, had sought help from a
homeopathic doctor in 1990 (Eisenberg et al., 1993).
Those who are licensed to practice homeopathy
in the United States vary according to state-by-state "scope
of practice" guidelines, but they include M.D.s, D.O.s,
dentists, naturopaths (N.D.s), chiropractors, veterinarians,
acupuncturists, nurse practitioners, and physician assistants.
Three states now have specific licensing boards for homeopathic
physicians: Arizona, Connecticut, and Nevada. Specialty
certification diplomas for those prescribing homeopathic drugs
are established through national boards of examination for
M.D.s/D.O.s and N.D.s. Self-help as well as professional training
courses in homeopathy are offered through the National Center for
Homeopathy (NCH) in Alexandria, Virginia. NCH serves as an
umbrella organization for consumer support of homeopathy as well
as a focus for coordination among an increasing number of
organizations and specialty societies offering lay and
professional training programs in homeopathy.
Homeopathic medicine also is currently widely
practiced worldwide, especially in Europe, Latin America, and
Asia. In France, 32 percent of family physicians use homeopathy,
while 42 percent of British physicians refer patients to
homeopaths (Bouchayer, 1990; Wharton and Lewith, 1986). In India,
homeopathy is practiced in the national health service, and there
are more than 100 homeopathic medical colleges and more than
100,000 homeopathic physicians (Kishore, 1983).
In the United States today, the homeopathic
drug market has grown to become a multimillion-dollar industry; a
significant increase has occurred in the importation and domestic
marketing of homeopathic drugs. Homeopathic remedies are
recognized and regulated by the FDA and are manufactured by
established pharmaceutical companies under strict guidelines
established by the Homeopathic Pharmacopoeia of the United
States. Products that are offered for the treatment of serious
conditions must be dispensed under the care of a licensed
practitioner. Other products offered for the use of self-limiting
conditions such as colds and allergies may be marketed as
Homeopathy is used to treat both acute and
chronic health problems as well as for health prevention and
promotion in healthy people. Homeopathic medicines are prescribed
on the basis of a wide constellation of physical, emotional, and
mental symptoms. The one remedy that most closely fits all of the
symptoms of a given individual is called the similimum for that
person. Thus, homeopathic treatment is individualized, and two or
more people with the same diagnosis may be given different
medicines, depending on the specific symptoms of illness in each
person. A person with a sore throat, for instance, may need one
of six or seven common remedies for sore throats, depending on
whether the pain is worse on the right or left side, what time of
day it is worse, what the person's mood is, and his or her body
temperature, thirst, and appetite (Jouanny, 1980).
Hahnemann also discovered that if the
homeopathic remedies were "potentized" by diluting them
in a water-alcohol solution and then shaking, side effects could
be diminished. He found that after the medicines were potentized
to high dilutions, there was still a medicinal effect, and side
effects were minimal. Some homeopathic medicines are diluted to
concentrations as low as 10-30 to 10-20,000. This particular
aspect of homeopathic theory and practice has caused many modern
scientists to reject homeopathic medicine outright. Critics of
homeopathy contend that such extreme dilutions of the medicines
are beyond the point at which any molecules of the medicine can
theoretically still be found in the solution (When to believe...,
On the other hand, scientists who accept the
validity of homeopathic theory suggest several theories to
explain how highly diluted homeopathic medicines may act. Using
recent developments in quantum physics, they have proposed that
electromagnetic energy may exist in the medicines and interact
with the body on some level (Delinick, 1991). Researchers in
physical chemistry have proposed the "memory of water"
theory, whereby the structure of the water-alcohol solution is
altered by the medicine during the process of dilution and
retains this structure even after none of the actual substance
remains (Davenas et al., 1988).
Recent research accomplishments. Basic science
research in homeopathy has primarily involved investigations into
the chemical and biological activity of highly diluted
substances. The most thought-provoking research has involved
observation of the physiological responses of living systems to
homeopathically potentized solutions. For example, in the 1920s a
German researcher conducted a series of studies spanning 12 years
in which he showed periodic variations in the growth patterns of
plants that had been exposed to a series of homeopathic dilutions
of metallic salts (Kolisko, 1932). With the focus of modern
biological laboratory research on cellular and organ function,
homeopathic studies have more recently been conducted in this
area. Such laboratory studies have shown positive effects of
homeopathically prepared microdoses on mouse white blood cells
(Davenas et al., 1987), arsenic excretion in the rat (Cazin et
al., 1987), bleeding time with aspirin (Doutremepuich et al.,
1987), and degranulation of human basophils--blood cells that
mediate allergic reactions--(Davenas et al., 1988; Poitevin et
Furthermore, recent clinical trials in Europe
have suggested a positive effect of homeopathic medicines on such
conditions as allergic rhinitis (Reilly et al., 1986), fibrositis
(Fisher et al., 1989), and influenza (Ferley et al., 1989), while
an earlier study showed no apparent effect in the treatment of
osteoarthritis by a homeopathic medicine (Shipley et al., 1983).
The British Medical Journal published a meta-analysis in 1992 of
homeopathic clinical trials, which found that 15 of 22
well-designed studies showed positive results. This study
concluded that more methodologically rigorous trials should be
done to address the question of efficacy of homeopathic treatment
(Kleijnen et al., 1991). A recent double-blind study comparing
homeopathic treatment with placebo in the treatment of acute
childhood diarrhea found a statistically significant improvement
in the group receiving the homeopathic treatment (Jacobs et al.,
Homeopathic research study design has used
different methodologies depending on the question being asked.
One of the earliest studies of homeopathy in a peer-reviewed
conventional medical journal asked the question, "Is the
homeopathic medical system taken as a whole more effective or
less detrimental than another treatment or placebo in the
condition studied?" In this study, which focused on
rheumatoid arthritis, 195 patients who had previously been
treated with nonsteroidal anti-inflammatory drugs were allocated
to placebo treatment or active treatment. The active-treatment
population then was divided between aspirin and a homeopathic
medication. The homeopathic doctors were allowed to prescribe any
medication at whatever interval, frequency, or potency they
The trial was conducted for a year, and by the
end of the year almost 43 percent of the homeopathic treatment
group had stopped other treatments and were judged to have
improved since the beginning of the study. Another 24 percent of
the homeopathic group improved, but they continued on their
conventional medications. In contrast, only 15 percent of the
aspirin group were maintained and improved on the treatment. The
entire placebo group had dropped out within 6 weeks.
This study, however, was criticized on some
methodological grounds--principally that the homeopathic
prescribers were more committed to the treatment and the patients
were easily able to determine who was in the placebo group
(Gibson et al., 1978). Subsequently, the same researchers
conducted another trial of this type, in which a specific disease
was subjected to homeopathic treatment by any one of a number of
clinically indicated homeopathic medications. This time, a
placebo-controlled, double-blind study showed that the
improvements among the homeopathically treated patients were
statistically more significant than those of the placebo group
(Gibson et al., 1980).
A second type of homeopathic study has been
used to ask a more specific question, namely, Is a particular
homeopathic medication more effective than another treatment or
placebo for a particular disease? Fisher and colleagues (1989)
asked this question in a study of primary fibromyalgia, a type of
inflammation; patients who met recognized diagnostic criteria for
fibromyalgia were further stratified as patients for whom a
particular homeopathic medicine, rhus toxicodendron 6C, was
homeopathically indicated. Patients with the active treatment
were better on all variables, and a number of their tender points
were reduced by 25 percent at the end of 4 weeks of active
treatment in comparison with controls.
In a similar study, Reilly and colleagues
(1986) used homeopathic medications with hay fever patients to
address the issue of whether homeopathic medications are in fact
placebos. The researchers directly treated matched groups of
approximately 70 patients with a homeopathic medication made from
mixed grass pollens at the dilution of one part in 1060. This was
done to address the assertion that a potency lacking in any of
the original substances could act as more than a placebo.
Patients took one tablet twice daily of either placebo or the
test drug and were free to use a standard antihistamine at any
time during the 5-week study. Only the homeopathically treated
group showed a clear reduction in symptoms, and in comparison
with the placebo-treated group, twice as many of the
homeopathically treated patients had discontinued their
antihistamines. This study also demonstrated that even a simple
study design requires careful analysis of potential confounding
variables, including the clinical observations that some
homeopathically treated patients experience temporary aggravation
of their symptoms before achieving a sustained improvement.
A third type of study simply looks at
comparative utilization figures for homeopathic practitioners in
a health care system with or without attention to the comparative
clinical outcomes. For example, in France, research on
cost-effectiveness has shown that the annual cost to the social
security system for a homeopathic physician is 54 percent lower
than the cost for a conventional physician. Moreover, the same
study found that the price of the average homeopathic medicine is
one-third that of standard drugs (CNAM, 1991).
Research opportunities. Research into the basic
science areas of quantum physics, physical chemistry, and
biochemistry may determine whether a homeopathic medicine's
mechanism of action can be elucidated. Existing studies of the
effects of the succussion process on the physical-energetic
nature of medicinal dilutions should be repeated and extended
(Smith and Boericke, 1967). Moreover, modern-day herbal,
biological, or pharmaceutically synthesized agents should be
subjected to homeopathic "provings." This scientific
documentation of effects and side effects in healthy people would
enable new homeopathic drug development.
Evaluating the clinical efficacy of homeopathy
using randomized, double-blind clinical trials for the treatment
of acute problems such as diarrhea, otitis media, and
postoperative pain as well as for chronic illnesses is a fertile
area for research. Existing studies should be repeated with
different investigators, giving attention to rigorous
methodology. Special emphasis should be given to research in
areas where modern medicine does not have an established,
satisfactory solution, such as arthritis, AIDS, asthma,
headaches, and inflammatory bowel disease.
More clinical research also needs to be
directed toward analyzing and improving the accuracy of the
clinical data in the homeopathic literature, much of which is
currently at least a century old. Indeed, homeopaths in Great
Britain are currently establishing a system using a modern,
computerized medical database and standardized subjective and
objective outcome measures to analyze the outcomes of patients
treated with various homeopathic medications (van Haseln and
Fisher, 1990). This sort of study will help homeopathic
clinicians to investigate the differential efficacy of various
homeopathic medications and allow for an updating of the
prescribing criteria for various medications in the homeopathic
In addition to clinical trials on conditions
with specific diagnoses, studies also need to be done to evaluate
the possible benefits of long-term treatment with the system of
homeopathic medicine. Since proponents of this discipline claim
that homeopathy improves overall physical and mental health,
health status indicators should be used to evaluate changes in
health in patients treated this way for several months or years.
Recent surveys in the United States found that
most homeopathic patients seek care for chronic illnesses (Jacobs
and Crothers, 1991) and that homeopathic physicians spend twice
as much time with their patients, order half as many laboratory
tests and procedures, and prescribe fewer drugs (Jacobs, 1992).
Since treatment of chronic illness accounts for a large
proportion of health care expenditures in the United States, the
cost-effectiveness of homeopathic medicine should be investigated
by comparing homeopathy with conventional treatments for specific
chronic illnesses such as recurrent childhood ear infections,
allergies, arthritis, headaches, depression, and asthma. Clinical
outcomes should be measured as well as such factors as
utilization of health services, number of missed days of work or
school, patient satisfaction, and overall cost of health care.
This research will help determine whether incorporating
homeopathy into the national health care scheme would
significantly reduce health care costs.
Anthroposophically Extended Medicine
Overview. The foundations of anthroposophically
extended medicine were laid down by the Austrian philosopher and
spiritual scientist Rudolf Steiner, Ph.D. (1861-1925). Steiner's
"anthroposophy" (anthropos [human]; sophia [wisdom])
proposed a philosophical or spiritual-scientific model of human
individuality. He took rigorous precision and methodologies of
scientific empiricism and extended them into the spiritual
domain, into what he called the "supersensible world,"
the domain underlying all human life, thought, and physical
well-being. Steiner's theories were applied to agriculture
(biodynamics), education (Waldorf Schools), and social theories
(threefold social order) as well as art, painting, sculpture,
dance (eurythmy), architecture, music, and speech (e.g., for
performance, education, and therapeutics).
In the 1920s Ita Wegman, M.D. (a Dutch
physician, 1876-1943), and Steiner coauthored a foundational work
for physicians seeking to broaden their medical practice
according to these anthroposophical principles (Steiner and
Wegman, 1925). Steiner's intention was to outline a
"rationally exact medical mode of thinking" as part of
his larger, lifelong program of approaching issues of spiritual
knowledge as a scientist. He gave an extended series of lectures
and training courses for physicians, nurses, social workers, and
pastoral counselors. This effort to extend therapeutics through
the anthroposophical paradigm was based on Steiner's 34 years of
work with the scientific method and encompassed therapeutic
efforts based on botany, anatomy, natural sciences, and the
dynamics of healing. Steiner and his physician followers
attempted to reorient medical therapeutics so that they would
encompass the spiritual depths of human existence. "Medicine
will be broadened by a spiritual conception of man to an art of
healing or else it will remain a souless technology that removes
only symptoms. Through the concrete inclusion of the spirit and
soul of man, a humanization of medicine is possible" (Wolff,
As an extension of Western medicine,
anthroposophical medicine builds on three preexisting movements
and therapeutics. The first is natural medicine or naturopathy,
which involves the use of material substances in nondegraded,
non-chemically separated forms. Naturopathy, established in
Europe in the early 19th century, is now practiced in an
increasing number of States in the United States (see below). The
second foundation is homeopathy, introduced by the German
physician Samuel Hahnemann in the 18th century (see the
"Homeopathic Medicine" section). The third foundation
for anthroposophical medicine is modern scientific medicine
itself. Steiner insisted that anthroposophically extended
medicine be practiced only on the foundation of a Western medical
training and credentials, and thus only M.D.s could become
Estimates of the number of M.D.s who mainly or
exclusively practice anthroposophical medicine range from 1,000
to 6,000 worldwide with between 30 and 100 such physicians in the
United States (Ministry of Science and Technology, Federal
Republic of Germany, 1992; Scharff, 1993). Most practitioners are
concentrated in Switzerland, Germany, Sweden, and Holland, and
there are more than a dozen hospitals and clinics in Europe
specializing in anthroposophically extended medicine. The
Witten-Herdecke Medical School, established in 1983 near
Dortmund, Germany, teaches anthroposophical medicine and grants
M.D. degrees. Efforts are under way to formally certify
physicians with anthroposophical training, and the Board of the
American College of Anthroposophically Extended Medicine has been
established in the United States (Scharff, 1993).
Hundreds of uniquely formulated medications are
used in anthroposophical practice. Some are prepared by a
multiple dilution and succussion (potentization) process, which
is similar to that used in standard homeopathic pharmaceuticals.
About 85 percent of the remedies are such potentized
preparations, and the remaining 15 percent are similar to other
botanical or traditional herbal medicines. All the basic
substances go through a standardized pharmaceutical process and
are made into remedies according to the official pharmacopoeia of
the country of manufacture. The preparation of medications seeks
to match the "archetypal forces" in plants, animals,
and minerals with disease processes in humans and, through this
correspondence, to stimulate healing.
Two major pharmaceutical firms prepare
anthroposophical medications for physicians around the world:
Waleda and Wala, which are both located in Europe with
subsidiaries in many countries, including the United States. Use
of these products is not limited exclusively to anthroposophical
medicine specialists. In the United States approximately 300
physicians regularly order anthroposophical pharmaceuticals,
while in Germany up to 15,000 physicians prescribe these
products, mainly preparations of the mistletoe plant for
treatment of cancers (Ministry of Science and Technology, Federal
Republic of Germany, 1992).
Today, anthroposophical physicians augment
conventional science by including new scientific approaches to
the living processes of nature, the soul, and the human spirit.
One model for approaching this task is to identify three
different interdependent aspects of a human's body-mind
processes. First, the "sense-nerve" system, which
includes the nervous system and the brain organization that
support the mind and the thinking process. Second, there is the
"rhythmic" system, which includes physical processes of
a rhythmic or periodic nature (e.g., the pulse, breathing,
intestinal rhythms) and supports the emotional or feeling
processes. Third is the "metabolic-limb" system, which
includes digestion, elimination, energetic metabolism, and the
voluntary movement processes. This third system supports the
aspects of human behavior that express the will.
This threefold model gives the physician a
diagnostic scheme for understanding an illness as a deviation
from the harmonious internal balance of the functions of the
bodily self and the spiritual self. In this approach, a person's
physical, human makeup is seen as continually interacting with
the soul or spiritual nature of that person. This
anthroposophical model is used by practitioners as a creative
entry for therapeutic insight into what are now recognized as the
processes of mind-body interactions in health and disease.
Research base. Much of the research in the
field of anthroposophically extended medicine has been connected
with attempts to understand the nature of disease, assess it
qualitatively, and understand how the essential properties of the
objects under investigation could be applied in therapy. For
instance, Steiner suggested that mistletoe might have a role in
cancer therapy. It was observed that mistletoe had unusual
biological properties as a relatively undifferentiated plant as
well as a tendency to show regular rhythmic changes in both a
seasonal and a lunar cycle. From this observation came an
extensive series of studies in Europe on iscador, iscucin,
abnoba, vysorel, and helixor, cancer remedies made from
mistletoe. This work suggests that these mistletoe remedies can
stimulate the body's immunological defense systems and act as
chemostatic agents to prevent further growth of tumors. Mistletoe
extracts have been analyzed for their chemical fractions, which
include lectins, polysaccharides, and proteins. A review of 36
controlled clinical trials using mistletoe in cancer therapy
showed six as statistically significant, having results pointing
to a life-extending effect (Keine, 1989). (See the
"Pharmacological and Biological Treatments" chapter and
the "Research Methodologies" chapter for further
information on mistletoe research.)
In recent years, collaboration between
anthroposophical scientists and established university-based
researchers has led to improvement in the quality and mutual
acceptability of "unconventional" anthroposophical
research in Germany. Of particular note is the work done by
Professor G. Hildebrandt and his colleagues at the University of
Marburg. In the past 30 years they have contributed more than 500
papers to the world's scientific literature, placing particular
emphasis on the chronobiology (biorhythms) of body physiology in
stress, disease, and therapy (Hildebrandt and Hensel, 1982;
Hildebrandt, 1986). An example of the application of this line of
research is shown by the work of von Laue and Henn, who reported
studies of the time rhythms of cancer patients and tumor growths
and how these abnormal rhythmic functions in cancer could be
altered with mistletoe therapy (von Laue and Henn, 1991).
The qualitative and analytical aspects of
anthroposophical research are further illustrated in the
psychosomatic field by the work of Fischer and Grosshans with
colitis patients at Herdecke Hospital. They conducted a
structured interview with 60 patients admitted with ulcerative
colitis or Crohn's disease (inflammations of the bowel) for a
2-year period and found that in addition to the well-known
physical characteristics of these two diseases, the patients
displayed other characteristic behaviors, including distinct
underlying mood tendencies, communication styles,
self-perceptions, and typical attitudinal relationships to past
and future events. These psychological responses differentiated
the Crohn's disease and ulcerative colitis patients along a
pattern that could be interpreted as a parallel to the clinical
symptoms (Fischer and Grosshans, 1992).
Cost and effectiveness issues in health care
delivery are important in European countries as well as the
United States. In Germany, von Hauff and Praetorius, an economist
and a political scientist, conducted a pilot study (1990) on the
performance structure of alternative medical practices. They used
a nonrandom poll of established practitioners of conventional,
homeopathic, or anthroposophical practices and were able to
qualitatively analyze the practices under consideration as well
as show quantitative differences in health care utilization. They
found that the patients being treated by homeopathic and
anthroposophical practitioners claimed 30 percent to 50 percent
fewer illness days, respectively, than patients being treated by
conventional practitioners. Furthermore, the homeopathic and
anthroposophical practices had fewer referrals for
hospitalization, fewer referrals to specialists, and fewer
Research opportunities. Anthroposophical
physicians approach issues of medical research by stressing basic
methodological issues. For instance, the current dominant model
of medical practice based on classical physics is seen as
inadequate for understanding the laws of living organisms. This
criticism extends to clinical research, where anthroposophical
principles emphasize the overall therapeutic strategies being
studied and not the isolated effect of specific chemical
medicines. A truly scientific research agenda, according to the
anthroposophical approach, must match the study methods and
questions posed with the subject under investigation. In other
words, inorganic systems require one type of science, living
organic systems require another, psychological processes another,
and intellectual-spiritual activities yet another. Although a
single rational scientific method may be valid throughout these
various domains of human endeavor, the specific nature of the
scientific approach must be different and appropriate to the
context of each domain. A recent poll in Germany of
anthroposophical physicians identified this methodological issue
as the major problem for future medical research (Ministry of
Science and Technology, Federal Republic of Germany, 1992).
Particular areas of recommended research for
anthroposophical medicine include the following:
* Establishing comprehensive valid criteria for
assessing quality-of-life outcomes in therapy trials.
* Conducting comparison trials of isolated
active ingredients versus extracts from the whole plant.
* Comparing a single-therapy approach to a
combination-therapy approach (e.g., medical treatment, diet, and
curative eurythmy artistic therapies for groups of patients with
given clinical conditions).
* Documenting the effect of the use of
anthroposophical remedies from a chronobiological perspective.
* Prospectively evaluating the effect of using
anthroposophical methods for early detection and correction of
tendencies toward illness before they manifest as serious
pathology requiring expensive medical interventions.
Overview. As a distinct American health care
profession, naturopathic medicine is almost 100 years old. It was
founded as a formal health care system at the turn of the century
by a variety of medical practitioners from various natural
therapeutic disciplines. By the early 1900s there were more than
20 naturopathic medical schools, and naturopathic physicians,
called "eclectic" physicians at the time, were licensed
in most of the States. After the Flexner Report in 1910 and the
rise in belief that pharmaceutical drugs could eliminate all
disease, the practice of naturopathic medicine experienced a
dramatic decline. It has experienced a resurgence in the past two
decades, however, as a health-conscious public began to seek
natural therapies delivered by professionals skilled in these
Today, there are more than 1,000 licensed
naturopathic doctors (N.D.s) in the United States. Currently,
there are two accredited U.S. naturopathic medical schools: the
National College of Naturopathic Medicine (NCNM) in Portland, OR,
and Bastyr College of Natural Sciences in Seattle, WA, which
graduate approximately 50 physicians each per year. A third
naturopathic medical school, Southwest College of Naturo-pathic
Medicine in Scottsdale, AZ, began classes in September 1993.
Seven U.S. States and four Canadian provinces grant licenses to
practice naturopathic medicine. In addition, a number of other
States have legal statutes that allow the practice of
naturopathic medicine within a specific context. The American
Association of Naturopathic Physicians publishes the Journal of
Naturopathic Medicine, which includes articles on original
research, research reviews, and news and review articles relating
to naturopathic medicine.
As it is practiced today, naturopathic medicine
integrates traditional natural therapeutics--including botanical
medicine, clinical nutrition, homeopathy, acupuncture,
traditional oriental medicine, hydrotherapy, and naturopathic
manipulative therapy--with modern scientific medical diagnostic
science and standards of care. Naturopathic physicians are
trained in anatomy, cell biology, nutrition, physiology,
pathology, neurosciences, histology, pharmacology, biostatistics,
epidemiology, public health, and other conventional medical
disciplines, and they receive specialized training in the
alternative medicine disciplines. They integrate this knowledge
into a cohesive medical practice and tailor their approaches to
the needs of an individual patient according to these eight
1. Recognition of the inherent healing ability
of the body.
2. Identification and treatment of the cause of
diseases rather than mere elimination or suppression of symptoms.
3. Use of therapies that do no harm.
4. The doctor's primary role as teacher.
5. Establishment and maintenance of optimal
health and balance.
6. Treatment of the whole person.
7. Prevention of disease through a healthy
lifestyle and control of risk factors.
8. Therapeutic use of nutrition to promote
health and to combat chronic and degenerative diseases.
Research base. Medical research on
naturo-pathic practice is based on the empirical documentation of
treatments with case history observations, medical records, and
summaries of practitioners' clinical experiences. Naturopathic
physicians have conducted scientific research in natural
medicines in China, Germany, India, France, and England as well
as U.S. research in clinical nutrition.
The two current accredited naturopathic medical
schools have active research departments. For example, NCNM
participated in a 10-year nationwide study of the cervical cap as
a method of birth control. Study conclusions were submitted to
the FDA (National College of Naturopathic Medicine Clinical
Faculty, 1991). Naturopathic researchers also have investigated
the pharmacology and physiological effects of nutritional and
natural therapeutic agents (Barrie et al., 1987a, 1987b; Mittman,
1990). Digestive tract stresses and their treatment with natural
methods also have been a focus of study (Blair et al., 1991;
Collins and Mittman, 1990; Thom, 1992), and naturopathic
physicians have been active in the investigation of new
homeopathic remedies (Brown and Lange, 1992).
Naturopathic medical researchers have shown a
particular interest in the natural treatment of women's health
problems. One series of clinical research studies evaluated a
naturo-pathic treatment protocol for women with cervical
dysplasia (abnormal Pap smears). All subjects received oral
nutritional and botanical supplementation, local topical
cleansings, and suppositories made from herbal and nutritional
agents (Hudson, 1991). Eight distinct naturopathic protocols were
used depending on the severity of the abnormal Pap smears.
Treatment included topical applications of Bromelia, Calendula,
zinc chloride, and Sanguinaria. Additional home treatments
included vaginal suppositories with myrrh, Echinacea, Usnea,
Hydrastis, Althaea, geranium, and yarrow. The patients also used
vitamin A suppositories, vitamin C, beta-carotene, folic acid,
selenium, and Lomatium systemically as well as a botanical
formula including (a) Trifolium, (b) Taraxacum, (c) Glycyrrhiza
and Hydrastis, or (d) Thuja plus Echinacea and Ligustrum (Hudson,
Of the 43 women in the study, 38 returned to
normal Pap smears and normal tissue biopsy. Three had partial
improvement, two showed no change, and none progressed toward
more advanced disease states during treatment (Hudson, 1993a). It
was suggested that partial use of these protocols might also
benefit the long-term outcome in patients undergoing conventional
treatment of cervical dysplasia including cryosurgery,
conization, or loop electrosurgical excision procedures.
The most recently completed naturopathic study
in women's health tested the clinical and endocrine effects of a
botanical formula as an alternative to estrogen replacement
therapy. Results of this study suggest a clinically significant
benefit (measured as reduction in the total number of menopausal
symptoms) in 100 percent of the women versus 17 percent in the
placebo group (Hudson and Standish, 1993).
Future research opportunities. The following
areas in the field of naturopathy offer the best opportunities
for yielding significant research results:
* Clinical trials on naturopathic botanical
formulas as an alternative to hormone replacement therapy.
* Effects of individual herbs on specific
disease, for example, Glycyrrhiza for peptic ulcer disease,
Crataegus for hypertension, Echinacea as an antiviral, Ulmus
fulva for irritable bowel, and Taraxacum as a diuretic.
* Evaluations of the postsurgical outcomes of
patients who have used naturopathic medicine to accelerate
healing and improve their recovery.
* Evaluations of naturopathic protocols for
treatment of hyperlipidemia, cervical dysplasia, otitis media,
diabetes, and hypertension.
* Clinical trials on the outcome of breast
cancer patients who use naturopathic medicine with their
conventional therapy versus patients who use only conventional
* Facilitation of research into ethnomedicines
by documenting oral traditions and studying them in the context
of their cultures--for example, hydrotherapy and European
traditions, native plants of developing countries and their local
use by native healers, and traditional diets of native peoples.
* Clinical trials to evaluate the effectiveness
of combination naturopathic medical protocols and rigorous
evaluation of single-agent botanical medicines and naturopathic
modalities in the treatment of HIV and AIDS.
Overview. Environmental medicine is an
alternative system of medical practice based on the science of
assessing the impact of environmental factors on health. It is
the result of continuing study of the interfaces among chemicals,
foods, and inhalants in the environment and the biological
function of the individual.
Environmental medicine traces its roots to the
practice of allergy treatment. In the 1940s Theron Randolph, the
founding father of environmental medicine, identified a wide
range of medical problems he believed were caused by food
allergies. Working with the techniques developed by Herbert
Rinkel, Randolph identified multiple symptoms due to a variety of
common foods such as corn, wheat, milk, and eggs--symptoms
previously unrecognized as caused by food exposure. Using
Rinkel's method of unmasking food allergies by avoiding the
suspect food for at least 4 days before challenging, Randolph was
able to identify food-related triggers for symptoms such as
arthritis, asthma, depression and anxiety, enuresis, colitis,
fatigue, hyperactivity, and others (Randolph, 1962).
In the 1950s Randolph noted that in small
amounts, chemicals such as natural gas, industrial solvents,
pesticides, car exhaust, and formaldehyde were also responsible
for significant and previously unrecognized health problems
(Randolph, 1962). It was noted that certain individuals were more
sensitive to these minute exposures and that illness could be
triggered in such hypersensitive individuals by amounts of
chemicals that most people could tolerate without apparent
Many of the findings of Randolph and others
were originally identified through the use of environmental
control units (strictly controlled environments in hospitals). In
these settings, patients' allergies and sensitivities were
unmasked through fasting and complete avoidance of incitant
chemicals. When foods or chemicals were introduced in a
systematic fashion, cause and effect could be identified. Today
there are several environmental control units in the United
States and a Canadian Government-sponsored unit in Nova Scotia,
Through careful and detailed environmentally
focused clinical observations of thousands of patients, Randolph
and others developed a new model and associated clinical
principles that helped explain and treat many of the complex
problems seen in medical practice today. By assessing the
interaction between the individual's internal state and exposure
to external factors, the physician may understand the cause of an
illness. This type of medical practice goes beyond traditional
medical concepts because it emphasizes the effects of food and
chemicals in health.
The problems treated by environmental medicine
include both diagnosis of problems that are traditionally
considered allergic problems--asthma, hay fever, allergic
rhinoconjunctivitis, eczema, and anaphylactic food allergies
mediated by immunoglobulin E (IgE) antibody as well as other
factors--and other diagnoses for which the underlying
immunological aspects are not yet understood: arthritis, colitis,
depression, fatigue, attention deficit disorder, cardiovascular
disease, migraine and other headaches, urinary tract disorders,
and other functional illnesses.
Of particular importance is the recognition of
the effects of chemicals in the home and workplace, such as in
the "sick building syndrome." With the changing
environment found in workplaces and homes as well as outdoors,
the incidence of environmentally triggered illness has increased.
Chemically induced environmental illness is already affecting 4
million to 5 million Americans, and it is estimated that no more
than 5 percent have been identified and treated. If patients with
problems stemming from environmental exposure are not seen by a
physician knowledgeable in environmental illness, they are often
misdiagnosed or told they have psychiatric problems or
hypochondriases (Randolph and Moss, 1980; Rea and Mitchell,
In 1965, Randolph and his colleagues founded
the Society for Clinical Ecology to further explore the
connection between the environment and illness. Today, courses
organized by the American Academy of Environmental Medicine are
available for training in the techniques and principles of this
field. This organization, the successor to the Society for
Clinical Ecology, has annual scientific meetings to further
research and education. It publishes the peer-reviewed journal
Environmental Medicine (formerly Clinical Ecology).
Today, environmental medicine is a medical
specialty practiced by more than 3,000 physicians worldwide, most
of them in the United States, Canada, and Great Britain. Many of
these clinicians and researchers are members of one of the
following professional medical organizations: the American
Academy of Environmental Medicine, the Pan American Allergy
Society, or the American Academy of Otolaryngologic Allergy. More
than 50 percent of the members in the American Academy of
Environmental Medicine are board certified in one or more of 19
medical specialties. The binding factor in these diverse
physicians' backgrounds is an expanded view of health and
illness, including an emphasis on the role the environment plays
in a wide variety of medical disorders. This view of health and
illness allows environmental medicine to be considered as an
"alternative system" of medical practices developed
from within the Western heritage of biomedical science.
Principles of environmental medicine. Many
complex problems in medicine are called idiopathic: there is no
readily apparent cause for the illness. The conventional medical
model holds that similar illnesses have the same cause in all
patients and should be treated similarly. This is not the case in
the paradigm of environmental medicine.
Environmental medicine recognizes that illness
in the individual can be caused by a broad range of inciting
substances, including foods; chemicals found in the home and
workplace; chemicals in air, water, and food; and inhalant
materials, including pollens, molds, dust, dust mites, and
danders. Individual susceptibility to these exposures can vary
widely. The response to these exposures over time is specific to
each person's own level of susceptibility and can manifest
differently from person to person. Therefore, the specific
symptoms and illnesses developed depend on all these factors, and
environmental medicine attempts to answer the question why a
particular patient has a particular symptom at a particular time.
One key to understanding the diagnosis in
environmental medicine is a detailed chronological history. The
emphasis of this history is on environmentally focused events and
stressors over time. A thorough medical history and a physical
examination are also needed. The detail of the home and work
environment is explored to identify possible incitants.
The factors contributing to the sensitivity of
the patient are related to genetics, nutritional status,
effectiveness of detoxification pathways, and total allergic and
chemical load at the time. Biochemical individuality determines
the adequacy of nutritional stores and influences the ability to
operate the detoxification pathways effectively and thus
contributes to the individual's degree of sensitivity. Other
factors that can induce immune system dysfunction, such as
emotional stress, may have a major impact on the outcome of an
exposure to a chemical toxin, a food exposure, or an inhalant
The onset of illness coincides with the
person's inability to continue coping with the total allergic
load. This onset can occur either with a large acute exposure or
with low-level, gradual exposures. The total allergic load is
defined as the total level of exposure to substances that the
person can be sensitive to, and it varies significantly over
time. The total allergic load is often the determining factor in
maintaining health (homeostasis) versus falling ill.
Environmental medicine practitioners believe
that large amounts of toxic substances affect all those exposed,
but minute amounts affect only those who are susceptible to the
material. This fact explains the varied response to a material
such as formaldehyde; 10 percent of the population is highly
sensitive to small amounts of this poison and 90 percent is not.
Thus, a susceptible person may get sick from a small workplace
exposure, while others who are not susceptible suffer no ill
effects. This situation often leads to missing a diagnosis while
ignoring the patient's individual susceptibility. Indeed, many
patients and physicians are unaware of the effects of chemical
exposures as a contributing factor in illnesses. As a result,
patients are often labeled "hypochondriacs" or told
their illness is psychosomatic ("all in their mind")
(Choffres, 1987; Davis, 1985; Saifer and Saifer, 1987).
Another concept that can help to explain the
course of events in environmental illnesses is adaptation.
Adaptation is the process by which the body attempts to maintain
homeostasis. There are four distinct phases of adaptation:
preadapted-nonadapted (alarm), adapted (masked), maladapted, and
exhausted-nonadapted. The first three stages occur sequentially
and if left uninterrupted can lead to the exhausted stage, or the
onset of disease.
An example of adaptation phenomena is a
sensitivity to wheat. At first exposure, wheat might cause
symptoms such as fatigue (preadapted phase). After further
exposure, the homeostatic mechanism creates an adapted state with
no reactions. On further and frequent exposure, however, overt
symptoms can occur (maladapted phase); for example, headaches to
wheat may be labeled migraine and treated with medication.
Eventually, with continued exposure, more serious symptoms can
occur (exhausted phase). If the person stops being exposed to the
food for at least 4 days and challenging (deadaptation) then
causes the symptoms to reappear, cause and effect have been
observed clearly. This sequence can also be seen with low-level
Another observed phenomenon in environmental
medicine is the spreading phenomenon. There are two aspects: (1)
new onset of acute or chronic susceptibility to previously
tolerated substances, and (2) spreading of susceptibility to new
target organs. These events can occur with a single large
exposure to a chemical that damages particular biological
mechanisms and causes sensitivity to occur to other chemicals in
addition to the primary incitant substance. This phenomenon is
frequently seen with solvent or pesticide exposure causing a
person to become a "universal reactor" to many other
The type of symptoms experienced in the
reaction to an offending substance (food, chemical, or inhalant)
is not specific to the substance but is determined by a
combination of factors specific to the person. In contrast, all
individuals exposed to a highly toxic chemical have similar
symptoms (e.g., respiratory symptoms from exposure to
formaldehyde). Symptoms of sensitivity to small levels of
exposure can affect many target organs; widespread central
nervous system effects such as fatigue, depression, anxiety, or
poor memory and concentration may occur and can differ from
person to person. This observation often makes the cause of these
problems extremely difficult to identify and underlines the need
for the multifactorial approach, which is the basis of
The final pattern described in environmental
medicine is labeled the switch phenomenon. In this situation,
symptoms change and can affect different organ systems; symptoms
may range from psychological (e.g., anxiety) to asthma, fatigue,
and hyperactivity. This movement of symptoms was described by
Randolph as bipolar and bi-phasic responses of the biological
mechanism ranging from stimulatory phases (+1 to +4) to
withdrawal phases (-1 to - 4). It is possible to range from
stimulation to withdrawal in the course of the illness (Randolph,
Diagnostic and treatment techniques. Several
aspects of the assessment and treatment approaches employed in
environmental medicine are unique to this specialty. The key to
proper treatment is an accurate environmental history. With a
broader view of the connection between environment and illness,
many illnesses that are attributed to other causes by traditional
medicine are assessed in terms of environmental aspects.
The environmental history details the
chronology of the symptoms as well as the current form of the
illness. Using the chronological history and the assessment of
the detailed circumstances of the symptoms can lead to a greater
understanding of the etiology. There is a search for a history of
adverse reactions to specific environmental substances, including
biological inhalants, foods, and chemicals. A detailed
description of the home, the workplace, and the effects of
season, activity, and other environmental factors is necessary. A
thorough understanding of the pathophysiology of the
dysfunctioning systems is also required. The effects of total
allergic load, the spreading phenomenon, the switch phenomenon,
and biochemical individuality need to be recognized so that the
etiology of the illness can be assessed.
The physical examination and laboratory
assessment look for evidence of nutritional deficiencies, organ
system dysfunction, and disorders of detoxification systems.
Blood tests might include standard assessments such as chemistry
panels, blood counts, and hormonal function tests. In addition,
tests that further assess immune function are required, such as
lymphocyte subset panels, immunoglobulin levels, autoantibody
screens, viral and chemical antibody panels, and in vitro
assessment of allergy to foods, inhalants, and chemicals.
Furthermore, assessment of nutritional status is often included,
involving in vitro analysis of minerals and vitamins through
enzyme system activation, as well as serum, plasma, leukocyte, or
erythrocyte levels. Levels of toxic chemicals and minerals may be
measured in serum or other biological markers.
In-office testing for allergies and
hypersensitivity is often the most important aspect of assessing
a patient with environmental illness. The techniques employed
include serial end-point titration, provocative neutralization,
and bronchoprovocation. These techniques test a wide range of
antigens including bacteria, foods, chemicals, and inhalants such
as dust, mites, pollens, and molds. The antigen sources are the
same ones used in traditional allergy testing, but these
techniques can more effectively assess the non-IgE sensitivity
reaction (King, 1989; McGovern, 1981; Miller, 1972; Morris, 1981;
Rinkel, 1963). Although the validity of these techniques is
controversial, a significant number of studies support these
approaches (Brostoff, 1988; Gerdes, 1993; King, 1981).
Provocative testing is in essence a
quantitative bioassay. Individual skin tests with progressively
weaker blinded dilutions of extract can reproduce many of the
patient's symptoms. Subjective and objective monitoring can show
changes in heart rate, blood pressure, nasal patency, respiratory
function, cognitive function, and handwriting during and after
single allergy tests.
When complex patients cannot be evaluated as
outpatients, inpatient environmental control units are available
in several locations in the United States and Canada. In these
settings, the patients are in hospital rooms that are
environmentally controlled and are free of all common chemical
exposures. They are fasted on water until all symptoms disappear.
At this point, they are challenged with foods by mouth and with
chemicals in inhalant booths. The symptomatic response to these
substances can help clarify the cause of the illness.
Treatment approaches to these complex problems
require a full understanding of the nature of environmentally
induced illness. Immunotherapy based on the results of the in
vivo allergy testing techniques can be used to reduce the
sensitivity to these antigens through a variety of mechanisms,
including modulation by T-suppressor cells and altering the ratio
of antibody to antigen, which affects the formation of immune
complexes and histamine release (Rapp, 1986).
Educating the patient is critical in
environmental medicine. A thorough understanding of the factors
contributing to illness must be emphasized for long-term
improvement to occur. Emphasis is placed on environmental
controls in the home and workplace to reduce exposure to
inhalants as well as chemicals. Where possible, the patient is
informed about alternatives to using chemicals such as pesticides
in the home and the workplace.
Dietary management is based on avoidance of
food antigens and on the 4-day rotary diversified diet. With the
rotary diet and avoidance of repetitive food exposures, it is
possible to reduce sensitivity to foods and hasten recovery from
food allergies. Nutritional supplements are prescribed as
indicated by both objective nutritional testing and
symptomatology. Improving the xenobiotic detoxification pathways
through therapeutic nutrition is often required. In this respect
the practice of environmental medicine overlaps
"orthomolecular" nutrition practices. (See the
"Diet and Nutrition" chapter.)
Research accomplishments. Research in the field
has been directed at both clinical treatment of ill patients and
evaluation of the diagnostic and treatment techniques used by
practitioners. Studies have been done that support the approach
of environmental medicine in arthritis (Panush, 1986), asthma
(Gerrard, 1989), chemical sensitivity (Rea, 1991), colitis (Lake,
1982), depression (Randolph, 1959), eczema (Atherton, 1988), eye
allergy (Shirakawa and Rea, 1990), fatigue (Rowe, 1950), food
allergy (Rapp, 1947), hyperactivity (Rapp, 1979), migraine (Munro
et al., 1980), psychological complaints (Campbell, 1973),
urticaria (August, 1989), and vascular disease (Rea, 1991).
Published bibliographies on environmental medicine discuss other
studies and background in this area (Oberg, 1990; Randolph, 1987;
Rea et al. (1984) studied 20 patients with
known food sensitivity. Using neutralization therapy in a
double-blind study they found significant improvement (p
<0.001) in signs and symptoms of allergy reactions to those
foods. Mabry (1982), treating women with premenstrual tension
syndrome, used progesterone neutralization and found that 65
percent of them preferred the active treatment to placebo.
Gerdes (1993) performed critical reviews of 31
studies of the provocation-neutralization technique done between
1969 and 1988. Twenty-one studies showed evidence for the
effectiveness of the technique, and 10 had negative results. Only
10 of the 31 studies reviewed were methodologically sound,
however. Among these potentially replicable studies, 8 were
supportive of the technique, 1 was not, and 1 could be cited by
either side in the controversy. (See the "Diet and
Nutrition" chapter for data on food allergy studies.)
Future directions for research. Despite its
designation as an "alternative" professional specialty
within the biomedical community, environmental medicine remains a
controversial field. Practitioners of environmental medicine have
been criticized for "nonstandard" diagnostic techniques
and "unorthodox" treatment methods, as have other
practitioners of alternative forms of medicine. The principal
detractors have been the American Academy of Allergy and
Immunology and the American College of Allergy and Immunology
(Gerdes, 1993). Proponents claim, however, that the basic
principles of environmental medicine are critical to designing
the types of studies that could further validate the field.
Research has also been hampered by application of the
"unconventional" label to practices that attract
patients who have failed to be helped by conventional internal
medicine, allergy, and psychological approaches. The problem of
chemical hypersensitivity and chemically induced illness and
worker's disability led to a report by the New Jersey State
Department of Health in 1989, which summarizes much of the
controversy in this area (Ashford and Miller, 1989). Another
major review of the complex medico-legal and social problems
encountered with workers with multiple chemical sensitivities was
published by Rosenstock and Cullen in 1994.
Although the belief that humans may get sick
from accumulated low-level environmental stress is not well
accepted in the conventional community, sick building syndrome
and other diseases of the 20th century are being seen with
greater frequency. Indeed, according to The National Research
Council of the National Academy of Sciences, the U.S. population
is exposed to at least 50,000 chemicals, most of which have not
been studied sufficiently in relation to their effects on human
health (National Research Council, 1975). Those that have been
studied are assessed only in terms of their carcinogenicity in
animal models and not in terms of a myriad of other aspects
affecting human health. In addition, no work has been done on the
additive effects of repeated low-level exposures to pesticides,
solvents, formaldehyde, and the other common substances found in
the immediate environment (Elkington, 1986).
Future occupational toxicology studies should
include clinicians trained in environmental medicine. Peer review
committees in allergy and toxicology grant review processes
should not be dominated by persons whose belief system is
threatened by the environmental medicine philosophy.
The testing techniques of environmental
medicine need further validating studies, as do the various
immunological and nutritional treatment methods. The research
protocols must, however, actually test the paradigm. For example,
food or chemical challenges in the exhausted stage of illness
might yield different results if the study subjects were first
deadapted (allowed to recover) before being challenged. Careful
qualitative research might be needed to validate variable
biological responses such as those described in the switch
Since quality-of-life issues surround many of
the complex illnesses treated by environmental medicine,
qualitative outcomes research comparing patients treated by these
principles versus "orthodox medicine" could give
insight into the best use of this approach in the U.S. health
Environmental medicine offers an alternative
view of the causation, prevention, and treatment of many common
illnesses. It emphasizes self-care and the use of
nonpharmaceutical approaches. Environmental medicine presents a
dynamic and potentially cost-effective paradigm to deal with the
many common illnesses seen in today's increasingly complex
environment. It has been estimated by the U.S. Public Health
Service (1990) that diet and environment play a role in 90
percent of cancers and cardiovascular disease. Environmental
medicine is in a position to be a leading force in the
investigation of ways to reduce the incidence of these and other
Community-Based Health Care Practices
All of the systems discussed in this section
are community based in several ways. Most important, an
individual's sickness is viewed as a sickness of the entire
community. That is, when one person becomes sick, the whole
community is believed to be in danger. Therefore, the treatment
must address the whole community rather than just the patient.
Because the concepts of "medicine"
and "religion" in these systems often are fused, no
sickness can affect only one part of the body. Rather, it affects
the whole network of existence, the natural world, and the
spiritual world. Accordingly, in addition to their expertise in
naturalistic healing (i.e., the use of herbs), community-based
health care practitioners are expected to have expertise in
dealing with relationships (between partners, between parents and
children, etc.), mediating disputes and communicating with the
spirit world. Also, health care is delivered in public, with
members of the family and community present.
Community-based health care practices are
varied and found throughout the United States, although many
people would not consider that they were participating in such a
system when they attend a healing service at a local church or go
to a meeting of Weight Watchers. Like other health care
specialists, community-based healers may emphasize naturalistic,
personalistic, or energetic explanatory models or a combination.
Traditional midwives and herbalists--and nowadays, pragmatic
weight loss specialists--are probably the best known of
community-based practitioners who follow the naturalistic model._
Though most traditional healers will accept
gifts, many refuse pay for their healing work. They believe they
are the agents of God or the spirit world and that their power
and skill should be used to help the needy. Most community-based
healers do not advertise their skills, which are therefore mainly
known locally. There are two types of personalistic healers: the
shaman, and others who do not quite fit this model and whose
practice can be called "shamanistic."
A shaman is a type of spiritual healer
distinguished by the practice of journeying to nonordinary
reality to make contact with the world of spirits, to ask their
direction in bringing healing back to people and the community
(Atkinson, 1987, 1992; Brown, 1988; Eliade, 1964; Halifax, 1979;
Harner, 1990; Ingerman, 1991; Laderman, 1988; McClenon, 1993;
Myerhoff, 1976). The journey is a controlled trance state that
practitioners induce by using repetitive sound (drums, rattles)
or movement (dancing) and occasionally by consuming plant
substances (e.g., peyote or certain mushrooms).
Characteristically experiential and cooperative, shamanic healing
is found worldwide. It is fundamental to much traditional
European, African, Asian, and Native American Indian folk
practice and is rapidly gaining popularity among nonnative urban
Americans, in which setting it is sometimes called neo-shamanism
Shamanic practices define healing broadly: not
only are people to be healed of their spiritual and psychic
wounds, but shamans also attempt to heal communities, modify the
weather, and find lost objects. Many traditional shamans are also
skilled in manipulative or herbal practices (Atkinson, 1987;
Clinical evidence of results is anecdotal,
consisting of the stories successful shamans tell of their curing
and healing activities (Black Elk and Lyon, 1990; Harner, 1990;
Ingerman, 1991; Yellowtail and Fitzgerald, 1991; Young, 1989).
Some interpretations of shamanism have tended to categorize its
effectiveness in the same range as psychotherapy, but wider
interpretations may be more accurate (Atkinson, 1992; Brown,
1988; Laderman, 1988; McClenon, 1993).
Shamans are concerned with helping patients
discover "meaning," but such meaning is not limited to
the interior dialog. It expands to include the entire natural and
spiritual community. For example, shamanic journeying and the
precision with which shamans can "tell" a patient's
life and concerns to a patient convince many that the spirit
world is real and supportive. Also, shamans commonly help
individual patients see their illness not as a personal failure
but as a concern of the larger sociopolitical unit, thus drawing
community support toward the sick. Shamanic care can also result
in physical "curing." In summary, the shamanic approach
is complex and paradigmatically quite different from mainstream
Western explanatory models.
Personalistic specialists who do not practice
journeying are not shamans. Nor can practices that depend on
fixed rituals or charms, and thus are not experiential, be
considered shamanic practices. However, to the extent that
mediums, channelers, prayer healers, and others call on the
unseen or on the spirit world to intervene for the benefit of
people in the material world, they are "shamanistic."
In contrast to professionalized practitioners,
community-based healers often do not have set locations--such as
offices or clinics--for delivering care but do so in homes, at
ceremonial sites, or even right where they stand. Community-based
healing of the personalistic variety can also be
"distant," that is, it does not require that
practitioner and patient be in each other's presence. Prayers or
shamanic journeys, for example, can be requested and
"administered" at any time, and charm cures are
sometimes delivered by telephone.
An example of rural community-based
practitioners is the "powwowers." These are "wise
women" or elders who by reason of birth or calling have been
recognized as having the requisite "power" to say the
verbal charms or prayers to cure trauma and disease in powwowing
(Hostetler, 1976; Yoder, 1976). The term is borrowed from the
Algonquin Indians, although the practices did not originate with
the Native American Indian. Instead they date back many centuries
in Europe. The original German dialect words, brauche or
braucherei, are still sometimes used.
Powwowing closely resembles traditional
European practices found elsewhere in the United States (Hufford,
1988, 1992; Kirkland, 1992; Reimansnyder, 1989; Wigginton, 1972;
Wilkinson, 1987). "Granny women" deliver care in the
Appalachians, traiteurs in Louisiana, and "power
doctors" in the Ozarks, and similar ideas may be found in
almost any State. A similar niche in African-American communities
is filled by "rootwork." This community-based system is
found throughout the Southern United States and in
African-American communities elsewhere, sometimes under alternate
names such as "conjure" and "hoo-doo"
(Lichstein, 1992; Mathews, 1987, 1992; Snow, 1993; Terrell, 1990;
Weidmann, 1978). Although not familiar to most urban peoples,
these systems serve considerable numbers of rural Americans.
Meanwhile, community-based systems also thrive
in urban areas. These systems include the popular weight loss
programs and other 12-step programs. Often the practitioners rent
office space and emphasize contact between client and
practitioner, and they may charge considerable fees. Since these
practitioners depend on their healing practice for their
livelihood, they advertise and so may be easier to identify and
contact for study purposes.
The following discusses the community-based
health care practices of certain Native American Indian tribes,
rural Latin American communities, and urban self-help systems.
Native American Indian Health Care Practices
Although each Native American Indian
community-based medical system has its distinct characteristics,
all share the following rituals and practices.
* Sweating and purging. Both techniques are
intended to purify the body as well as the spirit. Herbal
preparations, such as the famous "black drink" of the
southeastern tribes, were formerly used to induce vomiting
(Hudson, 1979). The goal was to strengthen the body and prepare
it for challenges--a form of preventive medicine. Sweating
continues to be widely practiced, often in special "sweat
lodges" (McGaa, 1990). Typically, these are small conical
structures where hot rocks are doused with water to create steam.
Participants pray, sing, and drum to purify their spirits while
sweating to cleanse their bodies. This practice is also
considered a means of preventing imbalance and illness; in some
cases it is also used to heal. In the Lakota community, a
complete lodge ceremony lasts several hours and is recommended
both for general purification (e.g., monthly for men, a kind of
parallel to women's monthly menses) and for help in reaching
major life decisions or dealing with major life challenges. In
addition, praying in the sweat lodge commonly precedes and
follows vision questing and sun dancing.
* Herbal remedies. All indigenous Americans
depended on a variety of herbal remedies gathered from the
surrounding environment and sometimes traded over long distances.
The "Herbal Medicine" chapter gives more details on the
types and applications of herbal remedies used by certain tribes.
* Shamanic healing. Shamanic healing is also an
important part of virtually all Native American Indian health
care. Most tribal people have one or more types of health care
specialists in naturalistic or personalistic healing. Frequently,
the two overlap--thus a midwife or a medicine man or woman might
focus primarily on naturalistic explanations and healing but
sometimes also uses prayer, suggestion, or other techniques
characteristic of a personalistic framework. "Holy
people" or shamans (each tribe has its own name for this
specialist type) emphasize personalistic healing but often are
also knowledgeable about herbs, massage, and other naturalistic
Shamanic practice is relatively well maintained
in a number of tribes today and in several cases is expanding
into the larger society. On the other hand, herbal and other
practices have largely disappeared in many localities. There are
some current efforts to save vanishing knowledge, and the next
few years may see more young people apprentice themselves to
elders and become naturalistic or personalistic healing
Below, major practices in two Native American
Indian tribal communities are briefly outlined: the Lakota Sioux
and the Dineh (Navajo). These two were selected because
traditional healing practices have been relatively well
maintained and well studied in these communities, and because
they help to show the wide variety of practices used by Native
American Indian peoples. There is a large literature on different
groups, however, and the reader is also referred to sources such
as Johnston, 1982; Morse et al., 1991; Naranjo and Swentzell,
1989; and Young, 1989.
Lakota practices. The Lakota--one of several
branches of a tribe often called Sioux, who live primarily in
North and South Dakota, Minnesota, and Manitoba--are perhaps
unique in their recent efforts to inform the wider society of
their psychosocial healing techniques (Black Elk and Lyon, 1990;
McGaa, 1990; Neihardt, 1932; Powers, 1977, 1982). Though the
Lakota have their own distinctive ways of practice, in broad
outline their techniques are shared with other Plains tribes as
well as with other groups from Wisconsin to Washington (Farrer,
1991; Harrod, 1992; Storm, 1972; Yellowtail and Fitzgerald,
Lakota techniques are based on the assumption
of the absolute continuity of body and spirit; for the Lakota,
"medicine" and "religion" are not separate.
The two most famous Lakota religiomedical practices are the sweat
lodge and the medicine wheel (sacred hoop.) Other techniques,
such as the vision quest and sun dance, are familiar to many
non-Native American Indians. Other practices, such as the yuwipi
ceremony (Powers, 1982), are little known to outsiders.
All these healing ceremonials are led by
specialists, usually called medicine women or men or holy men or
women, who are essentially shamanic in their approach to healing
(Hultkrantz, 1985). Some also have knowledge of herbal remedies
or manipulative techniques. One usually discovers that one's path
is to become a medicine person through a dream or vision,
sometimes sought (as in the vision quest), sometimes unsought
(appearing during the course of serious illness or in lucid
dreaming). Shamanic skills also tend to run in families. Once
called, one seeks training, usually by apprenticing oneself to a
successful medicine man or woman, often for several years.
Training is complete when the teacher says it is complete and
when the candidate has practiced his or her skills publicly and
The medicine wheel or sacred hoop is both a
conceptual scheme and a major ceremonial. The wheel or hoop
represents all of cosmology and life in a circle of four
quarters, plus the directions of up, down, and center. Each of
the four quarters has a character or power, which can be
expressed in many ways; as an aspect of some form of wisdom, as
an animal, as a color, as an energy, or as a season. The four
quarters are separated by two "roads," one red for
happiness, one black for sorrow. Everyone is born with the gift
of one of the powers, and the thoughtful person will
"journey" his or her life to develop the other forms of
wisdom, know that happiness and sorrow come to everyone, and
recognize the relatedness of the whole. This deeply ecological
cosmology is expressed in virtually all Lakota prayer, and with
the phrase "Mitakuye oyasin" ("Thanks to all our
relatives"). The wheel or hoop is represented on much Lakota
artwork; periodically it is represented as a stone circle on the
ground, around which a ceremonial is held. Participation in the
ceremonial is considered generally healing, and in addition,
individuals can seek specific healing through prayer.
Dineh or Navajo practices. The Dineh are a
herding people who have lived in the southwestern United States
for some centuries; they are the largest tribe in North America
today. Like the Lakota, in their traditional practice the Dineh
make essentially no distinction between reli-gious and medical
practices. Here, discussion is limited to the famous Navajo
healing "sings" or "chants" and the
specialists who make them possible (Luckert and Cooke, 1979;
Morgan, 1931/1977; Reichard, 1939, 1950; Sandner, 1979, 1991;
Topper, 1987; Wyman and Haile, 1970).
A sing is a healing ceremonial that lasts from
2 to 9 days and nights. It is guided by a highly skilled
specialist called a "singer." Although focused on
helping an individual, sings are commonly attended by as many in
the community as can come, for just being present is considered
healing. Navajo cosmology teaches that health is present when all
things are in harmony. The full concept is impossible to
translate into English, so it is often rendered as the Navajo
word hozro, which summarizes many things such as happiness,
connection, and balance. Its opposite is something like
"evil"; indeed, where there is disharmony, there is
sickness and disease, and vice versa. A long-time student of
Navajo singers notes:
This "evil" must be controlled or
banished and goodness restored. To implement this desired state
of affairs, the Navajos have created a great body of symbolic
rituals [that] attempt to placate or expel the destructive powers
and attract the good, helpful ones. By doing this they
reestablish the basic harmony, cure individual illness, and bring
general blessing to the tribe (Sandner, 1979, p. 118).
There are three basic categories of chants:
"holyway," "ghostway," and
"lifeway." Holyway chants--including the most famous,
called "blessingway"--are used to attract good, to
cure, and to repair. Ghostway chants are used to remove evil and
are often performed to heal Dineh who have had too much contact
with strangers (non-Navajo), as in the armed forces or at
college, or who have had contact with dead bodies. Lifeway chants
are used to treat what westerners would call "physical"
injuries and accidents; such treatment includes both restoring
cosmological harmony and repairing trauma--by setting broken
bones, for example.
The two kinds of healing specialists among the
Dineh are the "diagnosticians" and the aforementioned
singers. Diagnosticians are usually "called" to their
profession by nonordinary experiences and receive little formal
training in their skill. They diagnose deep cause by going into
trance. While in trance, "hand tremblers" pass their
shaking hands over the body of the patient; when the hands stop
trembling, the locale of the illness is shown and the cause is
usually nameable. "Star gazers" also enter trance to
read cause in the stars. "Listeners" do not go into
trance but listen to the patient's story and on that basis
diagnose deep cause. Once cause is known--and it is always
phrased in terms of harmony and disharmony--patients seek a
singer who can provide the indicated treatment.
Singers are specialists of symbology who have a
good deal in common both with priests and with psychotherapists;
in addition, their moral probity and high intellectual powers
mean that they usually perform as community leaders as well. They
are not shamans and are not "called" by supernatural
powers to their profession. Instead, interest and patience are
the prerequisites, as well as demonstrated dependability and
economic success. To learn a single chant can take up to several
years, for the performance of each chant involves memorizing what
amounts to a long epic poem (one that takes 2 to 9 nights to
repeat) along with the recipes for the accompanying herbal
preparations and sand paintings. The singer must also know where
to find the herbs, how to prepare them, and how to use them. He
must know where to find the colored sands necessary for the sand
paintings, and he must learn to make--without error--the
intricate sand paintings specific to the chant he is learning.
Because the training is so arduous, most singers learn only a few
chants in a lifetime.
The Dineh have depended on singers and chants
for many centuries; today they are used in combination with
conventional medicine. It remains common for Dineh both on and
off the reservation to seek sings to treat conditions that
conventional medicine does not recognize and to use sings for
healing along with conventional medicine used curatively.
Numerous observers have asked why the sings
"work." Topper (1987, p. 248) remarks that sings are
restorative: "They restore an individual's ego functions and
integrate the patient back into the social setting from which he
or she has become estranged." Sandner (1979, 1991) analyzes
the process further: First, the herbal remedies often have
requisite physiological effects. Second, the patient's
expectation is encouraged time and again during the chant by its
intricate psychological structure. Third, the patient is socially
supported by the entire community, who are centrally concerned
since, by Navajo cosmology, the well-being of all is threatened
by disharmony in one. Fourth, the chant wordings guide the sick
person to finding culturally appropriate answers to difficult
cosmological problems, such as the management of evil and the
inevitability of death.
Formal research into the healing ceremonies and
herbal medicines conducted and used by bona fide Native American
Indian healers or holy people is almost nonexistent, even though
Native American Indians believe they positively cure both the
mind and body. Ailments and diseases such as heart disease,
diabetes, thyroid conditions, cancer, skin rashes, and asthma
reportedly have been cured by Native American Indian doctors who
are knowledgeable about the complex ceremonies. Among Native
American Indians living today there are many stories about
seemingly impossible cures that have been wrought by holy people.
However, the information on what was done is closely guarded and
not readily rendered to non-Native American Indian investigators.
It has been suggested that if Congress restored religious freedom
to Native American Indians, then collaborative research into
Native American Indian healing and healing practices could be
possible (Locke, 1993).
Latin American Rural Practices
Curanderismo is a folk system used in Latin
America and among many Hispanic-Americans in the United States.
Hispanic-American refers to Americans of Spanish or
Spanish-American descent; in the United States most trace their
roots to Mexico (63 percent), Puerto Rico (12 percent), and Cuba,
but increasing numbers of immigrants are arriving from Central
America (Wright, 1990). The population of Hispanics is rapidly
growing in the United States, and today about 22 million people
call themselves Hispanic. More than half of this population lives
in Texas and California, and large populations are also in
Colorado, Arizona, Florida, Illinois, New Jersey, New Mexico, and
Curanderismo typically includes two distinct
components, a humoral model for classifying activity, food,
drugs, and illness; and a series of folk illnesses such as
"evil eye," "fright," "blockage,"
and "fallen fontanelle." Curanderismo as described
herein is most characteristic of Mexican-Americans, especially
those who are little assimilated; variants on the humoral
component typify most of Latin America, while the folk diseases
and the treatment modalities reflect national background. Thus
the Cuban-American folk system is not curanderismo, but santeria,
and it is African influenced.
Although no formal effectiveness studies seem
to have been done on this system, its wide popularity and the
research suggesting the relevance of the folk diagnoses for
biomedical practice indicate the need for further demographic and
In the humoral component of curanderismo things
could be classified as having qualitative (not literal)
characteristics of hot or cold, dry or moist. (Harwood, 1971;
Messer, 1981; Weller, 1983). According to this theory, good
health is maintained by maintaining a balance of hot and cold.
Thus, a good meal will contain both hot and cold foods, and a
person with a hot disease must be given cold remedies and vice
versa. Again, a person who is exposed to cold when excessively
hot may "take cold" and become ill.
While this model is simple in theory, how
people perceive in practice the hotness or coldness of substances
varies greatly by region. Thus, while most can be expected to
classify chili peppers as "hot" and milk as
"cold," the classification of pork or penicillin is not
The second component, the folk illnesses, is
actively in use in much of Mexico and among less educated
Hispanic U.S. citizens (Rubel, 1960, 1964; Rubel et al., 1984;
Young, 1981). Trotter (1985) did more than 2,000 clinic
interviews in Texas, Arizona, and New Mexico and found that 32
percent to 96 percent of Mexican-American households (more
frequent in the less Americanized communities) treated members
for Hispanic folk illnesses. Baer and colleagues found similarly
high use patterns among Mexican migrant workers in Florida and
Mexico (Baer and Penzell, 1993; Baer and Bustillo, 1993).
Four important Mexican-American folk illnesses
are mal de ojo, susto, empacho, and caida de mollera. Mal de ojo,
or evil eye, is a worldwide disease concept in which a person can
make another sick by looking at him or her. The one who gets
sick, typically an infant, is usually "weak." The one
who causes the illness is usually thought not to do it on
purpose--the person just has the misfortune to have a
"piercing" glance. Typical symptoms of mal de ojo
include fussiness, refusal to eat, and refusal to sleep. Infants
are protected from evil eye with amulets or by having their faces
covered in the presence of strangers. Treatment is primarily
Caida de mollera, or fallen fontanelle, is an
illness of infants before the anterior fontanelle (crown of the
head) closes. Common symptoms include diarrhea, excessive crying,
fever, loss of appetite, and irritability. Usual folk treatments
focus on raising the fontanelle by, for example, pushing up on
Empacho is thought to be caused by something
getting stuck in the intestines, causing blockage. Common
symptoms are diarrhea, constipation, indigestion, vomiting, and
bloating. The commonest treatment is massage along with herbal
teas; the former is for dislodging the blockage, and the latter
is for washing it out.
Susto, or fright (sometimes called magical
fright), develops when a person has had a sudden shock--a mother
may develop fright if she sees her child nearly drown, or someone
may experience fright after participating in an unusually intense
argument. The sick person experiences such symptoms as daytime
sleepiness combined with nighttime insomnia, irritability and
easy startling, palpitations, inability to stop thinking about
the shocking event, anxiety that it will be repeated, and
sometimes a sense of loss or a sadness that will not leave. The
mild form is treated with herb tea; more severe cases are treated
with ritual cleansings (barridas) to restore the harmony of body
When mild, these folk illnesses are commonly
treated at home, but if they persist, the help of
specialists--curanderos (men) or curanderas (women)--is sought.
The training of curanderos and curanderas varies widely. Most
practice a combination of shamanic healing and herbal or
practical first aid healing. Most are also astute at manipulating
symbols and "reading" the prevailing psychological and
social indicators. Some curanderas specialize in midwifery and
infant care. In some areas, becoming a healer is a matter of
inheritance; the skills are passed from mother to daughter or
perhaps aunt to niece. In some areas it is a matter of being
called. Typically, curanderos and curanderas spend several years
in apprenticeship; their subsequent reputation depends on the
number of their patients and how successful their patients judge
Treatment techniques, usually a combination of
the shamanic and the naturalistic, vary widely; interested
readers should consult specialist texts. An issue of concern is
that some curanderismo treatments, particularly for empacho,
involve feeding lead-or mercury-based remedies. Investigators'
efforts to test whether the amounts ingested were causing medical
complications were inconclusive. Although curanderas were found
to be largely aware of the danger of the remedies and used them
sparingly, intervention programs to limit use of these remedies
were begun (Baer et al., 1989; Trotter, 1985).
Trotter (1985) collected symptomatology lists
from more than 2,000 interviews and submitted symptom clusters to
medical doctors for "blind" diagnoses. He found, for
example, that caida de mollera appears to be symptomatic of
serious dehydration secondary to gastroenteritis or respiratory
infection. Trotter also found that people who are sicker than
average are more likely to be diagnosed with susto. Baer and
Penzell (1993) similarly report that migrant workers most
affected in a pesticide poisoning incident were also those most
likely to report suffering from susto. Susto fits the pattern of
"soul loss" (Ingerman, 1991), a shamanically recognized
disorder known worldwide that resembles several serious
psychotherapeutically recognized conditions, including depression
and posttraumatic stress syndrome. Therefore, people being
treated for folk diseases could be considered to have
conventional illnesses that are being treated outside the
conventional biomedical health care system.
Urban Community-Based Systems
Alcoholics Anonymous (AA) is a community-based
healing system for helping people whose lives are damaged by the
consumption of alcohol to stop drinking (Encyclopaedia
Britannica, 1990; Scott, 1993; Trice and Staudenmeier, 1989).
Founded in 1935 by Bob Smith, M.D., and Bill Wilson, two
alcoholics, it is a patient-centered self-help fellowship of men
and women. AA has burgeoned and today is widely considered the
most successful existing method for supporting sobriety.
Habitual excessive drinking or craving for
alcohol was first proposed as constituting a disease by Magnus
Huss in 1849. Currently many definitions of the condition exist,
but most emphasize that the drinker has "lost control"
(is addicted or dependent) and that alcohol use is causing
physical, social, mental, or economic harm to the drinker. The
concept of loss of control is especially important to AA, which
requires its members, as the first step toward sobriety, to
comprehend the extent to which they have lost control of their
lives. Only then--when they have understood that "playing
God" has led them to their sickness, that in fact they are
limited human beings in need of salvation--can they begin the
breakthroughs that support sobriety (Scott, 1993).
In contrast to most community-based systems, a
very large literature exists analyzing AA. Several models attempt
to explain its success. One popular psychometric model interprets
AA as a "cult" and the achievement of sobriety as a
"conversion experience" (Galanter, 1990; Greil and
Rudy, 1983; Rudy, 1987). Another model accepts AA's
interpretation of itself (Hufford, 1988; Kurtz, 1982; Scott,
1993): members recover by integrating their own experiences with
alcohol with those of others in the group and by learning and
practicing some new ways to behave. Through these new ways, AA
members feel as if they are living apart from the urban
materialist norm; that the cause of alcoholism is not at issue;
that people should share, not compete; and that the individual
need not rise above the rest (spiritual anonymity). In contrast
to the "conversion" theory of AA membership, learning
to live in the "new way" is not achieved through
catharsis but is an intellectual and educational process
requiring considerable work and perseverance. As Kurtz comments,
"AA addresses itself not to alcoholism, but to the
alcoholic" (Kurtz, 1982).
AA, by most accounts, is more successful than
any other system aimed at helping individuals to achieve
sobriety. Estimates put membership at about a half-million
members worldwide, and although it was originally an American
urban phenomenon, AA has found its way into isolated and rural
communities of completely different cultural backgrounds (Slagle
and Weibel-Orlando, 1986; Sutro, 1989). Recently, AA has seen a
rise in membership proportions of women, people younger than 30,
and people dually addicted to alcohol and drugs (Emrick, 1987).
Studies have concluded that active AA membership allows 60
percent to 68 percent of alcoholics to drink less or not at all
for up to a year, and 40 percent to 50 percent to achieve
sobriety for many years (Emrick, 1987). More active or dedicated
members (those who attend meetings more often) remain sober
longer. However, because AA defines alcoholism as a disease
controllable only by the cessation of drinking, it is a less
appropriate choice for those who simply want to cut down on their
drinking (Ogborne, 1989).
Despite these interesting effectiveness data,
some authors argue that no appropriate controlled studies of AA
effectiveness have been done (Peele, 1990); others hold that
difficult research design issues have not been sufficiently
addressed, such as how to measure psychosocial functioning before
and after AA, or the effects of AA plus some other intervention
(Glaser and Ogborne, 1982). Given the popularity and the apparent
success rates of AA, further careful research on AA seems highly
appropriate. The research design issues applicable to studying
AA's effectiveness would be relevant to other alternative
practices that include an individual's commitment to a shared
belief system and a social behavior pattern.
Community-based health practices are specific
to many subcultural groups in the United States, including
immigrant, rural, and Native American communities. The first step
in research would be to categorize and characterize these forms
of ethnomedicine practices using qualitative research methods
developed in the field of anthropology. Clinical research could
begin promptly on those systems that have already been well
described and are used widely and in which practitioners of the
systems are open to dialog.
A study of various symbolic or nonmaterial
concepts of healing such as shamanic healing might identify
effective principles of body-mind intervention that would be
useful to integrate in the training of future primary care
practitioners in the general community. Herbal agents and ethnic
herbal practitioners deserve study to identify fruitful clinical
areas for research in phytopharmaceutics (pharmacology of
plants). Practices and techniques that are rapidly spreading
beyond their original cultural confines, such as AA and the sweat
lodge, would be candidates for outcomes research. Careful
investigation of tribal and folk practices may illuminate larger
issues of health care and provide guidelines for low-cost
alternatives to existing conventional biomedical interventions.
Utilization studies of tribal and folk health care practices
could develop a realistic sense of the self-care patterns used by
the Nation's ethnic and cultural minorities and inform national
public health policies about these minority communities.
To effectively research and study the
alternative health practices people are using, it is necessary to
recognize that the operating assumptions of the conventional
biomedical way of thinking have led to these alternative systems
being ignored or suppressed. Historically the practices of these
systems have been scorned as cultic, superstitious, or sectarian,
and these systems have been suppressed economically, politically,
From an economic standpoint it is not
surprising that the institutions and agents charged with
maintaining the exclusive professional mandates of the biomedical
system have sought to eliminate competition from alternative
professionalized systems as well as folk and tribal
practitioners. This anticompetitive tendency is also extended to
popular health practices. Popular self-help health books now
routinely have a "consult your professional" disclaimer
to protect the authors from law suits for practicing
"unscientific" medicine in the media without a license.
In the political arena, current concerns about
FDA regulation of the health food industry have resulted from an
attempt to extend a level of governmental control mandated for a
professionalized drug-dispensing health care system into a whole
system of self-help and demand-driven popular health care. In
addition, the suppression of the tribal health care practices of
Native American Indian groups has been primarily due to the
dominant political and cultural view that it is in the best
interest of these peoples to be forcibly assimilated into the
Community-based practitioners themselves may
present barriers to research: some may not want to share their
knowledge. In some cases the explanatory model of the folk system
states that to share the knowledge, except under particular
circumstances, is to lose one's power, even to call down
punishment on one's head. In other cases, especially among Native
American Indians, it is felt that the sharing of traditional
secular and sacred knowledge has resulted in the misuse of that
knowledge, especially when it has been applied without sufficient
awareness of the social and environmental context.
Key Research Issues
In the current climate of concern about the
adequacy of the U.S. health care delivery system, a culturally
sensitive and scientifically grounded dialog about alternative
systems of health care is required. Therefore, cross-cultural
researchers must heed the insights of professionals who do health
The concept of cultural sensitivity means that
issues of conflicts between basic paradigms, worldviews, or
belief systems are recognized and openly dealt with when a
dominant culture tries to study, influence, or assist a different
culture or subculture. The goal of cultural sensitivity--to find
common ground among different cultures--has been widely
understood among outreach specialists for perhaps 20 years.
Cultural sensitivity is a worthy and necessary goal, but it is
not easy to achieve. Hufford (1992) notes that understanding the
other's position does not imply acceptance or agreement. Nor does
it imply that bridging models to accomplish good research is
easy. These studies require patience and often extensive
negotiation. In addition, the tendency to see differences can
sometimes overwhelm the ability to see similarities, thereby
unnecessarily focusing people on conflict and negotiation.
Most published studies in these areas have been
done by social scientists, folklorists, and historians.
Literature on the topic is extensive, including books (e.g.,
Harwood, 1981; Pedersen et al., 1989) and many articles. From
this database one can begin exploring the role of
nonprofessionalized health care in the human community.
The first job is, of course, to establish that
significant differences exist, and then to detail them. For
example, Aitken (1990), speaking as an insider, claims that
Native American Indians have distinctive values, and researchers
such as Dubray (1985) and Fox (1992) find ways to measure the
differences. Often, researchers do their best to identify the
differences, and outreach proceeds with certain assumed values,
for example, that clients should be asked to help in designing
programs intended to benefit them (e.g., Broken Nose, 1992).
Subsequently, evaluations can show which
research or outreach models were most successful in given
locales. For example, May (1986) and May and Smith (1988) report
that alcoholism is better controlled on reservations when
indigenous concepts are included in treatment plans; Guilmet and
Whited (1987), Marburg (1983), and Manson and colleagues (1987)
compare mental health outreach programs among Native American
Indians and conclude that the most effective ones reflect
indigenous value systems, such as team-based approaches in using
group and family therapy rather than individual one-on-one
counseling. Beauvais and LaBoueff (1985) state that the control
of drug and alcohol abuse will come about through
"bolstering the spirit of the community."
Thus, doing clinical research in
community-based health care requires questioning certain common
assumptions of researchers who are schooled in the biomedical
model. These assumptions include (1) that community-based systems
are disappearing and are not delivering health care to many
people; (2) that the care they deliver is psychosomatic or not
really significant, an idea made more sensible by the segregation
of body and mind that is characteristic of mainstream medicine;
and (3) that existing clinical research methods are sufficient to
analyze community-based practices.
A careful, culturally sensitive analysis of the
function and intent of various community-based practices will
help sort out the psychic from the somatic aspects of health
care. While similarities between systems may allow researchers to
pose interesting questions, the research must take into account
the particularities of the folk or tribal system being studied.
For example, Navajo singers share some characteristics with
psychotherapists, but they are not psychotherapists. Likewise,
members of AA share their experiences and thus
"counsel" other members, but they are not alcohol
counselors. Researchers must resist trying to fit these systems
into their existing categories.
The following are general recommendations and
priorities for research in the area of alternative
professionalized medical systems and community-based practices:
1. Establish a database with descriptive
information about traditional medical practice from medical and
nonmedical sources. Included should be a review of existing
scientific data, including a meta-analysis of studies in selected
2. Promote and publish consumer-based surveys
describing which alternative systems and traditional ethnic
medical practices are being used and for what illnesses.
3. Explore alternative and ethnic medical
systems, including historical traditions that may not be
replicable in the biomedical model, and recognizing the role of
body, mind, spirit, and environmental factors in health and
4. Conduct basic science research to
investigate the existence, nature, and role of "energy"
(chi, vital force) as a phenomenon active in health and disease.
5. Develop cross-agency guidelines to
facilitate research on alternative systems and traditional
practices by reducing legal barriers for research that may
already exist in other Federal agencies; encourage best case
series research, as has been done by NCI in other Federal
research agencies; and create an ongoing database of activities
in alternative systems and traditional medical practices.
6. Initiate an evaluation program for
traditional remedies and herbal medicines, including a global
ethnobotany inventory, investigation into issues of toxicity and
safety, and creation of an appropriate regulatory category for
herbal therapeutic agents.
7. Establish collaboration standards for
alternative medical practice research to ensure that the research
team respects the paradigm under study; that there is joint
involvement of representatives of alternative and traditional
practitioners along with existing biomedical research
institutions; and that joint involvement occurs at all stages of
the research project: conception, method design, funding, data
collection, evaluation, and publication.
8. Support the legislative intent of Congress
in creating the Office of Alternative Medicine by focusing on
socially and economically critical health conditions through
9. Encourage the addition of alternative
systems or ethnomedicine research components to current clinical
studies sponsored by the National Institutes of Health; for
example, adding traditional Asian therapy, naturopathic, or
homeopathic interventions to current studies in the Women's
10. Expand studies such as the International
Cooperative Biodiversity Group so that whole plant material is
used rather than isolating an active ingredient for
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- The term health care system is used two ways. In one
sense, a health care system encompasses all the health
care available to a nation of people. According to this
meaning, in the United States all people are immersed in
the health care system to the extent that they are
connected to the health-protective infrastructure (e.g.,
clean water, sewer systems, vaccinations) and use any
form of specialist health care, including both
community-based and professionalized health care
practitioners. In the second sense, a health care system
is all the components that together make up the practice
of any particular form of medical care, such as
osteopathy, acupuncture, psychotherapy, biomedicine, or
hands-on healing. Each such system provides explanations
for the cause and cure of illness; identifies and trains
specialists; provides locales, equipment, and materia
medica for practice; and arranges for social and legal
mandates for practice. All health care provided by
specialists (that is, apart from household and popular
remedies) is delivered from within a health care system.
However, the complexity and extension of health care
systems vary widely, from the relatively experiential and
localized practices of community-based traditional
healers to the extensive, complex, and intensely
professionalized practices of cosmopolitan doctors.
- The word qi is principally used in relation to the
biofield flux, the material of the biofield. The former
phonetic spelling is ch'i; both are pronounced
"chee"; originally also used as a root word
similar to the use of the word energy. It was used with
modifiers to describe hormones, nutrition factors, etc.,
such as the following. Ching qi: (meridian qi)--the qi
that flows through the twelve meridians. Fa qi--external
qi (wei qi) used in healing. Jing qi--essence (sexual
essence--ancient usage, hormones in current usage). Ku
qi--caloric energy from plants. Qi density--relative
quantity of qi. Ren qi--internal qi that fills the spaces
between the meridians in the body. Wei qi--external
portion of the body's qi (aura). Receiving hand--hand
with a polarity that receives the flow (qi). Sending
hand--hand with a polarity that sends the flow (qi).
Flows--movement of qi through the body or movement of qi
from one of the practitioner's hands to the other through
the patient's body.
- The Native American "medicine man" or
"medicine woman" is a traditional healer with
primarily naturalistic skills, that is, the skills of an
herbalist in particular (Hultkrantz, 1985). Some medicine
people are also shamans, in which case they are often
distinguished as "holy" men and women. This
distinction is usually not made in popular writing,
though it is understandably important to the Native
American Indian users.