Annals of Internal Medicine 2001 (Aug 7); 135 (3): 196–204 ~ FULL TEXT
Ted J. Kaptchuk, OMD, and David M. Eisenberg, MD
Beth Israel Deaconess Medical Center,
Harvard Medical School,
330 Brookline Avenue, W/K-400,
Boston, MA 02215, USA
The first of two essays in this issue demonstrated that the United States has had a rich history of medical pluralism. This essay seeks to present an overview of contemporary unconventional medical practices in the United States. No clear definition of "alternative medicine" is offered because it is a residual category composed of heterogeneous healing methods. A descriptive taxonomy of contemporary unconventional healing could be more helpful. Two broad categories of unconventional medicine are described here: a more prominent, "mainstream" complementary and alternative medicine (CAM) and a more culture-bound, "parochial" unconventional medicine. The CAM component can be divided into professional groups, layperson-initiated popular health reform movements, New Age healing, alternative psychological therapies, and non-normative scientific enterprises. The parochial category can be divided into ethno-medicine, religious healing, and folk medicine. A topologic examination of U.S. health care can provide an important conceptual framework through which health care providers can understand the current situation in U.S. medical pluralism.
From the FULL TEXT Article:
Defining unconventional medicine by “what it is”
does not work. Alternative medicine is an umbrellalike
term that “represents a heterogeneous population
promoting disparate beliefs and practices that vary considerably
from one movement or tradition to another
and form no consistent . . . body of knowledge”.  Alternative
medicine is a large residual category of health
care practices generally defined by their exclusion and
“alienation from the dominant medical profession”. 
Besides an absence of shared principles, an accurate
definition of alternative medicine is further confounded
because the boundary demarcating conventional and irregular
medicine has always been porous and flexible.  Therapies move across that border; for example,
nitroglycerin  and digitalis  began as alternative
drugs, just as corn flakes and graham crackers began as
unconventional health foods.  Entire professions
change sides. In 1903, when the American Medical Association
needed both a larger referral base for specialists
and new allies in its fight with osteopaths, chiropractors,
and Christian Scientists, it boldly reversed its policy and
declared homeopaths to be conventional MDs.  Likewise,
osteopathy ceased being a renegade profession after
World War II. [8–10]
The first of two essays in this issue (pp 189–195)
demonstrated that the United States has had a rich history
of medical pluralism. This essay offers an overview
of alternative medicine. Because of the inherent problems
in defining a flexible residual category, we present a
taxonomy of what is currently considered unconventional
healing in the United States.
The number of named alternative therapies available
in the United States easily soars into the hundreds. [11–16] Many classification systems have been proposed. [17–24] In an effort to further discussion, we
offer a new taxonomy that we believe configures the
domains of unconventional medicine across a broader
spectrum of health practices. We do not expect that our
attempt will be definitive (nor do we necessarily believe
a perfect schema is possible). Any classification system is
limited because such human phenomena resist discreteness
as well as being fixed in time. As we point out,
overlap often occurs. Inevitably, subjectivity affects the
categorization and perceptions of “affinities.” A summary
of our schema is presented in the Figure.
Unconventional healing practices can be divided
into two types: one that appeals to the general public
and another that confines itself to specific ethnic or religious
groups. The broadest category of unconventional
medicine is easily recognized because its health care
claims to be independent of any sectarian belief or faith
and is said to depend on universal and even “scientific”
laws.  It is the best-known variety of unconventional
medicine in the United States and recently, in a loose
alliance, has become known as complementary and alternative
medicine (CAM). 
The second kind of unconventional practice is typically
confined to narrow groups, such as members of
particular religions (for example, Pentecostal Christians), ethnic groups (for example, Puerto-Rican spiritism), or regions (for example, southern Appalachian folk
beliefs). These practices are culturally self-contained,
function outside any broader coalition, often lack the
markings of a health delivery system, and in this essay
are referred to as parochial unconventional medicine.
COMPLEMENTARY AND ALTERNATIVE MEDICINE
The wide-ranging category of CAM can be divided
into five main sectors, which are described below.
Professionalized or Distinct Medical Systems
Probably the most recognizable alternative healing
practices are those that are organized into medical movements
with distinct theories, practices, and institutions.
Licensure as an independent profession is a goal if not
always an actuality. Medical institutions, such as schools,
professional associations, and offices with secretaries and
billing procedures, are readily visible. An extensive corpus
of technical literature helps guide therapy and practice
and sharpens distinctness. Because they are easiest to
describe and define, these systems are the most prominent
in discussions of CAM. The six major components
of this sector of CAM are chiropractic, acupuncture,
homeopathy, naturopathy, massage, and dual-functioning
Chiropractic, the largest alternative medical profession
in the United States, accounts for almost a third of
all visits to CAM providers.  The body’s biomechanical
structure, especially the spine, is seen as basic
to health, and chiropractic emphasizes spinal manipulation
as treatment. [27, 28] Licensed as primary health
care providers in all 50 states, chiropractors especially
treat musculoskeletal disorders. [29, 30]
Osteopathy was once a second manual therapy competing
for the same patients as chiropractic. Since World
War II, osteopathy has reconfigured itself and has become
“conventional”; the status of an osteopathic physician
is equivalent to that of an MD. A minority of
patients (.17%) visiting DOs receives the kind of manipulative
therapy that would still be considered unconventional
by orthodox MDs. [31, 32]
Acupuncture relies on the insertion of fine needles
at well-defined specific sites to regulate and balance humoral
forces and “energy” (qi) and to promote health.  As a component of East Asian medicine, acupuncture
is often complemented with herbal treatment. Since
the 1970s, acupuncture has spread throughout the
United States and is independently licensed as a health
care profession in 37 states. 
Homeopathy uses the principle of “like cures like”:
A substance that produces a set of symptoms in a
healthy person is used to treat an identical symptom
complex in a sick person. [35, 36] The substance, however,
is extremely diluted, often to the extent that
none of the original substance is likely to remain. Currently,
homeopaths can be independently licensed in
only three states, but other licensed practitioners also
prescribe these remedies.
Naturopathy uses a wide assortment of therapies
that its practitioners call “natural.” Herbs, nutritional
supplements, dietary and lifestyle advice, homeopathy,
manipulation, and counseling can all be components of
the repertoire.  The term naturopathy was adopted
in 1902 to replace the old word hydropathy, which denoted
water-cure therapy. Currently, naturopaths can be
licensed as primary care providers in 11 states; naturopathy
is most common in the Pacific Northwest. 
Massage therapists can be professionally licensed in
more than 25 states.  Although massage therapists
(also called “body-workers” or “hands-on therapists”)
clearly perform unorthodox interventions [40–42], they
overlap with recognized biomedical professions, such as
physical therapy, or simple attempts at relaxation. Complementary
alternative medicine techniques that address
body alignment and awareness (such as the Feldenkrais
method  and the Alexander technique ) are
often classified as massage therapy because they involve
Medical doctors who have opted to deliver, supervise,
or advocate CAM are a significant force in alternative
medicine. [15, 46] These dual-trained practitioners
lend enormous prestige and legitimacy to alternative
medicine and can be prominent spokespersons. [47–50]
Providing what is sometimes called “integrative” medicine,
these physicians can deliver a broad range of CAM
services or can focus on a single therapy.
Popular Health Reform (Alternative Dietary and Lifestyle Practices)
The health food movement, also known as alternative
dietary and lifestyle practices, is an important component
of CAM. Depending on how one calculates, it
may in fact dwarf the professional sector.  In the
scholarly literature, this type of healing is labeled “popular
health reform” because these practices are often advocated
by untrained laypersons who often claim knowledge
superior to that of expert scientists. 
Popular health reform is delivered by a melange of
resources, such as health food stores, popular books and
journals, charismatic leaders, alternative provider recommendations,
mass media attention, and a considerable
amount of neighborly advice. This popular movement
usually espouses a vegetarian or near-vegetarian diet, or
avoidance of chemically treated and, more recently, radiated
or genetically altered food. Details of particular
programs tend to have enormous heterogeneity. Recommendations
might range from eating only cooked food
(for example, macrobiotics ) to eating only raw food
(for example, fruitarianism) , or from heavy reliance
on nutritional and botanical supplements or aromatherapy
to their absolute prohibition. Recent shifts in
biomedicine’s understanding of nutrition and its role in
pathophysiology have also encouraged a general social
movement toward behaviors that were once thought to
belong to health food “nuts”.  This, in turn, has
caused a blurring of the distinction between orthodox
and unorthodox lifestyles and has helped increase the
awareness of CAM in society. 
New Age Healing
The New Age is the source of many extremely disparate
beliefs and practices that can describe overlapping
religious and healing movements. [55, 56] Furthermore,
confounding discussion, the term New Age may not be
“adopted by a given individual (indeed, may be rejected),
even though to outsiders the practice appears to fall
into this category”.  As a religious movement, the
New Age is about a “new dispensation”: less about law
and limitation and more about unrestricted self-expression and unlimited abundance. Instead of any fixed religious doctrine, the movement emphases a fluid “spirituality.”
It is not uncommon to see an iconography that
is a grab bag of Hindu, Christian, Buddhist, Rosicrucian,
and pagan motifs. 
The New Age is also a health care category because
spiritual equanimity and physical health are considered
to be linked. In fact, New Age beliefs resist any separation
between spirituality and physical health or faith and
medicine. Scholars point out that the New Age seeks a
“third way,” “a spiritual science,” between revealed biblical
religion and “atheistic–materialist” science. 
A key New Age connection between the spiritual
and physical realms involves esoteric energies that resemble
a veritable “electromagnetic” dimension of wellness. [59, 60] The names of the energies change—life
force, universal innate intelligence, psychic, parapsychological,
psi, astral, spiritual vital force—but they inevitably
elude scientific detection.  Healers can transmit
these forces. Devices and substances that emit them,
such as radionic machines, magnetic devices, pyramids,
crystals, and other electromagnetic gadgets, are constantly
being incarnated. The health influence of planets
and stars and some medical astrology could be considered
another type of such energy.  Healing energy
therapies not explicitly connected to the New Age, such
as “therapeutic touch” (often applied by nurses) 
and “laying-on of hands” , can ultimately be traced
here. New “energy” forces are being recruited from Asia.
Chinese qigong  and Japanese Reiki , while obviously
not originally New Age, find it a hospitable environment
for cross-cultural migration. 
Sometimes the religious and health domains are
bridged through “clairvoyant physicians” or the healing
presence of the spirits, religious icons, or leaders. [67–70] Best-selling books by spirit mediums who describe
spiritual healing for “incurable diseases and maladies”
help keep the phenomena in prominent view.  A
third type of New Age healing connection between the
cosmos and human health operates through “mind”
forces and can also be considered a subcategory of CAM
psychological intervention (see following discussion).
Psychological Interventions: Mind Cure and “Mind–Body” Medicine
Psychotherapeutics in CAM has two sources: one
that is purely CAM and one that overlaps with conventional
psychological interventions. In the scholarly literature,
the exclusively CAM psychological tradition is referred
to as Mind Cure or New Thought. [17, 72–74]
These therapies, which can include a myriad assortment
of visualizations, affirmations, intentions, meditations,
and emotional release techniques, all share a single point:
Mental forces are the preeminent arbiters of health. Psychotherapists
affiliated with CAM believe that the mind
is the most dominant agency for restoring well-being
and maintaining health. The notions that “What you
think is what is real” and that “Your emotions determine
cancer or other major disease” are dogma repeated over
and over like mantras. Such bestsellers as Bernie Siegel’s
Love, Medicine and Miracles and Deepak Chopra’s
Ageless Body, Timeless Mind: The Quantum Alternative to
Growing Old testify to the appeal of these beliefs.
The other sector of CAM “mind–body” therapies
merges into conventional psychotherapy and cognitive–
behavioral interventions. The relationship can be confusing
or can produce gray areas. Generally speaking, in
conventional medicine, psychotherapeutics is conceded
only limited agency and is primarily used to treat psychological
problems or to help patients cope when conventional
treatments are not available or are insufficient.
Psychotherapeutics remains a subordinate component of
the conventional medical system. [75, 76]
However, whenever too much power or efficacy is
attributed to regular psychological therapies and they are
used “off-label,” they “transgress” and can become
CAM. For example, most MDs would consider psychotherapy
appropriate for reactive depression after a cancer
diagnosis, but psychotherapy used to cure a metastatic
tumor would be considered unconventional.  The
same holds true for various cognitive–behavioral therapies
that use “passive nonvolitional intention,” such as
biofeedback, stress management, relaxation response,
meditation, guided imagery, and hypnosis. When practitioners
of these techniques make modest claims limited
to small physiologic changes, the techniques are acceptable
as subordinate components of conventional medicine.
For example, biofeedback for fecal incontinence  or, more debatably, relaxation response for mild
hypertension [79, 80] can seem legitimate or can at least
achieve borderline acceptability, but both would be considered
distinctly alternative if used to treat diabetes.
Another source of CAM psychotherapeutics involves
the fact that between 250  and 400  named types of psychological treatments are thought to
exist. Any therapy deemed unacceptable by the mainstream
can find a receptive home in CAM. Also,
whether self-help groups, such as Alcoholics Anonymous,
are CAM is highly debatable, but to the extent
that they are not conventional they can automatically be
described as alternative. [83, 84]
Non-Normative Scientific Enterprises
Non-normative scientific enterprises typically appeal
to patients with potentially catastrophic illnesses,
such as cancer. These therapies can include sophisticated
pharmacologic agents and often revolve around a wellknown
proponent who can have legitimate and even
impressive scientific or medical credentials but advocates
theories and practices unacceptable to the general scientific
community. Examples include Dr. Stanislaw Burzynski’s
“antineoplastons” and Dr. Virginia Livingston-Wheeler’s “pleomorphic bacteria cancer vaccine”. [85, 86] Non-normative interventions can sometimes blur
into the conventional practice of prescribing recognized
pharmaceuticals for off-label uses. [87–89] Unvalidated
diagnostic methods and unconventional technological
devices that diagnose or heal can be considered part of
the non-normative science category. Representative examples
are hair analysis, which purportedly detects a
wide variety of diseases and nutrient imbalances ;
iridology, in which illness is diagnosed through a detailed
examination of the iris ; and chelation therapy
to reverse the processes of arteriosclerotic disease. 
PAROCHIAL UNCONVENTIONAL MEDICINE
Unlike CAM, parochial unconventional practices
appeal to a more narrowly defined constituency. Three
main parochial categories exist.
The healing practices of specific ethnic populations
make up a critical component of U.S. community
health care.  These practices are rooted in the widely
differing medical or religious traditions of various cultures.
Well-known examples include Puerto-Rican spiritism, [94, 95], Mexican-American curanderismo [96, 97], Haitian vodun [98, 99], Native American traditional
medicine , Hmong folk practices ,
African-American “rootwork” , and African-American
spiritual church healing. [103, 104] Occasionally, a
culture-bound medical system ventures outside its historical
sphere of influence and becomes another option
available to the general U.S. population. This is true of
acupuncture and seems to be coming true for India’s
Ayurvedic medicine as it follows in the footsteps of
yoga, its pioneering offspring.  Partly because of
New Age affinities, this may also happen with Tibetan
medicine and Native American ceremonies. [106, 107]
Nonetheless, as a general taxonomic statement, consistent
with stubborn racist prejudices, one could say that
medical practices of ethnic communities are described as
ethno-medicine while the “ethno-medicine” of mainstream
white Americans is generally classified as CAM.
Folk Medicine Practices
Folk healing practices form a deeply embedded, unorganized,
and seemingly spontaneous response to illness.
Many of these practices are confined to specific
geographic areas, such as southern Appalachia  or
rural New Hampshire.  Sometimes they can be
traced back to remnants of ethnic (including Anglo-
Saxon) magical traditions or earlier lay forms of self-care
and home remedies. Common practices include wearing
copper bracelets for arthritis, covering a wart with a
penny and then burying the penny, stopping a nosebleed
by placing a red string around the neck, and curing
a cold with chicken soup. [110–113] Besides cures,
folk beliefs can also generate culture-bound diseases,
symptoms, and treatment-seeking behaviors. [114, 115]
Some folk practices have a more widespread currency
and are derived from earlier layers of premodern medicine
(for example, humoral Hippocratic medicine) or
medieval medical schools (for example, astrological
medicine). [116, 117] Examples of remnants of Hippocratic
ideas include such folk wisdom as “Bundle up to
prevent a cold” or “Feed a cold and starve a fever”. [115, 118, 119]
Many Americans rely on religion for salutary effects
on their health. [120, 121] Generally, normative mainstream
religious institutions have seen their role as supporting
the “spiritual” dimension and avoid direct overlap
or competition with the biomedical system. 
This division of labor has weakened somewhat lately;
“healing” services of one kind or another have appeared
even in liberal churches and synagogues. [123, 124]
The most salient forms of religious healing for physical
disease can be found in Christian churches that see
their ministry as replicating the miraculous healings recorded
in the Bible. [125, 126] This is especially true of
the Pentecostal and charismatic churches, which seek to
encounter and affirm the divine as manifest in both
physical and mental healing. [127, 128] People rising
from wheelchairs or discarding crutches can be convincing
signs of God’s power. [129, 130] Christian Science,
whose origins may be closer to Mind Cure than to
Christianity, also continues to be an important nonnormative
source of healing in the United States. [131, 132] Some religious denominations are also known for
nonadherence to normative procedures (for example,
Jehovah’s Witnesses, who routinely decline blood transfusions). [133, 134] For any of these religious approaches,
genuine “faith” is required in exchange for the
promised effectiveness. Also, these approaches sharply
distinguish themselves from participation in any professed
coalition with the CAM movement. 
Unconventional healing is a far-flung landscape of
diverse practices. A taxonomy balances distinction with
commonality. Other perspectives that emphasize interconnection
and common themes are possible. Healing
behaviors can be grouped into those that focus on the
primacy of substances to be taken orally (herbs, homeopathy,
dietary supplements, or food), those that rely
on the human hand (manipulation, needles, or anointing
the sick), or those that emphasize words (ritual or
psychotherapy). [23, 136] One could also discuss CAM
approaches on the basis of shared common themes (for
example, belief in nature, vitalism, and spirituality), as
has been done extensively elsewhere.  No matter
how it is classified, however, this entire domain provides
concrete practices and “pathways of words, feelings, values,
expectations [and] beliefs” that reorder and organize
the illness experience.  Because patients include
unconventional healing as an important component of
their response to illness, physicians must understand this
complex spectrum of health care practices.
A single definition of alternative medicine that tries
to state “what it is” inevitably is not satisfying, since
alternative healing includes a wide assortment of heterogeneous
therapies and beliefs. A taxonomy of unconventional
health care practices can help define alternative
medicine and provide a conceptual framework for
it. Such a model can help physicians understand and
participate in the current discussion on unconventional
healing practices as it rapidly unfolds.
The authors thank Robb Scholten and Maria Van
Rompay for research assistance and June Cobb and Marcia Rich for
In part by educational grants from the National Institutes
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