This
book began years ago, long before complementary and alternative
medicine (CAM) became so popular. In the 1970s, we began, separately
and independently, academically and personally, to be involved in
different forms of alternative care. One of us (Wellman) studied
the Alexander Technique (postural re-education) while the other
(Kelner) undertook a national study of chiropractors in Canada.
These initiatives led us both to the offices of CAM practitioners.
As we spent time sitting in these offices awaiting our turn for
treatment, we both observed that the composition of the clientele
was undergoing changes. At the outset, the patients consisted of
a narrow slice of society. People attracted to the Alexander Technique
were almost entirely artists. They were either dancers, musicians
or actors; people who used their bodies strenuously. Those who were
drawn to chiropractic, on the other hand, were largely people who
did hard physical labour and had injured their backs in some way.
Over
time, the range of people who sought both kinds of care began to
expand and diversify. The artists were joined by truck drivers,
academics and people who were resisting the recommendation for surgery
they had received from their physicians. Similarly, chiropractic
patients included more and more patients who wanted a treatment
that was less invasive than surgery. Contrary to the stereotype
of CAM patients as poor and uneducated, these more recent patients
were obviously well dressed, well educated, affluent, and sophisticated
in their approach. We asked ourselves: What is going on? Why are
these people coming here when they must pay out of their own pockets
instead of going to a doctor who is reimbursed by the government?
And how are they learning about these options?
These
types of questions led to our meeting and a decision to pursue social
scientific research together that would help us find the answers.
When we began the research, it was considered exotic by our colleagues
and friends. They were skeptical, dismissive and interested, all
at the same time. They asked lots of questions but remained unconvinced
about the utility of CAM and the academic merits of researching
it. Later, people began coming up to us at social gatherings and
confiding that they had decided to try some form of CAM. What did
we know about it? And could we recommend somebody? The pace of inquiries
kept accelerating as did the attention paid to CAM by television,
newspapers, magazines and later on, by the Internet. We recognized
that a personal and academic interest had become a public phenomenon.
This book reflects the convergence of our personal, intellectual,
and scholarly worlds and also draws on an international frame of
reference, primarily covering the United States, Canada and Britain.
This comparative perspective is also represented in the international
editorial team which has been instrumental in putting together this
volume. This includes Merrijoy Kelner and Beverly Wellman from Canada,
Bernice Pescosolido from the United States and Mike Saks from Britain.
Complementary
and alternative medicine is not new. Unorthodox therapies such as
homoepathy, acupuncture and herbalism have been around before the
advent of scientific medicine. Most societies have historically
been medically pluralistic (Wallis and Morley, 1976). What we are
seeing today, however, is a new kind of medical pluralism. People
from various backgrounds and socio-economic groups are choosing
to consult CAM practitioners for a range of conditions while at
the same time continuing to use medical services. The popularity
of CAM therapies has become increasingly widespread since the 1960's,
as more and more people in Western societies have developed an interest
in using them. In the United Kingdom (Ernst 1996; Thomas et al,
1991; ), in the United States (Astin 1998; Eisenberg et al. 1993;
1998), in Canada (Kelner and Wellman 1997a; Blais et al. 1997; Millar,
1997; Verhoef and Sutherland 1995), and elsewhere in the industrialized
world (Fisher and Ward, 1994; MacLennan et al 1996), the use of
CAM is clearly on the rise.
This
book uses social science research to examine the emergence of this
dynamic change in the pattern of health care services. While the
mass media have showered an avalanche of attention on non-orthodox
therapies and healers, scholarly knowledge has lagged far behind.
Some reliable information is being amassed. Epidemiologists such
as Eisenberg and his colleagues (1998) and Paramore (1997) have
been conducting research on the use of CAM in the U.S. which shows
it now to be widespread and extensive. Similar surveys have been
done in the U.K., Europe, Australia and Canada. These surveys show
that in spite of the insurance for medical services available in
many of these countries, people are still choosing to pay (out of
pocket) for CAM services. Clinical scientists have also begun to
turn their attention to examining why and how CAM influences the
state of health. Under the aegis of the Office of Alternative Medicine
now the National Center for CAM (U.S. National Institutes of Health)
a series of studies have been initiated to test questions such as
the usefulness of acupuncture for treating drug addiction, the efficacy
of alternative approaches to pain control and the effectiveness
of CAM treatments for cancer. Physicians in some leading North American
hospitals are conducting experiments to test the impact of CAM therapies
such as therapeutic touch and energy healing on the rate of recovery
after surgery. Rigorous tests of efficacy are being conducted in
the United Kingdom where researchers are investigating issues such
as the utility of acupuncture in the treatment of asthma and the
effect of homeopathy on chronic headaches.
The
social sciences provide yet another way of understanding the phenomenon
of CAM, using the large canvasses of sociology, anthropology and
politics as well as the more detailed brush strokes of psychology.
In the pages of this book, a multidisciplinary, cross-national group
of social scientists apply their research experience and theoretical
expertise to building a valid knowledge base. They employ social
science concepts and research findings to clarify the social context
in which CAM has created such popular interest. This includes explanations
of who uses these therapies, why they choose to consult CAM practitioners
and how they find their way to their offices. The book also encompasses
the key issues of research and policy in response to user demands.
Less
developed in the book is analysis of the characteristics, aspirations
and motivations of CAM practitioners and physicians who elect to
use CAM therapies in their practice. This is because less work has
been done in this area to date. In the future social scientists
will undoubtedly focus more attention on practitioners and their
potential for winning professional recognition and a more central
role in the overall health system.
In
an environment where so much of the knowledge has been anecdotal
and subject to the biases and claims of various camps, this book
offers important information, new perspectives and creative models
for thinking about a significant social development. The readers
of this book can be confident that they will find here a compilation
of knowledge and ideas that reflect the work of reputable scholars.
Here we lay out some of the most complex questions currently troubling
scholars. The first issue we grapple with is the basic question
of how to define CAM.
Defining
CAM
The
definition of CAM is open to many interpretations, making it difficult
to ensure a common understanding. This lack of consistency is not
surprising in a field that has such diverse cultural and historical
roots, and is evolving so rapidly. There is confusion about which
therapies to include or exclude from the definition and how to classify
the multitude of therapies in some coherent way. There is confusion
even about what such therapies should be called -- alternative,
complementary, holistic, unorthodox, unconventional, non-scientific,
and marginal are only some of the many descriptors in the literature.
Indeed, the borders between orthodox medicine and CAM are themselves
unclear as particular CAM therapies such as osteopathy and chiropractic
continue to gain wide acceptance and it becomes increasingly difficult
to decide where to place them. Moreover, practices which are considered
‘alternative’ by the majority of people in Western society,
are thought of as conventional and mainstream by people in other
societies. As Millet (1999) observes “The problems of vocabulary
and confusion turn out to be problems of history, sociology, and
power.” As the field continues to develop, trying to achieve
a clear definition of CAM is like struggling to hit a moving target.
The
goal, however, must be to find a definition that expresses the essential
nature of CAM. The definition must apply fully to all kinds of alternative
therapies yet not delineate too broadly or too narrowly. Clarity
and care are essential since how the description is framed will
influence the choice of data for study. The challenge here is to
find appropriate language for description in an area where there
is still so much controversy around value conflict and political
dominance.
A
panel convened by the Office of Alternative Medicine in 1995 to
define and describe CAM, struggled with the difficulties outlined
here and came up with the following general definition:
Complementary
and alternative medicine (CAM) is a broad domain of healing resources
that encompasses all health systems, modalities, and practices and
their accompanying theories and beliefs, other than those intrinsic
to the politically dominant health system of a particular society
or culture in a given historical period. CAM includes all such practices
and ideas self-defined by their users as preventing or treating
illness or promoting well-being. Boundaries within CAM and between
the CAM domain and the domain of the dominant system are not always
sharp or fixed (1997, p. 50).
Such
a definition treats both conventional medicine and CAM on an equal
footing and avoids negative connotations. It also takes into account
the existence of multiple healing systems which have various degrees
of dominance and influence in the United States, Canada, Britain
and other western societies.
Regardless
of how they are defined, it is important to recognize that conventional
medicine and CAM tend to operate under very different paradigms
of theory and practice. In fact, Kuhn (1970) would probably describe
them as “incommensurate”, since they are based on different
assumptions. Conventional medicine typically treats disease as a
breakdown in the human body that can be repaired by direct biochemical
or surgical intervention. The theoretical underpinning is frequently
claimed to be rational and scientific. The model on which it is
based conceives illness as arising from specific pathogenic agents,
and views health as the absence of disease. The concept of CAM,
on the other hand, covers a diverse set of healing practices, which
do not normally fit under the scientific medical umbrella. Instead,
these practices emphasize the uniqueness of each individual, integration
of body, mind and spirit, the flow of energy as a source of healing,
and disease as having dimensions beyond the purely biological (Berliner
and Salmon, 1979). The life force is very commonly seen as a crucial
element of the healing process and strong emphasis is placed on
the environment, the subjective experience of patients, the healing
power of nature, and health as a positive state of being (Goldstein
1999).
One
way to think about the definition of CAM is to see it as a social
creation that depends on the perspective of the individual who is
doing the defining. For most medical scholars, CAM is defined by
its location “outside accepted medical thought, scientific
knowledge, or university teaching.” (Ernst, 1996b; p.244).
In other words, the definition is derived from its differences to
the dominant mode of health care which is conventional medicine.
But this residual form of definition does not do justice to the
healing capacities of CAM. Social scientists like O’Connor
(1995) define CAM based on its alternative belief system with its
distinctive views of the body, of health, and of the causes of illness.
A third way of defining CAM is as a complementary adjunct to medical
care. The term complementary implies the possibility of cooperation
with conventional medicine and recognizes the widespread research
finding that users of CAM also consult physicians on a regular basis
(Kelner and Wellman, 1997b). The term alternative highlights the
fact that CAM stands on the edges of the established health care
system and receives almost no support from the medical establishment
or the government (Saks, 1992). This definition points to the political
dominance of medicine and its role in controlling research funding,
and limiting inclusion of CAM in the basic medical curriculum.
Quoting
from Menger (1928, p76), Popper (1959, p55), reminds us: “Definitions
are dogmas; only the conclusions drawn from them can afford us any
new insight.” Each definition is arbitrary; each has its own
consequences and requires its own methodological decisions. For
the purposes of this book, a composite definition of CAM has been
chosen to provide an extensive opportunity to analyze the various
forms of health care described here. CAM is conceived as an approach
to health care that while different from conventional medicine,
is sometimes complementary to it and at other times is distinctly
alternative. The book focuses mainly on patient contacts with CAM
practitioners rather than the many informal alternative health care
activities that people employ such as use of megavitamins, special
diets, folk remedies, herbal supplements and meditation.
Up
to now, we have referred to CAM as a homogenous phenomenon. This
is misleading, however, since individual therapies vary according
to philosophy, terminology, practice, the degree of public acceptance,
and the extent of efficacy. There have been several attempts to
classify and categorize the various CAM therapies. One of the best
known has been developed by Fulder (1996) who proposes a typology
of five categories: ethnic medical systems (acupuncture, Chinese
medicine and Ayrurveda), manual therapies (chiropractic, reflexology
and massage therapy), therapies for mind/body (hypno-therapy, psychic
healing and radionics), nature- cure therapies (naturopathy and
hygienic methods), and non-allopathic medicinal systems (homeopathy
and herbalism).
Here
we suggest a different form of classification that arranges CAM
therapies according to the context in which they are delivered.
The categories are: (1) clinical forms (chiropractic, homeopathy,
acupuncture and naturopathy); (2) psychological/behavioural forms
(yoga, dance therapy, and biofeedback); and (3) social/community
forms (faith healing and folk medicine). Another useful way to classify
CAM therapies is based on the extent of legitimacy and public acceptance:
(1) top of the hierarchy (osteopathy, chiropractic and acupuncture);
(2) middle range (naturopathy and homeopathy); (3) bottom of the
hierarchy (rebirthing and Reiki). CAM therapies can be categorized
in still other ways; for example, according to the extent of scientific
evidence for their efficacy, or whether or not they involve touching
patients. The important point here is that these classifications
are not permanent; they will continue to shift according to clinical,
cultural, political and economic developments. Scholars have to
choose their typologies according to the particular questions they
are addressing at a given point in time.
What
is important is to recognize that CAM is a complex and constantly
changing social phenomenon which defies any arbitrary definition
or classification. As social scientists design CAM research, it
is not necessary or even possible that there be one agreed upon
definition.
Designing
Research on CAM
When
social scientists think about research methods, they need first
to establish the research question being asked. It is the question
rather than the paradigm which should drive the design , data collection
and data analysis used in the study. It is worth remembering that
we do not live in a single, objective reality; there are various
ways of looking at the world. Research questions emanate from a
variety of social contexts and cannot be separated from the environment
in which they are situated. This means that in order for research
paradigms to be appropriate, they need to reflect the social and
cultural setting of the question being investigated.
To
date, most social science research on CAM has been based on models
of health care which were developed to study peoples’ use of
medical care. These models make the assumption that people act in
rational ways when they make health care decisions. They are also
focused exclusively on individuals, thus neglecting the larger social
context in which people negotiate their health care options. This
approach has yielded reliable data concerning the extent to which
people use CAM, their motivations for doing so and something about
the nature of their encounters with CAM practitioners. New and different
models are needed to open up this research area to other kinds of
questions and the use of innovative investigative strategies. This
is one of the major purposes of this book.
One
such strategy is based on social networks (Wellman 1988). Network
analysis is a technique for mapping the people in an individual’s
network. It measures the frequency of contact, the closeness of
the bonds, and the relationships of the people in each person’s
network. Network analysis enables social scientists to answer questions
such as: who people turn to when they have a health problem, who
gives them recommendations to CAM therapies and therapists, and
who gives them constructive assistance with their health care. Another
perspective, communication research, allows us to explore the diffusion
of an innovation such as CAM. This makes it possible for social
scientists to chart the rate and extent to which new ideas and practices
are adopted by the society at large.
Building
on these research strategies, the Network Episode Model which Pescosolido
describes in chapter 10, presents a dynamic approach which views
all illness behaviours as embedded in day to day life. It includes
diverse kinds of health care rather than studying any particular
one in isolation. While previous models have been solely based on
rational choice of health care, this model also includes a social
component. It focuses on the illness episode as a dynamic process,
rather than on decision-making about health care at any one point
in time. This more inclusive approach views the individual as operating
within a multidimensional context of shifting treatment options
and service delivery systems. While the Network Episode Model adds
depth to current research parameters, it also highlights the need
to rethink the concepts and research strategies now being used to
examine the use of CAM.
The
field of anthropology provides an additional way of conceptualizing
health care and in particular, researching the use of CAM as illustrated
in chapter 2 by O'Connor. The ethnographic approach to studying
CAM relies on evaluative field studies in naturalistic settings
and stresses the importance of the patient’s perspective and
self-reports. These are the settings that best reveal the dynamics
of social processes and their impact on health care decisions. For
example, observational studies on folk or spiritual healing show
that it is important to consider both the social location and the
cultural relevance of healing practices. These considerations can
not only help to explain why people are attracted to CAM therapies
but also why they may be effective. Clinical studies certainly have
an important place in evaluating health outcomes, but they tell
only one part of the story. Adding real world conditions and focusing
on structure, process and outcomes of care, makes it possible to
gain a broader view of the healing process as a social intervention.
The
crucial question is, where should we go from here? Longitudinal,
prospective research is one obvious direction that would fill the
present knowledge gap. The cross-sectional data that has been compiled
to date, present a picture taken at only one point in time. Retrospective
studies, while valuable, are also limited in their usefulness by
the need for respondents to reconstruct their experiences over time.
Health care is a process which needs to be captured at different
points over a long period. Moreover, health status is a changing
condition; only longitudinal, prospective studies can adequately
capture these changes. With a longitudinal approach, for example,
scholars can chart the beliefs and attitudes of patients who have
left the practitioners they were using (leavers), and compare their
views with those who have stayed (stayers) or moved back and forth
among several practitioners (floaters).
Multi-dimensional
research designs can also enrich future understandings of the use
of CAM. While individual determinants of CAM use and the models
that have been used to explain it have given us descriptive profiles
of users, there is more to the total picture. In order to grasp
the complexity of the larger health care context, researchers need
to include different levels of analysis, from the individual to
the cultural and societal. Future research should include a focus
on dimensions such as personal experience, political and economic
opportunities and constraints, availability of resources, and the
zeitgeist of the times, in a model that integrates them all.
Another way to think about the future of CAM research is to take
a global perspective. As the number of scholars taking an interest
in CAM increases around the world, it becomes possible to carry
out high quality international research and to make cross-country
comparisons. Such comparisons could identify the effects of distinctive
socio-political conditions and cultural influences on the use of
CAM. This book is an example of collaboration between scholars from
different countries and different disciplines. It can help to develop
and test new, more inclusive approaches. Application of new models
to various settings can help to refine the fit between theory and
reality.
Evaluating
CAM
There
is a widespread assumption among the general public that CAM is
natural, and therefore safe. Many people are making use of CAM services
and practitioners without evidence-based assurances of safety or
efficacy. At the same time, growing numbers of health care providers
and policy makers are calling for accountability and regulation.
There is currently a lively and unresolved controversy about how
best to assure the safety and test the effectiveness of CAM therapies
(Ernst, 1996; Mitchell and Cormack, 1998). There is considerable
debate whether alternative health practices can be studied in the
same way that standard medical practices are assessed. Cant (1996)
suggests that the philosophical foundations of some alternative
health practices make it impossible to judge them by the same standards
as conventional medicine. Others argue that existing methodological
strategies are not useful for evaluating CAM therapies such as massage
therapy. A Quantitative Methods Working Group convened in 1995 at
the National Institutes of Health in the USA concluded that these
problems could be overcome. They found that there were existing
methodologies and data analysis procedures which were quite capable
of addressing the majority of study questions related to evaluating
CAM (Levin et al., 1997).
Some
attempts at evaluation are already underway. In the United States,
the Office of Alternative Medicine has been funding major tests
of efficacy primarily through university departments around the
country. In Europe, there have been evaluation studies on various
forms of acupuncture, chiropractic, homeopathy and other CAM practices
(for example, Meade et al. 1990). Worldwide, the Cochrane Collaboration
has become important (Sackett 1994). It is including CAM in its
goal of assessing the evidence base in all fields of medicine. In
Canada, evaluation research has also begun. An Office of Natural
Health Products has recently been established to ensure that medicinal
herbs and vitamins are safe for consumers to use (Globe and Mail,
March, 1999). These efforts represent the initial steps in what
will undoubtedly evolve into a systematic program in evaluative
research.
At
the moment, the randomized clinical trial (RCT) is considered to
be the gold standard of research design, the one by which all other
clinical studies are judged as Ernst argues in chapter 9. This is
a procedure in which research subjects are matched for similar illnesses
as well as demographic characteristics, and are then randomly assigned
to two or more groups. One group receives the intervention, for
example, a drug thought to be useful for their condition, while
the other group is untreated and serves as the control. Usually,
those who are not being treated are given a placebo so that they
will believe they are also receiving treatment. If the treated group
improves significantly (as determined by statistical procedures)
as compared to the control or placebo group, the intervention is
judged to have a positive therapeutic effect. Ideally, those who
administer the treatment and/or placebo and those who evaluate the
results of the study are blinded; that is they are not aware of
who has received the treatment and who has not.
RCTs
have proven to be the method of choice for assessing the effectiveness
of new drugs. When used to evaluate other kinds of therapies, however,
they have some definite limitations. The problem is that many therapies
are incompatible with this approach and do not lend themselves to
evaluation by RCTs. For example, surgery and psychotherapy are two
instances of conventional medicine in which it is extremely difficult
to blind the therapists or to simulate the therapy. CAM therapies
that use hands-on-techniques like acupuncture and chiropractic present
similar difficulties. Another difficulty lies in the nature of CAM
treatments; they are customarily tailored to the individual patient
rather than standardized for a specific condition. In addition,
most CAM practitioners see the placebo effect as something to be
used in a constructive fashion, rather than taking the medical view
that the placebo should be eliminated from consideration to assure
scientific rigour (Pietroni 1991). These limitations on the use
of RCTs to study alternative therapies have prompted Levin et al
(1997) in their Methodological Manifesto to proclaim that: “Clinical
trials are not the only game in town” (p 1086).
The
dominance of RCTs has meant that many alternative therapies have
been ignored or dismissed by the medical establishment because their
efficacy has not been demonstrated by this particular research strategy
(for example, British Medical Association 1986). RCTs work best
for simple interventions with diseases that are easily definable
and capable of being quantified. But this tactic is not always suited
to CAM therapies which take a holistic approach to treatment. A
holistic research strategy requires a broad view that can encompass
elements of the healing process such as the role of patients, the
impact of the therapeutic relationship and the non-technical aspects
of treatment
In
addition to these methodological problems, the RCT has important
economic and political ramifications. It is an enormously expensive
process that entails vast resources and is usually undertaken by
drug companies willing to invest large sums in the expectation that
they will reap big rewards when the successful drugs are marketed.
The same kind of financial incentives do not apply to substances
and practices that cannot be patented. Moreover, it is wise to remember
that many conventional medical techniques, including a number of
diagnostic and surgical techniques and treatments, have never been
subjected to double-blind controlled clinical trials (Saks 1994).
Furthermore, numerous medical remedies including aspirin and penicillin
became widely used long before experts knew how they worked (see,
for instance, MacEoin 1990). Critics of CAM often apply a double
standard, showing more enthusiasm in their efforts to discredit
unevaluated CAM therapies than they do in questioning the safety
and efficacy of conventional medicine.
It
seems clear that RCTs cannot and should not be applied to all procedures
and substances. The power of the medical profession, however, may
make it difficult to move away from the heavy reliance on RCTs that
medicine has normally insisted on for testing the efficacy of CAM
therapies. Medicine’s ways of knowing are grounded in a strong
background in the biomedical sciences. Medical research tends to
be based on the premise that biomedicine is impartial and empirically
verifiable and that there is only one objective picture of reality
and one valid empirical method of verifying it. This claim leaves
little room for more flexible definitions of health, more complex
pictures of reality and hence more pluralistic views of how evaluation
should be conducted.
Rather
than distorting CAM to fit the preexisting conventions of RCTs,
it makes sense to adapt current evaluation methods in ways that
fit with the underlying premises of CAM. The following examples
illustrate the range of other research methodologies that have been
suggested by a number of scholars (Glik 1993; Canter and Nanke 1993;
Black, 1996 Aldridge 1993; Moss 1992; Levin et al. 1997; Cant and
Sharma 1996).
(1)
Basic biological research - This applies biological research to
CAM healing therapies by assessing the effect of these therapies
on physiological changes in the body. For example, looking at the
effect of acupuncture treatment on blood pressure, the level of
certain chemical messengers between the brain and the body, or the
effects of healing energies on adhesion of cultured cells and haemodialysis
of blood cells.
(2)
Long term assessment - Tracing the long term effects of different
forms of treatment on specific groups, controlling for length of
time in treatment. It is also important, where appropriate, to ensure
that treatments are given by the same practitioner.
(3)
Co-operative inquiry - The patient, the researcher and the therapist
all form a team which works together to explore the ways in which
the treatment affects both patient and practitioner. This method
is useful for demonstrating the effects of factors such as patients’
lifestyle and the therapeutic relationship on treatment.
(4)
Single case study design - This method treats the patient as his/her
own control. It allows a patient to be monitored over time using
diverse treatments including a placebo. Such an approach can yield
valuable detailed information about the outcome of specific treatments.
(5)
Outcome studies - For evaluating CAM therapies, the conception of
outcomes should be broad enough to include considerations such as
“feeling better”, more energy, increased mobility, relief
of pain, and greater capacity to cope with the demands of daily
life.
(6)
Cost benefit analysis - At the individual level, it is fairly easy
to document what people are spending and what benefits they feel
they are receiving. At the societal level, however, it is exceedingly
difficult to assess with any degree of accuracy whether government
expenditures on health care are reduced as a result of CAM therapies.
Morbidity and mortality statistics usually form the basis for such
an analysis. Quality-of-life measures are not customarily included
in cost /benefit analyses even though CAM therapies may have their
greatest impact on this aspect of health.
Other
new methods for evaluating CAM therapies will undoubtedly be developed
as more practitioners/researchers are attracted to this phenomenon
and acknowledge the need to protect the health and safety of those
who use CAM. The argument that new, imaginative evaluation methods
are required, that take into account CAM’s special characteristics,
in no way negates the necessity for rigorous standards and peer
review. One single standard of evaluation for both CAM and medicine
is needed. Competent researchers should carry out well designed
experiments to ensure that their results have both validity and
reliability. All evaluation studies of CAM therapies should be able
to withstand the skeptical scrutiny of CAM’s harshest critics.
Social
Scientists Meet CAM
This
book is divided into four sections. Section One addresses the question
of why people choose to consult CAM practitioners. The growing number
of people turning to CAM has aroused the curiosity of researchers
trying to make sense of this social change in health care patterns.
Section Two examines social and health characteristics of CAM users
and analyzes their pathways to care. Section Three opens up new
avenues for doing research. Beginning with established, clinical
methods, this section presents new research strategies rooted in
the social sciences. Section Four uses social science knowledge
and concepts to make projections about how CAM will develop in the
future and how it might fit into the overall health care system.
Section
One
This
section explores the myriad explanations that have been offered
for the widespread popularity of CAM at this particular point in
time. Michael Goldstein, in chapter one, highlights the correspondence
between fitness, health promotion and the use of CAM. He argues
that people who are actively concerned with fitness and health promotion
are more likely to be users of CAM, since they share many significant
assumptions and beliefs about the body and about health. Goldstein
emphasizes the importance of the marketplace in promoting these
assumptions. Health, he argues, has become a commodity sold by corporations
who see fitness and CAM as a money-making opportunity. He concludes
by predicting that we can expect an increasing synergy between fitness
and CAM in the future.
In
chapter two, Bonnie Blair O’Connor recognizes that the use
of CAM is not a new phenomenon. Historically, the way people conceive
of the body has had a major influence on their decisions to incorporate
CAM into their health care. She points out that at various points
in the history of the United States, nonmedical conceptions of the
body and CAM approaches to maintaining health were widely popular.
Earlier in the 20th century, medicine became the dominant force
in health care. Today, she explains the resurgence of CAM by the
argument that alternative conceptions of health and of the body
are more congruent with people’s experiences of illness than
are the assumptions of the biomedical model.
Adrian
Furnham and Charles Vincent, in chapter three, address the question
of why people choose CAM when there is so little evidence that it
works. They examine a number of empirical studies that have been
carried out in an effort to answer this complex question. Furnham
and Vincent then identify nine possible reasons why people seek
out CAM practitioners, depending on the motives and the academic
disciplines of those who ask the question. They conclude by observing
that it is too simple to think in terms of patients who are either
“pushed” or “pulled” toward CAM by their particular
health histories; larger considerations such as environmental concerns
also shape peoples’ health care decisions.
Merrijoy
Kelner, in chapter four, explores the notion that it is the distinctive
kind of therapeutic relationship that exists between CAM practitioners
and their patients that accounts for the upsurge of interest in
CAM. She looks at the three main models that have been used to explore
the doctor- patient- relationship and applies them to patient relationships
with alternative practitioners. By examining the relationships experienced
across five kinds of treatment groups: family physicians, chiropractors,
acupuncturists/traditional Chinese doctors, naturopaths and Reiki
healers, she finds that all groups of patients place most value
on the shared decision- making model of care, but that this approach
is more commonly found among CAM practitioners and provides one
explanation for their growing popularity. Kelner's research also
shows that most people who use CAM have highly pragmatic motivations;
they seek relief from long-term chronic problems and will continue
to try new options in the hope of finding one that works.
Section
Two
The
second section of the book addresses two key questions: what kinds
of people use CAM and how do they find their way there? In chapter
five, John Astin describes the psycho-social characteristics of
CAM users based on a national survey of adults in the United States.
He goes beyond epidemiological identifiers such as social class
and gender (Eisenberg et al. 1993; 1998) to include specific cultural
values, previous health care experiences and particular world-views.
In the end, however, Astin concludes that it is people who have
been unable to find relief from continuing pain or discomfort who
are most likely to seek out CAM therapies. The sixth chapter by
Regis Blais is based on two health surveys carried out at different
periods of time, thus providing a longitudinal analysis of people
who use CAM. Blais finds that between the years of 1987 and 1993
the number of persons in Quebec, Canada using CAM has increased,
the type of CAM practitioners consulted has diversified and the
reasons for consultation have expanded. Overall, however, the demographic
profile of CAM users did not change. His description of CAM users
corresponds to the findings of other researchers in North America
and Europe; they are mainly female, young, well educated and affluent.
Thomas
Valente, in chapter seven, uses diffusion of innovation theory to
explain how people decide to adopt CAM use. He distinguishes between
the various types of CAM users, ranging from a few early adopters
through to the mass of majority adopters to the few laggards at
the end of the cycle. He associates progress through these stages
of diffusion with changes in personal perceptions and also with
the influence of the media. For early adopters, it is personal or
situational factors that are the most persuasive. Whereas for majority
and late adopters it is network influences that are most directly
responsible for the decision to seek an alternative practitioner.
In
chapter eight, Beverly Wellman uses network analysis to examine
the health ties of patients who consult either family physicians
or some form of CAM practitioner. She examines the nature of health
information and support that these patients receive from kin, friends,
physicians and alternative practitioners. In all the treatment groups
in the study, people have close health confidants who are influential
in determining where people go for their health care. The difference
is that the health networks of the alternative patients are broader
and more inclusive than those of the family physician patients,
thus providing access to more kinds of health care options.
Section
Three
Section
three of the book delves into the controversial issues surrounding
research on CAM. Different approaches are taken by scholars from
a range of disciplines and their different backgrounds influence
the shape of the models they propose. In chapter nine, Edzard Ernst
urges that the safety and efficacy and effectiveness of CAM become
paramount issues for researchers. He makes the point that although
some forms of CAM may be considered “natural”, that does
not mean that they are necessarily safe. With few exceptions, specific
effectiveness for CAM therapies has not been firmly established.
Ernst argues that double blind, clinical trials in defined situations
are the best way to test the effectiveness of CAM therapies. Where
sufficient numbers of good quality trials do not yet exist, systematic
reviews or meta-analyses are needed. He concludes that what is required
is high-quality and appropriate research and that without rigorously
derived evidence, the public should be wary of embracing CAM therapies.
In
chapter ten, Bernice Pescosolido, a sociologist, presents a network
episode model for understanding illness behaviour and the use of
CAM therapies. This model combines individual determinants of health
care decision-making with social considerations. She emphasizes
that the underlying mechanism of this model is interaction in social
networks. Illness behaviour is seen as a dynamic process, rather
than a choice of health care at any one point in time. She conceives
of the health care system as a changing set of providers and services
with which individuals may come into contact when they become ill.
Deborah
Glik, a social anthropologist, argues in chapter eleven that there
has been a bias toward studying professionalized forms of care,
to the neglect of indigenous or folk healing. She makes a case for
research models that include a broad range of societal factors such
as the therapeutic context and the cultural values of patients.
She contends that research conducted in naturalistic settings using
evaluative field methods is just as valuable as more clinical approaches.
Glik illustrates her argument by drawing on studies of spiritual
healing groups and patients of homeopathic practitioners.
Section
Four
This
final section of the book focuses on the future of CAM. In chapter
twelve, Ursula Sharma argues that the continuing re-emergence of
CAM in the UK and other western countries should be understood in
the context of a wider web of relationships, for example, the organization
of other health care professions. She points out that medical pluralism
of one kind or another is the norm in countries around the world
and that biomedicine does not enjoy a natural priority. She envisions
a more pluralistic health care system in the future. But this pluralism,
Sharma points out, is not the same as the medical pluralism that
was evident before the rise of biomedical hegemony. In the UK today,
some CAM therapies are situated in the public sector and at the
same time there is a flourishing market for private consumption
of CAM. Sharma predicts that while some types of CAM therapies will
remain on the margins and need to be purchased in the private market
place, other types will be recognized as legitimate and be incorporated
into the government supported health system.
In
chapter thirteen, Mike Saks explores the political implications
of the increasing efforts of alternative practitioners to win professional
acceptance. He points out that over the last century in Britain,
Canada and the United States, the profession of medicine has had
a legally underwritten monopoly in the marketplace. Since the 1960s,
however, many CAM practitioner groups have strengthened their position
vis-a-vis medicine through political lobbying and professionalization.
This trend has sharpened competition for those physicians who wish
to incorporate CAM into their practices as well as posing a substantial
challenge to the dominance of the medical establishment. Saks suggests
that the potential for CAM therapists to gain professional standing
may be limited in scope. This is due in part to the success of the
medical establishment in incorporating CAM therapies, and thus reducing
the threat of losing its dominance. Finally, Saks examines the question
of whether professionalization of CAM is desirable and deserves
support by the state.
In
the last chapter of the book, Allan Best and Deborah Glik present
a conceptual framework that positions CAM research as health services
research. They argue that such an approach can help to meet the
escalating public interest in using CAM therapies and also guide
the process of reforming health care. The authors believe that in
order to promote appropriate integration of CAM, research must examine
issues of utilization, cost-effectiveness and the evidence base
for practice. The chapter provides a working model for research
on integrative health services which outlines three distinct strategies:
healing, learning and research, to provide the data required for
making decisions about health reform. The need for development of
measures is also discussed and the authors sketch a provisional
conceptual map for organizing key constructs and relevant variables.
They make a case for establishing three areas of research priorities:
conceptualization, design, and analysis, and application. The chapter
concludes with recommendations for integrative research and emphasizes
that partnerships between the producers of research and the consumers
of this research are essential if the promise of better health services
is to become a reality.
Challenge
and Change
We
are seeing dramatic changes in the delivery of health care in industrialized
society today. Consumer demand is increasingly driving the shape
of health care which is becoming more and more pluralistic in nature.
The health care system is experiencing widespread restructuring
influenced in part by the growing dominance of corporate interests.
The future place of CAM in all of this is not yet determined. It
seems likely that insurance companies, managed care organizations,
national health insurance schemes and hospitals will incorporate
some aspects of CAM into their practices and policies. Medical schools
are also adding courses on CAM to their curricula and more research
funds are beginning to be directed by governments toward the study
of CAM treatments.
We
can expect that the demand for CAM will continue to expand. Indeed,
CAM has already become a viable business for many of its practitioners
and even more so for the companies that produce products associated
with it. The big question for the future is whether the practices
of CAM will be integrated into the mainstream of health care. Already,
some doctors are adding elements of CAM therapies to their own practices
while others are recommending it to some of their patients. If integration
is to occur, issues of licensure, credibility, and education will
need to be seriously pursued. One change that seems unlikely is
that people will turn away from conventional medicine. The medical
model still has a pervasive influence as does the infrastructure
that supports it. The question is, whether CAM will be able to coalesce
across therapies and develop its own organizational structure independent
of medicine. Or will it eventually be incorporated into the conventional
medical system?
Changes
of this magnitude pose a series of challenges for the delivery of
health care. One challenge is to thoroughly map the area called
CAM. While some of the therapies and practices are well known, there
are a myriad of others available for use but little known. In addition
to ascertaining what is out there, it will be essential to understand
what the different therapies offer and how their practices work.
In an era of evidence-based medicine, rigorous research on issues
of safety, efficacy and cost benefits is imperative. This kind of
knowledge will help to facilitate the appropriate integration of
CAM with conventional medicine, making it complementary rather than
alternative. If both systems can learn to work together in a synergistic
whole, the outcome can only be positive. The scientific expertise
of medicine and CAM’s emphasis on prevention, holism and personal
responsibility can combine to truly make the definition of health
mean more than the absence of illness.
Incorporation
into the existing health care system will entail the challenge of
educating doctors and CAM practitioners in each others' specialized
knowledge. Furthermore, CAM practitioners need to put aside differences
and unite to establish practice standards that will invite the trust
of the public. They will need to be licensed and accountable so
that the public perceives them as safe, reliable, and competent
and physicians will be willing to work with them as partners. A
challenge for CAM practitioners will be to co-exist in the new health
care system without losing their distinctive ways of practicing.
Finally, the challenge for society as a whole is to decide, if and
when CAM therapies have been shown to be effective and safe, how
they can be made available to everyone who needs them in the most
responsible way.
Appendix
There
are by now a plethora of books on aspects of CAM, but most are not
based on systematic research. A few books have been based on research
dealing with individual therapies such as homeopathy (Ernst and
Hahn 1998; Jonas and Jacobs 1996), chiropractic (Kelner et al. 1980;
Smith-Cunnien 1998), and acupuncture (Saks 1992). Books like these
provide descriptive detail that is beyond the scope of this book.
Here we take a broader perspective which encompasses the whole phenomena
of CAM and address the reasons for its current popularity. Listed
below and presented in chronological order is a representative sample
of the work done thus far by social scientists interested in CAM.
One
well-known, early effort to map the terrain was Warren Salmon’s
edited book on Alternative Medicines: Popular and Policy Perspectives
(1984). He reports the popular resurgence of interest and activity
in CAM in the United States and Europe. The book provides an understanding
and an overview of selected CAM therapies and offers a range of
viewpoints on their public acceptance and related policy issues.
Stephen Fulder’s The Handbook of Complementary Medicine (1988)
was published later with classifications and explanations of a wide
range of therapies including their philosophies and practices. He
draws portraits of patients of CAM in the United Kingdom at that
time and also describes the backgrounds of the therapists. Included
in the book is an international overview of the social and legal
position of the therapies in countries in Europe and elsewhere.
Norman Gevitz (1988) in his edited book, Other Healers: Unorthodox
Medicine in America, takes a scholarly perspective on CAM groups
and practices in the United States. The book outlines a number of
different types of therapies and uses historical perspectives and
descriptive analyses to explain their growing public acceptance.
Included in the book is an examination of spiritually oriented healing
movements as well as contemporary folk medicine.
Meredith
McGuire (1988) in her book Ritual Healing in Suburban America, reports
an in-depth study of several different types of ritual healing groups
frequented by suburban Americans in a small town in New Jersey.
The people involved in the groups, either as leaders or followers,
were interviewed in detail about their beliefs, attitudes and experiences
with healing. She found that orthodox medicine was only one among
many kinds of health care being used. People were becoming “contractors
of their own care” and making choices between mainstream medicine
and CAM therapies on the basis of their beliefs about what would
help them most. The people she studied viewed health, illness, and
healing from a perspective which went far beyond the biomedical
model. Her research suggested that there was a strong link between
health and healing and broader socio-cultural issues.
Rosalind
Coward accounts for the surge of interest of CAM in the United Kingdom
in The Whole Truth: The Myth of Alternative Health (1989). She describes
the dramatic change in public attitudes which now regard good health
as an ideal state which is one’s personal responsibility to
pursue. She contends that alternative therapies are based on a new
philosophy of nature, health and the body and that this new philosophy
has captured the popular consciousness. Coward is particularly interested
in the implications of these views for the ways in which people
think of themselves in both social and political terms. She regards
CAM therapies both as a spearhead and as a symptom of widespread
changes in attitudes and argues that individuals are attracted to
the new mythology about nature and health which surrounds these
practices. Coward concludes that while the new philosophy is critical
of excesses of industrialization, modernity and impersonality, these
criticisms rarely extend to a more complete challenge to the structures
of a capitalist society. She describes CAM as essentially an individualistic
approach in which each person assumes responsibility for their own
health and well-being.
As
the public interest in CAM has risen, the number and types of practitioners
have also increased. With this increase have come problems created
by the diverse nature of the numerous alternative practitioners
and therapies, which make it difficult for CAM to coalesce around
a central organizing thrust. Despite these differences, many CAM
practitioners are seeking professional recognition and legitimation.
Mike Saks, in an edited book entitled Alternative Medicine in Britain
(1992), was one of the first to write about the political and social
context in which CAM practitioners are attempting to go from a marginal
to a central role in the British health care system. He identifies
the obstacles in the path to full professional acceptance of CAM
practitioners, and highlights the difficulties posed by the power
and self protective interests of the medical profession. Saks argues
that the success experienced by the medical profession in the mid-nineteenth
century in attaining its dominant role in the health care division
of labour has served to underwrite the current position of biomedicine
as the basis of medical orthodoxy.
As
the use of CAM has become more prevalent, the issue of “efficacy”
(that is, does it work?) has assumed critical importance. The disparate
nature of CAM techniques create serious problems for evaluation
procedures. Furthermore, it has become clear that while conventional
clinical trial methods are the “gold standard” for evaluating
efficacy, there are difficulties in assessing all CAM procedures
using this one methodology. George Lewith and David Aldridge (1993)
edited Clinical Research Methodology for Complementary Therapies,
a book which addressed this problem. They outline a range of possibilities
for evaluating the efficacy of CAM including not only clinical trials
but also longitudinal studies of health care practice, co-ordinated
single case designs, and other social science research methods.
They conclude that with health care demands accelerating, it is
imperative to investigate new options which may serve to reduce
costs and encourage prevention.
Bonnie
Blair O’Connor (1995) in her book Healing Traditions: Alternative
Medicine and the Health Professions focuses on “vernacular”
health belief systems in the United States. She looks at the ways
in which people’s experiences, beliefs, and values influence
their choice of health care. Her book addresses the issues of how
people define health and illness; how and why people believe they
become sick; how they decide what to do about it; who they go to
for which kinds of care; and the implications of these beliefs and
decisions for health professionals in the “conventional western”
medical system. She cites as examples belief systems that have originated
in a wide range of cultural contexts and geographical locations.
She shows for example, that in the case of HIV/AIDS, conventional
medical treatment is augmented by elaborate vernacular treatment
strategies, particularly for middle and upper middle class white
men. It is they who largely comprise the organized gay community,
which in turn has served as a CAM information-sharing network. Finally,
O’Connor points out that patients evaluate options for health
care that go far beyond the conventional medical system. Today,
in America, vernacular health belief systems are strongly influencing
the kinds of health care resources that are being used and have
significant implications for conventional medical education and
health care delivery.
Ursula
Sharma (1995) conducted research on users and practitioners of CAM
in Complementary Medicine Today: Practitioners and Patients. She
carried out her study in a community in the Midlands in England
and identified a profile of typical CAM users. The people who were
most likely to consult CAM practitioners were female, middle-aged
and younger, well educated, well to do, with high occupational status.
This profile corresponds to the findings of similar studies in Europe,
Australia, United States, and Canada. Sharma analyzed how people
decided to use CAM for the first time; their patterns of use; their
complementary use of orthodox medicine; how they learned about CAM;
and the motivations which led them to the offices of CAM practitioners.
The second half of her book deals with the practice of CAM. She
studied the practitioners, examined the national context, and analyzed
the political arena in which CAM is being delivered.
In
Professions and the Public Interest: Medical Power, Altruism and
Alternative Medicine (1995), Saks uses the example of acupuncture
in Britain to illustrate how CAM therapies were initially rejected
by organized medicine which used its professional power to keep
acupuncture in a marginal position. In the first half of the nineteenth
century acupuncture had flourished and medicine had responded in
a relatively positive manner to consumer demand for this popular
lay practice. The state extended the monopoly rights of medicine
so that the medical rejection of acupuncture was legally reinforced.
At present, as more and more patients seek acupuncture therapy,
the position of medicine has started to shift from outright rejection
to limited incorporation. Medicine has responded by attempting to
co-opt the practice of acupuncture, using it as a supplement to
orthodox medical treatment and for a limited range of conditions.
In
1995, Carole Damiani published La Medecine Douce: Une Analyse De
Pratiques “Holistes” En Sante (Alternative Medicine: An
Analysis of Holistic Health Practices). Her study describes and
analyzes the emergence of alternative therapies in Canada in the
province of Quebec by focusing on the practitioners. She traces
their backgrounds including education and training, establishes
a portrait of their practices and identifies the socio-cultural
context in which they practice. She finds an eclectic group of practitioners
who are orienting themselves toward professionalization and future
integration into the larger health care system. She concludes that
CAM practitioners and patients are found throughout Quebec society
and patients are using CAM therapies for a wide range of health
problems.
In
their 1996 book, Complementary and Alternative Medicines: Knowledge
and Practice, two anthropologists, Sara Cant and Ursula Sharma have
compiled a series of articles which deal with the legitimation of
CAM knowledge and practices. The book highlights the fact that the
boundaries between orthodox and CAM medicines are far from fixed
and that a growing number of doctors are actually offering CAM therapies
in some form. The questions raised here focus on the public legitimation
of certain forms of knowledge such as medical knowledge and the
discreditation of others. The authors argue that expert knowledge
has become a fundamental resource of social life and is closely
associated with power. CAM therapists today are struggling to establish
their credentials as “experts” in order to gain legitimacy
and authority. Cant and Sharma describe the current environment
as one of “intense contestation” between biomedicine and
diverse healing modes, in which we can expect to see the emergence
of strategic realignments.
Charles
Vincent and Adrian Furnham in Complementary Medicine: A Research
Perspective (1997) focus on the research that has been done on CAM.
They examine the existing evidence for and against therapies such
as acupuncture, spinal manipulation, herbalism, homeopathy, and
naturopathy. They suggest research strategies which can evaluate
specific types of CAM therapies and recommend research priorities
including training in basic research methods for the CAM community.
They underscore the need for a range of studies, from small scale
analyses of practice procedures, to large scale surveys of the use
of CAM, through to more tightly controlled clinical research.
The
authors of Alternative Health Care in Canada: Nineteenth-and Twentieth-century
Perspectives, view the current preoccupation with CAM as a social
movement (Crellin et al 1997). They examine a selection of CAM practices
both past and present with a view toward understanding their historical
development. They also address aboriginal traditional medicine and
what they refer to as ‘ethnic’ practices and examine the
interface between these forms of care and CAM practices. The book
emphasizes the challenges posed to CAM by orthodox medicine throughout
history and in the current environment of shifting health care priorities.
The book concludes that while CAM has gained a significant place
in Canadian society, the future growth of CAM remains uncertain
unless it establishes rigorous standards and regulations for its
practices.
Most
recently Michael Goldstein (1999) in Alternative Health Care: Medicine,
Miracle or Mirage? makes the case that a fundamental change is taking
place in society’s orientation to health and healing. Alternative
health care, he argues, represents a true paradigm shift. The author
outlines six points that he believes represent the core of alternative
medicine. These six points are: (1) a belief in holism, (2) an emphasis
on the integration of body, mind and spirit, (3) a view of health
as a positive state on a continuum with illness, (4) a belief that
the body is suffused with the flow of energy, (5) a belief in vitalism,
and (6) a distinctive view of the healing process. Goldstein acknowledges
the difficulties in defining alternative medicine and prefers to
regard it as an identity movement, driven by massive demand. All
of this is occurring within a context of corporate dominance of
health care in the United States. Large corporations are entering
the health care market and influencing the nature and delivery of
conventional medical care. At the same time, the rapid growth of
alternative medicine has made it attractive to big corporations.
In the future, Goldstein sees the forces of consumer demand, combined
with the pressures from managed care, government and the media,
combining to bring alternative health care into the mainstream.
These
books have made important contributions to our understanding of
the psycho-social context of CAM. There remain, however, significant
unexplored issues and contentious unresolved areas in the knowledge
that social scientists have yet been able to develop.
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