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PREFACE

The Social Dynamics of Medical Pluralism

Wayne B. Jonas, M.D.

We are all faced with illness at some time in our lives and most of us end up caring for a loved one who is ill. When illness comes, be it a minor or major problem, we all purport to want basically the same thing - a rapid, gentle treatment that cures us or at least can allay our fears and alleviate our suffering. Yet, despite this apparently common goal the social responses to disease and illness are remarkably varied and differences are often strongly held. Who we approach for help, what we decide is the best treatment for us, how we evaluate success, and when we look for alternatives - depend on many factors including how we conceive of health and disease, what we believe has gone wrong and why, and who we associate with and get advise from. In short, it depends on our models and perceptions of the world, the preferences and values we share, and the perceived benefit we get from associating with trusted others. Even in the age of modern science, decisions about the nature of man, health and illness, its meaning and how to prevent and treat it is primarily a social process. It is logical then that in order to understand the forces that shape any prominent change of behavior toward health care - like the rising popularity of alternative medicine - we must carefully examine those social forces. This is the first book to do this in-depth and is therefore essential reading for anyone who wants to understand this phenomenon, be they scientist or statesman.

"Unofficial" medicine is always an important part of what the public uses in health care. Homeopaths and herbalists, folk practitioners and spiritualists provide a multiplicity of ways to address suffering. The public goes through periods of "enchantment" with un-orthodox medicine. Homeopaths, herbalists, hypnotists, and various "eclectics" were popular and public over hundred years ago. At that time, orthodox physicians had little to no training and there was little regulation of practice. The popularity and use of the unorthodox would vary, depending on the perceived value of orthodox medicine, needs of the public, and changing values in society. With the development of scientific medicine and its dramatic advances in the understanding and treatment of acute and infectious disease these practices largely subsided. (Gevitz, 1988)

The prominence of complementary and alternative medicine (CAM) is now rising rapidly. Two identical survey's of unconventional medicine use in the United States, done in 1990 and 1996, showed that CAM use has increased 45% by the public over that six year period. Visits to CAM practitioners went from 400 million to over 600 million visits per year and the amount spent on these practices rose from $14 billion to $27 billion - most of it not reimbursed. . (Eisenberg et al., 1998) The overwhelming effort now is toward an "integration" of these practices into the mainstream. Seventy five medical schools in the United States have begun to teach about CAM practices (Wetzel, Eisenberg & Kaptchuk, 1998), hospitals have developed complementary and integrated medicine programs, health management organizations and health insurers are offering "expanded" benefits packages that include alternative practitioners and services (Pelletier, Marie, Krasner & Haskell, 1997), and biomedical research organizations are investing more into the investigation of these practices. For example, the budget of the Office of Alternative Medicine at the US National Institutes of Health rose from $5 million to $50 million in 4 years and changed from a coordination office to an independent center. (Marwick, 1998) It appears that complementary and alternative medicine (CAM) has again "come of age".

This trend reflects not only changing behaviors but changing needs and values in modern society. It is the details of these changing values and behaviors that the scholars in this book examine. The book explores the psychosocial determinates of CAM use (Astin, Furnham), the "normalization" of users over time (Blais), how different concepts of the body influence health care practices (O'Connor), the relationship between the growing "fitness" movement and CAM (Goldstein) and the key role of the nature and quality of the therapeutic relationship in health care preferences (Kelner). Chapters also address how CAM practices diffuse throughout society (Valente), the role of health "networks" in determining therapeutic choices (Wellman). Of note is that CAM practices, like most conventional practices, are adopted and "normalized" long before scientific evidence has established safety and efficacy. Key differences in how this occurs however is that in conventional practice procedures are usually introduced by professionalized bodies or industry rather than the public. (McKinlay, 1981) This says something about the nature of public preferences and predicts that new "unconventional" practices will arise as current CAM groups become more "professionalized" and adopted by the mainstream.

This is not the first time that the importance or unorthodox medical practices has risen in prominence. Orthodox medicine usually fights CAM practices by attacking them, limiting access to them, calling them quackery, and penalizing those who practice them. When they persist, mainstream medicine then examines them, finding similarities with the orthodox, and adopting them into normal medical practice. (Worton, 1999) Medicine benefits from their selective integration by abandoning harmful therapies such as mercuralization, finding new drugs such as digitalis, and accepting more rigorous scientific methods with which to test them. (Gevitz, 1988; Kaptchuk, 1998)

We now have sophisticated scientific methods for the application of basic science to clinical practice and for the management of acute and infectious disease. However, current methods for examining chronic disease or practices that have no explanatory model in western terms are not adequately informed by science. (Linde & Jonas, 1999) CAM offers us the opportunity to debate and test new approaches for examining these areas as their importance increases in medicine. (Pincus, 1997) Four authors in this book examine the role of science for informing us about CAM by examining use of the randomized controlled trial (Ernst), naturalistic inquiry (Glik), non-dichotomous models of conceptualizing and researching illness behavior (Pescosolido), and the place of health services research in building a future of "integrated" medicine (Best and Glik).

Other social factors are also influencing the rise of the prominence of CAM. These include a rise in prevalence of chronic disease, increasing access to health information, increased "democratization" of medical care decision making, a declining faith that scientific breakthroughs will have positive effects on personal health, and an increased interest in spiritualism. (Fox, 1997; Starr, 1982) In addition, the public and professionals are increasingly concern over the side effects and escalating costs of conventional health care. (Lazarou, Pomeranz & Corey, 1998; Smith, Freeland, Heffler, McKusick & Team, 1998) As the public's use CAM accelerates, ignorance about these practices by physicians and scientists risks broadening the communication gap between the public and the profession that serves them. (Chez & Jonas, 1997; Eisenberg et al., 1998) This book addresses aspects of these broad influences by examining the reemergence of pluralism in medicine (Sharma), the political consequences of CAM professionalization (Saks), and new strategies for a social and scientific research agenda in CAM (Best and Glik).

If we do not examine more closely the social and scientific forces that shape medicine we are destined to repeat many of the divisive tactics that have characterized the relationship between mainstream and non-mainstream practices of the past. (Jonas, 1998) To adopt alternative medicine without developing quality standards for its practices, products and research is to return to a time in medicine when therapeutic confusion prevailed. Modern conventional medicine excels in the areas of quality healthcare and the use of science and CAM must change to adopt similar standards. Conventional medicine is also the world's leader in the management of infectious, traumatic and surgical diseases, in the study of pathology, and in biotechnology and drug development. All medical practices have the ethical obligation to retain these strengths for the benefit of patients. (Chez & Jonas, 1997)

At the same time, there are important characteristics of CAM that risk being lost in its "integration" with conventional care. The most important of these is an emphasis on self-healing as the lead approach for both improving wellness and for the treatment of disease. All the major CAM systems approach illness first by trying to support and induce the self-healing processes of the person. If recovery can occur from this, the likelihood of adverse effects and the need for high-impact, high-cost interventions is reduced (Jonas, 1999) It is this orientation toward self-healing and health promotion (salutogenesis rather than pathogenesis) that makes CAM approaches to chronic disease especially attractive. (Antonovsky, 1987)

The main "obstacles to discovery" writes Daniel Boorstin, in his book The Discoverers, are "the illusions of knowledge." (Boorstin, 1983) Humans fool themselves by making exaggerated claims of truth, clinging to unfounded explanations and denying observations they cannot explain. In addition, the complexity of disease and the powerful ability of the human body to recover often makes it difficult to apply science to clinical medicine. K.B. Thomas demonstrated that nearly 80% those who seek out medical care get better no matter what hand waving or pill popping we provide. (Thomas, 1994) I call this "The 80% Rule" meaning that data collected on novel therapies delivered in an enthusiastic clinical environment will frequently yield positive outcomes in 70-80% of patients. Often our most accepted conventional treatments are shown to be non-specific in nature (Roberts, Kewman, Mercier & Hovell, 1993) or even harmful (Pratt, 1990) when finally studied rigorously. Their apparent effectiveness in practice is due to the powerful ability of the body to heal (with or without expectation), statistical regression to the mean (a measurement problem), and self-delusion (sometimes called bias). (Jonas, 1994)

It is little wonder, then, that for the majority of physicians and patients there are many therapies, both orthodox and unorthodox, that seem to work. Science has emerged as one of the few truly powerful approaches for mitigating this self-delusionary capacity. It will not continue to be a useful guide to medicine, however, unless we are willing to use it rigorously to examine both the social as well as the statistical forces that shape what we perceive and accept as reality. This book goes a long way in doing that for unorthodox medicine and so for orthodox medicine also. Complementary and alternative medicine is here to stay. It is no longer an option to ignore it or treat it as something outside of the normal processes of science and medicine. Our challenge is to move forward carefully, using both reason and wisdom, as we attempt to separate the pearls from the mud.

References

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