Integrative medicine aaron j. michelfelder, md, faafp, faama

The discipline has evolved over millennia by drawing on the religiousbeliefs and social structures of numerous indigenous peoples, by exploiting naturalproducts in their environments, and more recently by developing and validatingtherapeutic and preventive approaches using the scientific method Alternative medicine or fringe medicine consists of practices claimed to have the healing effects of medicine but which are disproven, unproven, impossible to prove, or are excessively harmful in relation to their effect; and where the scientific consensus is that the therapy does not, or cannot, work because the known laws of .

Public health andmedical practices have now advanced to a point at which people cananticipate—and even feel entitled to—lives that are longer and ofbetter quality than ever before in human history.

Yet despite the pervasiveness, power, and promise of contemporary medical science, largesegments of humanity either cannot access its benefits or choose not to do so. More than80 percent of people in developing nations can barely afford the most basic medicalprocedures, drugs, and vaccines.

In the industrial nations, a surprisingly largeproportion of people opt for practices and products for which proof as to their safetyand efficacy is modest at best, practices that in the aggregate are known as complementary and alternative medicine (CAM) or as traditional medicine (TM). Much of this book considers the formidable challenges to advancing human health throughthe further dispersion of effective and economical medical practices.

This chapterconsiders both proven and unproven but popular CAM and TM approaches and attempts toportray their current and potential place in the overall practice of medicine. With globalization, the pattern of disease in developing countries is changing.

Unlike inthe past, when communicable diseases dominated, now 50 percent of the health burden indeveloping nations is due to noncommunicable diseases, such as cardiovascular diseases,diabetes, hypertension, depression, and use of tobacco and other addictive substances. Because lifestyle, diet, obesity, lack of exercise, and stress are importantcontributing factors in the causation of these noncommunicable diseases, CAM and TMapproaches to these factors in particular will be increasingly important for thedevelopment of future health care strategies for the developing world.

Definitions and Domains of Complementary and Alternative Medicine and TraditionalMedicineWe refer to medical practices that evolved with indigenous peoples and that they haveintroduced to other countries through emigration as traditional medicine. We referto approaches that emerged primarily in Western, industrial countries during thepast two centuries as scientific or Western medicine, although we acknowledge thatnot all Western medicine is based on scientifically proven knowledge.

The terms complementary and alternative describepractices and products that people choose as adjuncts to or as alternatives toWestern medical approaches. Increasingly, the terms CAM and Endless varieties of practices are scientifically unproven and poorly accepted bymedical authorities.

For the sake of organizing an agenda for research into theseapproaches, the U. National Institutes of Health has grouped them into fivesomewhat overlapping domains ( /health/whatiscam) as follows:Biologically based practices. These include use of avast array of vitamins and mineral supplements, natural products such aschondroitin sulfate, which is derived from bovine or shark cartilage;herbals, such as ginkgo biloba and echinacea; and unconventional diets,such as the low-carbohydrate approach to weight loss espoused by thelate Robert Atkins.

These kinds ofapproaches, which include massage, have been used throughout history.

Inthe 19th century, additional formal manipulative disciplines emerged inthe United States: chiropractic medicine and osteopathic medicine. Bothoriginated in an attempt to relieve structural forces on vertebrae andspinal nerve roots that practitioners perceived as evoking a panoply ofillnesses beyond mere musculoskeletal pain.

Many ancient cultures assumed thatthe mind exerts powerful influences on bodily functions and vice versa.

Attempts to reassert proper harmony between these bodily systems led tothe development of mind-body medicine, an array of approaches thatincorporate spiritual, meditative, and relaxation techniques. Whereas the ancient Greekspostulated that health requires a balance of vital humors, Asiancultures considered that health depends on the balance and flow of vitalenergies through the body. This latter theory underlies the practice ofacupuncture, for example, which asserts that vital energy flow can berestored by placing needles at critical body points.

This approach uses therapies thatinvolve the use of energy—either biofield- orbioelectromagnetic-based interventions.

An example of the former isReiki therapy, which aims to realign and strengthen healthful energiesthrough the intervention of energies radiating from the hands of amaster healer. Alternative systems of medicine use elements from each of these CAM and TM domains.

For example, traditional Chinese medicine incorporates acupuncture, herbalmedicines, special diets, and meditative exercises such as tai chi. Ayurveda inIndia similarly uses the meditative exercises of yoga, purifying diets, and naturalproducts.

In the West, homeopathic medicine and naturopathic medicine each arose inthe late 19th century as reactions to the largely ineffectual and toxic conventionalapproaches of the day: purging, bleeding, and treatments with heavy metals such asmercury and arsenicals. Demography, Use, Toxicity, and EfficacyThe use of CAM and TM varies widely between and within countries.

The World HealthOrganization (WHO) has published and summarized numerous surveys of use (table 69. In developing nations, TM isthe sole source of health care for all but the privileged few. By contrast, inaffluent countries individuals select CAM approaches according to their specificbeliefs.

For example, as many as 60 percent of those living in France, Germany, andthe United Kingdom consume homeopathic or herbal products. Only 1 to 2 percent ofAmericans use homeopathy, but 10 percent of adults use herbal medicines, 8 percentvisit chiropractors, and 1 to 2 percent undergo acupuncture every year (Ni, Simile, and Hardy 2002).

Use of CAM andTM among patients with chronic, painful, debilitating, or fatal conditions, such asHIV/AIDS and cancer, is far higher, ranging from 50 to 90 percent (Richardson and Straus 2002). Estimated Use of CAM and TM by Patients and PractitionersWorldwide.

There is remarkably little correlation between the use of CAM and TM approaches andscientific evidence that they are safe or effective. For many CAM and TM practices,the only evidence of their safety and efficacy is embodied in folklore.

Beginningmore than 1,500 years ago, data on the use of thousands of natural products wereassembled into impressive monographs in China, India, and Korea, but thesecompendiums—and similar texts from Arabic, Egyptian, Greek, and Persiansources and their major European derivatives—are merely catalogs ofproducts and their use rather than formal analyses of safety and efficacy. Many people who today choose herbal products in lieu of prescription medicationsassume that because these products are natural, they must be safe, even when theevidence for this assertion is essentially anecdotal.

Recent studies have shown thatherbals are highly variable in quality and composition, with many marketed productscontaining little of the intended ingredients and containing unintendedcontaminants, such as heavy metals and prescription drugs. A few herbals are bannedoutright in several countries.

Comfrey and kava have been associated with liverfailure, aristolochia with genitourinary cancer (De Smet 2002), and ephedra with heart attacks and strokes (Shekelle and others 2003). More important,herbals contain ingredients that can accelerate or inhibit the metabolism ofprescription drugs (table 69.

John's wort, which affects the metabolism of nearly 50percent of all prescription drugs (Markowitz andothers 2003). The cumulative data on the pharmacological and potentialadverse effects of herbal supplements now dictate that patients discuss their use ofsupplements with knowledgeable practitioners before initiating treatment.

Some Natural Products That May Alter Drug Actions. As to evidence of the efficacy of CAM and TM approaches, thousands of small studiesand case series have been reported over the past 50 years.

Few were rigorous enoughto be at all compelling, but they are sufficient to generate hypotheses that are nowbeing tested in robust clinical trials. The existing body of data already shows thatsome approaches are useless, that for many the evidence is positive but weak, andthat a few are highly encouraging (table69.

Economics of Complementary and Alternative Medicine and TraditionalMedicineAlthough social, medical, and cultural reasons may account for why people in a givencountry prefer CAM and TM to conventional (Western) medicine, economic forces arealso at play.

This section describes the socioeconomic determinants of seekingtreatment from traditional healers and providers of CAM; reviews the evidence on thecost-effectiveness of CAM and TM; and discusses cost-effective approaches toregulating, improving, and expanding the use of CAM and TM. Much of this evidence isfrom industrial countries; few studies have been conducted in or are applicable tolow- and middle-income countries.

First,the CAM and TM modalities discussed in this section may not be used in manydeveloping countries.

Second, the limited data on cost-effectiveness may not beapplicable in the case of those countries. Nevertheless, the data give a roughpicture of the relative cost-effectiveness of a number of CAM and TM practices.

Economic Factors That Influence the Use of Complementary and AlternativeMedicine and Traditional MedicineUsers of CAM and TM approaches choose health practices that resonate with theirbeliefs about health (Astin 1998). Although economic factors play a role in this choice, the underlying incentivesare not always predictable.

For instance, a common misconception is thatpatients opt for CAM and TM services because they are cheaper alternatives toconventional medical care. Even though there are certainly instances when thecost of treatment using CAM or TM is much cheaper than the cost of accessing aconventional medical service, several studies have found that CAM and TM costthe same or more than conventional treatments for the same conditions (see, forexample, Muela, Mushi, and Ribera2000).

At least one study has shown that financial considerations are rarely the primaryfactor in choosing a traditional healer, ranking behind such reasons asconfidence in the treatment, ease of access, and convenience (Winston and Patel 1995). In the UnitedStates, the average cost of a single visit to a Navajo healer was US$388, andthe average annual cost of using a traditional healer represented roughly afifth of the reported annual income of respondents in a survey (Kim and Kwok 1998).

The high cost ofusing a healer was cited as the most common barrier to seeking care from thissource. In Kenya, the average charge per patient per visit to a TM practitionerwas K Sh 46 (US$4 in 1981), which was significantly greater than the averagecharge per visit even in private health care facilities (Mwabu, Ainsworth and Nyamete 1993).

Finally, a survey inZimbabwe reported that the median cost of consulting an herbalist was Z$23 pervisit, compared with Z$1 for a government clinic and Z$29 for a private doctor(Winston and Patel 1995). The samesurvey found that outcomes tended to be better when patients went to governmentclinics (67.

3 percent of visits resulted in a good outcome) than when patientsconsulted herbalists (50 percent of visits resulted in a good outcome). TM is not always more expensive than conventional medicine, however.

Surveyrespondents in Ghana reported that the cost of malaria treatment at a healthclinic ranged from ¢1,900 to ¢3,000 (US$1. 00 in1997), treatment at home using drugs bought from pharmacies or health careworkers ranged between ¢200 and ¢1,000 (US$0. 70),and treatment by an herbalist was virtually free (Ahorlu and others 1997). Another common misconception is that the poor are more likely to use TM.

At leastone study shows that this may not be true. In Zimbabwe, the mean monthly incomeof households visiting an herbalist, Z$877, was greater than the mean monthlyincome of households using government clinics, Z$718 (Winston and Patel 1995).

Although some traditional healers charge more than conventional practitioners,their fees may be negotiable, the method of payment may be flexible (often oncredit or in exchange for labor), and payment may be contingent on outcome. Theavailability of an outcome-contingent contract favors TM over Western medicinewhen the disease condition requires providers to both exert effort in curingpatients and induce patients to comply with their recommendations.

Nonetheless,this strategy may be difficult to apply to the larger health care system. Furthermore, patients tend to seek care from traditional healers for conditionssuch as mental illness, impotence, and chronic disorders, which they perceive asrequiring greater involvement by the extended family and kinship group.

Accordingly, the availability of financial support for seeking treatments forthese disorders is greater than it is for illnesses such as malaria or diarrhea,for which patients more often seek conventional treatment. Few published data are available on the financial costs of TM in low- andmiddle-income countries.

The data presented here on the use of traditionalhealers are extracted from the World Bank's living standards surveys in Vietnamto provide one nationally representative snapshot of the situation. Of 28,254individuals in the sample, 10,033 had consulted a health care provider in thefour weeks preceding the survey.

These consultations included both home visitsand visits to a provider. Of the 10,033, 1,829 had been to a public provider,1,431 to a private provider, 7,650 to a pharmacy, and 259 to a traditionalhealer.

1 The most common reasons for visiting a traditional provider were headache,followed by cough and fever. The per visit drug cost for consulting atraditional healer was D 46, and the total cost per visit was D 51, comparedwith drug costs of D 38 and total costs of D 41 for going to a privateclinic.

One commonly cited motivation for using CAM and TM is that their use might lowerthe incidence and costs of side effects associated with conventional treatments,but the published evidence on this point remains mixed. There is some evidencethat CAM is used in addition to conventional treatments (Thomas and others 1991), but CAM may also have theeffect of displacing conventional treatments.

An outpatient survey found that,of 246 patients who had been receiving conventional treatment from the RoyalLondon Homeopathic Hospital since the onset of care, a third had halted theirconventional treatment and another third had reduced their intake ofconventional medication (van Haselen2000). 2 The extent to which homeopathic treatment displaced conventional treatmentvaried by indication.

The use of homeopathic treatment often replacedconventional treatments in patients with skin and respiratory infections; inpatients with cancer, its use was purely complementary and therefore added tooverall health care costs. Thomas and others (1991) observe thatpatients who use CAM and TM also commonly access conventional medical care.

Inindustrial countries, most CAM usage complements conventional care, but this isalso common in developing nations. For instance, Mwabu (1986) provides evidence from Kenya that patientsare likely to use more than one type of provider from the range of thoseavailable, such as government facilities, mission clinics, private clinics,pharmacies, and traditional healers.

Furthermore, the choice of provider dependson patients' illness, condition, socioeconomic status, and education Will duct tape cure my warts? Examining Complementary and Alternative Medicine National Center for Complementary & Alternative Medicine (NCCAM) established http://nccam.nih.gov/; First full scale article in JAMA on herbal medicine; Office of Cancer Complementary and Alternative Medicine (OCCAM) established .

Complementary and alternative medicine - slideshare

Finally, the quality of care—including efficiency of service andwaiting time at government and private clinics—is an importantdeterminant of whether patients choose to go to traditional healers. Mosttraditional healers surveyed in a second study referred patients to Westernpractices for treatment when necessary (Mwabu, Ainsworth, and Nyamete 1993).

Economic EvidenceAlthough most studies tend to focus on a specific CAM or TM practice, Sommer, Burgi, and Theiss (1999) lookedmore broadly at whether the provision of CAM and TM services through prepaidhealth plans or government insurance reduces the overall costs of health careand found that it does not. A possible reason is that few individuals who areoffered access to CAM use them, and those who do might access those services inaddition to, not in place of, more conventional health services.

Studies that compare the cost-effectiveness of different CAM and TM approachesusing the same analytical framework are rare. One such study in Peru looked atthe costs and cost-effectiveness of treatment using conventional medicine and TM(EsSalud and OPS 2000).

Complementary medical practices evaluated included acupuncture, homeopathy, taichi, meditation, reflexology, hydrotherapy, naturopathy, and massage. Patientswere enrolled in either the Western medicine group or the CAM group.

Patientswere not randomized between the two treatment groups, but they were matched bydisease pathology and severity, age, and sex. Furthermore, selected patients hadcompleted at least one year in the health system, as the investigators reasonedthat this would enable them to evaluate their follow-up.

Overall, theinvestigators found that complementary medicine was between 53 and 63 percentless expensive than conventional medicine for achieving equivalent levels ofeffectiveness. Complementary medicine was especially cost-effective forosteoarthritis, hypertension, facial paralysis, and peptic ulcers.

The rest of this section looks at the economic evidence on specific forms of CAMor TM. AcupunctureLindall's (1999) study finds thatan acupuncture referral for musculoskeletal conditions costs a mean ofUS$422, roughly 60 percent less than the cost of referral to a Westernpractitioner.

However, this study was not randomized, and patients had tohave failed first-line drug treatment before being offered the choice ofsecond line-treatment, either with acupuncture or with Western medicine. HomeopathyEvidence indicates that the cost of homeopathic medication is lower than theaverage cost of allopathic products, which would be an economic factor infavor of its use if homeopathy were proven to be effective.

A study by theNational Health Service in the United Kingdom found that the drug costsassociated with homeopathy were lower than those of allopathic practitioners(Swayne 1992). A four-yearstudy of 100 patients that compared homeopathic drug costs with those ofconventional drugs found an average cost saving of US$96 during the studyperiod for those using homeopathic drugs (Jain 2003).

AyurvedaA study that compared medical expenditures over a four-year period forparticipants in a comprehensive program of ayurvedic-based natural medicine(which included antioxidant strategies, mind-body medicine, and othertechniques) with participants whose expenditures were covered through aBlueCross BlueShield health insurance plan found that the expenditures forthe ayurvedic group were 50 percent lower per person (Orme-Johnson and Herron 1997). However, the studywas not randomized and failed to control for the inclination of only asubset of people to accept and remain compliant with ayurvedicapproaches.

ChiropracticSome studies found that spinal manipulation is less expensive thanconventional treatments for episodes of back pain. One nonrandomized studyfound that the cost of chiropractic treatment over a five-year period,including both provider costs and equipment costs (US$28,902), was 24percent less than the cost of Western pain therapy (US$38,029) (Kumar, Malik, and Demeria 2002).

Moreover, 15 percent of patients in the chiropractic group were able toreturn to work, compared with none in the control group. However, other larger and better-controlled studies failed to find adifference between chiropractic and physical therapy in terms of eitheroutcomes or costs (Cherkin and others1998; Skargren and others1997; Skargren, Carlsson, andOberg 1998).

A study of adults with low back pain who wererandomly assigned to physical therapy or chiropractic manipulation or werejust given an educational booklet found no significant differences in eitherthe mean costs of care or the outcomes between the physical therapy andchiropractic groups (Cherkin and others1998). Three-quarters of the participants in thesegroups—who incurred costs of roughly US$430 over the two-yearperiod of the study—reported that their outcome was either good orexcellent, compared with a third of those who were assigned booklets;however, the mean cost of care for the booklet group was only US$153 for thetwo-year period.

Mind-Body TreatmentsLittle evidence is available on the cost-effectiveness of practices such asmeditation and yoga, but the cost of acquiring the skills required for thesepractices, as well as the time costs of practicing them, are so low relativeto conventional medicine that evidence of their clinical effectiveness mightsuffice to justify their use on economic grounds. Available evidence fromclinical studies suggests that mind-body treatments can be cost-effective(Caudill and others 1991;Friedman and others 1995;Hellman and others 1990; Sobel 1995).

Blumenthal and others (2002) find significantdeclines in coronary events and in predicted costs of care for patients whowere assigned to a one-and-a-half-hour long weekly class on stressmanagement, relative to usual care for each of the first two years offollow-up and after five years. Beyond Cost-Effectiveness: Ancillary Benefits and Costs of CAM and TMAlthough cost-effectiveness is one guiding rationale for determining resourceallocations for expanding (or restricting) access to CAM and TM, additionalsocietal benefits and costs, such as effects on biodiversity, must also beconsidered.

CAM and TM could provide a rationale for conserving species, butoverharvesting of endangered species for medicinal purposes is also a concern. According to WHO, 85 percent of the world's population (principally those indeveloping countries) depends on plants for medicine, and 25 percent ofprescription drugs have an active ingredient derived from a flowering plant(Cox 2001).

The possibleextinction of medicinal plants is of concern not only to developing countriesbut also to industrial countries, as in the cases of poaching of Americanginseng and overharvesting of native saw palmetto. Similarly, the reliance ofChinese TM on tiger genitals, bear gallbladders, and black rhinoceros horns hasplayed an important role in poaching and threatens to wipe out these megafauna.

Local knowledge and culture regarding the uses of medicinal plants may beimportant determinants of whether a certain species will survive (Etkin 1998). In addition to thebiodiversity value of these saved species, scientists may be able to analyzethese plants for potential clinical application on a broader scale than TMpermits.

Although preserving traditional knowledge of healing practices helpspreserve the culture and identity of indigenous populations, CAM and TM mayimpose significant costs. In such instances, promoting conventional treatmentsthat do not depend on endangered species may bring important benefits tosociety.

Expanding the Beneficial Use of Complementary and Alternative Medicine andTraditional MedicineDespite the uncertainty about the clinical efficacy and cost-effectiveness of certainCAM and TM practices, expansion of their use in instances in which moderate evidenceof their efficacy and good evidence of their safety exists could yield health,social, and economic benefits. A number of surveys show that local pharmacies arethe primary source of treatment for many ailments, especially in rural areas wheregovernment or private clinics are less accessible.

In these situations, improvingthe quality of TM might serve as an effective substitute for allowing theunregulated use of conventional medical treatments. Training traditional healers issubstantially less expensive than training doctors or nurses.

A study of 52traditional healers interviewed as part of a survey in Kenya estimated that theaverage out-of-pocket (cash) costs of training to be a traditional healer were K Sh418 (US$40 in 1981) (Mwabu, Ainsworth, andNyamete 1993). Traditional healers can also be recruited into a more broadly based system fordelivering public health; for example, with additional training, traditional healerscan serve as primary health care workers (Hoff1997) and provide advice on such matters as sexually transmitted diseasesand oral rehydration therapy (Nations and deSouza 1997; Nations and others1988; Ndubani and Hojer 1999).

In addition, permitting access to CAM and TM within the context of the conventionalhealth care system would facilitate access to multiple health services at onelocation. Comprehensive policy on CAM and TM is lacking in most countries, including the UnitedStates.

According to the 1994 Dietary Supplement, Health, and Education Act, theU. Food and Drug Administration cannot require proof that dietary supplements andherbal products are safe and effective before they are sold, although it is chargedwith requiring good manufacturing practices. The quality of herbal products is notregulated, and herbal products typically differ from source to source and from batchto batch in terms of their component ingredients and respective amounts and in termsof whether they contain contaminants.

In the United States, no single entity isresponsible for all aspects of CAM and TM control, education, information, andresearch, and no national, voluntary system of self-regulation exists. Nationalnongovernmental organizations, such as the Accreditation Commission for Acupunctureand Oriental Medicine, the American Board of Medical Acupuncture, the Council ofChiropractic Education, the Council of Homeopathic Education, and the Commission onMassage Therapy Accreditation, accredit education in some CAM and TM fields, butsuch accreditation bodies do not exist in many developing countries.

Nearly allcountries lack rigorous research training programs in CAM and TM. A common misperception is that in the developing world CAM and TM is used primarilyby poorer, uneducated populations, while in industrial countries it is used more byaffluent and better-educated segments of the population (Eisenberg and others 1998).

In both settings, relativelylittle evidence supports this view. Many investigators have failed to criticallyassess the use of CAM and TM by minority and immigrant populations in Westernnations.

In Africa, nearly 85 percent of the population uses TM, often as the onlyway to obtain primary health care, and wealthier people in developing countriesoften use TM (WHO 2002). Investments inimproving the quality and consistency of TM could reduce the cost of health caredelivery, especially for chronic conditions such arthritic pain and AIDS, where TMinterventions may improve patients' sense of well-being, appetite, and energy.

Atthe same time, in the absence of resources to extend the public healthinfrastructure, a network of certified CAM and TM providers could provide theinfrastructure for delivering other care, such as immunizations and maternal-childhealth programs. Recognizing the redistributive nature of investment in TM is important.

Indigenouspeople will seek the help of traditional healers because of proximity, familiarity,and trust. Investments in TM could therefore be used strategically to increaseaccess to conventional preventive and therapeutic care.

Including the traditionalhealer as part of the health care team may thus be an important strategy both toattract patients and to upgrade the skills and training of traditional healers. How equity is affected by the proportions in which different condition-specificinterventions are combined and how other interventions (regulations, tax policy,managerial changes) are likely to affect equity need to be studied.

Given that themajority of indigenous populations in developing countries use TM for their primaryhealth care, the availability, safety, and affordability of TM, including herbalmedicines, should be ensured as a matter of equity. One way to do this is bysupporting local production of safe and effective herbals such as artemisia ataffordable prices.

In addition, rigorous research on TM should be supported. WHO iscurrently conducting collaborative studies on herbal treatments for HIV/AIDS,malaria, sickle cell anemia, and diabetes.

Ineffective or unsafe herbal productsidentified by such studies should be removed from use, while those with provenefficacy and safety should be made available for therapeutic use. Lessons Learned and ImplementationThe pervasiveness of different modalities of TM and CAM varies greatly from countryto country.

For example, in China, where traditional Chinese medicine is wellintegrated into the health system, many different modalities may be used to treat agiven condition. In the United States, by contrast, CAM programs are slowly beingintegrated with conventional medicine.

Several medical schools have nascent CAMprograms and have integrated them into medical school curricula to differingdegrees. One of the more acclaimed programs of this kind in the United States isthat developed by Andrew Weil at the University of Arizona Health Sciences Center.

His Integrative Medicine Fellowship Program trains physicians in CAM and TM andstrives to produce a new delivery model whereby physicians, patients, and nursesform a healing team for the care of the patient. However, this program needs to becritically evaluated before its adoption by more institutions can be urged.

Despite the complexity, diversity, and controversy surrounding CAM/TM approaches,some notable success stories reveal the influence of globalization, wherebymodalities discovered in the developing world have been adopted in the West, with orwithout modifications, and vice versa. ArtemisininArtemisinin is a recently developed, active metabolite of artemisia, an herbalextract that has been used in China for centuries to treat fever.

Chinesescientists determined the active ingredient of the herbal in the 1970s, andWestern pharmaceutical companies have developed several derivatives as drugs foruse against resistant Plasmodium malaria (Li and others 2000). Randomized clinical trials haveshown that one such drug, dihydroartemisinin-piperaquine, is effective againstdrug-resistant Plasmodium falciparum malaria (Hien and Dolecek 2004).

Anotherartemisinin derivative, artesunate, was shown to increase parasite clearance andreduce the gametocyte count when added to existing drugs to combat malaria(Adjuik and others 2004). AcupunctureAnother CAM and TM modality that has considerable acceptance is acupuncture.

Manypain management clinics, hospitals, and academic centers in the West now provideacupuncture services, and some insurance companies reimburse for acupunctureservices. Rigorous clinical trials have demonstrative positive efficacy in twoareas: (a) management of postoperative nausea and emesis (Shen and others 2000) and (b) amelioration of the painof chronic osteoarthritis (Ezzo and others2001; Soeken 2004; Tukmachi and others 2004).

Studiesproviding rational explanations of the mechanisms whereby acupuncture might beachieving its effects complement the evidence about its efficacy; for example,one mechanism of action appears to involve opioid-dependent brain pathways. Thiskind of two-step process—that is, initial demonstration of clinicalefficacy followed by scientific research into the mechanism ofaction—is one way that CAM and TM will gain scientific acceptance andintegration into conventional medicine.

Chiropractic Medicine and OsteopathyChiropractic medicine was invented in the American heartland during the waningyears of the 19th century. It uses spinal manipulation to treat an array ofconditions thought to arise because of abnormal alignment of or stresses onvertebrae, most often in patients with musculoskeletal complaints.

Two aspectsof chiropractic medicine are success stories. First, even though practitionersof conventional medicine ostracized practitioners of chiropractic medicine inthe late 19th century and the first half of the 20th century, it has graduallyevolved into a viable healing discipline that is increasingly accepted by theconventional medicine community.

The evolution of chiropractic can be comparedwith that of osteopathy. Osteopathy was developed in the United States inparallel with chiropractic, but the field elected to accommodate rather thanreject allopathic techniques.

The second success story is research showing that chiropractic manipulation forlow back pain is superior to bed rest, physical therapy, or provision of aneducational booklet (Cherkin and others1998). Chiropractic manipulation has also shown results comparable tothose achieved with nonsteroidal, anti-inflammatory drugs in alleviating backpain (Straus 2004).

HomeopathyHomeopathy is a success in terms of its broad appeal and use, not because of thestrength of evidence supporting it. Indeed, few conventional scientists andphysicians find homeopathy to be plausible.

According to the "principle ofsimilars" underlying homeopathy, practitioners choose remedies that, when givenin high concentrations, produce symptoms similar to those that the patientpresents with. The substance is then put in solution and serially diluted by asmuch as 1060, well beyond the point defined by Avogadro's number (atwhich a single molecule of the original substance could remain in the solution).

Homeopathy claims that the acts of serial diluting and vigorous shaking imprintinformation into water so that medicinal properties are retained even when no orfew molecules of the starting medicine are present. As implausible as this claim may seem, homeopathy is used worldwide with reportedsuccess (Jonas, Kaptchuk, and Linda2003).

Randomized controlled trials have suggested that it might beeffective for treating influenza (Vickers andSmith 2000), allergies (Taylor andothers 2000), and postoperative ileus (Barnes, Resch, and Ernst 1997). However, critics havequestioned the quality and analyses of these trials.

Some have questioned thevalidity of pooling data from trials of different populations, interventions,and outcome measures, as several reviews of homeopathy have done. Jonas, Kaptchuk, and Linda (2003, 393)assert that "there is a lack of conclusive evidence on the effectiveness ofhomeopathy for most conditions.

Homeopathy deserves an open-minded opportunityto demonstrate its value by using evidence-based principles, but it should notbe substituted for proven therapies. "Mind-Body InterventionThe work of David Spiegel at Stanford University on group support for breastcancer patients excited wide interest in the potential value of mind-bodyinterventions (Spiegel and others1989).

The study was a randomized controlled trial with a 10-yearfollow-up involving 86 women with metastasized breast cancer. A one-yearpsychosocial intervention consisting of weekly supportive group therapy withself-hypnosis for pain showed that the mean survival time in the treated groupwas 37 months, compared with 19 months for the control group.

Moreover, Spiegel (1994) notes that appropriatepsychotherapy (both group and individual) not only reduced depression andanxiety and improved coping skills, but also saved money by reducing the numberof office visits, diagnostic tests, medical procedures, and hospitaladmittances.

Complementary and alternative medicine - disease control priorities

The Research and Development AgendaThe lack of product quality and consistency and the absence of compelling data on thesafety and efficacy of most CAM and TM approaches present major challenges to anyeffort to optimize the distribution of precious health resources Who can do my alternative medicine presentation US Letter Size Academic British confidentiality Here are some practical tips and techniques that will help you write consistently impressive essays 20 Mar 2014 - For many such students, each essay brings with it the challenge of making it that little bit better than the last .

These difficultiesalso pose opportunities for research.

Other formidable challenges include thevariability in training, credentialing, and licensing CAM and TM practitioners. Increasingly, efforts are being made in several countries to regulate both productsand practitioners.

Ultimately, stringent controls on training, practices, andproducts must be complemented by rigorous research to ascertain which approaches aresafe and effective—and for which indications. The global use and potential effect of CAM and TM practices, the lack of adequatedata validating their safety and efficacy, and the existence of highly effectiveconventional alternatives for many of them dictate that resources should be devotedto fuller characterization and standardization of CAM and TM approaches.

Investingprecious resources in integrating such approaches further into health careinfrastructures can be justified only on the basis of compelling data. This pointleads to the question of what constitutes a rational agenda for this work.

For resource-rich industrial nations, one model for CAM and TM research is that beingimplemented by the National Center for Complementary and Alternative Medicine(NCCAM) of the U. In 2004,NCCAM planned to invest US$117 million in research and research training.

It issupporting some 800 individual projects at present, including studies of thecomposition of natural products and their pharmacological effects, studies of theneurobiological mechanisms of acupuncture and the placebo effect, and clinicaltrials with 30 to 30,000 participants. NCCAM now has a strategic plan for itsinternational programs that emphasizes research, training, and efforts to learnabout the rich, indigenous TM heritage.

Australia, through a government agencysimilar to NCCAM, is conducting research and training programs in collaboration withits indigenous people. Although the scope of NCCAM's research agenda is larger thanwhat most other nations could accommodate, its underlying philosophy should beuniversal.

That is, the standards for research into CAM and TM approaches should beno different from those used in conventional biomedical research. Both CAM and TM and biomedical practitioners need to understand the strengths,limitations, and contributions of their particular approaches so that they can worktogether in ways that ensure the best possible care for their patients and theachievement of their shared goals of improved individual and public health.

Oncethese issues have been addressed, countries could devote additional resources tostudying those CAM and TM approaches that appear to be the most promising inrelation to their most pressing public health problems. Some priority areas for CAMand TM research are widely applicable, including studies of approaches to palliatechronic pain and suffering, relieve depression, help release the grip of addictivesubstances, and slow the progression of degenerative disorders such as arthritis anddementia.

Artesunate Combinations for Treatment of Malaria:Meta-Analysis. Malaria-Related Beliefs and Behavior in Southern Ghana:Implications for Treatment, Prevention, and Control.

Why Patients Use Alternative Medicine: Results of a NationalStudy. Homeopathy for Postoperative Ileus? AMeta-Analysis.

Medicinal Properties of Echinacea: A CriticalReview.

A Randomized Trial of Acupuncture as an Adjunctive Therapy inOsteoarthritis of the Knee.

Usefulness of Psychosocial Treatment of Mental Stress-InducedMyocardial Ischemia in Men. Decreased Clinic Use by Chronic Pain Patients: Response toBehavioral Medicine Interventions. A Comparison of Physical Therapy, Chiropractic Manipulation, andProvision of an Educational Booklet for the Treatment of Patients with LowBack Pain. A Review of the Evidence for the Effectiveness, Safety, and Costof Acupuncture, Massage Therapy, and Spinal Manipulation for BackPain.

Cardiovascular and Endocrine Effects of Acupuncture inHypertensive Patients.

Trends in Alternative Medicine Use in the United States,1990–1997: Results of a Follow-Up National Survey.

PubMed: 9820257 EsSalud and OPS (Organizaci nPanamericana de Salud Pan American Health Organization ). "Estudiocosto-efectividad: Programa Nacional de Medicina Complementaria. Indigenous Patterns of Conserving Biodiversity: PharmacologicImplications.

Acupuncture for Osteoarthritis of the Knee: A SystematicReview. Behavioral Medicine, Clinical Health Psychology, and CostOffset. Randomized, Double-Blind, Placebo-Controlled Trial of SawPalmetto in Men with Lower Urinary Tract Symptoms. Piperaquine against Multidrug-Resistant Plasmodiumfalciparum Malaria. The Study of the Effectiveness of Two Group Behavioral MedicineInterventions for Patients with Psychosomatic Complaints. Traditional Health Practitioners as Primary Health CareWorkers. Pharmacological versus Non-Pharmacological Prophylaxis ofRecurrent Migraine Headache: A Meta-Analytic Review of ClinicalTrials. PubMed: 2146583 Hypericum Depression Trial Study Group.

The role of complementary and alternative medicine | the bmj

Milk Thistle for the Treatment of Liver Disease: A SystematicReview and Meta-Analysis.

Does Homeopathy Reduce the Cost of Conventional Drug Prescribing?A Study of Comparative Prescribing Costs in General Practice.

"Cranberries for Preventing Urinary Tract Infections. " Cochrane DatabaseSystematic Review CD001321 PMID:15106157 .

Ginkgo Biloba Extract EGb 761® in Dementia:Intent-to-Treat Analyses of a 24-Week, Multicenter, Double-Blind,Placebo-Controlled, Randomized Trial. Complementary and Alternative Approach for Menopause: A Review ofRandomized, Controlled Trials.

Treatment of Chronic Pain with Spinal Cord Stimulation versusAlternative Therapies: Cost-Effectiveness Analysis.

Efficacy of Chinese Acupuncture on Postoperative OralSurgery. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, andEndodontics.

A Placebo-Controlled, Double-Blind, Randomized Trial of anExtract of Ginkgo Biloba for Dementia, North American EGb StudyGroup. Synthesis of Antimalarial Activity of Artemisinin DerivativesContaining an Amino Group.

Is Acupuncture for Pain Relief in General PracticeCost-Effective? Acupuncture Medicine.

" Cochrane Database Systematic ReviewCD000008 PMID:11416076 20 Mar 2015 - ALTERNATIVE MEDICINE. 1. Presented by:- Seerin Ahmad; 2. Introduction Homeopathy Accupuncture Biofeedback Therapy Magnetotherapy Unani Conclusion Resources; 3. Alternative medicine are interventions that differ from the traditional or conventional biomedical treatment of .

Acupuncture for the Treatment of Cocaine Addiction: A RandomizedControlled Trial.

John's Wort on Drug Metabolism by Induction ofCytochrome P450 3A4 Enzyme. The Paradox of the Cost and Affordability of Traditional andGovernment Health Services in Tanzania.

Health Care Decisions at the Household Level: Results of a RuralHealth Survey in Kenya.

Quality of Medical Care and Choice of Medical Treatment inKenya.

Umbanda Healers as Effective AIDS Educators: Case Control Studyin Brazilian Urban Slums (Favelas) Tropical Doctor. Brazilian Popular Healers as Effective Promoters of OralRehydration Therapy (ORT) and Related Child SurvivalStrategies.

Bulletin of the Pan American Health Organization. Traditional Healers as a Source of Information and Advice forPeople with Sexually Transmitted Diseases in Rural Zambia. Utilization of Complementary and Alternative Medicine by UnitedStates Adults: Results from the 1999 National Health InterviewSurvey.

Side Effects of Complementary and AlternativeMedicine. An Innovative Approach to Reducing Medical Care Utilization andExpenditures.

Hawthorn Extract for Treating Chronic Heart Failure: AMeta-Analysis of Randomized Trials. Long-Term Effects of Glucosamine Sulphate on OsteoarthritisProgression: A Randomised, Placebo-Controlled Clinical Trial.

Complementary and Alternative Medicine: Opportunities andChallenges for Cancer Management and Research. Structural and Symptomatic Efficacy of Glucosamine andChondroitin in Knee Osteoarthritis: A ComprehensiveMeta-Analysis. A Randomized Controlled Trial of Stress Reduction forHypertension in Older African Americans. Efficacy and Safety of Ephedra and Ephedrine for Weight Loss andAthletic Performance: A Meta-Analysis. Electroacupuncture for Control of MyeloablativeChemotherapy-Induced Emesis: A Randomized Controlled Trial.

One-Year Follow-Up Comparison of the Cost and Effectiveness ofChiropractic and Physiotherapy as Primary Management for Back Pain: SubgroupAnalysis, Recurrence, and Additional Health Care Utilization. Cost and Effectiveness Analysis of Chiropractic and PhysiotherapyTreatment for Low Back and Neck Pain: Six-Month Follow-Up. Rethinking Medicine: Improving Health Outcomes withCost-Effective Psychosocial Interventions.

Selected CAM Therapies for Arthritis-Related Pain: The Evidencefrom Systematic Reviews. A Randomized Experiment of the Effects of Including AlternativeMedicine in the Mandatory Benefit Package of Health Insurance Funds inSwitzerland.

A Randomized, Wait-List Controlled Clinical Trial: The Effect ofa Mindfulness-Based Stress Reduction Program on Mood and Symptoms of Stressin Cancer Patients.

Health Caring, Psychosocial Support for Patients withCancer.

Effect of Psychosocial Treatment on Survival of Patients withMetastatic Breast Cancer. Efficacy and Safety of Echinacea in Treating Upper RespiratoryTract Infections in Children: A Randomized Controlled Trial. Randomised Controlled Trial of Homeopathy versus Placebo inPerennial Allergic Rhinitis with Overview of Four TrialSeries.

PMC free article: PMC27460 PubMed: 10948025 Thomas K. Use of Nonorthodox and Conventional Health Care in GreatBritain. PMC free article: PMC1669035 PubMed: 1998760 Tukmachi E.

The Effect of Acupuncture on Symptoms of Knee Osteoarthritis: AnOpen Randomized Controlled Study.

Artemisinin Drugs in the Treatment of Malaria: From MedicinalHerb to Registered Medication. The Economic Evaluation of Complementary Medicine: A StagedApproach at the Royal London Homoeopathic Hospital. "HomeopathicOscillococcinum for Preventing and Treating Influenza and Influenza-LikeSymptoms.

" Cochrane Database Systematic Review CD001957 PMID:10796675 . Individualized Homeopathy as an Adjunct in the Treatment ofChildhood Asthma: A Randomized Placebo Controlled Trial. PMC free article: PMC1746635 PubMed: 12668794 WHO (World Health Organization).

Effect of Magnetic versus Sham-Magnetic Insoles on Plantar HeelPain: A Randomized Controlled Trial. Use of Traditional and Orthodox Health Services in UrbanZimbabwe. PubMed: 8557433 Footnotes1Because some individuals had gone to more than one provider during thefour-week period, the total comes to more than 10,033.

23This study did not take into account the costs of physician time,the costs of laboratory tests, or patients' costs. Copyright © 2006, The International Bank for Reconstruction and Development/The World Bank Group.