Alternative, Complementary, or Integrative?

FROM: Complementary Therapies in Medicine 2003 (mar); 11 (1): 2-3 for premission to reproduce this article!

Guest Editorial

Gary Easthope

Associate Professor (Reader) in Sociology School of Sociology and Social Work,
University of Tasmania, Australia

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In the last thirty years there has been a change in how the non-orthodox therapies and medicines that are described, discussed and critiqued in this journal are identified. Once known as alternative medicine they became complementary medicine and are now beginning to be seen as part of integrative medicine. How has this change in nomenclature occurred? What has driven it and what are the implications for the future of both the orthodox and the non-orthodox?

The first point to note is that there is nothing new in the co-existence of more than one medical tradition. Until the 1900s there were a variety of medical systems in the west of which the two major forms were allopathy and homeopathy. As late as the early 1900s, in some parts of the world (e.g. New Zealand and Tasmania), when the allopaths were in dispute with the state the government put homeopaths in charge of medical services. The dominance of one form of medicine so that all others became alternative was in historical terms short lived, from approximately 1920 until 1980.

What changed in the 1980s was increased consumer demand for health. Health became a commodity that people expected to buy. A vibrant body was to be achieved through attending the gym, jogging, eating the right foods and taking alternative medications and/or visiting alternative therapists.[1] Why and how health became a commodity is still a matter of some dispute among sociologists but all agree it is now a commodity. This commodification took place at the same time as––and was linked to––changing values that included a stress on the natural. Doctors were faced with patients who wanted more than relief from symptoms and a cure for their illness. They also wanted ways to maintain health. During the same period in those countries, such as the UK where the state was considered responsible for health care, governments were moving to make health care more market driven. They consequently demanded of health systems and the doctors in them, that they should be consumer oriented. These pressures from both patients and government meant the patient became a consumer, a client. Faced with consumers who valued "natural" therapies doctors had to take account of their clients' preferences. One means to achieve this without losing clients completely was to see alternative medicine as a complement to orthodox medicine: the term complementary rather than alternative medicine was coined. It was a term that suited both doctors and non-orthodox therapists. Doctors saw such therapists as complementing their work in a similar manner to other allied health workers such as nurses or physiotherapists; useful adjuncts to medical practice. Most complementary therapists also embraced the new terminology as they saw it giving them a partnership with the powerful medical profession. As is often the case the same word meant two different things to two different interest groups. The word obscures, in a way that is useful to both groups, the greater power that orthodox medicine has when compared with non-orthodox medicine.

The increasing importance of evidence-based medicine in the 1990s was one of the forces leading toward the coining of the term integrative medicine. With evidence-based medicine there is no need to explain scientifically why a therapy works, just demonstrate scientifically that it does work. This gave a few non-orthodox therapies, the possibility of demonstrating their efficacy. For most, however, this is difficult or impossible because appropriate placebos are hard to find, and because the Randomised Control Trial (RCT), the gold standard of evidence-based medicine, is problematic for several reasons, e.g. as it demands standardisation of treatment which cannot be applied to many complementary therapies as they treat each individual uniquely. Nonetheless, even the idea of looking at non-orthodox therapies in terms of their outcomes rather than their methods meant, for some doctors, such therapies could be included in an integrated program of treatment.[2] A few doctors take a stronger position arguing bringing in CAM therapies is a way of transforming medicine and bringing it back to a focus on the patient not the disease. [3 and 4] They believe integrative medicine will, like the return to the words of the bible for the protestant, by its focus on the patient not the disease, return medicine to its pure origins.

A strong pressure toward the development of integrative medicine is the increasing control of medicine by global corporate interests. Alternative medicine was a "cottage industry" in the 1970s. Like late nineteenth century orthodox medicine it was run by individual entrepreneurs with little capital and with materials that could be stored in one room or even carried in one bag. By the turn of the last century, the demand from consumers for its products and its therapies meant that many CAM businesses had been floated on the stock exchange. In a matter of a few years mergers and take-overs created enterprises that supplied both orthodox and non-orthodox equipment and/or services; for example, integrated hospitals and chains of integrated clinics in the USA, pharmacies providing complementary medicines and practitioners in Australia and pharmaceutical companies producing vitamin and mineral supplements along with prescription medicines.[5]

Consumer demand and the possibility of testing non-orthodox therapies for their efficacy, coupled with global corporate capital's move into health care, have thus brought orthodox medicine into an uneasy association with non-orthodox medicine. There are several possible routes forward from here. The most unlikely is a merging of the two traditions. They are based on totally different worldviews, e.g. most orthodox practice focuses on the same treatment for the same disease while most non-orthodox focuses on different treatments for each sufferer. More likely is the incorporation of some of the non-orthodox therapies into the orthodox (acupuncture seems to be being incorporated in this way in Australia and the USA), the use of others for specific presenting complaints (e.g. chiropractic for back pain, as has been suggested in New Zealand) and the continued exclusion of others (e.g. crystal healing) into the remnant alternative medicine category.

Whatever the outcome, in the near future, it is clear that doctors are not going to be the major determining factor. The age when they could dismiss alternative therapies as quackery and refuse to have anything to do with them is past. Doctors are no longer the gatekeepers. That role is now in the hands of corporate commercial interests for whom most doctors are now working, even in that bastion of individualist free enterprise, the USA. Although doctors are not pipers who must play the tune set by these commercial interests they can no longer determine who else is allowed to play the music of healing. How far they will be forced by their employers to cooperate with the non-orthodox to produce a harmonious melody or how far each can play different tunes in the same institutions remains a matter for conjecture and empirical research.

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References

1. Easthope G. Consuming health. In: Tovey P, Easthope G, Adams J, eds. The mainstreaming of complementary medicine. London: Routledge, in press.

2. Willis E, White K. Evidence based medicine and complementary medicine. In: Tovey P, Easthope G, Adams J, eds. The mainstreaming of complementary medicine. London: Routledge, in press.

3. R. Smith, Restoring the soul of medicine (Editorial). BMJ 322 (2001), p. 117.

4. R. Snyderman and A.T. Weil, Integrative medicine: bringing medicine back to its roots. Arch. Intern. Med. 162 4 (2002), pp. 395–397.

5. Collyer F. The corporatisation and commercialisation of complementary and alternative medicine. In: Tovey P, Easthope G, Adams J, eds. The mainstreaming of complementary medicine. London: Routledge, in press.

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