Alternative Medicine--Learning From the Past,
Examining the Present, Advancing to the Future
JAMA 1998 (Nov 11); 280 Editorial: 1616-1618
Wayne B. Jonas, MDMedical practices outside the mainstream of "official" medicine have always been an important part of the public's health care. Healers and herbalists, bonesetters and barbers, shamans and spiritualists have offered the public a multiplicity of ways to address the confusion and suffering that accompany disease. A century ago in the United States there was a period of "enchantment" with unorthodox medicine. Homeopaths, herbalists, psychic and magnetic healers, and "eclectics" proliferated
most with little to no training, regulation of practice, or standards for quality of care. The prominence and configuration of these "irregulars," as they were called, has waxed and waned, depending on the perceived value of orthodox medicine, the needs of the public, and the changing values of society. The prominence of these practices subsided with the development of scientific medicine in this century and its dramatic advances in the understanding and treatment of disease.1
Historically, orthodox medicine fights these practices vigorously by denouncing and attacking them, restricting access to them, labeling them as antiscientific and quackery, and imposing penalties for practicing them. When these therapies persist and even rise in popularity despite this, mainstream medicine then turns more friendly, examining them, identifying similarities they have with the orthodox, and incorporating or "integrating" them into the routine practice of medicine.2 In the past, orthodox medicine has benefited from their selective integration by abandoning ineffective therapies such as bloodletting, adopting new drugs such as digitalis, and developing more rigorous scientific methods with which to test these practices, such as blinding and randomization.2, 3
The increasing popularity of complementary and alternative medicine (now used by more than 40% of the public) reflects changing needs and values in modern society in general.4 This includes a rise in prevalence of chronic disease, an increase in public access to worldwide health information, reduced tolerance for paternalism, an increased sense of entitlement to a quality life, declining faith that scientific breakthroughs will have relevance for the personal treatment of disease, and an increased interest in spiritualism.5-7 In addition, concern about the adverse effects and escalating costs of conventional health care are fueling the search for alternative approaches to the prevention and management of illness.6, 7 As the public's use of healing practices outside conventional medicine accelerates, ignorance about these practices by physicians and scientists risks broadening the communication gap between the public and the profession that serves them.4, 8
Today, the overwhelming effort is toward attempts at "integrating" alternative practices into the mainstream. Sixty percent of medical schools have begun to teach about alternative medicine practices,9 hospitals are creating complementary and integrated medicine programs, health suppliers are offering expanded benefits packages that include the services of alternative practitioners,10 and biomedical research organizations are investing more substantial amounts toward the investigation of these practices. For example, the Office of Alternative Medicine at the National Institutes of Health has just become the National Center for Complementary and Alternative Medicine, with a budget of $50 million. The activities of the Office of Alternative Medicine11 and the publication of this issue of JAMA illustrate that quality scientific research can be conducted and published on alternative medicine topics. It appears that complementary and alternative medicine has again "come of age" in the United States. However, the rush to embrace a new integration of alternative and conventional medicine should be approached with great caution. Alternative medicine, like conventional medicine, has pros and cons, promotes bad ideas and good ones, and promises to hold both benefits and risks. Without critical assessment of what should be integrated and what should not, we risk developing a health care system that costs more, is less safe, and fails to address the management of chronic disease in a publicly responsible manner. The potential risks and benefits of alternative medicine must be examined carefully before heading into a new but not necessarily better health care world.
Risks of Embracing Alternative Medicine
Quality of Care
The formal components of medical physician licensure usually are not required of alternative medicine practitioners. These include the content and length of time of training, testing and certification, a defined scope of practice, review and audit, and professional liability with regulatory protection and statutory authorization complete with codified disciplinary action.12 All 50 states do provide licensure requirements for chiropractic practice, but only about half do so for acupuncture and massage therapy and fewer do for homeopathy and naturopathy. Many of these practitioners operate largely unmonitored.13
Quality of Products
The "natural" products used by alternative medicine practitioners also are largely unmonitored and their quality is uncontrolled. These products are available on the market as dietary supplements and may be contaminated or vary tremendously in content, quality, and safety.14 Garlic, for example, claimed for many years to have cholesterol lowering effects, may not produce such effects if processed in certain ways.15 Thus, even if one product is proven safe and effective, other similar products on the market may have quite different effects that preclude consistent dosing. Fifteen million Americans are taking high-dose vitamins or herbal preparations along with prescription drugs, thereby risking adverse effects from unknown interactions.4
Quality of Science
The use of science for understanding alternative medicine is frequently missing from such practices. Most alternative medicine systems have been largely unchanged for hundreds or thousands of years. Often they begin from the teachings of a charismatic leader that are not advanced with new observations, hypothesis-driven testing, innovation, and peer-review. Claiming that their practices are too "individual" or "holistic" to study scientifically, many alternative medicine practices hide behind anecdote, case series, or "outcomes" research.16 To accept such views is to falsely label conventional medicine as nonholistic and reject the hard-fought gains made in the use of basic biological knowledge, the randomized, controlled clinical trial, and evidence-based medicine for health care decision making.17
To adopt alternative medicine without developing quality standards for its practices, products, and research is to return to a time in medicine when quackery and therapeutic confusion prevailed. Modern conventional medicine excels in the areas of quality health care and the use of science: alternative medicine 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.
Risks of Conventionalizing Alternative Medicine
Healing
Most alternative medicine systems carefully attend to the illness and suffering that accompanies all disease. The time spent with each patient by an alternative medicine practitioner usually exceeds that spent by the average conventional physician, and patients are often more satisfied with their interactions with unorthodox than orthodox medical practitioners.18 Alternative medicine practitioners provide patients with understanding, meaning, and self-care methods for managing their condition. Empowerment, participation in the healing process, time, and personal attention are essential elements of all medicine. These elements are easily lost in the subspecialization, technology, and economics of modern medicine. Conventional medicine must develop a better language for managing illness and suffering or lose this essential message that alternative medicine provides.
Adverse Effects
In the last century, unconventional medicine increased in popularity because of the use of severe treatments such as bloodletting, purging, and toxic metals by conventional medicine.2 The popularity of alternative medicine in this century is also driven by the perception that conventional treatments are too harsh to use for chronic and non–life-threatening disease.6, 7 Iatrogenic disease caused by conventional medicine is a major cause of death and hospitalization in the United States. While some alternative medicine practices have important toxicities, many have reduced potential for adverse effects when properly delivered.19 Conventional medicine can learn from alternative medicine how to "gentle" its approach by focusing on the patient's inherent capacity for self-healing.20
Costs
Skyrocketing costs of conventional medicine also are driving the search for alternatives. Savings from managed care now are maximized and health care costs are predicted to double in the next 10 years.21 If low-cost interventions such as lifestyle changes, diet, supplement therapy, and behavioral medicine can be delivered as substitutes for high-cost drugs and technological interventions, true cost reductions and the compression of morbidity might be achieved.22
If there is a single strength of alternative medicine that risks being lost in its "integration" with conventional care, it is an emphasis on self-healing as the lead approach for both improving wellness and for the treatment of disease. All the major alternative medicine 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.23 It is this orientation toward self-healing and health promotion (salutogenesis rather than pathogenesis) that makes alternative medicine approaches to chronic disease especially attractive.22
The Future of Alternative Medicine
The main "obstacles to discovery," writes Daniel Boorstin,24 are "the illusions of knowledge." Indeed, the capacity of humans to fool themselves by making claims of truth, postulating unfounded explanations, and denying the reality of observations they cannot explain is endless. Science has emerged as one of the few truly powerful approaches for mitigating this self-delusionary capacity. The clinical experimental method, in the form of the randomized, controlled trial, examines to what extent attributions and explanations of these therapies are accurate.25
The goals of medicine, no matter what the label, are the same for all practices.26 Is the current trend toward "integrated" medicine a deluded temptation that will turn out to be a nightmare of unscientific practices? Or will these newfound tools of scientific medicine be used to look deeper into the processes of healing for their utility in treating disease and alleviating suffering? In the last 50 years, powerful social forces have transformed medicine.5 If a new evidence-based "integrated" medicine does emerge, it will likely be subject to the same forces shaping the future of medicine in general. This includes the continued takeover of medicine by managed care, a more refined ability to manipulate individual susceptibilities using nanotechnology, and the ability to track quality of care and individual patient outcomes with networks of information monitoring.27 Research in alternative medicine will help identify what is safe and effective and will further the understanding of biology by exploring, rather than marginalizing, unorthodox medical claims and findings.28 Alternative medicine is here to stay. It is no longer an option to ignore it or treat it as something outside the normal processes of science and medicine. The challenge is to move forward carefully, using both reason and wisdom, as we attempt to separate the pearls from the mud.
Author/Article Information
From the Office of Alternative Medicine, National Institutes of Health, Bethesda, Md.
Reprints: Wayne B. Jonas, MD, Office of Alternative Medicine, National Institutes of Health, 900 Rockville Pike, Bldg 31, Room 5B-37, Bethesda, MD 20892 (e-mail: JonasW@od1em.1.od.nih.gov). Editorials represent the opinions of the authors and The Journal and not those of the American Medical Association
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