Professional Documents
Culture Documents
| Gerard Bodeker, EdD, and Fredi Kronenberg, PhD THE GROWTH OF PUBLIC and “conventional medicine”
interest in and use of traditional refers to “biomedicine” or mod-
medicine and complementary and ern medicine.
alternative medicine (T/CAM) has While much of the momentum
been well documented. Almost in the research and policy arenas
half the population in many in- has been driven by consumer de-
dustrialized countries now regu- mand or continued customary
larly use some form of T/CAM and traditional use, research and
(United States, 42%1; Australia, policy developments to date have
48%2; France, 49%3; Canada, tended to address clinical, regula-
70%4), and considerable use ex- tory, and supply-oriented issues,
Traditional medicine (a term used here to denote ists in many developing countries to the general neglect of wider
(China, 40%; Chile, 71%; Colom- public health dimensions.
the indigenous health traditions of the world) and bia, 40%; up to 80% in African Typically, research has focused
complementary and alternative medicine (T/CAM) countries5,6). Popular use of on efficacy, mechanisms of action
T/CAM has been accompanied and safety of complementary and
have, in the past 10 years, claimed an increasing by a growth in research and asso- traditional therapies. Educational
ciated literature, with an increase and training efforts, particularly
share of the public's awareness and the agenda of in an evidence-based approach in industrialized countries, have
medical researchers. Studies have documented that over the past decade.7 In develop- involved medical students and
ing countries, where T/CAM has conventional health care practi-
about half the population of many industrialized long been practiced both within tioners.10–12 Regulation of practi-
and outside the dominant health tioners and guidelines for licens-
countries now use T/CAM, and the proportion is as care system, interest has been ing and establishment of
high as 80% in many developing countries. building over the past decade for standards of practice and self-reg-
a policy framework for T/CAM ulation have only recently been
Most research has focused on clinical and ex- within national health care sys- considered in industrialized coun-
tems, and some guidelines have tries.13,14 Only 25 of the 191
perimental medicine (safety, efficacy, and mecha- been created.8,9 World Health Organization
nism of action) and regulatory issues, to the general The term “traditional medi- (WHO) member states have na-
cine” is used here to denote the tional policies on T/CAM. The
neglect of public health dimensions. Public health indigenous health traditions of newest WHO policy on T/CAM
the world; “complementary and focuses attention on regulation as
research must consider social, cultural, political, alternative medicine” primarily well as safety and efficacy issues.6
and economic contexts to maximize the contribution refers to methods outside the A concerted effort by public
biomedical mainstream, particu- health professionals to develop a
of T/CAM to health care systems globally. larly in industrialized countries; comprehensive view of the field,
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coverage for T/CAM is only par- chronic conditions that are costly Council serves as a catalyst to
tial (the United Kingdom, Japan, to society, such as chronic pain thought and discussion.
Germany, Australia, the United and arthritis, and more life-
States) or nonexistent (e.g., most threatening diseases, such as EQUITY
African countries; see also “Sus- heart disease, cancer, and HIV-
tainability and Integration” in this related illness.25–27 In poorer In industrialized societies, use
article). In Great Britain there is a countries, the search for effective of complementary medicine has
growing trend for the National and affordable treatments for been found to be associated with
Health Service to pay for the epidemic diseases such as higher income and higher educa-
services of complementary pro- malaria and opportunistic infec- tion.1,16,17 Yet for ethnic minorities
viders.24 Additionally, as growing tions associated with AIDS is in those same societies, tradi-
T/CAM markets lead to new driving renewed interest in tradi- tional medicine may at times be
economic possibilities, research tional medicine, although herbal the first-line treatment for the
and business interests may shift medicines are not always the first poor and those who do not speak
from providing affordable health treatment choice.6 Yet we do not the language of the dominant so-
care to developing products that have adequate data on current ciety. Inadequate and expensive
can be marketed. patterns of use and effectiveness conventional medical services are
Questions in this area include of the various treatments being
“
the following: Is the public get- used alone and in combination.
ting value for its money? What Additional information is needed In developing countries, and in ethnic
modalities are safest and most on health concerns of the elderly,
enclaves in industrialized countries,
cost-effective for managing the women, and children. And in-
conditions that impose the largest creasingly, patients are expecting the affordability, availability, and cultural
burden on national health budg- health professionals to guide familiarity of traditional medicine . . .
ets? Do T/CAM modalities con- them, on the basis of either for-
tribute cost savings by preventing mal evidence or clinical experi- contribute to the continued use of
illness? Why are people paying ence, in making decisions about traditional medical providers
”
out of pocket for complementary whether T/CAM or conventional
and medicines.
medical services when they have approaches work better, or
free conventional health services whether they might best be used
available, as in Great Britain, or together. factors in such reliance on tradi-
when they may have insurance tional medicine. “Complemen-
coverage for conventional ap- A POLICY FRAMEWORK tary” medicine in these situations
proaches, as in the United States? is not complementary, since basic
What impact does insurance cov- There are other important is- conventional medical care may
erage for T/CAM have on use? sues for consideration in the set- not be accessible to these people;
What are sound models of health ting of national and international thus there is a danger of facilitat-
financing for CAM and tradi- public health research priorities. ing a “separate but unequal care
tional medical services? In the One framework has been set forth system.”14
developing world, how might in- by the Council on Health Re- In industrialized countries,
ternational funders such as the search for Development, an inter- members of the dominant cul-
World Bank, WHO, the Gates national nongovernmental organi- ture who have lower incomes
and Rockefeller Foundations, the zation established to “promote, and educational levels tend not
Global Fund, and others evaluate facilitate, support and evaluate the to use complementary medicine.
and potentially include tradi- Essential National Health Re- This may be because they have
tional medicine within the treat- search strategy.” This includes un- less disposable income and less
ment spectrum for priority dis- derlying values and operating exposure to information about
eases in public health programs principles that are sufficiently gen- complementary therapies.17 The
that they support? eral to fit the T/CAM field as availability of broader choices in
much as any other area of health health care services in these
Priority Disease Management care.28 While there are other countries is increasingly concen-
T/CAM is being used by the frameworks for policy develop- trated among the educated and
public in the management of ment, the one developed by the well-to-do. Equity issues concern
October 2002, Vol 92, No. 10 | American Journal of Public Health Bodeker and Kronenberg | Peer Reviewed | Public Health Matters | 1585
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both the availability of conven- quired to “respect, preserve and SUSTAINABILITY AND
tional medicine and the afford- maintain knowledge, innovations INTEGRATION
ability of the more researched and practices of indigenous and
and increasingly expensive CAM local communities embodying A number of factors need to
treatments. An equity perspective traditional lifestyles . . . and pro- be addressed if new policies and
in developing-country health care mote involvement of the holders practices are to become en-
systems would ensure access to of such knowledge and practices trenched and endure.
affordable, high-quality services encourage the equitable sharing
for those who currently rely of the benefits arising from the Regulation of Practice
mostly on traditional medicine or utilisation of such knowledge, in- and Practitioners
who have little or no medical novations and practices.” Con- To achieve incorporation of
care. tracting parties should “encour- T/CAM into national health care
age and develop models of programs and systems, one must
ETHICS co-operation for the development distinguish qualified practitioners
and use of technologies, includ- and practices. Some countries
Clinical Research ing traditional and indigenous have taken steps to achieve this.
While there are international technologies.”32 The House of Lords Committee
guidelines for standards of clini- Until recently, the Convention on Complementary Medicine in
cal research,29 research in tradi- on Biological Diversity competed
“
Great Britain recommended that
To achieve incorpora- tional and complementary thera- for influence with the more pow- self-regulation be a cornerstone
pies may differ from clinical erful Trade Related Aspects of for the formalization of the com-
tion of T/CAM
evaluation of conventional drugs. Intellectual Property Systems plementary professions.13 In
into national health WHO guidelines for evaluation (TRIPS) of the World Trade Or- Great Britain, osteopaths and chi-
care programs and of herbal medicines consider that ganization. TRIPS makes no ref- ropractors have been registered
for traditional medicines with an erence to the protection of tradi- as official health professionals
systems, one
established history of use, it is tional knowledge, nor does it through an act of Parliament, and
must distinguish ethical to proceed from basic ani- acknowledge or distinguish be- the basis for maintenance of pro-
qualified practitioners mal toxicity studies directly to tween indigenous, community- fessional standards is self-regula-
”
phase 3 clinical trials.30 based knowledge and that of in- tion. The same principle is being
and practices.
Ethical dilemmas can present dustry. In early 2002, the World applied to medical herbalists and
themselves. In studies to evaluate Trade Organization began a acupuncturists, both of which are
tropical plants used to prevent process to harmonize TRIPS and on track for registration in Great
and treat malaria,31 research the Convention on Biological Di- Britain.
ethics may require that standard versity to ensure adequate pro- New Zealand has registered
conventional treatment be given tection for indigenous intellec- more than 600 Maori traditional
to all subjects, so the traditional tual and cultural property healers who provide services
remedy can be evaluated only in rights.33 within the wider health care sys-
conjunction with conventional Researchers evaluating tradi- tem. While the government reim-
treatment. Unless alternative tional medicines need to recog- burses their services under
models can be developed, the nize that under international law, health insurance, criteria for reg-
full therapeutic potential of tradi- the customary owner, and often istration and oversight of profes-
tional medical treatments that that owner’s country of origin, sional practice are the responsi-
are claimed to be effective may holds rights over the knowledge bility of Maori traditional health
never be known through clinical being evaluated. This has impli- practitioner associations.34
research. cations for patenting. If a patent Asia has seen the most
is sought by a nonindigenous progress in incorporating tradi-
Intellectual Property Rights group, prior informed consent tional health systems into na-
Exploitation of traditional and just benefit sharing with cus- tional health policy. In some
medical knowledge for drug de- tomary owners must be estab- Asian countries, such as China,
velopment without the consent of lished. The challenge here is how this has been achieved through
customary knowledge holders is to determine who represents a national policy.35 In others (e.g.,
not acceptable under interna- community and what represents India and South Korea), change
tional law. State parties are re- full consent. has come about as a result of
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Left to Right: Man undergoing cupping, a traditional Chinese remedy; sports massage; insertion of acupuncture needles into a patient’s back.
politicization of the traditional lic policy maximized the benefits the numbers dwindled from
medicine agenda. to Americans of Complementary there for other CAM services.14
In the United States, chiroprac- and Alternative Medicine.” The effect of user fees on
tors are licensed in all 50 states, health care utilization and health
and acupuncturists are licensed in Financing and Insurance outcomes was a subject of debate
41 states. The National Council Coverage in the 1990s, a debate centered
for Certification of Acupuncture In industrialized countries, in- on the ability and willingness of
and Oriental Medicine holds a na- surance coverage for CAM ser- households to pay out of pocket
tional exam for traditional Chi- vices is relatively new and in- for health care. Research indi-
nese herbal medicine. The Botan- complete, so out-of-pocket cates that the poor may sacrifice
ical Medicine Academy and the spending is considerable. Ameri- other basic needs to pay for
American Herbalists Guild are de- cans have been found to spend health care, often with serious
veloping a voluntary national ex- more on CAM than on all hospi- consequences.39 When funds are
amination for US practitioners of talizations.16,37 Australians spend allocated to the traditional medi-
Western herbal medicine.36 The more on CAM than on all pre- cine sector in resource-poor
United States recently conferred scription drugs.2 Some major countries, resentment can arise
greater national attention on the American medical insurers con- in underfunded sections of the
policy arena with the establish- fer some benefits for limited conventional medical sector.
ment in 2000 of the White complementary medical services, In developing countries, those
House Commission on Comple- primarily through employer- who can afford insurance will be
mentary and Alternative Medi- sponsored health plans.38 In beneficiaries of a more regulated
cine Policy. The commission’s 2000, 70% of employee-spon- and safe traditional medicine
mandate was to provide “legisla- sored programs covered chiro- practice, while the poor may be
tive and administrative recom- practic, 17% covered acupunc- purchasing unregulated drugs
mendations for assuring that pub- ture, 12% covered massage, and from unlicensed vendors. This
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leads to T/CAM utilization by tioners has increased greatly. conventional scientific research
those who can afford to pay for Claims rose from 655 000 in the in T/CAM. A public health
insurance, thus creating the financial year 1984/1985 to agenda is needed in addition to
skewing of services toward the 960 000 in 1996/1997, and the focus on experimental re-
more affluent that is found with Medicare reimbursements to doc- search. Public health profession-
complementary medicine use in tors for acupuncture rose from als need to define the public
industrialized societies. This is in $7.7 million to $17.7 million.40 health dimensions of traditional
contrast to the customary role of Evaluating health insurance and complementary medicine.
traditional medicine, that is, the records can be an effective way Adequate funding is of central
first and last resort for health of estimating whether there is a importance. In the United States,
care for the poorer members of cost savings from using tradi- funding was initially provided by
society. tional or complementary health private donors whose contribu-
In the case of ethnic minorities care. A retrospective study of tions resulted in programs at aca-
in industrialized societies, health Quebec health insurance enrol- demic medical centers.42 The ad-
lees compared a group of 1418 vent of NCCAM substantially
Transcendental Meditation (TM) legitimized CAM research and
practitioners with 1418 nonmedi- has been followed by funding ini-
tators. The yearly rate of increase tiatives from national and inter-
in payments in both groups was national foundations. The bio-
not significantly different before medical community’s response
the TM group learned medita- has escalated research. This
tion; after learning, the annual wave has yet to reach public
change in mean payments was a health research. In the absence
decline of 1% to 2% for the TM of a significant voice from the
group and an increase of up to public health research commu-
12% for nonmeditators. The esti- nity, funders have remained fo-
mated cost saving was as much cused on issues of safety, effi-
as $300 million per year.41 cacy, and the mechanisms of
Cost-benefit research could as- action of complementary and tra-
sess outcomes when traditional ditional medicine. Priority will
or complementary approaches need to be assigned to public
are compared with conventional health if knowledge generation is
care. This would assist health au- to keep abreast of consumer de-
thorities in making informed mand for cost-effective services
choices about the selection of and government and insurer de-
treatments and services to be in- mands for policy information.
corporated into integrated health
care programs. KNOWLEDGE
MANAGEMENT AND
Row of eyedroppers in an herbal KNOWLEDGE UTILIZATION
tonic cafe. insurance coverage can lead to a GENERATION
substantial increase in the use of To ensure sound standards of
traditional medical services. Again, The initiative taken by the US practice based on recognized lev-
there is the creation of an elite Congress a decade ago to estab- els of training and the use of
who can afford traditional medi- lish an Office of Alternative Med- T/CAM therapies that are safe
cine because they have insurance icine (now the National Center and effective, information and its
coverage, while the poor are less for Complementary and Alterna- dissemination are needed across
likely to have access to their tradi- tive Medicine [NCCAM]) at the a wide range of professional and
tional health care services. National Institutes of Health has commercial areas. Comprehen-
In Australia, since the intro- led to a focused program of clini- sive information resources will
duction of a Medicare rebate for cal and basic science research, be fundamental to the evolution
acupuncture in 1984, use of now seen internationally as a of research and policy activities,
acupuncture by medical practi- model for how to proceed in but developing them will be a
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tual healers.17 This trend and its lishing regulatory and policy ful comments on the manuscript and to 13. House of Lords Select Committee
origins and outcomes are impor- guidelines for ensuring the safety Eric Shaw for helping with research and on Science and Technology. Sixth report:
with putting the manuscript together. Complementary and Alternative Medicine,
tant areas of research. and quality of complementary 21 November 2000. Available at:
This material was originally presented
Comparative evaluations of and traditional health services, a in part by Dr Bodeker as an invited lec-
http://www.publications.parliament.uk/
complementary and conventional broad public health agenda is pa/ld199900/ldselect/ldsctech/123/
ture, titled “Use of Traditional and Com-
12301.htm. Accessed July 27, 2002.
medicine approaches to treating called for. This agenda should plementary Medicine: Relevance for
Public Health,” at the Rosenthal Center 14. White House Commission on
specific health conditions are evolve with an awareness of so- for Complementary and Alternative Complementary and Alternative Medi-
needed. This may include study cial, cultural, and political dimen- Medicine, Columbia University, New cine Policy. Final report, March 2002.
of cross-cultural healing practices sions and should address values York, NY, February 20, 2002. Available at: http://www.whccamp.hhs.
gov/finalreport.html. Accessed July 27,
to identify common treatments or (equity, ethics), sustainability 2002.
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Gerard Bodeker is with the University of
These should be applied in a
Oxford Medical School, Oxford, England. 7. Barnes J, Abbot NC, Harkness EF, 21. Kronenberg F, Wade C, Cushman
manner that is sensitive to the Fredi Kronenberg is with the Columbia Ernst E. Articles on complementary L, et al. CAM use among American
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system being evaluated in order Gerard Bodeker, EdD, GIFTS of Health, 1999;159:1721–1725. Mass.
to ensure that the research de- Green College, University of Oxford, Ox- 8. Nelson T. Commonwealth health
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sign adequately measures what ministers and NGOs seek health for all. F, et al. Ethnomedicine in the urban envi-
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one thinks is being studied. This article was accepted July 2, 2002. ronment: Dominican healers in New York
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Both authors contributed to the writing
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viding sound information to the and alternative medicine education op- 24. House of Lords Select Committee
portunities: an ongoing listing. J Altern on Science and Technology. Sixth Report:
public on what constitutes good Acknowledgments Complement Med. 2000;6:77–90. Complementary and Alternative Medicine,
health care. This work was funded in part by the 11. Marcus DM. How should alterna- 21 November 2000. Available at: http://
NIH National Center for Complemen- tive medicine be taught to medical stu- www.publications.parliament.uk/pa/
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