THE trend is unmistakable. We spend billions a year worldwide on herbal
remedies. In the US the use of complementary and alternative medicine has
doubled in the past decade. When Americans fall sick, they would rather turn
first to an alternative therapist than a family doctor. In Britain, almost half
the adult population admits to using an alternative therapy. More and more
doctors are referring patients for alternative treatments or are offering them
themselves.
But why? Many therapies that fall under the heading of complementary and
alternative medicine (CAM) have never been shown to work in scientific studies.
And therapies such as homeopathy directly challenge our understanding of the
world. If our science is right, they shouldn鈥檛 work at all.
Perhaps CAM is no more than a harmless fashion, like flared trousers. Or
maybe mass hysteria has gripped the world鈥攎illions are suffering the
delusion that needles, roots and incredibly dilute solutions really can cure
back pain, chronic fatigue and other ailments that conventional medicine can鈥檛
deal with. Or maybe there鈥檚 something more interesting going on: some CAM
techniques really do work, and it鈥檚 science that鈥檚 missing something.
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As you will read in this special report, the more scientists study CAM, the
more surprises and challenges it throws up. It is forcing researchers to rethink
some cherished ideas about medicine, from what makes an ideal drug and the
design of clinical trials to the underlying causes of disease.
The therapies classified as CAM are many and various. Roughly speaking, a
complementary therapy is something unorthodox that can be used alongside
conventional healthcare. Examples include herbal medicines, osteopathy and
acupuncture. An alternative therapy, on the other hand, has a different
philosophy from the orthodox biomedical system, and is meant to replace rather
than sit alongside conventional treatments. This category includes ancient
systems such as traditional Chinese or Ayurvedic medicines. In practice, things
aren鈥檛 always that tidy, and people will happily mix and match the different
philosophies.
So why are people turning to these therapies? Some are simply dissatisfied
with conventional medicine. But a stronger influence appears to be the pull of
the approaches associated with CAM. Many patients cite 鈥渘aturalness鈥� as its
appeal, or the desire to take control over their own health. Others are drawn by
the spiritual dimension or the emphasis on 鈥渉olism鈥�. Some researchers believe
that people are increasingly 鈥渟hopping for health鈥濃�攖rying all the
available options. With so much information available in magazines, newspapers
and on the Net, people rarely take a family doctor鈥檚 word for it when told
鈥渢here鈥檚 nothing more that can be done鈥�.
Who uses CAM? It鈥檚 hard to generalise, particularly when the term covers so
many diverse therapies. But surveys around the world suggest the typical CAM
user is affluent, more often female than male, young, employed and well
educated. CAM users are likely to be of average weight, exercise regularly, and
consume alcohol 鈥渁t a risk level鈥�. They are not simply irrational worriers with
a penchant for the far-out. Indeed, doctors are among the most frequent
users.
One thing that CAM therapies seem to emphasise is a mind-body link. Doctors
often overlook the influence of psychological and emotional factors on physical
health. They certainly don鈥檛 have time to explore it in the seven-minute
consultation that is the average people get with their family doctor in Britain.
CAM consultations are notably longer: many therapists offer half an hour, even
an hour.
So perhaps it鈥檚 not surprising that critics argue that some CAM therapies
offer nothing more than a sensitive ear. Others say this is too simplistic. A
CAM practitioner is armed with an alternative model of disease. Where convention
fails to provide a diagnosis, Chinese medicine might. And with diagnosis comes
hope of a cure.
As CAM has become more popular, so more money is being devoted to studying
it. The US National Institutes of Health, for example, invests nearly $90
million a year in the National Center for Complementary and Alternative
Medicine. The centre鈥檚 brief is wide-ranging. As well as more accepted therapies
such as herbal medicines, it covers what it describes as 鈥渇rontier medicine鈥�,
including magnets and energy healing, on the grounds that the public is using
them, so they need to be investigated.
Safety is one of the main preoccupations of research into CAM. If people are
going to use it, we need to be sure it鈥檚 safe. But the other question everyone
wants answered is: do CAM therapies work? Scientific studies have produced
patchy results. But these investigations also pose real puzzles for researchers
steeped in conventional medical science. They imply that the assumptions
underlying modern clinical research do not apply to CAM. Researchers need to
refine their thinking.
Take the gold standard in clinical research鈥攖he double-blind
placebo-controlled trial. When a pharmaceuticals company develops a new drug, it
gives it to half a group of patients, while the other half receives an
identical-looking dummy pill. Even the doctors don鈥檛 know who gets what.
Researchers do this because they know the placebo is a potent healer in its own
right. Much effort has gone into identifying the biochemicals that mediate this
effect. And scientists have recently found that acupuncture stimulates those
same biochemical pathways
(see 鈥淣eedlework鈥�).
What does this mean for acupucture? Does it merely mobilise the placebo effect?
And do we need to rethink the way trials are done?
The dummy pill is clinical science鈥檚 only concession to the placebo effect,
perhaps because it is the drug and not the doctor that is seen as the main agent
of healing. Yet we know that the attitude of the doctor is also important.
Doctors who are friendly, informal and reassuring are more effective healers.
How much more important is this effect in CAM, where therapists set great store
by their contact with patients?
Though these kinds of issues look like little more than changes of nuance,
they may mean the difference between a therapy being labelled as useless rather
than effective. But there are other results from trials that fly in the face of
conventional thinking, such as the finding that the mixtures of chemicals found
in herbs can be more potent than the single, purified ingredient so beloved of
drugs companies
(see 鈥淪wallow it whole鈥�).
Then there鈥檚 the fact that homeopathic remedies so
dilute that no trace of an active chemical should be left can still change the
activity of cells in a test tube
(see 鈥淎s if by magic鈥�).
So where does this leave us. Certainly not with a ringing endorsement of any
or every CAM therapy. Science will almost certainly show some of them to be
hokum. But insights from CAM do tell us that today鈥檚 conventional medicine is
not the last word in understanding pharmacology, the body, or healing. Studying
CAM is likely to generate valuable findings that will change the way we think
about medicine.
And that鈥檚 not the only benefit. The notion of 鈥渃linical鈥� medicine is central
to conventional healing. But the word has a second, less attractive connotation:
the implication that something is overly sterile, scientific and impersonal.
Doctors are increasingly realising that medicine too often sidelines the person
who should be at the centre of it all鈥攖he patient. If studying
complementary medicine helps to bring the focus of medicine back where it
belongs, then it must surely be in everyone鈥檚 interest.
Biological therapies
Herbal remedies: plants and plant extracts
Aromatherapy: treatment with essential oils, usually inhaled
Dietary therapies: a broad range of systems including eating to promote
general health, to increase energy or to prevent or control illness
Orthomolecular therapies: large vitamin doses or mineral supplements
There have been many clinical trials for different herbal remedies with very
mixed results. There have been some very promising effects, but also some
serious safety concerns
(see 鈥淪wallow it whole鈥�).
One recent study claims that aromatherapy is effective only if patients
believe it will be
(New 杏吧原创, 21 April, p 16).
There have been few detailed studies of specific diets and supplements,
partly because food supplements are not regulated and so you do not have to
demonstrate safety or effectiveness. Specially designed exclusion diets look
promising for some cases of rheumatoid arthritis, irritable bowel syndrome,
migraine, asthma and eczema.
Two large-scale trials, one of shark cartilage for lung cancer and one of the
Gonzalez protocol (a mix of pancreatic enzymes, dietary supplements and coffee
enemas) for pancreatic cancer are ongoing. No conclusions as yet.
Mind-body interventions
Hypnotherapy: hypnosis for behavioural and mental problems
Healing: prayer, directed thoughts, and spiritual healing
Meditation: deep breathing and inner reflection
A recent review found that evidence for healing was inconclusive (Annals
of Internal Medicine, vol 132, p 903). Trial of hypnotherapy for stopping
smoking concluded there was insufficient evidence to decide.
Diagnostic systems
Iridology: diagnosing illness by looking at the eyes
Dowsing: detecting illness with rods, as in dowsing for water
Radionics: study of invisible energy fields with instruments
Kinesiology: assessing energy imbalances in the muscles
These are not methods of healing, and as such there have been no systematic
clinical trials. Concerns about safety if used in isolation.
Energy therapies
Crystals: said to influence the patient鈥檚 鈥渁ura鈥�
Reiki: Japanese system channels spiritual energy to heal the spirit and
body
Laying on of hands: said to manipulate the body鈥檚 energy
No systematic reviews.
Manipulation therapies
Osteopathy: manipulation of muscles and joints with the aim of improving
blood flow
Chiropractic: manipulation of spine with the aim of improving nerve flow
Massage: any form of rubbing, kneading or pressure
Reflexology: massage of specific parts of the foot, said to influence other
parts of the body
There have been some promising effects from osteopathy, chiropractic and
massage for certain types of lower back pain, although there are also some
concerns about safety, particularly with excessive chiropractic use of X-rays
and the risk that therapy might cause fractures. Some chiropracters also object
to immunisation on philosophical grounds. Poor results for headache (
BMJ, vol 319, p1176 (1999); 鈥淢assage for low back pain鈥�, in the
Cochrane Database of Systematic Reviews).
Large systematic review of manual therapies for asthma proved inconclusive
(鈥淢anual therapy for asthma鈥�, in the Cochrane Database of Systematic
Reviews).
None of seven systematic trials of reflexology for anxiety, stress,
post-operative pain and diabetes found any specific benefit, but there is some
evidence that the technique might aid relaxation.
Alternative systems
Ayurveda: ancient Indian discipline鈥斺�漵cience of life鈥濃�攂ased on
belief of mind-body-spirit interaction.
Traditional Chinese medicine: a holistic approach for achieving balance and
good health, using herbs, diet, massage, lifestyle and acupuncture鈥攊n
which fine needles are inserted into the body at specified points.
Homeopathy: treating with compounds that mimic the patient鈥檚 symptoms,
usually in highly dilute solutions.
Naturopathy: promoting natural healing with diet, herbs and sunlight.
Complete systems of theory and practise that have developed independently of
the Western biomedical approach with different philosophies about health and
healing. Other systems from Tibetan, African, Aboriginal, American and
Middle-Eastern cultures. Impossible to compare systematically with conventional
medicine, but many individual elements have been tested and integrated within
more conventional medical systems.
Some herbs have been tested. Artemisinin, for example, is effective for
treating malaria. For more examples
see 鈥淪wallow it whole鈥�.
Acupuncture used in isolation shows promise for some kinds of pain and nausea
(see 鈥淣eedlework鈥�).
Large-scale review of homeopathy shows some effect above placebo
(see 鈥淎s if by magic鈥�).