Lessons Learned and Implementation
The pervasiveness of different modalities of TM and CAM varies greatly from country to country. For example, in China, where traditional Chinese medicine is well integrated into the health system, many different modalities may be used to treat a given condition. In the United States, by contrast, CAM programs are slowly being integrated with conventional medicine. Several medical schools have nascent CAM programs and have integrated them into medical school curricula to differing degrees. One of the more acclaimed programs of this kind in the United States is that developed by Andrew Weil at the University of Arizona Health Sciences Center. His Integrative Medicine Fellowship Program trains physicians in CAM and TM and strives to produce a new delivery model whereby physicians, patients, and nurses form a healing team for the care of the patient. However, this program needs to be critically 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, whereby modalities discovered in the developing world have been adopted in the West, with or without modifications, and vice versa.
Artemisinin
Artemisinin is a recently developed, active metabolite of artemisia, an herbal extract that has been used in China for centuries to treat fever. Chinese scientists determined the active ingredient of the herbal in the 1970s, and Western pharmaceutical companies have developed several derivatives as drugs for use against resistant Plasmodium malaria (Li and others 2000). Randomized clinical trials have shown that one such drug, dihydroartemisinin-piperaquine, is effective against drug-resistant Plasmodium falciparum malaria (Hien and Dolecek 2004). Another artemisinin derivative, artesunate, was shown to increase parasite clearance and reduce the gametocyte count when added to existing drugs to combat malaria (Adjuik and others 2004).
Acupuncture
Another CAM and TM modality that has considerable acceptance is acupuncture. Many pain management clinics, hospitals, and academic centers in the West now provide acupuncture services, and some insurance companies reimburse for acupuncture services. Rigorous clinical trials have demonstrative positive efficacy in two areas: (a) management of postoperative nausea and emesis (Shen and others 2000) and (b) amelioration of the pain of chronic osteoarthritis (Ezzo and others 2001; Soeken 2004; Tukmachi and others 2004). Studies providing rational explanations of the mechanisms whereby acupuncture might be achieving its effects complement the evidence about its efficacy; for example, one mechanism of action appears to involve opioid-dependent brain pathways. This kind of two-step process—that is, initial demonstration of clinical efficacy followed by scientific research into the mechanism of action—is one way that CAM and TM will gain scientific acceptance and integration into conventional medicine.
Chiropractic Medicine and Osteopathy
Chiropractic medicine was invented in the American heartland during the waning years of the 19th century. It uses spinal manipulation to treat an array of conditions thought to arise because of abnormal alignment of or stresses on vertebrae, most often in patients with musculoskeletal complaints. Two aspects of chiropractic medicine are success stories. First, even though practitioners of conventional medicine ostracized practitioners of chiropractic medicine in the late 19th century and the first half of the 20th century, it has gradually evolved into a viable healing discipline that is increasingly accepted by the conventional medicine community. The evolution of chiropractic can be compared with that of osteopathy. Osteopathy was developed in the United States in parallel with chiropractic, but the field elected to accommodate rather than reject allopathic techniques.
The second success story is research showing that chiropractic manipulation for low back pain is superior to bed rest, physical therapy, or provision of an educational booklet (Cherkin and others 1998). Chiropractic manipulation has also shown results comparable to those achieved with nonsteroidal, anti-inflammatory drugs in alleviating back pain (Straus 2004).
Homeopathy
Homeopathy is a success in terms of its broad appeal and use, not because of the strength of evidence supporting it. Indeed, few conventional scientists and physicians find homeopathy to be plausible. According to the "principle of similars" underlying homeopathy, practitioners choose remedies that, when given in high concentrations, produce symptoms similar to those that the patient presents with. The substance is then put in solution and serially diluted by as much as 1060, well beyond the point defined by Avogadro's number (at which a single molecule of the original substance could remain in the solution). Homeopathy claims that the acts of serial diluting and vigorous shaking imprint information into water so that medicinal properties are retained even when no or few molecules of the starting medicine are present.
As implausible as this claim may seem, homeopathy is used worldwide with reported success (Jonas, Kaptchuk, and Linda 2003). Randomized controlled trials have suggested that it might be effective for treating influenza (Vickers and Smith 2000), allergies (Taylor and others 2000), and postoperative ileus (Barnes, Resch, and Ernst 1997). However, critics have questioned the quality and analyses of these trials. Some have questioned the validity 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 of homeopathy for most conditions. Homeopathy deserves an open-minded opportunity to demonstrate its value by using evidence-based principles, but it should not be substituted for proven therapies."
Mind-Body Intervention
The work of David Spiegel at Stanford University on group support for breast cancer patients excited wide interest in the potential value of mind-body interventions (Spiegel and others 1989). The study was a randomized controlled trial with a 10-year follow-up involving 86 women with metastasized breast cancer. A one-year psychosocial intervention consisting of weekly supportive group therapy with self-hypnosis for pain showed that the mean survival time in the treated group was 37 months, compared with 19 months for the control group. Moreover, Spiegel (1994) notes that appropriate psychotherapy (both group and individual) not only reduced depression and anxiety and improved coping skills, but also saved money by reducing the number of office visits, diagnostic tests, medical procedures, and hospital admittances. Although Spiegel's findings have not been replicated, they do illustrate the potential benefits of mind-body intervention and have led to studies of possible mechanisms through which such interventions may operate.
