Complementary And Alternative Medicine (CAM)

Complementary And Alternative Medicine (CAM)

INTRODUCTION
Complementary and alternative medicine (CAM) refers to a broad range of healing philosophies, approaches and therapies that exist largely outside the institutions where conventional health care is taught and provided. But some of these are now institutionalized. Complementary medicine is an increasing feature of health-care practice, but considerable confusion remains about what exactly it is and what position the disciplines included under this term should hold in relation to conventional medicine.1
The Western health-care system has expanded and changed remarkably in recent years. Medical practices outside the mainstream of ‘official’ medicine (allopathy) have always been an important part of public health care. The prominence and configuration of these ‘irregulars’ as they were called, has waxed and waned depending on the perceived value of the orthodox medicine, the needs of the public, and the changing values of the society. The prominence of these practices subsided with the development of scientific medicine and its dramatic advances in the understanding and treatment of the disease2. However, in India, diverse systems of medicine are official and professionalized as to their service in education and research3.
CAM has now undergone a revival in the West. According to a recent study, no less than 42% of American households tried it during the recent years4. A similar trend exists worldwide5,6. Recognition of the rising use of alternative medicine and other non-traditional remedies led to the establishment of the Office of Alternative Medicine, a unit of National Institutes of Health (NIH, Bethesda, MD, USA) in 1992, which alone supports over 50 investigations into the usefulness of various alternative therapies2,7. The relative popularity of alternative therapies differs among countries, but public demand is strong and growing. Complementary medicine is quite popular in Europe8, Australia9, China10 and Israel11. It has increased dramatically throughout the Western world12, and plays a significant role in primary health care in India13. Recently, a Select Committee of the House of Lords of the British Parliament had categorized Ayurveda in the third group, which was changed to the first group after a scientific presentation3.
Media coverage, specialist publications and the numberof complementary therapists have all increased dramatically in the past 20 years14. Approximately 1500 articles on CAM are published annually in the literature covered in MEDLINE.15

What is CAM?
According to the definition used by the Cochrane Collaboration, ‘complementary and alternative medicine’ is a broad domain of healing resources that encompasses all health systems, modalities, practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas defined by their users as preventing or treating illness or promoting health and well-being. Boundaries within CAM and between the CAM domain and that of the dominant system are not always sharp or fixed1.
According to Eskinazi16, alternative medicine can be defined as a broad set of health-care practices (i.e. already available to the public) that are not readily integrated into the dominant health care model, because they pose challenges to diverse societal beliefs and practices (cultural, scientific, medical and educational). This definition brings into focus factors that may play a major role in the prior acceptance or rejection of various alternative health-care practices by any society. Unlike criteria of current definitions, those of the proposed definition would not be expected to change significantly without significant societal change.
Alternative medicine comprises a large and heterogeneous group of treatments, many of which are procedures that are not readily testable under double-blinded conditions. Furthermore, alternative medicine therapies may also possess a theoretical basis, may stem from a cultural tradition that is seemingly antithetical to a quantitative, biomedical framework, or may possess little foundational research on which to base a controlled evaluation16. It is also argued that the different sets of axioms in diverse systems require new modes of evidence than the currently dominant chemical paradigm.
In the 1970s and 1980s the therapeutics that were mainly provided as an alternative to conventional health care were collectively known as ‘alternative medicine’.The name ‘complementary medicine’ developed as the two systems began to be used alongside (to complement) each other. Over the years, ‘complementary’ has changed from describing this relationship between unconventional health-care disciplines and conventional care to defining the group of disciplines itself. Some authorities use the term ‘unconventional medicine’, synonymously1. Other terms that are also used for CAM are unproven, unorthodox, fraudulent, dubious, integrative, questionable, quackery17, irregular, unscientific and naturopathic18, propaganda-based medicine19 and opinion-based medicine15. Such a diversity of labels bespeaks of judgmental attitudes, conditioned by cultural beliefs.
According to Fontanarosa and Lundberg20 there is no alternative medicine. There is only scientifically-proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is ‘Eastern’ or ‘Western’, is conventional or mainstream, or involves mind–body techniques or molecular genetics is largely irrelevant, except for historical purposes and cultural interests.

Conceptual differences and commonalities betweebiomedicine and CAM
The characteristic common to traditional (alternative) system of health (vital force, spirituality and holism) seems to distinguish it from biomedicine. Biomedicine is founded in part on materialism (in contrast to the vital force explanation). Materialism, in this context, refers to the theory that ‘physical matter is the only or fundamental reality, and that all beings and processes and phenomena are manifestation or result of matter’. While biomedicine does not necessarily reject religion or spirituality, it does not routinely incorporate these aspects into diagnosis and treatment (unlike the traditional system)15. It negates any evidence of the role of the spirit, and the mind is viewed as merely a product of the brain.
Traditional medicine teaches that energy flows within, around and through all things in the universe. Energy cannot be destroyed, but can be affected negatively, leading to flow imbalance or disease. Traditional medicine does not exclusively view disease as an invasion or poisoning of the body by a foreign organism. Instead it sees the disease as a condition when the human body is out of balance with its milieu. Healing, therefore, is the art of manipulating the flow of energy to re-establish balance in the whole person, rather than just the area of complaint. Spirituality, unlike in allopathy, is an integral part of traditional medicine and, as a result, traditional medicine therapy can be very individualized, with no two people receiving the same treatment, despite similar complaints or the same disease. In contrast, Western medicine tends to divide the body into systems and compartments and measures functions by evaluating tissues and examining body fluids. Although there is a great deal of knowledge regarding the body’s complex interactions, abnormalities are often diagnosed and treated as individual entities apart from the patient. Western physicians frequently subspecialize and view disease as an invasion of the body by foreign organisms or a proliferation or death of individual cells. The focus of Western medicine is therefore to provide a cure for a specific ailment. The Western scientific method is applied rigorously and claims of its efficacy are documented and proved by repeated independent studies. Like traditional medicine, biomedicine also now advocates some changes in diet, environment and lifestyle to promote health21.

Different complementary and alternative medicinal systems
CAM can be broadly divided into seven major categories22, viz. (i) mind–body medicine, (ii) alternative medical systems, (iii) lifestyle and disease prevention, (iv) biologically-based therapies, (v) manipulative and body-based systems, (vi) biofield, and (vii) bioelectromagnetics. Within each category, medical practices that are not commonly used, accepted or available in conventional medicine are designated as CAM. Those practices that fall mainly within the domains of conventional medicine are designated as ‘Behavioural Medicine’. Practices that can be either CAM or behavioural are designated as overlapping.
Mind–body medicine involves behavioural, psychological, social and spiritual approaches to health. It is divided into four subcategories: (i) mind–body system, (ii) mind–body methods (e.g. yoga, internal Qi Gong, hypnosis, meditation), (iii) religion and spirituality (e.g. confession, spiritual healing, prayer), and (iv) social and contextual areas (e.g. holistic nursing, intuitive diagnosis, community-based approaches).
Alternative medical systems involve complete systems of theory and practice that have been developed outside the Western biomedical approaches. They are divided into four subcategories:
(i)  acupuncture and Oriental medicine
(ii) traditional indigenous systems (e.g. Ayurvedic medicine, Siddha, Unani-tibbi, native American medicine, Kampo medicine, traditional African medicine);
(iii) unconventional Western systems (e.g. Homeopathy, psionic medicine, orthomolecular medicine, functional medicine, environmental medicine), and
(iv) naturopathy.
Lifestyle and disease prevention category involves theories and practices designed to prevent the development of illness, identify and treat risk factors, or support the healing and recovery process. This system is concerned with integrated approaches for the prevention and management of chronic disease in general, or the common determinants of chronic disease. It is divided into three subcategories:
(i) clinical prevention practices (e.g. electrodermal diagnosis, medical intuition, panchakarma, chirography);
(ii) lifestyle therapies and
(iii) health promotion.
Biologically-based therapy includes natural and biologically-based practices, interventions and products. Many overlap with conventional medicine’s use of dietary supplements. This category is divided into four subcategories: (i) phytotherapy or herbalism (plant-derived preparations that are used for therapeutic and prevention purpose, e.g. Ginkgo biloba, garlic, ginseng, turmeric, aloe vera, echinacea, saw palmetto, capsicum, bee pollen, mistletoe); (ii) special diet therapies (e.g. vegetarian, high fibre, pritikin, ornish, Mediterranean, natural hygiene); (iii) orthomolecular medicine (products used as nutritional and food supplements and are not covered in other categories. These are usually used in combinations for prevention or therapeutic purpose, e.g. ascorbic acid, carotenes, folic acid, vitamin-A, riboflavin, lysine, iron, probiotics, biotin), and (iv) pharmacological, biological and instrumental interventions (include product and procedures applied in an unconventional manner, e.g. Coley’s toxin, ozone, 714X, enzyme therapy, cell therapy, EDTA, induced remission therapy, chirography, neural therapy iridology, MORO device, bioresonance, apitherapy).
Manipulative and body-based systems are based on manipulation and/or movement of the body. They are divided into three subcategories: (i) chiropractic medicine; (ii) massage and body work (e.g. osteopathic manipulative therapy, kinesiology, reflexology, Alexander technique, rolfing, Chinese tui na massage and acupressure), and (iii) unconventional physical therapies (e.g. hydrotherapy, colonics, diathermy, light and colour therapy, heat and electrotherapy).
Biofield medicine involves systems that use subtle energy fields in and around the body for medical purpose, viz. therapeutic touch, Reiki and external Qi Gong. Bioelectromagnetics refers to the unconventional use of electromagnetic fields for medical purposes.
A number of complementary and alternative medicinal systems are popular in India, with Ayurveda being the most popular23. CAM is mostly associated with the treatment of chronic diseases. Patients are also found using naturopathy, herbal medicine, biopathy, home remedies, wheat-grass therapy, hydrotherapy, electroenergizers, auto urine therapy, vipasana and traditional healing methods for the treatment of cancer pain24. Fish medicine is tried out in a large number of patients for the treatment and prevention of asthma. Mass meditation is practised for treatment of chronic problems25. Ayurvedic medicines are tried for epilepsy26. Other popular CAMs in India are yoga, massage, prayers, spiritual healing, tantra/mantra, astromedicine, gem therapy, hypnosis, acupuncture and magnet therapy. India, as quoted by Vaidya27 is literally a ‘therapeutic jungle’ with awaited serendipitous discoveries as well as lurking prelature of hazardous practices

Complementary and Alternative Medicine Approaches
The U.S. National Institutes of Health have categorized complementary and alternative medicine into five types:
 Biologically based practices. These include vitamin and mineral supplements, natural products derived from animals, plants (such as ginkgo biloba or echinacea), and unconventional diets.
 Manipulative and body-based approaches. They include massage therapy and chiropractic medicine.
 Mind-body medicine. This includes spiritual, meditative, and relaxation techniques.
 Energy medicine. This includes biofield- or bioelectromagnetic-based interventions, such as Reiki.
 Alternative medical systems. They include acupuncture, traditional Chinese medicine, homeopathic medicine, and Ayurveda.

These areas overlap to some degree and alternative medical systems use elements from many of them. Traditional Chinese medicine incorporates acupuncture, herbal medicines, special diets, and meditative exercises, such as tai chi. Ayurveda in India similarly uses the meditative exercises of yoga, purifying diets, and natural products. In the West, homeopathic and naturopathic medicine arose in the late 19th century as a reaction to the largely ineffectual and toxic conventional approaches of the day, such as purging, bleeding, and treatment with heavy metals such as mercury and arsenic.
CAM approaches vary widely between and within countries, according to the World Health Organization (see Table). In developing countries, CAM is the main source of health care for the majority of people. In developed countries, people selectively use these approaches: up to 60 percent of French, German, and British use homeopathic or herbal products, whereas only 1 to 2 percent of Americans use homeopathy, but up to 10 percent use herbals. More than 8 percent of Americans visit chiropractors28. For patients in developed countries with chronic, painful, debilitating, or fatal conditions, such as HIV/AIDS and cancer, use of CAM approaches is much higher, ranging from 50 to 90 percent29. Despite widespread use, scant scientific evidence confirms the safety or effectiveness of most complementary or alternative approaches. For example, in the United States, herbals are regulated by the U.S. Food and Drug Administration as “dietary supplements,” rather than as a “food or drug.” As a result of this labeling, they are regulated by less stringent standards. Herbals are highly variable in quality and composition and may contain unintended contaminants, such as heavy metals. Some research shows the harmful effects of herbals. Comfrey and kava have been associated with liver failure30. Ephedra has been linked to heart attacks and strokes31. Herbals, such as St. John’s wort, can contain ingredients that accelerate or inhibit the metabolism of prescription drugs32. Some herbals are banned in certain countries because of these ill effects.
Evidence of the effectiveness of some complementary and alternative approaches is beginning to demonstrate small, and highly encouraging, positive results. The potential of CAM, coupled with their already widespread use, encouraged the initiation in 1998, of the National Center for Complementary and Alternative Medicine (NCCAM) of the U.S. National institutes of health

Why do people use CAM ?
The increasing popularity of CAM reflects changing needs and values in modern society in general. This includes a rise in prevalence of chronic diseases, an increase in public access to worldwide health information, reduced tolerance for paternalism, an increased sense of entitlement to quality life, declining faith that scientific breakthrough will have relevance for the personal treatment of disease, and an increased interest in spiritualism. In addition, concern about the adverse effect and skyrocketing cost of conventional health care are fuelling the search for alternative approaches to the prevention and management of illness2.
As there are many factors like the sociocultural and personal (health status, belief, attitude, motivation, etc.), underlying a person’s decision to use alternative therapies, at present, there is no clear or comprehensive theoretical model to account for the increased use of alternative forms of health care33. Three assumptions have been proposed to explain the use of alternative medicine:
(1) Dissatisfaction: Patients are dissatisfied with conventional treatment because it has been ineffective, has produced adverse side effects, or is seen as impersonal, too technologically-oriented, and/or too costly.
(2) Need for personal control: Patients seek alternative therapies because they see them as less authoritarian with more personal autonomy and control over their health
care decisions.
(3) Philosophical congruence: Alternative therapies are attractive because they are seen as more compatible with patients’ values, world-view, spiritual/religious philosophy or beliefs regarding the nature and meaning of health and illness34.
Surveys of users of complementary medicine indicate that about 80% are satisfied with the treatment they receive. Interestingly, this is not always dependent on a simultaneous improvement in their condition. For example, one survey of cancer patients in the UK suggested that the users were more hopeful about their future and were emotionally stronger and less anxious, even if the cancer remained unchanged33. Previous research has indicated that patients with higher levels of education and poor health status are likely to be alternative medicine users35.
Economic Factors Influence User Behavior
Although social, cultural, and medical reasons account for most of the appeal of CAM approaches, economic factors also play a role. It is assumed that users of these approaches choose them because they are cheaper than conventional medical care. However, several studies have found that CAM approaches cost the same or more than conventional treatments for the same conditions; thus people seek them out for reasons other than cost36. At least one study showed that financial factors ranked behind such reasons as confidence in the treatment, ease of access, and convenience, in the choice a traditional healer37. Studies in Kenya and Zimbabwe showed that the cost of a traditional healer was greater than the charge at a health facility—in Zimbabwe, the cost was Z$23 per visit for a herbalist, compared to Z$1 to visit a government clinic, Outcomes were better at the clinic: 67 percent reported good outcomes compared to 50 percent who consulted an herbalist38.
Another common misconception is that the poor are more likely to use traditional medicine, but this is not always true. Another study from Zimbabwe showed that the mean monthly income of households visiting an herbalist was higher than the mean monthly income of households using government clinics39. Moreover, fees charged by a traditional herbalist may be negotiable, the method of payment flexible, and payment may depend on outcome.
Patients tend to seek care from traditional healers for conditions such as mental illness, impotence, and chronic disorders, which they perceive as requiring greater involvement by the extended family and kinship group. In these cases, financial support from family members is often greater than for illnesses such as malaria or diarrhea, for which patients more often seek conventional treatment.
Some patients seek CAM techniques because they believe the side effects will be lower. In both developed and developing countries, users of complementary methods also commonly seek conventional care. One study showed that patients are likely to use more than one type of provider40. And the choice of provider depends on patients’ illness, type and severity of condition, socioeconomic status, and education. If a first visit to one kind of provider does not yield positive results, a follow-up visit is made to another type of provider. Quality of care, including efficiency of service and waiting time, is an important factor in whether patients choose to go to traditional healers.
More broadly, some research has shown that the use of CAM practices does not reduce the overall costs of health care. However, one study in Peru found that complementary medicine was 53 percent to 63 percent less expensive than conventional medicine for achieving equivalent levels of effectiveness, and was especially cost-effective for osteoarthritis,hypertension, facial paralysis, and peptic ulcers.

Regulation of CAM
The interaction of politics and science in the arena of health care, one of the most lucrative industries in the US, has played a significant role in the recent development of alternative medicine there. In October 1991, the US Congress instructed the NIH to create an Office of Unconventional Medical Practices, later renamed the Office of Alternative Medicine (OAM). The mandate was met with a less-than-enthusiastic response from the NIH, but simultaneously with high public expectation. Compounding the difficulties other key governmental agencies, in particular the Food and Drug Administration (FDA), were overlooked in the mandate, although their role was necessary and complementary to that of the OAM. Similar to other federal programmes, the activities of the OAM must comply with FDA regulations and policies. Yet, FDA regulations designed for conventional drugs are devices not applicable for alternative medicine products16. Many contemporary cures are not pills and potions, but lifestyle-oriented remedies. These remedies are usually beyond the regulatory responsibility of the FDA17. Often the remedies of CAM are masked under the label of ‘dietary supplements’.
Regulation of CAM practitioners varies widely. In most countries only registered health professionals may practice, but in the UK practice is virtually unregulated8 except for osteopathic and chiropractic. The General Osteopathy Council and the General Chiropractic Council have been established by the act of parliamentary and statutory self regulation status with similar powers and functions as those of the General Medical Council. A small number of other disciplines, such as acupuncture, herbal medicine and homeopathy, have a single main regulatory body and are working towards statutory selfregulation1. Germany and some Scandinavian countries have intermediate systems8. Belgium’s parliament has recently paved the way for formal recognition of four types of complementary medicine, viz. acupuncture, homeopathy, osteopathy and chiropractic41. 
Since independence, four Indian systems of medicine, viz. Ayurveda, Homeopathy, Unani and Siddha have received considerable encouragement from both the central and state governments42. These systems are regulated by national health services. In India there are more than 500,000 Ayurvedic practitioners43 and 100,000 homeopathic physicians44.

Safety issue of CAM
CAM remedies are popular among patients with chronic diseases such as cancer45, AIDS46, arthritis47, asthma48, diabetes, epilepsy, etc49.. Cancer patients throughout the world use alternative medical methods50. Treatments include vitamins, herbs, diet, healing, ‘psychological treatment, folk medicines and homeopathy. However, the recent failure of the Luigi Di Bella cancer therapy51,52 and the wonder anti-cancer drug advocated by Asru Kumar Sinha53 has raised questions on the effectiveness of alternative therapies in dealing with chronic diseases like cancer. According to Durant54, most of the alternative cancer therapies are nothing but an attractive nuisance. However, there are remarkable anecdotal cure and survival up to five years in cancer patients treated with CAM, which need to be studied55.
All medicines can be toxic under specific circumstances; there is always a risk that an adverse reaction will present a hazard to patients with licensed medicines. However, regulations are expected to ensure that the risk is small and the pharmaceutical industries monitor the medicine’s efficacy, safety and quality. No such global control over natural medicine or herbal medicine exists. India has ayurvedic and herbal pharmacopoeias and the approval process for manufacturers of CAM. Patients with cancer and AIDS should be warned that some of the adverse effects of natural medicines are often similar to symptoms of problems associated with their disease or treatment, thus making it difficult to discern if the disease or the ‘remedy’ is the problem49. The harm caused by unproven therapies or poor quality CAM is not only medical, but also societal and can be summarized as follows:
(i) Economic harm – through loss of resources. It is estimated that four times more money is spent on quackery than on cancer research. In 1983 an estimated $ 200 million was to have been spent on cancer chemotherapy, and in 1981, $ 1 billion was estimated to have been spent on laetrile, which was found to be ineffective, despite anecdotal success.
(ii) Direct harm – cyanide toxicity death related to laetrile; metabolic disturbances caused by some diet, harmful effect of some megavitamin regimens and ruptured colons with coffee enemas. Transmission of viral and bacterial diseases with contaminated serologic product, etc. can recur.
(iii) Indirect harm – the harm of omission, total avoidance or delay in seeking responsible therapy while pursuing alternative therapies. Utilization of diet for cure rather than nutritional preservation. The psychological effect of prolonged denial, guilt associated with inability to self-control the disease and feelings of inadequacy. The incorrect diagnosis of cancer by iridology, kinesiology or a variety of serologic tests, and the resultant questionable treatment with its consequences.
(iv) Societal harm – the impact of large groups advocating mistrust of established institutions, frequently supported by the media, legislative bodies, etc., distorts progress by altering expenditure of funds, delaying public health measures and formation of laws17.
Alternative medicine offers more than physical and mental health care. In the words of one observer, it comprises a medical system that also dispenses a heavy dose of unconventional religion. Through the patient’s participation in Nature, vital forces and a ‘human’ science, the quest for health takes on sacred proportions, allowing the patient to discern the ultimate meaning and make profound connections with the universe56. Since ancient times, it has been known that the state of mind of a sick person influences the response to treatment. A recent study by Harris et al57. suggests that prayer may be an effective adjunct to standard medical care. However, the general uses of prayer as a modality of treatment for the sick is not itself a prima facie argument in favour of the efficacy of prayer58. In a recent incident, fundamentalist Christian parents resisted the conventional treatment of their son suffering from osteogenic sarcoma and believed a regimen of vitamins and prayer would heal their child59, which was really unfortunate. There is no doubt that the faith of an individual patient is relevant to recovery, but not at the cost of neglecting scientific therapy.
Complementary practitioners do not need a conventional diagnosis to initiate treatment. In fact, many think that their treatments are most effective in patients without organic pathology. The risks of missing serious conditions if complementary treatments are given to patients without definite diagnosis, are of great concern. Little is known about the malpractices of practitioners of CAM or about the relationship between conventional and alternative medicine60.
The amount of money some patients spend on complementary medicine is considerable. Costs vary widely, and higher prices do not necessarily mean better or more effective treatment. The lack of evidence concerning many complementary interventions means that the likelihood of a successful outcome is often impossible to predict, patients should be aware of the risk. They should also know in advance about the estimated cost for a complete course of treatment, including tests and medications, before starting complementary therapy39.
Little information has been published on the combined use of complementary and conventional treatment, but some serious interactions have mostly involved herbal products or dietary supplements. In a recent instance, several women developed rapidly progressive interstitialrenal fibrosis after taking Chinese herbs prescribed by a slimming clinic61. Doctors in Belgium have discovered recently that a Chinese herb, Aristolochia fangchi, is not only linked to kidney failure, but may cause cancer as well62. At several institutions in India, continued therapy of two systems of medicine is used. This needs good documentation, as to their safety and utility.
Most herbal products in the market today have not been subjected to the drug approval process to demonstrate their safety and effectiveness. Some of them contain mercury, lead, arsenic63, corticosteroids64 and poisonous organic substances in harmful amounts. Hepatic failure and even death following ingestion of herbal medicine have been reported65. A prospective study shows that 25% of corneal ulcer in Tanzania and 26% of childhood blindness in Nigeria and Malawi were associated with the use of traditional eye medicine66. Ayurvedic tablets for epilepsy cure were found to have higher phenytoin and phenobarbitone contents67. Such adulteration, though not universal, emphasizes the need for quality control of herbal drugs.
Herbal preparation should be used with caution and only on the advice of an herbalist or CAM practitioner who is familiar with the relevant conventional pharmacology. There are case reports of serious adverse effects after administration of herbal products. In most cases, the herbs involved were self-prescribed and bought over the counter or obtained from a source other than a registered practitioner. The lack of a formal adverse drug reaction reporting system makes their true incidence unknown and therefore more reliable information is needed. Encouraging patients who are taking conventional medication to disclose and discuss intentions to use complementary therapies, and to initiate treatment only under medical supervision may help reduce the risk67.
Obstacles to research in complementary and alternative medicine
About half the general population in developed countries uses complementary and alternative medicine (CAM)68. Yet many conventional healthcare professionals refuse to take CAM seriously — one often-voiced argument is “there is no research in CAM”69. Certainly, for some modalities there is no compelling evidence base, and some of the research into CAM has methodological flaws and biases70,71. On the other hand, many doctors and medical educators are uninformed about the quality evidence that does exist72. In this article, I discuss some of the obstacles to developing an evidence base for CAM.
 
Financial obstacles
In most countries, CAM research funding is on a very small scale. For instance, only 0.08% of the British National Health Service research budget goes towards CAM research73. Even though recent initiatives in the United Kingdom, United States and Australia have specifically freed up funds for CAM research, these amounts are minute compared with funding in other areas of medicine. It is likely that lack of plausibility of many CAM therapies deters scientific review committees from defining CAM as a priority. A vicious circle may ensue: little plausibility means no funds, therefore no preliminary research, therefore little plausibility.
Clinical trials of CAM can be even more expensive than those of conventional medicine. CAM treatments are often therapist-led, effect sizes are often small (requiring large sample sizes), and therapeutic effects may appear only after long treatment periods, all of which mean greater expense.  For most CAM modalities, intellectual property cannot be protected; thus commercial investments are rarely forthcoming.
This shortage of CAM research funds has three important
consequences:
■ it prevents relevant projects from happening;
■ it hinders the development of a research infrastructure similar to that of conventional medicine; and
■ it keeps well-trained career scientists from entering into the field.
Methodological obstacles
Many CAM therapies (eg, massage therapy) are physical by nature, which creates methodological challenges. What, for instance, is an acceptable “placebo” control for a trial of massage treatments? Like several other areas of conventional medicine (eg, physiotherapy, surgery, psychotherapy), blinding patients in clinical trials can be difficult or even impossible. Thus the highest level of scientific rigour can be barred to trials of CAM. Many CAM researchers also believe that their holistic approach can not be readily put into the “straightjacket” of a randomised controlled trial (RCT)74. This argument is demonstrably wrong, and its persistence in CAM circles continues to impede efficacy research. One can, of course, conduct an RCT comparing a complex, individualised, “holistic” treatment package to the standard care for that condition. This may require some innovative adaptations to the standard design, but, in principle, RCTs are usually feasible75.
For many people, CAM is an emotive subject. As a result, patients may not want to take a chance with randomisation, and many CAM practitioners may oppose scientific evaluation of their treatments, further hindering clinical trials.
There is more to most CAM interventions than meets the eye. For instance, some are based on theories that fly in the face of science. Researchers might conduct a clinical trial of traditional acupuncture, spiritual healing or homoeopathy and see this as a relatively straightforward exercise. Proponents of these therapies may, however, view it as a test of some ancient theories of life forces, spiritual energies or ultramolecular phenomena. Such discrepancies can (and usually do) create unforeseeable methodological problems, as well as obstacles for research and interpretation of results.
Ethical obstacles
It is an important ethical requirement for randomized clinical trials that the investigators be in the state of equipoise (ie, they must believe that the test intervention is at least as good as the control intervention or placebo). If this is not the case (as for many CAM researchers), it is, strictly speaking, unethical for investigators to conduct the study. “Randomisation is only ethical if there is substantial uncertainty about the best treatment for that patient”76.
A further important ethical requirement for clinical research is informed consent from patients or healthy volunteers77.  As mentioned above, this may be difficult or impossible to obtain in an environment where patients’ enthusiasm often is strongly in favour of CAM and against receiving a control (placebo or non-CAM) treatment. Such problems constitute further impediments to good CAM research.
Expanding the Use of Complementary and Alternative Methods
Some evidence of cost-effectiveness is available for specific forms of complementary and alternative practice. Scattered studies show evidence that:
• Acupuncture for musculoskeletal conditions costs roughly 60 percent less than the cost of referral to a Western practitioner78.
• Homeopathic drugs are cheaper than conventional drugs in the United Kingdom79.
• Expenditures for Ayurveda are 50 percent lower per person than conventional medicine80.
• Chiropractic medicine costs 24 percent less than Western pain therapy yet has better results81.
Despite the uncertainty about the safety, effectiveness, and cost-effectiveness of CAM methods, expanding their use, where reasonable evidence of their effectiveness and good evidence of their safety exists, might yield health, social, and economic benefits. For example, improving the information and services provided in local pharmacies, that are the primary source of treatment for many ailments in rural areas, might serve as an effective substitute for allowing unregulated use of conventional medical treatment. Training traditional healers is less expensive than training doctors or nurses, and could be useful if they were recruited into a more broadbased system for delivering public health programs, such as immunization and maternal-child health. However, few countries rigorously regulate CAM, and research and training in these approaches are generally weak worldwide. Thus, expanding CAM would require significant investment of time and resources if it is to be done appropriately and have an impact on population health.
In Africa, nearly 85 percent of the population uses traditional medicine, which is often the only way to obtain primary health care. Improving the quality and consistency of traditional medicine could reduce the cost of health care delivery, especially for chronic conditions such as arthritic pain and HIV/AIDS, where such interventions might improve patients’ sense of well-being, appetite, and energy. Since so many people use traditional medicine in developing countries, the availability, safety, and affordability of traditional medicine should be ensured as a matter of equity.
Some success stories show where approaches discovered or used in the developing world have been adopted in the West, with or without modification, and vice versa:
• Artemisinin, developed from the Chinese plant Artemisia, has been used for centuries to treat fever and is effective against malaria;
• Acupuncture has been shown to be highly effective in managing postoperative nausea as well as reducing the pain of chronic osteoarthritis;
• Chiropractic medicine has become increasingly accepted by the medical community and has proven better for lower back pain than bed rest, physical therapy, or instruction in back care;
• Homeopathy is widely used with reported effectiveness for treating influenza, allergies, and postoperative obstruction of the bowels;
• Mind-body interventions have been shown to increase the survival time for breast cancer patients, reduce depression and anxiety, and improve coping skills.
Priority areas for complementary and alternative medicine research include studies of interventions to reduce chronic pain, relieve depression, address substance addictions, and slow the progression of degenerative disorders like arthritis and dementia. An important role exists for CAM. However, more evidence is needed before CAM approaches can be broadly integrated into national health systems for diseases for which they have promise.
Future of CAM
Throughout the world, patients in unprecedented numbers are going outside of conventional medicine to look for help. This is a movement that has been building up since the late 1960s and it is now reaching the point that visits to alternative practitioners exceeds visits to primary care providers82. Many alternative therapies are now moving to the hospital sector83. The review by Austin84 suggests that a large number of physicians are either referring to or practicing some of the more prominent and well-known forms of CAM and that many physicians believe that these therapies are useful or efficacious. Yoga, for example, is being tried out for the management of carpal tunnel syndrome85,86. Yoga lifestyle intervention is also found to increase the regression of coronary atherosclerosis in patients with severe coronary artery disease87. Hypnosis is being tried out in cancer clinics for the management of pain. The American Medical Association (AMA) and other medical associations have formally recognized hypnosis as a viable medical treatment88.
Clinical outcome and research papers in several areas of complementary therapies now find a place in orthodox medical journals, and it is no longer possible to maintain the traditional medical stance that referring patients to complementary therapists is unethical89. The Union Ministry for Health and Family Welfare has asked the Medical Council of India to include the basic principles and concept of the Indian System of Medicine and Homeopathy in the course content of MBBS90.
The rapid increase in public interest and use of complementary and alternative therapies is exerting a powerful influence on medical education91 and has gained ground in several medical universities92,93. A significant number of medical students want instructions in complementary therapies94. Medical educators increasingly realize that it is not a question of whether to address these issues in the education of future physicians, but rather how to respond to these relentless challenges95.
The AMA has recognized the need for medical schools to respond to the growing interest in alternative health care practices. The result of the 1996–97 and 1997–98 Annual Medical School Questionnaire Part II distributed by the Liaison Committee on Medical Education indicated a notable increase in instruction in ‘alternative medicine’. Although no medical school reported offering a separate required course in complementary health care practice, medical schools covering these areas as part of a required course increased to 63 (from 46 in 1996–97) and medical schools offering a separate elective course increased to 54 (from 47 in 1996–97). In the 1996–97 academic year, 34 medical schools offered instruction as part of an elective course, and 28 offered other educational experiences96.
Multicentric clinical trials and research on CAM are lacking due to paucity of specific funding. In the UK, the Medical Research Council spent no money researching complementary therapies in 1998–99 and in 1999, the UK medical research charities spent only 0.05% of their total budget97. In the past 12 years, the Indian Council of Medical Research has set up a unique network throughout the country for carrying out controlled clinical trails for herbal medicines. Using this network, the council has shown the efficacy of several traditional medicines, including Picrorhizia kurroa in hepatitis and Pterocarpus marsupium in diabetes. As a result of the trials, these medicines can now be used in allopathic hospitals98. Double-blinded and well-designed clinical trials have also been conducted with Arogyawardhini in viral hepatitis99, Mucuna pruriens in Parkinson’s disease100, Phyllanthus amarus in hepatitis and Tinospora cordifolia in obstructive jaundice. But these have not been widely emulated101. Key policy issue of integrating CAM with mainstream medicine has been outlined by Commonwealth health ministers. The ministers established the Commonwealth Working Group on Traditional and Complementary Health Systems to promote the integration of traditional health systems and complementary medicine into national health care102.

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