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Monday, Jan. 29, 2001
INTEGRATED HEALTH CARE
Toward the future of medicine
By ROWAN HOOPER
How alternative is alternative medicine these days?
With U.S. expenditure approaching $40 billion a year, and at least 40 percent of general practices in the U.K. providing some complementary medicine services, it seems that what was once sidelined and even scorned by doctors is now part of the mainstream.
At the end of January the U.K.'s Royal College of Physicians and the U.S.'s National Center for Complementary and Alternative Medicine met in London to discuss how complementary and alternative medicine can best be integrated into conventional patient care.
About half the population of industrialized countries regularly use complementary medicine. Higher education, higher income and poor health predict its use (people who are better educated choose medicine for which there is little empirical proof). Patients are viewed holistically -- as people with minds and spirits as well as with bodies. Lifestyle factors such as diet, exercise, relationships and relaxation are taken into account in making a diagnosis.
In a joint paper in the British Medical Journal, Lesley Rees, director of education at the Royal College of Physicians, and Andrew Weil, director and professor of medicine of the Program in Integrative Medicine at the University of Arizona, wrote that integrated medicine (it is known as integrative medicine in the U.S.) encompasses more than complementary medicine -- its focus is on health and healing rather than disease and treatment.
All very well, but there lingers a "beans and pulses" hippie feel to complementary medicine, and the word "holistic" is still read with suspicion by many professionals. Similarly, most patients turn to alternative healing techniques out of frustration or desperation with conventional medicine. The London meeting was held to consider how best to overturn negative preconceptions among health professionals.
A British government report divided therapies into three groups -- the first, containing acupuncture, chiropractics, herbal medicine, homeopathy and osteopathy, is organized and regulated, has a research base and is available on the National Health Service. Acupuncture is now used in most chronic pain treatments.
The second group of therapies include aromatherapy and hypnotherapy, and while they are available on the NHS, they are poorly regulated.
The third group contains therapies for which there is no research evidence at all, and includes crystal therapy and dowsing. It is this group which seems to give alternative medicine a bad name.
"Integrated medicine is good medicine," stressed Rees and Weil. "Its success will be signaled by dropping the adjective. The integrated medicine of today should be the medicine of the new millennium."
David Reilly, consultant physician at Glasgow Homeopathic Hospital in Scotland, said that orthodox and complementary medicine concentrates too much on the tools in their toolboxes -- whether drugs or acupuncture needles. "We are the artists hoping to emulate Michaelangelo's David only by studying the chisels that made it," he said.
According to Reilly, the study of human healing should ask questions on multiple levels, and find answers from nonconventional places -- placebo effects, hypnotherapy, even parasocial studies, spiritual practices and art. Integrated medicine should balance short-term analytical thinking with longer-term holistic treatment.
In developing countries most of the population use traditional medicine, and their experience can provide lessons for integration in developed countries. A survey of village clinics in China's Zhejiang Province showed that children with respiratory tract infections were prescribed an average of four different drugs, always a mixture of Western and Chinese medicine.
"The challenge of integrated health care," said Gerard Bodeker, chair of the Commonwealth Working Group on Traditional and Complementary Health Systems at Oxford University, "is to generate evidence on which illnesses are best treated through which approach. The Zhejiang study found that simultaneous use of both types of treatment was so commonplace that their individual contributions were difficult to assess."
In Japan, Chinese herbal medicine (kanpo) was introduced around the fifth century but was officially banned about 100 years ago. This means that modern Western medicine is the form practiced in Japan.
Jiro Imanishi and colleagues at the Kyoto Prefectural University of Medicine surveyed doctors of their Prefectural Medical Association about their attitudes to complementary medicine. Their findings were published in the Lancet medical journal.
Almost all the doctors practicing complementary medicine were kanpo practitioners (96 percent), but only 8 percent practiced any other form of complementary medicine. Imanishi thought that this result was strange given the disparity with American and European doctors, so he asked Japanese doctors whether they regarded kanpo as a form of complementary medicine.
Chinese herbal medicine was not considered as complementary by 25 percent of respondents. "If a medicine works, we don't discriminate between Chinese and Western sources," said Shinji Sato, a doctor at Tokyo Medical College.
Often the drugs used in Western medicines originally came from Chinese herbs or Amazon plant extracts. For example, the diuretic furosemide is used after heart surgery all over the world to treat and prevent congestive heart failure. Yet it was originally isolated from a Chinese herbal preparation. St. John's wort is used to treat depression, and shark cartilage for lung cancer.
In such cases, there is already close integration between orthodox and complementary medicine -- so much so that many doctors do not consider it "complementary." The question is whether the same indiscriminate use will, and should, eventually apply to other branches of complementary medicine.