REIKI–REVIEW OF A BIOFIELD THERAPY HISTORY, THEORY, PRACTICE, AND RESEARCH
Pamela Miles and Gala True, PhD Pamela Miles, founder of the Institute for the Advancement of Complementary Therapies IACT, is a Reiki master and meditation teacher who lectures on complementary medicine and develops educational programs and research initiatives on energy medicine for hospitals and health care organizations in the Northeast Gala True, PhD, is a Senior Scientist and the Assistant Director of Medical Ethics at the Albert Einstein Center for Urban Health Policy and Research in Philadelphia, PA future directions for research and the development of programs that integrate Reiki into clinical care, raising questions and issues that must be considered in these endeavors The National Institutes of Health Center for Complementary and Alternative Medicine NCCAM has classified energy medicine therapies into 2 basic categories: biofield therapies and bioelectromagnetic-based therapies
According to the NCCAM classifications, biofield modalities are defined as those therapies intended to affect energy fields that purportedly surround and interpenetrate the human body These therapies, which include Reiki, Qigong, and Therapeutic Touch, involve touch or placement of the hands in or through biofields, the existence of which have not yet been scientifically proven Bioelectromagnetic-based therapies involve the use or manipulation of electromagnetic fields EMFs, invisible lines of electrical force or currents Although the existence of EMFs has been demonstrated, therapeutic use of these fields is unique to complementary modalities such as magnet therapy4 Biofield therapies, including Reiki, are generally accepted as low-risk interventions The widespread use of these therapies, coupled with anecdotal evidence of efficacy, indicate a need for further study of this important category of complementary and alternative medicine CAM Because of their foundation in subtle energies
that as yet lie beyond technologys ability to consistently measure, biofield therapies present a special research challenge An increasing number of nurses, physicians, and other healthcare providers have begun integrating biofield therapies into patient care, and a growing number of hospital-based programs offer these modalities to patients and staff The line between what is alternative, complementary, or integrative is often blurred when it comes to biofield therapies Despite these challenges, efforts to describe these modalities, their practice, and their use by patients, as well as development of well-designed studies of safety and efficacy, are important and underway TRADITIONAL MEDICAL SYSTEMS AND REIKI Understanding Reiki requires an awareness of indigenous healing traditions that exist alongside, and pre-date, the Western biomedical model In these systems, the ability to facilitate healing derives from knowledge and practices that are passed from master practitioner to student,
who in turn becomes a master

Reiki is a vibrational, or subtle energy, therapy most commonly facilitated by light touch, which is believed to balance the biofield and strengthen the bodys ability to heal itself Although systematic study of efficacy is scant thus far, Reiki is increasingly used as an adjunct to conventional medical care, both in and out of hospital settings This article will describe the practice and review the history and theory of Reiki, giving readers a context for the growing popularity of this healing modality Programs that incorporate Reiki into the clinical setting will be discussed, as well as important considerations in setting up such a program Finally, the research literature to date on Reiki will be reviewed and evaluated, and directions for future Reiki research will be suggested mericans increasingly reach beyond conventional medicine to meet their healthcare needs, and research indicates that therapies based in energy medicine are a favorite choice1,2
Consistent with findings of increased use is the recognition that patients seldom discuss the use of these therapies with their physician, and that the majority of conventional medical providers are unfamiliar with the principles underlying these modalities In this manuscript, we focus on Reiki RAY kee, a biofield therapy facilitated most commonly by light touch, 3 attempting to evaluate and synthesize what is known about the history, theory, and practice of Reiki, as well as give an overview of the state of Reiki research We conclude with thoughts about

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practitioner Such lineages of healers are seen across cultures and share common threads; however, there are always cultural and idiosyncratic variations The indigenous traditions of
China, Tibet, Africa, Russia, Native America, and India Ayurveda are known in the West In Europe, the Iceman who died 5300 years ago in the Swiss Alps and was recently discovered frozen in a glacier was noted to have parasites in his intestines He carried a medicine pouch and was deemed to be self-medicating with local mushrooms If this is true, the Iceman clearly had access to medical information through non-scientific means5 Although some indigenous and traditional medical systems are known to have used advanced medical technologies such as brain surgery in India and Africa, these systems often emphasize the development of skills in areas overlooked in conventional medicine For example, traditional healers use remedies from the natural environment and focus on accessing the subtle vibrational field, which is understood to be related to consciousness Intervening in the vibrational field is deemed necessary for lasting benefit The training of traditional healers requires they become
adept in navigating subjective realms of awareness, a skill developed through meditative techniques and disciplined spiritual practice HISTORY Mikao Usui 1865-1926, a lifelong practitioner of Tendai Buddhism and dedicated spiritual aspirant, formulated the roots of what has come to be called Reiki in early 20th century Japan He trained in a monastery as a young boy, and practiced martial arts from age 12, achieving mastery in several disciplines Perhaps because of Usuis background in Buddhism, Reiki is often referred to as an ancient Tibetan technique, although there is no evidence that this is true Mikao Usui clearly referred to himself as the founder of Reiki6 and Tibetan medicine does not include handson energetic healing Those who approached Usui for healing were given a few minutes of light healing touch before being instructed in his method of spiritual self-development The first level of teaching was freely given Thereafter, students had to earn other levels through disciplined
practice Each student was taught according to his nature, dedication, and accomplishment Usuis philosophy was non-dualist, and he stressed spiritual unfolding through regular practice of spiritual techniques which included the use of symbols in ways reminiscent of Taoist talismanic healing images His teaching was a system of spiritual practice; any physical, emotional, or mental healing that might occur was seen as a natural by-product personal communication, Kenneth Cohen, December 2002 Students referred to the teachings as UsuiTeate Usui Hand Touch or Usui Hand Healing Usui stressed the importance of peaceful mental demeanor, and offered his students 5 precepts to guide them: Just for today, do not anger Just for today, do not worry Be humble

Be honest in your work Be compassionate to yourself and others In the last year of his life, Usui was approached by his student Chujiro Hayashi 1878-1940, a retired naval officer, with a request to develop the therapeutic aspects of the system
separate from the stringent meditative practices Usui agreed After Usuis death, Hayashi further developed the system as a practical healing technique without the perceived encumbrance of spiritual practices He called his technique Hayashi Shiki Reiki, and although Usui sometimes used the word, it is likely from Hayashi that the system came to be called Reiki, Rei meaning universal or highest and Ki meaning subtle energy,7 like the Chinese chi It should be noted the vibration accessed in Reiki arises from nondual primordial chi, or Tao, as distinguished from the bioenergetic level of chi stimulated by therapeutic acupuncture 8 Although Hayashis technique was simplified from Usuis system of spiritual practices, his use of the word Reiki implied that even with his modifications, the healing technique remained rooted in spirituality, that he was accessing the same non-dual conscious vibration for healing Hayashi opened a small 8-bed clinic in Tokyo where 16 practitioners gave Reiki
treatment in pairs At some point, Hayashi diverged from Usuis typically Buddhist approach of making teachings and healing available at a low monetary cost, noting that people were more engaged when paying fees for their healing6,9 As Reiki became available beyond the circle of spiritual aspirants, it entered the medical marketplace and the issue of compensation for both training and treatment had to be addressed Mrs Hawayo Takata 1900-1980, a first generation American, came to Hayashis clinic in 1936 suffering from respiratory and abdominal complaints9 After receiving treatment for 4 months and recovering her health,10 she became his student and practiced in his clinic Takata returned home to Hawaii in 1937, carrying Hayashis instruction to bring Reiki to the West Hayashi visited Hawaii in 1938, teaching and lecturing, and trained Takata to be a Reiki master Hayashi signed a certificate on February 21, 1938 attesting that Takata was a fully credentialed Reiki master–the only one
outside Japan at the time, and the first woman Hayashi understood deeply that Usui wanted the teachings to be widely accessible, and was emboldened to step beyond the cultural tradition that would have restricted the practice to Japanese men Faced with the challenge of articulating a Japanese healing technique to a largely Christian population in the socio-political climate preceding World War II, Takata pragmatically reshaped the origins of Reiki, presenting Usui as a Christian minister6,9 She did not, however, vary the practice from what Hayashi had taught, emphasizing the foundation of consistent self-treatment Takata taught and shared Reiki for many years in Hawaii In 1973 she was invited to the mainland, where she taught for the last 7 years of her life Takata died in December 1980, having initiated 22 Reiki masters Hayashi and Usui each trained approximately 18

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In less than 15 years after her death, Reiki
had spread around the world and returned to Japan, although rarely according to the guidelines she taught In the mid 1990s, several Western Reiki masters discovered a small group of students who were originally trained by either Usui or Hayashi One of these students clarified the distinction between vibrational and bioenergetic healing by saying: Usui-sensei told [us] that [the] method is a spiritual healing technique and an energy healing technique Spiritual healing brings fundamental healing by helping us to become part of the universal consciousness, while energy healing centers around removing the symptoms of mind and body disorders6 Advanced practitioners of biofield therapies, including Reiki, conceptualize the biofield as a continuum from the vibrational, at the deepest and subtlest level, to the bioenergetic, closer to the physical realm While this distinction has not been scientifically tested, it is important within the system of Reiki healing and essential to the theory
behind Reiki, as will be discussed below The term Reiki refers to both the healing system and the vibration accessed Nearly all Reiki practitioners outside of Japan today trace their lineage to the 22 masters trained by Takata There are also two other teachers, Hiroshi Doi and Premaratna, who offer disciplined practices descended from Usui and Hayashi This paper uses the term Reiki to refer to the traditional technique as taught by Takata, unless otherwise specified In accordance with the philosophy of Asian spiritual practices in which the practitioner is always seen as a student of the system and a master properly thinks of himself as a master student, we use the terms practitioner and student interchangeably

TRADITIONAL REIKI TREATMENT Hands-on Reiki treatment is offered through light touch on a fully clothed recipient seated in a chair or reclining on a treatment table A quiet setting conducive to relaxation is desirable, but not necessary A full treatment typically includes
placing hands on 12 positions on the head, and on the front and back of the torso Hands can also be placed directly on the site of injury or pain if desired, but the technique is neither symptom nor pathology specific11 When even light touch is contraindicated, as in the presence of lesions, the hands can hover inches off the body12 A session can be as short or as long as needed,9 with full treatments typically lasting 45 to 75 minutes The receiver need not be conscious13 and Reiki can be offered during surgery11 The practice of Reiki is primarily passive, embodying the Asian philosophy of non-action14 Offering Reiki is refreshing to the practitioner as well as the recipient Practitioners believe Reiki has the potential to rebalance the biofield at the deepest vibrational level, thereby removing the subtle causes of illness9 while enhancing overall resilience Because Reiki is a holistic modality that supports overall healing and well-being, it is not possible to predict how quickly
specific symptoms may respond Generally, in addressing chronic conditions, a minimum of 4 complete treatments is advised before evaluating clinical benefit

REIKI TRAINING Reiki is practiced at the First degree, Second degree, and master level, with each level having a defined scope of practice At the core of the training, and unique to this practice, is a series of initiations, also called empowerments or attunements, which are believed to connect the student to primordial consciousness, the intelligence that permeates creation, maintaining life-sustaining functions and directing complex cellular processes, and which is the source of subtle Reiki vibration7 This connection is believed then to be available at any time, regardless the students health, mental state or intention Self-treatment is viewed as the foundational practice for all levels9 Reiki practice is considered selfrevealing, and students are not taught Reiki as much as they are taught how to learn Reiki Initiation at each
level marks the beginning of study at that level, not the culmination of learning6,9 First degree Reiki is easily learned12 and appropriate for students of any age or state of health who have the desire to practice First degree students are able to treat themselves and others using light, non-manipulative touch to precipitate a cascade of healing vibration The effectiveness of the treatment and the recipients ability to discern the energy do not seem to be related15 It is advisable to practice a minimum of 3 months before proceeding to Second degree3 Second degree practitioners are trained in the use of specific symbols to access Reiki mentally for distant healing First and Second degree training require 8 to 12 hours of class time each and are usually taught to groups, although private instruction may be arranged There are 4 initiations in First degree, and 1 initiation for each of the 2 remaining levels3 At all levels, Reiki develops through committed practice It is not necessary,
nor is it advisable, to take higher initiations to improve ones practice The reason to study another level is to acquire that particular skill–distant healing at Second degree, or teaching and initiation at the master level At any level, students can only advance through diligent self-treatment In this way, Reiki masters have not mastered Reiki; they are simply students who feel called to teach, and who continue to learn through teaching True mastery, in the sense of Usui, Hayashi, and Takata, is not a matter of receiving an initiation, but rather a life committed to practice3 Practicing Reiki 3 to 10 years creates a reasonable foundation for teaching Master training is an apprenticeship of at least a year3 When teaching at any level, it is the Reiki masters responsibility to consider any unusual circumstances and use his or her discretion in customizing the training to fit the individual6 Reiki is learned through direct transmission from a Reiki master and cannot be learned from a
book3 None of the traditional Reiki levels include training in either professional treatment or the dynamics of the therapeutic relationship The training described above is the ideal based on Takata However, since her death in 1980, many Reiki students have not received such thorough training Today, it is common for new students to receive less than a weekend of training and leave with the misguided impression they are now Reiki masters One can

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only grow in mastery through years of disciplined practice Although there are several professional organizations for Reiki masters, the Reiki Alliance adheres most consistently to the standards set by Takata It has more than 700 members in 45 countries who honor a code of ethics that includes respecting the physician/patient relationship3 There are also Reiki masters not affiliated with the Reiki Alliance who are committed to ethical practice and the complete training and
initiation of new students It is important to note that no certificate conveys reliable information about quality of training Thus, it is useful to include a number of factors when considering a Reiki practitioners credentials, such as consistency of self-treatment, extent of clinical practice, and length of time between training at different levels These issues are addressed in other sections of this article REIKI THEORY There is no agreed upon theory for how Reiki might work, and its mechanism of action is still unknown For this reason, Reiki is subject to the criticism leveled at other CAM modalities by skeptics: it cannot be efficacious because it lacks a known biological mechanism of action As David Hufford has argued, implicit in this view is the belief that CAM claims will be proven to be true or false on the basis of present scientific knowledge, and that the acceptance of any theoretically implausible claims would require the abandonment of current scientific knowledge16 This
of course ends all inquiry before it begins, leaving no room for making connections between theories underlying energy healing practices such as Reiki, Therapeutic touch, or Qi gong, and those emerging in various branches of the conventional sciences The concepts underlying energy therapies such as Reiki have theoretical commonalities with a variety of models in physics, none of which have been experimentally linked with medicine or clinical outcomes Models in bioelectromagnetism, quantum physics,17 and super string theory18 are consistent with Asian scripture19-23 in suggesting that very subtle vibration may be the substratum of reality as we know it, and therefore such vibration may have a role to play in health and disease For example, Jan Walleczek24 and Abe Liboff25 in the field of bioelectromagnetism offer credible scientific support for the potential role of the forces of subtle bioelectromagnetic fields in physiological processes Walleczek in particular has convincingly
demonstrated that subtle magnetic fields can have measurable interactions with biological systems in the area of redox potential and hydroxylation reactions Although this area of research is in its early stages, these connections suggest that the theoretical underpinnings of Reiki and other energy therapies may not be in direct contradiction to scientific models Reiki vibration is understood to be drawn through the practitioner according to the recipients need,26 within the ability of the practitioner to carry the vibration Beginning students often find it difficult to grasp that non-doing can be so effective The flow of Reiki is believed to increase as the practitioner becomes inwardly more still, an understanding acquired only through pro-

longed practice The fact that the vibrational flow is drawn by the recipient allows for great flexibility and ease of delivery While a practitioners ability to be a conduit for the vibrations may vary, there is ultimately no wrong technique9
Reikis self-regulatory mechanism precludes overdosing–even a dry sponge only absorbs to saturation Experienced practitioners claim to notice when the healing vibrational flow decreases, at which time they move to the next hand placement27 Recipients often sense a vibrational flow, sometimes feeling heat or coolness, or waves of relaxation throughout their body, or in specific areas that may or may not correspond to where the practitioners hands are placed26-28 Such experiences may be evidence of a subtle entrainment effect, similar to that of sound healing, whereby Reiki vibrations attune the recipients biofield to greater harmony Reiki is believed to rebalance the biofield, thus strengthening the bodys ability to heal29 and increasing systemic resistance to stress It appears to reduce stress and stimulate self-healing by relaxation and perhaps by resetting the resting tone of the autonomic nervous system Proponents of Reiki believe this might lead to enhancement of immune system
function and increased endorphin production Programs Currently Incorporating Reiki into Clinical Care Table 1 provides a summary of programs that incorporate Reiki into the clinical setting The majority of these programs have not been subject to systematic evaluation due to budgetary and time constraints However, staff, patients, and program administrators report a number of benefits including reduced anxiety and lower use of pain medications, increased patient satisfaction for surgical patients,29 and decreased numbers of selfreported common gerontological complaints such as anxiety, loneliness, insomnia, and pain among older individuals living in the community Reiki can easily fit within the harm reduction model30 and can be successfully used in self-treatment in combination with appropriate medical/psychiatric care by people with combined HIV and psychiatric diagnoses for emotional centering, pain management, and support in recovery readiness Children with cancer and their families
practice First degree Reiki on themselves and one another Reiki is a supportive therapy for hospice and palliative care31 OVERVIEW OF REIKI IN CLINICAL PRACTICE Although Reiki was first used in lay practice, it is increasingly used in a variety of medical settings including hospice care settings;26,31 emergency rooms;32 psychiatric settings;33operating rooms;29,34 nursing homes;35 pediatric,12 rehabilitation;35 and family practice centers, obstetrics, gynecology, and neonatal care units;36 HIV/AIDS;37,38 and organ transplantation care units;38 and for a variety of medical conditions such as cancer; 3 9 pain;27,29,34 autism/special needs; infertility; neurodegenerative disorders; and fatigue syndromes Reikis popularity among the lay population is evidenced by its mention in a wide variety of publications from the New York Times and Time, to Esquire and Town Country

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TABLE 1 Reiki hospital and community based
programs Program
GENERAL MEDICINE Wilcox Memorial Hospital Lihue, Kauai, Hawaii Center for Mind Body Medicine Mid-Columbia Medical Center The Dalles, Ore Portsmouth Regional Hospital Portsmouth, NH Center for Integrative Medicine George Washington University Hospital Washington, DC HIV/AIDS Samuels Center for Comprehensive Care St Lukes-Roosevelt Hospital Center New York, NY Siloam Philadelphia, Pa CANCER Direccion de Servicios Metropolitano Sur Metropolitan South Health Center 6 hospitals serving 7000 people Santiago, Chile Integrative Therapies Program for Children with Cancer Columbia Presbyterian Medical Center New York, NY Dartmouth Hitchcock Medical Center Lebanon, NH Integrative Medicine Outpatient Center Memorial Sloan Kettering Cancer Center New York, NY SURGERY Mercy Hospital Portland, Me COMMUNITY PROGRAMS Addison Gilbert Hospital Gloucester, Mass Bi-weekly Reiki clinics QuaLife Wellness Community Denver, Colo Respite Foundation New York, NY Wolfeboro Free Clinics 13
locations in NH and Me ELDER CARE Dorot New York, NY Knox Center for Long Term Care Rockland, Me Camden Health Care Center Camden, Me residents and staff treatment HOSPICE Hospice Maui Wailuku, Maui, HI Assured Home Health and Hospice Chehalis, Wash Good Samaritan Home Health and Hospice Puyallup, Wash Whidbey General Hospital Home Health Hospice Program Coupville, Wash

Persons Served
Patients Staff

Services Offered
Treatment Training

Inpatients and Outpatients Outpatients

Treatment Treatment and training

Adults with HIV/AIDS, family members and caregivers People with HIV/AIDS and families

Treatment and training

Treatment and training

Children with cancer

Treatment

Children with cancer and their families

Treatment and training

Radiation oncology patients Cancer patients

Treatment Treatment and training

Surgical patients and staff

Treatment

Community

Treatment

People with serious illnesses Families with special needs Community members

Treatment and training Treatment
Treatment

Elders Patients Residents and staff

Training Treatment Treatment

Patients Patients, families, caregivers, staff In-patients and out-patients

Treatment and training Treatment Treatment and training

Patients

Treatment

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There are 3 tiers of Reiki practice: Individuals who use Reiki for themselves, family, and friends; Licensed or unlicensed health care professionals either offering full Reiki treatment or combining Reiki with other modalities such as a massage therapist starting/ending treatment with a few minutes of Reiki, or a physician using Reiki to ease the discomfort of an examination; Hospital-affiliated and community-based programs offering Reiki treatment or training Reiki appears to be an effective stress reduction technique that easily integrates into conventional medicine12 because it involves neither the use of substances nor manipulative touch that might be contraindicated or carry
unknown risks, and because the protocol for Reiki treatment is flexible, adapting to both the need of the patient and of the medical circumstances Reiki can be used to support conventional medical interventions12,27,40 In addition, when used on a conscious patient, the experience is relaxing and pleasant, increasing patient comfort, enhancing relationships with caregivers, and possibly reducing side effects of procedures and medications Staff report they enjoy giving Reiki treatments12 Caregivers who routinely have to hurt patients in order administer needed medical care express gratitude for a tool that minimizes patient discomfort and quickly soothes distressed children 29,36 There is limited but promising preliminary research evidence for Reikis use in pain management First degree practice is easily learned and can be used in selftreatment26 Training patients to practice Reiki self-treatment may reduce the side effects of common medical interventions and empower patients with a
simple, effective skill to address anxiety, insomnia, and pain26 at modest cost41 A patient with resources to address his own suffering is better equipped to comply with conventional medical protocols and be a responsible partner to his medical caregivers11 INTRODUCING REIKI INTO CLINICAL PROGRAMS AND HOSPITALS Even in the absence of a large body of standardized research, clinicians and hospital administrators are including Reiki into patient care12 With this in mind, we outline some of the challenges and issues that are being faced42 There are 3 avenues through which Reiki is being incorporated into conventional medical care: Medical personnel are learning First degree Reiki, using it for self-care, and integrating comforting touch into routine medical care; Reiki practitioners are offering treatment to patients and staff; Hospital-based education programs are training patients, family members and caregivers in First degree Reiki It is a challenge to locate and identify Reiki
practitioners who have the training, clinical experience, and professionalism neces-

sary to be part of a healthcare team43,44 There is currently no licensing for Reiki, nor, given its diversity and apparent low-risk, is there likely to be The first step when bringing Reiki into clinical settings is the decision to offer treatment or training or both A Reiki master is needed if Reiki training will be offered, and a traditionally trained Reiki master who has taken training over several years and has additional years of clinical experience is best equipped to set up or supervise a program A First or Second degree practitioner who has adequate training and clinical experience, who values integrative medical collaboration, and who has references from medical practitioners is qualified to give treatment An otherwise qualified Reiki practitioner may need guidance on how to work in a medical rather than a private practice environment45 Once expectations are communicated and agreed upon,
there may be advantages to using non-medical Reiki practitioners rather than Reiki trained medical professionals when offering Reiki to patients Integrative medicine calls for the incorporation into medical settings of dedicated and experienced lay CAM practitioners even when their particular expertise lies outside the conventional academic paradigm16,46 There are no professional standards in the practice of Reiki and therefore certificates have little meaning Discussion of the following questions can be useful when evaluating a practitioners expertise and appropriateness for collaboration in a medical setting: 1 When did you complete each level of training and how many hours of training did you receive at each level? 2 Do you practice daily self-treatment? 3 What clinical experience have you had since your training? 4 How do you describe Reiki? 5 How would you respond to questions about the meaning of various sensations a recipient might have during or after treatment? 6 How do you
feel during and after giving treatment? 7 What role do you see yourself playing as part of an interdisciplinary healthcare team? The standard of care should be followed for any patient who is receiving Reiki therapy in a clinical setting, including close monitoring of medications Individuals with diabetes, in particular, have been reported to require less medication once beginning treatment Outpatients with HIV/AIDS have been able to reduce psychiatric medications under medical supervision when using Reiki self-treatment It is of interest that people with HIV/AIDS also report greater openness to availing themselves of the benefits of conventional pharmaceutical treatment and increased ease of compliance after using Reiki self-treatment47 STATE OF THE RESEARCH LITERATURE ON REIKI The preponderance of Reiki studies reported in the literature to date consists of a limited number of case reports, descriptive studies, or randomized controlled studies conducted with a small number of
patients This is in keeping with much of the current

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research on complementary therapies For example, Ke and colleagues reviewed CAM studies from 11 American Medical Association journals, and found that one third of the studies were traditional or narrative reviews and one fifth were randomized, controlled trials48 Although few of the published studies of Reiki are randomized controlled trials, it is important to review this literature in order to understand the context of current practice patterns of Reiki and to plan future research from health services research to randomized controlled trials Because of parallels between Reiki, Therapeutic Touch, and distant healing such as intercessory prayer, these modalities have sometimes been studied together, further confounding the ability to evaluate the separate effects of these therapies Relevant randomized, placebo-controlled studies looking at Reiki in combination
with these other forms of energy healing will be included here Table 2 Randomized controlled studies of Reiki and other energy healing and distance therapies Astin and colleagues undertook a systematic review of randomized trials of any form of distant healing, defined as strategies that purport to heal through some exchange or channeling of supraphysical energy49 This review included randomized placebo-controlled studies of Reiki, and it is worth reviewing selected findings Through an electronic review of MEDLINE, PsychLIT, EMBASE, CISCOM, and Cochrane Library databases, the researchers identified 23 trials involving 2774 patients Only studies that included random assignment and placebo or other control were included in the analysis Studies were also limited to those published in peer-reviewed journals and which were clinical, rather than experimental in nature Astin et al identified over 100 clinical trials of distant healing, with 23 meeting the criteria outlined above These studies
were broken down into 3 subcategories: distant healing including Reiki, prayer, and Therapeutic Touch Each study was evaluated for methodological quality using Jadads guidelines on method of randomization, description and method of placebo-control, and description of withdrawals and dropouts50 Each study was also evaluated as to whether or not it was adequately powered and whether randomization was successful The effect size for other distant healing which included Reiki was 038, P0073, for prayer the effect size was 025 P0009 and for Therapeutic Touch the effect size was 063 P0003 Effect sizes were also calculated for the 16 studies in which both patient and evaluator were blinded, which yielded an effect size 040, P001 In a series of studies beginning in the early 1990s, Wirth and his colleagues investigated the efficacy of Reiki, in combination with various other forms of energy and distance healing, on pain after extraction of the third molar;51 wound healing;52 hematological
measures;53 and multi-site surface electromyographic measurements sEMG and autonomic measures54 Wirth demonstrated significant reduction in pain and blood urea nitrogen BUN and a trend toward normalization of blood glucose for those subjects who had higher than normal levels53 Mansour and colleagues undertook a study to evaluate

whether subjects and independent observers could be successfully blinded to sham versus real Reiki55 The study used a 4round, crossover experimental design with 20 blinded subjects 12 college students, 4 breast cancer survivors, and 4 observers Two Reiki practitioners were recruited, and 2 actors who closely resembled them were trained in the movements of Reiki 33 Subjects received consecutive treatments from 2 different practitioners during each round of the intervention The following combinations of practitioners were used: Reiki plus Reiki, or placebo plus placebo, or Reiki plus placebo, or placebo plus Reiki The subjects were asked to evaluate the
interventions and guess which treatments were administered by a real Reiki practitioner and which by a placebo Reiki practitioner None of the subjects accurately distinguished the Reiki practitioners from the placebo practitioners, suggesting that studies using hands-on Reiki therapy can be blinded These findings support the work of Ai and colleagues, who reported successful blinding of patients and independent observers in the use of placebo versus real Qigong therapy56 Another interesting finding from the Mansour study came from subjects self-report of sensations, such as tingling and heat, that were experienced during each round of treatment Subjects indicated that these sensations were most intense during the second round of the intervention, when they received Reiki plus Reiki The investigators noted this might suggest a cumulative Reiki effect55 Finally, a study by Shiflett et al15 used a modified doubleblind placebo control design to investigate effects of Reiki on 50 subacute
ischemic stroke patients Ten patients were treated by a Reiki master, 10 were treated by practitioners trained in First degree, and 10 were treated by sham practitioners who had been trained in Reiki techniques but had not received initiation into Reiki An additional 20 historical control subjects identified through hospital records were used as a no-treatment comparison group Results showed no evidence of short-term benefit in terms of functioning or depression, as measured by standardized instruments However, the authors note that data on long-term and cognitive change were not available, and so it was not possible to measure the potential impact of Reiki on these dimensions Exploratory studies of physiological changes associated with Reiki One study by Wetzel, investigated the hypothesis that touch therapies increase oxygen-carrying capabilities as measured through changes in hemoglobin and hematocrit values57 Wetzel measured changes in these values over a 24-hour period, during
which the intervention group, 48 essentially healthy adults, participated in Level I Reiki training The intervention group demonstrated significant changes in both hemoglobin and hematocrit values, as compared to a small control group of 10 healthy medical professionals, which demonstrated no change Wardell and Engebretson used a single group repeated measure design to study the effects of 30-minutes of Reiki on 23 healthy subjects58 Data on biological markers related to the stress reduction response, including state anxiety, salivary IgA

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and cortisol, blood pressure, galvanic skin response, muscle tension, and skin temperature were collected before, during, and after the Reiki session Results indicated biochemical changes in the direction of increased relaxation and immune responsivity, with significant reduction in state anxiety, drop in systolic blood pressure, and increase in salivary IgA levels There was a
non-significant reduction in salivary cortisol, which has been linked to longevity in breast cancer survivors59 Brewitt, Vittetoe, and Hartwell studied 5 patients with a variety of chronic illnesses multiple sclerosis, lupus, fibromyalgia, and thyroid goiter who received 11 Reiki treatments over a 9week period60 They measured changes in electrical skin resistance at over 40 sites corresponding with acupuncture/conductance points, and collected patient reports of anxiety, pain, and mobility Significant changes occurred at 3 skin points corresponding to acupuncture meridians, and patients also reported increased relaxation, reduced pain, and increased mobility While results may have been biased by the lack of prior hypotheses regarding which specific points would be active, the study suggests interesting directions for future research Descriptive and phenomenological studies A number of recent observational and descriptive studies have focused on the effects of Reiki in reducing pain and
increasing relaxation and a sense of well-being in patients In 1997, Olson and Hansen investigated the impact of Reiki on chronic pain using a pre- and post-test design and validated self-report measures Twenty volunteers who experienced chronic pain from a variety of causes, including cancer, demonstrated a significant decrease in pain after receiving a single 75 minute Reiki session61This study is limited by its design and the existence of a number of potentially confounding variables, but it does point to possible clinical applications of Reiki that should be studied further The Windana Society in Melbourne, Australia has operated a Reiki clinic for more than 10 years and provides holistic care to clients who are undergoing treatment for withdrawal from drugs and alcohol62 The staff reviewed clinical records and conducted a client survey Both clients and staff attribute a number of client outcomes to Reiki therapy, including reduced pain and improvements in clients sleep patterns,
mood, and clarity of thinking Their data supports the hypothesis that Reiki promotes a greater sense of self-awareness and connectedness, and brings profound relaxation Clients described Reiki as bringing them a sense of peace and well-being that enabled them to continue with their recovery and enhanced their counseling sessions The heightened state of awareness and sense of inner peace and calm reported by clients at Windana were also identified as a major theme in qualitative data collected by Engebretson and Wardell58 Subjects expressed feelings of safety and perceived relationship with the practitioner Some also described what the authors defined as a liminal state of consciousness, hovering between awareness and sleep The authors noted that such liminal states are often associated with spiritual experiences and

cross-cultural ritual healing practices They propose that the subjective nature of the experience may be related to its effectiveness and that commonly used research
methods may lack the complexity needed to capture the non-linearity of the subjects experience Incorporating these viewpoints is essential to the effective design of future studies of Reiki The sense of connectedness felt by the above subjects towards an unfamiliar practitioner is of interest in light of studies that have identified practitioner-patient bonding as an important factor in healing63 Descriptive and qualitative data provide us with important insights into the perceived benefits of Reiki from the viewpoint of those who use it in a real world healthcare setting DIRECTIONS OF FUTURE RESEARCH Although it comes mostly from descriptive studies or randomized controlled trials with design limitations, evidence of the beneficial effects of Reiki makes a compelling case for the need for further research Future studies to identify possible mechanisms should build upon work already done and be informed by emerging theories in the physical sciences At the same time, it is critical to
undertake well-designed studies of specific biological effects, as well as potential clinical benefits of Reiki In the case of biofield therapies, it is important to understand what practitioners consider to be essential to the transmission of healing energy In Reiki, it is initiation and passive vibrational flow rather than intention that is essential and this explanatory model should be taken into account Involving practitioners who are knowledgeable regarding the theory and practice of Reiki and familiar with the methods and constraints of scientific inquiry in the earliest stages of study design will greatly enhance the quality of research A greater incorporation into CAM research of qualitative methods and mixed methodological design where qualitative methods are used to expand upon and elucidate findings from quantitative data would be useful in research in energy medicine46,-64-65 Thus, for example, if qualitative and descriptive data described above tells us that recipients of
Reiki report greater self-awareness, feelings of centeredness, and overall well-being, then these are important outcomes to try to measure, even if associations between these patient-centered outcomes and clinically meaningful outcomes, such as improvement in function or greater receptivity to therapeutic counseling, are difficult to measure Randomized, controlled trials may not be the ideal strategy in cases where the outcomes being measured are related to chronic disease with uncertain trajectory, or where the treatment being investigated is not easily standardized or consists of multiple components66 Further research using objective markers to track response to an intervention may be able to use cutting edge genetic tools such the TheraTrak gene and protein expression system from Source Precision Medicine Boulder, CO67 Here a patients blood is mixed with a panel of highly sensitive and calibrated inflammatory genetic markers that track a patients response to a therapeutic
intervention such as Reiki in much the same way we have historically used

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TABLE 2 Summary of Randomized, Controlled Studies of Reiki and Related Modalities Sample Size, Population 23 trials involving 2774 patients

Main Author, Year Astin 200049

Design Systematic review of randomized, placebo-controlled trials of distant healing modalities

Results 13 57 of 23 trials yielded statistically significant treatment effects, 9 showed no effect over control interventions, and 1 showed a negative effect

Comments The authors identified a number of limitations in studies of distance healing, including underpowered studies and inadequate randomization resulting in non-homogeneous study groups The authors concluded that further study of distant healing interventions is merited Study limited by small sample size and absence of a power analysis Use of a design where individual subjects served as their own control is both a
strength and a weakness of the study Studies limited by potential confounding variables, such as the presence of a research assistant in the room during intervention and by nonhomogeneous study groups

Wirth 199351

Randomized, controlled trials, intervention received Reiki and LeShan

21 patients with impacted third molar

Treatment group experienced less pain in degree and intensity, results were statistically significant

Wirth 199652

Review of 5 randomized, controlled trials, combinations of Reiki and Therapeutic Touch Randomized controlled trials, combination of Reiki, TT, LeShan and Qigong

Range of 15 to 44 healthy subjects, experimentally induced full thickness biopsy wounds

Inconclusive, some studies showed significantly faster healing in treatment group, while others showed nonsignificant effects or reverse significance Treatment group demonstrated significant reduction in blood urea nitrogen and trend toward normalization of blood glucose in subjects who had higher than
normal levels Statistically significant reduction in sEMG activity at thoracic and lumbar sites, corresponding to regions associated with autonomic system and relaxation response Participants were unable to differentiate between real and sham Reiki practitioner

Wirth 199653

14 healthy subjects, including Qi gong students

Limited by small sample size, absence of power analysis, and potentially confounding variables, including use of Qi gong students as subjects Demonstrated possible bioenergetic adaptogenic effect of energy therapy

Wirth 199754

Review of 3 randomized, controlled trials, Reiki, TT, and Qi gong

Range of 12 to 44 healthy subjects, sEMG and autonomic measures

Limited by confounding variables, use of multiple healers across treatment groups, and non-homogeneous study groups, including subjects with extensive meditation experience

Mansour 199955

Randomized, placebo-controlled crossover design, Reiki and sham Reiki

20 blinded subjects, outcome measures included
ability to identify real Reiki practitioner, sensations experienced 50 subacute ischemic stroke patients, plus 20 historical controls, outcome measures related to function and depression

Demonstrates that successful blinding of participants is possible Participants in the Reiki plus Reiki intervention reported greater intensity of sensations during treatment, suggesting that Reiki energy has a cumulative effect Data on long-term and cognitive change were not available, so potential impact of Reiki on those dimensions is unknown Use of historical controls may have biased results Inadequate sample size may have resulted in Type II error failing to detect significant differences when they do in fact exist

Shiflett in press15

Randomized, placebo-controlled trial, Reiki master, Reiki Level 1 or sham Reiki

No significant differences between intervention and control groups on overall function or depression Treatment groups showed some positive effects on mood and energy

sEMG surface
electromyographic measurements; TT Therapeutic Touch

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a patients hematocrit to track response to iron supplementation Currently, 3 studies of Reiki funded by NCCAM are in progress One at the University of Michigan is investigating the use of Reiki for patients with diabetic neuropathy A second study at Albert Einstein Medical Center in Philadelphia examines the use of Reiki to improve quality of life and spiritual well-being for patients with advanced HIV/AIDS70 The third, a study for patients with fibromyalgia, is being conducted out of the Department of Family Medicine of the University of Washington School of Medicine69 Whereas biofield therapies such as Reiki, Qi gong and Therapeutic Touch may themselves have different mechanisms of action, they all share with meditation the effect of moving the system in the direction of relaxation, which has been linked to health and healing Research that builds on this
commonality would advance our understanding of the process of healing while offering patients and clinicians the choice as to which technique is the best match for a particular situation or individual Many CAMs, and subtle energy therapies in particular, aim to relieve suffering, restore balance, and return each person to wholeness The standards of replicability and generalizability so central to the scientific paradigm can be at odds with the inherent individualization of actual Reiki practice and treatment However, the fact that so many people adopt Reiki as a spiritual and healing practice and so many more seek treatment from a Reiki provider, means that we must find ways to study its potential benefits and applications Research using currently available and emerging methods will provide us with data about possible mechanisms, but more importantly, we must investigate how Reiki might benefit patients, and in what specific areas The experiences and reports of Reikis benefits from
patients, healthcare providers, and Reiki practitioners require that we do so DISCUSSION Healing is a multidimensional process that is strengthened by reducing stress and accessing psychospiritual resources Research suggests that CAM users are seeking therapies congruent with their values, beliefs, and philosophical perspectives on life and wellbeing70 Patients experience Reiki as a relaxing practice, free of dogma, that connects them to their innate spirituality through experiences unique to each individual29,35 Future research on Reiki efficacy should identify outcomes measures, such as increased sense of spiritual well-being, that are relevant to patients experiences and that may have an impact on clinical outcomesThe creation of an integrated medical practice would be advanced by hospitals collaborating with professional, well trained, highly experienced Reiki masters to develop medically relevant First degree classes with Continuing Education Units that are open to all staff
members45 Graduates of such programs report First degree Reiki training is a simple, effective practice to support personal well-being, enhance clinical skills, and deepen their appreciation of what CAM offers conventional medicine, in terms of both techniques and perspective Reiki has come full circle Usui created a spiritual practice that includes healing as a side benefit Hayashi developed a healing tech-

nique that offers spiritual enhancement to those who receive treatment regularly from themselves or another Consistency is the key Through all its modifications, Reiki remains a spiritual discipline that must be practiced regularly for its full benefit to be realized
Acknowledgments

The authors would like to thank the following individuals for generously sharing their expertise: Kenneth Cohen, David Crow, Michael Gnatt MD, Brian Greene PhD, Sally Kempton, Barbara McDaniel, Lawrence Palevsky MD, and Eliot Tokar
References
1 Eisenberg DM, Kessler RC, Foster C, et al Unconventional
medicine in the United States N Engl J Med 1993; 3284: 246-252 2 Eisenberg DM, Davis R, Ettner S, et al Trends in alternative medicine use in the United States 1990-1997; Results of a follow-up national survey JAMA 1998;28018:1569-1575 3 Reiki Alliance wwwreikiallianceorg Accessed November 3, 2002 4 http://nccamnihgov/health/whatiscam/ Accessed November 13, 2002 5 Capasso L 5300 years ago, the Ice Man used natural laxatives and antibioticsLancet 1998 Dec 5;3529143:1864 6 Available at: http//reikihistorytopcitiescom Accessed November 3, 2002 7 Chang SO Meaning of Ki related to touch in caring Holist Nurs Pract XXOct:73 8 Becker RO Acupuncture points show increased DC electrical conductivity Am J Chin Med 1976:4;69 9 Haberley H Reiki: Hawayo Takatas Story Olney, MD: Archedigm; 1990 10 Matsuura, P Helping Hands Honolulu Advertiser Feb 25, 1974 11 Reiki therapy provides emotional well-being Patient Education Management November 2002 Volume 9, Number 11:130-132 12 Brill C, Kashurba M Each
Moment of Touch Nurs Adm Q Spring 2001 253:8 13 Bailey P Healing touch Hosp Physician 1997;33142 14 Lao-Tzu, Tao te Ching: A New English Version Mitchell S trans-ed Harper Collins, 1992 15 Shiflett SC, Nayak S, Bid C, Miles P, Agnostinelli S Effect of Reiki Treatments on Functional Recovery in Patients in Post-Stroke Rehabilitation: A Pilot Study J Alter Compl in press 16 Hufford, DJ CAM and cultural diversity: ethics and epistemology converge In: Callahan D, ed The Role of Complementary and Alternative Medicine: Accommodating Pluralism Washington, DC: Georgetown University Press; 2002:15-35 17 Albert D Quantum Mechanics and Experience Cambridge, MA: Harvard University Press; 1992 18 Greene B The Elegant Universe New York, NY: Norton Co; 1999 19 Dyczkowski MSG The Doctrine of Vibration Albany, NY: SUNY Press; 1987 20 Ksemaraja, Singh J Doctrine of Self-Recognition: a Translation of the Pratyabhinjnahrdayam with an introduction and notes by Ksemaraja Albany, NY: SUNY Press; 1990 21
Longchenpa, Guenther H Kindly Bent to Ease Us Berkeley, CA: Dharma Publishing; 1976 22 Snellgrove D The Hevajra Tantra: A critical study London Oriental Series, Vol 6 Oxford University Press; 1999 23 Wile D Tai-Chi Touchstones: Yang Family Secret Transmissions Bklyn, NY: Sweet ChiI Press; 1983 24 Walleczek J Magnetiokinetic Effects of Radical Pairs: A Paradigm for magnetic Field Interactions with Biological Systems at Lower than Thermal Energy Am Chem Soc 1995:396 -420 25 Liboff A R Interaction Between Electromagnetic Fields and Cells In: Chiabrera A, Nicolini C, Schwab H P, Eds NATA ASI Series A97;New York, NY: Plenum;1985:281-296 26 Sadock BJ, Sadock VA Alternative Medicine and Psychiatry In: Kapan and Sadocks Synopsis of Psychiatry Phildelphia, PA: Lippincott, Williams Wilkins; 2003 27 Scales B CAMPing in the PACU: using complementary and alternative medical practices in the PACU J Perianasth Nurs 2001;165325-334 28 Engebretson J, Wardell D Experience of a Reiki Session Altern Ther
Health Med 2002;8 2:48-53 29 Alandydy P, Alandydy K Using Reiki to support surgical patients J Nurs Care Qual 1999;132:89-91 30 Algarin, R Using Reiki as a harm reduction tool and as a stress management technique for participants and self Northeast Conference: Drugs, Sex and Harm Reduction Conference Syllabus Harm Reduction Coalition and the Drug Policy Foundation, the ACLU AIDS Project and the City University of New York 1995 31 Bullock M Reiki: a complementary therapy for life Am J Hosp Palliat Care 1997 JanFeb;141:31-33 32 Eos N Reiki and Medicine Grass Lake, MI: White Feather Press 1995 33 Nield-Anderson L, Ameling A Reiki: a complementary therapy for nursing practiceJ Psychosoc Nurs Ment Health Serv 2001 Apr;394:42-49 34 Dillard J The Chronic Pain Solution New York, NY: Bantam; 2002 35 Brennan K What is Reiki and how does it work? Student BMJ Aug 2001;292 36 Starn JR Energy healing with women and children J Obstet Gynecol Neonatal Nurs

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37 38 39 40 41 42 43 44 45 46

47 48 49 50 51 52 53 54

1998;275:576-584 Rivera E, Gethner J Weaving the basket of self-care: building a community of wellness Int Conf AIDS 2000 Jul 9-14;13 Goldner D Helping Hands POZ June 2000 American Cancer Society wwwcancerorg/ docroot/ eto/ content/ eto_5_3x_reiki asp?siteareaeto Accessed November 3, 2002 The bridge to conventional medicine: a call for Reiki case reports Reiki Magazine Intl 2002; 4332-33 Assefi N Reiki for Chronic Conditions: An Overview Available at:http:// wwwnewslettersonlinecom Accessed February 2003 Miles P Reiki training program development manual New York,NY:ACT; 2002 Adams KE, Cohen MH, Eisenberg D, Jonsen AR Ethical considerations of complementary and alternative medical therapies in conventional medical settings Ann Intern Med 2002;137:660-664 Cohen MH, Eisenberg, DM Potential physician malpractice liability associated with complementary and integrative medical therapies Ann Intern Med
2002;136:596-603 Curtis P, McDermott J, Gaylord S Preparing complementary and alternative practitioners to teach learners in conventional health professions Altern Ther Health Med 2002;86:54-59 OConnor BB Personal experience, popular epistemology, and complementary and alternative medicine research In: Callahan D, ed The Role of Complementary and Alternative Medicine: Accommodating Pluralism Washington, DC: Georgetown University Press; 2002:54-73 Schmehr REnhancing the treatment of HIV/AIDS with reiki training and treatmentAltn Ther Health Med 2003:9200-00 Ke M, Pittler MH, Ernst E Systematic research is needed in alternative medicine Arch Intern Med 1999; 15917:2090-2091 Astin JA, Harkness E, Ernst E The efficacy of distant healing: a systematic review Ann Intern Med 2000;13211:903-910 Jadad AR, Moore RA, Carroll D et al Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996; 171: 1-12 Wirth DP, Brenlan DR, Levine RJ, Rodriguez
CM The effect of complementary healing therapy on postoperative pain after urgical removal of impacted third molar teeth Complement Ther Med 1993;1:133-138 Wirth DP, Richardson JT, Eidelman WS Wound healing and complementary therapies: a review J Altern Complement Med 1996;24:493-502 Wirth DP, Chang RJ, Eidelman WS, Paxton JB Haematological indicators of complementary healing intervention Complement Ther Med 1996;4:14-20 Wirth DP, Cram JR Multisite surface electromyography and complementary healing

55 56 57 58 59 60 61 62 63 64 65 66 67

68 69 70

intervention: a comparative analysis J Altern Complement Med, 1997; 34:355-364 Mansour AA, Beuche M, Laing G, Leis A, Nurse J A study to test the effectiveness of placebo Reiki standardization procedures developed for a planned Reiki efficacy study J Altern Complement Med 1999;52:153-164 Ai AL, Peterson C, Gillespie B, Bolling SF, Jessup MG, Behling BA, et al Designing clinical trials on energy healing: ancient art encounters medical science
Altern Ther Health Med 2001;74:83-90 Wetzel, W Reiki Healing: a physiologic perspective J Holist Nurs 1989; Vol7, No 1 47-154 Wardell DW, Engebretson J Biological correlates of Reiki touch healing J Adv Nurs 2001;334:439-445 Sephton SE, Sapolsky RM, Kraemer HC, Spiegel D Diurnal cortisol rhythm as a predictor of breast cancer survival J Natl Cancer Inst 2000;9212:994-1000 Brewitt B, Vittetoe T, Hartwell B The efficacy of Reiki: Improvements in spleen and nervous system function as quantified by electro dermal screening Altern Ther 1997;3:89-97 Olson K, Hanson J Using Reiki to manage pain: a preliminary report Cancer Prev Control 1997;12:108-113 Chapman E, Milton G Reiki as an intervention in drug and alcohol withdrawal and rehabilitation: almost a decade of experience In Proceedings of The World Federation of Therapeutic Communities 21st World Conference, February 1-13,2002; Melbourne, Australia Wirth DP The significance of belief and expectancy within the spiritual healing encounter
Soc Sci Med 1995; 412:249-260 Cassidy CM Social science theory and methods in the study of alternative and complementary medicine J Altern Complement Med, 1995;11:19-40 Hufford DJ Cultural and social perspectives on alternative medicine: background and assumptions Altern Ther Health Med 1995;11:53-61 Jonas WB Evidence, ethics, and the evolution of global medicine In: Callahan D, ed The Role of Complementary and Alternative Medicine: Accommodating Pluralism Washington, DC: Georgetown University Press; 2002:122-147 Bankaitis-Davis B, Riley D, Tryon V, Trollinger D, Marsh V, Koga T, Storm K, Rihanek M, Nicholls N Application of Gene Expressions Technologies for the Evaluation and Comparison of CAM and Conventional Pharmaceutical Therapies International Scientific conference on Complementary, Alternative and Integrative Medicine Research; May 1719, 2001; San Francisco, CA Astin JA Why patients use alternative medicine: results of a national study JAMA, 1998;27919:1548-1553 Available at:
http://nccamnihgov/clinicaltrials/reikihtm Accessed November 14, 2002 Available at: http://wwwfammedwashingtonedu/predoctoral/CAM/ researchhtm November 17, 2002

ABSTRACT
Objective: We hypothesized that primary care physicians PCPs specializing in a nonpharmaceutical/nonsurgical approach as their primary modality and utilizing a variety of complementary/alternative medicine CAM techniques integrated with allopathic medicine would have superior clinical and cost outcomes compared with PCPs utilizing conventional medicine alone Design: Incurred claims and stratified randomized patient surveys were analyzed for clinical outcomes, cost offsets, and member satisfaction compared with normative values Comparative blinded data, using nonrandomized matched comparison groups, was analyzed for age/sex demographics and disease profiles to examine sample bias Setting: An integrative medicine independent provider association IPA contracted with a National Committee for

Quality Assurance NCQA-accredited health maintenance organization HMO in
metropolitan Chicago
Subjects: All members enrolled with the integrative medicine IPA from January 1, 1999 through December 31, 2002 Results: Analysis of clinical and cost outcomes on 21,743 member months over a 4-year period demonstrated decreases

of 430 in hospital admissions per 1000, 584 hospital days per 1000, 432 outpatient surgeries and procedures per 1000, and 518 pharmaceutical cost reductions when compared with normative conventional medicine IPA performance for the same HMO product in the same geography over the same time frame
Conclusion: In the limited population studied, PCPs utilizing an integrative medical approach emphasizing a variety

of CAM therapies had substantially improved clinical outcomes and cost offsets compared with PCPs utilizing conventional medicine alone While certainly promising, these initial results may not be consistent on a larger and more diverse population J Manipulative Physiol Ther 2004;27:336-47
Key Indexing Terms: CAM Therapy; Medicine;
Outcomes; Primary Care Physician; Managed Care

INTRODUCTION

T

he escalation of medical expenditures is an urgent problem Although various types of managed care, once thought by some to be part of the solution to increasing medical expenditures, have been used for decades, little evidence exists that this or any other costcontainment strategy has significantly influenced a 50-year trend of increasing medical expenses on a long-term basis1-5 Managed care rates are now posting double-digit

a President, Alternative Medicine Integration Group, LP, Highland Park, Ill b President, National University of Health Sciences, Lombard, Ill Submit requests for reprints to: Richard L Sarnat, MD, President, Alternative Medicine Integration Group, LP, 473 Central Avenue, Suite 2, Highland Park, IL 60035 e-mail: rsarnat@ amibestmedcom Paper submitted November 12, 2003 0161-4754/3000 Copyright n 2004 by National University of Health Sciences doi:101016/jjmpt200404007

annual increases,6 with
pharmaceuticals estimated to account for 50 of the cost increases over the past 3 years7 While the health care system excels in acute care and crisis disease state management, this accounts for only a small percentage of the total medical care in both cost and volume rendered daily8 The greater health care burden is the prevention and treatment of the multiple chronic disorders in the general population that now account for the majority of health care expenditures9 Chronic diseases are a major public problem in the United States Currently, about 40 of the US population approximately 100 million Americans suffer from at least 1 chronic disorder9 This high level of prevalence within the United States raises concerns about the efficacy and limitations of our conventional health care system10 Such concerns appear to contribute to public and professional interest in alternatives to conventional modern medicine Studies now suggest that 50 of the deaths11 and 70 of the diseases12 in the
United States are caused by unhealthy lifestyle habits such as smoking, alcohol abuse, and improper diet Unlike the preantibiotic era when mortality was

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primarily because of infectious diseases, our nation now faces a behavior-induced epidemic of chronic illness Managed care and government policy makers are faced with the dilemma of trying to decrease medical costs caused mainly by lifestyle choices while continuing to maintain personal freedom of choice Iatrogenic illness an adverse condition arising from the treatment of a physician is estimated as the etiology of 15 of our hospital days, and pharmaceuticals are estimated to cause between 100,000 to 250,000 deaths per year,13,14 as well as nonquantifiable morbidity Prescription drug addiction, administering the wrong drug, and prescription overdoses are a large percentage15,16 of reported deaths by
medical mistake The National Conference of State Legislatures, November/December 2000, estimates the cost of lost income, disability, and health care resulting from medical mistakes is as much as 29 billion per year17 Given these facts, it may be time to rethink this countrys current medical model with its overall reliance on pharmaceuticals as a first line option Complementary/alternative medicine is one viable approach that should be considered because it addresses the privacy, quality, and expense considerations facing health care delivery systems Unlike conventional medical education and care, which relies heavily on high technology and pharmaceuticals, complementary/alternative medicine exists in a low-tech arena Low-tech therapeutic modalities such as chiropractic manipulation, homeopathy, stress management, massage, and use of herbal medicines are perceived by the public as more gentle, less morbid, and less costly than conventional modern medicine18 Many previous studies on
various complementary/alternative medicine CAM modalities have illustrated improved clinical outcomes and substantially decreased costs compared with standard conventional medical practice protocols19-44 However, while individual diagnostic categories have been analyzed, a study of the clinical outcomes and cost effectiveness of primary care physicians PCPs specializing in CAM, and more particularly chiropractic care, within the context of a classical gatekeeper health maintenance organization HMO has never previously been attempted

outpatient surgery and procedures This information was collected prospectively over a 4-year period The HMO actuarial department prepared an annual financial projection for the IPA membership as an age/sex riskadjusted population On a cost basis, the discrepancies between the projected costs versus the actual costs were analyzed annually Standard managed care benchmarks, including hospital days per 1000, hospital admissions per 1000, outpatient surgeries
and procedures per 1000, and pharmaceutical utilization were reported annually by the HMO normative network values and then compared with the actual utilization of the integrative medicine IPA Randomized patient surveys were conducted annually by the HMO to assess member satisfaction, quality of care benchmarks, and member behavior patterns eg, tobacco usage

Integrative Medicine IPA-Development and Implementation
In 1996, a large HMO accredited by the National Committee for Quality Assurance NCQA servicing the metropolitan Chicago area was initially contacted to test the feasibility of gathering data on a CAM-oriented health care delivery system This HMO was a classical gatekeeper HMO with over 600,000 members enrolled in the greater Chicago area The projects objective was to build an integrated medicine system in the Chicago metropolitan area that would use primary care physicians who specialize in a nonpharmaceutical/nonsurgical approach as their primary modality These
nonpharmaceutically oriented PCPs, notably chiropractic physicians, were organized into a well-defined structure along with their more conventional allopathic counterparts to create a truly integrated health care system encompassing both CAM therapies and conventional modern medicine within a single comprehensive insurance benefit structure The project was designed for a gatekeeper HMO format because its structure simplified data collection and made mandatory reporting a contractual obligation To test this new model, an alternative medicine IPA, legally incorporated in 1997 as Alternative Medicine, Inc AMI, was formed to function within the classical gatekeeper HMO format under the same rules and regulations as any other contracted conventional allopathic IPA The data reported herein refer to the contractual relationship between AMI as an integrative medicine IPA and the specific HMO unless otherwise noted The formation of an IPA under contract with the HMO required specific
contractual elements to be met according to the National Committee for Quality Assurance The minimum requirements for PCP network support included: Contracted availability of all allopathic specialists Contractual relationships with regional hospitals to provide inpatient access

METHODS
Data reported in this study were drawn from incurred claims data, originating from both the integrative medicine independent provider association IPA and the HMO The IPA data included all inpatient and outpatient encounters for both cost and diagnosis, including the professional fees associated with patient referrals, outpatient diagnostics encounters and costs, and outpatient laboratories encounters and costs The HMO data included the encounters and costs of all pharmaceutical usage, inpatient admissions, and

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A minimum roster of both pediatricians and obstetricians/gynecologists
exclusive to the IPA HMO Peer Review Committee approval of the IPAs utilization management UM and utilization review UR plan policy and procedures As reported later in section IV, Medical Management, each of these prerequisites was successfully addressed prior to PCP impanelment All primary care physicians had to pass credentialing by the Credentialing Peer Review Committee of the HMO, which was composed of medical doctors MDs exclusively For a new IPA to be impaneled, every PCP needed to successfully pass the credentialing criteria A single failure would have prohibited the project from initiation Initial analysis identified 4 separate and independent but related processes that needed to occur to provide the foundation for successful execution: 1 Physician Recruitment: Targeting that subset of physicians who would be appropriate PCPs to function in a nonpharmaceutical/nonsurgical model In this study, only chiropractic physicians agreed to participate as PCPs 2 Credentialing Process:
Developing a credentialing process exceeding the existing NCQA requirements for CAM providers, a standardized process to quantify the performance of this subset of prospective primary care physicians according to accepted industry standards 3 Member Recruitment: Addressing the ability to recruit potential members or patients to test the hypothesis that primary care chiropractic physicians specializing in nonpharmaceutical/nonsurgical approaches as their primary modality and using CAM techniques integrated with allopathic medicine would have superior clinical and cost outcomes compared with PCPs utilizing conventional medicine alone4 4 Medical Management: Formalizing the medical management to provide integrated care between the CAM therapies delivered by the chiropractic physicians and other conventional medical specialists throughout the inpatient/outpatient cycle The following sections address the mechanics of how each element was defined and executed to successfully achieve the
outcomes reported herein Physician recruitment Nonpharmaceutical/nonsurgical physicians were defined to include those physicians who use as their primary diagnostic/treatment modalities such disciplines as chiropractic manipulation, osteopathic manipulation, naturopathy, homeopathy, Traditional Chinese Medicine TCM, acupuncture, Ayurvedic medicine, herbal medicine preference over pharmaceuticals, massage, and energy healing techniques Under the Medical Practice Act and Managed Care Act, the State of Illinois only licenses medical doctors, Doctors of Osteopathy DO, and Doctors of Chiropractic DC as primary care physicians Therefore, Doctors of Naturopa-

thy ND and Doctors of Oriental Medicine OMD, although licensed in other states, were automatically excluded from the IPA physician network At the projects inception, personal interviews were conducted with all categories of physicians, including MDs/DOs and DCs whose style of medical practice qualified them as potential CAM-oriented
PCPs For a variety of professional, personal, political, and economic reasons, only the Doctors of Chiropractic were willing to undertake the project All CAM-oriented MDs/DOs interviewed rejected participation for reasons including too restrictive a reimbursement model, philosophical or political issues with managed care in general, inability to meet credentialing requirements because of lack of board certification, or independent lone ranger personality, not comfortable with third-party oversight and review Credentialing process Since, to our knowledge, Doctors of Chiropractic had previously never served as PCPs in a classical gatekeeper HMO model, this presented an immediate credentialing challenge A unique credentialing process was developed to identify that subset of Doctors of Chiropractic who could successfully function as PCPs Each prospective PCP underwent a personal interview to review his or her treatment modalities, criterion for referrals, and comfort in dealing with a
primary care role Preference was given for such qualities as broad scope of practice patterns, history of appropriate interactions with other medical specialists, and demonstrated understanding of the pathophysiologic basis of disease as currently understood by evidence-based Western medicine This process has now been formalized into a standardized test and is currently offered as provisional credentialing to students at the National University of Health Sciences in Lombard, Illinois, as well as endorsed by the American Academy of Chiropractic Physicians AACP The credentialing process also involved an educational component, including seminars given by AMI MD medical directors to review conventional medicine diagnostic and referral decision trees Registered nurses provided the onsite component where prospective physicians and their office staff received training in Health Employer Data and Information Set HEDIS compliance, Occupational Safety Health Administration OSHA compliance, and
instruction in proper charting requirements Time spent in the onsite component varied between 4 hours and 20 hours to achieve successful completion All primary care chiropractic physicians were held accountable to the same criteria as their MD/DO counterparts under NCQA regulations It is important to note the educational training of the chiropractic physician While similar in many regards to medical training, there is no training in surgical procedures or in the use of drugs in the management of human illness The standard course of training is in excess of 4800 hours, with approximately one quarter spent in the clinical setting Course work encompasses programs in standard

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diagnosis ie, cardiovascular diagnosis, neurological diagnosis, gastrointestinal diagnosis, genitourinary diagnosis, etc, as well as more specifically chiropractic programs ie, manipulation
of the spine and extremities, physiotherapeutic modalities and other forms of CAM ie, homeopathy, herbal therapy, botanical medicine, etc45,46 The HMO Peer Review Committee formally approved all of AMIs primary care chiropractic physicians in the fall of 1998 AMI began patient encounters on January 1, 1999 with 16 fully credentialed primary care chiropractic physicians As of December 31, 2002, AMI had 30 primary care chiropractic physicians in the HMO model Member recruitment The HMO under contract had an enrollment of over 600,000 members and was available only to companies with a minimum employee base of 100 enrollees AMIs prospective members originated from open enrollment offered to the total population of the HMO Most members obtained information about AMI from the HMOs standard primary care and specialist physician directories or their companys human resource HR personnel The HMO used no marketing incentives to attract potential patient enrollees to the alternative medicine IPA
Like all classical HMOs, there was no exclusion of patients having preexisting illnesses In the first month of operation, January 1, 1999, AMIs HMO had an enrollment of 37 members Enrollment as of December 31, 2002 was 649 members Because marketing had been by word of mouth, growth in IPA enrollment was steady but slow IPA enrollment measured in member months mm per calendar year grew from 1726 mm calendar year 1999 to 4987 mm calendar year 2000, to 6932 mm calendar year 2001, and to 8098 mm calendar year 2002 In total, 21,743 mm of data were analyzed This standard managed care unit is calculated by multiplying each unique member by the number of months enrolled within the IPA during a calendar year The HMO calculates the ratio of new member transfer in versus transfer out for each IPA on a monthly basis AMIs range for transfer in lies between 343 and 553, and transfer out is between 283 and 350 The higher ratio of transfer in versus out correlates with the observed growth in member
enrollment Medical management The intention was to provide members with the best treatment that both chiropractic, using a variety of CAM techniques, and conventional modern medicine had to offer All of the AMI primary care chiropractic physicians focused primarily on the assessment and evaluation of all risk factors whether they were related to diet/nutrition, exercise, postural/structural problems, behavioral/emotional problems, physiological disease, or the need for improved stress management Similar to the role allopathic PCPs assume in a conventional medical IPA, all examinations, treatments, and procedures that occurred within the offices of the primary care chiropractic physicians were at the discretion of the

PCP The number of recommended visits, the choice of appropriate treatments, and ancillary modalities utilized did not require approval from the IPA MD medical directors All ancillary testing and treatment outside the personal office of the primary care chiropractic
physician was subject to MD medical director approval to benefit from the enhanced experience of allopathic physicians in dealing with more complex and varied disease states One inpatient-oriented and 2 outpatient-oriented MD medical directors were available 24 hours a day, 7 days per week to provide consultation and comanagement by phone or facsimile, as required, according to the complexity of the patients presentation Over 3000 medical specialists and 18 hospitals including university based were under contract by AMI as part of the IPA to provide integrated care as appropriate to medical necessity Ongoing telephonic and/or facsimile consultation and comanagement between the PCPs and the MD medical directors occurred daily In general, primary care chiropractic physicians practiced what they do best: nonpharmaceutical/nonsurgical prevention When and if acute life threatening disease or advanced disease management required inpatient status or conventional modern medicine, the PCP
delegated his/her authority to the attending medical physician consulted A registered nurse specializing in utilization management and utilization review coordinated continuity of care between the inpatient and outpatient cycle By design, AMIs PCPs had a higher number of encounters initially to correct structural dysfunctions and provide re-education in lifestyle choices that left unchanged may have manifested into more serious disease states It was not atypical for new AMI members to have PCP encounters at an average of twice per month This is in contrast to conventional medical IPAs, wherein the majority of members have PCP encounters on a crisisonly basis AMIs New Member Welcome letter informed the patient that it was IPA policy to have a mandatory initial visit with their PCP within the first 3 months of enrollment These frequent education-oriented encounters combined with hands-on healing were believed to forge a strong doctor/patient relationship The PCP then became the trusted
guide and assisted the patient with the required lifestyle changes or gave professional advice on the many and varied uses of CAM Many modalities of CAM remain unregulated and are most safely and effectively utilized when supervised by a licensed physician truly knowledgeable from extended training in CAM The chiropractic PCPs also utilized nonphysician CAM providers These providers were licensed and/or credentialed in various CAM therapies, such as massage, acupuncture, cranial sacral therapy, and stress management techniques, including meditation, yoga, and energy balancing, as well as more traditional cognitive therapy It

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Table 1 Diagnostic profile of AMIs HMO population year 2000
Diagnoses Wellness Orthopedic Other medical Mental health Gynecological Sinus/allergy Cardiac/hypertension Headaches all variations Neoplastic URI Asthma Gastrointestinal Thyroid disease
Diabetes Diagnoses by percentage 285 235 117 81 67 60 46 27 15 15 14 13 12 12 100 Diagnoses by members 149 123 61 43 35 31 24 14 8 8 7 7 6 6 522

Table 2 Comparison of well members AMI versus comparison groups I and II
Members with no or non-ICD-9 encounters 149 2618 3206 Percentage of members coded as wellness 285 347 420 Percentage of members coded for active disease 715 653 580

IPA AMI Control group I Control group II

Members enrolled 522 7549 7723

AMI, Alternative Medicine, Inc; IPA, independent provider association

522 members with diagnoses includes 31 severely ill patients multiple ICD-9 comorbidities AMI, Alternative Medicine, Inc; HMO, health maintenance organization; URI, upper respiratory infection Mental health defined as those patients requiring a referral to a mental health specialist

is important to note that the chiropractic physicians included in this study utilized all the modalities noted above and not just the chiropractic adjustment as a sole therapeutic
intervention It was anticipated that this increased intensity in prevention-oriented encounters and concomitant comanagement with AMIs MD medical directors would reduce the utilization of high-cost, high-technology conventional medicine downstream

Member Populations: AMI Versus Nonrandomized Matched Comparison Groups
In this section, Tables 1 through 3 compare various aspects of the AMI membership versus 2 nonrandomized matched comparison groups Both comparison groups represent separate conventional IPA enrollment within the same commercial HMO product, in the same geographic region, and during the same time frame as AMIs data AMI patient population demographics versus comparisons While the comparison groups demographics have been matched as much as possible to remove any underlying bias, certain dissimilarities exist Children, defined as member enrollment under the age of 20, represents a smaller population percentage in the AMI program compared with the comparison groups: 119 AMI
versus 328 comparison group I and 190 comparison group II The smaller percentage of children enrolled is not accidental Chiropractic physicians are unable to legally administer childhood immunizations because of limitations in the scope of prac-

tice of their licensure While AMI does not prohibit enrollment for children under 10, it is not encouraged Statistical analysis also reveals a slightly decreased average age of adult members in the AMI population 395 years compared with comparison groups I 413 years and II 403 years While this slight average age discrepancy certainly favors increased cost expenditures in the comparison groups, this may be offset by the fact that AMI has a greater percentage enrollment of female members compared with male members The actuarial department of the HMO predicts more than a 50 greater utilization within the IPA by female members versus male members The sex distribution of AMI membership is 616 female members and 384 male memers By contrast,
comparison group I had 589 female members and 411 male members; comparison group II had 591 female members and 409 male members The HMO forwarded age/sex distribution data to AMI in the form of monthly eligibility lists Comparison group data were forwarded to the authors from the conventional IPAs after receiving their individualized data from the HMO AMI patient population disease profile AMIs HMO membership, as reported herein, represented a unique population dissimilar from previously published literature of disease states commonly seen by chiropractors47 Chiropractors primarily care for patients with complaints of musculoskeletal origin or headaches As AMI was the first managed care program to utilize chiropractors in a PCP role, it was not surprising that membership included a wide range of disease states not seen in the typical chiropractic office, as illustrated in Table 1 When analyzing IPA data, diagnostic classification was assigned to individual patients based on PCP
encounter data, specialist encounter data, referral activity, and pharmaceutical usage When multiple International Classification of Diseases, Ninth Revision ICD-9 codes were listed on encounter data, the diagnosis requiring the higher expenditure for workup or treatment was chosen as the primary classification If the presence of prominent severe comorbidity such as hypertensive cardiac disease, diabetes

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Table 3 Comparison of ICD-9 diagnostic profile by percentage of member enrollment AMI versus comparison group I
Diagnosis Wellness Orthopedic Other medical Mental health Gyne non-OB Sinus/chronic allergy Cardiac/hypertension Headache all variants Neoplastic all URI Asthma GI Diabetes Thyroid disease all AMI 285 235 117 81 67 60 46 27 15 15 14 13 12 12 Comparison group I 347 80 170 13 94 28 94 07 11 104 13 09 34 14

Table 4 AMI outcomes comparison with HMO
network data
1999 2002
AMI percentage utilization vs HMO Hospital-based data Hospital admissions/1000 Hospital days/1000 Average length of stay Outpatient-based data Outpatient surgical cases/1000 Pharmaceutical usage cost AMI percentage reduction vs HMO

570 416 762 568 482

430 584 238 432 518

AMI, Alternative Medicine, Inc; HMO, health maintenance organization Obstetrics admissions excluded from comparison percentages

AMI, Alternative Medicine, Inc; GYN, gynecology; OB, obstetrics; URI, upper respiratory infection; GI, gastrointestinal

ICD-9 Profile of Nonrandomized Matched Medical Comparison Groups I and II
In this section, Tables 2 and 3 reflect membership breakdown by ICD-9 diagnostic coding percentage comparing AMIs membership with the membership of comparison groups I and II Both comparison groups represent conventional IPA enrollment for the same commercial HMO product in the same geographic region during the same time frame as AMIs data A blinded independent contractor
with previous employment in the medical records department of a local hospital analyzed ICD-9 coding data, compiling the disease profiles between AMIs membership and comparison group I membership Previously published literature indicates that users of CAM modalities are not necessarily the worried well and may actually represent an adverse selection of patients who are medical failures in the traditional medical system48,49 The prevalence of active disease in the AMI population as shown in Tables 2 and 3 is consistent with earlier reports of this phenomena The fact that potentially life-threatening disease states, such as cardiac disease, hypertension, and diabetes had higher enrollment in conventional medicine IPAs was not surprising The similar percentage enrollment of patients with asthma and neoplastic disease between conventional and integrative medicine IPAs was somewhat surprising The large enrollment disparity among patients with upper respiratory infections URI, as previously
mentioned, reflects the small percentage of AMIs enrollment under 10 years of age A comparison of smoker prevalence among the AMI population, the HMO population, and the general state population further demonstrates possible adverse selection in the AMI population Member satisfaction surveys, randomly distributed by stratified random selection to between 35,000 and 45,000 HMO members, annually elicited a response rate that varied between 25 and 30 These

mellitus, and bipolar disorder were all prominent in a patients encounter data, then the patient received 3 separate and distinct classifications This explains why 491 unique patients in the year 2000 received 522 disease classifications Table 1 The diagnostic category wellness referenced in Tables 1 through 3 was defined as: 1 members having patient encounters but not receiving ICD-9 codes these patients may have been symptomatic but received chiropractic codes for subluxation/dysfunction by their PCPs; 2 members having encounters for
nonsymptomatic screening test only; or 3 members having no encounters within a given calendar year The category other medical listed in Table 1 117 of AMIs population encompassed a wide range of diseases affecting 61 patients These diseases included listed in order of frequency but were not limited to the following: neurologic disorders, abdominal pain, dermatologic disorders, prostate disease, adrenal cortical insufficiency, chronic fatigue syndrome, cystitis, esophageal reflux, multiple sclerosis, tinnitus, temporomandibular joint TMJ, and human immunodeficiency virus HIV As Doctors of Chiropractic had not previously functioned as PCPs, the congruence of their diagnoses when compared with conventional PCPs when reporting on a Health Care Financing Administration HCFA 1500 encounter form was unknown When PCP diagnostic coding data were cross-correlated with both specialist referral data and pharmaceutical usage, agreement was found between the conventional medical specialist and the
chiropractic PCP 931 of the time When the diagnosis necessitated a treatment that required the use of pharmaceuticals or surgery, then an appropriate referral was made to a conventional medical specialist

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Table 5 Calendar year 2000 hospital days incurred among major Illinois Managed Care Organizations MCO versus AMI
Total member months 7,537,362 787,853 269,268 361,437 143,236 1,664,525 3,536,085 13,645 Total hospital days incurred per 1000 member months 34485 32002 28538 23675 20100 17764 17094 1150 AMI percentage utilization 333 359 403 486 572 647 673 AMI percentage reductions 667 641 597 514 428 353 327

Managed care entity HMO Illinois Personal Care Insurance Company of Illinois Prudential Health Care Plan United Healthcare of the Midwest CIGNA Healthcare of IL Aetna US Healthcare of IL Humana Health Plan, Inc AMI 3-year cumulative

AMI, Alternative Medicine,
Inc; HMO, health maintenance organization

surveys revealed a variance in the AMI population when measuring for smoker prevalence rate In calendar year 2001, the AMI membership showed its highest rate of smoker prevalence: 349 versus the HMO population rate of 180 versus the Illinois general population of 22350 In calendar year 2003, by contrast, AMI membership had its lowest smoker prevalence rate of 133 versus the HMO population rate of 163 We assume the large variance from year to year was secondary to the relatively low membership response rates elicited by the survey

These statistical benchmarks were reported as a comparison between the performance of AMI as an IPA and the HMO network as a whole Because of the HMOs proprietary concerns regarding their networks unique data points, AMIs outcomes are reported as percentage comparisons with HMO outcomes

RESULTS
Outcomes: Clinical
These data points are based on the HMOs corroborated data for the 4 calendar years 1999, 2000, 2001, and
2002 AMIs encounter data represent 21,743 member months over this 4-year period The traditional managed care benchmarks depicted in Table 4 illustrate AMIs apparent superior clinical outcomes compared with conventional IPA performance over the same time frame AMIs outcomes are reported as percentage utilization and percentage reduction versus the HMO network as a whole Percentage utilization is based on actual claims data after a 6-month runoff comparing AMIs utilization of key benchmarks versus the HMO network as a whole Percentage reduction reflects the mathematical complement of AMIs utilization percentages using the HMO network outcomes as the normative value of 100 Traditional P values of statistical significance could not be reported Insurance actuaries do not currently have data points for variance and mean on groups of similar size and demographics Only aggregate data the HMO normative network performance representing groups of all sizes and demographics were available Calendar
year 2000 data on hospital admission days Table 5 obtained from the Illinois Department of Insurance similarly reflect improved AMI outcomes compared with all the major HMOs in the Chicago metropolitan area The referral pattern of AMIs PCPs compares favorably with historical referral patterns generated by traditional

Data Analysis
AMIs outcomes data are based on claims incurred Data were collected in parallel by the HMO and Independent Health Resources IHR, which functions as AMIs thirdparty administrator TPA The HMO specifically analyzed all inpatient costs, outpatient facility costs, and pharmaceutical usage AMI, via its TPA, analyzed all inpatient and outpatient professional encounters and utilization, as well as outpatient laboratory The HMO reported all utilization back to AMI on a 6-month delay to allow for the reporting of all claims during the experience period This reporting method produced actual claims, removing the potential inaccuracies of claims incurred but not reported
IBNR

Data Reporting
The HMO prepared quarterly reports to AMI on such managed care benchmarks as: Hospital admissions per 1000 members Total hospital days per 1000 members Outpatient surgical cases and procedures per 1000 members Average length of stay Pharmaceutical utilization and cost per member/per month

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Table 6 Analysis of referral patterns on AMI HMO population,
calendar year 2000
1 Average number of members during 2000 4987 member months/12 2 Total number of referrals 3 Total number of unique patients requiring a referral 4 Percentage of population requiring referral to allopathic specialist 167/416 5 Percentage of population managed by chiropractic primary care physicians PCPs without allopathic referral 100 4 416 330 167 40 60

Outcomes: Cost
AMI also received an annual age/sex adjusted risk pool analysis of its members by the HMOs actuarial
department Derived from this risk pool analysis was a hypothetical budget of predicted expenditures excluding pharmaceuticals for AMIs actual membership defined as the utilization management fund UM fund This budget was calculated in target usage units that have an assigned dollar equivalency IPA actual performance was then calculated against IPA-predicted performance AMIs utilization management fund cost savings below predicted budget were 667, 881, 571, and 693 for the calendar years 1999, 2000, 2001, and 2002, respectively It is believed that the improvement in cost effectiveness between year 1 1999 and year 2 2000 occurred primarily due to an innovative mental health initiative In calendar year 1999 AMIs first year, 33 of the hospital days were categorized as mental health Beginning in calendar year 2000 AMIs second year, a quality initiative targeting stress management techniques was introduced to impact the high percentage of mental health admissions In the subsequent 3 years
following this initiative, mental health admissions have accounted for less than 2 of all hospital days utilized This protocol relied heavily on mind/body techniques such as cranial sacral therapy and energy balancing, as well as more traditional cognitive therapy

AMI, Alternative Medicine, Inc; HMO, health maintenance organization

allopathic IPAs utilizing internists, pediatricians, or OB/ GYNs as PCPs As shown in Table 6, the strategy of comanagement resulted in only 40 of the AMI membership requiring an allopathic specialist referral in the calendar year 2000 In other words, during the year 2000, 60 of \the patients were managed solely by their primary care chiropractic physicians Referral data analysis annualized for the year 2001 shows AMI primary care chiropractic physicians generated 1 referral per 33 patient encounters 1:33 ratio This is in contrast to data generated from comparison group II illustrating that conventional medicine PCPs generate 1 referral per 3 patient
encounters 1:3 ratio This referral pattern was consistent with our prediction that an increase in CAM-oriented PCP encounters initially would result in less utilization of conventional medicine downstream In addition to the clinical outcomes referenced in Table 6, measures of Quality Care were benchmarked by randomized patient satisfaction surveys and an annual audit of all UM/UR Committee documents by the HMO nursing administrators Annually, the HMO independently surveyed by stratified random selection over 45,000 patients Response rates were between 25 and 30 annually The HMO required a minimum score for patient satisfaction to be between 80 and 90, depending on the calendar year AMI member satisfaction scores for the first 4 years were 100, 89, 91, and 90, respectively Analysis of HMO member satisfaction surveys demonstrates the AMI members consistently rated their experience with AMI above the HMO network normative average Annual audit scores measuring IPA compliance with
Utilization Management Adherence/Utilization Review Activity written policy and procedures conducted by HMO onsite nurse auditors also were above the HMO network normative values AMIs annual audit scores for medical administration and medical management were between 97 and 100 in each category The HMO minimum required score for IPA performance is 90

DISCUSSION
Certainly, we now appreciate the importance of lifestyle and environmental factors in the optimization of health and subsequent prevention of disease Reliance on the conventional medical model, in which pharmaceuticals and surgical interventions represent first-line treatment, may not provide the best therapeutic index to our patients The AMI model seems to demonstrate the potential superiority of an integrated health system in which chiropractic and CAM therapies play a significant primary care role Traditional PCPs, be they MDs or DOs, have little formal training in the various evidence-based techniques within the CAM arena
Doctors of Chiropractic, however, receive extensive formal training in the arts of spinal manipulation, herbal medicine, and nutrition, as well as conventional modern physical diagnosis Most of the AMI PCPs electively received additional postgraduate training in homeopathy, TCM, and other CAM modalities Students of chiropractic learn to auscultate heart and lungs, draw blood, and read electrocardiograms EKGs, as well as perform pelvic and rectal exams However, the educational focus and scope of practice laws vary among chiropractic colleges and states, respectively

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It is incumbent on the primary care physician, of whatever licensure, to look at all evidence-based risk factors and seek to coordinate their reduction Most of the time this will involve the re-education of patients regarding lifestyle choices such as diet, exercise, nutrition, supplementation, correction
of posture, and stress management issues Lifestyle re-education emphasizing prevention and wellness may be best addressed by PCPs with an unconventional medical orientation, as opposed to conventional medical physicians who have been educated and focus primarily on disease management The AMI experience seems to indicate that a nonpharmaceutical/ nonsurgical orientation can reduce overall health care costs significantly and yet deliver high-quality care These results have been achieved not by decreasing or denying access to care but, rather, by increasing the frequency of PCP prevention-oriented encounters The chiropractic profession is the largest stakeholder in the ongoing evolution of integrating CAM therapies into mainstream conventional medicine Doctors of Chiropractic are licensed in all states, compared with Doctors of Naturopathy licensed in 11 states and Doctors of Oriental Medicine licensed in only 5 states Acupuncturists and massage therapists are licensed in 40 and 30
states, respectively Chiropractic is the most commonly utilized CAM therapy, as published in many previous surveys Yet, paradoxically, core coverage by insurance benefit design rarely includes unrestricted access to chiropractic Instead, a myriad of excuses both by the private insurance industry and by the federal government currently reduce ones personal freedom by restricting access to choose unconventional medicine, even when practiced by licensed physicians in good standing Various authors believe the restrictions on covered benefits for CAM therapies and unconventional physicians are indefensible, given the growing evidence base on these therapies51 Discount affinity programs promoted as a value added service are currently the most common insurance format by which CAM therapies are available In reality, these programs are not covered insurance benefits at all They do not place the mainstream insurance underwriter at financial risk Rather, they provide the insured with a discount
off market fee-for-service rates for severely restricted pseudo benefits52 The American Chiropractic Association ACA, the largest professional association representing the largest stakeholder to the delivery of CAM therapies, has formally rejected discount affinity programs as an insurance sham53 While the availability of discount affinity programs gives the public the illusion that CAM therapies are a covered service on par with conventional medicine, that is not the case The AMI Wellness Model, by contrast, has been formally recognized by both the ACA and the American Academy of Chiropractic Physicians as a future template of an integrated medical model, which is front-end loaded

to address prevention and wellness An increase in initial PCP services is required by the patient to re-educate and emphasize the modification of inappropriate lifestyle choices, thereby re-empowering the patient toward improved self-determination The good news is that within a 3- to 4-month time period,
much of the behavior responsible for the etiology of new or chronic disease has been modified The initial investment of time, energy, and financial resources for CAM therapies has been successful, apparently much more successful than a quick pharmaceutical prescription and a hasty visit with a conventional PCP typical of the way managed care is practiced today Recently published literature also suggests patient preference and increased satisfaction with integrative therapies for chronic disease states In the articles by Eisenberg et al54-56 comparing patients subjective perceptions as to the relative value of conventional care versus CAM therapies, in only 3 of 10 therapies was conventional medicine perceived as superior to CAM therapies The 3 disease states scoring higher for conventional medicine were high blood pressure, lung conditions, and digestive conditions By contrast, back conditions, allergies, fatigue, arthritis, headaches, neck conditions, and strains and sprains were
perceived better treated by CAM therapies54-56 AMIs higher percentage of members with ICD-9 codes for orthopedics, mental health, chronic sinus, allergy, gastrointestinal problems, and headaches versus the comparison group enrollment is consistent with this pattern

Limitations
This articles methodology is a nonrandomized longitudinal population study comparing and contrasting both clinical and cost outcomes among similar populations enrolled in the same insurance product for the same time frame and geography The strengths of this articles methodology are numerous: 1 study length of approximately 4 years; 2 cost and clinical data reported at arms length by the actuarial department of the HMO to the IPA; 3 availability of matched comparison groups for blinded analysis of membership population for ICD-9 comparisons; 4 availability of randomized patient surveys generated by the HMO to analyze both membership satisfaction with ongoing treatment and preexisting risk factors, such as
lifestyle behaviors tobacco usage; 5 availability of corroborating data, such as pharmaceutical usage and specialist consultations, to cross-check the accuracy of membership ICD-9 population profiles; and 6 patient-oriented medical management, whereby a variety of CAM therapies were individualized for each patient in the real life setting of a metropolitan-wide IPA doing business as a clinic without walls Of course, this articles methodology also suffers from inherent weaknesses: 1 the relatively limited enrollment

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of AMIs membership population versus the matched comparison groups; 2 the inability to determine the exact effect of membership transfer in and transfer out on the cost and clinical outcomes; 3 lack of uniformity in disease-specific treatment protocols utilized among all AMIs physicians; 4 no randomization of comparative IPA memberships; and 5
inability to perform standardized statistical probability analysis due to industry nonavailability of required actuarial data So, at the end of the day, where does this leave us? Have we derived valid and credible knowledge that is useful? At the very least, this article, for the first time, has demonstrated that a select group of chiropractic physicians successfully functioned in both a safe and effective manner as PCPs in a classical gatekeeper HMO model Second, it has demonstrated that these same chiropractic physicians were capable of initiating and coordinating care for patients with a broad spectrum of disease states, representing a wider variety of diagnostic presentations than is commonly seen in most chiropractic offices Third, the magnitude of improvement in both clinical and cost outcomes compared with normative values is so large that it is difficult to dismiss as purely coincidental to population bias and nothing more While admittedly the data are not definitive because of
all of the methodological concerns enumerated, this article seems to demonstrate, for the first time, the potential superiority of integrating a nonpharmaceutical/nonsurgical-oriented gatekeeper or entry point with our already existing conventional health care system Why should this change in PCP orientation make seemingly such a profound impact on outcomes?

benefits and that employee or insurance turnover is too high to wait for an extended turnaround time The AMI experience suggests that cost savings may occur in the first calendar year of operations The magnitude of improvement in both clinical outcomes and cost savings documented herein may not remain constant when the AMI model is utilized on larger and more diverse populations However, even a small percentage of the AMI outcomes would still have significant implications, given a 13 trillion national health care budget At such a high price, AMIs initial results should warrant additional funding for a larger and better controlled
replication of these findings

ACKNOWLEDGMENTS
We wish to acknowledge the following people: Dr Dana Lawrence for editing assistance, Jay M Jaffe, for actuarial consulting, Marcia Marek, Angela Miller, Rose H Homma, and Nancy J Rothermel for secretarial support, and all of our AMI HMO Primary Care Chiropractic physicians for their spirit and dedication to this project

REFERENCES
1 Jencks S, Schieber G Containing US health care costs: what bullet to bite? Health Care Financ Rev Annu Suppl 1991;1-12 2 Congressional Budget Office Managed competition and its potential role to reduce health spending Washington DC: US Government Printing Office; 1993 3 Teisberg E, Porter M, Brown G Making competition in health care work Harv Bus Rev 1994; July-August:131-141 4 Davis K, Anderson G, Rowland D, Steinberg E Health care cost containment Baltimore: Johns Hopkins University Press; 1990 5 Burner S, Waldo D, McKusik D National health expenditures projections through 2030 Health Care Financ Rev
1992;14: 1-29 6 Luke RT Health care in the United States: current and future challenges Manag Care 2001;10Suppl:2-6 7 Cowan CA, Lazenby HC, Martin AB, McDonnell AB, Sensenig AL, Smith CE, et al National health expenditures: 1999 Health Care Financ Rev 2001;22:77-110 8 Hadley J, Zuckerman S, Iezzoni LI Financial pressure and competition Changes in hospital efficiency and cost-shifting behavior Med Care 1996;34:205-19 9 Hoffman C, Rice D, Sung H Persons with chronic conditions: their prevalence and costs JAMA 1996;276: 1473-79 10 South-Paul JE, Grumbach C How does a changing country change family practice? Fam Med 2001;33:278-285 11 McGinnis J, Foege W Actual cause of death in the United States JAMA 1993;270:2207-12 12 US Department of Health and Human Services Healthy people 2000: national health promotion and disease prevention objectives Washington DC: Government Printing Office; 1991 DHHS Publication No PHS 91-50212

CONCLUSION
AMIs integrative medicine IPA represents a new model in
the delivery of managed care This unique model has demonstrated promising clinical and cost outcomes by the integration of complementary alternative medicine with conventional medicine in a defined program encompassing physician selection, medical management, and scientific accountability AMI believes this model to be replicable on a much larger scale and is currently implementing different programs, such as preferred provider organization PPO, point-of-service POS, and Workers Compensation to new geographies AMIs HMO outcomes reported herein were the results of an initial prototype still in evolution The performance of physicians with other licensures, such as Doctors of Naturopathy and Doctors of Oriental Medicine, as well as MDs and DOs who are nonpharmaceutically oriented needs to be studied in this context as well The traditional argument against coverage for preventionoriented medicine is that it will not reap immediate financial

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13 US Department of Health, Education and Welfare Task force on preparation of drugs: final report Mod Med p 35 Cited by: Griggs B Green pharmacy: the history and evolution of western medicine Rochester VT: Healing Arts Press; 1981, 1991 p 286 14 Classen DC, Pestonik SL, Evans SE, Burke JP Computerized surveillance of adverse drug events in hospital patients JAMA 1991;266:2847-51 15 Hayward RA Counting deaths due to medical errors JAMA 2002;288:2404-5 16 Gabel RA Counting deaths due to medical errors JAMA 2002;288:2404-5 17 New drug abuse trend: prescription medication Associated Press April 11, 2001 Cited by: Welshimer G Health care in crisis Associated Press September 4, 2001 p 2 18 Sanchez JE A look in the mirror A critical and exploratory study of public perceptions of the chiropractic profession in New Jersey J Manipulative Physiol Ther 1991; 14:165-76 19 Meade TW, Dyer S, Browne W, Townsend J, Frank AO Low
back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment BMJ 1990; 300:1431-7 20 Meade TW, Dyer S, Browne W, Townsend J, Frank AO Randomized comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow-up BMJ 1995;311:349-51 21 Koes BW, Bouter LM, van Mameren H, Essers AH, Verstegen GM, Hofhuizen DM, et al The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific neck and back complaints: a randomized clinical trial Spine 1992;17:28-35 22 Triano J, McGregor M, Hondras MA, Brennan PC Manipulative therapy versus education programs in chronic low back pain Spine 1995;20:948-55 23 Giles LGF, Muller R Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a non-steroidal antiinflammatory drug, and spinal manipulation J Manipulative Physiol Ther 1999;22:376-81 24 Bronfort G, Goldsmith C, Nelson CF, Boline PD, Anderson AV
Trunk exercise combined with spinal manipulative or NSAID therapy for chronic low back pain: a randomized, observer-blinded clinical trial J Manipulative Physiol Ther 1996;19:570-82 25 Kirklady-Willis WH, Cassidy JD Spinal manipulation in the treatment of low-back pain Can Fam Physician 1985;31: 535-40 26 Pope MH, Phillips RB, Haugh LD, Hsieh CY, MacDonald L, Haldeman S A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain Spine 1994;19:2571-7 27 Blomberg S, Varsudd K, Mildenberger F A controlled multicenter trial of manual therapy in low back pain: initial status, sick leave and pain score during follow-up J Orthop Med 1994;16:2-8 28 Berquist-Ullman M, Larsson U Acute low back pain in industry: a controlled prospective study with special reference to therapy and confounding factors Acta Orthop Scand 1977; 170Suppl:1-117 29 Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH
Spinal manipulation for low-back pain Ann Intern Med 1992;117:590-8 30 Anderson R, Meeker WC, Wirick BE, Mootz RD, Kirk DH, Adams A A meta-analysis of clinical trials of spi-

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nal manipulation J Manipulative Physiol Ther 1992;15: 181-94 Branson RA Cost comparison of chiropractic and medical treatment of common neuromusculoskeletal disorders: a review of the literature after 1980 Top Clin Chiropr 1999;6: 57-68 Jarvis KB, Phillips RB, Morris EK Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes J Occup Med 1191;33:847–52 Nyiendo J, Lamm L Disability low back Oregon workers compensation of claims Part I: methodology and clinical categorization of chiropractic and medical cases J Manipulative Physiol Ther 1991;14:177-84 Nyiendo J Disability low back Oregon workers compensation of claims Part II: time loss J Manipulative Physiol Ther
1991;14:231-9 Nyiendo J Disability low back Oregon workers compensation of claims Part III: diagnostic and treatment procedures and associated costs J Manipulative Physiol Ther 1991; 14:287-97 Johnson MR A comparison of chiropractic, medical and osteopathic care for work-related sprains/strains J Manipulative Physiol Ther 1989;12:335-44 Wolk S An analysis of Florida workers compensation claims for back-related injuries J Am Chiropr Assoc 1988; 27:50-9 Dean H, Schmidt R A comparison of the cost of chiropractors versus alternative medical practitioners Richmond VA: Virginia Chiropractic Association, 1992 Stano M, Smith M Chiropractic and medical costs of low back care Med Care 1996;34:191-204 Smith M, Stano M Costs and recurrences of chiropractic and medical episodes of low-back care J Manipulative Physiol Ther 1997;20:5-12 Manga P, Angus D, Papdopoulos C, Swan W The effectiveness and cost-effectiveness of chiropractic management of low-back pain Richmond Hill, Ontario, Canada:
Kenilworth Publishing; 1993 Manga P Enhanced chiropractic coverage under OHIP as a means for reducing health care costs, attaining better health outcomes and achieving equitable access to health services Report to the Ontario Ministry of Health 1998 Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR The outcomes and costs for acute low back pain among patients seen by primary care practitioners and orthopedic surgeons North Carolina Back Pain Project N Engl J Med 1995;333:913-7 Cherkin DC, MacCornack FA Patient evaluations of low back pain care from family physicians and chiropractors West J Med 1989;150:351-5 Bulletin, 2002 2003 Lombard IL: National University of Health Sciences; 2002 Doxey TT, Phillips RB Comparison of entrance requirements for health care professionals J Manipulative Physiol Ther 1997;20:86-91 Meeker W, Haldeman S Chiropractic: a profession at the crossroads of mainstream and alternative medicine Ann Intern Med 2002;136:216-27 Rao JK, Mihaliak K,
Kroenke K, Bradley J, Tierney WM, Weinberger M Use of complementary therapies for arthritis among patients of rheumatologists Ann Intern Med 1999; 131:409-16 Richardson MA, Sanders T, Palmer JL, Greisinger A, Single-

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50 51 52 53 54

S Complementary/alternative medicine use in a comprehensive cancer center and implications for oncology J Clin Oncol 2000;18:2505-14 National data source MMWR Morb Mortal Wkly Rep 2000;50:1101-6 Vandenbroucke JP, de Craen AJM Alternative medicine: a mirror image for scientific reasoning in conventional medicine Ann Intern Med 2001;135:507-13 Smith JC The CAM scam Clin Chiropr 1999;11-3 ACA on CAM J Am Chiropr Assoc 2000;374:28 Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins

DR, Delbianco TL Unconventional medicine in the United States New Engl J Med 1993;328:246-52 55 Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S,
Van Rompay M, et al Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey JAMA 1998;280:1569-75 56 Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S, et al Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey Ann Intern Med 2001;135:244-51

World Health Organization 2001
This document is not a formal publication of the World Health Organization WHO, and all rights are reserved by the Organization The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes The views expressed in this documents by named authors are solely the responsibility of those authors

Acknowledgements
The World Health Organization WHO acknowledges its indebtedness to our Member States, regional offices, and WHO Member State representative offices for actively providing data on the practice and legal status of traditional and complementary/alternative medicine in their countries and regions Thanks is also expressed to those international professional organizations, such as the World Federation of Acupuncture and Moxibustion Societies, World
Federation of Chiropractic, World Chiropractic Alliance, and Liga Medicorum Homeopathica Internationalis, who provided valuable information specific to their relevant therapies We especially thank Mr Neil Cummings Canada, Mr Josh Gagne USA, Ms Sophie Lasseur France, Ms Yong Li China, Mr Stefano Maddalena Switzerland, Ms Magali Ramillien France, Ms Valerie Truong Canada, and Mr Guoliang Zhang China for drafting and revising the document and Ms Kathleen Sheridan Netherlands and Ms Diane Whitney USA for editing the final draft Appreciation is extended to the Norwegian Royal Ministry of Health and Social Affairs for providing the financial support to print this review

Contents

Contents
Acknowledgements iii Foreword ix Introduction 1 Terminology 1 Widespread systems of traditional and complementary/alternative medicine 2 The situation in the use of traditional and complementary/alternative medicine 3 Africa 5 Angola 5 Benin 5 Botswana 6 Burkina Faso 7 Burundi 9 Cameroon 9 Cape
Verde 10 Central African Republic 10 Chad 11 Comoros 11 Congo 11 Côte dIvoire 13 Democratic Republic of the Congo 13 Equatorial Guinea 13 Ethiopia 14 Gabon 15 Gambia 15 Ghana 16 Guinea 18 Guinea-Bissau 19 Kenya 19 Lesotho 19 Liberia 20 Madagascar 21 Malawi 22 Mali22 Mauritania 25 Mauritius 26 Mozambique 26 Namibia 27 Niger 28 Nigeria 29
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Rwanda 31 Sao Tome and Principe 31 Senegal 31 Seychelles 32 Sierra Leone 32 South Africa 33 Swaziland 36 Togo 36 Uganda 36 United Republic of Tanzania 37 Zambia 38 Zimbabwe 39 The Americas 43 Argentina 43 Bolivia 43 Brazil 44 Canada 45 Chile 52 Colombia 53 Costa Rica 53 Cuba 54 Dominican Republic 55 Ecuador 56 Guatemala 57 Honduras 58 Jamaica 59 Mexico 60 Nicaragua 61 Panama 62 Peru 64 United States of America 65 Venezuela 71 Eastern Mediterranean 73 Algeria 73 Cyprus 73 Djibouti 74 Egypt 75 Islamic
Republic of Iran 75 Jordan 77 Kuwait 77 Pakistan 78 Saudi Arabia 81 Sudan 82 Syrian Arab Republic 82 United Arab Emirates 83 Europe 85 Austria 85 Belgium 86 Denmark 89
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Contents

Finland 91 France 93 Germany 95 Hungary 98 Ireland 100 Italy 101 Latvia 103 Liechtenstein 104 Luxembourg 105 Malta 106 Netherlands 108 Norway 110 Russian Federation 113 Spain 114 Sweden 117 Switzerland 119 Ukraine 123 United Kingdom of Great Britain and Northern Ireland 125 South-East Asia 129 Bangladesh 129 Bhutan 129 Democratic Peoples Republic of Korea 131 India 131 Indonesia 134 Myanmar 135 Nepal 137 Sri Lanka 138 Thailand 141 Western Pacific 145 Australia 145 Cambodia 148 China 148 Hong Kong Special Administrative Region of China 152 Fiji154 Japan 155 Kiribati 159 Lao Peoples Democratic Republic 159 Malaysia 160 Mongolia 163 New Zealand 164 Papua New Guinea 165 Philippines 165 Republic of Korea 166 Samoa 169 Singapore 169 Solomon Islands 170 Vanuatu 171 Viet
Nam 171 References 175
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Annex I The European Union 187 General principles 187 Directives on homeopathic products 187 Free movement of patients and practitioners and insurance coverage of complementary/alternative medicine products and treatments 188

viii

Foreword

Foreword
National policies are the basis for defining the role of traditional and complementary/alternative medicine in national health care programmes, ensuring that the necessary regulatory and legal mechanisms are created for promoting and maintaining good practice; assuring authenticity, safety and efficacy of traditional and complementary/alternative therapies; and providing equitable access to health care resources and information about those resources As seen in this review, national recognition and regulation of traditional and complementary/alternative medicine vary considerably The World Health Organization
works with countries to develop policies most appropriate for their situations This document provides information on the legal status of traditional and complementary/alternative medicine in a number of countries It is intended to facilitate the development of legal frameworks and the sharing of experiences between countries by introducing what some countries have done in terms of regulating traditional and complementary/alternative medicine This information will be beneficial not only to policy-makers, but also to researchers, universities, the public, insurance companies and pharmaceutical industries The preparation of this document took almost 10 years, largely because of a lack of financial resources Not only was it difficult to obtain accurate, precise information on the policies of all of the World Health Organizations 191 Member States, but because of the constant work of policy-makers on health-related issues, it was impossible for us to collect current data and keep it current
throughout the preparation and publication process Although we have worked tirelessly to collect data and keep it as up to date as possible, new policies have made some information included here obsolete and basic information for many countries is still lacking Regrettably, we were only able to include 123 countries in this review Some countries are not included as we were unable to find sufficient information and, for some countries that are included, we may have mistakenly provided inaccurate or misleading information We deeply apologize for any omissions or errors In this regard, we would sincerely appreciate countries and organizations providing necessary corrections and keeping us updated as their policies change, so that our next edition of this important document will be as accurate and complete as possible Thank you Dr Xiaorui Zhang Acting Coordinator Traditional Medicine World Health Organization Geneva, Switzerland

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Introduction

Introduction

Terminology
In this
document, medical providers and practices are generally described as traditional, complementary/alternative, or allopathic Provider and practitioner are used interchangeably In a few cases, particularly in the European section, the cumbersome term non-allopathic physician is used to refer to medical practitioners who are either not allopathic practitioners or who are allopathic providers but not physicians

Allopathic medicine
Allopathic medicine, in this document, refers to the broad category of medical practice that is sometimes called Western medicine, biomedicine, scientific medicine, or modern medicine This term has been used solely for convenience and does not refer to the treatment principles of any form of medicine described in this document

Complementary/Alternative medicine
The terms complementary medicine and alternative medicine are used interchangeably with traditional medicine in some countries Complementary/alternative medicine often refers to traditional medicine that
is practised in a country but is not part of the countrys own traditions As the terms complementary and alternative suggest, they are sometimes used to refer to health care that is considered supplementary to allopathic medicine However, this can be misleading In some countries, the legal standing of complementary/alternative medicine is equivalent to that of allopathic medicine, many practitioners are certified in both complementary/alternative medicine and allopathic medicine, and the primary care provider for many patients is a complementary/alternative practitioner

Herbal preparations and products
Herbal preparations are produced by subjecting herbal materials to extraction, fractionation, purification, concentration, or other physical or biological processes They may be produced for immediate consumption or as the basis for herbal products Herbal products may contain excipients, or inert ingredients, in addition to the active ingredients They are generally produced in larger
quantities for the purpose of retail sale 1

Traditional medicine
Traditional medicine includes a diversity of health practices, approaches, knowledge, and beliefs incorporating plant, animal, and/or mineral-based medicines; spiritual
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

therapies; manual techniques; and exercises, applied singly or in combination to maintain well-being, as well as to treat, diagnose, or prevent illness The comprehensiveness of the term traditional medicine and the wide range of practices it encompasses make it difficult to define or describe, especially in a global context Traditional medical knowledge may be passed on orally from generation to generation, in some cases with families specializing in specific treatments, or it may be taught in officially recognized universities Sometimes its practice is quite restricted geographically, and it may also be found in diverse regions of the world see the
section on complementary/alternative medicine, above However, in most cases, a medical system is called traditional when it is practised within the country of origin

Widespread systems of traditional and complementary/alternative medicine
Ayurveda
Ayurveda originated in the 10th century BC, but its current form took shape between the 5th century BC and the 5th century AD In Sanskrit, ayurveda means science of life Ayurvedic philosophy is attached to sacred texts, the Vedas, and based on the theory of Panchmahabhutas — all objects and living bodies are composed of the five basic elements: earth, water, fire, air, and sky 2 Similarly, there is a fundamental harmony between the environment and individuals, which is perceived as a macrocosm and microcosm relationship As such, acting on one influences the other Ayurveda is not only a system of medicine, but also a way of living It is used to both prevent and cure diseases Ayurvedic medicine includes herbal medicines and medicinal baths It
is widely practised in South Asia, especially in Bangladesh, India, Nepal, Pakistan, and Sri Lanka

Chinese traditional medicine
The earliest records of traditional Chinese medicine date back to the 8th century BC 3 Diagnosis and treatment are based on a holistic view of the patient and the patients symptoms, expressed in terms of the balance of yin and yang Yin represents the earth, cold, and femininity Yang represents the sky, heat, and masculinity The actions of yin and yang influence the interactions of the five elements composing the universe: metal, wood, water, fire, and earth Practitioners of Chinese traditional medicine seek to control the levels of yin and yang through 12 meridians, which bring energy to the body Chinese traditional medicine can be used for promoting health as well as preventing and curing diseases Chinese traditional medicine encompasses a range of practices, including acupuncture, moxibustion, herbal medicines, manual therapies, exercises, breathing
techniques, and diets 4 Surgery is rarely used Chinese medicine, particularly acupuncture, is the most widely used traditional medicine It is practised in every region of the world

2

Introduction

Chiropractic
Chiropractic was founded at the end of the 19 century by Daniel David Palmer, a magnetic therapist practising in Iowa, USA Chiropractic is based on an association between the spine and the nervous system and on the self-healing properties of the human body It is practised in every region of the world Chiropractic training programmes are recognized by the World Federation of Chiropractic if they adopt international standards of education and require a minimum of four years of full-time university-level education following entrance requirements
th

Homeopathy
Homeopathy was first mentioned by Hippocrates 462377 BC, but it was a German physician, Hahnemann 17551843, who established homeopathys basic principles: law of similarity, direction of cure, principle of single remedy, the
theory of minimum diluted dose, and the theory of chronic disease 2 In homeopathy, diseases are treated with remedies that in a healthy person would produce symptoms similar to those of the disease Rather than fighting the disease directly, medicines are intended th to stimulate the body to fight the disease By the latter half of the 19 century, homeopathy was practised throughout Europe as well as in Asia and North America Homeopathy has been integrated into the national health care systems of many countries, including India, Mexico, Pakistan, Sri Lanka, and the United Kingdom

Unani
Unani is based on Hippocrates 462377 BC theory of the four bodily humours: blood, phlegm, yellow bile, and black bile Galen 131210 AD, Rhazes 850925 AD, and Avicenna 9801037 AD heavily influenced unanis foundation and formed its structure Unani draws from the traditional systems of medicine of China, Egypt, India, Iraq, Persia, and the Syrian Arab Republic 5 It is also called Arabic medicine

The
situation in the use of traditional and complementary/alternative medicine
Traditional and complementary/alternative medicine is widely used in the prevention, diagnosis, and treatment of an extensive range of ailments There are numerous factors that have led to the widespread and increasing appeal of traditional and complementary/alternative medicine throughout the world, particularly in the past 20 years In some regions, traditional and complementary/alternative medicine is more accessible In fact, one-third of the worlds population and over half of the populations of the poorest parts of Asia and Africa do not have regular access to essential drugs However, the most commonly reported reasons for using traditional and complementary/alternative medicine are that it is more affordable, more closely corresponds to the patients ideology, and is less paternalistic than allopathic medicine Regardless of why an individual uses it, traditional and complementary/alternative medicine provides
an important health care service to persons both with and without geographic or financial access to allopathic medicine

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Traditional and complementary/alternative medicine has demonstrated efficacy in areas such as mental health, disease prevention, treatment of non-communicable diseases, and improvement of the quality of life for persons living with chronic diseases as well as for the ageing population Although further research, clinical trials, and evaluations are needed, traditional and complementary/alternative medicine has shown great potential to meet a broad spectrum of health care needs Recognizing the widespread use of traditional and complementary/alternative medicine and the tremendous expansion of international markets for herbal products, it is all the more important to ensure that the health care provided by traditional and complementary/alternative medicine is safe and
reliable; that standards for the safety, efficacy, and quality control of herbal products and traditional and complementary/alternative therapies are established and upheld; that practitioners have the qualifications they profess; and that the claims made for products and practices are valid These issues have become important concerns for both health authorities and the public National policies are a key part of addressing these concerns Each year the World Health Organization receives an increasing number of requests to provide standards, technical guidance, and informational support to Member States elaborating national policies on traditional and complementary/alternative medicine The World Health Organization encourages and supports Member States to integrate traditional and complementary/alternative medicine into national health care systems and to ensure their rational use Facilitating the exchange of information between Member States through regional meetings and the publication
of documents, the World Health Organization assists countries in sharing and learning from one anothers experiences in forming national policies on traditional and complementary/alternative medicine and developing appropriate innovative approaches to integrated health care In 1998, the World Health Organization Traditional Medicine Team issued the publication Regulatory situation of Herbal Medicines: A Worldwide Review Although it only includes information concerning the regulation of herbal medicines, this document attracted the attention of the national health authorities of World Health Organization Member States as well as of the general public Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review is much more comprehensive Both an update and an expansion of the 1998 document, it includes information on the regulation and registration of herbal medicines as well as of non-medication therapies and traditional and complementary/alternative
medical practitioners It is an easy reference, providing summaries of the policies enacted in different countries and indications of the variety of models of integration adopted by national policy-makers Through country-specific sections on Background information, Statistics, Regulatory situation, Education and training, and Insurance coverage, it is designed to facilitate the sharing of information between nations as they elaborate policies regulating traditional medicine and complementary/alternative medicine and as they develop integrated national health care systems
4

Africa

Africa

Angola
Regulatory situation
Although there is a registry of traditional health practitioners, there are no official legislative or regulatory texts governing the practice of traditional medicine, no licensing procedures for traditional medicine practitioners, no system for the official approval of traditional medical practices and remedies, and no local or national councils in charge of reviewing any
problems concerning traditional medicine 6 Traditional medicine practitioners are not involved in Angolas primary health care programme at the local or national level 6

Education and training
Angola does not have any official training facilities or programmes for traditional medicine 6

Benin
Background information
Widespread reliance on traditional medicines can be partially attributed to the high cost of allopathic pharmaceuticals, particularly after the devaluation of the Central African franc 7 Numerous persons from other countries use Beninese traditional medicine 7

Statistics
Eighty per cent of the population relies on traditional medicine 7 In the Regular Budget 19981999, US 14 000 was allocated to traditional medicine 8

Regulatory situation
There is a licensing process and a registry of traditional medicine practitioners in Benin 6 Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions Some traditional
medicine practitioners are involved in the primary health care programme in Benin 6 There are national as well as provincial intersectoral councils and groups in charge of reviewing problems concerning traditional medicine 6

5

Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Section 3 of Code 34, Quality of Health Care and Health Technology 9, relates to traditional medicine One objective under this section is the promotion of traditional pharmacopoeia through the following: updating and distributing a national list of traditional medicine practitioners by field of speciality–US 5000 is set aside for this task; developing and distributing a guide for the rational use of traditional pharmacopoeia–US 9000 is allocated for this task The Ministry of Health perceives obstacles to the promotion of traditional medicine in Benin to include the following 7: lack of means to evaluate the quality, safety, and efficacy of traditional medicine
products; lack of training in proper sanitation techniques for practitioners of traditional medicine, leading to unfavourable conditions in the practice of traditional medicine In consideration of these obstacles and in order to protect consumers, the Government has prioritized the following projects 7: a census of non-governmental organizations operating in the field of traditional medicine; a census of practitioners of traditional medicine; evaluation of the possibilities of integrating traditional medicine into the national health care system, particularly into health centres at the sub-prefecture level; training traditional medicine practitioners to refer serious cases of certain illnesses, such as malaria and HIV/AIDS, to allopathic health centres The Government envisions many opportunities for traditional medicine in Benin; these projects are just the first steps in a long process 7

Botswana
Background information
Practitioners of traditional medicine provided the only
health care services available in most of Botswana until the first part of the decade following independence in 1966 The recent introduction of allopathic services throughout the country appears to have reduced the influence and activities of traditional medicine practitioners, but only to a limited extent and mainly with respect to younger and more formally educated population groups Traditional health practitioners are well respected and influential

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Africa

in rural areas and remain central figures in the everyday lives of the majority of the rural population

Statistics
There are about 3100 traditional health practitioners in Botswana, approximately 95 of whom reside in rural areas 10

Regulatory situation
The first reference to the official acceptance of traditional medicine practitioners in Botswana appears in Section 1486 of the National Development Plan of 19761981:
Although not part of the modern health care system the traditional healer ngaka performs a significant role
in Botswana, especially in the rural areas The policy of the Ministry is to evaluate further the contribution of traditional healers to the health care system of the country and possibly then to seek ways of closer cooperation and consultation

Similarly, Section 1328 of Chapter 13 of the National Development Plan of 19791984 10, 11 reads:
There are a large number of traditional practitioners of various types who are frequently consulted on health and personal matters The Ministry of Health will continue its policy of gradually strengthening links with traditional practitioners — both diviners, herbalists, and faith healers The emphasis will be put on improving mutual understanding, especially about the practices and techniques of the traditional practitioners No full-scale integration is envisaged, but referrals between modern health care services and traditional practitioners will be encouraged where appropriate

The Medical, Dental, and Pharmacy Amendment Act of 1987 12 outlines
registration requirements for chiropractors, osteopaths, naturopaths, acupuncturists, and other complementary/alternative medical professionals in Botswana

Burkina Faso
Background information
Under colonialism, traditional medical practices were outlawed as harmful and dangerous Only after independence did the Government promote traditional medicine and begin to restore esteem to traditional medical practices However, due to a lack of political initiative and significant mistrust between allopathic practitioners and traditional medicine practitioners, it was not until the 1980s that noticeable efforts were made In 1983, the Government encouraged the formation of associations of traditional medicine practitioners as well as pharmacopoeia units within decentralized sanitary structures of the health system

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

According to the Burkina Faso Government, traditional medicine will always remain
an important source of health care for the majority of the population since traditional medicine is part of African sociocultural foundations

Statistics
More than 80 of the population in Burkina Faso use traditional medicine

Regulatory situation
The Natural Substances Research Institute and a Health Ministry service were created in 1978 to promote traditional medicine and pharmacopoeia In 1979, traditional medicine practitioners were officially recognized in Burkina Faso Title IV of the Public Health Code of 28 December 1970 13 pertains to traditional medicine Section 49 states:
The practice of traditional medicine by persons of known repute shall be provisionally tolerated; such persons shall remain responsible, under civil and penal law, for the acts which they perform Subsequent items of legislation shall define the practice of this form of medicine and the status of persons engaged therein A medical and scientific commission appointed by the Minister responsible for Public Health
shall conduct a study of the practice of traditional medicine and shall undertake investigations, notably in respect to traditional therapeutics, in order to identify the mode of action and posology of the drugs involved

The Practice and Organization of Traditional Medicine, Chapter IV of Law 23/94/ADP of 19 May 1994 14, promulgates the Public Health Code This chapter defines traditional medicine and traditional medicine practitioners and reiterates their official recognition in Burkina Faso In July 1996, the Government approved the National Pharmaceutical Policy In 1997, the National Pharmaceutical Directive Plan was adopted to define the global objectives of the National Pharmaceutical Policy in concrete terms One of the aims, as designated by the Ministry of Health, was the development and promotion of traditional medicine and traditional pharmacopoeia within the official Burkina Faso health care system in order to improve the health care delivered to the population The Plan will
be taken into consideration in the development of the National Sanitary Policies, which will cover the years 20012010 Decrees on the following issues are currently being elaborated: the modalities of private practice of traditional medicine, the creation of and assignments to the National Commission of Traditional Medicine and Traditional Pharmacopoeia, and an inventory of improved traditional medications In an effort to balance conservation of natural resources and the development of traditional medicines, the Government is also in the process of developing regulations on the exploitation of traditional

8

Africa

pharmacopoeia products with the collaboration of national and international partners, such as the World Health Organization Burkina Faso has local and national intersectoral councils in charge of reviewing problems related to traditional medicine 6 Local officials in Burkina Faso are allowed to authorize the practice of traditional medicine in their administrative and/or
health subdivisions Some practitioners of traditional medicine are involved in the primary health care programme 6

Education and training
There is no official recognition for the qualifications of traditional health practitioners However, there is a formal training programme in traditional medicine 6

Burundi
Regulatory situation
There are no procedures for the official approval of traditional medical practices or remedies Traditional health practitioners are not licensed, and local officials are not allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions, nor are traditional medicine practitioners involved in primary health care programmes at the local or national level in Burundi Burundi does not have any official or legislative texts regulating traditional medicine 6 However, in Burundis Public Health Code of 1982 15, which limits medical licences to those persons with formal training in tropical medicine, it is stated that
practitioners currently treating patients by means of traditional medicine may continue to practise under the conditions and in accordance with the detailed regulations laid down by the Minister responsible for public health

Education and training
Burundi does not have any official training facilities or programmes for traditional medicine 6

Cameroon
Regulatory situation
Law 81/12 of 27 November 1981 approved the Fifth Five-Year Social, Economic, and Political Development Plan 19811986 of Cameroon 16 Section 16-1315 states the following:
During the Fifth Plan, measures will be taken to lay down a joint strategy and method to effectively integrate traditional medicine into the national health plan by implementing a program on traditional medicine in conjunction with some of our neighbouring countries

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Under this plan, Cameroon created the Traditional Medicine Service within the Unit of
Community Medicine in the Yaounde Central Hospital and set up the Office of Traditional Medicine in the Ministry of Public Health A number of research projects on traditional medicine and training programmes for traditional medicine practitioners have also taken place 17 Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions, and some traditional medicine practitioners are involved in Cameroons primary health care programme 6

Cape Verde
Regulatory situation
Cape Verde does not have any official legislative or regulatory texts governing the practice of traditional medicine There are no licensing procedures for traditional medicine practitioners, nor are there any procedures for the official approval of traditional medical practices and remedies Traditional medicine practitioners are not involved in Cape Verdes primary health care programme at either the local or national level 6

Education and training
Cape Verde
does not have any official training facilities or programmes for traditional medicine 6

Central African Republic
Regulatory situation
The Central African Republic has local intersectoral councils for traditional medicine and a registry of traditional health practitioners However, there are no official legislative or regulatory texts governing the practice of traditional medicine There are no licensing procedures for traditional medicine practitioners, nor are there any procedures for the official approval of traditional medical practices and remedies Traditional medicine practitioners are not involved in the Central African Republics primary health care programme at the local or national level 6

Education and training
The Central African Republic does not have official training facilities or programmes for traditional medicine 6

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Africa

Chad
Regulatory situation
Although traditional medicine practitioners are involved in Chads primary health care programme, Chad does not have
any official legislative or regulatory texts governing the practice of traditional medicine There is no licensing process for traditional medicine practitioners, nor are there procedures for the official approval of traditional medical practices and remedies 6

Education and training
Chad has no official training facilities or programmes for traditional medicine 6

Comoros
Regulatory situation
Comoros does not have official legislative or regulatory texts governing the practice of traditional medicine There is no licensing process for traditional health practitioners, nor are there procedures for the official approval of traditional medical practices and remedies Traditional medicine practitioners are not involved in the primary health care programme in Comoros at either the local or national level 6

Education and training
Comoros does not have official training facilities or programmes for traditional medicine 6

Congo
Background information
In rural areas, herbalists and
spiritualists are the two most common practitioners of traditional medicine In urban areas, acupuncturists and natural medicine providers — medical practitioners who treat with mineral and animal products — are more common Through scientific analysis, independent researchers have confirmed the efficacy of a number of Congolese traditional medical products — such as manadiar, antougine, meyamium, and diazostimul — leading to their distribution throughout Africa

Statistics
For the treatment of pathologies of the reproductive system, 599 of Congolese women use traditional medicine Of these women, 382 report having experienced complications or side effects after using these medicines

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Regulatory situation
The traditional medicine branch of the Ministry of Health and Social Affairs was created in 1974 to develop a national herbarium and determine the number of traditional medicine
practitioners in the country In 1980, the National Union of TradiTherapists of Congo was founded In 1982, the traditional medicine branch was expanded, becoming the Traditional Medicine Service The Service, led by a pharmacist, was charged with conducting research, enriching the national herbarium, gathering medicinal formulas, popularizing traditional medicine, and integrating traditional and allopathic medicine In 1987, the National Centre of Traditional Medicine was established to promote research, manufacture traditional medical products, exchange information with other traditional medicine institutions, train allopathic doctors and students in traditional medicine, and teach techniques for the aseptic preparation of medicines to practitioners of traditional medicine Failure to collaborate with traditional medicine practitioners and a poor relationship between traditional medicine practitioners and allopathic practitioners proved to be obstacles to the Centres work Congo has
official legislative/regulatory texts governing the practice of traditional medicine It also has local and national intersectoral councils for traditional medicine Local officials in Congo are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions Some traditional medicine practitioners are also involved in the primary health care programme of Congo; however, in certain centres this integration is very weak 6 There is a licensing process, a national association, and a registry of traditional health practitioners The Management of Health Services of the Ministry of Health, the National Union of Tradi-Therapists, and other professional traditional medicine associations review the qualifications of traditional medicine practitioners, although there are no set criteria for these qualifications Traditional medicine practitioners are recognized by the Government and are well tolerated In 1996, legislation on the recognition of traditional
medicine and complementary/alternative medicine was drafted, but it has not yet been finalized because of the 19971999 armed conflict Under current regulations, only herbalists are permitted to practise in the official health care system

Education and training
No training in traditional medicine is integrated into the university medical curriculum

Insurance coverage
An attempt has been made to standardize the fees of traditional medicine practitioners in Congo, although no patient reimbursement exists for such fees 6

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Africa

Côte dIvoire
Regulatory situation
Côte dIvoire has neither official legislative nor regulatory texts governing traditional medicine There is no licensing process for traditional health practitioners, nor are there procedures for the official approval of traditional practices or remedies Traditional medicine practitioners are not involved with primary health care in Côte dIvoire on either the local or national level 6

Education and training
Côte dIvoire
does not have official training facilities or programmes for traditional medicine 6

Democratic Republic of the Congo
Regulatory situation
The Democratic Republic of the Congo retains health care legislation from the colonial era, including the Decree of 19 March 1952 on the practice of medicine, as amended 18, 19 The Decree grants exemplary status for traditional medicine practitioners, but also places limitations on their practice Section 15 states the following:
The provisions of this Decree shall not be applicable to nationals of the Belgian Congo or of neighbouring African territories who, in population groups where such customs prevail, carry out treatments and administer drugs in accordance with the usage custom provided they do not constitute a breach of public order

The Second Ordinary Congress of the Popular Revolutionary Movement in Zaire adopted a resolution in November 1977 20 encouraging research into the rehabilitation and recognition of traditional medicine as a
complement to allopathic medicine and urging the establishment of a division dedicated to traditional medicine within the Department of Health

Equatorial Guinea
Regulatory situation
Equatorial Guinea has official legislative/regulatory texts governing the practice of traditional medicine There is a licensing process and a registry of traditional health practitioners However, Equatorial Guinea does not have procedures for the official approval of traditional medical practices or remedies Local officials in Equatorial Guinea are not allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions Traditional medicine practitioners are not involved in Equatorial Guineas primary health care programme 6

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Education and training
Equatorial Guinea has training facilities and programmes in traditional medicine for both health providers and lay
persons 6

Insurance coverage
An attempt has been made to standardize the fees of traditional medicine practitioners in Equatorial Guinea, although no patient reimbursement exists for such fees 6

Ethiopia
Background information
Traditional medicine in Ethiopia includes medicinal preparations from plant, animal, and mineral substances, as well as spiritual healing, traditional midwifery, hydrotherapy, massage, cupping, counter-irritation, surgery, and bonesetting Traditional medical practices and remedies are recorded in oral tradition and in early medico-religious manuscripts and traditional pharmacopoeias, which, according to th the estimates of some historians, date back to the 15 century AD Traditional medicine is largely practised by traditional medicine practitioners, although, particularly for certain common health problems, it is also practised at home by the elderly and by mothers The Ethiopian Traditional Healers Association was organized to review the qualifications of
practitioners where no regulations exist

Statistics
Over 80 of the Ethiopian population rely on traditional medicine 21 This represents the majority of the rural population and sectors of the urban population where there is little or no access to allopathic health care In 1986, over 6000 practitioners of traditional medicine were registered with the Ethiopian Ministry of Health 22

Regulatory situation
Proclamation 100 of 1948, Penal Code 512/1957, and Civil Code 8/1987 all state conditions for the practice of traditional medicine and the importance of the development and use of traditional remedies The 1974 change of government in Ethiopia was followed by official attention to the promotion and development of traditional medicine, particularly after the adoption of the Primary Health Care Strategy in 1978 In November 1979, the Office for the Coordination of Traditional Medicine 21, 23, which is now a full-fledged department directly under the ViceMinister of Health, was established
to organize, train, and register traditional medicine practitioners, and to identify, describe, and register those traditional

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Africa

medicines with actual or potential efficacy The Ministry of Health also incorporated traditional medicine into the National Ten-Year Perspective Plan 19841994 24, which called for the organization, training, and supervised use of traditional medicine practitioners in strengthening and expanding primary health care services The Health Policy and the Drug Policy of 1993 both emphasize the need to develop the beneficial aspects of traditional medicine through research and through its use in the official health delivery services Proclamation 1999 was issued based on the National Drug Policy In Article 6, Sub-Article 8 of the Proclamation, it is stated that the Drug Administration and Control Authority shall prepare standards of safety, efficacy, and quality of traditional medicines and shall evaluate laboratory and clinical studies in order to ensure
that these standards are met The Authority shall also issue licences for the use of traditional medicines in the official health services

Education and training
No officially recognized education is provided in traditional or complementary/alternative medicine

Insurance coverage
There is no national health care insurance or private insurance covering traditional medicine

Gabon
Regulatory situation
Practitioners of traditional medicine in Gabon are involved in the countrys primary health care programme However, Gabon does not have official legislative or regulatory texts governing the practice of traditional medicine There are no licensing procedures for traditional health practitioners, nor are there procedures for the official approval of traditional medical practices and remedies 6

Education and training
Gabon does not have any official training facilities or programmes for traditional medicine 6

Gambia
Regulatory situation
Gambia has official legislative/regulatory texts
governing the practice of traditional medicine There is a licensing process for traditional health practitioners and some traditional medicine practitioners are involved in Gambias primary health care programme 6

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Education and training
Gambia has a training programme in traditional medicine for health workers 6

Ghana
Background information
Missionaries introduced allopathic medicine to Ghana during the colonial period After independence in 1957, the Government initiated a number of medical projects, promoting allopathic medicine as Ghanas official medical system 25 However, successive governments have recognized both traditional and complementary/alternative medicine, including acupuncture, homeopathy, naturopathy, osteopathy, and hydropathy Traditional medicine practitioners use herbs, spiritual beliefs, and local wisdom in providing health care There are a number of associations of
traditional medicine practitioners, including the Ghana Psychic and Traditional Medicine Practitioners Association, which was formed in 1961 26 In 1999, the Government brought all the traditional medicine associations together under one umbrella organization, the Ghana Federation of Traditional Medicine Practitioners Associations 25

Statistics
In Ghana, about 70 of the population depend exclusively on traditional medicine for their health care There is approximately one traditional medicine practitioner for every 400 people, compared to one allopathic doctor for every 12 000 people 27 With over 100 000 traditional medicine practitioners uniformly distributed nationally, they are not only more accessible to the public, but also the backbone of the health care delivery system 28

Regulatory situation
Restrictions contained in the Poisons Order 1952 limit the use of the substances listed in the Order to registered medical practitioners The Medical and Dental Decree of 1972 and the Nurses
and Midwives Decree of 1972 allow indigenous inhabitants of Ghana to practise traditional medicine, provided they do not practice life-endangering procedures The Centre for Scientific Research into Plant Medicine was established in 1975 In addition to its research capacity, the Centre operates a hospital providing both traditional and allopathic medicine Until the passage of the Traditional Medicine Practice Act, the Government worked with the Ghana Psychic and Traditional Medicine Practitioners Association to license and register traditional medicine practitioners and to ensure a standard of care 29,

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30 The Traditional Medicine Practice Act 595 was drafted by traditional medical practitioners, placed before the Parliament in 1999, and passed on 23 February 2000 The Act establishes a council to regulate the practice of traditional medicine, register practitioners and license them to practice and to regulate the preparation and sale of herbal medicines The Act defines
traditional medicine as practice based on beliefs and ideas recognized by the community to provide health care by using herbs and other naturally occurring substances and herbal medicines as any finished labelled medicinal products that contain as active ingredients aerial or underground parts of plants or other plant materials or the combination of them whether in crude state or plant preparation 31 The Act is divided into four parts 26 Part I concerns the Traditional Medicine Practice Council, including its establishment; function; membership; tenure of members; meetings; the appointment of committees such as Finance, General Purposes, Research, Training, Ethics, and Professional Standards; granting of allowances to members; and the establishment of regional and district offices Part II covers the registration of traditional medical practitioners Clause 9 states that no person shall operate or own a practice or produce herbal medicines for sale unless registered under this act The
qualifications for registration are given in Clause 10 Clause 11 provides for the temporary registration of foreigners who have a work permit, satisfy the requirements for registration under this act, and have a good working knowledge of English or a Ghanaian language The rest of Part II deals with matters concerning renewal of the certificate of registration, suspension of registration of practitioners, cancellation of registration, and representation to the Council In Clause 13, it is provided that the Minister of Health, on the recommendation of the Council in consultation with recognized associations of traditional medicine practitioners, may regulate the titles used by traditional medicine practitioners based on the types of services rendered and the qualifications of the practitioners Part III covers matters concerning the licensing of practices: mandatory licensing; method of application and conditions for licensing; issuance and renewal of licences; acquisition and display of
licences; ownership and operation of a practice by a foreign practitioner; revocation, suspension, and refusal to renew a licence and representations to the Council by aggrieved persons; powers of entry and inspection by an authorized inspector; and notification of death to a coroner Part IV concerns staff for the Traditional Medicine Practice Council as well as financial and miscellaneous provisions, such as the appointment of a registrar, the provision of the Register of Traditional Medicine Practitioners, offences, and regulations Clause 41 states categorically that the Act shall not derogate from the provisions of the Food and Drugs Board Law PNDCL 305B The Traditional Medicine Unit 26, 31 under Ghanas Ministry of Health was created in 1991 In 1999, this was upgraded to the status of a directorate The Ministry, in

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

collaboration with the Ghana Federation of Traditional Medicine
Practitioners Associations and other stakeholders, has developed a five-year strategic plan for traditional medicine, which outlines activities to be carried out from 2000 to 2004 It proposes, among other things, the development of a comprehensive training programme in traditional medicine from basic to tertiary levels Volume 1 of the Ghana Herbal Pharmacopoeia 31 contains scientific information on 50 medicinal plants A second volume is currently in preparation Efforts are being made to integrate traditional medicine into the official public health system It is expected that by the year 2004, certified efficacious herbal medicines will be prescribed and dispensed in hospitals and pharmacies Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions 6 The Government of Ghana has set aside the third week of March every year as Traditional Medicine Week, starting from the year 2000 31

Education and training
Training by
apprenticeship is required, accepted, and promoted for practitioners of traditional medicine The Ministry of Health is working towards including traditional medicine in the curricula of allopathic medical schools and towards the introduction of a diploma course in traditional medicine at the postgraduate level As a step in this direction, in the year 2000, the Ministry is planning to assess the training needs for traditional medicine practitioners 25 There are official training programmes for traditional birth attendants 30

Guinea
Regulatory situation
In Guinea, Ordinance 189 PRG of 18 September 1984 32 states that the profession of physician can only be practised by persons with a Guinean diploma of Doctor of Medicine, a foreign diploma granting equivalent status, or a foreign diploma that entitles its holder to practise medicine in his or her country of origin Various activities that constitute the unlawful practice of medicine are set out in Section 9 However, traditional medicine
seems relatively unaffected by this ordinance Guinea has official, applied, legislative/regulatory texts governing the practice of traditional medicine There is a licensing process and a registry of traditional health practitioners as well as local and national intersectoral councils for traditional medicine 6 Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions, and some traditional medicine practitioners are involved in Guineas primary health care programme 6

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Guinea-Bissau
Regulatory situation
Guinea-Bissau has local and national intersectoral councils for traditional medicine However, Guinea-Bissau does not have any official legislative or regulatory texts governing the practice of traditional medicine and there is no licensing process for traditional health practitioners Local officials are not allowed to authorize the practice of traditional medicine in their administrative and/or health
subdivisions and traditional medicine practitioners are not involved with Guinea-Bissaus primary health care programme 6

Kenya
Statistics
Traditional birth attendants deliver most of the babies born in Kenya — up to 75 in some regions 33

Regulatory situation
Traditional medicine started being incorporated into Kenyas national health policy framework in the late 1970s Kenyas Development Plan 19891993 34 recognized traditional medicine and made a commitment to promoting the welfare of traditional medicine practitioners The Ministry of Health and provincial authorities require the registration of traditional medicine practitioners In 1999, Kenyas patent law was revised to include protection for traditional medicines

Education and training
Traditional birth attendants participate in official training programmes in some districts

Lesotho
Regulatory situation
Lesotho has two statutes that regulate the practice of traditional medicine and limit it to registered practitioners Section 2 of
the Natural Therapeutic Practitioners Act of 1976 35 defines natural therapeutics as the provision of services for the purpose of preventing, healing, or alleviating sickness or disease or alleviating, preventing, or curing pain by any means other than those normally recognized by the medical profession Natural therapeutics includes methods commonly employed by homeopaths, naturopaths, osteopaths, chiropractors, and acupuncturists Section 3 prohibits non-registered persons from practising as natural therapeutic practitioners

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Applicants for registration must be at least 21 years of age, citizens of Lesotho, and recommended as qualified by the Natural Therapeutic Practitioners Association of Lesotho The Registrar of the register of natural therapeutics must be satisfied that it is in the public interest to permit the applicant to practise Persons who were practising prior to the date of
commencement of the Act are deemed to be qualified Authorised persons under the Act are prohibited from carrying out certain procedures, including performing operations or administering injections, practising midwifery, withdrawing blood, treating or offering to treat cancer, performing internal examinations, or claiming to be or leading people to infer that the individual is an allopathic physician The Act also prohibits preventing any person from being treated by an allopathic physician or improperly influencing any person to abstain from such treatment The Lesotho Universal Medicinemen and Herbalists Council Act of 1978 36 followed the Act of 1976 It provides for the establishment of the Universal Medicinemen and Herbalists Council Section 5 states the objectives of the Council: to promote and control the activities of traditional medicine practitioners, to provide facilities for the improvement of skills of traditional medicine practitioners, and to bring together all traditional
medicine practitioners into one associated group The Council is required to do all that is necessary to attain these objectives and to ensure that every traditional medicine practitioner has a valid licence to practise as such The Council must also keep a register of all its members Membership is open to every traditional medicine practitioner who pays the prescribed fee It is an offence to form or encourage the formation of any other association of traditional medicine practitioners

Education and training
Lesotho has a training programme in traditional medicine for health workers 6

Liberia
Regulatory situation
Liberia has official legislative/regulatory texts governing the practice of traditional medicine There is a registry of traditional health practitioners and there are local and national councils for traditional medicine Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions, and some traditional medicine
practitioners are involved in Liberias primary health care programme However, Liberia does not have licensing procedures for traditional health practitioners or procedures for the official approval of traditional medical practices and remedies 6

Education and training
Liberia has a training programme in traditional medicine for health workers 6

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Madagascar
Background information
The National Centre of Applied Pharmaceutical Research NCAPR, founded in 1976, is composed of five technical departments: ethnobotanical and botanical, chemistry, pharmacodynamics, galenic pharmacy, and experimental clinics NCAPR has the capacity to analyse herbal medicines from their ethnobotanical form to their manufactured form NCAPR received financial support from the United Nations Development Programme in 1984 to undertake several projects In 1985, NCAPR and the World Health Organization agreed to a four-year collaborative project on research into traditional medicines The main objectives
were to establish an inventory of medicinal plants and their indications, investigate the therapeutic and toxic effects of the registered plants, and undertake research standardizing and improving the presentation of traditional medicines In 1995, NCAPR began reviewing the practice of traditional medicine as a whole by analysing the role of traditional medicine practitioners in the primary health care system The National Tradi-Therapist Association of Madagascar was formed in 1997

Statistics
Serving a population of 123 million, there are 4500 allopathic physicians, 220 pharmacists, 360 dentists, 1635 midwives, 3124 nurses, 1282 sanitary aides, and more than 10 000 practitioners of traditional medicine

Regulatory situation
Traditional medicine practitioners are involved in Madagascars primary health care programme 6 In 1992, Madagascar had no legislative/regulatory texts governing the practice of traditional medicine, no licensing process for traditional health practitioners, and no
procedures for the official approval of traditional medical practices or remedies 6 In 1996, a commission was created to study the legal aspects of traditional medicine with the intention of regulating its practice In 1998, a project to grant official legal recognition to traditional medical practice was launched In the same year, a census of traditional medicine practitioners was conducted, and, in addition, a project in the eastern and northern parts of Madagascar began integrating traditional medicine practitioners into the official health system In 1999, regulations for herbal medicines were drafted These were approved by Parliament in 2000

Education and training
Madagascar does not have any official training facilities or programmes for traditional medicine for either health workers or lay persons 6
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Malawi
Regulatory situation
The Malawi Medical Practitioners and Dentists Act of
1987 37 makes detailed provisions for the registration, licensing, and training of allopathic physicians and dentists Regarding traditional medicine practitioners, Section 61 reads:
Nothing contained in this act will be construed to prohibit or prevent the practice of any African system of therapeutics by such persons in Malawi, provided that nothing in this section shall be construed to authorize performance by a person practising any African system of therapeutics of any act which is dangerous to life

Some traditional medicine practitioners are involved in Malawis primary health care programme 6

Education and training
Malawi has a training programme in traditional medicine for health workers 6

Mali
Statistics
Seventy-five per cent of the population of Mali uses traditional medicine There is approximately one traditional medicine practitioner for every 500 inhabitants Around 180 Herbalist Cards, 200 Therapist Cards, and 1000 Collaboration with the Traditional Medicine Department
Certificates have been issued There are 32 associations for practitioners of traditional medicine in the country

Regulatory situation
The Department of Traditional Medicine and the National Research Institute of Medicine and Traditional Medicine were created in 1973 They were designated to demonstrate the value of traditional medicine resources through scientific research and to differentiate the roles of herbalists from those of other traditional medicine practitioners, which included defining their respective status, regulations, and code of ethics The Department of Traditional Medicine is mandated to inventory medicinal plants and their indications, verify the therapeutic and toxic effects of the recorded plants, undertake studies to improve and standardize the forms of presentation of traditional medicines, train researchers in the fields of traditional medicine and traditional pharmacopoeia, involve traditional medicine practitioners in the politics of primary health care, write
technical notices related to traditional medicine, and set up expert advisory missions for national and international institutions interested in traditional medicine in Mali

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In order to fulfil this mandate, the Department has planned the following: a census of traditional medical practitioners; an umbrella association to bring together the 32 traditional medicine practitioner associations; the production of improved traditional medicines, some of which have status as essential medicine in Mali and are indexed in the National Therapeutic List; the set up of phytochemical analyses as well as pharmacological and clinical tests of medicinal plants; the training of national and foreign researchers; and participation in symposiums, seminars, and workshops An order issued by the Minister of Public Health and Social Affairs on 16 May 1980 38, 39 established a Scientific and Technical Committee to work in conjunction with the National Research Institute of Medicine and Traditional
Medicine The Committee, whose functions are defined in relation to the overall health care needs of the country, has drawn up draft regulations on the practice of traditional medicine By Decree 94/282/P-RM of 15 August 1994, the Government of Mali regulated the opening of private consultation clinics for traditional medicine, medicinal herbs stores, and improved production units for traditional medicine According to the Decree, private consultation clinics for traditional medicine are establishments that provide traditional medical care to patients Medicinal herbs stores are airy and clean premises, which possess shelves and a counter and are run by a chartered person The only purpose of the stores is to sell medicinal plants or medicines made from plants However, conventional pharmacists are also allowed to sell herbs Improved production units for traditional medicine are semi-industrial or industrial units that transform raw materials into herbal preparations and herbal products
Decree 95/1319/MSS-PA/SG of 22 June 1995 establishes organizational and functional rules for the private consultation clinics, medicinal herbs stores, and improved production units Under this decree, membership in a registered and recognized traditional health practitioner association facilitates ones ability to obtain a certificate of notoriety and morality Chartered traditional medical practitioners, medical staff, and retired traditional medicine paramedical staff may open private traditional medicine consultation clinics Chartered medicinal plant sellers, graduates from the Katibougou Rural Polytechnic Institute which specializes in water and forests or its equivalent, and graduates from the Superior Normal School which specializes in biology or its equivalent are allowed to open medicinal herbs stores Industrial exploitation of medicinal plants is authorized only when it involves herbs, leaves, stems, barks, and/or fruits and is permitted only when the plants are cultivated
Collection of wild plants for industrial exploitation is not permitted Improved traditional medicine production units must be supervised by a pharmacist, and a pharmacist, chemical engineer, or biologist must monitor the control procedures Article 8 of Decree 95/009/P-RM of January 1995, establishing permits for pharmaceutical products, outlines special rules for requests involving traditional medicines made from plants These requests should include the name and address of the person in charge of putting the product on the market, and if the latter is not the manufacturer, the name and address of the manufacturer; a summary of the products
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

characteristics name, form, pharmacological properties, therapeutic indications, posologies, and administration; chemical and pharmaceutical files; toxicological and pharmacological files; a clinical file; 10 samples of the product; and a receipt for
the registration fee Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions Some traditional medicine practitioners are involved in Malis primary health care programme 6

Education and training
Created in 1996, the Faculty of Medicine, Pharmacy, and Odonto-Stomatology of the University of Mali is responsible for training allopathic physicians and pharmacists Among the requirements for students and researchers are courses directly related to traditional medicine and traditional pharmacopoeia, such as Botany, Pharmacognosy, Vegetal Substances, Chemistry, Pharmaceutical Legislation, and Public Health Other schools, faculties, and institutes that collaborate with the Department of Traditional Medicine on training and research in traditional medicine include the Rural Polytechnic Institute, the Superior School of Health, the Central School of Commerce and Industry, the Rural Economy School, the Faculty of Science and
Technology, and the Faculty of Arts, Languages, and Human Sciences Universities, organizations, and international and foreign research centres — such as universities in Burkina Faso, Côte dIvoire, France, Italy, Norway, and Senegal; the Centers for Disease Control and the National Institutes of Health, both in the United States; and ACCT, CAMES, and the World Health Organization — collaborate together on postgraduate training, research, thesis supervision, and examination boards Periodic meetings, seminars, and workshops have been organized with traditional medicine practitioners, sometimes through their associations The main points of national health programmes on AIDS, mental health, and family health have been presented with the intention that traditional medicine practitioners act as intermediaries, informing the public, and in recognition of the fact that traditional medicine practitioners are involved in patient care The Department of Traditional Medicine organizes and
supervises exploratory meetings and missions between associations of traditional medicine practitioners and their foreign partners Each year the Department of Traditional Medicine organizes open houses on health information, education, and communication in traditional medicine Radio and television programmes on traditional medicine with independent traditional medicine practitioners, representatives of associations, or persons in charge of technical services are regularly transmitted on public and private stations

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Insurance coverage
National health insurance covers allopathic medical care for only 500 000 to 1 000 000 of Malis 11 000 000 inhabitants It does not cover traditional or complementary/alternative medical care

Mauritania
Regulatory situation
Adopted in 1981, Decision 1831 40 established a working group to examine problems concerning traditional medicine and traditional pharmacopoeia Section 2 of the Decision reads:
The task of the working group shall be to
determine the situation of traditional medicine and the traditional pharmacopoeia in Mauritania and, in particular: To examine the most appropriate and realistic ways and means of establishing an honest dialogue between the official health services and traditional practitioners in the spirit of the objective of health for all by the year 2000 through primary health care; and To propose the most appropriate mechanisms for identifying traditional practitioners who are amenable to such dialogue in order to determine and acknowledge the part that they can play in the system of comprehensive health care health promotion, prevention of disease and disability, diagnosis and early treatment of disease, and rehabilitation

Section 56 of Ordinance 83136 41 on the practice of medical professions states that the Ordinance does not apply to traditional medicine and traditional pharmacopoeia, as they are to be covered by separate legislation However, as of 1992 6, Mauritania did not have official
legislative/regulatory texts governing the practice of traditional medicine, any licensing process for traditional practitioners, or procedures for the official approval of traditional medical practices and remedies Traditional medicine practitioners are not involved in Mauritanias primary health care programme

Education and training
Mauritania does not have any official training facilities or programmes for traditional medicine 6

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Mauritius
Regulatory situation
The Ayurvedic and Other Traditional Medicines Act of 1989 42 governs traditional medicine in Mauritius In this Act, traditional medicine is defined as the practice of systems of therapeutics according to homeopathy, Ayurvedic, and Chinese methods The central provisions of the legislation include the establishment of a regulatory body, the Traditional Medicine Board, and a registration system that requires practitioners to
obtain a diploma in traditional medicine The Traditional Medicine Board, established in Section 3 of the Act, is composed of Government officials, medical practitioners, persons knowledgeable in traditional medicine, and laypersons The Boards functions, set out in Section 8, include disciplinary responsibilities, publication of a code of practice governing standards of professional conduct and ethics, and compilation of an annual list of traditional medicine practitioners The registration system for traditional Chinese medicine practitioners requires applicants to hold a diploma in traditional medicine Under Section 24, non-registered persons are not entitled to practise any act of traditional medicine for gain, unless exempted from registration However, no exemptions are listed in the Act Unregistered persons are also prohibited from presenting themselves as registered practitioners The Minister responsible for health has the power to make regulations, set out the basic qualifications
required for studying traditional medicine, and establish the terms and conditions under which it may be practised The Minister also has the power to impose restrictions on the practice of any aspect of traditional medicine Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions in Mauritius 6 There is no chiropractic law

Mozambique
Regulatory situation
Mozambique does not have official legislative/regulatory texts governing the practice of traditional medicine, any licensing process for traditional health practitioners, or procedures for the official approval of traditional medical practices and remedies 6 However, in 1991, a proposal was put forward for a three-year programme to establish a foundation for collaboration between the National Health Service and the practitioners of traditional medicine in Mozambique The proposal suggested that traditional medicine practitioners constitute a separate, parallel, and
self-regulating health service that collaborates with the Mozambique Government in the realization of specific public health goals In this regard, the three-year programme would do the following:
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establish workshops to train traditional medicine practitioners in the treatment of priority diseases; establish a research-derived information base about traditional beliefs and practices; educate Government health workers at all levels in traditional beliefs and practices; coordinate research in traditional medicines, although, due to a tight budget, this research would not be funded by the Government itself Collaborative programmes with traditional medicine practitioners also take place under the umbrella of the Department of Health In addition, there are a number of programmes sponsored by non-governmental organizations, most of which collaborate with either district or provincial health authorities 43

Namibia
Background information
Before independence, health services
were fragmented along racial lines, and traditional medicine was outlawed After Namibias independence in 1990, traditional medicine was legalised Since then, the Ministry of Health and Social Services has adopted the primary health care approach to the delivery of health services, and major restructuring has been undertaken The Namibia Eagle Traditional Healers Association was created in 1990

Statistics
According to the 1994 Lumpkin Report 44, there is at least one traditional medicine practitioner per 500 people in the Kavango and Owambo regions In the Caprivi region, there is about one traditional medicine practitioner per 300 people In Windhoek Katutura, the ratio is one traditional medicine practitioner per 1000 people There are three chiropractors practising in Namibia 45 A joint study by the Ministry of Health and Social Services and World Health Organization in 1997 reported that traditional medicine practitioners in Namibia can be classified as herbalists, faith-herbalists,
diviner-herbalists, diviners, faith healers, and traditional birth attendants

Regulatory situation
The Official National Primary Health Care/Community-based Health Care Guidelines were launched in 1992 In 1994, Lumpkin carried out a preliminary survey on the use of traditional medicine in the country The resulting report, Traditional Healers and Community Use of Traditional Medicine in Namibia, was submitted to the Ministry of Health and Social
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Services 44 Also in 1994, the Namibian Parliament passed an act requiring all health workers, including traditional medicine practitioners, to become legally registered The act delegated each professional group to elect a board to facilitate the registration process In 1996, the Namibian Traditional Medical Practitioners Board was created In 1997, the Ministry of Health and Social Services and the World Health Organization jointly undertook a
study entitled Scientific Evaluation, Standardization, and Regulation of Traditional Medical Practices in Namibia The findings of this study guided the development of the 1998 draft Traditional Healers Bill They were also used to prioritize activities and to inform the planning process for the 20002002 programme on the regulation and integration of traditional medicine The Traditional Healers Bill will establish the Traditional Healers Council to oversee the registration and regulation of the practice of traditional medicine providers The Council will be given the task of supervising and controlling the practice of traditional medicine practitioners, fostering research into traditional medicines, and making loans or grants available to traditional health practitioners Traditional medicine practitioners in Namibia, many of whom come from other African countries, are not currently registered and operate without any guidelines from the Ministry of Health and Social Services The aim of the
Bill is to protect the public from dangerous and opportunistic practices as well as to promote acceptable aspects of traditional medicine in Namibia Once legislation is in place, the Government intends to include traditional medicine practitioners in community-based health care programmes and incorporate the traditional medical system into the countrys official health services referral system The Allied Health Service Professions Act of 1993 46 permits the relevant Minister to create a professional board to regulate the chiropractic profession The objectives of the board, stated in Section 2, shall be to assist in promoting health, oversee professional training, and control the practice of chiropractic

Education and training
According to the joint study by the Ministry of Health and Social Services and World Health Organization in 1997, all traditional medicine practitioners, except traditional birth attendants, undergo apprenticeships ranging from one to three years

Niger
Regulatory
situation
In Niger, candidates for the licence to practise traditional medicine are assigned to the National Hospital in Niamey 47, where they practice under the supervision of the Chief Physician Once satisfied with the skills of the traditional medicine practitioner, the Chief Physician then recommends that the Ministry of Public Health and Social Affairs issue a licence

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A 1989 order established the Committee for Studies on Traditional Medicine and Traditional Pharmacopoeia 48 The Committees tasks include formulating the basic premises for a national policy on traditional medicine, preparing statutes for a national institution to be responsible for improving and developing the regulation of traditional medicine, and drafting legislation governing the practice of traditional medicine

Nigeria
Background information
There has been a rapid expansion of allopathic health care in Nigeria over the last three decades, including an increase in the number of allopathic health
care providers At the same time, because the majority of Nigerians use traditional medicine, the Government of Nigeria has shown appreciation for the importance of traditional medicine in the delivery of health care

Regulatory situation
Though informal interaction between the Government and traditional medicine practitioners can be traced back to the 19th century, formal legislation promoting traditional medicine dates to 1966 when the Ministry of Health authorized the University of Ibadan to conduct research into the medicinal properties of local herbs Efforts to promote traditional medicine continued throughout the 1970s in the form of conferences and training programmes In the 1980s, policies were established to accredit and register traditional medicine practitioners and regulate the practice of traditional medicine In 1984, the Federal Ministry of Health established the National Investigative Committee on Traditional and Alternative Medicine A committee to research and develop
traditional and complementary/alternative medicine was formed by the Federal Ministry of Science and Technology in 1988 49 The Nigerian Medical and Dental Practitioners Act of 1988 50 forbids the practice of medicine or dentistry by unregistered practitioners, specifically the issuance of death certificates, performance of post-mortems, or certification of leprosy or mental disability However, traditional medical activities are protected by a provision in Section 176, which reads as follows:
Where any person is acknowledged by the members generally of the community to which he belongs as having been trained in a system of therapeutics traditionally in use in that community, nothing in [the provisions of the Act dealing with offences] shall be construed as making it an offence for that person to practise or hold himself out to practise that system; but the exemption conferred by this subsection shall not extend to any activity other than circumcision involving an incision in human
tissue or to administering, supplying, or recommending the use of any dangerous drug within the meaning of Part V of the Dangerous Drugs Act

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Registration requirements for chiropractors and osteopaths are outlined in the Medical Rehabilitation Therapists Registration, etc Decree of 1988 51 A 1992 decree 52 created the National Primary Health Care Development Agency with a broad mandate concerning health matters, including the endorsement of traditional birth attendants Among other things, the Agency is responsible for supporting village health care systems by paying special attention to and providing maximum support for the training, development, logistic support, and supervision of village health workers and traditional birth assistants, along with the relationship between those workers and their communities and the mechanisms that link those workers to other levels of the health
system; paying special attention to the involvement of women and grassroots organization of women in the village health system In 1994, all state health ministries were mandated to set up boards of traditional medicine in order to enhance the contribution of traditional medicine to the nations official health care delivery system 49 The National Traditional Medicine Development Programme was established in 1997 Since then, the Federal Ministry of Health has been instituting measures to formally recognize and enhance the practice of traditional medicine These measures include the constitution and inauguration of the National Technical Working Group on Traditional Medicine; development of policy documents on traditional medicine, including the National Policy on Traditional Medicine, National Code of Ethics for the Practice of Traditional Medicine, the Federal Traditional Medicine Board Decree, and Minimum Standards for Traditional Medicine Practice in Nigeria; and advocacy for
traditional medicine at all levels and in relevant forums, such as the National Council on Health since 1997, Consultative Meetings of the Honourable Minister of Health with State Commissioners for Health and Local Government Chairmen in 1999, and the Presidential Think Tank Forum in 1999 In 2000, the Traditional Medicine Council of Nigeria Act was proposed The functions of the Council include facilitating the practice and development of traditional medicine; establishing guidelines for the regulation of traditional medical practice to protect the population from quackery, fraud, and incompetence; liaising with state boards of traditional medicine to ensure adherence to the policies and guidelines outlined in the Federal Traditional Medicine Board Act; establishing model traditional medicine clinics, herbal farms, botanical gardens, and traditional medicine manufacturing units in the geopolitical zones of the country; and collaborating with organizations with similar objectives within
and outside Nigeria The Nigeria Medical Council is contemplating integrating homeopathy into the countrys health care delivery system 53

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Rwanda
Regulatory situation
Rwanda has local and national intersectoral councils for traditional medicine and a registry of traditional health practitioners However, Rwanda does not have official legislative/regulatory texts governing the practice of traditional medicine, a licensing process for traditional health practitioners, or procedures for the official approval of traditional medical practices and remedies 6

Education and training
Rwanda has traditional medicine training facilities for lay persons 6

Sao Tome and Principe
Regulatory situation
Sao Tome and Principe has local and national intersectoral councils for traditional medicine However, there are no official legislative/regulatory texts governing the practice of traditional medicine, no licensing process for traditional health practitioners, and no procedures for the
official approval of traditional medical practices or remedies Traditional medicine practitioners are not involved in Sao Tome and Principes primary health care programme 6

Education and training
Sao Tome and Principe does not have any official training facilities or programmes for traditional medicine 6

Senegal
Background information
Despite repressive laws against the practice of traditional medicine during the colonial period, almost every village in Senegal has a traditional medicine practitioner 54 The Experimental Centre for Traditional Medicine was established in Senegal in 1987 It now has an active patient roster of over 30 000 persons and is made up of a professional staff of both allopathic and traditional medicine practitioners 55 Whether or not spiritualists should be considered as traditional medicine practitioners is currently being debated in Senegal

Regulatory situation
Traditional medicine was officially recognized by the Government of Senegal in 1985 55 Senegal has
a registry of traditional health practitioners 6 The Health Ministry
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

advocates the promotion and rehabilitation of traditional medicine and traditional pharmacopoeia There are official strategies and activities to encourage collaboration between traditional and allopathic medical practitioners

Education and training
Senegal has traditional medicine training facilities for lay persons 6

Seychelles
Regulatory situation
Seychelles does not have official legislative/regulatory texts governing the practice of traditional medicine, a licensing process for traditional health practitioners, or procedures for the official approval of traditional medical practices and remedies Practitioners of traditional medicine are not involved in Seychelles primary health care programme 6

Education and training
Seychelles has no official training facilities or programmes in traditional medicine 6

Sierra
Leone
Regulatory situation
In Sierra Leone, the Medical and Dental Surgeons Act of 1966 56 states that nothing in the Act is to be construed as prohibiting or preventing the practice of customary systems of therapeutics, provided that such systems are not dangerous to life or health The Medical Practitioners and Dental Surgeons Decree of 1994 57 repeals the Medical and Dental Surgeons Act of 1966 However, it retains exemptions for traditional medical practitioners Section 43 reads as follows:
Nothing in this Decree shall be construed to prohibit or prevent the practice of customary systems of therapeutics or the practice of druggists authorized by any law; but nothing in this Decree shall be construed to authorize the practice of any customary system of therapeutics which is dangerous to life or health

In Sierra Leone, some traditional medicine practitioners are involved with the primary health care programme 6 The Traditional Medicine Act of 1996 regulates the profession of
traditional medicine and controls the supply, manufacture, storage, and transportation of herbal medicines The Act establishes the Scientific and Technical Board on Traditional Medicine and two committees under it: the Disciplinary Committee to advise the Board on matters relating to the professional conduct of traditional medicine practitioners and the Drugs Committee to advise the Board on the classification and standardization of traditional medicines
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The Scientific and Technical Board is charged with securing the highest practicable standards in the provision of traditional medicine in Sierra Leone by promoting the proper training and examination of students of traditional medicine, controlling the registration of traditional health practitioners, and regulating the premises where traditional medicine is practised It is provided in the Traditional Medicine Act that the Board shall have a registrar who shall make and keep the Register of Traditional Medical
Practitioners Anyone whose name is entered in this Register shall be regarded as a member of the Sierra Leone Traditional Healers Association Cancellation and suspension of registration, annual publication of the list of registered traditional medicine practitioners, restriction on use of the title Traditional Medical Practitioner, and the provision of medical aid by traditional medicine practitioners are also covered by the law Part IV of the Act contains a list of the diseases for which traditional medical providers may not advertise treatments

Education and training
Sierra Leone has no official training facilities or programmes in traditional medicine 6

South Africa
Background information
Traditional healers — in South Africa known as inyangas, sangomas, and witchdoctors — have a crucial role in providing health care to the majority of South Africans They are deeply interwoven into the fabric of cultural and spiritual life In 1980, the Traditional Healers Organization was
created The National Department of Arts, Culture, Science, and Technology funds consortium research projects into traditional medicines 58

Statistics
Traditional healers are present in almost every community They are the first health providers to be consulted in up to 80 of cases, especially in rural areas 59 There are over 200 000 traditional healers in South Africa and only 27 000 allopathic medical practitioners The Traditional Healers Organization currently represents more than 180 000 traditional healers from South Africa and a number of neighbouring countries, including Swaziland, Zambia, and Zimbabwe 60 There are approximately 200 chiropractors practising in South Africa 45 Every year 1500 tons of traditional medicines are sold in medicine markets in Durban alone The traditional medicine industry is worth up to 2 300 000 South African rand per year

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Regulatory situation
South
Africa regulates general traditional healers, herbalists, chiropractors, homeopaths, osteopaths, and naturopaths under the Associated Health Service Professions Act of 1982, as amended 61 This Act sets up a registration and licensing scheme for various professions Registration entitles medical providers to practise for gain and call themselves members of that profession Practice for gain by a nonregistered person is an offence punishable by a fine and/or imprisonment of up to one year To qualify as a traditional healer, one has to serve an apprenticeship of between one and five years and must be well known within the community one serves and amongst other traditional healers Qualified traditional healers register with the Traditional Healers Organization and are given a book to certify that they are qualified healers The qualifications are valid in Africa, Asia, Latin America, Europe, and Australia 60 However, Section 41 of the Associated Health Service Professions Act of 1982 states
that the provisions of the Act shall not be read to derogate from the right which a medicine man or herbalist contemplated in the Code of Zulu Law may have to practise his profession The South African law also imposes restrictions on the professional nomenclature that can be adopted by traditional healers Use of the title Medical Practitioner, or a title suggesting that its holder is qualified as an allopathic medical practitioner, is prohibited Applicants for registration as chiropractors must show they hold a degree, diploma, or certificate demonstrating sufficient proficiency in chiropractic Such qualifications are not, in contrast, required for the registration of an osteopath or naturopath The Associated Health Service Professions Board may, on an individual basis, impose restrictions on the kind of work that can be carried out by chiropractors or require applicants for registration to obtain further practical experience, on terms stipulated by the Board Chiropractors and
osteopaths are prohibited from performing operations, administering injections other than intramuscular or hypodermic injections, practising obstetrics, and taking or analysing blood samples Additionally, chiropractors and osteopaths may not treat or offer to treat cancer or prescribe a remedy for cancer or pretend that any article, apparatus, or substance will or may be of value for the alleviation of the effects or for the curing or treatment of cancer There is also a prohibition against preventing or improperly discouraging a person from obtaining treatment by an allopathic physician or health care professional Osteopaths are subject to further restrictions, which, among other things, bar them from performing internal examinations or reading or interpreting Roentgen plates as part of a clinical diagnostic procedure In August 1998, the South African Parliament decided to enlist the help of traditional healers in achieving major goals in primary health care However, whether
traditional healers should become part of the Department of Health itself or belong to their own association in affiliation with the Department of Health remains controversial 59

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Africa

The National Department of Agriculture governs traditional medicines via the National Plant Genetic Resource Committee, of which a traditional healer is a member The National Department of Health produced the National Drug Policy For the purpose of implementing the National Drug Policy with respect to traditional medicines, the National Department of Health established the National Reference Centre for Traditional Medicines Traditional medicines are included in the Drug Policy section of the Governments Reconstruction and Development Programme The goals of the Traditional Medicines Programme of the Department of Pharmacology, University of Cape Town 62, 63, are to promote the use of safe, effective, and high-quality essential traditional medicines; to promote the documentation and scientific
validation of traditional medicines; to contribute to primary health care by providing appropriate information to traditional healers and other health professionals; to support industrial development in this sector; and to contribute to the training of traditional healers In 1994, the Programme participated in formulating an outline proposal on the registration and control of traditional medicines In 1998, the Parliament passed Act 132, the South African Medicines and Medical Devices Regulatory Authority Bill 64, covering the registration and regulation of traditional medicines and changing the regulation of medicines in the country The Bill establishes the South African Medicines and Medical Devices Regulatory Authority to replace the Medicines Control Council, which was set up in 1965 The Medicines Control Council held allopathic, traditional, and complementary/alternative medicines to the same set of standards and procedures The South African Medicines and Medical Devices Regulatory
Authority Bill, in contrast, makes provisions for different procedures to be applied when registering allopathic medicines and traditional and complementary/alternative medicines This is done by establishing separate expert committees for the two major types of medicine In the case of traditional medicines, issues of safety and quality take precedence over demonstrations of efficacy The aim is to regulate and not to prevent access to what many people use in preference to allopathic medicines

Education and training
In the 1960s, due to pressure from the South African Medical Council, non-allopathic medical colleges were closed Those practising at the time were grandfathered into a closed register Allopathic medical doctors retained the right to practise homeopathy regardless of their level of homeopathic education The Homeopathic Association of South Africa is currently working to gain recognition for homeopathic education as a pre-graduate and postgraduate university subject The
long-term vision is a chair of homeopathy at one of the universities As a first step, there are overtures to the South African College of Medicine for accreditation and application for registration of a South African Faculty of Homeopathy 53 There are two institutions offering sixyear chiropractic programmes leading to a Masters degree 65

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Swaziland
Regulatory situation
In Swaziland, the Control of Natural Therapeutic Practitioners Regulations of 1978 66 limits the definition of natural therapeutic practitioner to persons practising chiropractic, homeopathy, naturopathy, or electropathy The prohibitions on professional practice are similar to those in force in Lesotho Some traditional medicine practitioners are involved with Swazilands primary health care programme 6

Education and training
Swaziland has no official training facilities or programmes in traditional medicine
6

Togo
Regulatory situation
Togos law on health practitioners holds exemptions in favour of providers of traditional medicine In the first paragraph of Section 68 of the Criminal Code of 1980 67, the definition of the illegal practice of medicine very closely reflects Article L 372 of the French Code of Public Health However, the second paragraph of Section 68, states the following: The above provisions do not apply to medical practitioners who practise according to traditional methods Togo has a registry of traditional health practitioners Some traditional medicine practitioners are involved with Togos primary health care programme 6

Uganda
Background information
Practitioners of traditional medicine vastly outnumber allopathic doctors in Uganda 68 The National Traditional Healers and Herbalists Association has recently put forth a proposal to establish a hospital in Mengo, Kampala, where traditional health care will be offered This proposed 20-bed hospital would operate with
facilities worth US 89 million 69 Traditional and Modern Health Practitioners Together against AIDS and other diseases THETA 68 is an indigenous non-governmental organization dedicated to improving mutually respectful collaboration between traditional and allopathic health practitioners in Uganda THETA is working with traditional medicine practitioners in education, counselling, and improved clinical care for people with sexually transmitted diseases, including HIV/AIDS

36

Africa

Regulatory situation
The Medical Practitioners and Dental Surgeons Act 10 of 1968 prohibits unlicensed persons from practising medicine, dentistry, or surgery However, Section 36 allows the practise of any system of therapeutics by persons recognized to be duly trained in such practice by the community to which they belong, provided the practice is limited to that person and that community In Uganda, the Ministry of Health presides over allopathic practitioners, while the Ministry of Women in Development,
Culture, and Youth presides over traditional medicine practitioners The Government of Uganda has expressed interest in recognizing traditional health systems and has set up, under the Ministry of Health, the Natural Chemotherapeutics Research Laboratory to study the therapeutic potential of natural products 69 The intention is eventually to include in the National Health Service those products deemed efficacious Research is conducted jointly with traditional medicine practitioners The Government of Uganda is in the process of developing a health policy emphasizing primary health care The Health Review Commission 69 recommended that the Ministry of Health work closely with traditional medicine practitioners to achieve the objectives of health for all by the year 2000 The Commission specifically recommended including traditional health practitioners as members of community health teams and welcoming them to participate in primary health care

Education and training
THETA 68 organizes
training programmes for traditional medicine practitioners and is establishing and managing a resource and training centre to facilitate the collection and dissemination of information on traditional medicine

United Republic of Tanzania
Background information
Traditional medicine has been practised separately from allopathic medicine since the colonial period The practice of traditional medicine is threatened by a lack of written documentation on traditional medical practices, which has made its promotion difficult, and by a decline in biodiversity, including traditional medicinal resources, in certain localities There has also been a decline in the number of practitioners of traditional medicine 70 Beginning in the 1990s, complementary/alternative systems of health care have emerged in Tanzania These new medical options include magnetic therapy, homeopathic medicine, massage, and traditional Chinese, Korean, and Indian medicines

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Legal Status of Traditional Medicine and
Complementary/Alternative Medicine: A Worldwide Review

Regulatory situation
The Medical Practitioners and Dentists Ordinance 71, which was constituted before Tanzanias independence and is still in operation, holds exemplary status for traditional practitioners Chapter 9220 72 states the following:
Nothing contained in this ordinance shall be construed to prohibit or prevent the practice of systems of therapeutics according to native methods by persons recognized by the community to which they belong to be duly trained in such practice Provided that nothing in this section shall be construed to authorize any person to practise native systems of therapeutics except amongst the community to which he belongs, or the performance of an act on the part of any persons practising any such system which is dangerous to life

In an effort to promote and standardize traditional medicine, the Government established the Traditional Medicine Research Unit in 1974 as part of the University of Dar es
Salaam and the Muhimbili Medical Centre 73 In 1985, the Government of Tanzania was in the process of developing a law to register and license traditional practitioners In 1989, governance of traditional health services was shifted from the ministry responsible for culture to the Ministry of Health, which has established a Traditional Health Services Unit 70 This Unit is working to unify traditional health practitioners and mobilize them to form their own association The Unit is also involved in the formation of a traditional medicine policy, the overall goal of which is to improve the health status of the people through the use of effective and safe elements of traditional health care Traditional health services are officially recognized in the National Health Policy of 1990 73

Education and training
There has been no attempt to introduce or incorporate traditional medicine into the training curricula of allopathic medical students

Zambia
Background information
During the colonial
period, traditional medicine was denigrated After independence in 1964, the Zambian Government did not enact legislation to regulate traditional medicine, nor was a clear policy on the practice of traditional medicine postulated Nevertheless, traditional medicine continued to be practised and was tolerated by the authorities 74 Currently, herbal medicine, naturopathy, traditional Chinese medicine, reflexology, spiritualism, and other forms of medicine are practised in Zambia Both Zambians and foreign nationals practise traditional and complementary/alternative medicine
38

Africa

Statistics
At least 70 of Zambians use traditional medicine Traditional and complementary/alternative medicine is used and accepted by a great majority of the population, regardless of ethnic, religious, or social background There are more than 35 000 members of the Traditional Health Practitioners Association of Zambia, founded in 1978, and thousands of non-members 74

Regulatory situation
The Government
recognizes traditional and complementary/alternative medicine and there are national policies on traditional and complementary/alternative medicine The Traditional Health Practitioners Association reviews and registers traditional practitioners for licensing Although there are no official regulatory measures for recognizing the qualifications of practitioners, plans are under way to develop such regulations Traditional medicine and complementary/alternative medicine are neither integrated with allopathic medicine nor into the national health system However, Traditional Birth Attendants and Community Health Care Workers practise at the level of primary health care The National Drug Policy has a chapter on traditional medicines, which discusses the materia medica but not the practice of traditional medicine 74

Education and training
There is no formal training in traditional or complementary/alternative medicine at any allopathic training institutions

Insurance coverage
Traditional and
complementary/alternative medicine are not covered by insurance in Zambia

Zimbabwe
Background information
During the colonial period, although huge amounts of funds were allocated to the allopathic medical sector, no budgetary provisions were made for the traditional medical sector Zimbabwes independence in 1980 marked a turning point in the long antagonistic relationship between allopathic and traditional medicine 75 The Zimbabwe National Traditional Healers Association ZINATHA was formed the same year 76, 77, having been proposed at a meeting of 100 prominent traditional medical practitioners and Government officials organized by the then Minister of Health, Dr H Ushewokunze

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

The goals of ZINATHA 76 are to promote traditional medicine and practice, promote research into traditional medicine and methods of healing, promote training in the art of herbal and spiritual healing,
supervise the practice of traditional medicine and prevent abuse and quackery, and cooperate with the Ministry of Health to establish better working relations between traditional and allopathic practitioners

Statistics
In 1994, there were 11 000 workers in the allopathic health system in Zimbabwe At the same time, ZINATHA had 24 000 qualified members 69 There are now over 55 000 traditional medicine practitioners registered with ZINATHA 75 There are four chiropractors practising in Zimbabwe 45

Regulatory situation
In Zimbabwe, the Minister of Health presides over both allopathic and traditional health sectors In 1981, two significant statutes on the practice of traditional medicine were enacted in Zimbabwe The comprehensive scope of these acts provides a sharp contrast to the general legalisation on the practice of traditional medicine adopted in other jurisdictions The Natural Therapists Act of 1981 78 regulates the organization and registration of natural therapists, a term that
includes homeopaths, naturopaths, and osteopaths It is an offence for an unregistered person to engage in the practice of these professions for gain or to claim to be a registered natural therapist Licensing legislation regulates the educational standards and practice of chiropractic 81 The Traditional Medical Practitioners Council Act of 1981 79 is one of the most comprehensive pieces of legislation on the practice of traditional medicine that has been enacted anywhere in the world Under the terms of the Act, the practice of traditional medicine includes every act the object of which is to treat, identify, analyse, or diagnose, without the application of operative surgery, any illness of the body or mind by traditional methods The Traditional Medical Practitioners Council Act recognizes ZINATHA as the association for traditional medicine practitioners in Zimbabwe 80 This legislation also created the Traditional Medical Practitioners Council The objectives of the Traditional Medical
Practitioners Council are to supervise the control and practice of traditional medical practitioners, promote the practice of traditional medical practitioners, foster research into traditional medical practice, develop knowledge of traditional medical practice, hold inquiries for the purpose of the Traditional Medical Practitioners Council Act, and make grants or loans to associations or persons where the Council considers this necessary or desirable for, or incidental to, the attainment of the purposes of the Council The Minister of Health is to appoint a registrar to establish a register of traditional medicine practitioners The Traditional Medical Practitioners Council is to grant an application for registration if it is satisfied that the applicant possesses sufficient skill and ability to practise traditional medicine and is of good character Where appropriate, the Council may grant the applicant a qualification as a spirit medium

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Africa

The Minister of Health may also
grant registration as an honorary traditional medical practitioner, with or without qualification as a spirit medium, to traditional practitioners of special standing Registered practitioners may use the title Registered Traditional Medical Practitioner or Registered Spirit Medium An unregistered person commits an offence punishable by up to two years imprisonment and/or a fine if he or she practises or carries on business for gain as a traditional medical practitioner, whether or not purporting to be registered; pretends, or by any means whatsoever holds himself or herself out to be a registered traditional medical practitioner; or uses the title Registered Traditional Medical Practitioner or any name, title, description, or symbol indicating or calculated to lead persons to infer that he or she is registered as a traditional medical practitioner Falsely claiming to be a registered spirit medium constitutes a similar offence The Council has the authority to make by-laws to define
improper and disgraceful conduct in the case of registered traditional medical practitioners A registered practitioner who is found guilty of such conduct or who is grossly incompetent is liable to disciplinary measures, which include cancellation or temporary suspension of registration

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The Americas

The Americas

Argentina
Statistics
In Argentina, an estimated 3000 physicians and 500 pharmacists practise homeopathic medicine 53 There are three practising chiropractors 45 Some kinesiologists are also members of the chiropractic association 82

Regulatory situation
Traditional medicine is regulated by Article 75-17 of the Constitution, Ley 23302, Decreto 1269-96, and Resolution 83-94 82 Only professionally qualified doctors who have graduated from recognized medical schools may legally practise homeopathy In November 1997, the Chamber of Deputies of Cordoba Province regulated the prescription of homeopathic medications 53 There is no chiropractic law

Education and training
There
are seven homeopathic schools offering regular three-year degree programmes as well as intensive programmes 53 A chiropractic college is being established 82

Bolivia
Background information
The principal specialities of traditional medicine practitioners are coca qawiri, midwifery, aysiri, materos, qulliri, milluris, qaquidores, paqos, layqiri, and rezadores 83

Statistics
In Bolivia, where 505 of the population is indigenous, the proportion of the population with access to allopathic medicine ranges from 11 to 70, depending on the region 83 There is a strong preference for traditional medicine In southern Cochabamba, over 55 of the population prefer to use traditional medicine 83 There are an estimated 5000 practising traditional health providers 83 There is one practising chiropractor 45

Regulatory situation
In 1985, the practice of traditional medicine was legally recognized 84 Laws governing traditional medicine in Bolivia include Traditional Medicine Practice

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Legal Status
of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Regulation 198771-1984, Resolución Suprema 198771-84, and Personería Juridica de la Sociedad Boliviana de Medicina Tradicional 82 In order to practice traditional medicine in Bolivia, it is necessary to have an official licence granted by the Ministry of Human Development However, only an estimated 500 traditional medicine practitioners have this permit 82 Revalidation of ones Doctor of Chiropractic degree is required to practice chiropractic The National Division of Maternal and Child Health 85 was established in 1982 with regulations on the conduct of family health activities This division is authorized to regulate traditional birth attendants There is no official programme linking traditional medicine with allopathic medicine 83 There is no formal registry of traditional medicine practitioners In 1982, the Ministry of Health established regulations on herbal medicines 84, and as of January 2001, all
homeopathic medicines must be registered 84

Education and training
In 1982, the Ministry of Health set up a training programme for traditional practitioners at allopathic medical schools 84 KUSKA a civil organization devoted to multi-disciplinary research in health, education, agriculture, ecology, and ecotourism has two schools of traditional medicine: INKARI in Cochabamba and the Kallawaya Institute in La Paz At these schools, experienced traditional health practitioners offer seminars, workshops, lectures, meetings, and trimester courses, as well as opportunities for students to observe and practice consultations and treatments Formal courses, workshops, and seminars in traditional medicine are also available through the official health sector Workshops, principally sponsored by the Catholic Church, are offered for nurses and health promoters 83 Traditional medical knowledge may also be acquired through personal revelations and inspiration In Rahay Pampa, traditional medicine is
frequently taught to successive generations within a family

Brazil
Statistics
In Brazil, there are an estimated 12 000 homeopathic physicians, 200 homeopathic veterinarians, 100 homeopathic dentists, 1300 homeopathic pharmacists, and six homeopathic laboratories 53 There is a chiropractic association in Brazil

Regulatory situation
Regulations governing traditional medicine in Brazil include La Política de Atención Integral a la Salud Indígena de FUNASA, which promotes respect for the traditional systems of health of indigenous communities 82 In 1980, the Brazilian Medical

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The Americas

Association recognized homeopathy as a medical speciality In 1988, the Government recognized homeopathy and included it in the National Health System 86 Since 1995, the Federal Council of Pharmacy has recognized and standardized the title of Specialist in Homeopathic Pharmacy 53

Education and training
As of 1991, physicians seeking homeopathic specialization must complete a 1200-hour course: 450
hours of theory, 450 hours of practice, and 300 hours of monographs The Feevale Central University and University of Anhembi Morumbi offer chiropractic programmes recognized by the World Federation of Chiropractic

Canada
Background information
In Canada, complementary/alternative and traditional medicines are known as natural health products and are subject to food and drug regulations Natural health products include herbal medicines; traditional Chinese, ayurvedic, and native North American medicines; homeopathic preparations; and vitamin and mineral supplements There are a number of associations of complementary/alternative medical practitioners In 1983, the Chinese Medicine and Acupuncture Association of Canada CMAAC was established as a national organization 87 CMAAC works to unite practitioners and to lobby the Government for the regulation of traditional Chinese medicine and acupuncture In 1987, the World Federation of Acupuncture and Moxibustion Societies was formed with the
support of the World Health Organization In 1996, allopathic physicians interested in traditional and complementary/alternative medicine in Canada created the Canadian Complementary Medical Association 88

Statistics
Several reports from the late 1990s found that between 15 and 70 of the Canadian population had used complementary/alternative medicine in the proceeding six to 12 months 89, 90, 91 A 1999 study, for example, reported 70 of Canadians had used one or more natural health products in the preceding six months, but only 24 consulted one or more complementary/alternative health practitioners 92 The use of complementary/alternative medicine is increasing in Canada 92, 93 The following chart represents findings of the 1999 Berger Monitor survey on the sixmonth use of complementary/alternative health practitioners in 1993 and 1999 92 According to a study by the Fraser Institute 92, of the Canadians who have used complementary/alternative medicine, 36 have consulted a chiropractor,
23 have used relaxation techniques, 23 massage, 21 prayer, 17 herbal therapies, 12 special diet, 12 folk remedies, 12 acupuncture, 10 yoga, 8 self-help groups, 8 lifestyle diets, and 8 homeopathy
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Respondents who had consulted a practitioner of complementary/alternative medicine Complementary/Alternative medicine Chiropractors Massage/masseuses Herbalists Acupuncturists Homeopaths Reflexologists 1993 9 4 1 1 1 1 1999 12 10 3 2 2 2

A significant proportion of Canadians report spending 30 Canadian dollars or more per month on complementary/alternative health services or natural health products From 1996 to 1997, a total of 38 billion Canadian dollars was spent on complementary/alternative health care in Canada 92 The amount spent on vitamins and food supplements is rising by 20 a year 88 In general, the use of complementary/alternative health care in Canada 94 is higher at younger ages,
among women, among people with higher formal education and higher incomes, and in the West Canadian users of complementary/alternative medicine have more good health habits and better overall health However, these differences are partly minimized when adjusted for age, education, and household income Users of complementary/alternative medicine make fewer visits than nonusers to both allopathic general practitioners and specialists The most common reasons for which patients consult complementary/alternative practitioners are problems of the musculoskeletal system and connective tissue These complaints account for 56 of consultations Other problems include respiratory diseases, injuries, poisonings, ill-defined conditions, and special investigations Complementary/alternative practitioners provide most complementary/alternative treatments However, allopathic physicians are increasingly involved in the provision of complementary/alternative medicine There are approximately 4500
chiropractors practising in Canada 45

Regulatory situation
Canadian physicians choosing to provide alternative treatments must comply with guidelines set by the relevant provinces College of Physicians and Surgeons The Federal Food and Drug Act does not recognize traditional Chinese doctors, naturopaths, homeopaths, or herbalists However, the recent Federal Report supra noted that access to quality health care is tied to the education, training, and licensing of practitioners and products As such, it seems likely that Canada will soon give formal recognition to more complementary/alternative practitioners

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The Americas

Most of the health care legislation, such as the Canada Health Act, focuses on allopathic medical practitioners However, the regulation of professionals is a provincial matter, and many provinces have become tolerant of non-allopathic health care providers Ontarios Regulated Health Professions Act, SO 1991, c18 is an example of the more inclusive legislation
adopted by a number of provinces On 26 March 1999, the Federal Government accepted all 53 recommendations made by the Standing Committee on Health in their report, Natural Health Products: A New Vision While the Health Ministers formal acceptance of these recommendations will not immediately change the status of natural health products in Canada, the policy direction has been set A transition team was created and it is now working to implement these recommendations One of the recommendations led to the creation of the Office of Natural Health Products, which regulates the safety, quality, and proper labelling of these products It is also responsible for supporting epidemiological and social science research and for the dissemination of information to Canadian consumers to enable them to make informed self-care decisions Beginning in the spring of 2000, the Office of Natural Health Products invited comments and suggestions from a wide range of interested Canadians — including
manufacturers, distributors, and retailers of natural health products — on the formation of a regulatory framework for natural health products, covering their production, import, sale, and use in Canada 95 In March 2001, the Proposed Regulatory Framework for Natural Health Products was drafted The Framework contains provisions for natural products sold in Canada 96, including licensing of products and sites, good manufacturing practices, labelling and packaging, and reporting of adverse reactions The intent is to address consumers concerns for safety and product quality without being unduly restrictive of the natural health product industry The Expert Advisory Committee on Complementary Medicines was recently formed to provide scientific advice to the Therapeutic Products Programme of Health Canada on issues regarding the safety, quality, and efficacy of natural health products 97

Traditional Native North American medicine
In the Yukon Territory, the Health Act of 1990 98 endorses
traditional native North American medical practices Section 5 includes provisions to secure aboriginal control over traditional aboriginal nutritional and healing practices and to protect these healing practices as a viable alternative for seekers of health and healing services The Minister of Health also promotes mutual understanding, knowledge, and respect between providers of health and social services offered within the health and social service system and the providers of aboriginal nutrition and healing In Ontario 99, traditional birth attendants providing midwifery services to aboriginal persons or members of an aboriginal community are exempt from the general rule that restricts managing labour or conducting the delivery of a baby to allopathic physicians, nurses, and midwives Traditional birth attendants can adopt

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

the title Aboriginal Midwife as a professional designation and
portray themselves as qualified to practise in Ontario

Manipulative therapy
In at least nine Canadian provinces, special statutes restrict the practice of manipulative therapy to persons who fulfil specific requirements and have been registered and/or licensed 100 All provinces have laws regulating the practice of chiropractic In Ontario, manipulative therapy is regulated under the Regulated Health Professions Act of 1991 101 and the Chiropractic Act of 1991 101 The Health Professions Act states that it is an offence for a person to move the joints of the spine beyond the individuals usual physiological range of motion using a fast, low-amplitude thrust unless the person is authorized by one of the listed health profession acts, such as the Chiropractic Act The Chiropractic Act limits the practice of chiropractic to members of the College of Chiropractors The legislation permits the use of the title Doctor by members of the College of Chiropractors of Ontario No offence is committed
under the Health Professions Act when an otherwise impermissible joint movement is performed in the course of treating a person by prayer or spiritual means in accordance with the tenets of the religion of the person giving the treatment or where the treatment is performed by an aboriginal medical practitioner providing traditional medicine services to aboriginal persons or members of an aboriginal community Chiropractors have professional status in Alberta 102 In 1994, Alberta introduced requirements for the continuing education of licensed chiropractors 103 Practitioners must acquire 75 hours of continuing education every three years as a condition for renewal of their annual licence Full credit is given for participation in programmes accredited with listed professional bodies Credit may also be given for other educational activities with an emphasis in chiropractic, such as research or university studies In Saskatchewan, the Chiropractic Act of 1994 104 repeals the 1978 Act on the
same subject and prohibits anyone other than a member of the Chiropractors Association from using the titles Chiropractor, Doctor of Chiropractic, or any word, title or designation, abbreviated or otherwise, to imply that the person is engaged in or qualified to engage in the practice of chiropractic Section 22 of the Act lays out the restrictions on and exemptions to the practice of chiropractic in Saskatchewan:
1 No person other than a practising member shall engage, for fee or reward, in the practice of chiropractic 2 Subsection 1 does not apply to a person providing first aid or temporary assistance in cases of emergency 3 Nothing in this Act extends to or interferes with the privileges conferred on any person who practices a profession, trade or calling that the person is licensed or authorized to practise pursuant to any other Act

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The Americas

Traditional Chinese medicine and acupuncture
Health Canada, through the Therapeutic Products Programme, is actively pursuing the
National Initiative on Traditional Chinese Medicine 97 British Columbia, Alberta, and Quebec include acupuncture among their regulated health professions Saskatchewan and the Yukon Territory have guidelines on the practice of acupuncture A 1993 report by the British Columbia Health Professions Council 105 recommended the designation of acupuncture as a health profession with three limitations: acupuncture should not be used in the treatment of serious illnesses, such as cancer; acupuncture should not be used as anaesthesia during surgery, unless supervised by a physician or dentist; and the patient must be told to consult an allopathic physician, dentist, or naturopath if acupuncture fails to improve the patients condition within two months The Ministry of Health in British Columbia has agreed that traditional Chinese medicine and acupuncture should be regulated In April 1998, the British Columbia Health Professions Council 106 recommended designating the profession of traditional
Chinese medicine as a health profession under the Health Professions Act The Council also recommended that a college be established to govern both practitioners of acupuncture and practitioners of traditional Chinese medicine This college will ensure that practitioners complete adequate training based on Government standards The Health Disciplines Act of 1980 107 sets out a framework for the recognition and regulation of health disciplines in Alberta Acupuncture is governed by the accompanying Acupuncture Regulation In order to be registered as a member of the acupuncture health profession, an applicant, who need not be an allopathic physician, must complete both an approved programme of study and an examination Competence in English must also be demonstrated However, this requirement may be waived where the applicant practices under the supervision of an English-speaking acupuncturist Before acupuncture treatment is administered in Alberta, the patient must have consulted with an
allopathic physician or dentist and informed the acupuncturist of this Acupuncturists are prohibited from implying to patients that acupuncture cures diseases or advising patients to discontinue treatment recommended by an allopathic physician or dentist If an improvement in the patients condition does not occur within six months, the patient must be referred to an allopathic physician or dentist In Alberta, permissible technical modes of practice are restricted to needle acupuncture, electro-acupuncture, moxibustion, cupping, and acupressure Only noninvasive measuring equipment may be used in patient examinations The Acupuncture Regulation also lists a number of procedures that cannot be delegated to non-acupuncturists, including taking patients medical histories, using diagnostic instruments or therapeutic devices on patients, and inserting or removing acupuncture needles
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

The Quebec
Medical Act of 1973 108 required the Bureau of the Ordre des Médecins to enact rules for the training, practice, and annual registration of allopathic physicians practising acupuncture Rules were also introduced concerning the practice of acupuncture by non-physicians 109 Non-physician practitioners must hold a recognized college diploma and pass an acupuncture exam set by the Quebec medical regulatory body Detailed patient records must be kept covering matters such as diagnoses made, treatments rendered, and details of patient consultations with other medical professionals, including allopathic physicians Under Section 44 of the Medical Act of Quebec, no person can claim to be an acupuncturist unless he or she is a registered non-physician or allopathic physician who has undergone the required training in acupuncture Moreover, non-physician practitioners are precluded from using the title Doctor or any title that may infer that status unless they have a doctorate in acupuncture, in
which case they may use the title Doctor of Acupuncture A number of medical professional regulatory bodies in Canada have published guidelines relating to acupuncture In Saskatchewan, such guidelines were drawn up by the College of Physicians and Surgeons 110 These permit the practice of acupuncture by allopathic physicians who hold a recognized diploma The guidelines do not mention the practice of acupuncture by non-physicians Guidelines issued by the Yukon Medical Council 111, however, state that acupuncture is a medical procedure that should only be performed by allopathic physicians or dentists with an appropriate level of training The guidelines do not permit physicians to delegate acupuncture procedures to others, such as physiotherapists, except in an approved institutional setting such as a public hospital The reasoning behind this is that the Yukon guidelines acknowledge that acupuncture has a valid role in patient management but warn that, based on current knowledge, it does
not have a curative effect on the fundamental disease process The guidelines strongly endorse two training programmes recognized by the College of Physicians and Surgeons in British Columbia, but stop short of requiring completion of a programme of study

Naturopathy
Naturopathy is regulated in Alberta, Manitoba, and Saskatchewan 112 In each of these three provinces, naturopaths must meet specified educational requirements and be registered in order to practise naturopathy or use the title of Naturopath Educational requirements include the completion of a four-year college programme Manitoba and Saskatchewan also require an examination in anatomy, physiology, chemistry, general diagnosis, and the principles of naturopathy In all provinces, naturopaths are prohibited from performing certain health care activities, such as the prescription and administration of allopathic drugs, obstetrical practice, and surgery In Alberta, two corresponding provisions in the Chiropractic Profession Act
of 1984 113 forbid dual registration as a naturopath and chiropractor One states that

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The Americas

registered chiropractors cannot practise naturopathy and the other that practising naturopaths cannot be registered as chiropractors

Education and training
Complementary/alternative training programmes are provided by private institutes, universities, and community colleges, but there is no universal system of accrediting and validating programmes 92 Though there is no standardized complementary/alternative component in allopathic curricula, most medical schools offer some form of training in complementary/alternative medicine to their students of allopathic medicine 114, but this usually takes the form of a two-hour to four-hour lecture The 1998 Standing Committee Report states that there is increasing interest in having more training programmes and more standardized training curricula in complementary/alternative medicine for both complementary/alternative and allopathic
providers In 1985, the Institute of Chinese Medicine and Acupuncture 87 was established to promote the training standards of the Chinese Medicine and Acupuncture Association of Canada Students interested in entering the four-year programme offered by the Institute are required to have first completed three years of coursework in the sciences at a recognized university There are two chiropractic colleges in Canada recognized by the World Federation of Chiropractic 81

Insurance coverage
Coverage of complementary/alternative therapies by provincial health insurance plans and workers compensation boards is selective and minimal Some provincial health insurance plans cover chiropractic Alberta, British Columbia, Manitoba, Ontario, Saskatchewan, and New Brunswick only for seniors who purchase extended coverage, and one covers naturopathy British Columbia 92 Osteopathy is covered in Alberta 115 Workers compensation boards cover chiropractic in all provinces and territories Workers
compensation boards in British Columbia, Newfoundland, Ontario, Prince Edward Island, Quebec, and the Yukon Territory cover acupuncture on a case-by-case basis or on prescription by an allopathic physician 92, 116 The Alberta Health Care Insurance Plan discontinued its coverage of acupuncture on 1 March 1994 Patients are now solely responsible for the cost of acupuncture treatment 117 About 96 of the private health insurance coverage in Canada is group policies purchased primarily by employers This insurance is a non-taxable benefit so long as, among other things, reimbursement is only provided for qualified medical practitioners, which include chiropractors, osteopaths, naturopaths, therapists, acupuncturists, and dieticians 92

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Chile
Background information
The Mapuche Community Hospital 118 offers traditional and allopathic treatment options Practising at the hospital are traditional
medical providers, bonesetters, and two allopathic doctors The hospital is affiliated with Mapuche University Both the hospital and the university receive financial support from the Ministry of Health

Statistics
In Chile, 10 to 12 of the population is indigenous 118 Seventy-one per cent of the population uses complementary/alternative medicine 82 There are between 2000 and 10 000 traditional health practitioners in Chile Principal traditional medical specialities are herbalism, spiritualism, traditional birth attendance, aromatherapy, bach flowers, acupuncture, bonesetting, and chiropractic 83

Regulatory situation
National policies emphasize equal treatment for traditional and allopathic medicine 118 Homeopathy and the Homeopathic Pharmacopoeia are legally recognized The Public Health Institute recognizes homeopathic remedies 53 Traditional and complementary/alternative medicine are regulated by Ley 19253 of October 1993, which takes into consideration their role in public health 62
The Ministry of Health oversees the Unit of Traditional Medicine, which also governs complementary/alternative medicine, and the Unit of Indigenous Community Health The Unit of Traditional Medicine was established in August 1992 119 Its objectives are to set standards for the safety and efficacy of traditional medicines and to encourage the use of proven traditional medicines, including incorporating them into allopathic health programmes 83 The Unit of Indigenous Community Health develops the primary health care system at the community level 118 The Health Ministry issues licences for the practice of traditional medicine, but very few traditional medicine practitioners are licensed Unlicensed traditional health practitioners risk fines or the closure of their offices 83 There is no official registry of traditional medicine practitioners

Education and training
Mapuche University 118 offers programmes in traditional knowledge leading to Bachelors, Masters, and Doctorate degrees
Students of these programmes may choose to specialize in traditional medicine The university also cultivates medicinal plants and conducts research on traditional medicine Most students of traditional medicine learn through apprenticeships with experienced providers In some cases, these are family members Some practitioners receive medical insight through personal revelations

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Traditional medical training for official allopathic health personnel is not very extensive and consists of occasional informative events that may or may not be included in official training programmes 83 The Government has recognized homeopathy as a medical system, but there are no officially recognized training programmes or examinations 86 A chiropractic college is being established 81

Colombia
Background information
Traditional medicine is widely practised in Colombia 120

Statistics
Forty per cent of the population has used complementary/alternative medicine 82 There are six chiropractors
practising in Colombia 45

Regulatory situation
The Congress of Deputies officially recognized homeopathy as a system of medicine in 1905 In 1914, the Government standardized training requirements for homeopathic doctors and established a system of title protection 86 Only allopathic physicians may practice homeopathy The Institute of Medicaments and Food regulates the manufacturing of homeopathic remedies Integration of homeopathy into the Public Health Services is planned 53 Chiropractors are not permitted to use X-ray equipment However, chiropractors may request radiologists to provide X-ray services for their patients

Education and training
Homeopathy is taught in three schools authorized by the Ministry of Education The regular three-year courses are limited to licensed allopathic physicians 53

Costa Rica
Background information
There are no associations of traditional medicine practitioners in Costa Rica Women do not practice traditional medicine 83

Statistics
There are at
least 19 practitioners practising indigenous traditional medicine 83 There are two chiropractors practising in Costa Rica 45

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Regulatory situation
Though the production of traditional medications is regulated, the practice of traditional medicine is ignored in official health laws There is no registry of traditional health practitioners in Costa Rica Traditional medicine practitioners are not licensed, nor are they sanctioned for practising medicine This may soon change, however, as the Legislative Assembly is currently considering a bill that would regulate traditional medicine There are no official programmes linking traditional medicine with allopathic medicine 83 The College of Physicians and Surgeons recognized homeopathy as a medical speciality in 1994 By a pronouncement of the Sala de Jurisdicción Constitucional of the Supreme Court on 9 January 1998, allopathic medical doctors
can be accredited postgraduate homeopathic studies under the Medical Speciality Regulations Homeopathy is thereby treated as a branch of allopathic medicine and governed by the same regulations as other allopathic specialities 53 A chiropractic law is pending In 1996, a multidisciplinary committee composed of representatives from the Ministry of Health and colleges of pharmacy in Costa Rican universities convened to formulate regulations on herbal medicines 121 In 1998, the committee published Decree 26782S regulating the industrialization, registration, commercialization, and publication of herbal preparations and herbal products

Education and training
There are no institutions officially responsible for teaching traditional medicine 83 Postgraduate homeopathic studies are available through an institution recognized by the College of Physicians and Surgeons 53

Cuba
Statistics
Sixty per cent of the population use traditional or complementary/alternative medicine 122 Sixty per cent of
allopathic physicians are trained in traditional or complementary/alternative medicine 122 There are 579 registered herbal products made in Cuba An additional 295 registered herbal products are imported 122

Regulatory situation
Following the 1959 revolution, Cuban health authorities forbade the practice of traditional medicine by anyone except traditional birth attendants Traditional birth attendants were slowly integrated into Cubas health services as ancillary staff 123

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The 1983 Cuban Public Health Law 124 puts forth strict requirements for the qualification of health care workers Traditional medicine practitioners are not granted exemplary status Section 90 states the following:
Medical, dental, and pharmaceutical activities and other health professions shall be practised by persons who have followed special courses and hold a qualification conferred by a centre of higher education in Cuba or an equivalent foreign qualification; the activities of health
technicians, qualified staff, and other health workers shall be practised by persons who have followed special courses and hold a qualification granted by an institute, school, polytechnic, or centre for technical training in health

A 1988 decree 125, which contains regulations for the implementation of the Public Health Law, prohibits the practice of medicine by persons who do not meet these qualification criteria In 1992, the Ministry of Health officially recognized homeopathy 53 National and international homeopathic congresses were scheduled during 1997 and 1998, and there are an increasing number of physicians using homeopathic remedies Homeopathic dispensaries are spread all over the country A standard good manufacturing practice for the manufacture of homeopathic remedies has been accepted In 1992, acupuncture was integrated into the Cuban health care system 122 In 1995, the Traditional Medicine Programme 122 was instituted, prioritizing the cultivation of medicinal plants, the
education of practitioners, research into traditional medicine, and the integration of traditional medicine into the national health care system

Education and training
Courses on introductory and advanced homeopathy are given at the medical and pharmaceutical schools

Dominican Republic
Background information
The principal traditional medical specialities are vodun, ensalmadorismo, and herbalism 83

Statistics
There are between 2000 and 3000 practitioners practising traditional health in the Dominican Republic 83

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Regulatory situation
Although there is an official programme linking traditional medicine with allopathic medicine, there is no official registry of traditional health practitioners, and traditional medicine practitioners are not licensed in the Dominican Republic 83

Education and training
The Ministry of Health and Social Welfare offers training programmes for traditional
birth attendants in hospitals and health centres throughout the Dominican Republic The Pan American Health Organization assisted in revising these programmes in 1973 120, 126 There are no other institutions that teach traditional medicine Instead, traditional medicine is taught through apprenticeships with experienced practitioners Traditional medical knowledge may also be transmitted through dreams and personal revelations There are no official training programmes in traditional medicine for allopathic health personnel 83

Ecuador
Background information
In Ecuador, there are associations of traditional medicine practitioners that work at regional and local levels Some of these associations were created by indigenous organizations and others by state initiatives 83

Statistics
There are nine chiropractors practising in Ecuador 45

Regulatory situation
Section 174 of the Ecuadorian Health Code of 1971 127 limited the practice of physicians, pharmacists, dentists, midwives, and other
health practitioners to persons holding qualifications granted or validated by the University of Ecuador Under Section 179, health authorities were responsible for the detection and suppression of the illegal practice of medicine and allied professions without prejudice to normal judicial proceedings By Section 180, It shall be automatically assumed that a person is illegally practising [medicine] if, without holding a legally conferred qualification, diploma, or certificate, he possesses equipment or materials for such practice In the beginning of 1998, indigenous peoples proposed a bill to regulate traditional medicine 83 This bill was passed in June and came into force in August 1998 Based on this bill, the Constitutional Assembly included two articles in the Constitution that stipulate principles on which the practice of traditional medicine must be based Chapter 4, Section 4, Article 44 reads as follows:
The State will formulate national health policy and will monitor its
application It will control the operation of the entities of this sector It will acknowledge, respect and promote the development of traditional and alternative medicine, the practice

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of which will be regulated by law and will promote scientific and technological advancement in the health area subject to bio-ethical principles

The Constitution of the Republic, Chapter 5, Article 84, Numeral 12 establishes collective rights:
to the systems, knowledge and practice of Traditional Medicine, including the right to the protection of ritual and sacred places, plants, animals, minerals and ecosystems of interest to the State from the point of view of traditional medicine

There is no registry of traditional medicine practitioners in Ecuador and no licensing procedure for practitioners of traditional medicine There is no official institution in charge of regulating traditional medical practice 83 There is, however, the National Division of Indigenous Health, which was
created by a ministerial resolution to promote the development of traditional medicine 82 In Ecuador, there are no specific programmes linking traditional medicine with allopathic medicine But, with increasing interest in traditional medicine, particularly Quichua medicine, the State is focusing more attention on official linkages Some efforts have been made to coordinate with institutions and organizations affiliated with traditional medicine in Ecuador 83 In 1983, the Government recognized homeopathy as a medical practice 86 The Ecuadorian Medical Federation began officially recognizing homeopathy as a medical speciality in 1988 It is also recognized in the Constitution of the National Assembly 53 There is no chiropractic law

Education and training
Universidad Andina Simón Bolívar, a private Andean university in the city of Quito, is responsible for teaching traditional medicine in Ecuador Offerings include certificate programmes, seminars, workshops, and meetings The Ministry of
Public Health established training courses for traditional birth attendants in 1974 with the aim of incorporating them into the health services of rural areas 120, 128 There is no official training in traditional medicine offered to allopathic health personnel 83

Guatemala
Background information
The principal traditional medicine specialists in Guatemala are traditional birth attendants, bonesetters, herbalists, spiritualists, chupadores, massage therapists, and practitioners who specialize in muscle tears 83 A 1977 order established the Guatemalan Association of Acupuncture 130 The Association promotes the knowledge and the study of acupuncture and facilitates professional contacts with

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

acupuncturists in other countries Membership in this association does not license individuals to practise acupuncture The University of San Carlos is undertaking research on medicinal plants
129

Statistics
There are approximately three traditional health practitioners per municipality About 250 traditional health practitioners are registered with the TOTO-Integrado Association 83

Regulatory situation
The laws regulating traditional medicine in Guatemala include Acuerdos de Paz, the Political Constitution, the Health Code, and Regulations for the Quality Control of Herbal Products 82, 129 The Health Code defines, classifies, and outlines registration and licensing requirements for all medicines The Regulations for the Quality Control of Herbal Products classifies herbal products and registration procedures for them 129 Although there is no official licence to practise traditional medicine, 10 of traditional medicine practitioners have a permit to practise These permits are issued upon completion of a training course organized by the Public Health Ministry and local health centres The permits are not available throughout the country Traditional medicine practitioners
without permits may practise within their own communities, but they are rejected by institutions and risk being sued for malpractice 83 A registry of traditional health practitioners is currently being developed The programme of the Integral Healthcare System links traditional and allopathic medicine 83

Education and training
Courses in traditional medicine are available through the Public Health Ministry Additionally, CDRO in Totonicapan, Barefoot Doctors in Chinique, and Quiche Guatemala offer technical studies, seminars, informal presentations, and workshops that include instruction in traditional medicine Traditional medicine is also learned through apprenticeships, which may include practice, observation, readings, workshops, and videos How to treat a particular illness is sometimes learned as a result of having suffered from it oneself Personnel in the official health services do not receive training in traditional medicine 83

Honduras
Regulatory situation
Section 130 of the
Honduran Health Code of 1966 131 states the following:

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The practice of naturopathy, homeopathy, empiricism, and other occupations considered to be harmful or useless by the Secretariat for Public Health and Social Welfare shall be prohibited in the country

Practitioners of traditional medicine are not granted exemplary status There is no chiropractic law

Jamaica
Statistics
More than 8000 medicinal products, including 610 vitamins, 90 minerals, and 60 herbal remedies, were registered and licensed in Jamaica between 1975 and 2000 Of the 403 medicinal products registered in 1999, 95 were of herbal origin 132 Herbal products are a multi-million dollar industry in Jamaica 133

Regulatory situation
In 2000, the Parliament considered revisions to the Food and Drugs Act of 1964 and the Food and Drugs Regulations of 1974 The revisions 134 were aimed at ensuring the safety, efficacy, and quality control of herbal products In 2001, the Parliament approved the revisions,
under which the following applied: Products are subject to approval, requirements for which are similar to, but not as elaborate as, those for pharmaceuticals The onus is on manufacturers to substantiate quality, efficacy, and safety Products containing vitamins and minerals in less than three times the recommended daily amount are classified as foods and do not require formal registration Vitamins containing more than three times the recommended daily amount are classified as drugs Herbal products require registration if they contain substances used for conditions that normally need medical intervention Herbal products containing substances used for self-limiting conditions that do not normally require medical intervention do not require registration Registered products, like drugs, require a permit for importation Products that are not registered do not require a permit for importation; however, proof of quality is required annually or such other time, as deemed necessary The
revisions define an herbal medicine as a medicinal product consisting of a substance produced by subjecting a plant or plants to drying, crushing, or any other process or of a mixture whose sole ingredients are two or more substances so produced or of a mixture whose sole ingredients are one or more substances so
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

produced and water or some other inert substance This definition is adapted from Section 132 of the United Kingdoms Medicines Act of 1968 There is no chiropractic law Chiropractors are recognized as medical practitioners but prohibited from providing physical therapy services and from using the title of Doctor

Mexico
Background information
The principal traditional medical specialists are traditional birth attendants, herbalists, bonesetters, curanderos, snake culebreros, shamans, spiritualists, and sobadores 83, 135

Statistics
Traditional birth attendants preside over more
than two-thirds of childbirths in Mexico There are 55 to 60 chiropractors practising in Mexico 45 There are about 3000 homeopathic physicians 53

Regulatory situation
In 1980, the Mexican Institute of Social Security created a unit to study traditional medicine and medicinal plants Later, a programme was introduced to foster the integration of traditional and allopathic systems of medicine The programme was designed to involve traditional practitioners in the health activities of 3500 rural medical units within the Social Security System 135 The Mexican Institute of Social Security is also working with the national plan for depressed zones and marginalized groups Coplamar to integrate allopathic and traditional medicine 83 Mexicos registry of traditional medicine practitioners is kept by the National Indigenous Institute and the Mexican Institute of Social Security Traditional medicine forms an integral part of the health care delivery system Although there is no official licence for
the practice of traditional medicine, other than for traditional birth attendants, the authorities are currently working on creating such a licence Proposals for a bill to regulate traditional medical practice, aside from that of traditional birth attendants, have been made since 1989 83 The Regulations of 20 October 1976 136 established a distinct sector of the health field for qualified traditional birth attendants Section 2 of the Regulations define qualified traditional birth attendants as persons who have been attending deliveries without training and are licensed and qualified under the Regulations Licences are issued by health centres following the completion of a training course Section 9 states that entry to the course is restricted to persons who have attained majority, are literate, and are recognized by the communities in which they work as carrying out obstetric activities Section 13 specifies that traditional birth attendants may attend

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women in their
community during normal pregnancy, delivery, and the puerperium provided that they notify a health centre They may also prescribe appropriate medications in accordance with the instructions of the Secretariat for Health and Welfare There is a proposal to add provisions to the General Health Law that would regulate the quality control of medical activities, establishments, products, and services Chapter 4 of these proposed changes covers herbal medicines Homeopathy has been accepted and integrated into the national health system in Mexico In 1895, a presidential decree was issued to establish a national homeopathic school; to regulate training requirements for homeopathic doctors, including title protection; and to establish a national homeopathic hospital In 1996, the Government recognized homeopathy as a medical speciality 86 Licensing legislation regulates chiropractic educational standards and practice 81 Chiropractors have been licensed since 1988 Credentials must be periodically
revalidated 65

Education and training
The National Indigenous Institute has a unit dedicated to the organization, coordination, and instruction of traditional medicine In some states, the Institute coordinates with associations of traditional medicine practitioners to provide workshops, courses, and other activities where practitioners can gather and share their knowledge Traditional medicine is taught through apprentice programmes, including practice, observation, and workshops In some cases, families are known for a particular speciality The Mexican Institute of Social Security offers informal presentations and workshops on traditional medicine, medical anthropology, and community work techniques to personnel working in the official health services 83 There are several schools and hospitals teaching homeopathy Homeopatia de Mexico, an association for homeopathic practitioners, obtained official recognition for its postgraduate school in 1996 53 A chiropractic college is presently
being established 81

Nicaragua
Statistics
There are 2500 persons registered in the registry of traditional medical practitioners The principal traditional medical specialities are traditional birth attendance, herbalism, spiritualism, and massage 83

Regulatory situation
The Department of Traditional and Popular Medicine of the Ministry of Health regulates traditional medicine in Nicaragua 82 No licence is required to practice

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

traditional medicine While there are no restrictions or legal barriers that limit its practice, the Nicaraguan Academy of Homeopathic Medicine is working towards gaining official status for homeopathy The National Council of Universities supports homeopathy and accepts its practice by allopathic doctors 53 A regulation on the use of plant medicines 83 is currently being developed and will eventually be under the responsibility of the Department of Drugstores of
the Ministry of Health according to the General Law of Medication and Drugstores

Education and training
In 1989, the Ministry of Health established the National Centre of Popular and Traditional Medicine 62 with the objective of training health promoters and allopathic medical and paramedical persons in these fields In 1991, courses in traditional medicine were introduced into allopathic nursing schools, and allopathic nurses began being trained in basic plant therapy and medical anthropology After the change of government in the same year, the Centre became a non-profit foundation independent from the Ministry of Health Along with the National Autonomous University of Nicaragua and several institutions under the leadership of the Ministry of Health, the Centre forms a part of the National Commission for Essential Investigation Cecalli, Soynica, the School of Agriculture, UNAN, Real Nicaraguense de Sistemas Traditionales, and MINSA also offer training in traditional medicine Though
allopathic health personnel may follow these courses, training in traditional medicine is not offered through the official health services 83

Panama
Background information
The Government of Panama has made considerable efforts to register and train traditional birth attendants and to integrate them into the countrys health care system 137

Statistics
Although there is only one chiropractor practising in Panama, both the United States and Canada have been sending chiropractic missions to Panama since 1997 65

Regulatory situation
Law 4376 of August 1999 created the Area of Traditional Medicine under the National Directorate of Health Promotion The Area is charged with developing a strategy of action for the incorporation of traditional medicine into primary health care, including research on medicinal plants The Carta Organica Administrativa de la Comarca 138, following Executive Decree 194 of 26 August 1999, governs traditional medicine in the Ngöbe-Buglé region

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Americas

Article 258 of the Carta classifies traditional medical specialities, the services they offer, and their legal status regarding diagnosing ailments and dispensing medicines This same article recommends that traditional and allopathic medical practitioners cooperate and collaborate together Article 257 creates the Special Medical and Technical Commission to bring together traditional medicine and allopathic medicine Articles 261 and 262 refer to the organization of botanical gardens for the scientific study of medicinal plants and propose the publication of texts and health manuals Article 266 defines the functions of the Special Medical and Technical Commission, including the following: coordinating with the national health system; certifying traditional health practitioners; organizing the methodology for a study of traditional medical practice; educating the public about scientific investigations into the methods, uses, and effects of traditional medicine; preparing a
health infrastructure plan for the community; studying the medical history of the Ngöbe-Buglé In recognition of the existence, contribution, and importance of traditional medicine to the health of indigenous communities, Article 3 of Law 36 of 3 October 2000 138, a nationally applicable law, created an autonomous institute of indigenous traditional medicine The institute recognizes, protects, and promotes traditional knowledge related to the medicinal properties of plants, access to genetic resources in indigenous regions, and the return and distribution of benefits from the commercial application of this knowledge In Article 4 of Law 36, it is stated that at the institute there will be one representative of each indigenous community, one representative of traditional medicine practitioners, the Minister of Health or designate, and one representative of the Panamanian Medical Association Article 7 establishes traditional medicine as the patrimony of the communities from which it comes
and advances the conservation and promotion of traditional medicine in indigenous areas It also states that allopathic medicine should not be forced upon these communities Article 8 recognizes traditional health systems in indigenous communities Article 10 mandates indigenous authorities to mount a campaign of protection, promotion, and conservation of traditional medical practices Article 21 orders the establishment of a Faculty of Medicine and a Faculty of Pharmacy of indigenous materia medica and their use in the treatment of sickness The

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

rest of the articles of Law 36 refer to access to resources, benefit sharing, intellectual property, and the commercialization of medicinal plants Licensing legislation regulates chiropractic educational standards and practice 81 A chiropractic law was adopted in 1967, permitting chiropractors to examine, analyse and diagnose the human body by way
of any method physical, chemical, electrical, or the use of x-ray and provides for the adjusting, manipulation and treating of the human body 65

Peru
Background information
The principal traditional medical specialities are herbalism, traditional birth attendance, and bonesetting 83 The National Institute of Traditional Medicine has 17 branches throughout the country It disseminates information and conducts research on traditional medicine In particular, the Institute is responsible for a research programme in traditional medicine known as the General Direction of Research and Technology 83 This programme is responsible for carrying out clinical research, conducting medical anthropological research, gathering demographic statistics, and facilitating the integration of traditional and allopathic medicine It is also charged with promoting the protection, control, and cultivation of medicinal plants

Regulatory situation
Traditional medicine was officially prohibited in Peru in 1969, but
the prohibition was not enforced 120 The National Institute of Traditional Medicine is the official institution working on the regulation of traditional medicine 83 The Congress of the Republic is discussing potential laws and statutes for the regulation of traditional medicine 83 A bill on traditional medicine was proposed in 1999, but has not yet been passed Although there is no official licence in Peru for the practice of traditional medicine, the Ministry of Health issues practice permits A registry of traditional medicine practitioners is currently being developed in Peru The Ministerial Decree for the Creation of Rural and Urban Peripheral Health Services places priority on the investigation and preservation of traditional medicine 82 Section 4 of the Supreme Decree 010-97-SA of 1997 139 regulates plant medicines and natural resources of medicinal value It defines and classifies plant medicines and natural resources of medicinal value, outlines procedures and requirements for
their registration, and details the requirements that must be met for the manufacture and sale of plant medicines

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Education and training
Students of traditional medicine learn via apprenticeships involving practice, observation, and videos as well as from personal experiences, revelations, and dreams In some cases, medical skills are passed down within families The National Institute of Traditional Medicine provides official training programmes in traditional medicine In addition, some universities and non-governmental organizations registered with the Ministry of Health offer programmes in traditional medicine for traditional medicine practitioners Some universities offer seminars, workshops, meetings, and conferences in traditional medicine for students studying allopathic medicine Courses, workshops, and informal presentations are also offered to official health personnel 83

United States of America
Background information
Complementary/alternative medicine has a
substantial presence in the United States health care system Both public and professional interest in these therapies is increasing The College of Physicians and Surgeons at Columbia University and the Falk Institute of Pittsburgh University have research projects devoted to assigning an integrative role in the health care system to complementary/alternative therapies In 1991, Congress established the Office of Alternative Medicine within the National Institutes of Health to encourage scientific research in the field The National Institutes of Health Revitalization Act of June 1993 140 was a landmark It expanded the Office of Alternative Medicine within the National Institutes of Health from a staff of six to a staff of 12 The Offices objectives include the facilitation and evaluation of alternative medical treatment modalities, including acupuncture and Oriental medicine, homeopathic medicine, and physical manipulative therapies The Office is mandated to set up an advisory council,
establish an information clearinghouse to exchange information on traditional medicine, support research and training, and provide biennial reports on the Offices activities to the Director of the National Institutes of Health These reports are then included in biennial reports to the President and Congress

Statistics
A 1997 national survey 141 estimated that in the previous year 421 of the adult population in the United States had used at least one of the complementary/alternative therapies included in the survey This is an increase from 338 in 1990 The therapies included in the survey were relaxation techniques, herbal medicines, massage, chiropractic, spiritual healing by others, megavitamins, self-help groups, imagery, commercial diets, folk remedies, lifestyle diets, energy healing, homeopathy, hypnosis, biofeedback, and acupuncture Rates of use of complementary/alternative therapies in 1997 ranged from 32 to 54 in the socio-demographic groups examined The therapies with the
greatest increases in use included herbal medicines,

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massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy Visits to chiropractors and massage therapists accounted for nearly half of all visits to complementary/alternative medical practitioners in 1997 The probability of patients visiting a complementary/alternative medical practitioner increased from 363 to 463 between 1990 and 1997 The total number of visits to complementary/alternative medicine practitioners increased from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all primary care allopathic physicians Estimated expenditures for professional complementary/alternative medical services increased 452 between 1990 and 1997 For 1997, these expenditures are conservatively estimated at 212 billion with at least 122 billion of this paid out-ofpocket Total 1997
out-of-pocket expenditures relating to complementary/alternative therapies are conservatively estimated at 27 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all physician services Just over half of patients 64 in 1990 and 583 in 1997 of complementary/alternative medical practitioners pay entirely out-of-pocket for the services Approximately 3000 allopathic physicians and other health care practitioners currently use homeopathy 142 In 1993, more than 45 000 licensed chiropractors and 32 000 Doctors of Osteopathy were practising in the United States More than 60 of osteopathic physicians are involved in primary care The profession is responsible for approximately 10 of the total health care delivered in the United States Chiropractors currently see 10 to 15 of the population of the United States 143 There are about 6000 acupuncture practitioners in the United States An estimated 3000 allopathic physicians have taken courses in acupuncture with the
intention of incorporating it into their medical practices 143 There are over 1000 licensed naturopathic doctors in the United States There are approximately 50 000 biofield practitioners providing 18 million sessions annually There are approximately 50 000 qualified massage therapists in the United States, providing 45 million one-hour massage sessions per year There are 10 ayurvedic clinics in North America, including one hospital-based clinic that served 25 000 patients between 1985 and 1994 143

Regulatory situation
In the United States, regulatory controls surrounding complementary/alternative medicine involve six related areas of law: licensing, scope of practice, malpractice, professional discipline, third-party reimbursement, and access to treatments State laws dominate the first five areas Federal laws, particularly food and drug laws, largely control the sixth In each of these areas, legal rules aim to safeguard consumers against fraud and to ensure patient protection against
dangerous practices and practitioners Because allopathic medicine has historically dominated licensing, accreditation, reimbursement, and other regulatory structures, however, existing legal rules governing complementary/alternative therapies and providers arguably favour

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allopathic medicine and paternalism at the expense of concerns for patient choice and autonomy Licensing laws in each state provide that the unlicensed practice of medicine is a crime, with medicine being broadly defined to include such matters as diagnosis and treatment of disease or any human condition Both non-licensed providers of complementary/alternative care such as non-allopathic physician homeopaths, herbalists, iridologists, nutritionists, and spiritualists not practising within the tenets of a specific recognized religion and licensed complementary/alternative care providers such as chiropractors and, in many states, acupuncturists, massage therapists, and naturopaths who exceed their
legislatively authorized scope of practice risk prosecution for unlicensed medical practice Under malpractice rules, practitioners are liable when their professional practices deviate from standards of care applicable to their locale and speciality and when patient injury results This is problematic since complementary/alternative care by definition deviates from allopathic standards of care Professional disciplinary cases are frequently brought against allopathic providers integrating complementary/alternative practices, often in tandem with civil malpractice lawsuits Third-party reimbursement is regularly denied to patients receiving such treatments because the third parties consider the treatments to be experimental and/or not medically necessary Patients find access to complementary/alternative treatments restricted further on the grounds that the medicinal substances used to diagnose, cure, or mitigate disease are classified under federal law as new drugs and are thus subject to
extensive premarketing approval to show safety and efficacy before they may be used Although more and more complementary/alternative medical providers are being licensed in the United States, legal rules must continue to evolve to accommodate widespread consumer and provider use of therapies that have historically fallen outside the scope of allopathic medicine 144

Traditional Native North American medicine
Traditional Native North American medicine in the United States is regulated under the Self-Determination Act 82

Homeopathy
Arizona, Connecticut, and Nevada have specific licensing boards for homeopathic physicians The market for homeopathic medicine in the United States is a multi-million dollar industry Homeopathic remedies are recognized and regulated by the Food and Drug Administration and are manufactured by pharmaceutical companies under strict guidelines

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Manipulative
therapy
Statutes regulating the practice of manipulative therapy exist in every state of the United States 145 Practice is restricted to persons who fulfil certain requirements and have been registered and/or licensed In many cases, practising without a licence is an offence Licensing legislation regulates chiropractic educational standards 81 An example of such legislation is found in Sections 65516556 of Book 16 of the Consolidated Laws of New York 146, 147 The New York statute states that chiropractors may not treat specified diseases; perform operations; reduce fractures or dislocations; or prescribe, administer, dispense, or otherwise use medicines or medicaments in their practice Only licensed persons may practice chiropractic and use the title of Chiropractor To be eligible for a professional licence, an applicant must have completed two years of pre-professional college study and a four-year chiropractic resident programme as well as obtaining satisfactory experience and
passing the licensing examinations In the United States, practitioners of manipulative therapy are sometimes considered on the same professional level as allopathic physicians Part 59 of Title 57 of the United States Code of Federal Regulations 148 includes osteopathic general practice in the definition of allopathic family medicine However, with the exceptions of South Carolina and Arizona, all states require chiropractors to add an accompanying qualifying reference to chiropractic following the use of the title Doctor or Physician 149

Acupuncture
Section 355 of the Federal Food, Drug, and Cosmetic Act 150 covers the labelling of medicines and devices, including acupuncture needles and equipment In 1973, acupuncture was declared by the Food and Drug Administration to be a method of treatment for investigational use by licensed practitioners only until substantial scientific evidence is obtained by valid research studies supporting the safety and therapeutic usefulness of acupuncture
devices The Food and Drug Administration at that time published a notice calling for labelling requirements for such devices, including the following warning: Caution: experimental device limited to investigational use by or under the direct supervision of a medical or dental practitioner States have an array of provisions regarding the practice of acupuncture In New York, legislation 151 was passed in 1974 on the recommendation of the State Commission on Acupuncture The legislation allowed state boards responsible for medicine and dentistry to formulate rules and regulations governing the provision of acupuncture and to establish licensing procedures for its practice in New York The main prerequisites for a licence were that the applicant had practised acupuncture for at least 10 years and had a licence as a doctor of acupuncture, herb physician, or doctor of traditional Chinese medicine duly issued by the licensing board of any foreign country

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A 1991 statute 146
altered the above position by substituting licensing rules; creating a board of acupuncture made up of acupuncturists, licensed allopathic physicians, and members of the public; and obliging licensed acupuncturists to advise patients about the importance of consulting a licensed allopathic physician concerning their prognosis, and keep a record of the dispensation of this advice To qualify for a licence to practice acupuncture, applicants must satisfy a preprofessional education requirement of at least 60 hours in an approved university or college, including a minimum of nine hours in the biosciences They must then complete a professional programme, lasting a minimum of 450 hours, which involves classroom instruction in the biosciences and acupuncture and supervised clinical acupuncture experience Applicants must pass a licensing exam set by the National Commission for the Certification of Acupuncturists or other approved body Finally, applicants must be at least 21 years of age
Section 8216 permits the enactment of rules for the certification of allopathic physicians and dentists as acupuncturists Limited permits for applicants who meet the requirements for admission to the licensing exam can be issued However, practice under a limited permit must be under the supervision of a licensed acupuncturist During the 1970s, the legislatures of several other states established conditions for the licensing of acupuncturists who were not allopathic physicians As of 1981, nonallopathic physicians have been permitted to practise acupuncture under various conditions in at least 15 states 152 Under a 1978 act in Rhode Island 153:
[No treatment by acupuncture] shall be performed unless within a period of 12 months preceding the treatment the patient shall have undergone a diagnostic examination by a duly licensed and registered physician with regard to his illness or malady The doctor of acupuncture [as defined in the act] or the licensed acupuncture assistant [likewise
defined] shall first be familiar with the results of the said diagnostic examination

The act provides for the establishment of the State Board of Acupuncture and also defines the conditions under which the Board may issue licences to practise acupuncture or to perform as an acupuncture assistant The conditions for the issue of a licence in Rhode Island are as follows: the applicant must have successfully completed a course of study of 36 months in acupuncture at a college in the Hong Kong Special Administrative Region of China or have qualifications considered equivalent by the State Board of Acupuncture, the applicant must have practised acupuncture for 10 years, and the applicant must have passed examinations set by the Board In Florida 154, only persons certified by the Department of Professional Regulation may practise acupuncture Some of the conditions for certification are that the applicant must be at least 18 years of age, have undertaken two years of education in
acupuncture at a school or college approved by the Department experience may be

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

substituted for a part of this training, and pass an examination It is a misdemeanour to practise acupuncture without a valid certificate in Florida Californias Business and Professions Code 155 lays down an extensive set of provisions regulating the acupuncture profession California has appointed an Acupuncture Board, which consists of nine members By law, four of these members must be acupuncturists with at least five years of experience who are not also allopathic surgeons or physicians, one must be an allopathic physician or surgeon with two years of experience in acupuncture, the remaining four must be members of the public who are neither acupuncturists nor allopathic physicians or surgeons In California, in order to receive a licence to practise, applicants must be at least 18 years of age, have
completed an approved course in acupuncture or a tutorial programme in the practice of acupuncture, passed an examination administered by the appropriate Board, and completed a clinical internship programme of up to nine months The length of the internship depends on the applicants examination results and prior clinical training Internship requirements are waived for applicants who have previously completed 800 hours of clinical training Practising acupuncture without a licence is a misdemeanour A previous requirement that acupuncture treatments cannot be performed on a patient without a prior diagnosis or referral from a licensed physician, surgeon, dentist, podiatrist, or chiropractor has been removed from the legislation The completion of 30 hours of continuing education every two years is required for renewal of the annual practising licence

Naturopathy
Naturopathy remains relatively marginalized in the United States Few states license naturopaths 156 Although legislation on
naturopathy varies between states, a number of general regulations do exist Under state licensing procedures, naturopaths have a limited range of treatment options The use of electricity, heat, water, vibration, and muscular articulation are permitted as therapeutic modalities, but the general practice of medicine and surgery are prohibited The administration of toxic drugs is similarly prohibited 145

Hypnosis
Treatment involving the use of hypnosis is characterized as the practice of medicine and surgery and is therefore subject to licensing requirements

Biofield therapy
No state has licensing requirements for biofield practitioners Since legal constraints in many states restrict the use of the terms patient and treatment, most biofield practitioners use the terms receiver and session in describing their work

Education and training
The majority of allopathic medical schools in the United States now offer courses on complementary/alternative medicine 141 Beginning in 1997, primary
care allopathic physicians have been able to take courses designed to introduce them to homeopathy and to encourage them to incorporate homeopathy in their practices 53
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The United States has the largest number of chiropractic colleges of any country Sixteen colleges are recognized by the World Federation of Chiropractic and accredited by the Council on Chiropractic Education, the United States accrediting agency for the chiropractic profession The Council on Chiropractic Education establishes minimum standards and assesses institutional compliance with these standards as well as overall effectiveness 81 With only a few states licensing naturopaths 156, all except two naturopathic colleges have closed Entry to these colleges is conditional on two years of preprofessional coursework The programmes are four years in length

Insurance coverage
Complementary/alternative therapies are infrequently included in benefit packages, although the number of insurers and managed
care organizations offering coverage is increasing 141 When complementary/alternative therapies are covered, they tend to have high deductibles and co-payments that are subject to stringent limits on the number of visits or total dollar coverage Chiropractic care is the exception 116 In many states, chiropractic is covered in full or in part by Medicaid, Medicare, and other Social Security programmes as well as private health insurance The cost of chiropractic treatment can also be reclaimed under workers compensation legislation designed to reimburse, at least in part, medical expenses incurred by injured workers

Venezuela
Statistics
The Liga Medicorum Homeopathica Internationalis has 41 members in Venezuela 86 There are approximately 10 chiropractors practising in Venezuela 116

Regulatory situation
In Venezuela, health care is restricted to formally educated medical professionals Section 13 of the 1975 Venezuelan law on the practice of medicine 157 states that persons who perform
any act that is restricted to medical practitioners, without having fulfilled the requirements of the law, are deemed to be practising medicine illegally Only traditional birth attendants who have received a ministerial permit are exempted Allopathic physicians may practise homeopathic medicine after completing specialized postgraduate studies There is no chiropractic law, although the practice of chiropractic is permitted under common law by officially recognized health care providers

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Education and training
The School of Homeopathic Medicine of the Venezuelan Homeopathic Medical Association is responsible for training allopathic physicians specializing in homeopathy 53

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Eastern Mediterranean

Eastern Mediterranean

Algeria
Regulatory situation
The Algerian Public Health Code of 23 October 1976 158 rendered the practice of medicine without a licence an offence Apart from Section
364 on the practice of herbalists, no exceptions were made for the practice of traditional medicine Section 47 159 explicitly prohibited medical auxiliaries from using secret or occult procedures This monopoly on the practice of medicine was retained and fortified in Law 85-05 of 16 February 1985 160 relating to health protection and promotion, which repealed the 1976 Code, among other things Under Section 197, in order to practise as an allopathic physician or dentist, a person must be licensed and hold an Algerian diploma of Doctor of Medicine or Dentistry or a recognized foreign equivalent The exclusion of traditional medicine is underscored by the broad language of provisions contained in Section 214 that define the activities constituting the illegal practice of medicine or dentistry These include acting as a physician or dentist without a licence and further circumscribe the activities of
Persons who habitually take part, whether for consideration or not, even in the presence of
a physician or dentist, in making a diagnosis or in treating diseases or surgical or dental conditions, congenital or acquired, real or supposed, by personal acts, oral or written advice, or by any other means whatsoever, without fulfilling the conditions prescribed in Sections 197 or 198 [governing the mandatory qualifications for medical and dental specialists]

Section 225 includes provisions prohibiting medical auxiliaries from announcing or applying technical procedures other than those that are taught in national training programs Despite these restrictions, traditional medicine practitioners seem to be tolerated

Cyprus
Background information
Written records, especially from monasteries, record different types of traditional medicine and herbal preparations that were practised from the Middle Ages through the 19th century in Cyprus Most traditional forms of medicine involve mixing herbs

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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A
Worldwide Review

and abiding by certain behavioural rules promoting healthy diets and habits Since British colonization, allopathic doctors have provided health services

Statistics
Although most patients use allopathic medicine, some consult homeopaths and other complementary/alternative medical practitioners Only a few allopathic doctors practice homeopathy, acupuncture, or other forms of complementary/alternative medicine There are fewer than 10 complementary/alternative medical practitioners who are not also allopathic doctors These practitioners offer curative courses focused on using relaxation techniques or herbs to alleviate stress or stop smoking

Regulatory situation
Only allopathic doctors can provide medical treatment in Cyprus It is a criminal offence for others to practise medicine or give medications There is no official recognition of any kind of traditional or complementary/alternative medicine other than chiropractic Again except for chiropractic, there are no
national policies regulating traditional or complementary/alternative medicine, nor have traditional or complementary/alternative medicine been integrated with allopathic medicine A compulsory registration scheme for chiropractors was introduced in Cyprus in 1991 161 Registration is limited to persons holding a recognized degree, diploma, or certificate It is a criminal offence to practise chiropractic without being registered

Education and training
There are no official training courses in traditional or complementary/alternative medicine

Insurance coverage
No national or private health care insurance covers traditional or complementary/alternative medicine Traditional medicine is not included in the proposed National Health Insurance Scheme

Djibouti
Background information
Traditional medicine practitioners include cheiks, medical providers who use the Koran or other Islamic scriptures to treat patients, and herbalists Some practitioners combine both methods

Regulatory
situation
With the exception of traditional birth attendants, the Government tolerates, but does not officially recognize, traditional medicine Lacking legal status in Djibouti, no clear regulations control its practice A 1999 law advocating the necessity to legislate traditional medicine may lead to changes in this regard

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Only one category of traditional health practitioner has been integrated into the public health system: traditional birth attendants Traditional birth attendants work under the supervision of public health staff in the rural structure of the primary health care system

Egypt
Statistics
The practice of traditional medicine in Egypt is limited to a very few traditional medical providers 162 There is one chiropractor practising in Egypt 45

Regulatory situation
The National Drug Policy was promulgated at the beginning of 1999 as an essential part of the National Health Policy Within the framework of the National Drug Policy, reforms have
been carried out in the following five areas: rational use of drugs, issues related to the drug industry, quality assurance and quality control, management of drug supplies, and human resource development In Egypt, all herbal preparations and herbal products must meet the same standards as manufactured chemical preparations, according to the law on practising pharmacy Herbal preparations and herbal products must be manufactured in a licensed pharmaceutical plant according to local and international good manufacturing practices They must also be registered with the Central Administration of Pharmaceutical Affairs The National Organization for Drug Control and Research analyses medicinal plants and inspects herbal preparations and herbal products to ensure their safety Herbal preparations and herbal products are priced according to the law and are distributed only to pharmacies There is no chiropractic law

Islamic Republic of Iran
Background information
Traditional medicine and Islamic
medicine are practised in Iran through hokama who have small shops where they not only recommend medicines, but also prepare and sell them With the expansion of allopathic medicine and services, however, the number of hokama has diminished greatly The Shaheed Beheshti University of Medical Sciences 163 has done a lot of research on medicinal plants It has also organized an international congress on traditional medicine and materia medica Most of the research done on medicinal plants has been pre-clinical In Iran, there is no specific hospital for conducting clinical trials of herbal medicines 163

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Statistics
Over the last 10 years, the Government has undertaken an inventory of medicinal plants 163 So far, 2500 flora of Irans 8000 medicinal plants have been inventoried and recorded in 20 volumes of 125 herbs each One hundred fifty certificates for herbal medicine have been issued
Eighty-four herbal products have undergone clinical trials and been licensed These are included in Irans list of essential drugs By the end of 2004, the Government intends to have issued licences for 300 herbal products 163 Seven faculties of pharmacy are conducting research on medicinal plants in seven provinces 163 There are 30 pharmaceutical companies producing herbal medicines, 20 of which produce herbal products and 10 produce herbal preparations 163 There are also many small herbal shops that supply herbal materials and spices for medicinal use 163 There are 14 chiropractors practising in Iran 45

Regulatory situation
Traditional medicine practitioners are neither supported nor banned by the Government, provided patients are not harmed 162 A chiropractic law is pending Currently, chiropractors may practice in conjunction with allopathic physicians The Government of Iran is very interested in traditional medicines and has initiated a number of programmes related to them Since
1991, the Food and Drug Control Agency has been working in the field of herbal medicines In 1991, the National Academy of Traditional Medicine in Iran and Islam 163 was established It is mandated to support research on herbal medicines; to study the history of Iranian traditional medicine; to preserve Iranian traditional medicine; to investigate education in traditional medicine and recommend an education plan to the Ministry of Health and Medical Education, including the incorporation of traditional medicine training and research into allopathic medical programmes; to educate the public on the rational use of traditional medicine; and to republish famous Iranian books on traditional medicine In 2001, the Academy recommended that the Ministry of Health and Medical Education officially begin training allopathic medical students in Iranian traditional medicine In 1996, the Ministry of Health and Medical Education established the Council Committee of Medicinal Herbs and Products 163 The
Committee consists of a panel of experts charged with evaluating the safety and efficacy of herbs and herbal products and issuing rules and regulations for the packaging of herbal medicines In order to make allopathic drugs affordable, the Government subsidizes the pharmaceutical industrys importation of raw materials As the Government does not subsidize herbal products or locally produced herbal raw materials, herbal products are often more expensive than generic drugs

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There is no national patent office and no national patent law in Iran In 2000, a draft patent law was submitted to the Parliament, but it has not yet been approved 163

Education and training
All pharmacy students must study pharmacognosy In the Universities of Tehran and Isfahan, pharmacy students are required to write a thesis on research related to a medicinal plant 163

Insurance coverage
The Government health insurance covers 90 of the Iranian population, but only a few registered
herbal products are covered by the insurance 163

Jordan
Background information
Traditional medicine is deeply rooted in the history and culture of Jordan Traditional medical practitioners and remedies ensure equitable access to primary health care, particularly where a large portion of the population relies on it Over the last decade, there has been a growing interest in traditional and complementary/alternative medicine, including Chinese traditional medicine, acupuncture, phytotherapy, homeopathy, and chiropractic Traditional medicine is practised by herbalists, practitioners of traditional medicine, and allopathic doctors and other health professionals

Statistics
There is one chiropractor practising in Jordan 45

Regulatory situation
There are no national policies recognizing traditional or complementary/alternative medicine Traditional and complementary/alternative medicine are not integrated into allopathic medicine or into the national health system However, some traditional
and complementary/alternative medicine doctors and health professionals have been approved to practise in primary health care A chiropractic law is pending

Kuwait
Regulatory situation
Laws in Kuwait prohibit traditional medicine providers from practising medicine However, herbal medicines are not banned The use of medicinal plants in the official health sector began in 1978 Supplementing a ministerial resolution on the registration of all drugs, a document and guidelines were issued on the safety and quality assurance of herbal medicines This document describes the main principles that should be observed when registering herbal medicines, particularly in regard to
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

safety, efficacy, and consistency This document categorizes medicinal plants into three groups: plants used on a daily basis, plants subject to large-scale scientific studies and registered in pharmacopoeias, and new plants
that need to be studied For each of these plant types, there are specific registration requirements intended to encourage people to use plants that do not cause adverse reactions or require allopathic medical advice, as well as to protect people from plants with toxic elements and about which there are no published studies Following the document and guidelines, the Minister of Health issued a ministerial resolution organizing the handling and registration of herbal medicines in Kuwait A ministerial decree, based on World Health Organization recommendations, established the Centre for Islamic Medicine to undertake the registration of herbal medicines and to introduce the use of medicinal plants in the treatment of some diseases Among its various tasks, the Centre provides therapeutic services; undertakes the registration of herbal medicines imported into Kuwait, as decreed by the relevant ministerial decision; analyses and tests the efficacy and suitability of all medicinal plants
that enter into the country for human consumption; undertakes the importation of medicinal plants necessary for the preparation of drugs used in the treatment of some diseases; studies and evaluates the best pharmaceutical rendering of each herbal preparation and herbal product; carries out various studies on each plant, preparation, and product so as to identify the stability, efficacy, and safety of the active substances therein In 1986, together with the Islamic Organization for Medical Sciences and the World Health Organization Eastern Mediterranean Regional Office, Kuwait worked to establish regional standards for herbal medicines 164 Kuwaits registration policy was reviewed and endorsed by the Ministers of Health of the World Health Organization Eastern Mediterranean Region Member States and has become a reference and basis for the registration of herbal medicines throughout the region The Council of Arab Ministers of Health and the Council of Health Ministers of the Gulf also
endorsed the registration policy

Pakistan
Background information
Pakistans traditional unani and ayurvedic systems of medicine came to the United India via Arab physicians However, the unani medicine currently practised in Pakistan is vastly different from its Greek roots
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Most Pakistanis rely on unani medicine, finding it efficacious, safe, and cost effective The use of herbal medicines and homeopathy is also widespread The National Institute for Health has established a section on traditional medicine tibb

Statistics
Unani medicine is widely used throughout the country About 70 of the population, particularly in rural areas, use traditional and complementary/alternative medicine Approximately 52 600 registered unani medical practitioners serve the nation through both the public and private sectors in urban and rural areas About 360 tibb dispensaries and clinics provide free medication to the public under the control of the health departments of provincial
governments About 95 dispensaries have been established under provincial departments of Local Bodies and Rural Development, and one tibb clinic is working under the Provincial Department of Auqaf A separate Directorate of Hakims has also been established under the Federal Ministry of Population Welfare Programme, and 16 000 diploma-holding unani physicians of traditional medicine have been involved in the National Population Welfare Programme About 40 000 homeopathic physicians are registered with the National Council for Homeopathy 53

Regulatory situation
Unani, tibb, ayurveda, and homeopathy have been accepted and integrated into the national health system in Pakistan Ordinance 65 of 7 June 1962 165 was issued to prevent the misuse of the allopathic system It provided that only registered medical practitioners were entitled to use the title Doctor, to perform surgery, or to prescribe any specially listed antibiotics or dangerous drugs These prohibitions were also applicable to
practitioners of traditional medicine, it being prescribed that no person practising the allopathic, homeopathic, ayurvedic, etc, system of medicine may use the title of doctor, unless he is a registered practitioner Subsequently, the Unani, Ayurvedic and Homeopathic Practitioners Act of 1965 166 was passed to regulate qualifications and to provide for the registration of practitioners of the unani and ayurvedic systems of medicine The Act applied to tabibs, practitioners of unani medicine, and to voids, practitioners of ayurvedic medicine, both being prohibited from using the title Doctor Under the Act, the Board of Unani and Ayurvedic Systems of Medicine was established in order to arrange for the registration of qualified persons, to maintain adequate standards at recognized institutions, to conduct research, and to perform other activities Requirements for the registration of practitioners were laid down, and training at recognized institutions was fixed at four years The Act
established that the following persons might apply for registration: persons passing the qualifying examinations for the award of a diploma in the unani and ayurvedic systems; any tabib or void with not less than seven years of practice; any

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tabib or void with five to seven years of practice, who either satisfied the Board as to his or her knowledge or skill or passed, within a specified period, an approved test in the theory and practice of the unani and ayurvedic systems; and any person who passed a written and practical examination in the subject of the old system of medicine The Government thereafter issued the Unani, Ayurvedic and Homeopathic Systems of Medicine Rules of 1965 167, which included implementing provisions on the registration of practitioners, elections to the boards, and recognition of teaching institutions The Act introduced the title of Homeopathic Doctor for
registered homeopaths, although the use of analogous titles was forbidden to practitioners of ayurvedic and unani medicine Under this Act, courses in homeopathy provided by recognized institutions must be four years in duration, culminating in a qualifying examination Persons who have passed this examination, persons holding qualifications from an approved homeopathic institution, and certain practitioners of long standing, possessing the requisite knowledge and skill, are eligible for registration as homeopathic doctors The Board of Homeopathic Systems of Medicine was established in order, inter alia, to maintain adequate standards in recognized institutions and to make arrangements for the registration of duly qualified persons The legislation referred to above was also applicable in what was then known as East Pakistan, now Bangladesh The Ministry of Health, through the National Council for Tibb oversees the qualifications of practitioners After successful completion of tibb
qualifications, candidates are registered with the National Council for Tibb, allowing them to practise traditional medicine lawfully

Education and training
Tibbia colleges, Pakistans unani teaching institutions, are recognized by the Government and are under the direct control of the National Council for Tibb, Ministry of Health, which is responsible for maintaining standards of education in recognized teaching institutions, revising/modifying curricula and syllabuses, and holding annual examinations Twenty-six colleges in the private sector and one college in the public sector offer four-year diploma courses in Pakistani traditional unani and ayurvedic systems of medicine that follow the prescribed curriculum and conditions laid down in the regulations Hamdard University has recently introduced a five-year programme to follow intermediate FSc training About 5000 students are enrolled in its Faculty of Unani Medicine Annually about 950 persons graduate from the programme Seventy-six
colleges of homeopathic medicine offer officially recognized programmes for the fouryear Diploma of Homeopathic Medical Science Several hospitals, outpatient clinics, and dispensaries are attached to the homeopathic medical colleges 53

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Saudi Arabia
Background information
Traditional medicine in Saudi Arabia is based on herbal remedies and spiritual healing There is hardly a city or village in the country where traditional medicines are not used or sold They are also commonly used in home remedies for certain ailments In 1940, allopathic medicine began being used in large cities Since then, the health authorities have taken all possible measures to develop highly sophisticated allopathic hospitals The population of Saudi Arabia today enjoys very good health facilities There was official resistance to complementary/alternative medicine until the 1990s when more Saudi Arabians demanded access to complementary/alternative medicine, and some professionals who
had been trained abroad began to practise The most popular therapies are acupuncture; herbal, nutritional, and health food products; and homeopathy

Regulatory situation
A scientific research project on the merits and demerits of Saudi Arabian traditional medicines was undertaken as a precursor to drafting a regulatory framework and statutory provisions for the practice of Saudi Arabian traditional medicine and the sale and manufacture of the medicines used in it An act governing the practice of pharmacy and trade in medicines and medical products was issued by Royal Decree M/18 dated 18/3/1398 H equivalent to 26 February 1978 Articles 44 and 50 of this act prohibit the handling of locally produced or imported products prior to their registration with the Ministry of Health Paragraph 13A of the special provisions on registration regulations for pharmaceutical companies and their products, which was amended through Ministerial Resolution 1214/20 dated 17/6/1409 H equivalent to 25
January 1989 168, requires the registration of medicines and all products having medical claims, including herbal preparations containing active ingredients that possess medicinal effects The License Committee established under the Ministry of Health is responsible for approving or disapproving, mainly on the basis of safety and efficacy, the marketing and use of herbal preparations and herbal products, health food products, and natural health products, including items for cosmetic use The Ministry of Health has approved guidelines restricting licences to practice acupuncture to those persons who have at least 200 hours of training, are anaesthetists, rheumatologists, or orthopaedists, and who comply with hygienic standards Licensing legislation also regulates chiropractic educational standards and practice 81

Education and training
No formal education exists in traditional or complementary/alternative medicine in Saudi Arabia; interested allopathic physicians go abroad to receive
such training
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

Insurance coverage
Traditional medicine is not covered by the health insurance system; however, some traditional medicine practitioners, especially spiritualists, practise free of charge

Sudan
Background information
Traditional medicine in Sudan has roots in Islamic and West African medicine People in many areas of the country depend on herbal medicines, which are an integral part of the health care system There is wide experience with the use of herbs in medical treatment Many families specialize in herbal medicines and this knowledge is passed on from one generation to another Patients travel from the capital to rural regions to consult herbalists, especially for difficult diseases The Medicinal and Aromatic Herbs Research Institute was created 25 years ago and has trained a considerable number of specialists in different fields required for research in medicinal
plants

Statistics
The Sudan Atlas of Medicinal Plants records the scientific name of more than 2000 medicinal herbs collected from different parts of the country, many native to Sudan All of these herbs are in current use in traditional medicine

Regulatory situation
There is legislation for the registration of herbal preparations and herbal products

Syrian Arab Republic
Regulatory situation
No licences are issued to providers of herbal medicine; such practices are limited to specialists In 1997, the Ministry of Health issued decisions on the technical prerequisites necessary for the establishment of laboratories for herbal medicine In 1998, the Ministry issued decisions on the manufacture and distribution of herbal medicines and on a system of controls The manufacture of herbal medicines has been included in the national drug policy Both public and private laboratories have been active in processing medicinal herbs, and the Ministry of Health has given preliminary approval for the
establishment of laboratories that would manufacture herbal medicines A file concerning the manufacturing of herbal medicines has been developed in preparation for their registration

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Three draft laws covering herbal medicine have been prepared One concerns herbal medicines that would be used in primary health care

Education and training
A syllabus on treatment with herbal medicines has been recommended for inclusion in the curricula of faculties of medicine A syllabus on medicinal plants and herbal medicines has been introduced into the curricula of pharmacy faculties and at health institutes for technical assistant pharmacists

United Arab Emirates
Background information
In 1989, the Ministry of Healths Zayed Centre for Herbal Research and Traditional Medicine was established in Abu Dhabi to conduct research on medicinal plants and traditional medicine practitioners Similar research is conducted by the Desert Section of the Desert Marine Environment
Research Centre, the Department of Pharmacology at the Faculty of Medicine of the University of Al-Ain, the Society of National Culture, and the History and Culture Centre There is high consumer demand for herbal preparations and herbal products in the United Arab Emirates

Regulatory situation
Section 1 of Federal Law 7 of 1975 169 put in place licensing and registration requirements for the practice of medicine Only an allopathic physician who holds a medical degree may apply for a licence to practise medicine Under Section 2, noncitizens who seek to practise as general practitioners must complete an additional two years of post-internship medical practice In the United Arab Emirates, birth attendants are designated as medical professionals by Federal Law 5/1984 170, the practice of which is open to physicians, pharmacists, and other licensed individuals By Section 3, the Minister of Health is to publish licensing qualifications and outline the powers and duties of licensees In order
to provide a legal framework to ensure that their benefits could be enjoyed without unnecessary risks, registration criteria 171 for herbal medicines were published in January 1998 These criteria were established by a committee of allopathic physicians and personnel from the Zayed Centre and Emirates University The registration criteria include the following: documentation, including detailed monographs, for the herb; reference sample of the active ingredient of the herb;

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laboratory analysis for identity, purity, and quantity Priority in registration is given to single-ingredient products Products containing more than one herb must have a logical justification for the combination based on the uses of the finished product Therapeutic claims beyond traditional uses are not accepted unless scientifically justified As of April 1999 171, 27 applications had been received Seven of the
applications were completed and approved, seven had completed the laboratory screening process, and 13 were waiting for laboratory analysis These 27 applications had come from companies located in a number of countries, including Germany, Switzerland, Austria, India, Indonesia, and China A 1999 report 171 outlined several problems with the criteria Companies had difficulty fulfilling the documentary requirements, especially relating to stability data, and many companies wanted to register traditional products with more than 10 active ingredients, such as ayurvedic medicines Analysis of the active ingredients in the final products proved technically difficult because of both qualitative and quantitative interference in the assays Enforcing the law has also posed challenges

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Europe

Austria
Statistics
The chart below lists the distribution of allopathic physicians practising complementary/alternative medicine in Vienna in 1997 172
Complementary/Alternative Medicine
Acupuncture Homeopathy Neuraltherapy Bioresonance Other Number of Practising Allopathic Physicians 100 87 87 40 200

In 2000, the Liga Medicorum Homeopathica Internationalis had 670 members in Austria 86 While there are no homeopathic hospitals, homeopathic consultation takes place regularly in five allopathic hospitals in Vienna and in one allopathic hospital in Klagenfurt 53 Austria has one academy of holistic medicine

Regulatory situation
Only legally qualified and authorized medical professionals may practice medicine in Austria 172 Under Section 12 of the Federal Medical Law, medical acts are defined as all activities based on medico-scientific knowledge carried out directly or indirectly on human beings performed for the purposes of diagnosis, treatment, and prophylaxis Under the Law on Physicians of 1984 173, 174, medical acts that are not provided by authorized medical professionals, such as midwives, medical-technical assistants, and nurses, are reserved for allopathic
physicians Article 184 of the Penal Code states that unskilled persons who practise medical acts or activities reserved for allopathic physicians risk a fine or imprisonment of up to three months However, the courts have been tolerant with regard to complementary/alternative medical practitioners and charges of charlatanism In practice, Article 184 is enforced only when practitioners use methods that do not have any scientific support, such as mystic water treatment According to the Law on Health Services, only scientifically recognized medical care can be provided in hospitals Acupuncture, neuraltherapy, and chiropractic are recognized, but not homeopathy However, homeopathy is recognized by the National Committee of Medicals 53 Nonetheless, and despite the fact that there are

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neither specific legal or paralegal regulations nor draft regulations on the use of
complementary/alternative medicine in the country, allopathic physicians are implicitly permitted to use any medical technique they deem appropriate, provided they obtain the consent of their patients Under their own responsibility, therefore, allopathic physicians may use complementary/alternative medicine in their treatment regimes

Education and training
The Council of the Order of Physicians 172 issues diplomas officially recognized as medical qualifications in acupuncture, homeopathy, manual therapy, and neuraltherapy Training courses for these diplomas last between two and three years from 140 to 350 hours Neuraltherapy and chiropractic are taught in universities The National Medical Association recognizes the examination and title of Homeopathic Doctor 86 A three-year postgraduate homeopathic curriculum is available and leads to a diploma awarded by the official Medical Society of Austria Advanced training is offered through seminars, lectures, and conferences with Austrian and
international scholars 53 There are activities and associations for students interested in homeopathy at universities in Vienna, Graz, and Innsbruck As of 1 August 1996, the creation of a new educational institution of complementary/alternative medicine is punishable by imprisonment 174

Insurance coverage
Public insurance funds 172 have the following reimbursement criteria for medical treatments: scientific proof of effectiveness, cost-effectiveness, and appropriateness Complementary/alternative medicine is generally not covered Exceptions are made, however, for homeopathy and, for purposes of pain relief, massage, balneotherapy, and electrotherapy Exceptions are also made when allopathic treatments are unsuccessful and relatively recognized complementary/alternative treatments are the last resort The Oberösterreichische Gebietskrankenkasse partially reimburses acupuncture treatments Some private insurance companies cover complementary/alternative medicine
172

Belgium
Statistics
According to a 1998 poll 172, almost 40 of the Belgian population — women more than men — have used complementary/alternative medicine at least once Of these persons, 77 were satisfied with their treatment While the general public is in favour of the Ministry of Health giving official recognition to homeopathy, acupuncture, osteopathy, and chiropractic, allopathic physicians are evenly divided: 43 are in favour and 43 are opposed to such recognition

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The most widely consulted complementary/alternative therapies in Belgium 172 are homeopathy, accounting for 81 of complementary/alternative consultations; acupuncture, accounting for 38; osteopathy, 27; phytotherapy, 25; and chiropractic, 21 One allopathic physician out of four believes that these therapies should be reimbursed Fifty-nine per cent of patients who use complementary/alternative medicine and 36 of patients who do not use complementary/alternative medicine are willing to pay higher
premiums to cover this reimbursement Most providers of complementary/alternative treatments are allopathic doctors or physiotherapists 172 One allopathic physician out of four provides complementary/alternative treatments; these are mostly general practitioners The most commonly practised forms of complementary/alternative medicine are homeopathy, practised by 59 of providers of complementary/alternative medicine; acupuncture, practised by 40; and phytotherapy, 28 Thirty-three per cent of manipulative treatments are provided by physiotherapists and 34 by non-allopathic practitioners There are three homeopathic organizations for allopathic physicians and pharmacists and two for patients The Union of Acupuncturists Physicians was created in 1981

Regulatory situation
A monopoly on the practice of medicine was introduced by the Practice of Medicine Act of 1967 172 Under this act, the practice of medicine, which includes diagnosis, treatment, prescriptions, surgery, and preventive
medicine, was the exclusive domain of legally qualified allopathic physicians After the intervention of the European Commission with regard to the nonenforcement of European Directives on homeopathic products, the Government of Belgium asked the Federal Department of Public Health to draft legislation on complementary/alternative medicine On 29 April 1999, the new law was adopted by the Belgian Parliament 175 In November 1999, the Government enacted bylaws to ensure enforcement of the law Article 2 of the new law introduces provisions for homeopathy, chiropractic, osteopathy, and acupuncture and provides for the recognition of other complementary/alternative techniques Article 3 establishes a commission to advise the Government on the practice of complementary/alternative medicine, particularly registration of practitioners, membership in recognized professional organizations, insurance for professionals, regulation of advertising, and restrictions on medical acts In order to register,
practitioners must demonstrate that they provide high-quality and accessible care that has a positive influence on their patients health Article 6, Paragraph 1 requires the commission to be composed of five allopathic practitioners with at least one being a general practitioner, nominated by faculties of medicine, and five complementary/alternative practitioners, nominated by recognized professional organizations The commission, in Article 6, Paragraph 2, is also

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designated to advise the Government on organizing a peer-review system and a code of professional ethics By Article 8, the practice of a registered complementary/alternative form of medicine is allowed only when the practitioner is licensed for that practice by the Ministry of Social Affairs, Public Health, and Environment In Article 9, complementary/alternative practitioners are required to maintain medical records for each
patient Complementary/alternative practitioners who are not also allopathic physicians must obtain a recent allopathic physicians diagnosis from their patient prior to commencing treatment If patients choose not to consult an allopathic physician before seeing a complementary/alternative practitioner, they must put their wishes in writing Registered complementary/alternative practitioners must take precautions to ensure that patients are not deprived of allopathic treatment As a result, complementary/alternative practitioners who are not also allopathic physicians must keep allopathic physicians informed of the health of their patients With patient consent, complementary/alternative practitioners are permitted to seek the advice of other complementary/alternative practitioners who are not allopathic physicians Infringement of the law — in particular, practising complementary/alternative medicine without a licence or treating a patient without having obtained an allopathic physicians
diagnosis or without having the patients desire to avoid such diagnosis in writing — risks a fine under Article 11 or the suspension or withdrawal of the providers licence to practice under Article 8

Education and training
Complementary/alternative medicine is not taught in Belgian medical schools; however, the Belgian Medical Faculty of Homeopathy offers courses for allopathic physicians, surgeons, dentists, pharmacists, and veterinarians These courses comply with standards set by the European Committee for Homeopathy 172 The Belgian Acupuncture Federation is authorized by the Belgian Government to train acupuncturists to practise under the new licensing law 172 In order to be permitted to practise acupuncture, a provider must be certified as an allopathic medical doctor, dentist, physiotherapist, nurse, or midwife, as well as having completed at least 750 hours of acupuncture training — 250 hours of basic theoretical principles of traditional Chinese medicine, 250 hours of
traditional Chinese medicine pathology, and 250 hours of clinical practice — and having written a thesis There are two associations of acupuncturists offering three-year training programmes; however, most practitioners using acupuncture are trained in East Asia or France

Insurance coverage
The Belgian social security system 172 does not officially reimburse complementary/alternative treatments, regardless of whether they are provided by allopathic physicians or not Practically speaking, however, allopathic physicians using comple-

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mentary/alternative medicine may assure their patients that at least part of their fees will be reimbursed Osteopathic treatments are reimbursed so long as physiotherapists use a classic designation to prescribe them In March 1997, the Socialist Mutual Insurance of Tournai-Ath 172 was the first company to partially reimburse specific complementary/alternative treatments They reimburse 25 of homeopathic remedies up to a maximum cost of 6000
Belgian francs per year and per beneficiary They also reimburse 400 Belgian francs for each osteopathic treatment with a maximum of six treatments, but only if they have been provided by an allopathic physician, nurse, or physiotherapist The list of reimbursed homeopathic remedies is adapted from the European Union Directive on homeopathic products Reimbursement may soon be extended to other techniques, such as acupuncture and phytotherapy Private insurance companies 172 reimburse chiropractic care and, partially, acupuncture treatments

Denmark
Statistics
The complementary/alternative treatments most used by the Danish population are reflexology, acupuncture, massage, natural medicine, homeopathy, natural healing, kinesiology, and chiropractic 172 A 1994 study 172 reported that 33 of the adult population of Denmark had used complementary/alternative medicine during the previous year, women used it more frequently than men, and the average age of patients of complementary/alternative
medicine decreased in the period from 1970 to 1994 The study also found that of those who used complementary/alternative treatments, 77 considered themselves cured, 17 experienced no effect from the therapy, and 1 considered their health problems to have worsened as a result of their treatment People most often sought complementary/alternative therapies for joint and muscular problems Approximately 700 physicians are members of the Danish Society for Medical Acupuncture; 116 of these are newly certified 172 There are 265 chiropractors practising in Denmark 45 The Danish Chiropractic Association has 300 members There are 16 000 allopathic medical doctors in Denmark There are also several associations of non-allopathic physician providers

Regulatory situation
In Denmark, allopathic physicians holding an academic degree in medicine, having taken the Hippocratic oath before a faculty of medicine, and authorized by the National Health Service are not restricted as to the medical techniques
they may use The title of Physician is protected and only licensed allopathic physicians may call

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themselves such Public-sector medical positions are reserved for authorized doctors 172 Two laws 172 regulate the practice of complementary/alternative medicine The Medicine Act legislates the making and marketing of natural remedies and includes criteria for packaging, providing information to patients, and advertising The Practice of Medicine Act of 1970 permits non-allopathic physicians to practise medicine regardless of their training and without previous authorization However, non-allopathic physicians are not recognized as official health care providers, their titles are not protected, and they are not integrated into the national health care system By Articles 2326 of Order 426 of the Practice of Medicine Act of 1976, issued by the Minister of the Interior on 19 August 1976,
non-physicians may not perform specific medical acts that are reserved for licensed allopathic physicians, nor are they permitted to use needles except under the supervision of an allopathic physician The medical acts reserved for licensed physicians are the following: treating persons for venereal diseases, tuberculosis, or any other infectious disease; performing surgery; administering general or local anaesthetics; providing obstetric aid; applying medicines that may be dispensed only with a physicians prescription; using X-ray or radium treatments; or practising therapies using electric machines Violation of this limited monopoly is punishable by up to 12 months in prison However, nonallopathic practitioners are only prosecuted for selling harmful products, otherwise exposing patients to a provable danger, or causing the serious deterioration or death of their patients Sentencing is particularly severe in cases where the patient is mentally ill or handicapped, under 18 years of
age, or considered incapable of managing his/her own affairs Ancillary staff, by contrast, may practice complementary/alternative medicine without restriction Chiropractors are the exception to this law They are regulated by a 1992 law 65 Whenever patients consult a chiropractor without an allopathic physicians referral, the chiropractor must inform the patients practitioner of the diagnosis and treatment, whether the practitioner is an allopathic physician or not A Danish study on complementary/alternative treatments concluded that current legislation in this field is sufficient and further regulations are not necessary

Education and training
The Danish Society for Medical Acupuncture offers a 120-hour diploma course in acupuncture for allopathic physicians 172 The Danish Chiropractic Association 172 provides training for non-allopathic physicians Membership in the Danish Chiropractic Association is restricted to those persons trained at a college accredited by the American Council
on Chiropractic Education who have completed a six-month apprenticeship with a member of the Association and have passed the Association exam

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Insurance coverage
The Danish Chiropractic Association 172 is working to obtain official recognition and full social insurance reimbursement for chiropractic treatments In the meantime, reimbursement is determined by a 1975 agreement between public insurance schemes and chiropractors Under this agreement, public insurance covers one-third of the costs of up to five chiropractic consultations and one X-ray examination per year, on the condition that these are provided by chiropractors recognized by the Danish Chiropractic Council When patients are referred by licensed allopathic physicians, some acupuncture and osteopathic treatments are also reimbursed 172

Finland
Background information
The Ministry of Social Affairs and Health recognizes the increasing contribution of complementary/alternative therapies to the Finnish Health Care
System 172 Among older rural Finns, massage, bonesetting, and cupping are popular; among younger urban Finns, natural medicine, manipulation, acupuncture, and hypnosis are popular 172

Statistics
About 50 of the adult Finnish population have used complementary/alternative medicine at least once 172 There are 30 chiropractors practising in Finland 45 In 1987, there were 200 local health centres providing acupuncture treatment 172

Regulatory situation
Act 559 of 28 June 1994 176 regulates the licensing of medical practitioners By Article 4, the right to practise as an independent allopathic medical doctor can be granted to practitioners who have completed basic medical training and who have additional training in primary health care or special training in an allopathic medical speciality Professional allopathic medical providers who fulfil the required conditions have a number of rights, including the right to use a protected occupational title Only allopathic doctors and, by Decree
564/1994 172, registered chiropractors, naprapaths, and osteopaths are recognized health practitioners and allowed to practise medicine — specifically, to diagnose patients and charge fees However, according to Act 559, other medical practitioners may treat patients if they do not practise within public services and do not pretend to be health care professionals As a result, only allopathic doctors and registered chiropractors, naprapaths, and osteopaths are supervised by the medical authorities in practising complementary/alternative medicine Other medical practitioners are not supervised, nor is their licensing regulated While anyone can use an unqualified title, such as Chiropractor, by Act 559 only registered chiropractors, naprapaths, and osteopaths may use the descriptor

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Trained in describing themselves Act 559 also confers title protection to allopathic physicians Articles 34
and 35 of Act 559 relate to the illegal practice of medicine, punishable by fine or up to six months in prison, although prosecution is rare The objective of these articles is to protect patients and medical professionals working within public services A licence is necessary to market homeopathic products with a degree of dilution less than one million

Education and training
Since 1975, acupuncture has been an accepted part of allopathic medical practice, and training in acupuncture is a component of the medical curriculum of allopathic physicians 172 Chiropractors, naprapaths, and osteopaths must complete at least four consecutive years of training approved by the National Board of Medico-Legal Affairs Chiropractors generally train in the United States Other complementary/alternative therapists often attend schools in Sweden 172

Insurance coverage
When provided by an allopathic physician, acupuncture is covered by the Social Insurance Institution SII 172 In general, other
complementary/alternative therapies are also reimbursed by the SII, provided they are given by medically qualified allopathic doctors during their normal sessions and provided the doctors do not specify which treatment they used The SII covers treatments given by recognized chiropractors, naprapaths, and osteopaths when the following conditions are met: Patients can show that they first obtained a diagnosis and statement of required treatment from a licensed allopathic physician Patients are referred to the complementary/alternative therapist by a licensed allopathic physician The complementary/alternative therapist works in an institution led by a physiotherapist or an allopathic physician Complementary/alternative medications, however, are not covered by the SII In Finland, no private insurance companies 172 reimburse complementary/alternative medicine except in some cases of chiropractic treatment, where reimbursement follows the same criteria used by the
SII

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France
Background information
Homeopathic and herbal health care products are very popular in France The most popular forms of complementary/alternative medicine are, in order of popularity, homeopathy, acupuncture, herbal medicines, water cures, chiropractic, thalassotherapy, osteopathy, and iridology 172

Statistics
A 1987 survey found that 36 of allopathic doctors, mostly general practitioners, used at least one complementary/alternative technique in their medical practices Among allopathic physicians using complementary/alternative medicine, 54 used it exclusively; 207, often; and 728, occasionally The social security system qualifies allopathic physicians using complementary/alternative medicines as doctors with a particular type of practice MEP Any doctor can be so designated In 1993, physicians who were registered as MEPs represented 62 of the whole medical corpus Thirty per cent of MEPs provide acupuncture treatments Twenty per cent provide homeopathic
therapies 172 An additional 50 000 non-allopathic practitioners provide complementary/alternative therapy in France 172 There are approximately 390 chiropractors practising in France 65 There are between 2000 and 4000 kinesiotherapists 172 One survey 172 found 49 of the people questioned — 53 of the women surveyed and 44 of the men — had used complementary/alternative medicine at least once, 16 during the previous year Complementary/alternative medicine is most popular among people between the ages of 35 and 45, 59 of persons in this age group having reported using complementary/alternative medicine Sixty-eight per cent of executives and academics had used complementary/alternative medicine, compared to 60 of middle managers and intermediate professionals and 40 of farmers, the least likely group to use complementary/alternative medicine Those surveyed reported using a complementary/alternative medicine for minor diseases 49, chronic symptoms 54, serious illnesses 3, and the
prevention of disease and promotion of a healthy lifestyle 17 Seventy per cent of patients of complementary/alternative medicine considered it effective for minor diseases; 65, for chronic diseases; and 9, for serious illnesses Only 11 of patients considered these therapies ineffective for minor diseases; 15, for chronic diseases; and 38, for serious illnesses 172 France has many organizations for practitioners and patients of complementary/alternative medicine

Regulatory situation
Under Articles L 372 through L 376 of the Code of Public Health 172, persons other than licensed allopathic physicians who habitually or continuously diagnose or treat
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illnesses, real or supposed, or who perform activities constituting medical procedures are illegally practising medicine Persons wishing to obtain a licence to practise medicine must possess a State certificate; hold French, Tunisian,
Moroccan, or European Union citizenship; and be registered by the professional society of physicians Despite prosecution, non-allopathic practitioners — particularly physiotherapists using complementary/alternative methods such as chiropractic and osteopathy — continue to practise, and the number of allopathic physicians using complementary/alternative medicine is increasing Allopathic physicians providing complementary/alternative treatments either assist persons practising medicine illegally or practice complementary/alternative medicine themselves In both cases, they risk being tried for penal and disciplinary infractions Recent decisions, however, suggest that the courts are becoming more tolerant towards the practice of complementary/alternative medicine

Education and training
Teaching complementary/alternative medicine 172 to non-allopathic physicians is permitted The number of schools and courses in complementary/alternative medicine has recently increased, although they vary
widely in quality Private schools, however, may not issue diplomas to their graduates According to Article 4 of the Act of 18 March 1880, only the State has this power Despite the allopathic medical establishments opposition to the recognition of chiropractic, the Decree of 11 February 1953 provides for the incorporation of chiropractic into medical schools However, the Decree has not been applied and chiropractic has never been taught in French medical schools In fact, the practice of chiropractic is illegal in France Nonetheless, there is a school of chiropractic 65 The University of Bobigny 172 established the Department of Natural Medicines in 1982 Since then, diplomas have been awarded in acupuncture, homeopathy, phytotherapy, osteopathy, auriculotherapy, naturopathy, oligotherapy, and mesotherapy In 1990, the University Diploma in Natural Medicines 172 — training leading to an inter-university certification recognized by the French National Order of Physicians — was created for
acupuncture and osteopathy Recognition of a certification in homeopathy is under consideration Phytotherapy is already incorporated into training in pharmacy However, these therapies are not considered medical specialities In order to obtain recognition as a medical speciality, the discipline must be taught according to the criteria followed for an allopathic speciality, ie, the training should be full-time and include periods of clinical practice Some non-allopathic practitioners receive their training at foreign schools For example, kinesiotherapists/physiotherapists who also provide chiropractic treatments are usually trained in the United Kingdom or Germany 172

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Insurance coverage
In France, social security and private insurance 172 reimburse some forms of complementary/alternative medicine so long as an allopathic medical practitioner provides them Social security reimburses homeopathic prescriptions written by authorized physicians and specific medical activities and
products, including chiropractic, medical phytotherapy consultations, and complementary/alternative technical sessions with an approved kinesiotherapist Acupuncture treatments given by MEP physicians are also reimbursed, provided that the physicians observe regulations regarding allopathic consultations

Germany
Background information
In 1992, the Federal German Ministry of Research and Technology initiated an extensive research programme on complementary/alternative medicine coordinated by the University of Written/Herdecke 172

Statistics
Three-fourths of allopathic physicians use complementary/alternative medicine and 77 of pain clinics provide acupuncture treatments 172 In 1994, there were between 10 000 and 13 000 practitioners of complementary/alternative medicine, or Heilpraktikers, 8000 of whom were members of professional associations 172 There are approximately 40 chiropractors practising in Germany There were 20 million patient contacts with complementary/alternative
medicine in 1992 The most frequently sought complementary/alternative therapies are, in order of popularity, homeopathy accounting for 274 of patient contacts, acupuncture 154, procaine injection therapy, chiropractic, ozone and oxygen therapy, herbal medicines, humoural pathology, massage, and cell therapy 172 According to a 1992 poll 172, between 20 and 30 of the population had used complementary/alternative medicine, with 5 to 12 having used it during the previous year Complementary/alternative therapies are more popular with women than men Most complementary/alternative patients are between the ages of 18 and 65 and have a relatively high level of education In most cases, patients have first sought treatment with allopathic medicine There are many organizations for practitioners and patients of complementary/alternative medicine

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Regulatory situation
In Germany, there is no legal
monopoly on the practice of medicine 172 Thus, licensed non-allopathic physicians may practice medicine, and all licensed medical practitioners are allowed to use complementary/alternative medicine There are, however, some restrictions on the performance of particular medical acts Only allopathic physicians and dentists are allowed to practise dentistry Only allopathic physicians are allowed to treat sexual diseases, treat communicable and epidemic diseases, deliver specific medications, give or provide anaesthetics and narcotics, practise obstetrics and gynaecology, take X-rays, perform autopsies, and deliver death certificates Infringement may result in penal punishment In order to obtain a title as an allopathic physician, a person must have an academic degree in medicine, practical experience, a licence from public authorities, and a medical certificate confirming that there are no indications of physical or mental disability or addiction to drugs Licensed Heilpraktikers 172 may
practise medicine with the exclusion of these specific medical acts To qualify for a Heilpraktikers licence, a candidate must be at least 25 years old, have German or European Union citizenship, have completed primary school, have a good reputation in order to guarantee a normal professional practice, have a medical certificate confirming that there are no indications of physical or mental disability or addiction to drugs, and pass an examination before a health commission proving that the candidate has sufficient knowledge and ability to practise as a Heilpraktiker and that the candidates treatments do not negatively affect public health The exam verifies the candidates basic knowledge of anatomy, physiology, hygiene, pathology, sterilization, disinfecting, diagnosis, and health regulations, particularly the epidemic law However, the questions are required to be basic and understandable Chiropractors must obtain a Heilpraktiker licence regardless of whether or not they have a degree
from an accredited institution 65

Education and training
As part of the standard curriculum, allopathic medical schools are required to test students on their knowledge of complementary/alternative medicine Students may also select a postgraduate specialization in complementary/alternative medicine 172 Heilpraktiker candidates do not have to follow standardized training in order to pass the licensing exam, which has resulted in a wide variety of teaching methods as well as variations in the length and quality of training According to a recent poll, only 10 of Heilpraktikers did not have any form of training, while 88 had from one to four years of training 172 The German Federal Association of Heilpraktikers organizes training in 29 cities for persons who desire to obtain a Heilpraktiker licence Some of this training lasts three years or 350 hours 172

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In Germany, the title Homeopathic Physician is legally protected The Medical Chamber bestows this title after a three-year
training programme 86 Advanced obligatory training courses for homeopathic professors are given on a regular basis Official homeopathic teaching contracts exist with the medical faculties in Berlin, Dusseldorf, Hannover, Heidelberg, and Freiburg 53 Chiropractors holding a degree from a regionally accredited institution may use the title Doctor of Chiropractic 65

Insurance coverage
In Germany, public and private insurance 172 provides the same kind of coverage Both currently reimburse some complementary/alternative treatments and are moving towards broadening this coverage Even though there is no constitutional right to obtain reimbursement, the following criteria have been established to determine the coverage of complementary/alternative medicine by both social insurance and private insurance: If no allopathic treatment is available to treat a specific illness or to reduce its pain or if the aetiology is unknown — for example, for multiple sclerosis or certain forms of cancer –
the use of complementary/alternative medicine is reimbursed provided the treatment has a minimum chance of success whether or not the method of treatment is generally scientifically recognized If the aetiology is known, but no allopathic treatment is available, the recourse to complementary/alternative medicine is allowed, provided there is a minimum chance of success according to the aetiology The same allowance is given when a previous allopathic treatment has been unsuccessful When an allopathic treatment and a complementary/alternative treatment are both available but the allopathic treatment has side effects or risks for the patient, in general or in particular, the use of complementary/alternative medicine is reimbursed However, in this case, it is necessary to balance the risks and the costeffectiveness of the treatment If there are safe allopathic and non-allopathic treatments at a patients disposal, he/she may choose the less expensive treatment Anthroposophic,
phytotherapeutic, and homeopathic products are reimbursed By Articles 92 al 1 and 135 al 1 Sozialgestezbuch, in order to be reimbursed, experimental treatments have to be recognized, in broad terms, as useful and safe Some private insurance companies also reimburse treatments not scientifically recognized if they are provided by Heilpraktikers and if their effectiveness is not completely rejected

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Hungary
Statistics
The Hungarian Homeopathic Medical Association has 340 members 172 There are three practising chiropractors in Hungary 65

Regulatory situation
Although allopathic physicians are the most common providers of complementary/alternative medicine, non-allopathic physicians and non-allopathic practitioners may provide specific complementary/alternative treatments In February 1997, the Hungarian legislature passed two pieces of comprehensive legislation on natural medicine:
Government Decree 40/1997 IV 5 Korm r on natural medicine and the Decree of the Minister of Welfare 11/1997 V 28 on some aspects of the practice of natural medicine 172 These two decrees clearly and officially integrate allopathic and non-allopathic physicians who practise complementary/alternative medicine into the national health care system The Decrees came into force on 1 July 1997 The Decrees outline precise rules regarding the curriculum of complementary/alternative medical training as well as its practice Each complementary/alternative discipline has its own training requirements and State exam Within a legal framework, non-allopathic physicians are allowed to use complementary/alternative medicine once they have passed the exam Articles 1 through 7 of the Decrees regulate conditions for practising complementary/alternative medicine Annexes 1 through 4 list the specific requirements for each form of complementary/alternative medicine Article 1 identifies three categories of
authorized medical practitioners: allopathic physicians, practitioners with a non-academic higher medical qualification, and other non-allopathic practitioners Natural doctors are authorized practitioners who have passed the required exams and are permitted to use complementary/alternative medicine Article 1 also contains restrictions on the use of complementary/alternative medicine Only allopathic physicians may practise homeopathy, Chinese and Tibetan medicine including acupuncture, biologic dentistry, therapies using oxygenation, neuraltherapy, anthroposophy, and magnetic bioresonance Both allopathic physicians and medical practitioners with a non-academic higher health qualification may provide manual therapies Practitioners who do not hold a higher health qualification may provide acupressure, massage therapy, lifestyle counselling, reflexotherapy, bioenergy, phytotherapy, and auriculotherapy Article 2 clarifies the legal framework in which natural doctors are allowed to practise
Paragraph 1 of Article 2 states that allopathic physicians are in charge of diagnosis, therapy planning, and patient follow-up Other practitioners who have the necessary qualifications may participate in patient care at the request of the patient or

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through an allopathic physicians referral Natural doctors who are non-allopathic physicians are allowed either to practise under the supervision of an allopathic physician or, more independently, to provide care after an allopathic physician has made a diagnosis Consulting allopathic physicians may not oppose a patients choice to seek treatment from a natural doctor Article 2 Paragraph 2 delineates medical acts that may not be performed by nonallopathic physicians If a patient is under the treatment of an allopathic physician, natural doctors must consult the patients allopathic physician Article 2 Paragraph 3 stipulates that only qualified psychologists or allopathic physicians with a qualification as psychotherapists are
allowed to provide psychotherapeutic care based on natural medicine By Article 3, natural doctors must submit to the same directives as other medical practitioners, such as respecting obligations, abiding by ethical rules, and keeping patient records Article 4 permits the use of all regular drugs under the provision of complementary/alternative medicine Homeopathic products not registered in Hungary can be used if the registration procedure is in process Article 5 gives the Institute of Health, under the authority of the Ministry of Social Welfare, the responsibility of regulating the training and examination of natural doctors Under Article 7, allopathic physicians with an academic degree in medicine may ask for a licence to practise as natural doctors without being required to take another exam They are also allowed to use the title of Natural Doctor, but to use the title of specialists in particular therapies, they must take the exam Allopathic physicians are the only practitioners
who do not have to pass the exams to practice complementary/alternative medicine Psychologists with higher health qualifications and other practitioners must take a specific examination in natural medicine before they may use the title of Natural Doctor Natural doctors are registered and supervised by a special commission Annex 1 contains a complete list of authorized complementary/alternative treatments and of the medical practitioners who are allowed to provide them Annex 2 outlines the information that natural doctors must record, such as patient histories and a description of the current treatment Annex 4 gives the theoretical and practical requirements for examinations in acupuncture, massage techniques, lifestyle counselling, reflexology, physiotherapy, bioenergy, and auriculotherapy For each therapy, the Annex lists the definition of the technique, practical and theoretical requirements, rules on ethics, and specific topics for examination

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In 1977, the Government recognized homeopathy as a medical method, but there is no officially recognized training programme or examination 86 Chiropractic is regulated, but not defined, by law The Ministry of Education recognizes the Doctor of Chiropractic degree 65

Ireland
Statistics
There are 55 chiropractors practising in Ireland 45 There are numerous associations of professional complementary/alternative practitioners

Regulatory situation
As in the United Kingdom, the Medical Council 172 is the statutory body that regulates the medical profession In order to practise medicine as an allopathic physician, a provider must possess a certificate of qualification from a medical school and be registered with the Medical Council Although allopathic physicians do not have a legal monopoly on medical practice, registered allopathic practitioners have some exclusive rights Only those who are registered as doctors are
permitted to treat venereal diseases, practise obstetrics, certify death, issue medical certificates for official purposes, prescribe a wide range of controlled drugs, give advice in court on specific issues, supply services to police for alcohol-linked traffic offences, and administer anaesthetics All medical positions in State services, the army, civil service, or private industry are restricted to registered allopathic medical practitioners Persons without an allopathic medical degree are tolerated by law to practice complementary/alternative medicine; however, only medical practitioners with a university degree in allopathic medicine are recognized Under Section 61 of Part V, Fitness to Practise, of the Medical Practitioners Act of 1978 172, it is an offence for non-registered practitioners to provide medical treatment under the pretence of being a registered practitioner People who make false declarations for the purpose of obtaining registration are punishable by a fine and/or
imprisonment There is no chiropractic law, although the practice of chiropractic is permitted under common law Chiropractors may obtain a licence to operate X-ray equipment 65

Education and training
There is no postgraduate training for allopathic physicians in complementary/alternative medicine

Insurance coverage
When a registered allopathic doctor provides complementary/alternative treatment, it is not distinguished from other medical care and is covered by the General Medical Services 172

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Italy
Background information
The private sector ensures the availability of complementary/alternative medicine 172 The Societa Italiana di Omeopatia, founded in 1947, links the different societies and schools of homeopathy 172

Statistics
Of Italys 250 000 allopathic physicians, 5000 use complementary/alternative techniques Of those using complementary/alternative techniques, around 1300 practise acupuncture 172 There are approximately 200 chiropractors practising in Italy 65
Twenty-four per cent of adults have used complementary/alternative medicine at least once Women, particularly those between 25 and 50 years of age, are the most likely to use complementary/alternative medicine 172 In order of popularity, homeopathy, acupuncture, herbal remedies, prana therapy, anthroposophic medicine, and chiropractic are the most popular complementary/alternative therapies 172 More than three million people, 525 of the population, use homeopathy Ninetytwo per cent of these patients are female, 79 are adults, and 69 are middle class There are about 5000 homeopathic doctors, 7000 pharmacies selling homeopathic products, and 20 companies that produce or distribute homeopathic medicines The market for homeopathic products in Italy grew from 10 billion lira in 1982 to 120 billion lira in 1994 177 In September 1996, a petition enclosing 300 000 signatures of patients of homeopathic medicine asked the Italian Parliament to give official recognition to homeopathy
172

Regulatory situation
In order to practice as an allopathic physician 172, a person must have a degree in medicine or surgery, must have passed the corresponding State exam, and must be registered in a professional register Paramedics are specifically excluded from practicing complementary/alternative medicine According to a decision by the Criminal Supreme Court of Appeals in Perugia, only registered allopathic physicians may practice complementary/alternative medicine Allopathic physicians using complementary/alternative, rather than allopathic, techniques are responsible for any consequences to their patients Allopathic physicians are not permitted to aid or cooperate with non-allopathic practitioners to illegally provide medical care of any kind However, the courts have also ruled that chiropractic is a profession, even though it is not licensed 65 Chiropractors are considered medical auxiliaries rather than medical specialists and must work under the supervision of an
allopathic doctor Complementary/alternative practitioners who are not also allopathic physicians can be prosecuted under Article 348 of the Italian Penal Code, although this rarely occurs
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172 Indeed, the Criminal Supreme Court of Appeals in Perugias decision noted that even if acupuncture is taught in Italian universities, only physicians and surgeons are allowed to practise it The Court considers medical and/or surgical expertise necessary to establish an exact diagnosis and avoid prejudicial consequences to patients Law 175 of 5 February 1992 172 expressly prohibits the use of titles that are not recognized by the State No forms of complementary/alternative medicine are recognized as medical specialities under this law Specific regulations on complementary/alternative medicine currently cover only homeopathy and anthroposophic medicine 177 Homeopathy has a long history in Italy;
attempts to regulate it began in the middle of the nineteenth century On 17 March 1995, legislative Decree 185 was adopted, executing Directive 92/73/CEE, which regulates the marketing and registration of homeopathic and anthroposophic products

Education and training
Acupuncture training 172 is available for both allopathic physicians and nonallopathic physicians Some anaesthesiology programmes include specialities in acupuncture The University of Catania, Sicily, offers a postgraduate programme in acupuncture The Society of Italian Acupuncturists and the Paracelse Institute also offer training The latter is a member of the World Federation of Acupuncturists and Moxibustion Society However, training programmes in complementary/alternative medicine, even when offered at the university level, are not legally recognized

Insurance coverage
Each Italian region has its own regulations on the reimbursement of health care 172 In Lombardy, for example, there is a co-payment of 70 000 Italian
lira for complementary/alternative medicine The National Health Service pays the remainder When provided by an allopathic doctor holding a university medical degree, acupuncture, hypnosis, antalgic lasertherapy, pressing massotherapy, lymphatic drainage, reflexive massotherapy, biofeedback, and vertebral manipulation and other articulation massage are reimbursed Since the Italian Government is working to reduce National Health Service expenses, this information is likely to change soon 172 Not all private insurance programmes 172 reimburse complementary/alternative medicine services Those that do vary in the amount they reimburse and they generally require treatments to be provided by allopathic physicians, except in the case of articulation manipulation Insurance premiums vary according to the age, sex, and health status of the patient They are approximately 500 000 Italian lira annually for a child and 1 500 000 Italian lira annually for an adult

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Latvia
Background
information
Several methods of complementary/alternative medicine are integrated into the social welfare system of Latvia 172

Statistics
Homeopathy and acupuncture are the most popular types of complementary/alternative medicine Most complementary/alternative practitioners are allopathic physicians 172 There are several complementary/alternative medical associations

Regulatory situation
The Council of Ministers of the Republic of Latvia has delegated the power to regulate and supervise all medical specialities to the Medical Society of the Republic of Latvia The Cabinet of Ministers Regulations on the Certification of Health Professionals of 1995 172 provides procedures for licensing medical professionals In order to practise legally as a recognized physician, a candidate must have graduated from a local medical academy or from any other medical college delivering a recognized diploma Candidates must also obtain authorization according to local legislation Before allopathic
physicians can legally practice complementary/alternative medicine, they must complete the requisite course and exam for the State licence, which is valid for five years In order to renew a licence, a practitioner must complete a new course and examination Allopathic physicians providing complementary/alternative treatments — such as acupuncture, homeopathy, auriculotherapy, iridology, magnetotherapy, osteoreflexotherapy, phytotherapy, naturopathy, lasertherapy, biofeedback, Ci-Gun, and Su-Jok — are supervised by a commission of experts that includes members of medical associations and the Medical Society of the Republic of Latvia Acupuncture and homeopathy have the same clinical speciality status as allopathic specialities 172 Local laws regulate complementary/alternative medicine 172 The Administrative Codex 172 prohibits non-allopathic practitioners from practising medicine of any kind However, patient lawsuits are uncommon except in cases of serious harm to their
health

Education and training
Since 1990, over 300 physicians from the Scandinavian and Baltic States of Latvia, Estonia, and Lithuania have completed training in acupuncture and traditional Chinese medicine 172 There are a few special programmes 172 for non-allopathic physicians intended to give them basic medical knowledge These programmes consist of between one and

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two years of medical courses at a medical school Qualification courses in the Reiki method and medical astrology are also offered

Insurance coverage
Complementary/alternative treatments are generally not covered by the compulsory health insurance 172 Acupuncture and homeopathy are exceptions: in 1994 they were included in the list of medical specialities reimbursable by social insurance In September 1998, two insurance companies, Balta and Parex, began coverage of legally provided complementary/alternative medicine
They cover two-thirds of expenses for consultations and treatments by acupuncture, homeopathy, Dr R Voll electropuncture, iridodiagnosis, and bioresonance when are provided by authorized allopathic physicians Treatments given by non-physicians are not covered 172

Liechtenstein
Statistics
There are three chiropractors practising in Liechtenstein 45

Regulatory situation
According to Order I and Article 49 of the Health Law 172, to practise medicine in Liechtenstein, a candidate must be a citizen of Liechtenstein; live in Liechtenstein; be a graduate of a Swiss, German, or Austrian school of medicine; have the necessary capacity, reputation, and hygienic knowledge; respect the duties of a general physician; and obtain a licence to practise The right to work as an independent allopathic general practitioner and the right to use a specialist title require postgraduate studies followed by an internship According to Article 22 of the Health Law, chiropractors are considered medical
professionals The practice of complementary/alternative medicine by allopathic physicians is not regulated Allopathic physicians may use complementary/alternative therapies without having to pass a supplementary exam However, Article 9 of Order I states that physicians have to practise only in their speciality and according to their knowledge, with the exception of emergencies Paramedics are also permitted to provide complementary/alternative medicine By Article 24 Paragraph A Lit I of the Health Law of 18 December 1985 178, 179, 180, complementary/alternative practitioners may provide health care so long as they refrain from those acts reserved for allopathic physicians Although there are no court rulings on this point, none of the medical acts included in Article 24 Paragraph A Lit I are considered to be reserved for allopathic physicians in particular those related to natural medicine Therefore complementary/alternative providers only need a business licence to provide treatment
legally, even though they are not

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allowed to provide care in the national health care system A new medical department is in charge of issuing licences and controlling conditions of practice Although complementary/alternative practitioners have yet to be subject to prosecution, Article 184 of the Penal Code 172 specifies that an unqualified person who performs medical acts that are legally reserved for allopathic physicians — such as surgery, treatment of infectious diseases, or prescription of controlled medications — can be punished with a fine or a prison sentence of up to three months The State health authorities perceive a contradiction between Article 24 Paragraph A Lit I of the Health Law and Article 184 of the Penal Code They are considering two ways of resolving it: either introducing a law to cover practitioners of natural medicine or abolishing Article 24 Lit I of the Health Law There is currently a controversial draft Law on Natural Medicine that, if passed,
would resolve the contradiction by loosening the restrictions on the right to perform medical acts

Education and training
Complementary/alternative practitioners are generally trained in foreign countries

Insurance coverage
Complementary/alternative treatments are not covered by compulsory social insurance 172 To obtain reimbursement for such services, it is necessary to have complementary/alternative medical insurance Coverage under this insurance is limited to 5001500 Swiss francs per year

Luxembourg
Regulatory situation
In order to practise medicine as a physician, a candidate must hold a university certificate, obtain authorization from the Minister of Health, and have the consent of the Medical College Treatment, diagnosis, and prevention of disease are restricted to members of the allopathic medical corpus Article 7 of the Law of 29 April 1983 172 stipulates that persons without the required qualifications who practise or participate in the diagnosis or treatment of real or
supposed pathological disorders through personal acts, verbal or written consultations, or other methods, can be prosecuted Non-allopathic practitioners using complementary/alternative medicine are regularly prosecuted Though not legally binding, the Code of Professional Ethics 172 states that it is unethical for allopathic physicians to recommend, to either their patients or acquaintances, therapies that are based on illusory methods or which are not scientifically proven The Medical College 172 is unequivocally opposed to the practice of complementary/alternative medicine in Luxembourg It considers practitioners of

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complementary/alternative medicine to be quacks and crooks Nevertheless, members of Parliament are in favour of granting official recognition to complementary/alternative practitioners and techniques

Education and training
There is no officially recognized
complementary/alternative medical training in Luxembourg 172

Insurance coverage
Reimbursed at 80 of fees, homeopathy is the only officially covered complementary/alternative practice In the case of other complementary/alternative therapies, there is no specific reimbursement rate in the list of publicly covered medical acts and services, meaning that theoretically, they are not covered by public health insurance However, when they are legally provided by a recognized allopathic health care professional, complementary/alternative treatments are unofficially reimbursed in the context of a normal consultation Approved allopathic physicians are thereby free to choose the treatment they provide 172 There are no private insurance companies offering coverage for complementary/alternative medicine 172

Malta
Background information
Traditional Chinese medicine, chiropractic, and osteopathy are widely practised 172

Statistics
There are no established professional organizations or
self-regulating bodies for complementary/alternative practitioners in Malta 172

Regulatory situation
The medical professions are regulated by Part II of the Medical and Kindred Professions Ordinance Chapter 31 of the Laws of Malta and Part IV of the Department of Health Ordinance Chapter 94 of the Laws of Malta 172 Only registered allopathic medical professionals are allowed to practise medicine In order to practise, a candidate must have a licence issued by the President of Malta and be registered in the Medical Register To obtain this licence, the candidate must have successfully completed a university programme leading to a degree as an allopathic medical doctor or the equivalent Allopathic physicians may practice complementary/alternative medicine Non-allopathic practitioners are not legally recognized in Malta, and at present, there is no registration system for such practitioners As stipulated in Chapter 31 of the Laws of Malta, non-allopathic practitioners are not allowed to
perform procedures

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reserved for recognized allopathic medical professionals such as physiotherapists, physicians, and pharmacists However, they are not prohibited from practising medicine Although there are no legal sanctions on complementary/alternative practitioners themselves, a breach of the regulations outlined in Chapter 31 usually constitutes a criminal offence and is punishable by a fine, imprisonment, or both, according to the specific article breached There are also restrictions on advertising treatments and clinics The court exercises its discretion when determining appropriate punishment By Section 98 of Chapter 31 of the Laws of Malta, the only forms of complementary/alternative medicine licensed by the Ministry of Health are acupuncture, moxibustion, and traditional Chinese medicine Conditions of licensing are imposed by the Ministry of Health as deemed fit Article 3 of the provisions requires clinics for traditional Chinese medicine to provide only
traditional Chinese medicine It further stipulates that patients diagnosed with an infectious disease must be referred to a registered allopathic medical practitioner for treatment and that no treatment for infectious diseases can be given at the clinics Article 6 of the provisions outlines hygienic standards for the clinics, and Article 7 states that all persons treated by traditional Chinese medicine, including acupuncture, must be referred by an allopathic doctor registered to practise in Malta The Public Health Department must be informed of the name and qualifications of every person employed under licence The Department is also responsible for carrying out inspections Acupuncture is not registered as a profession in Malta 172 Acupuncture licences are conditional upon proof of adequate training and experience The licensee must renew the licence annually via a written application Acupuncturists employed by the Mediterranean Centre for Traditional Chinese Medicine are usually
qualified allopathic doctors as well as acupuncturists Malta is considering allowing specific complementary/alternative providers, particularly chiropractors and osteopaths, to be registered by the local Board of Professions Supplementary to Medicine alongside allopathic professions 172

Education and training
Bonesetters are usually taught through family training Some chiropractors and osteopaths are certified by overseas teaching institutions As there is no local registration of these practitioners, there are no standardized qualifications to practice 172

Insurance coverage
The State runs acupuncture clinics within the public health services Treatment at these clinics is provided free of charge Private acupuncture clinics provide their

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treatment on a fee-for-service basis The costs of acupuncture and other complementary/alternative medical services obtained privately are not
reimbursed 172 Private insurance does not cover complementary/alternative care 172

Netherlands
Background information
The Dutch Association of Homeopathic Doctors was established in 1898 172

Statistics
According to a 1985 study, 18 of the population has used complementary/alternative medicine at least once — 6 to 7 during the previous 12 months In 1990, over 900 000 people consulted a complementary/alternative practitioner other than their own allopathic general practitioner 172 More women than men use complementary/alternative medicine, especially those between the ages of 35 to 50 Most patients treated with herbal medicines and by paranormal healing have little formal education; most patients of other forms of complementary/alternative medicine are executives and professionals 172 The 1985 survey reported more than 4000 complementary/alternative practitioners in the Netherlands: 735 naturopaths, 300 paranormal healers, 220 homeopaths, 475 anthroposophical professionals either
allopathic doctors or other professionals, such as anthroposophical nurses, 945 acupuncturists, and 1450 manual therapists There are 125 chiropractors practising in the Netherlands 45 In addition to these providers, according to a 1992 survey, almost half of Dutch general practitioners have provided complementary/alternative treatment at least once — 40 have used homeopathy, 9 manipulative medicine, 4 acupuncture, and 4 naturopathy 172 The most popular forms of complementary/alternative medicine are, in order of popularity: homeopathy, herbal medicine, manual therapies, paranormal healing, acupuncture, diet therapy, naturopathy, and anthroposophical medicine 172 The most common conditions presented to complementary/alternative practitioners are musculoskeletal pain and complaints of nervous origin 172 Patients most often report that they use complementary/alternative therapy because allopathic methods are ineffective for their chronic disorders Only 14 of patients seek
complementary/alternative care without having first consulted an allopathic practitioner In one survey of patients treated with complementary/alternative medicine, 56 said that their health condition improved quite a lot, 22 felt that some improvement had occurred, and 22 saw no improvement at all According to a consumer survey, about 80 of the Dutch population would like to have complete freedom of choice over their medical treatments; specifically, they would like health insurance schemes to recognize complementary/alternative

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medicine Sixty per cent of the Dutch population is ready to pay higher insurance premiums in order to have this choice

Regulatory situation
Since 1993, when the Medical Practice Act of 1865 was replaced by the Individual Health Care Professionals Act 172, non-allopathic providers have been allowed to practice medicine in the Netherlands The new act came into force on 1 December 1997, bringing the legal status of non-allopathic practitioners in
line with that of allopathic paramedics: they may practise medicine provided they do not perform specific medical acts reserved for allopathic physicians, except under the orders of an allopathic physician Violation of this limited monopoly can be prosecuted The medical acts reserved for physicians are surgical procedures, obstetric procedures, catheterizations and endoscopies, punctures and injections, general anaesthesia, procedures involving the use of radioactive substances and ionizing radiation, cardioversion, defibrillation, electroconvulsive therapy, lithotripsy, and artificial insemination The Individual Health Care Professions Act also introduces a system to protect the titles of a limited number of professional groups, with the possibility of creating new medical specialities under specific conditions It also defines the training requirements necessary for registration as one of these medical professionals The eight professions regulated are allopathic medical doctor,
dentist, pharmaceutical chemist, health care psychologist, psychotherapist, physiotherapist, midwife, and nurse While nonallopathic practitioners are not allowed to use these titles or to work in the national health services, procedures are now in place for them to obtain recognition for their speciality, including a protected title There are also legal registers in which qualified medical practitioners of homeopathy, herbal medicine, manual therapies such as chiropractic and osteopathy, paranormal healing, acupuncture, diet therapy, naturopathy, and anthroposophical medicine are entitled to be registered once they satisfy specific legal requirements This registration gives them the right to practice under a protected title, with the aim of insuring they are qualified in a specific field of health care 172

Education and training
According to the Dutch Health Council, complementary/alternative medical institutions have organized a number of training courses, taken steps to develop
standards of training and professionalism, and established national registration systems 172 About 60 of the members of complementary/alternative professional organizations have undergone training in a field of allopathic medicine, often as a physician, physical therapist, or nurse 172 Introductory courses on complementary/alternative medicine are included in the curriculum of several Dutch medical schools 172 Allopathic doctors wishing to be trained in anthroposophical medicine, acupuncture, homeopathy, or manipulative therapy can attend part-time courses for one to four

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years There are also postgraduate programmes for physical therapists, most of whom study acupuncture or manipulative therapy Without allopathic medical or paramedical training, individuals may register in one of the three academies for naturopathy offering full-time courses of three to four years 172 Students
completing the three-year basic course in homeopathy earn the designation Homeopathic Physician 53 Registration must be renewed every five years, based on proof of participation in compulsory continuing-education courses A disciplinary committee monitors and penalizes homeopathic malpractice

Insurance coverage
Officially, only homeopathic and anthroposophic medicines are reimbursed by social insurance 172 However, private health insurance reimburses all care given by allopathic general practitioners, whether allopathic or complementary/alternative Two-thirds of the population have private health insurance In 1988, all large private insurance companies 172 began covering homeopathy, acupuncture, and manipulative therapy as part of their standard or supplementary packages In addition to the legally defined standard package, which is the same for all 45 health insurance funds, the funds also offer a supplementary package to which their clients can voluntarily subscribe Under the
supplementary coverage, 26 of the 45 health insurance funds reimburse some kinds of complementary/alternative medicine if provided by an allopathic physician or a physiotherapist, usually homeopathy, acupuncture, and anthroposophical treatments In many cases, reimbursement was given only when care was provided by allopathic physicians or physical therapists who were members of a professional organization In 1991, in response to consumer demand, many packages were expanded to cover more types of complementary/alternative medicine and to cover care provided by non-allopathic practitioners As of 1998, 47 private insurance companies cover between 25 and 100 of complementary/alternative treatments provided by allopathic physicians or members of professional organizations — to a maximum of 300 to 2500 Dutch florins per year This coverage generally includes homeopathy, anthroposophy, acupuncture, manual therapies, chiropractic, naturopathy, and neuraltherapy

Norway
Background
information
Although some authorised allopathic doctors and other health personnel in Norway have integrated acupuncture and/or homeopathy into their practice, most usually do not use complementary/alternative therapies Some persons with authorization to practice as health personnel, such as nurses, have complementary/alternative medicine practices 172

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Statistics
A 1994 poll 172 reported that 23 of men and 30 of women had used complementary/alternative medicine at least once Most respondents in this group were middle-aged persons living in towns The most popular therapies are acupuncture, accounting for 35 of consultations for complementary/alternative treatments; homeopathy, accounting for 33; reflexology, 29; natural medicine, 29; chiropractic, 16; kinesiology, 7; natural healing, 3; and iridology, 3 172 The Norwegian Association of Chiropractors has about 100 members 172

Regulatory situation
In principle, everyone in Norway is allowed to treat patients, regardless of
training or profession However, only allopathic physicians, and to some extent dentists and persons assisting physicians and under the guidance of a physician, are allowed to use the title Doctor of Medicine, use a title indicating a speciality in a specific illness, or advertise 172 — although anyone can place an announcement in the press that contains only a name, address, consultation hours, and general information on services provided Specific medical acts are similarly restricted These include the use of controlled medications in treatment, surgical procedures, injections, general or local anaesthesia, diagnostic or therapeutic methods restricted to physicians, treatment of cancer, diabetes, dangerous anaemia, struma/goitre with sticky forms, and some contagious/infectious diseases mentioned in Act 55 of 5 August 1994 on contagious/infectious diseases such as venereal diseases, tuberculosis, infectious hepatitis, HIV, poliomyelitis, and infectious meningitis, as well as
practising in an itinerant way To receive authorization to practice as an allopathic medical doctor, a candidate must possess a medical degree from a Norwegian or other recognized university and have undergone an 18-month internship Norway has the oldest regulations in Europe on the practice of medicine by nonallopathic physicians 172 The first legislation of this kind in Norway dates back to 1619 A new law was adopted in 1871 The Act of 1871 was to some extent less restrictive than the current Act 9 of 19 June 1936 on the limitations of the right of persons who are not allopathic physicians or dentists to undertake treatment of ill persons Act 9 was used as a model for legislation in Sweden and Denmark Aside from allopathic physicians or dentists, anyone who wants to practise complementary/alternative medicine is subject to Act 9 of 19 June 1936 172 Under the law, non-physicians and non-dentists who treat patients are subject to a jail sentence of up to three months if the patients
life or health is exposed to serious danger either by the treatment or because the patient did not seek a health care provider who could have prevented the danger Anyone sentenced to prison for such violations can no longer practise medicine Except in the most serious cases, criminal sanctions are rarely used Allopathic practitioners are restricted from using complementary/alternative therapies unless the therapies are considered to be responsible practice within the

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practitioners profession, the patient is informed about the method and its status, and the patient agrees to the treatment 172 The insertion of acupuncture needles is considered a surgical intervention and can only be performed by allopathic physicians, dentists, or persons delegated by physicians 172 Since 1990, chiropractors have been officially recognized as health care professionals 172 Only licensed chiropractors
are permitted to use the title of Chiropractor To be licensed, a candidate must have completed a training programme and passed examinations at an approved institution; undertaken additional training in Norwegian health law and chiropractic disciplines; completed one year of practical training; and not be in a position that would lead to withdrawal of the authorization — for instance, the candidate must not be found unsuitable for practising chiropractic due to old age, illness, alcohol/drug abuse, or other circumstances To become a member of the Norwegian Association of Chiropractors, chiropractors must have completed a course approved by the American Council on Chiropractic Education and undergone three months of clinical training With some exceptions, homeopathic medicines may only be sold from pharmacies 172 A licence is necessary to market homeopathic products when the degree of dilution is less than one million In June 1995, the Storting parliament examined the place of
complementary/alternative medicine in the Norwegian health service Among other things, the Storting decided to consider introducing certification of the various types of training and education available for complementary/alternative medical professions In 1997, with the intention of revising the 1936 law, the Ministry of Health appointed a committee to write a report on complementary/alternative medicine The report was delivered to the Ministry in December 1998 It describes the situation of complementary/alternative medicine in Norway and includes a discussion of the clinical effects of treatments, possible legal measures, and means of communicating research results and other information to the public The Government has not yet decided how to follow up on the report In Beijing on 6 April 1999, the Ministers of Health of Norway and China signed a memorandum of understanding on Chinese/Norwegian cooperation in the field of health to increase the knowledge and understanding of traditional
Chinese medicine among Norwegian health personnel 181

Education and training
The 1990 chiropractic law regulates the training of chiropractors; however, there are no recognized schools of chiropractic in the country 172 There are two schools of homeopathy in Norway 53 One offers courses to all persons with some education in allopathic medicine Beginning with the basics, it is a five-year programme with classes taught one weekend each month The other school only offers courses to persons who have the minimum qualifications to practice allopathic nursing
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Insurance coverage
Public reimbursement is not available for what is regarded in Norway as complementary/alternative medicine Coverage for homeopathic treatments, for example, is not included under the official health care system 53 However, by the regulations governing the national insurance scheme, partial reimbursement is available for chiropractic treatment provided the chiropractor is authorized as a health care
professional although not necessarily a member of the Norwegian Association on Chiropractic and the patient was referred to the chiropractor by an allopathic physician This coverage is limited to a maximum of between 10 and 14 consultations per year 172 In Norway, Norsk Helseforsikring 172, which is connected to International Health Insurance Denmark AS, is the only private insurance company offering partial reimbursement for complementary/alternative medicine The insurance covers chiropractic and, when performed by a licensed allopathic physician as part of medical treatment, acupuncture

Russian Federation
Statistics
There are one or two chiropractors practising in the Russian Federation 65

Regulatory situation
The Russian Federation provides a striking example of a change in policy towards complementary/alternative medicine that may be followed in other former socialist countries Section 34 of the Fundamental Principles of the Health Legislation of the Union of the Soviet Socialist
Republics and of the Union Republics required physicians to use only those diagnostic, prophylactic, and therapeutic methods and pharmaceutical products authorized by the Ministry of Health Neither homeopathy nor homeopathic medicines were authorized By contrast, the right to practise the art of healing by popular medicine is protected by Section 57 of the Russian Federation legislation governing health care 182 It remains to be seen how this provision will be interpreted, but its general open-ended language suggests that it is likely that complementary/alternative practitioners will have wide powers to practise A 1995 decree refers to homeopathy in the Russian Federation It permits the use of homeopathy in every clinic and hospital, giving it official recognition There is no law specifically regulating chiropractic, although some chiropractors have been permitted to practise

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Review

Education and training
The State Scientific and Practical Centre of Traditional Medicine and Homeopathy of the Ministry of Public Health of the Russian Federation was created in 1999 The Centres goals include organizing and conducting scientific research and coordinating and realizing educational activities in complementary/alternative medicine A standard Government education programme in homeopathy has been developed by the Committee for Homeopathy of Russia and approved by the Ministry of Health 53 Homeopathy has also been introduced at the Russian Medical Academy as a postgraduate speciality 86

Spain
Background information
Homeopathy was introduced into Spain in the beginning of the 19 century 172 The first Spanish homeopathic hospital, the Fundacion Instituto Homeopatico y Hospital de San Jose in Madrid, was founded in 1878 The Academia Medico Homeopatica de Barcelona was founded in 1890 There is an outpatient homeopathic clinic at the Hospital del Nen Deu of Barcelona 53
The Spanish Society of Homeopathic Medicine was founded in 1996 It represents all homeopathic associations 172 In addition to homeopathy, popular complementary/alternative therapies include acupuncture, auriculotherapy, neuraltherapy, and biological medicine However, until 1987, complementary/alternative medicine with the exception of homeopathy had only a minor role in the Spanish health care system 172 There are several associations linked to complementary/alternative medicine in Spain Since 1996, the Spanish Medical Council has supported complementary/alternative medicine, provided it is practised by licensed physicians 172
th

Statistics
There are 50 chiropractors practising in Spain 45

Regulatory situation
In Spain, the practice of medicine is the exclusive right of allopathic doctors 172 In order to obtain the right to practise medicine, a candidate must hold an academic degree in medicine, have authorization from a medical college, pledge professional secrecy, be current in his
or her taxes, and as outlined in the Statutes of the Collegial Medical Organization, respect the Spanish Code of Professional Ethics of 1990 Natural medicine, by the Royal Decree of 27 March 1926, may only be practised by licensed allopathic physicians On 16 June 1997, the Code of Medical Professional Ethics 172 was adopted in Catalonia Article 44 of this code stipulates that doctors using complementary/alternative medicine must inform their patients of the importance of continuing necessary
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allopathic treatments and of the non-conventional character of the complementary/alternative therapy Furthermore, doctors must coordinate their supplementary therapy with the allopathic physician in charge of the patients basic treatment Article 44 forbids using methods that have not been scientifically validated to make a diagnosis or treat a patient Royal Decree 127/1984 does not include branches of complementary/alternative medicine as medical specialities 172 Opposing this,
professional associations registered with the Ministry of the Interior are seeking recognition from the Spanish Government for graduate practitioners using complementary/alternative medical techniques The Council of Medical Colleges of Catalonia wants to make homeopathy, acupuncture, and natural medicine official Under Article 62 of Royal Decree 3166/1966 of 23 December 1966, licensed paramedics are allowed to perform medical acts only under the supervision of an allopathic physician 172 The three categories of paramedic professions are practitioners of odontology, psychologists, and university graduates in nursing, which include, for example, physiotherapists Some paramedics illegally practice complementary/alternative medicine The illegal practice of medicine is regulated by Article 403 of the Penal Code, approved on 23 November 1995 172 This article states that if persons without relevant academic certificates practise acts specific to a profession, they risk imprisonment for a
period of up to 12 months This includes all intrusions made by non-allopathic physicians in the field of medicine State authorities are relatively tolerant with private allopathic doctors and nonallopathic practitioners using complementary/alternative medicine On 23 January 1984, in response to a case regarding acupuncture and reflexology, the Spanish Supreme Court declared that it is not necessary to have a degree in medicine in order to practise medicine 172 However, only approved medical professionals may make a diagnosis, give a clinical or medical examination, or decide to apply a specific therapy On 19 June 1989, in a Supreme Court decision, a non-allopathic practitioner of acupuncture-moxibustion was found not guilty of intrusion into the field of medicine on the basis of two points 172: first, the practitioner had several foreign certificates and was a member of the Latin American Association of Research on AcupunctureMoxibustion; second, as complementary/alternative medicine
is not taught within Spanish medical faculties and as there is no official certificate authorizing and legitimizing complementary/alternative medical practice, it does not legally exist Consequently, it does not correspond to any legally determined profession and therefore its practice cannot be the object of intrusion In January 1993, the Supreme Court released a non-physician acupuncturist 172 The argument was the same: complementary/alternative medicine is not included within

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the official list of medical specialities and therefore practising complementary/alternative medicine is not an intrusion into the field of medicine Similarly, the Spanish Association of Physiotherapists denounced certain chiropractors for intrusion into the field of medicine However, in an 18 March 1997 decision, the regional Court of Valencia stated that chiropractors and other practitioners using
complementary/alternative medicine are not committing intrusion Article 54 of the Law on Medicaments 25/1990 of 20 December 1990 and Royal Decree 2208/1994 of 16 November 1994 regulate homeopathic remedies and the commercialization of homeopathic products 53

Education and training
The medical universities of Madrid, Sevilla, Murcia, Zaragoza, Valladolid, Barcelona, and Santiago offer certificate courses in homeopathy, naturist medicine, and acupuncture to allopathic physicians The universities of Barcelona, Sevilla, Valladolid, and Murcia offer postgraduate training in homeopathy for physicians 53 For pharmacists and veterinarians, some universities offer basic and advanced homeopathic training programmes as well as other courses and certificates Sociedad Española Acupunctura and Sociedad Española de Medicos Acupunctores in Madrid offer two-week introductory courses, three 90-day training courses, and a complete three-year training programme With the sponsorship of the Council of
Europe and the World Health Organization, the Teaching Centre of Traditional Chinese Medicine in Spain provides comprehensive training for both physicians and non-physicians in acupuncture with the intention of gaining professional status for acupuncture Other professional organizations also provide courses in complementary/alternative medicine 172

Insurance coverage
Two public hospitals, Hospital del Nen Deu in Barcelona and Fundacion Instituto Homeopatico y Hospital de San Jose in Madrid, provide homeopathic care to outpatients on a fee-for-service basis Under Article 94 of Law 26/1990 of 20 December 1990, there is no justification for homeopathic products to be financed through the State insurance system, INSALUD Efforts by the Homeopathic Physicians Charter of the State of Spain to gain social security coverage for homeopathic medications have been unsuccessful 172 In Spain, only a few private insurance companies provide coverage for any complementary/alternative medicines
172

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Sweden
Statistics
In a 1989 survey 172, 20 of adults reported having received complementary/alternative medical treatment Forty per cent of patients of complementary/alternative medicine stated they had chosen these treatments because they were not satisfied with the National Health Service Seventy per cent stated that through their complementary/alternative treatment their health had improved or they had been cured of their illness; 1 stated their health had deteriorated Chiropractic is the most commonly consulted complementary/alternative medicine in Sweden Thirteen per cent of the population has consulted one of the 130 practising chiropractors at least once 45 The next most popular form of complementary/alternative medicine is homeopathy, accounting for 4 of consultations, followed by acupuncture, naturopathy, and herbal medicine

Regulatory situation
In Sweden, the National Board of Health and Welfare 172 maintains a registry of public health and medical
personnel Practitioners who are not included in the Supervision of Health and Medical Personnel list of medical practitioners which includes only allopathic doctors, dentists, nurses, midwives, and physiotherapists may not be registered Thus, officially only recognized medical practitioners are under public scrutiny The requirements for practising medicine are included in the Act on Competence 542 of 1984 and the Medical Care Act 786 of 1996 172 Although non-registered persons may treat patients, specific medical acts are restricted to allopathic physicians The specific treatments reserved for physicians are outlined in the Quackery Act — Law 409 of 1960 172, modified in 1982 Only a physician is allowed to act as a doctor in medicine; practise general or local anaesthesia; provide care with radiological methods; practise in an itinerant way; treat specific contagious diseases; treat cancer, diabetes, epilepsy, or pathological conditions associated with pregnancy or childbirth; treat a
child who is younger than eight years old; issue written recommendations or instructions for the treatment of patients who are not personally examined by them; provide acupuncture; and test or supply contact lenses The violation of these restrictions is an offence and may be prosecuted Non-allopathic practitioners who damage a persons health by using inappropriate therapies may be charged with charlatanism constituting a danger to health Practitioners found guilty of this charge are punishable under the penal law and may be prohibited from working in the health care field In 1989, Sweden granted recognition to chiropractors satisfying the standards of the Council of Chiropractic Education By Government Bill 1988/89:96 172, those chiropractors completing studies as doctors of chiropractic have the right to obtain a licence and to be registered under the National Health Service However, no Swedish
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training programme has so far been certified as meeting the appropriate standards Currently, all registered practitioners have been trained abroad Chiropractors trained at the Scandinavian College of Chiropractic in Stockholm are working to be included among the recognized practitioners Homeopathic remedies are legal and are manufactured according to good manufacturing practices 53 In 1994, official recognition was extended to naturopaths The Swedish Commission on Competence 172 does not intend to amend the rules of authorization for them Osteopaths remain unrecognised and the Swedish Commission on Competence does not have any proposals regarding osteopathy The Swedish Commission on Competence was delegated to undertake a comprehensive review of the principles governing authorization and competence and, in the light of this review, to put forward proposals concerning, for example, rules of authorization and competence for various categories of professional medical
care, including the Quackery Act The Swedish Parliament mandated the Commission on Alternative Medicine 172 to examine issues concerning the position of complementary/alternative medicine in Swedish society The recommendations of the Commission on Alternative Medicine 1989 and the proposals of the Swedish Commission on Competence 1996 can be summarized as follows: create an association of non-allopathic practitioners who have had at least one year of training and are registered by the National Board of Health and Welfare; create a State register of all non-allopathic practitioners who have passed their exams; create professional titles; uphold the law reserving specific medical acts for allopathic physicians; introduce some types of complementary/alternative medicine into the National Health Service and incorporate complementary/alternative practitioners into the National Health Service, provided specific conditions are fulfilled; strictly control the advertising of natural
remedies; plan scientific studies on the effectiveness of complementary/alternative medicine

Education and training
Most of the increasing numbers of homeopaths working in Sweden today have been educated at private institutions This education corresponds to that of allopathic physicians in many ways There are three private schools providing homeopathic training There is also a four-year basic medicine course taught by professors from the
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University of Upssala 53 No Swedish chiropractic training programme is officially recognized

Insurance coverage
While non-allopathic practitioners may treat patients in Sweden, their care is not reimbursed by the health care system 172 Only acupuncture provided by an allopathic physician is reimbursed by social insurance, and then only partially The Commission on Complementary/Alternative Medicine did not propose the reimbursement of treatments obtained from practitioners of complementary/alternative medicine

Switzerland
Background
information
Patients of complementary/alternative medicine who are ill report that they use complementary/alternative medicine because the therapies do not involve treatment with drugs or chemicals, there are no side effects, and allopathic medicine was unsuccessful in treating their illness Patients of complementary/alternative medicine who are not ill report that they use complementary/alternative medicine to improve their well-being and to keep from falling ill 172

Statistics
A 19921993 study 172 showed that the use of complementary/alternative medicine within the previous 12 months was closely related to whether or not a patient had complementary/alternative health insurance: Of those surveyed who had insurance covering complementary/alternative medicine, 207 did not use complementary/alternative medicine; 189 used one form of complementary/alternative medicine; 215, two forms; and 390, three or more forms Those without insurance covering complementary/alternative medicine
reported the following: 564 did not use complementary/alternative medicine; 205 used one form of complementary/alternative medicine; 134, two forms; and 97, three or more forms Persons living in the German-speaking and French-speaking parts of the country used complementary/alternative medicine more extensively than those living in the Italian-speaking region Women and persons with higher levels of formal education were more likely to consult a complementary/alternative medical practitioner than were men and persons with lower levels of formal education The most commonly consulted forms of complementary/alternative medicine are shown in the chart below

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Type of Complementary/Alternative Medicine Consulted Homeopathy Alternative massage therapies Phytotherapy Nutrition therapy Acupuncture Anthroposophic medicine Magnetotherapy

Patients with insurance coverage 63 41 27 22 18 13
8

Patients without insurance coverage 26 19 14 9 4 3 3

The percentages are the proportion of respondents who consulted a complementary/alternative practitioner, not the total number of people surveyed

There are approximately 180 chiropractors practising in Switzerland 45 Complementary/alternative therapies are provided by allopathic physicians, natural doctors, non-allopathic practitioners, pharmacists, and patients themselves 172 There are many organizations linked to complementary/alternative medicine in the country

Regulatory situation
In Switzerland, cantons similar to states or provinces make their own public health regulations, including the regulation of local medical practice 172 Nonetheless, some degree programmes and professions, such as allopathic physicians or chiropractors, are recognized throughout the country, and the titles of some professions, including Medical Doctor and Chiropractor, are protected The cantons allowing only allopathic physicians to practice
medicine are Appenzell internal Rhodes, Jura, Nidwalden, Uri, and, with the provisions noted, the following: Aargau: a licence is not required to provide care to healthy persons when treating nervousness, stress, sleeplessness, or phobias, for example Basel Stadt: authorized physiotherapists and masseurs are permitted to use reflexology Bern: the practice of acupuncture by non-allopathic practitioners is tolerated when provided under the orders of an allopathic physician Fribourg: the Department of Health may issue licences to practise complementary/alternative medicine on condition that practitioners do not use methods and techniques restricted to authorized health care professionals Geneva: recently, the authorities have been relatively tolerant of non-allopathic practitioners Glarus: reflexology, acupressure, and other similar forms of massage may be freely provided

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Schwyz: non-physicians may obtain a licence to practise acupuncture Solthurn: a draft law would
enable the practice of complementary/alternative medicine as a self-employed profession Vaud: recently, the authorities have been relatively tolerant of non-allopathic practitioners Zug: under the supervision of the health authority, reflexology, sport massage, acupressure, and health advising may be freely provided Acupuncture may be provided by persons who have completed three years of training, including comprehensive theoretical and practical courses, and who have passed a cantonal exam Zürich: magnetism is not considered a form of medicine and, therefore, its practice does not require official authorization Although the law in these cantons is typically monopolistic, the authorities are relatively tolerant with regard to non-allopathic practitioners In order to be allowed to practice in German-speaking cantons Appenzell external Rhodes, Basel Landschaft, Graubünden, Luzern, Obwalden, St Gallen, Shaffhausen, and Thurgau, non-allopathic providers must pass the State exam and
obtain a licence from State authorities In most German-speaking cantons, there are specific medical acts that are reserved for physicians In non-German-speaking cantons, the situation is slightly different In the canton of Neuchtel, since the introduction of a 1995 law, non-allopathic practitioners are permitted to provide non-dangerous complementary/alternative therapies While a licence to practice is not required, complementary/alternative medical providers may not advertise their services In Valais, the same restrictions apply, with two additional requirements: complementary/alternative providers must clearly inform their patients that they do not have any allopathic education and they must have a licence from the health department In the canton of Ticino, non-allopathic practitioners may practise medicine without a licence; however, they must clearly inform their patients that they do not have an allopathic education And, they are not permitted to advertise; use optical,
mechanical, electrical, or ionizing equipment; or prescribe medications or drugs Homeopathy is among the most frequently practised complementary/alternative therapies in Switzerland All persons legally providing health care may apply homeopathy according to the standards of good medical practice In some cantons, those not medically qualified may practice homeopathy as well 53 In 1998, the National Medical Association recognized homeopathy as a medical sub-speciality 86 Chiropractic is considered an independent medical profession that is federally regulated and recognized throughout the country 172 There are several requirements that must be met to be allowed to practise as a chiropractor, including

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limited competence in medical diagnosis and treatment To practice chiropractic, a person must have Swiss citizenship, hold a diploma giving access to a university, have studied at least
four years in a chiropractic college recognized by the American Council on Chiropractic Education, have passed the American commission exam, have passed the Swiss intercantonal exam, have passed the Swiss federal exam to be allowed to X-ray, and have completed at least a one-year internship with a Swissauthorized chiropractor

Education and training
The universities of Zürich and Bern include an introductory course on complementary/alternative medicine in the standard curriculum for allopathic physicians In Bern there are also more extensive courses on homeopathy, neuraltherapy, traditional Chinese medicine, phytotherapy, anthroposophic medicine, hydrotherapy, and bio-resonance 172 The Swiss Medical Association 172 has been aware of the need to establish complementary/alternative medical specialities In 1999 and 2000, it set up a new training programme for allopathic physicians Homeopathy, Chinese medicine, acupuncture, anthroposophic medicine, and neural therapy are now granted
speciality titles for allopathic physicians Training for these techniques, as with allopathic specialities such as cardiology or rheumatology, lasts between eight and 10 years Students who are not allopathic practitioners may study at any one of several private institutions offering training programmes in complementary/alternative medicine, including the following: Swiss Association of Natural Doctors: the programme, which lasts six semesters and is provided on weekends, includes introductions to anatomy, physiology, and biochemistry; seminars in physiology and pathology; and seminars on diagnostic and treatment techniques School for Natural Medicine in Zürich: two training options are available, both include basic courses in anatomy, physiology, and pathology Students then specialize either in homeopathy and traditional Chinese medicine or in several forms of complementary/alternative massage The programme lasts four years Academy for Natural Medicine in Basel: the school offers a
basic common course in anatomy, physiology, pathology, psychiatry, neurology, and physical diagnosis After completing this common course, students choose from among three specializations: homeopathy, phytotherapy and natural medicine; traditional Chinese medicine; or acupuncture The programme lasts four years plus a required four-month internship Swiss School for Osteopathy of Belmont/Lausanne: this school is working to obtain official recognition equivalent to a university faculty It offers a five-year diploma and a six-year doctorate programme

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Although chiropractic is a recognized profession in Switzerland, there are no recognized chiropractic schools in the country Practitioners must train abroad Some cantons — Appenzell external Rhodes, Basel Landschaft, Graubünden, Obwalden, St Gallen, Shaffhausen, and Thurgau — have specific rules concerning the exam that candidates must pass to be allowed to practise complementary/alternative medicine 172

Insurance
coverage
There are several levels of health care protection in Switzerland 172 Insured persons are free to choose between minimum basic coverage and extensive coverage provided through policies that provide coverage for complementary/alternative health care and medications Since July 1999, five commonly used complementary/alternative therapies — homeopathy, Chinese medicine, anthroposophic medicine, neural therapy, and phytotherapy — have been reimbursed by compulsory social insurance when they are provided by an allopathic physician with a postgraduate education recognized by the Swiss Medical Association Treatments provided by non-allopathic physicians are not reimbursed Except for acupuncture, in order for these therapies to continue to be reimbursable after 2005, their efficacy and cost-effectiveness have to be proven by that year The complementary/alternative medicine policies of private insurance companies influenced the Swiss Governments decision to cover the most commonly
used therapies 172 Private insurance companies, such as Caisse Vaudoise, generally offer complementary/alternative health care policies covering acupuncture, acupressure, Alexander technique, anthroposophy when provided by a physician, audiopsychophonology, auriculotherapy, lymphatic drainage, etiopathy, curative eurythmy, eutony, homeopathy, postural integration, iridology, colonic irrigation, Kneipp therapy, kinesiology, anthroposophic medicine, mesotherapy, naturopathy, osteopathy, polarity, energetic balancing, reflexology, relaxation, breathing techniques, shiatsu, sophrology, and sympathicotherapy The supplementary fee for complementary/alternative policies varies between 10 and 20 Swiss francs per month Reimbursement varies between 30 and 100 Swiss francs per consultation; three to 10 consultations are covered per year

Ukraine
Statistics
There are no hospitals in Ukraine in which only complementary/alternative therapies are used 172

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and Complementary/Alternative Medicine: A Worldwide Review

Regulatory situation
Though allopathic physicians may use allopathic or complementary/alternative therapies, only allopathic physicians and registered non-allopathic practitioners working under physicians are allowed to provide medical treatments 172 The Ministry of Health authorizes licences for physicians It requires an authenticated copy of documents attesting to the level of education and necessary qualifications for the practice of medicine, such as a medical diploma or a certificate of specialization, a letter of reference issued by a former employer, and approval from the designated local authority Complementary/alternative medicine is covered under general regulations 172 In order to be registered as a legal non-allopathic practitioner, it is necessary to complete a special programme given by the Academy of Physicians Postgraduate Education or by the Ukrainian National Medicine Association, which is under the
supervision of the Ukrainian Ministry of Public Health Some specific branches of complementary/alternative medicine, such as reflexotherapy, have their own code of speciality 172 Steps are being taken to introduce an official specialization in homeopathy for allopathic physicians 53 Homeopathic remedies are officially recognized by the Decree on Medicines of the Ministry of Health Quality control of homeopathic remedies is based on the German Pharmacopoeia 172 The Ukrainian Ministry of Public Health regulates the production of homeopathic medicines, and the Comission of the Pharmacological Committee on Homeopatic Medicines under the supervision of the Ukrainian Office for Public Health is responsible for delivering licences for their sale Specialised homeopathic chemist shops exist in Ukraine People can also buy homeopathic medicines from Germany and Austria

Education and training
The Academy of Physicians Postgraduate Education and the Ukrainian National Medicine Association offer
special courses for non-allopathic practitioners in homeopathy, iridology, reflexotherapy, aromatherapy, and phytotherapy 172

Insurance coverage
There is no public or private reimbursement of complementary/alternative medicine 172 Patients seeking complementary/alternative treatment must pay for the care themselves

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United Kingdom of Great Britain and Northern Ireland
Background information
Successive governments have ensured that as long as patients require complementary/alternative treatment, access to it will be guaranteed As a result, the United Kingdom is the only country in the European Union with public-sector hospitals for complementary/alternative medicine Indeed, there are National Health Service homeopathic hospitals in London, Glasgow, Liverpool, Bristol, and Tunbridge Wells 53 At Saint Marys Hospital, where relaxation, dietetic, yoga, and meditation therapies are available, allopathic physicians work closely with non-physicians Homeopathy provided by
allopathic physicians is included in the National Health Service 86 Complementary/alternative medications, homeopathic products, and other natural remedies are becoming increasingly popular and are now widely available in health food stores and pharmacies 172 In response to the increased use of complementary/alternative medicine by the public and the Governments concern over its effectiveness, the British Research Council on Complementary Medicines was formed in 1982 Among other things, it noticed the major role of complementary/alternative medicine in reducing the costs of the health care system 172 In general, in order to become a member of a professional organization, nonallopathic practitioners must be covered by insurance and adhere to the Code of Professional Ethics 172

Statistics
During the past 20 years, interest in complementary/alternative medicine has increased 172 Seventy per cent of the public is in favour of complementary/alternative medicine becoming widely available in
the National Health Service — particularly osteopathy, acupuncture, chiropractic, and homeopathy One-eighth of the British population has tried complementary/alternative medicine, and 90 of these people are ready to use it again Complementary/alternative medicine is most popular with middle-aged, middle-class women The complementary/alternative therapies most used are herbal medicines, osteopathy, homeopathy, acupuncture, hypnotherapy, and spiritual healing Much complementary/alternative medical practice centres on treating chronic diseases Most patients of complementary/alternative medicine are also patients of allopathic medicine 172 Complementary/alternative practitioners without an academic degree provide the largest proportion of complementary/alternative medicine In 1987, there were about 2000 non-allopathic medical practitioners In 1999, there were 50 000 complementary/alternative medical providers Approximately 10 000 of these are officially registered health professionals In
1998, up to five million patients consulted a com-

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plementary/alternative practitioner Patients spend about 16 billion pounds sterling each year on complementary/alternative medicine 183 There are approximately 1300 chiropractors practising in the United Kingdom 45 There are several professional associations of complementary/alternative practitioners

Regulatory situation
Although complementary/alternative medical practitioners without an allopathic medical degree are tolerated by law, only medical providers holding a university degree in allopathic medicine are officially recognized 172: to practise medicine as a physician, a person must posses a certificate or qualification from the faculty of medicine of a university and complete one year of general clinical training During the clinical training period, a physician candidate has provisional registration After satisfactorily
completing the training, the candidate may obtain full registration Being a registered medical practitioner confers privileges and responsibilities, including the right to use the title or describe oneself as a registered practitioner, to be recognized by law as a physician or surgeon, to recover fees for medical attendance or advice in a court of law, to hold specific posts, to provide general medical services in the National Health Service, and to give some statutory certificates The General Medical Council, a statutory body that regulates the medical profession, maintains the register of qualified allopathic doctors Although registration, for which specific training is required, provides certain privileges to non-allopathic practitioners as well, the right to practise medicine without formal recognition is established in British Common Law 172 This right protects an individuals freedom to carry out medical activities not specifically prohibited by an act of Parliament As a result,
given some restrictions and provided they do not breach the Medical Act of 1983, non-allopathic providers can practise medicine regardless of their training In principle, non-registered persons are even allowed to perform surgical acts with the consent of patients If such acts result in maltreatment, however, non-allopathic practitioners may be prosecuted under the penal law and the tort-based common law of negligence And if a patient dies, the practitioner may be prosecuted for involuntary homicide Registered physicians cannot be so prosecuted Under the terms of the Venereal Disease Act of 1917 and Section 4 of the Cancer Act of 1939 172, there are some limitations on the rights of non-allopathic practitioners Non-allopathic practitioners may not perform certain medical acts, practice specific professions, or use particular titles Only registered allopathic doctors may treat cancer, diabetes, epilepsy, glaucoma, and tuberculosis; prescribe controlled drugs; perform specific medical
acts such as abortion; or treat venereal diseases Unqualified practitioners may not claim to be or practise as pharmacists, midwives, or dentists, or imply that they are State-registered allopathic practitioners whose legal status is regulated by the Professions Supplementary to Medicine Act of 1960 This Act regulates dieticians, medical laboratory technicians, occupational therapists,

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physiotherapists, radiographers, and orthopaedists Further, commercial use of the term health care centre in relation to any premises where no allopathic doctors and nurses are employed is prohibited Allopathic physicians referring patients to non-allopathic practitioners for treatment retain clinical responsibility for their patients The Medical Act of 1983 172 does not regulate which forms of therapy may be practised by registered physicians Thus, there is no restriction on registered allopathic physicians using complementary/alternative medicine if they have the requisite skills and/or
qualifications Further, the agreement of 1 April 1990 between allopathic general practitioners and the Family Health Service Authorities does not define the staff that may work with an allopathic physician Thus, a physicians staff may include physiotherapists, chiropractors, and dieticians In 1950, the Government gave official recognition to homeopathy in the Faculty of Homeopathy Act The Government regulates osteopathy and chiropractic through the quite similar Osteopath and Chiropractor Acts of 1993 and 1994 172 While registered practitioners of these two professions have special rights, including title protection, they, like other non-allopathic practitioners, are not recognized as official health care providers and may not work in National Health Service hospitals Nonetheless, these two acts are considered to be important developments in complementary/alternative medicine Other practitioners, including acupuncturists, homeopaths, and herbalists, are now pursuing the same level of
recognition The regulation of chiropractors and osteopaths, as with all health care professionals, is based upon a register The right to use the title of Chiropractor or Osteopath is restricted to registered chiropractors and osteopaths, and registration depends on having recognized qualifications, although there are transitional provisions for experienced practitioners The General Chiropractic Council, which includes a significant number of nonchiropractors, is publishing its own Code of Professional Ethics Under the Osteopath and Chiropractor Acts of 1993 and 1994, the principal criteria for disciplinary action are professional incompetence, conduct that falls short of the standards required of a registered osteopath or chiropractor, conviction of a criminal offence, and serious health impairment affecting the ability to work as an osteopath or chiropractor Under this Code, practitioners facing disciplinary action from the Committee may be admonished, suspended, or dismissed The
right to practise is initially granted for a period of up to three years, then for periods of two to three years However, this is not yet in effect Homeopathic and other natural remedies are sold by many independent pharmacies The European Directive on Homeopathic Products regulates the making and marketing of homeopathic products in the United Kingdom 172 The licensing of other medicines is regulated by the Medicines Act of 1968 172 Applications for drug registration must be accompanied by details of relevant research and clinical trials

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Requirements are less stringent if the medicines do not contain a new chemical substance or if they are herbal preparations The Health Act of 1999 183 provides two options for achieving statutory regulation for a profession or therapy The first option allows associations representing a profession to apply for statutory regulation The second option
allows professions to join the Health Professions Council; membership in the Council confers title protection

Education and training
The British Medical Association recommends incorporating complementary/alternative medicine into the undergraduate curriculum of medical schools and making accredited postgraduate training available 172 While most non-allopathic practitioners have good training, the quality of complementary/alternative medical programmes varies The Institute of Complementary/Alternative Medicines is working with the Training Desk to establish national standards of training acceptable to both the public and the Government 172 There are 54 professional associations representing complementary/alternative practitioners and offering comprehensive full-time courses in anthroposophy, chiropractic, homeopathy, phytotherapy, naturopathy, and osteopathy, lasting for a minimum of three years 172 The Faculty of Homeopathy Act empowers the Faculty of Homeopathy to train, examine, and
confer diplomas in homeopathy to allopathic physicians and other statutorily recognized health professionals 172 There are four schools of chiropractic in the United Kingdom 65

Insurance coverage
With some exceptions, fees for complementary/alternative therapies are not reimbursed by the social security system 172 Exceptions are made for treatments available within National Health Service hospitals, which are provided free of charge, and occasionally for acupuncture, osteopathy, and chiropractic treatments An allopathic general practitioner may claim reimbursement for a wide range of staff, including physiotherapists, chiropractors, and dieticians; however, the authorities have the freedom to reimburse all, part, or none of these costs Some private insurance programmes 172 reimburse the five most popular forms of complementary/alternative therapy — homeopathy, osteopathy, herbalism, acupuncture, and naturopathy — when they are provided by allopathic physicians The services of
chiropractors and osteopaths are reimbursed by trade bodies and by several associations, such as industrial and veterans associations

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South-East Asia

Bangladesh
Background information
Ayurvedic medicine is widely practised in Bangladesh

Regulatory situation
When Bangladesh constituted the eastern part of Pakistan, the Pakistani Board of Unani and Ayurvedic Systems of Medicine was operative in the country Following independence, the Bangladesh Unani and Ayurvedic Practitioners Ordinance of 1972 restructured this body as the Board of Unani and Ayurvedic Systems of Medicine, Bangladesh 184 The Board is responsible for maintaining educational standards at teaching institutions, arranging for the registration of duly qualified persons including appointing a registrar, and arranging for the standardization of unani and ayurvedic systems of medicine A research institute has been functioning under the Board since 1976 The Bangladesh Unani and Ayurvedic Practitioners
Ordinance of 1983 185 prohibits the practice of unani and ayurvedic systems of medicine by unregistered persons A significant feature of the Ordinance is the deliberate omission of a provision contained in preceding legislation that made it an offence for an ayurvedic or unani practitioner to sign birth, medical, and physical-fitness certificates

Education and training
Control over the teaching of unani and ayurvedic medicine rests with the Board of Unani and Ayurvedic Systems of Medicine 186 There are nine teaching institutions under the Board, five for unani medicine and four for ayurvedic medicine They offer diplomas upon completion of a four-year programme The Registrar of the Board also serves as the Controller of Examinations

Bhutan
Background information
What is now classified as Bhutanese traditional medicine was introduced into Bhutan th in the beginning of the 16 century by Lam Shabdrung Ngawang Namgyal 187 This medical system has roots in Buddhism and Tibetan traditional
medicine During its early practice in Bhutan, providers of traditional medicine were trained in Tibet

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In addition to medications, Bhutanese traditional medicine includes acupressure, acupuncture, moxibustion, cupping, cauterization, medicated oil massage, herbal and steam baths, and the application of cold and warm poultices to the body 187 In 1988, a research unit was established in the Institute of Traditional Medicine Services 187 This unit conducts research for further quality control of raw materials and finished products for traditional medicines as well as developing new products It also ensures the sustainability of traditional medicine services and looks for ways to increase the cost-effectiveness of traditional medicine

Statistics
There is a hospital for traditional medicine in Thimphy, the capital city of Bhutan An additional 15 traditional medicine units across the
country provide services to about 60 of the countrys population The Government plans to establish more units, to cover all 20 districts in the country 187 There are more than 2990 different medicinal plants used in Bhutanese traditional medicines 187 About 130 traditionally used formularies are made from 110 different herbal preparations About 70 of the raw materials used in these preparations are available in the country, both as wild and cultivated stocks The remaining 30 are imported from India There are more than 300 herbal products produced in Bhutan Most are compound forms, with three to 90 ingredients 187

Regulatory situation
In 1967, in an effort to promote and preserve traditional medicine, it was formally recognized and institutionalized as an integral part of the national health system of Bhutan 187 In 1979, the Institute of Traditional Medicine Services 187 was founded It is housed in an allopathic hospital in order to encourage the integration of traditional and
allopathic medicine, particularly mutual consultation, treatment, and referrals, and to enable patients to have greater access to a range of health care choices Bhutans Institute of Traditional Medicine Services is charged with establishing a traditional medicine system that is scientifically sound and technologically appropriate, and which meets the needs of the population To fulfil this mandate, the Institute works to provide access to traditional medicine for the entire population; to attain self-reliance in raw materials for the production of traditional medicines, including the conservation, cultivation, rotational collection, and preservation of rare and endangered species of medicinal plants; to improve the quality of traditional medical services through training practitioners; and to increase the production of traditional medicines for export Profits from exporting traditional medicines are to be used to strengthen traditional medicine within Bhutan Small-scale mechanised
production of traditional medicines started in 1982 with the assistance of the World Health Organization; previously, all medicines had been prepared manually 187 All herbal products are now produced mechanically

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following good manufacturing practices, with an emphasis on quality control Herbal products take the form of pills, tablets, medicated ointments, syrups, and capsules and are purely natural — no artificial chemicals are used

Education and training
Officially recognized formal training of traditional medical doctors drungtsho began in 1971 with the establishment of a five-year drungtsho programme In 1978, the training curriculum was standardized In 1979, the programme became part of the National Institute of Traditional Medicine 187 The course now consists of five years of institutional training followed by a six-month internship: three months in an allopathic hospital and three months in the traditional medicine hospital and a traditional medicine
unit During the three-month internship in the allopathic hospital, interns are introduced to allopathic medicine and the health sciences 187

Democratic Peoples Republic of Korea
Regulatory situation
In the Democratic Peoples Republic of Korea, traditional medicine is integrated into the official health care system This policy of integration is reflected in a number of policy declarations since 1947 It was a prominent feature of the Governments 1967 political programme and was reiterated in a 1980 public health law 188 Under Article 15 of this law, with a view to preserving national therapeutic traditions, the State is required to combine traditional medical practices with allopathic diagnosis in medical establishments

India
Background information
For centuries, ayurveda, siddha, and unani systems of medicine have coexisted with yoga, naturopathy, and homeopathy 2 See the Introduction for descriptions of ayurveda, unani, and homeopathy Siddha 2 is one of the oldest systems of medicine
in India In Tamil, siddha means perfection and a siddha was a saintly figure who practised medicine Siddha has close similarities to ayurveda, the difference between these two systems being more linguistic — Tamil versus Sanskrit — than doctrinal In siddha, as in ayurveda, all objects in the universe, including the human body, are composed of the five basic elements: earth, water, fire, air, and sky Yoga 2 was propounded by Patanjali and is based upon observance of austerity, physical postures, breathing exercises, restraining of sense organs, contemplation, meditation, and samadhi

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Naturopathy 2 is a system of drugless treatment and a way of life It is very close to ayurveda The introduction of allopathic medicine during the colonial period led to the Governments neglect of traditional medical systems Now, however, ayurveda, unani, siddha, naturopathy, homeopathy, and yoga are well
integrated into the national health care system 2 There are State hospitals and dispensaries for both traditional medicine and homeopathy; however, traditional medicine and homeopathy are not always well integrated with allopathic medicine, particularly in allopathic hospitals

Statistics
Traditional medicine is widely used in India, especially in rural areas where 70 of the Indian population lives There are 2860 hospitals, with a total of 45 720 beds, providing traditional Indian systems of medicine and homeopathy in India In 1998, more than 75 of these beds were occupied by patients receiving ayurvedic treatment, which is by far the most commonly practised form of traditional medicine in India There are 22 100 dispensaries of traditional medicine 2 There are 587 536 registered traditional medicine practitioners and homeopaths, who are both institutionally and non-institutionally qualified 2

Regulatory situation
Ayurveda, unani, siddha, naturopathy, homeopathy, and yoga are all
recognized by the Government of India The first step in granting this recognition was the creation of the Central Council of Indian Medicine Act of 1970 2 The main mandates of the Central Council are as follows: to standardize training by prescribing minimum standards of education in traditional medicine, although not all traditional medicine practitioners and homeopaths need be institutionally trained to practice; to advise the central Government in matters relating to recognition/withdrawal of medical qualifications in traditional medicine in India; to maintain the central register of Indian medicine, revise the register from time to time, prescribe standards of professional conduct and etiquette, and develop a code of ethics to be observed by practitioners of traditional medicine in India All traditional medicine practitioners and homeopaths must be registered to practice The Central Council of Homeopathy 2, constituted in 1973, has the same mandates The Indian Government created
the Department of Indian Systems of Medicine Homeopathy in March 1995 2 The primary areas of work for the Department are education, standardization of medicines, enhancement of availability of raw materials, research and development, information dissemination, communication, and the involvement of traditional medicine and homeopathy in national health care More than 4000 personnel work in these areas
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The Indian Government seeks the active and positive use of traditional medicine and homeopathy in national health programmes, family welfare programmes, and primary health care 2

Education and training
Through the Central Council of Indian Medicine and the Central Homeopathy, the Indian Government is working to standardize the traditional medicine practitioners and homeopaths 2 In support of national institutes are under the control of the Department of Indian Medicine Homeopathy: Council of training of this, seven Systems of

National Institute of Ayurveda:
established in 1976, located in Jaïpur, offers a PhD MD in ayurveda; National Institute of Homeopathy: established in 1975, located in Calcutta, offers Bachelors and MD degrees in homeopathy; National Institute of Naturopathy: established in 1984, located in Pune, offers talks in Hindi and Marathi and programmes for teachers and doctors; National Institute of Unani Medicine: established in 1984, located in Bangalore, offers postgraduate research opportunities in unani; National Institute of Postgraduate Teaching and Research in Ayurveda: located in New Delhi, offers PhD and MD degrees in ayurveda; National Academy of Ayurveda: established in 1988, located in New Delhi, offers a Degree of Membership Certificate in ayurveda; National Institute of Yoga: established in 1976, located in New Delhi, offers a oneyear diploma in yoga An institution for siddha medicine is planned In addition to these national institutes, there are a number of facilities for medical education under the
Department of Indian Systems of Medicine Homeopathy 2:
Facilities Undergraduate Colleges Admission Capacity Postgraduate Colleges Admission Capacity Ayurveda 154 6117 33 462 Unani 32 1239 3 55 Siddha 2 155 1 35 Homeopathy 118 4318 10 69 Total 305 11829 47 621

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The health authorities review the qualifications of practitioners through the Central Council of Indian Medicine and the Central Council of Homeopathy, which can both determine whether these colleges and universities may continue to admit students

Insurance coverage
Few people besides State employees have medical insurance, although this insurance does cover traditional medicine

Indonesia
Background information
Indonesian practitioners of traditional medicine may be divided into four groups: herbalists; skilled practitioners, including traditional birth attendants, circumcisers, bonesetters, masseuses, and traditional
dentists; spiritualists; and supernaturalists 189

Statistics
The use of traditional medicine is increasing each year Traditional medicine provides an important resource for self-care within the health services and through traditional medicine practitioners 189 Forty per cent of Indonesias population uses traditional medicine, 70 in rural areas A 1995 Ministry of Health survey reported 281 492 practitioners of traditional medicine practising in Indonesia, a significant increase over the 112 974 reported in 1990 189, 190 Of these practitioners, 962 use traditional Indonesian methods of treatment The rest use medical treatments, such as acupuncture, that belong to the traditions of other countries 189 Among the 281 492 traditional medicine practitioners in Indonesia, 122 944 are traditional birth attendants, 51 383 are general traditional medicine practitioners, 25 077 are masseuses, 18 456 are circumcisers, 18 237 are tukang jamu gendong, 14 000 are herbalists, 12 496 are spiritualists,
10 118 are supernaturalists, and 8781 are bonesetters 189 Traditional birth attendants are an important feature of Indonesian health care According to national figures for the period 1983 to 1987, allopathic providers attended only 43 of childbirths The remainder were either unattended or attended by traditional birth attendants 191 At least 91 427 traditional birth attendants have completed a training programme offered by the Ministry of Health At the end of 1999, there were 723 manufacturers of traditional medicines in Indonesia, 92 of which were large-scale industries These companies produce thousands of registered traditional medicines 189

Regulatory situation
Article 1 of Indonesias Health Law Act 23-1992 189 places traditional medicine as an integral part of curative and nursing care Article 2 emphasizes the need for
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supervision of traditional medicine to ensure its safety and efficacy Article 3 supports further development and improvement of forms of
traditional medicine deemed safe and efficacious in order to fulfil the goal of optimal health for the community The Health Law Act classifies traditional medicines jamu into two groups: The first group consists of traditional medicines produced by individual persons or by home industries These medicines need not be registered They are made by traditional medicine practitioners for use by their own patients They may not be labelled or marked except with the empirical name The Minister of Health is responsible for helping the producers of these medicines ensure the quality of their products To this end, the Ministry permits the use of only 54 species of plants in these medicines The safety of all 54 species is known through traditional experience The second group consists of traditional medicines produced and packed on a commercial scale, whether large or small These medicines must be registered and licensed before they may be sold In order to be registered, jamu and traditional
medicines not indigenous to Indonesia must have undergone scientific study, including microbiological testing These studies are to ensure the safety and efficacy, composition and rationality of the composition, dosage form, and claimed indications for the medicines For use in formal health services, clinical trials must be carried out The Ministry of Health of Indonesia has produced a publication, Guidance for Clinical Trial of Traditional Drug, to help manufacturers fulfil these requirements In accordance with the 1993 General Guidelines, health efforts, including those for traditional medicine, have been strengthened within the framework of the national health care legislation 192 Traditional birth attendants are permitted to practise without registration or a licence 193 Allopathic physicians with appropriate training in acupuncture are able to practice acupuncture in public hospitals

Education and training
The Centre for Traditional Medicine Research, under the Ministry of Health
and Social Welfare, provides training in traditional medicine The Directorate of Selected Community Health Development, also under the Ministry of Health and Social Welfare, offers training programmes in primary health care for traditional practitioners of acupressure

Myanmar
Background information
Traditional medicine in Myanmar is based on ayurvedic concepts and influenced by Buddhist philosophy From 1885, the beginning of the colonial period in Myanmar,

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until the Second World War, allopathic medicine was promoted over traditional medicine During the Second World War, however, allopathic medicines were scarce and traditional medicine regained prominence

Statistics
The Department of Indigenous Medicine was established in August 1989 It houses more than 4000 ancient palm-leaf and parchment writings and books on traditional Myanmar medicine Since the promulgation of the Traditional
Medicine Law in 1996, a total of 3962 medicinal items have been registered and 632 manufacturers have been issued production licences Over 8000 practitioners of traditional medicine are registered in Myanmar There is one 50-bed hospital for traditional medicine in Mandalay, one 25-bed hospital in Yangon, and three 16-bed hospitals in other parts of the country There are 194 township-level traditional medicine departments, each with its own outpatient clinic

Regulatory situation
Prior to the Second World War, several national committees recommended that the Government recognize traditional medicine, but no action resulted Four years after Myanmars independence in 1948, the Myanmar Indigenous Medical Committee was formed The Committee drafted the Indigenous Myanmar Medical Practitioners Board Act 74, which was passed in 1953 and amended in 1955, 1962, and 1987 The Act established the Indigenous Myanmar Medical Practitioners Board, which advises the Government on the revival and
development of traditional Myanmar medicine, related research, and the promotion of public health, among other things Section 11 specifies suppression of charlatans or quacks who are earning their living by means of indigenous Myanmar medicine as a particular function of the Board Subject to the sanction of the Head of State, the Board is also empowered to prescribe topics for examination in traditional Myanmar medicine, register practitioners, and remove practitioners from the register if a defect in character or undesirable conduct is established Section 24 of the Act prescribes that subject to the provisions of Section 23 of the Myanmar Medical Act, practitioners of traditional medicine must be registered in order to sign medical certificates, which by law must be signed by a medical practitioner Similarly, unless he or she has obtained the prior sanction of the Head of State, an indigenous medical practitioner who is not registered may not hold certain specified appointments in
publicly supported hospitals or other health facilities Section 7 of the Indigenous Myanmar Medical Practitioners Board Rules of 1955 194 provides for the registration of traditional medicine practitioners under six categories The system of classification is essentially based on the division of Myanmar medicine into four branches: dhatu, ayurveda, astrology, and witchcraft In Section 9 of the Rules, details are given of the knowledge required for registration in each specific category Provision is made, in Section 10, for authors of works on indigenous

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medicine to be registered in one of three groups Section 10 also prohibits the registration of monks as medical practitioners Under Section 12 of the Rules, the Board is mandated to find ways to consolidate the four branches of medicine currently practised into a single system The Board is also mandated to conduct research and advise the authorities on standardizing methods of treatment provided in
Government-operated dispensaries The Indigenous Myanmar Medical Practitioners Board Amendment Act 48 of 1962 introduced Sections 22-A and 28-A empowering the Chairman of the Revolutionary Council of Myanmar to cancel the registration of indigenous medical practitioners, prescribe qualifications for registration, and terminate the services of any or all of the members of the Board and appoint new members in their place Under these powers, a new Board was appointed to initiate the re-registration of practitioners In 1996, the Government promulgated the Traditional Medicine Law in order to control the production and sale of traditional medicines The Ministry of Health has updated and revised the Indigenous Myanmar Medical Practitioners Board Amendment Act and renamed it the Traditional Medical Council Law It is now in the process of receiving State approval

Education and training
The Ministry of Health established an educational institution known as the Institute of Indigenous Medicine
in 1976 195 It offers a three-year training programme followed by a one-year internship The Institute also conducts a one-year course in primary health care for traditional medicine practitioners who have no certificate or licence to treat patients Those who are successful in the course receive a licence to practise traditional medicine

Nepal
Background information
The use of medicinal herbs in Nepals traditional medical system dates back to at least 500 AD In Nepal, traditional medicine, although low profile, has been an integral part of the national health system Parallel to the allopathic system, traditional medicine is encouraged in all spheres because of its efficacy, availability, safety, and affordability when compared to allopathic drugs 196

Statistics
Ayurvedic medicine is widely practised in Nepal It is the national medical system More than 75 of the population use traditional medicine, mainly that based on the ayurvedic system There are 141 ayurvedic dispensaries, 14 zonal
dispensaries, 15 district ayurvedic health centres, and two ayurvedic hospitals One of these hospitals is centrally located in Naradevi, Kathmandu, and the other is regionally located in Dang They have 50 and 15 beds, respectively
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There are 623 institutionally qualified practitioners of traditional medicine and about 4000 traditionally trained practitioners Homeopathy has been recently introduced into Nepal 53

Regulatory situation
The policy of the Government 197, based on five-year plans, involves a system of integrated health services in which both allopathic and ayurvedic medicine are practised Ayurvedic clinics are considered to be part of the basic health services, and there is a section responsible for ayurvedic medicine in the Office of the Director General of Health Services The programmes for health services included in the Fifth Five-Year Plan make provision for four
ayurvedic hospitals, one in each of the four development regions The Ayurvedic Governmental Pharmaceutical Unit works to provide inexpensive medicaments The Ayurvedic Medical Council was created through legislation passed in 1988 198 Section 21 of this Act gives the Councils mandate as, among other things, steering the ayurvedic medical system efficiently and registering suitably qualified physicians to practise ayurvedic medicine In Section 4, the legislation sets out highly detailed provisions for registration that classify applicant practitioners into four groups according to their qualifications and experience in ayurvedic science By Section 522, membership in a particular group fixes the range of ayurvedic medicines that a practitioner is permitted to prescribe Registered practitioners enjoy a monopoly over the practice of ayurvedic medicine: direct or indirect practice of ayurvedic medicine by other medical practitioners is forbidden by Section 511 Section 5 of the Act enables
registered ayurvedic practitioners to issue birth and death certificates as well as certificates concerning the ayurvedic medical system and patients physical and mental fitness

Education and training
Formal education in the ayurvedic system is under the supervision of the Institute of Medicine of Tribhuvon University 197 The Auxiliary Ayurveda Worker training programme is run from the Department of Ayurveda under the Council for Technical Training and Vocational Education 199

Sri Lanka
Background information
Traditional medicine forms an integral part of the health care delivery system in Sri Lanka Traditional and natural medicine founded on the concept of three humours has a long anecdotal history of effective diagnosis and treatment Unfortunately, there is a lack of scientific research to support this history Ayurvedic medicine is widely practised in Sri Lanka

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Statistics
In Sri Lanka, 60 to 70 of the rural population relies on traditional and natural
medicine for their primary health care

Regulatory situation
The popularity of traditional medicine led to the promulgation of the Indigenous Medicine Ordinance in 1941 This Ordinance provided for the establishment of the Board of Indigenous Medicine, whose duties include the registration of traditional medicine practitioners, and oversight of the College of Indigenous Medicine and the Hospital of Indigenous Medicine The establishment of the Department of Ayurveda within the Ministry of Health by Ayurveda Act 31 of 1961 200 constituted a landmark in the modern history of ayurveda Ayurveda, as defined in the Act, encompasses all medical systems indigenous to Asia, including siddha and unani The Act defined the Departments objectives as provision of establishments and services necessary for the treatment of disease and the preservation and promotion of the health of the people through ayurveda; encouraging the study of, and research into, ayurveda via scholarships and other facilities to
persons employed, or proposed to be employed, in the Department and by the grant of financial aid and other assistance to institutions providing courses of study or engaging in research into ayurveda; and taking, developing, or encouraging measures for the investigation of disease and the improvement of public health through ayurveda The Ayurveda Act 31 of 1961 also specified the duties of the Ayurvedic Medical Council, which include registration of ayurvedic practitioners, pharmacists, and nurses and regulation of their professional conduct as well as authority over the Ayurvedic College and Hospital Board and the Ayurvedic Research Committee The Ayurvedic Physicians Professional Conduct Rules of 1971 201 were made by the Ayurvedic Medical Council under Section 18 of the 1961 Act and approved by the Ministry of Health They establish a code of ethics for ayurvedic physicians Professional misconduct includes procuring or attempting to procure an abortion or miscarriage; issuing any
certificate regarding the efficacy of any ayurvedic medicine or any ayurvedic pharmaceutical product containing statements that the practitioner knows to be untrue or misleading; conviction of an offence under the Poisons, Opium and Dangerous Drugs Ordinance that was committed in the practitioners professional capacity; selling to the public, either directly or indirectly, any ayurvedic pharmaceutical product for which the prior sanction of the Ayurvedic Formulary Committee has not been obtained; and exhibiting or displaying any medical degree or medical diploma that has not been approved by the Ayurvedic Medical Council In early 1980, the Ministry of Indigenous Medicine was established as a separate department to be led by a senior parliamentarian — who is an ayurvedic practitioner by profession 202 Responsibility for the Department of Ayurveda was transferred to

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the Ministry A
central feature of the Ministrys operation has been the establishment of traditional medical dispensaries and hospitals that provide medical care at no cost The Cabinet Ministry for Indigenous Medicine was established in 1994; there was previously a State Minister for Indigenous Medicine Research and development activities are undertaken on behalf of these ministerial offices by the Department of Ayurveda and the Bandaranaike Memorial Ayurvedic Research Institute, founded June 1962 The Homeopathy Act of 1970 203 recognized homeopathy as a system of medicine and established the Homeopathic Council appointed by the Minister of Health in 1979 53 The Homeopathic Council is responsible for regulating and controlling the practice of homeopathic medicine and maintaining the Homeopathic Medical College The 1970 Act exempted persons practising homeopathic medicine, pharmacy, or nursing from the provisions of the Medical Ordinance and empowered the relevant Minister to make regulations for the
control of professional conduct and other matters In particular, the Council is empowered to register and recognize homeopathic medical practitioners; recognize homeopathic teaching institutes, dispensaries, and hospitals; hold examinations and award degrees in homeopathic medicine; and arrange for postgraduate study in homeopathy 86 The Council also maintains a register of homeopathic practitioners With some exceptions, qualification following a course of study of not less than four years is a prerequisite for registration Only registered practitioners may practise homeopathy for gain and use the title Registered Homeopathic Practitioner Such practitioners are also entitled to issue certificates or other documents required to be issued by medical practitioners; hold posts as medical officers in public medical institutions; and sign birth or death certificates, medical certificates, and certificates of physical fitness

Education and training
A World Health Organization/United Nations
Development Programme project for the development of traditional medicine in Sri Lanka SRL/84/020 was implemented in the 1980s Phase I began in October 1985 and ended in May 1988 Phase II SRL/87/029 began in 1989 The importance of human resource development in the traditional and natural medicine sector was highlighted in this project The project enhanced the teaching capability of eight instructors of traditional medical practice and the professional capability of 1217 general practitioners of traditional medicine to provide advice at the community level on the preventive and promotive aspects of primary health care and treating common ailments The same project provided incentives to establish the National Institute of Traditional Medicine, which carries out educational and training programmes for traditional and ayurvedic practitioners, school children, and the general public The Institute does not offer opportunities for advanced training or postgraduate education, so in 1993 the
Department of Ayurveda began to provide alternative resources for Ayurvedic Medical Officers to obtain postgraduate qualifications through the Institute of Indigenous Medicine at the University of Colombo, Rajagiriya

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Thailand
Background information
Thai traditional medicine draws from Indian and Chinese systems of traditional medicine 204 It encompasses a holistic philosophy and is based principally on plants, including the use of herbal saunas, herbal medicines, herbal steam baths, and hot compresses; traditional massage; acupressure; and reflexology Practitioners of traditional medicine represent an important resource for the Thai health care system Traditional Thai medicine is also practised in Cambodia, Lao, and Myanmar

Statistics
In 1998, Thailand imported more than 35 of its allopathic medicines and about 30 of its traditional medicines 204

Regulatory situation
Official policy towards traditional medicine in Thailand has a well-recorded history:
11821186: 102 hospitals were established, and at least 30 kinds of herbs were used in treatments 1504: traditional medicine formularies received official endorsement 1767: Thai traditional medicine and allopathic medicine were separated for the first time since the introduction of allopathic medicine 17821809: herbal medicine formularies were inscribed on the wall of the temple Wat Potharam 18241851: protocols for diagnosis and treatment were inscribed on the wall of the temple 205 Allopathic medicine was reintroduced by missionaries who used quinine to treat malaria 1888: the Siriraj Hospital, which combined both allopathic and traditional medicine, was established 1913: Thai traditional medicine and allopathic medicine were separated for the second time by the discontinuation of formal education in traditional medicine 1929: a law classifying medical practitioners increased the separation between traditional and allopathic medicine: Traditional medicine practitioners were
defined as those who practice medicine based on their observations and experiences that were passed on by word and in traditional textbooks but were not based on scientific grounds 204 1941: the production and sale of 10 traditional medicine formulas by the Government dispensary were stopped
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In the last few decades, particularly following the Alma-Ata Declaration and a World Health Organization conference on traditional medicine, Thai traditional medicine has received renewed interest The National Institute of Thai Traditional Medicine was established on 24 March 1993 as a division of the Department of Medical Services The Institute is charged with facilitating the integration of Thai traditional medicine into the public health services In 1987, an amendment to a royal decree enabled the Ministry of Public Health to integrate ayurvedic doctors into the medical work force of both
State-run hospitals and private clinics Ayurvedic doctors and Thai traditional practitioners are allowed to use some basic allopathic medical tools in their practice, such as the thermometer and sphygmomanometer, but are not allowed to prescribe allopathic medicines The Government is currently working on developing the use of herbal medicines The goals of the Eighth Public Health Development Plan 19972001 204 are to increase the use of allopathic medicine, increase the use of traditional medicine, curb the use of extravagant medical and pharmaceutical technology, and promote traditional treatments within the national public health care system Included in this policy is the development of research into medicinal herbs, training of traditional medicine practitioners, and use of medicinal herbs and traditional medicine practitioners in an official capacity Specific objectives are as follows: support and promote Thai traditional medicine in the national health care system as a means to
improve health through self-reliance at the personal, family, community, and national levels; upgrade the standard of Thai traditional medicine for acceptance and integration into the national health system; support the basis of Thai traditional medicine by developing a comprehensive system and strategy for its official use, including academic development, integration of administrative services into the national health care system, production of medicinal herbs and Thai traditional medicines, dissemination of information, and promotion of the use of Thai traditional medicine; support organizations and agencies that deal with Thai traditional medicine in both the Government and private sectors; increase the use of medicinal herbs by supporting the production of plants, developing the pharmacopoeia, and collaborating with traditional medicine practitioners By 1999, Thai traditional medicine was integrated into the facilities of 1120 health centres Most of these health centres are
health stations at the sub-district level, which represent more than 75 of health facilities 204 All types of traditional medicine practitioners are registered with the Medical Registration of the Ministry of Public Health

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Education and training
The first school for Thai traditional medicine was established in 1957 at Wat Po Since 1962, graduates from such schools have been licensed to practice general traditional medicine In December 1997, the Ministry of Healths National Institute of Thai Traditional Medicine established the Thai Traditional Medicine Training Centre, where programmes in pharmacy, Thai traditional healing, Thai traditional massage, and reflexology are offered For people who do not have the opportunity to attend a university, the National Institute of Thai Traditional Medicine, in collaboration with the Department of Non-Formal Education, offers courses in Thai traditional medicine at non-formal education centres at the primary and secondary
school levels An ayurved-vidyalaya college was established in 1982 by the Foundation for the Promotion of Thai Traditional Medicine, a private organization supported by the Government During its three-year programme, students study not only aspects of Thai traditional medicine, but also basic science and allopathic diagnostics This later training is intended to facilitate their ability to communicate with other health care professionals Students of allopathic medicine receive no training in traditional medicine Act 7 of 30 December 1966, however, enables allopathic physicians, pharmacists, nurses, and midwives who want to practice Thai traditional medicine to do so To be eligible to practice traditional medicine, allopathic practitioners are required to follow a threeyear course of training and instruction with a registered and licensed traditional medicine practitioner and to pass an examination set by the Commission for the Control of the Practice of the Art of
Healing

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Western Pacific

Australia
Background information
Traditional Chinese medicine has been practised in Australia since the influx of th Chinese migrants to the Australian gold fields in the 19 century Its popularity is growing, as reflected by the proliferation of traditional Chinese medicine practitioners, training courses, and professional associations during the last decade

Statistics
Approximately one billion Australian dollars are spent on complementary/alternative medicine each year 206 A 1996 study reported that 48 of the population has used complementary/alternative medicine at least once There are approximately 2500 chiropractors practising in Australia 45 In December 1995, the Victorian Department of Human Services commissioned a study on the practice of traditional Chinese medicine The study found that traditional Chinese medicine accounts for an increasing percentage of total health care services There are at least 28 million consultations
each year, representing an annual turnover of over 84 million Australian dollars In 1995, over 1500 primary practitioners reported their principal health occupation as traditional Chinese medicine This number was expected to almost double by the year 2000, with the graduation of over 1100 students from qualifying programmes for traditional Chinese medicine There are 23 professional associations representing different segments of traditional Chinese medicine Traditional Chinese medicine is provided to patients of all ages, including infants Two out of three patients are female, 50 have a tertiary education, and over 80 have English as their first language Although 44 of cases are rheumatological or neurological in origin, traditional Chinese medicine treats a broad range of complaints Over 75 of patients are treated for a recurrent problem of at least three months duration

Regulatory situation
Seven Australian territories — Capital Territory, Northern Territory, Territory of Christmas
Island, Territory of the Cogos Keeling Islands, Norfolk Island, South Australia, and Western Australia — grant allopathic physicians an exclusive monopoly on medical care by prohibiting the practice of medicine by unregistered or unqualified persons 207 No provisions directly govern the practice of traditional

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Chinese medicine, although practitioners are regulated in part by various state and/or federal regulations and guidelines In New South Wales, Queensland, Tasmania, and Victoria, there is general freedom to practise medicine or surgery, but it is tempered by a number of restrictions For instance, unqualified persons may not recover fees or treat venereal diseases In addition, New South Wales makes it an offence to treat cancer a similar prohibition exists in Victoria, tuberculosis, poliomyelitis, epilepsy, diabetes, and other specific diseases In Australia, there is a long
history of efforts by associations of chiropractors and osteopaths to obtain statutory recognition for their professions This is reflected in the laws regulating chiropractic and osteopathy In certain Australian states, chiropractors are specifically exempted from the allopathic physicians monopoly to practice medicine For instance, the Medical Act 18941968 of Western Australia prohibits persons other than allopathic medical practitioners from practising medicine or surgery, provided that this paragraph shall not apply to a person practising as a chiropractor who gives chiropractic advice or service 208 Chiropractic and osteopathy are the subject of specific legislation in South Australia, Capital Territory, Victoria, and New South Wales 208 In Victoria, chiropractors and osteopaths must hold an approved degree or diploma in order to be registered by the territorial board Although registration is not compulsory, only registered persons and allopathic medical practitioners are
permitted to recover fees or charge for their professional services In 1974, the Australian Parliament set up the Committee of Inquiry into Chiropractic, Osteopathy, Homeopathy, and Naturopathy The Committee published an extensive report in 1977 209 In New South Wales, the re-enactment of the Medical Practitioners Act 1938 as the Medical Practice Act 1992 210 resulted in several amendments to the 1938 text The growing acceptance of traditional medicine was at the root of changes to a number of prohibitions on the cures and treatments offered of by non-allopathic practitioners In 1998, the Therapeutic Goods Act was established with the objective of providing a national framework for the regulation of therapeutic goods in Australia, particularly to ensure their quality, safety, efficacy, and timely availability Most products claiming therapeutic benefit must be registered with the Australian Register of Therapeutic Goods before being sold in Australia The Therapeutic Goods Administration
is responsible for administering the Act 211 In 2000, the Therapeutic Goods Administration developed the Guidelines for Levels and Kinds of Evidence to Support Claims for Therapeutic Goods 1 The Complementary Medicines Evaluation Committee recognizes two types of evidence to support claims on therapeutic goods: scientific evidence and traditional use The extent of required evidence depends on the claims made for the product For the Committee, traditional use refers to written or orally recorded evidence that a substance has been

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used for three or more generations for specific health-related or medicinal purposes Some exceptions to this requirement are made for homeopathy The regulations include clauses for the use of medicines as one component of a multifaceted treatment, the use of treatments that combine a number of traditions, and the use of treatments that are recent modifications of traditional therapies Traditional therapies are considered to include
traditional Chinese medicine, traditional ayurvedic medicine, traditional European herbal medicine, traditional homeopathic medicine, aromatherapy, and other traditional medicines

Education and training
The number of traditional Chinese medicine programmes offered by universities and private colleges is growing Programmes, some of which lead to diplomas, range from 50 hours to over 300 hours There are also traditional Chinese medicine programmes available for qualified allopathic practitioners These range from 50 to 250 hours The Royal Melbourne Institute of Technology, the University of Technology at Sydney, and the Victoria University of Technology have degree programmes in traditional Chinese medicine These programmes are offered within the schools of Applied Science or Health Science Acupuncture was first offered as a formal education programme in Sydney in 1969 with the founding of the privately owned school, Acupuncture Colleges, Australia 212 This programme subsequently formed
the basis of the Diploma of Applied Science Acupuncture accredited by the New South Wales Higher Education Board in 1987 and the four-year Bachelor of Applied Science Acupuncture accredited by the New South Wales Higher Education Unit in 1992 Following the same programme, the Victoria University of Technology began offering a Bachelor of Health Science Acupuncture in 1992 The Royal Melbourne Institute of Technology, the University of Technology at Sydney, and the Victoria University of Technology also offer Masters degrees and graduate diplomas in acupuncture 213 With growing acceptance of acupuncture by the public and by allopathic practitioners, graduates are able to play a larger part in the public-health sector of the community, working in allopathic hospitals, community health centres, and in areas of specialized health services The Bachelor of Health Sciences in Acupuncture prepares graduates for this role in general health care 213 Training in homeopathy has been from the level
of the FHom of London 53 There are two chiropractic colleges recognized by the World Federation of Chiropractic 81 Naturopathy, European herbalism, homeopathy, and nutrition are taught at the Southern Cross University in New South Wales 213

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