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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ALTERNATIVE THERAPIES,
mar/apr 2003, VOL 9, NO 2

71

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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Cambodia
Background information
The Ministry of Health has established the Centre for Traditional Medicine, which is limited to basic work in a few botanical medicines and has little input into pharmaceutical issues Much of the knowledge available on botanical specimens is based on their use in neighbouring countries Shops throughout the country sell traditional medicines from around the world

Regulatory situation
A law on the organization of traditional therapeutics and traditional pharmacopoeia was enacted in 1964 214 This law defines traditional therapeutics as treatment and care using traditional methods, excluding surgical and obstetrical
procedures, dental surgery, and electrical, chemical, or bacteriological methods of therapy and analysis To practice, traditional medicine practitioners must be at least 25 years old, have completed a three-year apprenticeship, and possess a licence issued by the Minister of Health Traditional medicine may not be practised on the premises of allopathic health care establishments 215 The National Drug Policy 216, developed with technical collaboration from the World Health Organization, is intended to increase the importance of traditional medicine and encourage traditional medical practice as a complement to allopathic medicine The Policy states that fundamental and applied research on traditional remedies will be pursued and diseases that can be treated effectively with traditional medicines will be identified The Law on the Management of Pharmaceuticals was adopted on 9 May 1996 216, replacing relevant existing legislation Following the adoption of this law by the National Assembly,
a draft decree pertaining to the manufacture, importation, exportation, and supply of traditional medicines was submitted by the Ministry of Health to the Council of Ministers

Education and training
There is no officially recognized curriculum incorporating the use of traditional medicines

China
Background information
Over the last century, traditional Chinese medicine has co-existed with allopathic medicine 217 See the Introduction for a description of traditional Chinese medicine

Statistics
There are 350 000 staff working at more than 2500 hospitals of traditional medicine in China In addition, 95 of general hospitals have units for traditional medicine and
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50 of rural doctors are able to provide both traditional and allopathic medicine 213 In 1949, there were 276 000 practitioners of traditional medicine in China The figure increased to 393 000 in 1965 and 525 000 in 1995 Among these traditional medicine practitioners are 257 000 traditional medical doctors
who graduated from traditional medical universities with a knowledge of both traditional and allopathic medicine, 10 000 allopathic medical doctors retrained in traditional medicine, 83 000 pharmacists who are specialists in herbal medicines and who have graduated from traditional medicine universities, 72 000 assistant traditional medicine doctors, and 55 000 assistant herbal pharmacists trained in traditional medicine secondary schools 219 In China, traditional medicines account for 30 to 50 of total consumption 218 There are 800 manufacturers of herbal products, with a total annual output worth US 1800 million There are over 600 manufacturing bases and 13 000 central farms specialized in the production of materials for traditional medicines There are 340 000 farmers who cultivate medicinal plants The total planting area for medicinal herbs is 348 000 acres 219 There are 170 research institutions across the country with perhaps the most prestigious being the Academy of Traditional
Medicine in Beijing

Regulatory situation
In China, the integration of traditional medicine into the national health care system and the integrated training of health practitioners are both officially promoted 219 The Government of China has reinforced its commitment to the integration of traditional and allopathic medicine on a number of occasions Adopted in 1982, Article 21 of the Constitution of the Peoples Republic of China promotes both allopathic and traditional Chinese medicine The Bureau of Traditional Medicine was set up as part of the Central Health Administration in 1984 In 1986, the State Administration of Traditional Chinese Medicine was established 4 In 1988, the Central Secretariat of the Chinese Communist Party stated the following 220:
Traditional Chinese medicine and Western medicine should be given equal importance On the one hand, our unique successes in public health and hygiene can be attributed to traditional Chinese medicine Hence, traditional medicine should
not be abandoned Instead, it is to be well preserved and developed further On the other hand, traditional Chinese medicine must make full active use of advanced science and technology to ensure its further development The policy of integration of traditional Chinese medicine and Western medicine should persist Both systems should cooperate with each other, learning from each others merit to make up their own shortcomings Both should strive for the full play of their own predominance

Again in 1997, the Government reiterated that one of its guiding principles in the field of health care is equality in policies related to traditional and allopathic medicine The integrated nature of the Chinese medical system is underscored by the fact that

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traditional and allopathic medicine are practised alongside each other at every level of the health care system 221:
Western-style and traditional
Chinese doctors work together at the [township] centre according to the policy of integrating the two systems of medicine Patients may see either type of doctor

The 1985 Management Stipulations for Physicians and Assistants of Traditional Chinese Medicine requires traditional medicine practitioners to learn and make use of innovations in allopathic medical technology 213 The criteria for qualification as a traditional Chinese medical physician or assistant are also set out in the Management Stipulations 222 Qualification as a traditional medical physician can be achieved through a number of routes, typically combining post-secondary academic studies and one to two years of practising, teaching, or researching traditional medicine By Article 5 of the Stipulations, the academic component can be undertaken at a university or college devoted to traditional medicine, within a department of traditional medicine at a school of allopathic medicine, or by completion of a State-approved diploma
or certificate Under Article 7, a similar, but less demanding, combination of academic studies and one year of practical involvement in traditional medicine is typically needed for qualification as a traditional medicine assistant Under a 1985 circular 223 issued by the Chinese Ministry of Public Healths Department of Traditional Chinese Medicine, persons who studied under the former apprenticeship system — in place before the 1960s when formal examinations were not required — may take the formal examinations leading to qualification as a traditional medical physician or assistant The examinations follow the completion of courses administered by private institutions with Government recognition The courses may be taken as correspondence courses, night classes, or at workers universities Candidates who fail these tests, or persons who decide not to take them, must pass a unified examination offered by the Health Department before their qualifications to practise as traditional Chinese
medicine assistants or physicians will be recognized For assistants, the examination is based on information taught at the secondary school level There is a more demanding unified exam based on a three-year post-secondary education for those in the apprenticeship system who wish to convert their existing status to the level of pharmacist or physician of traditional medicine In addition to physicians and assistants, a third tier of health professional exists in traditional Chinese medicine: individuals examined and officially recognized as proficient in a particular branch of traditional medicine However, the absence of a uniform method of assessment for these practitioners has led to some unqualified individuals being able to obtain official recognition, according to a 1989 circular issued by the State Administration of Traditional Chinese Medicine 224 Motivated by a desire to protect the integrity of traditional medicine and to safeguard patients interests, the response of the State
Administration has been to introduce annual testing of practitioners in this third tier Tests are administered by a group of senior
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traditional medicine practitioners The annual testing involves both a theoretical component and a clinical examination Successful completion of the annual testing leads to a certificate, which details the candidates specific skills and the range of diseases that can be treated Failing the annual test results in cancellation of the candidates certificate and right to practise, pending re-examination Released in 1988, a series of Provisional Management Stipulations 225 regulates private health care offered by traditional Chinese medical physicians within the Statesponsored socialist health-care system Article 4 of the Stipulations endorses an official policy favouring preventive care and instructs private-sector physicians to undertake primary health care as designated by the local health authority The right to practise traditional
Chinese medicine privately is restricted to those who have passed the unified examination and technical assessment or who have met the Ministry of Public Healths requirements for regulation as a health professional and have practised medicine in State-owned or collective medical institutions for three years A licence must be obtained to open a private practice and the licence holder shall strictly observe the approved practice, place, range of service and business limits to the practice Under 1989 regulations 226, traditional Chinese medical assistants are only permitted to open their own practice in rural towns, which include county-level townships and villages In small towns and cities, they may only serve in private physicians clinics Under Article 2, persons with a certified proficiency in a particular branch of traditional Chinese medicine, subject to annual retesting, are only permitted to open a practice at the local county or district level Prompted by a desire to protect
patients from abuse and deception, regulations concerning medical qigong were enacted in China in 1989 227 Qigong is described in the preamble to the regulations as a self-cultivation approach to keep fit through dredging meridians, adjusting the mind, and balancing yin, yang, qi, and blood to get rid of diseases The regulations provide that practitioners of qigong must obtain approval from the local health authority to teach qigong in public places By Article 1, teaching must be based on scientific approaches Under Article 2, qigong practitioners working in medical institutions must possess medical qigong skills and be qualified as traditional Chinese medical physicians or assistants under the Management Stipulations described above According to Article 4, those who intend to treat patients with emitted qi energy must have their methodology and the claimed curative effect approved by the city health authority If the curative effect is shown to be tenable, based on a study of 30 cases
of the same type of illness by a designated medical institution, a licence will be issued Article 6 prohibits non-medical institutions, including the army, from rendering medical treatment

Education and training
Traditional Chinese medicine used to be taught through apprenticeships 217 Now, there are 57 secondary schools teaching traditional Chinese medicine, with an enrolment of 29 000 students These schools train medical personnel for rural and

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basic units There are also 28 universities and colleges of Chinese traditional medicine and pharmacology, with a total enrolment of 46 000 students, including 2800 undergraduates Together, these universities and colleges provide 14 professional undergraduate programmes along with programmes for Masters and Doctorate degrees 4 A chiropractic college is presently being established 81 To qualify as a physician of traditional Chinese medicine,
a candidate must typically complete five years of study Admissions standards to colleges or universities generally require completion of middle school seven grades, but there is some flexibility: in some colleges, a primary school education four grades is sufficient 191 As mentioned above, medical education is integrated in China 228 Although there are more allopathic medical schools in China than traditional medical schools, every allopathic medical school contains a department of traditional medicine and every traditional medical school contains a department of allopathic medicine Between 10 and 20 of the teaching in allopathic medical schools is allocated to traditional medicine 229 A somewhat greater emphasis is placed on allopathic medicine in colleges of traditional medicine The Division of Traditional Medicine in the Ministry of Public Health suggests orienting 30 of teaching in these schools to allopathic medicine

Insurance coverage
Health insurance covers both allopathic and
traditional medicine 218

Hong Kong Special Administrative Region of China
Background information
Although traditional Chinese medicine is widely used, allopathic medicine has been the focus of the health care system in the Hong Kong Special Administrative Region of China Hong Kong SAR 230

Statistics
In a general household survey conducted by the Census and Statistics Department of the Government of Hong Kong SAR in 1996, it was reported that traditional Chinese medicine practitioners provide 105 of medical consultations An earlier survey showed that up to 60 of Hong Kong SARs population had used traditional Chinese medicine either for treatment of disease or maintenance of health According to the 1996 survey, there are 6890 traditional Chinese medicine practitioners in Hong Kong SAR, of whom 66 are full-time practitioners There are 37 chiropractors practising in Hong Kong SAR 45 There are approximately 2000 types of Chinese medicinal herbs for sale in Hong Kong SAR About 3300 brands
of proprietary traditional Chinese medicines are available, of which 500 brands are manufactured locally Information provided by the Govern152

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ments Census and Statistics Department showed that in 1998, 500 trading organizations were involved in the import/export, wholesale distribution, and retail sales of traditional Chinese medicines

Regulatory situation
Until recently, there was no specific legal control or recognition of traditional Chinese medicine in Hong Kong SAR Regulations fell under the Public Health and Municipal Services Ordinance, which controls the sale of drugs unfit for human consumption, and the Pharmacy and Poisons Ordinance, which prohibits the adulteration of traditional Chinese medicines with allopathic drugs The Basic Law of Hong Kong SAR provides that the Government shall formulate policies to develop allopathic and traditional Chinese medicine and to improve medical and health services In 1989, to promote the proper use and good practice of
traditional Chinese medicine, the Secretary for Health and Welfare set up the Working Party on Chinese Medicine The Party was mandated to review the use and practice of traditional Chinese medicine in Hong Kong SAR In 1995, the Secretary for Health and Welfare appointed the Preparatory Committee on Chinese Medicine In March 1997 and March 1999, the Committee submitted reports on the regulation and development of traditional Chinese medicine in Hong Kong SAR In his 1997 policy address, the Chief Executive of Hong Kong SAR announced that for the protection of public health, a statutory framework providing legal recognition to traditional Chinese medicine and appropriate regulation of its practice, use, and trade would be established The Chinese Medicine Bill was drawn up in 1998 and was introduced in the Legislative Council in February 1999 The Legislative Council passed the Chinese Medicine Ordinance, which is based on self-regulation, in July 1999 The Chinese Medicine Council — a
regulatory body comprised of traditional Chinese medicine providers, trade professionals, academics, lay persons, and Government officials — is responsible for implementing the regulatory measures The Department of Health will provide administrative support and enforce the regulations A registration system for practitioners of traditional Chinese medicine will be created in 2000 Likewise, a registration and licensing system to regulate the manufacture and trade of traditional Chinese medicines will be set up in phases in 2000 The safety, efficacy, and quality of proprietary traditional Chinese medicines will be assessed before they are registered The dispensation, storage, and labelling of traditional Chinese medicines will also be regulated

Education and training
Educational institutions offer refresher courses for providers and dispensers of traditional Chinese medicine to upgrade their knowledge and skills Undergraduate courses in traditional Chinese medicine practice and pharmacy
have recently been introduced at local universities

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Fiji
Background information
In Fiji, both the traditional medicine of the indigenous population and that of IndoFijians who brought with them their own medicinal plants and medicinal plant knowledge are practised Rural Fijians are the primary users of traditional medicine, though its popularity in urban areas is increasing Traditional medicine practitioners are often consulted before allopathic medical providers Many allopathic providers also practice traditional medicine 231

Statistics
Founded in 1993, the Womens Association for Natural Medicinal Therapy, a nongovernmental organization promoting traditional medicine, has begun a survey of over 2000 practising providers of traditional medicine in 13 of the 14 provinces in Fiji In two of these provinces, the surveys have been completed These surveys and conversations with local
people indicate great faith in allopathic medicine even though villagers may find traditional medicine to be more effective and cost efficient The surveys further suggest that many people, including practitioners of allopathic medicine, use traditional medicine but hesitate to call it such because traditional medicine is associated with witchcraft Between 60 and 80 of the population use traditional medicine 231 According to Fijis Biodiversity Strategy and Action Plan, the average Fijian household uses US 200 worth of medicinal plants annually If these traditional medicines were replaced by allopathic medicines, this would amount to a total of US 75 million annually

Regulatory situation
The Medical and Dental Practitioners Act of 1971 232 empowers the Minister of Health to issue regulations governing chiropractic, acupuncture, and chiropody Such regulations were issued in 1976 233 In 2000, the Cabinet of the Government of Fiji instructed the Minister of Health to develop a national
policy on traditional medicine 231 In Fiji, the lawful practice of acupuncture is subject to registration by the Permanent Secretary for Health 233 Applicants for registration must prove either that they are licensed as acupuncturists in the United Kingdom, Canada, New Zealand, or any of the states of the United States or that they possess a certificate from the health authorities of China, the Province of Taiwan, Hong Kong Special Administrative Region of China, Singapore, or the Philippines to the effect that they have practised acupuncture in any of those locations for a period of not less than three years

Education and training
Most students of traditional medicine receive their training through oral instruction from established practitioners 231 No great importance is attached to formal

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education in either traditional medicine or complementary/alternative medicine at universities or medical schools, although some training is done through primary health
care The Government and medical associations review the qualifications of practitioners, but there is no regulatory measure for recognizing the qualifications Licensing legislation regulates educational standards for chiropractic 81

Insurance coverage
Practised outside of the national health care system, traditional medicine is not covered by insurance

Japan
Background information
In Japan, traditional medicines are classified into two broad groups: kampo medicine and traditional medicine indigenous to Japan 234 Traditional Chinese medicine, introduced to Japan between the 3rd and 8th centuries, was modified to meet local needs and became known as kampo medicine For about 10 centuries, from the time of its introduction until it was superseded by allopathic medicine in 1875, kampo medicine was the mainstream Japanese medicine Following the Meiji Restoration in 1886, the newly established Japanese Government endorsed German allopathic medicine over kampo medicine After 1885, new
doctors were trained only in allopathic medicine, with the result that kampo medicine almost disappeared By 1920, fewer than 100 doctors were practising kampo medicine 235, but after the Second World War, there was a resurgence of public interest in kampo medicine and today it is practised extensively Acupuncture, moxibustion, Japanese traditional massage/finger pressure, and judotherapy are also widely practised in Japan

Statistics
The 1998 production value of kampo medicines in Japan was 97 708 million yen, or 17 of total medicine production Of this, prescription kampo medicines accounted for 832; proprietary medicines, for 159; and household distribution, 09 236 A nationwide survey conducted in October 2000 found that 72 of registered allopathic doctors currently use kampo medicines in their clinical services 237 In addition to the 268 611 registered allopathic medical doctors, the number of registered medical practitioners at the end of 1998 included 69 236 acupuncturists, 67 746
moxacauterists, 94 655 massage practitioners, and 29 087 judotherapists 238 There were also 125 953 registered pharmacists at the end of 1998 239

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Regulatory situation
Under the Medical Practitioners Law 201 of 1948 235, only allopathic physicians may practice medicine, including kampo medicine However, there are no restrictions on the types of medical procedures allopathic physicians may use in their practice According to the Pharmacists Law 146 of 1960, a person must be qualified as a pharmacist in order to engage in services related to traditional medicines The Subcommittee on Kampo Medicines and Products of Animal and Plant Origin of the Central Pharmaceutical Affairs Council has developed regulations governing kampo medicines as proprietary medicines 240 These regulations also apply, with necessary modifications, to prescription medicines The Pharmaceutical Affairs Law in Japan
does not distinguish between traditional and allopathic medicines; both types of preparations are subject to the same regulations Kampo medicines are products prepared for use in accordance with kampo medicine formulae 239, which, according to the principles set out by the Central Pharmaceutical Affairs Council, are formulae described in established books on kampo medicine currently and frequently used in Japan The formulae include standard formulae, added or subtracted formulae, and combined formulae They include formulae containing vitamins B1, B2, and/or C for nutritional supplementation The extracts prepared from kampo medicine formulae should be limited to those that have previously been used as decoctions Any ingredient, efficacy, or indication that is not appropriate for proprietary medicines is not accepted Standards for medicinal plant materials are included in Japanese Pharmacopoeia 241, the Japanese Herbal Medicine Codex 242, and Japanese Standards for Herbal Medicines
242

Japanese Pharmacopoeia
First established in 1886 by the Minister of Health and Welfare, and in accordance with Article 41 of the Pharmaceutical Affairs Law 145 of 1960, the Japanese Pharmacopoeia is an official standard regulating the properties and qualities of medicines Some herbal medicines are included in the Japanese Pharmacopoeia th The 14 edition is expected in 2001 239, 241

Japanese Herbal Medicine Codex
Standards have been established separately for herbal medicines not included in the Japanese Pharmacopoeia Herbal medicines in frequent use, which are not in the Japanese Pharmacopoeia, are examined according to specific criteria and made official by inclusion in the Japanese Herbal Medicine Codex 242

Japanese Standards for Herbal Medicines
Published in 1993, Japanese Standards for Herbal Medicines contains 248 articles: 165 from the Japanese Pharmacopoeia XII and 83 from the Japanese Herbal Medicine Codex When using substances listed in Japanese Standards for Herbal
Medicines as materials or ingredients of pharmaceutical products to be manufactured in, or

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imported into, Japan, manufacturers and importers should comply with the provisions in this book 242 When the Pharmaceutical Affairs Law was amended in April 1993, the Regulations for Manufacturing Control and Quality Control of Drugs were changed from manufacturing requirements for drug companies to a prerequisite for licences to manufacture drugs The Regulations, including new validation requirements, came into effect in April 1996 Moreover, good manufacturing practices for investigational products were adopted via a notice issued by the Director-General of the Pharmaceutical Affairs Bureau of the Ministry of Health and Welfare in April 1997 The Japan Pharmacists Education Centre 243 issues a certificate for pharmacists specializing in kampo medicines and herbal materials in accordance with its own qualification criteria Renewal of this certification is required every
three years In 1990, the Society of Japanese Oriental Medicine 235 started a registration system of allopathic physicians specializing in kampo medicine This system requires all registered specialists to attend authorized meetings of the Society and to present relevant scientific papers and medical journals at the meetings This registration system requires registration as a specialist in kampo medicine to be renewed every five years, in accordance with the rules set out by the Society The Practitioners of Massage, Finger Pressure, Acupuncture and Moxibustion, etc Law 217 of 1947 stipulates in Article 1 that anyone other than an allopathic physician who wishes to practise acupuncture, moxibustion, or massage/finger pressure must pass the relevant national examination and obtain either a licence in massage/finger pressure alone or a combination licence in acupuncture, moxibustion, and massage/finger pressure from the Minister of Health and Welfare Article 2 outlines the requirements that
must be met in order to take the national exams: candidates must be eligible to enter a university according to Article 56 of the School Education Law 26 of 1947; have studied more than three years at a school recognized by the Minister of Education, Science, and Culture or at a training institution recognized by the Minister of Health and Welfare; and have obtained the knowledge and technical skill necessary to be an acupuncturist, moxacauterist, or massage practitioner, including knowledge of anatomy, physiology, pathology, and hygiene In Article 182, an exception to these criteria is made for persons with visual impairment: persons with visual impairment, as defined by a Ministry of Health and Welfare ordinance, may take the exams if they are eligible to enter a high school according to Article 47 of the School Education Law 26 of 1947; have studied at a school recognized by the Minister of Education, Science, and Culture or at a training institution recognized by the Minister of
Health and Welfare; and have obtained the knowledge and technical skill necessary to be an acupuncturist, moxacauterist, or massage practitioner, including at least three years of study in anatomy, physiology, pathology, and hygiene for certification as a massage practitioner only or five years of

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study in anatomy, physiology, pathology, and hygiene for joint certification as an acupuncturist, moxacauterist, and massage practitioner In 1999, the Japan Society for Acupuncture and Moxibustion 244 began a registration system for allopathic medical doctors specializing in acupuncture and moxibustion The rules for qualification set out by the Society require registration to be renewed every five years Judotherapists are regulated under the Judo Therapists Law 19 of 1970 By Article 3, in order to become qualified as a judotherapist, a candidate must pass the national judotherapist
examination and obtain a licence from the Minister of Health and Welfare Under Article 12, candidates must be eligible to enter a university according to Article 56 of the School Education Law 26 of 1947; have studied more than three years at a school recognized by the Minister of Education, Science, and Culture or at a training institution recognized by the Minister of Health and Welfare; and have obtained the knowledge and technical skill necessary to be a judotherapist, including knowledge of anatomy, physiology, pathology, and hygiene

Education and training
As of 2000, there are 80 medical schools offering six-year allopathic medical programmes in Japan Though there is no systematic programme exclusively teaching kampo medicine, the Toyama Medical and Pharmaceutical University offers a fouryear postgraduate Doctorate programme in kampo medicine as well as the only officially recognized undergraduate medical curriculum where kampo medicine is taught alongside allopathic medicine
235 A 1998 national survey reported that 18 medical schools have either an elective or required class on complementary/alternative medicine, mainly kampo medicine and/or acupuncture 245 Beginning in 1998, each year the Japan Society for Oriental Medicine offers a summer programme in kampo medicine for 60 undergraduate students of allopathic medical schools 246 Forty-six colleges and universities across Japan provide four-year undergraduate programmes in pharmaceutical sciences with traditional medicines as part of the curriculum, with a new enrolment of 7720 students in these programmes each year 239 The Research Institute for Natural Medicines 247, established in 1963 as part of the national Toyama Medical and Pharmaceutical University, is a unique national research institute in the fields of kampo medicine and pharmaceutical sciences It provides undergraduate, two-year Masters, and four-year Doctorate programmes In April 2000, the Japan Pharmacists Education Centre launched a special
training course on kampo medicine and herbal materials in collaboration with the Japanese Society of Pharmacognosy 243 Both acupuncturists and moxacauterists must complete a minimum three-year training programme Twenty-two schools and training institutions offer three-year programmes in acupuncture and moxibustion One university offers a four-year programme Eighty-seven schools and training institutions offer joint programmes in
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acupuncture, moxibustion, and Japanese traditional massage/finger pressure Seven of these are five-year programmes and 22 are three-year programmes There are 91 schools and training institutions offering a three-year programme in only Japanese traditional massage/finger pressure 238 Twenty-five schools and training institutions offer three-year programmes in judotherapy 238 For visually impaired persons, 31 schools and training institutions offer three-year programmes in Japanese traditional massage/finger pressure alone and seven schools
and training institutions offer five-year joint programmes in acupuncture, moxibustion, and Japanese traditional massage/finger pressure 238

Insurance coverage
As of April 2000, the National Health Insurance Reimbursement List included 147 prescription kampo formulae and 192 herbal materials used in prescription kampo formulae Acupuncture, moxibustion, Japanese traditional massage, and judotherapy are also covered by national health insurance 238

Kiribati
Background information
Kiribati traditional medicine includes bonesetting, herbal medicine, massage, traditional birth attendance, and word and wind medicine 248 Allopathic medicine was introduced to Kiribati during the colonial period in the early 1890s In the 1940s, traditional medicine was outlawed on the grounds that there was no scientific evidence as to its efficacy Despite the prohibition, traditional medicine continued to be practised 249

Regulatory situation
The Medical and Dental Practitioners Amended Act of 1981 250
authorizes some aspects of traditional medicine in Section 37, which states, Nothing in the Medical and Dental Practitioners Ordinance shall affect the right of anyone of Kiribati to practise in a responsible manner Kiribati traditional healing by means of herbal therapy, bonesetting and massage, and to demand and recover reasonable charges in respect of such practice

Lao Peoples Democratic Republic
Background information
The Lao phrase for traditional medicine is ya phurn meung, which translated literally means medicine from the foundation of the country Lao traditional medicine dates back to at least the 12th century, when the country was united With unification, traditional Buddhist and Indian medical systems were integrated into the society, quickly influencing traditional Laotian medicine Allopathic medicine came to the Lao

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Peoples Democratic Republic in 1893 when the French
invaded the country Lao traditional medicine remains an important element in the prevention and treatment of disease 251

Statistics
Thirty to forty per cent of both allopathic and traditional medicines are produced domestically There are seven factories producing allopathic medicines in Laos Three factories in the Vientiane municipality produce traditional medicines There are traditional medicine hospitals at all levels 251

Regulatory situation
The Lao Peoples Democratic Republic has a national programme on traditional medicine with a five-year work plan The third in a series of national seminars on traditional medicine was held in February 1993 to review the use of traditional medicine in primary health care at the provincial and district levels A draft national policy on traditional medicine was discussed at a national workshop on traditional medicine held in December 1995 and thereafter submitted to the Ministry of Health 252

Education and training
In 1996, training courses were
held in Sayaboury and Champasack provinces on the use of traditional medicine in communities 206 The courses were intended to promote the rational use of traditional medicine

Malaysia
Background information
Traditional medical practices brought by Indian and Chinese traders and migrants complemented, but did not replace, the indigenous medical system in Malaysia The introduction of Islam by Indians and Arabs, on the other hand, led to major changes in the traditional medical system Among them was treatment by recitation of verses from the Koran The diversity in medical systems in Malaysia reflects the diverse population of Malay, Chinese, Indian, and indigenous heritage In addition to allopathic medicine, the major systems of medicine practised in Malaysia include ayurveda, siddha, unani, traditional Chinese medicine, and traditional systems of medicine, such as that provided by traditional medicine practitioners, spiritualists, bonesetters, traditional birth attendants, and others
who use home remedies Medical options also include homeopathy, naturopathy, reflexology, aromatherapy, and chiropractic Traditional Malay medical practices can be traced mainly to Indonesia These medical practices are especially popular among Malay in rural areas and rely on practical experience and observation handed down orally and in writing from generation to
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generation Medical treatment may include reciting incantations over water and giving it to the patient to drink, administering herbs internally or externally, giving amulets, and prescribing special baths, with lime flowers or holy water, for example More than one of these options may be used and more than one traditional medicine practitioner may be called upon Chinese traditional medicine is believed to have been introduced into Malaysia by Chinese migrants working in the tin mines These migrants brought herbal medicines as well as other forms of treatment, including acupuncture Chinese medical
practitioners hold high status and are known as sinseh Today, traditional Chinese medicine is also used in urban centres Siddha, ayurveda, and unani — all traditional Indian medical systems — are practised in Malaysia The majority of medicines used in these systems are of vegetable, mineral, and animal origin Herbal preparations and herbal products are imported from India as medical tablets, oils, ointments, metals, mineral concoctions, and herbal powders

Statistics
The 1996 National Health Morbidity Survey II found that 23 of the people sampled consulted a traditional or complementary/alternative medical practitioner and 38 used both allopathic medicine and traditional Chinese medicine Although no statistics are available, traditional medicine is mainly practised by providers of traditional medicine, whereas allopathic medical providers practise complementary/alternative medicine as well as allopathic medicine In Malaysia, sales of traditional and complementary/alternative
medicines are estimated to be 1000 million Malaysian ringgit annually, compared with a market of 900 million Malaysian ringgit for allopathic pharmaceuticals There are 12 chiropractors practising in Malaysia 45

Regulatory situation
The official health care system adopted and implemented by the Malaysian Government is an allopathic one Subsection 1 of Section 34 of the Medical Act of 1971 contains the following broad general exemption 253:
Subject to the provisions of subsection 2 and regulations made under this Act, nothing in this Act shall be deemed to affect the right of any person, not being a person taking or using any name, title, addition or description calculated to induce any person to believe that he is qualified to practise medicine or surgery according to modern scientific methods, to practise systems of therapeutics or surgery according to purely Malay, Chinese, Indian or other native methods, and to demand and recover reasonable charges in respect of such
practice

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Subsection 2 limits the treatment of eye diseases to practitioners of allopathic medicine Likewise, the Poisons Ordinance of 1952 restricts the use of certain substances to practitioners of allopathic medicine The Midwives Registration Regulations of 1971 254 legalize the practice of eligible traditional birth attendants Subsection 2 of Section 11 of the Regulations permits midwifery to be practised by the following:
Any person untrained in the practice of midwifery, who within four years of the commencement of [the Midwives Act of 1966] satisfies the Registrar that such person has during a period of two years immediately preceding application for registration attended to women during childbirth

There are no other laws affecting traditional medical practice in Malaysia; however, there are a number of laws that regulate the production and sale of traditional medicines
These are the Poison Act of 1952, Sale of Drug Act of 1952, Advertisement and Sale Act of 1956, and the Control of Drugs and Cosmetics Regulations of 1984 Since 1992, traditional medicine products have been registered 255 The Drug Control Authority is responsible for product registration, including quality and safety Every manufacturer of traditional medicine is required to comply with good manufacturing practices, and importers are required to comply with good storage practices All homeopathic medicines have to be registered with the National Pharmaceutical and Drug Control Board 53 In the past, the Government has taken a neutral stand on the practice of traditional Chinese medicine However, in recognition of the current and potential contribution of traditional and complementary/alternative medicine to health care, the Government is now considering bringing traditional Chinese medicine into the official health care system 255 The Ministry of Health has set up the Steering Committee
on Complementary Medicine with a multisectoral membership to advise and assist the Minister in formulating policies and strategies for monitoring the practice of traditional Chinese medicine in the country A national policy is being drafted on traditional Chinese medicine to encourage established practitioners to form their own self-regulatory bodies These bodies will enable a system of official recognition of member-practitioners To ensure that the qualifications of practitioners are recognized and can be accredited for formal registration, the bodies are required to set formal standards, including training, for their own practices They are also encouraged to update the skills and knowledge of their members The Unit of Traditional Chinese Medicine has been established at the Primary Health Care Section, Family Health Development Division, Ministry of Health It will be responsible for monitoring and facilitating the implementation of the Ministrys policies as well as strengthening
national and international collaboration There is no chiropractic law

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Education and training
Recently, the umbrella body for traditional Chinese medicine has issued a Practice Approval Certificate for practitioners who have taken its courses or courses from a recognized university This certificate is needed for a Business License Certificate Homeopathy will be introduced as a discipline at the newly established Faculty of Biomedicine 53

Insurance coverage
Neither national healthcare insurance nor private insurance covers traditional Chinese medicine in Malaysia

Mongolia
Background information
Traditional Mongolian medicine has a known history of more than 2500 years Rooted in Tibetan and Indian medicine, traditional Mongolian medicine is part of the broader cultural heritage of the people and reflects their lifestyle as well as geographic and climatic conditions From the 1930s until the end of the 1980s, traditional medicine was officially ignored
Socio-economic changes in Mongolia during the 1990s led to the development of the national culture, including revival of the traditional medical heritage Traditional medicine is now more popular and accessible to communities Acupuncture and moxibustion have gradually been recognized as clinically effective in the treatment of disease and in the promotion of health In 1991, two non-governmental organizations, the Association of Acupuncture and the Association of Traditional Medicine, were established 256

Statistics
There is one 100-bed hospital for traditional medicine, 15 small traditional medicine hospitals with 10 to 20 beds, 19 outpatient clinics for traditional medicine near Government health centres, and 81 private clinics and units of traditional medicine There are also five manufacturing units for traditional medicines 257 Including those who have taken short-term courses in traditional medicine, there are about 600 — from a total of 5875 — allopathic physicians providing
traditional medicine, acupuncture, and glass-cupping therapy

Regulatory situation
The Government of Mongolia considers traditional medicine to be an important health care resource for the population and is therefore working to incorporate traditional medical remedies into the official health service 258

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In 1991, the Health Minister issued an order to begin developing traditional medicine from 1991 to 1995 This led to the establishment of an official structure for traditional medical care within the overall health system In 1996, the Ministry of Health and Social Welfare worked out a development plan for traditional medicine for 19972000, focusing on training new personnel, standardizing training curricula, improving research, and expanding the manufacture of herbal medicines A draft policy on the development of Mongolian traditional medicine was discussed at the Conference on
National Policy on Traditional Medicine in 1998 and was adopted by the State Great Khural Parliament on 2 July 1999 258 This document contains plans for developing Mongolian traditional medicine over the next 10 to 15 years and covers 19 areas of work, including the following: developing the structure and organization of hospitals of traditional medicine further; interrelating the activities of training and re-training of traditional medicine personnel; producing safe herbal medicines with naturally extracted herbs, in line with good manufacturing practices; providing support to doctors of traditional medicine and to private health institutions; exploring possibilities of curing critical diseases with traditional methods; applying some methods of traditional medicine to ambulance services as well as primary health care

Education and training
Before 1989, there were no formally qualified doctors of traditional medicine Since then, 24 to 26 students have been admitted and enrolled
each year in the Department of Traditional Medicine at the national medical university Many of the teaching materials, including acupuncture textbooks and facilities, are from neighbouring countries In both the three-year programme and the six-year programme, many hours are allotted to traditional medicine but only a minimal amount of time is set aside for acupuncture 256

New Zealand
Statistics
There are 170 chiropractors practising in New Zealand 45

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Regulatory situation
The Government of New Zealand recognizes homeopathy, osteopathy, and chiropractic 218 Chiropractic has been regulated by law since 1962, and chiropractors are permitted to use X-ray equipment 65

Education and training
There is one school of chiropractic in New Zealand 45

Papua New Guinea
Background information
Traditional medicine is widely accepted and practised in rural areas where the majority of the population lives The use of traditional plants for curing common ailments and afflictions
in village communities is encouraged by private and nongovernmental organizations on the grounds that it is a sensible option in the face of the rising costs of allopathic medicine, transport difficulties, and the poor facilities at aid posts and rural health centres

Regulatory situation
Although important for individuals and communities, traditional medicine remains outside the formal health system It is expected that a policy in support of the rational use of traditional medicine will be developed soon and that a role for traditional medicine will be embodied in the new National Health Plan 20012010 Provisions for the introduction of proven traditional medicines have already been made in the recently approved National Drug Policy 259

Philippines
Background information
The National Health Care Delivery System in the Philippines is predominantly allopathic

Statistics
There are about 250 000 practitioners of traditional medicine in the country Approximately five to eight
chiropractors are practising in the Philippines 45 There are no privately owned hospitals providing formal traditional or complementary/alternative medical services As of 1999, only a handful of Government hospitals offered acupuncture services to the general public Natural medicines are marketed over the counter in dozens of health food stores and in a limited number of pharmacies 260

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Regulatory situation
The Department of Health has developed a national programme on traditional medicine together with a six-year plan of work In 1993, a traditional medicine division was established within the Department of Health to support the integration of traditional medicine into the national health care system as appropriate, with technical support from the World Health Organization 261 The Traditional and Alternative Medicine Act was signed by the President in December 1997 It states that it
is the policy of the Government to improve the quality and delivery of health care services to the Filipino people through the development of traditional and complementary/alternative medicine and its integration into the national health care delivery system The Act created the Philippine Institute of Traditional and Complementary/Alternative Health Care 213, which will be established as an autonomous agency of the Department of Health The Institutes mission is to accelerate the development of traditional and complementary/alternative health care in the Philippines, provide for a development fund for traditional and complementary/alternative health care, and support traditional and complementary/alternative medicine in other ways Training in traditional medicine for allopathic practitioners is a priority in the country Collaboration on education and research between institutions in the Philippines and other countries has also been established 213 In the Philippines, traditional birth
attendants may legally work only in areas where physicians or registered midwives are not available The Board of Medicine Resolution 31 of 2 March 1983 262 recognizes acupuncture as a modality of treatment for certain ailments to be practised only by registered physicians in the Philippines The Board is mandated to promulgate rules and regulations to govern the practice of acupuncture and to evaluate and assess the annual reports submitted by practitioners on their experiences and the results of their clinical treatment of cases to determine if they may continue to practice legally There is no chiropractic law

Education and training
More than 200 Government allopathic physicians have been trained in acupuncture

Republic of Korea
Background information
In the Republic of Korea, the oldest record of traditional medicine, known as oriental medicine, dates to the Gochosun period, about 4332 years ago Oriental medicine flourished until 1894 when the Gab-O Reform abolished the law of
oriental medicine,

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leading to its decline in favour of allopathic medicine In 1945, oriental medicine was revitalised and is very popular today Intended to represent oriental medical doctors and foster legal order, the Korean Oriental Medical Association KOMA 263 was organized on 16 December 1952 to promote health through the development of oriental medical science and by facilitating cooperation among its members KOMA has 16 branch offices established under the National Medical Treatment Law in 1952 These are located in both cities and provinces The establishment of the Korea Institute of Oriental Medicine 264 was initiated on 24 March 1994 by National Act 4758 The Institute opened on 10 October 1994 It employs over 30 persons, and in 2000, it had a budget of 5047 million won Among other things, the Institute focuses on clinical trials of oriental medicine, research on the standardization and development of oriental medicines, investigation and analysis of
acupuncture, and research to assist in the development of the oriental medicine industry Plans for expanding the Institute are expected to make it a major research institute for oriental medicine and a worldwide centre for research and study of traditional and complementary/alternative medicine

Statistics
There are 107 oriental medical hospitals and 6590 oriental medical clinics There are 9914 oriental medical doctors 264 Public health doctors of oriental medicine work at 69 provincial Government health centres Oriental medicine doctors have worked for the Surgeon General in the army since 1989 There are about 133 acupuncturists, 41 moxibustion practitioners, and 76 acupuncture/moxibustion clinics Approximately 30 chiropractors are practising in the Republic of Korea 45 The Korean Oriental Medical Association has about 10 000 members According to national medical insurance records, 13 907 000 persons received oriental medical treatment in 1998 This represents 48 of the total number of
people receiving medical treatment

Regulatory situation
The Civil Medical Treatment Law, brought into force in 1951, established a dual system of medical treatment comprised of oriental and allopathic medicine In 1969, the Ministry of Public Health and Welfare published a notification permitting pharmaceutical companies to produce herbal preparations whose formula is described in the 11 classic books on traditional Korean and Chinese medicine, without first having to submit clinical or toxicological data 219 The Medical Affairs Division under the Medical Bureau of the Ministry of Health and Welfare was in charge of the administrative management of oriental medical treatment until 1993, when the Oriental Medicine Division was established In November 1996, this Division was expanded into the Oriental Medicine Bureau 264, a major bureau of the Ministry of Health and Welfare, with two of its own divisions

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A Worldwide Review

The Oriental Medicine Bureau works on short-term and long-term policy planning, research on oriental medical systems, and the administration of oriental medicine One project is a programme of cooperation with China involving collaborative scientific research and the exchange of researchers and research information Another project, intended to promote oriental medicine abroad, offers free medical examinations and treatment by oriental medicine in the World Health Organization Western Pacific Region Member States Future plans for the Bureau emphasize the importance of quality control in manufacturing and distributing oriental medicines, particularly through licensing Research will also be carried out to index materials and develop methods of chemical analysis of oriental medicines In 1993, an advisory council on oriental medical policy was established in the Ministry of Health and Welfare 264 Oriental medical doctors are allowed to perform medical acts, including
acupuncture and moxibustion However, they do not have the right to order X-rays and pathological tests To get an oriental medical doctors licence, one must graduate from an oriental medical college and pass the national examination for oriental medical doctors Under the Medical Treatment Act 265, acupuncture can only be practised by persons holding a certificate of qualification The policy of cultivating acupuncturists was abolished in 1962 and since then only oriental medicine doctors can practise acupuncture Under the Pharmacist Law, which became effective on 1 July 1994, pharmacists must pass the national oriental medicine exam in order to practise oriental medicine 264 There is no chiropractic law

Education and training
The education system for oriental medicine in Korea was established in 1964 Oriental medical studies 263 consist of a preparatory two-year programme and a regular four-year programme covering the basic subjects of oriental and allopathic medicine In 1994, there
were 3922 students majoring in oriental medical sciences enrolled in sixyear programmes at 11 colleges throughout the country Every graduate school has a Masters and Doctorate programme in oriental medical sciences In each case there is an affiliated oriental medicine hospital providing clinical education In 1996, the Government approved the establishment of oriental pharmacy departments at several universities 213

Insurance coverage
A national medical insurance programme covering oriental medical services has been in effect since 1 February 1987 Included in the coverage are oriental medical diagnosis, acupuncture, moxibustion, and 56 kinds of medicines based on herbal extracts 263 Total medical insurance payments for oriental medicine treatments in 1998 were 31555 billion won, or 3 of the total medical insurance payments for medical treatment Patients treated with unauthorised complementary/alternative medicine are not covered by the medical insurance scheme

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Samoa
Background information
Traditional medical practitioners in Samoa have used medicinal plants and other forms of non-drug treatment for centuries This knowledge is typically passed down within families 266

Statistics
The exact number of traditional medicine practitioners in Samoa is unknown, but a recent survey concerning primary health care workers estimated that there are about 150 full-time practitioners of traditional medicine Visiting acupuncturists from the Peoples Republic of China have been providing acupuncture treatments in the country for about 10 years Approximately 55 000 patients have been treated

Regulatory situation
There is no legislation on traditional medicine in Samoa Although the Medical Practitioners Act states that only registered persons can practise medicine, practitioners of traditional medicine are not considered to be breaking the law The Health Sector Reform has included traditional medicine as a sub-component for institutional
strengthening/reform

Singapore
Background information
Singapores health services are based on allopathic medicine However, it is common practice among the various ethnic groups to consult traditional practitioners for general ailments Chinese, Indian, and Malay traditional therapies all have a part in complementary/alternative health care in Singapore

Statistics
About 45 of the population have consulted traditional medicine providers Traditional Chinese medicine is the most prominent traditional therapy, both in terms of the number of its practitioners and patients and in its far-reaching appeal 213 A list published by the local traditional Chinese medicine community in 1997 reported 1807 practitioners of traditional Chinese medicine in Singapore, most of whom were more than 40 years old Half of them practised traditional Chinese medicine on a fulltime basis, one-third practised part-time, and the remainder were not practising at the time of the listing 267 Approximately 10
chiropractors practise in Singapore 45 Traditional Chinese medical practice is restricted to outpatient services in Singapore About 10 000 persons visit traditional Chinese medicine clinics each day, compared to 74 000 persons who visit allopathic clinics

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Regulatory situation
The health authorities recognize the importance of traditional medicine in the provision of health care and have initiated efforts to promote and ensure the safe practice of traditional medicine A traditional medicine unit was set up in the Ministry of Health in November 1995 268 Act 34, the Traditional Chinese Medicine Practitioners Act of 2000, was passed by Parliament on 14 November 2000 and assented to by the President on 2 December 2000 The Act provides for the establishment of the Traditional Chinese Medicine Practitioner Board to approve or reject applications for registration and to accredit courses in
the practice of traditional Chinese medicine, among other things This accreditation is intended to facilitate registration The Register of Traditional Chinese Medicine Practitioners shall be kept by the Registrar appointed by the Board A registered practitioner who desires to obtain a certificate to practice must make an application to the Board Unlawful engagement in prescribed practices of traditional Chinese medicine is punishable by a fine, imprisonment, or both Under the power conferred by the Traditional Chinese Medicine Practitioners Act of 2000, the Minister for Health issued the Traditional Chinese Medicine Practitioners Registration of Acupuncturists Regulations of 2001, which came into effect 23 February 2001 The Traditional Chinese Medicine Practitioners Board, with the approval of the Minister for Health, issued the Traditional Chinese Medicine Practitioners Register and Practising Certificates Regulations of 2001, which came into effect on 18 April 2001 There is no
chiropractic law

Education and training
Schools of traditional Chinese medicine have made valuable contributions to the training of traditional Chinese medicine practitioners in the past Singapore has adopted a standardized six-year part-time training programme in traditional Chinese medicine National examinations for both acupuncture and traditional Chinese medicine will soon be required for practitioners 268

Solomon Islands
Background information
There is very little documentation on traditional medicine in the Solomon Islands Traditional medicine practitioners regard the medicines they use as their personal property and conduct their practices under very strict confidence Many of the natural materials used to make the traditional medicines can only be collected at specific times 269

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Regulatory situation
In 1979, the Government officially recognized and accepted the use of traditional medicine as a supplement to allopathic medicine in rural communities where
the availability of allopathic drugs is limited The policy states that traditional medical practice is not to be institutionalized but, rather, is to remain largely in the hands of individual practitioners

Vanuatu
Regulatory situation
In Vanuatu, under the Health Practitioners Act of 1984 270, amended in 1985 271, osteopathy and chiropractic are designated as ancillary allopathic medical professions subject to registration By Section 5 of the Act, a person is eligible to be registered if, in the opinion of the Health Practitioners Board, he or she has sufficient training, skill, and practical experience At its discretion, the Board can require applicants who do not meet these criteria to complete a recognized training course Section 18 makes it an offence for a non-registered person to practise medicine or claim to be registered to practise medicine

Viet Nam
Background information
In Viet Nam, traditional medicine can be divided into two categories: Vietnamese traditional medicine,
which is influenced by Chinese traditional medicine, and oriental medicine In the countryside and in remote and mountainous areas, Vietnamese traditional medicine is more commonly used In the delta, lowlands, and cities, patients more commonly use a combination of Vietnamese traditional medicine and oriental medicine Both Vietnamese traditional medicine and oriental medicine form an integral part of the national health care system in Viet Nam and have an important role in promoting the health of the Vietnamese people, particularly in difficult cases, geriatric diseases, and primary health care at the commune level Allopathic doctors who have graduated from medical universities and who have been trained in traditional medicine have become some of the most outspoken supporters of traditional medicine They are actively engaged in promoting the rational use of traditional medicine in their institutes and hospitals 272

Statistics
According to Ministry of Health statistics, about 30 of
patients receive treatment with traditional medicine Treatment is provided by traditional medicine practitioners who have not received any formal education and by traditional medical doctors who have graduated from a department of traditional medicine at one of the medical
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

universities in Hanoi, Ho Chi Minh City, or Haiphong There are about 1000 traditional medicine practitioners, 5000 traditional medical doctors, 2000 assistant traditional medical doctors, and 209 traditional medicine pharmacists 272 Additionally, there are approximately 8000 private practitioners of traditional medicine Of this number, about 1400 are acupuncturists The Viet Nam Association of Traditional Medicine Practitioners has 24 000 members Of this number, 461 work in public hospitals The Viet Nam National Association of Acupuncture has 18 000 members, 4500 of whom work in public hospitals 272 A Traditional
Medicine Hospital of the Ministry of Interior Affairs was inaugurated at the end of 1996 273 Additionally, there are 286 departments of traditional medicine in general hospitals, 45 provincial hospitals of traditional medicine, and four institutes of traditional medicine in Viet Nam 274 There are three medical colleges that have a faculty of traditional medicine, two pharmaceutical colleges, two secondary schools of traditional medicine, two State pharmaceutical companies, two State pharmaceutical manufacturers of herbal medicine, and three national research institutes for traditional medicine 219 An Army Institute of Traditional Medicine was established in 1978, with a staff of 100 doctors and pharmacists The tasks of the Institute include clinical work, research, training, and the manufacture of herbal products It serves about 20 000 outpatients and 2500 inpatients each year The Viet Nam Acupuncture Institute operates under the authority of the Ministry of Health The Institute is
responsible for giving nationwide guidance on acupuncture and other medical therapies that reduce or avoid the use of drugs in treatment It has 350 beds and serves approximately 2500 inpatients and 8500 outpatients each year

Regulatory situation
The Government supports public-sector facilities for traditional medicine and encourages people to mobilize resources for the development of traditional medicine, especially for primary health care Government programmes include training health workers at the community level in using traditional medical methods to treat common and recently defined diseases and encouraging people to plant medicinal vegetables, ornamental plants, and fruit trees These three groups of plants are intended for use in treating common diseases in the community as well as improving family incomes This model has become a countrywide programme A number of official documents indicate clear support for traditional medicine There is official recognition for a number of
traditional therapies, including medications made from plants and animals, massage, acupuncture, acupressure, moxibustion, vital preservation, cupping, and thread embedding Article 39 of the Constitution of the Socialist Republic of Viet Nam outlines State undertakings to develop and integrate allopathic and traditional medical and pharmaceutical practices as well as to develop and integrate official health care,

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traditional medicine, and private medical care More detailed provisions on traditional medicine can be found in a 1989 public health law 275 and 1991 regulations made under it 276 Among the objectives of health care, Section 2 of the 1989 law lists the development of official Vietnamese medicine on the basis of traditional medicine and pharmacy and the integration of allopathic and traditional medicine The promotion of these objectives is the shared responsibility of the Ministry of Health, the Vietnamese Traditional Medicine Association, and the Viet
Nam General Union of Medicine and Pharmacy Under Section 341, these organizations are additionally charged with ensuring conditions for the operation of all major hospitals and institutes of traditional medicine Section 342 provides that the medical services and the peoples committees at all levels are to consolidate and broaden the health-care network using traditional medicine Section 35 permits licensed traditional medicine practitioners to practise in any State, collective, or private health care institution This includes acupuncturists who have been trained, who have attended courses in traditional medicine, or whose knowledge of traditional medicine was passed down to them through their family Traditional medicine practitioners may examine and treat patients as well as offer preventive advice However, before new treatment methods can be used, they must be approved by the Ministry of Health or provincial health office and the Traditional Medicine Association Superstitious practice
is forbidden by Section 36 Private practice of traditional medicine is subject to management by the Government and the Ministry of Health The 1991 regulations specify required qualifications for traditional medicine practitioners as well as the permitted range of procedures practitioners may use A breach of any of these rules that results in serious harm to life or health of another person is punishable under the Criminal Code by imprisonment 277 The 1993 Vietnamese Ordinance on Private Medical and Pharmaceutical Practice 278 includes detailed provisions on the private practice of traditional medicine The Ordinance permits certified practitioners of traditional medicine to privately practise the range of activities for which they are certified, provided they have a permit to do so and subject to State overview Article 5 lists permitted activities as including practice in a traditional medical hospital or clinic and providing traditional forms of treatment such as acupuncture, massage,
acupressure, and herbal saunas Article 7 requires traditional practitioners to hold a diploma of Doctor of Medicine or Assistant Doctor Specialising in Traditional Medicine and to have practised traditional medicine for a minimum period that varies between two and five years A number of measures are included in the Ordinance to further safeguard patients interests Under Article 17, practitioners must put up a name board that sets out the activities they are permitted to practice Private practitioners must obtain the permission of the Ministry of Health to use novel treatment techniques or drugs Superstitious practices are not permitted according to Article 19 Private practice without a certificate or practice that exceeds the range of permitted activities is subject to administrative, disciplinary, or criminal sanctions under Article 34
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Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review

The Government entrusts the health service
system with issuing licences to traditional practitioners through an assessing committee Anyone who has 13 certificates issued by an assessing committee and the Ministry of Health can privately practise traditional medicine In the area of acupuncture, the regulatory qualifications of practitioners include Professor, Associate Professor, PhD, Acupuncture Speciality Doctor Level I, Acupuncture Speciality Doctor Level II, and Acupuncture-Oriented Doctor The Ministry of Health advocates socialization and diversification of traditional medicine

Education and training
There is no college or university of traditional medicine in Viet Nam Although Hanoi Medical University has a department of traditional medicine, it does not meet the needs of developing traditional medicine in Viet Nam Two secondary schools are the main seats of learning in traditional medicine There is strong support for a facility of higher education in traditional medicine, and the Government is planning to create a
university of traditional medicine to provide programmes for secondary, undergraduate, and postgraduate study 278, 279

Insurance coverage
Health insurance covers costs for both allopathic and traditional medicine 218; however, this is not on an equal basis in all areas because of differential access to care

174

References

References
1 General guidelines for methodologies on research and evaluation of traditional medicine Geneva, World Health Organization, 2000 unpublished document WHO/EDM/TRM/20001; available on request from Traditional Medicine, Department of Essential Drugs and Medicines Policy, World Health Organization, 1211 Geneva 27, Switzerland Annual report 19981999 Ministry of Health and Family Welfare, Government of India La médecine Chinoise Paris, Encyclopédie Hachette, 2001 Liu B The national government policy and efforts on promoting traditional medicine in China In: Traditional medicine, its contribution to human health development in the new century: report of an
international symposium, Kobe, Japan, 6 November 1999 Kobe, Japan, World Health Organization Centre for Health Development, 2000 unpublished document; available on request from the WHO Centre for Health Development, IHD Centre Building, 9th Floor, 1-5-1 WakinohamaKaigandori, Chuo-ku Kobe 651-0073, Japan Unani medicine in India New Delhi, Central Council for Research in Unani Medicine, Ministry of Health and Family Welfare, Government of India, 1997 Analysis of questionnaire on traditional medicine Geneva, World Health Organization, 1992 unpublished document WHO DOC 5183A/REV DOC 6136A Massougbodji MA, Tevoedjre A Communication with WHO Cotonou, Ministère de la Santé, de la Protection Sociale, et de la Condition Féminine and Ministère du Plan, de la Restructuration Economique, et de la Promotion de lEmploi, République du Bénin, 27 October 1997 Epa K Communication with WHO WHO Representative, Benin, 10 November 1997 Plan daction 19981999 Cotonou, République du Bénin, 1997 Staugard F
Traditional medicine in a transitional society: Botswana moving towards the year 2000 Gaborone, Ipelegeng Publishers, 1989 Haram L Tswana medicine in interaction with biomedicine Social science and medicine, 1991, 33:167175 The Medical, Dental, and Pharmacy Amendment Act, 1987 International digest of health legislation, 1989, 40:819 Upper Volta, Public Health Code, Part II, Tilte IV: Traditional medicine International digest of health legislation, 1973, 24:649 Burkina Faso Law No 23/94/ADP of 19 May 1994 promulgating the Public Health Code International digest of health legislation, 1995, 46:449454 Decree-Law no 1/16 of 17 May 1982 International digest of health legislation, 1984, 35:1 Fifth five-year social, economic, and political development plan 19811986 Yaounde, Department of Planning, Ministry of Economic Affairs and Planning, Republic of Cameroon, 1981 Lantum DN Traditional medicine-men of Cameroon, the case of Bui division: a socio-demographic and epidemiological profile
Yaounde, Yaounde Public Health Unit, University Centre for Health Sciences UCHS/CUSS, University of Yaounde, 1985 Decree of 19 March 1952 Bulletin officiel du Congo Belge, 15 May 1952, Part L: 882890 Codes et lois du Congo Belge, 1952, 3:616 Traditional medicine in Zaire: present and potential contribution to the health services Ottawa, International Development Research Centre, 1980 Bishaw M Promoting traditional medicine in Ethiopia: a brief historical review of government policy Social science and medicine, 1991, 33:193200 Serto Ader, Yekatit 13:1978 EC 20 February 1986 Ethiopia

2 3 4

5 6 7

8 9 10 11 12 13 14 15 16 17

18 19 20 21 22

175

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

23 24 25

26

27

28

29 30 31

A study regarding the future development of traditional medicine Addis Ababa, Ministry of Health, Ethiopia, 1984/1985 Ten-year perspective plan Addis Ababa, Provisional Military Government of Socialist Ethiopia,
1983/1984 Mensah EN Traditional medicine in Ghana: situation, policies, development and challenges of st the 21 century Presented at the International Congress on Traditional Medicine, Beijing, China, 2224 April 2000 Oppong-Boachie K Strategy for traditional medicine for the African region: the experience of Ghana Presented at the WHO consultative meeting on strategy for traditional medicine for the African region 20012010, Harare, Zimbabwe, 1315 December 1999 Commodore SGO Welcome address Presented at Traditional medicine and modern health care: partnership for the future, a two-day national consensus-building symposium on the policies on traditional medicine in Ghana, 1516 March 1995 Mensah MLK, Sarpong K Training of the traditional medicine practitioners and the preservation of our medical heritage: options and challenges Presented at Traditional medicine and modern health care: partnership for the future, a two-day national consensus-building symposium on the policies on
traditional medicine in Ghana, 1516 March 1995 Sanders AJGM Towards the legalisation of African folk therapy Medicine and the law, 1989, 7:523 528 Le Grand A, Wondergem P Herbal medicine and health promotion: a comparative study of herbal drugs in primary health care Amsterdam, Royal Tropical Institute, 1990 Bodeker G Planning for cost-effective traditional health services In: Traditional medicine, better science, policy and services for health development: proceedings of a WHO international symposium, Awaji Island, Hyogo Prefecture, Japan, 1113 September 2000 WHO Centre for Health Development, Kobe, 2001 unpublished document; available on request from the WHO Centre for Health Development, IHD Centre Building, 9th Floor, 1-5-1 Wakinohama-Kaigandori, Chuo-ku Kobe 651-0073, Japan Ordinance no 189 PRG of 18 September 1984 on the practice of the medical profession, Sections 1 and 2 International digest of health legislation, 1985, 36:21 Nyamwaya D African indigenous medicine: an
anthropological perspective for policy makers and primary care managers Nairobi, African Medical and Research Foundation, 1992 Development plan, 19891993 Kenya Lesotho Practice of traditional medicine International digest of health legislation, 1978, 29:160161 Lesotho An Act No 17 of 1978 to provide for the establishment of a Medicinemen and Herbalists Council to promote and control the activities of medicinemen and herbalists association International digest of health legislation, 1981, 32:402 Malawi An act No 17 of 1987 to provide for the establishment of the Medical Council of Malawi, the registration and disciplining of medical practitioners and dentists, the licensing of private practice of medical practitioners and dentists, the regulation of training within Malawi of medical personnel and generally for the control and regulation of the medical profession and practice in Malawi and for matters incidental to or connected therewith International digest of health legislation, 1988,
39:613616 Koumare M La médecine traditionnelle au Mali Bamako, Institut National de Recherches sur la Pharmacopée et La Médecine Traditionelle, 1980 Sall B La médecine traditionelle en République du Mali Revue juridique et politique, indépendance et coopération, 1981, 35:117 Decision no 1831 of 9 December 1981 International digest of health legislation, 1983, 34:122 Ordinance no 83136 of 6 June 1983 International digest of health legislation, 1983, 34:369 Mauritius An Act to provide for the practice and control of Ayurvedic and other traditional systems of therapeutics in Mauritius International digest of health legislation, 1991, 42:424426 Clarke E Traditional medicine in Mozambique Health systems trust update, October 1998, 37:11 Information provided to WHO by the Ministry of Health and Social Services, Namibia, February 2000 Communication with WHO Chandler, Arizona, World Chiropractic Alliance, January 2001

32 33 34 35 36

37

38 39 40 41 42 43 44 45
176

References

46 47 48

49
50 51 52 53 54 55 56 57

Allied Health Service Professions Act, 1993 Act no 20, 1993 Government Gazette, 2 September 1993, 2:710 Namibia Ousseini H Communication with WHO Chief Physician of the Niamey Hospital, Republic of Niger, 25 August 1982 Order no 32/MSP/AS/CF of 31 March 1989 establishing the Committee for Studies on Traditional Medicine and Traditional Pharmacopoeia International digest of health legislation, 1990, 41:308 Sule S Communication with WHO National Traditional Medicine Development Programme, Federal Ministry of Health, Nigeria, 11 May 2000 Ajai O The integration of traditional medicine into the Nigerian health care delivery system: legal implications and complications Medicine and the law, 1990, 8:308 The Medical Rehabilitation Therapists Registration, etc Decree 1988 International digest of health legislation, 1990, 41:598 The National Primary Health Care Development Agency Decree 1992 International digest of health legislation, 1993, 44:576 Liga Medicorum
Homeopathica Internationalis, ed World homeopathy 1998 Selva, Spain, Liga medicorum homeopathica internationalis, 1998 Baldé S, Sterck C Traditional healers in Casamance, Senegal World health forum, 1994, 15:390392 Floyd VD Communication with WHO PROMETRA Promotion des Médecines Traditionnelles, Dakar, Republic of Senegal, 21 July 1997 Sierra Leone Registration of physicians and dentists International digest of health legislation, 1969, 20:133 Sierra Leone A Decree N P R C Decree No 12 of 1994 to establish the Medical and Dental Council, to provide for the registration of medical practitioners and dental surgeons and for other related matters International digest of health legislation, 1994, 45:462463 Mayeng I Integrating traditional medicine into national health care systems, is it an attainable objective? Presented at the WHO consultative meeting on strategy for traditional medicine for the African region 20012010, Harare, Zimbabwe, 1315 December 1999 Clarke E The collaboration
between traditional healers and the department of health Health systems trust update, October 1998, 37:5 Hess S Traditional healers in SA Health systems trust update, October 1998, 37:67 Associated Health Service Professions Act, no 63 of 1982, as amended by the Associated Health Service Professions Amendment Act, no 108 of 1985 and the Associated Health Service Professions Amendment Act, no 10 of 1990 South Africa Regulatory situation of herbal medicines: a worldwide review Geneva, World Health Organization, 1998 unpublished document WHO/TRM/981; available on request from Traditional Medicine, Department of Essential Drugs and Medicines Policy, World Health Organization, 1211 Geneva 27, Switzerland Felhaber T, Gericke N TRAMED final narrative report: 1 June 199430 April 1996 Traditional Medicine Programme, University of Capetown, South Africa, 1996 unpublished document Gray A The registration of traditional medicines: a new medicines bill Health systems trust update, October 1998,
37:910 Communication with WHO Chandler, Arizona, World Chiropractic Alliance, July 2000 Swaziland Practice of medicine, dentistry, allied health professions, and traditional medicine International digest of health legislation, 1978, 29:818 Law no 801 of 13 August 1980 embodying the criminal code Journal officiel de la République Togolaise, 13 August 1980, Special Issue:1 Togo Clarke E Traditional medicine in Uganda Health systems trust update, October 1998, 37:12 Amooti-Kyomya S Traditional health systems and the conventional system in Uganda In: Islam A, Wiltshire R, eds Traditional health systems and public policy Ottawa, International Development Research Centre, 1994 Mhame P Development of national policy on traditional medicine and strategies for integrating traditional medicine into health systems Presented at the WHO consultative meeting on strategy

58

59 60 61

62

63 64 65 66 67 68 69

70

177

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

71 72 73 74

for traditional medicine for the African region 20012010, Harare, Zimbabwe, 1315 December 1999 Tanzania laws Chapter 409, Section 37 and Chapter 416, Section 53 Tanzania Swantz L The medicine man among the Zamaro of Dar es Salaam Uppsala, The Scandinavian Institute of African Studies in cooperation with Dar es Salaam University Press, 1990 The national traditional and birth attendants implementation policy Dar es Salaam, Ministry of Health, United Republic of Tanzania, 1999 Mudondo CM The role of traditional medicine in the health system: Zambian situation Presented at the African forum on the role of traditional medicine in health systems, Harare, Zimbabwe, 1618 February 2000 Matondo IN Traditional medicine in Zimbabwe Presented at the International congress on traditional medicine, Beijing, China, 2224 April 2000 Cavender T The professionalisation of traditional medicine in Zimbabwe Human organization, 1988, 47:251254 Ushewokunze H An agenda for
Zimbabwe Harare, Zimbabwe, College Press, 1984 Zimbabwe An Act No 31 of 1981 to establish a Natural Therapists Council of Zimbabwe; to provide for the registration and regulation of the practice of homoeopaths, naturopaths and osteopaths in Zimbabwe, and to provide for matters incidental to or connected with the foregoing International digest of health legislation, 1982, 33:1012 Zimbabwe An Act No 38 of 1981 to establish a Traditional Medical Practitioners Council; to provide for the registration and regulation of the practice of traditional medical practitioners; and to provide for matters incidental to or connected with the foregoing International digest of health legislation, 1982, 33:1214 Chavundka G ZINATHA: the organization of traditional medicine in Zimbabwe In: Last M, Chavundka G, eds The professionalisation of African medicine Manchester, Manchester University Press, 1986 The chiropractic profession: first draft of technical information on the chiropractic profession Prepared
for the World Health Organization by the World Federation of Chiropractic, 15 January 1999 unpublished document Report of the working group of OPS/OMS on traditional, complementary and alternative medicines and therapies, Washington DC, 1516 November 1999 Washington DC, Pan American Health Organization/World Health Organization, 1999 Traditional health systems in Latin America and the Caribbean: baseline information Washington DC, Pan American Health Organization/World Health Organization, July 2000 Technical report of a project funded by the National Institutes of Health, USA Alvarez W Country presentation Presented at the WHO workshop on traditional and indigenous medicine in the Americas, Guatemala City, Guatemala, 1823 March 2001 VI Family health Bolivia Regulation on the conduct of family health activities in Bolivia International digest of health legislation, 1983, 34:510512 Liga Medicorum Homeopathica Internationalis, ed World homeopathy, 2000 Selva, Spain, Liga Medicorum
Homeopathica Internationalis, 2000 History of the Chinese Medicine and Acupuncture Association of Canada In: Progress report 19831998 London, Canada, The Chinese Medicine and Acupuncture Association of Canada, 1998 Gray C Growing popularity of complementary medicine leads to national organization for MDs Canadian medical association journal, 1997, 157:186188 Millar WJ Use of alternative health care practitioners by Canadians Canadian journal of public health, 1997, 88:154158 Popularity of alternative medicine still growing in the US, Canada, poll finds Alternative therapies, 1998, 4:29 Natural health products: a new vision Ottawa, Library of Parliament, 1998 Perspectives on complementary and alternative health care: a collection of papers prepared for Health Canada Ottawa, Health Canada, 2001

75 76 77 78

79

80

81

82

83

84 85 86 87

88 89 90 91 92

178

References

93 94 95 96 97

Natural health products: recent chronology Ottawa, Health Canada, March 1999 Blais RB, Maiga A,
Aboubacar A How different are users and non-users of alternative medicine? Canadian journal of public health, 1997, 88:159162 Workbook, ONHP consultation 2000 Available online at http://wwwhc-scgcca/hpb/onhp Proposed regulatory framework for natural health products Ottawa, Health Canada, March 2001 Rock A Presentation by the Health Minister of Canada to the House of Commons Standing Committee on Health Reproduced in The Chinese Medicine and Acupuncture Association of Canada, 1998, 6:21 Canada Yukon Territory The Health Act International digest of health legislation, 1993, 44:15 Regulated Health Professions Act, 1991, Sections 27 and 35 International digest of health legislation, 1993, 44:204 For the relevant laws of the Canadian provinces, see Alberta: International digest of health legislation, 1967, 18:275276 and 1969, 20:195 British Columbia: International digest of health legislation, 1961, 12:718 and 1969, 20:198 New Brunswick: International digest of health legislation, 1960,
11:88 Newfoundland and Labrador: The Chiropractors Act, 1992 Nova Scotia: International digest of health legislation, 1973, 24:67 Ontario: Regulated Health Professions Act, 1991, Statutes of Ontario, c18 and The Chiropractic Act, 1991, c21 Prince Edward Island: International digest of health legislation, 1969, 20:422423 Quebec: International digest of health legislation, 1975, 26:327328 Saskatchewan: Osteopathic Practice Act, c0-7 Statutes of Ontario, 1991 Ontario, Canada Chiropractic Profession Act, RSA 1980, c-91 Ottawa, Canada Chiropractic Profession Amendment Regulation Alberta, Alta Reg 82/94, at Section 101 The Alberta gazette, 1994, 90:264 Canada Saskatchewan An Act Chapter C-101 respecting chiropractors International digest of health legislation, 1997, 48:34 Wigod R Legalize, regulate acupuncture, Health Professions Council says The Vancouver sun, 26 November 1993:B7 Cheung CK Presidents address The Chinese Medicine and Acupuncture Association of Canada, 1998, 6:12 Health
Disciplines Act Alberta, Chap H-35, RSA, as amended, 1980 Alberta, Canada Medical Act, 1973, Chapter M-9, as amended Quebec, Canada Regulations respecting the practice of acupuncture by persons other than physicians International digest of health legislation, 1993, 44:208 Guidelines for the practice of acupuncture in the Province of Saskatchewan Undated Regina, Canada Directive issuing acupuncture guidelines Whitehorse, Yukon Territory, Yukon Medical Council, 6 May 1986 For the relevant laws of the Canadian provinces, see the following: Alberta: Naturopathy Act Alberta, RSA 1980 cN-6 Manitoba: Naturopathic Act Manitoba, LRM 1987, cN-80 Saskatchewan: Naturopathy Act Saskatchewan, c N-4 Chiropractic Profession Act Alberta c 91, 1984 Alberta, Canada Ruedy J Paper on medical schools approach to the demand for AM/CM at the alternative and complementary medicine conference Toronto, Institute for International Research, March 1998 The Alberta Health Care Insurance Act International digest of
health legislation, 1993, 44:581 Chapman-Smith D The chiropractic profession The chiropractic report, 1993, 7:2 Alberta health bulletin, 26 January 1994, 4:1 Ibacache J, Quidel J, Saez M Country presentation Presented at the WHO workshop on traditional and indigenous medicine in the Americas, Guatemala City, Guatemala, 1823 March 2001

98 99 100

101 102 103 104 105 106 107 108 109 110 111 112

113 114 115 116 117 118

179

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

119 120

121

122 123

Medina CE Medicina tradicional en los sistemas locales de salud, informe de Chile Santiago, Unidad de Medicina Tradicional y Otras Prácticas Médicas Alternativas, Ministerio de Salud de Chile, 1994 Velimirovic B, Velimirovic H The utilization of traditional medicine and its practitioners in health services: a global overview In: Velimirovic B, ed Modern medicine and medical anthropology in the United States/Mexico border population Washington DC,
Pan American Health Organization, 1978 Scientific Publication, No 359 Martinez S Encuentro regional sobre aspectos regulatorios de productos a base de hierbas Presented at the Regional meeting on regulatory aspects of herbal products, Kingston, Jamaica, 1316 November 2000 Padron L Country presentation Presented at the WHO workshop on traditional and indigenous medicine in the Americas, Guatemala City, Guatemala, 1823 March 2001 Cubas health care system In: Djukanovic V, Mach EP, eds Alternative approaches to meeting basic health needs in developing countries, a joint UNICEF/WHO study Geneva, World Health Organization, 1975 Law no 41 of 13 July 1983 on public health International digest of health legislation, 1985, 36:13 Decree no 139 of 4 February 1988 promulgating regulations for the implementation of the law on public health International digest of health legislation, 1989, 40:800 Manual para el adiestramiento de parteras empiricas, revised ed Santo Domingo, Ministry of Health and
Social Welfare of the Dominican Republic, 1973 Supreme Decree no 188 of 4 February 1971 embodying the health code International digest of health legislation, 1973, 24:130 Manual de capacitación de parteras empiricas Quito, Ministry of Health, Ecuador, 1976 unpublished document Regulación y Control de Productos Farmaceuticos y Afines Direccion General de Regulación, Vigilancia y Control de la Salud, November 1999 Guatemala Guatemala Acupuncture: Guatemalan Acupuncture Association International digest of health legislation, 1980, 31:310 Decree no 75 of 14 November 1966 promulgating the health code of the Republic of Honduras International digest of health legislation, 1967, 18:733 Changes to Food and Drugs Act proposed Jamaica gleaner, 28 January 2000 Roxborough P Natural medicines a hit: distributors raking in big money Jamaica gleaner, 23 January 2000 Amendments to the Food and Drugs Act and food and drugs regulations to include herbal products: draft cabinet submission Kingston,
Jamaica, Ministry of Health, 2 March 1999 Report of the consultation on approaches for policy development for traditional health practitioners, including traditional birth attendants Geneva, World Health Organization, 1985 unpublished document NUR/TRM/851; available on request from Traditional Medicine, Department of Essential Drugs and Medicines Policy, World Health Organization, 1211 Geneva 27, Switzerland Regulations of 20 October 1976 International digest of health legislation, 1978, 29:606 Stepan J Traditional and alternative systems of medicine: a comparative review of legislation International digest of health legislation, 1985, 36:283333 Villalba ED Salud de los pueblos indigenas El caso de los Ngöbe-Buglé de Panama: informe de consultoria Organización Panamericana de la Salud Panama, December 2000 unpublished document Decreto Supremo no 010-97-SA Reglamento para el Registro, Control y Vigilancia Sanitaria de Productos Farmaceuticos y Afines Ministry of Health, 1997 Peru Public
Law 103-43, 10 June 1993 United States of America Eisenberg D et al Trends in alternative medicine use in the US, 19901997 Journal of the American Medical Association, 11 November 1998, 280:15691575 Eisenberg D et al Unconventional medicine in the US: prevalence, costs, and patterns of use English journal of medicine, 1993, 323:673

124 125 126 127 128 129 130 131 132 133 134 135

136 137 138

139 140 141 142

180

References

143

144 145 146 147 148 149 150

Alternative medicine: expanding medical horizons A report to the National Institutes of Health on alternative medical systems and practices in the United States Washington DC, US Government Printing Office, 1994 Cohen MH Legal boundaries and regulatory perspectives Baltimore, The Johns Hopkins University Press, 1998 Corpus juris secundum St Paul, Minnesota, West Publishing Co, 1987, 70:396 McKinneys consolidated laws of New York annotated Book 16 St Paul, Minn, West Publishing Co United States of America Practice of certain
health professions: miscellaneous provisions International digest of health legislation, 1974, 25:461464 United States of America Grants for establishment of departments of family medicine International digest of health legislation, 1983, 34:498499 19931994 Official directory: chiropractic licensure and practice statistics Greeley, Colorado, Federation of Chiropractic Licensing Boards Riddle JW Report of the New York State Commission on Acupuncture legal considerations In: Kao FF, Kao JJ, eds Recent advances in acupuncture research Garden City, New York, Institute for Advanced Research in Asian Science and Medicine, 1979 Unites States of America Acupuncture International digest of health legislation, 1975, 26:899900 Schwartz R Acupuncture and expertise: a challenge to physician control The Hastings Centre report, 1981, 11:5 United States of America Rhode Island Acupuncture International digest of health legislation, 1979, 30:665666 An act Chapter 168 of the Laws of 1980 relating to
acupuncture clinics International digest of health legislation, 1982, 33:252264 Laws and regulations relating to the practice of acupuncture, 2000 Sacramento, California, Acupuncture Board, 2000 Wardwell WI Alternative medicine in the United States Social science and medicine, 1994, 38:1061 Law of 9 August 1975 International digest of health legislation, 1979, 30:905 Algeria Protection of public health: Public Health Code International digest of health legislation, 1978, 29:261317 Journal officiel de la République Algérienne Démocratique et Populaire, 17 February 1985, 8:122 Law no 85-05 of 16 February 1985 on health protection and promotion International digest of health legislation, 1985, 36:909 as amended by Law no 90-17 of 31 July 1990 International digest of health legislation, 1991, 42:229 The Chiropractors Registration Law of 1991 No 62 of 1991 Cyprus Report on the intercountry expert meeting on traditional medicine and primary health care, Cairo, Egypt, 30 November3 December
1992 Alexandria, WHO Regional Office for the Eastern Mediterranean, December 1992 Zhang X Duty travel report Geneva, World Health Organization, 15 May 2001 unpublished document An act and notes for guidance aiming at ensuring the safety and quality of herbal remedies The Herbal Remedies Act Sulaibekhat, Kuwait, The Islamic Organization for Medical Sciences and the World Health Organization, 2123 April 1986 Ordinance no 65 of 7 June 1962 International digest of health legislation, 1965, 16:168 Pakistan Practice of traditional medicine International digest of health legislation, 1967, 18:428 Statutory rules and orders, 1970, V:7889 Pakistan Regulations for registration of herbal preparations, health and supplementary food, cosmetics and antiseptics that have medical claims Directorate of Pharmaceutical Licences, General Directorate of Medical and Pharmaceutical Licences, Ministry of Health, Kingdom of Saudi Arabia undated Saudi Arabia Federal Law no 7 of 1975 on the practice of human
medicine International digest of health legislation, 1976, 27:893

151 152 153 154 155 156 157 158 159 160

161 162

163 164

165 166 167 168

169

181

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

170 171 172 173 174 175

176 177

Federal Law no 5/1984 on the practice of certain medical professions by persons other than physicians and pharmacists, Sections 1 and 2 International digest of health legislation, 1984, 35:745 Galadari M Herbal drug registration in the UAE Presented at the Ninth international conference of drug regulatory authorities, Berlin, Germany, 28 April 1999 Maddalena S The legal status of complementary medicines in Europe — a comparative analysis Bern, Stämpfli, 1999 Ärztegezetzes 1984 BGBl Bundesgesetzblätter no 373 Austria BGBl Bundesgesetzblätter no 378/1996 Austria Loi du 29 avril 1999 relative aux pratiques non conventionnelles dans les domaines de lart médical, de lart pharmaceutique, de la kinésithérapie,
de lart infirmier et des professions médicales Moniteur Belge, 24 June 1999, 169 Belgium The Act Concerning Health Care Professionals 559/1994 of 28 June 1994 Finland Solimene U Communication with WHO Direttore Professor Centro di Ricerche in Bioclimatologia Medica Biotechnologie Medicine Naturali, Universita Degli Studi di Milano, Italie Professor and Director, Centre of Research in Bioclimatology, Biotechnologies and Natural Medicine, State University of Milan, Milan, Italy, 1999 Gesetz über das Gesundheitswesen vom 18 Dezember 1985 Liechtensteinisches Landesgestzblatt, 1986, 12 Verordnung über die medizinischen Berufe vom 8 November 1988 Order I Liechtensteinisches Landesgestzblatt, 1988, 51 Verordnung über die andere Berufe der Gesundheitspflege vom 16 März 1989 Order II Liechtensteinisches Landesgestzblatt, 1989, 30 Report of the Chinese-Norwegian health seminar, Oslo, Norway, 2023 November 2000 Oslo, Norwegian Ministry of Health and Social Affairs, January 2001 Russian
Federation Principles of the legislation of the Russian Federation on the protection of the health of citizens International digest of health legislation, 1994, 45:36 Complementary and alternative medicine, 6 report London, House of Lords Select Committee on Science and Technology, 21 November 2000 Rahman L, Azizul Islam HH Development of indigenous systems of medicine in Bangladesh Presented at the WHO regional seminar on the Traditional Medicine Programme, Colombo, Sri Lanka, 15 April 1977 unpublished document SEA/Trad Med/1 II Health Manpower Bangladesh An Ordinance No XXXII of 1983 to provide for the regulation of the qualifications and registration of practitioners of Unani and Ayurvedic systems of medicine International digest of health legislation, 1984, 35:565-568 Islam HA Legislation in the development of traditional medicine in Bangladesh International digest of health legislation, 1985, 36:525, 527 Dorji P Traditional medicine system in Bhutan In: Traditional medicine,
better science, policy and services for health development: proceedings of a WHO International Symposium, Awaji Island, Hyogo Prefecture, Japan, 1113 September 2000 Kobe, Japan, World Health Organization Centre for Health Development, 2001 unpublished document; available on request from the WHO Centre for Health Development, IHD Centre Building, 9th Floor, 1-5-1 Wakinohama-Kaigandori, Chuo-ku Kobe 651-0073, Japan Democratic Peoples Republic of Korea Health protection and promotion: general provisions International digest of health legislation, 1980, 31:490493 Ritiasa K Jamu and traditional medicine practices in Indonesia In: Traditional medicine, better science, policy and services for health development: proceedings of a WHO International Symposium, Awaji Island, Hyogo Prefecture, Japan, 1113 September 2000 Kobe, Japan, World Health Organization Centre for Health Development, 2001 unpublished document; available on request from the WHO Centre for Health Development, IHD Centre
Building, 9th Floor, 1-5-1 Wakinohama-Kaigandori, Chuo-ku Kobe 651-0073, Japan Untoro R Database inventory and registry of biological resources and traditional knowledge Presented at the ASEAN workshop on the TRIPS agreement and traditional medicine, Jakarta, Indonesia, 1215 February 2001 Roemer MI National health systems of the world Vol 1 New York, Oxford University Press, 1991
th

178 179 180 181 182 183 184

185

186 187

188 189

190

191
182

References

192 193

194 195

Kim-Farley RJ Communication with WHO WHO Representative, Indonesia, 22 February 1994 Country review of traditional medicine programme in Indonesia Presented at the WHO regional seminar on the Traditional Medicine Programme, Colombo, Sri Lanka, 15 April 1977 unpublished document SEA/Trad Med/1 Rules of 25 August 1955 of the Ministry of Health Myanmar Tin U Traditional medicine of Burma Presented at the WHO regional seminar on the Traditional Medicine Programme, Colombo, Sri Lanka, 15 April 1977 unpublished
document SEA/Trad Med/1 Khakurel BK The regulation of herbal medicines in Nepal Presented at the Eighth international conference of drug regulatory authorities, Manama, Bahrain, 11 November 1996 A short account of the ayurvedic activities in Nepal Presented at the WHO regional seminar on the Traditional Medicine Programme, Colombo, Sri Lanka, 15 April 1977 unpublished document SEA/Trad Med/1 The Ayurvedic Medical Council Act, no 21 of 2045 1988 International digest of health legislation, 1992, 43:24 Pigott W Research and development of traditional and natural medicine WHO representative, Nepal, 13 February 1996 unpublished document Country review from Sri Lanka Presented at the WHO regional seminar on the Traditional Medicine Programme, Colombo, Sri Lanka, 15 April 1977 unpublished document SEA/Trad Med/1 The ayurvedic physicians professional conduct rules, 1971 International digest of health legislation, 1974, 25:435 Development, 19311981 Colombo, Sri Lanka, Ministry of Plan
Implementation, 1981 Ceylon Homeopathy International digest of health legislation, 1971, 22:209210 Herbal medicine practice in Thailand In: Traditional medicine, its contribution to human health development in the new century, report of an international symposium, Kobe, Japan, 6 November 1999 Kobe, Japan, World Health Organization Centre for Health Development, 2000 unpublished document; available on request from the WHO Centre for Health Development, IHD Centre Building, 9th Floor, 1-5-1 Wakinohama-Kaigandori, Chuo-ku Kobe 651-0073, Japan Thaïlande In: Grand Larousse Encyclopédique Paris, Larousse Memorandum on the draft process report by the Director-General to the Fifty-first world health assembly on TRM Manila, Traditional Medicine, WHO Western Pacific Regional Office, 20 March 1997 Australian commentary on Halsburys laws of England, 4th ed Sydney, Butterworths, 1990 For the relevant laws of the Australian states, see the following: South Australia: The Chiropractors Act 1991 no 6
of 1991 International digest of health legislation, 1992, 43:22 Capital Territory: The Chiropractors Registration Ordinance 1983 no 28 of 1983 International digest of health legislation, 1987, 38:456 Victoria: The Chiropractors and Osteopaths Act 1978, no 9161 New South Wales: Chiropractic Act, 1978, no 132 Chiropractic, osteopathy, homeopathy and naturopathy: report of committee of inquiry Canberra, The Acting Commonwealth Government Printer, 1977 Parliamentary Paper, No 102/1977 Commonwealth Law bulletin, October 1993, 1362 Overview of the regulatory requirements for the manufacture and supply of medicine in Australia and for export Woden, Australia, Therapeutic Goods Administration, November 1999 Acupuncture college handbook 1994 Sydney, Australia, University of Technology, 1994 Technical briefing on traditional medicine Presented at the Forty-ninth regional committee meeting, Manila, Philippines, WHO Regional Office for the Western Pacific, 18 September 1998 Cambodia Practice of
unofficial medicine and pharmacy International digest of health legislation, 1965, 16:4041 Hiegel JP The ICRC and traditional Khmer medicine International review of the Red Cross, 1981, 21:251

196 197

198 199 200

201 202 203 204

205 206

207 208

209 210 211 212 213 214 215

183

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

216 217

218

219

Drug registration: mission report in Cambodia 17 January13 February 1997 Manila, WHO Regional Office for the Western Pacific, 24 April 1997 Xiaopin W Review of traditional Chinese medicine practice in China In: Traditional medicine, better science, policy and services for health development: proceedings of a WHO International Symposium, Awaji Island, Hyogo Prefecture, Japan, 1113 September 2000 Kobe, Japan, World Health Organization Centre for Health Development, 2001 unpublished document; available on request from the WHO Centre for Health Development, IHD Centre Building, 9th Floor, 1-5-1
Wakinohama-Kaigandori, Chuo-ku Kobe 651-0073, Japan Zhang X Traditional medicine world-wide review In: Traditional medicine, better science, policy and services for health development: proceedings of a WHO International Symposium, Awaji Island, Hyogo Prefecture, Japan, 1113 September 2000 Kobe, Japan, World Health Organization Centre for Health Development, 2001 unpublished document; available on request from the WHO Centre for Health Development, IHD Centre Building, 9th Floor, 1-5-1 Wakinohama-Kaigandori, Chuo-ku Kobe 651-0073, Japan Zhang X Integration of traditional medicine into national health care systems Presented at the Medicus Mundi Switzerland workshop on the integration of traditional medicine into public health, Lausanne, Switzerland, 4 April 1998 Jingfeng C Integration of traditional Chinese medicine with Western medicine — right or wrong? Social science and medicine, 1988, 27:521528 Chen PC Population and health policy in the Peoples Republic of China Washington DC,
Interdisciplinary Communications Programme, Smithsonian Institution, 1976 Occasional Monograph Series, No 9 State administration of traditional Chinese medicine, 14 January 1989 Beijing Department of Traditional Chinese Medicine, Ministry of Public Health and Personnel Department for the Unified Examination Given to Personnel without Official Education Employed as Physicians Assistants of Traditional Chinese Medicine Herbs, 31 December 1985 Beijing Circular of re-check of persons who are proficient in a particular branch of traditional Chinese medicine Beijing, State Administration of Traditional Chinese Medicine, 12 August 1989 Provisional management stipulations for privately practising doctors of Western medicine and physicians of traditional Chinese medicine Beijing, Ministry of Public Health and State Administration of Traditional Chinese Medicine, 21 November 1988 Additional regulations to the management stipulations for privately practising personnel of traditional Chinese
medicine Beijing, State Administration of Traditional Chinese Medicine, 3 May 1989 Some regulations for strengthening the management of medical qigong treatment trial implementation Beijing, State Administration of Traditional Chinese Medicine, 19 October 1989 Roemer MI Comparative national policies on health care New York, M Dekker, 1977 Rosenthal MM Modernization and health care in the Peoples Republic of China: the period of transition In: Rosenthal MM, ed Health care systems and their patients: an international perspective Boulder, Westview Press, 1992 Leung TH Traditional medicine in Hong Kong, China Presented at the Workshop on development of national policy on traditional medicine, Beijing, China, 1115 October 1999 Chen K Fiji national workshop on traditional medicine: mission report 2531 March 2001 Manila, WHO Regional Office for the Western Pacific, 10 July 2001 Fiji Practice of medicine, dentistry, chiropractic, and acupuncture International digest of health legislation,
1979, 30:531533 The Acupuncturists, Chiropractors and Chiropodists Qualification Regulations, 1976, and the Acupuncturists, Chiropractors and Chiropodists Regulations, 1976 International digest of health legislation, 1979, 30:532 Yamamura Y The history of kampo medicine and its development in modern Japan In: Hosoya E, Yamamura Y, eds Recent advances in the pharmacology of kampo Japanese herbal medicines Tokyo, Excerpta Medica Ltd, 1988 International Congress Series 854

220 221

222 223

224 225

226

227 228 229

230 231 232 233

234

184

References

235

236 237 238 239 240

Terasawa K The problems that should be resolved in Japanese oriental kampo medicine In: International forum on Japanese oriental kampo medicine in Toyama, Japan, 2929 July 1990 Toyama, Japan, Department of Japanese Oriental Kampo Medicine, Toyama Medical and Pharmaceutical University, 1990 Ministry of Health and Welfare The year book of statistics of production by the pharmaceutical industry, 1998 original in
Japanese Tokyo, Ministry of Health and Welfare, 1999 Nikkei Medical, October 2000 Supplement original in Japanese Communication with WHO The Ministry of Health and Welfare, Government of Japan, August 2000 original in Japanese Japanese/English pharmaceutical administration in Japan, 9th ed Tokyo, Yakuji Nippo, Ltd, 2000 Ministry of Health and Welfare Traditional medicines in Japan In: Proceedings of the fourth international conference of drug regulatory authorities, Tokyo, 611 July 1986 Tokyo, Ministry of Health and Welfare, 1986 Japanese pharmacopoeia, 13th ed Tokyo, Ministry of Health and Welfare, 1996 The Japanese standards for herbal medicines Tokyo, Yakuji Nippo, Ltd, 1993 Communication with WHO Japan Pharmacists Education Centre, August 2000 original in Japanese Communication with WHO The Japan Society of Acupuncture and Moxibustion, August 2000 original in Japanese Tsuruoka K, Tsuruoka Y, Kajii E Complementary medicine education in Japanese medical schools: a survey
Complementary therapies in medicine, 2001, 9:2833 Communication with WHO The Japan Society for Oriental Medicine, August 2000 original in Japanese General information on the research institute for WAKAN-YAKU Toyama, Japan, Toyama Medical and Pharmaceutical University, March 1990 original in Japanese Metai A Traditional medicine practices in Kiribati Presented at the International congress on traditional medicine, Beijing, China, 2224 April 2000 Ekeieta B Traditional medicine in Kiribati Presented at the Workshop on development of national policy on traditional medicine, Beijing, China, 1115 October 1999 Kiribati An Act No 9 of 1981 to amend the Medical and Dental Practitioners Ordinance Cap 55 so as to legalise the practice of traditional healing methods and permit practitioners to charge for their services International digest of health legislation, 1982, 33:243 Keola K Traditional medicine in the Lao Peoples Democratic Republic Presented at the Workshop on development of national
policy on traditional medicine, Beijing, China, 1115 October 1999 The work of WHO in the Western Pacific Region: proposed programme budget 19911993 In: Diagnostic, therapeutic and rehabilitative technology Manila, WHO Western Pacific Regional Office, 1993 Malaysia Registration of physicians and practice of medicine International digest of health legislation, 1975, 26:170172 Malaysia Registration of midwives International digest of health legislation, 1975, 26:165166 National seminar on uses of traditional/alternative medicine in contemporary health care: mission report in Kuala Lumpur, Malaysia, 2125 December 1997 Manila, WHO Regional Office for the Western Pacific, 12 May 1998 Acupuncture and moxibustion for primary medical care: mission report in Ulaanbaatar, Mongolia, 14 June14 July 1998 Manila, WHO Regional Office for the Western Pacific, 23 October 1998 Bold S Country report: Mongolia Presented at the Workshop on development of national policy on traditional medicine, Beijing,
China, 1115 October 1999 Research methods on medicinal plants and their role as immunostimulants: mission report in Ulaanbaatar, Mongolia, 10 September3 October 1998 Manila, WHO Regional Office for the Western Pacific, 27 November 1998 Ambihaipahar U Country report: Papua New Guinea Presented at the Workshop on development of national policy on traditional medicine, Beijing, China, 1115 October 1999

241 242 243 244 245 246 247 248 249 250

251

252

253 254 255

256 257 258

259

185

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

260 261

Banaynal ET Country report: Philippines Presented at the Workshop on development of national policy on traditional medicine, Beijing, China, 1115 October 1999 The work of WHO in the Western Pacific Region: proposed programme budget 19931995 In: Diagnostic, therapeutic and rehabilitative technology Manila, WHO Western Pacific Regional Office, 1995 Official gazette, 28 March 1983, 79:1852 Philippines
Oriental medicine in Korea Republic of Korea, Ministry of Health and Social Affairs, 1994 2000 Health and Welfare Services Republic of Korea, Ministry of Health and Welfare, 2000 Republic of Korea The Medical Treatment Act International digest of health legislation, 1992, 43:14 15 Ainuu LSP Traditional medicine in Samoa Presented at the Workshop on development of national policy on traditional medicine, Beijing, China, 1115 October 1999 Chea CHA The development of national policy on traditional medicine in Singapore Presented at the Workshop on development of national policy on traditional medicine, Beijing, China, 1115 October 1999 The work of WHO in the Western Pacific Region: proposed programme budget 19951996 In: Diagnostic, therapeutic and rehabilitative technology Manila, WHO Western Pacific Regional Office, 1996 Maenuu LP Traditional medicine in Solomon Islands Presented at the Workshop on development of national policy on traditional medicine, Beijing, China, 1115 October 1999
The Health Practitioners Act no 5 of 1984 Date of assent: April 20, 1983 Vanuatu The Health Practitioners Ancillary Medical Profession Order no 32 of 1985 International digest of health legislation, 1987, 38:31 Developing a national policy and strategic plan for traditional medicine: mission report in Hanoi, Viet Nam, 1131 October 1997 Manila, WHO Regional Office for the Western Pacific, 29 May 1998 Workshop on the modernisation of traditional medicine: mission report in Hanoi, Viet Nam, 711 April 1997 Manila, WHO Regional Office for the Western Pacific, 16 May 1997 Integration of acupuncture with modern rehabilitation medicine: mission report in Hanoi, Viet Nam, 1128 October 1997 Manila, WHO Regional Office for the Western Pacific, 25 May 1998 Law of 30 June 1989 on the protection of public health International digest of health legislation, 1990, 41:15 Regulations of 1991 on medical examinations and treatment within the framework of the national system of traditional medicine
International digest of health legislation, 1993, 44:18 The Criminal Code of the Socialist Republic of Viet Nam, Section 196 International digest of health legislation, 1988, 39:2 Ordinance on Private Medical and Pharmaceutical Practice Hanoi, Vietnam, Permanent Committee of the Ninth National Assembly of the Socialist Republic of Viet Nam, 13 October 1993 Second national workshop on national policy on traditional medicine: mission report in Hanoi and Ho Chi Minh City, Viet Nam, 28 June5 July 1998 Manila, WHO Regional Office for the Western Pacific, 28 September 1998 Baeyens A Free movement of goods and services in health care: a comment on the court cases Decker and Kohll from a Belgian point of view European journal of health law, 1999, 6:373383 Keller K Homeopathic medicinal products in Germany and Europe: legal requirements for registration and marketing authorization Drug information journal, 1998, 32:803811 Official Journal EC, 13 October 1992, L 297:811, 1215 Official Journal
EC, 22 April 1992, L 102:2324, 102155

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280 281 282 283

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Annex I The European Union

Annex I The European Union

General principles
The Treaty on the European Union EU came into force 1 November 1993 The Treaty instituting the European Economic Community EEC was intended to open a large market zone without borders, enabling the free movement of persons, goods, services, and capital It is Treaty regulations on the movement of persons and goods, in particular, which affect health services and medications 172, 280, 281 For the purpose of employment or for activities as a self-employed person, citizens of the European Union, under Articles 39 to 55 of the Treaty, have the right to move and take residence freely within the European Union Some limitations and conditions on this freedom are outlined in Articles 12 and 39 of the Treaty Moreover, by Directive 65/221/EEC, individual countries can limit the right of
free movement on justified grounds of public health Specific directives ensure the mutual recognition of diplomas of allopathic doctors, dentists, pharmacists, midwives, and nurses Similarly, directives based on Article 95 of the Treaty regarding Union-wide harmonization of legislation regulate, among other things, pharmaceuticals, blood products, medical devices, foodstuffs, dangerous substances and preparations, cosmetics, safety of products, precursors, tobacco products, personal protective equipment, and the protection of personal medical data

Directives on homeopathic products
The first phase of European Union legislative harmonization in homeopathy was the adoption of two European Directives that came into force on 1 January 1994 282 — one on homeopathic products for humans and one on homeopathic veterinary products These Directives ensure a single European Market for homeopathic products and outline provisions regulating their manufacture, inspection, marketing, and labelling
They also establish a simplified registration procedure for medications containing less than one part per 10 000 of undiluted tincture or less than 1/100th of the smallest dose used in allopathic medicine 281 According to the 1995 European Commission report to the Parliament and the Council on the application of Directives 92/73 and 92/74, however, the existing level of legislative harmonization is insufficient The EEC Directive regulates the marketing of proprietary medicinal products 283 However, individual countries are free to restrict the licensing of herbal medicines

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Germany and the United Kingdom have chosen to restrict such licences in order to protect their populations from the possible carcinogenic effects of pyrolizidine alkaloids, which occur in a number of medicinal herbs

Free movement of patients and practitioners and insurance coverage of complementary/alternative
medicine products and treatments
Directives on the free movement of patients and practitioners and on insurance coverage of complementary/alternative medicine are more difficult to implement Although the free movement of persons within the European Union is a cornerstone of the Treaty of Rome, the diversity of national policies severely limits its applicability to practitioners of complementary/alternative medicine Case 61/89 of the European Court of Justice involved an acupuncturist without allopathic medical qualifications practising in France The Courts decision confirmed the right of individual countries to make their own legislation on whether or not to reserve the practice of medicine to allopathic doctors As social insurance remains the province of national governments rather than an issue for European Union consideration, insurance coverage of complementary/alternative products and treatments is unlikely to become the subject of a European Directive 280 Nonetheless, in April
1994, European Deputy Paul Lannoye presented a proposal on the status of complementary/alternative medicine to the European Parliament Committee on the Environment, Public Health, and Consumer Protection He asked for provisions for complementary/alternative medicine within social security systems, the incorporation of complementary/alternative medical systems into the European Pharmacopoeia, an end to prosecutions of non-allopathic practitioners in countries where the practice of medicine is the exclusive domain of allopathic providers, and a pan-European system of recognition and regulation of complementary/alternative medical practitioners along the lines of the British Osteopath and Chiropractor Acts He also requested a research budget of 10 million Euros per year for five years At the last moment, the European Parliament cancelled the vote on the proposal At the end of 1995, the Conference of Presidents of the European Parliament put forward a report intended to engage the European
Commission in the process of recognizing complementary/alternative medicine 172 On 27 February 1997 the Committee on the Environment, Public Health, and Consumer Protection began a study of complementary/alternative medicine On 29 May 1997 the European Parliament passed a resolution,

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4 Call[ing] on the Commission, if the results of the study allow, to start the process for the recognition of non-conventional medicines and, for this purpose, to take the necessary steps to encourage the establishment of appropriate committees; 5 Call[ing] on the Commission to carry out a thorough study on the safety, effectiveness, scope of application and the complementarity and alternative nature of all non-conventional medicines, and to prepare a comparative study of the various national legal models to which non-conventional medical practitioners are subjected; 6 Call[ing] on the Commission, in formulating European legislation on nonconventional forms of medicine,
to make a clear distinction between nonconventional medicines which are complementary in nature and ones which are alternative in the sense that they replace conventional medicine; 7 Call[ing] on the Council, after completion of the preliminary works referred to in paragraph 2 above, to encourage the development of research programmes in the field of non-conventional medicines covering the individual and holistic approach, the preventive role and the specific characteristics of the nonconventional medicine; 8 Call[ing] on the Commission to submit a proposal for a Directive on food supplements which are frequently situated on the boundaries between dietary and medicinal products Such legislation should help guarantee good manufacturing practices to secure consumer protection without restricting freedom of access or choice and ensure the freedom of all practitioners to recommend such products; 9 Call[ing] on the Commission to remove trade barriers between Member States by giving
manufacturers of health products free access to all markets in the EU

A Resolution of the European Parliament, however, is not a binding act, but a declaration of policy Nonetheless, the adoption of the resolution has led several countries to consider revising their legislation The European Commissions COST European Cooperation in the Field of Scientific and Technical Research programme undertook Project B4, a European initiative for comprehensive research on complementary/alternative medicine The Governments of Belgium, Croatia, Denmark, Finland, Germany, Hungary, Italy, Netherlands, Norway, Slovenia, Spain, Sweden, Switzerland the projects initiator, and the United Kingdom all participated in the project The goals of the project were to demonstrate the possibilities, limitations and significance of complementary/alternative medicine by establishing a common scientific background, helping to control health care costs, and harmonizing legislation The project was completed in
1998

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Source:reikiinmedicine.org

The State of CAM in UK Cancer Care: Advances in Research, Practice and Delivery

Dr Michelle Kohn, MB BS, BSc, MRCP UK Complementary Therapies Medical Advisor to Macmillan Cancer Relief, UK and the Department of Health, UK

The NCI Office of Cancer Complementary and Alternative Medicine Invited Speakers Series The State of Complementary and Alternative Medicine in United Kingdom Cancer Care: Advances in Research, Practice and Delivery

CONTENTS Preface3 Summary5 Slides9

Preface

The National Cancer Institutes Office of Cancer Complementary and Alternative Medicine OCCAM hosted Dr Michelle Kohn, MB BS, BSc, MRCP UK for the third in its Invited Speakers Series, on March 26, 2003 Dr Kohn is the Complementary Therapies Medical Advisor to MacMillan Cancer Relief, UK, and serves as Advisor to the Department of Health, UK Her presentation, The State of Complementary and Alternative Medicine in United
Kingdom Cancer Care: Advances in Research, Practice and Delivery, describes some of the historical development of complementary medical practices in the UK, the relationship between palliative and support care and complementary medicine, and the growing interest by cancer patients in the UK in these interventions and practices In addition, she describes UK organizations such as The National Cancer Research Institute, a collaborative body with representation from the Department of Health, Medical Research Council, Cancer Research UK, industry leaders, and several primary cancer research charities in the UK and their interest in complementary approaches She also presents information from commissioned reports, such as The 1998 Complementary Therapies in Cancer Care, which may be of interest to US researchers, practitioners and the public The video cast of Dr Kohns presentation is available through the OCCAM website at http://cancergov/cam This document is designed to provide a summary of
Dr Kohns presentation and provide the materials necessary to follow her presentation on the web cast By describing some of the latest work from the UK, we hope this presentation will stimulate similar activities in the US and abroad, encourage potential collaborative activities with our UK colleagues and continue to develop interest in cancer CAM research

Jeffrey D White, MD Director, Office of Cancer Complementary and Alternative Medicine National Cancer Institute

Wendy B Smith, MA, PhD Program Director, Research Development and Support Program Office of Cancer Complementary and Alternative Medicine National Cancer Institute

The State of CAM in UK Cancer Care: Advances in Research, Practice, and Delivery
Dr Michelle Kohn, MB BS, BSc, MRCP UK Complementary Therapies Medical Advisor to Macmillan Cancer Relief, UK and the Department of Health, UK Summary The United Kingdom did not acknowledge the practice of alternative medicine until 1858, with the advent of orthodox medicine and
the passing of the Medical Registration Act Prior to 1858, medicine was largely a free for all, characterized by open markets of herbalists, midwives, and healers, competing for custom with physicians, surgeons, and apothecaries In the early 20th century, newly enacted legislation limited the claims that non-medically qualified practitioners could make, precipitating a sharp drop in the number of alternative practitioners, who operated without a regulating body In the 1960s, the United Kingdom witnessed a resurgence in the practice of alternative medicine; primarily fuelled by consumers desire for greater control over their own well-being, and the perception that orthodox biomedicine was limited in terms of safety and efficacy The orthodox biomedical communitys response to the resurgence was initially negative For instance, a 1986 British Medical Association BMA report associated alternative approaches to healthcare with witchcraft, and described alternative healthcare as a passing fad
By the 1990s, the orthodox medical response grew more positive, exemplified by a 1993 BMA report, which coined the term complementary, and recommended training in complementary therapies for doctors and other healthcare professionals This served as a catalyst for the public to relinquish the perception of complementary and alternative care as unconventional In 1997, the Foundation for Integrated Medicine published a report on integrated healthcare, a move that challenged the previous biomedical model of healthcare and held the promise of a more unified package of care The House of Lords Select Committee report 2000 followed US protocol and adopted the term Complementary and Alternative Medicine CAM, which represented a further shift in healthcare terminology and medical culture This report also provided a classification system, which grouped therapies according to their professional regulation affiliation and evidence base The recommendations put forth by the House of Lords Select
Committee report were not met with blanket acceptance; cancer care providers were resistant to the shift in terminology and ideology Orthodox cancer care practitioners commonly accept complementary use ie alongside orthodox medical treatment, as opposed to alternative use ie in place of conventional treatment of non-orthodox medical treatments Consequently, the term CAM is used in the research literature in the UK, but there are calls for greater clarification of terminology in both practical and research settings Lessons learned from the evolution of the palliative care movement are highly applicable to the embryonic field of complementary medicine The 1950s were marked by great human suffering and pain, and antiquated methods of care There were significant breakthroughs in technology and specific treatments for disease; however, much suffering remained unaddressed In 1964, the concept of total pain was

introduced, a concept that addressed not only the physical symptoms of a disease
but associated mental distress and social and spiritual problems as well Dame Cicely Saunders was a chief advocate for providing total care, and was primarily responsible for revolutionizing the hospice movement and pioneering the introduction of palliative care practices In the post-war era, she intensively studied orthodox medicine and accumulated a wealth of research on pain and healthcare Dame Cicely created a methodology, which consisted of listening, recording, and analyzing patient experiences to attain the goal of living until you die, and almost single-handedly transformed the concept of the hospice into one of a charitable organization with a broad spiritual foundation In subsequent years, she credited the success of the hospice and the palliative care movements to the introduction of new methods to assess quality of life and spiritual and existential distress, combined with continued efforts to ensure academic validity in patient care and research By the 1980s, palliative
care practice evolved into a fusion of technological intervention and a humanist approach to healthcare The value patients place on complementary approaches to attain total care was exemplified in the Complementary Therapies in Cancer Care CTCC report1 The CTCC report also highlighted the increasingly supportive attitudes of healthcare professionals to complementary practices Surveys of health professionals revealed that the majority of those interviewed regularly volunteered information on complementary approaches and were keen to learn more The report suggested that patients were pulled towards complementary medicine by various factors, most notably because it provided them with touch, time, and talk The CTCC report demonstrated that supportive care was emerging as an integral element of the cancer treatment continuum; a trend further validated by surveys indicating that as many as one third of women with breast cancer sought out complementary resources In spite of increased support
and use of complementary healthcare, fiscal pressures in the socialized health service confounded physicians perceptions of the need for complementary practices Issues surrounding evidence, training, regulation, ethics, confidentiality, and research in a clinical setting also contributed to stagnation in the expansion of complementary healthcare promotion by physicians To respond to the public and professional demand for further information on local resources, Macmillan Cancer Relief published the Directory of Complementary Therapy Services in UK Cancer Care2 in 2002, listing complementary services available throughout the UK Services in the Directory offered over forty types of complementary healthcare therapies A full one third of the services offered complementary therapies in hospitals, another one-third in hospices, and one-fifth offered services in the voluntary sector Touch therapies and mind-body therapies were the most common therapies listed in the Directory Over 90 of the
services in the Directory offered touch therapies, such as aromatherapy, massage, and reflexology, while mind-body therapies, like relaxation and visualization, were offered through over 80 of services Healing and energy work,
Complementary Therapies in Cancer Care Abridged report of a study produced for Macmillan Cancer Relief, June 1999 Dr Michelle Kohn author Published by Macmillan Cancer Relief UK Directory of Complementary Therapy Services in UK Cancer Care, 2002 Published by Macmillan Cancer Relief UK
2 1

including reiki, spiritual healing and therapeutic touch, were available in over 40 of services Creative therapies, such as art therapy, were also available through over 40 of the services, while over 20 of the services offered nutritional and medicinal therapies Services listed in the Directory frequently provided complementary therapy services to orthodox healthcare providers and staff, as well as patients Encouragingly, 70 of services provided therapeutic work free of
charge to patients, orthodox healthcare providers, and staff Increased use and acceptance of complementary therapy practices and research inspired a restructuring of orthodox treatment methods for cancer The 2000 National Cancer Plan NCP defined cancer treatment as a three-part system comprising diagnosis, treatment, and newly established Supportive Care practices As a whole, complementary therapies were designated as one of eleven elements in the new supportive care model; the NCP guide will be published in 2004 In 2001, the Prince of Waless Foundation for Integrated Health and the National Council for Hospice and Specialist Palliative Care Services began a collaborative effort to establish National Guidelines for the Use of Complementary Therapies in Supportive and Palliative Care3 The Guidelines are designed to enable healthcare providers and employees to set up and maintain services The Guidelines address issues such as recruitment, configuration of teams, supervision, ethics, and
accountability, in addition to appraisals of the most commonly used therapies and clinical considerations Following the House of Lords Select Committee report 2000, the government pledged to fund research into designated priority areas to better understand CAM use In 2002, the National Health Service Research and Development Programme commissioned work to examine CAM use in patients with cancer The Programme specifically called for exploration of CAM patient populations, stages of illness from diagnosis through to palliative and terminal care, impetus for use, perceived benefits of use, and comparisons with orthodox care The National Cancer Research Institute NCRI was established to allow for proficient strategic planning relating to cancer research NCRI is a collaborative body comprised of the main funding supporters of cancer research, including the Department of Health, the Medical Research Council, Cancer Research UK, industry leaders, and several primary cancer charities, and was
based on a model developed in collaboration with colleagues in the United States Common scientific method allows for comparisons to be drawn on the types of research being conducted CAM research guided by NCRI fits into three main categories: 1 prevention, 2 treatment, 3 control, survival, and outcomes At present, government spending in the areas most applicable to CAM, those of cancer control, survival and outcomes, and cancer prevention, remains low Research activity in the UK is currently focused on complementary rather than alternative approaches, mind-body interventions and touch techniques in particular Several researchers are developing the evidence base in these areas, collaborating with orthodox and complementary practitioners, to better understand the role and value of these
National guidelines for the Use of Complementary Therapies in Supportive and Palliative Care, 2003 Published by the Prince of Waless Foundation for Integrated Health and the National Council for Hospice
and Specialist Palliative Care Services
3

practices and design trials accordingly Although there has been limited activity to date, this is more a reflection of the lack of CAM researchers, infrastructure, and funding than a lack of interest in the field Factors contributing to funding apprehension arise from a lack of effort to validate efficacy, a failure to focus on specific research questions, a lack of clarity in research goals, and insufficient understanding of how complementary mechanisms work Researchers must first focus on therapeutic relationships and develop methodological tools to accurately and appropriately measure holistic practices The future success of CAM research is contingent on patient-centered research Including people affected with cancer in CAM research, improving the evidence base, developing better methodological tools, and concentrating on areas of most concern to patients, will foster increased use of CAM practices, as well as improve orthodox care How
society integrates the interplay of technological advances, the delivery of services, and the financing of healthcare will dictate how complementary therapies can assist individuals along their cancer journey

Solomon Islands, South Pacific

The State of CAM in UK Cancer Care: Advances in Research, Practice and Delivery
10 9 11 13

Dr Michelle Kohn MB BS, BSc, MRCP UK
March 26th 2003

Collecting medicinal herbs

12

Professor Tony Dickenson and team, University College London

Detail from a 13th Century German manuscript PseudoMusa, De herba vettonica

A hydrotherapy cure

14

King George III taking the waters at Cheltenham, 1812

Gräfenberg, Germany Lithograph, c 1860

11

Professor Mike Saks Pro Vice Chancellor, University of Lincoln
A woman patient at a spa is told by her doctor that the treatment for her fertility might be helped by the presence of a diverting friend

15 17 19

16

Orthodox and Alternative Medicine Politics, Professionalization and Health Care
Lithograph by M
Stephane, c 1896

Shift in Attitudes

1986 BMA Report passing fad 1993 BMA Report Complementary medicine

The Past

18

1997 Foundation for Integrated Medicine - Integrated healthcare 2000 House of Lords Select Committee Report on CAM 2001 BMJ Integrated medicine coincided with conference at Royal College of Physicians

House of Lords Classification Table

Foundation for Integrated Medicine
Integrated Healthcare: A way forward for the next five years A discussion document, 1997

Table 111 Complementary and Alternative Medicine Disciplines as grouped by the House of Lords Science and Technology Select Committee 6th Report into Complementary and Alternative Therapies November 2000 Group 1 Professionally organised alternative therapies
Acupuncture Chiropractic Herbal medicine includes Essiac Homoeopathy Osteopathy 20

Group 2 Complementary therapies
Alexander Technique Aromatherapy Bach and other flower remedies Bodywork therapies including massage Counselling stress therapy
Hypnotherapy Meditation Reflexology Shiatsu Healing Marharishi Ayurvedic Medicine Nutritional Medicine Yoga

Group 3 Alternative disciplines
3a: Long established traditional systems of health care Anthroposophical medicine includes Iscador Ayurvedic medicine Chinese Herbal Medicine Eastern Medicine Naturopathy Traditional Chinese Medicine 3b: Other alternative disciplines Crystal therapy Dowsing Iridology Kinesiology Radionics

National Charity est 1996 by The Prince of Wales Research and development Education and training Regulation Delivery mechanisms

Re-branded as Prince of Waless Foundation for Integrated Health, 2002

21

CAM Use
Integrated medicine of today should be the medicine of the new millennium
21 22

Recent surveys Rees et al, 2000 1,023 women with breast cancer, 315 had consulted a CAM practitioner since diagnosis Lewith et al, 2002 32 of those with cancer were receiving CAM, 49 not receiving CAM would have liked to

BMJ 20 January 2001, Issue 7279

Cancer Care
in the UK: A historical perspective
23 24

The evolution of palliative care

Etching showing a couple visiting the sick in a hospice where the man attempts to feed one some nourishment

Dame Cicely Saunders OM

The past

Palliative Active Treatment Care

25

26

The present

Active Treatment Palliative Care
The evolution of palliative care Journal of the Royal Society of Medicine, Volume 94 September 2001

31

Macmillan Cancer Relief Macmillan Cancer Relief

A national cancer care charity founded in 1911 I want to see homes for cancer patients throughout the land, where attention will be provided freely or at low cost, as circumstances dictate I want also to see panels of voluntary nurses, who can be detailed off to attend to necessitous patients in their own homes Douglas Macmillan, 1931 Vision statement

27 29 31

28

Imagine a time when every person in the land has equal and ready access to the best information, treatment and care for cancer and unnecessary levels of fear are set
aside

Macmillan Cancer Relief

Macmillan Cancer Relief
A voice for life; changing perceptions

A voice for life; changing perceptions battle fight struggle struck down suffering victim stricken anguish

30

We always seem to hear the horror stories But I know what a difference it makes if youre given hope A patients view

Macmillan Cancer Relief

Macmillan Cancer Relief
A voice for life; changing perceptions Oxford English Dictionary - definition
32

A voice for life; changing perceptions Oxford English Dictionary - definition Cancer : a malignant growth or tumour in different parts of the body, that tends to spread indefinitely and to reproduce itself, also to return after removal; it eats away or corrodes the part in which it is situated, and generally ends in death As defined in 1888

Cancer : a malignant tumour or growth of body tissue that tends to spread and may recur if removed As defined in 1999

41

Complementary Therapies in Cancer Care
Nurses comments on
therapies
Therapy Aromatherapy Reflexology Massage Psychological interventions eg relaxation Healing Acupuncture Homoeopathy Comments Yes please Nice, safe, probably nonsense Very relaxing Patients can do something for themselves Its a bit over the top It seems to help with pain It interferes with medical treatment It lacks plausibility

33

34

Complementary Therapies in Cancer Care
Nursing practice survey conclusions Most nurses 97 are asked about complementary therapies

Complementary Therapies in Cancer Care
Doctors comments on therapies
Therapy Comments The patient gets extra time with someone who can listen Im happy for patients to try anything Great for muscle spasm I offer hypnotherapy its been very worthwhile Im sceptical, but if it helps, fine I practise it it helps localised pain I find the concept difficult to believe in, but I dont mind patients trying it

Most 94 volunteer information at some time
35 36

Aromatherapy Reflexology Massage Psychological interventions eg
relaxation Healing Acupuncture Homoeopathy

30 have taken courses in complementary therapies 15 practise complementary therapies Most would welcome information/education about complementary therapies 92 and information on local therapists and resources 94

Complementary Therapies in Cancer Care
Medical practice survey comments
GPs have increasingly become maligned for their communication skills Its just that we dont have time time permitting, perhaps complementary therapies would not be needed GP, Birmingham
38

Complementary Therapies in Cancer Care
Medical practice survey conclusions
Most physicians, 96 are asked about complementary therapies Most, 92 volunteer information at some time Therapies most widely offered are aromatherapy, reflexology, massage, and acupuncture 36 have taken courses in complementary therapies 20 practise complementary therapies Most would welcome information/education about complementary therapies 76 and information on local therapists and
resources 84

37

Evidence is Needed Palliative care physician, Nottingham

It keeps patients out of the surgery GP, Avon If it helps the patient, we should support it But we must not mislead patients GP, Plymouth

51

Complementary Therapies in Cancer Care
Barriers to integration

1 The role in cancer care
39 40

2 The dialogue or lack of 3 The appropriate research

Complementary Therapies in Cancer Care

Complementary Therapies in Cancer Care

Orthodox medicine push factors Failure to produce curative treatments Adverse effects of orthodox medicine Lack of time with practitioner, loss of bedside skills Dissatisfaction with the technical approach Fragmentation of care due to specialisation

Complementary therapies pull factors Media reports of dramatic improvements Belief that these therapies are natural Empowerment of patient Focus on spiritual and emotional well-being Provisions of touch, talk and time

41 43

42

Complementary Therapies in Cancer Care
Rationing
and prioritisation of services We cant pump money into massaging patients when we havent got the money to cut their tumours out Cancer surgeon How much of our resources are we prepared to put into complementary medicine compared to cancer treatments such as chemotherapy? Consultant oncologist

Complementary Therapies in Cancer Care
Rationing and prioritisation of services Maybe oncologists would reconsider giving last-ditch chemotherapy to desperately sick patients if they had something else to offer It may save money from the drug budget
44

Palliative care physician Educated middle-class women mainly use complementary therapies Such people can often afford private care Often they are the worried well Consultant oncologist

61

Complementary Therapies in Cancer Care
Rationing and prioritisation of services

Complementary Therapies in Cancer Care
Issues surrounding use Evidence Whats the evidence that being rubbed down with lavender oil is better than a day trip to France, a shampoo
and set, or giving patients gift vouchers? Cancer surgeon Training Doctors need training to have the knowledge and confidence to discuss complementary therapies with their patients Physician

The complementary therapy scheme is an essential part of the comprehensive care that should be available to all cancer patients

45 47 49

46

Consultant radiotherapist

Complementary Therapies in Cancer Care
Issues surrounding use

Complementary Therapies in Cancer Care
Future directions

Training With all the new degree courses, there will be an increase in clinical practice but do the therapists have the clinical skills? Policy maker Regulation My aromatherapist thinks it will inspire confidence if she tells me of her famous patients who come for treatments Patient

Research Regulation Education training Information Collaboration

48 50

71

 I believe this directory will be of great value both to cancer patients and health professionals Professor Mike Richards National Cancer
Director Complementary therapy really can make a difference to the experience of cancer In fact it should now be an integral part of any cancer treatment service Professor Malcolm McIllmurray Macmillan Consultant in Medical Oncology Royal Lancaster Infirmary A very timely and worthwhile innovation by Macmillan to bring together this directory of complementary therapy services for people effected by cancer I am certain it will prove to be an invaluable resource Professor Jessica Corner Professor in Cancer and Palliative Care School of Nursing and Midwifery, University of Southampton

51

52

Directory of Complementary Therapy Services in UK Cancer Care Data set of 320
of centres Hospice Hospital
53

Directory of Complementary Therapy Services in UK Cancer Care
Touch and Manipulative Touch and manipulative Therapies therapies

number of centres 119 103
54

36 31 18

Mind-body therapies Mind/Body Therapies Healing Energy work Healing andand energy work
Creative Therapies Creative
therapies Medicial and Nutritional Medicinal and Therapies nutritional therapies Movement Therapies Movement therapies

Voluntary organisation/group Community Other/not specified

59

9 5

31
Other therapies Others

18

0

10

20

30

40

50

60

70

80

90

100

of centres that provide CT of centres that provide CT

Table 1: Setting for complementary therapy centre

Figure 1: Percentage of centres who provide selected complementary therapies

Directory of Complementary Therapy Services in UK Cancer Care
Figure 2: Percentage of centreswho provide Mind/B Therapies ody R elaxation
Aromotherapy

Directory of Complementary Therapy Services in UK Cancer Care
Figure 3: Percentage of centreswho provide Touch and Manipulative Therapies

C ounselling Visualisation Meditation H yponotherapy/H ypnosis
55 56

M assage Reflexology Acupuncture Shiatsu Indian Head and NeckM assage Osteopathy Cranio-SacralTherapy Chiropractic Biodynamic M assage ThaiM assage ChairM assage Bowen Technique

N
euro-Linguistic Program ming Autogenic training C olour T herapy D ream T herapy Psychotherapy 00 100 200 300 400 500 600 700 800 900 1000

00

100

200

300

400

500

600

700

800

900

1000

of of centres that provide CT centres that provide CT

of of centres that provide CT CT centres that provide

Figure 2: Percentage of centres who provide mind-body therapies

Figure 3: Percentage of centres who provide touch and manipulative therapies

81

Figure 4: Percentage of centres who provide Healing and Energy Work

Directory of Complementary Therapy Services in UK Cancer Care
F u 4 P rc n g o c n sw op v eHa ga dEe yWrk ig re : e e ta e f e tre h ro id e lin n n rg o

Directory of Complementary Therapy Services in UK Cancer Care
F u 5P ig re : ercen e o c tresw op v e M v en T erap tag f en h ro id o em t h ies Yg oa Yoga

Riki Reikie Siritu l p Spiritual Healing a
57 58

A xa d r T ch iq le n e e n ue Alexander Technique T Ci a h Taii Chi
Dance Therapy D n T e py a ce h ra Chii
Kung C K ng hu

Te pTouch h h ra u u Therapeutic e ticto c CTherapyy l h ra Crystalrysta Te p 0 0 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 0 1 0 0 0 0 0 0 0 0 0 0 0 0 fc that provide T o n s a roid CT of centrese tre th t p v eC

0 0

1 0 0

2 0 0

3 0 0

4 0 0

5 0 0

6 0 0

7 0 8 0 00

9 0 1 00 0 0

o ce tre th p v eC f n s a ro id T of centres thattprovide CT

Figure 4: Percentage of centres who provide healing and energy work

Figure 5: Percentage of centres who provide movement therapies

Directory of Complementary Therapy Services in UK Cancer Care

Directory of Complementary Therapy Services in UK Cancer Care
Rate per 100,000 cancer patients diagnosed each year 300 250 200 150 100 50 0 Wales Scotland Northern Ireland England
UK upper range Rate per 100,000 cancer patients diagnosed per year UK lower range

Art Art M usic Music

Touch and Manipulative Therapies

Medicinal and Medicial

Mind/Body Therapies

Healing and Energy work

Movement Therapies

Creative Therapies

9 10 11

12
12

Table 2: Range of therapies offered by centres in the UK

Figure 8: Number of centres offering various complementary therapies to cancer patients, their carers and staff

Nutritional Therapies

O ther therapies

59 61

60

Dramaa D ram
0 10 20 30 40 50 60 70 80 90 1 00

f vide T ofo centres tha pro C CT centres thatt provide

Figure 6: Percentage of centres who provide creative therapies

Figure 7: Rate of complementary therapy centres per 100,000 cancer patients diagnosed each year by region of the UK

Directory of Complementary Therapy Services in UK Cancer Care Number of therapies
1 2 34 56 78

Directory of Complementary Therapy Services in UK Cancer Care
Number of centres
350 300 250 200 150 100 50 0

Percent
10 22 24 20
62

Cancer patients Carers Staff

91

Complementary Therapies in Cancer Care

Complementary Therapies in Cancer Care

Summary points:

Summary points ctd

90 of centres offer a touch and manipulative therapy 80 of centres offer aromatherapy, making it the
most widely available therapy 80 provide at least one mind-body therapy 40 complementary therapies offered across the UK but one third are only available in 1 of centres

70 of centres have no charges for any
64

63 65 67

complementary therapies to patients, carers and staff 80 of centres offer services to carers 50 of centres offer at least one complementary therapy to staff

The National Cancer Plan 2000
The concept of supportive care

The Present

Introduced in the NHS Cancer Plan 2000 Acknowledged that supportive care should be provided throughout the patients and carers cancer journeys Positive concept Includes complementary therapies as one of 12 services to empower patients and their carers to develop strategies for living with cancer, and support them in the process

66

The Definition of Supportive Care
Supportive care is that which helps the patient and their family to cope with cancer and treatment of it from prediagnosis, through the process of diagnosis and
treatment, to cure, continuing illness or death and into bereavement It helps the patient to maximise the benefits of treatment and to live as well as possible with the effects of the disease It is given equal priority alongside diagnosis and treatment Developed by the National Council for Hospice and Specialist Palliative Care Services NCHSPCS 2002

The Definition of Palliative Care

Palliative care is the active holistic care of patients with advanced, progressive illness Management of pain and other symptoms and provision of psychological, social and spiritual support is paramount The goal of palliative care is achievement of the best quality of life for patients and their families Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with other treatment NCHSPCS 2002

68

101

The Principles of Palliative Care
Palliative care aims to:

Department of Health Delivering the NHS Cancer Plan Supportive and Palliative Care
Strategy
Guidance on improving supportive and palliative care for adults with cancer Information Communication Symptom control Specialist palliative care Terminal care Rehabilitation Psychological support Spiritual support Social support Complementary therapies User involvement Support for carers including bereavement
70

Affirm life and regard dying as a natural process Provide relief from pain and other symptoms Integrate the psychological and spiritual aspects of patient care Offer a support system to help patients live as actively as possible until death Offer a support system to help the family cope during the patients illness and in their own bereavement NCHSPCS 2002

69 71 73

Initiated by the DoH developed under the auspices of NICE

Guidelines for the use of Complementary Therapies in Supportive and Palliative Care

Guidelines for the use of Complementary Therapies in Supportive and Palliative Care
What will the guidelines cover?

The Prince of Waless
Foundation for Integrated Health The initial development of a service Management and on-going development Configuration of teams/services some examples Recruitment Volunteers Ethics and accountability

72

National Council for Hospice and Specialist Palliative Care Services NCHSPCS The scope of the guidelines Who are the guidelines for? Employers and/or providers of services

Guidelines for the use of Complementary Therapies in Supportive and Palliative Care
What will the guidelines cover? cont Supervision Most commonly used therapies: massage, acupuncture, aromatherapy, reflexology, healing, homeopathy and hypnotherapy Clinical issues: cancer, motor neurone disease, Parkinsons disease, multiple sclerosis Clinical governance Other sources of information

Research

74

111

In science you dont need to be polite, you only have to be right
75 76

we are witnessing today — a revolution in medical science whose implications far surpass even the discovery of antibiotics, the
first great technological triumph of the 21st century And every so often in the history of human endeavour there comes a breakthrough that takes humankind across a frontier and into a new era Tony Blair
Remarks on the completion of the first survey of the entire human genome project, June 26th 2000

Winston Churchill

Todays announcement represents more than just an epicmaking triumph of science and reason After all, when Galileo discovered he could use the tools of mathematics and mechanics to understand the motion of celestial bodies, he felt, in the words of one eminent researcher, that he had learned the language in which God created the universe
77 79 78

Sir Alexander Fleming at work in his laboratory at St Marys Hospital, London

Today, we are learning the language in which God created life We are gaining ever more awe for the complexity, the beauty, the wonder of Gods most divine and sacred gift Bill Clinton

Remarks from the US President on the completion of the first survey
of the entire human genome project, June 26th 2000

Periodical, Britain Today 1942

Research Capacity

80

121

An analysis of cancer research funding in the UK NCRI members
NCRI member
Association for International Cancer Research AICR
Biotechnology and Biological Sciences Research Council BBSRC

Funding agency
Charity Government Charity Charity Government Charity Charity Charity Charity Government Government Government Charity Government Charity

Website
wwwaicrorguk wwwbbscracuk wwwbreakthroughorguk wwwcancerresearchukorg wwwdohgovuk wwwdialpipexcom/lrf wwwludwiguclacuk wwwmacmillanorguk wwwmariecurieorguk wwwmrcacuk wwwrdocsan-inhsuk/rdo/ indexhtml wwwshowscotnhsuk/cso wwwtenovuscom dspacedialpipexcom/word wwwycrorguk

Breakthrough Breast Cancer Cancer Research UK Dept of Health Leukaemia Research Fund Ludwig Institute for Cancer Research Macmillan Cancer Relief Marie Curie Cancer Care Medical Research Council MRC Northern Ireland HPSS RD Scottish Executive Health Dept Tenovus
Wales Office of RD Yorkshire Cancer Research 81 82

An analysis of cancer research funding in the UK
The Common Scientific Outline CS0 groups research into 7 broad areas:

An analysis of cancer research funding in the UK
Prevention 35 Complementary and alternative prevention approaches Examples of science that would fit: Discovery, development and testing of complementary/alternative prevention approaches such as diet, herbs, supplements or other interventions which are not widely used in conventional medicine or are being applied in different ways as compared to conventional medical uses Hypnotherapy, relaxation, transcendental meditation, imagery, spiritual healing, massage, biofeedback, etc used as a preventive measure
84

Biology Aetiology Prevention Early detection, diagnosis and prognosis Treatment Cancer control, survival and outcomes research

83 85

Scientific model systems These areas are in turn, further subdivided to give a total of 38 individual CSO categories

An
analysis of cancer research funding in the UK
Treatment 56 Complementary and alternative treatment approaches Examples of science that would fit: Discovery, development and clinical application of complementary/alternative treatment approaches such as diet, herbs, supplements, natural substances or other interventions which are not widely used in conventional medicine or are being applied in different ways as compared to conventional medical uses
86

An analysis of cancer research funding in the UK
Cancer control, survival and outcomes research 68 Complementary and alternative approaches for supportive care of patients and survivors Examples of science that would fit: Hypnotherapy, relaxation, transcendental meditation, imagery, spiritual healing, massage, biofeedback, etc, as used for the supportive care of patients and survivors Discovery, development and testing of complementary/alternative approaches such as diet, herbs, supplements or other interventions that are not widely
used in conventional medicine or are being applied in different ways as compared to conventional medical uses

131

An analysis of cancer research funding in the UK
Types of research being conducted Analysis of the Cancer Research Database CRD by CSO has provided information on the balance between different types of research in the collective UK portfolio as follows [see figure 1]:
87 88

Nature Reviews Cancer 3: An analysis of cancer research funding in the UK

Biology Treatment Aetiology Early detection, diagnosis and prognosis Cancer control, survival and outcomes Scientific model systems Prevention

41 22 16 8 6 5 2

Figure 1 | Proportion of total NCRI partners spend by CSO

An analysis of cancer research funding in the UK
Some reasons given to explain differing levels of spend within the combined research portfolio are as follows: Biology
89 90

An analysis of cancer research funding in the UK
Treatment Co-ordination and networking particularly beneficial NCRI partners are
working together to ensure development of coherent national approach to clinical cancer research National networks for clinical trials have been reorganised through NCRI action NCRI action has also brought about provision of new government investment in research infrastructure within the NHS

The UK has an excellent reputation for high-quality biological research relevant to cancer This research area is fundamental to better understanding of cancer, necessary for the development of improved, rationally based treatment and prevention strategies

An analysis of cancer research funding in the UK
Cancer control, survival and outcomes research

An analysis of cancer research funding in the UK
Prevention Spend on research aimed at direct application of interventions designed to prevent cancer is low
92

Much of the research is aimed at understanding and improving those factors that affect a patients experience of cancer Type of research is probably less expensive than some other
fields of research Spend is low in this area

91

Other elements of prevention research like identification of suitable targets and preventive interventions and investigation of factors that cause cancer are well supported across several CSO categories

141

An analysis of cancer research funding in the UK

Nature Reviews Cancer 3 : An analysis of cancer research funding in the UK

Most NCRI partners predominantly fund biology, aetiology and treatment research Few focus their research activities on prevention and cancer control with the exception of Macmillan Cancer Relief, which is active only in the area of cancer control, survival and outcomes research

93 95 97

94

[The percentage of NCRI member spend by CSO is shown in figure 2]
Figure 2 | Percentage of each NCRI members spend by CSO

An analysis of cancer research funding in the UK
Disease site funding analysis 40 of the NCRI partners spend is disease specific This is compared with incidence and mortality figures
96

An
analysis of cancer research funding in the UK

There are some cancers where the relative funding is higher than the pattern of disease burden eg leukaemia, ovarian, cervical There are some where spend is significantly lower eg lung, pancreas, stomach, oesophagus and bladder

The key observations are: The relative proportion of funding of different tumour sites generally follows the increasing disease burden associated with those tumours eg breast, colon, rectal and prostate

OToole L, Nurse P and Radda G An analysis of cancer research funding in the UK Nature Reviews / Cancer February 2003, Volume 3

Cancer Research UK

Cancer Research UK

Examples of CAM research within the CR-UK portfolio Professor Leslie Walker, Institute of Rehabilitation, University of Hull School of Medicine
98

Examples of CAM research within the CR-UK portfolio Deborah Fenlon, University of Southampton, School of Nursing and Midwifery The use of relaxation therapy as an intervention for hot flushes in women
with breast cancer

A randomised controlled study of the relative psychoneuroimmunological effects of relaxation therapy and guided imagery, alone and in combination, in patients with colorectal cancer

151

Cancer Research UK

Cancer Research UK

Examples of CAM research within the CR-UK portfolio Professor Ken Fox, Department of Exercise and Health Sciences, University of Bristol Centre for Sport, Exercise Health Studentship: The role of exercise in the enhancement of quality of life and mental well-being of recovering cancer patients in the UK

Examples of CAM research within the CR-UK portfolio Professor Stephen Morley, Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds School of Medicine Attention management as an adjunctive treatment for cancer pain

100

99 101 103

Cancer Research UK

Examples of CAM research within the CR-UK portfolio Dr Amanda Daley, Sheffield Hallam University

NHS Research Development Programme
Commissioning Brief
Research on the
Role of Complementary and Alternative Medicine CAM in the Care of Patients with Cancer
102

Effects of exercise therapy upon quality of life in women who have had breast cancer

NHS Research Development Programme Commissioning Brief

NHS Research Development Programme Commissioning Brief

Following the House of Lords Select Committee report on CAM: The budget available is up to 300,000 Research into the CAM genre itself, including social research into the motivation of those patients seeking CAM and the usage patterns of CAM The focus is on: CAM therapies as an adjunct to conventional forms of treatment and in palliative/supportive care
104

The outputs will help to inform both the provision of integrated services within the NHS and the future research agenda for CAM in the cancer field

161

NHS Research Development Programme Commissioning Brief
Research questions Proposals should address some or all of the following areas of interest: How are perceptions of CAM treatments
influenced by personal background, sources of information, the nature and stage of the disease, the orthodox treatment received or proposed, and professionals views? How are preferences for or against CAM treatments determined? What are patients expectations of cancer care and how far and in what ways are these met by CAM therapies? Do these expectations change at successive stages of illness?

NHS Research Development Programme Commissioning Brief
Research questions

What aspects of different CAM treatments and of the therapeutic relationship are particularly valued, and how are these compared with the experience of orthodox treatments? In what way do patients interactions with orthodox and CAM practitioners differ? Are there measurable effects on quality of life among those receiving CAM treatments?

105 107 109

106

NHS Research Development Programme Commissioning Brief
Patient groups Groups of interest include the following: Patients receiving potentially curative treatment
which might be surgery, radiotherapy and/or chemotherapy Patients who have received potentially curative treatment and are now clinically free of disease Patients with metastatic disease who are receiving or have been recommended orthodox anti-cancer treatment Patients with advanced disease who are receiving or are candidates for palliative care
108

NHS Research Development Programme Commissioning Brief
Research methods Proposals should be supported by systematic review of the relevant literature Researchers may propose the study designs which are considered most informative in addressing the questions set out above but should include a strong qualitative component Applicants are asked to justify their proposed study methods and sampling strategy The research team will be multidisciplinary and likely to have representation from social sciences, CAM, cancer specialties, health services research and patients

NHS Research Development Programme Commissioning Brief
Grants Awarded
December 2002 1 Dr Philip Tovey Principal Research Fellow, School of Healthcare Studies, University of Leeds Professor Jessica Corner Professor in Cancer and Palliative care, School of Nursing and Midwifery, University of Southampton Dr Alison Shaw Non Clinical Lecturer Division of Primary Healthcare, University of Bristol

Marie Curie and CAM
The Marie Curie Palliative Care Research and Development Unit seeks to improve care for those affected by life-limiting illnesses Encourages carries out research into a broad spectrum of issues relating to palliative care Its work includes investigations into a wide range of subjects and issues, including aromatherapy massage, constipation in cancer patients and communication skills for healthcare professionals The unit is based at the Royal Free and UCL Medical School, London, headed by Dr Susie Wilkinson

110

2

3

171

Professor Leslie Walker The Institute of Rehabilitation The University of Hull

Professor Leslie Walker The Institute
of Rehabilitation, The University of Hull
Research The research strategy is to collaborate with clinicians and basic scientists Funded by the Medical Research Council, Cancer Research UK, the HTA Programme and the NHS RD Executive, current studies includes: Psychoneuroimmunological studies Psychosocial aspects of cancer screening The evaluation of different models of providing psychosocial care The evaluation of the effects of complementary interventions on quality of life

111

112

Professor Leslie Walker The Institute of Rehabilitation, The University of Hull
Current clinical trials: A randomised, controlled, clinical trial of the effects of reflexology on quality of life including mood, adjustment, function, coping and patient satisfaction in women with early breast cancer 180 patients: 3 years commencing May 2002 A randomised, controlled trial of the relative effects of relaxation therapy and guided imagery, alone and in combination, on host defences, mood, adjustment,
quality of life and patient satisfaction in patients with colorectal cancer 180 patients: 3 years commencing January 2003 A randomised, controlled trial of reflexology versus relaxation therapy and guided imagery on host defences, mood, adjustment, quality of life and patient satisfaction in patients with advanced lung cancer 180 patients: 3 years commencing April 2003

113

114

Dr Jane Maher Mount Vernon Cancer Centre, University College London

Dr Jane Maher
A common sense approach?

Dr Jane Maher
A common sense approach?

1 Reviewed which CAMs used
115 116

5 Measurement tools 6 Focus group end of pilot 7 Published regular reports 8 Co investigators Cancer Research UK randomised controlled trial

2 Identified, screened trained cohort of therapists 3 Introduced therapies one by one: context of care package 4 Focus on shared language

181

Mount Vernon Cancer Centre
What are the priorities? Data base 30,000
Psycho
117 119 121 118

Develop an evidence base for new safe
medicine Develop information for patients professionals about CAMs Improve orthodox care through learning from CAMs

Touch / talk

Crisis intervention

Information

Listening

More evidence is our only priority there is only medicine which has been adequately tested medicine which has not

Shared understanding is the priority

The real issue for conventional medicineis to learn from alternative practicesto regain the knowledge we have lost in information

120

Angell Kassirer NEJM 1998, 339:839-841 Davidoff Ann Intern Med 1998, 129:1068-1070

Dr Jane Maher
Who will fund research into areas which do not result in a profitable product? Developing the tools which measure things not serious enough to be pathological To explore the links between mind, body spirit Therapeutic relationship

Dr Jane Maher

Stamp out non-evidence based practice

By 1995 70 of cancer centres and hospices in the UK offered at least one complementary therapy Commonly aromatherapy massage Charitably
funded

122

191

No evidence for it?
123 125 127

Cooke B, Ernst E Aromatherapy : a systematic review Br J Gen prac June 2000, 493-496 The reviewers conclude that the effects of aromatherapy are probably not strong enough to be useful
124

The cost of getting evidence

To demonstrate a significant increase in success rate between massage with without aromatherapy would need a sample size of over 1000

Stamping out non evidence based practice Does this mean that aromatherapy massage should cease in UK cancer centres and hospices? Andrew Vickers BJGP June 2000

A patients view

Evidence common sense

126

To be honest, I dont really care if it works for 100 other people or not, it works for me and thats enough

Some cancer centres have a hairdresser who comes round the wards it makes people feel better have we got to do a randomised trial now to prove its a good idea?

Volunteer support centre

Dr Jane Maher

Dr Jane Maher

Stamping out non-evidence based practice
128

Three
lessons Value the people skills of therapists Develop a shared language to produce high quality information design high quality studies Develop better tools to measure nonpathological distress

UK Patients will continue to receive aromatherapy massage in the UK American patients will also continue to receive multiple fractions of RT for bone metastases

201

Dr Jane Maher

Dr Jane Maher
Multiple perspectives of investigators Nurse/therapist Dr Susie Wilkinson Oncologist Dr Jane Maher Psychiatrist Professor Amanda Ramirez

Aims
129

To evaluate the effectiveness of aromatherapy massage in improving the life quality of cancer patients A multi-centre randomised study in a real life setting Clinically important outcome measures

130

CR-UK/ICRF/Marie Curie/Macmillan Cancer Relief Mount Vernon Cancer Centre Clatterbridge Cancer Centre

Dr Jane Maher

Dr Jane Maher

Multiple settings Cancer centre Radiotherapy department Hospice Cancer support and information centre
Appropriate target group Advanced but not terminal disease Measurable distress HADS/STAI

Problem : Therapies had different meanings for patients Aromatherapy - passive Need permission Not self help

Relaxation - active Dont need permission Self help

131 133

132

Walker et al, 1999

Dr Jane Maher
Lessons Long set up time Expensive 300K
134

Using traditional acupuncture for hot flushes and night sweats in women taking Tamoxifen A pilot study
de Valois B,1 Young T,1 Hunter M,2 Lucey R,1 Maher E J1
1

Multiple perspectives Multiple end points Need a common language Difficult to accrue Not all complementary therapies are the same

2

Supportive Oncology Research Team, Lynda Jackson Macmillan Centre, Mount Vernon Hospital, Rickmansworth Road, Northwood, Middlesex HA6 2RN Cancer Research UK London Psychosocial Group, Guys, Kings St Thomas School of Medicine, St Thomas Hospital, London SE1 7EH

Objective To evaluate the effectiveness and acceptability of using traditional
acupuncture to manage hot flushes and night sweats experienced by women taking Tamoxifen as an adjuvant treatment for breast cancer

211

Dr Elizabeth Thompson
Consultant Homeopathic Physician and Honorary Senior Lecturer in Palliative care Bristol Homeopathic Hospital
4

Dr Elizabeth Thompson
Research projects investigation levels of psychiatric morbidity and coping strategies in cancer patients using CAM Plan to take part in multi-centred trial with TRAUMEEL stomatitis for adults undergoing BMT Plan to conduct RCT with iscador re supporting immune function and QoL

1 Homeopathic approach to symptom control in the cancer patient 2 Clinical Trials Steering Group and Regional Complementary Therapy Research Group 3 Association of Palliative Medicine Task Group for Complementary Therapies reviewing holistic tools to create a handbook of tools

136

135 137 139

5 MD thesis RCT of women with breast cancer and menopausal symptoms using homeopathy Assessment of symptom control, mood
disturbance and QoL 6 Homeopathic consultation the process

Dr Elizabeth Thompson A Nutraceutical Approach to Glioma Management
References: The Homeopathic Approach to the Treatment of Symptoms of Oestrogen Withdrawal in the Breast Cancer Patient A Prospective Observational Study
138

Thompson EA Reilly D accepted for publication Homeopathy Feb 2003

A Pilot Randomised Placebo-Controlled Trial of Homeopathy in the Management of Menopausal Symptoms in Breast Cancer Survivors
Thompson E, Douglas D, Norrie J, Reilly D Oral presentation 8th International Conference of CAM, Exeter University Homeopathy in cancer careBr Homeopath J 2000 Apr;892:61-2

Dr Bali Rooprai /Professor Geoffrey Pilkington Institute of Psychiatry, Kings College, London

Dr Bali Rooprai /Professor Geoffrey Pilkington

Dr Bali Rooprai /Professor Geoffrey Pilkington
Research plan to study the effects of citrus flavonoids on gliomas Effects of citrus flavonoids on parameters of brain tumour invasion in cell cultures
derived from adult paediatric brain tumour biopsies Tissue Culture Dr Bali Rooprai Miss Maria Christidou Blood-Brain Barrier Animal and Human Dr David Dexter Miss Maria Christidou

Citrus flavonoids:

Several reports suggest that citrus flavonoids have antiinvasive, anti-proliferative and anti-angiogenic effects in other cancers No reports of effects of citrus flavonoids in brain tumours apart from our studies

140

221

Dr Bali Rooprai /Professor Geoffrey Pilkington
Protocols used to study the Effects of Citrus Flavonoids on Gliomas Viability assays Flow cytometry Collaboration with Dr Davies, Cancer Research UK
141 142

Dr Bali Rooprai /Professor Geoffrey Pilkington
Cumulative results
CITRUS FLAVONOIDS Tangeretin/nobiletin - downregulation of Proteases MMPs mediating invasion ISOFLAVONES Soya/Red Clover - upregulation of NCAMs reduction of cell motility RED GRAPE SEED EXTRACT - downregulation of CD44 upregulation of NCAMs - Angiogenesis ? CHOKEBERRY EXTRACT - downregulation
of MMPs CD44 LYCOPENE Tomatoes - reduction of motility SELENIUM - induction of apoptosis

Time lapse video microscopy Collaboration with Dr Zicha, Cancer Research UK Blood-Brain-Barrier Collaboration with Neurosurgeons at Kings College Hospital Gene expression of degradative enzymes proteases Collaboration with Prof Edwards- University of East Anglia

Dr Bali Rooprai /Professor Geoffrey Pilkington
Clinical trial: Nutraceutical Approach to Glioma Management
Tangeretin [citrus flavonoids] 200 mg/day Isoflavones red clover/soya 350 mg/day

Dr Bali Rooprai /Professor Geoffrey Pilkington
Clinical trial: nutraceutical approach to glioma management Ethical approval obtained from Kings College Hospital in November 2000
144

143 145

Have to activate trial within 3 years
Red grape seed 300 mg x twice daily Chokeberry extract flavonoids /lectins 200 mg/day Selenium 200 g/day

Negotiated with all suppliers for flavonoids from USA and Israel for the trial There is NO FUNDING to
activate the trial yet

Lycopene tomato 25 mg/day

Dr Jacqueline Filshie Consultant in Anaesthesia Pain Management Royal Marsden Hospital, London and Surrey Honorary Senior Lecturer, Institute of Cancer Research The Use of Acupuncture in Symptom Management in Palliative Care

Dr Jacqueline Filshie

146

Breast Pain

231

Dr Jacqueline Filshie
Breast Pain

Radionecrotic Ulcers

67 patients Average pain Worst pain Distress levels Interference with lifestyle Pain behaviour Anxiety Depression

age n56

Timescale one month

improvement p0001 improvement p0001 improvement p0001 improvement p0001 improvement p0001 marginal fall significant fall p005 Filshie, 1997

147 149 151

148

Dr Jacqueline Filshie

Dr Jacqueline Filshie
Advanced cancer related breathlessness Pilot study 20 patients Subjective improvement of breathlessness Borg VAS Objective improvement of breathlessness Respiratory rate Profound sense of relaxation

P0005 P 002

150

Advanced cancer related breathlessness

P0005
Limited duration 14/20 marked symptomatic relief from treatment Filshie et al, 1996

Dr Jacqueline Filshie

Dr Jacqueline Filshie
Acupuncture can mask cancer and serious problems, therefore should be given or supervised by a physician with knowledge about the clinical stage and treatment
152

An energetic diagnosis alone may be risky in these patients The British Medical Acupuncture Society has made the whole safety issue of AIM available free of charge via its website: wwwmedical-acupuncturecouk

Anxiety, sickness and dyspnoea - indwelling ASAD points

241

Funders of Research in CAM
NHS RD Programme within both the Health Technology Assessment Programme and Regional Programmes The UK Research Councils

CAM Research - General

153 155 157

154

Other medical research charities some with a specific interest in CAM Commercial and industrial sources Also, university based institutions and centres within departments of medicine, hospital sites, primary care, private
institutions

Dr George Lewith University of Southampton Complementary Medicine Research Unit
Randomised controlled trials investigating the use of acupuncture in disabling breathlessness in submission to Thorax A survey of the use of complementary medicine within the cancer care directorate in Southampton University Hospitals Trust Complementary Therapies in Medicine, 2002 An investigation using qualitative techniques into the drivers behind CAM use in cancer and palliative care Department of Health grant involving cooperation between the School of Medicine and the School of Nursing and Midwifery, University of Southampton

156

Professor Edzard Ernst edzardernst@pmsacuk

Peninsula Medical School

The School of Integrated Health at the University of Westminster
The largest higher education provider of CAM professional training in the UK Students can study CAM from undergraduate through to PhD level
158

Clinical training is based within the University training clinic and
placements with other health care providers, for example hospices Research initiatives within the School include assessing the production and safety of plant-based interventions, and the development of a clinical governance framework for CAM practitioners working in primary care http://wwwwminacuk/sih/

Dr Adrian White

251

Research Council for Complementary Medicine RCCM
The aims: Facilitation of appropriate research Foster a network of researchers Complementary and Alternative Medicine Researcher Network CAMRN and promote, undertake, commission and facilitate research

Research Council for Complementary Medicine RCCM
Exploration of the relationship between CAM and conventional medicine Dissemination To collect, review and disseminate research-based information about CAM treatments and philosophies, to provide the public, government organisations, researchers and practitioners with an evidence-base
160

159 161 163

http://wwwrccmorguk

Research Council for Complementary Medicine
RCCM
Database of research citations in CAM This Centralised Information System in Complementary Medicine CISCOM contains over 83,000 records and applies a specialist thesaurus in order to index and retrieve the citations More than 3,500 of these records relate to CAM research in cancer

Research Council for Complementary Medicine RCCM
The development of a database of CAM in cancer care is underway Funded by the UK Department of Health This development includes the synthesis, through a systematic review and appraisal process, of the research literature relating to 10 CAM therapies and their use in cancer Undertaken in association with the School of Integrated Health at the University of Westminster -Dr Janet Richardson wwwrccmorguk
162 164

Building CAM Research Capacity

Jos Kleijnen

261

Department of Health
Strategy to Develop CAM Research Capacity

Department of Health
Strategy to Develop CAM Research Capacity The structure of the capacity building initiative will comprise four
elements:

an environment that supports and values the development of research skills and experience, enables access to research training opportunities and resources to undertake research activity, provides secure and attractive career pathways and encourages the development of high quality research projects Professor Cliff Bailey NHS Research Capacity Development Programme

1 Identification of host academic institutions, with a demonstrable track record of appropriate research activity and collaboration with CAM organisations, to provide methodological advice, skills development and research support 2 Personal award schemes at postdoctoral and training fellowship levels 3 Establishment of a commissioning mechanism 4 Development of a research support network

165 167 169

166

Wellcome Trust
Funding of research in CAM 4 major panels, each with their own scientific remit neurosciences, infection and immunity, physiology and pharmacology and molecular and cell CAM research must fall
within the biomedical remit and the science is judged by peers must be of sufficiently high quality to avoid bias, scientific officers go to great lengths to select referees with the necessary expertise to peer review proposals

Wellcome Trust
Funding of research in CAM CAM is reviewed through the panel system enhances its credibility among other areas of science rather than being viewed as a second rate science
168

Majority of funded research is in counselling and nutrition The Trusts History of Medicine Programme offers opportunities to explore the development and understanding of CAM therapies by exploring the cultural, social and economic contexts of these areas

Issues in CAM Research

Issues in CAM Research

Safety Efficacy Effectiveness Cost effectiveness

The role Plausibility Pseudoscience

Funding Prioritising

Trial design Outcome measures Measuring tools

170

Placebo response Therapeutic relationship

CAM vs orthodox practitioners perspectives Shared language
Dialogue

271

Addressing Safety

Plausibility

Pet Diagnostics
171 172

Can canines detect cancer?
Church J and Williams H Another sniffer dog for the clinic? Lancet 2001 Sept 15; 3589285: 9300

Trial Design

The reasonable man adapts himself to the world: the unreasonable man persists in trying to adapt the world to himself Therefore all progress depends on the unreasonable man George Bernard Shaw

173

174

Challenges of dealing with alien language

Dealing with claims

The human body is an electromagnet, producing a radiating energy field aura affected by incoming energy channelled through the healer

the essential oil germanium is very effective for menopausal problems, diabetes, blood disorders, throat infections applications from frostbite to infertility

175

176

Worwood VA, The Fragrant Pharmacy 1991 : 25

281

Collaboration

Oxford English dictionary definition Consort traitorously with the enemy

The Therapeutic Relationship

177 179 181

178

OR

Work jointly with each
other

180

A visit from the doctor
Print, by Thomas Rowlandson, Smith, RAL, Bath, London, Batsford, 1944

The consultation, or last hope
Engraving, May 12, 1808, by Thomas Rowlandson

182

A gouty patient in his room full of unproductive doctors
Coloured etching by Thomas Rowlandson, 1808

The Therapeutic Relationship

291

The Therapeutic Relationship

183

184

BMJ 28th September 2002 Issue: 7366

Courtesy of The Advertising Archives

Measurement Tools

Dr Charlotte Paterson
Measure Yourself Concerns and Wellbeing MYCAW
Follow up form self completion version

Developing a tool to measure holistic practice: a missing dimension in outcomes measurement within complementary therapies
185 186

Todays date Look overleaf at the concerns that you wrote down before please do not change these On this side of the form, circle a number to show how severe each of those concerns or problems is now: Concern or problem 1: 0 1 2 Not bothering me at all Concern or problem 2: 0 1 Not bothering me
at all 2 3 4 5 6 bothers me greatly 6 bothers me greatly

Long AF, Mercer G, Hughes K Health Care Practice RD Unit, University of Salford, UK

3

4

5

Dr Charlotte Paterson
Wellbeing: How would you rate your general feeling of wellbeing now ? How do you feel in yourself? 0 1 As good as it could be
187

Spirituality and Clinical Care

2

3

4

5

6 As bad as it could be
188

Other things affecting your health The treatment that you have received here may not be the only thing affecting your concern or problem If there is anything else which you think is important, such as changes which you have made yourself, or other things happening in your life, please write it here What has been most important for you? Reflecting on your time with this Centre, what were the most important aspects for you? write overleaf if you need more space Thank you for completing this form

BMJ 21st December 2002 Vol 325 Issue: 7378

301

Rosetta Life
Rosetta Life is an artist-led organisation enabling
people with life threatening illnesses and their families to explore their experiences through video, photography, drama, poetry, fiction and other art forms

Patient Centred Research

189

190

We have now received funding to work in partnership with a network of hospices creating a shared website for palliative care users served by multi-media arts centres at each site

Macmillan Cancer Relief

Macmillan Cancer Relief

Developing a research programme

User involvement in shaping the agenda Ensuring people affected by cancer are involved in research

Improving the evidence base Involving people affected by cancer in research Ensuring that research in areas prioritised by people affected by cancer are taken forward Influencing the research priorities of other funders

191 193

192

CancerVOICES, is a well established and widely respected network of over 400 user representatives The CancerVOICES Reference Group will act as key advisors on the development of the research
strategy

Macmillan Cancer Relief

Complementary Therapy in Cancer Charity Group

The User Involvement Programme has been established as one of Macmillans five key service programmes for 2002 and beyond

Macmillan Cancer Relief Prince of Waless Foundation for Integrated Health Marie Curie Cancer Care Breakthrough Breast Cancer Bristol Cancer Help Centre

194

Collaborative Group supported by HRH the Prince of Wales to promote and encourage research in the field

311

Issues in CAM Research

The Future

Safety Efficacy Effectiveness Cost effectiveness

The role Plausibility Pseudoscience

Funding Prioritising

Trial design Outcome measures Measuring tools

195 197 199

196

Placebo response Therapeutic relationship

CAM vs orthodox practitioners perspectives Shared language Dialogue

Delivering Care

How complementary therapies can help patients during their cancer journey
Conveying the patients voice

Technology Delivery Finance Society

Its acupuncture thats helped me to
cope with the chemo Maggie on the reduction in nausea she experiences since she started having acupuncture before each chemotherapy treatment Ive learnt to carry on the relaxation at home too I sleep better and dont get so worked up Arthur, who attends a weekly relaxation group Massage simply makes me feel better and more able to cope Rose, whose husband has cancer

198

Dr Michelle Kohn
MB BS, BSc, MRCP UK

Complementary Therapies Medical Advisor to Macmillan Cancer Relief UK and Advisor to the Department of Health UK
NCIs - OCCAM March 26th 2003

321

Source:chirohealth.org

The Use of Complementary, Alternative, and Integrative Therapies in Cancer Care
Complementary and alternative therapies are described best as those not presently considered an integral part of conventional medicine Complementary therapies are used in conjunction with conventional medicine, alternative therapies are used in place of conventional medicine, and integrative therapies combine mainstream medical therapies with complementary or alternative therapies for which some high-quality scientific evidence of safety and efficacy exists National Center for Complementary and Alternative Medicine [NCCAM], 2004 Approximately 72 million adults in the United States use complementary and alternative therapies Tindle, Davis, Phillips, Eisenberg, 2005, and more than 34 billion per year is spent out-of-pocket for these therapies Herman, Craig, Caspi, 2005 Many researchers are examining the efficacy and safety of complementary and alternative therapies The
National Institutes of Health established NCCAM to fund research in complementary and alternative medicine CAM and created the Office of Cancer Complementary and Alternative Therapies to coordinate and enhance the National Cancer Institutes CAM activities Complementary and alternative practices have been categorized broadly as mind-body interventions, manipulative and body-based methods, biologically based methods, energy therapies, and alternative medical systems NCCAM, 2004 However, the list of complementary and alternative practices will continue to evolve as new therapies are proven to be safe and effective, accepted as mainstream healthcare practices, and integrated into patient care The most frequently used CAM therapies include prayer, natural products, deep breathing, meditation, chiropractic, yoga, and massage Barnes, Powell-Griner, McFann, Nahin, 2004 Researchers have reported that 5083 of patients with cancer use CAM therapies Basch Ulbricht, 2004, and the most common
reason for using CAM is a strong belief in its efficacy Verhoef, Balneaves, Boon, Vroegindewey, 2005 However, 4077 of people who use CAM therapies do not disclose CAM use because of concerns that healthcare providers will react negatively, because of a belief that healthcare providers do not need to know that they are using CAM because they regard it as natural and safe to use, and finally, because healthcare providers do not ask about CAM use Robinson McGrail, 2004 Oncology nurses may be caring for patients without knowledge of concurrent CAM use Routine assessment of CAM use and close monitoring of patients using CAM therapies have the potential to enhance patient safety and promote integrative care Lee, 2004

It Is the Position of ONS That
Oncology nurses should expand their individual knowledge regarding complementary, alternative, and integrative therapies in oncology care Formal cancer care education programs in schools of nursing and continuing education offerings should
include information and access to complementary, alternative, and integrative therapies and promote integrated education with other health disciplines Oncology nurses should seek proper training and obtain necessary credentials if practicing complementary, alternative, and integrative therapies Oncology nurses should develop a working knowledge of cost, reimbursement, liability, ethical, and legal issues surrounding complementary,

alternative, and integrative therapies in oncology care Oncology nurses should evaluate their personal and professional beliefs regarding the use of complementary, alternative, and integrative practices and recognize how these values can affect the care of patients seeking or using these therapies Oncology nurses should assess patients for the use of therapies and provide evidence-based information and resources regarding therapies as well as information about verifying practitioners qualifications and credentials Oncology nurses should have an
awareness of the differences among terms applied to CAM and use the terms alternative, complementary, and Continued on next page

Continued from previous page integrative with consistency and in an appropriate context Oncology nurses should develop an awareness of CAM therapies that potentially can interfere with the outcome of other cancer treatments Oncology nurses should document patients use of and response to CAM therapies Oncology nurses should establish evidence-based practice in these areas by synthesizing present knowledge with regard to safety, efficacy, concurrent use with conventional therapy, and long-term use ONS and its affiliates promote funding and collaboration in the design of methodologically rigorous cancer CAM treatment and supportive care clinical trials to study the impact of complementary, alternative, and integrative therapies on cancer care outcomes

References
Barnes, PM, Powell-Griner, E, McFann, K, Nahin, RL 2004 Complementary and alternative
medicine use among adults: United States, 2002 Advance Data, 27, 119 Basch, E, Ulbricht, C 2004 Prevalence of CAM use among

US cancer patients: An update [Editorial] Journal of Cancer Integrative Medicine, 21, 1314 Herman, PM, Craig, BM, Caspi, O 2005 Is complementary and alternative CAM cost-effective? A systematic review BMC Complementary and Alternative Medicine, 2, 11 Lee, CO 2004 Clinical trials in cancer part II Biomedical, complementary, and alternative medicine: Significant issues Clinical Journal of Oncology Nursing, 8, 670674 National Center for Complementary and Alternative Medicine 2004 The use of complementary and alternative medicine in the United States Retrieved November 16, 2004, from http://nccamnihgov/news/camsurvey_fs1htm Robinson, A, McGrail, MR 2004 Disclosure of CAM use to medical practitioners: A review of qualitative and quantitative studies Complementary Therapies in Medicine, 12, 9098 Tindle, HA, Davis, RB, Phillips, RS, Eisenberg, DM 2005 Trends in use
of complementary and alternative medicine by US adults: 19972002 Alternative Therapies in Health and Medicine, 11, 4249 Verhoef, MJ, Balneaves, LG, Boon, HS, Vroegindewey, A 2005 Reasons for and characteristics associated with complementary and alternative medicine use among adult cancer patients: A systematic review Integrative Cancer Therapies, 4, 274286

Approved by the ONS Board of Directors 04/00; revised 06/02, 10/04, 03/06

To obtain copies of this or any ONS position, contact the Customer Service Center at the ONS National Office at 125 Enterprise Drive, Pittsburgh, PA 15275-1214 866-257-4ONS; customerservice@onsorg Positions also may be downloaded from the ONS Web site wwwonsorg

Source:ayurveda-seminars.com

Executive Summary of Integrative Medicine at WFUSM 1 Recent Growth in Integrative Medicine at WFUSM 3 Standing Committees and Task Forces N9 3 Research Funding N82 5 Research Publications, peer reviewed N104 16 Review articles, chapters and books N21 24 Abstracts N14 26 Holistic and Integrative Medical Education 28 Local CME/Grand Rounds/NW AHEC Presentations to Professionals N22 31 Regional, National and International Presentations N42 33 Clinical Outreach N12 37 Community Outreach N18 38 National Advisory Boards 40 Editorial Boards 40 Honors: 40

2 August 1, 2005

Recent Growth in Integrative Medicine at WFUSM

Research Projects Funded 90 80 70 60 50 40 30 20 10 0 2003 2004 2005

Research Funding
30,000,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000

0
2003 2004 2005

Publications peer reviewed articles, chapters, books 160 140 120 100 80 60 40 20 0 2003 2004 2005

3 August 1, 2005

Standing Committees and Task Forces N8
CAM in the Community Committee
Facilitator - Arcury Family Medicine Started 10/01 Projects - Seminar Series; BestHealth lecture series; BestHealth internet site; CAM Community Mixer Distribution List: N200 Committee for Holistic and Integrative Medical Education CHIME Chairs - Ober Internal Medicine and Kemper Pediatrics Started 4/03 Activities- updated cases for Phase IA; updated med student web site; elective Distribution List: N 46 Subcommittee on PhD Program in Integrative Medicine Chairs: Ski Chilton Phys/Pharm, Kemper Peds and Shumaker Office Research 2005Consortium for Academic Health Centers for Integrative Medicine CAHCIM NEW WFUSM accepted 2004 Clinical Working Group Delegate: Feldman Education Working Group Delegates: Ober and Lischke Research Working Group Delegates: Arcury and Dailey Executive Steering Committee Delegate: Kemper Council on Bioenergetic Healing Research CBH Chair - Kemper Pediatrics Activities: Research, Education, Clinical Services volunteer Distribution list: N 51 Council on
Mind-Body Medicine NEW Chair Feldman Neuropsychology and Kemper Pediatrics Started 2004 Distribution list: N 17 Herb and Dietary Supplement Task Force HDSTF Chairs - Kemper Pediatrics and Schwatrz Cancer Center Started 2003 Activities: Booke visiting professors Distribution list: N 81 Nutrition Epidemiology Research and Applications Journal Club Facilitator -Vitolins Started 1996 Activities monthly journal club Co-sponsors Booke visiting professors Spirituality and Healing Facilitator Mark Jensen, Pastoral Care

4 August 1, 2005

Research Funding N82 Biofield therapies/Spirituality: Acupuncture, Healing Touch, Qigong, Prayer
PI: Avis Source: NIH/NCI Total: 300,000 Term: 06/18/2004-05/31/2006 Status: Funded Title: Acupuncture treatment for menopausal hot flashes PI: Kemper KJ Source: Komen Foundation Total: 4,000 Term: 2/15/04-1/31/05 Status: Funded Title: Biofield-Touch Therapy for Breast Cancer Patients Rosalyn Bruyere, Visiting Professor

Biomechanical
PI: Karlson K, Kemper KJ,
Rubin B Total: Status: Unfunded Title: Preliminary study regarding massage therapy in cystic fibrosis patients

Cancer CAM Support Overall awarded amount - 1,374,651
PI: Dailey M Total: Included in above total Status: Funded Title: Mindfulness-Based Stress Reduction in Patients with Non-Small Cell Lung Cancer CA 12197-S1 Renewed 02/18/04 PI: Hall Total: Included in above total Status: Submitted and Pending Title: IRB Approval Date for Phase II Trial of Lycopene for Biochemical Relapse of Prostate Cancer Following Definitive Local Therapy PI: Koumenis C Total: Included in above total Status: Project completed: ACUC protocol termination 09/04 Title: Bee Propolis An Active Ingredient in CAPE:

5 August 1, 2005

PI: Naughton M, Shaw E Total: Included in above total Status: Funded Title: Phase II Study of St Johns Wort for the Treatment of Hot Flushes in Women with a History of Breast Cancer PI: Pitovski D Total: Included in above total Status: Protocol Pending Title: Efficacy and safety
of propolis in preventing radiation-induced mucositis: A randomized double blind pilot study PI: Robbins M Total: Included in above total Status: Funded Title: Mediated Modulated of Radiation Induced Cognitive Impairment in the Rat PI: Schwartz G Total: Included in above total Status: Completed Closed to accrual 09/17/04 Title: IRB Approval Date for Effects of fish oil supplementation on PSA levels in healthy men PI: Schwartz, G Source: NCI/NCCAM Total: 74,905 Term: 03/01/1996-03/31/2004 Status: Funded Title: Orthomolecular Vitamin D3 in Low Risk Myelodysplastic Syndrome: An open-label clinical trial PI: Wallin R Total: Included in above total Status: Funded Title: Vitamin K, Bone and Arterial Calcification

Communication, Clinician-Patient Relationship and Cultural Competence
PI: Crandall C, Family Community Medicine, Total: 398,520 Source: PHS DHHS Status: Funded Term: 2003-2006 Title: Creating a Comprehensive Core Communications Curriculum PI: Marion G, Family and Community
Medicine, Total: 779,450 Source: PHS DHHS Status: Funded Period: 2004-2007 Total Funds: 779,450 Title: Advancing Communication, Cultural Competency and Diversity 6 August 1, 2005

Epidemiology/Health Services
PI: Arcury T Source: R21 AT002241 NCCAM Total: 312,000 Term: 2004-2006 Status: Funded Title: Differences in CAM use Among Minority Older Adults PI: Grzywacz J Source: NIH/NCCAM Total: 359,063 Term: 1/1/2004-12/31/2005 Status: Funded Title: Conceptual approach to life-course variation in CAM use

Herbs and Dietary Supplements
PI: Adams M Source: NIH/NILBI Total: 1,148,000 Term: 4/1/2000-3/31/2009 Status: Funded Title: Dietary Soy Supplements Cardioprotective Mechanisms PI: Adams M Source: DHHS Total: 287,000 Term: 4/1/2005-3/31/2006 Status: Funded Title: Dietary Soy Supplements: Cardioprotective Mechanisms PI: Bowden D Source: University of Colorado Total: 36,772 Term: 7/1/2004-6/30/2005 Status: Funded Title: Effects of Vitamin D Genes on Measures of Insulin Secretion, Insulin
Sensitivity, and Adiposity PI: Burke G Source: University of Pittsburgh Total: 416,192 Term: 9/30/1999-07/31/2005 Status: Funded Title: Ginkgo Biloba Prevention Trial in Older Adults Clinical Center PI: Burke G, Vitolins M Source: CDC: TS 501-16/16 Total: 138,210 Term: 10/01/2000-09/30/2004 Status: Funded Title: Lipid lowering from soy protein and isoflavone extract PI: Chen Y Source: National Institute of Health Total: 294,461 Term: 4/1/2004-5/31/2005 Status: Funded Title: Mechanisms of Fish Oil Supplements in Prevention of Prostate Cancer 7 August 1, 2005

PI: Chilton F Source: Dept of Health and Human Services Total: 7,500,000 Term: 4/1/2005-3/31/2006 Status: Funded Title: The Wake Forest and Harvard Center for Botanical Lipids PI: Clarkson T Total: 250,000 Status: Funded Title: Soy/HRT Combinations Source: Protein Technologies Term: 6/25/2002-5/31/2005

PI: Cline M Source: NIH/NCCAM Total: 100,000 Term: 09/01/2003-08/30/2004 Status: Funded Title: Effects of dietary soy on
biomarkers in prostate cancer PI: Cline M Total: 298,486 Status: Funded Title: Soy and estrogen interactions in the breast Source: NIH/NCCAM Term: 09/18/2000-06/30/2004

PI: Cramer S Source: National Institutes of Health Total: 922,500 Term: 9/30/2004-8/31/2009 Status: Funded Title: Vitamin D and Soy Isoflavone Inhibition of LCAT, Lipids and Atherosclerosis PI: Cramer S Source: Army Med RD Command Total: 179,375 Term: 08/31/2004-11/30/2007 Status: Funded Title: Vitamin D and Genistein Inhibition of Prostate Growth PI: Edwards I Source: American Institute for Cancer Research Total: 150,000 Term: 07/31/2005-06/30-2007 Status: Funded Title: Fatty Acids, Proteoglycans and Breast Cancer PI: Edwards I Total: Status: Submitted and Pending Title: Syndecan 1 regulation by n-3 PUFA Source: NIH/NCI Term:

PI: Furberg C, Rapp S Source: University of Pittsburg Total: 297,493 Term: 9/30/1999 - 7/31/2005 Status: Funded Title: Ginkgo Biloba prevention Trial in Older Induviduals - Clinical Coordinating
Center 8 August 1, 2005

PI: Garcia S

Total: 47,296 Status: Funded Title: Manganese Neurotoxicity in Developing Non-Deficient Rats PI: Hu J Source: National Cancer Institute Total: 215,250 Term: 7/10/2003-6/30/2006 Status: Funded Title: Effects of Fruit and Vegetable Extracts on Cancer Markers PI: Kaplan JR Source: NIH Total: 690,334 Term: 1/1/2005-12/31/2009 Status: Funded Title: Soy, Life Stage, Stress and Atherosclerosis in Females PI: Kemper KJ Source: Private donor Total: 10,000 Term: 09/1/2003-8/31/2004 Status: Funded Title: Visiting professors in herbs and dietary supplements

Source: National Institute of Environmental Health Sciences NIEHS Term: 9/30/2003-9/29/2005

PI: Kemper KJ Source: Fullerton Foundation Total: 14,589 Term: 12/01/2004-11/30/2005 Status: Funded Title: Feasibility of educating South Carolina clinicians about herbs and supplements by internet PI: Kemper KJ Source: Revival Soy Total: 6,636 Term: 09/01/2004-8/31/2005 Status: Submitted and Pending Title: Use
of soy and other complementary therapies for nausea and vomiting of pregnancy PI: Kemper KJ Source: Private Donor Total: 15,000 Term: 9/1/2004-8/31/2005 Status: Funded Title: Visiting professors in herbs and dietary supplements PI: Kemper KJ Source: NIH/NLM RO1 Total: 365,552 Term: 2/1/2004-1/31/2006 Status: Funded Title: Evaluating an Internet-Based Curriculum About Herbs and Dietary Supplements PI: Koumenis C Source: NIH Total: Term: 4/1/2005-3/30/2009 Status: Submitted and Pending Title: Phenolic antioxidants as tumor/radio/chemosensitizers: properties of CAPE and curcumin in vitro and in vivo 9 August 1, 2005

PI: Kute T Source: Vaughn-Jordon Total: 40,000 Term: 6/14/2004-6/13/2007 Status: Funded Title: Use of Soy products to Enhance Herceptin Treatment for Cancer Patients PI: Laurienti P Source: NIH Total: 386,883 Term: 4/01/2005-01/31/2006 Status: Funded Title: Effective caffeine on function and perfusion MRI PI: Lee R Source: Southwest Oncology Group Total: 3,154 Term:
6/1/1993-5/31/2004 Status: Funded Title: Selenium and Vitamin E Chemoprevention Trial: Clinical Center PI: Molnar I, Schwartz G Source: NCI/NCCAM Total: 74,905 Term: 1/2003-12/2005 Status: Funded Title: Orthomolecular Vitamin D3 in Treatment of Patients with MDS CA 012197-S1 PI: Parks J Total: 225,000 Status: Funded Title: Dietary PUFA effects of LCAT reactivity PI: Parks J Total: 34,999 Status: Funded Title: LCAT Lipids and Atherosclerosis PI: Parks J, Chen Y Total: 358,750 Status: Funded Title: LCAT Lipids and Atherosclerosis Source: NIH NHLBI Term: 03/01/1996-03/31/2004

Source: WFUSM Venture Grant Term: 03/12/2004-03/31/2005

Source: NHLBI Term: 1/1/2005-12/31/2009

PI: Robertson J VTech, WFUSM Hess, Robbins, Shaw, Shaw Source: Equine Foundation Total: 10,000 Term: 6/1/2004-5/31/2005 Status: Funded Title: Evaluation of Therapeutic Grade Essential Plant Oils for treatment of Equine Sarcoids, Melanomas, Squamous Cell Carcinoma, in vitro and kinetic studie

10 August 1, 2005

PI:
Robertson J VTech, WFUSM Hess, Robbins, Shaw, Shaw Source: WFUBMC Total: 9,200 Term: 4/1/2004-3/31/2005 Status: Funded Title: Phase I-II clinical trial of therapeutic grade essential plant oils for spontaneous cutaneous tumors in dogs and horses PI: Schwartz G Source: NCI/NCCAM Total: 90,000 direct costs Term: 12/2003-11/2004 Status: Funded Title: Do dietary supplements of antioxidants and zinc reduce serum cadmium levels in smokers? PI: Shaw E Source: NCI/ CCCWFU CCOP Total: 310,707 Term: 03/2001- 04/2005 Status: Funded Title: Phase III Double Blind Randomized Trial comparing sertraline and hypricum perforatum in cancer patients with mild to moderate depression PI: Shaw E Source: Total: Term: Status: Pending Title: Phase II Studies of donepezil and ginkgo biloba in irradiated brain tumor patients PI: Shaw E Source: NCI/NIH Total: 15,000 Term: Status: Title: The in vitro and in vivo efficacy of therapeutic grade essential oils PI: Shively C Source: United Soybean Board, Soy Health
Research Program Term: One-time award

Total: 10,000 Status: Funded Title: Effect of soy on behavior, mood and neural serotonergetic function of the female cynomolgus monkeys PI: Toole J

Total: 2,113,126 Status: Funded Title: Vitamin Intervention for Stroke Prevention VISP

Source: National Institute of Neurological Disorders and Stroke NINDS Term: 9/15/1996-7/31/2006

PI: Torti S Source: American Institute for Cancer Research Total: 82,500 Term: 1/31/2005-12/31/2006 Status: Funded Title: Iron and the Chemopreventative Activity of Curcumin 11 August 1, 2005

PI: Vitolins M Total: 38,636 Status: Funded Title: Soy Trial of the Prostate

Source: Ohio State University Term: 7/1/2002-3/31/2005

PI: Vitolins M Source: Total: Pending Term: Status: Pending Title: Randomized study of soy protein and effexor on vasomotor symptoms of men with prostate cancer PI: Wagner J Source: WFUSM Venture Grant Total: 15,000 Term: 5/19/2004-5/31/2005 Status: Funded Title: Mechanisms whereby dietary soy
protein improves insulin sensitivity in premenopausal monkeys PI: Wallin R Total: 322,875 Status: Funded Title: Vitamin K, Bone and Arterial Calcification Source: NIH Term: 7/1/2003-6/30/2007

PI: Westcott C Source: Adolor Total: 44,245 Term: 6/30/2005-7/19/2004 Status: Funded Title: Lipid HDL Reverse Cholesterol Transport in African Green Monkeys PI: Williamson J Source: NIH-NIA Total: 25,000 Term: 3/15/2005-3/14/2006 Status: Funded Title: Ginkgo Evaluation of Memory-Inflammation and Neuroimaging GEMINI PI: Kaplan J Source: NHLBI Total: 2,298,609 Term: 4/1/2003-3/31/2005 Status: Funded Title: Cardiovascular Benefits of Soy Phytoestrogens PI: Levine M Source: Penn State University Total: 130,050 Term: 10/6/2004-6/30/2005 Status: Funded Title: A Comparison of the Ability of Two Protein Ginger Products to Reduce the Delayed Nausea Following Chemotherapy

12 August 1, 2005

Legal, Ethical and Policy Issues
PI: Cohen M, Kemper KJ Source: Greenwall Foundation Total: 1,000 Term:
06/07/2004-06/06/2005 Status: Funded Title: Pediatric Use of Complementary Therapies by Parents: Ethical and Policy Choices

Lifestyle and Mind-Body
PI: Avis N Source: NCI/NCCAM Total: Term: Status: Pending Title: Yoga Intervention for Menopausal Hot Flashes PI: Dailey M, McCarty A Source: NCAA-IM Total: 3,000 Term: 9/2005 Status: Funded Title: Mindfulness-Based Stress Reduction MBSR for Overweight and Obesity in Adolescents PI: Danhauer SC Source: ACS Total: Term: continuation 1/1/2005-12/31/2005 Status: Funded Title: Restorative Yoga for Symptom Management Stress Reduction in Women with Breast Cancer PI: Danhauer SC Source: ACS institutional Total: 18,013 Term: 1/1/2004-12/31/2004 Status: Funded Title: Restorative Yoga for Symptom management and Stress Reduction in Women with Ovarian Cancer PI: Danhauer SC Source: NCAA-IM Total: 3,000 Term: 4/2004-3/2005 Status: Funded Title: Use of Music Guided Imagery to Reduce Anxiety Pain Perceived for Women Undergoing Colposcopy PI: Kelly E
Source: NCAA-IM Total: 3,000 Term: 2/1/2004-1/31/2005 Status: Funded Title: Impact of music on heart rate variability in pediatric oncology patients

13 August 1, 2005

PI: Kemper KJ Source: NIH NCCAM K24 Total: 455,155 Term: 02/1/2005-1/31/2006 Status: Funded Title: Heart rate variability in response to CAM in pediatrics PI: Kemper KJ Source: NIH NCCAM R21 Total: 215,250 Term: 4/1/2005-3/31/2007 Status: Funded Title: Harp Music: Effects on HRV, Cortisol and Activity PI: McCarty A, Dailey M Source: Consortium of Academic Health Centers for Integrative Medicine Term: 6/2005-5/2006

Total: 4,800 Status: Funded Title: Expanding Mind-Body Experiential Training

PI: Shively C Source: NIH/NIMH Total: 303,182 Term: 12/01/1998-11/30/2004 Status: Funded Title: Imaging Dopamine Function in Stress and Depression PI: Shively C Total: 48,269 Status: Funded Title: Social Status and Allostatic load Source: John D and Catherine T MacArthur Foundation Term: 07/01/2003-06/30/2004

Other
PI: Bonds
Source: NIH Total: Term: 1/1/06-12/30/08 Status: Pending Title: Trial of Advanced Strain Counterstrain for Reducing Overactive Bladder Syndrome PI: Kemper KJ Source: Kohlberg Foundation Total: 50,000 Term: 01/01/2004-12/30/2005 Status: Funded Title: North Carolina Academic Alliance for Integrative Medicine PI: Kemper KJ Source: NIH NCCAM Total: 1,606,708 Term: 10/01/2000-09/30/2005 Status: Funded Title: Center for Pediatric Integrative Medical Education

14 August 1, 2005

Spirituality
PI: Arcury T, Grzywacz J Source: NIH Total: 179,390 Term: 01/01/2006-12/30/2008 Status: Submitted and Pending Title: Spirituality Quality Dying: A Feasiblity Study of Prospective End-of-Life Research PI: Reifler B Total: 1,225,169 Status: Funded Title: Faith in Action, Phase II Source: Robert Wood Johnson Foundation Term: 2/1/2001-4/30/2006

PI: Suggs P Source: Jessie Bell DuPont Fund Total: 45,000 Term: 07/01/2002-06/30/2006 Status: Funded Title: Health and Spirituality in African-American
Congregation

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Research Publications, peer reviewed N105 Biofield therapies/Spirituality: Acupuncture, Electromagnetic fields, Reiki, Healing Touch, Prayer
2004 Duflo F, Zhang Y, Eisenach JC Electrical field stimulation to study inhibitory mechanisms in individual sensory neurons in culture Anesthesiology, 2004;1003:740-743 Kemper KJ, Kelly EA Treating children with therapeutic and healing touch Pediatr Ann, 2004;334:248-252,254,255

2004

Clinician/Patient Relationship
2004 Bonds DE, Camacho F, Bell RA, Duren-Winfield VT, Anderson RT, Goff DC The association of patient trust and self-care among patients with diabetes mellitus [online only] BMC Fam Pract, 2004;51:article 26 Bonds DE, Foley KL, Dugan E, Hall MA, Extrom P An exploration of patients trust in physicians in training J Health Care Poor Underserved, 2004;152:294-306 Hall MA A corporate ethic of care in health care Seattle J Social Justice, 2004;31:417-428 Hall MA Caring, curing, and trust: a response to
Gatter Wake Forest Law Rev, 2004;392:447-451 Mihalko SL, Brenes GA, Farmer DF, Katula JA, Balkrishnan R, Bowen DJ Challenges and innovations in enhancing adherence Control Clin Trials, 2004;255:447-457 Thom DH, Hall MA, Pawlson LG Measuring patients trust in physicians when assessing quality of care Health Aff Millwood, 2004;234:124-132 Hall MA Can you trust a doctor you cant sue? DePaul Law Rev, 2005;542:303-313 Hall MA The importance of trust for ethics, law, and public policy Camb Q Healthc Ethics, 2005;142:156-167 Trachtenberg F, Dugan E, Hall MA How patients trust relates to their involvement in medical care J Fam Pract, 2005;544:344-352

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Epidemiology/Health Services
2004 Arcury TA, Preisser JS, Jr, Gesler WM, Sherman JE Complementary and Alternative Medicine Use Among Rural Residents in Western North Carolina Complementary Health Practice Review 92:93-102, 2004 Gardiner P, Dvorkin L, Kemper KJ Supplement use growing among children and
adolescents Pediatr Ann, 2004;334:227-232 Highfield ES, Kaptchuk TJ, Ott MJ Barnes L, Kemper KJ Availability of Acupuncture in the Hospitals of a Major Academic Medical Center: pilot study Complementary Therapies in Medicine, 2004, 113:177-83 16 August 1, 2005

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2004

Kemper KJ, OConner K Pediatricians Recommendations for Complementary and Alternative Medical Therapies, Ambulatory Pediatrics, 2004;4:482-7 Arcury TA, Bell RA, Vitolins MZ, Quandt SA Rural older adults beliefs and behavior related to complementary and alternative medicine use Complement Health Pract Rev 2005:101:33-44 Bell RA, Suerken CK, Grzywacz JG, Lang W, Quandt SA, Arcury TA CAM use for health treatment among adults with diabetes in the US [abstract] 2005 Diabetes, 54Suppl 1:A242 Grzywacz JG, Lang W, Suerken C, Quandt SA, Bell RA, Arcury TA Age, race, and ethnicity in the use of complementary and alternative medicines CAM for health self management: Evidenced from the 2002 National Health Interview Survey
Journal of Aging and Health, in press Quandt SA, Chen H, Grzywacz JG, Bell RA, Lang W, Arcury TA Use of Complementary and Alternative Medicine by Persons with Doctor-Diagnosed Arthritis: Results of the NHIS Arthritis Care and Research, in press Grzywacz JG, Arcury TA, Bell RA, Lang W, Suerken C, Smith SL, Quandt SA Ethnic differences in elders home remedy use: sociostructural explainations American Journal of Health Behaviour, in press Highfield E, McLellan M, Kemper K, Risko W, Woolf AD Integration of Complementary and Alternative medicine in a Major Pediatric Teaching Hospital: An Initial Overview J Altern Complement Med, 2005: Apr;112:373-80 Sahmoun AE, Case LD, Jackson SA, Schwartz GG Cadmium and prostate cancer: a critical epidemiologic analysis Cancer Invest, 2005;233:256-263

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Herbs and Dietary Supplements
2004 Adams MR, Golden DL, Franke AA, Potter SM, Smith HS, Anthony MS Dietary soy Conglycinin 7S globulin inhibits atherosclerosis in
mice J Nutr 2004:1343: 511-516 Boyapati SM, Bostick RM, McGlynn KA, Fina MF, Roufail WM, Geisinger KR, Hebert JR, Coker A, Wargovich M Folate intake, MTHFR C677T polymorphism, alcohol consumption, and risk for sporadic colorectal adenoma United States Cancer Causes Control, 2004;155:493-501 Buss JL, Greene BT, Turner J, Torti FM, Torti SV, Iron chelators in cancer chemotherapy Curr Top Med Chem, 2004;415:1623-1635 Buss JL, Neuzil J, Ponka P Oxidative stress mediates toxicity of pyridoxal isonicotinoyl hydrazone analogs Arch Biochem Biophys, 2004;4211:1-9 Cesari M, Pahor M, Bartali B, Cherubini A, Penninx B, Williams GR, Atkinson H, Martin A, Guralnik JM Antioxidants and physical performance in elderly persons: the Invecchiare in Chianti InCHIANTI study Am J Clin Nutr, 2004;792: 289-294 Cline JM, Franke AA, Golden DL, Adams MR Effects of dietary aglycone isoflavones on the reproductive tract of male and female mice Toxicologic Pathology, 2004; 321:91-99 Cline JM, Franke A, Register TC,
Golden DL, Adams MR Effects of dietary 17 August 1, 2005

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isoflavone aglycones on the reproductive tract of male and female mice Toxicol Path 2004 Jan-Feb;321:91-99 Connors N, Merrill D Antioxidants for prevention of preterm delivery Clin Obstet Gynecol, 2004;474:822-832 Dobson AW, Erikson KM, Aschner M Manganese neurotoxicity Ann N Y Acad Sci, 2004;1012:115-128 Edwards I, Berquin, I, Sun H, OFlaherty J, Daniel L, Thomas M, Rudel L, Wykle R, Chen Y Differential effects of omega-3 fatty acids to human cancer cells by lowdensity lipoproteins versus albumin 2004 Clinical Cancer Research 10: 827-8283 Erikson KM, Dobson AW, Dorman DC, Aschner M Manganese exposure and induced oxidative stress in the rat brain Sci Total Environ, 2004;334-335:409-416 Erikson KM, Dorman DC, Lash LH, Dobson AW, Aschner M Airborne manganese exposure differentially affects end points of
oxidative stress in an age- and sexdependent manner Biol Trace Elem Res, 2004;1001:49-62 Hantgan RR, Stahle MC, Connor JH, Lyles DS, Horita DA, Rocco M, Nagaswami C, Weisel JW, McLane MA The disintegrin echistatin stabilizes integrin alphaIIbbeta3s open conformation and promotes its oligomerization J Mol Biol, 2004;3425:1625-1636 Ilyasova D, Morrow JD, Ivanova A, Wagenknecht LE Epidemiological marker for oxidant status: comparison of the ELISA and the gas chromatography/mass spectrometry assay for urine 2,3-dinor-5,6-dihydro-15-F2t-isoprostane Ann Epidemiol, 2004;1410:793-797 Insull W Jr, McGovern ME, Schrott H, Thompson P, Crouse JR, Zieve F, Corbelli J Efficacy of extended-release niacin with lovastatin for hypercholesterolemia: assessing all reasonable doses with innovative surface graph analysis Arch Intern Med, 2004;16410:1121-1127 John EM, Dreon DM, Koo J, Schwartz GG Residential sunlight exposure is associated with a decreased risk of prostate cancer J Steroid Biochem Mol Biol,
2004;89-90:549-552 Keung YK, Owen J Iron deficiency and thrombosis: literature review Clin Appl Thromb Hemost, 2004;104:387-391 Laniewski NG, Grayson JM Antioxidant treatment reduces expansion and contraction of antigen-specific CD8 T cells during primary but not secondary viral infection J Virol, 2004;7820:11246-11257 Molnar I, Kute T, Willingham MC, Schwartz GG 19-Nor-1-alpha, 25dihydroxyvitamin D2 paricalcitol exerts anticancer activity against HL-60 cells in vitro at clinically achievable concentrations Mozaffarian D, Rimm EB, Herrington DM Dietary fats, carbohydrate, and progression of coronary atherosclerosis in postmenopausal women Am J Clin Nutr, 2004;805:1175-1184 Porcelli PJ, Greene H, Adcock E A modified vitamin regimen for vitamin B2, A, and E administration in very-low-birth-weight infants J Pediatr Gastroenterol Nutr, 2004;384:392-400 Rao A, Coan A, Welsh JE, Barclay WW, Koumenis C, Cramer SD p27Kip1 is Essential for the Antiproliferative Action of 1,25-dihydroxyvitamin
D3 in Primary 18

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but not Immortalized Mouse Fibroblasts J Biol Chem 2002 Oct 4; 27740: 37301-6 Epub 2002 Aug 5 Rao A, Coan A, Welsh J-E, Barclay WW, Koumenis C, Cramer SD 2004 Vitamin D Receptor and p21/WAF1 are Targets of Genistein and 1,25-dihydroxyvitamin D3 in Human Prostate Cancer Cells Cancer Research: 64:2143-2147 Schwartz GG, Eads D, Rao A, Cramer SD, Willingham MC, Chen TC, Jamieson DP, Wang L, Burnstein KL, Holick MF, Koumenis C Pancreatic cancer cells express 25-hydroxyvitamin D-1 alpha-hydroxylase and their proliferation is inhibited by the prohormone 25-hydroxyvitamin D3 Carcinogenesis 2004 Jun;256:1015-26 Shively CA, Register TC, Grant KA, Johnson JL, Cline JM Effects of dietary isoflavone aglycones on the reproductive tract of male and female mice Toxicol Pathol 2004; 321:91-99 Simon NG, Kaplan JR, Hu S, Register TC, Adams MR Increased aggressive behavior and decreased affiliative
behavior in adult male monkeys after long-term consumption of diets rich in soy protein and isoflavones Horm Behav, 2004;454:278-284 Steck-Scott S, Paskett E, Cooper MR, Quandt S, DeGraffinreid C, Bradham K, Kent L, Self M, Boyles D Carotenoids, vitamin A and risk of adenomatous polyp recurrence in the Polyp Prevention Trial Int J Cancer, 2004;1122:295-305 Stredrick DL, Stokes AH, Worst TJ, Freeman WM, Johnson EA, Lash LH, Aschner M, Vrana KE Manganese-induced cytotoxicity in dopamine-producing cells Neurotoxicology, 2004;254:543-553 Surette ME, Edens M, Chilton FH, Tramposch KM Dietary echium oil increases plasma and neutrophil long-chain n-3 fatty acids and lowers serum triacylglycerols in hypertriglyceridemic humans J Nutr 2004 Jun;1346:1406-11 Wood, CE, Cline JM, Anthony MS, Register TC, Kaplan JR Adrenocortical effects of oral estrogens and soy isoflavones in female monkeys J Clin Endocrinol Metab 2004; 895:2319-2325 Wood CE, Register TC, Anthony MS, Kock ND, Cline JM Breast and
uterine effects of soy isoflavones and conjugated equine estrogens in postmenopausal female monkeys J Clin Endocrinol Metab 2004; 897:3462-3468 Young MV, Schwartz GG, Wang L, Jamieson DP, Whitlatch LW, Flanagan JN, Lokeshwar BL, Holick MF, Chen TC The prostate 25-hydroxyvitamin D-1 alphahydroxylase is not influenced by parathyroid hormone and calcium: implications for prostate cancer chemoprevention by vitamin D Carcinogenesis, 2004;256:967971 Zhao R, Planalp RP, Ma R, Greene BT ,Jones BT, Brechbiel MW, Torti FM, Torti SV Role of zinc and iron chelation in apoptosis mediated by tachpyridine, an anticancer iron chelator Biochem Pharmacol, 2004;679:1677-1688 Aschner M, Erikson KM, Dorman DC Manganese dosimetry: species differences and implications for neurotoxicity Crit Rev Toxicol, 2005;351:1-32 Canner PL, Furberg CD, Terrin ML ,McGovern ME Benefits of niacin by glycemic status in patients with healed myocardial infarction Am J Cardiol, 2005;952:254257 19

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Djousse L, Arnett DK, Carr JJ, Eckfeldt JH, Hopkins PN, Province MA, Ellison RC Dietary linolenic acid and adjusted QT and JT intervals in the National Heart, Lung, and Blood Institute Family Heart Study Circulation, 2005;11122:2921-2926 Djousse L, Rautaharju PM, Hopkins PN, Whitsel EA, Arnett DK, Eckfeldt JH, Province MA, Ellison RC Dietary linolenic acid is inversely associated with calcified atherosclerotic plaque in the coronary arteries: the National Heart, Lung, and Blood Institute Family Heart Study J Am Coll Cardiol, 2005;4510: 1716-1722 Erikson KM, Dorman DC, Lash LH, Aschner M Persistent alterations in biomarkers of oxidative stress resulting from combined in utero and neonatal manganese inhalation Biol Trace Elem Res, 2005;1042:151-164 John EM, Schwartz GG, Koo J, Van Den Berg D Sun exposure, vitaminD receptor gene polymorphisms, and risk of advanced prostate cancer Cancer Res,
2005;6512:5470-5479 Kemper KJ, Super E, Woods C, Nagaraj S Cranberry use among pediatric nephrology patients Ambulatory Pediatrics, 2005;54:249-252 Land MH, Rouster-Stevens K, Woods CR, Cannon ML, Cnota J, Shetty AK Lactobacillus sepsis associated with probiotic therapy Pediatrics, 2005;1151: 178-181 Lim D, Morgan RJ, Akman S, Margolin K, Carr BI, Leong L, Odujinrin O, Doroshow JH Phase I trial of menadiol diphosphate vitamin K-3 in advanced malignancy Invest New Drugs, 2005;233:235-239 Lippman SM, Goodman PJ, Klein EA, Parnes HL, Thompson IM Jr, Kristal AR, Santella RM, Probstfield JL, Moinpour CM Designing the Selenium and Vitamin E Cancer Prevention Trial SELECT J Natl Cancer Inst, 2005;972:94-102 Poole C, Peters U, Ilyasova D, Arab L Black tea and cardiovascular disease [reply to letter] Int J Epidemiol, 2005;342:483 Register TC, Cann JA, Kaplan JR, Williams JK, Adams MR, Morgan TM, Anthony MS, Blair RM, Wagner JD Effects of soy isoflavones and conjugated equine estrogens on
inflammatory markers in atherosclerotic, ovariectomized monkeys J Clin Endocrinol Metab, 2005;903:1734-1740 Sun H, Berquin IM and Edwards IJ Omega-3 polyunsaturated fatty acids regulate syndecan 1 expression in human breast cancer cells Cancer Res, 2005, 65: 10 4442-4447 Swann AC, Birnbaum D, Jagar AA, Dougherty DM, Moeller FG Acute Yohimbine increases laboratory-measured impulsivity in normal subjects Biol Psychiatry, 2005;5710:1209-1211 Wajih N, Sane DC, Hutson SM, Wallin R Engineering of a recombinant vitamin Kdependent gamma-carboxylation system with enhanced gamma-carboxyglutamic acid forming capacity: evidence for a functional CXXC redox center in the system J Biol Chem, 2005;28011:10540-10547

Legal, Ethical and Policy Issues
2005 Cohen MH, Hrbek A Davis RB, Schachter SC, Boyer E, Kemper KJ, Eisenberg DM Emerging credentialing practices, malpractice liability policies, and guidelines 20 August 1, 2005

2005 2005

governing complementary and alternative medical practices and
dietary supplement recommendations Arch Intern Med 2005;165:289-95 Cohen MH, Kemper KJ Complementary therapies in pediatrics: a legal perspective Pediatrics 2005;1153:774-780 Cohen MK, Kemper KJ, Stevens L, Hashimoto D, Gilmour J Pediatric use of a complementary therapy: ethical and policy choices Pediatrics, 2005 in press

Lifestyle
2004 Brach JS, Simonsick EM, Kritchevsky S, Yaffe K, Newman AB The association between physical function and lifestyle activity and exercise in the Health, Aging and Body Composition study J Am Geriatr Soc, 2004;524:502-509 Buchanan CK, High KP Nutrition, aging, and infection Clin Geriatr, 2004;122:4453 Colbert LH, Visser M, Simonsick EM, Tracy RP, Newman AB, Kritchevsky SB, Pahor M, Taaffe DR, Brach J Physical activity, exercise, and inflammatory markers in older adults: findings from the Health, Aging and Body Composition Study J Am Geriatr Soc, 2004;527:1098-1104 Danhauer SC, Oliveira B, Myll J, Berra K, Haskell W Successful dietary changes in
cardiovascular risk reduction intervention are differentially predicted by biopsychosocial characteristics Prev Med, 2004;394:783-790 Dennis LK, Snetselaar LG, Smith BJ, Stewart RE, Robbins MEC Problems with the assessment of dietary fat in prostate cancer studies Am J Epidemiol, 2004;1605:436-444 Erkkila AT, Lichtenstein AH, Mozaffarian D, Herrington DM Fish intake is associated with a reduced progression of coronary artery atherosclerosis in postmenopausal women with coronary artery disease Am J Clin Nutr, 2004;803:626632 Focht BC, Brawley LR, Rejeski WJ, Ambrosius WT Group-mediated activity counseling and traditional exercise therapy programs: effects on health-related quality of life among older adults in cardiac rehabilitation Ann Behav Med, 2004;281:52-61 Grzywacz JG, Keyes CLM Toward health promotion: physical and social behaviors in complete health Am J Health Behav, 2004;282:99-111 Hauret KG, Bostick RM, Matthews CE, Hussey JR, Fina MF, Geisinger KR, Roufail WM Physical
activity and reduced risk of incident sporadic colorectal adenomas: observational support for mechanisms involving energy balance and inflammation modulation Am J Epidemiol, 2004;15910:983-992 Kritchevsky SB A review of scientific research and recommendations regarding eggs J Am Coll Nutr, 2004;236 Suppl:596S-600S Landi F, Cesari M, Onder G, Lattanzio F, Gravina EM, Bernabei R Physical activity and mortality in frail, community-living elderly patients J Gerontol A Biol Sci Med Sci, 2004;59A8:833-837 Lee JS, Kritchevsky SB, Tylavsky FA, Harris T, Everhart J, Simonsick EM, Rubin SM, Newman AB Weight-loss intention in the well-functioning, community-dwelling elderly: associations with diet quality, physical activity, and weight change Am J Clin Nutr, 2004;802:466-474 21 August 1, 2005

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Mellen PB, Palla SL, Goff DC Jr, Bonds DE Prevalence of nutrition and exercise counseling for
patients with hypertension: United States, 1999 to 2000 J Gen Intern Med, 2004;199:917-924 Messier SP, Loeser RF, Miller GD, Morgan TM, Rejeski WJ, Sevick MA, Ettinger WH Jr, Pahor M, Williamson JD Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial Arthritis Rheum, 2004;505:1501-1510 Mozaffarian D, Psaty BM, Rimm EB, Lemaitre RN, Burke GL, Lyles MF, Lefkowitz D, Siscovick DS Fish intake and risk of incident atrial fibrillation Circulation, 2004;1104:368-373 Nicklas BJ, Ambrosius W, Messier SP, Miller GD, Penninx B, Loeser RF, Palla S, Bleecker E, Pahor M Diet-induced weight loss, exercise, and chronic inflammation in older, obese adults: a randomized controlled clinical trial Am J Clin Nutr, 2004;794:544-551 Patterson RE, Prentice RL, Beresford S,Caan B, Chlebowski RT, Granek IA, Haines PS, Hubbell FA, Jackson R Dietary adherence in the Womens Health Initiative Dietary Modification Trial J Am
Diet Assoc, 2004;1044:654-658 Rocco MV Poor nutritional status and inflammation: mechanisms and treatment Semin Dial, 2004;176:425-426 Simon NG, Kaplan JR, Hu S, Register TC, Adams MR Increased aggressive behavior and decreased affiliative behavior in adult male monkeys after long-term consumption of diets rich in soy protein and isoflavones Hormones and Behavior 2004; 454:278-284 You T, Berman DM, Ryan AS, Nicklas BJ Effects of hypocaloric diet and exercise training on inflammation and adipocyte lipolysis in obese postmenopausal women J Clin Endocrinol Metab, 2004;894:1739-1746 Mozaffarian D, Longstreth WT Jr, Lemaitre RN, Manolio TA, Kuller LH, Burke GL, Siscovick DS Fish consumption and stroke risk in elderly individuals: the Cardiovascular Health Study Arch Intern Med, 2005;1652:200-206 Mozaffarian D, Rimm EB, Psaty BM, Siscovick DS, Lemaitre RN, Burke GL, Lyles MF, Lefkowitz D Letter regarding article by Mozaffarian et al, Fish intake and risk of incident atrial fibrillation:
response [reply to letter] [online only] Circulation, 2005;1114:e37 van Gool CH, Penninx B, Kempen G, Rejeski WJ, Miller GD, van Eijk J, Pahor M, Messier SP Effects of exercise adherence on physical function among overweight older adults with knee osteoarthritis Arthritis Rheum, 2005;531:24-32

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Mind Body and Music
2004 2004 Feldman JB The neurobiology of pain, affect and hypnosis Am J Clin Hypn, 2004;463:187-200 Kemper KJ, Martin K, Block SM, Shoaf R, Woods C Attitudes and Expectations about Music Therapy for Premature Infants in a Neonatal Intensive Care Unit Alt Ther Health Med, 2004, Mar-Apr; 102:50-54 22 August 1, 2005

2004 2004

2004

Shively CA, Bethea CL Cognition, mood disorders, and sex hormones ILAR J 2004; 45:189-199 Shively CA, Register TC, Grant KA, Johnson JL, Cline CM Effects of social status and moderate alcohol consumption on mammary gland and endometrium of surgically menopausal monkeys Menopause 2004;114:389-399 Stern RM, Vitellaro K, Thomas M,
Higgins SC, Koch KL Electrogastrographic biofeedback: a technique for enhancing normal gastric activity Neurogastroenterol Motil, 2004;166:753-757

Other
2004 Hess, SM, Shaw, C, Anderson, J, Shaw, E DNA Damage and Cytotoxicity of Therapeutic Grade Essential Oils Journal of Cancer Integrative Medicine 12: 41, 2004 Kemper KJ, Woods CR, Yard B, Cohen D, McLean T, Atkinson M Heart Rate Variability in Pediatric Patients with Leukemia - a brief report J Cancer Integr Med Summer;23:137-143 Schroeder EB, Whitsel EA, Evans GW, Prineas RJ, Chambless LE, Heiss G Repeatability of heart rate variability measures J Electrocardiol, 2004;373: 163-172

2004

2004

23 August 1, 2005

Review articles, chapters and books N21 Biofield therapies/Spirituality: Acupuncture, Reiki, Healing Touch, Qigong, Prayer
2004 Kemper KJ, Kelly EA Treating Children with Therapeutic and Healing Touch Pediatric Annals, 2004; 334:248-252 Hess S and Clewell S Energy Medicine in Integrative Oncology, Principles and Practice,
edited by Matt Member, MD, Parthenon, CRC Press, 2005 in press Hess, S, Shaw E, Stark N Research and Evidence in Integrative Oncology, Principles and Practice, edited by Matt Member, MD, Parthenon, CRC Press, 2005, in press

2005 2005

Herbs and Dietary Supplements
2004 Birt DF, Anthony M, Alekel DL, Hendrich S Soybean and the prevention of chronic human disease In: Boerma HR, Sprecht JE eds, Soybean Monograph, 3rd edition, American Society of Agronomy, Madison, WI in press Clarkson TB, Appt SE Cardiovascular effects of dietary soy In: Watson RR, Preedy VR, eds Nutrition and Heart Disease: Causation and Prevention Boca Raton, FL, CRC Press 2004:215-236 Gardiner P, Dvorkin L, Kemper KJ Supplement Use Growing Among Children and Adolescents Pediatric Annals 2004; 334:227-232 Kemper KJ, Singla M, Gardiner P Herbs and Dietary Supplements for Asthma Clinical Pulmonary Medicine, 2005;122:67-75 Gardiner P and Kemper KJ Herbs and Supplements for GI Disorders Contemporary Pediatrics, 2005, in
press Kemper KJ and Gardiner P Herbal Medicine, Chaper 713 Nelsons Textbook of Pediatrics 18th Edition, in press Surette ME, Tramposch KM, Chilton FH Dietary echium oil increases tissue long chain n-3 fatty acids and lowers serum triacylglycerols in hypertriglyceridemic humans [abstract] FASEB J, 2005;195 Pt II:A972

2004

2004 2005 2005 2005 2005

Legal, Ethical and Policy Issues
2004 Kemper KJ, Cohen M Ethics meet complementary and alternative medicine: New light on old principles Contemporary Pediatrics 2004; 213:61-72

Mind Body
2005 2005 Kemper KJ and Danhauer SC Music as Therapy Southern Medical Journal, 2005:983:282-288 Kemper KJ, Jennings D Consider the benefits of music therapy for your patients Contemporary Pediatrics 2005;222:59-66 24 August 1, 2005

Other
2004 Block KI, Burns B, Cohen AJ, Dobs AS, Hess SM, Vic Point-counterpoint: using clinical trials for the evaluation of integrative cancer therapies Integr Cancer Ther 31:66-81, 2004 Kemper KJ, McLellan MC, Highfield ES
Massage therapy and acupuncture for children with chronic pulmonary disease Clinical Pulmonary Medicine, 2004; 114:242-250 Kemper KJ and McLean TW Complementary and Alternative Medical Therapies in Pediatric Oncology In Pizzo PA and Poplack DG, eds Principles and Practice of Pediatric Oncology, 5th ed Philadelphia, PA: Lippincott Williams Wilkins In Press Kemper KJ Overview of complementary and alternative medical therapies, part I Up to Date in Pediatrics, 2004;101 CD-ROM Kemper KJ Overview of complementary and alternative medical therapies, part II Up to Date in Pediatrics, 2004; 101 CD-ROM Kemper KJ Nonpharmacologic approaches to treating chronic pain Audio-Digest Pediatrics Kemper KJ Asthma: adjuncts for easier breathing nonpharmacologic approaches to therapy Audio-Digest Pediatrics Kemper KJ and Walcott C Integrative Pediatrics; Chapter 307 Pediatrics, edited by Lucy Osborn, Thomas DeWitt, Lewis First, and Joseph Zenel, 2005: 1959-1964

2004

2004

2004 2004

2005 2005 2005

25
August 1, 2005

Abstracts N14 not cited elsewhere Epidemiology/Health Services
2005 DeMattia A, Kemper KJ Who receives appropriate recommendations about complementary and alternative medical therapies? Abstract presentation at 2005 Eastern Society for Pediatric Research Annual Meeting, Old Greenwich, CT March 6, 2005 Bell RA, Suerken CK, Grzywacz JG, Lang W, Quandt SA, Arcury TA CAM use for health treatment among adults with diabetes in the US Diabetes, 2005 54 Supplement 1

2005

Clinician/Patient Relationships and Communication
2005 Guest C, Hawes D, Khanna V, Feldman S Use of a consultation/prescription form to improve communication with referring doctors [abstract] J Am Acad Dermatol, 2005;523 Suppl 1:P108

Herbs and Dietary Supplements
2004 2004 Lees CJ, Register TC, Kaplan JR Soy increases bone density in skeletally mature, premenopausal monkeys Menopause 2004;116 Pt 1:652 Register TC, Kaplan JR, Adams MR, Anthony MS, Williams JK, Blair RM, Wagner JD, Clarkson TB Soy isoflavone
consumption is associated with reduced serum soluble vascular cell adhesion molecule-1 sVCAM-l in postmenopausal monkeys J Nutr 2004;1345:1244S Borden LS, Clark PE, Miller A, Lee WR, Hu J, Stindt D, Torti FM, Hall MC Prospective dose-escalation trial of lycopene in men with recurrent prostate cancer following definitive local therapy [abstract] J Urol, 2005;1734 Suppl:275 Dougherty DM, Marsh DM, Mathias CW, Morgan CJ, Bradley DM, Badawy AA-B Impulsive behavior differences following combined alcohol and Ltryptophan depletion/loading manipulation [abstract] J Psychopharmacol, 2005;183 Suppl:A32 Erikson KM, Jones SR, Aschner M Brain manganese accumulation due to toxic exposure is mediated by the dopamine transporter [abstract] FASEB J 2005;195 Pt II:A1033-A1034 Gu L, Prior RL, Fang N, Ronis MJ, Clarkson TB, Badger TM Interspecies differences of isoflavone metabolic phenotypes in female rats, pigs, monkeys and humans [abstract] FASEB J, 2005;194 Pt I:A446 Kaplan JR, Wagner J Low social
status and soy protein increase insulin sensitivity in premenopausal monkeys [abstract] Am J Phys Anthropol, 26 August 1, 2005

2005

2005

2005

2005

2005

2005

2005

2005;126S40:126-127 Kavanagh KA, Zhang L, Davis M, Rudel LL, Williams JK, Wagner JD Comparison of dietary soy and estrogen effects on hepatic cholesterol metabolism in ovariectomized cynomolgus monkeys [abstract] FASEB J, 2005;195 Pt II:A1460 Wood CE, Register TC, Cline JM Soy isoflavone effects on endogenous estrogen metabolism in the breast Gene Expression in Reproduction: The 14th Annual Meeting of the Triangle Conference on Reproductive Biology UNC-Chapel Hill, Chapel Hill, NC February, 2005

Lifestyle
2005 Liese AD, Schulz M, Du S, DAgostino R Jr, Wolever TM Dietary glycemic index, glycemic load, carbohydrate intake and plasma lipids: the Insulin Resistance Atherosclerosis Study [abstract] Circulation, 2005;11114:218

Other
2005 Kemper KJ, Larrimore D, Dozier J, Woods C Electives in Complementary Medicine: Are we
preaching to the choir? Poster presentation at Pediatric Academic Society Meeting, Washington, DC May 2005

27 August 1, 2005

Holistic and Integrative Medical Education
Since 2004, holistic and Integrative Medicine has been a THEME in the undergraduate medical curriculum PA students 2004 Kemper Introduction to Holistic and Integrative Medicine WFUSM 7/28/04 2004 Mentored Research projects PA Student: Erica Kelly 2003-2004 Effect of music on heart rate variability in pediatric oncology patients Mentor: Kemper Cherise Kaper 2003-2004 The efficacy of Reiki alone and with chemotherapy in a colon cancer xenograft model Mentor: Hess Medical Students mentored research: 2004 Sarah Barbour: Use of dietary supplements by women with NVP Mentor: Kemper Elizabeth Super Cranberry use among pediatric nephrology patients Mentor: Kemper and Nagaraj April Gay: The effects of essential oils on lung and colon cancer cell lines Mentor: Hess 2005 Barry A Mindfulness Based Stress Reduction for obesity
Mentor:Dailey Annie Bouhairie: HRV in response to music in pediatric oncology patients Mentor: Kemper Cases for case-based teaching include CAM content

1st year medical students

2nd year medical students 8 Cases in the Organ System/Physiology courses include CAM content 2003-2004 Elective: Kemper and Larrimore, Therapeutic and Healing Touch - 7 week Elective 2004 Barnes, L The Cultural Formation of the Physician: Implications for Practice WFUSM September 30, 2004 lecture 2004 2005 Nutrition Course Includes lecture on herbs and dietary supplements 2004 MAAP Student lecture Kemper CAM or Holistic and Integrative Healing September 2, 2004 2004 MAAP Student lecture on Spirituality Suggs 2004 2005 Elective: Kemper and Larrimore, Therapeutic and Healing Touch - 7 week Elective 3rd year medical students 2004 2005 Kemper: Cultivating Compassion required seminars for 3rd year students on pediatrics 28 August 1, 2005

Seniors Phase V 2004 Therapeutic and Healing Touch Massage
Mindfulness Based Stress Reduction Reiki Residents 2004 Pediatric Resident orientation: Kemper: Introduction to Emotional Self-management and Healing Touch June 29, 2004

Fellows 2004 2005 Mentored Research opportunities

Faculty/staff development Dietary supplements GCRC and Grand Rounds lectures visiting professors 75-150 faculty/staff each 1/04 Abram Hoffer, MD, PhD Orthomolecular Psychiatry Psychiatry, Canada Booke Visiting Professor for Herbs and Dietary Supplements 3/04 Reinhold Vieth, PhD Vitamin D Cancer Center, Toronto Booke Visiting Professor for Herbs and Dietary Supplements 5/04 Joseph Hibbeln, MD Omega 3 fatty acids in depression and aggression Pediatric Grand Rounds, NIH Booke Visiting Professor for Herbs and Dietary Supplements 5/04 Joseph Hibbeln, MD The Clinical Effects of Omega-3 Fatty Acids GCRC Lecture WFUSM Winston Salem, NC National Institutes of Health Booke Visiting Professor for Herbs and Dietary Supplements 9/04 Connie Weaver, MD Soy and Bone Health
Comparative Medicine, Indiana Booke Visiting Professor for Herbs and Dietary Supplements 3/05 Robert Fletcher, MD Multivitamins: Do they really improve health? Booke Visiting Professor for Herbs and Dietary Supplements GCRC WFUSM Harvard Medical School

CAM-Community lecture series 50 -100 participants each 1/04 3/04 5/04 9/10/04 11/5/04 Ronny Bell, PhD CAM Epidemiology in NC Todd Smith, DC - Homeopathy Jeff Williamson, MD Ginkgo and Memory Study GEMS Graham A Myofascial Release: Gentle Relief for Acute and Chronic Pain Isley-Landreth B Guided Meditation: Respite for Body, Mind and Spirit 29 August 1, 2005

5/05

Mitch Krucoff Duke The MANTRA Project: Music, Imagery, Touch and Prayer Therapy for Interventional Cardiac Care 5/12/05 Caryl Guth, MD Magnetic Therapy: Clinical Experience and Evidence Other 2004

Suggs Drumming Demonstration; CAM Community Mixer, WFUSM, March 29, 2004 Tai Chi weekly classes for faculty and staff Piedmont Plaza Yoga 2 weekly classes Hanes Bldg and Comp
Rehab Pilates weekly classes for faculty and staff Comp Rehab

National education: 2004 2005 e-curriculum on Herbs and Dietary Supplements 1,200 enrollees Kemper and Northwest AHEC

30 August 1, 2005

Local CME/Grand Rounds/NW AHEC Presentations to Professionals N22
Biofield therapies/Spirituality: Acupuncture, Reiki, Healing Touch, Qigong, Prayer
2004 2004 2004 2004 Isley-Landreth-Lap Labyrinths/Tools for Balance, Spirituality and the Body/Mind Spirit, CPE Residents, WFUBMC July 12, 2004 Isley-Landreth Chi Kung, Music, Meditation and Cymatics Spirituality and the Body/Mind/Spirit, CPE Residents, WFUBMC July 19, 2004 Isley-Landreth, Larrimore Healing Touch Clinic for Staff Hospice and Palliative Care Center, Winston Salem, NC July 19, 2004 Isaacs, A sponsored by NWAHEC and the Synergy Clinical Consulting Services Physical Emotional Intelligence: Clinical applications of the Enneagram September 11, 2004 Wake Forest University Larrimore D Nursing Inservice on Healing Touch 48
participants February 8 and February 23, 2005 Larrimore D Healing Touch Presentation Brenner Childrens Hospital Nursing Unit Managers March 28, 2005 Larrimore D Healing Touch Demonstration for Nurses National Nurses Week WFUSM May 23, 2005

2005 2005 2005

Epidemiology/Health Services
2004 Barbour S Prevalence of CAM and home remedies among women with nausea and vomiting of pregnancy Presented at Student Research Day Mentor: Kemper

Herbs and Dietary Supplements
2004 2004 Kemper KJ Herbal Jeopardy WFUSM Alumni Weekend WFUSM Winston Salem, NC October 8, 2004 Kemper KJ Herbal Jeopardy Grand Rounds Moses Cone Hospital Greensboro, NC August 11, 2004 Kemper KJ Herbal Jeopardy Grand Rounds, Family Medicine, UNC January 29, 2005 Fletcher R Harvard Medical School, visiting professorEvidence-Based Medicine: In the mainstream but threatened by zealots Piedmont Plaza Epidemiology Seminar WFUSM Winston-Salem, NC March 17, 2005 Kemper KJ Herbal Jeopardy Grand Rounds, Pediatrics, UNC May 6,
2005

2005 2005

2005

31 August 1, 2005

Mind Body
2004 2004 2004 2004 Isley-Landreth Impact of Stress/Relaxation Responses on the Body/Mind/Spirit Mind/Body Medicine Seminar, CPE Residents, WFUBMC January 26, 2004 Isley-Landreth Guided Meditation in the Management of Pain Mind/Body Medicine Seminar, CPE Residents, WFUBMC February 10, 2004 Isley-Landreth Making Lap Labyrinths/Tools for Balance Brain Tumor Support Group, Cancer Services Winston Salem, NC April 13, 2004 Isley-Landreth Guided Meditation in the Management of Pain Adolescent Sickle Cell Support Group, WFUBMC June 8, 2004 Erica Kelly Poster Music and HRV In Pediatric Oncology Patients UNC Conference on Integrated Medicine March 18-19, 2005 Erica Kelly Poster Music and HRV in Pediatric Oncology Patients WFUSM Student Poster Presentation April, 2005

2005 2005

Spirituality
2004 Barnes L Spirituality, Religion and Pediatrics: Intersecting Worlds of Healing WFUSM Pediatric Grand Rounds September 29, 2004 Boston Medical
Center visiting professor

Other
2004 Barnes L Cultures, Clinics, and Qualitative Research: Notes from a Medical Anthropologist GCRC Noon Seminar September 29, 2004 Boston Medical Center Hess, et al Alternative Medicine, Five Keys to Wellness, Interdisciplinary Study 130, Team presentation lectures on complementary alternative medicine, energy medicine and essential oils Continuing Education Program, Northwest Area Health Education Center NWAHEC, Wake Forest University Health Sciences, Winston-Salem, NC

2004

32 August 1, 2005

Regional, National and International Presentations N42
Biofield therapies/Spirituality: Reiki, Healing Touch, Therapeutic Touch, Qigong, Prayer
2004 2004 Kemper Therapeutic Touch The Ecology of Healing, Global Medicine Education Foundation, Petaluma, CA March 14, 2004 Kemper Therapeutic Touch national invitational mentorship program Pumpkin Hollow Craryville, NY, July 16-23, 2004 Kemper KJ Therapeutic Touch Pediatric Academic Society Meeting Special interest
group in pain Washington, DC May 13, 2005 Kemper KJ, Larrimore D Cultivating Compassion: Tools from Therapeutic and Healing Touch Pediatric Academic Society Meeting Workshop Washington, DC May 16, 2005

2005 2005

Communication, Clinician-Patient Relationship, Cultural Competence
2004 Blue, AV, Crandall, SJ Creating and closing the loop on gender and cultural biases in health care for the medical school curriculum Southern Group on Educational Affairs of the Association of American Medical Colleges Regional Meeting, April 15-17, 2004, Savannah, Georgia Blue, AV, Crandall, SJ Enhancing cultural competency curricula through faculty development Southern Group on Educational Affairs of the Association of American Medical Colleges Regional Meeting, April 1517, 2004, Savannah, Georgia Crandall, SJ, Davis, S Empowering Empathy Through the Medical Humanities The Generalists in Medical Education Conference, Boston, MA, November 6-7, 2004 Crandall, SJ, Spangler, JG, Walker, K, Vaden, K, Marion,
GS Description of a Training Program to Prepare Tobacco-specific Standardized Patient Instructors Society of Teachers of Family Medicine Annual Spring Conference, New Orleans, LA, April 30-May 4, 2005 Koontz-Anthony, J Marion, GS, Crandall, SJ Using the Common Ground Communications Model to Provide More Culturally Competent Patient Care Southern Group on Educational Affairs of the Association of American Medical Colleges Regional Meeting, Winston Salem, North Carolina, April 7-10, 2005 Marion, GS, Palla, SL, Rigsbee, B, Crandall, SJ Learner Attitudes Toward the Patient-Provider Relationship: Fostering Provider Accountability to an Increasingly Diverse Demography American 33 August 1, 2005

2004

2004

2005

2005

2005

Educational Research Association Conference, Montréal, Québec, Canada, April 11-15, 2005

Epidemiology/Health Services
2005 2005 Arcury TA CAM Use in North Carolina Vegetarian Society of Forsyth County March 1, 2005 Dunn EC, Yu KJ, Danhauer SC, McQuellon RP Miller BE
Characteristics of complementary and alternative medicine users in the outpatient gynecologic oncology clinic 2005 Annual Meeting on Womens Cancer March 2005 Rosen L, Garnecho A, Patrick PA CAM use by families of children with Autistic Spectrum Disorder SPR/APA May, 2005

2005

Herbs and Dietary Supplements
2004 Blair RM, Cline JM, Wood CE, Adams MR Dietary Phytoestrogens: Beneficial and Adverse Effects on the Reproductive System 13th Annual Meeting of the Triangle Consortium for Reproductive Biology Environmental Protection Agency, Research Triangle Park, February 7, 2004 Clarkson TB - Soy Equol? as Co-Postmenopausal Hormone Therapy The American College of Obstetricians and Gynecologists 52nd Annual Meeting Philadelphia, PA May 1-2, 2004 Clarkson TB Soy and Tibolone A Nearly Ideal Postmenopausal Therapy? Fourth Annual Purdue-UAB Botanicals Center Symposium Botanicals and Age-Related Disease Birmingham, AL February 26, 2004 Edwards I Differential effects of delivery of n-3 fatty
acids to human breast cancer cells by low density lipoproteins versus albumin International Research Conference on Food, Nutrition and Cancer of the American Instute for Cancer Research, Washington DC July 15, 2004 Kemper KJ Herbal Jeopardy Super CME 2004, Orlando FL April 30, 2004 Vitolins M- Can soy isoflavones replace traditional hormone replacement therapy? Annual meeting of the Tennessee Dietetic Association 2004 Clarkson TB Soy as Complementary HT 2nd Annual OB/GYN Research Symposium at Meharry Medical College Kemper KJ Herbal Jeopardy UNC Conference on Integrative Medicine, Chapel Hill, NC March, 2005 Kemper KJ Herbal Jeopardy Advances in Pediatrics 16th Annual Las Vegas Postgraduate Pediatric Meeting Las Vegas NV April 15, 2005 Kemper KJ Herbal Jeopardy Symposia Medicus, St Thomas, VI May 20, 2005 34 August 1, 2005

2004

2004

2004

2004 2004

2005 2005 2005 2005

2005

Torti S Potential role for iron chelation in the chemopreventative activity of curcumin Annual Meeting for
the Society for Free Radicals in Biology and Medicine 2005

Mind Body
2004 Danhauer SC Mind-body approaches in cancer care Spring Oncology Symposium, Gibbs Regional Cancer Center, Spartanburg Regional Health System, Spartanburg, SC April 2004 Kemper KJ Complementary and Alternative Medicine - The Yin and the Yang of Healing Work AAP Super CME Orlando FL April 30, 2004 Shively C Social stress and disease susceptibility in nonhuman primates Conference on Allostatic Load and the Response to Traumatic Injury National Institute of General Medical Sciences Bethesda, MD March 2003 Shively C Social inequalities in health: a comparative perspective Texas Program for Society and Health Houston, TX January 13, 2004 Dailey M, McCarty A Experiential Training in Mindfulness Based Stress Reduction to OR Nurses February 23, 2005 Danhauer SC, Rutherford CA, Ashbury DY, Marier B, McQuellon RP, Lovato JF, Miller BE Music or guided imagery for women undergoing colposcopy: Effects on anxiety pain levels
5th Annual UNC Integrative Medicine Conference, Chapel Hill, NC March, 2005

2004 2004

2004

2005 2005

Other
2004 Kemper KJ Complementary and Alternative Therapies for Chronic Pulmonary Conditions in Children 6th International Congress on Pediatric Pulmonology Lisbon, Portugal March 2, 2004 Kemper KJ - Complementary and Alternative Medicine AAP Super CME, Orlando, FL May 1, 2004 Kemper KJ Holistic Pediatric Health Care: Caring for the Whole Child Kahn Family Foundation International Conference on Pediatrics Kennebunkport, ME September 18, 2004 Kemper KJ Pediatric Integrative Medicine Summit Pediatric Integrative Medicine Summit St Paul, MN October 8, 2004 Kemper KJ Kemper-Visiting Professor Childrens Memorial Hospital Chicago, IL November 12, 2004 Kemper KJ Whats the Buzz?: Talking with Patients about Complementary Therapies Advances in Pediatrics 16th Annual Las Vegas Postgraduate Pediatric Meeting Las Vegas NV April 15, 2005 Kemper KJ Non Pharmacologic Approaches to Treating
Chronic Pain Advances in Pediatrics 16th Annual Las Vegas Postgraduate Pediatric Meeting Las Vegas NV April 16, 2005 Kemper KJ Asthma Adjuncts for Easier Breathing Non-Pharmacologic 35 August 1, 2005

2004 2004

2004 2004

2005

2005

2005

2005

2005 2005

2005

Approaches to Therapy Advances in Pediatrics 16th Annual Las Vegas Postgraduate Pediatric Meeting Las Vegas NV April 17, 2005 Kemper KJ Holistic and Integrative Medicine A General Pediatric Perspective Symposia Medicus Conference, St Thomas, VI May 19, 2005 Kemper KJ ADHD: Diagnosis and Treatment Symposia Medicus, St Thomas, VI May 19, 2005 Kemper KJ Asthma Adjuncts for Easier Breathing Non-Pharmacologic Approaches to Therapy Symposia Medicus St Thomas, VI May 21, 2005 Williams J Integration of Complementary and Alternative Medicine into Clinical Practice: Evidence-Based Medicine John Hopkins June 8, 2005

36 August 1, 2005

Clinical N12 Biofield therapies/Spirituality: Acupuncture, Healing Touch, Qigong, Prayer
2004 2004
2004 Larrimore D Healing Touch class offered by NWAHEC October 28-29, 2004 Seeber S, Graham A Dao Yin Yoga Best Health 1/14/05 Graham ATai Chi Sickle Cell Adolescent Support Group, Winston Salem, NC July 6, 2004 Larrimore D Healing Touch - Tenderly Touching Your Tuesdays Brenner Childrens Hospital Oncology Section Monthly sessions Larrimore D Gatherings of Grace Free Healing Touch Clinic held monthly

2005 2005

Herbs and Dietary Supplements
2005 Fletcher R Vitamins Supplements Best Health, WFUSM March 16, 2005

Mind Body
2004 2005 2005 2005 Massage Therapy interest group Pediatrics established in September, 2004 Feldman J Functional Restoration Program - Hypnosis/Guided Imagery WFUBMC Melcher S, Boyce D, Dean C, Godfrey M, Howell D Massage Therapy WFUSM Fitness Center Arts for Life non-profit Art and Music Therapy provided to children at Brenners Childrens Hospital - 70 hours a week Value estimated at 70,000 Arts for Life non-profit Art and Music Therapy provided to adult patients at
the Comprehensive Cancer Center Child Life Program Pet therapy provided at Brenner Childrens Hospital

2005 2005

37 August 1, 2005

Community Outreach N18 Biofield therapies/Spirituality: Acupuncture, Reiki, Healing Touch, Prayer
2004 2004 Hess S - Reiki as a Complementary Therapy Best Health 55 lecture series, Kernersville YMCA, Kernersville, NC , May 12, 2004 Larrimore D Healing Touch for Health Professionals Northwest AHEC Winston-Salem, NC October 22-23, 2004 Graham A, Seeber S Best Health Program QiGong and Prayer on February 24, 2005

2005

Herbs and Dietary Supplements
2004 2004 2004 2004 2004 2004 Kemper K Herbal Remedies BestHealth, Winston Salem, NC March 19, 2004 Kemper K Supplementing Youth BestHealth, Winston Salem, NC September 22, 2004 Vitolins M - Soy, the joy of it BestHealth Winston-Salem, NC 2004 Vitolins M - What should you eat? First Church of the Nazarene WinstonSalem, NC, 2004 Vitolins M - Healthy eating and good table manners Best Health Kids,
Winston-Salem, NC 2004 Vitolins M - Alternative treatments to hormone replacement therapy Womens Health conference, Forsyth County Health Department, Winston-Salem, NC 2004 Fletcher R Multivitamins BestHealth March 16, 2005 Harvard Medical School, Booke visiting professor for Dietary Supplements

2005

Mind Body
2005 2005 2005 Melcher, S Medicine of Massage Best Health April 1, 2005 Isley-Landreth B Guided Meditation Workshop Your Yoga April 3, 2005 Dailey M Teacher Development Intensive in Mindfulness Based Stress Reduction, Worcester, MA Center for Mindfulness in Medicine, Health Care and Society April 6-14, 2005

Other
2004 2004 Hess S - Bridging the Gap Between Conventional and Complementary Medicine, Shepherd Center, Winston-Salem, NC, April 1, 2004 Hess S - Bridging the Gap Between Conventional and Complementary Medicine, Connecting the Rhythms: A networking event for the CAM and Medical Communities, Invited Speaker, NWAHEC, Winston-Salem, 38 August 1, 2005

2004 2004 2004

NC,
March 29, 2004 Hess S - Complementary and Alternative Medicine and Cancer, Cancer Services, Winston-Salem, NC, February 17, 2004 Kemper K Complementary and Alternative, Holistic and Integrative Medicine at WFUSM Rotary Club, Winston Salem, NC March 9, 2004 Smith TA Homeopathy; Douglas D Brendle Integrative Medicine Seminar Series WFUSM March 10, 2004

39 August 1, 2005

National Advisory Boards
2001 2004 2001 - present 2002 - present 2003 - present 2003 - present 2003 present 2004 - present 2005 present 2005 present Kemper KJ- American Academy of Pediatrics, Task Force on CAM Kemper KJ - Scientific Advisory Council, Massachusetts College of Pharmacy and Allied Health Sciences, Boston, Massachusetts Kemper KJ- Ambulatory Pediatric Association Guidelines on Residency Core Curriculum Kemper KJ - American Medical Student Association, CAM Education Panel Kemper KJ- J Miller Integrative Medicine Initiative, Northwestern University Kemper KJ - Many Streams Healing Systems, non-profit
corporation, Rome, Georgia Kemper KJ - Complementary and Alternative Research and Education, Alberta, Canada Kemper KJ - Advisory Board for Aspen Center for Integrative Health Kemper KJ Chair Provisional Section for Complementary, Holistic and Integrative Medicine American Academy of Pediatrics

Editorial Boards
2002 present 2003 present 2003 present 2004 present 2005 - present Kemper - Ambulatory Pediatrics Kemper - Alternative Medicine Alert Newsletter Hess Journal of Cancer Integrative Medicine Kemper - Explore: Journal of Science and Healing Kemper - Journal of Cancer Integrative Medicine

Honors
2004 2005 Kemper K -YWCA Woman of Vision Award Kemper K Finalist, Bravewell Leadership Award in Integrative Medicine

40 August 1, 2005

Source:cancer.gov

Volume 3, No 1, Fall 1997

FromtheDirector The Business of Bioethics Ought to Be A Bit More-Business
Arthur Caplan, PhD I finish my talk on ethics and the challenge of cost containment in the auditorium of the small liberal arts college A number of people come forward to ask me questions while the rest of the audience files out I quickly scan the ten or so people who want to chat further and notice there is an older man, probably in his early sixties, hanging back in the small circle of people who have hung around I work my way through the questions and people begin to trickle away The man does not ask anything, he just listens to the exchanges between me and the others After everyone else has gone I turn to him and ask what is on his mind He glances down at the floor then up at me and says you know, having listened to
your talk and these questions I am a bit embarrassed to tell you that I work for the managed care industry But, I do And when you talk about the ethics of managed care and cost containment you and a lot of people in this audience do not give us a fair shake Does bioethics give managed care a fair shake? For that matter, does bioethics give the business of health care a fair shake? One way to respond to these questions, a way that I find tempting in these sorts of situations, is with indignation Politeness often mandates a silent form of indignation, but indignation it is As the executive from managed care began to plead his case I thought to myself: Of course, bioethics does not give business a fair shake Those in the business of health can look after themselves quite nicely They hardly need the commiseration of ethicists
continued on page 5

Alternative Medicine and Corporate Medicine
Paul Root Wolpe, PhD Medical services today seem paradoxically to be going in two opposing directions
On one hand, we are dazzled by new sophisticated biotechnologies: viral genetic delivery vectors, synthesized pharmaceuticals, new internal imaging techniques On the other hand, interest in low-tech alternative therapies is exploding, and managed care companies, elite medical centers, and practitioners are scrambling to meet demand While ethicists have been paying a lot of attention to the issues of high-tech medicine, few have noted or addressed the social and ethical paradoxes inherent in the turn to low-tech alternatives Who would have predicted that the very medical centers and hospitals that vilified alternative medicine as quackery for most of the century would suddenly be opening clinics, hiring practitioners, and advertising alternative, traditional, and spiritually-based therapies to their patients? Over thirty-five medical schools now include courses in alternative or complementary or integrative medicine in their curriculum NIH is funding research through its new Office of
Alternative Medicine Community hospitals and academic medical centers are opening new services such as the Division of Complementary Medicine University of Maryland, The Center for Integrative Medicine Thomas Jefferson University Hospital and The Center for Alternative Medicine and Longevity Columbias Miami Heart Institute Advocates of alternative medicine have long argued that many modalities are effective, have few side effects, can be scientifically validated, and involve a closer practitioner-patient relationship Yet the change of heart in establishment medicine has not been due to new scientific findings, a new appreciation of traditional healers, or a spiritual awakening on the part of hospital administrators The watershed moment was unquestionably the publication, in January of 1993, of a landmark article in The New England Journal of Medicine by Harvards David Eisenberg and five colleagues Eisenberg et al found that over a third of the 1,539 adults they surveyed had used
alternative therapies in the past year, averaging 19 visits per person The article calculated that the nation spends about 10 billion per year out-of-pocket for alternative medical care, only three billion less than out-of pocket-expenses for all hospitalizations in the United States Ten billion dollars was the kind of persuasion that medical centers understood For years, institutionally-based physicians had practiced or referred patients to alternative modalities in secret, fearing ridicule or even ostracism from colleagues Now, suddenly, hospitals started polling their staff to see what modalities they were qualified to offer Administrators and physician executives began calling meetings to discuss how to best provide alternative medical services to their patients And clinics, departments, and consultation services in alternative medicine began to appear What are we to make of this latest trend? Clearly there is benefit in opening up the medical armamentarium to low-tech, effective
therapies Certainly there is relief that the hubris that dismissed traditional therapies out of hand seems to have diminished In a time of monetary cutback for care, what could be more attractive than therapies that are preventive in philosophical outlook, can often be practiced by allied medical personnel in outpatient settings, and that have the added benefit of being high in patient satisfaction?
continued on page 4

1

Lock Out Back Door Eugenics
David Magnus, PhD Among the greatest sources of anxiety with respect to the new genetics is the worry that we are witnessing the birth of a new eugenics movement The eugenics movement often masked race and class prejudice in a pseudo-scientific guise and became an excuse to engage in many different kinds of discriminatory practices Should eugenics be a major concern for us as we head into the 21st century? In India and parts of China, the killing of unwanted female infants has been augmented by the abortion of unwanted female fetuses
thanks to the development of amniocentesis The result is unbalanced sex ratios significantly more males than females This is an illustration of what is often called back-door eugenics Unlike some of the earlier eugenics programs which ultimately involved the state through sterilization laws, immigration restrictions, tax incentives, etc the new eugenics is a result of the collective effect of individual choices Will back-door eugenics take place in this country? Are there potential dangers which will result? As Philip Kitcher has argued, back-door eugenics is to some extent inevitable and unproblematic One of the benefits of genetic testing is the potential for parents to make more informed decisions Those who are at risk for some of the most serious genetic disorders previously had a choice between having no children or risking the creation of a horribly diseased child Genetic testing allows parents to abort fetuses and reduce the incidence of many of the worst diseases imaginable
While providing parents with the power to avoid bearing children with these terrible diseases seems a blessing, there are difficult questions which arise At what point do we draw the line between those in India who abort unwanted female fetuses, and parents who perhaps aided by a genetic counselor choose to abort a fetus destined to die an early painful death? Some patients with Huntingtons feel that the several healthy decades of life that they have is what really matters Other genetic traits many cause lesser health problems and risks Will testing eventually stigmatize all those who are unhealthy or abnormal in any way? Will parents choose to test for other socially important traits, such as being thin, or tall? Will they test for homosexuality along with a propensity to develop heart disease? In response to these worries, two very different attitudes have developed While accepting that some degree of eugenics is inevitable, one group argues that ultimately, we must leave
reproductive decision-making in the hands of parents If the ability to test for a trait is available and affordable, the medical community must allow parents access to the test And once a woman has the information, it is ultimately her decision whether to abort or continue with a pregnancy On this view, any other option would violate the fundamental rights of any patient Principles of autonomy which underlie much of medical ethics strongly support this position So, too, does a mistrust of the state — allowing governmental interference in issues as personal and private as reproductive decision-making is seen as the first step towards the old eugenics This view is opposed by those who are unwilling to allow the market place to operate unchecked They worry that obsessive concern for individual rights and patient autonomy and a mistrust of the government may leave us without adequate state regulation The potential negative consequences of an unregulated market are seen by many as a far
more likely source of danger This group claims that concern for individual rights may lead us to pay insufficient attention to communal and social welfare In this debate, broader philosophical and political issues may be at stake as much as scientific issues The trade-off between individual rights and the social good, and the relative roles of the market and government regulation are as central to these debates as the difference between dominant and recessive characters Whatever solutions are advocated for each of the problems discussed so far, there is one point of universal agreement An educated public is a necessary prerequisite for addressing the serious ethical and social decisions we are facing Those who argue that we ought to trust parents with reproductive decision-making rely on
continued on page 4
Publications Services/XXXXX/1097/6M/RCMM

FA C U LT Y S TA F F
DI RECTO R S TAFF

Arthur Caplan, PhD
FACU LT Y

Janet Abrahm, MD Robert Aronowitz, MD David Asch, MD, MBA Charles
Bosk, PhD Mildred Cho, PhD Bernard Kaplan, MD Jason Karlawish, MD Sara Kinsman, MD Paul Lanken, MD Donald Light, PhD David Magnus, PhD Mimi Mahon, MSN, PhD Glenn McGee, PhD Jon Merz, JD, PhD, MBA Sally Nunn, RN Pamela Sankar, PhD Lois Snyder, JD Peter Ubel, MD Paul Root Wolpe, PhD
VI SI T I NG FACU LT Y

Janice Clinkscales Nicole DeNigro Jeff Goodman Garth Green Megan Hallam Porsha Simmons Ellen Wise
RES E ARCH S TAFF

Monica Arruda Jacqueline Hart Jennifer Klocinski David Weeks
W EB S TAFF

Jamie Blank Jocelyn Garavoy Myrna Kuo Larry Miller Yehuda Potok Brett Wilson Alexia Wolf
H OW TO REAC H U S

Robert Baker, PhD
F ELLOW S

James McCartney, PhD
ADM I NI ST RAT I VE DI RECTO R

phone: 215-898-7136 fax: 215-573-3036 http://wwwmedupennedu/ bioethics

Antoniéta Rouse

Correspondence and Items of Interest should be addressed to: Glenn McGee, Editor, Center for Bioethics Newsletter, 3401 Market Street, Suite 320, Philadelphia, PA 19104-3308
The Center for Bioethics Newsletter is produced
by the Center for Bioethics of the University of Pennsylvania for the dissemination of information and as a reference for its constituents The Editorial Staff has sole authority over and responsibility for the content of the Newsletter All inquiries or complaints concerning content should be directed to the Editors at the address above We welcome comments, letters, contributions, and general input The Center for Bioethics Newsletter is published quarterly free of charge and is distributed nationally to the Centers subscription and mailing lists If you are interested in being added to the subscription list, please contact Porsha Simmons at simmonsp@mailmedupennedu or fax 215573-3036 No part of the Newsletter may be reproduced in any form, in whole or in part, without the express written consent of the Managing Editor and Editor Editor: Glenn McGee, PhD / Managing Editor: Ellen G Wise

2

FromtheEditor Subject to Payment? Cash and Informed Consent
Glenn McGee, PhD
Fifty years after the
worlds conversation at Nuremberg about medical research abuses, Jean, a 20-year-old college senior, sits in the office of the clinical director of her universitys egg donation program He tells her about hyperovulation drugs and a short, outpatient procedure with a few risks She daydreams about how strange it is to be talking with this man, and about how to handle the 12,000 on her Visa bill Her mom and dad would faint if they knew about it He is nice, she thinks He looks professional and sounds honest He asks more questions about her dreams and plans than have any of her professors As Jean sips a cappuccino and reads through the consent form, she decides to take the money offered, and enroll as an egg donor in a small infertility protocol Shell still have 8,000 worth of credit card debt, but she thinks a year of part-time work and conscientious time management can mipe that out Thirty years after Henry Beechers article exposing abuses in US clinical research, the youngest of the
psychiatry team are meeting to discuss recruiting issues These 35-year-old clinicians are also assistant professors who will soon stand or fall on their ability to produce discoveries in psychoactive drugs They are talking about a controlled study of a new antidepressant A week later the back page of the local newspaper carries a 6-inch advertisement for their study: Depressed? Research treatment is available at no cost Qualified persons will receive 3 months of research therapy with a psychiatrist and may also receive an experimental drug designed to treat depression At the close of the study, you will receive free referral to an outside clinic if you so desire Meanwhile Carl is halfheartedly watching Donahue as he thumbs through the paper and sees the ad He is miserable and has been for the 2 years since the death of his wife But he has no money and his managed care plan does not provide for outpatient psychiatric treatment He makes the call Many of us who work in health care have
paused to remember the atrocities detailed at Nuremberg and to celebrate its affirmation of human rights But one part of Nuremberg seems more distant with every passing year Ironically, it is articulated in the primary principle of the Nuremberg Code, informed consent: the person involved should be situated to exercise free power of choice, without the intervention of any ulterior form of constraint or coercion With todays emphasis on the rights of individuals rather than the social context of choices, we have tended to see the prohibition of coercion as a simple reminder not to strong-arm potential participants But the point of the Nuremberg Code, enunciated again in the Belmont Commission report, was much more fundamental: Researchers should take great care to make sure that prospective participants enroll in experiments on the basis of their evaluation of the study, not because of large cash enticements or other rewards they are ill-suited to refuse An article in the Wall Street
Journal detailed the extensive recruiting of homeless and indigent persons into clinical research by a large US pharmaceutical firm Homeless, alcoholic enrollees described their attempts to conceal both their own medical histories and the deleterious effects of studied drugs in order to secure gainful employment as a research subject At issue is the meaning of freely given informed consent How free is our 20year-old? How free the depressed widower? The conventional wisdom in research holds that paying participants with cash or free treatments is no problem at all as long as participants understand the risks and benefits of enrolling in a particular study Concerns about payment to participants can seem patronizing or an affront to the rights of the individual Why shouldnt a person be paid handsomely for participating in a risky trial? But the conventional wisdom is wrong Every choice about participation in research is situated in a context and some contexts limit the freedom of
participants If children and mentally incompetent persons cannot be correctly informed, neither can those who are poor be correctly informed in the presence of
continued on page 5

NewFaculty
Mimi Mahon Mimi Mahon is a pediatric nurse practitioner who has practiced in the areas of pediatric neurosurgery/neurology, intensive care, and trauma She received her BSN from Loyola University Chicago, and her MSN, PhD, and nurse practitioner certification from the University of Pennsylvania Dr Mahons program of research includes factors that affect childhood bereavement She has studied factors that affect childrens understanding of death, including violent death, sibling death, and cultural influences Mimi will serve as Center Faculty and liason to the prestigious Penn School of Nursing is an Associate Professor of Medicine in the Hematology/Oncology Division She attended medical school at the University of California at San Francisco, did residency training at the Massachusetts General
Hospital, and returned in 1977 to Penn to complete her fellowship training She joined the faculty in 1980 Her clinical work has been done at the Philadelphia VAMC, where she served first as Section Chief of Hematology/Oncology 1984-1994 and then Chief of the Medical Service 1994- 1997 Her area of interest is pain management and palliative care, especially in patients with cancer Dr Abrahm, a member of the University of Pennsylvania Cancer Center faculty, has recently been selected as a Soros Faculty Scholar, sponsored by the Project on Death in America Her project will be to improve palliative care as well as the care of the dying and the bereaved throughout the University of Pennsylvania Health System Dr Abrahm will also serve as center faculty

Dr Janet Abrahm

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Alternative Medicine continued from page 1
The competition to offer alternative modalities in hospitals is not without its dangers, however Alternative practitioners are often undertrained, unlicensed, and may be unskilled
in recognizing illness signs that call for a referral to other kinds of care Alternative modalities are so hot right now that they are being accepted uncritically Hundreds of therapies can be grouped under the unfortunate name alternative, yet they can be as different from each other as they are from orthodox medicine What is the common ground among chelation therapy, a sophisticated chemical infusion technique that was first developed after World War II for heavy metal toxicity and is now touted as a circulatory enhancer; acupuncture, a 5,000 year old Chinese healing modality based on energy meridians; and chiropractic, a spinal manipulation technique invented in the 1880s by a magnetic healer in Iowa? Only that orthodox American medicine has, until recently, rejected all three Community-based hospitals seem to be competing to offer consumers as many alternative modalities as possible While most university-based centers will only hire alternative practitioners who can be certified or
licensed, the brochure for the Center for Alternative Medicine and Longevity at Miami Heart Institute lists at least 26 modalities, from applied kinesiology to bio-oxidative therapies to QiGong to iridology The indiscriminate rush to offer anything alternative seems driven by the assumption that the bigger the menu, the larger the potential market share While many alternative therapies — though not all — can cause little active harm, American medicine has traditionally had a role in quality control, a promise to offer only those therapies that are both effective and safe Many alternative therapies clearly fit the bill Indiscriminate laundry lists of modalities do not The great irony of the assimilation of alternative services into medical institutions is that the rise of alternative medicine over the last few decades was due as much to its cultural symbolism as to its healing potential In a time of stuffy, closeminded medical thinking, going alternative was symbolic of the rejection
of establishment medicine, a countercultural display akin to bra-burning or pink trianglewearing Acupuncture loses its countercultural symbolism when it is taught at Harvard medical school Alternative medicine is becoming corporate, becoming just another valueadded service to market to consumers Alternative practitioners will soon become just another set of allied medical personnel under the direction of a primary care doctor, and will lose much of what made their care so desirable in the first place As it has so many times before, establishment medicine is inviting a rejected group to nestle under its protective wings Alternative practitioners who rush medical centers may do well to study the fate of homeopaths, midwives, bone setters, osteopaths, and others who fell prey to the promises of establishment medicine, only to disappear within its clutches

Lock Out

continued from page 2

those parents being well-informed: the market is more likely to lead to bad consequences if those
making decisions do not have enough information to weigh risks and benefits Similarly, those who urge more regulation of the new genetics require a well-educated and informed public to insure sufficient vigilance and critical scrutiny, lest we slide into the problems of the eugenics of the past Whatever views one holds about the particular solutions to some of the other problems caused by genetic technology insurance discrimination, reductionism, allocation of resources they will all require a well-informed public This is necessary to properly understand the way genes and environment interact; the probable limits and potential benefits of genetic technology; and to develop an adequate health care policy

we must leave reproductive decisionmaking in the hands of the parents
This analysis has three implications First, we need to do a better job of integrating bioethics into science education at every level from primary through medical school Second, bioethicists must continue to be
publicly visible and to utilize mass media to communicate with the public Journalists and bioethicists should work together to produce a more informed citizenry Third, given the level of knowledge the public actually possesses, we need to create institutions which can help avoid the troubling consequences of leaving our ethical decision-making in the hands of the market Intermediate institutions such as professional organizations offer potential precisely because they are made up of individuals more likely to be well informed, yet without the dangers state intervention represents However, for these institutions to act in a regulatory capacity, it is important that they be willing to act: the AMA for example must be more willing to censure its members for unethical behavior The new genetics will require that bioethicists play a prominent role in each of these activities

Center Faculty Receive Major Grants
Pamela Sankar and Jon Merz were awarded a grant by the Charles E Culpeper
Foundation for a 2 year observational and survey study of patient privacy and the confidentiality of the medical record Mildred Cho, Pamela Sankar, Paul Wolpe, Lynn Godmilow of the Department of Genetics, and Jesse Berlin of the Department of Biostatistics and Epidemiology have been awarded a grant from the Ethical, Legal, and Social Implications program of the National Human Genome Research Institute for a three year study to examine factors associated with use of BRCA1/2 genetic testing for hereditary breast and ovarian cancer The study will examine the role of both patients and their health care providers in decisionmaking about genetic testing and medical treatments or preventive measures for cancer Jon Merz, Pamela Sankar, Emma Meagher of the Department of Medicine, and Tim Rebbeck of the Center for Clinical Epidemiology and Biostatistics have been awarded a grant from the Ethical, Legal, and Social Implications program of the National Human Genome Research Institute for a three
year study to develop and improve methods of securing informed consent for the banking of DNA for research

4

From the Director

continued from page 1

And anyway ethicists who worry about the business aspects of health care are at best misguided and at worst apologists for power This is a moderately interesting, rhetorical soliloquy I must say even as I reflect back on it now But is it at all valid? Isnt it true that one of the main responsibilities of those who do bioethics is to challenge the stances of the powerful and the well-off in order to make sure that the interests of the vulnerable and the disadvantaged are protected? Bioethicists need to be fair but the way to be fair to the captains, colonels and generals of the trillion dollar health care industry is to tweak their consciences rather than curry their favor It is of course precisely sentiments like these that lead some to diagnose bioethics as suffering from a bad case of 1960s counter-culturism Bioethics relationship
with the world of business grows even icier when so much of what is wrong about American health care looks like it is a function of aggressive business practices being imported into health care When

the American Medical Association signs an endorsement contract with the Sunbeam Corporation or a giant health care chain like Columbia-HCA attains unprecedented profits following predatory acquisition and billing

removed from the businesses that created them may make this fact hard to see but it is nonetheless a fact Bioethical skepticism is further fueled by the fact that the health care industry is both distrustful and secretive when it comes to letting bioethicists learn something about business If you pull your favorite bioethics anthology off the shelf you will quickly see that business is not excoriated in the writings of bioethicists–it is just ignored There are never any case studies of business decisions–good or bad Well, I am as willing as any maybe more willing than most to
whine about the sins of money and power in medicine But I think the man from managed care is right Bioethics does not give business a fair shake Not because it is wrong to be critical or challenging but because it is wrong to be ignorant of the forces, traditions, people and instutitions that so fundamentally shape American health care and naive to think that bioethics is not shaped and supported by that business

Bioethics does not give business a fair shake
practices, bioethicists are quick to arrive on the scene of the moral crime, fingers cocked and ready to point, tongues poised to fulminate near any open microphone The problem with my reaction to my critic and with an unremittingly hostile stance toward the business of health care is that it is simply too naive Business has always been a part of health care Centers housed in academic medical centers or receiving funds from foundations two or three generations

From the Editor

continued from page 3

an offer they literally cannot
refuse The key to informed consent is proportional reward, the acceptable relationship, to be determined by investigators and institutional review boards, of reward-torisk and reward-to-participant context Investigators do have a responsibility to offer treatment for any anticipated adverse effects and bad outcomes to participants But risks should not be involved in calculating compensation Large cash awards, whose real motive is to recruit participants that otherwise might be unwilling to enroll, cannot be justified as front-loading to offset qualitatively significant but statistically rare risks, such as the risk of future infertility for the 20year-old egg donor The participant must feel that risk has been compensated only by conscientious study design, consistent monitoring of participants and treatment of adverse effects or unanticipated exigencies resulting from enrollment A proportional reward will thus consider only the amount of time and effort required Where participants are
being offered large rewards, extra care should be taken by the institutional review board to ascertain that the risk itself is not being compensated

While it is certainly appropriate to include office evaluations by a psychiatrist in the process of studying a potential psychoactive drug, it is irresponsible to package those visits as therapy unless the researchers are willing to take on the responsibilities of clinicians with their subjects, including the obligation not to simply abandon the patient after the study Researcher administration of intake interviews or questionnaires designed to test efficacy, the bulk of what is being offered to our depression participant, carry an allure that is reminiscent of the spinal taps offered as treatment to black men in Macon County, Alabama during the Tuskegee study If researchers offer therapy to participants, it needs to be therapy per se And even then, because the depressed person is in no position to refuse free therapy as an inducement to
enroll, the value of that therapy should not exceed in value the calculations proposed below A benchmark for proportional reward calculations is the mean hourly salary of those in the demographic pool of potential participants multiplied by the anticipated actual research contribution time If the pool of potential participants

is citizens of Dallas, those citizens average hourly wage may be calculated and a figure derived from the time required for the study multiplied by that wage This formula should be included in the consent form and explained at time of enrollment We must not forget the legacy of the Nuremberg Code: informed consent means consent without coercion Proportional reward recruiting policies can help ensure that freedom Adapted with permission from A Piece of My Mind, in Journal of the American Medical Association, July 16,1997, Vol 278, No 3

Roe vs Wade After 25 Years
The University of Pennsylvania Center for Bioethics and the Boston University School of Public
Health, Health Law Department are sponsoring a conference, The 25th Anniversary of Roe v Wade, on January 23-24, 1998 on the campus of Boston University, Boston, Massachusetts For further information please contact George Annas at annasgj@buedu or fax 617-638-5299

5

Talks Publications
David Asch recently published the following articles: Euthanasia among US critical care nurses: practices, attitudes, and social and professional correlates with Dekay in Medical Care, 35:890-900; What predicts gastroenterologists and surgeons diagnosis and management of common bile duct stones? with Shea, Johnson, Staroscik, et al in Gastrointestinal Endoscopy, 46:40-7; Are supplementary services provided during methadone maintenance really cost-effective? with Kraft, Rothbard, Hadley, McLellan in Am J Psychiatry, 154:1214-19; Prenatal screening for Toxoplasmosis with Bader and Macones in Obstet Gynecol, 90:457-64; The Philadelphia PRIME program: A model for primary care education with Bellini in Med
Educ Online, 2:2; and Costs, true costs, and whose costs in economic analysis in medicine? with Macones in Am J Managed Care, 3:915-7 published Crisis, Ethics and the American Medical Association: 1847 and 1997 with Arthur Caplan, Linda Emanuel, and Stephen Latham in the Journal of the American Medical Association, 278, pp 163-164 and Un modelo teórico le ética transcultural: postmodernismo, relativismo y el Código de Nuremberg, in Perspectivas Bioéticas en las Américas, :12-37 His book reviews of Advisory Committee on Human Radiation Experiments, The Human Radiation Experiments and Hans-Georg Gadamer, The enigma of health: the art of healing in a scientific age, recently appeared in Medical History, v 41 Dr Bakers recent talks include History of the Goals of Medicine The Goals of Medicine: Priorities for the Future, co-sponsored by the Hastings Center and Istituto Italiano per gle Studi Filosofici in Naples, Italy this past June and Revolutionizing the Researcher-Patient Relationship:
A Historical Analysis, at the XI Annual Conference of the European Society for Philosophy, Medicine and Healthcare Collegio Antonianium in Padova, Italy in August Together with Laurence McCullough of the Center for Medical Ethics and Health Policy of the Baylor College of Medicine, he has been commissioned by Cambridge University Press to co-edit the first English-language history of medical ethics It is a five-year project, that will involve over fifty authors; the anticipated publication date is 2002 new book Due Consideration: Controversy in the Age of Medical Miracles, published by John Wiley and Sons, Inc has just been released His upcoming speaking engagements include: Har Zion Temple in Gladwyn, PA on November 23 for information, contact Rabbi Gerald Wolpe at 610-667-5000, the Kaner Lecture at the Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire on November 24 contact Dr Richard Dow at 603-650-7400, Changing Conceptions: How Science and Law are Shaping Future
Generations at the Kent College of Law, Illinois Institute of Technology in Chicago on December 5 contact Lori Andrews at 312-9065000, the ethics talk on Informed Consent? at McGill University in Montreal on December 16 contact Gerald Baptist, Grand Rounds at the Dana Farber Cancer Institute in Boston on January 12 contact Zeke Emanuel at 215-898-7136, and the University of Puget Sound in Tacoma, Washington on February 18 for information, call 206-756-3205 will be speaking on March 13 at the AMA Conference on Genetic Medicine and the Practicing Physician, in New Orleans and on March 16 at the Bowman Gray School of Medicine Seminar on academic-industry relations and conflicts of interest in medical research has published Community equipoise and the architecture of clinical research with Lantos in Cambridge Quarterly of Healthcare Ethics, 6:385-96 and Permissible risk and acceptable benefit: The ethics of research involving the cognitively impaired in FORUM: Trends in Experimental and
Clinical Medicine, 7: 39-49 He recently presented Nursing home research: The positive effect of instructions for authors on the quality of reported research ethics at the Third International Congress on Biomedical Peer Review and Global Communications in Prague, Czech Republic in September and Are waivers and modifications of informed consent in research guided by adequate regulations? Or, informed consent: How do I waive thee? Let me count the ways with Curt Naser and Jon Merz at the 1997 Joint Meeting of the American Association of Bioethics, the Society for Bioethics Consultations, and the Sociey for Health and Human Values Annual Meeting in Baltimore on November 5-9, 1997 His upcoming talks include Legal and ethical decisions: Protecting your client for the Alzheimers Disease Seminar Series, jointly sponsored by the University of Pennsylvania Boettner Center of Financial Gerontology and Institute on Aging, the Bryn Mawr Trust Company, and The Alzheimers Association on January 22,
1998 was Co-Chairman of the American Thoracic Society Bioethics Task Force responsible for the position paper Fair Allocation of Intensive Care Unit Resources published in the American Journal of Respiratory Critical Care Medicine in October The paper was also officially endorsed by the American Association of Critical Care Nurses, the American College of Physicians, and the Society of Critical Care Medicine

Robert Baker

Art Caplans

Mildred Cho

Jason Karlawish

Paul Lanken

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Donald Light

gave the inaugural lecture on The real ethics of rationing at the Institute of Medicine, Law and Bioethics at the University of Manchester, England Part of it was published in the BMJ 1997; 315:112-115 He gave talks in London, Manchester, and Swansea Wales in July Two more articles on organizational arrangements that lead to more rationing at the bedside will soon appear in the Health Service Journal London He is working with Art Caplan on the ethics of managed care has co-organized a series
of sessions on normative issues in genetics for the International Society for the History, Philosophy, and Social Studies of Biology meeting in Seattle, Washington July 17-20; presented a paper, The Concept of Genetic Disease, at the same meeting; has become treasurer and chief operating officer for the Society; will be presenting a paper on The Implications of our Conceptions of Genetic Disease at the American Association of Bioethics meeting in Baltimore, Nov 6; will be a panelist for a session organized by Glenn McGee on genetics and public health at the American Public Health Association meeting in Indianapolis, November 10; will be presenting a paper on Genetic Programs–implications for society at the SLOAN sponsored workshop, Knowability of Scientific Entities: Genes and Genetic Programs, Dec 6, Oxnard, California; has agreed to write a book review for ISIS; and his Evolution without Change in Gene Frequencies will appear shortly in Biology and Philosophy gave Grand Rounds at
Methodist Hospital and Germantown Hospital on ethical issues in managed care and at DuPont Childrens Hospital on Prozac and Pediatrics, and joined Penn President Judith Rodin for a discussion of Ethics and Genetics in London in September He gave the Waxman DNA Lecture at Iowa State in October Upcoming talks include grand rounds October 15 at Wilmington Hospital, a lecture to Zeneca Pharmaceutical staff on ethics and genetics in Berkeley October 27, a public talk at both CDC and Emory University October 29th, lectures at UNESCO Bioethics Summit in Kobe, Japan November 4-6, a session on genetics and public health at APHA in Indianapolis October 10, and a debate with LeRoy Hood at the University of Montana November 15th He published A Crossroads in Ethics and Genetic Counseling with Monica Arruda in Cambridge Quarterly, and Moral Issues in Oocyte and Embryo Donation with A Caplan and J Anchor in M Sauer, ed, Egg and Oocyte Donation 1997: Springer gave a talk entitled: Stupid Patents:
Disease Gene Patenting is a Bad Innovation at Carnegie Mellon University on September 25 A related commentary coauthored with Mildred Cho, Madeline Robertson, and Debra Leonard criticizing the patenting of genetic diagnosis of specific genetic mutations will appear in the December issue of Molecular Diagnosis He also gave a lecture on bioethics at the Philadelphia College of Textiles and Science on September 22, and presented a paper on genetic technology in clinical and research medicine in a regional conference organized by CMU Student Pugwash entitled Technologies of Peace on September 26-28 presented talks on Is Cost-Effectiveness a Morally Acceptable Way to Set Health Care Priorities? at Duke University and St Vincents Medical Center of Richmond in Staten Island, NY Should Physicians Ever Ration Whatever That Means at Duke University and at Presbyterian University Hospital in Philadelphia His recent publications include Rationing By Any Other Name with Asch in NEJM, 336: 1668 -
1671 and Kidney Transplant Candidates Views of the Transplant Allocation System with Louis and Sankar in JGIM, 12:478-484 His article with Arnold and Caplan on Rationing Failure: Ethical Lessons of Retransplantation was selected as a chapter in Pences Classic Works in Medical Ethics: Core Philosphical Readings, McGraw-Hill Dr Ubel will receive the 1997 Award for Outstanding Paper by a Young Investigator from the Society for Medical Decision Making at its Annual Meeting in Houston later this year

David Magnus

Glenn McGee

Jon Merz

Peter Ubel

Paul Root Wolpe has recently had articles appear on genetic essentialism in The Kennedy Institute for Ethics Journal, on umbilical cord blood ethics in the Journal of the American Medical Association, and on new emergency room informed consent rules in the Forum for Applied Research and Public Policy He has spoken on genetics at Drexel university and Temple university, and has lectured at Penn medical school on socialization into the medical
profession and social and cultural views of death and dying Coming up soon are two sessions at the American Association of Bioethics conference in November on genetics and on social science and bioethics, and a talk to the American Medical Students Association He was a co-Principle Investigator of the NIH grant on genetic testing awarded to the Center, along with Principle Investigator Mildred Cho and co-PI Pamela Sankar

7

Calendar1997/98
December 7, 1997 TUSKEGEE: Can Past Lessons Guide Research in the Future? The Annual Meeting of Applied Research Ethics National Association ARENA To be held at The Sheraton Hotel, Boston, MA Topics to be addressed include: The impending challenges for IRBs; the Tuskegee legacy; IRB liability issues; Regulatory updates from the FDA and OPRR For more information, contact: ARENA, 132 Boylston Street, Boston, MA 02116 Phone: 617-4234112; Fax: 617-423-1185 E-mail: PRMR@AOLCOM http://wwwaamcorg/research/primr December 8, 1997 Ethical Research in an
Ethical SocietyAnnual meeting of Public Responsibility in Medicine and Research PRIMR To be held in conjunction with the above posted conference at The Sheraton Hotel, Boston, MA For more information, contact: ARENA, 132 Boylston Street, Boston, MA 02116 Phone: 617-4234112; Fax: 617-423-1185 E-mail: PRMR@AOLCOM http://wwwaamcorg/research/primr December 16, 1997 Biomedical Ethics: A Symposium to Honour the Memory of Dr Benjamin Freedman, sponsored by McGill University Centre for Translational Research in Cancer, McGill Biomedical Ethics Unit, and the Jewish General Hospital Research Ethics Office This event will be held in the Block Amphitheatre, Sir Mortimer B Davis-Jewish General Hospital of McGill University in Montreal For further information contact: Dr Gerald Batist at tel: 514-3407915, fax: 514-340-7916 or e-mail: GBatist@oncJGHMcGillCA January 23-24, 1998 The 25th Anniversary of Roe v Wade, co-sponsored by the Center for Bioethics at the University of Pennsylvania and Boston
University will be held on the campus of Boston University For further information, contact George Annas at annasgj@buedu or fax 617-638-5299 February 26-28, 1998 Seventh Annual Meeting of the Association for Practical and Professional EthicsTo be held in Dallas, Texas Highlights will include a keynote address, Ethical Systems and Public Policy: The National Bioethics Advisory Commission Experience, by Harold Shapiro, President of Princeton University The Fourth Intercollegiate Ethics Bowl will again be held in conjunction with the Annual Meeting on Thursday, as will the Ethics Center Colloquium For more information on the program, contact the Association at 410 North Park Avenue, Bloomington, IN 47405; phone 812-855-6450; Fax: 812-855-3315; e-mail: appe@indianaedu; http://phpucsindianaedu/appe/homehtml March 13-14, 1998 20th Anniversary Conference sponsored by the Department of Medical Humanities, East Carolina University To be held in conjunction with the spring meeting of the
Society for Health and Human Values To be held in Greenville, NC The conference will be divided into two sections: March 13th: Decisions at the End of Life Presentations by Dan Brock, Arthur L Caplan, Laurie Zoloth-Dorfman, H Tristram Engelhardt, Jr, Steven Miles and Stuart Youngner March 14th: David Hume and Bioethics Presentations by Tom Beauchamp, Larry Churchill, Ray Frey, Loretta M Kopelman and Larry McCullough For more information, contact: Program Committee, Department of Medical Humanities, East Carolina University School of Medicine, Brody 2S-17, Greenville, NC 27858 May 3 and 4, 1998 A conference on the state of Jewish Bioethics at the turn of the millennium will bring together international scholars in Philadelphia sponsored by Allegheny University of Health Sciences, The Center for Bioethics at the University of Pennsylvania, The Finkelstein Institute of the Jewish Theological Seminary, The Jewish Museum, and the Israel 50 Committee For information, contact Paul Root Wolpe
at 215-898-7136 or D Walter Cohen at 215-8427008 May 21 and 22, 1998 Families on the Frontier of Dying A conference at the Ritz Carlton Hotel in Philadelphia For information, contact Sally Nunn at sjnunn@aolcom or at Shore Memorial Hospital, 1 East New York Ave, Somers Point, NJ 08244-2387 These listings are from our calendar and the International Calendar of Bioethics Events from the Division for Medical Humanities at the University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School For more details see their website at http://www2umdnjedu/ethicweb/upcomehtm

In thisIssue
Art Caplan on Bioethics and Business Glenn McGee on Payment for Research Participants David Magnus on Genetics and Education Paul Root Wolpe on Alternative Medicine

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University of Pennsylvania 3401 Market Street, Suite 320 Philadelphia, PA 19104-3308

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Alternative Medicine New Way to Lose Weight By Nishanth Reddy

Weight loss is one of the big topics-no pun intended-on the late night television circuit While flipping through the channels after 11pm, you are likely to come across several advertisements for weight loss pills and diet supplements, each promising to assist you drop those unwanted pounds and remove stubborn belly fat once and for all Lets face it, if these pills really worked, America wouldnt be the top overweight country in the world There are types of alternative medicine, which can help with weight loss, however, and with great results While no alternative medicine is a magic solution, practicing these principles can help you become more limber, feel more energetic, and the end result-or side effect if you will,
is weight loss Take yoga for example The low impact stretching involved with yoga will help you feel less stressed, and as a result less likely to over eat as a result of depression or anger Acupuncture has exact pressure points in the ear which help reduce cravings, and detoxifying teas and herbs can help you feel healthier, and the side effect would be thinking twice before deciding that you want to pollute yourself again with oily and fatty foods In this regard, alternative medicine is wonderful for loosing weight The majority alternative medicines for weight loss come in the form of detoxifying teas, energy supplements, and vitamins The exercise and diet plans are the basis, as they should be, for safe and effective long-term weight loss There is no magic potion to lose weight In fact dropping pounds and keeping them off requires regular daily exercise and a change in eating habits, period However, to get you ready for weight loss, here are some alternative medicine detoxifying
teas and interesting supplements Take turmeric, ginger, and lemon-about a half teaspoon each and the juice of half a lemon, and boil it all in 2 cups of water Drink every morning as a detoxifier before you start your diet All diets should consist of fresh fruits and vegetables, and buying a juicer is a great way to make a habit out of eating healthy Please see your doctor before starting any kind of diet plan Visit your local food co op or herbalist, they can get you set up with all sorts of alternative teas and nutrition advice, and can refer you to a good homeopathic doctor who will evaluate you as to what your individual nutrition needs are Bovine and shark cartilage are two dietary supplements to hit the alternative market Both have been used for years outside of the United States and Britain, but now are big business in the health food

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stores The most popular form of alternative medicine for weight loss isnt really medicine at all, rather behavior modification through hypnosis Hypnosis doesnt make you rely on will power, thats one of the reasons its so popular How hypnosis works is that it examines what is subconsciously holding you to the thinking and eating habits that keep you overweight Hypnotists believe that if the root cause of the obesity can be alleviated, the patient will naturally begin to lose weight It is actually a very efficient form of alternative medicine, and overall can cost much less than trips to day spas and expensive over the counter weight loss pills Through hypnosis you can let go of fears that keep you from eating healthy, and begin to allow a positive energy flow through you, causing you to want to stick to the new way of eating and exercising Nishanth Reddy is an author and publisher of many health related websites For more information on how to lose
weight, Fitness and Wellness visit: http://wwwfitness-wellness-guidecom

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How Should Alternative Medicine Be Defined By Thomas DeReyna

There is still no strict definition on what alternative medicine really is But presently, it borders on the broadness of description covered by what we know of as conventional or orthodox medicine However, to define alternative medicine as we believe it to be, it may be a knowledge that is considered as unaccepted, untested and unscientific All these were true if we are to look some years back But since alternative medicine has been studied in the later years, employed by numberless institutions such as spas and the likes and accepted by many as cure to their ailments even those that may be resolved through conventional medicine, this definition for
alternative medicine may already be considered as obsolete On other terms, alternative medicines are practices that may be considered false that sometime go to the extent of quackery However, this definition is much abused by several authorities that have their own systems of beliefs and other things to support to Still others would define it as practices that may not be tested, refuse to undergo tests and may continuously fail tests On other peoples view, this may be too unfair for those practicing the knowledge that comprise alternative medicine and too sweeping a statement since many have gained healing by means of alternative medicine This debate on the authenticity of alternative medicine is further made complicated by the number of practices that are labeled as alternative medicine, which has some truths in them In actuality, alternative medicine covers procedures involving metaphysical principles, spiritual and religious underpinnings, new sets of healing approaches and
non-European medicine practices These are enough reasons why alternative medicine is much harder to accept in the West rather than in the East where most these practices originated In addition to these, many proponents of alternative medicine contradict and many individual belief systems may reject others Furthermore, critics of alternative medicine may further define it as therapy, treatment and diagnosis that may be performed legally by unlicensed practitioners Yet, a number of doctors and physicians find good uses of alternative medicine when combined with the conventional medicine when they are trying to hit the balance But there are more logical and unbiased definitions that are accepted by most Many of which deal only on the safety and affectivity of the alternative medicine without the protection on economic interests, political views and turf protection One such definition is that alternative medicine is a field of healing, therapy and diagnosis that are not based on controlled
studies There are however some therapies that were once covered by alternative medicine that are now accepted within the medical community since they passed approval over their affectivity On the opposite, there were medical practices that are now disregarded within the medical circles since there are no profound evidences that prove their efficiency in healing In reality, the term alternative medicine is quite misleading Both critics and advocates of the said practices support this view Some support the idea that Western medical practices are the alternative medicines since they were preceded by ancient practices, which is somewhat true Others would claim that the term alternative medicine was only devised by advocates of conventional medicine to discredit the natural methods of healing

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Detractors on alternative
medicine claim that it is not worth as being accepted by the medical circles since it lacks components that may be used to support its efficiency Yet many assert that once alternative medicine is fully tested, then there would be great rooms for wide acceptance Thomas DeReyna is a freelance publisher based in Cupertino, California He publishes articles and reports in various ezines and provides a news blog http://wwwhunkyexplorerinfo

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Source:bioethics.upenn.edu

You dont have to be injected, picked at, poked, or peeled to bring a bloom to your cheeks, a lift to your chin, or a smooth line to your jaw While spas and doctors offices offer myriad procedures to beautify skin, few qualify as natural and fewer still as gentle Botox and fillers read botulinum toxin and chemicals can result in bruising, inflammation, discomfort, and some recovery time When did skincare become a contact sport? Instead of quick fixes that plump and numb, consider noninvasive, soothing treatments that use sound, light, or electrical current to stimulate the skin so it can heal and renew itself These more holistic approaches address the underlying causes of dull, slack skin, such as internal imbalances or the cumulative effect of
passing years They work gently and naturally to restore healthy, vibrant skin tone and texture TUNING IN FOR A TUNE-UP The face, according to Chinese medicine, reflects both the bodys overall health and ones equanimity of spirit A beautiful face is clear, allowing the spirit to shine through,

Facial Soundscapes offers the benefits of acupuncture without needles

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine Actions 31 CAM wellness and prevention activities should be included in Federal worksite wellness and health promotion programs and Federal health coverage plans 32 Federal agencies, in conjunction with the business community, should develop
incentives for employers to include CAM wellness and prevention activities in their workplace wellness programs and health coverage, and to decrease insurance premiums for those that participate in them Recommendation 4: Public, private, and Federal health care delivery systems and health-related programs should incorporate safe and effective CAM practices into their services to help promote wellness and health Actions 41 The Secretaries of the Department of Health and Human Services and the Department of Agriculture, and the Commissioner of the Administration for Children and Families, should establish task forces to develop strategies for incorporating CAM wellness and health promotion activities and professionals into Federal health programs such as Head Start, Meals on Wheels, The Special Supplemental Nutrition Program for Women, Infants and Children, the Healthy Mothers/Healthy Babies Program, and the State Childrens Health Insurance Program 42 Federal health care delivery systems
in the Department of Defense, Department of Veterans Affairs, Indian Health Service, and community and migrant health centers should establish task forces to develop strategies that will incorporate CAM wellness and health promotion activities and professionals in their services 43 Funding should be provided for demonstration projects to evaluate the impact of CAM practices in wellness, health promotion, chronic illness, and end-of-life programs offered by the Department of Veterans Affairs and Department of Defense 44 The Secretary of Health and Human Services should establish a task force to develop strategies for incorporating CAM wellness and health promotion activities in the nations hospitals and long-term care facilities and in programs serving the aging, the dying, and those with chronic illness 45 CAM and conventional health professional training programs should include the teaching of self-care and lifestyle decision making to improve practitioners health and to enable
practitioners to impart this knowledge to their patients or clients Coordination of Research Recommendations Recommendation 1: Federal agencies should receive increased funding for clinical, basic, and health services CAM research Actions 11 All Federal agencies with research or related health care missions should increase their research and related activities with respect to CAM and make them known to CAM professionals Activities should include funding initiatives such as requests for applications and proposals; CAM-focused offices or centers; CAM-focused staff

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine positions; CAM planning and advisory committees or the representation of qualified CAM professionals on such groups 12 Congress should provide adequate public funding for research on frequently used of promising CAM products that would be unlikely to receive a patent and therefore unlikely to attract private research support
Recommendation 2: Congress and the Administration should enact legislative and administrative reforms to provide greater incentives to stimulate private sector investment in CAM research on products that may not be patentable Actions 21 Incentives to stimulate private sector investment in CAM research should focus on 1 research on dietary supplements and other natural products that may not be patentable; 2 research on other CAM products that may not be patentable, including therapeutic devices; and 3 the development of analytical methods for producing better quality CAM products 22 The Federal and private sectors should provide support for workshops to discuss the research needed by regulatory agencies for their review and approval processes for CAM products and devices 23 Federal agencies should develop outreach programs to inform manufacturers of CAM products and devices about the Federal research support available to private industry and how the agency can assist them 24
Manufacturers of CAM products and devices should become acquainted with potential sources of research funding and the requirements they must meet to access such resources successfully Recommendation 3: Federal, private, and nonprofit sectors should support research on CAM practices that build on lifestyle and self care, and on therapeutic approaches that integrate CAM and conventional medicine Actions 31 The Federal government should stimulate private investment in research on CAM modalities and approaches that are designed to improve self care and wellness behaviors Recommendation 4: Federal, private, and nonprofit sectors should support new and innovative CAM research on CAM practices and products, and on core questions posed by frontier areas of scientific study associated with CAM that might expand our understanding of health and disease Actions 41 The Federal, private, and nonprofit sectors should support more research on 1 complex compounds/mixtures frequently found in CAM
products, 2 clinical interventions consisting of multiple treatments, 3 patient-practitioner interactions, and 4 individualizing treatments

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine 42 NCCAM, assisted by the National Science Foundation, the Institute of Medicine, the World Health Organization, or other Federal or non-Federal body, should conduct a review on core research questions associated with CAM that are outside the current research paradigm 43 The National Institute of General Medical Sciences of the NIH, the Department of Energy, the Department of Defense, and the National Science Foundation are among the Federal organizations that should consider contributing collaboratively or independently to the support of research on core questions in areas described in many CAM systems 44 Multidisciplinary workshops and expert panels should be convened by Federal, private and nonprofit organizations, collaboratively or independently,
to explore the challenges in design and methodology presented by research questions in CAM areas that are outside the current research paradigm Recommendation5: It should be duly noted that human subjects participating in CAM related clinical trials are entitled to the same protections as required in conventional medical research Actions 51 Licensed practitioners using CAM systems and modalities who wish to conduct or collaborate in clinical research should follow the same requirements as in conventional medical research They should develop, or partner with a research institution to develop, a scientifically valid research protocol and obtain IRB approval to ensure that they meet accepted standards of ethical conduct and their responsibilities to protect human subjects 52 Accredited CAM institutions and CAM professional organizations should establish IRBs where possible, ad guide their colleagues and members to utilize the IRB process, which is required to conduct clinical research 53
IRBs that review CAM research studies should include the expertise of qualified CAM professionals in the review 54 Research institutions, NIH Institutes and Centers, and other Federal research and health care agencies should be more proactive in developing programs that 1 provide opportunities for expert review of promising CAM practice-based observational data by experienced researchers, 2 stimulate practitioner response to the opportunities offered by the programs and 3 facilitate communication and stimulate partnerships between CAM practitioners and conventionally-trained researchers in designing and implementing clinical studies Recommendation 6: State professional regulatory bodies should include language in their guidelines stating that licensed or other authorized practitioners will not be sanctioned solely because they are engaged in CAM research if they are 1 engaged in research that is approved by an appropriately constituted IRB, 2 are following the requirements for the
protection of human subjects, and 3 are meeting the same licensing or other authorizing standards of practice to which all similarly licensed or authorized practitioners are held

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine Recommendation 7: To facilitate CAM integration into the health care system, increased efforts should be made to strengthen the emerging dialogue among CAM and conventional medical practitioners, researchers and accredited research institutions; Federal and state research, health care, and regulatory agencies; the private and nonprofit sectors; and the general public Actions 71 CAM and conventional medical researchers and practitioners should adhere to the same high standards of quality and ethics in all aspect of research and related activities 72 Federal agencies should develop programs to stimulate cooperation and partnerships between CAM and conventional medical professionals and accredited institutions 73
Committees reviewing or advising on research, journal submissions, regulatory compliance, and health insurance coverage in both the public and private sectors should include as members or consultants trained, experienced, and properly qualified CAM health care professionals 74 Multidisciplinary conferences, workshops, and expert panels on CAM research and related activities, including research methodology, should be supported independently or collaboratively by the public, private, and nonprofit sectors 75 The nonprofit sector and the private sector should create funding partnerships, whether independently or with Federal agencies, to augment support for CAM research, research infrastructure and training, research conferences, and information dissemination 76 The Federal government should support research, including population-based research, to learn more about why people use CAM practices and products How they determine the safety and effectiveness of the practices and products they
use, and what they find satisfying or unsatisfying about them 77 To benefit patients and future research protocol development and to add to our knowledge about the use of CAM, IRBs should consider requiring that all research subjects be asked about their use of herbal or other dietary supplements, and hospitals should consider requiring that all inpatients and outpatients be asked about their supplement use 78 Federal agencies supporting biomedical and health services research should develop orientation and training programs for public representatives to enhance the effectiveness of their participation on advisory committees concerned with CAM Recommendation 8: Public and private resources should be increased to strengthen the CAM research and research training infrastructure at conventional medical and CAM institutions and to expand the cadre of basic, clinical, and health services researchers who are knowledgeable about CAM and have received rigorous research training Actions 81 The
leadership at accredited CAM and conventional medical institutions should develop programs that examine CAM research questions and that stimulate cross-

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine institutional collaborations involving faculty and students in research and research training The leadership at accredited CAM and conventional medical institutions should support joint research and professional education and training programs to enhance the quality and clinical relevance of CAM research and link the research with evidence-based education and training of practitioners Federal health agencies with research training programs and responsibilities that encompass CAM-related questions should be given adequate support to increase research training in CAM Existing resources, such as NCCAM-supported centers and the National Center for Research Resources General Clinical Research Centers should be utilized to increase opportunities
to conduct clinical research and training on CAM and examine the integration of CAM into the clinical setting Federal support should be increased for career development awards, including those that enable investigators focusing on CAM to develop into independent investigators and faculty members, and mid-career awards that provide the time required to mentor new CAM investigators

82

83 84

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Recommendation 9: Public and private resources should be used to support, conduct, and update systematic reviews of the peer-reviewed research literature on the safety and efficacy of CAM practices and products Actions 91 The Agency for Health Care Research and quality should expand its Evidence-based Practice Center systematic reviews on CAM systems and treatments for use by private and public entities in developing tools, such as practice guidelines, performance measures, and review criteria, and for identifying future research needs 92 NCCAM should issue a comprehensive and regularly updated
summary of current clinical evidence on the safety and efficacy of CAM systems and treatments for Health care practitioners and the public Education and Training Recommendation 1: The education and training of CAM and conventional practitioners should be improved to ensure public safety, and to increase the availability of qualified CAM practitioners and knowledgeable conventional practitioners Actions 11 Conventional health professional schools, postgraduate training programs, and continuing education programs should develop core curricula of knowledge about CAM in conjunction with CAM experts and CAM institutions so that conventional health professionals can discuss CAM with their patients and clients and guide them in the appropriate use of CAM

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine 12 All CAM education and training programs should develop curricula that reflect the fundamental elements of biomedical science and conventional
practice in order to ensure safe and beneficial care of patients 13 All CAM and conventional education and training programs should develop curricula and other methods to facilitate communication and foster collaboration between CAM and conventional students, practitioners, researchers, educators, institutions and organizations 14 Increased Federal, state, and private sector support should be made available to expand CAM faculty, curricula, and program development at accredited CAM and conventional institutions 15 The eligibility of CAM students for existing loan and scholarship programs should be expanded 16 The Department of Health and Human Service should conduct demonstration projects to determine the feasibility of CAM students participating in the National Health Service Corps scholarship program 17 The Department of Health and Human Services and other Federal Departments and Agencies should convene conferences of the leaders of CAM, conventional health, public health, evolving
health professions, and the public; of educational institutions; and of appropriate organizations to facilitate establishment of CAM education and training Subsequently, the guidelines should be made available to the states and professions for their consideration 18 Demonstration projects of residencies and postgraduate training for appropriately educated and trained CAM practitioners should be conducted to determine the feasibility of such programs and their impact on clinical competency, quality of health care, and collaboration with conventional providers 19 All practitioners who provide CAM services and products should consider completing appropriate CAM continuing education programs to enhance and protect the publics health and safety

CAM Information Development and Dissemination
Recommendation 1: The availability of reliable, useful, and easily accessible information for the public on CAM practices and products should be enhanced Actions 11 The Secretary of Health and Human
Services should establish a task force to enhance the development and dissemination of CAM information within the Federal government and to eliminate existing gaps in CAM information The task force should include consumers, CAM providers, scientists, and conventional health care practitioners Resources should subsequently be provided to close identified gaps and improve the availability, coordination, and dissemination of information 12 All Federal Departments and Agencies with missions or activities relevant to CAM should 1 develop informational materials about CAM that are easy to understand and use; and 2 support and collaborate with national and local community leaders and CAM leaders and organizations to identify strategies for enhancing the

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine development, availability, and accessibility of information on the safety and effectiveness of CAM products 13 Increased funding should be
provided to the National Library of Medicine and the American Library Association to expand training of librarians to include helping consumers find information on CAM 14 The Secretary of Health and Human Services should direct resources to streamline the process of identifying and making available relevant, high-quality CAM information from other countries and in other languages Recommendation 2: The quality and accuracy of CAM information on the internet should be improved Actions 21 The Secretary of Health and Human Services should form a public-private partnership to review new and existing websites and to develop voluntary standards promoting accuracy, fairness, comprehensiveness, and timeliness of information on CAM websites, as well as the disclosure of sources of support and any conflicts of interest Sites reviewed and found in compliance with the standards could publicize the fact and display a logo denoting their merit 22 Funding should be provided to the Department of Health
and Human Services and the Department of Education to conduct a joint public education campaign that teaches consumers how to evaluate health care information, including CAM information, on the internet and elsewhere 23 Congress should protect consumers privacy by requiring all health information sites, including CAM sites, to disclose whether they track users and if so, how that information is used and stored, including whether it is sold to third parties Recommendation 3: Information on the training and education of providers of CAM services should be made easily available to the public Actions 31 States should require all persons providing CAM services to make information regarding their level and scope of training easily available to consumers 32 States should make information on state guidelines, requirements, licensure, certification, and disciplinary actions of health providers, including CAM providers, available and easily accessible to the public Recommendation 4: CAM products
that are available to US consumers should meet or exceed minimum standards of quality and consistency Actions 41 The efforts of both the public and private sectors to ensure the development, validation, and dissemination of analytical methods and reference materials for dietary supplements should be enhanced and accelerated 42 The proposal concerning Good Manufacturing practices for Dietary Supplements should be published expeditiously, followed by a timely review of comments and

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine completion of final rule The Food and Drug Administration should be provided with adequate resources to complete this complex task 43 Adequate funding should be provided to appropriate Federal agencies, including US Customs and Food and Drug Administration inspection authorities, to enforce current laws monitoring the quality of imported raw materials and finished products intended for use as dietary supplements
44 Manufacturers should make available scientific information to substantiate their determinations of safety, and current statutory provisions should be periodically reexamined to determine whether safety requirements for dietary supplements are adequate Recommendation 5: The public should have accurate information on the quality and safety of CAM products Actions 51 Congress and the Department of Health and Human Services should expeditiously solicit further public input on the labeling of dietary supplements, followed by proposed rulemaking, and/or appropriate oversight and legislative reform by Congress so that consumers have truthful, complete, and scientifically valid information on the benefits and appropriate uses of dietary supplements on the product label and at the point of sale 52 Congress should provide additional support to the Federal Trade Commission to 1 expand efforts to identify false and deceptive advertising of CAM- related health services and products and take
appropriate enforcement action when necessary; 2 use CAM experts in the process of examination of CAM-related advertising, 3 increase activities to help consumers distinguish useful and reliable information from deceptive and unsubstantiated advertising in all forms of marketing and advertising, including at the point of purchase; and 4 seek additional public comment on the benefits and potential problems in the advertising of CAM-related services and products 53 Current provisions requiring disclosure of material facts by manufacturers of CAM products should be enforced and manufacturers should meet their responsibility to disclose material facts so that the public will know about known risks and welldocumented significant interactions 54 An independent review board should be established to develop objective methods of evaluating and reviewing the safety of dietary supplements 55 The Food and Drug Administration and other agencies with regulatory responsibilities should be provided
with additional resources to 1 enforce current requirements regarding labeling of dietary supplements, 2 enforce current provisions requiring that dietary supplements be labeled in English, even if the same information is also included in another language, and 3 employ additional professionals with expertise in dietary supplements Recommendation 6: The collection and dissemination of information about adverse events stemming from the use of dietary supplements should be improved

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine Actions 61 Congress should require dietary supplement manufacturers and suppliers to register with the Food and Drug Administration and the agency should encourage voluntary registration until such a requirement is in effect so that manufacturers and suppliers can be promptly notified if a serious adverse event is identified 62 Recent congressional support for improving the Food and Drug Administrations adverse
events reporting system should be enhanced by requiring dietary supplement manufacturers and suppliers to maintain records and report serious adverse events to the agency 63 Additional resources and support should be provided to the Food and Drug Administration to 1 simplify the adverse event reporting system for dietary supplements to make it easier to use; 2 streamline the database for timely review and follow-up on received reports, and 3 increase outreach activities to consumers, health professionals including poison control centers, emergency room physicians, CAM practitioners, and mid-level marketers in order to improve both manufacturers and the publics awareness of and participation in voluntary event reporting Access to and Delivery of CAM Recommendation 1: Access to qualified and competent practitioners, and to safe, effective, affordable CAM services and beneficial CAM products should be improved for all Americans Recommendation 2: Practitioners who provide CAM services and
products should be regulated by states using a standard, understandable framework that ensures accountability to the public and that contains provisions for registration, licensure, and exemptions Actions 1 The Secretary of Health and Human Services should convene a national policy advisory committee to address issues related to the regulation of CAM practitioners, provide guidance to the states, and provide a forum for dialogue on other issues related to maximizing access 2 The Federal government, in collaboration with states, should assist CAM practitioners in developing consensus on the definition of their profession or practice and standards of practice, including educations and training Their conclusions should be considered by states and regulatory bodies in determining the appropriate status of these practitioners, including registration, licensure, or exemption 3 The Department of Health and Human Services advisory committee should work closely with state legislatures,
regulatory boards, and CAM practitioners to develop guidelines for the regulation and oversight of licensed and registered practitioners who utilize CAM services and products

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine 4 Nationally recognized accrediting bodies of health care organizations and facilities should establish ongoing access to CAM expertise to ensure that accreditation standards reflect emerging developments in CAM 5 Nationally recognized accrediting bodies of health care organizations and facilities should clarify how accreditation requirements apply to CAM and should promote appropriate collaboration with CAM practitioners in order to foster understanding and awareness of CAM 6 The Department of Health and Human Services and other appropriate Federal agencies should use health care workforce data; data from national surveys on CAM, and regional public health reports on CAM activities to identify current and future
health care needs that qualified CAM practitioners my help address 7 The Federal Government should convene conferences on effective approaches to the integration of safe and beneficial CAM practices and products into conventional medical setting and make this information available to practitioners and the public 8 The Secretary of Health and Human Services should identify common uses and practices of indigenous healing in the United States and recommend ways of improving collaboration between indigenous healing traditions and the current health care system This should be done in a manner that protects the cultural heritage of indigenous healing traditions, educates health care practitioners, includes members of indigenous groups, and maximizes access to qualified practitioners, safe and beneficial services, and effective products Coverage and Reimbursement Recommendation 1: Evidence should be developed and disseminated as to the costeffectiveness of CAM interventions as well as optimum
models for complementary and integrated care Actions 11 The Secretary of Health and Human Services should convene a joint public and private task force to identify and set priorities for studying health services issues related to CAM and to help purchasers and health plans make prudent decisions regarding coverage of and access to CAM 12 Federal agencies, states, and private organizations should increase funding for health services research, demonstrations, and evaluations related to CAM, including outcomes of CAM interventions, coverage and access, effective sequencing and integration with conventional therapies, effective models for service delivery, and the use of CAM in underserved, vulnerable, and special populations 13 Federal, state, and private entities should fund health services research on the costs and cost-effectiveness of CAM interventions and wellness programs 14 The Secretary of Health and Human Services should conduct a study to analyze nationally used coding
processes, CAM coding systems, and the issues associated with a single merged versus separate coding, systems, and make recommendations

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine Further, the Secretary should facilitate implementation of the studys recommendations 15 The National Center for Complementary and Alternative Medicine, through its clearinghouse, should provide information on health services research, demonstrations, and evaluations of CAM services and products 16 Health professional, service, insurance, managed care, and other industry associations and organizations should provide their members with information about CAM and incorporate CAM onto the agendas of their professional meetings 17 Public agencies and private organizations should support the development of informational programs on CAM targeted to health plan purchasers and sponsors, health insurers, managed care organizations, consumer groups, and others
involved in the provision of health care services 18 Congress should request periodic reports form appropriate Federal departments on the status of and impediments to coverage and reimbursement of CAM services and products for Federal beneficiaries, Federal employees, military personnel, veterans, and eligible family members and retirees Recommendation 2: Purchasers, insurers, and managed care organizations should extend health plan coverage to safe and effective CAM services and products provided by qualified practitioners Actions 21 Health insurance and managed care companies should modify their benefit design and coverage processes in order to offer purchasers products that include safe and effective CAM interventions 22 Employers, federal agencies, other purchasers and sponsors should enhance the processes they use to develop health benefits and give consideration to safe and effective CAM interventions 23 Public and private organizations should include CAM practitioners and
experts on advisory bodies, workgroups, and committees considering CAM benefits and other health care coverage 24 CAM practitioners, their associations and their institutions should identify opportunities and actively seek to participate on public and private advisory bodies, especially in areas of health services research on CAM and coverage of CAM interventions 25 DHHS, preferably the federal CAM coordinating office when established, should maintain a list of opportunities for CAM experts to participate on advisory committees and other workgroups 26 Congress and the Executive Branch should amend the federal tax code to include CAM in the favorable tax treatment of health benefits granted to employers 27 The Secretary of Health and Human Services should direct agencies under his authority to convene workgroups and conferences to assess the state-of-the-science of CAM services and products and to develop consensus and other guidance on their use 28 Health insurers, managed care
organizations, CAM professional associations, CAM experts, private organizations that develop medical criteria, and federal agencies

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Draft Final Recommendations White House Commission on Complementary and Alternative Medicine should support cooperative efforts to develop criteria and guidelines for the use of CAM services and products 29 State governments should address barriers to third party converge of safe and beneficial CAM interventions that stem from the practitioners need for legal authority to provide those interventions Coordinating Federal CAM Efforts Recommendation 1: The President, Secretary of Health and Human Services, or Congress should create and office to coordinate and facilitate integration of safe and effective complementary and alternative health care practices and products into the nations health care system Actions 11 The office should be established at the highest possible and most appropriate Federal level, with sufficient staff and budget to meet its
responsibilities 12 The office should charter and advisory council with members from both the private and public sectors to guide and advise the office about its activities 13 The offices responsibilities should include, but not be limited to, coordinating Federal CAM activities; serving as a Federal CAM policy liaison with conventional health care and CAM professionals, organizations, institutions, and commercial ventures; planning, facilitating, and convening conferences, workshops, and advisory groups; acting as a centralized Federal point of contact regarding CAM for the public, CAM practitioners, conventional health care providers, and the media; and facilitating implementation of the Commissions recommendations and actions

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Allied and alternative medicine is increasingly accepted worldwide Many health care professionals are interested and want to know more but are unsure where to look AMED is the answer AMED is an invaluable resource of Allied and Alternative Medicine covering a wide variety of topics in this growing field AMED covers relevant references to articles from around 512 journals, the majority of which are in English A large number of these titles are not indexed by any other biomedical sources In addition to the specialist journals on AMEDs subjects, a range of key general journals are checked for relevant articles As well as the basic bibliographic information, each record includes index terms using the AMED Thesaurus and an abstract summarizing the article being
cited AMED Allied and Complementary Medicine from Ovid offers a unique bonus - FREE full text via our exclusive Database Link Packages To view a list of free and open access journals as well as the range of authoritative Internet resources available, click here
n n

Over 510 journals, many not indexed by other biomedical sources Links to Journals@Ovid

Broad Subjects: Clinical Medicine Access Options: n Ovid Internet, updated Monthly n SilverPlatter Internet, updated Monthly n SilverPlatter Local, updated Monthly Other Information: n Coverage: 1985-Present n Data Type: Bibliographic with Abstracts n Records Added Annually: 12,000

Specific Subjects: Alternative Medicine

n n

Print Equivalent: Complimentary Medicine Index Number of Records: 152,000

MERCURY ELIMINATION WITH ORAL DMPS, DMSA, VITAMIN C, AND GLUTATHIONE: AN OBSERVATIONAL CLINICAL REVIEW Peter J Muran,
MD

Tissue mercury levels in humans have increased during the past 50 years to an alarming concentration, with possible deleterious effects that may involve neurological, cardiovascular, and immunological pathology This article reviews the protocol for the use of oral 2,3-dimercaptopropane-1-sulfonate DMPS and

oral meso-2, 3-dimercaptosuccinic acid DMSA in combination with intravenous glutathione and high-dose vitamin C for treatment of high-level mercury This protocol yielded an average 69 reduction of urine mercury by provocation analysis Altern Ther Health Med 2006;123:70-75

Peter J Muran, MD, practices medicine at the Longevity Healthcare Center in San Luis Obispo, Calif, focusing on conventional and alternative medicine

uring the past 50 years, tissue mercury levels have increased in humans1-3 The cause of this is environmentally multifactoral
and cumulative 4,5 The implications of chronic low-dose mercury exposure resulting in high tissue mercury levels appear to have a direct effect on cellular metabolism and development We see an increase in incidents of disease that is dependent upon the specificity of DNA to cellular, and eventually, organ system functions6 Some conditions that have been implicated by chronic high tissue mercury levels are central and peripheral neuropathy7-9 including autism10 and Alzheimers disease11, autoimmune disease,12 and cardiovascular disease13,14 An in vitro study demonstrated the degeneration of the neurite membrane with exposure to mercury vapor15 Another study demonstrated that the fetus could have 70 higher blood levels of mercury than the pregnant mother In the United States during the year 2000, more than 300,000 newborns who were exposed in utero to levels of methyl mercury higher than those allowable by US Environmental Protection Agency recommendations were at risk for adverse
neurodevelopmental effects16,17 Concerns about high tissue mercury levels as a contributing factor to various disease states have motivated clinicians to try to decrease these levels Various methods of mercury detoxification have been undertaken with varying results 18-21 This article describes a unique method of mercury binding and detoxification using oral DMSA and oral DMPS in conjunction with intravenous glutathione and high-dose vitamin C

D

A variety of patients are included in this review Some had current or past dental amalgams; some had been exposed to mercury-toxic regions; others regularly consumed fish The possibility of excess tissue mercury as a contributing factor in their disease process was explained The patients were then offered further testing for tissue mercury load via provocation METHODS The tissue mercury load was determined using DMPS provocation22 DMPS provocation is the most reliable method of determining tissue levels of mercury other than obtaining tissue
biopsies from multiple sites Also, DMPS provocation can be reliably duplicated Patients were instructed not to eat any fish or take any minerals or supplements for 2 days before the provocation Patients collected a urine sample by completely emptying their bladders in the morning before taking the DMPS Mercury levels subsequently analyzed in this sample were used as a baseline measurement Next, patients took the prescribed amount of DMPS and drank 1 to 15 liters of water The DMPS provocation is performed using oral DMPS 10 mg/kg up to a maximum of 500 mg as a one-time dose The next 6-hour cumulative urine was collected, mixed well, and sent to Doctors Data, Inc, St Charles, Ill, for analysis The urine sample underwent heavy metal urine screening using inductively couple plasma mass spectrometry ICPMS methodology According to Doctors Data, Toxic metals are reported as g/g of creatinine to account for urine dilution variations Reference ranges are representative of a healthy population
under non-challenged or non-provoked conditions23 Doctors Data results are reported in a graph format reflecting the expected range based on age and gender Specifically, adult females with elevated mercury values are between 41 and

70

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A Clinical Review of Mercury Elimination

12 g/g of creatinine, and very elevated are 12 g/g of creatinine, while adult males with elevated mercury values are between 31 and 9 g/g of creatinine, and very elevated are 9 g/g Patients in the very elevated mercury range, as reported in the DMPS provocation results, were candidates for this mercury elimination program Their participation was discretionary Additional laboratory analysis was performed at the beginning and end of the program to evaluate the patients CBC, basic chemistry, RBC protein and vitamin level, as well as renal and hepatic status Sensitivity to all medications was tested Patients were also screened for a possible sensitivity to
high-dose vitamin C via glucose-6-phosphate dehydrogenase deficiency G6PDH or hemochromatosis Our current mercury elimination program protocol is a modification of the Holmes and Cathcart protocol24-26 Our protocol consisted of 5, 2-week cycles or a cumulative 10-week program Table 1 A cycle begins with taking an oral dose of 133 mg of either DMPS or DMSA depending on the cycle 3 times a day for 3 days On the fourth day, an intravenous infusion of sodium ascorbate pH balanced to 70 mixed with vitamins and minerals vials A and B, respectively–see Table 2 in 500 mL of a sterile water solution was followed by a slow intravenous push of glutathione The schedule of DMPS and DMSA with the vitamin C and glutathione is shown in Table 1 During the remaining 10 days of the cycle, patients received an oral mineral and vitamin supplement following the oral chelator and intravenous fluids Again, patients were instructed not to have any fish or additional mineral supplements 2 days before the DMPS
or DMSA oral administration At the end of the first 2-week cycle, another 2week cycle began Upon completion of the full 10-week program and a 10day rest period, the patient underwent a repeat of the DMPS urine provocation
TABLE 1 Mercury Elimination Protocol Treatment Cycle Number–2 weeks per cycle 1 Chelator–first 3 days of each cycle DMPS 133 mg TID PO DMSA 133 mg TID PO IV infusion–fourth day of each cycle Ascorbate vitamin C Calcium gluconate dosage Vial A vitamin complex Vial B minerals Magnesium 2 3 4 5

TABLE 2 Contents of Intravenous Infusion Vial A: B Complex Pyridoxine Thiamin Riboflavin-5-phosphate Niacinamide Dexpanthenol Hydroxocobalamin Folic acid 100 mg 100 mg 5 mg 100 mg 1g 1000 g 5 mg Vial B: Minerals Magnesium Zinc Manganese Selenium Molybdenum 2g 10 mg 2 mg 200 g 250 g

RESULTS Our study group of 16 total patients was skewed based on concomitant ailments that were of a chronic nature with exposure to significant mercury from either a food source, environmental
toxins, or amalgams Twelve of the 16 patients 75 showed extremely elevated levels of mercury with DMPS provocation Of these 12 patients, 4 had amalgams removed before the provocation test Six of the 12 patients with extremely elevated mercury levels elected to participate in the mercury elimination program The mercury elimination program showed a significant reduction see percent change in mercury levels in 10 weeks Their pre- and post-elimination DMPS mercury provocation test results are shown in Table 3 DISCUSSION DMPS is an antidote for the treatment of acute and chronic toxic metal poisoning that has been used extensively in Europe for more than 50 years After oral administration, re-absorption of DMPS in the gastrointestinal tract, presumably by passive diffusion, occurs in 37 hours22,27 Approximately 50 of the orally administered DMPS is detected in the urine Neither DMPS nor its metabolites are detected 12 hours after administration Irrespective of the size of the administered
dose, the highest concentrations of DMPS are achieved in plasma and the kidneys High concentrations are also measured in the skin In the remaining organs, particularly the brain, only very slight amounts are found Chronic illness may arise when mercury displaces trace elements In many cases, the deficiency is asymptomatic Zinc displacement is likely to result in a specific deficiency syndrome Mercury masks the zinc deficiency by functioning as an inferior replacement to the zinc Once mercury elimination with the use of DMPS occurs, a zinc deficiency syndrome is revealed Longterm treatment with DMPS does not cause a zinc deficiency As measured in the plasma, more than half of the absorbed orally administered DMPS is excreted in the first 6 hours in the urine and feces The greatest DMPS concentration in urine is in the first 2 to 3 hours after oral administration Similar to the elimination of DMPS in plasma, the concentration quickly decreases in the organs The kidneys excrete
approximately 80 of DMPS, the remainder mostly by the hepato-biliary system No accumulation of the active substance is observed after repeated administrations

X

X

X X X

15 g 900 mg X X 4g

25 g 900 mg X X 4g

50 g 900 mg X X 4g

50 g 900 mg X X 4g

50 g 900 mg X X 4g

IVP slow–after IV infusion L-glutathione 750 mg 1500 mg 1500 mg 1500 mg 1500 mg
Preparation by ApothéCure, Inc, Dallas, Tex

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TABLE 2 Clinical Results Mercury Levels g/g creatinine Age Patient years WM RC CH MG NH SD MM MY MC 47 21 40 80 59 53 54 71 52 Chief complaint Before provocation After After treatment Percent change date provocation date 47 32 49 39 12 36 38 21 38 no treatment no treatment no treatment no treatment no treatment no treatment no treatment no treatment no treatment

Increase in flu and colds requiring taking off work; current otitis with tinnitus in right 17 1/25/04 ear; lethargy; SOB; eczema;
multiple fungal sites feet and mouth; food allergies IV drug abuse; depression; symptoms of ADD and psychotic behavior; neurotransmit- 13 5/12/03 ter deficiency; paranoia; food allergies Recurrent candidiasis; IBS; prostatitis; discomfort at hepatic fossa; dyspareunia; food allergies Recent decline in health and short-term memory; history of amalgams; patient is concerned about possible mercury accumulation Type 1 diabetes with onset at 55 years old; osteopenia chronic fatigue Recurrent headaches; recurrent allergies; weight retention; history of extensive dental work with prior amalgams, all removed 5 years before DMPS provocation 08 6/15/03 3 9/15/03 07 1/19/04 21 3/21/04

Recurrent candidiasis from mouth to anus; IBS; hypothyroid; chronic fatigue syndrome; 71 8/31/03 nervous and depression syndrome X; adrenal fatigue; amalgams throughout mouth Diabetes type 2; hepatic cavernous hemangioma; dental amalgams 17 9/15/03

Microadenoma other posterior aspect of the pituitary; fatigue;
osteopenia; insomnia; 05 9/17/03 weight retention; recurrent UTI; recurrent ovarian cyst; DVT after taking BCPs; fibroid cyst of the breast; IBS; chronic fatigue; menopausal Generalized fungal body rash started 14 yrs prior when treated with high dose of 51 8/26/03 prednisone for rash; current use of any cortisone increases rash; marked amount of amalgams with fractured molars with amalgams exposed; eczema; recurrent UTI; food allergies; asthma; IBS; recurrent vaginal candidiasis; perianal pruritus; parasites from living in Mexico city Vulvadysdinia; migraines; depression; recurrent vaginal candidiasis; IBS; gastrointestinal 1 5/26/03 dysbiosis with hemolytic E coli; developed a rash with DMSA treatment with prednisone and fluconazole with resolution; amalgams removed before mercury elimination program Alcoholic/depression; symptoms of neurotransmitter dysfunction; amalgams removed before mercury elimination program; developed a rash with DMSA treatment with prednisone and fluconazole
with resolution Marked amount of amalgams; squamous cell cancer developed on cheek adjacent to fractured molars with amalgams exposed, touching mucous membranes; BPH; thromboembolism with primary blood dyscrasia of protein S deficiency; treatment with coumadin resulting in ankle skin necrosis Amyotrophic lateral sclerosis with marked muscle atrophy at the thenar aspects of both hands and bilateral upper extremity weakness; 10 years prior was a resident of Minamata Bay, Japan; had amalgams 1 year prior to DMPS provocation 09 5/22/03

MR

57

81

no treatment

JN

27

14

81 10/20/03

42

CW

46

20

33 4/25/04

84

IY

74

47 8/24/03 09 7/6/03 42 9/25/03

45 27 33

86 4/11/04 91 10/8/03 96 12/20/03

81 66 71

GB

32

PH

59

Myocardial infarction at 40 years old, in father at 45 years old; multiple drug and food allergies; chronic upper UTI; unprotected amalgam removal; osteoporosis; pulmonary 16 9/29/03 mass?; SOB; cardiac palpitations with arrhythmia; ASHD; hypertension Multiple
mycardial infarctions with intermittent angina; ASHD with angioplasty x3 96,97,01; recurrent SOB: ASHD; menopausal: depression, neurotransmitter deficiency; lethargy; syndrome x; hypertension; amalgams replaced with crowns; history of living below dairy farm with water source a well

37

30 5/2/04

19

PB

67

ADDattention deficit disorder; ASHDatherosclerotic heart disease; BCPsbirth control pills; BPHbenign prostatic hypertrophy; DVTdeep venous thrombosis; IBSirritable bowel syndrome; SOBshortness of breath; UTIurinary tract infection Between before and after treament provocations

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The elimination half-life of DMPS in plasma and blood when given intravenously is 11 and 09 hours, respectively The elimination half-life of DMPS in plasma and blood when given orally is 99 and 91 hours, respectively The oral form is used in both acute and chronic poisoning, whereas intravenous IV
administration is used primarily in acute poisonings or when an oral treatment cannot be administered26 Animal experiments have shown that DMPS does not increase the metal level in the brain DMPS is excreted rapidly via the kidneys after IV administration 50 of the total dose is excreted in 1 hour, and 90 is excreted in 24 hours DMPS is also excreted through the hepato-biliary system with IV dosing Adverse effects of DMPS may be due to the increased presence of circulating heavy metal or related toxins Skin reactions are similar to those of acute mercury toxicity These skin reactions are similar to allergic reactions in nature, are generally mild, and include itching, nausea, dizziness, fever, weakness, skin reactions eg, rash, urticaria mucous membrane reactions, increased body temperature or shivering and fever No cases of anaphylactic shock have been reported Allergic reactions generally regress after withdrawal of DMPS within 3 to 5 days without treatment Exclusively, rapid IV
injection may have cardiovascular effects, such as dizziness, weakness, nausea, palpitations, and a feeling of chest pressure DMSA has been approved by the US Food and Drug Administration for treatment of lead intoxication DMSA has a higher affinity for mercury than it does for lead DMSA is only available as an oral preparation When used at its recommended dosage, there is no significant excretion of essential metals Blood levels following oral administration of DMSA appear to reach maximum concentration in about 3 hours The elimination half-time ie, the time for half of the substance to be converted or disappear was 32 hours Elimination of 20 of the total dose of DMSA appears in the urine The remaining 80 of the total oral dose in the gastrointestinal tract either is not absorbed by the gut or is returned to the gut via the hepato-biliary system This portion is available for further binding of mercury, which may occur with hepato-biliary circulation DMPS and DMSA combined are
excellent chelators of mercury28 The pharmacokinetic parameters between DMPS and DMSA differ, resulting in a different point of elimination of mercury from the cells According to rat studies, DMSA does not readily enter liver cells, as does DMPS; however, there is a marked difference between rat and human models In addition, DMPS has a higher affinity for mercury both inorganic and organic than DMSA Some studies report that DMSA is 3 times more effective than DMPS in removing mercury from the brain29 Also, DMSA has lower toxicity levels DMSA is commonly used in Asia and Eastern Europe to manage environmental disasters involving excess toxic metal contamination Some researchers believe that DMPS has a higher efficacy than DMSA because the terminal succinic acid group of the DMSA interferes with the succinic acid phase of the Krebs cycle, which slows the mercury binding process21 DMPS does not readily cross the

blood brain barrier or increase the deposit of mercury into the brain
Studies performed at Doctors Data, Inc, indicated that oral DMSA 30mg/kg/day for 1 to 3 days yields about one-fifth to one-tenth the amount of mercury in the urine as does a single IV or oral dose of DMPS personal communication with David W Quig, PhD, 2004 Therefore, DMPS is more effective for provocation Oral DMPS and DMSA were selected for this mercury elimination protocol due to their different binding profiles It is advantageous to give DMPS and DMSA orally because both are partially absorbed from the gastrointestinal tract, leaving the remainder available to bind to any mercury product that may circulate via the hepato-biliary system during this elimination process, thus increasing the excretion of the mercury Vitamin C given intravenously in high doses has been used to treat acute mercury toxicity, beginning with the pharmaceutical use of mercurial diuretics in the 1940s30 Historically, vitamin C has been used to treat a broad range of maladies from infectious disease to toxicity
Tom Levy, MD, JD, reviewed more than 1,200 medical and scientific journal articles on vitamin C and describes the overwhelming benefits of its use31 It was once believed that vitamin C increased the development of renal stones This has been refuted by recent studies by The New York Academy of Sciences and a recent review of 20,000 patients32,33 Vitamin C use has some unique side effects, however Individuals with glucose-6-phosphate dehydrogenase deficiency might experience red blood cell hemolysis with intravenous infusion, and individuals who are homozygous for hemochromatosis may develop an increase in iron uptake with vitamin C ingestion It is not known whether people who are heterozygous experience a problematic increase in iron uptake Glutathione is present in millimolecular amounts in most cells34 As an endogenous thiol-containing molecule, it has a high affinity for binding its reduced sulfur atoms to the mercuric ion, thereby decreasing the glutathione availability for other
cellular function and locking the mercuric-glutathione complex within the cell membrane The addition of glutathione significantly enhances the release of mercury from the astrocytes, where the mercury and glutathione are complexes, thus increasing the availability of mercury for binding and excretion35 Glutathione is 50 as effective as DMSA in preventing inorganic mercury accumulation in renal cells36 Conflicting data from an animal study using rats concluded that intraperitoneal vitamin C, glutathione, and lipoic acid did not reduce the elemental mercury tissue load37 This study investigated the induction of elemental mercury from the mercury vapor exposure of amalgams and did not measure the organic mercury mostly methylmercury and ethylmercury, which are derived from seafood or vaccinations and the ready conversion of elemental mercury to organic mercury by the gastrointestinal flora Organic mercury is more neurotoxic than elemental mercury The author contends that vitamin
C-producing animals should not be used as a comparison model for vitamin C usage This includes all animals other than humans and guinea pigs This contention has been supported by

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Cathcart oral communication with Robert F Cathcart III, MD, February 2005 and Levy38 Cathcart suggests that the problem with mercury is not toxicity, but rather a sensitivity reaction Toxicity leads to death, whereas sensitivity leads to an inflammatory process with pathological results The specificity and magnitude of this sensitivity reaction may vary depending on genetics and influential environmental factors Results indicate that the action of vitamin C may not be the displacement of mercury but rather the decrease in sensitivity to the mercury This is similar to the property of acute vs chronic mercury exposure Individuals may exhibit varied adverse effects; they may not experience all or even the same
symptoms 39 HL Sam Queen, CCN, CNS, founder and president of The Institute for Health Realities, Colorado Springs, Colo, suggests another limitation of the experimental model He contends that vitamin C and GSH given by intraperitoneal instillation as opposed to the IV route restrict the delivery and concentration of both GSH and vitamin C oral communication with Dr Queen, April 2004 The conclusion is that this model would not contradict the findings in this article OBSERVATIONS Of the 6 patients undergoing the mercury elimination program, 2 had a break in the protocol These breaks occurred either in the 5, 2-week cycles that were not consecutive or when the time span between the completion of the last cycle and the final DMPS provocation test was greater than 3 months Both patients had final DMPS provocation results within the 69 reduction range Two people developed a rash with urticaria and pruritus that completely resolved with treatment with fluconazole and prednisone In both
instances, the rash occurred during the third cycle with DMPS and did not reoccur with the final DMPS provocation As mentioned previously, it is unknown if the rash is a primary drug allergy to DMPS secondary to increased Candida albicans growth or an increase in circulating mercury Compared to other fungal species, C albicans favors the mercurial environment and tends to proliferate and produce methyl mercury from inorganic mercury while other fungal and bacterial growth decline40 Of the whole group in the mercury elimination program, only 1 patient showed less than a 69 reduction in the final DMPS provocation; this patient showed a reduction of only 19 The patient was not included in the efficacy rate of the treatment because of outlier circumstances The patient lived near a large dairy farm and drank well water that was contaminated and sometimes blackish in color A stool sample was sent to Great Smokies Diagnostic Laboratory, Asheville, NC, for analysis Results included severe
bacterial dysbiosis with marked mycosal overgrowth, including high growth of the fungal parasite Geotrichum The patient developed an intestinal parasite that might have interfered with the mercury binding treatment The author has discussed this with other providers, and there is agreement that the anticipated results from mercury binding treatment in such circumstances would be seen only after treatment with antiparasitic medication This requires further investigation

Patient Outcomes Mercury sensitivity is not a disease in itself but contributes to the underlying pathology of disease states Our patients presented with multiple diagnoses and accompanying symptoms, including vulvadysdinia with chronic candidiasis, squamous cell cancer, neurotransmitter dysfunction with depression, drug and food allergies with chronic upper respiratory tract infection, and amyotrophic lateral sclerosis All patients who experienced a reduction in mercury levels reported improved overall health, increased
energy, and decreased symptoms Chronic candidiasis and squamous cell cancer resolved as a possible result of the mercury extraction and other appropriate treatment protocols Symptoms of depression and allergies were markedly reduced The patient with amyotrophic lateral sclerosis showed no signs of disease progression during the 6-month timeframe of the study CONCLUSION As environmental mercury levels continue to increase, a safe and standard mercury elimination and desensitization program needs to be developed A program protocol including the use of oral DMSA and oral DMPS in combination with intravenous high-dose vitamin C and glutathione has shown substantial merit for consideration in treatment of patients with high levels of mercury There might be a basis for a more formal study based on these pilot clinical observations Changes in our protocol would be consistent with closely following laboratory markers of inflammation and antibody response to mercury A focus on the etiology of
the rash with proactive management could yield useful data Also, for central and peripheral neurological protection, there is some suggestion that using intravenous phosphatidyl choline and glutathione facilitates the intracellular removal of mercury and fat-soluble neurotoxins41
REFERENCES
1 Bolger PM, Schwetz BA Mercury and health Food and Drug Administration N Engl J Med 2002;34722: 1735-1736 2 Clarkson TW, Magos L, Myers G The toxicology of mercury current exposures and clinical manifestations N Engl J Med 2003;34918:1731-1737 3 Comment on: N Engl J Med 2003 Oct 30;34918:1731-1737 N Engl J Med 2004;3509:945-947; author reply 945-947 4 Burger J,Gochfeld M Mercury in canned tuna: white versus light and temporal variation Environ Res 2004;963:239-49 5 Lindberg A, Bjornberg KA, Vahter M, Berglund M Exposure to methyl mercury in non-fish-eating people in Sweden Environ Res 2004;961:28-33 6 Quig D Cysteine metabolism and metal toxicity Altern Med Rev 1998;34:262-270 7 Davidson PW, Myers
GJ, Weiss B Mercury exposure and child development outcomes Pediatrics 2004;113:1023-1029 8 Gatti R, Belletti S, Uggeri J, et al Methylmercury cytotoxicity in PC12 cells is mediated by primary glutathione depletion independent of excess reactive oxygen species generation Toxicology 2004;2042-3:175-185 9 Sakamoto M, Kakita A, de Oliveira RB, Sheng Pan H, Takahashi H Dose-dependent effects of methylmercury administered during neonatal brain spurt in rats Brain Res Dev Brain Res 2004;1522:171-176 10 Kidd PM Autism, an extreme challenge to integrative medicine Part 1: The knowledge base Altern Med Rev 2002;74:292-316 11 Hock C, Drasch G, Golombowski S, et al Increased blood mercury levels in patients with Alzheimers disease J Neural Transm 1998;1051:59-68 12 Pelletier L, Pasquier R, Rossert J, Vial MC, Mandet C, Druet P Autoreactive T cells in mercury-induced autoimmunity Ability to induce the autoimmune disease J Immunol 1988;1403:750-754 13 Salonen JT, Seppanen K, Nyyssonen K, et al
Intake of mercury from fish, lipid peroxidation, and the risk of myocardial infarction and coronary, cardiovascular, and any death in eastern Finnish men Circulation 1995;913:645-655

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14 Salonen JT, Seppanen K, Lakka TA, et al Mercury accumulation and accelerated progression of carotid atherosclerosis: a population-based prospective 4-year follow-up study in men in eastern Finland Atherosclerosis 2000;1482:265-273 15 Leong CC, Syed NI, Lorscheider FL Retrograde degeneration of neurite membrane structural integrity of nerve growth cones following in vitro exposure to mercury Neuroreport 2001;124:733-737 16 Mahaffey KR, Clickner RP, Bodurow CC, Blood organic mercury and dietary mercury intake: national health and nutrition examination survey, 1999 and 2000 Environ Health Perspect 2004;1125:562-570 17 Center for Disease Control and Prevention CDC Blood mercury levels in young children and
childbearing-aged women–United States, 1999-2002 MMWR Morb Mortal Wkly Rep 2004;5343:1018-1020 18 Cline J Detoxfying specific toxicants Paper presented at: Institute for Functional Medicine Conference; March 7, 2005; Seattle, Wash 19 Buttar R The treatment of cancer using immune modulating peptide analogs Paper presented at: American College for Advancement in Medicine Conference; November 19, 2004; San Diego, Calif 20 Hibberd AR, Howard MA, Hunnisett AG Mercury from dental amalgam fillings: studies on oral chelating agents for accessing and reducing mercury burdens in humans J Nutr Env Med 1998;8:219-231 21 College Pharmacy DMPS Protocol Pharmacyinfo@collegepharmacycom 22 Aposhian HV, Maiorino RM, Gonzalez-Ramirez D, et al Mobilization of heavy metals by newer, therapeutically useful chelating agents Toxicology 1995;97:23-38 23 Roth E Laboratory report for toxic metals Doctors Data, Inc; St Charles, Ill 24 Holmes A Heavy metal toxicity in autistic spectrum disorders Mercury toxicity
In: Rimland B, ed DAN Defeat Autism Now Fall 2001 Conference Practitioner Training San Diego, Calif: Autism Reseach Institute; 2002 25 Cathcart RF Mercury Chelation Protocol Los Altos, Calif: Medical Practice; 2002 26 Kidd PM Autism, an extreme challenge to integrative medicine Part 2: medical management Altern Med Review 2002;76:472-499 27 Ruprecht J Scientific Monograph: Dimaval DMPS Heyltex Corp, 6th ed, 1997

28 Aposhian HV, Maiorino R, Rivera M, et al Human studies with the chelating agents, DMPS and DMSA J Toxicol Clin Toxicol 1992;304:505-528 29 Aaseth J, Jacobsen D, Andersen O, Wickstrom E Treatment of mercury and lead poisonings with dimercaptosuccinic acid DMSA and sodium dimercaptopropanesulfonate DMPS Analyst 1995;1203:853-854 30 Chapman DW, Shaffer CF Mercurial diuretics A comparison of acute cardiac toxicity in animals and the effect of ascorbic acid on detoxification in their intravenous administration Arch Intern Med 1947;79:449-456 31 Levy T Vitamin C, Infectious
Disease, and Toxins–Curing the Incurable Philadelphia, Pa: Xlibris Corp; 2002:452 32 Burns JJ, Rivers JM, Machlin LJ Third Conference on Vitamin C New York: New York Academy of Sciences; 1987 33 Rea WJ Chemical Sensitivity, vol 4 Boca Raton, Fla: CRC Press, Inc; 1997:2600 34 Patrick L Mercury toxicity and antioxidants: Part 1: role of glutathione and alphalipoic acid in the treatment of mercury toxicity Altern Med Rev 2002;76:456-471 35 Cookson MR, Pentreath VW Protective roles of glutathione in the toxicity of mercury and cadmium compounds to C6 glioma cells Toxicol in Vitro 1996;103:257-264 36 Endo T, Sakata M Effects of sulfhydryl compounds on the accumulation, removal and cytotoxicity of inorganic mercury by primary cultures of rat cortical epithelial cells Pharmacol Toxicol 1995;763:190-195 37 Aposhian HV, Morgan DL, Queen HL, Maiorino RM, Aposhian MM Vitamin C, glutathione, or lipoic acid did not decrease brain or kidney mercury in rats exposed to mercury vapor J Toxicol Clin
Toxicol 2003;414:339-347 38 Levy T Vitamin C, calcium and circulation Paper presented at the Society for Orthomolecular Health-Medicine Conference; February 25, 2005; San Francisco, Calif 39 The Institute for Functional Medicine Clinical Nutrition: A Functional Approach, 2nd edition Gig Harbor, Wash: The Institute for Functional Medicine; 2004 40 Yannai S, Berdicevsky I, Duek L Transformations of inorganic mercury by Candida albicans and Saccharomyces cerevisiae Appl Environ Microbiol 1991;571:245-247 41 Foster J, Kane P, Speight N The Detoxx system: detoxification of biotoxins in chronic neurotoxic syndromes Townsend Letter for Doctors Patients November 2002

Source:crnusa.org

Clinical Bulletin
Information for Health Professionals

Complementary and Alternative Medicine in MS
by Allen C Bowling, MD, PhD, Rocky Mountain MS Center COMPLEMENTARY AND ALTERNATIVE MEDICINE
n the United States, there is growing interest in what has become known as alternative medicine, especially among people with chronic diseases such as multiple sclerosis MS The use of unconventional therapies may be complementary used in combination with conventional medicine or alternative used instead of conventional medicine A broad term that includes both of these approaches is complementary and alternative medicine, or CAM Recent studies indicate that 5060 of people with MS use some form of CAM Popular CAM therapies include diets, dietary supplements, acupuncture, meditation, massage, and yoga Approximately 90 of people with MS who use CAM also use conventional medicine In other words, CAM is usually used in a
complementary manner by people with MS Unfortunately, MS patients often withhold information about their CAM use from their physicians Physicians often lack understanding about the use of CAM, and accurate information about CAM that is relevant to the treatment of MS is difficult to find To address these gaps, the CAM Program was developed at the Rocky Mountain MS Center This bulletin is based on information compiled from this source

I

COMPLEMENTARY AND ALTERNATIVE THERAPIES
Herbal Medicine
Herbal therapy is one of the most accessible forms of CAM Since herbs are not under strict FDA regulation, they should be used with caution There are several important principles about herbal therapy:
x Herbs are often used as drugs x Herbs contain many different compounds, some of which may be toxic or interact with

other drugs
Tel: 1-866-MS-TREAT 678-7328 E-mail: MD_info@nmssorg HealthProf_info@nmssorg wwwnationalmssocietyorg/PRCasp

Complementary and Alternative Medicine in MS page 2

A
Clinical Bulletin from the Professional Resource Center of the National Multiple Sclerosis Society

x Herbs may contain compounds that have not been identified or characterized, and may

be different from those on the label
x The quality and composition of herbal preparations are variable x Herbs should only be used for a short time, for benign, self-limited conditions x Herbs should be avoided in women who are pregnant or breastfeeding, people with multi-

ple medical problems or taking multiple medications, and children Herbal preparations that may be effective include cranberry tablets for the prevention of urinary tract infections and psyllium for constipation FDA approved Valerian may be effective for insomnia St Johns wort has long been widely used in Europe for the treatment of depression While it may have an antidepressant effect, the strength of this effect and the full range of toxicity have not been established In an effort to clarify these issues, a multi-center
placebo-controlled clinical trial was conducted at Vanderbilt University Results of this study indicated that St Johns wort is not effective for moderate or severe depression A three-year, multi-site, clinical trial coordinated by Duke University and funded by the National Institutes of Health confirmed that St Johns wort is no more effective than placebo for moderately severe depression In separate studies, St Johns wort has been found to interact with an antiviral medication for HIV infection called indinavir, and with cyclosporine, a drug used to prevent rejection of organ transplants St Johns wort may also interfere with the effectiveness of oral contraceptives and medications for heart disease, seizures, and certain cancers Certain herbs might worsen MS or interact with medications MS patients should use care with herbs that may have immune-stimulating properties, including alfalfa, astragalus, echinacea, garlic, and Asian ginseng Patients who have fatigue or take sedating
medications, such as lioresal Baclofen, tizanidine Zanaflex, and diazepam Valium, should be careful about using potentially sedating herbs, which include chamomile, Asian and Siberian ginseng, goldenseal, kava kava, stinging nettle, passionflower, sage, St Johns wort, and valerian Steroid side effects may be worsened by some herbs, including aloe, bayberry, Asian ginseng, and licorice Herbs sometimes recommended for MS that may cause serious side effects include chaparral, comfrey, lobelia, and yohimbe

Vitamins
There are theoretical reasons why antioxidant vitamins, which include vitamins A, C, and E, may be beneficial for MS Antioxidant vitamins decrease the levels of free radicals, which, according to some evidence, may be a factor in the myelin and nerve damage that occurs in MS On the other hand, antioxidants stimulate the immune system and this could be harmful for MS MS can increase the risk for developing osteoporosis, and vitamin D and calcium may be beneficial in this regard
There is no clear indication for the use of vitamin B12 therapy in MS, except for the rare patient who also has documented vitamin B12 deficiency

Complementary and Alternative Medicine in MS page 3

A Clinical Bulletin from the Professional Resource Center of the National Multiple Sclerosis Society

High doses of some vitamins and minerals may produce toxic effects Doses of vitamins and minerals to avoid include:
x Vitamin A or beta-carotene: greater than 10,000 IU daily may produce liver injury and

other toxic effects
x Vitamin B6 pyridoxine: greater than 50 milligrams daily may produce nerve injury x Vitamin C: greater than 1,000 milligrams daily may produce diarrhea and kidney stones x Vitamin D: greater than 1,000 IU daily may produce liver injury x Selenium: greater than 200 micrograms daily may produce multiple toxic effects

In addition, vitamin A and beta-carotene should probably be avoided in smokers, and warfarin Coumadin should not be taken with coenzyme Q10, vitamin E,
vitamin K, and possibly vitamin C

Other Supplements
Zinc is sometimes used to prevent or limit the severity of the common cold Often for unclear reasons, some CAM books recommend zinc supplements specifically for MS In people with MS, it may be best to avoid or limit zinc supplements since zinc may stimulate specific cells in the immune system Similarly, melatonin and DHEA, two hormones that are available as supplements, may activate the immune system

Traditional Chinese Medicine
Traditional Chinese medicine includes acupuncture and herbal therapy Acupuncture is increasingly recognized for its effectiveness in some types of pain and nausea, but studies in MS have been limited and contradictory Chinese herbal medicine should be used cautiously and with a clear understanding of the effects of the herbs Asian ginseng and astragalus, which are common components of Chinese herbal preparations, may stimulate the immune system Another form of Chinese medicine, Chinese proprietary medicine,
should probably be avoided since there are no well-established benefits in MS and some ingredients may be toxic

Other Possibly Beneficial Therapies
Limited studies indicate that several CAM therapies may be beneficial for people with MS Cooling therapy, which involves the use of cooling suits, may improve some MS symptoms Mindbody approaches, such as meditation, guided imagery, and yoga, may relieve anxiety and pain Yoga may also be helpful for spasticity Tai chi, which is a Chinese exercise regimen that involves slow body movements and specific breathing techniques, may improve walking ability and decrease spasticity Massage may be beneficial for anxiety, depression, pain, and spasticity Horseback riding, known as hippotherapy, may provide multiple therapeutic effects Rigorous clinical studies are needed to further evaluate the effectiveness of these therapies

Complementary and Alternative Medicine in MS page 4

A Clinical Bulletin from the Professional Resource Center of the
National Multiple Sclerosis Society

Miscellaneous Therapies Lacking Proven Benefit
Bee venom therapy is currently being studied in humans, but preliminary results from animal studies at Allegheny University indicate that it has no effect and may be harmful Therapies in which there is no strong evidence for a beneficial effect in MS include calcium EAP, chelation therapy, craniosacral therapy, enemas, hyperbaric oxygen, and dental mercury amalgam removal

PRINCIPLES OF CAM USE
Several guidelines should be followed when patients are considering CAM use:
x Consider conventional medicine first x Evaluate and directly address the reasons for wanting to use CAM x If CAM is chosen, direct the patient to keep the physician informed; monitor the response

to the therapy; and discontinue therapy when appropriate
x Stress caution to the patient

THE PLACEBO EFFECT
In trials of immunomodulating agents, the placebo effect has been quite high, with a transient 3040 reduction in relapses In some
trials, placebos have actually produced greater improvement than active medications Some studies have even suggested that placebos produce beneficial effects on specific cells in the immune system The placebo effect demonstrates the powerful influence that the mind may have over the body or brain This mind-body effect may be under-utilized in conventional medicine and may be an important component of some forms of CAM

A WELLNESS APPROACH
CAM and the influence of the mind over the body are two areas that may be incorporated into a more inclusive wellness approach that optimizes functioning in the different components of the MS patients life: health, physical fitness, psychological well-being, social connectedness, nutrition, sexuality, spirituality, and bowel and bladder function These components are interwoven; in a state of wellness, there is a sense of wholeness and balance among them A chronic disease such as MS may disrupt this wholeness and balance Integration of neurologic care
with a wellness focus requires a multidisciplinary approach, including medical, psychological, nursing, dietetic, and rehabilitation services

Complementary and Alternative Medicine in MS page 5

A Clinical Bulletin from the Professional Resource Center of the National Multiple Sclerosis Society

HYPE OR HOPE?
Does CAM use in MS provide hope or is it simply meaningless hype? The answer is both Some therapies have produced promising results, others are excessively promoted but ineffective or unsafe, and a large number have yet to be studied carefully in people with MS This large variability in the possible effectiveness of different therapies is the cause for much of the confusion and controversy in CAM Improving the way in which CAM is used involves increasing communication between people with MS and health care professionals, providing accurate CAM information to people with MS, and conducting reliable studies to determine which therapies are effective

ADDITIONAL INFORMATION
The CAM
Initiative at the Rocky Mountain MS Center offers the following resources:
x Bowling AC: Alternative Medicine and Multiple Sclerosis Demos Medical Publishing, 2000 x wwwms-camorg: An interactive, regularly updated Website devoted exclusively to CAM

and MS Other helpful books on CAM include:
x Cassileth B: The Alternative Medicine Handbook Norton, 1998 x Foster SE, Tyler VE: Tylers Honest Herbal Haworth Herbal Press, 1999 x Jellin JM, Batz F, Hitchens K: Natural Medicines Comprehensive Database Therapeutic Research

Faculty, 1999
x Sarubin A: The Health Professionals Guide to Popular Dietary Supplements The American Dietetic

Association, 2000
x Spencer JW, Jacobs JJ: Complementary/Alternative Medicine; An Evidence-Based Approach Mosby,

1999 Supported by an unrestricted educational grant from Biogen Inc

2004 National Multiple Sclerosis Society

Source:ovid.com

The Science and Practice of Complementary Alternative Medicine Research by Allied Health Nursing Professionals
November 17, 2004 Hilton-Woodbridge 120 Wood Ave South Iselin, NJ

The Science and Practice of Complementary Alternative Medicine Research by Allied Health Nursing Professionals Schedule: 8:00 - 8:30 8:30 8:30 - 9:30 Registration Continental Breakfast Welcome Riva Touger-Decker, PhD, RD, FADA Keynote Address: CAM: Current State of the Art in Research, Education and Practice and Future Directions in Allied Health Nursing M J Kreitzer, PhD, RN Legal and Ethical Issues in CAM Research Practice Kathleen Boozang, PhD, LLD Break and Poster Sessions Dietary Supplements: Current State of the Science Cynthia Thomson, PhD, RD Lunch and Networking Manipulative and Body Based Therapies: Current State of the Science Judith E Deutsch, PhD, PT Mind body Medicine: Research Opportunities for Allied Health and Nursing Professionals M J Kreitzer, PhD, RN Panel Discussion: How Can
Allied Health and Nursing Professionals Integrate CAM in Practice? Setting the CAM Research Agenda for Allied Health and Nursing Moderator: David M Gibson, EdD Panelists: Julie OSullivan Maillet, PhD, RD, FADA MJ Krietzer, PhD, RN Suzanne Smeltzer, RN, EdD, FAAN Kathleen Boozang, PhD, LLD Cynthia Thomson, PhD, RD Judith E Deutsch, PhD, PT Closing Remarks Adam Perlman, MD, MPH

9:30 - 10:30 10:30 - 11:30 11:30 - 12:30 12:30 - 1:45 1:45 - 2:45

UMDNJ-Center for Advanced and Continuing Education 1776 Raritan Rd Scotch Plains, NJ 07076

The Science and Practice of CAM Research by Allied Health Nursing Professionals 05ACAM01

University of Medicine and Dentistry of New Jersey School of Health Related Professions The Institute for Complementary Alternative Medicine The Center for Advanced and Continuing Education
This conference is supported in part by funds from an R13 grant from the National Center for Complementary and Alternative Medicine and the UMDNJ Foundation

2:45 - 3:45 3:45 -
4:30

4:30

Call for Abstracts for the Poster Session Information and Applications are available at wwwumdnjedu/icam
Objectives: Upon conclusion of this program participants should be able to: 1 Discuss legal and ethical issues in CAM research and practices 2 Describe dietary supplements used in CAM 3 Explain the manipulative and body based therapies of CAM 4 Apply evidence based methods to their practice and/or research approaches to CAM

Faculty:
Judith E Deutsch, PhD, PT Director: Research in Virtual Environments and Rehabilitation Sciences RIVERS Lab Associate Professor School of Health Related Professions University of Medicine and Dentistry of New Jersey Dept of Developmental and Rehabilitation Science Newark, NJ Cynthia Thomson, PhD, RD Assistant Professor Nutritional Services Arizona Cancer Center University of Arizona Tucson, AZ MJ Krietzer, PhD, RN Director, Center for Spirituality and Healing Academic Health Center Associate Professor School of Nursing University of
Minnesota Minneapolis, MN Kathleen Boozang, PhD, LLD Associate Dean of Academic Affairs Seton Hall School of Law Seton Hall University Newark, NJ

General Information
Intended Audience: Physicians, Nurses, Physicians Assistants, Physical Therapists, Dietitians, and other Allied Health Professionals Cancellation of Course: Each course requires a minimum enrollment Courses may be canceled because of insufficient enrollment In the event a course is canceled, you will be notified by telephone and given the option of a full refund or enrolling in another course Refund Policy: A written notification must be submitted to the Center for Advanced and Continuing Education A full refund less a 2500 cancellation fee will be charged if notice is received one week prior to the seminar No refund will be given if the cancellation is received the day of the seminar Confirmation and Directions: A confirmation letter and directions will be sent to you Important Phone Numbers: Registration information
call: 1-800-227-4852 Course content information call: 908 -889-2560 CACE WEB Site: http://wwwumdnjedu/cceweb/caceweb/caceframhtml Continuing Education Credit: The UMDNJ-SHRP Graduate Programs in Clinical Nutrition, in conjunction with the UMDNJ-Center for Advanced and Continuing Education, is a Continuing Professional Education CPE Accredited Provider Provider Number UN001 with the Commission on Dietetic Registration CDR Registered dietitians RDs and dietetic technicians, registered DTRs will receive 6 continuing professional education units CPEUs for completion of this program/materials This activity is pending nursing credit approval This activity is provided by the UMDNJ-Center for Continuing and Outreach Education CCOE The UMDNJ-CCOE is accredited by the Accreditation Council for Continuing Medical Education ACCME to provide medical education for physicians The UMDNJ-CCOE designates this educational activity for up to 6 hours toward the AMA Physicians Recognition Award Nursing
credit approval pending

Complementary Alternative Medicine 05ACAM01 REGISTRATION FORM

Fee: 7500
Name: __________________________________ SS___________________________________ Degree/Certification________________________ Specialty________________________________ Affiliation: ________________________________ Home Address: __________________________ City: State: ____Zip: _____

Panelists:
David M Gibson, EdD, FASAHP Dean, School of Health Related Professions Professor, Dept of Interdisciplinary Studies University of Medicine and Dentistry of New Jersey MJ Krietzer, PhD, RN Cynthia Thomson, PhD, RD Kathleen Boozang, PhD, LLD Judith E Deutsch, PhD, PT Julie OSullivan Maillet, PhD, RD, FADA Associate Dean for Academic Affairs and Research Chair Professor, Dept of Primary Care School of Health Related Professions University of Medicine and Dentistry of New Jersey Suzanne Smeltzer, RN, EdD, FAAN Professor Director, Nursing Research Villanova University College of Nursing Villanova,
PA

Daytime Phone: _____ ___________________ Evening Phone: _________________________ Fax Number: _____ ___________________ E-mail:
How did you hear about this course? Circle One
Word of Mouth Brochure Web Journal Other

Enclosed is my check for payable to: UMDNJ-CCOE Please charge Visa Master Card to my: American Express

Program Directors Planning Committee:
Riva Touger-Decker, PhD, RD, FADA Associate Professor and Program Director Graduate Programs in Clinical Nutrition Dept of Primary Care School of Health Related Professions Director, Division of Nutrition, Dept of Diagnostic Sciences New Jersey Dental School University of Medicine and Dentistry of New Jersey Adam Perlman, MD, MPH UMDNJ Endowed Professor of Complementary Alternative Medicine Executive Director The Institute for Complementary Alternative Medicine School of Health Related Professions University of Medicine and Dentistry of New Jersey Nancy S Redeker, PhD, RN, CS Professor Associate Dean for Research School of
Nursing University of Medicine and Dentistry of New Jersey

Card No________________________________ Exp Date _______________________________ Authorized Signature: ______________________ Fax completed reg form to: 973-972-7128 Mail to: UMDNJ-CCOE PO Box 1709 Newark, NJ 07101-1709 On-line registration:

wwwpeoplewarenet/0646c

Source:alternativemedicinehealthcare.com

Alfred P Fishman, MD Editor-in-Chief Senior Associate Dean

STUDYING THE MEDITATING BRAIN
Andrew Newberg, MD, Assistant Professor of Radiology

Alternative Medicine in the Academic Medical Center
Academic medical centers are currently facing up to the challenge of incorporating so-called Alternative Medicine into the education programs of their scientifically-based institutions No longer is the question should it be done? Instead, the question is how to do it? Among the barriers to be overcome are the overcrowded medical curriculum, ambiguities in nomenclature, the unsettled contemporary medical scene, and mutual misunderstanding The typical curriculum is a conglomerate which is already bulging at the seams with the triumphs of scientific medicine Simply adding courses is neither feasible nor desirable Integration holds more promise for meaningful incorporation of alternative medicine into the medical curriculum than does addition
continued on page
7

T

he study of meditation, a complex mental task, is potentially one of the most important areas of research that may be pursued by medical science in the next decade This may not be an understatement since meditation offers a fascinating window into human consciousness, psychology, and experience; the relationship between mental states and body physiology; emotional and cognitive processing; and the biological correlates of religious experience In the past thirty years, scientists have explored the biological effects and mechanism of meditation in great detail Initial studies measured changes in autonomic activity such as heart rate and blood pressure as well as electroencephalographic changes More recent studies have explored changes in hormonal and immunological function associated with meditation While many of these studies have utilized peripheral measurements of different substances, they are consistent with a number of central neurochemical changes including observed changes
in blood concentration of cortisol, serotonin, norepinephrine, and vasopressin Studies have also explored the clinical effects of meditation in both physical and psychological disorders Functional neuroimaging has opened a new window into the investigation of meditative states by exploring the neurological correlates of these experiences The neuroimaging techniques include positron emission tomography PET, IN THIS ISSUE single photon emission computed tomography SPECT, and functional The Placebo Response page 3 magnetic resonance imaging fMRI A Medical Students Perspective Each of these techniques provide differpage 3 ent advantages and disadvantages in CAM at Penn: the study of meditation
continued on page 2

Integration or Pluralism? page 4

The Meditating Brain
continued from page 1

Our brain imaging studies see Figures of Tibetan Buddhist meditators showed measurable changes that occur during intense meditation and suggest several coordinated cognitive processes Specifically,
changes in the inferior frontal lobe and prefrontal cortex are suggestive of intense

Figure 2 Axial SPECT images, slightly higher up in the brain demonstrate decreased activity in the superior parietal lobe lower right shows up as yellow rather than the red on the left image during meditation compared to the resting state

Figure 1 The SPECT images were obtained during our study of the neurophysiological correlates of Tibetan Buddhist meditation These axial images show the results from a baseline scan on the left ie at rest and during a peak of meditation shown on the right The images demonstrate that the frontal lobes, usually involved in focusing attention, are more active during meditation increased red activity

concentration while decreases in the parietal lobe may be attributed to the subjective alterations in the sense of space and time described by subjects during meditation We also observed significant increases in activity in the thalamus, a key relay in the brain We hope
that our future studies will explore various types of meditation both within traditions and across traditions and also how meditation may affect various physical and mental health parameters

The Future of Herbal Medicine
By Michael D Cirigliano, MD, FACP Associate Professor of Medicine

C

onsumer use of herbal medicines has begun to slow over the past several years following a remarkable rise in popularity in the 1990s Despite this trend, clinicians continue to be confronted with the question of safety and efficacy on a daily basis Patients routinely present with a number of natural products along with their standard pharmaceutical agents This has historically led to both frustration and confusion amongst both patient and clinician For Western medical professionals, it has been tantamount to fitting a square peg into a round hole Well-designed clinical trials on herbal remedies are appearing more regularly in the mainstream medical literature However, many have failed to show a
significant benefit

to use and in fact, several have uncovered significant side effects adding to the dilemma for clinicians In addition, the question of safe manufacturing and regulatory standards continue to plague the industry Numerous case reports have found contaminants in natural products leading to adverse events For these reasons, the question remains as to where we go with herbal medicine? For many of us, the answer is simple Although scientific data has been mixed recently, the large body of historical information that exists and the thousands of years of use by cultures throughout the world have convinced many of us that there is a role for natural products in clinical practice Use of herbal remedies in selected
continued on page 7

A MEDICAL STUDENTS PERSPECTIVE

WHY US, WHY NOW?
by Jessica Buckley MS2

The Placebo Response
by Alfred P Fishman, MD

I

ts widely expected that we all want the best possible care and outcomes for our patients, but are we equipping ourselves
to provide it? Americans are opening their minds to treatments that arent written on prescription pads As their guides towards better health and quality of life it is our responsibility to expand our horizons with them As medical students, we believe that it is our responsibility to learn about ACE inhibitors and bisphosphonates, but what if a patient is taking St Johns Wort or Chondroitin Sulfate? In our classes we have picked up a few tidbits about altered distribution or metabolism as a result of herb-drug interactions, and perhaps we do feel well-informed about the preventative benefits of a healthy lifestyle Yet many of us also feel that there are further changes we would like to see incorporated into our education We would like to hear from holistic physicians, MDs who have chosen to incorporate aspects of CAM into their practices We would also like to hear from allopathic physicians about how they encounter CAM in their practices What is shiatsu, why do patients use it, is it
something that might be of benefit, could it harm them? We would like to discuss interdisciplinary collaboration Most importantly, where can we go to educate ourselves? As a child, I was chronically congested, but for fourteen years we were unable to establish a cause I was finally told that I was probably

allergic to dust mites and given a nasal inhaler though I have no memory of the name of the medication At that time my mother, who worked as an acupuncturists assistant, persuaded me to try an acupuncture session A few needles and an empty inhaler later, I could breathe easily through my newly cleared nasal passages Even now hardly a day goes by when I dont appreciate the ability to detect a subtle scent I dont know whether the acupuncture made a difference, or if I underwent a normal physiological change Its possible the medication stimulated endogenous antihistamine production, or that I believed in these interventions enough to experience the placebo effect personally Sitting
here writing this, I dont care what actually happened; I care that I can breathe easily Our patients are coming to us with much the same attitude They dont care what the biological mechanisms are, they just want to feel better, and will often take symptomatic relief into their own hands If we hope to achieve their best outcome we must be prepared to discuss this openly and knowledgeably with them and amongst ourselves, and we should start now

P

lacebos are usually regarded as substances on procedures that are biologically inert This is true only in the pharmacological sense This definition ignores the fact that placebos can alter psychological states and brain activity which can, in turn, elicit major changes in the functioning of body organs and tissues Over the years, a variety of psychological mechanisms, such as conditioning and expectation, have been invoked to explain the placebo response These studies have relied primarily on behavioral and electrophysiological studies in
normal and brain-damaged animals and humans However, recent technological advances in neuroimaging and computational modeling have provided new tools and fresh approaches to explore brain mechanisms involved in the placebo response, to map the involved brain circuitry and to display connections to the periphery which influence autonomic, endocrine and immune functions Neuroimaging studies have begun to illuminate the sites and mechanisms of the brain involved in the placebo response One particular target of recent studies has been clarification of the role played by expectation By manipulating expectation, areas of the brain which are responsive have been located, mediators and pathways that are excited by manipulations of expectation have been tracked, and the corresponding subjective experience documented and analyzed Studies of brain-systemic connections
continued on page 8

HEADS UP

CAM AT PENN: INTEGRATION OR PLURALISM?
By Paul Root Wolpe, PhD,Department of Psychiatry,
Department of Medical Ethics, Department of Sociology, Center for Bioethics The advances made by CAM over the last decade or so are startling On the federal level, the National Institutes of Health has established the National Center for Complementary and Alternative Medicine, and the National Cancer Institute has set up a similar Office of Cancer Complementary and Alternative Medicine Surfing through federal agency websites, you can find information about alternative therapies for diabetes from the National Institute of Diabetes and Digestive and Kidney Diseases, information about St Johns Wort from the National Institute of Mental Health, and the Agency for Healthcare Research and Quality would be happy to send you papers with titles like Ayurvedic Interventions for Diabetes Mellitus,Garlic: Effects on Cardiovascular Risks and Disease and Mind-Body Interventions for Gastrointestinal Conditions Most major medical schools now teach CAM in one form or another, and academic medical
cenWhich is, in itself, remarkable It was not that long ago that people who studied CAM, never mind advocating it, were seen as snake-oil salesman who had left their scientific rigor and their brains at the door, and who had somehow been bewitched by mantra-chanting vegans that did Tai Chi and took Chinese herbs Of course, now we realize that a vegan-type diet that eschews high carbohydrates, dairy products, and fatty meats is probably the most healthy for you; that meditation has profound stress-reduction effects that decrease blood pressure and a host of other risk factors; that Tai Chi is therapeutic in both stress reduction and overall physical health; and that herbs have profound healing properties Today, in contrast, CAM is increasingly seen as a valuable asset by scientific medicine Physicians are referring patients to massage therapists, acupuncturists, and yoga classes, and some centers are trying to bring those therapies into in-house clinical service It would seem that CAM
and scientific medicine have made their peace, and that all is left is for integrated medicine to become the standard of care at academic medical centers throughout the nation As in most things, however, the reality is not that simple There are resistances on both sides that must be understood before we can determine the appropriate relationship of CAM to establishment medicine On one side are the skeptics who have not changed their minds about alternative medicine broadly writ, and write about it in the same sentence as astrology, crop circles and alien abductions Despite the enormous scientific literature that supports certain CAM modal-

ters have set up clinics, programs, centers, and offices dedicated to CAM Conferences on integrating CAM into hospitals and medical centers are so common these days as to be almost unremarkable

ities and, most certainly, finds little value in some others, these skeptics prefer to lump all CAM modalities together and then shake their heads at the
credulity of the American public for believing in such nonsense It seems wholesale dismissal of CAM is easier than actually reading the literature Setting up CAM as a straw man is in reality a profoundly unscientific posture; medical history has shown over and over again that modalities that are dismissed as absurd without adequate scientific evidence too often turn out to the breakthroughs of the next generation Semmelweis lives with us still On the other hand, there are those in the medical establishment willing to engage CAM, but who do not understand its nature Anxious to quickly incorporate CAM modalities into the medical center, these advocates may end up undermining the very modalities they claim to champion The effectiveness of many CAM modalities is enhanced by the cultural and social contexts in which they are offered Going to the office of a massage therapist where there is music playing and incense burning, relaxing first in a lounge chair sipping organic juices, and then
engaging a therapist who can spend a full hour in slow hands-on healing cannot be duplicated easily at HUP Part of the appeal of acupuncture to some is precisely that it is a counter-cultural experience, and they may not be interested in obtaining it in the sterile institutional settings we can offer The point is not that Penn should give up on these modalities Rather, we need to choose carefully what we are offering and to whom, and be prepared to refer those who want a

different kind of experience to the community practitioners who are already providing the bulk of these services Of course, they must be screened, and only competent, well-trained practitioners should make up our referral base But integrated medicine need not mean imperial medicine, where the academic medical center becomes the sole locus of care A pluralistic system, where Penn offers a set of services but which also encourages community practitioners to continue to offer services in their own offices with referrals
from Penn medical staff may ultimately be the best answer to true medical integration

Acupuncture Alive and Well at UPHSPresbyterian and HUP Campuses
by Patrick J LaRiccia, MD, R Ac, Presbyterian Medical Center UPHS

A

cupuncture has been around for at least two thousand years It originated in China and spread to other Asian countries before heading to the West In the Orient acupuncture is a component of traditional Chinese medicine, ie it is part of a full system of medi-

tive dental pain Less conclusive evidence from sources other than randomized controlled trials existed for other medical conditions such as fibromyalgia, myofascial pain, and tennis elbow This evidence was similar to that which supported the use of non-steroidal-anti-inflammatory drugs NSAIDs and steroid injections However, acupuncture has a better safety profile In keeping with different schools of thought, there are many different ways to perform an acupuncture treatment These schools include Traditional
Chinese Medicine TCM, Japanese, Korean, French Energetics, Worsley Five Element, etc Successes and failures have occurred with each of these approaches However, the optimal method is difficult to establish since acupuncture is really a family of methods that uses needles to access a proposed system of pathways called meridians and places of focus called acupuncture points through which the proposed vital energy called Qi courses This makes the scientific study of acupuncture challenging Also, the different types of acupuncture are a source of confusion to the public and to researchers CURRENT ACUPUNCTURE RESEARCH AT PENN Currently, a variety of research projects at Penn are in progress These include: 1 A randomized placebo-controlled study of acupuncture and exercise physical therapy in the treatment of osteoarthritis of the knee; 2 Brain imaging of the effect of acupuncture on patients with chronic pain; 3 A pilot study of the use of acupuncture for the treatment of fatigue in cancer
patients receiving radiation therapy; and 4 A pilot study in use of acupuncture in reducing pain in breast cancer patients caused by photodynamic therapy The principle investigators in these studies include Abass Alavi, MD brain imaging, John Farrar, MD acupuncture and osteoarthritis of the knee; acupuncture treatment of fatigue in cancer patients, and Robert Lustig, MD the use of acupuncture in conjunction with photodynamic therapy Drs Abass Alavi and Andrew Newberg have been central to the research on acupuncture that involves brain imaging

cine In the United States its principal use until recently has been in the treatment of chronic pain However, considerable evidence from different parts of the world indicates that it can be applied to a variety of other medical problems In 1997 the National Institute of Health NIH held a consensus panel on acupuncture The consensus indicated that acupuncture is a safe form of treatment Indeed, based on records of severe adverse events,
acupuncture appears to be safer than Western pharmaceutical and surgical interventions The 1997 NIH consensus panel on acupuncture concluded that randomized controlled trials supported the use of acupuncture for post-chemotherapy nausea and vomiting, post-operative nausea and vomiting, and post-opera-

Alternative Medicine
continued from page 1

However, the process of integration requires understanding and accommodation by clinical scientists who are apt to be reluctant to make way for therapies which they regard as unconventional and unproven In a research university, promising and popular therapies can be evaluated for efficacy, efficiency and cost-effectiveness Ambiguity in terminology not only

hampers communication but also compromises research and education For medical educators, the designation Alternative Medicine entails the threat of displacing conventional medicine for the sake of unproven therapies from other medical traditions Moreover, although Alternative Medicine
covers a panoply of diverse therapies, it lacks the organization and processes of scientific medicine As a

practical expedient, the term Complementary is more relevant than Alternative for the missions of the research university The term signifies that a given therapy borrowed from another culture is an addition to, or an enhancement of, Western medical therapy and not a substitute As a corollary, once safety and efficacy are proven by Western criteria, complementary therapies become part of conventional medicine Even more pervasive than Complementary has become the abbreviation CAM Originally a by-product of the creation of a center at the National Institutes of Health for Complementary/Alternative Medicine, the abbreviation has become commonplace, more often used as a synonym for a complementary than for an alternative therapy Few would challenge that contemporary medicine is restless and undergoing dramatic change Forces outside of medicine are shaping the practice of medicine
while physicians, educated to deliver acute care, face novel demands imposed by the need for chronic care, unanticipated epidemics and increasingly diverse populations Meanwhile, scientific medicine and technologic advance are in high gear, rapidly generating new, albeit expensive, diagnostic methods and therapies In this unsteady state, how can the education of the physician with respect to complementary therapies contribute to the care of the patient?
continued on page 8

Herbal Medicine
continued from page 2

settings after a careful evaluation and proper diagnosis can be a useful adjunct to standard care Natural medicines not only can aid in specific biologically based illnesses but also can be a starting point for discussions about health in general and most importantly preventive medicine Some critics of complementary and alternative medicine may say that the placebo effect is at play and nothing else It is my firm belief that the true healing power of the body itself has yet to
be fully understood and remains the final frontier in overall health Much research and interest is being expended on the concept of placebo and its remarkable effects on health and more importantly, patient behavior In my own clinical practice, I have found that the overall benefits of herbal medicine and natural product use have far outweighed any negatives With proper knowledge of interactions and adverse effects, patients overall health and well-being have been enriched by the use of these agents as well as from the resulting discussions of health and well being The future of herbal medicine I believe is bright More research and better manufacturing standards will help propel us as healthcare providers into a more holistic and gentler form of healthcare delivery and patient care

The Placebo Response
continued from page 5

Alternative Medicine
continued from page 7

involved in the placebo response have also begun but these are still in their infancy Many studies of the placebo
response have dealt with the interplay between mind, brain, body and health This topic clearly relates to the patientdoctor relationship which, in turn, is one form of a placebo effect: a compassionate interplay between the health professional and the patient can promote health Oppositely, an ineffective relationship may not only be a lost opportunity for health care but even retard or impair healing, ie elicit a nocebo response

Health care practitioners of unconventional therapies are usually unfamiliar with the principles and practice of scientific medicine, just as practitioners of conventional medicine rarely have insights into the cultures and beliefs of those who practice unconventional therapies Many of the latter are not physicians Of the two deficiencies, the more readily remediable seems to be an increase in the appreciation of cultural diversity by Western physicians This insight would promise not only better utilization of therapies derived from other traditions, but also
better interplay with patients from diverse backgrounds Less corrigible for the immediate future is the lack of research

training by health professionals who practice unconventional therapies There is little question that complementary therapies are here to stay Indeed, their usage is on the increase Physicians need to be aware of the risk/benefit ratios of these therapies and take them into proper account with respect to providing added value for conventional therapies while avoiding adverse events

We would welcome your questions, comments and suggestions
For more information contact: Betsy Ann Bozzarello, Director, Office of Program Development University of Pennsylvania Health System 1320 Blockley Hall, 423 Guardian Drive Philadelphia, PA 19104-6021 Ph: 215-662-3195 Fax: 215-662-6393 Email: bozzarel@mailmedupennedu
Graphic Design by Sandra Degenhardt

8

University of Pennsylvania Health System 1320 Blockley Hall, 423 Guardian Drive Philadelphia, PA 19104-6021
Non-Profit Org US
Postage PAID Philadelphia,PA Permit No 2563

Source:eatrightalaska.org

Chapter 6: Access and Delivery
In Town Hall meetings across the country during the past two years, people voiced a number of concerns about access of the public to Complementary and Alternative Medicine CAM practitioners and products Issues raised include access to qualified CAM practitioners, state regulation of CAM practitioners, integration of CAM and conventional health care, collaboration between CAM and conventional practitioners, and the cost of CAM services Many people who testified, including those who have only limited access to basic health care, expressed a desire for increased access to safe and effective CAM, along with conventional services As is true for conventional health care, many factors influence access to CAM services and their delivery The distribution and availability of local providers, regulation and credentialing of providers, policies concerning coverage and reimbursement,
and characteristics of the health care delivery system all affect the quality and availability of care and consumer satisfaction Equally important, access is limited by income, since most CAM practices and products are not covered under public or private health insurance programs As with conventional care, access to CAM is more problematic for rural, uninsured, underinsured, and other special populations The issue of access is further compounded by lack of scientific evidence regarding safety and effectiveness of many CAM practices and products A better understanding of how the public uses CAM is needed in order to determine what can be done to improve access to safe and effective CAM within the context of other public health and medical needs In addition, more information is needed on what constitutes appropriate access to CAM services Most CAM practices have developed independently of the conventional health care system and are not uniformly regulated by the states or the Federal
government A variety of market mechanisms and other arrangements have developed to pay for these services, including out-of-pocket payments, discounted fees, insurance reimbursement, and donated services Where the public has had access to CAM services it has often been with little assurance of safety, quality, or efficacy Moreover, because most consumers have had to pay for CAM services directly, access often has been limited to those with higher discretionary income1 An overview of insurance coverage and reimbursement for CAM is presented in Chapter 7 As interest in CAM grows and as CAM increasingly enters the mainstream of American health care, mechanisms that worked in the past to help ensure safety and quality may no longer be adequate For example, if CAM practices become eligible for reimbursement through the health insurance system, issues that now confront the conventional health care system - including safety, fraud, and

Chapter 6 Access and Delivery

88

White House
Commission on Complementary and Alternative Medicine Policy March 2002

practitioner malpractice or incompetence - will need to be addressed for CAM In addition, if private health insurance reimbursement for CAM services increases, questions of equity arise for beneficiaries of Federal - and state- sponsored health care programs, the underinsured, and uninsured Some people believe that existing practice structures have worked well for those who use CAM and that no further action is required But market demand for CAM is already reshaping the dynamics of health care delivery, requiring that some issues be addressed For example, insurers and managed care plans are offering CAM options more frequently, and integrated medical clinics and private practices are spreading As more evidence is published on the safety and effectiveness of CAM practices, they are more likely to be incorporated into health care treatment protocols Now is the time to look at policy options for the future and to
design strategies for addressing potential issues of access and safety Beyond these basic concerns, protecting the public, maintaining free competition in the provision of CAM services, and maintaining the consumers freedom to choose appropriate health professionals are issues to be considered when developing strategies and policies Moreover, the need to maintain CAM styles of practice, rather than allowing them to be subsumed into the conventional medical model, also must be considered when addressing these issues If approached with both imagination and caution, the policy planning process could not only address these issues more effectively, but also a broader set of health issues affecting the nation, such as whether access to safe and effective CAM services can: Benefit vulnerable populations including those with chronic diseases, the terminally ill, and other populations with special needs; Lower health care costs and possibly increase access to conventional health care
services for some segments of the population, such as the chronically and terminally ill; and, Help solve issues of equity and quality that do not set up a zero-sum struggle over limited resources

The present state of evidence concerning the safety and effectiveness of various CAM practices precludes any final assessment of their contributions to and limitations in addressing these broader health issues The process of gathering evidence is on-going, however, and as evidence increases concerning ways that various CAM approaches do or do not affect health, processes of living and dying, and costs for other care, access to and delivery of some CAM practices and services are likely to become more pressing public policy issues Meanwhile, public interest in CAM, and the market dynamics that have evolved in response to it, have brought issues of access to the forefront Policy-makers

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should begin to address these issues and examine the implications of different kinds of policy for consumers and practitioners, for clinics, hospitals and other organizational settings where health care is now delivered, and for the system as a whole ———————————————————————–CAM Practitioners and Public Safety The public has expressed interest in maintaining easy access to CAM practitioners and in having sufficient information about them to make informed choices Perceptions of the relative importance of being able to take responsibility for ones own health and health decisions, yet be protected from incompetent practitioners, underlie differences in consumers response to possible state or Federal regulation of CAM Public sentiment on the need for and degree of regulation ranges, with some calling for more regulation of CAM, to others who are opposed to any regulation The Commission recognizes that Americans want to be able to
choose from both conventional and CAM practices and that they want assurances that practitioners are qualified CAM practitioners have raised additional issues that are important to the public because they affect freedom of access to CAM providers Some health care practitioners, both CAM and conventional, are concerned about liability and prosecution if the services they provide are not commonly accepted within conventional medical practice Another concern of some CAM professionals is that they are licensed to practice in some states but not others, and that even where licensed, their scope of practice may vary across the country While some CAM professions endorse licensure requirements in order to participate fully in the health care delivery system, several people testified that licensure is not feasible for some categories of CAM practitioners, such as Native American and other traditional healers Some CAM practitioners consider their disciplines to be educational Alexander Technique
or spiritual Reiki and have expressed concerns about being licensed as health professionals Some conventional health care practitioners who incorporate CAM modalities into their practices want to broaden the scope of practice laws to allow these modalities to be used Establishing legal authority to practice requires states to establish standards of practice, including training, education and continuing education requirements, as well as scope of practice Some CAM professionals believe that to reorganize CAM on the conventional professional model, with the kind of licensure, registration, or exemption procedures that this implies, will damage the fundamental character of much of CAM Some believe that in the past, legislation to protect the public was often used to restrict competition in the provision of services

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Five important issues of access and delivery concern
both the public and practitioners: Protecting the public from the inappropriate practice of health care, Providing opportunities for appropriately trained and qualified health practitioners to offer the full range of services in which they are trained and competent, Maintaining competition in the provision of CAM and other health services, Preserving CAM styles and traditions that have been valued by both practitioners and consumers, and Determining the extent of the publics choice among health care modalities

If addressed separately, these concerns can lead to very different public policies, and state legislation that affects access to CAM practices varies in its emphasis on these concerns Therefore, when developing strategies to address problems of access to CAM practitioners, all of these criteria should be considered ———————————————————————–Evaluating State Approaches Legislative and regulatory policies that affect conventional
and CAM practitioners fall largely under the aegis of state governments, primarily through regulation of practice In recent years, a few states have passed legislation and enacted regulations that affect access to CAM practitioners These regulations provide a natural experiment for solutions to access and delivery of CAM If properly documented and evaluated, these ventures could provide information that may guide other states and the Federal government in future policy development Minnesota provides almost unlimited freedom to practice Unlicensed practitioners must inform clients of their education, experience, and intended treatments, as well as possible side effects or known risks of the treatments Clients must sign an informed consent statement acknowledging the practitioner is unlicensed, that complaints may be filed with the Minnesota Department of Health if treatment is unsatisfactory, and that they have the right to seek licensed care at any time Requirements for practice are
minimal, but practitioners are not exempted from liability for untoward outcomes Licensed health professionals also may provide CAM services, as long as their provision of the services is consistent with regulations governing their licensure In short, the Minnesota law preserves maximum freedom for CAM practitioners and consumers and relies primarily upon informed consent for protection of health care consumers In contrast, Washington provides licensure, registration, or exemption for various categories of CAM professionals, based on their education and the extent to which their profession prepares practitioners to assume responsibility for the total health care of clients Regulations delineate standards of practice, the scope of practice allowable, education and training requirements for licensure, registration,

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or exemption, and required professional oversight
Four CAM professional groups naturopathic physicians, acupuncturists, massage therapists, and chiropractors are licensed and regulated The emphasis in Minnesota is placed on granting all CAM professionals the freedom to practice with minimal restrictions, while holding them accountable for outcomes The Washington law emphasizes licensure as the route to protecting consumers and the practice rights of some CAM professionals The Minnesota law preserves the range of CAM practices without distinguishing among them, whereas the Washington law requires CAM practitioners to fit into a professional model in order to receive the rights and responsibilities granted conventional health care professions Other states vary considerably in their regulatory approaches to licensure and scope of practice For example, chiropractors are licensed in all states, while acupuncturists, massage therapists, and naturopathic physicians are licensed in 40, 30, and 11 states, respectively Table 1 shows the
distribution of CAM specialties by state These variations affect access to and delivery of CAM by limiting practitioners ability to practice lawfully and to obtain malpractice insurance On the Federal level, several bills have been introduced into recent sessions of Congress that could affect access to CAM, including some that allow greater latitude for unconventional treatments Any Federal legislation drafted in the future should consider the experience states are acquiring through their various legislative initiatives A number of factors should be studied when evaluating state models of creating access and delivery and protecting the public Health services research should document how different legal frameworks affect access to CAM and how this different access affects health outcomes Other issues to be considered include how state regulations affect the supply and distribution of various CAM practices and practitioners over time, as well as competition and costs of services Also
important are the effects of different regulatory models on the safety of the population, problems that may arise from use of different models, and the impact on conventional health care practitioners Changes in the amount of time and quality of interaction with consumers of CAM services might also be assessed through periodic surveys As evidence becomes available about the impact each regulatory model is having, the lessons learned can help inform choices that other states and the Federal government will be making Authority to practice has real impact on access to and delivery of services The Department of Health and Human Services should gather and assess information about effects of these laws on the publics health as well as on access to CAM and CAM practitioners

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———————————————————————–Recommendation 18: The
Department of Health and Human Services should evaluate current barriers to consumer access to safe and effective CAM practices and to qualified practitioners and should develop strategies for removing those barriers in order to increase access and to ensure accountability Actions 181 The Department of Health and Human Services should assist the states in evaluating the impact of legislation enacted by various states on access to CAM practices and on public safety 182 The Department of Health and Human Services and other appropriate Federal agencies should use health care workforce data, data from national surveys on use of CAM, regional public health reports on CAM activities and other studies to identify current and future health care needs and the relevance of safe and effective CAM services for helping address these needs

———————————————————————–Regulatory Frameworks States, in exercising their authority over health care
practitioners, should consider where a regulatory infrastructure for CAM practitioners might be necessary in order to promote quality of care and patient safety The primary mechanisms used by states to regulate health care practitioners are: Mandatory Licensure, which prohibits the practice of a profession without a license Licensure denotes a high degree of professional development, including consensus within the profession concerning standards of education, training, and practice, and the ability to self-regulate Title Licensure, which permits anyone to practice the modality, but allows only those granted a license to use the title A demonstrable level of skill or training normally is required for title licensure Registration, which is granted in some states to professionals such as dieticians and pharmacists upon completion of required training and exams, is in other states simply a requirement that a provider register his or her name, address, and training with a designated state
agency This type of registration prohibits non-registered individuals from practicing and gives the agency authority to receive consumer complaints and revoke registrations Exemption, which accords special status to religious healers Medical licensing statutes do not apply to these healers, provided they practice within the tenets of a recognized church

State and Federal policy-makers and others with an interest in these issues should recognize three unique challenges that face regulation of CAM

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practitioners First, views vary among CAM practitioners regarding how much training should be required for licensure in any given field, the extent to which such training should be required for licensure, and whether and how such education and training can incorporate intuitive skills and individualized approaches to providing health care services For many CAM
providers, licensure presents a tension between the desire to increase standardization of CAM education, training, and practices across states and the desire to keep CAM practice flexible, non-standardized, and linked to subjective, interpersonal and intuitive aspects of care While increased licensure of CAM may help facilitate research, ease referrals, enhance patient access, and increase consumer protection, it may decrease individualization of services, time spent per patient, and range of patient options, qualities of CAM practice valued by practitioners and patients alike Second, variation in what constitutes CAM makes any assessment of CAM as value-added services difficult Disagreement also surrounds the nature and scope of various CAM professions In 2001, the University of California, San Francisco Center for Health Professions published a report that addresses this issue2 Questions it raised include: How does the profession describe itself in terms of the types of care it
provides, and the types of care that are beyond its professional scope? Are there differences of opinion within the profession about the range of care that is appropriate for the profession to provide? What interventions and modalities does the profession use? Answers to these questions will help define the various CAM professions A third, related concern involves the confusion and potential legal consequences that arise from the overlap of approaches and techniques used by CAM practitioners For example, some states include homeopathy and acupuncture within the definition of the practice scopes for naturopathy or chiropractic, whereas others do not Practitioners from states with a broad scope of practice who move to states with a more limited one may be unsure whether they risk state censure by providing these services Confusion and legal risk can occur within a state if the legal authority to practice is not well defined or lacks clarity as to boundaries for practice The potential for
liability creates fear and uncertainty for some CAM practitioners All providers, CAM and conventional, can be prosecuted if they are considered to have exceeded their scope of practice To address some of these issues the Pew Health Professions Commission, established in 1989, conducted an in-depth study of reform in the regulation of health care practitioners They recognized that health care workforce reform would necessitate regulatory reform and created a task force to propose new approaches that would better serve the publics interest In 1995, they published 10 recommendations for regulatory reform and offered policy options, hoping to stimulate debate and discussion by states3 The recommendations focus primarily on regulation of conventional health care practitioners but they are

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applicable to CAM practitioners as well Recommendations from the Pew Commission
Taskforce are in Appendix B ———————————————————————–Recommendation 19: The Federal Government should offer assistance to states and professional organizations in 1 developing and evaluating guidelines for practitioner accountability and competence in CAM delivery, including regulation of practice, and 2 periodic review and assessment of the effects of regulations on consumer protection Actions 191 The Secretary of Health and Human Services should create a policy advisory committee, including CAM and conventional practitioners and representatives of the public, to address issues related to providing access to qualified CAM practitioners, provide guidance to the states concerning regulation possibilities, and provide a forum for dialogue on other issues related to maximizing access 192 The Secretary of Health and Human Services, in collaboration with states, should assist CAM organizations that wish to develop consensus within their field of
practice regarding standards of practice, including education and training The conclusions reached by CAM professional groups concerning these matters should be considered by states and regulatory bodies in determining the appropriate status of these practitioners for such regulatory options as registration, licensure or exemption

———————————————————————–Recommendation 20: States should evaluate and review their regulation of CAM practitioners and ensure their accountability to the public States should, as appropriate, implement provisions for licensure, registration, and exemption consistent with the practitioners education, training, and scope of practice Actions 201 The Department of Health and Human Services policy advisory committee, in partnership with state legislatures, regulatory boards, and CAM practitioners, should develop model guidelines or other guidance for the regulation and oversight of licensed and registered
practitioners who use CAM services and products This guidance should balance concerns regarding protection of the public from the inappropriate practice of health care, provide opportunities for appropriately trained and qualified health practitioners to offer the full range of services in which they are trained and competent, maintain competition in the provision of CAM and other health services, preserve CAM styles and traditions that have been valued by both practitioners and consumers, and determine the extent of the publics choice among health care modalities

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———————————————————————–Hospitals, Nursing Homes, Hospice, Community Health Centers, and other Health Care Delivery Organizations Hospitals and Other Conventional Health Care Settings Because of the increased use of CAM, access and safety issues involving
delivery of CAM in hospitals, hospices, nursing homes, community health centers, and other health delivery organizations are increasing Patients sometimes bring CAM products and even CAM practitioners into inpatient settings Health delivery organizations vary in their policies and procedures regarding such situations, and there is little monitoring of interactions between CAM and conventional health care in these settings Health care facilities credential practitioners who provide services at their facilities The question of who may practice and under what conditions within health delivery facilities is not addressed consistently for CAM practitioners In some facilities, CAM practitioners who are not credentialed are permitted to provide services to patients; in others, only practitioners already credentialed by the facility may provide services Issues of safety and quality of care also arise when conventional practitioners who are credentialed by a facility use CAM in their practice
An increasing number of physicians use CAM practices for their patients in both inpatient and outpatient settings One way to address the growing number of issues related to the use of CAM interventions in hospitals, nursing homes, hospices, other clinical settings, and home health care is through the initiatives and leadership of nationally recognized accrediting organizations, including those that accredit health care networks and managed care organizations For example, the Joint Commission on Accreditation of Healthcare Organizations JCAHO, an independent nonprofit organization, surveys and accredits nearly 18,000 facilities, other health delivery settings, and health plans using professionally based standards to measure compliance Other nationally recognized accrediting organizations include the National Committee for Quality Assurance and the American Accreditation HealthCare Commission The efforts of these organizations to address CAM in all health care settings will contribute
greatly to the publics safety In addition, these efforts will assist state and Federal regulators of health delivery organizations and health plans, who often use accreditation as a proxy for government oversight One important initiative that national accrediting organizations may take is to review their standards, guidelines, and interpretations for areas that affect or are affected by trends in CAM For instance, one JCAHO standard addresses the

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relationship of the hospital staff and its staff members to other health care providers, educational institutions, and payers In this case, more specific guidance is needed as to how a facility can meet the standard when incorporating CAM interventions into hospital services, serving as a component of an integrated delivery system that includes CAM, or participating in collaborative treatment plans with CAM providers The
work of national accrediting organizations includes not only a wide range of standards and guidance, but also measurement tools, quality and performance improvement initiatives, and surveys The work usually is conducted by staff along with representatives of the health care industry, other industry experts, and consumers who serve on various committees and special working groups It is important for national accrediting organizations to include CAM experts and representatives of CAM organizations on any group that addresses issues related to CAM ———————————————————————–Recommendation 21: Nationally recognized accrediting bodies should evaluate how health care organizations under their oversight are using CAM practices and should develop strategies for the safe and appropriate use of qualified CAM practitioners and safe and effective products in these organizations Actions 211 National accrediting bodies, in partnership with other public and
private organizations, should evaluate present uses of CAM practitioners in health care delivery settings and develop strategies for their appropriate use in ways that will benefit the public 212 Nationally recognized accrediting bodies of health care organizations and facilities should consider increasing on-going access to CAM expertise to ensure that processes to develop accreditation standards and interpretations reflect emerging developments in the health care field Nationally recognized accrediting bodies, using CAM experts, should review and evaluate current standards and guidelines to ensure the safe use of CAM practices and products in health care delivery organizations

213

———————————————————————–Community Health Centers, Hospices, Independent Centers and Other Programs A growing number of Americans use community health centers and other public health programs to meet their health care needs, including help with mental health
and substance abuse treatment These centers and programs often emphasize patient-centered care A few community health centers have begun to

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use the services of CAM practitioners such as chiropractors, naturopathic physicians and acupuncturists These centers might serve as models for the use of CAM practitioners by other community health centers and other public health service programs; however, they need to be evaluated to determine their impact on health care access and cost-benefits Hospice care for the terminally ill is another important model that should be evaluated further Some hospice programs are beginning to include CAM practitioners on the treatment team Some of the CAM practices they use are chiropractic, acupuncture, music therapy, meditation, and visualization In some instances, these services are believed to help reduce anxiety and pain Some
independent CAM centers, which may not have any direct hospital affiliation and may not have a physician on staff, also offer a variety of CAM services These centers tend to be client-oriented with flexible hours and a broad spectrum of practitioners available Many of the centers encourage patients to actively improve their health and concentrate on health maintenance rather than disease care and encourage coordination and collaboration among CAM practitioners who are seeing the same patient or client More information is needed on who uses these centers, their impact on access and delivery, whether appropriate referral procedures are in place, and the quality of care provided Only when more systematic data are available can the advantages and disadvantages of independent CAM centers be assessed ———————————————————————–Special and Vulnerable Populations Special populations, such as racial and ethnic minorities, and vulnerable populations,
such as the chronically and terminally ill, have unique challenges and needs regarding access to CAM Efforts to address access to CAM need to be balanced with the need for access to conventional health care Scarce resources need to be carefully allocated so that these populations are not denied opportunities available to others to access safe and effective conventional and CAM services Increased information on CAM use and barriers to access for these populations is needed Although some studies have described CAM use among African Americans, Native Americans, Hispanics, and Asian Americans, reliable access and utilization data are largely lacking In the case of Native Americans, information gathering is limited by their status as sovereign nations Nonetheless, the Indian Health Service has a program to encourage communication with practitioners of traditional Indian medicine, which will help ensure safety when both Native American and conventional medical systems are used Surveys of CAM
use in the general population indicate that it is being used disproportionately by highly educated, and upper-income Americans4 However,

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early studies used telephone interviews with English speakers, thus providing little information about CAM use among those who do not speak or have limited ability in English, who have lower income, or who lack telephones5 Later studies corrected for these biases, but they did not use adequate statistical sampling to estimate the use of CAM in minority populations6, 7, 8, 9, 10, 11 Other surveys have focused on low-income and ethnic groups, but these studies frequently had small, unrepresentative samples12, 13, 14, 15 The National Center for Health Statistics is conducting a nationwide survey on access to and use of CAM among racial and ethnic minorities that is expected to provide statistically reliable estimates of CAM use in
these groups In an October 2000 letter to community health centers and other public health programs, the Health Resources and Services Administrations Bureau of Primary Health Care BPHC endorsed the use of CAM in these centers where appropriate 16 In 2001 they began surveying the use of CAM by persons receiving health services from BPHC-funded community health centers Information being gathered includes participants use of six modalities acupuncture, manual healing, botanicals and herbs, homeopathy, traditional healing, and mind-body techniques; whether the CAM service was provided onsite or by referral, either with or without payment by the community health center; and demographic data Results should be available in 2002 and will provide a significant, statistically reliable portrait of the use of a variety of CAM services and products by community health center clients, whose come disproportionately from rural, low-income, and minority populations It is important to continue
collecting this kind of information in the future Discussions are currently underway between BPHC and the National Center for Complementary and Alternative Medicine to include clients of community health centers in CAM clinical trials, in order to increase the relevance of findings for application to the health needs of minority populations Use of CAM is especially high among populations with potentially life-threatening diseases Surveys show that people with cancer use CAM practices and products more frequently than the population as a whole, with CAM most often being used in conjunction with conventional therapies17, 18,19 Similarly, there is high use of CAM by people who are terminally ill and their care-takers Many people in these vulnerable populations are using CAM services regardless of whether they have insurance coverage and sometimes without the knowledge or cooperation of their conventional physician The chronically and terminally ill consume more health care resources than
the rest of the population Approximately 75 percent of all health care spending in the US currently is for the treatment of chronic disease 20, and 25 percent of Medicare spending is for costs incurred during the last year of life21 The great interest in CAM practices among the chronically ill, those with life-threatening conditions, and those at the end of their lives suggests that increased access to

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some CAM services among these groups could have significant implications for the health care system Health services research, demonstrations, and evaluations are needed to assess whether CAM services can improve care and quality of life for people in these groups, and possibly lessen the use of expensive technological interventions With the number of older Americans expected to increase dramatically over the next 20 years, alternative strategies for dealing with
end-of-life processes will be increasingly important in public policy This demographic shift should influence priorities for the kinds of research and demonstration projects that would be carried out in the near future A more careful assessment of the potential and limitations of CAM approaches in the health care system as a whole might lead to more effective use of resources For example, Congress could direct the Center for Medicare and Medicaid Services to develop a demonstration project to study evidence-based CAM interventions as part of comprehensive care of persons with chronic disease in both the Medicare and Medicaid programs The demonstrations would assess health outcomes and total costs of care for beneficiaries in settings where physician leaders are committed to evidencebased medicine, high quality, client-centered care, and openness to CAM approaches If evaluations show that some uses of CAM can lessen the need for more expensive conventional care in these populations, the
economic implications for these Medicare and Medicaid could be significant If safe and effective CAM practices become more available to the general population, special and vulnerable populations should also have access to these services, along with conventional healthcare CAM would not be a replacement for conventional health care, but would be part of the options available for treatment In some cases, CAM practices may be an equal or superior option Evidence for assessing the potential of CAM interventions in treating vulnerable and special populations is still being gathered While it is too early to judge the effectiveness of CAM in addressing their health care needs, CAM nonetheless offers the possibility of a new paradigm of integrated health care that could affect the affordability, accessibility, and delivery of health care services for millions of Americans ———————————————————————–Recommendation 22: The Federal government should
facilitate and support the evaluation and implementation of safe and effective CAM practices to help meet the health care needs of special and vulnerable populations Actions 221 The Department of Health and Human Services and other Federal Departments should identify models of health care delivery that include safe and effective CAM practices, evaluate them, and then support those

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models which are successful for use with special and vulnerable populations, including the chronically and terminally ill 222 The Department of Health and Human Services should sponsor the development and evaluation of demonstration projects that integrate the use of safe and effective CAM services as part of the health care programs in hospices and community health centers The Department of Health and Human Services should identify ways to support the practice of indigenous healing in
the United States and to improve communication among indigenous healers, conventional health care professionals, and CAM practitioners

223

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Table 1 Provider Licensing by State and Specialty

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References 1 Eisenberg, DM, Kestrel RC, Foster C, et al Unconventional Medicine in the United States: Prevalence, Costs, and Patterns of Use New England Journal of Medicine 1993; 3284: 246-252 University of California, San Francisco The Center for the Health Professions Profiling the Professions: A Model for Evaluating Emerging Health Professions 2001 University of California, San Francisco The Center for the Health Professions Reforming Health Care Workforce Regulation Policy: Considerations for the 21st Century 1995 Eisenberg DM, Davis RB, Ettner SL, et
al Trends in Alternative Medicine Use in the United States, 1990-1997: Results of a Follow-up National Survey Journal of the American Medical Association 1998; 280:15691575 Wootton JC, Sparber A Surveys of Complementary and Alternative Medicine: Part I General Trends and Demographic Groups Journal of Alternative and Complementary Medicine 2001; 72: 195-208 Allen R, Cushman LF, Morris S, et al Use of Complementary and Alternative Medicine Among Dominican Emergency Department Patients American Journal of Emergency Medicine 2000; 18:51-54 Cushman LF, Wade C, Factor-Litvak P, et al Use of Complementary and Alternative Medicine Among African-American and Hispanic Women in New York City: Pilot Study Journal of the American Medical Womens Association 1999; 54 4: 193-195 Keegan L Use of Alternative Therapies Among Mexican-Americans in the Texas Rio Grande Valley Journal of Holistic Nursing 1996; 14 4: 277294 Kim C, Kwok YS Navajo Use of Native Healers Archives of Internal Medicine 1998;
158:2245-2249 Ma GX Between Two Worlds: The Use of Traditional and Western Health Services by Chinese Immigrants Journal of Community Health 1999; 246: 421-437 Risser AL, Mzur LJ Use of Folk Remedies in a Hispanic Population Archives of Pediatric Adolescent Medicine 1995; 149: 978-981

2

3

4

5

6

7

8

9

10

11

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12

Breunner CC, Barry PJ, Kemper KJ Alternative Medicine Use by Homeless Youth Archives of Pediatric Adolescent Medicine 1998; 152: 1071-1075 Burg MA, Hatch RL, Neims AH Lifetime Use of Alternative Therapy: a Study of Florida Residents Southern Medical Journal 1998; 9112: 11261131 Johnson JE Older Rural Women and the Use of Complementary Therapies Journal of Community Health Nursing 1999; 164: 223-232 Pourat N, Lubben J, Wallace SP, Moon A Predictors of Use of Traditional Korean Healers Among Elderly Koreans in Los Angeles Gerentologist 1999; 396:
711-719 Program Assistance Letter, Bureau of Primary Health Care, October 2001 Friedman T, Slayton WB, Allen L, et al Use of Alternative Therapies for Children with Cancer [abstr] Pediatrics 1997; 1006 E1 Kelly KM, Jacobson JS, Kennedy DD, et al Use of Unconventional Therapies by Children with Cancer at an Urban Medical Center Journal of Pediatric Hematology and Oncology 2000; 225: 412-416 Wyatt GK, Friedman LL, Given CW, et al Complementary Therapy Use Among Older Cancer Patients Cancer Practice 1997; 73: 136-144 Hoffman C, Rice D, Sung HY Persons with Chronic Conditions: Their Prevalence and Costs Journal of the American Medical Association 1996; 27618: 1473-1479 Hogan C, Lunney J, Gabel J, et al Medicare Beneficiaries Costs of Care in the Last Year of Life Health Affairs 2001; 20: 188-195

13

14

15

16

17

18

19

20

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Source:pilchuckvet.com

The Landmark Report II

on HMOs and Alternative Care

A b o u tt Abou tt h ii ss h

ss tt u d yy ud
Undeniably, the demand for alternative care among health care consumers is growing, as evidenced by several recent studies on the use of alternative medicine among the general public To date, however, there has been little published information about the perceptions of a key link in the future of alternative care–the health maintenance organizations HMOs which lie at the center of the managed care system in the United States To gain a better understanding of how HMOs view alternative care, their current and planned addition of these therapies to their product offerings, their motivations for adding or not adding these therapies, and their beliefs about the future of alternative care in the United States, Landmark Healthcare, Inc commissioned a study on HMOs and alternative care

HMOs and their alternative care programs

33 of HMOs
do not
offer alternative care

67 of HMOs
offer at least one type of alternative care therapy

Conducted from late November 1998 through early January 1999, this study consisted of telephone interviews with 114 senior executives of HMOs from across the country Commissioned by Landmark, a California-based complementary alternative health care company, and conducted by National Market Measures, Inc, a full-service marketing research company, the purpose of the study was to examine the alternative care market from the standpoint of HMOs As the organizations at the forefront of managed health care in the United States, HMOs have the potential to play a significant role in the future of alternative care over the next decade The population of HMOs nationwide that qualified for this study was 449, so this sample represents 25 of the entire universe In a random sample of 114, the maximum statistical error is 79 in a two-way split of the data at the 95 confidence level after applying the finite
population correction factor

This includes 5 of HMOs that offer chiropractic but do not consider it to be alternative care

Selected findings from a nationwide study of HMO senior executives examining their perceptions, the prevalence and future of alternative care in the United States

Selected
Types of alternative care currently offered by HMOs
Chiropractic Acupuncture Massage Therapy Vitamin Therapy Relaxation Therapy Herbal Therapy Homeopathy Guided Imagery Acupressure Stress Management Tai Chi Yoga Biofeedback Naturopathy Nutritional Therapy Hypnotherapy
6 5 30 4 4 4 4 4 3 3 2 2 2 2
21 think
alternative care reduces total health care costs
10 20 30 40 50 60 70

F

i

n

d

i

n

g

s

Average proportion of membership provided with alternative care among HMOs that offer it
65
The most common type of alternative care is chiropractic, which is offered by two-thirds of all HMOs

Most important reasons HMOs add alternative care among HMOs that offer it
Members, employers, groups
asked Required by law, mandate Clinically effective

70 60 48 50 40 56

This 8 percentage point change represents a 17 increase

38 reasons for adding

The most important alternative care are to

31 11

38 meet member, employer 8 7 5 4
5 10 15 20 25 30 35 40

and group demand or legal requirements

Differentiate from competitors Meet competition Attract members
0

20 10 0 Now 2-3 Years

Perceived impact of alternative care on total health care costs

Relationship between alternative and traditional care
0 think that care will move further apart

Outlook on consumer demand for alternative care
0 think there will be no
consumer demand for alternative care

Reflexology 1 Meditation 1
0

15 think there will be no change 49 think

34 believe
demand will be strong

40 believe demand
will be moderate

Nearly three-fourths of HMOs believe consumer demand will be moderate to strong Figures do not total 100 due to rounding

30 think alternative care has a neutral impact on total health care
costs

alternative care adds to total health care costs

85 think care will move closer together

27 believe demand will be mild

About Landmark Healthcare
Landmark Healthcare, Inc is a national health care company expressly focusing on complementary and alternative pathways to health With a long history of arranging for clinically supported complementary alternative medicine CAM programs within the managed care environment, Landmark continues to broaden the array of CAM products available to the US health care market Landmark will continue to assess the market and future for complementary alternative care, its legitimacy and clinical efficacy–sharing this information with the community at large and with health care professionals, given the relevance of this information in decision-making about overall health care For more information about this study, to request a full report, or to find out more about Landmark, please visit our web site at wwwlandmarkhealthcarecom or call us at 800
638-4557

1750 Howe Avenue, Suite 300 Sacramento, CA 95825 800 638-4557 wwwlandmarkhealthcarecom 1999 Landmark Healthcare, Inc

Source:landmarkhealthcare.com

The Tower of Babel: Communication and Medicine
An Essay on Medical Education and Complementary-Alternative Medicine
Opher Caspi, MD; Iris R Bell, MD, PhD; David Rychener, PhD; Tracy W Gaudet, MD; Andrew T Weil, MD

As society changes, medical education also must change1

omplementary and alternative medicine CAM is constantly gaining in popularity2-6 Despite its widespread use, valid concerns have been raised regarding the integration of CAM into the health care system7 Certainly, the gap between allopathy and CAM is very substantive It pertains to methodology and rigorous applications of scientific standards of evidence, among other issues, as well as to the meaning and context of illness and health At present, it remains unclear 1 whether a true integration of conventional and unconventional therapies is even possible, 2 what this integration would look like, and 3 whether we are ready for the new era of medicine that would then result8-10
The most commonly addressed
aspects of CAM in the medical literature are its safety, efficacy, and legislation These issues are discussed and presented in detail elsewhere11,12 However, what very may well be one of the most difficult obstacles in the implementation of a true health integration is unfortunately rarely addressed: the lack of a common language among CAM providers and allopathic physicians In this article, we use the Tower of Babel as a metaphor to advocate dialogue as a way to bridge that gap between these 2 camps In doing so, we stress the important role of medical education in developing appropriate communication skills among all health care providers Despite the fact that we often herein refer to a deficiency in CAM training for allopathic students, we strongly believe that this development should be a perfectly symmetrical reciprocal process, ie, that the depth and breadth of the training of CAM practitioners should be such that they would be able to speak the biomedical language The ability to
communicate is the foundation of medical practice When communication with patients is impossible, treatment is far from ideal The same
From the Program in Integrative Medicine, Departments of Medicine Drs Caspi, Bell, Rychener, Gaudet, and Weil, Psychology Drs Caspi and Bell, Psychiatry Dr Bell, and Family and Community Medicine Dr Weil, University of Arizona College of Medicine, Tucson
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holds true with regard to communication among health care providers Today, competent physicians are expected to have a knowledge base that extends well beyond specific diseases and disorders pertaining to their medical fields The importance of communication is not merely for the purpose of dialogue: it is an essential requirement for the optimizing of treatment Interdisciplinary medical discourse is therefore the bread and butter of practicing medicine It is that belief in broad-based knowledge that concerns us most when it applies to CAM The
present relative scarcity of thorough exposure of allopathic medical students to the diversity of CAM therapies and their fundamental concepts13 and of students of CAM to allopathy and its related sciences14 is far from ideal This scarcity may result in a lack of understanding of all health systems and may create a risky situation in which future practitioners, allopathic and CAM alike, may not be optimally able to discuss in depth all legitimate evidence-based treatment options with their patients For most allopathic physicians, a genuine understanding of the underlying concepts and practices of CAM, such as acupuncture and homeopathy, is almost beyond achievement15 This lack of understanding is not because physicians do not have the ability or willingness to un-

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derstand CAM, but because of a much simpler reason: the 2 domains do not speak the same language The root of this discrepancy, in our viewpoint, is
directly related to the entire process of medical education of both conventional and unconventional practitioners Studying pathophysiology, principles and applications of epidemiology, pharmacology, molecular biology, and other disciplines that are rich in concepts and methodology throughout medical training is basically possible because we as a profession have succeeded in creating a common language, one that scientifically makes sense Like trainees in many other professions, allopathic medical students are required to learn both the vocabulary ie, medical terms and the grammar ie, how to use these terms of almost all biomedical disciplines Indeed, going through medical school is very much about learning this new biomedical jargon If we are taught only 1 set of vocabulary, communication is less rich and therefore at times less effective, and if we miss words, we often miss concepts How can we expect CAM and allopathy to be integrated when skilled practitioners in both camps are only
partially familiar with the vocabulary and grammar of the other? What do we allopathic practitioners really know about Qi the Chinese term for vital energy? The widespread use of jargon that is peculiar to particular CAM practices can clearly act as an impediment to constructive dialogue16 We must admit that the majority of us know very little about the basic ideas of CAM17 Likewise, what do CAM providers really know about applied molecular biology? Not much, we suspect In such a climate, communication between both schools of thought is almost impossible Is this not a modern form of the Tower of Babel? So, how can we overcome this language obstacle in our long march toward a full implementation of integrative medicine? The key answer, in our opinion, lies in the medical education paradigm We believe that studying the ABC language17 of the most common CAM disciplines in medical schools, along

with the conventional curriculum, will help to educate a new generation of physicians with a
better ability to communicate with CAM providers Such an integrative curriculum is fully justified when the World Health Organization classifies 65 to 80 of the worlds health care services as alternative medicine18 Indeed, in a recent survey, more than 80 of medical students in the United States and the United Kingdom stated that they would like to have more training in CAM practices19,20 A 1997 American Medical Association report on encouraging medical student education in complementary health care practice21 concluded that medical schools should be free to design their own required or elective experience related to CAM A 1997-1998 survey of 117 US medical schools13 found that 64 offered an elective course in alternative medicine or included information about alternative medicine in a regular course Topics included chiropractic, acupuncture, homeopathy, herbal therapies, and mindbody techniques Sixty-eight percent of the courses were stand-alone courses, whereas 31 were part of a
required course In trying to develop a more consistent educational approach to CAM, Wetzel et al13 made the following suggestions: 1 Focus on critical thinking and critical reading of the literature; 2 Identify thematic content ; 3 Include an experiential component; 4 Promote a willingness to communicate professionally with alternative health care clinicians; and 5 Teach students to talk to patients about alternative therapies We strongly agree; therefore, we believe that CAM education should not be regarded as an optional dessert but rather as part of the main course For us, the crucial question is not how many CAM modalities will be covered in such a course, but will future physicians practice a more human oriented healing? We believe that a trial to study the impact of changing medical education toward healing using an integrative curriculum is warranted before a wide-scale application will be merited The Program in Integrative Medicine at the University of Ari-

zona, Tucson of
which all authors are part, pioneers this approach, and its mission is changing medical education22 Support of our proposition comes from the recently published Suggested Curriculum Guidelines on Complementary and Alternative Medicine, developed by the Society of Teachers of Family Medicine Group on Alternative Medicine23 The guidelines, to be included in residency training, indicate the knowledge, skills, and attitudes that graduating residents should acquire to be able to function as unbiased advocates and advisors to patients about CAM Using the authors own words to communicate effectively with patients about alternative therapies requires that our graduates have a reasonable knowledge base in this area23 Providing medical students the fundamental concepts of CAM will hopefully contribute to our ability to communicate on 3 different levels First, and most importantly, these concepts might help make physicians less biased, and therefore more able to objectively or effectively judge
the appropriateness of CAM therapies Second, the physicians will also be knowledgeable enough to impart the relevant information regarding different CAM modalities to their patients Third, having been exposed to different models of medicine, they may serve as a pool of future researchers, educators, and open-minded skeptics for the vast body of research that is so vitally needed regarding CAM and integrative medicine The establishment of evidencebased CAM is highly dependent on the proper allocation of resources, in terms of professionals and funds, by the medical community Opponents of integrative medicine usually discount CAM, citing a lack of scientific evidence24 We believe that the creation of a new generation of CAM-educated physicians, with the ability to speak the CAM language, will give us an opportunity to investigate what is actually behind the scenes of these unconventional forms of treatment We wish to see special CAM departments in conventional medical schools that will
provide a rigorous atmosphere

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wherein academic reward will be available, research facilities will be abundant, money to support such research will be duly allocated, and there will be no shortage of research expertise25,26 Once this goal is accomplished, safety and efficacy can be more thoroughly addressed Assuming that reorganizing this dimension of medical schools will take much time, we are calling for the ad hoc establishment of interdisciplinary including both conventional and unconventional practitioners forums of dialogue that can serve as a bridge for continuous medical education for the benefit of both patients and health providers Because more and more scientists realize that domains of knowledge, and their application, are virtually infinite, there is now a strong metascientific call for interdisciplinarity, one that crosses boundaries of
disciplines and institutions A genuine need for interdisciplinarity is hence not unique to medicine For further discussion of this intriguing concept, the reader is kindly referred to an excellent article by Bugliarello27 The widespread use of CAM makes dealing with different aspects of the integration of CAM and conventional therapies not solely the interest of CAM practitioners, but rather in everybodys domain Since patients who seek alternative medical treatments are not alternative patients, they have the right to be treated according to the same ethics and standard of treatment28 as those of conventional medicine Unfortunately, even though at present we are far away from evidencebased complementary medicine, we must strive toward it29-33 The perceived lack of hard data regarding CAM greatly limits our ability to provide our patients with enough information to make informed decisions As a result, there are many misconceptions about CAM, misconceptions that leave both physicians and
patients with a high degree of uncertainty34 We truly do not know what the gold standard for care that applies to integrative approaches is All we can do at present is to provide our patients with informed skepticism 35 Again, change in medical education seems

a justified approach for improving our knowledge and practice A real breakthrough in CAM as a legitimate form of therapy can only occur when the 2 schools of thought learn a common language in which to communicate and consequently begin to truly collaborate This new and unique dimension of the health care system, integrative medicine, can then bring current health care to new horizons Accepted for publication May 18, 2000 Corresponding author: Opher Caspi, MD, Program in Integrative Medicine, Department of Medicine, College of Medicine, University of Arizona Health Sciences Center, PO Box 245153, Tucson, AZ 85724-5153 e-mail: ocaspi@ahscarizonaedu
REFERENCES
1 Wetzel MS, Eisenberg DM, Kaptchuk TJ Courses involving complementary
and alternative medicine at US medical schools [letter] JAMA 1999; 281:609-611 2 Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL Unconventional medicine in the United States: prevalence, costs, and patterns of use N Engl J Med 1993;328:246252 3 Fisher P, Ward A Complementary medicine in Europe BMJ 1994;309:107-111 4 MacLennan AH, Wilson DH, Taylor AW Prevalence and cost of alternative medicine in Australia Lancet 1996;347:569-573 5 Abbot NC, White AR, Ernst E Complementary medicine Nature 1996;381:361 6 Astin JA Why patients use alternative medicine: results of a national study JAMA 1998;279:15481553 7 Coates JR, Jobst KA Integrated healthcare: a way forward for the next five years? a discussion document from the Prince of Waless Initiative on Integrated Medicine J Altern Complement Med 1998;4:209-247 8 Dalen EJ Conventional and unconventional medicine: can they be integrated [editorial]? Arch Intern Med 1998;158:2179-2181 9 Anderson R A case study in
integrative medicine: alternative theories and the language of biomedicine J Altern Complement Med 1999;5:165-173 10 Dacher ES A personal response to A case study in integrative medicine: alternative theories and the language of biomedicine J Altern Complement Med 1999;5:175-176 11 Ernst E The risks of acupuncture Int J Risk Safety Med 1995;6:179-186 12 Vickers A, Cassileth B, Ernst E, et al How should we research unconventional therapies? a panel report from the Conference on Complementary and Alternative Medicine Research Methodology, National Institutes of Health Int J Technol Assess Health Care 1997;13:111-121 13 Wetzel MS, Eisenberg DM, Kaptchuk TJ Courses involving complementary and alternative medi-

14

15

16

17

18 19

20

21

22

23

24 25 26

27

28 29 30

31

32

33

34 35

cine at US medical schools JAMA 1998;280: 784-787 Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M A comparative study of chiropractic and medical education Altern Ther Health Med 1998;4: 64-75 Ernst
E, Resch KL, White AR Complementary medicine: what physicians think of it: a metaanalysis Arch Intern Med 1995;155:24052408 Eskinazi D, Muehsam D Factors that shape alternative medicine: the role of the alternative medicine research community Altern Ther Health Med 2000;6:49-53 Zollman C, Vickers A ABC of complementary medicine: what is complementary medicine? BMJ 1999;319:693-696 Jonas WB Researching alternative medicine Nat Med 1997;3:824-827 Halliday J, Taylor M, Jenkins A, Reilly D Medical students and complementary medicine Complement Ther Med 1993;1suppl:32-33 Hopper I, Cohen M Complementary therapies and the medical profession: a study of medical students attitudes Altern Ther Health Med 1998;4: 68-73 American Medical Association Council on Medical Education Encouraging Medical Students Education in Complementary Health Care Practices Chicago, Ill: American Medical Association; June 1997 Gaudet TW Integrative medicine: the evolution of a new approach to medicine and to medical
education Integr Med 1998;1:67-73 Kligler B, Gordon A, Stuart M, Sierpina V Suggested curriculum guidelines on complementary and alternative medicine: recommendations of the Society of Teachers of Family Medicine Group on Alternative Medicine Fam Med 1999;31:30-33 Coulson J Doctors need evidence on complementary medicine BMA News Review July 1995:16 Horton R Andrew Weil: working towards an integrated medicine Lancet 1997;350:1374 Ernst E The Department of Complementary Medicine at Exeter: the first three years Int J Altern Complement Med May 1997:9-12 Burgliarello G The interdisciplinarity imperative to create new knowledge and uses of knowledge across boundaries of disciplines and institutions In: Roy R, ed Interdisciplinarity Revisited: Interactive Research and Education, Still an Elusive Goal in Academia Campbell, Calif: iUniversecom Inc In press Gillon R Medical ethics: four principles plus attention to scope BMJ 1994;309:184-188 Ernst E Complementary medicine: scrutinizing the
alternatives Lancet 1993;341:1626 Van Haselen R, Fisher P Evidence influencing British health authorities decisions in purchasing complementary medicine [letter] JAMA 1998; 280:1564-1565 Fontanarosa PB, Lundberg GD Alternative medicine meets science [editorial] JAMA 1998;280: 1618-1619 Margolin A, Avants SK, Kelber HD Investigating alternative medicine therapies in randomized controlled trials JAMA 1998;280:1626-1628 Ezzo J, Berman BM, Vickers AJ, Linde K Complementary medicine and the Cochrane Collaboration JAMA 1998;280:1628-1630 Ernst E Complementary medicine: common misconceptions J R Soc Med 1995;88:244-247 Eisenberg DM Advising patients who seek alternative medical therapies Ann Intern Med 1997; 127:61-69

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Use of complementary and alternative medicine among United States adults: the influences of personality, coping strategies, and social support
Keiko Honda, PhD, MPH and Judith S Jacobson, DrPH
Department of Epidemiology, Columbia University, New York, NY 10032, USA Available online 26 June 2004

Abstract Background Although patterns of utilization of complementary and alternative medicine CAM in the community have begun to be described, few studies have addressed the relationships between dispositional psychological factors and the use of CAM The aim of this study was to examine the associations between CAM use and personality, coping strategies, and perceived social support in a representative sample of adults in the United States Methods Data were drawn from the Midlife Development in the United States Survey MIDUS, a representative sample of 3,032 adults aged 25 74 in the US population We analyzed use of acupuncture,
biofeedback, chiropractic, energy healing, exercise/movement therapy, herbal medicine, high-dose megavitamins, homeopathy, hypnosis, imagery techniques, massage, prayer/spiritual practice, relaxation/ mediation, and special diet within the last year Multiple logistic regression analyses were used to evaluate the association of personality, dispositional coping strategies primary and secondary control, and perceived social support and strain with CAM use, controlling for sociodemographic factors, medical care access, and physical and mental disorders Results Openness was positively associated with the use of all types of CAM except manipulative body-based methods Extroversion was inversely correlated with the use of mind body therapies Primary control was inversely and secondary control directly correlated with the use of CAM Perceived friend support was positively associated with the use of mind body therapies, manipulative body-based methods, and alternative medical systems
Perceived partner strain was positively associated with the use of biologically based therapies, and family strain increased the odds of manipulative body-based methods Conclusions This study is the first to document a significant association between specific domains of personality, coping strategies, and social support, and the use of CAM among adults in the general population Understanding the relationships between psychological factors and CAM use may help researchers and health care providers to address patients needs more effectively and to achieve better adherence to treatment recommendations D 2004 The Institute For Cancer Prevention and Elsevier Inc All rights reserved
Keywords: Complementary and alternative medicine; Coping style; Psychological; Social support; Personality

Introduction Complementary and alternative medicine CAM is increasingly accepted in the United States both as treatment for illness and as self-care to promote health and well-being [1 3] Many mainstream
physicians are either referring patients to or practicing CAM modalities, and appear to understand the potential usefulness of CAM [4 6] However, little is known about the dispositional personal factors
Corresponding author Department of Epidemiology, Columbia University, Room 719, 722 West 168th Street, New York, NY 10032 Fax: 1-212-305-9413 E-mail address: kh2086@columbiaedu K Honda

associated with CAM use and CAM choices in the general population Understanding these associations may facilitate the development of evidence-based CAM and enhance adherence to therapeutic recommendations The National Center for Complementary and Alternative Medicine NCCAM has supported research on how health is related to cognition, personality, and social ties [3], but studies of how CAM use is related to these factors may also be worthwhile Clinical observations [7 9] suggest that several psychological factors may be relevant to CAM use: 1 dispositional coping strategies ie, optimism and pessimism; 2
congruence between the patients personal values and beliefs about CAM and the physicians perspective; and

0091-7435/ - see front matter D 2004 The Institute For Cancer Prevention and Elsevier Inc All rights reserved doi:101016/jypmed200405001

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47

3 previous experiences of the patient, family members, and friends with the medical system Several investigators [10 13] have quantitatively or qualitatively examined the relationship of CAM use with personality, coping styles, ethnicity/culture, and the influence of family and friends For example, in a study of cancer patients [13], active coping style and religiousness, but not lack of social support or information, were significantly associated with increased use of CAM Using the Tellgen Absorption Scale TAS, another study conducted among clinical and community samples [10] found absorption,1 which is known to be positively correlated with the trait of openness to experience [14],
to be an independent predictor of CAM use Because most patients make choices about CAM use without guidance from a conventional care provider, their own psychosocial characteristics may play a much greater role in their CAM use than in their conventional medical care Three features of previous studies have limited our understanding of the roles of psychological factors in CAM use in the community: 1 studies using convenience samples drawn from treatment settings have had limited generalizability; 2 studies of community-based samples have focused on demographic factors and medical conditions and have not explored psychological factors; and 3 few studies have assessed the predictors of specific types of CAM use The aim of this study is to evaluate the association of personality, coping strategies, and perceived social support with CAM use and their relative importance in CAM choices

4,242 subjects unweighted corresponds to 3,032, weighted for selection probabilities and non-response to
permit generalizability to the US population on age, gender, race, and education [15] Measures CAM use Respondents were asked whether they had received any of the following 14 CAM modalities in the past 12 months: acupuncture, biofeedback, chiropractic, energy healing, exercise/movement therapy, herbal medicine, high-dose megavitamins, homeopathy, hypnosis, imagery techniques, massage, prayer/spiritual practice, relaxation/meditation, special diet We grouped these practices into the five domains proposed by the NCCAM: alternative medical systems eg, acupuncture, homeopathy; body mind therapies eg, biofeedback, hypnosis, relaxation/meditation, imagery techniques, and prayer/spiritual practice; biologically based therapies eg, herbal medicine, high-dose megavitamins, special diets; energy therapies eg, healing touch, Reiki; and manipulative/body-based methods eg, massage therapy, exercise/movement therapies, chiropractic [3] Personality traits Assessment of personality traits in the
MIDUS was based on the big five factor model [17], which was tested in a pilot study conducted in 1994 with a probability sample of 1,000 men and women, age 30 70 574 valid cases were usable for item analysis Respondents were given a list of adjectives representing aspects of personality and asked to use a four-level Likert-scale to describe how much of the time all, most, some, or a little each word described them The adjectives were interpreted as comprising five traits or scales: Agreeableness helpful, warm, caring, softhearted, sympathetic a 080 five-item scale; Openness to experience creative, imaginative, intelligent, curious, sophisticated, adventurous a 077 seven-item scale; Conscientiousness [organized, responsible, hardworking, not careless] a 057 four-item scale; Extroversion outgoing, friendly, lively, active, talkative a 078 five-item scale; and Neuroticism moody, worrying, nervous, not calm a 074 four-item scale The alphas are based on the MIDUS national sample For
each respondent who provided valid values for at least half the adjectives comprising a trait, the trait was scored as the mean of the responses for that trait Primary and secondary control strategies The two-process model of primary and secondary control is a conceptualization that proposes two main coping strategies by which people may develop a sense of control [18 20] Primary control refers to individuals attempts to make external social and physical or behavioral circumstances conform to their personal needs and desires, whereas secondary control refers to individuals efforts to adapt

Methods Sample The Midlife Development in the United States Survey MIDUS is a nationally representative survey of 4,242 persons aged 25 74 years in the noninstitutionalized civilian population of the 48 coterminous United States [15] The MIDUS Survey was carried out by the John D and Catherine T MacArthur Foundation Network on Successful Midlife Development between January 1995 and January 1996 All
respondents completed a 30-min telephone interview and filled out two mailed questionnaires estimated to take a total of about 90 min to complete 868 conditional response rate in the subsample of telephone respondents The overall response rate was 608 More details on the MIDUS Survey design, filed procedures, and representativeness are provided elsewhere [15] The total sample of
Absorption refers to the disposition to display episodes of total attention during which the available representational apparatus seems to be entirely dedicated to experiencing and modeling the attentional object, be it a landscape, a human being, a sound, a remembered incident, or an aspect of ones self [16], p 274
1

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their cognitive and affective states in response to stressful life events [20] Respondents were asked to indicate how well each of 14 items described them, using a four-point Likert scale 1 not at all, 4 a lot [21] Assessment of
control strategies in the MIDUS used a three-factor model developed from a study conducted by Wrosch et al [21] Scales included a primary control persistence in goal striving a 077 five-item scale, a secondary control positive reappraisals a 078 four-item scale; and a secondary control lowering aspiration a 063 fiveitem scale Items were recoded so that higher scores indicated higher primary or secondary control Perceived social support and strain In the MIDUS, social support and social strain were evaluated as emanating from family members other than the spouse/partner, friends, and spouse/partner Supportive network exchanges were measured through four items that were parallel for spouse/partner, family members, and friends The four items were:

included in the model because it is known to affect health care utilization Data analysis First, F-based tests for independence were conducted to compare the sociodemographic, clinical, and psychosocial personality, coping, and social
support characteristics of respondents who had and had not used any CAM in the past 12 months Next, descriptive analyses were used to assess the prevalence of each CAM modality by presence and absence of mental and physical disorders Finally, multiple logistic regression analyses were used to examine the relationships between psychological factors personality, control strategies, and perceived social support and strain, and CAM use, controlling for sociodemographics age, gender, race, education, and marital status, health care access, and physical and mental health conditions major depression, anxiety disorders, panic disorders, heart-related problems, cancer, and obesity All psychological factors were measured on a continuous four-point scale We calculated the mean by summing the scales and dividing by the number of scales for each factor Hence, these associations reflect the increase in CAM use associated with every 1-point increase in the mean score for each psychological factor All
results reported here are based on weighted data, adjusted for differential probabilities of selection within households and for differences between the sample distribution and the census population distribution on a range of sociodemographic variables

How much do they family members, not including your spouse or partner; friends; spouse/partner understand the way you feel about things? How much do they really care about you? How much can you rely on them for help if you have a serious problem? And, how much can you open up to them if you need to talk about your worries? Strained network exchanges were also measured through four parallel items that read:

How often do they criticize you? How often do they make too many demands on you? How often do they let you down when you are counting on them? And, how often do they get on your nerves? All items were answered on a four-point Likert-type scale support items: 1 a lot; 4 not at all; strain items: 1 often, 4 never Items were
recoded so that higher scores indicated higher support or strain Cronbachs alpha scores were: Family support 082, Family strain 080, Friend support 088, Friend strain 079, Partner support 086, and Partner strain 081 [22] Covariates Based on previous studies [1,2,7,13,23,24], certain sociodemographic and health-related factors were hypothesized to predispose to CAM use Health factors including major depression, panic attacks, generalized anxiety disorder as well as heart-related problems, cancer, and obesity were assessed and included in the regression model Age, gender, marital status, race/ethnicity, and education were included in the model Health insurance coverage was also

Results Overall, 54 of the sample n 3,032 reported having used any kind of CAM in the past 12 months Individuals who reported CAM use were more likely to be female, white, or college educated than, but were similar in age and marital status to, those who did not use any CAM see Table 1 Users of CAM were more
likely to report mental disorders major depression and panic disorders than nonusers Users were also more likely than nonusers to report physical disorders, but the associations did not reach statistical significance Users of CAM were more likely than nonusers to be neurotic, to be open, to receive support from friends, and to experience strain from all social ties measured see Table 1 Table 2 shows the percentage of individuals with and without mental and physical disorders who reported using the 14 CAM modalities Among all respondent groups, the most commonly used CAM modality was prayer/spiritual practice, which was used by about 28 of all respondents Among those with no mental or physical disorders n 1,540, the second most commonly used CAM modality was exercise/movement therapy, and the third was relaxa-

K Honda, JS Jacobson / Preventive Medicine 40 2005 4653 Table 1 Clinical, sociodemographic, and psychosocial characteristics associated with use of CAM past 12 months among
adults in the community N 3,032 Characteristic Age [mean SD] Gender Male Female Education Less than GED High school diploma Some college Bachelors degree Graduate degree s Race White Ethnic Marital status Married Separated Divorced Widowed Never married Mental/emotional disorders Major depression ref no Anxiety disorders ref no Panic disorders ref no Physical disorders Heart-related conditions ref no Cancer ref no Obese ref no Personality traits [mean SD] Agreeableness continuous Neuroticism continuous Openness continuous Extroversion continuous Conscientiousness continuous Control strategies [mean SD] Persistence continuous Positive reappraisals continuous Lowering aspirations continuous Social support and strain [mean SD] Partner support continuous Family support continuous Friend support continuous Partner strain continuous Family strain continuous Friend strain continuous No use of CAM n 1,392 weighted 448 038 498 502 170 422 225 110 74 797 207 687 34 123 50 106 107 26 35
114 59 258 349 225 298 323 339 001 002 002 002 001 Use of ANY CAM n 1,640 weighted 458 044 375 625 96 346 284 161 113 841 159 676 21 137 43 124 174 39 100 130 69 261 352 231 305 320 341 001 002 001 002 001 F, P value ns

49

F 375, P 00001

F 169, P 00001

F 632, P 0012

ns

F 205, P 00001 ns F 382, P 00001 ns ns ns ns F 449, P 005 F 759, P 001 ns ns ns ns F 682, P 001 ns ns F F F F

326 002 314 002 263 002 353 340 314 217 208 191 002 002 002 002 002 002

322 002 317 002 255 002 352 341 328 225 220 199 002 002 002 002 002 001

2286, P 00001 507, P 005 2008, P 00001 1054, P 001

tion/meditation The leading two modalities among individuals with mental disorders n 322 and with physical disorders n 943, were similar to those of healthy individuals, but the third most commonly used modality was special diets Among individuals with both mental and physical disorders n 227, the second and third most common modalities were special diets and exercise/movement therapy
Those with both mental and physical disorders were more likely than the other respondent groups to use all types of CAM except energy healing Those with both mental and physical disorders were nearly twice as likely as healthy individuals to use herbal medicine and acupuncture and more than twice as likely to use biofeedback and high-dose megavitamins

Table 3 presents multiple logistic regression results for models in which the dependent variables were the five domains of CAM use and any CAM use In the prediction of mind body intervention use, female gender, more education, and mental disorders were associated with significantly increased likelihood of use Higher levels of openness were associated with the use of all domains of CAM except manipulative body-based methods The strongest association was that between openness and energy therapies Positive reappraisals and friend support were associated with a significantly increased likelihood of using mind body modalities Higher levels
of extroversion and primary control were associated with reduced likelihood of use of such modalities Having a physical disorder was associated with the use of

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Table 2 Use of different methods of CAM N 3,032 Method Use of CAM weighted No mental and physical only n 1,540 Body/mind therapies Biofeedback Hypnosis Relaxation/meditation Imagery technique Prayer/spiritual practice Biologically based therapies Herbal medicine High-dose megavitamins Special diet Manipulative/body-based methods Massage therapy Exercise therapy Chiropractic Alternative medical system Acupuncture Homeopathy Energy therapies Energy healing 06 16 132 27 279 Mental disorders only n 322 06 11 122 25 287 Physical disorders only n 943 03 12 86 19 276 Both mental and physical disorders n 227 19 16 192 35 382 Total

08 13 134 29 296

49 36 78

49 39 114

36 30 146

97 95 222

53 42 117

78 155 94

75 163 101

57 165 105

122 202 136

82 175 109

08
21

09 20

09 16

16 35

11 24

16

13

07

14

17

biologically based and manipulative body-based therapies, but having a mental disorder was associated with use of body mind interventions Partner strain was associated with a significantly increased likelihood of use of biologically based therapies, while primary control was associated with a significantly decreased likelihood of use of such therapies White respondents were about twice as likely as nonwhites to use manipulative/body-based methods The use of alternative medical systems and energy therapies were not associated with sociodemographic or health factors but with high levels of openness and secondary control and with low level of primary control

Discussion These results suggest that individual psychological characteristics such as personality, coping, and perceived social support may influence CAM use Assessment of personality and beliefs may therefore provide insight into CAM-seeking behaviors that may affect clinical and
research outcomes For example, openness to experience appeared to be associated with use of almost all types of CAM Individuals who are open to experience may be more likely than others to use CAM, even when it is not recommended or appropriate Extroversion was associated with a low frequency of use of mind body interventions Extroverted individuals appeared to favor more concrete or active types of CAM From a practical point of view, extroverted people may be

more likely than others to reject therapeutic recommendations or to be non-adherent to mind body interventions in trials or treatment We hypothesized that coping style might also be associated with CAM choices Specifically, we hypothesized that those who exercise primary control, which involves modifying the environment, and those who exercise secondary control, which involves modifying the self, might make different choices among CAM modalities Psychologists differ as to whether coping style is an internal attribute trait or a
transient state brought about by external life circumstances [25] However, a study of a large number of normal male and female twins [26] found a strong genetic influence on coping strategies including defense, emotional coping, substitution, and active coping, supporting the notion of coping style itself as a partially heritable trait On the other hand, some evidence [27] suggests that secondary control strategies become increasingly common in late life Cross-sectional studies [28,29] also suggest that the predominance of secondary control vs primary control is associated with culture eg, traditional Japanese culture as compared to Western culture These observations suggest that sense of control is not a fixed aspect of coping style However, adjusting for age and ethnicity as a proxy for culture, we observed that those with high levels of primary control were significantly less likely to use all types of CAM, except for manipulative body-based methods, than those with lower levels On
the other hand, secondary control appeared to be associated with use of mind body

K Honda, JS Jacobson / Preventive Medicine 40 2005 4653 Table 3 Predictors of any CAM and five domains of CAM use past 12 months among adults in the community Predictors Odds ratio 95 CI Body/mind intervention Sociodemographic Age continuous Gender ref male Race ref ethnic Marital status ref nonmarried Education ref no college Healthcare access Insurance coverage ref no Medical comorbidities Psychiatric disorders ref no Physical disorders ref no Personality traits Agreeableness continuous Neuroticism continuous Openness continuous Extraversion continuous Conscientiousness continuous Control strategies Persistence continuous Positive reappraisals continuous Lowering aspirations continuous Social support and strain Partner support continuous Family support continuous Friend support continuous Partner strain continuous Family strain continuous Friend strain continuous Predictors 100 184 134 134 169
098 101 131 257 084 215 080 223 122 232 Biologically based therapies 100 190 115 098 159 099 102 126 286 066 201 054 178 108 234

51

Manipulative/body-based methods 101 095 202 085 107 100 103 067 134 108 378 050 145 076 149

104 073 148

109 070 171

121 081 180

164 109 248 080 058 109

142 089 226 170 117 247

132 084 199 144 104 200

113 092 152 064 092

073 174 070 120 106 217 045 093 064 133

115 126 220 094 071

072 183 090 176 143 339 062 143 046 110

085 107 138 097 124

056 131 081 141 095 199 068 140 082 186

059 041 085 186 134 257 100 073 136

056 037 084 152 097 237 101 070 145

094 064 137 091 065 129 085 061 118

100 115 140 104 134 116

073 137 085 155 107 182 078 140 098 182 082 163

138 099 105 151 114 115

096 199 069 141 075 146 107 215 079 164 078 168

119 099 145 099 158 098

086 164 074 134 109 192 071 138 113 222 070 137

Odds ratio 95 CI Alternative medical systems Energy therapies 099 167 085
028 419 096 103 032 877 017 411 007 119 097 1818 Any CAM 100 161 150 126 157 098 101 118 221 095 237 078 202 115 215

Sociodemographic Age continuous Gender ref male Race ref ethnic Marital status ref nonmarried Education ref no college Health care access Insurance coverage ref no Medical comorbidities Psychiatric disorders ref no Physical disorders ref no Personality traits Agreeableness continuous Neuroticism continuous Openness continuous Extraversion continuous Conscientiousness continuous Predictors

102 198 065 050 189

098 106 080 489 025 170 017 144 081 439

052 028 152

109 028 418

102 072 144

260 099 679 091 039 209

139 030 637 053 012 233

170 113 254 113 083 153

169 040 718 130 051 333 355 133 944 085 031 228 090 035 232 Odds ratio 95 CI

241 034 1708 079 033 190 1577 286 8687 096 026 360 164 035 779

106 088 165 065 094

073 156 069 113 118 231 046 091 065 135

continued on next page

52 Table 3 continued

K Honda, JS
Jacobson / Preventive Medicine 40 2005 4653

Alternative medical systems Control strategies Persistence continuous Positive reappraisals continuous Lowering aspirations continuous Social support and strain Partner support continuous Family support continuous Friend support continuous Partner strain continuous Family strain continuous Friend strain continuous 024 011 051 341 119 934 090 048 170

Energy therapies 018 003 093 307 077 1233 262 101 677

Any CAM 067 047 095 120 089 162 086 064 116

111 054 228 086 046 200 281 123 641 117 061 225 089 051 158 133 062 285

141 071 353 072 190 026

044 445 022 226 095 1312 029 178 078 462 006 111

111 082 149 127 096 169 137 107 174 111 084 146 154 115 206 115 082 159

interventions and alternative medical systems Assessing individual differences in coping strategies may help us understand how to tailor patient education The effects of social support or strain from friends, family, and partner on the use of CAM are
important because they are amenable to psychological interventions Although these social support measures are self-reported and may not be a true reflection of social support received, we found that social support from friends was associated with most CAM modalities such as mind body interventions, manipulative bodybased methods, and alternative medical systems Future research could further examine the structural aspects eg, size and kind of friend network and actual support exchanges eg, informational, decisional in relation to CAM use Partner strain and family strain were associated with increased use of biologically based therapies and manipulative body-based methods, respectively Although the reasons for these associations are beyond the scope of this study, it is possible that some individuals respond to familial strain by using certain types of CAM modalities Future research is needed on the pathways that link social strain, potentially comorbid psychological distress, personal
resources, and CAM use This study has several limitations Our theoretical model proposes that individuals trait- and cognitive-oriented characteristics affect their CAM use The cross-sectional design, however, does not allow us to assess causality For example, as a result of using mind/body CAM, individuals may become more tolerant of a difficult situation and may therefore appear in the MIDUS data to have high secondary control Similarly, using CAM without adverse effects, at least in the short term, may encourage greater openness to experience However, personality traits are believed to develop early in life and to remain relatively stable over a persons life span [30,31] The questions in the MIDUS instrument focus on CAM use during the past 12 months We therefore doubt that CAM use is the causal agent in most of the associations we observed However, longitudinal research is needed to test the hypothesis that aspects of personality are predictors of CAM choices Another limitation is
that the survey instrument was not specifically

designed to assess determinants of CAM use For example, specific mental and physical disorders that the MIDUS instrument does not measure may also have played a role in CAM use The survey used a dichotomous measure of CAM use Data on dose or frequency of CAM use might shed additional light on CAM seeking behavior The MIDUS sample included only individuals aged 25 74 years Some studies have found that older people are less likely to use CAM than younger people We found no association of CAM use with age, but we cannot generalize our findings to very old or very young adults Despite these limitations, the current study has identified direct relationships between trait-oriented and cognitiveoriented characteristics and CAM choices in a sample of the general population If these factors do affect CAM choices, they may also predict adherence to and outcomes of treatment recommendations in general Psychosocial data might help providers and
patients select treatments for their compatibility with a patients psychosocial profile Even now, psychosocial testing is sometimes used to assess the eligibility of candidates for participation in clinical trials It may be also have the potential to provide not just a general judgment of emotional stability but also an assessment of the fit between the intervention and the subject In studies of treatments that are expected not to have dramatic short-term effects, small variations in adherence may have important consequences for the interpretability of results We therefore suggest that future trials, especially in but not limited to CAM, incorporate measurements of psychosocial factors and evaluate them as predictors of adherence Key points Individual psychosocial characteristics such as personality, coping, and perceived social support may influence CAM use Policy implications Assessment of personality and coping style has the potential to provide not just a general judgment of
emotional

K Honda, JS Jacobson / Preventive Medicine 40 2005 4653

53

stability but also an assessment of the fit between the intervention and the subject
[14]

Acknowledgments
[15]

KH is supported by a postdoctoral fellowship from the National Cancer Institute CA09529
[16]

References
[1] Gordon NP, Lin TY Use of complementary and alternative medicine by the adult membership of a large northern California health maintenance organization, 1999 J Ambul Care Manage 2004;27:12 24 [2] Ni H, Simile C, Hardy AM Utilization of complementary and alternative medicine by United States adults Med Care 2002;40:353 8 [3] Anonymous General information about CAM and the NCCAM National Institute of Health Available at: http://nccamnihgov/nccam/ an/general/indexhtml Accessed Feb 14, 2004 [4] Astin JA, Marie A, Pelletier KR, Hansen E, Haskell WL A review of the incorporation of complementary and alternative medicine by mainstream physicians Arch Intern Med 1998;158:2303 10 [5] Berman BM, Singh
BB, Hartnoll SM, Singh BK, Reilly D Primary care physicians and complementary-alternative medicine: training, attitudes, and practice patterns J Am Board Fam Pract 1998;11:272 81 [6] Hall J, Bulik R, Sierpina V Community preceptors attitudes toward and practices of complementary and alternative medicine: a Texas survey Tex Med 2003;99:50 3 [7] Mackenzie ER, Taylor L, Bloom BS, Hufford DJ, Johnson JC Ethnic minority use of complementary and alternative medicine CAM: a national probability of CAM utilizers Altern Ther Health Med 2003;9:50 6 [8] Ritvo P, Irvine J, Katz J, Matthew A, Sacamano J, Shaw BF The patients motivation in seeking complementary therapies Patient Educ Couns 1999;38:161 5 [9] Truant T, Bottorff JL Decision making related to complementary therapies: a process of regarding regaining control Patient Educ Couns 1999;38:131 42 [10] Owen JE, Taylor AG, Degood D Complementary and alternative medicine and psychologic factors: toward an individual differences model of
complementary and alternative medicine use and outcomes J Altern Complement Med 1999;5:529 41 [11] Maskarinec G, Shumay DM, Kakai H, Gotay CC Ethnic differences in complementary and alternative medicine use among cancer patients J Altern Complement Med 2000;6:531 8 [12] Boon H, Brown JB, Gavin A, Kennard MA, Stewart M Breast cancer survivors perception of complementary/alternative medicine CAM: making the decision to use or not to use Qual Health Res 1999;9:639 53 [13] Sollner W, Maislinger S, DeVries A, Rumpold G, Lukas P Use of complementary and alternative medicine by cancer patients

[17]

[18]

[19] [20]

[21]

[22]

[23]

[24]

[25]

[26]

[27]

[28]

[29] [30]

[31]

is not associated with perceived distress or poor compliance with standard treatment but with active coping behavior Cancer 2000;89:873 80 Radtke HL, Stam HJ The relationship between absorption, openness to experience, anhedonia, and susceptibility Int J Clin Exp Hypn 1991;39:39 56 Kessler RC, DuPont RL,
Berglund P, Wittchen HU Impairment in pure and comorbid generalized anxiety disorder and major depression at 12 months in 2 national surveys Am J Psychiatry 1999;156:1915 23 Tellegen A, Atkinson G Openness to absorbing and self-altering experiences absorption, a trait related to hypnotic susceptibility J Abnorm Psychology 1974;83:268 77 Costa PT, McCrae RR Revised NEO Personality Inventory NEO-PIR and NEO Five Factor Inventory NEO-FFI: Professional Manual Odessa, FL: Psychological Assessment Resources, 1992 Heckhausen J, Schluz R Optimisation by selection and compensation: balancing primary and secondary control in life-span development Int J Behav Dev 1993;16:287 303 Heckhausen J, Schluz R A life-span theory of control Psychol Rev 1995;102:284 304 Rothbaum F, Weisz JR, Snyder SS Changing the world and changing the self: a two-process model of perceived control J Pers Soc Psychol 1982;42:5 37 Wrosch C, Heckhausen J, Lachman ME Primary and secondary control strategies for managing
health and financial stress across adulthood Psychol Aging 2000;15:387 99 Walen HR, Lachman ME Social support and strain from partner, family, and friends: costs and benefits for men and women in adulthood J Soc Pers Relationsh 2000;17:5 30 Cuellar N, Aycock T, Cahill B, Ford J Complementary and alternative medicine CAM use by African American AA and Caucasian American CA older adults in a rural setting: a descriptive, comparative study BMC Complement Altern Med 2003;3:8 Bausel BR, Lee WL, Berman BM Demographic and health-related correlates of visits to complementary and alternative medical providers Med Care 2001;39:90 6 Beutler LE, Moos RH Coping and coping styles in personality and treatment planning: introduction to the special series J Clin Psychol 2003;59:1045 7 Busjahn A, Faulhaber HD, Freier K, Luft FC Genetic and environmental influences on coping styles: a twin study Psychosom Med 1999;61:469 75 Chipperfield JG, Perry RP, Menec VH Primary and secondary control-enhancing
strategies: implications for health in later life J Aging Health 1999;11:517 39 Weisz JR, Rothbaum FM, Blackman TC Standing out and standing in: the psychology of control in America and Japan Am Psychol 1984;39:955 69 Azuma H Secondary control as a heterogeneous category Am Psychol 1984;39:970 1 Costa PT, McCrae RR Personality in adulthood: a six-year longitudinal study of self-reports and spouse ratings on the NEO Personality Inventory J Pers Soc Psychol 1998;54:853 63 Roberts BW, DelVecchio WF The rank-order consistency of personality traits from childhood to old age: a quantitative review of longitudinal studies Psychol Bull 2000;126:3 25

Santa Fe Economic Development, Inc PO Box 8184 Santa Fe, NM 87504-8184 505-984-2842 sfedi@sfediorg wwwsfediorg
Santa Fe Economic Development, Inc Medical Practitioners Cluster Report Page 1

Number of Firms in the Industry
Once known as the place to take the Santa Fe Cure many newcomers migrated here in the early 20th Century for health reasons Today, people still seek its crisp, clean air and dry, nourishing climate Today, it is one of the largest centers of holistic medicine Industry estimates range from around 2000 to 8000 practitioners of traditional, complimentary and alternative medicine Consistently ranked as one of the top places to retire, Santa Fe has a particular interest in creating a healthy environment As the demographics shift to increase the percentage of older residents and decrease the Hispanic population, investigation into traditional, complimentary and alternative healing methods will continue Note:
Trends show Hispanics in New Mexico tend to utilize less formal methods of alternative healing, thus avoiding industrial paths of recognition such as gross receipts taxes One of the key issues with cluster identification is the variety of practitioners in the area who self-classify in the category For organizational purposes, a variety of different approaches were taken, primarily in terms of service provided and whether conventional or alternative medical therapies are applied Department of Labor classifications did not always apply, and crossover disciplines made it difficult to determine how individuals would self-classify Additionally, no information was given as to whether or not classified individuals are licensed or certified to practice medicine or alternative therapies in the state of New Mexico The decision was made to count all practitioners, and then recommend the reader exercise caution when approaching individual practitioners Often overlooked are the contributions a
medical community makes in a community the size of Santa Fe As a regional base for traditional medical treatment and nationally recognized for alternative therapies, the medical cluster has long been a significant contributor to Santa Fes economy The National Institutes of Health recognizes Complimentary and Alternative Medicine CAM as a viable medical field, enabling traditional research in the fields through funding While many disciplines in CAM are regulated and recognized, many therapies still lie in a different realm

Contribution to Santa Fes Economy Gross Receipts Taxes
New Mexico health practitioners are frustrated with the unique-in-the-nation requirement to pay gross receipts taxes While Hawaii has a gross receipts tax on medical services, it is 2 and is dedicated to indigent medical care while New Mexico doctors pay around 6, nearly all of which goes into the states general fund New Mexico Business Weekly, June 2003 Medical gross receipts taxes account for approximately 5
of the total GRT revenue, indicating the City of Santa Fe would have to reduce the general fund monies from gross receipts taxes by 5, should this tax be revoked While there is some effort in the state legislature to do so, it has not yet passed The total amount is an estimated 16 to 20 million for the statewide collections The New Mexico Health Policy Commission estimates that slightly more than half of the 6100 registered physicians still have active practices in New Mexico More than a third of the physicians are registered here, but reside outside the state in order to avoid gross receipts taxes, income taxes, and the lower Medicare reimbursements levied in this state Because of most insurance reimbursement policies, the gross receipts tax cannot be passed on to patients

Traditional Medicine
For the purpose of this document, traditional medicine involves jobs in the following categories:
Santa Fe Economic Development, Inc Medical Practitioners Cluster Report Page 2

Dentists
Dietitians and Nutritionists Pharmacists Family and General practitioners Physician Assistants Registered Nurses Occupational Therapists Physical Therapists Speech-Language Pathologists Veterinarians Medical and Clinical Laboratory Technologists Dental Hygienists Radiologic Technologists and Technicians Licensed Practical and Licensed Vocational Nurses Medical Records and Health Information Technicians Occupational Health and Safety Specialists and Technicians Home Health Aides Nursing Aides, Orderlies and Attendants Massage Therapists Dental Assistants Medical Assistants Medical Transcriptionists Veterinary Assistants and Laboratory Animal Caretakers Standard DOL Classifications for Medical Occupations In addition, the following are becoming more and more mainstream in their studies: Acupuncture Optometrists Doctors of Oriental Medicine Chiropractors Herbologists

Complementary and Alternative Medicine
In addition, a number of local practitioners follow the precepts of the following
They are less likely to be regulated and more difficult to study Complementary and alternative medicine, as defined by NCCAM National Center for Complementary and Alternative Medicine, found under the auspices of the National Institute of Health, is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine1,2 While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies–questions such as whether they are safe and whether they work for the diseases or medical conditions for which they are used The list of what is considered to be CAM changes continually, as those therapies that are proven to be safe and effective become adopted into conventional health care and as new approaches to health care emerge Complementary medicine is used together with conventional medicine An example of a
complementary therapy is using aromatherapy to help lessen a patients discomfort following surgery Alternative medicine is used in place of conventional medicine An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor Integrative medicine, as defined by NCCAM, combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness
Santa Fe Economic Development, Inc Medical Practitioners Cluster Report Page 3

NCCAM classifies CAM therapies into five categories, or domains: 1 Alternative Medical Systems Alternative medical systems are built upon complete systems of theory and practice Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States Examples of alternative medical systems that have developed in Western cultures
include homeopathic medicine and naturopathic medicine Examples of systems that have developed in non-Western cultures include traditional Chinese medicine and Ayurveda 2 Mind-Body Interventions Mind-body medicine uses a variety of techniques designed to enhance the minds capacity to affect bodily function and symptoms Some techniques that were considered CAM in the past have become mainstream for example, patient support groups and cognitive-behavioral therapy Other mind-body techniques are still considered CAM, including meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance 3 Biologically Based Therapies Biologically based therapies in CAM use substances found in nature, such as herbs, foods, and vitamins Some examples include dietary supplements,3 herbal products, and the use of other so-called natural but as yet scientifically unproven therapies for example, using shark cartilage to treat cancer 4 Manipulative and Body-Based
Methods Manipulative and body-based methods in CAM are based on manipulation and/or movement of one or more parts of the body Some examples include chiropractic or osteopathic manipulation, and massage 5 Energy Therapies Energy therapies involve the use of energy fields They are of two types: Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body The existence of such fields has not yet been scientifically proven Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields Examples include qi gong, Reiki, and Therapeutic Touch Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating current or direct current fields
____________ 1

Conventional medicine is medicine as practiced by holders of MD medical doctor or DO doctor of osteopathy degrees and by
their allied health professionals, such as physical therapists, psychologists, and registered nurses Other terms for conventional medicine include allopathy; Western, mainstream, orthodox, and regular medicine; and biomedicine Some conventional medical practitioners are also practitioners of CAM

Other terms for complementary and alternative medicine include unconventional, non-conventional, unproven, and irregular medicine or health care Some uses of dietary supplements have been incorporated into conventional medicine For example, scientists have found that folic acid prevents certain birth defects, and a regimen of vitamins and zinc can slow the progression of an eye disease called age-related macular degeneration AMD
3

2

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Ability to bring quality jobs to the region
In taking straight employment statistics number of workers instead of number of firms the New Mexico Department of Labor indicates the
following growth in Santa Fe County through 2010 Recent reporting changes show these statistics in a different format: Community and Social Services Santa Fe County
Employment Prospects Employment 2000 1,340 1,230 250 20 110 100 510 390 50 70 480 80 190 210 2010 1,750 1,610 330 30 150 120 650 500 70 90 630 100 220 310 2000-2010 Employment Change Number Percent 410 31 380 80 10 50 20 140 100 20 20 160 20 30 100 31 32 50 45 20 27 26 40 29 33 25 16 48

Community and Social Services Occupations Counselors, Social Workers, and Other Community and Social Service Specialists Counselors Substance Abuse and Behavioral Disorder Counselors Educational, Vocational, and School Counselors Rehabilitation Counselors Social Workers Child, Family, and School Social Workers Medical and Public Health Social Workers Mental Health and Substance Abuse Social Workers Miscellaneous Community and Social Service Specialists Health Educators Probation Officers and Correctional Treatment Specialists Social and
Human Service Assistants

Santa Fe Economic Development, Inc Medical Practitioners Cluster Report Page 5

Healthcare Practitioners and Technical Santa Fe County
Employment Prospects Employment 2000 3,520 2,100 60 150 50 130 410 190 120 50 40 900 260 50 100 20 80 50 40 1,240 200 110 90 250 90 60 70 230 90 40 40 30 250 90 70 180 40 140 2010 4,510 2,680 70 170 50 180 490 220 140 60 60 1,180 370 70 130 30 120 50 50 1,610 270 150 120 330 120 80 90 300 140 50 50 30 290 120 80 230 50 180 2000-2010 Employment Change Number Percent 1000 28 580 10 20 10 50 80 40 30 10 20 280 110 20 30 10 40 0 10 370 70 40 30 80 30 20 20 80 50 10 10 0 50 30 10 50 10 40 28 17 13 20 38 20 21 25 20 50 31 42 40 30 50 50 0 25 30 35 36 33 32 33 33 29 35 56 25 25 0 20 33 14 28 25 29

Healthcare Practitioners and Technical Operations Health Diagnosing and Treating Practitioners Chiropractors Dentists Dietitians and Nutritionists Pharmacists Physicians and Surgeons Family and General Practitioners Internists, General
Physicians and Surgeons, all other Physician Assistants Registered Nurses Therapists Occupational Therapists Physical Therapists Respiratory Therapists Speech-Language Pathologists Veterinarians Miscellaneous Health Diagnosing and Treating Practitioners Health Technologists and Technicians Clinical Laboratory Technologists and Technicians Medical and Clinical Laboratory Technologists Medical and Clinical Laboratory Technicians Dental Hygienists Diagnostic Related Technologists and Technicians Radiologic Technologists and Technicians Emergency Medical Technicians and Paramedics Health Diagnosing and Treating Practitioner Support Technicians Pharmacy Technicians Psychiatric Technicians Surgical Technologists Veterinary Technologists and Technicians Licensed Practical and Licensed Vocational Nurses Medical Records and Health Information Technicians Opticians, Dispensing Other Healthcare Practitioners and Technical Occupations Occupational Health and Safety Specialists and Technicians
Miscellaneous Health Practitioners and Technical Workers

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Healthcare Support Santa Fe County
Employment Prospects Employment 2000 1,640 760 270 490 60 40 30 820 30 790 250 130 50 90 30 60 180 2010 2,140 990 360 630 80 60 40 1,070 50 1,020 350 180 60 110 40 60 220 2000-2010 Employment Change Number Percent 500 30 230 30 90 33 140 29 30 50 20 10 250 10 230 100 50 10 30 10 0 40 50 33 30 33 29 40 38 20 33 33 0 22

Healthcare Support Occupations Nursing, Psychiatric, and Home Health Aides Home Health Aides Nursing Aides, Orderlies, and Attendants Occupational and Physical Therapist Assistants and Aides Physical Therapist Assistants and Aides Physical Therapist Aides Other Healthcare Support Occupations Massage Therapists Miscellaneous Healthcare Support Occupations Dental Assistants Medical Assistants Medial Equipment Preparers Medial Transcriptionists Pharmacy Aides Veterinary Assistants and Laboratory
Animal Caretakers Healthcare Support Workers All Other

Note on Massage Therapists: While there are at least 45 massage therapists on rotation at Ten Thousand Waves, they are subcontractors, and are responsible for reporting self-employment It is unknown as to why the numbers are low for this category This may be due to the delineation between full-time and part-time employment Note on numbers: Some adjustments were made to the Department of Labor numbers due to math errors

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Number and Types of Jobs
The following is from a 2000 study from the New Mexico Department of Labor It is for Santa Fe MSA and not all statistics for additional occupations were available
Healthcare Practitioners and Technical Occupations Wage Estimates Occupation Title Employment Median Hourly Mean Hourly Mean Annual Healthcare 2,070 2019 2434 50,630 Practitioners and Technical Occupations Dentists 110 2481 2896 60,230 Dietitians
and 30 1338 1452 30,210 Nutritionists Pharmacists 90 3317 3246 67,520 Family and General 160 6179 5893 122,560 Practitioners Physician 50 2920 2860 59,480 Assistants Registered Nurses 460 1765 1826 37,990 Occupational 30 1885 1973 41,030 Therapists Physical Therapists n/a 2400 2573 53,520 Speech-Language 70 1858 2073 43,110 Pathologists Veterinarians 50 2592 2526 52,540 Medical and 100 1659 1863 38,750 Clinical Laboratory Technologists Dental Hygienists n/a 2469 2464 51,250 Radiologic 60 1551 1620 33,700 Technologists and Technicians Pharmacy 70 1015 1008 20,960 Technicians Licensed Practical 110 1543 1522 31,660 and Licensed Vocational Nurses Medical Records 50 1094 1122 23,350 and Health Information Technicians Occupational 40 1589 1844 38,360 Health and Safety Specialists and Technicians

Mean RSE 59

180 47 33 138 57 28 85 58 127 75 69

58 94

23 21

26

29

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Santa Fe MSA, 2000
data
Healthcare Support Occupations Wage Estimates Occupation Title Employment Median Hourly Mean Hourly Healthcare Support 1,500 903 1011 Occupations Home Health Aides 510 768 827 Nursing Aides, 220 802 839 Orderlies, and Attendants Massage n/a 1523 1818 Therapists Dental Assistants 180 1197 1192 Medical Assistants 170 1034 1053 Medical n/a 1366 1456 Transcriptionists Veterinary 70 806 815 Assistants and Laboratory Animal Caretakers Source: US Department of Labor, Bureau of Labor Statistics Mean Annual 21,020 17,200 17,460 Mean RSE 56 45 31

37,810 24,790 21,900 30,280 16,960

262 31 55 28 131

Due to the unregulated nature of the industry, the above are the only classifications available New Mexico does not monitor additional job classifications and some are flying below the radar Availability and Sufficiency of Training Programs Schools in Santa Fe There are a number of alternative therapy and courses available in Santa Fe While this list is by no means comprehensive, it
lists the schools with the largest numbers of enrollees Santa Fe also benefits from the proximity of UNM Medical School, which has added an Internal Medicine curriculum in Integrative Medicine based on the Mandala of Health Physical, Social/Mental, Spiritual, and Emotional Scherer Institute of Natural Healing Core Curriculum The Healing Quality of Touch Nurturing, Therapeutic Massage Medical Massage and Connective Tissue Bodywork Energy Work Modalities, including Shiatsu, Intuitive Massage, Cranio-Sacral, and Polarity Anatomy, Physiology, Pathophysiology Business and Professional Development Clinical Internship Related Healing Arts Chair Massage Recognizing Trauma Naturopathic Principles and Techniques, including Bach Flower Remedies, Aromatherapy, Hydrotherapy, Facilitated Stretching, Herbal Medicine, and Reflexology Process Skills and Community Building New Mexico Academy of Healing Arts Listed Curriculum: Massage Therapy Somatic Polarity Therapy Ortho-Bionomy Cranial
Sacral Therapy
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Oriental Bodywork Sports Massage Southwest Acupuncture College Clinical Education Herbal Curriculum Biomedical Clinical Sciences International Institute of Chinese Medicine At this writing, the International Institute of Chinese medicine is in bankruptcy proceedings and students have been referred to other schools Southwestern College Southwestern College offers two-year masters degrees in counseling and art therapy along with certificate programs in art therapy, school counseling, grief counseling and action methods Graduates leave Southwestern College as well-qualified professionals for mental health jobs Santa Fe Community College The goal of the Division of Fitness Education is to provide quality instruction in exercise science, health/wellness, physical education and recreation Students have several innovative degree plans to pursue: exercise science, fitness leadership, health and
physical education, and outdoor education leadership The associate of applied science degree in exercise science and the certificate in fitness leadership prepare students for entry-level positions in the fitness and wellness industry The associate of science degree in health and physical education is designed for students who intend to transfer to four-year colleges or universities The associate of arts degree in outdoor education leadership prepares students to transfer to colleges or universities or to enter the job market after completing the degree Many courses will be offered through distance education in the proposed nutrition degree program Challenging, success-oriented courses are designed and taught to provide students with knowledge and skills to pursue a variety of careers The Division of Health/Physical Education and Human Performance promotes the concept of healthier living by providing information to students to facilitate development of healthy lifestyles to enhance
their quality of life Additional health and healing arts related programs include certificates and degrees in Biological and Physical Sciences and Nursing The Nursing program is a fully accredited two-year full-time program with a practical component It is regarded as one of the best in the area

Regional Education UNM Medical School College of Nursing College of Pharmacy School of Medicine Our vision is to identify and solve the most important questions of human health in education, scholarship and clinical care in New Mexico The strength of our mission lies in the interdependence of our education, patient care and research programs, and our emphasis on forming productive partnerships that leverage our resources The University of New Mexico Health Sciences Center has earned an international reputation for incorporating these mission elements to address the unique health care needs of New Mexicos urban and rural populations

Opportunities for Economic Diversity
Santa Fe Economic
Development, Inc Medical Practitioners Cluster Report Page 10

Since this cluster has been primarily attracting its own national and international attention, and organized effort has not been made to publicize and promote it as an industry Small efforts have been made in this regard, but a comprehensive approach could increase attention and revenue for the region

Opportunities to bring dollars into the region
As a center for holistic health, Santa Fe could attract not only those businesses involved in direct treatment, but also the more lucrative manufacturing and development businesses that fit within our economic scope Work is being accomplished to try to continue to recruit complimentary businesses While tourism contributes to the economy, it does have the dollar/impact value of other industries that may be attracted by innovative research at Sandia National Laboratory and with some of the health-related complexity businesses in the area

Ability to maintain the special
character of Santa Fe
This industry is part of the special character of Santa Fe

Medical cluster cultivation: progress to date Cluster activation
Santa Fe Economic Development, Inc SFEDI has been working with biomedicine through the biotechnology cluster to begin to diversify and strengthen this cluster While many attempts have been made to enable the traditional, complimentary, and alternative practitioners to collaborate, this is the most difficult cluster to date to organize due to the differing priorities by each of the individual practitioners The collaborative practitioners have continued efforts on their own to communicate and education all workers of health Action steps completed 1 The medical cluster has met to discuss issues and raised the gross receipts tax issue as the primary concern Next action steps 2 The medical cluster continues to lobby to eliminate the gross receipts tax on medical services 3 Find more areas for collaboration

Cluster support
SFEDI continues to work
with collaborative businesses and practitioners to create a healthier Santa Fe when support for the industry is needed

Challenges
While many of the nationally known practitioners are in the area, they are often in demand in other parts of the country more dedicated to healthy communities Without support for this industry from a variety of constituencies: education, civic leaders, and community groups, it will continue to reside primarily as a gross receipts tax issue, rather than a thriving industry

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Dictionary of Terms
Aromatherapy ah-roam-uh-THER-ah-py: Aromatherapy involves the use of essential oils extracts or essences from flowers, herbs, and trees to promote health and well being Ayurveda ah-yur-VAY-dah is a CAM alternative medical system that has been practiced primarily in the Indian subcontinent for 5,000 years Ayurveda includes diet and herbal remedies and emphasizes the use of body, mind,
and spirit in disease prevention and treatment Chiropractic ki-roh-PRAC-tic is a CAM alternative medical system It focuses on the relationship between bodily structure primarily that of the spine and function, and how that relationship affects the preservation and restoration of health Chiropractors use manipulative therapy as an integral treatment tool Dietary supplements: Congress defined the term dietary supplement in the Dietary Supplement Health and Education Act DSHEA of 1994 A dietary supplement is a product other than tobacco taken by mouth that contains a dietary ingredient intended to supplement the diet Dietary ingredients may include vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, and metabolites Dietary supplements come in many forms, including extracts, concentrates, tablets, capsules, gel caps, liquids, and powders They have special requirements for labeling Under DSHEA, dietary supplements are considered foods,
not drugs Electromagnetic fields: Electromagnetic fields EMFs, also called electric and magnetic fields are invisible lines of force that surround all electrical devices The Earth also produces EMFs; electric fields are produced when there is thunderstorm activity, and magnetic fields are believed to be produced by electric currents flowing at the Earths core Homeopathic home-ee-oh-PATH-ic medicine is a CAM alternative medical system In homeopathic medicine, there is a belief that like cures like meaning that small, highly diluted quantities of medicinal substances are given to cure symptoms, when the same substances given at higher or more concentrated doses would actually cause those symptoms Massage muh-SAHJ therapists manipulate muscle and connective tissue to enhance function of those tissues and promote relaxation and well being Naturopathic nay-chur-o-PATH-ic medicine is a CAM alternative medical system in which practitioners work with natural healing forces within the body,
with a goal of helping the body heal from disease and attain better health Practices may include dietary modifications, massage, exercise, acupuncture, minor surgery, and various other interventions Osteopathic ahs-tee-oh-PATH-ic medicine is a form of conventional medicine that, in part, emphasizes diseases arising in the musculoskeletal system There is an underlying belief that all of the bodys systems work together, and disturbances in one system may affect function elsewhere in the body Some osteopathic physicians practice osteopathic manipulation, a full-body system of hands-on techniques to alleviate pain, restore function, and promote health and well being Qi gong chee-GUNG is a component of traditional Chinese medicine that combines movement, meditation, and regulation of breathing to enhance the flow of qi an ancient term given to what is believed to be vital energy in the body, improve blood circulation, and enhance immune function Reiki RAY-kee is a Japanese word representing
Universal Life Energy Reiki is based on the belief that when spiritual energy is channeled through a Reiki practitioner, the patients spirit is healed, which in turn heals the physical body Therapeutic Touch is derived from an ancient technique called laying-on of hands It is based on the premise that it is the healing force of the therapist that affects the patients recovery; healing is promoted when the bodys energies are in balance; and, by passing their hands over the patient, healers can identify energy imbalances Definition Reference: NCCAM Publication No D167, August 2002, Public Domain

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Some Businesses for Reference in Santa Fe The list is not comprehensive due to the organic nature of this cluster Additionally, individual practitioners have not been listed, however, some collaborative practices have been listed as examples Numbers in parenthesis are individual practitioners that were listed by
name and are estimates
Alternative Therapies Magazine Past Life Regression Reflexology by Kevin Kunz Sunlit Center of Santa Fe Touched by an Angel Massage University of Natural Medicine Ayurveda for Radian Health Body Wisdom of Santa Fe Dahn Center Diet Center of Santa Fe Holistic Bodywork Holistic healing Solutions Holistic Health Integrated Health Center International Chamber for Health and Well-Being Jenny Craig Journey to health Kototama Life Therapy Light Harmonics Inc New Mexico Alternative health Zens Inn Bodywork Sanctuary E-Spacom Inc Floating World Santa Fe Massage Santa Fe Spa Studio 2000 Ten Thousand Waves High Desert Healthcare and Massage Alive n kicking Bulldog Gym Carl and Sandras Conditioning Club International Family Center Core Connection Curves for Women El Gancho Fitness Swim Club Evolve Fitness/Plus Human Performance Center Mandrills Gym Momentum Pilates and Gyrotonic New Mexico Sports, Fitness, and Physical Therapy New
Mexico Tae Kwon Do Institute Pilates Santa Fe Quail Run Santa Fe Spa Renaissance Personal Fitness Tai Chi Chuan Institute Tango USA/Studio East Zia Nia Santa Fe Health for Life Blue Iris Acupuncture Acupuncture Associates of America Alternative Medical Associates Eldorado Acupuncture and Wellness Center Mountainview Medicine Rocky Mountain Spine Institute Cerrillos Alternative Health Acupuncturists 55 individual practitioners Herbs, Etc Santa Fe Health Ticos Health Food Shop Vitamin World Wild Oats Whole Foods The Marketplace Santa Fe Center for Audiology Southwestern Ear, Nose, and Throat Advanced Hearing Clinics Sandia Hearing Aids Homeopaths 5 Alternative Therapy Associates Physical Therapy Plus The St Francis Health Center The Hospice Center The Community End of Life Care Network Odyssey Healthcare of Santa Fe Able 2 Scoot Lincare Walgreens Health Initiatives East Tao Herb Company and Acupuncture Clinic El Milagro Herbs For the Love of
Lavender Center for Mindful Medicine Light and Love Naturopathic Center Holistic Practitioners 14 Genesis Southwest Center for Interactive Medicine Holistic Healing Solutions Jurlique Products Del Norte Pharmacy and Home Medical Fraser Pharmacy Kiva Pharmacy K-mart Stores Lovelace Pharmacy Medical Center Pharmacy Medicap Pharmacy Nambe Drugs Sav-on Drug Smiths Food and Drug Centers Walgreens Drug Stores Hand Dance Massage Therapy Bodyworkers Store The Floating World Active Recovery Massage Therapists 26 note: These are only the individual practitioners, and do not include the 90 full and part-time massage therapist employed at Ten Thousand Waves, High Dessert Healthcare, Santa Fe Massage, and Lovelace for example Lovelace Massage Clinic Massage and Banya Spa New Mexico Academy of Healing Arts La Posada Sonrise Springs Sterling Institute Hanger Prosthetics and Orthotics PMS Home Care Presbyterian Medical Services New Mexico Sports Fitness and Physical Therapy
Novacare Rehabilitation Preferred Rehabilitation Services Santa Fe Sports Medicine Santa Fe Pain Center Santa Fe Medical Acupuncture Cancer Institute of New Mexico

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New Mexico Anesthesia Consultants GreatSkincom Eye Associates New Mexico Eye Clinic Lovelace Galisteo OB-GYN Associates New Mexico Center for Sleep Medicine Santa Fe Community Yoga Center Yoga Moves

Chiropractors classified as physicians Psychologists and Psychiatrists classified as physicians

See statistics for physicians and related disciplines

Facilities: St Vincents Hospital Santa Fe Indian Hospital Santa Fe Cares Womens Health Horizon A private hospital has been proposed, but is not yet active City Facilities: Genoveva Chavez Community Center

Agencies: NM Department of Health Healthlink NM NM Poison Control Center Massage Therapy Board

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Cluster Report Page 14