Hi Natalie,
Before I start I have to tell you, I am blown away by what I’ve
learned here. The psychology and sociology behind the public’s shift
to alternative forms of treatment is much more complex than I ever
imagined.
Like many people, I have always chalked this alternative health
movement up to being a recent fad. It turns out, it’s not. I also
figured that many of the people jumping on the bandwagon were either
uneducated, gullible, desperate, poor, or defiantly antiestablishment.
Turns out they are not. And finally, I thought the orthodox medical
establishment maintained an arms-crossed supercilious attitude towards
alternative health options. It turns out, they do not.
So I’ve been educated today.
There’s a lot of information out there on this topic – hundreds of
articles. What I tried to do in researching this, is first get a
sense of the overall state of the alternative health movement. Then,
once I got that nailed down, I selected representative articles and
the major studies and reports to illustrate each of the different
topics I’ve addressed.
So, here we go. I’ll start with the Short Answer – basically a summary
and then give you all the supporting explanation and documentation.
=====================
THE SHORT ANSWER
=====================
The use of ALTERNATIVE MEDICINE -- that is, treatment options that are
not normally provided or accepted by the conventional Western medical
community -– is, and has been on the rise since the 1950’s.
Today the term that’s used is CAM: COMPLEMENTARY AND ALTERNATIVE
MEDICINE
The reason for the rise in CAM usage can be attributed on the one hand
to what is possibly a single underlying human drive and at the same
time can be attributed to cultural factors that open the door to CAM
therapies and to individual circumstances that trigger patients to use
them.
In the end it seems to boil down to this: Patients seek medical
treatments that mesh with their own personal value systems. They
choose treatments and health-care providers that make them feel
comfortable. To this end, they often have little regard to what has
been proven to be effective or even safe.
People’s value systems are shaped both internally and by their world
around them. Their ultimate decision to step in the direction of
alternative therapies is a reflection of their opinions of their
current health and of how they perceive the medical establishment
responding to their needs.
For the past 50 years the scene has been set for a mismatch between
the values of the baby boom and post-baby boom cohort groups and the
traditional focus of conventional medicine. These cohorts are people
who value empowerment and control. They have access to lots of
information and want to have a hand in managing their own treatments
(remember, these are the same people who want to manage their own
stock portfolios) But, most importantly, they want to be considered by
their doctors as a whole person, not just a disease. They want their
mind and bodies treated as one. The 1960’s counter-culture helped to
open the doors to new alternative therapies that fit these bills.
However, it’s important to understand that using CAM is not a new
phenomenon. Alternative or unaccepted medical therapies have drawn
large audiences throughout US history, only falling to a low point
during the 1940s and 1950 medical breakthrough boom. Hence, what we
are seeing now may well be the norm – the only difference being that
conventional physicians (probably because they are of the same cohort
as their patients) are more accepting of concurrent use of alternative
treatments than in past eras.
And now, the Long Answer --------
==================================
DEFINING ALTERNATIVE MEDICINE
==================================
This is probably more than you were expecting, but the specific
definitions and classifications are important when it comes to
understanding how and why people use alternative therapies and the
trends that have occurred in the field of alternative medicine. It’s
also helpful to understand just which therapies are considered
alternative.
In general, ALTERNATIVE MEDICINE is a catch-all phrase for treatments
that have not been fully accepted by the mainstream Western medical
establishment.
However, since physicians are becoming more accepting of many formerly
discounted “alternative” treatment options and since most patients use
alternative therapies in conjunction with conventional therapies, the
term now being used by professionals is COMPLEMENTARY AND ALTERNATIVE
MEDICINE or CAM.
In the United States, NIH has created an oversight body, The National
Center for Complementary and Alternative Medicine (NCCAM), to support
research on CAM treatments, train researchers in CAM, and disseminate
information to the public and professionals on the effectiveness of
CAM therapies.
NCCAM uses the following definitions:
CAM: a group of diverse medical and health care systems, practices,
and products that are not presently considered to be part of
conventional medicine.
COMPLEMENTARY MEDICINE: Used together with conventional medicine. Eg:
using aromatherapy to help lessen a patient's discomfort following
surgery.
ALTERNATIVE MEDICINE: Used in place of conventional medicine. Eg:
using a special diet to treat cancer instead of undergoing surgery,
radiation, or chemotherapy.
CAM classifies CAM therapies into five categories, or domains:
1. Alternative Medical Systems – those built upon complete systems of
theory and practice that usually have evolved apart from and earlier
than the conventional medical approach. Eg: homeopathy, naturopathy,
Ayurvedic medicine.
2. Mind-Body Interventions - using techniques designed to enhance the
mind's capacity to affect bodily function and symptoms. Eg: prayer,
meditation, art and music therapies.
3. Biologically Based Therapies - using substances found in nature,
such as herbs, foods, and vitamins. Eg: dietary supplements, herbal
products, shark cartilage.
4. Manipulative and Body-Based Methods - based on manipulation and/or
movement of one or more parts of the body. Eg: chiropractic,
osteopathic manipulation, massage.
5. Energy Therapies - involve the use of either of two types of energy
fields: Biofield therapies (qui gong, Reiki) and
Bioelectromagnetic-based therapies (pulsed fields, magnetic fields).
DEFINITION RESOURCES ----------------------------
NCCAM - What Is Complementary and Alternative Medicine (CAM)?
http://nccam.nih.gov/health/whatiscam/
MEDICAL DICTIONARY - ALTERNATIVE MEDICINE
http://www.books.md/A/dic/alternativemedicine.php
THE ALTERNATIVE MEDICINE HOME PAGE
http://www.pitt.edu/~cbw/altm.html
===============================
TRENDS IN THE USE OF CAM
===============================
You are correct in your assumption that there has been an increase in
the use of CAM in the US. According to NCCAM:
Utilization of CAM Practices is pervasive, appealing and rapidly
growing:
40% of Americans, over 2/3rds world-wide
30% increase in use and visits to CAM practitioners since 1990
$27 billion in out-of-pocket expenses [1]
One team of researchers at Harvard Medical School and Center for
Alternative Medicine Research and Education, Beth Israel Deaconess
Medical Center, in Boston (see Eisenberg [2] & [3] below) has
conducted several large retrospective and cohort studies plotting the
use and acceptance of CAM therapies. They found that between 1990 and
1997:
“Use of at least 1 of 16 alternative therapies increased from 33.8% in
1990 to 42.1% in 1997. The therapies increasing the most included
herbal medicine, massage, megavitamins, self-help groups, folk
remedies, energy healing, and homeopathy. The probability of users
visiting an alternative medicine practitioner increased from 36.3% to
46.3%.” [2]
However, this increased interest in alternative therapies is not new.
What the team also found is that the lifetime prevalence of CAM
therapy use in the United States has been increasing steadily since
the 1950s.
Even more interestingly, CAM therapies were used extensively in the
1850’s and in 1900 and are also documented in the 1920’s and 1930’s.
From this the researchers postulate that their data may be
demonstrating a resurgence in CAM use after a period of reduced use
during the 1940s and 1950s – a time when conventional medical
breakthroughs (antibiotics, vaccines) were at a peak. [3] *
RESOURCES FOR TRENDS & STATISTICS -------------------
[1] Challenges and Opportunities for Collaboration with Industry
National Center for Complementary and Alternative Medicine (NCCAM)
Industry Colloquium - Washington, DC - May 14, 2001
http://nccam.nih.gov/news/pastmeetings/051401/straus/index.htm
[2] 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 [PMID: 9820257]
JAMA. 1998;280:1569-75
http://jama.ama-assn.org/cgi/content/abstract/280/18/1569
[3] David M. Eisenberg, MD; Ronald C. Kessler, PhD; David F.
Foster, MD; Roger B. Davis, ScD; et al. Long-Term Trends in the Use
of Complementary and Alternative Medical Therapies in the United
States; 21 August 2001, Volume 135 Issue 4. Pages 262-268
http://www.annals.org/cgi/content/full/135/4/262 *
*this is an in-depth prevalence study based on a retrospective survey
of 2055 respondents. It includes many tables and graphs and
discussions of the rise and fall of specific types of therapies,
cohort group trends, aggregate statistics, and a long view of the
history of CAM use. I will be referring to it throughout my answer.
==========================================
FACTORS DRIVING THE GROWTH IN CAM USAGE
=========================================
Ok, now the hard part -- WHY?
Here we have to consider two things: the distal and the proximal
causes for the rise in CAM.
Identifying the distal causes will tell us the answer to the question:
Why has CAM therapy grown to be such a large part of today’s medical
arsenal?
Identifying the proximal causes will give us the answer to the
question: Why does an individual makes a decision to switch or add CAM
to their medical treatment.
DISTAL DRIVING FORCES ----------------------------------------------
The distal reasons are the things that are inherent “in the air” –
what’s going on in the world around us culturally, scientifically, and
even biologically. These are things that act on everyone. They are:
------------------
COHORT GROUP
------------------
Not to be confused with age, a patient’s cohort group, that is the
group of people who were born around the same time as the patient and
who travel through time with him/her is an important predictor of the
likelihood of that patient trying and using a alternative therapy.
Cohort groups move in a like-fashion due to shared underlying belief
systems that stem from being born and coming of age in the same
space/time in cultural history.
Again citing Eisenberg et al. [3] :
“… Lifetime use steadily increased with age across three age cohorts:
Approximately 3 of every 10 respondents in the pre–baby boom cohort
[pre-1945], 5 of 10 in the baby boom cohort [1945-1964], and 7 of 10
in the post–baby boom cohort [post 1964] reported using some type of
CAM therapy by age 33 years…Of note are the dramatic differences in
use among cohorts..
“…These consistent and pervasive results should dispel any suggestion
that use has increased for only singular complementary or alternative
modalities or that the use of CAM therapies is a passing fad
associated with one particular generation or fringe segment of the
population.”
As you can see from that, the baby boom and post baby boom cohorts are
a driving force in the overall use of CAM. The purchase power of these
two groups comprises a large portion of the US market. Anything that
appeals to them will certainly take market share.
--------------------------------------------
SHIFT IN PHYSICIAN ATTITUDE TOWARDS CAM
--------------------------------------------
There has been a shift towards acceptance of CAM by conventional
practitioners. Of course this is a chicken-egg scenario; the market
has had a role in driving the process of physician acceptance, and
that acceptance has subsequently increased the growth of CAM usage.
Kaptchuk and Eisenberg (below) sum it up thusly:
“…the new biomedical discussion is probably substantially due to
changes in the internal orientation of the biomedical community …
“…Managed care, insurance carriers, hospital providers, major academic
medical centers, and individual MDs are increasingly receptive to
developing new "integrative" models of health care that would have
been unthinkable just a short time ago …
“…there is a widespread acknowledgment of the need for new dialogue
and a new relationship between what were once regarded as opposing
forces.
“…Alternative medicine has also shifted. … Instead of provoking
antagonism, complementary and integrative medicine have become the new
politically correct buzzwords. Many alternative providers see
themselves in a partnership with biomedicine. A cease-fire, if not a
complete armistice, has been declared.”
Varieties of Healing. 1: Medical Pluralism in the United States
Ted J. Kaptchuk, OMD and David M. Eisenberg, MD
7 August 2001 | Volume 135 Issue 3 | Pages 189-195
http://www.annals.org/cgi/content/full/135/3/189
Berman BM, Singh BK, Lao L, Singh BB, Ferentz KS, Hartnoll SM.
Physicians' attitudes toward complementary or alternative medicine: a
regional survey. J Am Board Fam Pract. 1995 Sep-Oct;8(5):361-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7484223&dopt=Abstract
Boucher TA, Lenz SK. An organizational survey of physicians' attitudes
about and practice of complementary and alternative medicine. Altern
Ther Health Med. 1998 Nov;4(6):59-65.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9810068&dopt=Abstract
Astin, John A., et. A Review of the Incorporation of Complementary
and Alternative Medicine by Mainstream Physicians Arch Intern Med 1998
158: 2303-2310
http://archinte.ama-assn.org/cgi/content/abstract/158/21/2303
-----------------------------------------------------
INCREASED INSURANCE COVERAGE FOR SOME TREATMENTS
-----------------------------------------------------
Again, chicken-egg. Some CAM treatments such as chiropractic are now
being at least partially covered by insurance. This opens the door to
patients who could not previously afford alternative treatments.
Pelletier KR, Marie A, Krasner M, Haskell WL. Current trends in the
integration and reimbursement of complementary and alternative
medicine by managed care, insurance carriers, and hospital providers.
Am J Health Promot. 1997 Nov-Dec;12(2):112-22.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10174663&dopt=Abstract
Steyer TE, Freed GL, Lantz PM. Medicaid reimbursement for alternative
therapies.
Altern Ther Health Med. 2002 Nov-Dec;8(6):84-8
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12440844&dopt=Abstract
---------------------------------
GENDER / EDUCATION / INCOME
---------------------------------
I group these because many of the studies include all three variables.
In general researchers agree that people who use CAM tend to be more
educated and of slightly higher or similar income than non-CAM users,
and most often female. Here are the major studies:
“The 1994-95 National Population Health Survey shows Canadians who
consult rejected alternative health care providers compared with those
who consult accepted health care providers have similar incomes, more
education, slightly fewer chronic diseases and slightly more good
health habits. For both groups, alternative health care supplements
orthodox health care rather than being an alternative to it. Two major
differences emerge: women outnumber men more than two to one as
opposed to being only a slight majority, and usage peaks in Quebec,
not Western Canada.”
Fries CJ, Menzies KS. Gullible fools or desperate pragmatists? A
profile of people who use rejected alternative health care providers.
Can J Public Health. 2000 May-Jun;91(3):217-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10927852&dopt=Abstract
*Astin, JA. Why Patients Use Alternative Medicine: Results of a
National Study
JAMA.1998; 279: 1548- 1553.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9605899&dopt=Abstract
* The above is an important study, cited by many other researchers.
Unfortunately, it is not available for free online. However, the paper
cited below does summarize at least a portion of the data.
This paper is taken from a University student’s overview of the major
studies surrounding CAM usage. No points for design, but good marks
for compiling a single source of data and all of the pertinent
bibliographies checked out.
“In a national study in the US, Astin (1998) found education to be the
#1 sociodemographic variable that predicted use of alternative
medicine; individuals with higher educational attainment were more
likely to use alternative forms of healthcare.”
“Eisenberg et al. (1998) in their 1997 US-wide study found a similar
difference between genders (48.9% of women were consumers of CAM vs.
37.8% of men) as well as other similar patterns to those found in the
Canadian studies—e.g. higher rates of use among people aged 35-49,
people with some college education and people earning higher incomes.
As expected, however, rates of use ranged from 32% to 54% in the wide
range of sociodemographic groups examined.”
Patients' use of CAM
http://sprojects.mmi.mcgill.ca/cam/patients.htm
“[CAM] appears to be common in all socio-economic groups, although AT
use is apparently slightly less among low-income persons than in the
general population.”
Use of alternative therapies by a low income population.
Krastins M, Ristinen E, Cimino JA, Mamtani R.
Preventive Medicine Residency Program, New York Medical College, USA
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9789588&dopt=Abstract
---------------------------------------
MEDIA / ADVERTISING / WORD OF MOUTH
---------------------------------------
The word is out. Everywhere you look alternative therapies are being
preached and pushed. Even accepted pharmaceuticals are being
advertised directly to consumers through magazines, television and
online. The overall effect is that consumers are driving the market
for certain drugs and treatment options in both the accepted and
alternative realms of medicine.
Driving the alternative therapies into the forefront is their
proponent’s ability to profess blatant unfounded claims of medical
success. Whereas orthodox pharmaceutical companies and medical
professionals are bound by laws that restrict them to accurate claims
of efficacy and safety, many alternative products and practitioners
are not. This dichotomy makes alternative therapies look much more
attractive than conventional ones.
“To people who are unwell, any promise of a cure is especially
beguiling. In this vulnerable state, false hope easily supplants
common sense, and patients often accept sophisticated marketing as
sufficient grounds to try new therapies. Another characteristic of
decisions to consult a CAM practitioner seems to be that they are
mediated by the opinions of friends, relatives or neighbors.”
Patients' use of CAM
http://sprojects.mmi.mcgill.ca/cam/patients.htm
“Why would so many well-educated people continue to sell and purchase
such a treatment? The answer, I believe, lies in a combination of
vigorous marketing of unsubstantiated claims by "alternative" healers
(Beyerstein and Sampson 1996), the poor level of scientific knowledge
in the public at large (Kiernan 1995), and the "will to believe" so
prevalent among seekers attracted to the New Age movement (Basil 1988;
Gross and Levitt 1994).”
SKEPTICAL INQUIRER - Why Bogus Therapies Seem to Work
Barry L. Beyerstein, Ph.D
http://www.csicop.org/si/9709/beyer.html
PROXIMAL DRIVING FORCES ------------------------------------
Given that all of the above are out there in our environment acting on
all of us – the media, our disposable income, the subtle expectations
of our cohorts, our doctor’s open-mindedness – why don’t we all add
CAM to our own treatment plans?
One reason would be that many CAM therapies simply have not been
proven to work. They are truly snake-oil. In fact, given what’s
documented about most of these therapies, you would think that the
more educated we are, the less likely we’d be to choose CAM. But now
we know that’s not true. In fact our education makes us more likely to
add CAM to our repertoire of treatments.
So, there must be a difference between those who make the leap to from
merely being susceptible to the draw of CAM therapies and those
actually taking action.
NCCAM describes the general “PUSHES” that drive us away from
conventional treatment and the “PULLS” that draw us to CAM therapies.
Some of these we’ve addressed above, but others are more personal in
nature:
Conventional Medicine - 'Push' Factors
Failure to yield cures
Adverse effects of orthodox regimens
Lack of practitioner time
Dissatisfaction with the technical approach
Fragmentation of care by specialists
CAM Therapies - 'Pull' Factors
Media reports of dramatic results
Belief that CAM treatments are natural
Empowerment of patient
Focus on spiritual and emotional well-being
Provision by therapist of "touch, talk and time
Challenges and Opportunities for Collaboration with Industry
National Center for Complementary and Alternative Medicine (NCCAM)
Industry Colloquium - Washington, DC - May 14, 2001
http://nccam.nih.gov/news/pastmeetings/051401/straus/index.htm
Here are some studies that address a patient’s specific motivations
for choosing a CAM therapy:
------------------------------------------------
EMPOWERMENT / PARTICIPATORY NATURE OF CAM
------------------------------------------------
Below Kaptchuk and Eisenberg give us an educated postulation based on
observations of numerous research results. The authors’ points are
good. They surmise that although there is no proof of efficacy for
many CAM therapies, people seem to prefer the participatory nature of
CAM therapies to conventional treatments and also the unbounded claims
of CAM provide a more optimistic outlook than the realistic claims of
orthodox treatments.
“…It may be that independent of any … efficacy, the attraction of
alternative medicine is related to … a participatory experience of
empowerment, authenticity, and enlarged self-identity when illness
threatens their sense of intactness and connection to the world.
…. It may be that biomedicine, when it is honest, is less optimistic
and more realistically accepts the limitations and finitude of the
human condition.”
The Persuasive Appeal of Alternative Medicine
Ted J. Kaptchuk, OMD and David M. Eisenberg, MD
15 December 1998 | Volume 129 Issue 12 | Pages 1061-1065
http://www.annals.org/cgi/content/full/129/12/1061
----------------------------------------------------
SEVERITY AND DURATION OF ILLNESS / PROGNOSIS
----------------------------------------------------
It is clear that the severity and real or perceived hopelessness of a
patient’s illness has a direct bearing on their adoption of CAM. CAM
is most frequently added by patients with medical conditions not
easily treated by modern medicine. These include chronic pain, poor
mental health, HIV infection, and cancer.
Driving forces include the need to maintain personal control, the
perception of having been abandoned by their physician, and the need
to “do something” when other treatments have failed.
“We concluded that cancer patients have a higher usage rate and
expenditure for CAM, particularly while they are receiving medical
therapy, and are more likely to discuss the use of alternative
therapies with their physicians. CAM was perceived as helpful by
patients despite the lack of scientific data about its effect.
Von Gruenigen VE, White LJ, Kirven MS, Showalter AL, Hopkins MP,
Jenison EL. A comparison of complementary and alternative medicine use
by gynecology and gynecologic oncology patients. Int J Gynecol Cancer.
2001 May-Jun;11(3):205-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11437926&dopt=Abstract
“Astin (1998) finds a significant negative correlation between health
status and CAM use, with use increasing as health status declined. A
number of specific health problems (i.e., back problems, chronic pain,
anxiety, and urinary tract problems”
Patients' use of CAM
http://sprojects.mmi.mcgill.ca/cam/patients.htm
For an in depth look at the use of alternative therapies by cancer
patients, see this 12-chapter National Technical Information Service
(NTIS) Report:
NTIS - Unconventional Cancer Treatments
OTA-H-405 / NTIS order #PB91-104893
http://www.wws.princeton.edu/~ota/disk2/1990/9044.html
Some excerpts from Chapter 7: Patients Who Use Unconventional Cancer
Treatments and How They Find Out About Them
Patient Characteristics
“The published literature on unconventional cancer treatments has
often depicted users of these treatments as deviant, poor, marginal
persons, hostile to mainstream medicine, mentally unstable, ignorant,
gullible, “straw-graspers," or as uninformed “miracle-seekers” (see,
e.g., (104)). These stereotypes generally reflect the opinions of the
writers and society, and are not backed by systematic observation.”
“… the majority of patients in the study who used unconventional
treatments, either exclusively or in addition to conventional
treatment, were well educated, and had accepted mainstream medical
care before getting cancer…”
Patient Attitudes and Motivations
“The desire to mitigate feelings of helplessness and hopelessness may
specifically motivate cancer patients to use unconventional
treatments… exploring unconventional cancer treatments serves to both
restore a degree of personal control and offer a perceived antidote to
the cause of turmoil..”
“Some cancer patients may be motivated to use unconventional
treatments by their feelings of abandonment or rejection by mainstream
physicians ..”
“A cancer patient’s personal and financial resources, belief system,
and personal style of seeking health care all help to determine which
sources of information are used, how information is interpreted, and
how treatment decisions are made.”
--------------------------------------
PERSONAL VALUES AND BELIEF SYSTEMS
--------------------------------------
“…. the majority of alternative medicine users appear to be doing so
not so much as a result of being dissatisfied with conventional
medicine but largely because they find these health care alternatives
to be more congruent with their own values, beliefs, and philosophical
orientations toward health and life.”
Astin, JA. Why Patients Use Alternative Medicine: Results of a
National Study
JAMA.1998; 279: 1548- 1553.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9605899&dopt=Abstract
“The major difference between the two groups were the fact that the AP
group were more critical and skeptical about the efficacy of modern
medicine; they believed their health could be improved; they stayed
loyal to their chosen practitioner; they had tried more alternative
therapies and have more self- and ecologically aware lifestyles; and
they believed that treatment should concentrate on the whole person
and greater knowledge of the physiology of the body.”
Furnham A, Forey J. The attitudes, behaviors and beliefs of patients
of conventional vs. complementary (alternative) medicine. J Clin
Psychol. 1994 May;50(3):458-69.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8071452&dopt=Abstract
Finally, I’d like to address pinkfreud’s comment below because it
illustrates a good point. Her observation that interest in alternative
medicine parallels the increase in interest in Eastern religions is
probably valid, but in the sense that it tells us not WHY people use
CAM therapies but WHICH CAM therapies they embrace.
The 1960’s counter-culture movement, backed by the baby boom, launched
America’s interest in all-things Eastern; Buddhism, Taoism,
meditation, yoga, enlightenment, karma were all buzzwords of the day.
Our current interest in related therapies has clearly grown (but in
many cases has diverged) from that root. However, as I said earlier,
various different CAM therapies were prevalent in earlier decades.
Kaptchuk and Eisenberg give examples of previous forms of alternative
therapies that have been embraced by the American public. Between
1850 and 1931 they include:
Indian doctors, clairvoyants, natural bone-setters, mesmerists [and
practitioners of] galvanic, astrologic, magnetic, uriscope, 7th sons,
Homeopaths, eclectic physicians, magnetic healers, drugless
practitioners, osteopaths, chiropractors, midwives, faith healers,
cults, Christian Scientists, naturopaths, and medicine show ‘cure-all’
frauds.
Varieties of Healing. 1: Medical Pluralism in the United States
Ted J. Kaptchuk, OMD and David M. Eisenberg, MD
7 August 2001 | Volume 135 Issue 3 | Pages 189-195
http://www.annals.org/cgi/content/full/135/3/189
I dwell on this point to reiterate that the current wave of CAM usage
is clearly nothing new. It merely presents a different face today than
it has in the past. It may well be that throughout history humans have
sought alternatives to what they perceive as the limited scope and
promise of orthodox medicine or a mismatch between their values and
the prevalent medical practices.
This has been a fascinating research topic Natalie. I’m truly glad to
have had the opportunity to research it. Many of the behavioral
mysteries surrounding the use of alternative therapies have been
cleared up for me.
Take your time going through what I’ve presented here. It’s a lot of
information. If you come across anything that needs explanation or
further bolstering with hard data, let me know. Or, if you just want
to bounce some ideas or questions off me, I’m happy to discuss them
with you.
Let me know if you need anything –
-K~
search strategy:
Once I had the term CAM, it was a matter of wading through the
numerous articles in PubMed until I figured out which studies carried
the most weight. Once I had those, I followed bibliographical leads to
other research. |
Clarification of Answer by
knowledge_seeker-ga
on
18 Oct 2003 15:17 PDT
Well Natalie, what I’m finding is very interesting and surprising. (Do
I keep saying that?)
The results of my research were giving me conflicting answers to the
insurance issue. On the one hand, as we saw above, the profile for CAM
users in the major retrospective studies is that of the educated upper
to middle economic classes. However, I’m also finding information
that’s pointing in the other direction – towards high CAM usage in the
less educated lower economic strata.
After taking a good hard look at the research and reading nearly the
entire transcript from a 2001 White House Commission on Complementary
and Alternative Medicine Policy hearing, I’m fairly confident that I
have a handle on what this apparent dichotomy is telling us.
When Eisenberg analyzes insurance usage among his study population, he
finds a correlation between insurance coverage and frequency of use of
CAM. Among his mostly educated and financially secure segment of the
population, having insurance coverage increased the frequency of
visits to CAM providers.
“OBJECTIVE: To examine the effect of insurance coverage on frequency
of use of CAM providers. … CONCLUSIONS: A small minority of persons
accounted for more than 75% of visits to CAM providers. Extent of
insurance coverage for CAM providers and use for wellness are strong
correlates of frequent use of CAM providers.”
Wolsko PM, Eisenberg DM, Davis RB, Ettner SL, Phillips RS
Insurance coverage, medical conditions, and visits to alternative
medicine providers: results of a national survey. Arch Intern Med.
2002 Feb 11;162(3):281-7
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11822920&dopt=Abstract
But repeated visits to a CAM provider by an educated financially
secure patient is a far cry difference from the poor uninsured patient
who relies on alternative medicine self-treatment options to save
money.
The ethnic demographic of study participants appears to have a great
deal to do with whether or not a lack of insurance coverage for
treatment effects their selection of CAM. Eisenberg’s notes in his
studies that the telephone survey was directed to people with a good
grasp of English and obviously, to those owning telephones. A segment
of his original study group was eliminated due to poor English.
(Note, I focus on Eisenberg here because most of the statistics I’ve
read refer to his study. His are the numbers everyone is spouting.)
It’s my own speculation, based on everything I read, that this
eliminated group may well be the population that is showing high CAM
usage. First, because many are recent immigrants who will tend to have
low paying jobs and no insurance. And second, because this population
brings with them traditional folk remedies that they are comfortable
falling back on (or even prefer) when they can’t afford orthodox
medical treatment.
What it seems that Eisenberg was focused on were populations that
switched (either fully or partially) from orthodox medicine to CAM.
What this immigrant population represents are those people who have
not traditionally relied on what we consider to be “modern medicine.”
One thing that is clear is that the employed, insured segment of the
CAM using population is putting enormous pressure on employers and
insurance companies to cover the cost of CAM therapies.
Before I present you with the data, a word about one of the sources.
As I mentioned, I read transcript from a 2001 White House Commission
on CAM Policy hearing. I’ll give you the links to that at the end, but
will include references to it along the way. It’s extremely long so
I’ve notated the citations by presenter to make it easier for you to
find them on the page when you follow up. (I have not given them to
you in order of appearance in the transcript.)
===================================================
STUDIES RELATING CAM USAGE TO INSURANCE COVERAGE
===================================================
“In our study use of traditional folk remedies was inversely
associated with levels of education and acculturation and positively
associated with Hispanic ethnicity and being foreign-born.
Low-acculturated, predominately Hispanic immigrants are more likely to
be uninsured or underinsured, not able to afford cannot afford
conventional treatment, and be more familiar with the efficacy of
those traditional folk remedies.”
Lawrence A. Palinkas, PhD; Martin L. Kabongo, MD, PhD; The Use of
Complementary and Alternative Medicine by Primary Care Patients; The
Journal of Family Practice, DEC 2000. Vol. 49, No. 12
http://www.jfponline.com/content/2000/12/jfp_1200_11210.asp
--------------
“ OBJECTIVE: To investigate the sociodemographic characteristics of
CAM utilizers in a national probability sample, one containing an
over-sampling of ethnic minorities.
CONCLUSION: Use of CAM is equally prevalent among white,
African-American/black, Latino, Asian, and Native American populations
in the US, but characteristics of utilizers vary considerably by
specific CAM modality.”
Mackenzie ER, Taylor L, Bloom BS, Hufford DJ, Johnson JC.
Ethnic minority use of complementary and alternative medicine (CAM): a
national probability survey of CAM utilizers. Altern Ther Health Med.
2003 Jul-Aug;9(4):50-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12868252&dopt=Abstract
-------------------
“…Insurance status played an important role in determining health
behavior among Chinese men. Uninsured fathers were perceived as more
likely to use complementary and alternative therapies (CAM) than
mothers. Male students and fathers who had private insurance were
perceived to access and utilize health services equally as the women.
Gender differences are seemingly less apparent among parents who are
using CAM…”
Ray-Mazumder S. Role of gender, insurance status and culture in
attitudes and health behavior in a US Chinese student population. Ethn
Health. 2001 Aug-Nov;6(3-4):197-209.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11696931&dopt=Abstract
--------------------------------------------------------------
White House Commission on CAM Policy hearing
Presenter: Doriane Miller, M.D.
Director of the Program Development and Grantmaking; Robert Wood
Johnson Foundation
“As we see shifts in the demographics of our population, with
increased immigration from Asia, Latin America and the Caribbean,
people are bringing more traditional health beliefs and practices that
include the use of CAM….
“…I spent many years working in a low-income, inner city clinic in San
Francisco where the percentage of uninsured was about 70 percent. Many
of my patients were first and second generation migrants from Texas
and Louisiana. For some of my older patients, even though they were
U.S.-born, English for them was a second language because they were
raised speaking French-Creole.…
“… When some of these patients ran out of money to buy medicine for
treatment for their high blood pressure, they turned to drinking
garlic juice instead of purchasing a prescribed diuretic or beta
blocker…
“…Lack of widespread knowledge of the efficacy of CAM exists for
people of all socioeconomic groups. However, low-income people may be
more vulnerable due to a lack of money to pay for traditional
prescribed services.”
-------------------------------------------------------------
White House Commission on CAM Policy hearing
Presenter: Nathan Stinson, M.D., Ph.D., M.P.H.
Deputy assistant secretary for Minority Health in the U.S. Department
of Health and Human Services
“When we have looked at some of the studies that have been conducted
on the use of CAM by race and ethnicity, there has been a diversity of
opinions and a diversity of results. AHRQ's Medical Expenditure Panel
Survey have found the use of CAM medical providers to be lower for
Hispanics and African Americans than for whites. The use of
chiropractors was also found by the Rand Health Insurance Experiment
to be higher for whites than for racial and ethnic minorities.
“…Conversely, there have been other studies, Walsco and others, that
found that, on an overall basis, race and ethnicity were not always
predictors of the use of alternative medicine practitioners among
clinic attendees. But we have also found that in some of the other
studies, in particular populations, some of the studies relating to
Mexican Americans and other groups, there has been a higher percentage
of use of complementary and alternative medicine providers.
“…As many of you know, many of the racial and ethnic groups have a
very high percentage of uninsurance and underinsurance. Some of the
procedures that are currently paid for by insurance and Medicare
organizations are also some of the procedures that aren't the most
commonly used by some of the organizations.”
-----------------------------------------------------------
White House Commission on CAM Policy hearing
Presenter: Daniel Hawkins
Vice president for Federal and State Affairs; National Association of
Community Health Centers.
“..Native Hawaiian and Native American health services among many of
the health centers, also, acupuncture and herbal medicine. … on
average 25 to 50 percent of health centers offer one or another forms
of complementary and alternative medicine. The most common,
acupuncture, massage, chiropractic, and folk healing..”
----------------------------------------
White House Commission on CAM Policy hearing
Presenter: Kathleen King
On behalf of the Washington Business Group on Health
“…results from the 2000 census indicate, the U.S. population is
changing … In addition to people from other cultures, such as people
from Eastern cultures, having a faith and practices in things like
acupuncture, acupressure, tai chi, those type of treatments are
becoming much more broadly disseminated in the culture overall, and
that is something that employees bring to the table…
------------------
“..This study estimates unmet need and barriers to alcohol, drug, and
mental health (ADM) services in 1997 to 1998 using data from a
national household survey… Economic barriers are highest for the
uninsured, but also are high among the privately insured. Individuals
with unmet need are significantly more likely to use complementary and
alternative medicine (CAM). Those with no conventional mental health
care rely on self-administered treatment, while those with
delayed/insufficient conventional care use CAM providers and
self-administered treatment.”
Sturm R, Sherbourne CD. Are barriers to mental health and substance
abuse care still rising? J Behav Health Serv Res. 2001 Feb;28(1):81-8
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11330001&dopt=Abstract
---------------------
“Factors shown to be related to greater utilization of [CAM] services
included: younger age, higher household income, employed or student
status, private health insurance coverage, and having received
chemotherapy.
Gray RE, Fitch M, Goel V, Franssen E, Labrecque M.
Utilization of complementary/alternative services by women with breast
cancer. J Health Soc Policy. 2003;16(4):75-84.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12943333&dopt=Abstract
-----------------
“Results. Overall, [of HIV patients studied] 15.4% had used an
alternative therapist, and among users, 53.9% had fewer than 5 visits
in the past 6 months. Use was higher for people who were gay/ lesbian,
had incomes above $40000, lived in the Northeast and West, were
depressed, and wanted more information about and more decision making
Involvement in their care. Among users, number of visits was
associated with age, education, sexual orientation, insurance status,
and CD4 count.
“…. of people in care for HIV in early 1996….Most had some form of
public insurance (31.7% had Medicaid; 19.2% had Medicare); however,
19.8% had no health insurance.”
Use of Alternative Therapists Among People in Care for HIV in the
United States
http://www-cpr.maxwell.syr.edu/faculty/london/London%20AJPH2003.pdf
==============================================================
PRESSURE OF CAM USERS ON INSURANCE PROVIDERS AND EMPLOYERS
==============================================================
White House Commission on CAM Policy hearing
Presenter: Kathleen King
On behalf of the Washington Business Group on Health
“A recent survey by "Modern Healthcare" has found that about 69
percent of respondents said that they wanted health insurance to cover
CAM treatments. About 77 percent said they wanted more research
devoted to alternative medicine.
“… our workforce is aging. The baby boom generation is increasingly
interested in things that prolong their health and vitality…
“Employees themselves want more corporate support for non-conventional
treatment options. … complementary and alternative medicine is the
fastest growing sector of the health care industry. The public's
desire and demand for something more than pills and shots for the
treatment of symptoms is fueling the demand for corporate support for
these types of services.”
---------------------------------------------------------------
White House Commission on CAM Policy hearing
Presenter: Tom Sawyer
On behalf of William M. Mercer, human resource consulting firm
“Primarily because employee demand for such services exists, plan
sponsors have increasingly implemented CAM programs into their
sponsored PPOs, POS plans, HMOs, and indemnity plans…”
Sawyer goes on to present the results of a 2000 survey:
84% PPOs and indemnity plans and 66% of HMO plans offered chiropractic
care coverage. Of the five modalities surveyed [acupressure /
acupuncture, biofeedback, chiropractic, homeopathy, and massage
therapy] biofeedback was least often covered. As compared to the 1998
survey, the percent of employers offering these modalities has
increased somewhat from 3 percent for massage therapy to 21 percent
increase for chiropractic, regardless of the type of health plan.
-------------------------------
CONCLUSION: Consumer demand for CAM is motivating more MCOs and
insurance companies to assess the clinical and cost benefits of
incorporating CAM.
Pelletier KR, Astin JA. Integration and reimbursement of complementary
and alternative medicine by managed care and insurance providers: 2000
update and cohort analysis. Altern Ther Health Med. 2002
Jan-Feb;8(1):38-9, 42, 44 passim.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11795621&dopt=Abstract
======================================
WE AREN’T THE ONLY ONES CONFUSED
=====================================
White House Commission on CAM Policy hearing
From the Panel Discussion Q & A
DR. BERNIER: “I don't know if I am making that clear, but it seems to
me that the utilization of CAM products is, in some ways, proportional
to the affluence of the population that is using it. .. Contrary-wise,
as people are decreasing the level of CAM activities, it is a
reflection of decreased access to other kinds of health care as
well….”
DR. STINSON: …let me put it to you that way -- that if you look at
several different studies, some will show that, and some will show
other things, depending on what specific modality you may be looking
at.
DR. BERNIER: So that, the extrapolation that I just made would not
necessarily be a valid one.
DR. STINSON: I think that the statement is too general, at least from
my own perspective. …the literature is as diverse in its conclusions
as the populations we deal with.
============================
REFERENCES
============================
WHITE HOUSE COMMISSION on COMPLEMENTARY and ALTERNATIVE MEDICINE
POLICY – May 14th, 2001 - Volume 1 Part 2
Meeting Topic I: CAM: Understanding Coverage and Reimbursement
http://www.whccamp.hhs.gov/meetings/transcript_5_14_04v1p2.html#stinson
HOME PAGE: WHITE HOUSE COMMISSION on COMPLEMENTARY and ALTERNATIVE
MEDICINE POLICY – May 14-16, 2001
http://www.whccamp.hhs.gov/meetings/transcript_5_14_01main.html
In closing, what we’re seeing here is the difference between two
populations:
1 - Those who electively choose expensive supplemental CAM therapies
and therapists to enhance their conventional treatments and are
pushing their employers to offer coverage so they can use CAM more
frequently;
2 – Those who are either forced by economics and lack of insurance or
drawn by tradition to fall back on inexpensive folk solutions when
conventional treatment becomes unaffordable.
In the end, it’s the difference between hiring a personal trainer and
having to walk 5 miles to work because you can’t afford a car.
Let me know if you need anything further Natalie. I’ll be back here
Monday. Enjoy your weekend.
-K~
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