The rise and rise of CAM

Integrated medicine (known as integrative medicine in the USA) is rapidly gaining credibility and support in the UK. An issue of the respected British Medical Journal (BMJ) in January 2001 devotes a large section to discussing how medicine could benefit from the integration of complementary and alternative medicine (CAM) into conventional care (1).

This follows a House of Lords Select Committee on Science and Technology report of November 2000, which reviewed the current status and popularity of CAM in the UK (2). In the week beginning 22 January, the Royal College of Physicians and the US National Centre for Complementary and Alternative Medicine put on a conference to raise CAM’s UK profile further.

But does alternative medicine need its profile raised further? It is already too well respected by the medical profession – and rather too popular among the public.

The distinction between CAM and orthodox medicine is their relationship to medical science: namely, that orthodox medicine has one, and CAM does not. After sifting through the numerous definitions of CAM, the House of Lords select committee decided against adopting any – instead stating that ‘complementary disciplines [are] those which usually, if not invariably, complement conventional medical treatment, while the alternative disciplines are those which purport to offer diagnostic and therapeutic alternatives to conventional medicine’.

Unlike orthodox medicine, which often provides one form of treatment for one particular ailment, CAM never claims to be a superior form of healthcare practice. The abject relativism of CAM may help to explain its popularity among patients – CAM seems to offer something for everybody. But it is precisely this relativism that should make doctors more suspicious of alternative therapies, not more accepting of them.

The new vogue for CAM, particularly within the medical profession, seems particularly strange when we consider that scientific medicine progressed and developed by questioning, among other things, divine and secular authority. It insisted on excellence in its pursuit of truth, advances in diagnosis and treatment of disease. Its search has resulted in triumphs such as organ growth and transplantation, haemodialysis, cardiac surgery, chemotherapy, gene manipulation.…The successes are too numerous to list.

Yet despite all this progress, the medical profession is now willingly embracing the very mystical practices it transcended 200 years ago. Why?

The growing popularity of CAM may have had an impact. Citing research commissioned by the Department of Health in 1999, the House of Lords select committee report states that:

• Up to five million patients had consulted a CAM practitioner in the past year.
• At least 40 percent of general practices in the UK provide some CAM services.
• There were 50,000 CAM practitioners in the UK.
• 10,000 statutory registered health professionals practice some form of CAM.

Such popularity makes CAM quite a lucrative business. The BBC, following a commissioned telephone survey in 1999, estimated that £1.6billion was spent on CAM annually in the UK (3). The Royal Pharmaceutical Society has estimated that retail sales of CAM (herbals, homeopathic preparations and aromatherapy essential oils) totalled £93million in 1998: an increase of 50 percent from 1994. Predictions for 2002 put the retail sales of CAM at £126million.

What accounts for this love affair with alternative therapies? Most patients with ill health who consult CAM practitioners suffer complex chronic conditions, which have not been sympathetically managed by the NHS and often considered ‘heartsink’ by GPs. Chronic fatigue syndrome, irritable bowel syndrome, eczema and non-specific allergies, back pain and migraine are conditions regularly treated by CAM practitioners.

But the BBC survey discovered that, for the majority of respondents, CAM was popular not because they couldn’t get satisfactory treatment on the NHS, but because they liked CAM. The respondents found it relaxing, they used it to promote good health and wellbeing. Some did not believe conventional medicine worked; they used CAM to find out about new ways of life and to help relieve injuries or medical conditions. These findings corresponded with the results of a US survey, which discovered that users find CAM ‘more congruent with their own values, beliefs and philosophical orientations towards health and life’ (4).

But there is more to the rise of CAM than simply that people seem to like it. The fact that it is now taken seriously among the medical profession suggests a decline in medics’ confidence in the very foundations of their own profession.

The sentiments expressed in the BMJ in January are a long way from those confidently expressed in 1980, when the same journal characterised the public’s growing support for complementary therapies as symptomatic of ‘a flight from science’. Then, the BMJ recommended that the scientific foundation of medicine be taken more seriously (5).

The British Medical Association (BMA) followed with a trenchant criticism of CAM in its 1986 report ‘Alternative Therapy’ (6). The BMA emphasised that the ‘fundamental division’ separating orthodox and alternative approaches was ‘the scientific principle which underlies the former and the testing of theories by systematic observation which that principle implies’. It rejected alternative medicines’ reliance on descriptions of energy flows to account for the effect of alternative therapies as ‘no more than dogmatic metaphysics’, and practitioners’ support for them as a ‘reversion to primitive beliefs’.

But the hostile reaction to this report forced the BMA to adopt a more conciliatory tone. Its 1993 follow-up report, ‘Complementary Medicine: New Approaches to Good Practice’, offered instead a pragmatic definition of ‘conventional medicine’ as ‘that treatment which is delivered by a registered medical practitioner’. It made no reference to medicine’s scientific base. It arbitrarily recommended that the ‘big five’ therapies – acupuncture, chiropractic, herbalism, homeopathy and osteopathy – could be regarded as ‘discrete clinical disciplines’, and encouraged their professionalisation.

Some in the medical profession have professed discomfort with the extent to which CAM has been embraced, arguing that the commitment to CAM downplays the role of science in medicine. ‘Medicine aims to build itself upon science’, stated Professor Louis Wolpert of the Academy of Medical Sciences, in his submission to the House of Lords committee. ‘I am sorry that any complementary or alternative medicine procedure for which one can see no reasonable scientific basis should be supported.’ It seems extraordinary that medicine, which owes its success entirely to medical science, should be so keen to give credence to forms of ‘alternative therapy’ that have no scientific basis at all.

The report by the House of Lords select committee was a continuation of the BMA’s gradual acceptance of non-scientific medicine. The select committee accepted that therapies, notably osteopathy, chiropractic and herbal medicine, have established efficacy in the treatment of a limited range of ailments. Surprisingly, the committee considered the conclusions from research into the efficacy of CAMs outside the remit of the report. It acknowledged, however, that most CAMs lack scientifically controlled evidence.

The committee suggested that the public’s interest would best be served by improving regulatory structures for many of the professionals involved. Yet it ignored the far more serious consequences that legitimising unscientific practices could have for patients – and for those who treat them.

The growing acceptance of CAM by the medical profession and the House of Lords is already having an impact on medical practice. Medical schools were strongly recommended to ensure that all medical undergraduates were exposed to a level of CAM familiarisation, to alert them to the choices their patients might make. The select committee report also suggested that all medical schools should consider whether or not to make available optional Special Study Modules in CAM, for those students with a particular interest in this area. The Royal Colleges were recommended to assist doctors, dentists and veterinary surgeons in familiarising themselves with CAM therapies through continuing professional development opportunities.

The popularity of CAM has also had an impact on nursing, which is thought to lend itself naturally to CAM because nurses tend to have more physical contact with patients than doctors. Nurses frequently incorporate some form of complementary therapy such as massage, aromatherapy and reflexology in their practice. A growing interest in CAM has been reported among nurses. The Royal College of Nursing (RCN) Complementary Therapies Forum has a voluntary membership of just over 4000 (7).

Yet even so, the RCN and the nurses’ regulatory body, the United Kingdom Central Council (UKCC), have been criticised for ‘their passive approach to CAM’ and ‘the lack of work being undertaken by these bodies in relation to nurses’ use of CAM and their training in the awareness of CAM practices’. The House of Lords select committee report recommended that postgraduate nurses should have access to a list of approved training courses in CAM, to be compiled by the RCN and UKCC.

Despite all these official moves to embrace CAM, the reason for its growing importance lies not within any medical contribution CAM has made, but in the medical profession’s own defensiveness about its own achievements. For example, there is an idea that CAM is special because of its holistic approach. This ignores the fact that orthodox medicine is fully cognisant of the need to deal with the mind and body, and the relationship between them (it is only bad medicine that is not). The attempt to talk up the potential benefits of CAM obscures the most obvious benefit of medical science – that it diagnoses diseases and cures them.

The consequence of all this is that CAM – the ‘medicine’ based on the mysticism of the distant past – looks set to become the popular medicine of the new millennium. This cannot be healthy.

Bríd Hehir is a contributor to Alternative Medicine: Should We Swallow It? (Hodder & Stoughton, 2002). Buy this book from Amazon (UK).

Read on:

Put alternative medicine back in its box, by Dr Michael Fitzpatrick

Head cases, by Bríd Hehir

Watered-down science, by Howard Fienberg

Touching a nerve, by Sarah Glazer

(1) BMJ 322: 20, January 2001
(2) House of Lords Select Committee on Science and Technology, Sixth Report, 2000
(3) ‘The BBC survey of complementary use in the UK’, E Ernst and A White, in Complementary Therapies in Medicine, 8 (2000), 32-36
(4) ‘Why patients use alternative medicine. Results of a national survey’, JA Astin The Journal of the American Medical Association, 279 (1998) 1548-1553
(5) BMJ editorial, 5 January 1980
(6)Alternative Therapy, BMA, Chameleon Press 1986
(7) In Touch: the RCN Newsletter for Complementary Therapies in Nursing Forum, Spring 2001