Is There a Role for Complementary and Alternative Medicine in Preventive and Promotive Health? An Anthropological Assessment in the Context of U.S. Health Reform

Governing therapeutic pluralism: An environmental scan of the statutory regulation and government reimbursement of traditional and complementary medicine practitioners in the United States

The World Health Organization has called on nation-states to statutorily govern, and integrate into state-funded healthcare systems, practitioners of traditional and complementary medicine (T&CM) (whose therapeutic approaches that fall outside the boundaries of conventional biomedicine). To date, however, there exist few rigorous reports of the degree to which individual nations have responded to this call. This study, an environmental scan, comprehensively documents the statutory governance and government reimbursement of T&CM practitioners in the United States (US). Across the US, where health practitioner governance falls within state and territorial (rather than federal) jurisdiction, over 300 laws have been enacted to statutorily regulate a wide range of T&CM practitioners. Nurse-midwives and chiropractors are universally licensed across all 56 US regulatory jurisdictions (50 states, 5 territories and the District of Columbia); other major T&CM practitioner groups are regulated in fewer jurisdictions (acupuncturists, n = 52; massage therapists, n = 50; direct-entry [non-nurse] midwives, n = 36; naturopaths, n = 24). Additional statutory stipulations exist to govern chiropractic assistants (n = 30), auricular (ear) acupuncture practitioners (n = 24), homeopathic practitioners (n = 3), and psychedelic facilitators (n = 1), as well as biomedical professionals who practice acupuncture and related techniques, e.g., 'dry needling' (n = 44). While professional entry requirements for licensed T&CM practitioners are substantially harmonized across jurisdictions, restricted titles and statutory scopes of practice vary. Ten states have furthermore implemented 'safe harbor' ('negative licensing') exemption laws enabling otherwise-unregulated T&CM practitioners to legally practice. Limited government reimbursement for T&CM care is available across several federal and state programs, including Medicare, Tricare, Veterans Health Authority, and Medicaid. Nurse-midwifery and chiropractic care is most frequently reimbursed; acupuncturists, naturopaths and massage therapists are eligible for much more limited coverage. Medicaid programs for low-income people in ten states furthermore cover the services of (unlicensed but statutorily-recognized) birth doulas. Additional research is needed to assess the impact of these regulations on US health care.

Alternative medicine, worker health, and absenteeism in the United States

Health related absenteeism costs an estimated $153 billion annually in the United States (Witters and Agrawal, 2011).¹ Chronic conditions (major contributors to absenteeism) are often successfully managed by Complementary and Alternative Medicine (CAM). As CAM becomes an increasingly visible component of healthcare, firms may wish to consider whether CAM therapies can help reduce illness-related absenteeism. This paper aims to extend the literature on healthcare utilization and absenteeism by exploring whether CAM treatment is associated with fewer workdays missed due to illness.

METHODS

Using the 2007 National Health Interview Survey (NHIS) and propensity score matching (PSM), this study estimates the relationship between visits to CAM practitioners, health, and illness-related absenteeism.

RESULTS

In a sample of 8820 workers, the average annual number of workdays lost due to illness is 3.69. Visiting an acupuncturist correlates with lower absenteeism among men (1.182 fewer workdays missed, p<0.05), whereas visiting a naturopathic doctor correlates with 2.359 and 2.521 fewer workdays missed for women and men, respectively (both p<0.001). Active mind-body practices, massage, chiropractic and acupuncture treatments are all significantly associated with improved health.

CONCLUSIONS

Estimates suggest that some CAM modalities correlate with lower absenteeism, and many correlate with improved health. Two limitations of this study are worth noting. First, a small proportion of the sample uses CAM, limiting the generalizability of results. Second, if health conscious individuals are more likely to use CAM, then health attitudes may be contributing to lower absenteeism among the treated. Further research is needed to identify a causal relationship between CAM treatment, health, and absenteeism.

Traditional, complementary, and alternative medicine approaches to mental health care and psychological wellbeing in India and China

India and China face the same challenge of having too few trained psychiatric personnel to manage effectively the substantial burden of mental illness within their population. At the same time, both countries have many practitioners of traditional, complementary, and alternative medicine who are a potential resource for delivery of mental health care. In our paper, part of The Lancet and Lancet Psychiatry's Series about the China-India Mental Health Alliance, we describe and compare types of traditional, complementary, and alternative medicine in India and China. Further, we provide a systematic overview of evidence assessing the effectiveness of these alternative approaches for mental illness and discuss challenges in research. We suggest how practitioners of traditional, complementary, and alternative medicine and mental health professionals might forge collaborative relationships to provide more accessible, affordable, and acceptable mental health care in India and China. A substantial proportion of individuals with mental illness use traditional, complementary, and alternative medicine, either exclusively or with biomedicine, for reasons ranging from faith and cultural congruence to accessibility, cost, and belief that these approaches are safe. Systematic reviews of the effectiveness of traditional, complementary, and alternative medicine find several approaches to be promising for treatment of mental illness, but most clinical trials included in these systematic reviews have methodological limitations. Contemporary methods to establish efficacy and safety-typically through randomised controlled trials-need to be complemented by other means. The community of practice built on collaborative relationships between practitioners of traditional, complementary, and alternative medicine and providers of mental health care holds promise in bridging the treatment gap in mental health care in India and China.

The characteristics, experiences and perceptions of naturopathic and herbal medicine practitioners: results from a national survey in New Zealand

Background

Despite the popularity of naturopathic and herbal medicine in New Zealand there remains limited data on New Zealand-based naturopathic and herbal medicine practice.

In response, this paper reports findings from the first national survey examining the characteristics, perceptions and experiences of New Zealand-based naturopaths and herbal medicine practitioners across multiple domains relating to their role and practice.

Methods

An online survey (covering 6 domains: demographics; practice characteristics; research; integrative practice; regulation and funding; contribution to national health objectives) was administered to naturopaths and herbal medicine practitioners. From a total of 338 naturopaths and herbal medicine practitioners, 107 responded providing a response rate of 32%. Data were statistically analysed using STATA.

Results

A majority of the naturopaths and herbal medicine practitioners surveyed were female (91%), and aged between 45 and 54 years. Most practiced part-time (64%), with practitioner caseloads averaging 8 new clients and over 20 follow-up clients per month.

Our analysis shows that researched information impacts upon and is useful for naturopaths and herbal medicine practitioners to validate their practices.

However, the sources of researched information utilised by New Zealand naturopaths and herbal medicine practitioners remain variable, with many sources beyond publications in peer-reviewed journals being utilised. Most naturopathic and herbal medicine practitioners (82%) supported registration, with statutory registration being favoured (75%). Integration with conventional care was considered desirable by the majority of naturopaths and herbal medicine practitioners surveyed (83%).

Naturopaths and herbal medicine practitioners feel that they contribute to several key national health objectives, including: improved nutrition (93%); increased physical activity (85%); reducing incidence and impact of CVD (79%); reducing incidence and impact of cancer (68%).

Conclusions

There is a need for greater understanding and communication between practitioners of conventional care and naturopathic and herbal medicine which could support informed, coordinated and effective health provision within the New Zealand health care system. There is a need for further in-depth research examining naturopaths and herbal medicine practitioners’ perceptions and practices, to provide insights of benefit to all those practising and managing health services as well as those directing health policy in New Zealand.