What is the history of complementary medicine?
The history of complementary medicine (CM) includes two distinct but overlapping narratives: the histories of the various complementary treatments and practices, themselves a collection of more than one hundred different approaches, and the history of their definition as complementary. One immediate problem is the lack of an agreed-upon definition of CM. The National Center for Complementary and Alternative Medicine (NCCAM) defines CM as “the use of a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine . . . together with conventional medicine.” The National Cancer Institute (NCI) defines CM as “any medical system, practice, or product that is not thought of as standard care” and that is used “with standard medicine.”
The Institute of Medicine (IOM), however, notes that the identification of any treatment as complementary is in part a historical judgment; IOM defines CM as that which contrasts “the dominant health system of a particular society or culture in a given historical period.” This essay will focus on the evolution of complementary medicine in the United States, which has been a unique historical laboratory for unconventional approaches to health care.
The term “complementary medicine” is a recent coinage, the result of two major changes in the landscape of health care in the United States. The first change was the transition in the nineteenth and early twentieth centuries from a range of patterns of medical education and competing philosophies of health care to the standardization of educational requirements for physicians and the establishment of Western scientific medicine as the yardstick against which all other approaches were measured. The second major change was the opposition to this standardization that began in the 1960s.
What is now considered the center of a physician’s education, the university-related medical school, was the exception rather than the rule for the first century of the existence of the United States. Only two such schools had been founded before the American Revolution, one at the University of Pennsylvania (1765) and the other at Columbia University (1767). Because of the vast size of the continent and the difficulties of practicing medicine on the frontier, other ways of training physicians were adopted. Training now included apprenticeships with practicing physicians, at the end of which the fledgling practitioner was admitted to the local medical society on the basis of a letter of recommendation from the student’s mentor. There were no state or national board examinations at this time.
Another development was the establishment of proprietary schools of medicine, so called because they were owned privately (usually by a group of local physicians) and operated for profit. Although some of the older East Coast institutions had founded schools of medicine separate from their undergraduate colleges (such as Harvard in 1782 and Yale in 1810), the proprietary schools met the needs of underserved rural areas in the Midwest and deep South. The proprietary schools also allowed for the emergence of alternatives to what had not yet been defined as mainstream scientific medicine.
Several competing approaches to health care flourished in the nineteenth century, ranging from such American innovations as Thomsonianism (1820s), osteopathy (1892), and chiropractic (1897) to such European imports as hydrotherapy (1844) and homeopathy (1848). Perhaps the most typically American development was eclectic medicine, which emerged in the 1830s and combined Thomsonianism with conventional medicine, physical therapy, and Native American herbalism. Its mix-and-match utilization of different therapies was a forerunner of CM as defined today.
In 1908, educator Abraham Flexner was asked by the Carnegie Foundation to evaluate the condition of medical education in the United States. Flexner’s report, published in 1910, marked the end of the proprietary schools; their approach to medicine went underground for half a century, to reemerge in the wake of the counterculture of the 1960s. Flexner recommended the closure of half the 155 medical schools then operating in the United States; the establishment of the university-related school of medicine as the ideal pattern; the requirement of college-level preparation before admission to medical school; and strict adherence to mainstream science in teaching and research. Schools of homeopathy, naturopathy, and similar approaches were forced to abandon courses in these alternatives or to close down. The exception was osteopathy, which survived because the American Osteopathic Association was able to bring most schools of osteopathic medicine into line with Flexner’s stipulations.
From the period following World War I until the 1960s, Western allopathic (conventional) medicine was considered normative in the United States, with all other therapies classified as mere historical curiosities. The situation began to change in the 1960s for several reasons. First, mainstream medicine was discredited because of such emotionally painful episodes as the thalidomide disaster of 1961 and the withdrawal of diethylstilbestrol (DES) after 1971. The discovery that drugs developed to treat anxiety and the risk of miscarriage, respectively, had teratogenic or carcinogenic side effects led to skepticism regarding the benefits of so-called scientific medicine. Second, the bureaucratization of medicine spurred by the passage of the Health Maintenance Organization Act of 1973 and the rise of managed care caused widespread discontent among health consumers, who resented the denial of treatments they considered necessary; many also complained that medicine was becoming too impersonal.
The third factor that helped to revive interest in other approaches to health care was the emergence of new religious movements (NRMs) in the 1960s and 1970s. Some of these groups had affinities with Eastern religions and explored such ancient Asian medical systems as Ayurveda and traditional Chinese medicine. Others, influenced by the back-to-nature enthusiasm of the environmental movement, began to study Western herbalism and folk remedies in preference to the “artificial” prescription drugs produced in laboratories. Fourth, the emphasis of traditional Judaism and Christianity and NRMs on the importance of spiritual and physical well-being resonated with many who were dissatisfied with the assembly-line treatment they received in conventional health maintenance organizations. Part of the appeal of such therapies as chiropractic and naturopathy was that their practitioners spent time with their patients rather than rushing them through appointments as quickly as possible.
In the early twenty-first century, unconventional therapies were used much more often as complementary treatments than as strict alternatives to mainstream medicine. As a result, CAM’s relationship to mainstream medicine is constantly changing. Three basic patterns define in the relationship of various complementary approaches to conventional medicine.
Defining ancient practices as complementary therapies. According to NCCAM, as of 2007, meditation and yoga were not only two of the most commonly used complementary approaches in the United States among adults but also among those that have shown the greatest increase in use since 2002. When prayer is included in NCCAM statistics, it appears to be the single complementary approach used most often in North America. Prayer for healing has been practiced by Jews and Christians since at least the first millennium b.c.e. Yoga as a spiritual discipline among Hindus goes back to about 600 b.c.e., although yoga was not widely practiced in North America until the 1970s and was added to college curricula in physical education departments rather than as a form of spirituality. What is significant about NCCAM’s classification of these practices is its definition of them as therapies, given that they are far older than conventional medicine.
Mainstreaming of formerly unconventional treatments. Some approaches once considered unconventional are now regarded as mainstream practice. The most notable example is osteopathy, which began in the United States in the 1890s. Osteopathic schools chose to accept the recommendations of the 1910 Flexner report, reorganizing their curricula to increase the similarity of osteopathy to conventional medicine. By 1969, doctors of osteopathy (D.O.s) were accepted as members by the American Medical Association, and by 2000, they were accepted into almost all hospital postgraduate programs on an equal basis with medical doctors (M.D.s). The use of osteopathic manipulative medicine, the remaining distinctive feature of osteopathic training, is in decline; fewer osteopaths perform it today, and more recommend surgery as first-line treatment.
An example of an Asian therapy that is increasingly regarded as mainstream rather than complementary in the United States is acupuncture. Considered an exotic Chinese treatment until the early 1970s, acupuncture has been used by about 1 percent of the American population for pain relief as of 2007. The U.S. Food and Drug Administration (FDA) approved the use of properly manufactured acupuncture needles by licensed practitioners as early as 1996.
Complementary therapies in the United States considered mainstream elsewhere. Herbal medicine is an example of a therapy classified as complementary in the United States but regarded as mainstream practice elsewhere, in this case in Europe and Japan. Herbal preparations are defined as dietary supplements in the United States and can be purchased over the counter. The Dietary Supplement Health and Education Act (DSHEA), passed by Congress in 1994, gave the FDA authority to monitor the safety of herbal products once on the market and to recall or impound those found to be contaminated or otherwise unsafe. Manufacturers of these products, however, are not required to demonstrate their safety or effectiveness before marketing them.
In Germany and Japan, by contrast, herbal preparations are prescribed by licensed physicians. In 1978, Commission E, a regulatory agency of the German government composed of pharmacists, physicians, and botanists, was formed to evaluate the safety and efficacy of more than three hundred herbs. The sale of prescription herbal medicines has been rising rapidly in Germany since the 1990s, driven by consumer demands for natural alternatives to synthetic drugs. The Japanese equivalent is Kampo, a group of 148 traditional herbal formulae originally derived from Chinese medicine and approved by the Japanese ministry of health beginning in 1967. The manufacture of Kampo formulae is rigorously supervised by the government, and the medicines must be obtained by prescription from licensed physicians.
Given the increasing fluidity of the boundaries between complementary and conventional therapies, many observers (particularly Edzard Ernst, the world’s first professor of CM) are calling for an end to the classification of medicine as either mainstream or unconventional. Ernst stated in a 2008 interview, “There is no such thing as alternative medicine. There is either medicine that is effective or not, medicine that is safe or not.”
Bodeker, G., et al. WHO Global Atlas of Traditional, Complementary, and Alternative Medicine. Kobe, Japan: WHO Kobe Centre, 2005. This two-volume publication consists of a map volume and a text volume. The map volume provides information not only on CAM therapies worldwide but also on legislation and professional regulation of CAM practitioners. The text volume offers detailed descriptions and analyses of the use of traditional and CAM therapies in twenty-three countries.
Ernst, Edzard, Max H. Pittler, and Barbara Wider, eds. Complementary Therapies for Pain Management: An Evidence-Based Approach. New York: Mosby/Elsevier, 2007. Coedited by a European expert on CM, this book offers concise summaries of complementary approaches to pain relief and analyses of clinical trial data for their effectiveness.
Institute of Medicine of the National Academies. Alternative Medicine in the United States. Washington, D.C.: National Academies Press, 2005. This report, originally commissioned by the National Academies of Science in 2002, discusses questions of public policy, identifies scientific issues regarding CM, and analyzes the populations that use complementary therapies most often.
National Center for Complementary and Alternative Medicine. http://nccam.nih.gov. A comprehensive site for basic information about CAM therapies and for demographic statistics about the use of CAM in the United States.
Office of Cancer Complementary and Alternative Medicine. http://www.cancer.gov/cam. Provides an introduction to the various complementary therapies for persons with cancer and information about clinical trials of CAM therapies.
Whorton, James C. Nature Cures: The History of Alternative Medicine in America. New York: Oxford University Press, 2002. This book is one of the few historical overviews of CAM therapies in the United States, as distinct from descriptions of the therapies themselves.