The history of complementary and integrative medicine.

As a child in the 50s and later as a medical student in the 70s, my first exposures to the area of nonconventional, complementary and alternative healing were home remedies. The vitamins, salves, elixirs, nutritional supplements, and Polish peasant foods prescribed by my mother later intersected powerfully with natural remedies offered by my medical school mentor, Dr. Kenneth Kessel. Ken had been a pharmacist before becoming a family doctor and a part of his practice required meeting the needs of European immigrants in the Chicago area who imported their herbal remedies with them. They expected their pharmacist to stock them, and he did. Those were the days when pharmacists still had courses in pharmacognosy to learn and understand the healing powers of plants. Besides bottles of pills to count and dispense, the pharmacy still had drawers and jars with plant materials and herbs that required the mortar and pestle, a scale, extracting solvents, flavorings, and other special ingredients and skills of the compounding pharmacist.

I still remember a sunny, crisp autumn day when as a junior medical student Dr. Ken took me on a field trip to the Morton Arboretum's medicinal herbal garden. Seeing the plants which were the source of many of the drugs I had studied from foxglove, willow, and belladonna to what were then to me mostly unknown herbs like echinacea, aloe, and bilberry was like a mystic revelation. Drugs were derived from herbs, and herbs themselves were healing agents. What a concept! In addition, herbs that were generally considered culinary such as rosemary, sage, garlic, parsley, and dill also had a variety of medicinal effects.

Ken had a farm in Wisconsin and a greenhouse and garden in his home in the Chicago suburbs. He raised (and still raises) organic vegetables as well as medicinal and culinary herbs. His gardening and botanical interests grounded the reality of my interest in home remedies and herbs, an interest I have maintained throughout my medical career.

As we look at the history of natural cures and medicine in America, we find a number of interesting trends. (1,2) Initially, in the mid 19th century, alternative systems were out to destroy and eliminate the then toxic allopathic system. No doubt, such calls for reform were reasonable when the standard of care called for bleeding, heavy metals, and a variety of toxic nostrums which were a real risk to patients. Recall Dr. Oliver W. Holmes' call to sink the entire materia medica into the ocean to benefit patients though it would clearly be to the detriment of the fishes. Practitioners of homeopathy, naturopathy, mental healing, spiritual healing, chiropractic, herbalism, hydrotherapy, and other naturalistic approaches could reasonably proclaim that their treatments were much less likely to kill their patients than the medicine of the day.

Ushering in the current center stage position of modern medicine in American culture were some remarkable developments. The evolution of a more scientific basis to medical practice and particularly with the powers of antibiotics and other pharmaceuticals, the development of effective anesthetics, of safe and sterile surgical procedures, of Osler's methods of scientific rigor and bedside compassion, all were nodal. While a wide variety of alternative practitioners remained active, they were (and continue to be) politically, culturally, financially, and scientifically relegated to a therapeutic side stream.

Of what benefit was grandmother's herbal tea for the cough when sulfa and penicillin were so effective for pneumonia? And how could a bonesetter or chiropractor claim to compete with the obvious benefits of spinal surgery and other orthopedic procedures? How could childbirth be ethically and safely done in the traditional home setting when hospitals provided immediate access to cesarean section, blood transfusion, and other emergency procedures sometimes required during the birthing process? And wasn't scientifically manufactured formula better than old fashioned breast milk to help babies grow fast and fat?

Such was the power of modern medicine's promise. Cancer would eventually be cured. Degenerative and neurologic diseases like muscular dystrophy, amyotrophic lateral sclerosis, heart disease, and arthritis could all be treated or eliminated with more research.

Indeed, the power of antibiotics, effective vaccines for polio and other dread childhood diseases reinforced the belief system of the public and the profession in the promise of technological and scientific medicine. Without doubt, these were highly useful treatments. How could we argue against them and accept any complementary or alternative systems of care?

Yet such alternative practices continued as a parallel and significant subculture in American medicine. As our mastery of acute disease improved, chronic conditions and their treatment became a greater challenge. Appendicitis was cured with surgery, cardiac disease was arrested or delayed with medication or surgery, diabetes was better managed with insulin and other hypoglycemics, infectious diseases were largely controlled with antibiotics and public health measures, and neonatal and maternal mortality reduced. Now people live longer and develop other problems such as heart failure, cancer, arthritis, and dementia.

The promises of medical research have sometimes come to fruition at a glacial pace in such conditions. More people die from medical mistakes annually than they would from a jet airliner crashing daily over the same period. (3) And our epistemic and philosophical challenges have become more obvious when the remedies of modern medicine do not work.

This remains the context and content of complementary, alternative, and integrative medicine. Patients either not responding to, fearful of, or dissatisfied with contemporary medicine, or wishing to integrate alternative with conventional therapies continue to abound.

It is vital that we learn to work in teams and collaborate with other practitioners in a pluralistic health care system for the benefit of our patients' problems, be they rooted in mind, body, or spirit. These other practitioners are often specialists and experts in their domains as surely as are our own medical specialty colleagues. They have levels of expertise that we need not master but that require us to understand the processes of care and referral.

So much remains for us to learn about nutrition, botanical therapeutics, mind-body medicine, manual healing methods, acupuncture, spirituality and medicine, and other healing systems. Indeed, much of the scientific evidence for safety and efficacy in these areas has yet to be widely translated into clinical practice. Applying our scientific methods as well as our core desire to be truly helpful to our patients can create a new era of health care

Perhaps by returning to traditions of health and healing long thought obsolete due to our technological advances, we can promote integral, holistic, relationship-centered care. The path to this is by respecting patients' values and choices for integrating conventional and complementary therapies. We must learn what we can of the evidence supporting or contradicting alternative approaches and the methods of our non-medical health professionals. This is done best by developing deep listening, tolerance, and cultural fluency. By knowing our own profession's history, we will be better poised to heal our patients, ourselves, and our profession in an integral way.

References

1. Whorton JC. Nature Cures: The History of Alternative Medicine in America. Oxford, Oxford University Press, 2002.

2. Starr P. The Social Transformation of American Medicine. New York, Basic Books, 1982.

3. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA 2001;286:415-420.

The louder he talked of his honor, the faster we counted our spoons.
--Ralph Waldo Emerson

Victor S. Sierpina, MD

From the Department of Family Medicine, University of Texas Medical Branch, Galveston, TX.

Reprint requests to Victor S. Sierpina, MD, WD and Laura Nell Nicholson Family Professor of Integrative Medicine, Associate Professor, Family Medicine, University of Texas Medical Branch, Galveston, TX 77555.