Extinction and Diversity in Alternative Medicine
Dr. Stephen Fulder
The medical and alternative medical community is a community of professionals, and as such is dominated by professional concerns. These include effectiveness, theories, models of action, issues of evidence and reliability, safety and so on. But there is a larger picture, which treats medicine as a cultural knowledge, not so different from knowledge or skill required to grow food, write language or build houses. This is a form of knowledge in which the entire society participates, not just the professionals. It is concerned for example with issues of epistemology (ways of knowing that are regarded as significant and legitimate), of values (for example of harmlessness), of definitions (such as models of health) of methods (such as acupuncture or surgery), of status, of ritual, of metaphor and of objectives (such as endpoints of therapy).
These cultural issues often involve an implicit consensus, which is mostly unconscious. The alternative medicine community, perhaps because of its struggle for legitimization and for acceptance, prefers to get on with therapy and seems little interested in developing dialogue on the basic implications of CAM within a pluralistic medical culture. But without considering these issues, we are left with paradoxes and confusions. For example, scientific evidence is regarded as the legitimate form of knowledge to assess the effectiveness of therapy, however practitioners rarely use it to guide therapeutic practice; if acupuncturists agreed to carry out only those actions proved by science all acupuncture would stop immediately, possibly for generations to come. Another example: alternative medicine embodies radically different worldviews, and concepts of the body. The body in Chinese medicine is energetic, in yoga and healing is spiritual, in modern medicine is physicochemical, in homeopathy is phenomenological, in naturopathy is vital, etc., all of which do not necessarily overlap with each other. Such a range of diverse views co-exist within every clinic that offers medical and CAM treatments, and every University and College where CAM is taught, yet it is rare to find research and dialogue on the philosophy or anthropology of such a medical drama ( for a rare example of an exploration of the anthropology of CAM see Johannessen et al 1995). This may be because the success of CAM is underpinned by another layer of cultural values that are even stronger than the need for inquiry. These are Western values of efficiency, functionality and, of course, shopping; that is, the individual freedom to purchase, use and select services. These are powerful forces, which have pushed into the shadows considerations about worldviews and epistemologies.
One of the paradoxes that needs our attention is the fact that while there has never been as much interest in natural medicine, and the Western world is flocking to the health shops to buy natural remedies, indigenous medicine, which is alternative medicine par excellence, is in some areas verging on extinction. In particular, where traditional medicine is a verbal rather than literate tradition, it has contracted severely in the face of modernization, such as in rural India (Shankar, 1996), or in the Bedouin tribes (Abu-Rabia, 1994). These latter particularly concern me in my work on preservation of the indigenous medicine and medicinal plants of the Middle East. In Israel and the Palestinian areas, modern medical services are widely available, and this has contributed to a virtual disappearance of local traditional medicine, which is Arabic/Hippocratic medicine. Arabic/Hippocratic medicine is a huge knowledge, much of it written down in traditional texts, which encompasses diagnosis and treatment, using at least 600 medicinal plants. Yet our research found barely a handful of practitioners left in the Middle Eastern region, familiar with an average of no more than 20 medicinal plants, and often relying on shepherds to identify them. The paradox lies in the fact that as we see in the paper by Grinstein (2002) in this issue, CAM use in Israel itself has been growing dramatically, and in a relatively short time, it has reached similar levels of usage and availability to those in Europe and the US. The health product and herbal industry has grown to match. Therefore the population is highly interested in purchasing and using CAM products and services, while the local indigenous medicine, probably the most authentic CAM in the region, is rapidly disappearing.
It could be argued that it doesn’t really matter, as the modernized version of alternative medicine is better adapted to the modern world and is checked for reliability and efficacy. Here is where the kind of questions mentioned above open up. For example, a modern medicinal herb or formula becomes known, sold and used both by practitioners and the public because it has received a popular consensus which is then validated by some scientific, preferably clinical research on its safety and efficacy. In traditional Arabic medicine herbs are selected because of a long practical tradition, validated by traditional texts. Is the kind of assessment agreed upon as valid by CAM likely to create more effective health products than the kind of checking agreed upon as valid by practitioners of Arabic/Hippocratic medicine? What has been gained in this westernized CAM and what has been lost? Do we know enough about the indigenous medicine that modern alternative remedies are replacing to be able to compare them? Is anyone comparing them, or is it a purely cultural transition that has nothing to do with fair comparison? There is a poignant aspect to this. That is that Arabic/Hippocratic medicine is the theoretical and conceptual basis of both modern medicine and modern Western herbalism. The herbs on sale in the health shops were mostly discovered by the Greeks and Arabs and this knowledge was brought into Europe in the medieval times. Some of the top selling herbs in the modern world, such as milk thistle, feverfew, and garlic are thought to be direct imports from the Near East. Thus people are going into health shops in Israel to buy American or European herbal products that are derived originally from a local Arabic medicine that is becoming extinct in the process. This is more than simply ironic. There is one serious problem. That is that the herbs are only as good as our knowledge of their use. The knowledge of preparation, effectiveness, guidance on usage, formulation, varieties/plant parts, rational combination, and the herbalist’s skill that is embodied in modern health products is often minimal. If traditional medicine disappears, so too does its knowledge, which could otherwise provide major improvements in the effectiveness of herbs and modern health products. For example, we all know that St. John’s Wort is used for depression. However in the texts of Arabic medicine one can find extraordinary detail on which kind of person and which kind of depression best responds to St. John’s Wort and which kind responds to other herbs, which kinds of varieties and plant parts are best to use, which other kinds of conditions can be treated by St. John’s Wort and how, what are the best method of gathering, extraction and preparation of the plant for this use compared to other uses, which other herbs should be combined with it and how, for each particular health problem, etc. Virtually none of this is known and employed by those formulating the St. John’s Wort products that are available today. Indeed the effectiveness of St. John’s Wort even for the single agreed indication of depression is still in debate (McIntyre, 2000). Another example concerns kava, which like St. John’s Wort is a herb derived from indigenous medicine and now used massively in the Western world. The paper by Alison Denham et al in the last issue of this journal (Denham, 2002) explains that commercial standardized extracts of kava often use nonpolar solvents, deviating significantly from the traditional aqueous cold percolation method, which produces a radically different extract with a much higher proportion of kavalactones. The paper argues convincingly that this may be unwise, creating an untried product with increased potential toxicity without corresponding therapeutic benefit.
Israel is a dynamic and pioneering society, strongly identified with modern Western values and the American way of life. The nature of CAM in Israel reflects this. It is very fast growing. It has reached into primary and secondary health care to a greater extent than many other western countries, and this is driven by a culture of experimentation and also consumer demand. At the same time there is an earlier traditional medicine that is severely contracted because of the success of modern medicine, combined with the pressures on the expression of traditional Arab culture. The character of CAM in this country, and in others, therefore to some extent reflects social, political and cultural values. It is not yet a globalized system, and it takes part of the ebb and flow of cultural change. We should be aware that this could imply extinction of previous bodies of knowledge of great potential value. We may need to be more active in preserving the source of our CAM knowledge, and protecting the cultural diversity of alternative medicine.
Johannessen H, Olesen SG, Andersen JO, eds. Studies in Alternative Therapy. Body and Nature. Odense: Odense University Press, 1995.
Abu-Rabia A. Cross-cultural Bedouin medicine. Coll Anthropol 1994;18:215-218.
Denham A, McIntyre M, Whitehouse J. Kava – the Unfolding Story: Report on a Work-in-Progress. J. Altern Complement Med 2002;8:237-251.
Grinstein O., Elhayany A., Goldberg A., Shvarts, S. Complementary Medicine in Israel. J. Altern Complement Med. 2002;8:pp??
McIntyre, M. A review of the benefits, adverse events, drug interactions and safety of St. John’s Wort (Hypericum perforatum): the implications with regard to the regulation of herbal medicines. J. Altern Complement Med 2000;6:115-124.
Shankar, D. Conserving the medicinal plants of India: the need for a biocultural perspective. J. Altern Complement Med 1996;2: 349-358.