Complementary and Alternative Medicine
The terms ‘alternative medicine’ and ‘complementary medicine’ refer to all therapies and treatments which are not currently part of mainstream conventional medicine. During the 1970s and 1980s, the term alternative medicine was the first universally accepted title. By the 1990s however, the term complementary medicine had gradually become more popular, primarily because it denotes working alongside conventional medicine rather than in opposition to it. This is a particularly important distinction for both people who work in the sector and researchers, many of who do not wish to be thought of as involved in a marginal or hostile field. Because the title alternative medicine has remained the most popular in North America, in order to avoid further confusion and unnecessary debate, the all inclusive term ‘complementary and alternative medicine’ (often abbreviated to and pronounced CAM) has become preferred in the international literature. Occasionally, the terms ‘holistic medicine’, ‘integrative medicine’, and ‘nonconventional medicine’ are also used as universal titles. One could argue that re searchers could select from these different titles to describe subtly different engagements between conventional and other medicines. However, though this is sometimes done, it is the search for an acceptable inclusive term for the entire sector that has dominated discussion.
CAM refers to an extremely diverse set of practices, grouped together as much because of their shared dis tinction from conventional medicine as because of their commonalities. Indeed, CAM is not a unified field, but is constituted of a wide range of materials and practices. Twelve core practice modalities of CAM exist: acupuncture, chiropractic, creative and sensory therapies, healing, herbalism, homeopathy, hypnotherapy, massage, reflexology, naturopathy, and osteopathy. When taking into account various subvarieties of these modalities, together with many other less known varieties, it is possible to list many hundreds of distinct forms of CAM. Moreover, the borders of CAM become blurred and its forms much more numerous, as it becomes incorporated into many materials and practices of everyday life. In this respect CAM increasingly permeates the daily lives of westerners ranging from aromatherapy shampoos to yoga workouts at workplace stations.
There are a number of ways of classifying and grouping different CAM modalities. A typical scenario is under four broad categories: ‘mind body therapies’, ‘biological therapies’, ‘energy therapies’, and ‘physical therapies’. Such a classification serves the purposes of research where it is necessary to talk collectively yet provide some distinctions (e.g., with regard to education, policy, and regulation). In terms of regulation, certain CAM modalities are fully regulated often by national scale representative organizations. Other modalities are partially regulated and some continue largely unregulated. Much however depends on the particular modality and the national context.
Other important differences between particular modalities of CAM relate to their relationships with conventional medicine. Some modalities are far more integrated with conventional medicine than others. In deed, those that draw closest to the medical model, in terms of their scientific basis and ability to provide an acceptable evidence base, typically have strongest relationships and often share spaces for practice (such as osteopathy and chiropractic). However, some researchers argue that debates about ‘letting CAM into’ conventional medicine and the categorization of CAM in terms of its difference and distance from conventional medicine (often for stated purposes of safety and regulation) serve as an orthodox medical control over CAM.
Research has shown that CAM has grown very rapidly during the last 20 years, and some commentators have called it the most significant health related consumer trend of the twentieth century. Studies frequently identify that over a quarter of the general populations of developed world countries use CAM regularly for a variety of conditions – chronic, long term, musculoskeletal, and psychological being the most common categories. A great deal of provision is by the small business private sector, the hundreds of thousands of private therapists worldwide – either working alone or in small group practices – constituting an extensive global but cottage industry. Increasingly however, CAM is available in conventional healthcare settings, the most common scenario being its provision alongside general/family practice. Some orthodox health professionals (such as nurses) with interests and expertise in CAM have developed therapies as part of their everyday work routines. This however is often in an unofficial capacity and therefore, on a service level, can be inconsistent. Less typical, yet becoming more common, is for CAM to be provided in hospitals and community settings through dedicated service initiatives. Meanwhile, a number of large companies selling herbal supplements, or with chains of outlets, represent the involvement of much bigger business in CAM. Nevertheless, much depends on the particular national context. North America, for example, is home to much larger CAM businesses than Europe.
The Organization of CAM Research
CAM research has developed into a discipline in its own right. Indeed, reflecting this are a number of dedicated academic journals and regular international conferences (see, e.g., the journals Complementary Therapies in Clinical Practice and Complementary and Alternative Medicine). Moreover, many scholars now research and teach CAM exclusively and regard themselves primarily as CAM re searchers. It is a discipline constituted of many different perspectives, including biomedical, economic, sociological, psychological, policy, anthropological, and geographical. However, this diversity also reflects its disparate institutional character. There are very few dedicated university departments of CAM (see, e.g., the Department of Complementary Medicine at Exeter University, UK), and consequently the majority of re searchers are located in departments that reflect their ‘parent’ disciplines.
A small number of CAM research institutes exist and also places that disseminate research findings to the practice community. One example is IN CAM, the Canadian Interdisciplinary Network for Complementary and Alternative Medicine Research, created to foster excellence in CAM research. Specifically, its objectives are to build a sustainable network that facilitates and supports research; promote knowledge transfer among researchers, CAM and conventional practitioners, policymakers, and research funding agencies and – to avoid the duplication of research efforts – link with other CAM networks and institutions. Another example, also in Canada, but with a more regional orientation, is CAMera – Complementary and Alterative Medicine Education and Research Net work of Alberta.
Meanwhile, reflecting the emergence of online CAM resources and research evidence is CAMline, an evidence based website for both health professionals and the public. It offers access to an evidence base on natural health products, therapies, practitioners, and health conditions.
Social Scientific Fact Finding
Mirroring the relative infancy of CAM as a form of healthcare, research is still very much in an initial information accumulation phase. Much research has been in the form of clinical trials, designed to establish at least the beginnings of a scientific evidence base. Initial social science research on CAM during the 1980s, and throughout the 1990s, was also engaged in some basic ‘fact finding’ about the social nature of production and consumption. For example, rates of use were investigated for both CAM as a whole and between therapies, studies finding various manual therapies (such as massage and reflexology) to the most frequently provided and used. With regard to who uses CAM, studies have found females, younger adults, and the more affluent to be the largest groups of users, particularly due to the need to find out of pocket payments for many treatments. However, contrary to popular opinion, studies have also found that, with the exception of children, many sections of society, and all age groups, use CAM regularly. With regard to some trends in use, studies have found users to actively mix and match conventional medicine and CAM and feel empowered in creating their own treatment profiles. They have found people to be frequent users (typically one a week or every 2 weeks), and that they use CAM over long time periods, often for their general health maintenance.
It is also recognized that broader social trends and transitions have underpinned the recent CAM phenomenon. Commentators have found CAM use to be associated with an emerging health consumer culture, and a greater number of people – often referred to as ‘smart consumers’ – who inform themselves about health and illness and exercise this knowledge when selecting from the treatment options available to them, or otherwise seek alternatives. Some commentators have linked CAM to spiritual cultures that have developed alternative philosophical visions toward health. However, in response, others have been quick to stress that, while these cultures might have been common 20 years ago, CAM is now far more mainstream in terms of its users and their motivations. More practically, regarding the immediate reasons for using CAM, researchers have identified push factors from conventional medicine, including perceptions of its impersonal nature, a lack of caring, long waiting lists, and its inability of to cure long term chronic conditions. Meanwhile, identified pull factors of CAM include the longer time and dedicated attention that therapists are able to give to clients, and the individualized nature of their care.
Of research focused squarely on CAM provision, a great deal discusses technical issues relating to practice development. Recent work, however, is focused much more broadly on features and contexts of production. For example, the career pathways of therapists have been investigated – studies finding therapists to have entered the CAM sector from other caring professions (e.g., nursing, social work, and teaching). A range of ethical and moral issues in practice have also been discussed. These have included when and whether therapists refer clients to conventional practitioners, when and whether they discontinue treatments, and what they do if a client can no longer afford to pay for their services. Businesses, business planning, and career aspirations have been investigated – studies finding these to be typically short term, low level, and ‘realistic’. Other research has considered regulation and professionalization, particularly in the context of current policy debates on how CAM should be provided in and integrated with conventional medicine. One of the main debates here has been agreeing on acceptable methods to collect evidence for practice. Some therapists claim that because their therapies do not work on scientific principles, they should not be subjected to clinical trials. Meanwhile others argue that the often subtle health gains obtained through using CAM are not adequately captured by clinical trials. However, most doctors, policymakers, and researchers strongly disagree and suggest that clinical trials are both appropriate and necessary in order for conventional healthcare systems to fund CAM, and for their clinicians to take CAM seriously.
The Origins of a Geographical Perspective
Mirroring the growing popularity of CAM during the past 20 years, and its connections to many aspects of social and cultural life, like other social scientists, human geographers are becoming increasingly interested in it as a subject of study. However, just as the roots of many forms of CAM are located in traditional medicine – often from the developing world and East Asia – so are the roots of geographical research on CAM. Traditional medicine typically refers to treatments associated with ancient societies, passed down through their generations, often in the form of oral knowledge. It is the methods, beliefs, and approaches that people employed to restore health before the arrival of conventional biomedicine. Examples include Pinyin (China), bone setters (world wide), ayurvedic medicine (India), and Kampoh medicinal preparation (China).
The study of traditional medicine was an important interest of early medical geography. Charles Good’s 1977 paper outlined an agenda that heavily influenced and directed research. Good pointed out the substantial health problems facing Africa, Asia, and Latin America, the lack of conventional services in many areas but, at the same time, the widespread availability and use of traditional medicine. He noted the vast manpower, resources, and access to local populations available to conventional medicine through integration or collaboration with traditional medicine. Although Good clearly assumed the superiority of conventional medicine, he did indicate the potential for collaboration from the national scale to the scale of individual facilities, and the need to investigate how integration relates to wider national and regional health goals and health planning. Mirroring the perspectives and concerns of the medical geography in the 1970s, the research agenda Good posed was focused on the accessibility and utilization of services, including investigating spatial arrangements of traditional medicine in urban and rural areas, factors in seeking traditional medicine, and various obstacles related to distance. Al though these issues are still investigated to the present day by geographers, many now look for a deeper and often qualitative understanding of the cultures, values, and belief systems that relate to traditional medicine in particular places of the developing world. Meanwhile, other scholars have started to investigate the roles of traditional medicines used by indigenous people located in developed world countries (such as First Nation communities in Australia and Canada). Research here suggests that ideas about medicine and healing are often part of a broader cultural association with place and landscape. These can often conflict with dominant Western ideas. In contrast to these tensions, Maori notions of health and landscape have actively informed health policy in New Zealand.
Consumer and Provider Geographies
Not all research on CAM that has a geographical orientation has been conducted by geographers or is labeled as geography. For example, numerous studies by CAM researchers have considered regulatory issues within well defined areas of political jurisdiction, and profiles of CAM provision and use within and between places ranging in scale from countries to individual institutions. However, beyond sampling frames, in these studies, spatial issues are not often prioritized and given a central place in research questions and analysis.
The need for explicit geographical research on CAM was first highlighted by Anyinam in 1990. His argument was for wide ranging quantitative inquiry, including attention to local, regional, and national distributions of therapists, their relationships to biomedical services, their referral networks, and practice catchment areas. Only a modest number of studies answered this call and the ones that did mainly considered spatial trends in CAM pro vision at the regional level. In retrospect, given the vast range of CAM provided in so many places, responding effectively in this way was always going to be a very tall order. Moreover, another important disciplinary context was that very shortly after Anyinam’s paper, medical geography was to undergo a significant reform that would witness the emergence of a qualitative ‘postmedical’ geography of health, focused far more on experiences of health and disease, than on distributive features of service provision as emphasized by Anyinam.
Since 2001, qualitative research on CAM, by Wiles, Andrews, Adams, Doel, Segrott, Williams, and others has been more varied and has had very different priorities. A consistent theme has been attention to cultural and consumer geographies of CAM. Studies are attempting to understand who uses CAM and why, how this differs between and across places, and how place itself shapes and is shaped by CAM. A variety of cultures are explored and articulated in research ranging from local spiritual and ‘alternative’ cultures in CAM, to ‘high’ consumer CAM cultures as progressed, for example, through lifestyle magazines. Research has also begun to consider how different cultures of CAM may be associated with versions ofurbanicity and rurality. For ex ample, a study in Devon, UK, articulated how certain forms of CAM are associated with spiritual ancient landscapes, idyllic landscapes, and certain rural cultures. Meanwhile other studies articulate how CAM is associated with urban living and city quarters. Studies have also considered design features of CAM settings and how they play an important part in the overall CAM consumer experience. For example, research has observed that some therapists’ clinics are clearly decorated by them to resemble conventional medical places, though the majority of CAM clinics are purposefully designed and decorated to exert a subtle calming effect, and to provide a spiritual experience. Other research has focused on professional spaces where orthodox medicine and CAM are increasingly combined (such as GP surgeries).
Place and Presence
An emerging field of research considers the ways, beyond co presence, that place plays a part in the clinical practices and consumer experience of CAM. Williams termed this ‘landscapes of the mind’ in her discussion of imagery and visualization of place in psychotherapeutic practices, autogenic training, relaxation techniques, and meditation. Similarly, Bondi noted that many forms of counseling (often part of CAM) involve going ‘with’ someone – perhaps to the past, and often to a place, that may be real or may be metaphorical, and that places whether they are based on reality and fantasy, are used to explore clients’ ‘inner worlds’. Obvious connections can be made here to broader disciplinary theoretical interests such as psychoanalytic geographies. Indeed, Bondi suggested that some of the key theoretical texts that inform psycho therapeutic practices have geographical components such as Winnicott (potential space); Klein (splitting); Freud (time and unconscious); Wright (positions and view points), and Kopp (journeying). These kinds of inquiry do offer critical insights into the nature of human perceptions and emotions and on the complex cognitive processes that link people and places. Notably, then, they also potentially extend interest in CAM to a wider audience of human geographers.
In 2004, Andrews followed up these observations on imagery and place with a qualitative empirical investigation of CAM practices. Imagined therapeutic places were found to be constructed and manipulated by both therapists and their clients. It was observed that, in some cases, mental imagery was subtle and supportive to other therapeutic techniques particularly manual techniques. In other instances, it was found to be a central feature of therapies and used more directly, particularly in dedicated imagework to construct mind bridges with past life events. Hypnotherapists, for example used their clients’ un conscious minds in doing this. Connecting with nature and natural landscapes was found to play a significant part in mental imagery. These might be idyllic for purposes of relaxation or they might be strongly unpleasant and awesome places that clients paint as pictures and back drops of how they feel. The issue of power relationships between therapists and their clients in mental imagery was also highlighted in Andrews research, particularly in terms of who moves imagery forward. Indeed, particular places being imagined by clients may be suggested or guided by the therapist, or may be directly chosen by the client, depending on the particular modality of CAM and the illness context. Certainly, a major observation of this study was that a degree of trust has to be necessarily given to those therapists who use imagework. Indeed, using mental imagery of places is not a fail safe method and a variety of problems are encountered, particularly with helping clients obtain or reach a specific state of mind.
Calls for Future Inquiry
Because CAM is a relatively new field of inquiry for geographers, naturally there are many opinions as to what future research should focus on and the perspectives it should take. CAM deconstructs traditional understandings of health and illness, and fuses a vast array of materials and practices. It therefore poses a serious challenge to human geography in terms of how to approach it. With its traditional concerns for services and health experiences, health geography alone might not be able to cover all the necessary ground. Indeed, as Doel and Segrott have noted, for health geographers terms like health, disease, illness medicine, and place need and use, are constant points of reference. However, as they also suggest, in CAM these are precisely the kinds of things that are subverted and redefined. Consequently, future geographical study on CAM will have to be able to deal with CAM much more broadly as a wide ranging consumer phenomenon. This, as Doel and Segrott mention, should not be an overly difficult task as CAM is consistent with human geography’s current engagements with aspects of everyday life, human practices, and performativity. Moreover, they suggest that CAM is consistent with the principles of the emerging style of human geography with its emphasis on situated practice and nonrepresentational theory.
Others have argued that future research is needed to explore a greater variety of CAM places and practices. With regard to places, imagined places in practices (as outlined above), certainly provide an avenue for future inquiry. Another important issue is the transportation of traditional medicine from the places of their origin to the West. In this respect, postcolonial theory needs to be brought to bear in understanding of how traditional medicines might be morphed into CAM in new Western social and cultural contexts. With regard to perspectives, research on the political and economic geographies of CAM would certainly be welcomed. On the micro scale, this could involve, for example, researching aspects of integration with conventional medicine in shared places, and how different modalities of CAM may be integrated differently within different conventional places for healthcare. Also in terms of perspectives, there certainly needs to be a more thorough examination of gendered characteristics of CAM through a feminist lens, and commentators need to understand the ways in which gender may play out in various places for CAM. Also required is attention to how CAM is important to his tories of places, the historical identity of places, and how it might be associated with heritage sites and industries. There are certainly many other places and perspectives to be followed. However, the key message is that because CAM spans so many materials and practices of everyday social, cultural, and economic life, researching it must inevitably embrace multiple perspectives.