Interest in complementary and alternative medicine (CAM) is growing rapidly, driven principally by increased public demand. In the UK, it is estimated that 20 per cent of the population use these therapies, spending over £500 million a year. In the USA the proportion is even higher: 40 per cent of the population regularly use CAM, spending £15–20 billion a year between them. There are now more CAM practitioners than GPs in the UK, and some treatments are even delivered on the NHS. With this level of popularity, the CAM phenomenon cannot be ignored by the Western medical establishment.

On 10 March 2000 an all-day workshop at the Wellcome Trust brought together researchers and practitioners from a wide range of different fields in CAM and orthodox medicine. The aim was to discuss research issues in CAM and help inform Trust policy making in this area.

Why have such therapies become so popular? One reason is that CAM, like counselling services, has developed in response to certain needs that are not being met by modern medicine: in particular, there is evidence that people turn to CAM for complex, relapsing, possibly stress-related conditions, such as chronic fatigue syndrome and allergies, that do not respond well to conventional treatment. CAM practitioners tend to take a ‘holistic’ view, looking at the patient as an individual rather than a set of symptoms, an approach at odds with the typically more reductionist interventions of conventional medicine.

The strong emphasis placed on the patient–practitioner relationship is also important, a stark contrast to the NHS, where the time doctors can devote to their patients is frequently eroded (the average duration of an NHS consultation is 4.6 minutes). In addition, alternative medicine is empowering, since products can be bought over the counter without recourse to doctors’ prescriptions. Nevertheless, in general, patients want to augment rather than replace the care they are getting from their doctors, and most CAM consultations take place in parallel with orthodox medicine.

Unfortunately, the very elements that appeal to the patient pose difficulties for rigorous scientific assessment of CAM. Therapies are often aimed at improving general well being – an outcome that is vague and hard to measure. Moreover, a vast spectrum of diverse remedies fall under the general umbrella of CAM therapies. Although some of these, such as herbal medicine, have agents that can be isolated and tested (artemisinin, derived from the ancient Chinese herbal remedy, quinghaosu, is now an important treatment for malaria), some, like crystal therapy, appear to have no plausible mechanism of action. To cloud matters further, CAM tends to use cultural explanations or indeterminate terms such as ‘readjust balances’ or ‘restore homeostasis’ rather than precise, scientific terminology.

There has also been little definition of what exactly people expect from these therapies – whether they are intended to cure or contain disease, for example – and this lack of clarity extends to the use of CAM in NHS primary care. GPs often refer patients to CAM practitioners for general reasons, because the patient is distressed, rather than because of any specific condition. On the other hand, despite what science might call this ‘vagueness’, the psychological ‘feel good’ factor integral to so many CAM therapies may in itself have a significant effect in terms of clinical improvement. Indeed, the ‘placebo effect’ – the medical improvement shown by patients treated with an inert or dummy treatment in medical trials – is further evidence of the potential importance of psychological factors.

Nevertheless, despite these difficulties, CAM therapies should be amenable to rigorous scientific enquiry. A sophisticated level of thinking will be required to develop methodology to look at psychological, physiological and nutritional variables simultaneously – but it should still be achievable. Randomised controlled trials could be adapted to answer more than one question at a time, and large-scale observational studies and sophisticated statistical analysis would also be as useful in the assessment of CAM as in conventional medicine.

Trial design may therefore be difficult but not impossible. However, the difficulties in scientifically assessing CAM are compounded by the absence of a research base able to carry out the experiments. Not only does CAM lack specialist centres and library resources, it also has no real evaluative tradition or culture, and much of the evidence to date is anecdotal, heterogeneous and fragmented. Studies have been conducted either without placebo controls, making them unreliable by today’s rigorous standards of evidence-based medicine, or with small samples in restricted populations from which it is difficult to generalise results.

Despite a general perception that funding bodies are biased against their field, funding is available for good-quality applications in the UK. Both the Wellcome Trust and the Medical Research Council will fund CAM proposals if the science is of a high enough standard. The success rate for CAM applications to the Trust is actually higher than for ‘conventional’ research proposals. Nevertheless, the number of applications received is very small.

In the USA, the situation is rather different. The National Center for Complementary and Alternative Medicine (NCCAM) was established in 1998 specifically to support CAM research; NCCAM will spend US$68.7 million this year. This ‘ring-fencing’ of money for CAM through NCCAM is a powerful way of encouraging research. It attracts high-quality researchers, inspires CAM practitioners to join a research team, and helps overcome misconceptions that review panels are prejudiced against CAM. On the other hand, ring-fencing shields researchers from the competitive pressures of peer review and may mean poor-quality projects are funded. One compromise is for funds to be provided for a limited period to kickstart research, then phased out when the discipline is strong enough to compete with orthodox medical research.

The public sector clearly has an important role to play in safeguarding public health and assessing safety and effectiveness. But what of commercial bodies? Pharmaceutical companies routinely plough around 25 per cent of their profits back into research to evaluate the safety and efficacy of their agents before they appear on the market. Perhaps CAM manufacturers should be encouraged to do the same, for example by forming partnerships with funding bodies. At present CAM products are not classified as medicines, and there may be a need to standardise and even license products before they are offered to the public.

Another obstacle to research in CAM is the mutual suspicion that exists between the orthodox and alternative communities. Many scientists argue that money for CAM research is wasted on fantasy, whilst CAM practitioners often fear that truly valuable traditions will be undone by the demands of orthodox research – a cultural divide that clearly needs to be bridged if CAM research is to benefit from the mutual expertise in both fields. One solution might be to provide CAM practitioners with training in conventional research methodology, or to establish career development fellowships to attract high-calibre research scientists from the orthodox field into CAM research.

What are the possible ways forward for scientific investigation of CAM? A first step for the CAM community might be to set priorities, deciding which areas research should be focused on first. The placebo response is likely to be high on the list. In fact, in November, NCCAM will lead an NIH-wide workshop on this effect in the USA, and issue a call for research proposals on the placebo response for next year. In Europe and the UK, there appears to be a need for some form of over-arching structure to coordinate disparate activities and help devise a coherent strategy for the development of research and education in CAM.

All this will require a considerable degree of collaboration and resources of time and money. Although there is enthusiasm in many quarters, a question mark remains over whether CAM research is actually going to move forwards in this country the way it has done in the USA under the auspices of the NIH and NCCAM.

The Wellcome Trust is actively considering the issue of CAM research but currently has no plans to launch a special initiative. A report on the Trust’s workshop was presented to the House of Lords select committee on 23 May 2000.

External links

• NCCAM (National Center for Complementary and Alternative Medicine)
• House of Lords
• Bandolier: Evidence-based healthcare information on complementary and alternative therapies