Integrative medicine and culture: toward an anthropology of CAM.

Marc Micozzi’s article draws much needed attention to the field of complementary and alternative medicine (CAM), a significant topic that I believe holds unrealized research potential for medical anthropologists. Why has such an important subject remained understudied? Micozzi makes the point that contemporary biomedical research is primarily focused on “the investigation of mechanisms of action and clinical outcomes” related to CAM. I agree that CAM research, as it is presently conducted in academic medical institutions across the United States, is revealing the incompleteness of a reductionist biomedical paradigm. Anthropological research is necessary both for the understanding of the limitations of our present models and, of potentially greater importance, for the construction of new ones. We need to offer our anthropological perspectives on both the diachronic and synchronic contexts in which this cultural phenomenon, frequently termed integrative medicine, manifests itself. I do not mean to imply that the voices of medical anthropology have been absent—only too faint. In the early days of the National Institutes of Health Office of Alternative Medicine (OAM; later elevated to the National Center for Complementary and Alternative Medicine), the impact of the participation of anthropologists (and medical folklorists) was evident. For example, the efforts of the OAM Panel on Definition and Description to circumscribe the field were clearly culturally informed: “Complementary and alternative medicine is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period” (1997:50, emphasis added). It is high time that medical anthropologists reintroduce this nascent critical perspective, both historical and cultural, into a field in which theoretical debates remain largely unformed. We need to study the anthropology of complementary and alternative medicine and integrative medicine as culture. CAM is neither a wholly new phenomenon nor has it “returned” from being away. Alternative medicine has been a persistent presence in U.S. health care (Adler 1999). It is the recent increased awareness on the part of researchers and the general populace, the “acknowledgment of postmodern medical diversity” (Kaptchuk and Eisenberg 2001: 189), that merits investigation. Furthermore, although the term integrative medicine has only recently come into vogue, people have been practicing this type of health care for quite some time. Individuals’ personal healing systems are frequently attempts at rendering disparate elements coherent. Patients’ integration of biomedical and CAM therapies is, of course, not desperate and haphazard, as historically depicted in the biomedical literature; patients’ health care practices are deliberate and complex. My research with women with breast cancer indicates that individuals combine disparate elements—from what may appear to be mutually exclusive health traditions—into a syncretic whole (Adler 2001). Biomedical and alternative health traditions may only appear to be irreconcilable: their apparent inconsistencies are not viewed as such or are deemed insignificant by those who engage in them, either concurrently or sequentially. Micozzi concludes from his rich experience as both a physician and an anthropologist that “no one system of medicine alone can provide a formula that will offer effective medical care for the entire human family.” In juxtaposition to this pluralistic view stand assertions from within the field of biomedicine, such as the remarks in a 1998 New England Journal of Medicine editorial that “there cannot be two kinds of medicine—conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work” (Angell and Kassirer 1998:841). The emerging field of integrative medicine is an attempt to resolve these issues by combining elements of varied healing systems in order to eliminate the deficiencies of any single one. The term integrative is used here not as a substitute for alternative, but to indicate a collaborative, multidisciplinary approach that requires the application of the best options from different healing systems—that is, experts from a variety of biomedical and CAM fields focus the diagnostic and therapeutic strengths of a combination of systems into a comprehensive and individualized treatment strategy that encourages patient participation. What does medical anthropology make of this form of medical hybridity? Does integration mean the end of medical pluralism? Historically, folk medical and ethnomedical research in the United States has been conducted among marginal or peripheral communities, to the exclusion of more mainstream groups. The legacy of 19th-century social theories applied to the study of “alternative” treatment use continued to affect (non-anthropological) research into CAM until quite recently. Over the past decade, the focus has shifted dramatically. It is as if contemporary CAM researchers are overcompensating for their predecessors’ misconceptions. The fact that several large surveys have indicated that the use of CAM is most common among relatively well-educated, well-off, “nonethnic minorities” remains a source of fascination—as evidenced by myriad references to these types of sociodemographic findings in the biomedical literature. The result is that CAM research, when approached from a conventional biomedical perspective, has become increasingly decontextualized. Where’s the culture? There is a clear need for medical anthropologists to integrate the study of integrative medicine. Many CAM studies, from randomized, controlled, clinical trials to qualitative investigations, can benefit by being made truly interdisciplinary. Let us not limit ourselves to a preservationist approach but, rather, also apply our understandings of traditional healing systems to the consumer-driven U.S. health care environment. Whereas traditional anthropological methods can be engaged in the study of emerging sites, for example, conducting an ethnography of an integrative medicine clinic, there is also a great need for the development of new, mixed methodological—that is, qualitative-quantitative—approaches. How can studies be designed that are cognizant of biomedicine’s and CAM systems’ unrelated diagnostic categories? How can clinical trials be developed to allow for CAM modalities’ traditions of individualized healing approaches or “subjective” outcomes? Micozzi correctly notes that in the separation between mind and body that characterizes Western biomedicine’s take on Cartesian dualism, the mind, and by extension all aspects of “bioenergy,” are given short (if any) shrift. It s i a given that many great biomedical advances will reveal that we have reached the limit of what our current paradigms can contain, much as research into the human genome is serving to debunk centuries-old “scientific” notions of “race” as a biologically valid construct. As this new, integrative medical dialog emerges and encourages a paradigm shift in health and medicine, it is imperative that medical anthropology inform the discussion.