Integrating conventional and complementary medicine
A formidable academic volume by a team of Israeli sociologists looks at how healthcare is slowly changing due to public demand.
Alternative medicine (Illustrative) Photo: MCT
Whether you think the techniques are motivated by profit-making, cater to
desperate and gullible people and could even be harmful, or that they relieve
pain and cure illness, save lives and are suppressed by physicians who fear
competition, complementary and alternative medicine (CAM) is definitely here to
An impressive new English-language book, written by a veteran
Hebrew University professor (emerita) of sociology and a young HU researcher
with a newly minted doctorate in the field, is the result of a decade of joint
Titled Alternative and Bio-Medicine in Israel: Boundaries and
Bridges, the volume does not judge whether CAM is effective or has been proven
by scientific evidence. Instead, Prof. Judith Shuval and Dr. Emma
Averbuch – supplemented by nine academic contributors – provides a fascinating
historical analysis of CAM in pre-state and contemporary Israel. It is also a
formidable examination of how CAM is carried out by physicians and those without
formal medical credentials; the cultural and political context; conflicts and
partnerships; and recommendations of where to go in the future.
by the Academic Studies Press in Brighton, Massachusetts, the 245-page
hard-cover volume carries a hefty price of $70 for libraries and other academic
institutions, but it is hoped that it will come out in a more affordable
soft-cover format so that a larger audience can appreciate it.
authors dedicated it to the memory of Bar-Ilan University sociology Prof.
Revital Gross, a senior health researcher at Jerusalem’s Myers-JDC-Brookdale
Institute, who died tragically of illness in her 50s last year.
volume is a very intelligent and serious piece of work,” comments Shaare Zedek
Medical Center director- general Prof. Jonathan Halevy, who some five years ago
published a Hebrew-language volume examining CAM techniques based on scientific
evidence – or the lack thereof. “I think many of the claimed benefits of CAM are
due to the placebo effect, but it can’t be ignored. It should be integrated into
conventional medicine and provided by physicians trained in it. It can’t be
provided by someone who takes a week-long course. And it should be
supervised by state regulators. If it isn’t, it is second-best.”
authors note in the preface that while the US National Institutes of Health have
provided scientific evidence for the effectiveness of some forms of CAM, many of
the methods have never been scientifically scrutinized or have not passed
rigorous tests for efficacy.
“The lack of scientific evidence hardly
troubles users of alternative medicine; what counts for them is the fact that in
many cases it works – they have little interest in how or why. Failures are
largely ignored, while success is touted.” They were intrigued by the fact that
many physicians and other healthcare professionals refer patients to CAM
practitioners when they cannot do more for the patient; and have studied CAM
techniques and practiced it themselves as “integrated medicine.” A small number
have even abandoned conventional medicine and shifted to a predominantly
alternative form of practice.
The authors of Alternative and Bio-Medicine
in Israel use the term “bio-medicine” to describe objective, evidence-based
medicine practiced by MDs. They use “alternative” or “complementary and
alternative medicine” for the mostly unproven therapies – terms that have
changed from the time when MDs absolutely rejected it to when, today, many have
an open mind, realizing that a growing number of patients seek it,
enthusiastically endorse it or practice it. The therapies include acupuncture,
herbal remedies, naturotherapy, shiatsu, reflexology, touch therapies, hypnosis,
biofeedback, mediation, yoga, tai chi, Feldenkreis and Paula.
THERE WAS a
time when the Health Ministry confiscated homeopathic preparations from
pharmacies and health food stores. In 1991, the Israel Medical Association
forced the Elon Commission on Alternative Medicine to shelf its report based on
over four years of hearings because its conclusions were too radical, allowing
almost anyone to offer CAM, with lawsuits by patients just about the only
deterrence against quackery. Since then, the IMA has established a council on
integrative medicine to represent physicians that are involved in it. In the
face of ministry failure to take any action, practitioners are not licensed and
almost anything goes.
The sociologist team report that five years ago, 12
percent of Israeli adults reported using an alternative practitioner at least
once during the previous year – a 100% increase since 1993. Three of the four
health funds (Clalit, Maccabi and Meuhedet) established their own CAM networks,
and the smallest, Leumit, has CAM practitioners at some of its community
clinics. However, health fund members have to pay for treatment fully or under
subsidized supplementary health insurance polices.
Last year, there were
an estimated 20,000 CAM full- or part-time practitioners in the country, but
only 2,800 of them were members of professional organizations and an even
smaller number were licensed physicians.
As Halevy states in his own
book, CAM techniques do not cure but can relieve pain and other symptoms. He
notes that some therapies, such as acupuncture and various stress-reduction
techniques, have become integrated with conventional medical
The fact that CAM practitioners spend much more time with
their patients than MDs and regard them holistically raises patient
satisfaction, even if the methods do not cure.
An amusing historical
recollection goes back to 1948, when Ephraim Katzir – then commander of the
Israel Defense Forces’ Science Corps who in 1973 became Israel’s fourth
president, persuaded Moshe Feldenkreis to join his rocket-development team. He
proved useless in rocket science, but the Ukranian-born Feldenkreis, who had
been hurt in a soccer injury, investigated knee movement, postural change and
gait and “cured” himself. He eventually became the “personal healer” of
then-prime minister David Ben-Gurion and taught him to stand on his head for
extended periods to relieve his chronic back pain. Today, the Feldenkreis
technique is still taught and used by CAM practitioners to treat orthopedic
MKs such as Mordechai Ben-Porat endorsed alternative medicine
in the early ’80s and railed against MDs for protecting their own
According to the sociologists, “the legitimacy and credibility that
CAM receives today developed from the establishment of a new elite consisting of
practitioners and physicians practicing CAM... It in effect mediated between new
perceptions of health and illness and traditional concepts of conventional
medicine by conducting collaborative research programs, making joint appearances
in conferences and building a cooperative work model in clinics. The most
developed CAM programs in hospitals today are in oncology wards; they are not
claimed to cure cancer but to relieve patients’ anxiety and pain and strengthen
their coping strategies.”
Nevertheless, many CAM services at hospitals
are held at arm’s length, with outpatient clinics physically located outside the
core of basic hospital services and non-MDs who practice given less prestige or
Those working in hospitals don’t receive
accreditation, or even payment in many cases, unless they are MDs.
are the “boundaries” and “bridges” that the authors refer to in the
HOMEOPATHY, DEVELOPED in the late 18th and early 19th centuries by
a German doctor, Samuel Hahnemann, is based on highly diluted substances that in
their original dosage would supposedly cause disease. As such, it negates
scientific theory, but even some MDs use it. The authors quote physicians using
their surnames followed by “Dr.” when they quote their positions on homeopathy
in the chapter focusing on this therapy.
“The biggest obstacle in
homeopathy is reconciling oneself to the existence of unobservable processes and
phenomena. I found it very hard to accept the notion that things that we cannot
see nonetheless exist,” said “Dr. Limor.”
“When I see a 3-4-month-old
baby with recurrent ear infections, and I treat it, and the infections clear up,
it’s very hard to believe it is a coincidence, that it’s mere psychology. Even
veterinarians are using homeopathy,” said “Dr. Ephraim.” Yet others note that
ear infections can clear up by themselves and that a large percentage of
physical complaints disappear by themselves but can recur later as
The sociologists note that relatively few Israeli nurses have
incorporated CAM into their professional work, perhaps because the field of
nursing has grown into an academic profession that integrates more advanced
elements of biomedicine, social sciences, psychology, sociology and
communications theory. Those interviewed by the book’s researchers said they
“didn’t want to get in trouble” with their hospitals by introducing CAM methods
in the wards.
Yet some midwives use it for women in labor, and a number
of nurses use CAM in private practices off hospital premises. CAM provides
nurses with an increased sense of autonomy, “enabling them to move beyond the
control of the physician,” Shuval and Averbuch suggest.
The fact that
giving birth is not regarded as a disease and that natural childbirth is popular
in Israel also makes hospitals more amenable to CAM pain relief; and midwives
are in most deliveries left alone by obstetricians who do not usually deliver
babies but only intervene when there are complications.
in the community are increasingly using integrative medicine in their practices,
“Some patients chose me because they know I integrate CAM in
my practice, but some don’t know and view me as a family practitioner. The
[health] fund does not identify me as an integrative doctor in its list of
practitioners,” one doctor says. “I would rather not use Western medicine when I
know that CAM is more effective. It all depends on the specific situation... I
try to convince the patient that CAM is better.”
“I don’t know what I
would do if I were not a fullfledged doctor. It’s what gives me a tremendous
amount of knowledge. I wouldn’t feel really confident dealing with patients
without this basic knowledge,” says another.
“My problem is that it is
illegal for me to provide private care (fee for service) to members of [a
health] fund in my clinic – ever, at any time... what I can do is to refer them
to... the sick fund’s CAM clinic network... I myself wouldn’t work for the
[health] fund’s CAM clinics...
They opened them [only] to make money, and
they have no ideals or principles... They impose lots of technical limitations
on the length and number of treatments...
all to make sure they make a
profit,” maintained a third physician.
THE AUTHORS interviewed
policymakers, physicians and patients on the use of integrated care and sent a
summary to the Health Ministry, IMA and health fund officials in key positions.
Shuval and Averbuch asked them questions on their views and reactions. These
varied widely, from those who said that CAM practiced by physicians meets a
public need and is good as a holistic approach, to concern “about deceit and
charlatanism even if CAM is administered by physicians since money is dazzling.
It’s easy money... Because of the money, there will be many rotten apples (among
the doctors) that forget where they came from and will offer only the
Some noted that it was impossible to offer CAM
techniques in health fund facilities because doctors are bound to see a large
number of patients per hour. The solution for some idealists and CAM devotees
has been to set aside an extra (and unpaid) last hour of practice for people who
want CAM treatments.
As the Health Ministry does not seem to be moving
toward a resolution of the differences and disputes between conventional
medicine and CAM, the authors suggest ways of bringing them together by using a
“gradual approach to regulation in which the public needs to be protected and
developing the regulation in cooperation with all stakeholders to gain their
As is done in Alberta, Canada, they write, physicians could be
registered as providing CAM after they show proof of acceptable education and
clinical experience in this. Registration could be voluntary, allowing a
physician to choose whether or not to participate. “The need for regulation is
critical since [integrated care] involves high costs for patients and high
income for physicians who may thus be tempted to enter the field, possibly
compromising the quality of training in CAM methods.”
The authors stress
that CAM is best provided by specially trained physicians. “Licensing for
non-medical CAM practitioners is a complex problem that needs to be addressed
creatively, taking into consideration the considerable differences among the
various CAM specialties and their specific needs,” they write near the
As for the medical schools, students should be exposed to the basics
of CAM , not in order to be trained as CAM practitioners but so they will have a
basis for understanding the options available to their patients for referrals.
They must also be to understand patients who have already undergone CAM therapy.
If, as predicted, CAM treatments will be included in patients’ medical records,
bio-medical practitioners will have to be able to understand them.