ANSWER
We refer to medical practices that evolved with indigenous peoples and that they have introduced to other countries through emigration as traditional medicine. We refer to approaches that emerged primarily in Western industrial countries during the past two centuries as scientific or Western medicine. However, we acknowledge that not all Western medicine is based on scientifically proven knowledge. The terms complementary and alternative describe practices and products people choose as adjuncts or alternatives to Western medical approaches. CAM and TM are increasingly used interchangeably (Kaptchuk & Eisenberg, 2001; Straus, 2004). (Kaptchuk and Eisenberg 2001; Straus 2004).
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Endless varieties of practices need to be scientifically proven and better accepted by medical authorities. For the sake of organizing an agenda for research into these approaches, the U.S. National Institutes of Health has grouped them into five somewhat overlapping domains (http://nccam.nih.gov/health/whatiscam) as follows:

Biologically based practices. These include the use of a vast array of vitamins and mineral supplements, natural products such as chondroitin sulfate, which is derived from bovine or shark cartilage; herbals, such as ginkgo biloba and echinacea; and unconventional diets, such as the low-carbohydrate approach to weight loss espoused by the late Robert Atkins.
Manipulative and body-based approaches. These approaches, including massage, have been used throughout history. Additional formal manipulative disciplines emerged in the United States in the nineteenth century: chiropractic medicine and osteopathic medicine. Both arose from an attempt to alleviate structural forces on vertebrae and spinal nerve roots that practitioners perceived as causing a slew of illnesses other than musculoskeletal pain.
Medicine of the mind and body. Many ancient cultures believed that the mind influenced bodily functions and vice versa. Attempts to reestablish proper harmony between these bodily systems resulted in the development of mind-body medicine, a diverse set of approaches that includes spiritual, meditative, and relaxation techniques.
Medical systems that are not conventional. Whereas the ancient Greeks believed that health was dependent on the balance and flow of vital energies through the body, Asian cultures believed that health was dependent on the balance and flow of vital energies through the body. This latter theory, for example, underpins the practice of acupuncture, which asserts that vital energy flow can be restored by inserting needles into crucial body points.
Medicine is based on energy. This method employs energy-based therapies, such as biofield or bioelectromagnetic interventions. Reiki therapy, for example, aims to realign and strengthen healthful energies through the intervention of energies radiating from the hands of a master healer.
Alternative medical systems incorporate elements from each of these CAM and TM domains. Traditional Chinese medicine, for example, includes acupuncture, herbal medicines, special diets, and meditative exercises such as tai chi. Yoga meditative exercises, purifying diets, and natural products are all used in Ayurveda in India. Homeopathy and naturopathy emerged in the late nineteenth century in the West as responses to the largely ineffective and toxic conventional approaches of the day: purging, bleeding, and treatments with heavy metals such as mercury and arsenic.

Visit the following pages: Demography, Use, Toxicity, and Efficacy.
The application of CAM and TM varies significantly between and within countries. Numerous use surveys have been published and summarized by the World Health Organization (WHO) (table 69.1). Except for the privileged few, TM is the only source of health care in developing countries. On the other hand, individuals in affluent countries choose CAM approaches based on their specific beliefs. Homeopathic or herbal products, for example, are used by up to 60% of people in France, Germany, and the United Kingdom. Only 1 to 2 percent of Americans use homeopathy, 10% of adults use herbal medicines, 8% see chiropractors, and 1% to 2% get acupuncture yearly (Ni, Simile, and Hardy 2002). Patients with chronic, painful, debilitating, or fatal conditions, such as HIV/AIDS and cancer, use CAM and TM at much higher rates, ranging from 50 to 90 percent (Richardson & Straus, 2002).

Table 69.1. Global Estimated Use of CAM and TM by Patients and Practitioners.
Table 69.1 Estimated Worldwide Use of CAM and TM by Patients and Practitioners.

There is remarkably little correlation between using complementary and alternative medicine (CAM) and scientific evidence that they are safe or effective. Folklore is the only evidence of the safety and efficacy of many CAM and TM practices. Data on the use of thousands of natural products was compiled into impressive monographs in China, India, and Korea more than 1,500 years ago. However, these compendiums—and similar texts from Arabic, Egyptian, Greek, and Persian sources, as well as their major European derivatives—are merely catalogs of products and their use rather than formal analyses of safety and efficacy.

Many people who use herbal products instead of prescription medications believe that because they are natural, they must be safe, even though the evidence for this claim is mainly anecdotal. Recent research has revealed that herbals vary significantly in quality and composition, with many marketed products containing little of the intended ingredients and unintended contaminants such as heavy metals and prescription drugs. Several herbals are outright prohibited in several countries. Comfrey and kava have been linked to liver failure, Aristolochia to genitourinary cancer, and ephedra to heart attacks and strokes (De Smet, 2002). (Shekelle and others 2003). More importantly, herbals contain ingredients that can either speed up or slow down the metabolism of prescription drugs (table 69.2). The most well-known of these is St. John’s wort, which interferes with the metabolism of nearly half of all prescription drugs (Markowitz and others, 2003). The body of evidence on herbal supplements’ pharmacological and potential adverse effects now requires that patients consult with knowledgeable practitioners before beginning treatment.

Table 69.2. Natural Products That May Modify Drug Actions.
Table 69.2 Natural Products That May Modify Drug Actions.

Thousands of small studies and case series have been reported over the last 50 years as evidence of the efficacy of CAM and TM approaches. Few were rigorous enough to be compelling, but they generated hypotheses that are now being tested in rigorous clinical trials. The existing body of evidence already shows that some approaches are ineffective, that evidence for many is positive but weak, and that a few are highly encouraging (table 69.3).

Levels of Evidence for the Efficacy of Selected CAM and TM Approaches, Table 69.3.
Table 69.3 Evidence Levels for the Efficacy of Selected CAM and TM Approaches.

Visit Complementary and Alternative Medicine Economics and Traditional Medicine.
Although social, medical, and cultural factors may explain why people in a given country prefer complementary and alternative medicine (CAM) to conventional (Western) medicine, economic forces are also at work. This section discusses cost-effective approaches to regulating, improving, and expanding the use of CAM and TM and reviews the evidence on the cost-effectiveness of CAM and TM. It describes the socioeconomic determinants of seeking treatment from traditional healers and providers of CAM. Most evidence comes from industrialized countries; few studies have been conducted in or applied to low- and middle-income countries. This qualifier is significant for two reasons. First, many developing countries may not use the CAM and TM modalities discussed in this section. Second, the limited cost-effectiveness data may only be applicable in some countries. Nonetheless, the data provide a rough picture of the relative cost-effectiveness of various complementary and alternative medicine (CAM) and traditional medicine (TM) practices.

Economic Factors Affecting Complementary and Alternative Medicine and Traditional Medicine Use
Users of CAM and TM approaches select health practices that align with their health beliefs (Astin, 1998). While economic factors influence this decision, the underlying incentives are only sometimes predictable. One common misconception is that patients choose CAM and TM services because they are less expensive than conventional medical care. Although there are times when the cost of CAM or TM treatment is significantly less than the cost of accessing a conventional medical service, several studies have found that CAM and TM cost the same as or more than conventional treatments for the same conditions (see, for example, Muela, Mushi, and Ribera 2000).

According to at least one study, financial considerations are rarely the primary factor in selecting a traditional healer, ranking behind factors such as trust in the treatment, ease of access, and convenience (Winston & Patel, 1995). The average cost of a single visit to a Navajo healer in the United States was $388, and the average annual cost of using a traditional healer represented roughly one-fifth of respondents who reported annual income in a survey (Kim & Kwok, 1998). The most common barrier to seeking care from this source was the high cost of using a healer. The average patient per visit to a TM practitioner in Kenya was K Sh 46 (US$4 in 1981), significantly higher than the average charge per visit in private healthcare facilities (Mwabu, Ainsworth, and Nyamete 1993). Finally, according to a survey conducted in Zimbabwe, the median cost of consulting a herbalist was Z$23 per visit, compared to Z$1 for a government clinic and Z$29 for a private doctor (Winston & Patel, 1995). According to the same survey, patients had better outcomes when they went to government clinics (67.3 percent of visits resulted in a good outcome) than when they went to herbalists (50 percent of visits resulted in a good outcome).

However, TM is only sometimes more expensive than conventional medicine. According to survey respondents in Ghana, the cost of malaria treatment at a health clinic ranged from 1,900 to 3,000 (US$1.30 to US$2.00 in 1997), treatment at home using drugs purchased from pharmacies or health care workers ranged from 200 to 1,000 (US$0.10 to US$0.70), and treatment by a herbalist was virtually free (Ahorlu and others 1997).

Another common misconception is that TM is more prevalent among the poor. At least one study suggests that this is not the case. In Zimbabwe, the average monthly income of households visiting a herbalist was Z$877, which was higher than that of households visiting government clinics, which was Z$718 (Winston & Patel, 1995).

Although some traditional healers charge more than conventional practitioners, their fees may be negotiable, payment methods may be flexible (often on credit or in exchange for labor), and payment may be conditional on the outcome. When the disease condition requires providers to exert effort in curing patients and induce patients to comply with their recommendations, the availability of an outcome-contingent contract favors TM over Western medicine. However, this strategy may take more work to implement in the more extensive healthcare system.

Furthermore, patients seek treatment from traditional healers for conditions such as mental illness, impotence, and chronic disorders, which they believe require more extended family and kinship group involvement. As a result, financial assistance for seeking treatment for these disorders is more readily available than for illnesses such as malaria or diarrhea, for which patients seek conventional treatment more frequently.

There are few published data on the financial costs of TM in low- and middle-income countries. The data on traditional healers presented here are drawn from the World Bank’s living standards surveys in Vietnam to provide a nationally representative snapshot of the situation. In the four weeks preceding the survey, 10,033 of the 28,254 people in the sample had seen a doctor. These consultations included both home visits and provider visits. There were 1,829 visits to a public provider, 1,431 visits to a private provider, 7,650 visits to a pharmacy, and 259 visits to a traditional healer among the 10,033. 1 Headache was the most common reason for seeing a traditional provider, followed by cough and fever. The drug cost per visit for consulting a traditional healer was D 46, and the total cost per visit was D 51, compared to D 38 for drug costs and D 41 for total costs for going to a private clinic.

One frequently cited reason for using CAM and TM is that they may reduce the incidence and costs of side effects associated with conventional treatments, but the published evidence on this point is mixed. There is some evidence that complementary and alternative medicine (CAM) is used in addition to conventional treatments (Thomas and others 1991), but CAM may also displace conventional treatments. According to an outpatient survey, one-third of 246 patients who had been receiving conventional treatment from the Royal London Homeopathic Hospital since the beginning of care had discontinued conventional treatment, and another third had reduced their intake of conventional medication (van Haselen, 2000). 2 Homeopathic treatment displaced conventional treatment to varying degrees depending on the indication. Homeopathic treatment frequently replaced conventional treatments in patients with skin and respiratory infections; in patients with cancer, it was purely complementary and thus added to overall healthcare costs.

According to Thomas and colleagues (1991), CAM and TM patients frequently seek conventional medical care. Most CAM used in developed countries is to supplement conventional care, but it is also common in developing countries. Mwabu (1986), for example, provides evidence from Kenya that patients are likely to use more than one type of provider from the available options, such as government facilities, mission clinics, private clinics, pharmacies, and traditional healers. Furthermore, the provider of choice is determined by the patient’s illness, condition, socioeconomic status, and education. If an initial visit to one provider did not satisfactorily resolve the disease, a follow-up visit was made to a different type of provider. Finally, the quality of care—including service efficiency and waiting time at government and private clinics—is essential in determining whether patients seek traditional healers. When necessary, most traditional healers polled in a second study referred patients to Western practices for treatment (Mwabu, Ainsworth, and Nyamete 1993).

Economic Proof
Although most studies focus on a specific CAM or TM practice, Sommer, Burgi, and Theiss (1999) investigated whether providing CAM and TM services through prepaid health plans or government insurance reduces overall healthcare costs and discovered that it does not. One possible explanation is that only some people who have access to CAM use it, and those who do may use it in addition to, rather than more conventional, health services.

Rare are studies that compare the cost-effectiveness of various CAM and TM approaches using the same analytical framework. One such study in Peru examined the costs and cost-effectiveness of conventional medicine and TM treatment (EsSalud & OPS, 2000). The complementary medical practices studied were acupuncture, homeopathy, tai chi, meditation, reflexology, hydrotherapy, naturopathy, and massage. Patients were randomly assigned to either Western medicine or complementary and alternative medicine groups. Patients were not randomly assigned to one of two treatment groups but were matched based on disease pathology and severity, age, and gender.
Furthermore, the investigators chose patients who had spent at least one year in the health system, believing that this would allow them to evaluate their follow-up. Overall, the researchers discovered that complementary medicine was 53 to 63 percent less expensive than conventional medicine for achieving comparable levels of effectiveness. For osteoarthritis, hypertension, facial paralysis, and peptic ulcers, complementary medicine were exceptionally cost-effective.

The remainder of this section examines the economic evidence for various types of CAM or TM.

According to Lindall’s (1999) research, an acupuncture referral for musculoskeletal conditions costs, on average, US$422, roughly 60% less than a referral to a Western practitioner. This study, however, was not randomized, and patients had to have failed first-line drug treatment before being offered the option of second-line treatment with acupuncture or Western medicine.

Homeopathy
Evidence suggests that homeopathic medication costs less than the average cost of allopathic products, which would be an economic factor in favor of its use if homeopathy were proven effective. According to a study by the National Health Service in the United Kingdom, the drug costs associated with homeopathy were lower than those associated with allopathic practitioners (Swayne, 1992). A four-year study of 100 patients comparing homeopathic drug costs to those of conventional drugs discovered that those using homeopathic drugs saved an average of US$96 during the study period (Jain, 2003). 3

Ayurveda
A study that compared medical expenditures over four years for participants in an ayurvedic-based natural medicine program (which included antioxidant strategies, mind-body medicine, and other techniques) with participants whose expenditures were covered by a BlueCross BlueShield health insurance plan discovered that the ayurvedic group’s expenditures were 50% lower per person (Orme-Johnson & Herron, 1997). However, the study was not randomized and failed to account for the tendency of only a subset of people to accept and adhere to ayurvedic approaches.

Chiropractic
According to some studies, spinal manipulation is less expensive than traditional treatments for episodes of back pain. One nonrandomized study discovered that the cost of chiropractic treatment over five years (US$28,902), including both provider and equipment costs, was 24% less than the cost of Western pain therapy (US$38029) (Kumar, Malik, and Demeria 2002). Furthermore, 15% of patients in the chiropractic group were able to return to work, whereas none in the control group were.

However, other more extensive and better-controlled studies found no difference in outcomes or costs between chiropractic and physical therapy (Cherkin and others 1998; Skargren and others 1997; Skargren, Carlsson, and Oberg 1998). A study of adults with low back pain who were randomly assigned to physical therapy or chiropractic manipulation or were given an educational booklet discovered no significant differences in the mean costs of care or the outcomes between the physical therapy and chiropractic groups (Cherkin and others 1998). Three-quarters of the participants in these groups—who spent approximately US$430 over the two-year study period—reported that their outcome was either good or excellent, compared to one-third of those assigned booklets; however, the booklet group’s mean cost of care was only US$153 over the two years.

Mind-Body Medicine
There is little evidence of the cost-effectiveness of practices such as meditation and yoga. However, the cost of acquiring the skills required for these practices and the time costs of practicing them are so low in comparison to conventional medicine that evidence of clinical efficacy may be sufficient to justify their use on economic grounds. Clinical study evidence suggests that mind-body treatments can be cost-effective (Caudill and others, 1991; Friedman and others, 1995; Hellman and others, 1990; Sobel, 1995). Blumenthal and colleagues (2002) discovered significant reductions in coronary events. They predicted care costs for patients assigned to a one-and-a-half-hour weekly stress management class compared to usual care for the first two years of follow-up and after five years.

Beyond Cost-Effectiveness: CAM and TM Ancillary Benefits and Costs
Although cost-effectiveness is one guiding rationale for allocating resources to expand (or restrict) access to CAM and TM, other societal benefits and costs, such as the effects on biodiversity, must also be considered. Although CAM and TM may provide a rationale for species conservation, overharvesting of endangered species for medicinal purposes is also a concern. According to the World Health Organization, 85 percent of the world’s population (primarily in developing countries) relies on plants for medicine, and 25 percent of prescription drugs contain an active ingredient derived from a flowering plant (Cox, 2001). The potential extinction of medicinal plants concerns developing and developed countries, as evidenced by the poaching of American ginseng and the overharvesting of native saw palmetto. Similarly, Chinese TM’s reliance on tiger genitals, bear gallbladders, and black rhinoceros horns has aided poaching and threatens to wipe out these megafaunas.

Local knowledge and culture regarding medicinal plant uses may be important determinants of whether a species survives (Etkin, 1998). In addition to the value of these saved species for biodiversity, scientists can analyze these plants for potential clinical applications on a larger scale than TM allows. Although preserving traditional knowledge of healing practices aids in preserving indigenous populations’ culture and identity, CAM and TM may impose high costs. In such cases, promoting conventional treatments that do not rely on endangered species may have significant societal benefits.

Visit: Increasing the Use of Complementary and Alternative Medicine and Traditional Medicine
Despite uncertainty about the clinical efficacy and cost-effectiveness of certain CAM and TM practices, increasing their use in cases with moderate evidence of efficacy and good evidence of safety could result in health, social, and economic benefits. According to several surveys, local pharmacies are the primary source of treatment for many ailments, particularly in rural areas where government or private clinics are less accessible. In these cases, improving the quality of TM may be a viable alternative to allowing the unregulated use of conventional medical treatments. Training traditional healers are significantly cheaper than training doctors or nurses. A survey of 52 traditional healers in Kenya found that the average out-of-pocket (cash) cost of training to be a traditional healer was K Sh 418 (US$40 in 1981). (Mwabu, Ainsworth, and Nyamete 1993).

Traditional healers can also be recruited into a more extensive public health delivery system; for example, with additional training, traditional healers can serve as primary healthcare workers (Hoff, 1997) and provide advice on topics such as sexually transmitted diseases and oral rehydration therapy (Nations and de Souza 1997; Nations and others 1988; Ndubani & Hojer, 1999). Furthermore, allowing access to CAM and TM within the context of the conventional healthcare system would make it easier to access multiple health services in one location.

Most countries, including the United States, need a comprehensive policy on CAM and TM. The Dietary Supplement, Health, and Education Act of 1994 states that the US Food and Drug Administration must only require proof that dietary supplements and herbal products are safe and effective after they are sold. However, it is responsible for requiring good manufacturing practices. Herbal products’ quality is unregulated, and they typically differ from source to source and batch to batch in terms of their component ingredients and respective amounts, as well as whether they contain contaminants. No single entity in the United States is responsible for all aspects of CAM and TM control, education, information, and research, and there is no national, voluntary system of self-regulation. National nongovernmental organizations accredit education in some CAM and TM fields, such as the Accreditation Commission for Acupuncture and Oriental Medicine, the American Board of Medical Acupuncture, the Council of Chiropractic Education, the Council of Homeopathic Education, and the Commission on Massage Therapy Accreditation. However, such accreditation bodies only exist in some developing countries. Almost all countries lack rigorous CAM and TM research training programs.

A common misconception is that CAM and TM are used primarily by poorer, uneducated populations in developing countries. In contrast, they are used more by affluent and better-educated populations in industrial countries (Eisenberg and others 1998). In both cases, there is little evidence to support this viewpoint. Many researchers have failed to critically assess the use of complementary and alternative medicine (CAM) and traditional medicine (TM) by minority and immigrant populations in Western countries. Nearly 85 percent of the population in Africa uses TM, which is often the only way to obtain primary health care, and wealthier people in developing countries frequently use TM (WHO, 2002). Investing in improving the quality and consistency of TM could lower the cost of health care delivery, particularly for chronic conditions like arthritic pain and AIDS, where TM interventions can improve patients’ sense of well-being, appetite, and energy. Simultaneously, without resources to expand public health infrastructure, a network of certified CAM and TM providers could provide the infrastructure for other types of care, such as immunizations and maternal-child health programs.

Recognizing the redistributive nature of investment in TM is essential. Indigenous people will seek the help of traditional healers because of proximity, familiarity, and trust. Investments in TM could therefore be used strategically to increase access to conventional preventive and therapeutic care. Including the traditional healer as part of the health care team is an essential strategy both to attract patients and upgrade traditional healers’ skills and training.

How equity is affected by the proportions in which different condition-specific interventions are combined and how other interventions (regulations, tax policy, managerial changes) are likely to affect equity need to be studied. Given that most indigenous populations in developing countries use TM for their primary health care, the availability, safety, and affordability of TM, including herbal medicines, should be ensured as a matter of equity. One way to accomplish this is to encourage the local production of safe and effective herbals such as artemisia at reasonable prices. Furthermore, rigorous research on TM should be encouraged. The World Health Organization is currently conducting collaborative research on herbal treatments for HIV/AIDS, malaria, sickle cell anemia, and diabetes. Such studies should be used to eliminate ineffective or unsafe herbal products, while those with proven efficacy and safety should be made available for therapeutic use.

Go to: Implementation and Lessons Learned
The prevalence of various TM and CAM modalities varies significantly from country to country. Many different modalities may be used to treat a given condition in China, where traditional Chinese medicine is well integrated into the health system. In the United States, on the other hand, complementary and alternative medicine (CAM) programs are gradually being integrated with conventional medicine. Several medical schools have fledgling CAM programs integrated to varying degrees into medical school curricula. Andrew Weil’s program at the University of Arizona Health Sciences Center is among the most lauded in the United States. His Integrative Medicine Fellowship Program trains physicians in CAM and TM. It aims to create a new delivery model in which physicians, patients, and nurses collaborate to care for the patient as a healing team. However, it must be critically evaluated before more institutions are urged to adopt this program.

Despite the complexity, diversity, and controversy surrounding CAM/TM approaches, some notable success stories demonstrate the impact of globalization, with modalities discovered in the developing world being adopted in the West, with or without modifications, and vice versa.

Artemisinin
Artemisinin is a newly discovered active metabolite of artemisia, a herbal extract used for centuries to treat fever in China. In the 1970s, Chinese scientists discovered the active ingredient in the herbal, and Western pharmaceutical companies developed several derivatives as drugs to combat resistant Plasmodium malaria (Li and others 2000). One such drug, dihydroartemisinin-piperaquine, has been shown in randomized clinical trials to be effective against drug-resistant Plasmodium falciparum malaria (Hien & Dolecek, 2004). When added to existing malaria drugs, another artemisinin derivative, artesunate, was shown to increase parasite clearance and decrease gametocyte count (Adjuik and others, 2004).

Acupuncture
Acupuncture is another CAM and TM modality that has gained popularity. Acupuncture services are available in many pain management clinics, hospitals, and academic centers worldwide, and some insurance companies reimburse them. Rigorous clinical trials have demonstrated positive efficacy in two areas: (a) management of postoperative nausea and emesis (Shen and others 2000) and (b) pain relief in chronic osteoarthritis (Shen and others 2000). (Ezzo and others 2001; Soeken 2004; Tukmachi and others 2004). Studies that provide rational explanations for how acupuncture may achieve its effects supplement evidence of efficacy; for example, one mechanism of action appears to involve opioid-dependent brain pathways. This type of two-step process—initial clinical efficacy demonstration followed by scientific research into the mechanism of action—is one way for CAM and TM to gain scientific acceptance and integration into conventional medicine.

Osteopathy and chiropractic medicine
During the last years of the nineteenth century, chiropractic medicine was invented in the American heartland. It employs spinal manipulation to treat various conditions thought to be caused by abnormal vertebral alignment or stresses, most commonly in patients with musculoskeletal complaints. There are two success stories in chiropractic medicine. First, although conventional medicine practitioners ostracized chiropractors in the late nineteenth and early twentieth centuries, it has gradually evolved into a viable healing discipline that is increasingly accepted by the orthodox medical community. Chiropractic’s evolution can be compared to that of osteopathy. Osteopathy developed alongside chiropractic in the United States, but the field chose to accommodate rather than reject allopathic techniques.

The second success story is research demonstrating that chiropractic manipulation is superior to bed rest, physical therapy, or the distribution of an educational booklet for low back pain (Cherkin and others 1998). Chiropractic manipulation has also shown results in relieving back pain compared to those obtained with nonsteroidal anti-inflammatory drugs (Straus, 2004).

Homeopathy
Homeopathy is a success because of its widespread acceptance and use, not because of the strength of the evidence supporting it. Indeed, few conventional scientists and physicians believe in homeopathy. According to the “principle of similars” that underpins homeopathy, practitioners select remedies that produce symptoms similar to the patients when administered in high concentrations. The substance is then placed in solution and serially diluted up to 1060 times, far exceeding the point defined by Avogadro’s number (at which a single molecule of the original substance could remain in the solution). According to homeopathy, serial diluting and vigorous shaking imprint information into the water, retaining medicinal properties even when no or few molecules of the starting medicine are present.

As unlikely as this claim may appear, homeopathy is used successfully worldwide (Jonas, Kaptchuk, and Linda, 2003). Randomized controlled trials have suggested that it may be effective in treating influenza (Vickers & Smith, 2000), allergies (Taylor and others, 2000), and postoperative ileus (Vickers & Smith, 2000). (Barnes, Resch, and Ernst 1997). However, critics have questioned the trials’ quality and analyses. Several reviews of homeopathy have questioned the validity of pooling data from trials of different populations, interventions, and outcome measures. According to Jonas, Kaptchuk, and Linda (2003, 393), “There is insufficient evidence to support the effectiveness of homeopathy for most conditions. Homeopathy deserves a fair chance to demonstrate its worth by employing evidence-based principles, but it should not be used in place of proven therapies.”

Intervention with the Mind-Body System
David Spiegel’s research at Stanford University on group support for breast cancer patients sparked widespread interest in the potential value of mind-body interventions (Spiegel and others 1989). The study included 86 women with metastasized breast cancer in a randomized controlled trial with a 10-year follow-up. A one-year psychosocial intervention consisting of weekly supportive group therapy with self-hypnosis for pain resulted in a mean survival time of 37 months in the treated group versus 19 months in the control group. According to Spiegel (1994), appropriate psychotherapy (both group and individual) not only reduced depression and anxiety and improved coping skills but also saved money by reducing the number of office visits, diagnostic tests, medical procedures, and hospital visits admissions. Although Spiegel’s findings have not been replicated, they demonstrate the potential benefits of mind-body intervention and have prompted research into how such interventions might work.

Visit the Research and Development Agenda.
The absence of compelling data on the safety and efficacy of most CAM and TM approaches and a lack of product quality and consistency pose significant challenges to any effort to optimize the distribution of precious health resources. These difficulties also present research opportunities. Other formidable challenges include CAM and TM practitioner training, credentialing, and licensing variations. Several countries are making tremendous efforts to regulate both products and practitioners. Finally, strict controls on training, practices, and products must be accompanied by rigorous research to determine which approaches are safe and effective—and for what indications.

The global use and potential impact of complementary and alternative medicine (CAM) and complementary and alternative medicine (TM) practices, the lack of adequate data validating their safety and efficacy, and the existence of highly effective conventional alternatives for many of them all necessitate that resources are devoted to fuller characterization and standardization of CAM, and TM approaches. Only compelling data can justify investing precious resources in further integrating such approaches into healthcare infrastructures. This raises the issue of what constitutes a rational agenda for this work.

For resource-rich industrial nations, one model for CAM and TM research is that being implemented by the National Center for Complementary and Alternative Medicine (NCCAM) of the U.S. National Institutes of Health (http://nccam.nih.gov). In 2004, NCCAM planned to invest US$117 million in research and training. It supports some 800 individual projects, including studies of the composition of natural products and their pharmacological effects, studies of the neurobiological mechanisms of acupuncture and the placebo effect, and clinical trials with 30 to 30,000 participants. NCCAM now has a strategic plan for its international programs that emphasizes research, training, and efforts to learn about the rich, indigenous TM heritage. Australia, through a government agency similar to NCCAM, conducts research and training programs in collaboration with its indigenous people. Although the scope of NCCAM’s research agenda is more extensive than what most other nations could accommodate, its underlying philosophy should be universal. That is, the standards for research into CAM and TM approaches should be no different from those used in conventional biomedical research.

Both CAM and TM and biomedical practitioners need to understand the strengths, limitations, and contributions of their particular approaches to working together to ensure the best possible care for their patients and achieve their shared goals of improved individual and public health. Once these issues have been addressed, countries could devote additional resources to studying those CAM and TM approaches that appear to be the most promising about their most pressing public health problems. Some priority areas for CAM and TM research are widely applicable, including studies of approaches to palliate chronic pain and suffering, relieve depression, help release the grip of addictive substances, and slow the progression of degenerative disorders such as arthritis and dementia.
QUESTION
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Part 1: Advanced Primary Care of Family

Topic: Respiratory case

SUBJECTIVE:

Janis, a 59 – year – old female, presents with tachypnea, dyspnea on exertion, and mild chest discomfort. She was diagnosed with emphysema four years ago and was placed on bronchodilator therapy. She has an 80-pack-year history of smoking. “ I feel short of breath when I walk, and my chest is sore. ” She describes her chest soreness as mild pressure, rated as two on a 1 – 10 scale. The pain is over the anterior thorax, more pronounced in the ribs, which she believes has developed from coughing hard. She states that she has had a nonproductive cough for four days and feels more fatigued than usual.

Past medical history

She has osteoarthritis in the hands and knees. She has a surgical history of appendectomy and cholecystectomy. In the past year, she has had two exacerbations of her COPD and has attempted to stop smoking, using nicotine gum replacement unsuccessfully.

Family history

Noncontributory.

Social history

She lives with her husband, who also smokes two packs of cigarettes per day and cares for her elderly mother, who lives with them and is frail but ambulatory.

Medications

Albuterol MDI, 90 mcg/inhalation, two puffs as needed every 4 – 6 hours; ipratropium bromide MDI, 18 mcg/inhalation, two puffs four times/day; ibuprofen as needed for arthritic pain.

Allergies

Janis is allergic to Keflex and penicillin.

OBJECTIVE:

General: Janis is dyspneic at rest, sitting. The use of accessory muscles is evident. Pursed lip breathing noted.

Vital signs: BP: 122/64; P: 92; R: 26; T: 100.2; SpO2: 88. AP to transverse ratio is 1:1.

Skin: Warm and dry.

HEENT: Negative.

Cardiovascular: RRR: S1/S2; no murmurs, clips, rubs, or gallops. No evidence of peripheral edema. Posterior tibial and dorsalis pedis pulses 2 + /4 + .

Respiratory: Lungs have diffused wheezing and crackles in the right upper lobe. Tenderness to palpation along intercostal spaces on the right and left anterior and lateral thorax from the 2nd to 5th intercostal spaces. PFT conducted two months prior to the visit showed obstructive flow patterns and reduced FEV1/FVC.

Abdomen: Soft, with bowel sounds; tympanic to percussion.

Neurologic: Negative.

Based on the described case scenario, please answer two of the following questions:

1. Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? (one paragraph)

a. Explain (one paragraph)

2. What is the most likely differential diagnosis, and why? (one paragraph)

a. Explain

3. What is your plan of treatment? (one paragraph)

a. Pharmacology

b. Nonpharmacology

4. What is your plan for follow-up care? also, include (one paragraph)

a. Are any referrals needed?

a. Explain and justify

5. What are additional risk factors evident for this patient? (one paragraph)

6. Explain two standardized guidelines that you should use to treat this patient (one paragraph)

Part 2: Advanced Primary Care of Family

Topic: Respiratory case

SUBJECTIVE:

Janis, a 59 – year – old female, presents with tachypnea, dyspnea on exertion, and mild chest discomfort. She was diagnosed with emphysema four years ago and was placed on bronchodilator therapy. She has an 80-pack-year history of smoking. “ I feel short of breath when I walk, and my chest is sore. ” She describes her chest soreness as mild pressure, rated as two on a 1 – 10 scale. The pain is over the anterior thorax, more pronounced in the ribs, which she believes has developed from coughing hard. She states that she has had a nonproductive cough for four days and feels more fatigued than usual.

Past medical history

She has osteoarthritis in the hands and knees. She has a surgical history of appendectomy and cholecystectomy. In the past year, she has had two exacerbations of her COPD and has attempted to stop smoking, using nicotine gum replacement unsuccessfully.

Family history

Noncontributory.

Social history

She lives with her husband, who also smokes two packs of cigarettes per day and cares for her elderly mother, who lives with them and is frail but ambulatory.

Medications

Albuterol MDI, 90 mcg/inhalation, two puffs as needed every 4 – 6 hours; ipratropium bromide MDI, 18 mcg/inhalation, two puffs four times/day; ibuprofen as needed for arthritic pain.

Allergies

Janis is allergic to Keflex and penicillin.

OBJECTIVE:

General: Janis is dyspneic at rest, sitting. The use of accessory muscles is evident. Pursed lip breathing noted.

Vital signs: BP: 122/64; P: 92; R: 26; T: 100.2; SpO2: 88. AP to transverse ratio is 1:1.

Skin: Warm and dry.

HEENT: Negative.

Cardiovascular: RRR: S1/S2; no murmurs, clips, rubs, or gallops. No evidence of peripheral edema. Posterior tibial and dorsalis pedis pulses 2 + /4 + .

Respiratory: Lungs have diffused wheezing and crackles in the right upper lobe. Tenderness to palpation along intercostal spaces on the right and left anterior and lateral thorax from the 2nd to 5th intercostal spaces. PFT conducted two months prior to the visit showed obstructive flow patterns and reduced FEV1/FVC.

Abdomen: Soft, with bowel sounds; tympanic to percussion.

Neurologic: Negative.

Based on the described case scenario, please answer two of the following questions:

1. Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? (one paragraph)

a. Explain (one paragraph)

2. What is the most likely differential diagnosis, and why? (one paragraph)

a. Explain

3. What is your plan of treatment? (one paragraph)

a. Pharmacology

b. Nonpharmacology

4. What is your plan for follow-up care? also, include (one paragraph)

a. Are any referrals needed?

b. Explain

5. What are additional risk factors evident for this patient? (one paragraph)

6. Explain two standardized guidelines that you should use to treat this patient (one paragraph)

Part 3: Complementary and Alternative Health Care

1. What is Complementary and alternative medicine (CAM) (One paragraph)

2. How Complementary and alternative medicine (CAM) and nursing links (One paragraph)

3. How nurses can incorporate alternative medicine into a holistic approach to patient care (One paragraph)

4. Explain the benefits for the patient when nurses incorporate alternative medicine into a holistic approach to patient care (One paragraph)

5. Explain how holism and humanism improve the nurse’s patient care (One paragraph)

6. Explain the benefits for the patient when they get holism and humanism care from nurses (One paragraph)

Part 4: Crisis Intervention

Topic: Posttraumatic Stress Disorder

1. Introduction (One paragraph)

2. What is PTSD ? (One paragraph)

3. Explain the statistics data in the last 5 years of PTSD (Three paragraphs)

a. Global (One paragraph)

b. The USA (One paragraph)

c. Florida (One paragraph)

4. According to (ONLY) to DSM5 explain PTSD (Two paragraphs)

a. Diagnostic criteria (One paragraph)

b. Categorization (One paragraph)

5. Explain the physiological responses of PTSD (Two paragraphs)

6. Explain the maladaptive patterns of PTSD (Two paragraphs)

7. Interventions / Treatments (Two paragraphs)

a. Pharmacological (One paragraph)

b. Non-pharmacological (One paragraph)

8. Explain other considerations in the management of PTSD (Three paragraphs)

a. Management of behaviors (One paragraph)

b. Family considerations (One paragraph)

c. Challenges in the care of patients with this disorder (One paragraph)

9. Explain one evidence-based practice guidelines/research for nurses for the management of PTSD patient (One paragraph)

10. Explain one nursing theory that support the identification of clinical problems of PTSD patient (One paragraph)

11. Explain the important of implementation and imporve of nursing skills in the care of adults with this disorder. (Two paragraphs)

a. Which nursing skills are vitals (One paragraph)

b. Which nursing skills are secundaries (One paragraph)

12. Conclusion for nurses (One paragraph)