THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 15, Number 9, 2009, pp. 959–962 ª Mary Ann Liebert, Inc. DOI: 10.1089=acm.2009.0030
Original Article
Emerging Complementary and Alternative Medicine Policy Initiatives and the Need for Dialogue Kjersti E. Knox, B.A.,1 Vinjar Fønnebø, M.D., Ph.D.,2 and Torkel Falkenberg, Ph.D.1
Abstract
Objectives: This article explores the regulation of complementary and alternative medicine (CAM) and uses Swedish policy to bring to light paradoxes between CAM policies and CAM practice. It asserts that increases in CAM use challenge national health policies across the globe to simultaneously prioritize patient safety and treatment efficacy yet offer choices that promote patient ownership of health. In response to these challenges, many countries have established or are in the process of establishing a national CAM policy. Methods: Using Sweden as an example, current health law, the CAM policy–practice paradox, and efforts to change CAM policy are considered. This article offers recommendations for future policy development based on recent Norwegian reforms and World Health Organization guidelines and calls for dialogue on this topic. Conclusions: It is of the utmost importance that the rarely discussed paradoxes between CAM policy and CAM practice are addressed in health sector reforms globally.
Introduction
C
omplementary and alternative medicine (CAM) is defined by the World Health Organization (WHO) as ‘‘a broad set of healthcare practices that are not part of a country’s own tradition and are not integrated into the dominant healthcare system.’’1 The WHO global survey of national health policies on CAM in 2002 found that 68% of surveyed countries either had an established national CAM policy or were in the process of establishing such a policy1 (Fig. 1). The specific policies, however, differed greatly by country.2 The same WHO survey additionally identified a lack of (1) research on CAM, (2) quality control, and (3) knowledge within national drug authorities as impediments to the challenging task of updating and developing national CAM policies.1 Recognizing and resolving contradictions between old health policies and current practice by developing dialogue and, if called for, appropriate partnerships between the many actors in the health arena is therefore of urgent importance. Such initiatives could improve patient safety, treatment efficacy, and offer choices that promote patient ownership of health. The Swedish Example: CAM Policy Sweden’s CAM policy is unofficially written in the Professional Activity in the Health Services (1998:531) Act. This act defines which personnel are considered official health
personnel and their basic responsibilities. Health personnel are defined as those who have health certification or a protected occupational title (meaning that only those with a specific educational and=or practical background may use the title), provide care in a hospital or clinic, produce or distribute pharmaceuticals, or provide emergency care or advice. CAM practitioners are not included in the Swedish definition of health personnel. The Professional Activity in the Health Services (1998:531) Act excludes health personnel from practicing CAM by requiring all health personnel to practice in accordance with ‘‘science and experiential knowledge.’’ The phrase ‘‘science and experiential knowledge’’ is most often interpreted by the National Board of Health and Welfare as science and experiential knowledge acquired in the Western world. Health personnel must uphold the responsibilities of certification, and thus act in accordance with ‘‘science and experiential knowledge,’’ 24 hours a day, 7 days a week. They are therefore generally prohibited from practicing CAM both inside and outside their profession. A small exception to this rule is included in the act. It states that health personnel may be permitted to practice CAM on the rare occasion when a patient initiates the request for it, no alternative conventional treatment options exist, and the treatment is given in conjunction with normal care. It is also required that no risk associated with the treatment be expected.
1 Unit for Studies of Integrative Health Care, Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden. 2 National Research Centre in Complementary and Alternative Medicine, University of Tromsø, Tromsø, Norway.
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FIG. 1. Increases in the number of World Health Organization (WHO) member states with national policies on traditional medicine=complementary and alternative medicine by year. (Copyright: World Health Organization. National Policy on Traditional Medicine and Complementary=Alternative Medicine. Geneva: World Health Organization, 2005; used with permission.)
Very little written legislation explicitly regulates CAM practitioners in Sweden. The Professional Activity in the Health Services (1998:531) Act prohibits CAM practitioners from using radiology or treating specific contagious diseases, diabetes, epilepsy, diseases associated with pregnancy or delivery, or cancer and other malignant tumors. They are also barred from treating patients under anesthesia and children under the age of 8. No legislation outlines how CAM practitioners are sanctioned to practice. CAM practitioners are otherwise self-regulated. Table 1. Complementary Methods Used by Swedish Health Personnel Complementary method Acupressure Acupuncture Anthroposophy Body awareness therapy Chiropractic Feldenkrais Hypnosis Light therapy Lymph drainage Massagea Music therapy Naprapathy Osteopathy Qigong Relaxation therapy Rosen method T’ai chi TENS Yoga
Evidence according to Cochrane collaboration Evidence based4 Evidence based5 No review No review Inconclusive6 No review Inconclusive7 Inconclusive8 Inconclusive9 Evidence based10 Evidence based11 No review Inconclusive12 No review Evidence based13 No review Evidence based14 Inconclusive15 Inconclusive16
a The term massage includes the multiple different forms of massage. TENS, transcutaneous electrical nerve stimulation.
The Swedish Example: CAM in Practice In 2001, the Federation of County Councils (the legislative bodies responsible for health care provision and funding within Sweden) outlined ongoing CAM use within the established health care system.3 They reported that health personnel utilized 19 different complementary methods. Six (6) of the reported methods are considered evidence-based in Cochrane Collaboration reviews (Table 1).4–16 Thus, Sweden is an example of a WHO member country with national health legislation that contradicts practice. Health personnel do in fact practice non-‘‘scientific’’ and non-‘‘experiential[ly]’’ proven CAM methods. Resolving this contradiction requires enforcement of current legislation or legislative reform. Previous Reform Efforts Although there is a policy–practice paradox and legal separation between CAM and the biomedical community in Sweden, the country has made small steps toward reconciling the two. Such steps include (1) a proposed governmentsupported CAM registry, (2) courses on CAM provided at universities around the country, and (3) the establishment of CAM research units at medical universities. Furthermore, the Federation of County Councils has expressed a need and interest in giving priority to CAM research in the future.3 In their 2002–2006 political program, the Stockholm County’s Social Democratic, Left, and Environmental parties’ coalition also encouraged collaboration and experiential exchange between CAM and biomedical practitioners.17 Additionally, the Stockholm County Council launched a two-year project to develop a county CAM policy. However, the project was postponed, partly due to the fact that the Stockholm Medical Association strongly opposed the policy work based on a perceived conflict with ‘‘science and experiential knowledge.’’18 Also, the county of Norrland has, in consultation with the National Research Center in Complementary and Alternative Medicine (NAFKAM) in Norway, initiated a
CAM POLICY REFORM process of exploring whether certain CAM treatments could be integrated into the conventional health care system. Despite the absence of a centralized strategic plan for reform in Sweden, the Ministry of Health and Social Affairs recently announced that a commissioner has been appointed to review The Professional Activity in the Health Services Act (1998:531), which will be finalized by October 1, 2010. This initiative is promising and could facilitate the resolving of the policy–practice paradox, at least at the policy and legislative levels. Recommendations Confronting a policy–practice paradox may be challenging for countries; however, published literature and examples provided by other countries can provide some guidance. The WHO recommends that health policies be designed to recognize the contribution of CAM to patient health and to promote safety, efficacy, quality, access, and rational use of CAM.19 The Executive Board of WHO’s resolution on traditional medicine has further urged ‘‘member states … to draft and implement national policies and regulations on traditional and complementary and alternative medicine in support of the proper use of traditional medicine, and its integration into national health care systems, depending on the circumstances in their countries.’’20 Boon et al. write that health policies should take into account the diverse numbers of health care combinations that a population actually uses.21 Countries, such as Sweden, that are struggling with how to address their CAM policy–practice paradox can further look to other states that have addressed a policy–practice paradox for guidance. Norway, for instance, chose to address its CAM policy–practice paradox in 2003 by adopting a CAM policy written in unprecedented language that outlines not only illegal CAM practices but also permissible CAM practices. In this legislation, Norway also established that CAM practitioners are required to meet the same standards as other health personnel if they choose to seek authorization under the Norwegian Health Personnel Act. The new policy thus encourages CAM practitioners to organize themselves and move toward authorization while allowing CAM practice to continue unaltered. The government intends that this self-organization will allow the various CAM disciplines to distinguish serious from nonserious practitioners, improve patient safety, and develop closer contact with the Norwegian government.22 This Norwegian policy was established following a long process beginning with active lobbying of politicians. This lobbying was done by individuals committed to increased research in the field and thereby recognition of CAM practitioners. The process was probably accelerated by leading politicians’ (including the prime minister) public affirmation of their use of CAM for their own health problems. Government funding of CAM research was in place by the early 1990s, and in 1997 the government constituted a committee to write an ‘‘Official Norwegian Report’’ on CAM. The report was presented to the Minister of Health in December 1998, and had a thorough description of both the practice and legal situation of CAM at that time. Recommendations for action were made both in the area of legislation, research, and other regulatory measures as described above.
961 Conclusions The practice and use of CAM challenges Sweden and other countries around the world to recognize the role CAM now has in their society and to adjust their health policies. As Timmerman writes, ‘‘unfortunately, the discussion on policy choices is at times obscured by a lack of clarity on the objectives to be pursued, and is further compounded by the fact that concepts and perspectives differ, that objectives are multiple and that some of the potential strategies are conflicting.’’23 Despite the difficulties and challenges, a dialogue must be established between CAM, biomedical, political, and patient communities that will improve patient safety on the one hand and represent patients’ interests on the other. In accordance with the WHO’s global health agenda for 2006– 2015, partnerships and new health care policies must reflect domestic health care in its entirety whereby ‘‘many groups in civil society make essential contributions and should be part of any consultative process for major change in the health system. These groups include private providers, traditional practitioners, community-based organizations, nongovernmental organizations and home-based care providers.’’24 As previous literature has indicated, partnerships need to be developed to improve national policies within the broadest and non-hierarchical sense of evidence-based medicine.25,26 With CAM policy development on the rise, countries around the world face the challenge of developing appropriate health regulations that reflect contemporary practice or enforcing existing laws. This health policy challenge affects not just Sweden but also other developed and developing countries that face discrepancies between current health practice and established health policies. It is likely that countries will look to other states as role models as they decide whether to write new health policy and follow WHO recommendations or enforce previous regulations. As the many players in health communities worldwide confront this issue, they should work together to structure appropriate health care policies with patients in the focus. Acknowledgments The research reported in this article was supported by an award from the Fulbright Program. The authors would like to acknowledge Tobias Sundberg for his counsel during the preparation of this manuscript and the World Health Organization for permission to reproduce Figure 1. Disclosure Statement The authors state that no competing financial interests exist. References 1. World Health Organization. National Policy on Traditional Medicine and Complementary=Alternative Medicine. Geneva: World Health Organization, 2005. 2. World Health Organization. Legal Status of Traditional Medicine and Complementary=Alternative Medicine: A Worldwide Review. Geneva: World Health Organization, 2001. ¨ rebro Universitetet. Complemen3. Landstingsfo¨rbundet & O tary medicine’s distribution and use within the country’s ¨ rebro, Sweden: Repro, O ¨ rebro Unicounties [in Swedish]. O versitet, 2001.
962 4. Ezzo JM, Richardson MA, Vickers A, et al. Acupuncturepoint stimulation for chemotherapy-induced nausea or vomiting. Cochrane Database Syst Rev 2006;2:CD002285. 5. Lee A, Done ML. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev 2004;3:CD003281. 6. Glazener CM, Evans JH, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2005;2:CD005230. 7. Webb AN, Kukuruzovic RH, Catto-Smith AG, Sawyer SM. Hypnotherapy for treatment of irritable bowel syndrome. Cochrane Database Syst Rev 2007;4:CD005110. 8. Tuunainen A, Kripke DF, Endo T. Light therapy for nonseasonal depression. Cochrane Database Syst Rev 2004;2: CD004050. 9. Badger C, Preston N, Seers K, Mortimer P. Physical therapies for reducing and controlling lymphoedema of the limbs. Cochrane Database Syst Rev 2004;4:CD003141. 10. Beckmann MM, Garrett AJ. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev 2006;1:CD005123. 11. Gold C, Heldal TO, Dahle T, Wigram T. Music therapy for schizophrenia or schizophrenia-like illnesses. Cochrane Database Syst Rev 2005;2:CD004025. 12. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev 2005;2:CD001002. 13. Ostelo RW, van Tulder MW, Vlaeyen JW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev 2005;1:CD002014. 14. Han A, Judd MG, Robinson VA. Tai chi for treating rheumatoid arthritis. Cochrane Database Syst Rev 2004;3: CD004849. 15. Robb KA, Bennett MI, Johnson MI, et al. Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database Syst Rev 2008;3:CD006276. 16. O’Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev 2003;1:CD003219. 17. Miljo¨partiet de Gro¨na, Va¨nsterpartiet och Socialdemokraterna i Stockholms la¨ns landsting. Political platform for mandate period 2002–2006 [in Swedish]. Online document
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Address correspondence to: Torkel Falkenberg, Ph.D. Unit for Studies of Integrative Health Care Division of Nursing Department of Neurobiology Care Sciences and Society Karolinska Institutet Huddinge Sweden E-mail:
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