Dating from the 1970s, medical professionals, sociologists, anthropologists and other commentators noted the increasing visibility of a wide variety of health practices that had neither derived directly from nor been verified by biomedical science.[53] Since that time, those who have analyzed this trend have deliberated over the most apt language with which to describe this emergent health field.[53] A variety of terms have been used, including heterodox, irregular, fringe and alternative medicine while others, particularly medical commentators, have been satisfied to label them as instances of quackery.[53] The most persistent term has been alternative medicine but its use is problematic as it assumes a value-laden dichotomy between a medical fringe, implicitly of borderline acceptability at best, and a privileged medical orthodoxy, associated with validated medico-scientific norms.[54] The use of the category of alternative medicine has also been criticized as it cannot be studied as an independent entity but must be understood in terms of a regionally and temporally specific medical orthodoxy.[55] Its use can also be misleading as it may erroneously imply that a real medical alternative exists.[56] As with near-synonymous expressions, such as unorthodox, complementary, marginal, or quackery, these linguistic devices have served, in the context of processes of professionalisation and market competition, to establish the authority of official medicine and police the boundary between it and its unconventional rivals.[54]
From a historical perspective, the emergence of alternative medicine, if not the term itself, is typically dated to the 19th century.[57] This is despite the fact that there are variants of Western non-conventional medicine that arose in the late-eighteenth century or earlier and some non-Western medical traditions, currently considered alternative in the West and elsewhere, which boast extended historical pedigrees.[54] Alternative medical systems, however, can only be said to exist when there is an identifiable, regularized and authoritative standard medical practice, such as arose in the West during the nineteenth-century, to which they can function as an alternative.[58]
During the late eighteenth and nineteenth centuries regular and irregular medical practitioners became more clearly differentiated throughout much of Europe and,[59] as the nineteenth century progressed, most Western states converged in the creation of legally delimited and semi-protected medical markets.[60] It is at this point that an "official" medicine, created in cooperation with the state and employing a scientific rhetoric of legitimacy, emerges as a recognizable entity and that the concept of alternative medicine as a historical category becomes tenable.[61] As part of this process, professional adherents of mainstream medicine in countries such as Germany, France, and Britain increasingly invoked the scientific basis of their discipline as a means of engendering internal professional unity and of external differentiation in the face of sustained market competition from homeopaths, naturopaths, mesmerists and other nonconventional medical practitioners, finally achieving a degree of imperfect dominance through alliance with the state and the passage of regulatory legislation.[54][56] In the US the Johns Hopkins University School of Medicine, based in Baltimore, Maryland, opened in 1893 and was the first medical school devoted to teaching "German scientific medicine".[62] Buttressed by the increased authority consequent to the significant advances in the medical sciences of the late 19th century onwards — including the development and application of the germ theory of disease by the chemist Louis Pasteur and the surgeon Joseph Lister, 1st Baron Lister, of microbiology co-founded by Robert Koch (in 1885 appointed professor of hygiene at the University of Berlin), and of the use of X-rays (Röntgen rays) — the 1910 Flexner Report called upon American medical schools to follow the model set by the Johns Hopkins School of Medicine and adhere to mainstream science in their teaching and research. This was in a belief, mentioned in the Report's introduction, that the preliminary and professional training then prevailing in medical schools should be reformed in view of the new means for diagnosing and combating disease being made available to physicians and surgeons by the sciences on which medicine depended.[n 7][64] An early instance of the influence of the Flexner Report outside North America is Peking Union Medical College.[65][n 8][n 9]
Among putative medical practices available at the time which later became known as "alternative medicine" were homeopathy (founded in Germany in the early 19c.) and chiropractic (founded in North America in the late 19c.). These conflicted in principle with the developments in medical science upon which the Flexner reforms were based, and they have not become compatible with further advances of medical science such as listed in Timeline of medicine and medical technology, 1900-1999 and 2000–present, nor have Ayurveda, acupuncture or other kinds of alternative medicine.
At the same time "Tropical medicine" was being developed as a specialist branch of western medicine in research establishments such as Liverpool School of Tropical Medicine founded 1898, London School of Hygiene & Tropical Medicine, founded 1899 and Tulane University School of Public Health and Tropical Medicine, founded 1912. A distinction was being made between western scientific medicine and indigenous systems. An example is given by an official report about indigenous systems of medicine in India, including Ayurveda, submitted by Mohammad Usman of Madras and others in 1923. This stated that the first question the Committee considered was "to decide whether the indigenous systems of medicine were scientific or not".[66][67][68]
By the later twentieth century the term 'alternative medicine' had come into use for the purposes of public discussion,[n 10][70] but it was not always being used with the same meaning by all parties. Arnold S. Relman remarked in 1998 that in the best kind of medical practice, all proposed treatments must be tested objectively, and that in the end there will only be treatments that pass and those that do not, those that are proven worthwhile and those that are not. He asked 'Can there be any reasonable "alternative"?'[71] But also in 1998 the then Surgeon General of the United States, David Satcher,[72] issued public information about eight common alternative treatments (including acupuncture, holistic and massage), together with information about common diseases and conditions, on nutrition, diet, and lifestyle changes, and about helping consumers to decipher fraud and quackery, and to find healthcare centers and doctors who practiced alternative medicine.[73]
In respect of alternative medicine since the 1970s in North America, Great Britain and elsewhere, there has been a tendency for the terms ‘alternative’ and ‘complementary’ to be used interchangeably to describe a wide diversity of therapies that attempt to use the self-healing powers of the body by amplifying natural recuperative processes to restore health. By 1990, approximately 60 million Americans had used one or more complementary or alternative therapies to address health issues, according to a nationwide survey in the US published in 1993 by David Eisenberg.[74] A study published in the November 11, 1998 issue of the Journal of the American Medical Association reported that 42% of Americans had used complementary and alternative therapies, up from 34% in 1990.[75] However, despite the growth in patient demand for complementary medicine, most of the early alternative/complementary medical centers failed.[76]
Medical education since 1910Provestra reviews


Mainly as a result of reforms following the Flexner Report of 1910[77] medical education in established medical schools in the US has generally not included alternative medicine as a teaching topic.[n 11] Typically, their teaching is based on current practice and scientific knowledge about: anatomy, physiology, histology, embryology, neuroanatomy, pathology, pharmacology, microbiology and immunology.[79] Medical schools' teaching includes such topics as doctor-patient communication, ethics, the art of medicine,[80] and engaging in complex clinical reasoning (medical decision-making).[81] Writing in 2002, Snyderman and Weil remarked that by the early twentieth century the Flexner model had helped to create the 20th-century academic health center in which education, research and practice were inseparable. While this had much improved medical practice by defining with increasing certainty the pathophysiological basis of disease, a single-minded focus on the pathophysiological had diverted much of mainstream American medicine from clinical conditions which were not well understood in mechanistic terms and were not effectively treated by conventional therapies.[52]
By 2001 some form of CAM training was being offered by at least 75 out of 125 medical schools in the US.[82] Exceptionally, the School of Medicine of the University of Maryland, Baltimore includes a research institute for integrative medicine (a member entity of the Cochrane Collaboration).[83][84] Medical schools are responsible for conferring medical degrees, but a physician typically may not legally practice medicine until licensed by the local government authority. Licensed physicians in the US who have attended one of the established medical schools there have usually graduated Doctor of Medicine (MD).[85] All states require that applicants for MD licensure be graduates of an approved medical school and complete the United States Medical Licensing Exam (USMLE).[85]
The British Medical Association, in its publication Complementary Medicine, New Approach to Good Practice (1993), gave as a working definition of non-conventional therapies (including acupuncture, chiropractic and homeopathy): "those forms of treatment which are not widely used by the orthodox health-care professions, and the skills of which are not part of the undergraduate curriculum of orthodox medical and paramedical health-care courses".[86] By 2000 some medical schools in the UK were offering CAM familiarisation courses to undergraduate medical students while some were also offering modules specifically on CAM.[87]

Proponents and opponents

The Cochrane Collaboration Complementary Medicine Field explains its "Scope and Topics" by giving a broad and general definition for complementary medicine as including practices and ideas which are outside the domain of conventional medicine in several countries and defined by its users as preventing or treating illness, or promoting health and well being, and which complement mainstream medicine in three ways: by contributing to a common whole, by satisfying a demand not met by conventional practices, and by diversifying the conceptual framework of medicine.[88]
Proponents of an evidence-base for medicine[n 12][90][91][92][93] such as the Cochrane Collaboration (founded in 1993 and from 2011 providing input for WHO resolutions) take a position that all systematic reviews of treatments, whether "mainstream" or "alternative", ought to be held to the current standards of scientific method.[84] In a study titled Development and classification of an operational definition of complementary and alternative medicine for the Cochrane Collaboration (2011) it was proposed that indicators that a therapy is accepted include government licensing of practitioners, coverage by health insurance, statements of approval by government agencies, and recommendation as part of a practice guideline; and that if something is currently a standard, accepted therapy, then it is not likely to be widely considered as CAM.[36]
That alternative medicine has been on the rise "in countries where Western science and scientific method generally are accepted as the major foundations for healthcare, and 'evidence-based' practice is the dominant paradigm" was described as an "enigma" in the Medical Journal of Australia.[94]
Critics in the US say the expression is deceptive because it implies there is an effective alternative to science-based medicine, and that complementary is deceptive because the word implies that the treatment increases the effectiveness of (complements) science-based medicine, while alternative medicines which have been tested nearly always have no measurable positive effect compared to a placebo.[95][96][97][98]
Some opponents, focused upon health fraud, misinformation, and quackery as public health problems in the US, are highly critical of alternative medicine, notably Wallace Sampson and Paul Kurtz founders of Scientific Review of Alternative Medicine and Stephen Barrett, co-founder of The National Council Against Health Fraud and webmaster of Quackwatch.[99]
Grounds for opposing alternative medicine which have been stated in the US and elsewhere are:
that it is usually based on religion, tradition, superstition, belief in supernatural energies, pseudoscience, errors in reasoning, propaganda, or fraud.[1][95][100][101]
that alternative therapies typically lack any scientific validation, and their effectiveness is either unproved or disproved.[95][102][103][dubious – discuss]
that the treatments are those that are not part of the conventional, science-based healthcare system.[24][49][104][105]
that research on alternative medicine is frequently of low quality and methodologically flawed.[106][full citation needed]
that where alternative treatments are used in place of conventional science-based medicine, even with the very safest alternative medicines, failure to use or delay in using conventional science-based medicine has resulted in deaths.[107][108]
Paul Offit has proposed four ways in which "alternative medicine becomes quackery":[109]
"...by recommending against conventional therapies that are helpful."
"...by promoting genfx
potentially harmful therapies without adequate warning."
"...by draining patients' bank accounts,..."
"...by promoting magical thinking,..."
Alternative medicine practices and beliefs are diverse in their foundations and methodologies, and typically make use of preparations and dosages other than such as are included in the Pharmacopeia recognised by established medical schools. Methods may incorporate or base themselves on traditional medicine, folk knowledge, spiritual beliefs, ignorance or misunderstanding of scientific principles, errors in reasoning, or newly conceived approaches claiming to heal.[95][100][110] African, Caribbean, Pacific Island, Native American, and other regional cultures have traditional medical systems as diverse as their diversity of cultures.[24]
Examples and classes