Is There a Role for Complementary and Alternative Medicine in Preventive and Promotive Health? An...

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Jennifer Jo Thompson

Department of Crop and Soil Sciences, Department of Anthropology

University of Georgia ([email protected])

Mark Nichter

School of Anthropology, Department of Family and Community Medicine, School of Public

Health

University of Arizona

Is There a Role for Complementary and Alternative Medicine in Preventive and Promotive

Health? An Anthropological Assessment in the Context of U.S. Health Reform

Medical Anthropology Quarterly

[rh]The Role of CAM in Preventive and Promotive Health

mailto:[email protected]


[h1]Chronic conditions associated with lifestyle and modifiable behaviors are the leading

causes of morbidity and mortality in the United States. The implementation of the Affordable

Care Act offers an historic opportunity to consider novel approaches to addressing the

nation’s public health concerns. We adopt an anticipatory anthropological perspective to

consider lifestyle behavior change as common ground shared by practitioners of both

biomedicine and common forms of complementary and alternative medicine (CAM). At issue

is whether CAM practitioners might play a more proactive and publicly endorsed role in

delivering preventive and promotive health services to address these needs. Recognizing that

this is a contentious issue, we consider two constructive roles for engaged medical

anthropologists: (1) as culture brokers helping to facilitate interprofessional communities of

preventive and promotive health practice and (2) in collaboration with health service

researchers developing patient-near evaluations of preventive and promotive health services

on patient well-being and behavior change. [health reform, complementary and alternative

medicine, Affordable Care Act, health promotion]

[h1]U.S. Health Care Crisis

The United States is facing a major health care crisis demanding more proactive preventive

and promotive health efforts and better management of chronic diseases. Chronic diseases

like heart disease, cancer, stroke, and diabetes account for nearly 70% of U.S. deaths. These

and other conditions like chronic pain, arthritis, and depression and anxiety are also

responsible for widespread morbidity. Half of American adults report at least one chronic

condition, a quarter of whom experience significant limitations to daily activity (CDC 2012).

The costs of chronic disease are immense and increasing steadily. In 2010, U.S. health care

costs equaled 17.9% of the nation’s GDP (Martin et al. 2012), with chronic disease

accounting for nearly 75% of these (CDC 2009).


Lifestyle factors are commonly linked to poor health status (Fine et al. 2004; Manson

et al. 2004), and at the population level they are closely tied to social and societal

determinants ranging from poor access to healthy food, clean air, and safe neighborhoods to

the toxic effects of discrimination, limited employment opportunities, and unavailability of

affordable health care options (Braveman et al. 2011; Krieger 2014). The immediate and

lifecourse impacts of these factors render segments of the population structurally vulnerable

(Quesada et al. 2011) and contribute substantially to individuals’ abilities to make good

decisions about the so-called modifiable risk factors (e.g., diet, physical activity, tobacco use,

excessive alcohol use).

Social determinants of health and health disparities clearly need to be addressed

through political and community action aimed at improving population health by reducing

social inequality (Baum and Fisher 2014; Solar and Irwin 2010). Optimally, health care

providers from all health care systems in America’s pluralistic health care arena should

promote population health and address health practices in context (Baer et al. 2012; Cohn

2014) as well as employ times of illness as teachable moments to encourage behavioral

change at individual- and household-levels.

In this article, we adopt an anticipatory anthropological perspective (Mead 2005)

oriented toward implementation science (Heurtin-Roberts 2014). Building on growing

recognition of the importance of counseling about lifestyle-related behavior change in

primary health care (Whitlock et al. 2002), we consider how practitioners of complementary

and alternative medicine (CAM) might play a more proactive role in providing these services,

what it would take for them to attain insurance reimbursement for doing so, and how

implementation of the Affordable Care Act (ACA) might provide an opportunity to bring

diverse health care providers together to form a collaborative community of practice around

health promotion. We take as our departure points: (1) increasing rates of chronic disease in


the United States; (2) implementation of U.S. health reform, which aims to (a) reduce the

burden of chronic disease through integrated programming supporting wellness, health

promotion, and disease prevention, and (b) expand access to primary care services, thereby

increasing demand on the current system of providers; and (3) many of the largest CAM

disciplines are already oriented toward and trained in providing promotive and preventive

health services to their patients. Recognizing that this is an issue of contention in biomedical

and legislative circles, we consider the roles engaged medical anthropologists might play in

cultivating interprofessional common ground around shared public health goals.

[h1]The Affordable Care Act

The 2010 Affordable Care Act aims to increase health insurance coverage and contain the

costs of health care in the United States. Among its provisions are initiatives specifically

aimed at reducing the burden—in both dollars and lives—that chronic disease places on the

U.S. health system, communities, and individuals.

At the level of the U.S. health care system, the ACA expands efforts to track and

monitor chronic disease across populations. State- and community-level initiatives aim to

expand access and coordination of comprehensive care through programs like Accountable

Care Organizations (ACOs) and “health homes” for Medicaid recipients. The ACA’s

Prevention and Public Health Fund, “designed to expand and sustain the necessary

infrastructure to prevent disease, detect it early, and manage conditions before they become

severe” (DHHS 2010) also provides incentives for employers to implement worksite wellness

programs for employees. These programs, Anderko et al. argue, “will become part of a

national public health strategy to address the increase in chronic diseases” (2012). The act

also provides funds for public education and the promotion of individual “healthy choices” to

promote health and prevent chronic disease.


At the individual level, the ACA expands access to core preventive health services,

including screenings and routine services, intended to facilitate early detection and

intervention through newly implemented “Essential Health Benefits” that most plans are

required to meet. Efforts toward prevention and early detection of chronic disease are crucial

steps in interrupting current trends; however, the ACA does little to impact the

comprehensive management of chronic disease and co-/multi-morbidities through programs

that coordinate patient care across providers and settings or provide consistent support for

patients to succeed in implementing and maintaining lifestyle and behavior change and self-

care practices (Cartwright-Smith 2011).

Expanding wellness services aimed at curbing the prevalence of chronic disease is

likely to put a massive burden on health care providers (Bodenheimer et al. 2009; Goodell et

al. 2011). At issue is whether CAM providers constitute a potentially effective and largely

untapped resource for health promotion and preventive health care (Hawk et al. 2012a).

[h1]What Is CAM?

Americans have long integrated traditional, folk, and natural healing practices into their use

of conventional medicine as part of a pluralistic medical tradition, and in recent decades

globalization and dissatisfaction with mainstream medicine have further increased consumer

interest in holistic or alternative medicine. It is beyond the scope of this article to review or

debate various definitions of CAM (see IOM 2005). Here, we adopt the Institute of

Medicine’s definition, bearing in mind the diversity in theoretical orientations, rigor of

training, and evidence of safety and effectiveness across disciplines:

Complementary and alternative medicine (CAM) is a broad domain of resources that

encompasses health systems, modalities, and practices and their accompanying

theories and beliefs, other than those intrinsic to the dominant health system of a


particular society or culture in a given historical period. CAM includes such resources

perceived by their users as associated with positive health outcomes. (IOM 2005:19)

Our aim is to consider the potential for practitioners operating outside of the structure

of conventional medicine to provide patient-centered and evidence-based health promotion

services universally recognized as relevant and applicable across all systems of medicine.

This approach will require consensus building, training, mutual respect, and possibly

certification. Its aim is to provide the widest outreach to patient populations where—and with

whom—they seek care.

[h1]How Is CAM Used by the American Public?

CAM represents a small but important segment of the U.S. health care system. According to

the most recent data, nearly four out of 10 Americans used some form of CAM in the last 12

months (Barnes et al. 2008), with an estimated 16% reporting the use of at least one provider-

based CAM therapy (Su and Li 2011). The most commonly used practitioner-based CAM

services were chiropractic or osteopathic manipulation (used by 8.4% of U.S. adults in the

last 12 months), massage (8.1%), and acupuncture (1.4%) (Hawk et al. 2012a).

These data also indicate that U.S. adults spent nearly $34 billion out-of-pocket dollars

on CAM (broadly defined) in 2007, accounting for 1.5% of total U.S. health care

expenditures and 11.2% of total out-of-pocket health expenditures. Of these, one-third ($11.9

billion) was spent on visits to CAM practitioners. The cost of CAM services has risen far

more slowly than the cost of conventional care in recent years, suggesting that the cost of

CAM services is more self-regulating than conventional medicine (Davis et al. 2013). How

much of this is due to the out-of-pocket nature of most CAM care—and thus, tied to self-

regulation on the part of prudent patient-consumers—is unclear.

Davis et al. (2011a) estimate that 17.4% of CAM users were doing so exclusively to

treat an illness. In contrast, 27.4% were using CAM solely for health promotion, and the


remainder reported both treatment and health promotion goals. Among all groups, the vast

majority of CAM use is “complementary” rather than “alternative” to biomedical care (Astin

1998; Barnes et al. 2008). Eisenberg and colleagues (2001) found that nearly four out of five

CAM users agreed that using both CAM and conventional medicine was better than either

one alone. Moreover, the greatest users of CAM were also the highest users of medical

services in general.

At the same time, there is growing evidence that a small segment of Americans

(approximately 4%)—generally those who lack health insurance—are using CAM as an

alternative to conventional medical care (Nahin et al. 2010). CAM use is associated with

having unmet medical needs or having delayed conventional medical care due to cost (Su and

Li 2011). Those using CAM as an alternative source of care are more likely to be poorer and

in worse health than those using conventional medicine (Nahin et al. 2010). This suggests

that CAM providers also treat a patient population that lacks regular access to conventional

health promotion and prevention services.

As the ACA is implemented, it will be important to investigate who continues to turn

to CAM for primary care if conventional care is more readily accessible because of the

personal insurance mandate.1 The impacts of two possible scenarios beg consideration. In the

first case, some classes of CAM providers could be more fully integrated into state health

care systems to address the existing primary care provider shortfall. Under this scenario, it is

likely that the provider classes considered for broader inclusion would be those who already

provide insurable services and have explicit training in primary care (most notably,

chiropractic and naturopathic physicians). In the second scenario, most CAM providers

would remain excluded from insurance coverage and continue to function primarily as a fee-

for-service resource. In either case, anthropologists need to investigate who continues to see

CAM providers as an alternative to conventional care, and for what reasons. Are some groups


of patients more likely to access CAM providers because they remain marginalized or

excluded from the ACA expansion of health coverage (e.g., undocumented residents, those

falling into ACA subsidy gaps, or because they cannot afford effective health insurance

despite subsidies”)? Are patients with chronic conditions more likely to seek CAM treatment

despite expanded access to conventional care? In line with the focus of this article, should

changing insurance regulations include CAM providers offering health promotion services to

patients with health risks (e.g., obesity, tobacco and alcohol dependence, sedentary lifestyle),

and will they be used when offered—either independently or within coordinated care

systems?

[h1]What Is the Role for CAM in Health Promotion and Disease Prevention?

Although CAM users, as a class, are more likely than non-users to report their health status as

“excellent” or “better” than 12 months ago, they also report more health problems than non-

users (Nguyen et al. 2011). U.S. adults with chronic disease are more likely to use CAM than

those with none (Saydah and Eberhardt 2006), and the rate of CAM use increases with the

number of reported health conditions and the number of doctor visits in the last 12 months

(Barnes et al. 2008).

Given the public health goals of the ACA, visits to CAM practitioners may be ideal

opportunities for lifestyle and behavior change counseling (Davis et al. 2011b). Many of

those using provider-based CAM therapies have health conditions (e.g., hypertension, high

cholesterol, prediabetes, or diabetes) or lifestyle conditions (e.g., overweight or obesity,

tobacco dependence, physical inactivity) that could benefit from receiving health promotion

counseling and support (Hawk et al. 2012a). In addition, they most often see their providers

two to five times per year. Hawk et al. argue that “these repeated visits provide increased

opportunities to reinforce health promotion and disease prevention messages. This is

important since “high intensity” health behavior interventions—i.e., those with greater


numbers of contacts or time spent—have been found to increase effectiveness” (2012a:22;

USPSTF 2014). As such, it would be pragmatic to more fully engage CAM providers in the

delivery of promotive health services.

Attention to health promotion and disease prevention is already widespread across the

largest groups of CAM providers and their professional organizations (see aaihm.org,

acatoday.org, accahc.org, imprime.org, and naturopathic.org). It is part of the training

standards for acupuncture and oriental medicine, chiropractic medicine, and naturopathic

medicine (see Goldstein and Weeks 2013). And although attention to prevention and

promotion in the clinical encounter varies across and within disciplines, most CAM providers

advocate a holistic approach to patient-centered care that includes spending more time with

patients, collecting detailed patient histories and information about personal habits and life

circumstances, and advocating for lifestyle changes conducive to improving health

(Williams-Piehota et al. 2011). CAM providers are predisposed to using the clinical

encounter as a “teachable moment” (Hawk et al. 2012a), to establish a connection between

health complaints and risky behaviors, and to encourage and support healthful shifts in

behavior. We view this as common ground with movement in conventional medicine toward

patient-centered care attentive to lifestyle and behavior change.

[h1]The Example of CAM Reach

Take the example of tobacco use. Although national rates of smoking declined between 2002

and 2007, rates of smoking among those using practitioner-based CAM remained the same

(Hamm et al. 2013). This puts CAM users at increased risk for cancer, heart and respiratory

diseases, and complications related to chronic illness ranging from diabetes to back pain.

Recognizing the potential role for CAM providers in catalyzing lifestyle and behavior

change, anthropologists Mark Nichter and Cheryl Ritenbaugh have been working with

addiction specialists at the University of Arizona in a pilot project training chiropractors,


traditional Chinese medicine practitioners, and massage therapists to integrate smoking

cessation into their routine practice. In this project, CAM Reach, practitioners are trained to

use brief motivational interviewing strategies to encourage patients to reconsider their

smoking (and exposure to second-hand smoke) in relation to their current health problems,

the additional health risks and economic sequela of their smoking, ways of addressing

obstacles to quitting, and the benefits of doing so (Muramoto et al. 2013).

CAM Reach has found that practitioners are enthusiastic about both getting involved

in tobacco control as a national public health issue and receiving training around catalyzing

behavioral change. Indeed, practitioners commented that they were frustrated with their

previous attempts to encourage behavior change and thus embraced the opportunity to learn

new skills. Although several were initially concerned about whether proactively advocating

for behavior change might threaten the popularity of their practice and be a business liability,

practitioners who went through the training and implemented brief cessation advice into their

practices found that their patients did not find it intrusive, nor did it adversely affect their

practice. Whether providing cessation support enhances their practice and brings in new

clients is a topic of ongoing research. Importantly, several practitioners also adapted and

applied their communication training to advocate other kinds of behavior change, including

dietary change and increased physical activity.

Reimbursement for unsolicited promotive health services emerged as an issue in this

project. Like their biomedical colleagues, CAM practitioners were concerned about the

pragmatics of reimbursement for additional time spent promoting, and then following up on,

interventions such as smoking cessation. Most CAM providers are paid out of pocket, and

they did not feel they could pass additional charges to their patients. They queried how they

might have their services covered by insurance once a practitioner received continuing

education (CEUs) and accreditation in behavior change counseling. This issue of


reimbursement for services related to health promotion and disease prevention begs some

important questions: What counts as allowable services under the ACA, and how will this be

determined? What are the best ways to evaluate behavior change and other “whole system”

impacts of CAM (Ritenbaugh et al. 2003; Verhoef et al. 2006)?

[h1]Health Insurance Coverage for CAM

Health insurance coverage for CAM varies across states due to differences in the regulation

of CAM professions and insurance plans. Although most private and public insurance plans

offer some CAM coverage (most often chiropractic manipulation), this usually includes

limitations on services covered for specific conditions as well as the number of visits

(Pelletier and Astin 2002; Steyer et al. 2002).

Given that the vast majority of CAM use is paid out of pocket, rates of practitioner-

based CAM use would likely rise if it were more widely covered by health insurance

(Wolsko et al. 2002). This raises the issue of how higher rates of practitioner-based CAM use

would affect overall health care spending. In Washington State, where insurance coverage for

services by licensed CAM providers has been mandated since 1996, data indicate that the net

effect on health insurance spending is very small (Lafferty et al. 2006; Lind et al. 2010).

Although rigorous economic evaluations of CAM are scarce, a recent systematic review of 31

better-quality studies found that nearly 30% of the cost comparisons indicated a cost-effective

health improvement that was, in fact, cost saving for certain health conditions (Herman et al.

2012). This research suggests that although more patients are likely to use CAM if covered

by insurance, resulting in a greater number of office visits to CAM practitioners, increases in

CAM services may offset overall health care costs by reducing visits to conventional

providers for problems managed by CAM practitioners at lower costs. Interventions focusing

on lifestyle change, such as diet and physical activity, might be handled by these practitioners


at lower costs as well. If so, how would the outcomes of these services compare with those

from conventional providers?

[h1]ACA and CAM

In recent years, there has been increased consideration of how to expand patient access to

CAM (Duncan et al. 2011; Vos and Brennan 2010) and whether to further integrate CAM

into existing and emerging health systems (Davis et al. 2011b; Gilmour et al. 2011; Goldstein

and Weeks 2013; Hawk et al. 2012b). In addition to navigating ideological differences

between and among CAM and biomedical providers,2 any effort to systematically integrate

CAM providers into the U.S. health system will require bridging significant structural

barriers—specifically, the dearth of data demonstrating efficacy of CAM therapies in

biomedical terms and the inconsistent regulation and licensure of CAM professions (Tillman

2002). Research and advocacy to address these barriers is ongoing in the CAM community,

and below, we suggest ways for anthropologists to contribute.

From a structural perspective, the passage of the ACA provides an historic

opportunity to reconsider how CAM providers might be integrated into the U.S. health

insurance landscape. Specifically, Section 2706 of the law expressly forbids health insurance

providers to “discriminate … against any health care provider who is acting within the scope

of that provider’s license or certification under applicable State law” (DHHS 2010). Although

the Department of Health and Human Services (DHHS) has declined to issue regulations

regarding this section (CCIIO 2013), advocates have interpreted it to mean that, whether or

not they accept CAM providers into their network, insurers will be required to cover services

performed by any CAM provider licensed to provide those services so long as they cover the

same services performed by another provider (Senn 2013).3

How widely Section 2706 will be implemented and enforced with regard to CAM

providers is yet unclear—especially considering state variation in the regulation of CAM


providers. The most obvious example of services for which CAM practitioners might seek

reimbursement under the ACA is the Essential Health Benefits (EHB) provision, which

requires new insurance plans to provide coverage for 10 categories of services, including

preventive and wellness services and chronic disease management (Cassidy 2013).4 Trained,

and in some states licensed, to provide primary care services, chiropractic and naturopathic

physicians and professional and advocacy organizations such as the Integrative Healthcare

Policy Consortium have been on the forefront of building awareness and support for full

implementation of Section 2706. From their perspectives, the ACA’s emphasis on prevention,

wellness, and personal responsibility ideally suits the care that chiropractic and naturopathic

physicians are already providing (American Chiropractic Association 2013; Goldstein and

Weeks 2013; Standish et al. 2006; see also ihpc.org, naturopathic.org, and acatoday.org).

By 2016, DHHS is likely to revisit the criteria for EHBs (Cassidy 2013). Key to

justifying CAM insurance coverage for preventive and promotive health activities will be

data demonstrating a measurable impact on chronic disease management and behavior

change. With regard to the latter, it will be important to demonstrate that CAM practitioners

trained in behavior change techniques and basic motivational interviewing are using these

skills in their practices, and achieving results as good as—if not better than—their biomedical

and allied health colleagues.

[h1]Cultivating Common Ground

In the remainder of this article, we address ways in which cooperation, if not collaboration, in

addressing the nation’s preventive and promotive health care priorities might provide a

foundation for cultivating common ground between CAM and biomedicine around shared

goals of public health. This suggestion is likely to draw ire from a number of quarters: social

scientists critical of the focus on individual health behaviors, inasmuch as it responsibilizes

the individual while obscuring social and societal inequalities that underpin health disparities;


professional organizations of CAM providers, who view themselves as already well trained to

provide promotive health care; and “quackwatchers,” who argue that any collaboration with

CAM providers amounts to condoning pseudoscience. Nevertheless, we argue that it is

advantageous to find common ground when it comes to enhancing health communication in

the service of health promotion and chronic disease prevention. And we suggest that

anthropologists, with our long history of cross-cultural translation, are well situated to help

navigate this fraught territory and clear a space for dialogue and possible collaboration.

By supporting decentralized decision-making, the ACA provides ample opportunity to

consider possible approaches to collaboration. Because CAM regulation is left up to states,

how to integrate CAM providers into the health system is likely to be addressed through

state-by-state, CAM discipline-by-discipline, experimentation. Anthropologists interested in

implementation science will have an opportunity to observe state-level deliberations and

approaches to CAM involvement in promotive health as well as practitioner-level responses

to emerging policies around training and certification—especially if reimbursement

frameworks are established. What are the local contexts that support or derail these efforts?

What are the impacts of broader involvement in promotive health by CAM providers, and

how should these impacts be evaluated, beyond measuring shifts in overt behavior?

[h1]Developing Communities of Practice

Like their biomedical counterparts, many CAM providers are already actively involved in

caring for patients with chronic conditions. Finding ways to better encourage and support

patients to achieve behavior change is a shared interest and can serve as a site for the

development of an interprofessional community of promotive health practice. By definition, a

community of practice (CoP) consists of individuals (practitioners) who come together to

exchange information and experiences around a shared domain of knowledge and activity

(practice) (Wenger 1998). CoPs are often loose networks of individuals built around areas of


mutual concern, shared language and practices, and a sense of mutual respect. They can

provide unique opportunities for members of diverse groups—many of whom would not

ordinarily interact with one another—to develop a shared body of knowledge and shared

professional norms and identity, including shared training and certification.

Developing interprofessional CoPs around preventive and promotive health will

require efforts to bridge epistemological differences between conventional and CAM

providers. Given our long history of translating across cultural intersections, anthropologists

are well suited to act as knowledge brokers in this process (Kislov et al. 2011). By conducting

ethnographic research into how different professions approach prevention and wellness,

anthropologists have and should continue to identify commonalities (e.g., boundary objects

that include shared language and practices, as well as shared challenges and frustrations) that

can facilitate productive dialogue and enable conceptual translation across disciplines (Star

and Griesemer 1989; Swan et al. 2007). Along these lines, anthropologists can assist in

identifying issues that practitioners across disciplines agree need improvement and are

willing to engage in new ways.

For example, CAM Reach is attempting to establish a CoP around smoking cessation

that builds on the observation that both conventional and CAM practitioners recognize a need

for more concerted efforts to change patient behavior, are frustrated with their current lack of

success doing so, and are open to learning new evidence-based communication techniques

toward this end. Shared approaches—like training in the 5As (Ask, Advise, Assess, Assist,

and Arrange) and 5Rs (Relevance, Risks, Rewards, Roadblocks, and Repetition) of tobacco

cessation (Fiore et al. 2009; Whitlock et al. 2002), and in basic motivational interviewing

skills (Miller and Rollnick 2009)—provide common language and a shared knowledge base

that enables communication, referral, and the sharing of experiences to enhance the

experiential knowledge generated through clinical practice.


A number of studies have pointed to interprofessional education as a means of

facilitating collaboration among diverse professionals (Leathard 2013). Although there have

been substantial efforts to integrate biomedical knowledge into the curricula of the largest

CAM disciplines, as well as efforts to integrate basic knowledge of CAM disciplines into

medical training, to date there has been little collaborative, interprofessional education

focused on areas of shared interest (see Gaboury et al. 2009). Ethnographic research can

contribute to the development of training programs focused on health promotion and disease

prevention that crosscut therapeutic systems while maintaining respect for the principles of

each. Detailed information about the opportunities and challenges different kinds of

practitioners face when providing behavior-related counseling and support will aid in the

design of interprofessional training programs that address the concerns of a diverse, emerging

CoP while simultaneously helping to build a shared body of knowledge and shared language

around health promotion and behavior change.

Establishing interprofessional CoPs around health promotion and illness prevention

addresses national public health priorities and constitutes a positive step toward bridging

epistemological and structural divides across systems of medicine that share some common

goals. By supporting efforts to create CoPs focused on specific health concerns—like

smoking, obesity, or wellness among patients with chronic illness—medical anthropologists

have the opportunity to contribute to implementation science. They may do so at multiple

levels: participation in the development of interprofessional pilot projects at the community

level, collaboration with national- and state-level professional organizations and colleges, and

engagement with efforts to investigate the effects of these collaborations at all levels. Many

challenges will need to be addressed, not the least of which will be related to development of

shared accreditation, certification,5 or licensure for skills in behavior change, and a

framework for reimbursement for these services.


[h1]Evaluating Effectiveness

Another key area for anthropological contribution is in the development of patient-centered

measures of treatment effectiveness to complement standardized measures of behavior

change. At the center of contemporary biomedicine is evidence-based medicine (EBM), a

framework that simultaneously works to orient, govern, and legitimate biomedicine (Nichter

2013). EBM is currently under critical review by both biomedical and CAM researchers

engaging in a reflexive critique of science through science (see Lambert 2006; Mykhalovskiy

and Weir 2004). These critiques scrutinize the methods that have been held up as generating

so-called gold standard evidence beyond dispute and call for an expansion of the kinds of

evidence that can provide valuable insight into the effects of health interventions.

At the top of the hierarchy of biomedical evidence is the randomized controlled trial

(RCT). In theory, RCTs are the means by which scientific biomedicine can identify the most

efficacious and efficient way to treat, manage, or cure any given disease and rule out

treatments that are ineffective or unsafe. In many ways, this scientific rigor is what has made

scientific biomedicine highly successful in reducing the morbidity and mortality of disease

and infection around the world. Yet RCTs are not free from research bias and they produce

only a particular kind of evidence: evidence of population-level, statistical efficacy under

particular conditions (Kaptchuk 2001).6

A key criticism that biomedicine and proponents of EBM have levied against CAM

has been its general inability to hold up to RCT scrutiny. For a number of reasons related to

problems with appropriate controls, blinding, and standardization of protocol, CAM

interventions have generally not performed well in RCTs. With notable exceptions (e.g.,

Vickers et al. 2012), CAM therapies often perform “no better than placebo” in RCTs and are

thus dismissed as ineffectual, with clinical benefit being ascribed to the placebo effect (Shang

et al. 2005). However, limiting assessments of an intervention to the data regularly produced


in RCTs can overlook evidence suggesting that these same interventions may have important

therapeutic effects, including support for broad shifts in behavior (Fonnebo et al. 2007;

Verhoef et al. 2002).

We do not suggest that CAM be held to a different standard of evidence; rather, we

suggest that there is room for an expanded view of what counts as evidence—in both

biomedicine and CAM—when it comes to evaluating the effectiveness of interventions aimed

at supporting behavior change. We concur with the IOM Committee on the Use of

Complementary and Alternative Medicine by the American Public, which recommends that:

the same principles and standards of evidence of treatment effectiveness apply to all

treatments, whether currently labeled as conventional medicine or CAM.

Implementing this recommendation requires that investigators use and develop as

necessary common methods, measures, and standards for the generation and

interpretation of evidence necessary for making decisions about the use of CAM and

conventional therapies. (IOM 2005:2)

Recognizing that RCTs may not always be the most practical way to evaluate the

effectiveness of complex therapies in the real world, the IOM committee encouraged

innovation in research design—including preference trials and observation studies—aimed at

generating better evidence for use in a patient-centered treatment context. This work is

underway (see Caspi et al. 2000; Fonnebo et al. 2007; Paterson et al. 2009; Verhoef et al.

2005).

More recently, the ACA established the Patient-Centered Outcomes Research Institute

(PCORI) to fund research focused on helping patients make “better-informed health care

decisions.” Among the factors considered in this process are “individual’s preferences,

autonomy and needs, focusing on outcomes that people notice and care about” (PCORI

2013).7 As such, this may be an opportune time to broaden research on shifts in health and


wellness beyond specific disease-oriented outcome measures. One line of research receiving

increased attention in both biomedical and CAM circles pays credence to patient-reported

outcomes (PROs): subjective reports of the overall impact of interventions in terms of quality

of life, state of wellness, and the ability to engage in and sustain behavior change (Basch

2014; Coon and McLeod 2013). PROs are not a study design, but rather measures within a

design, whether interventional (e.g., RCTs) or observational (e.g., cohort studies). Measures

along these lines may be better suited to evaluate the effectiveness of interventions aimed at

catalyzing and sustaining behavior change than standard disease-specific outcome measures.

Further, they could readily be adapted for use by providers of all types to map changes in

patterns of risky and healthful behaviors and to identify patients at increased risk for

comorbidities including mental health concerns that frequently accompany chronic disease.

Medical anthropologists have a long history of studying subjective accounts of both

illness and treatment experience and can play a key role in developing measures of

effectiveness that are attentive to patient-reported and whole-systems outcomes. For example,

a Self-Assessment of Change Questionnaire was developed by Ritenbaugh and colleagues

after analyzing patients’ narratives of first-hand experiences with CAM therapies to identify

items grounded in lay language that identified multidimensional shifts in well-being not

captured by existing instruments (Ritenbaugh et al. 2011). This instrument has been

extensively evaluated to confirm that it is representative of patients’ lived-experiences with

CAM (Thompson et al. 2011). This is just one example of the type of research

anthropologists may be involved in that can contribute to better evaluation of the

effectiveness of interventions from an experience-near perspective.

What remains to be investigated is whether perceived shifts in cognition, embodied

states, identity, and so on translate into a sustained sense of well-being and behavior

change—and, for health service researchers, lower overall health costs. Anthropologists are


ideally suited to examine both the meaning of evidence and the effectiveness of behavioral

interventions from perspectives that are both experience-near and grounded in structural

critique. This dual approach allows us to better understand how the lived experience of social

and societal determinants of health moderates the impacts of individual-focused behavior

change interventions and their short-term and sustained effectiveness (Messac et al. 2013).

[h1]Conclusion

Chronic conditions associated with smoking and obesity, chronic pain, anxiety, and

depression are the leading causes of morbidity and mortality in the United States. These are

shared areas of concern for biomedical and CAM providers. Efforts to encourage individual

behavioral change are clearly limited by social and societal determinants of health that must

be redressed through political and community action. We do not argue that including CAM

providers in efforts to encourage and support behavior change will solve population health

problems, but we do see it as one piece in the puzzle—a piece with the potential to reinforce

messages that many patients are already receiving from conventional providers. We also see

CAM practitioners reaching patient populations not accessing conventional providers, either

because of ideology or systemic factors like cost or citizenship status.

The implementation of the ACA offers an historic opportunity to consider novel

approaches to address the nation’s critical public health needs. We have considered the

potential to engage the largest classes of CAM providers more fully in preventive and

promotive health efforts. This is pragmatic: CAM practitioners already promote holistic

wellness, have longer appointments, and engage patients in discussions about the relationship

between lifestyle and health. Studies like CAM Reach demonstrate that CAM providers are

enthusiastic about developing and implementing new skills aimed at advocating behavior

change, and projects like The Academic Consortium for Complementary and Alternative


Health Care’s “Primary Care Project” indicate that colleges training CAM practitioners want

to be involved in disseminating these skills (Goldstein and Weeks 2013).

Medical anthropologists can help identify and cultivate common ground shared by

conventional and CAM providers (and their professional organizations), assist in the

implementation and monitoring of interprofessional programs, and participate in the

development of culturally sensitive and patient-near evaluations of behavior change

effectiveness. Health providers of all stripes are frustrated in their efforts to communicate

urgency around chronic disease prevention and to catalyze behavior change. This is an ideal

place to begin productive dialogue and an exchange of experience between diverse types of

practitioners who are ultimately committed to the same patient and population health goals.

The development of interprofessional training, certification, and the formation of

communities of practice around health promotion and illness prevention appear to us to be

bold endeavors worth attempting as a means of addressing the nation’s public health

priorities.

[h1]Notes

Acknowledgments. We are grateful to Amy Dao, Jessica Mulligan, and Cheryl Ritenbaugh,

as well as two anonymous reviewers, for careful critiques and feedback on earlier versions of

this article. Preliminary work on this essay was supported by NIH/NCCAM Arizona

Complementary and Alternative Medicine Research Training Program, T32 AT01287 (Iris

Bell, PI), in which JJT was a predoctoral fellow and MN faculty. MN is a co-investigator on

NIH/NCI Tobacco Cessation Training for Acupuncture, Massage, and Chiropractic

Practitioners (CAM Reach), R01

CA137375-01A1 (Myra Muramoto, PI).


1. It is unclear the degree to which the ACA will make conventional health care

available to those currently excluded or marginalized from the system. The Congressional

Budget Office estimates that the law would expand coverage—and thus access to basic

care—to 14 million non-elderly Americans by 2014 and another 13 to 16 million in the

following decade (CBO 2012). Following the close of the turbulent 2014 open-enrollment

period, the White House reports that enrollment has topped 8 million through the health care

exchanges, with another 3 million enrolling in Medicaid and the Children’s Health Insurance

Program through February 2014 (OPS 2014).

2. In-depth consideration of the ideological barriers to integration is beyond the scope

of this article. See Kaptchuk and Miller (2005), Hollenberg and Muzzin (2010), and

aihm.org, imprime.org, and imconsortium.org.

3. This is the site of contentious debate between administrators, lawmakers, and

health care providers. See DHHS advice on the implementation of Section 2706(a) (CCIIO

2013), Senator Tom Harkin’s response (U.S. Senate 2013), and the debate between bloggers

at theintegratorblog.com and sciencebasedmedicine.org.

4. In contrast to recommendations from the IOM Committee on Defining and

Revising an Essential Health Benefits Package for Qualified Health Plans (2012), DHHS has

directed each state to define its own EHB package based on a state “benchmark plan.” Thus,

how comprehensive the EHBs for prevention and management of chronic disease are is likely

to vary from state to state.

5. Although regulation is in the hands of the governing body of each therapeutic

system, certification in behavior change techniques such as smoking cessation or

motivational interviewing toward behavior change could be established with the same

standards of training offered as CEUs across disciplines. CAM Reach is currently looking


into this possibility for tobacco cessation training. See aihm.org for efforts emerging within

the CAM and integrative medicine communities.

6. Although EBM is undergirded by positivist notions of objectivity and universal

truth, the application of RCT data in clinical practice is far more nuanced, and RCT findings

are subject to interpretation by clinicians who use population-based data to inform individual

patient care (Nichter 2013). In the context of patient-centered care, patients and clinicians

draw on RCT evidence as one resource—along with information about what services are

covered by insurers, and patient preferences, values, and goals—to inform and guide shared

clinical decision-making (Thompson 2010).

7. While PCORI’s primary goal is an empirical, comparative assessment of the

clinical effectiveness of medical intervention, attention to patients’ values and preferences as

relevant factors in the evaluation of health interventions is notable and makes strides toward

IOM’s call for attending to patient preferences in clinical research.

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