by the conventional, biomedically oriented health care system. The remaining 70 to 90 percent of health care sought out by people includes everything from self-care according to folk principles to care rendered in an organized health care system based on an alternative tradition of practice (Dean, 1981; Hufford, 1992).

Such strikingly high usage of alternative health care systems also is reflected in a number of recent surveys. For example, a nationwide telephone survey of 1,539 people, conducted in 1990, indicated that up to one in three Americans used alternative therapies (Eisenberg et al., 1993). Another telephone survey conducted in 1992 in the States of Maryland and Pennsylvania reported that someone in 33 percent of 1,165 households consulted chiropractors, 25 percent, massage therapists; and 16 percent, spiritual healers (Kirby, 1992). One biomedical clinic survey of 660 cancer patients showed that 54 percent used alternative medical care along with conventional care, and 8 percent used strictly alternative care (Cassileth et al., 1984). In addition, a survey of 628 cancer patients found the utilization rate of folk treatments for cancer to be 70 percent (Hufford, 1992). Finally, an acupuncture clinic survey of 180 general-care patients showed that 70 percent sought other alternative professional or community-based health care in addition to biomedical and acupuncture care (Cassidy, 1994).

Given the immense political and economic investment this country has made in its "mainstream" medicine, these statistics are quite surprising. However, to better understand why alternative systems of medicine not only survive but thrive, it is worthwhile to first examine how people typically go about choosing their health

care.

Studies show that most people go through a "hierarchy of resort" when seeking health care assistance (Romanuicci-Ross, 1969). That is, when ill, they usually begin by trying simple home remedies, often consulting friends and family about what to do. Only if the condition persists and worsens do people typically seek help from health care specialists.

The hierarchy of health care specialists includes the popular, community-based, and professionalized (Hufford, 1988; Kleinman, 1980). All are similar in that they aim to help people stay or get well and use manipulation (from laying on of

hands to surgery), chemical substances (foods and drugs), or psychospiritual approaches (e.g., talking, suggesting, praying, drumming) as therapeutic techniques. They differ, however, in factors such as how much training they require of practitioners, how intensely they scrutinize and theorize about their own methods, how widely their practice is spread, and to whom they primarily aim their care.

Popular health care is what most people practice and receive at home, such as drinking hot honey and lemonade to relieve a sore throat. People get information about popular health care primarily from family or friends; it can be centuries old or relatively new to that family or social circle. People also learn about popular medicine from magazines, television, and other informal sources. In the United States, popular medicine often uses the words but not necessarily the underlying thinking of biomedicine.

Community-based health care refers to the nonprofessionalized yet specialized health care practices of both rural and urban people. The term community-based is used to avoid the stereotypes associated with the terms folk and tribal. Information in such systems is commonly passed on orally (through workshops, apprenticeships, and so on) and through informal and popular media sources. Some community-based practices have ancient roots (such as rootwork among AfricanAmericans, powwowing among EuropeanAmericans, curanderismo among HispanicAmericans, and religious pilgrimage and psychic healing traditions), while others have developed relatively recently, such as the various 12-step programs (e.g., Alcoholics Anonymous), popular weight loss programs, and various health and natural foods dietary practices. In contrast to popular and professionalized systems, these community-based systems characteristically focus on community health care or on the individual as part of the community. They also usually fuse concepts of medicine and religion or spirituality in such a way that all care is explained as being influenced by a "higher power."

Professionalized health care is characteristically urban and complexly organized. It is the most intellectualized and formalized type of health care. Certain of these have been called the "Great Tradition" medical care systems. Examples of such professionalized health care systems include conventional Western biomedicine, Asian

Indian Ayurveda, traditional oriental medicine, and traditional Persian medicine (Unani), all of which have evolved over time within major urban cultures. Other systems such as chiropractic medicine, osteopathic medicine, anthroposophically extended medicine, environmental medicine, and homeopathic medicine have been the result of the formalization and expansion of the teachings of a specific creative founder within the Western rational and intellectual culture. Each of these major formal systems of medical practice has the following general characteristics: (1) a theory of health and disease; (2) an educational scheme to teach its concepts; (3) a delivery system involving practitioners who usually practice in offices, clinics, or hospitals; (4) a material support system to produce its medicines and therapeutic devices; (5) a legal and economic mandate to regulate its practice; (6) a set of cultural expectations on the role of the medical system; and (7) a means to confer "professional" status on the approved providers.

Two major types of illnesses are recognized in most of these systems, though one or the other is usually emphasized: the naturalistic illness (which results from an accident, infection, intoxication, malformation, aging, environmental stress, etc.) and the personalistic illness (which is the result of malfunction in relationships between people). A third category of illness is increasingly proposed: the energetic illness, which is the result of abnormalities in the flow of subtle energies.

Studies show that people are quite astute at knowing what sorts of conditions to take to what sorts of practitioners. The practitioners at the top of the hierarchy, those that are the most "socially foreign" (i.e., hard to reach from the point of view of the patient), are consulted last and usually only when the condition is unresponsive, very serious, or chronically debilitating. For example, rural Mexicans go to the curandero or curandera for "folk" illnesses, to the nun or nurse for mild biomedical conditions, and to the biomedical physician for the most serious conditions (Young, 1981). Likewise, in urban America many people consult a registered nurse, pharmacist, or health food salesperson before taking their concerns to the medical doctor. One-third of the users of unconventional therapy are estimated to use it for "nonserious" conditions, health promotion, or disease prevention. However, in the case of more serious health problems, the medical doctor is

not the most socially foreign type of practitioner in the United States, because M.D.s and D.O.s (doctors of osteopathy) are abundant. People consulting alternative practitioners for an identified health problem are much more likely to have first consulted a medical doctor (Eisenberg et al., 1993). This point suggests that many of the alternative practitioners are rendering care to people with conditions either unresponsive to or unsatisfactorily treated by standard biomedical care.

Of the types of health care listed above, only the professionalized practitioners have received much, if any, scientific study regarding the causes of illness and the explanations and results of treatment. Indeed, community-based practices have been virtually ignored by conventional medicine on the assumption that these superstitious ways are dying out. On the other hand, popular and community-based systems have been studied primarily by social scientists, historians, and folklorists. These researchers, though not primarily concerned with clinical results or health outcomes, have provided most of the clinical material currently available. Health educators have made use of such studies in designing culturally sensitive outreach programs (see the "Diet and Nutrition" chapter).

In recent years, the professionalized biomedical health care system has initiated a number of programs in an attempt to influence popular health practices on the basis of sound epidemiological concerns, addressing such issues as smoking and health, diet and cardiovascular disease, sexual behavior and human immunodeficiency virus (HIV), and healthy childbirth practices. The comparative clinical effectiveness of indigenous community-based health care practices remains, however, a fruitful field for further research.

The remainder of this chapter comprises three major sections, the first of which describes several examples of professionalized alternative health care systems. The following section focuses on community-based practices. Except for the epidemiological issues addressed in the "Diet and Nutrition" chapter, popular practices are not discussed in this document, because the emphasis is on health care delivered by the community of alternative medicine practitioners rather than by laypeople. The last major section addresses the barriers, key issues, and overall priorities for research in alternative systems of medical practice.

a specific section evaluating knowledge of herbal medicine in the state acupuncturist licensing examination. The legal sanctioning of oriental medical practice is most extensive in New Mexico, where the acupuncturists have established an exclusive profession of oriental medicine. Their legal scope of practice is currently similar to that of primary care M.D.s and D.O.s, and their State statute restricts other licensed New Mexico health professionals' ability to advertise or bill for oriental medicine or acupuncture services (New Mexico Association of Acupuncture and Oriental Medicine, 1993).

As with any new profession in the United States, the issues of appropriate formal training, State-by-State legal scope of practice, official title and privileges of practitioners, and professional monopoly on health practices are currently controversial, even among the community of oriental medicine advocates. Furthermore, the position of oriental medicine practices and practitioners within the broader U.S. health care system continues to be a subject of heated political, economic, and intellectual debate (Birch, 1993; Flaws, 1993; National Council Against Health Fraud, 1991; New Mexico Association of Acupuncture and Oriental Medicine, 1993).

The treatment modalities most associated with traditional oriental medicine and used regularly by practitioners include acupuncture, moxibustion, acupressure, remedial massage, cupping, qigong, herbal medicine, and nutritional and dietary interventions. These are discussed below. Acupressure, massage, and qigong are also discussed in the "Manual Healing Methods" chapter.

Acupuncture. It is important to remember that acupuncture was but one branch among several therapies. It involves the direct manipulation of the network of energetic meridians, which are believed to connect not only with the surface or structural body parts but also to influence the deeper internal organs. The needle is inserted at appropriately chosen energetic points to disperse or activate the qi by a variety of technical manipulations. Western-style research showing that acupuncture could relieve pain and cause surgical analgesia through the release of pain-inhibiting chemicals (endorphins) in the nervous system led to the first theories of how acupuncture might work in terms of a biomedical science model (Han,

1987). This model does not, however, account for the many different ways acupuncture is used clinically to improve or correct ailing body functions. Because acupuncture has attracted major interest in the United States, an expanded section on acupuncture is included in this chapter.

Moxibustion. Moxibustion using Artemisia vulgaris (a plant of the composite, or daisy, family) evolved in early times in northern China. In this cold, mountainous region, the effect of heating the body on the energetically active points was a logical development. Moxibustion is thought to have preceded the use of needles. The crushed leaves, or moxa, of vulgaris may be used in loose or cigar form. In theory, the burning from the moxa releases a radiant heat that penetrates deeply and is used to affect the balance and flow of qi.

Acupressure. The energy points and channels can be treated with direct physical pressure by the fingertips or hands of the therapist. Simple points may be used for first aid or symptomatic relief or entire systems of manual therapy (e.g., shiatsu, jin shin jyutsu) may be used to effect the overall well-being of the body.

Remedial massage. The techniques of remedial massage (an-mo and tuina) are described in medical texts of the Han period. Later, in the Tang dynasty, massage was taught in special institutes. An-mo tonifies the system using pressing and rubbing hand motions, while tuina soothes and sedates using thrusting and rolling hand motions. Both systems employ a complex series of hand movements called the eight kua on specific body areas to produce the desired effects.

Cupping. Cupping is a technique of applying suction over selected points or zones in the body. A vacuum is created by warming the air in a jar of bamboo or glass and overturning it onto the body to disperse areas of local congestion. This therapy is used in the treatment of arthritis, bronchitis, and sprains, among other ailments.

Qigong. Qigong is the art and science of using breath, movement, and meditation to cleanse, strengthen, and circulate the vital life energy and

blood.2 Three basic principles are observed in the performance of the exercises: relaxation and repose; association of breathing with attention; and the interaction of movement and rest. Tai chi and other practices of oriental physical culture emphasize maintaining internal and external balance while encountering one's environment. Certain of the qigong exercises, particularly the gou lin form, have been used for immune stimulation and selfhelp in cancer patients (Sancier, 1991, 1993). These personal practices are the "internal" qigong type. Certain qigong "masters" are considered to be "energetic healers," who via "external" qigong use some of their own energy to strengthen the vitality of others who have ailments.

Herbal medicine. There is a complex series of practices regarding the preparation and administering of herbs in Chinese medicine (Unschuld, 1986). The traditional materia medica in China included approximately 3,200 herbs and 300 mineral and animal extracts (Bensky and Gamble, 1986). Herbal prescriptions cover the entire range of medical ailments, including pain, hormone disturbances, breathing disorders, infections, and chronic debilitating illnesses. Medications are classified according to their energetic qualities (e.g., heating, cooling, moisturizing, drying) and prescribed for their action on corresponding organ dysfunction, energy disorders, disturbed internal energy, blockage of the meridians, or seasonal physical demands. One unique aspect of traditional prescribing is the use of complex mixtures containing many ingredients. Such prescriptions are systemically compounded to have several effects: to principally affect the disease or disharmony, to balance out any potential side effects of the principal therapy, and to direct the therapy to a specific area or a physical process in the body. (See the "Herbal Medicine" chapter for details on specific Chinese herbs and how they are used).

Nutrition and dietetics. Dietary interventions are also individualized on the basis of the physical characteristics of both the patient's constitution and the patient's illness disturbance. Foods are characterized according to their energetic qualities (e.g., tonifying, dispersing, heating, cooling, moistening, drying). Emphasis is given to eating in harmony with seasonal shifts and life activities.

Research base. Although extensive research has been done in China through the institutions of traditional Chinese medicine, much of this clinical research has been empirical, that is, reports of observed results of various treatments. Many of these reports have been difficult to translate into Western languages and into the standard formulas or analysis typical for Western biomedical research. Because of the interest in applying acupuncture for pain and for chronic conditions, much research has focused on these two areas. However, clinical practice experience in the Asian countries suggests there is a role for complementary use of traditional therapies with a myriad of modern Western "scientific" medical interventions (Sun, 1988; Unschuld, 1992; Wong et al., 1991).

Only in the past quarter-century have biomedical scientists in China been characterizing and identifying the active agents in much of the traditional medical formulary (Hsu et al., 1982, 1985). However, extensive research. has been published detailing the pharmacology and toxicity of many traditional oriental herbs (Bensky and Gamble, 1986; Hsu et al., 1982, 1985; Ng et al., 1991). How many clinical trials of traditional oriental herbal medicine have been conducted and what extent and validity the findings have are unclear. Few references to published studies appear in the databases available in the West. Although some individual studies appear quite promising, only preliminary conclusions can be drawn about the field until more complete literature searches are conducted. (See the "Herbal Medicine" chapter for a more complete