research departments. Naturopathic researchers have investigated the pharmacology and physiological effects of nutritional and natural therapeutic agents, and naturopathic physicians have been active in the investigation of new homeopathic remedies and in the natural treatment of women's health problems. The most recently completed naturopathic study in women's health tested the clinical and endocrine effects of a botanical formula as an alternative to estrogen replacement therapy. Results of this study showed a clinically significant benefit (measured as reduction in the total number of menopausal symptoms) among the treated women versus the placebo group.

Environmental medicine, like anthroposophically extended medicine, also can be viewed as an extension of modern biomedicine. Environmental medicine traces its roots to the practice of allergy treatment and the work of Dr. Theron Randolph in the 1940s, who identified a variety of common foods and chemicals that were able to trigger the onset of acute and chronic illness even when exposure was at relatively low levels.

Environmental medicine recognizes that illness in individuals can be caused by a broad range of incitant substances, including foods, chemicals found at home and in the workplace, and chemicals in the air, water, and food. Today there are 3,000 physicians worldwide practicing environmental medicine, and there are several environmental control units in the United States and one in Canada, where patients' sensitivities are unmasked through fasting and complete avoidance of potentially incitant chemicals.

Research in this field has been directed at clinical treatment of patients and at evaluation of the diagnostic and treatment techniques used by practitioners. Other studies have supported the use of the approaches of environmental medicine in treating arthritis, asthma, chemical sensitivity, colitis, depression, eczema, fatigue, and hyperactivity.

The belief that humans can get sick from cumulative low-level environmental exposure to certain incitants is not well accepted by the conventional medical community. However, because "sick building syndrome" and other chronic conditions that cannot be explained by other phenomena are being seen with greater frequency, environmental medicine offers a theoretical groundwork for dealing with such phe

nomena. Indeed, environmental medicine is in a position to be a leading force in the investigation of ways to reduce the incidence of these and other disorders.

Community-based health care practices. Community-based health care practices are varied and found throughout the United States. Like other health care specialists, community-based healers may emphasize naturalistic, personalistic, or energetic explanatory models or a combination. Traditional midwives and herbalists and nowadays, pragmatic weight loss specialists are probably the best known of community-based practitioners who follow the naturalistic model. In addition, the Native American medicine man or medicine woman is a community-based traditional healer with primarily naturalistic skills, that is, the skills of an herbalist in particular. Some medicine people are also shamans, in which case they are often distinguished as holy men and women.

In contrast to professionalized practitioners, community-based healers often do not have set locations such as offices or clinics for delivering care but do so in homes, at ceremonial sites, or even right where they stand. Community-based healing of the personalistic variety can also be "distant," that is, it does not require that practitioner and patient be in each other's presence. Prayers or shamanic journeys, for example, can be requested and “administered" at any time, and charm cures are sometimes delivered by telephone.

Meanwhile, community-based systems also thrive in urban areas. These systems include the popular weight loss programs and other 12-step programs. Often the practitioners rent office space and emphasize contact between client and practitioner, and they may charge considerable fees. Since these practitioners depend on their healing practice for their livelihood, they advertise and so may be easier to identify and contact for study purposes.

Native American Indian community-based medical systems all share the following rituals and practices: sweating and purging, usually done in a "sweat lodge"; the use of herbal remedies gathered from the surrounding environment and sometimes traded over long distances; and shamanic healing involving naturalistic or personalistic healing. Tribes such as the Lakota and Dineh (Navajo) also use practices such as the

medicine wheel, sacred hoop, and the "sing," which is a healing ceremonial that lasts from 2 to 9 days and nights and is guided by a highly skilled specialist called a "singer."

Formal research into the healing ceremonies and herbal medicines conducted and used by bona fide Native American Indian healers or holy people is almost nonexistent, even though Native American Indians believe they positively cure both the mind and body. Ailments and diseases such as heart disease, diabetes, thyroid conditions, cancer, skin rashes, and asthma reportedly have been cured by Native American Indian doctors who are knowledgeable about the complex ceremonies.

Latin American community-based practices include curanderismo, which is a folk system of medicine that includes two distinct components: a humoral model for classifying activity, food, drugs, and illness; and a series of folk illnesses.

In the humoral component of curanderismo things could be classified as having qualitative (not literal) characteristics of hot or cold, dry or moist. According to this theory, good health is maintained by maintaining a balance of hot and cold. Thus, a good meal will contain both hot and cold foods, and a person with a hot disease must be given cold remedies and vice versa. Again, a person who is exposed to cold when excessively hot may "take cold" and become ill.

The second component, the folk illnesses, is actively in use in much of Mexico and among less educated Hispanic U.S. citizens. Studies have found that as many as 96 percent of MexicanAmerican households (more frequent in the less Americanized communities) treated members for Hispanic folk illnesses. Similarly high use patterns among Mexican migrant workers has been found in Florida and Mexico.

Although no formal effectiveness studies seem to have been done on this system, its wide popularity and the research suggesting the relevance of the folk diagnoses for biomedical practice indicate the need for further demographic and effectiveness studies.

Alcoholics Anonymous (AA) is an example of an urban community-based healing system for helping people whose lives are damaged by the consumption of alcohol to stop drinking. Founded in 1935 by Bob Smith, M.D., and Bill Wilson, two

alcoholics, it is a patient-centered self-help fellowship of men and women. AA has burgeoned and today is widely considered the most successful existing method for supporting sobriety.

In contrast to most community-based systems, a very large literature exists analyzing AA. Several models attempt to explain its success. One popular psychometric model interprets AA as a "cult" and the achievement of sobriety as a "conversion experience." Another model, however, asserts that members recover by integrating their own experiences with alcohol with those of others in the group and by learning and practicing some new ways to behave. Through these new ways, AA members feel as if they are living apart from the urban materialist norm; that the cause of alcoholism is not at issue; that people should share, not compete; and that the individual need not rise above the rest (spiritual anonymity).

Studies have concluded that active AA membership allows up to 68 percent of alcoholics to drink less or not at all for up to a year, and 40 percent to 50 percent to achieve sobriety for many years. More active or dedicated members (those who attend meetings more often) remain sober longer.

Manual Healing Methods

Touch and manipulation with the hands have been in use in health and medical practice since the beginning of medical care. Physicians' hands were once their most important diagnostic and therapeutic tool. Today, however, many medical and health practitioners tend to retreat from physical contact with the patient, distanced by diagnostic equipment and legal and time constraints.

The manual healing methods are based on the understanding that dysfunction of a part of the body often affects secondarily the function of other discrete, not necessarily directly connected, body parts. Consequently, theories and processes have been developed for correcting secondary dysfunctions by manipulating soft tissues or realigning body parts. Overcoming misalignments and manipulating soft tissues bring the parts back to optimal function, and the body returns to health.

One of the earliest U.S. health care systems to use manual healing methods was osteopathic medicine. In 1993 more than 32,000 Americaneducated and -licensed D.O.s were practicing in

the United States. More than 60 percent of osteopathic physicians are involved in primary carefamily medicine, pediatrics, internal medicine, and obstetrics-gynecology. An extensive body of work supports the use of osteopathic techniques for musculoskeletal and nonmusculoskeletal problems. Nearly all osteopathically oriented research has been funded from the private sector.

Chiropractic science is concerned with investigating the relationship between structure (primarily of the spine) and function (primarily of the nervous system) of the human body to restore and preserve health. Chiropractic medicine applies such knowledge to diagnosing and treating structural dysfunctions that can affect the nervous system. Chiropractic physicians use manual procedures and interventions, not surgical or chemotherapeutic ones. In 1993 more than 45,000 licensed chiropractors were practicing in the United States.

Chiropractic specialty areas are extremely pertinent to other medical specialties, such as radiology, orthopedics, neurology, and sports medicine. Current chiropractic research interests include back and other pain, somatovisceral disorders, and reliability studies.

Massage therapy, one of the oldest methods in health care practice, is the scientific manipulation of the soft body tissues to return those tissues to their normal state. Massage consists of a group of manual techniques that include applying fixed or movable pressure and holding and causing the body to move. Primarily the hands are used, but sometimes forearms, elbows, and feet are used also. These techniques can affect the musculoskeletal, circulatory-lymphatic, and nervous systems. Massage therapy encompasses the concept of vis medicatrix naturae-helping the body heal itself-and is aimed at achieving or increasing health and well-being. Touch is the fundamental medium of massage therapy.

Massage therapists are licensed by 19 States and several localities. Most States require 500 or more hours of education from a recognized school program and a licensing examination. Massage therapy techniques include Swedish massage, deep-tissue massage, sports massage, neuromuscular massage, and manual lymph drainage. Other physical healing methods include reflexology, zone therapy, tuina, acupres

sure, Rolfing, Trager, Feldenkrais method, and Alexander technique.

Biofield therapeutics-laying on of hands-is also a very old form of healing. The earliest Eastern references are in the Huang Ti Nei Ching Su Wên (The Yellow Emperor's Classic of Internal Medicine), dated between 2,500 and 5,000 years ago. The underlying rationales cluster around two views: first, that the healing force comes from a source other than the practitioner-God, the cosmos, or another supernatural entity-and second, that a human biofield directed, modified, or amplified in some way by the practitioner is the operative mechanism.

During biofield treatment, the practitioner places hands directly on or near the patient's body to improve general health or treat a specific dysfunction. Treatment sessions may take from 20 minutes to an hour or more; a series of sessions is often needed to treat some disorders. There is consensus among practitioners that the biofield permeates the physical body and extends outward for several inches. Extension of the external biofield depends on the person's emotional state and health. Biofield practitioners have a holistic focus. About 50,000 practitioners provide 18 million sessions annually in the United States.

At least three forms of biofield therapeutics are used in medical care inpatient and outpatient settings: healing touch, therapeutic touch, and SHEN therapy. No generally accepted theory accounts for the effect of these therapies.

Pharmacological and Biological Treatments

Pharmacological and biological treatments are an assortment of drugs and vaccines not yet accepted by mainstream medicine. A sampling of biological and pharmacological treatments currently being offered by alternative medical practitioners includes the following:

• Antineoplastons-peptide fractions originally derived from normal human blood and urine, presently being used to treat certain kinds of tumors as well as AIDS.

Cartilage products derived from cattle, sheep, sharks, and chickens, which are being used to treat cancer and arthritis.

Ethylene diamine tetraacetic acid (EDTA) chelation therapy, used to treat heart disease,

circulatory problems, and rheumatoid arthritis and to prevent cancer.

Immunoaugmentive therapy, an experimental form of cancer immunotherapy consisting of daily injections of processed blood prod

ucts.

• 714-X, a nitrogen-providing compound injected into the lymph system near the abdomen to treat cancer and AIDS.

Coley's toxins, a mixture of killed cultures of bacteria from Streptococcus pyogenes and Serratia marcescens, used for treating cancer.

• MTH-68, a vaccine that uses an attenuated strain of the Newcastle disease virus of chickens (paramyxovirus), which may interfere with cancer-related viruses.

Neural therapy, which involves injecting local anesthetics into nerve cell bodies, peripheral nerves, scars, and elsewhere to treat chronic pain.

• Apitherapy, the medicinal use of various products of the common honeybee to treat a variety of diseases: rheumatic diseases such as arthritis; neurological diseases such as multiple sclerosis, low back pain, and migraine; dermatological conditions (e.g., eczema, psoriasis, herpesvirus infections); chronic pain; and cancer.

• Iscador, a liquid extract from mistletoe plants used to treat tumors.

well into the 20th century much of the pharmacopoeia of scientific medicine was derived from the herbal lore of native peoples. Many drugs commonly used today are of herbal origin. Indeed, about one-quarter of the prescription drugs dispensed by community pharmacies in the United States contain at least one active ingredient derived from plant material.

The World Health Organization (WHO) estimates that 4 billion people, 80 percent of the world population, presently use herbal medicine for some aspect of primary health care. Herbal medicine is a major component in all indigenous peoples' traditional medicine and a common element in Ayurvedic, homeopathic, naturopathic, traditional oriental, and Native American Indian medicine.

Although during the centuries the discovery of useful therapeutics from plants has changed the face of medicine and the course of civilization, many people, especially some in the Federal Government, evaluate herbal remedies as though they were either worthless or dangerous. Today in the United States, herbal products can be marketed only as food supplements. An herb manufacturer or distributor can make no specific health claims without FDA approval. Despite FDA skepticism, a growing number of Americans are interested in herbal preparations.

Two features of European drug regulation make that market more hospitable to natural remedies. First, it costs less and takes less time in Europe to approve medicines as safe and effective. This is especially true of substances that have a long use history and can be approved under the "doctrine of reasonable certainty." European guidelines for the assessment of herbal remedies follow up on WHO's Guidelines for the Assessment of Herbal Medicines, which state that a substance's historical use is a valid way to document safety and efficacy in the absence of scientific evidence to the contrary.

France, where traditional medicines can be sold with labeling based on traditional use, requires licensing by the French Licensing Committee and approval by the French Pharmacopoeia Committee. Germany considers whole herbal products one active ingredient; this makes it simpler to define and approve the product. The German Federal Health Office regulates products such as ginkgo and milk thistle extracts so

that potency and manufacturing processes are standardized. England generally follows the rule of prior use; that is, years of use with apparent positive effects and no evidence of detrimental side effects constitute enough evidence—in lieu of other scientific data-that the product is safe.

In Japan, China, and India, patent herbal remedies composed of dried and powdered whole herbs or herb extracts, often in tablet form, are the rule. Traditional herbals are the backbone of China's medicine. Japan's traditional medicine, kampo, is similar to and historically derived from Chinese medicine but includes traditional medicines from Japanese folklore. Herbal medicines are the staple of medical treatment in many developing countries and are used for many types of ailments.

European phytomedicines are among the world's best studied medicines, researched in leading European universities and hospitals. Some have been in clinical use under medical supervision for more than 10 years, with tens of millions of documented cases. This form of botanical medicine most closely resembles American medicine. In Europe there have been credible research studies reporting positive effects on a variety of chronic illnesses for herbs such as Silybum marianum (milk thistle), Ginkgo biloba (ginkgo), Vaccinium myrtillus (bilberry extract), and Ilex guayusa. Many herbs in China have been studied extensively by methods that are acceptable from the Western perspective; among these herbs are ginseng, fresh ginger rhizome, Chinese foxglove root, baical skullcap root, wild chrysanthemum flower, and licorice root. A number of Ayurvedic herbs also have recently been studied in India under modern scientific conditions, including Eclipta alba, Indian gooseberry, neem, turmeric, and trikatu.

Reports of positive effects of herbal preparations in developing countries and Native American Indian herbs are primarily anecdotal. However, since much modern-day medicine is directly or indirectly derived from such folklore sources, it seems illogical to conclude that there are no more significant treatments or cures for major diseases to be found in the world from plant sources.

Diet and Nutrition in the Prevention and
Treatment of Chronic Disease

Throughout evolution, human beings adapted to a wide range of naturally occurring foods, but the types of food and the mix of nutrients (in terms of carbohydrates, fats, and proteins) remained relatively constant. Food supplies were often precarious, and the threat of death from starvation was a constant preoccupation for most early humans.

However, about 10,000 years ago the agricultural revolution began making profound dietary changes in many human populations. The ability to produce and store large quantities of dried foods led to preferential cultivation of some foods, such as grains, which constituted new challenges to the human digestive system. Then about 200 years ago, the Industrial Revolution introduced advances in food production, processing, storage, and distribution. Recent technological innovations, along with increased material well-being and lifestyles that have allowed people more freedom in deciding what and when they wish to eat, have led to even further major dietary changes in developed countries. Because changes in the dietary patterns of the more technologically developed countries, such as the United States, have been so dramatic and rapid, the people consuming these affluent diets have had little time to adapt biologically to the types and quantities of food that are available to them today. The longer term adverse health effects of the diet prevailing in these countries-characterized by an excess of energy-dense foods rich in animal fat, partially hydrogenated vegetable oils, and refined carbohydrates but lacking in whole grains, fruits, and vegetables have become apparent only in recent decades.

Because of the recent, rapid rise in chronic illness related directly or indirectly to diet, the focus of nutrition research has shifted away from eliminating nutritional deficiency to dealing with chronic diseases caused by nutritional excess. Another concern among nutrition researchers is the accumulation of evidence indicating that less-than-adequate intake of some micronutrients over a long period may increase the risks of developing coronary heart disease, cancers, cataracts, and birth defects. In recent decades the data on the relationship between certain dietary habits and nutritional intake have been growing exponentially. Designing inter