Lack of Policy Regarding Complementary, Alternative and Integrative Medicine. Comments on the article: Complementary and alternative health care in Israel
Yael Keshet, Western Galilee Academic College
24 April 2012
The article offers a comprehensive review of the state of complementary and alternative medicine (CAM) and integrative medicine in Israel. It constitutes an important landmark in the documentation of the lack of policy regarding CAM in Israel. This review has the potential to contribute both to research in the Israeli and international contexts and to the formulation of health policy in Israel. It may serve as systematic background material that clarifies the way in which CAM and integrative medicine is organized in Israel. This information is a prerequisite for collaboration with researchers of CAM in other countries. The article emphasizes the need for the formulation of policy regarding CAM in Israel. Despite the widespread use of CAM over past decades and its penetration into healthcare organizations in Israel, attempts to shape policy on CAM have so far proved unsuccessful. And as Shuval and Averbuch [1] note: "The public as a whole and patients in particular are entitled to a safe system of CAM care."
Shuval and Averbuch present data pertaining to the increased use of CAM in Israel in recent years. Additional data is provided in the results of the national health survey conducted in 2009 [2], which found that people made 2,632,200 visits to CAM practitioners during the year. Women paid twice as many visits as men. Less than one percent of the visits were reported by Arabs, whereas they comprise 20.5% of the population [3]. In a study that we conducted in northern Israel [4] [5], interviewing 3713 patients, we found that Arabs and Jews reported a similar rate of use of overall non-conventional medicine during the previous year (Arabs 42.3%, Jews 45.6%). Arabs, however, appear to make greater use of indigenous herbal and folk-traditional medicine and consult herbalists and folk-traditional healers more frequently than do Israeli-born Jews. The latter largely favor imported CAM modalities that are more frequently used in Western nations, such as homeopathy, chiropractics, energy healing and mind¿body practices. As Shuval and Averbuch note, "Folk and traditional forms of health care, which may also be viewed as a form of CAM, have not been incorporated into the medical care system" They consequently did not address these modalities in the article. Yet since we are dealing with health policy and take a critical point of view, broadening the perspective may have some merits.
Taking a critical point of view, Shuval and Averbuch note that bio-medicine "exercises a dominant, often exclusive, monopoly over legitimate medical care in many societies." Power relations come to the fore in institutionalized Israeli integrative medicine, not only owing to the dominance of bio-medicine over CAM, but also because of the exclusion of local traditional medicine. CAM modalities, which accord with the Jewish majority's preferences more than with those of the Arab minority, are integrated within the biomedicine-dominated Israeli healthcare system. Although traditional medicine is not currently integrated [6], initial attempts are being made in this direction ¿ to integrate local traditional herbal medicine. These initial attempts alongside the extensive use of folk traditional medicine, raise the need for research related to healthcare policy and awareness of potential risks to patients, such as that related to herb-drug interactions.
The article, which systematically maps CAM health care in Israel, and argues the case for formulating policy concerning CAM, raises questions for future research. Further and deeper research is needed in order to reveal why Israeli health authorities have not succeeded in establishing formal jurisdictional regulation or control of CAM. Why is the state shirking its responsibility to protect the public by ensuring that CAM is practiced in accordance with professional and ethical standards? Which types of regulation and control can be introduced, and why have none of these alternatives been implemented? How can CAM be subjected to formal jurisdictional regulation or control in such a way that CAM will not "look like and feel like bio-medicine?" How can the Ministry of Health introduce regulatory legislation to control CAM practice, education, and licensing, while at the same time maintaining the unique spirit of CAM?
Yael Keshet, PhD
Senior lecturer, Head of Health and Wellness Sub-Department, Sociology and Anthropology Department, Western Galilee Academic College
[1] Shuval, T. J. and Averbuch E. Complementary and alternative health care in Israel. Israel Journal of Health Policy Research 2012 1:7.
[2] Central Bureau of Statistics, 2009 http://ow.ly/atCQG
[3] Central Bureau of Statistics, 2011 http://www.cbs.gov.il/shnaton62/st02_01.pdf
[4] Ben-Arye, E., Karkabi, K., Karkabi, S., Keshet, Y., Haddad, M., Frenkel, M. Attitudes of Arab and Jewish patients towards integration of complementary medicine in primary care clinics in Israel: A Cross-cultural study. Social Science and Medicine 2009; 68 (1): 177-182.
[5] Keshet, Yael and Ben-Arye, Eran. Patients' Views: Cultural and Healthcare pluralism in Northern Israel. In: Shuval, T. Judith and Averbuch, Emma (eds.), Alternative and bio-medicine in Israel: Boundaries and bridges. Boston: Academic Studies Press. 2012; Pp.199-218.
[6] Keshet, Y. Ben Arye, E. Which complementary and alternative medicine modalities are integrated within Israeli healthcare organizations and do they match the public's preferences? Harefuah 2011; 150 (8): 635-638 (Hebrew).
Competing interests
None declared
Is complementary and alternative health care a challenge to biomedicine?
Jochanan Benbassat, JDC Brookdale Institute
16 May 2012
The paper by Shuval and Averbuch (1) is an excellent comprehensive review of complementary and alternative medicine (CAM) in Israel, and I agree with them that the Israeli experience can be useful to health policy planners in other countries. However, while I found all of the authors' findings highly illuminating, I feel uncomfortable with some of their statements.
First, on six occasions throughout their paper, Shuval and Averbuch either state or imply that the Israel Medical Association / medical establishment / bio-medical care system / bio-medical institutions feel challenged by CAM and anxious to protect their exclusive hegemony on patient care. The authors correctly note that over 1.7 million visits to CAM practitioners are estimated to take place annually in Israel. However, the readers might benefit from the added information that the utilization of bio-medical services is thirty times as high: in 2003, the number of visits to bio-medical family doctors, general practitioners or specialists exceeded 53 million, and in 2010, there were 1.4 million hospital discharges (2). As stated by the authors, in most cases patients do not abandon conventional bio-medicine but turn to CAM as an additional mode of care. Therefore, there is no reason why the bio-medical care system should feel challenged by CAM.
Second, the authors imply that the absence of teaching of CAM in medical schools, and of governmental control on CAM is due to attempts to perpetuate the dominance of bio-medicine in Israel. I suggest that this absence is mostly due to difficulties in coping with the large number of treatment modalities that are included in CAM, the broad array of their theoretical bases and the heterogeneity of practices even within the same CAM mode. It would be difficult to justify answers to questions about the duration of a CAM teaching course within the restricted curricular time schedule, whether it should include a sample (which?) or all CAM disciplines, the level of familiarity with CAM that would be expected from medical students, and about the professional background of the teachers. Similarly, considering the multiplicity of CAM approaches and absence of evidence for their efficacy, it would be difficult to design and implement an effective governmental control on CAM practitioners. Finally, the authors' conclusion that it is possible that public confidence in bio-medicine may further (my emphasis) decline thus augmenting the likelihood of increased use of CAM in future years, is at odds with the results of public opinion surveys in Israel that attest to stable satisfaction rates from the bio-medical health care services that exceed 88% (3).
It would be fair to disclose that I am a retired biomedical physician. For the last three decades I have been strongly biased in favor of an approach to medical education and practice that is based on the assessment of clinical interventions by the level of evidence for their efficacy. Therefore, my personal attitude to CAM is ambivalent.
On the one hand, I agree with the authors that the use of CAM is an important social process. I also agree that this process, and specifically, the attitudes of biomedical practitioners to CAM, should be subject of scientific scrutiny. On the other hand, I cannot envisage an instant solution to the problem, which Shuval and Averbuch have correctly identified, namely, how to design an effective governmental control on the quality of CAM care, and which governmental agency should implement this control.
On the one hand, the ethical principle of respect of patient's autonomy supports an individual's right to select a health care provider of his/her choice. On the other hand, the ethical principle of fair distribution of health resources implies that the health care system cannot provide free-of-charge CAM services of mostly unproven or untested efficacy, and still exclude from the package of benefits medications and technology of proven efficacy because of their cost.
On the one hand, obviously, CAM responds to the needs of some patients, and I believe that bio-medical practitioners should strive to emulate the mutual trust that characterizes the relationship between patients and CAM practitioners. On the other hand, while both bio-medicine and CAM abound with anecdotal reports of individual successes, only bio-medicine can claim to breakthrough treatment modalities, such as vitamins, vaccinations, antibiotics, antiviral medication, insulin and chemotherapy for childhood cancer, that have affected the well-being and even life expectancy of entire patient populations. Therefore, I believe that the bio-medical care system will continue to shoulder the responsibility for patient care, and I doubt that CAM will ever be considered an alternative to biomedicine.
Jochanan Benbassat MD
Smokler Center for Health Policy Research
Myers-Brookdale-JDC institute
Jerusalem
REFERENCES
1. Shuval J, Averbuch E. Complementary and alternative health care in Israel. Israel Journal of Health Policy Research 2012, 1:7.
2. Israel Central Bureau of Statistics 2011.
http://tinyurl.com/cxb2hmm
Accessed on May 12, 2012.
3. S. Brammli-Greenberg, R. Gross, Y. Yair, E. Akiva. Public Opinion on the Level of Service and Performance of the Healthcare System in 2009 and in Comparison with Previous Years. Research report 587-11 of the Myers-JDC-Brookdale Institute, 2011.
Israel Journal of Health Policy Research
Lack of Policy Regarding Complementary, Alternative and Integrative Medicine. Comments on the article: Complementary and alternative health care in Israel
24 April 2012
The article offers a comprehensive review of the state of complementary and alternative medicine (CAM) and integrative medicine in Israel. It constitutes an important landmark in the documentation of the lack of policy regarding CAM in Israel. This review has the potential to contribute both to research in the Israeli and international contexts and to the formulation of health policy in Israel. It may serve as systematic background material that clarifies the way in which CAM and integrative medicine is organized in Israel. This information is a prerequisite for collaboration with researchers of CAM in other countries. The article emphasizes the need for the formulation of policy regarding CAM in Israel. Despite the widespread use of CAM over past decades and its penetration into healthcare organizations in Israel, attempts to shape policy on CAM have so far proved unsuccessful. And as Shuval and Averbuch [1] note: "The public as a whole and patients in particular are entitled to a safe system of CAM care."
Shuval and Averbuch present data pertaining to the increased use of CAM in Israel in recent years. Additional data is provided in the results of the national health survey conducted in 2009 [2], which found that people made 2,632,200 visits to CAM practitioners during the year. Women paid twice as many visits as men. Less than one percent of the visits were reported by Arabs, whereas they comprise 20.5% of the population [3]. In a study that we conducted in northern Israel [4] [5], interviewing 3713 patients, we found that Arabs and Jews reported a similar rate of use of overall non-conventional medicine during the previous year (Arabs 42.3%, Jews 45.6%). Arabs, however, appear to make greater use of indigenous herbal and folk-traditional medicine and consult herbalists and folk-traditional healers more frequently than do Israeli-born Jews. The latter largely favor imported CAM modalities that are more frequently used in Western nations, such as homeopathy, chiropractics, energy healing and mind¿body practices. As Shuval and Averbuch note, "Folk and traditional forms of health care, which may also be viewed as a form of CAM, have not been incorporated into the medical care system" They consequently did not address these modalities in the article. Yet since we are dealing with health policy and take a critical point of view, broadening the perspective may have some merits.
Taking a critical point of view, Shuval and Averbuch note that bio-medicine "exercises a dominant, often exclusive, monopoly over legitimate medical care in many societies." Power relations come to the fore in institutionalized Israeli integrative medicine, not only owing to the dominance of bio-medicine over CAM, but also because of the exclusion of local traditional medicine. CAM modalities, which accord with the Jewish majority's preferences more than with those of the Arab minority, are integrated within the biomedicine-dominated Israeli healthcare system. Although traditional medicine is not currently integrated [6], initial attempts are being made in this direction ¿ to integrate local traditional herbal medicine. These initial attempts alongside the extensive use of folk traditional medicine, raise the need for research related to healthcare policy and awareness of potential risks to patients, such as that related to herb-drug interactions.
The article, which systematically maps CAM health care in Israel, and argues the case for formulating policy concerning CAM, raises questions for future research. Further and deeper research is needed in order to reveal why Israeli health authorities have not succeeded in establishing formal jurisdictional regulation or control of CAM. Why is the state shirking its responsibility to protect the public by ensuring that CAM is practiced in accordance with professional and ethical standards? Which types of regulation and control can be introduced, and why have none of these alternatives been implemented? How can CAM be subjected to formal jurisdictional regulation or control in such a way that CAM will not "look like and feel like bio-medicine?" How can the Ministry of Health introduce regulatory legislation to control CAM practice, education, and licensing, while at the same time maintaining the unique spirit of CAM?
Yael Keshet, PhD
Senior lecturer, Head of Health and Wellness Sub-Department, Sociology and Anthropology Department, Western Galilee Academic College
[1] Shuval, T. J. and Averbuch E. Complementary and alternative health care in Israel. Israel Journal of Health Policy Research 2012 1:7.
[2] Central Bureau of Statistics, 2009 http://ow.ly/atCQG
[3] Central Bureau of Statistics, 2011 http://www.cbs.gov.il/shnaton62/st02_01.pdf
[4] Ben-Arye, E., Karkabi, K., Karkabi, S., Keshet, Y., Haddad, M., Frenkel, M. Attitudes of Arab and Jewish patients towards integration of complementary medicine in primary care clinics in Israel: A Cross-cultural study. Social Science and Medicine 2009; 68 (1): 177-182.
[5] Keshet, Yael and Ben-Arye, Eran. Patients' Views: Cultural and Healthcare pluralism in Northern Israel. In: Shuval, T. Judith and Averbuch, Emma (eds.), Alternative and bio-medicine in Israel: Boundaries and bridges. Boston: Academic Studies Press. 2012; Pp.199-218.
[6] Keshet, Y. Ben Arye, E. Which complementary and alternative medicine modalities are integrated within Israeli healthcare organizations and do they match the public's preferences? Harefuah 2011; 150 (8): 635-638 (Hebrew).
Competing interests
None declared
Is complementary and alternative health care a challenge to biomedicine?
16 May 2012
The paper by Shuval and Averbuch (1) is an excellent comprehensive review of complementary and alternative medicine (CAM) in Israel, and I agree with them that the Israeli experience can be useful to health policy planners in other countries. However, while I found all of the authors' findings highly illuminating, I feel uncomfortable with some of their statements.
First, on six occasions throughout their paper, Shuval and Averbuch either state or imply that the Israel Medical Association / medical establishment / bio-medical care system / bio-medical institutions feel challenged by CAM and anxious to protect their exclusive hegemony on patient care. The authors correctly note that over 1.7 million visits to CAM practitioners are estimated to take place annually in Israel. However, the readers might benefit from the added information that the utilization of bio-medical services is thirty times as high: in 2003, the number of visits to bio-medical family doctors, general practitioners or specialists exceeded 53 million, and in 2010, there were 1.4 million hospital discharges (2). As stated by the authors, in most cases patients do not abandon conventional bio-medicine but turn to CAM as an additional mode of care. Therefore, there is no reason why the bio-medical care system should feel challenged by CAM.
Second, the authors imply that the absence of teaching of CAM in medical schools, and of governmental control on CAM is due to attempts to perpetuate the dominance of bio-medicine in Israel. I suggest that this absence is mostly due to difficulties in coping with the large number of treatment modalities that are included in CAM, the broad array of their theoretical bases and the heterogeneity of practices even within the same CAM mode. It would be difficult to justify answers to questions about the duration of a CAM teaching course within the restricted curricular time schedule, whether it should include a sample (which?) or all CAM disciplines, the level of familiarity with CAM that would be expected from medical students, and about the professional background of the teachers. Similarly, considering the multiplicity of CAM approaches and absence of evidence for their efficacy, it would be difficult to design and implement an effective governmental control on CAM practitioners. Finally, the authors' conclusion that it is possible that public confidence in bio-medicine may further (my emphasis) decline thus augmenting the likelihood of increased use of CAM in future years, is at odds with the results of public opinion surveys in Israel that attest to stable satisfaction rates from the bio-medical health care services that exceed 88% (3).
It would be fair to disclose that I am a retired biomedical physician. For the last three decades I have been strongly biased in favor of an approach to medical education and practice that is based on the assessment of clinical interventions by the level of evidence for their efficacy. Therefore, my personal attitude to CAM is ambivalent.
On the one hand, I agree with the authors that the use of CAM is an important social process. I also agree that this process, and specifically, the attitudes of biomedical practitioners to CAM, should be subject of scientific scrutiny. On the other hand, I cannot envisage an instant solution to the problem, which Shuval and Averbuch have correctly identified, namely, how to design an effective governmental control on the quality of CAM care, and which governmental agency should implement this control.
On the one hand, the ethical principle of respect of patient's autonomy supports an individual's right to select a health care provider of his/her choice. On the other hand, the ethical principle of fair distribution of health resources implies that the health care system cannot provide free-of-charge CAM services of mostly unproven or untested efficacy, and still exclude from the package of benefits medications and technology of proven efficacy because of their cost.
On the one hand, obviously, CAM responds to the needs of some patients, and I believe that bio-medical practitioners should strive to emulate the mutual trust that characterizes the relationship between patients and CAM practitioners. On the other hand, while both bio-medicine and CAM abound with anecdotal reports of individual successes, only bio-medicine can claim to breakthrough treatment modalities, such as vitamins, vaccinations, antibiotics, antiviral medication, insulin and chemotherapy for childhood cancer, that have affected the well-being and even life expectancy of entire patient populations. Therefore, I believe that the bio-medical care system will continue to shoulder the responsibility for patient care, and I doubt that CAM will ever be considered an alternative to biomedicine.
Jochanan Benbassat MD
Smokler Center for Health Policy Research
Myers-Brookdale-JDC institute
Jerusalem
REFERENCES
1. Shuval J, Averbuch E. Complementary and alternative health care in Israel. Israel Journal of Health Policy Research 2012, 1:7.
2. Israel Central Bureau of Statistics 2011.
http://tinyurl.com/cxb2hmm
Accessed on May 12, 2012.
3. S. Brammli-Greenberg, R. Gross, Y. Yair, E. Akiva. Public Opinion on the Level of Service and Performance of the Healthcare System in 2009 and in Comparison with Previous Years. Research report 587-11 of the Myers-JDC-Brookdale Institute, 2011.
Competing interests
None