Overview of Integrative Medicine Practices and Policies in NATO Participant Countries

Abstract

Background: CAMbrella is a European research network for complementary and alternative medicine (CAM). Between January 2010 and December 2013 the CAMbrella consortium reviewed the status of CAM in Europe from the perspectives of: (1) terminology for description; (2) citizens' needs and expectations; (3) patients' usage patterns; (4) providers' practice patterns; and (5) regulatory and legal status in Europe. Together, this data was used to form a set of recommendations to the European Commission, the European Parliament, and national policy makers and civil society stakeholders. These recommendations can serve as a roadmap for European CAM research.

Objective: This article aims to inform the reader about CAM prevalence, usage perspectives, and the future roadmap for CAM practices and research within the European Union.

Method: This overview describes CAM status in the European Union, using the CAMbrella consortium projects as the source of information.

Conclusions: The North Atlantic Treaty Organization is positioned as a potential foundation for inclusion of CAM modalities within the militaries as well for as collaborative research on safe and cost-effective practices.

Introduction

“Everyone has the right to benefit from any measures enabling [him or her] to enjoy the highest possible standard of health attainable.”

—European Social Charter adopted by the Council of Europe (1961, revised 1996)¹

Complementary and alternative medicine (CAM) represents a heterogeneous group of medical practices, often considered to be non-conventional. The public use of these modalities has been increasing over the past several decades.^2–8 In 2004, The European Federation for Complementary and Alternative Medicine (EFCAM) was founded to serve as a forum for specific CAM modalities as well as for national CAM umbrella organizations. The principal objective of the EFCAM is to ensure equal access to CAM modalities throughout Europe. The EFCAM states that “CAM's particular strength is the combination of individualised holistic care, capacity to provide health maintenance, illness prevention and non-invasive illness treatment as part of an integrated package.”⁹

In 2009, the European Commission requested an evaluation of the status of CAM within Europe. The resulting coordination project, the CAMbrella Consortium, was formed with sixteen institutions from twelve European countries (Fig. 1). The Consortium addressed the following areas: (1) the definition of CAM; (2) the prevalence of CAM usage; and (3) the attitudes of providers and patients regarding CAM. CAMbrella developed nine work packages and recommended six core areas, as a roadmap for the potential contribution of CAM for health care needs in the European Union.

FIG. 1.

CAMbrella Consortium Organization. Regional distribution and major expertise of the CAMbrella project partners. WP, work package; CAM, complementary and alternative medicine; WHO, World Health Organization; EU, European Union. Reprinted with permission from © S. Karger AG. Source: Weidenhammer et al., 2011.

There is much debate surrounding CAM also known as Integrative Medicine (IM). The status of CAM in Europe is characterized by enormous heterogeneity in all aspects, including terminology used, methods provided, prevalence, and national legal status and regulation.¹⁰ As such, there is no commonly accepted definition for CAM. There have been numerous efforts to define CAM. The U.S. National Center for Complementary and Alternative Medicine (NCCAM) once defined CAM as “a group of diverse medical and health care systems, practices and products that are not generally considered part of conventional medicine.”¹¹ Thus, once a practice modality is accepted as a conventional medicine modality, it is no longer considered to be CAM. Therefore, the list of CAM modalities changes as the modalities become accepted conventional medicine modalities. To add to confusion, the terms complementary and alternative medicine, complementary medicine, alternative medicine, integrative medicine, and integrative health and healing are often used interchangeably.

The CAMbrella consortium reviewed numerous sources for the definition of CAM and selected the World Health Organization's (WHO) definition of traditional medicine as the basis for a pan-European definition. CAMbrella defines CAM as

a variety of different medical systems and therapies based on the knowledge, skills and practices derived from theories, philosophies and experiences used to maintain and improve health, as well as to prevent, diagnose, relieve or treat physical and mental illness. CAM has been mainly used outside conventional health care, but in some countries certain treatments are being adopted or adapted by conventional health care.¹²

Adding to the difficulty in defining CAM, differences exist from country to country regarding what modalities are considered to be part of CAM. As an example, spiritual healing is considered to be a CAM modality within the United States and is included as a Medical Subject Heading (MeSH); however, this modality is excluded from the European definition of Spiritual practices because of the history of CAM within Europe.

Because there is no widespread acceptable definition of CAM and the modalities of medicine that contribute to it, this may have a negative impact on clinical practices, patient and provider perspectives, and research endeavors, especially research on collaborative efforts between CAM and conventional medicine practices.

Needs and Expectations Regarding CAM

Europe, like the rest of the world, faces a growing number of health care challenges. The aging population has resulted in a transformation of health care from care for acute illness to that of chronic disease management. The increasing development of technology and medications, coupled with the demand for their implementation, among other factors, has resulted in ever escalating health care costs and budgets. In addition, patients are searching for services that are consistent with personal beliefs as well as approaches that offer best results for health. CAM may offer solutions to these challenges as innovative and cost/health-added values for health care in Europe.

Complementary and Alternative Medicine Utilization in the European Union

The prevalence of CAM utilization across the European Union is unclear. The CAMbrella consortium performed a systematic literature review on the subject. The group reviewed 87 general population studies on CAM utilization and concluded that the quality of reporting was poor. CAM use varied widely, with country variations from 0.3% to 86% (Table 1). In addition, there were only available data from fourteen of the thirty-nine European Union states. Therefore, making determinations on utilization based on population demographics was not possible. However, it was possible to report on the data descriptively. Herbal medicine was the most commonly reported CAM modality, followed by homeopathy, chiropractic, and acupuncture and reflexology (Table 2).

Table 1.

Prevalence of CAM in the EU

Country	Prevalence rates %
Denmark	45–59
Finland	11–43
France	21
Ireland	15
Germany	4.6–62
Israel	5–43
Italy	16–84
Netherlands	17.2
Norway	9–53
Poland	14.4
Portugal	43.7
Slovenia	6.6
Spain	15–47
Sweden	5–64
Switzerland	5–57
Turkey	48–86
United Kingdom	0.3–71

CAM, complementary and alternative medicine; EU, European Union.

Table 2.

Top Five Most Commonly Reported CAM Therapies in the EU

Therapy	Prevalence rates %
Herbal medicine	5.9–48.3
Homeopathy	2–27
Chiropractic	0.4–28.8
Acupuncture	0.44–23
Reflexology	0.4–21

EU, European Union.

Patients' use of CAM modalities varied. Patient dissatisfaction with conventional medicine was the most common reason for using CAM. Other reasons for the use of CAM included associated side-effects of medications, preference for natural treatments, and a therapeutic alliance with CAM providers.¹³ The CAMbrella study supported the study by the NCCAM which showed that CAM is most often used for musculoskeletal conditions.^11,13 The European Information Centre for Complementary and Alternative Medicine suggests that more than 100 million European Union citizens are regular users of CAM, largely for addressing chronic conditions.¹⁴ EFCAM reports that

between 20% and 80% of citizens in different EU countries have used CAM in their health care. They want to choose the therapeutic approach that they consider will produce the best result for their health, whether it is to maintain good health and to prevent illness, or to alleviate a health problem, and whether that belongs to conventional medicine or to CAM.⁹

The therapeutic spectrum of diseases seen in CAM practice differs from those seen in conventional practice. This conclusion cannot be drawn from the statements of numerous CAM organizations, but arises from systematic investigations of users and physician providers, such as the PEK [Programm Evaluation Komplementärmedizin] performed in Switzerland.¹⁵ Patients with chronic diseases that are mostly resistant to conventional therapies tend to choose CAM therapies (e.g., symptom control for cancer, pain, psychosomatic illness, and musculoskeletal conditions, as well as women with specific gynecologic problems, such as menstrual difficulties, pregnancy-related complications, and menopause, and for their children, who often have self-limiting minor problems).¹⁶

Health care costs/budgets and patient-covered benefits have an effect on the use of CAM. Within the European Union, access to CAM is often limited to patients who can pay for it. In the United Kingdom, it was shown in 1998 that 90% of CAM provision is purchased privately.¹⁷ The effect of health care costs on national budgets threatens the health care system and sustainability. Health care costs are > 17% of the gross national product (GNP) in the United States and are expected to rise to nearly 20% of the GNP by 2025.¹⁸ Within the European Union, CAM may count for ≤ 10% of service, sales, and market of the GNP in the European Union. Therefore, globally, health care costs and utilization of CAM modalities have significant economic and social impacts. Therefore because CAM can be a lower-cost modality, CAM may have a significant impact on national budgets. Thus, shifts from this inequitable access, chronic disease management, and increasing costs are required. The sustainability of health care services is at stake. The shift needs to be toward promotion and prevention of illness, more cost-effective treatments, and manageable costs. Although more data are required, CAM treatments and the CAM provider workforce may contribute to this needed shift.⁹

Providers' Patterns

It is difficult to identify provider numbers within the European Union because of CAM's varying legal status from country to country. CAMbrella reviewed various CAM societies in the European Union and crosschecked the results with available governmental data. CAMbrella reported that there are ≈ 305,000 registered CAM providers in the European Union. The breakdown is as follows: ≈145,000 medical doctors (MDs) and ≈158,000 non-medical practitioners. Comparatively, this translates to 65 CAM providers per 100,000 inhabitants versus 95 MD general practitioners (GPs) per 100,000 inhabitants. The number of practitioners in the top five CAM methods were acupuncture (96,380), homeopathy (50,300), herbal medicine (29,000), reflexology (24,600) and naturopathy (22,300). See Table 3 for data on the top 15 CAM methods.¹⁶ MDs dominate the fields of acupuncture and homeopathy whereas non-medical practitioners, by self-declaration, almost exclusively provide herbal medicine and reflexology. Anthroposophic medicine has very few non-MDs and neural therapy is practiced only by MDs. Although CAM is predominantly provided privately there is evidence that, at least in some countries, CAM is provided collaboratively with conventional practitioners. According to the European Federation for Complementary and Alternative Medicine, CAM practitioners “offer a whole person approach to health with a focus on supporting the person's health-maintaining capacities and within which illness is treated according to the distinct diagnostic and treatment methods of the modalities used.”⁹ This statement was independent of whether the CAM treatment was offered as a stand-alone method or was complementary with conventional medicine.⁹

Table 3.

Most Frequently Provided CAM Disciplines in the EU 27+12 (by End of 2010)¹⁶

CAM discipline		Non-medical practitioners	MDs (physicians)	MDs + non-medical practitioners	Therapists per 100,000 inhabitants
(1)	Acupuncturea	16,380	80,000	96,380	21
(2)	Individual homeopathy	4500	45,000	50,300	11
(3)	Herbal medicine/phytotherapya	29,000	c	>29,000	6.5
(4)	Reflexology	24,600	c	>24,600	5.5
(5)	Naturopathy (GER: Naturheilverfahren)	7,300	15,000	22,300	5.0
(6)	Antihomotoxicology (complex homeopathy)	20,000	10,000	>20,000	4.5
(7)	Humoral/drain-off therapy (purgation therapy)	17,000	c	>17,000	3.8
(8)	Kinesiology	7600	c	>7600	1.7
(9)	Shiatsu—massage therapy	7400	c	>7400	1.7
(10)	Orthomolecular therapy	7000	2000	>7000	1.5
(11)	Manual therapies (chiropractic, osteopathy)	4900	500	>5000	1.2
(12)	Anthroposophic medicine	(GER: 20)	4500	4500	1.0
(13)	Oxygen/ozone therapy	3000	c	>3000	0.6
(14)	Kneipp therapy (GER)	2500	500	>2500	0.5
(15)	Neural therapy (Huneke)	—	1500	1500	0.3
	Total	≈158,000	≈145,000	≈305,300 (100%)b	65

^aDoes not include Chinese practitioners in 26 countries.

^bTotal number of registered CAM providers in the EU.

^cNo MD data available.

CAM, complementary and alternative medicine; EU, European Union; GER, Germany.

Reporting of CAM varies within the European Union. Geographically, the best data acquisition was possible for MDs in northern and central Europe with limited provision in the south more than the north and the east more than the west. Individual therapists using multiple provisions of CAM disciplines may contribute to the reporting bias. As an example, in Switzerland, 1665 individually counted therapies were reported as being provided by 995 non-medical Traditional Chinese Medicine practitioners. As a result, CAMbrella was unable to include 30,410 practitioners in 26 countries practicing acupuncture and Chinese herbal medicine.

Complementary Medicine and Medical Education

The fact that there is increasing demand for availability of, and accessibility to, CAM modalities and an acceptance of CAM in public health care systems of the world, CAM or IM needs to become a part of undergraduate and postgraduate medical education.¹⁹ However, there are sparse data on the CAM training for providers in the European Union. Furthermore, there are substantial variations in the professional backgrounds of identical CAM providers across the European Union. In 1986, Wharton and Lewith assessed the attitudes of GPs regarding CAM. This study showed that about “38% of GPs had received some training in CAM and about 10% had completed specialist training in complementary medicine. Further approximately 15% desired to acquire CAM skills.”²⁰ Steiner and Wegman founded the concept of anthroposophic medicine (AM), a medical approach incorporating both conventional and complementary medicine in the 1920s.²¹ Anthroposophic hospitals exist within the public health care systems in Germany and Switzerland and offer postmedical education in individual holistic medicine treatments. In Europe, there are > 2000 AM trained physicians; worldwide AM physicians practice exists in 56 countries.²²

Providers' Perspectives on CAM

Despite the lack of significant CAM education, medical providers nonetheless use CAM modalities in their practices. In the Wharton and Lewith study of providers' perspectives, it was shown that 59% of doctors (GPs) thought that the complementary techniques being assessed were useful to their patients: 76% had referred patients for this type of treatment over the past year to medically qualified colleagues and 72% had referred patients to non-medically qualified practitioners. These researchers concluded that the GP views were influenced positively by the observed benefit to their patients (41%) and personal or family experiences of benefit (38%).²⁰ Other studies support Wharton and Lewith's findings. Déglon-Fischer et al. queried 750 Swiss primary care physicians regarding CAM in their practices. The researchers found that 14.2% of the physicians were qualified in at least one CAM discipline while 62.5% referred their patients to CAM providers.²³ Three-quarters of British fund-holding GPs want complementary medicine available through the National Health Service, particularly osteopathy, acupuncture, chiropractic, and homeopathy.²⁴

Status of CAM Research in the European Union

Barriers to the integration of CAM within conventional medicine often have foundations in the lack of sufficient scientific evidence. Clinically relevant publications were very scarce. Eight peer-reviewed papers dealing primarily with clinical European CAM provision were identified in the last decade: Joos et al.²⁵ Déglon Fischer et al.,²³ van Haselen et al.²⁶ Thomas et al.,^27,28 Lewith et al.,²⁹ Schmidt et al.³⁰ and Thomas et al.¹⁷. CAM research in Europe is not well-funded by the countries or research organizations, unlike CAM research in the United States. Much of European CAM research is charitably supported. Often, conventional medicine research receives award monies, resulting in limited research funds that must be competed for. The impact of limited CAM research on the decision-making processes regarding CAM practices cannot be understated. CAM research needs to be advanced, with national and international organizations in order to achieve a systematic and unbiased view of the cost-effectiveness of CAM so as to allow integration of CAM with conventional medicine.

Impact of Crossborder Variations

When practitioners cross borders, these practitioners encounter substantial variations in CAM practices within Europe. This raises serious concerns with regard to the predictability, quality, and safety of health care delivery to European citizens. When CAM professions in some countries are tightly regulated, while the same professional categories in other countries are totally unregulated, an establishment of collegial common ground is very challenging. When researchers cross borders these researchers find that research on efficacy and effectiveness of CAM is hampered severely by the conglomerate of European regulations. Practices and practitioners are not comparable across national boundaries, and any observational or experimental study will therefore be generalizable only within a narrow national or cultural context.

Regulatory and Legal Status of CAM in Europe

There is no unifying legislative consensus of non-conventional practices within the European Union. In fact, there seems to be two distinct streams of thought that are in conflict with each other. One concept is that only medical professionals (MDs or comparable to MDs) are entitled to practice health care and treat illnesses. The other concept allows for anyone with a desire to practice health care to do so. This can cause significant problems leading to unequal treatments for European citizens.

In fact, various European Union treaties have established repeatedly that health policies are national responsibilities for the member states, even if several European Union directives, regulations, and resolutions influence how member states organize their national health policies and services. The crossborder health care directive of the European Parliament in 2011 respected the established differences in national health care systems.³¹ The aim of the directive was to remove obstacles to the fundamental freedom of patients to choose health care across borders. This could potentially also include CAM treatments in countries where CAM treatment is included in the public health services. Regional collaboration among providers, purchasers, and regulators from the different member states can ensure safe, high-quality, and efficient crossborder health care at regional levels. Historical and cultural similarities between neighboring countries would thus seem to have the best chance to facilitate crossborder opportunities in the CAM area more than European Union–wide directives, regulations, and decisions.³²

CAM treatment is either unregulated or regulated within the framework of the public health systems. The only commonality across the European Union is that structuring legislation and regulation differs in each country. A review of the policies of thirty-nine countries was performed. Of those thirty-nine countries, nineteen have general CAM legislation, eleven have specific CAM laws, and six have sections on CAM included within their health laws, such as “law on health care” or “law on health professionals.” Detailed information regarding the European Union counties is presented in the CAMbrella deliverable report.³⁰

A review of twelve treatment modalities showed considerable variation as well. Acupuncture and chiropractic are regulated in twenty-six countries, homeopathy in twenty-four countries, massage in twenty countries, osteopathy in fifteen countries, traditional Chinese and herbal/phytotherapy medicine in ten countries, naturopathy in eight countries, anthroposophic medicine in seven countries, Ayurveda in five countries, neural therapy in three countries, and, finally, naprapathy in two countries. Regulation of practice is in general mostly tied to formal education and/or training in conventional or non-conventional medicine. Regulated providers of CAM are usually identified as: (1) MDs; (2) health professionals; or (3) non-conventional practitioners. The latter category can include individuals with little or no medical training. Germany, Switzerland, and Liechtenstein have established the title of Heilpraktiker or Naturheilpraktiker or health practitioner.³⁰

Harmonization of Regulations for Increased Patient Safety

Patient choice in health care is seen as a core value within Europe and is reflected in the diversity in CAM legislation/regulations. Varied and inconsistent provider backgrounds makes seeking informed treatments very challenging. Predictable and safe health care is a necessary requirement for patient care. Across Europe, conventional medicine is predictable enough because of the passage of various directives. This is not the case with CAM practices. The harmonization of CAM legislation and regulations may be an important step forward for wider acceptance of CAM within the medical communities.

In principle, there are two options for achieving a higher degree of harmonization: (1) legislation and regulation at the European Union and European Economic Area (EU/EEA) level or (2) voluntary harmonization. It is unlikely that there will be EU/EEA level legislation/regulation in the foreseeable future because the European Union has repeatedly upheld its position of leaving this to the individual country. Voluntary harmonization is, however, possible within current legislation. The successful mutual recognition of physiotherapists across Europe shows how this can be done and could be a potential template for development of harmonized regulation also of CAM professions in Europe (Fig. 2). As such, physiotherapists have few obstacles when they move from one country to another. Furthermore, patients are ensured that physiotherapists across the European Union have similar backgrounds and experience.³⁰

FIG. 2.

Regulation of physiotherapy within the European Union (EU). Reprinted with permission from © Bruce Jones Design, Inc. 2006.

Discussion

The difficulty in evaluating complementary medicine across the European Union is multifactorial and is as complex as the differences between the countries. Despite this, some general comments can be made. Health care systems are being jeopardized largely because of escalating health care costs and budgets compounded by the shift from acute care to chronic disease management. Furthermore, patients are increasingly dissatisfied with conventional medicine. Therefore, patients as well as providers perceive CAM as a viable option to meet these challenges.

The data on CAM utilization across the European Union is unclear as a result of varying education standards, regulatory differences, and reporting mechanisms. However, it is clear that the population is using CAM and that it is either used alone or in conjunction with conventional medicine. CAM is used to address many conditions and problems; most commonly and consistently across various countries, it is used to treat musculoskeletal issues. In addition, patients are seeking treatments that are consistent with these patients' beliefs about health and health care. At times, this is contradictory to the established medical communities' point of view. Therefore, the goal needs to be cooperation and a desire to develop a new system that blends aspects of conventional medicine with CAM to optimize health care delivery and the health of the population. The net results will be greater patient and provider satisfaction and less strain on national budgets, with lower health care costs as well as a shift from disease management to health maintenance.

Conclusions

CAM is leading to a rethinking of our current health care systems, albeit this is contentious at times. CAM potentially offers a system of cost-saving, low-risk treatments that can be used in conjunction with conventional medicine. However, there are numerous problematic areas within CAM that need to be addressed before it will achieve wide acceptance.

First, a universally acceptable definition of the CAM terminology is needed. This lack of consistency makes evaluation of CAM methods and modalities nearly impossible. Thus, common language would assist collaborative partnerships, evaluations, and research endeavors to improve health care delivery systems. The overall net effect could be a healthier population with better outcomes and patient satisfaction.

Second, there needs to be common regulations regarding provision of care, credentialing of providers, and educational standards. In areas with little-to-no regulations, CAM providers exist with little or no medical education. This can lead to CAM being vulnerable to the claim that CAM is nothing more than quackery. Consistent regulations in all areas will elevate the field of CAM so that there is greater acceptability within the established medical community; a community that often dictates policy and budgets.

Finally, collaborative research efforts in CAM modalities are necessary. Cost-effectiveness research of individual CAM modalities as well as combined treatment plans of CAM with conventional medicine should be emphasized.

Each area listed is pivotal to the success of the others. The ultimate goal for the medical community must be the health of the population—locally, regionally, and globally. It is necessary to put all “egos” aside and reevaluate the status quo of our current systems. Only when all work together will it be possible to improve health care to one of caring for health.

Recommendations

There is worldwide interest and positive attitudes regarding CAM. Patients are pushing health systems to be holistic, cost-effective, and patient-centered. CAM practices are multicultural and, therefore, international partnerships are required. The North Atlantic Treaty Organization (NATO) medical communities can serve as an outstanding foundation for these partnerships. Effective and safe therapies can be officially introduced in NATO military systems. NATO-sponsored, collaborative, international, and crosscultural research on improved performance, improved mental–psychologic–emotional well-being, and budget-reducing treatments needs to be conducted. The high degree of receptivity suggests the need for both faculty training for MDs working in the military systems as well as in curriculum development.

Author Disclosure Statement

Gabriella Hegyi, MD, PhD, was appointed to NATO panel-195 (“Integrative Medicine Interventions for Military Personnel”) as a technical team member from Hungary. He participated in CAMbrella Pan-European Project as researcher professor from Péc University, CAM Department (2010-2012, European Committee).The meeting's lodging expenses were not supported by any governmental office. The remaining expenses were paid through personal resources. No competing financial conflicts exist. COL Richard Petri, MC (MD), is an Active Duty Service Member in the United States Army and was appointed to the NATO panel HFM-195 (“Integrative Medicine Interventions for Military Personnel”) as a technical team member. He was selected to the Chair of the panel in September 2013. Resources from the United States Army supported the travel expenses to the first four team meetings. The fifth meeting lodging expenses were partially supported by a grant from the Geneva Foundation. The remaining expenses were paid through personal resources. No competing financial conflicts exist. Paolo Roberti di Sarsina, MD, is a psychiatrist, actually working as researcher for the Observatory and Methods for Health at University of Milano-Bicocca, Milano, Italy, where he is the academic coordinator of the postgraduate Master course in "Healthcare Systems, Traditional and Unconventional Medicine". He is the founder and president of the Charity for Person Centered Medicine, an Italian Moral Entity active in Italy in the field of social advocacy, promotion and research. From 2010 to 2012, he has been Italian participant to the EU FP7 funded CAMbrella Consortium, the first ever consortium for a coordination project in the field of Complementary and Alternative Medicine in the history of the European Union, under the Seventh Framework Programme (FP7). The author is strongly active in networking action in Europe. He served from 2006 to 2013 as the Expert for Non-Conventional Medicine, High Council of Health, Ministry of Health, Italy. He is the sole Italian researcher whose articles are quoted in the recent WHO Traditional Medicine Strategy 2014-2023. He was appointed to the NATO panel HFM-195 (“Integrative Medicine Interventions for Military Personnel”) as a technical team member for the duration of the Team. He supported the travel expenses to the team meetings. The author did not receive any specific funding by governmental or non-governmental organizations to write this report. The author was never employed or paid by any military or religious organization. No competing financial conflicts exist. COL Richard Niemtzow, MC (Ret MD, PhD), is a retired Colonel from the United States Air Force. He is currently employee with the United States Department of Defense. He was appointed to the NATO panel HFM-195 (“Integrative Medicine Interventions for Military Personnel”) as a technical team member. Resources from the Department of the United States Air Force supported the travel expenses to the first five team meetings. The sixth meeting was paid through personal resources. No competing financial conflicts exist.