Crisis and Change in the Health Care System

Since the late 1960s, health care in the United States has commonly been described as being in a state of "crisis," "transformation," or "flux.'' While the specifics of what constituted a "crisis" varied widely, academics, journalists and politicians came to agree that we were embarking upon a period of major and significant change.

		Contemporary portrayals of the changes taking place in health care range from the highly optimistic to the very pessimistic. Most of the optimism derives from hoped-for advances in the techniques of care. The public expectantly awaits genetic interventions, improvements in surgical techniques, or new vaccines. But it has generally viewed the ongoing and rapidly accelerating changes in the organization of health care more ambivalently, if not ominously. This fearful or pessimistic view of the evolution of our health care system can be traced to many sources, with a wide range of opinions about which factors have primacy. However, the key elements, regardless of their relative import, are well agreed upon.

		The problem most frequently cited is simply the cost of health care to the society as a whole. In 1960 the United States spent well under 6 percent of its gross domestic product on medical care. By 1989 that proportion had doubled, and by 1994 it was just under 14 percent, where it has remained since. The 4.4 percent growth in health care spending for 1996 was the smallest percent change in over thirty years, but still about 25 percent above the overall rise in the gross domestic product. In absolute terms this expenditure exceeded $1 trillion for health care in 1996, or $3,759 a person. Even with such immense outlays, about forty-two million Americans have absolutely no health insurance coverage. While 99.7 percent of those aged sixty-five and older have coverage via Medicare or some other federally subsidized program, about 22 percent of those between the ages of sixteen and twenty-five have no health insurance at all. A 1996 report from the Census Bureau found that 38.2 percent of the Hispanic population and 30.1 percent of the Black population lacked health insurance for at least some portion of a twenty-eight-month period ending in August 1994, compared to 21.0 percent of Whites. No one is pleased by these figures. Not surprisingly, the majority of money is spent on individuals who are ill. Medical services for those who are the most sick, who also tend to be the oldest and most likely to be covered by insurance, account for a disproportionate amount of health care expenditures. Those with chronic conditions account for about three-quarters of all the nation's health care costs. Ten percent of all Medicare recipients account for 70 percent of the program's outlays. The aging of the American population can only exacerbate these spending patterns. For example, the expected rapid growth among the "oldest old," those aged eighty-five and above, is projected to yield a 600 percent increase in Medicare costs by the year 2040 when the surviving "baby boomers" reach that age. In that same year, the number of nursing home residents over eighty-five years of age is expected to be about three times the total of today's entire nursing home population. Concern regarding health care costs goes well beyond their absolute magnitude. In the United States, a higher percentage of total costs is devoted to administrative costs than in other industrialized nations, and these costs are growing. Despite widespread attention and concern, it appears that the health care system is becoming more inefficient. The current emphasis on managed care and converting nonprofit facilities and insurers, such as Blue Cross, into proprietary operations has heightened this trend. Administrative costs, profit, and costly high technology interventions for those most ill, often during the last few months of life, have been consuming ever larger shares of the nation's total health care expenses. Given the immense amounts of money involved, much of it flowing directly or indirectly from government coffers, it is surprising how little evidence there is that greater expenditures for medical care produce better health or more healing. Although some researchers have argued that there is a marginal gain in the health status of the population in an industrialized nation when expenditures for medical care go up, most economists, epidemiologists, and others have been more skeptical. The proportion of the national gross domestic product spent on health care has been of more interest to politicians, policymakers, and academics than to the average citizen. The typical patient is more concerned with the changing manner in which care has come to be provided. The decade after 1985 saw a massive change in the organization of American medicine in the form of the rise of "managed care." Simply put, this means that large for-profit corporations have become responsible for a growing share of health care services. By 1993, a majority of Americans who were privately insured were in managed care plans that restricted their choice of physicians. Large employers were the leaders in promoting this trend; 65 percent of their employees were covered under managed care plans. The most common form of managed care, the HMO or health maintenance organization, was fast transforming from what was a traditionally nonprofit organization, into a profit-making corporation. Managed care companies themselves were engaged in rapid consolidation. Mergers and acquisitions among managed care plans for the years 1993 and 1994 were valued at about $ 38 billion, and the rate and value of joint ventures has increased since that time. Medicine is no longer largely a cottage industry of small providers (typically individual physicians) who interact through professional organizations and informal networks, sometimes coordinate their work in hospitals, and receive compensation on a piecework basis from both clients and insurance companies. Increasingly, physicians work for large profit or nonprofit corporations under contracts that subject them to detailed oversight, restrict their ability to exercise clinical judgement, and offer financial incentives to limit or skew the services they provide as a means of enhancing corporate profit. Managed care companies behave just like any other large corporation. Medicine is now "big business" and health care is a commodity. It is not necessary here to judge whether managed care is a good or bad thing for the quality of American health care, or the health of the American population. A large quantity of both popular and academic literature has already emerged on that topic. What is clear is that the overall environment in which many, if not most, Americans receive their health care has shifted dramatically. Traditional arrangements and relationships between patients, physicians, hospitals, and insurers have all been changed in such a way as to limit long-term involvement, heighten distrust, and make medicine less "special" for all parties. The sense that health care is a commodity like any other is far more widespread and influential today than at any other time in the past. In addition to these broad changes in the organization of health care, and its rising cost to the nation, there is a growing mood of disenchantment with medicine. A number of recent polls report the public's growing dissatisfaction with managed care. Over half of Americans surveyed in a 1997 Lou Harris Poll felt managed care was actually harmful to their health. What doctors do, and how well they do it, has emerged as a matter of attention and concern in the minds of clients, policymakers, and the general public. A notable but typical example is the controversy regarding the treatment and prevention of breast cancer, which has been highly publicized in recent years. Initially, disputes emerged when data from trials conducted under the supervision of the National Cancer Institute suggested that lumpectomy (surgical removal of the tumor) followed by radiation treatment was as effective in treating breast cancer as mastectomy. These findings suggested that thousands of women had undergone unnecessary body-altering surgery. However, confidence in the enterprise of medical research itself was undermined seriously in April 1994 when the Chicago Tribune reported that one of the participating research physicians had falsified information about the patients he entered in the lumpectomy study, as well as those in a concurrent study, on the use of tamoxifen, a drug used in hormone therapy for breast cancer survivors. Though the falsifications did not influence the outcomes of the study, both the occurrence of the fraud and the fact that project administrators had not disclosed it in the more than four years in which they had known of its occurrence contributed enormously to popular disenchantment with the medical establishment. The public's confusion about breast cancer was heightened in 1997, when the guidelines for using mammography to detect breast cancer in asymptomatic women in their forties became the subject of ongoing debate. The official recommendations of national institutions such as the American Cancer Society and the National Cancer Institute had changed no less than six times during the proceeding few years. Therefore, at the request of the National Cancer Institute, the NIH convened a panel of experts to evaluate existing data and determine mammography guidelines for women younger than fifty years of age. As is common practice when research findings are confusing, the panel reached its decision through a "consensus conference." Traditionally, the conclusions of such conferences are so highly valued that they are used by insurance companies to determine benefits and by doctors and hospitals to determine standards of care. However, when the mammography panel announced its findings, both the health sector and the public responded with outrage. Neither group wanted to accept the panel's conclusion that "at the present time the available data do not warrant a single recommendation for mammography for all women in their forties. Each woman should decide for herself whether to undergo mammography." The director of the National Cancer Institute, Dr. Richard Klausner, at whose behest the panel was convened, said he was "shocked" and noted that an advisory board to the National Cancer Institute would review the decision the next month. The American Cancer Society issued a statement saying that it was "disappointed'' in the report and stood by its recommendation that women in their forties have regular mammograms. One radiologist said he believed that the panel's actions were "tantamount to a death sentence" for women in their forties and that he "grieved for them." Another radiologist from the Harvard School of Medicine called the report "fraudulent" and admonished that it should not be released to the public until it was "corrected." The panel stood by its findings, noting that the data indicates 98.5 percent of women who get mammograms in their forties receive no benefit and that mammography carries risks of its own, including falsely telling women that there might be a tumor present, treating as cancerous a tiny lump that might or might not be cancerous but would require treatment if it were cancer, and giving women a false sense of security. Members of the panel also characterized the reactions to their report as "scary," and the chairman of the panel noted that "the arguments have gotten so strident that people are unwilling to listen." Some analysts have explained the intensity of the reaction by noting that mammography is a big business in the United States. Others have commented that mammography has been widely promoted to women as a preventive measure that can save them from a dreaded disease, a reassurance and sense of protection with which women are reluctant to part. However, a more basic concern is that when the leading experts disagree so vehemently on how breast cancer should be diagnosed and treated, it raises basic questions about whom the public can trust. While the health issues brought up in the breast cancer and mammography controversies are highly specific, and of greatest concern to only a portion of the population, they are typical of many similar examples. Taken together, the frequency and intensity of such conflicts have abetted the broader decline in confidence about medicine in general. The outpouring of concern about specific medical procedures and practices is, in some large measure, due to the rise in health care costs and discontent about the changing organization of care. Those factors have been central in motivating government and insurance companies to begin evaluating more precisely where their money is going. Increasingly the government and the insurance industry have been funding and carrying out research, varyingly called "health services research," "evaluation research," and "outcomes research," in order to get "hard data" (i.e., statistical evidence, as opposed to clinical reports) about a vast array of clinical procedures and tests. Almost inevitably, the data supports their initial concerns that the interventions are ineffective or overused, fostering still more concern and research. The results of research on medical techniques, judgement, and practices heightens the public's mistrust about mainstream medicine in a number of ways. For example, in the United States each year, over 2 percent of all women have hysterectomies—a rate almost ten times as high as it is for women in France. This finding is typical of repeated demonstrations that regional and national political boundaries strongly influence the utilization of specific medical procedures, even when the incidence of a problem is similar. Results like this, along with research specifying the personal and idiosyncratic factors physicians use in deciding who to treat or what new procedures to adopt, causes clinical decision-making to appear more a matter of social norms and values than of the objective application of rationality. Most unsettling for mainstream medicine has been the repeated finding that many "standard" medical procedures and therapies are of limited value, or even harmful. The culturally cherished "annual physical exam" for adults has been revealed as having no use in the screening for asymptomatic illness. A report in the Journal of the American Medical Association (JAMA) found that the widely publicized and heavily promoted PSA (prostate specific antigen) screening exam for prostate cancer leads to "a net health harm rather than a net health benefit." NEJM published a report concluding that it may be pure coincidence that people with chronic back pain, the second most common reason for visiting a physician, have disc abnormalities. The same prestigious journal reported that experienced board certified radiologists disagreed more than 20 percent of the time when reading mammograms on whether a biopsy should be performed. One study found that the medical records of 60 percent of elderly people admitted to the hospital failed to list the important medications being taken. A review of over thirty thousand randomly selected medical records from acute care hospitals in New York found 4 percent of the patients seriously injured by their treatment. More than 13 percent of these injuries led to death. A study by the American Hospital Association estimated that in 1983, 7 percent of all hospital admissions (approximately 2.7 million admissions in that year) were related to the misuse of pharmaceuticals prescribed by physicians and that such drug-induced illnesses cost up to $5 billion. A 1998 meta-analysis published in JAMA suggested that even when drugs are used properly, adverse reactions kill more than one hundred thousand Americans each year. The significance of these examples lies not in the "facts" they report. Rather, they are important because they represent a large and growing universe of similar findings in the medical literature and because each of them, along with numerous others, received prominent coverage in the popular media. Conflicts, ambiguities, and failures of modern medicine, along with news of "magic bullets" and medical heroism, are a regular part of the news in the 1990s. Cover stories in national magazines, front-page stories in the daily paper, and reports on radio and TV are commonly devoted to the sorts of critical findings cited above. This media attention indicates how important detailed information about health and medicine has become in our collective awareness. Yet often, the substance and tone of what is reported can only raise the consumer's level of skepticism, distance, and distrust. When medical researchers criticize their colleagues for undertreating pain and ignoring the evidence on how well pain medications work if used properly, while the chief medical writer for the Los Angeles Times gives major coverage to the overuse of pain medication and the resulting need for patients to "tolerate discomfort," the underlying message to the general public is one of confusion. Ironically, it is the application of the scientific method to study the effectiveness of medical care that has yielded the intellectual power and empirical analyses which inspire doubt in mainstream "scientific" medicine itself. Observers inside and outside of the medical profession have long commented upon how little of what is considered standard treatment has any documented scientific basis showing it is indeed efficacious. In 1978, a report from the Congressional Office of Technology Assessment indicated that only 10 to 20 percent of all procedures currently used in medical practice had been shown to work in clinical trials. There has been little, if any, improvement since that time. Yet until recently, these research findings have had minimal impact on the public and policymakers. Despite the equivocal evidence, scientific rationality and the practice of medicine have been inextricably linked in the public mind. As the dominance of the medical profession has grown and the expense of medical care burgeoned, the government, insurers, and industry (who foot the bills for most care) have become much more interested in knowing how much rational basis actually exists for the expenses they incur. It has become common for federal agencies such as the National Institutes of Health, the Health Care Financing Agency, and the Agency for Health Care Policy Research, as well as private foundations and "think tanks" such as Rand, to rely on randomized clinical trials, outcome evaluations, and epidemiological research to judge the true value of medical tests and procedures. Those who fund and carry out this research have been quite aggressive in publicizing their findings to the medical profession and the general public. Their predominantly negative or, at best, equivocal conclusions have helped foster and legitimize skepticism toward conventional medicine among policymakers and the general public. Beyond its own intrinsic merit, the outcome of this research has an affinity with a number of other streams of academic thought that have been critical of medicine and the medical profession, such as "labeling theory" in sociology, and "attribution theory" in psychology. These perspectives emphasize the way in which the words we use shape our reactions to phenomena in the world. Both perspectives have stressed the ways in which "medical names" for signs, symptoms, conditions, and behaviors can highly stigmatize the individuals to whom they are applied. Researchers have found this to be especially true in regard to disabilities, physical illnesses like AIDS, and mental illnesses such as schizophrenia. This extensive criticism of medicine has had a broad impact upon society. Analysts and policymakers have come to sharply divergent conclusions. Some view the epidemiologic and health service research as reason for some sort of national health care restructuring based upon federal insurance and increased government involvement in medicine. Others have come to a very different conclusion, arguing that the best policies arc those which treat health care as any other commodity in the marketplace. Individuals, especially those most economically secure and highly educated, have heightened their skepticism about the medical profession and have developed a high degree of "consumerism" toward medical care. Consumer publications such as Consumer Reports magazine and other media directed toward general audiences, such as "lifestyle" sections of many daily newspapers, have begun to report in detail about all sorts of medical and surgical techniques. Much of this material offers "user friendly" summaries of health services evaluations and outcomes research. These popular accounts have encompassed the widest range of medical interventions, including many that emerge from alternative approaches. Typical examples include the use of beta carotene in preventing heart disease and cancer, spinal manipulation as a treatment for back pain, herbal remedies to relieve depression, diet and relaxation techniques to reduce blood pressure, and melatonin for just about everything. Each of these summaries is consistent in noting that regardless of the specific topic being considered, medical experts disagree. This combination of skepticism (sometimes carrying over into overt hostility) toward mainstream medicine and consumerism has become an important dimension of a number of social movements. The women's movement, the gay liberation movement, and movements for the rights of the disabled, chronically ill, and abused all have stressed that a medically dominated understanding of their members' problems is usually not helpful, and that medical solutions to these problems are highly questionable. The gay and lesbian communities' extensive advocacy for the declassification of homosexuality as an "illness" is one of the best examples of a successful challenge to a medically dominated characterization of a group of people. The women's movement has advocated for the reconceptualization of birth as a natural process, not a "medical condition," and the hospice movement has sought to redefine death and dying. Skepticism about medicine is one element all of these movements hold in common. These individuals and groups do not deny that medicine may have much that they need or desire Rather, they wish to carefully evaluate what medicine has to offer, instead of uncritically accepting medical explanations for their problems and medical strategies for their improvement. They want to use medicine on their own terms. They are acutely aware that in the past medicine has harmed minorities and women in their quest for both individual and collective advancement. This outlook is epitomized by The New Our Bodies, Ourselves, the best selling health manual of the women's movement. In the book's chapter entitled "The Politics of Women and Medical Care," the authors cite "thousands" of personal accounts of the harm done to women by physicians and other medical personnel in medical settings who have: not listened to them or believed what they said; withheld knowledge, lied to them, treated them without their consent; not warned of risks and negative effects of treatment; overcharged them; experimented on them . . .; treated them poorly because of their race, sexual preference, age, or disability; offered them tranquilizers or moral advice instead of medical care or useful help from community resources . . .; administered treatments which were unnecessarily mutilating and too extreme for their problem, or which resulted in permanent disability or even death; prescribed drugs which hooked them, sickened them, changed their entire lives; performed operations which they later found were unnecessary, and removed organs which were in no way diseased; and abused them sexually. The New Our Bodies, Ourselves debunks as "myth" popular ideas about the superiority of the American medical system, the contributions of medicine to world health, the scientific basis of medicine, the safety and efficacy of medical treatments, and the role of medicine in promoting health. Furthermore, the authors explicitly critique the medical system as an instrument for the social control and suppression of women. One outgrowth or manifestation of this skepticism is an openness to alternative approaches, as exemplified in the introduction to the book which states that while "we do need professional help with health problems . . . medical approaches are not always the best, with their excessive emphasis on drugs, surgery, and crisis intervention." The book includes information on both biomedical and alternative approaches to health care. Each of these criticisms of mainstream medicine—excessive cost, skewed access, inadequate current health care organizations, and lack of medical effectiveness—has its own history, proponents, strengths, and weaknesses. Yet increasingly they are presented as a coherent whole, reinforcing and deepening each other. Demonstrations that a particular treatment is not very efficacious are strengthened if the treatment is also costly. Organizational arrangements that lead to reductions in desired treatments are all the worse if the reductions are justified by the need for raising corporate profits, or the treatments are allocated such that those most in need are least likely to receive them. Criticisms of medicine and the organization of health care services are widespread across the political spectrum, and these views have taken on a quality of enhanced legitimacy. The coming together of these strands of critical thinking was epitomized in the findings and proposals of President Clinton's Health Care Commission. The commission's final report premised each of its proposals on the acceptance of the criticisms we've just described. The politicians who rejected, and eventually scuttled, the report's conclusions did so not on the basis of a rejection of its premises about the costliness, inefficiencies, or ineffectiveness of medicine. Rather, their opposing views were based upon belief that more governmental intervention would make things worse and/or that a greater role by market driven economic forces, not government mandates, could rectify the situation. Extensive criticism of medicine as an institution in American society is now commonly articulated at high levels of the government, the academy, and the corporate sector of the economy.

Health and Community

Biologists have long noted that all species, plant or animal, live in communities. Existence apart from others for any extensive

length of time is rare and usually futile. Literature, anecdotal commentary, and scores of research reports have set out the consequences of social isolation for the physical health of humans. Anthropologists have described the rapid onset of death in members of small tribal groups who are ostracized, and numerous contemporary statistical accounts show the impact of bereavement upon the short-term mortality rates of those who survive. A typical finding in this literature is that about 20 percent of those who die within a year after the death of their spouse do so in direct physiologic response to the psychological impact of the loss. Scientists have demonstrated the physiological mechanism by which loneliness and isolation lead to poor physical health among primates, and it is generally thought to operate similarly in humans. Recently, a large study of nine hundred forty-two Finnish men found that feelings of hostility, hopelessness, and cynicism sharply accelerated atherosclerosis in carotid arteries, a major precursor to stroke.

		Since the 1960s a large body of rigorous research has demonstrated how job-related stress can adversely affect one's health. In 1973, Work in America: Report of a Special Task Force to the Secretary of Health, Education and Welfare found that dissatisfaction with one's work was the single best predictor of a heart attack—superior to blood pressure, cholesterol, or any other traditional "risk factor." Subsequent research has been able to specify those particular job characteristics that lead to especially high risk, such as limited decision-making ability coupled with high job demands. Researchers have also identified certain job characteristics that are protective against heart attacks, such as feelings of control and commitment. Large epidemiologic studies, carried out in Britain, have clearly shown the relationship of the type of job one holds in the occupational hierarchy to be related to most major causes of death, independent of risk factors like smoking and blood pressure, or of access to medical care.

		This research has not primarily focused on the health of individuals in a clinical context. Rather, these studies have dealt with the health of populations and groups. However, the findings from these population-based community studies suggest associations that are similar to the results of the more individually-focused psychological work on social isolation described earlier. Common to both approaches is an emphasis on the interpenetration of the mental and the physical realms of life. Social relationships and events can either create distress and literally make someone sick, or relieve distress and make someone well. Health and illness exist as points on a continuum, in a constantly changing relationship to each other. Resources for maintaining health or fighting illness may exist in an individual's environment, but they must be perceived as beneficial if they are to be effective. It is perceived meaning, our thoughts, derived from the sum total of our life experience that determines our propensity to be healthy or ill. The implication of all this work is clear: the communal environment, which includes our relationships with other people, enters our bodies via the symbols and categories in our minds. As in the development of social psychology and in the studies of the placebo effect, the essence of this research is that the line between our selves and those around us is blurred. Thus, a basic tenet of the "medical" view of illness is undermined. As in the case of the placebo effect, despite having been conducted under the auspices of medical institutions, this research has had only a minimal impact on clinical practice. Regardless of conventional medicine's neglect of these ideas about the interpenetration of mind, body, and the community, such notions are quite compatible with the views held by most forms of Judeo-Christian religion, as well as various types of Eastern, "new age," and humanistic spiritual groups. The former have always been an important force within American life. The latter have come to play an increasingly significant role as the population has become more ethnically diverse, more highly educated, and more secular. Although the major religions have been very receptive towards mainstream scientific medicine, each encompasses a tradition that stresses the potential of body-mind interaction and the importance of the relationship between the suffering patient and healer, along with the connection between the individual and the community as both a source of sickness and healing. To the extent that religion and spirituality have provided a counterpoint to the dominant American values of scientific rationalism, they have also offered an alternative to scientific biomedicine for understanding health and healing. The recent ascendancy of charismatic, Pentecostal, and "born again" movements within American Christianity has greatly enlarged the number of people who know about and accept some alternative views of how healing may occur. Many Americans have become familiar with a quasi-religious perspective on healing through their contact with 12-step programs and other self-help groups. Modeled on the premises of Alcoholics Anonymous, 12-step programs require turning oneself over to a "higher power" as a condition of help or healing. Robert Wuthnow, a professor of sociology at Princeton University, estimates that there are approximately three million spiritually oriented self-help groups in the United States, many in churches and others based on the 12-step framework. The twenty-year-old New Age movement has also had a significant impact on Americans' spiritual beliefs. Respected public opinion polls repeatedly find that belief in various forms of "alternative realities" is common and positively associated with education. At least half the adult population admits to a belief in the existence of angels, and in the period between 1990 and 1995, over two hundred books concerned with the topic of angels have been published. The World Wide Web boasts approximately three thousand mystically-oriented sites. Even physicians are joining the ranks of those who believe that there is a role for spirituality in healing. According to a 1996 statement released by the Harvard Medical School, over 99 percent of the three hundred family physicians interviewed by an independent research firm reported that they "believe in the ability of religious beliefs to contribute positively to the healing process." Additionally, 80 percent of the surveyed physicians believe in the "palliative powers of meditation and prayer," and 55 percent reported that they use relaxation and meditation techniques in their practice. This widespread prevalence of groups proclaiming and promoting a spiritual or religious dimension to healing as well as the rise and ubiquity of 12-step programs reflects and reinforces beliefs about health and illness that are fundamentally at odds with the traditional biomedical worldview. Prevention versus Curing Since its earliest days, Western medicine has encompassed a range of views about how a state of health is best achieved. Dubos describes the "competition" between the Greek gods Hygeia and Asclepius. Hygeia represented the possibility of preventing or forestalling illness by living in a healthy manner, what today would be called "health promotion." Asclepius, the first physician according to Greek legend, achieved fame not by teaching wisdom but by "the use of the knife and the bandage of curative plants." There is little doubt that Asclepius's approach became the dominant view of medicine. Today his image and name are frequently represented on medical institutions. However, the views of Hygeia did not disappear completely. Those seeking the ''laws" of a healthy life, the prevention of illness, and the building of healthy communities maintained a presence within medicine, most commonly under the rubric of "public health." Although this catchall term has, for many, become synonymous with the units of state and local government that bear the name, the field is much broader. As seen in schools of public health (which originally were restricted to the post-graduate training of physicians and other health professionals), public health includes the assessment and measurement of community health, prevention of illness, and effects of environmental factors on human health, along with the administrative dimension of health care. In many respects public health schools and agencies have served as a refuge on the border of mainstream medicine for health providers working to improve the health of communities. Despite its marginalized status, public health research has consistently documented the limited role that clinical medicine and medical technology have played in reducing mortality in industrialized nations. Public health research has also provided evidence of the crucial roles played by social status, working conditions, the physical environment, and social relationships in promoting health. Removed from its bureaucratic and professional "home" in public health schools and agencies, the underlying message of public health is strikingly similar to the views held by other critics of mainstream medicine: Health is a product of community life which reflects social distinctions and hierarchies and is modifiable by environmental change and alteration in the way in which people relate to each other. Aggressive calls for the primacy of a "public health paradigm"—or a "biopsychosocial model"—over the dominant biomedical model have recently become relatively common among public health leadership. After-the-fact clinical interventions are seen as a diversion from the goal of preventing illness. In the case of problems such as chronic illness, substance abuse, and mental illness, prevention is heavily dependent upon changes in the consciousness, or the ''empowerment" of people and groups. The congruencies and convergence among public health advocates, psychologists documenting mind-body interaction, and social scientists charting the influence of the community on health are striking. Although many commentators such as Rick Carlson, Ivan Illich, and Irving Zola noted the intersecting lines of thought and saw the potential affinity between them, these critics of conventional biomedicine have carried on their work independently of each other. Yet despite their relative infrequency and isolation, these criticisms of mainstream medicine have become increasingly influential. The heightened prominence, synergy, and impact of these critiques have not been due to any newfound validity as much as to their affinity with a wholly distinct set of changes in the mainstream medical care system.

Changing Views of Health and Illness

		Mind and Body

		A central tenet of views critical of "scientific medicine" has been the overriding importance of the interconnectedness of mind and body. Scientific medicine's roots in the dualism of Descartes has precluded it from viewing the human being as an organic whole. This has led to the neglect, minimizing, and denial of the mind's ability to produce and remove symptoms, if not create and cure illness. The opposing "holistic" view starts with the assumption that an organism (the whole) is more than the sum of its parts. According to this perspective, the nature of the parts is determined by the whole with each part understandable only as an interdependent part of the whole. While the dominant views in medical education and practice since Flexner have given short shrift to holism, developments in psychology, laboratory science, epidemiology, physics, and many other fields did not.

		The development of psychology as a field of inquiry and clinical practice exemplifies this gap with medicine. The work of many notable psychologists from John Dewey to Freud and the gestalt psychologists such as Wolfgang Kohler and Kurt Koffka, as well as the "human potential" psychologists such as Abraham Maslow, all viewed the human being as an indivisible unit of mind and body. The essence of living, and in particular the potential or overall goal-directed nature of the organism, could not be understood unless one comprehended this unity. While each of their perspectives influenced the development of American psychology, their work extended beyond the academic and clinical realms. This has been especially true of Maslow's theories, which directly led to the development of the "human potential movement" by Carl Rogers and others. The human potential movement was instrumental in carrying the message of holism to the fields of education, management, and organizational development, as well as to the worlds of art and music during the 1960s. Thus, psychology has been influential in contributing to holistic ideas about the interpenetration of mind and body and establishing them among the public, especially among the most educated and accomplished. The growing recognition and understanding of the "placebo effect" has contradicted views that proclaim the mind and body as fundamentally separate. The placebo effect occurs when substances lacking intrinsic actions produce cures, distinguishing them from the results of "real" treatments. Although many mainstream clinicians had long recognized that part of their power to heal people derived from the symbolism and expectations both patients and practitioners brought to the therapeutic encounter, the formal recognition of that fact by medical educators and organized medicine was consistently downplayed. Remission of symptoms and cures lacking a "scientific" rationale could be dismissed as being "only the placebo effect." Mainstream practitioners have often trivialized the placebo effect, not because a suffering patient would reject being cured on that basis, but because it undermines the rational scientific approach of Western medicine. As Linnie Price put it, ''The implications of the placebo effect for medicine, then, is that it relocates healing in the realm of the irrational. . . . If the pharmaceutical industry were able to produce a drug which was as reliable, of such wide-ranging applicability, and with a record of efficacy as impressive as that of the placebo effect, it would no doubt be proclaimed as a miracle panacea and attributed to the wonders of science." Despite scientific medicine's ideological discomfort with the placebo effect, it has been the subject of much cross-cultural research as well as a topic of interest to a small number of physicians, who have described its omnipresence in every sort of medical encounter from psychotherapy to surgery. Placebos have been shown to effectively treat a wide variety of conditions, including mood changes, angina pectoris, headache, seasickness, anxiety, hypertension, depression, and the common cold. Placebos can work for years, reducing symptoms as long as the patient believes them to be "real." Additionally, placebos have been shown to mimic the effect of active pharmacological agents and to be capable of producing many of the formal traits of drug dependency. Moreover, several studies have chronicled negative side effects in patients being treated with placebos and indicated that "just as a belief that a placebo is a 'real' drug produced a 'real' effect, belief that a real drug is a placebo produces a lack of effect." These studies provide evidence that the placebo effect remains as powerful as ever in the age of "scientific medicine." Ironically, it was the cumulative efforts of medical researchers, most of whom wished to demonstrate the efficacy of a new drug or technique, that provided the strongest testimony of the prominence and prevalence of the placebo effect. According to the standards of Western scientific medicine, "proof" of the efficacy of a new drug or technique requires the use of socalled "double blind" randomized controlled trails. By using random assignment to determine whether study participants will receive either a treatment drug or a placebo, and keeping both the participant and the clinician ignorant of which subjects have received which treatments, this type of study design is considered the most rigorous means of ascertaining the "true" effect of the drug being evaluated. This approach to medical research explicitly minimized the usefulness of clinical reports of success. The entire methodology was based upon the premise that if either the doctor or the patient (no less both) knew which treatment was "supposed to'' work, it would indeed succeed. The working assumption in medical research was that the placebo effect was an overriding presence, in constant need of being excluded if any sense was to be made of proposed innovations. Yet despite this omnipresent acknowledgment of the placebo effect's ubiquity and power, little attention was given to how its impact might be enhanced for the benefit of patients, much less what it implied about the underlying assumptions concerning the relation of body and mind. In like fashion, the critique of classical physics arising from the development of "the new physics" has raised questions about the adequacy of the current scientific biomedical model. The new physics refers to the theories of quantum mechanics, based on Max Planck's theory of quanta in 1900, and relativity, which began with Albert Einstein's special theory of relativity in 1905. According to the new physics, a complete understanding of reality lies beyond the capabilities of rational thought, and, at best, physics can merely describe the statistical behavior of systems and predict probabilities. That is to say, the new physics contravenes positivism, disputing the possibility of a detached and objective science in pursuit of "absolute truth." Indeed, Bell's Theorem, a keystone of the new physics, posits that ''underneath" ordinary space-time phenomena, there lies a deep nonlocal reality in which none of the "laws" of classical physics apply. Moreover, the new physics insists that it is not possible to observe reality without changing it; there is no objective reality apart from our experience. Therefore, our experience of the event occurs at the moment we observe the event. This implies that our experience of reality is determined by our own consciousness. Thus, these developments in physics question the validity of the assumptions upon which conventional scientific medicine is based. Additionally, they transcend traditional views which hold that mental and physical phenomena are functionally different.

Victims of Medicine

Victims of Medicine

		To what is "alternative medicine" an alternative? In the United States health care institutions and professionals exist in such great numbers and diversity that defining what is meant by "mainstream" medicine is an increasingly difficult undertaking. In what observers call the "medicalization of everything," medical terms, workers, and institutions have come to encompass most every domain of human interaction. Given such profusion, defining mainstream medicine as that which is typically taught in medical schools and practiced in hospitals may seem reasonable.

		In fact, mainstream medicine is undergoing constant change. Over the past few decades its credibility and status in society have been repeatedly challenged. Taken together, these challenges have fueled a search for new ways of understanding the nature of illness and of delivering health care. Alternative medicine is one response to this crisis in conventional care. Typically, the conceptual basis for delineating the medical mainstream is the notion that it is roughly synonymous with "scientific medicine," also frequently called "biomedicine." It is the dominance of scientific medicine and its elaboration in research, clinical practice, and the development of medical technology and specialties that comprise the medical mainstream.

		Scientific medicine in America is usually traced to the reforms of the Flexner Report of 1910. The explicit goals of the Flexner Report, as well as the Carnegie Foundation that sponsored it and the small elite of European trained physicians who avidly supported it, were both to establish empirical scientific rationality as the basis of future medical training and practice in the United States and to dismiss any other form of medicine as nonscientific, and hence, illegitimate. Although the precise premises of "scientific medicine" were nowhere set out, they were fairly clear and have remained so: Our bodies exist in an objective physical world. Each person's body is an entity unto itself, connected to others only by the physical aspects of genetic transmission. Although thoughts and emotions are likely to have a biophysical reality in the brain, the mind (and/or soul) of the individual is fundamentally separate from the body. The body is best understood mechanistically through the methods of laboratory science and experimentation, which are largely free of bias and the best means of discovering "truth." The development and progressive domination of mainstream scientific medicine cannot be understood without an appreciation of the importance and (perceived) success of these premises as a means of comprehending and manipulating the natural world. Despite the overwhelming dominance of this "scientific perspective" in medicine as it developed after Flexner, other ways of understanding the meaning and origins of health and illness persisted. These "alternative" views were often associated with specific healing techniques, such as acupuncture or herbalism. Sometimes they were connected to spiritual or religious movements such as Christian Science or Seventh Day Adventism. What most of these perspectives have in common is a rejection of the "objective" and physically knowable world as the sole locus of the sources of illness. The body is understood not as a machine, reducible to its constituent parts, but "holistically," as a system that is fully integrated and interpenetrating. While each of these specific approaches to illness has had its own views and language to explain the origins of health and illness, they have all held certain fundamental beliefs in common. These core beliefs are described in the next chapter. However, advocates of these alternative forms of healing were not the only groups in society to hold these views. In at least three respects, major currents of American intellectual life have been developing along lines that also conflict with the dominant perspective of post-Flexner, "scientific" medicine.

Why Alternative Medicine "The Emergence of Alternative Medicine"

In 1983 when Joshua, my oldest son, was eighteen months old, a hot iron fell on his foot and remained there until the person watching him discovered it. Most of the skin on the top of his tiny foot was gone. The emergency room doctor, his pediatrician, and three or four physician friends who examined him all agreed this was a "third-degree burn." There was no way it could ever heal by itself. The only reasonable course of action was a skin graft. The well-known surgeon at a highly regarded bum center concurred. Laura (his mother) and I both felt lucky that the surgery could be scheduled very quickly. But our feelings changed when we found out that our son would have to be tied to his bed for the entire lengthy hospitalization to prevent him from scratching at the graft, and that the sight of this would be so upsetting that we would be restricted to a brief visit each day.

		There had to be something else we could try before subjecting our little baby, no less ourselves, to such an ordeal. Laura's brother had a suggestion. He knew that in Japan, after the atomic bomb was dropped, the juice of the aloe vera plant had been used to treat people with much more severe burns. When we decided to try this ourselves, the Japanese proprietor of a nearby nursery offered helpful advice on which parts of the plant to use and how to start growing our own supply so as not to be dependent on him. Three times a day I carefully dripped the freshly cut aloe vera onto the wound. As I did, I drew on my own knowledge about how imagery affects the body. I would speak to my son in a soothing voice, pointing his finger at his foot and describing over and over what I wanted to happen: "The white part of your skin at the edge is a tiny bit bigger than it was yesterday, the dark part is a tiny bit smaller. . . . Good, good. Your skin is getting stronger. Let's think about how the juice is helping your skin grow." In about three months the foot had healed. By the time Joshua was six, only the slightest outline of the burn could be detected. As soon as it was clear that the bum had healed, Laura proposed that we get in touch with all the physicians who had advised a skin graft for our son. Surely they would want to know about a less intrusive and less costly alternative. Those we spoke with were all happy about the outcome. But not a single one was willing to say that they might suggest our solution to someone else in a similar predicament. It wasn't only their fear of a malpractice suit. Most were frank: treating a third-degree burn with aloe vera was just too far removed from what they had learned, and what their colleagues would find acceptable. Our experience, no matter how important for us, meant little or nothing to them. By 1996, when I started to write this book, the situation was vastly different. In September of that year, a Life Magazine cover story, "The Healing Revolution," predicted that health care in America was about to be "completely transformed" by the integration of ''ancient medicine and new science to treat everything from the common cold to heart disease." The first page featured a dramatic photograph of cardiac surgery being performed at New York City's Columbia-Presbyterian Hospital, with an "energy healer" laying on hands alongside the surgeon. Anyone who frequents a newsstand would hardly have been surprised to come upon this cover story. During the few months prior, stories about alternative medicine had appeared on the covers of both Newsweek and Time. These prominent cover stories are but one manifestation of the immense amount of attention that the mass media have given to something that is variously referred to as "alternative medicine," "holistic medicine," or "complementary medicine.'' A visit to any large chain bookstore will reveal an abundance of books about alternative medicine; they fill the large sections devoted to health, medicine, self care, and self help. Just one of Deepak Chopra's books on alternative medicine, Ageless Body, Timeless Mind: The Quantum Alternative to Growing Old, has sold more than seven million copies since it was first published in 1993. Sales figures for this book and similar ones by physician-authors like Larry Dossey, Bernie Siegel, and Andrew Weil have consistently placed them atop the best seller lists. To the extent that the American public reads nonfiction books, they are likely to be about alternative medicine. Some of the media attention and popular concern comes from the vivid personal testimony offered on behalf of various alternative treatments. Celebrity accounts have received a good deal of attention. Shirley Maclaine, who has abandoned Western medical pharmacology for "the healing powers to be found in acupuncture, spirit messages and crystal rocks," now teaches that we can all learn to heal ourselves by visualizing colors specific to each area of the body. The powerful description by cultural critic Norman Cousins of his battle with "an incurable illness," ankylosing spondylitis, was particularly influential. Cousins attributed his success in recovering from what doctors thought to be an irreversible illness to his alternative approach to healing. He reasoned that "if negative emotions produce negative chemical reactions in the body, wouldn't the positive emotions produce positive chemical changes?" On this basis he stopped his medication, checked himself out of the hospital, began an innovative regimen of massive doses of vitamin C and amusing movies, and sought "love, hope, faith, laughter, confidence, and the will to live. . . ." His successful recovery made him a crusader for his views. Since he was well connected and widely respected for his probing intellect, those who may have scoffed at the anecdotes of others were less likely to dismiss Cousins's story. Although his experience became widely known through his book, the initial account (upon which the book is based) appeared in the highly prestigious New England Journal of Medicine (NEJM) and included his assertion that "the hospital was no place for a person who was seriously ill." Cousins spent the remainder of his years on a medical school faculty trying to persuade academic medical researchers to take his ideas seriously. Vivid stories detailing all sorts of personal battles and triumphs over life-threatening diseases through the use of alternative healing practices have become common. Double Vision: An East-West Collaboration for Coping with Cancer is among the most impressive. This book details how when twenty-one-year-old Drew Todd was diagnosed with a rare form of aggressive cancer, his mother Alexandra set out on an unrelenting quest to discover what was available beyond conventional care. Their story and similar accounts not only acquaint readers with many of the specific alternative techniques (Todd used a macrobiotic diet, relaxation, visualization, and acupuncture, among others), but deliver powerful messages about the possibility of personal transcendence and the shortcomings of the mainstream health care system. For the most part, however, the media has paid attention to alternative medicine not merely because of the triumphs of the famous. Rather, a consistent stream of well-researched academic reports has emerged over the past several years, portraying the American population as actively engaged in alternative practices and as believing in the ideas that underlie many such techniques. The most frequently cited of these accounts, a 1990 survey of a national sample of American adults, found that about one-third had used what was termed "unconventional medi- cine" in the past year to treat a medical problem. In 1997, when the researchers repeated the survey, those who reported using alternative therapies in the past year had jumped to over 42 percent. In both years affluent, highly educated whites were the most typical users. Although almost all the users of these unconventional techniques were using mainstream care at the same time, in both surveys over two thirds of the users did not discuss the unconventional therapy with their physician. The authors speculate that this "deficiency in patient-doctor relations" might "derive from medical doctors' mistaken assumption that their patients do not routinely use unconventional therapies for serious medical problems." Those who used unconventional treatments made an average of nineteen visits per year to "alternative providers" to receive care. By extrapolation the authors conclude that the 427 million visits Americans made to alternative practitioners in 1990 had grown by 47.3% to 629 million visits in 1997. This far exceeds the 336 million visits made to all primary care physicians that same year. The total out of pocket cost of all this alternative care was estimated to have increased by a similar proportion to more than 27 billion dollars in 1997, well in excess of what was spent out of pocket on all physician services. Yet the methodology of the study specifically excluded any visit or use of unconventional medicine for the purpose of prevention or health promotion, considered by many advocates to be the primary strengths of unconventional medicine. Therefore, these findings should be seen as very conservative estimates of the magnitude of the alternative medicine phenomenon. In fact, two other national surveys reported in 1998 also found that 42 percent of households polled had used some type of alternative care within the past year. Research on specific forms of alternative care consistently presents a similarly impressive picture of extensive use. For example, approximately a third of all those who suffer from back pain—an extremely common, chronic condition—chose chi- ropractic rather than mainstream medicine for treatment. Depending on the study, between a quarter and a half of all individuals with a terminal illness seek alternative care at some point in the course of their disease. The prevalence of alternative medicine appears to be widespread regardless of the severity of the medical problem. Studies have indicated that socio-economic status is either independent of the use of alternative medicine, or that higher status and more highly educated individuals are overrepresented among alternative medicine users. Alternative health care is not always easy to define, however, or to distinguish from broader health promotion activities. This can make specific statistical findings difficult to interpret. For example, Natural Foods Merchandiser reports that sales of "natural foods" totaled $9.17 billion in 1995. But it is unclear how much of this sum can reasonably be considered to have been spent on alternative medicine. The $1.5 billion reported by the Los Angeles Times that Americans spent on "medicinal herbs" in that same year might be a better estimate, although to use this value assumes that we know how these herbs are being used. Thousands of people use "cat's claw" (a vine from the Amazon, long used by Peruvians for many types of healing) because they believe it will strengthen their immune systems. Are they practicing alternative medicine even if they are in good health? What if the user is HIV positive? Does using herbs for weight loss qualify as "alternative medicine"? Attempting to resolve these ambiguities leads to the matter of defining precisely what is meant by the term ''alternative medicine," as well as the terms "prevention" and "cure," along with the most basic notions of "health" and "illness" themselves. However these conceptual matters are resolved, the media, the public, policymakers, and many people in the established health professions have already begun to act in ways that break down whatever distinctions exist between alternative and conventional care. Just a few years ago, it would have been difficult to imagine an "energy healer" working side by side with a cardiac surgeon in the operating room at one of the nation's lead- ing academic medical centers, much less the hospital allowing the scene to be photographed for Life Magazine. The growing trend of many health maintenance organizations (HMOs) to develop or "contract out" for "spiritual healing" programs could be dismissed as purely a marketing device, a public relations stunt, or even a cynical substitution of a very inexpensive form of care for one more costly. But a 1997 survey of three hundred HMO executives found that 94 percent believe personal prayer or other spiritual practices can aid medical treatment and accelerate healing. Recent reports have depicted numerous examples of conventional health care organizations recognizing alternative medicine. For example, in 1996 a panel of one hundred fourteen leading scientists and representatives of academia, drug companies, and community groups appointed by the National Institutes of Health (NIH) to review the nation's AIDS research effort issued a blistering report that recommends a greater focus on alternative medicine in future HIV/AIDS research. In the same year, Oxford Health Plan, which provides care to 1.4 million people in the eastern United States, announced that it would add alternative medicine to some of its health plans. The initial group assembled by Oxford included approximately one thousand chiropractors, acupuncturists, naturopathic doctors, massage therapists, and yoga instructors, with plans already underway to add practitioners of T'ai Chi and reflexology. In the wake of such reports, it is becoming increasingly difficult to ignore the possibility that a more fundamental change in society's orientation to health and healing is taking place. Mainstream medicine's growing openness to various forms of alternative care is just beginning to have an impact on daily medical practice. In Europe, fairly high proportions of the established medical community either accept or practice alternative medicine to some degree. For example, in Britain about 40 percent of general practitioners state that they find homeopathy to be effective in some situations, and either refer clients or practice it themselves. In the United States, there has always been a small number of physicians who have practiced some form of alternative treatment. For the most part they have restricted their work to one or a few specific modes of treatment, and have been shunned by most other M.D.'s and the major medical organizations. Today, however, medical schools openly hold courses on many forms of alternative care, along with support groups for holistic and alternative physicians. There is even a national organization, the American Holistic Medical Association, that restricts its membership to M.D.'s and medical students. By any measure of the number of people involved, money spent, professional regard, or public opinion, alternative medicine has taken on a significant and growing presence in America. Thus, it should be no surprise that the popular media are filled with news about alternative medicine. The national media have long given attention to developments in medicine and health care. Until recently, the media considered innovation and scientific or technical advances to be the essence of what was "newsworthy." It is striking, then, that the media, hundreds of newsletters, Internet sites, and other sources devoted to alternative medicine actually contain very little that is "new." The techniques and approaches to health and healing that are extolled (or condemned)—such as acupuncture, massage, homeopathy, chiropractic, naturopathy, and herbal medicine—are almost all therapeutic systems and modalities that have existed for hundreds or even thousands of years. Any long-time observer of alternative medicine in America would wonder, why this glut of attention now? Understanding alternative medicine's position within the broader health care scene requires some description of how perceptions of health and health care among the general public and policymakers have changed over the past several decades. The successes and domination of "scientific" medicine have helped foster a climate of high costs, unreasonable expectations, distance, and distrust. These factors have combined with more longstanding critiques of the biomedical model of American health care to create what might be described as a popular "grievance" against Western medicine. The career of Ralph Moss is a good example of how this "grievance" develops and interacts with the field of alternative medicine. Moss was a well-regarded science writer who eventually became assistant director of Public Affairs at the Sloan-Kettering Cancer Center in New York. His growing public disenchantment with the effectiveness of conventional cancer therapies, especially chemotherapy, led to his firing, and a new view of himself as a muckraking crusader whose articles and books like The Cancer Industry and Questioning Chemotherapy would give patients and their families an "insider's perspective." Over the past twenty years his writing has come to include more and more information about alternative cancer therapies, and he was asked to serve on the original advisory board of the federal government's Office of Alternative Medicine (OAM). Currently he supports himself by producing a regular journal on cancer therapy (The Cancer Chronicles) both in print and on-line, as well as reports on treatment options for people with cancer. He charges $ 275 each for each of these "Moss Reports.'' The ambiguities that surround alternative medicine inhere in the term itself. Does "alternative medicine" indicate cohesion around some underlying conceptual framework, or is it merely a phrase of convenience? The popular media and many practitioners often speak of a "paradigm shift" or a "revolution" in understanding disease and healing. At the same time, other practitioners stress that alternative approaches can and should be integrated into mainstream health care. Is there truly a paradigm shift that underlies these techniques and approaches? If there is, what is it? If a "new paradigm" exists, can it coexist with mainstream doctors and hospitals, no less the rapidly changing health care system as it moves toward "managed care"? It seems clear that there is a coherent underlying set of commonalties that justifies viewing alternative medicine as a single, if broad and diverse, phenomenon. It would be a mistake to think of alternative medicine as merely a name for a residual list of techniques omitted from the standard medical school curriculum. To find that alternative medicine is a conceptually coherent category does not necessarily imply that there is a corresponding empirical or organizational reality. There is no doubt that a plethora of professional associations, conferences, publications, support groups, and commercial enterprises devote themselves to "alternative medicine." But it is still not clear to what extent "alternative medicine" exists as an empirically verifiable social reality and how it relates to mainstream medicine. Do the people who practice some form of alternative medicine, and those who utilize some facet of it for real health problems, see it as a cohesive entity? The answer here is not at all clear-cut. However, an organizational reality increasingly is emerging and gaining acceptance among the public, the government, and the health care establishment. The extension of thirdparty insurance coverage to alternative therapies, the decision of some HMOs to develop networks of alternative medicine practitioners, and the opening of the Office of Alternative Medicine at the National Institutes of Health all indicate that the climate in the late 1990s is far more open to alternative medicine than it was just a few years ago. The central role of religion and spirituality in many forms of alternative medicine is one factor that complicates the future of alternative medicine in America. Many health professionals have a difficult time accepting spirituality as a core component of health and healing. Understanding this tension is vital to predicting the future relationship between alternative and mainstream medicine. Another potentially pivotal characteristic of alternative medicine is that it draws on ideologies associated with both the political "right" and "left," thereby transcending common po- litical categories. Many of its basic criticisms of mainstream medicine emerge from a left perspective that opposes the dominance of professionals as well as excess profit-making in medicine. Alternative medicine also encompasses a strong counter-cultural component whose roots are on the left. Yet, the strong focus on enhanced individual responsibility for health, along with an emphasis on nongovernmental solutions to health problems, often gives alternative medicine a distinctly rightward cast. Examining a number of "political" struggles, such as the formation of the Office of Alternative Medicine at the National Institutes of Health and the efforts of alternative providers to gain licensure and third-party reimbursement, is the best way to understand the relationship of various political ideologies to alternative medicine. Mainstream medicine in the United States is being fundamentally altered by nationwide efforts to hold down the costs of care and increase corporate control (usually referred to as "managed care"). In addition, there is ongoing debate about the escalating cost of health care to the government. These developments have significant implications for the future of alternative medicine. Both contain the potential for fostering its integration into the broader health care system and imposing restraints on the form and content of that integration. Any predictions about the future of alternative medicine will need to keep this new economic context in mind. There is ample evidence that alternative medicine is assuming a greater role in the currents of American life. This will no doubt require more interaction, if not cooperation, with the medical mainstream, bringing with it the potential for cooptation and assimilation of that which is truly distinctive. The powerful economic forces changing mainstream medicine will likely exacerbate this possibility. At the same time, alternative medicine may be developing into an "identity movement" that offers a new understanding of what is possible both to its adherents and to society at large.Today my son Joshua is a teenager with no real memory of his badly burned foot or of how it healed. His injury and recovery in 1983 has become only one of the many stories all families tell about themselves. It has much in common with the story the Todd family tells about Drew's cancer, and the stories Ralph Moss, Deepak Chopra, Andrew Weil, and many others offer their readers. All of these stories suggest that with some knowledge and effort you can harness the resources to triumph over much illness, suffering, and disability. This is a powerful message.