alternative and complementary therapy for asthma

Clinical Reviews in Allergy and Immunology �9 Copyright 1996 by Humana Press Inc. 1080-0549/96/241-245/$6.25

Introduction

Alternative and Complementary Therapy for Asthma

The most complete and objective analysis of alternative medicine to date can be found in a recently published report prepared for the National Institutes of Health (NIH) entitled Alternative Medicine: Expanding Medical Horizons based on a workshop held in Chantilly, VA in September 1992 (Superintendent of US Documents, publication 7578). This report, in particular the Executive Summary, details several important statistics. For example, the World Health Organization sug- gests that 80% of the world's population, or approx 4 billion people, use some form of herbal medicine for primary care. Moreover, in the United States, 30-70% of people use some form of alternative therapy, and many do not disclose it to their physician. The potential impact of these practices should not be ignored by conventional practitioners. The overwhelming impact of medical economics in both the United States and the world is threatening many national budgets because of the impact of chronic disease. At present, the cost of treatment for chronic diseases is extraordinary. Indeed, there are approx 35 million Americans who have significant functional limitations in daily activity because of chronic disease; as many as 8-9 million are so severely limited they are unable to work because of their disease. In one example, coronary artery disease, there are approx 8-9 billion doUars/yr spent on bypass graft operations. It is therefore not surprising, either because of economic influences or failure to successfully treat chronic disease, that people have been increas- ingly searching for alternative/complementary treatment programs.

The Office of Alternative Medicine, at the NIH, was established in 1991 with several goals in mind. These goals included the development of baseline information on the nature of alternative medicine in the United States. The goals also include validation of alternative therapies in several key specific areas of illness in the United States. One such area is asthma and allergy, and led to the establishment by the NIH of a Center for Alternative/Complementary Medicine in Asthma and Aller- gies at the University of California at Davis (www: http: //camra.ucdavis.edu).

There are many fields of practice of complementary medicine described in the Chantilly Report, including mind-body interventions,

Clinical Reviews in Allergy and Immunology 241 Volume 14, 1996

242 Introduction

psychotherapy, support groups, meditation, imagery, hypnosis, biofeedback, yoga, dance therapy, art therapy, and prayer/mental heal- ing. It is often difficult to classify or develop a taxonomy of the types of alternative therapies available. Clearly any taxonomy would include traditional oriental medicine, such as acupuncture, ayurveda, herbal medicine, qugong and oriental massage, homeopathy, and naturopathy. We do not propose to cover all of these in this short dedicated theme issue of Clinical Reviews in Allergy and Immunology.

The editors of this volume are trained and practice in traditional and scientifically based methods. We have been professors and teach- ers who have, individually, more than 20 years of experience at large California medical schools. We recognize the evidence that the inci- dence of allergies and asthma and the severity of asthma continue to increase in our population. Paradoxically, the mortality from asthma has risen in virtually every western nation since the late 1970s and is now significantly higher than it was 20 years ago. We appreciate the significance of developing complementary therapy that would potentially help patients to cope with their disease and treatment. Moreover, we also recognize the importance of disseminating information, developing a taxonomy, and creating a database that details the currently available complementary practices for treating allergy and asthma in the United States. Toward this end, we have developed this unique theme in Clinical Reviews in Allergy and Immunology. The articles constituting this theme issue have been prepared by practitioners in a wide variety of disciplines, each of which attempts to provide objective information on selected aspects of complementary therapy.

The vast majority of physicians in the United States and Canada, and most physicians practicing in Europe, Japan, and other so-called developed or Westernized countries, practice "scientific medicine" as taught in medical schools and postgraduate training programs. In the paradigm of scientifically based medical practice, treatment of the patient complaining of illness is predicated on the use of the diagnostic process to define as precisely as possible the disease causing the patient's illness. Diagnosis comes from the history of the patient's symptoms and the physician's physical examination, followed if neces- sary by selective laboratory testing, including anatomic imaging stud- ies (X-rays, computed tomography, and so forth), physiologic testing (pulmonary function testing, and so on), endoscopies, biochemical measurements of blood and other f luids, and microscopic or cytometric examination on blood samples or biopsied organs. Initia- tion of treatment for chronic diseases, such as allergic diseases, almost always can await the results of a complete diagnostic evaluation. Treat- ment of acute illnesses, such as pneumonia or myocardial infarction, must often be started when most, but not all, of the diagnostic process

Clinical Reviews in Allergy and Immunology Volume 14, 1996

Introduction 243

has been completed. However, even in an emergency, some form of diagnostic examination is required to direct specific treatment (e.g., res- piratory failure, cardiac arrhythmia, blood loss, epileptic seizure).

The physician practicing scientific medicine can treat a patient with allergic disease with an individualized program, a program that includes drugs whose chemical composition, pharmacologic properties, adverse effects, and purity are known; environmental manipulation to avoid allergens and irritants; and immunotherapy. The practice of scientific medicine also involves a patient-physician relationship that includes information about the patient's psychosocial milieu to optimize effec- tiveness and minimize inconvenience to the patient's chosen lifestyle.

The scientific practice of medicine today rests on a foundation of biomedical research designed to understand the normal structure and function of the human body, the cause and pathology of disease, and to provide valuable diagnostic procedures and therapeutic maneuvers. A continuing and expanding medical research base translates into a dynamic and continually improving pattern of clinical practice.

This issue addresses the subject of unscientific treatment of allergy and asthma. By definition, these are treatments that are based on tradi- tion, philosophy, or empiricism, rather than evidence of efficacy and safety. Unscientific methods used for diagnosis and treatment of disease are often described as controversial or unconventional. Practitio- ners of these methods often refer to them as complementary or alternative, implying an equal status with scientific methods. Clearly, science and belief are not equal. They are very different ways of trying to understand natural phenomena.

Most of the unscientific treatments used for allergy or asthma are in fact treatment systems or philosophies that their proponents use in a wide range of other conditions. These are listed in Table 1. Because these methods are recommended by their proponents to treat allergies, infections, gastrointestinal disease, joint disease, cancer, and many other ailments, the requirement for a specific diagnosis is obviated. In some cases, such as acupuncture, the same maneuver is used both for diagnosis and treatment.

As pointed out by several authors in this issue, many of the unscientific practices used for asthma today originated in Asia or the Indian subcontinent. The origin of acupuncture and herbal therapy can be traced back thousands of years.

Several authors speculate on the resurgence of interest in Eastern medical practice in those countries with highly developed and available scientific medicine. Regardless of the reason, many allergic patients will try both conventional and unconventional treatment, often at the same time, so the physician must be knowledgeable about these procedures, some of which may have dangerous side effects.


244 Introduction

Table 1

Unscientific Practice Systems Acupuncture Ayurverdic medicine Chiropractic Herbalism Homeopathy Hypnosis Massage Naturopathy Yoga Diet therapy (Macrobiotic, Megavitamin) Diet supplements (Megavitamins)

As stated, it is not the purpose of this issue to present an exhaus- tive review of the subject. Rather, it is to present an international view- point as seen by physicians knowledgeable in both scientific and unscientific practices recommended for allergic patients. Clearly, the editors do not endorse any unscientific or unproven methods. We do, however, recognize that most of the drugs used by allergists today have their origin in botanical or other natural sources. These include adrenergic and anticholinergic agents, theophylline, cromolyn, glucocorticoids, and antibiotics. It should be noted, however, that bronchodilator drugs with ~-2 adrenergic specificity have a well-documented benefit/risk ratio advantage over ephedrine found in ma huang. Credit for our current "scientific" drug armamentarium for asthma must be shared by both the power of modern pharmacologic research and the keen clinical observations of the ancestral healers.

As pointed out in the article by Chanez et al., nontraditional care in Western countries, such as France, seems to be a fashion, whereas these practices are the norm in much of Asia. Nevertheless, visitors to Paris may feel that homeopathy pharmacies are as prevalent as outdoor cafes. The article by But and Chang provides a cogent description of the Chinese view of herbal therapy. Although they mention that an occa- sional control study appears to show efficacy, the realities of clinical investigation, epidemiologic methods, and statistical analysis remind us that the results of a single study are more often anecdotal than defin- itive. Malka et al. make an important point that is not often mentioned. Folk medicine in South America is used out of economic necessity. The cost of high-quality biomedical research today is staggering, so scientifically based medical practice does not come cheap. Furthermore, some countries in the South American hemisphere lack an organized medical system or tight governmental regulation of medical practice. It is also instructive that certain treatments once common in the United


Introduction 245

States, such as bacterial vaccines, intravenous calcium infusions, and arsenicals are still in use in South America.

Ziment 's article is a scholarly account of information about natural sources of some of our current specific medications. Pharmaceutical research today is heavily directed toward the de novo design of chemical compounds to simulate or inhibit inflammatory mediators and receptors, and the manufacturing of some of these products by recom- binant gene technology. There may well still be a role for the alert clini- cian to discover a useful drug already existing in nature. Finally, Black, a psychiatrist, balances the discussions of unscientific therapies with a description and analysis of the controversial diagnosis of environmental illness or multiple chemical sensitivities. The danger to the patient of an incorrect diagnosis resting on an untenable theory is potentially much more dangerous than ineffective therapy, again emphasizing the importance of a scientific foundation for medical practice.

M. Eric Gershwin Abba Terr

University o~ Cali~ornia at Davis
