As late as 1990, the AMA was still battling the incursion of unconventional practitioners in American health care. It had set up a Committee on Quackery in 1963 to condemn the practice of chiropractic and invoked Section 3 of the AMA's Principles of Medical Ethics to impede medical physicians from associating professionally with unscientific practitioners. By the 1970s, chiropractors had gained a sufficiently strong national organization to sue the AMA on antitrust grounds. The AMA began to make some concessions soon after the lawsuit was first filed in 1976 – begrudgingly, according to the U.S. Court of Appeals for the Seventh Circuit – such as permitting medical physicians to refer patients to chiropractors and officially admitting that some chiropractic treatments are not without therapeutic value. However, these concessions did not satisfy chiropractors. They finally won their lawsuit in 1987, after ten years of legal maneuvering by the AMA. There were more appeals, but the decision was upheld for the last time in 1990. Although the AMA eventually allowed that physicians could make their own judgments, it has never conceded that chiropractic services might be based on scientific standards.

The AMA has frequently used words such as “sorcery” and “voodoo” to refer to unconventional modalities (Cohen 1998, 21); in 1955, the organization was still claiming that osteopathy was a form of “cultist healing.”

The preceding chapters set out to answer certain questions: what is CAM, why are so many people using it, why is this growth occurring now, how is the relationship between CAM and medicine changing, and what consequences will any of this have for health care. In answering these questions, I have outlined at the same time a remarkable change within the last several years in the status of CAM. It has moved from being a vaguely understood collection of marginal and, per some people, disreputable practices to being a mixed bag of practices – some are better understood and becoming valued, others are still fuzzy and unimpressive. There have been a number of drivers behind this change in status: users of CAM, physicians, researchers, insurance companies, and government. All are making distinctions among different alternative therapies and selecting certain therapies for further exploration. Each set of actors is drawing on different but related kinds of knowledge as they engage in these activities. The result is a mainstreaming of certain therapies – those that people are using; that physicians are recommending and, in some cases, practicing; that researchers are investigating and finding to be safe and effective; that insurers are reimbursing; and that government is supporting through NIH funding for research. I turn now to the task of pulling these strands together, highlighting the role of each of these main actors, and weighing their relative contributions to the process of mainstreaming.

In 1971, New York Times reporter James Reston was stricken with acute appendicitis while in China to cover the Secretary of State's visit. He had surgery in a Beijing hospital. His article, describing how his postoperative pain was relieved by acupuncture, stimulated interest in the United States. Today Americans make more than 5 million visits per year to acupuncturists (Eisenberg et al. 1998).

In 1975, Herbert Benson, a cardiologist at Harvard Medical School, published a pathbreaking book, The Relaxation Response, which showed how cardiac disease could be slowed, even reversed, through meditation. New knowledge about nutrition also began to help heart patients. Dietary guidelines, revised in the 1980s, warned against eating red meat and other animal fats and encouraged heart patients to increase their intake of fiber.

In the early 1990s, cancer clinics across the United States introduced patients to stress reduction, visualization, music therapy, and aromatherapy, to name a few novel treatments, to help them through the traumas of chemotherapy and survive the trials of their illnesses. Palliative care clinics also expanded and are now a gratifying source of solace for dying patients and their families.

In the late 1990s, reports that sham surgery – that is, placebo – worked as well as real surgery for patients with Parkinson's disease and for people with arthritis of the knee stunned the medical community and put some surgeons in a precarious position.

CAM has become one of the fastest growing fields in health care. In 1991, approximately 33% of respondents to a survey were using at least one type of unconventional therapy annually and the total number of visits to unconventional practitioners exceeded the number of visits to all primary care physicians in the United States (Eisenberg et al. 1993). Expenditures on these therapies and practitioners at that time were estimated at about $14 billion per year, $10.5 billion of which was paid out of pocket, an amount comparable to out-of-pocket expenditures for all hospitalizations in the United States. The survey was repeated in 1997, and it found substantial increases (Eisenberg et al. 1998). Approximately 42% of the respondents were using alternative medicine and, once again, they were visiting alternative practitioners more than primary care physicians. Also, expenditures on alternative medicine had grown to about $21 billion, $12 billion of which was out of pocket. According to various estimates, Americans are currently spending more than $20 billion on dietary supplements alone.

There are a number of other dimensions to the growth of CAM on both supply and demand sides, indicating that it has become a widespread phenomenon. For instance, several new colleges or schools have sprouted across the U.S. to train CAM practitioners, and increasingly more medical schools are offering elective courses on CAM.

Do herbs heal? Does acupuncture relieve pain? How do these and other modalities work? Why aren't they effective for everyone with the same condition? These questions and a host of others motivated major new research initiatives in the 1990s, most of them funded by the NIH. This research has begun the process of legitimizing CAM in American medicine. At the same time, however, certain types of CAM have become delegitimized. Some have been shown to be harmful, others useless. This chapter explores how processes of legitimation and delegitimation have evolved within the political and, most important, scientific institutions of American society. As social institutions, government and science each have distinctive sets of norms and values and both affect and are affected by their social and cultural contexts (Zuckerman 1988).

In 1991, the Senate Appropriations Committee held hearings on the use of “unconventional medicine” in the United States. The result was the establishment at the NIH of, first, an advisory panel on unconventional medical practices, and then, officially in 1992, the OAM, which began operations with a budget of $2 million. The politics behind the creation of the OAM are a classic example of the vagaries of legislative initiative, highlighting in this case the role of individuals and their personal interests. Senator Thomas R. Harkin, a Democrat from Iowa and Chair of the Appropriations Committee, had recently been converted to the benefits of alternative medicine when he used bee pollen to treat his allergies.

Many of the therapies housed under the rubric of CAM are not new in the United States. In the 19th century and into the early years of the 20th century, practices that we would now consider alternative flourished. Some of these therapies have persisted, and some, such as osteopathy and chiropractic, have even been legitimized by the courts. However, the present practice of these two modalities barely resembles their common roots in bone setting. Other therapies – nostrums and secret potions, exorcism, and mesmerism – fell out of favor long ago. The same is true of medicine. Certain centuries-old methods of diagnosis and treatment used by medical professionals have also experienced lasting value, whereas others have not withstood the test of time. Physicians still examine a patient's temperature to ascertain the presence of infection. They no longer, however, subject patients to bloodletting, purging with calomel, or dosing with strychnine (the latter for post surgery patients), to name a few.

Despite these similarities, the course of alternative medicine and its place in American health care diverged widely from that of conventional medicine as the 20th century progressed. In becoming alternative, these practices also became ostracized. They were no longer part of “regular” medicine because their practitioners were not trained as physicians and their practices were not based on science, which had gradually come to inform the practice of medicine. As the status of medicine advanced, alternative practices seemed to disappear.

The NIH has become the most important source of funding for research on CAM, and the key to its legitimacy, both scientific and political. Although several divisions at the NIH fund CAM research, the most important is the NCCAM. It now undertakes a wide range of activities, including funding for both extramural and intramural research, research training, the development of scientific databases, and public information; it works with educators and researchers in the United States and worldwide. The portfolio of projects funded is broad and both short- and long-term, ranging from exploratory investigations to large multicenter clinical trials. These activities and others grew slowly at first, reflecting a limited budget. But once the transformation from an office to a center was underway in 1997, a change directed by Congress, the growth curve spiraled. From an initial budget of $2 million in 1992, the NCCAM administered $89.1 million in FY 2000, the largest increase that year of any NIH center or institute. In FY 2002, the budget was $104.6 million. The director of the NCCAM testifies before both the Senate and the House Committees on Appropriations at least once per year, and thus far, Congress is responding favorably to developments at the center.

This chapter focuses on the kind of research that the NCCAM funds and that is at the core of its growing reputation. A large portion of these funds is allocated to, currently, 16 CAM research centers located at universities and medical or other specialized centers across the U.S.

A social transformation is taking place in American health care. It started as more and more people (now millions) began to spend out-of-pocket dollars (now billions) on what has come to be called complementary and alternative medicine (CAM). Policymakers in both government and health care began to take notice of this groundswell of interest. Some of them are simply watching and waiting to see what happens next, whereas others are actively supporting change. Most interestingly, growing numbers of physicians have begun to take courses on therapies that stood outside the norms of medicine throughout the 20th century, even though some had been used for millenia. These physicians want to learn more about what their patients are trying to convey to them – how healing is as important to health care as curing. Insurance companies are also hearing the sounds of consumer interest and slowly responding to market demand. For its part, government has done more than listen to people who are using alternative medicine. Congress, the National Institutes of Health, and the White House have each recognized that the government must respond to impending changes in health care by, in this instance, fulfilling its obligation to assess the safety and efficacy of products that heretofore have existed in a totally unregulated private market. Millions of dollars are being devoted to scientific research that is paving the way for further consideration of regulatory measures.