Abstract
Purpose. Complementary and traditional medicine (CTM) plays an important role in culture-centered care for cancer patients in the Middle East. In this article, we have studied the attitudes of Arab CTM therapists concerning integration of complementary medicine within the conventional supportive cancer care of Arab patients in northern Israel. Methods. Semistructured interviews were held with 27 Arab therapists who use medicinal herbs, the Quran, and various CTM modalities, with the aim of characterizing their treatment practices and learning about their perspectives regarding conventional cancer care. Results. We first summarized the different characteristics of the various CTM therapists, including training, typical practice, and so on. Thematic analysis revealed that folk healers and complementary medicine therapists describe their role as supportive and secondary to that of physicians. Their goal was not to cure patients with cancer but rather to enhance their quality of life by reducing the severity of both the disease symptoms and the side effects of cancer treatment. Religious healers, by contrast, purport to cure the disease. While folk healers opt for parallel alternative care and complementary therapists support integrative care, religious healers claimed that they offer an alternative to conventional medicine in terms of both etiology and practice. Conclusions. The majority of Arab CTM therapists support integration of their treatments with the conventional system, but in practice, they are not sure how to bring about this change or create a parallel model in which 2 different systems are active, but not integrated. Our findings emphasized the need to promote doctor–CTM practitioner communication based on structured referral and bidirectional consultation. Moreover, we recommend intensifying research on the efficacy and safety of CTM in the Middle East and the potential role in promoting culture-based supportive care.
Introduction
In recent years, the concept of culture-centered supportive and palliative care in cancer has been gaining recognition among physicians and health care providers in the Middle East.1,2 Introducing complementary and traditional medicine (CTM) in Middle Eastern supportive cancer care has become an important axis for multinational and multidisciplinary collaborations. 3 In 2012, researchers from Israel, the Palestinian Authority, Jordan, Turkey, Egypt, and Morocco traced 143 articles on CTM and cancer care that had been published in 12 Middle Eastern countries. 4 Of the many types of CTM modalities, herbal medicine was found to be the most widely studied and practiced therapy among the Arab population5-8 followed by mind–body and spiritual practices in cancer care, which are occasionally combined with traditional herbal medicine.9-12 Preliminary clinical studies suggest CTM’s beneficial role in improving psychological distress of cancer patients 13 as well as fatigue, 14 pain, 15 xerostomia, 16 stomatitis, 17 and general well-being. 18 Integration of CTM in clinical practice is a challenging theme. In Israel, researchers have called for establishment of integrative oncology consultation within the conventional supportive care, based on 3 core elements: scientific research; nonjudgmental doctor–patient communication; and an ethical perspective regarding efficacy, safety, quality, and professionalism. 19
In 2008, the Integrative Oncology Program was founded by a family physician within the community-centered oncology service of the Haifa and Western Galilee District in Clalit Health Services aiming to improve patients’ quality of life (QOL) during chemotherapy and active disease. 20 During the first 2 years of the program’s operation, difficulties emerged in providing treatment to Arab patients, which necessitated devising a program that addresses their unique social, cultural, and spiritual aspects. 21 These difficulties included a gap between patients’ expectations regarding the role of CTM in extending survival as opposed to its supportive and palliative care context in improving patients’ QOL. We hypothesize that these expectation gaps may be related not only to patients’ attitudes regarding CTM’s role in cancer care but also to their CTM practitioners’ consultation goals. To overcome the barriers to integrate CTM into the supportive care of Arab patients, we designed a study to assess the attitudes of CTM therapists who treat Arab cancer patients in Israel toward integrative medicine.
Methods
This qualitative study was based on semistructured interviews with 27 Arab therapists in Israel whose clientele includes Arab cancer patients. Participants were selected by the first author (AP-G) who has conducted a qualitative research among traditional Arab women healers in Israel22,23 and the third author C (EB-A), a family physician trained in CTM who has coordinated quantitative studies analyzing the attitudes of Arab and Jewish patients regarding integration of complementary medicine into family medicine clinics in north Israel, 24 taking into consideration specific populations25,26 and gender aspects. 27
Participants were selected by snowball sampling. The third author phoned 49 contacts (physicians, therapists, researchers, and/or patients), informed them about the purpose of this study, and asked for their recommendation for candidates who meet the research criteria: Arab CTM therapists who treat Arab cancer patients. Based on the collected recommendations, 56 therapists were identified as potential participants. The third author contacted 37 therapists to confirm their eligibility for the research. Nineteen potential practitioners were excluded for one or more of the following reasons, including difficulty to reach or contact practitioners, geographical limitations, and lack of sufficient clinical exposure to Arab cancer patients. Ten practitioners did not consent to interview or were not able to allocate time (matched with the interviewer schedule) for a 1-hour interview. Interviews, which extended over 1 to 1½ hours, with 27 therapists, were conducted in Hebrew, except in one case of simultaneous translation from Arabic to Hebrew. Interviews were transcribed and analysis was performed to identify key themes in the text.
Results
The study involves 27 Arab CTM practitioners who reported treating Arab cancer patients living in northern Israel. Table 1 summarizes participants’ demographics and classifies 3 subgroups of practitioners: folk, complementary and religious practitioners. This classification is based on the way community members (including patients) view the practitioners—their training, legitimacy, and repertoire of treatment practices.
Participants’ Characteristics and Demographics.
Practitioners’ Conceptions of Their Chief Treatment Objectives
Folk healers who use medicinal herbs, although some also use massage, burns and incisions. Therapists in this group were 40 years and older. All have families with at least 3 children. Educational levels ranged from elementary education to advanced academic degrees (2 BA, 2 MD, 2 PhD). Most of the folk healers acquired their expertise through apprenticeships with traditional healers or family members who practiced traditional Arab medicine. This group of therapists primarily serves patients in Arab villages. Consultation was offered in private clinics or at the practitioner’s home. Therapists may recommend specific herbs for self-picking or purchase but often provide these herbs directly to patients. Payment for service was usually not determined in advance and may range from a small fee, offered at the time as a gift or donation, up to an extremely high fee (for “secret” or “miraculous” remedies).
Folk healers mostly focus their treatment goal on improving patients’ general QOL by reducing the severity of cancer symptoms burden or chemotherapy side effects. The majority did not purport to cure patients and described themselves as “playing ‘second fiddle’” to physicians.
QOL improvement may be represented by several secondary goals:
Strengthening the body’s energies is an important focus of treatment:
First of all, you have to reinforce their bodies and then give them treatment [chemotherapy]. (Amina, folk healer)
Detoxification:
We recommend that people who are ill and are receiving chemical treatment eat as much of herbs such as mustard and radish as possible and it will help them . . . It cleanses their bodies. (Abed, folk healer)
Psychological improvement:
Raising morale, that’s my job . . . He [the patient] may sometimes become healthy from words . . . Speech has an even greater effect than medication. (Ibrahim, folk healer)
b. Complementary therapists with professional training based on structured studies at CAM colleges (acupuncture, shiatsu, tuina, Reiki, sujok, reflexology, homeopathy, and naturopathy, etc). Most of these therapists were relatively young (in their 30s or 40s). Their family status is rather unusual for Arabs in Israel: Four of the female participants were unmarried, 2 have been married for a long time with no children, 1 male therapist was married without children and the others had small families (1-2 children in most cases). Most of the therapists practice CAM through clinics affiliated with health maintenance organizations but also see patients on a private basis with a relatively fixed fee for service.
Complementary therapists tend to formulate a treatment plan centering on the person rather than the disease:
Conventional medicine relates to the disease and looks at the person as a number . . . It’s different for us: The patient is at the top of the pyramid. (Fars, complementary healer)
1. Emotional treatment was common:
There are people who come to me who keep a lot bottled up inside. When I insert the needles, I see the tears in their eyes. I explain to them that they should not repress what they are feeling. If they feel a need to cry, they should cry. (Fars, complementary healer)
Concepts of “balance,” “awareness,” and “connectedness” characterize the emotional–spiritual axis of treatment:
I direct treatment towards balance between body and soul and they feel calmer, with more internal tranquility despite all the pain, fear and anxiety that surround the disease. (Fars, complementary healer)
2. Strengthening the body’s energies is an important focus of treatment addressed in energetic context. “Strengthening” refers to the internal process of reinforcing the body’s self-healing powers. The systems that affect strength and creation of energy are sometimes considered to be blocked, either physically or emotionally:
I identify the energy barriers in the body . . . I return to the source, to the base, which is the soul. You have to process the crisis and release it. (Nasr, complementary healer)
Another way of achieving patient strength (often referred to the strengthening concept of the body’s immune system) is by forming a “defense” system for the patient, who is assumed to be weak and vulnerable:
We start by creating defense . . . some think of light, some think of iron and some think of herbs. After this, you have to appeal to the universe. (Dalal, complementary healer)
This defense concept:
3. Complementary therapists aspire to change the patient’s lifestyle by encouraging healthful nutrition, lowering stress in everyday life, and exercise.
Let us fix what can be fixed in our lifestyle. In the way we think . . . I work with the people, not with the disease . . . I teach them to meditate often. . . . I plan a nutritious diet that suits the patient according to disease, situation and age. (Dalal, complementary healer)
c. Religious–spiritual healers who use the Quran, amulets, and cupping based their practice on traditional Muslim medicine that may also include medicinal herbs. These therapists were 40 years and older and have large families. All hold secondary general education or bachelor’s degrees and one was a qualified physician. Most of these therapists acquired their credentials through religious studies.
Unlike folk healers and complementary therapists, religious healers claimed that they can cure patients and not only improve their QOL. From the religious healers’ point of view, the cause of the illness is rooted in the supernatural world—the evil eye, demons, or spells. The cause of the disease is what is substantive in their eyes, more so than the symptoms: Spells, the evil eye and demons are the same thing . . . The disease is the same . . . and the treatment is [also] the same—the Quran. (Asraf, religious healer)
In many respects, religious healing is rapid and dramatic:
Sometimes, a person has cancer . . . Who do we think makes that black spot? It is a demon within the body that makes it appear. They’ll say “Here’s the cancer.” But in our medicine we find it quickly . . . We’ll read [the Quran] over it for two hours and then it goes away. (Imad, religious healer)
Therapists’ Conceptions of Integration With Conventional Medicine
The majority of interviewed therapists responded affirmatively to the idea of combining CTM with the conventional medical system: “We need integration and I think now is the time” (Abed, folk healer). Only one therapist objected to integration unequivocally: “There can be integration . . . but not for cancer . . . Because I raise energy and they lower it” (Rani, folk healer).
The therapists’ interpretation of “integration” varied considerably. Some related to integration positively, in principle, but described it as a distant vision:
I believe in integrative medicine . . . but when it comes to being there, I would be happy to help, though I don’t know how. (Dalal, complementary healer)
Some therapists relate to integration positively, yet their remarks depict a parallel and separate model:
The doctor has his method. He does not know my method . . . I gave you my treatment but there is another parallel treatment that may help you. (Amina, folk healer) This is integration with separation: I do my part, they do theirs, but it’s integrated. (Asraf, religious healer)
The complexity of defining complementary medicine as either the opposite of the conventional system or an integral part, thereof was evident in interviews in which therapists described nonconventional medicine as a negative image of professional medicine, using terms such as “we” and “they”:
We have lots of knowledge and experience. True, they have knowledge . . . and they have experience, but our knowledge is different. They look at the body and we look at the very basic factors, where everything begins. (Maryam, complementary healer) He [the physician] specializes in organs . . . We specialize in treatment method. (Salman, folk healer) I reinforce the immune system and he destroys it with medicines. (Nora, complementary healer)
The dichotomy between “we” and “they” is not always apparent. Several complementary therapists long to be regarded as an integral part of the healing professions. “I am between two [worlds] . . . I believe that between the two there is room for everyone” (Nasrin, complementary healer).
Some healers, especially folk healers, declared their support of integration, but their statements revealed their aspiration to use integration as leverage for clinical testing of their remedies, leading to scientific approval and legitimacy, recognition, and even recompense.
I think that in the future, we will prepare special formulas that will be accepted by HMOs and hospitals. (Hakam, folk healer)
Practical Strategies Proposed by Therapists to Bridge Gaps Between the Two Conceptions
Complementary and traditional medicine practitioners’ general support of integration was accompanied by mentioning barriers, such as lack of CTM regulation and poor awareness of complementary medicine’s contribution to patients’ supportive care. Many interviews attested to practitioners’ taking initiative to bridge gaps between complementary medicine and conventional oncology. Their bridging strategies may be categorized according to the type of gesture each embodies:
1. Cooperation based on personal ties and trust between a particular therapist and a physician. CTM therapist–physician collaboration may be informal, extra-institutional and at times clandestine and regarded within the context of a “phone buddy”:
I have many friends who are physicians, so when I have a problem, I pick up the phone. (Hakam, folk healer)
2. An open channel of communication between physician and therapist, including appropriate referral procedures:
There are doctors who call me . . . There are patients that Dr. X refers to us. Sometimes I talk to him on the phone. Once I wrote him a letter. That’s ideal cooperation. (Fars, complementary healer) I have to use medical language, the language of therapy and medicine. It has to be a good letter and I send it with all due respect. (Maryam, complementary healer)
3. Having the conventional physician assume responsibility for integration initiative:
Cooperation management has to be left to the oncologist. (Dalal, complementary healer) A cancer patient belongs to the oncologist and that’s who treats him. He has to obtain all the information. If he refers [the patient] to me, I have to report to the oncologist regarding what I’ve done and the patient’s condition. (Fars, complementary healer)
Discussion
Many of the interviewed Arab CTM therapists were eager for integration into the professional system, including the oncologyl establishment. Such favorable views were particularly prominent among complementary therapists, many of whom seek to integrate not only into the medical fortress but also into Israeli society. Numerous folk healers indeed aspire toward integration in theory, but the actual picture was more complex in which the majority prefers a parallel model—alternative medicine alongside conventional medicine—for example, treatment of the patient’s problem without requiring contact or cooperation with medical professionals. However, the religious healers openly avowed their support of integration, rejected it in practice, considering religious healing to be the only “true” healing, claiming that they alone offer a significant alternative to conventional healing in terms of etiology and practice alike.
Complementary therapists thus support integration, folk healers favor parallel medicine and religious healers believe in alternative medicine. In other words, the complementary therapists and folk healers perceive themselves as reinforcing professional medical healing, whereas the religious healers regard themselves as replacing it.
The theme of complementary and alternative medicine practitioners’ attitudes to integration echoes across a variety of cultural settings. In Australia, Wiese and Oster 28 studied 19 complementary medicine practitioners and concluded that their leading concern regarded “becoming accepted” as a legitimate health care provider in the mainstream health system. In 2 studies, researchers in the United States and Israel suggested that compared with non-MD CAM practitioners, dual-trained practitioners (physicians trained in complementary medicine) were more oriented toward integrative medicine and promoted more co-management with and making referrals to CAM practitioners.29,30 In developing societies, such as India, on the other hand, it was found that religious healing is an alternative to the medical establishment, and does not integrate therein, particularly in cases of mental distress. 31 These studies illustrate the complexity of the integrative vision, which may be also complemented with challenges and obstacles (eg, CTM practitioners’ concerns of professional identity lost, perceiving conventional paradigm as too dogmatic and disease-centered as opposed to patient-centered holistic approach, etc). 32 In this study, we also report that although practitioners of the 3 groups (complementary, folk, and religious healers) generally support integration, they differ in their perspectives toward the practical meaning of integration in clinical practice.
Based on the reported observation, we conclude that several preliminary steps are required to lay the groundwork. First, research is understood to be a substantive basis for cooperation between professional medical and CTM practitioners. Participation of CTM practitioners in a collaborative multidisciplinary research group may foster CTM practitioners’ awareness to the rigorous methodology needed to evaluate clinical efficacy and safety. As shown in this study, most CTM practitioners acknowledge the dominant role of conventional medicine in cancer diagnosis and provision of life-saving treatment. This attitude may be regarded as a first step in CTM practitioners’ acknowledgment in the importance of safety as manifested by avoidance of radical alternative approach to oncology treatment. Nevertheless, more studies are warranted to assess CTM outlook regarding the risk versus safety of specific dietary and herbal remedies concerning side effects and interactions with chemotherapy and other conventional cancer treatments. Other benefits of collaborative conventional–CTM research is in building a common vocabulary, creating the image of status and in granting legitimacy and professionalism to nonconventional medicine among physicians and patients alike. Furthermore, it expands the corpus of medical knowledge and establishes it as an entity shared by conventional and nonconventional medicine.
Second, CTM practitioners emphasized the need to raise the Arab society’s awareness vis-à-vis the role of CTM in cancer supportive care. Moreover, patients may be at the present time challenged to differentiate between 3 diverse concepts of TCM-related care: alternative medicine (al tibb al-badil), complementary medicine (al tibb al-mukamel), and the more recent integrative agenda (al tibb al mudmaj) that calls for incorporation of CTM within the medical system. Healers we interviewed were pleased with the rise in CTM awareness, resulting from an increased demand for complementary medicine in Western Europe and the United States and from the Arabs’ long-standing affinity for folk and traditional medicine. Awareness of an integrative conceptualization of CTM may be increased by disseminating updated knowledge through lectures, workshops, guidance and study sessions, marketing campaigns, and a presence in the Arab media.
Third, CTM practitioners, mostly the complementary healers, who are currently more prone to integration within the conventional medical establishment, consider the basic conditions for cooperation to be institutionalization, supervision, and regulation of nonconventional medicine. In traditional Arab society, healers enjoyed prestige, legitimacy, and authority. 33 Training was built into the culture, while control and supervision were exercised by the watchful eyes of those in the social circle. Today, however, CTM lacks proper training for therapists as well as control, supervision, accreditation, and legislation. As a result, the healers also complained that they were not accorded due authority, respect, and recognition. Such recognition, together with supervision and regulation, would consolidate the profession and perhaps bring about mutual respect, authority, and accreditation, while preventing possible damage to patients’ health.
The gaps to be bridged between CTM and conventional medicine are vast indeed: differences in knowledge, lack of awareness, resentment and bitterness. Derision, criticism, feelings of inferiority and ignorance are still manifold, with each side demanding that the other meet it halfway. At this stage, a key role is reserved for pioneers, the trailblazers on both sides, those who lay the groundwork for integration prior to the involvement of others who may still be influenced by ignorance and ridicule. Trailblazers—perhaps in every field—overcome opposition and strive for fulfillment of their vision, clearing new paths in places where there was once only wilderness.
The cooperation vanguard can affect rapprochement between physicians and healers, with both sides constituting a bridge for patients. Physicians require strength, faith, and dedication:
We need a conventional physician who has the power . . . who has the will, who displays initiative, who believes in both [kinds of medicine], who is willing to participate in a joint project . . . Someone who considers it his life’s work and is prepared to make sacrifices for it as well. (Hakam, folk healer)
If they are healers, they require the relevant education and affinity for the organizational culture of professional medicine:
As far as I’m concerned, the right people are those who studied, people who have the right certificates, people with professional knowledge . . . who understand conventional medicine. (Nabil, complementary healer)
Complementary therapists in particular—and also physicians who also practice alternative medicine—are considered most suitable to be integration pioneers. 34 They are hybrids, neither here nor there, or perhaps both here and there, who vacillate between the Arab and Jewish populations in Israel, between the professional and alternative spheres, between past and present, between East and West, between modernity and tradition. As “professional” trailblazers, they can rise above the boundaries of religion, nationality, profession, and tradition.
Limitations of Research
This qualitative study was conducted with 27 CAM practitioners from the Arab population in Israel who treat cancer patients in this same group. No comparisons were undertaken with views of other practitioners, such as Jewish complementary practitioners, family physicians, or oncologists. Arab patients’ expectations regarding integrative versus traditional treatment were not examined and the relevant study group was not characterized. The findings are thus limited, and the conclusions should not be extended to additional populations and/or treatment settings that combine complementary medicine and oncology services.
Footnotes
Acknowledgements
We thank Clalit Research Institution for granting financial research support and the following physicians, researchers, medical directors and health providers for their assistance: Dr Motti Levi, Ms Margalit Shilo, Prof Bashar Saad, Mr Abu-Sabri, Dr Ibrahim Hujeirat, Ms Ofra Bruno, Dr Steven Fulder, Ms Maria Hadad, and Mr Iaas Masalha. We are grateful to Ms. Marianne Steinmetz for editing the article.
Authors’ Note
The authors have full control of all primary data and agree to allow the journal to review their data if requested.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial research support was granted by the Clalit Research Institution.