Prolog: Naomi experiencing integrative homeopathy and palliative care

Naomi, a 70-year-old Jewish woman, married and living in a village in northern Israel, was admitted to the oncology service at the Lin Medical Center in Haifa with a diagnosis of metastatic endometrial cancer. She had begun palliative treatment with a regimen of carboplatin and paclitaxel, and was referred by her oncologist to an integrative physician (IP) working in the oncology service for consultation. The IP is a conventional physician (MD) with extensive training in complementary medicine (CM) and supportive cancer care who provides patients with information regarding the use of CM in conjunction with conventional care. Patients are then referred to a number of CM treatment modalities, with the goal of alleviating symptoms and improving quality-of-life (QOL)-related outcomes. The IP consultation and CM treatments are provided at the center without charge, and are part of an integrative oncology program provided to patients undergoing chemotherapy and/or palliative treatment.

The issues raised during Naomi’s IP consultation were related to her main concerns and symptoms, with the ultimate goal of improving QOL-related outcomes. She subsequently underwent ten CM treatment sessions, this in addition to a wide range of nutritional and dietary supplements which she had been taking upon her presentation to the IP. These included the homeopathic remedies Traumeel (a homeopathic remedy) and Glutamine–Zinc–Aloe, which she took to reduce the severity of mouth sores; the herb Euphrasia officinalis, which she was taking to alleviate the sensation of eye dryness; and wheatgrass juice, which she was taking to improve cancer-related fatigue. In addition to the CM treatments, Naomi participated in a series of cuisine workshops which provide patients with hands-on experience in the use of traditional medicine herbs, as well as guided imagery and weekly acupuncture sessions. The integrative treatment regimen brought Naomi significant relief for a number of her symptoms, especially stomatitis, insomnia, and chemotherapy-induced peripheral neuropathy. She continued the CM treatments for a year (once to twice weekly).

At the end of her chemotherapy regimen, Naomi began radiation therapy for lung metastases. At this time, Naomi’s main concerns included severe fatigue and dry cough, for which the IP recommended the use of Thyme- and Astragalus-based herbal formulas, with moderate improvement of fatigue but no change in the cough, which by now had become Naomi’s main QOL-related concern. Naomi was consulted by a pulmonologist who prescribed gentamycin inhalations with no improvement, and she was being considered for palliative left-sided lobectomy. It was at this point that Naomi asked the IP about other alternatives, and was prescribed a homeopathic remedy aimed at alleviating her cough and tendency to hoarseness which included high dilutions of the compounds Drosera rotundifolia, Cuprum metallicum, and Bryonia alba (all 5CH, or 1 × 10−10), and Arum triphyllum (30CH, or 1 × 10−60). At the follow-up IP visit a week later Naomi reported an improvement in the cough, which she attributed to the homeopathic treatment. Throughout the ensuing 2 years Naomi has undergone more than 80 integrative treatment sessions, during each of which the CM practitioner re-assesses her main concerns and expectations. During this period, the IP has maintained a structured communication with Naomi’s oncologist, oncology nurse, psycho-oncologist, and family physician.

Patients’ narratives in the context of complementary and traditional medicine in the Middle-East

Naomi’s narrative characterizes the use of homeopathic remedies in one of the most challenging settings, that of cancer care. In the unique oncology setting described, homeopathy is part of an integrative oncology program which serves an integral role in a palliative treatment service and is part of a wide range of CM treatments prescribed by an integrative physician (MD). The integrative context of medical care, in which CM is provided within the conventional “fortress” of modern medicine, is notably different from that of the more commonly seen alternative context of care being used by patients across the Middle-East [1]. In many countries in this area of the world CM is perceived by patients and health care providers as something outside of conventional care. The exclusionary approach is evident in studies which have shown low rates of patient disclosure regarding their use of CM to their physicians (e.g., only 32 % in Palestine, 41 % in Turkey) [2, 3]. Middle-Eastern physicians are often skeptical about the benefits of CM, as can be seen in a study of Jordanian physicians at the King Hussein Cancer Center, who describe these treatments as “not evidence-based” [4].

However, in recent years more and more Middle-Eastern clinicians and researchers are moving with worldwide trends regarding the recognition of CM as a research-based and feasible modality, and have called for a dialog between the two medical paradigms [5, 6]. The increasing openness toward the integration of CM into standard medical care is also based on ethical considerations, addressing patient autonomy; the physician’s commitment to provide non-judgmental advice regarding the potential benefits and risks of these treatments; and public accountability, especially in countries where traditional medicine is highly correlated with the local culture and religion [7].

The evolving pluralistic approach to CM has encouraged a wide spectrum of Middle-Eastern researchers to call for the need to respect the “rights” of traditional, complementary, and alternative medical practices, this across a wide spectrum of therapeutic contexts [8]. In the Middle-Eastern contexts ethical and cross-cultural factors are central, considering the widespread use of herbals in this region as well as mind–body, spiritual, and manual therapies which are often part of traditional medical systems. In addition to the impact that local traditional medical practice has had on this process, emerging research findings and an increased interest in other traditional schools of medicine (e.g., Chinese and Ayurvedic medicine, as well as others) have encouraged researchers in the Middle-East to acknowledge the potential benefits of indigenous treatments. This is especially true for traditional Muslim healing, which is often considered as essentially Greco-Arab medicine [9].

The advancement of CM research in the Middle-East has encompassed countries with diverse cultures, each with its own geographical–botanical character: from Morocco in the West to Iran in the East; from the Turkish shores of the Black sea to the southern coasts of Saudi Arabia, Yemen and the Persian Gulf. Ancient herbal prescriptions of leading physicians in the ancient world, such as the Muslim scholar Ibn-Sina and the Jewish Rabbi Moses Ben Maimon (Maimonides) have become a focal point for contemporary research, and not just an anecdotal source of old-fashioned potions [10]. Still, CM research in this part of the world has focused primarily on Middle-Eastern herbal practices and not on Western-oriented modalities such as homeopathy, which was founded in 19th century Europe.

In the present article, we examine the role of homeopathy within the context of an evolving acceptance of CM among Middle-Eastern medical practitioners, as well as within the framework of clinical practice and in light of the integrative process currently developing in clinical practice and research.

Homeopathy within the context of traditional medicine in the Middle-East

Homeopathy is a CM treatment modality which was established by the German physician Samuel Hahnemann in the late 18th century, and is a relatively “new” therapy from a Middle-Eastern perspective. Upon careful observation, a number of the fundamental concepts central to homeopathy are similar to those of traditional Middle-Eastern medicine. An example of this is the homeopathic Law of Similars, or ‘let like cure like’. In the book of Exodus in the Hebrew bible the prophet Moses, upon his descent from Mount Sinai with the ten commandments, discovers to his dismay that the Israelites have been worshipping the golden calf. To save his people from the wrath of God, Moses orders the destruction of the golden calf, which is then melted, ground into powder and dissolved in water which the Israelites are forced to drink [11]. The stated goal of this act is to “cleanse” the children of Israel from their idolatry, demonstrating the understanding that the cause of an affliction is also its cure (‘let like cure like’).

In ancient Greek medicine and later on in Muslim medicine, the homeopathic principle of “like cures like” often served as the paradigm for those cases where the medical practitioner uses the patient’s symptoms to decide which qualities of herbs, minerals, or animal-derived remedies were to be administered. In this process, the practitioner sets out to explore a remedy’s physical qualities, as well as its symbolic meaning to decode its medical properties. Such an approach was based historically on a series of correspondences between the Microcosmos and Macrocosmos in the ancient worlds of Greece, India (the 5-elements theory in Ayurvedic medicine), and China (Yin-Yang and the 5-phase theory) [12]. With the rise of Islamic medicine during the Middle Ages a multi-cultural medical dialog between the traditional schools of Western and Eastern medicine was set in motion. Medieval and Ottoman physicians based their medical diagnosis on a doctrine of signatures, where remedy and symptom were regarded as a mirror image of each other (i.e., the “like cures like” principle) [13]. This symbolic and metaphoric perspective was further advanced with the rise of alchemy, in which Muslim physicians mediated between Indian, Chinese, and European concepts on the interactions between matter and process [14]. While the more common materialistic form of alchemy focused on the creation of gold from inferior materials, a parallel concept of alchemy focused on the process of metamorphosis as opposed to the ultimate outcome [15]. In this sense, a number of parallels can be found between Arab and European alchemists, the doctrine of signatures, and the second fundamental concept of homeopathy, that of the “vital force” [16].

In the modern era schools of homeopathic medicine flourished throughout Europe, the Americas, India, and many other countries across the globe. The widespread use of homeopathy can be traced in part to the Middle-East, primarily French-controlled areas of northern Africa [17]. Homeopathic clinics were also established in Israel, reflecting its orientation toward Western complementary medicine modalities, and in the Persian Gulf area, where treatment was provided to foreign workers from India. There is a limited amount of information available regarding the legislative status of homeopathy in the Middle-East, except for Israel where homeopathy and other complementary medicine treatment modalities (except hypnosis) do not require any official licensing process [18]. However, training programs in homeopathy are available for both medical (physicians, dentists, nurses, etc.) and non-medical practitioners, and are provided in non-academic colleges of complementary medicine which offer courses in both classical as well as clinical (often French- or German-oriented) homeopathy. The Israeli Association of Classic Homeopathy is one of many organizations which self-regulate the professional status of trained homeopathic practitioners in Israel, though their decisions are not legally binding [19].

Unfortunately, the literature available on the use of homeopathy in the Middle-East is limited, with few articles discussing the prevalence of this practice in Israel and the United Arab Emirates (Table 1). This contrasts significantly with other CM treatment modalities such as herbal medicine and acupuncture, which have been researched extensively. In one of the few cross-cultural surveys on the prevalence of CM use in northern Israel, a study of oncology patients found a significantly higher use of homeopathy in a cohort of Jewish patients with cancer compared to their Arab counterparts, with only 1.7 % of Arab patients reporting homeopathy use altogether [20]. The discrepancy between the widespread use of herbal medicinal and infrequent use of European-based CM modalities such as homeopathy in Middle-Eastern countries highlights the need for an in-depth study, this within a broad historical and socio-cultural context.

Table 1 Published research on homeopathy from Middle-Eastern countries
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Research on homeopathy across the Middle-East

A list of research published on the use of homeopathy in the Middle-East is presented in Table 1. Though several studies have focused on attitudes and perspectives of health care practitioners regarding CM, the use of homeopathy as a study outcome was only marginal. Indeed, little has been published on the interaction between the physician and the homeopath, or on the dialog between the physician and the patient using homeopathy. In contrast, there is a large body of research examining the effectiveness of homeopathy, both in animal and human clinical studies. Such research has been taking place throughout the Middle-East in countries which include Egypt, Iran, Iraq, Israel, and Lebanon. Researchers have conducted animal studies of individual homeopathic remedies (e.g., Hypericum perforatum [21], Tarantula cubensis [22], Calendula officinalis [23]) as well as multi-component homeopathic supplements (e.g. Engystol [24], Traumeel S [25] ) (Table 2).

Table 2 Frequently used Middle-Eastern traditional herbal and homeopathic remedies
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Clinical studies have examined the effects of homeopathy in gynecology (postpartum bleeding and premenstrual syndrome) [26, 27] ), hemato-oncology (chemotherapy-induced stomatitis) [28], neurology (cerebral palsy and trigeminal neuralgia) [29, 30], orthopedics (hallux valgus surgery) [31], oral health (stomatitis, aphthous ulcerations) [28, 32], pediatrics (cerebral palsy, asthma,) [29, 33], and psychiatry (generalized anxiety disorder) [34]. Researchers have also addressed related issues, such as the safety of homeopathic treatment in infants [35] and conducted a cost-effective analysis in atopic patients.

Research objectives for homeopathy in the Middle-East

Although currently limited, research on homeopathy in the Middle-East is advancing and is expected to spread throughout the region. There is therefore a need for a multi-national study which will examine the prevalence of homeopathy use, including homeopathic consultations and over-the-counter self-use of remedies as a primary outcome parameter. In addition, qualitative research on the use of homeopathy in settings such as cancer treatment may provide further insight into patient expectations and motivation for seeking out this modality, as well as the attitudes of health care professionals responsible for their care.

While the question of how homeopathy can induce physiological processes using compounds which have often been diluted well past Avogadro’s number (i.e., the number of units in mole of a substance, or 6.02 × 10−23) is important, research on homeopathy may extend our understanding on patient-centered care. In the UK, Brien et al. [36] studied the clinical benefits of homeopathy in rheumatoid arthritis patients and concluded that it is the consultation process and not the homeopathic remedy which improves patients’ symptoms. In a subsequent study, the same group of researchers analyzed the themes associated with enhanced coping and well-being, and found an increased awareness following the exploration of the narrative of illness [37].

An additional area of research which needs to be examined is the integration of homeopathic and traditional herbal medicine in Middle-Eastern countries. Table 2 presents the integration of these two treatment modalities, showing traditional herbals which are often administered as homeopathic remedies. Studies examining the cost-effectiveness and safety of homeopathic medicine should be conducted as well, especially in this part of the world, where sub-optimal medical care is often present.

Epilogue

The case of Naomi, a cancer patient treated with both conventional and homeopathic supportive care in an integrative oncology setting, should encourage research of this treatment modality. Her case also emphasizes the need for clinicians, researchers, and medical educators to develop a more patient-centered approach, with an awareness of patients’ health belief models as well as their traditional medicine legacy.