2.1 Policies, laws, regulations, programmes, national centers

In recent times the Office of Alternative Medicine (OAM) in the USA, strongly supported by two political chairpersons in the US, changed to a national center, the National Center for Complementary and Alternative Medicine (NCCAM) in 1995 [8].

Any government-sponsored center or office that is officially mandated and in charge of issues related to TM&CM can be defined as a national office for TM&CM clarified the report of the World Health Organization [5].

The data published in 2019 clearly showed that more and more countries are recognizing the medical role of TM&CM in their national health systems [5].

By 2018, 98 UN Member States had developed national policies on TM&CM, 109 had launched national laws or regulations on TM&CM, and 124 had implemented regulations on herbal medicines [5]. The UN Member States took steps between 2005 and 2018 to promote the safety, quality and effectiveness of TM&CM [5]. 88% UN Member States have acknowledged their use of TM&CM which corresponds to approximately 170 Member States [5]. These are the countries that have, for example, formally developed policies, laws, regulations, programmes and offices for TM&CM, and the actual number of countries using TM&CM is likely to be even higher underlined the World Health Organization (WHO) in her report in 2019.

Unfortunately, only 79 member states out of the 194 Member States (40%) reported having a national programme for TM&CM [5]. Surprisingly member states without a national programme or a national office for TM&CM in 2018 are Germany and Switzerland (p.21/WHO 2019; p.23/WHO 2019).

But in Switzerland after a poll, the national policy for TM&CM is embedded in the Swiss Federal Constitution, in Article 118a: “Complementary medicine: The Confederation and the Cantons shall within the scope of their powers ensure that consideration is given to complementary medicine”, issued in 2009 (WHO 2019, p.140) with the implementation in the Swiss health insurances, named “Grundversicherung” and “Zusatzversicherung”.

2.2 The use of CAM (complementary and alternative medicine)- inputs

Kemppainen et al. [9] announced that (CAM) has become more popular and accepted in Europe [10-13].

This trend which reflects other trends is observed in other western countries outside of Europe [14].

In a population-based survey in Pakistan related to trends in the use of complementary and alternative medicine, the overall trend in Pakistan shows that 51.7% (CI 54.3-49.1) chose complementary and alternative medicine (CAM) while 48.3% (CI 50.71-48.89) chose biomedicine, unfortunately often patients did not reveal the use of CAM to the biomedicine practitioners [15]. In Japan, with a current population of more than 126 million people, 50-76% of the population uses at least one type of CAM each year [16-19].

Also, in other countries like in Switzerland the trend to use CAM increases from currently 1/3 of the population[20,21].

Kemppainen et al. published further in 2018 that in total, 25.9% of the general population had used CAM during the last 12 months. The use of CAM varied hereby greatly by country, from 10% in Hungary to almost 40% in Germany [9].

2.3 Consumer and practitioner in Europe

A workshop with the title “Complementary and Alternative Therapies for Patients Today and Tomorrow” was held at the European Parliament in Brussels in autumn 2017 with closing remarks that, that CAM therapy will bring benefits to patients in the EU, namely a more varied choice of therapies [22]. Alone for Europe the European Commission estimates that consumers’ spending on CAM is almost EUR 100 million [22,23]. In Europe, CAM is practiced by approximately 145.000 physicians (trained in both conventional/ traditional medicine and CAM therapies), as well as more than 160.000 non-medical practitioners (NMP) [22].

2.4 Aspects of difficulties & lacks, efficacy, and effects

In 2012 the European Commission’s Directorate-General for Research and Innovation founded the so named CAMbrella project: a three-year survey of the status of CAM in Europe between 2010 and 2012.

The overall findings of the project were published in 2013, and showed

• a lack of data concerning the efficacy of CAM treatments,
• as well as a lack of commonly agreed standards concerning definition,
• a lack of legal status, and
• a lack of provisions of CAM.

The CAMbrella project also concluded that there is an evident lack of integration of CAM into national public health systems, as well as an inadequate availability of research facilities [22].

Sugito and Son in 2019 [16] added concerning obstacles to the use of complementary and alternative medicine by primary care physicians.

They concluded that various factors interfere in the use of complementary and alternative medicine by primary care physicians.

They suggested to develop approaches to overcome lack of education and insufficient collaboration among regional health professionals, but additional the authors presented results of another study of Morion et al. [24], to overcome

• the absence of common language,
• to face the organizational and legal context, and
• the limited scientific evidence like concluded with other scientific data [24].

Further the co-authors presented an overview about barriers to use of CAM in a table and underlined the existing

• deficits in the awareness of health-care providers, like the lack of knowledge and understanding about CAM,
• deficits about characteristics of CAM, like insufficient aspects of evidence for therapeutic effects,
• deficits in the medical system and organizations like the lack of CAM education or disrespect for CAM, and
• regional factors like insufficient cooperation between experts in the region [16].

Segar underlined 2011 that debates and discussions over the efficacy of complementary and alternative medicine (CAM) are often highly polarized and have received much publicity of late. Critics of CAM so Segar is often point to the lack of scientific evidence demonstrating its efficacy. The lack of evidence gathered by means of randomized controlled trials is used to make the claim that CAM is no more effective than placebo, means like a sugar pill.

Segar concluded that quite often CAM therapists and patients do not reflect the polarities evident in the public debate in their own understanding and usage of CAM. Segar comes to the conclusion that they are pragmatic pluralists with clear ideas about when CAM treatment is appropriate [25].

2.5 Efficacy

But nevertheless, Tan et al. concluded after their analyses and based on the guidelines of the Clinical Psychology Division of the American Psychological Association, that their findings indicate that

1. some CAM modalities have a solid track record of efficacy, whereas others are promising but require additional scientific research, Tan et al. [26].
2. data of another study of Boston et al. [27] with 80 patients from a private herbal clinic and the Georgetown Public Hospital Diabetic and Medical Outpatient Clinic indicated that a significant number of diabetic patients using herbs alone for their treatment had after the interventions normal results.
3. data of another detailed scientific analyses by Fischer et al. [28] with an extensive search of the main medical databases EBSCO, CINAHL, Medline, AMED and SCOPUS with 7006 records of which 113 papers were screened has documented that women's assessment of efficacy of different CAM modalities is positive.

2.6 Aspects of solutions

• More understanding for and knowledge about CAM und CM is requested.
• More scientific exchange between the medical disciplines should happen.
• More interdisciplinary scientific exchange should happen.
• More documentations, and more scientific presentations should be given related to TM, CM, and CAM.
• More research should be undertaken to prove the effectiveness of complimentary or CAM therapies [29].
• Evidence is required for biological or clinical plausibility [29].

1. Building up an expert panel like suggested from WHO [30] in this context could be supportive.
2. An e-databank with studies and publications in the field to avoid further overlapping CAM /CM studies and to allow to build up a cooperation platform for e-data, e- services, innovations, development, and scientific exchange.
3. Another possibility is to explore the patients, to ask them about CM, CAM effects and healing processes from their point of view with tools, scientific analyses, interviews and other forms of interventions.