Complementary and Alternative Medicine in Brazil : one concept , different meanings

This article discusses the various meanings ascribed to the concept of Complementary and Alternative Medicine (CAM) in Brazil, where research on this theme has a limited tradition in terms of influences from anthropology, sociology of knowledge and epistemology, and sociology of CAM and clinical medicine. By means of the concepts identified in the literature, we elaborated a table with types of meanings. The terms Alternative Medicine and Complementary Medicine were found in more than one of the types in the table. Alternative Medicine identifies a model of medical practice influenced by the social, political, and economic context and by the logic of scientific production based on opposing pairs. Beginning in the 1980s, the important volume of reflections on official medical practice and the search for other forms of knowledge production led to the creation of the concept of Complementary Medicine. Its meaning is that of a new epistemological form of knowledge production between the official and alternative poles, a set of therapeutic practices, and confusion with the nomenclature for ancillary medical diagnostic tests, referred to in Portuguese as “com-


Introduction
The purpose of this article is to discuss the different meanings ascribed to the concepts of Complementary and Alternative Medicine (CAM) in Brazil.Interest in CAM has increased worldwide among users, researchers, funding agencies, and healthcare services 1,2,3 .
In Latin America in general, there are few researchers who have investigated this issue systematically.Most of the existing research output has been in the form of theses, dissertations, and books.In Brazil, CAM research has a limited tradition, although it has taken four directions.The first is influenced by anthropology and is the most extensive, since popular health practices and care have been studied since the 1940s 4,5,6,7,8,9 .The second is more recent, but spans over a decade and is more influenced by the sociology of knowledge and the philosophy of science, discussing scientific medical rationality and alternative medical rationality 10,11,12,13,14,15,16 .The third direction is even more recent and is influenced by sociology.It aims to develop a sociology of CAM using both qualitative and quantitative research with health services users, different professionals, public and private managers, and health policy administrators 17,18,19,20,21 .The fourth is the most recent and is mostly influenced by clinical medicine in the search for evidence for potential use of CAM in specific treatments 22,23 .
Brazilian CAM research is guided by the belief that one form of medicine is not opposed to another.Therefore, in principle, the issue is not to denounce given practices or to nurture deeply-rooted love-hate feelings.Neither is it about self-promotion, as some Brazilian journalists insist 24 .It is not about pointing out the therapeutic potential of official or unofficial medical practices, but rather to socially bring alternative and complementary practices together in different contexts, taking the literature as its basis and including research with CAM practitioners.

Materials and methods
This article is the result of a survey to answer the following epistemological question: why do physicians with an allopathic background (with its clear-cut definition and social recognition) opt to practice some sort of CAM?
Rational knowledge in the perception of the world, in the general sense, is developed on the basis of oppositions (e.g., night and day, heat and cold, life and death, etc.).In the history of dual classifications, Cartesian rationalism, Bacon's empiricism, and Comte's positivism added their strengths to guarantee a more official nature to the physical and natural worlds as sources of knowledge, relegating the human and metaphysical worlds to the status of alternative knowledge.The presence of alternative knowledge was mostly felt in the fields that produced practices, beliefs, social symbols, and values.However, this has led to the possibility of more than one meaning for the same word, which in turn is the aim of our analysis, i.e., to reflect on the production of a polysemy for CAM 25 .
We used Bourdieu's approach to data classification and analysis 26,27,28,29 .Using the concepts of field and habitus, we produced macrosociological and micro-sociological analysis and found emerging relations between them.From a macro-sociological perspective, we situate CAM in the Brazilian health field by discussing the theories used in CAM studies, the institutions that produce CAM in the health field, and correlated fields that support CAM ideas and development.Using the habitus perspective, we developed an analysis showing the individual ways, behaviors, and beliefs concerning CAM, emphasizing the relationship between individual and social interactions.
In this study, we have organized the various terms found in both a general and a specific way.To identify these terms in a broader sense, we use a table of names and types (Table 1).In order to discuss these terms in a more specific dimension, we reflect on their relationships, correlations, and particular meanings.With the concepts collected, we produced the abovementioned table, which we used to discuss the different meanings of CAM.
The "scientific" type is formed by the set of concepts which the health field labels as "official".This official identification stemmed from the connection between medical knowledge and the modern state 30,31 and the creation of the concept of biomedicine 32 , which meant the union of experimental biological precision and the existential "imprecision" of medical practice.
The "antithetical" type was identified in the health field as alternative because its practices maintained a less formalized dimension and it was more focused on the symbolic universe of the health-disease process.We find a first conceptual imprecision here, since alternative knowledge dates back to rational production in opposing pairs, which tells us that there was always the possibility of alternative practices.However, the 1960s counter-culture movement produced the specific Alternative Medicine model, with alternative practices opposed to official and hegemonic ones.This process started at a specific time and place, since the Cold War was in force, with each side punishing and excluding certain practices.There was a growing awareness of the fallacy of the development and progress concepts, which produced environmental destruction and social misery.Those were very productive times for (epistemological) philosophy, raising questions which remained unanswered and generating insecurity in the Western cosmological structure.There was intense experimentation in the educational field, with alternative pedagogical initiatives, and in social and sexual behavior as well.Disillusionment in the health sector led to the search for alternatives to the high costs of medical treatment, the multinational cartels, medicalization and iatrogenics, and distancing of medical professionals from patients.Last but not least, there was a reappraisal of knowledge production models in the "harder" sciences like physics and biology and the human sciences like sociology and philosophy.
From the "antithetical" group came medical rationality and the new therapeutic models.In the early 1990s the conceptual matrix of medical rationality was produced, which enabled an important differentiation in the epistemological study of CAM in Brazil.A medical rationality consists of a cosmology, medical doctrine, morphology, physiology, or vital dy-namics and a diagnostic and therapeutic system 10 .Armed with this conceptual corpus, it was possible to differentiate alternative medical rationalities and the set of alternative medical practices.Thus, the "rationality" type presents the medical models in their biological dimensions, such as morphology, physiology, and therapeutic systems, and philosophical dimensions such as medical cosmology and medical doctrine.As long as a medical activity possesses all these elements, it can be recognized as a medical rationality, while the absence of one of these elements positions the activity as a diagnostic or therapeutic practice.
The new therapeutic models present a set of names for the practices they employ to build the elements of rationality or simply operate as alternative diagnostics or therapeutics.

Discussion
As observed in numerous studies 33,34 and in our table, Alternative Medicine presents the following types: official, antithetical, and new therapeutic models.For each of these types, the name is ultimately responsible for constructing its meaning, which can be defined as something "in relation to" and not a thing in itself.Moreover, meaning does not exist in itself but is determined by ideological positions in play during the socio-historical process in which the words were produced.The meaning of words change according to the position in which they are used 35,36 .
The meaning of Alternative Medicine as used in the "official" type may be understood as the foundation of the first meaning of Alternative Medicine.For example, a reference search on MEDLINE suffices to understand its projection, since there is a long list of citations on alternative medicine in relation to diagnostic construction, alternative surgical interventions, and even alternative clinical treatments.
The second meaning of Alternative Medicine is expressed in the "antithetical" type, which functions as a space for reformulation/substitution of the official model that can thereby operate reforms of the management model or the technical assistance model.The greatest mentor of this meaning of Alternative Medicine in Latin America was Ivan Illich in his book Limits to Medicine: Medical Nemesis, the Expropriation of Health 37 , presenting strong criticism of the collective and individual iatrogenic process promoted by the official or biomedical model.
The third meaning of Alternative Medicine is in the typology of new therapeutic systems.If the biomedical model had enjoyed greater capacity in the past, this model probably would never have existed.The official type operated according to a logic based on exclusion, which did not recognize any alternative perspective that differed from those that permitted its in- ternal reformation.This increased the amount of conceptual confusion regarding the use of the Alternative Medicine concept until it became possible to differentiate between an alternative medical rationality and a non-biomedical alternative therapy.This differentiation clarified the structure of the new therapeutic systems based on elements and different rationality techniques.This imprecision also repeated itself in relation to the concept of Complementary Medicine, differing in that it dealt with a more recent discussion, although originally the notion of scientific complementariness emerged in the late 1920s, as proposed by Louis de Broglie and Niels Bohr.Complementariness originates in physics, where research demonstrated that an electron has characteristics that are complemented by energy and matter.This notion indicated another construction of knowledge, no longer based on opposition and joined with other epistemological criticism 38 .
In the early 1980s, science accumulated a major body of evidence that signaled an imprecision in science itself, and subsequently the volume of questions concerning Alternative Medicine could no longer be ignored 39,40,41,42 .Hence, the need and desire to incorporate new therapeutic practices into the official medical systems helped create the concept of Complementary Medicine 43,44 .
Originally, the concept was produced to transmit the logic of inclusion, as opposed to the exclusive logic of scientific epistemology 36,45 .This is obviously a confounding factor, because Complementary Medicine lacks the capacity of medical rationality, but is not only an alternative technique 9,10,46 .The logic of knowledge production is certainly more profound than the internal reforms of the antithetical type, since it proposes the incorporation of difference.This confusion was soon identified as a conceptual imprecision, more so after using the concept of Complementary Medicine to refer to a group of practices.
The health field in Brazil entered the 1980s with a confusion of meanings in Complementary Medicine.At times it had an epistemological dimension, and was therefore a group of categories and concepts, and at other times it had the dimension of a concept referring to a group of practices.When this imprecision was submitted to sociological observation, it was possible to perceive two perspectives: (1) Complementary Medicine, viewed as a modern synonym of Alternative Medicine in which the renomination of previously excluded practices would be fundamental for its incorporation into the official health services and (2) the maintenance of the original meaning of complementary logic that is being replaced by the concept of Integrative Medicine 47,48 .In Brazil, the CAM concept shows yet another confounding element.In Portuguese, in medical practice, ordering an ancillary diagnostic test is referred to as a "complementary tests order".Thus, when one speaks of "complementary medicine", many health professionals interpret the term as part of the biomedical model.This may explain why some professionals working with CAM practices now refer to themselves as Integrative Medicine professionals.

Table 1
Typologies and concepts of medical practice in the field of healthcare.