EDITORIALS

American Journal of Public Health | October 2002, Vol 92, No. 101564 | Editorials

dard of positivist biomedical sci-ence may not always be a fairpoint of departure, it is nonethe-less the framework within whichwe decide truth. It can be apurely reductionist model of sci-entific reason, with its linearmodel of causality and attemptsat objectivity. It can also be aless reductionist approach,where causality may be under-stood more as a web rather thana thread, and the subjectivity oflived experience once again as-sumes a prominent role in un-derstanding health and well-being. With this less reductionistapproach, the interrelationshipsbetween cultural and personal,public and individual healthbegin to become clearer.

The works collected here rep-resent the beginning of an im-portant dialog for public health.Although in different ways,complementary and alternativehealth care and healing prac-

tices represent a vast and as yetunrealized sector of the publichealth systems of developed anddeveloping nations. Moreover,the limits of our current bio-medical knowledge and capabil-ities cannot be denied. We donot, as yet, have all the answers,or even, for that matter, knowall the questions. There aremore things in heaven and earththan can be dreamt of in ourcurrent biomedical philosophies.Stagnant biomedical orthodoxycannot achieve the fullness ofpublic healths potential and hasno role to play in human prog-ress. Maintaining an openness tothis reality may serve to helpmarshal the resources of indige-nous, complementary, and alter-native health practices in theservice of public health, nowand in the future.

Vincent M. B. Silenzio, MD, MPHGuest Editor

About the AuthorVincent M.B. Silenzio is with the Centerfor Family Medicine, Columbia University,New York, NY.

Requests for reprints should be sent toVincent M.B. Silenzio, MD, MPH, 630W 168th St, VC 12-217, New York, NY10032.

This editorial was accepted June 26,2002.

References1. World Health Organization(WHO). WHO launches the first globalstrategy on traditional and alternativemedicine. Available at: http://www.who.int/inf/en/pr-2002-38.html. AccessedMay 20, 2002.

2. McNeil D. With folk medicine onrise, health group is monitoring. NewYork Times. May 17, 2002:A8.

3. National Center for Complemen-tary and Alternative Medicine. Majordomains of complementary and alterna-tive medicine. Available at: http://nccam.nih.gov/nccam/fcp/classify. Ac-cessed June 7, 2001.

4. Green LA, Fryer GE Jr, Yawn BP,Lanier D, Dovey SM. The ecology ofmedicine revisited. N Engl J Med. 2001;344:20212025.

5. Weiss R, Fintelmann V. HerbalMedicine. New York, NY: Thieme;2000.

6. Kleinman A. Patients and Healersin the Context of Culture: An Explorationof the Borderland Between Anthropology,Medicine, and Psychiatry. Berkeley: Uni-versity of California Press; 1980.

7. Baer H. Biomedicine and Alterna-tive Healing Systems in America: Issues ofClass, Race, Ethnicity and Gender. Madi-son: University of Wisconsin Press;2001.

8. Green E. Engaging indigenous Af-rican healers in the prevention of HIVand STDs. In: Hahn R, ed. Anthropologyand Public Health: Bridging Differences inCulture and Society. New York, NY: Ox-ford University Press; 1999:6383.

9. Blank M. Alternative mental healthservices: the role of the Black church inthe South. Am J Public Health. 2002;92:16681672.

10. Helman C. Culture, Health and Ill-ness: An Introduction for Health Profes-sionals. Oxford, England: Butterworth-Heinemann; 1997.

11. Napoli M. Holistic health care fornative women: an integrated model. AmJ Public Health. 2002;92:15731575.

12. Dobkin de Rios M. Lessons fromshamanic healing: brief psychotherapywith Latino immigrant clients. Am JPublic Health. 2002;92:15761578.

Walter B.Cannon and VoodooDeath:A PerspectiveFrom 60Years On

The remarkable accuracy of Wal-ter B. Cannons 1942 article Voodoo Death, excerpted inthis issue of the Journal,1 propos-ing a scientific basis for voodoodeath is at once surprising andnot surprising. Voodoo death, asdefined by Cannon, is sudden,unexplained death resulthingfrom a voodoo curse. At firstglance, it is surprising that scien-tific discoveries over the last 60years have largely filled out thedetails ofbut not overturnedmost of Cannons proposed ex-planation of the physiological un-derpinnings of this phenomenon.On the other hand, it is not sur-prising when one considers thefact that Cannons researchformed the basis for much of ourmodern understanding of thephysiological response systems

involved in linking emotions,such as fear, with illness.

If submitted to a scientificjournal today, this paper wouldnot make it beyond the reviewprocess, as it would be described(probably with some disdain) assimply anecdotal and hypothet-ical. However, fortunately for ourgeneration, our predecessorswere apparently not averse torecording oral reports of inexpli-cable phenomena in detailevendown to the names of the indi-viduals who experienced or per-petrated these events.

Thus, Cannon starts his articlewith several anecdotal case re-ports, all of which share severalimportant features that lead himto propose, first, that there mayindeed be a physiological basisfor the phenomenon of voodoo

death and, second, what thatphysiological basis might be.

The dramatic suddenness ofthe illness following the threat,coupled with a lack of any appar-ent injury, exposure to toxins, orinfection suggested to Cannonthat merely the fear of deathcould, through physiological re-sponse mechanisms initiated byfear, precipitate death itself.

Cannon focused on the sym-pathetic and sympathico-adrenal divisions of the nervoussystemterms still in use today(although sympatho-adrenal isnow the more common term).He outlines all the aspects ofbodily function over which thisarm of the nervous system exertscontrolblood vessel contraction,dilation of bronchioles, adrena-line release, release of sugar

EDITORIALS

October 2002, Vol 92, No. 10 | American Journal of Public Health Editorials | 1565

from the liverall effects that to-gether prepare the animal to at-tack or runto fight or flee.Cannon thus elegantly lays outboth the physiology and the evo-lutionary rationale for the fightor flight response, a term still inuse today that he coined to de-scribe this neurophysiologicalbehavioral response pattern.

We could not have provided abetter rationale for this aspect ofthe phenomenon today. Thispiece has stood the test of time.In the 60 years since Cannonfirst published his work, we havesimply gained a clearer under-standing of the brain regions thatbecome activated when a fearfulstimulus is experienced and abetter road map of the pathwayslinking those brain centers in-volved in receiving sensory sig-nals (in Cannons example, seeinga bone pointed at one) to thepart of the brain that processesthe emotional component offearthe amygdala. In todaysterms, we would call this thevision-to-fear pathway or audi-tory-to-fear pathway, dependingon the sense through which thethreat is initially received.

We have a deeper understand-ing of the neurotransmitters andneuropeptides involved in initiat-ing these responses and perpetu-ating them through learning andmemory. We know how suchchemical signals are translatedinto electrical impulses and howquickly or slowly they are con-veyed along nerve fibers. Andwe now know that such nervechemicals and proteins are madeby genes within the nucleus ofnerve cells, that are switched onand off by all sorts of chemicaland physical signals. We knowthat when we learn to fear some-thing there are permanentchanges in the shape and wiringof nerve cells that make it more

likely that the next time we expe-rience the fearful stimulus, thosesame pathways will be switchedon all the more rapidly.

Strikingly absent, however,from Cannons explanation is thehormonal stress responsethecascade of hormones releasedfrom the brain, pituitary gland,and adrenal gland within min-utes of exposure to any sort ofstressor. This is because in 1942,when the article was written,many of these hormones wereyet to be discovered. Further-more, the term stress, popular-ized by Cannons admirer HansSelye and others in the postwarperiod, was not yet in generaluse. The structure of cortisol, thehormone released from the cor-tex of the adrenal glands duringstress, was identified in 1936 byEdward Kendall and TadeusReichstein,2,3 who received theNobel Prize for their discoveriesin 1950 together with PhilipHench. However, the full cascadeof hormones involved in the hor-monal stress response was notfully elucidated until the identityof the brains hypothalamic stresshormone, corticotropin releasinghormone or CRH, was discov-ered by Wylie Vale in 1981.4

Thus, Cannon could not haveincluded in his scenario of thepossible causes of voodoo deaththe role of hypothalamic CRH re-leased after signals from theamygdala, the brains fear center,reached the hypothalamus. Norcould he include how the cross-talk between the brain stemadrenaline centers involved ininitiation of the sympathetic re-sponse could coordinate withhormones released from thebrains hypothalamic stress cen-ter5 to cause a massive release ofboth adrenaline-like nerve chem-icals and stress hormones. To-gether these might well cause ill-

ness,69 including loss of appetite,weakness, cardiac arrhythmias,and even vascular collapse thatcould result in death.

Thus, Cannons rather simplis-tic explanation of how shockcould ensue simply by removalof blood volume through sympa-thetic clamping of peripheral ar-terioles is in part correct, but hecould not know of the complex-ity of hormones and nerve chem-icals that, when all released to-gether, might be more likely toproduce the cardiac arrhythmiasand vascular collapse than hepredicted.

Finally, he did not have thetools to go beyond hypothesisinto the experimental stage inhumansto measure the re-sponses he predicted and toprove through such measureswhich parts of his hypotheseswere correct. He could not, aswe can today, use neuroimagingtechnologies, electroencephalo-grams, and even single neuronrecordings to measure nerve cellactivation in different stress- andfear-related brain regions. Hecould not use telemetry devicesand complex computer-gener-ated mathematical analyses tononinvasively measure changesin heart rate variability, bloodpressure, and cardiac blood flowin humans while they are goingabout their daily routines. Norcould he ask his subjects to re-spond to questions, programmedin their palm-pilots and synchro-nized with their heart rate moni-tors, about their moment-to-moment emotional states, toindicate within millisecondswhether a given threat caused aparticular arrhythmia. He couldnot imagine that one could mea-sure minute amounts of stresshormones and nerve chemicalsreleased into the saliva duringfear, simply by asking the subject

to chew on a lemon-soaked cot-ton swab and spit into a cup.And he could not imagine howsuch hormones and nerve chem-icals could possibly affect cells ofthe immune system to causechronic wasting or disease.

Cannon could not imaginehow one could accomplish allthis because the tools of neuro-science, molecular biology,computational mathematics, bio-engineering, neuroimaging, en-docrinology, and cellular immu-nology had not yet beeninvented or discovered. But, onthe basis of observation, logic,and deduction, he did imaginethat there could be a biologicalbasis to the seemingly magicalphenomenon of voodoo death.And, whats more, he had thecourage to predict and record inwriting that there should be,some day, a way to get the an-swers. In this, Cannon was per-haps among the first physiolo-gists to apply his scientificbackground to attempt to ex-plain otherwise inexplicable ill-nesses and phenomena thatseemed to link emotions and dis-ease. This approach, combiningopen-mindedness and scientificrigor, is the essence of moderncomplementary and alternativemedicine research.

Esther M. Sternberg, MD

About the AuthorThe author is with the Integrative NeuralImmune Program and the Section on Neu-roendocrine Immunology and Behavior,National Institute of Mental Health, Na-tional Institutes of Health, Bethesda, Md.

Requests for reprints should be sent toEsther M. Sternberg, MD, Bldg 36, Rm1A-23, 36 Convent Dr, MSC 4020, Na-tional Institute of Mental Health, NationalInstitutes of Health, Bethesda, MD20892-4020 (e-mail: ems@codon.nih.gov).

This editorial was accepted June 7,2002.

EDITORIALS

American Journal of Public Health | October 2002, Vol 92, No. 101566 | Editorials

References1. Cannon WB. Voodoo death. AmJ Public Health. 2002;92:15931596.

2. Mason HL, Myers CS, Kendall EC.The chemistry of crystalline substancesisolated from the suprarenal gland.J Biol Chem. 1936;114:613631.

3. Hench PS, Kendall EC, SlocumbCH, et al. Effects of cortisone acetateand primary ACTH on rheumatoid

arthritis, rheumatic fever and certainother conditions. Arch Intern Med.1950;85:545666.

4. Spiess J, Rivier J, Rivier C, Vale W.Primary structure of corticotropin-releasing factor from ovine hypothala-mus. Proc Natl Acad Sci USA. 1981;78:65176521.

5. Sawchenko PE, Li HY, Ericsson A.Circuits and mechanisms governing hy-

pothalamic responses to stress: a tale oftwo paradigms. Prog Brain Res. 2000;122:6178.

6. Webster JI, Tonelli L, SternbergEM. Neuroendocrine regulation of im-munity. Annu Rev Immunol. 2002;20:125163.

7. Elenkov IJ, Wilder RL, ChrousosGP, Vizi ES. The sympathetic nerveanintegrative interface between two super-

systems: the brain and the immune sys-tem. Pharmacol Rev. 2000;52:595638.

8. Goldstein, DS. The Autonomic Ner-vous System in Health and Disease. NewYork, NY: Marcel Dekker Inc; 2001.

9. Sternberg EM. The Balance Within:The Science Connecting Health and Emo-tions. New York, NY: W.H. Freemanand Co; 2000.

AlternativeTherapies andPublic Health:Crisis orOpportunity?

In 1994, Jennifer Jacobs, MD,MPH, contacted the national of-fice of the American PublicHealth Association (APHA) aboutprocedures to start a new organi-zational component of the associ-ation and to schedule time for anorganizational business meetingat the 1994 annual meeting. Theresult was a new Special PrimaryInterest Group (SPIG) that, aftermuch discussion at the annualmeeting, was eventually namedAlternative and ComplementaryHealth Practices (A. Trachten-berg, oral communication, 2002).The term health practices waschosen to reflect a neutral stanceon whether such practices mightbe therapeutic, preventive, oreven harmful.

At the 1994 meeting, about30 members elected the newSPIGs first cochairs, Jennifer Ja-cobs and Alan Trachtenberg, MD,MPH, who at that time was alsodirecting the National Institutes ofHealth (NIH) Office of Alterna-tive Medicine. Lawrence Kushi,ScD, was elected the SPIGs firstprogram chair. From 1995 to thepresent, the SPIG has presentedan interesting and well-attendedscientific program at every an-nual meeting and has grown toover 200 primary members.

The public health imperativefor the study of these health prac-tices was their sheer prevalence,which had been brought to majorpublic attention by the survey byEisenberg et al. in the New En-gland Journal of Medicine.1 Mem-

bers of the new SPIG assumedthat some practices would be help-ful, some harmful, and somemerely an unnecessary expense,and that sound clinical researchwas required to separate thewheat from the chaff. However,we recognized that a public healthapproach to alternative healthpractices would also require alarger view, one that incorporatescultural competence as an impor-tant value in primary health care.For instance, if a health center wasproviding community-oriented pri-mary care for a particular commu-nity, the health practices, beliefs,and traditions of that communitymight need to be addressed to en-sure adequate medical utilizationand compliance by members ofthe community, as well as to pro-vide for community input, partici-pation, and self-governance ofhealth care. The new SPIG wasaware of the World Health Orga-nizations (WHO) traditional medi-cine initiative,2 which sought to in-corporate traditional tribal healersinto the public health infrastruc-ture around the world, as well asthe practice at many IndianHealth Service units of finding cre-ative ways to provide space andeven positions for tribal healers.

ALTERNATIVE IN THEIRORIGIN

Therapies and other healthpractices seem to have been la-beled alternative in the Westernbiomedical setting because they

came from outside that setting.They are alternative primarily intheir origin. Therapies like sur-gery, psychotherapy, and the earlyantibiotics came from within ourown Western biomedical traditionand predated the advent of evi-dence-based medicine. Some havesince been confirmed by rigorousmethodology, but many have not.3

Likewise, new technologies suchas intrapartum fetal monitoringmay emerge from within our ownbiomedical culture and becomewidespread, despite an absence ofrigorous data on benefits.

The arts of medicine and pub-lic health policy have often re-quired that practitioners maketheir best educated guess as towhat to do, even in the absenceof adequate data. Doing nothingmay be even worse, or may beunacceptable to the patient or tothe public. Such educatedguesses, made with the best ofintentions, will clearly reflect cul-tural and individual biases.

Other biomedical cultures,many as scientifically oriented asour own, have made very differentdecisions than we in the UnitedStates have about the incorpora-tion of what we call alternativetherapies into national health pro-grams. (Some would say that thefact they these countries have na-tional health programs, while theUnited States still does not, sug-gests a certain superiority of thesenations general approaches.) Forinstance, phytomedicines (herbalpreparations) and even homeo-