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sys-tem notorious for its controversial principles, and why do they do so? Despite homeopathy’s worldwide popularity, we have relatively little information about homeopathic patients as a group to help us answer these questions. A disproportionate amount of the available data are from studies of what we have come to call complementary and alternative medicine (CAM) in the United States. Homeopathy is but a small portion of CAM, and Americans represent a relatively small fraction of worldwide users of homeopathy. It is therefore difficult to answer broad questions about homeopathic patients worldwide. Despite the relative mystery, however, the data are sufficient to conclude that modern homeopathic patients, at least in the Western world, are different from patients who choose only conventional treatment.

Who Uses Homeopathy?

Homeopathy Is Growing Rapidly

One of the signal events in the rising awareness of complementary medicine in the United States was a 1993 article by David Eisenberg and associates in New England Journal of Medicine.¹This study repre-sented the first national measuring stick for

“unconventional medicine,” as Eisenberg then labeled CAM. The popularity of CAM surprised many and led to a swelling tide of investigation and even greater popularity.

Eisenberg’s survey found only modest use of homeopathic medicine in his study population. In 1990, approximately 600,000 American adults saw homeopathic practitioners, a very small fragment of users of CAM at the time. However, the survey made a particularly interesting finding about homeopathy.

In addition to the 600,000 adult homeopathic patients, another 1.2 million American adults used homeopathy for self-care.¹ In other words, approxi-mately two thirds of patients using homeopathy did so without professional supervision.

Although the 1990 popularity of homeopathy was small, it had already been growing rapidly. In the 1980s, sales of homeopathic medicine rose at an annual rate of approximately 20%.² Evidence is accumulating that this rising interest has not abated, but that the pace of homeopathic expansion has actually accelerated.

In 1997, a survey by Landmark Healthcare³found that 5% of the American adult population (approxi-mately 9 million people) reported use of homeo-pathic products in the prior year. Self-treatment accounted for 73% of that use. In addition, 61% of those who had heard of homeopathy reported they were either very likely or somewhat likely to turn to homeopathy if the need arose.

Eisenberg and his associates at Harvard conducted another national survey in 1997,⁴following up on their 1990 data. This time they found that the use of home-opathy increased fivefold to 6.7 million adults—3.4% of the adult population. They also found that the previ-ous dominance of homeopathic self-treatment over professional care increased to more than 82%. This meant that 5.5 million American adults were using homeopathy without professional supervision.

Assuming that the popularity of homeopathy has continued to grow at the same pace, the number of adult Americans using homeopathy in 2002 would have risen to 12 to 13 million, with 8 to 10 million using it on their own.

Although these projections are impressive, a 1999 survey suggests they might significantly underesti-mate the popularity of homeopathy.⁵ Roper Starch Worldwide conducted telephone interviews with 1000 Americans who identified themselves as the pri-mary grocery shopper for their families; 17% reported using homeopathic remedies to maintain health.

Homeopathy in Children

As with CAM use in general, the use of homeopathy in children is disappointingly mysterious. Many of

the most popular homeopathic products in the United States are specifically intended for pediatric use, and a number of studies have been published regarding the use of homeopathy in a variety of pedi-atric conditions.^6-9 However, we have only limited national data regarding the extent and nature of pediatric use.¹⁰ Studies in other countries suggest that although the use of CAM is less common in pediatric populations than among adults, homeop-athy represents a relatively larger portion of that pediatric use.^11-14

Many who are concerned with pediatric use of CAM therapies are concerned about the children, whose use of CAM therapies is not self-determined. It is possible that children may suffer adverse effects from CAM treatment or from neglect of beneficial conventional treatment. A recent regional study raised this issue in the homeopathic community.

As a part of a survey of professional homeopaths and naturopaths in the Boston area, investigators asked how they would manage a febrile newborn infant.¹⁵ Half of the nonphysician homeopaths reported that they would not immediately refer a febrile newborn to a conventional physician (slightly better than the 60% nonreferral rate among the naturopaths). Although the high incidence of this questionable response creates anxiety about the qual-ity of nonphysician homeopathic care, it is only one small bit of data from a small survey considering one very specific clinical scenario. This finding was sur-prising because all major homeopathic training pro-grams in the United States include instruction about appropriate medical referrals. Clearly, we need more data about the use of homeopathy among pediatric populations, and homeopathic educational institu-tions must be certain that graduating students rec-ognize their limitations and the need to cooperate with conventional physicians.

Much of Homeopathy is Self-care

One of the most important facts for conventional health care providers to grasp about homeopathy is the predominance of self-care. This pattern is import-ant, because most of those who use homeopathy are not doing so under the supervision of professionally trained homeopathic practitioners. Thus most ho-meopathy users are quite likely to receive their medical care from conventional health care providers.

Because of the increased time they spend with each patient, classical homeopaths tend to see many fewer

patients in a day than do physicians. As a result, in some areas of the United States the average busy pri-mary care physician might see more patients who use homeopathy than does the homeopathic practitioner down the street.

Unfortunately, considerable evidence supports the belief that most patients who use CAM do not tell their physicians.^1,4,16-18So, not only do many con-ventional primary care physicians care for a large number of patients who use homeopathic remedies, they are unaware of this usage. For the patient to maximize the benefit from treatment while minimiz-ing adverse effects, the physician must be aware of all elements of that treatment. Homeopathy is especially challenging in this way because of its popularity as a self-care modality.

Patient use of homeopathy unfettered by profes-sional supervision is not a new phenomenon, but rather a long-standing tradition. Since the middle of the nineteenth century, homeopathy’s greatest popu-larity has been among laypeople treating themselves or family members, particularly mothers treating their families. For more than 150 years, until the late 1980s, the largest-selling book on homeopathy was Constantine Hering’s Domestic Physician. Written ini-tially as a self-treatment manual for Moravian mis-sionaries, the author describes his book in the introduction: “It is intended to be an advisor in many cases of indisposition, when one will not or cannot consult a physician.”¹⁹ It was most widely used by

“Dr. Moms” throughout North America. Profes-sionally administered homeopathy has always been the exception rather than the rule.

CAM Demographics

More specific information, although still quite lim-ited, is just now becoming available about users of homeopathic medicine. Again, because the bulk of data we have pertains to the larger population of CAM users, let us first consider that information and then use the meager homeopathy-specific data to dif-ferentiate the homeopathic subpopulation. The best quality data come from Eisenberg’s most recent U.S.

survey.⁴

CAM users had more education and higher incomes than Americans who did not use CAM. CAM use was most common among females, adults in the 35-to 49-year-old age-group, and Americans living in the Western states. All ethnic groups used CAM, although it was least common among African-Americans (33.1%).

These distinctions are only a matter of degree. CAM practices are so common that essentially all popula-tions in all parts of the United States use them often.

Homeopathy Demographics

Demographic information about homeopathic patients is largely confined to data from two studies, Goldstein and Glik’s survey of patients seeking pro-fessional homeopathic care in the Los Angeles area²⁰ and a national sample of physicians practicing home-opathy conducted by Jennifer Jacobs and associates.¹⁰ Both studies surveyed the subset of professional American homeopathy rather than the more preva-lent self-care. Although both surveys are limited in scope, the data appear meaningful and useful in our attempts to understand professional homeopathic practice.

Goldstein’s regional study found a pattern of demographic characteristics that was much the same as the one seen in general surveys of CAM users.

Homeopathic patients had above-average incomes and were highly educated, even more so than average CAM users. More than two thirds of the patients sur-veyed had completed a college degree, and 95% had attended college.

Jacob’s survey, like Eisenberg’s, found significant differences in the financial aspects of the homeo-pathic encounter compared with conventional medi-cine. Jacob’s survey was conducted in 1992, which may alter interpretation of some of the data.

Although both Eisenberg surveys found that well more than half of the expenses for professional CAM treatments were not reimbursed by health insurance, Jacobs found that less than 20% of homeopathic vis-its were not reimbursable by insurance. Given the recent growth in insurance plans that restrict the panel of providers and the rarity of homeopaths prac-ticing within such restrictions, a new survey is likely to reveal significantly different insurance figures.

Homeopathic practitioners commonly report that many of their patients with health insurance pay out-of-pocket for homeopathic services because their insurance does not cover visits to a homeopath.

Jacobs learned that the ages of patients seeking homeopathic treatment diverged significantly from those seeing conventional physicians. The portion of conventional patients who were elderly was twice that of homeopathic patients. Similar differences were seen in the 15- to 24-year-old age-group (5.2% of homeopathic patients versus 11.6% of conventional

patients). Patients aged 25 to 64 represent a some-what larger percentage of homeopathic practitioners’

patients.

Finally, given our limited data about CAM use in children, the data in this study add significantly to our understanding. Jacobs found that 23.9% of homeopathic patients in the sample were 14 years or younger compared to only 16.6% of conventional patients. Two of the three conditions most com-monly treated by homeopaths (asthma and otitis media) are quite common in the pediatric popula-tion. Jacob’s data and the popularity of homeopathic over-the-counter (OTC) products specifically intended for use in children suggest that the strength of the homeopathic presence in pediatrics may dis-tinguish it from other CAM therapies.

Homeopathic Regular Age Physicians (%) Physicians (%)

>64 10.5 20.5

45-64 27.8 22.8

25-44 32.6 28.5

15-24 5.2 11.6

<15 23.9 16.6

Homeopathic Practice Patterns

Jacob’s survey disclosed other highly important dif-ferences in the practice patterns of homeopaths com-pared with conventional physicians. Visit length, number of medications prescribed, and use of labora-tory testing all contrasted markedly. These differ-ences could certainly account for some of the appeal of homeopathy to patients who are concerned about overuse of prescription medication and frustrated by the increasingly limited time they have to discuss their concerns with their physician.

Homeopaths spent more time with their patients.

Nearly 75% of homeopathic visits were more than 15 minutes in length, compared with 23.2% of conven-tional visits. Similarly, the mean duration of a homeo-pathic visit was 30 minutes, but only 12.5 minutes for a conventional practitioner. Given the great amount of clinical information required for classical homeo-pathic diagnosis and treatment, this dissimilarity is easy to understand.

Another distinction, which is obvious given the his-torical roots and philosophic impulses of homeopathy, is that homeopathic physicians prescribed much less conventional medication. Conventional physicians pre-scribed pharmaceutic medications in 68.7% of visits, whereas homeopaths did so only 27.5% of the time.

A final variation, which could prove interesting in this climate of economic restraint in medical prac-tice, was that homeopathic physicians used much less diagnostic testing (39.9% versus 68.3% for conven-tional physicians). This finding may reflect nothing more than the high frequency with which homeo-pathic patients had already sought conventional treatment and already received diagnostic tests. This possibility was not investigated in Jacob’s survey, and further study is necessary to determine the real meaning of this finding.