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dard of positivist biomedical science may not always be a fair

point of departure, it is nonetheless the framework within which
we decide truth. It can be a
purely reductionist model of scientific reason, with its linear
model of causality and attempts
at objectivity. It can also be a
less reductionist approach,
where causality may be understood more as a web rather than
a thread, and the subjectivity of
lived experience once again assumes a prominent role in understanding health and wellbeing. With this less reductionist
approach, the interrelationships
between cultural and personal,
public and individual health
begin to become clearer.
The works collected here represent the beginning of an important dialog for public health.
Although in different ways,
complementary and alternative
health care and healing prac-

tices represent a vast and as yet

unrealized sector of the public
health systems of developed and
developing nations. Moreover,
the limits of our current biomedical knowledge and capabilities cannot be denied. We do
not, as yet, have all the answers,
or even, for that matter, know
all the questions. There are
more things in heaven and earth
than can be dreamt of in our
current biomedical philosophies.
Stagnant biomedical orthodoxy
cannot achieve the fullness of
public healths potential and has
no role to play in human progress. Maintaining an openness to
this reality may serve to help
marshal the resources of indigenous, complementary, and alternative health practices in the
service of public health, now
and in the future.

Walter B.
Cannon and
A Perspective
From 60
Years On

The remarkable accuracy of Walter B. Cannons 1942 article

Voodoo Death, excerpted in
this issue of the Journal,1 proposing a scientific basis for voodoo
death is at once surprising and
not surprising. Voodoo death, as
defined by Cannon, is sudden,
unexplained death resulthing
from a voodoo curse. At first
glance, it is surprising that scientific discoveries over the last 60
years have largely filled out the
details ofbut not overturned
most of Cannons proposed explanation of the physiological underpinnings of this phenomenon.
On the other hand, it is not surprising when one considers the
fact that Cannons research
formed the basis for much of our
modern understanding of the
physiological response systems

1564 | Editorials

Vincent M. B. Silenzio, MD, MPH

Guest Editor

About the Author

Vincent M. B. Silenzio is with the Center
for Family Medicine, Columbia University,
New York, NY.
Requests for reprints should be sent to
Vincent M. B. Silenzio, MD, MPH, 630
W 168th St, VC 12-217, New York, NY
This editorial was accepted June 26,

1. World Health Organization
(WHO). WHO launches the first global
strategy on traditional and alternative
medicine. Available at: http://www.who.
int/inf/en/pr-2002-38.html. Accessed
May 20, 2002.
2. McNeil D. With folk medicine on
rise, health group is monitoring. New
York Times. May 17, 2002:A8.
3. National Center for Complementary and Alternative Medicine. Major
domains of complementary and alternative medicine. Available at: http:// Accessed June 7, 2001.
4. Green LA, Fryer GE Jr, Yawn BP,
Lanier D, Dovey SM. The ecology of
medicine revisited. N Engl J Med. 2001;
5. Weiss R, Fintelmann V. Herbal
Medicine. New York, NY: Thieme;

involved in linking emotions,

such as fear, with illness.
If submitted to a scientific
journal today, this paper would
not make it beyond the review
process, as it would be described
(probably with some disdain) as
simply anecdotal and hypothetical. However, fortunately for our
generation, our predecessors
were apparently not averse to
recording oral reports of inexplicable phenomena in detaileven
down to the names of the individuals who experienced or perpetrated these events.
Thus, Cannon starts his article
with several anecdotal case reports, all of which share several
important features that lead him
to propose, first, that there may
indeed be a physiological basis
for the phenomenon of voodoo

6. Kleinman A. Patients and Healers

in the Context of Culture: An Exploration
of the Borderland Between Anthropology,
Medicine, and Psychiatry. Berkeley: University of California Press; 1980.
7. Baer H. Biomedicine and Alternative Healing Systems in America: Issues of
Class, Race, Ethnicity and Gender. Madison: University of Wisconsin Press;
8. Green E. Engaging indigenous African healers in the prevention of HIV
and STDs. In: Hahn R, ed. Anthropology
and Public Health: Bridging Differences in
Culture and Society. New York, NY: Oxford University Press; 1999:6383.
9. Blank M. Alternative mental health
services: the role of the Black church in
the South. Am J Public Health. 2002;
10. Helman C. Culture, Health and Illness: An Introduction for Health Professionals. Oxford, England: ButterworthHeinemann; 1997.
11. Napoli M. Holistic health care for
native women: an integrated model. Am
J Public Health. 2002;92:15731575.
12. Dobkin de Rios M. Lessons from
shamanic healing: brief psychotherapy
with Latino immigrant clients. Am J
Public Health. 2002;92:15761578.

death and, second, what that

physiological basis might be.
The dramatic suddenness of
the illness following the threat,
coupled with a lack of any apparent injury, exposure to toxins, or
infection suggested to Cannon
that merely the fear of death
could, through physiological response mechanisms initiated by
fear, precipitate death itself.
Cannon focused on the sympathetic and sympathicoadrenal divisions of the nervous
systemterms still in use today
(although sympatho-adrenal is
now the more common term).
He outlines all the aspects of
bodily function over which this
arm of the nervous system exerts
controlblood vessel contraction,
dilation of bronchioles, adrenaline release, release of sugar

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


from the liverall effects that together prepare the animal to attack or runto fight or flee.
Cannon thus elegantly lays out
both the physiology and the evolutionary rationale for the fight
or flight response, a term still in
use today that he coined to describe this neurophysiological
behavioral response pattern.
We could not have provided a
better rationale for this aspect of
the phenomenon today. This
piece has stood the test of time.
In the 60 years since Cannon
first published his work, we have
simply gained a clearer understanding of the brain regions that
become activated when a fearful
stimulus is experienced and a
better road map of the pathways
linking those brain centers involved in receiving sensory signals (in Cannons example, seeing
a bone pointed at one) to the
part of the brain that processes
the emotional component of
fearthe amygdala. In todays
terms, we would call this the
vision-to-fear pathway or auditory-to-fear pathway, depending
on the sense through which the
threat is initially received.
We have a deeper understanding of the neurotransmitters and
neuropeptides involved in initiating these responses and perpetuating them through learning and
memory. We know how such
chemical signals are translated
into electrical impulses and how
quickly or slowly they are conveyed along nerve fibers. And
we now know that such nerve
chemicals and proteins are made
by genes within the nucleus of
nerve cells, that are switched on
and off by all sorts of chemical
and physical signals. We know
that when we learn to fear something there are permanent
changes in the shape and wiring
of nerve cells that make it more

likely that the next time we experience the fearful stimulus, those
same pathways will be switched
on all the more rapidly.
Strikingly absent, however,
from Cannons explanation is the
hormonal stress responsethe
cascade of hormones released
from the brain, pituitary gland,
and adrenal gland within minutes of exposure to any sort of
stressor. This is because in 1942,
when the article was written,
many of these hormones were
yet to be discovered. Furthermore, the term stress, popularized by Cannons admirer Hans
Selye and others in the postwar
period, was not yet in general
use. The structure of cortisol, the
hormone released from the cortex of the adrenal glands during
stress, was identified in 1936 by
Edward Kendall and Tadeus
Reichstein,2,3 who received the
Nobel Prize for their discoveries
in 1950 together with Philip
Hench. However, the full cascade
of hormones involved in the hormonal stress response was not
fully elucidated until the identity
of the brains hypothalamic stress
hormone, corticotropin releasing
hormone or CRH, was discovered by Wylie Vale in 1981.4
Thus, Cannon could not have
included in his scenario of the
possible causes of voodoo death
the role of hypothalamic CRH released after signals from the
amygdala, the brains fear center,
reached the hypothalamus. Nor
could he include how the crosstalk between the brain stem
adrenaline centers involved in
initiation of the sympathetic response could coordinate with
hormones released from the
brains hypothalamic stress center5 to cause a massive release of
both adrenaline-like nerve chemicals and stress hormones. Together these might well cause ill-

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

ness,69 including loss of appetite,

weakness, cardiac arrhythmias,
and even vascular collapse that
could result in death.
Thus, Cannons rather simplistic explanation of how shock
could ensue simply by removal
of blood volume through sympathetic clamping of peripheral arterioles is in part correct, but he
could not know of the complexity of hormones and nerve chemicals that, when all released together, might be more likely to
produce the cardiac arrhythmias
and vascular collapse than he
Finally, he did not have the
tools to go beyond hypothesis
into the experimental stage in
humansto measure the responses he predicted and to
prove through such measures
which parts of his hypotheses
were correct. He could not, as
we can today, use neuroimaging
technologies, electroencephalograms, and even single neuron
recordings to measure nerve cell
activation in different stress- and
fear-related brain regions. He
could not use telemetry devices
and complex computer-generated mathematical analyses to
noninvasively measure changes
in heart rate variability, blood
pressure, and cardiac blood flow
in humans while they are going
about their daily routines. Nor
could he ask his subjects to respond to questions, programmed
in their palm-pilots and synchronized with their heart rate monitors, about their moment-tomoment emotional states, to
indicate within milliseconds
whether a given threat caused a
particular arrhythmia. He could
not imagine that one could measure minute amounts of stress
hormones and nerve chemicals
released into the saliva during
fear, simply by asking the subject

to chew on a lemon-soaked cotton swab and spit into a cup.

And he could not imagine how
such hormones and nerve chemicals could possibly affect cells of
the immune system to cause
chronic wasting or disease.
Cannon could not imagine
how one could accomplish all
this because the tools of neuroscience, molecular biology,
computational mathematics, bioengineering, neuroimaging, endocrinology, and cellular immunology had not yet been
invented or discovered. But, on
the basis of observation, logic,
and deduction, he did imagine
that there could be a biological
basis to the seemingly magical
phenomenon of voodoo death.
And, whats more, he had the
courage to predict and record in
writing that there should be,
some day, a way to get the answers. In this, Cannon was perhaps among the first physiologists to apply his scientific
background to attempt to explain otherwise inexplicable illnesses and phenomena that
seemed to link emotions and disease. This approach, combining
open-mindedness and scientific
rigor, is the essence of modern
complementary and alternative
medicine research.
Esther M. Sternberg, MD

About the Author

The author is with the Integrative Neural
Immune Program and the Section on Neuroendocrine Immunology and Behavior,
National Institute of Mental Health, National Institutes of Health, Bethesda, Md.
Requests for reprints should be sent to
Esther M. Sternberg, MD, Bldg 36, Rm
1A-23, 36 Convent Dr, MSC 4020, National Institute of Mental Health, National
Institutes of Health, Bethesda, MD
20892-4020 (e-mail: ems@codon.nih.
This editorial was accepted June 7,

Editorials | 1565


1. Cannon WB. Voodoo death. Am
J Public Health. 2002;92:15931596.
2. Mason HL, Myers CS, Kendall EC.
The chemistry of crystalline substances
isolated from the suprarenal gland.
J Biol Chem. 1936;114:613631.
3. Hench PS, Kendall EC, Slocumb
CH, et al. Effects of cortisone acetate
and primary ACTH on rheumatoid

Therapies and
Public Health:
Crisis or

1566 | Editorials

arthritis, rheumatic fever and certain

other conditions. Arch Intern Med.

pothalamic responses to stress: a tale of

two paradigms. Prog Brain Res. 2000;

systems: the brain and the immune system. Pharmacol Rev. 2000;52:

4. Spiess J, Rivier J, Rivier C, Vale W.

Primary structure of corticotropinreleasing factor from ovine hypothalamus. Proc Natl Acad Sci USA. 1981;78:

6. Webster JI, Tonelli L, Sternberg

EM. Neuroendocrine regulation of immunity. Annu Rev Immunol. 2002;20:

8. Goldstein, DS. The Autonomic Nervous System in Health and Disease. New
York, NY: Marcel Dekker Inc; 2001.

5. Sawchenko PE, Li HY, Ericsson A.

Circuits and mechanisms governing hy-

In 1994, Jennifer Jacobs, MD,

MPH, contacted the national office of the American Public
Health Association (APHA) about
procedures to start a new organizational component of the association and to schedule time for an
organizational business meeting
at the 1994 annual meeting. The
result was a new Special Primary
Interest Group (SPIG) that, after
much discussion at the annual
meeting, was eventually named
Alternative and Complementary
Health Practices (A. Trachtenberg, oral communication, 2002).
The term health practices was
chosen to reflect a neutral stance
on whether such practices might
be therapeutic, preventive, or
even harmful.
At the 1994 meeting, about
30 members elected the new
SPIGs first cochairs, Jennifer Jacobs and Alan Trachtenberg, MD,
MPH, who at that time was also
directing the National Institutes of
Health (NIH) Office of Alternative Medicine. Lawrence Kushi,
ScD, was elected the SPIGs first
program chair. From 1995 to the
present, the SPIG has presented
an interesting and well-attended
scientific program at every annual meeting and has grown to
over 200 primary members.
The public health imperative
for the study of these health practices was their sheer prevalence,
which had been brought to major
public attention by the survey by
Eisenberg et al. in the New England Journal of Medicine.1 Mem-

7. Elenkov IJ, Wilder RL, Chrousos

GP, Vizi ES. The sympathetic nervean
integrative interface between two super-

bers of the new SPIG assumed

that some practices would be helpful, some harmful, and some
merely an unnecessary expense,
and that sound clinical research
was required to separate the
wheat from the chaff. However,
we recognized that a public health
approach to alternative health
practices would also require a
larger view, one that incorporates
cultural competence as an important value in primary health care.
For instance, if a health center was
providing community-oriented primary care for a particular community, the health practices, beliefs,
and traditions of that community
might need to be addressed to ensure adequate medical utilization
and compliance by members of
the community, as well as to provide for community input, participation, and self-governance of
health care. The new SPIG was
aware of the World Health Organizations (WHO) traditional medicine initiative,2 which sought to incorporate traditional tribal healers
into the public health infrastructure around the world, as well as
the practice at many Indian
Health Service units of finding creative ways to provide space and
even positions for tribal healers.

Therapies and other health
practices seem to have been labeled alternative in the Western
biomedical setting because they

9. Sternberg EM. The Balance Within:

The Science Connecting Health and Emotions. New York, NY: W. H. Freeman
and Co; 2000.

came from outside that setting.

They are alternative primarily in
their origin. Therapies like surgery, psychotherapy, and the early
antibiotics came from within our
own Western biomedical tradition
and predated the advent of evidence-based medicine. Some have
since been confirmed by rigorous
methodology, but many have not.3
Likewise, new technologies such
as intrapartum fetal monitoring
may emerge from within our own
biomedical culture and become
widespread, despite an absence of
rigorous data on benefits.
The arts of medicine and public health policy have often required that practitioners make
their best educated guess as to
what to do, even in the absence
of adequate data. Doing nothing
may be even worse, or may be
unacceptable to the patient or to
the public. Such educated
guesses, made with the best of
intentions, will clearly reflect cultural and individual biases.
Other biomedical cultures,
many as scientifically oriented as
our own, have made very different
decisions than we in the United
States have about the incorporation of what we call alternative
therapies into national health programs. (Some would say that the
fact they these countries have national health programs, while the
United States still does not, suggests a certain superiority of these
nations general approaches.) For
instance, phytomedicines (herbal
preparations) and even homeo-

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