Evidence-based medicine and traditional, complementary, and integrative medicines: an unfinished agenda

Abstract

Evidence-based medicine (EBM) has contributed to scientifically update diagnostic and therapeutic decisions. However, its application to traditional, complementary and integrative medicine (TCIM) faces challenges, especially in primary health care (PHC). This essay analyzes problems in the application of EBM to TCIM in PHC. It argues against the tendency to limit such application to the assessment of the methodological quality of quantitative evidence. It defends the insufficiency/inadequacy of EBM as the sole criterion for validating TCIM in PHC, the need to consider the complexity of some of these practices and the full application of EBM, integrating critical evaluation of the best scientific evidence, professionals' experience, users' preferences/values, and care circumstances - consensual pillars of EBM that have not been applied in a balanced way. Thus, EBM would be better used in integrating TCIM into health care in PHC.

Keywords
Evidence-based medicine; Traditional medicine; Complementary therapies; Primary health care

Resumo

A Medicina Baseada em Evidências (MBE) tem contribuído para atualizar cientificamente as decisões diagnósticas e terapêuticas. Contudo, sua aplicação às medicinas tradicionais, complementares e integrativas (MTCI) enfrenta desafios, sobretudo na Atenção Primária à Saúde (APS). Este ensaio analisa os problemas da aplicação da MBE às MTCI na APS; argumenta contra a tendência de limitar essa aplicação à mera avaliação da qualidade metodológica de evidências quantitativas; e defende a insuficiência da MBE como critério único para validar as MTCI na APS, ressaltando a necessidade de considerar a complexidade dessas práticas e de exercer a MBE de forma plena, integrando a avaliação crítica das melhores evidências científicas, a experiência dos profissionais, as preferências e valores dos usuários e as circunstâncias do cuidado – pilares consensuais da MBE que, frequentemente, não são aplicados de maneira equilibrada. Assim, a MBE teria maior utilidade na integração das MTCI à assistência à saúde na APS.

Palavras-chave
Medicina baseada em evidências; Medicina tradicional; Terapias complementares; Atenção primária à saúde

Resumen

La medicina basada en la evidencia (MBE) ha actualizado científicamente las decisiones clínicas, aplicándose también a las medicinas tradicionales, complementarias e integrativas (MTCI). Analizamos los problemas en la aplicación de la MBE a la MTCI en la Atención Primaria de Salud (APS). Argumentamos contra la limitación de esta aplicación a la evaluación de la calidad metodológica de la evidencia cuantitativa. Defendemos la insuficiencia/inadecuación de la MBE como único criterio de validación de las MTCI, la necesidad de considerar la complejidad de estas prácticas y la plena aplicación de la MBE, integrando la evaluación crítica de la mejor evidencia científica, la experiencia de los profesionales, las preferencias/valores de los usuarios y las circunstancias asistenciales - pilares consensuados de la MBE que no se han aplicado de forma equilibrada, mejorando así la integración de las MTCI en la APS.

Palabras clave
Medicina basada en la evidencia; Medicina tradicional; Terapias complementarias; Atención primaria de salud

Introduction

Evidence-Based Medicine (EBM) is the conscious, explicit, and judicious use of the best current evidence in clinical decision-making¹. Initially focused on teaching the analysis and interpretation of scientific literature², its concept has since been expanded: EBM now requires the integration of individual clinical expertise with the best available external clinical evidence obtained through systematic research, as well as the unique values and circumstances of the patient³.

At the beginning of EBM, there was great heterogeneity in medical practices across countries and physicians⁴. Additionally, the increasing availability of published scientific knowledge, facilitated by the internet, was often underutilized in clinical decisions. EBM introduced methods for critical analysis, systematization, and synthesis of studies. Systematic reviews and meta-analyses enhanced the rigor, reliability, and precision of treatment efficacy estimates and adverse effects. EBM also established a hierarchy of scientific evidence, created strategies to improve access to updated knowledge, and reinforced the necessity of continuous professional learning⁵.

However, several issues have been identified: ethical concerns regarding the integrity of evidence production⁶; the persistence of conflicts of interest, with harmful market influences in the healthcare sector, legislation, and public policies⁷; the reduction of clinicians’ autonomy due to the authority of evidence-based guidelines; and the emergence of a new bureaucratic clinical governance⁸.

At the same time, a growing demand for Traditional, Complementary, and Integrative Medicines (TCIM) was recognized, particularly among populations in high-income countries who primarily rely on biomedicine. TCIM encompasses knowledge, practices, and health-related products outside conventional medicine⁹.

Since the 1990s, there has been an effort to evaluate TCIM using EBM’s quantitative methodologies¹⁰, which was tacitly accepted. As research on TCIM expanded, so did EBM’s epistemic and institutional authority as the primary validation framework for these practices.

This essay aims to critically analyze the limitations of EBM in its application to TCIM within the context of primary healthcare (PHC). The first two sections revisit the foundational pillars of EBM, outline its major issues, and summarize the challenges of evaluating TCIM under this paradigm. The third section presents a critique of the current role of MBE in validating TCIM. The final section explores potential strategies for addressing the highlighted issues.

Pillars and challenges of evidence-based medicine

Over time, the core pillars or foundations of EBM have evolved and become well-established:

1. “Best Available Evidence”. The use of the highest-quality scientific research, such as randomized clinical trials and systematic reviews, to support clinical decisions. This is the oldest, most well-known, widely disseminated, and highly valued pillar.

2. “Clinical Expertise”. The knowledge gained through professional training and experience is essential for clinical reasoning, interpreting evidence, and applying it in practice.

3. “Patient Values and Preferences”. Clinical decisions should consider patients’ values, expectations, and preferences. Although some evidence exists on these aspects and users are increasingly involved in clinical guideline development, this is still insufficient. Effective implementation requires active and real-time patient participation in decision-making.

4. “Clinical Circumstances and Institutional Context”. The availability of resources (financial, material, and human) and the social, cultural, and organizational context (especially access to care) influence the applicability of evidence in clinical practice and, consequently, decision-making^11,12 (Figure 1).

   

   Figure 1
   Evolution of frameworks, the pillars of evidence-based medicine. Highlight for the repositioning of the 4th pillar clinical circumstances.
   

   Some versions of EBM include only three pillars, but in these cases, the fourth is implicitly present in discussions on practical application, as it always requires an assessment of clinical and organizational circumstances^11,13. For this reason, we prefer to explicitly acknowledge the fourth pillar.

Initially, EBM emphasized the first pillar. It was quickly criticized for potentially being used to cut costs and suppress clinical autonomy, a critique that its proponents later accepted¹. The other pillars gained recognition as criticisms emerged and were gradually incorporated into the framework. EBM evolved to recognize the limitations of evidence alone, emphasizing the need to combine critical assessment of evidence with patient values and shared decision-making².

EBM developed a systematic approach to creating reliable clinical recommendations based on empirical evidence, increasingly influencing medical education and healthcare services. However, several issues have been identified.

EBM faces challenges that threaten its integrity and objectives, particularly in the production, processing, and application of evidence. Half of all clinical trials are never published, and studies with positive results are twice as likely to be published as those with negative outcomes^14,15. A third of scientists have admitted to questionable practices, such as data manipulation to obtain statistical significance. The cost of clinical trials has increased fivefold in a decade, making it increasingly difficult (though necessary) to fund research without conflicts of interest. As the incremental benefits of new medical interventions decrease - since more effective therapies are already used as baselines - larger trials are needed. These tend to overestimate potential benefits, which may be statistically significant but clinically irrelevant¹⁶.

Conflicts of interest persist despite efforts to limit or disclose them. Even with billion-dollar fines for civil and criminal violations, the pharmaceutical industry has not changed its practices, raising concerns about the integrity and reliability of scientific publications¹⁴. These conflicts influence research agendas and the application of results. Accepting ‘evidence’ funded by the industry is equivalent to allowing politicians to count their own votes⁶.

As EBM became more influential, it was seized by commercial agendas and interests. The majority of randomized clinical trials (RCTs) are funded by the industry, which manages them effectively, scores higher in quality assessments, and publishes results more quickly than non-industry-sponsored trials¹⁷. There was a proposal that studies with conflicts of interest be explicitly downgraded in value⁶, but this was not collectively adopted in biomedicine.

There are overlooked issues: the emphasis of EBM on statistical significance (p-values) has been criticized for narrowing the focus and generating bias and misleading conclusions. This methodological rigidity often excludes weak signals or rare cases, restricting innovative and personalized approaches. Another concern is the increasing bureaucratic burden imposed by EBM through electronic records and the proliferation of detailed guidelines, which reduce interaction with patients and increase administrative workload, ultimately harming the quality of care. Additionally, performance-based payments linked to guidelines threaten the flexibility and objectivity of EBM: they create systemic pressures that divert attention away from the patient, prioritizing standardization¹³.

The publication of low-quality protocols and evidence leads to inadequate practices, with excessive interventions in diagnostic testing, prescription of medications, and medical procedures, resulting in overdiagnosis, iatrogenesis, and an imbalance in cost-effectiveness^14,15. Making clinical decisions based on evidence can be compromised by the restricted quality and scope of what is considered ‘the best available evidence’¹⁸.

Despite growing recognition of its problems, EBM continues to gain power in assessing the effectiveness and cost-effectiveness of interventions, fueling a governance that benefits from its scientific legitimacy now extended to clinical decisions. New actors have gained unprecedented influence: reviewers, meta-analysts, statisticians, funders, clinical trial coordinators, guideline and decision algorithm developers, journals; that stand between the professional and his decisions. The colossal growth of publications, many full of conflicts of interest, but with the legitimacy of EBM, influences the decision-making of managers and professionals, standardizing clinical practices.

The digitalization of medical records promotes a culture of clinical auditing and professional performance evaluation, supposedly guided by the best available evidence. This also alters clinical governance and restricts professional autonomy, forcing adherence to algorithms and guidelines. Harrison referred to this new governance as scientific-bureaucratic medicine⁸, which continues to expand, contrary to the original good intentions of EBM¹⁷. The lack of statistical literacy among professionals limits their ability to critically evaluate evidence, leaving them at the mercy of protocols. Another underdiscussed aspect of EBM is its tendency to reinforce the centralization of decision-making within the medical professional, who often does not engage with other healthcare providers or adopt successful strategies such as task-sharing¹⁹.

There are other problems and limitations, particularly in PHC: a large proportion of patients are not represented in RCTs, which create artificial disease scenarios and exclude complex cases, such as multimorbid patients, the elderly, those with chronic diseases, and patients with unexplained clinical symptoms. In these cases, polypharmacy is often the norm, requiring a careful and individualized approach, in which EBM is necessary but insufficient²⁰.

EBM and TCIM - general criticisms

EBM has played a role in the integration of TCIM into conventional healthcare services. However, from the outset, there have been disagreements regarding the application of EBM and its gold-standard methodologies for determining the effectiveness of TCIM. Problematic methodological issues have been identified and gradually discussed²¹, yet they have had little impact on how evidence is evaluated.

These issues are diverse within TCIM: their therapeutic scope is often built through dynamic clinical interactions and based on the user’s perception of health and well-being, which presents limitations for objective measurement. Many TCIM practices tend to be individualized, in contrast to the standardized and replicable approach of RCTs, whose inclusion criteria and outcomes are based on scientifically classified diseases, symptoms, or syndromes²². According to Baars and Hamre²², there are unresolved ontological, epistemological, and methodological deficiencies, and attempting to validate TCIM through EBM may be delaying the transformation of biomedicine rather than accelerating its improvement²².

Adjustments and greater flexibility in EBM’s gold-standard methodologies have been advocated to better accommodate TCIM, emphasizing a greater combination of evaluation methods: variations of RCTs (pragmatic RCTs, n-of-1 trials, and preference trials) combined with observational studies and qualitative methods²³.

The complexity and holism of many TCIM approaches, particularly whole medical systems^22,24,25, should be acknowledged and emphasized. Their comprehensive approach and multi-pathway mechanisms, tailored to the individual, challenge standardized interventions required by RCTs. Whole medical systems, such as the vitalist medical rationalities described by Luz²⁶, have their own classifications of illnesses and employ multiple individualized interventions, some involving active patient participation. This violates the standardized interventions required in RCTs, which demand the isolation and standardization of specific interventions to assess their efficacy. However, this can distort the therapeutic approach of TCIM, making RCTs unsuitable for their evaluation. Study designs must be aligned with the system being evaluated, incorporating dual classification (biomedical and TCIM-based)²³.

The systematic review by Fischer et al.²⁷ identified a consensus on the importance of combining different methodological designs according to the research question²⁷. Quantitative methods, especially RCTs, present limitations such as high costs and lack of external validity due to the rigid standardization of interventions and participants. A better alternative would be pragmatic research, which evaluates clinical effects in real-world settings, compares treatment alternatives, includes a variety of users, and considers outcomes relevant from their perspective^27,28. Another consensus was that mixed methods, combining quantitative and qualitative approaches, allow for a deeper understanding of TCIM, giving equal value to both approaches²⁷. This enables the evaluation of results that are meaningful to users, biomedicine, and the assessed system²³.

The COVID-19 pandemic exposed weaknesses, limitations, and the dogmatic rigidity of EBM. Greenhalgh et al.²⁹. argued that the rigidity of the evidence hierarchy proved insufficient to manage the complexity and urgency of the pandemic and advocated for bringing a broader range of evidence and a more pluralistic approach to defining what counts as ‘high-quality’ evidence.

One rigidity of EBM is its insensitivity and invariance (in both criteria and methods) when addressing clinical problems. This approach is always the same, regardless of the severity of the problem and the clinical and institutional circumstances. Such blind uniformity makes little sense: the types of problems and the contexts in which they occur and are managed should be considered in EBM, rather than being projected solely on to professionals. The safety net and clinical risk, the institutional context, the probable prognosis, and access to care should influence how evidence is interpreted and applied.

The arguments about EBM’s rigidity during the pandemic (which required urgent interventions) can, in the case of PHC, be used in the opposite direction. The circumstances of PHC are different from the higher clinical severity of patients in hospitals and specialized clinics. The clinical conditions of most users are benign, with favorable prognoses and no urgency, with additional safety derived from accessible biomedical expertise, especially in early-stage, nonspecific conditions and common mental health problems. Many illnesses, pain syndromes, medically unexplained symptoms, and mental health disorders can be addressed through TCIM, via complex multimodal interventions, particularly in whole medical systems. Also, the use of watchful waiting can be enriched with rebalancing actions and self-care through TCIM, accepted by users³⁰. In these abundant situations in PHC, TCIM can be used and deserve perhaps a distinct treatment, currently non-existent. It seems necessary to introduce greater flexibility in the hierarchy of evidence in the context of PHC.

The changes required by TCIM in PHC are challenging: it must consider, without dogma, knowledge systems, cosmologies, doctrines, diagnoses and interventions foreign to biomedicine, since there are systemic prejudices and negative attitudes against TCIM research and its integration into health care³¹. There are also questions of biological plausibility of some TCIM, generally evaluated through a physicalist and mechanistic approach, disregarding cutting-edge research. EBM is presumptuous in relation to knowledge external to biomedicine, disqualifying it. Even so, the epistemic validation of TCIM has progressed slowly, its effectiveness has been recognized and some of its practices are marginally used in PHC.

EBM and TCIM: partial and biased application

EBM has not been adequately applied to TCIM. Clinical guidelines are developed by committees that must conduct a rigorous analysis of the scientific literature using tools such as GRADE (Grading of Recommendations Assessment, Development, and Evaluation) or similar frameworks that systematize the assessment of evidence quality³².

However, evidence-based clinical guidelines may neglect the core principles of EBM, favoring certain practices while excluding others. A striking example, involving one of the most studied and tested TCIMs through EBM, is the low back pain guideline from the National Institute for Health and Care Excellence (NICE)³³. Despite acceptable-quality evidence supporting the effectiveness of acupuncture^34-36, it was contraindicated³³. The justification was that the difference in benefits between acupuncture and sham acupuncture was not clinically significant, which was required by the protocol. The rigid application of the protocol resulted in not offering a more effective and safer intervention than those recommended. The guideline suggests anti-inflammatories, and if they are contraindicated, not tolerated, or ineffective, weak opioids, based on expert opinion (without supporting evidence). The protocol’s application was inconsistent and unequal - strict for acupuncture and vague for other interventions³⁷. This seriously challenges EBM, given that this NICE guideline is considered high quality²⁰.

A second example is PACK (Practical Approach to Care Kit)³⁸, a set of clinical guidelines developed to support primary care professionals, also used in Brazil. In the PACK, only two TCIM modalities were included: auriculotherapy, restricted to the treatment of mechanical back pain and neck pain, and acupuncture, limited to various types of pain and dyspepsia/heartburn. Probably only clinical trials deemed high quality were used as a validation criterion. This approach ignores the need for specific methodologies to assess TCIM. Although the use of evidence-based guidelines in PHC, such as PACK, may have positive results (more and better sharing and distribution of tasks between PHC doctors and nurses; introduction of EBM in clinical conducts³⁹), if they are restricted to a high hierarchy of evidence and the conclusion that such evidence is scarce and its quality is low, their use will exclude the vast majority of TCIM.

Our central criticism of the use of EBM in TCIM is that discussions revolve exclusively around the first pillar of EBM (quality of available evidence) and usually finish there, without considering the other pillars (professional experience, patient values and preferences, and clinical circumstances). If the other pillars were considered, they would influence the direction and strength of recommendations and decisions. GRADE indirectly acknowledges this influence when stating: “Panels may issue a strong recommendation against an intervention when there is uncertainty about the benefits but confidence in the adverse effects and resource use”⁴⁰ (p. 731). Similarly, if there is low certainty about the benefits but confidence that the adverse effects are minimal and the costs are low, a recommendation in favor may be issued for a TCIM in a specific context. This is the case for the use of auriculotherapy (AT) in PHC with non-invasive skin-adhered seeds.

To develop clinical recommendations for the use of AT in PHC, systematic reviews following GRADE were conducted for 13 common clinical conditions (anxiety, constipation, depression, dysmenorrhea, chronic pain, insomnia, low back pain, nausea and vomiting, obesity, osteoarthritis, dental problems, rhinitis, smoking cessation). 98 clinical trials were analyzed, whose main methodological problems involved a small number of studies per condition (ranging from two to 16), small sample sizes, short follow-ups, and issues with allocation, blinding, and intention-to-treat analysis. Six trials were of high quality, 33 of acceptable quality, and 59 of low quality, according to SIGN-50⁴¹. The results were almost systematically positive compared to controls, including those of high quality.

To broaden the empirical basis of the recommendations, 31 systematic reviews were also analyzed, covering nine of these conditions. According to SIGN-50, 11 were of high quality, 16 of acceptable quality, and only four of low quality. They converged on an indication of probable efficacy superior to controls, but their conclusions were all cautious due to the quality issues mentioned above.

Given the safety of AT⁴², its biological plausibility via known neurophysiological mechanisms⁴³, its low cost, its use environment (PHC), the professional experience, and the high acceptance by Brazilian users, all widely positive (as documented in the national literature, which is consensual on the subject), the recommendations issued were favorable to AT⁴⁴. However, these are the only known positive guidelines to date. AT exemplifies our argument that the application of EBM to TCIM prematurely and negatively concludes at the critique of evidence quality, without considering the other pillars. But what is known about the other pillars of EBM in relation to TCIM?

Generally, TCIM practitioners working in conventional outpatient settings are enthusiasts of these practices, having learned them on their own initiative and practicing them under adverse conditions (for TCIM), needing to adapt these practices to the biomedical cultural-institutional context. They typically provide these services without conflicts with their professional ideals, based on various justifications^45,46. Their clinical experience and the knowledge derived from it (the second pillar of EBM), which are valued in conventional care, generally influence favorably the use of TCIM. Consider, for instance, the use of auriculotherapy (AT) for mental health issues in PHC in Brazil^47-49.

Furthermore, conventional professionals trained in TCIM are able to address some public health challenges, such as antimicrobial resistance, by using biomedical resources (antibiotics) more rationally⁵⁰, suggesting beneficial side effects from TCIM expertise.

In some TCIM modalities, especially whole medical systems, clinical experience and accumulated knowledge span centuries. In these cases, the knowledge, techniques, and clinical reasoning have been shaped by the experience of many generations of practitioners and should be considered in evidence-based practice. Thus, the silence on this subject in guideline development and EBM application contradicts EBM itself.

The generally positive clinical experience with TCIM does not exist among non-practicing professionals, yet a significant portion of them do practice it⁵¹. The central point in this argument is that for those with experience in TCIM, it should be taken into account.

Values play a crucial role in the production and application of evidence⁵². Ignoring patient values (the third pillar of EBM) can lead to decisions that are technically acceptable in biomedicine but detrimental to care, particularly when personalization is crucial to effectiveness, as in various TCIM modalities. A significant proportion of users have philosophical/cosmological affinities with TCIM⁵³. Many prefer reducing iatrogenesis, a common feature of various TCIM modalities, especially in chronic diseases. TCIM practitioners tend to have better clinical relationships, encourage patient involvement in care and self-care, and facilitate patient empowerment and shared decision-making⁵⁴, all of which are predictors of better clinical outcomes.

The practice of many TCIM modalities involves holistic and individualized diagnoses and treatments, as well as values such as balance and harmony⁵⁵, with etiological concepts that emphasize social, environmental, emotional, and spiritual factors⁵⁶. TCIM stimulates self-healing, an aspect lacking in conventional care. This is especially relevant in PHC, where most users still have substantial vitality and can benefit from self-regulation processes, promoting healing from within, an approach valued by many patients⁵⁷.

According to the last pillar of EBM, clinical decisions should consider the clinical and organizational context, available resources, costs, access, and type of healthcare system. These factors influence what is possible or preferable¹¹. As mentioned, clinical severity is generally low in PHC. Undifferentiated conditions and medically unexplained symptoms account for up to 45% of medical consultations in PHC⁵⁸. Combined with purely descriptive diagnoses (such as low back pain, headaches, arthralgia, and myalgia), these cases make up more than half of consultations, often receiving a poor biomedical interpretation and symptomatic pharmacological management, leading to adverse effects. Additionally, mental health issues account for 20–25% of patient demand, and growing evidence suggests worse long-term outcomes with psychotropic medication use⁵⁹. These PHC circumstances are conducive to the use of TCIM.

On the other hand, multimorbidity and polypharmacy are prevalent, particularly among the elderly and individuals with chronic diseases. RCTs, by their design, tend to exclude patients without clear diagnoses, those with multiple conditions, the elderly, and those with chronic illnesses. Biomedicine tends to focus on the pharmacological control of symptoms, physiopathological parameters, and risk factors, which is associated with iatrogenesis and chronic medical care. However, in PHC, there is additional safety derived from longitudinal care, person-centered approaches, easy access, and the biomedical expertise of professionals, making TCIM a promising and widely practiced option⁶⁰.

Considering all the pillars of EBM, its application to TCIM in the PHC context should generate several favorable recommendations, but this has not been the case: only a few TCIM modalities have slowly been incorporated into guidelines and manuals. Guidelines tend to ignore TCIM or even contraindicate them, relying solely on the scarcity and low quality of the available evidence. This hinders their use, creating a professionally and scientifically adverse atmosphere. Corporate and economic interests, along with a prejudiced biomedical subculture opposed to TCIM, likely contribute to the relative scarcity of research and the weakness of favorable recommendations for TCIM use in PHC. Clinical guidelines do not differentiate the PHC context from other healthcare settings. This appears to be a symptom of the disregard for clinical circumstances in the application of EBM. As a result, the legitimization process of TCIM has been slower and more marginal than what a fair and rational EBM approach would predict, and it has been described as a form of its colonization by biomedicine^61,62.

Proposals and challenges

Whole medical systems or medical rationalities deserve special methodological approaches due to their epistemic and cultural otherness, which has been highlighted in scientific literature. Their unfamiliarity and potential competition with biomedicine should inspire curiosity and openness rather than antipathy, while their distinctiveness justifies thorough scrutiny. EBM should be applied across all four of its pillars, fully and comprehensively, and it is crucial that it remains flexible and self-reflective about its limitations and challenges.

Greater investment is needed in the development of innovative methodologies⁶³. Real-world evidence, derived from real-world data, offers a sensitive and insightful perspective on TCIM⁶⁴. Some successful experiences demonstrate the effective integration of traditional medicines in hospital settings^65,66. These approaches originate from health services research methodologies that take a multidisciplinary approach, considering how social factors, financing, structures, organizational processes, technologies, and personal behaviors affect access to care and its quality⁶⁷. This provides an alternative beyond RCTs.

Obtaining information from traditional knowledge requires decolonial approaches⁶⁸. The rich ethnic diversity and traditional knowledge of the Americas⁶⁹ are undervalued within the Eurocentric approach to TCIM. Colonizers extract and pirate natural resources; biomedicine does the same with traditional knowledge on health and disease. This can be improved by engaging Indigenous researchers to avoid erroneous translations, knowledge appropriation, and biases, while ensuring that research provides benefits to the studied communities. One example is the study by João Paulo Barreto Yurupi, a Tukano anthropologist, who mapped the construction of an Indigenous health-disease rationality⁷⁰.

Final considerations

The use of EBM in the slow process of integrating TCIM into Western healthcare systems has treated the latter discriminatorily. This seems to favor the maintenance of the conventional care status quo at the expense of exploring the contributions of TCIM, all while being justified as evidence-based. A rational application of EBM to TCIM could be more favorable than it has been, if, as is widely agreed, all its fundamental pillars were considered: best available evidence, professional experience, user values/preferences, and clinical and care circumstances.

Acknowledgments

We would like to thank both Professor Itamar S. Santos (FM/USP) for critical reading and comments and Simone Alleotti Tesser for her spelling review.

• Tesser CD, Dall’Alba R, Sato ME. Evidence-based medicine and traditional, complementary, and integrative medicines: an unfinished agenda. Interface (Botucatu). 2026; 30(Supl 1): e250071 https://doi.org/10.1590/interface.250071
• Funding
  Tesser CD received a research productivity grant from the National Council for Research and Development (CNPq) – process number 313822/2021-2).

Data Availability

The contents underlying the research text are non-handwritten contents.

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Edited by

• Editor
  Antonio Pithon Cyrino https://orcid.org/0000-0002-9184-5927

• Associated convidado
  Nelson Barros https://orcid.org/0000-0002-2389-0056

Publication Dates

• Publication in this collection
  17 Apr 2026
• Date of issue
  2026

History

• Received
  11 Feb 2025
• Accepted
  10 Oct 2025