Yael Keshet Department of Sociology Western Galilee Academic College Ariela Popper-Giveon Department of Adult Education The David Yellin Academic College of Education

Integrative Health Care in Israel and Traditional Arab Herbal Medicine: When Health Care Interfaces with Culture and Politics This article contributes to contemporary critical debate in medical anthropology concerning medical pluralism and integrative medicine by highlighting the issue of exclusion of traditional medicine (TM) and presenting attempts at border crossing. Although complementary medicine (CM) modalities are integrated into most Israeli mainstream health care organizations, local indigenous TM modalities are not. Ethnographic fieldwork focused on a group of Israeli dual-trained integrative physicians that has recently begun to integrate traditional herbal medicine preferred by the Arab minority, using it as a boundary object to bridge professional gaps between biomedicine, CM, and TM. This article highlights the relevance of political tensions, ethnicity, and medical inequality to the field of integrative health care. It shows that using herbal medicine as a boundary object can overcome barriers and provide opportunities for dialog and reciprocal learning. [ethnicity, herbal medicine, integrative medicine, politics]

Introduction This article adds to the contemporary debate in medical anthropology concerning the current state of medical pluralism and integrative medicine. The term integrative medicine, also known as integrated or integrative health care, is used to describe the combination of biomedicine and complementary medicine (CM), which is now widespread in both Western and non-Western health care systems (Adams et al. 2009; Hollenberg and Muzzin 2010). The study of medical pluralism has been criticized for producing only functionalist typologies or for having “reached a theoretical impasse” (Brodwin 1996:15). Medical pluralism nevertheless remains a central concern in medical anthropology because of the steady growth of integrative medicine and the development of a critical theoretical perspective (Baer 2011). Israeli scholar Judith Shuval and her MEDICAL ANTHROPOLOGY QUARTERLY, Vol. 27, Issue 3, pp. 368–384, ISSN 0745C 2013 by the American Anthropological Association. All rights 5194, online ISSN 1548-1387.  reserved. DOI: 10.1111/maq.12049

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colleagues (2002) were among the first to document and analyze the marginalization of CM practitioners in biomedical settings through structural, symbolic, and geographical aspects of biomedical dominance. Other researchers of integrative medicine have been critically analyzed power relations between CM and biomedicine (e.g., Adler 2002; Broom and Tovey 2007; Hollenberg and Muzzin 2010). A critical social science perspective, which addresses complex power relations, inclusionary/exclusionary strategies, and inter-professional dynamics in medicine, reveals the intricacies and tensions inherent in the integration of different paradigms of health care practice. This critical perspective highlights the social and historical construction of specific forms of integrative health care. Empirical research that examines the dynamics between health care practices and sociopolitical relations is required to further our understanding of recent transformations in health care practice and issues surrounding biomedicine, CM, and traditional medicine (TM) (Adams et al. 2009). The term traditional medicine is used in this article to denote folk medicines and healing knowledge originating from a local indigenous population. The term complementary medicine is used for medicines and healing practices that often draw on indigenous TM, but are practiced in non-indigenous, generally Western health care settings. We use CM rather than the common term CAM (complementary and alternative medicine) because it highlights the secondary role and marginality of these therapies relative to conventional biomedical health care (Shuval and Averbuch 2012). Although current debate concerning integrative medicine concentrates on the power relations between CM and biomedicine in integrative settings, the issue of the exclusion of local TM from the conventional health care system has been neglected. By highlighting an attempt at border crossing—which includes the introduction of local indigenous TM modalities to an integrative CM setting—this article seeks to contribute to the debate concerning power relations and medical pluralism. It adds a further perspective to the critical analysis of the social, cultural, and political aspects of the relatively new phenomenon of integrative health care (Adams et al. 2009; Baer 2001; Baer and Coulter 2008; Coulter 2004; Hollenberg and Muzzin 2010). Using a critical theoretical perspective (Adams et al. 2009; Kaptchuk and Miller 2005), we examine whose worldview is expressed and whose is excluded. It appears that the current proliferation of CM among higher socioeconomic status groups has changed the conventional image of TM, which, until the 1970s, was associated with lower income, less-educated populations as well as with ethnic and religious minorities (Hufford 1988; Mackenzie et al. 2003). Many indigenous non-Western cultures embrace a holistic approach to health and illness, which includes a focus on interconnections between the mind, body, and spirit (Mark and Lyons 2010). Some of them, like traditional Chinese medicine, were adopted by Western countries under the umbrella of CM. This and other factors led many researchers to consider indigenous TM as part of CM (e.g., Mackenzie et al. 2003) and to use the term traditional, complementary and alternative medicine (e.g., Broom et al. 2009; Wootton 2006). Power relations, however, unavoidably came into play. The very terms complementary and alternative medicine and traditional medicine reflect hierarchical divisions and power relations. TM and CM

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are constructed designations of systems in which practices may not be differentiated by actual philosophies and ideologies but rather by economic class and ethnic distinctions (Baer 2001; Holliday 2008). The difference between CM and TM often comes to the fore in institutionalized integrative medicine when CM is integrated into the mainstream medical system. This is the case in Israel, where Western-oriented CM modalities, which accord with the Jewish majority’s preferences more than with those of the Arab minority, are integrated within the Israeli biomedicine-dominated health care system. The more common among these modalities are: reflexology, Chinese medicine and acupuncture, massage, Shiatsu, Twina, homeopathy, and naturopathy. Arabs in Israel, on the other hand, are more oriented toward indigenous Arabic TM, which includes local Mediterranean and Arab traditional herbal medicine. This is practiced mainly by traditional healers and is not formally integrated into Israeli health care organizations (Ben Arye et al. 2009; Keshet and Ben Arye 2011, 2012). Against the political background of Jewish–Palestinian tension and struggle, this issue becomes contentious.

Traditional Arab Medicine in Israel The State of Israel is a small country with a Jewish majority surrounded by Arab Muslim Middle Eastern states. Arabs form the largest minority group in the country, comprising some 20% of the country’s total population. The Arabs are an indigenous minority, having populated Palestine for centuries, whereas most Jews are firstto third-generation immigrants with religious and historical ties to the country. As Israel is surrounded by Arab states, the Arabs in Israel are tied by language, culture, identity, history, collective memory, narratives, and loyalty to Palestinian nationalism and pan-Arabism. They see themselves as part of the world’s population of Palestinians, which constitutes a source of political tension. Despite a degree of modernization, their way of life is still semi-traditional, and the Palestinian population is far less modern and secular than the dominant Jewish culture (Smooha 2010). The Arabs in Israel constitute a low-status minority (Herzog 2004; Mana 1999). Along with their lower socioeconomic levels, health indicators in Israel present a picture of poorer health among the Arabs compared to the Jewish population (Israel Center for Disease Control 2005). Differences between the socioeconomic status of Arab and Jewish men may explain disparities in physical health (Baron-Epel and Kaplan 2009). It has also been suggested that individual levels of social capital (such as networks, norms, and social trust that facilitate coordination and cooperation for mutual benefit), which appear lower among the Arab minority than among the Jewish majority in Israel, are positively associated with self-rated health, primarily in the Jewish population and less so in the Arab population (Baron-Epel et al. 2007). Yet, because Israel has a comprehensive system of national health insurance, there is little disparity between the populations with regard to access to health care services, and Arabs’ use of these services is similar to that reported by Jews (Baron-Epel et al. 2007). Alongside the modern health care services, Arabs tend to use also TM (Ben Arye et al. 2009).

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Traditional Arab healers (sheikh, darvish, moalj bel Qur’an [healer by the Quran]) diagnose their patients using the Qur’an, or by means of an object belonging to the patient, by placing hands on the patient’s body, by observing oil or ink signs, or with the help of demons with whom they connect during prayer (AlKrenawi et al. 1996; Gorkin and Othman 1994). Female healers (sheikhah, darvisha, hajah, fataha) often diagnose using coffee or palm readings (Popper-Giveon 2009). The core of the patient’s problem—be it frustration, depression and anxiety, spinsterhood, infertility, childhood ailments, or problems related to economic livelihood—is attributed to possession by a demon, the evil eye, or witchcraft. Treatment is dispensed via use of the Qur’an or other books with astrological and destiny calendars based on numerological attributes of the patient’s name and his or her mother’s name, amulets, or the use of medicinal plants (Popper-Giveon 2009). Patients consult healers in their homes. Male healers generally receive clients in a designated room at home or in the yard, near their house; female healers may have a special room in their home or receive their patients in the kitchen or the guest room (Popper-Giveon and Ventura 2009). Arab TM treatments are usually not considered part of CM and are not being integrated into Israel’s conventional health care system. The cost of such treatments tends to be rather high and may come to hundreds and even thousands of Israeli shekels. Integrative Health Care in Israel From the late 1980s, imported CM modalities have gradually attracted a growing number of consumers and practitioners. In 2009, for example, Israelis paid 2,632,000 visits to CM practitioners (Central Bureau of Statistics 2009). Israel has never instituted formal regulation or control mechanisms with regard to CM, yet growing consumer demand for CM services has led conventional health care organizations to provide CM treatments to their clients. Sixty-five percent of CM treatments in Israel are practiced in conventional health care settings, namely hospitals and public clinics run by health maintenance organizations (Shuval and Averbuch 2012). These treatments are not included in the package of health care entitlements under the national health law, and patients are required to pay for them, although they are generally partially subsidized. CM and conventional medicine are joined in diverse modes (Shuval and Averbuch 2012). Typically, a dually trained physician, namely a medical doctor trained also in one or more modalities of CM, initiates and promotes integration of CM into the conventional health care setting and heads this service (Keshet 2013). CM treatments are provided by CM practitioners in networks of special public clinics established by the sick funds. In some hospital departments, CM practitioners provide treatments to ambulatory or hospitalized patients. For the most part, the treatments provided are imported foreign modalities such as reflexology, Chinese medicine and acupuncture, massage, Shiatsu, Twina, homeopathy, and naturopathy (Keshet and Ben Arye 2011). Boundary Crossing Over the past five years, a group of dual-trained physicians initiated attempts to promote integration of indigenous Arab TM into the Israeli health care system,

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thereby addressing the Arab population’s preferences. Their pioneering attempts can be regarded as a form of social, ethnic, professional, and political boundary crossing. The idea of boundaries has come to play a key role across the social sciences in recent years. It has been associated with research on cognition, social and collective identity, cultural capital, racial and ethnic group positioning, professional jurisdictions, scientific controversies, and more (Lamont and Molnar 2002). A boundary may be regarded as a sociocultural difference leading to discontinuity in action or interaction (Akkerman and Bakker 2011), and the concept is used to investigate how markers of difference are created, maintained, or contested at many different levels of institutionalization and categorization (Lamont and Molnar 2002). The term boundary crossing was introduced to denote how professionals at work may need to move and interact across different sites (Suchman 1994). Under the influences of postmodernism, poststructuralism, postcolonialism, and feminism, the concept of boundary crossing is likewise used to focus on the marginal and the de-centered as alternatives to discourses of the power of the center (Edwards and Fowler 2007).

The Question of Intent The current research seeks to examine attempts to integrate hitherto excluded local Arab TM modalities into an integrative CM–biomedical setting. The questions of intent were: How can medical, ethnic, and political borders be crossed? How can cross-cultural integrative medicine be promoted? Focusing on the Israeli case, this article seeks to set the promotion of institutionalized integrative medicine within broad cultural and political contexts. Its specific research questions were: Which steps are being taken to overcome barriers that inhibit the integration of local Arab TM into Israeli health care organizations? Which dialogical phenomena and learning processes occur when boundaries are crossed?

Methodology Data were gathered by applying two interconnected research methods: participant observation and content analysis of texts written by the research participants. For research purposes, the first author (Y.K.) became a non-M.D. member of the CM Society, which is a professional sub-association of the Israeli Medical Association. The CM Society was founded by Israeli dual-trained integrative physicians. Beginning with approximately fifty members in 2005, the CM Society grew to some 150 members at the end of 2011. Most of the members are physicians working in health care organizations—hospitals and community public health care organizations— and head CM clinics or services in those organizations. They possess diverse kinds of medical expertise in areas such as family medicine, psychiatry, neurology, and gynecology, along with expertise in certain CM modalities, such as homeopathy, Chinese medicine, hypnosis, and anthroposophical medicine. In addition to these integrative physicians’ clinical practice of medicine, their academic activities (e.g., publications and conferences) mediate the context in which Arab TM and CM are perceived.

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For six years, between 2005 and 2011, the first author participated in diverse processes that some of these integrative physicians initiated and promoted. These included initiating and leading CM units within health care organizations, research projects, organizing professional conferences, publishing medical articles, and so forth. After obtaining the agreement of the participants, the first author recorded lectures in conferences and discussions in working meetings, took notes, made transcripts, and analyzed 24 medical articles dealing with TM written by these members of the CM Society. One of the latest and most meaningful observations was conducted at a conference held in May 2011. Jointly organized by the CM Society and the Al-Qasemi Research Center, this conference addressed ways of integrating TM in research and clinical practice. The conference was one of the high points in attempts to promote cross-cultural integrative medicine. It was held in three languages: Hebrew, Arabic, and English, and the lunch, defined as “kosher vegetarian with an emphasis on traditional Arab cuisine” well exemplified the crossing of professional, religious, and national borders. The conference took place in the Al Qasemi Arab Academic College in the town of Baqa-El-Gharbia in Israel. Al-Qasemi College was founded in 1989 as an institute of Sharia and Islamic studies. Students study various aspects of Islam, Arabic, and English language and literature, mathematics, computer science, and education (http://www.qsm.ac.il/PR/). The Al-Qasemi Research Center was launched in 2008, with a view to fostering research in biology and biochemistry. Basic and applied research is conducted on medicinal plants, which includes in-vitro evaluation of the safety and efficacy of herb-based medicines, including the anticancer properties of medicinal plants (http://www.qsm.ac.il/mop/Science.aspx?LabId=1071). The second author (A.P.G.) conducted ethnography during the years 2001–2005, focusing on traditional Arab women healers and the Arab women who consult them (Popper-Giveon 2012). From 2011 to 2012, she surveyed/documented and interviewed Arab practitioners (folk healers, CAM practitioners, and religious healers) who treat Arab oncological patients in the Galilee area of northern Israel. The data were analyzed according to Akkerman and Bakker’s (2011) suggestion to regard boundaries as dialogical phenomena. In this context, boundaries are defined as social, cultural, and political differences leading to discontinuities in action and interaction. Reviewing literature dealing with boundary crossing and boundary objects, Akkerman and Bakker (2011) suggest that boundaries may promote four dialogical learning mechanisms. These are identification, coordination, reflection, and transformation. These mechanisms indicate various ways in which boundaries function as resources for the development of intersecting identities and practices.

Findings Using Akkerman and Bakker’s four dialogical learning mechanisms, we followed a number of pioneering attempts to integrate local TM into an integrative CM– biomedical setting. We found that these endeavors involve actions of medical, ethnic, and political border crossing. These included medical borders between TM, CM, and biomedicine; ethnic borders between Israeli Arabs and Jews; and political borders between Israelis, Palestinians, and other Middle Eastern Arab countries.

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Identification: Different Yet Related Practices and Identities The identification stage included two dialogical processes (as suggested by Akkerman and Bakker 2011). One of these is “othering,” which entails defining one practice in terms of another practice and delineating how it differs from the other practice. The second is identifying the underlying need for legitimizing coexistence. The othering process involved professional as well as religious and national identities. Treatments by Muslim healers are conducted primarily via the use of the Qur’an verses. The healers read Qur’anic prayers over the patient’s head. They prepare amulets, which contain phrases from the Qur’an. The amulets are dissolved in water, which may be drunk or poured on the patient’s wounds. The healers may recommend drinking Zamzam water from a spring in Mecca. They may also use medicinal plants, such as saffron, which are considered to possess magical powers. Possession, generally considered to be a consequence of neglecting religion and its commandments, is treated by the healers through attempts to exorcise the demon (jinn, jnun) from the patient’s body. During the exorcising ceremony, the healer first prays and then communicates with the demons and identifies the particular one responsible for the patient’s suffering. He then demands that the bothersome demon explain why it is harming the patient; then he subdues and finally banishes it. This procedure is accompanied by readings from the Qur’an, drumming and, should the demon refuse to relent, even physically beating the patient. The healer encourages the patient to instigate changes in his or her lifestyle, such as adhering to the religious commandments or strengthening belief in God. The woman healer provides the patient with new interpretations concerning her reality. She seeks to restore the patient’s place within her family and community by leading the patient—through the use of amulets and spells—to resume her traditional gender roles, particularly those of mother and wife. According to the healers, adherence to these culturally accepted gender roles establishes the patient’s self-identity and social status and mitigates anxiety related to acute social transformations. The healer encourages the patient to accept the conventional collective and patriarchal values, tries to promote her integration within her family and her adoption of cultural gender roles, and strives to moderate any individualistic traits on her part, which may underlie the rift between her and her relatives. The healer’s advice tends to direct the patient toward submissiveness, obedience, and acceptance of the status quo. This derives from the understanding that the patriarchal social structure is not given to significant change. Thus, the healer makes no attempt to undermine it; on the contrary, her goal is to integrate the patient within the social context—the “domestic sphere”—and provide her tools whereby to maximize its advantages (Popper-Giveon and Weiner-Levy 2012). Such practices, which constitute an important part of local Arab TM, are generally regarded by the conventional medical world as providing psychological support rather than as having any intrinsic effect. These practices differ from CM practices in their emphasis on traditional religious spirituality. The professional identity of the studied integrative physicians is far removed from this religious world. Moreover, most of these physicians are secular and all are Jews. As Israeli physicians, they are subject to the tensions inherent in the Israeli–Palestinian dispute. One of the

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physicians, for example, is involved in the physicians for human rights movement, which voluntarily administers medical treatment to patients in the Palestinian territories. The othering process is exemplified in a session titled “Spiritual Treatment of the Patient: Mind, Body, Religion and Science,” which took place at the conference held in Al Qasemi College. Three speakers participated. The first, head of the Department of Islamic Studies, lectured on “The Spirit of Islam: Spiritual Treatment amongst the Sufi.” The second speaker, a Jewish researcher, spoke about the “Kabbalah and Hassidim.” The third lecturer, a religious Jewish physician, talked about “Scientific Perspectives of the Link between Spirituality and Health.” The first lecturer described spiritual healing called Ruqia as a “type of psychological healing.” It involves the reading of verses of the Qur’an over the patient, and hanging a written Ruqia (an amulet) on the patient. Al-Ruqia, which is employed to counter an evil-eye, poisonous creatures, physical pain, insomnia, or nocturnal sorcery, is not viewed as healing in its own right, but rather as healing that derives from Allah. Seeking to connect to the conference’s main theme, he talked about honey and the Qur’an being used to heal body and spirit and maintained that reading verses from the Qur’an over water alters the water’s physical properties. The second speaker addressed the belief in the healing power of words according to Jewish mysticism and Kabbalah. The third speaker presented clinical research that demonstrates the importance of spiritual chaplaincy in improving patients’ well-being. The dynamics in this session demonstrated the strength of boundaries between medicine and religion, between Jews and Muslims, between Israelis and Arabs, and between biomedicine and spiritual support. The Arab speaker wore traditional Sufi religious clothing and a matching headdress. He insisted on speaking only in Arabic, a language that most of the audience did not understand. He was simultaneously translated to English, although most of the other lecturers and most of the audience were Hebrew speakers (the main language in Israel). When he completed his lecture, he left the room. Although some questions from the audience were taken at the end of the session, there was no discussion between the various speakers. The identification stage of boundary crossing involves a second process of recognizing the underlying need for legitimizing coexistence (Akkerman and Bakker 2011). In our research field, recognition of the need for legitimizing coexistence emerged from the desire to treat the patient as a person by addressing the full range of his or her objective as well as subjective problems, in the context of her or his culture. This patient-centered treatment requires acquaintance with patients’ health-belief model and therapeutic preferences (Ben-Arye et al. 2006). In light of the cultural–ethnic–religious differences between Arabs and Jews in Israel, and the relatively minor interest shown by Arab patients in CM treatments, integrative physicians conducted a cross-cultural study in northern Israel during 2005–2006. The research objective was to evaluate Arab and Jewish patients’ patterns of TM and CM use and their perspectives on its integration within primary care clinics. The Arab respondents reported relatively higher rates of usage of TM (50.4%) and traditional herbs (35.0%), and favored the addition of a herbalist to the biomedical setting far more than did Jews (Ben Arye et al. 2009). Among the diverse Arab TM practices, herbal medicine was identified by Arab

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patients as well as by some integrative physicians and Arab and Jewish researchers as a legitimate practice that could be integrated into health care systems as part of CM. Traditional herbal medicine was recognized as a potential base for patientcentered treatment and as a potential learning source. Coordination: Using Herbal Medicine as a Boundary Object The legitimization of herbal medicine by some integrative physicians and Arab and Jewish researchers, who identified it as a practice that could be integrated into health care systems as part of CM, positioned it as a boundary object. The concept of boundary object was coined by Star and Griesemer (1989) to explain how cooperation is facilitated despite the heterogeneity of scientific work, which comprises many different actors and viewpoints. Boundary objects are: both plastic enough to adapt to local needs and the constraints of the several parties employing them, yet robust enough to maintain a common identity across sites. . . . The creation and management of boundary objects is a key process in developing and maintaining coherence across intersecting social worlds. [Star and Griesemer 1989:393] Integrative physicians, as well as Arab and Jewish scientists, used herbal medicine as a boundary object to bridge professional, religious, national, and political borders. First, herbal medicine was used to bridge medical borders between TM, CM, and biomedicine. There are significant differences between the approach taken by TM, CM, and biomedicine toward herbal medicine. TM practitioners tend to believe in the magical powers of herbal medicine. Most CM modalities recommend using the crude plant and emphasize the synergetic influences of its diverse components. Practitioners of diverse CM modalities may also stress the “energetic” influences (Keshet 2011) and “vital forces” of herbs. The biomedical model of evidence-based medicine contrasts with these types of knowledge. In biomedicine, a particular herbal extract is prepared in specific doses, relying on evidence of the specific physical efficacy of these herbal preparations. Despite these differences, integrative physicians, as well as Arab and Jewish biomedical researchers who participated in the Al Qasemi conference, considered herbal medicine to be a legitimate form of medicine that could mediate the boundaries between biomedicine, CM, and TM. An example is provided by a study that focuses on the beneficial effects of local plants such as olives, dates, licorice root, red wine, and pomegranates on cholesterol levels (Aviram et al. 2005). Another example is research conducted on the safety and anti-diabetic effects of Glucolevel, a mixture of a dry extract of leaves of four anti-diabetes plants used in traditional Arab herbal medicine (Said et al. 2008). Yet another example is the willingness of Arab TM researchers to collaborate with Israeli integrative physicians in trying to gain institutional legitimacy for Arabic Islamic TM as part of CM. This endeavor is manifested in the title of the article: “Traditional Arabic and Islamic Medicine (TAIM) now joins TCM [Traditional Chinese Medicine], CAM [Complementary and Alternative Medicine], Kampo and Ayurveda” (Azaizeh et al. 2007).

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Second, herbal medicine was used as a boundary object to bridge ethnic borders between Israeli Arabs and Jews. In Israel, Arab and Jewish physicians usually work together in health care organizations. They share a common biomedical professional education and practice as colleagues on an equal footing. Yet, when religious and political issues surface, rifts and conflicts tend to appear. A case in point is the use of traditional herbal medicine as a resource to express and reinforce ethnic and religious identities. Although Jews who likewise use local medicinal herbs (although to a lesser extent than Arabs) use the term “Israeli” or “biblical herbs,” Arab researchers use the terms “Arab TM” (Saad et al. 2005:475) and “Arabic and Islamic medicine” (Azaizeh et al. 2007:364) for the same herbs. A prominent researcher of traditional Arab herbal medicine referred to medicinal herbs not only in the pharmacological sense but also raised political and ethnic aspects of the historical local conflict: We are indigenous people . . . what is known about medical herbs is deeply rooted in our local historical consciousness, and we see the Jewish state—they came from everywhere, and wanted to take over the land, they took our land and destroyed five hundred villages and established cities and we have become fifth class citizens. Our first reaction is to grab and hold on to things that belong to us. People like us, when we see how falafel becomes “Israeli” and hyssop becomes “Israeli” and hummus becomes “Israeli,” revert to nationalism and begin believing in a national theme and emphasizing identity. . . . Why did our ancestors survive? That’s because they were close to the land and plants and each plant has a story. A plant—my grandmother told how her grandfather had used it. And it is part of the return to the roots in opposition to the process the State of Israel began, to Judaize the area and delete the so-called historical memory of this place. This political and ethnic aspect of the conflict surfaced at the conference as well as in articles published in the medical literature. One of the traditional Arab herbal medicine researchers, Omar Said, was arrested by the Israeli security service in 2010. The political context is likewise manifested in the location at which a conference designed “to revive the heritage of traditional Arabic and Islamic medicine” was held: “in a location (Amman, Jordan), where many Arab and Muslim scientists could participate . . . in order to release it from the political restrictions of the Middle East” (Azaizeh et al. 2007:364). Despite these political differences, a notable attempt to use herbal medicine to establish Arab–Jewish collaboration took place at the Al Qasemi conference. The conference included lectures on topics ranging from the renowned Jewish and Islamic physicians of the Middle Ages, to current evidence-based medicine. The historical context of shared Arab–Jewish ethnobotanical TM was employed to translate and mediate the diverse identities. Figures such as Avicenna and Maimonides were invoked to highlight the shared origin of current medicine. An Arab scholar spoke about the Golden Age of Arab Islamic civilization, which “lasted from the seventh to the fifteenth century and extended from Spain to Central Asia and India.” Avicenna was mentioned as one of the greatest and most influential physicians of Greco– Arab and Islamic medicine. In the same session, a Jewish physician spoke about the

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Jewish physician Maimonides who lived and worked in Cordoba (in today’s Spain). He emphasized the historical interconnectedness and mutual influences of Arabic and Jewish TM, which are both based on the use of herbs and spices, and which linked East to West. Third, herbal medicine was used as a boundary object to bridge political borders between Israelis, Palestinians, and other Middle East Arab Countries. MiddleEastern multidisciplinary and multinational collaborative initiatives have been undertaken. An integrative oncology research center was established via the Middle East Cancer Consortium. Researchers from Israel, Egypt, Turkey, the Palestinian Authority, Jordan, and Morocco assembled to perform a comprehensive literature review of published data on TM and CM in supportive cancer care in the Middle East. Meetings were conducted in Arabic, Hebrew, French, and Turkish. The review found many studies that addressed herbal medicine use, along with spiritual and other practices. “Considerable effort was invested to overcome language bias by referring non-English publications to authors who read fluent Arabic, Turkish, French, and Hebrew” (Ben Arye et al. 2011b:7). A further research project was likewise conducted by a multinational team (Israel, Egypt, and Turkey) comprising family physicians, medicine specialists, oncologists, an Islamic medicine history specialist, a TM ethnobotanist, and a basic research scientist. This search yielded 44 herbs associated with cancer treatment. It concluded that: “A multidisciplinary approach combining traditional herbal knowledge with contemporary research is a valuable methodology for identifying potential herbs with possible clinical significance in cancer care. We therefore propose that the Middle East could serve as a unique region for future collaborative multiculturaloriented cancer research” (Ben Arye et al. 2012:216, 218).

Reflection: The Conscious Effect of Boundary Crossing Boundaries have potential in terms of reflection. Crossing boundaries can lead to awareness of the differences between practices and enable people to learn about their own and others’ practices. This may enrich people’s views of the world and likewise further enrich their identity (Akkerman and Bakker 2011). Some such effects were found in this study. First, the role of integrative physicians as mediators of integration was enhanced. Integrative physicians potentially play a pivotal role, not only in promoting communication between the physician and the CM practitioner (Ben Arye 2010), but also in mediating TM integration into the health care system. Second, multidisciplinary, multi-professional, and multinational collaborative research was found to be significantly enriching knowledge of local and endemic herbal medicines (Ben Arye et al. 2011a). Third, the researchers hope that their joint efforts will encourage future collaboration among researchers and clinicians in the Middle East. They believe that future regional collaboration will enhance knowledge in the field in various ways: by validating the practical benefits of herbal treatments; discovering possible interactions with conventional drugs; and by understanding the clinical impact of integration in real-life clinical practice (Ben Arye et al. 2011c).

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Fourth, future collaborative projects were proposed to study mind–body interaction as well as other TM and CM modalities with the potential of improving patients’ quality of life (Ben Arye et al. 2011b). Fifth, enhanced collaboration with TM scholars was seen to have the potential to enrich health care practices using diverse Mediterranean herbs (Ben Arye et al. 2011c). Enriching the repertoire of practices, especially through employment of culturally oriented therapies, enhances the availability of patient-centered treatment. Using TM as part of patient-centered treatment may empower patients (Ben Arye et al. 2011c), especially those belonging to minority groups. Transformation: The Peak of Boundary Crossing Reflection is a learning process that emphasizes perspectives and identities, but transformation is the practical result of boundary crossing that leads to profound changes in practices (Akkerman and Bakker 2011). Thus far, the crossing of boundaries has led primarily to learning in terms of reflection and has only begun the initial stage of transformation in the relationships between CM, TM, and integrative medicine in Israel. It is one thing to create initial hybridization at the boundary; it is quite another to embed it in practice and achieve tangible results. Continuous collaboration along the boundary is required to sustain boundary crossing. Although indigenous Arabic TM is not currently integrated into Israeli health care organizations (Keshet and Ben Arye 2011), initial attempts are being made to integrate traditional herbal medicine. For example, in an integrative program operating within a large medical center in Israel, a multidisciplinary team developed “nutritional herbal prescriptions” and “medicinal food” that are recommended to patients with cancer during chemotherapy and/or advanced disease. The team comprises an integrative physician, CM practitioners, psycho-oncologists, a spiritual counselor, occupational therapists, and a clinical dietician. These nutritional herbal prescriptions and medicinal foods were developed in the context of traditional Arab cuisine and traditional herbal medicine and are adapted to the habits of this minority group. Several questions have yet to be resolved. Will new routines and procedures be developed that embody what has been created and learned? Will boundary permeability be enhanced to the extent that the differences between practices become less acute simply because actions and interactions proceed smoothly? Will TM practices and practitioners become integrated into the Israeli public health care system? Will local Mediterranean traditional herbal medicine be taught alongside Western and Chinese herbal medicine? Will collaboration between Jewish and Arab researchers from diverse disciplines and countries continue and become routine?

Conclusions The case study of traditional Arab herbal medicine and integrative health care in Israel highlights the relevance of political tensions, ethnicity, and medical inequality to the field of integrative health care. As previously argued (Baer and Coulter 2008; Broom and Tovey 2007; Hollenberg and Muzzin 2010), integrating CM into conventional health care organizations does not eliminate power relations. When

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the issue of TM is added to the equation, strong social, ethnic, and political forces come into play. Although indigenous Arabic TM is not currently formally integrated into Israeli health care organizations (Keshet and Ben Arye 2011), initial attempts are being made in this direction. This article presents the steps that have been taken to overcome barriers that inhibit the integration of local Arab TM into Israeli health care organizations. These pioneering attempts included othering as well as recognizing the underlying need for legitimizing coexistence; using herbal medicine to bridge medical borders between TM, CM, and biomedicine; and being aware of the differences between practices that enabled reflections. These resulted only in some initial steps toward transformation, which are the practical result of boundary crossing. Herbal medicine is perceived—by integrative physicians as well as Arab and Jewish researchers—as a boundary object that can serve to overcome barriers and provide opportunities for dialog and reciprocal learning. Herbal medicine is probably a more appropriate boundary object than other Arab TM modalities (such as religious healing) for several reasons. Regardless of the competing Arab and Jewish cultural and political background and frames of reference, the local medicinal herbs are basically the same herbs. These plants—familiar to the region’s inhabitants—can therefore form a bridge between the two main ethnic groups—Arabs and Jews—in Israel. Furthermore, despite religious, ethnic, and political conflicts between Arabs and Jews in the Middle East, when it comes to traditional herbal medicine, the shared Arab–Jewish historical context of ethnobotanical TM can be employed to translate and mediate the diverse identities. Figures such as Avicenna and Maimonides can be invoked to highlight the shared origin of current traditional herbal medicine. Medicinal herbs are particularly suited to serve as a boundary object because they constitute a widely researched modality (Ben Arye et al. 2011b). Many studies have been conducted on herbal medicine; only a few have been carried out with other nonconventional modalities, especially religious or spiritual ones. Moreover, the “objective” sphere of biological, pharmacological, and biomedical research of medical herbs serves as a neutral site for scientific and practical medical collaboration. In addition, treating Arab patients through traditional Arab herbal medicine is perceived—both by the patients and Arab traditional practitioners—as a relatively safe treatment devoid of harmful or dangerous side effects such as those associated with other drugs (Popper-Giveon et al. 2013). Among the diverse Arab TM practices, therefore, herbal medicine has been identified as a legitimate practice that can be integrated into health care systems as part of CM. Traditional herbal medicine is recognized as a potential base for patient-centered treatment and as an important potential learning source. Medical pluralism and patient-centered care are two of the central principles declared by integrative medicine. This means that health care should accord with patients’ cultural tastes and preferences. We accordingly suggest the need for future critical research in the field of integrative health care that will examine whether attempts to overcome political tensions, ethnicity, and medical inequality are being made, and, if so, which mechanisms are currently used in other cultural contexts.

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