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Naturopaths vie for Medicare reimbursement with a dubious survey

Naturopathy is a pseudodiscipline that resembles a Chinese menu of quackery, in which naturopaths select one from column A and two from column B, with each column containing a list of modalities ranging from pure quackery like homeopathy and traditional Chinese medicine to mundane modalities that naturopaths embrace, “rebrand” as “alternative,” and woo-ify and oversell in the process, such as nutrition and lifestyle interventions like exercise. Despite this, naturopaths are deluded enough to believe themselves qualified to be primary care practitioners. Worse, they’ve been having some success at achieving licensure in far too many states, most recently Maryland. (They’re even trying to achieve this in my own state.) Meanwhile, in a seeming contradiction to their entire philosophy that “natural” is better, they keep pushing for more prescribing rights that would allow them to prescribe real pharmaceutical medications, despite their utter lack of qualifications to do so and their hostility towards science.

For all their successes in state legislatures at becoming licensed in more and more states, naturopaths still have one hurdle that they so want to leap. That hurdle is the insurance issue. They want their specialty to be treated like real medicine, like a legitimate medical specialty, by insurance companies. Basically, they want to be able to bill insurance companies for their services. Even more than that, they want to be accepted by Medicare, because whatever Medicare reimburses, most insurance companies will agree to reimburse. If naturopaths could crack that Medicare nut, then full reimbursement from most, if not all, insurance companies would soon follow. Knowing that, you will know the purpose of a survey that’s being touted by the American Association of Naturopathic Physicians (AANP), with a press release proclaiming, Study Finds High Demand for Naturopathic Physicians Among Older Americans. Basically, it was a survey of older Americans living in states in which naturopaths are licensed. The key finding was that 55% of older Americans who live in states that license naturopathic physicians would consider seeking care from a naturopathic physician and that “100% would likely visit a naturopathic physician if the visit were covered by Medicare.”

From the press release:

Dr. Kasra Pournadeali, President of the AANP, remarked, “The seniors I and many other naturopathic physicians see understand the importance of self-care, personal responsibility, and non-drug methods in staying healthy. They also understand how naturopathic physicians have training in natural and conventional methods and are best-equipped to recommend effective non-drug treatments when appropriate. Isn’t it time to end the mandate that seniors can only access a physician trained solely in costly, drug therapies? Isn’t it time to allow our elderly access to other effective and less-costly methods?”

And:

“The study is a wake-up call to policy makers,” commented Jud Richland, CEO of the American Association of Naturopathic Physicians (AANP). “Seniors are saying loud and clear that they want Medicare to provide access to holistic care providers such as licensed naturopathic physicians. Millions of Americans have paid Medicare taxes all their working lives, but when the time comes to participate in Medicare, they find that the services they want aren’t available.”

Seldom have I seen the purpose of a survey so blatant. The AANP is basically arguing that, because seniors are interested in naturopathy and would consider going to a naturopath if naturopathic services were reimbursed, Medicare should reimburse naturopaths for their services. It’s not a particularly persuasive argument, even less so after I perused the actual survey report itself, and how it’s constructed.

Unfortunately, I don’t see the actual survey itself anywhere; so I can’t judge the validity of the questions. A company called Infosurv, which appears to specialize in marketing research and customer surveys, which seems appropriate in this case given that the AANP was clearly doing this survey as market research designed to be used to influence legislators. In any event, simply from the way that the results are reported, I can tell that a lot of assumptions went into the survey and potentially skewed the results. For example, the first issue examined, apparently, involved questions about whether the respondents (384 adults age 65 and over in states in which naturopaths are licensed) were interested in “natural healing.” Not surprisingly, they were:

Three-quarters of Medicare beneficiaries prefer that their doctor use natural therapies, such as improved diet or supplements, before prescribing drugs or surgery. This finding is not surprising given the number of older Americans who take one or more prescription drugs and who worry about the side effects of those drugs. The survey found that 88% of seniors are currently taking prescription drugs, and more than four in ten seniors who take prescription drugs worry about side effects.

Of course, most people don’t want to have surgery! Of course, most people don’t want to have to take prescription drugs! Surgery is painful and, depending on the nature of the surgery, can lay you up for a while. Taking drugs every day is drudgery, and there are certainly potential side effects, which can range from barely noticeable to debilitating. Indeed, I’m surprised that only 42% of the respondents who take prescription drugs reported being worried about side effects, while 58% were not. In other words, well under half of seniors taking prescription drugs number reported worried about side effects. (See? I can spin things, too!) It’s very obvious, though, what this survey is doing. It sets up the idea that seniors want “natural” treatments (never mind that supplements, by and large, are no more “natural” than pharmaceutical drugs).

Next, the survey asks about interest in naturopaths and finds that 55% of seniors would “consider seeing a naturopathic physician for their health care needs.” One wonders what percentage of respondents actually know what a naturopath is. My guess is that the survey told them, and told them this (taken from the survey report):

Naturopathic physicians emphasize non-invasive, natural therapies. They resort to prescribing drugs only when absolutely necessary or to referring patients to other health care professionals when surgery may be advisable.

If I didn’t know what naturopathy is, how it encompasses all manner of “natural” quackery, how it is based on prescientific vitalism at its core, I’d be half tempted to be favorably inclined to a medical specialty described thusly myself. Of course, I do know, and I wouldn’t be the least bit interested in going to a naturopath. My guess, however, is that few of the respondents knew what, exactly, a naturopath is or what sorts of treatments they recommend. If they knew what homeopathy was and that training in homeopathy is required in schools of naturopathy and the naturopathic licensing examination, they might not be so impressed with the promise of “natural therapy.” If they knew how slight the evidence base for naturopathy was and how traditional physicians do promote prevention and “natural” treatments that naturopaths have co-opted from science-based medicine (such as dietary changes and exercise), they might be less impressed. If they knew how naturopaths frequently use pseudoscientific diagnostic modalities like traditional Chinese medicine “tongue diagnosis,” they might be a lot less impressed.

Finally, here’s the pitch:

Federal law does not currently include naturopathic physicians among those health professionals who can participate in Medicare. As a result, many seniors are not able to obtain care from a naturopathic physician despite their desire to do so.

Of those seniors who would consider seeing a naturopathic physician, only 23% would do so if they had to pay the full cost of the visit out of pocket. However, when Medicare coverage is an option for individuals who would consider seeing a naturopathic physician, the picture is much different. Nearly 100% of respondents said they would consider seeking care from a naturopathic physician if the naturopathic physician were included in Medicare.

Of course, seniors would consider naturopathy if it were reimbursed by Medicare! If you don’t have to pay more than a co-pay for something like naturopathy, that puts it on the same tier as a regular doctor visit as far as cost. Add to that the apparently glowing description of naturopathy as “natural” and resorting to drugs and surgery only as a last resort, and of course naturopathy seems appealing, particularly when coupled with a dire estimate of the number of deaths due to adverse drug reactions, a commonly cited but questionable (at best) and misleading (at worst) statistic, which is mentioned in the AANP survey report. It’s not clear whether it’s mentioned in the survey itself, but it wouldn’t surprise me.

This survey is worse than useless, being nothing more than a blatant advertising tool for the AANP in its never-ending war to get more states to license naturopaths and to persuade CMS to allow Medicare to reimburse for naturopathic services. It’s so thin and transparent, so utterly without substance, that I wonder why the AANP even bothered.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

37 replies on “Naturopaths vie for Medicare reimbursement with a dubious survey”

From the house organ a few weeks ago, a looming crisis:

Many patients, upon becoming eligible for Medicare, are likely to face serious disruptions in care. Millions of people in the pre-Medicare population will have access to an ND as a result of naturopathic medicine’s growing popularity and as a result of the ACA’s non-discrimination provision. But when they turn 65, under current law their naturopathic physicians will not be able to participate in Medicare.

I wonder if this would reduce medicare costs? At least some people would die prematurely from untreated illness, which might create substantial savings!

(Offered in the spirit of Swift’s “Modest Proposal”.)

I see this as an example of naturopathy preying on seniors. The older you are the more likely you are to have a chronic condition that is not yet treatable by SBM. Desperation drives them to seek out anyone who says they can help whether or not there is evidence of efficacy.

This survey is worse than useless

…for those of us who prefer science-based medicine. But you can fool some of the people all of the time, and if the critical decision makers are among that “some of the people”, then this survey is quite useful to the AANP. They aren’t trying to fool you or me; they are trying to fool bureaucrats and lawmakers in Washington, many of whom (especially the latter group) are quite gullible.

It’s not a particularly persuasive argument, even less so after I perused the actual survey itself, and how it’s constructed.

Unfortunately, I don’t see the actual survey itself anywhere; so I can’t judge the validity of the questions.

So how did you peruse the “actual survey itself”?

Large insurance companies are initating metrics programs to monitor large groups of of their patients in certain diagnostic groups like diabetes & CHD. I’m certainly not advocating insurance payments for NDs but it would be interesting to see how patients seen by NDs compare. Their compensation might be dependent on actual progress as interpreted by the metrics.

“pure quackery like Traditional Chinese Medicine” – And yet there was just some publicity for the fact that clinical trials keep finding Chinese herbs may be as good as pharma drugs for rheumatoid arthritis. But that’s science, I guess, not Science.

…clinical trials keep finding Chinese herbs may be as good as pharma drugs for rheumatoid arthritis.

So why don’t you link to a few? Is it because they’re of the same poor quality as the xiao yao san metastudy that Orac took apart just a few days ago? Maybe you should respond to the criticisms on that thread before you pop up over here and try the exact same tactic.

And yet there was just some publicity for the fact that clinical trials keep finding Chinese herbs may be as good as pharma drugs for rheumatoid arthritis.

It would really help if you didn’t make people scurry around to figure out what you’re talking about. In this case, it’s this, which does not amount to “clinical trials keep finding,” particularly considering that in 2011 it looks like there was bupkis, which is even corroborated by the non-MEDLINE Evidence-based Complementary and Alternative Medicine.

But that’s science, I guess, not Science.

Or something.

Rheumatoid arthritis is exactly the type of condition to which Tony @3 refers:
older people suffer from joint pain despite a multtude of SB therapies which may only work partially, insufficiently, expensively ( joint replacement), time-consuming ( PT) or that cause disturbing side effects( GI bleeding).The condition is chronic, can be cyclic to a degree and limits mobility making people feel frustrated and depressed thus motivated to find relief.

Woo- as the g-d of the gaps- provides alternative treatments ( accupuncture, homeopathy, supplements, TCM, nutrition, energy medicine) which may waste money as well as time: there’s no good evidence that shows that any of it works.

There are a startling number of nutritional/ supplemental products that address arthritis-
glucosamine/ chondroitin, MSM, antho- proanthocyanidins,
hylauronic acids etc. I have yet to see really acceptable research that shows G/ C as being effective yet many peple swear by it. Doesn’t mean that it works.

I chanced upon this website and thought it might be considered a good read to be saved to my bookmarks, but this article was all I needed to change my mind. Personally I have seen the wonders of what the right nutrition and lifestyle can do to naturally heal the body. Nature has something for everything, you just have to research. Also, there are some great super food in aiding the reversal of illnesses without any need for pharmaceutical drugs or procedures. I’m speaking out of experience with myself and my family. It’s only a great pity that I had to only discover all these after what I’ve witness was done to my mother who has passed away, not because of the cancer she had, but because of all the radiation and morphine given. This article is truly narrow-mindedly written, if you only knew the real poison here.

@ Narad:

I swear, it happens all of the time.
I have a way ( or my way, is it?) with words.

Grace: Nature does not like us. Nature tries to kill us, in many ways and on many occasions. Nature is not benign and will not magically produce little flowers and twigs to heal diabetes, cancer, high blood pressure, or anything else.

If your family — or anyone else — has conducted properly-designed trials to prove otherwise, please provide a link.

Evidence-based Complementary and Alternative Medicine

I’m not doubting that such a journal exists, but that title is up there with “jumbo shrimp” or “military intelligence”. I’d imagine the print volumes are a bit thin, especially if you took out the studies that found null results.

Also, there are some great super food in aiding the reversal of illnesses without any need for pharmaceutical drugs or procedures.

Which superfoods, for what illnesses (I trust they are not self-limiting)? What exactly does ‘aiding the reversal of illnesses’ translate to in real-world terms, and how can this be accurately assessed, with respect to what metric?

let’s smplify things as much as possible: please provide what you believe to be the single most compelling piece of evidence demonstrating a superfood is as effective at treating a non-self-limiting injury or illness as are current standard of care SBM treatments or intervention.

I’d imagine the print volumes are a bit thin, especially if you took out the studies that found null results.

At $3195 per hear, it’s Hindawi’s second most expensive subscription. They were averaging 70–80 papers per year until 2011, when it suddenly went to 546, then 880, and then 1326. I haven’t found any negative results yet.

“There are certain limitations in this study. First, this study was not a double-blind, placebo-controlled clinical trial. Reduning was given as an injection, whereas TCM enema was given by rectal administration. We could not find appropriate placebos for these Chinese herbal medicines before the trial began. As this trial focused on children with severe [hand, foot, and mouth disease], more caution should be taken to decrease the possible risks to a minimum, and a placebo-controlled design might not be applicable…. [N]o adverse events were reported in our study, most likely because such adverse events as vomiting, diarrhea, nausea, and headache were common in all three groups. It is difficult to determine whether these events were HFMD-related or intervention-related events.”

@ grace:

“I chanced upon this website and thought it might be considered a good read to be saved to my bookmarks, but this article was all I needed to change my mind. Personally I have seen the wonders of what the right nutrition and lifestyle can do to naturally heal the body. Nature has something for everything, you just have to research. Also, there are some great super food in aiding the reversal of illnesses without any need for pharmaceutical drugs or procedures.”

Would you care to inform us about “right nutrition” preventing vaccine-preventable-diseases. or curing those diseases?

“I’m speaking out of experience with myself and my family. It’s only a great pity that I had to only discover all these after what I’ve witness was done to my mother who has passed away, not because of the cancer she had, but because of all the radiation and morphine given. This article is truly narrow-mindedly written, if you only knew the real poison here.”

What was the type of cancer (be specific, and include the staging and grading) did your mother have?

Which foods, (“right nutrition and lifestyle”), in your expert opinion, would have cured your mother?

Which alternative medicine and which “right nutrition and lifestyle” would you have substituted for morphine for pain relief?

that title is up there with “jumbo shrimp” or “military intelligence”.

I resemble that remark.

grace, did you bother to read this post before you dropped a general, condescending “I was considering reading your website, but now I won’t” comment?

Orac explicitly notes that nutrition and exercise can be beneficial, and that naturopaths are using them as cover for trying to sell things like homeopathy and prayer in place of medical care. So coming in here and saying “but nutrition is better than morphine” suggests that you may or may not know what naturopathy is, but you don’t know what science-based medicine is.

I suppose this is a negative result, although they do their damndest to avoid saying so, going so far as to abandon the topic of the paper (surgical patients) in the analgesia section and then instead attack a random study on pain perception in general:

“In this apparently well-controlled study, there is one missing information, which is the quality and source of lavender ‘odor’. It is possible that the lack of efficacy beyond the placebo effect is in fact related to the choice of the EO.”

Palindrome @ 2 beat me to it, but I would just offer that perhaps that study is evidence that a) the Alzheimer’s pandemic is already occurring, and b) it will be, pardon the expression, self-limiting, something for which NDs can claim partial ‘credit.’;-)

Seriously though: Two can play at this game: There’s ‘natural’ medicine, and there’s ‘supernatural’ medicine. Pharmaceuticals are natural, ‘energy healing’ is supernatural. MDs who practice SBM could advertise, ‘natural-science-based care,’ and point out that those who wish to have ‘supernatural care’ don’t have to ‘pay to pray,’ since they can pray for themselves. ‘A truly loving deity doesn’t care if you don’t get the words exactly right.’

Re. morphine: Well, there’s always the ancient herbal analgesic from the mysterious East, commonly known as _opium_. It comes from a plant, and it’s supposed to have a nice fragrance (what’s the woo term for magic sniffs? Aromatherapy?). It does everything morphine does, because it has morphine in it. But it also has something morphine doesn’t have: Plant spirits! Right!

It is very interesting that survey’s are being made on naturopathic medicine as it is obvious how more people are looking for an alternative and less painful way of treatment. You mentioned how it’s not a very impressive branch of medicine but wouldn’t it be a valuable one if doctors had a medical and nautropathic background? This way they could view a medical condition and critically analyse it in the best interest of the patient, thereby being aware of possible natural medicine that could too cure the condition and also lessen possible side effects.

Every branch of medicine has its positive and negative effects regardless so wouldn’t a combination or fusion of different branches lead to a more positive effect in some cases? I think then senior and other people would then feel so skeptical about their diagnostics if they knew that they aren’t solely based on either pseudoscience or the bio-medical model. People need that assurance that doctor’s genuinely care for their well-being and at the moment naturopaths come across with this approach which makes them seem more appealing.

It is very interesting that survey’s are being made on naturopathic medicine as it is obvious how more people are looking for an alternative and less painful way of treatment.

That’s not quite what they’re looking for, though, is it? What they’re actually looking for is are alternative less painfal treatments that are also safe and effective/i>. And if one has to choose between a treatment that’s more painful but is demonstrably effective, versus a treatment that is less painful but for which there’s no evidence suggesting efficacy…well, I know which line I’m going to be on.

Every branch of medicine has its positive and negative effects regardless so wouldn’t a combination or fusion of different branches lead to a more positive effect in some cases?

If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse. There’s no rational reason to presume mixing teatments that have not been shown to be beneficial (alt med or naturopathy) with treatments that have (SBM) you’ll improve patient outcomes.

People need that assurance that doctor’s genuinely care for their well-being and at the moment naturopaths come across with this approach which makes them seem more appealing.

That appearance is false, however: if they genuinely cared for their patients they wouldn’t be peddling homeopathy, acupuncture, aromatherapy, etc. in the absence of any real evidence these interventions will benefit their clients.

I could run a survey that 80% of seniors would like their kids to call more often, but that doesn’t mean that anyone should be changing FCC regulations.

Isn’t there some famouse quote about gentle lies and the hard truth?

Sorry to come to the discussion late.

The full report on the survey is here: http://aanp.membershipsoftware.org/files/About_Naturopathic_Medicine/Medicare%20survey%20report.pdf

It’s only 2-1/2 pages long, and mighty thin. They sum up the dangers of prescription drugs: “all drugs come with side effects. Many are minor, some are just an inconvenience, a few are serious, and some are just plain strange. Adverse drug reactions are among the leading causes of death in the United States, accounting for more than 100,000 deaths each year. In addition, they result in more than 2 million hospitalizations and serious injuries.” They cite WebMD, that bastion of medical wisdom, as their source.

The report says, “Naturopathic physicians emphasize noninvasive, natural therapies.” But then they list these treatments: naturopathic manipulative therapy, immunizations, minor surgery, acupuncture, prescription medication, and intravenous and injection therapy. How are these treatments natural and non-invasive?

The report says, “They resort to prescribing drugs only when absolutely necessary or to referring patients to other health care professionals when surgery may be advisable.” Orac, please forgive me just this once for mentioning grammar, but this isn’t even a sentence.

They chose 384 people over 65 years of age “randomly identified from a bona fide online survey sampling panel.” (They give no explanation of what in the world this means.)

Only 50 of those people would pay money to see a naturopath. Eighty-five (22%) take no prescription drugs at all. Of those who do take prescription drugs, more than half don’t worry about the side effects.

My primary doctor is a bona-fide science-based doctor and Medicare pays for my visits with her. She always recommends natural treatments first.
– High cholesterol! Change your diet.
– Feet, hips, shoulders, and back hurt? Exercise.
– Constipated? Eat some fruit.
– Can’t sleep? Exercise.
– Don’t like your weight? Change your diet AND exercise.

I wish she would knock it off! 😉

She and her science-based colleagues save the surgery and pharmaceuticals for the big stuff, like cancer. Exactly as it should be, and is, with the vast majority of mainstream medical doctors.

I wonder if you work for Sandoz Pharmaceutical or some other major multi-billion corporate Rx maker? Your argument is so blantantly cynical and one-sided that it makes one clearly think your only agenda is to discredit the N.D. unto oblivion. Health care should be meant to have “best outcomes” for health and wellness and in order to achieve that it does not mean that we are contained by the field of medical or osteopathic doctors. Are we not trying to lower the cost of the Medicare and Medicaid entitlement program costs upending are nation fiscally? If the field of naturopathy could truly be trained “credibly” with good clinical and didactic training then why should we not only receive them openly, but yes, also allow them to gain licensure and the ability to receive reimbursement. There are some, albeit very few, excellent Naturopathy programs out there whose curriculum has a high level of academic toughness in pathophysiology, biochemistry, etc.; very comparable to graduation from medical school. I am from the world of traditional medicine and many, many M.D.s and D.O.s, strongly attest to the validity and promise of natural medicine and your description of it as “quackery” is unfair. It is the slipshod so-called naturopathic programs (some who send degree through the mail), and unqualified people who use them who are wrecking this field. So, in order to protect the public, and give them natural medicine practices which are performed by highly trained, qualified practitioners we need licensure and naturopathic schools that are accredited and staffed with academic advisory who are M.D.s. And sir, in my career I have run into one too many P.A.s and N.P.s who prescribe prescription drugs who have very little knowledge of what the chemical make-up of the drugs they are prescribing, their half-lifes, contraindications, or their side effects; sometimes they cannot even pronounce them correctly. It is sad, and unproductive, for you to write such a rant without providing your audience with all the facts.

t makes one clearly think your only agenda is to discredit the N.D. unto oblivion.

Gee, you say that as though it were a bad thing.

In any case, one notes not a single shred of evidence presented by you to back up your position, just a rant and your biased anecdotes.

By Post Author

“….I am from the world of traditional medicine and many, many M.D.s and D.O.s, strongly attest to the validity and promise of natural medicine and your description of it as “quackery” is unfair. It is the slipshod so-called naturopathic programs (some who send degree through the mail), and unqualified people who use them who are wrecking this field….”

Care to share with us what your how you earn your living in “the field of traditional medicine”?

“Health care should be meant to have “best outcomes” for health and wellness and in order to achieve that it does not mean that we are contained by the field of medical or osteopathic doctors. ”

So how would you treat a young man with obstructive hypertrophic cardiomyopathy? What would you do if he complains that one of his arms is numb, and then his speech becomes unintelligible?

“There are some, albeit very few, excellent Naturopathy programs out there whose curriculum has a high level of academic toughness in pathophysiology, biochemistry, etc.; very comparable to graduation from medical school.”

So how well did you do on the US Medical Licensing Exam? How many years of residency did you do?

I am from the world of traditional medicine and many, many M.D.s and D.O.s, strongly attest to the validity and promise of natural medicine and your description of it as “quackery” is unfair.

Mr. Chew, you are a nontraditional public-health master’s student at Ashford University with aspirations to become a physician’s assistant. Somehow this does not stop you from holding yourself out as a “health care professional.” I am having exactly no luck finding evidence of the company that you claim to own, “Endosupply,” actually existing.

So kindly put a sock in the puffery.

Well naturopathy should be available as an alternative. Modern medicine seems to neglect the roll natural diet and lifestyle as a preventative and often curative measure for illness. Luckily I have experienced the wonders of this way of living before I had a chance to be put on life-draining pharmaceuticals.

“Modern medicine seems to neglect the roll natural diet and lifestyle as a preventative and often curative measure for illness.”

That is regurgitated bovine excrement.

First every primary care physician attempts to get their patients to eat a healthy diet and exercise. This is why my dear hubby has been able to fend off type 2 diabetes for over two years.

And second you need to define “natural diet and lifestyle.” Is that low carb high protein, vegetarian, raw food, paleo… or going way back to hunter/gatherer while living in trees?

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