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Integrative Medicine in 2021: An Imagined Retrospective
GUEST EDITORIAL
Integrative Medicine in 2021: An Imagined Retrospective David Eisenberg, MD
The Samueli Institute, the Washington, DC-based philanthropic organization dedicated to the exploration and dissemination of an integrative approach to healthcare, celebrated its 10th anniversary on October 4-5, 2011. The theme of the conference was “Celebrating in 2011. Envisioning 2021.” David Eisenberg, MD, one of the foremost pioneers in the integrative medicine field, was one of the featured speakers. We are happy to publish Dr. Eisenberg’s remarks in Explore. —Larry Dossey, MD, Executive Editor t’s 2021, the 20th anniversary celebration of the Samueli Institute. We’ve been asked to reflect on how the field of integrative medicine (IM) has impacted societal perceptions of wellness, healing, and the delivery of healthcare during the past decade. In this retrospective, let’s first consider what might have happened during the first half of the decade between 2011 and 2021. In this imagined scenario, the global economy contracted; a much feared double-dip recession occurred; China emerged as an economic power and national surveys in China (and these data are current) revealed that 88% of its citizens (ie, 1 billion) used TCM (herbs, acupuncture, massage, Tai Chi) on a regular basis, making it the single largest “consumer” of complementary and alternative medicine (CAM) in the world. India was a close second, with nearly a billion people using some form of Ayurvedic medicine routinely. Meanwhile, back in the United States, epidemiological surveys revealed that more than 75% of Americans were overweight or obese; the Centers for Disease Control and Prevention (CDC) formally predicted that one in three children born after 2000 would become diabetics,
I
Guest Editorial
and the Institute of Medicine said “That the great advances in genetics and biomedical research could be offset by the burden of illness, disability, and death caused by too many people eating too much and moving too little”. Parenthetically, as of 2010, China’s childhood overweight/obesity figures had skyrocketed from 2% in 1985 to 25% of boys and 15% of girls being overweight or obese in cities with a million or more residents. U.S. medical insurance premiums continued to increase at rates which choked the economy, and U.S. Veterans Administration (VA) hospitals were caring for thousands of veterans from Mideast wars who needed treatment for chronic pain, posttraumatic stress disorder and brain injury, many of whom sought a combination of conventional and CAM therapies in their treatment. There was a significant decrease in National Institutes of Health (NIH) funding across the board during these difficult years, and fewer medical professionals sought careers in medical research. This period was also marked by heated debates on healthcare reform and the need to rethink how health promotion and medical care are paid for and reimbursed by third parties. Importantly, there was an unequivocal trend, begun with legislation passed in 2010, that the old “fee-for-service” financial paradigm—which incentivized hospitals and physicians to treat disease, but not to promote health, prevent or manage diseases efficiently— had to be abandoned and replaced by new models with incentives on the basis of “payment for performance” and on a capitated scheme that included a fixed fee to be allocated per person. These allocated health care dollars needed to include preventive, diagnostic, and therapeutic services. As a result, for the very first time “wellness,” “self-care,” and participatory, “life-
style”-related approaches, all of which are core principles of CAM/IM, were viewed favorably by health planners and decision makers as potentially valuable components of future, more sustainable health care delivery models. Medical and public health leaders, under tremendous financial and political pressure, sought to explore a return on investment, that is, a documentable “value proposition” from integrative medical care and enhanced self-care (eg, diet, exercise, mind– body techniques, etc.) as possible ways to reduce disease prevalence and improve health outcomes while reducing overall costs. Finally, demographic changes by 2015 resulted in the “Baby Boom” generation taking the reins of power in medical, economic, and political spheres of influence. This unleashed sensibilities that were new, that celebrated medical diversity and globalization and that were capable of creating paradigms that differed significantly from those created and protected by the generation before them. In this scenario, looking backwards from 2021 to 2011, “IM” changed societal perceptions of wellness and healing in several ways. A few examples are listed in the sections to follow.
PAIN MANAGEMENT As a result of research implemented by NIH, we learned enough about the mechanism of action of individual CAM therapies, like acupuncture, chiropractic, massage, and meditation for pain management, and clinical investigators documented the adjunctive effectiveness of these individual therapies in the treatment and management of pain-related conditions (eg, low back pain, headache, chronic joint pain, peripheral neuropathies) in real-world settings so that
EXPLORE March/April 2012, Vol. 8, No. 2
81
pain, the accepted fifth vital sign, is now, in 2021, routinely treated with a combination of both conventional and CAM therapies (ie, by integrative models of clinical care). This set the stage for more licensed CAM practitioners to be employed within the mainstream medical workforce in both inpatient and outpatient settings. This, in turn, led to increased attention to the educational requirements, credentialing, licensure, scope of practice and competency testing of CAM professionals, many of whom now routinely work in hospitals, medical and nursing schools, HMOs, community health centers, and physicians’ offices.
THE DEVELOPMENT AND INCREASED AVAILABILITY OF “INTEGRATIVE CARE TEAMS” INVOLVING BOTH CONVENTIONAL AND CAM PRACTITIONERS Drawing on the Institute of Medicine Report on CAM in the United States (2005) and work supported by the National Center for Complementary and Alternative Medicine 2009 Strategic Plan, the NIH was joined by the Agency for Healthcare Research and Quality, Medicare and Medicaid, the Department of Defense, VA, and CDC to formally test the hypothesis that coordinated access to well-trained teams of licensed healthcare professionals which include both conventional and CAM practitioners could result in the following: (1) improved clinical outcomes; (2) reduced overall healthcare costs: and (3) increased return to work rates, increased worker productivity, as well as decreased disability costs. This pragmatic research, slow to get off the ground, picked up steam once major self-insured companies and major labor unions joined with federal agencies to develop multidisciplinary care teams within “patient-centered medical homes” and “accountable care organizations” throughout the United States. Selfinsured companies and labor unions were highly motivated to participate in these provocative randomized controlled trials in the hope of improving employee health outcomes while reducing medical costs (which could be pocketed) and increasing overall worker productivity, employee satisfaction, and loyalty. A few well-designed demonstrations involving employees with persistent back pain
82
showed that those employees with coordinated access to integrative care did better and cost less than those with access to “usualcare” only. These experiments netted considerable cost savings for participating companies and unions and served as game changers. China set in motion parallel studies of “East-West-Integrative Care Centers” (ie, the Chinese equivalent of multidisciplinary integrative care teams) on a massive scale in Beijing, Shanghai, Guangzhou, and Hong Kong and simultaneously documented improved clinical outcomes at reduced overall costs for Chinese workers with back pain, neck pain, joint pain, and recurrent headache. The Chinese ability to implement (and fund) large randomized controlled trials with thousands of subjects recruited across multiple cities in record time, and their willingness to work with U.S. and European co-investigators, expedited this change in perception about IM and its potential cost effectiveness. As the United States moved from a fee for service to a capitated reimbursement model between 2011 and 2021, more and more integrative care centers were established and third-party payers, at the insistence of self-insured corporations (their bosses), paid for these integrative care services. By 2021, integrative care teams were being trained through broad coalitions of medical and nursing schools, schools of oriental medicine, acupuncture, chiropractic, naturopathy, and massage. The first coalitions were established in Portland, Oregon and Minneapolis, Minnesota, where these various CAM professional schools had previously partnered on numerous NIH educations grants during the previous decade. By 2021, China (and India) had established whole departments that integrated modern conventional (Western) medicine with traditional Chinese (or Ayurvedic) medicine in their major hospitals and universities, and their dual-trained Chairmen/women sit at the decision making table with chiefs of medicine, surgery and those responsible for health policy and funding for several billion Asians.
2011 to an estimated $500B/year in 2021 because of an annual increase of more than 25%/year (this is the actual rate of increase since 2004, by the way). The majority of these increases came from out-of-pocket expenditures by Chinese and Indian adults with greater expendable incomes. Along with this spike in herbal consumption, scientific discoveries ultimately occurred once the top biotech institutions in China and India— both public and private— committed the necessary financial and intellectual capital to systematically evaluate medicinal plants, both individually and in complex mixtures as they are routinely prescribed, to elucidate their biological activity and explicit mechanisms of action. They also had to make sure these plants were safe, reproducible, and free of adulterants like pesticides and heavy metals, as NIH-funded studies had pressured them to do so. By deciding to go beyond the western pharmaceutical paradigm of identifying active single compounds in favor of searching for predictable combinations of compounds with synergistic effects, teams of scientists, working hand in hand with experts in TCM and Ayurveda, finally identified examples of novel mechanisms of action of individual compounds as well as novel additive and synergistic biological effects of multiple compounds on targets relating to the biology of cancer, cardiovascular disease, neurodegeneration and aging. Some of these discoveries led to patents and, in turn, to a fresh investment of capital from large pharmaceutical companies, the majority of whom had given up on natural product research two decades earlier. By 2021, the large, global drug companies were back in this game. These discoveries also led to a resurgence of interest in medicinal plants, their traditional uses, their safety, reproducibility, clinical applications and cost effectiveness. Partnerships with environmental groups in Europe, North and South America, Hawaii, Africa, and Asia also grew once it was determined that selected plants had considerable commercial value and their cultivation could represent a new source of jobs and sustainable agriculture across multiple continents.
HERBAL MEDICINES AND OTHER DIETARY SUPPLEMENTS The global market for medicinal plant remedies and non-herbal dietary supplements increased from an estimated $100B/year in
RESEARCH INVOLVING PLACEBOS AND MIND–BODY INTERACTIONS Our growing understanding of when and how placebos work, the degree to which they are genetically or environmentally
EXPLORE March/April 2012, Vol. 8, No. 2
Guest Editorial
(ie, contextually) amplified or diminished, and how they can be optimized has substantially altered the way we design current clinical trials and has garnered the attention of big pharma as well as insurers, both of whom now support research on methods to ethically and scientifically maximize placebo effects in an effort to improve patient outcomes and reduce toxicity from prescribed drugs (and other interventions). By 2021, the hunt for the “placebo gene or genes” is ongoing. This work, also begun through funding from the NIH, changed the way we view health, illness, responses to therapies, and the design of clinical trials. It is a true example of disruptive scientific discovery and innovation emanating from CAM/IM research, with implications for clinical and basic science research as well as medical education.
NOVEL MULTIDISCIPLINARY APPROACHES TO ADDRESS OBESITY By 2012, the American public, its government, its military, and the private sector were finally sufficiently shocked by rates of obesity and diabetes to take action. The scientific community reached a consensus view that no specific “diet” alone had proven to be effective in a sustained way for more than a trivial percentage of adults; that individual lifestyle modalities, like exercise, were only modestly effective on a population level; that the addictive properties of salt, sugar, and fat also had to be factored into the development of novel strategies; and that the food industry itself, regrettably dependent on governmental agencies and Federal subsidies for meat, dairy, and corn, needed a radical makeover to rectify the status quo when it came to food and nutrition in the United States. Importantly for the IM community, multidisciplinary models began to emerge that combined conventional nutritional counseling and exercise prescription along with reproducible educational programs involving mindful eating techniques, health coaching, and culinary education—yes hands-on food preparation education. These combined lifestyle/CAM approaches were developed by the use of reproducible protocols and began to demonstrate significant and sustained changes in personal behaviors, clinical outcomes, and health-related costs as well as quality of life for a
Guest Editorial
significant percentage of those willing to learn such self-care “skills for life.” These innovative, multidisciplinary models were tested in hospitals and worksites and then refined between 2011 and 2021 for subsequent roll out in other venues. Slowly but steadily they began to be incorporated as required classes in K-12 schools, colleges, and universities. As a result of these educational interventions (which included a range of CAM mindfulness based practices as well as exercise and nutritional education) these new models, when combined with new market forces which favored the consumption of predominantly plant-based, nonprocessed, sustainable foods, rates of obesity finally began to decrease for the first time in 40 years. The rest of the world took notice and built upon these critically important models of self-care instruction. Interestingly, the mindfulness aspects of eating wisely were more rapidly accepted outside the United States, as mindfulness practices were to be found in every culture and could be rejuvenated more easily than expected across multiple (non western) national populations.
INCREASED INTERNATIONAL COLLABORATION After the Fourth and Fifth International Congress on Integrative Medicine Research, sponsored by the U.S. Consortium of Academic Health Centers for Integrative Medicine in partnership with multiple non-U.S. groups, an International Consortium of Integrative Medicine Research Centers and Governmental Funding Agencies from the United States, Canada, Australia, Europe, the United Kingdom, Japan, India, and China was formally established. There is now, in 2021, a far more coordinated and strategic approach to the prioritization, design, and implementation of CAM/IM research, education, and policy development worldwide. Now, research on individual CAM therapies (like acupuncture or herbal treatments) and on models of multidisciplinary, integrative care for common diseases like lower back pain or arthritis, can be developed and funded far more efficiently and effectively than had been the case before 2011. Inefficient, redundant research and unnecessary competition have been replaced by formal collaboration—a united front!
HOW OUR INCREASED UNDERSTANDING OF THE HUMAN GENOME IMPACTS ACCESS TO AND REIMBURSEMENT FOR CAM/ IM THERAPIES As our predictive powers based on DNA testing at birth improved, it became easier to identify individuals at greater risk for those diseases known to be significantly impacted by lifestyle choices in areas of diet and nutrition, exercise, and stress management. Building upon models of “personalized medicine” described in 2011, new healthcare delivery models were established whereby children and adults at increased risk for certain diseases like obesity, diabetes, or heart disease and selected malignancies were preferentially encouraged to learn dietary, exercise, and mind– body practices to (1) reduce their lifelong risk or (2) modify the natural course of their disease. As such, health and medical care delivery models now routinely include and provide both genetic testing and third-party reimbursement for (1) personalized exercise prescription, (2) nutritional counseling and instruction in food selection and preparation, and (3) a range of mind⫺body therapies as adjuncts to routine psychopharmacology and psychotherapy. As such, in 2021 more CAM/ IM modalities are available to all regardless of their sociodemographic backgrounds or income levels. Why? Because this approach, as documented by several decades of rigorous research, reduces our societal disease burden, saves money and improves public health.
CHANGES IN EDUCATION—BEYOND MY TIME LIMIT Suffice it to say that as a result of 30 years of research and with a growing repository of scientific evidence as to which CAM modalities work and which do not, which are reproducible and safe and which are not, which interact positively or negatively with other therapies and the precise mechanisms through which individual CAM therapies work, and, armed with cost-effectiveness evidence that selected IM models based in patient-centered-medical-homes, can, in selected instances, result in improved health outcomes at lower costs, CAM and IM topics have, during the past decade, been more fully incorporated into required—and not just optional— curricula within schools of medicine, nursing, allied health, veterinary
EXPLORE March/April 2012, Vol. 8, No. 2
83
medicine as well as schools of the CAM professions (eg, chiropractic, massage, acupuncture and Asian medicine, and naturopathy).
WHAT CHANGED TO SPARK THESE (IMAGINED) EVENTS AND CHANGES IN PERCEPTION? Several factors are worth noting: 1. Funding for CAM and IM research had to be expanded from the NIH as the major—if not solitary—funder to investments on the part of Agency for Healthcare Research and Quality, Department of Defense, Medicare and Medicaid, CDC, various Presidential Commissions (eg, Patient-Centered Outcomes Research Institute), HMOs, insurers, drug companies, self-insured corporations, and labor unions in addition to philanthropic foundations (which had less to give after the economic decline in 2009) and private companies intent on selling products and services to promote health and reduce disease risk. Each of these entities had much to gain and the decade of 2011⫺2021 was the decade to
84
“translate” 30 years of IM research into new models of health and lifestyle medicine promotion and medical care delivery that improved outcomes and reduced costs locally, nationally and globally. 2. Financial challenges in the United States and globally sparked pragmatic research seeking a “return on investment” from new models of care that incorporated conventional and CAM/IM care along with enhanced self-care strategies. 3. The obesity pandemic galvanized governments around the world to take bolder action to protect their people and their pocketbooks from this public health “tsunami.” 4. China and India emerged as willing and capable partners in the design, implementation, and funding of major scientific, medical, and health services research in this area. A larger international consortium of researchers and governmental funding agencies also had to be established to make the best use of internationally available resources and to avoid redundancy and unnecessary competition.
EXPLORE March/April 2012, Vol. 8, No. 2
5. The generation of American and world leaders in the period 2011⫺2021, coming from the Baby Boom generation, were (as I imagine them) more apt to celebrate medical diversity as yet another unavoidable consequence of globalization. The field of IM, which is of great interest to billions of people around the world, and the shared desire to perpetually refine our respective models of comprehensive healthcare delivery, unites public health leaders and medical professionals from all traditions both ancient and modern. This is fundamentally why the field of IM will flourish and likely be discussed, yet again, by the Samueli Institute in 2021 at its 20th Anniversary Celebration!
David M Eisenberg, MD is the Bernard Osher Distinguished Associate Professor of Medicine at the Harvard Medical School and is also an Associate Professor of Nutrition at the Harvard School of Public Health in Boston, MA. Additionally, he is a Senior Fellow at the Samueli Institute.
Guest Editorial
Integrative Medicine in 2021: An Imagined Retrospective David Eisenberg, MD
The Samueli Institute, the Washington, DC-based philanthropic organization dedicated to the exploration and dissemination of an integrative approach to healthcare, celebrated its 10th anniversary on October 4-5, 2011. The theme of the conference was “Celebrating in 2011. Envisioning 2021.” David Eisenberg, MD, one of the foremost pioneers in the integrative medicine field, was one of the featured speakers. We are happy to publish Dr. Eisenberg’s remarks in Explore. —Larry Dossey, MD, Executive Editor t’s 2021, the 20th anniversary celebration of the Samueli Institute. We’ve been asked to reflect on how the field of integrative medicine (IM) has impacted societal perceptions of wellness, healing, and the delivery of healthcare during the past decade. In this retrospective, let’s first consider what might have happened during the first half of the decade between 2011 and 2021. In this imagined scenario, the global economy contracted; a much feared double-dip recession occurred; China emerged as an economic power and national surveys in China (and these data are current) revealed that 88% of its citizens (ie, 1 billion) used TCM (herbs, acupuncture, massage, Tai Chi) on a regular basis, making it the single largest “consumer” of complementary and alternative medicine (CAM) in the world. India was a close second, with nearly a billion people using some form of Ayurvedic medicine routinely. Meanwhile, back in the United States, epidemiological surveys revealed that more than 75% of Americans were overweight or obese; the Centers for Disease Control and Prevention (CDC) formally predicted that one in three children born after 2000 would become diabetics,
I
Guest Editorial
and the Institute of Medicine said “That the great advances in genetics and biomedical research could be offset by the burden of illness, disability, and death caused by too many people eating too much and moving too little”. Parenthetically, as of 2010, China’s childhood overweight/obesity figures had skyrocketed from 2% in 1985 to 25% of boys and 15% of girls being overweight or obese in cities with a million or more residents. U.S. medical insurance premiums continued to increase at rates which choked the economy, and U.S. Veterans Administration (VA) hospitals were caring for thousands of veterans from Mideast wars who needed treatment for chronic pain, posttraumatic stress disorder and brain injury, many of whom sought a combination of conventional and CAM therapies in their treatment. There was a significant decrease in National Institutes of Health (NIH) funding across the board during these difficult years, and fewer medical professionals sought careers in medical research. This period was also marked by heated debates on healthcare reform and the need to rethink how health promotion and medical care are paid for and reimbursed by third parties. Importantly, there was an unequivocal trend, begun with legislation passed in 2010, that the old “fee-for-service” financial paradigm—which incentivized hospitals and physicians to treat disease, but not to promote health, prevent or manage diseases efficiently— had to be abandoned and replaced by new models with incentives on the basis of “payment for performance” and on a capitated scheme that included a fixed fee to be allocated per person. These allocated health care dollars needed to include preventive, diagnostic, and therapeutic services. As a result, for the very first time “wellness,” “self-care,” and participatory, “life-
style”-related approaches, all of which are core principles of CAM/IM, were viewed favorably by health planners and decision makers as potentially valuable components of future, more sustainable health care delivery models. Medical and public health leaders, under tremendous financial and political pressure, sought to explore a return on investment, that is, a documentable “value proposition” from integrative medical care and enhanced self-care (eg, diet, exercise, mind– body techniques, etc.) as possible ways to reduce disease prevalence and improve health outcomes while reducing overall costs. Finally, demographic changes by 2015 resulted in the “Baby Boom” generation taking the reins of power in medical, economic, and political spheres of influence. This unleashed sensibilities that were new, that celebrated medical diversity and globalization and that were capable of creating paradigms that differed significantly from those created and protected by the generation before them. In this scenario, looking backwards from 2021 to 2011, “IM” changed societal perceptions of wellness and healing in several ways. A few examples are listed in the sections to follow.
PAIN MANAGEMENT As a result of research implemented by NIH, we learned enough about the mechanism of action of individual CAM therapies, like acupuncture, chiropractic, massage, and meditation for pain management, and clinical investigators documented the adjunctive effectiveness of these individual therapies in the treatment and management of pain-related conditions (eg, low back pain, headache, chronic joint pain, peripheral neuropathies) in real-world settings so that
EXPLORE March/April 2012, Vol. 8, No. 2
81
pain, the accepted fifth vital sign, is now, in 2021, routinely treated with a combination of both conventional and CAM therapies (ie, by integrative models of clinical care). This set the stage for more licensed CAM practitioners to be employed within the mainstream medical workforce in both inpatient and outpatient settings. This, in turn, led to increased attention to the educational requirements, credentialing, licensure, scope of practice and competency testing of CAM professionals, many of whom now routinely work in hospitals, medical and nursing schools, HMOs, community health centers, and physicians’ offices.
THE DEVELOPMENT AND INCREASED AVAILABILITY OF “INTEGRATIVE CARE TEAMS” INVOLVING BOTH CONVENTIONAL AND CAM PRACTITIONERS Drawing on the Institute of Medicine Report on CAM in the United States (2005) and work supported by the National Center for Complementary and Alternative Medicine 2009 Strategic Plan, the NIH was joined by the Agency for Healthcare Research and Quality, Medicare and Medicaid, the Department of Defense, VA, and CDC to formally test the hypothesis that coordinated access to well-trained teams of licensed healthcare professionals which include both conventional and CAM practitioners could result in the following: (1) improved clinical outcomes; (2) reduced overall healthcare costs: and (3) increased return to work rates, increased worker productivity, as well as decreased disability costs. This pragmatic research, slow to get off the ground, picked up steam once major self-insured companies and major labor unions joined with federal agencies to develop multidisciplinary care teams within “patient-centered medical homes” and “accountable care organizations” throughout the United States. Selfinsured companies and labor unions were highly motivated to participate in these provocative randomized controlled trials in the hope of improving employee health outcomes while reducing medical costs (which could be pocketed) and increasing overall worker productivity, employee satisfaction, and loyalty. A few well-designed demonstrations involving employees with persistent back pain
82
showed that those employees with coordinated access to integrative care did better and cost less than those with access to “usualcare” only. These experiments netted considerable cost savings for participating companies and unions and served as game changers. China set in motion parallel studies of “East-West-Integrative Care Centers” (ie, the Chinese equivalent of multidisciplinary integrative care teams) on a massive scale in Beijing, Shanghai, Guangzhou, and Hong Kong and simultaneously documented improved clinical outcomes at reduced overall costs for Chinese workers with back pain, neck pain, joint pain, and recurrent headache. The Chinese ability to implement (and fund) large randomized controlled trials with thousands of subjects recruited across multiple cities in record time, and their willingness to work with U.S. and European co-investigators, expedited this change in perception about IM and its potential cost effectiveness. As the United States moved from a fee for service to a capitated reimbursement model between 2011 and 2021, more and more integrative care centers were established and third-party payers, at the insistence of self-insured corporations (their bosses), paid for these integrative care services. By 2021, integrative care teams were being trained through broad coalitions of medical and nursing schools, schools of oriental medicine, acupuncture, chiropractic, naturopathy, and massage. The first coalitions were established in Portland, Oregon and Minneapolis, Minnesota, where these various CAM professional schools had previously partnered on numerous NIH educations grants during the previous decade. By 2021, China (and India) had established whole departments that integrated modern conventional (Western) medicine with traditional Chinese (or Ayurvedic) medicine in their major hospitals and universities, and their dual-trained Chairmen/women sit at the decision making table with chiefs of medicine, surgery and those responsible for health policy and funding for several billion Asians.
2011 to an estimated $500B/year in 2021 because of an annual increase of more than 25%/year (this is the actual rate of increase since 2004, by the way). The majority of these increases came from out-of-pocket expenditures by Chinese and Indian adults with greater expendable incomes. Along with this spike in herbal consumption, scientific discoveries ultimately occurred once the top biotech institutions in China and India— both public and private— committed the necessary financial and intellectual capital to systematically evaluate medicinal plants, both individually and in complex mixtures as they are routinely prescribed, to elucidate their biological activity and explicit mechanisms of action. They also had to make sure these plants were safe, reproducible, and free of adulterants like pesticides and heavy metals, as NIH-funded studies had pressured them to do so. By deciding to go beyond the western pharmaceutical paradigm of identifying active single compounds in favor of searching for predictable combinations of compounds with synergistic effects, teams of scientists, working hand in hand with experts in TCM and Ayurveda, finally identified examples of novel mechanisms of action of individual compounds as well as novel additive and synergistic biological effects of multiple compounds on targets relating to the biology of cancer, cardiovascular disease, neurodegeneration and aging. Some of these discoveries led to patents and, in turn, to a fresh investment of capital from large pharmaceutical companies, the majority of whom had given up on natural product research two decades earlier. By 2021, the large, global drug companies were back in this game. These discoveries also led to a resurgence of interest in medicinal plants, their traditional uses, their safety, reproducibility, clinical applications and cost effectiveness. Partnerships with environmental groups in Europe, North and South America, Hawaii, Africa, and Asia also grew once it was determined that selected plants had considerable commercial value and their cultivation could represent a new source of jobs and sustainable agriculture across multiple continents.
HERBAL MEDICINES AND OTHER DIETARY SUPPLEMENTS The global market for medicinal plant remedies and non-herbal dietary supplements increased from an estimated $100B/year in
RESEARCH INVOLVING PLACEBOS AND MIND–BODY INTERACTIONS Our growing understanding of when and how placebos work, the degree to which they are genetically or environmentally
EXPLORE March/April 2012, Vol. 8, No. 2
Guest Editorial
(ie, contextually) amplified or diminished, and how they can be optimized has substantially altered the way we design current clinical trials and has garnered the attention of big pharma as well as insurers, both of whom now support research on methods to ethically and scientifically maximize placebo effects in an effort to improve patient outcomes and reduce toxicity from prescribed drugs (and other interventions). By 2021, the hunt for the “placebo gene or genes” is ongoing. This work, also begun through funding from the NIH, changed the way we view health, illness, responses to therapies, and the design of clinical trials. It is a true example of disruptive scientific discovery and innovation emanating from CAM/IM research, with implications for clinical and basic science research as well as medical education.
NOVEL MULTIDISCIPLINARY APPROACHES TO ADDRESS OBESITY By 2012, the American public, its government, its military, and the private sector were finally sufficiently shocked by rates of obesity and diabetes to take action. The scientific community reached a consensus view that no specific “diet” alone had proven to be effective in a sustained way for more than a trivial percentage of adults; that individual lifestyle modalities, like exercise, were only modestly effective on a population level; that the addictive properties of salt, sugar, and fat also had to be factored into the development of novel strategies; and that the food industry itself, regrettably dependent on governmental agencies and Federal subsidies for meat, dairy, and corn, needed a radical makeover to rectify the status quo when it came to food and nutrition in the United States. Importantly for the IM community, multidisciplinary models began to emerge that combined conventional nutritional counseling and exercise prescription along with reproducible educational programs involving mindful eating techniques, health coaching, and culinary education—yes hands-on food preparation education. These combined lifestyle/CAM approaches were developed by the use of reproducible protocols and began to demonstrate significant and sustained changes in personal behaviors, clinical outcomes, and health-related costs as well as quality of life for a
Guest Editorial
significant percentage of those willing to learn such self-care “skills for life.” These innovative, multidisciplinary models were tested in hospitals and worksites and then refined between 2011 and 2021 for subsequent roll out in other venues. Slowly but steadily they began to be incorporated as required classes in K-12 schools, colleges, and universities. As a result of these educational interventions (which included a range of CAM mindfulness based practices as well as exercise and nutritional education) these new models, when combined with new market forces which favored the consumption of predominantly plant-based, nonprocessed, sustainable foods, rates of obesity finally began to decrease for the first time in 40 years. The rest of the world took notice and built upon these critically important models of self-care instruction. Interestingly, the mindfulness aspects of eating wisely were more rapidly accepted outside the United States, as mindfulness practices were to be found in every culture and could be rejuvenated more easily than expected across multiple (non western) national populations.
INCREASED INTERNATIONAL COLLABORATION After the Fourth and Fifth International Congress on Integrative Medicine Research, sponsored by the U.S. Consortium of Academic Health Centers for Integrative Medicine in partnership with multiple non-U.S. groups, an International Consortium of Integrative Medicine Research Centers and Governmental Funding Agencies from the United States, Canada, Australia, Europe, the United Kingdom, Japan, India, and China was formally established. There is now, in 2021, a far more coordinated and strategic approach to the prioritization, design, and implementation of CAM/IM research, education, and policy development worldwide. Now, research on individual CAM therapies (like acupuncture or herbal treatments) and on models of multidisciplinary, integrative care for common diseases like lower back pain or arthritis, can be developed and funded far more efficiently and effectively than had been the case before 2011. Inefficient, redundant research and unnecessary competition have been replaced by formal collaboration—a united front!
HOW OUR INCREASED UNDERSTANDING OF THE HUMAN GENOME IMPACTS ACCESS TO AND REIMBURSEMENT FOR CAM/ IM THERAPIES As our predictive powers based on DNA testing at birth improved, it became easier to identify individuals at greater risk for those diseases known to be significantly impacted by lifestyle choices in areas of diet and nutrition, exercise, and stress management. Building upon models of “personalized medicine” described in 2011, new healthcare delivery models were established whereby children and adults at increased risk for certain diseases like obesity, diabetes, or heart disease and selected malignancies were preferentially encouraged to learn dietary, exercise, and mind– body practices to (1) reduce their lifelong risk or (2) modify the natural course of their disease. As such, health and medical care delivery models now routinely include and provide both genetic testing and third-party reimbursement for (1) personalized exercise prescription, (2) nutritional counseling and instruction in food selection and preparation, and (3) a range of mind⫺body therapies as adjuncts to routine psychopharmacology and psychotherapy. As such, in 2021 more CAM/ IM modalities are available to all regardless of their sociodemographic backgrounds or income levels. Why? Because this approach, as documented by several decades of rigorous research, reduces our societal disease burden, saves money and improves public health.
CHANGES IN EDUCATION—BEYOND MY TIME LIMIT Suffice it to say that as a result of 30 years of research and with a growing repository of scientific evidence as to which CAM modalities work and which do not, which are reproducible and safe and which are not, which interact positively or negatively with other therapies and the precise mechanisms through which individual CAM therapies work, and, armed with cost-effectiveness evidence that selected IM models based in patient-centered-medical-homes, can, in selected instances, result in improved health outcomes at lower costs, CAM and IM topics have, during the past decade, been more fully incorporated into required—and not just optional— curricula within schools of medicine, nursing, allied health, veterinary
EXPLORE March/April 2012, Vol. 8, No. 2
83
medicine as well as schools of the CAM professions (eg, chiropractic, massage, acupuncture and Asian medicine, and naturopathy).
WHAT CHANGED TO SPARK THESE (IMAGINED) EVENTS AND CHANGES IN PERCEPTION? Several factors are worth noting: 1. Funding for CAM and IM research had to be expanded from the NIH as the major—if not solitary—funder to investments on the part of Agency for Healthcare Research and Quality, Department of Defense, Medicare and Medicaid, CDC, various Presidential Commissions (eg, Patient-Centered Outcomes Research Institute), HMOs, insurers, drug companies, self-insured corporations, and labor unions in addition to philanthropic foundations (which had less to give after the economic decline in 2009) and private companies intent on selling products and services to promote health and reduce disease risk. Each of these entities had much to gain and the decade of 2011⫺2021 was the decade to
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“translate” 30 years of IM research into new models of health and lifestyle medicine promotion and medical care delivery that improved outcomes and reduced costs locally, nationally and globally. 2. Financial challenges in the United States and globally sparked pragmatic research seeking a “return on investment” from new models of care that incorporated conventional and CAM/IM care along with enhanced self-care strategies. 3. The obesity pandemic galvanized governments around the world to take bolder action to protect their people and their pocketbooks from this public health “tsunami.” 4. China and India emerged as willing and capable partners in the design, implementation, and funding of major scientific, medical, and health services research in this area. A larger international consortium of researchers and governmental funding agencies also had to be established to make the best use of internationally available resources and to avoid redundancy and unnecessary competition.
EXPLORE March/April 2012, Vol. 8, No. 2
5. The generation of American and world leaders in the period 2011⫺2021, coming from the Baby Boom generation, were (as I imagine them) more apt to celebrate medical diversity as yet another unavoidable consequence of globalization. The field of IM, which is of great interest to billions of people around the world, and the shared desire to perpetually refine our respective models of comprehensive healthcare delivery, unites public health leaders and medical professionals from all traditions both ancient and modern. This is fundamentally why the field of IM will flourish and likely be discussed, yet again, by the Samueli Institute in 2021 at its 20th Anniversary Celebration!
David M Eisenberg, MD is the Bernard Osher Distinguished Associate Professor of Medicine at the Harvard Medical School and is also an Associate Professor of Nutrition at the Harvard School of Public Health in Boston, MA. Additionally, he is a Senior Fellow at the Samueli Institute.
Guest Editorial