Five Eras and 125 Milestones in The Rise of Integrative Health and Medicine … plus more

Five Eras and 125 Milestones in The Rise of Integrative Health and Medicine

Two decades after integrative was named as a direction for medicine in 1995, no definitive history of the field has emerged. The hole is beginning to be filled. In the recent The Bravewell Story, for instance, author Bonnie Horrigan1 captured the massive, 15-year strategic influence of a collaborative of philanthropists backing this transformation. Early chapters in James Maskell’s functional medicine-leaning Evolution of Medicine describe shifts in medical understanding that are stimulating growth of the field.2 Now, the 50 years since the field’s birth in the 1960s are beginning to receive additional treatment. My own chronicling as captured in the slide deck from a plenary for the Academy of Integrative Health and Medicine3 is beginning to perk more interest. Via refinement in subsequent presentations at Duke University, Georgetown University, AMSA Integrative Medicine Scholars, and elsewhere, I have proposed 5 “eras” for the field4:

• Era 1 (1963–1978): Origins in Counterculture, Milestones 1–9.

• Era 2 (1979–1995): Advancing in Silos, Milestones 10–24.

• Era 3 (1995–present): Nonintegrated Integration/still working on this, Milestones 25–44.

• Era 4 (2001–present): Advancing in Collaboration, Milestones 45–79.

• Era 5 (2010–present): Convergence in Health Creation, Milestones 80–125.

The “milestones” noted here refer to the most useful overview of this shared history yet to emerge, the 125 events and actions highlighted in The Rise of Integrative Health and Medicine.5 The 92-page free e-book, coauthored by Glenn Sabin and Taylor Walsh, begins with the chiropractors gaining federal recognition of their accrediting agency in 1963. It moves through the founding of the American College for the Advancement of Medicine (1973), the American Holistic Medical Association (1978), the first new naturopathic colleges in decades (1978), the American Holistic Nurses Association (1979), and other foundational organizations. Key actions at the National Institutes of Health and of the entrance of academic medical institutions in the 1990s and early 2000s are among the milestones that follow. Key federal policy actions and state legislation with national influence are highlighted. Sabin and Walsh seek to be inclusive. Milestones relate to massage, acupuncture, the herb industry, naturopathic medicine, holistic nursing, yoga therapy, natural childbirth, and more. For those interested, the 2 authors are interviewed in a 30-minute publicly available podcast.6

Comment: I was asked by Sabin to write a brief introduction to Rise. I chose to start with a set of questions: “At what point can an emergent movement look back and claim a history? And what is that history if, over the course of the time chronicled, separate strands have knit together into a whole that was unimagined at the outset? Do the lineages of each become the shared ancestry of what is emerging?” My guess is that most reading this do not feel fully connected with the disparate streams that braid together to become the strength of the present movement. Diving into and claiming a history is important. As the early 20th-century writer, Walter Benjamin, wrote, “History is written by the victors.” If so, what are the chances for a victory for a movement with no embraced history? Each of the documents referenced here are available for free. Take looks.

Opioids Issues Provoke Medical Organizations to Urge Coverage for Nonpharmacologic, Integrative Options

California acupuncturist, Mathew Bauer, lac, the president of the Acupuncture Now Foundation (ANF), chose to troll through the more than 4372 public comments submitted to the US Centers for Disease Control and Prevention (CDC) on its then draft “Guidelines for Prescribing Opioids for Chronic Pain.” His goal was to see where any commenting individual or organization showed interest in acupuncture, integrative strategies, or the broader category of nonpharmacological approaches. His finding stunned him: “Mainstream group after mainstream group [is] telling the CDC that physicians can’t act on the CDC’s number one recommendation regarding how to avoid relying on opioids because of a lack of insurance coverage for CAM/integrative therapies. I have never seen anything like this.”18 Bauer, who was also collaborating with the American Society of Acupuncturists (ASA) in his work, shared examples19:

• American Medical Association: “Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Providers should only consider using opioid therapy if expected benefits for pain and/or function are anticipated to outweigh risks. In order to achieve this goal, public and private payer policies must be fundamentally altered and aligned to support payment for non-pharmacologic treatments and multimodal care.”

• Trust for America’s Health: “Many insurers don’t adequately cover or reimburse for non-pharmacologic therapies such as acupuncture, biofeedback, relaxation, and other interactive, multimodal therapies. Payer policies—both public and private—would need to be fundamentally changed to support this recommendation.”

• American Pain Society: “We believe that patients should have both pharmacological and non-pharmacological approaches available and reimbursed . . . for the management of their chronic pain.”

• American Academy of Pain Management: “At a bare minimum, recommendations that payers provide universal coverage for the five types of nonpharmacologic care mentioned in the [Department of Defense/Veterans Administration] pain guideline (physical manipulation, massage, acupuncture, biofeedback, and yoga) should be issued.”

• Medical Board of California: “While it is true that many non-pharmacologic modalities are effective for the treatment/control of chronic pain, the [draft] Guidelines fail to address the fact that many patients do not have access to these modalities, due to lack of insurance coverage or low availability.”

ShortTakes

• ▶ American Specialty Health, the manager of acupuncture benefits for multiple major insurers, has produced a report that shows positive outcomes in patient experience of care by licensed acupuncturists.7

• ▶ The Integrator Blog News & Reports published its 2016 Top 10 in Policy and Action in Integrative Health and Medicine.8

• ▶ US Congressman Tim Ryan (D-OH), known for his long-time support of mind-body approaches, strongly promotes integrative health and medicine in a Wisdom 2.0 presentation.9

• ▶ China has issued its first “white paper” on traditional Chinese medicine, detailing that nation’s massive investment in the traditional Chinese medicine portion that represents approximately 15% of its medical industry.10

• ▶ A key pain group, the American Society of Regional Anesthesia and Pain Medicine, has published a formal position statement on medical marijuana that pushes the Drug Enforcement Administration to remove the inappropriate Schedule 1 designation.11

• ▶ Pennsylvania joined the states that now regulate naturopathic doctors.12

• ▶ Barry Gallison, dnp, ms, arnp-bc, from Broward Health, is in line to become the first male president of the American Holistic Nurses Association.13

• ▶ Integrative health connector, inspirer, and philanthropist, Ruth Westreich, is coauthor with Jan Phillips of a new book, Creativity Unzipped.14

• ▶ In the JAMA article “As Opioid Epidemic Rages, Complementary Health Approaches to Pain Gain Traction,” the organization representing conventional medical doctors would appear to be taking a step toward integrative pain care.15

• ▶ Also regarding JAMA, the journal’s former editor and current Medscape editor-at-large, George Lundberg, md, shares a powerful personal testimony to the value of acupuncture for sciatica.16

• ▶ Top acupuncturists globally are protesting new British guidelines leaving acupuncture out of guidelines for low-back pain.17

The ANF-ASA compilation of comments includes similar statements from others: the American College of Physicians, Providence Health, Alliance for Patient Access, American Academy of Addiction Psychiatry, and the American Osteopathic Academy of Addiction Medicine.

Comment: For many of these organizations, one can safely bet that nonpharmacologic does not extend to acupuncture or to chiropractic or to mind-body services or multiple other methods for pain care used by, or referred from, integrative clinicians. Yet even promoting coverage schemes for less inclusive integrative approaches is a giant step in the right direction. One wonders: Will these quietly offered comments, though now more widely public thanks to Bauer, make the list of priorities for these organizations’ lobbyists? These organizations need to walk their talk to the CDC if practitioners will be able to overcome, as one medical doctor put it, their “tendency to default to medications.”20

Tough News in Medical Organization-based Major Integrative Centers

Visits to the once-robust Web sites of 2 significant integrative health and medicine clinics now greet one with single, explanatory pages. The first site to be transformed was that associated with Phoenix-based Arizona Integrative Health Center where the Andrew Weil–founded Arizona Center for Integrative Medicine (ACIM) anticipated proving integrative health’s business model as a low-cost option for chronic disease.21 Following a list of accomplishments at the clinic that would seem to presage an announcement of a clinical expansion, the text quickly shifts to information on changes in ownership and then the decision: “There came a time we could not continue to operate with an uncertain future.” A part of the story is that the medical school merged its clinical services into the $7 billion Banner Health, which showed no interest in ACIM’s pilot. Stated ACIM executive director, Victoria Maizes, md: “When health systems merge, if you’re not at the top of the list of priorities, anything can happen.” 22

In making her shoulder-shrugging point, Maizes pointed to a recent development of a merger that ended the life of another integrative center on the East Coast^. The referenced player was the powerfully influential Continuum Center for Health and Healing where the present Web site leads by noting “16 years of comprehensive and innovative clinical practice, research, and education in the field of Integrative Healthcare.” They then announce the closure.23 The center, as I learned from an interview with its clinical leader Ben Kligler, md, mph, no longer fit into the plans of the center’s new parent organization, the $3.5-billion-plus Mount Sinai Health System. The center and its related Department of Integrative Medicine were known for multiple breakthrough projects across the range of research, interprofessional education, inpatient yoga, and training of acupuncturists.

Comment: When the Arizona clinic was founded in 2012 as a research pilot developed in collaboration with major employer, Maricopa County, Andrew Weil, md, announced, “We believe our findings will help change priorities of reimbursement and ultimately affect how health care is delivered on a national level.” The copy that still exists on the Web site suggests that the experience there was trending in the direction Weil foresaw. Banner, apparently, did not much care. The Continuum Center—already a major contributor in multiple arenas to the integrative care movement—provoked similar disinterest. In a discussion, a leader at one of these centers quipped, “Our centers are little more than ‘rounding errors’ in these budgets.”

The challenge for these centers remains today what it has been for 20 years: a profound economic misalignment between the “volume-based” and technology-driven medical industry and the mission-and-value orientation of relatively low cost, human-intensive, integrative care. Why invest in clinical services that, if successful, will diminish need for the high-cost medical procedures that are the medical industry’s bread and butter? Poet and naturalist, Wendell Berry, writes of the importance of diversity and of maintaining the wilder strains at the edge of our close-cropped fields. It is a shame that these captains of the medical industry chose to quash these species of care that were clearly contributing to knowledge of what health and medicine can yet mean to the species.