Measuring Integrative Influence: Two Glasses—One Half Full, One Needing to Be Filled Up

Reflecting on the history of the natural health and functional and integrative medicine movements over the past 30 years stimulates two polar emotions. The first is a satisfying astonishment with the surprising uptake of integrative practices and practitioners. The context of such a response is recalling the scrambling in the 1980s to lay institutional and organizational foundations for natural and integrative health amidst the medical cold war between biomedicine and those making alternative choices. We’ve come a long way. The other response is utter dismay that we have accomplished so little in our efforts to shift toward a system that focuses on creating health within a medical industry that consumes an ever-larger portion of the public good from producing voluminous services to manage disease. Have we had any impact?

The evidence of the first is everywhere. Partnerships of practitioners and patients convinced legislators to vastly expand access to licensed natural health practices across the country: massage therapists and acupuncturists are now legit in most states, homebirth midwives in nearly two thirds, and naturopathic doctors in nearly two dozen.¹ Integrative health—a term not yet conceived in 1990—is formally written into federal policy.² A chiropractor is vice chair of the quasi-public Patient-Centered Outcomes Research Institute.³ Seventy-five medical schools have programs in integrative medicine.⁴ Integrative medical doctors who pioneered two of these programs are directing the Veterans Administration Office of Patient Centered Care and Cultural Transformation.⁵ The VA’s institutional goal is nothing less than to implant an integratively-formulated “whole health model” throughout the 18 regions of the VA. The Society for Integrative Oncology has partnered with the National Cancer Institute on multiple projects, and developed guidelines endorsed by major cancer organizations.⁶ A naturopathic physician recently served as the acting deputy director of the National Center for Complementary and Integrative Health at the National Institutes of Health.⁷ That center, lobbied into being 20 years ago, contributed to developing a research base that, in the last half-decade, helped place acupuncture, mindfulness, chiropractic, massage, yoga, tai chi and other natural health modalities and practices into one or more pain guidelines at the Joint Commission, the American College of Physicians, National Academy of Medicine, and the FDA.⁸ Remarkably, two-thirds of the members of the National Associations of Attorneys General lobbied the nation’s insurance commissioners to promote coverage of such integrative practitioners and practices to transform the nation’s chronic pain treatment amidst the present crisis from over-reliance on addictive pharmaceuticals.⁹ Acupuncturists convinced legislators in multiple states to cover their services for Medicaid populations. From the Cold War of the 1980s, this is the stuff of fantasy.

Yet here we are, yet, still battered as a people by a medical industry in which a third to a half of what is done is waste.¹⁰ That’s roughly a trillion dollars per year, give-or-take. It’s an industry that a Johns Hopkins researcher recently assessed as killing an estimated 250 000 people annually. This makes the medical industry the nation’s third most significant cause of death.¹¹ The medical processes that lead to these awful outcomes remain rushed, relationship-diminishing, and performed by practitioners whose burnout is considered a public health issue of its own. It would seem doubtless that the transformative forces in healthcare evidenced by the renewal of the naturopathic profession in the 1980s and the founding of functional medicine and integrative medicine a few years later would appear to have had little impact in the huge medical complexes that bring the vast majority of people what is typically misnamed as “health care.”

Yet at the same time, the influence of the health-focused integrative, naturopathic, and functional models reached millions through venues for payment and delivery outside the dominant structures of regular medicine through which the majority of people receive treatment. From the beginning, the searching of both patients and practitioners for alternative approaches to medicine and health was a popular movement, outside of the mainstream. This external positioning has continued as more recent adopters of these approaches have driven the growth of concierge, boutique and cash practices, tending further away from the mainstream of payment and delivery.

Not surprisingly, this disengagement in professional practice begets parallel disinterest and even disdain for policy work to change US medicine. Many if not most have a reasonable unwillingness to substantially invest themselves or their organizations in formal change efforts. Few professional organizations have a presence of any size in the nation’s political Beltway. The Integrative Health Policy Consortium (IHPC), formed to provide such agency, has made some significant in-roads yet has rarely mustered a budget of over $120,000 per year. With such limited investment in change efforts, representatives of integrative, functional, and naturopathic models are mostly not in the dialogue about strategies for the future of medicine. The issue is less of exclusion than of a failure to show up. Bottom line, as the lobbyists’ joke puts it: if one is not at the table, one is lunch.

Opportunity is presently knocking. A time of ripeness and convergence is opening in which our perspectives are increasingly sought and welcomed. The kick-starter is the chronic pain treatment crisis (aka “opioid crisis”) that is opening eyes to the evidence of value in integrative methods that feature nonpharma methods. The concept in pain treatment of starting with less invasive, nonpharmaceutical approaches first model what can be a long-term teaching campaign for the functional and integrative communities to implant this fundamental principle in care delivery. Early data from the Cleveland Clinic Center for Functional Medicine supports the approach in both team-based and group-based models.¹²

Ears are opening. Advancing science prompts the dominant school of medicine to finally acknowledge that the mind and body are connected, and that nutrition and stress are factors in health. “Holistic” thinking and “wellbeing”—once fringe—are buzzwords. A principal leader in a movement for radical change toward a “salutogenic” model from inside mainstream medical delivery—a past administrator of the Centers for Medicare and Medicaid Services—credits integrative medicine leaders as his mentors in framing the 30-year campaign he recommends toward such a health creating future.¹³ He suggests that the solutions may be “more radical than we have imagined.” A past chair of the American Hospital Association similarly promotes this necessary shift from disease to health while acknowledging to his medical industry colleagues that “none of us really knows the recipe.”¹⁴

Consider that the biomedical leaders have been living in disease models for 20–30 years of their professional lives. With such backgrounds, are they likely to be founts of wisdom on health and wellbeing models? Meantime, during the same period as described in this column, the naturopathic, functional, integrative and other natural health communities have developing and refining clinical models that focused on getting to root causes, undoing patterns, and creating health. Might essential components of this “recipe” for health for the dominant school be in the hands and practices of these communities? Might they effectively be withholding critically needed elements by not being at these table, and in these dialogues?

Thanks to growing collaborations of many in organizations like the Academy of Integrative Health and Medicine, the Institute for Functional Medicine, Academic Consortium for Integrative Medicine and Health, American Society of Acupuncturists, Integrative Medicine for the Underserved, Academic Collaborative for Integrative Health, and the American Association of Naturopathic Physicians, a foundational web of respectful interprofessional relationships is in place. These can choose to take concerted action on shared priorities to shift policy toward integrative models that remove obstacles to cure and aid and abet healing. IHPC, with which most are directly or indirectly involved, has set an infrastructure for more influential participation in federal policy through the Congressional Integrative Health and Wellness Caucus.¹⁵ Consider that one big kitchen, among many, to offer collaborative contributions to the recipes for health for this coming 30-year process.