by John Weeks
Editor’s note: Attendees at the February 2009 Integrative Healthcare Symposium will have an opportunity to look more closely at the questions raised here.
Tom Ballard, RN, ND a neighbor who practices as a primary care physician in Seattle recently forwarded me a letter to the editor he wrote which was published in the Seattle Times.1 A Times article on MRSA (methicillin-resistant Staphylococcus aureus) failed to mention that we humans helped cause that problem via overuse of antibiotics. Ballard ended his letter to the Times with this hope: “Perhaps the crisis of MRSA will help swing the medical pendulum back toward a whole-systems approach to infections: First strengthen the host and utilize natural compounds, saving drug therapy for last.”
Ballard’s statement reminded me of a favorite wouldn’t it be wonderful if which at one point seemed a valuable idea for research in integrative care. Wouldn’t it be wonderful if we spent some of the $120-million a year budget of the NIH National Center for Complementary and Alternative Medicine to test the effectiveness of doing just what Ballard suggests. What if we looked at the effectiveness of an integrative approach which aids the patient in heightening resistance and uses natural agents first, before antibiotics? Such research might show how integrative practices could significantly contribute to both individual health and population health.
Why had I let this wouldn’t it be wonderful if idea go? More importantly, why am I presently allowing myself to think that we might have a chance to repatriate exiled ideas back into our research dialogue?
A part of the answer to why I let go of my excitement with Ballard’s question, and other intriguing approaches to evaluating integrative practice, can be found in some numbers from NIH NCCAM which another colleague emailed me last month.1 These data detail the priorities, by modality, for NIH NCCAM funding during fiscal years 2005-2007. These years marked the end of the era of NCCAM’s founding, controversial and now deceased director, Stephen Straus, MD. Straus once told a New York Times writer that he’d never used complementary or alternative medicine and never planned to. Here is how his agency prioritized spending.
Dietary Supplements - $158,379,299
Herbs/Botanicals - $99,913,254
Acupuncture - $31,180,080
Manipulative/Body-Based Therapies - $17,449,912*
Meditation - $8,303,160
Yoga - $7,743,906*
Massage - $5,132,633*
Homeopathy - $2,203,656
Healing touch - $1,866,937
Ayurvedic Medicine - $1,582,975
Chelation - $1,529,447
Reiki - $570,299
Oxygen Therapy (hyperbaric oxygen) - $386,808
Aromatherapy - $186,875
(*) I am not sure whether these categories are redundant.
The blunt fact is that Straus’s NCCAM focused on what conventional, outpatient medicine is best known for: single agent, drug approaches. Over 70% of the $362-million NCCAM budget went to the top 2 categories, dietary supplements and botanicals.
The agency appears to have done what one might expect under a leader who had no experience or investment in integrative medicine. It took the strange (integrative practice) and translated it into what it knew best (single agent interventions). It sought to learn things about these agents which might add to their potential for synthesizing pharmaceuticals.
I am reminded of camels, eyes of needles and thus of the chances integrative practice has, in this scenario, to reach the heaven of NIH-affirmed value. Virtually every one of the efficacy trials has been negative, the most recent a major Gingko study.2 Yet the research doesn’t appear to be shifting integrative practices. Why? An herb or supplement as single-agent therapy is not typically how integrative practitioners use these substances.
The next two most significant categories for funding, acupuncture and manipulative/body-based therapies, represent another 13% of the expenditures. Again, the mind of the NIH attempts to translate these practitioner-dependent, whole practice interventions into single agent efficacy trials. First, remove whatever else an integrative acupuncturist or chiropractor may be doing beyond needles or use of their hands. Among these are any self-care teaching, other modalities (massage, natural agents, etc.) and the caring relationship, all of which may help “strengthen the host,” as Ballard puts it. Then create a trial which pits “real” versus “sham.” Such trials for both manipulation and needles have often found that both real and sham are effective. The media sound-bite, however, is typically that since the “real” may not be statistically better than the sham, the intervention is worthless.
Thus some least 83% of the NCCAM budget has been spent on studies which, for the most part, have two things in common. First, the headlines read “does not work.” Second, integrative providers continue to use the therapies, regardless, because the study premises and measures match neither their practices nor the values they believe their patients are receiving.
Somewhere in this investment in reductive, efficacy research which Straus’s NCCAM favored the wouldn’t it be wonderful if questions for NIH NCCAM were suppressed. To use a present day image, putting the integrative practice research agenda in Straus’s hands was like giving SUV-addicted auto industry the responsibility to imagine, develop and promote a green machine. Whatever happened to the electric car?
This story has a hopeful mid-point. Richard Nahin, PhD, MPH, NCCAM’s senior advisor and acting director of extramural research recently told a group of employers that under NCCAM’s new director, Josephine Briggs, MD, NCCAM will shift its focus to “effectiveness” research and real-world outcomes.3
That Nahin was speaking to a conference of employers was already a sign of NCCAM leaving its Strausian confines in the Briggs era. Happily, when I recently interviewed Briggs for a soon-to-be published IntegrativePractitioner.com article, she confirmed Nahin’s statement. Yes, NCCAM will show increased interest in effectiveness research. NCCAM will increasingly appreciate that the agency is typically looking at modalities and approaches that are already in the hands of consumers and practitioners, and in many cases, are already part of offerings of 3rd party payers.
This new direction for NCCAM doesn’t mean that our best ideas will quickly be repatriated into the dialogue. Yet there is cause for hope. Those who attend the February 2009 Integrative Healthcare Symposium will have a chance to listen to Briggs share her vision. She will be at a point roughly a year into her new position when she takes part in the give-and-take of a keynote policy forum on roadmaps to the future.
I will have the pleasure of moderating the panel. I may just ask Briggs what she thinks about research on “a whole systems approach to infections” such as Ballard recommends in his Seattle Times letter. Is it possible that a stand-alone agent that may not be efficacious as a single agent might be an effective component of a whole practice approach to diminishing our need for antibiotics?
Wouldn’t it be wonderful if we can begin, anew, identifying and hopefully putting significant resources behind questions which might show far-reaching contributions from integrative practice?
1 - Accessed November 20, 2008 at http://blog.seattletimes.nwsource.com/northwestvoices/2008/11/18/mrsa_coverup.html
2 - All figures in the chart are from data provided by NCCAM’s public affair office. Thanks to Taylor Walsh for most of the data. I followed up with NCCAM for additional information on two modalities.
3 - Ginkgo biloba for Prevention of Dementia. JAMA. 2008;300(19):2253-2262.
4 - Eighth Annual International Conference. Institute for Health and Productivity Management, Phoenix, Arizona, October 15, 2009. Nahin’s keynote was entitled “Integrative Health Care-Vision and Current Practice.”
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