Dana Ullman, MPH, reviews the Institute of Medicine’s Summit on Integrative Medicine, which took place February 25-27, 2009 in Washington, D.C.
By Dana Ullman, MPH
The Institute of Medicine (IOM) is considered America’s preeminent body of physicians, scientists and academians interested in health and medical issues. It is a part of the United States National Academies, which also includes the National Academy of Sciences. The Institute of Medicine produces independent recommendations and policy reports by enlisting various experts to address the scientific and technical aspects of some of society’s health problems.
On February 25-27, 2009, the IOM convened a “Summit on Integrative Medicine and the Health of the Public” at its headquarters in Washington, DC. Approximately 600 people participated in this historic meeting which included a wide variety of experts in integrative medicine as well as people in leading positions in government, industry, and academia. This Summit was co-sponsored by the Bravewell Collaboration, a foundation composed of leading philanthropists dedicated to transforming the culture and delivery of health care.
The summit content and discussions provided vital information for transforming the U.S. health care system. Topics included: patient-centered care, the scientific basis of integrative medicine, health care financing reform and value-driven care, and mind-body relationships and health. Prior to the conference, the IOM commissioned several papers to provide background information on integrative medicine’s performance in prevention and wellness, patient-centered care, research, public education, professional education, and economics and policy.
The speakers at this Summit included many of the movement’s high profile leaders, including Dean Ornish, Mehmet Oz, and Kenneth Pelletier. Evidence of interest in the broad field of integrative medicine was the inclusion on the program of Thomas Donahue (the CEO of the US Chamber of Commerce), George Halvoson (Chairman and CEO, Kaiser Foundation Health Plan), Senator Tom Harkin (Iowa), Bill Novelli (CEO, AARP), and Reed Tuckson (Chief of Medical Affairs, United Health Group, a major HMO, and former Senior Vice President, AMA). Other speakers included Mimi Guarneri, (cardiologist and medical director of the Scripps Center for Integrative Medicine), David Katz (internist and founder of Yale’s Prevention Research Center), Victor Sierpina (University of Texas), Victoria Maizes (University of Arizona), Tracy Gaudet (Duke University), and Josephine Briggs (Director, NIH’s National Center for Complementary and Alternative Medicine). The chairperson of the planning committee for the conference was the eminent Ralph Snyderman, Chancellor Emeritus, Duke University.
Perhaps most impressive of all was the audience itself who consisted of many health and medical experts who often serve as keynoters at health conferences, including: Jeffrey Bland, Jon Kabat-Zinn, Larry Dossey, Woodson Merrill, and Wayne Jonas, as well as dozens of professors of medicines who teach at leading medical schools, naturopathic, nursing, acupuncture and chiropractic colleges.
Harvey Feinberg, the President of the IOM, welcomed attendees and acknowledged that integrative medicine is a bit like a Rorschach blot test because it meaning seems so varied.
Ralph Synderman gave the opening address expressing concern about the state of medicine today. He asserted, “No other industry holds its customers in such high disregard, except perhaps the airline industry.” He described health care today as uncoordinated, disease-oriented, reactive, physician-directed, not personalized or safe, and extremely expensive. Synderman expressed his strong appreciation for modern medical science, but he humbly acknowledged that most drugs and technologies have not been proven efficacious and that at best it may only impact around 25% of modern health concerns.
Reed Tuckson, who represents one of the large HMOs, warned attendees that we all may want health care reform, but whatever changes we want must have evidence of benefit. He urged scientific inquiry as well as evaluation of demonstration projects. However, Tuckson also noted that “the enemy of the good is the perfect,” and we cannot wait until all of the evidence is in or that there is wide consensus before we begin to make serious changes.
Kenneth Pelletier echoed a similar viewpoint by asserting, “Trust in God, but everyone else must present data.” Pelletier noted that we may not necessarily need new monies in health care but just better allocation of present resources. Because so many high-tech methods presently used have not yet been proven efficacious, there are great savings to be obtained by no longer providing reimbursement for questionably effective (and expensive) health interventions.
Pelletier has served as a consultant to many major American corporations who have developed various disease prevention and health promotion programs for their employees. He noted that 62 of 63 studies of cost-effectiveness, cost benefit, and return on investment have shown positive results. According to his review of this research, a return on investment for health programs usually takes only 3.25 years. Further, evidence-based return on investment ranges from $3.50 to $4.90 for every $1.00 invested.
Bill George, a professor of Business Management at Harvard Business School, was the CEO, President, and Chairman of the Board at Medtronic, Inc., the largest medical technology company in the world that began by creating heart pacemakers. His wife, Penny George, was past President of the Bravewell Collaboration, co-sponsor of this Summit, and the George Family Foundation has been a leading supporter of many Bravewell efforts (yes, there does seem to be a bit of social and spiritual justice that profits from high-tech medical endeavors are being used to support various high-touch health strategies). Bill George spoke about his personal experience at Medtronic during his presentation. He insisted that it was important for employers to reward good healthy behaviors rather than punish bad ones. He noted that his company gave employees $50/month ($600/year) for complying with some healthy behaviors. He also noted that a gym is not a perk of an office but is a necessary component of it.
THE MOST POWERFUL PRESENTATION…
Dean Ornish made what many attendees considered to be the most powerful presentation of the Summit. He described his and many others research that showed significant changes in the health status of people suffering from many of the leading causes of mortality in the US. Ornish’s own research has shown that significant changes in dietary and exercise were substantially effective in improving health status in people suffering from cardiovascular disease and prostate cancer. Further, he noted that the minor dietary and exercise recommendations of the American Heart Association and the National Cancer Society were simply inadequate to create significant positive results, thereby leading to poor compliance due to the small health improvements.
Ornish’s wisdom and experience here seems in sync with President Obama’s desire to make significant changes in various orthodox institutions in order to create real solutions that work. With America’s present health statistics rank us 37th (!) in the world, suggesting that doing more of the same or making minor changes in health reform will not provide the real improvements that Americans want and need today.
Ornish also made reference to one study in which curcumin (an active ingredient in the herb, tumeric) was found to have 2,000% increase in bioavailability and therefore significant better health benefits when used with a type of pepper used in curries. Ornish sought to warn attendees to avoid looking at studies that test simply one ingredient. Many recent studies, for instance, have found little or no results from using vitamin C or E or a single type of multi-vitamin, when, in fact, most nutritional-oriented physicians and practitioners do not limit themselves to such single ingredient treatments.
Ornish also discussed several bodymind treatment programs, including certain meditative, visualization, and yoga practices, to improve health status and quality of life for people suffering from a host of serious ailments. He also noted their importance for soldiers as they return from combat operations, usually suffering from PTSD.
Many speakers made reference to the challenge in health care today in which physicians and other primary care clinicians do not have the time or expertise to be their patients’ “health coach.” There seems to be a real need for a person on the health care team who works personally with the patient to help enact behavioral changes that are health enriching. Some attendees thought that psychologists might fill this role, others thought nurses may be best, and others wondered if a new type of health professional was needed.
Further, Ornish reported on genetic research on telomeres, a gene associated with long life. Ornish’s research published in Lancet Oncology (November 2008) discovered that significant dietary changes had direct effects on telomeres, thereby verifying that our genetic heritage can be influenced and changed. While our genes may indeed have powerful effects upon our health and life, such influences are not in stone but can be transformed.
Ornish’s expansive message also included reference to the provocative notion that a vegetarian diet is not only healthier for people but also for our planet. He noted that livestock production leads to more global warming effects than all transportation sources combined.
A VIEW TO AND FROM THE HILL…
Two days before the conference began, the Senate Sub-committee on Health, Education, Labor, and Pensions held a hearing on integrative medicine. Chaired by Maryland Senator Barbara Mikulski, testimony from Wayne Jonas, James Gordon, Sister Charlotte Kerr, Mary Jo Kreitzer, and Cathy Baase, corporate medical director for Dow Chemical Company was presented to the sub-committee and for the public record. Then, in the middle of the Summit, Senator Harkin held another hearing on integrative medicine with what some of us referred to as the “integrative health dream team,” including Dean Ornish, Andrew Weil, Mehmet Oz, and Mark Hyman.
The third day of the Summit began with a rousing presentation from Senator Tom Harkin. Harkin reported on these Senate hearings noting that just that week President Obama had asserted that health reform was a major priority for him and for the American people and that prevention and wellness programs have to have an important place in this health reform. President Obama has also designated that over $1 billion would be devoted to outcomes evaluation for health and medical treatment programs to begin to be evaluated to determine what really works.
Harkin asserted, “American always do the right thing…after they have tried everything else.” Indeed. Harkin has been a long-term advocate for integrative health (although he originally expressed interest and support for “integrative medicine,” an attendee suggested to him what others at this Summit had previously expressed: “integrative health” is more comprehensive a term than “integrative medicine;” within the remaining time of the Q&A session with Harkin, he referred to integrative health). Harkin was the primary sponsor that created the Office of Alternative Medicine, as well as the National Center for Complementary and Alternative Medicine.
Harkin noted that the status quo (which he also called the “stagnant quo”) has reimbursement and incentive priorities in the wrong place. Harkin promised to make certain that these priorities be changed.
In 1993, I served as a consultant to the World Health Organization at a special conference they sponsored that sought to inquire what they should and would be doing in the year 2020. Whenever one attempts to predict the future, it is important, perhaps necessary, to include some heretics because what may be unconventional or even heretical today may be an integral part of the future. What is equally true about the future is that what is conventional today is tomorrow’s quackery. These observations are not actually predictions; they are statements of the evolution of social history.
At this WHO meeting, Harvey Feinberg, MD, PhD, who was at the time the dean of Harvard’s School of Public Health, was a fellow consultant. He was one of a select few who reached out to me to learn more about homeopathy. He and I shared a private lunch, and his inquiring mind gave me a certain confidence that our paths again would cross. Indeed, we have.
The very concept of “integrative health” is quite comprehensive, and yet, with respect to getting the biggest bang for the buck, we must honor the Hippocratic tradition that asserts “First, do no harm.” How this translates into health improvements is that we should explore and exhaust safer methods first before resorting to the big (and expensive) guns of medicine and medical technology. Also, there is general recognition that we need to move our thinking about health care where the physician is at the center to where the PERSON is at the center.
Several speakers at this Summit expressed the need and the demand for “data.” During audience participation moments at this Summit, I voiced my concurrence, but I also voiced a warning. In homeopathic and naturopathic thought and practice, there is a profound respect for the “wisdom of the body.” If we set up clinical trials that simply evaluate whether a treatment is effective in getting rid of a symptom, we may be discovering that this treatment is effective but only in suppressing a symptom and sometimes creating a more serious chronic ailment rather than enacting a true cure.
We therefore need to have clinical trials, but they must not only evaluate specific symptoms but also overall health status. They must not ignore side effects because such new symptoms are not side effects at all; they are usually the direct result of a drug’s toxicity or its ability to suppress the disease to deeper and more serious levels.
Further, when we seek ‘evidence,” we should not only evaluate evidence obtained from randomized double-blind trials, but we should also evaluate evidence from outcome studies, cost-effectiveness studies, and when possible and appropriate, basic science trials.
We need to remember that we today accept most surgical practices even though the vast majority of them have not been proven to be effective based on double-blind placebo controlled trials. Few people consider surgery to be “unscientific” just because it is not viable to conduct placebo-controlled trials. And yet, many physicians, scientists, and health policy analysts assume certain that some alternative treatment methods are unscientific because they too cannot be evaluated in placebo controlled trials (how does one give a placebo meditation or a placebo yoga posture?).
Likewise, many treatments that “integrative practitioners” use comprise a “package of treatments” that include various dietary changes, vitamin and mineral supplements, herbal remedies, homeopathic medicines, yoga practice, stress management methods, and on and on. Evaluations of the outcomes of such packages of treatment are truly necessary.
At the Summit, I made reference to two cost-effectiveness studies that were conducted by the French government. In 1991, the totality of costs associated with homeopathic care per physician was approximately one-half of the totality of care provided by conventional primary care physicians. However, because homeopathic physicians, on average, saw significantly fewer patients due to the more labor-intensive tendency of homeopathic care, the overall cost per patient under homeopathic care was still a significant 15% less. It is also interesting to note that these savings appear to increase the longer a physician has been using homeopathy. A follow-up study in 1996 confirmed these results.
This survey also noted that the number of paid sick leave days by patients under the care of conventional physicians (general practitioners) were 3.5 times more than patients under the care of homeopathic physicians. These figures suggest further benefit and savings to the homeopathic approach to care.
At this Summit, there were several professors of genetics and other basic sciences who discussed the most recent scientific discoveries in their fields. However, I was a bit surprised at the casual reference to “genetic causes” of illness and to new (and old) infective agents that “cause” this or that disease. My concern here is that because language is so important, it is necessary that we draw from systems biology and systems thinking to realize that it is more accurate to say that these influences are “co-factors” to diseases, not causes of them. The concept of causality tends to be linear, when, in fact, cause is rarely so simple. The susceptibility of the host always influences whether infective agent leads to disease or not, and as Dean Ornish and others have now noted, even genetic status of an individual can be altered.
Finally, we must be more humble in how we all make use of the words and concepts of “scientific medicine.” An IOM special report, “Informing the Future: Critical Issues in Health” (published in 2007), noted that 1/3 of Americans today take five or more medications. And yet, even if all of these drugs have been proven “scientifically” to work, each drug was tested individually, not in combination with one or two, let alone five, drugs. Further, most of the studies conducted have not been on children or the elderly, and yet, the high quantities of drugs are prescribed them. Still further disconcerting is that most medication is tested for very short periods of time, even though many drugs are used over years or decades. I certainly realize that such evaluations are complex and difficult, but these issues simply mean that we must remain humble in our sense of which drugs work, when, and for whom.
Dana Ullman, MPH, is a leading advocate for homeopathic medicine. He has authored 10 books in the field, including his best-selling Everybody’s Guide to Homeopathic Medicines and his newest book is The Homeopathic Revolution: Why Famous People and Cultural Heroes Choose Homeopathy. His ebook is the most up-to-date source of information on clinical research in homeopathy (“Homeopathic Family Medicine: Evidence Based Homeopathy” –available at www.homeopathic.com.) Dana can be reached at firstname.lastname@example.org.