Carol Green was busy filling out medical-school
applications several years ago when she had an epiphany.
She could devote herself to a single healing tradition,
she realized, or she could take a chance on something more
inclusive. “I was interested in integrating Eastern
and Western philosophies and finding a common language.”
So Green tossed her med-school applications and pursued
a degree in traditional Chinese medicine at the New England
School of Acupuncture.
Today she has a busy practice at
the Marino Center for Progressive Health in Dedham, Mass.
She loves sharing her knowledge of herbs and acupuncture
with patients. And though she worried at first that conventionally
trained physicians would shun her, she has found they’re
as eager as she is to break down old boundaries. She sends
her patients to M.D.s when she can’t help them —
and M.D.s send just as many to her. She gets referrals from
internists, orthopedic surgeons, even psychiatrists. “Why
should people use just one modality?” she asks.
Nearly half of all U.S. adults
now go outside the health system for some of their care.
We make more visits to nonconventional healers (some 600
million a year) than we do to M.D.s, and we spend more of
our own money for the privilege — about $30 billion
a year by recent estimates. Complementary and alternative
medicine, or CAM, is not a single, unified tradition. The
term covers practices ranging from the credible (acupuncture,
chiropractic) to the laughable (coffee enemas). Because
few of these therapies have been thoroughly evaluated in
controlled studies, their effectiveness is still widely
debated. But no one now disputes their significance. “The
treatments are already in widespread use,” says Dr.
Susan Folkman of the University of California, San Francisco
— ”and the public believes in them.”
So after dismissing CAM therapies as
quackery for the better part of a century, the medical establishment
now finds itself racing to evaluate them. At many of the
country’s leading hospitals and research institutions,
conventionally trained physicians are studying herbs, acupuncture,
tai chi and biofeedback as rigorously as they would a new
antibiotic. The short-term goal is to identify the CAM practices
with the greatest benefits and the fewest hazards, and to
make them part of routine clinical practice. But this movement
is more than a search for new remedies. Its larger mission
is to spawn a new kind of medicine — an integrative
medicine that employs the rigor of modern science without
being constrained by it. If the dream is realized, the terms
“complementary” and “alternative”
will become meaningless, proponents say. We’ll have
one health system instead of two, and healers of every stripe
will work together while being guided by science.
SPLITTING IN TWO
Until a decade ago, no one realized
how quickly the health system was splitting in two. The
wake-up call came in 1993, when Dr. David Eisenberg of Harvard
Medical School published a now famous survey showing that
34 percent of all U.S. adults had received at least one
unconventional therapy in 1990. The medical community was
flabbergasted, but the excitement was just beginning. CAM
use increased by an additional 25 percent between 1990 and
1997, according to a later survey by Eisenberg’s group,
and the percentage of Americans taking herbs nearly quadrupled.
Consumers weren’t abandoning conventional medicine.
But because few people were telling their M.D.s about their
other sources of treatment, an estimated 15 million were
risking adverse interactions between supplements and prescription
drugs. Alarmed by this breakdown in communication, Eisenberg’s
group called on “federal agencies, private corporations,
foundations and academic institutions” to “adopt
a more proactive posture” on CAM.
That wish was quickly realized. In 1998,
the National Institutes of Health turned its tiny Office
of Alternative Medicine into a full-strength federal agency
and christened it the National Center for Complementary
and Alternative Medicine (NCCAM). Its budget, which once
hovered around $2 million a year, rose quickly to more than
$100 million. The money and excitement spread quickly to
the philanthropic and academic worlds, spawning not only
new research but whole new programs at many leading medical
schools. Today Columbia, Duke, Harvard and the University
of California, San Francisco, all have centers for integrative
medicine, and at least two thirds of U.S. medical colleges
offer courses in CAM. The number of hospitals offering complementary
therapies doubled between 1998 and 2000 (topping 15 percent),
and even health — insurers warmed up to some therapies.
Not everyone is pleased, of
course. The Washington Monthly has dubbed NCCAM “an
expensive medical swindle being abetted by the nation’s
leading medical schools.” And when a White House commission
called last spring for more efforts to integrate safe, effective
CAM therapies into conventional medicine, a group called
Citizens for Science in Medicine accused the panel of trying
to “overthrow science-based medicine” in favor
of “unvalidated voodoo.” Such polemics were
once commonplace, but the old party lines on CAM —
both the uncritical enthusiasm and the uninformed hostility
— are now dissolving. “We’re not out to
promote or debunk anything,” says Dr. Stephen Straus,
the conventionally trained physician who heads NCCAM. “We
want to test therapies that have a plausible basis and address
some unmet need.”
NCCAM’s signature projects
are large clinical trials designed to assess the merits
of popular therapies. For example, researchers in 11 states
are now enrolling osteoarthritis sufferers in a five-year,
$16 million study of the supplements glucosamine and chondroitin
sulfate. Over the course of the study, each volunteer will
take one of five identical-looking pills: a placebo, a prescription
medication (Celebrex), a glucosamine supplement, a chondroitin
supplement or a pill containing both of the supplements.
By tracking everyone’s symptoms, side effects and
disease progression — and comparing outcomes for each
of the five groups — researchers will gain unprecedented
insights into the risks and benefits of each regimen. NCCAM
is sponsoring similar studies to see whether acupuncture
can ease arthritis pain, whether vitamin E and selenium
help prevent prostate cancer and whether Ginkgo biloba can
preserve mental function in healthy old folks.
While these huge clinical trials
plod along, researchers are using state-of-the-art laboratory
techniques to glimpse the physiological effects of different
CAM remedies. At the University of California, Irvine, for
example, radiology professor Zang-Hee Cho uses a high-speed
imaging technique called fMRI (functional magnetic resonance
imaging) to watch what happens in the brain when acupuncture
needles enter the foot. Cho showed four years ago that an
acupuncture point traditionally used to ease eye problems
did in fact stimulate the visual cortex. In a more recent
study he found that needling other points on the foot can
modulate activity in the four brain areas involved in pain
perception, enabling people to hold their fingers in 122-degree
water without discomfort. “We used to think these
were mysterious energies,” Cho says, “but not
anymore. As we learn how acupuncture really works, we may
find that one well-placed needle can do what we now do with
20.”
There’s no substitute
for knowledge. By placing CAM under the microscope, scientists
will no doubt gain a better sense of which therapies work,
how they work, whether they’re safe and who is most
likely to benefit. But making CAM more efficient is one
thing, restoring a measure of humanity to the health system
quite another. What draws people to CAM and integrative
medicine is not a desire for efficiency but a longing to
be cared for. From a patient’s perspective, acupuncture
is a ritual in which a therapist touches you and talks to
you and helps you feel better. By the logic of scientific
medicine, acupuncture is an encounter between a patient
and a needle. Its true effect is the one you can measure
after factoring out such “confounders” as care
and compassion. “Some things that count can’t
be measured,” says Dr. Tieraona Low Dog, an Albuquerque,
N.M., internist and a leader in the integrative-medicine
movement. “We need a health system that can do more
than count.”
Can a system built on one
paradigm accommodate another? Is there room for care and
compassion within science-based medicine? Anyone who doubts
it would do well to visit New York’s Weill-Cornell
Center for Integrative Medicine. Its medical director, Dr.
Mitchell Gaynor, is a conventionally trained M.D., board
certified in both oncology and hematology. When a newly
diagnosed cancer patient comes into his office, he takes
a history and physical, goes over CT and MRI scans, reviews
the pathology reports and discusses the likely effects (and
side effects) of — surgery, radiation and chemotherapy.
Then instead of bidding the patient good day, as convention
dictates, he helps her cope with the experience of life-threatening
illness.
When 54-year-old Marisa Harris
showed up in Gaynor’s office four years ago, she had
just learned she had stage 4 cancer and a life expectancy
of roughly nine months. What could the medical world do
for her? she had asked several oncologists, and each had
given her the same answer. She would get five to six months
of debilitating chemotherapy. Then she would die. Gaynor
reviewed her chart, took some blood, then delivered an utterly
different message. “You know,” he said, “there’s
a lot you can do for yourself.” He asked her about
her fears and regrets, even her diet, and suggested strategies
for asserting control over her life. Gaynor didn’t
argue with her initial decision to forgo chemo, but he invited
her to join his support group and meditation class. Those
experiences changed everything.
Harris thought the doctor was planning to make pasta when
he arrived at the meditation class bearing an assortment
of metal and crystal bowls. The bowls were in fact musical
instruments from Egypt and Tibet. As Gaynor tapped them
with a wooden mallet, Harris says she felt the music “washing
through every cell in my body” — a fair description
considering that water (which makes up 70 percent of our
mass) is a perfect medium for sound waves. The words of
the other doctors — ”incurable,” “medically
untreatable,” “nine months if you’re lucky”
— were still echoing oppressively in Harris’s
head. But meditation helped her quiet them and summon her
dad’s old refrain: “We’re survivors; we
don’t give up.” Within four months, she had
changed her mind about chemo. With Gaynor’s encouragement
and the support of her peers, she was able to approach it
not as perdition but as “a wonderful gift.”
She experienced what she now recalls as “a state of
grace and healing.” Four years later, she’s
as happy as she has ever been in her life.
Why is such care still the exception
instead of the rule? Training is part of the problem. Though
many medical schools now offer elective courses in integrative
medicine, few of today’s doctors have learned to look
beyond lab tests to grapple with the patient’s experience
of illness and — quest for health. The future looks
bright, though. In addition to revamping their curricula,
some medical colleges are now offering fellowships to help
practicing physicians catch up. And 12 leading medical schools
have recently formed a consortium to push for what its founders
call “fundamental changes in the way we are training
future physicians.” It shouldn’t be a hard sell.
Surveys suggest that doctors are as unhappy as patients
about the current state of health care, and that most are
eager to expand their roles. “Duke is as classical
as any medical school,” says Dr. Ralph Snyderman,
the school’s chancellor. “But our faculty shows
overwhelming interest in integrative care.” When Duke
polled 200 of its affiliated doctors, half said they would
happily collaborate with CAM providers and 30 percent expressed
interest in studying CAM therapies themselves.
There is one other catch, and it’s
a big one. From Medicare down to the smallest private health
plan, the reimbursement system is still strongly biased
against holistic care. The nation’s insurers spend
$30 billion a year on bypass and angioplasty for cardiovascular
disease, for example, but only 40 of them cover the lifestyle-based
program developed by Dr. Dean Ornish — despite repeated
demonstrations that it is safe, effective and vastly less
expensive than surgery. “Integrative medicine can
be viable in a small practice where patients pay as they
go,” says Dr. Mary Hardy, director of the integrative-medicine
program at L.A.’s Cedars Sinai Medical Center, “but
it’s still hard to succeed on a larger scale.”
In Hardy’s hospital-based clinic, M.D.s serve as team
leaders, and patients draw freely on many traditions at
once. But their insurance tends to cover only what is conventional.
This will surely change. Insurers,
including Medicare, are now launching small pilot projects
in integrative medicine. CAM treatments have begun to show
up in the American Medical Association’s vast directory
of billable procedures. And the flurry of research now going
on will give insurers a clearer sense of what works and
what is affordable. Snyderman believes the transformation
underway could prove as epochal as the birth of scientific
medicine a century ago. What’s at stake is not just
the status of some individual therapies but the whole meaning
of health care.
With Anne
Underwood and Brian Braiker
© 2002 Newsweek, Inc., Dec. 2, 2002
