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JACM joined with the British BMC CAM and German Forschende Komplementärmedizin to jointly publish and promote awareness of the document in May 2017. Put the accent here on “promote.” We chose to use these peer-reviewed, indexed journals in the service of a form of advocacy for, as the preamble states, “a global movement to orient care, and the education, research and policy that support it, toward a model that draws on biomedical, complementary and traditional medicine practices and respects multiple healthcare philosophies.” It's a stake in the ground to announce commitment to this movement.
But advocacy and commitment for what? And how does such advocacy align with the conceit of a researcher walled off in objective and earnest disinterest? Such questions are that much more provocative given the notably polarized climate in which integrative medicine researchers sometimes operate. The very act of deigning to participate in research on alternative and complementary practices has been attacked by a substantial cadre of antagonistic academics as “nothing more than polishing a turd.” 2 Recently in Toronto, Canada, an integrative health researcher was subject to a petition campaign for the mere act of researching a homeopathic remedy. 3,4 The nearly half-year process of the WCIMH committee in development of the Berlin Agreement broached multiple questions including the extent to which professionals in the complementary and integrative medicine research community can comfortably sign a document that will certainly be viewed by some as advocating for a direction for medicine. Wording was crafted in part to limit critiques.
The Berlin Agreement consists of a preamble and 14 distinct, action-oriented statements. Some of these, while perhaps prescient when originally articulated by the field 20 years ago, presently reflect multiple emerging trends in all of healthcare: “Model Health” in one's own behavior; “Engage Patients” in their own self-healing processes; “Promote Interprofessionalism and Team Care”; “Commit to Evidence-Informed Dialogue and Practice”; “Bridge Clinical Care with Prevention, Community and Public Health”; and “Stimulate Collaboration.” Each is a central tenet in the shift of the medical industry from volume to value 5 in the convergent “value-based care” movement captured in the United States as the “Quadruple Aim.” 6 These are virtually all core themes, for instance, of the Global Forum on Innovation in Health Professional Education at the National Academy of Medicine, where health professions from across the spectrum from medicine to nursing to social work to some representing chiropractic and acupuncture have set collaborative priorities over a 5-year engagement. 7
Yet in themselves, these statements of agreement already push researchers beyond what may be their usual zones of comfort in exploration. One might ask, for instance, if one's focus and methods take into consideration the emergence of health as a dynamic outcome, rather than staid biomedical endpoints that merely indicate a diminution of pathology. Similarly, has the importance of engaging patients, rather than merely measuring things done to them as passive recipients, found a place in one's research design? Does agreement to this more inclusive, collaborative care paradigm bring with it a commitment to advocate research directions with multimodal inputs that may not fit well with present research mores?
The remaining elements of the Berlin Agreement push more deeply into territory that may be viewed as vanguard for healthcare's emerging value set. To Recognize the importance of traditional medicine in global healthcare is the central tenet of the World Health Organization's Traditional Medicine Strategic Plan 2014–2023. Yet one is hard-pressed to find affirmative engagement in any projects promoted, for instance, through the Bill and Melinda Gates Foundation, or sponsored through most nongovernmental organizations. The charge to those who endorse the Berlin Agreement is to “highlight the importance of global investment to systematically develop best practices in these diverse systems that supports their safe and effective use and integration with biomedical practices.”
The Berlin Agreement speaks directly to research priorities in a two-part segment entitled Foster Whole Systems Research. Each of the dimensions urges the complementary and integrative community to promote choices that would reorient budgets in the biomedical research establishment.
Foster Whole Systems Research
Committed to practices that respect the whole human being through use of diverse modalities and often through teams of practitioners, we personally champion development of methods, funding, and dissemination of research that address chronic diseases from multiple etiologies and treatments that often are best resolved through whole person and whole systems approaches.
Aware that questions related to cost are often an obstacle to the system-wide implementation of these models and thus access to these services, we will personally endeavor to support heightened focus on research that includes the economic dimensions of integrative models of care.
In the United States, leading academic research organizations in complementary and integrative health have taken stands for these directions. A collaborative of complementary and alternative medicine researchers representing the professions of chiropractic, naturopathic medicine, acupuncture and Oriental medicine, massage therapy and direct-entry midwifery has publicly advocated for these directions. They published a paper on their priorities, first noting whole systems research and secondly, promote explorations of “cost, cost-savings and cost offsets.” 8 In 2010, a consortium of academic medical centers that now represents 70 North American institutions publicly declared for a research investment to reflect a “balance of basic science, clinical trials and outcomes research.” Such a direction would, if implemented, effect a vast increase in funding of “outcomes research and effectiveness [as] a major priority going forward.” 9
To “champion” is to wear such directions on one's lapel. One learns the elevator speech through which to make one's case. To champion is to make the point, whenever professionals are gathered in dialogue about funding policies and priorities on research and health, of the need to promote “development of methods, funding, and dissemination of research that address chronic diseases from multiple etiologies and treatments that often are best resolved through whole person and whole systems approaches.” To not engage the complex social and economic biases against prioritizing these directions allows pharma-shaped research methods to obstruct the research community from its optimal contributions to health and well-being.
The need for such advocacy is not abstract. As I shared in this column 3 months ago, 10 the crucible of cost is presently a cross upon which non-pharmacological, integrative approaches are presently relegated to ill-use. In the wake of such policy shortcomings are untold human and social costs. These integrative strategies, notably, are typically whole system approaches, often utilizing traditional medical therapies and practitioners. The American Medical Association, American Society of Anesthesiologists, American Pain Society and the California Medical Board are among those urging dramatic shifts in payment policy toward coverage of non-pharmacologic approaches.
A colleague on the World Congress on Integrative Medicine and Health team who was intimately involved in developing the Berlin Agreement looked upon the finished product and opined to me, via e-mail, that perhaps it is time to re-think the practitioner's oath. Might these tenets in the Berlin Agreement be among the guiding principles to shape practices in a value-based era that respects emerging globalism, cross-cultural currents, interprofessionalism, social determinants, multi-factorial chronic conditions, and the mounting understanding that health is a function of a whole system? We can be proud to put a stake in this ground. Organizations interested in endorsing can follow the instructions in the introductory note accompanying the Berlin Agreement.