The Early Movement for Research Evidence in Modern Naturopathy: Fighting Above Its Weight Class

Connecting the Dots for Science-Based Natural Medicine and Naturopathy

This column recapitulates, from a personal viewpoint, a very U.S.-centric view of some of that journey in research and science. It reflects the perimeters of my own involvement over these years. As early as the mid-1980s, some leaders of the profession's revival began speaking of the re-emergent field as “science-based natural medicine.” In retrospect, it is remarkable that this language and the intent it encompassed are roughly coincident with the evidence-based medicine paradigm that was awakening in regular medicine. This commitment to evidence of a subset of new leaders that shaped the modern-era schools continues through the development of the program with which Steel is affiliated and with which JACM is pleased to partner for this special issue. The Naturopathic Research Leadership Program at the Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), University of Technology Sydney, is the first effort to galvanize global research efforts for the field.

A substantive and enduring evidence-informed contribution of the naturopathic profession arrived in North America coincident with the dovetailing movements for “science based natural medicine” and health care's broader call for “evidence-based medicine.” Joseph Pizzorno, ND, the current editor in chief of Integrative Medicine: A Clinician's Journal, and his then mentee Michael Murray, ND, published under their naturopathic college's imprimatur what from a commercial perspective they wisely presented—more broadly than with the name of their small profession—as the Textbook of Natural Medicine. Within years, they published a derivative consumer version, the Encyclopedia of Natural Medicine. The former was an edited volume mainly of contributions of naturopathic doctors and sprinklings of contributions from members of other professions. Each book was an ambitious effort to codify a knowledge—not formerly synthesized—a major excavation of journals, old and new, from library stacks, and from new sources that computers were beginning to access. Start with a condition or an agent. Lasso any scientific evidence that might cast light: human trials, animal and laboratory studies, or recent primary outcomes or merely incidental, historic, local, European, or Indian or other origin. Pack these together around the subject matter of otitis media or echinacea or vitamin E and there it was: the existing English-accessible scientific basis for the tools and suggested natural health approaches for multiple agents and conditions. Naturopathy's eclecticism manifested again in this omnivore's buffet of evidence. The timeliness and perceived value are evident in that both remain in print, with sales of >100,000 for the professional volume and 3 million for the consumer version. The reach is clearly well beyond the profession's small numbers.

Revealing the Science-Based Commons for Natural Health Care

The point made by these naturopathic doctors—and carried into their professional guild—was that, although the science did not arrange itself neatly into hierarchies crowned by systematic reviews, there was a constellation of evidence around these approaches. Evidence existed, substantive in its volume, citable, and creating an impressionistic picture. Although far from perfect, the work made its point: natural health care was not antiscience as the mainstream tended to charge in those days. Ironically, naturopathy was in its own way addressing the call inside biomedicine that was just beginning to expose skeletons in biomedicine's own evidence closet. The naturopathic doctors were, for instance, building the science base for clinical nutrition at a time when the medical mainstream still tended to disparage the role of nutrition as an influence on health.

This work to synthesize the supportive science from diverse sources into what was primarily intended to be a clinically useful guide—but that was also useful to the naturopaths in multiple policy, media, fund-raising, and other environments—created issues among staunch advocates for strict attention to the grade of evidence. This version of the application of the science could be questioned by conventional academics. Ben Kligler, MD, MPH, co-editor-in-chief of Explore: The Journal of Science and Healing and I explored these differences between naturopathic and functional medicine, on one hand, and biomedicine, on the other, in “Finding a Common Language: Resolving the Town and Gown Tension in Moving Toward Evidence-Informed Practice.” ⁷ The debate is real—but it was no longer over whether there was evidence, but rather over the type and the strength of conclusions. The work of these naturopathic doctor authors effectively kick-started aggregating the global evidence commons for natural health care.

Generating Research by Naturopathic Doctors

Virtually all the available pieces of evidence they found, although provided insight into the tools naturopaths used, was neither researched by naturopathic doctors nor of naturopathic practice, per se. The field needed to develop and claim its distinctive body of knowledge. The naturopathic profession was presented with a classic Catch 22: to engage the research they needed to attract resources that typically are only available if one can apply for funding based on prior evidence. In that polarized time in the 1980s, the opportunity for U.S. National Institutes of Health funding of research on naturopathic medicine was still a decade away. In fact, given the polarization, such support was virtually impossible to imagine. State and federal agencies had no open doors. Nor did large foundations, with typically nonsupportive medical advisers at their gates.

One direction that was open was to take a page from regular medicine and tap the pharmaceutical industry—in this case, the natural products industry. To add a degree of difficulty, most of the U.S. herb and dietary supplement industry was not accustomed to supporting clinical research. Nor were they legally allowed to make claims directly, if they had in fact funded positive research. Two $5000 industry grants in the early 1980s led to publications of cross-over trials on otherwise healthy students led by a 1983 naturopathic school graduate. ^8,9 They were celebrated as the first peer-reviewed publications in mainstream journals in the modern era. Then, a few years later, grants of $12000 each from two natural products companies supported the first ever hiring by a naturopathic college of a research director, if in a part-time capacity. Product donations and volunteerism allowed a Healing AIDS Research Project led by Leanna Standish, ND, PhD, Lac, to take root in late 1988 as the AIDS crisis mounted. The long march began with these boot-strapping steps.

Breakthrough into Federal Funding

Word emerged in 1991 of a new initiative at the NIH. The naturopathic profession made itself present. One of its members, Standish, a naturopathic physician with a doctorate in neuroscience, was invited to serve on the first ad hoc advisory committee. (We learned early to put forward names of individuals who also had advanced degrees in conventional fields.) When what was then the NIH Office of Alternative Medicine issued its first major center grant decisions in 1994, a naturopathic institution was the recipient of one—based on the AIDS-ARC work underway through volunteering and donated product. ¹⁰ A pattern of vigilance emerged in the naturopathic profession to seek to continuously have at least one naturopathic physician on the National Advisory Council for Complementary and Integrative Health (NCCIH) for the NIH. (RAND researcher Patricia Herman, ND, PhD, is presently there. ¹¹ ) The profession is also present at the NIH through Wendy Weber, ND, PhD, MPH, who recently completed 1 year as acting deputy director of the NCCIH and continues as branch chief for the Clinical Research in Complementary and Integrative Health Branch in the Division of Extramural Research.

In the late 1990s, the U.S. Congress, led by the then U.S. Senator Tom Harkin, began considering converting the office into what is now the NCCIH. A cofounder of a naturopathic school, Sheila Quinn, who was then directing the American Association of Naturopathic Physicians, and Pamela Snider, ND, and Carlo Calabrese, ND, MPH—each imbedded within a naturopathic academic institution—were deep in the weeds of the final negotiation of the Congressional language to establish the office. They sought to ensure that at least some of the future NIH funds would be directed to naturopathic and other schools that were not then on NIH's horizon. Through Congressional allies, they successfully placed this language: “The provision of support for the development and operation of such centers shall include accredited complementary and alternative medicine research and education facilities.” ¹² Meantime others landed research positions in conventional academic medicine institutions at Yale, University of Michigan, Columbia University, University of Washington, University of California San Diego, and elsewhere through which most have engaged in NIH-funded projects. A notable example is Lynne Shinto, ND, MPH, whose research-based career at Oregon Health and Science University includes multiple NIH awards that led to her 2018 appointment as a full professor.

In the early years of the NCCIH, members of the naturopathic profession secured a grant to engage a community-wide process to establish research priorities for the field, publishing, in 2006, The Naturopathic Medical Research Agenda: The Future and Foundation of Naturopathic Medical Science. ¹³ People with type 2 diabetes and the health of the elderly were identified as top areas of focus. (Notably, guest issue coeditor Ryan Bradley, ND, MPH, became the profession's lead in the diabetes area.) Although just two of the five U.S. institutions with accredited naturopathic institutions have successfully received NIH grants, as of 2013 they netted $22 million or then 35% of the funds that went to “accredited complementary and alternative medicine research and education facilities.” ¹⁴

Whole System Naturopathic Medicine: “Researching the Way We Practice”

Yet a continuing challenge has been to find resources for the multimodal, whole person approaches that naturopaths use in practice that the NIH, with its pharmaceutical culture, has been slow to research. Bradley and Erica Oberg, ND, MPH, and others modeled it for diabetes, via mixed methods investigations. ¹⁵ Dugald Seely, ND, and a team from Canadian College of Naturopathic Medicine used philanthropically funded research to examine whole person approaches to prevention of cardiac disease that resulted in a positive naturopathic medicine trial in the high-impact Canadian Medical Association Journal—a rare publication feat for complementary and integrative health researchers. ¹⁶

Calabrese, a former member of the NCCIH Advisory Council, was at that time a leader of a multidisciplinary team that, through a series of letters, calls, and a large face-to-face meeting, urged as its first priority that whole systems research (“researching the way we practice”) be explicitly part of the NCCIH's second strategic plan. ¹⁷ The second priority was for research capacity building. Calabrese had pushed the agenda during a term on the advisory council, but to no avail. Oberg, Bradley, and Calabrese subsequently were all part of a team that published a review of all the field's multimodal research. ¹⁸ (A much expanded global update is offered by Stephen Myers, ND, B Med, PhD, and Vanessa Vigar, BNat-Hons, in this special issue.)

This Global Moment for Naturopathy

This story of the efforts of the naturopathic profession to create and advance its evidence base has been U.S. centric. Parallel stories can be told from Canada—where a naturopathic doctor was selected as the first director of Health Canada's natural products directorate—from Australia, and elsewhere. That this is so is evident in four additional significant developments—three from Australia—that have emerged in the time frame of the development of this special issue. Steel and others have helped lead efforts that have created the beginnings of a global network of naturopathic academic institutions to jointly engage research. ¹⁹ A team lead by Bradley, under NIH funding, has developed and published “Design of a Multi-Disciplinary Training Program in Complementary and Integrative Health Clinical Research: Building Research across Inter-Disciplinary Gaps (BRIDG).” ²⁰ The Australian natural products firm Blackmores has announced the profession's single largest grant of $10 million to endow a naturopathic research center. ²¹ And one sign of the ARCCIM team's significant involvement with global health was the publication of a widely covered systematic review on the use of traditional medicine in sub-Saharan Africa. ²²

For this issue, the best efforts were made to reach naturopathic researchers anywhere in the 27-nation global web of the World Naturopathic Federation and via every informal network that could be reached. The roughly 30 submissions were a reminder that the total number of naturopathic researchers remains small—and the number of naturopathic researchers funded through large government grants is smaller yet. Contributions of naturopathic educational institutions to fund research are not yet standard in the culture, instead ebbing and flowing based on enrollment and predilections of the institution's leaders.

Yet, this 40-year pattern of action and maturation, leading up to and through the ARCCIM Naturopathic Research Leadership Program—with which we partner for this special issue—suggests the public good in investing further, from multiple public and private sources, in firing up the naturopathic profession's research engines. As in biomedicine, a subset of the members of the naturopathic profession is clearly eager to perform more research and is not shying away from the challenge to self-scrutinize. They are becoming increasingly savvy with finding the funding to do so through academic and industry partnerships. Notably, the profession's pattern of both internal wizening and of growing inclusion parallels the path over this same period of the evidence for several of the natural health therapies that naturopaths have been trained to use and recommend, such as meditation, adjustment, and yoga for chronic pain.

That these have reached the critical quality threshold to be included in significant policy recommendations and clinical management guidelines begs questions related to naturopathic doctors' parallel path. Will this field's efforts to show its value, through research, boost its cultural valuation and usage in primary and chronic disease care, and in shifting practice paradigms toward addressing whole systems and creating health as an outcome? The articles included in this special issue point to a growing sophistication in research activities that give a nod toward an affirmative response. Although the primary relevance of these articles is to naturopathic practice, these eclectic contributions to scientific knowledge ripple across the broader endeavor to establish an integrative health and medicine norm across medical delivery. For naturopathic professionals and their institutions, one lesson from this narrative is quite clear: upping their internal engagement with research is likely to serve them well.