Abstract
The beginning of the integrative era was quietly gory. The lifelike cornucopia of whole person practices with all their multimodal, mind-and-body, individualized, and shifting nature met the buzz saw of reductive biomedical science. It was not pretty. Holistic medical doctors, practitioners of traditional Chinese medicine, naturopathic doctors, adherents of Ayurveda, and of multiple other traditional systems might as well have been the Inca Tupac Amaru II drawn-and-quartered by Spaniards in the square at Cuzco. 1
It was a rough cross-cultural encounter. The search for the gold of mechanism and the efficacy of single agents parted the bodies of whole systems. What in actual practice of an “acupuncturist,” for instance, may be a combination of tuina, counseling, moxibustion, nutritional advice, traditional Chinese formulations, and the insertion of acupuncture needles became an exploration of the latter agent's irritation of the dermis. Even the addition of an oral herbal medicine to needles was deemed an unfundable research proposition when advanced by the acupuncture researcher most substantially funded by what is now the U.S. National Institutes of Health National Center for Complementary and Integrative Health (B. Berman, MD, pers. comm., University of Maryland School of Medicine, May 2009) Although the public agency was charged with exploring the value of complementary and alternative medicine “systems and disciplines” 2 and the integration of these with the conventional delivery system, inside the NIH culture the whole became a Maya-like jungle through which the intrepid reductive researcher must venture to discover what, if anything, a fractionated part might do to move a biomedical marker.
This portrait is harsh. It may appear to dismiss the basic research discoveries of Langevin, for instance, regarding the nature of connective tissue at the point of a needle's probing 3 and the neuroimaging by Napadow of the changes in brain activation through these tools. 4 It downplays the significant and valuable efforts to separate specific from nonspecific effects of treatment with acupuncture needles and for our understanding of the role of placebo in medicine. 5 The list can go on. MacPherson and other leaders of the Society for Acupuncture Research aggregated the “unanticipated insights into biomedicine” from acupuncture research. 6 No dismissal of these is intended. They merely live in other rooms of what Jonas, to construct a less hierarchical view of the research endeavor, has called “The Evidence House.” 7
Yet the image of the tortured Inca enlivens an all too common feature of cross-cultural exchanges characterized by one dominant party encountering another less powerful culture. Adverse consequences to the subordinate tend to be invisible to, or downplayed by, the former. In response, clinicians using multi-modal approaches to treat the whole person have often dismissed or become disinterested in the agency's funded directions. Key professional and academic organizations have advocated—with only marginal response—for “researching the way we practice.” 8 The call is for whole systems research. Dissent has been registered more vociferously abroad. Governmental representatives for complementary and traditional medicine practices and practitioners throughout the Americas, meeting under the aegis of the Pan American Health Organization (PAHO), rejected the “integrative” impulse as a colonial undertaking. The preferred a form of relationship they described as “articulation” between the two medical cultures. 9 University of Toronto researchers Ijaz and Boon echoed the “colonial” language in their examination of the regulatory aspects of the cross-cultural encounter. 10
Failure to examine the practice has potent political ramifications. Research that parts out the whole system practice can clarify evidence for a set of profession-neutral tools—needles, a herb, Chinese massage, and so on. These become available for use by members of the dominant school and any other profession. Yet for the outsider, nondominant party seeking more respect, inclusion, opportunity, and payment through the integrative engagement, it is research on the impact of the whole practice that can best guide stakeholders to understand the outcomes should they decide to bring a new set of professionals, with all of their licensed capacities, into payment or delivery settings. Notably, these questions framed the real-world wisdom of the U.S. Congress when they gave the NCCIH for the health services-oriented mandate to “study the integration of alternative treatment, diagnostic and prevention systems, modalities, and disciplines with the practice of conventional medicine as a complement to such medicine and into health care delivery systems in the United States.” The value of whole systems and disciplines was squarely on the table.
The most significant harm from the NCCIH after its own predilections is only coming home to roost now. It was not cultural insensitivity. It was not even questionable compliance with Congressional intent. Rather, it is that now, amidst the U.S. crisis in chronic pain management, less is known than might have been about the best use of practitioners of nonpharmacologic services for specific populations, or in new types of team-based integrative configurations. A case in point: U.S. Medicare, on exploring coverage of acupuncture, finds that few seniors, with their multiple comorbidities, have been accepted as subjects in acupuncture trials. 11 Another example is the dearth of research investment into use of acupuncturists as members of Medicaid-covered practitioner teams in tapering opioid use in underserved populations. 12 Primary care practices 13 and governmental agencies 14 have limited practical guidance in seeking to implement inclusion of nonpharmacologic strategies. The state of Vermont, for instance, knew next to nothing on this topic when it joined a handful of other U.S. states in pilot coverage of acupuncture in to pain management. 15 Although the past half decade has witnessed positive opening to pragmatic needs, in general the dominant culture of the NIH has gilded certain rooms in the evidence house, whereas those that might have enlightened stakeholders on the optimal use of these professionals, with all of their tools of relationship and practice, remained relatively impoverished, barren and neglected—to our loss, today.
The June 2019 conference of the Society for Acupuncture Research took giant steps toward bringing the research community into better alignment with present-day real-world needs of stakeholders, practitioners, and the public. The title was “Acupuncture Research, Health Care Policy, & Community Health…Closing the Loop.” Featured keynotes and panelists represented insurers, hospitals, and governmental agencies. A grant from the quasi-governmental Patient-Centered Outcomes Research Institute helped set the energy of the conference by involving a subset of participants in an intense examination of strategies to disseminate existing research to facilitate its uptake. 16 A conference cochair framed the exploration as a public health emergency. Might morbidity and mortality be reduced by more rapid uptake of the practices of the nation's 35,000 licensed East Asian health care professionals and the uses of needles by others? A plenary session turned attention of the participants to the emerging role of implementation research in bridging evidence into practice.
The location in Burlington, Vermont, was fitting. The state is not only the home of the SAR co-president Robert Davis, LAc, MS who was credited as the prime mover of the conference's theme. As noted earlier, the state's Medicaid arm recently explored acupuncture in a pilot. 17 Its largest private insurer, Blue Cross Blue Shield, helped to set the tone of conference by announcing a partnership with the University of Vermont integrative medicine through which the payer would begin to cover a bundled integrative pain pilot. 18 The urgency for useful answers to help with decisions on the ground about best use of acupuncturists was not abstract.
Davis provided a short plenary on a research model developed in Vermont, with guidance from SAR board members, to pilot a legislatively funded acupuncture pilot. Vermont's policy makers, he explained, wanted to know the impact of practices that are “complex, interactive, individualized, and multicomponent encounter in which the needle is a small part” and in which practice also varies from practitioner to practitioner. Fellow SAR board member, Hugh MacPherson, PhD, MBAcC, in-laid data from a pragmatic trial that examined “specific effects beyond needling” in the practice of acupuncturists. The cornucopia of the whole practice emerged. These data showed that diagnostic-related lifestyle advice from acupuncture practitioners about self-care to patients with chronic neck pain was associated with increased self-efficacy and reduced pain. 19 Of those studied, 27% routinely used localized heating modalities, 9% tuina, 21% traditional Chinese formulas, 9% food, 8% cupping, and 5% t'ai chi. The list does not end there. 20 Further underscoring the complex breadth of practice of these professionals were findings that 84% of the patients received “lifestyle advice” from their acupuncturists with such counseling reaching across multiple domains, from rest and relaxation to diet and even work. 21 What self-respecting professional with a practice of such breadth would not be resentful at being reduced to a technician with needles as has been the effective focus of research related to the acupuncture field?
The conference setting was appropriate for another reason. A continuously present participant was acupuncturist and researcher Helene Langevin, MD, who in late 2018 was selected as the third director of the NIH NCCIH. Two decades earlier, Langevin directed integrative health at the University of Vermont. In her laboratory, she engaged ground-breaking basic research on how acupuncture needles work even as she was continuing her study of diverse systems and disciplines within the acupuncture field. She became a SAR board member and served as its chair. While maintaining a Burlington home, Langevin moved her academic base to Harvard University where she directed the Osher Center for Integrative Medicine at Harvard Medical School and Brigham and Women's Hospital. For SAR, Langevin's appointment at NCCIH was a feather in its cap. For the entire integrative health field, the appointment was a sigh of relief. For the first time the agency would be led by a director whose professional career was forged in the dialogues, challenges, excitement, and complexities that mark whole systems of treatment.
Langevin did not disappoint. After commending SAR for a pattern of taking on challenging scientific issues, Langevin used an informal, postbanquet talk to take on the whole system elephant that has rumbled around NCCIH's living room for 20 years. She shared how, in her short tenure, she has gained increasing comfort with the meaning of NCCIH framing “mind-and-body” practices as a core priority. Acupuncturists, she noted, are among professionals who work with both mind and body at once. She identified this as a unifying characteristic of what she then called “whole systems.” She named global traditional medicine practices, yoga therapy, Ayurveda, naturopathy, and others as examples. “We need to address the whole,” Langevin said, “not have it cut up into pieces.” She framed the question: “How do we understand the whole body as a whole?” She spoke to the grant writers in the room: “We will try to design some RFAs [requests for applications] to guide people to some questions on whole systems that are answerable. When we work on the next strategic plan, this is one thing we will be asking about.” This direction was rousingly applauded.
Who knows what Langevin and her NCCIH team will do when they run this whole system theme through their cultural filters for “answerable questions”? One only hopes that they keep their eyes on the stakeholders the 2019 SAR conference and the members of Congress who formulated the NCCIH's real-world mandate each targeted: health care employers, insurers, governmental decision-makers, and members of the public. How effective and cost-effective is the whole practice of a traditional East Asian practitioner compared with usual care, in various settings? How do we best implement such a professional into a pain management and health creation team? How can these practitioners bring their entire skill sets to be most useful in supporting an aging Medicare-insured population? For the research work force to help payers and employers gain comfort, they must frame “answerable” in the context of the ambiguities of whole person, multimodal, and personalized treatment. Answering such questions would close a very large loop—and finally bridge a major chasm. Such an end, to paraphrase the early 20th century poet T.S. Elliot, would be a beginning. “We shall not cease from exploration,” Elliott wrote, “and the end of all our exploring will be to arrive where we started and know the place for the first time.”