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The long strange road to normalizing the “integration” of quackery with medicine [Respectful Insolence]

Monday, November 28, 2016 2:09
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(Before It's News)

It’s been a long time since I’ve encountered Glenn Sabin. You might remember him, though. He runs a consulting firm, FON Therapeutics, which is dedicated to the promotion of “integrative” health, or, as I like to put it, the “integration of pseudoscience and quackery with science-based medicine. What I remember most about Sabin is how he once proclaimed that “integrative medicine” was a brand, not a specialty. Unfortunately, he was correct in his assessment. Basically, he declared, “CAM [complementary and alternative medicine] is dead. The evolution of evidence-based, personalized integrative medicine, and its implementation in clinic, lives on.” The reason CAM was being killed by its advocates was, of course, because the term CAM contains the word “alternative” in it, and that was a barrier to mainstream acceptance. It didn’t bother Sabin one whit that there’s a lot of unscientific and unproven quackery in the CAM that has mostly become integrative medicine:

It’s true that not all stress reduction techniques, say, Reiki, boast a solid evidence base. But many clinicians who offer services like Reiki do so because they’ve observed it helping many of their patients to relax, thus lessening their need for certain medications. They rationalize that since the intervention is not potentially harmful and their patient is more relaxed and reporting beneficial value, then what difference does it really make if we don’t yet know exactly how it works?

To him, “integrative” health and medicine were the future, mainly because the connotation is much more favorable. To paraphrase how I put it at the time, no longer were CAM practitioners content to have their favorite quackery be “complementary” to real medicine. After all, “complementary” implied a subsidiary position. Medicine was the cake, and their nostrums were just the icing, and that wasn’t anywhere good enough. Those promoting CAM craved respect. They wanted to be co-equals with physicians and science- and evidence-based medicine. The term “integrative medicine” served their purpose perfectly. No longer were their treatments merely “complementary” to real medicine. Oh, no. Now they were “integrating” their treatments with those of science- and evidence-based medicine! The implication, the very, very, very intentional implication, was that alternative medicine was co-equal to science- and evidence-based medicine, an equal partner in the “integrating.”

Unfortunately, that brand has spread and metastasized far beyond what anyone could have imagined even just 10 years ago. Such were my thoughts when I received an e-mail from FON Therapeutics (whose e-mail list I’m still on) touting an e-book by Glenn Sabin and Taylor Walsh entitled The Rise of Integrative Health and Medicine: 1963 to the Present. My curiosity was piqued, given the source, which is about as pro-CAM, pro-”integrative” medicine as you can possibly get outside of John Weeks. I wanted to see what, exactly, Mr. Sabin viewed as the most important milestones in the acceptance of integrative medicine have been over the last 53 years. And what do you know? John Weeks even makes an appearance in the introduction.

Unfortunately, to download the e-book, you have to provide your name and e-mail address, and then FON Therapeutics sends you a link. I understand if many of you might be reluctant to do that (although if you’re really interested there are so many free e-mail services that it’s easy to make a throwaway account just for this purpose). So I took the bullet so that you don’t have to.

First, a word from our sponsor…

The first thing I noted upon reading this e-book was a big ad right after the copyright and publisher page for XYMOGEN supplements, in particular its “ePedigree Verified” (ePV) system designed to ensure only “registered” practitioners were selling its products over the Internet, bragging on its website:

We are the only nutraceutical company that is truly exclusive, and this exclusivity extends to you. We want to make sure you are the only source of XYMOGEN formulas for your patients. This allows you to better track their progress, ensure compliance, and foster relationships.

Well, alrighty then. I guess that this is just XYMOGEN’s way of bragging that its detoxification, cell-life regulation, immune system support, adrenal support, and whatever other support you can think of supplements are better than every other company’s detoxification, cell-life regulation, immune system support, adrenal support, and whatever other support you can think of supplements. Of course, registering with XYMOGEN just requires filling out a web form or paper form, providing a credit card number, and signing a contract and agreeing to terms like this if you want to sell XYMOGEN products online:

…please refer to the No Internet Sales Policy, which supplies an outline of XYMOGEN’s requests for conducting business online. Our primary concerns are that there are no prices listed, no discounts offered, no referral code disclosures, and that the only means by which the general public can purchase our formulas online is through a licensed healthcare practitioner.

Ah, yes. No discounts.

Enter John Weeks

So this is the nature of the sponsor of this e-book. What does our good old buddy John Weeks have to say? To be honest, I didn’t expect to be discussing anything related to Mr. Weeks again so soon, particularly after he accused Steve Novella, Edzard Ernst, Michael Vagg, and I of “polarization-based medicine” and compared us to Donald Trump, not once but twice. The first time around, Weeks, a well-known activist in favor of “integrating” pseudoscience into medicine in the form of “integrative medicine” who has featured in this blog from time to time, was incensed at our criticism of a shoddily executed systematic review of “complementary and alternative medicine” (CAM) or “integrative medicine” approaches to pain from the National Center for Complementary and Integrative Health (NCCIH) which was roundly criticized by Dr. Novella, Dr. Vagg, Professor Ernst, and myself. Basically, Mr. Weeks abused his position as the newly-hired editor of the Journal of Alternative and Complementary Medicine (JACM) in order to attack critics of the NCCIH review in near-apocalyptic terms, while trying to paint himself as the voice of “moderation.”

The second time around, he did it again, this time on what I like to half-jokingly refer to as the “wretched hive of scum and quackery,” The Huffington Post, he attacked Juliana LeMieux of the American Council for Science and Health and us again for having criticized a commentary article in JAMA by Jennifer Abbasi entitled “As Opioid Epidemic Rages, Complementary Health Approaches to Pain Gain Traction” that basically accepted the NCCIH review at face value. LeMieux referred to JAMA as the “journal of medical atrocities,” which actually makes me look a bit tame by comparison. (I might have to up my game.) Now, regular readers know that I’m not exactly a big fan of the ACSH. I view it as too sympathetic to industry interests, particularly pesticide manufacturers as evidenced by its repetition of typical anti-environmentalist smears against Rachel Carson and remarks by its founder dismissing concerns about potentially toxic chemicals, especially pesticides, as “chemophobia,” which she characterized as an “emotional, psychiatric problem.” However, as much as I tended to distrust ACSH, I do have to admit that it’s gotten somewhat less blatant in supporting corporate interests since Hank Campbell took over, which is perhaps why it irritates me a lot less than before. This time around, Dr. LeMieux and I are pretty much in agreement.

Mr. Weeks begins by asking:

At what point can an emergent movement look back and claim a history? And what is that history if, over the course of the time chronicled, separate strands have knit together into a whole that was unimagined at the outset? Do the lineages of each become the shared ancestry of what is emerging?

These questions face anyone who chooses to look back on the evolution of what many of us now call the “movement for integrative health and medicine.” What’s in? What’s out? What stories will rise to frequent retelling in this melded family history? Which will be hushed up or edited down?

The first of the 120 notable achievements in this timeline from Glenn Sabin and Taylor Walsh begins, appropriately, in the ’60s. East met West. Back to nature. Whole foods. Rise of the feminine. Whole systems. That one herb that made us think about the power of others. Environmentalism. Globalism. Social justice.

I can’t help but guess that one thing that will be hushed up and edited down (that has been hushed up and edited down since the dawn of integrating quackery into medicine) is, in fact, the rank pseudoscience inherent in so many CAM—excuse me, integrative medicine—modalities: reiki, acupuncture, the rest of traditional Chinese medicine, reflexology, naturopathy, homeopathy, applied kinesiology, high dose vitamin C for cancer, and many many more. On the other hand, I can’t help but agree that part of the impetus for what is now “integrative medicine” probably does lie back in the 1960s, although I would quibble and say that it really should go back to the late 1940s and early 1950s when, in the wake of World War II, Chairman Mao Zedong found himself unable to provide science-based medicine for his people. So he instead retconned the history of the many strains of Chinese folk medicine to create something called “traditional Chinese medicine” (TCM) and proceeded to show people like Weeks and Sabin the way in terms of “integrating” TCM with “Western” medicine. Indeed, I’ll repost some Chinese party slogans about TCM that Dr. Kimball Atwood wrote about years ago about TCM and Mao’s role in promoting it to the West:

1945-50: ‘The Co-operation of Chinese and Western Medicines’

1950-58: ‘The Unification of Chinese and Western Medicines’

1950-53: ‘Chinese Medicine studies Western Medicine’

1954-58: ‘Western Medicine studies Chinese Medicine’

1958 on: ‘The Integration of Chinese and Western Medicines’

Sounds eerily prescient now, doesn’t it? I’d argue that the last 25 years have been the fulfilment of the last two slogans. No wonder Weeks and Sabin don’t go 10 or 15 years further back in time. This is exactly the sort of thing that’s been hushed up and edited down by proponents of integrative medicine.

Oh, and Chairman Mao didn’t believe in TCM. He preferred “Western” medicine.

Weeks goes on to note that in the 1970s, things started to percolate more. There were the births of societies for “holistic” doctors and nurses. There was the first new naturopathy school in decades. Other events in the late 1970s included the first herb industry association and a national organization for acupuncturists. Weeks notes:

In Washington, DC, during a 1979 congressional briefing, the internationally honored futurist, Clement Bezold, PhD—who 20 years later would become a player in the integrative care movement—had his finger on the pulse. He told the assembled elected officials and their staff that there was a trend taking shape. He called it “alternative medicine.”

In reality, “alternative medicine” is a newer term than most think. It really didn’t gain credence until the 1970s. Before that, what was to become known as alternative medicine was routinely referred to as folk medicine (if the person writing was charitable) or quackery or health fraud (more commonly). I like to remind people of a commentary published in the New England Journal of Medicine by Clark Glymour and Douglas Stalker, “Engineers, cranks, physicians, magicians,” in which “holistic medicine” (which appeared to be used interchangeably with “alternative medicine”) was dismissed as a “pabulum of common sense and nonsense offered by cranks, quacks, and failed pedants who share an attachment to magic and an animosity toward reason” and concluding that it “does no good to join forces with cranks and quacks, magicians and madmen.”

Unfortunately, Weeks is not entirely wrong (although his presentation is very biased) when he notes:

We can, with confidence, now point to distinct eras. Work in silos, following the emergence from the stew. Fifteen years later, the shock to regular medicine and other mainstream stakeholders from a 1993 publication out of Harvard showing widespread patient use and billions spent. The quick synthesis in the invention of “integrative medicine.” Then, just after the century turned, the birth of multiple collaborations and consortia to power up the new potential. Inclusion in a series of Institute of Medicine reports. Key provisions—including a call for “non-discrimination”— in the Affordable Care Act. Barriers between disciplines lowering.

Now with this maturation, we see a potential convergence for these carriers of whole system, patient-centered, conservative care. They increasingly come together with the medical industry’s efforts to form delivery and payment methods that focus on what former Center for Medicare and Medicaid Services administrator Donald Berwick, MD, MPH learned from integrative care leaders to call “salutogenesis” or “creating health.”

Yes, as I’ve described many times, riding on a change in the use of language coupled with a different viewpoint, the brand that is “integrative medicine” has become quite a powerful one, leading to what I like to refer to as “quackademic medicine,” where academic medical centers embrace and study quackery that they would have dismissed even a couple of decades ago.

So what are these milestones? They fall into several categories, of which I can only focus on a handful. First, of course, there is the National Center for Complementary and Integrative Health (NCCIH), formerly the National Center for Complementary and Alternative Medicine (NCCAM), and, before that, the Office of Alternative Medicine (OAM).

Infiltrating the NIH: A major milestone in integrating quackery with medicine

A list of 120 “milestones” is just too long (even for me) to want to devote the verbiage to discussing all of them. After all, the e-book is 92 pages long. So, naturally, I’m going to gravitate towards the examples that interest me, either because of their significance, because of the difference between how Sabin views them and skeptic view them, or both. I won’t necessarily discuss them in chronological order, either, although Sabin does present them as a timeline, complete with years and in some cases dates. Not surprisingly, several of these milestones have to do with the NCCIH, a center devoted to studying pseudoscience mixed with plausible lifestyle interventions that almost nobody wanted, at least nobody in the scientific community. However, Senator Tom Harkin did, which is why I start with #23 Congress Establishes the Office of Alternative Medicine, which occurred in 1992. Here’s how Sabin describes it:

With the leadership of Sen. Tom Harkin, D-Iowa, Congress established the Office of Alternative Medicine (OAM) in 1991 (Title 404E Section 601 of the Public Health Service Act), to serve as a coordinating center within the Office of Director (OD) at NIH. Its mandate: “facilitate the evaluation of alternative medical treatment modalities” through coordinated research and other initiatives with NIH’s institutes and centers. OAM’s primary mission, in its first six years, was to emphasize rigorous scientific evaluation of complementary and alternative medicine (CAM) treatments, develop an infrastructure to coordinate and conduct research, and to provide information to the public.

And, later in 1992, 24. “Chantilly Report:” First NIH-Organized Workshops on Complementary and Alternative Medicine:

In 1992, the NIH Office of Alternative Medicine (OAM) conducted two workshops in Chantilly, Va. to develop a baseline of information on CAM use in the United States. The meetings examined six fields of alternative medicine and addressed issues of research infrastructure, research, and methodologies. The resulting “Chantilly Report” or “Alternative Medicine: Expanding Medical Horizons”—was released in 1995. It is significant because it was the result of the first NIH sanctioned meetings held to discuss the field of complementary and alternative medicine as a whole.

These initial OAM meetings on CAM are described in the 2002 report from the Institute of Medicine (IOM), “Complementary and Alternative Medicine in the United States.”

And then, in 1998, there was 36. Congress Creates The National Center for Complementary and Alternative Medicine (NCCAM):

Through an informal coalition of integrative health and CAM leaders inside and outside of government, six years after establishing the Office of Alternative Medicine, the US Congress elevated that office to the National Center for Complementary and Alternative Medicine (NCCAM). At that time, the NIH director said the new NCCAM: “…will provide greater autonomy to initiate research projects at a time when the public is increasingly interested in CAM therapies.” A 16–member outside advisory council was also created (50% of its members were to be from the CAM professions, but that ratio has not been achieved since the founding of the council). Also see 2015 entry 118. “NCCAM becomes the National Center for Complementary and Integrative Health (NCCIH)”

I can’t help but note my take on #118, in which NCCAM became NCCIH. As for the rest, this history, of course, ignores the background and context, which has been discussed here many times before. Basically, the OAM ran into trouble almost immediately when its first director, Joseph M. Jacobs, ran afoul of Sen. Harkin by insisting on rigorous scientific methodology to study alternative medicine. To get an idea of what Jacobs was up against, consider that in 1995 Harkin wrote not just one, but two, commentaries, “The Third Approach” and “A Journal and a Journey.” In these two articles, Harkin basically advocated studying what has been “called ‘left-out medicine,’ therapies that show promise but that have not yet been accepted into the mainstream of modern medicine.” and explicitly stated that “mainstreaming alternative practices that work is our next step.” Unfortunately, Sen. Harkin had a bit of a problem with the way medical science actually goes about determining whether a health practice—any health practice—works, and railed against what he characterized as the “unbendable rules of randomized clinical trials.” Citing his use of bee pollen to treat his allergies, he went on to assert, “It is not necessary for the scientific community to understand the process before the American public can benefit from these therapies.”

Ultimately Jacobs resigned under pressure from Harkin, who repeatedly sided with the quacks. It also didn’t help that Jacobs complained about various “Harkinites” on the advisory panel who represented cancer scams such as Laetrile and Tijuana cancer clinics. That Jacobs became tired of fighting and finally resigned is especially noteworthy given that Jacobs himself had been picked to run OAM precisely because of his openness to the idea that there were gems to be found in the muck of alternative therapies. Meddling by Harkin was a theme that kept repeating itself. Later, in 1998 after the then-NIH director had tried to impose more scientific rigor on the OAM, Harkin sponsored legislation to elevate the OAM to a full center, and thus was the NCCAM born. Not coincidentally, the NIH director has much less control over full centers than over offices. Interference by Sen. Harkin whenever the NIH director or NCCIH director tries to enforce more rigorous science has been a recurring theme, right up until Sen. Harkin retired a couple of years ago.

The legitimization of quackery through NCCIH and others

Another area that these “milestones” quite frequently represent are steps on the way towards legitimizing quackery. For example, guess what the number one milestone is, dating back to 1963? It’s 1. Chiropractic Care Attains Insurance Coverage:

Delaware enacted the first state mandate for chiropractic benefits in 1963, followed by 19 states in the 1970s, and 24 in the 1980s. The American Chiropractic Association estimates that by 2015, some 87% of all insured American workers have chiropractic coverage. All 50 states, the District of Columbia, Puerto Rico, and the United States Virgin Islands officially recognize chiropractic as a health care profession, with services available under state workers’ compensation laws. Chiropractic care is available at armed forces and veterans’ medical facilities. Certain services are covered by Medicare and Medicaid.

To be honest, it’s hard to argue with the inclusion of the first state mandate to cover chiropractic as a major milestone towards the legitimization of unscientific medicine. Chiropractic, despite its seeming respectability these days, is based on prescientific vitalism and anatomic abnormalities (“subluxations”) that no one has ever been able to demonstrate in the form chiropractors claim. As I like to say, chiropractors are really incompetent physical therapists with delusions of grandeur. If there ever were a “success” story for the integration of quackery with medicine and the legitimization of pseudoscience, the acceptance of chiropractic in all 50 states is one. It’s a model that naturopaths are now currently trying to emulate.

On a related note, Sabin also views what happened in Washington in 1994 in Washington as even more important, 31. Washington State Enacts “Every Category of Provider” Statute:

In 1995 the Washington legislature passed the Alternative Provider Statute (Every Category of Provider law), becoming the first state to require insurers to include in their coverage plans: licensed practitioners of naturopathic medicine, massage therapy (soft-tissue manipulation), acupuncture and Oriental medicine, chiropractic, direct-entry (homebirth) midwives, and other licensed specialists.

The law, which was successfully defended against insurer attack by then Washington State Insurance Commissioner Deborah Senn, JD, required that insurers “permit every category of health care provider to provide health services or care for conditions included in the basic health plan.” It did not apply to Medicare, Medicaid, state-subsidized Basic Health Plans, or to self-funded plans. The state has since supplied a treasure trove of data on real world integration.

Great, going, Washington!

Not surprisingly, there are a number of steps listed here that have to do with the legitimization of “integrative medicine,” including: the US recognizing the chiropractic education accrediting agency (#2, 1974); the founding of the American Holistic Medical Association (#6, 1978); the founding of Cancer Treatment Centers of American (#16, 1988), about which I can’t help but note that we’ve written about how devoted to integrating quackery CTCA is; the founding of the University of Arizona Center for Integrative Medicine by Andrew Weil (#29, 1994); the formation of the Bravewell Collaborative (52, 2002); and many more.

Education corrupted

Over the years, I’ve discussed more examples than I care to note of the corruption of education by the infiltration of pseudoscience into the medical curriculum, both at the undergraduate and graduate medical education levels. Not surprisingly, Sabin agrees that these are important milestones, although, unlike myself, he thinks these milestones are a good thing. For instance, Sabin lists: the first NCCAM grant for education in CAM (#40, 1999); military training for medics in the use of battlefield acupuncture (#107, 2014), something I’ve written about many times; a meeting at Georgetown University to advance integrative health care (#48, 2001), with Georgetown later fully embracing the “integration” of CAM education into its curriculum and becoming a bastion of quackademic medicine; the funding by NCCAM of integrative medicine in preventative medicine residencies (#95, 2012); and, of course many more. Oddly enough, Sabin didn’t seem to think that board certification in holistic medicine or the formation of the first integrative medicine residencies were that big a deal. Whatever.

The bottom line is that this list is a depressing litany of just how far integrative medicine has come in becoming normalized (to use a common phrase these days) or mainstreamed.

The future

At the end of the list, Sabin and Walsh remark:

What was utterly outside of regular practice is increasingly explored in conventional medical delivery. The calls of the integrative care community for “health care”, rather than the limited reactivity of “sick care”, are increasingly intoned in the pages of American Hospital Association publications. Calls from the integrative and functional medicine movement for a system that focuses on salutogenesis and health creation are percolating in hospital board rooms.

These struggles of the medical industry to become value-based are prying open hearts, minds, and budgets to new contributions.

The answers are not clear, or easy. What will the next milestones be? What is ahead in this new era of convergence? Most important, how will you or your organization fit into this emerging paradigm?

Well, I don’t plan on “fitting” into this emerging paradigm. However, I can’t help but note how this last passage shows how blatantly integrative medicine co-opts terms and strategies that do not require the embrace of quackery to achieve, such as “wellness” and “health care” rather than “sick care,” in addition to value-based health care. Regarding the latter, I can’t help but note that treatments not based in science and not demonstrated to be effective by science can never be of high value, at least not economically, which is the value that Sabin is trying to co-opt. As for “wellness” and “health care,” one doesn’t have to embrace acupuncture, TCM, homeopathy, naturopathy, functional medicine, or any other unscientific version of medicine in order to promote these as goals. Yet that is exactly what integrative medicine advocates like Sabin, Walsh, and Weeks try to argue.

Amusingly, right after this argument, there is another ad for XYMOGEN supplements, followed by another ad for the XYMOGEN Exclusive Series Healing the New Epidemics. The two speakers, who have been appearing throughout the country as part of this series, include Richard Horowitz, who is speaking about a nonexistent disease widely treated by quacks, “Solving the Mystery of Chronic Lyme Disease and Associated Tick-Borne Co-Infections,” and Kenneth Bock, who is also speaking on a questionable disease that dubiously blamed for autism, “Healing the New Childhood Epidemics: PANDAS/PANS and the “4A” Disorders (Autism, ADHD, Asthma and Allergies).”

This is the sort of other medicine that is being “integrated” with science-based medicine. It probably wasn’t intended as such, but I found the inclusion of that ad right after the last passage of Sabin and Walsh’s book to be more appropriate than they will ever realize.

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