by Nicholas Gonzalez, M.D.
The date of July 13, 2000 may very well go down in history as a
turning point for the future of medicine and health care in the
United States. On that typically hot, humid Washington D.C. day,
President William Clinton appointed 13 members to the White House
Commission on Complementary and Alternative Medicine. By that act
President Clinton has formally and officially recognized at the
highest levels of government the importance of non-traditional medicine
in the lives of American citizens.
President Clinton created the Commission by direct executive order,
with a two-year agenda to evaluate the changing presence and importance
of complementary and alternative medicine (CAM) and to provide guidance
and recommendations to governmental agencies for its orderly study
and incorporation into mainstream medicine. The creation of the
commission represents an extraordinary turning point in the history
of alternative medicine in this country and is the result of unusual
bipartisan support in Washington.
The roots of the commission really go back 10 years when a group
of senators led by Tom Harkin, D-Iowa, first proposed the creation
of an office at the National Institutes of Health to investigate
and validate promising alternative therapies amidst much opposition
from the government scientific bureaucracies. At the time, mainstream
academic medicine, particularly at the federal level, perceived
alternative medicine practices as at best "unscientific,"
and at worst, outright "quackery." But Senator Harkin
was responding to his own successful use of alternative medicine
for treatment of his resistant allergies as well as the growing
demand by his constituents that the government begin evaluating
alternative approaches fairly. Senator Harkin, as chair of the subcommittee
that funds health research, convinced his colleagues to allocate
$2 million to create the then Office of Alternative Medicine. In
the context of a $20 billion federal medical research budget, two
million might seem slight but it was a beginning. And indeed the
original OAM was small, underfunded and under attack by many in
mainstream medicine. From that humble start grew the now powerful
National Center for Complementary and Alternative Medicine, an independent
agency with an impressive $87 million budget and a directive to
evaluate fairly and objectively the best of alternative medicine.
As the Office grew in stature, members of both Houses of Congress
and members from both parties began to realize the growing importance
of alternative medical practices. By 1997 it was estimated that
over 40 million Americans used some form of alternative medicine
and Americans made 629 million yearly visits to alternative practitioners,
with a total expenditure of $27 billion, most not covered by insurance.
Americans were taking alternative medicine seriously and Congress
listened. Representative Dan Burton, a conservative Republican and
chairman of the influential House Committee on Government Reform
and Oversight, held a series of pivotal hearings that sought to
bring alternative practitioners and government officials together.
Senator Tom Harkin, a liberal Democrat, forcefully lobbied yearly
to increase the funding and staff of the Office of Alternative Medicine
until it achieved its current stature as an independent research
center.
The various government agencies themselves began responding to
the mushrooming popularity of alternative approaches by the American
people. In October 1998 the National Cancer Institute established
the Office of Cancer Complementary and Alternative Medicine within
the NCI, headed by Jeffrey D. White, M.D., a career NCI research
scientist and a strong advocate for fair investigation of promising
alternative treatments.
Inevitably the growing interest in alternative practices would
reach the presidential level. Senator Hillary Clinton particularly,
with her great interest in health care issues in general, has long
been an advocate of increased expenditure for CAM research. And
President Clinton himself has argued for increased research support
for non-traditional approaches.
Clearly, alternative medicine was an issue that crossed all boundaries,
all socioeconomic and political divisions. Americans from all walks
of life want alternative medicine and want it taken seriously.
All this reached an historic watershed when on March 8, 2000 President
Clinton created the White House Commission on Complementary and
Alternative Medicine Policy under the Federal Advisory Committee
Act. This act allows the president to create commissions to advise
on important public policy issues without the need to go through
Congress and without the need to create new legislation. The commission
was placed under the umbrella of the Department of Health and Human
Services, which directly oversees all government research agencies
such as the National Institutes of Health and the National Cancer
Institute. But the commission from the outset was perceived as an
independent working group that would answer directly to the president
and provide advice on issues related to CAM practices. The commission
is independent from the National Center for Complementary and Alternative
Medicine, which is directly under the National Institutes of Health
and serves primarily as a funding agency for CAM research. The commission
will not provide funding but rather public policy suggestions.
The executive order outlines the specific function of the commission,
and its impressive agenda:
"Sec. 2. Function. The Commission shall provide a report,
through the Secretary (of Health and Human Services) to the President
on legislative and administrative recommendations for assuring that
public policy maximizes the benefits to Americans of complementary
and alternative medicine. The recommendations shall address the
following:
"a) the education and training of health care practitioners
in complementary and alternative medicine;
"b) coordinated research to increase knowledge about complementary
and alternative medicine practices and products;
"c) the provision to health care professionals of reliable
and useful information about complementary and alternative medicine
that can be made readily accessible and understandable to the general
public; and
"d) guidance for appropriate access to and delivery of complementary
and alternative medicine."
Importantly the order directs that the "heads of executive
departments and agencies" work with the commission, and provide
assistance as needed. Thus, the commission has access to the multitude
of scientific agencies, government scientists and scientific resources
in Washington.
Initially President Clinton suggested the commission consist of
"not more than 15 members appointed by the president from knowledgeable
representatives in health care practice and complementary and alternative
medicine." This was subsequently amended to allow for 20 members,
including a chair. The president did indeed select the commission
members, who represent a variety of backgrounds and interests. The
current 19 members include George M. Bernier, Jr., M.D., an oncologist
and vice president for education at the University of Texas Medical
Branch, Galveston; David Bresler, Ph.D., an acupuncturist; Thomas
Chappell, Co-Founder of Tom's of Maine Inc.; Effie Yew Chow, a Ph.D.
practitioner of Traditional Chinese Medicine and President of East
West Academy of Healing Arts in San Francisco; Charlotte Kerr, an
acupuncturist in Maryland; Linnea Signe Larson, associate director
of the Center for Integrative Medicine in Oak Park, Illinois; Tieraona
Low Dog, M.D., medical director for the Tree House Center of Integrative
Medicine in Albuquerque, New Mexico; Dean Ornish, M.D., president,
Preventive Medicine Research Institute in Sausalito, California;
George DeVries, III, CEO, American Specialty Health Plans in San
Diego; William Fair, M.D., formerly chairman, Department of Urology,
Memorial Hospital, New York; Joseph Fins, M.D., director of medical
ethics, Weill Medical College of Cornell University; Veronica Gutierrez,
D.C., a chiropractor from Arlington, Washington State; Wayne B.
Jonas, M.D., formerly director of the Office of Alternative Medicine
of the NIH and currently in the Department of Family Medicine at
the Uniformed Services University of the Health Sciences, Bethesda,
Maryland; Conchita M. Paz, M.D. in family practice in Las Cruces,
New Mexico; Buford L. Rolin, Poarch Band of Creek Indians in Atmore,
Alabama; Julia Scott, president, National Black Women's Health Project,
Washington, D.C.; Xiaoming Tian, M.D., Wildwood Acupuncture Center,
Bethesda, Maryland; and Donald W. Warren, D.D.S., of Clinton, Arkansas.
President Clinton chose as chairman James S. Gordon, M.D., director
of the Center for Mind-Body Medicine in Washington D.C., and previously
chair of the Program Advisory Council at the Office of Alternative
Medicine.
After several months of planning the commission officially got
off the ground at the July 13th, 2000 ceremony, when the first 13
members of the commission took an oath of office. Donna Shalala,
the Secretary of Health and Human Services, presided over the meeting.
In addition to the Commission members, it included appearances and
speeches by Senators Tom Harkin and Barbara Mikulski, who were instrumental,
along with the president, in creating the commission. President
Clinton's own statement clearly defined the purposes of the commission:
"This commission, created by an executive order on March 8,
2000, is charged with developing a set of legislative and administrative
recommendations to maximize the benefits of complementary and alternative
medicine for the general public…
"If we are going to hold complementary and alternative therapies
to an appropriate scientific standard of accountability, we need
to invest in research so health care professionals and consumers
can make informed judgements about the appropriate use of these
services. In that vein, we have worked with Senator Harkin and a
bipartisan coalition of members of Congress to establish the NIH
Center for Complementary and Alternative Medicine to invest resources
in scientific analysis to make such information available.
"But we need to do more. We need to be able to use information
about alternative therapies to set the national agenda for the education
and training of health care practitioners in this field and provide
recommendations for advisable coverage policies for alternative
therapies…"
Secretary Shalala, in her remarks, called for a national policy
for alternative medicine and clearly revealed a new attitude among
government scientific agencies. She said, "As the utilization
of CAM interventions continues to increase, the need becomes more
essential for administrative policies and legislative initiatives
to address the integration of CAM services into the medical care
system, provide for adequate reimbursement for CAM services, appropriate
licensing, training and education of all providers of CAM interventions,
and methods to provide readily accessible and easy to read information
describing the benefits and shortcomings of these interventions
to health care providers and the general public.
"The task of the commission is to provide recommendations
to me that can be transmitted to the president for appropriate administrative
and legislative initiatives to improve the health care and wellness
of all segments of the United States population.
"By signing the Executive Order this year, the President lifted
the issues related to Complementary and Alternative Medicine to
the highest levels of government. As the head of the Department
responsible for these activities, I intend to keep them there. The
needs of all citizens must be a core mission of every Federal department
and agency. I don't consider this simply an administrative obligation.
This is a moral obligation to the public - and good government being
responsive to the needs of its citizenry.
Senator Harkin gave a particularly impassioned speech outlining
his own involvement in the creation of the Office of Alternative
Medicine, his fight to increase its funding and his battle to have
alternative medical practices considered seriously in Washington.
He said, "Today is a great moment in history…" emphasizing
the importance of the Commission, and its independence from agency
politics: "And let me be clear," Senator Harkin stated,
"this commission does not answer to NIH or anyone else. This
is a White House commission formed to answer to the American people."
The Commission, funded in excess of $1 million, was given two years
to investigate the status of CAM treatments in the country, and
write a position paper for the president with legislative and administrative
suggestions. The change of administrations, and of political parties,
should make very little difference. Support for alternative medicine
research strongly crosses party lines and both of President Bush's
parents have used alternative medical practices.
Members of the commission, under Dr. Gordon's direction, got to
work at once. They conceived a program of town meetings around the
country, to give American citizens from all walks of life the opportunity
to directly address the commission and express their wishes and
needs regarding alternative medicine and health care. The commission
held the first town meeting on September 8, 2000, in San Francisco.
The meeting, attended by several hundred people, was a great success,
generating much discussion and much enthusiasm. The second meeting,
held in Seattle in late October, was equally successful and the
next regional town meeting will be held January 23, 2001 in New
York City.
In addition to these regional town meetings, the commission planned
intensive, formal hearings in Washington D.C., at which officials
from the various government agencies as well as alternative practitioners
would be invited to discuss their perspectives, hopes for, and opinions
about CAM. The first of these was a two-day event held October 5-6,
2000 at the Hubert H. Humphrey Building amidst the federal complex
in D.C. The purpose of this particular hearing was succinctly outlined
in the announcement of the event:
1. What can be done to expand the current research environment
so that practices and interventions that lie outside conventional
science are adequately and appropriately addressed?
2. What types of incentives are needed to stimulate the research
of CAM practices and interventions by the public and private sectors?
3. How can we more effectively integrate the CAM and conventional
research communities to stimulate and coordinate research?
This was truly a star studded hearing, bringing together influential
representatives from major federal research agencies. Individual
sessions were arranged by topics with each topic presented by one
or more speakers. On Day One, at Session I, Dr. Leon Rosenberg,
chair of the Institute of Medicine Committee on the NIH Priority-Setting
Process, discussed changing attitudes toward CAM at high levels
of the NIH. A particularly impressive session titled "Federal
(NIH) Support for CAM Research," brought together Dr. Jeff
White of the NCI, Dr. Claude Lenfant, director of the National Heart,
Lung and Blood Institute, Dr. Marvin Cassman, director of the National
Institute of General Medical Sciences, Dr. Steven Hausman, director
of the National Institute of Arthritis and Musculoskeletal and Skin
Diseases and Dr. Paul Coates, Office of the Director/Office of Dietary
Supplements, the recently created agency given the task of formulating
policy regarding nutritional and herbal supplements. All these influential
speakers discussed their intention to support CAM research enthusiastically
and scientifically, to help sort out what works from what does not.
Dr. Stephen E. Straus, director of the National Center on Complementary
and Alternative Medicine, gave a long and insightful presentation
on his office's varied research projects. His talk was one of the
highlights of the day.
The complex regulatory and legal issues surrounding CAM practices
and CAM approaches were discussed extensively during several presentations
on both days. At the session "Facilitating CAM Research and
Regulatory Challenges," five officials from the Food and Drug
Administration talked of FDA's changing approach to nutritional,
herbal and alternative medicine. What became clear is that there
is indeed a new attitude toward alternative medicine at the FDA
and a willingness to support CAM research.
A particularly significant panel included a presentation by Dr.
James Winn, rector of the Federation of State Medical Boards. Traditionally
the state medical boards have been notoriously antagonistic toward
most, if not all, forms of nutritional, herbal and alternative medicine,
using loss of license as a very direct way to control CAM practices.
But Dr. Winn spoke of his hope that controversial alternative practices,
such as chelation -- which have led to many battles between alternative
proponents and state boards -- be given a fair chance to prove themselves.
He stated that he would not want any useful alternative therapy
to be unfairly oppressed. If this proves true, this certainly represents
a turning point in the attitudes of state medical boards.
I spoke myself, at the end of Day One, as part of a panel chosen
to discuss "Outcomes Research: Interface Between CAM Research
and Regulatory Agencies." I presented, along with Dr. White
of the National Cancer Institute, Dr. Ann McCombs and Dr. Devi Nambudripad,
who both use an acupuncture-based system for allergy treatment.
Dr. Gordon had specifically asked me to highlight -within the framework
of the allotted 10 minutes - a brief history of my own approach
to the treatment of cancer with pancreatic enzymes, the roots of
which go back 100 years. I was also asked to discuss the subtle
and direct harassment I have endured in my attempts to have my work
properly tested and my success in gaining research support.
After our panel presentation, the commissioners questioned us for
over an hour, so interested were they in the political and legal
problems faced by alternative practitioners who work outside the
academic mainstream. For me it was an extraordinary experience to
relate to a receptive audience the struggles I've faced to have
my work tested and hopefully accepted by academic medicine. It was
evident that commission members not only take their directive very
seriously but that they are going to work hard to insure that future
researchers, who may begin outside the mainstream, will have an
easier time getting their work evaluated.
Some time after the October session I had the opportunity to sit
down with Dr. Gordon, and discuss his plans and hopes for the Commission.
He has impressive credentials: a graduate of Harvard College and
Harvard Medical School, he completed a residency in psychiatry before
moving to the National Institutes of Health as a research psychiatrist.
There, over a 10-year period, he developed the first national program
for runaway and homeless youth. He directed the Special Study on
Alternative Services for President Carter's Commission on Mental
Health. He is a clinical professor in psychiatry at the Georgetown
University School of Medicine, served as first chair of the Program
Advisory Council of the National Institutes of Health's Office of
Alternative Medicine and currently is director of the Center for
Mind-Body Medicine. He is the author of numerous books including
Manifesto for a New Medicine, which greatly affected Senator Hillary
Clinton's attitude toward alternative medicine, and his newest,
Comprehensive Cancer Care.
Dr. Gordon was quite enthusiastic when he discussed the importance
of the commission; he believes that the commission will have nothing
less than a revolutionary effect on the future of medicine. He said,
"I believe that the report we are going to provide the president
in two years has the potential to be, for medicine in the 21st century,
as important as the Flexner report was to medicine in the 20th century.
The Flexner report was the result of a committee created at the
beginning of the 20th century to develop policies and standards
for medical education. The report of the Flexner commission had
a profound effect in establishing standards for scientific medical
education that helped bring American medicine into modern times.
I believe our commission can have an equally significant effect
in this century. I don't perceive our goal as limited to discussing
research approaches to CAM practices; I see it far more expansive.
I believe this commission has an opportunity to look at medicine
and health care from a different perspective that can lead to a
new model of medicine and even a new model of human biology.
"I believe we need to change our fundamental orientation from
a too narrow focus on end stage disease management to keeping people
healthy, whole and well. We need to change the distribution of resources
from overwhelming emphasis on acute care at the end of the line
to teaching people how to stay well. We need to begin with health
care education in the schools, as early as possible.
"Alternative and complementary medicine has much to teach
us and the rewards can be great on many levels. For example, recently
Tiffany Field, Ph.D. completed a study on the use of massage with
premature infants. Volunteers gave the infants in the neonatal ward
30 minutes of gentle massage daily. The end results from this simple
alternative intervention were remarkable; babies treated with daily
massage left the hospital significantly earlier, they needed less
medical and high tech intervention, they were healthier, and in
terms of the bottom line, the hospital saved an average of $10,000
per baby in medical costs.
"Similarly, patients who have been taught simple relaxation
techniques prior to surgery have a much better outcome, with fewer
complications and overall more rapid recovery. These are simple
interventions that can help make surgery less difficult.
"We need a model of medicine that doesn't just look at the
disease or just treat the immediate problem. We need a model of
medicine that looks at the total person, his/her body, mind and
spirit, nutrition, structure and psychology. And I am convinced,
after 30 years of learning about, practicing and advocating such
medicine, that this commission can be the vehicle to help transport
medicine in that new, and I believe, better direction."
For further information on the commission, browse their Web site
at: www.whccamp.hhs.gov.
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