Learning from the History of Integrative Preventive Medicine to Address Our Current Healthcare Challenges
Medical practices that were not part of conventional, Western medicine, have been part of all health systems, from the time that Western medicine was itself “complementary and alternative” to Ayurveda in 19th-century India. The division increased after the formalization of professional guilds in the 17th century and the Flexner Report in 1916 that established the domination of a more reductionist prevention and disease management system.1,2 These practices have been described with a variety of terms including “irregular medicine,” “unconventional,” “nonmainstream,” “unorthodox,” “quackery,” “folk,” “alternative,” “complementary,” and “adjunctive.” In the last 20 years, the terms “complementary and alternative medicine” (CAM) and, more recently, “integrative medicine” (IM) have emerged. While, CAM and IM are the latest terms for practices that are not generally accepted by the dominant medical culture, what has now been included under the term “integrative medicine” has expanded to include many practices already accepted in conventional preventive medicine, such a nutrition, smoking cessation, and physical activity. In addition, IM seeks not only to deliver CAM and conventional practices but also to coordinate their use in such a way as to maximize the benefit they each bring to the prevention and treatment of illness. Thus, integrative preventive medicine (IPM) is the coordinated delivery of evidence-based, conventional and CAM medical practices for the primary, secondary, and tertiary prevention of disease and illness. What can we learn from this evolution for the future of healthcare? What might IPM look like in design and delivery?
Lessons Learned from the History of Integrative Medicine
A detailed summary of the evolution of CAM and IM in the United States was published in a special issue of Forschende Komplementarmedizin in 2013.3 In that article the first author described many of the lessons learned in the mainstreaming of CAM into practice. A key issue for IPM is to pay close attention to the social forces such as power, resources, and scope of practice. Prevention secures less than 5% of the funding in the healthcare industry, despite the large contributions to population health it makes. While also securing only small amounts of public and private funding, CAM enjoys widespread public support, with between 40% to 70% of the public regularly using CAM and often paying out of pocket for its products and services. Much of this public use is for “wellness” and to stay healthy, thus aligning concepts in preventive medicine and CAM in the public’s mind.4 Thus, developing clear communication strategies for the public on what IPM is will be crucial for its success.
Another common feature between CAM and preventive medicine is the nature of “evidence-based medicine” in addressing public health issues. Like many preventive practices, CAM practices often use long-term, complex, and “whole systems” approaches involving self-care and behavior change, where randomized controlled trials (RCTs) are often difficult or the results of RCTs ambiguous. Thus, small studies or epidemiological and observational studies are the only information available. This type of research is often rejected for clinical decision-making or for reimbursement purposes. Without solid science, many CAM therapies are considered “experimental” and thereby not reimbursable by insurers. The emergence of “personalized” or “precision” medicine and an increasing appreciation for whole practice “comparative effectiveness research” (CER) is changing this thinking and allowing the development of new methodologies that may be more useful for IPM.
A concerted effort to do more high-quality research on IPM is also needed. Studies on truly integrated, integrative medical models are rare, so this research gap will plague IPM.5 Expanding the definition of IPM to include more firmly established preventive practices such as diet and lifestyle practices could bolster the evidence for the field. In addition, solid areas of science showing common ground between prevention and complementary practices should also be explored. The Wellness Initiative for the Nation6 and the National Prevention Strategy are efforts in the United States to link integrative, lifestyle, and more conventional public health efforts. Later in this chapter, we describe another one of those areas (hormesis and the dose-adaptive response) that forms a scientific foundation for many of the healing practices IPM seeks to advance.
The current healthcare system is dramatically successful for acute, infectious, and mechanically correctable disease. It falls short in prevention, integrative practices, and the management of many chronic diseases; and it is too expensive. Integrative preventive medicine might be able to address these challenges, but it needs a deeper examination of how these practices impact healing. More emphasis on enhanced self-care skills and health promotion are needed. A paradigm for tapping a population’s resilience and healing potential must become central to IPM. Healing should be as important as cure. Passage of the Patient Protection and Affordable Care Act of 2010 (ACA) in the United States has brought an opportunity to truly reform our approach to preventive medicine. While ACA is currently focused on expanding coverage for conventional services for those without health insurance, the most far-reaching aspect of the ACA is undoubtedly its potential to lead a shift from sickness to wellness as the organizing principle of our thinking in healthcare delivery. This reunderstanding of the path to health can bring cost savings while simultaneously improving people’s lives. The remainder of this chapter explores how these lessons might form the foundation for solving our current healthcare challenges.
The National Prevention Council: A New Era
In 2008, the Samueli Institute released the Wellness Initiative for the Nation (WIN) to advance the process of healing (“salutogenesis”) as a formative concept for healthcare in the United States. A core feature of WIN was to establish a platform for health in all national policies.6 As a result of this and other legislative work, the National Prevention, Health Promotion and Public Health Council (Council) was established. The Council is the most comprehensive effort to date that links prevention, health promotion, public health, and IM. Its members represent 17 cabinet-level agencies and offices, and are advised by a grassroots Advisory Group (AG) on Prevention, Health Promotion, Integrative Medicine and Public Health.7 The Council is the US federal embodiment of IPM and the principle of health in all policies.
The full names of the Council and AG, while cumbersome, are instructive for IPM, as each body is charged to address the full territory of their name. If the Council is used to its fullest capacity, it can make a great difference in the health of the nation. The charge for the Council includes the following provisions:8
(a) provide coordination and leadership at the Federal level, and among all executive departments and agencies, with respect to prevention, wellness, and health promotion practices, the public health system, and integrative health care in the United States;
(b) develop . . . a national prevention, health promotion, public health, and integrative health care strategy . . . ;
(c) provide recommendations to the President and the Congress concerning the most pressing health issues confronting the United States and changes in Federal policy to achieve national wellness, health promotion, and public health goals . . .
(d) consider and propose evidence-based models, policies, and innovative approaches for the promotion of transformative models of prevention, integrative health, and public health on individual and community levels across the United States.
The central charge for the AG is to “develop policy and program recommendations and advise the Council on lifestyle-based chronic disease prevention and management, integrative health care practices, and health promotion.” The primary work of the Council to date has been the creation of a National Prevention Strategy (NPS) and the National Prevention Council Action Plan (AP). It is in the AP that each agency represented on the Council makes specific commitments for activities to be undertaken that implement the vision, goal, priorities, and recommendations in the NPS.
Transforming Our Thinking and Approach to Health
Fulfilling the mission of the Wellness Initiative for the Nation and the National Prevention Council would be transformative for healthcare. Transformation is needed in our approach to health because in the last 100 years a radical change has already occurred in what ails us, largely because of advances in knowledge about preventive medicine. The current and future ailments around the world are chronic, lifestyle and socially caused diseases and diseases of aging. The greatest contemporary dangers to health are our daily habits, the public and private environments we create and how we live in them. Most of us are not dying from outbreaks of infectious diseases, except in some underdeveloped countries and soon, even in those countries, chronic, lifestyle-related diseases will predominate.9 We are now plagued by chronic diseases that we are largely creating collectively and individually and that come at great economic and human cost. For this reason, it is important that IPM refocus its attention from an acute, disease-oriented system to creation of a health and wellness–oriented system that spans the full spectrum of life. We need to transform our thinking that healthcare, community wellness, and access to medicinal treatment are one and the same. We need to understand that, while medical care is required at times, health is supported or compromised by an array of social determinants, personal choices, and local and national policies.
Three important concepts can help the IPM field understand and achieve the potential of this reorientation.
Salutogenesis and Health Promotion
The first concept is salutogenesis,10,11,12 the process of health creation, which stands in contrast to pathogenesis, the mechanisms by which disease occurs. We know a lot about pathogenesis, with medical science having identified more than 8,000 specific disease-causing factors. It is time we focus comparable scientific and public health attention on the routes to health and wellness, and how to use them as individuals, foundations, organizations, communities, and as a nation and a world. Chronic disease management is not about answering a yes/no question to whether someone has a disease. Disease and health exist as a continuum. One does not go from being in good health to being morbidly obese and diabetic overnight. One moves into increasingly problematic states of ill health day by day, and the world has been doing this at an alarming and costly rate. Yet even chronic disease can often be reversed and treated with these same social and behavioral factors—thus integrating prevention and treatment into a unified model. Figure 1.1 illustrates this reorientation and the integration of salutogenesis and pathogenesis.13
Research reveals that four specific health-promoting actions can prevent, slow, and even reverse many chronic diseases. No matter one’s current stage of life or degree of health/illness, our health potential lies in the access to the following: (1) optimum nutrition and proper substance use; (2) physical exercise and rest; (3) resilience and stress management; and (4) social connectivity and integration. These four factors reflect many of the needs addressed by Abraham Maslow in his 1950s “hierarchy of human needs,” which moves from the physiological, to safety, love, belonging, and esteem, culminating in self-actualization.14 This corresponds also to the full definition of health created by WHO in 1948.15 However, in Maslow’s model the top needs can only be addressed when the prior needs have been met. We now know that humans and communities often attain flourishing through any and all levels with the aspirational component of a personally meaningful life as the core driver, even when some of the other needs are not being met. This calls for a reorganization of the human health model into a systems approach rather than a hierarchy. We illustrate this later in the chapter.
So the first key concept in IPM is the importance of reframing health from a “Salutogenic” perspective and applying that perspective in science, medical care and in public health.
Whole Systems Approaches
The second concept for IPM is using whole person and whole systems in contrast to reductionist thinking. Integrative preventive medicine should embrace the realization that all behavior, mental and physical, is inherently health-related, and that national health is best created when government and public health agencies function holistically and collaboratively, sharing and respecting all perspectives and resources. The National Prevention Strategy calls specifically for the integration of clinical and public health in our efforts at prevention and health promotion, recognizing the inherent interrelationship of individual health and community health and the importance of enhancing synergies between these disciplines. For decades, millions of consumers have integrated various natural therapies into their own healthcare. Consumers want access to the best products and practices of alternative, complementary, conventional, and traditional healthcare systems and modalities, and they want the professionals involved to work collaboratively on behalf of the patients’ well-being—which is the true meaning of patient-centered care.
Whole systems healthcare also requires that wellness and health promotion practices be facilitated in the full context of the individual and group. Significant differences in health promotion and wellness exist from person to person depending on social, cultural, racial, and historical circumstances. The place they are born and the environment in which they live are often the major drivers in their ability to attain health and engage in productive and prosperous behavior. Educational level, living location, and economic opportunities are three of the largest drivers of health, well-being, and longevity. These contexts enable or inhibit the ability to engage in responsible behavior, even when there is an intention and effort to do so. Thus, both individual and community wellness require these factors be addressed when creating health.16
There are systems of medicine that exemplify whole person and whole system thinking. These include Eastern and Western systems, some of ancient origin and others recently developed. These approaches strongly emphasize the importance of good diet, exercise, sleep, harmonious relationships, and methods of managing stress. An Eastern example is Chinese medicine,17 with its accompanying concepts of balance and prevention. Oriental medicine focuses on identifying the root causes of what may seem from a reductionist perspective to be distinct, even unrelated symptoms. It promotes health by promoting balance—balance within the person, and also between the person and family, community and environment, including being in balance with nature and the seasons. Figure 1.2 illustrates these comparisons between our earth and our bodies.
In Western medicine, a relatively recent approach called functional medicine18 looks at the influence of lifestyle and environment on genetic vulnerability in the initiation and progression of chronic disease. While conventional diagnoses are certainly recognized, functional medicine aims to identify the underlying causes of disease states, through focusing on a patient’s core nutritional imbalances, fundamental physiological processes, environmental inputs, and genetic predispositions.
The systems just mentioned—one Eastern and one Western derived—are examples of whole systems thinking in healthcare and each embodies aspects of what we need in 21st-century healthcare and IPM. Honoring patient requests for collaboration by different kinds of healthcare providers so that the patients may benefit from the strengths of each and can elect health approaches that fit their condition, preference, and disposition is in keeping with Sackett et al’s definition of evidence-based medicine as a tripartite approach incorporating “the integration of best research evidence with clinical expertise and patient values.”19
A key to integration at all levels is collaborative team care. Collaboration at a national level will ensure that tax dollars are being used effectively and efficiently, with government agencies working to address the same problem through coordinated programs. Collaboration at the provider level can protect patients from receiving inadequate, inappropriate, or contradictory treatments when healthcare professionals remain ignorant of one another’s role in the patient’s total care. Collaboration at the organizational level would allow for continuous integration of processes while tracking outcomes and making adjustments for optimal care. Collaboration in research integration would mean drawing from multiple methodologies to tap both the brilliance of reductionist science and the wisdom of a whole system and personalized approach, including incorporation of the patients’ perspectives. The work of the Patient-Centered Outcomes Research Institute (PCORI) is bringing greater rigor to whole systems research that includes patient input at all phases of research.20
The second concept, then, is that IPM be supported by whole systems thinking—an essentially ecological view that sees things in their contexts and relationships, not in isolation.
Harnessing Adaptive Responses
The concept of a signal or stress-adaption response is another lesson for consideration as a core scientific concept for IPM. The principle derives from the area of hormesis—a dose-response relationship characterized by low-dose stimulation and a high-dose inhibition. This dose response is typically reported in the published literature by either an inverted U or J-shaped dose response, depending on the type of biological effects that are plotted. Multiple large databases using rigorous a priori entry and evaluative criteria have revealed that hormesis is widely observed in the biological and biomedical literature and is independent of biological model, endpoint measured, inducing agent, level of biological organization, cell type, and mechanism.21,22,23,24,25,26 Thus, hormesis has very high generality, and is a basic biological concept for a healing-oriented science at the subcellular, cellular, organ, and whole person levels.
The hormetic nature of dose and signal-responses have important clinical and public health implications, since they define the biological constraints within which pharmaceutical agents, herbal treatments, lifestyle changes, mind-body practices, and other medical and public health interventions will work. Detailed evaluations of vast preclinical studies of numerous drug categories and natural products reveal that maximal responses are consistent with the quantitative features of the hormetic dose response. This means that the degree to which drugs and natural products (e.g., anxiolytic, antiseizure, memory, pain, immune-enhancing agents, wound-healing treatments) can improve healing and performance is limited by these constraints of plasticity. This is also the case regardless of the potency of the agent. Thus, the hormesis concept not only is important to preventive and therapeutic medicine but also is a determining feature of its clinical efficacy. In fact, the optimal dose selected for a clinical trial is typically the optimal hormetic dose reported in the preclinical study.
This feature of dose response is also central to developmental processes, affecting numerous functions including how systems create biological curvatures, as seen with capillary formation, the rounding of the eye and the head of the femur, and numerous other cases.27 Integrative preventive medicine can use this science to design interventions that precondition (for primary prevention) or postcondition (for secondary prevention). Over the past several decades, the concept of conditioning (both pre and post) for adaptive responses has been revealed to be perhaps the most powerful response to protect biological systems both before and after significant or life-threatening challenges and stresses. That is, a prior conditioning with an agent or stressor within an optimal temporal widow can up-regulate adaptive processes that protect against threats in conditions such as heart attacks, strokes, shock, brain traumatic injury, and other serious conditions. Detailed dose-response assessments of these pre- and post-conditioning studies have revealed that these processes conform to the same quantitative features of the dose response defined by hormesis and are likewise independent of model, endpoint, agent, and mechanism.28,29 The preconditioning concept is particularly significant because it permits biological systems to create the equivalent of a biological “shield” that can protect itself for specific periods of time from a vast array of life-threatening challenges and then to repeat the process again and again. This concept has the potential to profoundly affect public health practices, including laying a solid scientific basis for the proper use of natural products and numerous lifestyle choices in prevention and throughout treatment as well as during follow-up activities. Thus, it may be a key to elucidating the mechanisms of prevention in integrative and conventional medicine.
One limitation of preconditioning is that it may occur early in development and is active well into adult life, which points to the need for careful integration of these practices with the salutogenic approach. For example, in older, and especially elderly men and women, the capacity for conditioning adaptive responses can profoundly degrade.30,31 These types of performance degradations also may occur in younger adults when associated with comorbidities such as diabetes, atherosclerosis, and obesity. The degradation of the capacity to induce conditioning adaptive responses may have profound implications on health quality and longevity. Thus, support of health optimization methods such as with smoking cessation, nutrition, sleep, and physical activity become key to the effectiveness of condition as a preventive and therapeutic approach. Used properly, preconditioning along with salutogenic support could be used to reduce risks of numerous serious conditions such as glaucoma, hearing loss, and bone fractures. Thus, the capacity to optimize physiological processes and build biological shields via the use of dose adaptation represents an important integrative prevention and treatment strategy. Of particular importance is that many preconditioning activities are part of lifestyle choices regardless of income and societal healthcare benefits. As such, these concepts can and should be integrated into health plans and therapeutic strategies.
The third concept, then, is that harnessing adaptive responses for IPM is a powerful vehicle to enhance health and well-being throughout the entire life cycle.
Becoming a Healthy World
Becoming a healthy nation requires a focused effort at all levels, from federal policy to individual daily choices. In the 21st century, when we recognize the central role of human behavior and environments in determining the quality of our health, we need a definition of health that motivates us to take care of ourselves and one another, a vision that recognizes human variation and offers something that is attainable for every individual and community. While the World Health Organization (WHO) definition of health, used since 1948, was a helpful move forward in its time, it does not serve us fully today and has been critiqued by many over the years.32 That definition, which speaks of “a state of complete physical wellbeing,” something unattainable for most, must be replaced with one that speaks to the process of healing and health creation—a process available to us all.
Treatment as Well as Prevention
Current science indicates that treatments previously thought of largely as prevention or disease management can actually reverse disease. For example, Dean Ornish and others have explored the potential of an intensive program of lifestyle management to improve one’s health and reduce or avoid symptoms of heart disease, diabetes, and prostate cancer—the first two being among the most expensive conditions plaguing Americans.33,34 Subjects in the experimental arms of these trials were asked to adhere to a regimen including a whole foods, low fat, plant-based diet; no smoking; moderate exercise; stress management (often either yoga and /or meditation); and support group attendance. In short, a strong integrative program addressing mind and body. Results of these and other studies indicate that disease can actually be reversed and costs can be reduced using these approaches.35 Thus, lifestyle and complementary medicine can be used for treatment of disease, not just for prevention, and so these approaches are a central tenet of IM, yet they are the same practices for IPM.
This growing body of work holds important lessons. First, health promotion efforts sometimes function as prevention and sometimes as disease-reversing treatment. Second, the trajectory of adoption of lifestyle and IPM work illustrates the challenge of translating research findings into primary care and both clinical and community-based public health efforts. Third, these areas demonstrate the importance of investigating complex interventions as whole systems. We recommend support for comparable research on other complex systems like acupuncture and oriental medicine, as well as traditional Chinese and Ayurvedic medicine, naturopathic medicine, and functional medicine—testing the whole system’s approach rather than single elements at a time, which would likely lose important synergies.
The Importance of Social Context and the Environment
We suggest that health is a physical, mental, emotional, social, and spiritual state of well-being that allows an individual to cope with stresses, contribute to the community, and enjoy a happy life. Since we are all born with different capacities, and different circumstances, the needs to attain optimal health vary from one individual to another. The social, cultural, historical, economic, and physical context must all be considered when seeking to enhance health. With such a holistic definition of health we can move more purposely to attain it, and to reclaim it, through prevention, health promotion, and other public health and clinical efforts.36
The Integrative Healthcare Center of the Future
How would these principles be delivered to the public in clinical care? What is the role of the community health center and public health services given this new vision of IPM? What would the clinic deliver? What would an IPM center look like?
Figure 1.3 illustrates the core components of an IPM center of the future.
The primary purpose of this IPM center would be to teach the public about and help deliver to them primary components of salutogenesis. We suggest they are the following:
Stress Management and Resilience. Research has demonstrated the benefits of achieving a mind-body state that is known to counter the stress response and to improve receptivity and motivational factors for lifestyle change. Recent research has shown that mind-body practices can be learned and that they can counter the physical, psychological, and even genetic effects of stress. They can prevent or alleviate post-traumatic stress disorder (PTSD), improve fitness and weight management, and enhance cognition and overall physical function—all of which serve to enhance health and strengthen personal resilience.
Physical Exercise and Sleep. Physical exercise and sleep can reduce stress, improve brain function, slow aging and heart disease, and help establish and maintain optimum weight. Fitness, along with proper rest and sleep, maintains functioning and productivity of the whole person throughout the lifespan and in any stage of health or illness.
Optimum Nutrition and Substance Use. Ideal weight and optimal physiological function occur best in the context of proper nutrition and reduced exposure to toxic substances—nicotine, alcohol, drugs—that impair function. Food and substance management require systematic motivational structures, environmental controls, food selection training, and family, peer, and community involvement.
Social Cohesion and Service. The social environment is a key to health and to healing, as is service to self and others. Both health and happiness are socially contagious. Social bonding and cohesion is not only health enhancing in its own right but also is essential for sustainable behavioral change in any community, whether it is in a combat brigade, a business worksite, a federal agency, or a local school or community. Health promotion can be effectively achieved in any social context, where common values are shared among peers, friends, family, coworkers, and residents. As continued economic pressures add to social stress and disproportionately affect underserved communities, programs of resilience and behavior change offered by the community can help to alleviate stress-inducing factors that lead to illness and premature death.
The Inner and Outer Environments. These behavioral components of human flourishing are embedded in a healthy physical environment and cultivation of a purposeful life. A healthy environment attends to the physical structures and settings that facilitate healing and minimize the adverse impact on the earth. Attention to architecture, art, and exposure to nature, sound, smell, and light are key elements. Building and operating with “green” principles completes the ecological and sustainable nature of an optimal healing environment.
Integrative Medicine. This foundation of core health-producing factors would be supported by a community of care and treatment practitioners whose work facilitates whole-person healing. These practices—sometimes referred to as holistic or integrative medicine—catalyze and accelerate healing when recovery is stopped or delayed. They also serve as complements to conventional treatment regimens. When effective, these practices can do far more than simply address a disease process or control a single condition, because the whole-person view that guides them can engage multiple levels of healing—mind, body, and spirit.
Conventional Medicine. Elimination of specific diseases with drugs and surgery are a key feature of the new integrative medical home. These interventions are delivered with teams fully coordinated with the lifestyle and CAM practices described above. Vaccines, screening tests, and risk factor modification drawn from evidence-based practices are available in a manner that supports and reinforces the vision of health promotion and IPM embodied in this center.
What might an IPM center of the future actually look like? Figure 1.4a is a rendering of such a “clinic.” Notice that the central part of the clinic is a hands-on educational center where the public comes not only to learn about IPM but also to take home knowledge and skills for implementing health-promotion behaviors in their life. Figure 1.4a shows the first floor and entryway for such a clinic that holds the primary interventions for all chronic illness, as described previously. Figure 1.4b shows specific treatment modalities—whether conventional (e.g., drugs and surgery) or complementary (e.g., acupuncture or chiropractic) or involving natural products (e.g., homeopathy or herbs). Notice that these are second-tier (and second-floor) activities provided only after the core basics of health promotion and self-care are understood and delivered.
All societies flourish by supporting individuals within communities in their pursuit of health and happiness, enabling them to prosper and give back to society. Many nations are declining in key measures of health and wellness. The gap is widening between those who are able to prosper and those that are denied the opportunity. The world continues to spend more of its wealth on healthcare and gets far too little in return. National and global well-being is declining, as evidenced by increasing disparities; decreasing quality of life and life expectancy, educational attainment, and employment readiness; strained military service members, veterans, and their families; rising medical bills and social service costs; and sagging business productivity. The result is a world that is shortchanging its children and undermining the productivity, preparedness, peace, and prosperity of its citizens.
Yet, we have a vast storehouse of knowledge and resources that can produce health, wellness, and prosperity. By widely practicing the core components of IPM, people can be more productive, prosperity can spread equitably, and, simultaneously, the costs of poor health, shorter lives, and national debt can be reduced. Recently, there has been a proliferation of efforts focused on creating community health and well-being, and those efforts have come from a number of sectors. Funders, businesses, community leaders, and governments are starting to take bold steps to change the culture of health and move from healthcare to health creation. They are on the right track and now need all sectors of the economy across all nations to actively engage. These efforts could benefit by enhanced collective dialogue around the emerging field of IPM.
The authors thank Viviane Enslein for assistance in preparation of this chapter.
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