The History and Policy

Wellness is a Journey, Not a Destination The History and Policy of Complementary and Alternative Medicine in the United States Michael Tereo // 18 April 2016 The United States health care policy is in dire need of attention not only from policymakers, but also health care professionals, and the community at large. A conflict between the two major medical traditions, conventional medicine and complementary and alternative medicine (CAM), complicated the relationship between policy makers, professional medical communities, and patients. While the health care system changed rapidly throughout the course of the twentieth century, conventional medicine became the orthodoxy. Underneath the systems complex evolution, economic mechanisms, principally marketing and profitability, blurred the lines between alternative and conventional medicine. 1 The American Medical Association (AMA) was and remains a key proponent of conventional health care and the main employer of these economic mechanisms. As a result, it has gained a strong influence on the public perception, medical journals, medical schools, state medical societies, and the U.S. Congress. While conventional medicine has introduced some break through procedures and remedies, the focus of health care in America has lost sight of promoting what is best for the patient. Over the past thirty years, there has been a growing interest in complementary and alternative medicine practices. Reform needs to refocus the system on nurturing wellness through an approach that seeks to prevent illness and promote a balanced lifestyle. Updated programs and channeled support from the federal government and medical practitioners will be instrumental in improving The history of modern health care in the United States began its convoluted and complex evolution in the late nineteenth century when the development of the “Germ Theory” and accompanying scientific validation, technique, and innovations revolutionized the medical field. 2 Up until this point, health care in the United States did not favor a particular approach to 1 Michael S. Goldstein, The persistence and resurgence of medical pluralism, 940. 2 Norma G. Cuellar, 2007. Conversations in complementary and alternative medicine, 5. 2

medicine and largely consisted of home remedies. This all changed when Louis Pasteur proposed the Germ Theory, which blamed all disease related conditions on foreign agents that were outside of the patient’s control. 3 Focus shifted to treating the symptoms rather than the underlying medical problem. This methodology developed into allopathic or conventional medicine, which focuses on isolating a medical condition and prescribing either one or several allopathic methods, such as drugs, surgery, and other technological approaches. These allopathic methods “have come to dominate conventional health care.” 4 On the other side, practitioners of CAM believe in healing the body from within, and believe it is an interconnected system on a whole. Different practices of alternative medicine strive to nourish and help the body back into balance through support and natural treatments that promote the strengthening of the body as a whole. Common CAM practices include chiropractic, acupuncture, massage therapy, dietary supplements, and homeotherapy. Toward the end of the nineteenth and beginning of the twentieth centuries, scientific advances backed by the Germ Theory, and changes to medical education, helped conventional medicine evolve into the dominant system. 5 As a consolidated field of conventional medicine formed, a business, and eventually a monopoly, emerged from medical professionals who formed guild-type organizations and tactics for complete control over medicine, such as the American Medical Association. 6 Not only did members establish market control early on, but they also devised the rules, regulations, and modern legislative institutions of the state. 7 By treating the medical field like a business, they effectively created scarcity, monopolized supply, and eliminated external competition. With the Germ Theory and other scientific findings, 3 Norma G. Cuellar, 2007. Conversations in complementary and alternative medicine, 5. 4 “White House Commission on Complementary and Alternative Medicine Policy.” WHCCAMP. 5 Norma G. Cuellar, 2007. Conversations in complementary and alternative medicine, 5. 6 Jeffrey Lionel Berlant, Profession and Monopoly, 50. 3 individuals had a set of validated data to back their position along with the right allocations of The underlying platform to success for conventional medicine was the transformation in medical education along with various scientific breakthroughs. The medical community and public in general valued rational scientific data and results, which seemed to be evident in practices such as surgery, vaccinations, and various drugs. As a result, a strong majority believed in the superiority of scientific medicine. 8 The conventional approach to medicine was systematic and procedural, which led to a demand for a formalized, scientific approach that was universal to every patient. Additionally, in 1904, the American Medical Association created the Council on Medical Education (CME) and mandated the reform of medical education as its primary goal. As a result, it devised an ideal medical curriculum that completely favored the conventional In 1892, William Osler published The Principles and Practice of Medicine, a textbook that formalized a curriculum around conventional techniques and eventually evolved into the primary textbook in medical schools. 9 This created a strong relationship between medical schools and the American Medical Association. Within this relationship, the AMA grasped control over licensing boards, which fall under the responsibility of representatives from state medical societies. 10 This armed the AMA with legal power and a large influence over education, which any accredited physician must obtain in order to legally practice. The AMA controlled the curriculum of medical schools and only pushed material that applied to conventional medicine. Another setback for CAM came as a result of the Flexner Report. 11 In 1910, the Carnegie 8 WG Rothstein, American Physicians in the Nineteenth Century: From Sects to Science. 9 “White House Commission on Complementary and Alternative Medicine Policy.” WHCCAMP. 10 Jeffrey Lionel Berlant, Profession and Monopoly, 57. 11 John Abramson, Overdo$ed America, 196.

4 foundation donated large sums of money to the CME in order to conduct a report and develop strict requirements for medical practice under state jurisdiction. This had a direct consequence on alternative medicine, as “schools for many unorthodox healing systems either ceased to exist or became marginalized.” 12 Since alternative medicine does not isolate regions of the body and treats the body as an interconnected system, “The AMA sought to eliminate schools that failed to adopt this rigorous brand of systematized, experiential medical education.” 13 Many medical practices that failed to meet the new standard geared toward conventional methods had to adapt to these scientific standards or shutdown. The AMA confirmed its leading role in the medical field and enacted doctrine that strictly limited health care providers. In addition, the AMA, with a strong reputation among the medical community and public, became the centralized authority of health care. As such, it pushed standards that defined the medical profession and doctrine, such as the Principles of Ethics. 14 With work carefully crafted by the AMA, all medical professionals felt pressured to conform to AMA standards and obtain membership, as those who did not adhere to the streamlined agenda pushed by the AMA were perceived as unqualified physicians. 15 Conventional medicine pushed a dominant role early on and imposed standards that were not inclusive of CAM practices. The conventional system pushed physician superiority and eliminated patient autonomy, as “the physician claims authority to define the patient’s interest and to select the means for achieving them, and the patient is expected to comply.” 16 Most Americans bought into this system, and “a third or more of Americans were patronizing CAM practitioners at that time in the 1920’s.” 17 12 “White House Commission on Complementary and Alternative Medicine Policy.” WHCCAMP. 13 A. H. Beck, “The Flexner Report and the Standardization of American Medical Education.” 14 Jeffrey Lionel Berlant, Profession and Monopoly, 112. 17 Norma G. Cuellar, 2007. Conversations in complementary and alternative medicine, 3. 5 Before examining the impact of licensing on the CAM community, it is important to observe the relationship between the AMA and state medical societies. Policy stands taken by the AMA more often than not came from representatives of medical societies who held positions in the AMA, such as on the Board of Trustees. State medical societies would proceed to adopt the policy stand, revealing the interconnected nature of the two entities. The AMA action of granting state medical societies licensure privileges attested to the most enduring part of the tie it had created. The AMA highly valued this relationship and successfully attempted to use state influence to prevent bureaucratic changes in the federal government, and in the private sector, from diminishing the AMA’s influence. 18

Although licensing for CAM began in the late nineteenth century, it has always been an arduous process for practitioners and a challenge throughout the late twentieth century. Conventional practices united early on and engaged in both economic tactics and legal maneuvers within state legislatures to eliminate competition. 19 Medical societies had a strong influence on state licensing boards and medical doctors placed immense pressure on individual states from passing licensing laws for CAM. 20 However, CAM practitioners resisted and filed law suits against conventional medical associations. It was not until the 1970s that chiropractic and osteopathy received licensing protection in all fifty states. 21 Additionally, medical doctors, in joint efforts with state medical societies and the AMA, censured members who coordinated with CAM practitioners and “successfully opposed the appointment of CAM practitioners to positions in public schools, medical hospitals, medical schools, and the military medical corps.” 22 The AMA continued to push legislation that favored allopathic medicine and hindered 18 Jeffrey Lionel Berlant, Profession and Monopoly, 248. 21 Norma G. Cuellar, 2007. Conversations in complementary and alternative medicine, 5. 6 other practices of medicine. It engaged in actions that served to damage the reputation of CAM practitioners. Since the early nineteenth century, the AMA has strongly vilified alternative practices, labeling them as “cultic” and “dangerous”. Most spokespersons of regular medicine would commonly use the term “quackery”, pushing that alternative medicine lacked research, scientific backing, and any real results. 23 Much of this behavior came to light in the case of Wilk vs. American Medical Association in 1987. 24 Judge Susan Getzendanner found the AMA and others guilty of undermining chiropractic in the case, as she described the conspiracy as a ”systematic, long-term wrongdoing and the long-term intent to destroy a licensed profession.’” 25 The court found the AMA guilty of injuring the reputation of chiropractic, forbidding doctors from referring patients to chiropractors, and forming the Committee on Quackery with the intent to destroy the chiropractic profession. The AMA formed the Committee of Quackery in and empowered it to use overt and covert tactics to slander and eliminate chiropractic. 26 The arrival of external third parties in 1912 posed an additional challenge to CAM practices. With the intent of ensuring its monopoly, the AMA developed relationships with many institutions, such as commercial health insurance plans, Mayo Clinic, Kaiser-Permanente, and the Blue Cross and Blue Shield Plans. 27 Perhaps the largest growing third party entity was the pharmaceutical companies, as the emergence of sulfa drugs in the 1930s and antibiotics in the 1940s garnered further support for conventional medicine. 28 With scientific validity behind drugs and antibiotics, the public labeled many alternative methods as “unscientific relics of the past.” 29 Drugs offer an easy and quick fix to perceived health problems even though most of them only 23 Charles E.Rosenberg, Our Present Complaint : American Medicine, Then and Now, 124. 24 Wilk v. American Medical Association, 895 F.2d 352 (7th Cir. 1990). 25 “U.S. Judge Finds Medical Group Conspired Against Chiropractors,” The New York Times. 26 Simpson, J. Keith. “The influence of political medicine”. 27 Jeffrey Lionel Berlant, Profession and Monopoly, 107. 28 Norma G. Cuellar, 2007. Conversations in complementary and alternative medicine, 3. 29 “White House Commission on Complementary and Alternative Medicine Policy.” WHCCAMP. 7 provide temporary relief to symptoms. Drugs are man-made substances composed of an unnatural, synthetic chemical that makes them patentable. Once again, economic mechanisms employed by allopathic medicine became a driving force behind health care. Behind these massive corporations are strategic and expensive advertising campaigns that heavily outweigh any advertising pushed by CAM. Big pharmaceutical companies spend a lot of money each year pushing the scientific validity of mainstream medicine through commercials, medical publications, and the general media.

Three important trends fully emerged around 1970 that were instrumental in gaining support for CAM. The first was the rise of chronic and degenerative illnesses that came as a result of conventional medicine. The average lifespan increased during the twentieth century. Allopathic medicine had to address the accompanying chronic illnesses, such as back pain and arthritis, but could not adequately solve these issues through conventional approaches despite its efforts. This growing issue consequently led to the second trend of rising healthcare costs. Between 1965 and 1975, national health care expenditures more than tripled, rising from just over $41 billion to nearly $130 billion. 30 These two trends culminated in a growing skepticism and frustration with conventional practices, as patients were paying more than ever before without seeing the promised results. For example, patients with lower back pain, one of the chronic issues that emerged during this time period, did not have effective results using conventional treatments, especially in the long run, despite the push from mainstream medicine. 31 Some medical doctors realized the limited scope of what drugs could accomplish and began to accept CAM as a medical field. As a result, some of these medical doctors incorporated holistic practices on their own or referred patients to a CAM practice. More than anything, the actual 30 “White House Commission on Complementary and Alternative Medicine Policy.” WHCCAMP. 8 driving force of this transition was the patient. However, due to the divided line between the two medical fields, communication between the two and with the patient has ceased to exist. Toward the end of the twentieth century, the reemergence of CAM set the stage for needed policy action and changes to the health care community. Before CAM can gain any sort of major traction, the creation of policy and other organization needs to address certain obstacles. First, there needs to be a thorough resource that provides information on the capabilities of all CAM practices with sound research data. Second, there needs to be full cooperation from external parties, particularly the full reimbursement for CAM practices. Third, there needs to be attempts to merge the education and communication gap between conventional and CAM practitioners with the underlying intention of providing the best possible care to patients. Opponents of CAM have always claimed that its practices are unscientific and lack the support of clinical trials. However, this is not necessarily the case and should not be used as a reason to completely squander a practice that may offer potential healing and wellness benefits. From early on, a negative connotation has been associated with CAM by the medical community and the public. This has caused many patients to not inform their primary physician of their desire or current usage of CAM practices. For example, one survey found that around 55 to 85 percent of those who used CAM therapies did not inform their physicians because “they assumed the physicians would not be interested, would respond negatively, would not understand, or would dominate the conversation due to assumed disinterest.” 32 In another survey conveying the physician’s perspective, 57 percent of doctors were unaware that their patients were using CAM services. 33 All parties, particularly medical doctors, need to become more knowledgeable and 32 “White House Commission on Complementary and Alternative Medicine Policy.” WHCCAMP.

9 accepting of the benefits that CAM can offer. The past thirty years has witnessed a rise in support and cooperation from external agencies and the federal government. Several organizations began to form, such as the American Holistic Medical, and Nurses Associations. Many CAM oriented conferences, clinics, and centers also emerged as a result. 34 However, a majority of Americans do not have coverage for CAM services. In the early twenty first century, solutions to this problem were in movement, as there was a growing interest to cover CAM services among insurance and managed care industries. 35 Despite the conventional domination in medical schools, there has also been a recent merger of the two fields in the educational setting. Moving into the twenty first century, more than two-thirds of mainstream medical schools currently offer courses and material on CAM practices. 36 Scientific findings, medical schools, and external third parties have always had an integral part of setting the attitude and agenda of health care in the U.S., and continue to impact the direction of the medical field today. There has been a call for a national health and wellness initiative to address the nation’s appalling health trajectory through a refined focus on prevention and wellness. Federal expenditures for CAM have been on the rise since the 1990s. In 1991, Congress passed legislation that allocated two million dollars to establish the Office of Alternative Medicine within the National Institutes of Health. 37 Gradual and effective integration between conventional and CAM services should focus on incorporating the best of each. Before constructing policy for integration, there needs to be collaborative efforts on all parts. Collaborative efforts could resemble a referral system, which would establish a network of physicians and CAM 34 “White House Commission on Complementary and Alternative Medicine Policy.” WHCCAMP. 35 Mary Ann Liebert, Interim Progress Report, 710. 36 “White House Commission on Complementary and Alternative Medicine Policy.” WHCCAMP. 37 Susanna Hornig Priest, Encyclopedia of science and technology communication, 34. 10 practitioners for patients to access at their convenience. Within this network, there needs to be a streamlined agenda that promotes wellness, not profits. In order for this to happen, health care reforms need to include better mechanisms for communication between patients and their health care providers. Consumers, health care practitioners, and other members of the public have expressed a desire for a centralized source within the Federal government to get objective and comprehensive information on CAM. 38 Despite what resources are available, information on CAM from the Federal government is inconsistently available and often difficult to locate. One major step that facilitated efforts in the right direction was the White House Commission on Complementary and Alternative Medicine Policy (WHCCAMP), which “was established in March 2000 to address issues related to the access and delivery of CAM, priorities for research, and the need for better education of consumers and healthcare professionals about CAM.” 39 Former U.S. President Bill Clinton established this commission of twenty members through an executive order and sought to formulate policy action around CAM practices. Overall, it highlighted the need for a centralized coordination of federal efforts. The establishment of the commission had a bilateral effect on the rest of the CAM community. The Commissioners have urged for more funding in research on CAM practices that offer the greatest potential for addressing pertinent, ingrained health issues in order to help citizens understand the benefits and the liabilities of various practices. 40 Also, the Commissioners strongly believed in holding all systems of health and healing, both conventional and CAM, to the same standards, which would make the system more accountable and effective. Moving forward, the health care system needs to implement aspects of the Patient Protection and Affordable Care Act (PPACA) to their full advantage, as there are many inherent 38 “White House Commission on Complementary and Alternative Medicine Policy.” WHCCAMP.

11 implications for CAM within the polices. The underlying focus of the PPACA of 2010 is prevention and wellness. Section 4001 established a National Prevention, Health Promotion, and Public Health Council. The purpose of this is “to provide coordination and leadership at the federal level, on prevention, wellness, and health promotion practices through the public health system and through integrative health care.” 41 After the implementation of the PPACA, the Council and Advisory Group had up to one year to develop and set specific goals and objectives for improving health promotion and public health programs. In addition, the Council was required to report to the President by July 1, 2010, and each year after on its progress. Keeping a balanced approach centered on wellness is critical for any success. Section 4002 established a Prevention and Public Health Fund that is supposed to expand and sustain “investment for prevention, wellness, and public health activities.” 42 The PPACA, from the perspective of CAM, has many portions that will place health care in the right direction, as it “seeks to open doors that have previously been closed.” 43 There will be a constant need to adapt and change when it comes to policy making. The medical field must put its differences aside and formulate a flexible plan that puts patients in control with full access to reliable information and services. Additionally, policy needs to adapt to the needs of the patient and related scientific data. For this to be possible, scientific findings on CAM must be transparent and accessible by all parties, as they will provide a reliable, objective basis for policy making. Any individual or entity involved in the healthcare system must return the focus solely to ensuring patient wellness, and corresponding policy must keep the system accountable. Although the inner working of the human body are complex, the process of living healthy is a relatively simple process, and with the right direction from the health care 41 “Patient Protection and Affordable Care Act Prevention and Wellness Provisions.” AUCD, 1. 43 Daniel Redwood, Health reform, prevention and health promotion, 3. 12 community and corresponding policy, the United States can make significant strides in its overall Bibliography 13 Abramson, John. 2005. Overdo$ed America : The Broken Promise of American Medicine. New York: Harper Perennial. Beck, A. H. “The Flexner Report and the Standardization of American Medical Education.” JAMA: The Journal of the American Medical Association 291, no. 17 (2004): 2139-140. Accessed March 28, 2016. doi:10.1001/jama.291.17.2139. Berlant, Jeffrey Lionel. 1975. Profession and Monopoly : A Study of Medicine in the United States and Great Britain. Berkeley: University of California Press. Cuellar, Norma G. 2007. Conversations in complementary and alternative medicine: Insights and perspectives from leading practitioners. The Journal of Alternative and Complementary Medicine 13 (1). Goldstein, Michael S. 2004. The persistence and resurgence of medical pluralism. Journal of Health Politics, Policy and Law 29 (4). Liebert, Mary Ann. “Interim Progress Report: White House Commission on Complementary and Alternative Medicine Policy.” The Journal of Alternative and Complementary Medicine “Patient Protection and Affordable Care Act Prevention and Wellness Provisions.” AUCD. June 03, 2010. Accessed April 08, 2016. http://www.aucd.org/template/page.cfm?id=966. Priest, Susanna Hornig. 2010. Encyclopedia of science and technology communication. Thousand Oaks, Calif: SAGE. Redwood, Daniel. 2010. “Health reform, prevention and health promotion: Milestone moment on a long journey.” Journal of Alternative and Complementary Medicine (New York, N.Y.). Rosenberg, Charles E. 2007. Our Present Complaint : American Medicine, Then and Now. Baltimore: Johns Hopkins University Press. http://catdir.loc.gov/catdir/toc/ecip0715/2007013960.html. Rothstein, William G., and Stanton A. Friedberg, M.D. Rare Book Collection of Rush University Medical Center at the University of Chicago. 1972. American Physicians in the Nineteenth Century: From Sects to Science. Baltimore: Johns Hopkins University Press. Simpson, J. Keith. “The influence of political medicine in the development of the chiropractic profession in Australia.” (2002). “U.S. Judge Finds Medical Group Conspired Against Chiropractors.” The New York Times. August 28, 1987. Accessed March 28, 2016. http://www.nytimes.com/1987/08/29/us/us judge-finds- medical-group- conspired-against- chiropractors.html. “White House Commission on Complementary and Alternative Medicine Policy.” WHCCAMP. Accessed April 2, 2016. http://whccamp.hhs.gov/. 14