NADA Amidst the 50-year Evolution Toward Integrative Health

1. NADA Amidst the 50-year Evolution Toward Integrative Health National Acupuncture Detox Association Austin, Texas – March 22, 2019 John Weeks Publisher-Editor, Integrator Blog News & Reports Editor-in-Chief, JACM – Paradigm, Practice and Policy Advancing Integrative Health (The Journal of Alternative and Complementary Medicine) Columnist: Today’s Practitioner Columnist: Integrative Medicine-A Clinician’s Journal Blogger: Academy of Integrative Health and Medicine www.johnweeks-integrator.com

2. Overview Credits Cliff’s Notes History • 5 Eras for IHM • Dominant school: shadow history • Convergence • Strategies Bill Wulsin, ND, MA, MPH, LAc Ruth Westreich Southern California University of Health Sciences Chief Philanthropic Partners Jeana Kimball, RDHs, ND, LM, MPH Chief Co-Conspirator Some threads – acupuncture, group-delivered services, mindfulness, relationship Disclosure: I have no conflicts of interest. I do have multiple alignments of interest, including as JACM editor-in-chief, and volunteer roles with multiple not-for-profit IHM organizations.

3. Interested in the History? 5 Eras in the History of IHM – Webinar for Duke Leadership Program in Integrative Medicine June 14, 2018 Slides from 2015 J Weeks AIHM talk - “A Winner’s History for IHM” http://functionalforum.com/wp-content/uploads/2015/11/AIHM-J-Weeks-Plenary-102515.pdf Podcast interview on the history with James Maskell/Evolution of Medicine: December 16, 2016 http://goevomed.libsyn.com/webpage/page/7/size/10 The Rise of Integrative Health and Medicine: 120 Milestones 1963-present (Sabin, Walsh, Weeks) https://fonconsulting.com/resources/the-rise/ “History is written by the victors.” Walter Benjamin 1892-1940 George Santayana 1863-1952 “Those who cannot remember the past are condemned to repeat it.”

4. A chosen framing for our history

5. Cliff Notes IHM History: 5 Eras

6. Pre-History: The Way We Weren’t“The Best Medicine in the World” Oops, sort of missed … Authoritarianism/abuse Men’s club Surgeon’s club Primary care failure Interprofessional failure Mono-culturalism/N Europe Mono-racial Reductive perspective Focus on production High costs, poor outcomes

7. Era #1: Origins in Affirming New Waysa.k.a. “Counterculture”-1965-1978 Women’s movement ”take back our bodies” Rachel Carson: A Silent Spring Adele Davis: Eat Right for Your Health Back to the Land: Re-Connecting to Natural Process Opening to the East, Globalism Herbs can be powerful agents We Shall Overcome, some day

8. Disclosure

9. Lincoln Detox 1970-1978 November 10, 1970 “Using surprise as the main tactic, we took over the residents’ auditorium and announced that we had decided to run a drug detoxification program right there. Thus the Lincoln Detox Program was born. Before the astonished eyes of many personnel, we began organizing the space and setting up as casually as someone might change the furniture at home.” Young Lord leader Mickey Melendez Mutulu Shakur Lincoln Detox Acupuncturist; Co-founder, Black Acupuncture Advisory Assn. of North America Michael Smith Lincoln Detox Medical Doctor and Acupuncturist; NADA Founder Thanks to Robert Lederer’s 2014 Master’s Paper: “An Exploratory Study of New York City Community Acupuncture Clinics Serving Low-Income Communities”

10. James Reston: N of (a Very Influential) 1 New York Times Reporter James Reston (1971): For the acupuncture field, a timely appendicitis

11. Era #2: Advancing in Silos 1978-1995 Naturopathic Medicine Resurgence: John Bastyr College of NM (Seattle) Canadian College of NM (ON) Founded 1978 Founded 1981 Founded: 1979 Founded 1978 Founded 1977 Founded: 1982 Beginning of patient-centered care movement: Founded 1979 Founded 1973 Founded: 1983

12. Early Mindfulness/Mind-Body Research • 1977: Herbert Benson, MD - The Relaxation Response • 1977: Kenneth Pelletier, PhD, MD (hc) – Mind as Healer, Mind as Slayer • 1979: Jon Kabat Zinn, PhD – The Stress Reduction Program (MBSR)

13. Medical Exchange with China: Harvard’s David Eisenberg, MD (1979) Under National Academy of Sciences auspices First medical exchange student to the People’s Republic of China (1979) Ted Kaptchuk, OMD Eisenberg’s Harvard collaborator & author: The Web That Has No Weaver

14. Incorporated 1985

15. Action in Silos: Getting One’s House in Order to Create Standing *Only schools accredited via the Commission on Massage Therapy Accreditation. There are over 1300 schools. Source: Clinicians and Educators Desk Reference on the Licensed Complementary and Alternative Healthcare Professions. ACCAHC. Goldblatt, Weeks, Rosenthal et al. 3rd Edition, 2017.

16. 1993 Turning Point for Integrative Health & Medicine:Survey of Consumer Use (Not a Trial or Review)Unconventional Medicine in the United States (1991 survey data)Eisenberg, et al New England Journal of Medicine, January 28, 1993 • 34% of the population had used some “unconventional” treatment • $13.8 billion spent, mainly out-of-pocket • Little communication with conventional providers ____________________________ Impact was transformative: Market interest from hospitals, insurers, media, political figures Individual activists empowered: I am not alone Publication revealed breadth of the popular movement Academic center for research team; David Eisenberg, MD, Lead Author

17. Era #3: “Non-Integrated Integration”1995 – still working on this Delivery: Stand-alone health system-sponsored “integrative medicine clinic” Payment: Insurance coverage for “CAM” but not in the core benefit

18. 2 Big Lessons (Non)

19. Perverse Incentives in Insurance: The 80/20 Rule If you are running the insurance corporation, what does your self-interest favor?

20. Perverse Incentives in Delivery: The Tendencies of a Production Orientation It doesn’t mean that production drives everything … • If a CFO targets X angioplasties, what is a successful year? • What is the attraction of an Ornish program when you have a huge heart center? • 30% of what we do is waste, and much of it harmful (IOM)

21. Challenge of “Perverse Incentives” “It is difficult to get a man to understand something, when his salary depends on his not understanding it.” Upton Sinclair 1876-1968

22. Yet Some Good Signs …

23. Relationship Based Medicine Practitioner-Patient Practitioner-Practitioner Practitioner-Community Fetzer Foundation Pew Center on Health Professions 1994

24. Congressional NCCIH Appropriations - Federal Budget(more CA /IM in other NIH institutes)

25. Founding of SAR – 1992/93 Stephen Birch, LAc Hannah Bradford, LAc Patricia Culliton, LAc

26. First Major “CAM” NIH Grants – with ND and LAc PIs! Bastyr College: AIDS/HIV Leanna Standish, PhD, ND, LAc Hennepin Faculty Assoc: Acu-Pain Patricia Culliton, MA, LAc _________________ How? Former National College of Naturopathic Medicine student was acting director of the NIH OAM: Alan Trachtenberg, MD, MPH

27. First Peer-Reviewed (soon to be indexed) Journals in the Field 1995-1996

28. Huge Federal EBM Steps for Acupuncture 1995: FDA approves needles as devices 1997: NIH Consensus Conference

29. Acupuncture EfficacyA Compendium of Controlled Clinical Trials (August 1996) Sponsor: National Academy of Acupuncture and Oriental Medicine Authors: Stephen Birch, LAc & Richard Hammerschlag, PhD Timing: Just after FDA action

30. An Encounter with Michael Smith: AHA “CAM in Hospitals” Conference, January 2001 “If you want to empower patients, just put more patients than providers in the room.”

31. Era #4: Advancing in Collaboration 2001 - present 2001: now 70+ academic health centers and delivery orgs 2001: now 27 Partners for Health 2004: now Multidisciplinary, 17 national organizations plus 40 schools 2001: Philanthropists: numerous important strategic investments 2009: 6 physician level IHM organizations Two Interprofessional “Big Tents”

32. IHPC Partners for Health

33. “The Consortium” Organizational Growth • From 8 to 72+ Key Publications • Definition of IM • Competencies in IM Major Research Conferences • 2006, 2009, 2012, 2014, 2016, 2018 – with NIH backing Major Philanthropic Partnership • Bravewell Collaborative

34. Relationship-Oriented & Interprofessional Integrative medicine and health reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare professionals and disciplines to achieve optimal health and healing. Definition of Integrative Medicine and Health

35. Cliff Notes: Shadow History of the Dominant School

36. Out of the Shadows: Medical Deaths 1999: IOM’s To Err is Human Est. 100,000 deaths/year due to medical errors 2001: IOM’s Crossing the Quality Chasm BMJ 2016: Est. 251,000 medical deaths a year https://www.bmj.com/content/353/bmj.i2139

37. https://www.huffingtonpost.com/entry/chronicle-of-health-creation-the-shadow-in-berwicks-call-for-a-moral-era-for-medicine_b_9396516.htmlhttps://www.huffingtonpost.com/entry/chronicle-of-health-creation-the-shadow-in-berwicks-call-for-a-moral-era-for-medicine_b_9396516.html

38. Era #5: Convergence - 2011 to present

39. “Value-Based Medicine” Shifting Payment Incentives Patient-Centered Care Quadruple Aim: Value-Based Medicine Interprofessionalism/team care Personalized “Precision” Medicine Focus on Healthy Communities and Health Creation: Whole Systems

40. VBM: Countering Stress, Burnout

41. From “Sick Care” to “Creation of Health” – How-to Questions Jonathan Perlin, MD, PhD Past Chair, AHA Donald Berwick, MD Former CMS Administrator Berwick (2013): “ … the new way, the way to health, may be vastly further from the current design of care than we may at first wish it to be, or believe it to be …The pursuit of health, the creation of health, may require something even bolder [than the Triple Aim]. The redesign we need may be even more radical than we have imagined." AHA’s Perlin (2013): “We have been honed to focus on sick care … It is a tough transition, but we have to learn how to move from sick care to health care. I'm not sure that any of us fully understands or knows the recipe."

42. Growing Values Alignment

43. Integrative Leadership of Health Care - 2018 Private Not for Profit Medicine Government Medicine/VA Berwick: “My mentors in salute-genesis … “ “You are the center of mass for the ignition of the transformation of health care in this country.” Former US Army Surgeon General Eric Schoomaker, MD, PhD, ICIMH, May 9, 2018 https://www.huffingtonpost.com/john-weeks/don-berwick-integrative-m_b_4781105.html Integrative healthv health leaders are mentoring the most significant influencer of reform in US medicine

44. Multimodal Approaches in Integrative Health: Whole Persons, Whole Practices, Whole Systems https://www.liebertpub.com/toc/acm/25/S1

45. Global Alignment, Briefly …

46. WHO-PAHO Traditional Complementary and Integrative Medicine Strategy WHO’s strategy promotes use of traditional medicine “products, practices and practitioners” to help meet goal of universal health care and primary care for all https://www.who.int/traditional-complementary-integrative-medicine/en/ http://mtci.bvsalud.org/en/

47. But … How to Create Convergence in Access?

48. The Integrative/Functional Medicine Cash Practice Problem • Eisenberg: IHM clientele, higher income, higher education, white • Business models: With little insurance inclusion and model misfits, cash based • Concierge integrative/FM practices: Direct targeting of a wealthy clienteles

49. Embracing the IHM Access Issues • From 1980s into 1990s: “CAM” academic institution partnerships with community clinics • 1995: First Government-funded natural medicine center (in an FQHC) • Prompted by staffer for WA State Sen. Kent Pullen (R) staffer Merrilee Manthee • 1997: HHS-sponsored workshop in complementary, alternative and traditional medicine • Year: APHA begins special interest group, now Section on Integrative, Complementary And Traditional Health Practices

50. Since 1990s: Gathering Streams for Group-Delivered Services • Mindfulness Models Ornish, Benson, Jon Kabat-Zinn programs all group based • Stanford/Breast Cancer David Spiegel and support group intervention • HMO/Kaiser: Drop-In Group Medical Appointments (“DIGMAs”) • Patient Centered Medical Home