Integrating Chinese Traditional Medicine into a U.S. Public Health ...

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 10, Number 4, 2004, pp. 706–710 © Mary Ann Liebert, Inc.

Integrating Chinese Traditional Medicine into a U.S. Public Health Paradigm JAMES GIORDANO, Ph.D.,1–4 MARY K. GARCIA, Dr.P.H., L.Ac.,4,5 and GEORGE STRICKLAND, Ph.D.3

ABSTRACT Chinese traditional medicine (CTM) is a health care system with an extensive history of practical clinical experience. The foundation of CTM, while relatively simple, is substantively different from much of allopathic medicine. Such differences are difficult to explain using a Western medical vocabulary, and extend beyond linguistic foundations. This proves challenging when trying to identify appropriate teaching and research methods that are sensitive to the CTM paradigm and yet relevant to a public health orientation. Given the increased use of CTM, it becomes important to address possibilities that would ensure successful integration of CTM into a public health framework. We propose a model in which both CTM and biomedical clinical services could be offered to provide diverse, yet truly integrative, therapeutic approaches. Within this model, it is critical to enhance reciprocal educational and research-directed opportunities for both CTM practitioners and allopathic clinicians. Considerable responsibility rests upon academic institutions in becoming proactive in developing and implementing educational curricula and research programs that illustrate more effectively the potential bilateral benefit(s), limitations, and, ultimately, roles that CTM and biomedical approaches may assume within an integrative system of care.

BACKGROUND

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hinese traditional medicine (CTM) is a health care system rooted in more than 2500 years of practical clinical experience. The main disciplines are acupuncture, herbology, food therapy, tuina (manual therapy), t’ai chi (therapeutic exercise) and qigong (energy therapy; see Kaptchuk, 1983, for overview). Throughout this paper, Chinese traditional medicine (CTM) is used to describe the system of healing that embraces the broad sense of physical balance and constitution as a foundation of practice. In contrast, the term Traditional Chinese Medicine (TCM), although widely and popularly used, actually refers to a style of practice originating in the 1950s at the behest of Mao Tse

Tung as an effort to use some (but not all) of the CTM approaches and selectively merge them, with particular emphasis on rejection of energetics and constitutional appreciation. Thus, in the context of integrating Chinese healing systems into public health, CTM represents a more accurate description. The clinical frame of reference maintained by CTM is often difficult to explain using Western medical terminology. Differences between Eastern and Western medicine extend beyond linguistic foundations, however, and the logical sequencing underlying clinical decision making varies considerably between the two systems. In CTM, a symptom or sign can only be understood in terms of how it relates to the integrity of the whole patient, with particular consideration

1Clinical

Research and Integrative Medicine Programs, Moody Health Center, TCC, Pasadena, TX. of Texas, School of Public Health, Houston, TX. 3Department of Health and Kinesiology, Lamar University, Beaumont, TX. 4American College of Acupuncture and Oriental Medicine, Houston, TX. 5University of Texas, M.D. Anderson Cancer Center, Houston, TX. 2University

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INTEGRATING CHINESE TRADITIONAL MEDICINE for environmental interactions (e.g., external/internal, hot/ cold, excess/deficient, mind/body). Diagnoses are based upon manifestations of root cause(s) (versus sequelae of illness as in allopathic medicine), and the treatment strategy is developed with consideration for individual patient characteristics. Although CTM may seem confusing when attempting to define it within a Western framework, CTM constructs are not less logical but rather represent a different analytic approach. This frequently proves challenging when trying to identify appropriate research strategies and methodologies that are effective within the CTM paradigm, yet can effectively elucidate mechanisms and/or demonstrate empiric outcomes that resonate with a biomedical orientation (and may be reciprocally beneficial). Care must be taken not to proverbially compare “apples to oranges.” Another of the primary distinctions between CTM and allopathic medicine is that the former has been relatively more qualitative while biomedicine has been only recently more relatively quantitative. Allopathic medicine maintains a substantive archive of data to support specific treatments and/or programs. Despite a longitudinal record of anecdotal data, however, CTM treatment modalities have historically been considered empirically deficient by many Occidental critics, not because of any inherent failure of benefit to patients, but because past study designs were weak and frequently did not include randomized control groups (RCGs). This is particularly important since: (1) CTM is often a slow and gentle medicine and time itself can be a confounding factor when assessing patient outcome(s); and (2) the use of an RCG may not necessarily be applicable in all research designs relevant to CTM outcomes. Yet, it is interesting to note that evidence for many therapies, such as acupuncture and some herbal medicines, however, is as strong as (or stronger than, in some cases) the documented support for many surgical procedures (Gray et al., 2002). The fact that CTM has been used as a primary source of health care by millions of people for generations should speak for itself as a basis of pragmatic validity. However, if CTM is to be used within, and be reciprocally complementary with, a public health model of health care and not simply coopted, specific domains of relevance and application must be quantitatively demonstrated. Still, such quantitative demonstration, while derived from studies that maintain methodologic rigor, might involve new approaches, perspectives, or both, as components of epistemologic change (see below). Public health, by its nature, is integrative. It is those medical activities that utilize any/all available resources to promote and ensure that individuals and communities can be healthy. Health promotion, primary care, and restoration of wellness are the cornerstones of this model, and the focus of these activities must be resonant with the goals and aims of the community (i.e., a patient-centered approach). Thus, in many ways, CTM has been practiced

with an orientation that is consistent with the accepted public health paradigm. As with many forms of complementary and alternative medicine (CAM), CTM may be viewed as an “alternative,” stand-alone approach that is completely separate from the allopathic medical orientation in its practical implementation of patient care. While this is certainly possible—and, according to Cassidy (2001), may reflect the majority of CTM’s current pattern of use in the United States to date— it may not be the most beneficial or effective use of CTM resources. Ideally, it would be best to integrate CTM practices for which efficacy can be demonstrated into a biomedical paradigm so as to use those techniques that are “alternative” yet bilaterally “complementary” with the biomedical approach to public health. Offering well-regulated, reciprocal resources (i.e., a bicameral exchange of empirically effective techniques from both allopathic and CTM practices) affords quality care to a demographically broader and more diverse patient population.

INTEGRATING CTM/CAM INTO U.S. PUBLIC HEALTH PROGRAMS In 1997, Culliton (cited in Cassidy, 1998) estimated that more than 1 million patients yearly were treated by certified CTM practitioners. In general, any healing practice should be expected to “fit” into the political and socially endorsed model of health care that is predominant in the society in which it is to be utilized (Simpson, 2001). This is not to say that the practice should abandon or diffuse its fundamental orientation. Quite to the contrary, the ideal nature of true integration is when a particular healing approach or system retains its philosophical foundations of health and practical therapeutic skills that are then ultimately supported by scientific principle(s). Sometimes, however, the scientific knowledge bases and/or orientations have not progressed to a point that may allow adequate investigation, evaluation, or validation of such practices (e.g., the “evolution” of biomedical investigation and substantiation of outcomes/mechanisms of acupuncture). Thus, it may be that an epistemological shift is needed to study more fully the basis of certain forms of healing that are not well- or easily defined within the present scope of examination. Figure 1 depicts a scheme in which CTM might be integrated within a mainstream public health resource infrastructure that emphasizes scientific evidence while retaining the values and belief system of CTM. It is important to note that such “scientific evidence” may require novel “ways of looking” and, while based upon the rigors of scientific method, would be free to develop new paradigms commensurate with technical (and/or philosophical) advances. We posit that, within this model, clinical services could be offered to a variety of distributional resources (e.g., hospitals, clinics, community programs) in order to maintain

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FIG. 1. Integrating Chinese traditional medicine (CTM) into a public health paradigm emphasizing scientific evidence united with the values and belief systems of patients seeking services.

and improve health and wellness of the population served. The broader and more integrative each component becomes (including the scientific base and value/belief systems of the patients served), the more far reaching and capable the paradigm in providing enhanced health services to an increasingly diverse group of patients. While this may be conceptually attractive, in order to integrate CTM or other CAM practices into public health programs, it is important to understand that such programs are primarily funded by government subsidies and administered by a multitiered bureaucracy. Thus, any action undertaken in a public health program tends to be reactive, conservative, and well-documented. Currently many, if not most, academic programs in CTM are offered through privately owned and operated colleges and schools that lack sufficient faculty and resources to provide the level of research training to develop students as potential clinical scholars who could conduct and/or lead studies addressing pertinent areas of CTM productively. Figure 2 illustrates how CTM might be integrated into a broad program of public health through enhancement of education and research involving both CTM practitioners and biomedical clinicians. To implement such a model most effectively, there is need for each of the entities involved to clearly establish defined roles and work in a coordinated effort toward the goal of integration (Giordano et al., 2002). The primary step must be taken by academic institutions to maintain faculty that are productive in research and foster an environment that is conducive to enfranchising students in re-

GIORDANO ET AL. search efforts that are supportive of medical integration (Flanagan and Giordano, 2002; Giordano et al., 2003). This would provide a resource to generate clinicians that are both well-versed in scientific method and oriented toward safe, outcomes-based care. At present, training programs in CTM in the United States have standardized clinically based curricula and are formally accredited by the Accreditation Commission for Acupuncture and Oriental Medicine, and most states now require successful completion of the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM, 2002) board examination as a prerequisite for licensure to practice CTM (Korngold and Faass, 2001). The NCCAOM, a non-profit organization, was established in 1982 to promote nationally recognized standards of competence and safety. The primary mission of NCCAOM is to protect the public by examining and certifying competence in the practice of acupuncture, Chinese herbology, and Asian bodywork (tuina) through national board examinations. But is this enough? While this might provide an acceptable level of competence for entry-level clinical practice, it does little to promote the diversity of knowledge, skills, and abilities that would facilitate mainstream integration. The World Health Organization (2002) has advocated that the public should seek CTM practitioners who maintain a demonstrable and working knowledge of biomedicine. Cursory sampling has shown that the majority of licensed CTM practitioners who provide services within an integrative medical framework have had significant biomedical education and/or clinical experience prior to either commencing CTM education, completing requirements for licensure, or both. (J. Giordano, unpublished observation). Yet, the tools for promoting CTM’s use within an integrative framework should not solely be the responsibility of the individual student or practitioner. Once again, a considerable onus of obligation falls upon academic institutions (Giordano et al., 2003). The institutional agendas of both CTM and allopathic

FIG. 2. Interface of Chinese traditional medicine (CTM) with public health through research and education of both CTM practitioners and mainstream clinicians.

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INTEGRATING CHINESE TRADITIONAL MEDICINE medical teaching facilities (i.e., schools, teaching hospitals, and clinics) should be considerably more proactive toward advancing integrative health care. This could be achieved by developing and implementing curricula that foster a mutual understanding of the potential benefits, limitations, and, ultimately, roles that CTM and allopathic approaches may each assume within the integrative model. Wetzel et al. (1998) suggested critical educational objectives that should be addressed when approaching integration between allopathy and CAM-based medical models. In this light, the ability to recognize fundamental strengths, weaknesses, applications, and contraindications is critical but remains wholly reliant upon students’ capacity for communication, critical analyses, and use of evidence-based strategies for care. If true integration is to occur, it is equally important for biomedical and CTM clinicians to learn how to use each others’ practices pragmatically and to develop knowledge-based skills in integrative referral. However, even given the notable rise in CAM-based didactic courses, there remains a distinct paucity of direct training opportunities in CTM for students in biomedicine (Marshall, 2000). Similarly, there is a lack of opportunity for CTM (and other CAM) students to train in biomedical clinics. This may be due, in part, to a perceived lack of opportunity and/or cooperation between CTM schools and schools of public health but may also reflect the lack of subsidizing that would support such alliances. This speaks strongly to the fact that such educational and clinical cooperative projects must receive the support necessary to both fulfill their practical missions and expand programs to meet increasing demands. It is the role of the institution to create environments that not only encourage such programs but are also attractive to extramural subsidizing (Flanagan and Giordano, 2002). If CTM is to be effectively integrated into a public health model and, if education is fundamental to such integration, then both CTM and biomedical educational institutions must take steps to promote the development and implementation of academic and research programs that consistently support progress in this direction. A number of problems may be inherent to this process, including: (1) a lack of viable faculty to conduct research both in CTM schools and CAM programs in mainstream medical academia; (2) insufficient student interest or ability to conjoin faculty in research; and (3) lack of collaborative efforts between CTM and mainstream medical schools.

CONCLUSIONS As public demand for CAM and/or CTM therapies continues to grow, the need for competent professionals, both clinically skilled and trained in research-based practice, grows with it. Before a critical mass of qualified practi-

tioners providing evidence-based care can be established, however, a viable faculty to train them must be made available. Methods for recruiting good students into faculty positions used by other public health specialties could be applied to CAM. For example, stipend programs for doctoral and postdoctoral training could create incentives for qualified applicants to develop the knowledge base necessary for faculty practice (i.e., research, teaching, and clinical care). Until this happens, studies designed and conducted by researchers who do not understand CTM/CAM therapies or by CAM practitioners who do not understand research will continue to be weak, and the empiric data needed to differentiate “what works from what doesn’t” will continue to be lacking. When a core of well-trained specialists addresses these questions, the utility of CTM (and other CAM interventions) will be elucidated better. This will foster a more functional medical integration and the public health needs of our diverse population will be met more adequately.

REFERENCES Cassidy CM. Chinese users in the United States: Part I. J Altern Complement Med 1998;4:17–27. Cassidy CM. Chinese medicine in the United States: Utilization and satisfaction. In: Faass N, ed. Integrating Complementary Medicine into Health Systems. Gaithersburg, MD: Aspen Publishers, 2001:511–518. Faass N. The discipline of acupuncture: Utilization data. Acceptance of acupuncture in the United States. In: Faass N, ed. Integrating Complementary Medicine into Health Systems. Gaithersburg, MD: Aspen Publishers, 2001:498–499. Flanagan J, Giordano J. The role of the institution in developing the next generation chiropractor: Clinician and researcher. J Manipu Physiol Ther 2002;25:193–196. Giordano J, Boatwright D, Stapleton S, Huff L. Blending the boundaries: Steps toward an integration of complementary and alternative medicine into mainstream practice. J Altern Complement Med 2002;8:897–906. Giordano J, Garcia MK, Boatwright D, Klein K. Complementary and alternative medicine in mainstream public health: A role for research in fostering integration. J Altern Complement Med 2003;9:3:441–445. Gray CM, Tan AW, Pronk NP, O’Connor PJ. Complementary and alternative medicine use among health plan members: A crosssectional survey. Eff Clin Pract 2002;5:17–22. Kaptchuk TJ. The web that has no weaver: Understanding Chinese medicine. Chicago: Congdon & Weed, 1983. Korngold E, Faass N. Overview of clinical acupuncture. In: Faass N, ed. Integrating Complementary Medicine into Health Systems. Gaithersburg, MD, Aspen Publishers, 2001:500–510. Marshall E. Bastions of tradition adapt to alternative medicine. Science 2000;288:1571–1573. National Certification Commission for Acupuncture and Oriental Medicine. Online document at: www.nccaom.org 2002. Accessed July 15, 2003.

710 Simpson CA. Pursuing integration: A model of integrated delivery of complementary and alternative medicine. In: Faass N, ed. Integrating Complementary Medicine into Health Systems. Gaithersburg, MD, Aspen Publishers, 2001:105–114. Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving complementary and alternative medicine at U.S. medical schools. JAMA 1998;280:784–787. World Health Organization. WHO Traditional Medicine Strategy 2002–2005. Geneva: World Health Organization, 2002.

GIORDANO ET AL. Address reprint requests to: James Giordano, Ph.D. Clinical Research and Integrative Medicine Programs Moody Health Center, TCC 5912 Spencer Highway Pasadena, TX 77505 E-mail: [email protected]