| The 1950Ís the American Cancer
Society had a Committee on Quackery. Later that turned into
a committee on "unproven methods of cancer management," superseded
by one on "questionable methods." The names indicate a gradual
acceptance of the unconventional; today the cancer society has
a Committee on Complementary and Alternative Medicine (CAM).
The evolving vocabulary also reflects a sea change underway
throughout medicine. in the last few years, the term "alternative,"
suggesting something done instead of conventional medicine,
has been giving way to "complementary," a therapy done along
with mainstream treatment. ‹, Both words may ultimately be replaced
by "integrative medicine"-the use of techniques like acupuncture,
massage, herbal treatments, and meditation in regular medical
practice.
Such therapies, which mainstream
doctors once considered useless, puzzling, or even dangerous,
are now welcome into the labs, classrooms, and clinics of
academic medical center including those of Harvard Medical
School (HMS). "Medical care is both a science and a connection
between patient and healer," HMS dean Joseph B. Martin has
declared. As in the past, some treatments that are now `alternative'
will become standard treatments."
Martin made that remark at
an October reception celebrating a $1o-million grant from
the Bernard Osher Foundation for the medical school's new
Division for Research and Education in Complementary and Integrative
Medical Therapies, launched in the spring of 2000. (Philanthropist
Osher, a Maine resident who relocated to San Francisco, cofounded
Golden West Financial. He also owned the Butterfield &
Butterfield auction house, which he sold to eBay in 1999.)
Augmented by $2 million from HMS, the foundations gift to
Harvard endows several positions and programs, including an
Osher professorship in complementary and integrative medical
therapies.
That chair's first occupant, David M. Eisenberg'76,
M.D. '8o, is an impeccably credentialed academic doctor who
directs the division and has emerged as a leading figure in
this new field poised at the confluence of several healing
traditions. "Any new therapy is temporarily an `alternative'
therapy," he says. "In the past, the environment didnt allow
for the application of skeptical science to these unconventional
treatments. But that environment now exists."
It exists because of a grassroots,
bottom-up revolution in the nation's patterns of healthcare.
"Integrative medicine's time has come," declared Bernard Osher
at the reception. "It is here because of patient demand, and
it has come about only because of patient demand." In a landmark
1993 New England Journal of Medicine article, Eisenberg and
several colleagues documented the vast extent of that demand,
describing what is virtually a parallel industry to standard
medicine. The article reported a 199o national survey ("a
way to biopsy what is happening in the marketplace," Eisenberg
says) showing that 34 percent of American adults had used
at least one unconventional therapy in the previous year,
and estimated that Americans made 425 million visits to providers
of such therapies-exceeding the number to primary care physicians
(388 million). This, despite the fact that 75 percent of CAM
therapy expenditures were paid out of pocket-for a total annual
out-of-pocket expense approximating the comparable figure
for all hospitalizations in the United States.
The report, which described
a phenomenon underway for at least half a century, made a
splash. ("That article is cited everywhere," Martin says.)
And the trend has only strengthened since 1990; by 1997, visits
to CAM providers had increased 47 percent, to 625 million.
Today, half of all adults use CAM treatments, creating a $3o-billion
growth industry. Health insurers, HMOs, and For tune 500 companies
are now endorsing some alternative treatments as part of health
benefits. In 1992, the National Institutes of Health (NIH)
created an office of Alternative Medicine with a $2-million
budget; in 1998 the office became the National Center for
Complementary and Alternative Medicine, and today its research
budget has increased fifty-fold, to $10o million. Furthermore,
with 7o percent of their generation routinely using CAM therapies,
today's medical students increasingly demand education in
this area.
The 1990 survey also identified
a factor of special import for practicing physicians. Of patients
who used unconventional therapies for serious medical conditions,
83 percent also sought treatment from a medical doctor-but
72 percent of that group did not inform their doctors about
their CAM treatments. "It's not that they think their doctor
will disapprove or discourage these therapies," Eisenberg
says. "The perception is that the physician won't t know enough
about these treatments to incorporate them into the patient's
care." However, CAM treatments can interact with conventional
therapies, perhaps in unexpected ways, so overall patient
care may suffer when physicians are unaware of the full range
of treatments in play.
Hence the need to bring CAM
into the mainstream of medical education and research-a task
that amounts to a fair summary of Eisenberg's life mission.
"David is a pioneer," says Jon KabatZinn, professor of medicine
emeritus at the University of Massachusetts Medical School
and author of Full Catastrophe Living, a best-selling book
on stress management. "There are a dozen prestigious medical
centers in the United States moving in this direction, but
when Harvard invests in something, other institutions look
up and take notice." Perhaps partly due to Harvard's influential
status, the NIH recently awarded the new HMS division a $2-million
grant to build the first clinical model of integrative care
within an academic teaching hospital-a model that could eventually
be replicated throughout the United States. The first clinical
trial in the proposed integrative-care center will involve
lower back pain, the leading complaint for which people seek
CAM treatment. The volunteer subjects will be nurses from
Harvard teaching hospitals who have thrown out their lower
backs while lifting patients and have been out of work four
weeks; they will be invited to be randomly assigned to conventional
or integrative treatment to compare the modalities.
A survey of the 5,ooo-member Medical
School faculty drew 436 responses expressing a variety of
interests in CAM research and education-"an extremely high
return for a mailing to faculty," says Walter Distinguished
Professor of medicine and medical education Daniel D. Federman
'49, M.D. '53, formerly dean for medical education. Yet Federman
adds, Among people whose lives are based on rigorous scientific
evidence, there is plenty of suspicion of such treatments.
I have friends who think it's all nonsense, all placebo effects;
I could name 10 doctors who are household names who would
tell you that this is not the way to go-an inappropriate area
for a medical school's involvement." Federman uses a literary
metaphor to indicate the scorn that parts of the medical establishment
have for such treatments: "Coleridge said that poetry deserves
the willing suspension of disbelief. So does complementary
medicine. But we can't even get unwilling suspension of disbelief!"
A combination of personal losses
and world events propelled Eisenberg along his unique career
path, which was in place by the time he was 25. The grandson
of Jewish immigrants who escaped persecution in Poland and
Russia, Eisenberg grew up on Long Island. His father, a baker,
and mother, a lawyer, had four children. When Eisenberg was
10 both his grandmothers died of illnesses within a week of
each other; then, only six weeks later, his father died of
a heart attack at age 39. Within two years he lost his remaining
grandfather. The deaths of his father and three grandparents
within two years "molded my personality and subsequent choice
of profession," he says. One grandmother, he later learned,
had perished from a misdiagnosed bacterial infection. The
other one died of multiple medical problems, and his father's
death had been sudden and early. The mystery of human health
and disease took on a compelling interest for the teenager.
Eisenberg matriculated at Harvard
in the fall of 1972, barely six months after President Richard
Nixon made his groundbreaking visit to the People's Republic
of China. Then-New York Times columnist James Reston had accompanied
the Nixon delegation to China, only to undergo emergency surgery
for acute appendicitis in Beijing. Reston wrote a front-page
story in the Times-"an obituary to his appendix," as Eisenberg
recalls it-that described how his intense postoperative pain
was relieved by acupuncture, an ancient technique of Chinese
medicine then unknown in the West. "This was an intellectual
shot heard round the world," Eisenberg says. "It resulted
in NIH sending teams of scientists and clinicians to China
to see if acupuncture anesthesia had any validity."
The 17-year-old Harvard freshman
was fascinated. "It was something out of Star Trek-the idea
that acupuncture needles could change pain sensations in a
human being was like magic," Eisenberg recalls. He won approval
for an independent study on acupuncture anesthesia, supervised
by the late Nobel Prize-winning biologist George Wald and
his wife, Ruth Hubbard '45, Ph.D. '5o, now professor of biology
emerita. But Eisenberg could not find a single word in English
on the subject in all the Harvard libraries. He did discover
one gem: The Yellow Emperor's Classic of internal Medicine,
a book written circa 400 B.c. that remains a primary reference
for traditional medicine throughout the Pacific rim. The text
included two quotations (see pages 49 and 100)-one on prevention,
the other on mind-body interactions-whose profundity impressed
Eisenberg. He was already pre-med, so he thought, "I'll just
study Chinese medicine, too. The next logical step was to
study Chinese language, philosophy, and history, with great
teachers like John King Fairbank. I fell in love with Chinese
culture and civilization."
During the summer before his second
year at Harvard Medical School, Eisenberg went to Taipei on
a Paul Dudley White Traveling Fellowship. He studied both
the Chinese language and traditional Chinese healers-herbalists,
acupuncturists, faith healers. He also had a lifechanging
experience. "In China and all East Asian countries, there's
a long history of training children who are blind to go into
the profession of massage," he explains. "Massage therapists
are highly valued and can make a good living. Blind massage
therapists can use their heightened tactile abilities. I was
fascinated by this, and invited the local blind massage therapist
to work on me. He spoke Taiwanese and I spoke Mandarin-we
didn't have one word in common. Yet, after only 90 seconds
of scanning my body with his hands, he understood a lot about
me. And within five minutes he had put me into a state I have
never experienced before or since. It was complete relaxation-every
part of my body felt like Jell-O; yet at the same time, I
was acutely aware of the environment with all my senses, almost
hypervigilant. This is what meditation does, fusing relaxation
with hyperacuity; he did it with a few well-placed fingertips.
In that moment I knew he had something to teach me with his
hands that I was probably not going to be exposed to on my
rounds at Harvard Medical School. That was enough to convince
me I needed to go back to Asia.
"If and when we build an integrative
medicine clinic at a Harvard teaching hospital," Eisenberg
continues, "one idea I carry with me is to work with local
schools for the blind and local massage } therapy institutes
to develop a special curriculum for people who are visually
impaired."
In 1978, Eisenberg returned to China
as the only medical student--and only Chinese speaker--among
15 members of the first HMS delegation to that country. He
needed permission to miss several weeks of classes, but then-admissions
dean Gerald S. Foster, M.D. '51, now associate clinical professor
of medicine, immediately saw the trip's value and passed on
a bit of received wisdom: "DonÍt ever let your schooling get
in the way of your education." President Jimmy Carter normalized
diplomatic relations with Beijing that year, and in 1979,
Eisenberg returned to China as the first American medical-exchange
student to visit since 1949. (In 1993, when television host
Bill Moyers and Eisenberg traveled to China to film the first
episode of the public TV series Healing and the Mind, they
interviewed some of Eisenberg's Chinese teachers for the show)
In 1985, Eisenberg published his book Encounters with Qi,
describing his experiences with traditional Chinese healing
treatments. (Qi, pronounced chee, is a Chinese word meaning
"life energy.")
In China, "Whenever I saw beneficial
effects of unfamiliar treatments, I intuitively asked, `Is
it the therapy, or belief in the therapy? The needle or belief
in the needle?"' Eisenberg recalls. "A central research question
is: to what degree can belief or cultural conditioning increase
or decrease the effect of any therapy-including radiation
or chemotherapy? Can the patient's belief-or the clinicians
belief, or both affect the result? This is testable."
In fact, Eisenberg asserts,
the vast majority of CAM treatments are testable. His mantra
is "open-minded skepticism," the intellectual attitude that
he considers to be Harvard's strength. "In the clinical world,"
he says, "the language is shifting from `Does it work?'-a
black-and-white question-to `What is sufficiently proven by
science to recommend its use?' The field is entering the mainstream
logic of clinical medicine." The new HMS division applies
this open-yet-skeptical approach to its research and education
activities (it does not yet offer clinical treatments), continuing
and extending work that Eisenberg has pursued since 1994,
when he founded the Center for Alternative Medicine Research
and Education at Beth Israel Hospital (now Beth Israel Deaconess
Medical Center), a Harvard teaching hospital.
"I am passionate in my view
that the tools we have are adequate to investigate the overwhelming
majority of alternative and complementary therapies," Eisenberg
says. "And we have new tools that didn't exist 10 years ago."
There are now all sorts of scanning technologies to look at
brain states, reports Jon Kabat-Zinn. "Neuro-imaging tools
can help explore the connection between subjective intrapsychic
states and more objective measures of cognitive functioning,
and so expand our knowledge of the mind-body interface." A
recent Science article on Parkinson's disease, for example,
reported how positron-emission tomography (PET scans) detected
the release of the neurotransmitter dopamine in the brain
in response to placebos. In another area, Eisenberg mentions
"robotic tools for drug discovery that in one day can screen
thousands of herbal extracts and other biological substances
for their effects on biological targets."
There is also a whole new horizon
of basic science unfolding that explores the mechanisms by
which CAM treatments work. "There's no doubt that you can
do certain types of surgery under acupuncture anesthesia,"
says Federman. "But no one knows why. There's work needed
on the brain, on pain pathways in the brain, and how acupuncture
affects perceptions of pain. And there are herbal remedies
crying out for study. The use of many of these herbs goes
back thousands of years, and it seems hard to imagine that
everybody has been duped all this time, or that the placebo
mechanism is the only factor. There are active ingredients
in some herbal medicines, but how do they have their effect?
Cell-biology researchers study herbals in the lab, rather
than in the patient. Drug companies are now trying to detect
their clinically effective components."
Eisenberg is interested in "unbundling"
the placebo phenomenon, the well-established observation that
belief in a treatment enhances its effectiveness. "In every
randomized study there are a handful of subjects who have
an extraordinary response to the placebo. What are the characteristics
of those extraordinary responders? What about their brains,
bodies, or mental sets distinguishes them from others? Are
they high responders across all treatments or only a particular
one?"
Admittedly, there are a few therapies that do not neatly lend
themselves to scientific testing. "Teaching someone to think
in a particular way is difficult to control," Eisenberg says.
"It's also hard to create a sham control for acupuncture or
massage." But innovations are underway. German researchers,
for example, have developed springloaded acupuncture devices
that position the needle inside a guiding tube, and prick
the skin without penetrating it-giving control subjects the
sensation of acupuncture without the actual treatment.
"Today, the basic science community
is fascinated by the mechanisms involved in these treatments--how
do they alter physiology?" says Eisenberg. " "This field
used to have a very high 'anti-tenure titer.' Someone eager
to investigate these phenomena was seen as their advocate--but
advocacy is unscientific. Since NIH began funding the area
and has seen its value and potential, young scientists are
no longer shying away. It's now a politically correct field
for a neuroscientist, or any biomedical investigator. And
that is new--the shift has occurred in the last two or three
years. One of the most pleasurable aspects is that the skeptics
are now interested, if not in the actual research question,
then in how to answer the question. When the challenge of
creating a methodology becomes intellectually stimulating
and fun, that's when a field has staying power."
Indeed complementary therapies
are here to stay, and appear to be on their way to increasing
use in Western medicine. In some ways they holdout great promise.
The Moyers television program showed a Chinese doctor performing
brain surgery on a conscious patient primarily anesthetized
with acupuncture, using less than half the chemical anesthesia
typical in the West. Clinical trials funded y NIH„some now
in Phase III„suggest that gingko extract may e effectie for
AlzheimerÍs disease, that chondroitin sulfate may affect osteoarthritis,
and that saw-palmetteo extract might ameliorate benign prostatic
hypertrophy. An NIH consensus conference agreet that meditation
and other mind-body techniques can help treat pain and insomnia.
At Massachusetts General Hospital, associate professor of
psychiatry Andrew Nierenberg is running a clinical trial exploring
the value of St. John's wort for mild to moderate depression.
Such innovative treatments
will probably enter conventional practice in varied ways.
Best-selling author Andrew Weil '6q, M.D. '68, has launched
a two-year fellowship program in integrative medicine at the
University of Arizona that offers doctors a broad training
in the field. Yet integrative medicine may never become a
board-certified specialty; instead, it may gradually infuse
the whole of medical practice. It might become another standard
tool of the medical arts, and like any medical innovation,
some of its practices could eventually supplant conventional
therapies. Integrative clinics tied to teaching hospitals
may some day become a truly "disruptive technology" by meeting
a vast popular demand for CAM treatments practiced with the
oersight and support of traditional academic medicine. If
this happens, medical institutions that dismiss or ignore
patientsÍ desire for CAM will risk being left behind.
Eisenberg foresees medical
schools "teaching eerybody a modest amount about these treatments.
Then, in every domain, there would be somebody more expert
than his or her peers. In every oncology group, each dermatology
group, and so on, there would be someone who had studied herbs,
massage, or meditation, who could inform colleagues on a given
case."
Federman sees complementary therapies
as something that will be "integrated into patient care by
the people who have the patients-rather than referring them
to the Qi specialist down the street." He cites a bit of medical
history: "The proposition that obstetricians were carrying
puerperal infections from one patient to another was extremely
unpopular until it was seen that the evidence was overwhelming.
If something works, it should be incorporated into medical
care. In the long run, there is no such thing as alternative
medicine."
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