Integrative Health

Pathway to Health Reform and a Healthier Nation

Mary Jo Kreitzer

“Healing is a matter of time, but it is also sometimes a matter of opportunity.”

—Hippocrates

In February 2009, the United States Senate Committee on Health, Education, Labor and Pensions held two hearings on integrative health as the early conversation on health care reform began in Washington. The titles of the hearings reflect the interest at a federal level in what is now commonly called integrative health: Integrative Health: Pathway to Health Reform; and Integrative Health: Pathway to a Healthier Nation (U.S. Senate Committee on Health, Education, Labor and Pensions, 2009). The hearings included evidence on consumer demand for expanded health care options and on clinical outcomes of integrated care.

The same week as these two senate hearings, the Institute of Medicine (IOM) and the Bravewell Collaborative convened a meeting to explore the science and practice of integrative medicine and examine ways that integrative approaches might shift the orientation of our health care system from the current sporadic, reactive, and physician-centric approach to one that fosters an emphasis on health, wellness, early intervention for disease, and patient empowerment (IOM, 2009).

Integrative health or medicine is the phrase increasingly used to describe the combination of conventional and complementary and alternative (CAM) treatments. The field commonly referred to as CAM is large, complex, and diverse. It is estimated to include over 1800 different therapies such as guided imagery, healing touch, and herbal medicine as well as culturally based systems of healing including traditional Chinese medicine, Ayurveda, homeopathy, and naturopathy. Even the title used to describe this continuum of healing approaches is laden with controversy and political considerations.

For many years, the term alternative medicine was used to describe these healing approaches. They were viewed as part of the “counterculture” and often used in lieu of conventional care. The term itself implies an “either-or” mentality. As it became more apparent that these healing approaches were used in conjunction with conventional care, the phrase complementary medicine began to emerge. Although accurate for some consumers, others would argue that complementary approaches for conditions such as pain and stress management are primary, and that the term complementary inaccurately and inappropriately deemphasizes their contribution and importance.

Within the discipline of medicine, the preferred term is integrative medicine. The Consortium of Academic Health Centers for Integrative Medicine (CAHCIM), an organization of 45 medical schools, defines integrative medicine as “the practice of medicine that 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 approaches, health care professionals and disciplines to achieve optimal health and healing” (CAHCIM, 2009). This definition is broad in that it could refer to any type of practitioner and patient and it highlights the importance of relationship-centered and whole-person care. Within the nursing literature, complementary or integrative therapies and healing practices are the terms more commonly used. For many in nursing, the term medicine is associated with the discipline and practice of medicine and therefore is not an acceptable term for a broad range of healing approaches practiced by different types of health care professionals. In this chapter, the terms integrative therapies, complementary therapies, and CAM are used interchangeably, given that CAM is the acronym or phrase most commonly used in national policy documents as well as the National Institutes of Health (NIH).

Consumer demand for complementary therapies has increased dramatically over the past 15 years though remaining fairly stable since 2002. According to data released in 2009 by the National Center for Complementary and Alternative Medicine (NCCAM), approximately 38% of adults in the U.S. aged 18 years and over and nearly 12% of U.S. children aged 17 years and under use some form of CAM (Barnes, Bloom, & Nahin, 2008). The majority of people use CAM as a complement to conventional biomedicine, not as an alternative (Astin, 1998; Eisenberg et al., 1998; Barnes, Powell-Griner, McFann, & Nahin, 2004). Reasons commonly cited for using complementary therapies include compatibility with personal values, desire to be actively involved with decision-making regarding care, dissatisfaction with conventional care or a perception that conventional care cannot adequately address symptoms or health conditions, and a preference for care that is more attentive to the whole person—body, mind, and spirit.

With the growth in the use of complementary therapies, many policy issues have surfaced that include access to care and reimbursement for services, education and credentialing of providers, regulation of practice, funding of research, consumer education, and the creation of integrated care delivery systems.

Use of Complementary Therapies within Nursing

Much of what is called “complementary therapy” has been within the domain of nursing for centuries. In her Notes on Nursing published in 1860, Florence Nightingale described nursing as a holistic and integrated pursuit. She advocated that the role of the nurse was to help the patient attain the best possible condition so that nature could act and self-healing could occur. She wrote about the importance of good hygiene and sanitation, fresh air, light, touch, diet, and spirituality (Dossey, 2000).

Although nursing has a long tradition of caring, healing, and wholeness, concerns have been raised about the visibility of nursing in the contemporary complementary therapies or integrative health movement. The noted absence of nursing leadership within many national initiatives, underrepresentation of nurses among investigators successfully obtaining funding from NIH, inadequate focus on complementary therapies in undergraduate and graduate curricula, reimbursement issues for nurses providing complementary therapies, and significant differences in how boards of nursing are addressing the inclusion of complementary therapies in nurse practice acts led a group of nurse leaders to convene the Gillette Nursing Summit in 2002 (Kreitzer & Disch, 2003). The proceedings described a set of strategies that focused on ways to better align and position nursing relative to the integrative health care movement, thus assuring a more visible presence in decision-making forums that are shaping the future of health care in the U.S.

National Institutes of Health

In response to growing public interest in and use of complementary therapies, U.S. Congress passed in 1991 Public Law 102-170, which provided $2 million to NIH to establish an office and an advisory panel to recommend a research program that would focus on promising unconventional medical practices. In 1993, as part of the NIH Revitalization Act, the Office of Alternative Medicine (OAM) was established within the Office of the Director of NIH. The purpose of the Office was to facilitate the evaluation of alternative medical treatment modalities and to disseminate information to the public via an information clearinghouse. In 1998, Public Law 105-277, the Omnibus Consolidated and Emergency Supplemental Appropriations Act, elevated the status and expanded the mandate of the OAM by authorizing the establishment of NCCAM. NCCAM is one of 27 institutes and centers that compose NIH. The mission of NCCAM is to explore CAM in the context of rigorous science, train CAM researchers, and disseminate authoritative information to the public and health professionals. Funding for NCCAM has increased significantly since its inception, as reflected in the fiscal year (FY) 2009 budget of $125.5 million.

The White House Commission on Cam Policy

Since 2002, there have been two national policy initiatives on CAM: the White House Commission on Complementary and Alternative Medicine Policy (2002) and the Institute of Medicine (IOM) CAM Study Committee (2005). Nurses were appointed to serve as members of both groups, and nurses provided testimony in open hearings that were part of the deliberations of both groups. President William J. Clinton issued an executive order (Executive Order No. 13147) in March 2000 that established the White House Commission on Complementary and Alternative Medicine Policy (WHCCAMP). The primary task of the commission was to provide the Secretary of Health and Human Services (HHS) with legislative and administrative recommendations for “ensuring that public policy maximizes the potential benefits of CAM therapies to consumers” (www.whccamp.hhs.gov/finalreport.html). The 20-member commission focused on the following four areas: