When members of Congress established what is now the NIH National Center for Complementary and Integrative Health, they cared about whole things. Eight times in two pages, the new Center was charged to examine not just basic research or reductive trials on individual modalities. They pointedly sought to turn the NIH’s attention to the value of complementary and alternative “systems and disciplines … in health care delivery systems in the United States.” This shift of focus was resisted. The first director Stephen Straus, MD famously shouted down his former NCCIH advisory council member Carlo Calabrese, ND, MPH when Calabrese courageously asked for research whole disciplines and whole practices like those of licensed naturopathic and traditional Chinese medicine practitioners. All integrative disciplines urged Straus’ successor Josie Briggs, MD to focus her 2011-2015 strategic plan on “researching the way we practice”. Briggs showed interest but showed no one the money to engage these questions. So when the NCCIH’s current director Helene Langevin, MD opened the NCCIH 2021-2025 strategic planning process with a February 18, 2020 video-cast webinar by focusing on “whole person health,” there was, among many, a great deal of anticipation and pent-up-demand. What might this mean?
For Langevin, a rare combination of basic science researcher and medical acupuncturist, the webinar was not an isolated engagement. At the June 2019 conference of the Society for Acupuncture Research – on the board of which she formerly served – Langevin’s introduced her intrigue with the topic in an after dinner presentation. I captured it this way:
Langevin spoke to her increasing comfort with the NIH’s framing of “mind-and-body” practices as a core priority. Acupuncture is among those that work with both mind and body at once. This is a characteristic of what she called “whole systems” – [noting] global traditional medicine practices, naturopathy, yoga therapy, Ayurveda and others. “We need to address the whole – not have it cut up into pieces. How do we understanding the whole body as a whole?” The initiative is yet young . She offered that she anticipated that at NCCIH “we will try to design some RFAs [requests for applications] to guide people to some questions on whole systems that are answerable. When we work on the next strategic plan, this is one thing we will be asking about.”
Langevin is fulfilling on the promise. Anyone who doubts should note that she also titled her planned keynote at the most significant global meeting on research in complementary and integrative health, the April 25-27, 2020 International Congress on Integrative Medicine and Health, as “Whole Person Health: Mapping a Strategic Vision for NCCIH.”
Langevin opened the webinar by invoking the NCCIH’s definition of “integrative health”. She noted that it had in common with other such definitions the central reference to the “whole person”:
“[Integrative health] emphasizes a patient-focused approach to health care and wellness – often including mental, emotional, functional, spiritual, social and community aspects – treating the whole person rather than, for instance, one organ system.”
In alignment, Langevin added that the NCCIH office uses this definition of “whole person health”:
Whole person health considers the whole person and the relationships among numerous factors, including biologic, environmental, behavioral, mental, and social factors, in determining health.
For those involved with fields like functional and integrative medicine, and the naturopathy and TCM that Calabrese urged Strauss to examine 15 years ago, these are heart, soul and mind of what the new paradigm for a health-focused clinical practice and related research should consider.
Analysis, synthesis … and a Biblical separation of the firmament
Langevin went on to distinguish the focus on the whole – on what she called “integration and synthesis” – with medicine’s steadfast love of analysis and of breaking things into “more and more refined levels, starting with organs, then cells, signaling pathways, molecules, and even genes.” She noted how this dissembling leads toward biochemistry which in turns drives clinical solutions toward pharmacology. From the perspective of the organization of medicine, the love of analysis has led to specialization in medical education and practice: “We compartmentalize when we specialize.”
Langevin pointed out ways that regular medicine today works the opposite way, toward the whole. She referenced family medicine’s biopsychosocial model. She particularly shared recent scientific understanding through genomics of, for instance, the gut-brain access. It was notable that the evidence of conventional medicine’s concern for the whole is notably sparse, if growing. This underscores the scientific courage and pioneering vision Langevin is showing in stepping into a defining this new field of research action. Some might say she is finally claiming the integrative community’s research birthright.
Her description of these separate and distinctive impulses in medicine was reminiscent of action on the heels of the Affordable Care Act’s move from the production-oriented industry toward “value-based medicine.” Institute for Healthcare Improvement co-founder Don Berwick, MD and others began urging the mainstream of medicine to see their job as “health creation.” They first clarified the distinction of “managing disease” and the new course they are recommending toward “salutogensis”. As the former American Hospital Association president Jonathan Perlin, MD, PhD put it, an entity that excels in managing disease may “not even know the recipe” for health creation.
Langevin is carving a parallel distinction for the medicine’s dominant, reductive school of research. In each case, the paradigmatic moment is an almost Biblical separation of the firmament. If one’s culture, colleagues, life-work, and world view is in reductive disease management, then whole new vistas must be pried opened, examined – and new lines of inquiry clarified. New recipes must be developed and tested. Research on integrative health, Langevin asserted, “can play an important role in putting the body back together.”
For long-timers in the field, Langevin’s opening comments were a familiar and reassuring music. She shared how in this “whole” view, disease prevention and health promotion are not separate but are on a continuum. She referenced a WHO definition that spoke of “restoring health” as the role of treatment. She added: “We need to know how to address behavioral dysfunction at an early stage, not just to treat disease but to restore health.” (I personally learned of the idea of “treating disease by restoring health” as a core principle of the naturopathic doctors when I worked with them 35 years ago.) And: “Understanding health requires that we think of the whole person in an integrative way.” All of these ideas, she said, are “linked to the concept of whole person health.”
While these are familiar music to many in the field, Langevin’s comment had a powerful new resonance inside the NIH’s philharmonic hall. She closed the pre-discussion portion of the webinar by sharing, generally, that these whole person health concepts need to be woven into NCCIH’s actions across the whole band of its research responsibility: from basic research to effectiveness, pragmatic trials and dissemination.
Some anticipated whole person health research applications
A panel that followed included Langevin, deputy director David Shurtleff, PhD and director of extramural research Emmeline Edwards, PhD. Their responses to questions – the NCCIH indicated they were very happy with a strong turnout on the webinar – provided a mosaic of understandings about how researching the whole is shaping up inside the NCCIH. A few examples:
The elephant in the room: existing, licensed whole person practices
A remarkable feature of the webinar was how little mentioned were any of the existing, licensed professions that presently provide whole person, integrative health to hundreds of thousands of patients every day. Don’t these warrant highlighting in this context? “Acupuncture” was mentioned – but the whole system of traditional Chinese medicine with tuina, herbs, cupping, lifestyle consultation and needles? It wasn’t.
Nor was there direct mention in Langevin’s presentation or by panel of the whole, of the philosophically “whole person health” practitioners of functional medicine, traditional East Asian medicine, naturopathic medicine, or even the practice of the sometimes board certified “integrative medical doctor.” These are the professionals who are presently best educated and equipped to bring “whole person health” into healthcare delivery systems in the United States.
The allusions to “multi-modal care” are a frustratingly meager reference to this important and long-delayed NCCIH work. Onme wishes the NCCIH team had directly spoken to the complex practices of the “systems and disciplines” that Strauss and Briggs largely disregarded and yet were front-of-mind for US Senators Tom Harkin and Barbara Mikulski and others when they established what is now the NCCIH? Why weren’t research directions like these openly on the table:
Some involved in these integrative, whole person health-oriented fields – and I count myself among these – have been waiting on this theme at the NCCIH for two decades. Many have not only waited. Some have previously registered this priority with the NCCIH – see here and here in the Integrator from public comments on a prior strategic plan. Others at the Academic Collaborative for Integrative Health (“the Collaborative”) directly petitioned and met with NIH teams to seek to move the dial toward exploring not their therapies but their whole systems. (See ACCAHC-NCCAM [ACIH-NCCIH] Correspondence 2009-2011.) An ACIH team of researchers from chiropractic, acupuncture and Oriental medicine, naturopathic medicine, and massage therapy led by Martha Menard, PhD, LMT with which I was involved published in the peer-reviewed press: Consensus Recommendations to NCCIH from Research Faculty in a Transdisciplinary Academic Consortium for Complementary and Integrative Health and Medicine.
In this context, to have the whole person health theme arrive, and yet to hardly be directly mentioned in the room, seemed a peculiar slight. One hopes that this is not residue of an abiding distaste in regular medicine for anyone discovering that another profession’s outcomes or approach – whether nursing or chiropractic or “integrative medicine” – outperforms their own methods. If one doesn’t ask, one cannot not learn. Why, in particular, in an era in which the likes of Berwick and Perlin are calling for a shift to “health creation” – an area in which these fields have long proclaimed their expertise – is NCCIH not showing an explicit enthusiasm for exploring these whole practices?
(Side-note: During the webinar, I attempted to submit a question on this topic three times. The emails bounced back. A colleague who had a similar question relative to traditional medical systems also mentioned having bounce-back problems and not being able to submit. This was an unfortunate technology glitch that limited the dialogue. I wonder how many others had such problems. The NCCIH panel was clearly willing to spend more time and transparently field all queries.)
A view from whole systems research scholar Nadine Ijaz, PhD
I asked University of Toronto scholar and webinar participant Nadine Ijaz, PhD, lead author of the 2019 Whole Systems Research in Health Care: A Systematic Scoping Review – and the other participant noted immediately above – for her perspective on the webinar. She sent this note via e-mail.
I was pleased to hear Dr. Langevin acknowledge the centrality of complex, multi-modal interventions in traditional, complementary and integrative care. Dr. Langevin also recognized the significant methodological advances (e.g., in pragmatic and whole systems research) that make well-funded investigations of such interventions a viable NCCIH priority moving forward. She made clear her agency’s support for practice-based research, while calling for additional work to develop this field further. These are all encouraging signs that promise to address the distinct paradigmatic features of care in our field; and I look forward to seeing the aforementioned research approaches codified within the NCCIH’s next strategic plan. As Dr. Langevin continues the NCCIH consultation process, I am eager to hear more about the agency’s role in supporting important health services / implementation science / mixed methods research, as well as prioritizing care for underserved populations.
The public process for the NCCIH 2021-2025 strategic plan has only just commenced. The NCCIH will produce additional webinars. They will be soliciting comments. When the draft is released in the fall of 2020, interested parties will have an opportunity again to shape the final plan. “This is a really exciting time for us,” said Langevin. “I want to make sure that we have really good communication with the research community.”
This is an exciting time for everyone associated with the integrative health community. The desire for a paradigm shift or transformation from reaction to disease to health focused models has always been crippled by an antagonistic or disinterested research establishment. Now the doors at the NCCIH to input from interested parties in the integrative health community are clearly open. The terrain that Langevin and the NCCIH team are entering, and the questions they are inviting, resound far beyond “complementary and integrative health.” Answered well, this “whole person health” venture can shape optimal research, and thus optimal care, for multiple chronic and acute conditions. It is incumbent on anyone who has complained, or dreamed, to re-fashion such impulses into research-able questions.