The Integrator Blog News & Reports annually marks the winter solstice with a Top 10 for Policy and Action in Integrative Health and Medicine. In the selection of the Top 10, “the accent is on the affirmative” as the jazzman sings. Thus the Coming of the Light from individuals and organizations in the field making positive contributions to shift the medical industry toward a system that focuses on creating health. Less positive things sometimes make the list. Integrator articles are now published at johnweeks-integrator.com/posts with content going back to 2006 at the original Integrator site, Prior Top 10 lists, a sort of Cliff Notes of the movement’s history, are linked at the bottom of this column. Below are the Top 10 for 2019. Happy Solstice!

1. Expansion of the Veterans Administration (Integrative) Whole Health Model at the Standard of Care

Those inside the Veteran’s Administration (VA) will quickly point out that the movement to the “future state” of a whole health system is small and not visible everywhere. Yet according to longtime integrative medicine leader Ben Kligler, MD, MPH, acting director of the VA Center for Patient Centered Care and Cultural Transformation, support for the Whole Health model is secure at the top. He shared evidence. Facilities where the model is implemented will more than triple this year, from 18 to 55. Sixty acupuncturists have been hired with more coming on, joining already employed chiropractors. Massage therapy is approved and naturopathic physicians help direct the VA’s whole health in parts of Arizona and Texas. Kligler clarifies that the model is less about the new types of non-pharmacologic practices and practitioners than the philosophy that animates the structure with the veteran and his or her family in the center. Credit Tracy Gaudet, MD who left her founding directorship in August for the great start. Civilian medicine is an intended beneficiary: the VA’s whole health researchers published What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration and Gaudet and Kilgler explored new research questions needed if “whole health” and cultural transformation are the endpoints of care (How Will We Know We have Reached the “Future State”?) All totaled, this is the single most significant influence the integrative movement has had on US health care. It’s noteworthy amidst the national debate in healthcare that the VA’s “whole health” has taken root in the incentive structures of the VA’s single payer model.

2. AIPM to AACIPM: The Death and Re-Birth of a Policy Change Engine toward an Integrative Pain Care Model

February brought bad news of the Huge Loss to US Pain Policy: Academy of Integrative Pain Management (AIPM) Shuts Down. AIPM, under Bob Twillman, PhD’s leadership, had twice convened some 70 leading stakeholders representing some of the biggest private payers and government stakeholders to advance an integrative pain model. What a loss! Little did we know that Twillman’s long-time right hand person, Amy Goldstein, MSW, wasn’t about to let the powerful organizing die. Goldstein and colleagues secured philanthropic partnership from the David and Lura Lovell Foundation for operations of a new Alliance to Advance Comprehensive Integrative Pain Management. In an early December note to participants, Goldstein announced that its members Adam Seidner, MD, MPH, CMO from The Hartford and Cheryl Larson, CEO of the Midwest Business Group on Health produced a quality editorial for the integrative model at the influential Morning Consult. Great first step of renewal! The convening and advocacy is continuing. A new website is just up. Yes!

3. Censorship? Google Turns Off or Diverts Traffic at Multiple Natural Health and Integrative Medicine Websites

At a certain point in seeking to self-police the “fake news” shaping politics and industry, Google put natural health information sources for literally millions of patients under their lens. The process was non-transparent. No one seems to know if they consulted with any integrative experts. With a few algorithm-changing keystrokes, and perhaps some hand manipulation, multiple websites include Dr.Weil.com and Holistic Primary Care (HPC) saw their traffic drop 50% to 95% overnight.  HPC editor Erik Goldman, a long-time medical reporter with a strongly evidence-informed business model laid out existing theories about what is going on. Scenarios range from the positive (basic public health concern) to the conspiratorial (Google’s heavy investment in multiple pharmaceutical firms in the last 4 years). With this news yet undigested, a second type of non-transparent Google process was summarily shoved down the field’s throat. The Academy of Integrative Health and Medicine (AIHM) and naturopathic and integrative pain clinician Michael Cronin, ND were among those who saw their businesses harmed with their Google ads suddenly lifted.  Who else has felt the sting? One concern is arbitrary behavior. Leaders in the field like AIHM’s Tabatha Parker, ND believe a coordinated response is needed to get the ear of Google as a basic first step. Since Google is an octopus reaching in multiple ways into our lives, Google’s “other shoe” can yet keep dropping repeatedly. Bottom line: the private sector, non-transparent and non-regulated manipulation of artificial intelligence to dictate what people have an opportunity to learn about their health choices will be a fact of life – if there is no intervention. This is in a movement that, after years of suppression, thrived since the miud-1990s in the buyer beware first era of the Internet. This is sure to be a 202o story as well.

4. Cleveland Clinic, EvoMed and JACM: Group Integrative Services Push through for Equity and Access

An abiding shame on the integrative house has been the inbuilt, economic bias toward providing services mainly to the cash-paying well-to-do, leaving the less fortunate with little access to integrative services. This year marked multiple breakthroughs for a method to surmount these obstacles via group-delivered integrative services. Two leaders in developing and researching group integrative services, University of Massachusetts’ Paula Gardiner, MD, MPH and UCSF’s Maria Chao, DrPh, MPA, gathered a team and partners – including Integrative Medicine for the Underserved – to publish a Special Focus Issue on Innovation in Group Delivered Services at JACM-Paradigm, Practice and Policy Advancing Integrative Health. (I had the opportunity to work with them on this issue.) Earlier in the year, Mark Hyman, MD with the Cleveland Clinic Center for Functional Medicine shared during a talk fascinating news. Early data from the Center’s group functional medicine model found patient-reported outcomes better via group than than in the usual, more expensive, functional medicine model. Meantime, author and functional medicine promoter James Maskell of EvoMed included CC’s chief administrator Tawny Jones in an impressive series of now 10 interviews of group visit clinical leaders. These led to his Group Visit Challenge to help clinicians of all types roll group visits into their practices. Maskell also completed his book on the subject due out January 14, 2020 that captures in the title the special sauce in group visits: Community Cure: Transforming Health Outcomes Together.  It’s about time for this natural partner for integrative care to gain stature, and uptake.

5. $20 Million Here, $20 Million There – Pretty Soon its Real Money: Integrative Philanthropic Partnerships at U Arizona and Jefferson

Two very substantial philanthropic partners for academic integrative medicine and health renewed their commitments in big ways in 2019. At Jefferson University, Home Depot founder Bernie Marcus committed an additional $20-million to substantially advance the work of Jefferson University Medical School longtime integrative medicine leader Daniel Monti, MD.  As director of the new Marcus Institute of Integrative Health, Monti is also running what may be the first fully recognized integrative medicine department at a major medicakl school. Meanwhile, kitty-corner across the country, Andrew Weil, MD, the founder of the integrative medicine program at the University of Arizona, chose to direct earnings from the sale his stake in True Food Kitchen to bring to $20-million the total he will have invested in what is now the Andrew Weil Center for Integrative Medicine. That Center’s educational contributions have have already led to their pioneering fellowship program and multiple other models to shoe-horn integrative into med school curricula. In the work of US healthcare, philanthropic partnerships fuel mu h of the most significant action. Terrific to see these two influential research and education centers more securely planted in their institutions with these real money commitments.

6. Christine Goertz, DC, PhD Selected to Chair the Federal Patient Centered Outcomes Research Institute (PCORI)

Decades ago, I recall dismissing a colleague’s suggestion that an integrative leader might one day be at the tops of a major federal agency. The work at the VA (see #1 above) suggests I lacked sufficient faith. Now, if the “quasi-public” Patient Centered Outcomes Research Institute (PCORI) is accepted as the federal influencer that it is, my colleague was spot on. Remarkably, the first to ascend to the top is not an integrative MD but chiropractor and health services researcher Christine Goertz, DC, PhD. Early in her carrier, Goertz, the barrier-breaker, parlayed her real world research skills in chiropractic into a role as the first licensed complementary and integrative health practitioner hired as a program officer at the National Institutes of Health (and perhaps anywhere in the federal bureaucracy). Goertz subsequently served as deputy director at the Samueli Institute, a rare interprofessional leadership position for a chiropractor. Then at Palmer College where Goertz was vice chancellor, she and her team built a research portfolio totaling $27-million, huge in integrative dollars. In an interview, Goertz lived up to her practical and data-driven orientation. She providing readers with two useful lists, including one of all of the PCORI grants to complementary and integrative researchers. Continuing in the barrier breaking, Goertz this year joined the Duke University School of Medicine Department of Orthopaedic Surgery as a professor and the Director of System Development and Coordination for Spine Health at Duke Health. Go Christine!

7. Whole Systems Research: Langevin at NCCIH, Society for Acupunture Research, HEALM, and a Special Issue

First in June at the Society for Acupuncture Research (SAR) conference and then at the September meeting of her National Advisory Committee for Complementary and Integrative Health, the new director of the NIH National Center for  Complementary and Integrative Health, Helene Langevin, MD announced that, for the first time, whole systems research will be in the NCCIH’s upcoming strategic plan. The first mention was the SAR conference that focused on real world themes including the value of the whole East Asian medicine practice and not just needles. This theme was a top priority 10 years ago when the integrative community unsuccessfully petitioned for researching the way we practice in the NCCIH’s goals (see here and here). The acupuncturists were not the only field active on this front. David Katz. MD, PhD led the American College of Lifestyle Medicine doctors to challenge the “tyranny of the RCT” (Randomized Controlled Trials) by publishing its Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM). For the naturopathic profession, Australian Stephen Myers, ND, PhD led publication of a systematic scoping review on naturopathic whole system research that became a political football his country. For the whole integrative field, University of Toronto researcher Nadine Ijaz, PhD led a team for a massive first ever review of Whole Systems Research Methods in Health Care that was a centerpiece of a special issue on the topic from JACM.  The paper provides baseline information about what the field has been doing while NCCIH has been looking in other directions. In a remarkable development that underscores the importance of the NCCIH’s new direction, a half dozen papers in the special issue researched efforts to transform whole systems of pain treatment toward multimodal methods featuring whole systems that include non-pharmacologic approaches. Here’s hoping the NCCIH will go on a listening tour in the clinician community and not just limit its inputs – and ultimately its review sections – to investigators constipated by their decades of forcing research through the pharma-friendly keyhole of the RCT. If there was ever a place where the truism about new paradigms not coming from old minds, it is here. Make the process big, and open, Dr. Langevin!

8. Demise of CHI Health Care:  Bambi Meets Godzilla as the Nation’s Leading Integrative Primary Care Medical Home is Steam-Rollered Due to the Economic Bureaucracy of “Accountable Care”

David Fogel, MD and his team were dedicated to “accounting” their outcomes at CHI Health Care (originally the Casey Health Institute). They found it: lower pharmacy costs, lower ER visits, and lower hospitalizations. Outcomes were good enough to attract a visit from a US Surgeon General who was exploring successful innovations in the accountable care era. Notably, the CHI model was the most conscientiously interprofessional model the integrative field has produced. Yet as Fogel and his Blue Cross Blue Shield CareFirst-recognized PCMH signed on to become part of an A.C.O. they found that good intentions could not overcome structural barriers. In May, word of the end of Godzilla’s crushing step finally came. Despite it’s positive outcomes, growth, and savings, the Maryland Center was forced to shut down. That the lumbering environment of current accountable care is abhorrent to growing something new is captured in Slow Uptake of Value-Based Payment Kills Proven Integrative Model: CHI Health Care to Close. The movement from volume to value appears to be engineered to exclude anything relatively small, thoughtful, and health creating.  Crushing loss after a fine effort. Links to multiple pieces on the CHI experience are here at the Academic Collaborative for Integrative Health’s resource site of its Project for Integrative Health and the Triple Aim.

9. WHO Traditional Medicine Strategy Prompts Significant Action Globally; PAHO Network Models Collaborative Action

For all of the hoopla over “integrative health and medicine” advance that might be stirred up in North America and Europe, the Big Game in integrating non-pharmacologic and historic practices with biomedicine is elsewhere. It is that which is guided in scores of nations in Asia, the Middle East, Africa and South America by the 2014-2023 Traditional Medicine Strategy of the World Health Organization (WHO) and its regional affiliates. A WHO report marking half way in the strategic plan’s 10-year cycle reported significant jumps in activity on traditional and complementary medicine in multiple nations and in multiple domains. These include broad measures like having federal regulations, national plans, expert advisory teams and national research institutes for traditional and complementary medicine. The WHO affiliate for the Americas , the Pan American Health Organization (PAHO), evidenced particularly exemplary leadership. Its collaboratively developed and publicly available Virtual Health Library on Traditional, Complementary, and Integrative Medicine (VHL TCIM) in considered a model globally. The PAHO site includes the elaborate MOSAICO Database (Models of Health and Traditional, Complementary, and Integrative Medicines in the Americas). Ratcheting things up a notch for the WHO, 2019 also included WHO’s controversial inclusion of TCM codes in the new ICD-11, a decision that has received significant push-back.

10. CBDs Ecstasy Psychoactives CBDs Michael Pollan Psilocybin CBDs Scott Shannon MDMA CBDs CBDs

The Integrator has only barely covered the remarkable and controversial ascension of the cannabanoids (CBDs) from the wacky weed and the increased respect given other agents related, via era-associated experience (in the remaining portions of some of our Sixties minds): LSD, psilocybin, MDMA, etc. In the endless 2019 tour following publication of Michael Pollan’s powerful 2018 book, How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression and Transcendence, the lid came fully off Pandora’s box. These – and CBDs in particular – are everywhere in the news for those who follow alternative and complementary medicine topics. The one related Integrator venture was an interview with author, researcher, integrative psychiatrist and Academy of Integrative Health and Medicine co-founder Scott Shannon, MD on his participation as a researcher in the Phase III trial for MDMA (a.k.a. “Molly” or “Ecstasy”). A perspective Shannon brought into the picture is the potentially devastatingly disruptive effect such controlled experiences might have on the pharma industry’s constant ka-ching of tens of millions of souls daily dosing on antidepressants. Pollan has also raised the question of what influence these potentially disruptive agents can have on psychotherapy.

And in the Spirit of Coco: Exited Leaders Whose Spirits We Serve Ourselves to Keep Alive- Crinnion, Sensenig and Bigg

The movie Coco two years ago was a wonderful meditation on death and dying that took place during a Mexican Day of the Dead. The message is one of continuing connection with those who come before us. In 2019, three significant leaders exited. Two were trained as naturopathic physicians. Walter Crinnion, ND worked clinically in detoxification and then in environmental medicine as an activist, author and lecturer where he brought his influence to a much larger interprofessional community.  James Sensenig, ND was the founding president of the American Association of Naturopathic Physicians and senior editor of the Foundations for Naturopathic Medicine project. In recent years, he grew concerned that the profession was straying from its roots and led creation of the Naturopathic Medicine Institute to re-invigorate that part of the field.  Dort Bigg was played an important role for the acupuncture and Oriental medicine profession from 1999-2010 a executive director for the Accreditation Commission of Acupuncture and Oriental Medicine (ACAOM). He subsequently served as director of the Atlantic Institute of Oriental Medicine.

A sort of apology: The special issues of a journal with which I am associated, JACM, reflect the interests of colleagues (and my own) in exploring what we believe are important emerging themes. Thus they have a way of showing up when I engage this task of making choices on actions to highlight. Let me know what I have missed!

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