|
||||||||
|
INTEGRATIVE MEDICINE Korea Conference Explores 'Alternative Medicine' Talks Show Need for Physicians, Scientists to Catch Up with Patient Demand Though some practitioners of conventional, allopathic medicine may dismiss complementary and alternative medicine (CAM) as unscientific, currents in health care spending and research funding are carrying CAM closer to the mainstream. Experts from the U.S., Korea, and Scotland who spoke at a conference in Seoul on July 2 and 3 made the argument that awareness of CAM usage and investigation of CAM therapies—chiropractic, acupuncture, massage, herbal treatments, and others—provide opportunities for physicians and scientists worldwide to improve patient care. Titled "Scientific Integration of Western Medicine and Complementary–Alternative/Mind–Body Medicine," the conference was sponsored by Harvard Medical International (HMI) and Korea's Asan Medical Center. A nonprofit subsidiary of the Medical School, HMI was conceived in 1994 with the goal of improving health care around the world through partnerships with leading foreign institutions to develop joint programs in health care services, medical education, and research. HMI formed its agreement with Asan Medical Center in 1996, the first of HMI's international partnerships. A major teaching hospital, Asan is affiliated with the University of Ulsan College of Medicine. The presentations at the July conference were framed by the keynote address of Joseph B. Martin, dean of the Faculty of Medicine, and the closing critique of Kenneth Shine, president of the National Academy of Sciences' Institute of Medicine. In his talk, Martin said that it is "foolish" to reject an idea simply because it differs from common practice. He said one reason HMS took part in the program is the "increasingly urgent need for physicians in the United States and other Western countries to understand complementary and alternative medicine–to find out what kinds of therapies their patients are using, how they work, and how they might interact with the medicines the physicians themselves prescribe." He cautioned that if CAM therapies are to prove their value, they will have to undergo the same rigorous scientific testing that other new treatments are given. Yet, he said, "We have good reason to believe that some of the therapies that are now considered 'alternative' will eventually prove their worth and become standard practice in both East and West." Shine's penultimate talk took a global perspective, emphasizing the current "revolution in information systems" that gives biomedical science the capacity to determine which therapies work and which do not–and which may be dangerous. Scientists should focus their efforts on areas of CAM that have particular promise and an accompanying risk, he said. Herbal treatments belong in this category. Shine found fault with the term complementary and alternative medicine, saying "There is only one medicine." He said he favors complementary therapies, arguing that CAM does not imply a new concept of medicine but a range of possible therapeutic techniques. Considering mind–body medicine in assembling his vision of the future, Shine said, "Mind and brain interaction with the rest of the body is one of the great challenges of the 21st century." Mind Mending BodyMind–body medicine had been singled out earlier in the program by Gregg Jacobs, assistant professor of psychiatry at Beth Israel Deaconess and senior scientist at the Mind–Body Medical Institute, who said that it should not be considered part of CAM but of mainstream medicine. "Mind–body medicine is based on over 2,000 peer-reviewed studies," he said. Its recent history goes back about 60 years to Walter Cannon from HMS, who defined the physiology of mind–body interactions by studying the fight or flight response. The placebo effect also powerfully illustrates the connection between mind and body since one third of patients show clinical improvement when given a placebo.
"The question is no longer whether mind–body interactions are real but whether they can be controlled via mind–body techniques and to what extent," Jacobs said. Relaxation and other mind–body techniques have been effective in treating headaches, insomnia, and cardiovascular disorders. He cited an insomnia study he conducted in which insomniacs who had taken an average of 77 minutes to fall asleep prior to treatment took only an average of 19 minutes afterward, which is normal. William Harlan Jr., acting director of the National Center for Complementary and Alternative Medicine at the NIH, highlighted some U.S. initiatives that reflect the growing interest in CAM. The center is new this year, having begun as the Office of Alternative Medicine in 1992. Since then, the research budget has grown from $881,000 in fiscal 1993 to an appropriation of $50 million in 1999. According to Harlan, an additional $50 million is budgeted for CAM in 1999 by different branches of the NIH. Harlan said one approach the national center is taking is to "develop large randomized, controlled trials of promising CAM modalities." These include St. John's wort for depression and acupuncture for osteoarthritis. Guiding the search for treatments with high potential are systematic reviews of previous investigations. Other federal studies of CAM include those presented at the conference by Colonel Brian Schuster, associate director of the Walter Reed Army Institute of Research, who discussed the development of ethnomedical products. CAM in KoreaAdding to the context of the conference was Changgi Hong, vice president for health affairs at the University of Ulsan and dean of its College of Medicine. He addressed the current and prospective use of CAM, or oriental medicine, in Korea. The country has 41 colleges for Western medicine that graduate about 3,000 students each year and 11 for oriental medicine that graduate about 800. Western medicine took precedence over the centuries-old oriental techniques in the late 19th century. "Mistrust of CAM has been common among [Western] medical communities," Hong said, "mainly because the proofs of clinical efficacy are claimed usually by different criteria": personal experience rather than objective evidence, for example. "The standards and criteria for judging the safety and effectiveness of treatment and diagnostic interventions must be formulated by consensus. This consensus-building may be the challenge for everyone to overcome," he said. A study by Hong and his colleagues found that 29 percent of Koreans had used some form of CAM during the previous year, putting the country's prevalence rate behind those of France, Australia, Germany, and the U.S., as determined by other studies. Hong said he and his colleagues calculated that in Korea per capita "spending for professional CAM is in the range of 50 to 55 percent" of that in the U.S., whose total as estimated by fellow presenter David Eisenberg was $21.2 billion for 1997.
An assistant professor of medicine at HMS and director of the Center for Alternative Medicine Research and Education at Beth Israel Deaconess, Eisenberg gave an overview of CAM usage in the U.S. and of education in CAM at American medical schools. From surveys he and his colleagues conducted, they estimated that expenditures for professional CAM services increased 45.2 percent from 1990 to 1997, rising to the $21.2 billion figure cited by Hong. The researchers also found that adult use of at least one of 16 CAM therapies during the previous year increased from 33.8 percent in 1990 to 42.1 percent in 1997. "Between 27 and 34 billion dollars was spent out-of-pocket on complementary and alternative medicine," Eisenberg said, considering all CAM-related expenditures in 1997. This range is comparable to the estimated amount Americans spent out-of-pocket the same year for all physician services. Eisenberg also described a study he and colleagues conducted in which 117 out of 125 U.S. medical schools responded to a survey on CAM in their curriculum, and 75, or 64 percent, reported that their institutions offered elective courses in CAM or included these topics in required courses. In 1995, the number of medical schools whose curriculum addressed CAM was about 25, he said. "Complementary medicine is being driven by the market," Eisenberg said, stepping back from the data. "...We need more science to navigate." He noted that growth in CAM is occurring even though in the U.S., insurance is just beginning to cover these therapies. Eisenberg described the patient–doctor relationship as a mutual journey, saying that patients want physicians to guide them in whatever therapies they use. Presenter David Reilly, consultant physician at Glasgow Homeopathic Hospital reviewed the use of CAM in Europe. He called CAM "the second biggest growth industry in Europe," underscoring Eisenberg's point that use of CAM is largely patient-driven. How Acupuncture WorksThree of the speakers at the conference discussed research on acupuncture: Brian Berman, director of the University of Maryland Complementary Medicine Program and associate professor of family medicine; Myung Hwan Kim, associate professor of internal medicine at the University of Ulsan College of Medicine; and Joannie Shen, senior staff fellow in the Laboratory of Clinical Science at the NIH institute on alcohol abuse and alcoholism. Shen reported research on acupuncture's neurophysiological mechanisms. One study, in rabbits, showed that the analgesic effect of acupuncture can be transferred from donor to recipient by cerebrospinal fluid. More recent work showed that electroacupuncture of different frequencies activates different brain regions through differential gene expression. Shen cited another study demonstrating acupuncture's effect on regulation of the autonomic nervous system. Low frequency electroacupuncture was shown to protect the myocardium by inhibiting the sympathetic pressor response and decreasing myocardial oxygen demand. "This protective effect continued for hours," she said. Hers was the last of the scientific presentations. At the beginning of the conference, attendees heard greetings by Pyung Chul Min, president of Asan Medical Center and professor of surgery at the University of Ulsan College of Medicine; Robert Crone, president and CEO of HMI and clinical professor of anesthetics and dean of international programs at HMS; and Je Geun Chi, president of the Korean Academy of Medical Sciences and professor of pathology at Seoul National University College of Medicine. The University of Ulsan College of Medicine, the Asan Institute for Life Sciences, and Harvard Medical School were cosponsors of the event. Among the speakers culminating the conference was Phil Fontanarosa, interim co-editor of JAMA who emphasized the need for leading medical journals to publish evidence-based information on CAM. Closing remarks were given by Mitchell Spellman, director of academic alliances and international exchange programs at HMI. In summary, Spellman said, "We have come to Seoul ... to share data as well as to promote linkages for support of collaboration in discovery, translation research, and evaluation of findings with the aim of advancing CAM as a scientific discipline." —Robert Neal |
