Traditionally, public health relies extensively on conventional (allopathic) medicine in its mission to prevent and treat disease. It accepts reductionistic methods to identify the origin of illness at the cellular and subcellular level, and then applies these principles in assessing and addressing risk factors in populations. This results in a three-tiered approach to the delivery of public health services: (1) primary prevention, which involves efforts to reduce exposure to risk factors for injury and illness; (2) secondary prevention, which involves the identification and control of disease in its early stages; and (3) tertiary prevention, which attempts to control the impact of existing illness and injury through prolonged treatment and rehabilitative services.
Paralleling the growth of technology-based medicine (and its effectiveness), however, has been a simultaneous rise in chronic illnesses that are resistant to current treatment modalities and very costly to society. Leading causes of morbidity in the early 1900s, such as trauma and infectious disease, have been supplanted by chronic conditions such as cancer, heart disease, and HIV (human immunodeficiency virus) infection. This requires the development of a new model of health care that is multidimensional and that recognizes all factors influencing health and illness. At a public health level, multidimensional problems require multidimensional interventions, which is the basis of the integrative medical approach.
COMPLEMENTARY AND ALTERNATIVE MEDICINE
In 1948, the World Health Organization (WHO) defined health as "a complete state of physical, mental, and social well-being and not merely the absence of disease or infirmity." The public increasingly embraces "holistic" medicine when seeking treatment for chronic medical conditions. This philosophical shift has led to a sharp increase in the use of complementary and alternative medicine (CAM), defined as modalities (e.g., acupuncture, herbal therapy, massage therapy), employed in place of, or as adjuncts to, conventional medical therapies. Surveys reveal that almost half of the U.S. population turns to such modalities, with acceptance and use of CAM expanding during the 1990s. Studies showing that CAM use tends to be higher among patients with diseases (e.g., cancer, arthritis), that are often inadequately treated by conventional approaches may suggest an inherent dissatisfaction with Western medicine. Research suggests, however, that the public is actually turning to CAM because its doctrines parallel their own personal values and belief systems. For example, patients want physicians who regard them as whole persons—minds and spirits as well as bodies—and who believe in the healing power of nature. In fact, although CAM therapies are very diverse, ranging from well-established cultural traditions (e.g., Chinese traditional medicine) to quasi-allopathic modalities marginally supported by current science (e.g., chelation therapy), most share common underlying philosophies. These include a belief in the interconnectedness of mind and body and respect for the innate mechanisms of healing.
INTEGRATIVE MEDICINE
Practioners of conventional medicine are justifiably proud of the achievements of their profession—most notably the diagnostic, pharmacological, and surgical advances of the twentieth century. Total reliance on such technologies, however, has led to the dismissal of CAM modalities as archaic or ineffective. The result has been increasing divisiveness between proponents and opponents of unconventional therapies.
The descriptive phrase "integrative medicine," coined in the late twentieth century, characterizes a new model of health care rooted both in conventional and alternative medicine. In the broadest sense, integrative medicine employs modalities drawn from all medical therapeutic paradigms, providing patients with individualized treatment plans optimized for their specific clinical situations. The underlying philosophy recognizes and relies upon the innate healing capacity of the human body and emphasizes the importance of the relationship between practitioner and patient in fostering this capacity.
While incorporating aspects of both conventional medicine and CAM, integrative medicine does not uncritically accept either without evidence of validity and efficacy. Additionally, in weighing both the benefits and risks inherent to any therapy, regardless of its origin, the integrative practitioner initially selects the least invasive, least toxic, and least costly interventions appropriate to the situation.
A cornerstone of the integrative model is the assertion that health and healing optimally occur when all factors that influence the organism are addressed. To quote Sir William Osler (1849–1919), "It is more important to know what sort of patient has a disease than what sort of disease a patient has." Therefore, although a patient presents specific symptoms, the integrative practitioner inquires into all lifestyle, psychosocial, and spiritual influences affecting quality of life. The ensuing treatment plan includes recommendations such as dietary change, increase in physical activity, and stress reduction in addition to any specific therapies. Positive coping skills such as biofeedback, yoga, prayer, meditation, and community involvement are promoted.
Although the breadth and depth of CAM is beyond the scope of this chapter, a few of the more recognized and researched modalities are listed below:
Acupuncture: The insertion of thin, stainless steel needles into the skin at specific locations (channels or acupoints) to affect the flow of Qi (energy) in the body. Releasing blockages of energy flow facilitates symptom relief and healing of illness.
Homeopathy: Developed in Germany in the eighteenth century, homeopathic remedies are created from plant, animal, or mineral products diluted thousands-fold in water or alcohol. Based on the theory of "like cures like," the remedies are used to treat illnesses whose symptoms might be elicited by administration of the full-strength product.
Massage therapy: A wide variety of physical manipulative techniques designed to promote relaxation, thereby treating conditions exacerbated by tension such as headaches, insomnia, and post-surgical trauma.
Naturopathic medicine: Although similar to allopathic medicine in diagnostic techniques, naturopathic physicians avoid drugs, major surgery, and cutting-edge technology and instead rely on treatment approaches designed to strengthen the body's own healing capabilities.
Prayer and spirituality: Often considered "alternative" by conventional medical standards, prayer and spirituality help patients maintain a sense of purpose, meaning, and hope in the face of pain, suffering, and uncertainty through relationship with one's own God or supreme being.
Chinese traditional medicine: Utilizing methods such as herbal remedies, acupuncture, diet, meditation, and exercises such as qigong and tai chi, CTM seeks to achieve overall balance of health in preventing as well as treating illness.
Fundamental to the integrative model is the therapeutic relationship between the patient and doctor. Practitioners recognize that they are not the source of healing, but the means by which patients discover, or rediscover, their innate capacity to regain health. Therapeutic modalities, whether conventional or alternative, are simply adjuncts to this process; patients must take responsibility for their own health and well-being. To this end, each therapeutic decision is the result of a consideration of all appropriate modalities, whether conventional or CAM. Patients are thus active partners in choosing therapies consistent with their values and philosophical beliefs.
INTEGRATIVE MEDICINE AND THE FUTURE OF HEALTH CARE
No one denies the existence of a crisis in the delivery and financing of health care. The arrangement of unregulated fee-for-service practices, reimbursement through managed care, and costly defensive medicine has complicated rather than alleviated the burden of escalating chronic illness associated with an aging population. The ensuing national debate has focused upon repair of this system, rather than the creation of a new design.
An integrative approach to public health redefines the ideology of the system rather than attempting to repair the current model. It looks to equitable and universal access to health maintenance services, and focuses on disease prevention as well as on current treatments, which may not always be effective. Decisions regarding the provision of health care therefore do not simply originate from within the medical and reimbursement sectors, but become a social contract among individuals, providers, hospitals, academic institutions, corporations, communities, and governmental agencies. Individuals become accountable for the impact their behavioral choices have upon the community as well as on their own personal wellbeing. Health care providers and hospitals work to prevent illness as well as treat it, emphasizing accountability to the individual and the community over financial profit. Academic institutions develop programs that promote the synergistic training of students of medicine, nursing, pharmacy, and others involved in patient care. Corporations recognize the overall value of healthy employees and invest in individual and organized wellness programs. Communities acknowledge that health in not only the result of good medical care, but also of adequate housing, sanitation, and education. Finally, government serves as a safety net, ensuring access to medical care when all other resources fail, as well as enacting and enforcing legislation designed to protect both the individual and the health care system. Thus, the concept of integrative medicine encompasses not only the health of the individual, but of society as a whole.
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