WHITE HOUSE COMMISSION
COMPLEMENTARY and ALTERNATIVE MEDICINE POLICY
MEETING ON THE ACCESS AND DELIVERY OF
COMPLEMENTARY AND ALTERNATIVE MEDICINE SERVICES
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Monday, December 4, 2000
Hubert H. Humphrey Building, Room 800
200 Independence Avenue, SW
James S. Gordon, M.D., Director
The Center for Mind-Body Medicine
George M. Bernier, Jr., M.D.
Vice President for Education
University of Texas Medical Branch
David Bresler, Ph.D., LAc, OME
Founder and Executive Director
The Bresler Center, Inc.
Co-Founder and President
Tom's of Maine, Inc.
Effie Poy Yew Chow, Ph.D., R.N., DiplAc (NCCA)
President, East-West Academy of Healing Arts
George T. DeVries, III
Chairman, CEO of American Specialty Health
William R. Fair, M.D.
Attending Surgeon, Urology (Emeritus)
Memorial Sloan-Kettering Cancer Center
Chairman, Clinical Advisory Board of Health, LLC
Joseph J. Fins, M.D., F.A.C.P.
Associate Professor of Medicine
Weill Medical College of Cornell University
Director of Medical Ethics
New York Presbyterian Hospital-Cornell Campus
Veronica Gutierrez, D.C.
Gutierrez Family Chiropractic
Wayne B. Jonas, M.D.
Department of Family Medicine
Uniformed Services University of the Health Sciences
Charlotte Kerr, R.S.M.
Traditional Acupuncture Institute, Inc.
Linnea Signe Larson, LCSW, LMFT
West Suburban Health Care
Center for Integrative Medicine
Tieraona Low Dog, M.D., A.H.G.
Conchita M. Paz, M.D.
Buford L. Rolin
Poarch Band of Creek Indians
Julia R. Scott
National Black Women's Health Project
Xiao Ming Tian, M.D., LAc
Director, Wildwood Acupuncture Center
Director, Academy of Acupuncture &
Wildwood Medical Center
Donald W. Warren, D.D.S.
Diplomate of the American Board of
Head, Neck & Facial Pain
Commission Members Not Present:
Dean Ornish, M.D.
Preventative Medicine Research Institute
Clinical Professor of Medicine
University of California, San Francisco
Stephen C. Groft, Pharm.D.
Michele M. Chang, C.M.F., M.P.H.
Doris A. Kingsbury
Geraldine B. Pollen, M.A.
Senior Program Analyst
Joseph M. Kaczmarczyk, D.O., M.P.H.
Senior Medical Advisor
C O N T E N T S
Welcome and Introductions
Dr. James S. Gordon ................................ 7
Dr. Stephen C. Groft ............................... 15
Session I: Overview of CAM Utilization
Dr. James S. Gordon ................................ 19
Commission Discussion ................................ 37
Session II: Clinical and Cost Effectiveness of
Selected CAM Services
William Meeker, D.C., MPH .......................... 43
Konrad Kail, ND, PA ................................ 48
Patricia Culliton, LAc ............................. 54
Joyce Frye, DO, MBA, FACOG ......................... 59
Tiffany Field, Ph.D. ............................... 65
Panel Discussion ..................................... 69
Dennis Awang, Ph.D., SCIC ......................... 103
Christopher Hobbs, LAc, AHG ....................... 106
Alan Gaby, M.D..................................... 111
Patsy Brannon, Ph.D., RD .......................... 116
Harley Goldberg, DO ............................... 121
Panel Discussion .................................... 132
Francine Butler ................................... 158
Nancy Dolores Kolenda ............................. 162
Diana Chambers .................................... 164
Rustrum Roy ....................................... 167
Panel Discussion .................................... 170
Dr. David Murray Blalwas .......................... 181
Kathleen Golden ................................... 185
Natalia Egorov .................................... 189
Dr. David Edgar Molony ............................ 191
Panel Discussion .................................... 195
Dr. Bruce Dooley .................................. 213
Dr. Salvatore D'Onofrio ........................... 216
Panel Discussion .................................... 219
Session III: Use of CAM for Selected Health
Addiction and HIV/AIDS
Howard Josepher ................................... 224
Denise Drayton .................................... 228
Jeanne Andrews .................................... 232
Richard Collins, M.D. ............................. 236
Walter Czapliewicz ................................ 240
J. Donald Schumacher, PsyD ........................ 245
Panel Discussion .................................... 251
Session IV: Issues in Integrating CAM in
Richard Miles ..................................... 278
The Honorable Berkley Bedell ...................... 283
The National Foundation for Alternative Medicine
Paul Kurtz, MA Ph.D. ............................. 288
Committee for the Scientific Investigation of
Claims of the Paranormal
Panel Discussion .................................... 293
Donald Kendall, OMD, Ph.D., LAc
Office of Professional and Employees
International Union ............................. 332
American Preventative Medical Association ......... 335
Michele Forzley, JD
American Bar Association .......................... 340
Panel Discussion .................................... 345
Adjournment ......................................... 368
P R O C E E D I N G S [8:25 a.m.]
Dr. GORDON: Good morning, everybody. Welcome to
this meeting of the White House Commission on Complementary
and Alternative Medicine Policy.
At the beginning of our meetings, we sit for a
moment quietly and bring ourselves into the room. So I
invite everyone who is here with us today just to sit for a
[Moment of silence observed.]
Dr. GORDON: Thank you. It is nice, especially
before a rich and complex meeting, to have a little time to
sit and be quiet with each other.
What I would like to do is to begin by asking each
of the new commissioners, and we do have some new
commissioners, to introduce him or herself and say a couple
of words, and then Dr. Steve Groft, who is our executive
director, will be explaining what the work is that we are
going to be doing today, and then I will be giving an
overview of the development of CAM services and, in
particular, some of the surveys of use of CAM services.
Then, we will be moving into the testimony for the day.
It is wonderful to have all the commissioners, the
commissioners who are here. Our friend and colleague, Dean
Ornish, and his wife Molly just had a baby, and so Dean is
not here today. We send our good wishes and our love to
him, as he does to us. Then, we will be moving ahead.
David, do you want to begin.
Dr. BRESLER: I am David Bresler. I am a
professor in the medical school at UCLA. Effie Chow and I
were just reminiscing that it was 1969 when we took our
first acupuncture course together, so this is my 32nd year
of doing acupuncture.
We started our research at UCLA in 1972, and we
were the first medical center to get an NIH grant to begin
acupuncture research. Back then we used to laugh
hysterically about thinking that one day American medicine
would take a real serious look at acupuncture and it would
be integrated into traditional care, so that a primary care
physician seeing a headache patient or a patient with other
types of pain would recommend acupuncture first, and we fell
on the floor laughing about the prospect of this.
Here we are today talking about this is a very
real possibility. I am very excited to be here. I also
have an interest in guided imagery, homeopathy, and many
other aspects of complementary medicine which we have been
doing some research over the years. So, it is great to be
Dr. GORDON: Thank you, David.
Dr. GUTIERREZ: I am a chiropractor from
Washington State. I have been in practice for 36 years.
One of the things I would like to achieve through my time
and service on the commission is to raise the public
awareness about the role of chiropractic as it relates to
health, wellness, and quality of life.
Dr. GORDON: Good. Thank you.
Ms. LARSON: My name is Linnea Larson. I have
worked as a social worker and a family therapist primarily
in medically under-served areas. I have a particular
interest in providing these services in those areas and a
particular another interest in the relationship of these
modalities to hospice care.
Dr. GORDON: Thank you.
Dr. WARREN: I am Don Warren. I am from Clinton,
Arkansas. I am a general dentist. I practice holistic
dentistry, I am a biologic dentist, and that I disagree with
some of our colleagues that mercury is a poison, I think it
I use homeopathy, I use cranial manipulations
through the Sutherland cranial technique of osteopathy. I
believe that chiropractic is a big factor in holistic
wellness, and to me the opportunity of being on this
commission is an opportunity to make a difference, and I
look forward to that challenge.
Dr. GORDON: Thank you, Don.
Dr. TIAN: My name is Xiao Ming Tian. I
specialize in acupuncture and Chinese medicine. I am
involved with clinical work in Bethesda and also I am
involved with NIH, am an NIH clinical consultant on
acupuncture. This program has been set up 10 years ago as a
daily basis to provide service for NIH patients.
Also, I do clinical research with Georgetown
Medical School NIH-funded. I treat fibromyalgia patients,
and spend more time, more energy to study Chinese herbal
medicine to treat osteoarthritis, fibromyalgia,
osteoporosis, and sports injuries.
Dr. GORDON: Thank you, Ming, very much.
Just so everybody will know everybody, we will go
around with the other commissioners who we have gotten to
know each other, but we are just meeting the new
commissioners, many of us for the first time this morning.
So, Conchita, would you like to begin.
Dr. PAZ: I am Conchita Paz. I am in private
practice and family practice in Las Cruces, New Mexico. I
am happy to be on this commission.
Dr. GORDON: We will just come right around,
Mr. ROLIN: My name is Buford Rolin. I am health
administrator. I work with the Poarch Band of Creek Indians
in Alabama and I am very active on the National Indian
Health Board and the National Congress of American Indians.
Ms. SCOTT: Good morning. My name is Julia Scott.
I am president and CEO of the National Black Women's Health
Dr. LOW DOG: Good morning. I am Tieraona Low
Dog. I am in private practice in family medicine in
Albuquerque, New Mexico, where I work in an integrative
medical center, and I have a special passion for herbal
SISTER KERR: Good morning. I am Charlotte Kerr.
I have been a practitioner of traditional acupuncture and
faculty member for 24 years, and before that, Assistant
Professor of Nursing at the University of Maryland. I am
real happy to be here and look forward to hearing from
everybody. Thank you.
Dr. JONAS: I am Wayne Jonas. I am a family
physician and researcher at the Uniformed Services
University of the Health Sciences in Bethesda.
Dr. FINS: I am Joe Fins. I am a general
internist and medical ethicist at Weill Medical College of
Cornell University and New York Presbyterian Hospital.
Dr. FAIR: I am Bill Fair. I was formerly at
Memorial Sloan-Kettering and Emeritus there, and also at
Cornell. Currently, I am chairman of the Clinical Advisory
Board of Health, spelled H-a-e-l-t-h, a complementary
medical center in Manhattan.
Mr. DeVRIES: I am George DeVries. I am chairman
and CEO of American Specialty Health. We are a health
services organization for complementary health care
Dr. CHOW: Hello. I am Effie Chow. I am
president of East West Academy of Healing Arts in San
Francisco and I practice Chinese medicine and am Qigong
Master and I greet all of you and welcome, and I look
forward to hearing from you.
Dr. BERNIER: I am George Bernier. I am vice
president for Education at the University of Texas at
Galveston. I am a hematologist/oncologist by background.
Dr. GORDON: We have one member who will be coming
later, who is Tom Chappell, who is the co-founder of Tom's
of Maine. He will be along fairly soon. He is flying in
I am Jim Gordon. I am the founder and director of
the Center for Mind-Body Medicine here in Washington, D.C.,
and a clinical professor at Georgetown Medical School. It
is great to be with everybody again.
I now turn the meeting over to Steve for a few
Dr. GROFT: Thank you, Jim, and welcome to
everyone especially to the presenters who I guess we have
asked to give a five-minute presentation. Many of you have
traveled a great distance just to provide us your wisdom and
experience and knowledge on CAM interventions, so I do thank
It is an awful lot to ask for you to travel that
far just for a short period of time, but I think your
expanded comments and recommendations that you will provide
will be extremely helpful to the Commission.
I think if you just look at what you have seen the
members of the Commission carry into the room is a massive
document. We had our first meeting in July, a very, very
thin thing, and the second meeting was about like this, and
I am not sure where we are going by the end of March of
2002, but we are going to try to reduce the volume, but I
want you to know that the information you see here is what
you generate, it is not what we generated, so we thank you
for doing that. It is extremely helpful. You know the
issues as well as anyone else, and we really are looking to
you for the expertise.
The focus of this meeting is access to, and
delivery of, CAM services. We originally had scheduled
reimbursement to go along with this issue, but I think as we
got into it, we realized how large both of these sections
were, and so we are separating out the reimbursement. We
will talk about that later on in the spring, so it will be
quite a busy time the next two days.
We are going to be using a representative sample
of CAM interventions, and, please, what we have today and
what is presented, there are many, many more interventions
that we could have selected, but I think we tried to look at
those that have some evidence of clinical effectiveness and
cost effectiveness, that we might be able to use it as
examples for the Commission's report.
We wanted to look at model delivery systems or
systems that could be utilized to integrate CAM services
into conventional medicine, again, to be utilized within the
So, you will see the focus of the meeting shifting
a little bit as we go along, and we tried to keep it
Michele Chang, who is over here to Jim's left, is
the executive secretary to the Commission, has taken a
tremendous role of putting this meeting together, and
Joe Kaczmarczyk, who many of you know from his days with
HRSA, has been the program analyst, policy analyst, has done
a great deal of work, the bulk of the work just to get this
meeting together and to talk with most of you in the
audience about the presentations and the need to come and
give us that information. So, I would like to thank both of
Two other people, who maybe you have seen, Doris
Kingsbury, who is around, I am not sure, she may be outside,
and Geri Pollen, if Geri is in the audience -- we have got a
great working schedule. I am not sure where we have been or
where we are going, but we are here today.
Again, if any of the staff members, if you have
any concerns or needs, both the commission members and the
audience, please see one of us and express your concerns or
needs, and we will try to respond to them as well as we can.
For the commission members, we are at the point
where we have to start to thinking of recommendations. We
need to develop an interim report by July. We will talk
more about this later on. So, start to think about what
recommendations you might want to see.
We have had two town meetings, town hall meetings,
we will have a third one in January. This is our second
major issues, so by the end of these two sessions, we will
have some idea of what we might want to think about for
We also need your guidance, if the format that we
are presenting, if this is adequate to give you the
information you need or however else you would like us to
structure the meetings, so we will have time to discuss this
as the two days go on here, so we are looking forward to
One last person that I would like to introduce is
Jim Swyers. Jim is a medical writer/editor who will be
helping us write and edit the report, so you know we are
getting serious once we start employing a writer/editor we
I think we are ready to go and Jim is ready to go,
and so we are anxious for a good session these next two
Dr. GORDON: Thank you, Steve.
Session I: Overview of CAM Utilization
Dr. GORDON: Just a couple things I wanted to say
about planning of future sessions. Everybody here signed up
I believe for at least one of the committees for future
This morning when Tieraona and George DeVries and
I were talking, I realized how much they knew and how
valuable their contributions would be in the area of
education and licensure, so I asked if they would volunteer
to be on those committees, and they graciously agreed.
So, what I want to do is encourage everyone here
on the commission to please jump in, we really need
everybody's thoughts and everybody's input to formulate
these sessions just as we have done for this session, so
come ahead if you are interested in participating.
Also, we are going to have one of the issues that
was raised in the last commission meeting was having time
for us to get together both informally and also to have more
discussion, so most of you were here at breakfast this
morning, which was great, just to have time to hang out with
each other, and at the end of the second day we are also
going to have some time to review what has happened in these
two days. A number of people said that that would be useful
to do. So, if you look on the schedule, you will see that
there is time.
The other thing I want to say is that we are going
to make -- one of the great things about the way the
commission is evolving is that so many more people from the
community are coming and wanting to participate, and we have
two full agendas of public comment, and we are going to do
our best to add on some more time for those of you who also
want to be involved in public comment, and I think that this
is a very exciting development as the commission gathers
I just want to say a couple words about the
Seattle meeting, which a number of us were present at in the
town hall, and that it was, I think we all agreed because we
talked about it afterwards, a very inspiring experience in
that we saw a whole community which had not only moved ahead
to offer CAM and make CAM services much more available to
the citizens, but that it truly had taken major steps toward
integration at every level from the provision of services in
the community to research projects jointly undertaken by CAM
institutions like Bastyr and conventional medical schools
like the University of Washington, to a public agenda set by
the Washington State Insurance Commissioner mandating
coverage of CAM services.
In a way, most impressively of all, at least to
me, the passion of the King County Council for creating a
more integrative medicine that would truly serve all the
people in King County.
Several of them came and testified and they
welcomed us to their council chambers, and, in fact, they
are the ones that are responsible for pulling together the
entire meeting, so it was very exciting and a real example,
I think, and the summaries and transcripts of that meeting
are being put up on our web site now, so everybody can take
a look at them.
The other thing I want to say, both to the
commissioners here and also to everybody in the audience is
that these town hall meetings are immensely valuable and
they are valuable to us in shaping our recommendations.
They are valuable in terms of helping us to decide
who we will invite here to Washington, and several of you
are here because we have heard you in Seattle and now we
want all of the commissioners to hear you.
They are also valuable, and this is really
important, for helping communities to organize themselves
and to get together. One of the things we heard from the
people in Seattle was how useful planning for the meeting
and working together was, not only in presenting material to
us at the meeting, but also in advancing through
thoughtfulness about integrative medicine in the community
as a whole.
So, we urge all of you, our schedule of our
meetings of our town halls is all up on the web site, and I
would ask all of the commissioners, as we come to areas near
you, to work with people in those areas to help to bring
I am going to open the meeting fairly briefly and
give a little bit of survey of some of the surveys on CAM
usage. This meeting, as Steve said, is really about
services and service delivery and access to services.
So, we thought it would be useful to begin by
sharing, that I could share a little bit of my perspective
on the evolution of CAM services, and share with you some of
the studies, some of the information from some of the many
studies, and as Joe pulled together the abstracts and the
papers for me, I saw how many studies there are now on the
usage of CAM services in various communities for various
kinds of illnesses at various ages. It is a rich
I want to recommend both to the commissioners and
to people in the audience I think a kind of nice summary of
the surveys, which I hope we will be able to provide that to
everybody. There is a paper by Jackie Wooten and Andrew
Sparber called appropriately enough, "Surveys of
Complementary and Alternative Medicine," and it is in the
current Review of Alternative Medicine from 1999. It gives
I think a very nice survey of all the surveys with some of
the essential findings in the surveys.
I am not going to try to be encyclopedic in 10
minutes this morning. What I want to do is hit on a few
highlights and then we can take a couple minutes if people
would like to add thoughts to this overview.
As David was speaking earlier this morning and
introducing himself, I was thinking back to the work that he
and I began to do almost 25 years ago, and that I began to
do at NIMH in the early 1970s, looking at this new field of
holistic -- what we then called "holistic" medicine, and
often still do call "holistic" medicine -- and thinking
about the change is really quite extraordinary because, on
the one hand, it is something that all of us felt in our
bones might well happen and yet at the same time, we are
both surprised and delighted that it is happening at this
level, that we really are interested in creating a much
larger vision of what medicine can be.
What we have seen in recent years is an
acceleration of this process, an acceleration in people
using these therapies, in the integration of these therapies
into medical school and other professional school curricula,
in the coverage of these therapies by insurance companies,
and in the development of research and of integrative
I just want to touch a little bit on some of these
developments and indicate how they relate to our mission as
Two of the more important studies in this area
that have been done in recent years were by Eisenberg and
his colleagues, the initial study on 1990 data, and the
second one on 1997 data, on the use of alternative therapies
I am sure these figures are familiar to most, if
not all of you, but I am just going to go over a few of them
The 1990 survey, which was published in January
1993 in the New England Journal of Medicine, showed that 34
percent of all Americans had, in 1990, used one or another
alternative therapy as part of their health care and that
they had then made 427 million visits to alternative care
The 1997 survey, the figures were 42 percent and
629 million visits. That was more visits then to all
primary care physicians. An American spent more money on
that care, and the estimates vary from 27 to 34 billion out
of pocket than they did on visits to primary care physicians
out of pocket.
Now, there have been a number of other studies
that have been done, John Astin's study, for example, which
also appeared in the Journal of the American Medical
The numbers of people using alternative therapies
-- and the definitions differ slightly, however, I would
hasten to add that whatever the definitions, they include
all of the therapies that are going to be presented this
morning, on which data are going to be presented -- the
numbers differ slightly, but the number of 40 percent stands
as a reasonably reliable number across all populations.
One thing I do want to add, though, that was noted
in the second Eisenberg study, and I think is very important
for us here, is that that number is based on phone surveys
of English-speaking people, and that there is a huge group
of people in this country who do not speak English, for whom
what we call "alternative or complementary medicine" is, in
fact, primary care, and I think one of the charges of the
Commission is to address the needs of those people and to
understand the importance of the contributions that those
people make to our health care system, as well as the needs
that they have from our health care system.
There are a few myths. One of the other things
about the Eisenberg study that is very interesting is that
in the last seven years, some of the things that have shown
up are some of the usage of alternative therapies has
increased somewhat, but the usage of some therapies has gone
up at a much greater rate.
For example, there is 130 percent greater usage of
megavitamin therapy in 1997 than in 1990, and 380 percent
greater usage of herbal therapies and almost as great an
increase in usage of homeopathic remedies.
So, this is another area in which we need to pay
attention, understanding that some therapies are increasing
steadily as, for example, the use of chiropractic, but that
other therapies that were used very little are now being
used a great deal more.
There are a few myths that have come up and that I
think that the survey data, taken as a whole, tends to
dissipate. One is that people who use alternative therapies
tend to turn their back on conventional medicine.
I think it is pretty clear from the surveys that
that is not true at all, that in the Astin survey, for
example, only 5 percent of those people who used
complementary or alternative therapies felt somehow in
opposition to, and totally disillusioned with, conventional
The rest of the people saw these therapies as very
much a part of an integrative approach, so I think that is a
myth or, if you will, a red herring that we are talking
about something that is in opposition even though there may
be reasons why people move away from conventional therapies.
The second myth is that this is essentially an
upper middle-class movement, and I think partly because of
the way the surveys are done, that people have tended to
believe that, that it is better educated, mostly white
people who use these therapies.
When you look at other populations, when you look
at rural poor populations, or indeed a population of
homeless young people in the city, in this case in Seattle,
Washington, who have access to CAM services, the utilization
goes way up. So, for example, 70 percent of runaway and
homeless kids were using CAM therapies.
When you look at minority communities -- we will
hear some testimony later in the day from a program with
which I work, ARRIVE, in New York, which is about 80 percent
minority, HIV-positive, mostly, although not all, ex-
prisoners -- the vast majority of those people are using
complementary and alternative therapies because they believe
they work and because they have access to them.
A third myth that sometimes comes up is that these
are therapies that are used by the worried well or by people
who are in life-threatening situations. Some of the
interesting surveys are on people coming in for cardiac
surgery and other kinds of surgery, which showed that prior
to the surgery, anywhere from 70 to 80 percent of the people
who are coming in for surgery are using one or more
complementary or alternative therapies, particularly
nutritional therapies and use of megavitamins.
I also think it is important to say that when you
look through the surveys, that although an earlier survey by
Ernst and Kastle, that showed a very variable use of CAM
therapies by people with one particular life-threatening
illness, cancer, and their range was from 7 to 64 percent,
more recent surveys, for example, Mary Ann Richardson's
survey from the Journal of Clinical Oncology this July, or
another survey, which was done in M.D. Anderson, or another
survey by Kelly at Columbia Presbyterian Hospital on
children, people with pediatric cancers, are showing that
the figures of usage are anywhere between the high 60s and
the low 80 percent of people with cancer are using these
So, it seems like especially in the area of life-
threatening illness that there is a significant increase in
the use of these therapies. The same is true with HIV and
AIDS, and not only, I would add, among perhaps the better
educated gay population, but also among people who are IV
drug users who tend to have less education, that there is a
I was recently speaking at AIDS Day in New Jersey,
and many of the programs there, there is close to 100
percent desire to use CAM therapies and up to 70 to 80
percent of the programs, and there is some interesting
surveys that have been done on that, as well.
Now, not only are CAM therapies being more widely
utilized, but physicians are increasingly willing to refer
to CAM therapists. A couple of studies that have been done,
one by Berman in the Journal of the American Board of Family
Practice and another by Astin in the Archives of Internal
Medicine show an increasing willingness of physicians,
particularly of primary care physicians, to refer to
complementary and alternative practitioners.
Eighty to 90 percent are willing to refer to
people who work with hypnosis and biofeedback, imagery, and
other mind-body therapies. About 40 percent are referring
now in both of those surveys to acupuncturists, and these
physicians are also extremely eager for information about
The data on medical schools show that the
physicians to be in allopathic medical schools are also very
eager for these, to learn more about these therapies, and
the study that was published by Wetzel and Eisenberg and
others in JAMA in 1998 showed that 64 percent of all medical
schools were offering at least elective courses in these
therapies, and I would imagine, based on my own
observations, the figure is significantly higher now.
Now, a few problems arise, and these are some of
the problems that we are going to be addressing here, a few
of the sort of areas that we clearly need more information.
One is -- and this is the primary purpose of
today's meeting and, as well, of tomorrow's -- is we need
more data on effectiveness and cost effectiveness, and this
is why we have called in all of you whom we have called in
to present to us. We have asked you the question: Are
these therapies working, in which areas, what are the
limitations, and what is the data on cost effectiveness, so-
We also need to work much more on the issue of
integration, and this is something that we have talked
about, talked continually about, but I think is central and
I think we are going to be called on to make recommendations
in this area.
Here are 40, perhaps 50 percent of the people in
the United States using these therapies with life-
threatening illnesses like cancer and HIV, up to 70, 80
percent of people, how well are these therapies currently
integrated, and we are going to hear today about some models
of integration, and we are going to be asking those of you
who are presenting data on those models how we can improve
on it, what are the lessons you are learning, how well is it
working, what more would you like to do.
In many areas, integration is not working terribly
well so far. As I reviewed the studies on treatment of HIV,
it was very, very interesting and very disheartening that
very few of the people who are HIV-positive talked about
their use of CAM therapies to their physicians.
There is an interesting study, some of the studies
as low as 17 percent, and when you ask people, as I have
done, why not, they say because every time I start to bring
it up, my physician seems very uncomfortable, and I don't
want to upset him, and I don't want him to be angry with me.
On the other side, there is a very interesting
study that I read for the first time by Winnea showing that
only 26 percent of physicians who are treating HIV-positive
people are asking them whether or not they are using CAM
therapies even though 36 percent of the physicians
themselves use CAM therapies.
So, there is something of a disconnect, and I
think on both sides we have to consider how do we encourage
people to talk with their physicians, how do we encourage
physicians to talk with their patients, and how do we
encourage more integration.
This is not only confined to the area of HIV.
There was another study on surgical procedures, cardiac
surgical procedures. Only 17 percent of people getting
ready for cardiac surgery told their physicians about the
CAM therapies they were using, and, of course, many of those
people were using therapies that might affect coagulability,
so they might make for an operative risk by not talking
about the use of therapies.
The other thing that I found interesting is that
48 percent of those people did not want to talk,
deliberately did not want to talk, and did not want to ever
talk with their physicians about their use of CAM therapies
because they were afraid of the response that they might
So, I think there are a lot of possibilities for
us today. I think, number one, we are being asked very
strongly by the people who are using these therapies, we are
asked for help in determining which of them work and which
of them don't work and in which situations.
We are asked by the people who are providing
coverage for the people who are using these therapies how
can this be done, what is the cost effectiveness, how can we
still survive as an entity and provide coverage, how can we
provide standard medical coverage and coverage for these
We will come back to some of these issues when we
focus on reimbursement in the spring. Right now what we are
focusing on is what is the data that we have, but I think we
always need, as a number of you have said in the last
meetings, we always need to have in our mind how is this
going to fit into a schema of reimbursement.
If these therapies are effective, what kind of
models of integration should we be recommending? This is an
important issue, and we will be hearing from some people
with models of integration.
If physicians are interested, what kind of
information, what kind of education do they need, and
physicians do seem increasingly to be interested, what kind
of information, as, for example, the information that is
being presented to us, and what other information do they
need to be presented with.
Finally, how can we encourage, since we know that
if these therapies are available to people, if they are
available to people with cancer, they would use them, if
they were available to poor people and people of color who
are HIV-positive, they would use them, if they are available
to homeless people and homeless children, they, as well as
middle-class people with significant education, will use
So, the final challenge and where we come down to
with this meeting, is how do we, having sorted out or having
helped sort out which of these therapies seem to be most
effective, how do we not only find out the information that
we need to determine more definitively which are most
effective, but as we determine this, how do we make sure
they are available in an integrative way to everyone in this
Let me conclude with that, and if there are any
additions or comments, we can spend a couple minutes on
SISTER KERR: Just a quick question. When you
mentioned the 380 percent increase, and you said it was
herbal and homeopathic, did they separate that?
Dr. GORDON: No, those are separate. It is 380
percent for herbal. There is about a 300 percent increase
SISTER KERR: Is there, by any chance, any
relationship to when marketing began with the herbal
Dr. GORDON: The suggestion has been that the
relationship is to DuShea, in part, yes, and therefore to
marketing, as well. That was a suggestion made by actually
several different surveys that showed that increase in
Dr. JONAS: Just along those same lines, which,
Charlotte, I think you are getting at is kind of behind the
statistics are the reasons why there is the increased access
or utilization, and I think if we are going to address
access, we need to begin to delve into those.
Along those lines, as you know, Jim, there was a
book that has just come out on the social dynamics of CAM
use, and this was actually the result of a conference that
the OAM sponsored, we sponsored with the University of
Toronto about two years ago, which looked at a number of
surveys, as well as detailed qualitative assessments as to
why individuals actually were interested, how they were
using them, how are they getting information about them, and
what the influence circles were, so I think this would be
important information. I am sure we will get some of that.
Dr. GORDON: Thank you. One thing that I just
want to mention, and I am glad you reminded me, is that a
couple of the factors that are really important are, number
one, people coming up against the limitations of what is
available in conventional medicine, but also, and equally
importantly, it would seem a different kind of relationship
with CAM providers that people perceive and often find.
John Astin certainly talks about a congruence of
world view, and I think in another sense -- and this again
gets to the whole reimbursement issue -- time spent is a
major issue, and I think we do have to pay attention to
that, that regardless of what people are doing, they are
spending more time, they are listening more, they are paying
attention more to the whole person who is in front of them,
and that is one of the shaping factors.
Dr. FINS: Jim, did you come across any data
linking increased utilization of CAM therapies with
decreased access to health insurance and sort of the overall
question of access in general, because I have increasingly
heard of some who are disenfranchised, marginalized members
of our community turning to CAM, not as an alternative, but
as a substitute for proven convention therapy, and I think
we need to put that on the table because I think we wouldn't
want to see this as a substitute, but only as an
alternative, as an integrative approach, and not as a
Dr. GORDON: I haven't come across that. Have
you, Wayne, or has anybody else?
Dr. JONAS: Yes, actually, a couple of the surveys
that you mentioned, very few -- and this is why actually I
mentioned getting behind just the statistical data to try to
find out why people are doing this, and in some of the
homeless data, there is evidence that they don't have
access, they don't go and seek the conventional types of
care, and yet, they seek remedies on their own of a variety
of types. So, whether that is due to the fact that they
would or not, I don't know.
On the other hand, individuals that do have health
insurance, then, it is often the lack of reimbursement then
is actually an interference with them. They would say "I
would go get it if, in fact, it was reimbursed." So, I
think it could work either way.
Dr. GORDON: I would actually interpret the
homeless data somewhat differently. The people I work with,
the reason they don't go is not because they don't have
access to it.
They don't like the way they are treated, because
poor people, street people know you can always go to a
hospital, and hospitals are often places that street people
sleep even when they don't go for care, but they often don't
feel they are cared for when they go there, and I think that
that, rather than the absolute denial of access, is the
The people I work with, a lot of them do live on
the street, and that is what they will say, and not just
street people, but sort of working poor people.
I think any of us, well, we know if you go to a
city hospital system, you wait for a long, long time, and if
you can go to a clinic -- and we will be hearing from some
of the clinics here and also in New York where people go
where they see someone within 20 minutes or half an hour
instead of waiting four or five hours, but I think we might
want to take a closer look at those issues, too, and see
what is going on.
Thank you. We can come back and discuss this
context and some of these issues at the end of tomorrow
afternoon as we pull together everything that we will have
learned in two days.
Let's call the first panel.
Ms. CHANG: If the following speakers can come up
to the panel, we will take four at a time here -
Dr. Kail, Patricia Culliton, and Joyce Frye, and Tiffany
Field actually. We will have to get another chair, sorry
Dr. GORDON: We need another chair and a little
It is wonderful to see you all and we welcome you,
and I think we will try to provide a little more table space
from now on. Beyond that, we are very glad to have you and
we are going to be forced to ask you to be brief in your
Let me explain to everyone that is partly because
there are so many people from whom we want to hear, partly
because we want to have the commissioners have an
opportunity to have a dialogue and to take more time with
dialogue about the issues that are raised.
Also, we do welcome -- and I want to say this
again to all of the people who are presenting -- we do
welcome not only the written testimony that you have given
us so far, but any additional written testimony that you
have. We will be reading it and integrating it.
Let's begin with Bill Meeker.
Session II: Clinical and Cost Effectiveness of Selected CAM Services
Dr. MEEKER: Good morning, everybody. Thank you
very much for inviting me once again to address this panel.
I am very honored to do that.
As you know, I am going to make some very brief
commentary related to the things that I submitted already
and hopefully, in our discussion later, will be able to give
you a chance to kind of dive into some of the details.
I do want to say right up-front, though, that
there are three very, very key references I think that the
Commission should be aware of, and I mentioned them in my
Two of them are government-sponsored monographs,
one by the U.S. Government, the Agency for Health Care
Policy and Research, Monograph on Chiropractic. Another
one, sponsored by the Canadian Government VIRGE made to this
panel entitled, "The Effectiveness and Cost Effectiveness of
Chiropractic Medicine on Low Back Pain by Pran Manger and a
team of economists, and then finally, a very recent
monograph put out by the National Board of Chiropractic
Examiners, which is a major survey and job analysis of
chiropractic practices based on a random survey of practices
in the United States.
I think these are very key documents that would be
very useful to the panel as you look into this profession.
I also have a summary report of the Manger report
here to pass out if anybody would like to have that.
I was asked to address the clinical effectiveness
of chiropractic practice and to summarize the data regarding
some specific health conditions, the populations, the
practice settings, and the type of practitioner. I want to
say right up-front that chiropractic is a very mainstream
profession already. Chiropractors see about 25 million
patients a year in the United States.
I also want to make the point, as I did once
before, that when we are talking about CAM in general, we
have to make a distinction between CAM professions and CAM
procedures and substances, because the issues for an entire
profession, a CAM profession, may be a little more -- well,
I don't want to say a "little more complex" -- I think they
are quite more complex than simply dealing with innovative
or new procedures or behaviors or substances that might be
part of the CAM constellation of things. We have to keep
that distinction in mind as we talk about integration and
cost effectiveness and effectiveness in addition to
Chiropractors, of course, use spinal adjustments,
spinal manipulations is their primary signature treatment.
Chiropractors also deliver a great deal of other forms of
care especially exercise and nutrition advice, health
promotion, preventive advice, physical therapy modalities,
So, when we talk about studies on the
effectiveness and cost effectiveness of chiropractic, we are
really talking about packages of various types of
procedures, and it is very hard to distinguish one thing
from the other, so most of my commentary is going to be
today, I want to talk about effectiveness studies. I am
going to be talking about randomized controlled trials of
spinal manipulation or spinal adjustment only. We are not
talking about chiropractor care as a package. That has not
been studied all that much, although there are some studies
When I talk about cost effectiveness studies,
however, we are comparing usually chiropractic care to
medical care for some specific types of conditions.
Usually, those have been workplace injuries, very often are
for low back pain or neck pain.
In terms of the types of patients that go to
chiropractors, it pretty much is a cross-section of
demographic categories in the United States. Chiropractic
patients come from all walks of life, all age and
occupational groups, educational levels, economic levels, et
Patients less than 18 years old account for
approximately 12 percent, and patients 65 years and older
make up approximately 15 percent of the chiropractic patient
My goodness, that time sure does go fast.
There are about 70 randomized trials of spinal
manipulation or adjustment for various types of conditions,
mostly head pain, back pain, and neck pain, and about two-
thirds of those have shown advantage to manipulation.
Manipulation has been rated as an effective treatment by the
United States Government, by the UK, Denmark, New Zealand,
Australia, and Sweden, and I think a few others, as well.
In terms of cost effectiveness studies, there are
approximately 40 studies in this area. Those have all
suffered from various methodological problems, and suffice
as to say that at this point, it looks like chiropractic and
medical care is about the same cost except that chiropractic
patients tend to be much more highly satisfied with their
care, a great area there for additional work.
I will try to quickly summarize. Let me say this
about integration just quickly here. Chiropractic is very
well integrated at the health consumer level and, to some
extent, at the reimbursement and the delivery systems
levels, but when it comes to true interdisciplinary
practice, it is very, very rare and we have a lot of work to
do in that regard, but when we are talking about
interdisciplinary practice, it is really a different animal
than talking about integration at that level, you are
talking about a much different animal than integration at
the health consumer level.
Dr. GORDON: Next is Konrad Kail.
Dr. KAIL: Good morning.
Naturopathic medical education trains family
practitioners in preventive medicine and natural
therapeutics. There are four accredited schools in North
America which teach primary alternative mentalities of
lifestyle modification, clinical orthomolecular nutrition,
botanical medicine, energy medicine, physical medicine,
psychological medicine, minor surgery, and obstetrics.
These schools teach about 200 classroom hours per
modality. The scope of practice varies according to the
jurisdiction and the licensure. The broadest scope
jurisdictions include prescription and controlled substances
and all routes of administration including intravenous.
It has only been recently with the advent of the
National Center on Complementary and Alternative Medicine
that we have actually had funding to be able to look at
outcomes. However, a Medline search of peer-reviewed
literature showed between 300 and 7,000 citations in the
peer-reviewed literature for these various modalities,
however, all of these studies look at individual modalities,
however, naturopathic medicine combines these modalities
into treatment protocols. That has never been studied at
Also, there is a relative paucity of controlled
clinical trials available for review. There is also only a
short history of limited third-party reimbursement to look
at utilization and cost effectiveness issues.
A 1996 study by Emsley, et al., published in
Complementary Therapies in Medicine, compared the efficacy
of orthodox medicine and manipulation, homeopathy,
botanicals, and acupuncture in a variety of conditions.
On a scale of 1 to 5, with 1 not being effective
and 5 very effective, manipulation scored about 2.14,
botanicals 2.9, homeopathy 2.9, and acupuncture 3.6 compared
to orthodox medicine, which was 2.48.
Orthodox medicine was rated most efficacious in
severe, acute problems, but ranked less efficacious in less
acute and chronic diseases.
The same study showed varying results when broken
down by specific diseases. Patients of naturopathic
physicians tend to regard them as their primary care
physicians, although many also see allopathic physicians
because of insurance reimbursement. Ninety-seven percent of
those surveyed said if insurance was no issue, their
naturopathic physicians would be their first and primary
Potential cost savings come from several areas.
Because patients are educated about how to stay healthier
through lifestyle intervention and because the nutritional,
botanical, and homeopathic medicines that are prescribed by
their naturopathic physicians become a home medical chest,
so to speak, for patients to treat themselves, patients
require less office visits, and that greatly reduces the
A survey done by John Weekes in 1996 showed that
respondents actually used less pharmaceutical medication and
actually avoided surgery and other procedures.
When you look at numbers of visits and duration of
care, the average number of visits per year of naturopathic
physicians was 2.6 when compared with 2.4 visits per year to
orthodox family physicians. Sicker people required more
visits, and duration of relationships was similar to family
The American Association of Naturopathic
Physicians showed that when looking at cost comparisons of
allopathic and naturopathic care for an acute problem, such
as otitis media, minimal care costs were similar.
When looking at extended care for the same
problem, the cost differential was large. Naturopathic
physicians rarely need to refer patients for insertions of
ear drainage tubes.
When looking at allopathic and naturopathic
management of chronic diseases, the cost differential varies
depending on the disease. For example, the cost of treating
hypertension is almost identical in the two systems, but
when looking at rheumatoid arthritis, the cost differential
is large when comparing allopathic and naturopathic
Unfortunately, few third-party payers reimburse
for naturopathic medical care. Most patients still pay out
of pocket for alternative care. The Abbott Northwestern
Hospital consumer study done by National Research
Corporation found that most people spent between 100 and
$300 out of pocket in expenses for alternative care between
1993 and 1995.
Botanical and homeopathic therapeutics were rated
as the most satisfactory of alternative treatments with
dietary and chiropractic services being less satisfactory,
however, in general, consumers were well satisfied with
their alternative medical experience.
Naturopathic medicine is a stand-alone primary
health care and is most effective in areas where allopathic
disease management is least effective, that is, in
prevention of disease and in chronic disease management.
The two systems of medicine complement each other
well, and the American public would greatly benefit from
their integration. Naturopathic medicine must be able to
apply the same level of scrutiny that has been applied to
conventional medicine in order for it to be proven safe and
efficacious by use by the American public.
I urge you to recommend greater funding for the
National Center for the Complementary and Alternative
Medicine, which is still funded at less than one-tenth of 1
percent of the NIH budget.
I also find it unfortunate that the vast majority
of people who need this medicine the most have no access to
it. I am referring to the elderly, the poor, and the
disenfranchised who are unable to pay out of pocket for
It is extremely important that you recommend
inclusionary language for alternative medicine in
entitlement acts, such as Medicare, Medicaid, Indian Health
Service, and CHAMPUS for the military. Only then will
third-party payers reimburse for these services to any great
extent. Only then will the great majority of Americans be
able to realize the right to choose the physician and health
care services they want.
I will conclude with a quote from the U.S.
Preventative Services Task Force. "Lack of evidence of
effectiveness does not constitute evidence of
Thank you for your time and attention.
Dr. GORDON: Thank you, Konrad.
Ms. CULLITON: Thank you. Good morning. Thank
you very much for having me here. I am going to speak on
acupuncture, cost effectiveness and clinical efficacy, and
hopefully have a little bit of time to mention some policy
Dr. Kaczmarczyk sent me a list of questions
to answer for this commission, I looked at it and said,
well, give me three years, a hefty budget, and turn me
loose, I would love to find out the answers to these
questions, but unfortunately, I had one week, and so I will
do what I can.
Many of you on the panel know about acupuncture,
and so I don't feel that I need to spend a lot of time
talking about the clinical efficacy of acupuncture with its
4,000-year history and rapid growth in the United States,
but it might surprise you to know that there have only been
79 NIH-funded projects to research the use of acupuncture,
half of those being done in the early seventies with people
like you, and when the United States kind of first
discovered acupuncture after we opened our relationships
Thirty-eight studies have been done since 1992
with the funding of the Office of Alternative Medicine, so
as the naturopathic data is similar to the acupuncture data
in that it is in its infancy in being developed.
We do know that there are clinical efficacy
studies. The National Institutes of Health held a consensus
development conference on acupuncture in 1997, so that puts
it in a different status I think than a lot of other
alternative modalities, but in that consensus conference,
only two areas of utilization for acupuncture were
considered to have definitive data, and then there are
several other areas that had positive trends.
So, again, I also would strongly recommend further
research dollars for the research relative to the clinical
efficacy of acupuncture, but clearly, we have a very good
beginning to that from everything from angina. A lot of
people think that acupuncture is useful for musculoskeletal
pain and analgesia, but there are also good data on
acupuncture for such things as breech version and nausea and
vomiting, dysmenorrhea, bladder disorders, et cetera, so the
whole wide range of what acupuncture might be beneficial
for, and, of course, the development of clinical pathways,
et cetera, is yet to be accomplished.
Relative to cost effectiveness, there are no major
cost effectiveness studies that have been done yet on
acupuncture. There are several studies that were clinical
studies that in the analysis of data, we are able to
discover that people in the experimental group that received
acupuncture had significant financial savings than people
that were in the control group. Again, I would love to be
involved or I would highly recommend that a large clinical
effectiveness study or cost effectiveness study for
acupuncture be implemented.
Because this is a policy commission, I thought, as
I said, since so many of you are familiar with acupuncture
data already, what I really wanted to devote most of my
attention to is the consideration of some policies.
I think it is extremely important that medical
education, nursing education include an overview of all
complementary medicine, and as
Dr. Gordon said, that is
happening already, but in 1957, all the practicing
physicians in China were required to study acupuncture for
two years. They weren't happy about it, but it certainly
changed the health care delivery system in China after that.
I am not saying that I want you to request that
all physicians suddenly go back to college for two more
years, but to strongly recommend that CME courses and CEU
courses be available specific to acupuncture, but for CAM
modalities in general, I think is just absolutely necessary
at this point.
Public education, some of the surveys that have
been done on acupuncture, Eisenberg and the Paramor and the
Robert Wood Johnson Foundation study, all done in 1997, say
that less than 1 percent of Americans have ever tried
acupuncture, and a 1999 landmark study said it is up to
about 2 percent of Americans, but that a very small portion
of the United States has even tried acupuncture. Since we
do tend to think that the data supports clinical and cost
effectiveness, I would like to see a public education
program implemented, as well.
One thing that is very dear to my heart is public
health, and I would like you to consider a school loan
forgiveness program for those people going to acupuncture
school, that would commit themselves to work in public
health agencies after graduation.
I know I just have a few seconds, but I want to
say that I am involved with the National Acupuncture
Detoxification Association, as well as other acupuncture
organizations, but thousands of Americans right now are
being deferred from prison into acupuncture programs for
first-time felony cocaine offenses. Forty percent of the
drug courts in the United States use acupuncture as their
The estimates are that it is between 30- and
$40,000 per year for a one-year incarceration, and thousands
of people have avoided incarceration by the use of
acupuncture in the drug court program.
That cost savings is staggering, and nobody has
really looked at those numbers, but we can just extrapolate
those numbers that just relative to public health, the cost
savings to the American health system I think are absolutely
staggering. I encourage you to consider that.
Dr. GORDON: Thank you very much.
Dr. FRYE: Good morning and thank you for the
opportunity to join you today.
According to the World Health Organization,
homeopathy is the second most widely practiced form of
medicine around the globe. The International Homeopathic
Medical Organization LIGA has thousands of members in five
continents in over 40 countries.
Unfortunately, although there are an estimated
2,500 medical practitioners using homeopathy in the U.S.,
research on both clinical efficacy and cost effectiveness
has suffered from limitations that are common to all of the
Thus, our assumptions about the advantages of
fully integrating homeopathy into the U.S. health care
system are augmented with international and historical data,
as well as a 200-year collection of thousands of case
The most useful summary of clinical efficacy is
provided by the meta-analysis of 89 placebo-controlled
trials published by Lynde, et al., in Lancet September 1997,
indicating that patients using homeopathy were two and a
half times more likely to have a therapeutic effect compared
to placebo in a variety of conditions.
References to a number of additional studies on
treatment of specific conditions are included I believe in
The most complete data on cost effectiveness comes
from the French Government report on 1991 Social Security
statistics which demonstrated significantly reduced costs
using homeopathic versus conventional medical care.
The total cost of care in the office setting for a
physician utilizing homeopathy was approximately one-half of
the total cost of care provided by conventional primary care
physicians even when factoring in the cost of fewer patients
seen per homeopathic physician, the overall cost per patient
under homeopathic care was 15 percent less, and savings
increased the longer a physician had been using homeopathy.
Additionally, in a further review of the data, the
number of paid sick leave days by patients under the care of
homeopathic physicians was three and a half times less than
patients under the care of conventional practitioners, and
while homeopathic prescriptions, which are reimbursable in
the French health care system, represented 5 percent of all
medicines prescribed, they represented only 1.2 percent of
all drug reimbursements due to their lower costs per
These data are particularly compelling in view of
France's number one rank in overall health system
performance, and number three rank in life expectancy
according to the World Health Organization compared to
number 37 and 24 for the U.S. respectively.
In the U.S., a small study surveyed 27 physicians
specializing in homeopathy and compared them to the 205
general and family practitioners in the 1990 National
Ambulatory Medical Care Survey.
The comparison tables and charts from that study
are also provided in your handout. Again, although spending
more time with patients, they ordered fewer tests and
prescribed fewer conventional medicines for similar
Homeopathy also compared favorably with
naturopathic and acupuncture services in a Seattle study
that concluded that homeopathy was the least costly and that
patient visits to homeopaths were less frequent than to
other alternative care professionals.
Patient satisfaction with homeopathic care tends
to be high if for no other reason than the time a
practitioner takes in listening to the story. However, a
California study also surveyed patients regarding their
Eighty percent of them had previously sought
conventional care for their condition. After four months of
homeopathic care, 60 percent reported improved overall
health status and outlook, 70 percent reported at least
partial improvement in their chief complaint, and 80 percent
planned to continue homeopathic care.
Homeopathy is effective for a variety of health
conditions throughout the continuum of care from pregnancy
to the end of life without regard to age, gender, or
With respect to our colleagues, the organism is
certainly best equipped to respond to a homeopathic medicine
when it is also well nourished and in musculoskeletal
alignment, however, we see homeopathy as the first therapy
to consider in many circumstances.
We have no data comparing costs from one setting
to another, and I would propose that the most appropriate
setting, degree of collaboration, and type of practitioner
vary with the type and acuity of the condition being
treated. Consider the following framework.
For minor viral infections and traumas, the most
appropriate care setting is usually in the home. An
estimated 3.4 percent of the U.S. population was using
homeopathy in the 1997 Eisenberg study. It is difficult to
assess how many physician visits might be avoided all
together if public awareness of homeopathic self-care was
That, in turn, would decrease the accompanying
long-term sequelae of inappropriate antibiotic use,
increasing antibiotic resistance, and iatrogenic illness.
For more serious acute conditions, homeopathy may
provide complete care in the hands of the primary care
provider. Indeed, in the flu pandemic of 1918, where over
half a million Americans succumbed and the average mortality
was 30 percent, less than 1 percent of patients treated
homeopathically were lost, with some homeopathic physicians
reporting treatment of thousands of cases.
In the realm of obstetrics, I have used homeopathy
to treat nausea and vomiting, to arrest preterm labor, to
convert breech presentations, to facilitate labor, thereby
avoiding numerous hospitalizations, procedures, and
intensive care days.
The framework goes on through the entire continuum
I would like to just cover what we perceive as the
Dr. GORDON: We need to move very quickly, though.
Dr. FRYE: Okay. Patients confuse the "h" words,
holistic, herbal, and homeopathy, thinking that they are
synonymous. The number of homeopathic medical practitioners
is very limited due to expensive and prolonged postgraduate
education and lack of CME accreditation.
Insurance policies and billing codes are biased
towards procedures rather than time spent, and nonmedically
licensed practitioners, who wish to practice homeopathy, are
similar to their counterparts in Great Britain and other
countries, have uncertain legal status in the U.S.
Dr. GORDON: Thank you, and we will come back to
the recommendations in the discussion period. Thank you
Dr. FIELD: Thank you for inviting me. I am going
to talk about massage therapy, which I guess could be
classified, along with acupuncture, as one of the oldest
therapies. If one goes back to Hippocrates in 400 B.C., he
said that medicine was the art of rubbing.
That has been pretty much forgotten. Massage
therapy disappeared from the hospital scene. Perhaps you
remember if you were hospitalized in the forties, you
routinely got a back rub at least to avoid bed sores, but in
the fifties, much of that disappeared from the hospital
According to Eisenberg and a number of those other
epidemiology studies that have been done, massage therapy is
among the top half dozen or so of the alternative therapies
that are being sought by the American public, and the field
of massage therapy itself is one of the fastest growing
professions at least in the United States, so there is some
sense of movement of the field being reinstated as a
There is not very much research on the
effectiveness of massage therapy. Much of the research that
has been conducted has come out of the touch research
institutes over the last decade, and we have conducted
approximately 83 studies in different areas from growth
problems, for example, reducing prematurity and low birth
rates associated with pregnancy, stress, and anxiety,
enhancing the growth of preterm babies whose agenda once
they are out of medical jeopardy is to gain weight.
A number of studies in the psychiatric area
including attention deficit disorder, autism, depression,
related addictions, such as eating disorders and smoking,
and then a number of pain syndromes including migraine
headaches, low back pain, fibromyalgia, premenstrual
syndrome, and so on.
Much of our recent work has been focused on
autoimmune problems, everything from asthma to diabetes to
dermatitis, and immune problems, namely, HIV and cancer.
I think the most exciting findings aside from the
preemie growth studies, which I am going to elaborate on a
little bit for the cost effectiveness part of this, but
aside from that, I think the most exciting data are the data
associated with the HIV and breast cancer studies showing
that not only can we increase natural killer cells and
natural killer cell cytotoxicity, such that the immune-
compromised HIV victim, for example, will be less likely to
die of opportunistic infections, but also in a recent study
just published, we were able to alter the disease marker,
the CD-4/CD-8 ratio in adolescents with HIV. So, I think
those are some of the most exciting data that are coming out
of the efficacy studies.
With respect to cost effectiveness, there has been
very little done mostly because the studies have focused on
subjects who are clients who are not hospitalized, and so
the cost savings cannot be determined, the hospital cost
So, the only study that we have cost effectiveness
data on is the preemie studies where we are able to actually
determine the costs of hospital savings and the cost of the
treatment, and to give you an example of that, eight years
ago when 470,000 preemies were being born for a year in the
United States, if they were to receive the massage therapy
for the 10-day period that they did in our studies, they
would be discharged six days earlier at a hospital savings
of $10,000 per baby.
If you multiply that by the 470,000 babies, you
have a $4.7 billion hospital cost savings. Now, an
interesting wrinkle in that is that the other part of the
equation that could not be determined is cost savings
associated with using elderly volunteers to actually do the
therapy, in which case we had reductions in stress hormones
in these elderly people, we had fewer trips to the doctors'
offices, and variables like that, that reflected that their
health was better following giving these preemies the
So, that is basically all I can say at this point.
The research continues. Fortunately, the Center for
Alternative Medicine has funded some new projects in the
area of massage therapy, and the massage therapy
associations are trying to get research training to the
massage therapists, so there will be more people doing
Dr. GORDON: Thank you very much. Thank you all.
It was really extremely valuable and helpful to us.
For questions, the way we will do it is if the
commissioners will raise your hands, and I will go around
and just pick people in the order in which you raised your
hands. Remember, we have set aside more time. We have
about 20 minutes to ask this panel questions, so please make
the questions brief and to the point, and let's engage them
in discussion. We have them for 20 minutes or so.
Who would like to ask questions? Veronica and
Dr. GUTIERREZ: I would like to direct my
Dr. Meeker, and I would like to know how Palmer
College and the consortium plan to address the clinical
benefits of chiropractic care in patients without ailments,
that is, the quality of life issues.
Dr. MEEKER: As
Dr. Gutierrez knows, Palmer has
more the NCAM-supported centers in the United States,
focuses chiropractic care, validity, effectiveness, and
We address quality of life issues in all of the
clinical trials that we are involved in right now, and we
are looking, at least in a clinical sense, and we are also
embarking on a very interesting basic science series of
studies using some animal models to investigate what happens
when we have spinal dysfunctions, fixations, et cetera, what
happens to the physiology of the body when it happens.
We have discovered there are some very interesting
effects that we have been able to create, and now we are
working on whether or not we will be able to reverse those
sorts of things. So, this is a very intense area of
research, and we are looking at that as quickly as we can
with relatively limited resources right now.
Dr. GORDON: David.
Dr. BRESLER: We know that one of the things that
will impact greatly on access and delivery is the extent to
which we can teach patients self-management. I would just
be interested very, very briefly on comments about how each
you feel your professions are addressing this issue.
In pharmacotherapy, for example, we have over-the-
counter medications that people can take for themselves and
prescription medicine that they have to see professionals
for. How much is chiropractic and naturopathic, how much
within your professions is there a dedication to teaching
self-management of your techniques to the public?
Dr. MEEKER: There could be a long discussion, but
the quick answer is that chiropractors are very interested
in preventing the kinds of problems that arise, and
primarily we are interested in the locomotor system, the way
people move in their environment, and this, of course, leads
to considerations of general fitness, symmetry of movement
and ergonomics, and the impact of those things on lifestyle,
the effect of smoking, for example, which affects the spine,
and the effects of nutrition, as well.
Dr. BRESLER: But there are some simple
manipulations, for example, that you could teach patients to
do to each other. For example, is there interest within the
profession to do that?
Dr. MEEKER: I am not necessarily in favor of
that. I think that it takes some skill to be able to figure
out what needs to be adjusted and to be able to deliver the
appropriate adjustment at the right time. I think there are
some safety issues with respect to that.
Dr. KAIL: Many of the therapeutic agents that
people commonly use are available over the counter, so many
patients, almost all the patients that naturopathic
physicians treat are self-medicating at home.
The Weekes study that I mentioned also looked at
training of home care for people, and it did show that the
great majority of patients were treating themselves at home
now, when they had to previously go to the doctor for care
once they had been educated by the patients.
This also gets in the lifestyle issues. The
biggest thing that reduces chronic degenerative disease is
not taking any modality, it is changing lifestyle, and
education about lifestyle and awareness about lifestyle
actually increases compliance in the patients.
In my own study of my own patients, I got about 92
percent compliance in people following medication use at
home, treating themselves at home, and following their
Ms. CULLITON: Self-care is an integral part of
Chinese medicine and acupuncture and dietary
recommendations, exercise, such as Qigong and Tai Chi, but
also I think just in general acupuncturists teach their
patients how to do acupressure for self-care between visits.
But if I could just take a little extra time, and
I don't know if it's in your book, the two pictures that I
sent the pre- and post-, if you could find that in your
books, a self portrait of a 16-year-old girl with Downs
syndrome, ADHD, and nystagmus, and one week after wearing a
acupressure tab, there was a second self portrait which I
think, if we want to talk about public health and public
education, you know, who needs randomized controlled
clinical trials when you can see how this one child, who was
affected after one week, but the important part of this is
that this was a technique applied by her mother.
The acupuncturist did an education session in a
public school, taught the teachers and the parents how to
apply an acupressure tab on the ear for their children, and
so this kind of public education is what I was referring to
earlier, as well.
Dr. FRYE: The National Center for Homeopathy has
affiliated study groups, which encourage anybody who wants
to learn about homeopathy to get together in a small group,
and it supports them with educational materials and
conferences and volunteer regional coordinators, so that
they can learn about how to use homeopathy for themselves
and their families.
The most common sales of homeopathic products,
though, are in the combination remedy realm where people
just pick up a bottle of allergy or migraine, or whatever
the combination might be, and actually, the teething product
is the second overall leader in sales in that category, but
the feedback from the manufacturer on that product is that
only 11 percent of the people who use it know that they are
actually using homeopathic products.
So, we do have a big problem of translating the
use of the product to understanding the bigger paradigm of
homeopathy and how to use it more specifically.
Dr. FIELD: A lot of our massage therapy studies
are self-massage. All of the chronic illness in children's
studies, the therapies are provided by the parents on a
daily basis just before bedtime, so they can have intensive
A lot of self-massage is taught in the adult
studies. For example, we just completed a carpal tunnel
syndrome study that was entirely administered by people to
themselves during the course of their work hours.
Then, of course, you have all those gadgets you
can buy at Brookstone, chopper image, and brush yourself in
the shower, and so on, just as long as you stimulate deep
pressure receptors. We don't get any of the effects we talk
about unless there is stimulation of the deep pressure
receptors. Some of that you can get in exercise and sports,
and so on.
Dr. GORDON: Thank you all for your comments.
Dr. JONAS: Thank you, Jim. I basically have
three questions targeted to different individuals.
First, Bill Meeker. There are some good examples
of integration, maybe not a lot, but there are a few good
examples of integration. Could you help the panel and kind
of pointing to some of those? You don't necessarily have to
do it here, but if you could provide us with some examples
of that, but if there aren't any, then, let me know right
My question actually to you is slightly different
than that, unless you wanted to respond briefly to that.
Dr. MEEKER: Go ahead, Wayne.
Dr. JONAS: Okay. Was there a perception prior to
some of the direct cost effectiveness studies that have been
done in chiropractic, that chiropractic was more cost
effective than many of the conventional therapies, was there
a perception of that putting satisfaction aside for a
Dr. MEEKER: Satisfaction aside, studies go back
to the 1960s, comparing cost of chiropractic care versus
cost of something else, and most of the studies before 1990
do demonstrate that chiropractic care is probably less
Studies since 1990 using much more sophisticated
techniques now have been a mixed bag in terms of which have
turned out to be better. I think we can say that
chiropractic care has now risen to the dubious level of
perhaps being as expensive as medical care.
Dr. JONAS: This really relates to my second
question, is that there is a perception usually prior to
direct quality trials that, gee, this is cheaper, I can do
it and my patients are satisfied, which is usually the case.
In acupuncture and naturopathy and homeopathy,
where there have been no direct assessments of cost
effectiveness, I guess my question to you all is where do
you think those studies should be directed, should we look
at modalities, for example, which are easier to look at, and
you can look at the cost add-on to that, or should we look
at whole systems, because I know these systems have their
own philosophy and their own approach, which is much
different than simply adding on a modality.
I think the lesson from chiropractic is when you
look at a whole system, you get very different answers than
when you are looking at a different modality. I wonder if
there is any suggestions or comments on that.
Dr. KAIL: From the naturopathic perspective,
again, we never practice single modalities in individuals.
It is always a whole system or a protocol which always
includes lifestyle management, as well as various agents
that might be applied to any given condition.
So, I think taking the modality approach really
does disservice to the power of medicine. I think you have
to look at the whole syste
We certainly have been pushing in that direction
at NCAM, trying to develop protocols that will look at whole
systems, which is very difficult methodologically as you can
see, but we need to overcome those difficulties and come up
with new methods to look at whole systems and how it affects
things, because I think that is really where the cost
effectiveness is going to be demonstrated.
Dr. JONAS: I would wonder about that given the
chiropractic data that is more sophisticated now than some
of the others and developed. Also, one of the main problems
is there is heterogeneous types of practices, so if there
is, in fact, something that you are going to practice, that
has to be systematized in some way.
Dr. MEEKER: Can I follow up? I should say this.
There is not one single randomized controlled trial that
has used the proper economic variables and analyses of
chiropractic care that I know of in the world.
Economists argue vociferously with each other
about the proper models to apply, as well, so this is not a
Dr. JONAS: It isn't simple. In fact, it is very
hard to do cost effectiveness studies in general in any
area, and I think what a lot of you are referring to is not
just cost effectiveness, you are talking about cost-benefit,
not just, you know, does it work for this particular thing,
but what is the overall benefit that you are getting
including satisfaction and other types of value issues that
can be incorporated into cost issues.
Then, I had one question for Tiffany. What are
the barriers to delivery of massage therapy in areas, such
as neonatal or intensive care units where there has
apparently been demonstrated quite remarkable, dramatic cost
Dr. FIELD: In neonatal intensive care, which I am
most familiar with, there has been a no-touch or minimal
touch policy. It is sort of shades of where we were two
decades ago when we stopped feeding these babies because we
thought that we shouldn't be feeding them, and similarly,
now, we think we shouldn't be stimulating them because they
will get physiologically disorganized.
So, it goes against a whole grain of education
that these neonatologists have had, and it is going to take
time and more data. There was a study that just came out
showing not only is there weight gain associated with this
kind of treatment, but there is increase in bone mineral
content and the actual growth of bone.
So, this will be more convincing and with the
FMRIs that are going on, that will be more persuasive to
Dr. JONAS: You are saying it is largely a
conceptual barrier then.
Dr. FIELD: Yes, we need underlying mechanism
studies is what we need to persuade the physicians that
these things are working.
Dr. JONAS: Interesting.
Ms. CULLITON: If I could comment on that, though,
Dr. Jonas, I think there is also an issue of hospital
privileging and credentialing for non-physician or nurse
providers to come in.
I know I have been going through that in Minnesota
where I run a program, and you can get a lot of people
within a system to say yes, we would like that, and then
there is still another barrier of actually getting
permission for the massage therapist to come to the site.
Dr. GORDON: Tiffany, I wonder if you could help
us get some data on the controversy, if you would, about the
sort of different views of growth and development and of
what interferes and what facilitates it.
Dr. FIELD: Uh-huh.
Dr. GORDON: Thank you.
Dr. FAIR: For
Dr. Kail. I was struck by the
study that was in your handout, the Emsley study, and I want
you to comment on the quality of the data and whether or not
there is a confusion between patient satisfaction, patient
perception, and efficacy.
For example, in one of the slides, pneumonia is
treated conventionally, you know, somewhat better than
alternative therapies, but not dramatically better, on a
five-point Liker scale.
Was this actually asking patients their
perceptions of efficacy or was it a true marker of efficacy?
Dr. KAIL: I believe most of this is patient
perception because I think most of this was done through
surveys of the patients. I don't think there was any real
hard markers of efficacy really established in the study,
but as I said, there is very positive studies, and this one
seems to be one that represents at least something that is
out there around efficacy that looks at a whole lot of
different modalities rather than a single modality.
Dr. FAIR: Because there is a sort of statistical
awareness that when patients are asked, they tend to over-
inflate patient satisfaction in a whole range of surveys
including in the airline industry, they will overestimate
the true efficacy of the experience.
So, I am just wondering if you could make some
concrete recommendations of the kinds of studies that you
did bring a lot of this together, of the kinds of data that
will be more convincing and more helpful in organizing the
assessment of the disease categories that you are outlining
How would you design studies and what kind of data
would you like?
Dr. KAIL: Well, I think you are going to have to
do clinical controlled studies of a whole system, but you
need to step-wise it. Again, it is hard to do with a
placebo, for instance.
So, I think comparing it to conventional care in a
step-wise fashion where, for instance, such as if you want
to treat a clinical condition like, let's just say
allergies, to pick one, that you start with what is parallel
to conventional. So, they start with using antihistamines,
decongestants. Well, you start with doing similar things
using natural agents.
Then, they step up to doing some kind of
desensitization procedure. Then, you step to doing a
desensitization procedure using a natural agent. You
compare them across the board for just medication use,
symptom decline, and any objective parameters you could,
antibody levels, cytokines, chemokines, something like that,
and there are some trials that at least we are proposing to
do that are going to look at those kind of issues, but I
think looking at step-wise models that really compare
conventional with the alternative models, I think that is
the best way to get at that without trying to use a double-
blind crossover placebo-controlled trial. I just don't
think that those methods are going to work for looking at
Dr. FAIR: Thank you.
Dr. GORDON: I have Tom, Bill, Charlotte, and
Effie, and then we are pretty much going to have to stop
Dr. Kail, I would like to explore
your recommendation that the CAM be supported by Medicare
reimbursement, Medicare/Medicaid. As you were saying in
your report that both modalities, that is, allopathic and
naturopathic integrate well, but I would like to understand,
I think more specifically, how the orientation towards
prevention of disease or promotion of wellness can be broken
down into a reimbursable segment of time and services.
Can you help me understand, in your report, for
instance, when you talk about the different treatments and
modalities that are taught in the institutions of lifestyle
modification, nutritional supplementation, herbal
prescription, we are not just talking about chronic
problems, but prevention.
How do you envision that reimbursement, what would
that look like in your opinion?
Dr. KAIL: As there are now, there are new codes
that look at interventions that are more preventive. There
are codes that you have for time allowed for discussion and
education that are not being used by the insurance industry
They are still sticking to pretty much the old
allopathic definitions of what time and reimbursement is
used, but there are new codes that have been specifically
set up for looking at time in educating patients on how to
do lifestyle intervention.
In my own case, I usually spend an entire office
visit talking about those issues, and after screening a
patient, giving them information about what is appropriate
for them to do, and then asking them to do that. But I
think you have to build it into the office visit, which
requires more time. You have to get away from the 10-minute
office visit. I schedule 30-minute office visits for all my
patients because a large part of what I do is convincing
them to take better care of themselves.
So, that is reimbursable under most insurance
schemes right now if you are looking at 30-minute visits,
but it does take time to educate patients. You have got to
give them a reason to do these things, and that is where the
objectivity comes in of what you can measure, but it is an
educational effort, and I think that is the best way to do
it, is build it into the office visits as far as time.
Mr. CHAPPELL: Should I assume that Medicare and
Medicaid are standards, in your opinion, for reimbursement?
Dr. KAIL: Well, I think that is a standard of
Mr. CHAPPELL: That is my real question. Are we
looking for credibility or economic sustainability?
Dr. KAIL: I think the credibilities may come more
from the research side. I think the economic stability is
going to come from the reimbursement side, but you don't get
one without the other is the problem, and I think that
inclusionary language will allow more people to come
forward, so that insurance companies can get better data.
Right now, for instance, some of the insurance
companies that have been reimbursing are not reimbursing for
certain programs anymore. I can give you one example.
There was a program that put a cost of $7.00 per member per
month for reimbursement for alternative services. That was
not well advertised, and even though there was a cohort of
people that had access to this care that were seniors,
because it was poorly advertised to the seniors and because
it was such a great expense and not well sold to the buyers,
it was an underused program that was not continued because
of lack of use.
Well, had that been a different thing where it
would have been more like 50 cents per member per month,
which some plans have advocated, and it was well sold to the
people that were buying it, the employers, et cetera, they
would have had a better outcome and they would have
continued that longer, and they would have had better
statistics to use for their own utilization statistics.
That is proprietary information. There are
granting mechanisms that the NIH have come up with now, that
hopefully, actuaries and other people will allow a pool of
information to stay in a non-proprietary fashion where we
can get those utilization statistics out, but reimbursement
is not going to come until there is better figures on
utilization, and I think forcing that a little bit by
inclusionary language in Medicare and Medicaid is the
fastest way to get that to come forward.
Dr. GORDON: Thank you.
Dr. FAIR: My background has been entirely,
professional background, entirely in medical schools, so I
am interested in education, and I will address this question
to Patricia, but it is really a global question to the
That is, how do we go about this education? You
had mentioned, I believe, that training physicians in
acupuncture, clearly, medical school, as jam-packed as it
is, we can't train physicians to be acupuncturists and
naturopaths and chiropractors and massage therapists, and so
forth, so is this education better spent in terms of
training medical students and physicians in the
effectiveness and perhaps a cost benefit of these things as
opposed to delivering the modalities themselves, or just how
do we get this training and what kind of training should it
Ms. CULLITON: Well, I agree with the second half
of your statement or totally of your statement. No, I do
not think that in medical schools we should try to
incorporate into medical education that everyone become an
acupuncturist and a homeopath, et cetera. It would be
impossible, unless we want our physicians to go to school
for 20 or 30 years.
Dr. FAIR: But Andy Weil, for instance, who
started this integrated fellowship, that is an example of
that type of approach.
Ms. CULLITON: That is an example, and my division
in Minneapolis is an example of a different type of approach
where we are actually within the Department of Medicine at
an academic institution, but all the providers are non-
physician providers. Salaries are significantly less, et
cetera, but there is also a wider depth of knowledge of a
particular intervention when somebody has studied strictly
Chinese medicine for five years.
So, my recommendation is that medical education
should include overviews of what is out there, clinical and
cost effectiveness, appropriate referrals, et cetera, and if
physicians have a dream, have a path, I know there is an
American Medical Acupuncture Association, and a lot of
physicians really have taken very seriously into studying
Those options would be available, but that isn't
part of the curriculum that I am talking about that I would
like to see in medical school education. It would be much
more the overview of how to interact, appropriate referrals,
those types of things.
Dr. MEEKER: I agree with you. I think that the
time is spent learning about those things with one
additional thing, and that is training in interdisciplinary
practice. A few health commissions have recommended that
interdisciplinary behavior be explicitly taught in medical
school, and I think that there is a big need for that.
It is difficult now even, and I think with respect
to the CAM professions, there is even a greater need to
train all health professionals, not just medical doctors,
but CAM professionals, as well, in how to interrelate to
Dr. FAIR: So, you would recommend then that the
various modalities under the CAM umbrella, if one could
categorize all of them, would be an integral part of the
education of medical students and young physicians?
Dr. MEEKER: Not to the point of actually
performing them, but, as you said, to understand them.
Dr. FAIR: Okay. Again, benefits and efficacy,
and so forth.
Dr. MEEKER: Right.
Dr. KAIL: I think that distinction needs to be
made very clear, though. I think there is a lot of
allopathic physicians out there that go and take a couple
courses in this and that, and then proceed to practice that
without a full appreciation of all the other stuff that goes
behind that culture.
I think it is very important that we make a big
distinction between this is informational, so that you will
have an appreciation for this modality and know whether or
not you want to recommend it to a patient as opposed to this
is the level at which you can start practicing this.
Again, I would recommend that if you don't have
200 hours of classroom, you probably shouldn't be reimbursed
and you probably shouldn't be practicing that modality.
Dr. FAIR: This is my concern. I think in New
York, an M.D., and I may have been off in the numbers, can
get a license as an acupuncturist in something like 300
hours where it may be 3,000 hours for someone that goes the
traditional route. I have no personal experience, but I
just can't imagine that you could learn as much in a tenth
of the time.
Dr. FRYE: I see the situation in homeopathy a
little differently. We actually have two levels of
certification. At this point they are not terribly well
established or disseminated, but there is an acute care
level, as well as a sort of specialist level, and I think
that given that homeopathic medicines are included in the
FDA Homeopathic Pharmacopeia, that having at least primary
acute level of training in homeopathy in medical school,
along with your traditional training in pharmacy or whatever
you might use to treat a particular condition is
Certainly, going to the level of specialist
training in medical school would be far too time-consuming,
but I think acute level of training is entirely possible.
Dr. GORDON: Thank you. We are going to have a
chance, I think this is a very important issue to come back
to this for the education panel.
Dr. FAIR: I have one question for Tiffany also.
What are the barriers to massage in cancer patients, because
I hear this a lot from massage therapists and also some
physicians, although it is sort of lessening from
physicians, but there was a time not too long ago, 20 years
ago, when children with abdominal tumors, for instance, they
would post signs on the bed, "Do not palpate," and I think
this is still imbued in some of the massage therapists'
philosophy. Am I correct?
Dr. FIELD: My understanding currently is that the
contraindications are coming from the massage therapists,
not from the pediatric oncologists. The argument they make,
the massage therapists are saying that basically, they are
concerned about metastasis and the spread of cancer by the
increase in blood flow and lymph, and so on.
Dr. FAIR: Is that real or theoretical? I guess
that is my question.
Dr. FIELD: It is certainly not real, it hasn't
been tested, but the oncologists will say, well, for the
same reason that you are concerned about the cancer being
spread, we are concerned about blood flow spreading the
immune cells. So, there is still a lot of controversy about
Dr. GORDON: Charlotte.
SISTER KERR: I heard important speaking this
morning on at least three points, and one was that caring
time and listening healed touch was essential to healing,
physical, mental, or spiritual, and that it was essential to
empower people to heal themselves.
Tiffany, I was very edified to hear about your
study with the elderly and the babies and to see the
mutuality and the healing, and what I wanted to ask you and
anyone on the panel is since the role of the prophet is one
of imagination, what could you imagine could be done? I am
looking specifically at grass-roots level at this moment of
public health in your particular area that might have a
significant effect within a local community.
For example, I could imagine that mothers sharing
massage, you know, would decrease postpartum depression and
probably a million other things, but a massage co-op, you
know, in the community, come in and you borrowed a massage.
So, I am wondering -- and it could come from other
members of the panel -- is there anything there you could
tell me now or, if not now, if you could give it to me later
for the panel.
Dr. FIELD: Well, I would like to say that I think
that our elderly are a wasted resource and are beginning to
present a lot of problem related to depression and touch
deprivation, and so on, to the medical community, and I
think that preschools, for example, could use elderly
volunteers in a very big way.
That would get a lot of touch going. I don't know
if you know, but a lot of mandates are out there now that
children should not be touched even in preschool because of
concern about the legal aspect of sexual abuse, and so on.
I can't imagine an elderly person being accused of
sexually abusing a preschooler. I mean it is less likely
than, say, a young man or something. So, I think that that
would be one way to get grass-roots preventive care going
for both sides, the elderly and the young people.
Dr. KAIL: I think partially it is a quality of
information problem. A lot of people are doing self- care,
as we said, but a lot of it is based on poor quality
information that is just in the lay press or especially
multilevel marketed stuff. There is a whole lot of bad
ideas being put out there by people that are uneducated and
a lot of poor recommendations out there by people that have
So, I think there needs to be some venue at the
community level where people can tap into to get quality
information about health care practices whether they be
alternative or conventional.
Dr. MEEKER: One last thing on this area. In
terms of prevention and health promotion, wellness care, I
think one of the biggest problems in clinical practice is
that doctors of all stripes don't get reimbursed for that
time, and if there was a way to recommend that billing
codes, reimbursement systems, et cetera, would start to
recognize that this an important part of clinical practice,
that perhaps we could start changing doctors' behavior, that
would soon start changing patient behavior, as well, but I
think one of the biggest barriers is at the reimbursement
Dr. GORDON: Effie.
Dr. CHOW: All the discussions that have taken
place leading to this sort of more global and visionary
question that I have is that we discuss about health
promotion and education and teaching self care, and care,
and giving time, and all that, is it appropriate to try and
look at integrating this into a medical model or in your
ideals and your dreams and your goals, what would you see
your profession, how does it stand, as separate or
integrated in a different way, setting a different parameter
or paradigm, or trying to squeeze it into the mold that we
have as a health care system?
I know you don't have time to answer this, but I
certainly would like some written things back, but if you
have some comments, I would really appreciate that.
Dr. KAIL: Just a brief comment. I think that
naturopathic medicine is inherently focused on prevention
and self-care issue. I think that if there was an
opportunity to have those issues addressed first in the
medical model, that that would go a long way, whether that
be integrating that care somehow by having them come in as
gatekeepers, and send them out to other people, I don't
know, but I think that some venue where early on in care
those issues are addressed at a stronger level than they are
now would facilitate the whole process.
Dr. GORDON: Thank you.
Tiffany, are you planning to replicate the study
Dr. FIELD: Well, we have done several
replications, and now there are approximately five
replications in other parts of the world using the same
Dr. GORDON: Could you give us that data, as well?
Dr. FIELD: Yes.
Dr. GORDON: That would be very helpful.
Tieraona, I know you want to ask a question.
Dr. LOW DOG: Real quick. Thank you.
I think this is for anybody, but especially for
Konrad. In Western medicine now, with the consort statement
and a lot of work being done on trying to improve quality
trials and trying to improve evidence, we are now looking at
taking away many things, we are not paying for as many
things, and it is changing the way physicians practice
medicine as we move more and more towards evidence-based
While I realize that there is just an absolute
shortage of funding for CAM therapies in general, so it puts
us in this place of a bind, is it a bit premature, are we
putting the cart before the horse a little bit to want to
include things that are not yet proven, it doesn't mean they
are ineffective, but not yet proven to be reimbursed by an
already overburdened system, such as Medicare and Medicaid?
Dr. KAIL: I think that is the catch-22 question
to end all catch-22 questions, how can you find out the
information without large bodies of people having access to
those types of care.
I think we are going to have to spend a few
dollars to let some at least controlled groups have
unlimited access to that care to see what happens.
I think you can do that in a controlled fashion,
but I think that is going to have to come first, so that a
good segment of the population, especially the poor people,
I mean there is a perception that is starting to change that
it isn't white, Anglo-Saxon, Protestant, higher educated
people, but I would like to see some more trials in specific
populations, the elderly and the poor folks, small children,
et cetera, that come forth.
But I think we are going to have to spend some
dollars and give some open access to at least a few groups
in controlled situations in order to get the data we need to
know what to spend more dollars on.
Dr. MEEKER: I think, Tieraona, that there are
issues of equity, too. Chiropractors are not reimbursed in
the Medicare system now even though spinal manipulations is
one of the most studied forms of care for back pain at
least, and is recommended by the U.S. Government, and yet we
are treated as third-class citizens in the Medicare system.
So, I think what it really comes down to when we
are talking about some of the stuff is not whether something
needs to be proven or not before it is included, but whether
or not the things that are already paid for actually have
evidence, as well, and is equity being applied to the entire
Dr. LOW DOG: I would just like to say be careful
of what you wish for because you might get it. I spent
about seven or eight years trying to get medical assistance
reimbursement for acupuncture in Minnesota, and we have it
now, and I am glad that we do, but we get $12.00
reimbursement, we probably spend $20.00 on paperwork, and we
would go broke if we only had a practice of people receiving
It is a wonderful gift to be able to offer that to
an expanded community, but I think we have to be cautious in
what we ask for.
Dr. FRYE: I think it is important to us while
looking for evidence, too, that we try to avoid doing just
the quick and dirty studies that give us, yes, this modality
works for this indication, where it is important to do more
longitudinal kinds of studies to show whether doing this now
actually helps to prevent further disease from developing
five or 10 years from now.
Dr. GORDON: Thank you very much. We are going to
break now. I would invite you -- would you send us that
information about the $12.00 reimbursement and $20.00
Dr. LOW DOG: Sure.
Dr. GORDON: And anybody else who has examples of
that kind. Our charge is to make legislative
recommendations, and we want to hear about it.
Thank you very much. We are going to take a five-
minute break only and then we are going to start the next
panel. We are a little behind time.
Dr. GORDON: We are going to begin with the next
panel now. The first speaker will be Dennis Awang.
Dr. AWANG: I think the Commission for inviting
me. I am neither clinician nor an economist, so my
contribution to clinical and cost effectiveness would be
related mainly to my familiarity with the literature in
herbal medicine and for 24 years I was associated with the
Bureau of Drug Research and head of the Natural Products
Section in Health Canada. As such, I was involved in
developing methodology for analysis of commercial herbal
products and for providing guidelines for the regulation of
As you probably know, the system for regulation in
Canada is somewhat different from what is in the United
States. However, it would seem to me obvious that the
potential for herbal medicines contribution to health care
would seem to be fundamentally related to the ability of the
consumer to have access to safe and efficacious products.
As it is now, judging the difference between
different commercial products is very hazardous and limited
mainly to the familiarity of the consumer with the
It seems to me also that the prime imperative for
the health care system, and indeed for the regulatory
agencies, to ensure that the consumer can have access to
safe and efficacious products.
The large interest of physicians, health care
professionals in herbal medicines recently has been
concerned primarily with the ability to be assured of a
consistent therapeutic medicinal effect from these products,
and the plain fact is that knowledge of the nature of active
principles and the mechanisms of action is severely limited.
Attempts have been mainly concentrated on trying
to characterize the substances chemically, but there has
been such a glaring lack of success in identifying these
active principles that I think the recent trend to develop
into biological assays would seem to me to be the most
promising combination, combination of chemical and
biological assays to establish some basis for real
standardization of these materials.
As it is now, there is very few examples where one
can be confident about standardization for consistent
I believe that the best contribution or
recommendation I can make is that a system, such as that
proposed by the World Health Organization for guidelines for
the assessment of herbal medicines, be instituted to ensure
proper identity and quality of both raw materials and
Most of the adverse reactions, for example, that
have been recorded have been due to substitution,
adulteration largely due to misidentification or linguistic
confusion, and it seems to me that it is not wise to leave
the establishment of the identity and quality of these
materials to manufacturers, as the FDA has recently
suggested regarding the Aristalochia problem.
There is such a very broad range of scientific
competence and technological capacity in this broad spectrum
of manufacturers, that it seems to me that sort of reliance
on manufacturers to ensure the identity and quality of these
materials is wrong-headed.
Also, I think that the effort that has been made
by the United States Pharmacopeia to establish sound
monographs, and there are a number of agencies that have
been involved in this, but I think that the approach of the
United States Pharmacopeia is commendable, and I think that
once they can get the proper group of people together to
establish reliable, accessible assays and characterization
of these materials, that we will advance the process
Dr. GORDON: Thank you very much.
Mr. HOBBS: Good morning and thank you very much
for inviting me today. I have certainly heard a lot of good
things from other presenters and certainly agree with a lot
of it. I am an herbalist and a licensed acupuncturist in
California and Oregon.
I have got a foot kind of in both worlds because
my mother and grandmother were herbalists, and my dad was a
scientist, so recently, for the last almost two years, we
have received funding from a large pharmaceutical company,
and we have been sifting through the literature on a hundred
herbs in great detail.
So, I am pretty familiar with what literature is
out there and what science is being done. Of course, the
quality varies quite a bit, as you know. But, for instance,
right now I am working on garlic. In our database we have
about 2- to 3,000 abstracts to sift through.
Now, looking at all those abstracts, a lot of them
are animal studies, a lot of them are in vitro studies, how
many human studies have actually been done of good quality
on herbs, how many herbs out there could you say that there
really is good science, a medical researcher would be
satisfied with the amount of evidence?
I would have to say that there are very few herbs
probably that have met that kind of international scientific
standard. Maybe hypericum or St. John's Wort, ginkgo has a
lot of evidence, and a few others, but when you really look
at the vast majority of herbs, for instance, in the Chinese
Pharmacopeia, there might be 5,000 herbs in the Chinese
How many of those herbs have actually been looked
at scientifically with good science? I would say very few
especially with human studies.
I have submitted written comments, and I am in the
process of looking at more studies on efficacy of herbs as
far as cost effectiveness in our health care system, and I
would be happy to put together another summary after I go
home. I didn't really have much chance. I was only called
at the last minute, so I haven't had a chance to write up
the studies, but there are an increasing amount of studies
Actually, on herbs, generally, when you look at
the vast amount of research, it really is mind-boggling. I
had no idea until I started really looking out there. We
researched 26 international electronic databases and
accessed a lot of foreign material, and there really is a
lot out there to sift through.
Now, I have a few other comments just about
herbalism in general. My feeling and my recommendation is
that well-trained herbalists really should be involved in
studying the safety and efficacy of herbs on a scientific
basis because I would say that it is possible that many
scientists have the view that herbs do not work until it is
proven that they do work, whereas, an herbalist might have
the feeling that they work, my feeling is that they work
until it is proven that they don't work.
So, I think that the questions that we ask in
designing studies are very important. Obviously, as Dennis
was saying, the quality of herbal products is so important
as when you really start looking at the cost effectiveness
of herbal medicine, we have to take into account the quality
of the herbs that are being used.
Now, a trained herbalist would know when to
harvest the herb, what season, what part of the herb. This
is a long history, a long tradition, and this type of
traditional knowledge has been passed down from generation
to generation, and can be quite detailed and quite complex,
although it is again difficult to study scientifically.
Another thing is that I certainly agree that
herbs, as far as cost effectiveness and integration, work a
lot better when used in a traditional system. For instance,
many people today are using ginkgo for better memory, so
they go into the drugstore and they buy a bottle of ginkgo
for better memory, and this isn't always going to be that
effective, whereas, if you go to a licensed acupuncturist or
a herbalist that has traditional knowledge and traditional
training, this is all integrated into a system whereby a
person -- again, I spend at least a half an hour, maybe an
hour with patients, and I consider myself their health
coach. I really encourage people to believe in their own
innate healing powers.
Herbal medicine really is a gentle medicine in the
sense that after all the years I have practiced, I have seen
really very few side effects. Yes, there are side effects,
and I would never say that just because it is natural, it
has no side effects, that is not true, but generally
speaking, herbs are far safer than drugs.
Dr. GORDON: Thank you. We understand we put you
under time constraints, and we would very much appreciate
you sharing those studies with us. It would be very helpful
to us as we move ahead.
Mr. HOBBS: Thank you.
Dr. GORDON: Alan Gaby.
Dr. GABY: Thank you for inviting me. I am a
medical doctor, and my hobby over the past 25 years has been
collecting and looking at studies in the field of
nutritional and herbal medicine.
I have been amazed at how many studies there are
that are not known about in conventional medicine. Some of
them are double-blind, placebo-controlled trials, some of
them are case reports, some of them are uncontrolled trials.
What we are dealing with here is substances which
are commodities, so therefore they are usually quite
inexpensive, and with a few situations where this is not
true, they are generally quite safe.
Having been in practice for 17 years, I have not
had a single patient have to go to the hospital because of
an adverse drug reaction, and most of the people come in
specifically because they are looking for other ways of
treating their conditions.
There is a legitimate concern in conventional
medicine that people will forego proven therapies and use
these instead, however, when people are guided
appropriately, and when they use their own common sense,
this doesn't occur.
There are only some situations, there are just a
few situations in conventional medicine where doing nothing
is dangerous. For example, if somebody comes in and their
joints hurt, and they are taking an anti-inflammatory drug
which is giving them an ulcer, and you put them on
niacinamide or glucosamine instead, and their joints don't
hurt anymore, there is no danger of foregoing conventional
If somebody has migraine headaches and you put
them on magnesium and vitamin B6, and they don't have any
migraines anymore, there is no danger in them going off of
their beta blocker.
There are other situations where there would be
danger, for example, in congestive heart failure, but even
in that condition, if somebody is appropriately monitored,
and you can demonstrate that their ejection faction has gone
up and their New York Heart Association Classification has
improved, then, one can cautiously wean an individual off of
So, nutritional therapy has a large body of
evidence behind it, and it fits very much the allopathic
model. It is just that we are using different substances.
Interestingly, there appears to be more resistance against
nutritional supplementation among academia than there is
among some other CAM approaches.
As a matter of fact, there was a study published
in the Archives of Internal Medicine by a conventional Ph.D.
who provided evidence that there is a bias against
micronutrient therapy among academia.
In support of his argument, he showed that
textbooks almost universally neglect mention of vitamin E
for the treatment of intermittent claudication even though
there is evidence that it works as well as the drug that is
In addition, there is uncritical acceptance of
adverse reactions, case reports where somebody is on six
hepatotoxic drugs and they happen to take a vitamin, and
they develop liver toxicity and they blame it on the
So, if we are going to move forward, we need to
utilize the research that has already been done. This is
one area of CAM where we actually could develop an effective
and cost effective approach right now based on what has
already been done.
I have given 10 examples in the handout. I just
picked those because they seem to be reasonable examples.
For example, $1,000 a month for growth hormone for a short
child, 75 cents a month for zinc, which according to one
study works approximately two-thirds as well as growth
hormone. $3.50 a month to prevent kidney stones using
magnesium and vitamin B6. $200 or more per month using the
brand version of potassium citrate.
So, there are many situations where one can
clearly demonstrate cost effectiveness. On the other hand,
there is the possibility of over-utilization, because there
is an inherent block against using prescription medications.
People don't love to take their prescription drugs, where
often they love to take their supplements.
So, we need to develop, in order to ensure cost
effectiveness, situations where it is appropriate to use
nutritional supplementation, and perhaps Medicare and other
insurance companies should pay for them as an alternative or
as an adjunct, and that there are other situations where it
may not be appropriate, such as the walking well who want to
take their supplements as opposed to the walking wounded who
are already spending thousands or tens of thousands of
As a final 23 seconds worth, I want to mention
something slightly off of my scope here, and that is the
identification of food allergy in the treatment of
conditions. I saw people that have spent thousands of
dollars on care that didn't work and in one visit they were
cured of their chronic problem because they had a food
allergy which was not identified.
So, we need to teach this in medical school, and
the cost of care will come down by billions of dollars.
Dr. GORDON: Thank you. Thank you for your superb
timing, Alan, and also for these examples, very useful.
Dr. BRANNON: I, too, want to thank you for the
invitation to speak to you about nutrition as a
complementary and alternative medicine. I am a registered
dietitian and a research nutritional biochemist.
I want to start by discussing nutrition as a very
broad continuum in health care. It ranges from self-
selected diet or dietary supplement choices by consumers
with no consultation with any health care provider of any
sort, to medical nutrition therapy in conventional health
care ambulatory and acute care settings.
The recent Institute of Medicine report on the
role of nutrition and malnutrition in maintaining health in
the nation's elderly defines two tiers of nutritional
services, and I think this is an important distinction to
consider as you consider complementary and alternative
The first is basic or general nutrition education
or advice that can be provided by a variety of health care
professionals including physicians, dieticians, nurses,
chiropractors, dentists, physical therapists, clinical
social workers, physician assistants, pharmacists,
psychologists, and others.
The second tier, however, is nutrition therapy or
medical nutrition therapy, which involves nutritional
assessment, evaluation of nutritional needs, intervention,
counseling, enteral, parenteral nutrition, and other
modalities, as well as follow-up care. This is generally
provided primarily by registered dietitians in a health care
team of physicians, nurses, pharmacists, physical
therapists, and psychologists.
Beyond these two tiers, however, exists the vast
majority of information going to consumers about nutrition,
and that is through the mass media. There are recent survey
data that suggest that this is the primary source of
information about nutrition for consumers and that fewer
than 5 to 9 percent of consumers seek nutritional advice
from a health care professional, such as a dietitian or a
I am going to focus my remarks today on nutrition
therapy in part because I knew Alan was going to speak about
dietary supplements and, in part, because this is the area
where we have the best research base evaluation of clinical
effectiveness and cost effectiveness.
This is not to say that we don't need to evaluate
basic nutrition education, Tier 1 services, and that need
remains high, and it is also not to say that we don't need
to determine clinical effectiveness of other dietary
interventions because we do.
Nutrition therapy is strongly supported by
observational studies, consensus documents, systematic
review, and extensive clinical trials of a wide variety of
size for the following conditions: dyslipidemia,
hypertension, diabetes, by reference obesity, and
Evidence with less robust clinical trial data also
exist for heart disease, predialysis kidney failure, and
under-nutrition. Less robust data, relying primarily on
observational data and epidemiological data, with less
robust clinical intervention data exists for Alzheimer's,
osteoarthritis, cancer, and other conditions.
The cost effectiveness of nutritional therapy has
been examined in several contexts. There are two Lewen
reports, one commissioned by the American Dietetics
Association on Medicare benefits, and study was done in
1997, and I will leave a copy courtesy of the American
Dietetics Association for you.
This estimates that a net seven-year cost to cover
all Medicare beneficiaries for the nutritional therapy for
the diseases for which there is strong data would be $370
million, an estimate savings including decreased
hospitalizations and patient benefits at $1.2 billion for
the same period. Savings is greater than the cost by the
third year of this seven-year analysis.
Another study done by Lewen for the Department of
Defense on tricare system estimates a net savings of $3.1
million per year by providing nutrition therapy.
A recent medical cost nutrition containment study
that was done by the Oxford Health Plan on an expanded pilot
program for the Elderly at Nutrition Risk in New Jersey and
New York, which included 160,000 elderly patients, estimated
a $10.00 savings per dollar invested in the program.
In a study by Gallagher and co-workers reviewed
research on malnutrition in hospitalized patients and
estimated a $4.20 benefit per dollar invested.
The clinical effectiveness I won't have time to
summarize, but it is extensive. The cost effectiveness data
are here for these studies, and the delivery was primarily
by dietitians with adults in acute and ambulatory care
We have one study that suggests there is a high
degree of patient satisfaction with nutrition therapy, but
more studies are clearly needed. We have a number of
barriers to nutrition therapy, and I am going to echo the
themes that have already been sounded.
The lack of recognition of nutritional therapy by
dietitians and other nutritional professionals by Medicare
and Medicaid in private practice health plans is clearly a
Recommendations. We have legislation currently in
Congress, H.R. 1187 and S. 660 to provide outpatient medical
care coverage for medical nutrition therapy for diabetes and
kidney disease, and we need this legislation, as well as to
consider expanded Medicare and Medicaid coverage as
recommended by the Institute of Medicine report for the
other chronic diseases for which nutritional therapy has
been documented effective.
We need to reevaluate reimbursement systems, and
we need to think about the research that is needed on
efficacy, safety, and cost effectiveness, particularly on
plant, food components, and phytonutrients for which many
Dr. GORDON: Thank you very much. We will look
forward to the study.
Our final speaker on this panel we are actually
giving 10 minutes to because he is talking about
integration, so you can either take them all or take less as
you choose. Harley Goldberg, who will talk about
integrating a number of CAM approaches.
Dr. GOLDBERG: Thank you very much. I am the
medical director for Complementary and Alternative Medicine
for Kaiser Permanente in Northern California, and I
appreciate your inviting me to speak, and take a slightly
We have heard some very compelling statements by a
large number of presenters here, and I think you appreciate
the difficulty of wrapping and lumping all of these issues
together and calling it CAM when they actually need to be
looked at independently in a case-by-case basis in order to
For the very reasons that your commission has been
executed by executive order from the President, for the same
reasons our executive director appointed a director of
Complementary and Alternative Medicine to provide
information on complementary and alternative practices to
our physicians, to our members, to our health care providers
of all types to coordinate a research program, to evaluate
what education and training would be appropriate for
providers that we were going to integrate into our program,
and to identify what would be the appropriate access and
delivery systems, much more than I could possibly cover in
10 minute, much less five.
So, we have taken a few steps to move forward and
because of that, I was asked to discuss how we have gone
about addressing these issues. By no means have we solved
them all, but I will explain to you the steps that we have
taken in order to try to grapple with the issues.
First, our history. I explained briefly in your
handout what Kaiser Permanente is, so that you can
appreciate the size of the organization and the complexity
of trying to answer some of these questions, but initially,
we also did a survey much as
Dr. Gordon reviewed the surveys
at the outset of this meeting. It was published in the
Western Journal of Medicine in September of 1998.
I will be glad to make that available to you if
you need it, but it basically gave the same kinds of
illustrations of data that you reviewed and showed that
there was a very strong interest amongst our members and our
patients, as well as amongst our physicians and clinicians
in complementary and alternative medicine, and it outlines
by breaking down, modality by modality, the percentage of
Suffice it to say that 50 to 75 percent of our
members were using, and are interested in using, various CAM
modalities. How you define that always changes the numbers.
In addition, however, what was really surprising
to us was the same percentage was true for our physicians
and health care professionals. That actually is what
generated the appointment of my office, and the way we have
recognized drivers for this issue basically is that there
are two drivers. Members have a belief in, and demand for,
Physicians have a request for evidence, physicians
and all health care providers have a request for evidence
and safety and effectiveness in order to know how to meet
those demands. Therein is the tension, and to address that
we basically chose which CAM areas to evaluate based on the
prioritization of member interest and how to evaluate them
was based on the physician requests for summaries of the
evidence on safety and effectiveness, not unlike the
discussions we have heard earlier today.
I guess I should say overall our approach to
complementary and alternative medicine as an integrated
health care delivery system is no different than that
approach that we take to our overall program.
Our strategy is to incorporate services that are
safe and effective treatments, providing the best access and
most efficient service, through integrating that in our
health care delivery system. That means we have major
medical centers and satellite facilities with providers of
all types integrated throughout the State of California.
So, we approach CAM in precisely the same way. In
order to do that, our advisory panel was appointed with
representatives from education, research, executive offices,
and clinicians involved in actually practicing modalities
that were the primary areas of interest.
This advisory panel directed the process and made
policy recommendations as we move along. The areas of
interest that were revealed in the survey were grouped into
general categories with all the difficulties that that might
Those were manual therapies and movement programs,
traditional systems of medicine. Subsets of that would be
acupuncture. Mind-body approaches to medical care of which
there are many, and nutritional supplements, herbs, and
dietary approaches, as well.
Given the magnitude of these areas, we prioritized
our work by differentiating, perhaps arbitrarily, treatments
that were for treatment of disease, and then methods for
Those treatments that were used for treatment of
disease were evaluated for safety and effectiveness, and,
when warranted, would be considered for integration by
Because of the nature of the fact that there is a
disease state involved, we felt it incumbent upon us to be
fully responsible for appropriately working up diagnosing,
et cetera, and rolling treatment into that.
For those methods that were identified primarily
as health promotion, they would be evaluated for integration
into an integrated health education program that we have,
that is integrated into all of our facilities, and that
would be by self-referral as distinctly different from
treatments for diseases.
The advisory panel then commissioned standing
committees on education and research. The Education
Committee has basically two charges, one to provide the
summary of information to our physicians and health care
providers, and the other to produce information along with
our Health Education Department, in another language, if you
will, for membership, as we term the public or patients, all
the same people.
The advisory panel commissioned multidisciplinary
work groups for each of those areas that were lumped, if you
will, to evaluate the evidence for safety and effectiveness
for each of these areas.
Essentially, this amounted to performing
systematic reviews, and as several people have talked about,
how much literature there is out there, that is a daunting
Having been at it for a while, I can assure you
that it is not as easy as it is to say, and we can talk
about that a little bit more at the end, if you like, but
systematic reviews basically drive the information.
All of this discussion is trying to put ourselves
on a foundation of what works and what is safe or not safe,
or what doesn't work or why, and that all skirts an issue
that we need to talk about at the end about belief, which
may be that interface between the public's demand and the
clinician's need for evidence-based, placebo-controlled,
Having said that, the systematic reviews drive the
information that the Education Committee puts out for
members and for clinicians. It also informs the research
agenda that is driven to answer the questions unanswered,
and therefore becomes the foundation of the work.
It is also used, this information is also used in
consideration of what services to deliver. In general, to
be considered as a treatment for a condition, that is, a
treatment for disease, that is, we require that there is
reasonable evidence of safety and effectiveness.
In addition, we ask that a quality assurance
system be available before we take the next step of
considering integrating something into a treatment program
for treatment of disease.
Who provides the service and where is actually
determined by very practical issues in the context of our
overall integrated health care system, and we can talk about
numbers of examples if we have dietitians involved and
If we have various practitioners of manual
therapies involved, where do those people actually live are
they in the Ortho Department, in Physical Therapy
Department, are they in Primary Care, et cetera.
There are answers actually to all of these issues,
but, in fact, what happens when you look at it carefully is
that there are many answers. It depends on the size of the
facility, if it is a small facility in a rural area versus a
large medical center in a major area versus whether or not
there is a specialty care process involved or primary care
Suffice it to say, it is not one answer, and it is
not a simple answer, and it is not a restrictive answer. It
is a "both and" answer, in other words, we can have, as we
do, physical therapists in our primary care modules, as well
as in our Orthopedics Department, as well as in a free-
standing department and how we integrate who sees them, when
and how is dependent on how the patient presents with their
clinical condition and where.
So, we are considering systems further to deliver
services when there is evidence of safety but effectiveness
is unknown, which, as has been stated before by panelists,
is largely the case.
When that is the case, actually, what we are
looking at is a self-referral system that is at patient's
cost, and something that hasn't been talked about much, but
should be, because it drives all of this really is who pays.
You have to identify that, and basically, we are looking at
various models to try to answer that.
It is not easy. There are many ethical issues
involved. It is very difficult to sometimes determine when
a therapy is a treatment of disease versus for health
We want to encourage health promotion, at the same
time, who pays is an issue when you have a single dollar, if
you will, pot to pay for all services, and I sit down in the
Chiefs of Medicine peer group meeting to discuss
implementation of all of medical care for that department,
and they look at me knowing what I am doing and say you are
the guy who wants to take some of the money, this is
essentially taking another primary care provider out of the
office or someone off call or someone out of the ER in order
to provide these other services.
The only way to answer those questions is with
good evaluations that show that we have equally or more
effective care that helps them and helps our member and our
patient most importantly, provide them the best health care
So, my policy recommendations, if I may quickly,
is that we need to fund an organized systematic reviews in a
coordinated fashion on specific CAM methods and by clinical
conditions. This will be the basis of the evidence-based
approach in forming the educational materials, and the
We need to increase research on clinical
implementation of specific CAM treatments for specific
conditions involving CAM practitioners and experienced
researchers, and we need to compare that to standard care
that is largely nonexistent right now.
Creating and supporting public and clinical
information systems out of that, and then accelerating the
research focused on belief and mind-body medicine which lies
at the interface of these two driving forces.
I would like to acknowledge that one of my
colleagues, David Sobel, who is the Director of Health
Education, was asked to come and present mind-body medicine,
but was unable to attend, so his materials are in your
packets. Very clear cost effective analyses are done on
mind-body approaches, and I think there is little question
about the effectiveness and safety of those approaches.
Dr. GORDON: Thank you very much, and we will be
asking David and some of this colleagues perhaps to come
back at a future session.
Questions from the commissioners.
Dr. GUTIERREZ: I would like to ask
two questions actually. The first is which services are you
providing based on guidelines versus clinical necessity, and
secondly, what services require gatekeepers at the present
and who fills the role of the gatekeeper?
Dr. GOLDBERG: Guidelines versus clinical
necessity? I am sorry, I don't understand. We developed
these recommendations. You could call those guidelines.
Those are driven initially to be looked at by clinical
necessity, but to answer your question about which services,
specifically, we provide acupuncture services in the context
of chronic pain progra
There is actually multiple answers here because
there are answers around what we do as an integrated base
coverage in our entire system versus other methods of
delivering systems as supplemental riders by self-referral
and/or access through affinity programs, if you appreciate
what I am talking about.
Those are just health care delivery systems
issues, but I will presume your question is about base and
then I will say that right now we are integrating
acupuncture as one component of our chronic pain delivery
systems, and that is a multidisciplinary program that is one
aspect of it.
In addition, manual therapies are provided through
our Physical Therapy Departments. Health education programs
have a whole array of choices of mind-body approaches. That
will be where I would stop for now.
Is that answering the question you are asking?
Dr. GUTIERREZ: Yes.
Dr. GOLDBERG: I think there was a second half,
but I am not sure I got it.
Dr. GUTIERREZ: I was asking who plays the role of
Dr. GOLDBERG: Oh, right. That is the
differentiation between if a service requires physician
referral and if a service is available on self or patient
referral. Basically, if it is a specific treatment for a
clinical condition, it requires a physician referral, and
the primary care provider, if you will, is the gatekeeper
although referrals can come from any specialist or any
provider in the system.
Dr. FINS: This is a related question for
Goldberg. What kind of consensus was generated, tell us a
little bit about the process, were consumers participating
in this process, was there disagreement, where were the
fault lines, where do people sort of disagree, and how did
you read those bright line distinctions which look good on
paper, but were probably difficult to achieve?
Dr. GOLDBERG: Right. I appreciate your
sensitivity to that. Basically, we selected, as I said, the
areas that we would evaluate based on the surveys, which
were done of tens of thousands of members, and the summaries
of those surveys, which is actually in that article I
referenced in the Western Journal of Medicine, September of
1998, Nancy Gordon and David Sobel, lead authors, basically,
we used that as our guide to start with, and then we used
multidisciplinary clinicians, so depending on the thing we
were evaluating, clinicians involved in that service, as
well as some clinicians experienced in epidemiologic
systematic review process to evaluate the data.
So, we didn't actually have members involved in
reviewing the evidence because we didn't feel that was where
they could be most helpful, but they were involved in
selecting what we chose to review first.
So, actually, my request of this panel is that the
Commission provides funding and support for systematic
reviews that would be done to help Christopher and to pay
Christopher to review herbs for us, and so then I don't have
to repeat what he is doing.
Obviously, he is doing a much more thorough job
perhaps than we did on the beginning of our herbs. It is
scattered throughout and it is the same evidence data, and
if we had respected people doing that work for us as a
whole, the whole country and world would benefit.
Dr. GORDON: Let me say who I have. I have George
Bernier, George DeVries, Bill, Tieraona, Ming, and Wayne.
Anyone else? Okay. David afterwards.
Go ahead, George, and then George.
Dr. BERNIER: I would like to ask you about the
educational process. Since that is one of the areas that we
have been asked to really comment on, you have had the
opportunity to develop educational processes for people at
What would your idealized system be? How could
you best educate the population --
Dr. GOLDBERG: When I asked that question to our
director of Physician Education, her answer was eight times,
eight different ways repetitively meaning to say that what
we do, in fact, is provide information in written format on
paper electronically, in summarized versions, in full
guideline versions including the bibliography of all the
work we did, the evidence tables that we created, the
summaries of that clinical information.
In addition, by video conference presentations
which we do on a quarterly basis for our system as a whole,
et cetera. Members also, and public, in addition, want
education, and basically the answer is that it is an entire
effort that must be conducted periodically and repetitively
on each of the areas of interest.
Is that answering your question?
Dr. BERNIER: Yes. Thank you.
Dr. GORDON: George.
Mr. DeVRIES: This question is directed to
Dr. Gaby, and Christopher Hobbs.
Do you have recommendations on improvements that
could be made to labeling regulations for herbal and dietary
supplements based on some of the concerns that were
Mr. HOBBS: One recommendation I have is to talk
about a traditional medicines category because again there
are so many herbs out there that are being sold and being
used, for instance, 5,000 herbs in the Chinese Materia
Medica, probably in this country, commonly used 500 herbs or
maybe at least 100 or 150 herbs in the common herbal
practice, and we can't have the level of evidence that we
would like in the next few years.
This is going to take years and years. It is
difficult to study herbs because they are not
monosubstances, they are so complex. So, a traditional
medicine category basically would look at the historical and
traditional, the best evidence in historical and traditional
medicine, which is vast, and it goes back several thousand
Hippocrates already talked about using Vitex
Agnus-Castus for hormonal imbalances, Dioscorides, which is
a Greek physician in the first century A.D., talked about
St. John's Wort for mania.
So, this has been around for a long time, but if
we have a traditional medicines category where the best
evidence of traditional use and efficacy is taken and
reviewed, and then manufacturers are able to put these types
of recommendations on their label, to better educate
consumers how to use these medicines or herbs, because they
are out there on every level.
They are in the drugstores, they are sold
everywhere, and multilevel marketing, and so forth, and
frankly, a lot of the advertising and a lot of the
information that is going out is not very good, it is not
high quality, and on the web you can read anything. What I
have seen out there is just ridiculous.
So, obviously, we can't study scientifically and
prove all of these herbs that are being used right now,
today, in a very short time. We have to have some system,
so that manufacturers and some guidelines, and American
Herbal Products Association is working on this, American
Herbalist Guild, some other organizations are working on
recommendations to the FDA for a traditional medicines
Dr. GABY: My answer is similar. In relation to
nutritional supplements, there is a lot that is already
known as far as adverse effects, other interactions, for
example, with drugs or nutrients, and there is also a lot
that is known on efficacy. Apparently, there is a law about
what you are allowed to say for efficacy, but you can always
say what the strength of the evidence is, for example, an
uncontrolled trial showed that something works, or
Jonas' double-blind study showed that niacinamide is
effective for osteoarthritis.
If you are taking more than a certain number of
milligrams, see your doctor. If you are taking so-and-so
drug, do not take this without seeing your doctor. This
would greatly enhance both the effectiveness and the safety,
and it would probably greatly reduce the number of visits to
doctors without causing harm to people.
Dr. AWANG: First of all, I would like to say that
there is a lot of information that can be put on a label,
and a lot of information has been put on a label. Much of
the information is unreliable.
I think at this point of the state of regulation
of these materials, which I think just about everybody
agrees they are pharmacologic agents, not nutritional
supplements, that the most useful information you can put is
warnings against possible adverse effects or toxicity, and
recommendations as to use, but that is a very difficult area
because if you are not going to allow claims about treatment
of disease, conditions, and so forth, then, you are severely
limiting what you can put on the label.
In fact, the pharmacologists, in an article some
time ago said -- I will read it here verbatim -- "Rather
than claims to treat disease, one sees vague suggestive
comments on herbal product labels and advertising material."
For example, Saw Palmetto is supposed to promote
prostate health rather than treat symptoms of benign
prostatic hyperplasia, which I think everybody knows is what
they are buying it for.
So, at this point, I mean you see so many labels
of Saw Palmetto saying 85 to 95 percent fatty acids. Now, I
have serious doubt that you can rely on that content in the
vast variety of products that claim that.
What has happened is that when the original
clinical research was done, and the material properly
characterized, the estimation was that the fatty acids
ranged between 85 and 95, so everybody else does that, as
they do for 24 percent of flavonoid glycosides and 6 percent
terpene lactones for just about every ginkgo product you
So, unless this area is better regulated, I think
the usefulness of the label is severely limited.
Mr. HOBBS: May I make just a quick comment?
Dr. GORDON: Yes. One thing I want to say to
everybody is for this panel, we have 15 minutes more and we
have to end.
Mr. HOBBS: Just that the label is more than what
is on the bottle. Remember that many manufacturers use
magazine articles, advertising on the web, and so forth, to
advertise, so really we have to consider the wider
conception of the label is a lot more than just what is on
Dr. GORDON: Bill.
Dr. FAIR: My question is to
Dr. Brannon. First
of all, thank you for this nice handout. As I look at the
mosaic of nutrition, I see there is the proper eating
portion, which I guess is nutritional therapy, and then I
think there is a role of supplements and some diseases,
vitamin E in heart disease, or Saw Palmetto, but I keep
getting more and more questions from people recently about
some of these approaches, what I guess you would call taking
function foods and desiccating them or lyophilizing them and
putting them into a capsule or a drink, I guess 2-Plus or
something like that is one, and it is often sold through a
multilevel marketing system.
My specific question is, is this a valid approach,
is this something that should be considered as a way of
increasing access to good nutritional habits if people say
they don't have the money or they don't have the time to eat
the way you would tell them to eat?
Dr. BRANNON: I think that we are going to see
more and more functional foods, so the issue of whether it
is appropriate or not is probably a lot less important than
how we are going to handle it.
You are going to see more, and I think it is being
driven by consumer demand, benecol-containing margarine is a
good example of that. However, what we are missing -- and I
think it is a thing that we are missing in all of nutrition
-- is how does it fit with what the diet as a whole is.
So, some of these foods, if a consumer thinks that
they are going to use benecol-containing margarine in a high
fat diet that has a lot of other saturated fat without any
of the rest of the aspects that we know are part of a
healthy diet for an average American, that is a
misconception, and it is not one that, as I looked at the
literature available, the literature available addresses
So, when I said I thought there was limited data
on dietary supplements -- and I would put functional foods
as maybe an unusual category of a dietary supplement -- in
the context of the diet as a whole, it is hard to know,
looking at these studies, what the rest of the diet looks
I think that is part of the efficacy problem that
we have in evaluating nutritional therapy.
Dr. FAIR: If people are skipping adequately
eating, can they make up for it by taking pills or drinks?
Dr. BRANNON: Well, that gets to the fact that for
many of the issues we don't know what the bioactive food
components are really, and I would point to the
recommendation that still holds up, which is increasing the
consumption of fruits and vegetables decreases your risk of
The hypothesis that was beta carotene mediated
doesn't appear to be true, and, in fact, we have some
evidence that beta carotene in high levels is not safe and
can actually increase the risk of cancer.
So, what it is, is that there are many things in
foods, and this is, I think, an important fundamental
principle as we move forward, that small amounts of many
different substances together can be more effective than
large amounts of any single substance, and we frankly don't
have data that evaluate that.
Dr. FAIR: My question is still do you have to eat
the fruits and vegetables to get this effect or can you get
it in a capsule or a drink that is supposedly made from the
juice of all these fruits and vegetables put together?
Dr. BRANNON: I don't think we have enough data to
give you a yes or no answer on that.
Dr. GORDON: Tieraona.
Dr. LOW DOG: It is sort of on the tail end of
that. You know, listening to all of this and talking about
access and delivery, there is such a big spectrum, isn't
there, from just talking about food and how you prepare your
food and eating a healthy diet to taking megavitamins or
orthomolecular medicine, heavy nutritional supplements, and
there is also the same argument with herbs, using whole
herbs, which again comes back to whole foods and recognizing
that there is probably lots of things in there that work
together to make it the whole more than just the sum of its
parts, and then there is standardized extracts, there is
this huge range, and part of what we are trying to figure
out is how to make recommendations, how do you make
recommendations that will enhance the access delivery in
health care of people here.
I guess I would like some ideas from you all when
there is such a broad spectrum, from whole herbs, whole
foods to minute dietary supplements, ancient wisdom that has
been around forever, and now new scientific technology with
very complex kinds of things.
How do we begin to address that, how do we begin
to make recommendations when it is so big and so vast?
Mr. HOBBS: My feeling is we will never
understand, we will never get to the bottom of the
complexity and the mystery of herbs and foods. Also, to
address your question, will juice powders give you the same
thing as a whole food, no, they will never give you the same
thing as a whole food. They can approximate it, they can
help supplement if a person is not eating any fruits and
vegetables, then, a juice powder is probably better than
nothing at all.
As far as herbs go, my feeling again is that go
back to the traditional herbalism, there is still, even in
this modern science of all the studies and all the science,
there is still a place for traditional medicine, there is
still a place for a traditional system of medicine like
traditional Chinese medicine, Ayurveda, because it deals
with whole substances, it deals with the whole herb in a
context that is very, very ancient, and it also deals with
We are not considering so much that --
standardization just hasn't have to do with the herb and
identifying the chemical constituents and the
pharmacological action. It also is how does that herb or
food interact with the person or the patient.
This is what traditional medicine studies, so each
person is evaluated, each person is looked at in the context
of that system, and then the herb and the food is applied.
So, I think, just to sum up, I think we have to go
back to traditional medicine and we have to promote the
study of traditional Chinese medicine, Ayurveda, some of
these systems that looks at the whole person and the whole
food and the whole herb in the context of an ancient
practice, and we can fragment these herbs and study them to
death, but we will never get to the bottom of all the
mysteries that are included in there, although I think we
Dr. BRANNON: I would also like to comment in the
sense that I think that in the absence of knowing about
effectiveness, that it is important we know about safety,
and one of the guidelines for food, in particular, in diet,
is that people make food choices for a lot of reasons, and
as long as the food choices they are making are safe or
don't have an adverse effect, then, how much should we worry
about that particular food choice.
I would argue that in this context, we should
probably worry about the food choices or supplement choices
for which there are adverse effects.
Dr. AWANG: I would just like to make a brief
comment about the whole versus extract thing on the
traditional versus modern usage. I feel fairly confident
that you can't take enough ginkgo leaf to affect your
memory, but because the modern evidence for it is for highly
concentrated extract, a 50 to 1 extract of ginkgo leaf, and
that is what has been shown to be useful in
Alzheimer's and memory, and so forth, but I don't think you
are going to get it in corn chips or in a food drink.
Also, ginkgo itself has toxic materials in it, and
you have to remove the ginkgolic acids and the ginkgo toxin,
so one has to be very careful about that, as well.
Dr. GABY: Just so we don't overlook what may be
most important in the discussion of standardized herbs and
concentrated nutrients and Juice-Plus, which probably should
be called Juice-Minus, we talk about functional foods when
our real policy, since the evidence is that eating whole
foods or avoiding dysfunctional foods promotes health, we
can create a policy which is somewhat outside the scope of
medical care, but within the purview of the public health,
to promote the use of whole foods in our society, and as a
public policy, it is very simple to do that. That would be
to tax junk food and to give a subsidy to whole food.
Dr. GORDON: Harley.
Dr. GOLDBERG: Just in response to
Dr. Low Dog's
comment, we cannot do randomized clinical trials on very
specific questions and get quick answers, it is a long
process. However, to answer questions quickly, you can use
epidemiologic data and other types of studies on populations
which have been done, for example, the Chinese data on the
use of soy in menopausal symptoms, et cetera, and get good,
relatively quick answers to begin the process, so the short
answer has to come from other types of studies than
randomized clinical trials, and the spectrum of types of
trials that are used and how they are weighted in terms of
evidence and what that means is standard and is available,
and we ought to use it.
Dr. GORDON: Ming. I think we are just going to
have time for Ming and for Wayne, and we are going to have
to end. We need time to digest our whole food lunch.
Dr. TIAN: My question is, I think that herbs are
very important, easy, and also very complicated, and are we
talking about the medicinal herbs or are we talking herb,
because in this country, FDA regulates herb as a food
supplement or a dietary supplement, so if it is a medicinal
herb, you should go to pharmacist or industry to do that.
When we do the herb, I think it will be very
important to address the issue, what are the herbs commonly
used, and also very safe, if you experts can list this, to
submit a list or with any scientific support.
Number two, if the herbs with any health claim, as
FDA requires, any label, you have to put that on it, but you
can't say that is a cure or prevention or treat any disease,
but again, what kind of a health claim would be reasonable
to put on the label to guide the American public, and the
medical profession, and to tell people which one is useful
and what is dosage, or you want to use serving size,
whatever you want to use, but that is very important.
I think American public and also medical
professionals are a little bit confused, a lot of them are
confused. They don't know which herbs you should take, so
that is very important.
Number three, you know, WHO already has the
guideline for herbal medicine, they call "herbal medicine,"
what we call "herbal remedies," whatever you call, it is the
same thing. Then, should we adopt that guideline for the
United States, otherwise, how do we evaluate such a big
issue? That is my question. Thank you.
Dr. GORDON: All in 30 seconds or less.
Mr. HOBBS: Oh. Well, first of all, there again
we talked about traditional medicine and whole herbs. That
generally can be thought of as being maybe a little safer
than when you start purifying herbs, like Dennis mentioned,
ginkgo, 50 to 1 extract.
Once you start isolating compounds and purifying
them, then, you get into a whole different ballgame. I
think, in that case, then, if you are using science and you
are using fractionation to isolate compounds, this is closer
to drugs, is it not?
Then, I think you have to have more safety data,
you have to have more efficacy data, and because it is a
different context now. You are getting into modern science,
you are getting into more pharmacy, and so forth. Then, it
requires more science, more efficacy studies, more safety
data, and more very specific labeling guidelines, whereas,
with traditional medicine, then, you are working with a
practitioner who understands the whole herbal medicines and
applies it to a system of practice.
So, it depends. I think there is a very real
division here between modern scientific herbal medicine,
fractionated herbal medicine, and traditional herbal
medicine, but I think both are necessary and both are
applicable, and both can be effective in our country.
Dr. GORDON: Wayne.
Dr. JONAS: Thank you. One short question also to
Mr. Hobbs. How do you know when you have a qualified
Mr. HOBBS: At this point, there are about five
schools of herbal medicine in this country, also
naturopathic physicians, which there are three approved
schools, also study herbal medicine. Nowadays,
chiropractors have some herbal training.
But really anybody can call themselves a
herbalist. There are no guidelines. In fact, I believe
that herbal medicine is not a real career choice in this
country. There are no real guidelines for it. There is no
official terminology or definition for what an herbalist is.
So, we are trying to do that now.
The American Herbalist Guild is the only national
organization in this country, and we currently are working
on registration. So, we are developing educational
standards, we are talking about registration, that you take
a test and you put your name on a registration roll, so at
least a person knows that if you are a registered herbalist
in the American Herbalist Guild, you have a certain modicum
But other than that, it is going to take time,
because there are so many different traditions, are there
not? There is traditional Chinese medicine, Ayurveda,
Western herbalism, and so forth.
So, this is going to take time to integrate it,
but it is a very exciting time in herbal medicine today
because all of these influences are coming to this country,
Ayurveda, Chinese medicine, so we are working all this out
right now as we speak, but I certainly agree with you it is
Dr. GORDON: Thank you very much. I apologize to
Charlotte and Tom.
Dr. JONAS: This is a yes or no answer.
Goldberg, I really appreciate what is going on there. I am
a little skeptical about systematic reviews, having done
many of them, sort of like counting chad, it depends on who
is doing the counting and whether it has been poked all the
way through or not.
Dr. JONAS: I have a very specific question. Does
your system provide acupuncture, does it make it available,
acupuncture, for the treatment of chemotherapy-associated
nausea and vomiting?
Dr. GOLDBERG: At this moment we don't. We
recognize that we need to move in that direction, and it is
a matter of developing access and delivery systems, and we
are working on that right now.
Dr. JONAS: Related to access and delivery, which
is what we are talking about, in the area of nutritional
therapy, for example, for hypertension, how much time and
how many visits are allowed for the nutritional treatment of
Dr. GOLDBERG: There isn't a limit.
Dr. JONAS: There is no limit.
Dr. GOLDBERG: Just like how much time and how
many treatments are available to the physician for the
treatment of hypertension. They come in, they get a
diagnosis, they get a treatment plan, they get followed up,
but they may not move to the same level of nutritional
Dr. Gaby is talking.
Dr. JONAS: I am sorry?
Dr. GOLDBERG: They may or may not depending on
the nutritionist's treatment program. It may or may not be
the same level of treatment that
Dr. Gaby is talking.
Dr. JONAS: So, it will be kind of an individual
consultation with a nutritionist.
Dr. GOLDBERG: Yes.
Dr. JONAS: And it will depend on those skills and
that type of thing.
Dr. GOLDBERG: Right.
Dr. GORDON: Thank you, Wayne.
One thing I would like to mention to the
commissioners aside from apologizing to those of you we
couldn't include in this time, we will have time to address
questions of licensure, education, research, and other
issues in subsequent sessions.
I think if we can focus even more, discipline
ourselves to focus on access to services and service
delivery, that will help us move ahead, and we can ask the
people on this panel, if we want them back, to address some
of these issues, for example, how do you know who an
herbalist is, and how do you proceed with that. We can ask
them back for the panels on education and licensure, et
So, we are going to take a break now. We will
return at 1:35.
[Lunch recess taken at 12:25 p.m.]
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