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Thursday, February 21, 2002 &
Friday, February 22, 2002

Thursday, February 21, 2002 - Morning Session
  • Meeting Contents and Participants (10K bytes)
  • Thursday, February 21, 2002 - Morning Session (180K bytes)
  • Thursday, February 21, 2002 - Afternoon Session (251K bytes)
  • Friday, February 22, 2002 - Morning Session (304K bytes)
  • Friday, February 22, 2002 - Afternoon Session (277K bytes)

    Page 1

    P R O C E E D I N G S
    [8:25 a.m.]

    DR. GORDON: If we could have a few moments of silence, and perhaps in these moments we can recollect our friend and colleague, Bill Fair, who as you know died about a month and a half ago. If we can just sit for a moment quietly before we begin.
    [Moment of silence observed.]

    Opening Remarks

    DR. GORDON: I would like to just say a couple of words about the process and then I want to give everybody a brief chance to speak, and then Steve will talk about our charge for the day. This is the last meeting of the Commission and we have a lot of work to do. I have appreciated the conversations and the e-mails, and I know there are some significant concerns that a number of you have about different sections of the report.

    I see our work here -- and we will talk about exactly how we are going to do it -- but our work here is really to see where we stand as a commission. Our charge is to serve the American people, to bring forward the best possible recommendations regard complementary and alternative medicine, complementary and alternative therapies, and how the benefits of them can be made available to the American people, how concerns about them can be appropriately addressed. So we have a very large task. There are a number of issues that are still on the table. I see if we all come together really in Bill's spirit, which is passion and compassion, critical thinking, a collegial way of relating, and a really firm commitment to do what is best beyond any specific self-interest that any of us might have, that we will come up with a report which we will feel good about, proud about as a group, and that will serve people of this country. What we are going to do is to give an opportunity for everybody, we are going to go through each of sections, and we are going to actually give more time to the sections than is on here on the schedule right now.

    We want to go through the sections and we want to hear very clearly what your concerns are about every section, whether it is concerns about text or concerns about recommendations. We are going to put them up on the board. We have some flip charts up here, and Ken is going to be working those. We are going to address those concerns and either we are going to see that we agree, and that will be clear, we are going to see that there are disagreements that we can work out, either work out in this meeting or work out in the next few days, but ones that are clearly workable.

    Page 2

    So, for example, if there is a change in text and the direction is clear, that we can then come together, get the change in text prepared, and get it out to you, or we are going to see that there are some areas where there may have been long-standing disagreements and we just haven't gotten over those disagreements, and we may have to let some of those recommendations go. Our preference is to come together as a commission and to come together on what we do agree on, what we do feel good about, what we do feel is in service to the highest good of the American people, and to let go if there are areas where we don't agree, to either say so in the text, which is fine, we are not compelled to agree on everything, and if there are areas where recommendations need to be scrapped, we will scrap the recommendations. We would much rather do this and come together than issue a minority report. If there are truly irreconcilable differences, and we can't let some of the recommendations go, we may have to have a minority report.

    But I think my preference, and I have heard from virtually everyone, as well as from those who are familiar with the way commissions work, is we are far better off if we can be strong and solid about what we all feel good about than to have a minority report and to have the report splintered. So that is what I would like to urge us all to do and to rise to that occasion with respect for the differing opinions and with an understanding that this is, as Joe Fins said to me earlier, this is a rare opportunity that we have to make a difference. Steve and I and some of the staff met with the staff of the Secretary of HHS the other day, and we have very strong interest in our work, a very strong commitment to some of the basic positions that we have taken, and we are in a position to move forward, and we want to move forward together.

    Now, we asked Max Heirich to come in and help with some of the rewriting sections. I am sure most of will remember Max from the very interesting presentation that he gave at the Commission. He has worked on national commissions before. He has been an observer of this movement for some 30 years, and teaches at the University of Michigan Medical School. I think he can be very helpful. So in addition to whatever comments you make here, if we have agreements about specific kinds of changes that we are going to make in the text, it might be useful if there are particular nuances or particular things you want included, to speak with Max. He will be around for the next couple of days, and he will be available to help Steve and me and the staff on the rewriting. We are going to be having lunch together today to talk about some administrative matters. We are going to go through until 6:00 today. I hope that is clear from the agenda.

    We are not going to focus on either the vision statement or the executive summary in this meeting because, for me, as I was preparing the vision statement and I realized that there were still so many issues and contradictions out there, I felt I really needed to wait until after I had heard everybody at this meeting, and then I would prepare it and send it out.

    Page 3

    Steve did a very long draft of the executive summary, but had a very similar kind of feeling, that we need to know what we are summarizing before we present the executive summary. I would like to give everyone a chance if you would like to make a very brief comment because this is our last meeting. George, do you want to begin? We will just begin from that side. If you have something to say, it would be wonderful; if not, that's okay, too.

    DR. BERNIER: First of all, I think everyone has done a fantastic job in going ahead, and if we look back to where we were two years ago, it to me is an amazing happening. The one area -- and it speaks up from a number of different places and different subcommittees, but I have a great concern that we are labeling as complete and usable concepts and practices which have not been proven to be safe and efficacious. That has been sort of a general phenomenon. I think some of the divisiveness that has come into the operation is really reflective of that. Now, I am not going to give you a page 12 change, but that is my concern.

    DR. GORDON: Great. Thank you very much, George, we appreciate that, and we will go through the text and look at those places. Linnea.

    MS. LARSON: The only substantive thing I have to say is what I wrote out in an e-mail to all of you about the criteria which I have used to examine the whole document.

    DR. GORDON: David.

    DR. BRESLER: I have a lot of concerns about the report, and I guess we will cover them as we go through section by section, but what it seems to me is that as we go through this weekend, maybe what we want to keep in mind is something we talked about in some of the earlier meetings, which is basically the posture of the Commission. I think we agree that we didn't come in here with a basic advocacy position, and I think it is okay for us to be able to say we have studied these things, we have looked at it, we have taken testimony, and so forth, and here are things which everybody from various diverse interests agrees are recommendations that need to be met, and here are the ones that we could not find any agreement on and that need further study. We may disagree on specific recommendations, but if we can create a report that we can all sign, which respects those disagreements, I think we are doing what you said, Jim, taking the strongest possible position.

    DR. GORDON: Thank you, David. Conchita.

    DR. PAZ: I pretty much agree with that because it is hard to find people from such diverse backgrounds trying to agree on every single point, it is pretty difficult. I think some of these points of contention may be something that we are certainly going to have to work our best with and see whether we can at least come to some agreement to disagree.

    Page 4

    DR. LOW DOG: Not much to add other than I am pretty much in agreement with what has been said. I think that my main problem thus far is that we talk about the science being needed before integration can occur, we say that in the Research Section, and that we go on in the document to just sort of move right into integration on a lot of levels. I think we need to take a step-by-step approach, so that the report is consistent. We are not saying these things should not be available, we are just saying that science needs to be done, research, which can include different outcome measures about patient satisfaction, quality of life. I mean there is lots of ways to measure effectiveness, and then data about delivery, cost-benefit, et cetera, and then you move to integration, and I think it is backwards to integrate and then go do the research and see if it works. I just think that is a backwards posture.

    The other thing is I hope that the Commission really makes sure that instead of trying to leap too far ahead, we set the foundation for as the research becomes available, that there are ways to move this into the health care system, and that we have been very thoughtful about laying the groundwork for that as that comes available. So set the stage for research and then set the stage for how do you move it from the research stage into the health care system.

    DR. GORDON: Thank you very much.

    DR. JONAS: I think that the report accurately reflects the area, which is one of great diversity and a huge number of constituencies that have different interests, different perceptions, and different views, and guess what - welcome to global medicine. I think, therefore, we should go forward and emphasize two areas. One is being clear that our vision statement and our guiding principles are as compelling as possible and catch people's eye, and, number two, that the actual recommendations are as concrete as possible, and not vague, so that we can go back to them and say this is actually what we would like to do or we think we need to do even if the recommendation is we need to do this type of research. I disagree that research has to follow integration. It never does in medicine, never has, never will. It is a parallel process along with professionalization and various public interests, and this type of thing. So I think we should move forward with the report and try to address those issues.

    DR. GORDON: Thank you. Charlotte.

    SISTER KERR: I have a general statement, and I just feel very confident that we can clarify and come to some reasonable consensus on all of these issues in order to offer a new vision of healing and vitality for America.

    DR. GORDON: Thanks.

    Page 5

    DR. PIZZORNO: I think there are three points I would like to make. First, I think we have made a lot of progress, and I thought Wayne was elegant as ever, and that is, this is a challenging area. I think we need two more meetings, frankly, to resolve things, because I see each time we get closer and closer to resolving our understanding. We need two more meetings. Second, I think that there has been one fundamental problem with our whole process, and that is a lack of a good taxonomy for CAM. I think many areas we have run into challenges where we have had disagreement is trying to apply a fairly consistent standard to an incredibly diverse group of practices ranging from professional CAM practitioners with a high level of training and some science, to those with no training whatsoever, and not much science, and trying to apply the same standards to all of them, I think is not working very well. Third, when I read through this document in total, in the airplane over here, I was impressed with what we had, and I think we make one major mistake, and that is, we put the Wellness Section first.

    The reason I say that is because while I think wellness is important, I think in the Wellness Section, we are making much stronger recommendations for integration than is justified by the research, and I think that once you read that section first, it then taints the whole rest of the document. Again, I think it is well written and I think we have done a lot of good work on it, but it is not the right piece to do first. As a matter of fact, I would even say it should be an appendix.

    It is not on our list of topics we are supposed to do from the presidential appointment, and I think it really has confused the whole issue. I think if you read the document with that as an appendix, I think it comes across as a much more balanced and appropriate approach. Thank you.

    DR. GORDON: Thank you, Joe. Joe.

    DR. FINS: First of all, I want to just say personally just how much I have really enjoyed getting to know everybody on the Commission, the friendships that have evolved, I think are going to be life-long, and to me, that is the most important and enduring outcome from a personal perspective. I also want to just thank the staff and Steve, and all you guys sitting here with the back benchers for all the amazing work that people did under a very difficult set of circumstances. I am sure many times it felt like you were trying to herd cats. I say that as a dog lover. But I also want to just say that I have some concerns about the report. I said to Jim that I think that there is this opportunity, but I think we were starting with so much diversity on the panel that it was very hard to maybe realize all that, but let me make a few points, and I will think we will say more as we go forward.

    Page 6

    I think there are many recommendations in this report that were made before there is adequate evidence to make those recommendations, scientific evidence or need, and I think if we take a public health perspective, it is not clear that the recommendations will promote the public health. I agree with Wayne that medicine historically has been based on anecdotal evidence and accretion of information, but there is this trend towards evidence-based medicine and its new standards.

    I think the report in many regards perpetuates the antagonism between conventional and CAM practice as if there were two silos that were impermeable because there is a membrane between them, but patients move back and forth, and we have adopted a stance about two competing systems, and not a patient standard approach, which might be a focus for consensus and more agreement. Patients move back and forth. They use these two modalities and two systems freely, and yet we kind of perpetuate the split in many regards editorially and elsewhere. I think that there are some things in here that are just problematic on the face of it, government funding for industry, grants to industry, so they can pursue their own profits. I think that it is vague editorially.

    There really often are no hierarchies of priority setting, no specificity. We talk about CAM this and CAM that, and as Joe Pizzorno said, you know, which CAM, which practitioners. There are category mistakes, misuse and disingenuous use sometimes of the data, saying 83 percent of patients use CAM when they have cancer, while probably upwards of 95 to 100 percent use chemotherapy, and the scope and the dimension of the use of one far exceeds the use of the other. Things like spirituality and prayer are counted as a use of a CAM modality. So there is kind of CAM creep throughout the report.

    Also, there is no mention as far as my close reading would suggest that the use of supplements has gone down, that Americans want more regulation vis-a-vis the Blendon Report. You would not know that from reading the report. I think the issue of scarcity is another issue. This commission was initiated at the time we had no deficits, we weren't at war. There was a lot more economic enthusiasm and optimism, and I think we have to really talk about this report in the context of that. Things like, you know, sort of tax breaks for insurance for CAM without a clear economic understanding of the implications and what we are sacrificing is a problem. Two more points, Jim.

    The other thing that I want to just say that I find troubling is any kind of equivalency by saying that primary care is primary care simply because we label it as such. Family practitioners, internists, I would add. Congress recently said that chiropractic was not primary care. Primary care means something, it's a discipline, and to say that Americans can be treated equally as well with others who are not trained in the primary care disciplines, I think disserves the American citizenry. It is not to say that CAM practitioners don't have something to add.

    Page 7

    I just want to summarize by saying that I think there is this opportunity, but I think that the focus should be a patient-centered focus, not an advocacy position for one field or another, and we should try to have a more integrative tone and less antagonism. So thank you for that opportunity.

    DR. GORDON: Thank you, Joe. Thank you for all those thoughts. Julia.

    MS. SCOTT: I agree with several of the comments around the table, although I will have to say I think I agree more with the assessment that Wayne provided. I want to also admit to the fact that I was a very active partner in the telephone calls and the whatever, so I think I bear that responsibility for what I am not happy about in the report, but maybe it took seeing it all together to really kind of bring that to fore. I won't repeat what other people have said, but maybe I will just try to say maybe two things that I am troubled by and would like to work towards reconciling for me at least. I do think there are way too many recommendations, that I do think we have to be tough and really winnow down and think of what it is that we think is important. I think we have an opportunity to be bold, and we should be bold. It is not like we expect all of this to happen tomorrow or next week, but I think where it needs to be said, it needs to be said. So I still feel very strongly about that.

    The other think that troubles me is that we seem throughout the report to be constantly using the medical model as to what it is that CAM should do, and I know it is expedient, and it's political, and that's the way things are, and people expect that that is the way things should be, but quite frankly, there are a lot of people who have not been -- large groups of people who have not been served well by this model, and I think CAM offers an opportunity, not withholding, we want safety, we want choice, and all of that. I think that we need to be bold, and I will just stop there because other people have said it.

    MR. ROLIN: Thank you. I, too, just want to commend the Commission for all the hard work that has been done. Certainly, it has been a joy for me to be a part of. I concur with the statements that have been made earlier by the Commission members, but just a couple of concerns I have here. Number one is, as Julia said in her comments, the recommendations, of course, we have established guiding principles that we need to adhere to, and I am wondering if some of these recommendations may have gotten out of line in that area. I can concur that in making these recommendations, we certainly need to be firm and bold about them, as well, it is what we are recommending, that it just shouldn't be a listing. Concerns, yes, but we should really be concerned about that.

    Page 8

    I, too, have concerns. We are talking about regulations and even the continuation in some form of this commission, and is the American public ready for that, and especially since what has happened in the last three months, four months here, is our nation, a nation thinking in terms of health care. Yes, I think they are, it is a primary concern, but then they have got these other issues to deal with. In line with that, I am thinking in terms of this report and how are the states, how are they going to really utilize this report in dealing with the people who need care. I go back to the access issue which we dealt with, so I am really concerned there. This, to me, is very serious, and I just wish that we had a little more time perhaps to really, as Joe has said, I really enjoyed reading this report. It is amazing when you stop and read it how much work has been done, but then you realize that there are certain areas that there are questions that you have. So those are my general comments. Thank you.

    DR. WARREN: Well, I sat down yesterday and talked with my staff at the office about really what are we trying to do here. We were brought together, not because -- well, it was a presidential thing -- but because of consumer-driven interest. I don't know that we would have this commission at all had the report not come out there was $14 billion spent on CAM. I don't think we would have this commission. I think it is basically financially driven. It is a process that the public wants, the public has shown the interest in it. They are going to continue to show the interest in it. Suddenly, they want something, they get it, and they want Big Brother to take care of them. Most people don't want to take responsibility for what is going on. I see our group here, yes, we are very diverse. I don't see a lot of people that try to understand the other man's position. I think we need this to be a win/win situation for everybody on this commission, and for the public, and for the Congress. But we have to do, as people on the commission, understand other people's position. Quit trying to persuade me to your position, learn to understand my position, and then let's move forward.

    There is some good stuff in this report. Yes, we have too many recommendations, we need to cut it down, but there is a lot of good stuff here, a lot of effort has gone into it. This staff has done a fantastic job, and the commissioners have done a fantastic job, but this has to be a win/win or dump it. I think the next two days we need to win/win or get rid of it. That's all.

    MS. GUTIERREZ: I have two things. First, with the document in general, I think today's challenge is going to be to balance the fear of loss, which is the status quo, with the desire for gain, which I see as growth, knowledge, and consumer choice in the marketplace. So I concur with Wayne and Julia, and other people around the table who quoted Beth Clay when she said be bold, this is our opportunity to do that. My second item has to do with text, and I did notice that when I was reading short pieces together, but reading through as a flowing document, we use the word "should" dozens and dozens, maybe hundreds of times, and I don't think it is our place to tell Congress what they should do. When our children were growing up, we told them you can't should, you either do it or you don't do it, you either act or you don't act. So before we proceed through the document, I would like to suggest that maybe we strike the word "should" and emphasize the action verb in all of the recommendations and action steps.

    Page 9

    MR. CHAPPELL: I am grateful for all of you, everyone, for what you have participated in and contributed, and I am pleased to have been part of this. For me, the work we are involved with is a journey, and this commission is not an event, it's part of a journey that will go on, and we are not going to solve all the answers, and we are not going to complete all of the hopes. So I would like to enter these next two days with a, oh, for myself, a little more sense of humility, that we are here to make progress on this journey, and not try to bring about a kind of perfection to everything that our minds would like to have. So with progress in mind, I feel that, as Don has said, we have got to decide individually where are the areas that we can let go of for the name of progress, for the sake of progress, what can we let go of that simply isn't that important in the bigger picture of progress.

    There are some things we won't be able to agree upon, but I don't think that is the subject of the report. I think that is stuff that is left on the roadside. I think the report should be about our common advocacy, what is it we agree upon, how is it we are contributing to the road of progress. So, for myself, I am here to let go of the things that I can for the sake of progress, and to just let the roadside collect the stuff that we can't agree on for a future group, a future day.

    Professionally speaking, let me tell you that the marketplace is unforgiving. That is the one thing you can count on. We don't have to trust in just ourselves. We can trust in the consumers. They are unforgiving. They will get what they want when they want it. Our job is to try to enhance their ability. That is why we are formed, enhance their decisionmaking with good information, access to better information, and they are really not going to be concerned about professional issues that we have. I am personally going to proceed these next two days with a sense of what it is I can let go of, what it is I can contribute for a document of positive advocacy, common advocacy, and progress in a road and a journey much longer than March 7, 2002.

    DR. CHOW: Good morning. I want to say just really how grateful I am to have all the diversity influences on my life with this commission. The Commission was set up because of demands of the people and because there was a recognition that there was this diversity and that there was unhappiness with the system as it was. I think we have to keep that in front of us, that we are here, not representing ourselves and our own views, but we have had nearly 1,000 people and more than that writing in, and we have been hearing, and that I don't think there is any problem with disagreeing with each other, with respect, and stating where the disagreements are. I don't even want to call it "disagreement," the diversities, and make it a positive aspect, because that is where growth is, and that is why we are here.

    Page 10

    So I would like to acknowledge that there will be things that we agree upon, and then the things that we don't have consensus about, not to portray it as a negative point, but it is a very positive point, because that is what is happening out in the field. Wayne said some of the things that I thought, and Julie, and Joe, that I don't think we should be afraid of having different opinions, and that we should state that in our document, and that it is one step towards the long mile, and we are only that, just like this life is only one chapter of many lives.

    So, therefore, I think we need to think more than the Commission, I think we need to represent what has been testified. We need to represent the divergent field, not really be stuck in sort of saying that there has to be one way. I think if we look at things positively, I think we can overcome what we are fearing about, in all our conversations, that we are not reaching a consensus. I know there is one consensus, that the Center needs to be done, and to carry on the work which the Commission has begun.

    It is just another step. AOM and NCCAM, we went through the same process, we couldn't accomplish as much as we could, and it's moving on. I think with that attitude, I think we might be able to come together and feel better about the report and that you are not signing the report because it is the end-all and be-it-all document.

    The list of the people at the end of our appendix is phenomenal, and you think you are going to get consensus from all of that? I really appreciate all the work that has been done, and like Joe, I want to thank the staff, too. It is really a muddy water that you have been wading through, and with all our different personalities and everything, it really is great where we have come. If we only put it on a positive vein and be courageous about stating the diversity, and not look at it as a fault, and I think that is what we have been presenting it all the time. That is what I am troubled about. Thank you.

    DR. GORDON: Thank you, Effie. Don, you wanted to add something?

    DR. WARREN: I was just sitting here thinking. We were brought together by the President, and his charge was to be an advocate. It seems like all of our four points that he gave us were to be an advocate. I think we need to be reasoned and logical in what we advocate, but we are here to be advocates. We are here to tell the Congress, tell the President how to possibly go about integrating CAM into the nation's health care system. I think we need to remember that. Don't be worried if we are going to step on somebody's toes, go ahead and step. We might make some enemies, we might make some friends.

    Page 11

    DR. GORDON: Thank you. I really appreciate everyone having spoken. I want to just add that I think that we have come a very, very long way. We have gotten to know each other in a variety of ways. We have come out with a number of different perspectives. We have covered a huge amount of territory. As Effie says, a thousand people have testified, more than a thousand more have submitted written testimony. I want to emphasize something that Don said as we go ahead with this discussion. This is not about argumentation. This is really about listening and about respect, and trying to come together to the highest place, whether it's agreement or disagreement, in the service of the people, not in the service of narrow interests or any of our particular foci. I think all of us have to be called to this higher work. The other thing I want to ask everyone to do, since this is our last meeting together, is please, put on the table the issues that you have. I think it is really important that if there is a significant concern, please state it, and state it directly and openly, and everybody take it in as this is this person's concern and let's see if we can deal with it in the course of our discussions.

    It is important not to -- I feel sort of funny saying this -- not to hold back, because this is our time to really deal with any of the concerns that are remaining about the report. I want to thank everybody. I want to thank the staff, as well as all the commissioners. Everybody has really worked very, very hard, and I think in a very collegial way. I am hoping we will continue these next couple of days and with any final work on the report. Steve, do you want to speak specifically to the charge?

    Charge for the Day

    DR. GROFT: Other than those issues, we have got an easy meeting.

    DR. GROFT: George DeVries is taking the red eye in from San Diego, and he will be here later, so when he gets in, we will give him an opportunity to address his position and thoughts, as well. Dean Ornish is due to come in tomorrow morning and perhaps we can hear from him. I think he also sent an e-mail to all of us, or that you probably got or didn't get during the night. We are going to get it copied and handed out to everyone. I think he has some comments on some of the subjects that will be discussed today, as well, just to let everybody know what his thoughts and suggestions were as far as the report, but he will be here later this evening and again all day tomorrow. It has been quite a journey, as Tom has referred to, our minds, bodies, and spirits, as I wrote in our note, and we have a lot to do. I think basically, the charge is to come up with a report that will reflect what the Executive Order asked us to do, and that is to provide recommendations to Congress and to the Administration.

    Page 12

    I am not so worried about shoulds and woulds. I think this is something that any commission writes. They are asking for direction, how we express it. I think even if you look, some of the earlier versions of the recommendations, we got rid of "The Commission recommends," and we tried to put in some action verbs. I think we will continue to do this as we go along whenever possible, and we will continue to reduce as we go through the meeting. I think that is something the staff is prepared to do. Again, I can't thank them enough. They have been great.

    DR. GROFT: Let me bring you some good news. First, Michele is doing relatively well. She has been confined to bed for the last three weeks, I guess. She was having some premature contractions and I said okay, you stay at home and work, so she is there. We are going to try to link up with her tomorrow and just for the wellness discussion and everything. She did want to be here, and I know how much she misses you all and everything else. We know what the charge is, what we have to do, and I think, looking at all of this, we are all pretty high achievers in our own respects. I look around at all of us, and I look at the audience too, over-achievers, I mean we are up there in the super category. I think we always want to win, we always want to do what is right, and get it right. You know, we aim for perfection, and we are not going to get that, but we are going to do something pretty good here, as we did back in 1991 and 1992, when OAM was started, and how we have moved from those days until where we are here.

    Wayne Jonas was along on a lot of that journey. Many of you have been on the same trip, participating as consultants to the government, and leading the charge. Jim has been involved, Effie has, a lot of us have been around, I, more peripherally than everyone else.

    The opportunity here is for us to give guidance, where should we go, how can we get this integration that everyone is looking towards. I agree, we don't want two separate systems, nobody wants that, but how can we best integrate the two systems, that we can give the best care to the patients that everyone sees. I think we can do that. We are going to have to do a lot of rewriting. The staff knows this, they are prepared to do it. We have spent a lot of yours listening and talking, and I really appreciate all of your presence and contributions during those many hours when we were talking and trying to figure out what is it that we wanted to present. I thank you. I don't know if you realize how much you have contributed to the report and how much your voice has been heard and has been inserted. I think if you read the report, you are going to see bits and pieces of everything -- not everything -- but many of the things that you stated, you are going to find in the report. That is what we tried to do. We felt all along that, gee, we are not sure what it is that the Commission really wants. I think this meeting here, we want you to collapse it all and then to rebuild it, keep that which is really good, but so often we have to focus on the negative of what is wrong with the report, and that is okay.

    Page 13

    There are a lot of good things in the report, and we don't want to forget those, but we do have to attack those that everybody is uncomfortable, so that when we leave here tomorrow night, there is a comfort level that this is a pretty good summation of where we think things should go. As I have mentioned to you, I am continually impressed by all of your efforts, what you do in your own personal lives and how you contribute, and the diversity of the group. I look at where we were in July, around July 5th or so, when I started calling everybody and say, hey, we are going to meet July 13th and 14th, and everyone showed up. I mean they took late night flights, everyone came. It is amazing accommodation to do what we had to do, and even now we have remained strong to that end, doing what we have to do, and that is how I look at the meeting today and tomorrow.

    We are going to get there. Just work with us and keep laying your feelings and your thoughts on the table, and discuss them. I think once we get your thoughts out, we can start to build that report that we need to go forth with. It is okay to have difference of opinions. We can state that. Five years ago, people would say no, you have got to have everything right. That is not the way the Administration is working.

    Everyone wants to hear options, and if there are areas of disagreements, we want to hear the areas of disagreements, so we can address those, so that when we finally do address each of the issues or when the parties who are responsible for addressing each of the issues, at some point in time, whether it be April 20th of this year, January of next year, what have you, they will see that the Commission said this, and they recognized these problems, and I think that is the wisdom we are looking for from all of you, that collective wisdom. We know there are problems here, we can address them, but we have to state what has to be done to keep things moving. Thank you.

    DR. GORDON: Tom.

    MR. CHAPPELL: Thanks, Jim. Steve, thank you for your openness. I want to ask Steve if one style device or a shaping device for the document might be for us to create, in each section, something called "Central Issues." I know that issues are either expressed or implied in the copy of the report, but sometimes the recommendations aren't able to hit the issue head-on, at least in an area that I am familiar with, they fail to do that. So, in a way, we sort of bypass identifying the real concern and issue of the consumer or the bigger picture. Example. What I am after with this idea is to try to capture the best of the hearing process, what did we hear out there. On safety, for instance, can we make a very clear statement that this is a huge issue, that our recommendations are not addressing head-on, but we are bypassing, our recommendations are bypassing the issue. This is one area I am sensitive to, but I wonder if -- we have done everything else so well -- could each section have an identification of key issues in that category.

    Page 14

    DR. GROFT: I think not only could we identify, but you create your hierarchy of issues, as well. So I think that is something we would welcome as we go through it, and I think that would help shape the executive summary, as well, if we could identify both the core issues, central issues, as well as the hierarchy of issues.

    DR. PIZZORNO: Jim, one of the comments you made was that we can incorporate into the report, areas where there was not agreement. Could you explain more about how we go about doing that, because I agree, it would be nice to have one report, and if we have some diversity, we could not figure out how to put it in.

    DR. GORDON: If there is an issue -- I will make up an issue. Let's say lighting in this room. The majority of the commissioners felt that the lighting was quite adequate in this room, but other commissioners were concerned that artificial lighting might pose a health threat although the research evidence is not in on it. Just coming off the top of my head, that is a way of raising the issue, and discussing the issue, and we can't say we absolutely have to have this lighting, we can discuss the pros and cons of having this lighting, and we don't really feel the evidence is finally in to decide whether we should have this lighting or bring in full spectrum lighting, something like that.

    DR. PIZZORNO: So could there be a section at the end of each of the sections that says "unresolved issues," is that what you are thinking?

    DR. GORDON: What I would like to do is to go through the report and see how we come, because I think it is going to be dealt with somewhat differently. We may want to do that, and that is a perfectly good idea, and I am open to hearing from other people about whether or not that makes sense, but we may also not want to do that, because it may only be applicable or the unresolved issues may not be important enough for us to give that emphasis in the report. I would rather see how we come out and then figure out how we deal with the material with that as an option. Charlotte.

    SISTER KERR: This is just input for how we would proceed. It is sort of a point of order. I foresee -- which I think is fantastic because it is saying we are still trying to burst forth with some new vision -- when we get into these points of lack of consensus, for example, I hear the one on primary care and the complementary medicine, and I think it is important, which everyone has said, you know, the honoring of the diversity, and so I am wondering, and I thought Tom might have a point on this, of when we identify either before, like if we listed the six things at the break of what we know are going to be kind of issues we want to clarify or refine, if we could actually have a process built in, okay, here is the point, kind of an arbitrator or how would we debate it, so we get it out without just 24, you know, "I want to" speaks, you know, if there is anything we need to reflect on that for how to proceed when we hit a snag of a point.

    Page 15

    DR. GORDON: I am open to any suggestions. My thought up until this point would be that we would bring out, let's say, a primary care issue as an issue, and we would just hear from people, keeping in mind the limitations of time, and that people, where your point of view was sort of where it exposed a crucial difference from the previous points of view, that it will be important to state, but it would not be important just to speak for the sake of speaking. I think we need to be economical, we need to hear the different perspectives, and then we have to see where we are, and at the end of each point, we would then say, okay, how are we going to proceed, is this one of those things we have significant disagreement on and we need to address in the way that Joe was suggesting, is this one of the things where if we change it in a minor way, we can get agreement, is this something where we agree, but the text just doesn't support, and so we ask the staff to help us get the text to support it. I don't know how many issues there are going to be, I don't know how difficult they are going to be. I don't know that there is a uniform process for all of them. I would like for us to start going through and see how it goes, and then if it is working, great, and if it is not working, let's change the process. Don.

    DR. WARREN: What is going to be the criterion for acceptance of a recommendation by the Commission or rejection?

    DR. GORDON: The thoughts that we had is that we would like at the end of each section, to see which recommendations we now accept.

    DR. WARREN: Will there be a vote? Will there be a majority, a three-quarter?

    DR. GORDON: I am open to the possibility. I think we have to see who is in favor. We will have some kind of vote. Most of the recommendations, most, not all, we have already had unanimous agreement on. There will be some where we either haven't or where people have realized this really don't work for me, I'm sorry, and then we are going to have to revisit those. But I think that we can indicate, and maybe with staff's help, we can reemphasize which recommendations there has been unanimous agreement on before, and maybe if each staff person in charge of the section can help us with that as we come up on those sections, and you can provide that for us. I know some of the recommendations we went back and we said we want to work on it again. So, if there is something we have unanimously agreed on, that we are now going back on, I think we really need to focus on why we are doing this, and if a couple of people don't agree, we may want to say this is a recommendation and a couple of people have concerns about it, or we may want to take that recommendation out. I think that is something we have to figure out when we come to it. Effie.

    Page 16

    DR. CHOW: I have trouble with rejecting anything because we can have total agreement, we can have moderate disagreement -- oh, I hate that word "disagreement" -- diversity on it, or divergent opinions on it. We brought out recommendations because it must have been brought forth in the testimony, and I still want to get to the fact that we are not representing ourselves. We keep talking about we voting what we feel like. It has come from the testimony of the people. So, therefore, for it to be in our paper right now is because we heard it so many times. So even if we all disagree, it must have come up because of what we have heard. So I am not sure that we throw out anything. I think we should categorize it that there is greater agreement with this, and then there is divergent feelings, and then there is this was brought up as an issue, an important issue, because at this point, throwing out something is just as bad as -- I don't know. I really feel we have gone through this report a lot, and we should have thrown it out before if, at this point, we needed to throw it out. So, I think there is import to it.

    DR. GORDON: Thank you. Tierona.

    DR. LOW DOG: I like the comments about divergent thinking and divergent opinions. I guess I still am having a little bit of problems with kind of the bias that we keep referring to as far as consumer-driven movements and the testimony that we heard, because there was a real bias in the testimony and the people who came, and even down to the invitations of people who were invited. So I feel like we got a sliver of what the American public feels, but I don't feel like we heard from all walks and all peoples of all opinions. So for myself, it is not just the people who showed up, but all the other people in our experience. We don't live in a vacuum. We all have our own interactions and interfaces with people. So I am hoping that for myself, that it is not just about just the people that I remember testifying, but all the things that I have read and all the things that I have heard and that I have written, so consumer-driven movement and testimony is one thing, but I think we want to keep in mind that there was definitely a bias in what we have heard and to keep that in mind as we go through the report.

    DR. CHOW: I agree with you on that. It is not just the testimony, but all of it.

    DR. GORDON: Charlotte.

    SISTER KERR: Mine again is just a point of order, which is separate from what we are saying. When we speak today, Mr. Chairman, could we be sure we speak -- for example, when Max did his response for us, I am really confused on what has been called a chapter and when it is 3.1, is it 3.1 of Chapter 3, so if you could just clarify every time we start, so I can be right on-board. Like the Health and Wellness doesn't have a chapter title. Just so we can get that down.

    Page 17

    DR. GORDON: I will, with assistance, do my best. Tom.

    MR. CHAPPELL: Thank you, Jim. I am concerned that if we just proceed with an arbitrary approach that we will see how we do, we will waste a lot of time. I wonder if, instead, you and Steve could come up with a recommendation of how we are going to proceed, what is going to be the decisionmaking method as we proceed. I think we would all benefit from a decision on that at the outset rather than along the way.

    DR. BRESLER: Just to make things simple, what I think we should do first around is just simply say here is a recommendation, do we all agree. Great. If we don't, we agree to disagree about it, and then let's look at the camps that are disagreed about it, but I think the whole tone of the report is we agree with all these recommendations, and we agree to disagree about these particular ones. I think as we go through it, I think we have great consensus on most of them, and I think we can get through a lot of it fairly quickly. There will be a half-dozen issues that will tie us up, but let's look at those.

    DR. GORDON: There is also the issue of text that I want to make sure we address. I think in some instances, we will have much more agreement on the recommendations, and the text may need significant work. So we can if people would like, we can work back from the recommendations to the text. Is that what you are suggesting, David?

    DR. BRESLER: We can go that way.

    DR. GORDON: Does that feel comfortable, Tom, as a means of working? Our initial plan was to go through the text and then look at the recommendations at the end, and then as we go through the text, see what issues there are, put them up on the board, and try to deal with them one by one after we have got the whole list of issues that need to be dealt with, whether they are in the text or in the recommendations.

    DR. BRESLER: Jim, for the sake of time, though, I would like to be able to dismiss a lot of the things that we are in agreement with, and have them fine-tuned and wordsmith it, and focus our time on the ones that we really need to work on.

    DR. GORDON: Okay. There is a recommendation from David, which I am assuming, if I am wording it correctly, is to deal with the recommendations first to see where we agree, and then to go through the other recommendations, and then to go back to the text?

    DR. BRESLER: That is kind of the way I thought you were going to go through the report that way, look at the recommendations, if there is consensus, see what concerns people have, then move on and focus on the ones where we have disagreements.

    Page 18

    DR. LOW DOG: Let's try it as an experiment.

    DR. GROFT: We are starting off with the introduction and the history, so there are no recommendations, so we essentially will be going through the text. So I would offer let's try that process first.

    DR. GORDON: For now, let's go through the introductory chapters. Then, we will take a break, we will come back, and the next time we can go to the recommendations first in the next chapter, and see where we are. Okay? Let's see how that works. If it works well, great; if it doesn't, we will go back to a way of working through the text.

    DR. GROFT: Perhaps at the break, we can talk about the procedures for gaining acceptance, whether it's a vote or a majority, or exactly how we want to go.

    DR. GORDON: Let's take a look at the Introduction. Thank you, this is great. We are all working at this together. There is no divine answer that we have received yet. So let's work on the Introduction and begin with that, and then look at the text and issues. Ken is going to write up any concerns or issues about the introduction. David, please begin.

    Open Discussion: Introduction and History of CAM, Guiding Principles of the Commission

    DR. BRESLER: I have a lot of problems with the Introduction. I think it misses the whole point of why this commission was formed. I mean anybody who is reading this is going to want to ask the question, "So what, and what does it mean to me." The whole point is that there was concern about the use of complementary and alternative medicine, concern in both directions, concern that it represented low technology, low-cost alternatives that might be beneficial to the American public, and concern that there was a lot of unproven techniques that were in widespread use that could be dangerous. I think that we have to justify the fact that there was a need for the commission, and that it is a good thing that the commission was formed, not just in the executive summary.

    DR. GORDON: Great.

    Page 19

    DR. BRESLER: The other comment I would make is that I think the IOM report and the Healthy People 2010 report should be appendices, and refer to, and the emphasis is this is a major concern for the American people, this is why we looked at it.

    DR. GORDON: Some of that was a mistake in the printing. All those details should not have been printed the way they were. That was a mistake. So thank you for that and thank you for your thoughts. Other thoughts about this first introductory section? I am going to try to move through these as quickly as we can, we get agreement about these issues, then, we can go back and, in these sections, it is a matter of rewriting to conform to the general agreement that we have among us. Joe, go ahead.

    DR. PIZZORNO: In an earlier version of this, we had a lot of language that was kind of anti-conventional medicine politics, which we all thought was too strong, and not it is totally gone from the document, and I am just appalled by lines 9 and 10 of the first page. That implied the only reason that CAM did not develop was because it was not scientific. That is clear, part of the problem. Their problem was the AMA did everything it could to suppress this form of medicine. That has to be stated. That is a matter of public record.

    DR. GORDON: Joe, how are you suggesting that be worded?

    DR. PIZZORNO: Well, I think it should be worded gently, but it has to be stated. I mean clearly, there has been a century and a half of opposition by the American Medical Association to this form of medicine, we can't pretend that does not exist.

    DR. LOW DOG: I am not sure where you are.

    DR. PIZZORNO: The very first page, Introduction.

    DR. LOW DOG: Where it says, "Until recently, the primary response has been" --

    DR. PIZZORNO: Right. That's the only statement about why it has not been more public. That is all that is stated.

    DR. GORDON: Let's hear the issues and then let's see where we come out. Tom.

    MR. CHAPPELL: In the section following the guiding principles, we have a section on the National Academy of Sciences Institute of Medicine's report, Ten Rules for Health Care Reform. It just feels odd to me -- okay.

    DR. GORDON: I think we have agreement on that, and we are not going to have that in with that kind of detail. That is what I have heard, that is what was conveyed initially to Jim Swyers from the comments, and it just didn't get in. They just wound up being in this detail. I think that the agreement that we had on this was it is important to mention the IOM and the congruence, but to have all the wording is not important in this section.

    Page 20

    MR. CHAPPELL: Or it could be handled in an appendix, too.

    DR. FINS: I agree with Tom on that, as well. I think it just kind of sits there and it doesn't necessarily follow, and it is too long, but I think there is something about that and why it is there that speaks to Joe's comment. I don't think this is a report, Joe Pizzorno, to refight the old battles. I really think that we need to get beyond settling the old scores. I think that what we need to do is somehow upfront, Joe, talk about the need, and I think this is what the crossing the quality chasm reference is about, is meeting the needs of patients as they move back and forth through these two systems of care. They are not served if that is two antagonistic systems or two competing systems, or we are fighting old, historical battles. So I think that the Introduction should be positive, and not accusatory in either direction and say, look, you know, there is increased use, people are living in both of these systems, and as long as there are two systems that are antagonistic and competitive and at odds, there is no cross-training, and there is no cross-education, that patients are going to be ill served, and that is a threat ultimately to the public health. So I think that should be the tone, and I think that is something that everybody can agree on, because, you know, Julie was saying this is for the people, this is patient centered. We have to serve the people, and we are not serving the people by going back and saying the AMA was this or the naturopaths were that. I think we have to recognize that in many respects, those old scores were settled by the establishment of this commission. That is the vindication in many ways.

    DR. GORDON: Okay. Any other comments on this introductory section? Joe, go ahead.

    DR. PIZZORNO: Joe, I appreciate that we don't want to go back and fight old historic battles, I agree with you 100 percent, and today, right now, the American Medical Association, the state associations is blocking the licensure and economic equivalents of CAM professionals. It is happening right now, so we can't pretend it doesn't exist. This is a real problem for the public because what happens it when you block credentialing of CAM practitioners, then, the public is left with what is left out there, and it is a huge public safety issue.

    DR. GORDON: I would like to suggest that there may be issues that need to be dealt with. I don't think the Introduction is the place to do that. I think that it is very important that the Introduction have the positive tone and that whatever historical or whatever present issues be dealt with as they come up in the text.

    DR. PIZZORNO: I am fine with that.

    Page 21

    DR. FINS: I think another point about equivalence is we are not equivalent. I am not equivalent to Joe Pizzorno, and he is not equivalent to me, and we all do different things around the table. That is not to say that one person has more or less value than the other person, but I think the notion that to strive for equivalence, you know, misses out on the diversity of perspectives. So we shouldn't talk about one replacing the other, but what, in the aggregation, what kind of synergisms exist. We are better off because, you know, there is a Joe Pizzorno and there is a Joe Kaczmarczyk and Joe Fins, and all the Joe's, so I think that is what we really need to focus on, and I think if we try to have equivalence, in many ways it is disrespectful because it diminishes the value that each of us singularly brings to the healing equation.

    DR. GORDON: Julia.

    MS. SCOTT: I think the tension here is that we have been charged as a body to bring together in this report, differing views, and I think we are trying to bend over backwards to make this balance, so that we are not falling in one camp or the other, but at the same time, I don't think we can always just gloss over or remake history. I think Joe's point is well taken. I don't agree that it belongs in the Introduction. I think lines 9 through 11 or 12 kind of says there was these kinds of barriers, but I do think in the history, we should point to it, not for pages and pages, but I think we can't rewrite history, we can say this is the way it has been, but this is what we have heard from the public on where we want it to move to the integration.

    DR. GORDON: I am going to keep on taking a role that is not unaccustomed, which is to move discussion forward with everybody's consent because we have a tremendous amount of material to go through. I want to focus here on the Introduction and get some general feeling, which I think we are coming to, and we can address some of the other issues later. Wayne.

    DR. JONAS: I am wondering if one way to make a bold statement and also keep it very positive is to try to formulate a vision of what we want we want to see, what we want to accomplish in this field, as we have discussed several times. I know that was something that I think was said was coming and we were going to deal with it, but I am wondering if that isn't an approach that would be useful.

    DR. GORDON: I think that what is happening is that aspects of the vision are emerging from this discussion, that it is there, and that that will be presented, but that the diversity is important, that the positive tone, that the collaboration is part of that vision.

    Page 22

    DR. JONAS: When will there be an opportunity to kind of review such a statement?

    DR. GORDON: Once we finish this meeting, and I have a clear sense of where everybody is, I will send it out to people within a day, two days -- within two days

    MR. CHAPPELL: I am wondering if the term "Introduction" would be better the Commission's charge, because that gets right to the nub of the point. Then, you can take out any attempt to try to approach this topic, and that is what is going on here. The Introduction is trying to approach the topic, and we are going to have differences of opinion about how to approach the topic, because other content is in history or guiding principles. Why don't we just name it? Let's call this, instead of Introduction, this is the Commission's charge, and then you have got history and guiding principles, and I think it just allows you to clean up --

    DR. GORDON: So what you are suggesting is Commission's charge together with guiding principles?

    MR. CHAPPELL: Well, you have got really three segments. You have got Introduction, History, and Guiding Principles. Instead of Introduction, I would rename that the Commission's charge.

    DR. GORDON: And where would the Guiding Principles go?

    MR. CHAPPELL: It would stay in the order that it is. All I am trying to do is in the report, where you have the section called Introduction -- oh, I see, the Introduction is embracing all those three segments, the Charge, the Principles, and the History. Is that right?

    DR. GORDON: The History is the second chapter. What I am hearing you say is that in the Introduction should just be the Charge and the Guiding Principles, or just the Charge?

    MR. CHAPPELL: Just the Charge.

    DR. GORDON: And then the Guiding Principles should be part of the Vision?


    DR. FINS: Make that a separate section, Tom?

    MR. CHAPPELL: I would leave History and Guiding Principles in their current sequence. I would just change the name of the title Introduction to the Commission's Charge, and then I would clean up all of the little sensitivities about how we found our way for this charge to be created. We don't care how the charge was created, it just was, so let's say that, and then we avoid Joe's and Joe's discussion at this point.

    Page 23

    DR. FINS: I agree. The charge is really the Executive Order. We should ground it in the Executive Order.

    MR. CHAPPELL: Fine, the Executive Order.

    DR. FINS: And talk about the Executive Order and review that. What we ran into in the July story, you know, our July meeting, we had those two or three days, and we had a much more ambitious, you know, verbose report, and we trimmed it down, and less was actually a hell of a lot more. I think Tom's editorial suggestion is a step in the right direction. I would make another suggestion that I think might really help us link up the text with the recommendations, is to have very brief introductions to each of the sections on the order of a page, like kind a real tight abstraction of what we need to achieve, and then have each of the recommendations followed by a supporting paragraph or two. This will help the writers because we have a short time frame. It will be able to explain why we are making that recommendation. If we can't support it or we see that it is a redundant recommendation, we will lose the recommendation, and it will help decrease the number of redundancy problems that we have all identified.

    DR. GORDON: I would like to come back to leaving that last part of the suggestion aside, come back to where we are with this Introduction. Is there agreement that what we are looking for is simply the Commission's charge and a brief description of the meetings that we have had, which is part of what is in here, and do we want the guiding principles in here? Where are we with that? David.

    DR. BRESLER: Again, with the addition as to what the concerns are that led to the Commission being formed.

    DR. GORDON: But stated in a positive way without resurfacing old battles. Okay? Tom.

    MR. CHAPPELL: My recommendation would be that we drop the word "Introduction," we rephrase that as the Commission's Charge, that we do not reference the history of how we got to have the charge, and that we employ the Guiding Principles in that same section, because it says basically, in doing that, you would have here is the charge and here is the orientation that the Commission adopted to go about that charge, i.e., guiding principles.

    DR. GORDON: And in the background --

    MR. CHAPPELL: The history. The history would be in the History Section.

    DR. BRESLER: I don't agree at all. I think nobody is going to read this report.

    Page 24

    DR. GORDON: I think that we are clear about the tone, we are clear for the need of the Commission's charge, and the guiding principles. There is a disagreement that David and Tom are voicing between whether or not to include some background as to why the Commission got the charge.

    DR. BRESLER: Not a history, but what the issues are of concern to the American people that led to the Commission being formed. That is all the background has to say, why there was a need to form this commission, and it was a damn good thing that they did, because there are major concerns that need to be addressed. I think that that needs to be stated.

    DR. GORDON: Tom, are you comfortable with that or not comfortable with that?

    MR. CHAPPELL: Well, I believe that the concerns and issues that led to the formation of the Executive Order need to come to light early on in the document. There is the financial component.

    DR. GORDON: Let me propose another possibility. I can discuss those issues in a vision statement which would be in front of this.

    MR. CHAPPELL: Fine.

    DR. GORDON: That might be one way to deal with it, and not have it in this section. Have this basically be the Commission's charge, and in the vision statement, talk about the issues that we all know well, the economic issues, issues of chronic illness, public health issues, and have that as part of the vision, and begin with that.

    MR. CHAPPELL: Fine.

    MR. SWYERS: Jim, can I weigh in on this for a second? Unless we go back to those legislative hearings for the Executive Order, I don't know that we can actually say what caused Congress to form the Commission. I wouldn't feel comfortable writing that without some sort of documentation.

    DR. GORDON: Okay. This is your section here, so that feels perfectly comfortable for me to discuss generally, since I was there in those discussions, in the vision statement.

    MR. SWYERS: Certainly. I don't have that institutional memory. I could guess, but I think it would cause more problems than it would solve.

    Page 25

    DR. GORDON: Joe, go ahead.

    DR. FINS: I want to go back to what we want to do. Do we want to have a rhetorical victory, whatever side you are on, or do you want to pragmatically influence the public health? I would be very uncomfortable with somebody trying to suggest why we got here, how we were legislatively constituted. I think it is simply enough to say that in response to a public health need, you know, consumer desires, concerns about safety and efficacy, the White House Commission was established, the Executive Order said this, that, and the other thing, and then we get to the History Section, which is open to interpretation. History, as you know, is a subjective take on things, it can happen later. History maybe should come second because it is background, it is early in the report, but I don't think we want to start off with this sort of editorializing, and I am also uncomfortable with the vision statement being so far up front, because it is sort of like where we got, it's our distillation, and without justification, it looks very sort of on shaky ground, not that it is wrong, but it may not belong there. I think the Introduction should be very crisp, to the point, and not alienate half the readership in the process.

    DR. GORDON: Joe, when I was speaking of including in the vision statement, I was going to include exactly those several points you made. This is not a huge disquisition. The question that I would like to solve very quickly, so we can move on, because we are really at the very beginning, is do we want that paragraph or so of explanation that Joe summarized perfectly well, do we want that here in this chapter that talks about the Commission's charge, or do we want to leave that -- there has got to be a little bit of background, and I think that you have described the little bit of background that is necessary in order to justify the existence of the Commission. Tierona.

    DR. LOW DOG: Well, I think if it was a paragraph, and very brief, that just a very brief summary and then writing to the executive charge, and then the guiding principles, and to keep it very narrow with the Commission's charge.

    DR. GORDON: Fine. Linnea.

    MS. LARSON: I think in this case, really, brevity is the soul of wit, and that to be very, very clear, and not go all over the map on that for what Joe Fins was saying, this is the reason, because then we get into the area of something that Jim Swyers brought in, it is legislative intent, and we do not know.

    DR. GORDON: Fine. So are we agreed, Tom, is that okay, that we have a brief introductory paragraph, we have the Commission's charge, description of the meetings, guiding principles? That is this chapter. Okay? We are on. We have got agreement on that.

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    DR. JONAS: Linnea, I think it was "Brevity is the soul of wisdom." But wit, too, I like that.

    DR. GORDON: I just want to add that I would like to work with Jim Swyers to take the liberty of rearranging the discussion of the meetings, so I think it is important to emphasize the full commission meetings first, the town hall second, because the full commission meetings were directed by us, and there were more of them, so that is just rearranging a couple of paragraphs.

    DR. FINS: Ultimately, I mean I think everybody's agreement on this is predicated upon a reading of the text and receipt of the text, so any agreement that I think any of the commissioners give right now has to be sort of conditional.

    DR. GORDON: Let me say that the agreement -- thank you for saying that -- the agreement here is on the guiding principles, if you will, of rewriting the text, and that that text will then be sent out to everyone, text of all of this, within the week for your thoughts, critique, but if we are clear what is guiding us in the writing of this, then, we should be okay. We are not at a point where we are saying, well, that shouldn't be in here or this should be in here. We are in basic agreement with what should be in here, and the text will then go to everybody for final approval. All right? Okay. I think that we might want to take a break. Let's take a break and then we will come back and we will talk about the History Section, and then we will move through the sections as we go along. Let's come back in 15 minutes, give everybody enough chance to do what they have to do, come back.


    DR. GORDON: Let's begin with CAM in the United States, Definition, Recent History, Current Status, and Prospects for the Future. Again, with Ken's help, we will put some of the issues up. Michele Chang is on the speaker phone with us, so if you want to say hi, say hi.

    MS. CHANG: Hello to everybody.

    DR. GORDON: Tom.

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    MR. CHAPPELL: With regard to this section, I have been part of the process here, and I guess I was making some assumptions that certain topics would be covered, that I don't see covered in the history, that I think really are a part of the formation of the whole CAM movement. Those pieces that are missing for me are, first, an awareness of the vitamin and dietary supplement business in the forties, fifties, and sixties, which was one expression and response by manufacturers to consumer needs. The second really was the development of the whole foods business in the sixties, seventies, and eighties, with the East-West Foundation, Air One, Paul Hawkins, Frank Ford, and so forth, that whole industry of natural foods as opposed to natural vitamins that grew up, and that was a parallel track to the vitamin industry. But that whole foods led to holistic medicine, then, to organic foods, and then CAM is all in and around there.

    DR. GORDON: Thank you, Tom. Let me just fill everyone in and remind everybody that we are making comments on issues that either need to be included, addressed differently, or perhaps not addressed in each section. For each section, the staff person who is responsible will be sitting, as Jim Swyers is sitting there, working with us on developing the section. So there is going to be a back and forth, they are hearing everything we are saying. We are going to put it up on the board. Ken is putting up on the board the issues, and then we will be discussing them one by one. So other issues for this section? Again, feel free, not only for topics, but also issues related to tone that you think we need to address. Joe.

    DR. PIZZORNO: Is it in this section that we mention the political challenges that CAM has faced over the last century, and that currently face? Where does that go?

    DR. GORDON: Potentially, that can go in this section and/or in sections related to specific topics, such as licensure, such as access, et cetera. So what are your thoughts about that, Joe?

    DR. PIZZORNO: I think we just need to have one paragraph in the History Section that talks about the political challenges that have faced CAM in the last century. I don't think we need to get into a high degree of conflict or browbeating, because I think it's a mutual issue, but we can't pretend it's not there.

    DR. GORDON: David, and then I think Linnea had her hand up, as well.

    DR. BRESLER: Just as Tom rightfully points out, the role of the whole foods industry, I think some mention should be made of the interest in Oriental medicine that occurred with James Restin's reports and the reports of surgery under acupuncture anesthesia, which really got a lot of attention and opened up kind of like Sputnik did, you know, a lot of interest in Oriental medicine. I think also in your Table I, there is no mention whatsoever of any of the mind-body medicine modalities. I also notice you were going to write up something about mind-body medicine. When will we see that, Jim?

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    DR. GORDON: I didn't know I was going to write it up until I saw the document. I have written the paragraph on it. Mind-body medicine, this table is not correct the way it is done. Mind-body medicine is a separate category. Here it says, "Herbal therapies and mind-body methods." In the revised version, it is "Mind-body methods." Do we have that revised version to hand out to everybody, Jim?

    MR. SWYERS: I did send it to you. No, I don't. I can get it for you by tomorrow.

    DR. GORDON: So we will hand that out, but, David, that is accounted for, both of those. Joe.

    DR. FINS: Just as a point of clarification, are we going through the whole section, or are just doing the History Section of this part? This whole thing is called History. There is a Current Status Section, which is later.

    DR. GORDON: We can do the whole section, Joe. I think in this instance, it is important because it is a whole section, so a later part of the section may reflect on the earlier parts, as well.

    DR. FINS: I am just going to go through it, if I could, a little bit. Part of what I am concerned about is we need to talk about what CAM is and the definitions of that, but we also need to I think do a better effort of saying that there are certain commonalities with the conventional approach. I think a comprehensive approach to disease treatment and health promotion that involves multiple interventions in the entire system, I am not sure what an "entire system" is. There is a kind of vagueness. But I also think that, in spirit, that is not different than what a good primary care internist does, you know, who tells people to exercise, lose weight, stop smoking, they may use Lipitor to lower their cholesterol, but that is not incompatible. I think if we could talk about this -- this is on page 3 and 4 of the common characteristics -- so I think the challenge here, Jim, editorially, is to talk about what is unique to CAM, but then to show that it is not necessarily and fundamentally, antithetical to what good medical care, conventional medical care is about.

    Page 29

    I have more, if I could. On page 5, we had talked about this, and I had referenced Paul Edelson's paper about the rise of Oslerian medicine, which I think should be cited here, but basically, Osler gained prominence as a physician because there was a heterogeneity of treatments, but there was no diagnostic clarity about what was wrong. You even have written about this to some extent, Jim, in your paper. I think that we should talk about that and say, you know, there were a mix of different kinds of practitioners, and the last 50 or 60 years was really a period of Oslerian -- well, actually from 1892 when his textbook was written -- was a period of diagnostic evolution.

    Now we have more diagnostic clarity, and there is more pluralism in therapeutic approaches instead of saying it was either/or. On pages 13 to 15 or so, it looks like scientific medicine took over somehow, and it should be said because of the success of scientific medicine. I mean we are lucky to have life-saving hormones, sulfa drugs, and antibiotics. I should say sulfa drugs or antibiotics. And it took over because of the success. Later on, on page 6, we also need to say that we have chronic illness because of the success of public health interventions and curative interventions that made us live longer. Now we live longer, and we are stricken with osteoarthritis.

    DR. GORDON: Which page, Joe?

    DR. FINS: Page 6. You don't like that? There are some conditions that I think life expectancy at the turn of the century was like in the 40's, and now it is approaching 80.

    DR. WARREN: But that is not just because we have got drug therapy that helps us supposedly live longer. It doesn't mean that that is the cause of our chronic degenerative diseases.

    DR. FINS: I said there were two things. There is public health interventions, as well as the medical interventions.

    DR. GORDON: What I would like to do is get all the issues up there and let's talk through them one by one, but let's get them all out on the table for this chapter.

    DR. FINS: I have got a few more things here. I could stop here and then I can come back if you would prefer to interrupt this, Jim, whatever you want to do.

    MR. CHAPPELL: I just want to be careful not to create a justification for Western medicine in this report.

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    DR. GORDON: What I would like to do is to go through and get all the issues on the table, and then we can come back and discuss responses like that and like Don's response. Let's let Joe finish. Joe is going to go through his whole list. Let him finish his whole list and then others can go through their lists of issues, as well.

    DR. FINS: The point I wanted to make was that we have chronic conditions for lots of reasons, but one is that we are living longer, and why we are living longer is multifactorial, and we need to just be clear about that. Now, on page 7, this is where I think that there is a kind of sort of, you know, it is one example doesn't make the argument problem. People have their hands up, and I feel like I have been talking too long. I will defer to Linnea or whoever.

    DR. GORDON: Effie.

    DR. CHOW: This will be gone over for like wording and spelling, and things like that, will it? I am just saying the health care industry has floundered in recent decades, and then the following sentence on page 6, clinicians, health care, or found that clinicians -- so things like that are kind of interspersed through the chapter.

    DR. GORDON: I think for those kinds of wordings, it would be probably easier if you want to write it out and hand it in, if it is that kind of line editing.

    MR. SWYERS: Jim, I just want to add it is not cost effective for us to proofread until we have kind of a final document.

    DR. CHOW: Okay, fine. One thing is that in here, Qigong is spelled with two words, and I want to make this comment for all Qigong in the whole document. Some are spelled Q-u-i-g-o-n-g. That definitely is not a spelling of Qigong.

    DR. GORDON: How do you spell it, Effie?

    DR. CHOW: One word, Q-i-g-o-n-g, not two words. This has been the new spelling in China for the past 15 years.

    DR. GORDON: Okay. Fair enough.

    DR. CHOW: So take it for the whole document.

    DR. GORDON: Other comments? Linnea.

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    MS. LARSON: This is addressing both Tom Chappell's interest, I believe, and Joseph Fins. I don't believe that including information about multifactorial process or multifactorial streams of what constitutes medicine in any way emphasizes Western medicine or Eastern medicine. I think that saying that basic public health really had a major point in lengthening life, that is simple fact. I would also like to go through and make some comments about one of the criteria that I used in looking at this document, what I called "CAM rhetoric," and that is not meant in any way as an insult. So maybe to help articulate what I mean, I will give you some examples here. One of them that could be construed as that is the statement beginning on page 7, "Partly because conventional medicine has been slow in developing adequate treatments for many chronic conditions," for me that I really do not know, you know. I mean we are making a judgment call here that we are unclear about, and then pointing it just in the direction of complementary and alternative medicine.

    Bear with me a little bit further on this, and I am going to look specifically at CAM and Cancer. It is page 8. It has to do with the uses of the research that we are using here. "A survey that assessed both the prevalence and predictors of CAM use in comprehensive cancer centers found that almost all of the patients, 99 percent, had heard of CAM. Of these patients, 83 percent has used at least one CAM approach." Now, this is the specific thing that has to do with it. "Spiritual practices were used by the largest percentage of patients." I have, not a problem with this report, I mean this report, but I think it misses the point. Probably many of those patients who used spiritual forms would not consider themselves to be proponents or opponents of something that they called CAM. They simply did what they did every day, and in our day and age, we have I think, unfortunately, confused the concept of religion and spirituality, and the claims that are made by many within complementary and alternative medicine is that it is somehow better because it is spiritual.

    It trivializes -- trivializes the thousands of years of traditions by saying that this is only a property of those who use or deploy complementary and alternative medicine. In that way, that is how I have looked. That is something I call CAM rhetoric.

    DR. GORDON: Thank you, Linnea. Ming, and then Tierona.

    DR. TIAN: A question for the Table I. First of all, I understand that, first, the category is a system, medicine system. Regarding traditional Chinese or Oriental medicine system, does that include the acupuncture, Chinese herbal medicine, because the definition here is Chinese and Oriental? I am a little confused what we are talking about here.

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    DR. GORDON: In this instance, I would just like to ask you, how would you say it was best worded?

    DR. TIAN: It should be traditional Chinese medicine. If you mention another, for instance, Ayurveda medicine, that is from India.

    DR. GORDON: One thing that I think, that is an important point, one thing is these lists are not exhaustive, so it's fine to have traditional Chinese medicine if that is clearer, I believe, and there many, many. There are a zillion other systems besides the ones that we are listing.

    DR. TIAN: Thank you. The second one, when we talk about second categories, I think we need to reorganize that, because you put that herbal therapies with mind and body methods, that is not accurate.

    DR. GORDON: No, it is not accurate, and we just covered that when David raised that point earlier.

    DR. TIAN: By the way, biological therapies is pretty confusing to me. What does that mean?

    DR. GORDON: I'm sorry, which?

    DR. TIAN: The first one, enzyme is very confusing. This sounds like conventional medicine, enzyme, does that belong to dietary supplement or not?

    DR. GORDON: Jim, do you want to address how you established these categories?

    MR. SWYERS: I am going to punt this one to Wayne, because this is adapted from the table he gave me, so I will let him answer this one.

    DR. JONES: Actually, this comes out of the five categories that NCCAM has in which there is biological and pharmacological therapies, and which they have a whole list, and if you want to list a bunch of them in parentheses to help clarify it, that could be done also.

    DR. LOW DOG: Could you add pharmacologic there, though? It might make more sense.

    DR. JONAS: I think it might be better to use the actual categories that are out of NCCAM, I mean the terminologies out of NCCAM. These are abbreviated in order to put them easily into a table form, but maybe you could sacrifice that and list the entire thing, which I can help you do if you want.

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    DR. GORDON: Wayne, what about just listing the categories as opposed to all the examples that NCCAM has?

    DR. JONAS: I think that would be fine. The examples, you don't have to list all the examples, but I think some of the example are helpful to clarify exactly what he said, what are biological therapies.

    MR. SWYERS: Jim, the other way we could deal with it is if we don't want a list in the table, we could put it in the glossary and say here is what these things are.

    DR. GORDON: I'm sorry. Let's come back to this issue again, because I want to move through all of them and I want to make sure we settle all of them in order. Tierona.

    DR. LOW DOG: I think that Linnea's comments about spirituality are very important to address because they are woven through much of this document, and I do think it is kind of a coaptation. The rhetoric is throughout the report, and I think we do have to be thoughtful. We may have read this so many times that we just don't even catch it ourselves, but even like on page 12, under Safety Issues, "Despite evidence that CAM systems, approaches, and products are effective in managing and treating a variety" -- you have made a big statement there. Actually, there is not that much evidence for a whole lot of them. It needs to say something like, "Despite evidence that some CAM systems," so I think we just have to be more thoughtful when we go back through the document, as a general comment in the text, to look for areas where we may have overstated or exaggerated.

    DR. GORDON: Great. Thank you. Let's put that as a separate category to be discussed, that kind of rhetoric, and we can make some comments here, and then we may want to make some as we go along, as well. Joe.

    DR. FINS: I am just going to echo some of these things. This point on page 7, line 7, partly because conventional medicine has been slow in developing adequate treatment, it is like, yeah, well, we were really asleep at the switch here and we really didn't care about chronic conditions, it is accusatory like we didn't care. I would just point out that there are lots of new drugs for diabetes, which is a chronic condition, that spare people from insulin; a psychiatric illness, which is a chronic condition, we have had a renaissance in the treatment of psychiatric illness in the last 10 years, Cox-2 inhibitors for arthritis. There is this editorial tone here which is really unacceptable.

    DR. GORDON: Okay. We have got that.

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    DR. FINS: Good. I want to just give you examples. Then, we go into the notion here that CAM has been helpful for people with chronic conditions. I would add here protease inhibitors is a treatment for a chronic condition and we have one example here, about back pain, and that simply talks about people's preferences for the choice of practitioner is now a proxy somehow for efficacy. The fact that people desired or chose or wanted to go to these people doesn't mean that it was safe and effective. Again, I think the disingenuous use of the data, about 83 percent of people using CAM for cancer ignores the vast majority who seek conventional treatment, and the scope of the intervention.

    If you went to church and you prayed, you got listed as using CAM, and it is problematic. Also, on page 10, there is a lot here, like on line 16. It doesn't makes safety and efficacy. People turned to CAM because they perceived their conventional drugs as ineffective. Perception is not necessarily evidence. It borders on anecdote. We see that again on page 11, line 7, where physicians believe in the efficacy of these treatments, and then I think the bullet points on page 12 are very vague, that heart disease, well, what is the first article there? Benefits of CAM for heart disease. Again, I think the point that Linnea and Tierona were making before is that it overstates the efficacy of these interventions to be proven, it understates the available treatments, and the final point, on page 14, line 29, is this line here that we want to have models where people are walking together, side by side, as equals. Now, each of us as human beings are equal, and we all have intrinsic worth, but the interventions are different. I do not want to equate what we all do as having parity. We make contributions in different ways. I think that if we get over that desire to say that CAM is as effective, and you are trying to use these numbers to sort of say, well, look at the prevalence of the use, as a proxy for efficacy and for parity, is problematic.

    DR. GORDON: Thank you, Joe. We are going to discuss each of these -- and I think the points are very well made -- we are going to discuss each of them in turn. I was just hurrying you through because I think we got the point that you are making. Tom.

    MR. CHAPPELL: Well, I think prevalence of use is an important indicator to understand the CAM movement and that efficacy is, in the final analysis, in the eyes of the beholder. You could give me a medicine that you say works in the lab, but if it doesn't work for me, it doesn't work for me. So I think prevalence of use is a highly viable monitor and benchmark.

    DR. GORDON: What I would like to do is to come back to that issue, not deal with that right now, but come back to that one in order and deal with it as we go along, prevalence versus efficacy.

    MR. CHAPPELL: Prevalence versus -- okay, prevalence versus proven.

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    DR. GORDON: So let's come back to that. What I would like to do is if these are the basic issues here, is to go through them one by one and have a discussion about them, and get a direction for the resolution of each one of these.

    SISTER KERR: Jim, one of the things that I feel clear about, although I don't know how to necessarily articulate it clearly or have the response clearly, and my brother Wayne over here, I have often asked him to help us with this, one of the things that I feel we could potentially do today and in this report is collapse -- what I hear we are beginning to do is collapse into this research issue. If you look at Dean's e-mail, you will see what he is saying. When we get into the evidence, and Wayne just made a comment I thought was good -- we were in the evidence rut. For myself, ever since we began the commission, I was always wanting this clarification on research because even the most honorable person who knows there is issues in research wants to defend the public, wants to do the right thing, and we say, well, we need more research. We all agree on that. But then we just collapse into this one model, and this conversation about paradigm and pluralism in research, I think we haven't really clarified that. My own bias is a clarity, a statement about this actually give us the jumping off point for being the most visionary we could possibly be and bold, because we don't know how to still have the same honor of defending the people and speak about research in a way that allows us to be diverse and include things like CAM. Let me acknowledge I am not being very clear and I am going to ask Wayne to help me out on this, but there is a clarity for me about the vision that is possible when we broaden this understanding, but speak it clearly about the potential of new paradigms in research, and because Wayne has volunteered to help me -- go ahead, Wayne.

    DR. GORDON: Let me just ask both you and Wayne whether this discussion is appropriate for this section or for the Research Section.

    SISTER KERR: Let me speak first while I am bringing it up now. To me, my listening is that everyone has spoken to research in the last, I would say, 80 percent of the comments in some form, and that is why again I am trying to bring it up in a vision statement actually.

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    DR. JONAS: Well, I hesitate a little bit to get us out of the rut because it is not our rut. We didn't dig the hole. It is a rut that the entire country and the community has been involved in for a long, long time and will continue to be involved in, so I think we need to clarify the issues around that, and I think that can be done in the Research Section if we could then reflect back in some of these areas to those how it relates to research, then, I think that is important. I think the way to deal with that in a section like this, which is not about research, is to try to come up with what has been suggested around the table, a nice, balanced tone, a tone that acknowledges the tremendous advances in conventional medicine that have really revolutionized health care around the world, that acknowledges some of the limitations of those and some of the reasons that the public is looking for alternatives, and then some of the potential contributions and concerns that there are about that, and that is how we should do that and try to get away from whether any of the statements are based completely on research or not completely on research. I think if we have a balanced tone on that, then, we won't fall into the rut in a section that really is not about addressing that, so that would just be my suggestion.

    DR. LOW DOG: I just want to make sure that we are very clear that I think that this is a problem in the report, though, where we talk about prevalence and consumer-driven movements. The 2001 Gallup poll was very interesting when you look at consumers' beliefs, just every-day Americans' beliefs in paranormal activity, you know, the amount of people who believe in astrology, you know, 40 percent of people believing in haunted houses and ghosts and witches, and things like that. So beliefs and what we believe are one aspect of this, and prevalence, you know, the prevalence of people eating high-fat foods and smoking, and things like that, are very, very high, as well, but I am not sure we would advocate for them.

    The last comment is I would have to say that I think that because Western medicine or conventional medicine has not found answers for all of the health problems or even something deeper that many people may be looking for, I am not sure that it is also going to found in CAM. I think the reason for evidence is before we just bring on more things, that may or may not be the answer to these problems, there needs to be some evidence before we take it into the system that it is actually going to do something. So I think prevalence and proof, I think that we have to address safety issues around prevalence because people are using things, so we need to make sure they are safe. I don't want to restrict their access to it as far as if you want to do it, but I think that before you begin to make public policies about what you are going to integrate into a system, there needs to be more evidence.

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    DR. GORDON: What I would like to do is address the issues as they come up in this chapter, having heard the general perspectives, and begin to move through this because otherwise we are not going to be able to get through the report. Joe.

    DR. FINS: There was a survey in the late nineties about how people dealt with pain, and one of the things that was really clear about it was how people endured a lot of pain, wouldn't go to doctors to get pain control because they didn't want to cede the locus of control to a provider. Part of that is consumer driven, but part of it is the fear that if I go to the doctor, I am really sick, if I need a stronger prescriptive medicine, there may be something wrong. I think part of what is going on here is the psychology and the sociology. This is not necessarily the promotion of wellness side for people who are sick, and how we engage in all kinds of denial to avoid the encounter which might break bad news to us.

    So I think that there are multifactorial reasons why we seek to promote our own wellness and to maintain control. Being ill, requiring a healer's presence whether it's a physician or a CAM provider, or whoever, is a ceding of certain kinds of control. So I would like a little more about the vulnerability, the sociology of illness here that captures why people might seek refuge in things that are less threatening.

    MR. SWYERS: Joe, I just want to add that in the case of CAM, the surveys show that most people that are using it are the sicker people who have already been to the doctor, so they have already gotten the bad news, so they are looking for more options.

    DR. FINS: That brings up the issue of palliative care, and I think one of the failings of conventional medicine is its failure to adequately integrate palliative care. People can go to the CAM provider because we are a death-denying society and say I am looking for the heroic cure, when, in fact, they might be better served by the wonderful services provided by the local hospice.

    DR. GORDON: I would like to move through the list. We can raise these issues as they come up. Ken, can we begin with the first of the issues?

    DR. FISHER: [Off mike.]

    DR. GORDON: On that issue raised by Tom, basically noting in the history that these were aspects of the movement in the direction of CAM, do we have agreement on this, that this is something that should be mentioned as part of the history of the movement?

    MR. CHAPPELL: Ken, the natural foods business had nothing to do with taste. It had to do with nutrition.

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    DR. FISHER: Yes.

    MR. CHAPPELL: It wasn't a culinary interest, it was a nutritional health fundamental, "I might live longer" issue.

    DR. FISHER: I was just checking to make sure you all were listening to what I am saying.

    DR. FISHER: Plus means that you want it added.

    DR. GORDON: This is part of the background. The other thing that I would add, that I have written in a previous critique, is that, in fact, long before Americans were using the words "complementary and alternative," they were using the word "holistic," and I think that the accurate history needs to be "holistic" first and with a little description of what was going on among holistic physicians and nurses, and then "complementary and alternative" after that. Okay. The second issue and, Ken, the political challenges to CAM?

    DR. FISHER: This was Joe Pizzorno's comment about the political challenges to CAM then and now.

    DR. GORDON: Joe, do you want to say what you feel is necessary to put in here given the fact that we want our tone to be fair and not be raising old battles that can't be solved?

    DR. PIZZORNO: Well, first, this is a History Section, so we are not raising old battles, we are just simply stating what was, I think that has to be said, and I think we also have to say that there is still opposition amongst state medical boards to the licensing of CAM practitioners, this being the fact. This is not us getting into an argument, the statement of facts, it is happening right now.

    DR. GORDON: Let's discuss this one. We have discussion. Tierona.

    DR. LOW DOG: I think that you can't have the conversation about the political aspect of blocking licensure without the discussion that a number of these CAM practices have not been shown to be scientifically based. It is a problem that we are having a hard time getting around, because it does impact the political system. So I think that it is both. It is both parts of it. It is an entrenched system that doesn't want to let go and doesn't want to relinquish power, and that is there, there is no question. There is also the flip side of that, which many of these are based on vitalistic sort of notions that may have been more relevant 100 years ago, may not be as relevant today, may be, but maybe not, and are not scientifically based.

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    DR. PIZZORNO: I just want to say, Tierona, I agree with you. We don't want to say we are opening the doors to anything, but I think we have to deal with the political realities. I think we should clearly mention the antitrust case that the chiropractors won against AMA, because that's clearly demonstrated it was based on economic realities, not on scientific realities. This is a matter of court record.

    DR. GORDON: Other thoughts about this? Linnea.

    MS. LARSON: I think this requires a little bit deeper thinking here. Joe Pizzorno, the doors are open to everything. Okay? But we do not legitimize through positive sanctions certain things. Okay. That could be how you put that in the history. That is how we get confused on access and delivery, et cetera. So making claims that there is nothing, that is not true.

    DR. GORDON: So how do you suggest framing this discussion? I think that is what we are looking for right now. Both Tierona and Joe seem to agree that it is important. The question is how to frame it in this context. It's Linnea, Effie, Joe, and then David.

    MS. LARSON: I just had a brain-block moment. David, you can have it.

    DR. CHOW: I think we are still looking at a medical model when we talk about licensing, even though we don't say it is. When you say we can only license something if it's scientifically proven, I think the Indians are very smart, the Chinese are not so smart. We are moving over the border and sacrificing our total approach, which is like taking acupuncture into separate entities.

    DR. GORDON: Effie, I would like everyone to focus, though, on this particular issue. We are not dealing with licensure here, we are dealing with the historical question. Forgive me if anybody feels I am being rude, I am really trying to get everyone to focus as closely as possible on the issue at hand, and the issue here is how do we deal with some of the historical and present conflicts between Western medicine and some of the other disciplines that are looking either for legitimatization or looking for licensure.

    DR. CHOW: Well, the politics that Joe mentioned, Tierona brought up licensing, that you can't deal with the politics without mentioning about licensing, and I think with licensing, we have got to talk about then the fact that some cannot be licensed in the usual manner. That is why I am bringing out the difference between the Indians. Perhaps their licensing is through the acceptance of the elders themselves, and by nobody else.

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    DR. GORDON: If I am following you correctly, you are saying that for a number of traditional forms of healing, that they lie outside of this kind of discourse.

    DR. CHOW: Yes, this is my point.

    DR. GORDON: Thank you. Joe is next, then David and Wayne.

    DR. FINS: I had asked I think at the very first or second meeting that we commission a historian to write the history of the movement, and I think now we know why that would have been a good idea. I think what we need to do is appreciate that history is a mosaic of lots of different perspectives, and what is written by one school might be different than another. I think the way we handle this perhaps is to cite scholars, not opinions. You know, this scholar in his work or her work suggests that it was economically driven. Others suggested that it was a response to hucksterism. Others, you know, it was the rise of the scientific model and the NIH, and just diversion of funds.

    I don't think the Commission can or should take sides on who was right or who was wrong but rather, just to explore the issues in a very balanced kind of way, and if people could supply -- maybe, Joe, if you can supply Jim with scholarly references of real historians, and then there are other sources, we can just kind of have a balanced treatment of it. I think scholarship is really what is needed here, it is not a commentary, it's a scholarly take on it.

    DR. GORDON: Thank you, Joe. David, Wayne, and then Joe Pizzorno I think again.

    DR. BRESLER: To take the balanced notion a little further, I mean those of us in the early days know what the resistance was like. In 1972, it was 17 submissions to the Medical Review Board at UCLA before we got an acupuncture protocol approved. So we could go ahead and list all these kinds of things, but in the spirit of balance and the spirit of keeping it positive, the fact is that they did approve it and that these changes did occur, and I think we can address some of the obstacles, but also address some of the ways that those obstacles were overcome and how basically, everybody is coming together to begin to facilitate this type of research now. Keep it in a positive.

    DR. GORDON: Thank you, David. Wayne.

    DR. JONAS: I think we do need to describe what has been often very rocky and contentious political debates, which sometimes includes science, but most of the time does not, and we also need to emphasize the tremendous advances in science and conventional medicine that largely overwhelmed some of the alternative perspectives including the perspective of holism in which there was minor movements that then kind of got buried, and this is now a resurgence of those, in fact, the third time in this country that they have come back in a prominent way. I think a description of that is important. I mean I am not saying anything anybody else has not already said, but I think the balance in the tone, I think is important in this area, but on the other hand, there are continued political battles that are ongoing right now that are continued extensions of the history of this. So we at least need to have an accurate description of those types of things.

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    DR. GORDON: So, Wayne, would you include those continuing battles, and if so, how would you address them?

    DR. JONAS: I think in the History Section we need to describe them and then simply reference that there are continuing battles, because actually in the body of the report, that is when we get into the meat of trying to address some of those issues, so I don't think those need to be described in the History Section, but I do think we think we need to acknowledge the fact that there is this, and has been, an ongoing kind of power struggle and political issues that involve practitioners of various types and the public and policymakers, and this type of thing.

    DR. PIZZORNO: Well, thank you to the Commissioners. I think this was a very balanced conversation, and Joe Fins, I think we have full agreement, just we want to just kind of matter of factly say this is what happened, not take sides, but not also use as a door to open up anything coming into the system either, because clearly, they are having problems with inappropriate practitioners that we don't want to have practice, but there has also been a problem there has been an economic drive to some of the things that have happened. So let's just be as objective about it as we can. It makes sense.

    DR. GORDON: Are we agreed then, is this a fair representation? I am wondering, Wayne, if I can ask you, since you have worked on this section, if you could help to draft some of these historical issues. Work with Jim.

    DR. JONAS: Jim has actually seen a number of the scholarly descriptions of this area. Again, the opinions even in those are quite diverse. Sure, I would be happy to help.

    DR. FINS: Maybe a way of casting the History Section here is to simply state that the history of the rise of modern medicine in the last hundred years and the concomitant sort of fall and then resurgence of CAM is a complicated story. It is informed by current political pressures, and it sort of feeds on itself. Anyone who is to engage in reform needs to be aware of this past and understand the continuing tensions that exist, but not take a stand, and then list different perspectives. I think I heard economic pressures, the rise of science, and then again I think education is another theme, and the Flexner Report needs to be mentioned and what that did for sort of the standardization of medicine. The Kenneth Ludimer book, "Time to Heal," is a wonderful source for this history. It just came out, and it does mention some of these things, and I think it is a wonderful volume.

    DR. GORDON: Do we have a sense of agreement and a sense of direction for Jim and perhaps with Wayne consulting and working with him on this? Good. Let's move on to the next one, Ken, please.

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    DR. FISHER: At the risk of being shot down, I would suggest that Item No. 7 is what you have sort of bridged over to Item No. 2 in terms of the success of conventional medicine, public health interventions, and the same. You have sort of talked about those in the same voice. So then with that success in mind, I would suggest that in addition, the discussion of Oriental medicine also belongs up with additional topics, and if you will buy that one, then, I would suggest that the issue of mind-body medicine and Item No. 9 all refer to the accuracy and completeness of the table on page 2.

    DR. GORDON: Ken, let me get clear. You are saying that No. 7 needs to be brought in as part of No. 2, and that that discussion needs to be woven together. Is everybody comfortable with that? Joe, are you comfortable with that?

    DR. FINS: Yes, I think it is part of that history story.

    DR. GORDON: Great. Wayne.

    DR. JONAS: I agree with what you are saying, and there is actually a fairly detailed taxonomy of CAM already laid out.

    DR. GORDON: That is the next topic. That is what we are coming to right now.

    DR. JONAS: This relates to the table.

    DR. GORDON: We are not on the table yet. We are talking about the evolution of conventional medicine going together with a discussion of the CAM/conventional medicine struggles. So that is all part of the history. The next part does have to do with the table, so please feel free to comment on that. It has to do with Oriental medicine, mind-body medicine, et cetera.

    DR. BRESLER: Oriental medicine goes with Restin --

    DR. GORDON: What you are saying is that part of the rise of CAM has to do with the interest in Chinese medicine in particular after the Restin article.

    DR. BRESLER: It just goes up with additional topics.

    MR. SWYERS: That is the James Restin article in the New York Times.

    DR. GORDON: So that is part of the history, just the way the history of holistic medicine is part of the history. The next issue has to do with the table. These are the points that Ming brought up, and that you brought up, too, and Wayne's suggestion was that we might look to the original table, the OAM and now NCCAM tables for the categories. Wayne, do you want to say more about that?

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    DR. JONAS: I would suggest that. I mean it has been worked on for many years, it is now kind of standard usage, and it's not perfect, but I think it would be useful to substitute that.

    MR. SWYERS: It's on the NCCAM website, too, if anyone wants to look at it.

    DR. JONAS: I would do that.

    DR. FINS: Just to briefly go back to the History Section as just a caveat, I think whatever we write, we need to say that a full comprehensive historical treatment of this complicated subject is way beyond the scope of this report, but suffice it to say, you know, and that readers are directed to, and maybe the bibliography for additional scholarly sources. But I think we want to be very clear, and not attempting to be historians or scholars, because we are only going to briefly treat it to set up the current context.

    DR. GORDON: Back to the table and the use of the NCCAM/OAM table.

    DR. TIAN: I have one suggestion. I think it was very good mention, medicine system or medicine. We should say medicine, therapy, and the product. These three things are different, so we should not put them together even from the original table from NIH, the definition was not quite clear. We need to adjust a little bit at least the wording, make this better.

    DR. GORDON: So these are different points of view, yours and Wayne's.

    DR. TIAN: No. I would suggest to add my suggestion because basically, we are still using NIH, that listed all of them, because this table does not include everything. As I remember last time, we had a reference. That table includes 33 medicines and the therapies if I remember the number. Now, we cut some of them. Must be a reason. We have to say why not including those or even mentioned in the paper, NIH definition of CAM.

    DR. GORDON: Wayne, do you want to address this?

    DR. JONAS: I think the distinction between system, modality, product, and practice, et cetera, actually perhaps -- I don't know if this is adequate -- but in the footnote under the table, there is actually a specific discussion of that. What happened in the classification is that systems became an entire category in which they talked about traditional systems, and they threw everything in. Well, in that one category are all the modalities, practices, products, et cetera, et cetera, if you were to simply look at the details of that.

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    Then, some of them were broken out and put into different categories primarily because these are ones that allowed Western folks to kind of get a grasp on aspects of it, like acupuncture, for example. So, yes, that exists in the current system, and it is kind an inadequate dissection, but it is a dissection that I think is accepted. I think if we use this reference on the bottom and explain this, and perhaps you would want it up in the text, but in a sense I like it set off. I think this, hopefully, would get at this issue of the system. I am not sure if we want to modify that other than just describe the issue that comes even with the NCCAM definition.

    DR. TIAN: I have no objection. I just wanted to mention that the medicine is medicine, therapy is therapy, and the product is product. The definition should be different.

    DR. GORDON: Okay. Are we okay? Let's move on to the next issue.

    DR. FINS: I think Ming's point is there is something there that is really important, and I think maybe stick with the table that was in the NCCAM iteration, but maybe say in the discussion that sometimes there are confusions that exist because we conflate all these things. You might have practitioners who are multiply skilled, therapies that could be considered as being part of several different systems, and it is not so clear, and that what we might want to argue for -- and we don't do a great job of it in the report, though -- is that any policy that exists regarding CAM has to be very clear and specific about what we are talking about. So definitional clarity, you know, any of us around the table is in favor of CAM at large. There are dimensions that we are against, and there are parts that we are for. So I think this might be a good place to talk about the need for diagnostic and definitional precision.

    DR. GORDON: I think that is what Wayne was saying also, that some of that work has been done.

    DR. FINS: Yes, but we didn't say it.

    DR. GORDON: And that would be said. Is everyone okay with this? Good. Let's move on then. Mind-body medicine. I have a paragraph, just a basic description of mine-body medicine, which I will give to Jim. Mind-body medicine is a separate. Was there more?

    DR. FISHER: Well, yes, you need to clarify that, I think, because the discussion suggested that all of the different modalities would be associated with the development of a more comprehensive table and explanation.

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    DR. GORDON: In the NCCAM definitions, mind-body medicine is a category, and it's in there. I am not sure what you are saying. We are going to use those tables. We are going to use their definitions.

    DR. FISHER: I guess what I am saying is that I am unclear. It was mentioned as a specific modality, but also so was holistic medicine, organic foods, Oriental medicine, but they all sort of subsume in a table.

    DR. GORDON: Let me try to clarify. There is a table that discusses the modalities, the approaches, the systems as they are laid out by NCCAM. There is agreement that we are going to use that table with the addendum that Joe is speaking of. There is a specific question in terms of the history of the development that relates to holism, relates to Oriental medicine, that is a separate consideration. Joe.

    DR. FINS: The other thing that goes with this, I think is sort of the rise of the psychoanalytic movement especially in the postwar period, and psychiatry, you know, the sort of inside-oriented psychotherapy was really in many ways a precursor, and I turn to you and David about linking up that history with this story, because in many ways, those are antecedents to some of the mind-body concerns and the therapeutic obsession that we all have.

    DR. BRESLER: The early TM work, the biofeedback work, all those things should be mentioned.

    DR. GORDON: I think the issue, though, is we have limitations of space, and I think we can mention it, otherwise, you are going to get into a whole complicated history which goes back much further. It goes back to Jung and other folks, as well.

    MR. SWYERS: Jim, we also have a major time limitation, too.

    DR. GORDON: Let's move on. I think commonalities of conventional medicine and CAM, have we addressed that sufficiently in the way we are taking up No. 7? In terms of the history, commonalities in CAM, do you want to re-specify what you meant, Joe, and say whether or not you feel this is covered?

    DR. FINS: I think we are talking about the Common Characteristics Section. We want to be a little less dichotomous, you know, those are them, and this is conventional, because there is that whole bio-psychosocial movement in medicine, and the primary care movement, in and of itself, was a counterculture movement in medicine, and the resurgence of family practice out of general practice. All these things are whole body, kind of whole person, nonreductionistic approaches. We also might want to say that in some states even, which maybe it will come up later, is that at least in New York State, I think that the reimbursement that the state gives to residency training programs has a multiplier effect if it's a primary care program.

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    DR. GORDON: What you are saying in this section is to indicate some of the commonalities of primary care and the CAM world view.

    DR. FINS: And I also would add more recently, the palliative care movement, which is totally total person, and not only person, but the patient and the family approach.

    DR. GORDON: Is everybody clear on what Joe is asking for, and in agreement?

    DR. PIZZORNO: I think actually, Joe is asking for a new section, which may be a good idea. I think this one is about commonality of CAM systems within different CAM systems, not with conventional medicine. So if you want to add another section about commonality with conventional medicine, that is probably a good idea, but that is different from what this section is supposed to be doing. This is within the CAM systems, between the CAM systems, not between CAM and conventional. It's page 3.

    DR. FINS: You know what might be a nice way to bring this chapter together in a kind of concord kind of way, you know, we start with the history initially, and, you know, how we all didn't quite get along, all the tensions and all those perspectives, and then talk about the various CAM systems, but in a sense, there may be more commonalities than the history would have suggested, and that gets us into more of an integrative theme. So if history, what is now Common Characteristics of CAM Systems, and then Shared Characteristics, then a move towards --

    DR. PIZZORNO: Another section.

    DR. FINS: A new section, I agree with Joe. It's a way of trying to bring the history back together.

    DR. GORDON: Linnea.

    MS. LARSON: I believe Wayne provided a few months ago some kind of visual aid. Didn't you do another one, Wayne? That was one of the suggestions about six, seven months ago.

    DR. JONAS: I put one in, and then I think, Joe, you modified it to make it more clear.

    DR. FINS: We should bring that back.

    MR. SWYERS: We have made several stabs at Vin diagrams. I think it would take a whole subcommittee a week to come up with one that everyone could agree on. I think language might be a little easier way to deal with it.

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    DR. GORDON: I want to get a sense, if we can, of agreement here. What is being suggested is that there be another section, albeit a brief section, that talks about some of the commonalities between some of the developments within Western medicine and some of the development and the ancient history of CAM perspectives.

    MR. SWYERS: Actually, I would like to suggest a section on convergence, how they are converging. I had made a feeble attempt to do this in an earlier draft that I could resurrect, but I think that is a better way to do it.

    DR. GORDON: Are we agreed on this now? Wayne, go ahead.

    DR. JONAS: I agree, I think that is good, however, what I would like to do is I would like to not just add it, I would like to substitute it for this section on common characteristics of CAM, because whoever wrote that I think should be taken out and shot, I think it's terrible, and we should eliminate that.

    MR. SWYERS: Actually, Wayne wrote some of it.

    DR. JONAS: I wrote most of it. That's why I can say that.

    DR. JONAS: I did write almost all of that section, and I think we should eliminate it, frankly, and we should substitute something along the lines of what we are talking about right now, which is the commonalities. Within that, we can embed some of the reasons people have classified things as CAM or not CAM, which could be a very short thing, rather than trying to describe the details.

    DR. GORDON: With or without gunpoint, would you undertake the job?

    DR. JONAS: I won't write the common characteristics, I think Joe should do that, but I would be willing to put in the paragraph saying here is why things have been classified as complementary medicine, the reasons that have been given, very briefly describe that.

    MR. CHAPPELL: I am wondering if it isn't more helpful to create that list of common interests as the interests of the consumer. I have the term "patient centered," but if we list these things as the longer list today of patient expectations or patient interests, then, neither camp has ownership and then you simply say that CAM has been early in some of these responses, and conventional medicine is also responding with its own, but it takes away the competition and conflict, and places the subject at the center with the consumer driving it. That is the way I would rather see this section structured than either/or.

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    DR. GORDON: Joe, we need to move ahead very quickly. We have a lot to cover. So I would like to get to some kind of closure with this. Joe.

    DR. PIZZORNO: Actually, Wayne, I don't think that person should be shot. I like what is in here because the idea is what is a commonality within the CAM systems, and I think this sums up pretty well, but I think we can do that commonality with conventional, we can bring in the parts that are appropriate, too, but I think that part of this is who are these CAM people, what is it about them, and that does this. If you remove this, then, we have actually lost our only effort to try and define who this group is, so I really think we need to keep this.

    DR. GORDON: Joe.

    DR. FINS: One of the things that might be a helpful distinction for Jim, and I think it is on point with what Tom was saying, that one of the major differences might be a means versus ends kind of thing. If the best of conventional medicine is to enable people to achieve their goals and to give them wellness, and to treat their illness, we might use a scientific means to get there. The distinction between how we got there versus what the goal is might be a way to have that convergence. I like convergence because, indeed, patients or consumers going back and forth are in their own persons converging these different streams. But I think distinguishing means and ends interventions and goals is a way to perhaps reach some convergence, admittedly acknowledging that some of the goals may still be different, and that is where the Vin diagram is not a complete overlay.

    MR. SWYERS: I would like to suggest a potential solution. We could save this common characteristics, but boil it down into a paragraph or two, put that up with the definitions and description, and then have this history flow into a convergence section, because I think it does flow into that more than it does the way it is structured now.

    DR. GORDON: Is that acceptable, agreeable to people? Okay. Charlotte, go ahead.

    SISTER KERR: My comment is just that I have been listening for the emphasis of this. I am not saying it is lacking, and it is probably in another chapter more, but when we talk about the chapter to talk about convergence and separateness and evolution, I just want to request that we are sure we have some of the philosophical developments, that we emphasize that, that we actually are moving into things like ecological paradigms, the re-enchantment of the earth, the understanding that the universe is an organism, that there are probability patterns of interconnectedness. To me, this has influence and informs how we are moving, and I never quite get comfortable feeling we have acknowledged that, because, to me, it also is why we have this issue that goes on with research, just like the concept again of pluralism. These are concepts that come out of real evolution of consciousness that is trying to go on. So I am really requesting that we emphasize that.

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    DR. GORDON: One suggestion I would have, Charlotte, I think that that aspect, that emerging world view really comes under the rubric of holism, that is, holism is one way to describe some of what you are talking about. So in the history of the development of holism, you could address some of these other sort of philosophical, cultural, spiritual issues.

    DR. JONAS: Exactly, and that forms the foundation for the commonalities that we are talking about and some of the characteristics we want to see emphasized.

    DR. GORDON: Jim, are you, as the man who discovered China used to say, perfectly clear?

    MR. SWYERS: Maybe. No, actually, I think I am seeing the light here, the light at the end of the tunnel starting to come through.

    DR. GORDON: It is important that either you are clear or that you get clear, because we are depending -- and this is true in working with all of the staff -- we don't have much time, so what needs to go out next to the Commissioners has to be as full and accurate a reflection of the discussion here as possible.

    MR. SWYERS: I think between Wayne and I working together and working with you, we will be able to answer all of these concerns. I don't think we will have much of a problem doing that. There is going to be a little more adjustment problems and seeing how it all fits together, but that is always a problem.

    DR. GORDON: Linnea, what?

    MS. LARSON: I can provide you technical assistance, too.

    DR. JONAS: May I mention just one other thing? There are some very nice things written about how research has evolved because of unconventional approaches, and I think you are familiar with those, but there is also a book that has just been published by the Hastings Center called "Pluralism in Medicine." It is specifically on complementary and alternative medicine, and there are some very nice things written about the historical issues and some of the topics we have talked about, so we can get you a copy.

    MR. SWYERS: I think if you look back to some of my earlier drafts, I did touch on some of these issues, so I can back. I mean we are not going to have to start from scratch to do this. So it's there, it is just a matter of pulling it all together.

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    DR. GORDON: Let's move ahead. Ken, we are on No. 6, I believe.

    DR. FISHER: Well, I am going to try another ploy since I had two successes and one failure, and that is, the issue of the rise of diagnostic clarity and the rise of pluralism really are a neutral and balanced part of No. 2 on political challenges.

    DR. FINS: History. History.

    DR. FISHER: On history, yes, thank you, Joe. So that leads us down to No. 8, which you have already identified as general aspects throughout the entire document. If you agree to that, then, we move to No. 10.

    DR. GORDON: What I would like to do is talk about No. 8 here and get some clarification of the concerns that people have about CAM rhetoric in this section, so that we can deal with them and make sure we are all on the same page. Joe.

    DR. FINS: I think the issue of prevalence is important vis-a-vis public interest, so I think if there was no prevalence, we wouldn't be here. That addresses Tom's emphasis, I think, on that. I want to just distinguish the difference, that prevalence should not be in any way equated with efficacy or demonstration of safety or efficacy. There are things that are prevalent, like smoking, which is dangerous, and it is effective in promoting lung cancer and heart disease. So the fact that people do it does not mean it is initially endorsed. So I think we can deal with some of these overreaching statements that somehow say that people perceive it to be efficacious, I mean it has meaning to them, and it is used, but it should not be presumed because it is used, that it is effective. We actually later on say that we need to demonstrate safety and efficacy, and we do come back to research, and the rut in that ground is, you know, it is a $20 billion endeavor with the NIH funding. I mean Congress, as a body, and the country, as a while, has invested itself in research to great effect, so I don't think we want to go against that. I think the balance here rhetorically is to say it is being used, people really value, it's important in their lives, but as yet, that does not in and of itself mean that it is safe or effective, and what we want to do is strive to have mechanisms that will that use more beneficial and less dangerous.

    DR. GORDON: This is an issue, Joe, I think you will agree that this is both No. 8 and No. 10 that we are talking about. The specific is under No. 10, prevalence versus efficacy, but it also relates to No. 8, which has to do with rhetoric.

    DR. FINS: The parity thing is a different issue, I think, which is 10.

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    DR. GORDON: No, we haven't discussed parity yet. No. 10 is also prevalence of use, efficacy of treatment. Let's have comments. What Joe is addressing is an issue that has to do with rhetoric, making a clear distinction between prevalence and efficacy with no implication that prevalence implies efficacy. Tom.

    MR. CHAPPELL: Joe, I think prevalence needs to still be held up for accountability of safety. It is not either/or, I think it is prevalence and accountability. I think if we start to use the word "accountability," you know, I am not saying CAM is accountable to conventional medicine, I am saying CAM is accountable to public health and the authorities of public health, which is the government, so I think prevalence which is supported by an accountability to safety and efficacy is the point.

    DR. GORDON: Jim.

    MR. SWYERS: I think a potential solution here is that we could keep the information on prevalence and usage, but add the caveat that Joe is talking about as a transition paragraph, then, that leads us into the safety and efficacy part, and then we can take a look at that language and make sure that that has been done.

    DR. GORDON: I would add to that I think this really is here, this is about prevalence. Efficacy will come in, in terms of discussing research, it will come in, in discussing cost-benefit studies. It may come in, in terms of access and delivery, other sections. I think here you are describing what the landscape is, and not saying necessarily that these things work.

    DR. FINS: The problem is as it is read. I know what we intend to do, but you don't have prevalence for the conventional interventions, and this is not conventional medicine, I admit that, but I am concerned that if we simply have a little caveat that prevalence is not to be equated with efficacy or safety, that it will be a one- or two-line thing, and then we go back and we create the same impression. So I just urge you to be editorially careful.

    MR. SWYERS: Well, I would ask if you could help us with that language.

    DR. FINS: It's on the record, I think.

    DR. GORDON: Joe, one simple thing, for example, is the study that is quoted, and this is the way I would quote it, the M.D. Anderson study, if you eliminate spirituality, the figure is 69 percent, and 100 percent of those people are using conventional therapy.

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    DR. FINS: But it is a matter of scope. See, that's the thing. I mean if somebody has gone through two years of chemotherapy, and let's hope they have done well, and they have had surgery and radiation, and their has been unfortunately dominated by that therapeutic endeavor, and they are taking vitamins once a day, the percentages, you say, well, were they using conventional, were they use complementary, it looks like there is parity. So we are not capturing the qualitative, the qualitative difference in the investment, the experience, and that is what gets somewhat misrepresented here.

    DR. GORDON: Is that clear, Jim? It is not clear. What is not clear?

    MR. SWYERS: I think it is important to present this kind of information, but how to present it in a way that it is not perceived as stating that CAM is somehow efficacious to these people, I am not quite sure how we can do that without going into the kind of language that Joe was talking about, saying that we have to emphasize that this doesn't mean that because people perceive --

    DR. GORDON: Are these responses to the question that Jim is raising? Joe Pizzorno, and then Tom.

    DR. PIZZORNO: I fully concur with Joe's point that we don't want to imply that prevalence is indication of safety or efficacy. I think the purpose of putting prevalence is to show why the work we are doing is so important, because, indeed, a lot of these things are being used. The medical practitioners don't know they are being used, and they can clearly impact the efficacy of the therapies being used and the safety of those therapies. So, clearly, the fact that they are being used is what is important, not whether they are safe and efficacious.

    DR. GORDON: Tom.

    MR. CHAPPELL: I think the Historical Section needs to deal with prevalence, and it needs to also deal with the current concerns for safety and efficacy, so I think it is sequential and it all leads right into the rest of the report.

    DR. GORDON: Jim, how are you having heard these two pieces?

    MR. SWYERS: I think we can improve on it, but I think it will take people like Joe to look at the language and make sure that we have done it properly.

    DR. GORDON: What is emerging here is that on certain sections, it is clear that commissioner input will simplify the process and make it much more likely to succeed. So I am wondering if we can rely on Joe, for example, for you to lend some help here.

    Page 53

    DR. FINS: I totally endorse that involvement, but I am very concerned about the logistics of this, the time frame, our availability, when we are going to get these documents, and I think that we haven't even gotten to a single recommendation yet, and there is a massive amount of work to do. I think we need to just, as they say, take a time out, and get a sense of just the game plan, because it is not enough that I am on-board, and then Tom has got to have a look at it and make sure that we haven't, you know, in moving in one direction, offended another commissioner's perspective.

    DR. GORDON: Which we will. What I want to do is over lunch we are going to discuss some of the logistics of this. I want to move through this section, finish this section, then go to lunch, and then talk about how we are going to work on recommendations and the rest of it over lunch, and then manifest it this afternoon as we get into the sections with recommendations.

    MR. SWYERS: Jim, could I ask a quick question? Is the feeling we need to enhance the prevalence, but that it needs to be presented in a very delicate manner, in an objective manner?

    DR. FINS: I think prevalence is why we are here, but I think the way it is currently drafted, it would suggest greater efficacy based on those good prevalence numbers, that has yet to be proven, and it's oppositional, too.

    MR. SWYERS: So, would it be better if we prefaced the information on prevalence with those kinds of caveats rather than as an afterthought? Would that be better?

    DR. FINS: Not to recapitulate what we said, but on page 7, line 7, it is because conventional medicine was slow on developing adequate treatments da-da-da, all these other things happened, and they are responding to a need that conventional medicine did not meet, and that is the kind of setup that sets this whole thing in opposition.

    MR. SWYERS: I have agreed we are going to address those kinds of things, those kinds of concerns.

    DR. GORDON: Any other issues on the rhetoric? Yes, Veronica.

    MS. GUTIERREZ: Before we get too far away from safety and efficacy, as it relates to CAM, I would like to say there is probably many people in this room that feel that there are questions about safety and efficacy in drugs and surgery, as well, so if we are going to discuss safety and efficacy, I would like to have it put in perspective of that is an assumption that we will use in addressing all approaches to health and disease.

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    DR. GORDON: Any response from other Commissioners?

    MS. LARSON: I don't understand what you just said, Veronica. Could you repeat it, please?

    MS. GUTIERREZ: We are talking about safety and efficacy. There is no drug that you take that doesn't have some safety factors and risks. The same for surgery, you go under general anesthesia, there are risks. So we need to address the whole picture and not put CAM aside as a separate concern.

    DR. GORDON: Any comments? Effie, you had your hand up.

    DR. CHOW: A simple one.

    DR. GORDON: On this particular document that Veronica has raised?

    DR. CHOW: No, I agree with her.

    DR. GORDON: You agree with her. This is something that has been sort of around since we began, how do we deal with issues of safety and efficacy with regard to both CAM and to conventional approaches, do we need to make a general statement, which we do in the Research Section? I think very clearly, we say the same standards. Do we need to make a statement in this section is the question Veronica is raising, about same standards for conventional medicine as for CAM. Tierona.

    DR. LOW DOG: The concept is very good, but yet if you have been in a car accident, and you are going in for emergent surgery to save your life, although there is risk of anesthesia and there is risk from the surgery, the necessity of that intervention is high. When you are talking about health promotion, and taking dietary supplements or vitamins and herbs that may or may not promote your health, may not contain what they are supposed to contain, may be adulterated, contaminated, et cetera, that is a very different risk-benefit. So, I think that safety and efficacy is very important, and all health care providers should choose the least toxic, but efficacious treatment for the particular condition. I think if we make those kinds of statements, that that is where we should be moving, the least toxic, but efficacious, realizing that sometimes for it to be efficacious, there may be greater risk.

    DR. GORDON: My question on the floor is do we need to make that kind of statement in this section, and if so, how.

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    DR. FINS: To add to Tierona's point, if you go to page 12, lines 16 through 18, the ethical doctrine that Tierona is referring to is proportionality and risk-benefit ratios. So, we will assume a huge risk if there is a greater benefit, and we will not be accepting any risk if there is no benefit, and yet, if you look at line 16, "despite evidence that CAM systems, approaches, and products are effective," okay, you have categorically said that it is effective, we have not studied safety, when, in fact, we haven't proven efficacy at any kind of -- I mean if a well person takes a supplement that they did not need, that is yet to be proven to be safe, and has a bad outcome, even if the incidence of that is very low, it is an unacceptable situation. That is what I think we are trying to say.

    DR. GORDON: Joe, I hear you, but how would you deal with this issue? I understand what you are saying about those sentences being inappropriate, and how would you deal with the issue that Veronica raised? Would you talk about a doctrine of proportionality, or would you just let it go in this section, not include it here?

    DR. FINS: I think what we need to say is that risk and -- and I just said it, and it's on the tape -- but risks and benefits have to be understood in their relationship to each other, and that's true for every intervention that we do.

    DR. GORDON: Understood. I am asking you, does that need to be said in this section or not? That is the question on the table right now.

    DR. FINS: I think again the Blendon paper that we keep on citing suggests that the American public, not the people who testified here, but the people who were randomly selected, who did not select themselves, to show up at commission hearings, which is a selection bias, they want more regulation because they want safety.

    DR. GORDON: I understand.

    DR. FINS: So, if we are taking the consumer mantra and what the American public wants, and we are being responsive to their needs, then safety is part of the reality. It is also true, I should just say, and you could say also the IOM report crosses the quality chasm and to err is human are also massively concerned about error and bad outcomes in the conventional side.

    DR. GORDON: Please, come back to my question. Should it be in this section?

    DR. FINS: Yes, I think it is a major driving force for why we are here.

    DR. GORDON: Good. Thank you. Effie.

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    DR. CHOW: On rhetoric --

    DR. GORDON: I want to talk about rhetoric, but I want to get some kind of clarity on this. Joe and Veronica agree, and Tierona agrees, that there needs to be a general statement about issues related across the board to benefits versus risks here in interventions. Is this something that the Commission feels is appropriate in this section? I just want to get that nailed down, so speak, pinned down, and then have people come back to the rhetoric.

    MR. CHAPPELL: On this point, I would like to see this common standard that Veronica is talking about addressed from the point of view of the accountability to public safety, that whatever system is employed, that that system, by nature of government authority, the government holds every system accountable for safety and efficacy.

    DR. GORDON: Is everybody agreed on this? Tierona.

    DR. LOW DOG: You even have under the crossing the quality chasm, No. 6, safety as a system property, and it talks about patients should be safe from injury caused by the care system, and I think you could just take that and add a few sentences around it that talk about that, and include it, and I don't think we have to have a lot more.

    DR. GORDON: Thank you. We are in agreement on this? Good. Julia.

    MS. SCOTT: I just felt this whole discussion, addressing Joe's and other people's concern about balance would mean that we would point, as an example, we would point out if there was imbalance in one system and another as we are trying to get to convergence. I mean clearly you can't just talk about what is lacking in safety and efficacy in CAM, without saying that there are also these things. This is the dilemma, there are also these things in other systems.

    DR. FINS: Maybe one way to do that is to say that there has been a concern about safety in two IOM reports, and that concern for safety with respect to conventional medicine really transcends the genre and should be applied to CAM, as well.

    DR. GORDON: Thank you, Joe. Let's move on. I think we have it. Jim, we have it?

    MR. SWYERS: Yes.

    DR. GORDON: Effie, you had a question about rhetoric. Any other issues about rhetoric? Rhetoric is still very much on the table. We have heard some of the concerns. Do you have any others, Linnea, anyone else?

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    DR. CHOW: I just want to make one point here, is that we talk about rhetoric, but we do have some statistics in here that talk about the success of CAM over conventional medicine, and the one that people keep referring back to is page 7, partly because conventional medicine has been slow in developing, but the page before, it gives an example about chronic lower back pain, not very effective, and if you look through, there are indications of studies. So, I think if you think a statement is rhetoric and an overall statement, should look back on what is stated as statistics given here. I don't think this is rhetoric as it has been put out to be, again, modifying that.

    DR. GORDON: I am trying to understand exactly what you are saying. Are you saying that the lines 12 through 15, because they are based on data, are not rhetoric, but it looks like -- maybe this is my interpolation -- line 7 on page 7, for example is rhetoric?

    DR. CHOW: I am saying that that has been pointed out as being rhetoric, and I think different parts in the section are stated as being rhetoric without reference back to the fact that there have been some statistics given. They said, "For many chronic conditions" -- page 6, line 11 -- "For many chronic conditions, conventional medicine," et cetera, "provide only modest gains," and it gave an example, not going into many examples.

    DR. GORDON: I would say that there is a difference between the two statements, that that statement on page 6, first of all, there is significant evidence to back it up. The statement on page 7, though, it is sort of an attribution almost of intention, which I think is unfair. It is not that conventional medicine hasn't been trying to find better solutions, it is just that there have been limitations in the solutions they have come up with. So, I think that is an example of rhetoric.

    MR. SWYERS: Jim, I think we can just say "because of the slow pace."

    DR. CHOW: It doesn't say it is incapable.
    [Simultaneous comments.]

    DR. GORDON: One at a time.

    DR. PIZZORNO: I have some wording for that, that I think would work well, and that is simply say, "Because of the growing incidence of chronic degenerative disease." That way, we say there is more of it, we are not assigning blame, but it is driving the public to looking for more solutions.

    DR. GORDON: Thank you, Joe.

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    DR. LOW DOG: I just also want to be careful when we have cited things, such as hypertension, heart disease, and diabetes, and even arthritis now, talking about only modest gains, and being careful, again using references that are 20 and 30 years old. I think the last 10 years have been really phenomenal at new drug therapies that we have, which is not to suggest that there is not an incredible role potentially for CAM therapies in here, but I think that is another form of rhetoric that is also just not reflective of where we are today with current therapy.

    DR. FINS: You have, like on page 12, lines 1 and 2, it's an oxymoron, "confirmed the potential benefits." If it's a benefit, it has been confirmed; if it's potential, it is yet to be confirmed. Anybody who reads this from sort of a sophisticated point of view, heart disease, it looks like it is like a 9th grade biology report, heart disease. I mean there are all kinds of heart diseases. There is no specificity here, and in a sense, you are hurting your argument by giving this as evidence of efficacy.

    DR. LOW DOG: The thing on heart disease was reduced or modified fat diet, so maybe it would be better just to put -- that that is what the Hooper paper is actually on. We need to be careful when you are talking about -- the reason we have added potential benefits is because the back pain and headache were not conclusive in their findings. Then, depression with St. John's wort, the Little and Parsons was glucosamine. So, maybe actually saying glucosamine for arthritis, reduced or modified fat diet for heart disease, so it is a little more specific in there.

    DR. GORDON: I like that very much. We are okay? Great. Thank you, Tierona. Joe.

    DR. FINS: Even that reference that he just gave us, dates back to Framingham. It is not CAM. Reducing fat in your diet is a public health intervention. It has been Healthy People going back 2000, et cetera, and it is not CAM. So, to allege that it is -- it's a category error.

    MR. SWYERS: These are all Cochrane systematic reviews in the Cochrane's CAM library.

    DR. FINS: That is how they have categorized it, but the question is --

    DR. GORDON: I think we have whole categories, some would call it CAM, some would call it conventional. I don't think we can arrogate it totally to CAM, and then there is the whole argument about how low a fat diet, the argument that Dean has versus extremely low fat diet versus not so low fat diet.

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    DR. FINS: But you are using this as evidence base. You know, the sentence that precedes this is the CAM approach.

    DR. GORDON: Why not say specifically what the approaches are, and not label them CAM or not CAM? So, the benefits of nutrition and exercise is here. The benefits of glucosamine is there. The benefits of whatever it may be, St. John's wort is there. Is that a way to --

    DR. FINS: This is an important distinction. I mean we are talking about glucosamine, we are talking about St. John's wort. Those things, I think are understood as complementary and alternative. But I am not sure that diet and exercise and fat reduction in your diet is CAM. I mean there are lots of mainstream cardiologists and epidemiologists from the public health arena who would see that as part of conventional practice.

    DR. GORDON: Why not just say these lifestyle changes, and don't call them CAM, just call them what they are.

    DR. FINS: Then, you can't use it as evidence of the benefit of CAM.

    DR. GORDON: What we are interested in is trying to promote the larger perspective, Joe, as I see, is what is healthy for the American people. If diet and lifestyle --

    DR. FINS: We don't disagree that that is a good thing. What I am disagreeing with is how it is being used as a justification here in the efficacy, but we will see how it turns out in the next draft.

    DR. GORDON: I think it is partly a question, as long as it is not seen -- well, this is a long discussion, I don't want to get into the whole discussion.

    DR. LOW DOG: I think the point we are going to keep coming back to it, though, is that because of the overlap that exists between complementary and alternative medicine and conventional medicine, there is going to be this sort of conflict, that CAM is co-opting things or otherwise. I think we are going to have to address this at some point. I know there is a number of Ph.D.'s or clinical nutritionists who have been sort of pounding the pavement, doing a lot of this research for 30 years, long time, who may have felt like they were CAM looking at how they were viewed, but they are very much within the conventional setting. I think that we are going to have to address this somewhere, and it is one of -- like the CAM rhetoric, it is something that is sort of throughout the document that we are going to need to come up with some language for.

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    DR. GORDON: I agree. Maybe one of the ways, though, is in this section on convergence, that part of the convergence has to do, not just with bio-psychosocial approach, but with the emphasis on nutrition, exercise, and stress management, not just as ancillary, but as primary therapeutic interventions. That is a difference. I think that the world view, the more holistic world view has pushed these ahead and helped to make them more powerful, but they are not exclusive to CAM, and it is a place where they do converge, and maybe if we can talk about the convergence in a way that is thoughtful, that will help lay the groundwork, so we won't be mired in disputes.

    DR. LOW DOG: Let me just throw out this here. To say that a reduced or modified fat diet is CAM, you are also going to have the other parts of CAM that are also under CAM, that believe that it is a high-fat, high-protein diet, that is most beneficial. So, within the umbrella of CAM, you have very diverging opinions about nutrition, and one would have to really argue that much of this research that has been done on reduced or modified fat diets have really been done through the conventional research, and that right now, CAM nutrition is kind of all over the board. What most of us would agree is a healthy diet is not shared by all people that fall under the rubric of CAM.

    DR. FINS: Brown and Goldstein won a Nobel Prize for characterizing cholesterol and fats. So this is mainstream science, this is not CAM. But I do think what we need to say here is that CAM, as a public movement, has mobilized people's adherence to healthy lifestyle. In other words, CAM doesn't get credit for the lipoprotein (a) receptor. It gets credit for people thinking about I shouldn't have another steak, I should eat 2 percent fat-free milk or something. It's a sociological influence perhaps that takes the best of science and mobilizes healthy behavior. That is where it is a win/win for both sides.

    DR. GORDON: Are we comfortable with this? Okay, great. Let's move on. Jim, are you clear, perfectly clear?

    MR. SWYERS: Yes.

    DR. GORDON: Ken, where are we now?

    DR. FISHER: Well, Issue No. 11. Making a suggestion, Issue No. 11 is going to come up under Research, so maybe it should be discussed there. No. 12, the Sociology of Illness, I don't know whether you have discussed or not.

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    DR. JONAS: First of all, we already addressed one issue, which is the importance of saying how modern research in conventional medicine did, in fact, cause a great rise in the interest and use of it, and that complementary medicine then was kind of pushed underground with that. I think that is what this is addressing. Maybe I already said this, I apologize if I did, but I think there is some very good evidence that looking at these areas has allowed us to develop new methodologies and have evolved research. So in the historical section, a reference and maybe a sentence or two on how the evolution of research methods has occurred because of the exploration of unconventional types of practices, blinding randomization, et cetera, for example, have evolved, and then were eventually brought into the mainstream because they were first used looking at complementary medicine, and this type of thing is continuing now in terms of trying to come up with standards.

    DR. GORDON: So, history, part of that history is the history of the development of research you are saying?

    DR. JONAS: Correct.

    DR. GORDON: Is everybody okay with that? Is that being included? Okay. Ken, do we have anything?

    DR. FISHER: Number 12.

    DR. GORDON: Number 12. Sociology of Illness. Tierona.

    DR. LOW DOG: I don't really know what it means exactly, what it was intended for, but when I read through some of the prevalence data here, I am also struck by cancer, HIV, pretty severe illnesses, and maybe this is part of the sociology of it, but why, when you are confronted with something that is very terrifying, why, people may be exploring lots and lots of way, I am going to cover all of my bases, I don't know if it is going to work or not, the studies haven't been done, but I am going to incorporate it into my belief system. I think there is a tremendous amount of fear and frustration when people are confronted with these life-threatening illnesses, and that may be a part of this. I am not sure we have really captured that in this document.

    DR. GORDON: So, a kind of framing the discussion of prevalence with the discussion of what the psychology is of people who are using these therapies. Tom.

    MR. CHAPPELL: Actually, it doesn't feel right to me. I am glad Joe has returned, because Joe brought this subject up. When Joe was making the point, I didn't agree with it. I think prevalence is simply a function of what consumers feel they need, and they seek out solutions. I don't think it has anything to do with whether they feel comfortable about finding out the truth from their conventional medical doctor. I just don't buy that premise at all. They are solution seekers. That was Joe's premise. I don't buy that premise, these are solution seekers, and that is why prevalence has occurred, and I think this runs the risk of sending us into an area that is really highly interpretive and irrelevant. I would strike it.

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    DR. LOW DOG: Keep the prevalence, but not try to explain why, just to leave the data.

    MR. CHAPPELL: Yes.

    DR. FINS: I think it's probably best to strike it, but I do think maybe a kind of glancing mention to why -- I think this is why we really needed a sociology, sort of historical overview at the beginning, because people seek out these things for all sorts of reasons, and empowerment. I mean people made allusions to the feminist movement, the civil rights movement, the rights movements of the sixties. People are empowered, and a lot of people have written about the empowerment movements. This is a kind of empowerment. It also gives people access to the fruits of science on their own terms. I think there are also people who seek out, and we heard about desperately ill people seeking out CAM interventions because they are unwilling to give up. So, I think there are all kinds of reasons why people do this. Ultimately, the bottom line is it becomes -- the markets reflect these individual needs in the aggregate. It's a complicated story, maybe it's too complicated to get into here.

    DR. GORDON: It's getting to be time for lunch. I want to see where we are with this particular issue, and this is the last issue on this chapter, and I would like to come to closure here, go to lunch, and then we will come back and begin with the other sections afterwards. Effie.

    DR. CHOW: I believe in the cautiousness and the quality and all of that about efficacious and safety, and all that. One thing we haven't really emphasized, and we have watered it down, is that people really do look to CAM, and they have been getting better. In my work, I work with thousands of people, not just my own work, but with other practitioners. This is part of my life. I would say I see 1,000 people every month in contact somehow, input to me, et cetera. People seek it, not just to feel a little bit better, or just seeking like out of desperation. Partly from desperation, but they are having side effects from drugs, and they are tired of not having the personal attention, and not having anybody to talk to, and we have said some of these things, but I think we keep watering this part down because we worry about efficacy and safety.

    So, cancer patients have gotten better because they have sought megavitamins and supplements, and all this, so we need a balance on that, that we really say very clearly that -- and there has not been -- there have been studies. Dean Ornish's study is one example, but there are some other studies, but there is not enough funding that is put in, so it goes back to research. But I don't think we should diminish the fact that prevalence -- prevalence of usage means people are happy. If it increases, they cannot because they are getting side effects from taking these things.

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    DR. LOW DOG: I would just have to disagree with that. I think if we are going to scratch comments about reasons why are things, we need to do that, and I actually think that is probably appropriate, because nobody can really guess the reason why people use and turn, unless it was directly part of the survey and part of the research. We would just be speculating then. I am not sure. Obviously, people are getting something from what they use, but again, I think we are over-speculating, so I would resist from using anecdotes and resist from putting more into the prevalence than what it is, because we have not mentioned the driving influence of the marketplace. There is a tremendous amount of advertising. There is a tremendous amount of misleading advertising out there as we heard from the FTC. That drives the use of products and services. I think if we want to just keep it short and sweet, we list the prevalence, we don't try to get into the reasons for why people or this movement is moving, because it's multifactorial, but to leave it kind of as it is with just the qualifier that prevalence we are not say indicates efficacy.

    DR. GORDON: Joe.

    DR. FINS: It cuts both ways. It is just sort, you know, why people do what they do, and we do lose something, because I think some of the changes in conventional medicine, the rise of managed care, the change in the doctor-patient relationship, the decline of the family practitioner, specialization, the impersonal quality of the medical encounter has led many people to the complementary and alternative practitioner. Both sides are responsible for all this, but I think it is so complicated, to do it justice would require a full report, and it opens up, as Dean would say if he were here, all kinds of red flags that we just don't need to navigate. The prevalence does speak for itself.

    DR. GORDON: Charlotte.

    SISTER KERR: I hesitate to speak, and I will, and I would like my fellow commissioners to listen, because I think I am really just again speaking back to my bias for how to proceed in general in terms of a philosophical basis and world view, because I feel when we get into these issues, again back to research, that it is true, and this is why I ask you to listen. If we speak out of a shifting consciousness in the population and a different world view, we do begin to evolve, and I know -- I guess we don't have the research for this -- in what therapies we choose. I will give you a clinical example. If a woman has a vaginal yeast infection, and the world view is one of cause and effect, reductionistic, you say why in the world would you not use Diflucan, you get rid of it, it is gone, that's it. There is no consequences. You perhaps might say, if you have a different world view of relationship and ecological, you might say I am going to look at the pH balance, I am going to look at my food, I am going to look at probiotics, I am going to think about what is my relationship to myself and to everything else.

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    It is the same reason as an acupuncturist, when I see research with osteoarthritis of the knee, and I put a study that the needle goes in the same place for everybody, I have absolutely no way to relate to that as an acupuncturist, because it's the valuing of the anthropological research, it's all the new models of research that, you know, God knows, Wayne has listened to me go on about this forever, and I frankly think this -- why we want to talk about convergence, we absolutely have a diversion because of shift in consciousness. Thank God. I go nuts when I see Diflucan on Prime Time Network ads. I think it's the biggest women's issue going. So, when I hear, you know, the research models and the same bloody thing coming out, and it is probably what I said two years ago, I just go, to me, it looks like a big compromise we are doing.

    DR. GORDON: I think it's getting to be time for us to go to lunch. I would like to make a suggestion and see how this sits with people. There is research evidence published in peer-reviewed journals that shows (a) that people are looking at these approaches when they have chronic illness, (b) that the world view of the practitioners is congruent --this is Astin's research -- with the world view of the people who are looking for help, and (c) that people feel some sense of empowerment, as Joe suggests. I would suggest that we can talk about those three as background issues without saying that they are defining, and that those three at least, and also the fourth issue has to do with more time spent, and I think that we are on safe ground as far as research goes if we say those things without saying necessarily that X, Y, or Z works, but at least these are clear reasons that are backed up by prevalence data and also backed up by the research data that has been done on motivation of people using these therapies. David.

    DR. BRESLER: I agree with you as long as prevalence data is suggestive and scientific data that is demonstrative, and as long as we keep that distinction.

    DR. GORDON: It sounds great, but tell me what you mean.

    DR. BRESLER: Well, prevalence data can suggest certain things. Controlled studies demonstrate that there is an effect there.

    DR. GORDON: I am not saying there is an effect. I am saying that prevalence data demonstrates that people are using the therapies for specific conditions, that's all. Is everybody okay with this way of approaching it without imputing other motives that we don't know about, I think it covers most of the bases that people are concerned about.

    DR. LOW DOG: Right, because in the Research Section, one of the things that we requested research on because we found the data to not be very conclusive was why do people use and turn to alternative and complementary therapies, and what do they find satisfactory and not satisfactory about it, and we dedicated a section on that, because we feel that this is an area that really does need to be explored more fully, but we felt that looking at the available research out there today, it is not very substantial.

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    DR. JONAS: I agree. I mean this is an issue, the issue of trying to get at values, and what are the values that motivate individuals can be investigated. That is all prevalence data, it is all extremely useful, it is all very important, and it has to be balanced and hopefully guide what you then study. There are two different categories of research that really are looking at different questions, providing different types of information, and that is something that could be better clarified in the Research Section, but one could point to it.

    DR. GORDON: That might be something to come back to when we come to the Research Section. Tom.

    MR. CHAPPELL: Jim, in the four points of motivation that you raised, I didn't hear you mention prevention or health maintenance, but I assumed in that topic of congruence.

    DR. GORDON: I think that in order to bring that one out, we need to present the data on it. This is one of Linnea's concerns. The date on health promotion is not in here in this section on that. Unless we present that data here, we cannot mention it here. If we present that data, and pull some of that data from the Wellness Section back, then, I think we can fairly mention it. So, that is a task, Jim, for you and Corinne perhaps to look at and see if we can do some of that.

    DR. LOW DOG: So, on the Sociology of Illness, sort of what I have heard is that we are going to leave the prevalence data, we are not going to try to expand on a lot of the reasons why that people are using it, and we may something to the effect of, you know, the many reasons that people explore complementary and alternative medicines is not completely understood, but then you may want to quote world view, more time spent, some of those things that there is some data for, and then we will go through the prevalence, and we will leave it at that.

    DR. FINS: And then maybe conclude by saying that really to further direct public policy in this area, additional research is needed to understand all the reasons why people seek out these interventions, and this will be addressed in the Research Section, which sets it up later on, the demography of CAM use.

    DR. GORDON: Thank you. We have come through the first two sections. We are going to take a break for lunch. I want to introduce to the Commissioners, Tripp Fair, Bill Fair's son, who is here. We welcome you, Tripp. It is great to see you. Please come have lunch with us. We will be eating lunch in the next room.

    We are going to take an hour break for lunch, and then we will be back, and we will start with Research this afternoon at 1:20. I apologize to those who came expecting Research in the morning. We are moving ahead with deliberate speed.

    Page 66

    Thank you, everybody.

    [Lunch recess taken at 12:20 p.m.]

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    This is to certify that the attached proceedings
    BEFORE:          White House Commission on Complementary
                     and Alternative Medicine Policy
    HELD:            February 21-22, 2002
    were held as herein appears and that this is the official
    transcript thereof for the file of the Department or
    DEBORAH TALLMAN, Court Reporter