Integration: How Long Does It Take?

This year, the U.S. can take pride in an accomplishment. Hundreds of years after importing Africans, enslaving them, freeing them and then slowly giving them rights, an African American is a viable candidate for the presidency. The point is that sometimes, integration can take longer than it should. I find myself asking: How long will it take before Chinese medicine has equal status in this country?

Will Chinese medicine ever be a viable option for children whose parents want natural treatment? Will athletes know that Chinese medicine would heal their injuries faster and more safely? Will gynecologists know that women's medicine is a subspecialty in Chinese medicine, without the risk of drug side effects? Will surgeons know that wound recovery happens faster and with less pain when using Chinese medicine, and would they know to refer? Or better yet, will Chinese medical practitioners ever be part of the care teams?

The TV screen displays a lingering shot of an ebullient Barack Obama, forcefully delivering a victory speech announcing the start of a new era for America - an era of cooperation and of change. The audience erupts in applause. The shot widens to show a stage in which two adorable African American children and a stately African American professional wife kiss their dad/husband in a show of solidarity. This is a public proclamation - a pentimento of an image cast more than 40 years ago of a young outsider making it to the center stage of American power. When Kennedy was elected, we learned that you didn't have to be Protestant to be the president. But an African-American man? The camera wasn't showing a protest in which a rainbow coalition symbolically shows cooperation during a staged demonstration, but a true display of an American ideal coming to life. Now this is integration in real time.

My family and I were watching the Iowa primary election. We marveled at the two leading contenders in the Democratic race, both "minorities," a woman and an African American. Two hundred and thirty-two years after the country was founded, announcing "inalienable rights" for "all men," 143 years after the abolition of slavery, 87 years after the passage of the 1920 Women's Suffrage Act and 44 years after the passage of the 1964 Civil Rights Act, a man of color and a woman are presidential contenders.

However, the history of integration is a tale of painfully slow change. For the growing community of practitioners, patients, researchers and educators in Chinese medicine, there is a lot to learn from the example of racial integration. Though one can never equate the pain of slavery with the indignity suffered by having unequal rights, we also started as an oppressed minority, practicing or receiving treatment in secret.

In 1972, the process of legitimization was stimulated by the publicity generated by front-page New York Times coverage of James Reston's appendectomy using acupuncture for anesthesia. Reston, a well-respected NY Times correspondent, was covering President Nixon's historic trip that officially opened American-Chinese political and trade relations. The American reader linked President Nixon's political approval of China to a belief that things Chinese might even be useful for us.

Suddenly, with that story, a door opened. Policy changes led to legislative changes and now, 35 years later, acupuncture (at least) is legal in almost every state. After 1972, state by state engaged in protracted lobbying efforts, rendering laws that legalized Chinese medicine.

One could argue that the complete legitimization of the practice of Chinese medicine should give its practitioners primary care status. In fact, the World Health Organization (WHO) endorses Chinese medicine as effective for primary care. Unfortunately, the U.S. is reticent to adopt international agreements. Be they guidelines about global warming (i.e., the Kyoto treaty) or herbal standards (using the Australian GNP standards for herb purity), we reject international standards in favor of engaging in protracted learning processes that restrict patient access. Our patients wait and some get worse. Many people who need treatment never get it. Chinese medicine remains on the periphery of mainstream health care systems.

I vividly remember my own years in the 1980s of crossing state lines to practice legally while awaiting passage of Pennsylvania's first Acupuncture Registration Act in 1987. Patients were not happy driving an extra hour to be treated, and they successfully argued that they were being denied a medical treatment of their choice by having to do so. We were a few but determined lot who lobbied for our rights.

We can work separately, but not equally. There is minimal government assistance for research, teaching or publishing within the Chinese medical community; most research dollars are being used to "prove" the efficacy of acupuncture for specific medical conditions rather than to show how care delivery systems can integrate Chinese medicine in ways that are best for public health. In short, our approach, though legal, has not achieved equality. We are in the post-civil war phase. We will not be prosecuted for practicing, but our approach is not considered fully valid; separate, but not equal.

The question is raised: Should our goal be "complementary" (i.e., separate but equal) or "integrated," in which we are part of the main health care delivery system? However, the real question is: What would be better for patients?

In 1997, the National Institutes of Health (NIH) assembled a 12-person blue-ribbon panel of experts representing the fields of acupuncture, pain, psychiatry, psychology, physical medicine and rehabilitation, drug abuse, family practice, internal medicine, health policy, epidemiology, statistics, physiology and biophysics.

The objective of the NIH Consensus Statement was to "inform biomedical research and clinical practice communities of the results of the NIH Consensus Development Conference on Acupuncture. The statement provides state-of-the-art information regarding the appropriate use of acupuncture." The conclusions listed specific instances in which acupuncture was recommended. "Promising results have emerged...showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain."

The NIH statement continues by showing that acupuncture treatment can actually be safer than the use of drugs. "One of the advantages of acupuncture is that the incidence of adverse effects is substantially lower than that of many drugs or accepted medical procedures used for the same conditions. As an example, musculoskeletal conditions such as fibromyalgia, myofascial pain and tennis elbow...are conditions for which acupuncture may be beneficial. These painful conditions are often treated with...anti-inflammatory medications (aspirin, ibuprofen, etc.) or with steroid injections. Both medical interventions have a potential for deleterious side effects but are still widely used and are considered acceptable treatments...In addition, there is ample clinical evidence, supported by some research data...that acupuncture may be a reasonable option...for postoperative pain and myofascial and low back pain."

A Case Study

John is a mentally vital 48-year-old man in a leadership position in a nonprofit organization. Verbally adept, poised in public and politically polished, he is a vibrant contributor in the field of child welfare. An effective lobbyist, he is personable, well-informed and persuasive. Recently, he can't fit into his suits and can barely move his body.

For years, he has suffered with fibromyalgia. A recent increase in his daily steroid medicines led to a ballooning in weight. As if the pain of fibromyalgia isn't enough, he is now further crippled by a 30-pound weight gain attributed to the side effects of steroids. Now his knees and lower back hurt more, and are no less swollen since the change in medicines. Although he thought his pain had no visible effect on his job performance, he confided in me that every day felt like an uphill battle. He seriously considered early retirement due to his medical condition. I met him while interviewing leaders in his organization, which was slating him for a more senior position. No one wanted him to leave. In fact, years earlier, they tried to promote him and wondered why he hadn't accepted advancement. He told me he couldn't do more without some relief from pain!

Treatment last year, using Chinese medicine (acupuncture and Chinese herbal formulas) brought vast relief. He slowly weaned off the steroids, took more lobbying trips without pain and enjoyed a promotion - results that could have come much earlier if his rheumatologist were aware of the 1997 NIH Consensus. The cost to him and his organization was severe because his rheumatologist was not aware of the NIH guidelines. One can calculate the cost of his medicine, lost time from work, possible inefficiency due to pain, as well as the cost of visits to hospitals and specialists. How might that time and money have been spent for a result known to be effective? Acupuncture is legal in his state, but not integrated. Separate, but not equal. As a result, this man has suffered, his organization has gotten less than it could from an employee, and the impact on child welfare has been compromised.

The NIH has begun to recommend acupuncture and research is underway that dramatically expands the list of conditions for which Chinese medicine can be used. Changes in prescribing patterns, public access, funding and facilities also are badly needed. Beyond achieving legal acceptance, Chinese medicine must be integrated as a viable health care option for those who need it. Employers will benefit and employees will be healthier. Costs for health care would likely drop. Diversity makes you stronger. Equality can only improve public health.