Integration or bust

Variations on the theme of medical crisis are reported persistently in the media: hospital waiting lists get longer; fewer psychiatric beds; life expectancy to decline due to obesity; more medication-related hospitalisations; more preventable deaths in hospital due to factors like medical error and overcrowding; hours worked by doctors unsustainable; one in four facing heart disease by 2051; spending on health 9.5 per cent of GDP and growing fast.

If no news is good news, medicine and the health system must be in dire straits.

The problem is real. There are too many patients, not enough beds, doctors or money. And the boomer bulge promises more chronic degenerative illness - that’s the type that’s hard to deal with, and expensive. It’s a bleak prospect.

Calls for more funding have been an inevitable response, but they miss the point, when the most efficient long-term solution must be to reduce demand. Other mooted solutions, like the use of nurse practitioners, promise to lighten the load on doctors, but still don’t go to the root of the problem.

One certain way to reduce demand on the medical system is still not being taken seriously enough: a shift towards a holistic, preventative model of integrative medicine (a coming together of conventional (or allopathic) medicine and complementary and alternative medicine (CAM).

Dr Marc Cohen, founding head of Complementary Medicine at RMIT and president of the AIMA (Australasian Integrative Medicine Association) says there is an “imperative for collaboration” between medical and CAM practitioners because of the improvement in patient care that it promises.

But there’s an economic imperative too. Proponents of integration see the current medical crisis as an inevitable product of the view that disease is best fought by (costly) technology. Modern medicine is not sustainable in the long term because it’s too expensive.

Many (some say most) patients visiting doctors don’t actually need allopathic medicine. They could be helped with much less expense.

In one example, the government spends hundreds of million dollars a year subsidising pharmaceutical treatments for osteoarthritis. But a recent large randomised controlled trial in the US found that acupuncture can be more effective. So can glucosomine, a cheaper natural substance.

Crucially, such remedies are less risky. Last year Vioxx, one of the top ten PBS (Pharmaceutical Benefits Scheme) drugs, was withdrawn after it was linked to thousands of heart attacks and deaths. In August last year a jury in the US awarded huge damages against the manufacturer, Merck, for one of those deaths. And a further 4,000 suits have been filed in the US alone.

The public attitude to the big pharmaceutical companies is changing. Consumers are starting to ask why they are paying so much for treatments that are more dangerous and often less effective. Specifically under attack are companies, like Merck, which have kept the lid on information about the risks associated with drugs. There’s a growing realisation that profit-making has been the priority, even at the expense of scientific review.

But still, there’s resistance from doctors to letting non-medical treatments in. Integration proponents have popular opinion on their side. For example, on the cover of Time magazine only last month was Dr Andrew Weil, US pioneer of integrative medicine and one of the country’s most popular and influential medical doctors. However integration proponents are still regarded at best as “alternative”, at worst as quacks, by diehards in the medical establishment.

When my father recently suggested to his doctor that he control his blood pressure himself by walking, the doctor said: “I’ll give you a prescription. You won’t have to walk.”

Only one fifth of GPs in Australia offer any form of CAM treatment and often only as a token gesture: so the public goes elsewhere. More than half of us visit a CAM practitioner each year.

Why is there a disconnection between doctors and their patients? Wouldn’t it be better if my father controlled his blood pressure with exercise, or at least with pills and exercise? Walking produces no adverse side effects - in fact it promises a myriad of other health benefits, not the least of which is prevention of other health problems.

The case for resistance is based largely on the perception that CAM is untested. (The irony of now-discredited pharmaceuticals having earlier undergone supposedly rigorous trials that allowed them onto the market is not lost on integration proponents.) But, in fact, there is a growing evidence base, one that has legitimised the use of many (previously dismissed) therapies. And it will only get bigger.

In 1998 the US Congress established the NCCAM (National Centre for Complementary and Alternative Medicine), which is dedicated to exploring CAM in the context of rigorous science.

Still, progress is slow. CAM therapies by their nature can be difficult to test with random clinical trials. And it’s still hard to get funding, particularly when there is a bias against many alternative therapies. In Australia, despite the announcement last year of a new federal government initiative on CAM research, funding is disproportionately small, considering the widespread public use of CAM.

But waiting for evidence may take too long, and there is a case to be made for looking for other ways of getting information, rather than dismissing something out of hand because it hasn’t met the gold standard of a random clinical trial. If there is little potential for a remedy to cause harm, perhaps the standard of evidence required should be less strict.

Many therapies (like my father’s walking) can’t hurt and holding out for proof can mean that we miss out on effective treatments. That recent endorsement of acupuncture wouldn’t have surprised the millions who have been using it “untested” for years.

Proponents of the integrative approach insist they’re not turning their backs on conventional medicine. They don’t want to be sent to a herbalist if they’ve broken their leg. And they admit that some therapies aren’t effective, or safe. But they think it’s myopic to brand CAM in toto as so much quackery. For Cohen, therapies are effective or ineffective, not “orthodox” or “unorthodox”.

Hippocrates said, “Extreme remedies are most appropriate for extreme diseases”. That the crisis facing our health system is serious is something on which everyone seems to agree. The solution may require nothing less than a radical makeover of the way medicine is practiced.