Alternative Medicine Ideas Widen Horizons In Biomedical Research

Editor's Note: This second part of a two-part series looks at researchers' efforts to establish rigorous methodologies to investigate alternative medical therapies. There are signs that tomorrow's medicine may be quite changed from today's, with medical schools now adding novel courses to their curricula, private funders helping establish new directions for biomedical investigations, and the United States searching for cost-effective health-care reforms. The first part of this series, which appeared in the March 7 issue, charted the ground shared by basic biomedical research and alternative medicine and the emerging synergy between the two. At the National Institutes of Health on July 11-13, the Office of Alternative Medicine (OAM) will hold its first technology assessment conference. One of the primary goals of the conferees will be to begin development of research methodologies appropriate to the study of such treatment approaches as traditional Chinese herbal medicine, acupuncture, and therapeutic touch, according to OAM officials and others. A follow-up meeting, it is hoped, will address specific issues of research design, measurement, and data analysis. Creating rigorous methodologies to test the efficacy of unconventional medical practices, scientists say, will become increasingly important as findings in some fast- moving biomedical research areas--psychoneuroimmunology and psycho- pharmacology, for example--converge with the integrative ideas of alternative medicine. Several innovative funding initiatives from philanthropic foundations are also expected to help in this task, they say, and newly established alternative medical education courses at a number of top medical schools should serve to further interweave establishment and alternative medical research. Investigators add that health-care reform, as it evolves, may emphasize the preventive and behavioral aspects of biomedicine, aspects considered central to many alternative therapies, also contributing to growth in those areas. "We're going to bring together people from the alternative medicine field with research methodologists, to try to see if there are new kinds of methodologies we can develop that are more appropriate to the kind of work we're doing," says James Gordon, a cochairman of the OAM methodology meeting and a clinical professor of psychiatry and community and family medicine at Georgetown University Medical School and director of the Center for Mind-Body Medicine, both in Washington, D.C. Gordon says some questions arising in alternative medical settings are crucial for health but will be difficult to address scientifically. "For example, what are the best ways of studying the interaction between the person who's giving help and the person who's receiving help?" Gordon asks. "How do we take account of the fact that so many of these modalities, used in an optimal way, are very carefully individualized?" The questions to be confronted in designing new methodologies to assess alternative treatments may challenge researchers' basic biomedical perspectives, according to David Eisenberg, an internist and instructor in medicine at the Beth Israel Hospital and Harvard Medical School, both in Boston. For example, he says, simply testing the effectiveness of a Chinese herbal remedy prescribed for migraine headache on migraine sufferers might be inappropriate, because the underlying diagnostic categories in Chinese medicine could differ dramatically from those in Western medicine. Ten people with a diagnosis of migraine in Western medicine might fall into three or four or more treatment categories using what Eisenberg calls the "pulse-and-tongue" diagnostic techniques of Chinese medicine. The diagnosis might be a liver deficiency, with the corresponding prescription of a certain herb. "It would be senseless and, I think, intellectually arrogant to simply look for an active ingredient without taking into account the diagnostic theory with which that herb has been used for a millennium," Eisenberg says. "We have to keep that in mind before offering the simplistic approach that if we just test all these herbs to see which ones fix migraines, it'll work. That's not the way they're used, so why test them that way?" Still, there are ways to study the diagnostic system of Chinese medicine, Eisenberg says. Researchers in China are now working with sensitive pressure meters, for example, to assess pulse aberrations on the radial artery. "[This work] not only cuts across medical specialties, it cuts across all the basic science disciplines as well," says Gordon. "And once you start thinking in terms of another diagnostic system, it calls into question all the conventional ways that we've looked at illness." Foundation Funders A handful of private foundations are playing leadership roles in supporting research into alternative therapies and into the basic science disciplines seeking to describe the biochemistry of mind-body links. For more than a decade, the John D. and Catherine T. MacArthur Foundation in Chicago has sought to address some of these questions and currently invests roughly $3 million annually in such research. "Our goal here is to bring hard-bitten science to bear on issues at the interface of mental and physical health, and of emotional state and physiological state," says Denis J. Prager, director of the health program at the MacArthur Foundation and a former deputy science adviser to Presidents Jimmy Carter and Ronald Reagan. "The alternative-medicine, mind-body, faith-and-healing area--whatever all this is called--is littered with anecdotal evidence and intuitions and personal experiences, but has not been characterized by much good science. "But there's enough work now to say that we know mental state has a role in health and in disease processes. We can't say anymore that we don't have enough data--we do. The questions are how can we get more data, how can we understand the mechanisms, and how can we take what we know to be proven and get it into practice?" Psychiatrist Robert M. Rose says that while alternative medical therapies are opening important new research questions, new scientific methods are not needed to answer them. Rose is head of the MacArthur Foundation's research network on mind-body interactions. "There are a lot of indications, mostly epidemiological, that psychological and social phenomena can affect health," says Rose. "But one doesn't have to invoke strategies that are not amenable to the same kinds of scientific rigor that are extant in most biomedical research. Our own network is an attempt to apply evolving new tools in studying how the mind-brain works and its control of peripheral physiological functioning [in a way] that is consonant with what is done in more standard laboratories." Rose's reference to a unified "mind-brain" suggests a view, similar to that of other researchers in this area, of the brain as more than just a physical organ--his concept also includes psychological, emotional, and other aspects of mental state. The Fetzer Institute in Kalamazoo, Mich., has also been a prominent supporter of research into alternative medical approaches, spending about $5 million a year currently. Among other projects, the institute supported journalist Bill Moyers's 1993 public television series "Healing and the Mind," and it is a funder of David Eisenberg's work at Harvard. Like others trying to structure investigations of alternative medicine, Fetzer staff are struggling with how best to address the new categories of questions being raised by their efforts. "I don't know of anyone who disputes the reality of interactions between the nervous and the immune systems," says Ken Klivington, Fetzer vice president for science. "But the real problem currently is [assessing] the clinical significance of psychologically induced changes in the functions of the immune system. And that's proving to be a real bear to wrestle with. There are so many variables involved in these clinical studies. People don't even agree on what aspects of immune function to measure." The institute's founder, John E. Fetzer, who was a pioneer in radio broadcasting--and one-time owner of the Detroit Tigers baseball team--had a special interest in the possible medical applications of electromagnetic waves, according to Kliving-ton. Now receiving funding from the institute is the work of Jan Walleczek at Loma Linda Veterans Administration Medical Center in California. Walleczek is working to develop instrumentation for the new field of bioelectromagnetics. "There are many people who believe," says Harvard's Eisenberg, "that the chemical alterations that we are most comfortable discussing in terms of biology are fundamentally electrical and electromagnetic field-related phenomena, and that it may be that, at the more basic level, it is the field phenomena that are driving the cell membranes and the chemistry, not the other way around. . . . What Jan Walleczek has done is create a new shielded apparatus to explore low-frequency radiation effects on cells." Klivington says Walleczek's experimental model looks at the interaction between weak electro- magnetic fields and biological systems, specifically the calcium uptake of various cells in culture. "Increasingly, hard-nosed scientists are willing to take a look at things that they would have dismissed out of hand not too long ago," Klivington says. Several top medical schools have introduced or are in the process of organizing alternative medicine components to their curricula. In these settings, too, researchers are making efforts to meld the scientific viewpoint and elements of alternative medical thinking. Educating tomorrow's biomedical professionals with a broader awareness of the healing arts may serve to inform new research approaches in the future, educators say. "Part of what we hope to do, in addition to conducting research, is also to develop courses for medical students and graduate students on different ways of thinking about research," says Fredi Kronenberg, associate professor of clinical physiology and director of the Richard and Hinda Rosenthal Center for Alternative/Complementary Medicine at the Columbia University College of Physicians and Surgeons in New York. "In clinical trials and medical research, the double-blind, placebo-controlled trial is the standard," Kronenberg says. "Well, there are a lot of things for which that is not appropriate. How do you do a double-blind study of acupuncture? How do you do a double-blind study of body-work techniques? People are beginning to talk about other methodologies, other ways of looking at the outcome of a particular treatment in order to determine effectiveness." This year, Kronenberg's center sponsored an elective course in alternative and complementary medicine at Columbia with invited lecturers presenting talks on such topics as nutritional medicine, hypnosis, biofeedback, chiropractic, homeopathy, and therapeutic touch. At a January lecture, Georgetown's James Gordon discussed mind-body medicine. In April, Ted Kaptchuk, associate course director for alternative medicine at Harvard Medical School, will address the "Historical Concept of Vital Energy in Alternative Medicine," and two sessions will review alternative cancer and AIDS therapies. Brian Berman, an assistant professor of anesthesiology and family medicine at the University of Maryland School of Medicine in Baltimore, has been working to design rigorous methodologies for acupuncture and pain studies. Berman is also director of the Laing/University of Maryland Complementary Medicine Program, started in 1991 with funding of $1 million from the Maurice Laing Foundation in London and matching funds from the university. "There are a lot of [acupuncture] studies, but not that many have good methodologies," Berman says. "You've got to have sham points, where one group gets acupuncture and the other gets needles in non-acupuncture points. But when we started to explore that, we realized that by doing that you are eliciting a well-known mechanism called diffuse noxious inhibitory control from the brain. You're actually doing something by just putting needles into what you think are nonacupuncture points. If that's the case, then you're really narrowing the difference between the two groups. So, we've come up with what we think is more of a real placebo, where we're not actually puncturing the skin." Berman adds: "But then--imagine the challenge--how do you do good research on meditation or prayer? And yet people have done it, good scientists. So, there's plenty of room for good researchers." This year, also, OAM is planning to begin funding a number of postdoctoral training fellowships to help attract qualified researchers to the alternative medicine area. The awards will be for periods of up to three years in length, with stipends ranging from $18,000 to $32,300 per year, depending on the recipient's postdoctoral experience. "These fellowships are for people who are trained in Western science and research who now have an interest to learn more and get more experience in alternative medicine," Berman says. "The idea is that they can eventually put in for research grants in this field. I've got [an application] on my desk right now from somebody who's saying, `I've got a Ph.D. in biochemistry and I'm interested in learning more about how that could be applied to research in this field. Do you have a slot for me?'" Among the aims of the new medical school programs in alternative medicine is to reintroduce integrative biological thinking, which some see as having been lost in much of current biomedicine. "I think we've lost touch with the whole," says Columbia's Fredi Kronenberg. "There are fewer and fewer biology departments around the country with whole-organism physiology. It's a lot of molecular and cellular physiology, which is fine, but there's a place for systems biology. You can take things apart, but you have to put them back together again to see how they work." Kronenberg sees the new thinking not necessarily as alternative to current biomedicine, but as supplemental to it. The MacArthur Foundation's Robert Rose agrees. "People are so worried about the molecularization of medicine," says Rose, "that they say, `Let's look at alternative treatments.' What I would argue is that we need additional complementary strategies. It's not that we shouldn't do biomedicine as it's evolving now, when we're understanding gene structures for a variety of things. The issue is how to then come back and be much more holistic or integrative. That's the challenge." Many researchers involved in bringing alternative medical thinking into establishment biomedical settings say there are implications for medical practice. As the United States confronts health-care reform and considers new ways to keep its population healthy, they say, behavioral and preventive aspects of medicine are likely to gain prominence. "We have a health-care system that was built on the model of fixing people when they get acutely ill and that responds as though the basic underlying causes of these illnesses are biological pathogens," says Denis Prager, at the MacArthur Foundation. "What we're not dealing with is the whole set of mental, emotional, and environmental influences on health. And that's what's breaking the bank, in a sense."

Alternative Medicine Ideas Widen Horizons In Biomedical Research

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