By James S. Gordon
Special To The Washington Post
Tuesday, August 20, 2002; Page HE01
The signs and symptoms of crisis in our health care system have become front-page news in recent weeks. Treatments that were routine -- widely accepted by physicians and embraced by the public -- have proven inappropriate, possibly dangerous and wasteful.
The federally funded Women's Health Initiative appears to have demonstrated that the hormone replacement therapy (HRT) that was supposed to prevent heart disease in menopausal women actually increases its likelihood. A well-executed study on the surgical treatment of osteoarthritis of the knee (published in the New England Journal of Medicine) showed that a placebo group -- patients who only thought they had surgery -- actually did as well as those who were operated on. And, a few weeks ago, a lead article in the New York Times reported on several major studies that show that more conventional health care and more medical specialists do not necessarily produce improvement in health status for both older people and newborns.
This cluster of disturbing findings is simply the most recent and visible manifestation of the limitations and counterproductiveness of an approach to health that places overwhelming emphasis on expensive and often side effect-laden surgical and pharmacological treatments, an approach that has largely devalued prevention, self-care and the perspectives and techniques of the world's systems of traditional medicine and healing.
Over the last several years we have learned that the treatments we routinely provide are, even when appropriately used, the fourth leading cause of death in our country.
While we argue about whether or not prescription drugs should be provided through Medicare, old people's medicine cabinets are bulging with prescribed bottles that are, according to many well-done studies, often unnecessary, redundant and dangerous, as well as prohibitively expensive.
In spite of tens of billions of dollars of investment in research and treatment -- and some real improvements in the treatment of some cancers -- more than 500,000 Americans still die of cancer each year, and millions more who "do well" suffer terribly from the side effects of their treatment.
The surgeon general tells us that the percentage of obese teenagers has doubled in the last two decades and that these overfed and under-exercised, and often anxious and depressed, young people are falling victim to chronic illnesses such as diabetes, heart disease and perhaps cancer at ever-earlier ages. Our newborns continue to die at rates significantly higher than those in a number of other developed countries.
Meanwhile, our health care costs, already more than twice as much per person as those of any other developed country, are escalating out of sight. A recent article in Health Affairs predicted that if costs continue to escalate at current rates, expenditures will double in 10 years.
Outside the System
Americans in unprecedented numbers are looking for relief outside the current system. They want help with preventing and treating the chronic illnesses that threaten, disable and dismay them -- heart disease, chronic pain, HIV, obesity, depression and cancer -- and from the side effects that the state-of-the-art conventional treatments for these illnesses often produce.
They are also looking for a more intimate relationship with their health care providers. They want health professionals who will respect them as partners in their care and who see and understand them as whole people with complex lives, not just "lesions" and lab values.
Many of these people are looking to other approaches to healing. According to one study, published in the Journal of the American Medical Association in 1998, 42 percent of all Americans are using other than conventional therapies as alternatives or complements to conventional medicine. They are making 200 million more visits to "complementary and alternative health care providers" -- acupuncturists, chiropractors, massage therapists and others -- than to primary care physicians.
The White House Commission on Complementary and Alternative Medicine Policy, which I chaired, was created in 2000 to assess these and other developments and to formulate recommendations to make the benefits of complementary and alternative medicine (CAM) and its broader, more holistic perspective available to all Americans. The commission was established because of enormous public and congressional interest in CAM. The commission's work coincided with a similar study by the World Health Organization on the possible benefits of traditional systems of healing and of such modern CAM approaches as large-dose vitamin supplementation and homeopathy.
The commission recently completed a report, which the White House is studying, that will soon be on the desks of all members of Congress.
The commission's recommendations -- based on 20 months of public testimony and discussion with most of the major conventional medical, as well as CAM, organizations -- can help to enlarge our perspective and refocus our attention. They point to the need for a better balance between the current research emphasis on finding "magic bullets" -- single drugs, procedures or, indeed, single alternative therapies -- and the creation and investigation of comprehensive therapeutic approaches that combine the best of conventional, complementary and alternative therapies.
In place of the current emphasis on finding and using more, and more expensive, high-tech interventions, the commission stresses the importance of an informed public, of self-awareness and self-care (including nutrition, exercise and mind-body approaches) in both clinical work and health professional education, and of the role of physicians as teachers as well as "treaters."
Time for a Change
The commission's report is particularly relevant now, as the results of studies that highlight health care shortcomings accumulate.
The newspapers tell us that osteoarthritis of the knee does not benefit from surgical intervention and does only middling well with anti-inflammatory drugs. The commission report offers another, nonsurgical, non-pharmacological way. We would suggest that it's time to do a major study on a comprehensive approach to osteoarthritis, one that combines self-care with safe and effective remedies that are largely free of side effects.
There is evidence, for example, that exercise, acupuncture, yoga, massage and an inexpensive supplement, glucosamine sulfate, are each of some help and that dietary change and weight loss can also produce real improvement in symptoms.
More than 40 million Americans currently suffer great pain and endure limitations of movement because of osteoarthritis. They pay tens of billions of dollars each year for doctors and drugs, and cost our economy tens of billions more in lost time at work.
Why not combine these CAM therapies, together with group support, and study this approach for cost-effectiveness as well as for safety and effectiveness? We can do the study with a tiny portion of the $1.5 billion we will save each year if we refrain from unnecessary knee surgery. And if this holistic approach proves helpful, we may find ourselves saving tens of billions more. The commission noted that Dean Ornish's program for reversing heart disease, the nation's leading cause of mortality, represents a pioneering effort to demonstrate the effectiveness and cost-effectiveness of this kind of comprehensive program.
In a program based on education and self-care, Ornish teaches patients to combine significant dietary modifications, physical exercise, yoga and stress management in the context of a supportive group. Several studies published in prestigious journals have demonstrated improved physical functioning and quality of life in Ornish's patients. The diameters of their coronary arteries have increased and they have no longer needed coronary bypass surgery. Meanwhile, their insurers have saved up to $30,000 for each person enrolled in the study.
Much medical effort is lavished on ensuring that patients "comply" with doctors' orders, whether or not these orders are for treatments that are effective, appropriate and cost-effective. The commission lays out a plan for the full participation of all Americans in every aspect of their health care -- in setting public health priorities, as well as in deciding on, formulating and carrying out their own therapeutic regimens.
The commission recommends that the government make it possible for us to make these decisions wisely by making the best information about the benefits and hazards of all forms of health care easily available -- to ordinary people as well as to the health professionals who serve them.
We urge as well a significant redirection of effort and funds to the prevention of illness and the promotion of health and wellness. Though some continue to argue about the state of the evidence, it seems to us quite clear that if our children learn to eat and exercise better, and learn how to deal with stress more effectively, they will be able to forestall much of the later suffering -- the debilitating and life-threatening chronic illnesses -- for which they seem to be headed.
Finally, we need to make sure that we continually keep the broadest possible perspective on what is and is not working, and are willing to raise questions about any orthodoxy -- conventional or alternative -- that may restrict our vision.
The bad news about hormone replacement therapy and current treatments for osteoarthritis, as well as the rising human and economic costs of our inefficient and too-often ineffective system of health care, can, we believe, be an opportunity. Now is the time to reassess and readdress the shortcomings in our approach to health care as well as in the individual interventions we use -- and to look closely at approaches that may save us all large sums of money, as well as untold suffering.
James S. Gordon, MD, former chair of the White House Commission on Complementary and Alternative Medicine Policy, is the director of the Center for Mind-Body Medicine in Washington, a clinical professor of psychiatry and family medicine at Georgetown Medical School and author of "Manifesto for a New Medicine: Your Guide to Healing Partnerships and the Wise Use of Alternative Therapies."