The overarching goal that proponents of so-called “complementary and alternative medicine” (CAM) or, as is becoming the preferred term, “integrative” medicine is the mainstreaming of the “unconventional” treatments that fall under the rubric of these two terms. Indeed, that’s the very reason why they so insisted on the shift from calling it CAM to calling it “integrative medicine.” Not being content with the subsidiary status as not quite “real” medicine” that the words “complementary” and “alternative” imply, they want their woo to be seen as full co-equals with scientific medicine, hence the name change. There’s a common saying among skeptics, versions of which have been attributed to Richard Dawkins, Tim Minchin, Dara Dara Ó Briain, and others, that basically points out that there’s no such thing as “alternative” medicine because when alternative medicine is scientifically validated it ceases to be “alternative” and becomes just “medicine.” To this, I often add that the vast majority of alternative medicine is either unproven or disproven. The problem with what “integrative” practitioners want to “integrate” into conventional medicine is that, aside from the rebranding of science-based modalities like nutrition, exercise, and lifestyle interventions, most of it is alternative medicine like acupuncture, traditional Chinese medicine, “energy” medicine, and other unproven or disproven treatments. They want to integrate pseudoscience with science, quackery with medicine.
As part of this effort towards integration, proponents labor under the assumption that what they are integrating is not only good, but should be considered co-equal with real medicine. Recently, I noted an example of this phenomenon in a study that examined why people do and do not use CAM, with an eye towards increasing CAM use. In other words, integrative practitioners so believe in their woo that they see it as a fit topic for health disparities research, which, as its name suggests, is designed to identify and remedy disparities in disease prevalence and health care based on race, socioeconomic status, gender, and the like. It’s an important area of medical research, given that there are often huge disparities in care based on socioeconomic factors and race. As proponents succeed in “mainstreaming” and “normalizing” CAM to the point that CAM is viewed as just another medical treatment in “conventional medicine,” then it’s only natural that researchers would study disparities in CAM care just like any other medical care.
And so it is again, with a study in PLoS ONE by Adam Burke at the Institute for Holistic Health Studies, Department of Health Education, San Francisco State University and Richard L. Nahin and Barbara J. Stussman, both at the National Center for Complementary and Integrative Health (NCCIH), which is the new, shiny name for the National Center for Complementary and Alternative Medicine (NCCAM). The study is entitled Limited Health Knowledge as a Reason for Non-Use of Four Common Complementary Health Practices. Yep, it’s a disparities study, with the cause of the “disparity” in usage of certain CAM modalities as being due to a lack of knowledge. In other words, if you don’t know about it, you won’t use it the implication being that it’s up to physicians to educate our patients. Let’s take a look.
The strategy of Burke et all was to use the 2007 National Health Interview Survey (NHIS) Complementary and Alternative Medicine supplement. I’ve discussed this particular survey before. Basically, the NHIS is a yearly survey conducted by the NIH regarding the health of the United States civilian, non-hospitalized population. The survey consists of four modules: Household, Family, Sample Child, and Sample Adult. The first two modules collect socio-demographic and health information for all families residing within a household. Then, within each family, additional information is collected from one randomly selected adult (the “sample adult”). The data from the NHIS are publicly available online. Burke et al also note that the NHIS oversamples black, Asian, and Hispanic populations to “allow more precise estimation of the health characteristics of these growing minority populations.”
We’ve encountered the NHIS before, particularly the 2007 NHIS, because this particular survey examined CAM usage and has frequently been used as the source of an argumentum ad populum that says that CAM is very popular and therefore we should study it and take it seriously—and also that physicians are prescribing more CAM. In reality, what the survey showed is that the rates of use of “hard core” CAM, such as homeopathy, naturopathy, chelation therapy, “energy healing,” and the like were in the low single digits, percent-wise. Even for acupuncture, only 6.55% of the sampled adults had ever seen an acupuncture practitioner. Massage and manipulation (either by chiropractor or osteopath) were more common with usage of 16.02% and 21.91%, respectively. As Steve Novella noted:
Back pain is an extremely common ailment, and is difficult to treat with any modality. It is therefore understandable that many patients will seek a variety of symptomatic treatments for their back pain. Use of massage and even manipulation is about as effective as physical therapy, medical management, or simple “back hygeine” – which is to say, not very effective. Massage and manipulation are also used by physical therapists, physiatrists, and sports medicine doctors – in other words, these modalities are mainstream to the extent that they are evidence-based and useful.
Manipulation and massage for back strain do not necessarily represent a different approach to medicine, a change in medical philosophy, or a new world order.
Thus, the NHIS is yet another survey or study that gives the impression that CAM is a lot more popular than it actually is.
In any case, Burke et al take it to a new level by concluding that a reason for nonuse of certain CAM modalities is lack of knowledge. The CAM modalities studied included acupuncture, chiropractic, natural products, and yoga. Two different data samples were analyzed. The first was a sample of 13,128 adults who had never used any of the four modalities studied, or 55% of the the entire NHIS study population. From that sample, they selected a subset of these non-users consisting of 2,580 adults, who, in addition to having reported never using acupuncture, chiropractic, natural products, or yoga, also reported having had low-back pain in the previous 3 months. To me, it’s amazing that only 2,500 of these respondents reported low back pain, given how common it is, but there you go.
Then the investigators did this:
In the 2007 NHIS supplement, respondents who did not use one or more of the common complementary practices were given ten response options to select from to ascertain their reasons for non-use. The response option “Never heard of it/Do not know much about it” (24% of respondents) was selected as the primary dependent variable for analysis. This reason was selected in order to specifically explore the relationship between health knowledge (of complementary health practices) and non-use. For the rest of the article this variable will be referred to as ‘lack of knowledge’. A second dependent variable, “Do not need it” (43% of respondents), was also selected. For the rest of the article this variable will be referred to as ‘lack of need’. These two items were chosen as they were among the most frequently selected, their implied meaning was clearer compared to response options like “Some other reason,” and they allowed for a parsimonious examination of the interrelated concepts of knowledge and need (particularly, need based on the presence of back pain and the hypothesized search for therapeutic information/knowledge). Associations between these two dependent variables—lack of knowledge and lack of need (as reasons for non-use)—and key independent variables were examined.
Some of the other reasons included:
- No reason
- Never thought about it
- Too expensive
- No evidence it works
- Provider said no
- It costs too much
- Do not believe
- It is not safe to use
Of course, looking at the table, the first thing I notice is not how many people don’t know about these CAM remedies. What disturbs me is how few of them state that the reason they don’t use this CAM is because it doesn’t work, which only around 1% of the respondents said. What I’d want to know is why that number is so low and how I could make it higher. But that’s just me. These are CAM practitioners; they assume that people who don’t use CAM don’t use it because they don’t know about its glories. So they go after that angle and try to identify factors that correlate with giving that particular response. They found that:
- Individuals with lower levels of education and lower incomes were more likely to cite “lack of knowledge” as the reason for not using CAM. (Surprise, surprise!)
- Contrary to expectations, having low back pain was not associated with higher levels of information seeking.
- Individuals with lower education and lower incomes were less likely to respond “lack of need” as a reason for CAM non-use, specifically chiropractic. The same was true of people who could not afford additional care with respect to acupuncture use. (Again, surprise, surprise! Given that most insurance still doesn’t pay for acupuncture, making acupuncture services mostly cash on the barrelhead.)
- People who were physically inactive were more likely to cite “lack of knowledge as a reason for not using all four CAM modalities, while those who were physically active were more likely to cite “lack of need.”
The authors conclude:
These results suggest that if individuals with health concerns, such as low back pain, knew about clinically appropriate complementary therapies they might use them. Indeed, a related study examining the relationship between health literacy and clinical outcomes found corroborating evidence. It was reported that in a sample of 310 cognitively intact veterans enrolled in a Veterans Administration primary care clinic, patients with lower health literacy knew less about the various medications they were taking. That difference in understanding, however, did not negatively impact medication adherence or adverse events . Although lack of health knowledge can reduce access to potentially beneficial provider-based and self-care therapies, it does not necessarily preclude utilization if those resources are made appropriately available to patients. Patient-oriented interventions addressing limitations in health knowledge have shown promise, such as tailoring educational interventions based on literacy levels [52–53]. Provider-oriented strategies could include broader implementation of best practice guidelines  with low socioeconomic status individuals, including recommendations of complementary therapies. Approaches such as these could help reduce inequities in health knowledge and understanding, and improve access to care for underserved populations.
Not surprisingly, NCCIH is touting this study on its website, stating explicitly, “Strategies are needed to help reduce the disparities in understanding and to improve access to health care.”
In other words, they’re arguing that CAM should be treated the same as scientifically validated medicine, even though the vast majority of it has not earned that status. If you think CAM is equivalent to real medicine, then it only follows that you should try to reduce disparities in access to CAM. Studies like this are the result. Unfortunately, they’re becoming more and more common, reinforcing the message that CAM is just the same as medicine.
18 replies on “Health disparities research and the mainstreaming of "integrative medicine"”
” the cause of the ‘disparity’ of usage in certain CAM modalities as being due to a lack of knowledge”
Only not how they think.
It’s really cynical of these people to conflate standard preventitive, after-care, and palliative measures with their quackery.
If it comes from a publicly funded body, I wonder if it doesn’t border on corruption.
What disturbs me is how few of them state that the reason they don’t use this CAM is because it doesn’t work, which only around 1% of the respondents said.
Were respondents allowed to choose more than one reason? If yes, then this is definitely a problem. If they were forced to give a single primary reason, then I could see people giving some of these other reasons instead. Some alt-med modalities are, in fact, not safe to use (MMS anyone?). “Do not believe” could include people who suspect, but don’t know for sure, that it doesn’t work (as I have said before, some alt-med modalities should be obviously bunk to a high-school graduate, but others are plausible enough to fool lay people). Given the propensity of alt-med practitioners to require cash payment (no insurance, please!), “too expensive” would be a rational response for many people. There are other reasons on that list that are arguably rational, at least for some fraction of respondents, including “do not need it”, which was apparently the most popular response.
So suddenly yoga represents alternative or complementary medical intervention?
I understand gentle exercise and stretching (especially for the muscles of the core, legs abdomen and and back muscle groups) to be about as mainstream a treatment for back pain as exists–who knew?
Right but does SBM teach you about prana?
Eric and Orac:
Don’t sweat the 1%. This kind of survey research is grossly unscientific, and the tabulated responses are often all but meaningless. Eric notes just one of many elements of survey design that can wildly skew results: in addition to the rules of choosing answers, there’s the way things are phrased, the way the series of items is structured… then the coders sort the responses in ways that are actually highly subjective but presented as mere ‘fact’.
Media Studies is an ‘interdisciplinary’ field – so even though my own stuff was all interpretive/speculative, we all studied social science research methods, had colleagues doing survey-based stuff, saw presentation and critiques in colloquium etc. Trust me, digging into how the sausage of these studies gets made reveals plenty of face-palming ingredients that aren’t visible in the published results. Thus, doozy inversions of reality like ‘too few people use chiro for low back pain because they don’t know about it’ are fairly common….
No, Dr. Burke (et al), too many people use chiro because the know it’s considered (wrongly) a specialty in delivering low-back pain relief. Sheesh… GIGO.
Of course, the jokes make themselves here. I’m sure the CAM disparity would go down if only the masses knew that listening to homeopathic mp3s cures cancer and ebola. Shall we wait for the disparity study that shows attendance at Evangelical Christian churches would be higher if the sinner just knew Christ was their only path to salvation capable of moving them from the path of damnation and eternal torture in the fiery pits of Hell?
Finally, the usage may not have originated with these authors, but the most frightening thing to me in this post is thinking about what kind of head-space someone has to be in to employ the phrase “a sample of cognitively intact veterans” in a totally off-hand, instrumental and trivial way…
And that’s exactly why I do not do yoga, only go to my local sports centre for something called “healthy back and stretching”. It includes elements of yoga, pilates and other exercises, done to some nice music – and seem to work fine for me.
Although, what really cured my lower back pain was losing 50lb.
Oh, I know!
I went to an ‘institute’ that included chanting, meditation, breathing- altho’ the actual religious stuff was available in separate classes they still managed to sneak some in.
Tragically the Spanish boy who came down with diphtheria because his parents believed the anti-vaxxers has died, in spite of heroic measures involving multiple countries. At least eight other children were exposed, but did not contract it because they had been vaccinated.
And this has to do with this post…exactly what?
Given the choice between hippy-dippy yoga with a little chanting or “worship of the perfect a$$ in $200 lycra tights” yoga, I’d actually choose the former pretty much every time, but I’m weird and have also never been averse to a little kirtan.*
This, in any case, is obligatory.
*I mean, whatever, though, hatha yoga is basically gymnastics and it was invented in the 20th century.
Sadly, traumatic brain injury is not uncommon among the veterans of the most recent conflicts.
In the meantime, we don’t get necessary medical research funded. Research dollars for science-based medicine get spent on stupidity trying to find better ways to sell placebos.
Integrating cow pie into apple pie does not result in an improved pie.
Australia, up until present, has been free of woo being taught at university level. How a university, where people strive for knowledge be implicated in teaching woo, I am yet to understand. However, I have heard a horrible rumour that Sydney University is considering the very unscientific “Integrated Medicine” idea. This dashes my hopes for the future of SBM in Australia.
Seems to me that recommending unproven CAM treatments would preclude a guideline from being best practice.
Sounds like you guys are doing significantly better down under than we are doing in the states. If it’s only at the point of considering, there’s probably still hope. I can’t imagine how we can get out of this given how entrenched quackademia has become.
I don.y know why they would bundle massage therapy and yoga in the “integrative medicine”… I mean it’s not even medicine! That’s like saying going to the gym to bench-press 315 lbs is medicine.
Yoga is just some form of light exercise and stretching, and massage… Well I’ll take a good massage any day, but I won’t pretend it’s gonna prevent a potential cancer.
[I]These results suggest that if individuals with health concerns, such as low back pain, knew about clinically appropriate complementary therapies they might use them.[/I]
How in the world can woo be “clinically appropriate”?