Health disparities research and the mainstreaming of "integrative medicine"

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 [51]. 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 [54] 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.