Our Ideals and the Politics of Affirmative Action: Should We Abandon ‘CAM’

A Canadian “CAM” researcher associated with Marja Verhoef, PhD’s highly respected shop at the University of Calgary sent me an email to see if leaders in the Academic Consortium for Complementary and Alternative Health Care (ACCAHC) might be interested in participating in a little research survey project.

The researcher, Isabelle Gaboury, PhD, was using a Delphi Method (1) process to understand how established leaders in “complementary and alternative medicine,” a.k.a. CAM, feel about this term. Is it time to let “CAM” go? Did anyone ever like it in the first place? What would we suggest in its place?

Gaboury had previously secured participation in the survey from the mainly MD leaders of the 45 medical programs that make up the Consortium of Academic Health Centers for Integrative Medicine. This group might be expected to have some shared perspectives. Through ACCAHC, Gaboury hoped to reach a different set of experienced educators and researchers, those associated with the licensed CAM disciplines of chiropractic, acupuncture and Oriental medicine, naturopathic medicine, massage therapy, homebirth midwifery and a couple of related fields.

This subject has been lively since the CAM term was first invented in the early-1990s. Back then, CAM was an ameliorative move from the oppositional U.S. term, “alternative medicine,” used in the U.S. The British term, “complementary” was incorporated. CAM became a drag net to scoop up everything off medicine’s ocean floor that was not conventionally accepted. A huge bolus was created of individual therapies, providers, modalities, cultural practices, licensed disciplines, out-and-out hocus pocus, traditional world medicines and emerging professions.

No wonder the discontent with the term! And yet how strong is the case that we have not yet advanced far enough in our mutual respect to let it go.

Debate over terms at the IOM Summit

Strong opinion over what to call ourselves was front and center in the March 28, 2008 announcement on the Charlie Rose Show that a Summit on Integrative Medicine and the Health of the Public was to take place. A spokesperson for the Bravewell Collaborative that sponsored the historic Institute of Medicine (IOM) gathering quickly set up a barrier at the top of the show. She declared: “This is not about CAM.” (2) This summit would instead be about “integrative medicine,” an MD-led movement to transform conventional medicine and conventional medical education. Indeed, from the looks of the initial planning committee, this term would not have seemed to include any of the “CAM” disciplines. It was only after education of the IOM staff that an ACCAHC representative from the licensed fields was appointed.

The experience leaves a mixed taste. A battle line exists over the extent to which promoters of “integrative medicine” believe that its leadership should include the licensed CAM disciplines. (Many of the MD leaders do, including notably Victor Sierpina, MD, chair, and other leaders of the conventional medical Consortium.)

The subject didn’t go away at the actual IOM Summit, 11 months later, or at the Congressional hearings arranged by US Senators Barbara Mikulski (D-MD) and Tom Harkin (D-Iowa) in that very active February 23-27, 2009 week. Many Summit attendees suggested the field should be called “integrative health care” or “integrative health,” rather than “integrative medicine.” The argument is that these terms are more inclusive and speak to a health-creating, rather than reactive, approach to patients. Others believe that if “medicine” is left on the cutting room floor, integrative practice will never be respected by the leaders of medicine who we need to transform.

Notably, no one was heard arguing much in favor of holding on to the terms “complementary and alternative medicine” or CAM.

Take the CAM out of NCCAM?

The stakes went up following a suggestion from Senator Harkin. Harkin proposed changing the name of the NIH National Center for Complementary and Alternative Medicine to the National Center for Integrative Medicine. Some urged him to amend this: How about the National Center for Integrative Health?

Suddenly, a fiscal note of NCCAM’s $120-million annual budget was attached to our armchair discussion of semantic choices. Is it time to erase “CAM” from its only prominent recognition in a significant government agency? What implications might this have? What’s in a name?

Again, there is an evidence base for concern among the licensed CAM disciplines. When NCCAM was created in 1998, Congress required that at least 50% of the members of the National Advisory Council on Complementary and Alternative Medicine be licensed members of the disciplines NCCAM is charged to explore. In the first years, this was interpreted to mean members of the distinctly licensed CAM disciplines. Ten years later, NCCAM, in their efforts to meet this statutory requirement, is choosing to include as “licensed CAM” political leaders of osteopathy and medical doctors who may use some CAM therapies. Many in the licensed CAM fields do not agree, some vehemently.(3) They see this as an erosion of their position in the integrative research dialogue. The percent of members from licensed CAM disciplines is down to 18% from the 50% many in the CAM fields believe is required.

Should members of these professions be comfortable if we take the CAM out of NCCAM?

Need for affirmative action?

Needless to say, Gaboury’s survey hit a receptive audience when I sent it to ACCAHC list. It wasn’t one-sided. I knew from informal comments and a small e-mail thread that the licensed CAM leaders who responded – and some 40 did – would be all over the map with their thinking.

Some of the most politically savvy were saying whoa, let’s not give up the CAM term. Here is a comment from one of them in an email which I can only use without attribution: “I’m concerned at the talk of phasing out the term CAM, especially as it is usually in the context of replacing it with Integrative Medicine (IM) or Integrative Health (IH), e.g. there were some not too subtle hints of this at the IOM conference. I feel strongly that switching to IM or IH will further marginalize our CAM professions and will place the conventional medicine folks in a stronger position to decide what gets ‘integrated.’ Call me paranoid, but in my view we need ‘affirmative action’ for CAM for a while longer, even as NCCAM moves to more narrowly define rather than to broaden what it considers under the CAM umbrella.”

The argument is that there is value in this continued clustering of professions as CAM and the shared identity of the CAM disciplines as fields that need some special, focused attention, given their historic ostracizing by mainstream medicine. The successful appeal from this set of professions, via ACCAHC, to the IOM for a representative on the Summit’s planning committee is an example of where the CAM grouping was instrumental in insuring inclusion in an otherwise exclusionary integrative medicine discussion.

Developing an “exit strategy”

Bill Meeker, DC, MPH, a leading NCCAM-funded chiropractic researcher and now president of Palmer College-West, spoke to the point via email:”I think that right now we need to keep some ‘affirmative action’ going so that policy makers can’t make it easy to dismiss us. But in the long term we need an appropriate exit strategy. This is a topic that should be addressed but rarely is. I don’t have any particular insights, however. Exits are going to be slow evolutionary affairs, I suspect.”

Most of us like the idea of our inclusive ideal, of one big tent, whether it is called integrative medicine, or integrative health or integrative practice or just good medicine.

This is integration at its aspirational best. We seek the Quixotic star of mutual respect, of actual clinical teams continuously declaring for the best interest of patients and leaving the economic self-interests and cultural biases of our guilds at the door. Our natural desire is to discard terms of division, such as CAM.

But to the extent there remains discrimination against the CAM professions, can leaders of CAM professions stop such practices by diminishing the focus which may come from maintaining this identity as CAM? Is this denial of the divisiveness that remains real?

United States Chief Justice John Roberts, writing on race recently, argued that “the way to stop discrimination on the basis of race is to stop discriminating on the basis of race.” (4)

Whatever one thinks about the status of race relations in the U.S., I don’t think medicine and health care are ready for Chief Justice Roberts’ prescription. Meeker is on to something. Let’s develop an “exit strategy” – an integrated plan to be conscious, open, respectful of differences, and of history, and plan our way into unity. To exit this acknowledgment of actual distinctions is to deny the politics that continue to inform the movements for integrative medicine, integrative health and integrative practice.

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