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Political-Economic Issues in Whole Systems Research Revealed by JACM Roundtable PDF Print E-mail
Written by John Weeks   

Political-Economic Issues in Whole Systems Research Revealed by JACM Roundtable

Summary: The Journal of Alternative and Complementary Medicine convened an international roundtable to explore the "methodological" challenges in the whole systems research strategies which respect the whole of what human beings are. Measuring economic outcomes was recommended by George Lewith, MD, PhD, and others. Percolating through the discussion are suggestions of the extent to which political-economic biases in the conventional research establishment are arrayed against whole systems research ever having a meaningful effect on health care. A political solution involving a focused funding campaign to US Senator Tom Harkin, the Congressional CAM Caucus and the 110th Congress is suggested.
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ImageTired of whole person and holistic practices being held to reductive standards that neither research actual practices nor use measures that reflect what complementary and integrative clinicians and their patients say they are accomplishing?

If so, you may be intrigued by the roundtable discussion convened by the editors of the Journal of Alternative and Complementary Medicine (JACM) in their November 2006 issue. (1) Among the comments was this pithy critique,
by participant Iris Bell, MD, PhD, of the limits of conventional research design:
" ... We may or may not be able to look at causality, and placebo designs are trying to focus on the specific causal role of a component of an intervention and the outcomes, and those may or may not be the relevant questions."

"If it is cost effective to provide a whole system and it's safe to provide a whole system, it may be reasonable to start there with well-designed observational studies."

CHarles Elder, MD, MPH, moderator
The roundtable was convened subsequent to a forum on whole systems research at the North American Research Conference on Complementary and Integrative Medicine in Edmonton in May of 2006. (Related Integrator article here.) The Edmonton panel was sponsored by the International Society of Complementary Medicine Research (ISCMR). Moderator Charles Elder, MD, MPH, characterized that exchange as having "generated considerable activity and excitement both at the conference and afterwards." The roundtable was entitled "Methodological Challenges in Whole Systems Research."

Elder, whose whole systems look at Ayurvedic medicine in diabetes care was featured in this Integrator article, kicked off the discussion asking for "the most important methodological issues facing whole systems research." A sample of the pot pourri of responses includes:

  • "One of the gifts that studies of alternative systems can bring back into biomedicine is: what patient-practitioner relationships, what qualities of a practitioner, what qualities of a setting, what qualities of a patient might allow .. positive outcomes to occur." (Ritenbaugh)
Roundtable Group

Charles Elder, MD, MPH

Mikel Aiken, PhD
Iris Bell, MD, PhD
Vinjar Fonnebo, MD, PhD
George Lewith, MD, PhD
Cheryl Ritenbaugh, PhD, MPH
Marja Verhoef, PhD

  • "It would be wonderful and very powerful to have economic components so that you can look at the cost-effectiveness of the intervention." (Lewith - bold added)
  • "In looking for innovative designs we can learn from (nursing, public health and psycho-oncology) and, maybe, move jointly forward." (Verhoef)
  • Link with "a growing, yet young science that has been called complex systems science, or network science." (Bell)
  • "This concept of individuality .. pervades whole systems research. It is a difficult problem as it has been considered 'noise' within biomedical research yet it is central in most alternative medicines." (Ritenbaugh)
  • Explore how "when people begin to feel they understand their illness, it has meaning to them." (Lewith)
  • "The more we talk, the more I feel that we need to step back a bit from the (randomized controlled) trial situation and try to understand what's going on." (Fonnebo)

Interwoven throughout the issues are a series of political-economic-spiritual issues that have less to do with proper methodology than the challenges of selling the work into the dominant, reductive research community.

  • "It's a change of consciousness debate rather than a debate about something that's completely new." (Lewith)
  • "Some of the things we are talking about requiring a certain amount of adventurousness or bravery, both in terms of designing studies and then getting the results published." (Aicken)
  • "This is a challenge of changing someone's mind. They have so painfully adopted, over some decades, (their) way of only trusting randomized clinical trials ... (We) need to influence them by slowly and deliberately tempting them into thinking differently, and that's why I think that we will not accomplish it with the rational mind." (Fonnebo)
  • Image
    Iris Bell, MD, PhD
    "So that's something we need to be conscious of, the different biases that operate in publishing in CAM than in other fields." (Ritenbaugh)
  • "The challenge is: How do you get these things funded? Because you have to change ... people's mindsets at least a little to get them to fund it in the firts place. So, it's a circle. Where do you break into a circle? It's so hard." (Aickin)
  • "Maybe we need to do this in a very deliberate manner." (Verhoef)

At the end the group acknowledged the pleasure in how quickly they had developed their whole systems caucus within the larger research endeavor. Said Bell: "It is an astonishing phenomenon that this has become such an international collaborative effort so quickly." She believes this may speak to a "universal appeal" to people working in these areas.

Lewith articulated a think globally, act locally strategy:
"We need to work internationally to persuade funders but we probably need to work, initially, locally and nationally to develop clinical trial methodology while continuing to communicate."

Comment: The discussion was given the research wonk title of "Methodological Challenges in Whole Systems Research." GUaranteed to think it had no meaning to most of us.

A more fetching and perhaps appropriate title might have been "Political Economic Challenges in Whole Systems Research." As noted, virtually every methodological issue is attached to a cluster of political-economic and even spiritual issues. The methodological is linked to the political-economic. Without funding, there is no research. Even with completed research, biases against whole systems methodology may be consciously or unconsciously barred from acceptance into conventional publications. Without publications, there is no respect. Strike a blues chord. As Mikel Aiken, PhD, said:
Where do you break into a circle? It's so hard.

A Way Out of this Blues

philanthropists need

to step into the void
left by the predilections
of the leaders of
the research

establishment for
they know over
what we need.

This will  allow
researchers to make

a living at the kinds of
studies which respect
whole human beings
the whole systems
that are
oriented to
lowering the
costs of poor health.

Otherwise, friends,
we're destined to keep
strumming the can't-

Here is a way out of this blues.

  • First, admit that whole systems research is virtually powerless against the depth of the political-economic bias against this paradigm shift in research funding and publication. Like the beginning of a 12-set program ... 
  • Explore where you have friends. Lewith guides us: Build in the economic measures.
  • Virtually all whole systems advocates believe that proper application of their system with help reform the cost crisis in health care. Own this claim, and go after it.
  • Develop a cost-savings based case for the need for funding of whole systems and whole practice research. Find interested allies among corporations and governments who are payers, distraught by where reductive practices have brought us.
  • Go, if you are working nationally in the United States, to the CAM Caucus of the upcoming 110th Congress and tell US Senator Tom Harkin that you need to have Congress mandate a focused piece of the NIH National Center for Complementary and Alternative Medicine (NCCAM) budget to fund whole systems and whole practice research. Make the case that this is the most expedient path to finding benefits of complementary and integrative providers and approaches for the nation's cost crisis.

Ironically, whole systems research is already in the NCCAM strategic plan. But we've yet to see a whole systems initiative funded. What's the delay? (See related Integrator article.)

Instead, reviewer bias against whole systems and against whole practice methodology shackle the advance of the field. Researchers who are drawn to whole systems research will, to get funded, abandon their passions for less worthy proposals that please the masters of an old but powerful paradigm which happens to hold the purse strings.

Credit the International Society for Complementary Medicine Research and the Liebert Blue Journal for focusing on this critical topic. Now Congress, philanthropists and progressive foundations need to step into the void left by the
predilections of the research establishment for what it already knows over what we as a society need. The dominant research community, left to its own devices will, well, favor its own single agent devices.

Funders must provide the wherewithal which will allow this and the next generation of researchers to make a living on the kinds of questions which respect whole human beings and utilize the whole systems that are oriented to lowering the global costs of poor health.

Otherwise, friends, we're destined to keep strumming the can't-get-out-of-this-circle blues.

Thanks to Jackie Wooten for arranging a complementary online subscription to JACL. Subscriptions are available to JACM by clicking here. The article is Elder, et al, Methodological Challenges in Whole Systems Research, JACM, Volume 12, Number 9, November 2006, pp. 843-850.

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