Britain’s Guidelines Promoting Home Birth Continue to Gain Attention in the United States

Wall Street JournalA recent article in The Wall Street Journal, New Support for Home Births, adds fire to a the most significant boost homebirth advocates in the Western world have seen in recent years. Last spring, the British National Institute for Health and Care Excellence (NICE) issued guidelines indicating that “home births are safer than hospital births for women who are having their second or later child with a low-risk pregnancy.” This was followed in the United States by commentary from Harvard professor Neel Shah, MD, (pictured) in The New England Journal of Medicine suggesting a reconsideration of the role of homebirths in the United States: “What was so paradigm-shifting about the NICE guidelines [was] they emphasize the dangers of over-intervention. That’s huge.” Shah concluded, “There are lessons to be learned from the British system. The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.” The writer for WSJ notes that a large Canadian study a decade ago of homebirth via midwives in British Columbia found parallel outcomes as those supporting the NICE guidelines.

Neel Shah, MDThe WSJ article quotes a representative of the American College of Obstetricians and Gynecologist (ACOG) who attributes ACOG’s continued opposition to homebirth, despite the evidence from the United Kingdom, to differences between the respective systems. In the United Kingdom, midwives are usually employees of the national healthcare system. They are built-in members of teams. Hand-offs from home to hospital are fluid. The head of midwifery at the Royal College of Midwives in London is quoted as speaking to this importance: “One of the riskiest times for a woman isn’t when things are going normally and she’s in her chosen place, but the point when she needs to transfer. Handover points are where things go wrong.”

Comment: My spouse, Jeana Kimball, ND, LM, MPH, was educated and licensed as a midwife in the early 1990s. She arranged to have training in Holland and in the United Kingdom, where midwifery services are valued—and indeed, a prideful treasure in the former and the subject of a successful TV series in the latter (see image). She also experienced births on the Texas-Mexico border and in Seattle, where they were not then embraced as part of the system.

Call the MidwifeIn Seattle in the pre–“integrative health and medicine” days, only one obstetrician in the greater urban area respectfully collaborated with the area’s licensed midwives. If transport was required to most other obstetricians in the same facility, or to any other location, the interprofessional experience was proof positive of a system that was the opposite of patient-centered. With no formal transport relationship, mothers on the very verge of delivery had to be dropped off at ERs. The midwife was typically not allowed to accompany the laboring mother. If she was, it was only as a friend and not as a professional. The midwife’s experience was routinely disdained and disregarded. In some cases, patients were routinely shuttled miles away from their nearest delivery hospital so that a friendly hand-off could be managed with the single, open-minded obstetrician. The risk to the patients wasn’t due to the lack of communication between the licensed midwives and their local hospitals. It rested squarely with the antagonism of the obstetricians.

There is good news in this personal story here in Seattle. Three years ago, my spouse accompanied a close friend through a birthing process in a comfortably appointed hospital wing staffed by nurse-midwives in a hospital she knew well. She recalled her “PTSD” on walking those halls, remembering the interprofessional mistreatment and concern for the mother-child who was her responsibility and then suddenly utterly out of her hands. Here she was invited fully into the process. She recalled the experience as profoundly healing. Change is possible. While most of the rest of the country is likely more like Seattle 20 years ago, change is possible.

The importance of this article is its location: a source of information for people who are expected to care about business and costs. Moving US birth policy toward the NICE guidelines can be a significant money saver. Given the Canadian and British data—and even the experience in Washington States as reported here in the Huffington Post—this may be one of those places where health and medicine is too important to leave to the doctors.


Harvard Team Finds Mind-Body Treatment Created 43% Reduction in Use of Healthcare Services

Relaxation Response Resiliency Program The title of the open access article at PLOS from a Harvard Benson-Henry Institute mind-body team is “Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization.” The team took a retrospective look at healthcare utilization of more than 4000 patients in the Relaxation Response Resiliency Program (3RP) and compared them to a usual care cohort. The intervention group was slightly more female, Jewish, or Asian vs Christian or black, better off economically, and less likely to include veterans.

The finding: “At one year, total utilization for the intervention group decreased by 43%, clinical encounters decreased by 41.9%, imaging by 50.3%, lab encounters by 43.5%, and procedures by 21.4%.  Measured by dollar, reduction was estimated as “on the order of $2360/patient/year.” The authors note that “this reduction is on the order of that found by 3 other groups in “other similar time-limited interventions.” They note that “mind body medicine interventions are inexpensive relative to the cost of an emergency room visit, a hospitalization or even other complementary and alternative medicine (CAM) therapies.”

Comment: These are huge numbers. I recall a co-panelist at the 2014 10th Annual Healthcare Workforce Conference of the Associated of American Medical Colleges, Lloyd Michener, MD, MPH, commenting that if medical leaders want to “bend the cost curve,” the easy money is not going to come from usual tertiary care quality initiatives. Rather, huge dips in utilization come via initiatives involving community health workers, social workers, and other strategies that connect clinical care with people in their communities.

Herbert Benson, MDThe practitioners whom Michener’s work highlights, like the therapeutic approaches explored by the Harvard team, come from the lower rungs of the medicine’s totem pole. The Red Adair heroes needed to stamp out the fires of the US cost crisis are neither high-end specialists nor products of the ‘omics revolution. The 3RP work is based on group-delivered services first researched by Herbert Benson, MD, (pictured) 4 decades ago and researched by Benson and Eileen Stuart, RN, PhD and others starting in the 1980s.

When I see solutions coming from turning what medicine typically values upside down, I think of the Biblical adage that “the last shall be first, and the first, the last.” I also think of that children’s book character, The Lowly Worm! The Wikipedia bit on this character says, “Lowly was (the author’s) favorite fictional creation.” Is there a better strategy for cost-savings than a massive, public health–styled application to all of the skills from this and other lowly, relationship-based, mind-body treatment?

Chinese Success Since 1996 in Globalizing Traditional Chinese Medicines Examined

WJTCMIn a timely theme following award of the Nobel in Medicine to research Tu Youyou, the World Journal of Traditional Chinese Medicine (WJTCM) has recently published an analysis of the success of the Chinese government’s effort, since 1996, to globalize acceptance of TCM. The authors note that TCM in its “broad sense” involves the philosophy and integration of all of TCM, including exercise, diet, foods, acupuncture, and health promotion. The interest in the article is globalization “in a narrow sense, refer[ing] to the successful registration of TCM products as prescription drugs in the drug regulatory agencies” of other countries.

They document some headway. The US Pharmacopeia has adopted a few TCM monographs, and “over 45 TCM quality monographs were recorded in the European Pharmacopoeia with 20 more in progress.” The Netherlands has registered a product, Diao Xin Xue Kang (pictured)—the first to gain such status in Europe. Others are in the process elsewhere. “So far,” however, with nine applications for recognition in the United States filed and in process, “there has been still not any TCM product authorized as a drug by the FDA regardless of a few TCM products in phase III or phase II clinical trials.”

Diao Xin Xue KangThe authors conclude that the Chinese government underestimated what globalization would take. This included background research in the basic areas of proving safety, efficacy, and quality. A better coordinated and more fully invested relationship between government, industry, and entrepreneurs is recommended. They suggest also that the Chinese pioneers in this realm need to be better schooled on how to work in the US and European systems. Without these escalations in the Chinese campaign, despite “long-term clinical practice in China [regulation] becomes a highly difficult and even unpractical matter” in the United States and Europe. The authors are each from the Institute of Materia Medica at the Chinese Academy of Sciences in Shanghai. WJTCM is sponsored by the World Federation of Chinese Medicine Societies (WFCMS).

Comment: I had hoped, on seeing the title of the piece—“Current Status and Future Perspective in the Globalization of Traditional Chinese Medicines”—that the authors would also concern themselves with the “broad” view of TCM. There is no mention of acupuncture at all, except perhaps as an “alternative medicine” that is part of TCM. A review of the global outcomes of the intentional investment of the Chinese government in acupuncture practice would reveal much greater headway. Yet while China can get cultural hegemony points via exporting acupuncture as TCM, the procedure’s non-patentability means that there is little attraction in that strategy for China’s booming industrialists.

Sustainability Issues and Dietary Guidelines: What Role for Integrative Organizations?

SustainabilityShould governmental dietary guidelines – and thus the policies that may follow – concern themselves with the effect of food sourcing on the environment? The global environmental lobbying group National Resources Defense Council and others advocated this position during the build up to the 2015 re-write of such dietary recommendations in the United States of America.

The argument gained enough backing amidst reportedly 29,000 public comments on the topic to have warranted a January 2014 presentation before the Dietary Guidelines Advisory Committee. The presenter, Kate Clancy, begins noting possible “Negative long-term impacts on food security and resilience” that she believes merit consideration. She includes: farmland loss, especially at the regional level; soil quantities (erosion, silting); soil qualities (lower tilth, altered soil microorganisms); water quantities (aquifer depletion); water and air qualities (dead zones); energy resources (fertilizer production, air-freight); climate change (greenhouse gases, water effects, planting zones); and biodiversity – plant, animal, and marine. Clancy then proceeds to answer the question: “What pattern of eating best contributes to food security and sustainability of land, air, and water?”

NRDCAdvocates of including sustainability consideration counter anticipated opposition with a legal opinion of the appropriateness in guidelines that is available here. The direction was successfully incorporated in the draft section of the Guidelines (Part D, Chapter 5). Here are two tastes “A diet higher in plant-based foods, such as vegetables, fruits, whole grains, legumes, nuts, and seeds, and lower in calories and animal-based foods is more health promoting and is associated with less environmental impact than is the current U.S. diet.” In addition: “Current evidence shows that the average U.S. diet has a larger environmental impact in terms of increased greenhouse gas emissions, land use, water use, and energy use, compared to the above dietary patterns.”

Despite the evidence, the US Secretary of Agriculture, Tom Vilsack, and Sylvia Burwell, US Secretary of Health and Human Services, each argued, according to this account at Yahoo News, that sustainability considerations are outside the scope of the panel’s authority in setting guuidelines. This piece at Climate Progress makes clear that the agency heads were bowing to industry pressures.

Comment: Many will say that dietary guidelines are already so controversial and conflicting that this request only adds another layer of confusing complexity. Superficially, this would seem to be the case. Yet at the same time, sustainability creates a referential values base for other debates. The issues articulated by Clancy and promoted by the NRDC provide terrain that, in and of themselves, move toward optimal guidelines. With the globalization of food, these choices are heard round the world.

This food-sustainability link is a movement that is a good fit for the integrative health and medicine community to embrace, and support. What whole system-oriented person or organization would not affirm these connections? Credit the professionals who brought sustainability issues into this debate. Where are you and your organization on this?

Aid as ObstableSecretaries Burwell and Vilsack proved unwilling, at this time, to take off the reductive blinders that channel answers to present food policy. In the USA, the linkage would have been better vetted through the National Prevention, Health Promotion and Public Health Council. This Council was established under the 2010 Affordable Care Act. That new agency was created to inject more systemic thinking into the silos of decision processes in separate education, health, environmental, transportation and other departments. The Council appears to have been asleep at the wheel on this one.

A final note, perhaps too controversial even for the NRDC. Anyone familiar with Francis Moore Lappe’s pioneering food aid research in the 1970s will know that there is another value of interest to this debate not yet on thetable. In such works as Aid as Obstacle (pictured), Lappe captured the disruptive impact of transnational food policy in the USA and abroad. Two interesting questions emerge. Is democracy or at least “political process” an issue of concern when we think of sustainability? Secondly, if so, what food choices favor the development of democracy? In the USA it is said that health care is local. It’s time to take a strong stance that this base of good health – food choices – is best local as well.

Quick Links to Global News in Traditional, Alternative, and Integrative Health and Medicine for September 2015

Quick linksThis Global Integrator monthly feature shares 97 developments in traditional medicine and alternative and integrative health during September 2015. Articles coming out of Africa Traditional Medicine Day in late August dominated news in early September (and led to this Global Integrator Blog summary article). Major regulatory move: The Zambian cabinet has approved a bill to regulate traditional medicines. Multiple stories this month on the Chinese government’s diversified investment in global expansion of TCM, from nearby Macao to Australia to Malta, Malaysia and Czechoslovakia.Robustr growth of AYUSH practices in India predated the government’s move establishing adepartment in late 2014, given the 50,000 new practitioners in 2013-2014. Much, much more.

If you wish to see developments in “integrativehealth and medicine” in the United States of American these are separately reported here.

Nobel Prize Based on a Traditional Chinese Medicine Text: Themes from the Robust Media Coverage

Chinese scientist Tu YouyouGlobal traditional medicine news is overflowing with multiple reflections on the meaning of the award of the Nobel Prize in Medicine to Chinese scientist Tu Youyou. The award followed the discovery by Tu and her team of the usefulness of a drug based on sweet wormwood (Artemesia annua) to combat malaria. The discovery has saved tens of millions of lives. Artemisinin-based drugs are still “routinely used by pharmaceuticals giants like Sanofi and Novartis in the fight against malaria.” All the Nobel awards, as reported here at Nature, stimulated dialogue in the Twittersphere, yet it was Tu “who inspired much of the online discussion.” Here are some of the intriguing themes in these media accounts, with some commentary built in. The announcement of the award is here.

A Turning Point for Traditional Medicines?

Traditional Chinese Medicine Wins Nobel Prize 2015One of the themes is whether this acknowledgement of the power of an herb will be part of a turning point for traditional medicines, from China and elsewhere. In Fortune, a writer speaks to the surprise with which the award was greeted: “Traditional medical knowledge anywhere in the world has not even been on the radar for Nobel Prize prospects. Until now, that is.” Then the question: “So how should we interpret this arguably seismic shift in international attention on traditional Chinese medicine?” In another piece the writer asks, “Traditional Chinese Medicine Wins Nobel Prize 2015; Western Science Ready to Embrace Alternative Medicine?”

WormwoodMost people raised in a medical culture dominated by big pharma and surgery are disconnected from awareness that a significant percentage of drugs are based on, or synthesized from, natural agents. The Nobel to Tu is a blunt lesson on the lifesaving power of one herb, processed correctly. Members of the Nobel committee shared views—see video here—that it is the potential power of traditional medicines as paths to new drugs that was their interest, rather than as herbal medicines themselves. A writer at The Conversation is cautious: “So can we hope to find new remedies by studying ancient medical texts, as Tu did so successfully? The answer to that question is complex and unfortunately cannot be an unmitigated, resounding ‘yes’.” Time will tell whether this highlighting of a traditional medicine might, for instance, boost interest in the four African herbs that former US Ambassador to the United Nations Andrew Young was urging exploration at this recent press conference.

Victory for China in its Global, Cultural Exportation of TCM

Chinese flagReaders of the Global Integrator Blog will know that medial evidence of the Chinese government’s commitment to exporting their traditional medicine appears routinely. In recent weeks, for instance, stories emerged of Chinese government-backed initiatives in Australia, Malta, Central Europe, multiple nations in Africa, and elsewhere, about this medico-cultural-industrial campaign. The award of the Nobel well certainly be a door-opener for the Chinese, where parties are wary, and a likely booster for initiatives already underway. The South China Morning Post characterized the award as “giving traditional Chinese medicine a shot in the arm.”

While lobbying is well known to happen for the Nobel Peace Prize, I have not seen any report that explores the extent to which China may have actively lobbied for Tu’s award. Given the importance of their global TCM campaign, that would not be surprising. The Telegraph of London quotes one Li Chenjian, a vice provost at Peking University: “This is indeed a glorious moment. This also is an acknowledgement to the traditional Chinese medicine, for the work began with herbal medicine.” An Indian science writer notes, “Chinese premier Li Keqiang has quickly positioned the Nobel prize as reflecting China’s ‘comprehensive national power and the uninterrupted rise of China’s global influence’.”

The Multiple Firsts in this Nobel Award: What, No PhD?

Much has been made of the award being the first Nobel to a Chinese woman, and the first award of a Nobel in Medicine to a Chinese national. The award was also remarkable for its elevation for a lowly-herb amidst the rarified “omics” in the modern era of genetic exploration. It is also likely the first award for a contribution to scientific advancement from Mao’s China.

Chinese scientist Tu YouyouYet perhaps even more remarkably, the award went to a person who does not have a doctoral degree. A Japanese account notes that Tu Youyou “is a ‘scientist with none of three key factors,’ namely the title of ‘master scholar’ presented to a scientist of highest caliber in China, doctoral degree and experience in overseas study.” There has been reportedly feverish interest in Tu in China. Her given name “Youyou” reportedly “derives from ‘phrases’ in the Classic of Poetry, which means ‘dear feeds on grass in the field, shedding tears.’”

Tu, however, as one writer asserts, “embodies, in both her history and her research, what I call medical bilingualism—the ability not only to read in two different medical languages but to understand their different histories, conceptual differences, and, most importantly for this unexpected news, potential value for therapeutic interventions in the present.” Remarkable at every level. A two-minute video of Tu is here. A look at her past is in this article entitled “The home, the herbalist and the high school: Feverish interest in Nobel Prize-winner Tu Youyou’s background.”

A Product of Maoist Science Stimulated by a War in Vietnam; Global Education Later

Multiple accounts place this increase of knowledge squarely in the zone of war-time discoveries with peace-time applications. Mao had a war in Indochina on his hands and “malaria became the number one affliction compromising Vietnamese soldiers’ health.” In this article, the writer describes how Mao initiated a covert operation entitled Project 52 that was “headed by a young Chinese medical researcher by the name of Tu Youyou.”

Interestingly, “the Chinese conditions prevented these discoveries from being reported beyond the Chinese language journals” because of the wartime environment. The breakthrough for the world came in 1979 when the China National Committee of Science and Technology, in Tu’s recollection, “granted us a National Invention Certificate in recognition of the discovery of artemisinin and its antimalarial efficacy.” Two years later, at the fourth meeting of the Scientific Working Group on the Chemotherapy of Malaria, in Beijing, sponsored by WHO and World Bank among others, the discovery reached the outside world.

The Remarkable Path of Discovery in a 1700 Year of Text

Herb posterTu’s Chinese team reviewed “systematically screened the well-documented texts and sifted through more than 2000 herb preparations of traditional Chinese herbs and from these identified 380 herb extracts and tested them on mice being infected by malaria parasites.” Sweet wormwood was a common denominator in many.

The breakthrough for the researchers came when Tu encountered the medical text of a fourth-century Chinese physician and alchemist named Ge Hong (circa 283-343). Ge Hong briefly described his primitive means of processing the herb: “A handful of qinghao immersed with 2 liters of water, wring out the juice and drink it all.” Tu Youyou comments: “This sentence gave me the idea that the heating involved in the conventional extraction step we had used might have destroyed the active components, and that extraction at a lower temperature might be necessary to preserve antimalarial activity. Indeed, we obtained much better activity after switching to a lower-temperature procedure.” Tu has reportedly “always maintained that she drew her inspiration” from Ge Hong.

Wake Up, India (and Japan)

A short article in The Hindu begins, “The success story of Tu Youyou, whose work was based on herbal pharmacology of ancient China, should serve as a spur to researchers in Indian traditional medicine.” Another Indian writer complains that “each time India takes forward her traditional knowledge into the realm of science, there has been a concerted effort from the Indian media to ridicule and negatively portray it.” An Indian writer suggests that the message for India is to link its traditional practices with modern sciences.

Msp of IndiaAnother Indian writer uses the prize to make a “call for unification” of India’s distinct traditional system. He is prompted to an unfavorable comparison of India to what he found in visits to China: “In China, one can see two hospitals standing side by side. One would be practicing traditional medicine while the other would provide modern treatments. After the disease is diagnosed, traditional treatments get more preference. Allopathy is tried as a last resort. Patients are given the option to select his or her treatment mode and most would opt for traditional treatments.” He adds, “Let the achievement of Youyou invigorate the traditional system of medicine in India.”

The Japanese account, noted above, looks at Mao’s plan with TCM as compared to the way Japan responded to the West’s medicines: “At the first national health and hygiene meeting in 1950, late Chinese supreme leader Mao Zedong established the principle that ‘Chinese medicine must combine with Western medicine’ as one of the four principles in health. The measure is contrasted with Japan’s decision to discard traditional medicine when it introduced Western medicine through the Meiji Restoration.” Notably, the Indian writer above similarly opines that the “Indo-phobe” perspective from India’s Nehru era was at least partly responsible for retarding the advance of traditional medicine in his country.

Meantime, in Jamaica, this article characterizes the Nobel as “encouragement for local scientists.” For instance, “We see similar research being done by the likes of Dr Henry Lowe, who, along with his team over the past 10 years, has made significant headway in the battle against cancer and other chronic diseases through the development of therapies from Jamaican plants such as ball moss.”

Conclusion: A Collision in Time, Space, Politics and Culture

Map of JapanThe elements of this story are outrageous: a war in Vietnam, Maoist medicine, a well-known herb, a 1700-year-old “recipe” and a researcher with relatively little formal education but with a curiosity toward and grasp of two medical cultures. One writer at ExtremeTech characterized the breakthrough of Tu and her team this way: “An ancient version of science managed to find the general location of this drug, but the modern version of science is what nailed it down.” Notably, it was also an ancient means of extraction that allowed the modern scientists to release the potency of anti-malarial properties.

Ray Yip, the former China director for the US Centers for Disease Control and Prevention and the Gates Foundation quipped as follows in this account: “The impact on traditional Chinese medicine could also be mixed, My. Yip said. While most advocates would welcome the exposure, it would irritate the purists, he said: ‘A lot of Chinese traditional medical practitioners actually hate this approach of extracting chemical compounds from a plant. They believe you need to take the herbs all together.’” The discovery may never have been made were the research direction left to such purists. Yu’s award honored a basic form of medical integration.