Abstract
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We propose that it is necessary, but insufficient, to use biomedical standards as the measures by which we judge the outcomes of our work. In addition to providing exceptional healthcare, offering high-quality education, and conducting rigorous science, integrative medicine must compassionately address the needs of all members of society. We advocate for health justice, the imperative that all people have the right to the highest attainable health, that social factors are fundamental determinants of health, and that systems and institutions should support the right to health by providing equal access to compassionate, affordable healthcare. We have a critical opportunity to review the formal scope of integrative medicine to include health justice as a central mission and diversity, equity, and inclusion as core principles.
Ironically, integrative medicine, a field predicated on medical pluralism and diverse approaches to health and well-being, has not completely shed its reputation as elite medicine for the worried well. Historically, folk medicine and ethnomedicine studies in the United States were conducted among marginalized communities—immigrants, people with limited income, and ethnic minorities—to the exclusion of mainstream groups. Until three decades ago, conventional scientific wisdom held that anyone with sufficient financial and intellectual resources would choose conventional (i.e., “the best”) medicine.
More recently, the stereotype of the “typical” consumer of integrative medicine has been transformed dramatically, following several large surveys indicating that complementary health approaches are most common among well-educated, well-off, white European Americans. 1 Integrative medicine has come to be thought of as pricey, nonessential healthcare practices for the “overserved.” The effect of this perspective is that integrative medicine, in both conventional biomedical and popular thinking, has become increasingly decontextualized. The historical and cultural circumstances that form the setting of diverse healing practices are often ignored or overlooked. The historic roots of integrative medicine include ubiquitous treatments that are impactful, in large part, because of their cultural availability and financial accessibility. Examples of these practices include acupuncture serving as “the people's medicine,” herbal medicine's presence in virtually all communities, and the breath as a mindfulness-enhancing tool available to everyone. The reputation of integrative medicine as elite also obscures the growing influence of current organizations, such as Integrative Medicine for the Underserved and the People's Organization of Community Acupuncture, both driven by overt missions to improve access to, including the affordability of, integrative healthcare. 2,3
Given new understandings of both historical developments and contemporary needs, how can the field of integrative medicine meet these societal challenges? We propose a threefold strategy to advance health justice through the use of integrative medicine principles.
(1) Leverage integrative medicine to advance health equity, that is, the attainment of the highest level of health for all people. Skeptics of this approach may note that vulnerable populations are facing life stressors—poverty, food insecurity, and unstable housing—well beyond the scope of integrative medicine. Although integrative medicine cannot directly solve the upstream causes of social inequities, it can contribute uniquely to reducing the burden of disease for those negatively impacted by health disparities. Illustrations of this approach include using acupuncture to improve quality of life and ameliorate pain for patients managing chronic conditions, providing tools to build resilience and health self-efficacy through patient-centered care, and reducing the deleterious effects of chronic stress and trauma through mind–body practices. Integrative medicine can also provide nonpharmacologic options to address the healthcare paradox of millions of people in the United States being overmedicated, but undertreated—a prime example of which is the current crisis created by overreliance on opioids in pain management.
For integrative medicine to achieve its potential, we need to address health equity explicitly through our clinical delivery, educational efforts, and research. Developing sustainable delivery models, such as group-based treatments, to improve access to and affordability of integrative medicine is critical to expanding the reach and broadening the impact and relevance of our field. Educating integrative medicine learners about social determinants of health and structural competency will provide much-needed awareness and skills to address health equity throughout healthcare. Proactively including underrepresented minorities in all phases of integrative medicine research is necessary to increase the generalizability of our evidence base.
(2) Promote an integrative medicine culture that upholds the values of diversity, equity, and inclusion. Only through understanding the cultural and sociopolitical history of the medicines that we practice can we truly value the tapestry of cultures and disciplines that comprise integrative medicine. Simply incorporating diverse cultural healing practices without cultural humility and sensitivity toward our colleagues and patients undermines the integrity of our work. While many practitioners are committed to improving access to integrative medicine, high cost and inadequate reimbursement preclude the appropriate provision of healthcare. Together with an explicit focus on health equity, it is critical to create and foster professional spaces that support diverse patients, practitioners, staff, and learners. This strategy includes, for example, implementing best practices for recruiting and retaining diverse staff and trainees; developing infrastructure (e.g., leadership and committees) to support diversity, equity, and inclusion; and training staff and practitioners to approach every patient encounter with nonjudgmental awareness of cultural and social differences.
(3) Address intrapersonal attitudes, beliefs, and behaviors that perpetuate bias and discrimination. We must also ensure that we continuously strengthen our individual awareness and cultivate our own skills to address bias. Unless we open-heartedly engage in (likely uncomfortable) self-reflection on how we contribute to inequities in subtle and overt ways, our efforts to advance health justice and create a culture of equity and inclusion will be limited. We must be willing to ask ourselves difficult questions (“How do I personally contribute to discrimination, how do my biases manifest, how do I benefit from the existing social hierarchy?”) and, based on our answers, we must accept the challenge of becoming better allies to patients, research participants, and professional colleagues. Tools of integrative medicine are well-suited to this work. Evidence suggests, for example, that mindfulness practices can reduce implicit bias, disrupt racism, and cultivate empathy and prosocial behavior. 4,5
These times of increased political and social divisiveness, amid racial injustice, fears of deportation, threats to affordable care, and catastrophic natural disasters, call upon us to reflect on the meaning, value, and day-to-day impact of the work that we do and the efforts we can make to help one another. What is our obligation to society as integrative medicine centers, integrative medicine professionals, and individuals? How can integrative medicine serve as a force for health justice? As proponents of integrative medicine, we can use our knowledge and skills more effectively to weigh in on critical health equity issues. We must overcome the perceived elitism of integrative medicine and the insularity of academic medicine to develop an inclusive, pluralistic approach to health and well-being. It is high time to make a concerted effort to advance understanding of the role that integrative medicine can play in achieving health justice.