SEVEN CORE PRINCIPLES OF
INTEGRATIVE MEDICINE
Seven core
principles of integrative medicine, proposed individually by the author previously,1-7 are brought
together to create a conceptual framework for the clinical practice of integrative
medicine. This will also address the issue of Whither Integrative Medicine? raised
recently in The Journal of Integrative Medicine.8 Those seven principles are: (1)
the principle of empiricism; (2) the principle of integration; (3) the principle of
integrity of cellular and tissue ecologic relationships; (4) the principle of
physician-patient reciprocity; (5) the principle of spontaneity of oxidation; (6) the
principle of spontaneity of healing; and (7) the principle of spiritual surrender.
1. The Principle of Empiricism
What is empiricism in medicine? It is a scientific discipline that concerns itself with
purity of clinical observations concerning the sick. Medical empiricism properly
recognizes the absence of experimental validation for its observations when such is the
case, but without suffering doubt about the validity of its observation. It should be
acknowledged that clinical associations in medicine have mostly preceded the establishment
of experimental evidence for the principles that underlie them, just as theorists
generally worked out the principles of electromagnetism after the inventors' work was
completed in the nineteenth and early twentieth centuries. However, experimental science
does catch up with the science of empiricism. I illustrate this principle with three
simple examples:
First, many African tribes empirically recognized association between malaria and
mosquitoes long before the Italians and the English insisted it was caused by bad air (mal
aire) of Italian swamps.9 And that was long before the malverdana parasite was identified.
Second, for decades all over the world,
general practitioners empirically administered injections of vitamin B12 (but not of
vitamins C or D) for their recognized value in relieving fatigue despite the ridicule of
academics. A spate of recent studies have conclusively demonstrated the value of this
vitamin for a variety of neuropsychiatric and disorders associated with fatigue.10-13 At the
Institute, the author and his colleagues have observed greater benefits with larger doses
of this vitamin (up to 20,000 mcg) in patients with fibromyalgia, CFS, chemical
sensitivity, Alzh-eimer's disease, and dementia who suffer from severe cognitive
difficulties.
Third, the efficacy of intravenously
administered hydrogen peroxide was empirically recognized.14 The author refrained from
using this therapy for his patients with fibromyalgia and chronic fatigue syndrome on the
ground that hydrogen peroxide is a potent oxidant and that ample clinical and experimental
evidence clearly established those syndromes to be related to accelerated oxidative
molecular injury.15 However, his recent high-resolution, phase-contrast studies of freshly
prepared peripheral blood samples led him to recognize the paradox of an in vitro oxidant
serving as an in vivo antioxidant.16 Now, the author and colleagues frequently employ hydrogen
peroxide therapy with good clinical results in a host of patients with accelerated
oxidative molecular injury.
2. The Principle of Integration
In clinical medicine, the principle of integration requires that the practitioner
integrate in the care of the patient all that is safe and effective without
subservience to one or more schools of medical thought. It is one of the profound ironies
of our time that the truth and relevance of this simple - and all too self-evident -
principle has escaped the main physician body for so many decades. This principle holds
that all outcome studies must assess the efficacy of integrated protocols in their
entirety and not of individual therapies. This is a point of crucial importance.
Empirical experience clearly demonstrates that clinical outcomes are far superior when the
benefits of individual therapies are complemented by other therapies. The true benefits of
integrated protocols far exceed the sum of the components therapies.
In the United States, the principle of integration has largely been ignored at an enormous
cost to the sick. A critical issue never addressed in the prevailing pharmacologic model
is the inappropriateness of prescribing four, five, or more drugs concurrently, and for
years, when the drug combinations used have not been evaluated even for months. No one can
testify to the safety of such drug regimens in their entirety.
Two recent studies are cited
below to define the magnitude of that problem.
The first study reported the clinical
efficacy of an integrated program for managing patients with advanced coronary artery
disease. The program emphasized the role of all elements that improve rheologic
characteristics of blood and reduce or prevent oxidative coagulopathy in circulating
blood, including self-regulation for stress control, optimal food choices to prevent sugar
overload and consequent hyperinsulinemic state, ample supplementation with antioxidant
nutrients, herbs to restore damage to the bowel-blood-liver ecosystems, noncompetitive
exercise, and EDTA chelation therapy. In a series of 26 patients with failed coronary
bypass surgery, angioplasty and multiple drug therapies, complete control of symptoms and
discontinuance of all drugs was achieved in 61%. In another 17%, symptom control and drug
dose reduction of over 75% was reported.17 In the second study, by contrast, a non-integrative management
plan focusing on coronary bypass surgery and angioplasty for patients hospitalized for
acute coronary syndromes actually showed that such procedures increase the odds of
death as compared to conservative management.18 Consider the following quote from the editorial published in the New
England Journal of Medicine commenting on that study:
With remarkable clarity and consistency, all four studies show that routine angiography
and revascularization do not reduce the incidence of nonfatal reinfarction or death as
compared with the more conservative, ischemia-guided approach. In fact, in the VANQWISH
study of patients with non-Q-wave infarction, the aggressive strategy [which these
investigators call "invasive"] was associated with increased mortality during
hospitalization, at one month, and at one year.19
3. The Principle of Integrity of
Cellular and Tissue Ecologic Relationships
A macroecologic tissue-organ model of the health-disease continuum (the Pyramid of Trios
of Human Ecosystems) based on a microecologic cellular model of illness (the ORPEC state)
was recently proposed.16 In this model, the central roles of oxidative coagulopathy
involving all elements of the circulating blood and accelerated oxidative injury to
3M ecologies (membrane-matrix-mitochondria) in the pathogenesis of diverse chronic
nutritional, autoimmune, ecologic, degenerative, and malignant disorders. That clinical
model is especially pertinent to such entities as fibromyalgia, chronic fatigue syndrome,
multiple chemical sensitivity syndrome, Gulf War syndrome, and severe but hard-to-define
and indolent autoimmune disorders. It was proposed that the common denominator among all
such clinical states is accelerated oxidative molecular injury which results in oxidative
damage to enzymes involved in oxygenative, redox, acid-base, and detox pathways.
The essential strength of the Pyramid of
Trios is that it focuses on: (1) a need for ecologic thinking that extends far beyond the
limited notions of diseases as defined by microscopic study of tissues after they
have been injured; (2) a model of living ecosystems that emphasizes relatedness
among the various body ecologies; and (3) the essential role of the base trio of
the bowel, blood and liver in the integrity of human defenses. The clinical validity of
this schematic model has been demonstrated.17,20
4. The Principle of
Physician-Patient Reciprocity
What was the most frivolous of all admonitions given during his medical school years? the
author sometimes wonders. There were so many. For instance, professors often insulted hakims,
herbalists of Pakistan, for their fixation on the bowel for problems of the head. Now, of
course, the author recognizes the central role of altered states of bowel ecology in the
pathogenesis of headache, cognitive disorders, and encephalopathy-like symptoms in
patients with fibromyalgia, chronic fatigue syndrome, Gulf War syndrome, and chemical
sensitivity. But what was the most frivolous of all the admonition? For the author,
unquestionably it was the firm and oft-repeated assertion that he must not allow his
patients to influence his clinical judgment. Hard to believe that intelligent, experienced
professors and clinicians thought that way!
If a physician can shut up for long enough, the patient will tell him what is wrong, so
went an old medical gag. But, is it just a gag? The chronically ill have an intuitive-visceral
sense of what is wrong with them. Those suffering from depression, obsessive-compulsive
disorders, schizophrenia and other "psychiatric" disorders have long known that
some nutrient deficiency or chemical imbalance was the cause of their torment. Many in
psychiatry ridiculed them for it. Yet, the sufferers held on to their intuitive-visceral
senses. Now for the author (and a growing number of like-minded physicians), there is no
question that there is a physical basis for every "psychiatric" hurt, though we
cannot recognize the biochemical lesion in many instances. The author has closely followed
many such persons who did very well with integrated programs designed to restore their
battered bowel-blood-liver ecosystems. The veracity of those patients (and their
intuitive-visceral sense of their ailments) simply cannot be questioned.
How do the patients know the true nature of their suffering in many instances long
before their physicians do? Because, in almost all cases the sufferers of
"psychiatric disorders" have lucid periods during which they reflect on their
suffering and suspect that there has to be a physical basis of their pain. We physicians
must acknowledge that the patient lives with and suffers from his illness at all
times, while we see that illness only for very short periods of time. So it is that the
patient learns things about his suffering that escape his physician for years. At a deeper
level, the sick do have a visceral-intuitive sense of their illness.
5. The Principle of Spontaneity of Oxidation
This principle holds that the essential
code of molecular injury is woven into the molecular structure and function. In 1983, the
author published his hypothesis that the phenomenon of spontaneity of oxidation in nature
is the core pathogenetic mechanism of molecular and cellular aging and forms the basis of
molecular and tissue injury in all disease processes.5 The notion that a single molecular
mechanism can serve as the core pathogenetic mechanism of molecular, cellular, and tissue
injury in all disease processes (as well as the aging process) appears to be too
simplistic to be valid. However, an extensive review of the literature pertaining to
oxidative phenomena in biology in general, and human health-disease continuum in
particular, fails to uncover any evidence to the contrary. Rather, the author's close
examination of redox regulation in health and a survey of redox dysregulation in all
diseases in which oxidative stress has been investigated yield strong evidence for his
view.21-23 Such studies led the author to consider clinical implications of the
hypothesis in integrative medicine in areas of nutritional medicine,24 clinical
ecology and autoimmunity,25 lack of physical fitness,26 adrenergic hypervigilance evoked by lifestyle stressors,27 and clinical
benefits of effective methods of self-regulation, meditation, and prayer. Specifically,
the author proposed and marshalled evidence for his hypothesis that chronic fatigue
syndrome results from accelerated oxidative molecular injury to diverse enzyme pathways of
human antioxidant and immune defense systems, as well as of digestive-absorptive and
energy functions. Recently, the author and his co-investigator, Omar Ali, introduced the
concepts of oxidative coagulopathy and AA oxidopathy as the core pathogenetic mechanisms
of ischemic heart disease. The term oxidative coagulopathy was introduced as an
all-encompassing term for all oxidatively triggered events in the circulating blood that
result in zones of plasma congealing and formation of microclots and microplaques. The
term AA oxidopathy refers to a much broader spectrum of energetic-molecular dysregulation
of the redox phenomena that affects not only the elements of circulating blood but also
patterns of oxidative injury involving cell membranes, extracellular matrix, and
intracellular organelles (such as mitochondria) seen in clinical states characterized by
accelerated oxidative molecular injury. Such states include acute and chronic ecologic,
nutritional, autoimmune, and degenerative disorders, as well as malignant tumors.
6. The Principle of Spontaneity of Healing
This principle holds that the essential
code of healing of injured tissues is also woven into their structure and function. The
beginning of life as well as its ending are spontaneous phenomena. This is not a
romanticist's view, nor is there anything metaphysical about it. These two aspects of life
are observable phenomena and constitute the two sides of life's essential
energetic-molecular equation.
What does spontaneity of healing mean? Simply that healing occurs in response to inner
cues. It is as natural for electrons to fly off (creating structural and functional
molecular disarray) as it is for them to autoregulate themselves (into structural
and functional coherence). Electron shuffles generate free radicals that oxidatively
lacerate molecules. That is spontaneity of oxidation and of molecular injury. Electron
shuffles also generate new molecular configuration that sustain life and health.
Some folks are enchanted by notions of spontaneous healing. I am at a loss as to the
source of their excitement. I served as a hospital pathologist for nearly three decades,
and observed the healing phenomena in injured tissues with a microscope. I do not know of
any unspontaneous healing. We pathologists have limited ideas about some observable
aspects of the healing response. However, the truth is that we have no inkling about the
inner energetic-molecular signals that injured molecules, cells, tissues, and organs
follow during healing. How can we? Our physicist friends have not yet figured out the
dynamics of the particle-wave distribution function within the electron clouds of atoms.
No one can claim to fully comprehend the mystery of life and healing. I devote Healing,
Miracles and the Bite of the Grey Dog, to this subject.
7. The Principle of Spiritual
Surrender
The true answer to the problem of stress is spiritualityCnot psychology.
Stress is an integral part of the innate injury-healing-injury cycle of life. Both injury
and healing are spontaneous phenomena. Healing is not an intellectual function. The
thinking mind cannot order healing in injured tissues. The author has never seen clear
evidence for that, notwithstanding the prevalent infatuation with the mind-over-body
healing dogma. The thinking mind endlessly recycles past misery. And when that is not
enough, the mind precycles feared future misery. It thrives on doubt. It embellishes fear.
Relentless recycling of past pain or feared, future suffering can drive body tissues into
rebellions, but it cannot coax rebellious tissues to function in healthy ways. The author
discusses this issue at length in The Cortical Monkey and Healing.
The ancient notion of the
mind-body-spirit trio is this: Whatever can be experienced with the physical senses or
perceived by the mind cannot be spiritual. For the spiritual to be discrete from the body
and the mind, it must be beyond the reach of either. One cannot reach the spiritual by
seeing, smelling or hearing or by superior thinking. Indeed, if that were true, there
would be no need for the trio. The popular press is infatuated with the mind-body
connection! Has it lost sight, then, of the third element?
How does one go about searching for the spiritual? One doesn't. Psychology is no
substitute for spirituality. One must begin with that truth. The spiritual involves
surrendering in silence to the larger presence that surrounds and permeates each of us.
Why is silence essential? Because sights, smells and other sensory perceptions are aspects
of the physical bodyCand language is the mind's turf. Clever thinking, alas, is just that:
thinking. And thinking, as I write above, is not spiritual. Consequently, a thinking mind
cannot be banished with clever words.
In What Do Lions Know About
Stress the author suggested some simple ways to escape the tyranny of the
thinking mindCthe relentless clutter of the cortical monkey. What that monkey cannot cope
with is the silent energy of the spiritual. Specifically, I make two suggestions that I
have found to be clinically useful: meditation with the silence of a candle flame in
winter and with the silence of a stone during summer. For further details about these two
methods, I refer the reader to the chapter, Is There Another Door? in the above-cited
volume. In essence, with these simple approaches to meditative silence, one lets either
the flame of a candle or the mellow color of a stone to lead him to perceive one's
essential link with the larger presence. These simple approaches are usually far more
rewarding and revealing than an elaborate ritual. The Holy Quran puts it thusly:
Paradise is nearer to you than the
thongs of your sandal.
I have seen few exceptions to the
clinical value of silence: for example, the early phases of severe anxiety states,
frequent panic attacks and depression. Metabolic roller coasters in anxiety and panic
disorders may make silence unbearable during meditation. In that case the practice of
saying the rosary and mantras, chanting or listening to spiritual music often helps to
reduce the inner turmoil that can make silence suffocating. Depression is a serious
disorder of neuronal and neurotransmitter function, which is frequently made worse by
metabolic roller coasters. In many cases meditative silence initially exaggerates these
malfunctions. Here again, healing sounds can be of great value during the initial stages.
After they are stabilized, I strongly urge my patients with anxiety-panic disorders and
depression to learn the profoundly healing practice of silence. Indeed, in my clinical
experience positive long-term results for such disorders cannot be obtained without
persistent and prolonged spiritual work.
One can know only as much divinity as
exists within oneself, I wrote in What Do Lions Know About Stress
this seems a befitting note to end the above brief remarks on the place of the spiritual
in healing.
Peer Review
An issue that divides integrative medicine from mainstream physicians is the
matter of peer review for publication of clinical and experimental observations. Of
course, the majority of medical editors have the notion that what cannot be blinded cannot
be scientific. This is an amazing display of shortsightedness, since in integrative models
neither the physician nor the patient can or wants to be blinded to the chosen therapies.
Even a cursory look at the above principles of integrative medicine brings out the
principal folly of twentieth-century medicine: the double-blind cross-over model of drug
evaluation for chronic illness.
How can anyone blind himself to choices in the kitchen, nutrient and herbal
supplementation programs, meditative exercise, and spiritual work? And do so for months?
Thus, physicians who insist on blinded outcome protocols simply cannot serve as peers to
those who seek to assess the efficacy of integrative protocols. Furthermore, since
mainstream editors readily reject submissions concerning integrative models, reports of
clinical outcome with integrative therapies simply do not get published. Indeed, the Journal
was founded to fill that need.
As I end this article, I am reminded of
the words of the English philosopher and journalist, Walter Bagshot: "The House of
Peers has never been a House where the most important peers were most important."
Where would Galileo, Copernicus, and Pasteur be if their work depended on peer review?
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