Robert Saper, MD, MPH, founded Boston Medical Center’s (BMC’s) Program for Integrative Medicine and Health Care Disparities in 2004 to bring safe, integrative therapies to underserved populations. Through research, education and clinical services, the program is achieving a range of positive outcomes, including increasing access to integrative therapies – such as acupuncture, massage therapy, and yoga – and creating safer national and international policies for the development of alternative therapies.
Having just completed the integrative medicine research fellowship at Harvard Medical School, Saper noticed that in the growing field of integrative and complementary medicine, very few programs were being established in safety net hospitals. “The existing programs were essentially serving people who had discretionary income that would allow them to utilize these kinds of services,” he notes. “From a philosophical and social justice perspective, I felt strongly that if these therapies are going to be tested, studied, taught to clinicians and offered to patients, they should be studied and made available to people regardless of income, race, socioeconomic status.”
As Saper explains, the impact of these types of therapies on vulnerable patients could be great. “Our patients suffer disproportionately in terms of morbidity and disease impact,” he says. For example, Saper notes that chronic low back pain is a huge problem for low-income patients. These patients often experience more intense pain, need more medication and suffer more substantially in their ability to work than their higher-income counterparts. “This type of pain has a very high direct medical and productivity cost to society,” Saper says. “There is tremendous need in this population to improve quality of life and disease management.”
But with all of the benefit these therapies could bring to low-income populations, their socioeconomic status is a major barrier to access. Saper notes the number of yoga studios, tai chi classes, acupuncturists and licensed massage therapists is far fewer in the urban communities served by BMC than in the more affluent suburb communities of Boston. He also explains that because low-income populations have less exposure to and information about these therapies, they are less likely to seek them out.
Saper and the staff at BMC are working to change these conditions through a variety of initiatives. Though the program for integrative medicine is housed within BMC’s department of family medicine, its reach spans across the organization. “It’s not a separate specialty,” Saper says. “The goal is to be integrated with traditional medicine across disciplines.”
For example, Saper and his staff are collaborating with the nursing department, which he feels is a natural fit. “Nurses have the greatest contact with inpatients and have an incredible opportunity to infuse the patient experience with an integrative, holistic approach,” he explains. Together, the two groups are working on the third annual integrative nursing conference in April 2013. BMC is also beginning to train all nurses in simple integrative techniques to perform at the bedside such as shoulder and foot massage and guided relaxation for pain reduction.
The program is also collaborating with Jennifer Rosen, MD, an oncological surgeon at BMC. They’re studying the effects of massage therapy on cancer patients immediately prior to and after the placement of portacatheters – long-term IV devices implanted for chemotherapy. “These patients are very nervous, as they are about to start their treatment,” Saper explains, “and we found that the massage substantially reduced their pre- and postoperative anxiety.”
The program’s collaboration extends beyond BMC as well, as Saper and his team are working with local educational institutions such as the New England School of Acupuncture, which is holding acupuncture student intern clinics at BMC’s family medicine clinic. The acupuncture faculty and students work side by side with family physicians, and medical students also rotate in for half days. As a result, patients receive free acupuncture services, the acupuncture students get an interesting exposure to the safety net environment and medical students benefit from a broader curriculum.
Another important aspect of the program’s work is its research into specific types of integrative and complementary medicine. Saper’s studies of yoga for chronic low back pain serve as a model for the program’s larger goals. “I’ve been interested in yoga for 30 years, since I started practicing in medical school,” he notes. “It seemed a natural progression to study something that I was personally interested in.” Saper had heard many patients describe the benefits of yoga in easing their back pain. He also knew yoga was not commonly used in vulnerable populations. Thus, he felt it was the perfect test therapy.
In 2007, he received a small grant from the National Institutes of Health (NIH) to do a pilot study. He recruited 30 patients at two of BMC’s community health centers. Half of the patients attended weekly yoga classes, and half received usual care for chronic low back pain. Almost immediately, Saper saw an indication that there was a tremendous unmet need for this therapy and significant openness to trying it. “People did not think patients in those communities would accept such a therapy,” Saper says, “but the opposite was true. Within 2 months, we had more than 200 people apply.”
In addition to the community response, the clinical results showed that yoga was more effective than usual care, at least in the short term, for reducing pain and medication use. For example, the proportion of yoga participants experiencing a minimal clinically significant decrease in pain at 12 weeks was 67 percent versus 13 percent for the control group. Yoga participants also reported a 54 percent decrease in use of pain medications, versus no change in the control group.
The findings enabled Saper to apply for a second, $2.75 million NIH grant in 2010 for two additional studies. One of these was a dosing study to determine whether yoga was more effective once or twice weekly. The other is a 320-patient study that compares yoga to physical therapy, which is the most common reimbursed treatment for chronic low back pain. “If yoga is even similarly effective, but perhaps less costly, it may become a very attractive potential therapy that insurance companies may consider covering and doctors could recommend,” Saper says.
Finally, Saper is interested in the benefits of yoga’s social component. “There is a wonderful interaction between patients and teachers,” he says. “The sharing of common problems and solutions breaks down the social isolation that many patients with chronic pain have. Yoga is a complex intervention involving stretching, meditation and relaxation, and a philosophical approach to life. We know that yoga works. A more challenging question is why, and to what degree is it the stretching, the relaxation or the social component?”
Researching All Sides
While many promising integrative and complementary therapies exist, there are also a host of others that may not be safe and effective. BMC’s integrative medicine program is reviewing therapies used by immigrant populations to determine whether they are safe enough to integrate into traditional American medicine. For example, in reviewing the traditional herbal medicines used by South Asian immigrants, the program staff found that while some hold a lot of potential promise for health – turmeric, for example, has been shown to have potential cancer-fighting properties – a small subset are contaminated with heavy metals such as lead, mercury and arsenic.
As a result of this research and the staff’s dissemination of it, the government of India has enacted laws and regulations limiting the amount of heavy metals in these products. In addition, the American Herbal Products Association created guidelines for their members on manufacturing these medicines.
“We’re looking at both positive and negative aspects of these therapies to ensure they are used appropriately,” Saper says. “Over the past 15 years there has been an increasing amount of federal and private funds directed toward research to determine which of these therapies are safe and effective and can be integrated into mainstream care, and conversely, which ones are unsafe or ineffective and therefore should be discouraged or avoided,” Saper says. “If that is going to be the agenda of federal organizations such as the NIH and large private foundations, we need to study these therapies not just in white, upper-class, well-educated populations but also in diverse populations, particularly those who may be in greater need of help.
For more information about BMC’s Program for Integrative Medicine and Health Care Disparities, please contact:
Robert Saper, MD, MPH
Director, Program for Integrative Medicine and Health Care Disparities, Boston Medical Center
Associate Professor of Family Medicine, Boston University School of Medicine