Naturopathic Medicine: Reflections on Historical and Current Regulatory Issues in the United States

· Inaugural Issue

Michael Traub, ND, DHANP, CCH Immediate Past President, American Association of Naturopathic Physicians

I was recently invited by the Oregon Association of Naturopathic Physicians to speak at their annual meeting about the naturopathic profession, where it has come from, where it is going. I have extracted from and expanded upon some of the comments I made there for this article.

Since Benedict Lust opened the American School of Naturopathy in midtown Manhattan in March 1901, and founded the Naturopathic Society of America the following year, the naturopathic profession has faced regulatory challenges in the United States as it has attempted to establish itself as part of the nation’s health care system.

Naturopathy expanded steadily through the first decades of the twentieth century, into a force not to be ignored. By the end of the 1920’s, there were more than a dozen schools of naturopathy in the United States. Twenty-five states licensed naturopaths at one point. Yet the profession’s development was retarded by several factors. One was the na├»ve embrace of virtually any therapy that could be rationalized somehow as “natural, along with the denial that allopathic medicine held any truth or benefit. The discovery of “wonder drugs” and technological advances in conventional medicine did much to draw patients away from naturopathy, but naturopaths themselves were responsible for their decline as well. Within a few years after Lust’s death in 1945, the profession was in disarray. The factionalism within the profession that had existed since the beginning had been contained by Lust, but after his passing, naturopathy fell apart. Contentious, belligerent individuals competed to assume leadership of the “one, true naturopathy,” resulting in no less than six different national associations claiming to represent the profession. Licensing acts were withdrawn or expired until by 1958 only five states still licensed naturopaths (Washington, Oregon, Arizona, Hawaii and Connecticut). From 1956 until 1978, only one college, the National College of Naturopathic Medicine (NCNM), remained in operation.

For years, Drs. Gerald Farnsworth, Earl Farnsworth, Joe Boucher, Doug Kirkbride and others would travel to Portland to teach and train a handful of students at NCNM, driving down the long single road through Canada to Seattle, where they would pick up Dr. John Bastyr and head south on Highway 99. Drs. Harold Dick and Bill Turska would come to teach their specialties. The commitment, dedication and sacrifices of these doctors is, – the sole reason why the naturopathic profession continues to exist today. We owe our gratitude and allegiance to these men. They preserved this profession.

In 1966, Medicare was launched to provide health care to senior citizens. One of the reasons that naturopaths were rejected as eligible providers was that there were only 553 practitioners in the country, and this number was rapidly decreasing. Another reason, however, was the same as that given for a much larger profession: chiropractic. Its “theory and practice are not based upon the body of basic knowledge related to health, disease, and health care that has been widely accepted by the scientific community.”

John Bastyr’s influence at NCNM and the John Bastyr College of Naturopathic Medicine (established in 1978), is a primary reason why naturopathic medicine is now positioned to take its rightful place as part of the healthcare system in the U.S. Bastyr recognized the necessity of naturopathic doctors keeping abreast of advances in medicine and integrating these into naturopathic practice consistent with its principles. Dr. Joe Pizzorno, Bastyr College’s co-founder and first president, knew that “anecdotal and unverified ‘cures,’ particu- larly when associated with unusual therapies, do our cause little good.” As the colleges grew into the 1980’s their curriculum focused not only on the relatively anecdotal nature cure aspects but began to concentrate more on the scientifi- cally verifiable components of natural medicine.

The American Association of Naturopathic Physicians (AANP) was established in the early 1980’s, bringing unity once again to the profession after more than thirty years of disorganiza- tion. From the inception of the AANP until today, one of its top priorities has been supporting efforts for licensing naturo- pathic doctors in all fifty states.
The first annual AANP convention was held in 1984. I did not attend it, but I have been at every convention since then. The AANP convention experience is always a fun, entertaining “family reunion” as well as an opportunity to meet new students and colleagues and learn valuable information and clinical pearls from a wide variety of inspiring and knowledge- able speakers. When I encourage people to attend, I will often say it is the best way, if not the only way, to really get a sense of the naturopathic profession as a community.
The AANP, since its inception, has been a major force galvanizing the growth of the naturopathic profession. It has provided the community a crucible for leadership, fostering the development of essential infrastructure and political skills. Bolstered by either direct experience through participation in the AANP, or simply inspired and supported by its services, individual NDs have pushed beyond their roles as practi- tioners and expanded the footprint of the profession. The past twenty-five years has seen exponential growth in the numbers of schools established and accredited, and jurisdictions licensed. Research on the safety and efficacy of naturopathic therapies is being funded, conducted and published The Council on Naturopathic Medical Education (CNME) was created in 1978. The CNME is accepted as the program- matic accrediting agency for naturopathic medical education by the four-year naturopathic colleges and programs in the United States and Canada, by the American and Canadian national naturopathic professional associations, and by the North American Board of Naturopathic Examiners (NABNE). The U.S. Secretary of Education recognizes CNME as the national accrediting agency for programs leading to the Doctor of Naturopathic Medicine (N.D. or N.M.D.) or Doctor of Naturopathy (N.D.) degree.

The Canadian College of Naturopathic Medicine was also established in 1978. Southwest College of Naturopathic Medicine was founded in Arizona in 1992. The University of Bridgeport College of Naturopathic Medicine opened in Connecticut in the late 1990s.
The NPLEX (Naturopathic Physicians Licensing Examinations) Board has been producing criterion-referenced examinations since 1986, and is used as the licensing examination for naturopathic physicians in all U.S. and Canadian jurisdictions.

The Journal of Naturopathic Medicine was a quantum leap in the profession’s scientific sophistication. It was first published by the AANP in 1990. The lead articles bore the titles “Effects of Colon Irrigation on Serum Electrolytes,” “Inhibition of Endocrine Function by Botanical Agents,” and “Anorectic and Mood-Altering Effects of Ketosis During Ketogenic Diets.”

The articles cited mainstream journals such as JAMA and the British Medical Journal, not merely references to naturopathic literature. Throughout the 90’s the journal served as evidence of naturopathic medicine’s scientific basis. Unfortunately, its publication has been suspended due to financial exigencies and other pressing priorities. For this reason, the birth of the International Journal of Naturopathic Medicine is especially welcome.
The NIH Office of Alternative Medicine (OAM) was established in 1992. In 1994, Bastyr University was awarded a landmark $840,000 grant by the OAM to establish a national center for research in alternative medicine treatments for HIV/AIDS.

In 1998, the status of the OAM was elevated to an NIH center, the National Center for Complementary and Alternative Medicine (NCCAM). The enabling legislation was strongly influenced by representatives of the naturopathic profession and the AANP. Several naturopathic physicians were selected to serve on NCCAM’s Advisory Council.
The North American Board of Naturopathic Examiners (NABNE) is a non-profit organization established in 1999. Its purpose is fourfold:

1. To set policies regarding the qualifications of applicants to sit for NPLEX examinations.
2. To set policies regarding the administration of the NPLEX examinations.
3. To verify the qualifications of applicants to take the NPLEX examinations.
4. To administer the NPLEX at testing sites in the United States and Canada
In the 1990’s the AANP formed the Alliance for State Licensing, and new licensing acts were passed in Maine, Montana, New Hampshire, Utah, Vermont, and Puerto Rico.
In the year 2000, President Clinton established the White House Commission on Complementary and Alternative Medicine. Dr. Joe Pizzorno was appointed to the Commission and had a major impact on the final recommendations in the Commission’s report.
The AANP moved its offices from Seattle to the Washington DC area during the summer of 2000. This move precipitated a major shift in the professionalism of the Board of Directors and the operations of the association. The AANP Bylaws were amended in their entirety, giving the membership voting rights to elect Board members and officers, and revamping the role of the House of Delegates.

The American Association of Naturopathic Medical Colleges was formed, heralding a new era of collaboration between the colleges. Joint marketing efforts were undertaken, affording the colleges much greater exposure together than they could have achieved alone.
Licensing of new states met with formidable, effective opposition by the Coalition for Natural Health (CNH) for several years. Finally, the logjam was broken by the passage of laws in the Virgin Islands and Kansas, and then, last year, in California. The impact of licensure in California is huge. Not only does it demonstrate that with an effective organiza- tion, the opposition of a monolithic institution like the California Medical Association could be overcome, not to mention the well-funded CNH, but it opens up a market for naturopathic physicians that has almost infinite potential. A long unmet need for Californians to have access to naturo- pathic doctors can now be addressed. California is such a populous, health conscious, affluent state (even with its current state budget deficit), that every graduating naturo- pathic doctor could go to California for the next twenty years and generate a successful practice. It is my belief that licensure in California is the single-most important event ever to occur in the history of naturopathic medicine.

In 1999 an 8 year old child with insulin dependent diabetes died in North Carolina. Her mother had followed the advice of a man with a correspondence school certificate naming him a naturopathic doctor. He told this mother to take away her daughter’s insulin and substitute an herbal “cleansing” regime. The practitioner has been convicted of manslaughter and is in prison. This tragedy is a compelling argument for the importance of educational standards and professional regulation of health care providers. Personal freedoms not withstanding, there is always a segment of the public so distressed by their circumstances as to be vulnerable to unscrupulous or simply under-educated practitioners in states where naturopathic medicine is not licensed.

One of the most vexing problems for the naturopathic profession is the burgeoning number of “naturopaths” from unaccredited correspondence programs. Unlicensable naturopaths act to the detriment of the public and the reputation of the legitimate profession. Furthermore, they and their lobbyists have the mistaken belief that licensure will restrict them from pursuing their livelihood, when in reality it will only require that they not use the title naturopathic doctor/physician. An important legal precedent was set last year when the Arkansas Attorney General successfully brought an injunction against the owners of an unaccredited correspondence school in that state. Unfortunately, the licensure laws in Puerto Rico, California, and Washington DC permit unlicensable naturopaths to use the title “naturopath.” Only time will tell whether this concession will strengthen or weaken the cause of naturopathic medicine.

Earlier this year the Washington DC City Council unanimously passed a bill that would establish licensure for naturopathic physicians there. The bill will be signed into law in the next sixty days. A licensing bill was narrowly defeated this month in Idaho. Legislation to license naturopathic physicians is still active in Missouri, Florida, North Carolina, Massachusetts and New York.

Lust wrote the following shortly before his death in 1945: “But there are others who claim to be naturopaths who are woeful misfits. Yes, and there are the outright fakers and cheats masking as naturopaths. That is the fate of any science, any profession, which the unjust laws place beyond the pale. Where there is no official recognition and regulation, you will find the charlatans operating on the same basis as the consci- entious practitioners.” Lest there be any doubt about Dr. Lust’s intentions for the profession, the following letter from his descendants make it clear:

“In the recent past, many individuals have been associating themselves with Dr. Benedict Lust, historically, currently, and professionally, to create an aura of validity and authenticity for their various involvements.

Those who have created mail order institutions, unlicensed and unaccredited degrees without substance, are suspect in our mind, and generally denigrate and destroy the principle educational processes established by our ancestor. Benedict Lust’s estate and his lineal descendants support legitimate education in the field through accredited schools qualified by the Council on Naturopathic Medical Education as candidates for such accreditation.”

At the federal level, several initiatives are underway that portend important advances for federal recognition of naturo- pathic medicine. First and foremost, it is imperative that student loan limits be increased and that naturopathic doctors qualify for federal and state loan forgiveness programs, to work off the huge educational debts that are incurred in earning an ND degree. This agenda, however, does not exist in isolation. It is intertwined with funding for naturopathic residency programs, for eligibility to be Medicare providers, and with insurance coding and reimbursement that involves the Center for Medicare Services (CMS) and its relationship not only to the Medicare Fee Schedule but the CPT Editorial Panel and the RUC. The CPT Editorial Panel is a joint undertaking of CMS and the American Medical Association. The RUC is a subcommittee of CPT, and establishes valuation for selected codes previously approved by the Editorial Panel. Fortunately, we are represented on the Medicare Coverage Advisory Committee by Drs. Joe Pizzorno and Pamela Snider, and on the CPT Editorial Panel by Dr. Bruce Milliman.

Dr. Snider and I also represent the naturopathic profession on the Executive Committee of the Integrated Healthcare Policy Consortium (IHPC). The IHPC’s agenda is to:

1. Create a federal office for integrated healthcare. 2. Increase appropriations for health services research to foster health promotion and disease prevention.
3. Secure federal support for education and training programs for both conventional and CAM schools to produce a core, integrated curriculum.
4. Enact legislation prohibiting discrimination against
CAM providers, schools, and educational programs in all federal programs and initiatives, especially in the removal of barriers to integrated health care in rural and underserved communities.

The AANP has endorsed the IHPC’s policy agenda. As Chair of the IHPC Advisory Committee, I have had the responsibility for identifying chairpersons for a task force for each of the above objectives. Several of the task force chairs and members are N.D.s or have close ties to the naturopathic profession.

Finally, in what may be one of the most important factors ultimately influencing state and federal recognition and regulation, the NIH funded Naturopathic Medical Research Agenda (NMRA) is in the final stages of being completed. Fundamental to gaining equality in the healthcare system is demonstrating efficacy. The challenge is designing whole practice clinical studies that meet rigorous scientific standards while remaining true to the principles and philosophy of individualizing care. As Rene’ Dubos wrote twenty years ago: “modern medicine will become really scientific only when physicians and their patients have learned to manage the forces of the body and the mind that operate in vis medicatrix naturae.”

The NMRA is based on a series of hypotheses that respect the historical tradition of naturopathic medicine and the observations of current naturopathic scholars and physicians about its health advantages.

These hypotheses are:
a. That increasing numbers of naturopathic physicians providing primary care will be both safe and effective.
b. That increasing numbers of naturopathic physicians providing primary care will improve public health outcomes including cost-effective ness.
c. That the scientific exploration of naturopathic medical principles and practice will yield important scientific insights.
The NMRA will initially focus on conditions that have been identified as having the largest burden of disease in the community or those rising extensively in prevalence. Diseases that have been identified that fulfill these criteria include diabetes, obesity, cardiovascular disease, asthma, and cancer. The NMRA will commence by addressing these five diseases; however, it is expected that the agenda will evolve as new diseases are recognized by public health authorities or the naturopathic medical community as having high public health priority.

The NMRA Core Team has identified that a model population for the study of naturopathic medicine is individuals with diabetes (Type II). In choosing this population the NMRA Core Team intends to assess the impact of naturopathic management on both the specific condition and its associated co-morbidities. Outcomes of whole practice research into the effects of naturopathic medicine on individuals with diabetes (Type II) will include bio-medical markers, health services and public health endpoints. This research will address the basic naturopathic premise that health outcomes are as important as disease outcomes.
Based on standard methodological approaches that build a body of knowledge systematically, the NMRA will undertake systematic reviews, observational studies and preliminary clinical data aimed at conducting a large randomized controlled trial comparing naturopathic medical care to standard care in a population of individuals with diabetes (Type II) within the next five years.

In conclusion, the naturopathic profession is repeating a course of evolution that all professions must pass through while becoming accountable to the public. As John Weeks recently wrote: “we find ourselves in an era beyond the polarization of alternative medicine and conventional medicine with an opportunity to become a seamless part of an integrated system that might rightfully be called, simply, health care.”