[Senate Hearing 105-875]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 105-875
 
                           MIND/BODY MEDICINE

=======================================================================

                                HEARING

                                before a

                          SUBCOMMITTEE OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                       ONE HUNDRED FIFTH CONGRESS

                             SECOND SESSION

                               __________

                            SPECIAL HEARING

                               __________

         Printed for the use of the Committee on Appropriations


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate

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                      U.S. GOVERNMENT PRINTING OFFICE
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                      COMMITTEE ON APPROPRIATIONS

                     TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi            ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania          DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico         ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri        PATRICK J. LEAHY, Vermont
SLADE GORTON, Washington             DALE BUMPERS, Arkansas
MITCH McCONNELL, Kentucky            FRANK R. LAUTENBERG, New Jersey
CONRAD BURNS, Montana                TOM HARKIN, Iowa
RICHARD C. SHELBY, Alabama           BARBARA A. MIKULSKI, Maryland
JUDD GREGG, New Hampshire            HARRY REID, Nevada
ROBERT F. BENNETT, Utah              HERB KOHL, Wisconsin
BEN NIGHTHORSE CAMPBELL, Colorado    PATTY MURRAY, Washington
LARRY CRAIG, Idaho                   BYRON DORGAN, North Dakota
LAUCH FAIRCLOTH, North Carolina      BARBARA BOXER, California
KAY BAILEY HUTCHISON, Texas
                   Steven J. Cortese, Staff Director
                 Lisa Sutherland, Deputy Staff Director
               James H. English, Minority Staff Director
                                 ------                                

 Subcommittee on Departments of Labor, Health and Human Services, and 
                    Education, and Related Agencies

                 ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi            TOM HARKIN, Iowa
SLADE GORTON, Washington             ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri        DANIEL K. INOUYE, Hawaii
JUDD GREGG, New Hampshire            DALE BUMPERS, Arkansas
LAUCH FAIRCLOTH, North Carolina      HARRY REID, Nevada
LARRY E. CRAIG, Idaho                HERB KOHL, Wisconsin
KAY BAILEY HUTCHISON, Texas          PATTY MURRAY, Washington
TED STEVENS, Alaska                  ROBERT C. BYRD, West Virginia
  (Ex officio)                         (Ex officio)
                      Majority Professional Staff
                            Bettilou Taylor
                             Mary Dietrich

                      Minority Professional Staff
                              Marsha Simon

                         Administrative Support
                   Jim Sourwine and Jennifer Stiefel


                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening remarks of Senator Arlen Specter.........................     1
Prepared statement of Hon. Tom Harkin, U.S. Senator from Iowa....     2
Statement of Norman B. Anderson, Ph.D., director, Office of 
  Behavioral Sciences Research...................................     3
    Prepared statement...........................................     4
National Institutes of Health for Behavioral and Social Sciences 
  Research.......................................................     7
Statement of Herbert Benson, M.D., president, Mind/Body Medical 
  Institute......................................................     7
    Prepared statement...........................................     9
Statement of Harold G. Koenig, M.D., director, Center for the 
  Study of Religion/Spirituality and Health, Duke University 
  Medical Center.................................................    16
Psychological and social stress..................................    16
Prepared statement of Harold G. Koenig...........................    17
Stress and relaxation............................................    26
Immune function..................................................    27
Heart disease--stress and high blood pressure....................    28
Self-care and relaxation.........................................    28
Susceptibility to breast cancer..................................    29
Stress and immune system functioning.............................    31
Religious beliefs and practice--better immune functioning........    31
Healing power of belief..........................................    32
Science and religion.............................................    34
Research.........................................................    36
Health and behavior..............................................    36
Alternative medicine and mind/body...............................    38
Changing people and their behavior...............................    39
Prepared statement of Caesar A. Giolito, executive director, 
  National Interfaith Coalition for Spiritual Healthcare and 
  Counseling.....................................................    40
  


                           MIND/BODY MEDICINE

                              ----------                              


                      TUESDAY, SEPTEMBER 22, 1998

                           U.S. Senate,    
    Subcommittee on Labor, Health and Human
     Services, and Education, and Related Agencies,
                               Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 11:01 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Arlen Specter (chairman) 
presiding.
    Present: Senator Specter.

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

                     National Institutes of Health

STATEMENT OF NORMAN B. ANDERSON, Ph.D., DIRECTOR, 
            OFFICE OF BEHAVIORAL SCIENCES RESEARCH

               opening statement of senator arlen specter

    Senator Specter. Good morning, ladies and gentlemen. The 
Subcommittee on Labor, Health and Human Services, and Education 
will now proceed.
    This morning we will focus on mind/body treatment which has 
come to be recognized as a very important part of medical 
treatment, emphasizing stress related illnesses and the 
elimination of stress contributing to a number of medical 
conditions that can be treated by so-called mind/body 
procedures contrasted with pharmaceutical or surgical 
approaches. The mind/body approach, such as relaxation response 
and those related to utilizing beliefs of the patients, have 
been utilized to successfully treat disorders and illnesses.
    In the fiscal year 1999 Labor, HHS bill, we have included 
provisions to establish mind/body centers to explore the 
benefits of mind/body medicine and to address issues of 
application and research including the cost effectiveness of 
mind/body interventions.
    We have a distinguished panel of experts today. We will 
begin with Dr. Norman Anderson who is Director of the Office of 
Behavioral and Social Sciences Research for the National 
Institutes of Health, a unit which was created in 1993. Dr. 
Anderson, we welcome you here.
    We would like to have a 5-minute rule generally, so we will 
turn the green light on at 5 and the yellow at 1 and a red at 
0. But we have some flexibility today on the timing, so we will 
not be rigidly bound by the lights.
    We may be joined by other Senators. Today is a very busy 
day here. Yesterday was Rosh Hashanah and some are celebrating 
it today. I do not have to specify the activities that are 
underway in Washington, DC. So, it is a busy time. Whether we 
will be joined or not by our colleagues will remain to be seen.

                           prepared statement

    At this point I would like to submit Senator Tom Harkins 
statement for the record.
    [The statement follows:]

                Prepared Statement of Senator Tom Harkin

    Thank you, Mr. Chairman, for providing this forum to discuss the 
promising field of mind-body medicine. As many of you know, I have 
taken a great interest over the years in complementary and alternative 
medicine (CAM). I believe strongly in the need for improved and 
expanded research in this field. It is this belief that led me to 
create the Office of Alternative Medicine at NIH in 1991 and more 
recently, to propose giving the Office Center status and grant making 
authority. I want to thank the Chairman for working with me on this 
issue, and including my Center proposal in the LHHS bill this year.
    Millions of Americans are turning to complementary and alternative 
medicine (CAM) and practices. Currently, patient visits to CAM 
practitioners outpace visits to conventional primary care physicians. 
According to a recent study by Harvard University researchers, 80 
million Americans regularly use complementary and alternative medicine, 
usually in conjunction with more conventional care.
    Harvard University reported that the public's out-of-pocket 
expenses for these CAM products and services is equal to that paid out-
of-pocket for traditional physician services and is three times that 
paid out-of-pocket for hospital expenses. In 1990, those costs equaled 
more than $14 billion, of which at least $10 billion were not 
reimbursed to patients by health insurance.
    These practices, which range from acupuncture to chiropractic care, 
to relaxation techniques, naturopathic, herbal and homeopathic 
remedies, are not simply complementary and alternative, but are 
integral to how millions of Americans are managing their health and 
treating their illnesses.
    Today, I am pleased to have the opportunity to hear from the 
distinguished scientist, Dr. Herbert Benson, about his work in the 
field of Mind/Body Medicine. The relaxation techniques espoused by Dr. 
Benson have been shown to significantly improve patients' recovery from 
a wide range of illnesses.
    The groundswell of public demand for CAM therapies, including the 
Mind/Body techniques described by Dr. Benson, has fueled the interest 
of conventional medical practitioners. Eighty percent of medical 
students in the U.S. have reported a desire for more structured 
training in complementary and alternative medicine and practices, 
including Mind/Body medicine. Indeed, the National Institutes of Health 
reports that more than 50 percent of conventional physicians in the 
U.S. now use or refer patients for alternative treatments.
    Yet the federal government lags behind providers and the public. 
The Federal agencies responsible for protecting and promoting public 
health remain ill-equipped to deal with the public's demand for 
information and answers regarding alternative and complementary health 
care. Additionally, we are in an era when we must take a closer look at 
ways to provide cost-effective, preventive health care. The movement 
toward integrated medicine promises a more comprehensive, more 
effective, and more responsive health care system. And evidence 
suggests that this approach may be far more cost-effective as well.
    As policymakers, we must act to promote quality research, provide 
useful information to patients about CAM therapies, and ensure adequate 
oversight of this burgeoning field. This hearing is an important step 
in that process. I look forward to the testimonies to be presented here 
today and urge the continued commitment of this Subcommittee in this 
important public health issue. Thank you.

                  summary statement of norman anderson

    Senator Specter. Dr. Anderson, all statements will be made 
a part of the record in full, and now the floor is yours.
    Dr. Anderson. Thank you, Mr. Chairman. It is really a 
pleasure for me to participate in the hearing today on mind/
body approaches to health. This area of research is 
particularly relevant to the mission of the Office of 
Behavioral and Social Sciences Research or OBSSR at the 
National Institutes of Health. Thank you for the opportunity to 
discuss the commitment of NIH to conducting and disseminating 
this vital research.
    I am a clinical psychologist with training in behavioral 
medicine, and I have served as the first Associate Director of 
NIH for Behavioral and Social Sciences Research for the past 3 
years. I am also an associate professor, currently on leave, at 
Duke University and president of the Society of Behavioral 
Medicine. In my role as Director of the OBSSR, I work with all 
of the institutes and centers of the NIH on issues related to 
basic behavioral and social sciences research and to research 
on behavioral treatment and prevention approaches. These areas 
of research have produced some of the strongest evidence for 
the role of the mind in healing and health.
    I would like to direct your attention to the picture on the 
easel. The figure illustrates how the seemingly independent 
factors affecting health are, in fact, integrated and 
dependent. Please note the three large boxes on the poster. NIH 
has a long and revered research tradition in the physiological 
realm and more recently there has been tremendous excitement in 
the realm of genetics research, but equally important is the 
recognition of the role that behavioral psychological, 
sociocultural, and environmental factors play in health. Our 
beliefs, our emotions, our behavior, our thoughts, our family 
and cultural systems, as well as the environmental context in 
which we live, all are as relevant to our health as genetic 
inheritance and our physiology.
    Some might say that there is nothing really new in this 
model, that we have long known that the mind, the body, and the 
context in which we live influence health. But this model 
brings a new oneness to our vision of the determinants of 
health. This oneness is captured not so much by the boxes in 
the poster, but by the arrows between the boxes which denote a 
unity of the factors that affect health. The arrows make 
salient the interaction and interdependence of the various 
influences on health. Health science has now reached a point 
where it is no longer accurate to talk about psychology versus 
biology, the mind versus the body, or nature versus nature. 
These processes are inextricably linked. When I talk about 
mind/body medicine, I am referring to these linkages, that is, 
the connections between psychological, behavioral, and 
sociocultural processes with all levels of biological 
functioning and with health.
    The figure not only illustrates the factors affecting 
health, but it also makes salient a number of scientific 
questions. For example, we know that social, psychological, and 
behavioral variables are important risk factors for illness, 
but the question now is, how do they affect health? That is, 
how do psychosocial and behavioral variables affect endocrine 
activity, the immune system, or even gene expression? How can 
we capitalize on discoveries in these areas to improve the 
treatment and prevention of disease? These are some of the key 
questions facing mind/body research today.
    Research supported by the NIH continues to make progress in 
addressing these questions. Here are just a few recent 
discoveries.
    Stress management training can reduce the fear and anxiety 
associated with the experience of asthma in children, resulting 
in more effective management of asthma attacks and fewer visits 
to the emergency room, and as a consequence, decreasing costs. 
Stress management training has also been shown to reduce the 
likelihood of cardiovascular morbidity.
    Breast and skin cancer patients who participate in 
supportive groups show improved mood, adjustment, and decreased 
pain and may actually experience a decrease in mortality.
    Finally, a variety of behavioral interventions such as 
relaxation training, which you will hear more about today, 
cognitive therapy, and biofeedback have now been demonstrated 
to reduce the chronic pain associated with a number of medical 
conditions.

                           prepared statement

    These and other findings reinforce the commitment to and 
enthusiasm for research at the intersection of sociobehavioral 
and biological science at the NIH.
    Thank you again for your interest in mind/body approaches 
to healing and health and for convening this hearing. I look 
forward to any questions you might have. Thank you.
    [The statement follows:]

                Prepared Statement of Norman B. Anderson

    Mr. Chairman, it is my pleasure to participate in the hearing today 
on mind/body approaches to health. This area of research is 
particularly relevant to the mission of the Office of Behavioral and 
Social Sciences Research (OBSSR) at the National Institutes of Health 
(NIH). Thank you for the opportunity to discuss the commitment of NIH 
to conducting and disseminating this vital research.
    I am a clinical psychologist with training in behavioral medicine, 
and I have served as the first Associate Director of NIH for Behavioral 
and Social Sciences Research for the past three years. I am also an 
Associate Professor (on leave) at Duke University, and President of the 
Society of Behavioral Medicine. In my role as Director of the OBSSR, I 
work with all the Institutes and Centers of NIH on issues related to 
basic behavioral and social science research, and to research on 
behavioral treatment and prevention approaches. These areas of research 
have produced some of the strongest evidence for the role of the mind 
in healing and health.
    I will focus my remarks on two questions: What are some recent 
developments in research on the role of the mind in healing and health? 
And what are the implications of this research for treatment and 
prevention?
    To address the first question, I direct your attention to the 
picture on the easel (see Figure 1, attached). The figure illustrates 
how the seemingly independent factors affecting health outcomes are, in 
fact, integrated and dependent. Please note the three large boxes on 
the poster. NIH has a long and revered tradition of funding research in 
the physiological realm, and more recently, there is tremendous 
excitement in the realm of genetics research. But equally important is 
the recognition of the role that behavioral, psychological, 
sociocultural and environmental factors play in health. Our beliefs, 
our emotions, our behavior, our thoughts, our family and cultural 
systems, as well as the environmental context in which we live, all are 
as relevant to our health as our genetic inheritance and our 
physiology.
    Some might say that there is nothing really new in this model--that 
we have long known that the mind, the body, and the context in which we 
live influence health. But this model brings a new oneness to our 
vision of the determinants of health. This oneness is captured not so 
much by the boxes in the poster, but by the arrows between the boxes, 
which denote unity of the factors that affect health. These arrows make 
salient the interaction and interdependence of the various influences 
on health. Health science has reached a point where it is no longer 
accurate to talk about psychology versus biology; the mind versus the 
body; or nature versus nuture. These processes are inextricably linked. 
When I talk about mind/body medicine, I am referring to these linkages. 
That is, the connections between psychological, behavioral, and 
sociocultural processes with all levels of biological functioning--from 
the organ systems, to the cellular, to the molecular--and with health.
    The figure not only illustrates the factors affecting health, but 
it also makes salient a number of scientific questions. For example, we 
know that social, psychological, and behavioral variables are risk 
factors for illness, but the question now is: How do they affect 
health? That is, how do psychosocial and behavioral variables affect 
neuroendocrine activity, the immune system, or gene expression? How can 
we capitalize on discoveries in these areas to improve the treatment 
and prevention of disease? These are some of the key questions facing 
mind/body research today.
                       interdisciplinary research
    Our next challenge is to seek a deeper understanding of mind/body 
interactions, and to do this we need research that cuts across 
disciplinary boundaries. That is, research that combines expertise from 
such social and behavioral science fields as psychology, sociology, 
demography, and anthropology, with expertise from the various fields of 
biomedicine. The OBSSR has made advancing this type of cross-
disciplinary research one of its three primary goals. In cooperation 
with the NIH Institutes and Centers, we have recently issued a Request 
for Applications (RFA) to fund educational workshops designed to create 
a larger contingent of scientists who are broadly trained in the 
methods, procedures, and theoretical perspectives of disciplines 
outside their own. The goal is not to turn, say, geneticists into 
psychologists or vice versa, but to provide researchers with sufficient 
understanding of other fields in order to better foster collaboration 
across disciplines. We believe this collaborative research will 
transcend the contributions of single disciplines, and produce entirely 
new ways of thinking about health.
    In recent years, we have made significant advances in the field of 
mind/body medicine. Let me provide some examples of studies that 
exemplify the influence of psychological, behavioral, and social 
processes on all levels of biological functioning and health.
    Asthma.--For persons suffering from asthma, especially children, 
the experience of breathlessness is a very traumatic symptom that can 
lead to panic which may aggravate the symptoms or make the person 
unable to assess symptoms to determine appropriate treatment, such as 
whether to use an inhaler or go to the emergency room. Studies funded 
by the National Heart, Lung, and Blood Institute have shown that stress 
management training can reduce the fear and anxiety associated with the 
asthma experience. This has been shown to result in more effective 
management of asthma attacks and more appropriate use of health 
services, e.g., fewer visits to the emergency room.
    Breast Cancer.--Many studies supported by the National Cancer 
Institute have demonstrated the positive effects of psychosocial group 
therapy for cancer patients, including improvements in mood, 
adjustment, and pain. It is also possible that psychotherapy can 
actually extend one's life, as well as improve its quality. In one 
study, patients with metastatic breast cancer who received weekly 
supportive group therapy actually lived an average of 18 months longer 
than did those who did not participate in the group treatment.
    Coronary Disease.--Although smoking and hypertension have long been 
documented as very important risk factors for the development of 
coronary disease, they do not fully account for the timing and 
triggering of heart attacks and sudden death. Recent research has shown 
that the onset of acute coronary syndromes does not occur at random. 
For example, between 17 percent and 30 percent of heart attacks appear 
to be triggered by external and behavioral factors. These include 
emotional stress, strenuous physical exercise, cold weather, cocaine 
abuse, sexual activity, and anger. Reducing trigger activities can 
provide protection against heart attack and coronary deaths. 
Preliminary studies funded by the National Heart, Lung, and Blood 
Institute suggest that certain cardioprotective interventions, such as 
those utilizing stress management and aerobic exercise training, show 
promise in reducing cardiovascular morbidity.
    Touch and Preterm Infant Survival.--Research funded by the National 
Institute of Mental Health and the National Institute of Child Health 
and Human Development has demonstrated the beneficial effects of touch 
in both animals and humans. When newborn rats are separated from their 
mothers, they are deprived of tactile stimulation. That deprivation of 
touch results in a decrease of hormones that are critical for growth 
and development. When the newborn is returned to its mother and 
touching resumes, these hormones return to normal levels. Animal 
research of this type has led to the development of behavioral 
interventions for human pre-term infants, resulting in improved growth 
and earlier hospital discharge.
    Personality and Health.--A number of personality factors have been 
linked to mortality in several studies. One characteristic, cynical 
hostility or lack of trust, was found to predict increased rate of 
death from all causes in several prospective epidemiological studies 
including a 20-year study of corporate executives; a 25-year study of 
physicians; and a 25-year study of attorneys. Recently, using data from 
a 70-year longitudinal study of gifted and talented children, 
scientists funded by the National Institute of Aging have discovered 
that participants with childhood personality characteristics of high 
social dependability or conscientiousness were, as adults, 30 percent 
less likely to die in a given year than those low on these 
characteristics. These findings on personality and health could not be 
explained by differences in traditional disease risk factors among 
participants.
    Behavior, Experience, and the Brain.--Several NIH Institutes, 
including The National Institute of Mental Health, the National 
Institute of Neurological Diseases and Stroke, the National Institute 
of Child Health and Human Development and others, have funded research 
on how behavior and experience may alter brain structure and 
intellectual functioning. Exposure to relatively enriched, complex, or 
stimulating environments can produce substantial changes in cellular 
functioning in the brain. Rats housed in environments with a variety of 
toys and objects with which to interact have increased brain weight and 
synapses (connections between brain cells). These findings have been 
extended to human populations, where intensive preschool interventions 
have led to demonstrable improvements in later intellectual functioning 
and lower rates of mental retardation.
    Chronic Pain.--Finally, because chronic pain afflicts so many in 
our society, NIH recently held a consensus conference to evaluate the 
use of behavioral medicine approaches in combating chronic pain and 
insomnia. The conference yielded the following conclusions. First, 
there is strong evidence for the efficacy of relaxation approaches in 
reducing chronic pain associated with a variety of medical conditions. 
Second, there is moderately strong evidence for the efficacy of 
cognitive behavior therapy for chronic pain syndromes. Importantly, the 
literature indicates that cognitive behavior therapy is superior to 
placebo and to routine care for alleviating low back pain and pain 
associated with rheumatoid arthritis and osteoarthritis. Finally, there 
is strong evidence for the efficacy of combined behavioral medicine 
treatments (e.g., cognitive therapy, relaxation, biofeedback, or 
hypnosis) for several categories of pain, including back and neck pain, 
dental or facial pain, joint pain, and migraine headache.
    Other Advances.--Behavioral and social treatment and prevention 
approaches have also been used successfully for problems such as 
diabetes, arthritis, gastrointestinal problems, violence, depression, 
and alcohol and drug abuse. I would be happy to answer any questions 
you have about these areas.
    My concluding remarks will briefly address the second question, 
``What are the implications of mind/body research for both treatment 
and prevention?'' The NIH, and my office in particular, take very 
seriously the responsibility to ensure that our scientific findings 
actually reach the people they are intended to benefit. For example, I 
have organized a special task force to develop a plan for working with 
health care providers and managed care companies to incorporate 
scientifically validated behavioral treatment approaches into medical 
care. As you know, many proven behavioral treatments are not reimbursed 
by insurance companies. This must change--and I believe it will, as 
companies become more aware of the cost savings they will accrue by 
covering behavioral treatments and therapies for conditions ranging 
from arthritis, diabetes, depression, and recovery from surgery. 
Furthermore, approximately half of the nation's annual premature deaths 
can be directly attributed to modifiable risk factors such as tobacco 
use, unhealthy diet, lack of exercise, alcohol and drug abuse, and 
risky sexual behavior. These and other behavioral and psychosocial risk 
factors have been linked to higher ambulatory care and hospitalization 
costs, with preventable illness accounting for as much as 70 percent of 
all medical care spending.
    Thank you again for your interest in mind/body approaches to health 
and healing, and for convening this hearing. I look forward to any 
additional questions you might have.
[GRAPHIC] [TIFF OMITTED] T07SE22.001

   national institutes of health for behavioral and social sciences 
                                research

    Senator Specter. Thank you very much, Dr. Anderson.
    I note that you are the first Associate Director of the 
National Institutes of Health for Behavioral and Social 
Sciences Research?
    Dr. Anderson. Yes.
    Senator Specter. Did this unit come into existence in 1993?
    Dr. Anderson. No; the legislation was passed in 1993. The 
office officially opened in 1995.
    Senator Specter. I see. What took so long?
    Dr. Anderson. I am not really sure. I was at Duke at the 
time and was recruited to this position by the NIH.
    Senator Specter. And you are an associate professor in the 
Departments of Psychiatry, Psychology, Social and Health 
Sciences at Duke University?
    Dr. Anderson. Yes.
    Senator Specter. And you have done extensive work on the 
issue of high blood pressure in African-Americans.
    Dr. Anderson. Yes.
    Senator Specter. Well, thank you very much. I am going to 
reserve the questions until we have heard from our full panel 
of witnesses.
STATEMENT OF HERBERT BENSON, M.D., PRESIDENT, MIND/BODY 
            MEDICAL INSTITUTE
    Senator Specter. We turn now to Dr. Herbert Benson who is a 
foremost expert in this field, founding president of the Mind/
Body Medical Institute, and associate professor of medicine at 
Harvard Medical School, and chief of the division of behavioral 
medicine at the Beth Israel Deaconess Medical Center. Dr. 
Benson is a pioneer in the field of behavioral medicine and 
mind/body studies, as well as spiritual healing, a graduate of 
Wesleyan, University of Harvard Medical School, author or 
coauthor of over 150 scientific publications and 6 books. We 
welcome you here, Dr. Benson, and look forward to your 
testimony.
    Dr. Benson. Thank you, Senator. Mr. Chairman, I am 
delighted to have this opportunity to testify before this 
committee today.
    A study, published this month, predicted that spending on 
health care is likely to double to $2.1 trillion by the year 
2007. Imaginative and responsible approaches to health care are 
needed. I propose that mind/body medicine with its self-care 
approaches holds great promise for the Nation's health and 
costs of health care.
    My testimony will be evidence-based. The data I will 
present will be scientific findings that have been published in 
peer-reviewed journals. Some of these data were evaluated and 
supported at a 1995 NIH technology assessment conference.
    Consider for a moment that I were here today discussing a 
new drug and the scientific evidence indicated that this new 
drug could successfully treat a very wide variety of prevalent 
medical disorders, conditions that lead to 60 to 90 percent of 
visits to doctors. Furthermore, consider that this new drug was 
safe and without dangerous side effects. It could also prevent 
these conditions from occurring and recurring. And, consider 
this new drug was demonstrated to decrease visits to doctors by 
as much as 50 percent and that this decrease could lead to 
annual cost savings of more than $54 billion. The discovery of 
such a drug would be front-page news and immediately embraced. 
Such scientifically validated mind/body therapies have been 
shown to produce such clinical and economic benefits, but as 
yet have not been so received.
    Why, given results such as these, have mind/body self-care 
therapies, such as the relaxation response, and those related 
to beliefs of patients not been more effectively integrated 
into mainstream medicine? Barriers to integration include: one, 
the lack of knowledge of the existing scientific data among 
health care providers, researchers in other fields, among 
patients, and among policymakers in Government and private 
industry; two, a bias against mind/body interventions in 
medical care as being soft science; three, inadequate insurance 
payments for these treatments; and four, a bias against 
shifting away from the overwhelming use of pharmaceuticals and 
surgeries and procedures.
    One way to overcome these barriers is the establishment of 
mind/body medical centers. They will make the benefits of mind/
body medicine, specifically those of the relaxation response, 
and those related to utilizing the beliefs of patients more 
visible. Mind/body medical centers would also markedly expand 
the hard science of mind/body interventions. It could be argued 
that NIH already has mechanisms in place to review mind/body 
proposals and some might ask, why the need for the new centers? 
NIH study sections do, indeed, skillfully assess and perform 
reviews of quite circumscribed research. Unfortunately, a 
striking paucity of study sections are equipped to adequately 
review proposals that investigate the simultaneously occurring, 
multiple mind/body linkages that involve human 
physicochemistry, biology, psychology, social behavior, and 
belief-related phenomena such as spirituality. Mind/body 
centers, under the aegis of the Office of Behavioral and Social 
Sciences Research at NIH, would be a meaningful step toward 
overcoming narrowly focused, exclusively reductionistic 
research. Understanding the interrelatedness of different 
systems should be carried out in already existing organizations 
that are experienced in mind/body research and treatments. It 
might be advisable to encourage the centers to work 
collaboratively together. The centers would also teach and 
train health care professionals in mind/body approaches and 
treatments. Finally, these NIH supported centers could markedly 
expand the cost effectiveness of mind/body interventions and 
provide data for new reimbursement strategies for Medicare and 
Medicaid, as well as for private insurers.

                           prepared statement

    The full integration of mind/body, self-care medicine is 
completely compatible with existing health care approaches. The 
integration is important not only for better health and well-
being, but also for a more economically feasible health care 
system. Mind/body medicine responsibly fulfills the needs of 
our people who want therapies that enhance and complement 
traditional medicine and that do so in a scientifically 
established safe and cost savings fashion. Mind/body medicine 
holds such promise that it should be further researched, 
advocated, and utilized for the health and well-being of the 
people of our Nation.
    Thank you.
    Senator Specter. Thank you very much, Dr. Benson. As I say, 
we will defer the questions until we have heard from Dr. Koenig 
as well.
    [The statement follows:]

                  Prepared Statement of Herbert Benson

    I'm delighted to be called to testify on mind/body medical 
interactions and their potential clinical applications.
    Before I start my testimony, let me say a few words about the Mind/
Body Medical Institute and the work I have been doing at the Harvard 
Medical School and its affiliated hospitals for the last thirty years. 
The Mind/Body Medical Institute is dedicated to performing research and 
to conducting teaching and training of health care professionals in 
mind/body and behavioral medicine approaches and transmitting this 
information to the general public. It is now just finishing its first 
ten years of existence. I myself occupy the Mind/Body Medical Institute 
Chair at the Harvard Medical School as an associate professor of 
medicine.
    A study, published this month, projected that spending on 
healthcare is likely to double to $2.1 trillion by the year 2007 (Smith 
et al., 1998). That's a trillion dollars more than we are spending now. 
According to this report, managed care savings have about run their 
course. What's driving this surge in costs? According to the report, it 
is expensive prescription drugs, enthusiasm for new medical technology 
and greater freedom to visit medical specialists whenever patients 
desire to do so. Imaginative and responsible approaches to healthcare 
are needed. I propose that mind/body medicine with its self-care 
approaches holds great promise for the nation's health and cost of 
healthcare (Friedman, et al., 1995).
    My testimony will be evidence-based; the data I will present will 
be scientific findings that have been published in peer-reviewed 
journals. Some of these data were evaluated and supported at a 1995 NIH 
Technology Assessment Conference.
    I will cover the following categories: stress and the fight-or-
flight response; the relaxation response; the placebo effect and the 
importance of belief in healing; the three-legged stool and the 
importance of self-care; and the proper use of mind/body therapies and 
the creation of mind/body medical centers.
    Stress contributes to many of the medical conditions confronted by 
healthcare practitioners. In fact, when the reasons for patients' 
visits to physicians are examined, between 60 to 90 percent of visits 
to physicians are related to stress and other psychosocial factors 
(Cummings, VandenBos, 1981; Kroenke, Mangelsdorff, 1989). Current 
pharmaceutical and surgical approaches cannot adequately treat stress-
related illness. Mind/body approaches including the relaxation 
response, nutrition and exercise, and the beliefs of patients have been 
demonstrated to successfully treat stress-related disorders. To better 
understand mind/body treatments it is best to first understand the 
physiology of the stress and the fight-or-flight response.
                stress and the fight-or-flight response
    Stress is defined as the perception of threat or danger that 
requires behavioral change. It results in increased metabolism, 
increased heart rate, increased blood pressure, increased rate of 
breathing and increased blood flow to the muscles. These internal 
physiologic changes prepare us to fight or run away and thus the stress 
reaction has been named the ``fight-or-flight'' response. The fight-or-
flight response was first described by the Harvard physiologist, Dr. 
Walter B. Cannon (1941) earlier in this century. It is mediated by 
increased release of catecholamines--epinephrine and norepinephrine 
(adrenalin and noradrenalin)--into the blood stream.
                        the relaxation response
    Building on the work of Swiss Nobel laureate Dr. Walter R. Hess, my 
colleagues and I more than 25 years ago described a physiological 
response that is the opposite of the fight-or-flight response. It 
results in decreased metabolism, decreased heart rate, decreased blood 
pressure, and decreased rate of breathing, as well as slower brain 
waves (Wallace, Benson, Wilson, 1971). We labeled this reaction the 
``relaxation response'' (Benson, Beary, Carol, 1974).
    The fight-or-flight response occurs automatically when one 
experiences stress, without requiring the use of a technique. In 
contrast, two steps are usually required to elicit the relaxation 
response. They are: (1) the repetition of a word, sound, prayer, phrase 
or muscular activity and (2) when other, everyday thoughts intrude, 
there is a passive return to the repetition (Benson, 1975; Hoffman, et 
al, 1982). Many different methods can be used to bring forth the 
relaxation response including: progressive muscle relaxation, 
meditation, autogenic training, yoga, and repetitive physical exercise. 
In addition, many forms of prayer can also be used. These include 
repetitive prayers such as the rosary as in the Catholic tradition, 
centering prayers in Protestant religions and pre-davening prayers in 
Judaism. The specific method used usually reflects the beliefs of the 
person eliciting the relaxation response (Benson, 1984). The method may 
be secular or religious, and performed either at rest or during 
exercise.
    Our research conducted at the Harvard Medical School and that of 
others has documented that relaxation-response based approaches 
generally used in combination with nutrition, exercise, and stress 
management interventions result in alleviation of many stress-related 
medical disorders. In fact, to the extent that stress causes or 
exacerbates any condition, mind/body approaches that invariably include 
the relaxation response have proven to be effective. Because of this 
scientifically-documented efficacy, a physiological basis for many 
millennia-old mind/body approaches has been established and has 
overcome a great deal of initial professional skepticism.
    It is essential to understand that regular elicitation of the 
relaxation response results in long-term physiologic changes that 
counteract the harmful effects of stress throughout the day, not only 
when the relaxation response is being brought forth (Hoffman, et al, 
1982). These mind/body approaches have been reported to be effective in 
the treatment of hypertension (Stuart, et al, 1987), cardiac 
arrhythmias (Benson, Alexander, Feldman, 1975), chronic pain (Caudill, 
et al., 1991), insomnia (Jacobs, et al, 1993; Jacobs et al, 1996), 
anxiety and mild and moderate depression (Benson et al., 1978), 
premenstrual syndrome (Goodale, Domar, Benson, 1990), and infertility 
(Domar, Seibel, Benson, 1990).
    As a result of the evidence-based data, the relaxation response is 
becoming a part of mainstream medicine. Approximately 60 percent of 
U.S. medical schools now teach the therapeutic use of relaxation-
response techniques (Friedman, Zuttermeister, Benson, 1993). They are 
recommended therapy in standard medical textbooks and a majority of 
family practitioners now use them in their practices.
       the placebo effect and the importance of belief in healing
    The importance of mind/body interactions in healing is also 
profoundly evidenced by the placebo effect. Throughout history, 
medicine and healing has relied heavily on non-specific factors such as 
the placebo effect (Benson, Friedman, 1996). In other words, what 
patients believe, think and feel has profound effects on the body. 
Physicians and other healers have historically appreciated the effects 
of both positive and negative emotions. However, modern medicine has 
largely disregarded and ridiculed the importance of mind/body 
interactions such as the placebo effect by using such statements as, 
``It's all in your head,'' ``It's just the placebo effect,'' or ``It's 
a dummy pill.'' These pejorative terms arose gradually over a period of 
decades as specific remedies for specific illnesses were developed and 
the reliance on what is now called non-specific healing factors--the 
placebo effect--diminished. Because the specific therapies were and 
are, so dramatically effective, they became the sole treatments 
utilized. Specific treatments such as insulin, antibiotics and cataract 
surgery are truly awe-inspiring. The result was that mind/body 
approaches were largely forgotten and pushed aside as the wondrous 
modern pharmaceuticals and surgeries and procedures advanced. Rather 
than using a combination of specific and belief-related therapies to 
promote healing, modern medicine has come to value and to rely 
exclusively on the specific effects of pharmacological and procedural 
interventions. It ignores the healing powers of beliefs.
    The pioneering work of Beecher (1955), established that in patients 
with conditions of pain, cough, drug-induced mood changes, headaches, 
seasickness, and the common cold, the placebo effect was effective in 
35 percent of the cases. Since these early findings, the placebo effect 
has been documented to be effective in 50 to 90 percent of diseases 
that include bronchial asthma, duodenal ulcer, angina pectoris, and 
herpes simplex (Benson, Friedman, 1996; Benson, 1996).
    The placebo effect is dependent on three sets of beliefs: (1) the 
beliefs of the patient; (2) the beliefs of the healthcare provider (the 
healer); and (3) the beliefs that ensue from the relationship between 
the healthcare provider and the patient.
    A study of Japanese students who were allergic to the wax of a 
lacquer tree, which produces a rash similar to that of poison ivy, 
provides one demonstration of the power of the belief of patient 
(Ikemi, Nakagawa, 1962). The students were first blindfolded and then 
told that one of their arms would be stroked with lacquer tree leaves, 
and that their other arm would be stroked with chestnut tree leaves, to 
which they were not allergic. However, the researchers switched the 
leaves. The skin that the subjects believed to have been brushed with 
the lacquer leaves, but that was actually stroked with chestnut tree 
leaves, developed a rash. The skin that had actual contact with the 
leaves of the lacquer tree, but that was believed to have been stroked 
with the chestnut tree leaves, did not react.
    A study of treatments for angina pectoris provides an example of 
how beliefs of the healthcare practitioner can effect disease (Benson, 
McCallie, 1979). A number of therapies for angina pectoris have been 
used throughout the decades that are now known to have no therapeutic 
value. These include cobra venom, vitamin E and bizarre internal 
mammary artery surgeries. When they were used and believed in by 
physicians, they had a dramatic effect. They were found to be 70 to 90 
percent effective in relieving the pain of angina pectoris. Not only 
would the pain disappear, but the patients' electrocardiograms and 
exercise tolerance would improve. However, when these therapies were 
later invalidated and no longer believed in by physicians, their 
effectiveness dropped to 30 percent or lower.
    The beliefs that ensue from the relationship between physicians and 
patients are the third component of the placebo effect. A study by 
researchers at the Massachusetts General Hospital (Egbert, et al, 1964) 
compared two matched groups of patients who were to undergo similar 
operations. The doctors responsible for their anesthesia visited both 
groups of patients, but interacted with them quite differently. They 
made only cursory remarks to patients in one group, but treated the 
other group with warm and sympathetic attention, detailing the steps of 
the operation and describing the pain they would experience. The 
patients who received the friendlier more supportive visits were 
discharged from the hospital an average of 2.7 days sooner and asked 
for half the amount of pain-alleviating medication than patients in the 
other group.
    Some insight into the possible brain mechanisms for the placebo 
effect is provided in a study conducted by Dr. Steven Kosslyn (Kosslyn, 
et al., 1993). He and his colleagues examined how the brain processes 
information, both real and imagined. Subjects were asked to look at a 
grid with a letter printed on it. As they did so, a PET Scan was used 
to determine what areas of the brain were active in seeing the grid and 
the letter. The subjects were then asked to look at the same grid 
without the letter on it, but asked to visualize the letter in their 
mind's eye. The PET scan was then repeated. The same area of the brain 
was stimulated in both situations. In other words, from the brain's 
perspective the visualization of a scene is similar to actually seeing 
the scene. This process helps to explain the placebo effect. All of our 
thoughts, actions, and memories, represent the activation of specific 
brain connections. Pain in an arm or leg is represented as activation 
of specific brain areas. There are memories in our brains of pain. 
There are also memories of being without pains. There are also brain 
connections for having a skin rash and of being without a skin rash. 
Thus, belief in a sugar pill or an inactive therapy can result in 
activating the brain connections to ``remember'' what it is to be 
without the pain or the rash. The pain or rash can be thus alleviated. 
In other words, thoughts can activate brain connections that can result 
in physical healing.
    The biased words ``placebo effect'' probably should be discarded 
and changed to ``remembered wellness.'' Remembered wellness is what 
explains this powerful mind/body reaction and the words, remembered 
wellness, have a positive connotation.
    Placebos are not the only way to evoke remembered wellness. 
Consider the most profound belief Americans share. Ninety five percent 
of the U.S. population believe in God (Gallup, 1990). Research by 
different investigators working in different locations throughout the 
United States have repeatedly demonstrated a connection amongst 
religious beliefs and greater well-being, better quality of life, and 
lower rates of depression, anxiety and substance abuse (Koenig, 1998). 
Religious beliefs and practices have been associated with enhanced 
physical health (Koenig et al, 1997; 1998). They are also associated 
with a lower use of expensive health services (Koenig, Larson, in 
press). Recently, such research has appeared in respected medical 
journals and has begun to influence both the education of physicians 
and the practice of medicine (Marwick, 1995; Levin et al., 1997).
    The effects of the relaxation response should not be confused with 
remembered wellness (the placebo effect). The relaxation response is a 
proven, specific mind/body intervention. The measurable, predictable, 
and reproducible changes of the relaxation response will occur when you 
follow the two specific steps--belief is not essential. It is like 
penicillin--it will work whether or not you believe in it.
         the three-legged stool and the importance of self-care
    Health and well being and the incorporation of mind/body therapies 
in medical care are best conceptualized in terms of an analogy of a 
three-legged stool (Benson, Friedman, 1996; Benson, 1996). One leg is 
pharmaceuticals, the second is surgery and procedures, and the third 
leg is self-care. Self-care consists of health habits and behaviors for 
which patients themselves can be responsible. Specifically, self-care 
includes the relaxation response, beliefs that promote health, stress 
management, nutrition and exercise. Health and well-being are balanced 
and optimal when all three legs of the stool are in place. Of course, 
attention to nutrition and exercise have been recognized for centuries. 
In contrast, the scientific documentation of mind/body interactions has 
only recently been presented.
    For more than a hundred years medicine has relied almost 
exclusively on the first two legs of the stool: pharmaceuticals and 
surgery. Without the support of the third leg through mind/body and 
behavioral approaches, the treatment of many medical conditions is 
imbalanced and inadequate. Patients receive less than optimal clinical 
care and the care they receive is more costly.
    As I noted earlier, if medical care continues to be based only on 
two legs, it is estimated that the costs for this care will double in 
the next decade (Smith et al, 1998). Mind/body therapies are 
scientifically-proven strategies that can be thoroughly integrated with 
pharmaceuticals and surgery and procedures and they offer cost savings. 
I've also noted that 60 to 90 percent of physician office visits are 
related to stress-related conditions. To estimate the monies that could 
be saved per year by the application of mind/body therapies, I used 75 
percent as an average. I estimated that half of these doctor office 
visits--or 37.5 percent--could be eliminated with a greater emphasis on 
mind/body health. Using 1994 statistics, there were approximately 
670,000 practicing physicians in the United States who reported an 
average of 74.2 patient visits per doctor per week, for a total of 
3,858.4 office visits per doctor that year. Each visit for an 
established patient cost an average of $56.2. Thus, the average cost 
per year was 670,000  3,858.4  $56.2 = $145.3 
billion. By reducing these visits by 37.5 percent, the cost savings 
would be $54.5 billion dollars, for one year alone (Benson, 1996).
    One example of how mind/body, behavioral interventions can reduce 
costs was shown through a study conducted at the Harvard Community 
Health Plan (Hellman, et al, 1990). Two group mind/body interventions 
were compared among high-utilizing primary care patients who 
experienced physical symptoms which had psychosocial components. The 
symptoms included: palpitations, shortness of breath, gastrointestinal 
complaints, headaches, and sleeplessness. Both interventions offered 
patients educational materials, relaxation-response training, and 
awareness training, and both included cognitive restructuring. These 
groups were compared with a randomized control group that received only 
information about stress management. Six months after treatment only 
the patients in the mind/body groups reported less physical and 
psychological discomfort and averaged about 50 percent fewer visits to 
the health plan than the patients in the control group. The estimated 
net savings to the HMO above the cost of the intervention for the 
behavioral medicine patients was $85 per participant in the first 6 
months.
    Chronic pain and insomnia are two other examples of the successful 
integration into mainstream medicine of mind/body interventions (NIH 
Technology Assessment Panel on Integration of Behavioral and Relaxation 
Approaches Into the Treatment of Chronic Pain and Insomnia, 1996).
    Millions of Americans are in chronic pain, which by definition, is 
pain that cannot be eliminated, but must be managed. Chronic pain 
sufferers, motivated both by medical and emotional factors, often 
become frequent users of the medical system. The treatment of chronic 
pain becomes extremely costly and frustrating for patients and 
healthcare providers. In one study, clinic usage was assessed among 
chronic pain patients at an HMO who participated in an outpatient 
behavioral medicine program, of which the relaxation response is an 
integral part (Caudill, et al., 1991). In addition to decreases in the 
severity of pain as well as in anxiety, depression and anger, there was 
a 36 percent reduction in clinic visits for over two years in the 
patients who participated in the behavioral medicine program as 
compared to their clinic usage prior to the intervention. In the 109 
patients studied, the decreased visits projected to an estimated net 
savings of $12,000 for the first year following treatment and $24,000 
for the second year.
    Another example of how these same mind/body interventions can 
result in better medical care and reduce medical costs is in the 
treatment of another extremely common disorder, insomnia (NIH 
Technology Assessment Panel on Integration of Behavioral and Relaxation 
Approaches Into the Treatment of chronic Pain and Insomnia, 1996). 
Approximately 35 percent of the adult population experiences insomnia. 
Half of these insomniacs consider it a serious problem. Billions of 
dollars are spent each year on sleeping medications, making insomnia an 
extremely expensive condition. In fact, the direct costs to the nation 
are approximately $15.4 billion yearly and the actual costs in terms of 
reduced quality of life, lowered productivity and increased morbidity 
are astronomical. Although frequently employed, sleeping pills are not 
effective in the long term.
    The shortcomings of such drug therapy, along with recognition of 
the role of behavioral features of insomnia, prompted the development 
of mind/body behavioral interventions for this condition. Researchers 
at our laboratories at the Mind/Body Medical Institute studied the 
efficacy of a multifactor behavioral intervention for insomnia that 
included relaxation-response training. Compared to controls, those 
subjects who received behavioral and relaxation-response treatment 
showed significantly more improvement in sleep patterns. On average, 
before treatment it took patients 78 minutes to fall asleep. After 
treatment, it took 19 minutes. Patients who received behavioral and 
relaxation response treatment became indistinguishable from normal 
sleepers. In fact, the 75 percent reduction in sleep-onset latency 
observed in the treated group is the highest ever reported in the 
literature (Jacobs, G.D. et al, 1993; Jacobs, Benson, Friedman, 1996).
    It is also important to remember that the research on mind/body, 
behavioral therapies in the treatment of both chronic pain and insomnia 
were reviewed in 1995 at a NIH Technology and Assessment Conference. 
The planning committee chairman was my late friend and colleague Dr. 
Richard Friedman. Dr. Julius Richmond, former Surgeon General of the 
United States Public Health Service and Assistant Secretary for Health 
of the Department of Health and Human Services under President Carter, 
was the chair of the independent panel (before he became a trustee of 
the Mind/Body Medical Institute) that reviewed the evidence. Dr. 
Richmond stated in a press conference that it was ``imperative'' that 
these interventions be integrated into routine medical care.
  the proper use of mind/body therapies and the creation of mind/body 
                            medical centers
    Consider for a moment that I were here today discussing a new drug 
and the scientific evidence indicated that this new drug could 
successfully treat a very wide variety of prevalent medical 
conditions--conditions that lead to 60 to 90 percent of visits to 
physicians. Furthermore, consider that this new drug was safe and 
without dangerous side effects. It could also prevent these conditions 
from occurring and recurring. And, consider that the new drug was 
demonstrated to decrease visits to doctors by as much as 50 percent and 
that this decrease could lead to annual cost savings of more than $54 
billion (Benson, 1996). The discovery of such a drug would be front 
page news and immediately embraced. Such scientifically-validated mind/
body therapies have been shown to produce such clinical and economic 
benefits, but as yet have not been so received.
    Why, given results such as these, have mind/body therapies such as 
the relaxation response and those related to the beliefs of patients 
not been more effectively integrated into mainstream medicine? Barriers 
to integration include: (1) the lack of knowledge of the existing 
scientific data among healthcare providers, researchers in other 
fields, among patients and among policy makers in government and 
private industry; (2) a bias against mind/body interventions in medical 
care as being ``soft'' science; (3) inadequate insurance payments for 
these treatments; and (4) a bias against shifting away from the 
overwhelming use of pharmaceuticals as well as surgeries and 
procedures.
    One way to overcome these barriers is the establishment of mind/
body medical centers. They will make the benefits of mind/body 
medicine, specifically those of the relaxation response and those 
related to utilizing the beliefs of patients more visible. Mind/body 
medical centers would also markedly expand the ``hard'' science base of 
mind/body interventions. It could be argued that NIH already has 
mechanisms in place to review mind/body proposals and some might ask, 
Why then the need for new centers? NIH study sections do skillfully 
assess and perform reviews of quite circumscribed research. 
Unfortunately, a striking paucity of study sections are equipped to 
adequately review proposals that investigate the simultaneously 
occurring multiple, mind/body linkages that involve human 
physicochemistry, biology, psychology, social behavior, and belief-
related phenomena such as spirituality. Mind/body medical centers under 
the aegis of the Office of Behavioral of Social Sciences Research of 
NIH would be a meaningful step toward overcoming narrowly-focused, 
exclusively reductionistic research. Understanding the inter-
relatedness of different systems should be carried out in already 
existing organizations that are experienced in mind/body research and 
treatments. It might be advisable to encourage the new centers to work 
collaboratively on joint projects. The centers would also teach and 
train healthcare professionals in mind/body approaches and promote 
responsible education to the public about mind/body mechanisms and 
treatments. Finally, these NIH supported centers could markedly expand 
studies of the cost effectiveness of mind/body interventions and 
provide data for new reimbursement strategies for Medicare and Medicaid 
as well as for private insurers.
    The full integration of mind/body, self-care medicine is completely 
compatible with existing healthcare approaches. The integration is 
important not only for better health and well-being, but also for a 
more economically-feasible healthcare system. Mind/body medicine 
responsibly fulfills the needs of our people who want therapies that 
enhance and complement traditional medicine and that do so in a 
scientifically-established, safe, and cost-savings fashion. Mind/body 
medicine holds such promise that it should be further researched, 
advocated and utilized for the health and well-being of the people of 
our nation.
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STATEMENT OF HAROLD G. KOENIG, M.D., DIRECTOR, CENTER 
            FOR THE STUDY OF RELIGION/SPIRITUALITY AND 
            HEALTH, DUKE UNIVERSITY MEDICAL CENTER
    Senator Specter. Dr. Harold Koenig is the director and 
founder of the Center for the Study of Religion, Spirituality 
and Health at Duke Medical Center. His areas of research 
include depression in the medically ill elderly, religion, 
aging and health, ethical issues, and geriatric psychiatry. Dr. 
Koenig received his undergraduate degree from Stanford, 
continued his education at the University of California at San 
Francisco, and furthered his medical education in geriatric 
medicine, psychiatry, and biostatistics at Duke University 
Medical Center. Welcome, Dr. Koenig, and the floor is yours.

                    psychological and social stress

    Dr. Koenig. Thank you, Senator.
    As Dr. Anderson and Dr. Benson have already spoken to, 
there is an increasing amount of scientific evidence that is 
establishing the link between psychological and social stress 
and a host of disabling and serious medical illnesses, 
particularly heart disease and cancer which are the major 
killers of Americans today. Traditional medical and surgical 
treatments typically do not include mind/body medicine 
approaches that could empower and motivate patients toward 
self-care, prevent illness, speed recovery, and reduce the 
costs of health care that are quickly spiraling out of control.
    Patients have become accustomed to relying on medical and 
surgical approaches to their illnesses rather than focusing on 
things that they can do to improve their health or prevent 
health conditions from occurring, and physicians have become 
accustomed to treating sick people like broken down cars, 
simply fix them and then send them out. Patients and physicians 
need to be educated about and encouraged to participate in 
self-care activities that help to maintain their wellness, 
speed recovery, and prevent disease.
    Now, the relaxation response and ways of eliciting it, like 
repetitive prayer, is easily taught and widely acceptable to 
Americans throughout the country. These techniques have been 
shown to enhance well-being by alleviating and reducing 
anxiety, pain, stress, and preventing substance abuse and 
alcoholism and drug use. Consequently, given the relationship 
between psychological stress and physical illness, we would 
expect that these techniques would reduce blood pressure, 
enhance coronary functioning, reduce coronary artery ischemia, 
lower the risk of cancer, and perhaps even increase immune 
system functioning.
    Likewise, certain beliefs have been associated with greater 
well-being and better physical health. Let us just take for an 
example religious or spiritual beliefs. Now, they could be 
beliefs really in anything, beliefs in your doctor or beliefs 
in a pill, but as an example we will take religious and 
spiritual beliefs because they are so prevalent in society.
    These have been associated with reduction of acute stress, 
prevention of depression, faster recovery from depression, 
faster adaptation to chronic stress, and prevention and 
treatment of drug and alcohol addiction. This has been shown by 
multiple different research groups located in many different 
areas of the country.
    Likewise, because of this mind/body connection, we would 
expect that perhaps religious beliefs and practices might be 
associated with better health, and indeed they have been found 
to be connected with a lower risk of coronary heart disease, 
lower blood pressure, enhanced recovery from open heart 
surgery, prevention of cancer, promotion of positive health 
behaviors, and enhancement of immune system functioning, and 
actually extension of overall survival.
    Finally, religious beliefs and practices are associated 
with quicker recovery from disabling illnesses like hip 
fracture and stroke, and they can also help to prevent costly 
disability in people that is causing a great increase naturally 
in the costs of health care.
    Now, again these religious beliefs and practices appear to 
also directly reduce the amount of acute hospital use which is 
the most costly form of health care. Indeed, we have found that 
again these beliefs seem to actually shorten the hospital stay 
of significantly ill older patients.

                           prepared statement

    Now, mind/body centers will be equipped with sufficient 
expertise to develop this new area in a way that NIH's typical 
programs simply cannot do. Only centers with a critical mass of 
investigators and core infrastructure can launch the ambitious 
and multi-disciplinary projects that are necessary to advance 
this field. Centers are also the best way of disseminating the 
research findings to the public and to clinicians and to 
rapidly moving these research findings into practical 
applications.
    Thank you.
    [The statement follows:]

                 Prepared Statement of Harold G. Koenig

the effects of stress, relaxation, and belief on health and healthcare 
                                 costs
    Thank you for inviting me to speak on this fascinating topic of 
mind-body medicine and the usefulness of establishing mind-body 
medicine centers to focus research and training in this area. I am a 
physician boarded in geriatric medicine and geriatric psychiatry, serve 
on the Duke University Medical Center faculty as an associate professor 
of psychiatry, and direct Duke's Center for the Study of Religion/
Spirituality and Health. For the past 15 years, our center scientists 
(now 8 in number) have investigated the effects of religious belief and 
practice on health, conducting over 50 research projects and publishing 
several hundred scientific papers. In my talk, I hope to accomplish 
four goals: (1) Provide further evidence for a link between Stress and 
physical health; (2) Examine the effects of the Relaxation Response on 
specific health problems; (3) Explore the effects of Belief on health 
and well-being; and (4) Demonstrate how mind-body practices may, 
through Relaxation Response related therapies and Belief, reduce health 
care Costs.
               a link between stress and physical health
    Mounting research is demonstrating that psychological stress 
negatively impacts physical health, and that mind-body medicine 
approaches are effective in relieving stress and counteracting its 
negative health effects. Below, Bruce McEwen reviews this research and 
Janice Kiecolt-Glaser provides a fascinating example that illustrates 
the effects of stress on wound healing.
    McEwen, B.S., and Stellar, E. (1993). Stress and the individual 
mechanisms leading to disease. Archives of Internal Medicine, 153, 
2093-2101. Examines diseases associated with stress, including asthma, 
diabetes, gastrointestinal disorders, myocardial infarction, 
hypertension, cancer, viral infections, and autoimmunity; discusses 
mechanisms, including neurochemistry (serotonin) and immunology 
(natural killer cell activity and cancer). See recent update in: 
McEwen, B.S. (1998). Protective and damaging effects of stress 
mediators. New England Journal of Medicine, 338, 171-179.
    Kiecolt-Glaser, J.K., Marucha, P.T., Malarkey, W.B., Mercado, A.M., 
and Glaser, R. (1996). Slowing of wound healing by psychological 
stress. Lancet, 346(8984): 1194-1196. Thirteen women (mean age 62) 
caring for demented relatives (high stress) were compared with 13 
controls matched for age (60 yo) and family income. Ball subjects 
underwent a 3.5 mm punch biopsy. Healing was assessed by photography of 
wound and response to hydrogen peroxide (healing defined as no 
foaming). Wounds in stressed caregivers took significantly longer to 
heal (48.7 vs 39.3 days, p<.05). Furthermore, peripheral blood 
leukocytes (white blood cells) of caregivers produced significantly 
less interleukin-1 beta mRNA in response to lipopolysaccharide 
stimulation (suggesting impaired functioning).
    If psychological stress adversely affects the cardiovascular and 
immune systems, then perhaps cognitive (beliefs and attitudes) and 
behavioral interventions may help decrease this effect.
                        the relaxation response
    Below I review studies of the relaxation response (and methods of 
eliciting it) on well-being and physical health.
Well-being
    Studies have shown that the Relaxation Response, and the many 
methods of eliciting it (such as repetitive prayer), help to relieve 
stress, chronic pain, and negative mental health states like anxiety 
disorder and drug and alcohol abuse. What are the nature of these 
studies?
Reducing Anxiety
    Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G., 
Fletcher, K.E., Pbert, L., Lenderking, W.R., and Santorelli, S.F. 
(1992). Effectiveness of a meditation-based stress reduction program in 
the treatment of anxiety disorders. American Journal of Psychiatry, 
149, 936-943. Study of 22 patients referred for meditation and 
relaxation program who had generalized anxiety disorder or panic 
disorder (ages 26-65, 17 women). The intervention consisted of a 8-week 
long course involving weekly 2-hour classes and a 7.5 hour intensive 
meditation retreat session in week six. Subjects were assessed at the 
start and end of intervention and at monthly intervals for 3 months 
after treatment. A. significant reduction in symptoms of anxiety and 
depression was identified during treatment and maintained for at least 
3 months after treatment ended. The authors indicated that a 3-year 
follow-up showed that 18/22 subjects maintained these beneficial 
effects.
    Azhar, M.Z., Varma, S.L., and Dharap, A.S. (1994). Religious 
psychotherapy in anxiety disorder patients. Acta Psychiatrica 
Scandinavica, 90, 1-3. Investigators randomized 62 Muslim patients with 
generalized anxiety disorder to either traditional treatment 
(supportive psychotherapy and anxiolytic drugs) or traditional 
treatment plus religious psychotherapy. Religious psychotherapy 
involved use of prayer and reading verses of the Holy Koran specific to 
the person's situation. Patients receiving religious psychotherapy 
experienced more rapid improvement in anxiety symptoms than those 
receiving traditional therapy.
Reducing Chronic Pain
    Kabat-Zinn, J., Lipworth, L., and Burney, R. (1985). The clinical 
use of mindfulness meditation for the self-regulation of chronic pain. 
Journal of Behavioral Medicine, 8, 163-190. Investigators compared 
patients in two hospital clinics involving. One hospital clinic treated 
patients using ``mindfulness meditation''; 90 chronic pain patients 
received 10 weeks of a Stress-Reduction and Relaxation Program (SSRP). 
In these patients, investigators found statistically significant 
reductions in pain symptoms, mood disturbance, and psychological 
symptoms. Pain-related drug utilization also decreased and self-esteem 
increased. Improvement was independent of sex, source of referral or 
type of pain. A comparison group of patients in the other hospital pain 
clinic (n=21) and referrals to the SRRP from the pain clinic (n=21) did 
not show similar improvement after traditional treatment protocols. At 
follow-up, improvements were maintained for 15 months for all measures 
except one measure of pain; the majority of subjects reported high 
compliance with daily meditation.
Preventing and Treating Substance Abuse
    Gelderloos, P., Walton, K.G., Orme-Johnson, D.W., and Alexander, 
C.N. (1991). Effectiveness of the transcendental meditation program in 
preventing and treating substance misuse: A Review. International 
Journal of the Addictions, 26, 293-325. These investigators reviewed 24 
studies on the benefits of Transcendental Meditation in treating and 
preventing substance abuse. They concluded from this review that ``all 
studies showed positive effects of the TM program.'' Only two studies, 
however, used longitudinal experimental designs with random assignment 
of subjects. Myers and Eisner (1974) randomly assigned young male 
students from a community college (selected from a large pool of 
volunteers). Sixty were assigned to TM, 60 to karate, and 60 to a no-
treatment control group. After 4 months, investigators compared groups 
on use of marijuana, psychedelics, uppers, downers, and hard drugs. 
There was a significant drop in one or more categories of substance 
abuse in TM participants relative to controls. The second study 
(Bounouar 1989), examined 925 TM participants and 6,145 controls who 
attended an introductory lecture on TM. Subjects were followed for 20 
months, examining tobacco consumption levels. Over 80 percent of those 
who meditated twice a day quit or decreased smoking after 20 months vs. 
55 percent of irregular meditators and 33 percent of controls 
(p<.0001). Also see Alexander, C.N., et al (1994). Treating and 
preventing alcohol, nicotine, and drug abuse through transcendental 
meditation: A review and meta-analysis. Alcoholism Treatment Quarterly, 
11(\1/2\), 13-87.
Physical Health
    Because mind body-medicine techniques help to reduce stress and 
anxiety, they also have a direct impact on stress-related physical 
illnesses like cardiovascular disease and cancer, the No. 1 and No. 2 
killers of Americans.
Reducing Blood Pressure
    Benson, H. (1977). Systemic hypertension and the relaxation 
response. New England Journal of Medicine, 296, 1152-1156. This article 
reviews research on the relaxation response and blood pressure (BP). In 
one of the studies reviewed, subjects were taught to elicit the 
relaxation response by meditating for 20 minutes twice/day. After two 
weeks, BPs were measured every two weeks for 6 months (BP's never 
measured after meditation). Among meditating subjects, there was and 
average drop in systolic BP (SBP) during 6 months of 7 mmHG lower than 
at baseline and diastolic BP (DBP) was 4 mmHG lower than at baseline. 
Subjects served as their own controls, with a 6-week run-in period when 
no BP changes were observed before start of study. For subjects who 
``chose to stop meditation,'' both SBP and DBP returned to initial high 
levels within 4 weeks of the end of the study. This review also 
discusses one study (published in 1973 in Lancet) that showed Yoga 
combined with biofeedback reduced SBP by 20 mmHG and DBP by 14 mmHG in 
hypertensive patients treated with antihypertensive medication, 
compared with no statistically significant change in a matched control 
group. A third study using a control group and Buddhist meditation 
reported reductions of 15 mm SBP and 10 mm DBP in patients with 
hypertension (NEJM, 1976). Other studies have also shown significant 
decreases in both SBP and DBP with the relaxation response in 
normotensive working populations.
    Chesney, M.A., Agras, s., Benson, H., Blumenthal, J.A., Engel, 
B.T., Foreyt, J.P., Kaufmann, P.G., Levenson, R.M., Pickering, T.G., 
Randall, W.C., Schwartz, P.J. (1987). Task Force 5: Nonpharmacologic 
approaches to the treatment of hypertension. Circulation, 76 (Suppl I), 
104-109. This is a more recent review of the literature. Authors 
conclude that since 20 million people in the U.S. alone have mild 
hypertension (HTN) and drug treatments for HTN have many potential 
negative side-effects, non-pharmacological treatments ``must be 
explored vigorously'' (p 104). Suggests that for the standard care of 
hypertensive individuals that ``Relaxation-based treatments should also 
be given early consideration in light of the evidence of their 
efficacy'' (p 105).
    Linden, W., and Chambers, L. (1994). Clinical effectiveness of non-
drug treatment for hypertension: A meta-analysis. Annals of Behavioral 
Medicine, 16, 35-45. Perhaps one of the best reviews ever performed of 
mind-body medicine strategies for reducing blood pressure. This review 
is unique in that the authors control for initial blood pressure 
levels. In previous reviews, persons with normal blood pressure were 
included (in such populations it is difficult to demonstrate an effect 
for mind-body strategies on blood pressure because the blood pressure 
cannot be reduced much further). The authors concluded that these 
approaches were equivalent to single drug therapy for hypertension.
    Schneider, R.H., Staggers, F., Alexander, C., Sheppard, W., 
Rainforth, M. Kondwani, K., Smith, S., and King, C.G. (1995). A 
randomized controlled trial of stress reduction for hypertension in 
older African Americans. Hypertension, 26, 820-829. Study involved 111 
African Americans in Oakland, CA, ages 55-85 with baseline blood 
pressures <=179/104 mmHg (mild hypertension). Subjects were enrolled in 
a randomized, controlled single-blind trial of Transcendental 
Meditation (TM) compared with progressive muscle relaxation (PMR) and a 
life-style modification education control program. TM and PMR sessions 
lasted 1.5 hours initially and 1.5 hours/month for 3 months; data 
collected every month. Investigators found that TM had significantly 
greater effects on systolic blood pressure (p=.02) and diastolic blood 
pressure (p=.03) than PMR; SBP was reduced by 10.7 mmHG (p<.003) and 
DBP reduced by 6.4 mm (P<,.0001) for TM. The investigators concluded 
that TM was twice as effective as PMR in reducing systolic and 
diastolic blood pressures.
    Koenig HG, George LK, Cohen HJ, Hays, JC, Blazer DG, Larson DB, 
Larson, DB (1998). The relationship between religious activities and 
blood pressure in older adults. International Journal of Psychiatry in 
Medicine 28, 189-213. Epidemiological study of 4,000 randomly selected 
older adults in North Carolina (NIA-supported Establishment of 
Populations for Epidemiologic Studies of the Elderly (EPESE). Persons 
who both attended religious services regularly and who prayed/meditated 
regularly were 40 percent less likely to have diastolic hypertension 
then those who did not (p<.0001, after controlling for age, sex, race, 
education, smoking, physical functioning, and body mass index). Among 
Black persons in the sample (54 percent of subjects), the effects on 
blood pressure were even greater. Religious activities (especially 
regular prayer and scripture reading) at one wave predicted lower blood 
pressure levels three years later, after controlling for baseline blood 
pressure and other compounding variables.
Heart Disease and Other Cardiovascular Risk Factors
    Zamarra, J.W., Schneider, R.H., Besseghini, I., Robinson, D.K., and 
Salerno, J.W. (1996). Usefulness of the transcendental meditation 
program in the treatment of patients with coronary artery disease. 
American Journal of Cardiology, 77, 867-870. A clinical trial that 
tested the hypothesis that stress reduction intervention with TM could 
reduce exercise-induced myocardial ischemia in patients with known CAD 
(coronary are to read disease). 21 pts with known CAD were recruited 
from the Buffalo, NY VA Hospital and prospectively studied. Subjects 
were randomly assigned to TM (n=12) or waitlist control group (n=9). TM 
group received 10 hrs of basic instruction and follow-up, including 
personal instruction for 60 minutes initially and 30 min twice/week for 
1st month and monthly thereafter. Subject were instructed to practice 
TM 20 min twice/day for 6-8 months. After 8 months, the TM group had a 
14.7 percent increase in exercise duration (p=.01), an 11.7 percent 
increase in maximal workload (p=.004), and an 18.1 percent delay of 
onset of ST depression (p=0.029), whereas control subjects showed no 
substantial changes in these outcomes. Furthermore, the TM group showed 
significantly greater reduction in rate-pressure products after 3 and 6 
minutes of exercise (p=.02), compared to controls.
    Leserman, J., Stuart, E.M., Mamish, M.E., and Benson, H. (1989). 
The efficacy of the relaxation response in preparing for cardiac 
surgery. Behavioral Medicine, Fall, 111-117. In this study, 27 cardiac 
surgery patients (mean age 68) were randomly assigned to either 
educational information + Relaxation Response vs. educational 
information only. On the Profile of Mood States scale, the relaxation 
response group experienced significantly greater reductions in tension 
and anger than the education only group. More importantly, the 
experimental group had lower incidence of supraventricular tachycardia 
(SVT) (p=.04), a dangerous heart rhythm often complicating cardiac 
surgery.
    Sudsuang, R., Chentanez, V., and Veluvan, K. (1991). Effect of 
Buddhist meditation on serum cortisol and total protein levels, blood 
pressure, pulse rate, lung volume and reaction time. Physiology and 
Behavior, 50, 543-548. This was a clinical trial involving 52 males 
ages 20-25 years practicing Dhammakaya Buddhist meditation (similar to 
Zen or transcendental meditation). Control group was 30 males of the 
same age group not meditating. Serum cortisol levels were significantly 
reduced in treatment group (combined A and B), and was different from 
controls (p<.01, all comparisons). Serum protein levels increased after 
6 weeks for combined group (p<.01) and different from controls (p<.05). 
Systolic and diastolic blood pressures both significantly different in 
combined treatment group (p<.01) and significantly different from 
controls (p<.01). Heart rate significantly different at 3 and 6 weeks 
(p<.01) and from controls (p<.01 at 3 wks, p<.05 at 6 wks). Pulmonary 
function (vital capacity, tidal volume, and maximum voluntary 
ventilation) significantly different at 3 and 6 weeks (p<.05) before 
and after in treatment group.
    Alexander, C.N., Robinson, P., Orme-Johnson, D.W., Schneider, R.H., 
and Walton, K.G. (1994). Effects of transcendental meditation compared 
to other methods of relaxation and meditation in reducing risk factors, 
morbidity and mortality. Homeostasis, 35, 243-264. Review of research 
showing that TM is associated with reduced cardiovascular risk factors 
such as hypertension, smoking, cholesterol.
Preventing Cancer and Limiting Cancer Spread
    Koenig HG, George LK, Cohen HJ, Hays JC, Blazer DG, Larson DB 
(1998). The relationship between religious activities and cigarette 
smoking in older adults. Journal of Gerontology (medical sciences), in 
press (November). Cigarette smoking and religious activities were 
assessed in a probability sample of 3,968 persons age 65 years or older 
participating in the Duke EPESE survey. Data were available for Waves 
I-III of the survey (1986, 1989, and 1992). Analyses were controlled 
for age, race, sex, education, alcohol use, physical health, and in the 
longitudinal analyses, smoking status at prior waves. Participants who 
frequently attended religious services were significantly less likely 
to smoke cigarettes at all three waves. Likewise, elders frequently 
involved in private prayer and meditation were less likely to smoke 
(Waves II and III). Total number of pack-years smoked was also 
inversely related to both attendance at religious services and private 
prayer/meditation. Among those who smoked, number of cigarettes smoked 
was inversely related to frequency of attendance at religious services 
and private prayer/meditation. Retrospective and prospective analyses 
revealed that religiously active persons were less likely to ever start 
smoking, not more likely to quit smoking. Those who both attended 
religious services at least once/week and prayed/meditated at least 
daily were almost 90 percent more likely not to smoke than persons less 
involved in these religious activities. The likely impact of religious 
beliefs and activities like prayer on smoking-related diseases--like 
lung cancer and chronic lung disease--is considerable.
    Spiegel, D., Bloom, J.R., Kraemer, H.C., and Gottheil, E. (1989). 
Effect of psychosocial treatment on survival of patients with 
metastatic breast cancer. The Lancet, 2(8668), 888-891. This clinical 
trial examined the effects of a psychosocial intervention on survival 
among 86 women with metastatic breast cancer. The 1-year intervention 
consisted of weekly supportive group therapy with self-hypnosis and 
relaxation for pain. At 10-year followup, only 3 patients were alive 
and death records obtained for the other 83 deceased patients. Among 
those receiving the intervention, average survival was 36.6 months 
compared to 18.9 months in the control group (p<.0001, Cox model). 
Interestingly, differences in survival began 8 months after the 
intervention ended.
Enhancing Immune Function (indirectly affecting cancer risk)
    Carson, V.B. (1993). Prayer, meditation, exercise, and special 
diets: Behaviors of the hardy person with HIV/AIDS. Journal of the 
Association of Nurses in AIDS Care, 4(3), 18-28. Investigators studied 
100 subjects who were either HIV positive or had AIDS. A Personal Views 
Survey developed by Kobasa was used to determine ``hardiness'' (related 
to longer survival in this population). Level of spirituality was 
measured by responses to questions concerning participation in prayer, 
meditation, use of imagery or visualization, reading religious 
literature, spiritual retreats, and church services. A single item 
examined the frequency of prayer. Spirituality (total score) was 
significantly related to greater hardiness (r=0.18, p=.04), although 
only prayer (r=0.233, p=.01) and meditation (r=0.262) were related to 
hardiness when individual items were examined. Hardiness is seen as an 
indirect measure of immune system functioning.
    Woods, T.E., Antoni, M.H., Ironson, G.H., and Kling, D.W. (1998). 
Religiosity is associated with affective and immune status in 
symptomatic HIV-infected gay men. Journal of Psychosomatic Research, in 
press. These investigators examined in the association between 
religious beliefs and behaviors and immune functioning in 106 HIV 
seropositive gay men. Religious activities--prayer or meditation, 
religious attendance, spiritual discussions, reading religious/
spiritual literature--were associated with significantly higher CD4+ 
counts and CD4+ percentages (T-helper-inducer cells) (controlling for 
self-efficacy and active coping with health situation, using regression 
modeling). The effects of religious behaviors on immune function was 
not confounded by disease progression (i.e., as disease worsened and 
immune function decreased, persons unable to participate in religious 
activity).
            utilization of beliefs in health and well-being
    Below I review studies that link beliefs with mental and physical 
health. Religious belief is used here as an example of a common belief 
that Americans possess. Other beliefs, however, might likewise serve as 
examples of the power that beliefs have in affecting health outcomes 
(i.e., belief in a drug or medical treatment, belief in a surgical 
treatment, belief in one's physician, etc.).
Beliefs and Well-being
    Beliefs have been shown to affect mental health by preventing or 
relieving psychological stress and thereby influencing a wide variety 
of psychiatric disorders.
Reducing Stress and Preventing Depression
    Koenig, H.G., Cohen, H.J., Blazer, D.G., Pieper, C., and Meador, 
K.G., Shelp, F., Goli, V., and DiPasquale, R. (1992). Religious coping 
and depression in elderly hospitalized medically ill men. American 
Journal of Psychiatry, 149, 1693-1700. In a consecutive sample of 850 
elderly men acutely admitted to the hospital, investigators found that 
patients who used prayer and religious belief to help them cope were 
significantly less depressed; among a subgroup of 201 subjects, extent 
of prayer and belief predicted lower depression scores 6 months later. 
There are over 100 other studies showing that those who are more 
religiously active experience lower rates of depression, commit suicide 
less often, and have greater well-being (Koenig et al 2000).
Speeding Recovery from Depression or Adaptation to Stress
    Koenig HG, George LK, Peterson BL (1998). Religiosity and remission 
from depression in medically ill older patients. American Journal of 
Psychiatry, 155, 536-542. One year prospective study of 87 medical 
inpatients with depressive disorder to determine predictors of being to 
remission. Twenty-eight physical health, mental health, social, and 
treatment factors were examined. Investigators found that depressed 
patients who had strong intrinsic religious belief recovered over 70 
percent faster from depression than did those with weaker religious 
commitment. In a subgroup of patients whose physical illness was not 
improving (not responding to medical treatments), intrinsically 
religious patients recovered over 100 percent faster. Other 
investigators have reported similar findings in children (Miller et al 
1997) and elderly persons in Europe (Braam et al 1997).
    Propst, L.R., Ostrom, R., Watkins, P., Dean, T., and Mashburn, D. 
(1992). Comparative efficacy of religious and nonreligious cognitive-
behavior therapy for the treatment of clinical depression in religious 
individuals. Journal of Consulting and Clinical Psychology, 60, 94-103. 
Examined the effectiveness of using religion-based psychotherapy in the 
treatment of 59 depressed religious patients. The religious therapy 
involved use of religious beliefs to counter irrational thoughts 
associated with depression. Religious belief therapy resulted in 
significantly faster recovery from depression compared to standard 
secular cognitive-behavioral therapy. What was surprising was that the 
benefits from religious-based therapy were most evident among patients 
who received religious therapy from non-religious therapists.
    Rabins, P.V., Fitting, M.D., Eastham, J., and Zabora, J. (1990). 
Emotional adaptation over time in caregivers for chronically ill 
elderly people. Age and Ageing, 19, 185-190. Followed 62 caregivers of 
persons with either Alzheimer's disease or recurrent metastatic cancer, 
examining factors that predicted adaptation two years later. Strong 
religious belief (p<.0001) and frequent social contacts were the two 
major predictors of adaptation in this group.
Preventing Substance Abuse
    Cochran, J.K., Beeghley, L., and Bock, E.W. (1988). Religiosity and 
alcohol behavior: an exploration of reference group theory. 
Sociological Forum, 3, 256-276. These investigators used survey data 
from General Social Surveys conducted between 1972-1984. During this 
time, 7,581 adults ages 18 or older were surveyed. Results indicated 
that four measures of religiousness (attendance at services, belief in 
life after death, strength of religious belief, and religious group 
memberships) were all inversely related to alcohol use or misuse, after 
controlling for age, race, sex, urbanity, region, education, income, 
and prestige. This study involved a large random national sample of 
Americans of all ages.
    Amey, C.H., Albrecht, S.L., and Miller, M.K. (1996). Racial 
differences in adolescent drug use: The impact of religion. Substance 
Use and Misuse, 31, 1311-1332. These investigators surveyed a random 
sample of 11,728 senior high school students. The dependent variable 
was substance use (LSD, cocaine, amphetamines, barbiturates, 
tranquilizers, heroin, other narcotics, and inhalants). Religious 
involvement was inversely related with all substances. Frequent church 
attendance was associated with 29 percent less cigarette smoking, 45 
percent less alcohol use, 33 percent less marijuana use, 21 percent 
less other drug use. Importance of religious beliefs was associated 
with 25 percent less cigarette smoking, 55 percent less alcohol use, 22 
percent less marijuana use, and 12 percent less other drug use.
                      beliefs and physical health
    Because beliefs impact mental health, they also have effects on 
physical health because of the link between psychological stress and 
physical disorders.
Preventing Cardiovascular Disease
    Goldbourt, U., Yaari, S., and Medalie, J.H. (1993). Factors 
predictive of long-term coronary heart disease mortality among 10,059 
male Israeli civil servants and municipal employees. Cardiology, 82, 
100-121. This was a prospective study of 10,059 Jewish males aged 40 or 
over working as civil servants or municipal employees in Israel. 
Subjects were first assessed in 1963 and mortality from heart disease 
(coronary artery disease) (CAD) was assessed in 1986 (23-year follow-
up). Religious orthodoxy was measured by 3 items (religious vs. secular 
education; self-definition as orthodox believers, traditional 
believers, or secular believers; and frequency of synagogue attendance) 
summed to create an orthodoxy of belief index. The most orthodox group 
had lowest rate of mortality from CAD (38 vs. 61 per 10,000) and other 
causes (135 vs. 168 per 10,000) than did non-believers. The risk of 
death from CAD among most orthodox believers during the 23-year follow-
up was at least 20 percent less than among non-orthodox Jews or non-
believers. These results remained significant after controlling for 
age, blood pressure, cholesterol, smoking, diabetes, body mass index, 
and baseline coronary heart disease.
    Koenig HG, George LK, Cohen HJ, Hays JC, Blazer DG, Larson DB, 
Larson DB (1998). The relationship between religious activities and 
blood pressure in older adults. International Journal of Psychiatry in 
Medicine 28, 189-213. (noted earlier) This was a study of 4,000 
randomly selected older adults in North Carolina participating in the 
NIA-sponsored EPESE study. Persons who both attended religious services 
regularly (reflecting belief) and who prayed/meditated regularly were 
40 percent less likely to have diastolic hypertension then those who 
did not (p<.0001, after controlling for age, sex, race, education, 
smoking, physical functioning, and body mass index). Among Black 
persons in the sample (54 percent of subjects) and younger elderly 
(ages 65-74), the effects on blood pressure were even greater. In these 
groups, religious activities at one wave predicted blood pressure 
levels three years later, after controlling for baseline blood pressure 
and other compounding variables.
Enhancing Recovery from Cardiac Surgery
    Oxman, T.E., Freeman, D.H., and Manheimer, E.D. (1995). Lack of 
social participation or religious strength and comfort as risk factors 
for death after cardiac surgery in the elderly. Psychosomatic Medicine, 
57, 5-15. These investigators at Dartmouth followed 232 adults for six 
months after open-heart surgery, examining predictors of mortality. The 
mortality rate in persons with low social support who did not depend on 
their religious beliefs for strength was 14 times that of persons with 
a strong support network who relied heavily on religion, after other 
covariates were controlled. Even when social factors were accounted 
for, persons who depended on religious beliefs were only about one-
third as likely to die as those who did not.
Preventing Cancer
    Dwyer, J.W., Clarke, L.L., and Miller, M.K. (1990). The effect of 
religious concentration and affiliation on county cancer mortality 
rates. Journal of Health and Social Behavior, 31, 185-202. These 
investigators used county-level cancer mortality data from the National 
Center for Health Statistics (3,063 counties) for 1968-1970, 1971-1974, 
and 1975-1980 to examine the relationship between religious affiliation 
and death from cancer. Investigators found that religion (defined as 
percent of population with full membership or as degree of religious 
conservativeness) had a significant impact on mortality rates from 
cancer, even after controlling for 15 factors known to affect cancer 
mortality. Conservative Protestants and Mormons had the lowest 
mortality rates and counties with higher concentrations of Jews or 
liberal Protestants had the highest cancer mortality. Investigators 
concluded that the general population in areas with high concentrations 
of religious participants may experience health benefits resulting from 
diminished exposure to or increased social disapproval of behaviors 
related to cancer mortality.
Enhancing Immune System Functioning
    Koenig HG, Cohen HJ, George LK, Hays JC, Larson DB, Blazer DG 
(1997). Attendance at religious services, interleukin-6, and other 
biological indicators of immune function in older adults. International 
Journal of Psychiatry in Medicine 27:233-250. First study to examine 
the relationship between religious activities and immune system 
functioning. Investigators found that frequent religious attendance 
(reflecting religious belief) in 1986, 1989, and 1992 predicted lower 
plasma interleukin-6 (IL-6) levels in a sample of 1,718 older adults 
followed over six years. IL-6 levels are elevated in patients with 
AIDS, osteoporosis, Alzheimer's disease, diabetes, lymphoma and other 
cancers. High levels of IL-6 indicate a weakened immune system. 
Findings suggest that persons who attend church frequently have 
stronger immune systems (lower levels of IL-6) than less frequent 
attenders, and may help explain why better physical health is 
characteristic of frequent church attenders.
    Woods, T.E., Antoni, M.H., Ironson, G.H., and Kling, D.W. (1998). 
Religiosity is associated with affective and immune status in 
symptomatic HIV-infected gay men. Journal of Psychosomatic Research, in 
press. (noted earlier) Study of 106 HIV seropositive gay men; religious 
activities--prayer or meditation, religious attendance, spiritual 
discussions, reading religious/spiritual literature (indicators of 
religious belief)--were associated with significantly higher CD4+ 
counts and CD4+ percentages (T-helper-inducer cells) (controlling for 
self-efficacy and active coping with health situation, using regression 
modeling).
Extending Overall Survival
    Strawbridge, W.J., Cohen, R.D., Shema, S.J., and Kaplan, G.A. 
(1997). Frequent attendance at religious services and mortality over 28 
years. American Journal of Public Health 87:957-961. Major study by 
researchers at the University of California at Berkeley reporting 
results of a 28-year follow-up of 5,000 adults involved in the Berkeley 
Human Population Laboratory. Mortality for persons attending religious 
services once/week or more often (reflecting religious belief) was 
almost 25 percent lower than for persons attending religious services 
less frequently; for women, the mortality rate was reduced by 35 
percent. Frequent attenders were more likely to stop smoking, increase 
exercising, increase social contacts, and stay married; even after 
these factors were controlled for, however, the mortality difference 
persisted.
    Multiple other studies (Duke, UC, and Michigan studies) soon to be 
published. The effects of religious attendance (once per week or more 
frequent) on survival are equivalent to 40-60 pack years of cigarette 
smoking.
         mind-body medicine and reduction of health care costs
    A number of studies have now demonstrated that Beliefs may help 
reduce health care costs. This may occur (1) by reducing physical 
disability (which leads to lost productivity, high caregiver costs, and 
expensive nursing home placement) and (2) by directly reducing the most 
expensive form of health care, acute hospitalization.
Reducing Physical Disability
    Pressman, P., Lyons, J.S., Larson, D.B., and Strain, J.J. (1990). 
Religious belief, depression, and ambulation status in elderly women 
with broken hips. American Journal of Psychiatry, 147, 758-759. 
Investigators studied time to recovery in 33 elderly women hospitalized 
with hip fracture. Women who expressed greater religious beliefs and 
devotional practices experienced less depression and were able to walk 
further at the time of hospital discharge (reflecting less disability 
and faster recovery).
    Idler, E.L., and Kasl, S.V. (1997). Religion among disabled and 
nondisabled elderly persons, II: Attendance at religious services as a 
predictor of the course of disability. Journal of Gerontology 52B, 
s306-s316. A 12-year longitudinal study of 2,812 older adults in New 
Haven, CT, conducted by Yale University researchers. Found that 
frequent religious attendance (reflecting religious belief) in 1982 was 
associated with significantly less disability during the 6-12 years of 
follow-up. These findings persisted after controlling for baseline 
physical functioning, health practices, social ties, and indicators of 
well-being.
Reducing Use of Acute Hospital Services
    McSherry E, Ciulla M, Salisbury S, Tsuang D (1987). Spiritual 
resources in older hospitalized men. Social Compass 35(4):515-537. 
Heart surgery patients with higher than average personal religious 
beliefs on admission had post-op lengths of stay that were 20 percent 
less than those with lower than average belief scores.
    Bliss JR, McSherry E, Fassett J (1995). Chaplain intervention 
reduces costs in major DRGs: An experimental study. In Heffernan H, 
McSherry E, Fitzgerald R (eds), Proceedings NIH Clinical Center 
Conference on Spirituality and Health Care Outcomes, March 21, 1995. 
Investigators randomized 331 open-heart surgery patients to either a 
chaplain intervention (supportive of religious belief) or usual care. 
Patients in the intervention group had an average 2 days shorter post-
op hospitalization, resulting in an overall cost of $4,200 per patient.
    Koenig HG, Larson DB (1998). Use of hospital services, church 
attendance, and religious affiliation. Southern Medical Journal, in 
press (October issue). Found an inverse relationship between frequency 
of religious service attendance (reflecting religious belief) and 
likelihood of hospital admission in a sample of 455 older patients. 
Those who attended church weekly or oftener were significantly less 
likely in the previous year to have been admitted to the hospital, had 
fewer hospital admissions, and spent fewer days in the hospital than 
those attending less often; these associations retained their 
significance after controlling for covariates. Patients unaffiliated 
with a religious community had significantly longer index hospital 
stays than those affiliated. Unaffiliated patients (reflecting 
religious belief) spent an average of 25 days in the hospital, compared 
with 11 days for affiliated patients (p<.0001); this association 
strengthened when physical health and other covariates were controlled. 
Intrinsic religious belief was also associated with fewer days in the 
hospital.
    Something needs to be done about rising costs of health care, 
particularly among persons aged 65 years or older. There will soon come 
a time when we will not be able to afford expensive medical and 
surgical treatments for all elderly people (Figure). For that reason, 
it is essential that we focus on relatively low cost mind-body 
therapies that patients can learn and practice themselves in order to 
maintain wellness and speed recovery from illness when it occurs. 
Supporting healthy belief systems may also help empower the self-care 
process. 
[GRAPHIC] [TIFF OMITTED] T07SE22.002

                        why are centers needed?
    First, current study sections and programs are not equipped with 
the sufficient expertise. This is a new area and in the case is being 
made for centers precisely because it doesn't fit typical NIH programs.
    Second, only centers can launch the ambitious, multi-disciplinary 
research projects needed to advance this field. No single investigator 
can do what must and needs to be done. A critical mass of investigators 
is essential.
    Third, centers help with dissemination, since they typically have a 
``dissemination core.'' Dissemination means creating manuals, holding 
workshops and symposia, communicating with media, and moving the 
research into clinical practice. Developing practical applications 
based on rigorous research are not typically a component of 
conventional NIH grants. So there is often a temporal lag between 
scientific findings and their use by clinicians and the public.
                                summary
    There is highly credible scientific research that has established a 
link between psychological and social stress and a host of debilitating 
and costly medical illnesses, particularly cardiovascular disorders and 
cancer, the major killers and disablers of Americans. Traditional 
medical and surgical treatments typically do not include mind-body 
approaches that may empower and motivate patients towards self-care, 
prevent illness, speed recovery, and reduce the costs of health care 
that are quickly spiraling out of control. Patients have become 
accustomed to relying on medical and surgical approaches to their 
illnesses (rather than focusing on things they can do to improve their 
conditions), and physicians have become accustomed to treating sick 
people like broken down cars (fix them when they're broke and send them 
on their way). Patients and physicians need to be educated about and 
encouraged to participate in self-care activities that help to maintain 
wellness and speed recovery.
    The Relaxation Response and ways of eliciting it (like prayer) is 
easily taught and widely acceptable to the American populous. These 
techniques have been shown to enhance well-being by alleviating or 
reducing anxiety, chronic pain, and stress, and by preventing or 
treating alcohol and drug abuse. Consequently, given the relationship 
between psychological stress and physical illness, it is expected and 
has been found that these techniques reduce blood pressure, coronary 
artery ischemia, cardiovascular risk factors (like smoking and 
cholesterol level), lower the risk of cancer or prevent its spread, and 
enhance immune system functioning.
    Likewise, certain Beliefs have been associated with greater well-
being and better physical health. Taking religious or spiritual beliefs 
as an example, these have been associated with lower levels of acute 
stress and prevention of depression, faster recovery from depression 
and adaptation to chronic stress, and prevention or treatment of 
alcohol and drug addiction. Likewise, religious beliefs and practices 
have been associated with a lower risk of death from coronary heart 
disease, with lower blood pressures, enhanced recovery from open-heart 
surgery, prevention of cancer, promotion of positive health behaviors, 
enhancement of immune system functioning, and the extension of overall 
survival. Finally, religious beliefs and practices are associated with 
quicker recovery from disabling illnesses and prevention of costly 
disability in older persons, and (along with chaplain interventions) 
are associated with reduced use of acute hospital services which are 
the most expensive form of health care.
    Mind-body medicine centers will be equipped with sufficient 
expertise to develop this new area in a way that typical NIH programs 
cannot do. Only centers with a critical mass of investigators and core 
infrastructure can launch ambitious, multidisciplinary projects that 
are necessary to advance this field. Centers are also the best way of 
disseminating research findings to the public and to clinicians and of 
rapidly moving the research findings into practical applications.

                         stress and relaxation

    Senator Specter. Thank you very much, Dr. Koenig.
    Dr. Benson, is the essence of mind/body the elimination of 
stress and relaxation?
    Dr. Benson. It is really much more than that, but stress 
and relaxation are perhaps the two best areas. Modern 
neurochemistry, neurobiology is showing us that the mind and 
body are inseparable. What we think influences our bodies; our 
bodies influence our mind. Frequently our minds have difficulty 
in differentiating a reality from a thought. Let me give you 
one example. I will cite the work of Dr. Harold Koenig--I am 
sorry--Dr. Steven Kosslyn. Your speech was so nice, I cited 
you. [Laughter.]
    Dr. Kosslyn at Harvard Medical School had people stare at a 
grid at Harvard University. There was a capital A within that 
grid. He did a PET scan. A certain area of their brain lit up, 
their occipital cortex. Then he had these same people stare at 
the same grid without a letter A.
    Senator Specter. Without a letter A?
    Dr. Benson. Without the letter, without the capital letter 
within it. But in their mind's eye visualized the letter A and 
did another PET scan. Exactly the same.
    The point is this.
    Senator Specter. They said to the individuals to visualize 
the same letter?
    Dr. Benson. That you had been looking at previously within 
the grid, but this time they are simply visualizing it without 
actually seeing it. He did another PET scan, Senator, and the 
same area of the brain lit up. In other words, whether you are 
actually viewing something or think you are viewing it in your 
mind's eye, from the brain's point of view it is a reality. So, 
you see our thoughts are often interpreted as realities to our 
bodies.
    Senator Specter. Well, how would you specify the work that 
you do with the mind as to how it impacts on the body? Dr. 
Anderson, I am going to come to you next on this question. You 
have all these dotted lines going back and forth between the 
behavioral and the physiological factors and the genetic 
factors.
    But, Dr. Benson, in laymen's language what goes on in the 
mind which then has a physiological impact on the body? Two 
examples were given by Dr. Koenig. He talked about cancer and 
about heart disease. Could you start with cancer as to how you 
could specify that?
    Dr. Benson. Yes; stress affects the immune system and 
enhanced stress depresses many immune functions. By focusing on 
a word, a sound, a prayer, a phrase and disregarding everyday 
often stressful thoughts when they come to mind, what happens 
is a set of physiologic changes within the body that are 
opposite to those of stress. Instead of increased metabolism, 
there is decreased metabolism. There is decreased blood 
pressure, decreased heart rate, decreased rate of breathing, 
and slower brain waves.
    Senator Specter. When the stress is relieved.

                            immune function

    Dr. Benson. No; when stress is relieved by focusing on 
thoughts that break the train of everyday stressful thoughts.
    These physiologic changes are opposite to those of stress 
and counteract the harmful effects of stress and, for example, 
have been shown to enhance immune function when regularly 
practiced.
    Senator Specter. Define the immune function please.
    Dr. Benson. Immune function is the ability of the body to 
counteract internal defense systems to foreign invaders. Cancer 
could be viewed as such a foreign invader. If the immune system 
is depressed, perhaps the growth of cancer would be enhanced by 
stress because the immune function would no longer be fully 
operant and controlling the cancer.
    Senator Specter. Well, is that really a good example in 
light of the fact that--or to what extent do we understand the 
causes of cancer so that that would be a factor in inhibiting 
the growth of cancer?
    Dr. Benson. There is no evidence whatsoever that stress 
causes cancer. There is evidence----
    Senator Specter. Is there evidence of the absence of stress 
stops the growth of cancer?
    Dr. Benson. There is no evidence for that, as far as I 
know, Senator.
    However, it has been shown that immune function, the 
protective aspects of the body, do influence perhaps the growth 
of cancer, and there are several studies that have shown that 
relaxation response based therapies do lead to longer survivals 
in patients who regularly carry out these behaviors.

             heart disease--stress and high blood pressure

    A much clearer picture is possible in heart disease where 
stress brings forth the hormones epinephrine and 
norepinephrine, also called adrenalin and noradrenalin. These 
can directly influence high blood pressure. They directly 
influence the amount of blood flow through the coronary 
arteries to the heart muscle, decreasing it, sometimes leading 
to angina pectoris and sometimes, when quite severe, even 
leading to or contributing to a myocardial infarction but 
certainly contributing to atherosclerosis.
    Senator Specter. Are there scientific tests which support 
the conclusion that relief of stress has a direct impact on 
heart disease?
    Dr. Benson. There are considerable studies that Dr. Koenig 
has, in fact, reviewed or at least alluded to that show that 
stress is a direct contributor to high blood pressure and that 
relief of stress can lower blood pressure which in turn lowers 
the risk of heart disease.
    Furthermore, stress has directly contributed to angina 
pectoris, and it is shown that belief system, for example--
thoughts of a person can directly influence angina pectoris. 
Let me be specific.
    Therapies have been used for angina pectoris for over 200 
years. The diagnosis has never been changed, but a number of 
bizarre therapies have come along. These include cobra venom, 
xanthines, aminophylline, vitamin E, bizarre surgeries such as 
ligation of the internal mammary artery. Absurd. It should not 
work and it does not. But at one time they were believed in by 
physicians, and we did a study that was published in the New 
England Journal of Medicine that showed when these therapies 
were believed in, before they were shown to be bogus, they were 
70 to 90 percent effective in alleviating angina pectoris. And 
not only did the relief of the pain of angina occur, but also 
the exercise tolerance of these patients improved and their 
electrocardiograms normalized. When these therapies were no 
longer believed in by patients, specifically by their 
physicians, their effectiveness dropped to 20 to 30 percent. In 
other words, belief here translated itself into a marked 
healing capacity.
    Senator Specter. So, you have relaxation and stress and you 
have belief as two big factors. Any others?
    Dr. Benson. Yes; health and well-being is best viewed as 
being akin to a three-legged stool being held up by one leg of 
pharmaceuticals, a second leg of surgery and procedures, but 
there should be a third leg to that three-legged stool and that 
third leg is self-care.

                        self-care and relaxation

    Now, two components of self-care are relaxation procedures 
and another is the belief system of patients. Several other 
components are nutrition, exercise. The cognitive, behavioral 
stress management approaches are also aspects of the third leg. 
So, in addition to relaxation----
    Senator Specter. Say that again. Cognitive what?
    Dr. Benson. Cognitive restructuring, psychological 
approaches, where your thinking is used to actively change your 
thoughts themselves which in turn influence the physiology.
    Senator Specter. Is that like belief?
    Dr. Benson. It is akin to belief. Yes; in a sense because 
it does restructure your belief system, but whereas belief 
tends to involve not only secular but also religious/spiritual 
approaches and cognitive/behavioral approaches are generally in 
the secular/psychological realm.
    Senator Specter. Cognitive is in the secular/psychological 
realm, unlike belief which has a religious component.
    Dr. Benson. As well, yes.
    Senator Specter. Dr. Anderson, would you amplify that 
dotted line between physiological factors and genetic factors?
    Dr. Anderson. Yes.
    Senator Specter. I always thought that the genes were 
pretty much out of our control.
    Dr. Anderson. Actually no. The genetic makeup that we are 
born with certainly is out of our control, but really one of 
the most exciting frontiers in genetics research is the 
question of what turns genes on and what turns them off. I 
think the area of gene expression now is showing very clearly 
that things outside of our genetic structure actually determine 
whether genes are activated.
    Senator Specter. So, genes are not immutable? If you have 
two parents who were 90, those genes are not going to carry you 
to 90 by themselves. They have to be turned on?
    Dr. Anderson. It depends on one's exposures across the life 
course, whether one is exposed to certain types of diet, 
perhaps even chronic stress. Other environmental factors will 
determine exactly which genes are turned on and turned off.
    You asked specifically about----
    Senator Specter. I can understand that genes might not be 
the sole determinant, but explain a little further, if you 
would, the turn on or the turn off of genes.
    Dr. Anderson. Well, I will go back to your original 
question about the physiological factors and genetic factors 
and that interaction. Research is now showing that 
neuroendocrine factors, such as adrenalin, noradrenalin, 
actually act on genes to cause the genes to produce proteins 
which then go on to produce other factors that affect health 
and illness. So, genes are not operating alone. They interact 
with physiological factors and, as we are learning now, 
behavioral factors.

                    susceptibility to breast cancer

    Senator Specter. Dr. Anderson, when we talk about tests 
which would examine the genes, say, of a young woman to make a 
determination as to susceptibility to breast cancer and we face 
all the difficult ethical questions about how to handle that 
and whether to tell the insurance company, are you saying that 
the analysis of the genes alone would not be determinative as 
to her developing breast cancer but it would depend upon other 
factors intervening to turn on or turn off the genes?
    Dr. Anderson. Yes; again, I will qualify my comments by 
stating that I am not a geneticist, but it is very clear that 
genes are significant risk factors--and I underscore that term, 
risk factors--for cancer. However, everyone who carries a 
genetic risk for cancer does not go on to develop the disorder. 
One of the areas of research that NIH is very interested in is 
determining among those people who have a genetic risk which 
ones then go on to develop cancer. The direction of this 
research is looking in part at nongenetic factors.
    Senator Specter. Are there scientific tests which have 
shown some basis for concluding what would prevent somebody 
with a gene, a predisposition to cancer, to avoid developing 
cancer?
    Dr. Anderson. I do not know of any specific test as yet. 
This is one of these areas of scientific opportunity that NIH 
is interested in, and we cannot say conclusively what factors, 
among those people with a genetic risk, will prevent them from 
going on to develop cancer.
    Senator Specter. How long has medical science really 
understood the genetic factor even to be able to conduct tests 
as to whether that is the dominant or influenceable by other 
considerations?
    Dr. Anderson. Well, interest in genetics has gone on for 
some time, but I think in the last decade or so with the 
advances in molecular biology, there has been obviously an 
increased interest as evidenced by the Genome Institute at NIH.
    What we have not done as yet is linked these boxes in the 
figure. We know a lot about genetic factors. We know a lot 
about behavioral and physiological factors, but we have not 
done as good a job as we could of linking these factors. 
Ultimately the things that cause disease are interdependent and 
linked.
    Senator Specter. I am just inquiring of staff how long the 
Genome Institute has been in high gear and I am told since 
1990. Are they, to your knowledge, conducting tests to see what 
would stop the path from predisposition, say, in the genes to 
cancer to eventuating in cancer?
    Dr. Anderson. I cannot answer that conclusively. I do not 
know all of their portfolio in the area. I would be happy to 
find out from Francis Collins about that.
    Senator Specter. Do you know whether they are studying any 
of the mind/body aspects as to what happens when there is a 
genome predisposition?
    Dr. Anderson. They do have a portfolio in their ethical, 
legal, and social aspects of genetics research.
    Senator Specter. Ethical, legal, and social.
    Dr. Anderson. Yes.
    Senator Specter. Would that cover mind/body?
    Dr. Anderson. Mind/body would be a part of that, yes.
    Senator Specter. So, you are saying the Genome Institute 
does have some mind/body in it?
    Dr. Anderson. Well, again, it depends on one's definition 
of mind/body.
    Senator Specter. Say Dr. Benson's definition of mind/body.
    Dr. Anderson. Well, what I would like to do, if I could, is 
go back to the figure. I am not sure that the Genome 
Institute--and again, I can determine this conclusively--
whether they are looking at these interactions, the 
interactions of physiological factors on genetics or behavioral 
and social on genetics. I am just not that familiar enough with 
their portfolio to say conclusively if they are doing that.
    Senator Specter. Well, we will check that out. Staff will 
do that. I would like to find that out.
    Dr. Koenig, you had mentioned cancer as a disease which 
would be influenced by mind/body studies. Would you amplify 
that please?

                  stress and immune system functioning

    Dr. Koenig. As Dr. Benson said, cancer has many different 
types of causes, and there is again this connection between 
stress and immune system functioning. Now, when people become 
depressed or stressed out, their body starts pouring out what 
is called cortisol. Cortisol comes from the adrenal glands, and 
what that does is that directly then impacts on the functioning 
of the blood cells that then attack cancer cells as they 
develop. It is called the theory of immune surveillance where 
the immune system actually guards and grabs hold of these 
cancer cells as they are initiating in the body, which is 
probably happening all the time.
    Now, again if people are less depressed, if they are 
experiencing less stress because of the mind/body techniques, 
belief, repetitive prayer, the relaxation response, then those 
negative health consequences, the cortisol being released, is 
not going to happen as likely.
    Furthermore, belief systems determine whether or not 
someone will drink alcohol, smoke cigarettes, and do a whole 
host of different activities that can lead to cancer.
    Senator Specter. When you feature so prominently, as you 
do, Dr. Koenig, the religion/spirituality aspect of mind/body, 
are there any scientific studies that show that people who are 
more religious have fewer diseases or fewer ailments?
    Dr. Koenig. Yes; there are, Senator. In the psychological 
health realm, there are probably well over 200 studies that 
have shown this. We have done at least 10 at Duke.
    We are also now looking again at physical health 
consequences. We have been able to show that people who attend 
religious services regularly and who frequently pray, read the 
Bible, that those people have a 40-percent reduction in the 
likelihood of having diastolic hypertension which is directly 
the factor that causes stroke and heart attack. We have also 
been able to show that people who are more religiously involved 
do not smoke cigarettes as often, and so invariably you are 
going to see lower rates of chronic pulmonary disease and lower 
rates of cancer.

       religious beliefs and practices--better immune functioning

    We have also been able to show that religious beliefs and 
practices are associated with better immune functioning. We can 
measure interleukin-6 levels in the blood stream and show that 
people who have a strong faith and are participating in 
religious activities actually are less likely to have high 
levels interleukin-6 in their blood stream which is an 
indicator of a weakened immune system. People who have AIDS 
have high levels of interleukin-6 in their blood stream. So, 
people who have a strong faith seem to have lower levels of 
this substance in their blood stream, suggesting that they have 
stronger immune systems.
    There have been at least six studies now that have shown 
that people with strong beliefs simply live longer, and these 
are studies performed at the University of California-Berkeley, 
as well as at Duke and institutions in different areas of the 
country. So, it is not simply one single research group that is 
finding these positive health effects. It is multiple, 
different, prominent investigators.
    Senator Specter. So, the religious aspect impacts on a 
number of areas related to this field. One is the belief in and 
of itself. When people pray, they have faith that they will get 
better because of divine intervention. So, they do get better?
    Dr. Koenig. That certainly can be a mechanism by which it 
occurs.
    Senator Specter. Is there any scientific evidence to 
support that in isolation?
    Dr. Koenig. Well, there are certainly lots of case reports 
that have shown that. For example, there is a case report 
published in, I believe, Archives of Internal Medicine that 
shows that an older woman who had atrial fibrillation, which is 
a serious cardiac arrhythmia, was going to go in for 
cardioversion.
    Senator Specter. How serious is atrial fibrillation?
    Dr. Koenig. Atrial fibrillation can increase the 
ventricular rate so that people can develop congestive heart 
failure and certainly, if they do not have cardiac reserve, 
they can die from it.
    Now, she was going to have a cardioversion where they put 
the paddles on and kind of snap the rhythm back, but she and 
her family got into a prayer group before the procedure and 
they prayed for and she prayed and did some chanting and it 
reversed completely.
    Another example is----
    Senator Specter. That can happen without prayer too, can it 
not?
    Dr. Koenig. Yes; it can.
    Senator Specter. Dr. Benson, you had your hand up. We are 
going to get back to you, Dr. Koenig. We are just beginning, 
but go ahead, Dr. Benson.

                        healing power of belief

    Dr. Benson. Thank you. Several points.
    Supporting what Dr. Koenig says, I would like to point out 
how we in medicine have dealt with belief system. We know in 
medicine that belief can heal, but we have dealt with the 
healing power of belief in a very pejorative fashion. We have 
labeled it the placebo effect: It is all in your head. What has 
evolved over these----
    Senator Specter. What is wrong with that? I thought if it 
was all in your head, it was good.
    Dr. Benson. All in your head is terrific, but take the case 
of a woman who was suffering from multiple symptoms of unclear 
etiology, four to five doctors all saying it is in your head. 
She was so upset because it was a pejorative that when she 
received----
    Senator Specter. Like gulf war syndrome.
    Dr. Benson. Pardon?
    Senator Specter. Like gulf war syndrome, told all the 
veterans from the Gulf it was all in their head. They became 
very distressed about that. It added a new level of distress to 
the gulf war veterans.
    Dr. Benson. Exactly.
    Let me finish up, if I may, Senator, with this woman's 
case. When she got the diagnosis of multiple sclerosis, which 
in her case was life-threatening, she was thankful for that. 
She was so put down by it is all in your head, that she would 
rather have a life-threatening disease.
    Now, we in medicine over this last 150 years have developed 
marvelously, awesomely, spectacularly effective treatments, the 
antibiotics, insulin, surgeries that by biblical standards are 
producing miracles on an assembly line basis. The blind can see 
again with cataract operations. We became in medicine depending 
only on the first two legs of the three-legged stool, 
pharmaceuticals, surgery and procedures, and said we do not 
need that third leg. We can do it all by your simply taking the 
drug or having this surgery.
    It is not enough because beliefs are effective and we know 
this in medicine when we test a new substance against, let us 
say, a placebo tablet, as we often do. Placebos are effective 
in 50 to 90 percent of cases that involve angina pectoris, 
asthma, congestive heart failure, rheumatoid arthritis, all 
forms of pain. In fact, death itself can be caused by belief. 
If you believe in voodoo and you have a hex placed on you, you 
could die.
    But we in medicine, comparing the placebos against a new 
drug, if both were 60 percent effective, we would drop them 
both because we are looking that the drug was better than 
belief. We have not focused enough on the power of belief and 
asked the question what is it that makes belief and placebos 
work? Now, that is the way we deal with belief in medicine and 
that has been a problem.
    Now, in America some 95 percent of people believe in God. 
This, for them, is their most powerful belief. It is no 
surprise then that such powerfully belief-related therapies, 
such as belief in God, can result in healing. We must pay more 
attention to it.
    Now, that is a long introduction to answer what I believe 
was your question, Senator, and that is, is religious belief 
the only way? No; belief itself is what is important, but the 
belief of the individual has to be honored. It could be 
secular. It could be religious. And that is what we are in a 
position to do now by paying attention to belief, by studying 
the mind/body effects whereby beliefs do lead to the findings 
that others have found, and I think mind/body centers would be 
a way to emphasize that. That is why belief related therapies 
will, of course, include religious beliefs but will include 
other beliefs as well.
    Senator Specter. What kind of beliefs other than religious 
beliefs?
    Dr. Benson. Belief in your doctor, belief in the healing 
power of your body to heal, nature's power to heal, belief in 
relationships. All of these are powerful beliefs.
    Take one study, if I may, that was done by Dr. Ochsman----
    Senator Specter. Because these beliefs will reduce stress 
and anxiety?
    Dr. Benson. Yes; and can have direct effects on disease.
    Men undergoing bypass surgery at Dartmouth Medical School--
this was a study by Ochsman. These were all men over 54. Those 
who believed in God had one-third the mortality. Those who 
believed in God and also had a very strong social support 
system, the very sort of aspects that the Office of Behavioral 
and Social Sciences Research look at, those who also had a 
strong support system, Senator, had one-tenth the mortality of 
those who did not. Support system is vital. This is a 
behavioral factor related to belief as well.
    Senator Specter. Let me come back to you, Dr. Koenig. When 
you were talking about the religious aspect, we started to talk 
about the belief, the religious aspect would also impact on 
stress and would also impact on items like smoking. So, there 
are quite a number of factors on mind/body which the religious 
beliefs would impact on.
    Dr. Koenig. That is correct, Senator.
    Senator Specter. To what extent is the issue of religious 
belief, having this medical benefit which you describe here, 
talked about and touted in the field of religion to induce 
people to go to religious services and become more religious?
    Dr. Koenig. Very little I think. I think that I have found 
that the clergy has not been tremendously receptive to this 
research, which is surprising to me because I would think that 
this would be----
    Senator Specter. A pretty good talking point.

                          science and religion

    Dr. Koenig. Right, but they really have not been all that 
receptive. I think that the barrier between science and 
religion----
    Senator Specter. They do not like to deal with doctors.
    Dr. Koenig. That could also certainly be, or subjective 
beliefs of the science.
    Senator Specter. When you talked about belief in the 
doctor, would that apply to lawyers, Dr. Benson?
    Dr. Benson. Would that apply to?
    Senator Specter. Lawyers?
    Dr. Benson. Belief in lawyers, belief in your lawyer. Yes; 
that is an interesting phenomenon and I am not totally 
qualified----
    Senator Specter. It is a question, Dr. Benson.
    Dr. Benson. Would belief in your lawyer lead to better 
health and well-being?
    Senator Specter. Well, you talk about a social support 
system. You mentioned doctors. It is just natural to ask a 
question about whether belief in the lawyer would have a 
similar beneficial effect.
    Dr. Benson. In my 30 years of answering questions, that is 
the first time I have faced that one, Senator. [Laughter.]
    Senator Specter. You ought to do more town meetings. You 
would find a lot of new questions. [Laughter.]
    Well, it is only said slightly in jest, Dr. Benson. You are 
talking about beliefs.
    How do you account for the fact, Dr. Anderson, that at 
least according to the information presented to me, these mind/
body studies are only at Harvard and Duke?
    Dr. Anderson. I think that probably reflects the panel that 
is assembled here, but in fact----
    Senator Specter. No; are there any besides Harvard and 
Duke?
    Dr. Benson. Are there mind/body medical centers?
    Senator Specter. Correct.
    Dr. Anderson. I do not think there are very many things 
called mind/body medical centers out there, no. But there are 
research groups at a number of universities around the country 
who are interested in and who study mind/body medicine, yes.
    Senator Specter. Can you give me an illustration of where 
such a study is undertaken and the parameters of it generally?
    Dr. Anderson. Certainly. Let us start with the University 
of Pittsburgh. They have a well-developed research program in 
an area called psychoneuroimmunology.
    Senator Specter. Psychoneuroimmunology.
    Dr. Anderson. And it is a field that the very long word 
suggests. It looks at the interaction of psychological, 
neuroendocrine, and immune system factors, particularly how 
stress affects the immune system. There are a number of groups 
that are interested in that very topic at Pittsburgh, at Ohio 
State, at UCLA, and the University of Miami in Florida, just to 
name four.
    Senator Specter. Well, stress is an important component of 
what has been discussed here today, but only one component.
    Dr. Anderson. It is only one component.
    Senator Specter. Does the psychoneuroimmunology group at 
Pittsburgh pick up the issue of beliefs?
    Dr. Anderson. In the broadest sense. I do know of one 
researcher there by the name of Mike Scheier who studies the 
influence of an optimistic attitude on the immune system and 
the cardiovascular system, that is, in a sense a belief in the 
broadest sense of that term that one will experience positive 
outcomes as opposed to negative outcomes.
    Senator Specter. Dr. Anderson, what is your professional 
opinion on the interest that the Senate, at least through the 
full Appropriations Committee, has stated on mind/body and 
allocating some $10 million? We are interested on the 
subcommittee in the wide range of research activities. NIH has 
a budget somewhat larger than $10 million. I do not know what 
fraction $10 million would be of $13.6 billion. We ought to 
figure that out. [Laughter.]
    And then the second part of the question would be what 
percentage it would be of $15.6 billion, if you get a $2 
billion increase.
    But do you think that this money would be well spent to try 
to develop other centers which would focus on the subject 
matter which your unit heads?
    Dr. Anderson. Let me provide a multi-layered response to 
that question. As a representative of the entire NIH and not 
just my office today, as you know, NIH really prefers maximum 
flexibility in creating funding initiatives and has----
    Senator Specter. Do you think for this committee to say $10 
million is too much direction on $13.6 billion?
    Dr. Anderson. Well, let me just complete this thought, that 
we do prefer maximum flexibility. However, if you are asking if 
there are areas of scientific opportunity enough to warrant 
funding supporting $10 million of research in this area, yes, 
there are a number of areas of scientific opportunity, only 
some of which were discussed today. If these funds are 
earmarked for NIH, we would prefer flexibility in creating the 
mechanism of funding, because for some research areas, centers 
are not the way to go. In other research areas, they might be.

                                research

    Senator Specter. What are other research possibilities are 
you thinking of, Dr. Anderson?
    Dr. Anderson. They could be research in--well, I will name 
three areas. One has to do with biological, psychological, and 
social interactions that we talked about earlier. There is a 
great deal of scientific opportunity in the 
psychoneuroimmunology area that I have already mentioned, the 
effects of behavior and stress on the brain, behavioral 
genetics, and behavioral cardiology. There is also----
    Senator Specter. Are those items taken up by NIH at the 
present time?
    Dr. Anderson. Yes; they are taken up by NIH, but there are 
also additional areas of scientific opportunity. These are 
areas that my office is actively pushing because there are so 
many questions that need to be addressed.
    Senator Specter. These are in the behavioral and social 
sciences research area.
    Dr. Anderson. Yes; under which I would put research on 
stress and research on belief.
    Senator Specter. What is the total budget of your unit?
    Dr. Anderson. My office? It is about $2.8 million.
    Senator Specter. $2.8 million?
    Dr. Anderson. Yes.
    Senator Specter. That is not a very large share of the NIH 
pie, is it?
    Dr. Anderson. No; it literally is not, but our recent 
estimate of how much the Institutes fund in the larger field of 
behavioral and social sciences research is over a billion 
dollars.
    Senator Specter. You say the overall figure for behavioral 
research is a billion dollars?
    Dr. Anderson. Yes.
    Senator Specter. Under whose office does that fall?
    Dr. Anderson. Well, this is all investigator initiated 
research. As you know, most of the research that NIH funds, NIH 
does not ask for proposals or set aside money for specific 
areas, but tells the investigators, send in your proposals, 
send in your ideas, and they get peer reviewed once they come 
into the NIH system.
    Senator Specter. So, you say a billion dollars is now being 
allocated on the behavioral subject?
    Dr. Anderson. Behavioral science, yes.
    Senator Specter. Behavioral science.
    Dr. Anderson. Of which the fields we are talking about 
today are a subset.
    Senator Specter. How much is being allocated to mind/body 
studies at the present time, if you know?

                          health and behavior

    Dr. Anderson. That is very hard to determine because of a 
lack of a clear definition. One definition that NIH has been 
assessing their portfolio based on is called health and 
behavior. The health and behavior number includes many of the 
things that we talked about today, but some additional things 
as well. The 1997 number was about $900 million, but that 
includes things such as research on diet, research on smoking, 
research on exercise, alcohol use, and drug abuse as well. So, 
it is much broader than the topic today.
    Senator Specter. Well, you say some items do not lend 
themselves to centers. Would you say the center at Duke on 
mind/body is a good organizational approach?
    Dr. Anderson. It has worked well at Duke, based on my 
understanding of the center, but when we talk about centers in 
an NIH context, we are talking about something very specific, 
that is, the center grant mechanism, which is a very specific 
mechanism, actually a set of mechanisms. I think there are 
about five or six. Most of these are fairly large research 
grants that have a core facility that a number of investigators 
use. And for some research areas, frankly they are not ready 
for centers yet. Others might be. What we would like to do is 
leave it to the investigators to determine whether the research 
they are interested in is appropriate for a center or what we 
call an RO1 or an investigator initiated grant, a program 
project grant, or a training grant.
    Senator Specter. What is your thinking on that, Dr. Benson? 
We have taken the center approach. I am not sure the 
nomenclature is necessarily the last word, but how do you 
respond to what Dr. Anderson has said?
    Dr. Benson. The progress that NIH has made with the 
approaches that Dr. Anderson has just outlined are truly 
spectacular. To be funded in a so-called RO1 grant, one has to 
go through appropriate study sections, and the study section 
approach tends to be quite narrow in its focus--has to be--
because the way that kind of science is defined is that it is 
next-step research, namely that there is ample research that 
brought you to this point, and the next logical question would 
be to have a given intervention, something changing, and then 
see what happens to the system under study.
    When you start getting into mind/body areas, you are 
looking at multiple simultaneously interacting systems. The 
present mechanisms at NIH cannot really do adequate justice to 
assessing such approaches because of their traditional narrow, 
reductionistic approach. This is why centers are necessary to 
be able to study simultaneously occurring phenomena at 
different levels, physicochemical, biological, social, and look 
at interventions that are not characteristically normally 
looked at. We are not looking at a new drug or a new chemical 
substance. We are looking at thought patterns.
    Senator Specter. Dr. Koenig, what do you think about Dr. 
Benson's approach?
    Dr. Koenig. I agree that the current NIH programs do need 
to focus in on specific kind of reductionistic areas, whereas 
centers have the option of bringing together multiple different 
disciplines together, the sociologist, psychologists, the 
medical physicians, the anthropologist, bringing them all 
together and working together. That is particularly important 
for a field like this that is relatively new and needs kind of 
initiation, and because it involves multiple different 
disciplines and expertise in each of those disciplines as 
opposed to just requiring, say, a single expertise such as in 
psychiatry.
    Senator Specter. Dr. Koenig, do you think that a $10 
million allocation is realistic to look toward initial 
financing of, say, half a dozen centers?
    Dr. Koenig. What I think is that actually probably the 
money would be better spent on only about three or four 
centers, simply because there are only about that number of 
centers that have the critical mass in place and the 
infrastructure that can really get up and start doing something 
because this is really----
    Senator Specter. Would you include Duke as one? [Laughter.]
    Dr. Koenig. Well, certainly we have the----
    Senator Specter. I would ask you if you would include 
Harvard as one and ask Dr. Benson if he would include Duke as 
one.
    Dr. Koenig. Yes; I think Duke has multiple, different 
disciplines and we have established----
    Senator Specter. What institutions beside Duke and Harvard, 
or Harvard and Duke?
    Dr. Koenig. Well, I think Dr. Anderson said Pittsburgh. 
Pittsburgh and UCLA are probably the two highest runners. There 
are multiple different investigators at each of those 
institutions that are already studying it.
    Senator Specter. Only one in Pennsylvania? [Laughter.]
    Dr. Benson. Where does your support system come? 
[Laughter.]
    Senator Specter. It is a challenging matter for the 
Congress to try to deal with these matters--the Senate, the 
committee, the subcommittee. There is a fair amount of 
resistance at NIH for congressional suggestions. There are some 
markers laid down on the prostate cancer this year, last year 
on Parkinson's, in the past on other lines. Generally there is 
not too much tension between the Congress and NIH because the 
Congress does not know very much and does not get very much 
involved, so we do not give you much trouble, Dr. Anderson. We 
pretty much leave you with billions of dollars to spend as you 
see fit.

                   alternative medicine and mind/body

    But my own sense is that on mind/body there is a different 
line and a need to develop it. Precisely how is really up to 
the experts. I have a sense that a center, as Dr. Koenig and 
Dr. Benson outline it, would be a good approach. It is going to 
have to be administered by NIH and there is going to have to be 
cooperation by NIH to whatever line Congress says, but we have 
given you a lot of money to work on other lines because we 
think you are so successful and are doing such very important 
work.
    Before we conclude the hearing, I think we ought to have a 
definition as to the distinction between mind/body which some 
may confuse with alternative medicine. Let me turn to you, Dr. 
Benson, to give a definitional distinction between alternative 
medicine and mind/body.
    Dr. Benson. Let us go back to the metaphor of the three-
legged stool, health and well-being being held by a three-
legged stool. One leg is pharmaceuticals. The second leg is 
surgery and procedures, and the third leg is that self-care 
leg. In that self-care leg, we have the relaxation response, 
belief, nutrition, exercise, and stress management, cognitive 
work.
    Now, first of all, mind/body medicine has a great deal of 
scientific evidence behind it. Mind/body medicine, therefore, 
is largely scientifically proved. Alternative medicine is not 
scientifically proved. If it were, it would no longer be 
alternative.
    Secondarily, alternative medicine is not in the self-care 
realm. There is little difference between an herb and a 
pharmaceutical. It is given to you.
    Secondarily, with the second leg, there is little 
difference between acupuncture, let us say, and a surgical 
procedure. It is done to you, whereas self-care is something 
you do for yourself.
    Another element of mind/body medicine that has not been 
adequately covered in this particular hearing, Senator, is the 
cost savings. Preliminary data now show that these self-care 
approaches decrease visits to doctors in HMO settings by 
upwards of 50 percent, and in capitated HMO settings, this is 
money in the bank.
    In contrast, alternative medicine appears to be cost 
additive. People do not give up their doctor. They do not give 
up their surgery, their penicillin, but they take an herb or 
they take a procedure with it. So, from a cost savings, long-
term point of view, these mind/body approaches will save money 
where alternative medicine will probably add money.
    Senator Specter. You say mind/body saves money for HMO's. 
Do HMO's include mind/body in their coverage sheet?
    Dr. Benson. The HMO scene to my assessment is a frightful 
one. They are simply cutting costs and they are cutting down on 
some--many of them are responding to anything new in a very 
defensive way. For example, for a belief to be enhanced, the 
doctor/patient relationship is vital. HMO's are cutting down on 
the amount of time that a doctor can spend with his or her 
patient. That is awful because that is undermining the----
    Senator Specter. Do HMO's generally cover mind/body?
    Dr. Benson. The HMO's are now beginning for the first time 
to cover mind/body approaches because they are beginning to see 
the cost savings aspect. In fact, the Mind/Body Medical 
Institute, of which I am president, has as one of its major 
programs teaching and training, and more and more HMO people 
are coming to us to learn these approaches that are being 
sponsored. For example, Kaiser in California is now learning 
our approaches. It is a beginning. We need much help, though. 
This is another thing the centers would do. They would enhance 
teaching and training capabilities. For example, we are much 
too small. If--and I hope--these approaches will catch on to 
teach and train the health care professionals of our Nation, 
and the centers would be one way to enhance such teaching and 
training.
    Senator Specter. Dr. Koenig, is there anything you would 
care to add before we conclude the hearing?

                   changing people and their behavior

    Dr. Koenig. Well, I would like to actually just continue to 
respond to your first question. Ten million dollars is a lot of 
money, and whether or not that should be appropriated. I think 
truly that is a small investment when you consider the 
potential benefits of these belief related and relaxation type 
responses. These are behaviors that can oftentimes change--
changing a belief system can potentially help a person's health 
for the rest of their life, and learning some of these very 
simple relaxation techniques can be incorporated and it can 
last again for years and years. The potential cost savings by 
changing people and their behavior, particularly with regard to 
smoking or drinking, could be potentially huge. We have to do 
something about that, given the costs of the baby boomers that 
are aging and just are overwhelming our health system.
    Senator Specter. Dr. Anderson, is there anything you care 
to add?
    Dr. Anderson. Yes; if an earmark is given for OBSSR, we 
would prefer to give investigators maximum flexibility in 
determining the mechanism, that is, not limiting it to centers, 
but including centers but also other mechanisms as well.
    Senator Specter. Could you give me a written response as to 
whether there are mechanisms you would like to see, how you 
would like to see it structured?
    Dr. Anderson. Yes.
    Senator Specter. In light of your administration of the 
program.
    Dr. Benson, a final word?
    Dr. Benson. We are very thankful. I am very thankful--we at 
the Mind/Body Medical Institute are--for this opportunity to 
present these data to the subcommittee.
    I would like to end with a financial consideration, that as 
I noted at the outset, we expect that data are now supporting 
that $2.1 trillion will be spent by the year 2007 on health 
care. This is a doubling. Yet, if we look at mind/body 
approaches that are inherently cost saving, our calculations 
show that conservatively they could save $54 billion per year 
by people learning to take better care of themselves with self-
care approaches that include those we have defined today.
    Senator Specter. $54 billion now or by 2007?
    Dr. Benson. 2007. This was published just recently, in 
fact, this month--these estimates of a doubling to $2.1 
trillion.

                           prepared statement

    Senator Specter. The following statement was received from 
Caesar A. Giolito, executive director, National Interfaith 
Coalition for Spiritual Healthcare and Counseling, Washington, 
DC, by the subcommittee and I would like it to be made part of 
the record at this time.
    [The statement follows:]

 Prepared Statement of Caesar A. Giolito, Executive Director, National 
      Interfaith Coalition for Spiritual Healthcare and Counseling

    The National Interfaith Coalition for Spiritual Healthcare and 
Counseling is composed of thirty-two national associations and faith 
groups responsible for the nationwide delivery of certified pastoral 
care and counseling services in a wide variety of settings such as 
medical and mental health facilities, pastoral counseling centers, 
churches, synagogues, diverse workplaces, military installations, 
correctional facilities, rehabilitative centers, nursing and long-term 
care facilities, addictive treatment centers, hospices, and through 
solo practitioners.
    These associations are composed of interfaith ministers and persons 
endorsed by religious faith groups and trained, certified, and/or 
licensed in pastoral care and counseling, including pastoral 
counselors, chaplains, clinical pastoral care educators, mental health 
clergy, parish ministers, and seminary professors. The associations 
also include accredited pastoral counseling centers and clinical 
pastoral education teaching institutions, as well as over 100 
theological schools throughout the nation. These providers of service 
and education have received specialized graduate training in both 
religion and the behavioral sciences, and practice and/or teach the 
integrated discipline of pastoral care and counseling.
    The purpose of this coalition is to promote the role of qualified 
pastoral care and counseling and make it accessible to the vast numbers 
of people in our nation who have the need and desire to integrate the 
spiritual dimension into their mental and physical healing.
    A vast growing number of the general public, clergy, theologians, 
physicians, clinical psychologists, clinical social workers, nurses, 
mental health counselors, medical community professionals and other 
practitioners, educators, and researchers agree that the underlying 
principles of spiritual healing are universal; that healing of the 
spirit promotes and accelerates healing of the mind and body, and that 
the total healing of the individual and society itself cannot be 
realized without the effective treatment of the whole person--mind, 
body, and spirit.
    It has been the usual case that spiritual healthcare providers have 
been the energizing force in the area of belief-related therapy, and 
continues to be so. Chaplains and pastoral counselors in many medical 
institutions around the country are very much part of the healthcare 
delivery team, and, for the most part, physicians, nurses, and other 
medical personnel have been interested and supporting onlookers.
    As studies in the area of the spiritual dimension and its effects 
on health have proliferated, with mounting evidence that it has 
positive impact in the healing process, the medical community has 
become increasingly interested and involved.
    Medical researchers such as Herbert Benson, M.D., Harold Koenig, 
M.D., and numbers of other prominent researchers, from both the medical 
and pastoral care communities, have uncovered compelling scientific 
evidence of the efficacy of belief-related therapy in healthcare.
    These studies have captured the imagination of physicians 
throughout the country. Many of them wish to know more about belief-
related therapy and the spiritual dimension to consider including it in 
their therapies, and to provide higher quality and more effective cures 
for their patients.
    Probably the greatest indicator of rising interest in the medical 
community is the growing number of courses in spirituality, religion, 
and ethics for medical students and residents. Many practicing 
physicians, who were not given that opportunity when they attended 
medical school, are now inquiring into this area.
    On May 15, 1998, the National Interfaith Coalition, and the Greene 
County, Missouri, Medical Society co-sponsored a day-long symposium for 
the physicians of that area, and 200 physicians, on a weekday, packed 
an auditorium at Southwest Missouri State University to hear 
presentations on this subject by a group of expert pastoral care 
researchers and physicians.
    The Coalition and physicians of Greene County now plan to establish 
a national model in Springfield, Missouri which integrates belief-
related therapy into the area's healthcare delivery system. This 
seminal project, the first of its kind in the United States, will also 
be sponsored by Springfield's medical institutions, including Columbia 
Hospital South, Cox Health Systems, Lakeland Regional Hospital, the 
Medical Center for Federal Prisoners, and St. John's Health System. The 
Greene County Public Health Department will be a sponsor as well.
    The project plans to provide spiritual assessments and belief-
related therapy for inpatient and outpatient services and to compare 
patient outcomes with a twin city that does not provide the spiritual 
dimension in its healthcare delivery.
    General Colin L. Powell, USA (Ret.) stated in regard to the 
project, ``I realize that you, the members of the National Interfaith 
Coalition for Spiritual Healthcare and Counseling and the Physicians of 
Greene County, Missouri, are attempting to break new ground. I thank 
each of you for reinvesting your collective energy, beliefs and special 
skills back into Main Street--back into America--and I look forward to 
even greater successes as you enlist others in the cause.''
    These initiatives must also be tested on ``Main Street,'' as 
General Powell puts it, if we are to thoroughly and scientifically 
study belief-related therapy as a component of healthcare in everyday 
life.
    Joni Scott, M.D., Clinical Director of the Breast Center in St. 
John's Hospital in Springfield, Missouri, and a member of the 
Physicians' Task Force for the project claims that this initiative to 
include the spiritual dimension in healthcare has been driven by the 
element of patient satisfaction, since 95 percent of Americans believe 
in God and wish to utilize their faith and prayer in times of crisis.
    As Dr. Herbert Benson has pointed out in his testimony, another 
significant factor spearheading this dimension is the rapidly rising 
cost of healthcare. He states that 60 to 90 percent of visits to 
physicians are stress related, and that utilization of belief-related 
therapy could lead to annual cost savings of more than $54 billion.
    Pastoral Counselors and Chaplains are a valuable national resource 
in delivering this care since they are professionally trained and 
nationally certified to do so. The Pastoral Care field is interested in 
making quality belief-related therapy accessible to those who desire 
it, with a special emphasis on the poor, elderly, disabled, infirm, 
addicted, incarcerated, and otherwise at risk persons.
    The National Interfaith Coalition has a broad spectrum of citizen 
support as shown by its National Advisory Committee. The members of the 
Coalition and Advisory Committee are listed herein:
 national interfaith coalition for spiritual healthcare and counseling
    Adventist Chaplaincy Ministries
    American Association for Ministry in the Workplace (AAMW)
    American Association of Pastoral Counselors (AAPC)
    American Association on Mental Retardation-Religion Division (AAMR)
    American Baptist Churches USA
    American Correctional Chaplains Association (ACCA)
    Assemblies of God
    Association for Clinical Pastoral Education (ACPE)
    Association of Professional Chaplains (APC)
    Catholic Health Association (CHA)
    Christian Church, Disciples of Christ
    Christian Reformed Church of North America (CRCNA)
    Church of the Brethren
    Episcopal Church: The Assembly of Episcopal Hospitals and 
Chaplains; Office for Bishop of Armed Forces
    Evangelical Covenant Church
    Evangelical Lutheran Church of America
    Independent Fundamental Church of America (IFCA)
    Kansas COMISS
    Lutheran Association for Maritime Ministry
    Lutheran Church-Missouri Synod
    National Association of Catholic Chaplains (NACC)
    National Association of Jewish Chaplains (NAJC)
    National Association of Veterans Affairs Chaplains (NAVAC)
    National Conference on Ministry to the Armed Forces
    National Conference of Veterans Affairs Catholic Chaplains (NCVACC)
    National Institute of Business and Industrial Chaplains (NIBIC)
    New York Board of Rabbis
    Presbyterian Church (USA), PHEWA
    Reformed Church of America
    Southern Baptist Convention
    United Church of Christ
    United Methodist Church
 national interfaith coalition for spiritual healthcare and counseling
                      national advisory committee
    Herbert Benson, M.D., President, Harvard Medical School's Mind/Body 
Institute
    Beatrice S. Braun, M.D., AARP Board of Directors
    Patricia A. Cahill, J.D., President and Chief Executive Officer, 
Catholic Health Initiatives
    Dr. Arthur Caliandro, Marble Collegiate Church
    Dr. Elbert C. Cole, National Council on Aging
    U.S. Senator Tom Harkin (D-IA)
    Mrs. Virginia Harris, Chairman, Christian Science Board of 
Directors
    Dr. James Kok, Crystal Cathedral
    David Larson, M.D., President, National Institute for Healthcare 
Research
    Bishop John Leibrecht, Springfield-Cape Gerardeau Catholic Diocese
    Mrs. Norman Vincent Peale, Blanton/Peale Institute
    Bishop Joe E. Pennel, Jr., United Methodist Church
    Rabbi Joseph Potasnik, New York Board of Rabbis
    Mr. Michael Quinlan, former Director of U.S. Bureau of Prisons
    Dr. Robert Schuller, Crystal Cathedral
    Dr. Martin E.P. Seligman, President, American Psychological Assn.
    Harvey Sloane, M.D., former Commissioner of Public Health, District 
of Columbia
    Dr. Thomas Smith, Executive Director, National Institute for 
Healthcare Research
    Dr. Gordon L. Sommers, Past President, National Council of Churches
    Sr. Teresa Stanley, General Superior, Incarnate Word Sisters, San 
Antonio
    Dr. Orlo Strunk, Jr., Journal of Pastoral Care
    Bishop Joseph M. Sullivan, Auxiliary Bishop of Brooklyn, N.Y. 
Catholic Diocese
    John M. Templeton, Jr., M.D., President, John Templeton Foundation
    U.S. Representative Edward Whitfield (R-KY)
    Dr. Robert Wicks, Loyola College, Maryland
    Bishop Roy Winbush, Chairman, Congress of National Black Churches
    Admiral Frank Young, M.D., former FDA Commissioner
    Mr. Raul Yzaguirre, President, National Council of La Raza

                         conclusion of hearing

    Senator Specter. Well, thank you very much, Dr. Anderson, 
Dr. Benson, and Dr. Koenig, and that concludes our hearing. 
Thank you. The subcommittee will stand in recess subject to the 
call of the Chair.
    [Whereupon, at 12:13 p.m., Tuesday, September 22, the 
hearing was concluded, and the subcommittee was recessed, to 
reconvene subject to the call of the Chair.]

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