Eastern Origins of Integrative Medicine and Modern Applications

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Chapter 1 Eastern Origins of Integrative Medicine and Modern Applications

Ira D. Zunin, MD, MPH, MBA, Michelle M. Wong, MD

Reader’s note: An essentially identical version of this chapter appeared in Integrative Medicine: A Clinician’s Journal (V2.2) and is reprinted with approval from InnoVision Communications.

Introduction

Emaho, the Tibetan word for “wondrous,” aptly describes the history of healing. The healing art of medicine is neither fixed in one theory of disease nor has its origins in a single body of perceptions. Its roots reveal rich and fascinating strands to its heritage. Each strand has developed potent theories and recommendations that inform prevention, illness, and treatment. These differences profoundly influence the vision and values among the members of a given culture—how to live well and how to address illness and health. Specifically, the contrasts in Eastern and Western approaches have been like strangers from afar, and now as of the twenty-first century, have become increasingly aware of each other in the evolving field of integrative medicine. Each has its advantages and limitations. Recognizing and skillfully combining the best of both approaches is an ongoing challenge and a noteworthy, positive advance for humanity.

In the past 20 years, medicine in the West has begun to diligently examine and resume its inclusion of indigenous traditions in medical practice. The term “integrative medicine” emerged in the early 1990s to describe a paradigm shift in modern medicine. Integrative medicine believes that drawing from multiple traditions better serves people, rather than using only one medical system. At the core of the integrative medicine movement in the West is how to examine indigenous healing modalities with scientific rigor for safety and efficacy, while retaining respect for their history and culture. With its emphasis on quality research evidence, integrative medicine modalities have gained further acceptance in the West, while having spawned a resurgence of indigenous medicines in their countries of origin.

Eastern healing traditions have made some of the greatest advances in integration with modern medicine. In this chapter, the authors briefly review the historical origins of Eastern and Western traditions and the contrast in their philosophies and examine some Eastern healing traditions more closely to better understand the application of Eastern healing modalities to modern medicine. Please note that the following is only an introduction to healing traditions that have had some success in practice with Western medicine. The authors encourage readers to actively engage in learning about other healing traditions specific to their local community.

Terminology

As the field of integrative medicine evolves, so does its terminology. “Modern medicine” in this chapter is used to describe the most mainstream medicine practiced and determined by the evolving scientific method, and “complementary and alternative medicine” (CAM) is used to describe practices that are not as well defined by the scientific method. Theories of medicine can also be grouped based on geographic origin: Western, originating from Greco-Roman philosophy, and Eastern, originating from Asian-Pacific philosophy. The term modern medicine implies fluidity, and it is fitting to use such terminology during the current period of expanding medical boundaries.

Comparison of Eastern and Western Medicine: Origins and Philosophies

Historical Origins

The foundation of several Eastern healing traditions inextricably embraces the philosophies of early Eastern thought, those of Buddhism, Taoism, and Hinduism. These philosophies still provide the underpinnings for many contemporary Eastern cultures, allowing Eastern indigenous healing traditions to maintain widespread acceptance and practice. Several unique but related traditions developed in the East before the Christian era and are still heavily practiced today as discrete systems, including Chinese medicine, Ayurveda (traditional Indian medicine), and Tibetan medicine. Other Eastern traditions enjoy moderate practice in their areas of origin, including Persian medicine, medicine as set forth in the Dead Sea Scrolls, and folk shamanism and animism. Chinese Ayurveda, and Tibetan medicine will be more closely examined and compared later in this chapter, along with their current transformations in the West.

In contrast, modern medicine in the West developed quite independently from religious thought. It was, and continues to be, shaped by science. Modern scientific thought evolved from the Greek philosophers beginning with Euclid around 300 BC and later Plato, Socrates, and Aristotle. The mathematic theories of these Greek philosophers set the foundation for Renaissance scientists more than 1500 years later, who further developed the scientific method. The scientific method, which describes a constant process of empirical observation, logical reasoning, and skepticism to discern knowledge, is still the thought process used today to validate modern medicine.

It was not until later in the twentieth century, however, that the scientific method became the mainstay of modern medicine. In the early nineteenth century, modern medicine was pluralistic in nature as “professional care was mostly provided by botanical healers and midwives, supplemented by surgeons, barber-surgeons, apothecaries, and uncounted cancer doctors, bonesetters, inoculators, abortionists, and sellers of nostrums.”¹ During much of this same period, the profession of naturopathy flourished to the benefit of many. At this time, the medical profession was still in its early stages in the United States. By the early to mid-twentieth century, medicine was much more narrowly defined through the scientific method. In the past 20 years, however, medicine in the United States has experienced another shift, arguably a shift again to the medical pluralism from more than 100 years ago. This raises the question: is this merely historical pattern or the birth of a unique era?

If modern medicine is experiencing yet another paradigm shift, the culture will necessarily move beyond the older ethos of the scientific method that defined its previous paradigm. Master Hong succinctly commented on this point, “What this [Qi Gong] master possesses isn’t magic. It is just science that has not yet been examined.”² In the twenty-first century, the culture of medicine is once again embracing its diverse options for health care, shifting yet again toward pluralism and reflecting the social landscape of a new generation. What is happening invites all healers to enlarge their ideas of disease and health and to welcome an expanded and deeper perspective.

Philosophies in Contrast

“Vive la différence.” The differences in Eastern and Western medical traditions stem directly from their foundational differences in world views. Judith Farqhuar described these essential differences in world views as “the difference between a world of fixed objects and a world of transforming effects. Like the solid inertial world of modern natural science traditions, the … transformative world of Chinese medicine seems to exist prior to all argument, observation, and intervention. Perhaps with a certain discomfort, Western readers must acknowledge that ‘their’ abstractions about such things make as much sense as ‘ours’.”³

One of the most obvious and far reaching differences between Eastern and Western medical traditions is the concept of inter- and intra-personal relationships. Stemming from the Socratic model and Cartesian dualism, Western medicine heavily delineates between mind and body, between doctor and patient, and between healthy and diseased. In contrast, medicine originating in the East finds little distinction in these areas. Instead, it views continuity and balance as vital to health. Illness is defined by imbalances of patterns that should naturally be in harmony. Multiple aspects of the being, including the mind, body, and spirit, are integral to this harmony. In contrast, illness in modern Western medicine is described by a specific pathology, caused by discrete foreign pollutants, and often cured by another foreign element.

In its extreme, the patient is an accident attached to the disease under treatment.

The fundamental concepts of Eastern healing traditions are deeply embedded in the philosophies of their cultures. Consequently, they are perceptions, ideas, and values shared by most society members. Although health is integral to one’s everyday life in Eastern societies, it is only one part of Western society. Likewise, health is defined in the East as a unity of individual, environmental, and societal factors. Although the Western definition of health has moved toward encompassing the physical, mental, social, and spiritual, each is still defined as a separate entity. In modern medical communities, divisions between physical and mental health and social work, are still at large, with these departments often not acting in concert.

These distinct differences shape the patient–doctor relationship. In Eastern traditions, a unique balance of these factors is critical to diagnosis and treatment of a patient’s disharmony rather than disease. Physicians in Western medicine often look beyond the patient–doctor relationship to an external body of knowledge to diagnose and treat, guided by categories of symptoms. A general comparison of Eastern and Western concepts with regard to health is shown in Table 1-1.

TABLE 1-1 Comparison of Western and Eastern Concepts

	WESTERN	EASTERN
World views	Reductionist	Holistic
Mechanism of disorder	Pathologic mechanism	Imbalance of harmonies
Foundational structure	Logic, mathematics	Eastern religions and philosophies
Patient–doctor relationship	Access external body of knowledge for diagnosis and treatment	Unique balance critical to diagnosis and treatment

Overview and Comparison of Eastern Traditions

As mentioned, although several indigenous healing traditions in the East have been preserved, Chinese, Ayurvedic, and Tibetan medicine remain among the most heavily practiced traditions in their respective regions. All three traditions stem largely from similar philosophical foundations; thus in all, health and disease are seen as inextricably interrelated. They play integral parts in the delicate balance of harmony and disharmony. Table 1-2 provides a comparison of these three traditions.

TABLE 1-2 Comparison of Tibetan, Ayurvedic, and Chinese Medicine

Origins

Tibetan medicine and Ayurvedic medicine have similar historical origins, since Ayurveda is the root of Tibetan medicine. Ayurvedic origins are found as early as the second millennium BC in the Rig Veda, with its second classical stage in the Brahmanic period in 800 BC, where it continued as an unbroken lineage until the Moslem conquest of India in the thirteenth century. During that time in the sixth century BC, the historical Buddha, Shakyamuni, was born in India, and after achieving Enlightenment under a Bodhi tree in Bodhgaya and delivering the teachings of the Four Noble Truths, Buddhism was born.^*

The Tibetan medical tradition offers that the Buddha, often called the “Great Physician,” taught the medical texts himself, including the Gyu-zhi, the most important Tibetan medical text. The Sanskrit version of the Gyu-zhi, however, was probably not written until around 400 AD.⁴ Although some scholars may debate whether the historical Buddha’s teachings are the precise origin of Tibetan and, thus, Ayurvedic medicine, Buddhism’s influence on these two healing traditions is unquestionable.

Like Ayurveda, the origins of Chinese medicine date back to at least the second millennium BC, to the era of the great Yellow Emperor, Huangdi (2698–2598 BC). The classic medical text written during his reign is Huangdi Nei Jing (The Yellow Emperor’s Inner Canon). Yet perhaps of more influence to Chinese medicine known today is the Nan Jing (The Classic of Difficult Issues), written around the first or second century AD. As Nolting notes in Chapter 31 on “Acupuncture” in this edition, the Nei Jing deals more with “demonological medicine and religious healing,” whereas the Nan Jing developed Chinese medicine as an original system, with well-defined and organized principles, diagnostics, and therapeutics.⁵

Chinese medicine also witnessed various transformations, most notably its recent evolution into Traditional Chinese Medicine (TCM), the modern form of Chinese medicine practiced in China and worldwide. Influenced by the advent of modern science, Chinese medicine was required during the 1950s to establish increased legitimacy in the face of the new Marxist ideology, which emphasized “natural science” and delegitimized Confucian influences. Initially, the People’s Republic of China denounced folk, demonic, and Buddhist temple medicine.⁶ However, in 1951, Mao Zedong revived and then canonized portions of the tradition with his “Chinese medicine is a great treasure-house” speech.⁷ In Mao’s Cultural Revolution, Chinese medicine was transformed to TCM and embraced as a means to preserve the “spirit of a nation.” The “new medicine” movement highlighted traditional medicine’s ability to arouse one’s own bodily defenses against illness while excluding metaphysical ideologies. TCM thus embodied one general theory of Chinese medicine and discouraged diverse readings and interpretations by practitioners and students.

Of the three traditions, Tibetan medicine enjoyed the most continuity in lineage until the Chinese invasion in 1959. With the Moslem invasion of India in the thirteenth century, much of the Ayurvedic medical system was destroyed, along with many Buddhist texts. Fortunately, by the seventh century AD, Ayurvedic medicine had traveled to Tibet and was safely preserved in the Himalayan Mountains. Once in Tibet, Buddhism and its medicine first adapted to the indigenous shamanic religious culture, Bon, whose greatest contribution to the Tibetan medical system was its knowledge of the indigenous medical herbs of the sub-Himalayan plateaus. With King Strongtsan Gampo’s formal introduction of Buddhism to Tibet in the early seventh century, the influence of Buddhism on its medicine flourished. This continued up until the Chinese invasion in 1959.

Despite its isolation in practice, Tibetan medicine shares several principles with other Eastern healing traditions. Its strongest ties are with Chinese medicine to the north and Ayurvedic medicine to the south. Eastern traditions of healing are undoubtedly intertwined in a rich tapestry, stemming partly from an extraordinary meeting of healers. During the seventh century, the Tibetan King Gampo held the world’s first recorded international medical conference. Noted physicians from India, China, Greece, Nepal, Persia, and Mongolia dialogued in a cross-cultural exchange, and texts from each medical tradition were translated.

Fundamental Philosophies: Tools to Assess Balance

The notion that ill health stems from the imbalance of certain fundamental forces or “textures” stands at the core of many Eastern healing traditions. Although the traditions may vary as to which fundamental forces, textures, or elements are involved in diagnosis and treatment, certain philosophies are shared. In these, the five elements, fundamental textures, and principles of opposites govern the universe. The five-element theory is the most common approach used to diagnose and restore health. The five elements are commonly understood to define, control, and at the same time be governed by a constellation of internal and external phenomena. These phenomena include human emotions, human senses, body organs, and climate.

Humoral pathology, central to Ayurvedic, Tibetan, Persian, and Greek systems, is the core principle that unifies the mind with the body and the individual with his environment. It defines the balance or imbalance of the textures that influence one’s state of health. These humors define an array of biological, physiopathologic, and psychological phenomena related to the body, the mind, and the environment. In both Tibetan and Ayurvedic medicine, three humors, or primary qualities, maintain aspects of health. In Tibetan medicine, they are Vayu (Tibetan Rlung), Pitta (Tibetan Khrid), and Kapha (Tibetan Bad-kan), translated as “wind,” “bile,” and “phlegm,” respectively. Yet the English translation is imprecise and limits the meanings of wind, bile, and phlegm principles, which further describe the mind, energy, and inert matter. Analogies can be drawn using conventional physics. Wind can be compared with kinetic energy, bile with caloric energy, and phlegm with mass energy. With reference to personality, those governed by air tend to be wiry and impulsive; bile types are muscular and quick to anger; and those ruled by phlegm are normally heavy set and tend to avoid conflict. Additionally, the humors are the products of the three delusions, which are the root cause of all suffering in the Buddhist tradition: phlegm, a product of ignorance, bile from anger, and wind from attachment. Understanding the humors as products of the three delusions underlines the interrelationship between Buddhism as a spiritual practice and the healing professions.

In Ayurvedic medicine, these humors are the three Doshas, known as Vat (or air principle), Pit (or fire principle), and Kaph (or water principle), and they carry specific actions. Vat is the bodily air principle and governs movement; Pit is the bodily fire principle that controls metabolism; and Kaph is the biological water principle that provides physical structure. These principles are also associated with the metabolic activities of anabolism, catabolism, and metabolism. In addition, they are associated with certain personalities and certain physical characteristics of dry or oily, light or heavy, and hot or cold. For a more complete discussion of the Doshas and their related properties and functions, see Chapter 32.

Chinese medicine encompasses a similar principle that certain fundamental qualities must be in balance to achieve a healthy state. These fundamental textures are the universal Qi, Blood (xue), Essence (jing), and Spirit (shen). Like the humors of Tibetan and Ayurvedic medicine, Qi is universal and encompasses and connects all animate phenomena internally (body, mind, organs, senses) and externally (organism to environment). Qi generates change both on a small scale and in the larger picture of Yin and Yang, those opposite forces, for example, of light and dark, female and male, that embody all organisms. Qi has five major functions: movement, protection, harmonious transformation, stability and retention, and warming of the body. The definition of blood in Chinese medicine goes beyond the physical concept of blood in Western medicine, since it is the Yin complement to the clinical Yang Qi, functioning to nourish, circulate, and moisten the body. Essence is specific to organic life and slowly perpetuates life forward. Although Qi is the fluid movement of ordinary time, Essence spans a lifetime and embodies all characteristics involved with birth, maturation, and death. Lastly, Spirit is unique to human life but is beyond mind-consciousness. It is what prompts humanity and relationships with one’s self and other humans, and it examines all facets of humanity—moral, social, mental, physical, and emotional.

Although the concept of Yin and Yang is at the core of Chinese medicine, principles of opposites to achieve balance and optimal health are central to all three traditions. The Tibetan and Ayurvedic systems employ “hot” and “cold” to depict opposites. These fundamental opposites, fundamental textures, and five elements are intricately related to one another, providing a holistic framework in which to consider health and illness.

Diagnostics and Treatments

In accordance with its foundational philosophies, diagnostics in Eastern traditions take into account the person as a whole. The patient’s physiologic characteristics, mental dispositions, and other personal, social, economic, and environmental details are assessed. In addition, diagnosis includes the following examinations: general physical, pulse, urine, tongue, eyes, skin, and ears.

The core principle in treatment is to restore the person’s health to equilibrium through several behavioral, lifestyle, diet, manual, and medicinal treatment approaches. Treatment methods in the Tibetan tradition are arranged in a hierarchy of usage: (1) behavioral practices (lifestyle, meditation), (2) diet, (3) herbal medicines, and (4) external treatments (acupuncture, massage, moxa, and surgery). Treatment therapies in Ayurveda include dietary alterations, yoga, exercise, herbal formulas, and surgical techniques. Ayurveda places special emphasis on diet as a modality, since it considers the human body a mental and physical product of the food consumed. Main treatment methods in Chinese medicine include acupuncture, herbal medicine, and sometimes Qi Gong.

Modern Applications: The Age of Integration

[The interpreter’s] task is rather to seize the vital conception of the art-work, to blend it with his own ego and the views of his period, and thus to imbue it with life and effectiveness. His artistry is a product of its mental culture. It develops and changes with the evolution of artistic requirements. His formative and emotional powers are derived from the spirit of the epoch to which he belongs.

Much that charmed former generations has no effect in ours; so much is part and parcel of its passing. Only what is exalted over time and place remains as eternal gain; and here, again, another generation finds new treasures that earlier ones passed by unheeding. This is the unfailing criterion of true greatness, that its creations continually beget ever-new, ever-changing values, that they bring to each successive generation new revelations.

—Max Spicker, 1912

As the social landscape changes, the culture of medicine continually redefines what is considered “conventional.” Numerous recent studies have shown that since the early 1990s, consumers have been demanding alternatives to modern care.⁸ Only since then has integrated medicine, including naturopathy, penetrated the Ivory Tower and research institutions in the United States. Driven by scientific advancement and a need for increased knowledge, this movement toward more pluralistic medicine has now brought us beyond the age of information and into the “age of integration.”

With the current plethora of health information, it is becoming more apparent that optimal healing is not the property of any one tradition or system. Integrative clinics that incorporate multiple healing systems now thrive throughout the country and at major academic medical institutions. Employers and managed care agencies are beginning to offer coverage for acupuncture, chiropractic, naturopathy, and massage services. The Academic Consortium for Integrative Medicine has been formed among top-ranked medical schools to integrate CAM into their curricula. The National Institutes of Health has devoted an institute just for CAM with a budget of over $130 million.^* Some medical residencies now include CAM in their training, and fellowships in integrative medicine now exist.

Despite the recent explosion of integrative medicine entering research, education, and clinical arenas, several barriers still limit the growth of integrative medicine in the United States. The most pressing and present barrier to clinical integration is reimbursement. To persuade insurers to cover the costs of CAM therapies, research evidence built on rigorous clinical trials and data that demonstrate cost efficacy of these modalities are necessary.

Perhaps an even greater barrier to integration is the challenge of how to establish safe and effective practices for these modalities, while carefully preserving the lineage of indigenous traditions. To examine this issue, the authors outline the birth and evolution of indigenous traditions as medical professions in the United States and later provide units on clinical practice, risk management, professional communications, practice management, and research that serve as essential tools for integration.

The current dilemma in the development of these CAM professions is how to perpetuate lineages during this integration with other health care professions, while not lowering standards for CAM practitioners. This present boom in alternative health care has resulted in the current state of integrative medicine: a confusing situation with too many practitioners offering a wide range of skills but leaving consumers without tools to decipher which are the most effective or true to tradition.

The middle path must be taken by raising the bar for practice standards. If the bar is too low, traditions will no longer be protected and they will not be as efficacious in practice. Consequently, practitioners may not be appreciated by either patients or traditional providers. If the bar is too high, few will find access and few will be able to practice. Either way, invaluable traditions may be lost.

The Birth and Evolution of a Medical Profession in the United States: Complementary and Alternative Medicine Professions

In the last years of the twentieth century, the United States witnessed the beginning transformations of indigenous healing traditions into CAM professions. After the counter-culture years of the 1960s and 1970s that challenged institutionalized medicine, interest in “natural healing” practices surged. As a result, chiropractic care and naturopathy were the first traditions to become formalized in modern medicine. Since then, Chinese medicine—via acupuncture—has made the largest entrance into health care in the United States, with more than 50 TCM and acupuncture schools in the United States and Canada accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM), adoption of licensure laws in the majority of states, and an increasing number of insurers offering coverage. A far second to Chinese medicine has been the development of Ayurvedic and Tibetan medicine, which are still in the early phases of their evolution as professions in the United States.

Every medical tradition, even current scientific-based modern medicine, began at the margin and progressed through a similar cycle to become an established practice or profession. Currently, CAM modalities are finding similar challenges as they endure this evolution toward becoming established professions. Typically, in stage 1, lone practitioners of the tradition arrive in the United States and provide informal workshops to the public and interested health care providers. These CAM practitioners practice their traditions informally. Stage 2 develops only after public and provider acceptance of safety and efficacy. Stage 2 marks the development of professional education and associations, provides standards for school accreditation and credentialing, and, ultimately, licensure by state boards. With regulation through professional associations, third-party payers become amenable to insurance reimbursement for CAM treatments. Finally, stage 3 results in set state and national standards for the profession, including education, practice, and methods to evaluate safety and efficacy, as well as widespread acceptance and practice. In this current era, the accomplishment of stage 3 is inherently dependent on the respectful and appropriate blending of these CAM traditions with the dominant medical paradigm based in science.

At this time in the United States, the professions of naturopathy, chiropractic, acupuncture, and massage are in early stage 3 of their professional and legislative developments, where accredited schools in all these fields have been undoubtedly established and licensure is being governed by state boards. For instance, acupuncture currently has two established organizations that help to set standards for training and practice: the ACAOM and the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). ACAOM is recognized by the U.S. Department of Education to accredit first professional master’s degree and master’s level programs in acupuncture and Oriental medicine and is currently petitioning to begin accrediting postgraduate, clinical doctoral programs. Acupuncturists are currently licensed according to state boards, but licensure laws vary from state to state. Many states recognize NCCAOM certification as a national standard, and thus practitioners can earn licensure with NCCAOM certification in these states. Acupuncture, as practiced by over 5000 medical doctors in the United States, is currently the fastest growing medical specialty. The American Academy for Medical Acupuncture now offers specialty board certification in the field. Nevertheless, although there is now some insurance coverage for modalities like acupuncture, barriers such as standardization in education, practice, and research still exist.

Tools for Integration

As providers of CAM services join professional networks and become increasingly integrated into conventional health delivery, the CAM professions gain both credibility and exposure. Integration brings with it a new set of responsibilities. Utilization is growing and evolving so quickly that the educational institutions preparing CAM providers for licensure are hard pressed to keep up with the trend. As a result, CAM provider education often does not fully prepare its graduates to meet the growing expectations of the public, the medical community, or the legal system. Providers must gain competency in “tools for integration” that lead to a new set of skills for clinical practice, risk management, professional communications, practice management, and research. These tools include, but are not limited to, those listed in Box 1-1.

The emerging field of integrative medicine has arrived at the end of the beginning. It is no longer simply a vision of what could be. Billions of dollars are now spent out of pocket for several hundred million visits to integrative providers and for herbs and nutraceuticals each year. The majority of medical schools now offer some form of CAM education for physicians in training. Yet until now, the consumer has carried the day. As physicians move forward into the twenty-first century, they are ready to enter the beginning of the middle. The transition is rapidly underway, and clinical models for integration and quality studies demonstrating efficacy and cost offsets are imperative to its success.

In practice, it is also increasingly necessary to build bridges between the indigenous community, evolving CAM professions, and established medical institutions. Researchers, academicians, and health care professionals from multiple backgrounds need to understand the challenges in integration to provide optimal health with wisdom for this generation and the next. Only through partnership can the best medicine be offered and this evolution in the culture of health care be assisted.

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3. Farquhar J. Knowing practice: the clinical encounter of Chinese medicine. In: Kaptchuk T., ed. The web that has no weaver: understanding Chinese medicine. 2nd ed. Chicago: Contemporary Books; 2000:67.

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5. Acupuncture Nolting M. Pizzorno J., Murray M. Textbook of natural medicine, 2nd ed. New York: Churchill Livingstone. 1999:254.

6. Unschuld P. Medicine in China: a history of ideas. Berkeley: University of California Press; 1985. 250

7. Farquhar J. Re-writing traditional medicine in post-Maoist China. In: Bates D., ed. Knowledge and the scholarly medical traditions. New York: Cambridge University Press; 1995:251.

8. Eisenberg D., Davis R., Ettner S., et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280:1569–1575.

^* Lineage refers to the descendants of a common ancestor considered to be the founder of the line.

^* Monetary figure from National Institutes of Health, Office of Budget website at http://officeofbudget.od.nih.gov/br.html for fiscal year 2012.

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