In 1993, a landmark study by Dr. David Eisenberg revealed that an astonishing one in three Americans had used some form of alternative or complemetary medicine, most of them without informing their physicians. FRONTLINE explores the impetus behind this recent surge in interest in alternative therapies with Eisenberg, Harvard University's Marcia Angell and Tom Delbanco, alternative practioner Andrew Weil and medical historian James Whorton.
As an intern and as a resident in internal medicine, my colleagues would constantly make fun of me because I was always asking patients a lot of questions about what they thought and about their lifestyle and about exercise and about diet.... By the time I graduated, I had begun to ask my patients were they using or thinking about using herbs or acupuncture or meditation or prayer or chiropractic. And whoever I asked, there was always either a receptivity to the question or an affirmation that yes in fact they were already doing this, and the shock that their doctor would ask them.
That was the AHA! observation for me, that was the epiphany. Even in my primary care clinic in a university hospital, if I asked ten patients were they using or thinking about using all these complementary alternative unproven techniques, three or four or five would say yes. And then it hit me, maybe the strategy was document the extent to which Americans in academic hospitals were using these things. Document how much money they were spending and then bring it to my academic colleagues and try to make the argument that we must out of concern for patients figure out which were safe, which were dangerous, which saved money, which cost money.
I proposed a survey in 1984 as a fellow, doing a research fellowship at Harvard Medical School. Nobody bought it, nobody paid for it, no foundation was interested. My mentors and I laugh about it now. [At the time, they] said, "Even if you do this and even if you show the numbers are large, no one will care."... But I think history would prove them wrong.
So we all predicted that the prevalence of use of complementary therapies--acupuncture, chiropractic, meditation--would be about ten percent or fifteen percent. And we powered the survey to prove that. But we were shocked by the time we got the data and I remember going home to my wife, almost shaking and saying, "Honey, the numbers are huge, it's one in three Americans. It's thirty-three percent of the United States adult population. It's thirteen billion dollars, it's not reimbursed. Very few of these people are ever discussing it with their physicians; this is enormous."
...I was not a well published veteran of academic affairs, but the data spoke for themselves, they made the case convincingly with really excellent science that these are the facts, incontrovertible as they are. And that was the beginning....That was the first time the American medical community saw the extent to which complementary, alternative, integrative, unproven therapies were part of the American medical system.
I think there are a whole host of reasons why patients have turned increasingly to alternative medicine in recent years. Part of it is that the allopathic doctors [conventional MDs] have been allotted fewer and fewer minutes per patient visit over the last twenty years and people do want to have more time seeing their practitioners. And alternative doctors do typically give patients quite a bit more time.
They also [tend to] pay more interest to the patient's personal subjective experience of the illness and not be quite so fixated on what the organic pathology is. I think there has been a reaction against science among the baby boomers, growing up with the bomb, seeing the negative things that science can do. We've become very distrustful of science. Especially since the 1960s as the baby boomers came of age and the counterculture movement swept through the country, we became very distrustful of people who claimed to be authorities and the way they might mislead us, whether it was Lyndon Johnson leading us into Vietnam or allopathic doctors saying we're the only people who know how to treat disease. There has been a reaction against the allopathic denial--I don't think it's too strong a word--of the importance of emotional and spiritual factors in illness and in the way people experience their illness. People wanted to go to someone who told them it wasn't just in their head.
I think another big factor has been that in a way allopathic medicine has been spoiled by its success in that most of the doctors trained during the 20th century were trained to deal with trauma and acute infectious disease, and historically acute infections were the big disease problem. If you go back to the beginning of the 20th century the leading causes of death were infectious diseases, pneumonia, tuberculosis, diphtheria, intestinal infections. They succeeded very well; by the middle of the 20th century most infectious diseases were pretty much under control, not so much through the actions of physicians, it was really more through preventive medicine and public health, but certainly with first the sulfa drugs of the 1930s, then the antibiotics in the 1940s … Infections faded into the background as the major type of health problem. And certainly mainstream medicine should be congratulated for that role.
The problem was that when that happened, a new disease pattern emerged, one that's dominated by chronic diseases that aren't necessarily curable, that have to be dealt with over a long period of time, have to be managed and that present a lot of difficult emotional challenges to patients. Doctors who were trained to diagnose an infection and select the right antibiotic for it were not as well equipped to deal with patients who were suffering from cancer or diabetes or heart disease and having to deal with these chronic problems for the rest of their lives, and so people became dissatisfied with physicians. …
[Another] one of the major forces supporting alternative medicine historically and I think down to the present is the harshness of some of the allopathic therapies. In the 19th century there was a great deal of uneasiness with the drugs that were prescribed by physicians. One in particular, calomel, a mercury compound that is a very powerful purgative, flushes the bowels very efficiently, and according to allopathic theory at the time, it made sense to give it. Calomel was given to just about everyone and many of the people who took it suffered mercury poisoning as a result. … There were other elements of allopathic therapy that were criticized as well, the dependence on drawing blood, a pint or more at a time, giving drugs to produce vomiting, treating the skin with blistering agents, applying leeches to draw blood, a whole range of therapies that appeared to alternative doctors to be going against the healing efforts of nature.
Calomel in particularly was justified by allopaths in the 19th century as a treatment that yes, did injure the patient, weaken the patient, but nevertheless was needed because its beneficial effects were greater. When we look at that today, I suspect our first reaction is, well, that seems a little questionable. But of course the same thing is done today with chemotherapy. Oncologists rationalize the use of chemotherapeutic drugs, the hair loss, the nausea, all the other things that come with it, with the argument that nevertheless it does more good than harm. Alternative practitioners will maintain that this has been a theme throughout the history of allopathic medicine, that there has never been adequate attention paid to the side effects of drugs and that the benefit of naturopathy or acupuncture or whatever other system you might consider is that there are no injurious side effects. …
There are an awful lot of reasons that people use alternative medicine these days. They read about it, they hear about it, and a lot of the news is positive. They invariably have friends who feel they've benefited from it. I believe everyone is always seeking something that, whether it's magic or not, holds the promise of improving the way one feels or maintaining health. I think quite frankly sometimes they're talked into it by people who are interested in making an extra buck.
I think certainly at times people feel let down by us in scientific medicine and they seek other approaches. That can lead them to alternative medicine. Similarly, I think there are a lot of people who want to cover all [their] bases. It makes sense in that context to say, well, I'll do what the doctor suggests, and I'll also seek other aids that...may help. ...People who have devastating illness for whom the traditional medical field has sometimes not so much to offer; they always need that precious commodity called hope. They often turn toward anything that will bring them hope, and alternative medicines are wonderfully situated to do that because of the way that they are purveyed, and their advocates' stories.
You mean the way they're marketed.
There's no question that alternative medicines are marketed to two groups of people. One is the healthy - those who want to maintain their lives as long as possible and live a life of virtue, goodness and well-being. And then also to those who are terribly ill, from whom hope is sometimes being robbed and who will reach out for anything that brings hope, quite understandably. Alternative medicine knows how to go after those people very effectively. …
It seems as though in this period of scientific advancements, there are many breakthroughs and failures, reversals and contradictions. Is this why people are confused? Has traditional science failed them? I never thought I'd live in a time where we publish a study one week that says do this and a week later come out with a study that says do that. That confuses everybody, doctor and patient alike. … At one level, we have many patients alive today who, when I was young, would have never been alive. That's clearly by virtue of the science that we brought to their care. At another level, people still die of cancer and in a certain sense they die more often of cancer because we do better with other things.
People are confused and angry. They relate primarily to their own experience, understandably, or their family's experience. So and so has died with this awful disease, the doctors couldn't do a damned thing about it, in fact they sometimes made them feel sicker by virtue of the medicines they gave them. On the other hand, my other friend is still alive and might not have been, because of what medicine brought them. People are confused, they're ambivalent, they're angry at times, they're thrilled at times and that's very much the human circumstance.
How do all the differing messages out there, especially about alternative medicine, add to the confusion?
It's terribly confusing to be a person these days, whether it be a doctor or a patient. Should you eat eggs or should you not eat eggs? What should you do if your back hurts? What is the proper screening to prevent cancer these days, or heart disease? The messages that people get from the newspapers, from television, from the drug manufacturers, from their doctors, from the alternative medicine people are different, they're compelling. There are articulate people telling them what to do and they all give them a different message. It's an unbelievably confusing time. With alternative medicine, the messages are definitive, clear, very emphatic as far as I can see, and from what I've read, based on incredibly little scientific evidence. That troubles me a lot. …
Is alternative medicine more accepted now within the conventional medical establishment?
There's a terrific push for acceptance of alternative medicine in the medical establishment. I'm not sure that's really taken much hold. I think we do understand better that we should ask more about alternative medicine and patients' use of that and their expectations. But in the gut of scientifically trained doctors and other health professionals, there's still a sense that much more is promised than can be delivered, that we're dealing primarily with a placebo effect which is a terrific medicine in itself.
I think one of the great appeals of alternative medicine is that it empowers people more than conventional medicine. I think people are very fed up with being passive recipients of authoritarian, paternalistic medicine. Many of these other systems make people feel that they are more autonomous, more in charge of their own destiny. I think that's a great longing of people today, and so I think that's a major motivation why people seek treatment elsewhere.
I think also there is increasing suspiciousness in this culture with things artificial, synthetic. A lot of people have had very bad experiences, with drugs especially. The statistics are that we're seeing a hundred thousand deaths a year in U.S. hospitals alone directly caused by pharmaceutical drugs. And this is not mistakes, it's not the wrong drug to the wrong person, it's the right drug to the right person and the right dose and the right condition, and a hundred thousand people die. That's not acceptable. It's now between the sixth and fourth leading cause of death. That's no good. So I think that there are an awful lot of people that are just turned off by that kind of medicine and they're looking for something else. …
I also think that a lot of people seek out alternative practitioners in frustration. If their first choice were available, it would be to go to a medically trained person, an MD who was open-minded and had knowledge of things beyond conventional medicine and could advise them about how to use them. …
I think it's ironic, in a way, that as we see this new horizon of being able to manipulate genes and really focus on specific mechanisms of disease, it's ironic that just at the time that that's happened there has been this incredible rise of diseases that completely confound medical doctors. We have diseases like chronic fatigue syndrome and fibromyalgia and irritable bowel syndrome, where we really don't see mechanisms. It's very difficult for doctors. Any rheumatologist would rather treat a case of gout than a case of fibromyalgia. Any gastroenterologist would much rather treat a case of peptic ulcer than a case of irritable bowel syndrome. But in fact these are the diseases that are popular today. So if you've got a disease that conventional medicine really doesn't have much to offer for, it seems reasonable to explore and see what else is out there. …
What do you think will be the ultimate catalysts that cause the change of perspective toward integrative medicine that you predict is on the horizon?
Well, I think it is true that the agent of change is consumers. It is this public pressure on institutions now expressed through the power of the purse that's forcing change at a time of great economic crisis. I also think that that consumer movement reflects something deeper, that this is really that zeitgeist, it is a change in the spirit of the times--a whole rise of questioning the value of technology, or realizing that technology is not simply a blessing, that it's ambivalent. That things artificial and synthetic have the potential to be harmful to us. It's part of people wanting empowerment in all spheres of life. … I think that this taps into more global, deeper socioeconomic changes. But it's clear that the agency of change is outside, it's not coming from within the medical profession….
As long as things were humming along in medicine it was very easy for them to ignore it and say that this was all fringy and the social workers could go to it and that medical doctors [didn't] have to pay attention. But once the medical institutions really began collapsing--and if you're not in medical institutions today you have no idea how bad it is. I mean it's really bad. Large academic medical centers have had to lay off significant percentage of faculties. Major hospitals, institutions have gone bankrupt. And the whole advent of managed care I think has just compounded all this. Nobody likes that. It's made the actual practice of medicine very unsatisfying for many doctors. For the first time you see practitioners leaving [the field]. This never happened before. … So I think the economic catastrophe combined with the evaporation of so many of the things that made medicine a rewarding profession have suddenly forced doctors and institutions to pay attention to what the consumers have been saying. …
I happen to think that there are many reasons that are all converging to make an astonishing comeback for a kind of thinking about medicine that had just about disappeared. … One is that even while scientific medicine has grown more and more powerful, the means for delivering it have become less and less satisfactory. As managed care began in earnest in the `80s and took over the health care system in the `90s, people became rightly more and more unhappy with a system in which doctors were rushed, insurers were trying to deprive patients of care, doctors just move patients through their waiting room at the rate of maybe one every seven minutes and... treatments to be sure are often harsh, particularly for diseases like cancer, chemotherapy, radiation, that's no fun. There was a lot of paperwork, a lot of bureaucracy, so the whole system became less and less friendly, and there was reaction and there was almost a tendency to throw out the baby with the bathwater.
Now, they don't really throw out the baby. You see that the people who are drawn to alternative medicine are often fairly healthy and they go to alternative medicine for what I call the "symptoms of life." Fatigue, joint pains, inability to concentrate, perhaps, the kinds of things that anyone over twenty-five gets at some point. … They accept the sort of talk about wellness and preventive care and healing yourself when they can afford to accept that. But they go to their conventional doctor when it's something really serious. So that goes on, and in a sense that's a sort of covering your bases. …
Then there are some very desperate people who really are mortally ill who have diseases like advanced cancer or advanced AIDS who go to alternative practitioners as a last resort. … I think there are a certain number of people who do it for that reason. And along with the rejection of the health care system, there's also a rejection of science and technology, a feeling that it's disdainful of more human virtues and humanism. That it's too cold, that it doesn't take account of the whole person, and there's some truth that as we have a more rushed, more highly technological system it does become in some sense colder, more specialized, more fragmented, you have one doctor for your kidneys and another doctor for your liver, another doctor for your heart, and at some point you wonder who is conducting the orchestra? Who's in charge of this? You like this feeling that alternative practitioners trade on, that they will take care of "the whole patient."
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posted november 4, 2003
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