the alternative fix

marcia angell
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Angell is a senior lecturer in the Department of Social Medicine at Harvard Medical School and the former Executive Editor of the New England Journal of Medicine. She writes frequently in professional journals on a wide range of topics, particularly medical ethics. She is a persistent critic of alternative medicine, and in this interview talked to FRONTLINE about her skepticism about the efficacy and safety of many alternative therapies. This interview was conducted on September 18, 2002.

Why do you think so many people use alternative medicine?

Well, 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. …

Alternative medicine practitioners have to pay more attention to you. ... They have to at least appear to be more compassionate because that's all they have to offer.

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 quote the whole patient.

What strides has science made that you think alternative practioners have rejected or ignored?

Well, just look at herbal remedies. It's essentially a throwback. It's saying you go to a plant and you mush it up and you stick it in the jar and you sell it and you eat it and it's going to cure what ails you. And that's the kind of stuff that people believed in the early 19th century. And you know maybe sometime something worked, but the indications were very uncertain, you didn't really know what was in that bottle, you had contaminants plus the active ingredient. You didn't know what the active ingredient was or how strong it was, and so yes, maybe occasionally, such things worked, but probably at a terrible price. Probably often did great harm.

For example, the foxglove from which digitalis was later isolated. That was a plant and people used to take it for dropsy, which is a kind of collection of fluid, edema that you can get from heart failure, and maybe taking the foxglove, the whole leaf, worked from time to time. But maybe it also kills you, which an overdose of digitalis can do. And maybe your dropsy didn't come from heart failure but it came from something else. So that's the kind of thing that happened. Then with the dawn of good pharmacology and analytic chemistry at the beginning of the 20th century, you began to be able to isolate the active compound, to purify it, and later to synthesize it. So instead of having foxglove as a plant, you had digitalis, and you could synthesize different forms of digitalis that had different speed of activity, different strengths and so forth.

Penicillamine was a mold and from that we got penicillin. Now we synthesize penicillin and related antibiotics with much different spectrums, much different kinds of use. It was a great advance to be able to identify the active ingredient, to isolate it, to purify it, to synthesize it. Why on earth would you want to go backwards? But that's what we see, at least [with] the dietary supplements.

But people think these things are safe because they are natural.

Oh yes, they think it's natural. You had asked me earlier about why do people go for complementary and alternative medicine; if you look at what these disparate methods have in common, I would say the most important thing they have in common is that they haven't been demonstrated. If they had been they would be incorporated into scientific medicine and there'd be nothing alternative about them. So that's the thing they have in common. Therapeutic touch, homeopathy, magnet therapy, herbal remedies, you name it. That's what they have in common: they have not been adequately tested scientifically. They also have other things in common and one is a certain ideology, a belief in things that are "natural," things that are "traditional"--as long as you don't add the words "Western Medicine" after traditional.

Believers in complementary and alternative medicine do have in common an ideology that celebrates the things that are natural, and things that are traditional, even though poison ivy is natural, and even though purging and bleeding are traditional. They still celebrate it in almost mindless way so when they take a bottle of something labeled "dietary supplements," they assume that there's something natural in there and therefore that that's good.

They also believe in something that is not really scientifically true, and that is that things can be simultaneously gentler and more potent. And unfortunately that's hardly ever the case. Strong medicines usually have strong side effects, and desperate illnesses often require desperate remedies. Cancer is a good example, where you might be very, very sick from the treatment. But you put up with it in hopes that it will cure your cancer. It's very seldom true that you find things that are truly potent that have no side effects at all, and yet people who take dietary supplements believe that somehow they're getting something that will cure whatever the thing is that they want to cure and do so at no cost whatsoever.

… I don't think people realize that there are no manufacturing standards whatsoever. There can be anything in these bottles, and in fact Consumer Reports did a study of ginseng showing that different brands of ginseng labeled as having the same concentration of ginseng in them, vary tenfold in the amounts of ginseng that they had in the bottles, and some of them didn't even have any ginseng in the bottles. I don't think people realize that manufacturers can put anything in those bottles, and there have been studies indeed that have found contaminants of all sorts. Estrogen in PC-Spes which is supposed to be a nonestrogen treatment for prostate cancer, digitalis contamination, heavy metals, lead, mercury, arsenic.

The General Accounting Office released a study warning seniors that dietary supplements up to eleven percent could have dangerous contaminants in them, and that, even worse from the agency's viewpoint, could often interfere with drugs that they were taking. Could make it so that the drugs they were taking wouldn't work. I don't think people realize that. They think this is utterly innocent when they pick up the bottle of gingko or ginseng.

Why is that?

Well, in 1994 under heavy lobbying from the dietary supplement industry and strong pressure of some of the members of Congress who are very responsive to the dietary supplement industry, Congress passed something called the Dietary Supplement Health and Education Act of 1994 which is known as DSHEA and according to DSHEA if something is labeled a dietary supplement it will not be subject to FDA regulation… which means the manufacturers do not have to show any evidence whatsoever that it's safe, that it's effective, or that what's in the bottle is what's said to be in the bottle on the label. You could put anything you want in a bottle, label it "dietary supplement" and sell it. You couldn't say "to cure your cancer," because the few stipulations that were made were one, that you have to say somewhere on the bottle that it was not FDA approved and two, you could not promote it for either preventing or curing disease. But you could promote it for functional improvements. … For example, one brand of I think it's Horse Chestnut Seed Extract is promoted on the label as promoting, the quote is promoting leg vein health. Well, nobody goes around and worries about their leg vein health. I mean nobody looks down and says, gosh do I have healthy leg veins? But they worry if they have varicose veins, so that's what that's for. Or there is a dietary supplement for prostate disease. And it says, "promotes prostate health." Well, what can that possibly mean? It can mean that it prevents an enlarged prostate, or it prevents or cures prostatic cancer. That's about it. Most men don't go around worrying about in some general vague way their prostate health. They worry about an enlarged prostate and they worry about prostate cancer. So there is an art form here of complying with DSHEA without really complying with it. …

How big a problem is the safety of herbal supplements?

Well my thoughts are that you don't know what's in that bottle. You have no idea what's in that bottle. There was a letter to the editor of the New England Journal of Medicine, I think in 1998, from some public health officials in the state of California, looking at dietary supplements imported from China and finding that a very large percentage had contaminants which included mercury, lead, arsenic. And then I think about the same year the New England Journal published a case of severe lead poisoning, I believe this was in Israel, from imports of dietary supplements from China as I recall. There are cases of kidney cancer from some Chinese herbs, mainly in Europe, in Belgium I think, particularly. There was a case of digitalis toxicity, two cases I believe, reported in the New England Journal of Medicine from a tonic of some sort. Ephedra has killed a large number of people. … So I think we have a real reason to be concerned. And since the FDA has no regulatory authority--except after the fact, if they find out that there have been deaths or severe side effects--you are not protected, nor do you necessarily know if people have been harmed because there's no surveillance system, there's no requirement that the FDA be informed, so if the FDA does get wind of serious side effects or death it's only accidentally that somebody thinks to tell them.

What do you say to those who argue that consumers should have "medical freedom" to choose whatever treatment they believe is right for them?

Well, there's a certain libertarian right-wing view that there should be no FDA, that people can decide for themselves whether medicines are safe and effective. That's nonsense. Most people don't have the expertise or the resources to mount a proper study to find out whether a treatment is safe or effective. If you were going to get an artificial heart valve put in, would you really want to kind of hold it up to the light and decide whether this was going to pump blood around for you for the rest of your life? I don't think so. You would be very happy that there was an FDA that had made sure that this was safe and effective. Or if you have a child with meningitis are you really going to go to the shelf and choose your antibiotic based on what? On what you think in your heart of hearts sounds good, or what the label says? You're going to be very glad that the FDA has made sure that the antibiotic your doctor prescribes has been shown safe and effective for meningitis.

I can't believe that very many Americans if they think about it would really not want experts to evaluate drugs and devices that could mean their lives for safety and effectiveness. And if you were going to use something, a twig, a leaf, a root as a drug, then it seems to me that's no different. If you take something as a drug, you should evaluate it as a drug. …

Do you think there will be regulation of dietary supplements in the future?

I think there will be. I think DSHEA is going to have to be changed sooner or later, because we're seeing increasing reports of interactions. St. John's Wort for example, interacts with many drugs. … It interferes with drugs for AIDS. It interferes with drugs for cancer. … I think people are beginning to realize that there is a downside to this unregulated market. That maybe they were a little bit too fast on this. So I believe sooner or later, particularly as we see more of these side effects, sooner or later DSHEA will have to be modified in some way. …

What will it take to change it?

Well it could be like water on a rock. I think there are a lot of drips now on that rock. The side effects that we're seeing from taking unregulated dietary supplements, also the scientific studies that are just now coming to light that show that these magic remedies aren't so magic, that they seem to be weak at best. … Whether it will add up to enough to change DSHEA or not, I don't know. It's a tough industry. And there's a lot of belief in this. …

Can you talk about the industry's marketing techniques?

One of the interesting things about the wave of alternative medicine is the degree to which it plays into the hands of a part of the establishment. Managed care came about with the HMO movement--health maintenance organizations. And the word is maintenance, and this had to do with the belief that if you behaved just right, if you ate the right things, if you exercised in precisely the right way, if you took the vitamins if you ran your life in some sense around staying healthy, certainly if you didn't smoke, you wore a seatbelt, you wore a helmet when you were on your motorcycle, if you lived right, you would remain healthy. You might even live forever. If you didn't eat any cholesterol you would never get a heart attack. and conversely if you had one egg, you were doomed.

Alternative medicine plays into this exaggerated notion that you can prevent disease simply by doing the right thing. And they advertise that if you take ginseng you won't get a cold. If you take gingko, you'll have a better memory. If you take horse chestnut seed your veins will be healthier, and so forth. And it plays into what we learn from our good old HMO, that it's all our fault, that nothing happens by bad luck, it's all a matter of your responsibility and you better be on your toes and not make a mistake. So I think that's a part of the marketing, that you're responsible for your own health. …

I'm not just talking about herbal remedies now, I'm talking mainly about some of the practices, acupuncture for example, chiropractic promotes itself as being gentler caring more about the whole patient, taking more time, and in fact, it does. And you have to look at the reasons. The reasons are that people still pay for this primarily out of pocket. They pay the piper, they call the tune. If they want a practitioner to spend an hour with them, the practitioner will do it. Whereas in standard medicine the third party payers pay for it, the employers, the government, they call the tune. And so you better get through a doctor's office in seven minutes. …

And then the other thing about this is that the alternative medicine practitioners have to pay more attention to you. They have to be gentler, they have to be kinder, they have to be warmer, they have to at least appear to be more compassionate because that's all they have to offer. Whereas if you go to your surgeon with an appendicitis and he takes out your appendix, he may forget to be kind and compassionate. … He figures he's got some good stuff to give you and he doesn't have to give you the hearts and flowers and the frills. Now, I think he's wrong about that. I think that medicine and doctors have too often--and let me say this loud and clear--been too arrogant, too busy and too highly specialized and technologically focused. So I think there's a lot to be said for the complaints on the side of complementary and alternative medicine in that department. Nevertheless you have to say that they're offering all of these touchy-feely things cause that's all they've got. Whereas you can get more if you have appendicitis or a heart attack or cancer from your standard doctor.

Tell me about Eisenberg's 1993 study that you published in the New England Journal of Medicine.

David Eisenberg sent the New England Journal of Medicine a survey that we published in 1993. At that time I was executive editor and while I didn't make the final decision I had primary responsibility for these types of articles, what we called special articles. I favored publishing it. I knew that alternative medicine was becoming more common, but I didn't really know how common. And this was the first large survey that I was aware of that attempted to put numbers to the use of alternative medicine, who was using it, why, what kinds were they using. So I think it was a very important study and I would publish it again if I were in the same place. …

Eisenberg's survey showed that many people were using alternative medicine. And it may be that doctors for the first time realized that some of their patients may be using alternative remedies and not telling them about it. I think it was beneficial insofar as doctors realized that and began to ask their patients about it. And maybe began to do a little introspection about the way they behaved toward their patients. Maybe doctors began to ask themselves am I being as accessible to my patients, as tuned in to their concerns as I should be? And if that was one outcome--and I don't know one way or the other--then I think that was a good outcome. I'm pleased with that.

While I take responsibility for publishing David Eisenberg's survey and I think it was a good survey and it addressed an important question--how many people are using these things--I don't take responsibility for all of the ripple effects, some of which I think are quite negative. One of them is the fact that medical schools began to say, "Hey, there's a market for this stuff, let's get on the bandwagon here and advertise ourselves as being friendly to alternative medicine." And they did that and they began to set up courses and centers and institutes that to my mind were pandering to a market. They weren't teaching alternative medicine in the sense of teaching about the evidence in support of it, or what it is, or who's doing it, they were going beyond that. They were offering it and they were proselytizing. Because everything is a market now, they were trying to attract customers that way. And insofar as that was the fallout from the Eisenberg piece, I regret it. … I'm very dismayed that the academic establishment decided you know, "Oh goody, we'll jump on this."

What do you think about what's being taught in American medical schools like Harvard about alternative and complementary medicine?

I think that you should teach something about alternative and complementary medicine, or whatever the term du jour is for it. You should teach about it because it's a real phenomenon out there and it has to do with medicine. So you ought to teach about it as a phenomenon, and then you should also teach about the various disparate practices that fall under that rubric: homeopathy, therapeutic touch, herbal remedies. You should teach what is known about the evidence. You should teach about the scientific evidence. Do we know it works? Do we know it doesn't work? Do we know nothing about it and is it just merely speculation and assertion? That's the kind of teaching that should go on in medical school, but in fact, [that's not happening].

Just this month in the Journal of Academic Medicine there was a very good survey of this, done by some scholars at the University of Indiana medical school, and they found that almost all medical schools do in fact offer courses in alternative medicine but they are not about it, and they certainly are not critical courses looking at the evidence for it. They are proselytizing courses and the teachers are proponents and often practitioners of these therapies for which there is no proof whatsoever, and they're indoctrinating the students in it. That's quite different, and that's my concern about teaching it. …

What's happening at Harvard?

In general I think Harvard has been very lax in its evaluation of complementary and alternative medicine. It seems to be applying a double standard, one standard to new treatments for heart failure and a different standard for things that are labeled "complementary and alternative medicine." It shouldn't do that. It should be embarrassed by that. It's not alone. Most of the other major research institutions are doing exactly the same thing. They too are setting up institutes funded by wealthy philanthropists who are believers in complementary and alternative medicine. They shouldn't do it either. I don't think Harvard is any worse, but it's not any better either.

Why are they doing it?

Well I think there are two reasons. And you should ask them, but I think there are two reasons, one is it's good marketing. People want it, particularly the people that teaching hospitals' practitioners would like to attract. These are well insured people who are relatively affluent, relatively well educated. These are the people who by and large subscribe to alternative medicine. Any HMO, any hospital is going to want to attract them. They don't cost as much.

I think that people who believe in alternative medicine would just be amazed at the extent to which they play into the hands of the establishment trying to save money. If you're an HMO and you offer yoga for example, this is very good niche marketing for two reasons, you're getting people who are likely to stay healthy and you're offering a service that's very cheap compared to say a prescription drug benefit. So if you're an HMO and you get paid so much per head and you get to keep that money if your patients don't cost very much, and you offer yoga, it's cheap and you get people who aren't going to get sick and you keep all that money as profits at the end of the day. And if on the other hand you were to offer a prescription drug benefit, that would break the bank and you would attract old people, sick people, people for whom that's important. So that's what's going on there, and I think that the Harvard teaching hospitals are doing the same thing. So I think that's one reason, it's good marketing. …

[And the people to whom they market these alternative therapies often] think of themselves as anti-establishment, but they are playing into the establishment. In fact, some of the big drug companies whom they love to hate have subsidiaries making herbal remedies, dietary supplements with sylvan names. They call it Romp in the Hay or Bubbling Stream or something like that.

One of the things that's so amazing to me is the way a lot of proponents of alternative medicine will follow anything Deepak Chopra says, anything Andy Weil says without any evidence whatsoever, faithfully on his word alone. And yet they think of themselves as critical, skeptical, they're critical of American Pfizer, they're skeptical about their doctor, but they're not skeptical about Andy Weil or Deepak Chopra. Why is that? So there's a double standard going on. …

Another reason that the medical schools are so willing to set up centers and institutes dedicated to essentially promoting complementary and alternative medicine is because they do get this infusion of money, first from wealthy philanthropists, but now from the NIH. And now that the National Center for Complementary and Alternative Medicine has real grants, real money, sizable grants to offer, they want them. And the academic medical centers, I'm sorry to say, have their eye on the bottom line at all times.

What do you think about the research that's being done at the NIH's Center for Complementary and Alternative Medicine or the other research organizations?

Well, there's no disease, is there, in "The Osher Institute" or the "Division for Complementary and Alternative Medicine"? So it's not focusing on a disease, it's focusing on a collection of methods or philosophies or approaches. And what that collection has in common is that it hasn't been demonstrated by scientific research. So you would think the answer would be, well quick, let's demonstrate it. At least if there's any possibility that it will work let's demonstrate it. But that isn't what's happening. It's more of an advocates' center. They're assuming that at least some of these things work, never mind the evidence. And you shouldn't do that in a research institution, you should never say never mind the evidence. Now they don't say it in quite those words, but that's how they've been behaving.

Eisenberg says to be patient.

Right. Well if you don't start it'll take forever, that's my answer to that. I have yet to see the starting of it, never mind the finishing of it. But in fact you know if you really are going to put a lot of effort into a line of research, it's amazing how fast it can be. Just look at what we learned about HIV in a short, short time. … It doesn't take as long as it's been taking. The Office of Alternative Medicine was set up in 1992. In 1998 I looked at what had come out of the first thirty grants, those grants were awarded in 1993. You would certainly expect that after six years you would have some results. There was nothing. Out of the thirty grants there were maybe twenty-eight little abstracts on the website and out of those there were nine papers and none of those nine papers was a controlled clinical trial of an alternative remedy that would give you an answer. I mean it was just incredibly bad research. I can hardly dignify it by calling it research. So that was six years after the first grants were awarded.

Now, to be sure, these were small grants and that's often what's argued. Well, they were small grants, they were just $30,000 apiece. Still, that's no excuse for doing bad research. Little research, yes. Bad research, no. Since David's own piece in 1993 there's been plenty of time to start to do good research. Now we've just begun to see some good research. It has not come, so far, from the National Center for Complementary and Alternative Medicine, it's come from the other institutes at the NIH. It's come from the National Institute on Aging, from the National Institute on Mental Health. From the NCI. From the Mayo Clinic. From the Canadian Provincial governments. We've seen studies now start to come out--well-designed, large studies and they've all been negative. They have all been negative.

A negative study is one that compares a new treatment with a placebo or an old treatment and finds no effect of the new treatment. Finds that it's no better than the old treatment or nothing. And the good studies, the credible studies that have begun to come out have been negative.

… There are a lot of people now who have a vested interest in complementary and alternative medicine, who sell it essentially, and so they have to say yes there's a study but it's in German and nobody's ever seen it that shows that homeopathy cures cancer. They have got to say that. They can't just say we're pushing something and there's never been any evidence for it. But you have to consider the source. They're not going to show you the evidence. They're going to allude to it. … Such people are going to have to say that there's research out there. But when they point to it, it's either very, very poor, or it's somehow disappears. It doesn't really exist.

Are they lying?

Are they lying? I don't like to say that. but it's not the truth.

Are there any studies showing an alternative therapy to work?

I know of no good study that has shown an alternative remedy to work. They've been flawed in some way, the ones that I've read that show that they work.

What do you think about the report from the White House Commission on Complementary and Alternative Medicine?

The White House Commission on Complementary and Alternative Medicine, before which I testified last year, consisted of people the majority of whom had financial ties to complementary and alternative medicine. They had vested interests. They were practitioners of complementary and alternative medicine. Or they owned businesses that offered complementary and alternative medicine. … That is an obvious conflict of interest. By definition you can't have a dispassionate, disinterested evaluation. So this committee was set up, the deck was stacked by our new age president [Bill Clinton] from the beginning…

When I testified, there was two days I think, and the first day was coverage and reimbursement and the second day was "does it work"? That's backwards. They are sure that it should be covered and reimbursed… In fact the premise of the sessions on "does it work" was what are new methods for studying it? Because clearly the old methods won't do. The old clinical trials, that's probably not applicable to something so mysterious as complementary and alternative medicine, so we need a new methodology, and when I spoke before the commission I said no, the old methodology is fine. But the premise was, surely we must need a new methodology.

You don't believe that because these are new techniques we need a new way of studying them?

…They try to suggest that it's somehow too complicated to study scientifically, that there has to be some other way of studying it, and that's wrong on several counts. The scientific method is not just a sort of flavor of the month like chocolate or vanilla, it is the only way you can find out about the natural world and our bodies are part of the natural world. It's not something that you choose to do, it's something that you have to do if you want to find the answer. And the scientific method is just a matter of formulating a hypothesis that can be tested, designing a study that will test it, collecting objective, verifiable data, and then drawing the conclusions and only those conclusions that follow from that data. That's all it is. But it's powerful. And it's the way we study all new treatments in medicine and it's responsible for the great flowering of scientific medicine in the 20th century. …

What is the evidence in favor of acupunture?

I have never seen a good study that shows that acupuncture works. Now the NIH a few years ago had a panel that ostensibly reviewed the world literature on acupuncture and suggested that there was evidence to the effect that it might work for two conditions. One I think was toothache, the pain from toothache, and the other was nausea of chemotherapy I believe. And that was it. A lot was made of that. It was suggested that the NIH had found and it was implied through its own research that acupuncture works, period. But in fact, looking at the whole body of research, it might work for these very, very narrow conditions out of the whole body of conditions for which it's been tried. Both of these conditions are subjective. It's not like reversing heart failure or curing your cancer. You're reporting that your toothache feels better. You're reporting that you're less nauseated. So you have to ask how well were these studies controlled? And a control means making sure it's not a placebo effect, that the subjects didn't imagine that they felt better, or feel better because they believed in it. So to control then for the placebo effect in acupuncture requires that the patients see needles going in in the same way that they might with acupuncture, that they be fooled. And I don't know whether these studies that were purportedly positive involved control groups where you fooled the control group or not. I just don't know. Other than that, I don't know of any good studies that have shown that it works. Certainly nothing like the claims that are made for it. It's generally accepted as, it works. And yet it's based on a philosophy so primitive that it's amazing to me that people could imagine that it does. I mean, these meridians of electrical fields and so forth. It's based on a philosophy that goes back to the period of time in which it developed. Which is quite primitive.

Why do people assume that it works?

I think because a lot of people are doing it. It feeds on itself. There also a lot of mythology about China, too, that everybody uses acupuncture there for anesthesia, for just about everything, but what we're seeing is as China becomes economically more developed, it's choosing to go to what's often called western medicine. To scientific medicine. And in fact this use of the term western medicine is irritating because the Japanese practice just about the same kind of medicine that we do. What we see is that scientific medicine developed in different countries at different rates around the world. It's not particularly western, it happened to develop first, mainly in the United States, because we were economically able to do it. It's more expensive. Scientific studies are expensive. To deliver it is expensive. But as countries have developed economically, whenever they possibly can, they use scientific medicine because it works. …

You have to ask yourself about these old traditional medical treatments. Ayurveda, Chinese traditional medicine, that started thousands of years ago, what life was like for the people who relied on those therapies. Well, it was nasty, brutish and short. That's what life was like. And yet somehow they're presented now as sort of exotic chic, as traditional chic that because they're old and because they come from a different culture, there must be something to them. …

I think it's fairly random that acupuncture has become so widely accepted. And people want to make it special in some way, without seeing that it's a part and parcel of the whole phenomenon. We had talked about why do people believe in this so much now, and we talked about many reasons. One reason is that people want to have some control over sickness and death as many ways as possible. it's scary, sickness and death and so they try acupuncture plus they try whatever their doctor offers. But there's another thing about alternative medicine and that is the religious appeal, which in my view is perhaps the most important reason. People are now drawn to alternative medicine I believe because of the mysticism, because of the spirituality, because of the offer of transcendence at a time when people aren't finding conventional religion all that satisfying. So it gives them the feeling that their mind has dominion over their body. It gives them some feeling of spirituality, and in a sense, the more implausible the method, the more it appeals to this metaphysical desire, this desire for mysticism and spirituality. I think acupuncture has that.

It's totally implausible; it's like angels dancing on the head of the pin, it has a sort of fussiness, and yet at bottom it's a belief in vitalism, and energy fields, the same thing you see in therapeutic touch and some of the other more implausible mechanisms. And I think that appeals to people. I think in a sense the more implausible it is for some people, the better. It satisfies a craving for spirituality, settles some old scores with conventional medicine, it makes people think that they're rising above themselves.

What's wrong with that?

Well, there's nothing wrong with people believing what they want to believe, as long as there's evidence for it. But there is something wrong I think to a sort of wholescale acceptance of matters of fact. [Whether] acupuncture will heal your appendicitis is a matter of fact. Either it will or it won't. … In so far as you're taking medicine to have an effect on your body, that is to cure your appendicitis, there has to be evidence that it works. And if you believe it in the absence of such evidence, then you're believing something that may not be true. And I think that's harmful.

What do you say to people who believe that acupuncture works?

Well it speaks to the power of the placebo effect, which is extremely powerful when it comes to subjective complaints like pain or nausea, particularly if they're not terribly severe. If you were in agony because your leg was crushed, probably the placebo would not work. But I suspect in most cases, acupuncture works through a placebo effect. People believe in it, the discomfort is not that severe and they're not objective complaints, but just subjective complaints. And so this placebo effect kicks in, they feel better. We can all see this. If you have a cold and you're feeling crummy and then something really nice happens to you, you forget the cold for a couple of hours. The placebo effect operates on all of us every day and I would suspect that that's what's going on with acupuncture. …

It's been said by some complementary and alternative medicine proponents that it doesn't matter whether their treatments work or not, that even if it is a placebo treatment that's fine. If it works, it's fine. And so it ought to be offered as a placebo, if nothing else. I have a lot of problems with that because I think that any use of a placebo without saying it's a placebo is deceptive. It's patronizing and I wouldn't think that consumers who've in some sense turned to alternative medicine because they see it as empowering, would want to sign on to something so infantilizing and patronizing as the idea that people can just give them placebos and tell them it works. I, I don't think that that's right.

What's wrong with hospitals offering patients alternative therapies?

When the Harvard teaching hospitals offer acupuncture or therapeutic touch they're usually doing it for pain. They're doing it for a subjective symptom. And they're doing it for patients who would like to have it. I was offered therapeutic touch at the Mass General two years ago for post-operative pain. I declined. But if I had said yes, I would have gotten totally implausible, impossible treatment given to me for pain at the Mass General Hospital. They're not offering it to you for cancer, thank goodness. When they offer it to you for pain, they're counting on the placebo effect. If you believe in it, then you're at least going to report that your pain is better. And if you don't believe in it you're going to decline it, as I declined it. So they figure it can't do any harm. May make their pain feel a little bit better, and it can't do any harm. And they're also going to give them conventional pain relief too. So it's good marketing--people like it, it's another choice. Consumers like lots and lots of choices and here's one for you.

But I think it's very bad and it's very bad for two reasons. One, it's unethical in the sense that you should not use a placebo except in a research setting. When you do a clinical trial and you use a placebo, what you're saying to the people who enter the trial is some of you may be getting a dummy pill, or a placebo, is that okay with you? And then people say yes, it's okay. But when you're giving it in the context of treatment, they don't say, would you like therapeutic touch it's a placebo, so it's deceptive in that sense. It implies that it works. And I think it's wrong to give a placebo if, if you're not honest about it. … I think placebos are unethical, except in a research setting. So that's number one.

Number two, it puts the Mass General Hospital's imprimatur on this. By the very act of offering it, they are saying this works. I mean, you have just gone to what some of the locals call man's greatest hospital, you expect the most sophisticated care in the world and you get it. And then you're offered this? The only thing a member of the public can possibly conclude is that this must have been found to work or the Mass General Hospital wouldn't offer it. So I think that's wrong, it's misleading on two counts. …

It also uses personnel who could be put to better use. At the time that I was offered the therapeutic touch at the Mass General Hospital, my daughter happened to be a resident there and I knew very well that they were short staffed in many respects and mainly they were short staffed of nurses. And yet my understanding is that nurses were going to be used for this. At least there was a nurse talking to me about it. So I think it's a misuse of resources. …

What do you know about Dr. Nicholas Gonzalez and his controversial cancer treatment regimen?

I read the New Yorker story about the Gonzalez therapy and I've read some about what it is. And this is, it seems to me, another instance of preying on desperate people. And it also shows the problem with the anecdote or the testimonial: it's no way to find out whether something works or not. You must do a proper trial to find out whether something works. The problem with the anecdote, saying that so and so got better, threw away his crutches, his tumor shrank is that you don't know what would have happened if he had not gotten that treatment. You don't know what caused the tumor to shrink. Now it's true that in cancer of the pancreas it's very unlikely to shrink on its own. But the natural course of many diseases is to wax and wane. And for those diseases it really is a problem. You don't know how many people got that treatment, who didn't get well because you only hear the success stories. …

What the anecdote tells you is this is something, if it's a well documented anecdote--and that's another problem, the alternative medicine gurus get letters from people who say, "I had cancer, my doctor gave me six months to live, and I drank carrot juice and now I'm alive and it's three years later," and maybe he's dead, that always adds to the story. You don't know whether he had cancer in the first place. You don't know what other treatment he was getting. So that's not documented, that's more of a testimonial. And a lot of complementary and alternative medicine is testimonials. Just "I know somebody who knew somebody who said this," without any effort to find out whether it's true.

The anecdote is a little bit different. It can be very well documented, and reputable medical journals--the New England Journal of Medicine occasionally would publish an anecdote if it's very well documented. If we got a study that said I have a patient and, just an anecdote, but he had cancer of the pancreas and I gave him carrot juice the tumor shrank and he's well and it's three years later, and they could document all of those facts, we might publish it. We would ask questions: how many people with cancer of the pancreas did you give carrot juice to? Who didn't get better? We would want a lot of documentation of it, but we might publish it. But we wouldn't publish it as evidence that carrot juice cures cancer of the pancreas. We would publish it as something that had to be looked at in a proper study. You would say this is a hypothesis-generating anecdote. It means this is something worth looking at, let's design a study. Say a small trial of people with cancer of the pancreas, and add carrot juice to the usual regimen in one half of the population, and don't do it in the other half and see how they do. And you would begin to look at something. A lot of accepted treatments come about in exactly this way. Theory, anecdote, and then the proper studies. So that's what an anecdote is good for. It is not proof of an effect at all. It's what it is.

The Gonzalez therapy is being studied now.

I don't think that's fair to patients. I really don't. People shouldn't have to spend what may be their last months taking a hundred and sixty pills and having coffee enemas and, and things that may be unpleasant, uncomfortable and debilitating. You'd have to have some prior probability that was pretty strong for me to think that that was a good way to go, that that was a good study to do. I don't know what the prior evidence was before this study was launched. I'd want to look at that very carefully. …

I think there's something sad about standing back in a way and watching desperate people spend what may be the last months of their life chasing after treatments that may be very unpleasant, very uncomfortable, very onerous on the belief that it might work. I mean nobody's going to do that unless they think it might work. And I think doctors have an obligation to talk honestly, compassionately but honestly with their patients about such wild goose chases. It doesn't seem kind to me. …

If somebody said to me, you have a devastating disease, cancer of the pancreas and you're probably going to survive no more than six months. And if you want, you can spend this six months having two coffee enemas a day and taking 160 pills a day, and I think there's a diet that didn't sound very palatable to me, on which you would probably lose weight, because it wouldn't taste very good, and going through a regimen that would take most of your waking hours--you can do this, there is zero evidence that it works. There is even less plausibility that it works. Or you can live your life with your family and your friends and going to Venice. Which would you rather do? Well it's, it's a no-brainer. But it's never presented to people quite like that. The way it's usually presented is, this might work, it's a chance, we don't know for sure, but it's tilted in that way so that people feel guilty unless they do do this.

And let me say that that's true for standard medicine too. Doctors don't like to say, I've done everything I can, I don't know what else you can do. I will keep you comfortable, I promise you. I will make sure you don't die alone, but other than that there's nothing I can do. They don't want to do that, so even in standard medicine I believe patients are often offered debilitating chemotherapy when the doctors know almost for a certainty that it won't work and that it may even make the remainder of their lives worse. And the same thing happens with something like the Gonzalez treatment. …

Some proponents of alternative and complementary medicine point out that many accepted scientific medical techniques have not been proven by double-blind clinical trials, either.

There are a number of standard medical treatments that have not yet been demonstrated in rigorous clinical trials. Usually there's some biological plausibility to them. For example, it's never been demonstrated in a rigorous clinical trial that a prostatectomy will extend your life in cancer of the prostate, as opposed to doing nothing. But there's some plausibility to that. If you have an organ that has a cancer in it, you take it out. And also, most people in standard medicine, at least most scientifically based doctors believe that that's a flaw, that you really shouldn't be giving treatments that have not been demonstrated to be effective in a clinical trial. And less and less is that being done. Certainly new treatments are now almost always demonstrated in a clinical trial. New drugs by law are demonstrated to be effective before the FDA.

So these old time practices that were just based on anecdotes are beginning to go the way of the dinosaur, and certainly people in standard medicine know that they should. People are going back now and looking at old treatments--hysterectomies for various indications where it wasn't really clear that that should happen, prostatectomy as I mentioned is now being looked at--going back and kind of cleaning up some practices that were accepted into the standard repertory without sufficient evidence.

Alternative medicine doesn't have quite that attitude toward it. If often promotes wildly implausible remedies and does so without saying, but we really should have the evidence on this, we really should subject it to a clinical trial. So I think there's a little bit of a difference. …

Where do you see alternative medicine in the future?

There are not two kinds of medicine. There's medicine that has been tested, and there's medicine that hasn't been tested. There's medicine that works, and there's medicine that may or may not work, we just don't know. There are a lot of changes in the way we approach health care that I think are very beneficial. The emphasis on a good diet and on exercise, while sometimes carried to bizarre lengths, is by and large a good thing. But it's based on evidence. We have shown in studies that exercise is good for you, that people who exercise, all things else being equal, are healthier, feel better. We know what constitutes a good diet. In medicine we didn't used to teach these things and that was wrong. We thought of ourselves mainly as fixers. Somebody has a disease, we'll fix that disease and we didn't think enough about how people can stay healthy.

I think there have been real changes, and I don't want to suggest for an instant that preventive care is not useful, and that there haven't been real changes in the focus in medicine, some of them driven by complementary and alternative medicine. Some of them have made doctors look more closely at what they do and think of themselves less as technicians. That's all to the good. But it is no substitute for scientific evidence showing that something works if you're going to use it. It is no substitute for that. …

In the case of complementary and alternative medicine, you have such a disparate, broad spectrum. There's an array of practices and methods, some of which are quite plausible. It's quite plausible that certain botanicals will be found useful. They were before. I mean we found digitalis from the foxglove, we found morphine from the opium poppy, we found quinine from cinchona bark. There is no earthly reason that we won't find other herbs that work. There's no shortcut to it. Once you have some indication, you're going to have to isolate them, purify them, do proper studies of them, but I have no doubt that some of them may prove to be helpful. It may be that St. John's Wort will prove to be helpful sooner or later in mild depression, for example. It may turn out that any of the things that are now being sold can turn out to be helpful. But you have to show that and to do that you have to know what it is you're studying, you have to have it isolated and purified, and study it properly.

Now at the other end of the spectrum, there are practices and theories that are not only wildly implausible, but impossible. One of those is homeopathy. If you dilute a substance to the point that there is not one single molecule left of that substance, it can't have an effect, period. Over and out. It can't. To imagine that it did would mean that you overturned all the laws of physics and chemistry, and that's simply not going to happen. Certainly the very least that could be said is that extreme claims demand extreme levels of proof. So anybody who wants to argue for homeopathy has got to do a lot of very good research. And then you might have to decide that you don't believe in gravity anymore and don't believe in a lot of other things. It's an astonishing sort of claim. And therapeutic touch the same thing. So within this range there are things that are more or less plausible.

After ten years? I have no doubt that you might find that some of these herbal remedies work. But the notion that you will find that this whole disparate array of things works is not very rational, and also not very likely.

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posted november 4, 2003

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