the alternative fix

the clash

· About the Program

The past decade has seen an explosion in the popularity—and profitability—of complementary and alternative medicine (CAM). Under pressure from everyone from consumers to Congress, major hospitals and medical schools have embraced therapies that they once dismissed as quackery. So commonplace, in fact, have alternative medical treatments become that an entire center of the National Institutes of Health is now devoted to studying them. But the questions remain: Do these treatments actually work? And are they safe? In "The Alternative Fix," airing Thursday, November 6, at 9 p.m. on PBS (check local listings), FRONTLINE examines the controversy over complementary and alternative medical treatments. Through interviews with staunch supporters, skeptical scientists, and observers on both sides of the debate, the one-hour documentary examines how these popular treatments are facing increased scrutiny as the first real studies of their effectiveness are published.

· About this Guide

What exactly is complementary and alternative medicine? What types of treatments are considered to be complementary or alternative? What evidence supports the belief by millions of Americans that such treatments work? And why do some alternative treatments prove so controversial, particularly within the mainstream medical community? This Viewer's Guide provides a brief overview of complementary and alternative medicine, including the causes behind its sudden surge in acceptance, a look at what scientific studies say about these treatments, a glossary of important terms, and a list of resources for learning more about alternative medical treatments.

· What is CAM?

Acupuncture. Chiropractic. Homeopathy. Aromatherapy. Reiki. Just about everyone today either has personal experience with or knows someone who has tried some form of complementary and alternative medicine (CAM)—the umbrella term that encompasses a vast array of alternative healing and medical treatments.

The National Center for Complementary and Alternative Medicine (NCCAM)—a division of the National Institutes of Health—defines CAM as "a group of diverse medical health care systems, practices, and products that are not presently considered to be part of conventional medicine." (Please see the Glossary for a list of well-known CAM terms and treatments.)

While many people tend to use the terms "complementary medicine" and "alternative medicine" interchangeably, NCCAM considers complementary medicine treatments to be those that are used in conjunction with conventional medicine, while alternative treatments are generally used in place of more traditional medical techniques—for example, treating cancer through dietary changes instead of with chemotherapy and radiation. But this is by no means the only acceptable term or definition; many colleges and universities, for example, prefer the term "integrative medicine," which emphasizes the convergence of both traditional and alternative health practices and the partnership between patient and care provider.

The mainstreaming of alternative medicine

From meditation to dietary supplements to traditional Chinese medicine, complementary and alternative medicine treatments have become increasingly popular during the past decade—so much so, in fact, that Americans now spend some $48 billion each year on alternative medicine. Yet alternative medical practices weren't always so widely accepted or well received—particularly by the mainstream medical community. Many doctors and alternative practitioners, in fact, recall a long-standing rift between the two healing camps that at times bordered on hostility.

chart of NIH Funding for the Study of CAM

"Until very recently, [alternative] medicine would best be characterized as antagonistic medicine," says Dr. Ted Kaptchuk, an assistant professor at Harvard Medical School. "It was a war between the `outs' and the people who ran the elite institutions in our country. What's happened in the last ten, fifteen years is that the strategy of war has ceased."

"The Alternative Fix" traces the sudden rise in acceptance of complementary and alternative medicine during the 1990s to the halls of Congress and one U.S. senator's allergies.

In the documentary, viewers meet Sen. Tom Harkin (D-Iowa), who recalls complaining to a friend about his terrible allergies. The friend said he knew someone who could cure Harkin's allergies using bee pollen.

"I went on this very tough regimen of taking a lot of bee pollen, sometimes as much as sixty pills a day," Harkin says. "And literally on about the tenth day, all of a sudden my allergies just left.

"Well, that's when I began to think, `We've got to have somebody looking at these different approaches.'"

Harkin, then chairman of the Labor, Health and Human Services, and Education Committee, convinced Congress to allocate $2 million to the National Institutes of Health for the study of alternative medicine. The legislation led to the creation of NCCAM and soon the availability of research funds prompted scores of once-skeptical hospitals and academic centers to venture into the world of alternative medicine.

Today, just eleven years after its founding, NCCAM has an annual budget of $115 million and a staff of seventy, and is conducting more than 200 research projects on CAM therapies. In addition, more than 20 percent of U.S. hospitals now offer some form of alternative therapy alongside their conventional medical treatments.

The public responds

Dr. Marcia Angell, a senior lecturer at Harvard Medical School, is critical of many complementary and alternative healing practices. She believes CAM's popularity grew partly in response to growing consumer frustration with the managed care, mainstream medical world of the 1990s.

"While medicine has grown more and more powerful," she says, "scientific medicine—the means for delivering it—has become less and less satisfactory."

Noted alternative healer Dr. Andrew Weil puts it another way. "People are fed up with being passive recipients of authoritarian, paternalistic medicine," says Weil, director of integrative medicine at the University of Arizona. "And many of these [alternative] systems make people feel they are more autonomous, more in charge of their own destiny."

· The CAM Controversy

While millions of Americans have embraced complementary and alternative treatments, such therapies are not without controversy. Critics like Harvard's Dr. Angell say that many of these treatments are based purely on anecdotal reports of favorable results—not the rigorous scientific research and empirical evidence required of conventional medical treatments.

"This is the cart before the horse. This is upside down. This is Alice in Wonderland," Angell says. "You do the evidence first and then you do the treatment and that's the problem with this." Others point to the broad spectrum of treatments that are being lumped under the CAM umbrella as problematic: While a body of evidence does support the use of acupuncture for treating certain types of pain, they say, other CAM treatments defy both scientific principle and basic logic.

In "The Alternative Fix" for example, several physicians are particularly critical of a homeopathic treatment being offered at New York City's Beth Israel Medical Center in which a five-year-old boy's behavior problems are treated with pills containing microscopic amounts of ground up tarantula.

· The CAM Explosion

•A 1991 telephone survey commissioned by Harvard Medical School found that 34 percent of Americans were using some form of alternative medicine. That number grew to 42 percent in 1997.

•Surveys indicate that more than 70 percent of those using CAM treatments did not disclose this fact to their physician.

•Today, Americans spend $48 billion a year on CAM treatments.

•More than 20 percent of the nation's hospitals now offer some type of alternative treatment.

By offering such dubious treatments, critics say, hospitals are providing a measure of credibility to therapies that may not only be ineffective, but harmful.

Dr. Matt Fink, former president and CEO of New York's Beth Israel Medical Center, defends his hospital's decision to offer homeopathy and other CAM treatments at its Continuum Center for Health and Healing, saying that medical centers have a responsibility to respond to patient demands.

"If hospitals don't get involved in these kinds of programs they will lose patients because patients will go elsewhere," Fink says. "My personal view of homeopathy is I don't understand how it works, and I'm not personally convinced that it does work. But that doesn't mean that I would prevent a homeopathy practitioner from working here."

Studying the studies

What does the research say about complementary and alternative medicine? Unfortunately, not enough clinical studies have been completed to produce a mass of conclusive evidence one way or the other. (Please see the Resources section for information about researching available studies on various complementary and alternative treatments.)

Since NCCAM's status was upgraded to a full-fledged research center in 1998, only one major study has been completed: a clinical study on the effectiveness of St. John's Wort in treating major depression. The conclusion: St. John's Wort had little effect on this type of depression. (CAM supporters counter, however, that the study was flawed; they say St. John's Wort is useful in treating mild to moderate depression—not major depression.) And while several large, multi-year studies are now underway, NCCAM notes that there are obstacles to conducting studies of some alternative therapies. Among them: the difficulty in conducting valid studies on dietary supplements when there are currently no standards or consistency among different brands sold on the market.

"If you want to study an herb, whose herb are you going to study?" asks NCCAM Director Dr. Stephen Straus, noting that different brands of the same dietary supplement can contain vastly different active ingredients in varying concentrations. "If we're going to study these things, we have to guarantee what we're studying because…if the study is positive, we're going to want people to be able to replicate our experience and expect beneficial outcomes."

Dietary supplements: what you see may NOT be what you get

The lack of standardized ingredients in dietary supplements is related to the fact that, unlike prescription drugs, dietary supplements are not required to prove that they are safe and effective before they go on the market. In fact, they don't even have to prove that what is inside the bottle is the same as what's listed on the outside.

· The Big Business of Supplements

•Since the 1994 passage of the Dietary Supplement Health and Education Act (DSHEA), which dramatically limits the FDA's ability to regulate supplements, the U.S. supplement industry has nearly doubled its sales.

•Dietary supplements are now an $18 billion a year business.

•Currently, there are approximately 900 supplement companies operating in the U.S.

•Since DSHEA's passage, the FDA has received more than 7,000 reports regarding adverse reactions to dietary supplements.

"Imagine if you were going to buy a Mercedes and somebody told you that there was a considerable chance that there was a Chevrolet engine under the hood and it was not a Mercedes," Straus says. "You might be upset. But that's the position Americans are in in the marketplace today in buying dietary supplements. There's no guarantee that what's on the label is in the bottle."

As a result of the 1994 Dietary Supplement Health and Education Act (DSHEA), the Food and Drug Administration (FDA) can only regulate such products after they have reached drug store and supermarket shelves. Even then, the agency can only step in if a supplement has been proven to cause harm—and the burden is on the FDA to prove a connection between the supplement and the illness or injury.

In addition, many consumers are unaware that some dietary supplements can cause serious interactions or side effects, particularly when taken with certain prescription medications. St. John's Wort, for example, has been linked to organ rejection in transplant recipients, while some supplements have been shown to reduce dramatically the effectiveness of AIDS drugs. (Please see "The Alternative Fix" Web site for more information on drug interactions).

"The problem is," says Harvard Medical School's Dr. David Eisenberg, "there's not enough warning to the public to say, `You cannot take these herbs with these drugs.'"

In the coming months and years, results from more and more of NCCAM's alternative medicine studies will be released. Currently, the center is conducting several large, multi-year studies, including one on the use of saw palmetto in treating benign prostate enlargement as well as the largest-ever controlled study of acupuncture for arthritis of the knee. Whether the findings of this research will confirm or refute the effectiveness of popular CAM treatments, however, remains to be seen.

· Considering CAM Therapies?

Individuals considering trying an alternative medicine treatment should keep the following points in mind, experts say:

1. Consult your physician. Surveys have shown that more than 70 percent of those who reported using CAM treatments did not disclose this fact to their primary care physician—a cause for concern given the fact that some alternative therapies can cause life-threatening interactions when taken with prescription medications. Before starting any type of health care treatment—be it CAM or traditional western medicine—consult your physician. You should also provide your physician with specific information about the type of CAM treatment you are considering, since many medical doctors are not experts in the wide variety of CAM treatments available.

2. Do your homework. Individuals interested in pursuing complementary and alternative medicine therapies will find no shortage of books, Web sites, and other resources on the topic. The key, experts say, is to identify credible sources that will provide straightforward, objective information on such treatments. In addition to a Glossary, this guide offers a list of Resources that provide a wealth of information on complementary and alternative medicine, as well as tips for finding other credible resources.

3. Ask questions. Whether you're consulting your doctor or surfing the Internet for information on CAM treatments, it helps to have some questions in mind to guide your research. Consider asking yourself questions such as: What does this treatment/product claim to do? Have any studies been conducted? If so, what did the results show? Are there any known side effects? And will this treatment interact or interfere with my prescription medication?

4. Consider the cost. Since many CAM therapies are not covered by insurance, be sure to ask your practitioner how much each individual treatment will cost, as well as how many treatments will be required to achieve the desired results.

5. Caveat emptor. While there are many reputable CAM practitioners, be wary of those who set unreasonable conditions for your treatment, such as insisting that you abandon all forms of traditional western medicine. Be especially wary of practitioners who make pie-in-the-sky promises of spectacular results.

· Resources

Government Resources

Professional Associations

Other Resources

· Glossary of Popular Therapies

Acupuncture: an ancient Chinese technique in which hair-thin needles are inserted into specific points in the body to prevent or treat illness.

Aromatherapy: the use of essential oils extracted from plants, trees, and herbs for therapeutic purposes. The aroma from the oils is believed to activate olfactory nerve cells, which then send impulses to the limbic system, the area of the brain associated with emotions and memory.

Chiropractic ("ki-roh-PRAK-tik"): an alternative medical system that focuses on the relationship between the body's physical structure and alignment and health.

Dietary Supplements: The 1994 Dietary Supplement Health and Education Act (DSHEA) defines dietary supplements as a product taken by mouth—other than tobacco—that contains a dietary ingredient intended to supplement the diet. Dietary supplements include vitamins, minerals, herbs, amino acids, enzymes, organ tissues, and metabolites.

Homeopathy: Based on the belief that "like cures like," homeopathy is an alternative medicine system that treats patients by giving them highly diluted, minute doses of a substance that advocates argue would cause that illness if given in greater doses.

Massage: the manipulation of soft tissues in the body in order to relieve pain, ease muscle tension, and speed healing.

Mind-body Therapy: includes a wide variety of strategies consumers can learn to facilitate the mind's capacity to improve psychological and physical health. These techniques can range from mainstream approaches such as lifestyle education (i.e., diet and exercise), behavioral strategies, and cognitive therapy to such complementary and alternative approaches as meditation and guided imagery.

Reiki ("RAY-kee"): a therapeutic technique in which a practitioner uses his/her hands to conduct healing energy through the patient in order to bring the body into physical, emotional, and spiritual balance.

Reflexology: the practice of applying pressure to specific points on the feet to encourage health and healing in various parts of the body.

· Credits

Special thanks to Raney Aronson, A Little Rain Productions; Tom Delbanco, M.D., Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center; and Alice Domar, Ph.D., director of the Mind/Body Center for Women's Health at Boston IVF, for advising on this guide.

"The Alternative Fix" is a FRONTLINE co-production with A Little Rain Productions. The producer, writer, and director is Raney Aronson. FRONTLINE is produced by WGBH Boston and is broadcast nationwide on PBS. Funding for FRONTLINE is provided through the support of PBS viewers. Additional support is provided by U.S. News & World Report. Additional funding for "The Alternative Fix" is provided by The Corporation for Public Broadcasting. FRONTLINE is closed-captioned for deaf and hard-of-hearing viewers. FRONTLINE is a registered trademark of WGBH Educational Foundation. Cover art © CORBIS.

The executive producer for FRONTLINE is David Fanning.

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posted november 4, 2003

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