The following letter was rejected for publication by the New England Journal of Medicine, the reason being that it was too long. No offer was made to present its views in a forum other than letters to the editor. The original Eisenberg article appeared in the January 1993 issue of the New England Journal of Medicine. In winter 2000, the Scientific Review of Alternative Medicine printed a critique by Timothy Gorski, MD. The critical points made here are remarkably similar, though neither author was aware of the writings of the other. Dr Jarvis brings his historical knowledge to bear as well. The original publication, we feel, marked a turning point in journal peer review failures. Present journals fail to face the defects of “alternative” medicine articles now, 8 years later. —Eds.
March 10, 1993
New England Journal of Medicine
10 Shattuck Street Boston, MA 02115-6094
Having tracked nonscientific health care for more than 20 years as part of an epidemiological analysis of quackery in the United States and Canada, I believe that the study by Eisenberg et al. provided useful data on the utilization of nonmedical services by the public. Unfortunately, the media are using it to send an erroneous message that an alleged increase in “alternative” medicine use is prompted by a growing disaffection with mainstream health care, with the implication that health care is too scientific and would be better (and cheaper) if it were less so. Indications are that medicine needs to be more scientific1,2 and medical discipline needs to be strengthened.3
Eisenberg et al.’s observation that “the frequency of use of unconventional therapy in the United States is far higher than previously reported” was based upon a combination of (1) a broader definition of what constitutes “unconventional medicine” than anyone has ever used before, and (2) reliance upon inadequate studies of use of nonmedical services in the past.
On the first point, Eisenberg et al. expanded the general concept of what constitutes “unconventional medicine” to include self-help groups such as Alcoholics Anonymous and commercial weight loss programs such as Weight Watchers, but they should have acknowledged that their wider definition greatly inflates their data on prevalence.
On the second point, Eisenberg et al. seem unfamiliar with national studies on the use of questionable remedies that would be more representative. The most elaborate study ever done on the topic found that questionable health practices were substantial in l969.4 A 1986 Louis Harris poll reported that 21% of American adults reported having used a questionable health-care product during the previous year. This was for a far narrower range of 15 specific health problems than Eisenberg et al.’s broad definition covered.5
An analysis of Eisenberg et al.’s, data on more traditionally defined “unconventional” practices was revealing. They reported that 10% of the sample had used chiropractic and 70% of those “saw a provider” (I’m curious as to how the other 30% utilized chiropractic without a provider). This means that 7% of the sample visited a chiropractor. This number does not reflect increased utilization.
Three percent reportedly used herbal medicine, but only 10% “saw a provider.” This means that 90% used self-care. Increased use of herbal remedies is due to aggressive marketing in the face of lax regulation by the FDA. According to health-food industry data, herbal sales (caps, tabs, bulk, etc.) for 1991 were $653.2 million, which was up 35% from $467.3 million in 1990.6 Several hundred million dollars more herbal OTC products are sold by multilevel marketers such as Sunrider, Nature’s Sunshine, Barley Green, Herbalife, Golden Pride, Melaleuca, Matol Km, and others.
Eisenberg et al. reported that 1% used homeopathy, 32% of whom “saw a provider.” This means that 0.32% of their sample saw a homeopath. This number is within the range reported twenty years ago by a larger national study (0.5%),4 and a regional study (1.9%).7 Any increase in the utilization of homeopathic OTC products was apparently among the 68% who self-medicated with OTC homeopathic remedies. Use burgeoned after the FDA decided not to require manufacturers to comply with the 1962 Kefauver-Harris premarketing efficacy standards that other drugs must meet. Again, lax regulatory standards signaled the drug industry that labeling products “homeopathic” provided an end run around the law. In 1985 the FDA estimated that there were “between 50 and 60 firms marketing homeopathic remedies in the United States.”8 The agency could have stood up for consumer protection by challenging these firms to meet the 1962 law, but chose not to (which was understandable under the antiregulatory Reagan administration). Again, aggressive marketing easily accounts for any increase.*
Eisenberg et al. reported that less than 1% utilized acupuncture, with 91% seeing a provider. This number, which represents fewer than 15 people in their sample of 1539 adults, is not impressive, and may even represent decreasing utilization as acupuncture’s newness wears off.
Media reporters are combining Eisenberg et al.’s study with a Time magazine cover story10 that also pumped up the utilization of “alternative” medicine. Time’s case was based upon a telephone poll of 500 American adults by Yankelovich Clancy Shulman on October 23, 1991, for Time/CNN, which found that about 30% had tried some form of unconventional therapy.10(p68) The breakdown was: chiropractor 31%, acupuncturist 6%, herbalist 5%, homeopathic doctor 3%, faith healer 2%.10(p75) It is obvious that the Time/CNN poll was not large enough to be representative and may have had other methodological flaws. When I tried to obtain the complete study for analysis, I was told by one of the Time story authors that it was not available.
Eisenberg et al.’s recommendation that medical doctors begin asking their patients about their use of unconventional therapy whenever they obtain a history should not have been necessary, since good history taking should include such practices, but calling physicians’ attention to the fact that there are many different kinds of health entrepreneurs out there promoting a wide variety of potent remedies to their patients should motivate them to become better informed about this problem.
William Jarvis, PhD
Professor, Loma Linda University
School of Public Health
* Addendum, April 1994: These suspicions were verified by Jay P. Borneman: “The homeopathic industry reports that sales of homeopathic medicines to non-homeopathic consumers, those that use proprietary medicines without much knowledge of homeopathy . . . are way up. Yet, sales to physicians and consumers using the more traditional or technical homeopathic medicines are fiat.”9
- U.S. Congress Office of Technology Assessment. Assessing the Efficacy and Safety of Medical Technologies, Washington, DC: Author; 1978.
- Smith R. Where is the wisdom? BMJ. 1992; 303: 798–799.
- Public Citizen Health Research Group. 6,892 Questionable Doctors. Washington, DC: Author; 1990.
- National Analysts. A Study of Health Practices and Opinions. Washington, DC: National Technical Information Service; 1972.
- Louis Harris & Associates. Health, Information and the Use of Questionable Treatments: A Study of the American Public. Washington, DC: U.S. Department of Health and Human Services; 1987.
- Health Foods Business. 1992; March: 38.
- Roebuck B, Hunter B. The awareness of health-care quackery as deviant behavior. J Health Soc Behav. 1972; 13: 162–166.
- Rados B. Riding the coattails of homeopathy’s revival. FDA Consumer. 1985; March: 30–34.
- Borneman JP. Is the homeopathic movement obsolete? Resonance. 1994; Jan–Feb: 23.
- Wallis C. Why New Age medicine is catching on. Time, November 4, 1991: 68–76.