People who believe that the practice of medicine should be limited to methods and procedures that meet available scientific standards of safety and efficacy, complementary methods used in the art of patient care that have compatible rationales, and conduct that is consistent with established ethical principles,* are justifiably concerned about the proliferation of alternative medicine centers affiliated with standard medical institutions, the establishment of a National Institutes of Health (NIH) Center and a White House Commission on Alternative and Complementary Medicine, the invasion of altemativism into medical education, and the unbridled promotion of dubious over-the-counter medicines under the rubric of “dietary supplements” by mainstream pharmaceutical companies. In this issue we wish to point out that it is also important to be aware of the threat altemativism poses to public health programs.
There is no greater success story for the 20th century than the public health advances reflected in record life expectancy, more disability-free years of life, a cleaner and safer environment, and a higher standard of living enabled by the increased efficiency of modem technology. Public health programs have been-and still are-dependent upon science and technology for these achievements.
Public health has always had to struggle with public resistance to progress. Modem public health science generally traces its beginning to London in 1849 when John Snow (1813-1858) mapped the cases of cholera and found that the victims all obtained their water from the same company, which was the only one downstream from the point where sewage entered the Thames River. Unable to get people to stop using the suspected source of contamination, Snow removed the handle of the Broad Street pump and the epidemic waned.
Resistance to “meddling” with the public water supply continued for years, and chlorination is still controversial in some places, but the lethal diseases it controls has resulted in general compliance. The same has not been true for nonlethal tooth decay. For generations, the most widespread human disease was dental caries, with 95% of the population affected. Then came the discovery that 1 part per million fluoride in drinking water could greatly reduce the incidence and prevalence of tooth decay without objectionable mottling (i.e., discoloration) or any adverse effects. Fluoridation has been a spectacular success, but despite more than half a century of practice that has confirmed the safety and benefits, there still exists an antifluoridation movement. And it has been shown that the same constituency that opposes fluoridation contains the political activists who fought for the legalization of the quack cancer remedy Laetrile.
Milk-borne diseases were a major problem at the beginning of the 20th century. Tuberculosis, undulant fever, listeriosis, salmonella poisoning, and other problems were eliminated by pasteurization. Nevertheless, there still exists a cadre of true believers who insist upon drinking raw milk. For years California’s largest dairy, Alta Dena-a $100 million operation-aggressively promoted certified raw milk (CRM) as a health food. The owner believed that unprocessed foods possess a mystical “life force.”* Alta Dena was the lone member of the American Association of Medical Milk Commissions (AAMMC) meaning that it regulated itself.
Alta Dena advertising claimed that CRM was the “safest, purest, most wholesome milk you can buy” and distributed “educational” materials falsely claiming that pasteurization markedly reduced the nutritional value of milk. Alta Dena refused to put warning labels on CRM. The Berkeley Co-op reported that the warning signs it voluntarily posted were repeatedly torn down by true-believing CRM buyers. The AIDS problem in San Francisco eventually caused its city council to require such a label. Political intervention in Sacramento continued to prevent the Department of Health Services from ordering Alta Dena to pasteurize. Meanwhile, Alta Dena distributed CRM to nine states. In 1984, Public Citizen Health Research Group petitioned the US Food and Drug Administration (FDA) to ban interstate distribution of CRM as a public health danger, but Alta Dena also had friends in Washington. Congressman William Dannemeyer was Alta Dena’s general counsel, and Ronald Reagan was a California Republican with a strong antiregulatory agenda-even in matters affecting public health. Reagan’s Health and Human Services secretary, Margaret Heckler, prevented the FDA from acting. Public Citizen then sued Heckler and won. This resulted in a 1987 federal court order directing the FDA to institute a ban. The judge found that Heckler had acted in an “arbitrary and capricious” manner by disregarding public health data on the risks of raw milk.1
A lawsuit brought by Consumer’s Union, the American Public Health Association, and the California Grey Panthers (a senior citizen consumer group) resulted in a 1985 court order requiring a warning label on CRM. Alta Dena’s owners, the Stueve family, continued to deny that CRM was responsible for health problems. Alta Dena financed an independent study by the University of California, Los Angeles (UCLA), School of Public Health to determine if CRM was actually a problem. Epidemiologists at UCLA estimated that more than one-third of reported Salmonella Dublin infections in California between 1980 and 1983 were attributable to raw milk consumption. It appeared that the incidence of infection was 8 to 35 per 100 000.2 It was determined that the relative risk of illness from S. Dublin infection for certified raw milk users in 1983 was established to be 158.0 based upon an estimated 1 pint per day per user consuming the 12 000 gallons produced daily.3 Alta Dena Dairy was sold by the Stueve family in the late 1980s, and all Alta Dena milk is now pasteurized, but the dairy continues to distribute CRM under the name Stueve’s Natural Raw Certified Milk.
*”Certified raw milk” has no public health status-it is a marketing term owned by the American Association of Medical Milk Commissions (AAMMC). AAMMC was organized in 1907 to develop uniform standard for the production of “certified raw milk.” An important feature at the time was the elimination of bovine tuberculosis from cow herds. However, by 1941, all the disease had been eliminated from all US herds. Hygienic standards are similar in all modem dairy operations. Unfortunately, cleanliness does not protect consumers from every disease that may be transmitted via unpasteurized milk, and animal testing cannot prevent dangerous Salmonella Dublin from contaminating milk.
Vaccination has a long history of public resistance. Doctors who inoculated people against smallpox were threatened with hanging.4 Anti-immunization groups are having a resurgence with the power of the Internet. Alternative health-care providers have been at the forefront of opposing and denigrating immunization. Nearly half of US chiropractors supported an official policy against the American Public Health Association resolution that acknowledges the risks of immunization but asserts that these are offset by the benefits. Naturopaths, likewise, have a strong anti-immunization history.5 In the United Kingdom, the most common reason for parental refusal to immunize children was found to be diversion by a homeopath; religious belief, mainly Christian Science, was next.6 In the Netherlands, there has been an alarming increase in cases of measles in the so-called Bible belt-86% of parents have given religious reasons for not having their children vaccinated. 7
Public health practices often run afoul of environmentalists. Pesticides, herbicides, fungicides, and modern agricultural techniques are under attack by the “organic” food movement. Despite its lack of scientific validity the government has caved in to demands that “organically grown” foods be given formal recognition. The media has amplified the problem by treating chemical names with disdain. PCBs, DDT, dioxin, and other chemicals are spoken of as if they were established killers on par with cholera, typhoid fever, diphtheria, and the like. In reality, the real threats these chemicals pose to public health are largely theoretical. DDT is still the most effective agent to employ against the world’s top killer, malaria.
Alternativism is a way of thinking that holds that science and technology degrade our lives. Public health salutes the World Health Organization’s definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease and