“The scientific games have begun, declared a New York Times article in response to the news that the National Institutes of Health (NIH) was allocating additional funds to U.S. academic researchers to assess the efficacy of as yet unproven “alternative” medical treatments.1 We would like to suggest that such “games,” whether “scientific” or not, involving competition between “standard medicine” and “alternative” medicine or treatment interventions, have deep historical roots.2 Even before the last century, when modern science gained political and cultural ascendance, various medical groups have sought legitimacy, power, and popular support on a variety of fronts and have co-opted governmental authorities to legitimize their causes.3 In the context of the present situation we will analyze 3 historical moments chosen because each reveals the relationship between culture, politics, and medical power. For the purposes of clarity and understanding, it is important to define the terms “scientific medicine,” “standard medicine,” “ ‘alternative’ medicine,” and “complementary medicine,” and to distinguish them from one another.
The 2000 edition of the American Heritage Dictionary defines “medicine” as “the science of diagnosing, treating, or preventing disease and other damage to the body or mind.”4 Medical interventions that originate from scientific investigation and methods based on the experimental methods developed during the last 125 years are the basis of scientific medicine.
To qualify as “scientific medicine,” all interventions, therapies, practices, and pharmacological agents are, ideally, verified by the scientific method. Use of a drug or procedure is based on criteria of efficacy and safety. A drug or procedure’s use may be modified in response to new data. The effectiveness and safety of new medical interventions are tested in various ways, including by randomized, controlled clinical trials.
Some critics, principally from the social sciences and humanities, have complained that scientific medicine objectifies its subjects, ignoring their individual subjectivity. This objectification is partly the result of the usual scientific paradigm under which scientific medicine operates. It posits a split between mind and body, with the body “understood as an interrelated set of component parts whose functioning is mechanistic.”5 Scientific studies must proceed in this fashion, since subjective viewpoints and feelings can skew data. However, from a patient’s or subject’s perspective, the objective approach of scientific medicine may sometimes seem cold and unyielding.
It is useful to distinguish between scientific and standard medicine. The term “standard” has several different connotations: the first refers to what are considered prevalent practices, which are not always identical to “best practices.” In this sense of “standard” treatment, methods may be popular and accepted, but may vary from region to region.
The second connotation of “standard” implies that a given intervention is standard in the sense that it lives up to the “gold standard” of modern medicine, i.e., validated by clinical trials.
“ALTERNATIVE” AND COMPLEMENTARY MEDICINE
On the most basic level, an “alternative” medicine is simply one that is not current or standard. But since medical practices either are or aim to be scientific, it becomes more important to realize that for all practical purposes, what constitutes “alternative” medicine is any nonscientific healing system, technique, or therapy. Such systems originate in other cultures or can be remnants of older, prescientific Western medical traditions. “ ‘Alternative’ medicine” thus can be fully defined as any medical system, technique, or practice that does not follow the principles of medical science and/or has not been scientifically scrutinized and tested.
“Complementary medicine” may be defined as alternative or nonscientific medical ideas or techniques that have been incorporated within the institutional structure of scientific medicine. Currently a number of vocal American doctors, educated in mainstream U.S. medical schools or affiliated with legitimate U.S. medical centers such as the University of Maryland and Harvard University, are tapping into the wave of popular discontent and alienation from modern medical science. These doctors endorse the inclusion of unscientific healing techniques in the body of standard practices under the scientific mantle. Some advocates have incorporated esoteric philosophies and techniques into their recommended practices. They employ scientific language to describe these techniques. However, they do not generally provide scientific studies to support their claim that such interventions are efficacious. A combination of social, cultural, political, and economic factors have brought us to a point where nonstandard “alternative” and standard medical practices overlap and may be confused with each other.
THE PRESENT IN LIGHT OF THE PAST
Three representative moments in the history of the continuing rivalry between scientific and “alternative” medicine in the West and the impact of governmental intervention upon them illuminate the situation just described. In each case, cultural beliefs about health and disease in tandem with politics helped to shape health policies, while scientific evidence and medical ethics have played a lesser role.
The case of early modern France
It was in early modern France (1500–1789)that physicians first classified different kinds of illicit healers and differentiated them from each other as well as from themselves. Since the founding of faculties of medicine in Europe in the 12th and 13th centuries, university-trained physicians attempted to control medical education and standards. From that time to the present, there have been pretenders, quacks, and otherwise unlicensed healers who practiced medicine. However, it was not until the 16th century in France that unlicensed healers were classified into distinct groups. This classification system revealed the cultural fault lines that existed between what was then considered standard and anomalous medicine. Confronted with a wide variety of medical rivals from various backgrounds, two university-trained physicians, André du Breil and Thomas Courval de Sonnet, catalogued a medical “other.” Breil and Courval claimed that their competitors were “vagabonds, atheists, exiles, priests, monks, shoemakers, carders, drapers, weavers, masons, madames and prostitutes” who practiced medicine on the side. Breil and Courval’s Catholic and Galenic loyalties also made them suspicious of Paracelsists, who tended to be Protestant and who challenged the teachings of Galen.
Breil and Courval called their rivals “charlatans,” a novel term at the time. The word “charlatan” first appeared in the French language in the mid–16th century and became associated with jugglers, treacle sellers, and street theater actors from the commedia dell’arte. The association of street theater and healing, related to the search for instant cures, panaceas, and the like, contrasted with Galenic university-trained physicians’ modus operandi, which was based on scholastic logic, humoral physiology, and concern for professional ethics.
While the classification of a medical “other” was a significant event, those practitioners who constituted that “other” did not lose their popular appeal. Their allure is best explained by the fact that empirical and magical practices were rooted in folk belief systems and values, some of which overlapped with official medical beliefs but which also embraced a wide variety of unorthodox ideas and techniques.6 Moreover, at the time the state did not have the power to enforce the medical standards of any medical group. The descendants of the licensed surgeons and university-trained physicians eventually received the backing of the 19th- and 20th-century state. The abolition of the corporate structure of France as a result of the French Revolution, and the reestablishment of the medical profession on new foundations under Napoleon, brought about the union of the medical and surgical corps into one profession. This process gradually legitimized the newly emerging standards and discoveries of scientific medicine and linked them with state-supported health care. Thus, Pasteur’s discoveries in microbiology and the development of more efficacious surgical procedures could only be implemented in a rigorous way after the reordering of the medical profession under Napoleon. Until then, there were so many competing medical groups that it was impossible for any one of them to obtain dominance over the medical field.7 In addition, it requied many decades to convince the public as well as all members of the medical profession of the efficacy of science as we regard it today.
The case of Gravidan and Aleksei Zamkov in Soviet Russia
The second historical example of the power of the state and culture to reinforce beliefs and to legitimize medical practice is that of the rise and fall of the Gravidan craze in early-20th-century Russia.8
In the late 1920s Aleksei Andreevich Zamkov developed Gravidan, a substance extracted from the sterilized urine of pregnant women and utilized as a treatment for ovarian dysfunction. At first, it appeared that Zamkov’s championing of Gravidan would end in early failure.* In 1930 13 research scientists at the Institute of Experimental Biology accused Zamkov of using Gravidan in “uncontrolled nonclinical testing” outside of the confines of the official Scientific Research Institute. The attack appears to have been part of a larger political campaign informed by Bolshevik revolutionary zeal against abortion and private medical practice. As a result Zamkov was exiled from Moscow. Zamkov then moved to the industrial city of Voronezh, 330 miles south of Moscow. There, Zamkov convinced government leaders of a large locomotive factory that Gravidan would energize workers who were in poor health. Zamkov made extravagant claims regarding the efficacy of his compound. He asserted that 80% of his patients had experienced significant improvement in their disorders, ranging from eye disease, schizophrenia, and postsurgical infections to cancer. Above all, Zamkov claimed that by raising “the general tone of the organism,” the industrial productivity of the treated workers greatly improved. Gravidan-treated patients were said to work 12- to 13-hour shifts for years without vacations. Such avowals led to the appearance of Gravidan in most Soviet pharmacies and its use in 345 Russian medical facilities.
This notion appealed greatly to both Soviet officials and workers who felt that productivity was the virtue par excellence of the ideologically correct Soviet proletariat. As a result of this convergence of ideology, politics, and medicine, the politburo (1932–33) supported Zamkov’s project by transforming his modest laboratory into an official Scientific Research Institute. Zamkov’s wife, Muktavina, a famous sculptor, also promoted Gravidan enthusiastically and made it popular in influential artistic circles. In the long run, however, Gravidan’s ideological suitability to represent the vitality of Stalin’s “scientific communism” proved the most important component of its success. In 1934 more than 15,000 Russians were treated with Gravidan.
Because of a variety of personal and political factors, Zamkov’s triumphant historical moment did not endure. First, the Soviet medical establishment began a campaign against independent and powerful institute directors, such as Zamkov. In addition, some of Zamkov’s former patients, who were his most powerful and highly placed supporters, died. Zamkov’s reputation further declined because of the appearance in 1938 of a new medical muckraking newspaper, Meditsinski Rabotnick. Its offices were in the same building as Zamkov’s Institute, and he was soon subject to scathing criticism. Indeed, one of the newspaper’s stated goals was to eliminate “feudal princedoms.” Soon an article titled “Ignorance or Charlatanism?” appeared, accompanied by a caricature of Zamkov. The byline stated that Zamkov had been peddling a panacea that consisted of “sure remedies for mice, epilepsy and earthquakes” and concluded that Gravidan’s “legend” was worse than a disease. During the same time as Zamkov was subject to such attacks in print, one of several commissions investigating him judged “the primitive method of the preparation practiced by Doctor Zamkov” unsatisfactory. Zamkov’s institute was closed and Zamkov died in 1942 of cardiac disease unresponsive to Gravidan. With him, Gravidan’s fame perished as well.
What is most striking about the example of Gravidan is the way in which cultural and political variables contributed to its rise and fall as much as or more than scientific evaluation and testing. In particular, it is striking to see how rapidly Gravidan’s popularity rose when it was believed to increase worker productivity. Workers and government sought it out with great eagerness. Patients who wrote to Zamkov seemed to be searching for a seamless convergence between Soviet ideology and their weak human flesh. When Zamkov gradually lost key political supporters, his whole endeavor began to be viewed as too “bourgeois” to suit Soviet ideology. The popularity of Gravidan bears witness to the way politically ascendant yet unsupported ideas continue to surface and obtain legitimacy through state sanctioning.
The Di Bella fiasco in Italy
On November 6, 1997, the magazine Modena Amica held a public meeting in Rome featuring Dr Luigi Di Bella.9 At the press conference that followed this meeting and which was then broadcast on national television, this 85-year-old retired professor of physiology claimed to have invented a miraculous cancer cure containing melatonin, somatostatin, retinoids, ACTH, and several vitamins. He spoke of thousands of patients who had used his medicine with great success. Soon after this press conference Dr Di Bella addressed the Commission of Social Affairs of Italy’s House of Deputies. Although he provided only 30 clinical records, he stressed that “with my method nobody ever died, nobody ever felt sick, over ninety percent of the patients who were using my drug had advantages.”9
A month later, in December of 1997, on the basis of these claims alone, a judge in a small town near Naples ruled that Di Bella’s treatment, which cost $350 a day, should be distributed by the National Health Service, free of charge and on demand. Italy’s National Federation of Medical Associations opposed this ruling, as did the Italian Oncology Society and Rosaria Bindi, Italy’s minister of health. Bindi argued that the national health coverage for chemotherapy did not cover a remedy such as Di Bella’s.
In response, 70,000 Di Bella supporters held demonstrations in front of various government ministries and St Peter’s Square. The pope, along with the fascist National Alliance Party, called for a reconciliation between Di Bella supporters and the government. The National Alliance Party also recruited Di Bella’s son, a physician, to criticize the health-care system for being inhumane and undemocratic. In February 1998 Ms Bindi ordered that 2000 patients be given Di Bella’s treatment for free. She also insisted that 397 cancer patients taking Di Bella’s remedy receive intensive retrospective clinical study. In May a court ruled that the government was guilty of economic discrimination and decreed that Di Bella’s therapy be given on demand. However, in July a panel of Italian and foreign doctors found that after 2 months none of the first 134 patients in the study showed improvement, while half the sample suffered from toxic side effects. Since the remedy appears only to have relatively harmless ingredients in small amounts, one might entertain doubts about the latter claim. But in any event, government funding ended soon thereafter.
There is a lesson to be learned from a review of these 3 “moments.” Clearly, there are risks in allowing political groups to define disease and bodily disorders and determine the value of medical interventions. What happened in western Europe and the former Soviet Union happens in the United States as well. In 1978, in spite of the FDA’s refusal to approve the use of laetrile (another bogus cancer treatment), 27 state legislatures legalized its medical use. The National Cancer Institute (NCI) gave in to public pressure and reviewed 67 cases. They found a good response in only 2 patients. They concluded that laetrile was ineffective as a cancer treatment. Four years later (in 1982) the NCI and FDA were forced to fund a prospective trial that found that laetrile had no benefit for a sample of 178 patients with advanced cancer.10
In the late 1980s Rep B. Bedell of Iowa, who suffered from Lyme disease and prostate cancer, resigned from Congress. Two years later he persuaded Sen Tom Harkin that he had been cured by “alternative” medicine. The senator began to treat his own allergies with bee pollen. These perceived cures encouraged the senator to modify an NIH appropriations bill to fund a National Institutes of Health Office of Alternative Medicine. This institute has become the NIH Center for Alternative Medicine with $68,000,000 in discretionary funds.
In conclusion, our 3 snapshot examples of medicine, science, and society emphasize the power of the state combined with economic and cultural predispositions in providing an explanation for the acceptance of anomalous medical techniques. Such factors largely explain the widespread acceptance of the many disparate components that constitute the amalgam of contemporary “alternative” medicine. Since government agencies play a significant role in determining health policy, they may foster the adoption of guidelines that are unlike scientific practice and more similar to “alternative” medicine interventions.
* Zamkov’s first discussion of his research was in a 1927 article, “O primenenii mochi beremennykh s lechebonoi tsel’iu” [“On the Use of Urine from Pregnant Women for the Purposes of Healing”], Klinicheskaia meditsina, 1927: 14. His institute published a journal, Urogravidanoterapiia, the first issue of which (1935) consisted entirely of reports of treatment using Gravidan. Zamkov’s article there was entitled “Gravidano-terapiia kak metod nespetsifich-eskoi terapii” [“Gravidan Therapy as a Method of Nonspecific Therapy”] See also his more general survey of the Institute’s achievements, “Gravidan v meditsine. Sluchainost’ i otkrytie” [“Gravidan in Medicine. Chance and Discovery”], Urogravidanoterapiia, 1935: 8.
- Alternative care gains a foothold. New York Times. January 21, 2000: A16.
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- Klairmont (Lingo) A. Empirics and charlatans in early modern France: the genesis of the classification of the ‘other’ in medical practice. J Soc Hist. 1986; 19: 583–603.
- Ramsey M. Professional and Popular Medicine in France, 1770–1830: The Social World of Medical Practice. New York: Cambridge University Press; 1988:125.
- Naiman E. Sex in Public: The Incarnation of Early Soviet Ideology. Princeton: Princeton University Press; 1999.
- Call it hope, or quackery, when cancer strikes. New York Times. July 31, 1998: 14.
- Relman A. Closing the books on laetrile. N Eng J Med. 1982; 306: 236.