Review

Dancing in the Dark, or Sleeping with the Enemy?

The June 6, 2000, issue of Academic Medicine contained an invited article by Stephen E. Straus, MD, director of the National Center for Complementary and Alternative Medicine (NCCAM). Academic Medicine, the journal of the Association of American Medical Colleges, is read largely by medical school faculties. I wrote this reply at the suggestion of several officials of the AAMC. Its edited contents will be printed in the March 2001 issue of that journal. The following is the unabridged version, submitted as a commentary article. The editors would allow its printing only as a letter to the editor.

 

The June 6, 2000 issue of Academic Medicine contained an invited article by Stephen E. Straus, MD, director of the National Center for Complementary and Alternative Medicine (NCCAM). In justifying the existence of the NCCAM, Dr. Straus’s article accepts presumptions and concepts that will divert medical education from reason and science. Some declarations are simply incorrect. I will address both the article’s facts and philosophical and political themes.

BACKGROUND

The present situation was predicted in several books of the 1970s and 1980s. The writers decried science and medicine’s evolution toward objectivity. Over two centuries, medicine isolated subjectivity, transcendentalism, and consciousness from perceived influence over disease. The authors conceived recreating medicine, returning to a status less scientific and rational, more self-centered and patient-directed, more mystical and “spiritual.” They predicted medicine’s return to eras of subjectivity, melding science and mysticism in order to accommodate all human experience, being more “holistic” and “New Age.” The advocates apparently believed this could come about without an ultimate decline in health and practice standards.

The New Age influence melded with movements in universities—cultural relativism and postmodernism. Cultural relativism conceptualizes objective standards for effectiveness in medicine as irrelevant or contingent on the aims of the society. Its advocates in anthropology and sociology accept medical systems from other cultural traditions as tools for maintaining integrity of the culture. Relativism in a medical sense conceives a plurality of medical subcultures in modern society—each supplying needs of its adherents.

Postmodernism demotes rational thought and problem solving to the significance of mere social interactions—as “just another way of knowing.” It considers facts as socially constructed—the results of specific cultural influences. Surprisingly, it considers language as the determinant of reality, rather than as a tool to describe reality. This has resulted in the idea that words with specific definitions reveal “bias.” One example is “quackery,” for which the term “alternative” was coined as an acceptable euphemism; another is that “prior probability” reveals bias in calculating likelihood.

Relativity and postmodern deconstruction are the intellectually orienting forces guiding the academic acceptance of anomalous medicine. They are late-twentieth-century developments that for two generations have fertilized and enabled the academic “alternative medicine” movement. The soil is human nature and its tendencies to suggestibility, misinterpretation, transcendentalism, and biasing sentiments, which contribute to a distortion of reality. Of course, more obvious is commercial self-interest, an intimate enabler of pseudoscience’s success in medicine.

The Straus article’s basic error was to disregard this philosophical and ideological geography. It stepped into the controversy as though there was little history preceding the NCCAM’s creation, and as if the problem were merely a contest between unproved practices and proved ones. The article overlooked or intentionally ignored the problem—the underlying rejection of many objective standards by which “alternatives” are to be measured.

The article states that the NCCAM was formed because the American people demanded attention to “alternatives.” Not so. The demanding advocates were a few members of Congress, influenced by advocates for offshore and border cancer clinics, the supplement industry, and a relatively small group of lay supporters. Perceiving their own medical problems to be cured by aberrant methods, they brought political pressures on the National Institutes of Health (NIH) to form the original Office of Alternative Medicine (OAM).

The NCCAM still reflects its dominance by sectarian and transcendental influences. It excludes rational opinion. Experts offering services to the OAM at its inception were rejected. Neither the OAM nor the NCCAM offered appointment of any to a council or committee. The first OAM director resigned under congressional pressure because he opposed advocates of fraudulent cancer methods on the OAM advisory council. In addition, congressional committees chaired by supporters have closed doors to critics at hearings on “alternative” medicine. There has been no movement within the NCCAM to correct this problem.

Congress also removed the OAM from the scientific influence of former NIH director Harold Varmus, progressively increasing the annual appropriation to over $70 million, and elevating the OAM to the independent NCCAM. No congressional voice has opposed the NCCAM. Although many physicians and academics oppose NCCAM policies and many oppose its existence, no medical organization has challenged NCCAM funding.

Dr. Straus calls for rigorous research on alternative methods, implying that rigorous trials have not been performed. But such trials have been performed, and adequate information already exists showing that the “alternatives” are ineffective. Although some meta-analyses make the point that most trials have not been of ideal quality, the meta-analyses consistently show several features. First, the best quality trials of the most common methods show the methods to be ineffective, while the poorest trials show the most effectiveness. Second, many of the positive trials contain such errors as to disqualify their results. When seen in overall perspective, the “alternatives” do not measure up. Most of this information existed prior to the OAM’s formation, yet the OAM has not acknowledged it.

There is no compelling reason to test most methods further. The best quality research shows homeopathy to be ineffective. Of scores of chiropractic manipulation studies, the best show lack of efficacy. Acupuncture trials show no effect in the best studies and most effect in the worst studies. Thirty-three meta-analyses and systematic reviews of over 200 acupuncture clinical trials show positive evidence only for nausea in two specific circumstances and for pain of postoperative dental origin and tennis elbow. Even in those conditions trial results are not consistent. Such results can easily be explained by chance and publication biases. When faced with such massive numbers, the NCCAM would have to be in existence for the next 50 years to approach its goals, which simple common sense and present information allow one to conclude now with reasonable certainty. Advocates do not address the issue of how many negative studies are necessary to determine their methods’ ineffectiveness. Negative studies seem not to affect them.

The Straus article claims a historical precedent for use of herbals and biologicals. The claim implies that we lack research in botanicals and that the NCCAM can supply it. The reality is that screening of natural products has been in place for decades through the National Cancer Institute, pharmaceutical companies, and by foreign agencies and companies. This pharmaceutical activity exceeds by orders of magnitude what the NCCAM can produce.

Dr. Straus calls for “creative and experienced investigators to conduct the clinical research” on natural products. But there is little reliable information on which to decide what plants merit study, or for which conditions. Herbal mixtures’ effects are unpredictable, containing contaminants and adulterants. Their contents vary with time of planting and harvest; manufacturing processes; storage life; effects of fungi, bacteria, and insects; and interactions with pharmaceuticals. There is little consistency between the historical folk uses of herbs, present marketing claims, and usefulness. It is difficult to imagine how the NCCAM could clarify the confusion generated by so many unfounded and invented claims.

The article states that history teaches that crude plant mixtures justify “alternatives.” History really teaches that effective and reliable materials come from modern pharmaceutical extraction, purification, and molecular alteration. Raw herbal use adds danger and complicates the practice of medicine.

The article repeats the cliché that medicine is an art. The statement is only partially true, and fosters a misconception that medicine is fundamentally unscientific. Wisdom and judgment are not the same as art. Wise medical decisions are based on a series of educated probability estimates, in turn based on accurate observations and knowledge. Although experimental science is recent, rational observation and thought in medicine are millennia old. Our predecessors were not all fools, and were aware of nonsensical claims. Oliver Wendell Holmes Sr. wrote of homeopathy’s errors 150 years ago.

The article states that in regard to chronic disease, physicians are sometimes unable to cure their patients or offer them adequate relief from symptoms. Yet we have effective treatment for most chronic disorders such as diabetes, atherosclerosis, cancers, arthritis, and many others. The cliché is actually based on a misguided utopian concept that that modern medicine must conquer all diseases and consequences of aging. In reality, medicine recognizes its limitations, extends life and increases comfort, and cures when it can. On the other hand, “alternatives” have little prospect for usefulness. Even the popular herbs such as Ginkgo, St. John’s wort, and PC-SPES have inconstant effects and have more reliable pharmaceutical equivalents.

The article states that alternatives “extend the healing process.” This statement is obscure, raises implications of benefit, but has no explicit meaning. The “healing process” is inadequately defined. Advocates seem to “know” what it means. No accelerated “healing” has been demonstrated as a result of an “alternative” sectarian method.

The article assumes another misconception—that complementary and alternative medicine (CAM) increases quality of life. Perhaps in large research institutions, quality-of-life concerns have, in the past, lacked attention. But in North America, medical practice has always been concerned with quality issues. Patient concerns were part of medical education and practice long before the present meanings of “alternative” and “holistic” were invented. Failures of quality awareness are usually problems of cost, individual professional decisions, and other local circumstances, not problems inherent to scientific medical practice.

Few recognize that CAM advocates have conscripted concerns of sensitivity and patient comfort to their own domain, to augment their quest for sympathy and power. Physicians, traditionally self-critical, have little awareness of this CAM sleight of hand to augment its own image.

Dr. Straus calls on medical education to be “more patient centered and less paternalistic.” In six words, centuries of self-critical, sensitive, and personal medical practice are dismissed and medicine’s self-examination is turned on itself. With this statement, Dr. Straus succumbs to propagandistic insult.

The article calls for the Association of American Medical Colleges “. . . to overcome the reluctance of conventional physicians to consider CAM therapies that are safe and effective for their patients.” This statement assumes that some anomalous therapies are safe and effective, that physicians would not use safe and effective methods, and that physicians are “conventional,” rather than intelligent, thoughtful beings. The author, perhaps unwittingly, adopted anomalistic semantics and language distortion, again demonizing the medical profession.

The contest between pseudoscience and rationality will not be settled by NCCAM research because rigorous studies have already been done. The thought floats about that more rigorous studies will define what works and settle the issue. That thought underestimates the staying power of irrational ideas. Pseudoscience advocates are not discouraged by negative studies any more than they are by their own implausible propositions. Claims for Laetrile, diet cancer cures, chelation, and vitamin C were disproved decades ago. They persist. Homeopathy, chiropractic, and acupuncture are implausible and rigorous clinical trials do not support their claims. They still exist.

The article calls for expanding medical schools’ curricula to include teaching of CAM. But some 150 courses now exist, most presented from a “neutral” viewpoint—or an advocacy one. Many courses present erroneous information with little science or critical analysis. In my survey of all medical schools in 1995–1997, only 5 approached erroneous claims critically.

I am informed that the Federation of American Societies for Experimental Biology has written Dr. Straus calling for inclusion of scientists in its councils and inclusion of basic science in its grants. Given the present political landscape, that is not likely to happen.

Some may question that any harm could come from people erroneously attributing improvement to an ineffective treatment, as long as patients get better. But the harm is illustrated by the attribution of AIDS to lifestyle and socioeconomic factors, dismissing the viral cause and modes of transmission. The error puts the world population at risk. Formation of the NCCAM itself resulted from the same error, made by a few senators and congressmen.

Most important is that NCCAM funding of medical research and education has the potential for corrupting the intellectual process. Some medical schools have silently welcomed funding from the NCCAM and from private, ideologically motivated institutions. Others, although opposing the NCCAM, have remained silent or neutral. In its first 8 years the NCCAM has not produced any substantive results. Its present course is not likely to, either. NCCAM investigations into “alternatives” as planned will pursue ephemeral statistical relationships through repetition with “suggestive” conclusions. Every chance association may become a new avenue for investigation and demand for more grant applications. Recognizing existing disconfirming information would save hundreds of millions of dollars, and prevent detours into progressively narrow corridors of scientific deadends.