By Edvard A. Hemmingsen
Life expectancy in the United States has increased from 48 years at the turn of the Century to over 76 years today. This spectacular achievement is due to improved nutrition, vigorous public health measures and mainstream medicine, all of which are based in scientific research.
In spite of its success, mainstream science-based medicine has yet to find cures for many serious, life-threatening diseases as well as various non-life threatening diseases and ailments. Paradoxically, because of the increased lifespan, diseases primarily related to aging are now more prevalent than before. These include certain forms of cancer, arthritis, dementia, hormonal changes and chronic pains. These are not given the same attention and resources as the more pressing medical problems.
A hodgepodge of alternative medical procedures are stepping into this void, led by acupuncture, homeopathy and the herbal/vitamin supplement industry, to the tune of an estimated 18 billion dollars a year in the United States alone. Chiropractic is another alternative medical treatment that has remained popular even though its effectiveness, like that of the others, has been questioned by the scientific medical community. Credible evidence exists (New England Journal of Medicine, Oct. 8, 1998) that chiropractic spinal manipulation is a somewhat effective therapy for some patients with low back pain; it is spinal manipulation in relation to other therapies that is being most challenged.
For all of the procedures that are short on objective evidence of efficacy, the advocates have attempted to establish some legitimacy in various ways. Thus, they may claim that they have government support. On examination, this "support" often is revealed as the removal or modification of some restrictions (for example, moving acupuncture needles from FDA Class III category to the less stringent Class II) making it easier for the proponents to conduct their business. Certainly, alternative medicine claims and products are subjected to less stringent regulation than are science-based procedures and medications. This raises legitimate concerns about the safety, not to mention the efficacy, of alternative medical remedies.
Last year we witnessed a case in which a government agency (NIH) let itself be used by the proponents of one such alternative medicine procedure (acupuncture) to proclaim that it works.(see Rational Inquiry, Jan.-Mar., 1998) This was a significant setback in the struggle to orchestrate an objective and scientific examination of this procedure. The fact that the agency has since been lambasted by distinguished scientists, health professionals and skeptics for allowing this to happen has received very little publicity.
What does alternative medicine (the term may not be appropriate, but O.K.) offer? "Comforting and less expensive treatments," say its supporters who rarely offer objective evidence that the treatments are safe and work as claimed. But the public, the health insurance companies and, yes, the government are listening. "Quackery, snake oil or placebos," say many scientists and health professionals, and with good reasons.
Many critics of alternative medicine would like to see most of these therapies and herbal remedies under much stricter regulation, especially when public funds, for example, from taxation or through insurance, are involved. Other critics merely ask that scientific or other convincing objective evidence for effectiveness and safety be provided.
Some of these therapies have been subjected to double-blind scientific studies. The results have shown either no effect or one that did not surpass the placebo level, indicating that it was induced solely by the patient's belief. But few of these efforts have been published in reputable refereed medical journals, which for better or for worse rarely accept studies with negative results.
In some cases, this may change. A new peer-reviewed journal, The Scientific Review of Alternative Medicine, has been established by Prometheus Press. Its aim is to assess scientifically the methods and treatments of unconventional medicine. Also, the November, 1998 issue of the Journal of the American Medical Association will be devoted exclusively to studies evaluating various alternative treatments.
A recent, lengthy editorial in the prestigious New England Journal of Medicine takes a somber and thoroughly professional look at the situation and at some of the tests that have been performed. It focuses on herbal remedies, the most common of alternative treatments.
The authors state that what most sets alternative medicine apart ". . .is that it has not been scientifically tested and its advocates largely deny the need for such testing. By testing, we mean the marshaling of rigorous evidence of safety and efficacy, as required by the Food and Drug Administration (FDA) for the approval of drugs and by the best peer-reviewed medical journals for the publication of research reports. Of course, many treatments used in conventional medicine have not been rigorously tested, either, but the scientific community generally acknowledges that this is a failing that needs to be remedied. Many advocates of alternative medicine, in contrast, believe the scientific method is simply not applicable to their remedies. They rely instead on anecdotes and theories."
The editorial further state that "Alternative medicine also distinguishes itself by an ideology that largely ignores biologic mechanisms, often disparages modern science, and relies on what are purported to be ancient practices and natural remedies (which are seen as somehow being simultaneously more potent and less toxic than conventional medicine). Accordingly, herbs or mixtures of herbs are considered superior to the active compounds isolated in the laboratory. And healing methods such as homeopathy and therapeutic touch are fervently promoted despite not only the lack of good clinical evidence of effectiveness, but the presence of a rationale that violates fundamental scientific laws - surely a circumstance that requires more, rather than less, evidence."
The authors admit that science-based medicine at times also relies on anecdote, sometimes even published as case reports in peer-reviewed journals. But these differ from the anecdotes offered by promoters of alternative medicine in one crucial way. The case reports describe well-documented findings that are published with the intention of encouraging further testing in proper clinical trials. Such testing is avoided or rejected in alternative medicine.
The editorial expresses many concerns with regard to the safety risks and dangers of unregulated and untested remedies. One reason is that Congress, in response to heavy lobbying by the dietary supplement industry has exempted their products from FDA regulation. Thus, the industry is free to make any claim they wish short of promoting their products as preventing or treating diseases. But labeling has become an exercise in doublespeak. No regulators pass on the list of ingredients and their concentrations, and no warnings need to be given regarding side effects, even potentially harmful ones. The products can be sold without any knowledge of their mechanism of action or purity.
The editorial goes into many of the safety aspects of alternative medicine and its remedies in some detail, and provides some excellent references to consult. In its conclusion, the authors state: It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine - conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted. But assertions, speculation, and testimonials do not substitute for evidence. Alternative treatments should be subjected to scientific testing no less rigorous than that required for conventional treatments.
Will this appeal have some effect on the rapidly growing alternative
medicine movement? Maybe some, but I will not bet on it. Many billions
of dollars are at stake and gullibility is too high. So far, the community
of science-based health professionals has been too complacent and willing
to go along. Frequently, the attitude has been "let us see if it works",
or "if the patients believe it works, it is harmless to give it to them."
Perhaps this will change when sufficient numbers of the alternative medicine
therapies and remedies are shown to be ineffective.
New England Journal of Medicine, September. 17, 1998, Editorial: Alternative Medicine - The Risks of Untested and Unregulated Remedies, by Marcia Angell and Jerome P. Kassirer. October 8, 1998, Editorial: What Role for Chiropractic in Health Care, by Paul G. Shekelle. Additional articles on chiropractic in the same issue. Available at http://www.nejm.org/content/
National Council Against Health Fraud, Inc. Home Page: http://www.ncahf.org
Los Angeles Times. A series of four articles on Alternative Medicine, published August 30 and 31, and September 1 and 2, 1998. Available at http//www.latimes.com/altmed
Edvard A. Hemmingsen is an Emeritus Physiologist at UCSD and the Editor
of Rational Inquiry