Oct 05 2007
There has been a recent debate among science popularizers about the issue of “framing,” which refers to the strategy of explaining science in the context of the real world and what it might mean for the target audience. The belief that scientists need to pay more attention to such things comes partly out of the recognition (and frustration) that the “other side,” those who have an agenda that is not purely scientific, are very good at framing their message. In fact in many cases “framing” becomes a polite word for propaganda.
Those who promote the dubious and vague concept of so-called “alternative medicine” have been very successful at framing the debate and media coverage to their extreme advantage, as is evidenced by a recent CNN Health article, 5 Alternative Medicine Treatments that Work.
The very name “alternative medicine” (and also “complementary” or “integrative” medicine – which I will refer to by the abbreviation CAM) is a good example of framing for the purpose of propaganda. These names suggest that such treatments are an acceptable alternative to scientific medicine. The notion of CAM also, and quite deliberately, creates the context for a double-standard. Promoters of CAM have diligently worked to create this double-standard, one for scientific medicine, and another for CAM.
There now exists in the US a government funded research institution – the National Center for Complementary and Alternative Medicine (NCCAM) that has its own standard for funding CAM research – research that would not qualify for more traditional funding. Many states now have “health care freedom” laws, which in practice carve out protection for CAM providers from the regulations that would otherwise establish a standard of care. Health products can be sold without FDA oversight as long as they are called “supplements,” even when their use is clearly intended for their pharmacological activity, not their nutritional value. Medical schools are admitting the teaching of CAM disciplines that fall far short of the academic and scientific standard usually required for their scientific topics. And the media habitually suspends their serious critical analysis of medical claims and adopts an utterly credulous approach to anything under the CAM umbrella.
In every meaningful way there is now a double standard in healthcare – traditional medicine that is based upon scientific evidence and strives for quality control, and “alternative” medicine that is magically immune to evidence, beyond the reach of science, and free from any quality standards. The CAM label is largely responsible for this.
The CNN Health article buys into the CAM framing without question, relying solely upon the recognized CAM gurus for information without seeking any balance from critics. The article presents 5 alleged CAM modalities that allegedly work, and concludes from this that “alternative medicine works.” Again we see CAM framing at work, for CAM is not a coherent discipline of health care. Under the umbrella of CAM are many modalities that are as incompatible with each other as they are with scientific medicine, and the efficacy of any one method for any particular condition says little about that method’s utility for other conditions and nothing about the effectiveness of other CAM modalities. But lumping everything that falls below the standard of scientific medicine together as CAM is good marketing.
While shopping recently for a new car I was annoyed that the manufacturer grouped an option I really wanted into a package with several expensive options I did not want. The purpose was clear, to lure me in with the useful option into buying options I did not really need. CAM proponents play the same game. They use those modalities that are at the barely plausible end of the spectrum and package them together with the grossly absurd, then try to sell the public on the whole CAM package. Even worse, they have tried to steel perfectly legitimate scientific medicine interventions, like physical therapy and nutrition, relabel them as “alternative” and then claim that they prove “alternative medicine works.” What a scam.
Let’s look at the five methods touted as evidence for CAM success. Incidently, the article claims they are supported by solid science, but if that were true they would no longer be alternative – they would just be medicine. The first is acupuncture, about which the article says:
Hands, down, this was the No. 1 recommendation from our panel of experts. They also recommended acupuncture for other problems, including nausea after surgery and chemotherapy.
Yet, the evidence does not support such recommendations. Studies of acupuncture are generally poor, and the good ones are very mixed, many being negative. There is yet no consistent pattern in acupuncture studies, except that the placement of needles seems to make no difference. Therefore “sham” acupuncture turns out to be as effective as “real” acupuncture – which completely contradicts the underlying theories of acupuncture. The most recent acupuncture study, looking at post-radiation therapy nausea, uses one of the best study designs I have yet seen, with true double blinding, and is completely negative.
The bottom line is that acupuncture is the best the CAM proponents can come up with and yet the evidence for it is weak and controversial. If acupuncture were a drug there is no way it would get FDA approval. (Do not confuse this statement with the fact that acupuncture needles are FDA approved as medical devices, but this does not approve their use as safe and effective.)
Number 2 is calcium, magnesium, and vitamin B6 for PMS. First, this is an example of falsely appropriately scientific medicine and relabeling it as alternative. The function of vitamins and minerals in biological organisms was discovered by standard scientific medicine, and has alway been a part of modern medicine. It is arguable whether or not enough emphasis has been placed on the role of nutrition in health, but that is irrelevant. There is nothing “alternative” about vitamins and mineral – except when the claims for them exceed the evidence. Whenever treatments go irresponsibly beyond the existing evidence, that is the realm of CAM.
The evidence for magnesium and B6 in PMS are very weak, and only slightly less weak for calcium. These supplements may be of some utility, but they are far from established.
The third touted CAM modality is St. John’s Wort for depression. St. John’s Wort, I will point out, is an herb and as such is being used as a drug – just one that is not purified and where the active ingredients are not all identified or quantified. So it’s a dirty drug – but a drug by any reasonable definition. Using plant-derived pharmaceuticals has been part of scientific medicine from the beginning, and is hardly alternative. But even with that point aside, again we are seeing a treatment touted as effective when the evidence is very weak. The latest systemic review says this:
Available evidence suggests that several specific extracts of St. John’s wort may be effective for treating mild to moderate depression, although the data are not fully convincing.
So far the best studies are negative, but more are underway. The scientific evidence will eventually sort out the effectiveness and safety of this herbal drug, but for now it is unconvincing.
Next at number 4 is guided imagery for pain. The evidence does indeed support the use of guided imagery for symptomatic relief of pain and other symptoms, but there is no reason to think that it is anything more than ritualized relaxation. Relaxation is recognized as an important component of treating many things, such as high blood pressure and pain, as these entities are worsened by stress. Basically, anything symptom or physiological parameter that is exacerbated or caused by stress can be helped by relaxation. However, there is no magic in the specific rituals by which relaxation is achieved, and there is no evidence that the more fanciful claims for guided imagery – that the mind can actually direct the body’s immune cells, for example, has any validity.
Finally, at number 5, is glucosamine for joint pain. Again, this is a nutritional supplement, not alternative magic. And again, the evidence is actually quite weak, with systematic reviews concluding there is mild to no benefit, and standard therapy with anti-inflammatories works better.
It is no coincidence that this promotional piece for CAM chose five modalities from the most plausible end of the CAM spectrum – a drug, two supplements, relaxation, and a physical intervention (acupuncture). And yet, the evidence for all of these most plausible CAM modalities (except the relaxation component of guided imagery, which is not alternative) is weak and unconvincing, far below what is generally accepted as the standard of evidence-based-medicine. Absent are the more magical CAM modalities of energy-based medicine, homeopathy which is nothing more than sugar pills and wishful thinking, dubious snake oils, implausible cancer cures, psychic surgery, prayer, detoxifications, and all the rest. And yet, by absurdly declaring that “alternative medicine works” these semi-plausible (yet still dubious) treatments are meant to sell the whole CAM package, worts and all.
The only rational position is to abandon this notion of a double standard in health care. As Marcia Angel and Jerome Kassirer wrote in the NEJM:
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.
In other words – we need a single standard for medicine. This standard should be based upon the best scientific reasoning and evidence available, and on standards of honesty, openness, and professionalism. All that matters is if treatments are safe and effective, and the only way to realiably answer that question is with careful systematic observations – in other words, science. “Alternative” labels, CAM marketing, and elaborate excuses and justifications only serve to undermine the quality of medicine.
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