Oct 05 2007

The Framing of Alternative Medicine

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.

10 responses so far

10 Responses to “The Framing of Alternative Medicine”

  1. nowooon 05 Oct 2007 at 6:43 pm

    “worts and all.” Nice.

  2. Sastraon 05 Oct 2007 at 8:39 pm

    Very thorough and incisive analysis. Thank you.

    I think Alternative Medicine has been successful in part because it has tapped into the popular public view that there is an “alternative” science. There is science as it is done by the professionals — and then there is the ordinary, common sense science as done by the common guy: why not try it for yourself and see? Experiment by taking something and then, if you feel better, you know it works for you.

    Contra this, the rigorous methods in science are actually close to the opposite of “try it for yourself and see if it works.” As SkepDoc Harriet Hall has pointed out, clinical experience and seeing what “works” is what drove bloodletting for hundreds of years. An uncontrolled study of one tells you nothing, not even if you’re smart, sincere, and really good at observing — but for the average person, the strength of personal experience is good-enough science, “alternative” to weighing yourself down with knowledge and expectations so you’re “open” to what your experience tells you. Anyone can do it. Think for yourself. Trust yourself.

    Very effective framing.

  3. jonny_ehon 06 Oct 2007 at 1:02 am

    I think alt med gets a lot of attention out of people’s dislike for big ‘faceless’ corporations like big pharma. They also get scared by the risks of real medicine (like side effects) and gullibly believe people that promise better ‘alternatives’. “It’s the corporations that lie, my naturopath is a member of my softball team, I can trust him”.

    Steve, I have a hunch that a lot of chiropractors/naturopaths wanted to be real doctors but didn’t have the grades. I notice that most have a bachelors of science, could they have just not made it into med school? Instead of giving up or retaking courses, they switched to alt med, which here in Canada might be more lucrative (since it’s private, and real medicine is public).

    Also, I read an argument somewhere from a CAM supporter that surgery does not need to prove its efficacy or safety, yet is practiced by doctors. Is this a bad analogy or a tu quoque? Was that last question a false dichotomy?

  4. The Framing of Alternative Medicine:on 06 Oct 2007 at 1:22 am

    […] Novella, host of the Skeptics’ Guide show, has an excellent blog post on the framing of alternative medicine. It discusses how alt-meds are presented to the public, and he replies to the CNN article “5 […]

  5. buckydocon 06 Oct 2007 at 8:24 am

    Of course these CAM folks — particularly CAM physicians who hover close to the interface with real medicine — face a dilemma. To the extent that CAM modalities “work,” its obviously due to their ability to leverage the placebo effect. Mystery and otherness are a big part of that. Legitimate study — even if it validates some aspects of a modality — will inevitably erase this mystery, and diminish its overall ability to leverage the placebo effect. Acupuncture is a great example of this.

  6. weingon 06 Oct 2007 at 11:39 am

    One of the reasons people look for alternative medicines is the acknowledgment by conventional medicine of risks associated with it, ie complications from surgery, side effects of drugs, etc. This is a double standard that is not applied to alternative medicine. I find it sad when a patient won’t use nicotene patches or gum because of all the side effects noted on the package insert and therefore continues to smoke.

  7. ellazimmon 07 Oct 2007 at 2:50 am

    Regarding your criticism of the writers/editors of the CNN article: is it possible they did talk to an actually qualified MD who is a believer? Think about it Dr Steve; if someone interviewed you about some neurological interventions would you expect them to look for a critic of your opinion? What weight should someone give to your degree and your position? Dr Egnor, Dr Behe and Dr Dembski sure look reputable. A good science reporter should know what is real and what is not but how many journalists are now that well educated or are given the time and space to really explore an issue.

    I know, I know, everyone should be aware that CAM is controversial but what does that mean to the general public? Some of them think Evolution is controversial. Some of them know there are disagreements but have already made up their minds; that’s the real problem. The important question is why have they already decided. It may be the lack of good reporting but I suspect most believers have other motivations.

  8. buckydocon 07 Oct 2007 at 7:22 am

    Clearly there is something very compelling about CAM, and though I’ve never looked at a formal demographic analysis, my sense is that it cuts across socio/political/religious classification to a surprising degree.

    I think there are a large number of folks who have rejected Western religious traditions because of their association with war, materialism, scandal etc. etc. and who embrace CAM as sort of a proxy for religious belief.

    On the other hand, I have observed a surprising number of CAM believers who also hold fundamentalist Christian beliefs. Even though some of these CAM modalities are not exactly consistent with Christian dogma, my sense is that its embraced because anything that seems to disprove a rationalistic world view, must not be all bad — “an enemy of my enemy…”

  9. JoHon 09 Oct 2007 at 9:07 am

    As usual a very to-the-point post.

    I haven’t watched that many debates between CAM and “traditional” medicine proponents, say on TV. I’m still waiting for one where the traditional side would, quite surprisingly, start from the basic approach that all medicine should be treated equal. And then proceed like “so we will accept clay therapy for colon cancer, reflexology, therapeutic touch, healing-over-the-telephone, magnets…” I bet some homeopath or accupuncturist would then feel obliged to answer with “I wouldn’t go THAT far.”, which could be a GREAT starting point to point out the double standard and systematically break down the WHOLE affair.

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