Dec 15 2008

Skeptical Battlegrounds: Part III – Alternative Medicine

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Being both a skeptic and a physician I have focused a great deal of my skeptical efforts towards science and medicine. While I endeavor to be a full-service skeptic, pseudoscience in medicine is definitely my specialty. It is therefore especially painful for me to admit that in this arena, more than any other, we are getting our butts kicked. We are almost at the point of being routed, with the defenders of scientific medicine being relegated to the role of insurgency. How did this happen?

What is Alternative Medicine?

I think the biggest victory scored by the promoters of complementary and alternative medicine (CAM) was the name itself. Fifty years ago what passes today as CAM was snake oil, fraud, folk medicine, and quackery. The promoters of dubious health claims were charlatans, quacks, and con artists. Somehow they managed to pull off the greatest con of all – a culture change in which fraud became a legitimate alternative to scientific medicine, the line between science and pseudoscience was deliberate blurred, regulations designed to protect the public from quackery were weakened or eliminated, and it became politically incorrect to defend scientific standards in medicine.

The goal of CAM proponents is nothing less than the elimination of the standard of care in medicine in exchange for an anything goes approach. Key to their strategy was the language game – getting people to talk about fraud and pseudoscience in medicine as if it were a legitimate “alternative”, that pseudoscience can “complement” science or be “integrated” with it. Scientific medicine was rebranded with derogatory labels such as “Western” and “allopathic.” Anyone defending the scientific standard of medicine was attacked as closed-minded, and accused of protectionism.

The very fact that there is a category of medicine such as CAM, whatever you call it, is a significant defeat for scientific medicine. CAM as a category includes an extremely diverse collection of claims and modalities that do not share a common theme or philosophy, including some that are mutually exclusive. The only thing they have in common is that they do not meet the scientific standards of mainstream medicine. The only purpose of the CAM category is to create a space in which substandard or unscientific modalities can exist. It exists to create a double standard.

A Perfect Storm of Anti-Science

Wallace Sampson, writing for Science-Based Medicine, gives an excellent overview of the last forty years of medicine and what went wrong. He points to several cultural trends that conspired together to allow the anti-scientific revolution to occur. These include political correctness – which has had the effect of rendering appropriate scientific criticism as impolite. The post-modernist influence in academia also played a major role, one aspect of which is the portrayal of science as just another narrative without any special relationship to the truth. In fact science, according to some post-modernists, is just a way for one group (in this case Western white males) to impose their power over minorities and the oppressed.

Add to this a general anti-establishment movement beginning in the 1960s. CAM proponents were successful in portraying scientific medicine as the Establishment – something that needed to be taken down. This evolved into the “health care freedom” movement, the ostensible purpose of which was to earn freedom for the public to access whatever health care they wanted. In reality the health care freedom movement is about earning freedom for practitioners to do whatever they want, free from any regulation meant to protect the public. I find it one of the greatest ironies of the CAM phenomenon that they have been able to pass laws that are overtly anti-consumer, in that they remove protection from fraud or incompetence, in the name of consumer freedom. Why hasn’t Ralph Nader noticed this? What if the auto industry promoted “automobile freedom” laws so that consumers could buy any vehicles they wanted, free from any government quality or safety regulation?

This brings up the political dimension of CAM. Proponents have been successful at working both sides of the aisle, appealing to anti-regulation sentiment on the right and anti-corporate/anti-establishment sentiment on the left. Unfortunately, science has no political party.

And of course all of this is happening in a generally scientifically illiterate society.  In my experience most of the public does not understand why homeopathy cannot possibly work (it’s just water), why scientists are confident that there is no mysterious life force at work in the body, why chiropractic subluxations make no sense, and why megadosing vitamins or the latest fad tropical fruit juice cannot cure everything.

And yes, of course, there are legitimate criticisms of mainstream medicine. The system is under great financial strain. Technology, while extremely effective, is very expensive and may render some medical encounters very unpleasant and frightening.  The ethical model in medicine has also shifted from a paternalistic model, where doctors just did what they thought was best, to a cooperative model that focuses on informed consent.  This is a good thing, but it means that physicians are ethically obliged to tell patients the whole and unpleasant truth. We do not have the luxury of lying to patients to make them feel better. Charlatans have no such constraints.

Tactical Defeats

The specific tactical defeats of scientific medicine include, first and foremost, the cultural non-judgmental acceptance of an “alternative” category of medicine. But in addition to this, there is the NCCAM (National Center for CAM), which was created specifically to fund CAM research. These funds, however, are generally spent doing studies designed to promote CAM, not answer the only question that really matters – does it safely work. More than a decade and hundreds of millions of dollars later, there has not been a single CAM modality that has been proven by research to the point that is has gained general acceptance, nor has any modality been rejected as disproven. Sorting what works from what does not work is the primary purpose of medical research, so in that regard the NCCAM is an unmitigated failure. But, it has lent incredible legitimacy to CAM.

Health care freedom laws have been passed in almost 20 states – eliminating the ability of states to act against practitioners simply because what they are doing is substandard (as long as they self-label what they do “alternative”). That’s right – eliminating the standard of care.

The Dietary Supplement Health and Education Act of 1994 removed “supplements” from the control of the FDA, and redefined supplements to include herbs used as drugs, and pretty much anything else that is not already a drug. It also created a separate category of health claims, so-called structure function claims, that are beyond regulation. This led to an explosion of the supplement industry.  This allows snake oil peddlers to decry the excesses of the highly regulated pharmaceutical industry, while making billions in the largely unregulated supplement industry. To further increase the irony, in many cases the two industries are one and the same.

A reasonable person might think that medical academia would be the last line of defense for scientific medicine. Surely trained medical scientists can see anti-scientific propaganda for what it is and will defend the scientific integrity of their profession. Unfortunately, this is largely not the case. Academics have been cowed by calls for “freedom” and political correctness. Promoters have learned to speak the language of academics to further subdue their skepticism – using pleasant terms like “holistic”, and “patient-centered” practice. Like most deceptions, there is always a kernel of truth to such ideas. But in the end it all amounts to a sweet-sounding justification for outright pseudoscientific quackery in medicine.

This happens, however, because the academics who should know better are largely asleep at the switch. They have mostly put CAM into the hands of proponents, because they are the ones who are interested. Most physicians and scientists are “shruggies” when it comes to CAM – they just don’t think about it and don’t want to think about it. So proponents have been able to become the gatekeepers of their own claims. CAM proponents are appointed to committees on CAM, are able to make CAM curricula for students, and decide what CAM journals should be registered with the International Library of Medicine (which means they can keep out critics). The foxes are in charge of the hen house.

What this also means is that those few of us who are trying to point out that the Emperor has no clothes (to use a tired metaphor), and defend science-based medicine are made to seem like ideological, closed-minded fanatics.  Defending science in medicine is no longer politically correct – at least not within the alternate reality of CAM.

Evidence-Based Medicine

More irony. Over the last couple of decades there has been a growing movement within mainstream medicine called evidence-based medicine (EBM). One might think that EBM would have worked to retard the advance of CAM but the opposite was true. It is an unfortunate happenstance of history that the minds behind EBM inadvertently played into the hands of CAM proponents.

The concept behind EBM is that  medical modalities should be judged primarily by the empirical evidence, not by their plausibility. The reason for this was the perception that too many practices were being widely used because they made sense – they were plausible – despite a lack of evidence that they actually worked. Therefore EBM was constructed to eliminate the advantage of plausibility. Medical claims require evidence no matter how plausible they are.

But by eliminating plausibility (or prior probability) from consideration EBM also leveled the field for highly implausible claims, even though this was never the intent. EBM is not unreasonable in a world where it is assumed that treatments and claims make basic scientific sense, but it is not equipped to deal with a world in which highly implausible claims are being promoted. This had the effect of almost eliminating basic science from consideration. Under EBM claims that are highly implausible are treated the same as claims that are highly plausible. This approach exists no where else in science.

Therefore, CAM proponents just adopted the language of EBM. It did not take long for CAM modalities to have the EBM label slapped on them, whether or not they earned it even by the flawed methods of EBM. I see “evidence-based homeopathy” or “evidence-based acupuncture” promoted all the time, even though these terms are oxymorons.  Even without consideration of prior plausibility CAM modalities do not fair well under EBM examination, so proponents simply lie. They claim their methods are EBM even when no formal EBM evaluation has validated them. They behave as if their personal assessment of the evidence is sufficient to support a claim of EBM, when in fact there are formal methods of systematic review that are required.

But the EBM infrastructure is vulnerable. They already fail to put CAM modalities in their proper scientific perspective by considering prior probability. And now they too are putting the foxes in charge of the hen house – allowing CAM proponents to perform and publish biased EBM reviews.

A Ray of Hope

I recently wrote about the National Health Statistics  on use of CAM by Americans. The stats have been misrepresented by proponents to argue that CAM is increasingly popular, followed by the argument ad populi that therefore they should be supported. A closer look at the data, however, shows that the hard-core CAM modalities are still marginal, and not significantly increasing. In the last year only 1.4% of Americans used acupuncture, 1.7% homeopathy, and 0.5% energy healing (by self report). These numbers are not significantly different than 20 years ago.

Use of these modalities remains marginal. I am not sure exactly how to interpret this. The best-case interpretation is that most of the public still regards the magical claims of homeopathy and acupuncture with skepticism. The most pessimistic interpretation is that the public accepts these modalities in greater numbers, but the infrastructure has not yet expanded to meet demand.

I also find some comfort in the fact that most of my colleagues have not drunk the Koolaid of CAM. They regard it as quackery – and yet frustratingly think it’s not their responsibility to do anything about it.  But perhaps there is a growing backlash against the nonsense. I think as CAM’s profile increases, the sham at its core is more apparent. Maybe.

Conclusion

The situation is grim. A generation of health care providers is being indoctrinated into unscientific acceptance of dubious claims and methods. The public has largely bought the framework of CAM. Even among skeptics I find that CAM is a frequent blind spot. The propaganda has simply been extremely effective.

Most disheartening is that academia has largely failed to recognize and confront this attack on science. They now understand well the threat of creationism/intelligent design. They get it. They do not understand how CAM erodes the scientific basis of medicine and the standard of care.

Those of us who are opposing the infiltration of pseudoscience into medicine have an uphill battle, and no apparent allies. We have been marginalized. We are also a couple of steps behind the CAM proponents in understanding how the language and the laws are being manipulated. We’re catching on, but we are already far behind.

The situation is not hopeless, but it is desperate. I think in the long run science always has the advantage that it actually works. But history has shown us that cultural inertia can be immense. As CAM becomes infused in the culture and in the institutions of health care it is becoming entrenched and will be difficult to remove. It will likely continue to be a drain 0n the effectiveness and efficiency of health care for decades to come.

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