The Braid of the "Alternative Medicine" Movement
Wallace I. Sampson, M.D.
Reporters ask us, "What are the reasons for the popularity of 'alternative medicine' ("AM",or "CAM" for "complementary and alternative medicine")? Why now?"
The question is challenging, the search for answers tantalizing, and the answers difficult to substantiate. Yet the temptation to answer is irresistible. As in a braid, no one factor can explain the whole phenomenon. Some factors are more important than others, some are antecedent, others are more direct and recent, and some feed on others then combine with their antecedents that again operate currently.
Predisposing and Antecedent Systems
There are a number of predisposing psychological and political influences. In North America, such influences include a mistrust of government, politicians, highbrows, elitists, professionals, and other authorities. Other factors are deregulation, loss of power of governmental agencies, increasing court awards for perceived injuries, and internet do-it-yourself medicine.
In Germany, perhaps a key factor is the feeling of unity with Nature (Naturphilosophie) required for action to be complete and satisfying. Add a tint of Hahnemann's homeopathy, Steiner's anthroposophical medicine, and a few mystical legends. In Britain, perhaps it is the tolerance of the unique, eccentric, and bizarre. In Asia, it is the sense of tradition and partnering of spirituality and cosmology with all phases of life.
North Americans are enamored of a melange of folkways from European countries, mixed through the eighteenth and nineteenth centuries into a new brand. Thomson, Kellogg, Post, Graham, and Mary Baker Eddy interpreted and recombined them, and passed them through D. D. Palmer to Jack Lalanne, Andrew Weil, and Larry Dossey.
Technical, professional, scientific medicine is about a hundred years old. We separate slowly from folkway methods that stick to common consciousness. We reflect and repeat our parents' quaint ideas and irritating habits. One of my family's holdovers was that fever came from toxins built up in the colon—a notion familiar to turn-of-the-century scholars as one of Kellogg's basic premises, putrefaction. It resulted in the feared, torturous enema, a punishment for having gotten ill.
Then there are customs like wearing of animal fat around the torso and the water cures (soaks and religious purification rites to drive out bad spirits that inhabit warm places). They appeal to those who want to explore the past, hoping to find Answers to Everything in mysteries, then proclaiming them to the unawakened public. These emotional-spiritual undercurrents of need are strong determinants of behavior, say historians and psychologists. We tend to agree.
Whether it is an undercurrent or a propelling force (a case could be made for either), the essence of all these threads seems to lead to a loss of standards for thought and action, and a disregard of intellectual discipline.
Cultural relativism was born in the early twentieth century, in the innocence of academic fairness and objectivity. Its intent was to omit prejudice and emotion in the investigation of other cultures. Previously one could read only xenophobic, supercilious descriptions of other cultures, even of our own subcultures. Observers used pejorative terms such as quaint, backward, primitive, pagan, savage. Relativism raised cultural anthropology from biased emotionality of supercultures and superraces to realistic, judgment-free, academically productive understandings. It allowed an appreciation for the healthy diversity of human cultural evolution.
But cultural relativism became inappropriately applied, like using a screwdriver to drive a nail. Relativism was applied to medical systems as if they merely reflected cultural differences instead of being approaches that were more or less useful for increasing health and longevity. Judgment-free description of the system replaced the system's objective value to health. In relativistic schemes, the number of days of illness, numbers and sizes of epidemics, mortality rates, life spans, cure rates, misery, and pain are all ignored. The measure of a medical system became how well it helped the culture's functioning and cohesiveness.
This disconnect persists despite scientific data about modern biomedicine's obvious objective benefits. Worthless and harmful traditional remedies are rationalized as being just "different," "alternative," "traditional," "unorthodox." Acupuncture, for example, is rationalized by saying "if it has worked for three thousand years, there must be something to it." But "worked" is never quantitatively defined. Of course, the same could be said for tiger parts used for male potency. Decimation of wild animal species for imagined effects of their parts does enter the perceived benefit equation. Cultural relativism results in this peculiar blindness to folkways' untoward consequences in favor of "nonjudgmental" description.
At the American Association for the Advancement of Science in 1979, sociologists convened a conference on laetrile, a fraudulent cancer remedy. Criminal backgrounds of promoters and the biochemical implausibilities of laetrile were deemphasized; no physician, biochemist, or pharmacologist was even invited to speak. A sociologist commented on another presenter's critique, ". . . [Prof.] Rich's [critical] paper is the most difficult to treat because of the bias I perceive. . . . His view is as valid as mine, so I present these thoughts as an alternative view to consider. . . . Any analysis of laetrile must carry some bias; even neutrality is a bias. . . . [A]ny bias will do as well as another. . . . He should consider the degree to which his perceptions and conclusions depend on his particular bias rather than on 'objective fact'."
I received much the same treatment in 1976 from the sociology department at a major university when I presented the cultlike characteristics of the laetrile community and asked for help in investigating it. The sociologists felt there was little difference between the society of medical scientists and the society of laetrile advocates.
Through the nonjudgmental, relativist eyes of the medical sociologist, even fraudulent medical schemes and cults are viewed as merely cultural differences. Observers' educated opinions become biases, whether they describe violation of laws of physics, chemistry, and pharmacology, or laws of the land.
The derivative of this relativism is the postmodern view exemplified by Michel Foucault, Jacques Derrida, Sandra Harding, Paul Feyerabend, and philosophers of science. They view science and knowledge as merely social constructions, relative to the individual's view, or to the society in which the knowledge is created.
Some versions of postmodernism deny the existence of an outside world or universe (or disease or treatment) that can be measured objectively and upon which one can take reasoned action. The result of this position is the dissolution of measurement—a world devoid of facts and judgment. Much of the liberal-arts and social-science academic community has been devoted to this view for several decades. Two generations of students have been educated in it, taking places in the legal community as attorneys and judges, politicians and officeholders, and in the media as reporters, editors, and producers. Administrators of granting agencies—both public and private—grounded in relativistic/constructivist principles, determine where and to whom research grants go. Prior to applying for an NIH grant to study the effects of traditional medical practices on chemotherapy compliance, I was told by a staffer to omit the word 'compliance' if I wanted to be funded.
Editors and staffs of professional journals are affected by the "niceness" straightjacket. Courses in "CAM" are taught in most medical schools without critique or evaluation of validity. "Therapeutic Touch" is not just tolerated, but taught in nursing schools.
There has always been a fringe of healers, doctor wannabes, willing to dispense information for a price, or just for the self-satisfaction of appearing to be real scientists and physicians. Their seeming reason for existence is to supply methods rejected by scientific biomedicine. Others make and sell products with debatable or no effects, competing with effective pharmaceuticals. All have succeeded in winning over a minority of the public that now has firm belief in the power of supplements, antioxidants, athletic fuel, brain food, and special diets. Bookstore sales on health, nutrition, and medicine are high, and magazine racks overflow. The competition for space is fierce. There has always been good grazing along the fringes of medicine.
But now wannabes are taking shark bites out of medicine's flesh. They have perfected techniques of sales, propaganda, legal maneuvering, and political contributing and have reached significant levels of influence. The supplement industry, of course, influenced Rep. Bill Richardson and Sen. Orrin Hatch, who wrote the Dietary Supplement Health and Education Act of 1994. The bill liberalized marketing of supplements and removed the Food and Drug Administration's preemptive control over unsafe products. Companies now market products without proof of effectiveness and flood the marketplace with unstandardized, sometimes toxic, herbs and supplements.
Organized chiropractic and other occupational guilds repeatedly seek increased scope of practice, claiming to be able to diagnose and treat as physicians. Political contributions from fringe practitioner guilds regularly retool legislatures.
Private foundations fund many "AM" activities and may be the largest source of "AM" funding. The $300-million Fetzer Foundation funded the Bill Moyers PBS TV series Cancer and the Mind and the 1993 Eisenberg New England Journal of Medicine "AM" study. It still funds the Beth Israel/Harvard and other medical school courses, postgraduate physician education courses, departments, and research projects. The Laing Foundation (>$1 million) funded the University of Maryland acupuncture (pain) program and other activities. The Rosenthal Foundation funds Columbia University's "AM" program to at least $750,000. The Templeton Foundation gives annual awards, funds research, and supports other nonprofit organizations for millions of dollars for support of spirituality and religion in medicine. Ten million dollars went to the University of California this year from the Osher Foundation for an "altmed" service. Endowments are in the hundreds of millions of dollars, with annual funding exceeding the $14-20 million per year of the Federal Office of Alternative Medicine.
These foundations are products of wealthy entrepreneurs with private ideologies they would like to see adopted by society. Financially strapped universities and medical schools accept these funds under conditions not acceptable a decade ago. A few years ago, Yale University declined a contribution from a conservative donor on ideological grounds, and was hailed by the academic community.
Propaganda and Language Distortion
We now see a new use of an ancient tool used by experts at manipulation of the public mind. Even the words "holistic," "alternative," "complementary," "unconventional," and "unorthodox" are invented euphemisms intended to mislead. They are benign terms covering a vast array of practices—most of them unproved, dubious, disproved, absurd, and fraudulent. Any politician knows one must find an enemy, even a straw one, to win elections. The term, "slash, burn, and poison' was invented by laetrile advocates to demean ethical cancer medicine, and it worked and it stuck.
In a strange twist of the braid, constructivist sociologist-historians of medicine in an "alternative medicine" journal have already turned the tables on our analysis of language distortion and accused rationalist scientists' use of realistic terms like quackery, misrepresentation, and fraud of being merely prejudicial and biased. They call for more neutral terms to describe absurd methods like homeopathy. Thus the strings of constructivism and propaganda complement each other in the braid.
Misrepresentation of Research Results
In the course of a legal action, I had opportunity to review the major papers claimed to be positive by homeopaths. We presented some analyses of these papers at the AAAS in 1997, in Skeptical Inquirer (Summer 1997), and in other journals. Most of the alleged positive reports showed serious defects including selected end points, analysis of aggregated data as if they were homogeneous, extraordinarily large confidence intervals with minimal significance, selected reporting of differences in recorded curves, miscalculations and misrecording of data, omissions of control and other objective data, and combining different disease categories into meta-analyses. Why peer reviewers miss such errors is unexplained. To make matters worse, another meta-analysis appearing in the Lancet in the fall of 1997 recorded the results of homeopathy studies at face value, despite the papers' faults. The meta-analysis is now a reference for the claim that homeopathy cannot be entirely explained by placebo action.
Once inaccuracies in "CAM" are reported as fact in medical literature, they are there for posterity. Even Hillary Clinton has quoted the seriously defective Byrd study on intercessory prayer in the coronary care unit as evidence for spirituality's effectiveness.
Good doctors know who the other good doctors are. One of the darkest, most secret, and little-mentioned factors in the "AM" controversy is that "AM" advocates are not in the higher ranks of good doctors. Many or most are probably in the lowest ranks of quality.
Although this is dangerous ground because of lack of data, there is clearly something wrong with the judgment of physicians who hold closely to ideologically driven methods that lack validity. Many of them have been disciplined by medical boards. The public usually has little sense for the quality of physicians, and there is little evidence that publication of lists of "best doctors" alters patient behavior. Most of us want to have our physicians be top quality, but apparently the customers of aberrant practitioners have other agendas in mind.
The press is the major vector for the spread of "CAM" through its uncritical reporting and misrepresentation. Several times a year in most newspapers, a novice reporter claiming skepticism consults an "alternative" practitioner, often an acupuncturist, and reports that some chronic aggravation improved. Not reported is the fact that controlled trials show the method is not effective. Nor does the article follow up on how often or how much the symptom recurs over the next year or five. These are facts most physicians must have and must divulge before obtaining informed consent for a procedure.
The July 3, 1998, San Jose Mercury News bore a small Washington Post article about rural China's 70% infestation rate by various parasites, most commonly worms, resulting in malnutrition, decreased intelligence, and general weakening of the workforce. The article was buried on page DD5. The previous week's acupuncture article was on page 1B, complete with half-page photo. This kind of editorial treatment is typical.
The press is also often scammed. In the August 16, 1998, issue of Parade magazine, there appeared an article about the marvels of acupuncture, including a smiling woman undergoing chest surgery with only ear acupuncture for anesthesia. The photo appeared to be a fake, as did the story (chest surgery without intubation and heart bypass or cooling?). Such scams or cons—or variants on them—are widespread, and the press frequently falls for them.
So where are acupuncture and moxibustion when we need them? The worm infestation above apparently does not respond to "AM." The failure of traditional Chinese medicine in China and its maximum 18% usage there is a testimonial to modern biomedicine's success. But this is assumed not to interest the public; at least it seems not to interest the press.
The typical "AM" article highlights a few advocates, but presents the scientific view in two paragraphs—usually in the middle or toward the end of the article. (In television, the skeptical or scientific view is reduced to one or two 15-second bites. The pseudoscience view usually gets the last word.) This is called balanced reporting.
Reporters say, "My duty is to inform, to present both sides, and let the (readers, patients, etc.) make up their own minds." Although the material is often false or misrepresented, reporters (like some sociologists) seem to be answering to a higher calling. It is a presumptuous rationalization to avoid a major social responsibility.
Traditionally, a distinguishing feature of quacks has been this: If they cannot prove their claims scientifically, they use the popular press and lobby for special privilege in legislatures. Twenty-seven states legalized laetrile in the 1970s and 1980s. Seven states have passed "access to medical treatment" (AMT) bills. These allow any licensed practitioner to practice any method within the legal scope of practice --proved or not—on any patient, provided "informed consent" is obtained. Regulatory boards, organized medicine, and public-service agencies oppose such bills. (Even now the Texas board is considering liberalizing regulations on aberrant practices to conform to policies resembling AMT bills.)
Pressure groups from the "CAM" community support these policies and contribute funds toward their passage. The primary pressure for AMTs comes from "chelation therapy" physicians. (Chelation is a worthless "alternative" therapy for heart and vascular disease.) Political pressures, not public need or scientific validity, were behind the rise of chiropractic, acupuncture, and other methods.
One quick test for the usefulness of an "alternative" therapy is to ask oneself, what would happen if this therapy were tomorrow no longer available? How much would acupuncture and homeopathy be missed? How about antineoplastons, immunoaugmentive therapy, laetrile, and unsupervised megavitamins? If the public had never heard of them, the common health would not suffer a bit. On the other hand, how would the public handle absence of antibiotics, X-rays, anesthesia, and major operations?
Gullibility, Misperceptions, and the Will to Believe
Much is written about these human traits, maybe too much to describe usefully here. So we recommend the reading of several books and critical research papers. Try How We Know What Isn't So by Thomas Gilovich, The Psychology of Anomalous Experience by Graham Reed, How to Think about Weird Things by Theodore Schick Jr. and Lewis Vaughn, any number of papers on belief perseverance by Lee Ross and others, Cults in Our Midst by Margaret Singer, The Psychology of Transcendence by Andrew Neher, Deception and Self-Deception by Richard Wiseman, "Memory" and "Eyewitness Testimony" by Elizabeth Loftus, and chapters by James Alcock and Barry Beyerstein in The Encyclopedia of the Paranormal. Throw in a few by Martin Gardner and James Randi for entertaining explorations of other oddities such as faith healers.
So the braid of the "AM" movement is complex and strong and will always lurk in our backgrounds, even if all human misery and disease were to be conquered. For now it grows into the interstices of scientific and ethical medicine's weaknesses and is fertilized by imagined faults. The movement has advanced socially and politically.
According to Prof. Edzard Ernst of Exeter University, the fascination with "AM" has peaked in the United Kingdom, and classes are poorly attended. The European Community is about to consider removing many worthless "AM" methods from lists for reimbursement. The same disenchantment may occur here in a few years. Yet we can learn from AM's existence and social successes. We can study misinterpretation of events and the formation of beliefs, increase our understanding of social movements, and perhaps tease out small kernels of benefits—even if only psychological—in some methods.
The challenge here is for us to increase our abilities to observe, measure, record, analyze, and reason, and not to allow the holes in our reality-sieve widen until we have lost our grip on it.
About the Author
Dr. Sampson, a retired cancer specialist, edits the Scientific Review of Alternative Medicine. He is a clinical professor of medicine at Stanford University School of Medicine and has been board chairman of the National Council Against Health Fraud.
This article was published in the Fall/Winter 1998 issue of the Scientific Review of Alternative Medicine. (© 1998 Prometheus Books, all rights reserved).This article was posted on June 21, 2001.