A fresh season of state legislative sessions is upon us and with it comes the ubiquitous attempts by purveyors of so called “complementary and alternative medicine” (or “CAM”) to join the health care provider fraternity. Via the magic of legislative alchemy, state legislatures transform pseudoscientific diagnoses (e.g., “chronic yeast overgrowth”) and treatments (e.g., homeopathy) into faux, but legal, health care. Once the imprimatur of legitimacy is bestowed by the state in the form of a health care practice act tailored to their special brand of quackery, these newly licensed health care providers are free to foist their practices onto an unsuspecting public and charge them for the privilege. All of this is done under the false assumption that such legislation is necessary to protect the public health, safety and welfare.
We might well want to consider how far this whole thing is going. Will practitioners of CAM split into an ever-expanding number of CAM provider guilds, all with their own practice acts? First, chiropractors were the only CAM practitioners who managed to get themselves licensed in all 50 states. Then along came acupuncturists, who are now licensed to practice in over 40 states. A few states license homeopaths. Some states licensed naturopaths early on. Now the naturopaths, licensed in 16 states, are in a full court press to catch up and legitimize themselves with licenses to practice “naturopathic medicine.”
Why? Because, according to Lorilee Schoenback, ND, a Vermont practitioner and American Association of Naturopathic Physicians (AANP) Board member:
If the law [the Affordable Care Act, or ACA] is implemented as intended NDs in 16 states will immediately be covered by insurance.
“Medicine is a very religious experience. I have my religion and you have yours. It becomes difficult for us to agree on what we think works, since so much of it is in the eye of the beholder. Data is rarely clean. You find the arguments that support your data, and it’s my fact versus your fact.”
- Mehmet Oz
The above quote is from a recent article for the New Yorker by Michael Specter about Dr. Oz, the most currently popular TV doctor. Specter described this sentiment as “chilling.” To me it sounds like a manifesto – a postmodernist attack on the scientific basic of modern medicine.
In my experience, this sentiment is often at the core of belief in so-called complementary and alternative medicine (CAM). In order to seem respectable and infiltrate the institutions of medical academia, proponents of CAM will say that their treatments are evidence-based and that they are scientific. They have a serious problem, however – their treatments are not evidence-based and are often grossly unscientific. Whenever someone bothers to look at their evidence and examine their science, therefore, they start to backtrack, eventually arriving at their true position, a postmodernist dismissal of science resembling Oz’s statement above. I have heard a hundred versions of the Oz manifesto from CAM supporters.
It can be frustrating, and sometimes even a little depressing, to be a skeptic. Promoting reason and science-based medicine often feels like a Sisyphean effort that garners lots of hostility and ad hominem attacks from proponents of pseudoscience and few concrete victories. But once in a while, something happens to give a little hope and inspiration.
In 2010, for example, the House of Commons Science and Technology Committee report on homeopathy came out, clearly unmasking homeopathy for the vitalist 18th century relic it is (though, sadly, politics is complicated and often unmoved by mere scientific truth, and the government didn’t eagerly embrace the findings or recommendations of the committee). About the same time, the British Medical Association called homeopathy “witchcraft,” and recommended it no longer be supported by the National Health Service. More recently, the Chief Medical Officer in Britain openly acknowledged homeopathy is “rubbish.” Perhaps there has been a shift in the winds? Maybe there is hope that the institutions of government and organized mainstream medicine here in the U.S. might be willing to start taking a stand against pseudoscience in the way they used to in the days before Wilk vs American Medical Association?
As a veterinarian, I was particularly delighted and inspired in March, 2012 when the Australian Veterinary Association (AVA) joined in this movement and took a firm and public stand on unscientific therapies, in particular washing its hands of homeopathy:
Australian Veterinary Association (AVA) resources will not be used to promote therapies that, in the Board’s opinion, are not compatible with current understanding of physiology and pathophysiology and have been demonstrated to be ineffective by the current accumulated body of knowledge.
That the Board agreed that the veterinary therapies of homeopathy and homotoxicology are considered ineffective therapies in accordance with the AVA promotion of ineffective therapies Board resolution.
This echoed the policies of the British Veterinary Association, and other national veterinary groups in Sweden, Denmark, and elsewhere in Europe. The idea that the central player in organized veterinary medicine in the U.S., the American Veterinary Medical Association (AVMA), which has as members more than 80% of the licensed veterinarians in the country, could be moved to take a similar stand started to seem like a realistic possibility.
Chiropractors are trying to rebrand themselves as primary care physicians, a topic both Harriet Hall and I have addressed (here and here) on SBM. Toward this end, they are seeking the expansion of their scope of practice, via the magic of legislative alchemy, to include the prescription and administration of drugs. Not drugs that any self-respecting M.D. would use, but drugs nonetheless. That effort succeeded to an extent in New Mexico. Recently Colorado got into the act. Other states have followed suit.
Chiropractors have claimed from the very beginning they are primary care physicians. Chiropractic was born in 1895 with the notion that virtually all diseases could be resolved with chiropractic treatment. This was Daniel David Palmer’s original contention, that the interruption of “nerve flow” by “subluxations” caused disease which could be remedied by spinal adjustment to restore the flow, thereby allowing the body to heal itself.
State chiropractic practice acts have always given chiropractors a broad scope of practice which allows them to diagnose and treat virtually any condition as long as they can squeeze the treatment into the “chiropractic paradigm.” If they can pretend the condition is amenable to chiropractic treatment via the detection and correction of subluxations, they can diagnose and treat it legally. This is how they are able to claim, falsely, that asthma, allergies, colic, and many other health problems can be resolved by chiropractic care. This is how “straight” chiropractors still practice.
I quite like Portlandia. I find it funny and it captures a part of Portland. I recognize large swaths of the city’s culture in the show. Other representations of the city I recognize less. Sunset publishes beautiful photographs of the NW, but when I look at the photos I think, that section of the city never looks that good. It is quite wonderful how Photoshop can improve on reality.
Like most major cities, Portland has a monthly magazine, Portland Monthly. The city represented in that magazine is mostly alien to me. I look at the advertisement, the articles, the photographs, and wonder when did Portland become a city with an average 7 figure income? The Portland in which I grew up and currently live is rarely found in the pages of Portland Monthly. If you are extremely well to do, I suppose you are in the demographic Portland Monthly. But when I flip through the pages of the magazine, I see little I recognize, but I have never completely abandoned the hippie/grunge aesthetic of my younger days.
Every January they have the best Doctors issue* and this year, for the first time, they offer The Portland Alternative Medicine Guide. Well, less a guide and more an extended infomercial filled with ‘facts’ that deserve the quotes. (more…)
I realize that I’ve said it many times before, but it bears repeating. Homeopathy is the perfect quackery. The reason that homeopathy is so perfect as a form of quackery is because it is quite literally nothing. On second thought, I suppose that it’s not exactly nothing. It is, after all, water or whatever other diluent that homeopaths use (usually ethanol). However, thanks to some basic laws of physics and chemistry and a little thing known as Avogadro’s number, any homeopathic dilution greater than 12C (twelve serial 100-fold dilutions) is incredibly unlikely to contain even a single molecule of starting compound. That unlikeliness reaches truly astonishing levels as we reach the common homeopathic dilution of 30C, which is the equivalent of a 1060-fold dilution. Given that that little thing known as Avogadro’s number, which describes how many molecules of a compound are in a mole, is only approximately 6 x 1023, a 30C dilution is on the order of 1036- to 1037-fold higher than Avogadro’s number. Even assuming that a homeopath started with a mole of remedy before diluting (unlikely, given the high molecular weight of most of the organic compounds that can serve as homeopathic remedies), the odds that a single molecule could remain behind after the serial dilution and succussion process is infinitesimal. Appropriately enough, the “law” in homeopathy that states that diluting a remedy will make it stronger is the law of infinitesimals.
It is also the reason that homeopathy is nothing.
Homeopaths have known these facts for many decades. Anyone who is any sort of a scientist or has an understanding of science, when confronted with these simple, well-established physical laws, might—just might—start to rethink his belief in something that is so utterly implausible from a scientific standpoint. Indeed, homeopathy is about as close to impossible as anything I can imagine, because for it to “work” multiple well-established laws of physics and chemistry would have to be not just wrong, but spectacularly wrong. Yet, as Richard Dawkins famously put it, undeterred, homeopaths bravely paddle up the river of pseudoscience and invent explanations to “explain” how homeopathy could work, the most famous of which is the so-called “memory of water,” in which the water in the homeopathic remedy remembers all the good bits meant to heal but, as Tim Minchin so famously put it, somehow forgets all the poo that’s been in it. Homeopathy is truly magical thinking, which is why I love to use it as an illustrative example of quackery. Not only is it magical thinking, but because it is nothing but water, it’s a very useful educational example for placebo effects and the general types of fallacious arguments quacks and pseudoscientists make. Apparently it’s time for another one.
Oh, the irony of it all! Quackery continues its increasingly successful assault on the citadel of medicine, viz: quackademic medicine, integrative medicine, credulous medical journal articles, shruggies, medical society support for CAM provider licensing. Will that nemesis of medical doctors, plaintiffs personal injury attorneys, turn out to be the last defenders of science in a world of health care fraught with so-called alternative medicine?
Maybe not. But the thought did occur to me while reading the Final Judgment and Order entered in Gallucci v. Boiron, the class action accusing the world’s largest manufacturer of homeopathic products of consumer fraud.
One of the core fictions of “complementary” or “integrative” medicine is that they are primarily offered in addition to science-based medicine and only to fill gaps in what SBM can offer. The original marketing label used to promote treatments that are not adequately supported by evidence , “alternative medicine,” was a bit more accurate in that at least it acknowledged that such treatments were being offered instead of SBM (the fiction being that they are a viable alternative, rather than just health fraud and pseudoscience). The switch to “complementary” and “integrative” did not reflect an evolving philosophy or practice, just an evolving marketing strategy.
Today proponents are likely to reassure the right people – journalists, regulators, and academics – that their offerings are not meant to replace proven therapies, but to complement them (the best of both worlds). (Mark Crislip is fond of pointing out that this is like mixing cow pie with apple pie. It doesn’t make the cow pie palatable, but it does ruin the apple pie.) However, behind closed doors practitioners of unscientific medicine generally prescribe their favorite pseudoscience instead of science-based treatments.
For example, Alice Tuff from Sense about Science investigated 10 homeopathic clinics in the UK.
In the consultations, Alice explained that she was planning to join a 10-week truck tour through Central and Southern Africa and that the anti-malarial drugs her doctor had prescribed made her feel queasy.
The results – all 10 homeopathy clinics offered homeopathic treatments for malaria protection, and none of them suggested this be done in addition to standard treatment. None of them referred Alice back to her medical doctor for further advice (in which case she could have been offered science-based alternative malaria treatments that she may have tolerated better). Only two homeopaths took a personal medical history.
As hard as it is to believe, the Science-Based Medicine blog that you’re so eagerly reading is fast approaching its fifth anniversary of existence. The very first post here was a statement of purpose by Steve Novella on January 1, 2008, and my very first post was a somewhat rambling introduction that in retrospect is mildly embarrassing to me. It is what it is, however. The reason I mention this is because I want to take a trip down memory lane in order to follow up on one of my earliest posts for SBM, which was entitled The National Center for Complementary and Alternative Medicine (NCCAM): Your tax dollars hard at work. Specifically, I want to follow up on one specific study I mentioned that was funded by NCCAM.
Even though I not-so-humbly think that, even nearly five years later, my original post is worth reading in its entirety (weighing in at only 3,394 words, it’s even rather short—for me, at least), I’ll spare you that and cut straight to the chase, the better to discuss the study. It is a study of homeopathy. Yes, in contrast to the protestations of Dr. Josephine Briggs, the current director of NCCAM, that NCCAM doesn’t fund studies of such pure pseudoscience as homeopathy anymore (although she does apparently meet with homeopaths for “balance”), prior to Dr. Briggs’ tenure NCCAM actually did fund studies of the magic water with mystical memory known as homeopathy. Two grants in particular I singled out for scorn. The principal investigator for both grants was Iris Bell, who is faculty at Andrew Weil’s center of woo at the University of Arizona. The first was an R21 grant for a project entitled Polysomnography in homeopathic remedy effects (NIH grant 1 R21 AT000388).
Your health insurance plan probably covers anti-inflammatory drugs. But does it cover acupuncture treatments? Should it? Which health services deliver good value for money? Lest you think the debate is limited to the United States (which is an outlier when it comes to health spending), even countries with publicly-run healthcare systems are scrutinizing spending. Devoting dollars to one area (say, hospitals) is effectively a decision not to spend on something else, (perhaps public health programs). All systems, be they public or private, allocate funds in ways to spend money in the most efficient way possible. Thoughtful decisions require a consideration of both benefits and costs.
One of the consistent positions put forward by contributors to this blog is that all health interventions should be evaluated based on the same evidence standard. From this perspective, there is no distinct basket of products and services which are labelled “alternative”, “complementary” or more recently “integrative”. There are only treatments and interventions which have been evaluated to be effective, and those that have not. The idea that these two categories should both be considered valid approaches is a testament to promoters of complementary and alternative medicine (CAM), who, unable to meet the scientific standard, have argued (largely successfully) for different standards and special consideration — be it product regulation (e.g., supplements) or practitioner regulation.
Yet promoters of CAM seek the imprimatur of legitimacy conferred by the tools of science. And in an environment of economic restraint in health spending, they further recognize that showing economic value of CAM is important. Consequently they use the tools of economics to argue a perspective, rather than answer a question. And that’s the case with a recent paper I noticed was being touted by alternative medicine practitioners. Entitled, Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations, it attempts to summarize economic evaluations conducted on CAM treatments. Why a systematic review? One of the more effective tools for evaluating health outcomes, a systematic review seeks to analyze all published (and unpublished) information on a focused question, using a standardized, transparent approach to evidence analysis. When done well, systematic reviews can sift through thousands of clinical trials to answer focused questions in ways that are less biased than cherry-picking individual studies. The Cochrane Review’s systematic reviews form one of the more respected sources of objective information (with some caveats) on the efficacy of different health interventions. So there’s been interest in applying the techniques of systematic reviews to questions of economics, where both costs and effects must be measured. Economic evaluations at their core seek to measure the “bang for the buck” of different health interventions. The most accurate economic analyses are built into prospective clinical trials. These studies collect real-world costs and patient consequences, and then allow an accurate evaluation of value-for-money. These types of analyses are rare, however. Most economic evaluations involve modelling (a little to a lot) where health effects and related costs are estimated, to arrive at a calculation of value. Then there’s a discussion of whether that value calculation is “cost-effective”. It’s little wonder that many health professionals look suspiciously at economic analyses: the models are complicated and involve so many variables with subjective inputs that it can be difficult to sort out what the real effects are. Not surprisingly, most economic analyses suggest treatments are cost-effective. Before diving into the study, let’s consider the approach: