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Chopra and Weil and Roy, oh my! Or: The Wall Street Journal, coopted.

The quest of advocates of unscientific medicine, the so-called “complementary and alternative medicine” (CAM) movement is to convince policy makers, patients, and physicians that it does not deserve the rubric of “alternative,” that it is in fact mainstream. Indeed, that is the very reason why “alternative” medicine morphed into CAM in order to soften the “alternative” label. Increasingly, however, advocates of such highly implausible medical practices appear no longer to like CAM as term for their dubious practicies, because it still uses the word “alternative.” That is, of course, because they recognize that labeling something as “alternative” in relationship to scientific medicine automatically implies inferiority, and CAM advocates are nothing if not full of hubris. Such a term conflicts with their desire to “go mainstream,” and they most definitely do want to go mainstream, but they want to do it on their own terms, without all that pesky mucking about with science, evidence, and rigorous clinical trials. Consequently, they increasingly use a new term, a shiny term, a term free of that pesky “alternative” label. Now they want to “integrate” their unscientific placebo-based practice with real, scientific medicine. Thus was born the term “integrative” medicine (IM, an abbreviation that is the same as that for internal medicine, an identity that I don’t consider coincidence).

One of the biggest complaints we at SBM (or at least I at SBM) have about the attitude of practitioners of scientific medicine towards CAM/IM is that most of them do not see it as a major problem. Dr. Jones characterized this attitude as the “shruggie” attitude, and it’s a perfect term. Equally perfect is her analogy as to why “integrating” pseudoscience with medical science is not a good idea. I myself have lamented the infiltration of pseudoscience and outright quackery into medical academia and the role that the National Center for Complementary and Alternative Medicine (NCCAM) has played in promoting that infiltration. In addition, wealthy patrons of CAM/IM such as Donna Karan and the Bravewell Collaborative have been generous spreading their money around. In this increasingly cash-strapped health care environment, hospitals know on which side their bread is buttered and see the “integration” of woo into their service portfolio as a means of beefing up the bottom line with cash on the barrelhead transactions that require no mucking about with nasty insurance forms. In fact, services such as reiki, homeopathy, acupuncture, and others often require no forms other than credit card receipts for the patient to sign.

Unfortunately, there has been very little pushback by advocates of scientific medicine. Sure, there were the two excellent books, Trick or Treatment: The Undeniable Facts about Alternative Medicine by Simon Singh and Edzard Ernst and Snake Oil Science: The Truth About Complementary and Alternative Medicine by R. Barker Bausell. There was even Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure by Paul Offit. However, none of these books were best sellers, and I estimate that the entire sales for all three of these books combined probably don’t match a month’s–or even a week’s–worth of sales for one of Kevin Trudeau’s books or Jenny McCarthy’s latest cheerleading for autism quackery.

That’s why over the holidays I was so happy to see an article in the Wall Street Journal entitled The Touch That Doesn’t Heal by Steve Salerno. It was that rarest of rare things in the mainstream media: an all-out frontal assault on what Dr. R. W. Donnell has termed “quackademic medicine” and the infiltration of pseudoscience into medical centers whose physicians should know better. It even expressed fear that any comprehensive health care reform promised by the incoming Obama administration could provide the opening for CAM advocates and their boosters in Congress like Dan Burton and Tom Harkin to coopt it and insert language into any reform legislation that would force the government not only to recognize (as NCCAM does) but pay for quackery. It is a fear I share, and I was happy to see a major newspaper like the WSJ publish such an editorial. I was even more happy to see the article’s conclusion:

Is there anecdotal evidence that unconventional therapies sometimes yield positive outcomes? Yes. There’s also anecdotal evidence that athletes who refuse to shave during winning streaks sometimes bring home championships. It was George D. Lundberg, a former editor of the Journal of the American Medical Association, who said: “There’s no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data.” We’d do well to keep that in mind as we plot the future of American health care. It’s not like we’ve got billions to waste.

Speak it, brother Salerno! (Perhaps I should invite him to do a guest post for SBM.) Not surprisingly, Salerno’s article also resulted in some pushback from the CAM/IM movement.

The Unholy Trinity of Pseudoscience launch a counterattack

Salerno’s article, predictably enough, riled Deepak Chopra. Indeed, Chopra was not happy about it at all. In fact, he was so unhappy that right before the end of 2008 he mobilized his buddies for a counterattack, including the Godfather of Quackademic Medicine and anecdotal evidence over controlled observations, Dr. Andrew Weil, and that King of Water Woo, particularly pseudoscientific arguments for homeopathy, Dr. Rustum Roy. Truly, this was an Unholy Trinity of Pseudoscience, and the results were very predictable. In response, they posted an article entitled Leave the Sinking Ship, in which they immediately attacked Salerno’s article as the “opening salvo” against CAM/IM, to that repository for antivaccination nonsense The Huffington Post and to Chopra’s own Intentblog.

Personally, I certainly hope Salerno’s article does represent an opening salvo against the sort of pseudoscientific nonsense represented by Chopra and his ilk. I certainly hope it’s the first salvo of a veritable barrage that would put the bombardment of Normandy in preparation for the D-Day invasion to shame. I hope it’s the first salvo of a barrage that flattens any pretensions Chopra and his ilk have to scientific legitimacy, pulverizing it to a cloud of woo-ful dust the way a shell pulverizes its target.

How’s that for an overblown metaphor?

But back to Chopra’s article. Perhaps above anything else, Dr. Chopra seemed the most upset at how he was characterized in Salerno’s article, and he started out with a bit of a whine:

Without discernible professional credentials in health reportage, the writer opened his piece by pledging allegiance to “scientifically proven, evidence-based medicine.” He next declared opposition to integrative medicine, and characterized as “gurus” two proponents of integrative medicine, Deepak Chopra and Andrew Weil, choosing to overlook that we both are highly trained MDs with almost 40 years of clinical-experience. Joining us in our response is Rustum Roy, an internationally known scientist, and member of five major National Academies of Science Engineering, who has spent ten years researching a wide range of health technologies, both ancient and modern. We predict that while they may try to dismiss us, the Wall Street Journal writer and editors will find they can’t dismiss a burgeoning field of medicine currently saving and improving millions of lives worldwide.

Regular readers of this blog and other skeptical blogs should recognize the classic “argument from authority.” How dare that unwashed non-M.D. plebeian criticize us? whined Chopra. After all, we’re doctors, dammit!

To which I respond: So what if you’re doctors?

Drs. Chopra and Weil long ago gave up their claim to being science-based. This is true of Chopra more than Weil, given Chopra’s “quantum consciousness” proclivities, On the other hand, Weil’s own proclivity for “integrating” the unproven and dubious with some sound medical advice while making in essence no distinction between the two is infuriating to no end, particularly his advocacy of “uncontrolled clinical observations” over sound clinical trials and epidemiology and his proselytization of CAM/IM to the point that he is “integrating” it into family medicine residencies. In this, Dr. Weil may well be the greater threat to science-based medicine than Dr. Chopra. That’s because Deepak Chopra, with his pseudoscientific nonsense, is so far off the deep end that very few in academia take him the least bit seriously. Andrew Weil, on the other hand, mixes just enough sound medicine with his woo that his mixture goes down a lot easier. It certainly has at the University of Arizona, where he has created a CAM/IM fiefdom. Also, you are unlikely ever to hear Dr. Weil going on and on about “quantum universal consciousness,” as Chopra does, but you will hear him blurring the distinction between medicine that is dubious and that is science-based, which allows him to be the Trojan horse filled with quackery that medical schools are now happily letting into the courtyards within the walls of their fortresses.

In any case, titles mean little here. An M.D. after a person’s name is no guarantee whatsoever that that person has the slightest understanding of the scientific method or what does and does not constitute good science. Indeed, Deepak Chopra is living proof of that, as are Andrew Weil, David Katz, not to mention the horde of physicians signing petitions expressing “Dissent from Darwin” over evolution on pro-”intelligent design” creationism sites. Come to think of it, Chopra has been known to say some very “misguided” things about evolution as well. Sadly, even a Ph.D. after one’s name is not always a guarantee, as Rustum Roy demonstrates. Even a Nobel Prize is no guarantee that a person won’t go wandering off the plantation when it comes to science, as Linus Pauling has demonstrated. Arguments matter, not titles, and Chopra and his trio can’t marshal them. Of course, it’s all a plot by The Man (and Big Pharma, of course) to keep The People down:

We believe that Salerno’s piece is the opening salvo from the right aiming to influence the incoming administration as it strategically allocates resources for improving the U.S. health and wellness system. Fortunately, Tom Daschle, the upcoming Health and Human Services Secretary is better informed than either the WSJ writer or those who dictate WSJ editorial policy. The co-author (along with Jeanne Lambrew) of Critical: What We Can Do About the Health Care Crises, Daschle names the principal challenge to true reform, “[S]pecial interests are especially numerous and influential in the health-care system. Health care comprises one-sixth of our economy… since cutting costs is tantamount to cutting profits for many of these special interests, it is reasonable to expect (an) all-out war to defeat reform.”

As in Mr. Salerno’s article, this war extends to advancing ill-informed pseudo-scientific arguments to discredit effective low-cost health care options precisely because they compete with the current high-cost system.

“Special interests”? It is, in fact, the CAM/IM movement spearheaded by the likes of Chopra and Weil that represent the quintessential “special interest” every bit as much as big pharma and the AMA. It shows a lot of chutzpah to try to appropriate the “reform” label, of course, because if any aspect of the health care system needs reform, it’s the Dietary Supplement Health and Education Act of 1994 (DSHEA), which allows supplement makers to sell their supplements with minimal oversight. As long as they don’t make specific claims to be able to treat or cure a disease or condition, they can pretty much say anything they want in their advertising. If I were reforming the health care system, one thing I’d most definitely want to do would be to repeal the DSHEA and give jurisdiction over supplement sales back to the FDA.

I also find it most curious that Chopra would politicize this as an attack from the “right.” If there’s one thing I want to emphasize about pseudoscience and quackery, it’s that it’s totally a bipartisan affair. The only difference between the “left” and the “right” when advocating quackery is that the type of quackery tends to differ, as do the reasons for supporting quackery. On the “left,” for example, the push for CAM/IM is associated with a “wholistic” treatment, New Age nonsense, and a whole lot of suspicion of big pharma, big medicine, and corporate interests. On the “right,” CAM/IM is sold more as an issue of “health freedom,” which in reality means the “freedom for quacks to do whatever they want” without any pesky interference wfrom the government. This view is best epitomized by Ron Paul, who is one of the greatest friends of quackery Congress has ever seen. Indeed, two of the biggest boosters of CAM/IM there are in Congress are both Republicans: Ron Paul and Dan Burton, the latter of whom is especially known for his antivaccine views and his support of autism quackery. So, whenever I see support for quackery represented as being a product of “liberals” or the “left,” I generally feel an irresistable twitching in my keyboard fingers to set such nonsense straight. When I’m really in a cantankerous mood, I will even risk Godwin’s wrath and mention that homeopathy and naturopathy were not only popular in Nazi Germany, but actively promoted by the regime as being more “völkisch” and “German,” as documented so well by Robert N. Proctor in his books.

Be that as it may, any true “reform” of the healthcare system should require evidence of efficacy for therapies for which the government pays. In this, CAM/IM, by and large, has failed miserably. Chopra et al seemingly almost implicitly recognized this failure, because the only arguments they were able to come up with were attacks against science-based medicine, not postive arguments based on science for the efficacy of their preferred CAM/IM modalities. Indeed, they presented not a single positive scientific argument, just vague claims and paranoid attacks:

Nor does it sustain a doctor’s sworn duty to “first do no harm.” Abundant evidence uncovers high-tech medicine, with its powerful drugs, as a major, possibly the leading, cause of death in this country. The National Academy’s data attributes 100,000 deaths per year to physicians’ errors, added to well over 100,000 deaths due to severe drug interactions and another 100,000 fatalities from hospital-based-infections. (For a detailed analysis, see Death By Medicine, by Gary S. Null, et al.)

Why is the allegedly “scientifically proven” health care that the WSJ writer champions so dangerous to health? The blind allegiance to “evidence-based medicine” overlooks how readily this form of research can be manipulated. It was first developed to isolate patentable agents for drug formulations. In scientific arenas outside of mainstream medicine, this “statistics-based medicine” is regarded as dubious science at best. Narrowly confining itself to costly, selectively published, industry-sponsored clinical trials, to promote pharmaceutical products, “evidence based medicine” is the marketing “icon” used by the current system to squelch lower cost competitors.

Science’s only gold standard are facts derived from reproducible results, however unpalatable those facts are to current theory. When theories fail to explain the facts, they lose viability. The spectacular failures of “evidence based” medical theories include the millions spent on ineffective AIDS vaccines, the collapse of interferon as the wonder drug for cancer, and the marginal decrease in cancer deaths despite billions wasted during decades of fruitless research. Many once-standard treatments devised via this theoretical model now stand discredited, like the use of Thalidomide and Thorazine.

Yes, you saw it right. Chopra et al cited Gary Null in support of their arguments. Let me repeat that: Chopra et al actually cited Gary Null! I hate to point out to Chopra that the article he cites is about as bad as pseudoscience and advocacy of quackery gets, full of cherry picking of data and ignoring any context or benefit. So bad is it that the relentlessly anti-evolution neurosurgeon Dr. Michael Egnor also cited it.

Gary Null is a known über-quack, HIV/AIDS denialist, coffee enema maven, and antivaccinationist. That Chopra et al would think him to be a reliable source for any analysis of science or medicine shows just how deluded they have become. I might have expected such a citation from Roy or Chopra, but I would have thought that Dr. Weil would value his apparent current respectability highly enough not to let himself be associated with the citation of such obvious cranks as Gary Null and Dr. Mercola. Apparently I was wrong. In any case, Harriet Hall and Peter Lipson both demolished this article. I’d suggest that Chopra read their analyses if I thought it would do any good, but it won’t. After all, if Chopra thinks that the failure to develop an HIV vaccine or the only modest improvement in most survival rates for cancers other than childhood cancers is evidence that evidence-based medicine is a failure, rather than a reflection of the difficulty involved in making an effective HIV vaccine or the extreme complexity of developing cancer treatments, respectively, he is even more clueless than I had thought before. I will admit that he does have one point though: Evidence-based medicine can be manipulated. Ironically, as Kimball Atwood pointed out, CAM/IM advocates are masters at using EBM to make it appear as though placebos such as homeopathy actually “work” and of making “inconvenient” clinical trial results mysteriously disappear, never to be published.

Chopra’s other attacks on science-based medicine relied, as do those of many apologists for quackery, on the “science has been wrong before” fallacy. Yes, science has been wrong before. Yes, what we believe about illness and its treatment today is likely to change based on new findings. Yes, our understanding of disease is incomplete. Here’s the rub. The reason that the treatments listed by Chopra were ultimately abandoned was not because some woo-meister doubted that they worked. It was because physicians applied the scientific method to the study of them and discovered that they did not work as well as thought or even did not work at all. Science is self-correcting. It may not be as quick as we would like; it is all too often far messier than non-scientists like Chopra and Weil like (or even scientists like me would like); but inevitably science does weed out ideas that don’t reflect nature and treatments that don’t work.

This self-correction is in marked contrast to CAM/IM, where there is no treatment that has ever been completely abandoned because science has shown it to be no more effective than placebo. Indeed, even Laetrile, whose lack of efficacy was conclusively demonstrated in the 1980s, is still touted in some sectors. Meanwhile, homeopathy, the 200 year old zombie placebo that won’t die, Rustum Roy’s handwaving about the “memory of water” and the utter failure of homeopaths to be able to distinguish homeopathically “potentized” treatments from water notwithstanding, continues to rear its ugly head in even academic medical centers. If there’s one thing that distinguishes CAM/IM from science- and evidence-based medicine, it’s that CAM/IM is faith-based more than anything else. In yet another irony, CAM/IM has even been able to co-opt evidence-based medicine by ignoring prior probability far more than big pharma could ever dream of. (See Prior Probability: The Dirty Little Secret of “Evidence-Based Alternative Medicine by Kimball Atwood IV and its two followups for more.) At least big pharma has to justify scientifically its treatments to a certain standard. We can argue whether that standard is sufficiently rigorous, but what we can’t argue is that in effect there is no equivalent requirement of CAM/IM.

The final part of the article boiled down to what Steve Novella, Mark Crislip, and I have termed right here on this very blog the “bait and switch” of CAM/IM (with a heaping dollop of argumentum ad populum and appeal to authority, no less). It began:

Over the last three decades, millions of Americans, and a dedicated group of physicians and practitioners have front-line, hands-on experience with integrative health care. Via concerted research and clinical practice, international scientists and practitioners, have progressively uncovered the root causes and the most effective treatments for health maintenance and restoration. This is science’s cutting edge.

Perhaps Chopra could point me in the direction of this CAM/IM “cutting edge” research that has “uncovered the root causes and the most effective treatments for health maintenance and restoration.” I’ve looked. Really I have. I’ve read scores upon scores of poorly designed CAM/IM trials purporting to show efficacy, as well as well-designed studies that fail to find efficacy greater than that of a placebo, and I’ve yet to see these amazing findings. I’ll settle for just a handful of studies representing “cutting edge” research in CAM that have uncovered the root causes and most effective treatments. I suspect I will wait a long time to see them.

Now here’s the bait and switch used by Chopra et al:

One sine qua non for any future sustainable U.S. health system is the necessity to empower, rather than undercut each citizen’s right to choose health care and take responsibility for his/her own wellness. Countless chronic diseases result from the neglect of basic wellness measures. The blame for underutilizing such proactive, cost-saving approaches lies directly with the official policy of blind reliance on drugs and surgery, whatever the cost. The public has been lulled into medical apathy on the false assumption that if something goes wrong, fix-it mechanics will tune up your body the way a garage tunes up your car.

A new integrative medicine system would marry the superb options of high tech emergency care, its brilliant surgical achievements, the tried and least harmful pharmaceuticals, by empowering and educating its citizens to maintain wellness and prevent disease, through improved nutrition, exercise, stress-management, and a wide range of other proven integrative approaches. Sadly, mainstream medicine largely ignores these viable health approaches, because they’re not financially lucrative.

The reason we at SBM call this a “bait and switch” is that CAM/IM apologists like Chopra try very hard to appropriate science- and evidence-based modalities like good nutrition and exercise, along with health maintenance measures, as being somehow “alternative” or “integrative” (the bait) when they are in the purview of “conventional medicine.” They take advantage of the observation that these modalities tend to be underemphasized in scientific medicine (although not as clearly so as Chopra would have you believe, given how hard lifestyle changes are to persuade patients to undertake) to subsume them into CAM/IM, and cleverly arguing that these modalities need to be emphasized more, only as part of CAM/IM. Indeed, the appropriation of such modalities by the CAM/IM movement is the “foot in the door,” so to speak, that (or so CAM/IM advocates hope) will allow the entrance of the more dubious therapies (the switch). Today, nutrition and excercise, tomorrow homeopathy. To CAM/IM advocates, it would seem, it’s all the same. Or at least that’s what they want patients, policy makers, and physicians to believe.

Basically, the argument made by the Unholy Trinity boils down to an attack on evidence-based medicine based on exaggeration and cherry picking, topped off with a huge dollop of conspiracy-mongering and playing the victim. There was not a single positive, science-based argument that Chopra’s woo or Andrew Weil’s “integration” of the dubious with the evidence-based produces better health outcomes than the evidence-based medicine they attack. I’ll concede it’s probably cheaper, but that’s just because, at least in this case, you usually get what you pay for.

Not satisified with this attack, Chopra decided to launch another salvo on Friday. This time, he found an outlet with a far larger readership and a lot more respectability than The Huffington Post. This time, it was an even more outrageous example of the bait and switch of CAM/IM but accompanied with a more explicit political agenda to “integrate” quackery with medicine in any government health care reform.

The Unholy Trinity of Pseudoscience become the Four Musketeers of Pseudoscience and launch another counterattack

On Friday, the opinion page of the Wall Street Journal published an editorial by Deepak Chopra, Dean Ornish, Rustum Roy, and Andrew Weil entitled “Alternative: Medicine Is Mainstream: The evidence is mounting that diet and lifestyle are the best cures for our worst afflictions. (The article was also published on Chopra’s Intentblog, along with some links). The d’Artagnan of Pseudoscience, Dean Ornish, happens to be Founder and President of the Preventive Medicine Research Institute and Clinical Professor at the University of California, San Francisco (UCSF). He is best known for his exaggerated claims that diet can treat prostate cancer. In this, he most resembles Andrew Weil in that he contaminates sound scientific medical advice with dubious and exaggerated claims about what dietary and lifestyle changes can do alone. In any event, this most recent article is the most explicit statement of the strategy of CAM/IM advocates that we at SBM have been warning about for a year now. It makes absolutely explicit that Dr. Chopra et al want nothing less than for their “alternative” medicine to be treated as co-equal to scientific medicine. It begins:

In mid-February, the Institute of Medicine of the National Academy of Sciences and the Bravewell Collaborative are convening a “Summit on Integrative Medicine and the Health of the Public.” This is a watershed in the evolution of integrative medicine, a holistic approach to health care that uses the best of conventional and alternative therapies such as meditation, yoga, acupuncture and herbal remedies. Many of these therapies are now scientifically documented to be not only medically effective but also cost effective.

President-elect Barack Obama and former Sen. Tom Daschle (the nominee for Secretary of Health and Human Services) understand that if we want to make affordable health care available to the 45 million Americans who do not have health insurance, then we need to address the fundamental causes of health and illness, and provide incentives for healthy ways of living rather than reimbursing only drugs and surgery.

Notice three things about this introduction. First, note who’s involved. It’s the Bravewell Collaborative, a group that has been a frequent topic of this blog. I am only speculating, but does anyone want to guess how such an article found its way into the WSJ? Think about it. The Bravewell Collaborative is a consortium dedicated to the promotion of CAM/IM in academia and “conventional” medical centers. More relevant, it is spearheaded by Christy Mack, wife of the multi-billionaire John J. Mack, CEO and Chairman of the Board of Morgan Stanley. Would it be speculating too much to wonder whether perhaps Christy Mack was not too happy when she saw Steve Salerno’s article and complained to her husband, who let it be known to the editorial board of the WSJ that some “balance” was required? Second, note the picture that accompanies the editorial. It shows a puzzled and unhappy doctor staring out of the window of his office watching a bunch of happy and healthy people, one of whom is reading a book on health foods, another of whom is meditating as she walks, and another exercising, all apparently not needing the poor physician’s services. This, of course, feeds into the typical CAM/IM myth that physicians aren’t concerned with health maintenance and are only interested in treating disease.

Finally, note yet another classic example of the bait and switch of CAM/IM. Note how Chopra et al refer to the “best of conventional and alternative therapies such as meditation, yoga, acupuncture and herbal remedies” and state that “many” of these “are now scientifically documented to be not only medically effective but also cost effective.” Note, as Skeptico did, how Chopra includes acupuncture, which is not scientifically validated and in fact nothing more than an elaborate placebo, along with meditation, which may be helpful for relaxation and therefore useful for some conditions, and herbal medicine, which may or may not be effective, given that herbs contain drugs, but are the equivalent to the way medicine was practiced 200 years ago.

Here’s where the bait comes in, and it’s a predictable bit of bait given the addition of Dean Ornish as a Musketeer:

These studies often used high-tech, state-of-the-art measures to prove the power of simple, low-tech, and low-cost interventions. Integrative medicine approaches such as plant-based diets, yoga, meditation and psychosocial support may stop or even reverse the progression of coronary heart disease, diabetes, hypertension, prostate cancer, obesity, hypercholesterolemia and other chronic conditions.

A recent study published in the Proceedings of the National Academy of Sciences found that these approaches may even change gene expression in hundreds of genes in only a few months. Genes associated with cancer, heart disease and inflammation were downregulated or “turned off” whereas protective genes were upregulated or “turned on.” A study published in The Lancet Oncology reported that these changes increase telomerase, the enzyme that lengthens telomeres, the ends of our chromosomes that control how long we live. Even drugs have not been shown to do this.

Note that the PNAS study examined a dietary intervention that is very, very hard to maintain, permitting only 10% of a person’s calories from fat and requiring an hour and a half of exercise and meditation daily. Very few people could maintain such a regimen, and it would take a lot of dedication and devotion to pull it off. Moreover, it was only a pilot study of 30 men. Unfortunately, that did not stop CAM/IM advocates like David Katz from misrepresenting the study as showing that diet and exercise can “reshuffle the genetic deck in our favor.” In any case, the study is provocative, but the men who participated were from a highly select group, only only 31 out of 127 eligible men. These patients were also a highly select group from another perspective in that they all had small, low grade prostate tumors deemed safe to be managed by “watchful waiting,” rather than immediate surgery or radiation therapy. These tumors all had low PSA levels and low Gleason scores. (The Gleason score is the standard measure used by pathologists to estimate how aggressive a prostate cancer is.) These men were also monitored very carefully to make sure that their tumors were not progressing during the study, and their tumors did not regress, nor did overall PSA levels change on average. Moreover, what Chopra, Cornish, et al neglect to mention is that only 1/3 of the samples contained actual tumor tissue; the rest contained only noncancerous prostate tissue. This wasn’t reported in the Results section and was only mentioned briefly in the Discussion section. Nor was enough information reported to allow a good assessment of whether this shortcoming introduced significant bias. Indeed, it would be rather important to know what proportion of matched tumors contained no tumor in the pre-treatment biopsy or no tumor in the post-treatment biopsy. If, for example, more matched pre and post sets contained tumor in the pre-treatment biopsy but no tumor in the post-treatment biopsy than contained tumor in the post-treatment biopsy but no tumor in the pre-treatment biopsy, that could introduce an artifact that would bias the results towards the sort of results seen. Unfortunately, most the same problems with the first PNAS study apply to this study, and, indeed, this Lancet paper looks to me like a bit of the ol’ “CV padding” in that it reports what appear to be a lot of the same things about cholesterol and triglyceride levels in the men participating in the study. Moreover, the bottom line is quite underwhelming in that telomerase activity was only mildly increased in the PBMCs, with huge error bars and a significant, but not outstandingly so, p-value.

Most importantly, though, as Skeptico points out, this is the “bait.” The interventions were diet and exercise. They were a difficult to follow diet and exercise regimen, but they were, when boiled down to their essence, diet and exercise nonetheless. No acupuncture. No homeopathy. No reiki. No CAM/IM. No nothing other than diet and exercise, plus meditation, which can be looked at as relaxation therapy more than anything else. Moreover, no one I’m aware of is saying that diet and exercise can’t have dramatic effects on health, and it’s not implausible that Dr. Ornish’s regimen might reduce the risk of prostate cancer or slow its progression (although his data do not really support that contention very strongly, if at all). Indeed, his two studies fall into the realm of science-based medicine. They may be preliminary and questionable science-based medicine, but they are not “alternative.” Funny how Chopra cites them as such. Next, he resorts to his usual attacks on science-based medicine:

Despite these costs, a randomized controlled trial published in April 2007 in The New England Journal of Medicine found that angioplasties and stents do not prolong life or even prevent heart attacks in stable patients (i.e., 95% of those who receive them). Coronary bypass surgery prolongs life in less than 3% of patients who receive it. So, Medicare and other insurers and individuals pay billions for surgical procedures like angioplasty and bypass surgery that are usually dangerous, invasive, expensive and largely ineffective. Yet they pay very little — if any money at all — for integrative medicine approaches that have been proven to reverse and prevent most chronic diseases that account for at least 75% of health-care costs. The INTERHEART study, published in September 2004 in The Lancet, followed 30,000 men and women on six continents and found that changing lifestyle could prevent at least 90% of all heart disease.

The study to which he is referring is this one. However, it is not exactly as Chopra represents it, as you can see if you click on the abstract. What this study did was to compare percutaneous coronary intervention (PCI, otherwise known as angioplasty) with optimal medical therapy plus PCI. Note that both sets of interventions are science-based and not in any way “alternative”. Also note how Chopra states that bypass surgery prolongs life in only 3% of those who receive it as though that was a conclusion of the study. It wasn’t, and Chopra does not cite his source. In any case, what Chopra fails to mention was that patients in the PCI plus medical intervention group required fewer procedures (32% of the medical therapy required additional revascularization procedures to 21.1% of the PCI/medical therapy group at 4.6 years) and a higher likelihood of being free from angina, albeit modest (42% versus 36% at 5 years). As for the INTERHEART study, this, too, is science-based medicine and suggests that diet and lifestyle could account for as much as 90% of all heart disease. It is also hardly new news. Yet Chopra appropriates diet and lifestyle as “alternative” so that he can make the “switch”:

And the same lifestyle changes that can prevent or even reverse heart disease also help prevent or reverse many other chronic diseases as well. Chronic pain is one of the major sources of worker’s compensation claims costs, yet studies show that it is often susceptible to acupuncture and Qi Gong. Herbs usually have far fewer side effects than pharmaceuticals.

Joy, pleasure, and freedom are sustainable, deprivation and austerity are not. When you eat a healthier diet, quit smoking, exercise, meditate and have more love in your life, then your brain receives more blood and oxygen, so you think more clearly, have more energy, need less sleep. Your brain may grow so many new neurons that it could get measurably bigger in only a few months. Your face gets more blood flow, so your skin glows more and wrinkles less. Your heart gets more blood flow, so you have more stamina and can even begin to reverse heart disease. Your sexual organs receive more blood flow, so you may become more potent — similar to the way that circulation-increasing drugs like Viagra work. For many people, these are choices worth making — not just to live longer, but also to live better.

Note the false dichotomy, how Chopra “switches” effortlessly from the bait of lifestyle changes and diet, both accepted–albeit arguably underemphasized–areas of science-based medicine, straight to woo like acupuncture and Qi Gong without citing any studies or acknowledging that none of the studies he has cited before had anything to do with acupuncture or Qi Gong, as Skeptico so astutely noted. He also makes the unsupported claim that herbs usually have fewer side effects than pharmaceuticals. Note how clever he is with this claim. He does not claim that herbs are more effective than pharmaceuticals–or even of equal effectiveness. There is, of course, no evidence that I’m aware of (or, I’d bet, that Chopra’s aware of) to support the claim of greater efficacy. Of course, the reason many herbal remedies have “fewer side effects” is because they have little or no pharmacological activity, or the effective drug within is diluted with all sorts of other contaminants from the plant. Indeed, as David Kroll pointed out, the reason scientific medicine moved toward isolating purified chemicals from plant extracts rather than using the extracts or plants themselves is because using the plants was too hit-or-miss, with variable potency from lot to lot and variable contamination from lot to lot, one reason why we don’t prescribe bark for cancer, as David Kroll put it. Meanwhile, these days many herbal remedies are contaminated with lead and other heavy metals.

As for the part about “joy, pleasure, and freedom,” that’s just a non sequitur. There’s no reason that anyone taking advantage of the fruits of scientific medicine can’t also have joy, pleasure, and freedom, although the implication that Chopra is making is that one cannot, at least not without accepting his “integrative” nonsense. It’s also a clever allusion to the entire “health freedom” movement. Again, eating a healthier diet, quitting smoking, and exercise are not outside the realm of scientific medicine, and there is plenty of evidence that they have beneficial health effects. The jury’s still out on meditation, but there’s no reason to doubt that “having more love in your life” makes your life better, regardless of whether it does all the other wonderful things that Chopra attributes to it, including his brilliant (from a marketing standpoint) implication that accepting his favored CAM/IM interventions will lead to better sex.

Ironically, however, there is one statement Chopra et al make that I actually mostly agree with, but not in the way they mean it:

It’s time to move past the debate of alternative medicine versus traditional medicine, and to focus on what works, what doesn’t, for whom, and under which circumstances. It will take serious government funding to find out, but these findings may help reduce costs and increase health.

I agree almost 100%. The part I don’t agree with is that it will take “serious government funding to find out.” Chopra’s implication is that more money will be needed, but between NCCAM and the National Cancer Institute’s Office of Cancer Complementary and Alternative Medicine (OCCAM), the U.S. government already spends a quarter of a billion dollars a year studying “alternative” medicine. Adding more money would be throwing good money after bad. In fact, from my perspective, there is nothing that NCCAM or OCCAM does that couldn’t be folded into the Institutes and evaluated in normal scientific study sections. Well, there is one thing that NCCAM does that couldn’t be done by Institutes, and that’s the promotion and encouragement of CAM/IM in academic medical centers. Losing that function would be a good thing. In any case, I do agree that we should move past “alternative medicine” and “traditional medicine” (although it is really “alternative” medicine that is “traditional,” given that the vast majority of it is based on either religion or a prescientific understanding of disease). Instead, we should concentrate on medicine that has been scientifically tested and found to be efficacious and safe versus medicine that is either untested or has been tested but has failed the test. Unfortunately for Chopra et al, other than their co-opted therapies (diet, exercise, etc.) the vast majority of so-called “alternative” medicine falls into one of the latter two categories and thus would not qualify as “medicine” if the distinction between “alternative” and scientific medicine were abolished.

Chopra’s two articles demonstrate beyond a shadow of a doubt is that advocates of unscientific medicine and quackery apologists are a potent political force, and their new strategy has become clear. With the impending inauguration of Barack Obama as the President of the United States, they see a huge opportunity in his plans to overhaul the government health care system to insert into legislation provisions that will pay for unproven and pseudoscientific CAM/IM modalities. They will sell these provisions as “reform” and as “health maintenance,” when they represent neither. Indeed, Chopra et al make this utterly explicit in the conclusion of their WSJ article:

Integrative medicine approaches bring together those in red states and blue states, liberals and conservatives, Democrats and Republicans, because these are human issues. They are both medically effective and, important in our current economic climate, cost effective. These approaches emphasize both personal responsibility and the opportunity to make affordable, quality health care available to those who most need it. Mr. Obama should make them an integral part of his health plan as soon as possible.

No doubt this is the implicit, if not explicit purpose of the “summit” being convened by the Bravewell Collaborative with the Institute of Medicine of the National Academy of Sciences. What I can’t figure out is why the IOM and NAS are going along with this. Clearly they do not understand that they are being used to push an ideological, non-science-based agenda on the new Obama Administration. If advocates of science- and evidence-based medicine remain silent, Chopra, Weil, and the Bravewell Collaborative, along with all the other forces trying to “integrate” the unscientific with the scientific in health care may well succeed.

Posted in: Medical Academia, Politics and Regulation, Science and Medicine, Science and the Media

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28 thoughts on “Chopra and Weil and Roy, oh my! Or: The Wall Street Journal, coopted.

  1. Mojo says:

    “Sure, there were the two excellent books, Trick or Treatment: The Undeniable Facts about Alternative Medicine by Simon Singh and Edzard Ernst and Snake Oil Science: The Truth About Complementary and Alternative Medicine by R. Barker Bausell. There was even Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure by Paul Offit. However, none of these books were best sellers…”

    On this side of the Atlantic we also had Ben Goldacre’s “Bad Science”, which has had reasonable sales – 4 months after publication it’s currently ranked #16 in all books on amazon.co.uk (and #1 in the “science and nature” category, where it is outselling “The Official Highway Code” and even “The very Hungry Caterpillar”), and was in the Sunday Times non-fiction paperback top 10 a couple of weeks ago.

  2. marilynmann says:

    Great post.

    “Fortunately, Tom Daschle, the upcoming Health and Human Services Secretary is better informed than either the WSJ writer or those who dictate WSJ editorial policy.” What are they talking about? It was an op-ed, written by someone unaffiliated with the WSJ.

    “IM, an abbreviation which, I don’t think coincidentally, is the same as that for internal medicine.” I don’t get this.

  3. Fifi says:

    Rupert Murdoch bought the WSJ, expect more Foxy news and infotainment of this kind as he slowly dismembers it. Pity, WSJ was pretty much the last American newspaper that had intelligent reporting. Expect it to die a slow and sad death as Murdoch tries to squeeze a profit from it and leave his “mark”. Really, those who want people mired in unreality based thinking don’t make right/left wing distinctions – they’re as happy to sell people the idea they’re new age “new science” rebels (particularly attractive to boomers and younger technofetishists) as they are that they’re righteous footsoldiers for God (evangelicals). Though Murdoch doesn’t actually sound self aware enough to truly know what he’s doing – he’s just a man/boy from a rather obscenely privileged Sydney family who likes to pretend he’s an Aussie battler (street fighting, self made man – the Australian archetype of the underdog). Australian men of a certain generation tend to like to see themselves this way – no matter how much a part of the establishment they and their families are. It’s like how James Packer (another Australian media baron from an elite Australian family) flirted with Scientology – there’s a desire to claim both the privileges of the elite establishment AND to be seen as a heroic, self-made man (not a lot of reality based thinking going on in the Murdoch or Packer households to begin with really – though Packer did drop out of Scientology and it’s really his old man Kerry who was the equivalent of Murdoch). Murdoch’s old, he’s thinking about his image and legacy and, being an Australian male of a certain vintage, being seen as a “maverick” that battles “authority” is something he sells because he believes this of himself and would like others to see him in this way.

    It’s been interesting watching George Bush trying to distance himself from the Christian right as he leaves office when he used them to get in. It’s interesting watching Obama pander to them now while also trying to distance himself them in other ways. I suspect there will be a groundswell of pseudoscience being pushed in the next couple of years as there’s an attempt to sell technological solutions to issues that are social and systemic in nature. Combine the glut of aging boomers with the nature of those who control most of the media and it’s almost inevitable.

  4. David Gorski says:

    Actually, the WSJ editorial page was pretty wingnutty long before Murdoch took over. One of the things about the “old” WSJ was that its reporting was top notch, while its editorial page was in essence a right wing echo chamber. However, there was a very strong wall of separation between the news reporting and editorial divisions, so that the politics of the editorial division generally did not dictate or contaminate what the news division reported.

    In any case, the conservative bias of the WSJ in its editorial pages may be that’s why Chopra didn’t repeat his complaint about the “right” trying to “stifle” health care “reform.”

  5. Dr Benway says:

    How do we help the public to understand that the alt.med argument is about evidentiary standards?

    Sadly, pre-rational, associative thinking is normal for humans. Enormous marketing effort over three decades has paired “alternative medicine” with preventive strategies and everything that isn’t prescription drugs or surgery. A moments reflection proves this dividing line false. Traditional doctors do not limit themselves to drugs and surgery.

    Evidentiary standards. There must be some way to help the public understand the fight.

  6. Fifi says:

    Dr Gorski – Thanks, I generally only tend to read news articles about things I’m specifically interested in not the editorials – I’m expecting it to get generally crappier at WSJ. However, I think that sort of points to the fact that there’s not much difference between left/right when it comes to CAM and unreality-based thinking, once again it’s the illusion of choice (much like Dem vs Repub is the illusion of choice, the only real difference being what social values they pretend to wear to disguise themselves as being different).

  7. Karl Withakay says:

    As I read this post, it occurred to me what really frightens me about “CAM” becoming mainstreamed and integrated with scientific medicine.

    It’s not the altruistic concern that people other than myself may suffer the consequences or expense of substituting CAM for legitimate medicine (or of delaying scientific medical treatment in favor or CAM), and it’s not the concern that my group health care premiums might go up as my insurance company covers more CAM modalities such as acupuncture and chiropractic in addition to services they currently cover.

    What really frightens me, now that I think about it, is that at some point, CAM is could become so mainstreamed and integrated, that my insurance company will force me to use “CAM” treatment instead of ponying up to pay for real medical therapy.

    If I have a medical condition for which I need some medical intervention, I don’t want to have to try acupuncture, chiropractic, or homeopathy because that is all my insurance company is willing to pay for.

    I could easily see insurance companies seeing integrated “CAM” as an opportunity to control skyrocketing costs. If such CAM modalities become integrated into accepted medical practice, insurance companies could claim they are viable options for treatment and should only be distinguished from other treatment options based on cost, as they would already be accepted as effective based on their inclusion into mainstream medicine. If it’s no longer alternative, it’s now just medicine.

  8. Joe says:

    Dr Benway on 12 Jan 2009 at 11:33 am asked “How do we help the public to understand that the alt.med argument is about evidentiary standards?”

    I am not sure that one can. However, I think you can get the message to legislators by op-ed notes, and articles, in major news outlets.

    When I have contacted irresponsible news editors, “I am not a doctor” usually ends the conversation. Damned annoying when I am taking-on antivaxers.

  9. wertys says:

    Politicians and their advisers usually monitor letters to editors and talk-back radio for opinions that are being expressed. Although you may not generate much response from the newspaper itself, it will usually be seen by policymakers if a consistent message is coming through..

    I totally agree with KW, this is the ultimate nightmare of ‘integrative medicine’, that non-clinicians will actually start recommending woo instead of traditional health care to save costs. That will be when we know we have lost.

  10. pmoran says:

    Informing the public about the do’s and don’ts of a healthy lifestyle can be achieved in much more cost-effective ways than erratic, expensive, mainly late in life, one-on-one encounters with any kind of medical practitioner, holistic or no.

    The information is simple, teachable by the non-expert, and most appropriately within the home, in schools, on TV and the ‘net, and it should be constantly reinforced by the same means.

    The REAL problem is how to get people to actually follow through on the advice, especially when young and not yet aware of one’s vulnerabilities . Nearly everyone has the knowledge, or can find it if so motivated, but there are potent counter-influences: often unsatisfactory habits in the home, peer pressure and the attractions of less healthy foods.

    Let us hope Governments understand this.

    This is also the gauntlet to throw down to the Chopras and Weils. We know from bitter experience how trying to argue out the science will leave most of the public, the media, politicians, and other authorities still unsure as what to think. We scientists take upon ourselves the difficult task of establishing certainties, or as near to that as can ever be reached, whereas “alternative” medical products and ideas have proved that they can flourish on uncertainty.

    In fact quackery preceded science and scientific methods. It is the terrain that science has been trying to claim over a mere century or so, not the reverse, as often claimed in these pages.

    I like Dr Benway’s wish to analyze, to get down to the root of things. But I think he is wrong if implying that quackery is simply a matter of differing scientific standards. A veneer of science helps leave possibilities open, but other factors are, I believe, far more important in the sustenance of the “alternative” marketplace for products and ideas.

    Science is OUR obsession, and we mistakenly assume that it has the same critical role for the supporters of “alternative” medicine that it has for us within the mainstream (why ever “traditional?”).

  11. Dr Benway says:

    But I think he is wrong if implying that quackery is simply a matter of differing scientific standards.

    We may be talking about different things.

    The line between medicine and pseudomedicine is defined by evidentiary standards. Any treatment proven effective according to widely accepted rules of evidence is medicine. Period.

    People who claim some treatment is proven effective without evidence are practicing pseudomedicine.

    The pseudomeds reframe the argument in many different ways – e.g., anti-bigPharma, low tech vs high tech, etc. But all these reframes are misdirections. They’re designed to confuse and mislead the public.

  12. Zetetic says:

    I noted that the majority of the responses the the WSJ article are pro-altie med. Maybe this is the wrong media to promote SBM?

  13. pmoran says:

    “We may be talking about different things. ”

    Very likely. What you say may be broadly true, but arguing out the evidence has not yet proved to be a very effective way of countering quackery. There seem to be other, stronger, influences keeping even reasonably sensible people off-balance and susceptible, despite the most exhaustive “debunkings”.

    I say “broadly true” in the above, as I think we are inclined to have a slightly romanticized view of evidence-based medicine. Our opponents, and even the fence-sitters, may sense that we are overstating the case even if they cannot spell out why.

    The underlying logic of clinical research is unchallengeable, yet in practice the acceptance of a medical treatment can depend upon quite arbitrary statistical judgments, arguable opinion concerning the quality and relevance of research and the trustworthiness of researchers, and prior plausibility often itself a subjective judgement. “Effectiveness” also needs examination, as I assume that placebo responses are not regarded as worthy of recognition.

    Then there is the fact that the vast majority of “alternative” use occurs in situations where there is no entirely satisfactory “working better than placebo” EBM-endorsed treatment method. What should we have to say about that?

  14. MedsVsTherapy says:

    “It’s time to move past the debate of alternative medicine versus traditional medicine, and to focus on what works, what doesn’t, for whom, and under which circumstances. It will take serious government funding to find out, but these findings may help reduce costs and increase health.”

    OK, Chopra: just like at the football game: let’s agree to a common set of rules, and play by them. When the final second ticks away, the team with the highest score wins. Moving the goalposts is not allowed. The winner is not decided by who has the craziest fans.

  15. overshoot says:

    What really frightens me, now that I think about it, is that at some point, CAM is could become so mainstreamed and integrated, that my insurance company will force me to use “CAM” treatment instead of ponying up to pay for real medical therapy.

    Tell me. I live in Arizona, so now I have to check all of the young internists I might see to find out whether they studied at a real college of medicine or are graduates of the UoA’s Andrew Weil School of Woo.

  16. khan says:

    >>Tell me. I live in Arizona, so now I have to check all of the young internists I might see to find out whether they studied at a real college of medicine or are graduates of the UoA’s Andrew Weil School of Woo.<<

    I find it annoying that I have to ‘vet’ an MD to find out if s/he is rational.

  17. wertys says:

    @khan

    At least there is a very high chance of the treatment being recommended having undergone some appropriate preclinical evaluation, even if the MD is a bit of a shruggie or outright woo-pedler.

    With crap-based medicine is only irrationality

  18. MedsVsTherapy says:

    “I find it annoying that I have to ‘vet’ an MD to find out if s/he is rational.” Agreed.

    Here is my method: ask their reason for choosing a diagnosis. Ask them their reason for choosing a specific intervention. Ask what the alternative treatments are, and ask what the risks would be of waiting versus beginning treatment.

    Think about it: for any acute or chronic conditions you have had or if you have kids, that your kids could have, you yourself as patient should have some kind of answer to these. You should, to some degree, know differential diagnosis. You should know the various treatment options and why one was chosen from amongst the others. You should be able to answer either why you might wait, or why you might really avoid waiting.

    These are perfectly reasonable questions. If your doc falters, it is because patients typically do not ask them. If your doc fails to answer your questions, spend your money elsewhere.

    I think a warning sign is when a doc gets hostile or dismissive when confronted with these questions. For the doc, it is just a day at the office. I understand that it can be frustrating for each patient to ask the same musguided or ingnorant questions. But for me, each new medical problem is a drastically notable and unusual new experience for me. Being hostile or dismissive means either a doc does not appreciate how this is all new to me, or truly is not strong in their knowledge on the issue. (As some posts here at SBM have indicated, the woo docs tend to bristle when you question them.)

  19. cooldaveb says:

    Two of Chopra’s comments provoked in me a nauseating anxiety about the future, mitigated only by the realisation that I don’t live in the USA (but you Americans dominate the research, so we’d end up having to read your wooified papers if his horrifying intentions came to pass).

    1. He has already renamed the US health system “the US health and wellness system”. Just imagine for a second, the CAM weasel-word “wellness” enshrined in public health policy.

    2. His main selling point for the use of CAM in national health policy is its affordability (or “cost-effectiveness”) for a cash-strapped government. Isn’t that what Mao Tse Tung did? Millions can’t afford real medicine, so let’s promote acupuncture? How did that work out for the health of the Chinese?

  20. dsrileymd says:

    To cooldaveb,

    If you read Chinese history you fill find that Mao actually tried to ban acupuncture because of its role in pre-communist China. And there are differences between the styles of acupuncture practiced by those trained in pre-Mao China with those who studied the acupuncture style (primarily TCM) that emerged after Mao’s attempt to purge acupuncture from China failed and it resurfaced.

  21. Jurjen S. says:

    The impression I got was that the CPC tried to eradicate TCM after they’d taken power in 1949, but found that they didn’t have the means to provide SBM on anything even vaguely resembling an adequate scale, they fell back on TCM as a means of providing mass health care (though those senior party members who had access to SBM stuck with that, Mao included) in the early 1960s, with TCM’s importance being further enhanced during the Cultural Revolution.

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