Apr 03 2009
Several years ago I stumbled upon disturbing information regarding my alma mater, the Harvard Medical School (HMS).† Its professed commitment to investigate implausible medical claims had somehow metamorphosed into the advocacy of such claims. I’ve previously mentioned some of this on SBM (here and here). A couple of pertinent essays appeared in the public domain in 2002 and 2003, but the full story was much more involved than those pieces revealed. In the wake of recent posts on SBM about medical schools exposing students to uncritical portrayals of pseudomedicine, it seems appropriate to tell more of it. I’ve also decided to name names, which is something that I would have been reticent to do a few years ago. The basis for that decision will become clear over the next few posts, I trust. This topic will require at least three posts.
My discovery that HMS had begun promoting pseudoscientific medical claims was occasioned by my experience on the Massachusetts Special Commission on Complementary and Alternative Medical Practitioners, which met from the fall of 2001 to the winter of 2003. Another member of that commission was David Eisenberg, the Director of the Harvard Medical School Center for Alternative Medicine Research and Education (CAMRE) and of the new Osher Center for Complementary and Integrative Medical Therapies. Dr. Eisenberg is best known for his 1993 article reporting the use of ‘unconventional therapies’ by Americans. He had been appointed to the commission by the MA Commissioner of Public Health at the time, Dr. Howard Koh–whom President Obama has recently nominated to be Assistant Secretary of HHS. I assumed then, and still do, that Dr. Koh presumed Dr. Eisenberg to be an objective expert on “CAM,” since that was the persona presented by HMS and by Dr. Eisenberg himself. I had my doubts, but before then I’d not bothered to look into the matter.
It was during commission meetings, when I had the opportunity to hear what Dr. Eisenberg and his surrogate had to say or not to say and when I examined some of their writings and funding sources, that I began to realize how far his project was deviating from what I imagined to be the agenda of HMS. Some of what I saw amounted to frank dishonesty: failure to disclose obvious conflicts of interest to the Commission, for example. I also discovered public promotions of dubious “CAM” practices and practitioners by the CAMRE, in spite of its formal purpose being that of investigating “CAM” practices in an attempt to find out if any might be useful. I was concerned enough to look at other “CAM” information offered in the name of Harvard, and I found more worrisome examples.
I also attended the Feb., 2001 Harvard Complementary and Integrative Medicine Course, directed by Dr. Eisenberg (here is a link to the similar 2002 course brochure). A few of the talks were reasonable, if banal. I did my best to give them the benefit of the doubt, because I still could not accept that HMS would seriously consider homeopathy, ‘life-force,’ and ‘subluxations’ as being worthy of study, much less advocacy. After attending a semi-rigorous talk on raw herbs as medicines (the presenter discussed some studies but not the looming question of why whole herbs might be preferable to purified molecules), I ran into Eisenberg and did my best to be polite and encouraging. I shouldn’t have, because most of the content of the course was misleading and pseudoscientific. Overall, its tone was more like a political rally or a religious revival than a scientific conference.
At that course I ran into Russell Phillips, who had been in my group of interns at the Beth Israel Hospital (Boston) in 1979. I’d seen him around from time to time over the years, and I’d known that he’d stayed on at the BI after his residency. I was surprised, however, to learn that he was now the Director of the Harvard CAMRE Fellowship program. I was even more surprised to learn, during a short conversation with him, that he was innocent of the chiropractic ‘subluxation theory’ and that he’d never heard of Quackwatch. It seemed to me that there was either a surprising naivete among this crowd or an attempt by some to shun unpleasant information.
I discussed these issues with Arnold Relman, the only other skeptical physician on the Commission. Dr. Relman was the emeritus Editor-in-Chief of the New England Journal of Medicine and Professor Emeritus at HMS. He agreed with me in every detail, even offering a terse explanation for why HMS would tolerate such folly: “The five-dollar word is ‘pusillanimous’.” Naively, I hoped that Dr. Relman would use his clout to lead a vanguard of reason back to HMS, and that the matter would be short-lived (I based this expectation on Relman’s recent demolition, in the New Republic, of Andrew Weil’s writings, which suggested to me that he would warm to a fight closer to home).
Dr. Relman, however, wanted little part of any formal complaint to HMS, stating that he had “other fish to fry” and warning that battling quackery was a bottomless pit that would consume me if I insisted on pursuing it. He also must have known something I didn’t yet know: that the “CAM” epidemic had already made zombies out of some at the highest levels of the HMS administration. Nevertheless, Dr. Relman eventually supported me in some very important ways, for which I’m grateful.
I decided to approach Dan Federman, then the Senior Dean for Alumni Relations and Clinical Teaching and the highest ranking member of the HMS administration whom I still knew from my medical school days in the ’70s. Dr. Federman, an endocrinologist, had been a role model for me and for many other students: he was a paragon of kindness, knowledge, rational thinking, and ability to communicate. It seemed to me that he couldn’t possibly be duped by the “CAM” machinations going on right under his nose, if only he knew about them. He had been quoted, when HMS announced the creation of the CAMRE in the summer of 2000, as follows:
The primary function of the new division is to coordinate research and evaluation of alternative and complementary remedies and approaches at Harvard Medical School,” says Daniel Federman, M.D., HMS Senior Dean for Alumni Relations and Clinical Teaching. “When research using standard methods of assessment has demonstrated effectiveness, there should be no need for the term complementary; and when it does not, support for such claims should be withdrawn. This is a large research agenda that will occupy much effort. At the same time, we will be teaching our students how to understand and evaluate complementary modalities and thus help their patients in a comprehensive therapeutic effort.
I first discussed the issue with Dr. Federman in the fall and winter of 2001-02, not long after philanthropist Bernard Osher had granted $10 million to the HMS CAMRE, including an endowed chair for Dr. Eisenberg. Harvard announced the grant in language similar to what Dr. Federman had said in the previous year:
The division rigorously evaluates complementary and integrative medical therapies to distinguish useful from useless treatments and to foster a rational, evidence-based introduction of complementary and integrative medical care into mainstream medical education and practice. The division concentrates on assessing the safety, efficacy, cost-effectiveness, and mechanisms of action of these treatments. Appropriate educational activities and policies pertaining to the clinical delivery of complementary medical therapies are being developed.
In retrospect, I should have recognized the last sentence of that announcement as a red flag.
Dr. Federman and I had 2-3 meetings and a few e-mail exchanges over a couple of months. He seemed appropriately concerned. He agreed that it would not do for the CAMRE to promote ‘CAM’ rather than merely perform ‘research and evaluation.’ He asked me to present him with written documentation of my charges, and promised that if it agreed with what I’d told him he would appoint an ad hoc faculty committee to investigate. I was mostly optimistic, although Dr. Federman made a comment that I found worrisome: he referred to Dr. Relman as a “zealot.”
In the late spring I sent Dr. Federman the documentation that he had requested, in the form of a draft of an article that I had hoped would be accepted by Harvard Magazine. The draft was a response to a misleading, promotional piece about Eisenberg and the CAMRE in the March-April issue (Harvard Magazine declined my offer, but published a letter instead). I’ve made minor language changes and added hyperlinks to sites that existed at the time, to the extent that they are still available. Here is part of it; the rest will follow next week or so.
Comments on Harvard Medical School’s “Center for Alternative Medicine Research and Education”
Readers of Craig Lambert’s “The New Ancient Trend in Medicine”(Harvard Magazine Mar/Apr 2002) can’t be faulted for concluding that the mission of HMS’s foray into “alternative medicine” is “the application of skeptical science to…unconventional treatments.” Even that goal is of dubious value and based on false premises, as will be discussed in subsequent parts of this article. The evidence shows, however, that a major additional goal of the project is the public promotion, ranging from implicit to explicit, of practices that are both absurd and dangerous.
Consider the following advice offered on the “information resources for consumers” webpage of the Caregroup/Harvard Medical School Center for Alternative Medicine Research and Education (CAMRE):
Please consult your local telephone yellow pages under these categories:
Massage – Therapeutic
In order to appreciate the implications of this appeal, it is necessary to examine the beliefs and practices of at least one of the recommended groups. “Naturopathic physicians” are a recent manifestation of the field known as “naturopathy,” whose origins were in the 19th century German “natural living” movement. Early naturopaths railed against contemporary medical advances such as the Germ Theory and vaccinations, but espoused the “water cure,” fasting, herbs, homeopathy, colonic “detoxification,” and other fanciful methods.
The content of the field has changed little since then, but the trappings have become distinctly modern. A subset of naturopaths now claims to practice “a distinct form of primary health care,” according to the official definition on the website of their national organization, the American Association of Naturopathic Physicians (AANP). They state that they are “primary care physicians, most of whom are in general private practice [and] trained to be the doctor first seen by the patient for general healthcare, for advice on keeping healthy, and for the diagnosis and treatment of acute and chronic conditions.”
“Naturopathic doctors” or “N.D.’s,” as they also call themselves, state that they have received training appropriate to the practice of medicine, including a basic science curriculum equivalent to that taught in medical schools. This training occurs in one of four schools in the U.S., each of which offers a four-year, on campus curriculum, but no significant hospital or residency experience. Three of the schools are unaffiliated with larger universities; the fourth, the University of Bridgeport College of Naturopathic Medicine in Connecticut, is owned by the Unification Church, known more commonly as the “Moonies.” The schools have little interaction with the scientific community at large.
Naturopaths believe in “vitalism,” the long discredited notion that biological processes don’t conform to universal physical and chemical principles. They claim to “treat the cause of a problem, rather than to merely eliminate or suppress the symptoms.” They claim to know how to “boost the immune system” with herbs and homeopathic preparations. They claim to have esoteric knowledge about preventive medicine that is, implicitly, unknown to “conventionally” trained physicians, public health experts, nurses, nutritionists, and others. They claim special expertise in nutrition and in the use of “natural remedies.”
What is the reality of these claims? Naturopaths invoke a few simplistic “theories” to explain the causes of all disease. These include the actions of ubiquitous, but ill-defined “toxins”; widespread “food allergies”; dietary sugar, fat, and gluten; inadequate vitamins and minerals (which naturopaths offer for sale); epidemic candidiasis (yeast infections); vertebral “misalignments” (a canard borrowed from chiropractic); and a few others. To “diagnose” these entities naturopaths use an assortment of absurd methods, among which are “iridology” or iris diagnosis, which claims that the entire body is represented on the iris of the eye; “applied kinesiology” by which, for example, an “allergy” to a particle of food is detected by placing the food particle in one hand of a patient and observing a resulting weakness in the other; hair analysis; “electrodiagnosis,” which measures the skin’s resistance to a tiny electric current; “live cell analysis”; and more.
Naturopathic “therapies” are an eclectic assortment of implausible and unproven methods, among which are “colonic irrigation” (enemas) and fasting for “detoxification,” hydrotherapy (wrapping part or all of the body in wet towels), homeopathy, acupuncture and “oriental medicine,” chiropractic manipulation, aromatherapy, arduous dietary schemes, intravenous vitamin C and hydrogen peroxide, whole enzyme pills, and other dubious “natural remedies” including botanical, animal, and mineral products, several of which are known to be dangerous. Naturopaths sell “remedies” to their clients at a considerable profit, an obvious conflict of interest that is formally approved by their national organization, the AANP.
How does all this translate into the practice of “naturopathic medicine?” Mainstream naturopathic literature shows numerous examples of practices and recommendations that are both absurd and dangerous. Among these are the repudiation of standard treatments of strep pharyngitis, acute otitis media, and other potentially catastrophic childhood infectious diseases, while offering instead such ineffective “alternatives” as homeopathy, hydrotherapy, and “natural antibiotics” (e.g., herbs such as Goldenseal); affiliation with the strident anti-vaccination movement; the repudiation of standard treatments of asthma, offering instead, for example, a hydrogen peroxide bath to “bring extra oxygen to the entire surface of the skin, thus making the lungs somewhat less oxygen hungry” or “gems and minerals…worn as jewelry, or placed around the home in special places”; warnings against proven medical and surgical treatments for hypertension, hyperlipidemia, and atherosclerosis, while instead recommending unproven herbs and EDTA chelation “therapy”;treatment of the acute stroke patient with damp compresses and aromatherapy; claims that NDs can diagnose chronic, debilitating diseases such as multiple sclerosis at a much earlier stage than can “conventional” physicians, and effect a cure by fanciful methods; claims that breast cancer can be prevented and cured by an assortment of unproven, expensive “supplements” and “tests” that are not appreciated by “conventional” doctors, nurses, and public health experts; ubiquitous “toxin” hysteria, including anti-fluoridation statements, warnings against most proven pharmaceuticals, and claims that “25% of Americans suffer from heavy metal toxicity”; claims that they can offer “natural childbirth” at home without complications; the exuberant promotion and sale of “dietary supplements” for all complaints, with little regard for safety; and much more. Naturopaths have not subjected these claims to rational study, because they are already convinced that they work. In summary, “naturopathic medicine” is best understood as a pseudoscientific cult.
A 1999 survey of the small number of N.D.s in Massachusetts, performed by two investigators from Children’s Hospital, is consistent with these findings. They found that only 20% of those surveyed would recommend that parents have their children vaccinated, and that only 40% would refer a two-week old infant with a temperature of 101° F (a dire, life-threatening emergency) for definitive medical care.
Is it possible that the authors of the Harvard CAMRE website are naïve about the recommendations they have made? Not likely. In 1997 David Eisenberg, the Director of the Harvard CAMRE and of the new Osher Center for Complementary and Integrative Medical Therapies, cited the 1st edition of the Textbook of Natural Medicine, the only general textbook of “naturopathic medicine,” in an article entitled “Advising Patients who Seek Alternative Therapies.” The textbook includes most of the claims documented above, but Dr. Eisenberg failed to discuss any of them. Instead of warning of the obvious dangers awaiting patients who seek “alternative therapies” from naturopaths, he blandly stated: “Naturopathy is licensed in 12 states and the District of Columbia. The AANP provides contacts for local licensing and regulatory boards and general information on naturopathy.”
In an address to the American Board of Internal Medicine, also in 1997, Dr. Eisenberg appeared to call for the nationwide licensure of naturopaths and other “CAM” practitioners:
Necessary Tools to Improve the Status Quo
· A national listing of licensed alternative medical providers (e.g., chiropractors, acupuncturists, massage therapists, naturopaths, and homeopaths) in each of the 50 states as well as a uniform credentialing process.”
If his intent had been to rein in dangerous practitioners through strict governmental regulation, this suggestion might have made some sense. It was not, as is clear from the following history.
The Massachusetts Special Commission on Complementary and Alternative Medical Practitioners
Beginning in the fall of 2000 and lasting for more than a year, Dr. Eisenberg was the official representative of the Massachusetts Department of Public Health to the Commonwealth’s “Special Commission on Complementary and Alternative Medical Practitioners.” In spite of its name, the main purpose of the Special Commission was to consider the request of “naturopathic physicians” to become licensed health care providers in Massachusetts. Two legislators friendly to the naturopathic licensing effort had urged the formation of the Commission, and both were among its members. The total membership was twelve, of whom only three were physicians. The other two physicians were Arnold Relman, representing the Board of Registration in Medicine (later represented by the BRM Chairman, Peter Madras), and I, representing the Massachusetts Medical Society. Of the remaining members, none was a scientist. The Commission was to study the naturopaths’ request and make a recommendation to the legislature.
The sort of licensure that these naturopaths were seeking would imply a tacit promise, by the Commonwealth to its citizenry, that “NDs” are legitimate health care providers whose methods have proven validity. It would give them a broad license to diagnose and treat illnesses and to call themselves “doctors” and “physicians.” They would answer to a board controlled by their own colleagues, and thus determine their own standard of care. They would be positioned in the political arena to demand third party reimbursement, as has already happened in the state of Washington. Naturopaths are now licensed in 11 states, with varying degrees of latitude for practice and self-regulation, but in all of these they are free to make broad claims of medical expertise.
Dr. Eisenberg came to only about half the meetings and largely refrained from discussing naturopathic practices. Usually he sent a surrogate, attorney Michael H. Cohen, “Director of Legal Programs, Division for Research and Education in Complementary & Integrative Medical Therapies, Harvard Medical School.” Mr. Cohen’s writings show that he is an unabashed champion of efforts by CAM practitioners to achieve legitimacy not through science, but through legal pressure. His distaste for, and misunderstanding of modern medicine is clear in this passage:
[B]iomedicine by and large perpetuates a delusional sense that a human being is only material–a three-dimensional substance locked in the physical body, amenable to mechanical interventions that are tightly controlled by a series of carefully circumscribed rules. Biomedicine encourages over-identification with the body: it is fear-based; disease induces desperation in the “race for the cure” rather than focus on “care of the soul.”
Later in the same essay he likens “biomedicine” to “sleep,” which “cannot bring us one iota closer to true reality.”
What, then, is the path to true reality in health care? Health and healing can involve the highest of which a human being is capable. Near-death experiences, encounters with angels, and events that touch the individual’s interior castle and border on mysticism-these experiences manifest ‘light,’ in the sense of coming closer to that which is Supreme at the edges of our consciousness.
In the purest sense, therapies from hypnosis to meditation aim to free the dis-eased seeker, and the culture as a whole, from the matrix of mechanism, reductionism, and other ills, to a realm where the human spirit finds rest. As Vasistha says: “Subdue the mind with the mind. Purify the mind by the mind. Destroy the mind by the mind.” When the mind is purified, the real can be grasped. Complementary and alternative therapies offer this possibility.
Elsewhere in the essay Mr. Cohen argues that prohibitions against health fraud are counterproductive, as are disciplinary actions by medical boards against practitioners who “[deviate] from conventionally agreed norms,” i.e., standards of care. In considering what the appropriate role of future health laws might be, he muses:
Would legal structures be able to handle the notion that healing involves mind, body, emotions, and spirit, but also such other dimensions of the human experience as inter-species communication and greater sense of earth-consciousness (Gaia)?
Mr. Cohen and Dr. Eisenberg helped to write the Special Commission’s pro-naturopathic licensure report, which recommends a broad license for naturopaths to diagnose and treat illnesses and to form a self-regulating board of “Naturopathic Medicine.” With a few minor exceptions, it is exactly what the naturopaths had requested. The report lacks any significant discussion of naturopathic claims per se, but clings to the superficial trappings of legitimacy such as the existence of schools, exams, accreditation, and so forth. As both Dr. Eisenberg and Mr. Cohen know, the standard of care for a self-regulating health profession is determined by that profession. Thus if the naturopathic board were to be realized it would inevitably promote, as its standards of care, substandard medical practices.
The pro-licensure report was signed in Jan. 2002 by six commissioners, including an Assistant Commissioner of Public Health who attended the final meeting in Dr. Eisenberg’s stead. An opposition report, which cited multiple examples of dangerous naturopathic claims, was signed by three, including the two remaining physician commissioners. Three commissioners abstained.
The implications of Dr. Eisenberg’s delegation of Atty. Cohen, and of his own lack of engagement in the debate at this commission, are not to be underestimated. Most of the non-expert commissioners deferred to him for guidance, but he was notably silent when the other two physicians characterized naturopathic claims as baseless and dangerous. In private, both Dr. Eisenberg and Mr. Cohen told me that I had called attention to the “excesses” of the field (of which Dr. Eisenberg said he had not previously been aware), implying that such practices don’t reflect those of the great majority of naturopathic “physicians.”
This erroneous view was somehow promulgated to others on the commission, because it was eventually invoked by the Senate Chairman of the Committee on Health Care, one of the abstaining commission members, in a letter to the rest. These practices are standard for “naturopathic physicians,” however, as evidenced by their sources: the Textbook of Natural Medicine, which Dr. Eisenberg had cited in one of his own papers, the Journal of Naturopathic Medicine, the Position Papers and other articles offered on the website of the AANP, which Dr. Eisenberg had also cited in the same paper, articles on the websites of the four naturopathic schools, and other published opinions of the “leaders” of the field.
I asked Dr. Eisenberg several times to meet outside of the din of commission meetings to discuss the issue at some length, but he declined. I subsequently wrote a letter to the Commissioner of Public Health suggesting that Dr. Eisenberg may have a conflict of interest regarding naturopaths. Dr. Eisenberg responded angrily, but did not offer any evidence to refute this charge. Below, it is shown to be true.
If Dr. Eisenberg had stressed to the commission that it must consider the irrational content of “naturopathic medicine,” the outcome might have been different. An example of the level of critical thinking that existed among the non-scientific members was this: In justifying his premature decision to end the debate, the Chairman, who is also the chairman of the Massachusetts Division of Professional Licensure, referred to arguments over scientific validity as merely a “battle of the bands,” with each side having no more claim to truth than the other. This crude postmodern relativism was not challenged by Dr. Eisenberg, who must know that dissolved oxygen can’t be absorbed through the skin in quantities sufficient to revive a suffocating asthmatic.
Does it sound as though the public health interests of the Commonwealth were well represented at this commission? Did its emissaries do Harvard Medical School proud?
This unfortunate affair is consistent with other facts of HMS’s involvement with “CAM.” Dr. Eisenberg accepts funding for his annual Harvard CAM conference from one of the aforementioned naturopathy schools, the Southwest College of Naturopathic Medicine (SCNM) in Tempe, Arizona. The school’s own list of donors is top-heavy with “dietary supplements” companies, beginning with GAIA Herbs, Inc.
The school’s Chief Medical Officer is Thomas Kruzel, ND. Kruzel claims that multiple sclerosis is caused by diets high in fat and sugar, and that naturopaths can diagnose the disease, using “tongue” and “pulse diagnosis,” at a much earlier stage than can “conventional” physicians. This, he writes, allows naturopaths to effect cures (not possible with “conventional” medicine) through a combination of homeopathy, wet compresses (to “increase oxygenation in the blood”), acupuncture, herbs, and a diet based on the patient’s blood type. Kruzel’s claims of medical expertise are broad: for cancer of the prostate he recommends “electrical current in the form of positive galvanism, applied transrectally.”
1. Textbook of Natural Medicine, 2nd. Edition (Pizzorno JE and Murray MT, eds. London. Churchill Livingstone, 1999). pp. 1463-1467
2. Textbook of Natural Medicine, 2nd. Edition. pp. 1078-1082
3. Textbook of Natural Medicine, 2nd. Edition. p. 438
4. Lee CCL and Kemper K. Homeopathy and Naturopathy: Practice Characteristics and Pediatric Care. Arch Ped and Adolesc Medicine. 2000. vol.154, pp.75-80
5. Pizzorno JE, Murray MT. A Textbook of Natural Medicine. Seattle, WA: John Bastyr College Publications; 1993.
6. Studdert DM and others. Medical malpractice implications of alternative medicine. JAMA 280:1610-1615, 1998.
Next: The Harvard CAMRE’s Director of Legal Programs and the American Association of Health Freedom
†The Harvard Medical School series:
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