Oct 02 2009
Editor’s note: Kausik Datta, Ph.D. is postdoctoral research fellow at the Johns Hopkins School of Medicine. He works in immunology, specifically as related to two major mycoses (Aspergillosis and Cryptococcosis). Rationality and skepticism have been his long-standing interests, which led him into science- and evidence-based medicine. This is his first contribution to this blog.
Quackademic ‘Medicine’* is a collective of pseudoscientific, data-free, evidence-less, nonsensical therapeutic modalities (the so-called “alternative” therapies) – otherwise known as “complementary and alternative” medicine (CAM) or integrative or holistic medicine. These include, among other things, chelation therapy (for autism and cardiovascular diseases); chiropractic; use of random nutritional supplements; abuse of various prescription drugs; coffee enemas; naturopathy; homeopathy; reiki; energy healing that invokes manipulation of ‘life force’ or qi; acupuncture; ‘healing touch’, and intercessory prayer – the list goes on, since there is essentially no limit to human stupidity and no depth that the human mind cannot plumb.
Qualified professionals – those who are in the business of doing the hard work of science to gather critical evidence regarding the action of a therapy, as well as those who implement those modalities routinely and save lives – may perhaps find it easy to dismiss the proponents of quackademic medicine as an ill-informed, misguided, or downright lunatic, fringe. However, much like a bad case of household mold infestation, this community with its myrmidons continues to thrive and grow, impervious to reason, immune to evidence, unable to comprehend the danger they pose (and the harm they cause) to themselves, their children and millions of others on the planet. As discussed in the science blog Respectful Insolence, a large part of that harm derives from their promotion of unfounded (and repeatedly proven to be untrue) fears of vaccines causing autism, discouraging a lot of parents from vaccinating their children and prompting many of them to seek quack treatments (some of which are potentially dangerous) to try to ‘cure’ autistic
children. But still another part – a far more pernicious and pervasive one – has to do with the growing presence (and, it seems, acceptance) of quackademic pseudoscience in establishments of mainstream academic medicine.
Most holistic medicine systems (of which CAM, in its current avatar, forms a part) were developed in pre-scientific cultures at a time when important tenets of modern medicine were not around, such as the germ theory of infectious disease (the basis for myriads of successful public health measures), in-depth knowledge of anatomy, physiology and biochemistry, and most importantly, the scientific method, including basic research, evidence-based medicine and clinical trials. Modern medicine emerged in the late 19th century, after much struggle with the existing alternative therapeutic practices. In modern times, much of the holistic medical systems have directly borrowed from outmoded, outdated, often incorrect, and mostly ideology- or religious faith-based concepts from the pre-modern medicine days; but a signficant part of the CAM movement has taken a different approach, euphemistically called ‘biomedical treatment’. This term has caught the fancy of the alternative medicine crowd, particularly those of the ‘vaccine-causes-autism’ flavor. In this approach, they take various substances of biological or biochemical origin at random – such as various amino acids (or chemical modifications thereof), vitamins, chelators of divalent cations (such as EDTA), enzymes and other nutritional supplements, probiotics, and so forth – and put them into the body of the so-called patients (including autistic children) through various routes. Of course, not only there isn’t a shred of evidence that any of this, alone or in combination, actually works to ‘cure’ anything (including autism), this approach unerringly reveals a profound ignorance of physiology and biochemistry of any healthy or diseased systems, as well as an egregious lack – on part of the CAM practitioners – of caring and empathy with the recipients, who are nothing less than victims of negligence and abuse, for unregulated alternative medical practices can turn quite deadly. And for the conspiracy theorists amongst the CAM crowd who insist that all medical research is sponsored the evil pharmaceutical companies whose only goal is taking people’s money, CAM therapies of various flavors can easily run upto thousands of dollars every month.
If CAM is all holistic medicine, why this insistence on using biochemical substances of doubtful provenance? Ah, therein lies the nub of the affair. All form of CAM practitioners, all purveyors of pseudoscientific nonsensical modalities, crave, above all, the veneer of legitimacy and respectability. They have been steadily pushing for that for quite some time now. The CAMsters desire to camouflage their ignorance and weird beliefs with science-y sounding ideas and concepts, so that their quackery is considered science without them having to go through the hard, often ill-remunerated, work that is the scientific method. As David Gorski has indicated in his post, the CAM crowd starts by co-opting and corrupting the language of science, resulting in scientifically untenable concepts (such as chelation therapy, and ‘detoxication’, an extremely popular term with the CAM followers), unethical practices (such as injection of untested stem cells into cerebrospinal fluid), oversimplified theories (such as gluten-free/casein-free diet fixing a “leaky gut”, when, in reality, the “leaky gut” is an extreme and potentially lethal stage in the progression of Celiac disease, a genetic condition), and so on. Next step in pushing CAM is to produce and publish in journals that appear to contain science, but not quite, as if an article in print were an automatic ascension to credence and respectability. And now to complete the circle, the CAMsters are holding meetings that have all the trappings of a scientific meet; this includes a recent meeting of a vaccine-denying, autism -pseudoscience-promoting group, that is to be held at the University of Toronto, an institution with a rich history of quality medical education and research (see below). This begs the questions: (a) Is the University of Toronto a willing accomplice to this woo-mongering, or has it been duped? (b) Is there a growing acceptance of pseudoscience at premier medical centers in North America? To answer, first a small history lesson:
Though modern medicine began its steady journey in the late 19th century, institutionalization of medical education and teaching in the United States did not commence until after 1910. Prior to that, medical education and practice in the US left a lot to be desired, with poor standards of training, understaffed and inadequate medical schools, wide disparity in their curricula, methods of assessment, and requirements for admission and graduation. In 1908, the Council on Medical Education of the American Medical Association commissioned the Carnegie Foundation for the Advancement of Teaching to survey the state of American medical education and suggest reform measures wherever necessary. The job was entrusted to Abraham Flexner, a professional educator with the Carnegie Foundation, with experience of the education system in continental Europe. He visited all of 155 medical schools in existence in North America at that time, and compiled a report in 1910, which made several bold recommendations (discussed here) that forever changed the structure and practices of American medical education and medicine in general. In his report, Flexner came down hard on various forms of ‘alternative’ medicine whose scientific validity was questionable, even recommending closure or loss of accreditation and underwriting support for such medical schools as offered training in those. On the other hand, several schools received praise for excellent performance, including the Harvard Medical School, Case Western Reserve University, McGill University, University of Toronto, and especially the Johns Hopkins University School of Medicine – the latter being described as ‘model for medical education’.
It is important to re-emphasize at this point that we are talking about premier medical education and research institutions, institutions that should necessarily distance themselves from pseudoscientific approaches on doubtful provenance and non-existent efficacies, or at least provide truthful information (as the Mayo Clinic has done). These are the institutions that should additionally recognize that ideology- or faith-based approaches to medicine, lacking evidence or any kind of rational justification, often engender false hope, leading the patients, their friends and family members through a deplorable waste of time, effort, energy, as well as of money. Therefore, we can perhaps reasonably expect them to be at the forefront of the scientific community’s battle against the proliferation of ignorance, delusions and pseudoscientific mumbo-jumbo, can’t we?
Erm… No, it appears!
In a thoughtfully presented report in 2008, the US News and World Report mentioned that:
All 18 hospitals on U.S. News’s 2008 “America’s Best Hospitals” superselective Honor Roll provide CAM of some type. Fifteen of the 18 also belong to the three-year-old Consortium of Academic Health Centers for Integrative Medicine, 36 U.S. teaching hospitals pushing to blend CAM with traditional care… Each center has its own notion of CAM and how best to fit it into the medical mix, which can be challenging. “There is rarely a consensus among CAM experts on the optimal product, dose, or intended users,” states a report from the National Center for Complementary and Alternative Medicine, an arm of the National Institutes of Health charged with doling out research funds and tidying the thicket of therapies deemed to fall within CAM’s broad reach.
The report also observed that:
At one extreme are found techniques such as yoga and massage, acknowledged by the most hard-line skeptics to have some benefit, if only to lower stress and anxiety. At the other are therapies that even many who applaud CAM’s new-found academic popularity call “woo-woo medicine” because of the sheer implausibility of their rationale. Homeopathy, which involves remedies often lacking a single molecule of active substance, is the poster child; some would add energy therapies such as healing touch. The broad middle takes in acupuncture, herbal medicine, and other CAM approaches that seem to benefit some people with certain conditions.
Until the mid-1990s, most academic centers treated CAM like a pack of scruffy mutts, noisy and unworthy of notice. A large pot of federal and foundation research funds—now close to $250 million per year just from NCCAM and the National Cancer Institute, plus tens of millions more from private donors such as the Bravewell Collaborative—helped turn that sniffy attitude into solicitous attention, says longtime CAM commentator Donald Marcus. “The funding gave them respect from the medical school community,” says Marcus, a professor of medicine and immunology at Baylor College of Medicine in Houston, where he has long taught a CAM course.
As mentioned above, many of the premier universities of the US now sport Centers for studying “integrative medicine” or CAM. Most of these centers are engaged in legitimate research work dealing with some psychological studies among HIV positive patients and yoga-breathing techniques for alleviation of chronic fatigue in cancer patients (The Osher Center for Integrative Medicine of the University of California at San Francisco); chronic pain management (as in cancer patients), including animal modeling and mechanistic studies related to genesis, metastasis and treatment of cancer (Johns Hopkins Center for Complementary and Alternative Medicine), and so forth. But not all. At the Cleveland Clinic, for example, NIH money has been poured into a clinical trial to investigate the effect of reiki, an “energy therapy”, in reduction of stress and anxiety in prostate cancer patients. The integrative medicine program at Children’s Memorial Hospital in Chicago, the principal pediatric teaching hospital for Northwestern University’s Feinberg School of Medicine, is involved in various types of unconventional therapy, and David Steinhorn, MD, a pediatric intensivist and medical director of the hospital’s CAM program, indicates that several privately funded trials are underway or in the works. According to the US News report, Steinhorn is a passionate champion of investigating CAM therapies, no matter how unlikely, if he believes they may help patients and are safe. “I’m a very serious, hard-core ICU doctor, but I have seen these therapies benefit my patients, even if I don’t know how,” he says. Other elite centers like the Mayo Clinic, Duke University Medical Center, the University of California San Francisco, University of Maryland School of Medicine, the Johns Hopkins University School of Medicine, and others now offer acupuncture, massage, and other CAM services.
It is often claimed in CAM literature that a few CAM treatments have demonstrated at least modest results. Massage shows promise for relieving postoperative pain. Studies were done demonstrate that acupuncture is somewhat effective at relieving nausea from chemotherapy or surgery and discomfort from dental procedures. It is used at Memorial Sloan-Kettering Cancer Center in New York, among others, for relief of chemotherapy-related nausea, and at many centers for chronic pain – from arthritis, for example. Clinical trials are still going on to determine the efficacy of acupuncture in a variety of different situations involving post-operative nausea and vomiting. However, analyses of reported studies on acupuncture/acupressure, as well as subsequent studies, have demonstrated (a) no effects on the natural history of any disease, (b) disappointing results in acute and chronic pain management, and (c) no evidence for a specific peri-operative antinausea or antiemetic effect (extensively reviewed here, here and here).
Perhaps it is a matter of great irony that schools named in the Flexner report of 1910 as paragons of virtues in medical education have all now embraced pseudoscientific, evidence-free therapeutic systems with great alacrity. I wrote above how University of Toronto seems to have bought into the autism-pseudoscience business. Harvard employs amongst its faculty Dr. Martha Herbert, who is known for her grandiose claims (completely unsupported by any evidence) that neuroinflammation is a major cause of autism, and that molds and other environmental influences trigger it; she is also very popular amongst the anti-vaccination crowd. McGill University of Canada, by far the sanest of all these, recently launched a searchable database of outcome measures intended for CAM researchers – the IN-CAM Outcomes Database – as a collaboration between its Health Centre Research Institute and the University of Calgary. Interestingly, Eric Fombonne, MD, the Head of the Division of Child Psychiatry at McGill and Director of the Department of Psychiatry at the Montreal Children’s Hospital, and a leading authority on Autism Spectrum Disorders, is the author of studies that showed (a) no difference in mercury levels between autistic children and the general population, thereby invalidating the entire chelation therapy business, and (b) no link between MMR-vaccine and autism, but one doesn’t – of course – find a mention of these studies in autism-pseudoscience literature.
I was particularly outraged by the description of a severe woo-woo infestation at the Johns Hopkins School of Nursing. Their Spring 2007 magazine was quite illuminating (the PDF of the issue here):
In an effort to broaden their methods for healing, Johns Hopkins nursing faculty and students are increasingly looking outside the scope of conventional training to explore Complementary and Alternative Therapies… techniques like massage therapy, acupuncture, meditation, yoga, herbs, Reiki, aromatherapy, and others that fall under a broad category of healing systems and methods called Complementary and Alternative Medicine (CAM)… At the Johns Hopkins University School of Nursing, the Introduction to Complementary and Alternative Healthcare has become a popular choice among students since it was first introduced in 1998…
As an evidence of the extent to which CAM has been institutionalized, faculty and students of the JH School of Nursing may also attend lectures and workshops (’at reduced rates’) at the Tai Sophia Institute, in Laurel, Maryland, which offers courses and master’s degree programs in acupuncture, herbal medicine, and applied healing arts.
Says Lori Edwards, MPH, RN, APRN, BC, who teaches the Introduction to CAM course, “Nursing students should be learning about CAM because the patients nurses are working with are using these modalities.” However, rather than discouraging these unproven, unscientific practices, the nurses are encouraged to “…teach patients how to blend alternative practices with conventional medical care…” In her course, Edwards discusses the four categories of CAM, as designated by the NCCAM: mind-body methods (such as meditation, yoga, and prayer); biologically-based methods (such as the use of herbs or homeopathy); manual healing methods (massage, acupuncture, and chiropractic care); and energy therapies (Reiki). Nursing School Faculty member Carol Libonati, MS, APRN, BC, CS-P, is a practitioner of Reiki, and uses a series of hand positions done either just above or directly on the body to restore “the normal energy flow”. According to her, “a subtle energy flows from the practitioner into the client, and the energy creates a healing effect.” Let me emphasize that: Prayer as medicine, Homeopathy, reiki – all under official sanction. The fact that there is an absolute lack of evidence that any of this works, ever, seems to have been conveniently dismissed.
It also turns out that according to a US Government report (from the NCCAM, no less), Complementary and alternative medicine such as acupuncture, herbal supplements and meditation are big business in the United States, totaling nearly $34 billion in out-of-pocket spending annually (giving the complete lie to the ‘pharma shill’ gambit that CAM proponents like to use to denigrate scientists working in mainstream medical research). And that is hardly surprising, considering how the Senate working groups on prevention and public health (Sen. Tom Harkin, D-IA) – yes, that Tom Harkin – and health care quality (Sen. Barbara Mikulski, D-MD) are tirelessly working to institute a system that rewards health promotion, wellness and quality in health care delivery in order to restore the vitality of American lives and also save money, which is why they invited two acupuncturists from the Tai Sophia Institute in Laurel, MD, to testify before the Senate Committee on Heath, Education, Labor and Pensions (HELP) and “share their recommendations for policy changes to help put the American health care system on the path to wellness“.
Oh, the insanity of it all!
A recent article in the New York Times reported on how the Mercy Medical Center in Merced, CA, has been employing Hmong Shamans for the benefit of their large Hmong (from Northern Laos) patient populations. Because many Hmong rely on their spiritual beliefs to get them through illnesses, the hospital’s new Hmong shaman policy, the country’s first, formally recognizes the “cultural role of traditional healers, inviting them to perform nine approved ceremonies in the hospital, including “soul calling” and chanting in a soft voice.” Traditionally, the Hmong fear Western medicine; in their belief system, surgery, anesthesia, blood transfusions and other common procedures are taboo. Therefore, the new Shaman-liaison program has been devised to defuse that fear and to provide a culturally sensitive context. The shamans are allowed to perform healing rituals, going into trances for hours, negotiating with and warding off evil spirits, and protecting the patient’s soul from being kidnapped by some dead near-relative.
I admit I felt uneasy about this. Granted, not many would see a huge problem with this. The Hmong are being given the same access as their clergy as with other religions. To many it would seem a rather reasonable compromise to get patients in sooner for proper care through scientific medicine, and that is being equitable to the people of this culture. I am just not sure that the best interest of the Hmong is served this way in the long run; perhaps it would serve the Hmong better to train their Shamans to dispel the fear and distrust about modern medicine and procedures amongst the Hmong community. My concern, upon reading that NY Times article, was more generalized, more to do with the fact that unreason and irrationality, in various forms, have crept in (and are continuing to do so) our hospitals and medical institutions, and general institutional policy seems to be restricted to encouraging that – not taking proactive steps so as to ensure that people (not just the patients, but ‘prospective’ patients as well) are not held in thrall to the said unreason and irrationality. Consider the instances of the reiki and Prayer Healing performed by nurses in some hospitals, including the Johns Hopkins. The patients obviously want those, and the nurses justify those pseudoscientific
procedures as ‘connecting’ to those patients through their cultural beliefs. And therein lies the slippery slope. I guess the question is: if and when a so-called cultural belief is mired in superstition, misinformation and ignorance, how far should an institutional policy go to pander to such a belief just because it is considered culturally appropriate? Where to draw the line?
Make no mistake about it: irrationality is like a cancer. Unless diagnosed early and treated aggressively, it will eventually overwhelm the system. The science-based medicine community must take cognizance of the potentially harmful effect of pseudoscience on humanity, and fight it at every step with reason, and evidence, and a heaping helping of scorn that it rightfully deserves.
* – The first time I came across this fantastic and apt term was in RW Donnell’s blog. If he has indeed coined it, a tip of my hat to him for a job well done!!
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