Feb 09 2009
Four weeks ago (was it really that long?), I wrote one of my usual lengthy essays for this blog in which I analyzed two editorials published by some very famous advocates of “complementary and alternative medicine” (CAM)/”integrative medicine” (IM). They included one in that credulous repository of all things antivaccine The Huffington Post (no, this isn’t about vaccines, but I can’t resist pointing out at every turn the antivaccine slant of that rather famous political blog) and in the Wall Street Journal. The first, published in HuffPo and written by Deepak Chopra, Andrew Weil, and Rustum Roy, was entitled Leaving the Sinking Ship, while the second added Dean Ornish to its team, switched from the highly liberal venue of hte previous article to the conservative WSJ, and was entitled “Alternative” Medicine Is Mainstream: The evidence is mounting that diet and lifestyle are the best cures for our worst afflictions. In doing so, advocates of unscientific and even pseudoscientific faith-based medical treatments seemingly covered the entire span of political thought, from highly liberal to highly conservative, with their message.
That message, as I have argued, along with Wally Sampson, Kimball Atwood, Val Jones, and Peter Lipson, is, to boil it down to its essence, this: The new Obama Administration has promised to make health care reform one of its top priorities, and CAM/IM advocates want to take advantage of this movement for reform as the “foot in the door” behind which they try to muscle their way in to be treated by the government as co-equal with established, science- and evidence-based medicine. How do they plan on doing this? As I have discussed before, they plan on doing this by coopting disease “prevention” strategies as being CAM/IM and using them as a Trojan horse. When the government brings the giant wooden horse into the fortress of government health care, along with the bona fide prevention strategies of diet and exercise a whole lot of woo will jump out of the belly of that horse and open the fortress doors to let in its comrades. Indeed, the same strategy can be seen in how CAM/IM advocates have coopted the Institute of Medicine with a joint conference.
In other words, because CAM/IM advocates have succeeded so well in tying the perfectly acceptable science- and evidence-based modalities of diet and exercise, as well as ghettoizing the respected pharmacology discipline of pharmacognosy by associating it with herbalism and, in essence, bringing it under the CAM umbrella, where it became unfairly and incorrectly tainted with its association with all the other woo that falls under the CAM/IM mantle, they expect that renewing an emphasis on diet and exercise by their definition and on their terms will lead to the opening of the door into the promised land of having their modalities be funded by the government. It’s a very conscious strategy, which is why Chopra et al’s articles so clearly tried to convince readers that diet and exercise are CAM/IM. Unfortunately, that they are able to do this with such success is in part because science- and evidence-based practitioners arguably underemphasize such health prevention strategies.
I learned of another salvo fired off by CAM/IM advocates through my somehow finding myself on the mailing list for The Mary Ann Liebert, Inc. family of medical journals. Unfortunately, one of the journals published by the Liebert group is the Journal of Alternative and Complementary Medicine. This particular e-mail was advertising an editorial written by a chiropractor named Daniel Redwood that spells out in the most detailed manner exactly how CAM/IM advocates plan on hijacking any health care reform that the Obama Administration might come up in order to persuade the government to fund what Wally frequently terms “sectarian medicine” and I simply like to call unscientific. The editorial is freely available to all (unlike the contents of JACM) and entitled Alternative and Complementary Medicine Should Have Role in New Era of Health Care Reform. It’s about as blatant a description of the goals of the CAM/IM movement as I have ever seen.
Redwood lays it on the line right from the beginning:
For the first time in 15 years, a major national health reform initiative is moving forward in the United States. Those of us who recall the events of 1993–1994, when the Clinton administration failed to pass its version of coverage for all, know that numerous pitfalls lie ahead with the potential to undermine the best-laid plans.
But for those of us who have seen the widespread and needless suffering caused by the dominant role of money in American health care, President Barack Obama’s clear commitment to change gives much cause for optimism. Currently, tens of millions of uninsured Americans lack adequate access to quality health services and uncounted millions more delay or decline needed care for financial reasons.
What I perceive in this article, along with the same coopting of diet, exercise, and prevention strategies as being somehow “alternative,” is something different than what I have seen before. As you will see, Redwood will argue that CAM/IM is necessary in order to bring about universal health care. More on that later. In the meantime, Redwood makes divides his article into four issues: universal coverage; prevention and health promotion; chiropractic; and complementary and alternative medicine (CAM). I will not discuss the first very much because, quite frankly, the issue of universal coverage is a political and moral issue over which reasonable people may disagree. I’ve made my position plain before on this blog, and repeating that position would be tangential to my point here. That leaves points #2 through #4.
It is worth noting that if every primary care medical physician in the nation delivered all preventive health services recommended for every patient by the U.S. Preventive Services Task Force, these physicians would have no time for anything else.1 There would be no time for other patient care, no record keeping, no time for continuing education, and no time for creative thinking. Therefore, simple mathematics dictates that either preventive services recommendations must be drastically scaled back (precisely the opposite of what policy analysts from left, right, and center are proposing) or other delivery channels must be developed. Any meaningful prevention and health promotion plan must mobilize the efforts of other health providers (nurses, physician’s assistants, chiropractors, naturopaths, acupuncturists, and others) for these preventive services, consistent with these practitioners’ training and licensure. Like medical physicians, however, these other providers have additional responsibilities. Enlisting their help is necessary but far from sufficient.
A new prevention and health promotion infrastructure must be developed as well, along the lines of the Samueli Institute’s (Alexandria, VA) superbly crafted Wellness Initiative for the Nation (WIN), which proposes implementation of new policies to “establish standards in comprehensive lifestyle and integrated health care approaches, and train individuals with qualifications to focus full-time on prevention.” A new cadre of Health and Wellness Coaches is envisioned to fill the gaping holes in our current prevention and health promotion infrastructure. Also included in the WIN model are “specialist certification for health professionals in prevention, health and wellness delivery in specific settings and populations—for example, schools, worksites, the military, health care settings, and long-term care facilities,” and creating “a Health Corps to provide an army of young and older people that would learn and model wellness behavior and support delivery of wellness education and training by the coaches.” The current draft of WIN—at www.siib.org—should be read by everyone seeking to understand the transformative potential of the health reform moment.
See what I mean? To Redwood, if we don’t have enough resources in primary care to do the preventative care that science- and evidence-based medicine considers important, the answer isn’t to add to the number of primary care doctors by somehow incentivizing medical students to enter primary care specialties rather than the more lucrative procedure-based specialties. Oh, no. Rather, it’s to bring in the woo by enlisting naturopaths, acupuncturists, and unspecified others. Also notice how Redwood conflates perfectly good and valuable science-based practitioners like nurses and physician’s assistants with practitioners of unscientific medicine like acupuncturists and naturopaths. Let me tell you, if I were a nurse or a PA, I’d be insulted. I’d be royally pissed off. Nurses and PAs are every bit as valuable as physicians in delivering science- and evidence-based health care. Indeed, expanding the roles of advanced practice nurses and other “physician extenders” like PAs may well be one way to alleviate this problem, but to conflate PAs and APNs with naturopaths and acupuncturists is a grave insult. At least, I’d view it as an insult if I belonged to one of those professions.
As for the Samueli Institute WIN initiative, suffice it to say that it’s another excellent example of the coopting of diet, exercise, and lifestyle interventions for purposes of a back door “Trojan horse” introduction of all manners of woo as services reimbursable by any new “reformed” government health care sytem. A lot of what’s in WIN is hard to argue with. It’s stuff like teaching healthy eating habits to children, encouraging exercise, and providing interactions to prevent chronic disease. However, some passages reveal the true colors of this initiative. For example:
- Central to a new model of prevention and health care are the development of “optimal healing environments” and “integrated health care practices” 20 that can support and stimulate inherent healing capacities on mental, social, spiritual and physical levels. As described below, many of these practices provide lower cost alternatives to current conventional practices.
- The widespread application of selected, evidence‐based integrated health care practices could markedly improve quality of life and reduce costs. Behavioral and mindbody practices have been repeatedly demonstrated to enhance quality of life, improve self‐care and reduce costs. 51 Acupuncture has now been definitively shown to improve chronic pain conditions (head, neck, knee and back) at almost twice the rate of guideline‐based conventional treatment. Massage may be even more cost effective in back pain. Massage has also been shown in multiple studies to accelerate recovery of premature babies, with projected cost savings of $4.7 billion per year if widely used. Training retired persons to deliver this infant massage results in reduced depression and enhanced quality of life in those giving the massage – a double benefit. Since under current policies, these practices are not profitable, they remain underutilized at the expense of higher cost and more heroic treatment approaches. A properly focused wellness policy would change this situation.
Of course, readers of this blog should know by now that acupuncture is nothing more than an elaborate placebo, perhaps with some counterirritant activity. Just peruse our articles on the topic for copious discussions of the matter, particularly Harriet Hall’s masterful debunking of the “acupuncture myth.” I also note that the article cited for the claim that massage accelerates recovery of premature infants is from 1993. A Cochrane review of the evidence from 2003 concluded:
Evidence that massage for preterm infants is of benefit for developmental outcomes is weak and does not warrant wider use of preterm infant massage. Where massage is currently provided by nurses, consideration should be given as to whether this is a cost-effective use of time. Future research should assess the effects of massage interventions on clinical outcome measures, such as medical complications or length of stay, and on process-of-care outcomes, such as care-giver or parental satisfaction.
In any case, even if massage did improve outcomes in preterm infants, there’s nothing about massage that is “alternative.” If science shows that massage improves outcomes in such infants, then massage is a science-based medical treatment.
Next, Redwood gets to the meat of the matter. He argues for full inclusion of chiropractic as being the equivalent to science- and evidence-based medicine:
Whether it [chiropractic] is specifically recognized as essential in the core benefits package of the emerging health reform plan may prove to be a bellwether (along with lifestyle-based prevention) as to the extent to which genuine, paradigm-shifting change is embodied in the Obama program. Chiropractors (D.C.s) and their 22 million patients in the United States were quite heartened when Obama sent three separate letters of support to the American Chiropractic Association (ACA) during the presidential campaign. Most encouraging was the fact that Obama, the eventual winner, was the only presidential candidate in either party to specifically respond to the ACA’s detailed candidate questionnaire.
Aside from inclusion in a core benefit package, arguably the most critical goal for chiropractors (and other non-M.D. practitioners), is to codify in federal law a policy of nondiscrimination among types of providers, for both coverage and reimbursement. In other words, if spinal manipulation (or massage, physical rehabilitation, nutritional counseling, mindfulness meditation instruction, or any other procedure) is covered when performed by a medical or osteopathic physician, then it must always be covered at the same rate of reimbursement for any health practitioner licensed to provide it. Freedom of choice among providers and a level playing field on coverage and reimbursement are ideas whose time has hopefully arrived.
Note how Redwood equates the inclusion of chiropractic as a reimbursable health care modality with “paradigm-shifting change.” Of course, he’s right. It would be paradigm-shifting. Unfortunately, it would be paradigm-shifting in the wrong direction, namely away from science-based practice and towards and towards unscientific modalities. That’s exactly what we who support science-based medicine are afraid of. Also note the false dichotomy that Redwood posits. To him, it’s either necessary to include chiropractic, or health care “reform” is not sufficiently embracing “wellness” inititatives and thus, to him at least, a failure. I would counter that including chiropractic, at least the flavors of chiropractic that embrace the pseudoscientific concept of “subluxations,” would be a waste of money and would actually detract from health care reform. To me, any health care reform that does not reward the practice of science-based medicine and discourage the use of unscientific health care modaliteis based on prescientific thinking (such as reiki, homeopathy, various “energy” therapies) or pseudoscientific concepts (such as subluxations) will be no “reform” at all. As we on this blog have argued time and time again, “integrating” pseudoscience with scientific medicine adds nothing to scientific medicine.
But don’t tell that to Redwood. He sees great strength in woo:
CAM’s contributions to health reform should grow organically from its areas of greatest strength. Foremost among these is the principled and pragmatic insistence that health be understood holistically, as a summation of various lifeaffirming inputs and not the mere absence of symptoms. The key corollary—still not sufficiently accepted by conventional medicine—is that, while single-intervention “silver bullet” therapies may dramatically eliminate symptoms (sometimes in life-saving ways), these therapies alone are not the road to long-term, sustainable health and wellness.
Thus, perhaps the most important policy change relevant to CAM would be to shift both CAM and conventional health research budgets away from the longstanding emphasis on single intervention therapeutics and toward multifactorial integrative and whole-systems approaches. (The Ornish lifestyle program that proved heart disease could be reversed through a combination of diet, exercise, stress management, and social support provides the best model for this approach.) Whether for heart disease, low-back pain, prostate cancer, or any other condition, NIH policies that funnel virtually all health research funds to single-agent (usually pharmaceutical) studies have led us into a cul-de-sac of historic proportions. This research strategy may have been effective for combating many infectious diseases, but it has proven far less applicable to the chronic diseases—cancer, heart disease, diabetes, obesity, arthritis, osteoporosis, and others—that are the bane of the developed world. CAM can play a helpful role in finding a way forward
Once again, note the same old trope about CAM/IM as somehow “holistically” understanding health and disease. This is utter tripe. If you look at CAM/IM modalities, you’ll find that many of them reduce all disease down to a single cause. For instance, if you are Hulda Clark, you see all disease as being caused by a liver fluke, and the cure for cancer, AIDS, and all diseases is to “zap” that liver fluke. If you are an acupuncturist, you see all disease as being caused by imbalances in the flow of some mystical life energy (qi), and the cure is to stick needles in various parts of the anatomy unrelated to any anatomic structures in order to “redirect” that flow of qi. Another example is the alt-med obsession with “contamination” and “toxins,” for which the answer is always “detoxification.” One example is the manner in which so many disparate maladies of highly different pathophysiology in CAM/IM are attributed to “heavy metal toxicity,” for which the treatment is always some form of chelation therapy. When CAM/IM advocates claim that CAM/IM modalities look at the “real cause” of disease as opposed to “just treating the symptoms,” it’s a load of fetid dingo’s kidneys. In reality, science-based medicine uses science to identify at the cellular and molecular level how the body goes wrong and what can be done to fix it. In contrast, CAM/IM just waves its hands.
There’s also a false dichotomy here that I get sick of seeing. To Redwood, there appear to be only two choices. Either we study only “single-agent” studies or we embrace all manner of pseudoscientific woo. There are two problems with this (at least). Even if it were true, the answer to “too narrow” research is not to embrace pseudoscience as co-equal to science in medicine or to “integrate” quackery with scientific medicine. It is to broaden the scope of scientific reasearch, to embrace new science-based approaches that look at more variables. Of course, the second thing that’s wrong with Redwood’s critique is that science has been evolving to looking at more multifactorial causes of disease as technology, such as genomics and proteomics, allows scientists to look at changes in the expression of every gene in the genome and at hundreds of proteins at once. There’s no need to invoke qi, imbalances of humors, multiple “toxins,” or any other woo.
Finally, Redwood puts the cart before the horse:
One other issue of great importance for both CAM and the rest of the health care Moreover, all practitioners of all types must become conversant with the full range of health care approaches (both conventional and CAM) available in the U.S. health care system. This does not mean that medical internists must themselves deliver spinal manipulation, acupuncture, or massage treatments; it means that such internists need to know what these therapies involve and where evidence supports their appropriate use. When those circumstances arise, referrals should be made. This is a two-way street; CAM practitioners must also be well-informed about the biomedical options available to patients in order to make appropriate referrals, and must not hesitate to do so. It must never be considered acceptable for either conventional or CAM practitioners to be ignorant of what other health care approaches have to offer. Wide-ranging knowledge and mutual respect must be our watchwords.
Again, let me repeat what I have said time and time again: The concept of alternative medicine (or CAM or IM) is a false dichotomy. There is no such thing as “alternative” medicine. There is either medicine that has been shown scientifically to work; medicine that has not; and medicine that has been shown not to work. Nearly all of CAM falls into one of the latter two categories. Moreover, when an “alternative” therapy is validated through scientific study and shown to work, it ceases to be “alternative” and becomes just medicine. I do, however, agree somewhat that conventional practitioners should know a bit about CAM in that various CAM remedies can interact with science-based medications, either increasing or decreasing their activities or side effects. It’s necessary to train physicians to know just which CAM modalities can interfere with science-based treatments.
Not surprisingly, Redwood sees grave–even apocalyptic–consequences if CAM is rejected in any health care reform:
The current health reform initiative is a high-impact event for all concerned. Failure by Congress and the Obama administration to enact universal coverage now would be likely to doom such efforts for a generation. Failure to properly fund and prioritize lifestyle-based prevention methods would more deeply entrench a status quo that has already proven woefully inadequate at serving society’s health needs. Failure to institute a level playing field among the professions would be tantamount to an endorsement of ongoing injustice. Excluding established professions that provide essential services from a national core benefit plan would mark a major step backward. Make no mistake—a very real possibility of disaster on many levels lurks in the shadows.
Leaving aside the political question of universal coverage, note how Redwood conflates “lifestyle-based prevention methods” with CAM/IM and characterizes not embracing such methods as “entrenching a status quo.” Of course, this is again an example of the “bait and switch,” where diet and lifestyle interventions are the bait and the switch is all the other pseudoscientific nonsense that comes along with CAM. Also note how Redwood invokes the ever-popular “health care freedom” canard so beloved of quacks and charlatans, painting failure to include CAM/IM as part of health care reform as a grave injustice and saying that a “level playing field” is necessary. Unfortunately for Redwood, this “health care freedom” does not represent freedom for patients at all but rather the freedom of quacks and charlatans to do whatever they want, free from any pesky interference from government regulatory agencies or state medical boards, and the “level playing field” he envisions is in reality spotting CAM/IM three touchdowns before the game even begins. Or, to mix metaphors, CAM/IM wants to be placed on third base and then call it a home run if it gets to tag up and go home on the basis of a fly ball out.
If CAM/IM had compelling science and evidence behind it, it would not be trying to manipulate the political process to give itself an unfair advantage, while whining that it is so persecuted. Unfortunately, with the backing of the Bravewell Collaborative, the Samueli Institute, and the National Center for Complementary and Alternative Medicine, advocates of CAM/IM are in a strong position to insert themselves into the upcoming political debate over health care reform. If science-based medicine is to repulse this infiltration, two things will have to happen. First, the Obama Administration’s science and medical advisors will have to be sufficiently savvy not to fall for the blandishments of sectarians and to promote science-based, not pseudoscience-based, medicine. On that score, I am cautiously optimistic. The second thing that will have to happen is that science-based physicians will have to mount an effort to influence legislators at least equal to what CAM advocates are already doing. Unfortunately, on that latter score, I am much less optimistic. Most science-based physicians are not political activists, and the power and wealth of the forces trying to insert CAM into any health care reform is potent. Still, that does not mean we shouldn’t try.
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