Editor’s Note: Please be aware that Ben is deployed in Iraq right now. What that means is that his Internet access is somewhat sporadic. He will show up from time to time to answer comments, however.
ERRARE HUMANUM EST, SED PERSEVERARE DIABOLICUM
– To err is human, but to persist diabolical –
Lucius Annaeus Seneca (c. 4 BC – 65 AD)
The California (CA) Department of Consumer Affairs (DCA) has an informational booklet on Acupuncture and Asian Medicine that besides depicting many New Age fantasies about prescientific medicine, also makes the unfounded claim that based on a 1997 consensus panel, the NIH formally “endorses” the use of acupuncture for a set of specific conditions, and that there is “clear evidence” that it is effective for some of them. This booklet is available at:
Wondering about this “clear evidence,” I wrote a letter a few months ago to the National Center for Complementary and Alternative Medicine (NCCAM) and asked for a clarification.
Their candid response explicitly stated that the CA booklet “misstates the purpose of the 1997 consensus panel on acupuncture.” The NCCAM also added that as a “Federal research agency, the NIH does not endorse any product, service or treatment, nor are NIH consensus documents statements of policy.”
Althought I and other SBM bloggers have criticized state medical boards for not doing enough to protect patients from physicians who practice pseudoscientific medicine and quackery, they do nonetheless serve a purpose. Moreover, critical to medical boards doing even the limited amount of enforcement that they do is the ability of health care providers or other citizens to submit anonymous complaints against physicians who are not practicing up to the standard of care or who may be in other ways taking advantage of patients. Unfortunately, the other day I found out via one of the that I frequent of a very disturbing case in Kermit, Texas. Two nurses who were dismayed and disturbed by a physician peddling all manner of herbal supplements reported him to the authorities. Now, they are facing jail:
In a stunning display of good ol’ boy idiocy and abuse of prosecutorial discretion, two West Texas nurses have been fired from their jobs and indicted with a third-degree felony carrying potential penalties of two-to-ten years’ imprisonment and a maximum fine of $10,000. Why? Because they exercised a basic tenet of the nurse’s Code of Ethics — the duty to advocate for the health and safety of their patients.
The nurses, in their 50s and both members of the American Nurses Association/Texas Nurses Association, reported concerns about a doctor practicing at Winkler County Memorial Hospital in Kermit. They were unamused by his improperly encouraging patients in the hospital emergency department and in the rural health clinic to buy his own herbal “medicines,” and they thought it improper for him to take hospital supplies to perform a procedure at a patient’s home rather than in the hospital. (The doctor did not succeed, as reportedly he was stopped by the hospital chief of staff.)
How can this be? This is how:
Kevin Trudeau has made millions of dollars selling dubious medical products. He started his snake-oil salesman career selling coral calcium through infomercials. Trudeau claimed that this magical form of calcium could cure cancer and whatever ails you. The Federal Trade Commission (FTC) investigated Trudeau, who was making millions off his claims, and found that he was being, let us say, less than honest. As a result the FTC banned Trudeau from selling health products through infomercials.
But Trudeau is tenacious and creative – an innovator. Prior to getting into infomercials he was small time – he was convicted for writing bad checks and credit card fraud and spent some time in prison. I always find it interesting that convicted con-artists seem to hit upon such well-guarded secrets. Dennis Lee claims to have found the secret of limitless energy, if only he were not attacked by Big Oil and a corrupt government. Kevin Trudeau claims to have found the cures for just about everything, but The Man is trying to shut him down.
Undeterred by the FTC ban, Trudeau decided that even though he could not sell health products he could sell information – that was protected under free speech – so he started selling books through infomercial, including Natural Cures They Don’t Want You To Know About. Trudeau claimed he went from writing bad checks to discovering not only hundreds of natural cures but uncovering a government and Big Medicine conspiracy to keep this vital information from the public.
PRELUDE: SOME BAD NEWS FOR ADVOCATES OF SCIENCE-BASED MEDICINE
It was a bad week for science-based medicine. It was a good week (sort of) for science-based medcine.
First the bad.
There has been a development that anyone who supports science in medicine and opposes quackery will likely find disturbing. Do you remember Senator Tom Harkin (D-IA)? We’ve written about him extensively over the last several months on this blog. First of all, he is the man most responsible for the creation of that government-sanctioned, government-funded bastion of pseudoscience, the National Center for Complementary and Alternative Medicine. He’s also one of the men most responsible for the Dietary Supplement Health and Education Act (DSHEA) of 1994, which has done more to protect the supplement industry from making dubious health claims than any other piece of federal legislation. More recently, Harkin has made a name for himself in the health care reform debate currently ongoing by inviting advocates of “integrative” medicine (IM), which in essence integrates quackery and the pseudoscientific with scientific medicine, to Capitol Hill as a means of trying to persuade his fellow legislators to include a CAM/IM version of “wellness” care as part of any bill that might pass this fall. In essence, he is trying to hijack any health care reform bill to include government sanction of unscientific medicine. Meanwhile, he has been chastising NCCAM because it hasn’t “validated” enough “alternative medicine” for his taste. (Actually, it’s validated none, because virtually none of it is likely to be valid.)
This is the man who, according to reports, will almost certainly be taking over the chair of the Senate Committee on Health, Education, Labor, and Pensions (HELP) after the death of its former chair, Senator Edward Kennedy. This committee is among the most important for government health policy and will be in the thick of the final negotiations and battles over any health care reform that may arise from Congress this fall.
The existence of powerful supporters of pseudoscience in the highest eschelons of government has real consequences. As I’ve described before, NCCAM, being based entirely on studying highly–even ridiculously implausible–notions about disease and how to treat it, has resulted in the infiltration of quackery into academia, where ideas once rightly dismissed as quackery are respectfully given deference and studied as though they were anything other than Tooth Fairy science, a process that Dr. R. W. Donnell has amusingly termed “quackademic medicine.” One result was the expenditure of $30 million on an unethical, poorly designed, and corrupt trial of chelation therapy for cardiovascular disease. Another result was an even more unethical trial of an even more scientifically implausible remedy for a deadly cancer. Although the fact that the trial was even done is a horror, at least last week we finally found out the results, which had been suppressed for nearly four years, namely that this protocol is not just useless, but worse than useless. It’s a Pyrrhic victory for science-based medicine and cold comfort to patients with pancreatic cancer who may have continued to use this protocol during those four years, but at least we finally know.
Let’s take a look at the study. But first, a little background.
One of the more bizarre and unpleasant “CAM” claims, but one taken very seriously at the NIH, at Columbia University, and on Capitol Hill, is the cancer “detoxification” regimen advocated by Dr. Nicholas Gonzalez:
Patients receive pancreatic enzymes orally every 4 hours and at meals daily on days 1-16, followed by 5 days of rest. Patients receive magnesium citrate and Papaya Plus with the pancreatic enzymes. Additionally, patients receive nutritional supplementation with vitamins, minerals, trace elements, and animal glandular products 4 times per day on days 1-16, followed by 5 days of rest. Courses repeat every 21 days until death despite relapse. Patients consume a moderate vegetarian metabolizer diet during the course of therapy, which excludes red meat, poultry, and white sugar. Coffee enemas are performed twice a day, along with skin brushing daily, skin cleansing once a week with castor oil during the first 6 months of therapy, and a salt and soda bath each week. Patients also undergo a complete liver flush and a clean sweep and purge on a rotating basis each month during the 5 days of rest.
Veteran SBM readers will recall that in the spring of 2008 I posted a series of essays* about this regimen and about the trial that compared it to standard treatment for subjects with cancer of the pancreas. The NIH had funded the trial, to be conducted under the auspices of Columbia, after arm-twisting by Rep. Dan Burton [R-IN], a powerful champion of quackery, and much to the delight of the “Harkinites.”
In the fall of 2008 I posted an addendum based on a little-known determination letter that the Office for Human Research Protections (OHRP) had sent to Columbia during the previous June. The letter revealed that the trial had been terminated in October, 2005, due to “pre-determined stopping criteria.” This demonstrated that Gonzalez’s regimen must have been found to be substantially worse than the current standard of care for cancer of the pancreas, as ineffective as that standard may be. I urge readers who require a review or an introduction to the topic to read that posting, which also considered why no formal report of the trial had yet been made available.
Now, finally, the formal report has been published online by the Journal of Clinical Oncology (JCO):
The state of California (CA) which is home to the most advanced education and research in biomedical sciences, computational biology, genomics and proteomics, etc, is also home to 19 institutions that have state-approved training programs in Traditional Chinese Medicine (TCM), a pseudo-medicine that is based on ideas and practices sourced by ancient cosmology, mythology, astrology, and a range of other pre-scientific beliefs that have been partially “sanitized” during the Maoist era.
Emerging out of the recent hype about complementary and alternative medicine (CAM), the educational curricula of these institutions include the study of acupuncture’s point-and-meridian system, the health and safety beliefs of ancient and medieval China, humoral pathology, herbalism, Asian massage, and a limited amount of modern biomedical sciences at a level below what is required from vocational nurses. These curricula are supposed to provide the necessary knowledge and skills for the graduates to pass a comprehensive state licensing exam and provide “primary” healthcare in CA. However, pursuant to CA Code of Regulations, Title 16, Section 1399.451(b) it is improper for these “primary” healthcare providers, “to disseminate any advertising which represents in any manner that they can cure any type of disease, condition or symptom!” Nonetheless, both the internet and the local press abound with ads by CA licensed practitioners who claim that acupuncture can cure or mitigate many diseases, ranging from allergies and infertility to stroke and paralysis.
Under the banner of CAM, a handful of these practitioners also advertise that they can communicate with spirits and heal with crystals, colors or sounds; they practice healing touch (reiki) and distance healing (via PayPal!); provide spiritual counseling and ministerial services, and make implausible medical claims such as healing a chronic condition with just one needle!
All 19 programs are approved by the CA Department Affairs’ (DCA) Board of Acupuncture, since CA law requires that the content of an acupuncture training program be assessed and approved by the State.
I will write occasional posts instead of being on a regular schedule. The reasons: There are more contributors than positions. Newer people to the field have more ambition and belly fire. I have a number of projects and papers to finish in increasingly limited time and decreasing efficiency. So have at it. Meanwhile, some non-random thoughts.
I am as concerned with social and political expression of pseudoscience as with its errors. Health care reformers can be just as pseudoscientific as sectarians who want to restructure the scientific edifice. Political ideologues want to centralize the medical system without solid evidence that their substitute would work, let alone work better. Sectarians already see a national government system as an opportunity for expansionism. Mark Hyman, the Functional Medicine promoter, met with the White House staff, displaying his vision of medicine under a federal plan. Word is out that other sects have also had input. Many hold suspicions that the proposals front for more ambitious formulations. I am suspicious of their confidence – that they can fix a complex, fluxing system using epidemiology, mathematical models, treatment paradigms, and top-down control. I might accept some proposals if it were not that all constructed systems are intrinsically inefficient, political, and corruptible. The closer the agents of control are to the controlled, the more control the controlled have over the controllers – if you can follow that.
It is my contention that terms such as “complementary and alternative medicine” and “integrative medicine” exist for two primary purposes. The first is marketing – they are an attempt at rebranding methods that do not meet the usual standards of unqualified “medicine”. The second is a very deliberate and often calculating attempt at creating a double standard.
We already have a standard of care within medicine, and although its application is imperfect its principles are clear – the best available scientific evidence should be used to determine that medical interventions meet a minimum standard of safety and effectiveness. Regulations have largely (although also imperfectly) reflected that principle, as have academia, publishing standards, professional organizations, licensing boards, and product regulation.
With the creation of the new brand of medicine (CAM and integrative) came the opportunity to change the rules of science and medicine to create an alternative standard, one tailor made for those modalities that do not meet existing scientific and even ethical standards for medicine. This manifests in many ways – the NCCAM was created so that these modalities would have an alternate standard for garnering federal dollars for research. Many states now have “health care freedom laws” which create a separate standard of care (actually an elimination of the standard of care) for self-proclaimed “alternative” practices.
One thing I always encourage my residents and students to do is to go to primary sources. If someone tells you that thiazide diruetics should be the first line treatment for hypertension, get on MedLine and see if that assertion is congruent with the evidence. It’s important to see how we arrive at broad treatment recommendations, how strong and consistent the evidence is, and the best way to do this is go back to the beginning.
This is not an explicitly political blog, and for that reason, I don’t feel it’s appropriate for me to advocate for one or another proposed health care reform plan. But I do want to encourage everyone to follow health care reform closely, and to go to the primary sources. Certain aspects of the proposed bill will be hard for any of us to understand, especially cost. There are all sorts of wild claims about how much reform will save us or cost us, and I’m betting that none of these claims is completely congruent with the truth. But some of what we’re hearing on the news is so far from the truth that to call them lies would be generous. (more…)