Respond to this Article April 2002

Science Fiction

After spending half a billion taxpayer dollars, alternative medicine gurus still can't prove their methods work--how convenient.

By Chris Mooney

High on a windswept mountainside in Northern India, an appropriate setting for dramatic discovery, a team of medical scientists from Harvard unpacks its equipment: notebooks, coils of tubing, and a black globular hanging thermometer. Once a makeshift laboratory has been assembled, the team turns to its research subject, a shaven-headed monk in flaming orange robes, and proceeds to wire his body with lightweight thermistors. The scientists have won special dispensation from the Dalai Lama himself to study this monk, an advanced practitioner of the sacred Tibetan technique known as tumo, in which true believers are said to dramatically increase their body temperatures through intensive meditation. Some tumo masters are rumored to have performed astonishing feats, such as steam-drying freezing wet sheets draped across their backs. On this day, however, the researchers register no such miracle. As they conclude their work, the monk, looking sheepish, explains through a translator that he simply couldn't meditate properly. He wasn't able to "turn the corner" and so failed to achieve the true "bliss consciousness" that tumo requires. The reason? Because of the invasive rectal thermometer inserted to measure the phenomenon.

This may sound like a joke, but it's closer to cutting-edge science. A documentary containing this scene was shown to me by Dr. Herbert Benson, the lead scientist in the tumo study and the director of Harvard's Mind/Body Medical Institute. A cardiologist by training who authored the 1975 bestseller The Relaxation Response, Benson is at the forefront of one of the most important medical movements in decades, the push to incorporate nontraditional or "alternative" healing methods into the canon of Western medicine. He is one of hundreds of researchers at dozens of medical schools studying these previously untested techniques, collectively referred to as "complementary and alternative medicine" or "CAM"---everything from meditation, acupuncture, and herbalism to radical procedures like chelation, colonics, and leech therapy. The goal is to determine which treatments hold legitimate medical value and which are mere superstition.

Though many techniques are centuries old, the American public's fascination with these treatments has lately boomed. Today, CAM is a rapidly growing $32 billion-a-year industry. As its popularity has mushroomed, so too has the medical community's interest in understanding it. As a result, a longstanding animosity between "alternative" practitioners and mainstream medical scientists has begun to thaw. Since the early 1990s, the National Institutes of Health has awarded hundreds of millions of dollars in grants to researchers studying CAM treatments. Many more have embarked on their own studies at medical schools across the country. The money and attention mean that alternative medicine's mythic claims of healing are finally being put to the test. In theory, this should be good news for everyone: Mainstream medicine can assimilate whatever proves worthy, while practitioners of legitimate alternative and complementary techniques can finally gain the authority of scientific approval and respect after decades of slights and ridicule.

But in practice it hasn't worked out that way. After a decade of studies, the truth about CAM is proving much harder to pin down than anyone imagined. This uncertainty hasn't hurt proponents; indeed, it's probably helped them. They've made inroads at all the top medical schools. Philanthropic organizations have showered money on programs and scholarship to boost CAM's visibility. The simple fact that medical schools are taking it seriously has lent alternative and complementary medicine an air of legitimacy. But the benefit to traditional science is much less clear. While a few techniques have proven reasonably effective---meditation, acupuncture, music and massage therapy, and some herbal remedies---they're the exception. The trouble has been identifying, once and for all, what doesn't work. While it should be relatively easy to gauge the merits of, say, leech therapy, in many cases CAM proponents have quietly ensured that it isn't. Rather that submit to scientific testing, they're using CAM's ambiguity to their advantage, and have often been frustratingly circumspect about conceding their failures. Some fall back on the old mantra that "more testing" is necessary. Others try to bend science to their own specifications. Still others take a page from the Tibetan tumo master by claiming that scientific testing simply cannot measure some kinds of CAM effects---claiming, in essence, that the scientific establishment should just take their word for it.

CAM's supporters are trying to have it both ways---and succeeding. Today, a guilty silence shrouds an increasingly important question: Can a field like alternative and complementary medicine, which in many cases is inherently hostile to science, survive its arrival into mainstream medicine? Or are American taxpayers the victims of an expensive medical swindle being abetted by the nation's leading medical schools?

Aches and Pains

The conflict between alternative and scientific medicine dates back at least a hundred years, during which time the two camps have become bitter foes. The medical establishment has long viewed techniques outside its purview as quackery; in return, it has been accused of closed-mindedness and protectionism. CAM devotees have frequently claimed that mainstream medicine has refused to test complementary and alternative treatments for fear that inexpensive herbs and other simple "cures" would render profitable surgery and pharmaceuticals unnecessary. So fierce is the debate that CAM's more fervent supporters have resorted to language typically associated with extremist groups, referring to medical doctors as "jackbooted thugs." But whether or not doctors endorsed it, more and more people resorted to CAM. Its sheer popularity proved too difficult to ignore.

Ironically, the triumph of scientific medicine is one cause of this surge. Some miracles of modern medicine, such as curing certain cancers, have raised the public's expectations of what medicine should be able to do---if it can cure cancer, why can't it fix carpal tunnel syndrome? Many CAM therapies purport to treat the sort of non-life-threatening chronic illnesses---arthritis, irritable bowel syndrome---that modern medicine hasn't solved. Indeed, by dramatically extending the average life span, scientific medicine has underscored chronic pain and end-of-life conditions, thereby opening the door for feel-good alternative treatments that emphasize individual well being and generally cultivate more emotional, and sometimes spiritual, patient/provider relationships. The impersonal nature of managed-care plans has also pushed people toward CAM. Science itself, in other words, has laid the groundwork for what could be an expanded sphere of medical treatments. But within that sphere, unfortunately, there's plenty of room for quackery.

Over the past decade, several events prompted the beginnings of a reconciliation between scientific medicine and CAM. In 1992, Sens. Tom Harkin (D-Iowa) and Orrin Hatch (R-Utah) convinced Congress that the NIH should establish an Office of Alternative Medicine and awarded it a $2 million budget (Harkin believed that bee pollen, a popular alternative treatment, cured his allergies and wanted further scientific study). The following year, Harvard's David Eisenberg published a groundbreaking study in the New England Journal of Medicine which revealed that one in three Americans had sought treatments outside the scientific mainstream, ranging from self-help groups and energy healing to homeopathy and prayer. The article served as a wake-up call to the medical community. As bestseller lists became cluttered with such testaments to complementary and alternative treatments as Andrew Weil's Natural Health, Natural Medicine and Benson's Timeless Healing, the need to better understand the field became evident. Doctors couldn't even say with certainty which CAM therapies were safe.

Most observers say the turning point came in 1998 when the NIH, after enduring years of criticism over its shoddy alternative medicine office, made a bid for credibility by announcing that it would recommit to serious scientific testing---and established, with great fanfare, the National Center for Complementary and Alternative Medicine (NCCAM). The name alone is noteworthy---"complementary and alternative medicine" is an NIH-inspired term that many proponents eagerly adopted for its ring of scientific legitimacy. Still more legitimizing is the center's growing budget, which this year will exceed $100 million.

Doctor of Leech Therapy

Eisenberg's study initiated a scientific catch-up game, as physicians strove to understand what their patients were doing. For the most part, CAM's proponents welcomed this attention and sought to capitalize on it. While the field, and particularly the herbal supplements industry, is largely unregulated by the FDA, many practitioners of techniques such as acupuncture and massage therapy are eager for scientific approval in order to reap the financial benefits of having more insurance companies cover their services (as some already do). Others point out that mainstream acceptance will encourage skeptical patients and expand their market. Many would also like to strengthen the affiliation with medical schools like Harvard, where programs like Benson's and Eisenberg's lend an immediate---if undeserved---credibility to the entire field.

In fact, that's already happening. Due to CAM's financial potential, and because it already has so many converts, proponents have had little trouble buying their way into the top medical schools. NIH remains the biggest single source of funding, but charitable foundations such as the Bernard Osher Foundation and the Richard and Hinda Rosenthal Foundation have done a diligent job of seducing universities with large donations to establish centers aimed at studying CAM "scientifically." One of the earliest was Columbia University's Rosenthal Center for Complementary and Alternative Medicine, founded in 1993. The following year, Andrew Weil founded the Program in Integrative Medicine at the University of Arizona. The race was on. Soon after, similar programs began cropping up at a number of top schools, like Duke's Center for Integrative Medicine and Harvard's Division for Research and Education in Complementary and Integrative Medical Therapies. Today, many top medical schools boast some type of CAM program---if not a full-fledged research center, then at least a class or two. Columbia's Rosenthal Center, which tracks such things, counts 129 courses and programs nationwide.

These are often funded by lavish patrons like John E. Fetzer, the late Detroit Tigers owner (and reincarnation buff) whose $450 million institute in Kalamazoo, Mich., explores the connection between spirituality and health. The biggest benefactor on the "mind-body" front, however, is Sir John M. Templeton, a retired financier whose $800 million Templeton Foundation encourages universities to teach spirituality "as a complement to traditional medicine." Templeton has funded a Benson research project on "intercessory prayer," which seeks to establish whether praying for loved ones actually helps them to heal, and helps underwrite the Center for the Study of Religion/Spirituality and Health, also at Duke.

Given all this federal and private largesse, it's little surprise that the number of studies involving complementary and alternative medicine has been doubling every five years. According to Andrew Vickers, a CAM researcher at the Memorial Sloan-Kettering Cancer Care Center, these studies are getting bigger and more professional. Last May, for instance, at a massive CAM conference jointly sponsored by Harvard and the University of California-San Francisco, 350 abstracts were presented, of which 221 saw publication. Research topics ranged from examinations of leech therapy and the herb black cohosh to attempts to design placebo needles for acupuncture studies. To some degree, things have changed even since 1998, when Marcia Angell and Jerome P. Kassirer wrote in a famous editorial against CAM in the New England Journal of Medicine: "What most sets alternative medicine apart...is that it has not been scientifically tested and its advocates largely deny the need for such testing." Today, many CAM proponents are happy to have their techniques tested. What they're denying are the results.

The Rectal Thermometer Loophole

Not long ago, I sat in on a typical acupuncture trial at the George Washington University Center for Integrative Medicine. Acupuncture is one of the more promising CAM treatments and is being widely tested for a variety of ailments. The lead practitioner in the study, Dr. Xiao Dong Cai of the Chevy Chase Wellness Center in Maryland, was expecting preliminary results as soon as this spring of whether acupuncture cured carpal tunnel syndrome.

When I arrived at the center, I discovered a cozy waiting room with pink and green chairs and soft lighting. It's common to view the public's infatuation with alternative treatments as a reaction against the cold sterility of modern managed care; the grandmotherly atmosphere of tolerance and understanding I encountered did little to cloud this impression. In fact, all that upset the vibe was Dr. Cai himself, a diminutive man and a very nervous acupuncturist.

Three afternoons a week, Cai visits the center to pop needles into patients suffering from carpal tunnel syndrome. But in only one in three cases does he insert the needles into points which, according to traditional Chinese medicine, can help balance the body's "energy" in a way that heals carpal tunnel. If each group shows the same result, it could "knock out thousands of years of treatment principle," suggests Dr. John Pan, who heads the George Washington Center and shares Cai's trepidation. "That would be very unfortunate."

Dr. Cai has another worry, too. The trial could turn out the way it's supposed to, which would suggest that he, the acupuncturist, is unnecessary. To keep from becoming a variable, Cai can't individualize his treatment or use his expertise to try to detect each patient's "energy field" while inserting the needles (a feeling which he likens to getting a tug on a rod when fishing). Instead, Cai must quickly swab and needle each patient with no more than a quick "hello." This means that if patients getting the real treatment post better results, then anybody who knew the correct points could perform acupuncture. You could even do it yourself. For this reason, Cai has "very confused feelings" about the study. The ideal outcome for practicing acupuncturists, he says, would probably be "if the result is in between."

Therein lies the problem implicit in testing popular CAM treatments---do too good a job, and you could find yourself out of work. So perhaps it's small wonder that many CAM proponents have figured out that the "ideal outcome" for any test is one that's inconclusive (or that can be made to seem that way). The past few years are rife with examples of scientific studies that have carefully debunked worthless practices, but which proponents continue to promote.

For example, last April the Journal of the American Medical Association (JAMA) published a study by Vanderbilt University psychology professor Richard Shelton that found that the popular herb St. John's Wort had no effect on major depression. Yet rather than accept his findings, groups like the Council for Responsible Nutrition (a dietary-supplement industry trade association) circled the wagons and denounced the study---along with Shelton's recommendation to discontinue the use of St. John's Wort until positive benefit can be proven.

The practice of reflexology postulates a correspondence between specific "zones" on the hands and feet which, when pressed, can heal ailments in other parts of the body. But it, too, has been tested and failed. A recent study in Complementary Therapies in Medicine proved that reflexologists were unable to identify specific illnesses in patients, and another in Respiratory Medicine revealed that reflexology fared no better than a placebo in curing bronchial asthma. But the 25,000-member International Institute of Reflexology in St. Petersburg, Fla., remains unconvinced.

Another discredited treatment is therapeutic touch, in which a practitioner's hands move over a subject's body to "decongest" or "balance" the patient's "energy field." As ridiculous as that sounds, it took a 1998 article in JAMA, based on the science project of a nine-year-old schoolgirl, to debunk it. In an accompanying note, JAMA's editor Dr. George Lundberg commented, "practitioners should disclose these results to patients, third-party payers should question whether they should pay for this procedure, and patients should save their money unless or until additional honest experimentation demonstrates an actual effect." Yet many top nursing school continue to teach and promote it.

The list goes on and on. Practices such as colonic irrigation (running a tube through a patient's rectum in order to "cleanse" the intestines with warm water), iridology (diagnosing illness by studying the iris of the human eye), and ear candling (inserting a burning candle in the ear canal to remove "impurities" from the brain and sinuses) have all been debunked as useless or dangerous (the FDA has even banned the importation of ear candles). That hasn't stopped many people from practicing them.

Other CAM techniques probably don't even merit study. For instance, as I waited to meet Dr. Cai at the George Washington center, I picked up a pamphlet on homeopathy, which, for the uninitiated, is a water-based treatment that uses substances ranging from belladonna and garlic to zinc and ambergris. The catch is that most of these potions are diluted to the point that they're just water---one tenet of homeopathy being that substances somehow become more powerful as they're diluted. No matter that this violates fundamental laws of chemistry. Homeopaths insist that water "remembers" the presence of a substance it once contained and uses it to cure illness. Even proponents have trouble explaining how that's possible. Yet legitimate medical schools like George Washington University continue to promote it, while the NIH wastes money studying it.

These are hardly isolated examples. Steven Novella, a neurology professor at the Yale University School of Medicine, cites a pattern of ignoring negative results by CAM proponents: "When you push them against the wall, I've had more than one say to me, Śwell, it's really hard to prove something doesn't work....'" Just like the Tibetan monk who couldn't perform for researchers, true believers try to argue their way around the science. Call it the rectal thermometer loophole.

Quackwatching

Theoretically, NIH, as a scientific arm of the federal government, should act as a referee. But practically since it established the Office of Alternative Medicine in 1992, it has come under fire from the medical establishment for funding what critics charge are shoddy experimental procedures. One problem is that from its outset, the office has been run by CAM boosters like Wayne Jonas, author of the 1996 book Healing with Homeopathy: The Natural Way to Promote Recovery and Restore Health. Even after 1998, when NIH made a great show of cleaning up its CAM program, things haven't much improved. Despite the mandate from Sens. Harkin and Hatch that alternative treatments undergo rigorous scientific testing, many researchers still consider NIH's program a joke. ""It's been about eight years now," complains Stephen Barrett, an M.D. who runs the website Quackwatch.com. "They've never said that anything didn't work."

For example, the NIH doled out $1 million for a study of "magnet therapy," which traces its roots to an 18th-century belief that blood circulation can be improved by mounting magnets at various points on the human body. Though the medical community emphatically dismisses the notion, the North American Academy of Magnetic Therapy continues to claim that it's healed scores of patients.

NIH has also funded expensive studies of "distance healing," homeopathy, and shark cartilage, the last of which may be the most egregious. NCCAM has awarded more than $1 million to Charles Loprinizi of the Community Clinical Oncology Program in Rochester, Minn., to study shark cartilage's ability to heal advanced colorectal or breast cancer---an idea even some of CAM's biggest boosters, such as Dr. Marc Micozzi of the College of Physicians in Philadelphia, admit is absolute nonsense (sharks themselves get cancer, including cancer of the cartilage).

Such studies actually exacerbate the problem. A lot of NIH money has gone to study techniques that on their face are patently ridiculous---but rather than disprove them, "inconclusive" research actually props them up by making it seem as though some legitimate scientific issue were at stake.

The poor record of NIH's testing program may soon get a lot more attention. In the latest issue of the Scientific Review of Alternative Medicine, Saul Green, a former professor of biochemistry at the Sloan-Kettering Cancer Institute, reviews the NIH's grant history, detailing how recipients used federal money not for original research, but to repeat or comment on studies already conducted. In other words, they published uncritical studies, or merely sowed confusion by weighing in on someone else's, thereby creating ambiguity over what works and what doesn't. In this regard---at great taxpayer expense---they've been astoundingly successful. Green's conclusion could hardly be more scathing: "To my knowledge, and based on a review of abstracts published by the OAM/NCCAM, no report stated that a treatment did not work. In the past nine years, no negative result has been published, nor have any of the methods studied been shown to work to the satisfaction of the medical science community."

Ivy League Faith Healers

The free pass given to CAM has had some alarming effects. One is the lingering respect that's begun to develop for many therapies, despite the fact that they remain largely untested. The more CAM is associated with serious study, the more likely it is to be seen as legitimate or even beneficial.

Because so few researchers are publicly demystifying CAM treatments, its proponents have gained a foothold in many of the top medical schools. This only worsens the problem, because in essence, the foxes are living in the henhouse. Figures like Benson and Weil---both best-selling authors---may look good to trustees, but they're very cautious in what they say. As some of CAM's staunchest advocates, they're often inhibited from calling even the most implausible treatments what they really are---quackery. This creates an environment of academic and scientific permissiveness, in which techniques such as acupuncture and relaxation, which do merit scientific study, open the door to absurd and even dangerous therapies such as homeopathy, touch therapy, and chelation, which do not.

This is the dark underbelly of alternative medicine. Chelation, for example, involves infusing chemicals into the blood to "purify" it and is promoted by practitioners as a "natural" method of curing arteriosclerosis, or clogged arteries. But the FDA has approved its use only for lead poisoning and removing heavy metals from the blood. Edzard Ernst, a CAM researcher at the University of Exeter who is respected by skeptics and believers alike, considers chelation downright dangerous. "I have published systematic reviews on chelation therapy," he says, "in which the last sentence was this: Śthis therapy should now be considered obsolete.'" Yet chelation continues to be promoted by the American College for Advancement in Medicine, which claims 1,000 practitioners mostly in the U.S. And it's on the syllabus in CAM classes at medical schools like University of North Carolina.

The same is true elsewhere. Tufts University offers a course on reiki, an ancient Japanese touch-healing practice that lacks any scientific merit. So has Yale. The University of California-San Francisco teaches "Introduction to Homeopathic Medicine." And lest there be any question of how this material is presented, Dr. Wallace Sampson of Stanford University, who edits the Scientific Review of Alternative Medicine, has published a survey of CAM classes at top medical schools and found that with the exception of a handful of courses, none teach the material from a skeptical standpoint. Even Harvard teaches homeopathy.

In fact, Harvard has been especially complicit in this trend. David Eisenberg, who directs its CAM program, claims to be devoted to separating the good from the bad in alternative medicine. In 1996, Eisenberg wrote in The New York Times: "The objective is to distinguish useful from useless therapies. Are they safe, effective and can they reduce health expenditures? When they work, do they work because of some herb, needle, pressure point or the belief in such?" Yet Eisenberg's 1987 book Encounters with Qi: Exploring Chinese Medicine sounds more like Obi-Wan Kenobi explaining the ways of "The Force." Eisenberg presents credulous accounts of psychokinesis, adopting a pose of contrived skepticism that lends the appearance of scientific inquiry to a book that has little. I tried contacting Eisenberg to ask him to reconcile these views, but was told I'd have to be "vetted." After vetting, my interview request was denied.

Ending Pseudoscience

While the debate over "alternative" medicine rages on among doctors and medical researchers, there's one sure way to determine where things stand: Ask CAM proponents for proof that testing works. Even those who insist rigorous scientific testing is occurring are often hard pressed to cite an example of a therapy that's plainly bogus. I put this question to Marc Micozzi, executive director of the College of Physicians in Philadelphia and the editor of Fundamentals of Complementary and Alternative Medicine, the first college-level CAM textbook. Micozzi could only come up with shark cartilage---and even now the NIH has yet to dismiss that. Meanwhile, many of Micozzi's colleagues bob and weave to avoid serious scrutiny.

Despite the dissembling, there are plenty of reasons to believe that much of CAM isn't compatible with mainstream medicine, that its proponents are practicing religion or philosophy as much as science. For one thing, some admit it. Micozzi says the testing data on CAM suggest that "there's another dimension to human life and healing that's not material." Perhaps. But while Micozzi says he fully accepts the need for proof, in the next breath he says that "Western" medicine has grown stagnant and protectionist and may be too limited to measure CAM's benefits. If you look past the serious-sounding textbook and the academic credentials, that's not very far removed from the tumo monk's claim that testing prevented him from performing his medical miracle. Until this cycle of excuses and doubletalk ends, the rest of us won't be able to separate the good from the bad.

CAM's proponents must do more than simply assert its medical value. They must finally cop to the rules of scientific rigor---no exceptions, no special pleading, no postmodern philosophy, and no hiding in the skirts of more legitimate treatments. Simply calling for "more research" won't do, since it's just another way of dodging the facts. And since so few proponents share Dr. Cai's willingness, however reluctant, to put their beliefs to the test, it should fall to NIH and the nation's top medical schools to do it for them. That means halting the CAM gravy train in which academic institutions are effectively lulled into submission by millions of dollars in foundation grants. The deans and presidents of respected schools like Harvard should step in and call out professors and directors who'd like to trade on their academic affiliation without living up to what that entails.

For all the money, studies, and attention given to CAM, in many cases we're still not much closer to knowing what works and what doesn't, what will heal and what will hurt. The observation of Marcia Angell and Jerome P. Kassirer in the New England Journal of Medicine still applies: "There cannot be two kinds of medicine---conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work... If it is found to be reasonably safe and effective, it will be accepted." And if it's found to be otherwise, it should be rejected. By everyone.

Does your insurance plan pay for alternative medicine? Read the sidebar.

Chris Mooney is a senior writer at The American Prospect.


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