Alternative medicine: Miracle cure or malpractice?

Unorthodox remedies may harm more than they help

by David Andrew Stoler

Last month, 300 members of a Protestant Church in South Korea stormed a Seoul television studio to oppose the broadcast of a documentary critical of their spiritual leader, Lee Jae-rok, a practitioner of "therapeutic touch." Also known as the laying on of hands, the theory of therapeutic touch posits that the body, more than simply a mass of blood, bones and guts, is a center of spiritual energy. Anything from stress to poor diet to simple spiritual disruption can throw this energy system out of whack, and, therapeutic touch practitioners contend, these disruptions are the cause of most, if not all, illnesses. Therapeutic touch, which practitioners like Lee claim to do with their hands, is the practice of manipulating that energy system back into sync to heal various diseases.

This practice is not limited to Korean Protestants or Southern fundamentalists, who try to deliver miracles under revival tents. Indeed, if you think Lee's following of 60,000 Koreans has nothing to do with the current American cultural milieu, you're wrong. Though far away, the strength of a group so devoted to the methods of an alternative healer is evidence of a trend that has very much invaded both the healthcare system and the general consciousness and consumptive habits of the United States.

The Seoul protest, for example, came on almost the same day that Blue Cross and Blue Shield of Massachusetts announced it was partnering with the alternative healthcare company Landmark Healthcare Inc. (which claims 4 million members) to provide Blue Cross's 1.6 million customers with options like acupuncture and massage therapy -- two therapies based on the same general principles of therapeutic touch. And just this month, the Rhode Island House Corporations Committee heard testimony on a bill that would require insurance companies to offer acupuncture coverage.

Therapeutic touch is, in fact, just one of a galaxy of practices (see "Alt.Medicine 101," page 11) that fall under the general category of alternative medicine -- some more odd than others, but all of which combine Eastern philosophies with Western capitalism -- and have changed the way healthcare is being practiced in the US. Many, like acupuncture, are based on the idea that a spiritual energy force called the Qi (pronounced "chee," which is Japanese for "life force" or "energy") can become unbalanced, causing physical illness and distress. These include acupuncture, therapeutic touch, reiki healing, qigong, Rolfing, and Zarlen therapy (a mental healing technique in which Zarlen, the past life incarnation of Dr. Jonathan Sherwood, repatterns a patient's brain functions and energy flow, all in a three-minute session). Others, such as herbs and chiropractic, focus more on the body as a total organism in which mechanics play a large part.

According to a recent Harvard Medical School study, Americans are flocking to practitioners of alternative therapies in greater numbers than those who go to traditional doctors. In all, some 40 percent of Americans have tried alternative medicine. In 1997, we collectively logged 629 million visits to alternative practitioners -- nearly 250 million more visits than were made to standard primary care physicians. This represents an increase of nearly 50 percent since 1990.

The $21.2 billion windfall spent on alternative medicine in 1997 ($9 billion of which was covered by insurance companies, according to the Harvard study) served as an abrupt wake-up call to mainstream medicine. As a result, a growing number of liberal conventional docs are adding elements of alternative medicine to their traditional practices or shifting their focus entirely. Indeed, the '90s have seen the terms "complementary" and "integrative" born into medicinal vocabulary to describe a practice in which an MD-turned-homeopath might be as likely to prescribe (and, often, vend) alterna-medicines, like a pill form of milk, as they are a strong antacid. And so follows the inevitable offspring of any American trend: products, and a whole mess of them. Ranging from Ginseng gum to St. John's Wort-laced Centrum, Americans have gone tonic-crazy, medicating ourselves like mad with a supply of new supplements that aren't regulated by the Food and Drug Administration, but which are on sale at a Store 24 near you.

The reasons for this explosion in popularity are varied, ranging from frustration with conventional treatments to the desperate yearning for a solution when other responses come up short. Alternative practitioners can also offer a soothing contrast to the worst of conventional medicine -- a managed care mess in which many patients no longer have a continuous relationship with their doctor and feel that their personal importance has been sacrificed to the maw of a faceless bureaucracy. Alternative practitioners, for example, claim to spend more time just chatting with their patients, finding out about their lives and how stress might be affecting their health. This perceived attentiveness gap has led many conventional doctors to reassess the way they interact with patients. In some cases, doctors are mixing traditional treatments for physical ailments with what is seen as the more empathetic manner of alternative practitioners.

All this causes deep dismay among many conventional doctors, who say that alternative practitioners are, more than anything, fooling patients, imbuing them with false hope and false beliefs, and charging them a lot of money to do so. The traditional medical establishment sees alternative medicine as not simply a threat to its own patient supply, but as a threat to the integrity of the medical field and the entire realm of rational thinking. Critics charge that alternative therapies simply do not work, that there is no evidence that they do, and, in fact, evidence that they don't. And though it's difficult to know how often this happens, conventional doctors say alternative treatments endanger the lives of patients who, believing them to be proven and effective, seek out dubious cures for life-threatening problems, instead of choosing scientifically documented responses.

Many critics also fault alternative medicine for bypassing the rigorous trial-and-error process that has yielded the greatest improvements in medicine and science. According to Dr. Arnold S. Relman, editor-in-chief emeritus of The New England Journal of Medicine and professor emeritus of medicine and social medicine at Harvard Medical School, alternative medicine is "undermining the rational approach to human problems."

Alternative practitioners say just the opposite: that conventional doctors are blocking advances because alternative medicine doesn't fit into the mainstream medicine paradigm. Trial-and-error is entirely essential to what they do, but the double-blind process that traditional medicine relies on is unrealistic for testing many alternative treatments. According to Donna George, co-director of the Marino Center for Progressive Health, a Cambridge-based center of traditional and alternative medicines, "it is impractical to use double-blind studies for something like acupuncture, yet people have been using it effectively for 2000 years. If they demand a placebo, it rules out so many treatments. We say that if we think that something is safe, let's see if it will be beneficial to a client."

But critics such as Relman say it is double-blind testing that has transformed medicine from quackery into the generally effective and trustworthy field of the 20th century. These critics contend that by abandoning critical methods, by placing faith in faith in hocus-pocus non-science, and by demanding that insurers pay for that, people legitimize bunk and thereby erode the credibility of all medicine and science. Says Relman, "When you soften the brain, encourage magical thinking and weird paranormal thinking as solutions to problems, you risk the possibility that we are [not] going to be able to deal in a realistic logical way with the real problems our society is facing."

Alternative treatments are, of course, nothing new. Homeopathy, whose main theory contends that illness should be treated with tiny amounts of substances that cause the illness, was invented in the 18th century by German scientist and linguist Samuel Hahneman, and has been used by even traditional physicians there ever since. Acupuncture has been used for millennia in Asia. Developed during a time when surgery more often than not meant death from infection, alternative medicines offered as viable an option for treatment as did their rival, the treatments that would become conventional medicine. Because alternative medicines relied on small dosages of herbs, for example, they were a welcome respite from, say, leeching.

Among the most visible leaders of the contemporary alternative medicine movement is Dr. Andrew Weil (click for an interview with Weil), who was a Harvard-educated conventional physician and botanist until he dropped out of the conservative medicinal world in response to what he considered its combative and poisonous approach to fighting illness. He spent three years in the Amazon researching shamans, tribal medicine men, and medicinal plants before moving to Arizona. Weil then conceived a theory of alternative medicine that eschews the traditional scientific view of the body as something that needs care only when ill. Instead, he prescribed a kind of well-being of the soul, based on stress-management and relaxation, along with daily dietary care and immune system conditioning.

Since then, Time magazine in 1997 named Weil one of the nation's most influential people, he has authored seven books, including three bestsellers, created a hit PBS series and an "Ask Dr. Weil" Web page that boasts hundreds of thousands of hits per day -- all of which revolve around the premise that conventional treatment is not the clear way to go and that alternative medicine should be setting a new paradigm.

One element that has galvanized support for alternative medicine is the belief that conventional medicine relies too much on caustic treatments, such as radiation therapy, that can harm the patients whom doctors are trying to heal. And even prominent critics of alternative medicine concede that the worst aspects of managed care have led many health care consumers to run in a different direction. "I think that [the popularity of alternative medicine] is in part a backlash against the current state of medicine," says Harvard's Relman, whose point-by-point criticism of Weil and his methodology was published in the New Republic in December 1998. "Managed care and the industry of medicine have made the delivery of medical care much less friendly; doctors are less available, less interested personally, and don't spend enough time with patients. And the costs keep going up. Patients are turned off."

It's these kinds of reasons that made alternative medicine appealing to Marjorie Turner of Bellingham, Massachusetts, who was diagnosed in 1993 with a brain tumor that paralyzed her entire right side. Following the advice of her doctor, she had surgery to remove the tumor. The experience left her both physically and mentally drained.

"About six months after the surgery I began having seizures" accompanied by acute exhaustion, Turner recalls. She began seeing a seizure specialist and experimenting with different medications but, she says, "the doctors I was seeing were telling me they weren't seizures. I was becoming very, very depressed. I thought I was dying. And I thought, `Is this as good as it gets?' "

Turner wasn't convinced, and so she sought out Dr. Keith Rafal, a Franklin, Massachusetts-based homeopath who is medical director of the Fibromyalgia Rehabilitation Center in North Smithfield. Along with a variety of substances like licorice and ginseng, Rafal put Turner on causticum, a homeopathic medicine used to treat a variety of diseases, from warts to incontinence. "All the sudden, the 10 days each month when I am extremely vulnerable to seizure were remarkably improved," Turner says.

At the same time, Turner's seizure specialist kept adjusting her medication to find the appropriate dosage. And when she stopped taking the Tegratol and Zoloft that the specialist prescribed for her, Turner experienced an instant increase in her seizures. But she places more importance on the time that Rafal spends with her, discussing her illness and treatment -- making her feel, in effect, that her health care is not something to be rushed through and experimented with. "I highly value it," she says. "He's an excellent listener. He always checks in and asks questions that other doctors never ask, always laughs at the right places. To me, it addresses the whole person."

Using a prevalent term in the realm of alternative medicine, Turner describes how Rafal treats her based on a "wellness model," instead of through the "illness model" of conventional medicine. In the same way, homeopathy necessitates treating all the different aspects of a patient before and during the treatment for a specific illness. It's a matter, Rafal says, of "bringing the body's physiology into balance. If we're out of balance, the effect may be physical or emotional. I need to understand the totality of a person's symptoms, the physical and emotional. The mind, the body, and the spirit are a big part of the services we provide. Inherently, many people feel like we're more than our head and our joints. What's more important is who is that patient? What is going on in their lives?"

The problem is, of course, that there is almost no evidence that alternative therapies work. In 1985, Consumer Reports asked Dr. Stephen Barrett, a now-retired psychiatrist from Allentown, Pennsylvania, to investigate the efficacy of alternative therapies. What Barrett found disturbed him. "It's absolute and complete rubbish," he says.

Barrett started a newsletter to monitor the evolving world of alternative medicine. The newsletter has since morphed into a Web-page, Quackwatch.com, which remains dedicated to debunking alternative therapies. In terms of science-based studies, "There is no evidence that [alternative medicine] is effective against any disease," he says.

Ample evidence exists in the form of patient testimonials and non-mainstream studies, according to alternative practitioners, but they say that conventional medical journals will not print them. "There have been a hundred studies world-wide, but you won't see them in the Journal of the American Medical Association (JAMA)," Rafal says. "People get very dogmatic about it; and there have traditionally been two camps out there, one who says, what we have is what we have. They don't want to see anything else."

But JAMA not long ago published an analysis that looked at the results of many of the recent alternative medicine studies. The analysis found that every study either had a design flaw or showed that alternative practices had an effect that was at or below the level of a placebo. In other words, alternative medicines essentially performed at the same level than no treatment at all. Despite this, JAMA still named complementary and alternative care as one of the topics most deserving of additional examination in the journal. The idea that conventional doctors would subvert positive studies, Relman says, "is just nonsense, an outright canard, as evidenced by JAMA's eagerness to put together an issue on it. The reason there have been so few is that they can't stand up to peer review. I would have been delighted; [but] in the 14 years that I was editor [of the New England Journal of Medicine], I never got a good paper."

There is, inversely, strong evidence otherwise: paper after paper showing that alternative therapies do not work. In April 1998, JAMA published a study designed by a 12-year-old Colorado girl (implemented by physicians and scientists, and sound enough that JAMA found no fault with its design, implementation, or results) that tested therapeutic touch. The study concluded that "no well-designed study demonstrates any health benefit from TT [therapeutic touch]. These facts, together with our experimental findings, suggest that TT claims are groundless and that further use of TT by health professionals is unjustified."

Confronted with this contrary-evidence, alternative physicians tend to talk about both the science of alternative therapies and about things that, though unprovable, make "common sense." Rafal, for example, gives the example of his feline. "My cat had hurt its leg, and it was limping around for two weeks. I was just about to take it to the vet, but instead I gave it a homeopathic remedy. It got better right away. If the remedy that I give them is not the correct remedy," he says. "They don't get better."

In actuality, though, homeopathy is based on sketchy science. For example, the standard homeopathic remedy consists of a sugar pill mixed with a much-diluted substance that causes the symptoms of the illness being treated. But according to Barrett, these substances have actually been diluted to such small virtually or non-existent percentages that to guarantee the presence of even one molecule of a standard homeopathic drug, one would need a container more than 30 billion times the size of the Earth. Rafal responds that this is clearly the case of traditional medicine being stuck in its own paradigm, unwilling to consider techniques and theories that don't fall within it. His explanation for homeopathy is based on what he claims to be an abstract form of quantum physics, but which is actually unsound chemistry. The substances in homeopathic remedies, though too small to detect, somehow leave "energy imprints" that affect all the other elements in the remedy, like the sugar that makes up the bulk of the pill, or the water that makes up most of the syrup, he says. "Even if there is none of that substance left, it would affect it."

Barrett says this begs the question, why don't other substances -- such as the air that we breathe or the other elements that make up a homeopathic pill -- have any effect? Why are we not affected every day by substances that get on our hands, into our food and water, like the cyanide in our cigarettes or the carbon monoxide in the air? In reality, were Rafal's theory to be true, only those elements that a homeopath intends to affect a patient would be able to stand up, separate themselves from all of the other ingredients, and behave in a way in which none of those impurities do. Relman says this is absurd. "There ain't no other paradigm -- you either base your behavior on evidence," he says, "or you lose yourself in the dream world."

Some alternative treatments clearly demand a closer look by the establishment. Acupuncture, for example, has been used for a long time by a lot of people, and in some limited trials has recently proven to be effective for a variety of applications, including the reduction of nausea in chemotherapy and postoperative patients, as well as in postoperative dental pain. It has also shown some value in treating such disparate conditions as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, lower back pain, arthritis, asthma, lower back pain, carpal tunnel syndrome, and all sorts of rheumatism. And while a recent National Institute of Health assessment of acupuncture analyses showed that most evidence is flawed in either its execution or in its interpretation of results, it concluded that, "promising results have emerged. Further research is likely to uncover additional areas where acupuncture interventions will be useful."

Marino Center co-director Donna George finds the fact that some people use acupuncture for surgical anesthesia convincing enough. "You either have pain or you don't. How can you argue with that?" she asks.

And then there is chiropractic, a wildly popular practice that was viewed a few decades ago as something akin to a brand of quackery. According to the American Chiropractic Association (ACA), one in 10 Americans have visited a chiropractor at least once. It is awfully difficult to argue with the millions of people who visit a chiropractor, get their backs manipulated, and come out feeling better. Dr. Jerome F. McAndrews, a spokesman for the ACA, says this kind of patient satisfaction is proof enough. "Go back to the real world and look what happened to real people who have used this," he suggests.

Even Weil, though, notes with caution in Spontaneous Healing, that many chiropractic devotees more closely resemble cash cows than patients. "In my experience," he writes, "chiropractors still take too many x-rays and are too likely to have patients commit to long and costly treatment packages . . . Some people see their chiropractors once or twice a week just to get adjusted, whether or not they have anything wrong with them."

But many other advocates of alternative medicine are content to find validation in the results that they help to deliver. George says she has often seen alternative treatments work -- and work easily -- where conventional treatments have simply failed, particularly in cases of allergies. "Patients [who visit conventional practitioners] are diagnosed with a severe allergy, and either there is little that can be done, or they have to go get an injection every week," she says. At the Marino Center, George treats allergies homeopathically by placing small doses of the allergy-causing substance directly under the tongues of patients. She says the results are clear. "It helps significantly. With pollen, for example, people find that their pollen allergies come down considerably," she says. "And what's better is that they can self-manage their allergies" with prescriptions that are more effective than standard prescription treatments, without side effects, and which can be taken at home.

Weil's Spontaneous Healing is full of cases of patients who have used alternative therapies to heal after facing debilitating illnesses. John Luja, of St. Louis, for example, was diagnosed in 1980 with scleroderma, a potentially fatal autoimmune disease in which the skin hardens, and becomes red and itchy. Doctors told Luja that he would likely die from the disease, but he recovered after instituting a regimen of vitamin E and vinegar-lemon tonics. As George says, "If the end result is, a patient gets better, isn't that what it is all about?"

When pressed, Barrett does concede that some alternative therapies can positively affect patients. He says that chiropractic "may have some usefulness on acute lower back pain, if properly diagnosed. Some herbs may be effective. Massage can make you feel better." He cites studies and the lack of good evidence to the contrary, though, in concluding that alternative therapies "have no effect on disease."

Barrett and other doctors are concerned with research not merely for academic reasons, but also because of the possibility that drugs and treatments can cause real harm to patients. Fen-phen, for example, was a popular weight-loss remedy before evidence emerged in 1997 that the drug combination posed a health risk, and the FDA asked manufacturers to voluntarily withdraw the product. Conventional doctors also know that removing symptoms and controlling pain do not necessarily indicate whether a patient is cured, but more frequently reflect a well-known phenomenon called the placebo effect; If a patient has belief and hope in a physician or a remedy, the patient will often feel better and show a decrease in symptoms, regardless of the effectiveness of that remedy. This effect happens even if a patient is, for example, given water by a trusted physician and told that it is a new medicine designed to fight their illness.

"Feeling better is not a good sign that you've been helped," Barrett says. "Twenty million people like astrology. It is a cult-like phenomenon where a tension is relieved by misinformation. You go to a religious service and you feel better. People who are worried and the chiropractor tells them this will help them, they feel better. The question of whether it is working, is very difficult to determine. Personal experience is not, in many situations, a valuable way to tell if a method has helped you."

There are also alternatives to the strict alternative and conventional paradigms, ways in which doctors are availing themselves to practices that might better connect them to their patients while still providing standard, conventional care. Dr. Cornelius "Skip" Granai, director of the women's oncology program at Women and Infants Hospital in Providence says the best part of alternative medicine, as conventional doctors see it thus far, provides conventional physicians with a bridge -- known as complementary care -- to treat patients more like humans, rather than grist for the managed care mill. "It's absolutely essential that people respect the protection of the scientific method," Granai says. "People have been selling snake oil for centuries. We have a reason behind what we do. But can you do more than that? More than what the scientific evidence will allow you to think about?"

Granai is slowly introducing non-standard practices into his treatment of women with cancer, not to change the outcome of their disease, but simply to make them feel better while they face treatments like chemotherapy and radiation. Similarly, "We started offering massage therapy during chemo, gave people the ability to have a pet with them during chemo, and we asked them what they thought. Virtually all of them said that it was significantly better. Poetry might not seem like a big thing, but if you try to spend some time writing a poem with a patient [during] chemo, it changes the whole relationship with a patient," he says.

The question, Granai says, is "can we do more than evidence-based medicine? Common sense says that we can, but we don't want to do it by breaching any common ethics. But can we enhance the moment without changing the outcome?"

Granai says conventional doctors will be supportive of some things once considered alternative if the context remains that of traditional science. "Slowly and carefully doctors are observing these things, and are more open to them," he says. As evidence that the landscape is shifting, Granai refers to a paper on complementary care that he recently presented to a conference of gynecological oncologists. "In 1993 or '94, I sent [the paper] in to our society. It was summarily rejected. And [again] in 1995. In 1997, without changing a word, it was accepted. At the end, after my talk, all of these doctors -- Nobel candidates -- they all begin to tell their own stories, they all want to talk about their experiences with this. So this year, they invited me back to speak."

The alternative landscape is also shifting. Instead of pushing an alternative care platform as in the past, pragmatic alterna-docs like Weil are talking more and more about preventive care. It sounds somewhat like the "apple a day" advice that traditional doctors have been prescribing for years. Weil's 1995 book, Spontaneous Healing, represents his evolution: a good third of the book revolves around things that aren't alternative at all, and it also emphasizes a healthy diet, stress relief, and good exercise (He also calls on readers to go out and buy flowers once a week). Sounding something like a contemporary fashion-fitness mag writer, Weil prescribes an eight-week program for optimizing health.

In Spontaneous Healing, Weil also expresses his own reluctance to accept testimonials carte-blanch, but he doesn't completely reject them either. "The essence of good science is open-minded inquiry," he writes, "so would it not make sense to try, at least, to verify the stories?"

Later, the one-time apostate of conventional medicine concedes that his traditional training was indeed necessary, and remains relevant, to his life's work. "How can doctors and patients access healing more of the time?" he asks. "I was looking for answers in the wrong way . . . I did not have to turn from my own land and culture, my formal education, and my own self to find the source of healing."

At its best, alternative medicine is at least forcing doctors to think about Weil's query and the way they are serving -- and disserving -- patients. Meanwhile, the rigorous examination of alternative medicine that conventional doctors clamor for seems to be on the way. In1998, the National Institute of Health announced that it would spend an extra $8 million this year in researching alternative therapies, ranging from tests of acupuncture to trials of the efficacy of shark or bovine cartilage in treating cancer. NIH expenditures for such research are up 1000 percent since 1992.

There are, however, issues greater still. In some cases alternative medicine's insistence on the merits of its therapies can have dangerous outcomes, as in the case of patients who skip prostate exams or mammograms in favor of a dubious alternative. Barrett says he hears roughly once a week about a similar, albeit more worrisome, scenario: a conventional physician tells a patient that they have a life-threatening disease, like cancer, and that they need to be treated by difficult, long, and not 100 percent effective treatments, like chemo or radiation. Scared or looking for an easier answer, patients often put all of their faith in an alternative physician's treatment, ignoring the conventional response they may desperately need. Says Barrett, "People who are sick very much want to hear that there was something very simple that they could do to make them better."

While there have been no published studies tracing how often this type of thing occurs, Relman says it clearly does. "There's no question of that happening -- people who don't tell their doctor, who are angry at the tradition for not being able to give them the answer they want to hear; people who go to Mexico and get some crazy operation and die from cancer two days later," he says.

This is the basis of an inherently human search, one that we all -- sick or well -- find extremely attractive, and one which alternative medicine caters to. It is one that existed long before the debate over conventional vs. alternative medicines, one that existed well before medicine was much more than superstition and prayer -- the belief that a magic cure can be found somewhere; in a plant in the remote rain forest; in the doctor's office; that some shaman, somewhere; or an unknown and ancient religion, maybe, possesses a secret into healing and our very soul. This is what is important. This belief animates our appetite for alternative medicine, motivates us to shell out collective millions for herbs and supplements -- looking for the magic pill, be it ginkgo biloba, vitamin E, or some hallucinogenic mushroom found only in a virgin rainforest.

After all, one of the things that science has always tried to cure, and always failed, is death. Conventional medicine, for the 30 years that it has added to our lifespans, hasn't found what Ponce deLeon looked for -- on a quest similar to Weil's search in the Amazon -- in our own once-exotic land: the fountain that denies our mortality, and confirms and reaffirms our spirituality. Alternative medicine often does make people feel better. So do for that matter, Christianity and other forms of organized religion. They both are, after all, appealing to the same desire. They both essentially tell us that there are yet things that we don't understand -- forces of energy both human and supernal -- and then, therefore, hope. And hope is a funny thing: it is hope, after all, that has put the thrust behind an infinite number of searches. It is hope that sparked this nation, and hope inspired the Civil Rights movement. Heck, it's hope that produced the scientific process in the first place. But it is also hope -- and hopes being ruined -- that has caused some of the most irrational behavior the planet has seen, from any religious conflict or persecution you can think of, to 300 followers of a Korean faith healer taking over a television station in Seoul.

Relman thinks that this hope is the real driving force behind the alternative medicine movement. "It is a kind of religion, a secular religion, in that it talks about soul and spirit and the individual mind and the world, and the ability of the mind and the soul to win out over the body and disease," he says. "A lot of people, in their hearts, are anti-science and anti-technology. They don't like the picture of the world and of the human body that science demands of them. They want to believe that there is something more spiritual, less indifferent to the fate of man."

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Alt.Medicine 101

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David Andrew Stoler can be reached at dstoler@gis.net.