Sunday, January 1, 2012

Putting Alternative Medicine to the Test

St. John's Wort
As the year 2012 begins, I'm taking stock of where this blog has gone.  It started as a way to record my thoughts on whatever bits of trivia tickled my fancy, but lately it's veered into slightly more serious territory.  Over the last year, while watching people squabble in the comment threads on Facebook and elsewhere, I've become convinced that people should spend more time coolly explaining what they believe, and why.  So, I've been trying to put my money where my mouth is, and do just that.  Interestingly, people have shown more interest in these philosophical posts than the ones about obscure songs and linguistic quirks.  Not to toot my own horn, but some of my recent posts have had tens and tens of people read them. I'm hitting the big time here.

Still, my day job as a reference librarian is the one that pays the bills.  One of the things I do in that job is put together guides to good information sources, and put them up on our website. The other day, I was looking up sources on health and medicine, trying to find accurate, unbiased information that could easily be understood by the public. This turned out to be harder than I thought.

As I've mentioned in a previous post, I'm pretty skeptical about complimentary and alternative medicine (CAM, as it's abbreviated nowadays).  My instinct is to agree with the comedian Tim Minchin:"You know what they call 'alternative medicine' that’s been proved to work? Medicine."  But, as a librarian, I'm supposed to give people access all sides of an issue.  This was a dilemma.  Should I give alternative medicine equal space with conventional medicine?  If so, which strand of alternative medicine?  Should chiropractic get the same coverage as acupuncture?  What about more fringe practices, like crystal healing?  The thing is, librarians are also supposed to help people evaluate information to see if it is reliable.  How do you evaluate the quality of something you don't believe in? 

I decided to try to find the most balanced book I could on alternative medicine, something that evaluates different treatments empirically and with a fair-mind, and gives the evidence about which ones work...and which ones don't.  Unexpectedly, I found a really good one.  It's called Trick or Treatment: The Undeniable Facts about Alternative Medicine.  One of the authors, Edzard Ernst, is an MD, and a recently retired professor of Complementary Medicine at the University of Exeter (more on his retirement later).  The other is Simon Singh, a well-known science journalist with a Ph.D in physics.  This struck me as a good, balanced combination.  In the book, they try to evaluate alternative medicine based on the only questions that ultimately matter in medicine:  Does a particular treatment measurably improve people's health, and does it do so more effectively than other treatments?  The book devotes whole chapters to the four most widespread alternative therapies--acupuncture, homeopathy, chiropractic therapy, and herbal medicine--and gives one-page evaluations of 36 other practices, including chelation therapy, crystal healing, massage therapy, naturopathy, and many others.

What Works?

After reading the book, I now know that most of the alternative therapies described do, in fact, make people feel better. knew there was going to be a "but", right?...sugar pills also make people feel better.  One of the most amazing things I learned from the book is how impressive the placebo effect really is.  If people think a treatment will make them feel better, even if that treatment has absolutely no physical or chemical effect on the body, it probably will make them feel better, at least for a while.  The placebo effect is, in fact, an effect, and a very powerful one.  So, with any kind of treatment, mainstream or alternative, the question is:  Does the treatment work better than a placebo?

The way to find out is to do an experiment, also known as a clinical trial.  You probably already know what this means, but here's a quick reminder.  In the simplest form of a clinical trial, you take a group of people (the more the better) and randomly assign them into two groups.  Give one group the treatment, and another a placebo.  Obviously, the placebo is as indistinguishable from the treatment as possible, and the patients are not told which one they are getting.  In fact, in the best experiments, even the people in the white coats don't know which treatment is which.  This is because experimenters tend to unconsciously treat the two groups differently.  If they know they are giving someone a placebo, they may talk to them less, avert their eyes, spend less time with them...that sort of thing.  Experiments that control for this are said to be double-blind, because both the researcher and the patients are blind to which treatment the patient is getting. 

When you look at alternative therapies using randomized, placebo-controlled, double-blind trials, they start to lose a lot of their luster.  Most of them don't work any better than a placebo, and the ones that do have far more limited effectiveness than most of their practitioners claim. Chiropractic seems to truly work for treating lower back pain, but not any of the other ailments chiropractors often claim to heal. Acupuncture may help with pain and nausea, but not much else, and the effect on pain and nausea is not much better than a placebo.  Hypnotherapy, massage therapy, meditation, and relaxation therapy can all have very positive effects, but they won't cure any serious physical problems.  Homeopathy, crystal therapy, reiki, and the various kinds of detox programs are based on concepts that, from a scientific point of view, make no sense. They are placebos at best, and scams at worst.  Chelation therapy, colonic irrigation, and many other fringe treatments can be downright dangerous.  Herbal therapy is, of course, a mixed bag, because it uses a variety of different herbs.  Chamomile and lavender don't seem to do much of anything besides taste or smell good.  Garlic, on the other hand, seems to really help with high cholesterol, while echinacea may help with colds, and St. John's Wort does seem to help with depression.  Ma huang, or ephedra, really can help you lose weight.  But it will probably damage your heart in the process.

What Are the Dangers?

Wait, what?  A herbal treatment can be dangerous?  A lot of people figure they may as well try alternative therapies, because, well...what can it hurt?  The answer is a lot, depending on the therapy.  There are real risks associated with almost all alternative medicines.  One is a sort of "risk by neglect".  Very often, people with life-threatening diseases seek alternative therapies, and fail to get the mainstream treatment that could really help them.  Of course, we've seen that many alternative therapies actually do make people better, at least for a while, because of the placebo effect.  But that doesn't mean there aren't real medicines out there that work much better than a placebo.  The placebo effect is powerful, but you don't want to rely on it to treat a really serious illness if there's something better.  Even if an alternative treatment has a real effect, as St. John's Wort seems to for depression, there may be more effective treatments available.

Besides the negative risks of forgoing effective treatment, many alternative therapies have positive risks: they are actively dangerous.  Besieds being really, really gross, a colonic irrigation can leave you with a perforated bowel.  Ephedra can give you a heart attack.  Chiropractic manipulation of your neck can increase your risk of stroke.  People assume that alternative therapies and natural remedies are harmless, but that assumption can be terribly wrong.  Take herbal remedies.  Many plants produce very potent chemicals, which can be dangerous or downright deadly.  Not only that, but quality control and regulation of herbal medicine (and the alternative medicine industry as a whole) is very weak.  This means one pill containing St. John's Wort could be much stronger than another, even from the same bottle.  Some alternative remedies have been found to have dangerous additives and contaminants.  A few have even been found to be laced with effective mainstream medicines, so that they will actually work.

Why is Alternative Medicine So Popular?

While some alternative therapies can be effective, many of them are elaborate placebos based on scientifically dubious or meaningless theories.  Some of them, such as ear candles, rely on outright trickery (the wax comes from the candle, not your ear).  Some of them can hurt or even kill you, and all but a handful can cost you time and money that would be better spent on lifestyle changes and mainstream treatments.  Despite all this, alternative therapies are hugely popular.  Why?

There are several possible reasons, of course, and many of them say fascinating things about human psychology.  A couple even have very good points to make.

Mainstream medicine can be awful

Possibly the biggest reason, or set of reasons, people choose CAM is revealed by the word "alternative": people want an alternative to mainstream medicine.  And it's not hard to see why.  We all know that conventional medicine has issues.  It can be horrifically expensive, and medical professionals are sometimes rude, rushed, and incompetent.  Hospitals and HMO's often put profit well in front of people; over-prescribing tests and drugs, rushing people through appointments, discharging patients too early, and so on.  Pharmaceutical companies have an especially bad reputation, and many of them have earned it.  They price-gouge, they don't research diseases they won't profit from, they don't study potential cures that aren't patentable, and they can twist and bend their studies in all sorts of ways to make their drugs seem better than they really are. But, despite all these problems, medical and pharmaceutical sciences have made astonishing breakthroughs in the last few decades. Antibiotics, vaccinations, new surgical procedures--all these things have saved millions of lives, far more lives than any alternative.   

Alternatives are seen as more natural 

Henri Rousseau, The Dream
Another reason people prefer many types of CAM, especially herbal medicine, naturopathy, and so on, is that it seems more natural.  This is another point of view I have some sympathy with.  Nature strikes many people, including me, as beautiful, and in some ways, harmonious.  I'm awestruck when I think about how perfectly adapted living things are to their habitat and to each other.  I'm amazed when I think about how nature recycles almost everything.  Clearly, we can learn a lot about how to live from nature.  However, a lot of people have a more mystical, romantic idea of nature's harmony.  They see how things fit together, and conclude that they were made to benefit each other.  Generally, they weren't.  Living things fit into their environment because they evolved to do so, not because they are there to play a beneficial role.  It's true that plants produce many amazing compounds with medicinal value, including taxol, digitalis, quinine, and many others.  But they don't produce these substances because they were put here to aid the human race.  Oftentimes, they produce them because they are toxic to animals trying to eat them.  For example, at the right dose, digitalis (which is produced by foxgloves) can steady an erratic heart.  At higher doses, it can stop it, and that is probably why it evolved--as a deterrent to animals that would like a foxglove salad.  As amazing as nature is, plenty of things in it will kill you dead.

Philosophers have long recognized that it's a fallacy to automatically equate "natural" with "good".  This is called the naturalistic fallacy, or the appeal to nature fallacy (there are subtle differences between the two).  If you take a close look at the animal world, for example, you will quickly find infanticide, siblicide, and forced sex.  Does that mean it's OK for us to do these things? Just because it's natural, doesn't mean its good. (The idea of the harmony and goodness of nature is a fascinating, complex topic that I can't begin to do justice to here. Sounds like a good blog post).  

Alternatives may be based on ancient traditions that people find appealing 

Traditional medicines like acupuncture and Ayurveda are very old, and come from cultures that have contributed astonishing things to the world.  Lots of modern westerners want to be open to non-western traditions.  I find this impulse admirable, and I also want to learn from other cultures.  However, I also believe that human error is cross-cultural.  Just because something is traditional doesn't mean it works, or that it makes sense.  Acupuncture may work sometimes, but probably not because of the traditional explanation: that the flow of Ch'i (subtle bodily energy) is being altered.  There is no scientific evidence of any such energy flows.  As far as I'm concerned, evidence is the bottom line.  If a treatment, even one that goes against modern scientific understanding, turns out to be safe and effective, let's use it, and then try to figure out what real, physical mechanism it is based on.  It may be that traditional medicine will give us remedies that revolutionize modern medicine.  But if so, they will be testable, and they will probably work differently than people in past ages suspected.  

Alternatives are seen as progressive or anti-establishment 

A lot of people want to rebel against tradition, mainstream culture, and the powers that be, and often for good reason.  I'm perfectly sympathetic to this impulse. A bunch of things about my culture (both old and new) strike me as idiotic.  I also think it's a good idea not to trust authority figures completely.  But how anti-establishment is alternative medicine, really?  In popular culture, it's widespread enough to be fairly mainstream.  Not only that, but some very powerful people support it.  Prince Charles--a representative of old school authority if there ever was one--is a big supporter of CAM, and his office has used some pretty heavy-handed tactics in promoting it. When Edzard Ernst, one of the authors of Trick or Treatment, questioned a report commissioned by the prince, he was accused of violating confidentiality, and saw his funding dry up.  He eventually took an early retirement. People who question alternative medicine can be seen as the real rebels.  In England, where libel is defined more loosely than the US, they are often sued.  Simon Singh, the other author of Trick or Treatment, and Ben Goldacre, another prominent alternative medicine skeptic, have both been sued for libel.  They won their cases, but the court costs ran into the hundreds of thousands of pounds, so, for all practical purposes, they were penalized for speaking the truth.

Of course, it's true that the mainstream medical establishment is powerful, and it's also true that they can't always be trusted.  However, that doesn't mean it's all a big conspiracy to keep alternative medicine down. When it gets right down to it, it doesn't matter whether a particular treatment is mainstream or alternative.  What matters is whether it works, and is safe.  The way to find that out is to test it under controlled conditions. For all its imperfections, modern, mainstream medicine is built on this method.  Alternative medicine, for the most part, is not.  

Alternatives seem more exciting and exotic 

Acupuncture Chart
People like mystery, magic, and the exotic.  Acupuncture is based on ancient Chinese traditions.  That's appealing to many westerners, in part because it strikes them as exotic and mysterious.  It seems to me that a lot of people are drawn to the unexplained because, well, it's unexplained.  That's what makes it exciting.  As soon as something is explained and familiar, people think it's less wondrous.  But consider this.  The universe is full of waves of primordial energy, flowing through space at mind-boggling speeds.  I have organs in my head that can detect these waves, process them, and allow me to form an image in my mind of distant objects.  These waves are called light, and those organs are called eyes.  Why aren't people as fascinated by light and sight (which are rather wondrous, if you think about it) as they are by things like Ch'i, ESP, and ghosts?  Because we are used to them, we know they exist, and science can (mostly) explain them.  Getting bored by the true wonders of the world is a woeful failure of imagination, and mistaking what is exotic for what is effective is a woeful failure of reason.  

Treatments may seem effective even when they aren't

As I've discussed, many CAM therapies are effective, strictly because of the placebo effect.  They're just not usually as effective as mainstream treatments.  Even without the placebo effect, though, people can easily get the impression that a treatment works, because they were going to get better anyway.  It's good to remember that the body has amazing abilities to heal itself.  Here's the thing:  most people go get medical treatment (alternative or mainstream) when they are feeling their very worst.  If you get treatment when you're at your lowest part of a short-term or cyclical ailment, it's all uphill from there, whether you take any medicine or not.  Scientists call this effect "regression to the mean", the "mean" being your normal state of health.  When people get better after getting an ineffective treatment, they tend to confuse correlation and causation.  They think, "I went and got that homeopathic remedy, and now that rash is better".  But the remedy probably didn't cause the improvement, any more than putting gas in your car caused you to have that flat tire later in the day.  The rash was probably going to get better on its own. The only way to know whether a treatment caused an improvement is to take a bunch of people with the same sort of rash, give some of them the homeopathic remedy, some of them an identical looking placebo, and for good measure, give some of them nothing.  My bet is that everyone would get better, although the people in the placebo and the homeopathy group might get better a little faster (since both groups took a placebo).  The mind is a powerful thing, even if it does play tricks on us.  

It looks like science, if you don't know what science looks like

It's a poor reflection on our education system, but most people have little idea what the scientific view of the world actually is.  They may hear about things like energy flows in the body, or footbaths that draw out "toxins", and assume that such things are perfectly in line with science.  They are not.  To make matters worse, lots of very dubious CAM treatments are dressed up in sciencey sounding language, throwing around words like "metabolism", "energy", "research", "toxins", and so on, but using them in a way that has nothing to do with real science.  Which brings us to the next issue.

Some CAM practitioners are dishonest, and others are just gullible 

Let's take a closer look at those detox foot baths. They are easy to find online, and this link will take you to one offered by the well-known company Gaiam.  You turn this device on, fill it with salt water, plug it in, and put your feet in it (yeah, it sounds dangerous to me, too).  Over the course of the 30-minute treatment the water will turn a rusty brown color.  The "D-Tox" in the product's name suggests that the color comes from toxins drawn out of your body through your feet.  What's actually happening is that the electricity going to the footbath causes a metal coil to react with the salt, and rust.  The water fills up with rust, which people think must be toxins from their body.  They are wrong.  You could let the thing run without your feet in it, and after thirty minutes it would look exactly the same--full of rusty water.  The fact is, this device is a scam.  The world has always had more than its share of snake oil salesmen, and unfortunately, that is the only way to describe many purveyors of the wackier sorts of CAM treatments.  Probably a far larger percentage of CAM practitioners have fallen for the scams and placebos themselves, and have convinced themselves, honesty but gullibly, that their methods work.  Scientifically-literate CAM practitioners, who look at hard evidence critically before using a treatment, are as rare as four-leaf clovers.
Whither Alternative Medicine?

As this long-winded post shows, I've done a lot of thinking about whether alternative medicine works or not, and why people believe in it.  I haven't pondered the future of alternative medicine as much, but I do have a couple of thoughts about what I would like to see happen.  For one thing, I disagree with people who don't think there should be public funding of CAM research.  There are those who think the National Center for Complementary and Alternative Medicine (part of the National Institutes of Health), should be de-funded.  I think an organization like this could be very valuable.  For example, the NCCAM website has a lot of good information about the evidence for different CAM treatments.  They can also fill in a gap in research.  It's true that pharmaceutical companies have little incentive to research a cheap, naturally occurring compound, (unless they think they can improve on it, patent it, and profit from it).  Public research into such potential medicines could take up that slack.  Also, there is an issue of fairness.  Some skeptics say that CAM research should be abandoned, because there's no evidence that it works.  If there's been exhaustive research on a treatment, and that treatment has been repeatedly shown not to work, then they are right.  However, if the evidence isn't there simply because there's been no research, then there needs to be more research.  You can't say, "There's no research to show that this treatment works", and then say, "We shouldn't fund research on that, because it doesn't work".  Well, you could, but it wouldn't be very cricket, would it? 

Of course, it's true that the majority of research funding should go to the most promising treatments.  If a treatment such as crystal healing claims to work based on forces unknown to science (and it does), then we probably shouldn't waste a whole lot of money studying it.  But perhaps we should research it a little.  If we find out that it doesn't work (and I'm 99.9 percent sure that we would) that is a useful result.  It's something that could be shown to people, to try to convince them not to waste their money on it.

Another thing that needs to happen is that CAM should be regulated just as tightly as the healthcare industry.  Right now, it's pretty lawless.  There needs to be better quality control on alternative pills and potions, so that they deliver standardized doses, and so they aren't contaminated with toxins.  Alternative health products should have to go through the same safety testing as mainstream drugs.  They should be labeled just as extensively, with warnings about possible side effects, and information on research into their effectiveness (or lack thereof).  Practitioners should be regulated just as tightly, too.  If the evidence shows that chiropractors can't help with major problems like heart disease, then they shouldn't be allowed to claim that they can.  Taking someone's money to treat a major disease with something proven to be ineffective--that's a lowdown, dirty thing to do, and there should be serious penalties for it. 

Generally, I think about medicine, alternative or mainstream, the same way I think about any proposal or idea--test it, and see if it stands up to scrutiny.  In science and philosophy, I think that we should give all ideas enough consideration to establish whether they make sense or not (this may not take long), and then try poke holes in them.  The ones that can stand up to our scrutiny are the ones we should accept as true.  The same goes for medical treatments.  Test them all, fairly but relentlessly.  If they works, keep them.  If not, let them go.

Links and Further Reading

Trick or Treatment:  The Undeniable Facts about Alternative Medicine / Edzard Ernst and Simon Singh

Bad Science:  Quacks, Hacks, and Big Pharma Flacks / Ben Goldacre  This is also a fabulous book, and Dr. Goldacre is a brilliantly witty writer.  He skewers a lot of alternative medicines, but he also skewers the tactics of the pharmaceutical industry.  Call me naive, but I don't think he's on their payroll.

Cochrane Summaries  The Cochrane Collaboration is an independent research program that does systematic reviews of the evidence for various medical treatments.  By reviewing multiple studies, they strengthen the statistics, allowing a more powerful, comprehensive look at whether a treatment (mainstream or alternative) really works.

National Center for Alternative and Complementary Medicine  Funds research into CAM, and has good information on the effectiveness of various treatments.