THE WHOLE STORY: Alternative Medicine On Trial? by Toby Murcott, Palgrave Macmillan, 2005, 192 pages, $24.95 (ISBN 1-4039-4500-4)
COPELAND'S CURE: Homeopathy and the War Between Conventional and Alternative Medicine, by Natalie Robins, Knopf, 2005, 352 pages, $24.95 (ISBN 0-375-41090-2)
Alternative medicine, or its use in combination with conventional medicine (collectively called complementary medicine), is like pornography: It's easier to recognize than to define. One possible definition is practices that differ from the conventional medical practices used by most physicians. But I agree with the former editors of the Journal of the American Medical Association and the New England Journal of Medicine, who have indicated that there can be only one type of medicine: that which has been tested and found to work.
Complementary and alternative medicine (CAM) encompasses a variety of therapies. Most widely accepted are chiropractic and acupuncture, which are licensed in 50 and 38 states, respectively. Spinal manipulation by chiropractors appears as effective as conventional medical treatment for acute low back pain, which generally improves on its own. However, there is no anatomical evidence for the presence of spinal "subluxations" that form the basis of spinal manipulation used by some chiropractors to treat such diverse ailments as earaches and urinary tract infections.
In a recent 26-week trial at the University of Maryland, acupuncture seemed to improve function and provide better pain relief for osteoarthritis of the knee compared with sham acupuncture or education (Ann. Intern. Med. 2004, 141, 901). (Sham acupuncture involves using a special device to place fake needles on the areas of the body where the patients who receive true acupuncture get real needles. The fake needles do not pierce the skin, but they create a needlelike feeling, and the device that holds the needles in place makes it look as if they have been inserted.) But proof of the theoretical underpinnings of acupuncture remains elusive, and few other controlled studies have shown benefit from such treatment.
Herbs, another variety of CAM, are widely purchased despite the general lack of evidence for their effectiveness and considerable documentation of possible dangers. Controlled trials of herbs have increased since the formation of the Office of Alternative Medicine at the National Institutes of Health in 1992. But the Dietary Supplement Health & Education Act of 1994, which prevents the Food & Drug Administration from determining the safety and effectiveness of herbs and other dietary supplements, hinders progress in that arena.
I find that some forms of CAM--for example, therapeutic touch, aromatherapy, and homeopathy--are especially questionable because they exceed limits of credibility. I simply cannot believe that ailments can be cured by touching the right spot, smelling the aroma of violets, or swallowing an almost infinitely diluted nostrum.
Toby Murcott, an experienced science writer with a Ph.D. in biochemistry, tackles the subject of complementary and alternative medicine in a new book, "The Whole Story: Alternative Medicine On Trial?" An excellent introduction to the topic, "The Whole Story" emphasizes the need to determine whether these treatments are effective and the hurdles that must be overcome to achieve this objective. The book also explores why CAM has become so popular that about a third of Americans, more often people who are better educated and have higher than average incomes, use some form of CAM every year.
As the author points out, the great advances in scientific medicine have led the public to expect a cure for everything, but medicine can do little for most chronic disorders. Discouraged patients turn instead to CAM remedies, which offer hope and often promise a cure, and to practitioners who spend more time with patients and provide more comfort than harried physicians. The worried well are attracted by spectacular claims in the media and on the Internet that these therapies provide even better health and well-being.
But does CAM work? The author addresses this issue in a thoughtful and evenhanded way that examines the positive features and shortcomings of these therapies, as well as those of conventional medicine. The overwhelming problem with these treatments is the almost total lack of scientific evidence that any of them work. Although the efficacy and safety of herbs and other dietary supplements can be determined by the same type of controlled clinical trials used to evaluate standard medications, such trials are less feasible for treatments that rely heavily on interactions between patient and therapist.
The difficulty is particularly great for homeopathy, which employs different remedies for patients with the same disorder or symptoms. As a result, it is very hard to enroll in a study enough patients who have received the same treatment. Benefits in conventional clinical trials are largely determined by objective measurements made by the therapist. By contrast, it is much more difficult to measure benefits of CAM treatments, which may only be apparent to the patient.
In fact, many conventional physicians believe that any benefits of CAM result only from a placebo effect or from the long time spent by practitioners with their patients. Advocates retort that as long as it works, so what if it's a placebo effect? In fact, many CAM practitioners are skeptical of the present rage for "evidence-based medicine."
One danger of this attitude is a possible unwillingness of CAM practitioners to accept firm proof that a form of this type of treatment is ineffective. For example, chelation therapy has become a popular treatment for heart problems such as atherosclerosis. The patient receives 30 intravenous infusions of ethylenediaminetetraacetic acid, which, it is claimed, removes calcium from atherosclerotic arterial plaques. The infusions also ostensibly inactivate heavy metals like copper to limit oxidation of lipids on cholesterol-carrying proteins, thus preventing them from depositing in the walls of arteries. But even after four careful trials showed that chelation therapy did not benefit patients with cardiovascular disease, one leading proponent commented that he would continue to use chelation because he had observed it was effective in his own patients.
Homeopathy, one of the most scientifically intractable forms of CAM, is the subject of Natalie Robins' new book "Copeland's Cure: Homeopathy and the War Between Conventional and Alternative Medicine." The title perfectly describes the content of the book, which interweaves a biography of the famous homeopathist Royal Copeland with the battles between the American Medical Association (AMA) and the practice of homeopathy. Robins, who has authored eight books, has no formal background in science or medicine, but she amply documents her sources. Although it's worthwhile to read about an influential man like Copeland, I'm not sure it's useful to learn so much about homeopathy, an illogical and dying form of medicine. (Homeopathic practice and teaching have declined considerably. At the turn of the century, there were 44 homeopathic medical schools; all disappeared by the mid-1940s. The 60 homeopathic hospitals found around the country in 1914 are also all gone.)
Copeland was a homeopathic eye specialist who devoted almost equal time to politics and efforts to advance homeopathy. He served as dean of the Homeopathic Medical School of Michigan and later dean of New York Homeopathic Hospital. He spoke often to lay and professional groups about homeopathy, wrote a nationally syndicated newspaper column entitled "Your Health" in the 1920s, started a weekly radio program in 1928, and was an entrepreneur who also endorsed a number of questionable health products such as "Pluto Concentrated Spring Water" as a cure for constipation. (His book, "Over Weight? Guard Your Health" might be appropriate for today's weighty Americans.) Copeland began his political career as mayor of Ann Arbor, Mich. After serving as health commissioner of New York City at the end of World War I, he was elected to three terms as a U.S. senator from New York.
A 1997 meta-analysis in the Lancet, which asked whether the clinical effects of homeopathy are due to placebo effects, begins with the statement, "Homeopathy seems scientifically implausible, but has widespread use." Judge for yourself whether homeopathy is plausible: Homeopathy was founded in 1796 by Christian Friedrich Samuel Hahnemann in Germany. Its two guiding principles are that like cures like-- that is, the effects of a curing substance must resemble the illness or symptoms that are treated--and that medications should be given in the smallest possible doses, usually one remedy at a time.
To achieve the second principle, herbs; minerals; or parts of insects, shellfish, or animals are dissolved in water or alcohol and then subjected to repeated dilution, followed by vigorous shaking, until the dilution is so great that not even a single molecule of the remedial compound could remain. The solution is then added to a sugar tablet to produce the therapeutic pill. Homeopathic advocates explain this seemingly irrational approach by arguing that the diluting substance maintains a "memory" of the medication. Because choice of the correct medication for a patient depends not only on symptoms but also on the individual's physical appearance and emotional state, homeopathic physicians must spend large amounts of time with their patients to gather this information.
Nevertheless, the authors of the meta-analysis concluded that the clinical results of homeopathy are not completely due to a placebo effect. They found "insufficient evidence that homeopathy is clearly efficacious for any single clinical condition," but stated that further rigorous research on homeopathy is warranted. These conclusions are similar to ones frequently reached in articles examining the efficacy of various forms of CAM. Such statements may leave the unwary reader with the feeling that homeopathy "may just be worth a try." But ideally, the conclusion would encourage homeopathic physicians to carry out well-controlled studies in a large enough number of patients with the same disorder to produce some valid results.
The last quarter of the book, largely a description of attempts to use scientific methods to determine the effectiveness of homeopathy, is less illuminating and interesting because these efforts have largely proven fruitless. In fact, I believe that no amount of study will prove the effectiveness of this irrational mode of treatment.
Some homeopaths have continued to try to prove their case, but to no avail. The only major scientific triumph of homeopathy was a 1992 publication in the peer-reviewed journal Pediatrics that reported some benefit of homeopathy in the treatment of childhood diarrhea in Nicaragua. But subsequent critical analyses raised many doubts about the results of the study and even questioned whether the article should have been accepted for publication.
I have the impression that Robins believes that homeopathy does work. Thus, she seems to identify the author of the Pediatrics paper as a kind of heroic figure for fostering the scientific study of homeopathy in general and for the continued effort to prove the value of homeopathy for the treatment of diarrhea. Robins also displays some antipathy to AMA's opposition to homeopathy and to its efforts to discourage the use of quackery and unproven treatments. For example, she states that AMA "contemptuously reported" unfavorably regarding naturopathic objections to the Salk vaccine.
While it's easy to object to many political positions of AMA, past and present, it's difficult to fault them for trying to protect what the author of "The Whole Story" terms a "vulnerable, credulous public." I might add that these characteristics of the public aptly describe one reason why CAM has become so popular. Protection of this public might therefore best be attained by modifying the Dietary Supplement Health & Education Act to require that FDA test the safety and effectiveness of complementary and alternative medical therapies.
Simeon Margolis is professor of medicine and biological chemistry at Johns Hopkins University School of Medicine; he has testified before the White House Commission on Complementary & Alternative Medicine.