Complementary and alternative medicine, or CAM, which includes herbal medicine, chiropractic, acupuncture, Ayurveda, and traditional Chinese medicine, sits at the awkward intersection of medicine, spirituality, and tradition.
Often touted for being antiestablishment, CAM is increasingly finding its way into the mainstream, through doctors’ offices, insurance companies, supplements, and the media. There’s even a division of the National Institutes of Health, the National Center for Complementary and Alternative Medicine (NCCAM), devoted entirely to CAM. Established in the early 90s, NCCAM’s mission is to determine which CAM therapies are effective and why. Medical schools, funded by NCCAM and private philanthropists, are now offering classes in and have their own research facilities devoted to CAM.
And while the recent popularization of CAM warrants analysis and criticism, this isn’t meant to be a post about whether CAM is good or bad, works or doesn’t; my aim is to gain a greater understanding of who (besides you, perhaps) benefits from the use of CAM and how our current fascination with CAM plays out in today’s market-driven world. For many of us, CAM has been instrumental in the healing process: whether because the treatments in and of themselves are more effective than a placebo; because of the placebo effect, or some other effect related to the mind-body connection; or whether time itself allowed healing to take place. While remaining agnostic to the role of CAM, my goal here is to understand how CAM is being distorted through the very process by which it is becoming “mainstreamed.”
I would define scientific medicine as the field of study which aims to understand and execute healing by the first healing method above-effectiveness beyond a placebo-but in practice employing the second and third methods as well (for example, “take an aspirin and call me in the morning if it still hurts”). CAM, on the other hand, involves healing not currently within the domain of scientific medicine. In an ongoing process, some of what was once considered CAM is now part of scientific medicine. Much of CAM, I believe, has the potential to be incorporated into medicine, but simply hasn’t been tested using the sort of rigorous scientific study that medicine requires. Some of CAM doesn’t fit within the domain of scientific medicine because it is difficult to come up with controlled experiments to validate its efficacy. And some of CAM’s value lies in its strong ties, through cultural practices or traditions, to the placebo effect. Finally, some of CAM may either be ineffective or prohibitively dangerous.
But this raises the question: Should we continue to scientize CAM, incorporating what fits into scientific medicine and discarding what doesn’t? Should it be covered under insurance, offered in doctor’s offices, studied in medical schools? Or does this very process destroy the cultural and traditional value of CAM in cultures around the world, including our own?
I think we need to rethink our desire to scientize CAM: our desire for scientific validation is transforming traditional healing from an empathetic, holistic, community-based practice into an impersonal arm of Medicine, Inc. And we, the public, are demanding this transformation. Whatever your position on CAM is, this transformation plays right into the hands of big business, all the while rendering medical science, a potentially empowering and useful tool in fostering good health, undiscerning and apathetic.
Increasingly, we feel the need to validate many of our practices and activities with scientific evidence which “proves” they accomplish health-related goals. There are numerous examples of this, from studies on whether or not prayer can heal, to research that Tai Chi might lower blood pressure and reduce chronic pain. And while this type of research isn’t necessarily bad in and of itself, it is an example of scientism-which claims that “science alone can render truth about the world and reality.” We are drawn to CAM for its spiritual and mystical underpinnings and holistic approach, so why do we need science to make CAM more “legitimate”? Are we really incapable of incorporating its spiritual wisdom and its potential for healing into our modern world without science’s stamp of approval?
While this sort of scientism is potentially destructive on many levels, perhaps the biggest problem is that it makes for bad science. Marcia Angell, M.D., former editor of the New England Journal of Medicine in an interview explains how wealthy believers in CAM essentially bribe universities into doing bad science:
[Harvard Medical School] seems to be applying a double standard, one standard to new treatments for heart failure and a different standard for things that are labeled “complementary and alternative medicine.” It shouldn’t do that. It should be embarrassed by that. It’s not alone. Most of the other major research institutions are doing exactly the same thing. They too are setting up institutes funded by wealthy philanthropists who are believers in complementary and alternative medicine.
NCCAM has attracted quite a bit of criticism as well. With a budget that has grown to $121.5 million in 2008, NCCAM has had little luck so far in producing positive results and has been criticized for publishing studies in less credible journals and using marginally scientific techniques. Furthermore, it tends to award grants to the same few individuals. Some claim that other divisions of the NIH wouldn’t be able to get away with producing so few and such mediocre results. More interestingly, some claim that CAM therapies, particularly herbal remedies, could be studied both more rigorously and credibly by other divisions of the NIH.
And there’s a good deal of criticism of how CAM is taught in medical schools. In the same interview, here’s what Dr. Angell says:
[I]n the Journal of Academic Medicine there was a very good survey [which]… found that almost all medical schools do in fact offer courses in alternative medicine but they are not about it, and they certainly are not critical courses looking at the evidence for it. They are proselytizing courses and the teachers are proponents and often practitioners of these therapies for which there is no proof whatsoever, and they’re indoctrinating the students in it.
Whether you are a CAM proponent or not, this approach fails the age-old medical test of “Do no harm.” It leave doctors, medical students, the media, and us, the consumers of medicine, feeling confused, manipulated, and even betrayed. Current research can show us that every type of treatment-medical, CAM, or otherwise-is more effective than a placebo, depending on the credibility of the researcher. At the end of the day, people are left to believe what they want (using science to support what they want to believe), while simultaneously criticizing the limitations of science when they don’t favor its results. Selective science is bad science, whether about CAM or the next pharmaceutical goldmine, and it leaves people confused and disempowered, unable to use scientific research to improve their health.
At a time while medicine is increasingly rushed, invasive, and specialized, people are increasingly drawn to CAM for its holistic, patient-centered approach-an approach that contributes to individual well-being and healing. CAM hearkens back to a time when medicine was simpler, cheaper, and easier to understand, a time when people felt more empowered about their health. So, while the public’s interest is understandable and reasonable, the problem is that the simultaneous public support for scientism plays right into the hands of the medical market forces.
The dietary supplement industry, which includes the sales of herbal supplements, is worth $25 billion. In 1994, it lobbied Congress to prevent the FDA from instituting tighter regulations; the result was less oversight. The FDA now has no oversight over supplement manufacturing and doesn’t even have the power to require that supplement manufacturers recall contaminated products, despite several cases where supplements have been contaminated or spiked with dangerous chemicals.
And talk about medicine being expensive: with more than a third of adults using some sort of CAM, out-of-pocket expenses are surprisingly large. Out-of-pocket spending on CAM is now about one-third of out-of-pocket spending on prescription drugs.
Health insurance companies make big bucks off CAM too. CAM tends to attract educated, wealthier, people aged 25 to 49-people who tend to be in better health. Such people are glad to pay a little extra if their health plan covers acupuncture, for example. And health insurance companies are happy to attract these people by adding a comparatively inexpensive service, knowing that such individuals will tend to cost less. An extra prescription drug benefit? That would attract the “wrong” people-people in poorer health who would cost more.
Medical schools and NCCAM benefit too. There are members of Congress, such as Tom Harkin, who are interested in continued support of CAM research whether or not it produces good results. So, medical schools and NCCAM continue doing research and offering classes in CAM, knowing that they’ll be the recipients of generous federal (and private) grants.
Ultimately, all of this leaves many questions regarding what place CAM should have in our society. Clearly, we should incorporate into medical practice the valuable things that attract people to CAM in the first place-its holistic and patient-friendly approach. And certainly we should focus on the best of what CAM offers; much of the science necessary to support its medical use isn’t there, but so what? CAM’s value is in the spiritual, cultural, and community benefits it offers. Let’s take advantage of the value that traditional healing has to offer rather than turning it into a profitable subdiscipline of scientific medicine. It’s just not worth the supposed benefits of bringing it under scientific medicine.
Medicine, of course, has plenty of serious and expensive problems all of its own making: conflicts of interest between doctors, insurance companies, and pharmaceutical giants; its ballooning and irrational costs; and its rushed and impersonal execution, especially for the working poor. And many of my same criticisms of CAM carry over directly into medicine, which, more often than one might suspect, relies on its own folklore and unscientific research executed by profit-driven pharmaceutical companies. Many have demonstrated that medicine, in its current execution, which aims to do no harm, is frequently iatrogenic-disease causing in and of itself-due to the overzealous use of risky treatments and invasive tests, poor sanitation, and the risks inherent to extremely potent pharmaceuticals.
But I’m left wondering: what would true antiestablishment healing look like? Would it even be possible in today’s world? If CAM isn’t antiestablishment (and it increasingly isn’t these days), what is?
At the very least, the profit motive shouldn’t get in the way of healing.
A note to readers: some of the links above are to articles in academic journals to which you may not have access. If you have a specific question regarding any of these articles, please leave a comment below.
WoW! i think this is an exceptionally thoughtful and analytic piece. ..on a tough subject. This is such an important articulation of the options open to sick people to heal, and how those options can be diminished or even symied by profiteering.
Sometimes when i hear the onslaught of ubiquitous drug commericials on televison, far too many of which have side effects far more deleterious than the condition being treated, i have to wonder if there aren’ t a nation of tv watchers, remote in hand (i have lost mine) muting the commercials and never actually “getting” the awful risks of these drugs.
One way we could sure cut down on overreliance on the drug culture is to ban prescription drug ads.
Anyway, the old TB sanitoriums at least provided fresh air, opportunity for rest and good food…non of which is readily available in hospitals today. having justy been through a remarkable period, in which i am still unable to afford conventional medical care yet have been literally deathly ill, i say thank God for the alternative therapies…rest and polarity therapy, food supplements (not vitamins) and COQ-10 with carnitine and alpha-lipoic acid kept me alive and has helped me to begin the healing process.i am now well enough to do some yoga, and can do more basic ADL (activities of daily living) with pacing.
The heart doctor i first visted advised me to put my affairs in order and have numerous expensive, risky tests and surgery. i am so glad the state of my finances caused me to decline…but it pointed out to em that one things i s clear…REST is very ahrd to come by and relentlessly high stress of the soul-eating, confidence- effacing , material wipe-out kind, kills people.
One point i wished to make: if we all have health portfolios and and allow people to choose their treatments from among all of those available to us,including so-called conventional and alternative, then that is an excellent way to stop infantilizing and exploiting people for profit in the “health industry”.
I was the daughter of a physician and a pharmacist, medical graduates of early 20th century. Dad could diagnose with his eyes and hands; Mother’s lab smelled of nature. Being the “victim” of one after another medical errors in my life, I am now the happy recipient of a variety of complementary practices. I resent having current medicine called “traditional,” when real tradition is ignored, defiled and degraded.
Luckily, in 1980 Theron Randolph, one of the initial graduates in allergy from Harvard, correctly diagnosed my complaints. He had been fired from a “respected” medical faculty for”non-standard” allergy investigation. If so-called scientists understood that science, including illness and health are subject to continuous hypotheses formation, not just the technologies and monies so derived by corporate industries we’d be healthier, happier and solvent.
The problem is the democratic impulse of the alternative is emasculated by the professionalism of the mainstream.
As the Whitehall studies show in my view (see also the blue zones) agency is important to health. Professionalism is literally unhealthy. I am in favour of people expanding their ability to improve their own health. The mainstream usually goes against this (whatever the intention).
Thank you for a very well articulated piece, Sarah!
I’ve felt frustrated over many years as a Western-trained physician and complementary practitioner.
So many studies could be easily done to prove or disprove a particular supplement, but the funding for research comes, of course, from large pharmaceutical companies. They will only fund a study if there is a potential profit for them. On the other hand, other treatments don’t lend themselves to study via scientific method because it is reductionistic, and we have complicated internal systems (neurological, immunological, hormonal, etc.) and human responses. On top of it all, we have “subtle energies” that are utilized in many of the alternative methods of treatment.
I, too, have noted the co-opting of CAM by large medical institutions. I believe the practitioners who work in these institutions are doing their best. It’s an “odd couple” situation. The medical institutions need alternative medicine centers for cutting edge marketing to healthcare customers. Yet, I suspect the CAM institutions are often seen by many mainstream physicians as practicing nonsense. Unfortunately, to compensate for this lower status, these institutions may feel the pressure to revert to scientific reductionistic studies to “prove” their worth.
Dear Sarah,
Thank you for a fascinating look at a complex and hotly fought over field. There are a few areas I can’t hold back from commenting on. You say, for example, “Current research can show us that every type of treatment-medical, CAM, or otherwise-is more effective than a placebo, depending on the credibility of the researcher.” But one of the problems medical studies are wrestling with is that this is not true: From Wired
You say, “Increasingly, we feel the need to validate many of our practices and activities with scientific evidence which “proves” they accomplish health-related goals…. And while this type of research isn’t necessarily bad in and of itself, it is an example of scientism-which claims that “science alone can render truth about the world and reality.” I agree that scientism is such a claim, but not that doing double-blind peer-evaluated studies of CAM constitute such a claim. If I have a disease, I have to choose between potential ways of addressing it, and knowing the statistics on success rates is part of the data I’d like to draw on to make such a decision. Certainly if a particular branch of CAM has been shown not to work any better than sugar pills, I’d like to know that.
You criticize that Medical schools offer courses in how to apply CAM, without exploring the efficacy of it. I’d offer a friendly amendment that both are necessary: many traditional medical courses offer how to do Western medical techniques without evaluating the relative value of that approach.
I wince when I read, “CAM’s value is in the spiritual, cultural, and community benefits it offers. Let’s take advantage of the value that traditional healing has to offer rather than turning it into a profitable subdiscipline of scientific medicine. It’s just not worth the supposed benefits of bringing it under scientific medicine.” To me that comes across as patronizing and arrogant, effectively saying “It’s not real medicine, but it makes people happy.” Here in Canada some alternative techniques have been tried, tested and approved (acupuncture, for example). People use it against chronic pain, without “spiritual, cultural or community” tendrils waving off the pins. (And of course, like all medical techniques, it’s paid for by the government.)
Real science is a useful way of exploring the world, one of a number of ways we experience and learn. To say that a branch of medicine should not be looked at that way is to take the first step in denying any validity to it. (Step two is saying there’s no evidence because in step one you decided not to look for any.)
You conclude, “At the very least, the profit motive shouldn’t get in the way of healing.” You’re right. But the solution isn’t in looking for approaches outside a corrupt and profit driven medical system, the solution is in changing that system.
Or at least that’s how I see it.
peter
The fact that acupuncture has been “approved” in Canada is really patronizing, man. Are you waiting for the government to authorize people to use an age-old Chinese cure? But, perhaps your confidence that the medical establishment has “tried, tested” and approved” acupuncture is misplaced. Can you show some credible sources?
At least the U.S. NIH hasn’t yet come to the same point as the RCMP: http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102276047.html (or see wikipedia, if you trust it more.)
In any case, the point is that you can make your own decisions, you really can, and some of them are not based on reductionistic analysis (as Abby Caplin points out).
Harold
Harold,
You say, “Are you waiting for the government to authorize people to use an age-old Chinese cure?”. No, I’m pleased that the choice isn’t between free western medicine or having to pay for other forms of medicine. I want people to have a choice as to what form they choose, and only paying for one modality doesn’t offer that.
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