Alternative Medicine: It's Time to Get Smart

Doctors and their patients often hold different ideas about disease and how to treat it. When it comes to alternative medicine, the line seems clear. The public prefers alternative treatments--acupuncture, herbal remedies, imagery, therapeutic touch--to the drugs, psychotherapies, and surgery offered by the medical establishment. According to a 1993 report in the New England Journal of Medicine (D.M. Eisenberg et al., 328:246-52) Americans make more visits to alternative healers and spend more money on alternative treatments than they do on conventional medicine. But physicians are skeptical about the value of such therapies and not infrequently hostile to them. The skepticism is well founded. Few alternative therapies have been subjected to scientific scrutiny, and many of them--touch therapy and homeopathy come to mind--are based on theories that are, at best, unconvincing. Nonetheless, practitioners of alternative medicine and their clients are convinced that these treatments work. U.S. Rep. Peter DeFazio (D-Ore.), an advocate for alternative medicine who has proposed a National Center for Integral Medicine, speaks for many when he declares, "We know many of these therapies work; we know they sometimes save lives." The conflict over alternative medicine is not simply academic. It has already influenced federal research expenditures and is beginning to determine which health services are covered by managed health care plans. For example, U.S. Sen. Tom Harkin (D-Iowa), who credits a bee-pollen preparation for curing his allergies after reams of conventional medicine had failed to do so, was instrumental in establishing the Office of Alternative Medicine (OAM). Part of the National Institutes of Health, the OAM's mission is to evaluate alternative therapies. Harkin would like to see the office become elevated to an institute, a $200-million-plus proposition. Failing to get an institute last year, he engineered, over the objections of medical researchers including NIH Director Harold Varmus, a phenomenal 60 percent increase in the OAM's 1998 budget. At first glance, the OAM seems a good solution to the conflict between advocates of unproved alternative medicine and those who view these treatments as quackery. But instead it has become a battleground. Those skeptical about the value of alternative medicine claim that the OAM does not take the proper dispassionate, scientific stance but acts instead as an advocate for alternative medicine. Skeptics point to studies supported by the OAM--and indeed there are some--that don't use the rigorous scientific methods of conventional medical research. Alternative medicine experts claim that the usual scientific methods, which include ensuring that everybody gets the same treatment in the same amount, are not applicable to alternative therapies that are often custom-tailored to the individual. The OAM is not the only battleground. Health maintenance organizations and other managed health care insurers are beginning to cover alternative therapies. Consumers and alternative treatment practitioners applaud this. Conventional medicine practitioners, skeptical of alternative therapies' value, see this development as driven more by marketing considerations than by a desire to offer good-quality health care. They claim that managed care organizations are pandering to consumer preference rather than providing good care. Given the phenomenal advances in medicine over the past two decades, including the development of indisputably effective drugs and procedures, what brings people in such droves and with such avidity to unproved alternative therapies? What are homeopathy, herbal medicine, therapeutic touch, and so on providing? First, alternative medicine resonates with deep-seated, primitive beliefs to which we are fiercely attached. The general theme of these beliefs is that nature is good. More specifically: natural substances are better for you than synthetic (foreign) ones; the body is best left to its own devices (and does a good job of healing itself); powerful mystical forces beyond ordinary understanding bring both disease and cure. Without too much of a stretch, one can imagine how natural selection might have shaped these beliefs. In the Stone Age--and that's pretty much where natural selection left us--some of these beliefs might well have had survival value. Down deep we are unprepared for and wary of microsurgery, MRI scans, and Prozac; we prefer plants, touch, a soothing voice. In addition, alternative health care now offers to a greater extent than conventional care the healing ingredients of the treatment situation most precious to those who are ill. These include a thorough evaluation, healing rituals and symbols, a healer's optimism, commitment, encouragement, and attention, and high expectations for improvement. These components of the traditional treatment situation--referred to sometimes disparagingly as "placebo"--are a powerful part of healing. They contribute to the benefit of all treatments and are the only benefit of many. Finally, people flock to alternative medicine because it works. It makes them feel better. The catch is, like most treatments of the past and many conventional treatments of today, most alternative therapies probably have no intrinsic therapeutic value; their benefit comes from the placebo effect; more precisely, the healing situation. So, both the advocates for alternative therapies, who insist that they work, and the opponents of alternative therapies, who insist that such treatments are not effective, are correct. Alternative treatments do often make people feel better, but most alternative therapies have not been subjected to the kind of rigorous study necessary to prove inherent effectiveness. And when alternative therapies have been subjected to scientific scrutiny, as in a recent study of therapeutic touch (L. Rosa et al., JAMA-The Journal of the American Medical Association, 279:1005-10, April 1, 1998) more often than not they come up short. Nonetheless, unproved alternative therapies do have a place in science-based health care. And that place has been defined not by the experts on either side but by the consumers. People with afflictions for which conventional medicine offers clearly effective treatment--bacterial infections, heart disease, diabetes, traumatic injuries--rarely seek alternative therapies, and when they do they use them as adjuncts to conventional treatment. The overwhelming majority of alternative medicine consumers have illnesses for which conventional medicine does not offer a cure, such as arthritis, allergies, and viral infections, or they have illnesses such as insomnia, depression, and chronic pain, which are stress related. Although people with these afflictions may or may not benefit from the manipulation of energy fields, herbal concoctions, huge doses of vitamins, or alterations in the flow of chi they so fervently embrace, they almost certainly benefit from the reassurance, hope, and relief of distress that comes from being in a healing situation. Thus, although alternative therapies are unproved and the theories as to how they work are often implausible, all indications suggest that people use such therapies in a sensible manner: that is, when they are most likely to be helpful and when the offerings of conventional medicine are less than compelling. Now it's time for the experts to get as smart as the public. To best serve their clients, naturopaths, acupuncturists, herbalists, and touch therapists need to bring their claims more in line with reality. And, when conventional medicine has little more to offer than unpleasant side effects, M.D.s could do a lot worse than to offer a bit of visualization or herbal tea. Walter A. Brown, M.D., is clinical professor of psychiatry, Brown University School of Medicine and Tufts University School of Medicine. E-mail: wbrown@edgenet.net [Editor's Note: See also the Nov. 11, 1998 issue of JAMA, vol. 280, for articles on alternative medicine. Web address: www.ama-assn.org/sci-pubs/journals/archive/jama/vol_280/no_18/toc.htm#top]

Alternative Medicine: It's Time to Get Smart

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