People have been living on earth for about 250,000 years. For the past 5,000 healers have been trying to heal the sick. For all but the past 200, they haven’t been very good at it.
- Dr. Paul Offit
Twenty years is a long time in medicine. I celebrated my 20th pharmacy class reunion last weekend. Of course reunions are time to reflect back to our early years as pharmacists. Lots has changed. Much of the therapeutics I was taught is now obsolete. In 1993, HIV was a death sentence and there were only three, largely ineffective drugs available. Thanks to new drugs, HIV can now be managed like a chronic disease, and some of my colleagues have HIV-focused pharmacy practices. The same dramatic changes have occurred in fields like cancer, and transplant medicine. And in some cases, the cause of disease has become more clear – my old textbooks make no mention of Helicobacter pylori as a cause of ulcers.
The practice of pharmacy has changed, too. On the positive side, pharmacists are working in new settings where they can focus on medication management, and not just dispensing prescriptions. Regulators are granting pharmacists the ability to take on new roles, and pharmacists are being compensated for more than simply “count, pour, lick and stick.” From that perspective, it’s a promising time to be a pharmacist. But there’s a much more disturbing side to the profession that’s emerging, too. Community (retail) pharmacy practice is under pricing and competitive pressure, and smaller pharmacies are being subsumed into big retailers where the pharmacy department is buried in the back – a loss leader to bring in patients, but hardly with a health-care focus. And most disturbingly, I see a move within retail pharmacy practice to leverage its professional credibility to sell all types of modern-day snake oil, ranging from detox kits and “cleanses” to dubious “food intolerance” testing. Homeopathic remedies (an elaborate placebo system of sugar pills) are increasingly found on pharmacy shelves, alongside real medicine. And don’t forget the enormous wall of vitamins that seems to get larger and larger. Yes, complementary and alternative medicine is booming, and pharmacy wants its share. Pharmacy regulators turn a blind eye. What do my pharmacy colleagues tell me? They’ll tell me it’s customer demand, and that they don’t recommend the quackery. To me, I see this trend as damaging the credibility of pharmacists in the eyes of the public and of other health professionals.
I understand that medicine is a business and that alternative medicine is a business; but part of the difference in medicine is that we’re supposed to have professional norms, professional values, and professional commitments. If you keep telling people it’s just a marketplace and that they’re just clients and that autonomy of the patient is what must be served to make them happy customers, they you have a collapse of professionalism in the face of consumer demand.
– Art Caplan
The progress of medicine, the changing face of pharmacy, and the growing demand for alternative medicine all been percolating in my mind over the past few weeks. It’s almost inconceivable that in 2013 the same pharmacist that dispenses your targeted cancer treatment, one that cost hundreds of millions to develop, and is literally saving your life, may also sell homeopathic remedies and other alternative medicine nostrums, some of which are based on medieval ideas of disease. In integrating alternative medicine into what should be a science-based practice, pharmacists aren’t improving patient care, but doing the opposite. They’re promoting magical thinking, and damaging the profession.
I’ve been writing about, and advocating for, science-based medicine since I spent an early part of my pharmacy career in pharmacy with a strong focus on alternative products. Not having learned much about these products in pharmacy school, I did my research. And what I found was disturbing. Not only were most of these products not backed by good evidence, but some were highly questionable – even risky. Yet the entire regulatory structure was tilted in favour of manufacturers. There was little manufacturing oversight, and even less oversight of the treatment claims being advertised. And never any mention of potential risks. Yet their popularity continued to grow.
If the lack of science supporting alternative and complementary medicine isn’t self-evident to health professionals, is it any surprise that the broader public can’t see the problem? And what explains its popularity in the face of the scientific evidence? Dr. Paul Offit’s new book, Do You Believe in Magic? is an attempt to address that. It’s a concise, comprehensive and highly readable summary of the facts of complementary and alternative medicine. While I’ve never met Dr. Offit, I’ve been an admirer for several years. It’s not just the real science he’s done, like leading the invention of the RotaTeq rotavirus vaccine, preventing infectious diarrhea which killed hundreds of thousands of children every year. And it’s not the fact that he’s a pediatric infectious disease physician. He continues to be a strong and vocal advocate for the safe and effective use of vaccines, which drives the anti-vaccine movement to distraction. He doesn’t flinch, he doesn’t hide, and he calls a spade a spade. One of my favorite references on the autism-vaccine manufactroversy is Offit’s 2008 book, Autism’s False Prophets, which exposes the anti-vaccine movement and its tactics. Not surprisingly the release of his new book is driving antivaccinationists apoplectic. Unbelievably, he’s even received death threats for his pro-science, pro-vaccine stances. It’s amazing he continues to take the heat of the public eye. But we’re lucky he does, because Offit is a gifted writer, with the ability to summarize complex topics in ways that are engaging and simple, without being simplistic or dismissive. It’s one of the reasons why I enjoyed his newest book so much. (In the interest of full disclosure, I should note that I received a copy of the book from Dr. Offit.)
Offit opens the book with a revealing and quite personal chapter – his own experience as a patient in the health care system. He describes the disappointing care he’s received throughout his life which is astonishing given Offit’s a physician himself – an insider. From being born with clubfeet (the treatment of which left him with chronic pain) through a cancer misdiagnosis in his twenties followed by orthopedic and prostate problems, he describes his medical care, its limitations, and the alternative medicine advice he received from others, ranging from acupuncture to chiropractic to naturopathy. Offit looked closely at the scientific evidence supporting these practices – and found them lacking or non-existent, which mystified him given their growing popularity.
Offit describes the rise and eventual fall of an alternative medicine treatment from the 1970’s called laetrile to illustrate the factors driving the popularity of alternative medicine. Laetrile is something that Kimball Atwood at Science-Based Medicine describes as “the most lucrative health fraud ever perpetrated in the United States.” And while Atwood and other have written at length about this quack cancer remedy, I admit that I didn’t fully understand the social and political context that drove its popularity. Offit describes the case of Joey Hofbauer, a seven-year-old child diagnosed with Hodgkin’s disease, a highly treatable cancer which can be cured (yes, cured) in many cases with chemotherapy and radiation. When Hofbauer’s parents decided to use a laetrile, a “natural” remedy derived from apricot pits, it set off a legal battle of medicine versus alternative medicine where ultimately, quackery prevailed – in the court, at least. A health victory, however, was denied to poor Joey who quickly died of the cancer; an unnecessary cancer death, and a young life cut short by the laetrile movement. Offit describes the contributors to laetrile’s popularity that he believes continue to drive alternative medicine’s popularity today:
- a distrust of modern medicine
- the idea that vitamin supplements are beneficial
- the belief that natural products are safe and effective
- the charisma of purveyors of natural products
- the power of celebrity
- the influence of the natural products industry
The remainder of the book weaves an analysis of these factors with a critical appraisal of alternative medicine practices, and its proponents.
Dr. Oz, Deepak Chopra, and the distrust of modern medicine
In a sense, The Dr. Oz show is a voyage back through the history of medicine, starting with our most primitive concepts of disease: supernatural forces.
– Dr. Paul Offit
I’ve called Dr. Mehmet Oz the biggest purveyor of health pseudoscience and bad health advice on television, and I stand by that description. He’s an accomplished surgeon who brings reiki into the operating room. Oz is the perfect host for a daytime television show that seems to prove each episode that there is no alternative health practice so absurd that it doesn’t deserve a breathless description (“miracle!”) and endorsement. The show, watched by millions daily, regularly promotes debunked, ineffective and even dangerous practices like homeopathy, naturopathy, acupuncture, and chiropractic. He’s profiled psychics and faith healers, too. Offit argues that common thread is Oz’s interest in the supernatural and the occult, which he seems to believe are equally legitimate as science-based treatments. In that way, Offit argues, Andrew Weil and Deepak Chopra have the same schtick – albeit with different approaches. For Weil, it’s Spontaneous Healing, where health is a manifestation of good and evil. For Oz, it’s Ageless Body, Timeless Mind, and what seems to be a never-ending collection of meaningless platitudes that are seem so inane that a bot can generate them.
Why are these gurus so popular? Offit argues it’s what they offer to the public: empowerment and certainty. Medicine is changing constantly as new scientific evidence emerges. It’s confusing and complicated. So why not try a healing system that hasn’t changed since it was invented – like homeopathy? Rather than appreciate the complexity of medicine, why not empower yourself with simplistic ancient wisdom, instead? Feel like you’re being treated with a cookie cutter approach to your health issues? Personalize your own care with what feels right to you. Follow the mantra, buy the book and watch the episode, and you will live a happier, more successful life. It’s natural, and natural is good.
The vitamin con
Do we need vitamins? Yes. Do we need vitamin supplements? In most cases, no. I’ve previously described one of the biggest contributors to the fallacious perception that vitamins are beneficial – Linus Pauling, a truly brilliant scientist whose descent into quackery was as impressive (yet unfortunate) as his scientific contributions. Offit uses Pauling as the starting point for a comprehensive yet concise overview of the current state of the evidence for vitamin supplementation. (There is a substantial excerpt available in a piece published in The Atlantic. What’s most baffling is not that most vitamins are useless at best and harmful at worst. What’s surprising is the sales of vitamins seem completely immune to negative publicity. One negative clinical trial can kill a drug, but Offit notes that vitamin sales seem to be impervious to the evidence. The reason will be well known to regular readers of this blog: a weak ineffective regulatory structure has been designed by the supplement industry to keep consumers as ignorant as possible about the evidence supporting these products.
Natural doesn’t equal safe or effective
One of the tenets of science-based medicine is that all products need to be held to a consistent, science-based standard of evidence. Simply because a product is naturally-derived doesn’t mean it is safe or effective, or merits a waiver of scientific scrutiny. Consequently, the impact and consequences of the American Dietary Supplement Health and Education Act of 1994 (DSHEA) and Canada’s Natural Health Products Regulations, which do just that, have been the subject of many posts. The DSHEA established the American regulatory framework for dietary supplements and effectively excludes manufacturers of these products from virtually all regulations that are in place for prescription and over-the-counter drugs. Remarkably, the DSHEA puts the requirement to demonstrate harm on the Food and Drug Administration, rather than putting the onus on the manufacturer to show a product is safe and effective. Offit dedicates a chapter to supplement regulation and DSHEA, contrasting it with drug regulation to illustrate how the current framework evolved. It wasn’t by accident: The natural products industry explicitly and deliberately set out to ensure it would be exempted from any requirement to demonstrate that their products were either safe or effective. While branded with a message of “health freedom” for consumers, it was really about the freedom for manufacturers to offer products without the testing expected of other products. The lobbying and politics were stunningly effective, which today leaves consumers largely in the dark about the products they’re buying. The result? A perpetuation of the dichotomy that supplements natural and therefore safe. On the other side are drug products, held to completely different standards. It’s important to note that a similar situation exists in Canada, where the regulatory frameworks also lacks the science-based standards necessary to assure consumers and health professionals that “approved” natural health products are indeed “safe and effective”
The consequences of a weakened regulatory structure
Today, there are thousands and thousands of supplements for sale. Do any work? The evidence is lacking for most. With little incentive to test their products, manufacturers often bring products to market without any credible evidence of efficacy. And the contrast with science-based medicine can be striking. There’s no effective drug treatment for dementia, but there are plenty of supplements with claims of benefit. Echinacea doesn’t prevent or treat colds, but it’s a $130 million-per-year business. Today you find supplements to treat most serious medical conditions, and even fake diseases like “adrenal fatigue”. Offit discusses the duds but also the products that do have some promising evidence, including omega-3 acids to prevent heart disease, calcium and vitamin D for osteoporosis, and folic acid during pregnancy.
Another consequence of a regulatory structure where the scientific evidence isn’t relevant is the influence of celebrity endorsements and even political pressure. Offit profiles three cases:
- Suzanne Somers, who promoted dangerous misinformation about cancer while also hyping bioidentical hormones as an anti-aging panacea.
- Jenny McCarthy, one of the most outspoken anti-vaccine advocates in the media today whose antics have been well documented at this blog. Offit explains the harms of her actions and describes how her anti-vaccine advocacy continues to threaten public health.
- US Attorney General Richard Blumenthal, who tried to legislate “Chronic Lyme Disease” into existence. Offit illustrates how the battle over Lyme disease has become politicized, illustrating the pseudoscientific and dangerous treatments that are offered in the absence of good evidence.
The Burzynski Clinic
Stanislaw Burzynski is a American cancer quack who promotes urine-based cancer treatments, (branded as “antineoplastons”) to desperate cancer patients. Offit dedicates full chapter to Burzynski’s story, illustrating his promising beginnings, his move away from credible science, and his current cancer practice. Importantly, Offit summarizes what multiple independent reviews of Burzyski’s treatments have concluded: that there is no convincing evidence that Burzynski’s antineoplastons work. The consequences are grim: these treatments continue to be sold for hundreds of thousands of dollars to patients in life-threatening circumstances. Perhaps not surprisingly, one of the biggest boosters of Burzynski is Suzanne Somers.
The chelation cure-all
Rashid Buttar is an equally dubious American physician. Buttar is a strong proponent of chelation, treatments which bind and eliminate heavy metals from the body. According to Buttar, virtually every medical illness is due to “toxins”, and chelation is the universal solution. Offit describes the lack of science underlying Buttar’s ideas, and how Buttar illustrates the hallmarks of today’s medical huckster: offering unproven, scientifically questionable treatments, stating that mainstream medicine is wrong and out to get him, and that his solution (while untested) should be trusted without any doubts.
Why we think alternative medicine works
Offit concludes his book with a thorough discussion of placebo effects, summarizing some of the research that has established that treatments like acupuncture lack any objective effects. That is, acupuncture is a theatrical placebo. As better-quality research increasingly confirms that the effects from alternative medicine appear to be attributable to placebo effects, it is important to note that there is no persuasive evidence to suggest that placebo effects offer any meaningful health benefits. If I had one quibble in this book, it is that Offit doesn’t discuss the newest tactic of alternative medicine promoters – as it becomes increasingly clear that many alternative medicine approaches have no therapeutic effects, “treatments” such as acupuncture or homeopathy are increasingly promoted as strategies that ”harness the power of placebo” without all the pesky costs or side effects of real medical interventions. We are seeing proponents spinning placebo effects as meaningful and worthy of pursuit. Offit’s arguments are somewhat congruent with this position, though he argues this can be done better with real medicine rather than the theatrical rituals and magical thinking offered by alternative medicine purveyors today.
Do You Believe in Magic? is a comprehensive and compelling analysis of the alternative medicine industry, which will appeal to both the regular and the casual SBM reader. More generally, it would be an excellent read for anyone with a passing or deep interest in alternative medicine. Importantly, Offit’s book nicely explains the problems with the continued false dichotomy of describing “alternative medicine” as an entity of treatments and products. Alternative medicine that actually works is no longer alternative: it is simply called medicine. The rest is unproven, or proven ineffective. I’m often asked for resources on science-based medicine for people that don’t read blogs. Offit’s book is an excellent single reference that accurately and concisely summarizes the facts of the alternative medicine industry.