I don’t know who Kent Sepkowitz is other than that he he’s an infectious disease specialist in New York and that he writes for Slate. I also know he’s written about penis enlargement, his dislike of magazines’ “best doctor” lists (a sentiment with which I can agree, actually), and that he has suggested that Americans should “eat more excrement.” What I didn’t know is that he was capable of slinging said excrement around (at least, the excrement left over after Americans eat more of it, I suppose), specifically slinging excrement about so-called “complementary and alternative medicine” (CAM) using verbiage of which Andrew Weil and David Katz would applaud enthusiastically.
I’m not amused.
I refer to an article he wrote a couple of days ago and published in Slate entitled Alternative Universe: The Homeopathic Crowd Meets Academic Medicine. He appears to approve heartily. As any regular reader of this blog knows, I do not.
Dr. Kimball Atwood IV over at the Science-Based Medicine blog has a recurring feature that he has dubbed The Weekly Waluation of the Weasel Words of Woo, or W^5/2 for short. In this feature, Dr. Atwood takes a paragraph or two culled from the CAM advocacy literature and challenges his audience to “translate” it into what the author is really saying under all the deceptive, postmodernist verbiage, as he did to amusing effect here. The point of the exercise is to demonstrate the obfuscations, straw man representations of scientific medicine, and general antiscientific relativism that is rampant among CAM advocates when they argue for CAM. Sadly, Dr. Sepkowitz’s entire article could serve as the basis for several exercises in Dr. Atwood’s sarcastic and fun little feature. As is often the case with such screeds, Dr. Sepkowitz starts right out of the box with a bit of contempt for that horrible reductionist science that we mavens of scientific medicine know and love:
And now there is the arrival at the NIH feeding trough of the alternative medicine crowd, angling for a mouthful of the same research dollars that currently fund investigations like “the structural basis for translation termination on the 70S ribosome.”
Though initially caught flat-footed, academic medicine rallied, as it always does when big bucks are on offer. After decades of belittling the alternative folk as a bunch of snake-oil salesmen and sleazeballs, academic medical centers suddenly realized that–guess what–they were big fans of the approach all along. Yale University is one of the latest brand-name institutions to go through the change. Last year, it joined 40 other medical schools in the Consortium of Academic Health Centers for Integrative Medicine, and began the awkward dance that has characterized such mergers.
He does have a bit of a point–or at least he would have if he hadn’t gone on to inundate what little germ of reason there was with a veritable tsunami of W^5/2-worthy prose later in his article. There’s little doubt that the infiltration of pseudoscientific woo into academic medicine is primarily about one thing: money. However, secondarily it’s about a misguided desire not to appear judgmental by correctly labeling the vast majority of the woo and magical thinking that make up nearly all of CAM (other than natural products such as herbs, which can have medicinal chemicals in them) a load of hooey. In other words, it’s about academic medicine being so open-minded that its brains are falling out. Whatever the relative contribution of these two factors to facilitating the infiltration of woo into academic medicine, it is clear that academic medicine has not exactly distinguished itself recently in the manner with which it’s handled the influx of CAM into the halls of some of its most hallowed institutions–but not for the reasons that Dr. Sepkowitz lists.
Here’s where Dr. Sepkowitz starts his descent into W^5/2 territory:
Viewed one way, the migration of alternative medicine to the academic mainstream is a fine example of the might of popular will. After all, a 2004 survey revealed that 36 percent of adults in the United States have used alternative medicine at one time or another. If megavitamins and prayer are included, the proportion rises to 62 percent.
Actually, the migration of CAM into academia isn’t really about “popular will.” It’s more about the influence of a few either very powerful (Dan Burton, Tom Harkin, etc.) or very rich (Christy Mack of the Bravewell Collaboration) boosters of alternative medicine pushing a magical Trojan horse made of fairy dust into academia to try to make it “respectable.” Dr. Sepkowitz also falls for the infamous “36% of adults using alternative medicine” trope that routinely shows up in the media all the time whenever there is a story about “alternative” medicine. Steve Novella has shown quite convincingly that this figure is deceptive and exaggerated in that it includes massage, relaxation, and other modalities that are among the “softest” of woo, lumping them together with the hardcore stuff like homeopathy. It’s clearly a planned strategy to make it appear as though more people use the really bizarre stuff than in fact actually do. Steve put it quite well when he wrote:
But the strategy is clear – make an argument for the popularity of CAM and inflate the perception of popularity by including a wide range of modalities, many of which can be scientific or are, at worst, a bit soft. Then the serious unscientific modalities, like homeopathy, can come along for the ride. In many way it’s a bait and switch, and the media have largely bought it without a hint of journalistic skepticism.
Sadly, Dr. Sepkowitz swallows the propaganda uncritically, hook, line, and sinker. Indeed, he goes beyond it:
Who should prevail in this struggle between naturalistic healers and ass-kickers with syringes full of chemotherapy? In a sense, neither side. Both have much to offer and plenty to be embarrassed about. To date, neither has established an all-encompassing operation so wondrous that it should demand monogamy from patients. So far, though, the problem with pairing the two disciplines at your corner medical center is that it mostly serves to diminish each: The West looks spent and flabby, a bully gone to seed, while the East seems like a kid with a new car and no clue how to drive.
What a load of utter rubbish! It’s the false equivalency argument writ large and exceedingly stupid. Dr. Sepkowitz seems to view the two modalities, “alternative” medicine and scientific medicine, as being roughly on par with each other, but nothing could be further from the truth. Whatever scientific medicine’s faults (and, yes, there are many), advances in life expectancy, the conquest of many infectious diseases that used to claim millions of children a year, the ability to cure some cancers and prolong the lives of victims of many others, the conversion of HIV infection from a death sentence to a manageable chronic illness, all of these advances and many, many more besides are the result of scientific medicine. No such achievements can be attributed to CAM. None. Indeed, the vast majority of CAM modalities are based on a prescientific understanding of disease (evil humors or disturbances in one’s life energy, anyone?), and those that are not, such as nutrition, exercise, and the use of natural products, are all too often twisted into a parody of themselves that no scientist can recognize. Dr. Robert O. Young’s unbelievably dumb attribution of “acidity” as the cause of all disease, particularly cancer, comes to mind, as does a lot of nutritional quackery that claims serious diseases can be treated with various supplements.
Worse, legitimate evidence-based scientific medicine, again such as nutrition or natural products, were unjustly “ghettoized” by CAM when they were coopted by woo-meisters and relabeled as “CAM.” The association with woo has made legitimate scientific modalities that have fallen under the CAM rubric take on the taint of pseudoscience. Even disciplines with a long and distinguished history in scientific medicine, such as pharmacognosy, have taken on an undeserved taint of quackery and pseudoscience by having been largely relegated to the backwaters of NCCAM. (Trust me on this, many natural products pharmacologists are not happy about this development.) In any case, Dr. Sepkowitz’s comparison ends up being about as W^5/2-worthy as I have seen.
The only thing I agree with Dr. Sepkowitz about is that pairing CAM with scientific medicine to produce the Frankenmedicine known as “integrative” medicine is a truly bad idea–but not for any of the reasons that Dr. Sepkowtiz lists. Not surprisingly I disagree most vehemently that this combination in any way diminishes CAM–quite the opposite, in fact. The very problem with the Frankenmedicine known as “integrative medicine” is that it elevates CAM far above where it deserves to be scientifically, with the legitimacy and undeniable successes of scientific medicine providing CAM with an undeserved patina of scientific respectability. Don’t think that CAM advocates don’t know this, either. It’s the very reason why they crave this association with scientific medicine so intensely. Why academic medical centers seek this association with “disciplines” that can only risk bringing scientific medicine into disrepute, I still haven’t figured out, other than a search for services that they can bill for cash on the barrelhead without all that unpleasant mucking about with insurance companies and third party payors or because it seems trendy and hip to be offering such services.
Here’s where Dr. Sepkowtiz truly goes off the rails:
The enforcers of the Western orthodoxy are the preening evidenced-based medicine crowd, those notorious killjoys who operate on the almost amusing premise that every square inch of medicine is built upon reason, the product of a rationally ordered stainless-steel world. If no evidence, they insist, then no truth. And if no truth, get thee out of my medical center. They briskly have swept away the entire alternative field, viewing chelation, St. John’s wort, and music therapy, for example, as interchangeably absurd.
Talk about a straw man characterization of evidence-based medicine! It’s so bad that I half expected Dr. Sepkowitz to invoke the dreaded specter of “microfascism.” His description of advocates of science- and evidence-based medicine could have easily been lifted from Mike Adam’s site of insanity NaturalNews.com, Dr. Mercola’s repository of quackery, or even John Scudamore’s collection of pseudoscience, conspiracy-mongering, and woo. He’s also just plain wrong. Scientific medicine didn’t “sweep away” the entire “alternative” field. Indeed, even before NCCAM it often studied such implausible medical claims. Moreover, chelation therapy and St. John’s wort weren’t rejected as “absurd,” even though a good argument could be made that the former should have been. St. John’s wort, for example, was viewed as a plausible remedy for various conditions because it likely contained chemicals with pharmacological activity. Both St. John’s wort and chelation therapy have been studied on multiple occasions, and they have been found wanting as either ineffective (chelation therapy for cardiovascular disease) or as having no compelling benefit better than existing therapies (St. John’s wort). Not that that stopped CAM mavens. They still managed to get a large study of chelation therapy in cardiovascular disease funded to the tune of $30 million and are still pushing for an unethical study of chelation therapy for autism. No amount of negative evidence ever satisfies them, because to them it’s all about ideology, not science.
Dr. Sepkowitz, to his credit, does mention that science has thus far failed to find compelling evidence of utility in most CAM therapies, although he seems sympathetic to the frequent appeal to other ways of knowing favored of CAM advocates, in which they attack the paradigm of scientific medicine and randomized clinical trials as being somehow inadequate, biased, or somehow otherwise unable to give a fair test to their favored modalities rather than admit that their woo is just that: woo. He then furthers the stereotype of the cold, brutal scientific doctor as contrasted with the nice, warm, and cuddly alterna-doc:
At the same time, to dismiss alternative medicine too quickly is to miss a central question: What is the role of health care? Is the enterprise aimed only at preventing and treating illness, or should it also try to make us feel better? Treating an illness Western-style can mean chopping off a leg, giving chemotherapy, hooking someone up to dialysis. All of this is done to score the touchdown of American medicine: extension of survival by a week, a month, a year, anything. No doctor wants a patient to suffer, but in the Western view the long-term goal of survival comes first. The focus of many Eastern approaches, on the other hand, is on feeling better now rather than lasting longer. And this is something altogether different.
The two goals–treatment and prevention on the one hand and making patients feel better on the other–really are often at odds. And in the future, they surely will diverge further as Western medicine becomes even more technologically sophisticated. A treatment with stem-cell or gene therapy isn’t going to be like drinking a glass of orange juice in the morning. The disruption and discomfort the therapies likely will inflict may make today’s medicine seem mild. The best response to the über-tech may be an equal and opposite move toward the more benign alternative realm.
As Elvis would say if he were Orac, that’s one hunk o’ hunk o’ burnin’ stupid! (Elvis used to sing about “burnin’ love”; Orac likes to appropriate Elvis to point out “burnin’ stupid.”)
Once again, Dr. Sepkowitz totally buys into the false dichotomy that CAM advocates push. If “modern,” “Western,” scientific medicine is too cold and uncaring, the answer must be to bring magic and fairy dust into the mix, right? Wrong! He also seems to be implicitly admitting that CAM or “Eastern” approaches have nothing to offer in terms of prolonging survival. After all, if the “Eastern approach” is to make someone “feel better now” rather than to “last longer,” that implies to me that it has little to offer in terms of making patients live longer. And what’s wrong with trying to cure disease and allow patients to live longer anyway? That’s what most patients want, even patients with terminal cancer. It’s true that there has to be a balance and a willingness to realize when prolongation of life is no longer possible and then to shift to palliation and symptom relief. Finally, I can’t help but point out that the whole East/West dichotomy is a load of bollocks, anyway. There is nothing “Eastern” about homeopathy, for instance, although there is considerable magical thinking contained in its core concepts.
Dr. Sepkowitz is also very likely dead wrong when he predicts that the “disruption and discomfort” of future therapies will likely “make today’s medicine seem mild.” What a load of tripe! If there has been one consistent trend in medicine, particularly in cancer medicine, over the last couple of decades, it’s been a trend towards less morbid and less invasive treatments. Open surgery has made way for laparoscopy for many common operations, while organs that used to be biopsied with open surgery are now biopsied under ultrasound or CT guidance or at worst through laparoscopy. In breast cancer, radical mastectomy has made way for modified radical mastectomy, which made way for lumpectomy and radiation therapy. Axillary dissection has made way for sentinel lymph node biopsy, which has reduced the incidence of lymphedema markedly. Big gun, cytotoxic chemotherapies are making way for gentler, molecularly targeted therapies, and genomic testing of tumors is helping more and more people avoid chemotherapy when it is highly unlikely to benefit them. In the cardiovascular realm, coronary artery bypass has largely given way to angioplasty and the placement of stents, with surgery only used in complex cases of multivessel disease, so much so that cardiac surgeons in many regions of the country are finding themselves short of work and more medical school advisors are suggesting to their charges that they pick another specialty if possible. Meanwhile, endovascular stents are making open repairs of abdominal aortic aneurysms uncommon, again to the point where vascular surgeons who have not learned the new endoluminal techniques are hurting for cases.
I could go on, but you get the idea. I wonder what planet Dr. Sepkowitz is living on if he thinks that future therapies will necessarily be nastier than today’s. He should know better. After all, he is on staff at Memorial Sloan-Kettering Cancer Center, where not a few of the cancer-related advances in less invasive and less morbid treatments I mentioned above were pioneered.
Dr. Sepkowitz then concludes that, even though there’s no good evidence this stuff works, we should still pour money into it because…well, because we should, apparently:
Alternative medicine needs money and many years to find its way, and despite the early setbacks for echinacea and other treatments, it would be a mistake to call off the federal investment. Such an absolutist stance ignores the observations of thousands of people over thousands of years as well as the true pace of medical progress, which is at best herky-jerky and aimless. That’s not to say that alternative medicine is the equal of Western medicine, or will prove to be, many millions of research funds later. As Steve Jobs discovered, a special organic diet will not cure pancreatic cancer, whereas a six-hour surgery might. As brutal as Western medicine is, it remains a wonder of the modern world. So let’s hope that the two sides can find room for each other: The West needs the East’s soothing calm to round out its prickliness, while the East needs the West’s thuggish urge to push ahead and prove results. I think that’s called yin and yang.
Once again, it’s another appeal to other ways of knowing. Just because that evil reductionist Western science can’t find evidence that woo works doesn’t mean it doesn’t because all those people over thousands of years have believed that it worked. Never mind that until only about 150 years ago, bloodletting was thought based on the exactly the same sort of “experience” to be a wonderfully effective treatment for all manner of diseases and conditions. Never mind that, based on their “personal experience,” after 200 years many people still believe homeopathy “works,” even though it has zero biological or scientific plausibility and no evidence from well-designed clinical trials that show it to be any better than a placebo. Never mind all that. Dr. Sepkowitz tells us that all that experience, which, thanks to the human tendency to find patterns even where there are none, must apparently be taken as seriously as the science that fails to find these patterns.
Particularly annoying to me is Dr. Sepkowtiz’s characterization of “Western” medicine as “thuggish.” What he sees as “thuggish,” I see as the highest aspiration of scientific medicine: to apply science to the understanding of disease and to use that understanding to develop treatments that cure disease or alleviate its symptoms. What’s thuggish about that?
Having read this article, I now understand one thing. I now understand why Dr. Jay Gordon liked the article well enough to forward it to me for my reading pleasure. Indeed, that’s one reason why I decided to apply some not-so-Respectful Insolence™ to the article (besides the fact that it just irritated me to read it). I wouldn’t want to disappoint Dr. Jay, after all.