White Coat Underground

Remember when President Obama said something about returning science to it’s rightful place? Well, our new president has a real tough climb ahead of him. The previous administration shoved science aside for political expediency and religious ideology. Now, forces in the president’s own party are trying to insert their own quasi-religious beliefs into health care reform, leaving science in a whole different place altogether.

Here’s the deal. Some years back, Senator Tom Harkin (D-IA) helped set up the National Center on Complementary and Alternative Medicine (NCCAM). The whole idea of setting up such an agency is a bit quixotic—after all, the National Institutes of Health already study health science. As my colleagues and I have written many times before, the very idea of the agency seems ridiculous. Many, many studies have been funded which fail basic tests of plausibility and ethical propriety. Also, a huge percentage of the studies funded fail to ever publish their results. Still, some studies have been published, and more often than not, they find that the “alternative” modality being studied fails to behave better than placebo. That’s probably the sole redeeming quality of the agency, but not enough to keep it open, as these studies could have been done under the auspices of the NIH.

It turns out that Senator Harkin agrees with me on one point: NCCAM is failing to validate many alternative modalities. The difference is that I find it heartening and Harkin finds it disturbing:

“One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. It think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving.”(from last week’s hearings, time marker approx. 17:20)

Well, at least he’s honest. He comes right out and bemoans the fact that science hasn’t upheld his quasi-religious medical beliefs. He just doesn’t get it. If you choose to investigate a scientific question, you have to be prepared for “bad news”. You don’t get to decide the outcome before the fact.

But Harkin makes his goals very clear, from his prepared statement, to the “experts” from whom he took testimony.


Harkin makes clear that these hearing are meant to guide health care reform—this isn’t some show hearing. Let’s start with his prepared statement, and I’ll just touch on a few highlights.

“It is time to end the discrimination against alternative health care practices.

“It is time for America’s health care system to emphasize coordination and continuity of care, patient-centeredness, and prevention.

“And it is time to adopt an integrative approach that takes advantage of the very best scientifically based medicines and therapies, whether conventional or alternative.

This familiar trope is right out of the Gary Null playbook. There is no “discrimination” against alternative health care. In fact, alternative health care enjoys a lack of oversight and regulation inconceivable in any real health field. Still, many doctors (such as myself) do scorn altmed—because it is a fairy tale. There is no alternative medicine; only medicine that has been proved to work, and medicine that has not. Then he links his fantasy “discrimination” with reasonable goals, such as coordination and continuity of care, making it seem as if the “mainstream” medical community would throw out basic tenets of medicine along with radical cult practices, such as homeopathy. And his stated wish to take advantage of the best in science-based therapies is belied by his complaint that NCCAM has failed to validate his pet alternative practices.

He then invokes the meme of “giving people what they want”—you know, the old health care freedom gambit, where quacks argue that patients should be given the freedom to choose crappy care.

Harkin’s choice of speakers certainly shore up his credentials as a believer in cult medicine. Let’s take a look.

First up, Dr. Mehmet Oz, current darling of Oprah. The guy likes to make very nice sounding pronouncements which often have little to do with science:

Part of the reason is that Americans are twice as sick as Europeans as a people because of our chronic disease burden. Since lifestyle choices drive 70% of the aging process, most experts agree that we should focus on what we put in our mouths (food and addictions), how we tune our engines (exercise and sleep) and how we cope with stress (community and psychological growth).

Begging the question a few times, Doctor. Are Americans twice as sick as Europeans? What would it mean to be twice as sick? What is a “chronic disease burden”? What does it even mean that “lifestyle choices” drive the aging process? And 70%? The entire statement is meaningless, unscientific drivel. He focuses a lot on the wishful and empty topic of longevity medicine. And a visit from a quack wouldn’t be complete without an appeal to authority and a sales pitch—Oz shows a picture of a left ventricular assist device, the kind he has presumably installed in patients, to show what a bright guy he is. That’s great, but being an expert in cardiac surgery doesn’t make you an expert in preventative medicine. Then of course he shows a picture of his book. Maybe Congress should buy one for every American!

Next up, Dr. Mark Hyman, expert in “functional medicine”. Functional medicine is a newer approach to unscientific medicine, and rests on many of the common myths popular in various health cults, such as the myth that mainstream medicine only treats “symptoms” of disease and not the “disease” itself (whatever that may mean). Dr. Hyman invokes the language of Kuhn, calling for a “paradigm shift.” Here, let’s look at his own words (in the same testimony during which he calls for large-scale funding of his cult):

This way of doing medicine, or Functional medicine, is a system of personalized, patient centered care based on how our environment and lifestyle choices act on our genes to create imbalances in our core biologic systems. Those imbalances show up as the signs and symptoms we call disease.

That’s very pretty, but doesn’t actually mean anything. His testimony shows a complete lack of understanding of the actual causes of disease, and ignorance of evidence-based prevention and treatment. His “paradigm shift” would shift us right back to the 17th century.

Dean Ornish. They called in Ornish. Really it’s more of the same. He gives another impassioned plea for ending the madness, the madness of treating sick people.

Our research, and the work of others, have shown that our bodies have a remarkable capacity to begin healing, and much more quickly than we had once realized, if we address the lifestyle factors that often cause these chronic diseases. Medicine today focuses primarily on drugs and surgery, genes and germs, microbes and molecules, but we are so much more than that.

Genes, germs, microbes, molecules…all those hard, science-y things. Does he have a diet to keep me from throwing up in my mouth?

But because the above assault on science-based medicine isn’t enough, they called the bearded guru of Arizona, Dr. Andrew Weil. He, of course, delivers the same old story:

For practitioners of IM [integrative medicine], preventing disease is not an afterthought, it is the cornerstone of our practice – the physician and patient form an ongoing partnership to maintain health, rather than fight illness, and IM practitioners are trained to be agents of lifestyle change. We treat illness promptly and aggressively when appropriate, but always seek to maximize the body’s innate capacity to stay healthy and resist disease and injury.

Andy’s a great salesman. He knows how to tell the best kind of lie—the one that contains a kernel of truth. The implication that real doctors don’t focus on prevention is ridiculous. When I see my diabetics, I make sure I examine their feet (thereby preventing amputation), I make sure they see the eye doctor (preventing blindness), and I make sure their blood pressure and cholesterol is under control (preventing stroke and heart attack). It would be lovely if I could have prevented them from being diabetic in the first place, however some people have trouble with all those pesky genes and molecules and end up diabetic despite their best efforts.

This is a very disturbing development. A horribly anti-science Republican administration has been replaced by a Democratic administration that promised to respect science. They also have a real mandate for health care reform. If this is how they are going to use their mandate, to give their imprimatur to cult medicine and to marginalize science-based medicine, we might have been better off with the devil we knew.

Addendum

Thanks to a commenter over at Science-Based medicine, we learn that the third largest contributor to Harkin’s campaign fund is Herbalife International.

Comments

  1. #1 Dave X
    March 2, 2009

    It reminds me of a line from Tim Minchin’s Poem “Storm”: “Do you know what they call alternative medicine that has been proven to work? Medicine.”

  2. #2 Denice Walter
    March 2, 2009

    It may be a dreary March day with actual snow, but I do feel somewhat hopeful:NCCAM is redundant and costs money -which should be its downfall.Also, with recent news (Wakefield/vaccine court decision), the silvery lunar sheen of alt med is getting a bit tarnished.I notice that some of our favorite woo-meisters seem defensive,clinging desparately to their already shaky positions,banding together,threatening lawsuits, or branching out to other fields of in-expertise(e.g. politics, economics).In short: scrambling.

  3. #3 Chas
    March 2, 2009

    Everyone interested in this is encouraged to visit Harkin’s website and leave comments recommending only evidence-based medicine deserves federal research and funding! Maybe we can start a ground swell and educate Mr. Harkin.

  4. #4 David
    March 2, 2009

    Pal, your points about prevention in the care of a patient with diabetes are well-taken, but those are “secondary prevention.” Primary prevention is something else, and it’s something that we doctors (I’m a neurologist) aren’t good at. Getting teens to avoid the first cigarette, buckle their seatbelts, skip the junk food, and use condoms is a task beyond the abilities of a white-coat in an office who’s cutting visits to shorter times because of reimbursement. There’s a segment of the public that resents doctors for not spending more time talking to well people, and the alt-med nuts feed on that core of resentment. That doesn’t make the alternative medicine treatments valid. I just want to point out that there are failures of the medical system that lead to dissatisfaction. One path to defeating quackery is to improve well-care in our system.

  5. #5 PalMD
    March 2, 2009

    Of course, David, you’re correct that we don’t always do a great job with primary prevention, although much of primary prevention is a public health issue.

    We understand what we need to do much of the time for primary prevention, but getting individuals to do it is another matter.

  6. #6 Kathy
    March 2, 2009

    Maybe instead of funding something like NCCAM, the new administration can look into the causes and cure for something like type 1 diabetes, which is frequently miscategorized with type 2 as a ‘lifestyle disease.’ Nothing ‘complementary’ will make my dead islet cells procude insulin again; I’m dependent on exogenous, manmade insulin for life. Literally. No amount of ‘lifestyle changes’ will make it go away. Just lots of sharp needles and little glass bottles from the ‘evil’ pharma industry. (Must be why I’m so obviously worse off–oops, that’s complication-free–sfter living with it for 26 years.)

    Sorry for the rant. It’s just the patent waste of resources on things like NCCAM that infuriates me. Type 1 diabetes is but one of many diseases that might be damn well cured by now, if it weren’t for these boondoggles. Sigh.

  7. #7 PalMD
    March 2, 2009

    Kathy, are you trying to tell me that reiki can’t fix your diabetes?

  8. #8 bob
    March 2, 2009

    Nice post, Pal. As I’m trying to point out to people on Pharyngula desperately (and maybe sarcastically) trying to come up with beneficial aspects of NCCAM, this is really just terrible in every way. CAM proponents have covered one sharp edge of science’s sword: they go nuts over ANY positive results (no matter how tenuous), and downplay any negative results. So, even the potentially “good” aspect of NCCAM (evidence that certain modalities are worthless) just gets swept under the rug. And now the father of NCCAM openly admits that he’s disappointed that the results haven’t proven the conclusion he arrived at ahead of time, and plays the persecution change. Ugh.

  9. #9 PalMD
    March 2, 2009

    Actually, i retract my last statement to dave. Most of the things i mentioned were, explicitly, primary prevention—preventing diabetic retinopathy, first MI or stroke, kidney failure—this is all primary prevention. It would also be primary prevention to prevent DM II in the first place, but this isn’t often possible.

    Secondary prevention would be preventing subsequent mi’s.

  10. #10 D. C. Sessions
    March 2, 2009

    Getting teens to avoid the first cigarette, buckle their seatbelts, skip the junk food, and use condoms is a task beyond the abilities of a white-coat in an office who’s cutting visits to shorter times because of reimbursement.

    Hmmm — that’s an interesting benchmark. How many hours a week would a teen have to spend with the family doctor to accomplish these goals, given that spending thirty or so with teachers and (one hopes) many more with parents don’t seem to be enough?

    Do the wooists have a magic formula for keeping keeping wicks dry, etc?

  11. #11 LtStorm
    March 2, 2009

    What I’d like to see is the NCCAM look into actual alternative medicines, such as Coley’s Concoction, an alternative to chemo/radiation treatment for cancer. It’s in use for a few very narrow applications, such as bladder cancer, but hasn’t seen wider spread use due to the mechanism of action for it not being well explained yet.

    Figuring out how it works is the perfect place for the NCCAM to use some of its funds for.

  12. #12 PalMD
    March 2, 2009

    Coley’s Toxin hasn’t been actually used to any real extent since the early part of the 20th century. IL-2 therapy, however, is used for renal cell cancer and melanoma.

  13. #13 PalMD
    March 2, 2009

    …and there is nothing particularly benign about Coley’s Toxin. It basically induces sepsis, and if you don’t die, it may or may not help. Either way, it’s misery.

  14. #14 Cath the Canberra Cook
    March 2, 2009

    bob, I think the Pharyngula people are being sensible but naive on this issue. Systematically testing the altmed woo to provide sound evidence on their effectiveness or lack of it? Great! It would be so useful to have a central place to check the claims.

    The problem isn’t the idea, so much as the actual execution of it.

  15. #15 LtStorm
    March 2, 2009

    Coley’s Toxin hasn’t been actually used to any real extent since the early part of the 20th century. IL-2 therapy, however, is used for renal cell cancer and melanoma.

    Ah, so that’s what it’s currently called. Though I’m sure since it’s actually accepted as a valid therapy the altmed circles don’t consider it an alternative treatment….

    …and there is nothing particularly benign about Coley’s Toxin. It basically induces sepsis, and if you don’t die, it may or may not help. Either way, it’s misery.

    Yeah, not a whole lot prettier than chemo/rad treatment, but at least it’s an actual alternative to them, rather than most of the junk the NCCAM has been testing.

  16. #16 Prometheus
    March 2, 2009

    Even though I made a New Year’s resolution to be less cynical, I can’t help being cynical on the topic of politicians and science. Obama made numerous pledges to “return science to its proper place”, but he never did mention where that “proper place” was, did he?

    As Sen. Harkin has demonstrated, most politicians feel that the “proper place” for science is squarely behind their political agenda. When it gets “out of place”, they feel a need to kick it back into line. Ergo Sen. Harkin’s diatribe about the NCCAM, an organization he set up with the express purpose of “proving” his beliefs about medicine.

    As long as science keeps supporting the current administration’s agenda, it will be treated with respect. If, however, some good science comes out that opposes that agenda, expect to see it vilified.

    Science needs to get over its need to be “liked” by politicians. That’s the only way it can keep from being run by them.

    As you said, “Meet the new boss, same as the old boss.”

    Prometheus

  17. #17 Donna B.
    March 2, 2009

    Pal, what do you prescribe for the nausea I have after reading this post?

    Since government provides so much of the funding for research (CAM or otherwise) how does science get off the political merry-go-round?

    I’m sure, in this forum, I’m gonna get slammed, but maybe Bush had the right idea — government shouldn’t be the only or, perhaps, even the primary funder of research.

    Before you completely blow my head off for suggesting that Bush wasn’t ALL bad, I’m not advocating the government cut off all funds, but rather I’m advocating that scientists and research institutions diversify their funding as much as possible.

    Just don’t get into complex derivative funding, OK?

    Oh, and where else does one throw up other than in their mouth? Is it possible to throw up through your nose?

  18. #18 SciPol
    March 3, 2009

    PalMD, You may not agree with Senator Harkin and that’s fair enough. I won’t argue your point about CAM. But is it really fair to call him anti-science? There are many champions for the NIH in Congress, and Tom Harkin is right up there with the best of them. As chair, and previously as the ranking member, of the House Labor-H appropriations subcommittee, he has worked with Arlen Specter to increase the NIH budget as a whole and I think that’s worth acknowledging.

  19. #19 Jon H
    March 3, 2009

    How much money does Harkin take from the Maharishi loonies in Iowa? They have their own *town* there, near Fairfield.

  20. #20 PalMD
    March 3, 2009

    With all respect, SciPol, I don’t see how prior good acts in any way mitigate Harkin’s current asshatery.

  21. #21 uoflcard
    March 4, 2009

    PalMD –

    My first time on this website, my first time reading your blog. I am not a doctor, so I will not challenge your expertise in any area that pertains to. But I have a few comments:

    The implication that real doctors don’t focus on prevention is ridiculous. When I see my diabetics, I make sure I examine their feet (thereby preventing amputation), I make sure they see the eye doctor (preventing blindness), and I make sure their blood pressure and cholesterol is under control (preventing stroke and heart attack).

    These don’t seem to exactly address what Weil said. To me it seems to be searching for a byproduct of the disease to treat. If the feet are okay, is anything done? If not, it is not truly preventative, although it is better than waiting for the patient to come to you in a later stage of decay. I’ve heard keeping feet clean and protecting them from injury can help prevent them from experiencing decay, and perhaps you could correct me on that. The doctor cannot force the patient to follow any instructions such as these. But the difference Weil seems to emphasize is that an IM practitioner would pursue this much more deligently in an “ongoing partnership” while other physicians would just periodically send them home with instructions. Now, what he means by “ongoing partnership” is the question. Is there significant follow-up on the instructions (in person, by phone, etc.)? Or is it just periodic office visits like a typical doctor?

    Briefly, here are my two most significant personal experiences with the standard healthcare system:

    – Several years ago, my wife was feeling ill quite often (headaches, upset stomach, etc.). She began seeing doctors. Each visit led to a new medication. Some medications replaced others, while some were just added on. But she always felt horrible, in one way or another. She was in her early 20’s and was on 3-5 medications per month. Finally she got advice to drop all of the medicine and change a few things in her diet (she’s a vegetarian; she wasn’t eating horribly to begin with). Within a month she felt 100%.

    – I began having shoulder pain a few years ago. I saw doctors about it, but the response was: ice, rest and ibuprofen (or a prescription, if I would like). I continued to have pain, but it “didn’t require surgery, yet”. Recently, I talked to a biomechanics researcher from the Netherlands. Within 5 minutes he knew what the problem was. My shoulder joint in my back (unsure of the medical term) was much too stiff. It was putting too much strain on particular ligaments in my shoulder. He gave me instructions for stretching this out. This was recent and I have not seen the full effect yet, but there has been progress (which I didn’t have with ice, rest and medicine). He said he had the same problem in his 30’s, but he began doing what he told me to do, and he hasn’t had any problem since (he’s in his 50’s).

    Whether these cases truly fall into “IM”, or whatever, I am unsure. They did seem much more preventative than the instructions and medications received from standard doctors. I don’t believe there is such a black-and-white division between the “standard” model and the “IM” model.

    Also, I don’t understand the need for the phrase “anti-science”. That just seems like a emotional appeal … once someone is dubbed “anti-science”, you would have to be a “quack” to side with them, right? You assert that “science-based” medicine uses preventative medicine – but so does the IM model. Also, both utilize disease fighting techniques. It just seems that each one emphasizes a different side. What, specifically, is anti-science about integrative medicine? (that is a real question, not a mocking, rhetorical one)

  22. #22 Pieter B
    March 4, 2009

    Donna B wrote

    Is it possible to throw up through your nose?

    Yes, unfortunately. Google norovirus. The briefest and most eloquent description I found was “Characterized by aggressive expulsion of fluids from the body.”

  23. #23 Donna B.
    March 4, 2009

    Pieter… thank you for that description. I would have thought it impossible and am extremely grateful I have never experienced it.

  24. #24 Dr Benway
    March 4, 2009

    I’m slowly recovering from my visit to NCCAM’s web site. Strange I’d never checked it out before.

    A little Risperdal in the water coolers over there might help.

  25. #25 PalMD
    March 5, 2009

    Erratum:

    Regarding my above comment about complications of diabetes—that is more properly known as “tertiary prevention”

  26. #26 James Jones
    March 19, 2009

    I thought I would mention this web site which discusses issues similar to the ones raised here.

    http://www.badscience.net/

    Ben Goldacre, the author, writes a weekly column in the Guardian newspaper. I have no connection with Ben other than as an admiring reader.

    http://www.guardian.co.uk/science/series/badscience
    “Medical scumbag’s masterclass in fraud”

    Catchy title?

    Thought there might be some scope for transatlantic co-operation.

  27. #27 PalMD
    March 19, 2009

    We all feel warm and fuzzy about ben, and I’ve supported him many times with is absurd legal battles.

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