It's no secret to my regular readers that it's highly unlikely that I'll ever be getting a job at the Cleveland Clinic Foundation (CCF) any time soon. After all, I've written posts about the CCF in which I've criticized its promotion of reiki, its establishment of a traditional Chinese medicine (TCM) herbal medicine clinic, complete with a naturopath running it, and its recent embrace of the founder of "functional medicine" (not to mention collaborator with antivaccine activist Robert F. Kennedy, Jr.) Dr. Mark Hyman. A quick Google would reveal me as the author of such criticisms. Such is life as a medical skeptic.
So here's another nail in the coffin of my chances of ever working for the CCF:
Children receiving care for chronic conditions such as anxiety, arthritis, nerve and muscle pain and even post-traumatic stress disorder will now be able to access complementary and integrative medical techniques to help them heal at the Cleveland Clinic Children's new Center for Integrative Medicine.
A team of pediatric rehabilitation specialists will offer acupuncture, biofeedback, guided imagery, hypnosis, reiki, relaxation and breathing strategies, therapeutic touch, yoga, and other treatments.
I suppose this shouldn't come as too much of a surprise. The CCF had already been subjecting children to acupuncture for at least two years now. In fact, we've met the leader of the this new program before, Dr. Benjamin Katholi, when he wrote an article advocating acupuncture for children, which I duly deconstructed in my own inimitable way. As I put it, he was mixing cow pie with apple pie in pediatrics, as he "integrated" quackery with science-based medicine. Personally, I've often wondered how one would get children to lay still and let someone stick needles into them or why one would want to.
So what's going on here? If, as I wrote about a while ago, the CCF has been offering these services to children for several years now, what's the big deal here? Why does it matter if there's a new Center for Integrative Medicine? Well, this is CCF's rationale:
Many of the children Katholi treats have post-concussive symptoms, juvenile arthritis and nerve-related pain, he said. Other children who use integrative services have chronic headaches, back pain, anxiety and other complex medical problems.
Cleveland Clinic Children's has offered many of these services to patients for several years, Katholi said, but did not have a centralized space for kids to receive care. That space will now be at the Clinic Children's Hospital for Rehabilitation on Martin Luther King Jr. Drive in Cleveland.
"The hospital has a lot of medically complex patients who are referred here for inpatient or outpatient care, so it made sense to have the center here to help enhance the quality of life for those patients and to help enhance their recovery." Katholi said.
So now there's an actual building for this woo, and, of course, if there's an actual formal name for the program with an administrative structure, that's a message that it's here to stay. So, curious, I wandered on over to the actual webpage for Cleveland Clinic Children’s Center for Pediatric Integrative Medicine . I knew it would probably raise my blood pressure, and it did. The thought of children being subjected to some of this quackery at an ostensibly respectable academic medical center is depressing to behold indeed. Here are the services offered:
- Acupuncture, Acupressure, Laser Acupuncture
- Craniosacral Therapy
- Guided Imagery
- Integrated Dry Needling
- Microcurrent Therapy (physician or therapist administered)
- Myofascial Release
- Relaxation/Breathing Strategies
- Therapeutic Touch (Babies)
That's quite a collection, isn't it? I particularly like the laser acupuncture, because, you know, everything's better with lasers. If sharks with laser beams on their head are better, why not acupuncture? Still, it's very, very disturbing to me that any academic medical center anywhere would offer craniosacral therapy for any reason—particularly to children. Doesn't Dr. Katholi know that craniosacral therapy is pure quackery? Basically having been pulled out of his nether regions by William Garner Sutherland, it's based on physiology that doesn't exist (craniosacral rhythms). Basically, Sutherland conjured up the idea that there is a "primary respiratory mechanism" that has five components:
- The inherent rhythmic motion of the brain and spinal cord.
- The fluctuation of the cerebrospinal fluid (CSF) that bathes and nourishes the brain and spinal cord.
- The shifting tensions of the membranous envelope (dura mater) surrounding the brain and spinal cord. This entire membranous structure acts as a unit and is called a “Reciprocal Tension Membrane.”
- The inherent rhythmic motion of the cranial bones.
- The involuntary motion of the sacrum (tailbone) between the ilia (hip bones).
But wait, there's more:
As the lungs breathe and the heart beats with a rhythmic alternating expansion and contraction, the central nervous system (CNS) also has its own involuntary rhythmic motion. Dr. Sutherland described this inherent activity of the CNS as a respiratory motion with “inhalation” and “exhalation” phases. The hands of a skilled osteopathic physician connect directly with the primary respiratory mechanism to bring about a therapeutic response. Primary respiration is the guiding principle; it is the inherent intelligence within. This Primary Respiratory Motion actually expresses itself through every cell of the body, influencing all body functions. Physicians trained in Cranial Osteopathy can place their hands on any part of the patient to perceive and influence this important mechanism.
Let's just put it this way. The "primary respiratory mechanism" that is based in physiology has little relationship to what Sutherland described. But note the "inherent intelligence." It's very much like what chiropractors like to call the "innate intelligence." Basically, it's vitalism, in which the practitioner is said to assist and facilitate the "inherent healing intelligence to reconnect with its state of balanced health." At its core, the "inherent intelligence" is no different from the chiropractor's "innate intelligence" or the qi (or life energy) of traditional Chinese medicine. By "detecting" (or "listening through the hands"), supposedly the CST practitioner can recognize the body's "subtle rhythms" that indicate "congestion" of cerebrospinal fluid, which they can then correct by various manipulations. In reality, all craniosacral therapists do is to gently massage the head, in order to treat almost anything.
It's utter pseudoscientific, vitalistic nonsense, of course. Unfortunately, it's utter pseudoscientific, vitalistic nonsense being sold to children by the CCF. I suppose that's appropriate, given that the CCF advertises acupuncture on its site by appealing to qi and to nerve stimulation.
Personally, reading the news story, I was intrigued (and not in a good way) by this passage:
The center will also begin research on several integrative treatments — acupuncture, reiki and a form of low-intensity electrical stimulation called frequency-specific microcurrent therapy — to figure out what their potential benefits are for kids.
The roots of Frequency Specific Microcurrent (FSM) date back to the early 1900's from Dr. Albert Abrams, who was the first physician to use calibrated instruments capable of detecting the radiations of living tissue. Dr. Abrams concluded that: all matter radiates electromagnetic energy; the characteristics of the radiations from any type of matter depend upon the molecular constituents of the material examined; and the radiations emitted by the different organs of living tissues can be detected, selectively differentiated, and the amplitudes measured. Dr. Abrams became convinced that the frequencies involved were radio waves and that electronic equipment could be developed to neutralize and eliminate disease radiations.
Oh, no. It's vibrations! Toujours vibrations! Don't believe me? Then check out how the mechanism behind FSM is explained:
Remember your high school chemistry class. Think about the explanation of the atom. At the center of the atom are the protons and neutrons. This is called the nucleus. The old theory, in the 1960s, was the electrons were spinning in orbits around the nucleus. Modern research has shown that the electrons actually vibrate back and forth in orbits around the nucleus, instead of spinning in continuous, mono-directional circles. This new understanding is the basis of our FSM theory.
Each tissue in the body has individualized frequencies. The individualized and specific vibrational characteristic of each atom, of each tissue type, varies even more specifically for varying conditions, such as: trauma, inflammation, stress, environmental influences, etc. To put the theory of vibrations in a better overall perspective: different vibrations / frequencies of sound, light, radio waves, etc., are responsible for notes of music, colors of light, and radio stations. Vibrations are specific and unique for all matter, inorganic and organic.
When an injury occurs to a tissue, the electrons in the affected tissue take on a different vibrational characteristic, unique to that injury or other abnormal condition. As the vibrations of the electrons change, it is believed the electrons concurrently may also change to a different "orbit" from what was normal for that tissue type.
FSM is "frequency specific" because we match the frequencies of the tissue disruptions with the frequencies we choose for our therapy. The new vibrational characteristics that occur from damage to a tissue are countered with specific microcurrent frequencies that match the exact abnormal frequencies that are present in the damaged tissue. The desired effect is to neutralize those frequencies that are incorrect for the damaged / affected tissues.
Yep. Vibrations again. What is it with woo-meisters and vibrations? Of course, there is no good evidence that when a tissue is injured it takes on a "different vibrational characteristic" (whatever that means). I can sense any physicists and chemists out there (and, remember, my undergraduate degree was in chemistry) cringing heavily. I mean seriously? Injuring tissues cause electrons to go into a different orbit? Don't these people know that that requires energy to do that? Not the kind of "life energy" that acupuncturists and other TCM practitioners believe in, a mystical magical "energy" that does no work and is undetectable to scientific instruments, but real energy! Don't they also know that such higher energy orbital states tend to be unstable, with the energy that moves the electron to its higher energy orbital being released as light. What's being described here is nothing but science-y sounding gobbledygook.
But it goes beyond that. The inventors of this woo seem to think that the vibrations of the electrons supposedly altered by injury can be corrected just by running low level electrical current at various frequencies through the area. It's utter nonsense that's based on, yes, a high school level understanding of physics, and a poor high school level of physics at that.
And CCF is seeking to combine this woo with reiki. I suppose it makes sense in a way. Both are invoking pseudoscientific "energy" as their explanation. Reiki's just a bit more fantastical.
What doesn't make sense is that a respected (fast becoming once respected) American bastion of academic medicine would offer this sort of quackery.
I use guided imagery as a thing to half-focus on to quiet my brain-chatter so I can fall asleep, it's great for that. Head massages feel good, so do breathing exercises! Of course, I don't pretend to be practicing medicine while doing any of those this.
I knew a composer of electronic music who wanted to write a piece including very low pitches through big subwoofers to try to set up resonance frequencies with people's bladders -- so the listeners would feel the sudden need to pee. That is all I can think of when I read about treatments using "vibrations."
Laser! Acupuncture! I can't even...
CCF seems to be heterodyning out of control. Their embrace of frequency & other quackery cannot end well - I recall the fate of the Tacoma Narrows bridge. Or have I tortured those metaphors beyond use? Really disappointed to hear that research money will be siphoned off into woo. I was offered a position in a lab there in the 90s; perhaps I dodged a bullet.
I had some hope that CCF's largest local competitor, University Hospitals of Cleveland, would exert some pushback, until a search on the terms alternative & complementary produced this: http://www.uhhospitals.org/search?s=complementary%20and%20integrative%2…
"The old theory, in the 1960s, was the electrons were spinning in orbits around the nucleus..."
WTF? Did that guy learn chemistry from cartoons? The Bohr-Rutherford model (circa 1911) was replaced by the quantum mechanical models of atoms around the mid-1920s. And electrons don't "vibrate back and forth" in any model. They occupy orbitals of discrete energy levels.
Yes, relaxation therapy/ deep breathing, guided imagery, some massage and yoga help patients relax, which is a good thing. The trouble is they mix the stuff that works , such as relaxation training, with complete nonsense such as reiki. Sadly, many patients think relaxation techniques actually prevent or cure or heal serious diseases. As Orac says, the apple pie gets mixed with cow pie.
When I was offered "healing touch" by RNs (they wave their hands over the patient) I said to my husband, "what's next? is the head of transplant going to come in a witch doctor outfit?"
S/he means s/he saw a TV science show produced in the '60s. That makes the viewer at least as knowledgeable as those Western reductionist PhDs.
Who pays for this rubbish?
OK, folks, time to triple the amount of hard-science training required of doctors.
I kid, I kid, but still.
The most likely explanation for why these programs are becoming ensconced at CCF is a major donor. Someone with some connection to CCF that has a lot of dispensable money and a penchant for woo probably made a sizable donation (in the 7+-figure range) to establish this nonsense. It's not likely that CCF (or most 501c3 academic medical centers) would turn down such philanthropy.
When I read the part about electrons jumping to higher energy states I got this great image of little sparks of light flashing every time someone gets injured. "Oooh, I see Bob got another papercut! Nice one!"
Seriously though, do these people learn chemistry and/or physics from a cereal box? It's like they took something that is, at bottom, technically true--the resonating frequencies of different types of matter do exist, but they have no therapeutic value whatsoever--and said to themselves, "What's the least believable thing we can say about this, and how much can we charge for it?"
When I read the part about electrons jumping to higher energy states I got this great image of little sparks of light flashing every time someone gets injured. “Oooh, I see Bob got another papercut! Nice one!”
Actually, I got a vision of someone's tissue glowing fluorescently as that new energy put into the orbitals discharges. :-)
If it's a big donor, usually that donor is acknowledged, often by naming a center or the fruit of the donation after the donor. I'm unaware of any of this stuff at CCF having been named after anyone, but I could well be wrong.
@ Todd- Yes, wealthy philanthropists are often at the heart of this - I don't know about CCF specifically. What I kept hearing was "it's what patients want". It's MARKETING.
Not wanting to be left behind...the Mayo Clinic has what would appear from their website to be comparable integrative medicine infrastructure, although it's not clear whether there is a dedicated building.
Mayo has a page dedicated to the funding sources for the initiative, which includes ten benefactors, plus NIH/NCCAM, Komen Foundation, and NCI. Collaborators include Johns Hopkins, MD Anderson, Tang Center for Herbal Research at the University of Chicago, and University of Minnesota Center for Spirituality and Healing.
Neither of these two - Mayo and CCF - have much of a presence on the current NCCAM grant list.
Generally, the center is named after the donor, yes. However, if the donor wishes to remain anonymous, the info won't be divulged.
Of course, it could also be a lot of smaller donors supporting an initiative started by a doc. If there were several donors, then I wouldn't expect to see a name associated with the center.
This sniplet of the FSM description is very illuminating:
"different vibrations / frequencies of [...] radio waves etc., are responsible for [...] radio stations."
Seems like a pretty theory of everything.
On a slightly more serious note: You _can_ injur tissue by putting electrons in a different orbit. The common name for this is "sunburn". Although you would not want to do something even remotely similar with electricity outside of an execution chamber.
It’s utter nonsense that’s based on, yes, a high school level understanding of physics, and a poor high school level of physics at that.
I'd say Orac's description of this kind of woo is generous. However, I graduated from high school mumblety-mumble years ago, so I may be overestimating the intelligence of current high school students.
This vibration stuff sounds like a horribly garbled interpretation of phonons in bulk materials. I have news for these folks: in a bulk material one has densities of states, so that instead of a few discrete frequencies one has frequency bands. Changing the frequencies would require a chemical change to the material, which could happen as a result of injury (flooding the site of the wound with dopamines, etc.). The catch is that applying these vibrations won't change it back; you need to do some chemistry, not physics, to get the healing to take place.
@palindrom: You may be kidding about increasing hard science requirements for pre-meds, but it deserves some serious thought. It turns out that physics really is useful in medical education--not just because it identifies certain people who should not become doctors, but also because it allows doctors to spot obvious woo like this, and run as fast as they can in the other direction.
Oh, and subjecting kids to this stuff is definitely over the line. It's one thing to offer woo treatments to a consenting adult, who in principle should know better, even if too many choose not to. Kids generally don't know better.
I read how the woosters talk about vibrations and honest to god I think they all did a batch of bad acid.
@ Joe Wear:
Not at all, they are merely more *sensitive* to the unseen world of subtle vibrational energies, spirits of the air and soulful fairies or suchlike than SB folk.
i experienced negative vibrations upon learning that our hospital system has hired an acupuncturist, whose ministrations are touted to not only relieve pain, but also "strengthen immunity' and treat allergies, anxiety and depression.
Better watch out for those negative vibrations, dude. They'll block the healing frequencies of qi from acupuncture and the healing frequencies of FSM...
Although you would not want to do something even remotely similar with electricity outside of an execution chamber.
If you don't mind, I'd rather not have that happen inside an execution chamber either.
@Dangerous Bacon #19:
and treat allergies, anxiety and depression.
Seems more like the acupuncturist may cause anxiety and depression!
The roots of Frequency Specific Microcurrent (FSM) date back to the early 1900’s from Dr. Albert Abrams
Goodness me, it's the old Radionics grift! I remember reading Martin Gardner's description of that in "Fads and Fallacies", and thinking how antiquated and old-fashioned it sounded. But no idea is too stupid or dishonest for Alt-Med.
Is it just me, or do others hear theremin music whenever they think of bad (or good) vibrations?
Correction - Electro-Theremin music.
Do health insurance carriers pay for this stuff? I know that mine will pay chiropractors but I'm pretty sure they would draw the line at reiki. Of course that clinic is out of network so they have other reasons to deny.
@MO'B: I tend to think of the Beach Boys, but maybe that's because of their hit song "Good Vibrations". Although falling in love can mimic certain medical conditions, these "Good Vibrations" are a symptom, not a treatment.
Why not vibrating laser acupuncture? Or would toes get stepped on? Like surgeons doing their own endoscopies?
@ Eric Lund
Conveniently, the song Good Vibrations features an electro-theremin, so the circle is complete.
FREE THE QI
Vibrations good like Sunkist,
Many wanna know who done this.
Marky Mark and I'm here to move you,
Rhymes will groove you.
@Mike, yet these are licensed and trained physicians. Trained at real medical schools and passed real licensing boards?
It's interesting to note that in 2002, the Federation of State Medical Boards issued a document titled "Model Guidelines for the Use of Complementary and Alternative Therapies in Medical Practice" (http://library.fsmb.org/pdf/2002_grpol_complementary_alternative_therap…).
A lot of the nonsensical "therapies" Orac describes above at Cleveland Clinic don't meet the guidelines of this document (such as being first effective, but also, as for acupuncture, safe). I've not been able to find a document of CAM guideline on the State Medical Board of Ohio web site. I have found such a document on my home state of Arizona's medical board site (http://azmd.gov/Files/Guidelines/AlternativeMedicineInPhysicianPractice…), but as pointed out by Mike in #32, there are medical schools, including ones in AZ, promoting this ridiculous CAM nonsense--with no apparent calling out from anyone based on these guidelines.
@Chris, as they are model guidelines, there is no guarantee that Ohio has adopted them.
Yet we had to spend two years convincing the VA to allow a free weekly session in focus and cleansing. Sometimes the insanity in this system is madding.
All that time I wasted...So many years working in child and adolescent mental health with bairns suffering things like anxiety or PTSD, the time spent on cognitive and behavioural programmes or exploring the meaning of a traumatic event, when I could have thrown some darts at them and had done with it.
What a fool I have been!
I imagine most of the costs of these treatments are being paid by the parents. Since most insurance won't cover 'elective' therapies unless there is a loophole somewhere. Plus I imagine parents will pay a lot on the promise that it will help their child. Particularly marketed at an actual medical institution. While you might be skeptical of an ad on a webpage or a storefront offering magical healing when your doctor turns down the corridor and points you to this shiny new clinic that will sucker you in. I think this has more to do with making money. As I would imagine most of these 'treatments' are self pay, they are a cash cow for the hospital. All gain and very little outlay of resources. Which is marketing and business at its finest.
Kiiri, your (American) insurance company has wide leeway to pay or not pay for almost any treatment, although restricted a bit with the Affordable Care Act. While chiropract are often paid for, with very good reason, most of those other types are not covered. Practically with a 25% copay and high out-pocket the voodoo treatment will be cheaper than AMA blessed treatment. Acupressure is cheap compared to an real medicine. I've heard from people still in the biz, that the poor insurance is part of the reason for the rise in alternative crap.
However, this is the part that gets complicated, while many voodoo techniques are not "covered" it does not guarantee that they will not go towards your maximum out-out-pocket. This varies greatly from state to state, but it become reasonable on a financial basis to meet your deductible and then your maximum out of pocket.
Say I spend a thousand of a blankety-blank chiropractor. My family deductible is $6500. After the chiropractor fails to improve my outcome, I undergo L2/L3 fusion, run up $100,000 in claims. I now pay $1000 to the chiro and $5500 to the surgeon which is my max out of pocket.
Now, suppose my neural entrap just happens to get better, and to be overly fair we had a chiropractor that suggested some strength exercises and at least didn't hurt the situation. If my L2/L3 situation gets better I've paid $1000. I've not exceeded my max out of pocket.
Now, since your insurance company has little vested interest in your health, their goal is either to pay the minimum outlay possible or if you become a high utilization individual their desire is to see you on the government's tab. This has improved some with the ACA, but not been eliminated.
I am pleasantly surprised that the Cleveland Clinic has not yet added snake oil to their list of services. Perhaps they are waiting for some scammer to rebrand it as a branch of TCM.
herr doktor bimler - perhaps they should consider snake WD-40.
Yet, still the Cleveland Clinic is ranked #1 in cardiology and I settle for a cardiologist that was Cleveland Clinic trained. When getting a second opinion over supposed gall bladder failure, a Cleveland Clinic trained gastroenterologist immediately recognized heart failure and fluid retention in the ab cav as the culprit, even without the oft observed swelling in the periph, and saved me from unneeded surgery. I like my gall bladder, it is my sixth favorite organ.
It is hard to tell the true from the false, the good from the bad.
I have a hypothesis: it's all about administrators building big administrative departments and feathering their nests.
Bear with me for a moment...
Björn Brembs (a neurobiologist at a university in Germany) recently wrote a criticism about the exploding costs of American university education. He believes that the root of the problem is hugely bloated administrations that take over and treat educational institutions like corporations, adding layers of middle management at 'competitive salaries,' driving up tuition to an unsustainable level.
He makes a compelling case based on the rising quantity of students per professor, and the rising quantity of administrators per professor. The way I would put it is, the admins set up a social ecosystem favourable the flourishing of more admins. The admins and their friends include marketeers, sales people, and bean counters.
Thus Cleveland Clinic. Some admin-culture people, whether managers, marketeers, sales, or bean-counters (none of whom know doodley-squat about medicine), get together and say 'let's build a House of Woo and we'll all have high-paid jobs for life.' They hire some woo-meisters, gin up some clever propaganda, and Ta-Daa!, they're 'in business' in more ways than one.
I'm quite sure that's what's happening here and in similar cases. Count up the admins at these places and see what you find.
That said, some of that woo might be useful in limited ways, having to do with relaxation. Biofeedback, guided imagery, hypnosis, and the like, are legit for that purpose, as long as they don't claim to tweak peoples' vibrations or twiddle their subtle energies. So I'm with Emma @ 1 on this. Mildly nutritious apple pie.
The cow pie is obvious, such as Reiki and 'electromedicine,' and one can only wonder when they'll add homeopathy to their list of 'healing modalities.' It would be better if the apple pie was 'integrated' with the rest of SBM, but there's more money to be made by fluffing it up with more BSM (I trust you can decipher that acronym).
So now you have naïve kids (and never underestimate: anguished parents!) seeking help with pain or whatever, and the kids do whatever procedure and feel relaxed, so placebo/expectation effects kick in and make the kids more likely to believe that magical hand-waving will also help.
But here's what I think actually goes on in the mind of a smart 8-year-old:
'These silly grownups with their silly emotional stuff, why don't they just learn to play "let's pretend" and have fun? Here comes that one again, she wants to wave her hands over me. OK, I'll sit still and smile, at least she's not going to stick me with needles like that other one! I wonder if I told him his needles made me want to vomit, would he go away? Or maybe they'd just give me another one of those funny cookies that smelled like pine trees and made me see ghosts...?'
I like my gall bladder, it is my sixth favorite organ.
Now that you are hanging out at RI, it helps to have a reliable and controllable supply of bile.
Herr Doktor, for that same reason I will likely tire of this den of rogues, rakes, n'erdowells, rapscallions and reptiles. While my heart is much improved, which I attributed to a combination of my Medtronics Viva™ XT and traditional "medicine", avoidance of stress is a common aspect in both traditions. I truly should retreat.
In fairness, my first gastro did not make a bad diagnosis. His logical conclusion was based was not due to poor reasoning, he even checked my feet to confirm that I had no apparent swelling. Still, I am rather pleased that I did some "doctor shopping" even if I had to pay out-of-pocket for a second opinion.
It is always useful when you find a person that has the talent and experience to tell the difference between the gait of a horse and a zebra.
I've noticed that even the aficionados of complementary/alternative/whatever-they're-calling-it-this-week medicine typically have low expectations for it (though they might deny it of challenged). So perhaps part of the appeal for places like the Cleveland Clinic is that it provides an additional source of profit while having a minimal effect on chances of a malpractice suit. Which started me wondering: Has there ever been a major malpractice suit over CAM treatment? Even if it hasn't happened yet I can't see that it isn't that far off.
Re. Sir Bedevere @ 44:
Most interesting!, and yes I do think you're on to something there. It also dovetails with my hypothesis about administrative types feathering their nests.
What a fabulous business model. High administrative salaries, low risk of lawsuits compared to other players in adjacent niches, a clientele who are happy to be merely 'heard and affirmed,' and a product that isn't much more than vaguely pleasant feelings with no objective correlates.
I saw this and I didn't know where else to put it.
There are actually several references to the placebo effect in this article.
@Julian Frost. You dismiss the power of "faith". There are times, you need to have the belief that you are going to get better, the need to be reassured that there is hope, that there is going to be path out of illness, that things will get better. Lump it in with the placebo effect, but hope works. When each step is agony, when each breath is a dagger of pain, to know that this too, shall pass. Take all of that away, and you will lay down and die.