Alternative Medicine: A Public Health Perspective

William T. Jarvis, Ph.D.

A Chinese proverb states that "the beginning of wisdom is to call things by their right names." To determine whether alternative medicine is science or snake oil, one must define it carefully. Webster's Dictionary defines "alternative" as "a choice between two or more things, only one of which may be chosen." Stung by instances in which patients have been lured from life-saving therapy, some alternativists have adopted the more benign-sounding term "complementary," which Webster's defines as "serving to fill out or complete" and "mutually supplying each other's lack." "Complementary medicine" claims to provide this but actually does not.

Modern health care abounds with genuine alternatives, for which reliable information about safety and effectiveness is available. "Alternative medicine" is defined by what it is not. Its methods are not part of standard health care. They not only lack scientific proof of safety and/or effectiveness. They also lack a plausible rationale.

The U.S. Public Health Service's Official Attitude

In the early 1990s,National Institutes of Health (NIH) Office of Alternative Medicine (OAM) defined alternative medicines as:

Any medical practice or intervention that (a) lacks sufficient documentation in the United States for safety and effectiveness against specific diseases and conditions; (b) is not generally taught in U.S. medical schools; and, (c) is not generally reimbursable by health insurance providers [1]

Despite the favorable publicity given to OAM's creation, NIH's position was expressed in bold-face type in the foreword to the book Alternative Medicine; Expanding Medical Horizons:

This document does not reflect endorsement of these therapies or recommendations for research by the NIH, the U.S. Public Health Service, or the U.S. Department of Health and Human Services. It reports on a series of opinions expressed by nongovernment participants in the workshops . . . .

The NIH cautions readers not to seek the therapies described in this document for serious health problems without consultation with a licensed physician. The NIH further cautions that many of the therapies described have not been subjected to rigorous scientific investigation to prove safety or efficacy; and many have not been approved by the U.S. Food and Drug Administration [2].

Marcia Angell, MD, executive editor of New England Journal of Medicine , has stated that the very name "alternative medicine" is Orwellian newspeak, because it falsely implies that it is a viable option. She considers the term a new name for snake oil [3]. Experts in the psychology of deception speak of "sleight of mind" techniques such as "doublespeak." William Lutz, editor of the Quarterly Journal of Doublespeak, states:

Doublespeak is language that pretends to communicate but does not, that makes the bad seem good, the repulsive appear attractive or at least tolerable. It is language that avoids, shifts, or denies responsibility, language at variance with its real or purported meaning. Basic to doublespeak is incongruity; the incongruity between what is said, or left unsaid, and what is; between the word and the referent. It perverts the essential function of language, which is communication, in order to mislead, distort, deceive, circumvent. Doublespeak is the deliberate use of language as a weapon or tool . . . to achieve their ends at the expense of others [4].

Physician Interest

Report that physicians are interested in alternative medicine require careful interpretation. Doctors are primarily interested in what their patients are doing. They hear about alternative medicine in the media, so they are curious. Current studies of medical attitudes toward "alternative" methods consistently find a combination of interest and ignorance. No data suggest that physicians perceive complementary medicine as useful and/or effective [5]. Unless predisposed to believing in a unscientific ideology, the more doctors learn about these procedures, the more negative their attitudes are likely to become.

Popularity among Americans

Many reports have misrepresented both the nature of alternative medicine and its popularity. In 1993, Eisenberg and others reported that 34% of Americans used "unconventional" medicine [6]. They did not use the term "alternative." The authors actually said that "unconventional therapies are generally used as adjuncts to conventional therapy rather than as a replacement for it." Their survey found that 13% used unspecified "relaxation techniques" for insomnia, headache, high blood pressure, digestive problems, anxiety, and depression; 10% used "chiropractic" for back problems and arthritis; and 7% used "massage" for back problems, sprains or strains. These three categories accounted for 30 of the 34% utilization, and only 36% of the users "saw a provider," reducing the percentage who used providers to 12%. Among the remainder were commercial weight-loss programs (e.g., Weight Watchers, Jenny Craig, NutriSystem), health spa methods, and self-help groups (e.g., Alcoholics Anonymous). These data did not support the authors' conclusion that the frequency of use of unconventional medicine in the United States was "far higher than previously reported."

The FDA's 1968 landmark study [7] found that 1% reported "ever having used" a naturopath, but naturopathy didn't even make a showing in 1990. Acupuncture use was under 1%, which was substantially less than the 4% Harris reported in 1987 [8]. The use of homeopaths was very low in both studies—.5% reported "ever having used" a homeopath in 1969, while 0.32% used a practitioner in 1990. Only two areas showed a significant increase in use: over-the-counter herbal and homeopathic remedies, both of which are clearly due to aggressive marketing in the face of lax regulation by the FDA. A major homeopathic manufacturer noted that although homeopathy had received much favorable publicity and sales of homeopathic medicines to consumers with little knowledge of homeopathy were "way up," sales to physicians and consumers using the more traditional homeopathic medicines were "flat." [9]

A recent study has confirmed that Eisenberg's figures were inflated. Using data from the 1996 Medical Expenditure Panel Survey, researchers from Yale University concluded that only 8.3% of Americans used the services of an "alternative" provider, with chiropractic use most common (used by 3.3% of the survey population), followed by massage (2%), herbal remedies (1.8%), spritual healing (1.8%), nutritional advice (1.1%), acupuncture (0.6%), meditation (0.5%), and homeopathic remedies (0.4%). This survey was more significant because it covered more than twelve times as many people as the Eisenberg study and interviewed a more representative population sample [10].

User Characteristics

Most people who clamor for alternative medicine ("traditional users") constitute a small segment of society. Such people are often referred to as "health conscious," "health enthusiasts," "health-seekers," and "the worried well." A survey of 1,036 Americans funded by the Fetzer Institute and the Institute for Noetic Sciences divided people into 3 groups: 47% modernists (cultural mainstream), 29% heartlanders (traditionalists), and 24% cultural creatives (trans-modernists). Of the latter, 13% were labeled "greens," and 11% as "New Agers deeply committed to the inner life." Fifty-two percent of cultural creatives reported using alternative health care in the previous year [11]. This is far higher than has been reported for any other group.

A 1996 survey of herbal supplement users found that most of the growth in use was coming from "first time tryers." Compared to "more traditional users," the first-timers were:

A marketing analyst stated that herbal marketers "were not off to a good start with consumers." The high cost of herbal supplements is discouraging to consumers, and less knowledgeable and skeptical new users can easily be disappointed if near-term results do not live up to expectations and claims. The analyst recommended "education" by herbal marketers [12].

The use of alternative health care is likely to increase among those "without much knowledge" due to the finding that people with persistent health concerns try everything they hear about (dubbed "rampant empiricism") [7]. This is likely to be enhanced for practices that do not have the stigma of quackery. Media reports showing health professionals taking an interest in alternative medicine is all the endorsement most people would need to give something a try. It also appears that the public holds many misconceptions about "alternative" health care (alt-care).

Common Misconceptions

In 1994, Washington and Alaska Blue-Cross (WABC) conducted an experiment in which 1,000 subscribers were enrolled on a first-come basis for one-year's coverage of alternative care. The AlternaPath program took in $170,000 and paid out $650,000. Some of the overcosts apparently were due to subscribers stocking up on supplements. Analysis of the data showed differences between consumer perceptions about alt-care and its realities [13].

Misconception #1: Alt-care would save money over
time because it emphasizes prevention and wellness.

The reality is that in many instances, adding alt-care has increased costs to insurers without providing any measurable benefits. In 1983, Blue Cross of Arizona was forced by the legislature to cover chiropractic on the theory that competition would cut healthcare costs. A 3-year study found an opposite outcome. The average chiropractic case cost was $587, which was 8% higher than surgeons, and 352% higher than general practice MDs. From 1984 to 1986 chiropractic claims rose much faster than hospital or MD costs (70% versus 23% and 33%, respectively). Within 79 categories of service, DCs were the most expensive in 32. Among the most common diagnoses for which DCs render services, their average charges were $370, versus $166 for DOs and $112 for MDs. Despite the increased costs to the system, there was no reduction in hospital admissions for conditions within the scope of chiropractic practice. The volume of chiropractic services increased to the point that by mid-1986, it accounted for more than all physician providers combined within the chiropractic scope of practice [14]. A comparison of DC v hospital outpatient care in the United Kingdom found DC care more expensive, despite being limited to 10 treatments [15]. CHAMPUS, the armed forces program for military dependents, conducted an 18-month demonstration project to determine the cost-effectiveness of chiropractic. It found that chiropractic care added costs to health care programs without improved the health of the insured population [16].

Misconception #2: Alt-care providers look at the whole person.
In reality, alt-care providers have a narrow view of disease and its treatment. Acupuncturists place needles on imaginary "points," chiropractors are obsessed with manipulating the spine which according to chiropractic theory is a near-panacea. Naturopaths overemphasize dietary supplements, herbal remedies, and tend to focus on the colon. Homeopaths are supposed to pay attention to emotional complaints, but prescribe medications in the same manner as do regular physicians. Alt-care providers focus more upon patient satisfaction than regular doctors, but much of this is contrived. Practice management seminars teach DCs how to trick their patients into unneeded care, how to rope them for a lifetime of useless "preventive" care, and how to make them believe that chiropractice care is "working." Patient deception has been intricately described by sociologists who worked as chiropractic assistants [17].

Misconception #3: Alt-care providers
spend more time with patients.

In fact, some alt-care practitioners do spend a lot of time with patients, but others do not. Classical homeopaths are trained to spend 30-90 minutes with patients, and to spread treatment over extended time periods, but this is inefficient and unlikely to be acceptable to managed care administrators. Most chiropractic practice-builders emphasize high-volume practices, and teach DCs to train assistants to line up patients so the "doctor" can go down the line "adjusting" spines. Some high-volume practitioners have reported "adjusting" over 300 patients a day.

Misconception #4: Alt-care providers focus more on prevention.
In reality, alt-care providers make a pretense of practicing preventive medicine by prescribing lots of dubious supplements. But their methods of prevention are apt to be just as unproven as their therapeutic procedures. The reality is that many alt-care providers attack scientifically proven preventive measures (eg, immunization, fluoridation, pasteurization, food irradiation). "Diversion by a homeopath" was the most common reason for parental refusal to immunize their children in the United Kingdom [18]. Only a minority of American chiropractors advocate immunization [19]. Naturopaths have traditionally bad-mouth immunization [20].

Misconception #5: Alt-care is more "natural."
Here again, people seem to be confused by semantics. Webster's Dictionary defines "natural" in many ways, including "being in accordance with or determined by nature," "untouched by the influences of civilization and society," and "having a form or appearance found in nature." Poking acupuncture needles into the skin, swallowing homeopathic concoctions elaborately prepared according to Hahnemannian principles, manipulating the spine, colonic irrigations, or swallowing handfuls of dietary supplements are no more "natural" than medical procedures. In the case of fluoridation, alt-care providers have been against this procedure which merely adjusts the level of fluoride in water to mimic the tooth decay prevention seen in areas where fluoride occurs naturally. Immunization also is based upon mimicking naturally-acquired immunity discovered by medical pioneers. Registered dietitians promote food rather than pills for good nutrition, but alt-care providers are notorious for pushing dietary supplements. Alt-care may be low tech, but it is not as natural as science-based medicine.

Misconception #5: Alt-care is more "holistic."
Acupuncture, chiropractic, homeopathy, naturopathy, and some types of massage therapy are rooted in vitalism, the theory that biological activities are directed by a supernatural force. Supernaturalism is the opposite of the naturalism upon which evidence-based medicine is based. Although most of the alt-care systems named claim to be "holistic," vitalism represents dualism, not holism. Vitalists believe in a Life Force that can exist apart from the physical body. Acupuncturists call the alleged force "chi," chiropractors call it "The Innate," homeopaths call it "vital energy," and naturopaths call it "vis medicatrix naturae." Some vitalists even interpret herb-induced hallucinations as "out of body" experiences. Some have said that the failure of a patient to respond to treatment meant that "the spirit has decided it is time to leave the body." Modern science is truly holistic because it holds that the "mind" is a functioning brain that is inseparable from its anatomy, not a metaphysical entity.

Conclusions

Having tracked health fraud, misinformation, and quackery as public health problems for more than 25 years, I conclude that little has changed besides increased attention to nonstandard health practices and a revision of the language used to describe them. Alt-med succeeds because its providers:

Although these tactics may improve patient satisfaction, they are not compatible with tight-fisted managed care programs. Anyone insuring alt-med should consider the nature of its hard-core users. Many are health neurotics with an insatiable appetite for attention and pill-taking. Alt-care is appealing to some insurers because it is low-tech and dietary supplements are cheaper than medications. The low cost of low-tech methods may offset the propensity of alt-care providers to overtreat, but as a policy-holder, I would not want my premium dollars wasted on alt-care. Insurance carriers should limit alt-care coverage to an optional accessory strictly on a business basis.

Should unusual approaches to health and healing be studied? Of course. Should we abandon the scientific method to allow questionable methods to compete openly with those that have met the standards of science and ethical care? Absolutely not. Patient well-being is at stake, and no one has the right to subvert responsible health care. Are some practices mislabeled as "alternative" that may be appropriately applied as "complementary" therapies as part of the art of medicine? Yes, but these require careful handling to avoid undesirable side-effects in emotionally vulnerable patients.

References

  1. NIH Office of Alternative Medicine. General information flyer, 10/4/94.
  2. Alternative Medicine: Expanding Medical Horizons A Report to the National Institutes of Health on Alternative Medical Systems and Practices in the United States. Washington, DC: Supt. of Documents. (Prepared under the auspices of the Workshop on Alternative Medicine, Chantilly, Virginia, September 14-16, 1992.)
  3. Kolata G. On the fringes of health care, untested therapies thrive. New York Times, June 17, 1996, p.A-1.
  4. Editor's Workshop, February, 1991, p.7.
  5. Ernst E and others. Complementary medicine. What physicians think of it: A meta-analysis. Archives of Internal Medicine 155:2405-2408, 1995.
  6. Eisenberg D and others. The use of unconventional medicine in the United States. New England Journal of Medicine 328:246-252, 1993.
  7. Food and Drug Administration: A Study of Health Practices and Opinions. Pub 210978. Springfield, Va., 1972, National Technical Information Service, US Dept. of Commerce.
  8. Louis Harris & Associates. Health, Information and the Use of Questionable Treatments: A Study of the American Public. US DHHS, Sept, 1987.
  9. Borneman J. Is Homeopathy obsolete? Resonance Jan-Feb, 1994, p.23.
  10. Druss BG, Rosenheck RA. Association between use of unconventional therapies and conventional medical services. JAMA 282:651-656, 1999.
  11. Ray PH. The rise of the cultural creatives. New Age Journal, Jan-Feb, '97.
  12. Wood L. Today's proactive consumer and herbal supplements. HerbalGram No. 40, Summer 1997, pp.50-1.
  13. Blue Cross of Washington and Alaska; Focus Groups with AlternaPath Subscribers. Endresen Research, Seattle, Oct 1995.
  14. Financial Impact of Chiropractic Benefits on Health Care in Arizona; Blue Cross/Blue Shield Experience, 1983-86. Arizona Blue Cross/Blue Shield, Feb 1987.
  15. Meade TW and others. Low back pain of mechanical origin: Randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal 300:1431-1437, 1990.
  16. CHAMPUS Chiropractic Demonstration, Aug 1993. Task III Report MRI Project No.8533-D, 1/24/86.
  17. Cowie JB, Roebuck JB. Ethnography of a Chiropractic Clinic. Macmillan Free Press, 1975.
  18. Simpson N, Lenton S, Randall R. Parental refusal to have children immunized: Extent and reasons. British Medical Journal 310:227, 1995.
  19. Colley F, Haas M. Attitudes on immunization: A survey of American chiropractors. Journal of Manipulative & Physiological Therapeutics 17:584-590, 1994.
  20. Halper J, Berger LR, Naturopaths and childhood immunizations: Heterodoxy among the unorthodox. Pediatrics 68:407-410, 1981.
  21. Neher A. The Psychology of Transcendence. Prentice-Hall, 1980, pp 51, 244.

Dr. Jarvis founded and was president of the National Council Against Health Fraud. In 2000, he retired from Loma Linda University, where for many years he served as Professor of Public Health and Preventive Medicine at the School of Medicine and Public Health.

This article was revised on August 16, 1999.