Quacks and Flacks

The pitfalls of seeking a scientific foundation for alternative medicine.

Chris Mooney from the June 2003 issue

(Page 3 of 4)

Naturopathy, in the words of its proponents, is an alternative medical system based on "the interconnectedness and interdependence of all living things." To distinguish themselves from M.D.s, naturopathic physicians claim to seek out the "underlying causes" of disease, to prescribe "natural" remedies, and above all to view the body as an "integrated whole." Before his resignation, Relman decided to find out just what this meant in practice. So he spent several days plowing through the 1,600-page Textbook of Natural Medicine, produced by two naturopaths at Bastyr University, the nation's leading school of naturopathic medicine, founded in 1978 near Seattle.

The naturopathic textbook describes itself as setting forth "well-documented standards of practice for naturopathic medicine." But in a memo Relman submitted to the commission, he objected that it listed only 70 specific health conditions, as opposed to the hundreds listed in standard medical textbooks. Omissions included cancer, heart attacks, kidney diseases, malaria, syphilis, and encephalitis. For those conditions listed in the textbook, Relman concluded that the recommended treatments are "not likely to be effective" because they tend to eschew pharmaceuticals in favor of unproven "natural" remedies such as herbs, dietary supplements, and even the radical and "totally irrational" chelation therapy. When it comes to HIV/AIDS, for example, Relman wrote that the Textbook of Natural Medicine gives "no information about conventional drug therapy" while recommending various herbal and natural cures.

Naturopaths have also been known to distrust or oppose child immunizations. A 1999 survey of Massachusetts naturopaths found that just 20 percent thought parents should have their children vaccinated. And naturopaths aren't likely to pick up much information about standard scientific treatments in their training; many study for four years at a naturopathic college but aren't required to have any significant hospital or residency experience.

All of this might be less objectionable if naturopaths were simply secondary health care providers whom patients might occasionally visit. The National College of Naturopathic Medicine, however, describes itself as a group of "primary care physicians, most of whom are in general private practice [and] trained to be the doctor first seen by the patient for general healthcare, for advice on keeping healthy, and for the diagnosis and treatment of acute and chronic conditions." In other words, if naturopaths misdiagnose their patients the results could be catastrophic because those patients may not visit an M.D. at all. Relman concluded that "the anti-pharmaceutical bias of naturopathic education...poses real risks for patients who rely on naturopaths for the management of their illnesses. Without prompt and appropriate drug therapy many patients with serious diseases will die."

Relman submitted his analysis of naturopathy to the commission. The Massachusetts Medical Society's Atwood, for his part, produced a voluminous treatise on the subject whose abstract read, "This monograph demonstrates, unequivocally and with extensive documentation, that naturopathy is a dangerous activity, and that no amount of regulation is likely to mitigate this fact." His paper was also submitted. And that's where the process reached an unexpected impasse.

The majority report of the commission, recommending licensure, scarcely mentions Relman's and Atwood's strongly expressed health concerns, despite their medical qualifications. One reason for this, both claim, is that Eisenberg refused to either side with them or refute the science they presented, thus making it appear there was a division among doctors.

"He completely failed to ever open his mouth at one of these commission meetings, and say that he was essentially very worried that such practitioners should ever be licensed in Massachusetts," says Atwood. "He completely kept his mouth shut. In fact, it was worse. He was very deferential to [the naturopaths on or appearing before the commission], in almost an obsequious sort of way." Relman's replacement, Dr. Peter Madras, did not observe Eisenberg himself on the commission but agreed with Relman and Atwood about the general proceedings: "To my knowledge, nobody ever disclaimed what had been brought up as dangerous practice by naturopaths."

Eisenberg, through a Harvard Medical School spokesperson, declined to respond to the criticisms from Atwood and Relman. But the commission chairman, Bill Wood, did address some of their remarks. According to Wood, the commission's "mission and charter was not necessarily to do a full scientific review" of the safety and efficacy of naturopathy. Thus he says that while it's true that Atwood's and Relman's arguments were not really engaged or refuted, and that Eisenberg "was largely silent on scientific debate issues," that's mainly because "the commission just did not engage in scientific debate." Eisenberg was sometimes absent, and at those times, says Wood, CAM advocate Michael Cohen was "there as the eyes and ears of Dr. Eisenberg."

Wood goes further, describing the difficult middle road that Eisenberg has tried to walk between medical skepticism and the outright embrace of CAM. Eisenberg, Wood says, "was under great pressure from Dr. Atwood and Dr. Relman to join their side. He seemed to be uncomfortable with the pressure that was coming down on him. Because of his background in acupuncture and Oriental medicine, I think he had an open mind about the broad universe of practices out there...but he was also a skeptic, in that he would not endorse any practice that did not have a basis of scientific research to support it."

Eisenberg did not endorse the majority report. But according to Wood he did help with some of its language (as did Cohen). In particular, Wood says Eisenberg contributed to a section that seemed to address some of Relman's and Atwood's criticisms by listing several herbal remedies used by naturopaths that had shown signs of efficacy, including "gingko, saw palmetto, St. John's wort, horse chestnut, kava kava, and cranberry juice."

When the anti-licensure minority saw this language they were stunned. In an addendum to their report, they noted: "There is good evidence that St. John's wort interferes with crucial anti-HIV medicines in patients with AIDS. Yet the Textbook of Natural Medicine, without any supporting evidence, promotes St. John's wort as a treatment for AIDS. There is no way to know how many unsuspecting AIDS patients...have suffered relapses because of this recommendation." What does Eisenberg think about this topic? We can't be sure, because his brief written response for this article did not address a question concerning the majority report's treatment of St. John's wort and other herbs.

Open Minds, Closed Mouths

Wood, the commission's chairman, makes one further point: that Eisenberg may have been constrained in his ability to either side with or critically engage Relman and Atwood because he was the official representative of the Massachusetts Department of Public Health. This is a surprising assertion. After Atwood sent a lengthy letter to Dean Daniel Federman complaining about Eisenberg's and Cohen's role on the commission and the ways that Harvard Medical School was supporting CAM, then�Massachusetts Commissioner of Public Health Dr. Howard Koh responded in Eisenberg's defense. Eisenberg, wrote Koh, had been selected to represent the Department of Public Health "based on his high level of scientific and clinical expertise" in the field of complementary and alternative medicine. If Eisenberg was selected for his expertise, it seems odd he would be expected not to apply it.

In any case, the damage has been done, and the commission has created considerable bad blood. Since its close, Atwood has engaged in a fiery correspondence with Federman about the Harvard CAM program and Eisenberg. Atwood's most recent letter concluded: "Eventually this chapter in the history of [Harvard Medical School] will be remembered with chagrin. Please reconsider now."

In Atwood's analysis of Eisenberg's behavior, there's a simple explanation for what happened. In short, Atwood views the complementary and alternative medicine community as a fraternity and Eisenberg as a member -- which makes him too close to various CAM practitioners and interests to be able to criticize them seriously.