Science

Quacks and Flacks

The pitfalls of seeking a scientific foundation for alternative medicine.

|

In 1979, shortly after the United States established diplomatic relations with the People's Republic of China, a young Harvard Medical School student named David Eisenberg became the first American in decades to visit the country on a medical exchange program. As a Harvard undergraduate, Eisenberg had been fascinated by Chinese history and culture. Now he found the opportunity to learn about traditional Chinese medicine in Beijing exotic and intoxicating. In a sense, it was the logical next step after ransacking Harvard's libraries for information on Chinese medicine and studying under Harvard's John King Fairbank, known as "the dean of American Chinese scholars."

In China, Eisenberg not only enjoyed great massages, practiced Tai Chi, and became something of an ascetic; he also carefully studied the healing arts of acupuncture and Chinese herbal therapy. In the early 1980s, Eisenberg would return to the country with a group of Western doctors, including his Harvard colleague Herbert Benson, to examine scientifically "the most fundamental and baffling element of Chinese medicine—Qi, the concept of 'vital energy.'"

Thus began a medical career that, given the state of mainstream Western medicine at the time, might have seemed unimaginable or even impossible. Yet more than two decades later, Eisenberg is arguably the nation's premier academic doctor involved in the growing field of research into complementary and alternative medicine (CAM)—sometimes also called "integrative medicine." In 2001 Eisenberg was named director of Harvard's new multimillion-dollar Osher Institute for Research and Education in Complementary and Integrative Medical Therapies. At a time when CAM programs are proliferating at the nation's top medical schools, Eisenberg now heads the flagship academic research institute devoted to this area. If traditional and complementary and alternative medicine can truly become "integrated" in a university setting, then Eisenberg will be the person to do it.

With CAM's increased prominence at Harvard, however, has come controversy. Skeptics have been watching the medical school and its affiliated hospitals closely for any sign that unproven CAM techniques are being vouched for as scientifically valid or otherwise promoted to the public. They've found several. For example, InteliHealth—a subsidiary of Aetna that draws upon Harvard Medical School's expertise to provide online consumer medical information—was recently caught referring patients to practitioners of homeopathy (a water-based therapy whose key premise, that solutions become more powerful through dilution, violates fundamental laws of physics and chemistry). The offending content was quickly revised—and made much less promotional—by the Harvard faculty.

Far more contentious is a controversy involving Eisen-berg's actions outside the context of Harvard Medical School. From 2000 to 2001, Eisenberg represented the Massachusetts Department of Public Health on a state commission charged with examining whether naturopaths, a group of alternative healers, should be licensed by the state as legitimate health practitioners. Regardless of one's position on the licensure of caregivers in general, the commission's experience shines a light on how CAM may eventually be legitimated. The commission members clashed heatedly over their work, eventually producing rival reports in January 2002. Afterward, fellow doctors serving on the commission accused Eisenberg of behaving in an equivocating and unscientific manner. As one complained to Harvard Medical School Senior Dean Daniel Federman, Eisenberg was "notably silent when the other two physicians characterized naturopathic claims as baseless and dangerous."

Eisenberg responded to written questions for this article with a brief statement of medical principles, asserting for example that "members of the Harvard faculty involved with the [Osher Institute] are neither advocates for or against the use of complementary and integrative medical therapies. Rather, they are advocates for the rigorous scientific evaluation of these therapies." In the end, Eisenberg did not sign either of the commission's rival reports, pro or con. But a majority of members, including two CAM practitioners and the Department of Public Health's Nancy Ridley (who appeared in Eisenberg's stead as the process wound down), endorsed the licensure of naturopaths. None was an M.D.

Two doctors and one Massachusetts state representative, on the other hand, signed a scathing minority report that rebuked the majority for disregarding scientific evidence about the potential dangers of naturopathic medicine. Signatory Dr. Peter Madras, chairman of the Massachusetts Board of Registration in Medicine, says of the commission meetings, "We were back in a proceeding that must have emulated the Tennessee courthouse at the time of the Scopes trial." Dr. Arnold Relman, professor emeritus at Harvard Medical School and the editor for 14 years of The New England Journal of Medicine, resigned from the commission in protest and was replaced by Madras. "It was stacked against the M.D.s on that commission from the word go," he says. "And David Eisenberg would not stand with us."

The problem isn't just Eisenberg, though. Naturopaths aren't just any alternative healers. They are notoriously suspicious of childhood vaccinations; the group's founder, Benedict Lust, rejected the germ theory of disease; their view of cancer, heart attacks, and many other such conditions differs markedly from that of mainstream medicine. By empaneling a special state commission whose majority then recommended the licensure of this group, the state of Massachusetts itself has lent legitimacy to their practices in the public eye, and has done so in the very center of modern medical and biotechnology research that is Boston and its environs.

True Believer?

In Eisenberg's case, the tension between scientifically examining CAM and believing in it can be traced back at least as far as his 1985 medical travelogue Encounters With Qi: Exploring Chinese Medicine, written with Thomas Lee Wright. The book contains numerous passages in which Eisenberg analyzes traditional Chinese healing methods and argues that Western and Chinese doctors alike "share the responsibility of applying rigorous scientific methods to the study of these techniques."

Thanks in part to Eisenberg, this argument has triumphed in medical schools nationwide. It is widely accepted today that due to their ever-growing popularity—documented by Eisenberg in a much-cited 1993 New England Journal of Medicine survey—non-Western medical practices such as acupuncture, Ayurvedic medicine (traditional medicine from India), and many herbal remedies must be evaluated according to scientific standards.

That effort is not merely required for patient safety. If nontraditional but medically sound healing techniques can be incorporated under the scientific umbrella, the result could be a broad improvement of medical care. As Eisenberg has put it, "My hope is that when five or 10 universities have sustainable infrastructure for research, education, and responsible patient care in this area, we will forget the terms alternative and complementary altogether and simply provide the best available medicine, based on the best available information."

This is certainly a worthy goal. Yet other passages in Eisenberg's book suggest a thinker who appears less inclined to analyze exotic techniques and claims critically. Encounters With Qi abounds with startling accounts of mystical Chinese Qi Gong practitioners splitting marble blocks with their foreheads, allowing themselves to be run over by vehicles, and, most astonishingly, engaging in "external Qi Gong"—a logical but radical extension of the basic philosophy of Chinese energy healing that supposedly allows for such paranormal feats as telepathy and psychokinesis (using the mind to move objects).

In one chapter of Eisenberg's book, young girls amazingly intuit the written content of sealed envelopes, leading Eisenberg to dub them "magical children." In several others, Qi Gong masters engage in Luke Skywalker feats such as moving objects and people without touching them. Unexplainable is the word Eisenberg uses to describe it all.

The likely truth is that Eisenberg was hoodwinked. His fellow Qi investigator Dr. Herbert Benson, who appears in Encounters With Qi and now directs Harvard's Mind/Body Medical Institute, says of external Qi Gong: "I've traveled to China to study this. I've seen nothing that defied physical laws." And since Eisenberg's writing, other skeptics, including the magician James Randi, have subjected various Chinese "psychic" children and Qi Gong masters to rigorous testing in controlled settings—whereupon their paranormal abilities have promptly vanished.

If Eisenberg was aware of this, it didn't stop him from traveling to China with Bill Moyers for his 1993 television series Healing and the Mind, which depicted the activities of Qi Gong masters with little warning that they may be mere manipulators. Psychologist Barry Beyerstein and Dr. Wallace Sampson, editor of The Scientific Review of Alternative Medicine, have written of Eisenberg's role in Moyers' series: "[He] continued to embrace the therapeutic effects of [traditional Chinese medicine] as enthusiastically as he had back in his student days when he accepted as real the kind of 'external Qi' that others have exposed as magic tricks."

Critical Defect

Will Eisenberg's complementary and alternative medicine program at Harvard succeed in setting research into exotic and nontraditional medical methods on a firm scientific foundation? There's certainly a great deal riding on the endeavor. Bernard Osher, a wealthy San Francisco philanthropist who co-founded Golden West Financial, gave Harvard a $10 million grant in the spring of 2001 to found Eisenberg's center.

"Integrative medicine's time has come," Osher proclaimed at a celebratory reception for the institute. Osher has created a similar program at the University of California?San Francisco; the two Osher centers now collaborate on conferences.

In one sense, Harvard's Osher Institute is just another in a long line of CAM programs at leading medical schools (including an earlier Eisenberg-run center at the Beth Israel Deaconess Medical Center, a Harvard teaching hospital). One of the oldest, Columbia University's Rosenthal Center for Complementary and Alternative Medicine, was established back in 1993; shortly afterward Dr. Andrew Weil founded the Program in Integrative Medicine at the University of Arizona. According to the Rosenthal Center, there are now well over 100 university courses, programs, and institutes in CAM. Yet Harvard's new Osher Institute is distinguished both by virtue of being at Harvard and by its generous funding.

Of course, no one will know which aspects of CAM really work and which don't unless medical schools help separate the wheat from the chaff. But already there are complaints about the research output from both the Osher Institute and Eisenberg's previous center (which was established in 1994). "They've now had a fair amount of money and a fair amount of time to get something done," says Relman, the former editor of The New England Journal of Medicine. "Most of what they publish is opinion and philosophy and speculation and surveys, and not much in the way of objective science."

Federman, Harvard Medical School's senior dean, has been charged with overseeing the growth of the university's CAM division. He admits little research has been conducted thus far at the Osher Institute but says that's mainly because things are still getting off the ground. Eisenberg himself, notes Federman, is not a doctor who's particularly well known for his background in clinical research. Rather, he's charged with a leadership role; research itself will be overseen by a board of senior medical scientists who will review proposals.

But when it comes to CAM, the difficulty of such a research agenda is that the subject excites extreme emotion from both skeptics and believers. In the relatively uncharted area of CAM research, the believers often wind up being the people designing the trials. "There are too few people in this field doing experiments without caring much how they come out," says Dr. Tom Delbanco, chief of the Division of General Medicine at the Beth Israel Deaconess Medical Center, who mentored Eisenberg and was a co-author of his famous 1993 New England Journal of Medicine paper. "Most of the people in the field are trying to prove something they believe in, rather than engaging in research with a truly open mind."

Some of Eisenberg's colleagues have expressed views that suggest a personal investment in CAM. One of his associates at the Osher Institute is an attorney and CAM legal expert named Michael H. Cohen, who attended meetings of the Massachusetts commission in Eisenberg's absence. Cohen's presence was controversial, with some panelists objecting to his appearing to represent the Department of Public Health despite his lack of a medical background. In an article on his personal Web site, Cohen decries a "delusional matrix of medico-legal reality" and argues that biomedicine—i.e., Western scientific medicine—"by and large perpetuates a delusional sense that a human being is only material." Cohen also criticizes biomedicine's "tendency to relegate valid, numinous encounters to the realm of psychological dysfunction or unprovable mysticism" and commends "near-death experiences" and "encounters with angels" for bringing humans closer to "that which is Supreme at the edge of consciousness."

Such arguments go far beyond a measured scientific approach to CAM in favor of a philosophical re-examination of the foundations of science itself. Cohen's writings demonstrate a hostility to conventional medicine and appeal to "other ways of knowing," both tendencies that Eisenberg himself warns against in his annual Harvard Medical School course, summarizing an article in Academic Medicine by the aforementioned Barry Beyerstein titled "Alternative Medicine and Common Errors of Reasoning." Eisenberg declines my request to address this seeming contradiction.

Another of Eisenberg's close associates at Harvard is Ted J. Kaptchuk, an acupuncturist and traditional Chinese medicine expert. Kaptchuk holds an overseas degree as a doctor of Oriental medicine. But according to a letter from Eisenberg to Dr. Carl Bartecchi of the University of Colorado Health Sciences Center, Kaptchuk is also a consultant for the Kan Herb Company, which sells a formula guide he created that includes such herbal products as "Women's Rhythm" and "Arouse Vigor." In other words, Kaptchuk has a financial stake in CAM. To his credit, Kaptchuk disclosed this fact in a recent article authored with Eisenberg for the Annals of Internal Medicine.

Healing Impaired

All of these tensions within Harvard's program—between belief and research, between expectation and investigation—seem to have exploded during the proceedings of the Massachusetts commission that weighed in on the legitimacy of naturopathy. Established by the legislature in 2000, the Special Commission on Complementary and Alternative Medical Practitioners was chaired by Bill Wood, director of the Massachusetts Division of Professional Licensure. The polarization, animosity, and accusations generated by the commission's work suggest how narrow a tightrope Harvard's new Osher Institute is trying to walk.

Despite its name, the commission ended up focusing on whether practitioners of naturopathy should be licensed in Massachusetts (as they are in 11 other states). Eisenberg represented the Massachusetts Department of Public Health on the commission; the other two medical doctors serving on the panel were the aforementioned Arnold Relman (representing the Massachusetts Board of Registration in Medicine) and Kimball Atwood, a Harvard Medical School graduate and anesthesiologist (representing the Massachusetts Medical Society).

Other members included six state legislators and the presidents of the Massachusetts Society of Naturopathic Physicians and the New England School of Acupuncture. When he resigned in protest, Relman objected that not enough time and attention had been devoted to the scientific aspects of the inquiry and that "there were several alternative medicine people on the commission who clearly had a terrible conflict [of interest]." He wanted to disassociate himself completely from the majority report recommending licensure.

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.

If you go to Bastyr University's Web site, for example, it turns out that the two authors of The Textbook of Natural Medicine—Joseph E. Pizzorno Jr., N.D., and Michael T. Murray, N.D.—prominently display the text of a "presentation at Harvard Medical School" that they delivered in 1999 at one of Eisenberg's conferences. Atwood also notes that the brochure of a recent Harvard course taught by Eisenberg stated that it had been supported in part by an "unrestricted educational grant" from the Southwest College of Naturopathic Medicine. A Harvard Medical School representative said this referred not to actual funding but rather to continuing education credit provided by the naturopathic school for members who attended the course.

Atwood also notes that Eisenberg's work in the past has been significantly underwritten by the Fetzer Institute in Kalamazoo, Michigan. Founded by a late Detroit Tigers owner and fan of reincarnation, the institute exists to explore the connection between mind, body, and spirituality in healing. Fetzer initiatives also have included a program "for producing standardized credentialing" of alternative health care providers. One Fetzer study on CAM licensing cited "the continuing interest of alternative providers in securing professional practice rights" and concluded, "it seems likely that the legislative arena will experience intense pressure in the coming years to accommodate alternative modes of care. If new enactments are predicated on a patient-centered ideal that accords the individual substantial freedom to select a mode of personal care, the interests of health care in the United States would indeed seem well served." The pro-licensure report of the Massachusetts special commission reached a similar conclusion.

Perhaps Harvard's clinical research into CAM will eventually silence all critics. For the time being, however, it's hard to dispute that naturopathy qualifies as "alternative medicine" and is far outside the medical mainstream. And though he's had ample opportunity to state his position on this treatment—and enjoys the academic freedom to do so—it's impossible to tell whether David Eisenberg, as a doctor and scientist, believes it to be safe and effective. If promoters of the ongoing academic attempt to study complementary and alternative medicine in a rigorous scientific fashion truly want this movement to succeed, they're going to have to start not just by debunking nonsense but by telling us what they really think.