I’m very happy to introduce my first guest writer, as this piece was a collaboration between me and Lee-Ann MacDonald. Lee-Ann is a Canadian mother of two, who has varied experience from studies into fields as diverse as Arts and Holistic Health as well as Nursing and Pharmacology. She is also an active member of science forums Healthy through Science and Alive with Science, where we discovered our shared interest of looking at alternative medicine from a scientific perspective.
Alternative medicine, Integrative medicine, or as it now brands itself, Complementary Alternative Medicine (CAM) gets referred to as the gentler, better approach to western medicine and pharmaceuticals, without the side effects or the money gouging. One of the main cries have been, “there needs to be more research because it obviously has merit”, and, “it doesn’t have the funding behind it that Big Pharma does to conduct research”. But is that true?
CAM is a multi-billion dollar industry almost on par with pharmaceuticals – revenues from CAM in the US in 2007 reached 34 billion dollars, equalling 17 % of the value of the sales of all pharmaceuticals, and yielding more than five times as much as the oft vilified vaccines (reported at 6 billion dollars for 2007). However, CAM is exempt from having to show the standards of safety and efficacy that pharmaceuticals have to go through before being put to use. The scientific world, however, largely with publicly funded efforts, has taken it upon itself to look into CAM and conduct research into many of its modalities and claims.
CAM is a big business, but its research funding comes mainly from the public sector
Tax payer money was used to set up a government funded National Center for Complementary and Integrative Health (NCCIH) to conduct research into Alternative and Complementary Medicine (CAM). The SkepticsDictionary details the history of the centre and its various names. In a viewpoint piece published in the Journal of American Medical Association, Dr. Paul Offit, chief of the Division of Infectious Diseases at the Children’s Hospital of Philadelphia, writes that the NCCIH (earlier NCCAM) had spent $1.6 billion since its inception in 1999. What does that research show? Live Science reports on it, noting the far-fetched nature of some of these studies:
[…] the National Center for Complementary and Alternative Medicine spent $750,000 on a study that found prayer does not hasten recovery from AIDS, and $700,000 to find out that magnets do not treat migraine headaches.
Homeopathy: studies looking into water as medicine
One popular field of alternative medicine, quickly growing in sales, is homeopathy: the practice of repeatedly diluting a substance until hardly a molecule of the original substance remains, and belief that the closer to pure water one gets, the stronger the effect. With global revenue of 60 billion dollars in 2013, and estimates of reaching whooping 115 billion in 2015 (discussed on this blog over at Following the money), the industry certainly deserves scientific scrutiny. So, has it been studied? You could say so. Health authorities both in the UK and Australia have reviewed the evidence, concluding homeopathic remedies to be ineffective and unethical. Have there been enough studies? The Independent reports on the latest Australian review as follows, in their piece Homeopathy effective for 0 out of 68 illnesses:
A total of 57 systematic reviews, containing the 176 individual studies, focused on 68 different health conditions – and found there to be no evidence homeopathy was more effective than placebo on any.
As does the Smithsonian magazine in their piece 1,800 Studies Later, Scientists Conclude Homeopathy Doesn’t Work:
After assessing more than 1,800 studies on homeopathy, Australia’s National Health and Medical Research Council was only able to find 225 that were rigorous enough to analyze. And a systematic review of these studies revealed “no good quality evidence to support the claim that homeopathy is effective in treating health conditions.”
Considering the low concentration of homeopathic preparations, which often lack even a single molecule of the diluted substance, one may ask: how much more public money should be put into confirming that a practice which completely ignores evidence – and the laws of physics, chemistry, and biology – does, indeed, not work?
What about the types of alternative medicine with actual substance?
Herbs, for instance, truly do have active ingredients, and our microbiome has an undeniable role in our well-being. Effects of many herbs have lead to study and development of medicines (say, aspirin), though after study and regulated production, these herbal-derived ingredients are generally no longer considered a part of alternative medicine. The Scientist covers a lot of ground in their 2012 piece on Alternative Medicine, taking a closer look at the status of topics such as probiotics, acupuncture, marijuana, and herbal supplements. They note that some areas, like probiotics, are exciting new fields of research which are partially catching on to the hype, with 200 clinical trials having investigated the use of probiotics to treat gastrointestinal disorders, but that results are still not very clear, the effects may be transient, strain-specific, and hard to confirm. For more on that, you can also read Kavin Senapathy’s poignant piece Keep Calm and Avoid Micorbiome Mayhem in Forbes.
However, on other areas, The Scientist notes that even existing studies with clear evidence of harm sometimes have little effect in removing an alternative remedy from use, as is the case with Aristolochia, commonly known as birthwort, pipevine or Dutchman’s pipe:
“Every culture in the world has used Aristolochia in their traditional medicines,” says Arthur Grollman, a professor at Stony Brook University School of Medicine. “Don’t they know this is one of the most potent carcinogens that’s ever been recorded, and it’s renotoxic?”
In Taiwan, for example, one study found that one out of three people had received a prescription that included Aristolochia before the country banned the herb, and that prescriptions continued even after the ban. Interestingly, Taiwan also has one of the highest rates of upper urinary tract cancers in the world.
Less dramatic, but all the more common a practice, on the other hand, is that no one draws their herbal supplements from the market when scientific evidence does clearly demonstrate that they lack any effect. An even more worrying trend is that many supplements, when not carefully regulated, don’t actually contain what they say they contain (see Following the money: supplements), and may even be contaminated with harmful unintended substances.
To get an idea of the herbal supplements that do have demonstrated effects on health, you should check out this interactive graph (only the static image version shown here) created by Information is Beautiful, which gives an idea of the landscape of evidence for supplements. It allows you to easily access the research papers on each product, and they include a cut-off near the middle that they deem the ‘worth it line’.
On acupuncture and chiropractic
Two other big areas of alternative medicine, acupuncture and chiropractic, have impressive track records on number of studies. Searching PubMed, the largest medical journal database, gives some idea: the search word ‘acupuncture’ returns 24,612 hits and ‘chiropractic’ 6,765. The Science-based medicine blog written by health care professionals has given extensive coverage to research into alternative medicine, and they also write about the money given to various sectors within that research in their piece Tens of millions for CAM research — and it’s all on your dime. Regarding public funding of studies into chiropratic and acupunture, they note:
Acupuncture, on the other hand, has received […] A whopping $76,848,958 since 2001, in the form of contracts, grants and direct payments. Small Business Association loans accounted for an additional $250,000, including $80,000 to the Eternal Health Wellness Acupuncture Center in San Jose, California, which claims to treat a wide variety of diseases and conditions, such as MS, macro [sic] degeneration, bipolar disorder and herpes, among many others. […]
One of the primary benefactors of government monies is Palmer Chiropractic College, which received $14 million from the NIH and the Department of HHS Health Resources and Services Administration, as well as the military.
This year, a study was conducted on “Effect of Lumbar Hypo & Hypermobility on Sensory Responses to Spinal Manipulation.” Let’s decode this title. Hypo/hypermobility of the vertebrae is of legitimate concern to manual therapists, but to some chiropractors this hypo/hypermobility is an indication of the presence of a “subluxation.” In other words, it appears Palmer researchers are continuing to look for evidence that the elusive subluxation actually exists.
This despite the fact that the chiropractic idea of subluxations has never been tied to tangible evidence. Paul Ingraham, who maintains a giant database of pain science studies over at Pain Science, presents an extensive overview of the topic, discussing the conclusions of several reviews (I’ll include links to a couple of them: here, here and here) on Spinal Manipulative Therapy (SMT). He notes that chiropractic is definitely not risk-free, and it offers no significant benefits when compared to other types of therapies for back pain. Paul Ingraham writes:
[…] there is no individual study that I know of that shows any significant benefit. Not one. If any specific flavour of SMT works especially well for any particular type of patient, that combination was not studied in any of the 26 experiments covered by this Cochrane review.
Dr. Steven Novella further writes on SBM about the difficulty of finding examples of modern alternative medicine that has proven truly effective through rigorous scientific study, and comments on the wealth of evidence failing to find benefits from acupuncture:
The best conclusion we can make from thousands of studies is that acupuncture points don’t exist, that it does not matter where (or even if) you stick the needles. In other words, the only scientifically valid and consistent conclusion based on thousands of studies is that acupuncture is little more than an elaborate placebo.
CAM proponents’ reactions to the research
Goalposts keep being moved when negative results occur over and over again. Excuses are made that border on mysticism: that science just hasn’t produced the instruments that can detect the molecules (homeopathy). That just because you don’t know how it works doesn’t mean it doesn’t work (homeopathy, reiki, placebo effect, mind and body practices).
Edzard Ernst (MD, PhD, FMedSci, FSB, FRCP, FRCPEd) is the first ever Professor in CAM, and an expert on the research of complementary medicine. He became a physician in Germany in 1978, and he also reports that he has “received hands-on training in acupuncture, autogenic training, herbalism, homoeopathy, massage therapy and spinal manipulation”. This is what he had to say in his summary on 20 years of CAM research:
[…] several research groups started conducting rigorous tests of the hypotheses underlying CAM. All too often, the results turned out to be disappointing, to say the least: not only did most of the therapies in question fail to show efficacy, they were also by no means free of risks. Worst of all, perhaps, much of CAM was disclosed as being biologically implausible. The realization that rigorous scientific scrutiny often generated findings which were not what proponents had hoped for led to a sharp decline in the willingness of CAM-proponents to conduct rigorous tests of their hypotheses. Consequently, many asked whether science was such a good idea after all. […]
What all of this really means is that, whenever the findings of research fail to disappoint CAM-proponents, the results are by definition false-negative. The obvious solution to this problem is to employ different (weaker) research methods, preferably those that cannot possibly generate a negative finding. Or, to put it bluntly: in CAM, science is acceptable only as long as it produces the desired results.
So whenever anyone tries to say that alternative therapies have not been researched, they should really be prompted to point out which practice they are referring to, because when it comes to a great majority of therapies, they have been extensively studied. And have been found wanting.
Science is always looking for answers to problems. And yes, that includes looking into the natural world as well. Taking anything that may show any promise, testing it, finding just what works and why, and determining best treatment regimens or stable consistent effects at carefully evaluated dosages in clinical trials is the bread and butter of science. Meanwhile, CAM does not need to do any of this. It does not have to hold itself accountable to having treatments that actually work. So why do we keep using alternative medicine?
Why does CAM remain popular?
Alternative medicine often comes in at a time when there is no clear or quick solution to a health problem. People may feel that believing in some treatment – perhaps any treatment – is better than having none, and even health professionals may feel better being able to offer something that purports to be able to help when an easy evidence-based solution is lacking. An insightful article on in The Wired on An Alternative-Medicine Believer’s Journey Back to Science, argues that hope is like a drug that can become addictive for patients and practitioners alike:
After the initial diagnosis, the man left the office, unable to cope with the fact that he had an incurable degenerative disease, likely to kill him within five years. He chose to visit a naturopath instead, who had redemptive news: conventional, narrow-minded medicine had misdiagnosed him. It wasn’t ALS, the naturopath said, but rather chronic Lyme disease, which could be treated with holistic, all-natural supplements. […]
And false hope isn’t just for patients. Doctors—traditional and integrative alike—also can become dependent. No doctor wants to be hope’s executioner, especially when they don’t know how to do it properly.
As long as there is life, there is hope. But offering hope while spreading false beliefs in treatments that lack any effect is a dangerous balance, which can tip to the side of actually causing harm, whether it be in the form of unknown side effects or in convincing people to forgo evidence-based therapies altogether (see for instance dangerous ‘alternative’ treatments of cancer or preventable diseases making a come-back). This is why you should carefully evaluate the kind of alternative therapy you choose and the claims you may hear from alternative medicine proponents. MayoClinic offers some advice on how to do just that in their Consumer Health guide.
Alternative medicine practices, when shown to be effective, cease to qualify as CAM
The bizarre thing is, that when an alternative medicine practice does become well studied and shows real evidence of benefits (like in the case of many medicines developed from herbs) they cease to be alternative – because being insufficiently studied (or, sadly, extensively studied but not shown to be effective) is actually part of the qualifications for what is considered alternative medicine. In the report published by US National Health Statistics in 2007, Complementary and Alternative Medicine Use Among Adults and Children, CAM is defined as follows:
Complementary Alternative Medicine (CAM) covers a heterogeneous spectrum of ancient to new-age approaches that purport to prevent or treat disease. By definition, CAM practices are not part of conventional medicine because there is insufficient proof that they are safe and effective.
Has alternative medicine been studied enough? Some argue that many practices have already been studied too much – they have used up too much public funding despite a lack of even basic plausibility. And in other cases it seem that no amount of study is going to be enough, for even when little or no evidential support has accumulated after a whole body of research, some merely use that for an excuse to go on claiming that the topic has not been studied enough.
Offering hope, comfort, and a sympathetic ear to someone suffering with health problems is nothing to scoff at, and some alternative – as well as conventional – medicine practices can provide that. But wide-spread promotion of false beliefs does come with a backlash. Making strong unfounded claims about treatments which are neither proven effective nor necessarily safe remains an unethical way to comfort a troubled patient.
If you would like to ask a question or have a discussion in the comments below, you are very welcome, but please take note of my Commenting policy. In a nutshell:
- Be respectful.
- Back up your claims with evidence.
If you like to read more on the topic, here are a few books that cover the alternative medicine industry in depth and with fantastic resources:
- Trick or Treatment? Alternative Medicine on Trial, By Professor Edzard Ernst and Simon Singh.
[…] the truth about the efficacy of alternative medicine is rigorously addressed for the first time by the scientist uniquely qualified to do so: Professor Edzard Ernst, the world’s first professor of complementary medicine. Having spent over a decade at Exeter University meticulously analyzing the bewildering evidence for and against alternative therapies, this former practitioner of both traditional and complementary medicine brings no bias to the subject.
Writing with him is the respected science writer, Simon Singh, who also brings his considerable scientific knowledge and scrupulous impartiality to this most controversial subject. Together, they deliver a hard-hitting, yet honest examination of more than thirty of the most popular treatments, such as Acupuncture, Homeopathy, Aromatherapy, Reflexology, Chiropractic and Herbal medicines.
- Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine, by Dr. Paul Offit.
Dr. Offit reveals how alternative medicine—an unregulated industry under no legal obligation to prove its claims or admit its risks—can actually be harmful to our health.
Using dramatic real-life stories, Offit separates the sense from the nonsense, showing why any therapy—alternative or traditional—should be scrutinized. He also shows how some nontraditional methods can do a great deal of good, in some cases exceeding therapies offered by conventional practitioners.
- Suckers: How Alternative Medicine Makes Fools of Us All, by Rose Shapiro
…an entertaining, well-argued and very provocative calling to account of a huge and rapidly-expanding industry.
Your article really does give a one-sided perspective. I have neither the time or inclination to cite counter-studies, or to explain the recent restriction in availabilty of Chinese medicinals in many countries, due to the carelessness of people who access herbs without an training. What I will say is this: I am a laboratory scientist, and have a master’s in Oriental Medicine. Yes, often acupuncture does not alleviate a specific long-term problem of the patient. We are often the last resort for the person who has tried everything, and then comes to us with unrealistic expectations after years of severe pain, for example. Someone who wants to get pregnant at 47 will also not find success with acupouncture if their FSH is elevated, and AMH shows no ovarian reserves.. However, I can tell you there are cases where acupuncture has helped people who were chronically ill and at the end of their rope. Those patients got better. Disruptions of mood, sleep. appetite became normalized. In some cases, Meniere’s disease improved.
Respectfuly, the tone of your article indicates that your belief is that people are guillable and easily misled, and need to be protected from their choices. There are almost no adverse results from acupuncture or homeopathy (leaving aside the question of how homeopathy can possibly work).
I don’t counsel my patients to avoid IVF, decline chemotherapy, or not take antibioitcs if there is really an infection present. I believe in keeping an open mind and staying informed.
Gabrielle Mathieu MSOM, SB in Medical Technology
Thank you for taking the time to comment in respectful way.
I am very happy to hear that you would never recommend that your patients to forgo scientifically proven medical treatments. As far as I know, fortunately acupunturists are not widely known for promoting such denial of medicine, or use of dangerous therapies (unfortunately they same cannot be said about homeopaths 😦 ). I believe you can offer valuable support to patients at their wits end, and as long as there are no far-out claims without basis, there is probably a benefit from seeing someone and the ritual of receiving a treatment, whether it be needles, massage, or other manual therapy. What I talk about in the article, however, is that there is no robust proven specific effect of acupuncture for a wide array of conditions, that the location of the needles does not change the subjective effect of the therapy (the acu points being an unconfirmed point about acupuncture), or even not sticking the needles at all, instead relying on toothpicks pricking the skin.
I understand that this is an important topic for you and reading my dismissal of it is not easy, and I am sorry if I have caused you grief. I do however wish to strongly express that I am in this effort in order to reach a profound understanding, I have nothing personally against acupuncture, and I do not wish to reach one conclusion on it or the other. I have simply communicated my best understanding of the topic. Claiming that my view is one-sided is not an argument that has merit unless it is backed up with considerable evidence.
It would be one-sided to rely on one study, or even a couple of studies, which find a positive effect of acupuncture, when the situation is such that thousands of studies have been conducted. It would be one-sided to rely only on small-sized studies, if large studies have also been conducted, or studies with questionable methodology, if more robustly designed studies are also available. The common low quality of acupuncture studies is commonly noted in most review articles.
Another point is that even studies which do (in the abstract) mention a positive effect, their results in fact show such a minor effect that it is clinically insignificant. In order to give acupuncture a robust scientific validation, after decades of research, this is just too weak. I can say, that my intuition and general understanding is, that finding support of some kind (from your doctor, from your family and friends, from alternative therapists, from counselors), and having the experience of being listened, taken seriously, and cared for does have a beneficial effect.
However, I can’t with good conscience say that acupuncture specifically would have a beneficial effect in any condition.
A german professor in Alternative Medicine, Dr Edzard Ernst (trained in acupuncture), has written the following review:
“Fifty-seven systematic reviews met the inclusion criteria. Four were of excellent methodological quality. Numerous contradictions and caveats emerged. Unanimously positive conclusions from more than one high-quality systematic review existed only for neck pain. Ninety-five cases of severe adverse effects including 5 fatalities were included. Pneumothorax and infections were the most frequently reported adverse effects. In conclusion, numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain. Serious adverse effects continue to be reported. Numerous reviews have produced little convincing evidence that acupuncture is effective in reducing pain. Serious adverse events, including deaths, continue to be reported.” http://www.ncbi.nlm.nih.gov/pubmed/21440191
He also blogs about his twenty years of research experience into Complementary Alternative Therapies, the acupunture articles can be found here: http://edzardernst.com/tag/acupuncture/
On Science-Based Medicine you can find a thorough analysis of numerous meta-analyses, looking at tens of thousands of patients and the effects of acupuncture. The whole piece is worth a read: https://www.sciencebasedmedicine.org/acupuncture-doesnt-work/
but I will post a lengthy quote here:
“Large multicenter clinical trials conducted in Germany7–10 and the United States11 consistently revealed that verum (or true) acupuncture and sham acupuncture treatments are no different in decreasing pain levels across multiple chronic pain disorders: migraine, tension headache, low back pain, and osteoarthritis of the knee.
If, indeed, sham acupuncture is no different from real acupuncture, the apparent improvement that may be seen after acupuncture is merely a placebo effect. Furthermore, it shows that the idea of meridians is purely imaginary. All that remains to be discussed is whether or not the placebo effect is big enough to be useful, and whether it is ethical to prescribe placebos.
Some meta-analyses have found that there may be a small difference between sham and real acupuncture. Madsen et al.12 looked at 13 trials with 3025 patients, in which acupuncture was used to treat a variety of painful conditions. There was a small difference between “real” and sham acupuncture (it did not matter which sort of sham was used), and a somewhat bigger difference between the acupuncture group and the no-acupuncture group. The crucial result was that even this bigger difference corresponded to only a 10-point improvement on a 100-point pain scale. A consensus report13 concluded that a change of this sort should be described as a “minimal” change or “little change.” It is not big enough for the patient to notice much effect.
The acupuncture and no-acupuncture groups were, of course, neither blind to the patients nor blind to the practitioner giving the treatment. It is not possible to say whether the observed difference is a real physiological action or whether it is a placebo effect of a rather dramatic intervention. Though it would be interesting to know this, it matters not a jot, because the effect just is not big enough to produce any tangible benefit.
Publication bias is likely to be an even greater problem for alternative medicine than it is for real medicine, so it is particularly interesting that the result just described has been confirmed by authors who practice, or sympathize with, acupuncture. Vickers et al.14 did a meta-analysis for 29 randomized controlled trials, with 17,922 patients. The patients were being treated for a variety of chronic pain conditions. The results were very similar to those of Madsen et al.12Real acupuncture was better than sham but by a tiny amount that lacked any clinical significance. Again there was a somewhat larger difference in the nonblind comparison of acupuncture and no-acupuncture, but again it was so small that patients would barely notice it.
Comparison of these 2 meta-analyses shows how important it is to read the results, not just the summaries. Although the outcomes were similar for both, the spin on the results in the abstracts (and consequently the tone of media reports) was very different.”
“There is now unanimity between acupuncturists and nonacupuncturists that any benefits that may exist are too small to provide any noticeable benefit to patients. That being the case, it is hard to see why acupuncture is still used. Certainly, such an accumulation of negative results would result in the withdrawal of any conventional treatment.”
I can’t in good faith demand one level of strict evidence from conventional medical treatment, and not demand the same proof of efficacy from a therapy just because it is part of alternative therapies.
Out of respect for people, not for any disdain for their right to choose, I campaign for their right not to be misled. I hope to promote critical thinking, and understanding how best to judge evidence. I wish to empower people with accurate information.
Thanks for your interest in my blog! I hope you understand that I have not reached my conclusions hastily and have made an effort not to look at the evidence in a one-sided fashion. I hope you can give the sources I’ve provided an open-minded review.
I wish you a great day!
I must say it is an amazing post with lots of information on alternative medicine. CAM is always the topics needs to be explored more. Thank you for the post.