Alternative Medicine: Swimming Outside the Mainstream

March 3, 1997


Linda Gooding, left, a microbiology and immunology professor, teaches an elective course for second-year students on complementary medical practices. She and Cindy Xu, a doctor of traditional Chinese medicine, are collaborating with dermatologist Mark Ling in an NIH-sponsored study comparing Eastern and Western therapies for warts. As Dr. Gooding tells her students, about 4 billion people in the world rely on some sort of traditional medicine, mostly herbs.


An alternative to what?
The wake-up call
Western medicine versus everything else
The burden of proof
A case in point
Harmonic convergence


The group of second-year Emory medical students are visiting an office that, at first glance, appears similar to that of any MD. The initials following this practitioner's name, however, are "ND," and he extols the virtues of his "holistic" specialty, naturopathy-an "alternative" mode of treating disease with herbs, special diets, vitamins, and cell salts.

On other treks, the students watch a veterinary acupuncturist insert tiny needles into her four-legged patients, listen to a Chinese herbal therapist explain how plants affect the body's "energy flow," and tour a school where massage is taught as a healing modality.

In the classroom, the future physicians are visited by a chiropractor who insists "adjustments of spinal subluxations" not only relieve back pain but promote good health. They read and discuss research on other alternative therapies like homeopathy, a controversial treatment based on the theory that symptoms can be alleviated by taking infinitesimally small amounts of a substance which, in large dosages, would cause the same symptoms.

Clearly, these kids aren't in Kansas anymore.

An alternative to what?

What's going on here? Is the School of Medicine forsaking rigorous, scientific education for some New Age bandwagon ride into the world of fringe medicine?

Linda Gooding, professor of immunology and microbiology, is emphatic that the answer is no. "We are not teaching our students to go out and do these things," says Dr. Gooding, who teaches the elective course "Complementary Medical Practices" to second-year med students. "Instead, we offer an overview of what these medical practices are and attempt to demystify alternative practitioners by visiting their offices and seeing what equipment they use. We want our students to know these people don't have two heads and aren't practicing out of the trunk of their cars."

Why? Because Americans are turning to alternative practitioners in record numbers. With this trend, and with an increasingly multicultural patient base, today's physicians find themselves faced with the need to understand and communicate effectively about practices they were never exposed to when they were in medical school.

In response, more than 30 US medical schools-including Yale, Harvard, Johns Hopkins, UCLA, Columbia, and Stanford-have joined Emory in offering courses on complementary, or alternative, medicine. Several schools also have opened research centers to study specific alternative techniques, and in l991 the National Institutes of Health became officially involved in investigating the efficacy of nonmainstream practices with its establishment of the Office of Alternative Medicine (OAM).

In just the past year, five alternative medical journals (four peer reviewed) have been launched, and Harvard Medical School sponsored the country's first continuing medical education (CME) course in alternative disciplines-an event that drew more than 400 health care professionals, two thirds of whom were medical doctors. Suddenly, it seems, the mainstream medical community is facing the alternative music.

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The wake-up call

The "wake-up call," as Dr. Gooding puts it, came in 1993 when the New England Journal of Medicine published a survey of 1,539 adults who were questioned about their use of unconventional therapies. The results? Based on participant responses, Americans in 1990 made about 425 million visits to alternative practitioners compared with 388 million visits to primary care physicians. While around 3% were looking for help with life-threatening conditions like cancer or AIDS, the vast majority were seeking remedies for long-term problems like obesity, chronic pain, anxiety, and depression. Tellingly, 72% declined to tell their medical doctors about these visits.

Dr. Gooding suspects these dramatic figures are actually low. "In fact," she says, "a recent random survey of 100 people in Atlanta, published in Atlanta Medicine, showed that half those questioned had tried alternative modalities; more than 90% said they would use nonmedical therapy if they thought it was indicated.

"The economics of all this are astounding. Somebody clearly thinks this stuff works," Dr. Gooding states, pointing to figures cited in the New England Journal study that indicate nearly $14 billion is spent annually on alternative care in this country. Furthermore, this amount is largely spent out-of-pocket, as few alternative therapies are reimbursed by insurance.

Why are so many people-including, as the New England Journal study pointed out, those who are well educated and well off-exploring this unproven, and in some cases dangerous, alternative realm when they have access to the finest health care system in the world?

"Of course, when people have AIDS or cancer, they may try anything," Dr. Gooding says. "But people also seek out alternatives for non-life-threatening conditions that their physicians can't seem to help. What I try to convey in my course is that there are health care practices not taught in medical school or readily available in hospitals that nonetheless seem to have therapeutic benefit for some people."

And some practices, she is quick to add, that hurt people. "I'm not going to defend someone who is giving shark cartilage to cancer patients instead of chemotherapy," she says. "I have found things commonly used in the alternative community that I think are bogus, and I cover those in the course as well."

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Western medicine versus everything else

It is important to remember, Dr. Gooding says, that "what is called 'alternative' in this country is semi-mainstream in Europe. Even the Queen of England has a homeopath. In Germany, 80% to 90% of cancer patients get some kind of alternative support or therapy along with their chemotherapy and radiation therapy."

Third-world countries are even more reliant on non-Western treatments. In fact, Dr. Gooding points out, approximately 4 billion people, three quarters of the world's population, depend on some sort of folk remedies, mostly herbs. And even though many modern drugs were originally derived from plant sources-aspirin, digitalis, and tamoxifen, for example-she notes that herbs are frequently dismissed by American physicians as either worthless or dangerous.

"There are examples in the literature of people dying or really injuring themselves with herbs," she says. "In every case, these were people who vastly overdid the recommended amounts of whatever they took. Comfrey tea is a hepatotoxin, for example-but only if you drink ten or 20 cups a day. If you look at the facts, less than one death a year is attributed to herb overdose, while about 90 a year are attributed to aspirin. And 100,000 deaths annually are due to adverse drug reactions. I want to put these facts in perspective for my students."

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The burden of proof

The most common criticism of complementary practices raised by physicians is that there is little if any good scientific data to back up the claims made by its practitioners. Anecdotal benefits are often dismissed as due simply to placebo effect.

But, Dr. Gooding emphasizes, the benefits of some alternative practices have been proven. "One example is cardiologist Dean Ornish's approach to reversing heart disease through lifestyle change-through such 'alternative' methods as meditation, stress reduction, and diet," she says. "Now some insurance companies are reimbursing when this treatment is used." She also points to research showing that breast cancer patients participating in support groups live twice as long as those without such an outlet to share their feelings.

As Dr. Gooding discusses in her course, researching nonmainstream techniques can be intrinsically problematic-because of a lack of research money and also because of special problems inherent in looking at these therapies. "It is difficult to do research in an area when you are working outside of the predominant paradigm," she says. "Too frequently, proof is not considered proof, seeing is not believing.

"There are also legitimate problems in testing some of these therapies, especially if the physician believes strongly in his approach and patients go to him because they really believe in it. We'll never be able to set up a controlled medical trial for faith and belief."

Nevertheless, the OAM has awarded more than 40 small grants (a maximum of $30,000) for the study of alternative therapies, including one to Dr. Gooding and Emory dermatologist Mark Ling to test the efficacy of combining Chinese herbs and cryotherapy to treat warts. The researchers have not yet completed analyzing their data.

Dr. Ling says the research is a good example of the unusual problems facing scientists as they study nonmainstream remedies. "One of the huge differences between Eastern and Western medical philosophies is that Eastern providers are convinced their treatments work. Period. That conviction prevented us from doing a real double-blind, controlled study because the Chinese herbalist we worked with refused, on ethical grounds, to supply us with a placebo."

Obtaining adequate funding, Drs. Ling and Gooding agree, is another frustrating aspect of investigating alternative therapies. "We can do the preliminary experiments, but we lack the financial resources to do large, statistically significant studies," Dr. Gooding says.

"The entire system is biased against nontraditional therapy research," Dr. Ling adds. "The gold standard in Western research is peer review, but if you hold to a nontraditional idea, then all of a sudden your peers become a group invested in supporting the status quo."

Still, he remains hopeful research will continue into herbal treatments for skin conditions. "I don't think anyone is saying Chinese herbal therapy is superior to Western medicine, or even that it works for most things. But there is intriguing anecdotal and scientific evidence that some of these therapies can be effective for some diseases. I think there is gold to be mined there."

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A case in point

When people ask "Where's the hard data?" Emory scientists can point to their research into the effectiveness of Tai Chi exercises in reducing frailty-related injuries.

As part of the National Institutes of Health research project FICSIT (Frailties and Injuries: Cooperative Studies of Intervention Techniques), Steven Wolf, director of research at the Center for Rehabilitation Medicine at Emory, worked with a team of multi-disciplinary investigators to study ways the ancient Chinese martial art can either reduce the incidence of falls or minimize the effects of frailty on the elderly through novel exercise interventions. Their findings were published last year in the New England Journal of Medicine.

The study began in 1991 and lasted three years. The results were nothing short of amazing, Dr. Wolf says. The Tai Chi intervention delayed the onset of falls more than any other intervention explored by FICSIT, which included thousands of research subjects in various studies nationwide.

"When my medical colleagues raise an eyebrow," Dr. Wolf says, "it's because they think Tai Chi is a fad, something for which there's no evidence. Now we've come up with hard-core measurements; when you put these pieces of evidence together, you have to think twice before labeling Tai Chi bogus simply because it's unconventional."

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Harmonic convergence

Researching promising alternative therapies makes good economic sense," according to Dr. Wolf. "In a time when reimbursement for clinical services is being scrutinized more carefully and when people are examining ways to save dollars spent on health care, prevention is the blatantly obvious goal.

"Other societies have looked at prevention for a long time-through alternative approaches involving self-control, self-regulation, the responsibility of individuals to help themselves as opposed to looking for a cure. Therein lies one of the major differences between Eastern and Western approaches. But I'm convinced the East and West will eventually meet on the information superhighway."

Linda Gooding agrees. She also believes the increasing interest in unconventional therapies may eventually result in Emory offering CME courses in complementary medical practices for community-based physicians and Emory alumni.

Does she envision the survey course she currently teaches ever being required of medical students, instead of being an elective?

"Absolutely!" Dr. Gooding answers with a laugh. "It won't happen right away, but the time is coming when physicians will have to learn more about alternative therapies. I think physicians in medical practice want to know what their patients are doing, what they are being exposed to, what's safe and what's not. Studying alternative therapies can only make them better at what they do."

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Sherry Baker is a freelance writer in Atlanta.
Reprinted from Emory Medicine Magazine, pp 34-39, Autumn 1996

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