I meet Brian Berman, a physician of gentle and upbeat demeanor, outside the stately Greek columns that form the facade of one of the nation’s oldest medical-lecture halls, at the edge of the University of Maryland Medical Center in downtown Baltimore. The research center that Berman directs sits next door, in a much smaller, plainer, but still venerable-looking two-story brick building. A staff of 33 works there, including several physician-researchers and practitioner-researchers, funded in part by $35 million in grants over the past 14 years from the National Institutes of Health, which has named the clinic a Research Center of Excellence. In addition to conducting research, the center provides medical care. Indeed, some patients wait as long as two months to begin treatment there—referrals from physicians all across the medical center have grown beyond the staff’s capacity. “That’s a big change,” says Berman, laughing. “We used to have trouble getting any physicians here to take us seriously.”
The Center for Integrative Medicine, Berman’s clinic, is focused on alternative medicine, sometimes known as “complementary” or “holistic” medicine. There’s no official list of what alternative medicine actually comprises, but treatments falling under the umbrella typically include acupuncture, homeopathy (the administration of a glass of water supposedly containing the undetectable remnants of various semi-toxic substances), chiropractic, herbal medicine, Reiki (“laying on of hands,” or “energy therapy”), meditation (now often called “mindfulness”), massage, aromatherapy, hypnosis, Ayurveda (a traditional medical practice originating in India), and several other treatments not normally prescribed by mainstream doctors. The term integrative medicine refers to the conjunction of these practices with mainstream medical care.
Berman’s clinic is hardly unique. In recent years, integrative medical-research clinics have been springing up all around the country, 42 of them at major academic medical institutions including Harvard, Yale, Duke, the University of California at San Francisco, and the Mayo Clinic. Most appear to be backed enthusiastically by administrators and many physicians. “Doctors tend to end up trained in silos of specialization,” says Jay Perman, president of the University of Maryland at Baltimore and a practicing pediatrician. “We’re taught to make a diagnosis, prescribe a therapy, and we’re done. But we’re not done. The patient’s environment matters. When it comes to alternative medicine, it’s not clear what the mechanism is that can make it helpful to patients, but it may be that it helps create the right environment.”
At one of the University of Maryland Medical Center’s hospitals, I introduced myself to Frank Corasaniti, a 60-year-old retired firefighter who had come in for an acupuncture treatment from Lixing Lao, a Ph.D. physiologist with Berman’s center. Corasaniti had injured his back falling down a steel staircase at a firehouse some 20 years earlier, and had subsequently injured both shoulders and his neck in the line of duty. Four surgeries, including one that fused the vertebrae in his neck, followed by regimens of steroid injections and painkillers, had only left him in increasing pain. He retired from the fire department in 2002 and took a less physically demanding job with Home Depot, but by last year his sharpening pain made even that work too difficult, and he gave it up. “I was starting to think I’d have to stop doing everything,” he told me. He was particularly worried that he’d be unable to continue helping out his mother, who had been battling cancer for two years.
His wife, a nurse, urged him to try acupuncture, and in February, with the blessing of his doctor, he finally met with Lao, who had trained in his native China as an acupuncturist. Their first visit had lasted well over an hour, Corasaniti says, time mostly spent discussing every aspect of his injuries and what seemed to ease or exacerbate them, and also other aspects of his health—he had been gaining weight, he was constipated, he was developing urinary problems. They talked at length about his diet, his physical activity, his responsibilities and how they weighed on him. Lao focused in on stress—what was causing it in Corasaniti’s life, and how did it aggravate the pain?—and they discussed the importance of finding ways to relax in everyday life.
Then Lao had explained how acupuncture would open blocked “energy pathways” in his body, allowing a more normal flow of energy that would lessen his pain and help restore general health. While soothing music played, Lao placed needles in and around the areas where Corasaniti felt pain, and also in his hands and legs, explaining that the energy pathways affecting him ran throughout his body. The needle emplacement itself took only about three minutes. Lao then asked Corasaniti to lie quietly for a while, and Corasaniti promptly fell asleep, awakening about 20 minutes later when Lao gently roused him. Corasaniti continued to come in for 40-minute sessions twice a week for six weeks, and since then had been coming in once a week.
Though of course alternative-medicine experiences can vary widely, certain aspects of Corasaniti’s visit are typical. These include a long initial meeting covering many details of the patient’s history; a calming atmosphere; an extensive discussion of how to improve diet and exercise; a strong focus on reducing everyday stress; an explanation of how the treatment will unleash the body’s ability to heal itself; assurance that over time the treatment will help both the problem that prompted the visit and also general health; gentle physical contact; and the establishment of frequent follow-up visits.
Corasaniti’s description of the results is fairly typical too. After two months of treatment, the worst area of pain, near his neck, had shrunk from a circle six inches across to the size of quarter, he said. He’d lost 10 pounds, and his constipation and urinary difficulties had cleared up. And because of his progress, he’d been cleared by his doctor to start a vigorous monitored-exercise program aimed at strengthening muscles in a way that should reduce the chances of reinjury, in addition to improving his general fitness. “I just feel so much better,” he said.
“It’s cleverly marketed, dangerous quackery,” says Steven Salzberg, a prominent biology researcher at the University of Maryland at College Park, an easy commuter-rail ride from the medical center. “These clinics throw together a little homeopathy, a little meditation, a little voodoo, and then they add in a little accepted medicine and call it integrative medicine, so there’s less criticism. There’s only one type of medicine, and that’s medicine whose treatments have been proven to work. When something works, it’s not all that hard to prove it. These people have been trying to prove their alternative treatments work for years, and they can’t do it. But they won’t admit it and move on. Of course they won’t. They’re making too much money on it.”
On his well-read blog and elsewhere, Salzberg has established himself as an expert on research studies related to alternative medicine—and as one of the angriest voices attacking the field. In particular, he calls for an end to government funding of clinics like Berman’s. He says the funding is in no way based on any genuine belief among scientists that alternative medicine merits further study. Rather, it is propelled by a handful of members of Congress—most notably Tom Harkin of Iowa, the chair of the Senate subcommittee that oversees NIH funding—who are determined to see their own misplaced faith in alternative medicine validated. (Harkin’s office declined to make him available for an interview.)
Medical centers are lining up to establish research clinics so that they can take NIH funding for alternative-medicine studies, Salzberg adds. Aggressive marketing of these clinics can also generate substantial patient demand (even a small integrative clinic can take in several million dollars a year). The anecdotal testimony these patients offer merely reflects their gullibility and self-selection into alternative care; subjective symptoms like pain and discomfort, he notes, are susceptible to the power of suggestion. These same symptoms also tend to be cyclical, meaning that people who see a practitioner when their symptoms flare up are likely to see the symptoms moderate, no matter what the practitioner does or doesn’t do. Patients simply misattribute the improvement to the treatment.
Alternative medicine wouldn’t be quite so bad if it were harmless, Salzberg says, but it isn’t. “If the treatment is herbal tea or yoga, fine; it won’t help, but at least it won’t hurt you,” he says. “But acupuncture carries a real risk of infection from needles. And when a chiropractor cracks your neck, there’s a small but nontrivial chance that he can shear an artery in your neck, and you’ll die.” (A British Medical Journal study last year found that only 200 cases of likely acupuncture-related infection have been reported globally, but that many more may have occurred. Evidence for a tiny risk of chiropractic artery-shearing and related stroke is scant, indirect, and contested, but seems plausible.) The biggest danger of all, Salzberg adds, is that patients who see alternative practitioners will stop getting mainstream care altogether. “The more time they spend getting fraudulent treatments, the less time they’ll spend getting treatments that work and that could save their lives.”
It’s not hard to see alternative medicine as a dubious business, or even, in some part, a scam, if one includes all the supplements, devices, and patently absurd therapies that are hawked in magazines and infomercials and at strip malls. Anyone can make vague health claims for almost any reasonably safe product or practice with the appropriate fine print—“The U.S. Food and Drug Administration has neither evaluated nor approved the claims for this product,” for instance. And so the public snatches up millions of hologrammed silicone bracelets that promise to revitalize the fatigued.
Most homeopaths, acupuncturists, and herbalists don’t have an M.D. and don’t work under the close supervision of a physician, so they are free to make exaggerated claims or offer ungrounded advice. It’s difficult to get too worked up about teenagers dropping 20 bucks on a hip but medically useless bracelet, but we should all feel uncomfortable hearing about young children with autism being pulled out of behavioral therapy and placed into herbal or spinal-manipulation treatment. About 40 percent of Americans have tried some form of alternative medicine at some point, and some $35 billion a year is spent on it. A certain amount of abuse seems like a given.
Concerns of outright malpractice or naked hucksterism seem grossly misplaced when applied to a clinic like Berman’s. Nonetheless, says Salzberg, the bottom line is that studies clearly show alternative medicine simply doesn’t work. And at first glance, that contention seems nearly incontrovertible. The scientific literature is replete with careful studies that show, again and again, that virtually all of the core treatments plied by alternative practitioners, including homeopathy, acupuncture, chiropractic, and others, help patients no more than do “sham” treatments designed to fool patients into thinking they’re getting the treatment when they’re really not. (Even acupuncture can be faked, by tapping the skin in random places with a metal tube; reliably, these taps produce treatment results identical to those of the needles themselves.) “Acupuncture is just a 3,000-year-old relative of bloodletting,” Salzberg told me.
You might think the weight of the clinical evidence would close the case on alternative medicine, at least in the eyes of mainstream physicians and scientists who aren’t in a position to make a buck on it. Yet many extremely well-credentialed scientists and physicians with no skin in the game take issue with the black-and-white view espoused by Salzberg and other critics. And on balance, the medical community seems to be growing more open to alternative medicine’s possibilities, not less.
That’s in large part because mainstream medicine itself is failing. “Modern medicine was formed around successes in fighting infectious disease,” says Elizabeth Blackburn, a biologist at the University of California at San Francisco and a Nobel laureate. “Infectious agents were the big sources of disease and mortality, up until the last century. We could find out what the agent was in a sick patient and attack the agent medically.” To a large degree, the medical infrastructure we have today was designed with infectious agents in mind. Physician training and practices, hospitals, the pharmaceutical industry, and health insurance all were built around the model of running tests on sick patients to determine which drug or surgical procedure would best deal with some discrete offending agent. The system works very well for that original purpose, against even the most challenging of these agents—as the taming of the AIDS virus attests.
But medicine’s triumph over infectious disease brought to the fore the so-called chronic, complex diseases—heart disease, cancer, diabetes, Alzheimer’s, and other illnesses without a clear causal agent. Now that we live longer, these typically late-developing diseases have become by far our biggest killers. Heart disease, prostate cancer, breast cancer, diabetes, obesity, and other chronic diseases now account for three-quarters of our health-care spending. “We face an entirely different set of big medical challenges today,” says Blackburn. “But we haven’t rethought the way we fight illness.” That is, the medical establishment still waits for us to develop some sign of one of these illnesses, then seeks to treat us with drugs and surgery.
Unfortunately, the drugs we’ve thrown at these complex illnesses are by and large inadequate or worse, as has been thoroughly documented in the medical literature. The list of much-hyped and in some cases heavily prescribed drugs that have failed to do much to combat complex diseases, while presenting a real risk of horrific side effects, is a long one, including Avastin for cancer (blood clots, heart failure, and bowel perforation), Avandia for diabetes (heart attacks), and torcetrapib for heart disease (death). In many cases, the drugs used to treat the most-serious cancers add mere months to patients’ lives, often at significant cost to quality of life. No drug has proved safe and effective against Alzheimer’s, nor in combating obesity, which significantly raises the risk of all complex diseases. Even cholesterol-lowering statins, which once seemed one of the few nearly unqualified successes against complex disease, are now regarded as of questionable benefit in lowering the risk of a first heart attack, the use for which they are most widely prescribed. Surgery, widely enlisted against heart disease, is proving nearly as disappointing. Recent studies have shown heart-bypass surgery and the emplacement of stents to prop open arteries to be of surprisingly little help in extending the lives of most patients.
It doesn’t help that some of these treatments are foisted on people who don’t need them. According to one study, a person who shows up at an emergency room complaining of chest pain has about an 80 percent chance of being admitted and subjected to a series of sophisticated tests, even when the patient is not at high risk for heart disease and thus has an almost negligible chance of actually being ill if a few routine tests don’t turn up any irregularities. The longer round of tests carries a significant chance of falsely indicating that a key artery is clogged, and sometimes leads to the utterly unnecessary surgical insertion of a stent, accompanied by a long-term drug regimen to fight off the real risk of clotting in that stent. In this way, many healthy people each year are converted into long-term patients.
All of these shortcomings add up to a grim reality: as a prominent 2000 study showed, America spends vastly more on health as a percentage of gross domestic product than every other country—40 percent more than France, the fourth-biggest payer. Yet while France was ranked No. 1 in health-care effectiveness and other major measures, the United States ranked 37th, near the bottom of all industrialized countries.