One of the arguments frequently made against the validity of alternative medicine is that it isn’t scientific, or that there is just “no evidence to support it”. The implication, of course, is that conventional medicine is scientific and that there is ample evidence to support the safety and effectiveness of conventional treatments.
As a doctor practicing natural medicine I hear this a lot. In addition, many of our patients also often hear this from family, friends and their conventional medical providers. This can be confusing and a source of stress for patients and, honestly, it is sometimes a source of stress for me, so I’d like to address the issue a little bit here.
To begin with, it is certainly true that less research is done on alternative therapies than conventional ones, but that has little to do with the promise of natural therapies and a lot to do with the economics of medicine. Research as it is currently done is very expensive and thus mostly driven by profit motive. It currently costs on the order of several hundred million dollars to get a new drug through the FDA approval process and no one (including the NIH) seems to want to spend that kind of money on natural products which cannot be patented and thus do not hold the possibility of providing a good return on investment.
For example, I am aware of two very promising alternative cancer therapies that have floundered in relative obscurity for decades despite consistently impressive clinical results and concerted efforts by their developers to secure research funding through conventional channels.
Another fundamental problem with the “there’s no evidence” argument is that it implies that the only valid form of evidence is scientific research as it is currently conducted. What is experienced by the physician and patient in the clinic is dismissed as “anecdotal” (a put down in medicine if ever there was one). We have therapies that we have used for years and with which we have seen consistent and repeatable results. Our patients recognize that they work because they come back feeling better and tell us so. But because there are no research studies supporting them they are not considered valid by this model.
The “there’s no evidence” argument also rejects the fact that many natural therapies have decades, centuries or in some cases millennia of clinical use behind them. This wealth of experience shared between generations of practitioners is not considered valid because there hasn’t been a clinic trial conducted on a few hundred people over a period of a few weeks to a few months.
OK, now that I’ve gotten that off my chest, let’s turn our attention to the argument that conventional medicine is solidly scientific and “evidenced based”. My view is that this perception has more to do with how conventional medicine is marketed or communicated to the public (and doctors) and less to do with the actuality of things.
How Good is the Research in Conventional Medicine?
Clinical research, or clinical trials as they are called, are used to determine what a therapy does, how well it does it, and how safe or dangerous it is. The idea is that after adequate research we know what to expect from a medicine. We know what it can be used for, how effective it is and what the potential adverse effects from it might be. This is why conventional medicine often uses the term “evidence based”. The evidence they’re talking about is clinical research data.
A close look at the research done in medicine suggests that the conclusions reached are often not that reliable, and further, that much of what actually goes on in conventional medical clinics and hospitals either isn’t supported by research or doesn’t reflect the results of the available research. Here are a few tidbits from the conventional medical literature that illustrate this:
Initial research findings on the effectiveness of treatments often don’t hold up
A 2005 study in the Journal of the American Medical Association (JAMA) found that of 45 highly respected research studies showing positive results on various medical treatments, 16% of the treatments studied were later found to be ineffective and another 16% were later found to be less effective than originally reported. This means that the results of about one third of these well respected, frequently cited studies were simply not accurate.
Initial research findings on the safety of treatments often don’t hold up
548 new drugs were approved by the FDA between 1975 and 1999. A little over 10% of those were later issued “black box warnings” or removed from the market. A black box warning is a statement placed at the beginning of a drug fact sheet that warns doctors about a potentially life threatening side effect that may occur when that drug is used. Similarly, a drug’s removal from the market generally occurs because it been shown to do great harm, not simply because it is ineffective.This suggests that all the research done from initial drug development through human clinical trials and final FDA approval still misses potentially fatal side effects in about 1 out of every 10 drugs that make it to market! It says nothing of less severe side effects that are also not detected during the research and approval process.
An example of this is the warning of increased risk of suicide in children, adolescents and young adults for the SSRI antidepressants such as Prozac. This black box warning was not placed on these medications until many years after their introduction.
Drugs may be approved even though they show no significant benefit
I don’t have a study on this, but here’s an example:
In 2006 the FDA approved the chemotherapy drug Gemzar (gemcitabine) for use in ovarian cancer based on the idea that it increased “disease-free survival” by 2.8 months. Although this sounds good, what it actually means is that, while on average, it took 2.8 months longer for cancer to be detected again, the patients died just as fast as patients on other existing treatments. The drug did not improve quality or length of life in any way. In fact, patients had more adverse effects on Gemzar than the pre-existing treatment. Interestingly, the FDA did this against the recommendations of it’s own drug approval review committee which said the drug should not be approved because of its lack of benefit.
All of this suggests that the research supporting conventional therapies may not be as solid as we would like to believe, both in terms of efficacy and safety.
In addition, other evidence suggests that, quality of research aside, medicine as it’s currently practiced doesn’t actually follow the available research very well either.
As it turns out, conventional medicine isn’t really that evidence based
In 2007, the British Medical Journal published a review of common medical treatments on its website “Clinical Evidence” (clinicalevidence.bmj.com). They looked at 2,500 conventional medical treatments and determined, based on existing research, that only 13% were actually “definitively beneficial”. Another 23% were determined to be “likely beneficial”, 8% were classified as being a “trade off between benefits and harms”, another 10% were categorized between “unlikely to be beneficial” and “likely to be harmful”, and a whopping 46% were determined to be of “unknown effectiveness”.
I am not trying to suggest in any way that there is something wrong with science itself. I think science is an incredibly important and, at its best, a noble human endeavor. I do think, however, that mixing science with commerce as is done in medicine and many other fields tends to degrade the quality of the science and hence the reliability of the results. To yield good results, the research done in medicine will have to be isolated from the profit motive of companies, something that is not likely to happen any time soon.
I also think there’s a bit of slight of hand going on by focusing everybody’s attention on the idea of treatments being “evidence based”. To put it bluntly, evidence based doesn’t necessarily mean good (think of Gemzar)! I believe that what patients want is to be well again. When they wake up in the morning without pain, or have their energy return, I don’t think they care very much about whether the treatment was “evidence based”. What they care about is that it worked. If they’re still in pain and exhausted, the fact that their treatment is evidence based isn’t that much of a comfort.
Perhaps in my next post I will take a look at the “evidence” for alternative medicine.
- Ioannidis JP Contradicted and initially stronger effects in highly sighted research. JAMA 2005 Jul 13;294(2):218-28.
- Lasser KE et. al Timing of New Black Box Warnings and Withdrawals for Prescription Medications. JAMA. 2002;287:2215-2220
- Moss R FDA approves Gemzar for ovarian cancer despite its lack of efficacy part -1 The Moss Reports Newsletter 08-05-06
- How Much Do We Know? BMJ Clinical Evidence. http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp (no longer published)