The Three Musketeers of Woo meet d'Artagnan to fight for woo on the editorial page of the Wall Street Journal

The seemingly never-ending quest of advocates of unscientific medicine, the so-called "complementary and alternative medicine" (CAM) movement is to convince policy makers, patients, and physicians that, really and truly, it no longer deserves the qualifier of "alternative," that it is in fact mainstream and even "scientific." That very search for respectability without accountability is the very reason why "alternative" medicine originally morphed into CAM in order to soften the "alternative" label a decade or two ago. Increasingly, however, advocates of such highly implausible medical practices appear no longer to like CAM as term for their dubious practices, because it still uses the word "alternative" and they recognize that labeling their woo as "alternative" in relationship to scientific medicine implies inferiority. Such a term conflicts with their desire to "go mainstream," and they most definitely do want to go mainstream. However, they want to do it on their own terms, without all that pesky mucking about with science, evidence, and rigorous clinical trials that we in the science- and evidence-based medicine biz have to contend with. Consequently, they increasingly use a new term, a shiny term, a term free of that pesky (and oh-so-buzz-killing, albeit rebellious) "alternative" label. Now they want to "integrate" their unscientific placebo-based practice with real, scientific medicine. Thus was born the term "integrative" medicine (IM), and it's becoming increasingly common and accepted.

These days, perhaps the biggest complaints I have about the attitude of practitioners of scientific medicine towards CAM/IM is that most of them do not see it as a major problem. Dr. Val Jones characterized this attitude as the "shruggie" attitude, and it's a perfect term, as is her analogy as to why "integrating" pseudoscience with medical science is not a good idea. I myself have lamented the infiltration of pseudoscience and outright quackery into medical academia and the role that the National Center for Complementary and Alternative Medicine (NCCAM) has played in promoting that infiltration. In addition, wealthy patrons of CAM/IM such as Donna Karan and the Bravewell Collaborative have been generous spreading their money around. In this increasingly cash-strapped health care environment, hospitals know on which side their bread is buttered and see the "integration" of woo into their service portfolio as a means of beefing up the bottom line with cash on the barrelhead transactions that require no mucking about with nasty insurance forms. Indeed, they require no forms other than little green pieces of paper or credit card forms.

Unfortunately, there has been very little pushback by advocates of scientific medicine. Sure, there were the two excellent books, Trick or Treatment: The Undeniable Facts about Alternative Medicine by Simon Singh and Edzard Ernst and Snake Oil Science: The Truth About Complementary and Alternative Medicine by R. Barker Bausell. There was even Autism's False Prophets: Bad Science, Risky Medicine, and the Search for a Cure by Paul Offit. However, none of these books were best sellers, and I estimate that the entire sales for all three of these books combined probably don't match a month's--or even a week's--worth of sales for one of Kevin Trudeau's books or Jenny McCarthy's latest cheerleading for autism quackery.

That's why over the holidays I was so happy to see an article in the Wall Street Journal entitled The Touch That Doesnt Heal by Steve Salerno. It was that rarest of rare things in the mainstream media: an all-out frontal assault on what Dr. R. W. Donnell has termed "quackademic medicine" and the infiltration of pseudoscience into medical centers whose physicians should know better. Amazingly, it even expressed fear that any comprehensive health care reform promised by the incoming Obama administration could provide the opening for CAM advocates and their boosters in Congress like Dan Burton and Tom Harkin to coopt it and insert language into any reform legislation that would force the government not only to recognize (as NCCAM does) but pay for quackery. It is a fear I share, and I was happy to see a major newspaper like the WSJ publish such an editorial. Indeed, so happy was I that when I saw Deepak Chopra recruit Andrew Weil and Rustum Roy on The Huffington Post to attack Salerno's article, I couldn't resist having more than a bit of fun deconstructing their nonsense with extreme prejudice.

Unfortunately, it looks as though Chopra isn't through yet. Indeed, somehow he managed to get a guest editorial published last Friday in the WSJ. Worse, he's even added one to his Unholy Trinity of Woo to produce an editorial by Deepak Chopra, Dean Ornish, Rustum Roy, and Andrew Weil entitled "Alternative: Medicine Is Mainstream: The evidence is mounting that diet and lifestyle are the best cures for our worst afflictions. Of course, the article was also published on Chopra's Intentblog, along with some links to some cherry picked studies. The new addition to Chopra's posse, apparently the d'Artagnan to Chopra's Three Musketeers of Woo, Dean Ornish, happens to be Founder and President of the Preventive Medicine Research Institute and Clinical Professor at the University of California, San Francisco (UCSF). He is best known for his somewhat exaggerated claims that diet can treat prostate cancer. In this, he most resembles Andrew Weil in his distressing tendency to contaminate sound scientific medical advice with dubious and exaggerated claims about what dietary and lifestyle changes can do in and of themselves. In any event, this most recent article is the most explicit statement of the strategy of CAM/IM advocates that I and others have been warning about. It makes it absolutely explicit that Dr. Chopra et al want nothing less than for their "alternative" medicine to be treated as co-equal to scientific medicine, no matter what science and the evidence say. It begins:

In mid-February, the Institute of Medicine of the National Academy of Sciences and the Bravewell Collaborative are convening a "Summit on Integrative Medicine and the Health of the Public." This is a watershed in the evolution of integrative medicine, a holistic approach to health care that uses the best of conventional and alternative therapies such as meditation, yoga, acupuncture and herbal remedies. Many of these therapies are now scientifically documented to be not only medically effective but also cost effective.

President-elect Barack Obama and former Sen. Tom Daschle (the nominee for Secretary of Health and Human Services) understand that if we want to make affordable health care available to the 45 million Americans who do not have health insurance, then we need to address the fundamental causes of health and illness, and provide incentives for healthy ways of living rather than reimbursing only drugs and surgery.

Notice three things about this introduction. First, notice who's involved. It's the Bravewell Collaborative, a group, a wealthy private foundation. I am only speculating, but does anyone want to guess how such an article as Chopra's found its way into the editorial pages of the WSJ? I admit I'm speculating, but think about it a moment. The Bravewell Collaborative is a consortium dedicated to the promotion of CAM/IM in academia and "conventional" medical centers. More relevant, it is spearheaded by Christy Mack, wife of the multi-billionaire John J. Mack, CEO and Chairman of the Board of Morgan Stanley. Would it be going too far to wonder whether perhaps Christy Mack saw Steve Salerno's article and was not particularly happy about it. Perhaps she complained to her husband, who let it be known to the editorial board of the WSJ that some "balance" was required? Or perhaps Mr. Mack saw the article himself, given how common it is for CEOs of large financial institutions to read the WSJ. Second, note the picture that accompanies the editorial. It shows a puzzled and unhappy doctor staring out of the window of his office watching a bunch of happy and healthy people, one of whom is reading a book on health foods, another of whom is meditating as she walks, and another exercising, all apparently not needing the poor physician's services. This, of course, feeds into the typical CAM/IM myth that physicians aren't concerned with health maintenance and are only interested in treating disease.

Finally, note yet another classic example of the bait and switch of CAM/IM, even more outrageous than Chopra's previous foray into this scam. Note how Chopra et al refer to the "best of conventional and alternative therapies such as meditation, yoga, acupuncture and herbal remedies" and state that "many" of these "are now scientifically documented to be not only medically effective but also cost effective." Note, as Skeptico did, how Chopra includes acupuncture, which is not scientifically validated and in fact nothing more than an elaborate placebo, along with meditation, which may be helpful for relaxation and therefore useful for some conditions, and herbal medicine, which may or may not be effective, given that herbs contain drugs, but is the equivalent to the way medicine was practiced 200 years ago.

Here's where the bait comes in, and it's a predictable bit of bait given the addition of Dean Ornish as a d'Artagnan:

These studies often used high-tech, state-of-the-art measures to prove the power of simple, low-tech, and low-cost interventions. Integrative medicine approaches such as plant-based diets, yoga, meditation and psychosocial support may stop or even reverse the progression of coronary heart disease, diabetes, hypertension, prostate cancer, obesity, hypercholesterolemia and other chronic conditions.

A recent study published in the Proceedings of the National Academy of Sciences found that these approaches may even change gene expression in hundreds of genes in only a few months. Genes associated with cancer, heart disease and inflammation were downregulated or "turned off" whereas protective genes were upregulated or "turned on." A study published in The Lancet Oncology reported that these changes increase telomerase, the enzyme that lengthens telomeres, the ends of our chromosomes that control how long we live. Even drugs have not been shown to do this.

Note that the PNAS study examined a dietary intervention that is very, very hard to maintain, permitting only 10% of a person's calories from fat and requiring an hour and a half of exercise and meditation daily. Very few people could maintain such a regimen, and it would take a lot of dedication and devotion to pull it off. Moreover, it was only a pilot study of 30 men. Unfortunately, that did not stop CAM/IM advocates like David Katz from misrepresenting the study as showing that diet and exercise can "reshuffle the genetic deck in our favor." In any case, the study is provocative, but the men who participated were from a highly select group, only only 31 out of 127 eligible men. These patients were also a highly select group from another perspective in that they all had small, low grade prostate tumors deemed safe to be managed by "watchful waiting," rather than immediate surgery or radiation therapy. These tumors all had low PSA levels and low Gleason scores. (The Gleason score is the standard measure used by pathologists to estimate how aggressive a prostate cancer is.) These men were also monitored very carefully to make sure that their tumors were not progressing during the study, and their tumors did not regress, nor did overall PSA levels change on average. Moreover, what Chopra, Cornish, et al neglect to mention is that only 1/3 of the samples contained actual tumor tissue; the rest contained only noncancerous prostate tissue, as I pointed out in my previous post. This wasn't reported in the Results section and was only mentioned briefly in the Discussion section. Worse, not enough information was reported to allow a reader to make a reasonable assessment of whether this shortcoming introduced significant bias into the results, as it very likely could have. Indeed, it would be rather important to know what proportion of matched tumors contained no tumor in the pre-treatment biopsy or no tumor in the post-treatment biopsy. If, for example, more matched pre and post sets contained tumor in the pre-treatment biopsy but no tumor in the post-treatment biopsy than contained tumor in the post-treatment biopsy but no tumor in the pre-treatment biopsy, that could introduce an artifact that would bias the results towards the sort of results seen.

The second study cited appears to be a followup of the same study, in which the same specimens from the same 30 men were examined for telomerase activity in their peripheral blood monocytes. To put it simply, telomeres are repetitive DNA sequences at the end of chromosomes. They serve to keep chromosomes from degradation because during replication the enzymes that replicate the chromosome cannot replicated all the way to the end of it. Consequently, during each round of cell division and chromosome replication, some sequence is lost. With telomeres at the end, what is lost is noncoding repetitive DNA, and no information is lost. In most eukaryotic organisms, an enzyme known as telomerase adds these DNA sequences to the end of the chromosomes. However, in the adult it is generally active only in cells that need to divide a lot, such as stem cells and immune cells but only expressed little, if at all, in most normal cells. During aging, eventually telomeres shorten to the point where it starts to effect chromosome function. However, one tissue that often expresses telomerase at high levels is cancer, and this is part of what allows cancerous cells to divide indefinitely and also why telomerase inhibitors are a promising class of anticancer drugs. Indeed, one of the biggest challenges of anti-aging medicine is to find out a strategy to keep telomerase turned on without causing cancer. Consequently, I can see why Ornish would want to measure telomerase activity in these men. Unfortunately, most the same problems with the first PNAS study apply to this study, and, indeed, this Lancet paper looks to me like a bit of the ol' "CV padding" in that it reports what appear to be a lot of the same things about cholesterol and triglyceride levels in the men participating in the study. Moreover, the bottom line is quite underwhelming in that telomerase activity was only mildly increased in the PBMCs, with huge error bars and a significant, but not outstandingly so, p-value.

Most importantly, though, as Skeptico points out, this is the "bait." The interventions were diet and exercise. They were a difficult to follow diet and exercise regimen, but they were, when boiled down to their essence, diet and exercise nonetheless. No acupuncture. No homeopathy. No reiki. No CAM/IM. No nothing that can be considered "alternative," with the possible exception of meditation therapy, which I tend to look upon as relaxation therapy more than anything else. Moreover, no one I'm aware of is saying that diet and exercise can't have dramatic effects on health. Indeed, it's not scientifically implausible that Dr. Ornish's regimen might actually reduce the risk of prostate cancer or slow its progression, although his data do not really support that contention very strongly, if at all, and his two studies do fall into the realm of science-based medicine. They may be preliminary, controversial, and even mediocre science-based medicine, but they are not by any stretch of the imagination "alternative." Funny how Chopra insists on citing them as such. Next, he resorts to his usual attacks on science-based medicine:

Despite these costs, a randomized controlled trial published in April 2007 in The New England Journal of Medicine found that angioplasties and stents do not prolong life or even prevent heart attacks in stable patients (i.e., 95% of those who receive them). Coronary bypass surgery prolongs life in less than 3% of patients who receive it. So, Medicare and other insurers and individuals pay billions for surgical procedures like angioplasty and bypass surgery that are usually dangerous, invasive, expensive and largely ineffective. Yet they pay very little -- if any money at all -- for integrative medicine approaches that have been proven to reverse and prevent most chronic diseases that account for at least 75% of health-care costs. The INTERHEART study, published in September 2004 in The Lancet, followed 30,000 men and women on six continents and found that changing lifestyle could prevent at least 90% of all heart disease.

The study to which he is referring is this one. However, it is not quite as Chopra represents it, as you can see if you click on the abstract and read the article. What this study did was to compare percutaneous coronary intervention (PCI, otherwise known as angioplasty) with optimal medical therapy plus PCI. Note that both sets of interventions are science-based and not in any way "alternative". All the investigators were looking at is whether the addition of PCI results in better outcomes than medical management alone. Also note how Chopra states that bypass surgery prolongs life in only 3% of those who receive it as though that was a conclusion of the study. It wasn't a conclusion of this study, and Chopra does not cite his source. In any case, what Chopra fails to mention was that, although overall mortality didn't vary much, the PCI group did have some better secondary outcomes. For example, patients in the PCI plus medical intervention group required fewer procedures (32% of the medical therapy required additional revascularization procedures to 21.1% of the PCI/medical therapy group at 4.6 years) and a higher likelihood of being free from angina, albeit modest (42% versus 36% at 5 years). As for the INTERHEART study, this, too, is science-based medicine and suggests that diet and lifestyle could account for as much as 90% of all heart disease. It is also hardly new news. Yet Chopra appropriates diet and lifestyle as "alternative" so that he can make the "switch":

And the same lifestyle changes that can prevent or even reverse heart disease also help prevent or reverse many other chronic diseases as well. Chronic pain is one of the major sources of worker's compensation claims costs, yet studies show that it is often susceptible to acupuncture and Qi Gong. Herbs usually have far fewer side effects than pharmaceuticals.

Joy, pleasure, and freedom are sustainable, deprivation and austerity are not. When you eat a healthier diet, quit smoking, exercise, meditate and have more love in your life, then your brain receives more blood and oxygen, so you think more clearly, have more energy, need less sleep. Your brain may grow so many new neurons that it could get measurably bigger in only a few months. Your face gets more blood flow, so your skin glows more and wrinkles less. Your heart gets more blood flow, so you have more stamina and can even begin to reverse heart disease. Your sexual organs receive more blood flow, so you may become more potent -- similar to the way that circulation-increasing drugs like Viagra work. For many people, these are choices worth making -- not just to live longer, but also to live better.

Note the false dichotomy, how Chopra's "switched" from the bait of lifestyle changes and diet, both accepted, albeit arguably underemphasized, interventions supported by science-based medicine straight to woo like acupuncture and Qi Gong without citing any studies or acknowledging that none of the studies he has cited before had anything to do with acupuncture or Qi Gong, as Skeptico so astutely noted. From my perspective, the answer to such a criticism is not to cede diet and exercise to woo-meisters like Chopra but rather to emphasize them and scientific research (not NCCAM research) into them, especially given how woo-meisters take results that show diet to be important for health and twist them into supporting the use of all sorts of supplements and other dubious interventions. Chopra also makes the unsupported claim that herbs usually have fewer side effects than pharmaceuticals. Note how clever he is. He does not claim that herbs are more effective than pharmaceuticals--or even of equal effectiveness. There is, of course, no evidence that I'm aware of to support the claim of greater efficacy. Also, the reason many herbal remedies have "fewer side effects" is because they have little or no activity, or the effective drug within is diluted with all sorts of other contaminants from the plants. Indeed, as David Kroll pointed out, the reason scientific medicine moved toward purified chemicals from plants is because using the plants themselves or extracts there of was too hit-or-miss, with variable potency from lot to lot and variable contamination from lot to lot, which is one reason why we don't prescribe bark for cancer. Meanwhile, these days many herbal remedies are contaminated with lead and other heavy metals.

As for the part about "joy, pleasure, and freedom," that's just a non sequitur. There's no reason that anyone taking advantage of the fruits of scientific medicine can't also have joy, pleasure, and freedom, although the implication that Chopra is making is that one cannot, at least not without accepting his "integrative" nonsense. It's also a clever allusion to the entire "health freedom" movement. Again, eating a healthier diet, quitting smoking, and exercise are not outside the realm of scientific medicine, and there is plenty of evidence that they have beneficial health effects. The jury's still out on meditation, but there's no reason to doubt that "having more love in your life" makes your life better, regardless of whether it does all the other wonderful things that Chopra attributes to it, including his his brilliant (from a marketing standpoint) implication that accepting his favored CAM/IM interventions will lead to better sex. The reason that woo-meisters like Chopra try to appropriate diet and exercise as part of CAM/IM at every turn because they represent the "foot in the door" for pure woo like reiki and homeopathy. The unspoken rationale is that, diet and exercise to lead to better health and can even treat some conditions; we consider them "alternative"; therefore all those other "alternative" modalities also have something to them.

Ironically, however, there is one statement Chopra and his Musketeers make that I actually mostly agree with, but not in the way they meant it:

It's time to move past the debate of alternative medicine versus traditional medicine, and to focus on what works, what doesn't, for whom, and under which circumstances. It will take serious government funding to find out, but these findings may help reduce costs and increase health.

I agree almost 100%. The part I don't agree with is that it will take "serious government funding to find out." Chopra's implication is that more money will be needed, but between NCCAM and the National Cancer Institute's Office of Cancer Complementary and Alternative Medicine (OCCAM), the U.S. government already spends a quarter of a billion dollars a year studying "alternative" medicine. Adding more money would be nothing more than throwing good money after bad. In fact, from my perspective, there is nothing that NCCAM or OCCAM does that couldn't be folded into the Institutes of the NIH and evaluated in regular scientific study sections. Well, actually, there is one thing that NCCAM does that couldn't be done by Institutes, and that's the promotion and encouragement of CAM/IM in academic medical centers. Losing that function would be a good thing. In any case, I do agree that we should move past "alternative medicine" and "traditional medicine" (although it is really "alternative" medicine that is "traditional," given that the vast majority of it is based on either religion or a prescientific understanding of disease). Instead, we should concentrate on medicine that has been scientifically tested and found to be efficacious and safe versus medicine that is either untested or has been tested but has failed the test. Unfortunately for Chopra et al, other than their co-opted therapies (diet, exercise, etc.) the vast majority of so-called "alternative" medicine falls into one of the latter two categories and thus would not qualify as "medicine" if the distinction between "alternative" and scientific medicine were abolished.

Chopra's two articles demonstrate beyond a shadow of a doubt what their new strategy will be in 2009. With the impending inauguration of Barack Obama as the President of the United States, it is clear that they perceive a once-in-a-decade opportunity. Obama's stated desire to overhaul the government health care system, coupled with an increasing belief held by policymakers, legislators, and the public that the healthcare system as currently constituted is "broken," provides Christy Mack and other influential promoters of woo the excuse to bend the ear of Congress towards their money to try to persuade them insert into any reform legislation provisions that will pay for unproven and pseudoscientific CAM/IM modalities and thereby legitimitize them--even systematize them. (Truly, if they have their way "integration" will triumph.) They will sell these provisions as "reform" and "cost-effective health maintenance," when they represent neither. Indeed, Chopra et al make this utterly explicit in the conclusion of their WSJ article:

Integrative medicine approaches bring together those in red states and blue states, liberals and conservatives, Democrats and Republicans, because these are human issues. They are both medically effective and, important in our current economic climate, cost effective. These approaches emphasize both personal responsibility and the opportunity to make affordable, quality health care available to those who most need it. Mr. Obama should make them an integral part of his health plan as soon as possible.

No doubt this is the implicit, if not explicit purpose of the "summit" being convened by the Bravewell Collaborative with the Institute of Medicine of the National Academy of Sciences. What I can't figure out is why the IOM and NAS are going along with this bald-faced propaganda exercise designed to provide a patina of respectability on the CAM/IM movement and forge alliances designed to persuade Congress to do Bravewell's bidding and promote woo at every level of the health care system and medical research. Clearly the esteemed scientists and physicians in the IOM and NAS have not yet perceived that they are being used to promote an ideological, non-science-based agenda to the new Obama Administration. If advocates of science- and evidence-based medicine remain silent, Chopra, Weil, and the Bravewell Collaborative, along with all the other forces trying to "integrate" the unscientific with the scientific in health care may well succeed. They may well succeed anyway, given their resources and how little the public understands how science is done and why "integrating" pseudoscience with science- and evidence-based medicine is not beneficial or cost effective--or even harmless.