Why The Atlantic's Article On New Age Medicine Is Wrong

Over at The Atlantic, David H. Freedman, the author of Wrong, the book, has a piece on "New Age Medicine" (actually it's really mostly about acupuncture) that makes some very interesting points and includes a white-hot quote from Forbes contributor Steven Salzberg, but then slides off into a bit of completely erroneous thinking, asserting that alternative medicine is becoming popular in "large part because mainstream medicine itself is failing." His evidence:

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.

via The Triumph of New Age Medicine - Magazine - The Atlantic.

I guess this is Wrong: The Magazine Article? Because that's all horse microbiome. Let's take those one by one. Saying we're not making strides against heart disease and cancer is just, well, wrong. Look at the below chart of mortality from both, courtesy of the Centers for Disease Control and Prevention. Notice something? They're both going down. Yes, attacking common diseases is hard, but acting like we're not making progress is missing the forest for the trees.

Which is how I'd explain most of Freedman's hand-wavy examples. I'm the first to argue that Avastin has not lived up to its promise, but it is a great drug in colorectal cancer, extending median survival by five months, and a good one in some types of lung cancer. Pfizer's torcetrapib proved deadly, but that was caught long before it would reach patients outside clinical trials. It's not news that experimental drugs fail. Merck and Roche are working on similar medicines that may prove to be life-savers. Avandia is basically gone, but partly because there was an alternative to take its place. Yes, the battle against heart disease and cancer is slow, grinding trench warfare, but that's because these are diseases written by evolution into our genetic code. And we're still winning.

Worst is Freedman's fashionable dismissal of statins in preventing first heart attacks. I don't think that after the Jupiter study of Crestor there's any doubt that these drugs prevent first heart attacks, certainly not in men. The problem is that first heart attacks, even in at-risk patients, are rare. So maybe the small absolute benefit of the drugs is not worth it. That's a fine argument -- but it will be true for any drug, and means just accepting that heart attacks will remain one of the biggest causes of death forever. It means giving up on prevention.

Freedman tortuously makes the opposite argument, that somehow alternative medicine is thriving because it focuses on prevention. But no form of alternative medicine has been shown to prevent common diseases like Alzheimer's or heart disease. People may be mistaking the bad headlines for lack of progress, but you shouldn't refuse all medicine because Avandia probably increased people's risk of heart attacks. You should just be a little more fussy about which medicines you take. Acupuncture and herbal remedies have not been proven to prevent anything. This is crazy. Your aerobics instructor is as good a bet for prevention as your acupuncturist.

What bothers me most about Freedman's argument is that he comes so close to being right. I actually agree that the success of alternative medicine is the result of mainstream medicine's failure. But it's not that alternative medicine is preventative but mainstream medicine is not. It's that mainstream medicine, especially with health insurance and care models that restrict the amount of time patients spend with doctors, has abandoned the power of ritual in making people feel better. (I previously wrote about this here.)

The Brigham's Marc Pfeffer, explaining why patients did so well in the placebo group of a trial testing Amgen's Aranesp, told me: "­"There is an art to medicine," Pfeffer said. A caring doctor can give a patient hope, he said. "It’s a wonderful feeling to make somebody feel better. Some of that is taking some of the weight off their shoulders."

For centuries, this was really most of what doctors did. Think back on all the treatments that used to be used, all the ineffective treatments from various tinctures and patent medicines to bloodletting. People still went to doctors, or healers, or medicine men. There is something powerful about being taken care of. It's the white lab coat effect, the sense that there is someone knowledgeable who is going to help you fight the mystery and emptiness of your own pain and illness.

Alternative medicine types may actually have a leg up doing this. And I think there's pretty good evidence that this missing component is present in lots of alternative medicine. One of the best examples of this comes from Ted J. Kaptchuk at Harvard, who was trained in traditional Chinese medicine but who has become one of the leading researchers in mind-body placebo effects. As I wrote here:

Though recurring tummy aches from irritable bowel syndrome are among patients' most common complaints, drugmakers have had trouble coming up with a safe and effective treatment. But in 2008 Harvard's Ted J. Kaptchuk devised a safe remedy that helps far more people than any designer drug ever did.

His magic cure: fake acupuncture delivered with lots of warm talk from a sympathetic acupuncturist--but no needles. In a trial of 262 patients with severe IBS, 62% of those who received the fake treatment got better, according to results published in the British Medical Journal. By comparison, only 28% of a control group of patients put on a waiting list saw their symptoms improve markedly. A third group who got the fake acupuncture, but without any warm talk, showed in-between results: 44% improved.

This is obviously a small experiment, but it's a great example of how the way that a treatment is given can impact how well it works. Kaptchuk believes these effects are limited to making people feel better, not to curing cancer or heart disease. But pain and discomfort are precisely what drugs are not so good at treating. Tummy aches are among the most common complaints, which is exactly why Novartis put lots of money into marketing a drug for irritable bowel syndrome that was only marginally effective -- until it was withdrawn because it might increase the risk of heart attacks.

When a drug is making you feel better just because it's being given with lots of TLC, we call that off-label marketing. (That's what happened with a Johnson & Johnson drug called Natrecor for heart failure -- patients were going to clinics for regular infusions, and it became a scandal. The medicine turned out to have only minimal effect, but also did no harm.) There's no question that alternative medicine is being judged by a different standard.

But if I start having serious pain, or gut aches that won't quit, I'm going in for sham acupuncture. And if I can't get that, I might well be willing to settle for the real thing.