Adapted from a speech given on October 14, 2000, at "Aesculapius in Cyberspace: Doctors, Patients and Quacks on the Internet," a symposium in Utrecht, The Netherlands organized by the Dutch Union Against Quackery [Vereniging tegen de Kwakzalverij (VtdK)]
The Internet is a powerful tool both for promoting quackery and for exposing it. I'll begin by telling you all about the important work of Dr. John Renner, who became president of our National Council Against Health Fraud in 1998 after serving as a member of our Board of Directors since the mid-1980s. When Dr. Renner died on September 2, 2000, following emergency heart surgery, we lost one of our most dedicated and influential advocates for patients and opponents of medical renegades and rascals. ("Medical renegades and rascals" is how he sometimes referred to the promoters of health misinformation, fraud, and quackery.) Dr. Renner's expertise was in the field of family and community medicine. He found a number of ways to reach out to families and communities. For example he debunked quack claims as a columnist for a daily newspaper, The Kansas City Star. His book Health Smarts is a collection of his columns. He also started the Consumer Health Information Research Institute, which served as a resource for consumers, reporters, and health insurers.
I don't think anyone else ever devoted as much in the way of personal financial resources to fighting quackery as John Renner did. He once stated that he spent more than $300,000 including money from his retirement accounts .
Dr. Renner was special in how generous he was with his time. He was responsive to patients who called him with questions about a wide range of alleged healing methods. He appeared on numerous radio and television programs. He led reporters through so-called "health food" stores and "holistic health" shows, to expose the different types of quackery on display. He also posed as a patient and visited suspected quacks in order to gather evidence of health fraud and abuse. As recently noted by Dr. William Jarvis, the founding president of The National Council Against Health Fraud:
One of [John's} greatest ruses was to disguise himself as a vulnerable invalid (bandaged head and body in a wheel chair) and to attend 'Natural Health Conventions,' which are really showplaces for marketing quackery. John would roll up to premier quacks and engage them in conversation. He once completely fooled the King of the Quacks. A circle of devotees was talking on the floor with John in the midst of the action. When the Quack King put his hand on John's shoulder during the conversation, John, in a voice that denoted great adulation, stated 'You touched me! You are the first doctor who has touched me! Thank you! Thank you!' The adulation flattered the Quack King and raised his immediate status to a notch above his competitors. Although obviously ambivalent about having more contact with this rather strange patient, he straightened up to strut the superiority John had just conferred upon him 
On another occasion, at a "Natural Health Convention," after John's wheelchair attendant left him, two quacks got into a fight over who was going to fleece him first. As Dr. Renner told a San Diego Union reporter:
One was into colonics and wanted to give me an enema; the other was a garlic salesman. They never even asked what I had. Later I told people I had a yeast infection. One guy wanted to draw my blood. He offered a 'show special': $900 worth of tests for only $600. All he wanted was my Medicare number." 
(Medicare is the federal health insurance program in the United States for persons 65 years of age of older and for certain disabled younger persons.)
In recent years, Dr. Renner visited health shows of various types that operate in cyberspace. He was unsurpassed in spending time on the Internet evaluating the accuracy of health-related Web sites. As part of his job as chief medical officer of Health Scout, he wrote a weekly Web site review column called "Stars and Stinkers." He gave four stars to the best sites and four stinkers to the worst. It was important to Dr. Renner to strive for fairness in his reviews. He made sure he rated each site in terms of predefined criteria: credibility, readability, navigability, usefulness, and quality of links. He didn't want his biases to affect the ratings. Once he gave a good evaluation to the Web site of an organization that he and I both thought was too sympathetic to quacks. Although he didn't support the organization's work, he also recognized that the organization was careful to avoid posting health misinformation. According to Dr. Renner's criteria, the site deserved a positive rating. By adhering to his rating criteria, Dr. Renner maintained the credibility that he built over many years as a leader in the field of patient education.
As Dr. Jarvis wrote: "When John Renner's big heart stopped . . . America lost a national treasure."
I think if Dr. Renner could have made it here, he would appreciate as much as I do something that is special about talking to Dutch people about quackery. It has to do with English word origins. It turns out that every American activist against quackery knows at least one Dutch word very well. I think you know what word I'm referring to.
My dictionary of English word origins states that there are two words 'quack.'  One, of course, denotes the call of a duck ("quack, quack") and originated as an imitation of the sound of itself. The other word 'quack' helps me to focus my feelings of outrage and I hope it does the same for you. My dictionary says it was borrowed from the early modern Dutch word quacksalver, a compound formed from quacken meaning 'chatter' or 'prattle' and salf, the Dutch relative of the English salve. The dictionary says that quacksalver etymologically denoted 'someone who prattles on or boasts about the efficacy of his remedies.'
I have no problem with anyone prattling on or boasting about the efficacy of remedies when there is sufficient scientific evidence to support the claims of efficacy. And I don't object to the use of unproven treatments per se as part of the art of caring, comfort, and cure, particularly when there is a rational basis for using the unproven treatments. But the word "quack" is fitting for those who can't present sufficient scientific evidence to back up their boasts about efficacy, especially in light of concerns about safety and the ethical principles of nonmaleficence (or first, do no harm) and veracity (or truth-telling).
In the college textbook Consumer Health: A Guide to Intelligent Decisions, Dr. Jarvis wrote:
Why should a critter as cute and harmless-looking as a duck be used to symbolize the vicious social menace of quackery? A vulture would seem to be more appropriate. But vultures actually wait until death occurs before engaging their targets. Thus, their conduct is too benign to symbolize quackery, which preys on the weak, the helpless, and the desperate.
Other birds of prey behave more like that of quacks, but the bald eagle, which is a national symbol [in the United States], would not be suitable for derision. An ostrich might be appropriate, because of its reputation for hiding its head in the sand, thus symbolizing the denial often seen in both quacks and their victims 
But Dr. Jarvis concludes that considering the origin of the word quack: "The duck personifies quackery because it makes a lot of noise about nothing." [Note: the duck has not caught on as a symbol of quackery in Holland.]
In 1984, a subcommittee of the United States House of Representatives Select Committee on Aging issued a report called Quackery: A $10 Billion Scandal , which recognized the noise made by quacks as a social menace. The report detailed numerous fraudulent endeavours including (a) clinics inside and outside the United States that provide bogus treatments for chronic and terminally ill patients using diet, drugs, and enemas for arthritis, cancer, heart disease, and other ailments; (b) foundations that encourage the use of unproven remedies; and (3) phony healers who use a religious healing image or claim powers generated by Satan or witchcraft.
By 1991, our Congress lost sight of quackery both as a social menace and as a concept. It gave the methods promoted by quacks a new respectability. Largely due to the efforts of a Senator Tom Harkin, who believes taking bee pollen cured his hay fever  and who was influenced by Berkeley Bedell, a former congressman who believed that drinking milk from cow udders injected with his blood had caused symptoms of Lyme disease to disappear . Congress mandated the creation of a so-called Office of Unconventional Medicine within the prestigious National Institutes of Health. In 1998 Congress passed legislation signed by President Clinton that transformed the Office into the National Center for Complementary and Alternative Medicine with a $50 million budget and created a White House Commission on Complementary and Alternative Medicine Policy. According to the National Center, "CAM covers a broad range of healing philosophies (schools of thought), approaches, and therapies that mainstream Western (conventional) medicine does not commonly use, accept, study, understand, or make available."  This definition, of course, covers all the dubious treatments that the 1984 report associated with quackery. The advisory boards to the Office and National Center have included promoters of unproven methods referred to euphemistically as "complementary and alternative."
For almost ten years now, the United States government has provided funds for basic and applied research to study methods that fit the official definitions of "complementary" and "alternative." However, it remains to be seen whether funded studies will demonstrate that any of these methods are valuable. Even if some eventually prove useful, that is unlikely to outweigh the publicity bonanza Congress has given to irrational methods.
Remarkably, the National Center for Complementary and Alternative Medicine even has funds available for research on practices such as so-called "energy healing," homeopathy, and therapeutic prayer, for which it acknowledges there is no plausible biomedical explanation of effect. The program that funds this research is called the Frontier Medicine Research Program . Homeopathy is more than 200 years old, but our government calls it "frontier medicine" and worthy of funding.
Meanwhile, I know of no federal funding program to support the study of quackery as a public health problem. The American Public Health Association has an interest group on "Alternative & Complementary Health Practices," but none on combating quackery.
A medical society has invited a graphologist to present a workshop at its business meeting in May on "The Medical Implications and Uses of Handwriting Analysis." The program announcement indicated: "Handwriting analysis is available for a $20 charge payable at the door." 
In American universities, proponents of postmodernist doctrine, who reject the notion that scientific methods are needed to separate fact from fiction in healthcare, and who celebrate personal subjectivity, refer to pseudoscientific and superstitious approaches to healthcare as "alternative" and "complementary."
Many medical schools and other schools that train health professionals offers courses that take uncritical approaches to discussing methods of healing that allegedly involve manipulation of a mystical "life force" distinct from physical forces that operate according to the laws of chemistry and physics. One exception is Stanford University's medical school where Dr. Wallace Sampson, one of the founders of The National Council Against Health Fraud, has taught a course for many years on medical pseudoscience. Dr. Sampson is the editor-in-chief of The Scientific Review of Alternative Medicine, the only journal I know that is devoted to skeptical inquiry about "alternative" medicine.
The large, influential American Cancer Society has published scientifically-based reports on more than 70 questionable methods of cancer management with help from its Committee on Questionable Methods. In the mid-1990s the committee's name changed to the Committee on Alternative and Complementary Methods, implying that such methods have earned legitimacy.
Drs. Marcia Angell and Jerome P. Kassirer, former editors of The New England Journal of Medicine have pointed out: "There cannot be two kinds of medicine-conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work." 
A judgment that a treatment is efficacious depends on quality scientific evidence. Quacks are good at convincing people that such evidence exists when it doesn't or convincing people to accept substandard evidence.
I have proposed that alternatives be classified into three categories: genuine, experimental, and questionable . Genuine alternatives are backed by sufficient scientific evidence showing that the potential for benefit exceeds the potential for harm to specific populations. Experimental methods are unproven, but are studied responsibly with special care given to seeking informed consent from study participants and protecting them from exploitation. Questionable methods are those for which scientific evidence is insufficient to support the claims made by proponents. Perhaps there should be a fourth category of plausible alternatives for which it is not clear whether the proven benefits outweigh the risks when used as intended. Estrogen replacement therapy for postmenopausal women might belong in this fourth category.
Everyone wants alternatives—genuine alternatives. Quacks exploit this by calling for "freedom of choice" for consumers. What quacks really want is freedom from accountability to consumers. They support the concept of caveat emptor, "let the buyer beware," but they have a problem with the concept of caveat vendor, "let the seller beware." Caveat vendor provides a rationale for consumer protection laws to compensate for the disadvantageous bargaining position consumers have in the health marketplace. It is difficult to evaluate claims for health products and services. We are vulnerable to mistaken perception and deception especially when we feel threats to our well-being and when we are desperate for answers. It is important to protect consumers from both intentional and unintentional deception. And it is also important to preserve true freedom of choice. Thus, the motto of the National Council against Health Fraud is: "Enhancing freedom of choice through reliable information."
Most people who seek questionable alternatives also seek genuine alternatives when available. Thus, many quacks promote questionable alternatives as "complementary" methods The word "complementary" means "serving to fill out or complete" or "mutually supplying each other's lack." But a method is genuinely complementary only if it adds to the outcome and not just to the overhead and other costs that get passed on to consumers or third-party payers. Scientific evidence is needed to demonstrate whether an alleged "complementary" method really adds to the outcome. Promoters of questionable complementary methods lack this evidence, but they like to take credit for any positive effects experienced by the patient. Many assign blame for any negative effects to the evidence-based treatments their patients take.
The promotion of questionable complementary and alternative methods—methods that supposedly treat the real, underlying causes of disease and unwellness—is big business in the United States.
On his award-winning Quackwatch Web site, Dr. Stephen Barrett describes how an overzealous promoter of apricot seeds for cancer was successfully sued after violating the membership agreement of the online service America Online by sending spam. He and and his company were penalized $631,585. I met the apricot seed pitchman three years ago when we were both scheduled to appear on a television show. I saw his medical records. He does have a kidney cancer and his doctor advised him to have the cancerous kidney removed. Instead he has turned to apricot pits and other methods he learned about in his church.
Some Internet sites seduce unwary consumers with claims for "miraculous" health products; others make deceptive attacks against benign products and established public health measures. Consumers taken in by health scares on Web sites spread the scares to family, friends, and associates by e-mail. Here are three examples of influential health scares on the Internet:
There is enormous potential for using the Internet to fight quackery. Through Quackwatch, you can join a very active Health Fraud Discussion List to send and receive e-mail to participants. The National Council Against Health Fraud also offers Consumer Health Digest (a free electronic newsletter) in addition to its print newsletter for subscribers and council members. The electronic newsletter reports, in part, on news identified by participants in the Health Fraud Discussion List. We expect this new offering to help us attract new members and keep our old members.
We need to inspire more members to get involved with our task forces on various special interest areas related to quackery. We need to start new task forces.
I believe that, as we grow, we will get more favorable publicity for mitigating the harmful impact of quackery. Much of our success will depend on how effectively we promote the principles of consumer protection law and science by harnessing (a word that American quacks like to use to inspire their followers) the power of the Internet.