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NCAHF News, July/August 1997

Volume 20, Issue #4

CATTLEMAN SUES OPRAH FOR MAD COW DISEASE SCARE

According to NBC Nightly News (6/5/97), a Texas rancher is suing Oprah Winfrey for making false claims about how beef cattle are fed in the USA. Oprah was said to have shown a film on Mad Cow Disease and to have declared that she would think a long time before eating another burger. The rancher had lost hundreds of thousands of dollars that day on the stock market.

The lawsuit is based on a law against making false statements regarding perishable foods that came about because of the Alar fiasco a few years back.  Apparently, 11 states now have such laws. "Mad Cow Disease" (Bovine spongiform encephalopathy, BSE) is theorized to have resulted from feeding cattle an offal mixture that contained the remains of sheep which suffered from scrapie, a spongiform encephalopathy. News about BSE in UK cattle caused a media sensation, and destroyed the UK beef export business.

The US Dept of Agriculture Animal and Plant Health Inspection Service (APHIS) says that there has never been a case of BSE in the USA, and just a single case in Canada in a cow imported from Great Britain (the cow, her herdmates, and other nearby cattle were destroyed). In contrast, over 163,000 cattle have been diagnosed with BSE in the UK.

BSE is a slowly progressive degenerative disease affecting the central nervous system of cattle.  It was first diagnosed in Great Britain in 1986.  In 1990, the British government established the Spongiform Encephalopathy Advisory Committee (SEAC) to study the problem. On March 20, 1996, the SEAC advised the government that it had become concerned about 10 cases of Creutzfeldt-Jakob Disease (CJD) identified through national surveillance. CJD occurs at a rate of 1-2/million worldwide. US incidence is 1/million. The SEAC concluded that there was no direct scientific evidence linking BSE and CJD, but in the absence of any credible alternative explanation, they were guessing that the cases may be linked to exposure before 1989.

No beef has been imported from the UK to the USA since 1985.  From 1981-89, 455 cattle were imported from the UK. All have been traced, are examined regularly, and some have been purchased by APHIS for research.  Thus far, no BSE has been detected in the USA.

Comment: The Mad Cow Disease story would be a non-story in the USA if it were not for the propaganda efforts of vegetarian groups. EarthSave, PETA, PCRM, and the Seventh-day Adventist website have seized upon the opportunity to frighten people into behaving in ways they find ideologically delightful.

During the same period of time that speculation has been running wild about the possible association between eating beef and BSE, there have been reports of sickness and death from eating strawberries and raspberries from central America contaminated by irrigation with untreated drain-water containing hepatitis virus.  No mention of these problems is made by the vegetarians. 

The reality is that any type of food can become unhealthful via contamination. It is curious that meat-eaters do not try to frighten people away from fruits and vegetables (they could exaggerate the dangers of pesticide residues, etc.), but ideological vegetarians never pass up a chance to attack animal products.

[For information on BSE, contact APHIS at 4700 River Road, Unit 51, Riverdale, MD 20737-1232; 301-734-7799; Fax: 734-5205.]

PLACEBO HELPS PROSTATE PROBLEMS LONGTERM

A study done in Canada found a remarkable placebo effect. Researchers followed 613 patients who were either given the Merck & Co. drug finasteride or a placebo (white flour in a capsule) for two years.  The subjects were tested by measuring the sizes of their prostate glands and by having them urinate into a metered device that determined the rate and volume of flow.

The finesteride patients experienced a 21% decrease in prostate-size, while the placebo group experienced an 8.4% increase in prostate-size.  Nevertheless, a significant number of the 303 men in the placebo group felt much better, and demonstrated improved urinary flow--even though their prostates grew in size! 

The urologist who headed the study is now willing to prescribe placebo therapy for benign prostatic hypertrophy rather than to fully discourage medication and do watchful waiting.  The only problem is that the placebo he has in mind is herbal therapy--most likely, saw palmetto. 

NCAHF president William Jarvis told the Associated Press that he doesn't think it wise for doctors to prescribe herbal product placebos because it would instill consumer confidence in the products of an industry that has failed to demonstrate that it can be trusted by consumers.  The herbal industry has not yet even developed manufacturing standards that assure consumers that they are getting what they pay for. Even worse, there is no effective system for tracking unanticipated adverse effects from herbal products. 

Physicians should not reward an industry that is strongly at odds with responsible behavior in connection with health maintenance. The study described above was reported during the week of April 18, 1997 at a meeting of the American Urological Association at New Orleans. It will be published in an upcoming issue of the association's journal.

[Houston Chronicle, April 18, 1997, p.20A]

Comment: This study seems to show that there is an important psychological component to the urinary performance of men with prostate problems. This increases the likelihood that a quack remedy can generate a substantial number of satisfied customers who will attest to the remedy's value when, in fact, their disease is worsening.  Placebos are not harmless if they mislead patients about the progress of a serious disease.

A USEFUL CONSUMER'S BOOK FOR DENTAL PATIENTS

Dentists Marvin J. Schissel and John E. Dodes have composed The Whole Tooth, a book to guide consumers in their quest for quality dental care. 

Part one describes problems plaguing dentistry as a profession.  These are many of the same problems eroding the whole concept of professionalism in modern society.   Part two explains dental care for the dental consumer.  It is very helpful to anyone who wants to know about the various dental procedures and when they are appropriate.  Part three covers quackery in general and dental quackery in particular.  Part four deals with insurance and managed care.  Part five concludes with recommendations for the ideal practice of dentistry.

This is a splendid book that should be part of every consumer health education library. The 1997 book is published by St. Martin's Press, 175 Fifth Avenue, NY, NY 10010-7848;212-674-5151; fax: 212-420-9314; price: $23.95, $31.99 Canada.

An article by the authors summarizing some of the problems covered by the book entitled, "Is it time to look for another dentist?" appeared in the current issue of Priorities (1997, #2).

Drs. Dodes and Schissel are president and vice-president respectively of the New York Chapter of NCAHF.

MAIL ORDER IQ TESTS STOPPED

The Board of Psychology, which is part of the Medical Board of California's Division of Medical Quality has obtained an agreement from Mr. Kevin Langdon to cease the unlicensed devising, distributing, and scoring IQ tests in California. According to a complainant, Mr. Langdon's principal objective in carrying on this illegal program was to inflate the IQs of his testees.  This was done to qualify them for enrollment in "high IQ societies" which he controlled and from which he derived prestige and dues income.  The California board was completely unaware of Langdon's IQ tests even thought one of them, the LAIT, had been published in Omni magazine in April, 1979.   Langdon is said to have carried on his operation for two decades during which he tested approximately 30,000 individuals, including about 4,000 Californians.

ALT-MED DOC EXPRESSES CONCERNS
ABOUT BLUE-GREEN ALGAE TOXICITY

John McPartland, DO, is director of the Vermont Alternative Medicine clinic in Middleburg, but he hasn't let his fondness for unusual medicine prevent him from seeing the down-side of blue-green algae.  In an article entitled, "Why blue-green algae makes me tired," (Townsend Letter, 6/97) McPartland says that he is tired of people trying to sell him blue-green algae, and provides an exceptional critique of Cell Tech, the main huckster of the substance. The article is a reprint of one published earlier in the Vermont Alternative Medicine Newsletter, which gave Cell Tech a chance to complain and McPartland the opportunity to respond in an epilogue. This is an excellent article for blue-green algae watchers.

COMMERCIALISM VERSUS PROFESSIONALISM

William Jarvis, PhD

John McArthur, DBA, of the Harvard Business School and Francis Moore, MD, of the Harvard Medical School point out that:

There are two contrasting streams, two distinct cultural traditions, for providing services in the United States: the commercial and the professional. While these two traditions stand in sharp contrast to each other, they have shared a central role in the evolution of our society and its institutions. It is our purpose here to explore threats to the quality and scope of medical care that arise when the tradition of medical professionalism is overtaken (emphasis added) by the commercial ethic and by corporations seeking profit for investors from the clinical care of the sick [1].

The differences between the cultures of commerce and professionalism is at the heart of the problems disrupting managed care today; and, as shall be shown below, involve the same principles that divide quackery and standard medicine. An editorial in the same issue of JAMA makes our point:

The American Medical Association (AMA) [was] formed in 1847 for the purpose of setting up a code of ethics and distinguishing between physicians and quacks.

Professional medical goals can be protected only if they are well understood [2].

The Culture of Professionalism

Professionalism is rooted in principles established by Hippocrates, the "father of medical science."  Hippocrates coined the term "physician" from physikos, Greek for "nature," to denote that health and disease are natural, not supernatural, processes.  The notion that healers possess supernatural powers (eg, faith healing, Therapeutic Touch, animal magnetism) lingers in the minds of many people, and is also seen in the messianic charisma of egomaniacal quacks.  Hippocrates told physicians to stop taking credit for their cures, the body has its own inherent healing capabilities; therefore, post hoc ergo propter hoc ("after it, therefore, because of it") was faulty logic.  The best that can be done is to aid these, and the worst that can be done is to impede these self-healing processes--primum non nocere, "above all, do no harm."  Further, because of the body's inherent healing ability, a physician could not know whether a remedy or nature brought about a cure; therefore, physicians could only learn what remedies do not work when a patient did not recover.

The idea of learning mainly from failures also underlies the reality that science is better at finding what does not work than it is at making medical breakthroughs.   Hippocrates urged physicians to seek out new remedies, but to be skeptical, ie, from Greek, skeptomai, "look at something carefully," "examine," and "consider" it [3]. Hippocrates taught humility, cooperation among physicians, social responsibility, and above all the commitment to the patient. McArthur and Moore point out:

The fundamental act of professional medical care is the assumption of responsibility for the patient's welfare--an unwritten contract ... acknowledged by the physician that "we will take care of you." The essential image of the professional is that of a practitioner who values the patient's welfare above his or her own and provides service even at a fiscal loss and despite discomfort or inconvenience [1].

McArthur and Moore also note:

When a corporation employing physicians seeks profit by selling their services, the physician-employees cease to act as free agents. Professional commitment to patient care is subordinated to new rules of practice that assure the profitability of the corporation [1].

The Culture of Commercialism

The commercial culture is rooted in the principles of Adam Smith, the "father of modern economics." Smith is the hero to free market ideologists such as Milton Friedman, whose book Free To Choose strongly influenced Ronald Reagan (Friedman advocates abolishing the FDA).

Adam Smith held that the wealth of nations would mount with each worker--including the quack--doing what he did best. Sociologist Herbert Spencer taught that government should not suppress quackery on the basis of Darwin's theory of natural selection.   Evolutionary progress meant that the fit should survive and prosper, whereas the unfit should perish.  Society, like nature, was red in tooth and claw. Government action protecting those so unfit as to succumb to quackery only impeded society's progress [4]. The culture of commercialism celebrates the profit motive, the law of supply and demand, competition, advertising, and so forth. Free market ideologists advocate laissez faire, with its inherent doctrine of caveat emptor, "let the buyer beware."

Caveat Emptor / Caveat Vendor

Caveat emptor is based upon the equality of bargaining positions of buyer and seller.  In medieval times this was practical because people bargained for common products with friends and neighbors.  As trade expanded, buyers were forced to trust the word of strangers that items were what they were represented to be. During the 15th century the concept of caveat vendor ("let the seller beware") became the rule for marketplace situations in which buyers and sellers were on unequal terms [5]. The judge charged the jury in a case involving the 1906 Pure Food and Drug Act saying:

This law was not passed to protect experts, especially not to protect scientific men who know the value and meaning of drugs, but for the protection of ordinary citizens [6].

Justice Frankfurter also restated the fundamental principle of caveat vendor in a case interpreting the 1938 Food, Drug, and Cosmetic Act:

The purposes of this legislation...touch phases of the lives and health of people which, in the circumstances of modern industrialism, are largely beyond self-protection [6]

Accountability

Professionalism supports the accountability inherent in the principle of caveat vendor.  Standard medicine cooperates with the FDA regarding medicines and medical devices, and conducts peer reviews of other procedures.  Peers possess equal knowledge and help judge the worth of medical procedures.

The FDA Center for Drug Safety has reported that 80% of reports on adverse reactions to drugs come from pharmaceutical companies themselves while virtually none are reported by the dietary supplement industry [7]. Commercial interests can escape accountability by providing label warnings. Such fulfills the "duty to warn."

The freedom allowed commercialism to confuse the issues in our society is exemplified by the tobacco industry. The industry uses free speech to misinform the public on the health effects of its products, while at the same time escaping accountability by placing warning labels on packaging and in advertising. 

Books promoting questionable health-care practices do the same.  A set of publications vigorously promoting "alternative" medicine is the Alternative Medicine Yellow Pages and Alternative Medicine; The Definitive Guide published by Burton Goldberg, a Florida land developer who believes that his girl friend's 19-year-old daughter was saved by unorthodox medicine. Goldberg alleges that the girl suffered from mental illness "caused by hypoglycemia, an imbalance created by food allergies, problems in her pancreas, and an overgrowth of bad bacteria in her gastrointestinal tract." [8] These are dubious diagnoses, but he believes. 

Although the book cover declares that it contains "everything you must know about effective therapies" (emphasis added), inside a carefully-crafted disclaimer that appears several times throughout the book hedges on the claim that therapies are effective by declaring that by definition, "alternative" methods "include those that have not been investigated or approved by any government or regulatory agency," and that "ultimately, you, the reader, must take full responsibility for your health and how you use this book."

The idea that consumers must "read the fine print" to find the disclaimers reflects the traditional duplicity of caveat emptor.

Incompatibility of Professionalism and Commercialism.

The hopeful idea for commercializing health care administration was that marketplace forces would stimulate inventiveness and marketplace efficiency.  Unfortunately, the social planners did not fully understand the contrasting cultures they were trying to marry.  And herein lies the common thread tying the problem of quackery to those perplexing problems within managed health care.  Little wonder that it has been so easy for some marketing-minded HMOs to integrate "alternative" medicine into their programs.  McArthur and Moore describe the heart of the problem:

The fundamental objective of commerce in providing medical care is achieving an excess of revenue over costs while caring for the sick, ensuring profit for corporate providers, investors, or insurers. A central feature in enhancing net of income over expense in a competitive market is a reduction in volume or quality of services so as to reduce costs, while maintaining prices to the purchaser.

In this setting, the operation of market forces is hampered because patients and families can rarely acquire the information necessary to discriminate as to suitability and quality among alternative clinical services and providers.  Without consumer input, market forces often fail completely, or behave perversely...

In purchasing commercial services, the public has learned to beware both of low quality and excessive pricing, as expressed in the Latin phrase caveat emptor--"let the buyer beware."  The American public is gradually becoming aware that caveat emptor may soon become caveat morbidus--"let the patient beware." [1]

Competition among Professionals

Inherent in marketplace competition is advancing oneself as superior to others in the same business. Jameson states that "it is the principle of self-advertisement that really defines quackery." [9] Superiority claims automatically turns colleagues into competitors.

Health professionals have traditionally worked together against humanity's common enemies of disease and death.  The Sherman Antitrust Act exempts cooperative scientific endeavors from the rules governing the business community (conspiracy, restraint of trade). In the world of commerce, companies jealously protect trade secrets, and "corporate espionage" is a lucrative form of economic treason; scientists work in the open and readily share information. Describing protocols in terms so clear that it enables others to reproduce their work facilitates the gold standard of science--replication.  Prohibiting secret remedies was the cornerstone of the 1906 Pure Food and Drug Act; and, one of the defining characteristics of quackery is claiming to have "a secret remedy."

Will It Sell vs Should It Be Sold?

The world of commerce is driven by supply and demand.  By contrast, in the world of professionalism, procedures found to be ineffective are discarded even though they would still attract consumers. Regarding standard health products, from 1990 to 1992, the FDA banned, or proposed to ban, 749 ineffective ingredients used in nonprescription drugs and weight loss products grandfathered by the 1962 Harris-Kefauver Amendment [10].

There is no indication that the companies that sold these ineffective drugs would have discontinued marketing them just because they didn't work. The poorly regulated nonprescription medicine marketplace is now filled with unproven homeopathic remedies and dietary supplements. 

Standard health services are also subjected to testing.  In the 1950s internal mammary ligation was widely used to relieve angina pectoris.  Patients reported increased working capacity and less chest pain.  Nevertheless, a test was done.   It found that patients who received only an incision did just as well as those who got the surgery [11]. As a result, surgeons stopped using the technique, not because there ceased to be a marketplace demand, nor because patients were dissatisfied, but because it simply did not work.

The discontinued mammary ligation procedure can be compared to the present-day marketing of chelation therapy for heart disease.  Patient demand is high because they wish to avoid bypass surgery, and subjective reports of improvement mirror those given for internal mammary ligation. There is strong evidence that the procedure is worthless. However, maverick doctors have banded together to lobby for commercial standards.  Their patients sometimes carry placards demanding that chelationists be excused from regulatory control.

"Medical Freedom Laws"

The rules of commercialism are gradually displacing professionalism.  At least 8 states have passed laws that prevent licensing boards from disciplining members for unprofessional conduct for substituting "alternative" or "complementary" methods for standard care.  This effectively does away with the peer review process of professionalism, and puts patients on their own for spotting inappropriate medicine. Senator Orrin Hatch, a chelation therapy user himself, weakened the health fraud section of the Kennedy-Kasselbaum Act by adding an amendment that provides some cover for nonstandard practitioners.  Congress has been working on what is known as the Access to Medical Treatment Act, that will open the public purse to nonstandard "alternative" health care.

Safety and Efficacy By Semantics vs Proof

Professionalism's rule of primum non nocere is supplanted by semantics. Homeopathy is touted as "the natural way to promote recovery and restore health," [12 ] but offers no sound evidence that it is either safe or effective. Chiropractic and naturopathy claim to be "natural and drug free" ways to health, but lack proof of safety and efficacy. Traditional healing systems such as ayurvedic and Chinese Medicine claim that having existed for thousands of years validates them, but offer little that will pass for scientific evidence. "Alternative-complementary" medicine providers talk the talk, but clamor to have the standards of science set aside so they can qualify. 

Those who understand the duplicity of commercialism know that it is important to listen carefully to words, and to understand their meanings. An expert in the deceptive language used in advertising warns that:

Weasel word(s) can make you hear things that are not being said, accept as truths things that have only been implied, and believe things that have only been suggested. When you hear a weasel word, you automatically hear the implication. Not the real meaning, but the meaning it wants you to hear [13].

Patient Satisfaction vs Clinical Effectiveness

Clinical effectiveness is established when a procedure performs better than "no treatment" and/or "placebo therapy." Placebo therapy can, by definition (literally "I shall please"), satisfy patients [14]. Questionable remedies also can claim subjectively reported "successes." Reported "success" with "alternative" arthritis remedies was from 8 to 56%. [15] The percentages of cancer patients reporting satisfaction with "unorthodox" treatment were only slightly lower than their satisfaction with standard care [16].

Patients of chiropractors were three times as likely as patients of family physicians to report that they were "very satisfied" with the care they received for low back pain, much more likely to have been satisfied with the amount of information they were given, to have perceived that their provider was concerned about them, and to have felt that their provider was comfortable and confident dealing with their problem [17], but there is no evidence that chiropractic care is more effective for low back pain [18]. Customer satisfaction is not incompatible with sound medicine, but the art of care should enhance, not supplant, the science of care.

Citations

  1. McArthur. "The two cultures and the health care revolution," JAMA;1997:277:985-9;
  2. Emanuel. "Bringing market medicine to professional account," JAMA 1997:277:1004-5;
  3. Funk. Word Origins. Bell Publ, 1978, p.109;
  4. Young. American Health Quackery. Princeton Univ Press, 1992, p.89;
  5. Magnuson. The Dark Side of the Marketplace. Prentice-Hall, 1972;
  6. US Congress, OTA. Unconventional Cancer Treatments. OTA-H-405 (Wash, DC., US Gov't Printing Office, 9/90), p.6;
  7. Rosa. "Teratogen update: vitamin A congeners," Teratology, 1986;33:355-64, p.360;
  8. Goldberg. "Why this book was written," in Alternative Medicine; The Definitive Guide. Future Medicine, 1993, p.xxxvi;
  9. Jameson. The Natural History of Quackery. Michael Joseph, 1961. p.13;
  10. "FDA Proposes banning 415 ineffective ingredients," FDA Consumer, 1992;26(9):2-3;
  11. Dimond, "Comparison of internal mammary artery ligation and sham operation for angina pectoris," Amer J Cardiology, 4/60;
  12. Jonas, Healing With Homeopathy. Warner Books, 1996;
  13. Wrighter. I Can Sell You Anything. Ballantine Books, 1972;
  14. Beecher. "The powerful placebo," JAMA, 12/24/55;
  15. Struthers, "The use of 'alternative treatments' by patients with rheumatoid arthritis," Rheumatol Int 1983;3:151-2;
  16. Cassileth, "Contemporary unorthodox treatments in cancer medicine," Annals Intern Med, 101:105-12, 1984;
  17. Cherkin, "Patient evaluations of low back pain care from family physicians and chiropractors," West J Med, 1989;150:351-5;
  18. Chiropractic Back Care, NCAHF ARM list, 1996.


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