Subsequent studies have been even more damning. In 2005, researchers from the Virginia School of Medicine reported in the New England Journal of Medicine that echinacea had no clinical impact, whether taken as a prophylactic or after exposure to a virus. Nor did it lessen the duration or intensity of any symptom. In addition, the American College of Pediatricians has urged parents to avoid echinacea mixtures for children who are less than a year old. The response? According to the latest data released by the federal government in 2008, echinacea remains the most heavily used supplement in the childhood arsenal. (It is still wildly popular with adults too, but fish oil is now in greater demand.)
Almost no restrictions were placed on the sale of supplements, vitamins, or other home remedies until 1906, when, reacting to the revelations in Upton Sinclair’s book The Jungle, Congress passed the Pure Food and Drug Act. The law permitted the Bureau of Chemistry, which preceded the Food and Drug Administration, to ensure that labels contained no false or misleading advertising. Since then, the pendulum has swung regularly between unregulated anarchy and restrictions that outrage many Americans. In 1922, the American Medical Association made an effort to limit the indiscriminate use of vitamins, describing their widespread promotion as “gigantic fraud.” It helped for a while. By 1966, the FDA tried to require the manufacturers of all multivitamins to carry this notice: “Vitamins and minerals are supplied in abundant amounts in the foods we eat. . . . Except for persons with special medical needs, there is no scientific basis for recommending routine use of dietary supplements.” The vitamin industry made certain that no such warning was ever issued.
The relationship between food, drugs, and supplements began to blur in the 1970s as connections between diet, food, and medicine became more fully understood. What began as a federal effort to improve nutrition and prevent confusion has ended up as a tacit endorsement of chaos and deceit. First, with a major report issued in 1977 by the Senate Select Committee on Nutrition and Human Needs, and then with studies by the National Academy of Sciences and other research groups, the government started telling Americans to alter their diets if they wanted to have long and healthy lives. That made sense, of course. Advice about ways to reduce the risk of heart disease, diabetes, many cancers, and other chronic illnesses became routine. There were food pyramids and instructions to eat less salt and fat and add fiber as well as whole grains; eat more fruits and vegetables and watch the calories. Still, it was against the law to suggest that there was a relationship between the ingredients in a commercial food and the treatment or prevention of a disease.
Then, in 1984, came the Original Sin. That year, the National Cancer Institute lent its unparalleled credibility to the Kellogg Company when together they launched a campaign in which All-Bran cereal was used to illustrate how a low-fat, high-fiber diet might reduce the risk for certain types of cancer. All-Bran was the first food permitted to carry a statement that was interpreted widely as “Eating this product will help prevent cancer.” That led to the era of product labels, and completely changed the way Americans think about not only foods but dietary supplements and ultimately about their health. Food was no longer simply food; it was a way to get healthy. Some of those changes made sense: flour was fortified with folate; juice enriched with calcium; and in 2004, in the name of health, General Mills started making every one of its breakfast cereals from whole grains.
They were exceptions. It would require Dickens’s narrative skills and Kafka’s insight into bureaucratic absurdity to decipher the meaning of most products for sale in American health food stores today. In the world of alternative medicine, words have become unmoored from their meanings. As long as a company doesn’t blatantly lie or claim to cure a specific disease such as cancer, diabetes, or AIDS, it can assert—without providing evidence of any kind—that a product is designed to support a healthy heart, or that it protects cells from damage or improves the function of a compromised immune system.
It’s still against the law to claim a product cures a disease—unless it actually does. But there is no injunction against saying that a food or supplement can affect the structure or function of the body. Such claims can appear on any food, no matter how unhealthy. You cannot advertise a product as a supplement that “reduces” cholesterol, but you can certainly mention that it “maintains healthy cholesterol levels.” It would be illegal to state that echinacea cures anything, since of course it has been shown to cure nothing. But it’s perfectly acceptable to say that echinacea is “an excellent herb for infections of all kinds,” although no such thing has been proven to be true.
Even claims that are true are often irrelevant. Vitamin A, for example, is essential for good vision—as supplements for sale in any health food store will tell you. Insufficient consumption of vitamin A causes hundreds of thousands of cases of blindness around the world each year, but not in the United States; here people don’t have vision problems arising from a lack of vitamin A. Although statements advertising vitamin A for good vision may, like many others, be legally permissible, they are meaningless. And since too much vitamin A can cause birth defects and osteoporosis, for example, its potential to harm American consumers is far greater than the likelihood that it will do good.
Not long ago, I was given a free bottle of Lifewater at my gym. “It’s the perfect energy drink,” the woman handing it out said, “because it’s an antioxidant and nutritious. And of course, it’s water.” Except that Lifewater is not really any of those things. Water has no calories. My “Agave Lemonade Vitamin Enhanced Beverage” with natural flavors contained 40 calories per eight-ounce serving. That’s five calories per fluid ounce, a little less than half the calorie count of regular Pepsi, the signature product of the corporation that sells Lifewater. Even that number, of course, is misleading. Nobody drinks eight ounces; Lifewater comes in a twenty-ounce bottle, which brings the calorie count to 100.
Okay, 100 calories is not that big a deal. But the main ingredient in the drink is sugar: 32 grams in what many people assume to be vitamin-enriched water. And that is not the kind of water we need to be drinking in a country where one-third of adults are obese, 8 percent are diabetics, and both of those numbers are rising rapidly. Lifewater contains no meaningful amount of agave, lemonade, yerba maté, or taurine, all of which are listed invitingly on the bottle.
Lifewater is hardly the only beverage created, named, or designed to dupe people into buying the opposite of what they are looking for; it’s probably not even the worst offender. In January 2009, the Center for Science in the Public Interest sued the Coca-Cola Company in federal district court, saying that the company’s Glacéau division relied on deceptive advertising and unsubstantiated claims when promoting VitaminWater as a “Nutrient-E nhanced Water Beverage” and by employing the motto “vitamins + water = all you need,” for a product that has almost as much sugar in it as a similarly sized can of Coke. “VitaminWater is Coke’s attempt to dress up soda in a physician’s white coat,” the CSPI litigation director Steve Gardner said when he filed the law-suit. “Underneath, it’s still sugar water, albeit sugar water that costs about ten bucks a gallon.”
IT WOULD BE sufficiently distressing to know that the federal government permits unproven therapies to flourish in the United States. Through the National Center for Complementary and Alternative Medicine, however, it actually encourages them. Josephine Briggs is an internationally renowned nephrologist who has published scores of scientific articles in prestigious journals. She served for nearly a decade as head of the Division of Kidney, Urologic, and Hematologic Diseases at the National Institute of Diabetes and Digestive and Kidney Diseases before moving, in 2006, to the Howard Hughes Medical Institute, where she had been named senior scientific officer. Briggs is agreeable personally, scientifically accomplished, and widely considered a talented administrator. It would be hard to imagine a less controversial choice to lead a branch of the National Institutes of Health.
Her appointment as director of the National Center
for Complementary and Alternative Medicine in 2007, however, was not exactly greeted with hosannas. Many of her scientific peers regard the center as a distraction and a waste of money—or worse. (Indeed, NCCAM has been opposed since the day it was created, in part because of the way the center came to be: NCCAM is the brainchild of Iowa senator Tom Harkin, who was inspired by his conviction that taking bee pollen cured his allergies—a belief he has stated publicly before Congress. There is no evidence that bee pollen cures allergies or lessens their symptoms. For some people, however, it can cause life-threatening allergic reactions.)
Traditional scientists expressed hesitation about Dr. Briggs’s appointment, but those were doubts about the center itself, not about her ability to do her job. The CAM community, on the other hand, saw themselves saddled once again with a “conventional” scientist as its leader. “New NIH NCCAM Director Wanted: No Experience or Interest in Field Required” ran the headline of one influential health blog, The Integrator, when word of the Briggs appointment surfaced in 2007. (The previous director, Stephen Straus, a renowned clinical virologist, died of brain cancer. He had also been criticized for his lifelong commitment to science-based medicine.) After Briggs was appointed, The Integrator was even more direct: “Oops, They Did It Again,” the publisher, John Weeks, wrote early in 2008. In an open letter to Briggs he continued: “Director Zerhouni appointed you, despite the fact that you too have no visible professional experience in the field that you were selected to lead. Of your 125 publications, none appear to touch on the kind of interventions which will be on your desk at your new job. . . . Perhaps you can explain why the NIH would choose a novice, for the second time—it’s officially 2 for 2 on this count—to run one of its domains? The answers that come to mind, and which I have heard from colleagues in the last 24 hours, range from fear to ignorance to suppression.”
Briggs says she was prepared for opposition from both sides. It started the moment she told colleagues at the Howard Hughes Medical Institute about her new position. “Some of the criticism from conventional medicine arises from the usual sort of turf wars, and some of it arises from areas where there is genuinely some quackery,” she said. “However, I think that we can steer this portfolio to the more mainstream practices, and the things that arouse the alarm of people who have been my colleagues all my scientific life are mostly things that are not being used by very many people.” In her laboratory, Briggs has studied the effect of antioxidants on kidney disease, but she has never used alternative medicine, personally or in her practice. “I myself am not a supplement user,” she said. “Vitamin D and calcium is my read of the literature”—by which she meant that those two supplements have proven their efficacy.
That’s a sensible, fact-based approach to the current state of knowledge about dietary supplements. It is not, however, the “read” of the people who care passionately about CAM, including Senator Harkin, who established the center’s precursor, the Office of Unconventional Medicine, in 1992 with $2 million in discretionary congressional funds. The word “unconventional” didn’t sit well with the healing community, however, so the name was soon changed to Office of Alternative Medicine. Its mandate was simple: investigate treatments that other scientists considered a waste of time and money.
The first director, Joseph Jacobs, resigned under pressure from Harkin after he objected to including some nominees for the center’s governing council. One of Harkin’s choices had even endorsed the use of laetrile—perhaps the definitive quack treatment for cancer. (The laetrile movement, founded in the early 1950s by Ernst T. Krebs Sr., was based on the idea that a chemical found naturally in the pits of apricots could fight tumors. It couldn’t, yet many desperate people spent the last days of their lives believing it would.) By 1998, the NIH director, Harold Varmus, a Nobel laureate who combined unimpeachable scientific credentials with a sophisticated understanding of Washington bureaucracy, wanted to place the Office of Alternative Medicine under more rigorous NIH scientific control. But Harkin wasn’t about to let that happen; in a deft bit of administrative jujitsu, he managed to elevate the office into an independent research center within NIH.
That made the center even more suspect among scientists than it had been before. Briggs, like her predecessor, finds herself in an intellectually precarious position. In effect, she is like an attorney who argues that the guilt or innocence of her client is beside the point because everyone has the right to a defense. The defense most commonly offered in support of CAM is its stunning popularity—and popularity can easily be confused with reality. It happens every day on the Internet. Confusing popularity with authority is one of the hallmarks of denialism. People take comfort in becoming part of a crowd. The sense that complex issues can be resolved by a kind of majority vote, as if it was an election, helps explain the widespread support for CAM. It is also a reason the anti-vaccine movement has been so successful. Democracy rules. Millions of people take antioxidant supplements. That’s unlikely to change. So the argument for NCCAM suggests that whatever we think of supplements, their popularity requires NIH to face reality and understand how they work.
Science doesn’t operate by rules of consensus, however, and the NIH exists in order to discover scientific solutions to the health problems of Americans. Briggs understands that. “I think that there is a tension in this area, and I feel this as a practitioner—that while I’m comfortable in trying to reassure people, I’m not comfortable in fooling them. And you know, I think any physician is aware that some of the confidence you build in someone is part of helping them get better, and when is that being a confidence man? That tension is kind of inherent in healing practices. It’s interesting; it’s not easily solvable.”
Briggs has become fascinated with the causes of the placebo effect—how it works on a biochemical level, and why. That the mind can affect the chemistry of the human body is not in doubt, and researchers have shown direct relationships between what a patient expects from a drug and its therapeutic results. In one experiment, Fabrizio Benedetti, professor of clinical and applied physiology at the University of Turin Medical School in Italy, demonstrated that a saline solution works just as well as conventional medicine to reduce tremors and muscle stiffness in people with Parkinson’s disease. Benedetti is also a consultant for the Placebo Project at NIH and a member of the Mind-Brain-Behavior Initiative at Harvard University. In the Parkinson’s study, he and his team found that neurons in patients’ brains responded rapidly to saline. In another experiment, Benedetti has shown that for people who have no idea that a switch has been made, a shot of saline can provide as much pain relief as one of morphine.
Briggs smiled but declined politely when I tried to steer the conversation toward the potential merits of homeopathy. Based on her scientific credentials, I have to assume that’s because she couldn’t have had much good to say about the practice, but neither can she afford to enrage her advisory council, some of whose members believe in it wholeheartedly. Briggs has begun to push NCCAM, and the studies it funds, to focus more seriously on chronic pain. It’s an excellent idea, since pain remains such a pervasive problem and conventional approaches at controlling it have shown only limited success.
Yet when an arm of the federal government devotes more than $100 million a year to a particular kind of research it makes a statement about the nation’s health priorities. NCCAM has spent its money looking into everything from the use of qi gong as a way to treat cocaine addiction to Therapeutic Touch for bone cancer. “NCCAM is presented as a scientific vehicle to study alternative medicine’s anomalous methods,” Wallace Sampson wrote in “Why the NCCAM Should Be Defunded,” the first of many appeals to close the center. “But it actually promotes the movement by assuming that false and implausible claims are legitimate things to study.” As Sampson and many others have pointed out, while the center has demonstrated the “ineffectiveness of some methods that we knew did not work before NCCAM was formed,” it has not proven the effectiveness of a single alternative ap
proach to medical treatment.
That is because, uniquely among NIH centers, most of the research has been driven by faith rather than by science. D. Allan Bromley, a physicist who was science adviser to President George H. W. Bush, once said that NCCAM lent prestige to “highly dubious practices” that “more clearly resemble witchcraft than medicine.” Paul Berg, a Stanford professor and Nobel laureate in chemistry, wrote that “quackery will always prey on the gullible and uninformed, but we should not provide it with cover from the N.I.H.” And Ezekiel Emanuel, long the head of the department of bioethics at NIH, and brother of Rahm Emanuel, President Obama’s chief of staff, has published widely on the ethics of placebo trials and the use of alternatives. Highly implausible or impossible methods, such as homeopathy, “psychic (distant) healing,” Therapeutic—or Healing—Touch, and many other CAM claims are what Emanuel and colleagues have referred to as “trifling hypotheses,” and the ethics of pursuing them are shaky at best. “Comparing relative value is integral to determinations of funding priorities when allocating limited funds among alternative research proposals,” he wrote in the Journal of the American Medical Association.
Josephine Briggs and others at NCCAM may rely on the scientific method when assessing alternative therapies, but the man who founded the center certainly does not. In Senate testimony in March 2009, Harkin said that he was disappointed in the work of the center because it had disproved too many alternative therapies. “One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short,” Harkin said. The senator pointed out that since its inception in 1998, the focus of NCCAM has been “disproving things rather than seeking out and approving things.”
Denialism: How Irrational Thinking Hinders Scientific Progress, Harms the Planet, and Threatens Our Lives Page 16