Statement on SB 217, an Act Relating to Complementary and Alternative Medicine
Thomas J. Wheeler, PhD
Kentucky Council Against Health Fraud
February 27, 2003
Senate Licensing, Occupations and Administrative Regulations Committee
Chairman Tapp and Committee Members,
I am speaking on behalf of the Kentucky Council Against Health Fraud, a consumer protection organization affiliated with the National Council Against Health Fraud. I am also speaking based on my experience of teaching a course on alternative medicine at the University of Louisville School of Medicine for the last ten years.
We are opposed to SB 217, which would license and certify acupuncturists and naturopaths.
Concerning acupuncture:
Our first point is that it is premature to grant official recognition to acupuncture. Before we license or certify acupuncturists, we should ask the question of whether acupuncture is good for anything. The answer is, “we don’t know.” You may have heard from satisfied patients, and from acupuncturists telling of their success stories. However, such anecdotal evidence is notoriously unreliable. The placebo effect and many other factors can give misleading results (1). Only carefully controlled studies can tell us whether acupuncture works.
In the last few years there have been many reviews of the scientific literature concerning acupuncture. Time after time, the conclusion has been that there is not yet convincing evidence that acupuncture is any better than placebo treatment, as we document in the material provided to you (2). Even many leading advocates of acupuncture admit that there is not much for which it has been shown to be useful (3).
Three years ago, I testified before the House Health and Welfare Committee on a bill to license acupuncture, and made the same point, that acupuncture had not been shown to be useful. Last year I testified before another House committee and noted that in the intervening two years, in major medical journals, I found three new papers indicating that acupuncture might be useful for some conditions - but four new research papers, and two new review articles, indicating that it is not useful for various conditions. Now, since that testimony last year, I have found one new paper and one new review supporting acupuncture, but seven new papers finding that it did not work! The case for acupuncture seems to be getting weaker every year!
Acupuncture is being investigated within the scientific and medical research communities. Let’s wait until we see whether it is useful before we decide to give it the status of a new recognized health profession.
Our second concern is that the bill is not just about acupuncture; it is a bill to recognize the entire system of traditional Chinese medicine. It refers to “other therapies based on traditional and modern Oriental medical theory,” which often include false ideas about the workings of the human body, such as manipulating “energy” and removing “toxins.” We are particularly concerned about reference to the use of herbal remedies and nutritional treatments. Herbs are drugs, and are potentially dangerous (4). We should not allow people without medical training, and who believe incorrect ideas about how the body works, to prescribe herbal drugs. It is also unwise to allow acupuncturists to prescribe nutritional treatments, since they most likely will lack proper training in this field (5).
We might expect practitioners recognized under this bill to recommend Chinese herbal remedies. But to a greater extent than other herbs, Chinese herbal remedies have been found to be adulterated with genuine drugs, contaminated with toxic chemicals, and labeled in such a way that one cannot know what they contain.
Concerning naturopathy: this is an invalid and potentially dangerous approach to health care. Rather than being based on scientific concepts, naturopathy is based on outmoded, 19th-century ideas such as vitalism (6) Thus, naturopaths are likely to embrace unscientific ideas such as balancing the body’s “energy”; to be overconfident in the body’s ability to heal itself; and to consider “natural” remedies such as herbs superior to more scientifically based treatments.
The following are some of the reasons why naturopathy should be rejected (7):
• Naturopathy holds that many diseases are due to the accumulation of “toxins,” a scientifically invalid concept.
• Many approaches used by naturopaths are outright pseudoscience, for example, homeopathy and iridology (discussed below), chelation therapy, colonic irrigation, hair analysis, and some electrical diagnostic devices. Others may have some basis but have not yet been shown to be safe and effective, for example, acupuncture, some herbal remedies, and some nutritional supplements.
• When a naturopathic treatment produces adverse reactions, these are sometimes interpreted as a “healing crisis” caused by the “toxins” coming out. Taking such warning signals as a positive sign that the therapy is working is potentially dangerous.
• Naturopathy has a history of opposition to science-based medicine, and has discouraged childhood immunizations (8).
• Finally, many naturopaths see themselves as being able to treat effectively most health problems, and wish to take on the role of primary physicians. This is potentially dangerous since naturopaths lack the rigorous training of medical doctors. Indeed, there is a major group of naturopaths who realize that they are not prepared for such roles, and are opposed to licensure.
Some naturopaths use the “N.D.” degree, which is easily confused with “M.D.” In addition, S.B. 217 would add to the confusion by permitting licensed naturopaths to refer to themselves as “physicians.” If this bill is passed, it is likely that some citizens will consult naturopaths while believing they are being treated by medical doctors.
Two pseudoscientific approaches are specifically recognized in SB 217 as being part of the practice of naturopathy. Homeopathy holds that if a substance causes symptoms similar to those of a disease, extremely dilute solutions of it can provoke the body to heal itself. These solutions are often so dilute that they do not contain any molecules of the original substance (in fact, they are simply inert placebos). Homeopathy also says that the more dilute the remedy, the stronger it is. These principles contradict numerous findings in chemistry, physics, biochemistry, pharmacology, physiology, etc., and many research studies show that homeopathy does not work (9). The premises of homeopathy are so absurd that those who endorse it have shown themselves to be lacking in understanding of basic scientific facts and methods. Yet the leading naturopathic colleges include homeopathy as a required part of the curriculum - thus showing that naturopathy as a field is a pseudoscientific one, not deserving of admission into the health care professions.
Iridology is diagnostic method in which it is claimed that the iris of the eye can be used to diagnose conditions of organs throughout the body. This claim is inconsistent with scientific knowledge, and controlled studies have shown that iridology does not work (10). I was surprised to see iridology listed in this bill, because it is such obvious quackery; the fact that it does appear shows a serious lacking of medical knowledge on the part of proponents of this bill.
To be sure, naturopathy includes many positive aspects, and may provide some appropriate treatments and useful recommendations for diet and lifestyle. It is also becoming more scientific, and conducting useful studies of herbs and dietary supplements. However, these positive aspects cannot overcome the deficiencies which I have described. While naturopathy employs some valid approaches, these can all be provided by existing licensed health care professions. To create a new profession of second-rate doctors, who mix valid and invalid treatments, and who do not recognize their limitations, would be to undermine the cause of health care in Kentucky
Both portions of this bill work against the cause of improved education, which is one of the highest priorities of Kentucky Citizens, because the bill gives official recognition to ideas which are false. Traditional Chinese medicine is a collection of prescientific and mystical ideas which arose long before we understood the structure and function of the human body (11). SB 217 refers specifically to stimulation of “specific acupuncture points on meridians,” which are supposed to be channels for the flow of the life force called “qi,” but meridians do not exist. New acupuncturists will be required to pass an examination on these and many other pseudoscientific concepts - they would have to learn things which are not true! Similarly, training in naturopathic colleges involves instruction in pseudoscientific ideas such as homeopathy and “energy medicine,” as well as traditional Chinese medicine. The General Assembly has recognized the need for cutting-edge, 21st century research progress in science and medicine through the “Bucks for Brains” and other programs; we should not be turning back to the medicine of the 19th century or false ideas from ancient times.
Finally, we are concerned that licensure and certification of acupuncture and naturopathy will be just the first step. Practitioners will later demand to be included in health insurance programs. They will claim that the fact that they are licensed or certified shows they must be doing something useful. Then we will all be paying for treatments which have not yet been shown to be beneficial. We should not start down this road by giving official recognition to acupuncture and naturopathy.
In summary, the bill gives official recognition to approaches which have not yet been shown to be useful, and which are based on invalid ideas about how the body works. To lend credibility to these methods, and to grant practitioners the right to recommend herbal medicines, would threaten the health of Kentucky citizens and cause them financial loss. We urge you to reject this bill.
NOTES
1. As pointed out in an article by David W. Ramey, DVM, and Jack Raso:
...many patients swear by acupuncture. Whenever acupuncture does work, its efficacy probably stems mainly from a placebo effect. If this is so, it would explain the coexistence of occasional very satisfying clinical experiences and the deficiency of evidence from rigorous studies that is favorable to proponents. Evidence from well-designed studies is considerable that acupuncture's nonspecific effects are impressive. Counterirritation -- irritation that distracts the subject from another irritation -- due to needle insertion may be significant. (If one has a headache and hammers one's thumb, the headache may not seem so bad!) Scientific evidence that acupuncture treatment has effects not reasonably ascribable to a placebo effect or to counterirritation is lacking. (Priorities for Health, Vol. 11, No. 2, p. 36 (1999))
(This article may be seen at: http://www.acsh.org/publications/priorities/1102/acu.html)
2. In general, the better designed the study of acupuncture, the smaller the beneficial effects observed.
The following are some individual studies in which acupuncture was ineffective or no more effective than placebo or sham (fake) acupuncture:
• Irnich et al. (BMJ 322, 1574-1577 (2001)) - chronic neck pain (better than massage, but no better than sham laser acupuncture)
• Cherkin et al. (Arch. Intern. Med. 161, 1081-1088 (2001)) - chronic low back pain
• Leibing et al. (Pain 96, 189-196 (2002) ) - chronic low back pain
• Shlay et al. (JAMA 280, 1590-1595 (1998)) - pain due to HIV-related peripheral neuropathy
• Goddard et al. (J. Orofac. Pain 16, 71-76 (2002)) - myofascial pain
• Näslund et al. (J. Rehab. Med. 34, 231-238 (2002)) - knee pain
• Bullock et al. (J. Substance Abuse Treatment 22, 71-77 (2002)) - alcohol dependence
• White et al. (Arch. Intern. Med. 158, 2251-2255 (1998)) - nicotine withdrawal symptoms
• White et al. (Tobacco Control 8, 393-397 (1999)) - smoking cessation
• Margolis et al. (JAMA 287, 55-63 (2002)) - cocaine addiction
• Shenkman et al. (Anesthesiology 90, 1311-1316 (1999)) - nausea after tonsillectomy
• Knight et al. (Obstet. Gynecol. 97, 184-188 (2001)) - nausea of pregnancy
• Shapira et al. (Chest 121, 1396-1400 (2002)) - asthma
• Stavem et al. (Seizure 9, 422-426 (2000)) - epilepsy
• Johansson et al. (Stroke 32, 707-713 (2001)) - stroke rehabilitation
The following are review articles, with generally negative conclusions (acupuncture is ineffective, or there was insufficient evidence to conclude that it is effective):
• ter Riet et al. (J. Clin. Epidemiol. 43, 1191-9 (1990)) - chronic pain
• Ezzo et al. (Pain 86, 217-225 (2000)) - chronic pain
• ter Riet et al. (Brit. J. Gen. Pract. 40, 379-382 (1990)) - addiction
• Moon and Latessa (Evaluation and Program Planning 17, 217-226 (1994)) - addiction
• Mayer (Annu. Rev. Med. 51, 49-63 (2000)) - addiction
• Kleijnen et al. (Thorax 46, 799-802 (1991)) - asthma
• Park et al. (Arch. Otolaryngol. Head Neck Surg. 126, 489-492 (2000)) - tinnitus
• Cochrane Collaboration reviews: low back pain (1999); elbow pain (2002); smoking cessation (2002); menstrual pain (2002); asthma (1999); induction of labor (2002) (no trials met inclusion criteria)
Ramey and Sampson (Sci. Rev. Altern. Med. 5, 195-201 (2001)) reviewed 33 reviews and meta-analyses, 1990 or later, and concluded that “effectiveness could not be established with confidence for any condition studied.”
3. A much publicized National Institutes of Health Consensus Conference on Acupuncture in 1997 endorsed the usefulness of acupuncture for some conditions. However, some important points concerning this conference are:
• The conclusions are not official conclusions of the NIH; they are only the conclusions of the conference panel
• The panel included only supporters of acupuncture; critics were not invited.
• Despite the fact that it was made up of researchers who believe in acupuncture, the panel stated that the evidence in favor of acupuncture was clear only for certain types of nausea and pain.
• For many other conditions, they found that the data were less convincing.
• They noted that in general the quality of research in support of acupuncture was quite poor.
• They recognized that there are some studies which show no benefits.
• They found that fake or “sham” acupuncture often works almost as well.
Mayer (Ann. Rev. Med. 51, 49-63 (2000)) examined the evidence behind the conclusions of the panel, and found that for most of the conditions “there is little evidence that acupuncture is either effective or ineffective.” Furthermore, he concluded that “some conclusions of the [panel] are either misleading (i.e., the conclusions regarding postoperative dental pain, carpal tunnel syndrome, asthma, opiate dependence, cocaine dependence, cigarette dependence), difficult to interpret (low back pain), or supported by data insufficient to indicate other than experimental use (menstrual cramps, tennis elbow, fibromyalgia).”
4. The following are some of the dangers related to herbal remedies:
• Some people think that herbs are harmless because they are “natural,” but they are mistaken. Herbs are drugs! They can have powerful effects on the body, including dangerous side effects. For example, recent evidence indicates that the popular herb kava may cause liver damage, leading several foreign countries to restrict or discourage its usage. Herbs can also interact in dangerous ways with other drugs that a person may be taking. One of the most popular herbs, St. John’s wort, causes numerous other drugs to become less effective. A popular Chinese medicinal herb has been shown to have potentially dangerous effects for patients taking warfarin. Allowing acupuncturists not trained in medicine and pharmacology to prescribe such drugs is unwise.
• Many Chinese herbal remedies have been found to be contaminated with toxic materials such as heavy metals, or to be adulterated with regular pharmaceuticals.
• The contents of active ingredients vary widely among different preparations of the same herbal remedy (in many cases the active ingredients are not even known). This means that you can never be sure whether you are getting an appropriate dose, an ineffectively low dose, or a dangerously high dose.
• Even a single herbal remedy is a mixture of many compounds, resulting in complicated effects which are not well understood. The problem is much worse with many Chinese herbal remedies, which are mixtures of a variety of separate preparations (some of which are not even herbs, but are animal parts!). The descriptions of these are often quite poor (for example, general names which could refer to any of thousands of possible plant species, or Chinese names which could be interpreted as several different possible types of plants). So it will be likely that neither the patient nor the practitioner will know what is being given.
5. It is only in the last century that nutrition has been put on a scientific basis (with an understanding of the basic chemistry of the body, the composition of foods, the roles of vitamins and minerals, etc.). Scientific research continues to explore the importance of dietary factors such as antioxidant vitamins in the prevention of disease. In contrast, traditional Chinese medicine knew nothing of such things; indeed, it was not even aware of all of the important organs in the human body! For sound dietary advice, we should turn to physicians, dietitians, and other health professionals who have been scientifically trained in food and nutrition.
6. Vitalism is the doctrine that living things have distinct “vital principles” or “life forces” which lie beyond regular scientific understanding of matter and energy.
7. For further information on naturopathy, see:
General article:
http://www.quackwatch.com/01QuackeryRelatedTopics/Naturopathy/naturopathy.html
Naturopathic opposition to immunization:
http://www.quackwatch.org/01QuackeryRelatedTopics/Naturopathy/immu.html
Why naturopaths should not be licensed:
http://www.quackwatch.org/01QuackeryRelatedTopics/Naturopathy/licensure.html
http://www.quackwatch.org/01QuackeryRelatedTopics/Naturopathy/relman3.html
8. Lee et al. (Arch. Pediatr. Adolesc. Med. 154, 75-80 (2000)) surveyed homeopaths and naturopaths in Massachusetts. “Nearly all reported treating children, but fewer than half of the practitioners reported any formal pediatric training...Most practitioners reported that they did not actively recommend immunizations and fewer than half of the nonphysician practitioners reported that they would refer a 2-week-old neonate with a fever to a medical doctor or emergency medical facility.”
9. While advocates of homeopathy have presented some evidence, it is extremely weak. It is far more likely that some mistakes have been made in giving apparently successful results. Moreover, many papers showing no effects of homeopathy have been published. These include:
• Lökken et al. (1995) BMJ 310, 1439-1442: treatment of pain and other events after oral surgery
• Hart et al. (1997) J. R. Soc. Med. 90, 73-78: postoperative recovery in hysterectomy
• de Lange de Klerk et al. (1997) BMJ 309, 1329-1332: children with respiratory infections
• Walach et al. (1997) Cephalogia 17, 119-126: chronic headaches
• Whitmarsh et al. (1997) Cephalogia 17, 600-604: migraine.
• Smolle et al. (1998) Arch. Dermatol. 134, 1368-1370: treatment of warts
• Fisher and Scott (2001) Rheumatology 40, 1052-1055: rheumatoid arthritis
• Lewith et al. (2002) BMJ 324, 520-523: asthma
Reviews which gave negative conclusions (homeopathy is ineffective, or there is insufficient evidence to conclude that it is effective):
• The Homoeopathic Medicine Research Group, a European expert panel: general review
• Cochrane Library (1997): asthma
• Ernst (1998) Arch. Surg. 333, 1187-1190: meta-analysis of studies on the most frequently used homeopathic remedy, arnica
• Ernst (J. Pain Symptom Manage. 18, 353-357 (1999)): headaches and migraine
• Prescrire Int. 10, 24 (2001)): prevention and treatment of influenza
For further information on homeopathy, see:
http://www.quackwatch.org/01QuackeryRelatedTopics/homeo.html
10. Controlled clinical studies, using iris photos, showed that iridologists were unable to detect disease:
• Simon, Worthen, Mitas (1979) - controls and kidney disease patients
• D. Cockburn (1981) - before/after photos of subjects with acute disease.
• P. Knipschild (1988) - gallbladder disease patients
Iridologists may make some apparently successful diagnoses, but this could involve the technique of "cold reading," such as employed by fortune-tellers, in which a combination of educated guesses and feedback from patient are used to give the impression that the reader has access to hidden information.
For further information on iridology, see:
http://www.quackwatch.org/01QuackeryRelatedTopics/iridology.html
11. The system of traditional Chinese medicine, which is given official recognition in SB 217, includes some of the following features:
• It is based on the flow of qi, a type of “life force” which is unknown to science. While it is often translated as “energy,” its true origin is related to concepts of “wind” or “vapor”; it has nothing to do with scientific concepts of energy. Supposedly qi not only moves through the body, but also flows in and out of the body between heaven and earth.
• Qi is claimed to flow through channels called meridians, but there are no such anatomical structures (and practitioners of Chinese medicine cannot agree on how many meridians there are).
• In addition to qi, the body is thought to be made of “moisture” and blood, with illness related to congestion or depletion of one of these.
• An imbalance resulting in disease can also be caused by the “pernicious influences” of wind, cold, fire, dampness, dryness, and summer heat.
• There is a complex system of five organ networks, which are related to the elements wood, fire, earth, metal, and water, and also to the five planets Jupiter, Mars, Saturn, Venus, and Mercury.
• In order to complete a symmetrical table of six yin and six yang organs, the Chinese invented an organ which does not exist, the “triple warmer.” However, they did not recognize the importance of the pancreas.
It is obvious that these ideas were the kinds of guesses that people could make about the body and health thousands of years ago. Since that time, scientific research has revealed in increasing detail the way the body actually works, and the real causes of disease. We can see that the principles of traditional Chinese medicine are not correct and do not provide a rational basis for medical care.
These comments should not be taken as prejudice against Chinese culture. People all over the world have gone through pre-scientific stages when they attempted to explain the causes of health and disease. European medicine has had its share of ideas which we have now discarded. Modern scientific medicine is not “Western medicine”; it is universal. The very best physicians from China and other countries all share a common framework for dealing with human health.