A Radical Suggestion

Like some of my posts from time to time, this is somewhat of a polemic meant to stir up debate. The issues are complex and both liberals and conservatives tend to be stubborn in their ideologies. So here goes...

In order to solve the health crisis of the uninsured, several factors must be addressed. First and foremost is healthcare delivery. Given the thrust of politics in this culture for the past 30 years, I think it highly unlikely that we will be seeing anything resembling a national healthcare service anytime soon. While the evidence when assessed neutrally shows that national healthcare result in fair distribution of service and little actual delay of vital care, there is just no will for another government program of this sort. With plans to dismantle social security, I hardly see a Canadian system in the works for healthcare. Some might say this is giving up the ship too fast. But at what point does one stop fighting the enemy, read the writing on the wall and try and get some work done.

The republicans have managed to barely pull off two election victories. They certainly have no mandate to act on behalf of the religious right despite current media rhetoric. But they are in power and the majority of Americans favor their fiscal policies on taxes and federal power. So we are about to embark upon a social experiment quite different from that of Europe over the past 50 years. It is possible that we will descend into a backwards theocracy, but only if we let it happen. There may be a third road between the theocratic right and the anarchistic left. That would be the restoration of the progressive libertarian republican party. Sort of a mix between Teddy Roosevelt and Barry Goldwater and Abraham Lincoln.

Since the republicans are in power, all democrats who share important common beliefs should consider switching parties, including sitting members of congress. Rather than try and win back the congress for the democrats, perhaps moderates and libertarians should just attempt to wrest control of the republican party for themselves, the true American majority. This indeed is the hope of many moderate republicans with whom I have acquaintance. We can either have a true ownership society as Mr. Bush has recently proposed or a blatant power grab by those who are already rich as many fear. But moderate democrats will really have to consider what issues are most important to them and how to best accomplish those goals. Many republicans are pro-choice, anti-militaristic, pro civil rights, environmentalist, free speech advocates. The reason they are republicans is because they see less harm to society from the religious zealots in their own party than they do from the equally zealous interest groups of the democrats. The majority of Americans will never join with the left. But the majority of Americans could insure the republicans party is a libertarian majority instead of a moral majority.

So how does a society care for its poorest without a vast government safety net. Well, it would be true that if everyone owned property, then they would be far less likely to ever need government help. The value of property over years and generations is immense. Property provides equity and collateral which equal security. If everyone had access to the resources that come with property ownership, many other issues would be moot, such as how to pay for health insurance. With no need to provide extensive government services to the poor and elderly, taxes on state and federal levels could be cut to bare bones. So the question is where does this property come from and how does it get in the hands of the poor? Hint: its not stocks.

A solution proposed by the Libertarian party is to sell off (at a nominal cost) federally held lands in homeowner sized plots (not corporate sized chunks for development). The federal government holds a huge amount of land and does not manage it well. They are responsible for much of the pollution in the country. We should finish the promise of the homestead act and give every American the right to own property. Sounds almost communist, but it was 19th century Americans who wrote it. Giving everyone a parcel large enough to raise a family would barely put a dent in current land holdings. And homeowners would steward the land well, no doubt better than the feds. With the playing field finally leveled once and for all, we could move forward into a Libertarian utopia, where everyone has the money to become educated and the time to ponder the important decisions of the electorate. At that point and only at that point will we have a true democracy in America.

In a completely market based healthcare system with no insurance, there would be competition for all healthcare services without government interference. Libertarian republicans generally favor free trade in herbs and minimal licensing laws. In other words, rather than increasing the barriers to practice with added titles and supposed prestige, the Libertarian solution would be to let anyone practice and educate the buyer to beware. As mentioned previously, voluntary systems of regulation could always be established if there was a true market demand (which I believe there would be). Education will replace regulation as the main executive task of the government. Competition and lower taxes will make all services more affordable. Some might predict a public health disaster if the government doesn't keep a tighter rein on things. Buts lets get real. What could be a worse disaster than the current 67% obesity epidemic. Our healthcare system has failed to deliver health, perhaps because it has failed to offer adequate affordable options.

There is little or no chance that we will ever have universal nationalized healthcare . Since the current system of regulations has not controlled costs nor allowed a true market system to develop, we also really have yet to see what would happen if we allowed the market to actually sort these things out. The argument that the market does not fairly distribute healthcare is a specious one when no such system has been used in the US for over three quarters of a century. Given that we often heark back to those simpler times in our hearts and souls, perhaps we should reconsider their economic models as well. The welfare society was started because so many indigent people were suffering so intensely. Yet so many still suffer after all this time. It is reasonable to ask whether things would have been different if all those indigents had been given some property that would have accrued in value rather than just checks to be spent hand to mouth? I bet it would have cost less .... in so many ways.

The Herbal Minefield - Oh My!

According to Stephen Barrett in his quackwatch article called The Herbal Minefield,

Herbal advocates like to point out that about half of today's medicines were derived from plants. (Digitalis, for example, was originally derived from leaves of the foxglove plant.) This statement is true but misleading. Drug products contain specified amounts of active ingredients. Herbs in their natural state can vary greatly from batch to batch and often contain chemicals that cause side effects but provide no benefit.

While plants do vary in the amount of their active constituents, they can be measured and extracted at consistent levels for those who insist on such things. As for the issue of unnecessary side effects from extraneous biochemicals, there is actually evidence that the "undesirable" compounds in herbs often augment or enhance the therapeutic activity, sometimes minimizing side effects. This is discussed at some length by Simon Mills in his Principles of Phytotherapy.

I was prepared to take Dr. Barrett to task for his positions, but in the end analysis, all he is really arguing for is standards regarding labeling and potency. I also oppose current labeling laws. The current situation allows corporate herb makers to bypass the healthcare professional and make their pitch directly to the consumer. Somewhat analogous to selling drugs on TV. The argument is the same. That consumers would have otherwise been deprived of vital health information. In fact, they are more often deprived of a necessary professional consultation and the only ones who benefit are stockholders. However I do not wish products to be pulled from the market. I think libertarians can live side by side with liberals when the only harm is to oneself.

As long as there is a market for controlled and regulated products, they will be made. But the free market should exist side by side, if for no other reason than to prevent a black market. The government should endorse voluntarily regulated products and educate the public to only buy unregulated products at their own risk. That should be sufficient for adults to protect themselves in a democracy. The same goes for herb potency. Set up a voluntary scheme. If I want to take risks and eat raw ginseng like carrots, so be it. Others might want some kind of lab test on the side of their bottle while I might judge mine by sense of smell. People just need information and then they can act accordingly.

Fact is some (perhaps many) will want to use government controlled products at least some of the time. I occasionally take an aspirin and I am glad I can trust it to actually be acetosalicylic acid. Now others might want to take a risk and get their antibiotics south of the border, but I'll trust the feds on this one. Served me well so far. This model of voluntary regulation already exists to some degree. For example, if you want a cheaper car, go to a state where they don't have lemon laws and the additional costs they add to a car. Or buy it from a private party. In both cases, you have no recourse after the sale is made. But if a cheaper price is worth the risk, that's fine as long as no deception was involved. I see no reason why a fully informed person can't kill themselves with herbs if they want to. We don't stop people from eating sugar or skydiving. Yet for some strange reason, we draw the line at the true scourge of the universe, plant consumption (for either medicine or pleasure). That good ol' American contempt for mother earth and her offspring is just all encompassing, it would seem.

The Politics of Healthcare Delivery

A comparison of the US and Canadian healthcare systems shows about equal costs and patient satisfaction when comparing insured americans with all Canadians. While one hears anecdotes about the long wait lists for certain procedures, the evidence suggests that this is not an actual issue affiecting morbidity and mortality. In addition, many of the expensive procedures that require long waits are procedures that would be largely unnecessary if the average citizen took better care of themselves. For example, how much heart surgery would be necessary if people ate right and exercised regularly? I have always been somewhat on the fence about socialized medicine. Here is the classic libertarian rebuttal. Nevertheless, the fact remains that 40,000,000 Americans are still uninsured. And when you factor the responses of the uninsured into the comparison, the US fares poorly. So when some pundit says that the American healthcare system is superior at timely delivery of services, this latter group must be left conveniently out of the equation. And then this latter group still utilizes emergency services footed by the taxpayers, services far more expensive than offering insurance to all these folks in the first place.

Some economists have thus argued that in highly technical matters like health care the free market fails as one group, the doctors, have far more knowledge than the patients. In Canada the government professionals are also experts in the field and thus, the argument goes, fairer rates are set. I had never really looked at it that way. Basically, the government, as a true representative of the people, negotiates on the behalf of their clients. Perhaps the American distrust of socialism is not only rooted in irrational residual mccarthyism. But also because our government has not been trustworthy to so many for so long. That is not the experience of Canadians who, with good reason, have largely trusted their politicians to be honest and work in their best interests. I think that's what's the founders actually meant by "we the people". So, if the rest of the developed world delivers healthcare in a fashion completely different than us, is it possible we are wrong or, dare I say it, that our government is not a truly representative one? Maybe if American politics was not so debased by corporate dollars, the politicians would actually suport a true citizen's agenda. It might be Libertarian or socialist or green, but we know for sure it would not be either republican or democrat.

Many in the field of acupuncture are basically apolitical, having more of a self-described spiritual orientation and a general disdain for worldly battles. Ironically they find themselves not in the midst of some blossoming new age, but rather in a profession engaged in a fierce battle for legitimacy and a piece of the American pie. Thus the rank and file are torn between open minded liberals and free trading republicans. Openminded liberals are often willing to consider alternatives to the norm. But typically with a hefty price tag in the form of excessive regulation. Republicans in the heartland are generally suspicious of the new and possibly satanic pagan arts, yet they are strong proponents of minimal licensing and obstacles to trade. With huge loan debts and the possibility of large incomes, many of those who begin Acupuncture school as starving liberals are fiscal conservatives after a few years in practice. This leads more and more in the field to support Republican fiscal policies purely for the issue of low taxes and unregulated herb markets. Yet the healthcare crisis is left unaddressed and many of those who entered the field of Acupuncture to make things better end up being part of a broken system no closer to being fixed. Clearly a partly regulated system does not work. We either need to try a true market approach or become completely socialized. Compromise and tinkering makes no one happy and clealry just results in endless spirals in costs. Its time to set aside cold war rhetoric and construct a true solution to these seemingly intractable problems.

Fuzzy Logic and Medicine

For those who want to read more about fuzzy logic and the intersection of 21st century medicine, there is huge collection of articles at Ray Kurweil's site. For the uninitiated, you might want to start with this interview first. Kurweil is a technology pioneer with quite a few real world accomplishments under his belt and a pretty good track record as a futurist. Kurzweil's theory is that technology will solve most medical problems and be able to extend life in about a quarter century. By century's end, he predicts some type of immortality will be possible, likely as a result of nanotechnology. He proposes a concept of a bridge to a bridge to a bridge. The first phase involves doing everything we now know leads to increased health and longevity (via nutrition, stress reduction and exercise). The second involves biotechnology such as stem cells and cloned organs. The third involves nanotechnology, the inevitable merging of man and machine. Inevitable according to Kurzweil, intriguing to me as a sci-fi buff and no doubt downright scary to others.

Phase one is the best we can currently do and the best way to maintain any upgrades we get along the way. The idea is that if one stays alive long enough, then phase 2 or biotech will be in high gear. This will allow rejuvenation therapies previously unknown. However, it will not be until the perfection of nanotechnology that complete repair of all cellular damage will be theoretically possible (plus so much more). Now this is where it gets really interesting to a futurist. The key to both biotechnology and nanotechnology is fuzzy logic. In both cases, we are talking about controlling the control systems of the body. The control systems of the body involve a network of immunological, neurological and endocrine mechanisms. In Chinese medicine, the main meaning of the mysterious term qi actually refers to nothing other than the various functions that maintain homeostasis (spleen qi is largely the function of digestion, for example, while lung qi is largely the function of respiration). When dysfunction occurs at this level, it is called a root disharmony and treatment is to restore function (or qi) of the internal organ networks.

Modern physiologists are well aware, just as were ancient Chinese doctors, that disease begins to take root first as a failure of some major physiological control mechanism. In autoimmune disease, the normal inhibitory components of immunity fail. In cancer, the normal surveillance function of the immune system is overwhelmed and single mutations multiply and become strong. Free radicals are not adequately cleared from the system, damaging blood vessels and promoting inflammation. Dietary factors, stress, drugs alter hormone and neurotransmitter levels leading to assorted gynecological and psychological problems. The list could go on. Western medicine has experimented with hormones and psychotropics to treat many "control" mechanism disorders. But such therapy has never proven curative to any major illness and side effects are typical with any such therapy. However, the model up until recently has begin one of linear precision. But the body does not work according to the sum total of all its chemical reactions. It works according to a more complex series of relationships between all the chemical reactions. In other words, you can't just add it all up and spit out a useful result. It takes some framework in which to organize the data. It is turning out that the organizing framework of animal physiology has much in common with fuzzy logic than simple arithmetic. The corollary of this observation is that controlling the control mechanisms will depend on a much more sophisticated approach to all this fuzz.

So here we are at an interesting crossroads. Western science needs to understand the fuzzy logic of human physiology in order to exert control over the endless molecules it has so painstakingly detailed. Chinese medicine, which has embraced fuzzy logic for millenia, may have much to offer in this regard. Chinese medicine has defined the fuzzy parameters of human physiology and pathophysiology in quite fuzzy terms. This fuzzy approach to physiology is already helping to build the first bridge Kurzweil describes by enhancing human health with all known means. But does TCM have anything to offer in the biotech and nanotech revolutions predicted by some. I personally have never believed a low tech form of chinese medicine would ever come to dominate modern healthcare. I think a small segment of the populations was once romanced by this idea, but it hardly holds any currency in the mainstream. People like to have option other than western medicine in this transitional period, but I think most believe that science will prevail. That means that the great advances in medicine will still come from within the mainstream. However it is quite possible that chinese insights into the fuzzy logic that is responsible for maintaining homeostasis (or zheng qi as TCM docs call "correct function") might prove useful in getting those stem cells or nanocytes to work properly. Even if the latter "bridges" are just a pipe dream, the nature of fuzzy logic as it is used in TCM will still provide important insights into the nature of human physiology.

Recent Chinese Research

The Journal of Chinese Medicine, which is published by Pacific College of Oriental Medicine, prints abstracts from the English language Journal of Traditional Chinese Medicine (JTCM), published in Beijing. Titles of all abstracts reprinted in the last 12 years are available at the JCM website. In the February 2004 issue of the Journal of Chinese Medicine (JCM), I noticed that most of the research summarized appeared to be quite high quality on paper. Studies typically included matched and randomized control groups, lab tests were often performed and in many cases, patients were subcategorized according to both Chinese (TCM) and western medical diagnoses (so, for example, one might see a diagnosis of Parkinson's due to Liver and Kidney Yin Vacuity).

Despite this effort to recognize TCM pattern differentiation in selecting the treatment, results were not typically reported according to these subgroups. So the report would tell us that X % of patients got well, but not whether treatment is more effective for those hypothetical Parkinson's patients diagnosed as Kidney Yin Vacuity versus those diagnosed as Phlegm-Wind. Consider a scenario where all the Kidney patients do well, but only a few of the Phlegm patients do. Yet the success rates are reported for the entire group. This obscures certain conclusions that might be made. While it would be anathema in TCM to do the following, western medical research, with its disease orientation, would be inclined to see how the Phlegm patients respond to the Kidney formula. That would seem perfectly logical to a westerner , but unethical to a TCM herbalist who would claim that the Kidney tonics would worsen the Phlegm and thus the Parkinson's.

So there are still gaps that must be bridged, but at least Chinese researchers are meeting their western counterparts halfway by applying the gold standards of modern research in recent studies. This is how paradigms shift. So-called "normal science" is confronted with evidence that does not quite fit, in this case the fuzzy logic of TCM diagnosis. By engaging modern science on its own terrain, TCM researchers can open a dialog that is sure to be fruitful for the further development of both science and medicine. The concept of fuzzy logic has not yet gained currency in medical applications, though it has already proven useful in a variety of other technological and analytical applications.

Basically, fuzzy logic is the term used to describe systems that are not defined by absolute parameters. Western medicine has opted for precision as it has evolved and largely dispensed with all that was fuzzy (EKGs and lab tests replace stethoscopes and observation as the final arbiters of illness). Yet in the race towards precision, we have overlooked the potential value of fuzziness that had developed in the medical systems of the ancient world for millennia. A holistic worldview must embrace both the fuzzy and the crisp or it is not whole. The adaptive solutions of the human mind are myriad and it would be hasty to ignore those adaptations that predate modernity by thousands of years. But to be clear, the gift of the ancients is not only their techniques, but also their ideas, fuzzy as they may be.

the superior physician

It was reported in the Lancet last month that over 100,000 Iraqi civilian deaths had occurred in the 18 months since the war started. The Lancet is a prestigious medical journal with one of history's finest reputations for exacting peer review. Their publication of this study immediately suggests it was done with rigor. However, given the political climate on the days the study was released (10/29/04), due consideration must be given prior to drawing any conclusions. I began with a benefit of the doubt that their methodology was sound. However that is certainly a matter for dispute. Fred Kaplan writes in Slate that the number could be "20,000 or 25,000, maybe 30,000 Iraqi civilians killed in a pre-emptive war waged (according to the latest rationale) on their behalf. That's a number more solidly rooted in reality than the Hopkins figure—and, given that fact, no less shocking." Now I am not sure what authority a journalist has to dispute a peer reviewed science journal, but his deflated conclusion isstill shocking indeed. To be clear, a conservative estimate is that as many as 30,000 or more innocent bystanders, mostly women and young children (not adolescent jihadis) have been killed a direct result of combat activities in the past 18 months. They are what is called collateral damage. Whether one accepts the low number or the high number, it is definitely agreed that this is an "excess" directly due to military activity.

One can argue that many of these people would have died or suffered anyway under the previous regime. That those who remain as well as all the rest of us will be better off in the long run. But all that is speculation. All the evidence suggests for now is that the activities of the coalition forces in Iraq have led to far more deaths than would have otherwise occurred. In addition, the quality of life under constant siege, with only sporadic water and electricity for over a year must be maddening to a largely middle class society, most oif whom are more highly educated than their American "liberators". Setting aside the issue of whether the world is better off this way or that way, I think those who are involved in healthcare need to ask themselves a more pressing question. What is the appropriate ethical role of the healer in wartime? In the yellow emperor's classic from ancient China, the student is taught that the superior physician does not solely treat diseases or even patients, but also seeks to heal the societal dysfunctions that are so often at the root of many illnesses through teaching the correct way of living (a prescient tale about combatting the effects of stress in the "modern" urban world of han China). Thus the tradition of Nourishing Life developed, a topic still given a thorough introduction in the most modern texts used in Chinese medical schools. But is that enough?

Here in the west, there is a certain ethic that has evolved regarding the role of the doctor. In one characterization well known from popular media, there is Alan Alda's rendition of Hawkeye Pierce on the long running and critically aclaimed 1970's sitcom, M*A*S*H. Hawkeye is the quintessential doctor who sees no distinction between friend and foe when medical care is necessary. He is a heroic character who has such impressive surgical skills that he gains a certain latitude in his otherwise poor behavior. He is constantly in conflict with the bumbling Frank Burns. Burns, the brainless ultrapatriot, who couldn't operate his way out of a paper bag would gladly watch a man die just because he was unsure of his political affiliation. There was a time when those who chose to become doctors wrestled with these issues of War and ethics. Organizations like Physicians for Social Responsibility and Doctors Without Borders implicitly promote an agenda where Doctors should be abhorrent to human suffering in all its forms and always work to resist and correct it. That it was more incumbent upon those involved in the healing arts to think twice and even thrice about the implicit or explicit support of any action by a person or government that led to immense human suffering, regardless of the supposed end. Amongst politicians, one can perhaps try and justify the means by the ends, but not so in any profession that would even feign to be one steeped in ethics. When in doubt, it never hurts to remember the most basic of basics and then its pretty much a no-brainer. First, do no harm.

Acupuncture or Quackupuncture

Before proceeding on with my critique of Barrett's article on herbs begun in the last post, I want to address the mention made of the same author's quite damning Quackwatch Acupuncture Article. In that article Barrett dismisses not only the current state of acupuncture research but also the philosophical underpinnings of oriental medicine altogether. He references a couple of articles from the Skeptical Inquirer to further buttress his case. One is on pseudoscience in China. It unfairly lumps together all forms of Chinese healing techniques. A more balanced critique from within the profession discusses the effects of the well known historical decline of acupuncture and the effects of that decline. Another is an oft referenced article by an MD named George Ulett. Ulett is actually a proponent of the type of neural stimulation achieved with acupuncture, he just dismisses all traditional theory as useless. However just becuase acupuncture can be practiced effectively without resort to traditional theory, it must be pointed out that studies that show this also show the success of acupuncture when purposely using traditional theory. Wouldn't it be just as true to say such a study proves one does not need modern science to practice acupuncture. Such a studies actually seem to show that both modern science and classical chinese theory are both effective at developing treatment strategies. I think all parties are eventually going to have to come to terms with this repeated finding.

The preliminary results of a large German Acupuncture Study hit the news in Europe last winter. It was a hotly debated topic on a professional forum I moderate as part of the Chinese Herb Academy. The study seemed to show that so-called sham acupuncture was equally effective as "real" acupuncture. Sham acupuncture involves the placement of needles on points that were not traditionally mapped in the "classics". However there are some serious questions about this study.

What are we to make of so-called sham acupuncture. On one hand, acupuncture works, but it doesn't seem to matter where you stick the needles. On the other hand, I assume the patients thought the tx was real. What would happen if you told the patients the experiment was to see if they could bear torture. I wonder if the results would be different. If acupuncture works regardless of points selected, but only if the patient believes they are receiving a therapeutic procedure, we are in a bind. It is illegal to administer placebos and pretend they are therapy. And if we spill the beans on the sham, then it won't work anymore.

The study did not show that acupuncture was ineffective. It worked quite well for most patients. Basic TCM
worked phenomenally. Much better than placebo or glorified relaxation. But sham acupuncture worked just as well in a small cohort of 900 that were examined for this effect. Using a supposedly more sophisticated style of acupuncture would not have changed the fact that sham acupuncture had a very high effectiveness rate. Rather than showing we need a more sophisticated style is necessary to make CM work, this study is being interpreted as showing that it does not matter at all what you do. It works regardless.

--- In chineseherbacademy@yahoogroups.com, "anonymous"
wrote:
> 1) has any investigation shown that greater education (many courses) gives
better clinical results?
>
> 2) IF sham is equal to "real" in double blinded investigations, then we should
look if results in the clinic (non-blinded) are better that blinded.


I think people are missing the point. By western medical standards, the results of this study were phenomenal. It did not show that regular and sham acupuncture both were equally ineffective. It showed they both were amazingly effective. Far more effective than placebo in all cases and even better than WM in others. If one included better educated practitioners (px) or studied real clinical patients, it would be hard to get better results than those already reported. But even if that was the case, it would still not negate the significant results that came from sham acupuncture. It would only show that trained acupuncturists could do a little better in the clinic than newbies involved in research. But if you think about it, that is a given in medicine. Individuals in a clinic can always do better than the controlled research. Clinic maximizes placebo effects. However research equalizes and averages differences in skill and training and intellect. It tells you what the average patient with the average px can expect. And remember if some px fall above the average, just as many fall below.

--- In chineseherbacademy@yahoogroups.com, "anonymous"
wrote: This is because we cannnot be certain (in advance) that the "Non-Active" points really
> are that. As many on the lists have said, any stimulus anywhere
> on the body can have some effects.

The fact that the results of either sham or regular acupuncture are far better than placebo proves that something "active" is going on in either case. It never occurred to me that this is merely the same as the placebo effect. but I
think you missed the point of my concern. It is not that sham points are inactive. I agree with you that this is a misleading terms. However, if one can get not only decent, but excellent, effects regardless of where one places
the points, then it does suggest that that traditional theory does not matter in this process.

One would still need to needle the patient, so some training in anatomy and technique and medicine in general are still necessary for this process. It could not be performed by a monkey. However, it is interesting to hear about non-insertion needling at the same time as we discuss this study. I would assume that non-insertion needling would be considered a sham approach to stimulating the points by most medical researchers. But it maybe is the case that all such approaches are "active"; it just does not matter which one you choose. The sham acupuncture must have been done by those who knew they were performing a sham, while regular acupuncture was done by believers. This should have skewed the results even more in favor of regular acupuncture. The fact that sham did just as well under these conditions suugests that the action is much more than placebo.

I do also consider placebo to be a true physiological response. If the physiology changes, it is real. Under controlled circumstances, placebo is low (30%) but jumps to as high as 90% for some conditions in a private clinic. It is no doubt the care of the doctor that also heals. So how much education is necessary to practice medicine and who gets to do it? Medicine is major financial drain on our society and if much of it can be performed with LESS training, than we should be thankful and move on.

--- In chineseherbacademy@yahoogroups.com, "anonymous" <> wrote:
"Patients were allocated at random to one of three treatment groups:
> real acupuncture plus standard medical care; sham acupuncture
> (needles were simply stuck into non-acupuncture points) plus standard
> medical care; or standard medical care alone."
Seems that 'standard medical care' should be consider part of the
> equation.

How does this change the results? One way to balance variables in a study is to include the normal mode of treatment for each group. Standard treatment has powerful placebo effects because it is the cultural norm. If standard treatment is not given to each group, then it may appear that standard treatment (tx) is far more effective than alternative tx. this study shows how much better people do with sham or real vs. no acu at all. are you suggesting that the standard care somehow affected the sham group differently than the real group? In addition, I assume standard care meant things like antiinflammatories, exercise and traction, which I would expect all our patients to be doing anyway. so this may be realisic since most patients seek out either WM care or both WM and CAM. very few (4% according to a harvard study) use only CAM .

"So do the German mega-studies suggest effectiveness or ineffectiveness? Apparently, there is less room for interpretation than one might think. One of the German investigators, Professor H J Trampisch from Bochum University, recently provided the answer. When asked whether these results demonstrate the success of acupuncture his response was decisive: "No, this cannot be. In our studies, we clearly determined that acupuncture will be deemed effective only if it is significantly superior to sham acupuncture. If this is true, the
biggest trials in the history of acupuncture might be the beginning of the end of this therapy."

We need to either do better or prove the studies flawed when they are finally published. If it turns out that doing certain styles of acupuncture can reliably give results more on the order of 95% or better for some complaint, then we may have a case. At least if the medical acupuncture fails, they would know where to refer. But we have to reconcile to the fact that europe is a socialist union and decisions about things like acupuncture are going to be made on a centralized cost benefit analysis. Canada and australia and new zealand will follow suit. Even more american insurers and workers comp will drop acupuncture services from coverage. The clock is ticking. Research or politics. We especially need herbal research as this is where are bound to have great success and thus preserve some foothold.

Basically I figure there are two groups of people. those who are waiting for evidence before they use or refer for acupuncture (that would be the 97% of the population that does not currently use acu). And the other 3% who out of either desperation or philosophy have chosen to give acupuncture a try. However, of the latter group, only the diehard believers are likely to keep coming when the evidence suggests the procedure is a sham. I would submit that this group of true believers is minute. The fact is that we have been sitting with heads in the sand again. We have assumed that our personal anecdotes and clinical experience would be enough to prove to our patients that acupuncture worked. We have spent a decade making arguments why we don't need to do research, why it doesn't apply to us, why its not fair to judge us on this standard, as if western culture was just going to disappear. I think our patient support, such as it is, is quite flimsy in reality. I think we have been given the benefit of the doubt by some in the absence of evidence to the contrary. It has been suggested that all we need to do to keep progressing is to keep parading our happy patients in front of legislators.

Once upon a time a lot of happy patients and docs loved a procedure called mammary artery ligation. It was the main procedure for angina in the fifties. Everyone thought it was highly successful. However a carefully designed
study proved that a sham operation that merely left a shallow scar without actually opening the chest and ligating the artery was actually more effective than the procedure itself. Doctors and patients screamed bloody murder, but in a few years, the procedure had all but disappered and was never heard from again. Pay attention to politics. The memory of the public is short and flawed. Put on the news that acupuncture is a sham and in a few years, most folks who got relief from needles will be claiming it was all in their heads. It also makes me wonder what kind of lawsuits this open for the huge number of patients who have spent a lot of money on acupuncture without success, especially if the px made any claims of success rates prior to treatment. For example, many peole put the WHO conditions apporved for acupuncture on their literature. This could easily be called a false advertising claim as none of these claims hs any proof to back it up.

fMRI's show that some acupuncture points affect specific brain areas and nearby sham points do not. This is reported by Kaptchuk in the Annals of internal medicine in 2002. He also reports and cites that the impossibility of blinding the acupuncturist plus other factors results in acupuncture studies exhibiting a high placebo effect which may make it impossible to distinguish between sham and actual intervention. Given that normal placebo rates are 30% and that sham points may cause some generalized endorphin response on top of this and that failure to blind the px results in another increment of placebo, it is easy to see how even sham acupuncture would have pretty good results. However it has been physiologically proven that acupuncture has specific CNS effects, so there is something more than sham going on. Its just hard to detect due to study control issues.

Nevertheless, the fact remains that good results can be had with minimal training, it would seem. Whether we like it or not, it is up to us to to prove we can do better. I think there are ways to design studies that address these issue without resorting to the cop-out that this method does not work for acupuncture. That attitude will just result in losing everything the profession has gained. After reading Kapchuk and looking at his other citations, I think the German researchers were not careful enough to address certain key issues. Their studies are flawed and thus can be contested.

There are some excellent points to consider about sham acupuncture and the nature of a "control". This so-called control is not really a control at all. On the other hand, the mere fact that the "sham" group does so well is still troubling. Whatever it reveals about the flaws in the study design, it also demonstrates that effective acupuncture can be performed with total disregard for traditional theory, point location and selection. So it may not technically be a sham, but the result is still troubling to me.

Outcomes studies are not adequate to demonstrate the cost effectiveness of a therapy. While you might be able to argue that an outcomes study shows that acupuncture in a normal clinical setting is an effective procedure for a wide range of complaints, that is not the sole variable in determining the viability of a therapy. While some doctors are rejecting the current HMO system and going back to cash based practices, it is pure fantasy to think
this trend will rapidly overwhelm the current status quo. 40,000,000 americans are uninsured and can't afford insurance, much less out of pocket care. Another group that size is on medicare or medicaid. Much of Europe
uses socialized medicine and that is actually why this study was undertaken - to determine if the German government would continue paying for acupuncture services. When it comes to a purely market based medicine, all that matters is outcomes. And because of this, some patients will continue to pay for acupuncture out of pocket because they prefer it to the fully covered alternatives. However when it comes to medicare, worker's comp, insurance, HMO's, etc., cost must go hand in hand with effectiveness.

On this level, it would seem to me that if you can train people to do "sham" or some form of minimal medical acupuncture in just a two year associate degree instead of 2-4 years undergrad plus 4 years masters that the savings to the healthcare system would be immense. With students making so minimal an investment in their careers, they could not expect to make more than $20 per hour, which would dramatically lower the cost of the service to patients and so on. With these issues in mind,I do not believe the decisonmakers will ever accept pure outcomes research. So I propose two other options. One is to compare acupuncture to standard therapies. Such a study could equalize some confounding variables regarding blinding by making each group (WM and CM) equally "unblinded". Rather than sorting out dr./pt. interaction and belief and intention, just try to make sure
these are pretty much the same in each group. Now such a study won't show what each therapy does all by it lonesome, but you should be able to compare the differences in each group after adding a sole variable, such as acumoxa vs. physical therapy. It then wouldn't matter if there was a sham or not. If acumoxa did better than an already covered service, logic would dictate it now be covered.

In addition, all future research should address the fMRI issue. You can't say the sham is the same as the real point when they have different effects on brain function. But we still may be left with the nagging fact that shamupuncture works. And this will no doubt bolster the cases of those who want acupuncture to be practiced by nurses and Physical Therapists. However it is not too soon to consider whether we should be devoting our resources to battles we cannot win. I have never felt it was worth fighting over the issue of who can insert needles into the body. I think now more than ever it is a losing cause to try and block MDs and lower tiers of the profession from doing medical acupuncture. We really need to somehow prove what we do works better and is more cost effective than alternatives. Because I see no reason for authorities to listen to us when we demand control of our turf, yet have no evidence to prove why we should be in charge. And other evidence does exist to challenge our very premise, that one must be expertly versed in chinese medicine in order to practice acupuncture.

--- In chineseherbacademy@yahoogroups.com, anonymous wrote:
And you are ready to throw out thousands of years of medical theory over this one study? To me your position is more than needlessly alarmist, in short, it lacks wisdom."

I think there are serious problems with this study and it is incumbent upon us to show the flaws in design and prove that a proper study will yield different results. I am troubled not only by this sham result, but dozens of other smaller studies that show the same thing. This is not one study negating thousands of years of theory. It is a recurring trend in acupuncture research that cannot be denied. I have offered ideas about more valid research and also the use of MRI's to prove the so-called sham is not the same as so-called real acupuncture. As for thousands of years of theory, I have made my position clear in past writings. Just because someone said it don't make it true. Paul Unschuld has clearly demonstrated that many chinese medical ideas served cultural needs and did not survive just due to medical efficacy (PDF). In other words, belief and bias was a big deal throughout all of Chinese Medical history. It is naive to assume that all Chinese ideas are efficacious or will translate effectively to a radically different culture. I categorically reject that we must have some faith in our tradition. We must have evidence pure and simple.

Longtime readers will realize that my tone is much less conciliatory than it used to be. I often advised people to settle down on these issues. But anyone who thinks a study of 500,000 people to be released in a few years is not a matter for alarm does not view time the way I do. A study of that size will overwhelm most other studies which have all largely been dismissed due to poor design and small sample rates. The only thing the NIH says has been proven about acupuncture is its use in nausea. There are literally a handful of so-so studies and the rest were rejected. Everything else "needs more research".

So there really is no true counterweight to this German study. This one study could dramatically impact lawmakers and insurers. The lead German researcher suggests the preliminary results point to eliminating acupunctue from the national healthcare service. This has certainly alarmed German patients. 4 years is right around the corner if we want to head off these guys at the pass, rather than try and play damage control after the fact. It will take us at least four years to get our own studies underway and producing enough preliminary results of our own to counter the German report when it comes out. What some call an alarmist lack of wisdom, I call strategic planning. It is certainly correct that the true believers will not support a guy who begins with skepticism rather than faith, but I am pretty sure mainstream decisionmakers are more interested in a skeptic doing research than a true believer.

herbal straw men

Let's take a closer look at the quackwatch article about herbs. It is titled "the herbal minefield", so we should expect it to be quite explosive. The author Stephen Barrett begins,

"Herbs are also marketed by naturopaths, acupuncturists, iridologists, chiropractors, and unlicensed herbalists, many of whom prescribe them for the entire gamut of health problems. Many such practitioners are not qualified to make appropriate medical diagnoses or to determine how the products they prescribe compare to proven drugs."

What he fails to say is that many, perhaps most, of those who make a career out of herbalism, are indeed qualified. Some may have undergone formal training at a federally accredited institution (such as ND, DC, LAc). If they are practicing herbalism legally in their state, then they have met certain standards including licensing examinations. In additon, common law gives all citizens the right to practice herbalism as long as certain precedents are adhered. These precedents have now been enshrined as Health Freedom acts in various states including California. Health freedom acts recognize the long history of safe practice of herbalism by assorted non medically trained practitioners. This would include native americans, chinatown herbalists and hispanic curanderos. Which is not to say that herbs are inherently safe, but rather there are ancient traditions that allow herbs to be used safely despite their risks. Such herbalists may not always have gone to a formal medical school, but are still able to be both safe and effective. The human mind has developed many strategies with which to cope with the natural world. We should be careful not to hastily dismiss the ideas of great civilizations despite their peculiar nature. China has perhaps not survived thousands of years by chance.

Health freedom acts require certain disclosures on the part of the herbalist and take a buyer beware philosophy as well. In other words, if the law if followed, the patient is acting with informed consent. Finally, lay herbalists are acutely aware of their precarious legal footing and often go to great lengths to insure that their patients seek conventional medical attnetion for all lingering or emergent complaints. If this were not true, there would have been a rash of adverse incidents in the past 2 decades. Instead, there are no incidents of incompetence or negligence related to the professional practice of herbalism (ND, DC, LAc) as far as we know. All the major media incidents involved self-medication, typically with stimulants like ephedra used for weight loss (a nontraditional use).

If its not obvious to everyone, the mandatory regulation of substances by the government is paternalism of the highest order. Citizens should have free access to information and substances and practitioners. At the same time, the government should encourage and oversee a voluntary framework that addresses licensing, certification, standardization, etc. The public should be made aware through televison advertising that while there are no restrictions on procuring any herbal products for any use nor upon contracting the services of any person for health advice, there is no inherent government protection for such actions either. The use of standardized products and licensed healthcare professionals ultimately makes it the government's responsibility if something goes wrong. I believe a large percentage of the population prefers this type of protection against loss as compared to the risk that comes from unguaranteed personal contracts. Thus there would always be a certain demand for a market that catered to this need. And doesn't a true libertarian government need to give those who want to have government oversight in certain areas that option (most of us would choose some degree of environmental, worker and food safety laws if history is to be any lesson to us).

But I see no reason why a parallel unregulated herb and herbalism market cannot exist side by side this regulated one. As long as consumers had a regulated option, how does the presence of a legal unregulated market affect those who choose risk. I think that is the crux. Certain elements of American society would prefer that one not even be able to choose certain risks (sure, you can eat donuts and bungie jump all you want, but god forbid you should use an herb to treat a headache much less treat your head). Arguably, though, there are times when an educated risk is necessary for a quantum leap forward. Republicans say they want small government. Well, let's start here. So while Mr. Barrett's intention is no doubt to protect us, I think we can each protect ourselves from the big bad herbalist on the corner. On the other hand, we all need protection from the big bad corporation on the internet that preys on us with endless misinformation designed solely to sell. I started this blog in part to help cut through all that. Stay tuned.

quackbusting

I thought I'd start this blog with a look at the strongest evidence the venerable quackwatch is throwing at the herbal profession these days. Well, they don't appear to have much new to say at all. The last time the herbal section of their website was updated was in 2000. This is the strongest wording they have at that time:

"Researchers from Harvard have evaluated claims made on 443 Web sites located by searching for information about eight widely used herbal supplements (ginkgo biloba, St John's wort, echinacea, ginseng, garlic, saw palmetto, kava kava, and valerian root). [10]. The researchers concluded:

• Among 443 sites, 338 (76%) were retail sites either selling product or directly linked to a vendor.
• 273 (81%) of the 338 retail Web sites made 1 or more health claims, with 149 (55%) claiming to treat, prevent, diagnose, or cure specific diseases.
• More than half (153/292; 52%) of sites with a health claim omitted the legally required standard federal disclaimer.
• Nonretail sites were more likely than retail sites to include literature references, but only 52 (12%) of the 443 Web sites provided referenced information without a link to a distributor or vendor.
• Consumers may be misled by vendors' claims that herbal products can treat, prevent, diagnose, or cure specific diseases, despite regulations prohibiting such statements. Physicians should be aware of this widespread and easily accessible information.
• More effective regulation is required to put this class of therapeutics on the same evidence-based footing as other medicinal products."

I can hardly disagree with these recomendations. They are strikingly similar to concerns I expressed in an article on the subject several years back . Does that make me a quackbuster? While quackwatch definitely takes some major swipes at acupuncture on their site, including a newish high profile article , their concerns about herbs are moderate and most could be easily addressed with voluntary industry and professional standards. More on all of this later.