Sunday, 8 April 2012

Medicines and placebos

A few decades ago “alternative” medicines mainly came from “head shops” and other fringe outlets that catered to the then-marginal counterculture. Today every health food store, pharmacist and supermarket sells a range of “natural” pills, juices, salves, teas and powders that promise to cure your cold, detoxify your body, sleep soundly, stave off illness, brighten your mood, remember your anniversary and return to the size you were when you were a teenager. Advertisements tout nutritionists, homeopaths, herbalists and therapists of all kinds to read your chi, your chakras or some other kind of pseudo-spiritual “energy.” In short, our poor health and dissatisfaction has created whole new fields of capitalism. 

It’s not difficult to see why; we’re getting sicker across the industrialised world, perhaps most in my native USA, where more than a third of the population is obese, and another third is overweight. Chronic illnesses like heart disease, cancer, strokes and diabetes have created skyrocketing medical costs – up 58 per cent in just nine years, according to one study. 

We can easily think of many reasons for this. For one thing, most Westerners are surrounded by cheap and unhealthy food. An increasing number of my own countrymen live in “food deserts”—especially, ironically in farmland -- where junk food is the only thing available for many miles. Most of us in the West live sedentary lives at work and home, working longer and more stressful hours in this declining economy, and have less to show for it. Moreover, that post-World-War-II Baby Boom is now entering pension age, so a disproportionate percentage of the population is getting much sicker. So we need doctors more, and can afford them less. 

Even those Westerners who can afford treatment don’t always get it; the number of parents who refuse to give their children vaccinations, for example, increased by 77 per cent from 2003 to 2008. Part of this might be because modern medicine has done its job so well, wiping out almost all major diseases in a mere century; if you’ve never heard of anyone getting polio, tuberculosis or measles, you might not be motivated to protect yourself against them. We have quickly forgotten what it was like many generations ago, when most children did not survive into adulthood and everyone knew someone who died or were crippled by these diseases. 

Part of it, however, might stem from an increasing scepticism of a medical establishment that seems so distant and costs so much, the same sentiment that makes pharmaceutical companies a reliable villain in Hollywood movies. Americans in particular must pay exorbitant rates for prescription drugs, so the companies charging such rates turn to other options. Unsurprisingly, then, more people spend money on alternative therapies -- Americans spent almost $15 billion on herbal pills, a third as much as was spent on conventional pharmaceuticals. 

If you think that medicine, like all aspects of modern society, will face a crisis in the coming decades, you might be inclined to cut alternative medicine some slack. If our fuel, economic and climate crises deepen, won’t fewer of us be able to afford CAT scans and chemotherapy, even if hospitals still have them or the electricity to power them?  Or if we value a more traditional way of life, shouldn’t we be exploring more traditional cures, and rediscover how to heal ourselves with a field of wildflowers?
Let’s get a few things straight. Firstly, words like “alternative” or “natural” cover a lot of ground, and will encompass methods that work and those that don’t. All foods affect the body – they’re food – and some have long-noticed effects beyond mere nutrition; dandelions, for example, are famous diuretics, as their colloquial name “piss-a-bed” suggests. 

Almost all humans in history knew a great deal about the plants all around them from the time they were children, and knew them as intimately as we do the sexual lives of celebrities. We would do well to rediscover that knowledge, and tend to our own health as much as we can before having to see a doctor. We can probably do more by simply eating well, exercising and spending time with loved ones, however, than we can by eating herbs once we get sick.

As much local knowledge as those practitioners of herbal medicine had, they lived only to about 40 years on average, until science brought microscopes, trial and error and peer review into the medical world in the 19th century. Few ancient skeletons appear older than that, whether Neanderthals from 100,000 years ago or bodies preserved in Irish bogs from 2,000 years ago. Even a century ago in the wealthy European nations, most people died before they were 50. Herbal wisdom could do some good, but it was no substitute for clean water and sterilisation.  

Secondly, most herbal medicines that actually work were isolated chemically long ago and sold in pure form – aspirin, for example, from willow bark. We still use them, but have stopped calling them herbal medicine. In order to become medicine, however, they had to stand up to scientific tests, and that’s where most alternative therapies fall apart. 

If we are less likely to be able to afford conventional medicine in the future, we might want to know what plants work as a backup; for example, to boil willow bark to make a headache cure. This should be backup knowledge for an emergency, though, for sterilised and standardised amounts are surely preferable to unknown amounts.

Thirdly, companies have an interest in patenting and selling cures that work, and pharmaceutical companies must follow public law to prove their products work. If such companies could spare themselves the trouble of manufacturing antidepressants and just patent an herb instead, they would save themselves money. The herbal cures that work were patented long ago; if an herbal cure has never been patented to make a profit, it probably doesn’t work. 

A landmark ten-year study by the US National Centre for Complementary and Alternative Medicine tested a wide variety of common herbal cures and found that none of them performed any better than sugar-pill placebos at alleviating the conditions they were supposed to cure. Specifically:

  • Gingko had no effect on memory.
  • Saw palmetto did nothing for prostate problems.
  • Shark cartilage was useless against cancer.
  • Black cohosh was useless for menopausal hot flashes.
  • Echinacea, at least in their experiments, did not help with colds.
Fourthly, alternative medicine is an industry, just like the mainstream pharmaceutical industry, run by executives in suits, making pills in mechanised factories. Their packaging might have pictures of sunbeams and rainforests, but they were made by corporations just like conventional remedies; the only difference is that the alternative medicine market, in many countries, doesn’t have to follow as many rules about what’s in their products. 

This is one of the most important things to take away: Most herbal pills don’t necessarily contain any of the substance they advertise on the package. A 2005 study published in the American Journal of Medicine found “high content variability” in herbal pills sold, with most companies not even testing how much gingko, say, is in the gingko pills. 

A 2003 study published in the Archives of Internal Medicine found that only half the Echinacea pills purchased contained the amount they were supposed to, and 10 per cent contained no Echinacea whatsoever. 

In addition, remember that “holistic” medicines don’t just come from Chinese monks or Amazonian Indians; “holistic” refers to the idea that the body has essential elements that need to be kept in balance, like yin and yang in Chinese medicine or chakras in India. Western tradition has the four humours, used from Polybus in the fifth century BC to the beginning of the 19th century AD, and which we still invoke when we refer to someone as melancholy or sanguine. 

Western writers came up with some creative cures using this method – when 11th-century Arabic physician Ibn Butlan saw a patient who felt cold and clammy, for example, he recommended eating a rooster, an animal that was hot and dry. It might sound ridiculous, but all other holistic medicines work on the same principle. 

Holistic theory was used because no one really understood how the body worked. Why did humours continue to be invoked for 2,400 years if their recommendations were so ridiculous -- she-goat urine poured into the ears for a stiff neck, to use an example from Pliny the Elder? Perhaps for the same reason many modern alternative medicines appear to work; people use them to treat problems like a cold or injury that eventually get better on their own anyway, leading the patient to think that the prescribed remedy was responsible. In cases where a patient gets measurably worse, perhaps, a certain anthropic principle comes into play; those patients who die aren’t around to complain that the cures didn’t work. Or – again, like modern alternative therapies – they treated symptoms that are particularly hard to measure, like “fatigue.”

If someone were to open a storefront today selling she-goat urine or literal snake oil, though, they would get few customers and might be shut down by the authorities. Nor, if your appendix bursts in China, will surgeons give you such treatments – they have modern medicine and pharmaceuticals, and use them. Why, then, do these now-disproven folk cures thrive in countries far removed from their origin?

I suspect that the reason has little to do with the medicines themselves, and everything to do with the Sixties counterculture, where most of the alternative medicines were first popularised. Countercultural types harshly criticised anything mainstream, modern, or Western – and criticism is often healthy. The problem was that they suspended such judgement for anything from Native Americans, Chinese, Africans or any other culture. 

Simply because we are willing to respect or explore a foreign culture does not mean we have to suspend the burden of proof. If the Chinese had been the civilisation to break out first and conquer the world, I would have hoped they would have treated the Beatitudes with the respect they deserve, but I would hope they would test Pliny and find that his cures don’t work.

Modern medicine works because researchers came up with a theory based on what they know, they tested various techniques and substances in laboratories, then on animals, and finally on humans, and made sure their findings were peer-reviewed before going out to the world. That is science, and the fact that most of us are still alive testifies to the fact that it works. That, ultimately, is why this issue is important, and is about more than alternative medicine.


Many people are rightly disgusted at our modern consumer culture for one reason or another, although different groups have fixated on different aspects of it. My more devoutly Christian friends in the USA mourn the loss of traditional, close-knit families and safe communities, while rural acquaintances have watched their towns slowly die as everyone drives to Wal-Mart. My more ecological friends grieve for the loss of so much of the natural world. My more countercultural friends dislike living at the non-existent mercy of global corporations.

These groups seem to be at radically different political and religious poles, yet they all have some things in common. Most of these subcultures – American libertarians, evangelical Christians, anti-corporate activism, alternative medicine enthusiasts and the environmental movement – all originated in their modern form from the Sixties counterculture. And most of them work selflessly and industriously in ways that are counter-productive, that not only don’t help their cause but worsen the situation they set out to help.

Again, it’s easy to see why: Like many people unhappy with modern consumer culture, they want to return to the simplicity of an earlier age. Yet they must live in modern culture – like most of us, they have families and careers, commutes and mortgages. Few can simply abandon their lives and take up farming, and those that try often discover that they don’t have the self-sufficient skills of our forebears, nor are they accustomed to isolated and long hours of physical labour. Many people, struggling in this economy, could live more self-sufficiently at home and try to have the best of both worlds, but that solution does not appeal to the all-or-nothing thinking that is so popular these days.

So most people I know, in one way or another, yearn for a simpler and more natural way of life, a way to get around big government and big corporations and deal with authentic people, to buy products whose ingredients they can pronounce. And so markets and movements have arisen to meet that demand, and give people the illusion of doing that.

Most conservative Christians I know have worked, selflessly and industriously, for issues and candidates that do not make families closer or restore communities; getting the Ten Commandments put up in courthouses, for example, will not get fathers to spend more time with their sons. When I reported from small towns, most of the townspeople were fighting their towns’ decay in ways that would only harm their populations; getting some kind of gambling casino, for example, might help some people get jobs in the short term, but will make the community poorer in the long term.

Many ecologically-minded friends, likewise, rally around actions that have no effect. Some of these are harmless – turning off the lights for an hour won’t save the world any fossil fuels, but it won’t waste any more. Others might or might not do some good, depending on circumstances; how much fuel do you spend driving your plastic bottles to the recycling centre, for example, or would you be better off just re-using them at home?

Some of the ways people try to live a more natural life, however, just do harm. Refusing vaccinations does not restore the collapsing plankton levels in the ocean, it just makes your children more vulnerable to disease. Buying “herbal” medicines sends money to corporations – just corporations that can work outside of mainstream medicine’s public rules, and so get to sell things that don’t work. 

I'm neither a doctor nor a politician, but I can think of a number of ways people can improve their and their neighbours' health. They could persuade many people to garden, getting excercise and fresh vegetables. They could persuade lawmakers to force herbal companies to abide by the same standards as pharmaceutical companies. Americans, with their more complicated and expensive health care, could create a community health fund like the ones Oddfellows or Masons used to have, or that the Ithaca Fund has now: people pay a small amount into a fund to pay for the amount not covered in their insurance deductible, thus allowing them to have cheap health insurance with a high deductible. Americans could also persuade lawmakers to change health-care laws, imitating what seems to work best in other parts of the world.

If more people feel sick, stressed and helpless in years to come, however, the danger is that, instead of doing any of these real things, they will be a prime target for hucksters selling placebos – things that only make them think they are fighting the good fight. 

Chinese medicine - seahorses.
Nineteenth-century medicines.
Nineteenth-century advertisement.
Chinese medicine - deer penis.
Nineteenth-century advertisement for tansy pills.  
All photos courtesy of Wikicommons.


More than a third of all Americans are obese, and more than another third are overweight: Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults: United States, Trends 1960–1962 Through 2007–2008

The number is projected to increase by more than one percent per year by 2030, resulting in an estimated chronically ill population of 171 million: Robert Wood Johnson Foundation & Partnership for Solutions. "Chronic Conditions: Making the Case for Ongoing Care." Johns Hopkins University, Baltimore, MD (September 2004 Update).

Chronic illnesses cause about 70% of deaths in the US and in 2002 chronic conditions (heart disease, cancers, stroke, chronic respiratory diseases, diabetes, Alzheimer’s disease and kidney diseases) were 6 of the top ten causes of mortality in the general US population: National Center for Health Statistics. “ Health, United States” / 2004.

Amount of herbal substance in herbal supplements: “Lack of herbal supplement characterization in published randomized controlled trials,” American Journal of Medicine, Oct. 2005.

39 percent of parents refused or delayed vaccinations: according to the study by the Centers for 
Disease Control and Prevention, the University of Rochester and the National Opinion Research Center.

The Use of Complementary and Alternative Medicine in the United States:

They don’t regulate whether there is any amount of the disease in the pill: The American Journal of Medicine 2005 Oct;118(10):1087-93.


Andy Brown said...

That's a big topic you've bitten off today, and I can think of a few responses I'd like to make. I'll limit myself to a traditional anthropological observation though. People resort to magic when they've reached the limit of what (they believe) they can do in the "real world". Azande potters knew all about working the clay and managing the temperature and so on, but still, sometimes the pot cracks in the heating. And to deal with that there is only magic or prayer. In your descriptions of healing and quackery, I see that dynamic. There are things we (believe we) can do or (we believe) modern medicine can do about our health and maladies. But maybe scientific medicine can't help us or we've lost our belief in it. Since "doing nothing (!)" isn't an option, we will inevitably do something that we're convinced will have an effect. And oddly enough, the human body seems to respond pretty positively to such a stratagem (e.g. the "placebo effect"), so the cycle gets reinforced.

In that part of the spectrum of human malady that responds to the placebo affect (and it is wider than most people realize), that's fine - and there I think is where much alternative medicine succeeds. Of course, scientific medicine has some pretty good mechanical cures that people are foolish to reject, and there are also serious mechanical problems that can crop up in the body that no amount or belief in quackery will cure.

To circle back to my Azande potters, I think my point (and I'm mostly through my third black and tan here, so be charitable) is that the trick is to keep track of the clay and the temperature before you resort to magic -- BUT, oddly enough the human body responds to magic in a way that the clay really doesn't. And for that reason I see the magic of alternative medicine as playing a more constructive role than most garden variety magic.

Anonymous said...

Where and when did *most* children did not survive into adulthood?

Brian Kaller said...

Thanks for the thoughtful response. I agree that placebos can have a powerful effect, and I suspect this is why alternative medicines, prayer, magic rituals and faith healers seem to work, at least for a while. I think it’s important to make two ethical distinctions, though. Firstly: prayer and sugar pills cost you nothing, while faith healers and homeopaths are profitable enterprises.
Secondly: It’s one thing to pray for the sick because it’s the kind thing to do -- I’m told people do get better faster when they know people are praying for them, and it certainly won’t make the situation worse. That’s not the same, though, as faith healers or alternative therapies, however, in which people are told the intervention is literally eliminating the pathogen. The latter basically assures someone they don’t need to see a doctor anymore – which could cost them their lives.
Does that make sense? Feel free to write back.

See, for example, “The History of Infant, Child and Adult Mortality in London, 1550-1850” in The London Journal, November 2007.

Andy Brown said...

I don’t have any more sympathy than you for charlatans who dissuade people from effective healing. I just wanted to make an observation and maybe take the opportunity to sort out my own thinking on the topic.

There is a “mechanical” effect that physically operates on a physical problem (e.g. a chemical that causes veins to dilate, a bacteria the produces toxins in the tissues). There’s also the “psychological” effect that can affect the body physically (e.g. the placebo affect, psychosomatic ailments, toxic stress, the power of positive thinking, etc.). For thousands of years people have used both – coupling actual mechanical effects with all the “theater” of healing and quackery to strengthen, focus and direct the psychological effects. In my opinion a school of healing worthy of the name makes use of both of these. In truth, for its day to day success modern medicine relies both on mechanics and on the psychological effects (e.g. placebo effect) that comes from people’s faith in science and medicine. (This is probably one reason why doctors so long insisted on all the trappings of authority – and the more recent disdain for human psychology is one reason why despite their impressive arsenal of treatments, modern doctors so often fail at actual healing.) I think herbalism, massage, chiropractics, etc. also manage both aspects, the mechanical and the psychological. There are others, like homeopathy, crystals, faith healing, that (in my opinion) can only avail of the second – and that makes them much, much weaker in general and completely inappropriate for healing things beyond the body’s psychosomatic abilities.

I guess what I’m saying is that a crystal healer who cures someone’s tension headaches is doing good work, (indeed better than the M.D. with his pain pills) while a crystal healer who says they can replace chemotherapy is a dangerous quack who needs to be shut down. On the other hand, I think that a doctor who considers it enough to prescribe Lipitor for the suicidal American diet, isn’t much of a healer either.

Brian Kaller said...


A fair point, although on the spectrum between the examples you give, where would you draw the line?

I wonder, based on what you've said, if one could measure the effectiveness of treatments when people had more faith in the treatment.

Andy Brown said...


I suppose I would draw the line at the traditional, "do no harm". That still leaves plenty of space for argument and discussion, however. Harm to the bank account is certainly a form of harm. And maybe leading people into superstition or misunderstanding of the world is a significant harm as well.

As for the science, there's a good rundown on some of the efforts to tease out what exactly is the placebo effect at skepdic. Sometimes the placebo effect just shows that people would've gotten better on their own (more or less regardless of whether the treatment was drugs or sugar pills) and sometimes the placebo seems to have actual physiological effects. In any case, I still think the whole mess of effects is integral to any effort to heal people, and healers have been sensitive to that fact for as far back as we can see.

Anonymous said...

A couple of comments. First, it's simply not true that most effective herbal medicines have been turned into pharma drugs. Most herbal medicines have multiple active ingredients, and many of those simply can't be turned into single-compound patentable pills with the same efficacy (much less safety). And the vast majority of non-Western plants have never been subjected to that type of study at all.

Second, the fact that people didn't know why things worked in the past doesn't prove that they were always delusional when they thought things did work. Those plants that you will admit to be effective because they have been turned into pharma drugs (e.g., aspirin, opioids) had their activities explained in terms of humors too. While the scientific method may (I say may) have been developed only in medieval Islamic society, "trial and error" is not something people were too mindless to do until recently; it is how people have always learned about their environment. How did the ancestors of today's Native Americans learn which plants could be used as food? By experimentation, no PhD needed.

And finally, many people fall victim to the claim that in the past, everyone died by 40 for the lack of modern allopathy. (The most imbecilic formulation I've seen claimed that the Romans died of old age at 20!) The main reason life expectancy was always so low, and still is so low in undeveloped countries, is that infant and young child mortality is horrific. Adults in the 30-40 range also ran a risk of dying from infectious disease, childbirth, or violence that we'd consider appalling today. But if you avoided those fates, you could indeed live to old age; quite a number of Romans made it to 70, 80, or even 100, and they were well familiar with the phenomenon of senile dementia. While allopathy has helped reduce the toll of infectious disease, with antibiotics and vaccinations, the biggest factor is public health measures such as clean water, clean food, and less crowded and polluted living space. No MD is required for the provision of those goods.