A new book subjects therapeutic claims made by complementary medicine to scientific study.
By JUDY SIEGEL-ITZKOVICH
Pharmacies and health food stores are filled with supplements containing anything from vitamin A to zinc and natural remedies ranging from aloe vera to witch hazel. Hundreds of thousands of Israelis flock to practitioners of homeopathy, acupuncture, reflexology, meditation, biofeedback and a slew of other therapies that promise relief from a wide variety of ailments.
But how many of these complementary and alternative medicine products and techniques have been proven safe and effective? Those who make fistfuls of money from them are usually reluctant to bring scientific evidence; instead, they supply personal testimony from satisfied customers.
But such "anecdotal evidence" (to use a medical term) is not enough. About eight of every 10 medical complaints involve "self-limiting conditions" (another medical term) that resolve themselves without treatment or explanation; many "improvements" are therefore not due to therapies, vitamins or other supplements. And the attention and time bestowed by practitioners can easily lead to a placebo effect; people believe such therapies and supplements will help ("placebo effect"), so their symptoms disappear, at least temporarily.
The Health Ministry doesn't license such practitioners, or even set down criteria or standards for most of them (except for those who offer invasive therapy such as acupuncturists). Its Food and Nutrition Service checks batches or documentation of imported or locally manufactured food supplements to keep dangerous substances from reaching the public, but the ministry doesn't guarantee that any substance has therapeutic value, and it is illegal to make claims to that effect for anything that is not a registered drug.
More than 13 years ago, a ministry-appointed commission headed by former Supreme Court justice Prof. Menahem Elon presented a 26-page report with recommendations and over 2,000 pages of appendices on the subject of complementary and alternative medicine. Elon, a believer in some of these therapies, presided for nearly three years over a team of experts that finally urged the elimination of doctors' monopoly as the only practitioners who may legally offer treatment. Non-medical practitioners would face lawsuits if they harmed customers, most commission members said, but they should be allowed to practice non-invasive procedures.
The minority view, written by Prof. Marcel Elyakim, charged that the report would create a "disastrous" situation in which "charlatans will have a field day." Under pressure from the Israel Medical Association, the ministry ignored the Elon Commission Report, and nothing was implemented. But since then, dozens of complementary medicine "colleges" and hundreds of courses - from quickie weekend lessons to curricula encompassing several years of study - popped up like mushrooms after a rain. With the lack of ministry supervision and intervention, widespread use of complementary and alternative therapies has resulted in confusion and sometimes downright quackery and even death. As far back as 1984, a subcommittee of the US Congress declared that quacks and charlatans cost the economy at least $10 billion a year.
SIGNIFICANT RELIEF may be provided by an authoritative new 399-page volume, Refuah Mashlima Ve'alternativit: Kol Ha'uvdot (Complementary and Alternative Medicine: All The Facts) by a professional whose qualifications cannot be dismissed. Prof. Jonathan Halevy, a gastroenterological and liver specialist who is director-general of Jerusalem's Shaare Zedek Medical Center, head of the Israel National Organ Transplant Center and a member of Ben-Gurion University's Health Sciences Faculty in Beersheba, spent a year writing the book in his spare time. His wife Adina, to whom the volume is dedicated, suggested that Halevy get away from it all several nights a week at the Mishkenot Sha'ananaim Guest House in Jerusalem. It is there that he did his research and wrote the NIS 89 book, which was published by Kinneret, Zmora-Bitan, Dvir Publishing House in Or Yehuda. (It may eventually be translated into English).
To be totally objective, Halevy said he didn't collaborate with - or even show the manuscript to - doctors in Shaare Zedek's unit for complementary medicine. When asked whether he uses any complementary technique or takes a dietary supplement, Halevy told The Jerusalem Post that he does take glucosamine sulphate and chondroitin sulfate capsules because of knee-joint pains he developed from jogging. "They certainly help in slowing the breakdown of cartilage," he said, and such pills are listed as safe and effective in the volume.
To research the subject, which had interested him for decades, he plowed through a mountain of individual randomized, controlled, double-blind studies and meta-analyses, combining and comparing many of them that were published in more than 30 journals (from American Family Physician and the British Medical Journal to The Cochrane Library, the New England Journal of Medicine and Scientific American) and computerized databases.
Halevy aimed the book at the general public, so he doesn't provide references for statements about which therapies and supplements have been proven beneficial, unproven or harmful. The lack of such documentation may frustrate doctors and researchers, but including it would have required many more pages and put off laymen. Still, the book is almost encyclopedic, although it does leave out a few popular techniques such as shiatsu and a discussion of the therapeutic benefits of prayer.
THE MAIN AIM of the book, Halevy says at the outset, is "to disperse as much as possible the fog and lack of clarity while discussing all the various branches of complementary medicine without prejudice, and by using the most objective tools possible." He notes that some therapies, such as acupuncture and various stress-reduction techniques, have become integrated with conventional medical treatments not only by Britain's National Health Service but also in Israel. Some of the most prominent universities, from Harvard to the University of California at San Francisco, have established complementary medicine departments and research centers.
The super-specialization of Israeli medicine, in which each bodily system and organ is covered by separate specialties, has made many patients uncomfortable, Halevy concedes. They want to be treated like human beings, not as disorders in human form, and this desire for holistic therapy has contributed to the growing demand for complementary approaches. The author notes that in his medical school classes, he stresses the importance of understanding complementary therapies but doesn't teach how to do them.
"As doctors, we can't remain apathetic to the flocking of patients to complementary and alternative techniques."
Although complementary medicine practitioners argue that some therapies such as mind-body techniques can't be proven by the scientific method, Halevy insists that there is no other acceptable yardstick. Therefore he sets up a rating system of one to three "plus" signs for efficacy (three plusses represent proven efficacy in high-quality research studies; two mean proof in studies of only moderate quality; and one means some efficacy shown in low-quality studies, with more research needed). A +/- sign means a therapy was no more effective than a placebo, while a "minus" sign means it was proven ineffective.
As for safety, three plus signs represent the maximum when used by an authorized practitioner, two mean various cautionary measures must be taken, one means its safety is in doubt and is not recommended, and a "minus" sign means it's dangerous and should not be used. After explaining each therapy and supplement, the author offers a useful rectangle that graphically rates safety and efficacy, adding warnings such as dangers to pregnant or lactating women, and a prohibition against swallowing or injecting material meant for external use only. Some chapters end with user-friendly charts that list all the supplements together and can be understood at a glance.
Among those shown to be effective and safe are manual manipulation techniques such as massage, osteopathy and chiropractic - but only for temporarily relieving pain in the neck or back after X-ray or other imaging rules out the possibility of causing harm, and if they are performed by a well-trained practitioner. Reflexology (the massage of specific regions of the sole of the foot) gets much poorer marks, as there is only moderate evidence that is brings relaxation and relieves anxiety, and it has not been proven effective for chronic back pain or for diagnosing diseases. It also should not be used on women in the final stages of pregnancy, as it can trigger premature labor.
Reiki, says Halevy, is safe (except for people with mental problems), but has not been proven to do anything except perhaps make people relax and improve general feeling. Hypnotism by an authorized practitioner can relieve back pain, headaches, toothache, cancer pain and postsurgical pain in some, but hasn't been proven to get smokers to quit and should not be used on mental patients or epileptics.
Acupuncture can be effective in relieving acute pain, such as from dental or oral surgery, with only moderate proof that it helps with chronic pain. It's no more effective than a placebo in alleviating asthma, and there is no proof at all that it promotes weight loss, helps people stop smoking or alleviates depression, alcoholism or drug abuse. Homeopathy got all-round low marks in efficacy against a variety of conditions - but it is safe.
Although generations of women have been using cabbage leaves (not eaten, but placed in the proper location) to relieve overproduction of mother's milk, Halevy writes that it is no more effective than cold compresses. As for supplements and vitamins, ginseng can help type II diabetics balance their sugar levels, echinacea won't help you cope with your cold, and the food supplement ephedra, promoted in the US for weight loss, is absolutely dangerous.
The bottom line, Halevy concludes, is that the majority of complementary and alternative techniques and supplements have not been proven effective, but some are clearly beneficial, and most will not cause harm (except to the pocketbook.) Those that are non-invasive and involve mind-body interaction, he says, can help sufferers even if only via the placebo effect.
The iron rule is that patients should never go to a practitioner or take supplements without first consulting a licensed physician.