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DBL%20Hendrix%20small.png College chemistry, 1983

Derek Lowe The 2002 Model

Dbl%20new%20portrait%20B%26W.png After 10 years of blogging. . .

Derek Lowe, an Arkansan by birth, got his BA from Hendrix College and his PhD in organic chemistry from Duke before spending time in Germany on a Humboldt Fellowship on his post-doc. He's worked for several major pharmaceutical companies since 1989 on drug discovery projects against schizophrenia, Alzheimer's, diabetes, osteoporosis and other diseases. To contact Derek email him directly: derekb.lowe@gmail.com Twitter: Dereklowe

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June 15, 2011

The Failure of Modern Medicine?

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Posted by Derek

I was going to take a shot at this article myself, a piece in The Atlantic called "The Triumph of New Age Medicine". But Matthew Herper at Forbes has done the job for me. The original article advances the thesis that modern medicine isn't doing much for chronic diseases, which is why people are turning to acupuncture, et al. Says Herper:

. . .that’s all horse microbiome. Let’s take those one by one. Saying we’re not making strides against heart disease and cancer is just, well, wrong. Look at the below chart of mortality from both, courtesy of the Centers for Disease Control and Prevention. Notice something? They’re both going down. . .Yes, the battle against heart disease and cancer is slow, grinding trench warfare, but that’s because these our diseases written by evolution into our genetic code. And we’re still winning.

He goes on to demolish one of the article's other sweeping claims - that alternative medicine focuses on prevention, but mainstream medicine doesn't. And he's got an interesting reason (which may have occurred to you before) for why most "alternative" therapies have such ardent fans. Hint: there really is a secret ingredient, which has been gradually removed from a lot of modern medical practice. . .

Comments (36) + TrackBacks (0) | Category: Press Coverage | Snake Oil


COMMENTS

1. cynic on June 15, 2011 11:53 AM writes...

I haven't read the article yet, but I'm going to make a guess on the secret ingredient first. Is it a sense of personal responsibility for one's own health instead of completely outsourcing it to some medical complex? I don't know how much of that there is in alternative medicine, but it appears to have been almost completely removed from mainstream medicine.

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2. In Vivo Veritas on June 15, 2011 12:25 PM writes...

See, I would have guessed that the secret ingredient is paying in cash.
Most modern medicine practitioners insist on accepting insurance and paying taxes. In other words, being slaves to the Medical Industrial Complex and Big Government. Both are sure signs of not caring for your health.
MOTHER NATURE DOES NOT COLLECT TAXES!!!!

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3. Paul on June 15, 2011 12:33 PM writes...

The failure of modern medicine is that doctors treat the disease, not the patient.

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4. David P on June 15, 2011 1:25 PM writes...

I clicked through to find the answer, but it was what I thought: that alternative medicine actually shows some caring toward their patients, some empathy. Doctors are so so busy that they have little time for any bedside manner.

Oh, also make sure you scroll down to the comments for the response from the Atlantic article's author.

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5. Matthew Herper on June 15, 2011 1:36 PM writes...

It's not that doctors don't care. It's that rituals make us feel better, and doctors have abandoned many of those.

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6. johnnyboy on June 15, 2011 1:41 PM writes...

I'm no fan of alternative medicine by any measure, but beyond the rituals that Matthew mentions, there's also the fact that alt-med practitioners generally take the time to actually listen to the patient's concerns. Don't know about you, but in my (thankfully very few) contacts with medical practitioners, there has been exceedingly little actual listening going on, but a whole lot of being treated like a 3-year old.

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7. Dennis on June 15, 2011 1:47 PM writes...

I didn't guess the correct "secret ingredient". Apparently quacks don't even add opium and large amounts of alcohol to their treatments any more?

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8. Paul E. on June 15, 2011 1:48 PM writes...

The mortality chart in the Forbes article doesn't label the Y-axis, and this makes me twitch.

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9. Dennis on June 15, 2011 1:49 PM writes...

I didn't guess the correct "secret ingredient". Apparently quacks don't even add opium and large amounts of alcohol to their treatments any more? At least the fake medicine of the 1800s got you something for your money other than stab wounds.

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10. Paul E. on June 15, 2011 1:49 PM writes...

The mortality chart in the Forbes article doesn't label the Y-axis, and this makes me twitch.

edit: On click-through, the Y-axis appears. It's cut off in the main article for some reason.

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11. CR on June 15, 2011 1:49 PM writes...

Oh, I was going to guess the secret ingredient was marijuana (or salt), but I would have been wrong.

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12. Hap on June 15, 2011 2:19 PM writes...

Relationship and caring can't explain all the attraction of alt medicine, though - people like Trudeau and the supplementeers have continued to make money without data or honesty, and their only relationship with their customers is as predator to prey.

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13. monoceros4 on June 15, 2011 2:43 PM writes...

There's one important "secret ingredient" in all this that hasn't been mentioned. It's that people who claim to set stock by "alternative" therapies still are likely to seek out proper medical care once the real need arises.

I suspect that for a lot of people, "alternative" non-treatments like herbs and acupuncture are indulged in much the same vein as indulging the whim to buy a lottery ticket every week. Maybe it'll work--probably it won't, but who knows? You might get lucky and, in any case, you're not out *too* much if it doesn't work and it's not like you're going to quit your day job and pin *all* your hopes on the lottery.

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14. MBM on June 15, 2011 3:22 PM writes...

Hap - i think a good portion of the money that's made by supplementeers is a result of the basic fact that there remains far more mystery to the art of medicine than science - as long as that's the case - snake oil will be produced by the ton.

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15. Untangled Health on June 15, 2011 3:44 PM writes...

The missing ingredient is compassion as measured by:
Time
Touch
Triage
Empathy

I prefer to call this integrative medicine as these are simply additional therapeutic interventions. If we take subjective assessment of quality adjusted life years into consideration they do in-fact offer benefit.

Just the same: Calcium Inlet Channel Blockers saved this diabetics kidneys when they came on the market BRAVO! No ESRD for this guy.

#untangledhealth

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16. Born on June 15, 2011 5:42 PM writes...

The failure is that American's can't innovate. The USA is just not known for it.

A Big push is underway by Obama to give every foreign US student a green-card.

http://www.bloomberg.com/news/2011-06-15/intel-ibm-may-benefit-from-green-card-bill-for-skilled-workers.html

You can't make this stuff up.

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17. pharmadude on June 15, 2011 10:25 PM writes...

I read both articles and I'm confused by Lowe's support of the second Harpers rebuttal. The rebuttal is not well written and isn't convincing. Most of the comments made by the Atlantic author (he commmented on the Harper article) are spot on.

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18. Spooms on June 15, 2011 11:41 PM writes...

This reminds me of a joke (Well, kinda a joke);

You know what they call alternative medicine that works?

Medicine.

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19. Biased Agonist on June 16, 2011 12:36 AM writes...

I would say the missing ingredient is the PLACEBO EFFECT.
Considered a nuisance in mainstream drug development, but a major (if not the only) driver of efficacy in alternative medicine.

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20. sepisp on June 16, 2011 2:15 AM writes...

"[W]ith severe IBS, 62% of those who received the fake treatment got better" - sounds like this "syndrome" is not a disease after all, at least for the 62% of patients that can be cured without any actual treatment. No wonder designing a drug is hard, when there is no underlying physical etiology in the first place. I think this is where "alternative medicine" attacks: when people don't have any disease to start with. #13 is right about it being like a lottery ticket. Realistically, you won't win, but hard cash is not what's being sold. The quack's competitor is not the doctor, it's the movie theater and the gym.

A darker reason is that medical care is not generally accessible in the U.S., and the result is the same as in any less developed country: witchdoctors take the part of real ones.

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21. Tuomas Pylkkö on June 16, 2011 3:47 AM writes...

The author of the original article (David H. Freedman) has apparently replied to the Forbes-article in the comments section. It seems that he believes that in addition to placebo, CAM-practicioners "(on average) spend more time with patients, place more emphasis on getting people to adopt healthier habits, and work harder to get people to have better attitudes about their health, especially with regard to reducing stress and anxiety, than do mainstream physicians."

Personally, I think the most interesting point in all this discussion is how relatively well treatments to infectious diseases were developed in comparison to other areas. That is, how easy it is to use a single molecule therapy (without other forms of therapy) to cure a possible deadly infection. It seems that one really can't expect an identical "success" in, say, the pharmaccotherapy of schizophrenia, ever. It's hard to believe that any curing single molecule pharmacotherapy for schizophrenia will ever emerge. In other words: illnesses are not easily comparable from this point of evaluation.

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22. AndrewD on June 16, 2011 4:05 AM writes...

Of course Orac commented at length(and how) on the original story here
http://scienceblogs.com/insolence/2011/06/the_triumph_of_new_age_medicine_the_atla.php
His "Friend" at science-based medicine does not appear to have commented yet. I see Resepectful Insolence is in Derek's blog role

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23. drug_hunter on June 16, 2011 7:02 AM writes...

#21 (Tuomas) - I don't see it quite the same way. Yes, schizophrenia will be a lot harder to cure than an infection. But tough infections require polypharmacy and very specialized supportive care as part of the treatment. It isn't just a matter of popping one pill and being cured. And we will gradually come to understand the underlying etiology of even the horribly complex diseases like schizophrenia. We will also learn that there are in fact many flavors of schizophrenia, each with its own causes. So I wouldn't say it is impossible to imagine that a complex therapeutic regimen involving drugs and other aspects will cure those diseases. Definitely, it will take longer. In fact, a hundred years from now, it might be that the only diseases left are infectious because the bugs keep evolving!

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24. NJBiologist on June 16, 2011 11:28 AM writes...

@20: Actually, regardless of your thoughts on IBS, there are reports of substantial placebo responses using objective measures and in serious disease states. It's old data, but in 1959, at least one group documented a 75% response rate for sham surgery in the treatment of angina pectoris by internal mammary artery ligation (Cobb LA et al 1959) NEJM vol 260 iss 22 pp 1115-8).

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25. David H. Freedman on June 16, 2011 12:23 PM writes...


Too bad you didn't have enough inspiration to take your own shot at my article in the Atlantic, you might have done a lot better than Herper. You hardly could have done worse, as I hope my response to his incredibly lame post made clear. (It seemed to be clear to him, to judge by his meek, defensive counter-response.) You might also want to take a look at my response to Gorski's bizarre screed, assuming he has the integrity to post it. (I imagine he will, he loves a good argument.) Let me also congratulate your comment-posters in their zeal to attack the article without reading it (as apparently Herper did as well). Now that's scientific thinking for you! It's really amusing to me, as well as a little appalling, to see how many people who position themselves as defenders of science approach this subject in such a closed-minded fashion. None of the claims I make in my article are particularly controversial in the mainstream medical community--namely that mainstream physicians no longer have enough time for their patients, that medicine hasn't focused on getting patients to undertake the behavior and attitude changes critical to prevent disease, that most drugs don't do much to help with serious disease for most patients. You can read this stuff in the NEJM and JAMA, along with studies that show alternative practices do a good job with relieving pain and discomfort--sure, it's the placebo effect, but so what? You don't have to buy the argument that alternative practitioners do a better job with patients when it comes to behavior and attitude change, but if you don't you'd be disagreeing with a vast range of highly credentialed physician-researchers at the nation's top academic medical centers. I don't claim anything in my article that isn't solidly backed up by mainstream medicine. What you and so many others really object to is the idea that someone would come and have something pretty good to say about alternative medicine, because you're so deeply opposed to it. You know what's right, and by God you're doing to trash any evidence, reason or opinion that doesn't fit in with what you already absolutely know to be true. Does that really feel like scientific thinking to you? Then again, people who feel comfortable attacking and dismissing arguments that they haven't even read probably really aren't in a good position to judge what's scientific and what isn't.

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26. Phil on June 16, 2011 1:51 PM writes...

After reading Freedman's article in its entirety, as well as Herper's response to it and the comments in this thread, I have to say: What an overreaction!

Other than in the title - which is a shame - Freedman does not prop up alternative medicine to be anything more than a well-sold placebo effect. The question we (those in drug development) should be asking ourselves is why don't we fare head and shoulders above the placebo effect in the areas he points out?

I really like the comment that Herper reposted in his blog: "The pharmaceutical industry, if it has failed, has done so in the same sense that Babe Ruth failed every season he failed to repeat his record of hitting 60 home runs." Great analogy. But that could also mean that the medical establishment - the one born out of treating infectious disease - is in a state of decline as far as its efficacy is concerned. It's not ridiculous to raise the question: Are we going about things the right way in treating chronic ailments such as heart disease?

Vaccines were incredibly effective at wiping out certain diseases, antibiotics at treating bacterial infections. Other drugs have had a great impact on survival rates for cancer, HIV, and countless other immediately life-threatening diseases. Pharma and the medical status quo have done great things for society - no one in their right mind denies that.

But it doesn't immediately follow that drug-based therapies are the best way to treat anything and everything. And the point Derek makes about mainstream medicine focusing on prevention: taken. But focus does not mean success. Freedman's point is that mainstream medicine hasn't been SUCCESSFUL at instilling preventative behavior in its patients.

Freedman's take home message, to me, was this paragraph, which maybe came too soon in the article: "With systemic costs in mind, it doesn’t even really make sense to ask physicians—who, after all, spend hundreds of thousands of dollars and a decade of their lives becoming trained in anatomy, biochemistry, high-tech diagnosis, pharmacology, and more—to spend long blocks of time bonding with patients. Other sorts of professionals could be better at the healing, bonding, and placebo-selling part, and for less money. These might include behavioral-medicine therapists, social workers, nurse practitioners, or even some entirely new sort of practitioner specially trained for the task—and working alongside or under the direction of a conventional physician, who could continue to focus on quickly prescribing conventional tests, drugs, and surgeries when they were specifically called for."

Why not? How does that hurt anyone?

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27. Derek Lowe on June 16, 2011 4:19 PM writes...

David Freedman, it hasn't been lack of inspiration as much as lack of time. It's been a ferocious week around here - keep in mind that I have a day job in the drug industry. But as things ease up, I'll gladly revisit your article and give it the personal touch.

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28. GreedyCynicalSelfInterested on June 16, 2011 4:29 PM writes...

You need to make your pills taste like fine Belgian chocolates and write, "Somebody loves you" on the side.

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29. Tuomas Pylkkö on June 17, 2011 5:09 AM writes...

drug_hunter, well, my point was that in the early days of drug development such advances were made that it is not wise to expect similar events in other therapeutical areas.

In other words, modern drug development is not a failure for the sole reason that it doesn't reach such miraculous levels of progress currently.

Most pharmacotherapies just don't cure. The diseases are too complex to be curable by such simple methods. Especially when it comes to complex CNS diseases with multiple genetic, epigenetic and environmental causal factors.

I also wanted to state that Mr. Freedman's points were more developed and elaborate than what perhaps was claimed by the "critical views" on him.

In addition, it's a problem that will never go away: health can be defined in both a naturalistic (scientific, measurable) way and from a point of personal well being. Sometimes these two coincide, but at other times not. When they don't, there will always be people that will chose the latter option. Actually people make this choice all the time: smokers, patients with so called "life-style illnesses" that refuse to adapt other ways of life etc.

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30. simpl on June 17, 2011 9:06 AM writes...

@placebos and IBS
A high placebo effect does not mean that the desease doesn't exist, or that medicines can't/don't work.
I recall our clinical people having trouble with terbinafine for athlete's foot, as the placebo cream had over 90% improvement - they speculated that washing feet and perhaps the preserving agent in the cream helped.
Same regarding IBS - we had a serotonine subtype antagonist in the US market, tegaserod, which got pulled for a possible heart effect. I don't know if the side effect was real, but the sales increases in Mexico suggests the lengths some customers would go to. I always felt that the patients it worked for got short-changed because the FDA underrated the benefits since placebo effects are high.

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31. Josh Bloom on June 17, 2011 10:19 AM writes...

From Freedman's article: " Yet while France was ranked No. 1 in health-care effectiveness and other major measures, the United States ranked 37th, near the bottom of all industrialized countries."
You can't imagine how tired I am of hearing this from critics of the American health system. See the Wall Street Journal at : http://blogs.wsj.com/numbersguy/does-the-us-lead-in-life-expectancy-223/.
When homicides, accidents etc. are normalized across the countries being compared, the life span in the US is #1, not 37. Yet, one never hears this.

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32. ChristianKl on June 18, 2011 8:24 AM writes...

I wonder why Matthew Herper from Forbes uses a 0 - 200 - 250 - 300 scale instead of using a linear one?
Maybe because his strange scale makes the numbers look more impressive?

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33. Phil on June 18, 2011 3:15 PM writes...

@31: Infant mortality rates. Explain.

http://www.cdc.gov/nchs/data/databriefs/db23_fig1.png

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34. pitikäsiima on June 18, 2011 5:14 PM writes...

#32: Yes, the scale is adjusted, but would you kill 50000 people just to make your point?

Sometimes it's good to be scientifically skeptical and insulated from the actual meaning of the data, in this case not.

#33: Niggers. (In 4chan terms.) In more PC terms, the United States is an extremely heterogeneous society, with little collective concern for the welfare of all citizens, something more often seen in less developed countries. In most civilized societies, the death of an infant from preventable causes would represent the ultimate failure of social security - and an outrage. Not so in the U.S., where it's accepted that since some people are poor, it's OK for their children to die.

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35. zjgdmc on June 20, 2011 1:58 PM writes...

all this brings up a value judgement about what the role of the physician is. in other words how much responsibility does the doctor have over the patients behavior?

my doctor tells me to drink less beer and eat more vegetables, i nod in agreement, and then we get on with business. he knows i'm not going to change, and he's not going to waste time explaining the benefits of vegetables to me when he already knows that i know.

this Friedman article seems to really be touting for the benefits of a collective opinion on public health rather than actual medicine. it seems Friedman's wet dream is to have all the patients follow their doctors advice on lifestyle and behavior so that everyone can live for a really long time and then that will be judged as a successful medical system.

it's a dumb article.

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36. pharmaboy on July 5, 2011 4:20 PM writes...

The focus on the original article is on the importance of the placebo effect for both alternative "medicine" and standard medicine. If it faults standard medical practice, it is for not producing enough of a placebo effect due to the loss of ritual and time with the practitioner. Perhaps the current standard of medical care relies too heavily on doctors as the primary contact and others (nurses, health coaches?) could more cost effectively take on the care of patients, saving doctors to treat disease.

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