Alternative medicine is essentially what you get when you remove science from the equation (at least as a method of determining if an intervention is safe and effective) and emphasize marketing. Pre-FDA, for example, we lived in an era of patent medicine, where marketing was everything and the market was full of useless snake oil with vague or unproven claims. We have partially returned to that world in the post-DSHEA era. Likewise alternative medicine (regardless of the branding de jour) at its core is about eliminating the standard of care or a scientific basis for medicine and letting market forces reign.
In such a world what matters is the narrative, the story are you trying to sell. Narratives, in turn, are supported by basic concepts and buzzwords, which substitute for evidence and careful thought. For example “natural” is a marketing term, based on the appeal to nature narrative which creates a health halo around any product or service that is labeled so. It is not a coherent or internally consistent principle, just a vague sense designed to make people feel good about a product. What, operationally, is “natural”? Why would we think that something evolved in nature is good for us? Nature is generally trying to kill us for its own survival.
I was reminded of all this when I saw an article about the “Naturopathic approach” to COVID-19. The article mostly recommends herbs and supplements, thinly sourced and typically making unsupported clinical claims based on pre-clinical data. As is common they start with some common-sense recommendations, like getting enough sleep, but the core of the article is unsupported herbalism. What struck me is that the recommendations were divided into three categories: “anti-oxidant support” (potentially dangerous), “upregulating the immune system” (what part?), and “anti-inflammatory support” (dubious).
The phrasing here is due to DSHEA, which allows for “structure-function” claims for supplements, but not disease claims. Anyone can claim that anything “supports” a biological function, without the need for evidence. As long as you don’t mention a disease by name, you won’t run afoul of the FDA. But perhaps more interestingly, three of the most common alternative medicine narratives are invoked, even though they are largely contradictory to each other. They nicely represent how a health-halo buzzword is all that matters when it comes to alternative medicine.
Let’s start with anti-oxidant support. The basic idea is that oxidative stress, resulting from metabolism and specifically creating ATP (energy carrying molecules) with oxygen in mitochondria, can cause cell damage. Anti-oxidants chemically neutralize oxygen free radicals and prevent cell damage from oxidative stress. At least, this is the 1980s version of the science. In the last few decades we have learned a few interesting things about the oxidative system.
First, the body makes its own anti-oxidants, and they are orders of magnitude more powerful than anything you can get in a supplement or in food. Therefore, if greater anti-oxidant activity were advantageous, why wouldn’t we have evolved to just make a little more? This question leads to other important facts we learned about oxygen free radicals – they are used by cells for important functions. For example, they are signal molecules that trigger important protective metabolic processes. They are also (and this is important) used by certain cells of the immune system to fight off invaders. Oxidative stress can also damage cells of the immune system, so free radicals are definitely a double-edged sword.
But that is the key – oxygen free radicals exist in a delicate homeostasis with endogenous anti-oxidants. This is a complex system, and there is no reason to think that taking extra (and wimpy) anti-oxidants will somehow improve this balance. In fact, during an infection may be the worst time to take them as they may impair the immune response to the infection. At the same time, the immune response to an active infection can itself cause harm to the body, and sometimes suppressing aspects of the immune system might have more benefit than harm. How do we balance the potential benefit vs harm in any intervention that inhibits immune activity during an infection?
This requires careful study for each individual infection type. It remains to be seen if anti-oxidants are useful in COVID-19, but there is some reason to think that they may be. That is not enough, however. We need rigorous clinical trials. Our track record of predicting whether or not altering immune function will be helpful or harmful is not very good. Immune function is extremely complex, and is a delicate balance of trade-offs. Simple narratives (such as “anti-oxidants good”) are not sufficient.
The same goes for boosting the immune system and anti-inflammatory treatments. Inflammation is also what the immune system does to fight infection, and it can cause damage to the host. Are we boosting the right part of the immune system? Will this unnecessarily cause more damage? If we suppress inflammation, will that worsen the infection? These answers differ for each type of infection.
In COVID-19 it turns out that perhaps the most effective treatment discovered so far is corticosteroids. This is an old-school anti-inflammatory drug. This will worsen some infections, and improve outcomes in others. It was researched in COVID-19 because it was recognized that the worst patient outcomes may be due to “cytokine storm” – a flare of immune activity triggered by severe infection that can be devastating. But not all kinds of anti-inflammatory treatment are the same. The immune system has many components, and if you suppress the wrong one that can hamper defenses against the virus. By the same token, if you increase immune activity you may help fight the virus or increase the risk of cytokine storm or other inflammatory damage.
There is therefore no rationale for simultaneously recommending some interventions that reduce immune activity and other interventions that increase immune activity as blanket recommendations, without evidence for net clinical outcomes from a specific treatment in a specific infection. But researching specific clinical outcomes would be doing science-based medicine, and that is not what alternative medicine is. Alternative medicine is based on marketable buzzwords, applied simplistically, and without proper evidence.