“The forces of graft and unrighteousness are peculiar to no country or clime, and they have their champions in the high places and the low. Until the people themselves are better educated concerning the danger and iniquity of quackery, they must be protected from the forces that prey. The popular understanding of these matters is becoming better every day, and, aided by proper laws, the time will come, perhaps, when quackery will be unprofitable.”
The above quote is from a recently published JAMA (Journal of the American Medical Association) article. I should say that it is republished, because it first appeared on June 8, 1912. The brief article outlines the issues surrounding the regulation of medical practice so as to protect the public from “quackery.” It is interesting to see that the issues faced 100 years ago are virtually identical (in broad brush strokes) to those we face today. Despite the fact that so much has changed in medicine over the last century, in this regard very little has changed.
To put this article into historical context, it was published just two years after the Flexner Report, generally recognized as the turning point in American and Canadian medical education when it truly embraced scientific and evidence-based practices. Mainstream medicine in 1912 was barely making the transition from being based upon tradition and authority to having scientific backing and genuine standards. Life expectancy in the US had just passed 50, up from a low of around 40 thirty years earlier. Phrenology was still practiced by mainstream psychiatrists and neurologists – although it was on the way out (having recently been refuted by scientific studies) and was increasingly being pushed to the fringe. The last purely homeopathic medical school in the US would not close until 1920. Patent medicines were still the norm, and the 1906 Pure Food and Drugs Act had only recently been enacted to establish some standards of safety in the medicine marketplace (this would essentially transform into the FDA in 1930).
Although nascent, a science-based standard of care was being embraced by the medical establishment in the early 20th century. The problem of quackery, or falsely pretending to have medical knowledge and expertise, was recognized for centuries. In 1912, as now, one key issue is regulation and the standard of care. The 1912 JAMA article states:
In Germany during the early part of the nineteenth century, laws against quackery were stringent and effective, but curiously enough, at the instance of the medical society of Berlin in 1869, the regulations against irregular practice were much relaxed and the result was a tremendous development of quackery in Germany. Berthenson1 says that in 1869 the number of quacks in Berlin was twenty-eight. In twenty-four years the number was over a thousand and the whole number practicing in Prussia was over five thousand.
We appear to be experiencing the same exact phenomenon now. As soon as regulations are lightened, dubious practitioners come out of the woodwork and thrive. There is a great deal of money to be made making false medical claims to people desperate for relief or a cure. The potential for profit is an effective an powerful force that will generate quackery to whatever extent it is allowed to exist. The article also mentions that the scope of practice for “unqualified practitioners” was greatly expanded in Prussia, leading to an explosion of quackery there.
In modern times the profit motive is coupled with the ability to lobby the government. This creates a situation in which non-scientific practitioners have a motive to persistently lobby the government for recognition, coverage, and expansion of their scope of practice. Even when those who seek to protect the public from unsafe practices oppose such lobbying efforts, it is often a losing game. Dubious practitioners ratchet up their privileges by tirelessly lobbying that overwhelms well-meaning vigilance. There is no money to be made in defending the science-based standard, while those who seek to erode that standard have a tremendous profit motive.
The only solution is for governments to recognize the need for effective regulation to protect the health consumer from fraud and from unsafe and ineffective practices.
It seems that those lobbying for a weakening of such regulations have been using the same strategy for at least a century – claim that such regulations are anti-freedom. The article notes:
This has led to strongly organized opposition, similar to the League for Medical Freedom in our country, and, as in the case of our own Congress, the opposition has found support in the Reichstag. This feeling was shown by the chilly reception which the first reading of the proposed legislation received in that body, the same reason being ascribed as here, namely, that the measure would create a “medical trust.”
The National League of Medical Freedom (1884 to 1956) served the same purpose as many “health care freedom” movements and organizations do today – to oppose any regulation that attempts to establish a standard of care. A 1910 editorial in the New York times by a Dr. Lyman Abbot demonstrates that the issues faced then were then same as now:
It is not easy to conceive any commercial interest opposed to the organization of such a bureau except the interests involved in the sale of quack medicines. The great issue of our time, perhaps of all times, is that joined in various forms between special interest and the public welfare. It is difficult to conceive any special interests more dangerous to the public welfare than those which are opposed to efficient measures for the protection of public health, unless it be those which are organized for the promotion of public vice.
Dr. Abbot was discussing the opposition by the National League of Medical Freedom to the creation of a National Bureau of Health specifically for the control of epidemics that were plaguing the country at that time, such as hookworm, bubonic plague, and “consumption” (tuberculosis). The National Bureau of Health apparently never came into being, and the Department of Health, Education and Welfare was not created until 1953.
We can see the core conflict between those attempting to promote public health through regulation and those opposing any government regulation of health care because it is inconvenient to dubious practices and health products. Today we have “health care freedom laws” in many states, the purpose of which is to erode the standard of care in medicine so that fraudulent practices cannot be regulated. Their rhetorical strategy is to convince the public that they are defending their freedoms, when in fact they are defending their own freedom to practice health fraud without government protections for the public. Health care freedom laws and anti-regulation movements are generally anti-consumer. They are designed to remove protections for the consumer from fraudulent and misleading practices and claims made by the “quack” medical industry.
DSHEA is another example of this – a law passed in 1994 as a gift to the supplement industry. In my opinion, this law is anti-consumer, and it demonstrably lead to an explosion of worthless supplement products with dubious health claims.
We can also see in the JAMA editorial another anti-regulation strategy – categorizing establishing a standard of care as elitism. The editorial refers to this as fears over establishing a “medical trust.” Of course any regulation that attempts to establish reasonable standards, quality control, and professionalism can be dismissed as elitism.
Finally, it was also interesting, and perhaps a bit disheartening, to see that the proposed fixes to the problem of quackery are the same as has been proposed by those of us defending science-based medicine today. The JAMA article concludes:
“The popular understanding of these matters is becoming better every day, and, aided by proper laws, the time will come, perhaps, when quackery will be unprofitable.”
In other words, the control of quackery is a matter of public education and effective regulation. That, in a nutshell, is exactly the agenda of Science-Based Medicine, the Institute for Science in Medicine, and other organizations dedicated today to opposing pseudoscience and quackery in health care. Our perspective tends to exist in a temporal bubble – we think that the conflicts of today are unique to us, and that we innovated the ideas we use to defend our causes. History, however, tells a different story. The conflict between reasonable standards in medicine and quackery is as old as medicine. It is no wonder that the notion of “eternal recurrence” is so common in literature and popular culture, from Peter Pan to Battlestar Galactica:
“All this has happened before, and all this will happen again.”