Well, I won’t back down
No, I won’t back down
You can stand me up at the gates of hell
But I won’t back down

Gonna stand my ground
Won’t be turned around
And I’ll keep this world from draggin’ me down
Gonna stand my ground
And I won’t back down

From “I Won’t Back Down” by Tom Petty, 1989

This week, in a little bit of a departure, I have a minor bone to pick with our fearless leader and his podcast partner in crime Rebecca Watson (a.k.a. the Skepchick), who both managed to annoy me a bit the other day. (Don’t worry, Steve and Rebecca, I still love you guys…)

I’ll explain. You see, I had originally had a much different topic in mind for this week. Indeed, I even had my post mostly written by Saturday morning, when I had to take care of some mundane personal business, namely getting an oil change and some minor work done on my car. Since I need my car to commute to work and the maintenance needed was relatively minor, I decided to wait for the work to be done. As is my wont when sitting in waiting rooms with nothing much else to do, I decided to plug my earphones into my iPhone and catch up on some podcasts. Since the dealer also had free wifi, I brought my laptop along as well, the better to finish up my originally intended post.

The first thing I realized as I perused the list of unlistened-to podcasts was that I had fallen far behind in listening to one of my favorite podcasts, The Skeptics’ Guide to the Universe. To begin catching up, I decided to start with what was at the time the most recently available episode, specifically the July 9 podcast, figuring I could work my way back to through the earlier ones and thereby catch up with at least two episodes before my car was ready. In the second segment (beginning around 14:31 minutes into the podcast), Steve Novella and crew discussed a bit the recent news that the National Institute of Mental Health was trying to resurrect a dubious and highly unethical clinical trial proposed to test chelation therapy as a treatment for autism, referencing his excellent post on this very blog about why the trial is scientifically dubious (at best) and totally unethical. So far, so good.

Then the conversation veered into another area that I agree with, namely the utter uselessness of National Center for Complementary and Alternative Medicine (NCCAM) and how its main purpose is more proselytization for “alternative” and “complementary” medicine than actual rigorous scientific research, as I pointed out before in one of my earliest posts for SBM. As Steve pointed out that, for all the hundreds of millions of dollars spent by NCCAM, not a single new medicine or treatment has been added to the armamentarium of modern medicine, nor, even more importantly, have CAM practitioners abandoned a single bit of unscientific medicine due to any of the negative studies. Indeed, their enthusiasm hasn’t been dampened in the least. This line of discussion led to the question of whether we, as skeptics and advocates of science- and evidence-based medicine need to rethink and refocus our efforts.

It was at this point that Steve pointed out that there are quite a few of us dedicated to science-based medicine who are a bit pessimistic, using my post, which I dubbed, tongue-in-cheek of course, Resistance Is Futile. Steve and Rebecca’s reaction to my post made me think that perhaps I should be rethinking more than just how I’m going to contribute to promoting science-based medicine and opposing the infiltration of pseudoscience into academia, because apparently Steve, at least, interpreted my post as though I were saying that the whole fight is pointless and that we might as well give up. (Rebecca, I think, didn’t actually read the article, but she should.) In any case, Steve seemed to think my article was a perfect representation of this pessimistic attitude, which Rebecca characterized as as a “useless attitude to have,” a sentiment to which Steve agreed.

I agree that’s a useless attitude to have. Of course, if that were truly my attitude, I would have politely informed Steve long ago that I no longer feel it’s worth my while to contribute to this blog. Yet here I remain, as cantankerous and histrionic as ever, and my other online activities against quackery and antiscience continue apace. If that were truly my attitude, I would no longer bother to write letters, open or otherwise, to station managers about “investigative reporting” that is no more than parroting of anti-vaccine propaganda. I would not take the chance that such letter-writing would come to the attention of the public relations director at my institution. If such were truly my attitude, I would not spend so much time reading and learning about CAM in order to understand it well enough to understand what is useless (the vast majority of it) and what little gems might be found in it.

After all, if it is true that “resistance is futile” and we have already lost, why bother? Better just to hunker down, keep my head down, save what can be saved, and avoid making too many waves.

In retrospect, I suspect that perhaps I didn’t make the tongue-in-cheek aspect of my post clear enough. As regular readers of SBM know, I’m usually not particularly subtle, and I didn’t think I was subtle with my post. However, I did give my geek side free rein, complete with allusions to Star Trek: The Next Generation, the Borg, and Locutus of Borg. It makes me wonder if Steve failed to recognize my loving appropriation of other direct quotes other than the famous “resistance is futile” from Star Trek: The Next Generation‘s best villains of all time, the Borg, slightly altered in order to make my point. When I said, “The Brave(well) New World is upon us. Resistance is futile. Your life as it has been is over. From this time forward, medical culture will adapt to service CAM. Science is irrelevant,” I was actually having a bit of fun making my point, as Star Trek fans probably recognized. Not enough, apparently. Perhaps next time I’ll put a smiley emoticon after it.

Sadly, of course, there are many reasons to be pessimistic. There’s no way of getting around it. By any measure you care to name, scientific medicine is presently losing the war against quackery at every level. Advocates of scientific medicine are outnumbered, outfunded, and outmaneuvered, while the vast majority of medicine and–this is what really galls me–even academic medical faculty remains apathetic. Consider:

  1. As both Wally Sampson and Kimball Atwood have pointed out, advocates of unscientific medicine have cleverly coopted the very language of science and medicine, turning it against those who would resist the infiltration of pseudoscience, leading to Wally’s lament over how accepting we as the medical profession have become towards pseudoscience. What once was “quackery” or “pseudoscience” is now merely “unconventional” or “complementary,” and extreme lack of scientific plausibility for a treatment modality seems no longer to be a barrier to clinical trials.
  2. Through the passage of the DSHEA of 1994, the federal government has hobbled the FDA and in essence given free rein to supplement manufacturers to make almost any dubious health claim they wish, as long as the claim is sufficiently vague. Meanwhile legislators such as Dan Burton and Ron Paul lobby aggressively for “health freedom” laws that would in essence inoculate quackery from prosecution and allow quacks to operate without any pesky interference from the FDA or FTC.
  3. Due to high profile cases where state child welfare agencies have attempted to strip parents of custody of children with cancer to prevent them from choosing quackery over scientific medicine for their child, ill-advised laws, such as “Abraham’s Law” in Virginia, have been passed that in effect strip protections against quackery from teens and older children unfortunate enough to have parents who believe in unscientific medicine.
  4. As I and others have pointed out, quackery has infiltrated academic medicine to such an extent that not only are many of our major academic medical centers dedicating divisions, centers, or departments to what Dr. R. W. Donnell has termed “quackademic medicine,” but at least one has required it as part of the mandatory medical school curriculum from day one, bringing a whole new meaning to the term “integrative” medicine, as it integrates scientific medicine with pseudoscientific quackery.
  5. Meanwhile, Dr. Andrew Weil has succeeded in “integrating” pseudoscience into the eight family practice residencies, with more virtually guaranteed to follow, and Dr. David Katz at Yale has constructed the foundation for an academic empire of woo based on a more “fluid” concept of evidence.
  6. The Bravewell Collaborative has many millions of dollars to spend promoting unscientific medicine to any medical school or academic medical center willing to receive its largesse.
  7. NCCAM has a budget of over $120 million a year and has spent over $1 billion so far researching, but also promoting CAM. Worse, it is funding trials that are not only scientifically dubious but arguably downright unethical; for example, the TACT trial of chelation therapy for atherosclerotic coronary artery disease, the trial of the “Gonzalez regimen” for pancreatic cancer, and the proposed trial of chelation therapy for autism. Adding an approximately equal money to the pot of CAM funding is the National Cancer Institute, which funds over $120 million a year worth of CAM research related to cancer.
  8. Legislatures are passing laws that not only recognize unscientific “healing” traditions as legitimate professions but some states have even mandated that health insurance plans pay for such “treatments.”
  9. Anti-vaccine activists are sowing fear and distrust over vaccines, even going so far as to march on Washington. As a result, in the U.K. measles, once thought conquered, has become endemic again, and in the U.S. measles outbreaks are increasingly common.
  10. Our government is making deals with China to study “traditional Chinese medicine,” possibly as a quid pro quo for the Chinese granting the FDA inspection stations in Chinese cities, possibly as an attempt to control adulteration of Chinese herbal medicines.

Yes, folks, it’s bad out there in medicine right now. Real bad. Horribly, bad. So bad that even our ever optimistic leader Steve recently agreed when Quackwatch webmaster Stephen Barrett characterized the era we live in as the “golden age of quackery and antiscience.” There’s nothing to be gained for us by pretending otherwise other than perhaps the happy self-delusion of ignorance, and we have to face facts: The situation isn’t going to get better any time soon, no matter what we do. In fact, it very well may continue to get worse for the foreseeable future. That’s not being “pessimistic.” It’s being realistic. The forces arrayed against scientific medicine are strong, well-funded, and utterly ruthless about forwarding their agenda, the “integration” of antiscience with science. Maybe resistance is futile. Maybe science is irrelevant. Maybe scientific medicine will be forced to adapt to serve CAM. Maybe Rebecca and Steve characterized my attitude correctly. Maybe we advocates of science-based medicine have already lost the struggle.

To which I reply: Hell, no! Or, to echo Rebecca Watson’s words right back at her, “Screw that!”

I can speak for no one but myself, but, as Steve said in his podcast, while breath remains in me and I can still do something, I will not give up, even though I do not anticipate anything resembling victory in the few decades I’m likely to have left on this earth. The stakes are too high, and future generations will not judge us kindly if we surrender to antiscience with a whimper. In this age of seeming science, where the human genome has been sequenced, where we understand more than at any time in history about how the body works and where things break down to result in disease, it is a bitter irony that it is at this very same time that academic medicine is retreating to therapies based on pre-scientific concepts of how nature and the human body work. Thanks to unprecedented scientific advances in our understanding of disease, we stand at the threshold of what could be a golden age of medicine and surgery. It is profoundly disturbing to me that it could be reasonably characterized by anybody as a “golden age of quackery.”

I happen to be a World War II buff and have been ever since I was around 12 or so. As a teenager, I used to devour books on World War II history. When I was a teenager I had a simplistic understanding of the war, but as I got older I realized that the situation was always more complex than the simple narrative that we are taught in school. I also now realize that using World War II analogies is fraught with danger in that it’s hard not to fall prey to Godwin’s Law. However, I point out that World War II remains a good analogy for not giving up even when things seem utterly beyond redemption.

Think of the world in May 1942, six months after Pearl Harbor. Put yourself in the Allies’ place. Europe was in the hands of the enemy, who was rapidly advancing east into Russia, having only been stopped within sight of the minarets of the Kremlin, only to advance on new fronts to the south in the spring. In the Pacific, Japanese forces had driven U.S forces out of Guam, the Philippines, Wake Island, and virtually the entire Pacific west of Hawaii other than Midway Island and Australia. By any measure, the Allies were in deep, deep trouble. I imagine myself alive at that time, beset by a constant barrage of bad news, of loss after loss and retreat after retreat. How could anyone alive at that time believe that the Allies would eventually not just prevail but utterly destroy their enemies less than four years hence? Or picture yourself in London in the fall of 1940, with wave after wave of bombers hitting your fair city and other cities in Britain, pushing the RAF to the brink of destruction fending them off. How could any Londoner alive in late 1940 ever envision total victory less than five years hence?

Of course, the battle we are in is not World War II and CAM advocates are certainly not Nazis (with the possible exception of Ernst Zündel and Dr. Lorraine Day; every movement has its bad apples, I guess), but in terms of whether medicine continues to strengthen its fragile commitment to a scientific basis for its treatments or retreats to the age of Samuel Hahnemann it is every bit as apocalyptic. In terms of the strategic situation, we advocates of science-based medicine are the Allies in 1942, except that we cannot count on a brief battle during four days in June near Midway Island to turn the tide of the war. There will be no sudden reversals. Our task is more akin to the “island hopping” that the U.S. Marines undertook in the Pacific, in which Marines starting with Guadalcanal had to take one little island after another away from the Japanese, than it is to D-Day.

And, yet, despite how badly we are outgunned, outnumbered, and out-spent, there is reason for hope. It is at the moment but a glimmer, but if we can convince enough physicians that there is a serious problem we may have a chance. Particularly heartening to me is that in the last year we have seen something I cannot recall ever seeing before: three major books on alternative medicine that do not represent feel-good, credulous acceptance of the tenets of unscientific medicine. They are not books whose authors you are likely ever to see on The Oprah Winfrey Show any time soon. No, rather they are hard-nosed, skeptical, and they take no prisoners in describing why the vast majority of so-called CAM is nothing more than a demonstration of the power of the placebo effect and all-too-human cognitive shortcomings that all humans, doctors and patients alike, have. I’m referring, of course, to R. Barker Bausell’s Snake Oil Science: The Truth about Complementary and Alternative Medicine; Simon Singh’s and Edzard Ernst’s Trick or Treatment: Alternative Medicine on Trial; and Rose Shapiro’s Suckers: How Alternative Medicine Makes Fools of Us All. Moreover, as the popularity of CAM grows and as it infiltrates “conventional” medicine more and more, inevitably its profile will become high enough that even the apathetic physicians may become alarmed as stories of patients who come to harm through quackery come to light. There will be a backlash; indeed, the backlash may have already started. For example, just last month, the FDA, roused out of its torpor for reasons known only to its leaders but nonetheless fortuitously, started an aggressive campaign to stop the selling of fraudulent cancer “cures.” Meanwhile, there is a growing and vibrant movement in the medical and scientific blogosphere to counter the pseudoscience that makes up so much of “alternative medicine.” Indeed, that may be our last, best hope for ultimately prevailing. All is not lost, but it could be if we allow ourselves to fall into complacency again.

Of course, what the Allies had in World War II were leaders who would not give up, who would not surrender, no matter how hopeless the situation seemed. There was Winston Churchill saying in the darkest depths of the war after the fall of France and the retreat at Dunkirk:

We shall go on to the end, we shall fight in France, we shall fight on the seas and oceans, we shall fight with growing confidence and growing strength in the air, we shall defend our Island, whatever the cost may be, we shall fight on the beaches, we shall fight on the landing grounds, we shall fight in the fields and in the streets, we shall fight in the hills; we shall never surrender, and even if, which I do not for a moment believe, this Island or a large part of it were subjugated and starving, then our Empire beyond the seas, armed and guarded by the British Fleet, would carry on the struggle, until, in God’s good time, the New World, with all its power and might, steps forth to the rescue and the liberation of the Old.

Where is science-based medicine’s Winston Churchill?

Speaking of World War II analogies, I’d even settle for science-based medicine’s Bluto Blutarski (from one of the greatest comedies of all time, Animal House) asking, “Was it over when the Germans bombed Pearl Harbor?” and confidently rallying the troops by bellowing, “Nothing is over until we decide it is”:

How’s that for a more accessible pop culture reference than the Borg? That scene from Animal House always makes me laugh. In this context, I can’t help but think that an SBM Deathmobile would be an über-cool thing to have, perhaps with the head from a statue of Samuel Hahnemann bolted to its hood instead than the head of Faber, as was used in the movie. The humor aside, the scene above also has a very cogent message for us: No matter how bad things are, never give up. There is always something that can be done, although in our current predicament as advocates of scientific medicine what should be done probably doesn’t involve armor-plating a car, painting it black with skulls on it, and crashing it into the grandstand at a parade. Bummer.

I realize that I’ve not only painted a very dire picture but probably also gone completely off the deep end with the World War II analogies. No doubt some of the woo-friendly commenters here (and perhaps even some of those on “our” side) will react to this post with the conclusion that Gorski has completely lost his friggin’ mind–or at least lost all sense of proportion and restraint. (I can see Steve holding his head in his hands, muttering under his breath something about what on earth was he thinking when he invited me as a regular on SBM.) But desperate times call for desperate rhetoric. Just as I painted an intentionally bleak picture in my last post as a wakeup call, in this post, I want to do the same thing, but without being so dark. I want you to realize that, as bad as things are now, there is still some reason to hope, but nurturing that hope from a sputtering spark to a roaring flame will require fuel, and that fuel is passion coupled with an understanding not only of what we’re up against but the will to act against it. Either that, or I’m bipolar, with my original post being written when I was in a depressive phase and this post being written while I am in a manic phase. You be the judge.

Fortunately, I also don’t think that resistance to the infiltration will require that a “really futile and stupid gesture be done on somebody’s part,” as Animal House tells us in the scene above. Taking the long view, I realize that it may, however, require the proverbial fight with conventional weapons that will take years. It will, mainly, require that advocates of science-based medicine who have until now been keeping their head down become involved and vocal. Too, it will require years, if not decades, of resistance, diplomacy, and, yes, public relations, as much as we hate that term. It will require fighting smart, because that’s the only way to win against forces that are so much stronger than us, and it may require us to get our hands dirty in politics. It may require strategic retreats, and it will definitely require that we as advocates of science-based medicine be willing and sufficiently open-minded to embrace any aspect of CAM that is actually scientifically validated, thereby making its strength our strength. Dedication to science and patient care demands no less, because, as I have said many times before, there is no such thing as “alternative medicine,” just medicine. Most importantly, however, it will require that we rethink what we are doing, because clearly what we are doing is not working. A major change in strategy is clearly required.

Whatever this battle requires, though, I ask myself and I ask the readers of this blog who are dismayed at the infiltration of woo in medicine: “Are we just the guys to do it?”

Well, are we?

And, if we are “just the guys (and gals) to do it,” then what, specifically, are we going to do? We’re getting our posteriors handed to us in a sling right now. Something has to change. I don’t yet know just what yet (stay tuned), but, as Pete Townsend once so eloquently put it, “The music must change.”

My answer to the question “Is resistance futile?” is this: Hell, no! And, even if it were, when the day comes when I lie on my deathbed looking back at my life, I would never be able to forgive myself if I just gave up now. But we need to realize something. If we don’t change tactics, we will lose, and it could be many decades before scientific medicine recovers.

So I ask again: What are we going to do about it?

COMING ATTRACTION: In a future segment (although probably not next week), I will try to lay out some suggestions of just what can be done now. Hopefully, I will accomplish this in a much more coherent and less histrionic fashion.

Posted by David Gorski

Dr. Gorski's full information can be found here, along with information for patients. David H. Gorski, MD, PhD, FACS is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute specializing in breast cancer surgery, where he also serves as the American College of Surgeons Committee on Cancer Liaison Physician as well as an Associate Professor of Surgery and member of the faculty of the Graduate Program in Cancer Biology at Wayne State University. If you are a potential patient and found this page through a Google search, please check out Dr. Gorski's biographical information, disclaimers regarding his writings, and notice to patients here.