Applying evolutionary principles to alternative medicine again

Yesterday, inspired by a post by fellow ScienceBlogger Martin, I had a little fun discussing the evolution of “alternative” medicine (a.k.a. “complementary and alternative medicine” or CAM), specifically speculating about the possible selective pressures, positive and negative, that have influenced the course that its evolution took. Essentially, the discussion centered around whether, by its very nature CAM undergoes negative selective pressure for having as little effect as possible, positive or negative, a point I found somewhat, but not entirely, convincing. Although the post inspired a bit of a troll invasion (well, one troll, anyway), the discussion in the comments was rather interesting. It also led me to believe that perhaps I hadn’t considered more recent developments in the history of CAM sufficiently in applying the principles of evolutionary biology.

As I pointed out before, the very terminology used to describe the hodge podge of non-evidence-based remedies has undergone considerable evolution to bring us to the politically correct term that seems to be used the most frequently, CAM. Originally, the term “alternative” medicine, under selective pressure to appear more mainstream, morphed into “complementary” medicine; i.e., medicine that was used alongside or in addition to conventional medicine. The problem, of course, is that many people do use these remedies largely instead of conventional medicine. Hence, the fusion of the two terms occurred, to “complementary and alternative medicine” (CAM). There’s a reason for this, and it has to do with the relationship between scientific medicine, as epitomized by academic medical centers, and CAM.

So what is that relationship? My first thought was that CAM was adopting an evolutionary strategy not unlike that of dogs or cats. In other words, it was subsuming itself to its more successful competitor, conventional medicine, in much the same way that ancient wolves were domesticated by humans and ultimately started to speciate into dogs. The problem with that analogy, of course, is that both human and dog gain benefits from their relationship. Humans gain companionship and work from dogs; dogs gain protection and a reliable source of food. It could be argued which species gains more, human or dog (probably humans early on and dogs now), but there is little doubt that both species benefit. So, in the relationship between CAM and conventional, who benefits?

The answer is obvious: CAM. Scientific medicine does not need CAM, but these days CAM appears to need scientific medicine. Indeed, the very name CAM was adopted to allow alternative medicine to seem more palatable to practitioners of conventional medicine and ease its ability to insinuate itself into academic medicine, which, as I’ve documented extensively, is having increasing success in doing so, even to the point of finding its way into the curriculum of various medical schools.

What this tells me is that we’re looking at a “speciation” event in alternative medicine. There is a strain of alternative medicine that fits in with the whole movement towards CAM in medical schools, and there is a strain of alternative medicine that does not. Now here’s where Martin’s idea of selective pressures favoring placeboes in alternative medicine comes in. The strain of alternative medicine that either excessively credulous or cynical academicians embrace falls under exactly the sort of selection pressure that Martin discussed that favors minimal effects. The reason is simple. The two most common justifications used for including CAM in academic medical centers are (1) the patients want it and (2) the perception among academic physicians that it won’t do any harm anyway and seems to make patients feel better. Consequently, the most common varieties of CAM in such settings are massage therapy, meditation, acupuncture, yoga, and nutrition-based therapies. Oddly enough, arguing against Martin’s idea is that seldom will you see homeopathy in academic medical centers, at least in the U.S. I speculate that that is because in such settings, there is also a negative selective pressure against extreme scientific implausibility–at least upon the initial incursion.

So what term best describes the relationship between CAM and academic medicine? Certainly CAM advocates would argue that it’s a symbiotic relationship. I would counter that it’s a parasitic relationship, and here’s why. Parasitism is defined as a relationship where one organism benefits and the other is harmed. CAM is indeed parasitic. It benefits from its association with academic scientific medicine by obtaining a level of plausibility and respectability that it could never obtain on its own, while it arguably harms academic medicine in the process. True evidence-based medicine is what academic medical centers are ostensibly built to promote, applying the scientific method to medical therapies in order to find more effective treatments. What academic medical centers should be doing is to educate the new generation of physicians in the scientific method, to better prepare them to be able to evaluate claims for treatment, whether they come from conventional medicine or elsewhere. This is how medicine has advanced so rapidly over the last 60 years. Blurring the line between science and non-science, evidence-based medicine and woo, through the enthusiastic promotion of CAM in medical school curricula, harms that endeavor, both by degrading the ability of physicians to think critically (thus preparing them to accept even more implausible treatments) and by wasting money and resources to study obviously highly implausible gobbledygook before there’s any good evidence that it does anything at all beyond the placebo effect that could be better used to study more promising science-based modalities. It would be one thing if CAM were being studied from a truly scientific perspective. I don’t object to that; indeed, I encourage it. A true scientific examination of the vast majority of CAM will likely find it useless, while a few gems might be pulled out of the dirt. Unfortunately, though, as I’ve mentioned before, that’s not what usually happens. What almost invariably happens is that CAM is used as a marketing tool.

As is often the case, Panda Bear, MD gets it right in describing this parasitic relationship:

Suppose I were to actually build a house. Along with a foundation it would require framing of the walls and floors, siding, wiring, glazing, plumbing and a dozen other skilled trades coordinating their efforts. The practioners of Complementary and Alternative Medicine would be like your Aunt Mildred telling you how to hang the toilet paper in the finished bathrooms and then trying to claim credit as an essential part in the construction. Complementary and alternative medicine only exists because real medicine does all of the heavy lifting leaving a risk-free enviroment in which it may ply its patent remedies. At best it’s an afterthought, something that legitimate hospitals add to their services to attract the kook money. At worst it’s a cynical ploy to fleece a little extra from the desperate, many of whom are dying and will gladly pay for another straw to grasp. In no way is it an essential part of medical therapy except that it provides entertainment to the patients and their families while medicine and nature run their courses.

Precisely.

Conventional medicine fights the real battles and faces the real danger of failure, while increasingly CAM attaches itself to conventional medicine, much as the parasitic roundworm Ascaris lumbricoide finds its way into the small intestine of its host. CAM benefits from its association, but its host, conventional medicine, most definitely does not. At best it is not harmed; at worst, grave harm to scientific medicine is possible.

All this speculation leads me to believe that the form of CAM that increasingly thrives in academic medical centers is indeed developing into a new “species” of woo, so to speak. It’s wraps itself in scientific-sounding terminology and, for the most part, discards the more outrageously silly religious and supernatural elements that it can, all in order to become seemingly inoffensive enough that academic physicians, although they may not approve of it, remain insufficiently sufficiently alarmed by it to rise up and purge the system of this parasite. Meanwhile, the parasite grows in number and strength, continually weakening the body of academic medicine the longer it stays. Eventually, like the roundworm, it spreads its eggs where more and more academic medical centers can pick it up until it is so entrenched and self-perpetuating that it can’t be dislodged without resulting in severe injury or death to the host.

MORE DISCUSSION OF THIS CONCEPT:

  1. Orac: Selective pressures and the evolution of alternative medicine
  2. Steve Novella: Alternative Medicine and the Evolution Analogy