1. INTRODUCTION:
In 1984, the British Columbia Medical Association (BCMA) set in motion an initiative the purpose of which, many believed, was to eliminate complementary and alternative medicine (CAM) from the Medical Services Plan of British Columbia (MSP) by the year 2000.
The intent of this report is to document the existence and activities of this plan.
2. BACKGROUND:
The Medical Services Plan of British Columbia (medicare) is the Provincially funded health-care system. The Plan provides British Columbians with a broad range of both conventional medical and "supplementary benefit" services. Supplementary benefit services include Registered Massage Therapy, Chiropractic, Physical Therapy, Naturopathy, Podiatry, and Optometry.
In the case of Registered Massage Therapy, Chiropractic, Physical Therapy, and Naturopathy, each MSP subscriber may receive 12-15 visits (12 before age 65, 15 at 65 and older) per year of each of these therapies, partially covered by their MSP premiums. Patients who wish to visit a Registered Massage Therapist must first obtain a physician's referral for treatment of a specific medical condition.
The fact that these services have been part of the Medical Services Plan for decades, and that physicians have traditionally referred to Massage Therapy and Physical Therapy regularly for medical conditions, is significant because it suggests all these services are, in some sense, "medical" or "medically necessary". The public also has the perception that, because these services are within the Medical Services Plan, they must be "medical" or "medically necessary". As we shall see, organized medicine is attempting to change the public's perception of what is, and is not, "medical" and "medically necessary", and therefore what should, and should not, be included under the Medical Services Plan.
3. COMPLEMENTARY AND ALTERNATIVE MEDICINE:
In the context of this report, when the title "Complementary and Alternative Medicine" (CAM) is used, the reference is specifically to those supplementary benefits included within MSP. Most often, the title refers to Registered Massage Therapy, Chiropractic, Naturopathy, Physical Therapy, because these (especially the first two) are the most frequently named targets of the BCMA's plan. It should be kept in mind, however, that Complementary and Alternative Medicine is a term in wide use in the year 2000 and encompasses just about every health-care practice except conventional Western medicine. However, the designation is fluid. Only a few years ago, Complementary and Alternative Medicine was defined by Dr. David Eisenberg as "medical interventions not taught widely at US medical schools or generally available at US hospitals. Examples include acupuncture, chiropractic, and massage therapy." (Eisenberg, et. al., "Unconventional Medicine in the United States", The New England Journal of Medicine, January 28, 1993.) In l998, Dr. Eisenberg, speaking in Vancouver, Canada at "The Art and Science of Healing" seminar, added that his earlier definition had become dated because, already, at least 30 medical schools in the US were teaching courses in CAM. And, he commented on the inadequacy of the original definition to describe a field so diversified as CAM.
In the context of this report, Complementary and Alternative Medicine (CAM) is being used exclusively to refer to supplementary benefits currently included within the Medical Services Plan of BC, and in some instances, alternative interventions which British Columbian physicians may be practicing: in short, those interventions and services targeted by the BCMA and College of Physicians and Surgeons for removal.
It will be seen later that organized medicine in British Columbia has very cleverly begun changing the designation from "Complementary and Alternative Medicine" to "Alternative Therapies". De-medicalizing CAM by changing "medicine" to "therapies" is an intentional substitution of words designed to manipulate people's perception. This tactic is used in advertizing, and here it is being applied to make people stop thinking of CAM as a form of medicine. If people stopped thinking of Chiropractic and Massage Therapy, for example, as broadly speaking forms of medicine, then it would be logical that they should not be included within the Medical Services Plan. People might be more willing to accept their removal, or even vote for it, if they no longer perceived supplementary benefits as part of the medical system.
4. CONVENTIONAL MEDICINE:
For the sake of this report, conventional medicine is being defined as so-called "evidence-based" Western medicine. This is the terminology which the BCMA and College of Physicians and Surgeons of BC (COPSBC) use. These groups wish to draw the distinction between interventions which (they say) are "evidence-based" and those which (they say) are not. As we shall see later, according to this view, only conventional medicine is evidence-based, that is, scientifically proven, while "alternative therapies" are generally (they say) unproven. This gross distinction serves to further exclude "Alternative Therapies" from the category of "medicine", again influencing perception--as well as policy. As we shall see, the BCMA wants only "proven" interventions to be funded by medicare. Since, it is alleged, only conventional medicine is a scientifically "proven" intervention, and all other interventions are "unproven", it follows that only medicine should be funded by medicare. Since this policy comes from the group most likely to benefit from its adoption, one must wonder at its objectivity.
5. PROJECT 2000:
Registered Massage Therapists, Chiropractors, Naturopaths and other complementary and alternative medical (CAM) practitioners currently receiving partial funding from Medical Services Plan of BC could lose their coverage if the British Columbia Medical Association (BCMA) and College of Physicians and Surgeons of BC (COPSBC) have their way.
As just indicated, these groups argue that CAM practices are "generally unproven therapies" with potential risk of harm and, as such, should not be funded by tax payers' dollars. Only "proven therapies", those scientifically demonstrated to be safe and effective, should be covered by MSP.
The argument continues that medical therapies are "proven" therapies; therefore, this logic insists, any therapy which is "unproven" cannot be medical. It would seem to follow, as a matter of definition, that non-medical services should not be covered by the Medical Services Plan. If events follow this logical course, the MSP would fall completely into the hands of physicians. Would the surgical removal of CAM from MSP truly be performed in the interest of the economic well-being of medicare and the safety of the public? Or, would it really be the final inning in a secret gameplan carefully constructed to eliminate competition with mainstream medicine within the medicare system?
The answer may be found sixteen years ago, in June 1984, when the BCMA Steering Committee introduced "Project 2000". Chaired by BCMA president Dr. Gerry Karr, Project 2000 was described as a "global political strategy plan" (BC Medical Journal, April 1985) and was disseminated in the form of a newsletter called Current bearing the BCMA logo on its cover. Circulated to "BCMA members and selected non-medical persons" (Project 2000 Current, December 1986, vol. 2, no.5), Project 2000 was a semi-secret initiative, its full dimensions and intent hidden from public scrutiny until now.
The plan "was designed to operate on two levels: public and political, creating an awareness in both arenas that changes were necessary to maintain top quality care." (Project 2000 Current, December 1986, vol. 2, no.5.) In the public arena: "The flagship of Project 2000 is the CBC television series, Doctor Doctor, starring the doctors of British Columbia." (Project 2000 Current, December 1986, vol. 2, no. 5) Dr. Gerry Karr appeared frequently on TV and radio talk shows. In the political arena: MDs attended workshops which "included presentations from key politicians...and included role-playing on how, and how not, to communicate with MLAs. A reception and individual dinner climaxed the day." Media relations, described as "always occupying a high priority with the BCMA", became "fined-tuned during the first year of Project 2000." Dr. Karr and a "team" from the BCMA "met with the editorial boards of two major newspapers and...(planned) sessions with individual journalists." (Project 2000 Current, December 1986, vol. 2, no. 5.)
As an overview of Project 2000, the Current newsletter pictured a labyrinthine flowchart, BCMA at the top, tentacular lines of influence extending from it to physicians, public, media, and government; leading to hoped for changes in opinion, policy, and legislation in these areas. Truly, a comprehensive or "global" strategy. But what was the message being sent?
The message of Project 2000 seems a matter of interpretation, depending upon whether one shared the values of the project's creators or not.
According to Dr. Gerry Karr, Chairman of Project 2000 and credited with spearheading its development, it was a public awareness program on health issues. In the BC Medical Journal, June 1985, he said: "Project 2000 will not spell doom and gloom. Nor will it be about the leadership of doctors...(but it will be about) excellence in health care in BC."
Critic Geoffrey York, writer for The Globe and Mail at the time, in his book, The High Price of Health, A Patient's Guide to the Hazards of Medical Politics (1985), presented a more cynical interpretation of Project 2000's objectives. Quoting the BCMA: "'(the objective is) to restore the strength of the profession (of medicine) and return it to its traditional role of being the senior health care providing group. It will attempt to decrease the influence and power of those individuals and groups, less qualified than physicians, who are making health-care decisions.'"
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Unfortunately, York did not document who in the BCMA said these words and if the quotation came from a primary source, such as Current. Consequently, as of this present writing, Project 2000's mission (beyond what was said in the pages of Current which this writer has been able to obtain, and what Dr. Karr and others on the committee said about Project 2000 in the BC Medical Journal) must remain in the realm of circumstantial evidence. York's statement represents one interpretation through which to view events between 1985 and the present.
Indeed, when the reader examines the stated targets of influence which were depicted in Current (government, media, public, physicians), and reads the BCMA's website today, and listens to recent news about the BCMA's activities in these targeted areas, some may agree with writer York's interpretation as to the underlying agenda of the BCMA because what is happening now looks like what he said was happening then. Ultimately, of course, it is the BCMA's present-day activities which are of most significance. Today, their agenda or mission is more easily discerned from primary sources such as the BCMA's website and the BC Medical Journal. More about this shortly.
But, back to the story in 1985:
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Was Project 2000 about the "leadership of doctors" after all? Indeed, in a seeming attempt to "decrease the influence and power" of CAM, the BC Medical Journal (April, 1985), warned: "Physicians...must exercise diligence in guarding the necessity that only needed medical services are paid for.... For example, the present practice of partial funding of chiropractic and massage therapy represents nothing more than government acquiescence to political pressure and media manipulation rather than a rational use of public funds for medically required services." In condescending, rather than scientific, language, this anonymous writer continues: "Alternative health-care providers are too willing to rely on untested theories while 'curing'; they often claim to treat nebulous problems for anxious or gullible patients, who are basically healthy but merely searching for reassurance. Physicians, on the other hand, rely on rational scientific validation of the methods they use to treat patients. It is these medical services that are based on scientific medicine which should be preserved for Medicare dollars, and no other." This article was unsigned, a peculiar footnote explained, because it did "not necessarily represent the opinions of the writer"! We cannot be sure the views expressed were those of Project 2000 sympathizers or those of the BCMA generally, but they seem likely to have been. On the other hand, identical messages are being sent by the BCMA today, and are clearly documented on their website and on the College's website, as well as at anti-CAM seminars where the BCMA sends its speakers. The core message being promoted: CAM services are "inessential"; CAM is "unscientific" and non-rational; conventional medicine is "scientific" and "rational"; and the public is "gullible".
That this view may have been influenced by Project 2000 is given further credibility by M. Jane Fulton in an essay, Comparative Lobbying Strategies Influencing Health Care Policy (1985). She quotes the Chair of the BCMA Public Awareness Committee of Project 2000 as saying: "'MDs cannot afford to let others dominate input on health care issues.'" She describes the BCMA as being driven by a need to increase revenue for physicians; as being subject to influence by personalities within the association; as having "almost no accountability to government." She describes the BCMA's targets for influence as the Ministry of Health, MSP, politicians, and top bureaucrats. Interestingly, she describes the BCMA as having low cohesion, that is, as being factional. The serious reader should, once again, note that F.J. Fulton's essay is not a primary source, and is thus in the realm of circumstantial evidence, not proof, but may be used to interpret current or future events.
Project 2000 formally dissolved three years after its creation, due to lack of funding. The medical mindset and message many believe it represented persist to this day in their incarnation as the BCMA's "Alternative Therapies and Allied Health Committee." The name has changed, as have some of the faces, but apparently not the mission. CAM has obviously not been destroyed by the year 2000--in fact, it is stronger than ever--but the BCMA is working to undermine CAM at the present time. Interestingly, unlike Project 2000, many of the BCMA's current plans are now public, being displayed for all to see on their website. Amazingly, the BCMA seems not to realize the potentially disturbing impact their activities may have on the public once they have been brought to their attention.
6. ALTERNATIVE THERAPIES AND ALLIED HEALTH COMMITTEE:
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The BCMA’s website (see web address at end of this report) clearly states a "seek-and-destroy" style mission. The BCMA's Alternative Therapies and Allied Health Committee's avowed intent is "to study so-called 'Alternative Therapies' by both licensed and unlicensed practitioners...and also the activity of so-called 'Allied Health' workers, both licensed and unlicensed. The committee focuses on the effects of these activities on the health of citizens in British Columbia, and the impact on medical practice in this province." While this sounds reasonable enough, a few lines later, in intimidating and not very scientific language, the BCMA warns that therapies "found to be non-efficacious, dangerous, exploitive or otherwise clinically or ethically unacceptable to the profession (of medicine), will be recommended to be exposed as such, and dealt with as judged appropriate by the board of the BCMA." (We are reminded of York's attributed quote from Project 2000 sixteen years earlier: "to decrease the influence and power of those individuals and groups, less qualified than physicians, who are making health-care decisions...") If this sounds heavy-handed and legalistic coming from a medical association, it should be recalled that the BCMA has no authority to judge anyone, even its own members, and it certainly has no legal power. Having said that, the BCMA does exert considerable influence on its target groups such as physicians, public, media, and government, as we have seen.
The Committee's determination to influence physicians' opinions about CAM--and change their referral patterns--is evident in their choice of speakers at their general meetings. In 1997, according to their website, the BCMA invited Dr. Barry Beyerstein from Simon Fraser University, "a well-known brain-behaviour scientist with a special interest in critical assessment of the claims of 'alternative medicine'. He also chairs the BC Skeptics. He...provided a penetrating review of the medical and psychological pseudoscience that is being uncritically promoted and currently receiving some acceptance."
Dr. Beyerstein is a frequent speaker at "CAM-slam" seminars, such as "Critically Evaluating Alternative Medicine: Assessing the Efficacy and Safety of Unconventional Medicine", held in Vancouver in November, 1999. He has his own website devoted to debunking "quacks", and often speaks in conjunction with Dr. Wallace Sampson, another well-known "quack-buster" who publishes a US journal entirely devoted to critically assessing CAM.
Inviting someone famous for his bias against CAM to speak to doctors--and not inviting representatives for the CAM position to the same meeting--is hardly being objective or fair to physicians.
How can physicians become informed about CAM, and advise their patients intelligently, if only the anti-CAM viewpoint is presented to them at their meetings and seminars? This bias goes beyond in-house intellectual or philosophical prejudice: what doctors think doctors ultimately act upon, and this unfortunately affects their patients--for good or for ill. If doctors are being taught prejudice, in the name of "scientific opinion", this is a dangerous thing for patients. The physicians' biased opinion about CAM could dissuade patients from taking advantage of what CAM has to offer--which could impact on their lives and health.
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The Committee is intent on getting the message to physicians everywhere. It sends speakers to CAM-slam seminars, such as the R.A.M. (Rational Alternative Medicine) seminars which tour Canada; and the Committee's Dr. Lloyd Oppel is president of Canadians for Rational Health Policy, a watch-dog organization that "advocates the development of health policies and programs based on the best available scientific evidence". The CRHP website features articles by Dr.Beyerstein and has links to quackwatch.com, chirowatch.com, the former National Council Against Health Fraud, and the McMaster University Evidence-Based Medicine Project. Always, the BCMA's Alternative Therapies and Allied Health Committee promulgates the same message: "unconventional therapies" are scientifically unproven as to safety and efficacy, while only conventional medicine is scientifically proven safe and effective. Over and over, it is stated that unproven therapies should not be funded by medicare. This relentless logic leads to the inescapable conclusion, therefore, that only conventional medicine should be funded by medicare. A great deal more will be said about this later. (Readers wanting to assure themselves that this is, indeed, the BCMA's position may refer to their website and to the website of the College of Physicians and Surgeons of BC where this position is made unmistakably clear.)
Acknowledging the influence CAM is having on the public, the BCMA says, almost defensively: "There is clearly a need to keep emphasizing the importance of Western mainstream evidence-based practice in medical care and health care, both to the public at large and to workers in the health-care field, including physicians." (One is reminded of Project 2000 sixteen years ago: "to restore the strength of the profession (of medicine) and return it to its traditional role of being the senior health care providing group.") It is also curious that this is one of the few times the term "Western" mainstream medicine is used. Apparently, the BCMA is sensitive to the increasing presence of "Eastern" medicine and sees a need to remind its members of the importance of Western medicine.
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Admitting a serious complaint about physicians which has frequently been voiced in national surveys and in their professional journals, the website continues: "Clearly, some members of the public feel that physicians do not meet their health-care needs. ...Technical competence may be present, but patients often complain that 'the doctor's always in a hurry' or 'he didn't seem to care'.... It seems likely that unconventional healers, being relieved of the requirements to practice medicine to current mainstream standards, intuitively put extra effort into achieving rapport with the patient." Apparently, the BCMA's explanation of this generally recognized complaint against physicians is that they are so involved with the technical demands of their work that they may sometimes lack the sensitivity to their patients which "those...less qualified than physicians, who are making health-care decisions", have the luxury to provide almost accidentally ("intuitively"), rather than according to their expertise in communication skills.
The BCMA's website continues, in somewhat derrogatory tones: "In many cases the specific modality, such as therapeutic touch, or homeopathy, may simply be a magical metaphor for caring and healing. A physician, by having more responsibilities, has more challenges, but medical training and experience still equips the physician, better than anyone else, to give needed medical care."
Is this not reminiscent of York's vision of Project 2000's mission "to attempt to decrease the influence and power" of the competition? In passing, it might be noted that the "magical metaphor", homeopathy, is widely practiced, and accepted, by physicians in Europe; and, therapeutic touch has been practiced regularly in Saint Paul's Hospital in Vancouver as well as at hospitals in New York City. Both homeopathy and therapeutic touch have studies written about them.
More concretely, the BCMA attempts to limit the competition by interposing its "Expert Advisory Committee" between the Insurance Corporation of British Columbia (ICBC) and CAM therapies: "Dr. Lloyd Oppel responded on behalf of the committee to a request from ICBC for assistance. He has organized a freestanding Expert Advisory Committee that will be available to advise ICBC on the available evidence to support requests for funding of unconventional therapies. This is a very important issue." (BCMA website) Important, indeed. Since the BCMA already considers CAM "unproven", and takes the position that unproven therapies should not be funded, is it any wonder what the Expert Advisory Committee will advise ICBC about funding therapies such as Registered Massage Therapy, Chiropractic, and perhaps other CAM therapies typically used to rehabilitate victims of motor-vehicle accidents?
Could this mean ICBC will cut funding to these therapies? We recall that Chiropractic and Massage Therapy--now the two most popular therapies in British Columbia, according to some surveys-- have been named targets of the BCMA since the days of Project 2000. Has anything changed?
Apparently not. In January 2000, The Vancouver Sun carried an article by BCMA president-elect Dr. Marshall Dahl. Commenting on the crisis in BC hospitals, Dr. Dahl opined that the public should be willing "to forgo some of the services currently available for people who are not so gravely ill." Cutbacks recommended: "naturopathy, chiropractic and massage". (He mistakenly included "homeopathy", which has never been an insured benefit under MSP but which some physicians practice, billing patients privately--which has no direct economic impact on MSP or the hospital crisis.) A disclaimer in tiny print at the bottom of the page informed readers that Dr. Dahl's opinions did not necessarily represent those of the BCMA (!). However, under his name, prominently displayed, was his title "president-elect of the BCMA". Many readers would surely be misled into thinking the view expressed was that of the BCMA. In any event, Dr. Dahl's view is consistent with that of the BCMA historically. And, it is a view transparently mistaken.
Dr. Dahl's suggestion (and, again, this has been the position of the BCMA whenever they have spoken out about cutting health costs) that supplementary benefit services are "unnecessary" and should, in the present instance, be cut in order to alleviate hospital budget over-runs and patient-crowded halls in our hospitals--makes no economic sense; not now, nor ever.
First of all, the budget for supplementary benefits (Chiropractic, Massage Therapy, Naturopathy, Physical Therapy, Podiatry, Optometry, etc.; in short, every health service on MSP except medicine, hospitals, pharmacare, etc.) is so miniscule in comparison to the total health budget that, even if it were cut completely, the difference it would make is insignificant. How insignificant? Right now, the total health budget (including for physicians, hospitals, acute care, pharmacare, as well as supplementary benefit services) is estimated at $7.9 billion. Physicians' services, alone, are approximately $1.8 billion. Compare these figures with the supplementary benefit budget, which is a mere $125.7 million. The budget Dr. Dahl wants to cut amounts to just 1.6% of the total health budget and about 7% of the MSP budget.( Statistics quoted and derived from BC Ministry of Health "Quick Facts", 1998-1999, and BC Ministry of Finance and Corporate Relations "Budget 99 Budget Reports".)
To grasp the reality in practical terms: if all $125.7 million of the supplementary benefits budget for the year were transferred into physicians' services and hospitals, acute care, pharmacare, etc., it would keep them running for approximately 5 days! If the supplementary benefits budget were given just to physicians, it would keep them in business for about 26 days. That is how humungous the usage of medicare money is by physicians and hospitals. And the BCMA wants to eliminate the supplementary benefits budget, thus removing some of the most popular services, such as Chiropractic and Massage Therapy--in order to keep themselves and the rest of the system in business for what amounts to less than one week!
If this miniscule amount of money is so incredibly important for the system, instead of taking services the public wants away from them, perhaps forever, all that would have to happen is for physicians to close their offices for several more days a year. The obvious point is that the supplementary benefits budget, itself, cannot be that important--because it is, relatively speaking, not a significant amount. However, what is important is the unchallenged control of the medicare system that the medical profession would gain if it could squeeze out the competition.
A second reason Dr. Dahl's suggestion makes no economic sense is that CAM practitioners maintain that their services help patients stay out of hospitals and physicians' offices, thereby saving medicare dollars. Cutting CAM would automatically increase use of physicians' services and probably hospitals, costing the system much more money than would be saved by cutting the $125.7 million per year. Again, what is the economic logic in doing this?
| TOTAL HEALTH BUDGET=$7.9 BILLION |
| PHYSICIANS' SERVICES =$1.8 BILLION |
| SUPPLEMENTARY BENEFITS (CAM) =$125.7 MILLION |
Putting the matter another way: we have a very revealing picture, one in which the largest users of medicare money (physicians and hospitals) are criticizing the smallest users of medicare money (who may actually return what is paid to them by medicare with "interest") for "wasting" medicare dollars. Does cutting supplementary benefit services, which use so little money from the system and may prevent greater usage, make any fiscal sense?
Yes, it does when one translates "save medicare dollars" as "save medicare dollars for doctors"; or, more to the point, "give the competition's money to the doctors."
Clearly, if MSP coverage of supplementary benefit services were cut, millions of CAM patients could not afford to pay out of their pockets. Many would be forced back into physicians' offices or even into hospitals, upping physicians' incomes."Protecting the public's health", "insuring the highest quality care", by ridding the system of "inessential services", seems more about the BCMA "decreasing the influence and power" of their competition, which was the attributed mandate of Project 2000.
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We have seen how the BCMA systematically tries to influence opinions and referral patterns of physicians through anti-CAM seminars. We have seen how their "Expert Advisory Committee" gets between the insurance company and CAM practitioners, likely advising them that CAM is "unproven". Increasingly, speakers from the BCMA appear on the radio and in the newspapers, advising that alternative medicine is "unproven" and may be dangerous (never mentioning how dangerous conventional medicine is!). And, we have seen Dr. Dahl and others, over the years, say that complementary and alternative medicine is "inessential", "unscientific", and should not be funded by medicare. We have seen the clever "de-medicalizing" of the accepted title "Complementary and Alternative Medicine" into "Alternative Therapies", so as to create a new perception, in the public's mind, that CAM is not "medical" and, perhaps, should not be on the Medical Services Plan. And, of course, the BCMA constantly lobbies the Ministry of Health in its own interest. These targets (physicians, media, public, government) are the same now as they were sixteen years ago in Project 2000. However, today, in the year 2000, the BCMA's sphere of influence is wider, even, than the architects of Project 2000 may have ever imagined....
The BCMA is not content to limit its focus to CAM within the medicare system; it also seeks to stop the propagation of CAM in other venues. When BC Institute of Technology proposed to establish a health sciences department, the Alternative Therapies and Allied Health Committee opposed the idea, citing what it said was the lack of acceptable research documenting the safety and efficacy of the "therapies" (Acupuncture, Chiropractic, Naturopathy) which were to form some of the content of BCIT's program. (BC Medical Journal, 1999.) Previously, the BCMA defeated the establishment of a Chiropractic school at University of British Columbia, Simon Fraser University, and University of Victoria.
Classically, organized medicine has always attacked the Chiropractic profession. In the United States, the Supreme Court found the American Medical Association (AMA) criminally libel for trying to destroy Chiropractic and ordered the AMA to print their admission of guilt and apology in full-page advertizements in every major newswpaper in the United States. Even that was not enough to stop the AMA, which tries to undermine the Chiropractic profession to this day in the US. In British Columbia, the battle has never been so overtly vicious. However, officially the College of Physicians and Surgeons prohibited physicians from sharing the same office with doctors of Chiropractic, and did not officially recognize the profession. In defeating the development of a Chiropractic school in British Columbia, the BCMA struck a telling blow to the growth of Chiropractic, to its perceived prestige (it is prestigious to have a school within a university setting), and to the affordability of Chiropractic education (private colleges usually cost more than provincially funded schools), thus making it more costly and difficult for students to enter the profession. The BCMA challenges Chiropractic to produce research demonstrating its safety and efficacy, but this takes substantial funding. By preventing the development of a Chiropractic school within a university setting, the BCMA limited an opportunity for Chiropractic research to flourish as well.
Briefly, let us look beyond the embattled CAM services whose survival on Medical Services Plan is in question. Let us see just how far the BCMA's tentacular influence has reached.
Not satisfied with influencing health services and training in this province, the BCMA now seeks to control health products. Their website announces: "Be it resolved: That the BC Medical Association call upon the BC College of Pharmacists to implement measures requiring members of that College to recommend only products shown to be effective in well-designed scientific trials." (So far, the College of Pharmacists has not complied; and, of course, they are not legally compelled to comply.)
The BCMA's resolution is supported by the Canadian Medical Association's (CMA's) federal initiative to regulate health products. According to the CMA's website: "...the physicians of Canada believe that the safe regulation of these products is critical to the overall health of Canadians"; and it likewise recommends that "Expert Advisory Committees" should develope regulatory standards. The BCMA and CMA are lockstep on this issue because they share the same mindset and goal, which is to control the sale of certain vitamins, food supplements, and herbal remedies. But why?
In evaluating possible motives, one must look behind the hype of concern for the public's health and remember that the billionaire drug giants have enormous vested interest in controlling these health products in order to maximize sale of their pharmaceuticals. As Dr. Guylane Lanctot said in her book The Medical Mafia (quoted in The Medical Post December 20, 1994): "(Colleges of Physicians and Surgeons) are serving industry and the industry cannot make money with homeopathy. They cannot patent natural remedies." One might add that, when some health products show signs of making big money, pharmaceutical giants descend and, instead of directly crushing their competition, make offers the health product manufacturers cannot refuse. The drug giants buy up the health food companies and then suppress or sell the same products. That is precisely why, in the latter l990's, health foods and vitamins began to appear in drug stores and ceased to be the exclusive domain of health food stores.
Do the BCMA and CMA want to regulate the sale of health products simply in order to protect the public from deceptive labelling practices, inflated claims, and possibly unsafe products, as they allege? Consider another possible motive: when drug companies prosper, more of their profits are pumped into medical schools and into medical research. And who does medical research? Doctors. And what is medical research mainly about? Drugs. Can organized medicine's attempt to regulate the sale of health products be an indirect way of enhancing the financial base and power of the medical profession as it dances hand-in-hand with the pharmaceutical companies?
And that is not all. The BCMA openly seeks to control to whom both provincial and federal health care funds are given. Says their website: "Be it resolved: That the BC Medical Association recommend to federal and provincial governments that standing scientific councils be established to evaluate and report on unconventional practices and practitioners to ensure public funds are allocated to health care appropriately." We have already seen that the BCMA considers that "unproven" therapies should not be funded; that CAM is generally "unproven"; that, therefore, CAM should not be funded; and that only conventional medicine is "proven". Clearly, it is one small step to draw the logical conclusion that, therefore, only conventional medicine should be funded--provincially and federally. In the extreme scenerio, CAM would receive zero medicare dollars from any source, if the BCMA has its way.
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Who, one might wonder, would sit on these "scientific councils"? Will BCMA members be on them? Will they be truly "scientific", that is, free from political bias? Or, will they share the beliefs of the BCMA? Would the BCMA really work so hard to set up such councils if they did not hope their mindset would have yet another vehicle through which to enact their agenda? Their agenda was spelled out bluntly by Project 2000: "'MDs cannot afford to let others dominate input on health care issues.'" (Chair of Project 2000's Public Awareness Committee, as quoted by M. Jane Fulton in Comparative Lobbying Strategies Influencing Health Care Policy (1985). Italics added.)
Whatever the answers, this much is clear: the mindset exemplified by Project 2000 is alive and well today and can be detected within the body of the medical establishment throughout Canada, and it even has its counterpart in the United States. This enveloping mindset gives greater meaning to Project 2000's phrase, "global political strategy"--one even its architects might not have envisioned.
7. COLLEGE OF PHYSICIANS AND SURGEONS OF BRITISH COLUMBIA:
Let us turn now to he College of Physicians and Surgeons of British Columbia (COPSBC) and see how it fits into the probable plan to destroy CAM. The College is the regulatory body for the medical profession. Its mandate is to protect the public. It has legal power to discipline its members for infractions such as ethical violations and malpractice. The College may reprimand, fine, restrict a physician's practice, or take away his/her license. One of the College's duties to the public is to make certain physicians practice within the scope of accepted medical procedures.
In June 1999, every physician in British Columbia received a letter from the College containing a newly-created section of their Policy Manual, "Complementary and Alternative Therapies". Essentially a position statement and warning to its members, this section begins: "The last few years have seen an enormous surge of interest in complementary and alternative therapies, and considerable confusion exists among physicians as to how to respond to this interest. The reasons for the phenomenon are complex and include patient dissatisfaction with available treatment and patient mistrust of scientific medicine." Alleging that herbal and other "unconventional treatments" can produce direct toxicity or interact with prescription medications or othr accepted treatments, the College acknowledges "a physician may remain relatively ignorant about unknown or untested preparations. It is this lack of knowledge about risk and benefit that makes unorthodox treatment so difficult for physicians and their patients. The popular notion that herbal remedies are always safe--because they are deemed natural--is not true." (See College of Physicians and Surgeons of BC website.)
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Next, the College makes a crucial distinction: "Complementary and alternative therapies differ from conventional medicines because they are generally unproven. When an alternative treatment undergoes rigorous testing, for example in a controlled and randomized trial, then the results dictate whether the unorthodox becomes accepted, and whether the unproven becomes proven. Assertions, speculations, and testimonials do not substitute for scientific evidence." (Italics added.) In a single bold stroke, conventional medicine is defined as "proven medicines" while CAM is defined as generally "unproven therapies". It follows from this that CAM is not medical. This de-medicalization of CAM is crucial, as was said earlier, because if CAM is not a medicine or medical, then why should it be included within the Medical Services Plan? Add to this the argument that CAM is "not an essential service", "wastes MSP money", "is unproven", as the BCMA repeatedly asserts, and people's perception of CAM as part of MSP could be affected. (COPSBC website.)
The College issues a solemn warning: "Physicians who consider using complementary and alternative methods should recall that, although some untested remedies may be harmless, the absence of good evidence about a given herbal or other agent makes recommendation of that treatment unethical." Presumably, this advice applies when considering all CAM therapies, not only an "herbal or other agent", because they are all said to be "untested". (COPSBC website.) Since the College has evidently concluded that sound scientific evidence of CAM's efficacy does not exist, it follows that the ethical physician will not refer to any CAM therapy. This warning is obviously intended to frighten physicians into not referring to CAM practitioners, at risk of being found guilty of an ethics violation.
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The warning becomes stronger: "Precepts" warn that "the ethical physician...must not expose the patient to any degree of risk from a complementary or alternative therapy of no proven benefit." (COPSBC website".) Any degree of risk? All therapies--especially conventional medical procedures--contain a degree of risk. To deem it unethical to refer to a CAM therapy unless it contains no risk of harm is to rule out referrals to CAM completely. If the same standard were applied to conventional medical procedures, well over half of them would likely have to be banned as unsafe! (More on this later.)
Another precept, likely arousing physicians' fear of legal reprecussions, warns that the ethical physician "must not associate with, or refer patients to, alternative practitioners who recommend unproven over proven therapies. By doing so, the physician assumes a degree of responsibility for the outcome of the treatment." Clearly, a CAM practitioner is not likely to agree with the College that his/her profession is an "unproven therapy" and is likely to recommend it over conventional medicine in appropriate cases. MDs refer their patients to CAM practitioners in increasing numbers, implying that these physicians believe CAM works better than conventional medicine in these cases. Are they "unethical" to be doing this? After literally millions of referrals from medical doctors over the decades, does this not establish professions such as Registered Massage Therapy (which has always involved physician referrals) as "complementary" rather than "alternative", and "medical" rather than being an "alternative therapy"? If these CAM professions did not have a record of safety and success--after several decades of referrals from medical doctors--would physicians still be referring patients to them? Since they are referring patients in increasing numbers, is the College going to punish thousands of physicians for "unethical" behaviour? If the College attempts this, will there be a revolution within the medical profession?
If, however, physicians did follow this precept, it would seriously affect patients who need referrals to access MSP or ICBC for services such as Massage Therapy. Obviously, this precept was not only designed to cut referrals but also to shut down all lines of communication between MDs and CAM practitioners. Taken literally, MDs might not refer to, consult with, work together on the patient's behalf, form multi-disciplinary "team" clinics, etc. The College is going against the current integrative trend in many physicians' thinking, and against many patients' concept of their own best interest. This will be a bitter "pill" to swallow.
The "pill" the COPSBC wants physicians and their patients to swallow is their mandate that the College is just protecting the public from harm by defining CAM as unproven and possibly unsafe; and that it is further protecting the public by making it unethical for physicians to refer to or associate with CAM practitioners who use unproven therapies. The College assertively stands ready to punish "unethical" physicians on the patients' behalf.
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The College acknowledges the patient's right to choose his/her own therapy--but with a caveat: "Although the patient is always an active participant in this process, it is the conscientious application of the experience and knowledge of the physician that is essential in determining the patient's best interest. It follows that the patient's preference cannot be sufficient grounds to select a given treatment...." (COPSBC website. Italics added.) Many will hear these words as an insult to one's intelligence, autonomy, and ability to decide what is best for oneself. Others may hear in them the idea of a partnership between physician and patient, in which the physician provides information necessary for the patient to make an "informed decision". In fact, this idea has its precedent in "informed consent", which is where a patient is apprised of the benefits and risks of an operation, for example, and on the basis of this medical information the patient makes the choice to accept or refuse the operation.
The whole idea of informed decision vs. the individual's right to decide what is best for him/herself is at the eye of the storm of public reaction against the College's perceived overly-protective, meddlesome stance. To many, the mandate seems to be--not protecting the public from harm--but protecting them from their own health. To a growing number of physicians, also, the mandate and various COPSBC and BCMA policies seem repressive to the evolution of the profession while serving only to preserve the status quo.
8. FREEDOM OF CHOICE IN HEALTH CARE:
Turning now to this hot issue of "freedom of choice" in health care vs. "informed decision", let us examine how people make choices. Most people who have chosen the services of a CAM practitioner probably did not make their choice on the basis of a scientific study! And, satisfied consumers of CAM therapies would likely not abandon their treatments if the BCMA told them that scientific studies proved that these therapies did not actually work. That would fly in the face of their own experience. The public is pragmatic: if they go for treatment and their pain goes away and they feel good, then as far as they are concerned, the treatment worked.
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On the other hand, based on their personal experience, the public is turning away from conventional medicine because they feel they can find better help elsewhere. According to Angus Reid (1997), "disenchantment with conventional health care is the driving force for many users of alternative medicines and practices. One in five...said they 'get better service from alternative medicine providers than from the regular health care system', and one in twenty said they simply 'don't trust modern medicines and doctors.'" (Italics added.) The largest group (48%) chose CAM because they "don't hurt...and may help." The next largest group (34%) chose CAM because "regular medicines on their own aren't working". Another third (33%) said "alternative medicines and practices are more natural". Tellingly, 71% of Canadians told Angus Reid that they "strongly agree" that "doctors can give advice, but people have the main responsibility to look after their own health." (Italics added.) People are saying they want to make their own choices, according to their own priorities, their own values. It seems that whether a therapy may be unscientific or not, people may not be concerned--while it is of the utmost concern to the BCMA and COPSBC. Herein lies the conflict.
The BCMA and COPSBC want the public to listen to their doctors before choosing any form of CAM therapy. They want the public to believe that "doctor knows best" (recall: "knowledge of the physician ...is essential in determining the patient's best interest...patient's preference cannot be sufficient grounds to select a given treatment...."). They want the patient to value science and decide what treatment to take on scientific grounds. In contrast, most patients value their own experience and that of people they trust. Trust of doctors is waning and trust of self and friends is increasing. The conflict is not just between organized medicine and its CAM competition; it is between organized medicine and the public. Or, to be more precise: there is a conflict of opposing values. Such conflicts are not easily resolved, because, at bottom, they are emotional, not scientific.
This reliance on personal experience in the absence of scientific proof galls some physicians, who call this orientation "scientific illiteracy." CAM de-bunker Dr. Barry Beyerstein writes: "Surveys consistently demonstrate that, despite our overwhelming dependence on technology for our safety, nutrition, health, transportation and entertainment, the average citizen of the industrialized world is shockingly ignorant when it comes to even the rudiments of science...." ("Why Do Bogus Health Products Seem to Work?" in A Guide to Alternative Medicine, 1997. ) Some, like US quack-buster Dr. Wallace Sampson, see in the public's resistance to physicians' advice a modern "anti-science" attitude, a kind of throwback phenomenon in societal evolution. (From the "Critically Evaluating Alternative Medicine" seminar in Vancouver, BC, November 1999.) As Dr. Lloyd Oppel, spearhead of the BCMA's Alternative Therapies and Allied Health Committee and president of Canadians for Rational Health Policy, writes: "We can be confident that if society dropped its standards of medical proof, a great financial benefit would certainly flow to quacks and to bureaucracies promoting sham treatments. ...The truly pressing need for action lies in warning the public about the growing number of health scams and ensuring that professional organizations, the College of Family Physicians among them, do not become unwitting and uncritical vehicles for promoting unproven therapies." (Oppel, et. al., letter to the Editor, Canadian Family Physician, September 1998.)
Not all authorities agree the public is ignoring science and medical advice or making "uninformed" decisions when it comes to their health. Angus Reid (1997) found that "more than one-half (56%) concurred that decisions about one's medical treatment should rest in the hands of the experts (presumably, medical doctors) although many respondents--41%--challenged this 'let the experts decide' view." Significantly, "while users of alternative medicines and practices were divided on this point (46% agreed, 51% disagreed), non-users were in agreement by a two-to-one margin (63% vs. 33%)." Surprisingly, too, The Fraser Institute (1999) said: "The majority of respondents felt that the most important factor in determing what should be covered by provincial health plans was either scientific evidence that the service or treatment is effective in terms of improving a person's health (36%) or whether or not the service is deemed medically necessary (35%). Public demand for the service was considered to be important by 20% of respondents, while only 5% thought the cost of a particular health service should be a determinant of whether it is insured by the government."
Perhaps when these surveys were taken the respondents did not understand that the medical establishment does not consider CAM therapies scientific. What would they have responded, knowing this? Would they still have said that scientific evidence or medical necessity should determine whether the CAM practices they used should be covered by MSP? Would they have been dissuaded from attending their favourite CAM therapies had they known that they were considered "unscientific"? Would they have said that they thought CAM should be removed from MSP if they had been told that the medical profession considers CAM unscientific and not medically necessary? Surely, these are questions worth including in the next surveys.
At the moment the question remains: how come these surveys say a majority believe scientific evidence of efficacy or medical necessity should determine which services are covered by medicare, and yet, personal testimony of efficacy--not scientific evidence or medical opinion--is the kind of evidence most often offered by people interviewed in the media?
These survey results and the assertion that the public is "scientifically illiterate" do raise the issue of whether the public does have a clear notion of what science is, and by implication, what informed decision means. Let us examine what is meant by "scientific evidence" and "proven therapies".
9. EVIDENCE-BASED MEDICINE?:
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Conventional medicine attempts to base its claims to efficacy and safety of its interventions (typically drugs and surgery) on objective evidence. Historically, "evidence-based medicine", as it has come to be called, began in the early 1960s with medical pioneers such as Dr. Kerr White and Dr. Archie Cochrane, a student of Dr. White's. When this interviewer asked Dr. White (in 1997 and 1999) what medicine was based on prior to the 1960s, he replied, in effect: "Not much. Physicians' opinions. They would get together and discuss the best procedures in their experience, and consensus would gradually arise, and whatever it was would become accepted medical practice at the time." Opinion, "anecdotal evidence", not hard facts, determined what drugs and surgeries were administered to patients! Quite obviously, physicians were experimenting on unknowing human beings. Have things changed?
Since the practice of scientific, evidence-based medicine began only about forty years ago, this means that there are physicians practicing today who are older than scientific medicine! But the core message here is that medical discoveries are occurring at such an accelerating pace that reasonable assurance of safety and efficacy--evidence-based medicine--has not kept pace. We shall see later how serious this safety issue really is.
The most "scientific" form of experiment, the "gold standard," is known as the "randomized, controlled trial" (RCT), and is considered, by many, to be the best method of proving an intervention works. When the BCMA says CAM therapies have not proven themselves, they mean that RCTs have not been performed to establish their efficacy and safety. The BCMA typically disregards any other accepted form of experimental design except "the gold standard" or RCT. They lead one to conclude that conventional medicine has done its homework and that all of its interventions are proven efficacious and safe according to the gold standard. Unfortunately, this is not true, because conventional medicine has not proven its efficacy and safety by its own standard, with dire consequences, as we shall read shortly.
What is a "randomized, controlled trial" experiment? Simply, it is a double-blind experiment in which neither the researcher nor the participant knows at any time whether the therapeutic agent has been applied or a placebo. A placebo is a "fake" resembling the therapeutic agent, for example a sugar pill that looks like the test drug. Participants receive the therapeutic agent or placebo randomly. If the outcome shows that the therapeutic agent correlates with the hoped for therapeutic result significantly more often than does the placebo, that is evidence that the therapeutic agent is effective and that the outcome is not due to the "placebo effect". A percentage of participants always experience therapeutic benefits from the placebo. The hope is that the therapeutic agent works better than the placebo! When it does, the therapeutic agent is said to be scientifically valid, or be "proven".
However, sometimes the placebo works as well, or better, than the therapeutic agent. The placebo has been reported to work as well as the therapeutic intervention as much as 56% of the time, perhaps more. This is important, because many drugs and surgical procedures do not work this well! Serious investigation might be done on how to use placebos intentionally in order to obtain therapeutic results, were it not for the fact that pharmaceutical companies could not derive profits from marketing placebos.
Critics of CAM frequently attribute the "apparent" success of these interventions to the "placebo effect", thereby implying that they "do not really work". These critics are forgetting that placebos can be even more powerful than so-called "proven" remedies much of the time.
Nevertheless, the BCMA expects CAM to perform this kind of RCT experiment to validate its efficacy and safety. However, it is perfectly obvious that this is asking the impossible of therapies such as Massage Therapy and Chiropractic. What, for instance, would a placebo or "fake" massage be? How would one perform a fake chiropractic adjustment? This form of experiment would be suitable for consumable naturopathic remedies, and might be appropriate for some physical therapy modalities, such as laser or ultra-sound, where the recipient cannot feel whether the modality is working or not. But what about rehabilitative exercise--so in fashion at the moment? How does one do placebo exercise? Rehabilitative exercise is supposed to have been "proven" to be the most effective treatment for whiplash injury. It has the backing of ICBC and other insurance companies, and doctors increasingly support this regime. Was it subjected to double-blind controlled trials? How does one do exercise and not know one is doing it? Why did rehabilitative exercise gain medical approval without being subjected to RCT double-blind studies, yet other therapies must do them? Intriguing questions, but back to the issue....
The "gold standard" form of experiment costs a lot of money to perform. Conventional medicine has this kind of money, due to its association with the drug companies and research centres at major medical schools. CAM does not have this kind of advantage.
It should be apparent that the BCMA is demanding CAM compete on a non-level playing field upon which only conventional medicine can win. Not having the financial resources to construct the requisite experiments, and being required to perform them on modalities which cannot be tested in this way by their very nature--is obviously unfair. Why would the BCMA demand this? The answer seems very simple: so conventional medicine will win and CAM will lose.
There is no scientific reason why therapies such as Massage and Chiropractic should be subjected to the same kind of experiment used to test drugs. In the same way, there is no scientific reason why medical researchers should use the same kind of experimental designs, and the same criteria of validity, as physicists use. For example, the accuracy of measurements required in particle physics is far more demanding than for medicine; and the predictability of results is far more reliable in particle physics than it is in medicine. In other words, physicists are not demanding physicians live up to their standards; there is no necessity that they should. In the same way, CAM modalities such as Massage Therapy and Chiropractic need not prove their efficacy and safety to the same degree that medicine must. Why? Because surgery and drugs are obviously vastly more dangerous than Massage Therapy. Medical safety standards have to be stringent because lives depend on them. Even with stringent medical safety standards in place, people die by the thousands every year from medically prescribed drugs and surgeries. Nobody dies from Massage Therapy, it may be added. The relatively few chiropractic accidents rate the 6:00 news, while the hundreds of doctors' daily deadly mistakes escape reportage. The point here is that safer modalities do not require the same stringent tests that more dangerous therapies do; and tests should suit the nature of the modality being tested. There are perfectly acceptable experimental designs suitable to test the safety and efficacy of CAM therapies, but the BCMA tends to ignore or discredit them.
It might be added that it is irrational and unscientific to demand a method of evaluation which cannot, by its very nature, be applied to the phenomenon being tested. The BCMA's insistence on using inappropriate methods to test CAM therapies--while appropriate ones are ignored--emphasizes their real intent, which is to prevent CAM from being funded by medicare.
10. IS CONVENTIONAL MEDICINE SAFE AND EFFECTIVE?:
Let us turn now to the legitimacy of conventional medicine's claim to the safety and efficacy of its own remedies.
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In 1997 and 1999, this writer had the honour of interviewing the world-famous epidemiologist and 1960s pioneer of what is today called "evidence-based medicine", Dr. Kerr White. Dr. White's credentials took literally five minutes to list on tape. He was the Deputy Director for Health Science, Rockefeller Foundation and holds many other distinctions. Dr. White is the authority often quoted as having said: "Although things are much better than they were a generation ago, it is still the case that only 15% of all contemporary clinical interventions are supported by objective scientific evidence that they do more good than harm. ...40-60% of all therapeutic benefits can be attributed to a combination of the placebo and Hawthorne effects...or what most people call 'love'." (Medicine and Culture by Lynn Payer (1988), introduction by Dr. Kerr White. ) In my interviews, Dr. White updated his statement made in 1988, by saying that medical interventions are (today) probably only about 15% proven to do more good than harm.
Do other authorities agree with Dr. White? Dr. R. Smith in "Where is the Wisdom...? The Poverty of Medical Evidence", in The British Medical Journal, vol. 303, 1991, cited the same 15% estimate of safety and efficacy.
"4200 papers, published...between 1959 and 1978 (were examined).... A median of 20.5%...of publications met their criteria for scientific adequacy.... The average practitioner will find relatively few journal articles that are scientifically sound in terms of reporting usable data providing even moderately strong support for their inferences.... (T)hat a substantial proportion of journal publications sampled were scientifically inadequate is impressive evidence of a serious problem. The mere fact that research reports are published, even in the most prestigious journals, is no guarantee of their quality." (Williamson, Goldschmidt, Colton, "The quality of Medical Literature: an Analysis of Validation Assessments", Ch. 19, Medical Uses of Statistics, New England Journal of Medical Books, 1986.)
The prestigious US mainstream medical journal The Lancet (1995) states: "commentators on the scientific basis for medical care lament the paucity of solid medical evidence for most medical interventions."
The famed Cochrane Collaboration "is literally hand-searching the world's literature to find and review all the randomized controlled trials ever published...(to assess) the latest state of knowledge about every available therapy or intervention...and should finally tell us when we have enough evidence to believe in something." (Science, April 1996.)
"It is a commonly held belief, particularly among conventional doctors, that most conventional medical practice is based on good scientific evidence and fundamental biological principles. ...In fact, the best estimates suggest that...85% of it isn't", writes Dr. Robert Buckman in Magic or Medicine? An Investigation of Healing and Healers (1993).
Dr. Alan R. Gaby writes in "Evidence-Based Medicine", an editorial in the Townsend Letter for Doctors and Patients (December 1999): "One of the reasons that 'alternative' medicine has become so popular, is that people are becoming more aware of the lack of documentation to support conventional practices."
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Physicians who follow practice guidelines are "'practicing medicine on a bowl of Jell-O because many of the current guidelines do not have a solid foundation of evidence.'" (Dr. David Eddy, consultant to the National Committee for Quality Assurance, quoted in the Townsend Letter for Doctors and Patients, December 1999.)
In 1881, Oliver Wendell Holmes wrote: 'I firmly believe that if the whole materia medica, as used now, could be sunk to the bottom of the sea, it would be all the better for mankind--and all the worse for the fishes." (Strauss, Familiar Medical Quotations, 1968.)
We can appreciate the significance of this 15-20% estimate of medicine's efficacy and safety when we realize that it means that about 80-85% of medical interventions may be dangerous or ineffective, or both. How many professions may have an 85% failure or disaster rate? How many have this potentially frightening rate and yet garner such public trust in spite of it?
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Few of us would drive our car if the manufacturer told us that there was only a 15% chance it would not blow up on the road. If you were pregnant and you learned that you had an 85% chance your baby would be born seriously deformed, you would be terribly concerned. If your broker informed you that your life's savings had an 85% liklihood of being lost, you would probably be horrified. Yet, Canadians gulp $35 billion worth of drugs every year with hardly a burp, and slide trustingly beneath surgeons' knives with nary a blink of the eye. Shouldn't we be examining our priorities?
The popular press is examining them. In a chilling article called "Doctors' Deadly Mistakes", Time (December 13, 1999) reported that doctors' interventions accidentally kill up to 98,000 patients every year in the US. This is more than the number who die from AIDS. And, what your doctor is not telling you is that he/she knows this, and has for a long time. The Journal of the American Medical Association (1998) reported that over 2,216,000 hospital patients had serious adverse drug reactions caused by doctors, while another 106,000 died for the same reason in 1994, making adverse drug reactions between the fourth and sixth leading cause of death. Perhaps bedside reading for every patient should include Time and JAMA.
It should also be added that these medically-caused deaths are happening during the era of "evidence-based medicine". When mainstream medical journal studies, and leaders in evidence-based medicine themselves, admit that only about 15% of what medicine does is safe, these statistics are not surprising, although nonetheless shocking.
When the BCMA and COPSBC accuse CAM therapies of being "unproven" and of presenting an unknown risk of harm, with no mention of the up to 98,000 deaths caused by "proven" medical interventions every year, one's credibility is stretched to the breaking-point.
Every physician swears the Hippocratic Oath to "First Do No Harm"; and the College of Physicians and Surgeons of BC has the legal responsibility to "protect the public". Yet COPSBC and the BCMA conceal the truth about "doctors' deadly mistakes" from the public. At the same time, these groups systematically seek to undermine their competition by raising suspicions that CAM may present some risk of harm. The truth is, there has never been anything reported remotely approaching 98,000 deaths annually caused by Massage Therapy, Chiropractic, Naturopathy or any of the other CAM professions, singly or combined. These "unproven therapies" simply do not present the serious risk--and incidence--of harm that "proven" medical interventions do, even in the age of "evidence-based medicine".
The terrible fact is, "evidence-based medicine" is still more of a comforting slogan than it is a guarantee of public safety. The irony is that conventional medicine has proven itself unsafe, while it accuses CAM of a possible risk of harm.
The College of Physicians and Surgeons' precepts includes requiring ethical physicians to inform their patients as to the risk/benefit ratio when choosing a course of CAM treatment. It would seem to be the duty of ethical physicians also to advise their patients as to the proven risks inherent in conventional medical treatment compared with the alleged possible risks involved in any particular CAM intervention. It seems that the BCMA and COPSBC owe it to the public's safety to include admission of "doctors' deadly mistakes", complete with statistics from medical and popular sources, which let the public know the risks they may face when they take prescription drugs and undergo surgery, publishing this information in the media and on their websites.
Finally, it is obvious from the above analysis that the BCMA and COPSBC are demanding that CAM live up to standards of safety and efficacy which conventional medicine has failed to achieve, even given all its financial and technological resources. The irony is that these "unproven therapies" have actually been safer, by far, than the supposedly "proven medicines". In fact, ironically, "evidence-based" medicine has proven itself to be highly dangerous. As to efficacy, the public would likely argue that, in their opinion, CAM is very often more effective than conventional treatments. (Cf. Angus Reid, 1997.)
Dr. Ian Chalmers, reknown research methodologist and director of the UK Cochrane Centre, confirms that there is a double standard wherein CAM is expected to prove its safety and effectiveness before being accepted, even though an estimated "60%" of conventional medicine is unproven by the same criteria. (Bower, "Double Standards Exist in Judging Traditional and Alternative Medicine", British Medical Journal, 1998: 316:1694.)
11. LEVELING THE PLAYING FIELD:
Echoing the BCMA's adamance that CAM adhere to the "gold standard" experimental design, Dr. Morley C. Sutter writes in "The Art and Science of Healing" (BC Medical Journal, vol. 41, no. 2, February 1999): "CAM must be tested by the methods of science with appropriate controls so that like is compared with like. This means that studies should be prospective, randomized, and double-blinded. If any of these qualities is missing, the possibility of erroneous conclusions is great. Despite the difficulty and the expense of such trials, they must be attempted in order to obtain evidence regarding CAM's true effectiveness. Opinions and testimonials seldom constitute evidence." As stated earlier, the great cost and unsuitableness of the RCT (double-blind study) make it nearly impossible for CAM to subject many, if not most, of its therapies to this form of experiment. And, as said earlier, the BCMA knows this and, like Dr. Sutter, it persists in expecting CAM to do these experiments anyway.
What might it take to level the playing field? Clearly, using experimental designs that can work with CAM modalities, is fair. It has been suggested that experimental designs appropriate to CAM modalities do exist, and are less costly that RCTs.
Eliminating intentional anti-CAM bias (prejudice) at medical seminars would also help. Sometimes this bias is cultural: many papers on homeopathy, for instance, are written in languages other than English and have not yet been translated. These tend to be ignored by American and Canadian CAM critics. A case in point is The Lancet (September 1997) study on homeopathy, "Are the Clinical Effects of Homeopathy Placebo Effects?". Linde, et. al. concluded: "We believe a serious effort to research homeopathy is clearly warranted despite its implausibility." The article concluded with a bibliography of 145 references from medical literature, many not in English. Although The Lancet article was written in English, and has attained some notice, what might the assessment of homeopathy be if all available evidence, such as the references in the bibliography, were in English? At other times, bias exists because anti-CAM researchers are told by those who fund them not to look in directions which might disclose evidence supporting CAM. Or, researchers submit unbiased findings but they are never published for the same reason of vested interest.
Inviting health professionals from the various CAM fields to speak at CAM-slam seminars would also be fairer treatment. At present, the criticism goes on behind their backs. Surely, it is the spirit of true science to objectively entertain both sides of any issue. Yet, this is not being done.
Also, since the public is affected by the eventual outcome of such seminars (which aim at dissuading physicians from referring to CAM therapies), and since the public pays for these therapies with their medicare premiums--surely the public deserves to be invited to these seminars.
The BCMA and COPSBC approach the issue of funding from a supposedly scientific perspective: that which is scientifically "unproven" should not be funded by medicare. The public, as said earlier, approaches CAM from a wholly different perspective, which is "personal experience", and they want medicare to fund it. Science vs. consumer demand (or, perhaps, medical monopolistic interest vs. public's interest). The government is in the position of having somehow to satisfy both the BCMA and the voters. In the end, it would be political suicide for the British Columbia government not to listen to the public, who have made their voice loud and clear.
Probably the single most significant thing organized medicine could do to "even the score" in the public's mind would be to "come clean" and be honest about the unproven and unsafe nature of conventional medicine. If the BCMA is going to point their fingers at CAM's alleged lack of scientific proof of its safety and efficacy, the least the BCMA could do is publish, on its website, and in the press, a truthful record of medicine's safety and efficacy in straightforward language everyone can understand. This would be one of the most powerful ways the BCMA and COPSBC could help the public make an "informed decision" about whether to choose conventional or CAM treatment. Undoubtedly, this remedy would be a "pill" too bitter for organized medicine to swallow.
12. CAM POPULARITY:
| $3.8 billion out-of-pocket spent on CAM...84% of British Columbians using CAM...90% satisfaction rate...47% of respondents said CAM brought faster relief than did conventional medicine...82% of British Columbians want CAM covered on MSP. |
Increasingly, the public is choosing CAM. The Fraser Institute (1999) estimated that 15 million Canadians "spent approximately $3.8 billion out-of-pocket on alternative medicine in the latter half of 1996 and the first half of 1997. More than $1.8 billion of that was spent on providers of alternative therapy, while the other $2 billion was spent on (health consumables, books, classes, and equipment)." Angus Reid (1997) reported that 56% of British Columbians used some form of CAM (including the supplementary benefit services funded by MSP). In 1999, CAM usage was a whopping 84%, according to The Fraser Institute; and satisfaction ran high, at 90%. 47% of respondents told The Fraser Institute that CAM brought faster relief than did conventional medicine. There is no doubt that CAM represents an economic threat to conventional medicine.
And British Columbians want CAM to be covered by Medical Services Plan: 70% of Canadians, 82% of British Columbian respondents, told Angus Reid (1997) that "the provincial health plan should pay for alternative medicines and practices the same way they pay for treatments and medicines that are prescribed by doctors." The public (73%) also said "the government should encourage people to use alternative medicines and practices because it could help to reduce the cost of our health care system." Contradictorily, 60.3% of Canadian respondents told The Fraser Institute (1999) that CAM "should be covered privately and not be included in provincial health plans." At the CAM-slam seminar "Critically Evaluating Alternative Medicine" held in Vancouver in 1999, speakers made reference to The Fraser Institute report and not to Angus Reid. As well, there was a speaker from The Fraser Institute on the program. The reason both reports were not presented and compared may be that the Angus Reid (1997) report is not as favourable to the medical establishment's position in this regard. In the interest of fairness, this writer believes readers who may be interested in exploring further should read both Angus Reid's and The Fraser Institute's reports, and draw their own conclusions. In any event, there is no argument that health care is becoming increasingly consumer-driven.
We have discussed CAM outside, or along side, conventional medicine, but we would be remiss to neglect to mention CAM within the medical profession. Increasingly, conventional physicians are using such CAM practices as acupuncture, meditation, homeopathy, chelation, nutrition, megavitamin therapy, and anti-aging medicine including hormone replacement therapy. As discussed, the College of Physicians and Surgeons of British Columbia currently frowns on many of these interventions, and in some cases, has taken action against physicians practicing them. Nevertheless, over the years, a growing number of physicians have banded together to form groups such as the Canadian Complementary Medical Association. These physicians believe their patients' needs--and the profession's needs--are not being served by the BCMA and COPSBC which, in their view, all too often serve only the status quo.
In years to come, we may witness a revolution within the field of medicine--not only in the scientific realm, which is already happening--but an institutional revolution which must take place if new frontiers of conventional medicine and CAM are to become part of medical practice in Canada and British Columbia in particular. As we have indicated, the revolution within health care is going to be consumer-driven. Now, we have to add that part of the big change will also be physician-driven. Inside and outside the medical system, the forces of change are fomenting. One thing appears certain: the status quo cannot be maintained. The old medical establishment, and the old medicare system dominated by conventional medicine, must evolve or they will surely disintegrate.
13. WHAT YOU CAN DO:
Even though it is tempting to think this tidal wave of change is "destined" to sweep away governmental and medical resistance to CAM, it would be imprudent to consider this event as inevitable. One may want to "push the wave", and in so doing, affirm individual and societal potency to enact the needed changes. It always feels--and is--stronger to be an active agent rather than a passive "victim" of circumstance, even when that circumstance is a wave we wish to ride upon.
Constructive consumer-based action might include:
1. Contacting the Health Action Network Society (represents the public, protects their freedom of choice in health care through information exchange and by a variety of high-profile activities): (604) 435-0512 in Vancouver, or visit the HANS website (address at end of this report).
2. Write and call the Minister of Health, urging him to keep CAM on MSP. Suggest that MSP not fund unsafe, unproven conventional medical interventions. (Remind him of the deadly statistics you read here, and quote them, citing sources.) Describe your own positive experiences with CAM therapies.
3. Call in to talk-shows and write letters to the newspapers. Use material you read here; quote original sources. Talk of your own positive experiences and suggestions for change. Speak out--84% of the BC population probably already agrees with you! Get your friends to call in or write with you.
4. Write or e-mail the BCMA and College of Physicians and Surgeons of BC and tell them to honestly and publicly declare the truth that most of conventional medicine has never been proven either safe or effective, according to their own criteria; and that medicine has a record of deadly accidents which pose a proven danger to the public's safety. Quote sources you read here. If you use other sources, always try to make them solidly-based, mainstream medical journal quotes because these command the most respect in the medical community. Insist the BCMA and COPSBC "do their own homework" before pointing accusing fingers at CAM's alleged lack of research.
5. Attend College of Physicians and Surgeons of BC meetings. The public is legally allowed to attend. Make your presence felt. Ask questions.
6. Periodically, the BCMA holds informal public meetings (without advertizing them much!) to sample opinions from targeted community groups. Make it a point to call the BCMA office and ask when the next one will be. Attend and ask questions. If something noteworthy, in your opinion, occurs, write or call the media and you may be invited to contribute a news item. Become informed. Your mere presence at such meetings is a statement in itself.
7. On a wider scale, organize forums in which the BCMA and CAM groups are invited to openly debate issues. If you do, be sure you contact the media beforehand and invite them to attend.
8. Create seminars which "critically evaluate conventional medicine". You could do road shows, the way the CAM-slam seminars do.
9. Become informed about scientific and medical issues and news, and as much as possible about how science and medicine work. Read such publications as The Medical Post, the British Columbia Medical Journal, the Townsend Letter to Doctors and Patients, Alternative Medicine, the Life Extension Foundation newsletter.
10. The most ambitious initiative could be to create new legislation. One such piece of legislation could be similar to Alberta's Bill 209, and Ontario's bill 2, which empower physicians to practice alternative interventions and places the onus on the College of Physicians and Surgeons to prove a particular CAM intervention is less safe than the usual medical one, in each individual circumstance. This shifts the cost of doing research into the safety of any unconventional intervention in question to the College and removes the financial burden from the individual practitioner. (UPDATE: As of the date of this re-editing, October 11, 2000, legislation has recently been introduced in British Columbia which would, if passed, accomplish much the same objective as these bills.)
Before one sets off on a crusade to change the future of our health-care system, it is wise to look at the past and see how we arrived where we are today:
Dr. Guylaine Lancetot, author of The Medical Mafia, reminds us: "The patient blindly obeys the doctor. The doctor blindly obeys the College of Physicians and Surgeons. The College blindly obeys the government. The government blindly obeys the multinationals." There is no doubt we must take responsibility for our own previous passive relationship to the government, the medical establishment, and to our personal physicians.
Over ten years ago, in 1984 (the same year the BCMA conceived Project 2000), John Naisbitt wrote in Megatrends: Ten New Directions Transforming Our Lives: "We had a part in the crisis and we must take back our responsibility for our own health: we allowed ourselves to act as passive bystanders, handing over to the medical establishment not only the responsibilities that it could handle, healing traumatic wounds and grave illnesses, but also the responsibility for our health and well-being. We revered doctors as our society's high priests and denigrated our own instincts. And in response, the medical establishment sought to live up to our misplaced expectations. Placing all our trust in the modern voodoo of drugs and surgery, they practiced their priesthood and we believed."
No longer.
14. WEBSITE ADDRESSES:
1. British Columbia Budget: www.bcbudget.gov.bc.ca
2. British Columbia Medical Association: www.bcma.org/committees/council_alternative.asp
3. British Columbia Ministry of Health and Ministry Responsible for Seniors: www.hlth.gov.bc.ca/msp/qkfacts.html
4. Canadian Complementary Medical Association: www.ccmadoctors.ca
5. Canadian Medical Association: www.cma.ca
6. Canadians for Rational Health Policy: www.crhp.net
7. College of Physicians and Surgeons of British Columbia: www.cpsbc.bc.ca
8. Health Action Network Society: www.hans.org
15. ABOUT THE AUTHOR AND HOW TO REACH HIM:
David Dressler is a freelance health and medical writer with articles in mainstream and alternative medical journals, including The Medical Post, Chronicle of Skin and Allergy, The Journal of Alternative and Complementary Medicine, Health Care News, Shared Vision, Alive, Monday Magazine, The B.C. Massage Practitioner. He is also a Registered Massage Therapist (RMT) practicing in British Columbia, Canada and is also licensed to practice in Ontario and Hawaii (LMT). He also teaches movement meditation and previously had a career in professional dance and the arts.
Anyone wishing to comment or offer information on topics related to the foregoing discussion is welcome to e-mail: talktome2@shaw.ca or telephone Health Action Network Society at (604) 435-0512. hans@hans.org
NOTE: The views expressed above do not necessarily represent those of the College of Massage Therapists of British Columbia or of the Massage Therapists' Association of British Columbia.
COPYRIGHT 2004. All rights reserved. This
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Transcribed by Web Master