Issues and Commentary
By Jack Challem, Publisher of The Nutrition Reporter
Alternative Medicine: What the JAMA Report Means for Retailers
A few months ago, we saw something we figured we'd never see: the Journal of the American Medical Association (JAMA) devoting an entire issue to a relatively balanced discussion of alternative medicine.
Some studies were positive, others were not. But that's the nature of science and medicine. Some things work, some do not, and others mysteriously work only some of the time.
On the positive side, researchers reported that saw palmetto (Serenoa repens) reduced urinary symptoms associated with benign prostatic hyperplasia (enlarged prostate). Another study found that a mix of 20 Chinese herbs reduced symptoms of irritable bowel syndrome. Still another reported that burning the Chinese herb mugwort (Artemisia vulgaris) near the little toe (an acupuncture point) of pregnant women often prompted fetuses to rotate, thereby avoiding a dangerous breech birth. (For more information see "Burning Mugwort Turns Breech Babies.")
On the negative side, research reports suggested acupuncture did not help ease nerve damage in people with HIV infections, the herb Garcinia cambogia as part of a high-fiber diet was reportedly less effective than placebo in promoting weight loss, and chiropractic manipulation did not make tension headaches go away.
| None of these issues would be written about in mainstream medical journals if alternative medicine had not become a force with which to be reckoned. |
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JAMA's lead article, by David M. Eisenberg, M.D., of Boston's Beth Israel Deaconess Medical Center, updated his 1993 study on consumer use of alternative medicine. According to Eisenberg's latest study, four of every 10 Americans used some form of alternative therapy in 1997, including herbs, megavitamins, massage, self-help groups and homeopathy. The prevalence of alternative medicine increased by 25 percent compared with 1993 numbers, and the total number of visits to practitioners increased by 47 percent.
He also estimated that in 1997 consumers visited alternative medicine practitioners 629 million times, in contrast to 386 million visits to conventional primary-care physicians. During the year, consumers spent about $27 billion on alternative therapies—about what they spent, not including insurance payments, on conventional physicians.1
Eisenberg's surveys are medical marketing studies in scientific guise, observes Abram Hoffer, M.D., of Victoria, Canada, a pioneer in the medical use of vitamins. The bottom line? Conventional medicine is continuing to lose market share, and complementary therapies—the term Hoffer prefers—are gaining ground. More and more people want options beyond what many consider to be essentially a high-tech slash, burn and poison medicine.
In devoting an entire issue of JAMA, as well as a majority of its nine other journals, to alternative medicine, the American Medical Association (AMA) responded to a remarkable shift in how both physicians and consumers perceive medicine. It certainly didn't hurt that George D. Lundberg, M.D., then editor-in-chief of JAMA, had an "academic interest" in alternative medicine.
Getting in Touch
A few years ago, AMA editors realized they were out of step with their readers. Every year, the editors and editorial board members of JAMA and AMA's nine specialty Archives journals decide which topics are of particular importance to their readers. In 1996, they ranked alternative medicine 68th out of 73 topics.
But when they polled a sampling of their physician readers, alternative medicine turned out to be the seventh most interesting topic. The handwriting was clearly on the wall: Doctors wanted to read more about alternative medicine.
In addition, AMA membership numbers have been dwindling steadily in recent years, in part because younger doctors seem to find the organization irrelevant to their needs or concerns. It's possible—just a hunch of mine—that AMA figured a small dose of alternative medicine might increase its relevance to members and readers.
But while JAMA tentatively offered an olive branch to alternative medicine, the New England Journal of Medicine slashed away with thorns. Marcia Angell, M.D., and Jerome P. Kassirer, M.D., editors of the NEJM, wrote an unbridled attack on alternative medicine in September 1998, arguing in part, "There cannot be two kinds of medicine—conventional and alternative."
In contrast to JAMA's measured approach to alternative medicine, Angell and Kassirer insisted, "It is time for the scientific community to stop giving alternative medicine a free ride."2
Unfortunately, medicine doesn't always have a lot to do with science. The economic and marketing power of drug companies—a $100 billion industry in the United States—has held medicine captive for years.
Consider a recent article in AMA's Archives of Internal Medicine. James A. Goodwin, M.D., and Michael R. Tangum, M.D., of the University of Texas, Galveston, explored why medical school professors have been historically antagonistic toward alternative medicine. It turned out to be a more sensitive topic than they had imagined. During the peer review of their article, they were accused of being pro-supplement—even though they went out of their way to be impartial.
Goodwin and Tangum came to the conclusion that medical academics resist the idea of vitamin therapy because it comes from a realm outside of medical schools. Goodwin and Tangum also hinted that the financial incentives of patentable drugs probably drive pharmaceutical companies more so than vitamins.3 These drug companies exert a major influence on medical practices through physician education, advertising—and even parties.4
Closing the Scientific Gap
In my mind, none of these issues would be written about in mainstream medical journals if alternative medicine had not become a force with which to be reckoned.
Compared with 10 years ago, the gap between conventional and alternative medicine has narrowed considerably. Almost every major journal regularly publishes some articles on alternative medicine, mostly on vitamins, minerals and herbs. The scientific foundation for the health benefits of these products is stronger than ever, and a simple Medline database search retrieves thousands of published articles on these topics each year.5 In fact, vitamins C and E have been studied in far greater depth than have most prescription or over-the-counter drugs.
Quite simply, physicians can no longer afford to ignore the alternative medicine landslide. With four out of 10 patients using alternative therapies, conventional medicine runs the risk of being swept away sometime in the new millennium. This is no exaggeration. The presence of alternative medicine is so pervasive that researchers, in a letter to JAMA, reported that more than half of the medical professionals at six teaching centers had used at least one type of alternative therapy.6
Supplements Go Mainstream
The outcome of all this, in my opinion, is something of an irony for the natural products industry: Be careful what you wish for—you might just get it.
For years, those in the health food and natural products industries wished medicine and the general public would be more open to alternative therapies, and now it really is starting to happen. Eisenberg's survey found that, between 1990 and 1997, consumers increased their use of herbal remedies by 380 percent and megadose vitamins by 130 percent.
Natural products retailers have witnessed firsthand the phenomenal growth of herbal and vitamin supplements. In recent years, the big drug companies have taken note. With the unprecedented popularity of herbal medicines, Bayer, Warner-Lambert and American Home Products now understand there's big money to be made.
Furthermore, the stage is already set with the professional sort of documentation physicians like to have. There is now an English translation of the German Commission E Monographs on herbs, and the publisher of the Physician's Desk Reference has just released the PDR for Herbal Medicines.7 Varro Tyler, Ph.D., an expert on botanical medicine and professor emeritus at Purdue University in Indiana, expects drug company "detail men" soon to be instructing physicians on over-the-counter herbal remedies along with prescription medicines.
Even the insurance companies, I believe, will get into the act. In time, they will recognize that vitamins and herbs promote health and are less expensive than drugs—and that a dollar saved will be a dollar earned.8
No Longer a Cozy Niche
The most obvious end for this is that all the good news about alternative medicine means stiffer competition for those who are selling it. In the store front, I predict independents, in particular—be they natural products retailers or pharmacists—will be facing challenges in the coming years.
The natural foods industry has served as a powerful catalyst, creating an awareness of supplements and alternative therapies among American consumers. But now you can't turn on the television without seeing a drug company ad for herbal supplements, or a once-venomous antivitamin doctor touting his own line of supplements.
What's the best strategy in such a market? Think about how some small-town merchants around the country have survived in the face of Wal-Mart. It's the David-and-Goliath business model. What you lack in brute strength you can make up for with ingenuity and integrity. Independent retailers can't compete with Wal-Mart prices, but Wal-Mart can't compete with quality, knowledge, selection and service.
As drug companies and mass-market retailers jump on the vitamin and herb bandwagon, the cozy niche of the past isn't so cozy anymore.
Brace yourself—as alternative therapies become even more popular, you're going to have to deal with more competition. You will have to work harder to stay on the cutting edge of alternative therapies. But, if it's any consolation, this is where larger and more conservative companies fear to tread.
Jack Challem, based in Aloha, Ore., writes and publishes The Nutrition ReporterTM newsletter, which can also be found at www.nutritionreporter.com on the Internet.
Editor's Note: George D. Lundberg, M.D., editor of JAMA for 17 years, was fired on January 15—a date astonishingly close to publication of the journal's issue on alternative medicine. For more information, see industry news.
References
1. Eisenberg DM, et al. Trends on alternative medicine use in the United States, 1990-1997. JAMA 1998;280:1569-75.
2. Angell M, Kassirer JP. Alternative medicinethe risks of untested and unregulated remedies. New Engl J Med 1998;339:839-41.
3. Goodwin JA, Tangum MR. Battling quackery: attitudes about micronutrient supplements in American academic medicine. Archives of Internal Med 1998;158:2187-91.
4. Shorri RI and Greene WL, A food-borne outbreak of expensive antibiotic use in a community teaching hospital. JAMA 1995 Jun 28;273:1908
5. National Institute of Health, Washington, D.C. http://www.nlm.nih.gov/databases/freemedl.html
6. Burg MA and Stoller EP. Personal use of alternative medicine therapies by health science center faculty. JAMA 1998;280:1563.
7. PDR for herbal medicines. Montvale (NJ): Medical Economics Co., 1999.
8. Challem J. Nutrition research, computer databases, and insurance cost-cutting. J Orthomolecular Med 1992;7:247-8.
