Snake Oil Science: The Truth About Complementary and Alternative Medicine [Paperback]

R. Barker Bausell is a biostatistician who worked for the NIH's Complimentary Medicine Program, which was designed to test the efficacy of Contemporary and Aleternative Medicine (CAM). As a biostatistician, Bausell is the one who designs studies so that they are as fair and unbiased as possible. His big "beef" with CAM? That the less biased the study, the less effective CAM seems to be.

This book has several strenghts and several weaknesses. I will go into the strengths first.

STENGTHS:
First, while the book suggests that it is primarily about 'debunking' alternative medicines, the bulk of the book is spent talking about how effective studies are designed and different things that can undermine the validity of studies (small sample sizes, shoddy control/placebo treatments, attrition). In short, this book offers a VERY good explanation of how science works. (Only after explaining how good studies are designed does our author go on to suggest that most CAM studies are quite poorly designed.)

This book spends a lot of time talking about the 'placebo effect,' a large player in CAM research. The placebo effect is a (generally) psychological effect where the person experiences betterment SOLELY from having any kind of treatment at all (even a sugar pill). Our author's point with explaining the placebo effect is to suggest that well-designed CAM studies point to one conclusion: that most CAM treatments are only as effective as any other placebo (incorrectly performed accupuncture is as effective as 'legitimate' acupuncture, not because accupuncture works, but because the subject wants or expects it to work).

The author is very far from biased. Despite its outragous title, Snake Oil Science is not a 'gotcha' book written by a mean-spirited and fun-poking author. The discourse is very professional and fair. The author never 'slams' CAM, but only suggests that CAM has ALOT of work to do in order to prove itself, assuming that it can.

WEAKNESSES:
For those wanting a comprehensive discussion 'debunking' CAM treatments and remedies, this book - again, despite its title - will not be satisfying. The author, a biostatistician, spends so much time talking about how to design a good study, how to spot a bad one, and adding caveat after caveat, that only one (and a half) chapters really discuss what the research actually saya. Really, the book should have been subtitled, "A primer on the methodology of clinical studies."

For those who want a somewhat friendly and relatively non-academic read, this book probably is not it. The author certainly tries to bring it down to non-specialist language, but when talking about statistics, controls, variables, and confounds, technical jargon and dry verbiage ls unavoidable. While this book is certialy informative about how clinical trials are designed, the placebo effect, and explaining why most CAM studies are poorly and hastily done, it is a somewhat dry read.

So, there you have it. If you want to become more familiar with how the medical profession tests their treatments (and compare it to how CAM proponents 'test' their treatments) this is a very good and exciting book. If you are looking for a good old-fashioned Shermer and Randi style 'debunking' of CAM, there are several other books you are better to read than this one. (Try "Trick or Treatment: The Undeniable Facts About Alternative Medicine.")

I am a practicing physician in Singapore and at one time, on staff teaching hematology in University College Hospital Medical School, London University and then Hong Kong University. Many years ago, while sitting on the Singapore National Medical Research Council, there was one grant applicatioin that asked for money to do a piece of research on "Acupuncture for the relief of osteoarthritic knee pain." There was no sham acupuncture control group mentioned. When I said in order to make the trial valid, there must be a control group. The answer came back, "We know no matter where we stick the needle, the pain will improve." That started me on my quest for more knowledge regarding acupuncture and other forms of Complementary and Alternative Medicine (CAM).

This book by R. Barker Bausell is the best one I have ever read. Bausell is a biostatistician, a Professor at the University of Maryland and at one time Research Director of an NIH funded CAM Specialized Research Center. The structure of the book could roughly be outlined as an attempt to finding answers to the following questions:
1. Is there such a thing as a therapeutic placebo effect?
2. Is there a plausible biochemical analgesic mechanism of action that could explain such an effect?
3. Is there such a thing as a CAM therapeutic effect over and above what can be attributed to the placebo effect (assuming that there is such a thing as the latter)?
4. Are there plausible biochemical mechanisms of action that could explain these CAM therapeutic effects (assuming there are such things)?

In the process of answering those questions, he explained in very clear terms the necessity for Randomized Control Trials (RCT), and preferably Double blinded RCT, where neither the physician nor the patient knew whether the patient was receiving the treatment or just a placebo, was necessary. As an aside, his book could be an introductory treatise on running RCTs for the rookie clinical research working planning his/her first clinical trial. Towards the end of the book, having laid out the criteria of what were meant to be good clinical trials, he found virtually nothing in the literature that pointed to the efficacy of CAM other than that due to placebo effects.

In summary his answers to those four questions posed at the beginning are:
1. The placebo effect is real and is capable of exerting at least a temporary pain reduction effect. It occurs only in the presence of the belief that an intervention (or therapy) is capable of exerting this effect. This belief can be instilled through classical conditioning, or simply by the suggestion of a respected individual that this intervention (or therapy) can reduce pain.
2. The placebo effect has a plausible, biochemical mechanism or action (at least for pain reduction), and that mechanism of action is the body's endogenous opiod system.
3. There is no compelling credible scientific evidence to sugges that any CAM therapy benefits only medical condition or reduces any medical symptom (pain or otherwise) better than a placebo.
4. No CAM therapy has a scientifically plausible biochemical mechanism of action over and above those proposed for the placebo effet.

FINAL CONCLUSION: CAM therapies are nothing more than cleverly packaged placebos.

Those of you who are old enough to remember the hu-ha that surrounded the stories regarding acupuncture anaesthesia that came out of China at the time of the Nixon-Mao meeting in the 70's perhaps would like to know what a professor of medicine in Beijing told me. They are no longer using that, and the party leaders, when they go for surgery of any form, inevitbaly would choose anaesthesia given conventionally over acupuncture.

I think that says it all.

Bausell does a great job in this book of explaining why Complementary and Alternative Medicine (CAM) is so popular, even though there's no good evidence that it works. To do this, he goes through several steps.

He explains how both consumers and medical practitioners could be convinced of the efficacy of CAM when it's not there. He explains the basics of good research, especially using a placebo control. He shows how bad most CAM research is. He provides compelling evidence that the placebo effect, at least for pain relief, is a real, physiological phenomenon. And he pulls this all together to show that CAM is no more effective than placebo.

I've seen criticisms that he lumps all CAM together. That's true, because every CAM technique suffers from the same two characteristics: there is no scientific basis for why it should work, and the research on it lousy. Most CAM therapies don't lend themselves towards placebo controls - how do you do a sham chiropractic adjustment? In fields such as homeopathy and acupuncture where there are good placebos, placebo-controlled trials are overwhelmingly negative. That's probably why most trials don't use placebos.

Note that Bausell doesn't say that CAM doesn't work. On the contrary, he just says it's no more effective than placebo. Since placebo effects are real, CAM effects are real, and CAM practitioners can provide some real relief. Does that put them on a par with mainstream Western medicine, which can provide treatments that greatly exceed the placebo effect? Of course not.

The book would have benefited from a discussion of how any CAM treatment that can survive quality research then ceases to be CAM. For example, he talks briefly about willow bark, which contains aspirin, and how it used to be an herbal remedy. There are other medicines or treatments that started as CAM and have moved into mainstream medicine as they were proven. This condemns CAM perpetually to be a wasteland of ineffective treatments. But Bausell doesn't really make that point, which I'm sure will leave some readers wondering if their local practitioner may this time have the miracle cure that's the one exception.

But that's a minor criticism for a book that tackles a very ambitious topic. I heartily recommend this book to anyone who cares about their health or their health care dollar.