I can’t believe I’m saying this, but I want you all to tune in to The Dr. Oz Show on Tuesday, April 26. Either that, or DVR it. Why am I asking you to do this? Have I lost my mind? Have I suddenly gone woo? Of course not. The reason is that, an episode I’ve been waiting for since I learned it was in the works last week will air on that date.

That’s right. Our fearless leader Steve Novella will be on The Doctor Oz Show this Tuesday to do battle in the belly of the beast.

Unfortunately, I fear for the results. I know Steve acquitted himself quite well, at least as well or better than any skeptic and booster of SBM could hope to do in such a hostile environment, but get a load of the title of the segment, Controversial Medicine: Why your doctor is afraid of alternative health?

Afraid?

Afraid?

Afraid?

No, no, no, no! A thousand times no!

I do worry a bit how the producers edited Steve’s segment, though. Look at the promo. In it Dr. Oz is doing what I was afraid of, trying to portray himself as the voice of reason and accusing Steve of being “dismissive.” I was afraid Dr. Oz would play the “don’t be close-minded” or “you’re too dismissive” card, and he appears to have done it. Then get a load of the advertised segment that follows, showing Dr. Oz dictating what’s true and not in medicine, as in “Dr. Oz approved.”

Truly, the man has no shame.

I’ll have to wait until Tuesday to see what the final results are. Whatever happens, we at SBM are all incredibly proud of Steve for going into the proverbial lions’ den. As managing editor, I’m also enormously proud of our stable of bloggers; after all, it is a collective effort that got us noticed by the producers of The Dr. Oz Show. Also, now that Dr. Oz and his producers have noticed us, however the segment turns out we promise to keep holding Dr. Oz’s feet to the fire when he starts promoting nonsense like faith healers, psychic mediums, dubious diabetes treatments, and über-quacks like Joe Mercola. This should be facilitated by our new partnership with the James Randi Educational Foundation that was announced earlier this week.

You can also rest assured that Steve will blog about his experience after the episode airs, and I hope our readers will dive into the discussion forums after the show.

The White Man’s burden, a bit of racism from the 19th century:

The term “the white man’s burden” has been interpreted as racist, or taken as a metaphor for a condescending view of non-Western national culture and economic traditions, identified as a sense of European ascendancy which has been called “cultural imperialism.” An alternative interpretation is the philanthropic view, common in Kipling’s formative years, that the rich have a moral duty and obligation to help “the poor” “better” themselves whether the poor want the help or not. The term “the white man’s burden” has been interpreted as racist, or taken as a metaphor for a condescending view of non-Western national culture and economic traditions, identified as a sense of European ascendancy which has been called “cultural imperialism.” An alternative interpretation is the philanthropic view, common in Kipling’s formative years, that the rich have a moral duty and obligation to help “the poor” “better” themselves whether the poor want the help or not.

I will let the commentators debate the meaning of the poem. There are places in the world so devastated by poverty, disease and political corruption that it may be beyond the capacity of the local populations to overcome. They need outside help. Certainly, the impulse to help those less fortunate than yourselves is a noble tradition. Haiti, Central America and Uganda are parts of the world that need assistance in overcoming an incredible number of problems to reach even a basic level of material support for its population.

What better way to help people in dire need of the basic requirements for health and material well being than to provide them with Western SCAMs?  At least in the industrialized West, we have options. If acupuncture or homeopathy or reiki does not take care of our problem or our diseases worsen, we are a quick trip away from the ER.  We may not be able to afford the care, health care being the number one cause of bankruptcy in the US, but at least effective health care is available. Other societies do not have that option. Often their one point of contact with health care  providers and/or shamans is their only contact and there is no infrastructure to take care of the ill.  Uganda spends $135 per capita on health care,  and has 0.047  physicians per 1,000 people. 1,500 doctors for a population of 35 million. Haiti spends  $82 per capita. I spend more each year on my daily peanut butter and jelly sandwich for lunch ($1.10)  By comparison, the US spends $6,000 a year per capita on health care.

These are societies where small amounts of money spent carefully can have enormous impact. Relatively small amounts of money can do enormous good in impoverished parts of the world. Ten dollars can buy a mosquito net and prevent malaria.  The measles vaccine costs less than a dollar a dose and can prevent devastating outbreaks of disease.  One hundred dollars  can provide the hungry with 2 chickens and a goat. So why spend the money on nonsense?  I know it is a false choice.  Just because money is being spent on something useless like homeopathy or acupuncture does not mean that the same money would go to a more rational choice if it were otherwise available.

In medicine we are aware of the ethical issues in treating vulnerable populations.  The poor and uneducated do not have the resources to separate fact from fiction and may lack the background to make truly informed decisions.

Yet none of this stops the sCAM believers from exporting their nonsense to the poor, the hungry, the under educated and the desperate.

Research

The only thing necessary for the triumph of disease is for good men to do homeopathy.

Diarrhea is a major source of morbidity and mortality in large parts of the world, the second (I originally wrote number 2)  cause of infant death in the world.  Treatment and prevention of diarrheal illness is key to decreasing infant mortality world wide.  How might I make a major impact?  Provide clean water?  Rotavirus vaccination? Wait, I have it! Let’s give random homeopathic medications to the children in the slums of Nicaragua and compare it to placebo and see if it helps their diarrhea.  Treatment of acute childhood diarrhea with homeopathic medicine: a randomized clinical trial in Nicaragua did just that.

So what did they use for treatments of diarrhea and why (besides normal hydration)?

Who had oversight on this study? From the paper:

Informed consent was obtained from the parent or guardian using a disclosure statement that had been approved by the human subjects review committee of the University of Washington.”

One third of Nicaraguans are illiterate and only half get a fifth grade education. I would think, obviously erroneously, University of Washington would recognize that the parents of children in Nicaraguan slums may not have the background to understand informed consent or the essential irrationality, er, science,  of homeopathic nostrums, and one would hope that the University  of Washington would be interested in protecting those who cannot protect themselves.   Evidently not, since their faculty continues to export magic to vulnerable  children and adults in third world countries. Not yet ethically Tuskegee level research, but they are working on it.

I understand that one persons lapse in medical and scientific understanding is another’s opportunity for a nationally syndicated television show, but they might have well piled the money spent on the study and burned it for all the good it did the subjects and the medical literature.  At least they could have used the heat to pasteurize some milk.

Homeopaths Without Borders. Or sense.

Men never do bad medicine so completely and cheerfully as when they do it from a homeopathic conviction.

Doctors Without Borders,  also known as Médecins Sans Frontières, is an organization that sends physicians to some of the most needy parts of the world.   Using the style, but not the substance of Doctors without Borders, is Homeopaths without Borders, or, as the RationalWiki called it, Médecins Sans Médicaments.  Their goal is to send homeopathic care to those in need.  Based in Florida, it appears to be the work of one homeopath and almost all its work is in Haiti.

“the poor health of the people here is striking. So many girls and women have vaginal infections. So many children have infected cuts. So many men have reddened eyes, rotten teeth, and injuries that are healing badly. The nurses and docs here are as dedicated as anywhere else, but they lack supplies, and they don’t have medicines.”

They need help.  Shall we provide money for antibiotics? Dental Care? Good nutrition?  Clean water?

So lets supply them with water, and not even enough to wash those infected cuts.  I have to admit this brings conflicting emotions.  I have to admire anyone who will take the time to go to a disaster like Haiti and work to help those in need.  On the other hand, they offer nothing but false hope and magic, so cannot make the lives of Haitians any better. Time, money and resources, which could be used so much more productively, wasted.  I see many patients who have pissed away their lives and opportunity with heroin or alcohol or other bad choices.

“Look, if you had one shot, or one opportunity
To seize everything you ever wanted-One moment
Would you capture it or just let it slip?
Give effective therapy or a homeopathy? “

Wasted opportunities always inspires angst. So does Médecins Sans Médicaments.

It does show how powerful delusional states can be for believers of nonsense, since as RationalWiki states “Essentially, they go to nations with sub-standard healthcare, and dilute it even more to make it 10^-430 times as good as the healthcare in wealthier nations.”

PanAfrican Acupuncture Project

The evil that is in the world almost always comes of ignorance, and good intentions may do as much harm as malevolence if they lack understanding.

How best to spend very limited resources and maximize the health in Uganda, where AIDS, malaria, and Tb are endemic and have devastated the country?  Mosquito nets and condoms would be a good start to prevent these blood and mosquito borne illnesses.  Naw.  That might actually improve peoples lives.  Or we could use acupuncture instead:

“The PanAfrican Acupuncture Project trains healthcare workers in Africa to use simple and effective acupuncture techniques that enable them to treat the devastating and debilitating symptoms associated with HIV/AIDS, malaria, and TB.”

Again, I do admire the urge to go to Africa and help others.  They ask for donations and trainers on the website, expecting the trainers to provide their own airfare and $3,000 (aka 300 mosquito nets) to cover their own costs.  No small commitment. Of course, they provide a vulnerable population worthless magic, and I can only imagine what four grand could provide for clean water or malaria nets, interventions  that would actually benefit the Ugandans.

But what is scary is the web page.  Uganda is rife with HIV, which is spread, by, hmmmm, lets see, sex, blood and needles. Unsterilized needles.  In Africa, reuse of needles has been common, often due to lack of resources for sterilization, and has helped to spread HIV and perhaps other infectious diseases. So they have photos of people sticking needles into patients who could and do have HIV. Not a glove to be seen. Remember that blood borne illnesses are spread with acupuncture needles: Hepatitis B, hepatitis C and, rarely in the West, HIV.  It is rare to spread these diseases where good technique is followed scrupulously.  Poor societies are not known for the resources that allow them to fastidiously take care of proper cleaning.  Would anyone besides me worry that some acupuncture needles have a chance of being reused after poking an HIV positive patient?

As best as I can tell from the website, they are training people to potentially spread HIV between patients when and if sterilization breaks down and placing the acupuncturist at small, but real, risk should a needle stick injury occur.  The have trained over 100 local acupuncturists and hope to spread acupuncture, and the occasional blood borne viral illness, beyond Uganda to other African countries.  No benefit and all risk. The PanAfrican Acupuncture Project may have a commitment to philanthropy, but I am not convinced they have a commitment to preventing disease transmission.

“Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!”
And waste their resources and health with CAM.

There are Chiropractors Without Borders and Naturopaths Without Borders who have three principles:

• Health care is a human right for all, not a privilege for the few.
• Everyone deserves the best healthcare, regardless of finances.
• Naturopathic Medicine is well suited for resource-poor settings.

Unfortunately, the third has no relationship to the first two.

There is Reiki Without Borders and Herbalists without Borders fortunately for the third world,  all seem to be the work of a few individuals, although Haiti appears to be the common destination.  Poor Haitians. They really need a border.

The West has a long and sordid history of exporting disaster to the third world.  It is nice to know that sCAMsters,  even if only a very small subset, are continuing the time honored tradition of maltreatment of indigenous peoples in the name of helping them.

Fortunately there are doctors, nurses, engineers, teachers, chemists and scientists without borders, who can offer substantive help.  Even Clowns without Borders would have something to offer, although not for everyone.

People aren’t either wicked or noble. They’re like chef’s salads, with good things and bad things chopped and mixed together in a vinaigrette of confusion and conflict and alternative medicine.

Not only his name and his titles of nobility were forged, but parts of the teachings of the man who introduced acupuncture to Europe were also invented. Even today, treatments are provided based on his fantasies.

– Hanjo Lehmann¹

Decades before President Nixon’s visit to communist China, and before the articles in the Western popular press on the use of acupuncture in surgery, a Frenchman by the name of George Soulié de Morant (1878-1955), published a series of colorful accounts of the use of acupuncture in early 20th-century China. His work led to the creation of a school of thought known as “French energetics,” which has become the theoretical foundation for many proponents of acupuncture in the West, including Joseph Helms, MD, the founder and former director of the American Academy of Medical Acupuncture (AAMA), and the founder of the acupuncture certification course for physicians.

But just as the medical community gradually learned that the reports of the use of acupuncture in surgery in communist China were inaccurate, exaggerated, or even fraudulent, we are now learning that the reports on the use and efficacy of acupuncture by Soulié de Morant were also fabricated.

According to a 2010 article published in Germany by Hanjo Lehmann in the Deutsches Ärzteblatt (a short version was published in Süddeutsche Zeitung), there is no real evidence that the Frenchman who is considered the father of Western acupuncture ever stuck a needle in anyone in China, and he probably never witnessed a needling.

A century prior to Soulié de Moran’s publications, the therapeutic use of needles enjoyed immense (though short-lived) popularity in Western Europe — mainly in France, Germany, Austria. This use of needles consisted mostly of the so-called locus dolendi treatment, where needles are placed solely in the vicinity of the affected area(s).² But due to its lack of significant efficacy, this treatment vanished just as rapidly and completely as it had appeared.

During that time, paradoxically, acupuncture was excluded from the Imperial Medical Institute of China by decree of the Emperor in 1822. The knowledge and skills were retained, however, either as an interest among academics or through everyday use by rural folk healers. With China’s increasing acceptance of scientific medicine at the start of the 20th-century, final ignominy for acupuncture arrived, when in 1929, it was outlawed, along with other forms of traditional medicine.³

The practice of acupuncture, however, reappeared in France a few years after it was outlawed in China, and from there it gradually spread to Western Europe and the US. This time, its theories were based on the laws of meridians (where points distant from the affected areas are needled according to intricate algorithms). This renaissance was largely due to Soulie de Morant’s legacy.

Soulié de Morant was born in Paris in 1878, and attended a Jesuit school. The prevailing story is that he was a child prodigy, and in addition to speaking fluent English and Spanish, he also learned Mandarin from a Chinese man who lived in Paris, and who (according to family friend Judith Gautier, a French writer) spent an afternoon with the young George writing Chinese characters (or ideograms) in the sand.

Soulié de Morant went to China at the turn of the 20th-century at the age of 21 to work for a French bank. The legend goes that he was fluent in Mandarin before going to China, and that once there, he also learned Mongolian. Reportedly, his language skills and his knowledge of Chinese culture brought him to the attention of the French Ministry of Foreign Affairs, who appointed him judge of the Joint French Court of Shanghai, and later the Vice-Consul of Foreign Affairs in Yunnan. Presumably, he then became the French Consul in several Chinese cities.

The legend also includes the story of how, while in office, Soulié de Morant witnessed a Chinese physician help the victims of a “terrible cholera epidemic that raged in Beijing at that time,” without recourse to modern medicine. His curiosity aroused, he began to read ancient medical texts, and studied acupuncture under several renowned physicians. Purportedly, he later practiced acupuncture himself, and it is reported that his knowledge and skills were such that he became respected by the Chinese — an incredible accomplishment for a foreigner, then or now.⁴

He returned to France in 1910, was married in Paris in 1911, and had two children. He then tried to return to China, but only succeeded to go back for a few months in 1917. After this final trip to China, he wrote several books on Chinese art and literature. Curiously, he didn’t mention acupuncture in any of his writings until 1929 — the same year it was outlawed in China.

Initially confronted with skepticism and derision, Soulié de Morant’s writings on acupuncture eventually managed to attract the support of several French physicians. His major work, L’acuponcture chinoise, outlines his “theory of energy” and its therapeutic manipulation by acupuncture. He is also known for coining the widespread term “meridian,” as a translation for the Chinese expression jingluo (??), which literally means “channel-network.” He translated the term qi (?), the Chinese equivalent of the Greek notion of pneuma (??????), into the modern term “energy.”

The 1994 translation of L’Acuponcture Chinoise. Image source: Paradigm Publications

One of the main people who challenge the authenticity of Soulié de Morant’s understanding of acupuncture and his interpretations of the Chinese classics is the American scholar, Donald (Deke) Kendall, PhD, who writes in the Dao of Chinese Medicine that by jingluo, the Chinese were simply referring to blood vessels. Kendall argues that Soulié de Morant’s theories are actually the result of profound misunderstandings and misinterpretations of the classics, which have resulted in the portrayal in the West of the rudimentary description of the vascular system by the Chinese as an elusive network of intangible “energy” channels.⁵

There is ample evidence in support of Kendall’s claims, including the work of the classics scholar Elizabeth Craik, who has convincingly argued that the Chinese notion of jingluo is quasi-identical to the Greek notions of phlebes (blood vessels in general) and neura (ligaments, nerves, etc.).⁶

But Hanjo Lehmann, the author of the recent article in Deutsches Ärzteblatt, goes a step further. Lehmann lists a set of contradictions and inconsistencies in Soulié de Morant’s account of his journey in the Far-East, which shed doubt on his overall character, the integrity of his narrative, and the credibility of his exposure to, and practice of, acupuncture in China. Lehmann calls him a scharlatan.

Lehmann first points out that it would be unlikely for a 21-year-old without any formal education in Chinese (and who had never lived in China) to master a complex language with several thousands of characters, even if he took courses regularly for several years. We recall that the only testimony of Soulié de Morant’s formal “studies” in Paris came from Judith Gautier (1845-1917), who affirmed that on one occasion, a Chinese friend of the family in Paris drew characters in the sand with him.

According to Lehmann, Soulié de Morant likely started his foreign service in 1903, as a low-level interpreter at the Shanghai Consulate, and not as a “judge” in Shanghai. The belief that he was actually nominated as a judge might come from the fact that in his book Exterritorialité et intérêts étrangers en chine, Soulié de Morant states that the French delegate in the Joint Court was “usually the first interpreter” of the consulate.

As for his consular nominations when he was only in his mid-twenties, Lehmann argues that they are certainly false. It is only after he left the French Foreign Office, (probably in 1924), that he received the title of “honorary consul.” In fact, it is only in his writings after 1925, that he calls himself Consul de France.

Lehmann also believes that his aristocratic name “Soulié de Morant” was a forgery, and that he was born simply Georges Soulié.

As for acupuncture, Soulié de Morant claims that he first saw and practiced the technique himself during a cholera outbreak in Bejing in 1908 — but no records of such an outbreak at that time exist. According to the History of Chinese Medicine by Wong and Wu, an epidemic of plague and typhus occurred roughly around that time, but in Hong Kong and Fuzhou in Jiangxi.⁷ There is no record of a cholera epidemic in Beijing or anywhere else.

Moreover, although Soulie de Morant recounts his studies with two renowned acupuncturists of academic rank, other Western writers remind us that during that time, only street practitioners and rural folk healers, worked with needles therapeutically; the use of needles was actually often associated with amulets and talismans, and thus frowned upon by the Chinese academia.⁸

These and dozens more inconsistencies that discredit Soulié de Morant, suggest that the his claims about acupuncture, and the lore of energy meridians and qi, are founded on sloppy translations, misconceptions, or even pure forgery. But the accuracy of these notions are never disputed by the Chinese, because — as Lehmann points out — the public image of acupuncture in China today is based mainly on its reputation in the West. The Chinese consider that any criticism or fundamental discussion would jeopardize that reputation.

Over the last half-century since his death, Soulié de Morant’s interpretation of the traditional tenets of acupuncture, known as “French energetics,” have inspired the creation of over a dozen methods, organizations, and schools abroad,⁹ each with different levels of orthodoxy, critical thinking, or even rationality.

Consider, for instance, a theoretical construct known as the “Energetics of Living Systems” that was developed by the French physician Maurice Mussat. He is one of the leaders of the French school of medical acupuncture, and has taught in the US under the auspices of Joseph Helms, MD. Mussast takes the fabulations of Soulié de Morant to the next level of absurdity by projecting cybernetics, complexity theory, and quantum mechanics onto meridian-based acupuncture.

Mussat indeed believes there is a parallelism between the energetics of the meridians and the “mathematical order inherent in the trigrams and hexagrams” of the I-Ching, a Chinese classic of geomancy (a type of divination based on patterns formed by tossed rocks, sticks, sand, etc.). Mussat, who believes he has connected the symbolism of the I-Ching with modern quantum physics, has devised “algebraic derivations” to measure meridian energetics, and has created a diagram that “incorporates nearly all of the fundamental energy relationships of acupuncture.”¹⁰ Mussat’s forced conflation of acupuncture and quantum physics is outlined in his 3-volume Energetics of the Living Systems Applied to Acupuncture, as well as in other creations of his overinclusive thinking.

A German book on Mussat’s “quantum-medicine” (1983). Image source: VGM Verlag GmbH for Integrative Medicine.

The cognitive derailments of Maurice Mussat have, in turn, greatly influenced Joseph Helms, the founder and former Director of the AAMA.¹¹ Helms, who combines family medicine, acupuncture, and homeopathy, served on the advisory panel of the Office of Alternative Medicine, NIH, and presented to the White House Commission on Complementary and Alternative Medicine Policy. In his book, Acupuncture Energetics, Helms writes:

Mussat inspired me with the strength of his conviction and his creative merging of two disparate traditions of thought and medicine. He guided me to perfect my clinical skills and to start teaching. My early clinical time with him, combined with the years we lectured together, created an indelible matrix of clear expression that I hope is manifested throughout this work.¹²

Since the 1980s, the AAMA has taught the fantasies of Soulié de Morant and Mussat on meridians and energy under the label of “medical acupuncture” to thousands of physicians in the US , many of whom were members of the military. In fact, in 2009, the office of the Surgeon General of the Air Force instituted a pilot program for active duty physicians to be trained by Helms Medical Institute, and gave out 32 scholarships on a competitive basis. According to Stars and Stripes, the US military’s independent news source, the program is now expanded to all service branches, and will certify 60 active duty physicians in 2011 as “medical acupuncturists.”

Meanwhile, well-conducted clinical trials have indicated over and over that needling location has little differential effect on outcomes, and that acupuncture is largely devoid of speci?c therapeutic effects.¹³ The support for this argument comes from a series of 8 large randomized controlled trials (RCTs) initiated by German health insurers. These RCTs were related to chronic back pain, migraine, tension headache, and knee osteoarthritis (2 trials for each indication). Their total sample size was in excess of 5000. Even though not entirely uniform, the results of these studies tend to demonstrate no or only small differences in terms of analgesic effects between real and placebo needling.¹⁴

This evidence indicates that the use of specific meridians, points, and particular types of stimulation are not critical factors independent of conditioning, expectancy or other neuropsychological factors. Needling seems to have a broad anti-inflammatory and antihyperalgesic effect, which could be attributed to the pain and tissue injury, or the neurostimualtion caused by the needle, regardless of the insertion point. In view of this, the meridian and point lore, and the premisses of “Acupuncture Energetics,” are all devoid of any scientific rationality.

Considering that acupuncture was reintroduced to the West based on a narrative that was apparently fraudulent; that its cultural assimilation has conflated it with New Age crackpottery; and that reliable RCTs contradict its medical claims, it’s time once-and-for-all to cease wasting taxpayer dollars on its dissemination.

NOTE: The opinions expressed here are those of the author, and do not reflect the positions of Hanjo Lehmann and Donald (Deke) Kendall.

REFERENCES

1. Lehmann H. Akupunktur im Westen: Am Anfang war ein Scharlatan. Dtsch Arztebl. 2010; 107(30): A-1454 / B-1288 / C-1268. Return to text
2. Feucht G. Streifzug Durch die Geschichte der Akupunktur in Deutschland, Deutsche Zeitschrift fur Akupunktur, 10. 1961. Return to text
3. Ma KW. The roots and development of Chinese acupuncture: from prehistory to early 20th century. Acupunct Med 1992;10(Suppl):92–9. Return to text
4. Soulié de Morant G. L’acuponcture chinoise. 2 vols. Paris: Mercure de France, 1939-1941. Published in English as Chinese Acupuncture, edited by Paul Zmiewski. Brookline, MA: Paradigm Publications. 1994. Return to text
5. Kendall DE. Dao of Chinese Medicine: Understanding an Ancient Healing Art. Oxford University Press, USA; 1 edition. 2002. Return to text
6. Craik EM. Hippocratic Bodily “Channels” and Oriental Parallels. Med Hist. 2009 January; 53(1): 105–116. Return to text
7. Wong KC, Wu TH. History of Chinese Medicine. Oriental Book Store. 1977. Return to text
8. Hillier SM, Jewell T. Health Care and Traditional Medicine in China 1800-1982. Routledge; 1 edition. 2005. Return to text
9. Hsu E. Outline of the History of Acupuncture in Europe, The Journal of Chinese Medicine, 29. 1989. Return to text
10. Mussat M. Energetique Physioloque de l’Acupuncture. Paris, France: Librairie le Francois. 1979. Return to text
11. Birch SJ, Felt RL. Understanding Acupuncture. Churchill Livingstone; 1 edition. 1999. Return to text
12. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Medical Acupuncture Publishers; 1st edition. 1995. Return to text
13. Ernst E. The American journal of medicine, Vol. 121, No. 12. December 2008. Return to text
14. Baecker M, Tao I, Dobos GJ. Acupuncture Quo Vadis? On the current discussion around its effectiveness and “point speci?city.” In: McCarthy M, Birch S, Cohen I, et al, eds. Thieme Almanac 2007: Acupuncture and Chinese Medicine. Stuttgart, Germany: Thieme; 2007:29-36. Return to text

I have been following the story of Dr. Zamboni, an Italian vascular surgeon who claims that multiple sclerosis (MS) is primarily caused by blockages in the veins that drain blood from the brain. This results in backup of blood in the brain, leading to inflammation around the blood vessels and MS. He sought to find the cause and cure for MS because his wife suffers from this disease – and he claims to have found one in his own specialty.

New ideas are presented in science and medicine all the time. This is healthy and necessary – we have to keep churning the pot so that new ideas can emerge and our thinking does not become calcified. But science is both a creative and destructive process, and most new ideas fall victim to the meatgrinder of research and peer-review. Ideally this process will take place mostly within  the halls of science, and then those ideas that survive at least initial examination will start to penetrate the broader culture.

This is not what often happens today, however. With the internet and mass media, preliminary speculative studies are often presented to the public as if they are a stunning breakthrough. When the scientific community responds with their typical and completely appropriate skepticism, this may lead some to think that they are being stodgy or dogmatic, or even that a cover-up is in the works. The originator of the speculative claim is usually portrayed as  a brave maverick, although sometimes the story can be framed as, “Brilliant scientist or dangerous crank? You decide.”  When the topic is a new medical treatment, the stakes can be quite high. In this case many patients with progressive MS are seeking treatment with the so-called liberation procedure to treat the highly speculative CCSVI as an alleged cause for their MS.

This story has all the makings of the kind of scientific and medical drama the mass media loves. While the controversy rages, the science is quietly being done in the background, and the results are not heading in a favorable direction for Zamboni. A recent study, the largest to date, drives a further stake into the heart of CCSVI as a cause of MS.

First, let us consider how to approach Zamboni’s claims. His data suggests that nearly 100% of patient with MS have CCSVI (detectable blockages in the veins that drain the brain) while 0% of non-MS patients do. This kind of evidence is correlation only, and does not prove (even if it might suggest) causation. Before we leap to treatment, the cautious scientific approach is to first confirm the correlation with replication. If the correlation holds, then studies need to be done that can shed light on causation – does the pattern of correlation fit the hypothesis that CCSVI causes MS, rather than MS causing CCSVI or both correlating with some other factor. Finally, before treating CCSVI, we would need to study this treatment directly in specific types of MS.

Proponents of the liberation procedure are skipping over all these research steps, and then use anecdotal evidence to support claims of efficacy. This is a story we have seen before, and it usually does not turn out well. Getting back to the first step – how have attempts to replication the correlation been going?

Last August I described the first four attempts at replication, three of which yielded negative results. Just last month I wrote a following up where I described three further studies of CCSVI – all negative. This month two more relevant studies have been published. The first compared 20 MS patients to 20 healthy controls, and found:

Only one healthy control and no MS patients fulfilled at least two criteria for CCSVI. Conclusions This triple-blinded extra- and transcranial duplex sonographic assessment of cervical and cerebral veins does not provide supportive evidence for the presence of CCSVI in MS patients. The findings cast serious doubt on the concept of CCSVI in MS.

Last week the largest CCSVI study was published, a study that enrolled 499 subjects, and compared MS patients to patients with other neurological disease (OND) and to healthy controls (HC). They found:

RESULTS: CCSVI prevalence with borderline cases included in the “no CCSVI” group was 56.1% in MS, 42.3% in OND, 38.1% in CIS, and 22.7% in HC (p < 0.001). The CCSVI prevalence figures were 62.5% for MS, 45.8% for OND, 42.1% for CIS, and 25.5% for HC when borderline cases were excluded (p < 0.001). The prevalence of one or more positive VH criteria was the highest in MS (81.3%), followed by CIS (76.2%), OND (65.4%), and HC (55.2%) (p < 0.001). CCSVI prevalence was higher in patients with progressive than in nonprogressive MS (p = 0.004).

CONCLUSIONS: Our findings are consistent with an increased prevalence of CCSVI in MS but with modest sensitivity/specificity. Our findings point against CCSVI having a primary causative role in the development of MS.

These findings are interesting – they do not entirely rule out a correlation between CCSVI and MS. However, the results are very ambiguous. There is a statistical correlation between MS and CCSVI, but there is also a correlation with other neurological diseases – with very different histories and probable causes than MS. CCSVI was also found in a quarter of healthy controls. So CCSVI is not specific to MS, and almost half of MS patients do not meet criteria for CCSVI.

Given the other negative studies, these results cannot be taken at face value but have to be put into context of the other research. At this time we can say that their might be a correlation, but it’s weak. It’s also still possible there is no correlation, and since there are some contradictory results more research would be helpful.

Even if there is a partial correlation, this study argues strongly against CCSVI being a significant cause of MS – if 44% of MS patients do not have it, and 42% of patients with OND do have CCSVI but not MS. This could mean that CCSVI only causes a subset of MS, or that it is a risk factor but not a direct cause. Or it could mean that MS (and apparently other diseases) cause CCSVI. This is plausible – we can imagine that the chronic inflammation caused by MS damages the veins over time resulting in CCSVI. It is even possible that this, in turn, will cause its own symptoms or worsen the MS and therefore treating it may be beneficial. This is all just speculation, however. In this case the phrase, “more research is needed” is appropriate.

One other recent study, that I have not written about previously, is worth mentioning. In this study researchers looked specifically at subjects at the very onset of their MS. If CCSVI causes MS then it should precede MS. They found no correlation, and concluded:

Our findings do not support a cause-effect relationship between CCSVI and pMS. Further studies are warranted to clarify whether CCSVI is associated with later disease stages and characterizes the progressive forms of MS.

Conclusion

With these latest studies the correlation between CCSVI and MS seems shaky – nonexistent to weak, but not entirely ruled out. That CCSVI is a significant cause of MS is even weaker. It cannot be ruled out as a late stage contributor, or a cause in a subset of MS patient, but neither is it established as a contributing cause at all, and the evidence is largely against it.

There is so far no controlled blinded studies of the liberation procedure in patients with CCSVI and MS. There is a controversy as to whether or not such studies would be ethical and appropriate. It would be getting ahead of the more basic research – we should determine that a phenomenon exists and is causative before studying a treatment of it. However, hype has generated great interest in the liberation procedure, and it is being done in various clinics. This is the Catch-22 that the modern information age has created for ethical medical researchers.

In a perfect world clinical trials of the liberation procedure would wait for more confirmatory studies, but we do not live in a perfect world. We may need to at least study those patients who are seeking out the treatment anyway, and provide useful data that future patients and practitioners can use to guide their decisions.