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Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.1: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont.)
Rave Reviews
In 1983, Ted Kaptchuk, the senior author of the recent “albuterol vs. placebo” article, and soon to become the long-time Second-in-Command of the Harvard Medical School “CAM” program, published The Web that Has No Weaver:
The book received rave reviews:
A major advance toward the synthesis of Western and Eastern theory. It will stimulate all practitioners to expand their understanding of the causes and treatment of disease.
–Paul Epstein, MD, Harvard Medical School
A lucid and penetrating exposition of the theory and practice of Chinese medicine. While the book’s rich detail makes it of great use to practicing healers, it is in its entirety very simply written, enjoyable reading for the layman…it brings a demystifying balance…Instructive, profound, and important!
Professor Martin Schwartz, University of California, Berkeley
…demystifies Oriental medicine in a remarkably rational analysis…
—Science Digest, Nov. 1982
…an encyclopedia of how to tell from the Eastern perspective ‘what is wrong.’
Dr. Kaptchuk has become a lyricist for the art of healing…
—Houston Chronicle
Although the book is explicitly detailed, it is readable and does not require previous knowledge of Chinese thought…
—Library Journal
The 2nd edition was published in 2000, to more acclaim:
…opens the great door of understanding to the profoundness of Chinese medicine.
—People’s Daily, Beijing, China
…weaves a picture…that is eminently understandable from a Westerner’s point of view…adds a valuable analysis of the current scientific understanding of how the therapies work and their effectiveness.
Ted Kaptchuk’s book was inspirational in the development of my acupuncture practice and gave me a deep understanding of traditional Chinese medicine…
…a gift for all who share an interest in deep understanding of healing. This new edition is essential reading…
—Michael Lerner, President, Commonweal
Even Edzard Ernst, still in his foggy period, called the 2nd edition “a brilliant synthesis of traditional and scientific knowledge…compulsory reading…”
Andrew Weil, who wrote a forward for the 2nd edition, praised Kaptchuk for “merg[ing] the insight of a Taoist sage with the skepticism of a modern, inquiring scientist,” and asserted that
…the emphasis of Chinese practitioners on energy and its balanced flow throughout the body is a stumbling block for Westerners who cannot see beyond the limitations of the paradigm of materialistic science.
Margaret Caudill, who wrote forwards to both editions, praised Kaptchuk for having written
…an important exposition of the ancient art of Chinese medicine in terms that can be understood by a Western audience. The author has deftly avoided, as much as possible, the pitfall of interpreting Chinese theory through Western terminology, thereby leaving the central Chinese concept of medical patterns and disharmonies undisturbed.
(One wonders if Caudill had read the book that she introduced. Kaptchuk himself, on the third page of his own introduction, states that he tried to “explain Chinese concepts with a Western vocabulary,” although he’d found that “at times [this] was a very great problem.”)
What readers might expect to find, then, is a book that is easy to read and understandable to Westerners, that is rational, that ‘demystifies’ its subject, that will provide a ‘deep’ understanding of healing, that will “expand their understanding of the causes and treatment of disease,” and that heralds a ‘synthesis’ of Eastern and Western medicine.
I perused the first edition of The Web around 10 years ago, when I was trying to learn something about acupuncture for my work on the Massachusetts Special Commission on Complementary and Alternative Medical Practitioners. A friend had it on his bookshelf, and let me borrow it; he hadn’t read it himself. A few days later I reported back to him: “there is sophistry on nearly every page.”
This review is mostly concerned with the first edition; I’ll mention some things about the 2000 edition in the next post.
“A Coherent and Independent System of Thought”
Kaptchuk begins by dismissing two, presumably dominant Western notions of Chinese medicine:
Some…see it as hocus-pocus—the product of primitive or magical thinking. If a patient is cured by means of herbs or acupuncture, they see only two possible explanations: either the cure was psychosomatic or it was an accident, the happy result of hit-or-miss pin-sticking that the practitioner did not understand. They assume that current Western science and medicine have a unique handle on truth—all else is superstition.
Other people have an equally erroneous view of Chinese medicine. Deeply and often justifiably disturbed by many of the products of Western science and culture, they assume that the Chinese system, because it is more ancient, more spiritual or more holisitic, is somehow more “true” than Western medicine. This attitude threatens to turn Chinese medicine from a rational body of knowledge into a religious faith system. Both attitudes mystify the subject—one by arrogantly undervaluing it, the other by setting it on a pedestal. Both are barriers to understanding.
But no more a barrier to understanding than the passage just quoted. We who ‘arrogantly’ undervalue Chinese medicine do so not because we see only two possible explanations for its apparent successes; we see many explanations, none involving hit-or-miss pin-sticking, accidental or otherwise. We deny that science is ‘Western,’ any more than the physics of Einstein was ‘Jewish’ (I confess to having used this quip repeatedly, but in my opinion it can’t be repeated enough). We immediately detect, in the phrase “current Western science,” the Galileo Gambit, and we reject that bit of sophistry. We’ve seen precious little evidence of cures by means of herbs or acupuncture, and 28 years later we’re still waiting. Those who think Chinese medicine is more true than ‘Western medicine’ have a problem with science other than merely being disturbed by its “products.” They are, er, deeply ignorant of it.
What, then, is Kaptchuk’s view of Chinese medicine?
Actually, Chinese medicine is a coherent and independent system of thought and practice that has been developed over two millennia. Based on ancient texts, it is the result of a continuous process of critical thinking, as well as extensive clinical observation and testing. It represents a thorough formulation and reformulation of material by respected clinicians and theoreticians. It is also, however, rooted in the philosophy, logic, sensibility and habits of a civilization entirely foreign to our own. It has therefore developed its own perception of the body and of health and disease.
If you’re bracing for an onslaught of the usual sCAMbits—unfalsifiable assertions, propaganda language devices, arguments from ignorance, arguments from tradition, special pleading, changing the rules ad lib, breezy contradictions, and all the rest—yer on the right track. Right off the bat, Kaptchuk asks that you check your own critical thinking skills at the door:
In order to understand it, we must first accept two principles: that another perspective, though different from our own, can be logical and have predictive validity, and that there can exist another method of healing. In other words, the world can contain two rational and effective medical systems, both describing the same phenomena, but describing them differently. Once we accept these premises, we can begin to understand the Chinese view of physiology.
I’ll give you a taste of that ‘physiology’ below, but first know that for Kaptchuk, Western medicine suffers from a severe case of reductionism, whereas Chinese medicine is far more interested in you as a whole person:
Western medicine is concerned mainly with isolable disease categories or agents of disease, which it zeroes in on, isolates, and tries to change, control, or destroy. The Western physician starts with a symptom, then searches for the underlying mechanism—a precise cause for a specific disease…
The Chinese physician, in contrast, directs his or her attention to the complete physiological and psychological individual. All relevant information, including the symptom as well as the patient’s other general characteristics, is gathered and woven together until it forms what Chinese medicine calls a “pattern of disharmony.”…Oriental diagnostic technique does not turn up a specific disease entity or a precise cause, but renders an almost poetic, yet workable, description of a whole person.
“An Effective Healing Method”
Kaptchuk asserts that Chinese medicine considers some things important that Western medicine does not, and vice versa:
…Chinese medical theory does not have the concept of a nervous system. Nevertheless, it has been demonstrated that Chinese medicine can be used to treat neurological disorders. Similarly, Chinese medicine does not perceive an endocrine system, yet it is used to treat what Western medicine calls endocrine disorders. Nor does traditional Chinese medicine recognize the bacteria Streptococcus pneumoniae as a pathological cause of pneumonia [sic], yet often it effectively treats the disease.
The first two claims are trivially true, of course, but beg the relevant question: the humoral system of medicine was also used to treat all sorts of diseases, as has every pre-scientific form of medicine. The pneumonia claim is another matter, for which Kaptchuk doesn’t offer particularly convincing evidence:
…the Chinese performed thousands of experiments and clinical studies during the fifties. The result was that in 1958 the Central Committee decided to give traditional and modern medicine equal respect and place in China…
The pages of such studies fill entire libraries, yet it is not their quantity that is important, but rather their conclusions: that traditional Chinese medicine can hold its own, that it does work clinically.
It is now evident that Chinese medicine is an effective healing method.
Kaptchuk proceeds to cite numerous, presumably positive or at least promising studies from China, involving heart disease, cancer, kidney disease, asthma, encephalitis, diphtheria, acupuncture anesthesia, and more. He points out that when these are “diseases recognized by the West,”
the actual application and methodology are clearly Western in orientation. The theory of Yin and Yang and other traditional concepts are left behind…
Fortunately for its future, however, the results of the studies generally demonstrate that traditional Chinese medicine does work best when left in the context of Chinese logic.
Continuing to plead the case for the unfalsifiable:
…the Chinese view of health and disease as inseparable from a specific person means that the treatment will be well tailored to that person. Such personal shaping seems to maximize the effectiveness of the therapies.
Nevertheless,
Western clinical studies (done in China) of traditional Chinese medicine, by proving its practical efficacy, have helped it win its battle for survival in the twentieth century, and promise it a place in the future of medicine.
Later, in a footnote, Kaptchuk mentions that those weren’t, like, real studies: they weren’t controlled or anything, and many used “imprecise assessment methods. They would most properly be called clinical observations.” Throughout the book he continues to cite them in support of various unlikely cure claims.
Sometimes he just makes stuff up without even attempting to justify it:
Chinese remedies are often more effective than Western ones, and they are always gentler and safer. Chinese prescriptions, for example, do not produce side effects because they are balanced to reflect a patient’s entire state of being.
Chinese medicine, because it emphasizes balance and relationship more than measurable quantity, can also frequently discover and treat a disorder before it is perceptible by the most sophisticated Western diagnostic techniques. Chinese medicine is capable of touching those places that evade the microscope…
Woah. Dr. Epstein, did you even read this stuff? Dr. Ernst? OK, Dossey, Weil, Berman, we expect them to quack right along, but really. Dr. Delbanco? (Not one of the reviewers quoted above, but one of my former mentors at Harvard, who told me a few years ago that he’d been Kaptchuk’s patron. Did he read this book?)
Kaptchuk never explains the real reasons that “the Central Committee decided to give traditional and modern medicine equal respect and place in China,” previously discussed here. In that post I also showed how one of the passages quoted above morph’d from the 1983 edition to the 2000 edition of The Web; it isn’t flattering to the ideal of intellectual honesty.
“Images of the Macrocosm”
What about that Chinese view of physiology? It turns out that Kaptchuk, who coined the phrase, asserts only a few pages later that there is no such thing. We already suspected that, but let’s play along:
The highly developed constructs [sic] of chemistry, biochemistry, anatomy, and physiology that form the groundwork for modern Western medicine are of little importance to the Chinese…Chinese medicine therefore has a very limited theory of the human organism itself.
But didn’t he tell us that the Chinese physician directs his or her attention to the complete physiological and psychological individual? I guess it depends on what your definition of “truth” is:
The essential ideas of Chinese medicine…are cultural and speculative constructs that provide orientation and direction for the practical patient situation…The ‘truth’ of these ideas lies in the way the physician can use them to treat real people with real complaints.
Maybe we’re getting somewhere, because the essential ideas are certainly cultural and speculative constructs; but there are those real complaints again, just like pneumococcal pneumonia. I thank Kaptchuk for now having made it clear that I needn’t go into excruciating detail about what I’d imagined he meant by the “Chinese view of physiology,” even as I cringe when I consider that he probably hadn’t intended to insult Chinese people in general.
But wait:
For the Chinese, Qi is not a metaphor; it is a real phenomenon that makes possible integrative descriptions of bodily changes.
Such contradictions are rampant throughout the book (and ya gotta love those “integrative descriptions”):
Chinese medicine is not primarily quantitative.
But:
It has standards of measurement that allow practitioners systematically to describe, diagnose, and treat illness.
Aren’t measurements quantitative? Silly, Western me:
Its measurements, however, are not the linear yardsticks of weight, number, time, and volume used by modern science but rather images of the macrocosm.
Hmmm. Images of the macrocosm: simple, lucid, rational, understandable, demystifying—and each one a measurement to boot! Heck, no less a measurement than Dolores Krieger’s, and the macrocosm’s been around for a helluva lot longer.
The “Chinese View of Physiology”
The ancient Chinese, according to Kaptchuk, were totally into Functions and Relationships, as I’ll explain a bit more below. I had therefore imagined that by “physiology” he must have meant the “Fundamental Substances”—Qi (“we can perhaps think of Qi as matter on the verge of becoming energy, or energy at the point of materializing”), Blood (“not the same as what the West calls blood), Jing (“Essence”), Shen (“Spirit”) and Fluids (“bodily liquids other than Blood”)—; and the Organs (“The Harmonious Landscape”: Yin Organs are Heart, Lungs, Spleen, Liver, and Kidneys; Yang Organs are Gall Bladder, Stomach, Small Intestine, Large Intestine, Bladder, and Triple Burner; Curious Organs are Brain, Marrow, Bone, Blood Vessels, Uterus, and Gall Bladder again); and, of course, how they all work together to get things done. That’s physiology!
The Chinese view, according to Kaptchuk? Let’s see:
The Heart:
- ‘rules the Blood and Blood vessels’
- ‘stores the Shen [Spirit]‘
- ‘opens into the tongue’
The Lungs:
- ‘rule Qi’
- ‘move and adjust the Water channels’
- ‘are the upper origin of water’
- ‘rule the exterior of the body’
- ‘open into the nose’
The Spleen:
- ‘rules transformation and transportation’
- ‘governs the blood’
- ‘rules the raising of the pure’
- ‘rules the muscles, flesh,’ and the four limbs
- is the origin of Qi and Blood
- ‘opens into the mouth’
Organs vs. organs
It goes on and on, but I think you get the point. Kaptchuk insists that the ancient Chinese did not seriously intend to portray those Organs as real:
…the Chinese have no system of anatomy comparable to that of the West.
In China, internal anatomy is generally irrelevant to clinical practice.
The Heart, Lung and Kidneys of this volume are not a physical heart, lung, or kidneys; instead they are personae in a descriptive drama of health and disease.
The Organs of the body, defined as they are by their functions and relationships, are another part of the bodily web. They cannot be discussed out of context. The Chinese notions about Organs (or anything else) are not meant to be hard pieces of a theory that can be proved or disproved. They are part of an organizing network to be used when convenient. The Chinese would be indifferent to proof in our accustomed scientific sense.
China’s lack of an anatomical theory like the West’s does not mean its system is unscientific; it means only that there exist alternate systems of thought, one Eastern, one Western.
What are the differences between the two? Here is the remainder of the paragraph partially quoted above:
The tendency of Chinese thought is to seek out dynamic functional activity rather than to look for the fixed somatic structures that perform the activities. Because of this, the Chinese have no system of anatomy comparable to that of the West. Thus, for example, the Organ known as the Liver is for the Chinese very different from the Western liver. The Chinese Liver is defined first by the functions associated with it, the Western liver by its physical structure. This divergence makes it possible for Chinese medicine to identify Organs not recognized by the West—such as the Triple Burner—and for it not to recognize organs and glands clearly identified by Western medicine—such as the pancreas and the adrenal glands.
So it seems that in the West, physicians view organs in much the same way that butchers do: as mere “somatic structures,” without regard to their functions and relationships. This is nonsense, of course. I’m sure that every MD who was trained at least since the Flexner Report has thought of organs as being part of an anatomical and physiological whole, with countless, real functions and functional relationships among them, more of which are being discovered all the time. That’s physiology!
In reality, the ancient Chinese rarely dissected cadavres, so a straightforward explanation for their Organ confusion is the same as that for the centuries-long persistence of Galen’s erroneous anatomy in the West: prior to the last few hundred years the Chinese, like the Europeans, didn’t know any better. What anatomical information they had likely came from fleeting observations of mangled soldiers on battlefields, by extrapolating from the butchery of farm animals or occasional dissections of primates, and from very rare, mostly secretive dissections of human cadavres. Because such dissections were frowned upon, and Arguments from Authority were ‘privileged’ in both cultures until recently, even legitimate challenges to conventional wisdom, if there were any, were not appreciated.
Kaptchuk knows some of this but, once again, you have to go to the small print of a footnote at the end of the chapter to find the relevant passage:
China…had Confucian religious and ethical prohibitions against dissection…
The straightforward explanation is supported by some of Kaptchuk’s Organ descriptions being crudely accurate (the lungs really do “open into the nose”; the Stomach does “receive and ripen” food) and by some being inaccurate in ways that are understandable from a simplistic, purely anatomical point of view. For example, according to Kaptchuk, the “Kidneys are called the ‘root of life’…the source of reproduction,” and dysfunctions thereof are responsible for “sterility or impotence…or lack of sexual maturation.” Well, no, the kidneys have almost nothing to do with those things, but you might think otherwise if you knew only that there are tubes that connect them to the bladder and the bladder to the external genitalia. So much for an understanding of function and relationships.
An “Important Taoist Notion”
There is nothing shameful about a pre-scientific history; all cultures have gone through it. So why the subterfuge? Apparently the straightforward explanation evokes a Pattern of Disharmony with Kaptchuk’s central claim:
Chinese medicine is a coherent system of thought that does not require validation by the West as an intellectual construct. Intellectually, the way to approach Chinese concepts is to see whether they are internally logical and consistent, not to disguise them as Western concepts or dismiss them because they do not conform to Western notions. And the system is internally consistent—it is an organization of all the observable manifestations of the body into an integrated set of functions and relationships. Understanding of these functions and relationships enables the practitioner to identify and treat a disharmony in them.
And finally, his absolute, you-got-no-answer-for-this trump card:
The important Taoist notion—that the Tao (or Dao, the balanced and harmonious Way) that can be talked about and described is not the Tao—pervades medicine.
Ya gotta love the Gish Gallop. You also gotta appreciate how that important Taoist notion morphs, almost seamlessly, into current Quantum Quackery, with its own purported trump cards, misplaced versions of the Observer Effect and of Quantum Entanglement. This is no mere coincidence: Quantum Mysticism was all the rage during the 1970s, especially with the publication of Fritjof Capra’s annoying book, The Tao of Physics. Kaptchuk had apparently read another such book, The Dancing Wu-Li Masters, from which he borrowed this quotation attributed to physicist David Bohm:
Parts…are seen to be an immediate connection, in which their dynamical relationships depend, in an irreproducible way, on the state of the whole system (and, indeed, on that of broader systems in which they are contained, extending ultimately and in principle to the entire universe). Thus, one is led to a new notion of unbroken wholeness which denies the classical idea of analyzability of the world into separately and independently existent parts…
That works perfectly for someone who is hell-bent on dissing “reductionism” in Western medicine. There is that little problem of physiology, though…ya gotta wonder how all those wise reviewers missed it and just about everything else.
But back to ‘observable manifestations of the body’: doesn’t their being ‘observable’ imply that they are real, not just ‘internally logical and consistent’? Which, by the way, sounds awfully ‘Western’ to me. Oops, I stumbled again: throughout the book Kaptchuk refers to “Chinese logic”; that must be different from Western logic.
OK, I’ll try to be a little less snide. It’s possible that a system of thought can be coherent and internally logical and consistent, and yet still not be valid. Astrology, or at least some schools of it, could be such a system. Homeopathy could be another. So could the activities of the Tooth Fairy. There is also the question of just how coherent and logical and consistent Chinese medicine is. I hope this is becoming evident throughout this review.
Meridians: Interior vs. Exterior
Meridians are another important part of the Chinese view of anatomy and physiology:
Meridians are channels or pathways that carry Qi and Blood through the body. They are not blood vessels. Rather, they comprise an invisible network that links together all the Fundamental Substances and Organs…The Nei Jing says: ‘The Meridians move the Qi and Blood, regulate Yin and Yang, moisten the tendons and bones, benefit the joints.’
Are we to take such pronouncements literally? After all, “The Chinese notions about Organs (or anything else) are not meant to be hard pieces of a theory that can be proved or disproved.” Remember, there are many contradictions in this book:
In Chinese Meridian theory, these channels are unseen but are thought to embody a physical reality—the Substances Qi and Blood move along them, carrying nourishment and strength.
The Meridians connect the interior of the body with the exterior. (As has been said earlier, the distinction between inner and outer has more to do with significance than with place—the interior is more important than the exterior.)
Huh? But we were just told that the Meridians embody a physical reality. So do they or don’t they?
This is the basis for acupuncture theory, that working with points on the surface of the body will affect what goes on inside the body, because it affects the activity of the Substances that are traveling through the Meridians. Most acupuncture points relate to the Meridians and most herbs a doctor prescribes will enter one or more Meridian pathways.
Well, the ‘exterior’ seems to really mean the exterior, i.e., the surface. But does “inside the body” not mean the “interior”? After all, “the interior is more important than the exterior.” But “the distinction between inner and outer has more to do with significance than with place,” and elsewhere Kaptchuk tells us that “in China, internal anatomy is generally irrelevant to clinical practice.” This is making me dizzy.
Kaptchuk next discusses the number of meridians and the number of acupuncture points, without mentioning their relation to astrology. Throughout the book he also fails to deal adequately with the abundance of military, political, geographical, and meteorological metaphors in pre-scientific Chinese medicine, as well as the conspicuous numerology (the number 5 recurs over and over again).
More rigorous historians, such as Paul Unschuld, have made compelling arguments that the Chinese actually thought of those entities as offering important insights—not merely convenient terms—for medical ‘theory.’ Unschuld reports that what Kaptchuk calls “Yin and Yang Organs,” the Chinese call “depot and palace organs,” respectively, even if they are “yin-yang pairs.” Unschuld does not agree with Kaptchuk’s mythologic view of Chinese ‘organs’; he (Unschuld) states that they were “understood as actual morphologic entities.” He also spells them in the lower case. According to Unschuld, such concepts as “stagnant qi” or “blocked qi” were likely derived from irrigation systems in farming. Such views would be an embarrassment to the claim that
…the world can contain two rational and effective medical systems, both describing the same phenomena, but describing them differently.
Patterns of Disharmony
Kaptchuk tells us that the Chinese are (were) not concerned with ultimate causes, but with patterns:
There is no distinction between the illness itself and the factor that “caused” it. The question of cause becomes incidental. In this sense, the word ’cause’ is almost a synonym for ‘effect.’ In Chinese pattern-thinking, what might at first seem to be a cause becomes part of the pattern, indistinguishable and inseparable from the effect. Pattern-thinking subsumes the cause, defining it in terms of the effect and making it part of the total pattern. What we in the West call a cause has little importance in Chinese thought. The lines of causality are bent into circles.
This concept is the basis for the title of the book: The Web that Has no Weaver. I have no reason to doubt that such circular thinking was true for some periods or for some aspects of pre-scientific Chinese medicine, because I don’t really know all that much about it other than what I’ve read in Kaptchuk’s book, in a couple of Unschuld’s books, and in a few essays here and there. I do suspect that Chinese physicians who held this view would have nevertheless jumped at the chance to learn about the real causes of disease, as they did in the late 19th century when the Germ Theory reached them, and as modern Chinese physicians are now doing through scientific research.
It seems, however, that not all pre-scientific Chinese physicians subscribed to the “cause has little importance” doctrine. According to Unschuld,
When a doctor who felt bound to the tradition of the medicine of systematic correspondence treated a patient, it was necessary for him to determine categorically which evil was afflicting the patient, via what organ the evil (if of exogenous origin) had found its way into the body, where it was currently located in the organism, what damage it had already caused in the economy of qi, and what other spheres it could possibly move into.
Back to Kaptchuk. Here are some of the “signs” that he would call ‘both cause and effect’ in Patterns of Disharmony: the Six Pernicious Influences (also called the Six Evils)—Wind, Cold, Fire or Heat, Dampness, Dryness, Summer Heat; the Seven Emotions—joy, anger, sadness, grief, pensiveness, fear, fright. Here are the Eight Principal Patterns of Disharmony: Yin/Yang, Interior/Exterior, Deficiency/Excess, Cold/Hot. According to Kaptchuk, the Eight Principal Patterns “are the fundamental model for mediating between [the] two realms” of Yin/Yang and the “signs of disharmony.”
Various combinations of these, which are countless, are beyond my patience to attempt to comprehend. The book is sprinkled with “clinical sketches,” however, which can help to give a flavor of how such Patterns are used. I’ll reproduce a couple of them shortly.
Tongue Diagnosis, Pulse Diagnosis and the $1 Million Challenge
Of the Four Examinations in Chinese medicine—Looking, Listening and Smelling, Asking, and Touching—there are two “pillars”: observing (Looking) at the tongue and feeling (Touching) the pulse. Kaptchuk writes that one of his own teachers “described the tongue as a piece of litmus paper that reveals the basic qualities of a disharmony.” Let’s see if this is credible. The following is a small sample of nearly four pages of tongue descriptions:
A scarlet tongue is deeper red than a red tongue, and points to an extreme Heat condition. In a disharmony characterized by External Heat, it indicates that Heat has entered the deepest levels of the body.
A purple tongue usually indicates that the Qi and Blood are not moving harmoniously and that there is a pattern of Stagnant Qi or Congealed Blood…A purple tongue may also be associated with the Liver’s failure to flow or spread properly.
Moss that is puddled with moisture is a sign of Excess Fluids, usually due to Deficient Yang (or Fire, the body’s internal Heat), but is also a possible sign of other patterns, such as Dampness.
A moss that appears firmly implanted on the tongue body, like grass sprouting from the ground, signifies strong Spleen and Stomach Qi. Moss that appears to be floating on the surface of the tongue is a sign of weak Spleen and Stomach Qi.
A greasy moss appears to be a thick, oily film covering the tongue or a portion of it. It can resemble a layer of white petroleum jelly or butter, and is a sign of Mucus or Dampness in the body.
A peeled tongue may be a sign of Deficient Yin or Fluids, or of Spleen Qi too weak to raise smoke.
A stiff tongue lacks flexibility…This type of tongue usually implies a Wind Pernicious Influence or Mucus obstructing the Heart Qi.
A trembling tongue seems to wiggle uncontrollably. When this type of tongue is pale, it is a sign that Qi is insufficient to regulate proper movement. If the tongue is red, the diagnosis is usually Internal Wind moving the tongue.
…particular areas of the tongue are said to correspond to particular Organs…which are helpful but are never considered absolute.
I quoted those passages not so much to demonstrate their absurdity—although I consider them to be absurd—as to demonstrate their obvious hopelessness as repeatable, agreed-upon physical findings (remember that there are many more where these came from). They remind me of the 35 or so shades of sputum that are listed in homeopathic repertories, each one requiring a match with about the same number of sputum textures, that must further be matched to each of hundreds or thousands of other multi-faceted “symptoms”; and even one little “mistake” among all those choices will purportedly make the crucial difference between choosing the simillimum and choosing a dud. (Look here, pp. 79-81)
Has a study ever shown inter-rater reliabilty for Chinese tongue diagnosis? Not that I know of. A couple of abstracts suggest the opposite, as you’d expect.
What about pulse diagnosis? This is the most important of all the Examinations, and is “far more complex than what we know in the modern West.” Kaptchuk takes it quite seriously. He spends about 16 pages describing “the 28 basic pulses.” They are categorized according to Depth, Speed, Width, Strength, Shape, Length, and Rhythm; some of them are the Floating Pulse, Sinking Pulse, Thin Pulse, Big Pulse, Full Pulse, Empty Pulse, Slippery Pulse, Choppy Pulse, Tight Pulse, Short Pulse, Long Pulse, Knotted Pulse, Flooding Pulse, Soggy Pulse, Leather Pulse, Spinning Bean Pulse. If these weren’t trouble enough, according to Kaptchuk they “are more often found in combination than in their pure form…”
Thus, writes Kaptchuk,
…pulse taking approaches the subtlety and complexity that bespeaks an art. It requires thorough training, great experience, and the gift of sensitivity. When the physician takes a pulse, he or she is alert to a tremendous array of sensations that must be expertly understood and arranged as a unity—the “feel” of an individual pulse…
…it is clear that the system is extremely complex, capable of infinite refinement. Pulse diagnosis is a very sophisticated art. It demands sublety and wisdom on the part of the physician to discern the relative importance of each variable and to make of them all an intelligent and precise diagnosis—to weave a useful pattern.
Wiser Weasel Words of Woo have Warely been Weaved.©
How is the pulse taken and what can it tell the physician? Rather than quote Kaptchuk, I’ll turn to Unschuld, who explains it in a clearer fashion, complete with a topographical metaphor that the ancient Chinese apparently took seriously. He notes that there are several methods:
One method was based on the notion that at the high point of the styloid process below (medial to) the wrist there was an imaginary line, called the “pass,” as a narrow passage through mountains. When a finger feels the pulse with light pressure above the “pass,” i.e., toward the wrist, the pulse offers evidence about the state of the lung and heart. The connection lies in the fact that the imaginary line, the “pass,” corresponds to the diaphragm in the human body. The lung and heart are located above this separation, in the yang area of the body. The lung and heart therefore manifest in pulse above the “pass” in the yang region. Below the pass, in the yin region, the pulse reflects the condition of the liver and kidney, organs which lie below the diaphragm in the yin region of the body. Right on the pass, the middle of the three fingers feels the state of the spleen, the organ that lies closest to the diaphragm.
A second method of pulse taking uses the pressure of a single finger. The finger exerts a light pressure in the area of the pass and feels the pulse just below the skin, that is, in a yang region, which provides information about the lung and heart. Somewhat greater pressure allows the finger to penetrate the level where the pulse of the spleen can be felt. Applying still greater pressure so that the fingertip enters the yin region and almost reaches the bone, the level of the liver and kidneys is reached.
This method stands alongside yet another by which the finger, by application of different degrees of pressure, feels the state of the five organs each at five different levels.
The “states” of the organs include the same possibilities that we saw for tongue diagnosis, e.g., dampness, cold, heat, congealed blood, stagnant qi, etc. It should be obvious to anyone with even a passing knowledge of anatomy and physiology, and with even a passing sense of reality—which apparently excludes the reviewers quoted above, assuming that they read the book—that the claims made for ancient Chinese pulse-taking are ridiculous. Dampness aside, if I were in charge of the Randi $1 million challenge, I’d offer it to anyone who could demonstrate that the maneuvres described above can repeatably yield information distinctly referable to each of the named organs, other than, of course, the heart.
The reports of dismal inter-rater reliability for tongue diagnosis also apply to pulse diagnosis.
“Clinical Sketches”
A patient suddenly gets a high fever and a severe sore throat. She has a red face, a dry, hacking cough, and no fear of cold. A Western physician takes a throat culture and discovers the presence of Group A beta hemolytic streptococcus. Antibiotics are prescribed, with good results. If the same patient had gone to a Chinese physician, he very likely would have diagnosed a Heat Pernicious Influence. Herbs like Coptis and Scutellena, which disperse and cool Fire, would have been prescribed. The results would have been adequate though perhaps slower to achieve than with the antibiotic treatment. Modern research shows, incidentally, that both Coptis and Scutellena inhibit the growth of streptococcus bacteria. Acupuncture treatment, such as needling Large Intestine 4 (He-gu, Adjoining Valleys), to cool Fire, would in this case have offered some symptomatic relief and heightened the body’s resistance, but would have been less effective than herbs.
Oh really? I haven’t pursued the claim made for the two herbs, but I suspect it goes something like this. Acupuncture would have “heightened the body’s resistance”? Spare me. The bigger problem is the blithe, ignorant dismissal of effective medicine: antibiotics don’t shorten the duration of uncomplicated acute streptococcal pharyngitis, so the ‘results’ of Chinese intervention, at least the results that Kaptchuk seems to be talking about, would have been no “slower to achieve.” What antibiotics do in this case—and the entire reason for taking them—is to prevent complications, most importantly post-streptococcal rheumatic fever. And you can bet, dollars to donuts, that neither the herbs nor acupuncture will accomplish that. Oops.
Here’s another Clinical Sketch, “taken from the author’s private practice”:
A woman, aged twenty-six, complained of wheezing, difficulty in breathing, and coughing, especially in the middle of the night. The pattern had begun suddenly when the patient was sixteen years old and had gotten steadily worse. The patient constantly felt tightness in her chest, unrelated to seasonal changes, and when an attack started, there was much sneezing and coughing. Phlegm with a thick and yellow quality was produced. The patient’s medical history was otherwise insignificant. Her appetite was good and her stools and urination were normal. She was very thin, with dark rings under her eyes. Her energy level was good except during an attack, and she did not report any emotional stress but seemed jumpy and anxious. Otherwise, her Shen was harmonious and clear. Her tongue was red and cracked in the middle and had scattered red dots. Her pulse was rapid (ninety-six beats per minute) and also slippery and slightly thin.
When she came for treatment, she was taking Western medication but wanted an alternative because the drugs made her dizzy, tired, and nauseated.
Many of the signs pointed to the pattern of Heat in the Lungs: yellow phlegm, rapid pulse, red tongue, and thirst. Other signs, such as the thin body, the chronic nature of the disorder, the peeled and cracked tongue, and thin pulse, pointed to Deficient Yin. The wheezing, thick phlegm, and slippery pulse indicated that Mucus was present. A combination of acupuncture and herbal treatments was administered to cool the Lung Heat, nourish the Yin of the Lungs, and eliminate Mucus. This therapy brought the symptoms under control within two weeks.
Although the patient is still subject to occasional attacks, they are much less frequent and intense. When needed, she takes herbs or uses an herbal inhalator [sic].
Kinda sounds like asthma, no? You’d think he might’ve asked about cigarette smoke, or maybe cats or dust in her abode. How about listening to her lungs, or maybe even considering (gasp) an objective test? Wasn’t he expected to gather “all relevant information?” (No matter, he kicked ass on the tongue and pulse exams.) An “herbal inhalator”?
Conclusion
How does the Web that Has No Weaver measure up (in the macrocosmic sense, of course) to the reviewers’ promises? Let’s see: is it a book that’s easy to read and understandable to Westerners, that is rational, that ‘demystifies’ its subject, that will provide a ‘deep’ understanding of healing, that will “expand [our] understanding of the causes and treatment of disease,” and that heralds a ‘synthesis’ of Eastern and Western medicine?
Wow. No. In a nutshell, there is sophistry on nearly every page. It continues to astound me that such drivel could have been taken seriously by academic physicians. I suppose the two most likely explanations are, in this order, that they didn’t read the book—can’t say I blame’em, it was like wading through molasses—or that they were utterly fooled by the rampant, misleading language. This post could have been the rilly advanced course in that little bundle, and let’s face it, most academics have just not had the privilege of learning about such esoterica. Whatever else you can say about Kaptchuk, he’s a Master of Misrepresentation.
Some might quibble with my not having cited some reasonable or even insightful passages in the book. It’s true that there are a few, and if taken out of context they can make the author look quite respectable, if you’ll excuse the tongue-in-cheek Bostonian observation. Put’em back in context, however, juxtaposed with all the meaningless adjectives, fallacies, contradictions, unsupported claims and the rest, and it’s ever more clear: sophistry. Ya gotta look at the whole.
I heard Kaptchuk speak at the 2001 Harvard Medical School “CAM” conference. Early in his talk he recounted, in a defiant and triumphant tone that brought cheers from the partisan audience, an episode during the 1980s—perhaps at about the time that he’d treated the woman in the second clinical sketch—when he’d been under threat of arrest for practicing medicine without a license. Go figure.
…
Next part: Dialectical materialism, PoMo gibberish, and an academic career built on sand.
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Caffeine for ADHD
“I don’t want to give my child any drugs or chemicals for their ADHD,” says a parent. “Instead, I’m thinking about using caffeine. Sound strategy?”
It may be dispensed by a barista and not a pharmacist, and the unit sizes may be small, medium and large, but caffeine is a chemical and also a drug, just as much as methylphenidate (Ritalin) is. Caffeine is even sold as a drug — alone and in combination with other products. But I regularly speak with consumers who are instinctively resistant to what they perceive as drug therapy — they want “natural” options. Caffeinehas been touted as a viable alternative to prescription drugs for ADHD. But is caffeine a science-based treatment option? This question is a good one to illustrate the process of applying science-based thinking to an individual patient question.
I’ve already described my personal fondness of caffeine, particularly when it’s in the form of freshly-roasted coffee. I’m not alone in my love. Caffeine is the most widely consumed drug in the world — more than alcohol, and more than tobacco: 90% of adults worldwide consume it daily. The average American consumption is 280mg per day — about two cups of coffee. The main source is coffee, but tea consumption is growing. And caffeinated soft drinks and energy drinks are a growing source of caffeine for children. Why do we love it so much?
Caffeine is quickly absorbed once consumed — and it immediately gets to work stimulating neurotransmitter release. Besides psychiatric effects, it has effects on alertness (positive), headache (also effective, except in withdrawal situations), athletic performance (another win), the cardiovascular system (my fingers are crossed), and the endocrine system, where it may improve diabetic control. It’s also being studied for effects on the gastrointestinal system, as well as its impact on cancer risk. In adults, caffeine consumption is associated with a negative relationship with all-cause mortality, largely due to a reduction of cardiovascular effects. Causation hasn’t been established though. Most of you are very familiar with the side effects of caffeine: agitation, tremors, insomnia, headache. Overall, despite documented cases of dependence and withdrawal, caffeine consumption has a generally attractive safety profile with a wide therapeutic range.
The symptoms of Attention Deficit Hyperactivity Disorder (inattention, impulsiveness and hyperactivity) have been identified for at least 100 years. But once the diagnosis appeared in the DSM-IV, its standardized criteria became commonly used, and the prevalence is now estimated at about 3-7% of children. The term Attention Deficit Hyperactivity Disorder is somewhat of a misnomer, as the dysfunction appears related to an inability to regulate attention — not a deficit. Magnetic resonance studies suggest ADHD may manifest as a weakening of inhibitory signalling in the frontal cortex.The cause appears most likely to be genetic, with environmental influences.
The two main interventions for ADHD are behavioural treatments and drug therapies. The traditional therapies are the stimulant drugs, including amphetamine (Adderall), methylphenidate (Ritalin), and dextroamphetaime (Dexedrine). Some have been in use since the 1960’s. Over time, a wide array of dosage forms including controlled-release versions have emerged, driven by the desire to stabilize blood levels. The basic drugs themselves are short-acting, leading to a fluctuation of effects and the need for mid-day treatments — not ideal for school-age children. Non-stimulant drug therapies (e.g., antidepressants) have more recently emerged as treatment options and may be combined with stimulants, as additional therapies where symptom control isn’t reached with stimulants.
The treatment goals with ADHD are symptom based, so dosing is dependent on the effects observed. Treatment goals usually include reductions in disruptive behaviours, improvements in relationships (with peers, siblings, teachers, and parents), or specific academic parameters. Ideally, treatment goals should be objective and measurable, and agreed-up by parents, teachers, physicians, and children.
The stimulant medications have an impressive safety record and are generally well tolerated. There’s a long history of use. Are they effective? There’s reasonably good data to suggest they are, although comparative data are lacking. [PDF] Response rates to ADHD treatments appears high — 60-80%, and side effects are generally mild and manageable.
So that brings us back to the original question — I developed a focused clinical question using the PICO framework:
- Patient: Who are what are we treating? In this case, children.
- Intervention: What are we treating with? Caffeine
- Comparison: Compared to what? Let’s assume stimulants.
- Outcome: The effect we want to measure. In this case, symptomatic control.
So the question may be summarized as: In children, how does caffeine compare to stimulants for symptomatic control of ADHD?
It’s helpful to start with pharmacology to consider plausibility before we look at clinical trials. Caffeine, or more properly, 1,3,7-trimethylxanthine, has central nervous system effects, mainly thought to be due to blocking adenosine receptors in the brain. Given we don’t know the specific mechanism of action of the ADHD drugs, I’ll accept caffeine as a plausible treatment: it crosses into the brain, and it has CNS stimulant effects.
So let’s look at the data. I started with a tertiary reference: the Natural Medicines Comprehensive Database rates caffeine as “possibly ineffective”. Then I went to PubMed, and ran my own search. Are there placebo-controlled, or head-to-head trials? Yes, and they’re disappointing:
The data are limited by small trials, mostly conducted in the 1970s. There doesn’t appear to be many trials exploring the dose-response relationship, and trials don’t seem to titrate doses — so it’s not clear if we’re evaluating comparable doses. While there don’t appear to be any systematic reviews, there are trials comparing caffeine to other drugs. In one comparison, 20mg of methylphenidate was found to be superior to 160mg of caffeine. In another trial, seventeen children who had positively responded to stimulant drugs were trialed on placebo, or two different doses of caffeine. Caffeine didn’t have any statistically significant effects on behavioural measures. In a trial comparing amphetamines to 600mg caffeine daily, plus amphetamines, caffeine was reported to provide incremental benefit, but side effects were noted. That’s not surprising: 600mg is the caffeine in two Starbucks Grande-sized coffees. A double-blind crossover examination of caffeine, methylphenidate, and dextroamphetamine in 29 children concluded that while the two stimulants had meaningful effects, caffeine was indistinguishable from placebo. Overall — no strong signals of efficacy in the evidence.
Conclusion
Caffeine is a questionable treatment option for ADHD. There is mixed to negative efficacy data, and no long-term safety information in children. Depending on the form given, there’s challenge of ensuring standard doses (especially when using coffee) and maintaining stable blood levels. In comparison, prescription stimulant medications offer a variety of drug choices that have more convincing efficacy data, and are accompanied by a long history of use. There’s also a wide array of product types, making it easier to customize a treatment regimen. So while I can understand the hesitation to medicate and to “go natural” instead, it’s not a trade off that’s attractive. “Go science” instead — look to the data, and make treatment decisions based on the best evidence.
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Pseudoscience Sells
It is an unfortunate truth that there is money in pseudoscience, particularly medical pseudoscience. Money both attracts charlatans and also funds their activities, which includes marketing pseudoscience and defending their claims from scientific scrutiny. In this way the game is rigged in favor of pseudoscience.
With0ut effective regulation, sites like ours are forced to play whack-a-mole with the medical pseudoscience du jour. The latest case in point is Titanium Ion Bands – which are just another version of the Power Balance bands that have been previously exposed as nonsense. The idea is that by wearing a small bracelet on one wrist you will experience improved athletic performance. This sounds impossible – because it is. But companies have successfully bamboozled enough of the public to rake in millions.
The marketing strategy is three-fold. First, get naive professional athletes to endorse the product. Second, give live demonstrations (deceptive parlor tricks) that convince the unsuspecting that something must be going on. And third, wow the scientifically illiterate with a confusing barrage of medical techno-babble. The combination is sadly effective.
Power Balance, for example, makes vague references to frequencies and energy as the explanation for how a little piece of rubber (with embedded holograms) can have any effect on human physiology. The company was eventually legally forced to admit: “”We admit that there is no credible scientific evidence that supports our claims.” The admission has not ended their sale, however.
Next up is the Titanium Ion Bands. Their claims are essentially the same – wear a little bracelet on your wrist and you will have improved performance. Instead of holograms and frequencies, their bands are alleged to work through negative ions. This is just another recycled pseudoscientific claim that has been around for years. Just search on “negative ions” and you will see a variety of products claiming to improve health with negative ions.
The bracelet claim is nonsense for two independent reasons. The first is that a piece of anything does not generate negative or positive ions. You cannot change the net electrical charge spontaneously – you need a source of energy. The only devices that actually generate negative ions are powered in some way, such as a machine that you plug into an outlet. A chemical reaction, such as occurs in a battery, is also a possible source – but not tourmaline and titanium discs, as the company claims.
Even if the bracelets did give off negative ions, there is no evidence of any healthy benefit from this. You might build up a static charge and get shocked when you grab the doorknob, but there is no evidence or reason to suspect that negative ions will increase blood flow, as the company claims. “Increasing blood flow” seems to be the go-to explanation for a wide variety of dubious health products, especially for those that involve magnets or any kind of electrical force. Such claims, however, are evidence-free.
The company touts “reports” of their own “inspections” using fancy technology like thermography to demonstrate their claimed effects. It’s all very sciencey, while being scientifically worthless. None of the proper controls are in place to make the information anything other than a marketing demonstration, similar to the parlor tricks used by Power Balance.
On the company website there are links to celebrity endorsements and testimonials – but no links to published peer-reviewed quality research backing up any component of their claims.
Conclusion
There is every reason to believe that these titanium bands are medically worthless. However current regulations allow the company to market them with deceptive health claims without the burden to provide reliable scientific evidence to back up their claims. The endless chain of such products will continue as long as the lax regulations allow them to.
At present the best we can do is to continue to educate the public about the underlying science and to be skeptical of all such products. Further, we can pressure pharmacies and other outlets not to sell pseudoscientific products. Further, there are mechanisms to force companies to retract deceptive or unsupported claims for their products. It is a game of whack-a-mole, but it’s better than nothing.
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TIME Magazine, Dr. Oz, What to Eat, and Supplements
Here on SBM we have frequently had cause to criticize the media for poor science reporting and for spreading misinformation. Among many other individual offenders, we have criticized Dr. Oz for promoting alternative medicine on his TV show and gullibly promoting guests who pretend to talk to the dead and pretend to heal people with carnival sideshow tricks. We tend to be negative and critical because somebody has to do it, but it’s not pleasant. For once, I have some good things to say.
The September 12 issue of TIME magazine was a Special Nutrition Issue. The cover featured pictures of food and the title “What to Eat Now: Uncovering the Myths about Food by Dr. Oz.” It devotes 7 pages to an article by him entitled “The Oz Diet: No more myths. No more fads. What you should eat — and why.” This is followed by a 5 page article by John Cloud “Nutrition in a Pill? I took 3000 supplements over five months. Here’s what happened.” Both articles have a rational, science-based perspective without any intrusions of woo-woo.
Oz on What to Eat
Oz acknowledges that the science of nutrition is not simple and that much of what we once believed has been discarded in the face of new knowledge. He debunks a number of popular misconceptions about diet. Most of what he says is consistent with scientific evidence and with mainstream diet advice.
- It’s not necessary to restrict ourselves to low-fat foods.
- It’s OK to eat eggs, whole milk, salt, fat, nuts, wine, chocolate and coffee — as long as we don’t overindulge.
- The only fat accepted as “bad” is trans-fat, and that has been stripped out of most foods.
- Dietary cholesterol is less important than we used to think and is irrelevant to some people who have good genes.
- Excess salt is dangerous mainly for the minority of people with salt-sensitive high blood pressure.
- Foods labeled “fat free” don’t taste as good, so manufacturers add more salt, sugar, and thickeners, and people tend to eat more calories.
- Fad diets work by restricting food choices: they result in fluid loss and decreased calorie intake, and the weight lost comes right back when people stop the diet.
- The low carb diets change nutritional balance in ways that may not be desirable.
- The paleo diet? Maybe not ideal: cavemen were shorter than modern people and died earlier.
- Individualized nutrition? Blanket recommendations don’t fit all individuals, but nutrigenomic studies do not yet have clinical applications.
- Weight loss is hard. To maintain a healthy weight, calories consumed must equal calories burned.
- High fiber foods augment satiety.
- One study showed that the foods most associated with weight gain are French fries, potato chips, sugary drinks, meat, sweets and refined grains and the foods most associated with successful weight loss are yogurt, nuts, whole grains, fruits and vegetables.
- There are no elusive “superfoods.”
- Exercise is important, but we mustn’t over-estimate its caloric benefit.
He mentions that coffee is the number one source of antioxidants in the Western world. I knew there was a reason I like coffee so much! Isn’t it refreshing to read an article about diet that doesn’t tell you to give up any of the foods you love? Isn’t science wonderful?
He doesn’t recommend vegetarianism, saying we are omnivores and there are multiple food groups for a reason. He concludes with the advice to
- Eat in moderation
- Choose foods that look like they did when they came out of the ground (minus the dirt, I hope!)
- Be an omnivore
- And get some exercise.
This is entirely consistent with what we have been hearing from other sources, from Mom to the American Dietetic Association, and with Michael Pollan’s advice to “Eat food. Not too much. Mainly plants.”
Going Beyond the Evidence
He does say a few things that I would argue with because I think he goes beyond the (good) evidence:
- Since red wine is good for you, you should drink some every day and also take resveratrol supplements.
- When you take all the fat out of milk, you’re left with too high a concentration of natural sugars, which interacts like candy with your hormones.
- Berries have a profound impact against age-related diseases
- Broccoli is good for the liver and strengthens the body’s natural detoxification systems.
- You should take a multivitamin.
Some of these are open to discussion and I can’t object strongly to any of them. On the whole, his advice is moderate and mainstream, without a hint of the kind of woo-woo he promotes on TV. Maybe writing for TIME has a restraining influence on him.
Nutrition in a Pill?
John Cloud experimented on himself. He consulted a supplement company and followed a plan custom-designed just for him. It involved 22 pills a day plus protein bars, powder drinks and psyllium fiber. He followed the plan for 5 months. It cost $1200 but TIME paid the bill. He had a panel of blood tests done before and after, and found that the supplements made no difference. Only two measurements changed significantly: his vitamin D level (which he could have raised much more cheaply with a generic vitamin D tablet) and his HDL level (which was unexplained by the supplements). He felt better on the supplements, but he attributed that to placebo effect.
He had one unfortunate side effect: he gained 10 pounds over 2 months. He attributes that to “the licensing effect.” He felt virtuous. He knew he was getting his nutrition in the pills, so he felt licensed to eat a less healthy diet with more calories. He managed to lose the weight, but it took him 3 months. When the experiment was over, he threw the rest of the supplements away. He discusses the history of vitamins and the inconclusive science behind supplement recommendations. He provides insight into way nutraceuticals are marketed. He interviews skeptical scientists including one who calls the vitamin business “the damnedest racket ever perpetrated upon the public.”
His conclusion makes a lot of sense to me:
On nutraceuticals, I had come to believe that health could be a set of tablets to take rather than a series of responsibilities to meet — water instead of soda, an apple instead of chips, real fish instead of giant fish-oil capsule. You can take vitamins on the faith that they will make you better and if you have a real vitamin deficiency, they will. But there’s more science behind another way of getting your vitamins: eating right.
Conclusion
Both of these articles are informative and reasonable, well written and entertaining, and are examples of good science journalism. TIME is no Science-Based Medicine, but it does a pretty good job for a popular publication. All too often, the media get science wrong; but sometimes they get it right. And when they do, we should say so. Good job, TIME!
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Chemotherapy doesn’t work? Not so fast…
“CHEMOTHERAPY DOESN’T WORK!!!!!”
“CHEMOTHERAPY IS POISON!!!!”
“CHEMOTHERAPY WILL KILL YOU!!!!”
I’ve lost count of how many times I’ve come across statements like the ones above, often in all caps, quite frequently with more than one exclamation point, on the websites of “natural healers,” purveyors of “alternative medicine.” In fact, if you Google “chemotherapy doesn’t work,” “chemotherapy is poison,” or “chemotherapy kills,” you’ll get thousands upon thousands of hits. In the case of “chemotherapy kills,” Google will even start autofilling it to read “chemotherapy kills more than it saves.” The vast majority of the hits from these searches usually come from websites hostile to science-based medicine. Examples include Mercola.com, the website of “alternative medicine entrepreneur” Dr. Joe Mercola and NaturalNews.com, the website of Mike Adams, where you will find cartoons like this one, which likens the administration of chemotherapy to a Nazi death camp:
Here’s another example, entitled The truth about chemotherapy and the cancer industry:
Note how Adams portrays screening for cancer and chemotherapy as a deadly scam designed solely to enrich the “cancer industry” as it kills patients.
As my final example, there’s this cartoon:
An article by Mike Adams entitled Chemotherapy Stickup that accompanies the cartoon above makes this astounding claim:
There is not a single cancer patient that has ever been cured by chemotherapy. Zero. They don’t exist. Not a single documented case in the history of western medicine.
And why is that? Because conventional medicine operates from the false belief that there is no cure for cancer! Thus, anyone offering a cure (or assisting in the body’s own natural reversal of the disease) is immediately dismissed as a quack. Meanwhile, the real quackery is found in the pushing of toxic chemotherapy chemicals that are injected into the bodies of patients and called “treatment” when they should really be called “torture.” (Nancy Pelosi, by the way, was never briefed on the fact that chemotherapy is torture…)
When I first encountered that cartoon a few years ago, I was a bit surprised that even Mike Adams would go so far as to make such an absolutist statement that not a single person has ever been cured of cancer by chemotherapy in the entire history of “western medicine.” All it would take is a single example to prove him wrong, like—oh, you know—Lance Armstrong, the patients cared for by my pediatric oncology colleagues, or the patients I saw during my training cured of anal cancer by the Nigro protocol. The Nigro protocol, by the way, consists of combined chemotherapy and radiation and is still the standard of care for anal cancer. That doesn’t even count all the patients with leukemia or lymphoma cured primarily by chemotherapy.
Unfortunately, this attitude isn’t just limited to cranks. There are legitimate scientists, even those who have published in magazines devoted to skepticism, who make very similar statements, although perhaps not quite as absolutist. Not quite, but close. For example, there’s Reynold Spector, whom Mark Crislip and I took to task for his article earlier this year in Skeptical Inquirer entitled Seven Deadly Medical Hypotheses. One of his “seven deadly medical hypotheses” read thusly:
From a cancer patient population and public health perspective, cancer chemotherapy (chemo) has been a major medical advance.
In other words, to Dr. Spector, the very idea that chemotherapy is a notable advance in the treatment of cancer is a “deadly medical hypothesis.” Of course, his statement is not a hypothesis at all, deadly or otherwise, as what one means by a “major medical advance” is very subjective (Dr. Spector really needs to get himself hence to a medical dictionary) and the weasel words of “from a patient population and public health perspective” give Dr. Spector wiggle room, but it’s very clear what his intent is. He doesn’t think chemotherapy works very well, if at all, even as he admits:
However, it cannot be denied that there are a few populations for which chemotherapy is marvelously effective, as noted above, and must be used.
So which is it?
In previous posts, such as Why haven’t we cured cancer yet? and Skepticism versus nihilism about cancer in science-based medicine, I explored some of these questions. In the former article, I pointed out just how complex the problem is, with cancer being hundreds of different diseases and using the example of just how messed up the prostate cancer genome is to provide an idea of the magnitude of the problem. In the second article, I pointed out an example of a specific cancer for which advances in chemotherapy have made a meaningful difference in both survival and quality of life outcomes. What I haven’t yet done is to look at the arguments cancer cranks use to try to convince people that chemotherapy doesn’t work.
Attacking chemotherapy
Any rational assessment of the efficacy of chemotherapy must be forced to include an admission that chemotherapy is only rarely curative in solid malignancies, particularly advanced solid malignancies. Notable exceptions include testicular cancer (which is what Lance Armstrong was cured of) and anal cancer. In contrast, for hematological malignancies, such as leukemia and lymphoma, chemotherapy is usually the mainstay of therapy. However, not being curative doesn’t mean that chemotherapy is useless anymore than the fact that beta blockers don’t cure hypertension and metformin doesn’t cure diabetes makes them “useless” drugs. Before we take a rational look at what chemotherapy can and can’t do, let me just point out that there are three studies that are frequently used by cranks to try to argue that chemotherapy is useless.
The first one is easily dismissed, but you’ll see it a lot anyway. It’s frequently cited in articles with titles like 75% of MDs Refuse Chemotherapy Themselves and the claim will go something like this:
Several full-time scientists at the McGill Cancer Center sent to 118 doctors, all experts on lung cancer, a questionnaire to determine the level of trust they had in the therapies they were applying; they were asked to imagine that they themselves had contracted the disease and which of the six current experimental therapies they would choose. 79 doctors answered, 64 of them said that they would not consent to undergo any treatment containing cis-platinum – one of the common chemotherapy drugs they used – while 58 out of 79 believed that all the experimental therapies above were not accepted because of the ineffectiveness and the elevated level of toxicity of chemotherapy. (Source: Philip Day, “Cancer: Why we’re still dying to know the truth”, Credence Publications, 2000)
Wow! This sounds really damning, doesn’t it? What hypocrites those oncologists are! Right?
It turns out that this survey is over 25 years old and was about a specific kind of chemotherapy, cisplatin for non-small cell lung cancer, which was a new therapy at the time and didn’t have a lot of evidence for it. As Anaximperator describes, a followup survey was conducted in 1997 at a session on the National Comprehensive Cancer Network (NCCN) clinical practice guidelines. Participants were asked to respond to the same question regarding chemotherapy:
You are a 60-year-old oncologist with non-small-cell lung cancer, one liver metastasis, and bone metastases.
Your performance status is 1. Would you take chemotherapy? Yes or no?
The results? Let Anaximperator tell the tale:
The overall results of the 1997 follow-up survey show that 64.5% would now take chemotherapy – which is almost a doubling from 34% to 64.5% of those willing to have chemotherapy and radiotherapy and a quadrupling from 17% to 64.5% of those who would take chemotherapy alone.
Anaximperator adds:
The study from 1991, “Oncologists vary in their willingness to undertake anti-cancer therapies,” pertains to many kinds of cancer and cancer stages, from early stage to terminal, as well as to experimental therapies. It shows percentages as high as 98% of doctors willing to undergo chemotherapy, while the remaining 2 % were uncertain, and none answered “definitely no” or “probably no” to chemotherapy.
Should another survey be conducted today, there’s a good chance the results would be even higher in favour of chemotherapy, given that over the years chemotherapy has shown enhanced clinical benefit and less side effects.
Indeed. One should also note that this question was constructed such that the clinical presentation of the cancer was incurable. Participants were presented with a scenario in which they are diagnosed with stage IV metastatic disease, a situation where opting for palliative care rather than aggressive treatment often makes sense, which makes the results even more striking. Also, I know from personal experience that it is not true that oncologists tend to turn down chemotherapy, even for advanced disease. having known oncologists who developed various cancers and underwent standard-of-care chemotherapy. Indeed, just this week, I was saddened to learn that an oncologist I used to know at my old job recently developed cancer and is currently undergoing chemotherapy. He’s also lost all his hair, just like many of his patients. In the end, this particular ploy serves two purposes. First, it implies that oncologists are hypocrites who don’t believe that the treatments they are giving patients are worthwhile. Second, it feeds into the conspiracy theories beloved of quacks with the implication that oncologists are hiding something about chemotherapy effectiveness. They’re not.
My favorite example of the use of the next study beloved of anti-chemotherapy cranks is by Andreas Moritz, who describes himself as “a medical intuitive; a practitioner of Ayurveda, iridology, shiatsu, and vibrational medicine; a writer; and an artist.” The article is entitled Can you trust chemotherapy to cure your cancer? and in it Moritz cites a study from Australia published in 2004:
An investigation by the Department of Radiation Oncology, Northern Sydney Cancer Centre, Australia, into the contribution of chemotherapy to 5-year survival in 22 major adult malignancies, showed startling results: The overall contribution of curative and adjuvant cytotoxic chemotherapy to 5-year survival in adults was estimated to be 2.3% in Australia and 2.1% in the USA.” [Royal North Shore Hospital Clin Oncol (R Coll Radiol) 2005 Jun;17(4):294.]
The research covered data from the Cancer Registry in Australia and the Surveillance Epidemiology and End Results in the USA for the year 1998. The current 5-year relative adult survival rate for cancer in Australia is over 60%, and no less than that in the USA. By comparison, a mere 2.3% contribution of chemotherapy to cancer survival does not justify the massive expense involved and the tremendous suffering patients experience because of severe, toxic side effects resulting from this treatment. With a meager success rate of 2.3%, selling chemotherapy as a medical treatment (instead of a scam), is one of the greatest fraudulent acts ever committed. The average chemotherapy earns the medical establishment a whopping $300,000 to $1,000,000 each year, and has so far earned those who promote this pseudo-medication (poison) over 1 trillion dollars. It’s no surprise that the medical establishment tries to keep this scam alive for as long as possible.
Here is the study to which Moritz refers and which is the origin of the claim that “chemotherapy only provides 2% benefit,” a favorite talking point used by cancer quacks. I’ve seen it on websites ranging from Moritz’s website to NaturalNews.com, to Mercola.com, to Whale.to (my favorite), to I forget how many others. Always it’s the same thing, a variant of a statement claiming that chemotherapy only contributes 2% to five year survival in adult malignancies, followed by conspiracy-mongering of the sort above in which chemotherapy is portrayed as a huge scam designed to enrich big pharma. Indeed, so common is this particular favorite that I proclaim it “The 2% Gambit.” It turns out that this is not such an impressive study. Indeed, it appears almost intentionally designed to have left out the very types of cancers for which chemotherapy provides the most benefit, and it uses 5 year survival exclusively, completely neglecting that in some common cancers (such as breast cancer) chemotherapy can prevent late relapses. There were also a lot of inconsistencies and omissions in that leukemias were not included, while leukemia is one type of cancer against which chemotherapy is most efficacious. Indeed, the very technique of lumping all newly diagnosed adult cancers together is guaranteed to obscure benefits of chemotherapy among subgroups by lumping in patients for whom chemotherapy is not even indicated. A letter to the editor listed these problems and several really egregious errors and omissions, too:
The authors omitted leukaemias, which they curiously justify in part by citing the fact that it is usually treated by clinical haematologists rather than medical oncologists. They also wrongly state that only intermediate and high-grade non-Hodgkin’s lymphoma of large-B cell type can be cured with chemotherapy, and ignore T-cell lymphomas and the highly curable Burkitt’s lymphoma. They neglect to mention the significant survival benefit achievable with high-dose chemotherapy and autologous stem-cell transplantation to treat newly-diagnosed multiple myeloma [4]. In ovarian cancer, they quote a survival benefit from chemotherapy of 11% at 5 years, based on a single randomised-controlled trial (RCT), in which chemotherapy was given in both arms [5]; however, subsequent trials have reported higher 5-year survival rates. In cancers such as myeloma and ovarian cancer, in which chemotherapy has been used long before our current era of well-designed RCTs, the lack of RCT comparing chemotherapy to best supportive care should not be misconstrued to dismiss or minimise any survival benefit. In head and neck cancer, the authors erroneously claim the benefit from chemotherapy given concomitantly with radiotherapy in a meta-analysis to be 4%, when 8% was in fact reported [6].
The authors do not address the important benefits from chemotherapy to treat advanced cancer. Many patients with cancers such as lung and colon present or relapse with advanced incurable disease. For these conditions, chemotherapy significantly improves median survival rates, and may also improve quality of life by reducing symptoms and complications of cancer.
Of course, those using this particular gambit almost invariably never include the criticism of this particular article. Another aspect of this particular study that always bothered me is that it appeared to lump patients undergoing adjuvant chemotherapy in with those undergoing chemotherapy for cure or palliation. Adjuvant chemotherapy is given after surgery in order to decrease the rate of recurrence, but the truly curative modality is the surgery itself. In early stage cancer, the absolute benefit of chemotherapy in terms of prolonging survival tends to be modest, often single digit percentages. Lumping adjuvant therapy in with other uses of chemotherapy again appears custom-designed to minimize the survival benefit due to chemotherapy observed.
The second study frequently cited by cancer quacks as evidence that “chemotherapy doesn’t work” is, not surprisingly, also cited by Moritz:
In 1990, the highly respected German epidemiologist, Dr. Ulrich Abel from the Tumor Clinic of the University of Heidelberg, conducted the most comprehensive investigation of every major clinical study on chemotherapy drugs ever done. Abel contacted 350 medical centers and asked them to send him anything they had ever published on chemotherapy. He also reviewed and analyzed thousands of scientific articles published in the most prestigious medical journals. It took Abel several years to collect and evaluate the data. Abel’s epidemiological study, which was published on August 10, 1991 in The Lancet, should have alerted every doctor and cancer patient about the risks of one of the most common treatments used for cancer and other diseases. In his paper, Abel came to the conclusion that the overall success rate of chemotherapy was “appalling.” According to this report, there was no scientific evidence available in any existing study to show that chemotherapy can “extend in any appreciable way the lives of patients suffering from the most common organic cancers.”
I looked for this study. In fact, I went to The Lancet’s website and looked up the August 10, 1991 issue. I could find no study by Ulrich Abel or anything about chemotherapy other than this study on stroke after chemotherapy for testicular cancer. So I went to PubMed and searched on Ulrich Abel’s name for 1991. All I could find were two articles, one on common infections in chemotherapy patients and another on Crohn’s disease. Nor was I the only blogger who couldn’t find this ethereal Lancet paper by Dr. Abel. So I started searching other years, and then I found what appears to be the paper to which Moritz referred, only it wasn’t published in 1991 but rather in 1992 and it wasn’t published in The Lancet but rather in Biomedicine & Pharmacotherapy, a much lower tier journal. Somehow, through the magic of playing “telephone” over the Internet, this article has morphed from being in a lower tier journal to having been in The Lancet—even published on a specific date!
It turns out that the Dr. Abel’s article is rather odd. It’s not really a study, and it’s definitely not a meta-analysis. Nor is it really a particularly good systematic review, given that the methodology of selecting papers isn’t exactly transparent, and the larger “review” to which he refers readers appears to be in German and not readily available on the web, as far as I can tell. In the abstract, Dr. Abel states that “as a result of the analysis and the comments received from hundreds of oncologists in reply to a request for information, the following facts can be noted.” More importantly, Dr. Abel was addressing a fairly limited situation that excludes two of the most effective uses of chemotherapy, as described in this English translation of a Der Spiegel article describing his work:
- Abel’s verdict against the medicinal treatment of cancer is emphatically untrue for various kinds of lymph cancer, Hodgkin’s disease, leukemias, sarcomas, and testicular cancers in the male. These kinds of malignancies can be cured by chemotherapy with a high degree of probability, especially in children — an undisputed success. But these are, in any case, only a very small part of the new cases of cancer diagnosed every year.
- Abel’s doubts are not directed against chemotherapy when it is used in support of a curative operation, in order to shrink the tumor beforehand; nor do they apply to chemotherapy used prophylactically after an operation, to prevent a relapse (as an adjuvant).
These are, of course, the two most effective uses of chemotherapy that there are. I’ll grant critics that the types of tumors that can be cured with chemotherapy with a high degree of probability are a minority of tumors, but, contrary to what is implied in many uses of Dr. Abel’s work, they are not insignificant. For example, leukemias and lymphomas (Hodgkins and non-Hodgkins) add up to almost 10% of newly diagnosed cancers every year, and they are cured primarily with chemotherapy. Sarcomas and testicular cancers are much less common, but add them in and the total exceeds 10%. A distinct minority, yes, but the fact that many of these cancers can be cured with chemotherapy puts the lie to statements like the one by Mike Adams quoted above, which, not surprisingly, is parroted in Andreas Moritz’s little screed.
The second indication left out of Dr. Abel’s analysis, adjuvant chemotherapy, can, depending on the circumstance and tumor, be highly effective. Admittedly in early stage breast cancer adjuvant chemotherapy adds on an absolute basis only low single digit percentages to five and ten year survivals, but in more locally advanced breast cancer, particularly so-called “triple negative” breast cancer, the benefit is much more substantial. For instance, using Adjuvant Online, it’s possible to use the latest literature to estimate the benefit of chemotherapy in specific clinical situations. Here’s an example of a hypothetical 40 year old woman with an estrogen receptor negative tumor measuring between 3 and 5 cm with 1-3 axillary lymph nodes positive for metastatic disease:
Note that standard chemotherapy increases this woman’s chance of survival by 18% on an absolute basis and by 35% on a relative basis. Either way, the survival benefit is substantial. These are women who otherwise would have died but did not, thanks to chemotherapy. These women could be your mother, your wife, your sister, or even your daughter. The bottom line is that, even though I wasn’t particularly impressed with his methodology, Dr. Abel was actually reasonably nuanced in his discussion in that he discussed overdiagnosis and stage migration as confounders that can make a treatment seem more effective than it is, as I myself have discussed many times on this blog, starting with this post.
Besides, few oncologists would disagree with this statement at the end of Dr. Abel’s abstract, “With few exceptions, there is no good scientific basis for the application of chemotherapy in symptom-free patients with advanced epithelial malignancy.” And, indeed, most oncologists do not recommend chemotherapy for patients with stage IV epithelial malignancies who are asymptomatic, because at that point all treatment is palliative, and you can’t palliate symptoms that don’t exist. That’s why chemotherapy is, in most cases, reserved for when tumor progression leads to symptoms. Moreover, this study only examined epithelial malignancies. These are cancers for which surgery can be curative if the tumor has not metastasized. Since 1991, also, we have made significant advances in improving survival using chemotherapy. I’ve used the example of colorectal cancer before, where, thanks to newer and better chemotherapy regimens developed over the last couple of decades that have improved survival in patients with liver metastases from 6 months to close to two years.
I also note that since 1992, Dr. Abel has been co-author on a number of studies involving chemotherapy, for instance, a trial in nephroblastoma and a clinical trial of high dose chemotherapy in aggressive lymphoma. As recently as 2009, Dr. Abel was co-author on a randomized multicenter study comparing two different chemotherapy regimens in pancreatic cancer. Yes, pancreatic cancer, that most intractable of cancer problems with a five-year survival rate of only around 20% in the most favorable cases; i.e., the ones that can be completely resected surgically. Clearly, Dr. Abel buys into the evil big pharma propaganda that chemotherapy can cure at least some forms of cancer and, as far as I can tell, has never written a followup to his 1992 paper.
The bottom line is that the “evidence” used by cranks and quacks to prove that “chemotherapy doesn’t work” is most often based on intellectually dishonest tactics. They either misrepresent studies, as they frequently do with the McGill study claiming that oncologists won’t use chemotherapy. True, thanks to the way these studies have been misrepresented over the years, many of these quacks probably honestly think they’re accurately representing them, but that just goes to show how lazy they are about going back to the primary sources to back up their claims. As for the rest, the Australian study was custom-designed to minimize the apparent utility of chemotherapy, while Dr. Abel’s study intentionally left out the types of situations where chemotherapy is most useful and looked at primarily advanced malignancies. In this latter case, there’s nothing wrong with that approach; the problem comes when the quacks either intentionally or unintentionally fail to disclose that qualification, lose any hint at nuance, and use the results to imply that chemotherapy doesn’t work for anything.
Framing the question
Considering the question of whether chemotherapy “works” or not is very similar to asking the question, “Why haven’t we cured cancer yet?” The reason is that it’s a question that’s so vague as to be almost meaningless. Cancer is, as I have pointed out, hundreds of diseases, each driven by a plethora of different combinations of disruptions in cell growth control mechanisms. A more appropriate question is whether we’ve cured this cancer or that cancer, not whether we’ve cured cancer. Similarly, asking the question of whether chemotherapy “works” is similarly vague and meaningless. The real questions are (1) whether this specific chemotherapy regimen “works” for this cancer, although there are some examples that in aggregate we can make some conclusions about and (2) whether specific chemotherapy regimens can cure specific cancers. As noted above, even some “skeptics” of chemotherapy admit that chemotherapy can be “marvelously effective” for some cancers; the argument that usually follows is that the cancers for which chemotherapy is effective are so few as not to matter. The other issue is that few cancers are treated only with chemotherapy. Multidisciplinary and multimodality therapy are more the rule than the exception, particularly for solid malignancies and includes chemotherapy, radiation therapy, surgery, hormonal therapy, and a variety of other less common therapies.
What needs to be understood is that chemotherapy is very good for some things. For instance, it’s very good for treating and curing leukemias and lymphomas. For certain cancers, it’s also very good at decreasing the chance of relapse after curative surgery. When given before curative surgery, chemotherapy can also make organ-preserving surgery possible. Prominent examples include using neoadjuvant chemotherapy (chemotherapy before surgery) to shrink breast cancers so that they can be removed without mastectomy and shrinking rectal cancers so that sphincter-sparing surgery is possible (i.e., surgery that leaves the anal sphincter intact and thereby spares the patient having to have a permanent colostomy). For specific tumors, chemotherapy has also contributed to significant increases in survival, but it is not a panacea. For example, chemotherapy usually does very little for pancreatic cancer, and metastatic melanoma laughs at most chemotherapy (although there are newer agents that provide hope that this will no longer be the case). For all its uses and advantages, chemotherapy alone is not very good at prolonging survival in advanced epithelial malignancies, and it’s not at all unreasonable to ask whether it is overused in such patients, who are, for the most part, currently incurable.
This reasonable skepticism devolves into nihilism or crankery, however, when tactics such as those used by Mike Adams, Andreas Moritz, or, yes, even the esteemed Reynold Spector are used to “prove” that chemotherapy is “useless.” Moreover, such “skepticism” completely dismisses as worthless survival benefits of a few months, which certainly aren’t “worthless” to many patients. Such briefly lengthened survival times can mean the difference between seeing a child graduate from college or not, seeing a child get married or not, or seeing the birth of a grandchild or not. It must also be remembered that the measured improvements in survival due to chemotherapy are usually medians. Not uncommonly, buried in that median are “outliers” who derive a huge survival benefit from the chemotherapy and survive many more months than expected, sometimes many more years than expected. Moreover, it does patients no favor to try to use the observation that chemotherapy has at best relatively modest benefits in patients with advanced epithelial malignancies to try to imply that chemotherapy doesn’t work for all patients. In particular, patients have to remember that just because chemotherapy doesn’t do that well against advanced malignancies does not, as the quacks would have you believe, imply that “alternative medicine” can do better.
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SoftLayer Features and Benefits – Automation
Features and benefits … They’re like husband and wife, horse and carriage, hammer and nails! They are inseparable and will always complement each other. I wanted to jump right into a key “features and benefits” analysis of one of the value propositions of the SoftLayer platform, but before I did, I want to make sure we are all on the same page about the difference between the two.
A feature is something prominent about a person, place or thing. It’s usually something that stands out and makes whatever you’re talking about stand out — for the purpose of this discussion it will be, at least. It could be something as simple as the new car you’re buying having a front windshield or the house you’re looking to buy having a garage. Maybe it’s something a little more distinct like having your car’s air conditioner stay cool and blow for 15 min after the ignition is switched to the ACC position when you turn your engine off while pumping gas. Maybe your house has a tank-less water heater. These examples are indeed real features, but the first two are more or less expected … The last two make this particular car and this particular house stand out.
So where do the benefits come in? Benefits are features that are useful or profitable to you. With you being the operative word here. Think about it: If a feature does not provide any use to you, why would you care? Let’s go back to the car with its unique A/C feature. What if you live in Greenland? Who cares that the A/C will stay on? You may not even care for the feature of having an air conditioner at all! Talk about that feature in Dallas, TX, where it has been over 100 degrees for the last 2 months and counting, and all of a sudden, this feature provides a real benefit!
It’s now your cue to ask how all of this relates to hosting or, more specifically, SoftLayer.
{ … Waiting for you to ask … }
I am glad you asked! If you haven’t noticed, SoftLayer boasts a wide array of features on our website, and I would like to point out some of the benefits that may not be apparent to everyone, starting with automation. You’re probably aware that SoftLayer has one of the most robust and full featured automation platforms in the industry.
Automation
Think about the last time your IT director sent an email that went into your junk mail folder … You happen to see it on Sunday night, and it reads, “Please stand up five test servers for a new project by the Monday morning meeting.” You know that the vendors you typically use take anywhere from 3 days to 2 weeks to stand up new servers, so you wouldn’t have had a problem if you saw the email a week ago when it was sent — but you didn’t. So to avoid getting a smudge on your perfect employee record, you stumble across softlayer.com where automation enables us to deliver your five servers in 2 hours. Talk about a benefit: You still have time to watch a little TV before going to bed … Five servers, to your exact specifications, all deployed before you could Google the orgin of “rubber baby buggy bumbers.” (For those who care, it was a tag line said by Arnold Schwarzenegger in the movie Last Action Hero.)
At the heart of our automation platform lives the dedicated server, and the blood that courses though our network is the API. All that’s left is the pretty face (which we call the Customer Portal). Our portal provides a graphical user interface to control every aspect of your account from ordering new servers, IP allocations and hardware reboots to port control, port speed selection and billing matters. If you’re more into the behind-the-scenes stuff, then you can use all the same controls from the comfort of your own application via the API. Sounds like a lot of features to me, where are the benefits?
To start, you have options! Who doesn’t like options? You get to choose how you want to manage your account and infrastructure. We don’t force you into “our” way. Secondly, being able to do most functions yourself enables you to be more efficient. You know what you want, so you can log in and get it. No need to wait two hours for your firewall rule set to update; just log in and change it. You want to add load balancing to your account? Log in and order it! How about SAN replication? … I think you see where I’m going with this. Our portal and automation bring this control to your computer anywhere in the world! Some of these features even extend to your iPhone and android platform. Now you can update your support tickets while at the park with the kids.
Look for a second installment of our study on SoftLayer Features and Benefits! There are many more features that I want to translate into benefits for you, so in the more familiar words of Arnold Schwarzenegger, “I’ll be back”!
-Harold