Alternative medicine is still exotic territory. Books that survey this terrain resemble earlier travel guides to new worlds. Depending on the writer's position, the reader is treated to tales ranging from Rousseau's accounts of noble savages to Hobbes's predatory heathens. If there were a rating scale for accounts of alternative medicine that ranged from wildly positive to utterly negative, the chapters in this book would hover close to the midpoint. This kind of unbiased collection is remarkable and shows that the scientific investigation of alternative medicine, although in its infancy, is beginning to make this unfamiliar world more accessible.
The book is able to remain evenhanded because it is almost entirely restricted to a compendium of scientific evidence, both positive and negative. The Cochrane Collaboration Field in Complementary Medicine has compiled data from over 3000 randomized, controlled trials, and although the various authors of this book seem unaware of this resource, it is a good benchmark for research. If one adds the relevant epidemiologic and basic-science research, the data can be daunting. Although this book does not cover all the evidence, by presenting mostly scientific testimony, it provides a valuable assessment of alternative medicine.
The main weakness of the book is related to its strength: it is essentially a compilation of research data. Much of the book reads like the list of titles a researcher gathers together before deciding whether there is enough information to perform a worthwhile systematic review or meta-analysis. Well-performed randomized, controlled trials are lumped with poor ones. The results of studies involving case series are mixed with those of animal or cell-culture studies. The evidence is only sometimes evaluated, is insufficiently contrasted with findings from other studies, and is weakly interpreted. The book can be tedious and reads like an annotated bibliography. The authors unanimously agree that more research is needed, but disappointingly and perhaps inevitably, the state of the field is still too primitive for many conclusions to be drawn.
Some chapters have been carefully crafted. The best are those on cancer, psychiatric disorders, allergy and asthma, and cardiovascular disease. But even the best chapters would have benefited from peer review. The information is so extensive that mistakes are unavoidable. For example, the chapter on cancer describes the intervention in the provocative cancer trial by Spiegal et al. as self-hypnosis, but it was actually group therapy. This chapter also fails to cite three randomized, controlled trials that showed a benefit of acupuncture in the treatment of emesis associated with cancer chemotherapy, and there is no mention of the controversy over the possibility that the Bristol diet trial was confounded by the unequal distribution of base-line characteristics in the study groups.
Some chapters are much weaker than others. For example, the chapter on naturopathy and women with human immunodeficiency virus infection presents little evidence. The chapter on preclinical studies is confined to the potential value of treating cancer by using a direct electrical current to induce apoptosis. An extended discussion of this topic seems unnecessary, and the brief recapitulation in the chapter on cancer is actually sharper.
The book has one additional problem, which is related to the attempt to make alternative medicine accessible to health care professionals. Most of the chapters focus on a specific condition (e.g., diabetes) or a selected population (e.g., children). Using primarily biomedical categories is helpful for sorting evidence but allows only the briefest discussion of the cultural systems within which alternative medicine is practiced. After reading this book, one knows very little about the beliefs or behavior of acupuncturists, homeopaths, herbalists, chiropractors, health-food enthusiasts, or psychics. Also, because certain biomedical categories, such as urology, are not covered, there is no mention of important alternative therapies such as the botanical saw palmetto.
Ultimately, the strengths of the book outweigh its weaknesses. Although not on the level of de Tocqueville's writing, this book is an important contribution to the effort to make unconventional medicine more approachable for health care professionals. Even for the reader who is already familiar with alternative medicine, this book is likely to provide new and valuable information.
Reviewed by Ted J. Kaptchuk, O.M.D.
Copyright © 1999 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
