How Healing Works Read online

  Niacinamide did work—a little. When we statistically analyzed the differences in response between those on the niacinamide and those on the placebo, the niacinamide did work better than the placebo, but by only a small amount. On average, those on the vitamin improved by 29%, compared to a 10% worsening in those on the placebo. While this was statistically significant in favor of the vitamin, the overall difference was small—and the placebo had fewer side effects. High-dose niacinamide can cause liver problems in some people. I was disappointed. I had not found a cure for arthritis after all. But I continued to wonder why Norma had gotten so much better. Something had triggered her healing. Was she just an unusual patient—an aberration? Did I just pick the wrong patients to include in the study? Did I do the study wrong? Pick the wrong treatment?

  It was not an aberration. When examined through rigorous science, using randomization, double-blinding, and placebo controls with adequate numbers of patients, most treatments for the most common chronic conditions either do not work or work only 20% to 30% of the time. Most of the drugs prescribed for pain, mental health, ulcers, hypertension, diabetes, Parkinson’s disease, and many other conditions show little benefit, with improvement in a minority of those studied. Even surgery, the king of modern medicine, works very little for chronic diseases (especially pain) when studied in a rigorous manner. For example, in a pooled analysis of over eighteen thousand patients, drawn from studies where half the patients got sham (fake) acupuncture (needles are put in the wrong points or not inserted into the skin at all) and the other half got real acupuncture, the groups getting the fake acupuncture had a healing rate of over 80% of that experienced by the those getting real acupuncture. While this rate of improvement from a fake treatment may seem stunning to many readers, it is actually a rather routine finding and also occurs with modern, scientifically developed treatments. For example, studies in which sham (fake) surgery (an imitation of surgery without the actual tissue manipulation) is “performed” on half of a patient test group with chronic pain, it produces 87% as much improvement as seen in those who receive the real surgery. In some studies, the fake surgery worked better than the real surgery and produced fewer side effects. In fact, this type of improvement with fake treatments is found in many areas of modern medicine. The majority of improvement for many treatments occurs with the fake or placebo treatment, whether the placebo is mimicking a drug, herb, needle, or knife. Can treatments still heal even when science has proven them wrong? Impossible, I thought. It took another patient to teach me that this was not impossible at all.

  SERGEANT MARTIN

  Sergeant Martin crawled from the tangled web of steel that had been his truck, bleeding from every orifice. Although dazed, he got to his buddy, who was lying unconscious and exposed in the middle of the road, and pulled him to safety. Sergeant Martin had suffered an insidious and incapacitating brain injury. Unfortunately, he is one of many: nearly three hundred thousand American service members are living with traumatic brain injury (TBI) suffered while fighting in Afghanistan or Iraq. Rather than penetrate the brain like a bullet, an improvised explosive device (IED) usually produces a close-range shock wave that impacts the brain as a whole. Damage and bleeding in the brain is often global, with small areas of injury spread throughout. Often the extent of the injury is not fully evident for months and gets worse until it stabilizes. The victim is left with multiple functional problems, from memory loss to language problems, mood swings, sleep disturbances, and chronic pain, especially headaches.

  Sergeant Martin had all these problems. He would duck at the sound of a door slamming. He avoided social gatherings, worried that something bad might happen. He had almost daily headaches and was constantly on painkillers. He would wake at night in a panic, sure that someone was breaking into the “green zone.” He was emotionally labile—sometimes acting like a loving kid, other times screaming at his wife to lock the doors. One morning his wife found a loaded handgun under his pillow. She told him to get rid of it. He said he needed it to sleep at night. They argued. Finally, he agreed to make sure it was not loaded. She threw the ammunition away but worried how this might end. He told her and everybody else that he was not suicidal. He said he had seen what happened to people who said they were; they were locked up in a mental ward.

  There is no cure for this type of brain injury. I juggled drugs for Sergeant Martin’s headaches, anxiety, sleep disturbances, and other symptoms. I sent him to physical therapy, group therapy, individual psychological counseling, and music therapy. Of those, the only one he really liked was music therapy. He especially loved to listen to Beethoven’s Ninth Symphony.

  I asked him to rest and work with several specialists in brain injury and PTSD. Over time he improved—but only incrementally and marginally. Soon he settled into chronic dysfunction and left the service with a permanent disability. From then on, all I could do for him was palliation, tweaking his medicines to minimize the side effects and providing him with slightly more relief. It was a discouraging practice. When I told him I had nothing new left to offer him, he dismissed me as his doctor. “I won’t accept that,” he said on his last visit with me. “You are keeping me stuck in Beethoven’s first movement. I know there is more.” He paused. “Friend,” he said (he had never called me that before), “when I was in Iraq and we hit that roadside bomb, I don’t recall pulling my buddy to safety from the road. Others told me I did that. The only thing I remember after the bomb is waking up in the hospital in a daze. I am still in that daze; and I need to wake up again.” He made no more appointments. Just like on the battlefield, Sergeant Martin was not going to give up. He was determined to win this battle, too. I only hoped he would eventually win the war going on inside himself.

  Doctors don’t like to give patients what they call “false hope.” The idea is that, when there are no effective treatments for a condition, it is better for patients to learn to cope with reality than seek ineffective and possibly harmful treatments that are unlikely to work. Science helps us determine what works and what does not—and so, we believe, distinguishes true hope from false hope. Sometimes patients interpret this to mean no hope and either fall into despair or, like Sergeant Martin, reject the suggestion that they must live with their condition.

  Before Sergeant Martin, I thought I knew how to determine true from false hope for my patients using science. Sergeant Martin, however, taught me that it was more complicated than I thought. Distinguishing true from false hope was not just a matter of science—it had to be done jointly by physician and patient together. Neither one alone had a lock on how to handle hope.

  Here is what happened: Several months later, I saw Sergeant Martin in the hallway of the hospital, and I hardly recognized him. He had improved remarkably. He said he had fewer headaches, better sleep, and less pain. He spoke more clearly. He was off most of the drugs I had prescribed. He was going back to school, had a part-time job, and was getting along with his family. What had he done, I asked?

  “Hyperbaric oxygen,” he answered.

  “Really?” I asked in disbelief.

  “Yep,” he continued. “Got forty treatments, and it cured me.” He was not cured, but he was clearly much better than I had ever seen him. It couldn’t be from that treatment, I thought to myself. I had studied hyperbaric oxygen (HBO) therapy and rejected it, as had most scientists, because the research evidence showed that it did not work.

  But Sergeant Martin did not care what I said about the science. He had done the impossible when he rescued his buddy after the bomb went off. He would face the impossible now and try to rescue himself. My opinion did not stop him. He had heard from his buddies that HBO might help brain injury, so he had done forty HBO treatments.

  I asked him to come in and tell me more about what he had done. He explained that it was his father who found the HBO center and agreed to pay for the treatment sessions, which were not covered by insurance. These sessions involved going into a special HBO center and entering a large chamber where
ten patients were treated at once. At the HBO center, Sergeant Martin met a physician, an HBO specialist, who described the treatment and the expected effects and evaluated patients for their baseline symptoms and function. Sergeant Martin went every day (except weekends) and would sit in the chamber with a group of other patients for an hour while breathing 100% oxygen through a mask. He often saw the same patients there each day, several of whom also had a brain injury. The air pressure in the chamber was turned up, which he could feel in his ears, sort of like when you dive down below the surface in a swimming pool.

  The technicians explained to him what HBO would do. The theory was that pressurized oxygen diffused into the brain and stimulated healing in damaged areas that had only been “stunned” by the bomb blast and were dormant. The extra oxygen was said to “wake up” the stunned brain and speed it on the road to healing. I didn’t buy that explanation, but Sergeant Martin did. And there he stood before me—largely healed. He had reached the final movement of his symphony. He had sung his “Ode to Joy.”

  He was not the only one. The advocates of HBO presented case after case of apparently miraculous healing. They convinced the United States Congress to authorize federal funding and test whether it truly worked, using rigorous scientific methods. The study conducted by the U.S. military cost more than $30 million. It compared three groups: real HBO; “fake” HBO subjects, who were told they got high oxygen but really got room air; and the usual treatment without either real or fake HBO. The study found that HBO did not work any better than a fake version of the treatment using room air instead of 100% oxygen. That didn’t satisfy the advocates of HBO, who said they knew it worked. They claimed they saw improvements in patients with brain injury every day. They also alleged that the study had been done poorly by skeptics who biased the results. At that point, the military asked an independent organization—Samueli Institute, which I directed at the time—to analyze all the studies on HBO (within and outside the military) and, with the help of a panel of experts, including both advocates and skeptics of HBO, to make a final determination on its effectiveness.

  The data was clear. The review confirmed that HBO did not work any better than a fake version, which involved sitting in a slightly pressurized chamber breathing room air for forty sessions. But the study revealed something few others had noticed: patients with brain injuries who received either real HBO or the fake HBO treatment did much better than those who got standard treatment alone—the kind of treatment I had provided Sergeant Martin. And the benefit was not small. Those who sat in the chamber for the full forty sessions had more than twice the improvement of those who received only drugs and other therapies. Adding oxygen did not increase that improvement, but going through the treatment helped. There was something about the ritual and delivery of the treatment that produced a dramatic healing effect. Perhaps it was the patients’ and physicians’ beliefs, perhaps it was the social engagement during the treatment, or perhaps it was some other factor. But it was not the oxygen. The military rejected the treatment after the HBO theory was disproved. But Sergeant Martin was right—he had hope, and he was better. I was happy for him, but confused. Was this another glimpse of a sleeping giant in modern medical research—the placebo effect—that I was to come to know well later in my career? What was I supposed to recommend to the next patient with a brain injury who came into my office? How could I trust my own judgment in medical practice to use the best treatment? And not to give false hope?

  CHARLEY

  As it turns out, many other physicians were also beginning to doubt their own experience—and with good reason. From the 1960s to the 1990s, a series of scholars using rigorous scientific methods showed repeatedly that many widely used treatments—even those considered “standard of care”—were not only ineffective but actually harmful. Medical opinion should be distrusted, they said, and in its place, a careful and structured process for summarizing clinical research, called “systematic reviews,” should be used. This was the approach Samueli Institute used to examine the effect of HBO on brain injury. While I believed in good evidence, the importance of this did not hit me until I inadvertently contributed to the death of a patient by using the standard of care. It still feels like a punch in the gut—and it’s no consolation knowing that medical errors are the third leading cause of death in the United States.

  Charley was a sixty-six-year-old former Marine whom I hospitalized with a suspected heart attack in 1985. It was a routine admission and management. He had chest pain and nausea that sounded like a possible heart attack; his EKG showed signs of possible heart ischemia (low oxygen) and irregular heartbeats. In 1985, it was routine to hospitalize someone with these symptoms and treat them with bed rest, morphine to ease the pain, nitrates to expand their coronary vessels, beta blockers to slow their heart rate and lower their blood pressure, and antiarrhythmic drugs to prevent the heartbeat from becoming irregular. Most patients improved and were discharged a few days later. Some went on to have further complications.

  Charley looked stable when I checked up on him before I went home that evening; he seemed perfectly comfortable. Blood tests indicated he had had a mild heart attack and would likely recover quickly. “See you in the morning,” I said.

  But that night, I was catching up on my medical journal reading and came across a study that showed I might be harming Charley with the antiarrhythmic drugs. The study randomized patients like Charley to receive either antiarrhythmic drugs or a placebo. Those who received this routine care and got the drugs actually died at a higher rate than those who did not. I put the article aside and decided I would bring it up in morning report. Had anyone else seen this article, I wondered? Should we stop giving these drugs?

  I didn’t get the chance to discuss it with my colleagues. At about 4 A.M. I got an urgent call from the hospital, telling me that Charley had died. His heart had gone into a fatal rhythm that could not be reversed. I rushed to the hospital to find his wife in his room weeping. What had happened? she asked. I didn’t know what to say. Did his heart attack spread and cause the fatal arrhythmia? An autopsy later showed no evidence of that. Had I killed him by giving him the antiarrhythmic drug, as the new study implied? That was the most likely explanation.

  The routine use of antiarrhythmics was stopped after the study I had read was confirmed. All in all, it was estimated that at the peak of antiarrhythmic drug use for suspected heart attacks, the medical profession was killing up to fifty thousand people a year. Expert clinical experience was harming patients. Only a placebo-controlled study revealed that.

  For thousands of years, medical treatments have been selected and passed down using clinical experience as the best approach to truth. But could accumulated medical wisdom, both from ancient practices like acupuncture and modern drugs like the one given to Charley, be wrong? If so, how could we explain healing?

  PARADOX

  Since 1991, I have had the good fortune to have jobs that allow me to explore these questions. First, as the director of the Medical Research Fellowship at Walter Reed Army Institute of Research, it was my job to teach the research fellows how to think critically about medical science and apply rigorous methods in their research. Each year we had five or six fellows who were taught in-depth research methods and learned critical evaluation skills. Each fellow did research on a cutting-edge medical topic and carried the study through from start to finish. I adopted evidence-based teaching methods that emerged from Oxford and McMaster universities to teach physicians how to counter the errors of clinical experience. The NIH later adopted some of those teaching methods in their courses on clinical research. Did these same principles apply to ancient healing methods and alternative healing approaches used by most people in the world? I had the opportunity to examine that when I took over as the director of the Office of Alternative Medicine at the NIH and a WHO Traditional Medicine Center of Excellence in 1996 and 1998, respectively. Later, when I was CEO of Samueli Institute, a nonprofit organization dedicated to e
xploring the science of healing, my team had the chance to do scientific deep dives into ancient and modern healing practices.

  This series of jobs allowed me to work with physicians, healers, patients, and researchers around the world to examine three main questions: First, to what extent do the health care practices from diverse traditions actually work when rigorously studied using gold-standard science? Second, what degree of improvement is found from these health care practices when used in regular clinical practice? And, third, are there any common characteristics that cut across all these traditions, ancient or modern, that can explain how their healing happens?

  I call what has emerged from this exploration the “paradox of healing.” When rigorously studied, ancient traditional practices such as acupuncture and herbal remedies, as well as more recent complementary and alternative treatments such as homeopathy, dietary supplements, and manual therapies, show disappointing results and only small effects. Likewise, data on most of our modern conventional treatments show the same thing. Most drugs for pain, mental health, ulcers, hypertension, and diabetes, for example, show little benefit—often only 20% to 30%. Furthermore, the more carefully the studies are done, the smaller the effects. Even more startling, only about one-third of well-done studies—executed in the laboratory or in the clinic—can be independently replicated. Thus our confidence that even a 20% improvement can be repeatedly obtained is low. Even surgery (when not simply changing anatomy, like fixing a leg or removing a tumor) works minimally. And when these treatments do work, it is often not for the reasons scientists think they do.

  Yet the paradox is that all these approaches can work, if applied properly. When we looked at the rate of improvement in patients who received very different types of treatments from around the world, we found that 70% to 80% of people will get better. Later in this book, I will describe Parkinson’s patients who get better with treatments as different as ancient Ayurvedic medicine and electrical stimulation of the brain, soldiers with PTSD who get better with yoga or psychotherapy, patients with pain who get better with acupuncture or opioids, and patients whose health improves when under the care of a homeopath or surgeon, even when rigorous studies show little if any effect from these treatments. We need to understand why they get better.