Medicine Wars
Will Alternative and Mainstream Medicine Ever Be Friends?

Barry F. Seidman

The very next month, a study in the Journal of the American College of Nutrition found that people who ate tofu more than three times a week showed more signs of impaired mental function later in life than those who rarely ate the soy product. The suspected culprit: the high intake of isoflavones in tofu.

Consumers could be pardoned for being baffled. Is tofu the next "wonder food," or will it shrink your brain in a way your psychologist never meant to? The Jekyll and Hyde story of tofu illustrates the tricky status of alternative (as well as complementary) medicines, whose remedies almost by definition have not been subject to the rigorous research and testing expected of mainstream medicine.

The term "alternative" usually refers to medicines meant to take the place of traditional medicine, while "complementary" indicates treatments used in addition to conventional medicine. Complementary medicine is also sometimes called "integrative medicine," which is supposed to unite the best of both worlds, marrying scientifically proven chemotherapy, for example, with herbal formulas supported by folk wisdom.

One reason alternative medicines (AM) and complementary medicines (CM) have not been as rigorously tested as traditional medicines may be that they do not attract the funding required for methodical scientific validation because typically they are not patentable. Another possible reason is that it is not in the interest of many AM promoters to undertake scientific studies of these remedies because they make a good deal of money selling them - untested and unregulated - over the counter as food supplements.

In part to quench the growing popular thirst for acceptance of alternative medicine, in 1998 the National Institutes of Health (NIH) created the National Center for Complementary and Alternative Medicine (NCCAM), which was charged with sorting the wheat from the chaff among the myriad unproven supplements and therapies by rigorous research and testing. To some, this move meant that the scientific standards of medicine would be upheld. But many others, including promoters of alternative medicine and their followers, took it as a legitimization of the whole field.

But how much credence is the American public putting in these various dietary supplements, herbs, and alternative practices? That depends on whom you ask.

"From 1990 to 1997, the use of herbal remedies increased 380 percent," reports Carol L. Norred, C.R.N.A., in a study published in the February 2000 Journal of the American Association of Nurse Anesthetists. She adds that data from 1998 indicate that about 37 percent of Americans used herbs during the previous year, spending more than $3.87 billion for these food supplements.

James N. Dillard, M.D., director of the Columbia College of Physicians and Surgeons, agrees with Norred's data and is indeed not surprised that so many people are attracted to alternative medicines. During a long career, which includes experience in both traditional and nontraditional medicine, he has found that many patients are not satisfied with - and in fact are quite distrustful of - conventional medicine and its practitioners, who are often referred to as "money-hungry" and "cold."

Additionally, Dillard, author of Alternative Medicine for Dummies, notes that an estimated 60 million Americans have no health insurance and can't afford conventional medical care with its costly prescription drugs and procedures.

To that background add the growing number of health-food products in stores and on the Internet and, according to Dillard, you'll see the reason why "one half to one third of Americans are using complementary medicines."

Other experts, however, believe the number of Americans who are being co-opted by the alternative medicine world has been greatly exaggerated. They feel that many nontraditional practitioners have laid the psychological groundwork that has led the general public to form the idea that America is becoming "an alternative medicine country."

For example, some skeptical practitioners point out that even the "serious" peer-reviewed medical journals sometimes err, fail to reveal the financial self-interest of researchers, and produce articles based more on bias than on solid research.

A "landmark" article in The New England Journal of Medicine in the winter of 1993 by David Eisenberg and colleagues contended that 34 percent of Americans had sought unconventional treatment during any given year, often from AM practitioners rather than their regular doctors.

This study was later evaluated by William Jarvis, professor of public health and preventative medicine at Loma Linda University in California, and contributing editor for the new peer-reviewed journal The Scientific Review of Alternative Medicine. Jarvis's survey found the percentage was much lower-around 10 percent, based on unconventional medicines used by patients seeking care from traditional practitioners.

One of Jarvis's colleagues, Wallace Sampson, M.D., formerly the associate chief of hematology and medical oncology at the Santa Clara Valley Medical Center in California, and a clinical professor of medicine at Stanford University School of Medicine, explains, "They [Eisenberg et al.] inflated or biased the study by including self-help groups, group psychotherapy, weight-loss clinics, ordinary prayer, and other procedures that are really just adjuncts to standard scientific medical care, and neither are alternative or 'complementary' methods. By creating a false impression of increased demand, the 'alt' system has created a self fulfilling prophecy."

Adding to SRAM's findings in 1999, the Journal of the American Medical Association (JAMA) published a study headed up by Benjamin G. Druss, M.D., M.P.H., of the departments of psychiatry and public health at Yale University, that found what Sampson says is a far more realistic assessment of AM usage. Druss's report is based on statistics provided by the 1997 Medical Expenditure Panel Survey (MEPS), which 24,676 people responded to. It found that in 1996 about 6.5 percent of Americans used both conventional and unconventional medical services. Only 1.8 percent used only unconventional services.

"Patients generally report using such therapies to augment their medical care rather than as a result of dissatisfaction with mainstream medicine," according to Druss.

"Nonetheless, there remains a perception among clinicians and in the popular press that unconventional treatments represent a rejection of, and challenge to, the mainstream medical system."

Dillard, however, finds no connection between the Eisenberg study and Druss's. "What Druss was interested in, in his study, was finding out if people use nontraditional medicines and standard medicine at the same time, not how many people in the country actually use alternative therapies," Dillard said. "Druss doesn't, for example, include how many people self-use these medicines at the [drugstore or health-food store] counter."

Dillard points out that Eisenberg looked at all the various alternative methods, from "garbage" that can't work to many herbs that have been found to be useful. Though Dillard himself believes that most alternative and complementary medicines are useless, he feels that certain herbs, acupuncture, and chiropractic ought to be included for the treatment of many patients' ailments because they have at least some scientific evidence backing up their efficacy.

One consistent finding regarding AM usage among general practitioners is that the more serious the disease, the more skeptical the people become. For instance, based on a number of research papers, including an unpublished survey by Shapiro and Associates for the American Cancer Society, Jarvis believes that the percentage of cancer patients who seek alternative treatments is smaller than that among the general public.

The Shapiro survey polled 36,000 homes and located 5,047 cancer patients living or deceased from 1987 and 1988. Shapiro considers "standard therapy" to include surgery, radiation, and chemotherapy. He found that 7 percent of the living patients and 14 percent of the deceased ones were reported to have used none of these treatments. Four percent of patients said they had no treatment whatsoever. "The difference between the 'no treatment' respondents and those who did not have the three methods mentioned are the users of alternative cancer treatments," says Jarvis. In other words, about 4 percent of patients.

The Shapiro survey also found that 80 percent of alternative or complementary therapy users continued to seek the service of their mainstream doctors while using the unproven methods, while 35 percent of users did not tell their physicians they were using these methods. And 2 percent used these methods even over the objection of their doctors.

The Traditional Point of View

"I performed an unpublished survey of 100 successive cancer patients in 1976 and found 60 percent had been taking some sort of unproved method. [It] got me to asking all cancer patients what they took besides what I gave them, and to discuss it freely. I also taught all [medical] residents and students to ask the same," remembers Sampson.

William Jarvis, who began studying quackery around the same time as Sampson, has dedicated his professional life to helping consumers and patients better educate themselves about the pitfalls in unconventional medicines. He has written a soon-to-be published analysis of this mission, to educate physicians on how to help patients deal with questionable treatments, from diagnosis to maintenance. Jarvis also includes ideas on how doctors can better understand patient behaviors and help patients decipher scientific "technobabble." Perhaps most important, he includes a section explaining why so many people believe in unproven therapies in the first place.

The extensive research Jarvis conducted to write his paper led him to develop a hypothesis that separates alternative and complementary medicine users into two categories: pragmatists and ideologists.

"Pragmatists are willing to try almost anything they hear about that sounds plausible. They expect to be able to tell whether something is helping or not in a relatively short period of time." He adds that pragmatists pay little attention to scientific reports on this or that therapy, but pay lots of attention to testimonial and anecdotal reports, which are difficult to check for veracity and may be anomalies.

"Ideologists are different," says Jarvis. "Health beliefs of various sorts constitute a kind of hygienic religion for ideologists. These people will stick with a program even when it is apparent to people around them that they are not doing any good. [These AM practitioners can convince ideologists] that cancer is only an illusion; [that if they] stop believing the cancer is there, it will go away. I know of many who have died trying to prove their ideologies were true. Even as they went downhill, they still believed that they had done the right thing."

Barrie Cassileth, Ph.D., of the Memorial Sloan-Kettering Cancer Center in New York City feels that one of the greatest obstacles scientists have to hurdle in investigating alternative and complementary medicine are the providers of these medicines themselves.

"The people who promote this stuff," a frustrated Cassileth argues, "make the public paranoid about traditional medicine. They say things like 'scientists don't want to cure cancer lest they'd be out of a job'; this is a ludicrous notion."

Both Cassileth and Jarvis feel that New Age gurus too often promote alternative methods as safer than "invasive, side-effect-ridden" therapies such as chemotherapy and bone marrow transplants-usually by referring to them as "ancient" (as though longevity implied validity), and "natural."

But because people have used a method for hundreds or thousands of years doesn't necessarily mean it works from a physiological standpoint, just that it might have had a powerful belief system behind it. If for generations people had been taking a remedy, and everyone, from grandmothers to medicine men, "knew" that is was good for them, then it was, for that reason, more likely in fact to help.

Also, "natural" doesn't exempt patients from danger or toxicity. After all, poison ivy and snake venom are "natural." James Dillard said, in a previous interview, that "many folks think that they can treat themselves with herbs, because herbal remedies 'are not really medicines.' This is incorrect . . . they [these herbs] are not the same as just eating a salad or vegetable."

One dangerous result of this kind of thinking arises when people take these medicines to assist them through serious medical challenges like surgery.

Norred, after surveying 500 patients, found that 255 of them, or 51 percent, took vitamins, herbs, dietary supplements, or homeopathic medicines just two weeks before surgery. Of these patients, 122 took 50 different herbs with other alternative medicines. Some of these herbs included garlic, cranberry, echinacea, and ginseng. One danger of such practices is that these herbs can prolong blood's coagulation time, leading to severe bleeding in surgery patients. She found that 27 percent of patients who ingest herbs before surgery encounter this complication.

The Alternative Point of View

Durk Pearson and Sandy Shaw are a team of scientists who have worked in the field of nutrition and complementary medicine for more than thirty years. They currently operate a company called Life Services, Inc., and conduct anti-aging and brain biochemistry research.

Careful to separate themselves from the average "miracle workers," Pearson points out that he has earned degrees from the Massachusetts Institute of Technology in physics, biology, and psychology, while Shaw graduated with a degree in biochemistry from the University of California at Los Angeles.

The team does not feel the average person today is as ignorant toward shams and charlatans as they might have been just ten years ago. Instead, they feel that patients today, especially cancer patients, educate themselves well enough regarding their condition. They feel that today, particularly with the advent of the Internet, many people can cross-reference myriad databases, quickly determining the differences between quackery and peer-reviewed studies.

Pearson and Shaw's gripe instead is with the Federal Drug Administration, which they see as a self-serving government agency with the power and money to dictate what kind of treatment will and will not be labeled appropriate or even seriously researched for approval.

In one clash with the powers that be, Pearson and Shaw came up on top. On January 15, 1999, the United States District Court for the District of Columbia under Circuit Judge Silberman decided that the FDA had violated Pearson and Shaw's constitutional rights to sell their dietary supplements without governmental approval. The court voted unanimously in their favor.

A statement added to the decision was tacked onto the official decision by Silberman, which assured that the decision would be published, indicating false motives on the part of the government. The government argued that the FDA was concerned with consumers' dietary health and safety, when in fact "The government had never contended that appellants' (Pearson and Shaw) dietary supplements, as opposed to other dietary supplements not at issue in this litigation, threaten consumers' health and safety," said Silberman.

Frustrated by what Pearson sees as the FDA's narrowness of vision, he notes, "It was once the policy of the FDA to say that the agency ought to be the 'sole authority' for determining what is good and what is bad medicine. Some still believe this is so; I think this is utterly laughable. . . . The FDA doesn't have a monopoly on truth," concluded Shaw.

When asked their opinions whether or not the NCCAM is helping to widen the playing field for potentially beneficial complementary medicines, Pearson said, "I think they [NCCAM] can be doing a better job in choosing what to look at. Some of the stuff they are studying doesn't have any more medical relevance than leeches! There are many, many other medicines much more worth studying like calcium and certain herbs."

Paul Bergner, editor of Medical Herbalism, an herb information Web site, makes herbs his livelihood. He argues that herbal medicine, especially Chinese tonic herbs, may improve the survival rates of cancer patients undergoing conventional treatments. "As a non-M.D. recommending herbal medicine to cancer patients, I do not hesitate to inform patients of the possible benefits. However, interactions between herbal medicines and chemotherapy are poorly understood. Therefore, I recommend that they fully disclose to their oncologist the regime that they are practicing."

So, in general, are doctors alerting their patients to the potential dangers of unproven therapies?

One clue that this may not always be the case is that often patients who do ask their doctor about this herb or that alternative therapy get blank stares-an acknowledgment, according to Dillard, that the doctors "don't have any idea what patients are talking about." Conversely, some physicians adopt an adversarial stance at the very mention of alternative medicines, even toward the few remedies that actually show some evidence of benefit.

AM and the Doctor/Patient Relationship

James M. Metz, M.D., assistant professor of radiation oncology at the University of Pennsylvania Cancer Center, in a study he presented May 23, 2000, at the 36th meeting of the American Cancer Society for Clinical Oncology, found that 40 percent of cancer patients used unproven therapies and did not disclose this information to their doctors until specifically prompted to.

Within a group of 79 patients who admitted using such therapies, 40 percent reported using mega-doses of vitamins such as C and E. Metz pointed out that these vitamins are antioxidants and could interfere with or inhibit radiation therapy. Metz told Ascribe: The Public Interest Newswire, "Patients should understand that just because a product is marketed as 'natural,' that doesn't make it completely safe. Many of our chemotherapy drugs are from natural sources, but the ingredients are known to have certain toxic effects." While researchers are asking these important questions of patients, they are largely neglecting to ask physicians the same questions.

John Renner, M.D., chief of medicine for HealthScout.com and the National Council for Reliable Health Information, and now retired from private practice, reflects on his relationship with the many patients he saw throughout his career. "I was a patient advocate. I even had a medical library in my office. I was very honest with my patients, and they seemed to return this honesty. I don't think many [took alternative medicines] behind my back."

Physician's assistant Helder Rebelo, P.A.C., of High Mountain Health in Wayne, New Jersey, agrees that most patients are honest with their doctors. He makes it clear to other physicians as well as patients that he'd never advise a patient, especially one with a condition as serious as cancer, to choose an alternative treatment, replacing traditional methods. "I can't approve of treating cancer, for instance, with such medicines as an alternative treatment unless, perhaps, if the patient has gone through chemotherapy and has had masses removed, but the cancer is very metastatic-basically, if there is little else that can be done."

For complementary methods like chiropractic, as well as some herbs like echinacea, Rebelo says that as long as they do not interfere with the current medications and treatment the patient is taking, he has no problem with patients trying them out. He found, though, that with many herbs, patients usually come to him after the fact, telling him, 'Hey, I tried this and it didn't work.'

Wallace Sampson says he never had problems with people withholding this kind of information. In fact, many people would bring pamphlets or books to his office and ask him what he thought. "Although I usually didn't agree with what the books said, I sat with them and discussed their options. [Are] patients keeping their involvement secret from their doctors? I'd say they don't. They just don't think it is very important."

Sampson does admit, however, that there are some patients who will never be happy with what he and most physicians might say about alternative or complementary medicines. "[Clinicians] are usually not going to prescribe these methods because most of the claims of 'success' are false."

Yet the attraction of some unproven treatments-the sense of empowerment they give users and their relative affordability (even though some such treatments can be surprisingly expensive)-can be very powerful.

Janet Zazha, a consumer of complementary products, sees great potential in their ability to both keep her healthy and prevent future ailments. She currently takes calcium glucorate (CdG), a "natural" chemical found in apples, grapefruits and broccoli, to prevent breast cancer, and BiosLife 2 (BL2), a dietary fiber supplement, to lower blood cholesterol. Her family doctor is not only aware that Zazha is taking CdG, but she say proudly, "after I told him about it, he is now taking BiosLife himself to lower his cholesterol, as he wants to stop taking Lipitor [a prescription cholesterol-lowing drug]."

"I would like to see a study where BiosLife 2 was measured against oatmeal," comments Stephen Barrett, M.D. Barrett has researched BiosLife and the company distributing it, Rexall, extensively. He feels that as far as controlling cholesterol, the product might have some positive effect, but that no one seems to want to submit a study to any peer-reviewed journals, and this leaves him suspicious.

"BiosLife is expensive. I'd really like to know if there is any data showing that it is more effective or even cost-effective than using oatmeal. Also, two people whose doctors prescribed BiosLife for their high cholesterol levels have recently consulted me. Neither of them was being optimally managed."

Indeed, Barrett says he found that these patients were never even asked to have regular blood work done to determine if BiosLife was working as advertised!

Barrett operates a health-based watchdog Web site at www.quackwatch.com, and there posts extensive articles and pertinent information about alternative cancer treatments and other such information. Among the cancer treatments he analyzes are CanCell (Cantron), Antineoplastons, Cell Specific Cancer Treatment, Essiac, Immune-augmentative Therapy, the Kelly/Gonzalez Metabolic Therapy, shark cartilage, and vitamin C. He notes that the American Cancer Society refers to these "treatments" as "lifestyle practices, clinical tests of therapeutic modalities that are promoted for general use for the prevention, diagnosis, or treatment of cancer and which are, on the bases of careful review by scientists and/or clinician, deemed to have no reasonable evidence of value."

"These products need to be studied one by one; using an umbrella term like 'alternative medicine' is meaningless and non-measurable," says Barrett. He cautions that many CM practitioners often take any one particular herb that might be helpful for preventing some ailment such as cancer, and then add to it lots of useless herbs and vitamins. When the patient doesn't get cancer, he or she credits the useless herbs along with the one useful one. "Personally," adds Barrett, "I feel that the complementary medicine practitioners are dishonest muddleheads offering a low quality of medical treatment."

Consilience?

Denis R. Miller, M.D., the global clinical manager of Aventis Pharmaceuticals in Bridgewater, New Jersey, and clinical professor of pediatrics at the Robert Wood Johnson Medical School in New Brunswick, New Jersey, feels that "Everything people can imagine taking as treatments for anything is testable. Those who argue against this are not being honest."

Miller makes a point to say that he is very much for any treatment that increases one's lifespan and improves the quality of life of any patients; so much so that he is willing to test any alternative medicine for its efficacy. He adds, "Paranoia has no place whatsoever in science."

Nathaniel Katz, M.D., co-coordinator of a multidisciplinary commentary task force at Dana Farber Cancer Institute in Boston, is part of a rare program where the goal is to combine traditional procedures such as nerve blocks with alternative therapies such as guided imagery, yoga, and Therapeutic Touch (TT).

As a response to any complaints from doctors not willing to place patients into the care of "unproven therapies," Katz argues that "every decade has its standard medicine and its non-orthodox ones. Some medicines from both groups, in time, can, and do, fall out of favor." He admits though, "I think people become interested in the non-orthodox medicine simply because they are non-orthodox."

Katz is a strong advocate of the usefulness of the placebo effect, one of the ways he deems some non-orthodox medicines "work." "There are two main ways placebos operate. One is the psychological way, where a patient simply believes that the nurse standing over them applying soothing touches, or the mind-clearing effect of yoga medication can produce a psychological effect, will do so and can allow the patient to feel better thereby helping their body to heal itself. The other is that some of these placebos might actually cause some biochemical effect in the brain that helps patients get better." Katz, arguing against the skeptical notion that placebos can only affect someone for a limited time, says he's known many patients who were still healthy years after they stopped taking a particular placebo even though the conditions were not known to get better on their own.

In disagreement with what Barrett calls Katz's "anecdotal evidence," the Quackwatch president points to very dubious information regarding one of Katz's treatments. He offers for evidence a study of TT designed by Laura Rosa, R.N. and her daughter Emily Rosa published in the April 1, 1998, Journal of the American Medical Association (JAMA).

"They tested twenty-one TT practitioners to determine whether they could detect one of her hands near theirs. Each subject was tested ten to twenty times. During the tests, the practitioners rested their forearms and hands, palms up, on a flat surface, approximately 10 to 12 inches apart. Emily then hovered her hand, palm down, a few inches above one of the subject's palms. A cardboard screen was used to prevent the subjects from seeing which hand was selected. The practitioners correctly located Emily's hand 122 (44%) of 280 trials, which is no better than would be expected by chance and guessing."

Barrett notes that Dr. George Lundberg, [then] editor of JAMA, himself believes that TT practitioners now have an ethical duty to disclose the results of this study to potential patients and that the third party payers should question whether they should pay for TT procedures. Lundberg also believes that patients should "refuse to pay for this procedure until and/or unless additional honest experimentation demonstrates and actual effect."

Katz indicated that patients at Dana Farber do not directly pay for the alternative therapies the new program offers, but admits that the practitioners are being paid for their services. How this eventually affects the overall Dana Farber patient billing procedures has not been disclosed to this reporter.

Barry Beyerstein, Ph.D., is concerned about using such unproven therapies. He says, "At least ten kinds of errors and biases can convince intelligent, honest people that cures have been achieved when indeed they have not!" In the September/October 1997 Skeptical Inquirer, Beyerstein, a psychologist at the Brain Behavior Laboratory at Simon Fraser University in British Columbia, Canada, noted that many complementary medicines stay around so long that they wind up forcing respect from hospitals and many doctors, usually due to all the so-called "satisfied testimonials" people offer to their worth.

"Essentially, they [the patients] are saying, 'I tried it and I got better, so it must be effective.' But even when symptoms do improve following a treatment, this, by itself, cannot prove that the therapy was responsible."

Among Beyerstein's "ten errors and biases" are: 1) the disease may have run its natural course; 2) Many diseases are cyclical: "That is, some diseases like arthritis and multiple sclerosis have their ups and downs"; 3) Spontaneous remissions: "Even with cancers that are nearly always fatal, tumors occasional disappear without further treatments"; 4) Symptomatic relief versus cure; and 5) the placebo effect.

"Through a combination of suggestion, belief, expectancy, cognitive reinterpretation, and the diversion of attention, patients given biologically useless treatments can often experience some measurable relief," said Beyerstein.

One kind of relief for patients with pain, for instance, can come from the placebo's effect to trick the brain into releasing endorphins-a natural morphine-like drug-into the body. Most skeptics do not wish to discredit the placebo effect for palliative reasons; one day science, they feel, might be able to "bottle the effect" and help patients use their brain's natural healing abilities to aid toward curing many diseases. However, they feel that for now, many of the nonorthodox therapies need to be tested via repeated "blinded" clinical trials. "Only if the improvements observed in the active treatment group exceed those in the control and placebo groups by a statistically significant amount can any therapy claim legitimacy," adds Beyerstein.

Perhaps the key to a harmonious coexistence of conventional and alternative medicines is a kind of divorce. Scientists, who are more qualified than any New Age practitioners or lay person to determine the value of unproven treatments, need to conduct research that will once and for all divorce the sensational claims of these treatments from any actual therapeutic qualities they might have. Then they have to be taken, one by one, into the laboratory. One thing is certain, however-alternative medicines can no longer be ignored.

References

• American Association of Nurse Anesthetists: http://www.aana.com.
• American Cancer Society: http://www.cancer.org.
• Barrett, Stephen, M.D. Personal interview, April 2000. Quackwatch at http://www.quackwatch.com.
• Bergner, Paul: Personal interview, April 2000. MedHerb: http://www.medherb.com.
• Beyerstein, Barry, Ph.D. Quotes from Skeptical Inquirer: http://www.csicop.org/si.
• Cassileth, Barrie, Ph.D. Quotes taken from 2000 Annual Conference of Science Writers hosted by the American Cancer Society in Tampa, Florida, March 2000.
• Dillard, James, M.D. Personal interview, May 2000.
• Jarvis, William, M.D. Personal interview, May 2000.
• Journal of American College of Nutrition: http://www.am-coll-nutr.org.
• Katz, Nathaniel, M.D. Personal interview, May 2000.
• Miller, Denis, M.D. Quotes taken from 2000 Annual Conference of Science Writers hosted by the American Cancer Society, in Tampa, Florida
• NCCAM (NIH): http://nccam.nih.gov.
• Norred, Carol, C.R.N.A. Personal interview, April 2000.
• Pearson & Shaw (Durk Pearson & Sandy Shaw): Personal interviews, May 2000. Life Services, Inc. at http://www.lifeservices.com.
• Rebelo, Helda, P.A.C. Personal interview, April 2000.
• Renner, John, M.D. Personal interview, April 2000. NCRHI at http://www.ncahf.org.
• Sampson, Wallace, M.D. Personal interview, May 2000.
• The Scientist: http://www.the-scientist.library.upenn.edu.
• The Scientific Journal of Alternative Medicine: http://www.hcrc.org/sram/.
• Zazha, Janet. Personal interview, April 2000. l

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