Smokey the Bear Medicine and Prevention

When I was an intern, we used to joke that we were practicing “Smokey the Bear” medicine: stamping out forest fires. Patients would wait until a spark of disease had developed into a dangerous flame, and then they’d expect us to deal with it. We were mostly doing disaster control, and we wished we could intervene sooner.

Our tongue-in-cheek analogy wasn’t really fair to Smokey. The idea of stamping out forest fires suggests treading on a flame, but Smokey was all about preventing the spark in the first place by being careful with matches and making sure campfires were extinguished. In medicine as in firefighting, everyone knows the best treatment is prevention.

Advocates of alternative medicine love to criticize mainstream doctors, as if finding flaws in reality-based medicine would somehow prove that the imaginings of fantasy-based medicine were true. It doesn’t work that way. Airplanes crash sometimes, but that doesn’t prove flying carpets will stay airborne.

The idiotic accusation that annoys me the most is “Doctors don’t do prevention.” Don’t they realize doctors invented prevention? Examples flood to mind. Doctors were responsible for all our vaccines; for eliminating smallpox from the face of the Earth; for quarantine measures; for inventing surgical gloves and sterile procedures; for prophylactic antibiotics; for contact tracing in infectious disease; for sanitary sewer systems and safe public water supplies; for water fluoridation; for screening tests; for well baby visits, prenatal exams, and annual physicals; for lowering high blood pressure before it can cause a stroke; for the guidelines of the U.S. Preventive Services Task Force (USPSTF); for tobacco legislation; for putting iodine in salt to prevent goiter; for adding folate to foods to prevent spina bifida… the list goes on. The American College of Preventive Medicine points out that “Preventive Medicine is practiced by all physicians to keep their patients healthy. It is also a unique medical specialty recognized by the American Board of Medical Specialties (ABMS).”

Do alternative medicine practitioners do prevention? They like to boast that they do. Chiropractors claim to prevent disease by keeping the spine in proper alignment. A chiropractor once told me he had never been vaccinated, but he was supremely confident that he could pass unscathed through a raging epidemic, that it would be impossible for him to get sick, because his spine was straight. He informed me that germs don’t cause disease; because if they did, we’d all be dead. Curiously his concept of prevention didn’t include weight control; he was morbidly obese. In an on-line forum, chiropractors had a long debate. Some of them thought that if you could really keep your spine in perfect alignment, you would never die. Others weren’t so sure. I’m pretty sure that isn’t true. I even remember a study showing that chiropractors died younger than MDs.

Acupuncturists claim to keep the body healthy by somehow improving the flow of imaginary qi in imaginary channels called meridians by sticking needles in them at imaginary acupoints. I don’t know of any evidence that patients of acupuncturists live longer than patients of MDs. Even the Chinese realize that traditional Chinese medicine (TCM) is inferior; they choose Western medicine whenever they can get it.

Andrew Lockie’s Family Guide to Homeopathy[1] tells us,

“At the deepest level, homeopathy is preventive in intent. Homeopathic remedies do not wade in and “zap” offending organisms, leaving the immune system less able to cope than before. Quite the opposite. They nudge the immune system – not only the white cell populations of the body but also the mental and emotional states which keep those populations healthy – into greater responsiveness and readiness so that disease is kept away or prevented from recurring. In fact, homeopaths are trained to look for diseases before they happen.”

Yes, homeopaths promise to prevent disease by diluting a substance until nothing is left but water, dripping the water onto a sugar pill, letting it evaporate, and giving you the pills. (Not too many, because they’re really strong!) Homeopaths have never demonstrated that they can effectively prevent anything (except perhaps critical thinking in their followers).

Naturopaths favor “prevention before cure.” (Don’t we all?) They offer education about healthy living, diet, and “natural” nontoxic approaches. They claim to have “evidence”[2] that naturopathy offers better prevention. When naturopathic care was added to conventional care, postal workers had an improved overall cardiovascular risk score. But most of the factors they measured, like weight, weren’t significantly improved. They didn’t measure any impact on meaningful clinical outcomes like heart attacks. They weren’t really evaluating naturopathy, they were evaluating the effect of a caring person spending a lot of extra time with patients (seven additional visits) and giving them personal attention, extensive health promotion counseling, and detailed dietary advice. That study is typical of the “pragmatic studies” favored by alternative medicine. Pragmatic studies were meant to compare the real-world effectiveness of two treatments already known to work. They don’t control for the many nonspecific factors in the provider/patient therapeutic interaction; they can’t establish whether a treatment is more than a placebo; they measure appearances, not real efficacy.

The reality is very different from the claims. The evidence indicates that alternative providers are worse at prevention than mainstream doctors. Studies have shown that the patients of naturopaths and other alternative providers are less likely to get vaccines and other preventive services recommended by the USPSTF.

One of the common myths in alternative medicine is that if you just lived right and ate the right foods, you would never get sick. That’s a comforting belief, but it’s a false comfort. We don’t have that much control over our destiny, although there is a lot we can do to improve our chances.

We have pretty good statistics for cancer.[3] A 2010 survey in the UK estimated that these 14 lifestyle and environmental risk factors were responsible for 42% of cancers: tobacco (19%); alcohol (4%); four elements of diet: red and processed meat (3%), too little fruits and vegetables (5%), too little fiber (2%), and too much salt (less than 1%); overweight (5%); lack of physical exercise (1%); occupational exposures like asbestos (4%); infections (3%); radiation (3% from sunlight and sun beds); ionizing radiation from natural and manmade sources (2%); use of hormone replacement therapy (1%); and not breast feeding or breast feeding less than 6 months(2%). Note: the numbers appear to add up to more than 42%, but they were rounded and are different for men and women.

So there are a lot of things we can do to prevent cancer. We can avoid tobacco, control our weight, eat more fruits and vegetables and fiber, eat less processed and red meat and salt, drink less alcohol, use sunscreen, be active, avoid occupational risks like asbestos, minimize certain infections like HPV (there’s a vaccine for that), minimize radiation such as unnecessary x-rays, breastfeed if possible, and minimize hormone replacement therapy after menopause.

But those lifestyle changes can only reduce our risk of some cancers. We have no hope of preventing all cancers, especially those that are caused by heredity (like familial breast cancers) and by chance mutations in DNA. A good percentage of cancers can be ascribed simply to bad luck.[4]

A lot of those same risk factors contribute to cardiovascular disease, along with high blood pressure, high cholesterol, and diabetes, all of which are controllable with medications. The CDC estimated[5] that 1/3 of deaths from heart disease are preventable: 200,000 out of a total of 600,000 yearly deaths. So the other 2/3 can be chalked up to bad genes or bad luck.

Cardiovascular diseases and cancer are the leading causes of death followed by chronic lung disease and diabetes. Influenza and pneumonia are 5th; get that flu shot! The 6th, Alzheimer’s, is not preventable. Motor vehicle accidents are 7th.

Smoking is by far the leading preventable cause of death, causing heart attacks, numerous kinds of cancers, and a long list of other health problems from miscarriage to macular degeneration. Smoking harms nearly every organ in the body and second-hand smoke puts 7500 to 15,000 young children in the hospital every year with respiratory problems. Clearly, smoking cessation should be the most important part of any preventive medicine effort. We have several effective behavioral and drug treatments to help patients stop smoking. Are alternative providers any more successful than mainstream medical providers? I don’t know of any studies, but naturopathic smoking cessation programs commonly include useless things like homeopathic remedies, acupuncture, “detoxification,” and untested natural diet supplements.

Doctors are not as successful at prevention as they would like to be. Patients reject preventive advice because of misinformation (vaccines cause autism!) or ideology (shots aren’t natural; they will contaminate my pristine body!).  And it’s notoriously hard to get people to stop smoking or drinking until they are good and ready. Doctors do try. At every appointment I am asked if I smoke or drink. Doctors get tired of asking and patients get tired of being nagged at, so it would be easy to understand if some doctors get discouraged and give up.

Science-based medicine has accomplished great feats of prevention (including preventing anyone from ever getting smallpox again) and has improved our health in untold ways. What has alternative medicine accomplished? How dare they say we “don’t do prevention”!  They pride themselves on their imagined expertise at prevention, but they are only fooling themselves.

In one sense that they didn’t intend, the critics of medicine are right. We can lead a horse to water, but we can’t make him drink. Doctors don’t do prevention; patients do.

[1] http://www.britishhomeopathic.org/bha-charity/how-we-can-help/conditions-a-z/the-preventive-role-of-homeopathy-and-the-treatment-of-headaches-and-migraine/

[2] http://www.ncbi.nlm.nih.gov/pubmed/23630244

[3] http://www.cancerresearchuk.org/cancer-info/cancerstats/causes/preventable/

[4] http://www.sciencebasedmedicine.org/is-cancer-due-mostly-to-bad-luck/

[5] http://www.cdc.gov/VitalSigns/HeartDisease-Stroke/

This article was originally published as a SkepDoc column in Skeptic magazine.

Dr. Hall is a contributing editor to both Skeptic magazine and the Skeptical Inquirer. She is a weekly contributor to the Science-Based Medicine Blog and is one of its editors. She has also contributed to Quackwatch and to a number of other respected journals and publications. She is the author of Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon and co-author of the textbook, Consumer Health: A Guide to Intelligent Decisions.