Battling Quackery

T H R O U G H O U T T H E 20th century American academic medicine has resisted the concept that supplementation with micronutrients might have health benefits. This resistance is evident in several ways: (1) by the uncritical acceptance of news of toxicity, such as the belief that vitamin C supplements cause kidney stones; (2) by the angry, scornful tone used in discussions of micronutrient supplementation in the leading textbooks of medicine; and (3) by ignoring evidence for possible efficacy of a micronutrient supplement, such as the use of vitamin E for intermittent claudication. Part of the resistance stems from the fact that the potential benefits of micronutrients were advanced by outsiders, who took their message directly to the public, and part from the fact that the concept of a deficiency disease did not fit in well with prevailing biomedical paradigms, particularly the germ theory. Similar factors might be expected to color the response of academic medicine to any alternative treatment. In The Crime of Galileo, historian Giorgio de Santillana presents a revisionist view of the great scientist’s struggle with the Catholic church. According to de Santillana, Galileo’s crime was not his propounding a heliocentric universe; it was that he wrote in Italian; he communicated his revolutionary ideas about astronomy directly to the public. Previous scientists wrote in Latin, limiting their audience to other scholars. Within this small community, controversial ideas could be entertained. Copernicus’ proposal of a heliocentric universe 70 years before Galileo’s treatises had elicited no attempts at suppression by the church. The 17th-century church represented the intellectual establishment, and Galileo’s persecutors included some of the finest minds of his time. Galileo was punished not for writing heresy, not for threatening paradigms, but for bypassing the intellectual establishment and taking his exciting ideas directly to the people. The establishment, threatened not so much by his ideas as by his methods, did what it could to destroy his credibility. In addition, Galileo did not respect professional boundaries. He was a mathematician, and yet his writings dealt with phenomena considered within the purview of philosophers, a profession of considerably higher status than mathematics. Thus, he was considered a usurper as well as a popularizer. In what follows we argue that the reaction of academic medicine to the concept of micronutrient supplementation can best be understood in light of the foregoing description of Galileo. Our thesis is that throughout much of the 20th century, American academic medicine was resistant to the concept that micronutrient supplementation might prove beneficial, and that the cause of this resistance was similar to that which faced Galileo. This resistance is evident in several ways: (1) by uncritical acceptance of bad news about micronutrient supplements; reports of toxic effects were rarely questioned and widely quoted; (2) by the scornful, dismissive tone of the discussions about micronutrient supplementation in textbooks of medicine, a tone avoided in most medical controversies; and (3) by the skeptical reaction greeting any claim of efficacy of a micronutrient, relative to other therapies; indeed, most claims were simply ignored. Note that in each of the areas mentioned above we examine the reaction to micronutrients relative to other therapies. It is not proof of bias to be concerned about toxicity or to be skeptical of claims of efficacy. Bias occurs when concern and skepticism are applied selectively. Also note that we are not proposing to prove that any particular micronutrient supplement is indeed efficacious. Some readers of earlier drafts of this article have concluded that we are apologists for megavitamins. We are not. Rather, the vitamin controversy is one of a series of examples we have used to discuss the forces that influence medical practice other than those stemming directly from scientific discovery. Herein we rely on the multiple editions of 2 major American medical textbooks: A Textbook of Medicine and Principles of Internal Medicine. Each has been published in 12 different editions between 1950 and 1992. They can be presumed to represent established opinions and can be used to sample how medical opinion changes over time. From the Center on Aging, The University of Texas Medical Branch, Galveston. COMMENTARY