Testimony
Before
the Committee on Government Reform
United
States House of Representatives
Comprehensive
Medical Care for Bioterrorism Exposure - - Are We Making
Evidenced Based Decisions?
Statement
of
Stephen
E. Straus, M.D.
Director,
National Center for Complimentary and Alternative Medicine,
National Institutes of Health,
HHS
For
Release on Delivery
Expected
at 1:00 pm
on
Wednesday, November 14, 2001
Mr. Chairman
and Members of the Committee:
As we sit here,
our fellow Americans are confronted by the fearsome prospect
of exposure to lethal biological weapons. In response,
there is great interest in exploring every potential means
of preventing or mitigating the health effects of such
exposures to themselves and their loved ones. You invited
my colleagues and me to comment on the potential value
and wisdom of some of these approaches.
As a physician
who for the past 25 years has specialized in the care
of patients with severe and life-threatening infections,
and as a public health official, I fully support the current
CDC recommendations for managing potential exposure to
and infection by anthrax. Moreover, I am impressed by
the efforts already mounted at the Federal, State, and
local levels in response to the intentional and malicious
dissemination of anthrax spores. The success of current
efforts to locate and disinfect contaminated sites and
dispense effective antibiotics to those exposed is evidenced
by the small numbers of infected persons and the even
smaller numbers of serious illnesses or death that have
resulted from such exposures. This has afforded us all
some measure of comfort. To a great extent, we are able,
as the President has urged, to pursue our normal activities.
In addition
to the already proven means of detecting anthrax spores
and preventing or treating exposures to them and other
potential pathogens, there is the very real promise that
research will reveal additional and even more effective
strategies. Those efforts being mounted through the formidable
scientific infrastructure of the National Institute of
Allergy and Infectious Diseases will be summarized here
today by my colleague Dr. Carole Heilman.
The specific
question you asked me to address today, Mr. Chairman,
in my capacity as Director of the National Center for
Complementary and Alternative Medicine (NCCAM) is whether
there are additional health tools and practices that could
effectively serve as alternatives or as complements to
the ones already implemented or forecast here by Dr. Heilman
to prevent or treat diseases from biological weapons.
In response to this, let me say first, that as public
servants it would be unworthy and unwise of us to do anything
but place our fullest confidence in those well-considered
resources that our public health authorities have already
summoned to meet the current national and personal threats.
Yet, we know
that no measures, except for some vaccines, including
the proven ones already being used, can totally prevent
infection by virulent biological agents once they are
deployed, and no words of comfort or medications are in
themselves sufficient to fully allay the concerns that
we may fall prey to such weapons. Understandably, people
are seeking additional measures to safeguard their health
and that of their loved ones. The issue is not whether
there is justification for continuing concern, but whether
the measures that some are promoting do anything more
than prey upon people's fears and distract them from taking
more prudent steps to protect themselves.
Some of the
approaches now being considered by our frightened countryman
are ones that were largely displaced by the emergence
of scientific medicine. Before the articulation of the
germ theory of disease in the late 19th century
and the subsequent development of vaccines and antibiotics,
people sought protection from epidemic diseases through
a variety of spiritual exercises and by ingesting natural
products. It was believed that specific rituals and selected
herbal extracts and tonics would, in current parlance,
eliminate the offending pathogens or boost one's resistance
to them. In fact, a characteristic shared by many of the
traditional healing systems of indigenous peoples, such
as Ayurvedic medicine, various forms of oriental medicine,
and the more recently developed systems like Naturopathy,
is an emphasis on maximizing the body's inherent capacity
to heal itself.
While augmenting
one's natural healing powers may prove beneficial for
some illnesses, and is a focus of much work funded by
NCCAM, there is no scientific basis to believe that this
approach would be of much value in the context of virulent
diseases incited by biological weapons. From the perspective
of contemporary immunology, diseases like anthrax, smallpox,
and tularemia exceed one's innate immunity to control
them, and progress too rapidly for specific and protective
antibody and lymphocyte responses to evolve. Simply stated,
they can kill us before we can arm ourselves fully to
defend against them.
As the eminent
microbiologist Hans Zinnser concluded some 65 years ago
in his acclaimed book entitled "Of Rats, Lice and History"
the course of human history has been indelibly marked
and shaped by plagues. Measles, yellow fever, cholera,
bubonic plague, smallpox, typhus, syphilis and tuberculosis,
and HIV in the current era, have exterminated native peoples
and forced wholesale migrations of populations. Had the
traditional healing rituals and natural products available
to pre-20th Century man been truly effective,
our history would have been rather different. Through
the availability of cleaner water, uncontaminated foodstuffs,
and vaccines and antibiotics, human lifespan has increased
by a greater proportion in the past century than through
all recorded history up to that time.
Despite these
impressive public health achievements, people still turn
today to natural products hoping them to help mitigate
infections. Among the most popular of these products for
the American consumer is Echinacea, a widespread herbal
medicine. Small studies suggest that it might lessen the
severity of colds and the flu. Therefore, we in NCCAM
are funding substantive and rigorous studies to determine
whether the preliminary observations about Echinacea hold
up. Nonetheless, even if Echinacea proves to mitigate
simple viral respiratory infections that almost always
resolve on their own, it would be a far stretch to believe
that it could prevent or ameliorate highly virulent and
disseminated bacterial or viral diseases with high mortality
rates. We must discourage any assumption that products
like Echinacea may serve in lieu of proven drugs like
ciprofloxacin or doxycycline for people exposed to anthrax
bacilli.
It may not
even be prudent to combine such natural products with
antibiotics because of the possibility that they would
interfere with the proper metabolism and action of the
drugs. An instructive example in this regard is the effect
of the herb St. Johns wort on the metabolism of indinavir,
a drug that has helped extend the lives of countless patients
with HIV/AIDS. St. Johns wort accelerates removal of indinavir
from the body, leaving drug levels that no longer are
adequate to block the replication of the HIV virus.
Traditional
healers of several Asian countries prescribed specific
rituals, exercises, diets and herbal remedies for the
treatment of virulent infections. Yet, there is no evidence
that these were of any value. In Korea, for example, the
primary approach to contagious diseases like typhoid and
malaria involved spiritual exorcisms. Smallpox was especially
feared and the deity Sonnim had to be assuaged if one
hoped to resolve the disease. In India, relief required
homage to the smallpox goddess Sitala.
Apparently,
some ancient preventative strategies were more effective.
From the time of the great Moslem physician Avicenna of
the 10th Century, Persians exposed their children
to cows infected with cowpox to protect them from smallpox.
Variolation with dried smallpox scabs was practiced in
China and Korea centuries before Jenner proved the effectiveness
and greater safety of classical vaccination. Since Jenner's
time, immunity to infectious agents has been induced by
administering small amounts of avirulent microbial components.
This is the well-proven basis for routine immunizations,
as for measles or polio, and which permitted the global
eradication of natural smallpox in the 1970s.
The prophylactic
benefits of exceedingly dilute substances are more in
doubt than those of conventional vaccines. Starting with
the use of ultra-high dilutions of belladonna to prevent
scarlet fever in the late 18th Century , there
have been numerous claims that homeopathic medicine can
prevent or treat infectious diseases. The premise of homeopathy
is that 'like cures like', meaning that administration
of infinitesimal quantities of a substance that in higher
concentrations provokes specific symptoms, will eliminate
those symptoms. Dilutions beyond those likely to leave
even a single molecule of the original offending substance
is often required to formulate a homeopathic treatment.
In the 19th century, practitioners of homeopathic
medicine proposed that miniscule concentrations of killed
anthrax or smallpox microbes could confer immunity to
these infections. Although there have been studies of
homeopathy's potential against infections, most prominently
for veterinary diseases, as concluded even by experts
in homeopathy in yesterday's Washington Post,
the overall evidence of efficacy is lacking.
I mention the
homeopathic approach here because products claiming activity
against anthrax and smallpox are now experiencing a renaissance
in the marketplace. Even though there is some doubt that
these products could be effective, we cannot prove the
claims to be entirely specious. It would be unethical
and dangerous to withhold proven drugs and vaccines in
order to see whether the homeopathic remedies protect
people who become exposed. Exploration of such approaches
should first involve careful studies in animals using
contemporary methodologies to discern whether they hold
any promise against diseases associated with biological
weapons. In the interim, however, lacking any competent
evidence that they work, the claims about these products
are dangerous both to the individual who uses them and
to the population in general who might become infected
if some refuse standard treatments.
Another example
of products being marketed by internet vendors to a frightened
populace involves colloidal silver. Silver, like many
substances, does possess antibacterial properties in
vitro, rendering it a topical disinfectant. Its systemic
use in humans, though, is limited by its toxicity. Even
more serious illnesses and death were associated with
exposure to heavy metals such as arsenic that was long
included in popular remedies.
In conclusion,
Mr. Chairman, we in NCCAM commit ourselves to apply exacting
research methods to expand the repertoire of healthcare
tools for countless medical conditions. We enjoy the generous
support of the American people and appreciate the partnerships
we have established with the other NIH institutes and
centers and research agencies in this undertaking. In
the instance of bioterrorism, however, the best approach
is to manifest, as I do, an unwavering trust in the currently
approved drugs and vaccines, and to not dissipate our
energies or to distract the public by pursuing unproven
remedies. The stakes are simply too high at this time
to do otherwise.
I would be
happy to take any questions you might have with regard
to NCCAM and complementary and alternative responses to
bioterrorism.
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Last revised: November 14, 2001