7 January 1999
3,500 words

Liebert's alternative medicine journals
targeted doctors, aspire to science,
need business writers, RNs and editors.

Medical establishment demands controlled trials

NEW YORK--In the crowded field of alternative medicine, Mary Ann Liebert's formula was: get there first with a good scientific publication that is clinically relevant.

As a medium-sized medical publisher, Mary Ann Liebert Inc. has to keep ahead of the trends, as they did with genetic engineering and AIDS, said Vicki Cohn, Senior Vice President and Editor-in-Chief of the Larchmont, NY publisher.

In alternative medicine, they had to give their readers information they can't get anywhere else, and "can't live without," said Cohn. So they must come up with content that isn't in the New York Times, the Journal of the American Medical Association (JAMA), Prevention, or the throwaways handed out in health food stores.

Cohn spoke at a meeting of the Editorial Freelancers Association on 10 December 1998.

(The Center for Medical Consumers, 237 Thompson St., New York, carries Alternative & Complementary Therapies in its library, along with Alternative Therapies in Health and Medicine, Integrative Medicine, HerbalGram, and Yoga Journal. For a list of 22 recommended alternative medicine publications and 11 national organizations, see the appendix to "The Complete Idiot's Guide to Alternative Medicine," by EFA co-exec Sheila Buff and Alan Pressman, DC, PhD, CCN. For a list of 160 publications--less than half in English--see Publist , and browse by subject for Medical, then Alternative Medicine.)

For a feature on an alternative treatment, Cohn and her editors expect a comprehensive story, which can be a lot of work for $500-800. But it can be done profitably, some freelancers said, especially if you're already familiar with the field. She's particularly looking for business writers, and registered nurses to write a column called Rx:RN, which covers holistic medicine from an RN point of view.

The alternative medicine books are certainly the most controversial of Mary Ann Liebert's 62 journals, predominantly in academic biomedicine, law, and science. "I look for editors as well as I look for writers," said Cohn. Mary Ann Liebert, Inc., is a big operation, with related operations like trade shows. Opportunities regularly open up. "We're always starting something new," said Cohn. She invited people to call her (after Christmas) and to send resumes (2 Madison Ave., Larchmont, NY 10538, (914) 834-3100, (914) 834-3771 (fax). She is likely to need people with special expertise and "I always keep a file."

"The editor has to be on top of the field, absolutely has to have a sixth sense," said Cohn. You can have good information but "nobody is going to read it" unless the editor can give it a snappy head and put it into a shape that makes it easy to read.

The controversy is shifting ground. Some proponents are MDs with academic appointments in major academic centers. Major medical journals are publishing peer-reviewed articles evaluating alternative treatments. The medical profession is willing to accept alternative practitioners if they will accept randomized controlled trials as the standard of evidence. The big legal and political battle will be over the same issue in the regulatory jurisdiction--whether alternative practitioners should be allowed to advertise claims that aren't supported by randomized controlled trials. Some alternative medicine practitioners accept the standard of randomized controlled trials. Some don't.

Peer-reviewed alternative health

Liebert's niche was peer-reviewed scientific journals and their spinoffs, explained Cohn. 5 years ago, physicians started to get interested in alternative medicine, some because they suspected it might be useful, and others because their patients were using it. Doctors were afraid that if they didn't have the answers about alternative medicine that their patients wanted, their patients would go elsewhere. As Cohn attended medical conferences, some physicians said that they were using alternative treatments themselves; others said, "I think it's garbage, but my patients want to know."

The company's founder, Mary Ann Liebert, felt that there was no authoritative, scientific, peer-reviewed journal in the field that was credible. In 1993, she founded the quarterly Journal of Alternative and Complementary Medicine, with an editorial board of mostly but not exclusively MDs and PhDs such as Fredi Kronenberg (Columbia University) and Andrew Weil. "The mission of this journal is to look at the field and tell people what the science is," said Liebert.

It turned out to be more theoretical and academic than they anticipated, so in 1995, Liebert started a practice-oriented spinoff, the bimonthly Alternative & Complementary Therapies, edited by Anne Coulter, PhD. In 1996 she started Natural Pharmacy, edited by Frances Goulart, a controlled-circulation tabloid aimed at pharmacists. Women's Health Alternative Medicine Report is a new monthly newsletter.

Freelancers write for the spinoffs

The markets for freelance writers are Alternative & Complementary Therapies (known as "the green journal") and Natural Pharmacy. "We thought the green journal would be largely for physicians," said Cohn. But physicians remain largely resistant to alternative medicine, so they are not as large a reader base as they anticipated. "The strongest audience is alternative practitioners, including holistic physicians and nurses, acupuncturists, massage therapists, and traditional healers." It is not a consumer magazine.

Writers also have to distinguish themselves in a field that is equally crowded with both solid information and freebees. They get articles in over the transom from practitioners, academics, product vendors and believers who are willing to write free. "We have a vision, and if we can't get what we want over the transom, we will assign a story to a writer," said Cohn. Their vision is a fairly comprehensive story of 2,000 words or more, plus sidebars, with about 10 interviews, literature and web citations, patient support groups, photos, and lists of do's and dont's, which would take about a week, for $500-800. "A lead article may pay more," she said. But not every article is so complicated and time-consuming. They also assign personality profiles and business stories.

Reishi mushroom

For example, an article in the August issue is on the reishi mushroom, which has been used since the 13th century in China and Japan as an aphrodisiac, tonic and anti-aging drug, and for rhinitis, ulcers, coronary heart disease and asthma. The story is 11 printed pages, with a review of the peer-reviewed western journals and Chinese traditional literature, animal studies, human studies, laboratory findings, and chemistry, in sleeping disorders, diabetes, cirrhosis and cancer. Sidebars give encyclopedic entries on reshi and its uses, suggested doses, toxicity, and precautions. It was written by Kenneth Jones, who is identified as president of Armana Research, Inc., Gibsons, British Columbia. The author, said Cohn, is "involved" with the mushrooms.

"A lot of people in the field are into product," said Cohn. "Although we sometimes use authors from industry, the articles have to be balanced and non-commercial."

Articles in Alternative & Complementary Therapies aren't peer-reviewed, but they are sent out for review by the editorial advisers. The field is so controversial, she said, that credibility is important. "You do the wrong thing, and it really gives you a black eye."

An 8-page article on the chemical detoxification procedure of William Rea, MD, quotes 2 of his critics (and then dismisses them).

Advertising requires an even more difficult balance between responsibility and open-mindedness. On the editorial side, "we don't pay attention to advertising," said Cohn. One advertiser was selling blue-green algae, for which there's "not too much evidence," she said, "but there's some." They wrote a story about it, which wasn't particularly enthusiastic, and the advertiser was unhappy.

Stephen Barrett, M.D., a retired psychiatrist in Allentown, PA, who runs an organization called Quackwatch, has reserved space for Mary Ann Liebert, Inc., on his web site Quackwatch under the listing of "Publishers That Promote Quackery," along with Rodale Press.

Savvy audience

Along with credibility and scientific accuracy, Cohen worries about the renewal card that the subscribers get every year. She has to give them a good reason to fill it out. "It has to provide something in every issue you can't live without," she said. The readers are very knowledgeable already, and it has to give them "a lot more than they know now."

This takes a writer with substantial skills. You must either know more than the readers know, "which is unlikely," said Cohn, "or you have to ask the right questions."

The key point, said Cohn, is "Know your audience. Know their level of knowledge, and give them what they don't know. You have to be ahead of the pack, and keep up with the science."

"When we hire a writer we want everything," said Cohn. "You have to know the audience. You have to know the terminology. You have to be able to make it an easy read. It has to be short. We want ancillary material that is easy to digest. We want the facts. We want an assessment. We want to know who the players are." You should interview both the allopathic doctors in the medical schools, and the alternative practitioners. You should know what's on Medline , and what's in the mainstream press. You should include any studies by the National Institutes of Health, and anything published in major medical journals.

We know all that

"I don't want generalities," said Cohn. "I don't want to know that I should use St. John's Wort for depression. I want to know how much."

(Not only do their readers know all about St. John's Wort, but they even know that it's going out of fashion. Natural Pharmacy's regular column, "The Checkout Counter," surveys pharmacists to find out "What's Hot" and "What's Not." St. John's Wort made the "What's Not" column, along with DHEA, and shark cartilage. What's Hot: Multivitamins, black cohosh, ginko bilboa, vitamin E, garlic, B complex, and omega-3 fatty acids.)

"There are so many publications out there," said Cohn. "We do not want to be publishing the same old stuff."

"I recognize writers do a better job on something they have a particular interest in or something they're already working on," said Cohn.

$27 billion industry

The business side of the $27 billion industry is also important to their readers. Some stories focus on business, and more general stories should include the business side. They have profiles of alternative medical centers, and centers at major academic centers. "People want to know how other people are practicing," said Cohn. She wants to know how the clinic came about, down to the financial details. "Who drove this? Who put up the money?" Readers want to know how to enhance their practice. They want to know how they will be affected by government regulation. "You must provide new information," she said. "You have to dig deep."

Natural Pharmacy is addressed to pharmacists. Pharmacists are "very conservative," said Cohn. Customers trust them, and ask their advice. "They will not sell you just anything," she said. "They prefer articles written by a PhD or MD or RPh, but will accept a journalist if the references are there." The pharmacist's natural competitor is the health food store, she said. The staff in health food stores are "really very knowledgeable." So the pharmacists must become equally or more knowledgeable about alternative products themselves. And Natural Pharmacy helps them with the business side, how to organize their shelves and so forth.

For Natural Pharmacy, "I look even more strongly than the green journal for people who are business writers," said Cohn.

The 2 publications have regular columns. Alternative & Complementary Therapies runs "Managed Care Update"; "Rx:RN," a nursing column; and "WebWatch," the computer column. Articles for the nursing column have been "hard to come by," said Cohn. "I would like to have articles from nurses."

Recent history

Cohn gave a quick history of the recent growth of the field. Terminology is tricky. JAMA uses the term "alternative," but some people don't like it, because it implies a dichotomy to "real" medicine, and they prefer "complementary." The newest buzz word is "integrative." "Traditional" is an ambiguous term that Cohn avoids, because it can apply to any tradition--western academic medicine or Tibetan. "Allopathic" refers to academic western medicine.

"I am a very allopathic type of person," said Cohn, who delegates the hands-on work to editors. "I am not an expert. I do not know the therapies. I am not for or against alternative medicine."

Taught in medical schools

"Physician interest is beginning to pick up," said Cohn. A lot of it is driven by medical schools. Major academic medical centers are opening alternative care centers--Stony Brook; Memorial Sloan-Kettering; Cedars Sinai in Los Angeles, the "hospital to the stars." They take an integrated approach, and are "almost always headed by a physician," she said. "The allopathic side runs things." (See "Courses involving complementary and alternative medicine at US medical schools," JAMA, Sep. 2, 1998;280:784-787)

"Alternative medicine has been dragged kicking and screaming" into the establishment, said Cohn. (Some people would say that establishment medicine has been dragged kicking and screaming to recognize alternative medicine.)

A lot of it is driven by financial incentives, said Cohn. Hospitals have to offer alternative medicine in order to bring in their patients.

A lot of it is driven by managed care. The managed care companies realize that it's a lot cheaper to pay a chiropractor than an orthopedist, said Cohn. "Herbs are cheaper than Cipro [ciprofloxacin]."

"Medical associations are trying to wrestle away the field of alternative medicine," said Cohn. "The alternative medicine community is going to be the losers. The people with the big centers are going to get the patients."

Now in major medical journals

The "pivotal point" in alternative (or whatever) medicine was an article by David M. Eisenberg, MD, Beth Israel Deaconess Medical Center, Boston, MA, in the 1993 issue of the New England Journal of Medicine ("Unconventional medicine in the United States. Prevalence, costs, and patterns of use," (N Engl J Med, Jan. 28, 1993;328(4):246-52)) That article "turned the medical world upside down," said Cohn. Eisenberg reported that one-third of Americans seek alternative medicine. There were some methodological problems--he classified Weight Watchers as alternative, for example--but the message that went out was, "there is money here, folks."

Before Eisenberg, alternative medicine was "almost underground," said Cohn. But the market grew, with "vitamins and herbs flying off the shelves." Homeopathy is "absolutely standard" in some places.

JAMA wars

The low point in recent times was an article in JAMA on therapeutic touch. JAMA "took enormous relish," said Cohn, publishing an article--on April Fools' Day--disparaging one form of alternative treatment, therapeutic touch (TT). A researcher, working with Barrett, wanted to test therapeutic touch, but was unable to get practitioners to cooperate, so she enlisted her 9-year-old daughter to perform a test as a "science fair" project. The practitioners were unable to detect the girl's "energy field," as their theory predicted, and the article concluded "that the claims of TT are groundless and that further professional use is unjustified." ("A Close Look at Therapeutic Touch," Linda Rosa, BSN, RN; Emily Rosa; Larry Sarner; Stephen Barrett, MD (JAMA Apr. 1, 1998;279:1005-1010))

But half a year later, JAMA devoted a special issue to alternative medicine (Nov. 11, 1998;280(18):1549-1640), including another article by Eisenberg. After reviewing the available randomized controlled trials, JAMA found that alternative treatments had mixed results, but some were supported by good evidence: (1) Moxibustion, a Chinese variant of acupuncture, reverses breech presentation in fetuses (2) Garcinia cambogia was ineffective for weight loss (3) Chinese herbal medicine improved 59% of patients with irritable bowel syndrome (4) Spinal manipulation was not helpful for tension headaches (5) Acupuncture was not helpful for HIV peripheral neuropathy (6) Yoga was effective for carpal tunnel syndrome. Furthermore, the American Medical Association's Archives journals, which cover the specialties, also devoted articles to reviews of controlled clinical trials of alternative treatments.

(The JAMA articles are available on the AMA's web site, as abstracts, often with accompanying press releases and sometimes in full text. They can be easily found by clicking on the AMA's search screen and entering "alternative medicine".)

Favorable book reviews

The NEJM has been "slower to recognize" alternative medicine, said Cohn. In its special issue (Sep. 17 1998;339(12):785-860), the NEJM printed an article, letters, book reviews and an editorial, which cite the (admittedly rare) case of a 9-year-old girl who died of treatable brain cancer after her parents treated her with shark cartilage instead, and several life-threatening episodes due to the use of alternative treatments.

(There have been a handful of deaths attributed to alternative drugs. That includes 8 deaths due to ephedrine (CDC MMWR Aug. 16, 1996 4(32)689-693) and 27 deaths due to tryptophan (JAMA, Oct. 3, 1990; 264(13)1698-1703).

Both the NEJM and JAMA favorably reviewed The Alternative Medicine Handbook, by Barrie R. Cassileth (Norton, $25), who insists that all therapies be validated by randomized controlled studies. Other well-reviewed books are Alternative Medicine: What Works, Adriane Fugh-Berman (Williams & Wilkins, $14.95) (a "medical journalist," noted the admiring reviewer with astonishment) and Alternative Medicine and Ethics, James M. Humber and Robert F. Almeder, eds. (Humana Press, $49.50).

National Institutes of Health

Another high point was the involvement of Sen. Tom Harkin (D-IA). Harkin claimed to have been cured of allergies by bee pollen he took at urging of Berkeley Bedell, former Iowa congressman and multimillionaire fishing tackle manufacturer. Harkin launched a crusade to create an Office of Alternative Medicine at the National Institutes of Health . The office was "not a favorite office in the NIH," which didn't take it seriously, said Cohn. "Some was foolish, some not."

The Office has been through several directors. In fact, they're advertising for a new director in Alternative & Complementary Therapies.

(Bedell told Science magazine that the NIH should identify therapists and "just simply find out whether what he claims is correct." Bedell brushed aside questions about details, saying "I'm not a scientist." But he insisted they could be done quickly and easily without fancy statistics or double-blinded controls. "The politics of alternative medicine; The head of NIH's Office of Alternative Medicine has quit, charging that a powerful senator and advocates of unconventional therapies are shaping the office's research agenda," Eliot Marshall, Science, Sep. 30, 1994; 265:2000-2002.)

On the regulatory side, the Federal Trade Commission has recently issued a "Dietary Supplements Advertising Guide for Industry" which would, in the FTC's view, require advertisers to provide scientific support for their claims, or, in the industry's view, restrict freedom of speech for advertisers.

Arnold S. Relman, editor emeritus of the NEJM, recently raised the standard complaints, in a review of Weyl's books. See . "A Trip to Stonesville: Andrew Weil, the boom in alternative medicine, and the retreat from science," The New Republic, December 14, 1998. "If intuition rules," wrote Relman, "how would we find the truth when one person's intuition conflicts with another?" Relman accused Weil of "casual dismissal of common sense and medical fact," including Weil's claim that allopathic physicians "have no effective drug for high blood pressure" and that patients can lower their blood pressure by "feedback control." Weil responded in "Ask Dr. Weil", Dec. 7, 1998.

The issue: Randomized trials

The editors of the 2 major medical journals, the NEJM and JAMA, are offering alternative therapies full acceptance on one condition: that they in turn accept randomized controlled trials. Some writers have argued that doctors should accommodate the unscientific preferences of their patients out of respect for patient autonomy, out of tolerance for alternative ideas and cultures, or out of pragmatism; but after much debate the editors rejected that position--one writer compared it to accepting female circumcision.

In "Alternative Medicine Meets Science," an editorial conclusion to the Nov. 11 1998 special issue, JAMA editors Phil B. Fontanarosa and George D. Lundberg wrote:

We encourage high-quality, rigorous research on alternative medicine and invite authors to submit their best papers for our objective evaluation and consideration for publication.

However, until solid evidence is available that demonstrates the safety, efficacy, and effectiveness of specific alternative medicine interventions, uncritical acceptance of untested and unproven alternative medicine therapies must stop. Alternative therapies that have been shown to be of no benefit (aside from possible placebo effect) or that cause harm should be abandoned immediately. Physicians, insurance plans, medical centers and hospitals, managed care organizations, and government policymakers should base decisions regarding incorporation of and payment for alternative medicine therapies on evidence-based research and objective cost-effectiveness analyses... rather than on consumer interest, market demand or competition, well-publicized anecdotal reports, or political pressures from well-organized and influential interest groups."

--Norman Bauman