Can We Say “Cure”?

Abstract
Most of the commonly prescribed conventional drugs treat only symptoms, not the underlying causes of a patient’s disease. This logically leads to a perception that much of modern medicine is about management of chronic disease and prevention of more serious sequelae—not actual cures. However, most health care professionals are attracted to medicine with the mission of curing patients leading to the cognitive discord that eventually leads them to integrative/functional medicine. Though use of the term cure has been actively discouraged except in limited types of cases, perhaps true health care reform needs to reclaim this term and concept. 

In the late 1970s and early 1980s when I was creating Bastyr University, I engaged in many conversations and debates with MDs in academic, foundations, and policy positions. After trying to make the case for the important role of natural medicine in health care, I was many times admonished to not assert that we could cure patients.
I remember vividly an argument with a professor at the local medical school who asked me to define hypertension after relating to him several successful patient outcomes. I then spent probably too long giving him a scientific overview of cardiac output, arterial elasticity, kidney function, etc. He looked at me and stated, “Oh, I thought you were misusing the term as a description for patients under a lot of stress.” Sure brought home how much work was needed to change conventional medicine’s perspectives of “alternative medicine.”
Nonetheless, after being told yet again to stop saying we were curing patients, I realized there was some truth to their advice. As I was working hard to establish a scientific foundation for naturopathic medicine, I could see the validity of their perspective—lack of double-blind, placebo-controlled studies of naturopathic concepts and interventions necessary to prove cure. Although I and my colleagues appeared to be having a lot of clinical success with our patients, realistically this was all anecdotal until objectively researched and validated (or invalidated). So I stopped using the term cure. But then in the early 1980s, Michael Murray, ND, and I began the arduous process of deeply digging through the peer-reviewed medical research to write The Textbook of Natural Medicine (TBNM). (I say arduous because when we started, the only way to find and access articles was through old-fashioned, thick, paper index volumes and searching isles and isles of journal racks—desperately hoping the article you wanted was not out for binding.) We were very pleasantly surprised to find a huge body of work documenting the efficacy of natural medicines in a wide variety of diseases (the fourth edition of the TBNM has more than 10 000 citations). Although the research was not yet to the state of directly validating naturopathic philosophy and practices, we found many supportive studies. The strongest were those showing that many diseases are due to a deficiency of specific nutrients, whereas other studies showed that supplementation resulted in apparent total reversal of the disease. I started thinking that maybe we could now start asserting cure was possible.
Then in the late 1980s, I was invited by the National Institutes of Health to debate the recently retired dean of a conventional medical school. He was quite aggressive and asserted that, except for some acute illness such as antibiotics for infections and insulin for type 1 diabetics, cure was not possible. All doctors could do was alleviate symptoms and try to prevent more serious sequelae. I must admit to being quite surprised by his pessimistic stance and even more surprised when I looked around the room and saw a lot of nodding heads. Happily, although we disagreed on almost everything, the debate was amicable and we each made a number of important points. On the flight home cross-country, I continued to think about our conversation. I was stuck on wondering why a well-respected medical leader would take such a strong anticure position that I thought would be quite discouraging to most anyone who entered medicine wanting to help people.
Then I happened to see a list of the top 10 most commonly prescribed drugs of the time. According to my understanding of cure (discussed later), 9 of the drugs only relieved symptoms while allowing the underlying disease to progress. I finally started to understand the problem—the interventions actually being used for the vast majority of patients were indeed only palliative. This also made much clearer the centuries-old philosophical conflict between “unconventional” medicine (by its various names) and conventional medicine.

How Do We Differentiate Between Symptom Palliation and Disease Cure?
I believe this is a foundational issue that must be fully addressed if the health care crisis is ever going to be cured. Anything else, such as the Affordable Care Act, is simply addressing symptoms rather than the underlying true causes. In Table 1, I list criteria that I suggest to students on how to evaluate the care they provide a patient to help determine whether their treatment is actually addressing the cause(s) or only transiently controlling symptoms—no matter how “natural” the intervention.

Table 1. Criteria for Determining Whether a Therapy Is Curative

1. Is the patient cured if all that is accomplished is that their symptoms are alleviated?
2. Is the intervention causing any adverse effects?
3. Do the symptoms recur when the intervention is stopped?
4. Does the patient report their general health as improving or getting worse over the course of care?

Criterion 1
Sometimes the symptoms are indeed the full manifestation of the disease. For example, unless only an analgesic is used, a child with an acute ear infection is cured in proportion to the degree to which symptoms are cleared and the physical signs normalize. However, if the child is having recurring ear infections, the intervention is clearly not curative. In contrast, providing a patient suffering depression an antidepressant is rarely curative. Depression is not caused by a lack of Prozac. Nor is it caused by a lack of St John’s Wort. The patient could be depressed due to deficiency of vitamin D (very common cause), a toxin such as mercury leaking from a “silver” filling (which is typically 55% neurotoxic mercury), or by their life choices not working for them and they need to make changes in their life. The problem with only treating the symptoms is that the underlying problem continues unabated and is very likely causing many more problems than only the symptoms. For example, being low in vitamin D increases all-cause mortality, cancer, osteoporosis, allergies, etc. Having a mouth full of mercury increases the rate of dementia, fatigue, etc.
Patient Example. An otherwise apparently healthy 35-year-old man came to see me acutely ill with high fever, cough, and rust-colored sputum. Physical examination, complete blood count, and Gram stain of his sputum made the diagnosis of bacterial pneumonia easy. Appropriate antibiotics resulted in complete resolution within a few days. As this was a regular patient whom I saw periodically and did not have recurrent infections, immune dysfunction was not a problem and intervention was clearly a cure.

Criterion 2
Adverse drug reactions and other side effects are a huge problem. Although not as common with “natural” drugs, this must always be considered. As is now well established, properly prescribed drugs are the fourth leading cause of death in the United States.1 I have many times recommended in my editorials N-acetylcysteine (NAC) as a very effective way to increase glutathione thus supporting detoxification and protecting mitochondria from oxidative stress. But for the small percentage of the population that has trouble metabolizing sulfur compounds, NAC can be toxic. The bottom line is that we need to ensure our interventions are not causing damage. No, I am NOT saying causing less damage than their benefits. I am saying that, except in very limited cases, we should not be using interventions that damage our patients. Period.
Patient Example. An 18-year-old young woman came to me for help with her ulcerative colitis. She had been first diagnosed when 14 years old and was getting worse, despite treatment. She had just seen her gastroenterologist who was recommending that she switch to another anti-inflammatory but had been delaying prescribing as patients experience so many side effects. But worse, he said her case was so bad that she would likely need a colectomy within only a few years. She came to me hoping for an alternative medicine miracle. Careful case history revealed that as a child she had suffered from recurrent urinary tract infections and was started on daily antibiotics at age 8 years. By age 11 years, she was constantly having intestinal upset and eventually was diagnosed with inflammatory bowel disease. The cause was clear to me: disruption of her healthy gut bacteria with whatever would grow there after all the antibiotics causing recolonization with inappropriate bacteria, chronic gut inflammation, and eventually leaky gut.
I started her on my usually successful protocol for this condition: improve diet food quality, cessation of wheat and dairy products, supplement with digestive aids, and reseed her gut with healthy bacteria using a multistrain product I have found quite effective. She was a very compliant patient but experienced only modest improvement—approximately 30% reduction in symptoms and continued dependency on the prescribed drugs. This being the modern age of the Internet with so much health information available online, she started researching her condition and learned about fecal transplants. She decided to do the transplant on her own using her father’s stools. After only 1 treatment, her symptoms quickly started to improve and after repeating one more a month later all her symptoms were gone and her surprised gastroenterologist proclaimed her in remission (apparently unwilling to say she was cured). As this is now 5 years later, a quick call revealed robust health and a clear cure.

Criterion 3
If the symptoms recur when the intervention is stopped, then it is very unlikely to be curative. Although in many ways this is pretty obvious, it is much more complex when considering biochemical individuality. The genomics revolution has greatly enhanced our ability to understand each of our patient’s unique nutritional needs and susceptibility to toxins. For example, we now know that many people have polymorphisms in the vitamin-D receptors requiring much high–levels of vitamin-D supplementation unless they get a lot of regular sun exposure. Others have trouble converting dietary folates to their activated forms. Some patients have very limited capability to detoxify the pesticides and herbicides that contaminate conventionally grown foods. In each of these situations, nutritional support is needed to maintain normal physiology.
Patient Example. A 50-year-old woman presented with osteopenia and a strong family history of every older woman in her family dying from complications of osteoporosis—typically hip fractures. Despite a very good diet, regular energetic exercise, estrogen replacement, and good supplementation, yearly dual-energy x-ray absorptiometry (DEXA) scans showed relentless loss of bone. A genomic test revealed 5 (of 6) single nucleotide polymorphisms impairing vitamin-D receptor site function. Intervention required supplementation with 14 000 units of vitamin D for 2 years (of course, must also supplement with vitamins A and K2) before bone loss was stopped. After 10 years, her bone density became normal but requiring a maintenance dose of 10 000 IU (many times the supposed recommended daily intake). This is a good example where the intervention was curative, but needed to be continued due to a unique biochemical need.

Criterion 4
This is the most difficult to address objectively but is well recognized by most every health care professional and may be the most important criterion of all. So many times I have had a patient profusely thank me for alleviation of a health problem that I had not consciously addressed. If a patient suffers depression due to a lack of vitamin D, for example, optimizing their levels will often also improve function of all the other biochemistry affected by the deficiency. As their biochemistry normalizes, they become healthier and more energetic.
Patient Example. A 55-year-old woman came to me with a chief complaint of depression. While examining her, I noticed a fairly strong “essential” tremor. She had dismissed it as a sign of growing old and had not even noted it on her intake form. Full neurological exam revealed no apparent abnormalities. However, I did notice a mouth full of amalgam fillings. Challenge testing showed high levels of mercury and lead. Putting her on my standard metal detoxification program not only resulted in reversal of depression, but her tremor fully abated and she remarked feeling better than she had in years. Yes, this is anecdotal—but when a patient responds with not only relief of the presenting complaint but improvement in other areas, I consider this a good indication that something curative has happened.

Applying This Logic to the Most Commonly Prescribed Drugs
Table 2 lists the most common drugs prescribed in the United States by number of prescriptions filled per month. As you can see from my comments, almost all of them only address symptoms, not the actual causes of disease.

Table 2. The 10 Most Commonly Prescribed Drugs in the United States2

Abbreviations: PCB, polychlorinated biphenyl; COPD, chronic obstructive pulmonary disease; ADHD, attention-deficit/hyperactivity disorder.

Conclusion
Please be clear that I am not recommending against use of these drugs. Rather, I am asserting that the best medicine first addresses the causes. Drugs are should only be used if addressing the causes does not produce the desired clinical results or patient safety requires transient use. I can confidentially state that virtually everyone reading this journal cares deeply about their patients and became a health care professional with the expectation of being in medicine to cure their patients. Symptom control is much easier and almost the only approach in a health care reimbursement system that limits doctors to only 10 minutes with a patient.
The only cure for the health care system is to address causes, not only symptoms. This requires restructuring medical education and the reimbursement system so that we have the skills and time needed to find and correct the causes. After all, aren’t we all in medicine because we want to cure our patients?

Joseph Pizzorno, ND, Editor in Chief
drpizzorno@innovisionhm.com
http://twitter.com/drpizzorno

References

1. Lazarou J, Pomeranz BH, Corey PN. Incidence of drug reactions in hospitalized patients: A meta-analysis of prospective studies. JAMA. 1998;279(15):1200-1205.
2. Brown T. The 10 most-prescribed and top-selling medications. Web MD Web site.  http://www.webmd.com/news/20150508/most-prescribed-top-selling-drugs. Published May 8, 2015. Accessed September 4, 2016.
3. Pizzorno J. Is the diabetes epidemic primarily due to toxins? Integrat Med Clin J. 2016;15(4):8-17.