Complementary and alternative cancer treatments in Germany.

I recently published an 82-page online report, "Complementary And Alternative (CAM) Cancer Treatments In Germany" (available at www.cancerdecisions.com). In 1998, I was made an honorary member of the German Society of Oncology (DGO), the first American to be so honored. (The occasion was the publication of the German translation of my book, Questioning Chemotherapy.) Because of my abiding interest in cancer clinics in Germany, and their use of unconventional as well as orthodox methods, I have made ten investigative trips to that country since then.

The present report came out of a tour of clinics that I made in May 2008, with follow-up trips in November 2008 and January 2009. But is more than just a rundown on unorthodox clinics. I also delve into the historical development and current status of oncologists, clinics, and hospitals in Germany that use, in addition to conventional treatment, CAM approaches to cancer.

German CAM treatment is a rich area for study. It draws on a 2,000-year-old tradition of botanical medicine. The Renaissance physician Paracelsus turned medicine toward a reliance on personal experience and experimentation. Hufeland, Priessnitz, and Kneipp advanced the exploration of the effects of dietary and lifestyle changes, water, and heat on health. The creation of many German health spas in the 19th and early 20th centuries provided a home base for doctors and laypersons who practiced "natural medicine." About half of German CAM clinics are still located in spa towns.

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My new report focuses on the development of CAM cancer treatments in the post-World War II environment. It explores the methods used at these clinics, including hyperthermia in its varied forms as well as mistletoe extracts; biological response modifiers; autologous, dendritic cell, and Newcastle disease virus vaccines; thymic peptides; orthomolecular medicine; and photodynamic therapy. It discusses six seminal figures who helped shape the development of the CAM in Germany: Issels, Hackethal, Nieper, Scheef, Ransberger, and von Ardenne. It concludes with an appraisal of eight clinics that I visited in 2008.

'Highly Organized and Diversified'

How and why did Germany become the preeminent leader in the CAM field? Before the National Socialists came to power in 1933, natural medicine in Germany was already both "highly organized and diversified." (1) There were 12,000 licensed practitioners of natural medicine in Germany, and 270,000 people paid out of pocket for their treatments. This was mainly a movement of laypersons. Initially, there were overtures from some of the Nazi leaders toward devotees of alternative healing systems. The Nazis sometimes spoke of creating a "New German Medicine" (Neue Deutsche Heilkunde). But it is a mistake to think that the Nazis in general promoted or favored naturopathy. As with many of their "populist" claims, the promised reforms disappeared after they came to power. In fact, they soon attempted to destroy the burgeoning natural health movement.

There was always a fundamental difference in attitude between the Nazi approach to medicine and that of yesterday or today's CAM practitioner. To quote Professor Edvard Ernst: "CAM is concerned with the welfare of the individual, whereas the 'Neue Deutsche Heilkunde' was aimed at ensuring the dominance of the Aryan race." (2) For instance, in 1937 the Nazi government announced strict new rules on naturopathic practice. The Natural Healer's Law (Heilpraktikergesetz) of February 17, 1939, required not only for all practitioners to be licensed, but also for naturopathy as a whole to be subordinated to the allopathic medical profession. In 1939, the Nazis dissolved the naturopathic medical schools and forbade the establishment of new ones. By 1942, the number of practitioners had fallen from 12,000 to 3,000-3,500; and, in the words of Professor Robert Proctor of Stanford University, "The German medical community had already acted to guarantee that these healers would ultimately disappear from Germany." (1) The law was explicitly designed to place the entire medical field in the hands of licensed allopathic physicians.

Postwar Germany

This experience of the collusion between Nazism and the allopathic medical community (not to mention many other crimes perpetrated by leading allopathic doctors) made many Germans in the postwar years wary of the "dictatorship" of one medical philosophy, allopathy, and its persistent attacks on all alternative schools of thought (homeopathy, naturopathy, chiropractic, Anthroposophical medicine, etc.). It was no secret in Germany that the Anthroposophical movement (which had been banned by the Nazis) provided most of the organizational effort to get new laws passed that would increase medical freedom (Therapiefreiheit). (3), (4)

In the post-World War II period, Germany pulled away from the rest of the Western world in the development and acceptance of CAM treatments and clinics. Building on its long traditions of herbalism, homeopathy, and naturopathy, and utilizing the superstructure provided by the spa network, some German doctors developed clinics where cancer was treated in more natural ways. In time, they also began to incorporate methods developed elsewhere.

The ultimate justification for a broader freedom for CAM practices was Article 12 of the German constitution. This section emphasizes individual responsibility. "All Germans shall have the right freely to choose their occupation or profession, their place of work, and their place of training. ... No person may be required to perform work of a particular kind except within the framework of a traditional duty of community service that applies generally and equally to all." German colleagues tell me that this article widened the scope of medical practice for German doctors.

Fear of allopathic dominance was reflected in several laws that affected the practice of CAM. One was still not allowed to select a CAM treatment if a conventional procedure was generally recognized as more effective. For a life-threatening illness, however, such as advanced cancer, if there was no generally recognized therapy, the physician was allowed to fall back on methods whose effectiveness was not yet proven, provided that there was a possibility of success. The Federal Constitutional Court in its decision of December 6, 2005, affirmed this principle. (5)

Medication Law of 1978

But there were also laws that more specifically validated the freedom to practice natural forms of medicine. In his 1994 US Congressional testimony, Jurgen Schurholz, MD, a German Anthroposophical practitioner and hospital administrator, explained how a 1978 German law essentially legalized alternative medicine. (6), (7) Speaking before Senator Tom Harkin (D-IA)'s Subcommittee on Labor, Health and Human Services, and Education of the Senate Committee on Appropriations, Schurholz stated:

  The medication law of 1978 was also important in that the government
  decided to acknowledge the following. First, freedom in one's choice
  of therapy by the doctor and the right of self-determination by the
  patient should be guaranteed. Second, the existence and equal
  justification of various lines of therapeutics should be expressly
  recognized. And, third, health authorities are obliged to take into
  consideration the state of scientific knowledge of each line of
  therapy or different schools of medicine when advising the public or
  practitioners about their benefits.

  In addition, it was also agreed upon that in all matters of medical
  treatment it was ultimately the obligation of each physician to
  listen to his conscience when considering treatment for his patients.
  However, he must also be able to give plausible reasons for his
  choice of treatment to his patients by being informed of the merits
  and risks associated with any treatment he may elect to use. This is
  where the commission's monographs on such remedies prove to be
  invaluable guides for the practitioner. (8)

This 1978 law gives a legal basis to Germany's unprecedented medical freedom, as well as its preeminence in various aspects of CAM. Once again, as they did before World War II, English-speaking doctors and scientists have begun to go to Germany to learn about the latest developments in their field. Without this German CAM perspective, conventional Western oncology would indeed be one-dimensional.

Prevalence of CAM Use

It may come as a surprise, then, that the prevalence of CAM use by German patients is about the same as in the US. In most of Germany, CAM is used by around 62% of the population. (10) This happens to be the identical figure for CAM use among American breast-cancer patients in a 2006 survey. (11)

What is profoundly different is the attitude of the medical profession. In 2008, researchers at Charite Hospital in Berlin interviewed 516 German physicians, who were qualified in 13 medical specialties. They found that a majority (51%) was in favor of CAM, while 26% was "very much in favor." Of the methods that were prescribed, "phytomedicine" (the use of herbs and botanicals) was the second most frequent, just behind physical therapy. The authors concluded: "This survey demonstrates a broader acceptance and practice of CAM by [German] physicians than hitherto believed." (12)

This was not a fluke. In 2008, researchers at the University of Heidelberg conducted a series of focus groups among German practitioners, which also revealed a high degree of acceptance for CAM: "The majority of the participating GPs considered CAM as a reasonable complementary approach within primary care," they wrote. The authors conclude that there "seems to be a need for increased funding for research, better education and remuneration by the Statutory Health Insurance in order to improve access to 'integrative medicine' in Germany." (13) The major exception is in the Eastern (former Communist) parts of the country. There, CAM usage continues to be lower than in the West, in some areas only around 6% of the population. (14)

There is no denying that acceptance of CAM among American doctors is also on the rise. (15) But, leaving aside uncertain quantitative comparisons, CAM is more respected by academic medicine in Germany than in the US. For instance, in May 2008 I attended a conference in Germany at which academics mingled comfortably with their CAM counterparts. There was a larger cohort of physicians from major universities than is typically the case at equivalent meetings in the US. Tenured professors rubbed elbow patches with clinicians who actually treat cancer patients using a variety of CAM techniques. Such fraternization between standard oncologists and CAM practitioners is more the exception that the rule in the US.

Thus, in October 2008 I attended the large "Frontiers of Integrative Oncology" meeting in Las Vegas, hosted by the American College for Advancement in Medicine (ACAM). (16) Although the speakers included some of the most prominent American CAM medical doctors, almost all lacked academic affiliations. In fact, I counted only a single tenured professor at a major university medical center among the speakers. I had similar experiences at the Annie Appleseed conference in West Palm Beach and the Institute of Women's Health conference in Portland, Oregon, both in January 2009. In fact, I find this quite typical of meetings of American physicians who have a CAM orientation. They exist in a world of their own, excluded from academic funding or esteem. Some might call this a "CAM ghetto."

That does not mean that there are no academic students of CAM in America - quite the contrary. Generous funding by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH) has generated the development of a CAM subspecialty at various high-level academic medical centers. But the Society for Integrative Oncology (SIO), which was founded by and for such researchers, has the opposite problem. Although its slogan is "Integration Across the Spectrum of Cancer Care," it seems somewhat uncomfortable associating with nonacademic CAM practitioners. The SIO included very few nonacademics among the many speakers at its 2008 annual meeting. (17) There is little overlap or interaction between the SIO speakers and those who speak at nonacademic CAM meetings. Overall, there is a more fruitful interaction of CAM and academic researchers in Germany than in the US. That, in turn, is a major reason for Germany's preeminence in this field.

Notes

(1.) Proctor RN. Racial Hygiene. Cambridge, MA: Harvard University Press; 1988:226.

(2.) Ernst E. "Neue Deutsche Heilkunde": Complementary/alternative medicine in the Third Reich. Complement Ther Med. 2001;9:49-51.

(3.) Ulzheimer K: Arztstrafrecht in der Praxis, 3rd ed. Heidelberg: C.-F.-Muller-Verlag: Heidelberg; 2003.

(4.) Fehn K. Der arztliche Behandlungsfehler im Abriss in: Zeitschrift fur arztliche Fortbildung und Qualitat im Gesundheitswesen 95/2001, S. 469-474.

(5.) Dierks C. Verfassungsrichter starken die Therapiefreiheit der Arzte in: Arzte Zeitung, 21. Dezember 2005 (Eingesehen April 18, 2007, vgl. auch die Entscheidung im Volltext eingesehen April 18, 2007). [The ruling is also designated Das Bundesverfassungsgericht (BVerfG) 1 BvR 347/98.]

(6.) Moss RW. Another step forward on the Hill: Hearings on Daschle bill reveal support for choice. The Cancer Chronicles 23; September 1994.

(7.) Hoffer A. The need to liberate physicians to practice complementary medicine. J Orthomolec Med. 1995;10:123-129.

(8.) Access to Medical Treatment Act: On S. 2140: To Permit an Individual to be Treated by a Health Care Practitioner with any Method of Medical Treatment such Individual Requests, and for other Purposes: Hearing before the Subcomm on Labor and Human Resources of the Senate Comm on Appropriations, 103d Cong., 2nd sess. (July 22, 1994). Available at: http://www.archive.org/stream/accesstomedicalt00unit/accesstomedicalt00unit_djvu.txt. Accessed March 10, 2009.

(9.) Eustachi A, Pajtler H, Linde K, Melchart D, Weidenhammer W. Patients of an interdisciplinary cancer treatment centre: use of, knowledge about, and demand for CAM treatment options. Integr Cancer Ther. 2009;8:56-62.

(10.) Buettner C, Kroenke CH, Phillips RS, Davis RB, Eisenberg DM, Holmes MD. Correlates of use of different types of complementary and alternative medicine by breast cancer survivors in the nurses' health study. Breast Cancer Res Treat. 2006;100:219-227.

(11.) Stange R, Amhof R, Moebus S. Complementary and alternative medicine: attitudes and patterns of use by German physicians in a national survey. J Altern Complement Med. 2008;14:1255-1261.

(12.) Joos S, Musselmann B, Miksch A, Rosemann T, Szecsenyi J. The role of complementary and alternative medicine (CAM) in Germany - a focus group study of GPs. BMC Health Serv Res. 2008;8:127.

(13.) Schwarz S, Messerschmidt H, Volzke H, Hoffmann W, Lucht M, Doren M. Use of complementary medicinal therapies in West Pomerania: a population-based study. Climacteric. 2008;11:124-134.

(14.) Kelsen DP, Daly JM, Kern SE, et al. Principles and Practice of Gastrointestinal Oncology, 2nd ed. Philadelphia: Wolters Kluwer Health; 2007:136.

(15.) The American College For Advancement in Medicine Announces "Frontiers of Integrative Oncology" Seminar and Trade Show. Available at: http://www.thefreelibrary.com. Accessed April 2, 2009.

(16.) Society for Integrative Oncology. Fifth SIO annual conference program & abstracts. Available at: http://www.integrativeonc.org/index.php/sio-events. Accessed April 2, 2009.

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by Ralph Moss, PhD

www.cancerdecisions.com