MEDICINE: AN ART THAT USES SCIENCE
by Lynn Lawson

Melvyn R. Werbach, MD, Third Line Medicine: Modern Treatment for Persistent Symptoms, Arkana Paperbacks, Routledge & Kegan Paul, New York, 1986, 215 pages.

Melvyn R. Werbach, MD, Nutritional Influences on Illness: A Source of Clinical Research, Keats Publishing, New Caanan, CT, 1988, 506 pages.

In Third Line Medicine, Dr. Melvyn Werbach, recent NOHA speaker, develops his concept of a "third line" of medical practitioners – those who, after a patient has been seen by one or more general practitioners (first line) and specialists (second line), attempt to look at all the factors affecting the patient’s persistent symptoms. This is an "ecological model," as opposed to modern medicine’s "doctrine of specific etiology," which attempts to find one specific cause for the symptom or symptoms. By following this doctrine, modern medicine has claimed to reduce, if not eradicate, many infectious diseases – though, Werbach points out, much of the improvement in this century resulted simply from better sanitation and nutrition.

However, as we all know, the greater health hazard now comes from the degenerative diseases – cardiovascular disease, cancer, diabetes, and other less fatal conditions. For these noninfectious diseases, modern medicine often first uses the more-dangerous rather than the less-dangerous treatment route, resulting in considerable iatrogenic (i.e. doctor- or hospital-induced) disease. Werbach quotes critic Ivan Illich: "Among murderous institutional torts, only modern malnutrition injures more people than iatrogenic disease in its various manifestations."

This is an "ecological model," as opposed to modern medicine’s "doctrine of specific etiology," which attempts to find one specific cause for the symptom or symptoms. By following this doctrine, modern medicine has claimed to reduce, if not eradicate, many infectious diseases – though, Werbach points out, much of the improvement in this century resulted simply from better sanitation and nutrition.

How much are most physicians taught about nutrition? According to a 1980 issue of the Journal of the American Medical Association cited by Werbach,

Most medical schools devote less than three hours of total instruction to nutritional deficiency and therapy . . . physicians in the United States are not required to have any understanding of nutrition to be licensed to practice medicine.

And nutritionist Jean Mayer has commented that his studies of Harvard physicians during specialty training "suggest that the average physician knows a little more about nutrition than the average secretary – unless the secretary has a weight problem, and then she probably knows more than the average physician."

Because of this neglect, Werbach observed, malnutrition has reached epidemic proportions in American hospitals. In a study of over 3,000 patients in 33 hospitals, 58 percent were found to be malnourished. In most cases, the hospitals had not done basic nutritional screening, though malnutrition is known to affect length of hospitalization, rates of infection, and wound healing. Another 1980 JAMA article pointed out that patients on intravenous feeding may die because of lack of protein rather than their illness. According to a 1982 American Journal of Clinical Nutrition article, IV patients will develop severe macronutrient deficiencies in one week if essential nutrients are not added to their IV solutions.

Most medical schools devote less than three hours of total instruction to nutritional deficiency and therapy . . . physicians in the United States are not required to have any understanding of nutrition to be licensed to practice medicine.

In an eight-page section on nutrition and health, Werbach, like Beasley and Swift, as cited in the Spring 1990 issue of NOHA NEWS, questions the usefulness of the Recommended Dietary Allowances (RDAs) for the individual patient:

Since there are at least 40 essential nutrients with a [Food-and-Nutrition-Board-Determined] 3 percent risk of deficiency for each, the risk that the RDA will be insufficient in one or more nutrients for a particular normal individual becomes substantial. In other words, if you ingest exactly the RDA of each nutrient, you are probably going to become deficient in at least one of them.

For this reason, and because third line patients often suffer from nutritional inadequacies and imbalances, third line physicians usually try to assess the nutritional status of the individual patients – instead of either ignoring nutrition altogether or asking only if the patient is meeting the RDA requirements.

Nutritional Influence on Illness belongs on every clinician’s desk – and in the home of anyone interested in optimal health. In the "healing alliance" envisioned in Third Line Medicine, both doctor and patient need to be as well informed as possible.

The good news is that, according to Werbach, diet is increasingly being recognized as playing a major role in cardiovascular disease, cancer, and mental illness, as well as many other conditions. Werbach quotes Jonathan V. Wright, MD, writing in the 1982 Prevention magazine about nutritional therapy:

I’ve watched numerous circulatory problems improve, including return of ulcerated bluish-black feet and lower legs to normal color. Diabetes mellitus of varying severity can usually be improved, even "cured," as can high blood pressure. . . . Nutritional-biochemical therapy may not always apply, or be best, but should always be considered before final decisions are made.

In his 18-page chapter "Cures for nondisease," with "nondisease" meant ironically, Werbach discusses marginal vitamin deficiencies, essential fatty acid deficiencies, heavy metal toxicity, food and chemical sensitivity (citing NOHA Professional Advisory Board member Theron G. Randolph, MD), and candida. For each, he lists associated symptoms and adverse health effects. In regard to food and chemical sensitivities, he considers it:

. . . frightening to think that environmental substances can produce varied and bizarre symptomatology which second line physicians will frequently dismiss as examples of nondisease. Even more unsettling is the evidence that environmental substances do not have to be toxic to produce devastating physical and mental symptoms. Ordinary foods, even foods considered to be especially nutritious, can be responsible for symptoms in susceptible people. Chemicals in our environment which are nontoxic to most people at the usual levels of exposure can also be responsible.

For the person with almost any chronic condition, this chapter is perhaps the meatiest section of the book, though Werbach’s other book, Nutritional Influence on Illness, covers existing research more completely.

The good news is that, according to Werbach, diet is increasingly being recognized as playing a major role in cardiovascular disease, cancer, and mental illness, as well as many other conditions.

In his deploring of modern medical specialization, Werbach notes that specialists tend to see each patient in terms of their own specialty – like the blind men feeling the elephant, each coming up with a different conclusion as to what the animal is. Actually, Werbach himself, trained in psychiatry, tends to emphasize the role of psychiatry at the expense of other factors, e.g. the growing influence of modern chemicals on human health. Much evidence now exists* of the ability of chemicals in such common products as perfumes, detergents, fabric softeners, cleaning solutions, and air fresheners to produce headaches, dizziness, nausea, disorientation, and other chronic symptoms. To meet the challenge of patients exhibiting multiple chemical sensitivities, third line physicians who are not already aware of the role of such products in human health will increasingly need to educate themselves in this burgeoning field.

In Nutritional Influences on Illness: A Sourcebook of Clinical Research, Werbach has presented the medical profession with an invaluable reference work. Exceptionally well organized and edited to make it easily usable, it offers in its main section short summaries of pertinent research for 113 conditions, alphabetically arranged from "acne rosacea" to "wound healing," with such subheadings as "Basic Diet," "Nutrients," and "Other Factors." Short, cautious statements give some direction to the reader, though Werbach stresses that "these statements are not therapeutic recommendations." For example, in the section on cardiac arrhythmia, under "Nutrients/Magnesium" are the statements "May be deficient" and "Arrhythmias may respond to supplementation," each followed by abstracts of research that either support or refute the statement. It is left to the clinician to decide how strong the scientific evidence is.

Ordinary foods, even foods considered to be especially nutritious, can be responsible for symptoms in susceptible people. Chemicals in our environment which are nontoxic to most people at the usual levels of exposure can also be responsible.

Werbach also included six appendices with suggestions as to their use: Common Nutritional Deficiencies, Dangers of Nutritional Supplementation, Guidelines to Nutritional Supplementation, Laboratory Methods for Nutritional Evaluation, Nutrient Bioavailability and Interactions, and Syndromes Due to Abnormal Tissue Nutrient Levels.

Though Werbach warns that clinical nutrition is a "young and still primitive field with an often disappointingly inadequate scientific literature," he has done an excellent job of organizing what existed up to 1987. Somewhat puzzling, however, is the main heading "Ilnesses and the effects of Nutrients, Toxics and Environmental Sensitivities," for the emphasis is definitely on nutrients rather than on toxics and environmental sensitivities. By "toxics" he means mainly heavy metals that can be tested for, and by "environmental sensitivities" he means food sensitivities. [We recall that Randolph has called food "our most intimate environmental exposure."] Once again, headaches: toxic chemicals as a cause of headaches are scarcely touched on, though they are a common cause of headaches. Obviously, an equally thorough coverage of toxic-chemical influences on illness needs to be done.

In the meantime, Nutritional Influence on Illness belongs on every clinician’s desk – and in the home of anyone interested in optimal health. In the "healing alliance" envisioned in Third Line Medicine, both doctor and patient need to be as well informed as possible.

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*See, for example, Randolph’s classic work, cited by Werbach, Human Ecology and Susceptibility to the Chemical Environment, Charles C. Thomas, Publisher, Springfield, Illinois, 1962; plus Theron G. Randolph, MD, and Ralph W. Moss, PhD, An Alternative Approach to Allergies: The New Field of Clinical Ecology Unravels the Environmental Causes of Mental and Physical Ills, Harper & Row, revised edition 1989. Also, Nicholas A. Ashford, PhD, JD, and Claudia S. Miller, MD, MS, Chemical Sensitivity: A Report to the New Jersey State Department of Health, December 1989; and Richard Mackarness, MB, DPM, Chemical Victims, Pan Books Ltd., London, 1980.

Article from NOHA NEWS, Vol. XV, No. 3, Summer 1990, pages 3-5.