MDs remain sceptical as chelation therapy goes mainstream in Saskatchewan
Murray Oliver
CMAJ 1997;157:750-3
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Murray Oliver is a freelance writer living in Regina.
© Murray Oliver
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In brief
The College of Physicians and Surgeons of Saskatchewan recently agreed to allow physicians to administer chelation therapy. Supporters, relying on anecdotal evidence, say it works wonders in overcoming heart disease, but many physicians remain profoundly sceptical. In Saskatchewan, the college decision has proved popular with patients but has drawn an angry reaction from doctors.
En bref
Le Collège des médecins et chirurgiens de la Saskatchewan a consenti récemment à permettre aux médecins d'administrer des traitements par chélation. Les partisans de cette technique qui s'appuient sur des données probantes anecdotiques affirment qu'elle fait des miracles pour guérir des cardiopathies, mais beaucoup de médecins demeurent très sceptiques. En Saskatchewan, la décision du Collège s'est révélée populaire auprès des patients, mais elle provoqué la colère chez les médecins.
It's 8:30 on a Wednesday morning at a small, nondescript strip mall along one of Regina's main thoroughfares. Inside a sparsely furnished office, 15 mostly elderly men and women sit on plush easy chairs. The warm murmur of their voices mimics the morning coffee-shop banter going on throughout the city.
However, the purpose of this get-together is a little different from the usual morning gatherings at Tim Horton's. IV bags are suspended above every chair, from which a clear solution slowly drips. The people are among the first in Canada to receive legal injections of ethylenediamine tetra-acetate, or EDTA, which is better known as the substance used to provide chelation therapy in the treatment of atherosclerosis.
Versions of EDTA have been used for years as a treatment for heavy-metal poisoning. The latest compound was approved by Health Canada in 1993 for use in reducing blood levels of lead in cases of lead poisoning and lead encephalopathy. However, its use as an alternative or "complementary" therapy for all manner of circulatory illnesses has been hotly debated.
Despite potential side effects and scanty evidence of its effectiveness, the College of Physicians and Surgeons of Saskatchewan made a controversial decision last December to let physicians administer chelation therapy.
Since the mid-1950s EDTA's supporters, including some physicians, have argued that intravenous or intramuscular administration of the fluid, when accompanied by the use of vitamins and minerals, will reduce coronary artery plaques. However, there is little solid evidence to support the claim. In March the Institute for Clinical Evaluative Sciences in Ontario said existing research doesn't provide acceptable evidence of any benefit when EDTA chelation therapy is used to treat atherosclerosis.
But science's lack of support for the efficacy of the procedure didn't stop some 300 patients from flocking to Saskatchewan's first 2 legally operating chelation clinics. Since April, 3 more clinics have opened in the province.
Each is run by a physician who has been judged qualified to administer EDTA after taking a training course in the US. Treatments are pricey and they're not covered by medicare, but devotees say the cost is worth it. When the Regina Chelation Clinic opened its doors in January, John Folk was one of the first people in line. "A year ago I needed a cane to walk," the 72-year-old former commissionaire says with gusto. "I used to fall all the time. Now I don't even need the cane anymore."
His story is typical of the anecdotes exchanged among seniors who flock to these clinics. Folk was left debilitated after a heart attack in 1975. When he developed congestive heart failure 3 years ago, a friend gave him a book on chelation therapy. Like others in Saskatchewan, Folk had either travelled to the US for the treatment or to other provinces such as Alberta and BC, where doctors have wrestled with their colleges and sometimes set up chelation clinics that operated on the edge of the law.
Folk even took 10 treatments last year at an illegal clinic run by an Alberta naturopath, which opened briefly in Regina. It closed after threats of legal action from the Saskatchewan college.
Today, Folk calls the college's decision to authorize chelation therapy "a blessing" that will save him hundreds of dollars in travel expenses and allow him to receive more frequent treatment. But if that expression of happiness is meant as thanks, the registrar of the Saskatchewan college is reluctant to receive it.
Dr. Dennis Kendel is adamant that his college has not endorsed chelation therapy -- he says it has simply accepted that the drug can be administered safely if treatment is provided by licensed physicians following accepted protocols. "This is not a long-repressed therapy that is going to open the gates of healing for people suffering from heart disease," Kendel says with a quick laugh.
The college motion approving provision of the therapy reflected its ambivalence. The college said that even though it remains unconvinced that chelation therapy will benefit patients, it nonetheless recognizes the strong public demand for safe access to the treatment. In fact, it may have been organized public campaigns that ultimately overturned the college's reluctance to approve the therapy.
The college had watched carefully as other provinces adopted what Kendel calls a "stand-off" approach to the therapy. In some cases doctors who illegally administered EDTA were prosecuted, while other colleges publicly dismissed chelation therapy as an unsupported treatment.
Then came Alberta's Bill 209. Driven by pubic pressure, this private member's bill proposed protection for doctors who utilize any form of alternative medicine, including chelation therapy, against interference by the College of Physicians and Surgeons of Alberta.
It swept through the Alberta legislature and became law last April. Its implications are still being vigorously contested. The situation is similar in the US, where state medical boards have sometimes been sued by physicians forbidden to administer chelation therapy to patients who demand it. In some recent cases, the boards have lost.
Back in Saskatchewan, these events had an impact on Kendel and the college, which had started talks with a prochelation lobby group, Citizens for Choice in Health Care. The organization supports the college's supervisory functions but insists that it should be more flexible in approving complementary therapies.
Their grass-roots campaign soon attracted political support from the governing New Democrats, and the college saw the writing on the wall.
In a January letter to the Alberta college written shortly after Saskatchewan authorized chelation therapy, Kendel suggested that his college had acted because the spectre of Alberta's Bill 209 was hanging over its head. "The [college] council perceived there [was] a very substantial risk that we would be hit with similar legislative amendments in this province if we did not take a more proactive approach."
But Kendel doesn't believe that public pressure forced the college into its decision. He says it was impressed by arguments from Citizens for Free Choice and by the organization's moderate stance concerning the college's regulation of Saskatchewan physicians. Kendel says the primary issue has always been public safety.
"Where there is a standoff between doctors and the regulatory bodies, the regulatory bodies lose control," Kendel says with a sigh. "They [college regulators] don't know what goes on in clinics."
In a nutshell, the college authorized chelation therapy because it was better for it to be able to regulate the treatment than to have it taking place anyway but in an unregulated and possibly dangerous or fraudulent fashion.
Kendel makes no apologies for the decision. Even though he remains sceptical about chelation therapy, he feels regulatory bodies like his must be more responsive to public demands for a voice in health care. "The society we serve is moving in droves to accessing alternative medicine, and if there's a big demand and it can be delivered safely. . . ."
Over at the Saskatchewan Medical Association (SMA), Dr. Allan Miller thinks carefully before offering his response. "Alternative therapies may be growing in popularity at the moment, but I'm not sure that because something is popular and trendy that's good enough reason for the medical profession to adopt it as the reasonable thing to do."
Miller, who was SMA president when the college made its ruling, is unhappy with it and says many of his colleagues feel the same way. In one case, a Saskatchewan television station used stock footage of a doctor in a story about chelation therapy during its supper-hour newscast. By the late-night newscast the station was issuing an apology to that physician, telling viewers the doctor was in no way associated with chelation therapy. That's one measure of the depth of suspicion and scepticism some Saskatchewan physicians feel toward it.
Miller isn't surprised that many physicians have expressed their anger to the college and the SMA. He notes that scientific validity is the major factor separating medicine from other types of health care. "As soon as we start offering treatments where there is no proof of effectiveness or safety, our credibility goes out the window."
Miller knows the college faced a tough situation in the chelation debate, but worries that its decision may indicate that public pressure now dictates health care policy. "If we're going to allow the public to decide which therapies are regulated by the college, we might as well roll over and accept a whole lot of unconventional treatments now," he says.
Others respond that giving patients more input is a positive development that will help cure people's disillusionment with "orthodox" medicine. "I think doctors and the medical profession are beginning to look at patients as people responsible for their own health care," says Jack Armitage, president of the 800-member Citizens for Choice in Health Care. "There are alternatives to cutting and alternatives to pills."
The retired farmer and high school principal is no stranger to the controversies surrounding chelation therapy, and recalls fondly his early chelation treatments in a garage in Prince Albert, Sask. "It was a young guy, a pretty good guy," he says of the man who administered the treatment. "I don't know if he was a doctor, or what."
But Armitage says just one issue is at stake in this debate: patients' right to free choice about their own health care. He considers health care a cooperative effort between doctors and their patients, meaning both sides have to give and take a little.
Armitage says Citizens for Choice never wanted to undermine the regulatory authority of the Saskatchewan college: he knows that alternative therapies sometimes attract fraud artists and is confident that the college's oversight role will prevent charlatans from exploiting the vulnerable. Still, Armitage admits, his group intended to ask its political supporters for legislation to bypass the college if chelation therapy continued to face restrictions.
So, what's next for Armitage's group? Flush with success, Citizens for Choice is looking into other restricted therapies and restrictions on health-food products. It's all being done, he says, in the interest of free choice for patients.
But Dr. Bill Semchuk is withholding his applause. Semchuk, who holds a PhD in pharmacy and is associate director of clinical education and research, pharmacy services, at the Pasqua Hospital in Regina, is outspoken about his concerns regarding alternative types of care like chelation therapy. "I think this and all alternative medicines [involve] people looking for a magic pill," says Semchuk, an assistant clinical professor at the University of Saskatchewan.
He says many books and articles written in support of alternative therapies are authored by people with dubious credentials, yet the public continues to buy their arguments and the therapies they advocate. That, he says, is simply a sign of the public's disenchantment with mainstream medicine.
Evidence-based medicine, which has become a mantra for physicians in North America, is dismissed by many supporters of alternative medicine as an effort to mislead the public and as a conspiracy orchestrated by the chief bogymen of alternative health care advocates, the drug companies. "It's almost turning into religion," he says.
Semchuk has heard many angry doctors speak about the college's decision and hopes its turnaround on the issue is an isolated incident. "If the college was forced into this decision, then that would be very scary," he says.
Scary is a word seldom heard at Regina's Chelation Clinic. Dr. Joseph Persram is sitting behind a cluttered desk, finishing some paperwork. He's closed his family medicine practice and now provides chelation therapy full time. He appears to be tired of answering questions about the validity of chelation therapy, although he accepts that the treatment is controversial.
"There's been no hostility directed towards me, but I know that most of the physicians who provide the therapy are ostracized by the clinical profession," he says grimly. "People don't want to have anything to do with them."
Persram insists that trials have proved that chelation therapy is effective, but at the same time expresses scepticism about the notion of controlled studies. The evidence he offers is mostly anecdotal.
For Persram's patients, however, anecdotal proof appears to be enough. "I think what's kept me alive so far is chelation," patient John Folk says confidently. "Nothing in the world could convince me to stop doing this."
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