Anec­dotes, place­bos and tra­di­tional medicine

Cosmos - - Contents -

NO­VAK DJOKOVIC LIKES Mel­bourne, and not just for the ten­nis. At a clinic just min­utes from where he has won the Aus­tralian Open six times, Djokovic gets a treat­ment he is con­vinced speeds his re­cov­ery be­tween matches. He gets into a cap­sule re­sem­bling a mini sub­ma­rine and spends time breath­ing 100% oxy­gen at high pres­sure.

Known as hy­per­baric oxy­gen ther­apy, it is a proven treat­ment for decompression sick­ness and car­bon-monox­ide poi­son­ing. Some Com­ple­men­tary and Al­ter­na­tive medicine (CAM) clin­ics also of­fer it for sport­ing in­juries. In­deed, re­search pub­lished in Jan­uary found it re­duces in­flam­ma­tion and ac­cel­er­ates mus­cle re­pair – but the study was in rats and a long way from show­ing it works in hu­mans.

Djokovic is one of mil­lions who em­brace CAM de­spite, in many cases, a lack of sci­en­tific proof. That trend raises deep ques­tions about the na­ture of ev­i­dence and peo­ple’s right to choose in an era of per­sonal au­ton­omy. It is also whip­ping up a storm of con­tro­versy in Aus­tralia.

Par­lia­ment re­cently passed into law a list of what CAM treat­ments can claim to do and the ev­i­dence needed to back that up. It has some per­plex­ing items. You can say, for ex­am­ple, that a treat­ment “moist­ens dry­ness” in the “triple burner”, an area be­tween the pelvis and neck in Tra­di­tional and Chi­nese Medicine (TCM). The ev­i­dence is “tra­di­tion of use” over a pe­riod of more than three gen­er­a­tions or 75 years.

The list has lobby group Friends of Science in Medicine (FSM) in a lather. They ar­gue it pro­motes pseu­do­science and wrongly gives tra­di­tional use equal weight to sci­en­tific ev­i­dence, po­ten­tially mis­lead­ing con­sumers and caus­ing them to forego valid treat­ments. FSM don’t deny tra­di­tional medicine can be valu­able – the malaria treat­ment artemesinin, for ex­am­ple, comes from a tra­di­tional Chi­nese rem­edy based on the worm­wood bush. Artemisinin was, how­ever, proven ef­fec­tive in clin­i­cal tri­als, the sci­en­tific gold stan­dard.

The core crit­i­cism of “tra­di­tional ev­i­dence” is that it is the ac­cu­mu­la­tion of in­di­vid­ual experience, leav­ing it un­clear if a rem­edy ac­tu­ally worked, if it caused a placebo re­sponse, or if the ill­ness sim­ply ran its course. Ad­vo­cates of TCM, though, com­plain of a dou­ble stan­dard when sin­gle-case reports are ac­cepted in biomed­i­cal jour­nals while in­di­vid­ual experience with al­ter­na­tive ther­a­pies is dis­missed.

Cer­tainly the ev­i­dence of anec­dote can be com­pelling. Marc Co­hen, a med­i­cal doc­tor and pro­fes­sor of com­ple­men­tary medicine at RMIT Univer­sity in Mel­bourne, has seen an asthma treat­ment work “dozens of times” where acupunc­ture nee­dles are in­serted in the notch above the breast­bone. “If I was up on a moun­tain some­where in a re­mote lo­ca­tion and some­one had an asthma at­tack I wouldn’t hes­i­tate to do that,” he says.

Univer­sity of Washington physi­cian Mark Tonelli even ar­gues that a pref­er­ence for clin­i­cal trial ev­i­dence over anec­dote is sim­ply a choice about knowl­edge and “not a sci­en­tific ne­ces­sity”.

This is a dan­ger­ous con­fla­tion. The clin­i­cal trial sits on top of the ortho­dox ev­i­dence lad­der be­cause it can root out the kinds of bi­ases that plague in­di­vid­ual reports. Take the placebo ef­fect, which is real and of­ten pow­er­ful, ac­count­ing for up to 75% of the ef­fect of an­tide­pres­sants, for in­stance. But a placebo is not al­ways be­nign. A 2011 study found a placebo asthma in­haler made peo­ple feel bet­ter with­out do­ing any­thing to im­prove lung func­tion. In real life that could de­lay get­ting proper treat­ment with tragic con­se­quences.

Co­hen says con­trolled tri­als for many CAM treat­ments aren’t fea­si­ble – it is im­pos­si­ble, for ex­am­ple, to test ice baths against a “sham” con­trol to show their ef­fect is more than a placebo. It is also the case that CAM are of­ten ex­cused the rig­or­ous tests of ev­i­dence-based medicine be­cause they are “low risk”.

For many folk that doesn’t ap­pear to be a prob­lem; ac­cord­ing to the World Health Or­gan­i­sa­tion nearly 100 mil­lion Euro­peans use TCM. Peo­ple, it seems, are vot­ing with their feet for the treat­ment, and the ev­i­dence, that suits them. The eth­i­cal rub is whether those choices are au­ton­o­mous, re­flect­ing an understanding of whether the medicine ac­tu­ally works.

FSM want to en­hance con­sumer choice by putting a la­bel on tra­di­tional medicines that reads: “This prod­uct is based on tra­di­tional be­liefs and not modern sci­en­tific ev­i­dence.”

That will only help, how­ever, if peo­ple are equipped to weigh both forms of ev­i­dence. Which is why au­ton­omy needs tur­bocharg­ing. Health lit­er­acy through, for ex­am­ple, ini­tia­tives such as Choos­ing Wisely Aus­tralia, must be­come a key skill for the 21st cen­tury. For many, that will mean ma­jor up­skilling. But with­out it there seems lit­tle hope, ten­nis aces in­cluded, of sort­ing the hy­per­baric from the hype and hot air.

Health lit­er­acy must be­come a key skill for the 21st cen­tury.

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