Anecdotes, placebos and traditional medicine
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.