Monday, 18 August 2008

Alternative Expectations

Scepticism is a balancing act. It’s not about a dismissive nature, any more than a credulous one. I like to think of myself as being a balanced, quite open-minded sceptic. Doubt, but don’t reject without evidence. Mind you, I get it wrong sometimes. Watching a fairly mindless piece of entertainment TV last week, I was introduced to the concept of light therapy, in particular for the treatment of depression as well as skin conditions. I could barely contain a snort of mockery as the wide-eyed presenter explained the serotonin-inducing and antibiotic wonders of various shades of intense light. Actually, I’m pretty sure I didn’t contain it at all. My automatic mistrust of the concept was hasty. After all, it is quite well established that sunlight may have all manner of influences on us, both emotional and physical. However, my scepticism led me to investigate further, which is never a bad thing. I visited Google Scholar to browse some of the peer-reviewed journals on light therapy. My aim; to find out if any evidence of the effectiveness of this therapy actually exists. Sure enough, there is some manner of science in there. Broadly, the studies performed to date have tended to be pretty inadequate in terms of sample size (rarely more than 20 patients) and time scale (weeks when we’d like years). So let’s say that the jury is still out, but that I look more favourably on the concept now than I did previously. I’m still a little dubious as to whether such treatments should already be available in clinics, when it appears as if a full-scale trial has yet to be conducted. It wouldn’t happen with a drug, after all. The wide-eyed presenter, perhaps familiar with the concept of “scepticism”, ensured us that the treatment was “scientifically proven”. Whatever that means.

So I figure that light therapy should not be dismissed. But it should certainly not be accepted on the basis of a TV personality’s assessment of what constitutes “scientific proof”. While light therapy may not be something that would conventionally be classed as “alternative medicine”, it did get me thinking about the topic. The very concept of alternative medicine is often offensive to many medics and scientists. It is a notion that thrives on the modern public’s disillusionment with science in general and the misguided concept that “another way” exists. The disillusionment is not entirely unjustified. And the philosophical rejection of reason shouldn’t prejudice our scientific judgement of the individual therapies classed under the blanket term of “alternative”.
Just where did this sense of disillusionment with conventional medicine come from? I have some notions on that. Following the sudden revolution that began with the sanitation practices of the late 19th century, the western world witnessed an unprecedented improvement in public health. The work of scientists such as Koch and Pasteur did away with vague notions of the nature of disease. Ever hear of miasma theory? Nope, because it’s rubbish. Koch and Pasteur, giants of medicine, saw to it that the war upon germs could begin in earnest. Within a century the world’s greatest killers, smallpox, tuberculosis and polio, were either utterly destroyed or reduced to a shadow of their former threat. It was a true revolution. It was the end result of a paradigm shift in biology; the formulation of germ theory. But things have settled down now, we’re back to normal science. Cancer, once largely unheard of, is now the big killer. Many blame modern life, and the science that brought it, for putting things into their food and environment. The newspapers are obsessed with reporting on “things that cause cancer”, which apparently is almost everything. It’s easy to forget of course that 100 years ago very few people lived long enough to get cancer. Modern medicine’s perceived inability to “cure” cancer, heart disease and AIDS, has lead people to lose faith, even to become cynical about the means and even motives of doctors and the health industry. Of course, we scientists and doctors have not helped. Our curious culture of maintaining aloof superiority has fuelled the common man’s sense that science has become disconnected from humanity. In the absence of understandable contact from us, what has anybody to go on other than the caricatures of the media?

So, the “other way” becomes attractive. Dismissive scepticism, the worst kind of scepticism, now rules when dealing with doctors. Many have come to the assumption that alternative medicine forms part of what They Don’t Want You to Know, for reasons that are never entirely clear. A grand conspiracy. This attitude is no better than the average scientist’s blanket views on alternative therapy. It’s really just a matter of getting more information, and if we actually look for it, the beginnings of what we need to know are often already there in the journals. What should the average prospective patient look out for? The journals don’t make for an easy read, but I’ll try to summarise what makes for good testing.

In evidence-based medicine, efficacy and safety are tested using clinical studies. Because humans are so very unique and variable, the only way to be sure that a technique or drug is effective and safe is to go large. To use the biggest study groups possible. We also have to ensure that we study the effects over extended time periods. Both features are vital for the statistical analysis needed to make sense of all that human unpredictability. Most importantly of all we must use what scientists call “controls”. A control in a clinical study is essentially a group, as large and as similar as possible to the group receiving the test treatment, which is treated differently for the sake of comparison. To properly test acupuncture, for example, the bare minimum would be a study of several thousand patients with one group receiving conventional treatment, one receiving acupuncture and one receiving “sham” acupuncture in which the needles are applied but applied incorrectly. The last two groups must be “blinded”, which is to say that neither group should be aware of which is receiving real acupuncture.

A recent-ish study of acupuncture for back-pain followed this very template. They found that acupuncture beat conventional therapy for pain relief. But that isn’t the full story. Firstly, the volunteers consisted of patients for whom conventional therapy had failed. Secondly, they found that the sham acupuncture was just as effective as real acupuncture. This may be an indication of what is called the placebo effect. This is an apparent beneficial effect caused by a fake control treatment, be it the administration of a sugar pill or random pinpricks. Or perhaps there’s some peculiar value to being poked with needles in general. Put simply, it’s not clear what’s going on there. Acupuncture must remain in the realms of the untested for now and we should treat it as such. With doubt, but not with contempt.

On the flip side, we can ditch reiki and reflexology as they have been tested quite thoroughly and found to have no greater benefit than a massage. “Allergy tests” based upon applied kinesiology (the one where bottles of varies substances are held near your muscles) are pure and utter witchcraft in my view. There’s no connection between the results of these and the standard medical allergy test. Hell, some of those tests use sealed bottles, so quite how your body could ever react to the contents is a mystery. As for chiropractic... don’t get me started. Few studies have been able to demonstrate anything more than a placebo effect. Most damningly of all, as pointed out by Ben Goldacre, some chiropractors would rather block the process of scientific criticism of their field. The New Zealand Chiropractors Association has taken the highly suspicious step of attempting to sue a peer-reviewed journal. With your health on the line, is this the sort of carry-on you should accept from your doctor? (Author's Note 21 Aug 2008: The British Chiropractic Association are also sueing journalist Simon Singh for an allegedly libellous article on their faith. I mean, science.)You can be quite sure that no reputable scientist has ever sued in response to academic criticism. Proper studies such as I outlined above are hard to conduct on chiropractic spinal manipulation. This is primarily because the medics who usually run studies are not trained in the methods and chiropractors are reluctant to get involved. What information there is tends to be both limited and self-contradictory. This isn’t a nail in the coffin by any means, but it’s clear that the professionals could be doing more to make us trust them. The general folk and herbal medicine scene is a whole can of worms in its own right. It’s quite clear that some of it works, after all many modern drugs are derived from plant and fungal components. But it’s clear that we don’t know enough about the complex mixture of active ingredients in many such preparations to draw generalisations. Much like light therapy and acupuncture, it remains for me at the fringes of reason for the time being.
Ultimately, the advice for navigating the maze that is alternative medicine is much the same as my advice regarding the reading of science in the mainstream media. Scepticism, but open scepticism. Demand evidence, statistics and hard facts. Mechanisms must be rooted in what we can observe. As for doctors, expect more from them too. Ask for explanations, don’t just accept prescriptions. Doctors are often impatient with patient questioning and take a dim view of patients coming to them with their own research from books or the internet. This needs to change. Try to open a dialogue, one that is respectful and yet still sceptical. Never forget that your doctor has some ten years of training and perhaps decades of practical experience. The relationship should ideally be a two-way communication.

As for “alternative medicine”, the term encompasses too wide a range of ideas and carries too much prejudice. To my mind there should be only two kinds of medicine. Tested and not. Only the successfully tested has a place in our lives. Much of what is now untested may one day be worthy of our trust, but right now our health and our lives are at stake. Nothing is more valuable, and nothing is more worthy of healthy scepticism.

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