The no evidence zone: A physician’s take on alternative health care
Brett Taylor is an associate professor of pediatrics and emergency medicine, and holds a Masters in health informatics. He works as a researcher, lecturer and emergency pediatrician through Dalhousie University and the IWK Health Centre in Halifax. His website is The Virtual Pediatrician.
Here’s a spot quiz for parents out there: If your three-year-old child has a cold with a stuffy, congested nose, how would you treat her? Pick any options that apply. Would you:
- Set her up with a good movie?
- Push fluids?
- Treat any pain (ears, throat, etc.) with acetaminophen or ibuprofen?
- Make sure she had her teddy?
- Put cold damp socks on her feet just before bed?
If you chose any of the first four, you are probably in the majority. While there are no double-blinded studies to prove it, teddies and good movies probably comfort young kids with ugly noses. Many don’t drink as much as they should when they are feeling sick, and it just isn’t fair to have a stuffed nose and a sore throat, too. So clap yourself on the back, you have what it takes to be a parent.
If, on the other hand, you went for the cold, damp socks, congratulations again! You have what it takes to be a naturopath.
I’m not joking. According to the Canadian Association of Naturopathic Doctors, on the treatment of cold and flu symptoms:
"Congestion is a form of stagnation or lack of movement of body fluids – often lymphatic fluid. The goal is to get the fluid to move and hence drain. Using a pair of cotton socks and a pair of wool socks, soak the cotton socks in cold water, wring them out and then put them on your feet. Put the wool socks on top and then go to bed. Warming socks is a form of hydrotherapy. It is technique that has been used for hundreds of years and can be understood by exploring how hydrotherapy (water therapy) works."
Now it probably seems rather petty to be challenging the national professional body for naturopathic medicine over a couple of unpleasantly damp clothing items. After all, should you actually convince your three-year-old to don cold wet socks (would never have worked in MY house), the risk of harm seems rather small.
The problem, though, with this sort of "alternative" medicine is the mindset that develops and advocates it. No matter how ridiculous the treatment may seem, attaching the phrase "has been used for hundreds of years" to some part of its defence is all that is needed to justify using it. And that, truly, is a problem.
For example, a few years ago I was approached by a student about to graduate from an alternative-care training program. This was a very dedicated young guy who only wanted the best for his patients; he knew of my interest in asthma and wanted to discuss the differences between traditional and alternative care. So we met for coffee to share some knowledge.
Despite the earnest attitude, I was surprised at what I learned. The specialized therapy that this trainee advocated was a form of deep chest massage, which, he opined, improved lung function, decreased symptoms, and eliminated the need for medication.
Now as it happens, this has been studied. In 2005, Maria Hondras, Klaus Linde and AP Jones did a review of the medical literature to date looking for well-designed research (randomized, controlled trials) that might answer the question: does any form of manipulation or mobilization benefit patients with asthma? Only two studies that used a sham intervention were found, but in these no improvement in quality of life, use of medications or asthma symptoms was noted with therapeutic manipulation, i.e. no evidence of benefit was found.
My earnest young colleague heard about this evidence from me, and while his faith was somewhat shaken, as of the last time we met he was still determined to go out and practise, and presumably charge for, what he had been taught. One has to wonder why.
Evidence and a 'respectful skepticism'
The underpinning of modern medicine is evidence. Our underlying doctrine is not faith in previous authors, but a respectful skepticism. The reason is quite simple: our decisions matter. Every choice, even a choice to do nothing, has potential benefits and risks. Our patients expect that before any therapy or course of action is prescribed the nature of these risks and benefits are known, that there is reason to believe the plan of action is sound, that there is something more than the writings of long dead medical philosophers supporting us.
In other words, that there is proof.
Many alternative health practitioners on the other hand hold, oddly enough, to tradition: the words of German physician Samuel Hahnemann, for example, who is generally recognized as the father of homeopathy, and who died in 1843. That was four years before Ignaz Semmelweis recognized the first example of the germ theory of illness in human beings. We shouldn’t confuse old theories with being knowledge based; Hahnemann died before he could understand that bacteria and viruses cause the diseases he was trying to treat. His attempts to find cures were a reaction to the purging and bloodletting that he saw being practised by his contemporaries. Compared with those treatments, which very often caused worse illness or even death, homeopathy looked pretty good.
These days, though, the fundamental principles of homeopathy seem pretty odd, to say the least. According to the Canadian Society of Homeopathy website — and other sources — one basis of homeopathy is "like cures like," stated simply the idea that the symptoms caused by a substance are those that it will treat.
If your nose and eyes are running, a derivative made from onion might somehow be of benefit. Extending this theory, presumably if your heart was beating too fast, taking a drug that makes it beat faster would somehow make it beat slower. No evidence is offered for this concept; rather, again, because the practice has been around for hundreds of years (there are "references to homeopathy in ancient writing"), it is considered valid.
By the same argument, I suppose, pharmacists should replace the acetaminophen on their shelves with bottled leeches.
Credit where credit is due
Homeopathy, naturopathy and other alternative health-care practices have been submitted to scientific study. A few techniques have shown promising results; acupuncture, for example, is effective in some pain syndromes and for the prevention of some nausea and vomiting, and has largely been accepted as a valid alternative to medication in those circumstances. When study support exists, I have no objections at all to using alternative measures. In fact, I would argue that once alternative care is supported by well-designed double-blinded placebo controlled trials it isn’t "alternative" any more, it is mainstream.
Generally, however, the results have been negative. Metanalyses have been published about the effect of homeopathy, for example, on attention deficit disorder, asthma, allergy, high blood pressure, both the treatment of cancer and the side effects of cancer chemotherapy, and bedwetting with little or no benefit demonstrated. Yet alternative-care practitioners continue to offer their services for these conditions undaunted.
I am a medical doctor; it would be easy to write off my arguments as an exercise in turf protection. But it would be the cheap shot, and frankly untrue. Canadian health care is stretched to the limit these days, particularly in emergency care, and particularly following the fall flu season we have all experienced. Any set of hands would be welcome.
Any hands, that is, that actually do something. Canadians spend $3.8 billion annually on alternative health care, according to a study in 1997 by the Fraser Institute. I couldn’t find a more recent reference, but I am sure it is higher now. Regardless — put $3.8 billion into nurses in this country, or sports complexes, or even just better driver education, and see how far that goes to making us a healthier nation. Each of these interventions has study support.
"Traditional" medical care has been working hard to justify its treatment plans for much of the last two generations. We routinely expose errors in medical thinking, and broadcast them to each other and our patients in an effort to improve. Alternative health care should be held to the same rigorous standards. If the naturopaths, homeopaths and others in the alternative health-care industry want to justify their multibillion-dollar existence, I think they have work to do. Agree to stop selling services that don’t have evidence of benefit, for one example. Rigorously define the risks of the treatments sold, for another.
And not by referencing 200-year-old dead men, thanks. In times of tight financial pressure, if alternative health care is going to justify its draw on the Canadian purse, it really has only one valid response.
Just show us.