White Coat Underground

I am culturally insensitive

A reader sent me an interesting post from her own blog. It’s well-written, compelling, and betrays an exceptional intelligence. It’s also completely wrong.

The piece is called, “Bias, Racism, and Alternative Medicine”, an intriguing title. The first part tries to establish that “Western medicine” in one of many ways of understanding health and disease. She starts with some personal anecdotes—always interesting, rarely generalizable:

While receiving Western biomedical treatment for ADD, the side effects of my therapy convinced me that western medication alone would not provide a solution to my problems.

One of the author’s fundamental misunderstandings is that the failure of a particular treatment to make her feel better does not invalidate all of medical science, and more important, it does not validate “other ways of thinking”. Still, I can understand how this happens. Personal experience is powerful; unfortunately, it is also misleading. I like this writer. She seems very kind. She goes on to describe her enlightenment further, but this is where a pleasant anecdote goes terribly wrong:

It was because eating the wrong kinds of foods, along with other stressors like studying all night, raises the inflammation of the body.

I worry for her medical soul.

Her statement about inflammation is just flat out wrong. If this is what she’s learned from medical school, she deserves a refund. “Raises inflammation in the body” is simply a meaningless statement. The author is trying to leverage her anecdotes about medical conditions that naturally wax an wane into a general statement about alternative medicine. This is a mistake.

This first part establishes her belief that so-called Western medicine is missing something, and that “other ways” of understanding disease have value. Having established that “Western” medicine doesn’t know everything, she tries to explain why this may be, not on the basis of scientific knowledge, but on the basis of cultural hegemony. Bad idea.

But neither am I in the group of Western medicine trained students or doctors who refuse to see other medical systems in their own rights, and therefore cannot make sense of why patients seek alternative treatments.

This statement rests on a faulty assumption, namely that we “Western” docs have failed to properly examine other medical systems, and have failed to understand why people believe in them.

I understand other systems—they are based on false, vitalistic, pre-scientific beliefs about nature. Understand, that’s not a moral judgment but a factual one. I also understand why people believe in things. We all have our own cultural context, our own baggage. We all wear blinders of one kind or another. I can’t tell you how many minority patients I’ve had who don’t trust doctors because of larger cultural experiences; it’s a lot though. But none of this changes what is biologically so. The fact that the Tuskegee Experiment allowed African American men to suffer and die from untreated syphilis does not change the biology of the spirochete; it changes the relationship of individuals and groups to the system as a whole. Failing to understand this can lead from one kind of neglect (e.g., Tuskegee) to another (e.g., Ayurveda).

An important thing to understand as a scientist (or as an “applied scientist” like a doctor) is that while what we do and how we do it is suffused with cultural biases and stereotypes, the physical reality is not. We may choose to ignore the genetic and cultural reasons that a minority group is more affected by a particular disease, but the genetics do not change. This is something the author has yet to learn:

Why do we lump all of these very different systems and practices of medicine into one category called CAM? What are these alternatives to? Missing from the picture is that CAM is only alternative to a Western biomedical system of medicine, and one form of CAM might be considered an alternative by a practitioner of a different CAM. This Eurocentric attitude, that the traditional Western biomedical system is the epitome of medicine itself, exists in even international organizations like WHO.

The answer to the question, “what are these alternatives to?” is “science-based medicine”, not “hegemonic, Eurocentric medical beliefs”. We consider science-based medicine to be the “default” because it is the one that reflects scientific reality. This doesn’t diminish the important role played by religio-medical beliefs in many people, but it does place them in the proper context: the are quasi-religious beliefs, not scientific ones, and people hold to them for various cultural and economic reasons—important reasons, but not science-based reasons.

Why are Africans and Asians said to use “traditional medicine” but not Europeans or Americans? In America, the Western biomedical system is our tradition.

Actually, our “tradition” has its roots in the vitalistic and humoral beliefs that we held to for most of our history. Our current understanding explicitly rejects these as pre-scientific and rather than forming a new “tradition” sets tradition aside for a reality-based system.

I understand where writing like this comes from. Many voices in this world are not heard, especially voices of women, non-whites, and the poor. These voices are particularly important in medicine, since we do not normally choose to serve only one population (although some do). The historic dearth of women and minorities in the sciences is an important fact, one that needs fixing for many reasons. One of these reasons is that we must serve everyone, and to serve everyone it helps to be everyone. Serving may mean understanding where someone’s beliefs come from, and even respecting these beliefs, but it does not mean endorsing these beliefs. They may be morally equal beliefs, but they are not scientifically equal.

She is right when she says we are biased, but not in what way we are biased:

Have we really recognized our own bias when evaluating a CAM therapy? We haven’t even removed the biggest bias of all, which is to see the Western biomedical system as the one and only valid form of science and medicine, instead of admitting that it is one system among many.

No. Our bias is not failing to recognize other ways of knowing, but in failing to treat other human beings with respect.

Our brave author closes with this:

I cannot comment on the efficacy of each non-Western medical system, because I’m not being trained in any of them, and I don’t have the understanding to praise or criticize those systems. Our version of medical reality has receptors, hormones and nerves, etc. Someone else’s medical reality includes energies, meridians, or doshas. We may be so ingrained in the traditional Western biomedical model that we’re unable to make sense of anything that doesn’t use the same concepts or language. However, many patients accurately see that there seems to be different ways of understanding a health condition, and they will choose the one that makes them feel the best at any given point in time. Even if we can’t accept their logic, we’ll have to accept that traditional medicine from other cultures will gain a stronghold in our population, just as we have imposed our traditional medicine on theirs.

In fact, as a trained physician and scientist, you can comment on “non-Western” systems quite effectively. You are in a special position to do so. This isn’t about “concepts and language” but truth and non-truth. To be better physicians and scientist we must understand why people believe what they do, and we must find ways to help our patients take advantage of real medicine in a way that does not violate their basic values. That is moral. What is not moral is placing other’s health at risk by declaring all knowledge equal but different, or in someone else’s words, “separate but equal”.

Comments

  1. #1 D. C. Sessions
    October 12, 2009

    In the end, it comes down to Schroedinger’s Patient:

    If your “other way of knowing” gets a different result from “Western Hegemonic Medicine” as to whether the patient is alive or not for their followup appointment, then we have something to talk about. Otherwise, the wavefunctions all collapse to the same result.

  2. #2 MC
    October 12, 2009

    you can comment on “non-Western” systems quite effectively

    i might be very wrong about this, but from what i understand is that there really isnt very much funding for testing non-western medicines. and if no one is doing any tests to see if something is effective, we can’t really comment on it…

  3. #3 PalMD
    October 12, 2009

    I don’t need to bash a hammer in to 35 randomly assigned subjects faces to know it’s a bad idea.

  4. #4 SkeptVet
    October 12, 2009

    Thanks for a cogent and clear response, with which I agree completely.

    Just to add a slightly different perspective on the argument to which you are responding, I would suggest that the cultural relativism underlying it is a two-edged sword. I tend to be a bit of an extremist myself in that I view many cultural values and institutions as arbitrary and having no universailty, no intrinsic meaning. And it is true that a certain degree of such relativism makes a nice antidote to the ethnic/religious/nationalistic myopia and bigotry that is all too common a human failing.

    However, while cultural reality may be a “construct,” as the post-modernists like to say, it’s not hard to demonstrate that physical reality is not. No cultural point of view prevents one from plummeting off a tall building. Antibiotics cure susceptible bacterial infections whether one believes in them or not. And homeopathy makes lousy birth control regardless of one’s perspective on the issue.

    I often find, however, that these post-modernist defenses of CAM are a bit inconsistent. While arguing that the realms of physics, chemistry, and biology are somehow relative to one’s point of view, despite the apparently obvious evidence to the contrary, the makers of such arguments often hold to universals in moral and cultural realms. They will proclaim that racism, homophobia, misogyny are always and universally wrong, yet illness and health are somehow a matter of perspective. Cancer, diabetes, swine flu are all just “Western” concepts, but human rights are universal and eternal. Prosyletizing for their morality, including the value of relativism itself, seems to be ok, but arguing for a universal reality behind human biology is an attempt to expand a patriarchal Western cultural hegemony.

    I happen to be a flaming liberal myself, so I tend to agree with the politics of the “pomos” while I find their perspective on matters of science shallow and naive. Yet I have yet to get a satisfactory response to why the relativism they promote is only supposed to apply to such matters and not to their own values.

  5. #5 Greg Laden
    October 12, 2009

    MC, actually, there has been quite a bit of research in non-western medicine, and from that research have come contributions to the way medicine is done. Alternative, CAM, and traditional treatment, healing, and “wellness” have changed the way things are done in some positive ways.

    I can give you a few examples.

    Many of our medical techniques and some of our drugs have been in use for as long as there have been modern doctors or longer, and these things come along with “modern medicine” historically. These are procedures or treatments that have been updated but are maintained in the modern system because they work.

    Aspirin, opiates, and a handful of other drugs have been around forever and are linked to various traditional medical cultures. … we now know how they work and the production is safer and the dosage better understood, but they’ve been around for a long time.

    Vaccination. It’s been around for hundreds of years and occurs in various cultures. Ironically, a lot of CAM sorts of people eschew it today, but it’s really rather traditional. I mean, really helping one’s own immune system fight disease strikes me as akin to traditional ways of doing things in many, especially eastern, cultures.

    Assisted delivery

    Cesarean and some other surgeries

    With respect to CAM, there are a number of environmental enhancements being built routinely into design of facilities such as dialysis treatment centers, hospital rooms, etc. It may well be that Doctors, for all their bedside manner, have been less sensitive to low-stress settings as a good thing for patients. But careful design of rooms and facilities can help people have a better time of it in the hospital or treatment center, and this is being done increasingly.

    (Just don’t bring in any actual candles!!!)

    A lot of research has been done on traditional techniques that are shamanisitc as well as potentially powerful drugs that could be extracted from rain forest plants, etc. The results of the former has been nil to minimal (I can only think of the so called Belgian Stone as an example), and the results of the latter have been disappointing. However, there are a large number of “natural products” that come from plants and animals (especially in the tropics) that are used in treatments or that form the basis for synthetic treatments, and these are significant, even if less numerous than originally hoped for.

    “Wellness” programs are a mixture of things but do include the very positive and proven component of healthy diet and healthy exercise routine as part of the bigger picture of individual health.

    If you page through a new-age-CAM style magazine or newspaper and look at all the ads for various products and techniques, it is possible that there is something there in the way of a real treatment for one disease or another that modern medicine shuns. But I doubt it. But, if you look closely at “regular” medicine you see the imprint of the traditional and alternative, and much of that imprint has occurred over the last decade or so.

    Recently, I think we are starting to get diminishing returns in this area.

  6. #6 #1 Dinosaur
    October 12, 2009

    @MC#2:

    You are indeed very wrong. The National Center for the study of CAM (NCCAM) had spent billions of dollars studying virtually every form of quackery alternative medicine, and so far (to the dismay of folks like Tom Harkin) has shown quite convincingly that none of them work.

  7. #7 cathyk
    October 12, 2009

    Actually, your correspondent is not completely off-base when she remarks that “[S]tressors like studying all night, raise… the inflammation of the body.”

    Meier-Ewert et al (2004) and many others have shown that sleep deprivation increases inflammatory markers that are known to be associated with cardiovascular disease and the metabolic syndrome ….

    Meanwhile, there is also evidence that “eating the wrong kinds of foods” (“such as higher intakes of red and processed meats, sweets, desserts, French fries, and refined grains”[Lopez-Garcia et al 2004]) may also be associated with higher levels of inflammation.

    Regarding her cultural point, it is true that earlier, colonial regimes were responsible for imposing false “science” (eg., eugenics, sterilization, institutionalization) on native subjects. In our present circumstances, it may be important to think about why specific individuals who receive specific diagnoses are attracted to anti-scientific thinking. An ethnographic perspective may be the most helpful approach. Although, flippancy is more fun to write, and, probably for most of your audience, more fun to read.

  8. #8 skeptifem
    October 12, 2009

    woaah there.

    “The answer to the question, “what are these alternatives to?” is “science-based medicine”, not “hegemonic, Eurocentric medical beliefs”. We consider science-based medicine to be the “default” because it is the one that reflects scientific reality.”

    I guess the biggest problem I find with the whole argument is that everything that we now see as being horrible is suddenly not science based medicine; that is a good thing but the past should not be ignored. those horrible practices and experiments were considered science based medicine and the same “you are just wrong!” talk would get thrown at people who had a problem with say, hospital birth practices from the 50′s and 60′s. the majority of people doing research or applied sciences in this area are from the same cultural, gender, race, and economic class. Historically that is extremely true. That being said, that doesn’t make alternative medicine work, it doesn’t make alternative medicine better. That doesn’t solve the problem of bias in conventional medicine and science either. Science is good but the people doing it are flawed, so there were times that doctors were doing things unrelated to the reality of a situation as well. I would say that science has a much better track record over all, but the level of authority that goes with that makes the mistakes made much much harder to avoid, and the people who are hurt the most are historically disadvantaged and less likely to be heard or taken seriously when they object.

    Over all these kinds of conflicts tend to end up being a case where the sciencey folks could learn a lot about humanities from the people they are arguing with, and the humanities folks could learn a lot about science too. That doesn’t seem to happen a lot, unfortunately. It is alienating for people who study both!

    Also, I wouldn’t trust doctors as the ambassadors of science they are portrayed as here. There are a lot of good ones out there, but there are a fair amount of creationist doctors too. That profession is all tied up in cultural expectations of success for many people who have no intention to change their mind to fit evidence, they simply want to be doctors.

  9. #9 becca
    October 12, 2009

    Sorry, PalMD. I call Bullshit.
    This is entirely about concepts and language.

    Why is it you assume “Western medicine” = “scientific medicine”?
    I realize the scientific tradition has, in many ways (but not by any means all) drawn heavily from Western culture.

    But isn’t Aristotle Western? How many teeth do I have again?
    According to what geography are quinine and artemisinin “Western”?

    My biggest problem is that you keep on using that word “alternative”- I do not think you know what it means. Or rather, you do not use it the way other people use it. I realize it’s popular around these parts to use it the way you are using it. But everytime somebody brings up a legitimately effective treatment that started out very much outside of the canon of modern US medical practice, the reply is always “well that isn’t CAM, because it stands up to scientific standards”.
    Most of CAM is probably bunk, but it is a diverse group of treatments. If you simply refuse to call anything that isn’t bunk by the term “CAM”, that just means you ‘win’ the argument by tautology. It’s… it’s… it’s…a BORING way to argue.
    *glare*

  10. #10 Stephanie Z
    October 13, 2009

    Becca, the term “traditional Western medicine” came from the post Pal’s commenting on. He’s arguing against it being a valid construct as much as you are; i.e., our traditions are just as much a mixture of ignorance and a small amount of knowledge as are any other culture’s. It’s only by applying scientific standards that any culture sorts out the knowledge from the ignorance.

  11. #11 T. Bruce McNeely
    October 13, 2009

    Our version of medical reality has receptors, hormones and nerves, etc. Someone else’s medical reality includes energies, meridians, or doshas

    Receptors, hormones and nerves also have anatomic, physiologic, chemical and physical reality. Energies, meridians and doshas (whatever the hell they are) have none of these characteristics. Or can you convince me otherwise?

  12. #12 Thomas
    October 13, 2009

    You are far, far too nice and accepting this person’s post as good coin, Pal. However this person came to arrive at this position (and their being a medical student makes me less sympathetic to the how), it’s critical to look at the social role this sort of bullshit thinking plays. Which you hint at here:

    What is not moral is placing other’s health at risk by declaring all knowledge equal but different, or in someone else’s words, “separate but equal”.

    This person dares to claim “cultural sensitivity” while covering for the preventable, horrible deaths of millions of Africans from AIDS. In the context of a world where HIV disease is a chronic condition in the West, but unavailability of drugs and doctors and medicine in Africa, often justified by defference to traditional whichdoctory, is creating a veritable shoah, this sort of “it’s okay for them because they think that way” bullshit is the height of immorality. It’s a cover for the man-made atrocity that is ravaging that continent.

  13. #13 Michael Ralston
    October 13, 2009

    But everytime somebody brings up a legitimately effective treatment that started out very much outside of the canon of modern US medical practice, the reply is always “well that isn’t CAM, because it stands up to scientific standards”.

    But that’s because we don’t give a shit where treatments started.

    The only thing we care about is if they work.

    If scientific standards support it, it isn’t alternative. It doesn’t matter if it was some traditional treatment by some obscure jungle tribe, or was accidentally discovered in some lab yesterday. If science indicates that it most likely works, the only reason it won’t be “standard” is if the current standard is somehow better.

    Science-based medicine can be wrong, and has in the past, yes. But so can anything else! Everything might be wrong. Science is the only worldview that recognizes this fact and can deal with it. The fact that science came out of a Western worldview doesn’t matter – the fact that science works matters.

  14. #14 BB
    October 13, 2009

    @cathyk, cherry-picking single citations does not a firm scientific basis make. For the people Lopez-Garcia found, there are millions who eat “wrong” with no such bad effects.

    Food does not cause inflammation (unless you have celiac sprue or the like and eat the wrong food).

  15. #15 becca
    October 13, 2009

    Stephanie, in arguing against the post, PalMD is assuming a certain definition for the term that I don’t believe is warranted (the examples I’ve noted indicate why it’s incorrect to say “Western medicine is correct medicine”). Furthermore, I can’t believe the author was using the term the way PalMD has (‘Western’ medicine = scientific medicine). Basically, it’s a linguistic dance to create a strawman argument (he’s arguing that non-scientific medicine is not correct medicine).

    “If scientific standards support it, it isn’t alternative.”
    This is ‘winning’ the argument by tautology. I just can’t see the utility of that definition. I think a more meaningful definition for CAM is “a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine”. Or “outside of the modern US medical approach”.

    “It doesn’t matter if it was some traditional treatment by some obscure jungle tribe, or was accidentally discovered in some lab yesterday. If science indicates that it most likely works, the only reason it won’t be “standard” is if the current standard is somehow better.”
    Science (as in, the body of scientific knowledge) is not as clear cut as “it works” or “it doesn’t”.
    What if we run a clinical trial on a traditional herb and determine it doesn’t work… yet local people keep using it and getting better. If, years down the line, we find a common polymorphism in that ethnic group that results in alternative xenobiotic metabolism that explains why the herb works for them, it’s suddenly a non-alternative treatment?

    (random quibbling: “Food does not cause inflammation (unless you have celiac sprue or the like and eat the wrong food).” Or are part of the 2-5% of the population with food allergies.
    Or are talking about the influence of long term dietary tends. Which can result in high fat, producing bloated little macrophages (awww, poor macrophages).
    Part of the terminology problem is that immunology has claimed lots of genes (like JNK) and cell types (like macrophages) that have such a diverse array of functions, including but not limited to inflammation, that it’s hard to say if their involvement should be taken as an accurate metric of inflammation. But you better believe those genes and cell types have a role to play in metabolic syndrome, cancer et al.
    Not that this necessarily tells you what to eat…

  16. #16 catgirl
    October 13, 2009

    What if we run a clinical trial on a traditional herb and determine it doesn’t work… yet local people keep using it and getting better.

    What if most people don’t actually get better and end up dying? We’ll never hear testimonials from those people, so the testimonials from the few people who get better will seem more important than they actually are. That’s why we can’t just accept stories at their face value. Failures don’t give testimonials. That’s why we need a well-designed study, including a control group. If a certain ethnic group has an important biological difference that makes the herb work for them, that means we need to study that group in a scientific, controlled way. Their testimonials mean that we need to have a more thorough scientific study, not that we should just accept that the herb works because they say so. Science does not mean that we ignore the possibility of ethnic difference. It means that we need to study that group in a scientific way.

  17. #17 Katharine
    October 13, 2009

    Who cares how culturally insensitive we’re being on this? A procedure and a tenet of some system of medicine is either scientifically supported or not, full stop, because like it or not, human bodies have the same basic workings, with only slight differences from one human to another, in the scheme of things.

  18. #18 cathyk
    October 13, 2009

    You guys pretend to care about science. But all you care about is arguing.

    For instance, BB says in reply to my post that anyone who agrees with the original post suggesting that diet causes inflammation is “cherry-picking” citations.

    Geez. Look it up. There are, literally, hundreds of articles including large epidemiological studies and prospective trials in top journals (JAMA [Esposito 2004], Jour of Am Cardiology [Chrysohoou 2004]) ) establishing that changing the way you eat (consuming a mediterranean diet, or nuts, or, in one study, grape seed extract), decreases inflammatory markers (CRP, inflammatory interleukins etc) that are significantly associated with cardiovascular disease.

    This new emphasis on the role of inflammation as causal in CVD and as partially related to diet is the current “state of the science.” So, when you think you’re quackbusting, make sure you stay ahead of the curve: pick up your finger and read some studies and reviews. You won’t win any arguments if you can’t get the science right.

  19. #19 bobh
    October 13, 2009

    #14

    “Furthermore, I can’t believe the author was using the term the way PalMD has (‘Western’ medicine = scientific medicine). Basically, it’s a linguistic dance to create a strawman argument (he’s arguing that non-scientific medicine is not correct medicine).”

    And yet: (from the post he is critiquing) “Our version of medical reality has receptors, hormones and nerves, etc. Someone else’s medical reality includes energies, meridians, or doshas”

    It seems obvious to me that PalMD was right in his interpretation of the authors meaning of the term “Western medicine”

  20. #20 PalMD
    October 13, 2009

    Apparently I’m to much of an insensitive, closed-minded egomaniac to have been that thoughtful.

  21. #21 Whitecoat Tales
    October 13, 2009

    @Becca

    Stephanie, in arguing against the post, PalMD is assuming a certain definition for the term that I don’t believe is warranted

    The author of the post Pal is discussing is a medical student. PalMD is a doctor. The definition of the term is the one that we’re taught as convention in medical school. When someone talks about artemisin to me, they aren’t calling it ayurveda, they aren’t talking about “nonwestern medicine.” They’re talking about western style conventional medicine, and thats how they’re couch their language.

    Argueing about that would seem to be a nonissue, because from the context of the post, Pal and desifeminists are using more or less the same definition of the term.

  22. #22 becca
    October 13, 2009

    “It means that we need to study that group in a scientific way.”
    Studying it in a scientific way means figuring out a mechanism. However interesting it is to me (as a basic scientist) we don’t actually need to know the mechanism of a treatment working on a group.
    What medicine needs is to know the scientific basis (or or lack thereof) of the mechanism by which people are getting better from a disease. Does the improvement relate to the treatment, or not?

    “And yet: (from the post he is critiquing) “Our version of medical reality has receptors, hormones and nerves, etc. Someone else’s medical reality includes energies, meridians, or doshas”
    And yet: as someone who studies receptors, hormones and nerves fairly extensively, I can tell you many of our hypotheses about mechanisms involving them will turn out to be bunk. Particularly in the areas of nutrition and inflammation. We’ll get parts of it right eventually, and people that think about doshas probably never will. The scientific approach is vital to scientific knowledge. But scientific knowledge is ‘merely’ incredibly advantageous, not vital, to healing people.
    The most basic form of experimentation,trial and error, is not the exclusive province of Western medicine.

    “A procedure and a tenet of some system of medicine is either scientifically supported or not, full stop, because like it or not, human bodies have the same basic workings, with only slight differences from one human to another, in the scheme of things.”
    AHAHAHAHHAHAHAHA You wanna tell NIH they’ve wasted millions on “personalized medicine” research, or should I?

    @Whitecoat Tales- are you saying artemisin, derived from a Chinese herb, would be perceived as a Western treatment by desifeminist?

  23. #23 Whitecoat Tales
    October 13, 2009

    Having read the post, my impression is that artemisin pills, in a dose regulated purified form and prescribed by an MD would be perceived as western medicine by desifeminist, whereas whatever traditional herbal preparation processed in what is considered the traditional manner and given by a practioner of whatever alternative system arteminsin derives from would be alternative medicine.

  24. #24 MC
    October 13, 2009

    I don’t need to bash a hammer in to 35 randomly assigned subjects faces to know it’s a bad idea.

    sure, there are some alternative medical practices that we can dismiss fairly easily as at best having a placebo effect. i think it’s perfectly possible that certain herbs might be effective.
    also, a hammer to the face is obviously harmful, while many alternative medicines are not.
    it is possible to comment on certain alternative medicines and dismiss them, but not all of them have been studies by scientists, and those that have not shouldnt be dismissed without any proof.

    You are indeed very wrong. The National Center for the study of CAM (NCCAM) had spent billions of dollars studying virtually every form of quackery alternative medicine, and so far (to the dismay of folks like Tom Harkin) has shown quite convincingly that none of them work.

    according to wikipedia, NCCAM has only started studying the effectiveness of herbalism in 2004.
    http://en.wikipedia.org/wiki/Herbalism#Clinical_studies
    they did a few and found those herbs to be ineffective, but i dont think it’s smart to dismiss every herb out there simply because a few were found to be ineffective. it seems like the amount of studies on CAM hasnt been all that huge.

  25. #25 PalMD
    October 13, 2009

    That is incorrect. No one has dismissed all natural substances as being ineffective. In fact most of our pharmacopaea is derived from natural substances.

    What we object to is the double standard often granted to “herbs”.

  26. #26 D. C. Sessions
    October 13, 2009

    Receptors, hormones and nerves also have anatomic, physiologic, chemical and physical reality. Energies, meridians and doshas (whatever the hell they are) have none of these characteristics. Or can you convince me otherwise?

    Shorter: I can propose a repeatable test for the existence of receptors etc. which gets the same results regardless of who’s doing it. When you can do the same for energies etc. we can talk.

  27. #27 becca
    October 13, 2009

    So, then PalMD’s argument becomes:
    “whatever traditional herbal preparation processed in what is considered the traditional manner and given by a practioner of whatever alternative system arteminsin derives from” is “based on false, vitalistic, pre-scientific beliefs about nature”.
    Which might be true. So what?
    I for one would rather get Qinghaosu then leave a case of malaria untreated.

  28. #28 bobh
    October 13, 2009

    becca at 21

    “And yet: as someone who studies receptors, hormones and nerves fairly extensively, I can tell you many of our hypotheses about mechanisms involving them will turn out to be bunk. Particularly in the areas of nutrition and inflammation. We’ll get parts of it right eventually, and people that think about doshas probably never will. The scientific approach is vital to scientific knowledge. But scientific knowledge is ‘merely’ incredibly advantageous, not vital, to healing people.”

    You mean as in even a blind pig will find a few acorns?

    Sorry, I cal bullshit. See 8 above

  29. #29 Katharine
    October 14, 2009

    Becca, I never said the NIH has wasted millions on personalized medicine research. I’m saying that these differences are relatively minute and that people have in general the same biological mechanisms.

    I do know that we’ve adapted some treatments that have turned out to work (but because they were sort of crapshoots by the people that used them) from ‘alternative medicine’-type peoples, such as the use of artemisinin; does that mean we should go about calling chakras and doshas legitimate? NOOOOOO. Because, as I said, these people’s finding of treatments that turned out to work were crapshoots.

    Trial and error is part of it. But there are numerous problems that can crop up, such as experimental bias, in an experiment. Alternative medicine and groups that do not subscribe to the scientific method do not rule these things out. Surely you, as a fellow member of the scientific community, know about certain things that have to be controlled for in scientific studies. Why do you think double-blind trials exist?

  30. #30 becca
    October 14, 2009

    I think I’m not communicating the distinction I draw between medicine and science.
    Medicine is the act of treating patients- the goal is to cure the disease.
    Science is the act of acquiring knowledge- the goal is to understand the mechanism of the treatment.

    Desifeminist and PalMD both seem to be conflating them.

    You can have a modern medical treatment and traditional way of looking at the mechanism (someone out there probably explains antibiotic efficacy using chakras). You can also have a traditional treatment, e.g. Qinghaosu, and a modern scientific explanation, e.g. ROS production (or ETC inhibition, or calcium transporter blockade, or whatever you like).
    Whether the explanation is correct is discrete from whether the treatment is effective.

    bobh- given that you can use pigs to hunt truffles in the night, I suspect blind ones could sniff out acorns.

    Taking that analogy back to the topic, let’s say finding the truffles = curing the disease.
    Follow scientific processes is like looking for truffles during the day. It allows you to describe the location in detail and report back to others so they might find your truffles.
    (For the record, I believe if you want to maximize collective future truffle finding, it’s the best show in town.)

    If you follow trial-and-error (as people have for thousands of years) it’s like using a pig to sniff out truffles in the dark.
    You won’t be able to tell anyone how to get there, but you still get some delicious, delicious truffles.

    When you try to find a new drug, there are lots of options.
    If you have a target, you can use it to screen a chemical library of existing pharmaceutical compounds and structural variants (comparably quick and cheap, but not especially likely to find novel treatments).

    You could also screen against random peptides (better at novelty but not necessarily effective).

    Whether you have a molecular target or not, you could go to the Amazon, or coral reefs, or another area of rich biological diversity, and collect specimens naturalist style. You can use your scientific reasoning about what might be useful (e.g. poison dart frogs might have Ca2+ channel blockers). Or you can harvest a bunch of plants to see what works in a tractable model or assay.

    Finally, you could talk to indigenous peoples and ask what their pharmacopeia contains, whether you end up using it against the same diseases they do or not.

    Each approach has pros and cons. Any of these approaches will lead to a very small number of hits for an enormous number of misses.
    The cultural insensitivity to avoid is the one that leads you to dismiss the later two approaches out of hand. Worse yet, cultural insensitivity could lead to remembering only the hits from the former approaches and only the misses from the later (unless you *check* yourself for this kind of bias, you’ll never even realize you’re doing it).
    Worst of all, cultural insensitivity can lead to assuming effective treatments cannot come out of the later processes.
    I don’t think PalMD explicitly believes these things. However, if one dismisses artemisinin because it’s original use was based on “false, vitalistic, pre-scientific beliefs about nature”, it would be both culturally insensitive and illogical.

    On the other hand, believing that artemisinin should not be accepted based solely on “false, vitalistic, pre-scientific beliefs about nature”… well that’s culturally insensitive too. In a sense, it’s culturally insensitive to think science is the best way of knowing. But at least there’s some logical support for this type of cultural insensitivity (“science: it works, bitches!”- xkcd)

    If PalMD only possesses the type of cultural insensitivity that leads him to value science, I (of all people) certainly can’t fault him. But he shouldn’t be shocked if sloppy communicating (e.g. lumping all CAM treatments together) leads people to think he’s guilty of the former types.

  31. #31 PalMD
    October 14, 2009

    becca, that’s very well said, but in many ways incorrect, but only because you are arguing against a point that hasn’t been made (at least not intentionally).

    We (meaning docs, etc) don’t very much care where our interventions come from, as long as they are shown to be safe and effective (in some sort of arbitrary balance). We know that many of our drugs were developed based on observations of “just plain folks”. That’s fine.

    What isn’t fine is the assumption that human observation is accurate enough to cause us to adopt a practice without subjecting it to modern analysis. Physical reality is apolitical—our interaction with it is not. As many readers have pointed out, antibiotics work whether or not you believe in them. Not so much for most so-called alternative therapies, and if we understand that they work and incorporate them into modern practice, it is not a tautology to say they are no longer alternative.

  32. #32 Radioactive afikomen
    October 16, 2009

    And to everyone’s comments I say: tl;dr :)

  33. #33 Aaron Boyden
    October 16, 2009

    There are plenty of people who use words like “scientific” and “objective” and for that matter even “evidence” without having much idea of what they really mean, even among those who would claim to be defending rather than criticizing scientific ideals. For them, “scientific” has a strong connection to current Western cultural practices, and it is unsurprising that there are critics who condemn the fetish version of science as just another cloak of Western imperialism (since that’s what it is). It’s also fairly unsurprising that the critics have trouble telling the difference between science as rhetorical cudgel and real science; almost everybody does, which is why science is so often misunderstood and misapplied by people who believe in it.

    Because empirical evidence trumps all in properly conducted science, in principle one could always check for one’s self to see if a particular scientific claim is well justified, or more realistically if a study has been done by people you don’t trust, you can try to find people you consider trustworthy who have done the same thing and see what results they get. Practically, we mostly rely on the fact that scientists are checking up on one another all the time, which certainly isn’t as good, but is obviously vastly better than nothing. At no point should anyone be accepting anything just because of authority, because Science says it (as if science were an individual, like a pagan god) or because some scientist says it; authority shouldn’t enter into the picture. But people like to exert authority, even scientists, and people like to trust authority at least some of the time, so the misuse of science as a source of authority is probably inevitably going to be widespread.

    I hesitantly suggest that one might make better progress at defending the real ideals of science by campaigning against those who misuse it as an authority than by attacking people who criticize its misuse as an authority. Even if the latter are more badly confused (as perhaps they are), they are also far less likely to be affected by your criticism, while the former are often in positions where they can be undermined and their influence lessened if their violations of the true ideals of science are publicized. Indeed, laughing at the critics of authority of science is disturbingly like the way the privileged always laugh at the inferiors they find so pathetic.

  34. #34 Joe
    October 16, 2009

    “I for one would rather get Qinghaosu then leave a case of malaria untreated. Posted by: becca | October 13, 2009 4:46 PM”

    I am too lazy to look it up; but if Qinghaosu is Artemisia, you should know that not every sample of that herb contains artemisinin. That is, taking the herb is not necessarily taking the drug. If Qinghaosu means something else, it is probably ineffective just like most Chinese herbs that were traditionally used for malaria.

  35. #35 MonkeyPox
    October 16, 2009

    Aaron summarized:

    Respect my athoriteh as a philosopher, dammit! you use words wrong! And you beat up on the wrong people!

    Dude, don’t you have your own blog?

  36. #36 ildi
    October 16, 2009

    MonkeyPox summarized:

    troll

  37. #37 riotnerd
    October 16, 2009

    This gives me a splendid idea based on a combination of traditional Christianity and Monty Python’s dead parrot sketch. As you “western” medical doctors probably aren’t aware, the traditional beliefs of the Christianity religion (a fairly obscure cult started in the middle-east that follows a dead charismatic)holds that life continues after the physical body perishes. My Christian mortality clinic will guarantee 0% mortality for all patients. People can come in with any disease they would like treated, hell they can wheel in corpses, and I will guarantee survival. All that is required is acceptance of my “other way of knowing,” i.e. Christianity. My patients will be much better off because instead of just treating the symptoms of death I will address the true causes and underlying problems, i.e. being dead.

  38. #38 adina
    October 16, 2009

    I hope this woman’s patients do not suffer from her faith in the practices of past ancestors, simply because it’s “traditional.” Some of my ancestors may have been intelligent, but I’m sure many of them thought the earth was flat, and loyalty does not oblige me to insist they were right. I don’t want my great-great grandchildren to uphold something that I believe, if the belief is later repudiated by evidence.
    Clinical evidence is essential for every-day medical decision-making, even for those who practice only modern medicine. If you get back a lab result, but you don’t know or understand the approximate positive predictive value of that particular test, how could you possibly assess whether or not the patient has the disease?
    How could you recommend an intervention or medication to a patient without caring about its efficacy or side effect rates, relative to a placebo? Based on what the local rumors are?
    Many people, throughout history have been wrong, and many traditional medical practices contradict others’ traditional medical practices. What does a willingness to update your fund of knowledge, based on evidence, have to do with the “West,” other than the fact that “Western” countries can afford to conduct a greater number of clinical trials?

  39. #39 red rabbit
    October 18, 2009

    @ becca: I see what you’re saying, but mechanism is not the only province of studies, regardless of which part of science you happen to know best.

    I learned proposed mechanisms for most of the drugs I prescribe on a daily basis, but the fact is, the mechanisms are only obliquely relevant if we have good evidence, from science, in terms of good quality randomised controlled trials, which shows that the drug in question indeed works. That’s where the “just because it works doesn’t mean it’s western medicine” falls down.

    Once there is evidence that it works, it BECOMES western medicine. Because there is evidence.

    Everything we have in western medicine was once a herbal remedy. Aspirin= willow bark. Digoxin= foxglove tea. Taxotere= yew bark extract.

    We use statins daily, but evidence points to what we considered the mechanism to be an irrelevant side effect, and the effect coming from a different action. Who cares: they work. Basic scientists will figure it out, but in the clinic, nobody cares.

    If there was evidence that acupuncture did the job, I don’t give a rodent’s rear how it works (well, I do, but that’s not the point), I’d be poking holes in my patients. SHOW ME THE STUDIES (a la Jerry Maguire).

  40. #40 Samia
    October 25, 2009

    Oh, Becca. *hearts* Sometimes there’s no point in even trying…

  41. #41 PalMD
    October 25, 2009

    Oh, samia, i totes want your input, if you’re willing.