Monday, January 23, 2006

I could have said it better

If you're a blogger, don't you hate it when a commenter either says something better than you did or makes a point that you should have made in a post?

So do I.

However, I believe in giving props to commenters who manage to one-up Orac, so much so that I even preempted my intended post for today (a rare straight medblog-style post about a rather disquieting patient encounter I had a while back--so stay tuned for it) with this post instead. So, regarding my post about "ethnoscience" and how I viewed it as nothing more than a a bunch of alties trying to change the definition of science to include their particular brand of woo-woo, much as "intelligent design" creationists did in Kansas recently, John Stone added this comment:
Ethnoscience is just good old whacked-out postmodernism with a few twists. (When is the last time you made an appointment with your witch-doctor?) Dr. Robert Imrie did a incredibly good job of disecting one "EthnoVeterinarian" case at this location. This is one of my favorite pieces of writing on the net.
He's absolutely right. That's exactly what it is, nothing other than a form of postmodernism, and the link he mentioned is well worth checking out. The best one-liner:
As we’ll see, in the context of ERD&E, the term “research” refers not to the critical scientific investigation of traditional or folk medical practices, but to their “judgment-free” investigation and “validation” in accordance with the tenets of cultural anthropology.
And that's exactly what advocates of "ethnoscience" want for their various unscientific and/or religious "healing arts." Indeed the Dr. Imrie nails it exactly right here:
In any case, I’m certain that advocates of scientific biomedicine share my conviction that various “traditional medical systems” merit rigorous but open-minded scientific evaluation. Who can say what treasures these resources might yield? I suspect that conventional “Western” and even “Third World” veterinarians share Dr. McCorkle’s and my eagerness to “integrate what works in folk medicine” with “what works in scientific biomedicine.” Where we differ seems to be in how we propose to determine “what works and what doesn’t.”
Precisely. Advocates of "ethnoscience" seem to think that we in Western medicine should just accept on faith that the various therapies they're enamored of do what the healers claim they do or that we should subject the claims of "ethnoscience" to a lesser standard of proof (special pleading again). Their underlying assumption seems to be that, because millions of people have believed for hundreds, if not thousands, of years that these therapies "work," they must have efficacy or, at the very least, there must be something to them. Well, maybe or maybe not. In many cases, that millions of people believe in something is irrelevant to whether that something is correct. For example, millions of people have believed for thousands of years that ghosts exist, among other examples of superstitious, religious, or pseudoscientific beliefs that large percentages of the population hold. Does that mean I should just accept that there might be something to the contention that ghosts exist and communicate with the living without demanding scientific evidence? No! What about astrology? Millions have believed in it for thousands of years as well? Should I just accept it as having the same validity as astronomy for that reason. Of course not! Yet the underlying assumption, usually unspoken but not always, of "ethnoscience" seems to be that we should, often with the not-so-subtle implication that, if we don't, it is due to racism or elitism. Indeed, the very coining of the term "ethnoscience" seems a conscious effort by its advocates to imply that we should accept its claims as co-equal with those of science.

So what's wrong with anecdotes, personal experience, and folk wisdom in determining what treatments "work." It's not that anything is "wrong" with it per se; it's more that we now know that it is not the best way to determine whether a treatment works or is widely applicable. We medical researchers know from the history of science and through long and bitter experience just how easy it is for limited sample size, confirmation bias, regression to the mean, selection bias, and other confounding factors can lead us into thinking a treatment works when it does no. We also know how easy it is for doctors to allow inherent biases and their desire to help people lead them to become too attached to a therapy's supposed efficacy. What seems to be poorly understood among the lay public is that randomized clinical trials exist not because we as physicians and investigators trust ourselves or other scientists but rather because we know that human nature is such that we can't trust ourselves or other scientists to be totally objective. In addition, as hard as it might be for us to accept, we can't trust our own personal experiences to be generalizable to all patients. That's why we need objective measurements, double-blinding where possible, and randomization.

What also infuriates me about much of alternative medicine is that the attitude seems to be that we should have to test everything, even if there is no plausible scientific basis for the proposed therapy. So, while I'm giving other bloggers props for explaining and reinforcing what I'm trying to say, I might as well point out that Dr. RW put it nicely when he decried this attitude:
Other notions proffered for “research” are, in my considered opinion, exercises in pseudoscience---attempts to validate claims that have been debunked and have no biologic plausibility. What’s the point of looking for clinical effects of energy fields undetectable by instruments of physicists and Star Wars forces left behind in water after active ingredients are diluted out?

A strict empiricist might object to my requirement of biologic plausibility, but I maintain a line must be drawn. Otherwise we might as well burn the chemistry and physics books and study every claim that comes along. Why stop with Therapeutic Touch, Homeopathy and Reiki? Let’s go on down the slippery slope and fund studies of astrology, telekinesis and shamanism. And while we’re on the subject of energy medicine why not resurrect Franz Mesmer’s theory of animal magnetism? If only we do enough research his claims will surely be validated. (Discredited in the 18th century, Mesmer would likely be on faculty at a medical school today).
This is a stronger statement what I've been saying all along, but have been perhaps a bit wimpy in emphasizing. Consider, for example, the very concept of homeopathy, the "healing art" that claims that you can dilute a substance to the point where there isn't even one molecule of the original substance in the water, and that the water somehow retains a "memory" of the compound such that it is effective in treating disease. For homeopathy to work, the very foundations of our understandings of chemistry, physics, and biochemistry would have to be seriously flawed or just plain wrong. It may be possible that homeopathy works by some previously understood chemical or biological mechanism, but it's so unlikely that it does that it is incumbent upon advocates of homeopathy to produce clearcut and convincing evidence that it works, not for conventional medicine to "prove" that it does not. The same should apply to any therapy that claims to manipulate "qi," an "life energy" that no physicist or instrument can seem to manage to measure (yet which practitioners of traditional Chinese medicine assure us that they can manipulate to heal patients), or to the African shamanism that whose inclusion in an exhibit on "ethnoscience" I decried. Why should I take this seriously if practitioners cannot show me how to measure qi empirically or by what mechanism chi can lead to healing?

Contrast this desire for acceptance without meeting the standard of science by "ethnoscience" advocates with a recent example from the world of conventional medicine, namely the discovery of H. pylori as the cause for most duodenal ulcers by Robin Warren and Barry Marshall. Yes, Marshall and Warren's ideas were met with extreme skepticism and even ridicule when they first presented their hypothesis that the cause of most duodenal ulcers was bacterial. One of the criticisms was that the proposed mechanism wasn't biologically plausible, that it didn't fit in with existing science. If Warren and Marshall had been alties, they likely would have whined that they weren't being taken seriously by the "conventional medical establishment" or perhaps tried to pull the Galileo gambit prematurely. Fortunately for ulcer patients everywhere, they were and are scientists. So they did what scientists do. They did experiments. They gathered more data. The data was convincing, so much so that other investigators started to wonder if maybe Marshall and Warren might be on to something about H. pylori after all. More investigators started looking into the possible connection and found the same thing. Over a decade, momentum gathered, until there was a paradigm shift in the late 1980's and early 1990's, and a new scientific consensus developed. Warren and Marshall earned the right to be taken seriously, and, in fact, their efforts led them to be taken so seriously that they were awarded the most prestigious prize in medicine last year.

As I've said time and time again, I'm all for scientifically testing various alternative medicines for efficacy and examining mechanisms by which those with efficacy exert their effect. However, we don't have the unlimited resources that it would take to do clinical trials on every claim made by alternative medicine advocates, which is why we need a "triage" system to decide which are worth looking at in more detail. We need reasonable criteria for determining which ones are worth evaluating scientifically. To me, one very basic first screen should be that the therapy being proposed should have a biologically plausible mechanism by which it might work, even if somewhat tenuous. By that standard, many herbal remedies would likely be worth checking out, given that many substances herbs and plants have pharmacological activity. Energy healing would not, because this energy or "qi" cannot be measured, detected, or even objectively described in a way that science can study it. Acupuncture would fall somewhere between as possibly worth checking out. Even though we have to do a bit of handwaving to come up with a semiplausible physiologic and biologic mechanism by which it might work, such mechanisms can be proposed. Not so for homeopathy, pyramid healing, various forms of shamanistic "spirit" healing, or distance healing. The likelihood that any new or efficacious therapy would come from studying these latter alternative medicine therapies is so low that they should be at the bottom of the list in terms of dedication of resources to study them.

It is indeed important to test alternative medical therapies, as there may indeed be hidden gems that we in medicine could appropriate and integrate into our therapies, to the benefit of our patients. However, it is equally important that we do not dilute this effort by evaluating therapies whose basis is without biological, chemical, or even scientific plausibility, unless very clear evidence of efficacy is demonstrated by their advocates.

10 example(s) of insolence returned:

At 1/23/2006 11:14 AM, Blogger BigHeathenMike said...

Another great post - you are the first site in my bookmarks and I read you every day. I can't tell you how many time I have to explain to people at my work (I'm a massage therapist) how homeopathy or reiki or reflexology have no basis in reality and that they just don't work. Thanks for the great writing!


At 1/23/2006 12:38 PM, Blogger MichaelBains said...

I can't tell you how many times I've sat peacefully in my personal pyramid and thanked Marshall and Warren for making Prilosec OTC possible!

You were actually a little, hhmmm, tamer than usual today Orac. Great, and as frequently is the case, quite helpful post.

(I am, of course, kiddin' 'bout sittin' in one of those pyramids! LOL!)


At 1/23/2006 3:52 PM, Anonymous Nana said...

On of my favorite articles at the vet-taskforce is the one debunking the myth that only "20% of Western medicine is evidenced based"

OT: Thanks,Orac, for adding the IE scrolling finger thanks you too.


At 1/23/2006 5:18 PM, Anonymous Sean Foley said...

Orac, as much as I enjoy your site and your criticisms of various bogus altieisms, I think you (and the page you link to) are coming at this from a problematic perspective. Imrie's claim that the purpose of ethnoscientific research is not critical scientific validiation is at least partially correct, but also misses the point. Ethnoscience in its broadest sense can include interdisciplinary interactions between the physical and biological sciences and the social sciences; take, for example, ethnobotany, a discipline that attempts to understand the cultural uses of plants. In examining how a certain population uses plant remedies (for example), it is not necessarily relevant to ask whether or not the treatment is actually effective to understand how it is used and understood within the context of the society being studied. As an analogue, consider your earlier posts on the exhibition of Egyptian medicine texts. Many or most of the treatments outlined in the exhibition are of little to no value in actually curing a patient's aliments, but were understood as legitimate medical practices by ancient Egyptians. In studying a particular culture, then, it is both possible and academically legitimate to examine "scientific" practices without necessarily considering how well (or even if) they match our current understanding of the relevant science.

This is not to say that "ethnoscientific" practices and understandings should necessarily be placed on equal footing with scientific practices and understandings, merely that Imrie criticising the anthropological aspects of ethnoscience for following anthropological methodologies seems to display a certain misunderstanding.


At 1/23/2006 6:08 PM, Blogger Orac said...

Actually, I think you may have missed the point (either that; or I didn't make it as well as I should have).

In this example, "ethnoscience" is clearly being used as a marketing term to give the patina of science to these various remedies. The museum was not advertising this event as simply an exhibit of what other cultures have done and what they have considered to "medicine" or science. If it had been (like, for example, the exhibit on Egyptian medicine, I would have had no problem with it.) No, in their advertisements, they actively encouraged people to try out these various altie remedies and gave forums to people who claim that these methods are effective/

Calderon, for example, was clearly trying equate "ethnoscience" and science. They also went out of their way to have talks by some academic physicians promoting these remedies.

No, I don't think I missed the point at all.


At 1/23/2006 11:00 PM, Anonymous Sean Foley said...

Sorry, I should have been more clear. I don't think your criticisms of the Newark Museum's program missed the point; that is, as you said, a misguided attempt to legitimize various forms of "ethnoscience" as equally effective alternatives to Western medicine. My criticism was of Dr. Imrie's essay which, to my mind, was overly vociferous in condemning the anthropological side of ethnoscience for being anthropological and, in turn, of what I saw as your endorsement of this point of view. I'm also not entirely clear on why the postmodern aspect of ethnoscience warrants such derision when considering the social science aspects of the discipline. (Not the medical or "hard" scientific aspects of it, of course. Yes, knowledge is socially constructed, but that doesn't mean echinacea will do a damn thing for the cold I've got.)


At 1/24/2006 7:16 AM, Anonymous robopox said...

Is there a list of plant-derived therapeutics that occur in plants in therapeutically significant levels? Digitalis from foxglove, salicylates from willow bark (but just how much of that tea would you have to drink to ease the pain of peasantry in 14th century Briton?), the opiods from poppy, quinine (but it was for shivering, and it's use predates the introduction of malaria to S. America).... and what else? (perhaps arteminisn.... if it truly was used for malaria in China).
Nothing else significant comes to mind.
Botanical/ethno chemistry has yielded some great drugs (but never a good antibacterial of proven 'historical' efficacy - strange they could never seem to do a damn thing about pneumonia, or gangrene, or scarlet fever, or leprosy, or diphtheria.....).
With the exceptions noted above, the rest seem to be vast exercise of post hoc pseudoscience.
"Culpeppers Herbal said it worked 300 years ago, and SEE! there WAS something there!"
yeah, sure..... both micrograms per kilo.


At 1/24/2006 7:45 AM, Blogger bcpmoon said...

This passage has let me think of the ID-movement:

"The core of the problem, of course, is that real science tends to work, and most “other ways of knowing” – including social and political “sciences” and cultural anthropology – tend not to work very well, or at least they fail to yield tangible and consistent results.

Rather than addressing the inherent deficiencies in their belief systems, some cultural and medical anthropologists have, instead, focused their energies on discrediting legitimate science under the rubric of cultural relativism."

Replace “other ways of knowing” and "belief systems" with religion and voilá: ID.


At 2/10/2006 1:01 PM, Anonymous alternative health said...

This comment has been removed by a blog administrator.


At 2/10/2006 1:55 PM, Blogger Orac said...

Comments closed due to comment spam. Sorry.


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