Notes On 'Trick Or Treatment'- Introduction & Chapter 1 by Ernst & Singh.

I've just started this book on the advice of Daniel viz. my Naturopathy blog the other day. While this is not strictly on that subject this book discusses so-called 'Alternative Medicine' (hereafter: "AM"), as this is a subject of this blog I shall include it (as well as posting it on my other blog too) here.

This book, at the introduction sets itself up as a science based book, explaining why that it is:

"Science employs experiments, observations, trials, argument and discussion in order to arrive at an objective consensus on the truth. Even when a conclusion has been decided, science still probes and prods its own proclamations just in case it has made a mistake, In contrast opinions are subjective and conflicting, and whoever has the most persuasive PR campaign has the best chance of promoting their opinion, regardless of whether they are right or wrong." (Ernst & Singh, pg-1, 2008)

They also define AM as follows:

"our definition of alternative medicine is any therapy that is not accepted by the majority of mainstream doctors, and typically this also means that the alternative therapies have mechanisms that lie outside the current understanding of modern medicine. In the language of science, alternative therapies are said to biologically implausible." (Ernst & Singh, pg-1, 2008)

As we see, on the first page, much of what I was trying to say, admittedly less effectively in the Naturopathy blog, is discussed here, and is in fact their manifesto. The authors are trying to distinguish between what they later call "evidence based medicine" (hereafter "E-BM") and opinion based medicine (and the important differences between both). Ernst and Singh take quite a strong stance on science, but the authors justify this by establishing just what we have science to thank for, in the sense that, everything we know about the universe, medicine, antiseptics, eradication of disease are all built upon "scientific foundations" (pg 5), we can apply their meaning to these purposes only without getting bogged down in a discussion about worldviews (at least in the first chapter anyway). They go so far as to claim that "the scientific method is without a doubt the best mechanism for getting to truth" (pg 5), which I personally agree with (or at least admit it is at the top of a very short list of things), but can see others contending that issue (though it is hard to argue with its results!).

Chapter 1- How Do You Determine The Truth?
In this chapter Enrst and Singh begin to define what they mean by an E-BM approach:

"(evidence-based medicine) has revolutionized the medicine practice, transforming it from an industry of charlatans and incompetents into a system of health care that can deliver such miracles as transplanting kidneys, removing cataracts, combating childhood diseases, eradicating smallpox and saving literally millions of lives a year." (Ernst & Singh, pg-7, 2008)

They go through several stories (including the apparent murder of George Washington [pg 11] due to the inaccuracy of his physicians) demonstrating some horrible techniques previously performed (bloodletting and leeching for example). Leading into the first uses around the time of Washington's death (1790's) of E-BM by Scottish Naval surgeon James Lind (pg 22-3), who Enrst and Singh accredit with being the first on record to perform clinical trials on the sailors of his ship who were dying from scurvy (discovered later to be caused by a lack of fruit on the boat), even if he failed to publish his accounts (which Enrst and Singh say is important as it gives others a chance to review, critique and test your methodology and conclusions pg 22).

The authors continue to weave a tale through history discussing the advances made in science and E-BM medicine by the lights of radical ideas (clinical trials, randomized trials etc), often those ideas pushed against the establishment and under opposition (as in the case of Hamilton who did the first randomized clinical trial to understand the mechanisms of bloodletting, pg 22). Enrst and Singh quote Alexander MacLean (who used medical trials in India in 1818 to test his treatments) in regards to those who practised medicine without any evidence as:

"a continued series of experiments upon the lives of our fellow creatures." (Ernst & Singh, pg-23, 2008)

From this we can see that even almost 200 years ago there was resistance by some people to the concept of merely letting doctors and health care professionals simply have at their patients, or running their practices based on authority, tradition, ad hoc reasoning or confirmation bias, that a call to reason was apparent. As Ernst and Singh elaborate:

"Prior to the clinical trial a doctor decided his treatment for a particular patient by relying on his own prejudices, or on what he had been taught by his peers, or on his misremembered experiences dealing with a handful of patients with a similar condition. After the advent of the clinical trial, doctors could choose their treatment for a single patient by examining the evidence from several trials, perhaps involving thousands of patients." (Ernst & Singh, pg-23, 2008)

This leads Enrst and Singh on to discussing the crux of this chapter, E-BM, how people outside of the medical establishment find it "cold, confusing and intimidating" (pg 24-5) which is something I've certainly noticed, I would also add that people tend to have an interesting distrust of E-BM (or perhaps pharmaceutical companies?). I think Ernst and Singh are referring more to proponents of AM, and how they perceive the E-BM crowd as trying to protect it's own members, their treatments and excluding outsiders (pg 26). They counter this by suggesting that E-BM actually works in an opposite fashion (pg 26) , that any remedy or cure, can be accepted by an E-BM advocate if it has adequate evidential support (more on exactly what that means later in the next chapter on Acupuncture where Ernst and Singh go into great depth on clinical trial methodology), as we will see below with the case of Florence Nightingale. They temper the response to E-BM with a reminder about how the world was before the widespread use of clinical trials (the examples of deaths in the book in a matter of 200 years runs into the millions, pg 25), the amount of unnecessary death was rampant.

An interesting story they tell is that of Florence Nightingale, who I knew in name only, (her story is an interesting one, for the full account see pages 26-31), she managed to show another benefit of E-BM and that is; in using it to disseminate the information gleaned from clinical trials. As Ernst and Singh elaborate:

"The results from scientific tests are so powerful that they even enable a relative unknown as Nightingale- a young woman, not part of the establishment, without great reputation- to prove that she is right and that those in power are wrong, Without medical testing, lone visionaries such as Nightingale would be ignored, while doctors would continue to operate according to a corrupt body of knowledge based merely on tradition, dogma, fashion, politics, marketing and anecdote." (Ernst & Singh, pg-31, 2008)

This demonstrates at least one example, and a stark one it is, of how the apparent medical establishment, who according to some, don't listen to the advice of outsiders, had to listen and be convinced by the evidence provided to them. It seems evidence is all it takes to convince people, if AM could provide some, perhaps we would listen? I'm getting ahead of myself a bit though.

A final example of the benefits of E-BM and perhaps one of the greatest findings of all time is the work done in 1954 by Hill and Doll in regards to the dangers of smoking. They started a study in 1951 to investigate smoking's link with cancer, they used 30,000 British doctors, to study over 5 decades, yet a clear pattern emerged in 1954! The cigarette companies fought Doll and Hill but they fought back:

"and demonstrated that rigorous scientific research can establish the truth with such a level of authority that even the most powerful organizations cannot deny the facts for long. The link between smoking and lung cancer was proved beyond all reasonable doubt because of evidence emerging from several independent sources, each one confirming the results of the other." (Ernst & Singh, pg-32, 2008)

Which leads Ernst and Singh into another salient point I think it worth mentioning about E-BM:

"It is worth re-iterating that progress in medicine requires independent replication- i.e similar studies by more than one research group showing similar findings. Any conclusion that emerges from such body of evidence is likely to be robust." (Ernst & Singh, pg-33, 2008)

Conclusion
This chapter to me at least, really demonstrated some of the horrors that have been committed, quite innocently mind you, by faulty methodology, by not following the evidence where it leads and allowing tradition to run the schema by which a doctor operates. Thankfully there were multiple visionaries who saw ways to independently and objectively verify their methods, so as to base their medicine on the evidence. Millions (and more) lives have been saved due to the advances in E-BM, in treatment, vaccines, hygiene, cures etc, all based on sound evidence, testing, review and publication. If we continue to treat people with methods that don't pass evidential muster, then we are rolling the dice with the outcome, which is a regressive mindset, one we fought, with a major loss of life, to shed ourselves of.

From this we move onto an analysis of Acupuncture. Stay tuned for more.

Reference
Ernst E., Singh,. S. (2008). Trick Or Treatment. New York, New York. W.W Norton & Company. Pp- 1, 5, 7,  22,  23, 24, 25, 26, 31, 32, 33.