Monopoly
Medicine Prevents Real Healthcare
by Alan Cassels
It
was 260 years ago this month (May 20th, 1747, to be exact) that a British
naval physician began what some have called the world's first clinical
trial. At the time, the biggest scourge of the Royal Navy was not enemy
cannon fire from the French or Spanish fleets, but scurvy, a disease that
left sailors weak, bleeding and incapacitated, often killing them.
No one knew anything about vitamins then, and even less about vitamin
deficiency. A 31-year-old naval surgeon, James Lind, hypothesised that
foods high in acid content might help, so he tested 12 sailors suffering
from scurvy and divided them into six pairs. In addition to their regular
meals, he fed each pair different things, such as garlic, seawater, cider,
vinegar, oranges and limes, and within a few weeks it was obvious which
worked best: While the orange and lime pair regained their strength and
went back to work, the others worsened. This discovery was of no small
import; preventing scurvy contributed enormously to the massive strength
of the British navy and Britannia would rule the waves for the next almost
200 years.
Lind's elegant, little nutrition experiment comes to mind when I ponder
the debates in Canada over the sustainability of healthcare, the perennial
discussions about how much healthcare we can afford and the public's concern
around what is considered ‘legitimate’ healthcare, worthy of
public coverage.
Canadians now spend in excess of $20 billion per year on prescription
drugs, an amount that is growing at a rate of about $1.5 billion per year.
While some argue that this money is a good investment in healthcare, leading
to longer and healthier lives, others say that our growing dependence
on high-tech pharmaceuticals is leading us in the opposite direction where
we get diminishing - and some would say negative - returns for all this
new money.
Like human-induced climate change, there are a lot of inconvenient truths
around the sustainability of publicly-funded medical care. Sadly, the
debate is mired in arguments around who should pay (public versus private),
as opposed to what we should pay for. Those who have thought deeply about
this issue have suggested ‘integrative solutions’ to the current
healthcare crises, where we start rethinking the contents of our publicly-funded
healthcare basket and make some hard choices about paying for effective
care.
At the end of May, a conference at the University of Victoria may hold
a key to cracking the nut of unsustainable health care. Sponsored by the
Association of Complementary and Integrative Physicians of BC (ACIPBC),
a group of physicians aiming to shape a healthcare system that draws from
both worlds - orthodox medicine and 'complementary and alternative' medicine
- the Body Heals Conference (http://www.bodyheals.ca)
brings together an array of luminaries in the fields of integrative care.
No doubt the conference will, at the very least, provide some grist for
the mill as the government continues its public ‘Conversation on
Health’ in BC.
BC's expert in the field of integrative medicine is Dr. Warren Bell, a
family physician from Salmon Arm who also happens to be the current president
of the ACIPBC. For the past 27 years, Dr. Bell has been a keen observer
of the relationship between the pharmaceutical industry and the medical
profession and the field of therapeutics in general. He maintains that
integrative healthcare chooses from the entire palette of effective options,
some of which are orthodox - drugs and surgery - while others are complementary,
such as massage therapy, nutrition therapy, naturopathy and herbal treatments.
Critiques of complementary or integrative medicine usually revolve around
three main concepts: Evidence, respect and public funding. Many doctors
and patients believe that ‘real’ medicine is based on solid,
scientific evidence, that it is respected and practised by the medical
mainstream and that it is taught in medical school and paid for by public
funds. These beliefs neglect to consider that a myriad of political decisions,
along the way, determine which therapies are included in the basket and
which aren't. Practitioners of integrative medicine, such as Dr. Bell,
are aware of the political and economic issues that influence the basket's
contents. They believe, as I think most of us do, that the value of a
therapy should be judged on its therapeutic efficacy, not on politics.
Let's look at the three arguments:
1) Integrative medicine is not evidence-based
In terms of ‘evidence,’ you won't find many 5,000-patient clinical
studies of complementary medicine (unlike patented pharmaceuticals), but
that doesn't mean these therapies aren't based on good research. Most
medical knowledge is not derived from studies of thousands of patients,
but physicians can still be guided by careful research, observation and
well-controlled, but smaller, studies. How many patients did it take to
prove the efficacy of lime juice to prevent and treat scurvy? Twelve.
With many big drug studies, the effect sizes are so miniscule that the
studies need thousands of patients to prove statistically-significant
results. Many experts will tell you that complementary medicine is not
evidence-based, but, as Dr. Bell notes, ‘Those who say that alternative
medicine isn't based on good evidence have resolutely refused to look
at the evidence.’
2) The medical mainstream does not respect integrative medicine
Many of us have had the experience of broaching the subject of this herb
or that vitamin with our doctors only to be warned that we shouldn't be
taking our chances with ‘untested’ therapies. Why do our doctors
dis the alternative or non-drug approaches to treating illness? The answer
is complex, but one key culprit is undoubtedly the dominance of the pharmaceutical
industry in the education of our physicians; the non-patented alternatives
rarely get much air-time. Physicians typically learn about new developments
in medicine at medical education seminars, dinner meetings and professional
conferences, which are still highly dominated by pharmaceutical industry
funding. When pharma is funding our doctors' education, which, by its
very nature tends to ignore or discredit the non-patented alternatives,
should we be surprised that those paying the piper are calling the tune?
3) Integrative medicine is not paid for by public funds, therefore
must not be worthy of payment
It's true that if the public pays for something, it is perceived to be
valuable, but there are many examples of low-cost, simple therapies that
aren't covered by the public purse. While we spend billions more every
year on new drugs, even a fraction of that money could fund interventions
to get patients eating better, exercising more and even supplying them
with important supplements. What about prescribing a shot of lime juice
to prevent patients from getting scurvy? This is not a facetious question;
some research has suggested that up to a quarter of the US population
may be deficient in vitamin C. Why the vitamin shot treatments are still
not covered is a mystery, especially in cases where there is clear evidence
that a patient is suffering from a proven vitamin deficiency, and that
vitamin supplementation may keep people out of hospitals and save them
paying for other costly medical treatments.
The one example that infuriates Warren Bell is the use of hyperbaric oxygen
in treating deep infections. Putting a patient in a hyperbaric chamber
and using oxygen in a pressurised environment can increase oxygen to injured
tissues, reduce swelling, improve healing and help fight infection. And
there is very good, randomised, controlled evidence that supports the
many benefits of hyperbaric oxygen. While it's no ‘miracle cure,’
by all accounts, it's very effective. For people with diabetes, who often
get ulcers in the lower extremities, which often require amputation, hyperbaric
oxygen therapy might be the best thing going. Bizarrely, in BC there are
very few hyperbaric chambers and not nearly enough medical use of the
ones that do exist. Of those, only MDs can order their use and approve
reimbursement for the patient. If you are a naturopath, tough luck. The
government won't pay for hyperbaric treatments for your patients.
Why don't we have a health care system that embraces, more thoroughly,
the concept of therapeutic efficacy, regardless of whether or not the
treatment has a patent? The real problem is not the power of the drug
companies, but the power of intellectual property rights (patents), which,
Dr. Bell says, effectively ‘... supplants most other forms of therapy
in our country.’ We're no doubt witnessing a world where pharmaceuticals
so eclipse the delivery of healthcare that a vast field of non-prescription
remedies go unused.
What's the one thing that integrative medicine practitioners are asking
for? A level playing field.
It seems to me that integrative healthcare, as I understand it, is all
about taking a central tenet of medicine seriously: ‘First do no
harm.’ If there are low-cost, low-tech, unpatented solutions for
many of our ills, why wouldn't we encourage their use?
Integrative medicine may well require a revolution in thinking. It requires
that medical education be more open and accepting, and that a medical
profession, even one absolutely sold on the drugs'n'surgery paradigm,
understands how something as simple as vitamin therapy could help patients.
If alternatives work, put them in the basket along with other forms of
medicine.
But be patient because all of this will take time. It took 42 years (and
thousands of scurvy deaths) before James Lind's famous experiment was
enacted into policy by the British Admiralty.
Alan Cassels is co-author of Selling Sickness and a drug policy researcher
at the University of Victoria. He is also the founder of Media Doctor
Canada, which evaluates reporting of medical treatments in Canada's media.
Web: http://www.mediadoctor.ca
Alan presents the talk Promiscuous Medicine on May 26th (between 10:15-11:15
AM) as part of the Body Heals Conference in Victoria.