G'day GuysSo heres my Australia update since I got here. We arrived in Sydney and we had to get a train and two buses to our hostel which ended up being around an hours walk from the city centre. The hostel itself was aboslutely disgusting and filthy there was no cutlery at all and the other people there were living there and working they werent actually backpacking Stacey was accused of
Si Phan Don 4000 islands
After a few hours on a bus we got a short boat ride to Don Det in the four thousand islands. This is where the Mekong River fans out and shit loads of river islands are created don't know whether there are 4000 but probably if you count every rock. They managed to chuck my and a few other peoples bags in the water which was a bit worrying but was only really my clothes that got wet and clothes
Arabian Nights
Sunday March 27th 2011Strait of Hormuz South of IranLatitude 25 degrees 13 minutes north Longitude 57 degrees 32 minutes eastArabia is behind us in a cloud of dust literally. We pulled out of Dubai yesterday afternoon and visibility was only about 500 feet. Luckily the dust storm did not roll in until we were on our way out of the harbor. In the morning we were still able to see the worl
Best weekend so far
Morning CampersJust thought I would give you a cheeky rundown of my weekend anticsWell to start with the last week Ive been keeping myself busy going for long walks and working out with good old Davina Mccall super body workout dvd its crackingWork is... well work nothing special happening on that front the teachers surprisingly are being relatively communicative and telling me in advanced
Lancashire
Healey DellThe group of girls and I headed to Healey Dell nature reserve to visit Sarah and her family for the first half of our intersemester break We attempted to play snooker but failed to finish a sin We explored the dell and found some prospective homes for the four of us and then after the two girls left Sarah and I explored the Greater Manchester area and all of the National Trust sites t
Last day in Rome before Heading to Florence
Saturday March 19 Last Day in RomeWe woke up somewhat early and decided to take a run through the streets of Rome. This was a great way to get exercise and also see more of Rome quickly. We ran through the streets while navigating the people who took up most of the sidewalks and the cars barely had enough room to drive on the roads themselves. We ran close to 4 miles and were glad we did.w
Vang Vieng
From tranquil Vientiane we went lively party town of Vang Vieng. Vang Vieng is a muststop on the Banana Pancake Trail through Asia Banana Pancake Trail is the route most travelers take through SE Asia so named because you can always find banana pancake stalls catering to Western tastes. The main attraction in Vang Vieng is 'Tubing' which is where you hire a inner tube from town and then get
Koh Samui Wash out
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March 24th27thRomania
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Ooty
This school term has been the longest so far. We started on January 10th and have just broken up on 25th March with one long weekend. One of my New Years Resolutions was to go somewhere different once a month i.e outside Bangalore. Anna who I teach with and I had decided back in January to go to Ooty for this one long weekend wed have which was at the end of February. She booked a dr
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Our first proper week in Nepal has come to an end far too quickly but then again we have been super busy We started it off sipping cocktails and some unbranded Nepali wine overlooking Phewa Tal Pokhara's famous lake. We hadn't realised how much we had missed moheetoes and used this as an excuse to celebrate the amazing 2 months we had in India.Though slightly exhausted from our Indian s
Southern Laos and getting there
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March 23rdSofia Bulgaria
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How popular is acupuncture?
Everybody’s Doing It
One argument that often comes up when skeptics and proponents of so-called complementary and alternative medicine (CAM) debate is the question of the popularity of various CAM practices. Advocates of CAM often claim these practices are widely used and growing rapidly in popularity. Obviously, CAM proponents have an interest in characterizing their practices as widely accepted and utilized. Even though the popularity of an idea is not a reliable indication of whether or not it is true, most people are inclined to accept that if a lot of people believe in something there must be at least some truth to it. The evidence against this idea is overwhelming, but it is a deeply intuitive, intransigent notion that can only rarely be dislodged.
It might therefore be useful to get some idea of whether or not the claims of great popularity for CAM treatments are true. If they are not, fruitless debates about the probative value of such popularity could potentially be avoided, and it might be possible to diminish the allure associated with the belief that “everybody’s doing it.”
Surveys of CAM Use
It is difficult to find good quality objective data on the popularity of particular CAM interventions, and many of the surveys that have been done are potentially misleading. For example,. the 2007 CDC National Health Interview Survey (NHIS) is widely cited as showing that about 30% of Americans use CAM therapies. A careful look at the details of this survey, however, shows that many of the supposed CAM therapies are really relaxation or exercise practices, such as massage and yoga, not medical therapies. Chiropractic is the only medical therapy generally classified as alternative that was used by more than 10% of people in the survey. And that was primarily for idiopathic lower back pain, an indication for which it is generally accepted, even by skeptics such as myself, as having some demonstrated benefit, about equal to standard medical interventions. These usage numbers haven’t changed in decades, which belies the notion that CAM is growing in popularity.
Similarly, much was made by the media of a recent CDC survey that supposedly showed widespread use of CAM therapies in hospice care facilities. A close analysis of this survey, also shows that most of the therapies listed are not truly alternative medical interventions and that fewer than half the facilities surveyed offered true CAM therapies, and fewer than 10% of patients in those facilities actually employed the CAM practices offered.
Studies of Acupuncture Use
I thought it might be useful to look at some of the data concerning the popularity acupuncture, since it is probably the most widely used and accepted CAM therapy after chiropractic, and there have been a few interesting studies in this area. There are certainly no comprehensive, high-quality data concerning how many people use acupuncture, for what indications, and with what sort of beliefs in its underlying theory or effectiveness. My purpose is not to make a definitive statement about how popular acupuncture is but simply to take a small step beyond vague impressions and unsupported claims about the popularity of this intervention and look at what research there is and what insight, if any, these numbers might give us.
The 2007 NHIS data indicated 6.5% of Americans had reported ever using acupuncture. Of these, 22% had seen an acupuncturist in the last 12 months. 25% of those who had tried acupuncture had done so once, and 70% had seen an acupuncturist fewer than 5 times. The vast majority of those who had seen an acupuncturist had done so for some kind of pain, primarily arthritis and other orthopedic pain, headaches, or fibromyalgia. About 40% of the people who reported using acupuncture for a specific condition specifically reported not using conventional therapies for that condition, while 20-40% reported using some kind of conventional medical therapy for the same condition.
It is often argued that lack of interest in the utilizing acupuncture is driven more by cultural prejudice or belief systems than by concerns about the evidence for its efficacy. There is likely some truth to the fact that people from different cultures prefer familiar styles of medical treatment, though of course this says nothing about what is actually safe or effective. And part of the appeal of acupuncture in the West is likely its exotic, “foreign” associations.
Some surveys of acupuncture use have looked at whether different ethnic groups in the West have differences in their utilization of acupuncture. Interestingly, one study from Canada found that while White and Chinese Canadians differed in their use of some CAM modalities, their overall use of CAM was the same, and their use of acupuncture specifically was about the same: roughly 8%. (Therapies included in definition of CAM in Quan et al 2008: Herbal remedies, massage therapy, chiropractic, acupuncture, amino acids, naturopathy, homeopathy, reiki, ayurvedic medicine, biofeedback, hypnosis.)
In contrast, a survey of Chinese Americans in a mental health services program found about 25% used acupuncture, and that this use was more prevalent among “less acculturated” individuals. This, of course, is a group not at all representative of the general population, so the relevance of this to overall acupuncture use among Chinese Americans and Americans of other ethnicities is not clear. Other studies have shown significant but complex relationships between ethnicity, education, and other variables and the likelihood of acupuncture use.
It seems reasonable that cultural traditions play some role in the acceptance or rejection of acupuncture as a medical therapy, but the current data do not support that cultural affiliation alone is the most important variable, and the reasons people use acupuncture seem quite consistent regardless of ethnicity or nationality. In any case, studies of populations in North America do not show anything approaching a majority of the population regularly using acupuncture as a medical therapy. Numbers vary from less than 10% to as high as 50% in some populations, but most tend to be in the lower end of that range.
Since acupuncture as it is currently understood and practiced in Europe and North America originated in China and has been employed there and in other Asian countries for a lot longer than it has been used in the West (though not nearly as long as is usually claimed), it makes sense that it would be far more widely used in that part of the world if it is truly as popular a therapy as its proponents claim.
One 2007 study in Taiwan found about 11% of beneficiaries of national health insurance had used acupuncture in a given year. Interestingly, while the survey found that overall use of Traditional Chinese Medicine (TCM) therapies was much higher than this (primarily due to use of herbal remedies), the use of TCM was still far behind the use of so-called “Western” medicine. TCM clinic visits accounted for only 9% of outpatient visits reimbursed under the national health insurance. This is similar to another study which found Chinese medicine (of all covered types) accounted for only 5% of the reimbursed care under the national health insurance system. The same study indicated that “Western” medicine was utilized more than Chinese medicine, especially among children, the elderly, and those with severe disease (consistent with the pattern of CAM use in the U.S., which is generally for self-limiting or chronic disease).
Yet another study in Taiwan specifically investigated acupuncture use and found about 6.2% of people covered by national health insurance utilized acupuncture in a given year, and over the seven years surveyed about 25% of covered individuals had received acupuncture treatment. As in the U.S., the vast majority of the acupuncture treatment sought was for musculoskeletal conditions or injuries (88%).
And a recently published series of surveys conducted in Japan found that about 5-7% of respondents used acupuncture in a given year, and that over a lifetime between 20-27% of respondents had at some time tried acupuncture. More than 80% of the use of acupuncture was for musculoskeletal complaints. About half of those who had used acupuncture indicated they would use it again, and about 37% indicated they would not.
The Bottom Line
So what does all of this mean? Well, probably not very much. Of course, differences in healthcare systems, insurance systems, study methods, and many other factors that are difficult to identify and asses, make direct comparisons between the use of specific CAM interventions in different countries very unreliable. I don’t believe the quality of the data generally allow very confident statements about the popularity of acupuncture or other specific CAM methods. However, proponents of acupuncture, and CAM generally often make such statements, trying to convey the impression that their approaches are growing rapidly in popularity and only perverse, closed-minded curmudgeons still resist them. The little evidence we have certainly does not support such claims.
In the case of acupuncture, for example, the data show relatively low levels of utilization even in those countries generally regarded as having long historical traditions of using acupuncture. Informal investigations (e.g. 1, 2) have suggested that acupuncture and other CAM practices associated with China may not be as popular even in their native land as proponents in North America claim, and the formal studies I have discussed here seem to support that impression.
A large majority of people who seek acupuncture therapy, regardless of ethnicity or nationality, do so for treatment of musculoskeletal conditions and pain. There is good evidence that the therapeutic ritual of acupuncture has some symptomatic benefit for such indications. This is almost certainly a non-specific treatment effect (aka “placebo”). It does not seem to matter where needles are inserted or if they are inserted at all, and acupuncture therapy does not appear to measurably affect the course of any actual disease. (The Skeptic’s Dictionary has a clear and concise review).
The research data on acupuncture utilization suggests that from about 5-25% of people, regardless of nationality or ethnicity, will at some time try acupuncture for, mostly for some kind of musculoskeletal pain. Conventional therapies are often used along with acupuncture, and they are far more popular overall, especially for serious or acute conditions. So the little research there is suggests that acupuncture occupies a niche common to many CAM therapies. It is used at a low level by a small to moderate proportion of the population for conditions that are either mild, self-limiting, or without a definitive conventional treatment, and it is rarely used in lieu of conventional medical care. This is hardly a mounting wave of enthusiasm for acupuncture itself, much less the mystical theories and postmodern cognitive relativism often associated with it.
So when proponents of acupuncture say it must work because it has been widely used for thousands of years in Asia and is growing rapidly in popularity in the West, rebutting the argumentum ad populum and argumentum ad antiquitatem fallacies may not be the skeptic’s only option. It may be worthwhile, and simpler, just to point out that acupuncture is neither as old nor as popular as is commonly supposed.
References
Chang LC. Huang N. Chou YJ. Lee CH. Kao FY. Huang YT. Utilization patterns of Chinese medicine and Western medicine under the National Health Insurance Program in Taiwan, a population-based study from 1997 to 2003. BMC Health Serv Res. 2008 Aug 9;8:170.
Chen FP. Chen TJ. Kung YY. Chen YC. Chou LF. Chen FJ. Hwang SJ. Use frequency of traditional Chinese medicine in Taiwan. BMC Health Serv Res. 2007 Feb 23;7:26.
Chen FP, Kung YY, Chen TJ, Hwang SJ. Demographics and patterns of acupuncture use in the Chinese population: the Taiwan experience. J Altern Complement Med. 2006 May;12(4):379-87.
Eisenberg DM. Kessler RC. Foster C. Norlock FE. Calkins DR. Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993 Jan 28;328(4):246-52.
Ishizaki N. Yano T. Kawakita K. Public status and prevalence of acupuncture in Japan. eCAM 2010;7(4):493-500.
Quan H. Lai D. Johnson D. Verhoef M. Musto R. Complementary and alternative medicine use among Chinese and White Canadians. Can Fam Physician. 2008 Nov;54(11):1563-9.
Upchurch DM. Burke A. Dye C. Chyu L. Kusunoki Y. Greendale GA.A Sociobehavioral Model of Acupuncture Use, Patterns, and Satisfaction Among Women in the US, 2002Womens Health Issues. 2008; 18(1): 62–71.
Asian Bear Bile Remedies: Traditional Medicine or Barbarism?
Imagine living 20 years spending 24 hours a day in a cage that tightly fits your body, not giving you room to stand up, stretch out, turn around, or move at all.
Imagine that twice a day during these years you would have a metal catheter inserted into a hole which has been cut into your abdomen, allowing the catheter to easily puncture your gall bladder, or maybe a long syringe inserted into your gall bladder, piercing through your skin again and again, by people who are not doctors.
Imagine becoming infected and cancerous because of this twice-daily physical invasion, and becoming neurotic due to your claustrophobic imprisonment.
Imagine having one or both of your hands cut off so someone can sell them for a lot of money.
Imagine you begin to chew at your hands, if you are lucky enough to have one or both left, due to your developing neuroticism, and to distract yourself from the pain you experience twice a day, every day, for your entire life.
This is reality for an estimated minimum of 12,000 bears across Asia.
– Sara Pegarella, JD
Currently, animal activists across China are up in arms because Gui Zhen Tang Pharmaceutical Corporation, a Fujian-based company that sells bear bile for use in Traditional Chinese Medicine (TCM), has tried to increase production through an initial public offering (IPO). The company is being accused of cruelty towards animals in the process of extracting their bile at an industrial scale. Bear bile, or Xiong Dan (??), is an important ingredient in TCM.
The issue is not new: since the early 2000s, animal activists have circulated hundreds of shocking articles, images, and videos that recount unimaginable cruelty towards caged bears in Asia. The practice has even outraged celebrities, such as Jackie Chan, who have pleaded with consumers to stop buying products made from bears and other endangered species. But now it’s all over the news. Gui Zhen Tang’s IPO has met with fierce public opposition, and has once again led environmentalists to appeal against the cruelty of live bear bile extraction.
As this documentary shows, bear bile is sold throughout Asia for a variety of conditions. The Chinese Herbal Medicine: Materia Medica (1986) by Dan Bensky, Andrew Gamble, and Ted Kaptchuk lists bear bile as a remedy for trauma, sprains, fractures, hemorrhoids, conjunctivitis, severe hepatitis, high fever, convulsions, and delirium. The Materia Medica also states that “because of the high price of bear bile (Xiong Dan), often cow bile, Fei Bovus (Niu Dan), is substituted at a higher dose.”1 There is no mention, however, of the horrific means by which the animal bile is obtained. The guide also lists other animal products (rhinoceros horn, tiger bones, deer musk, and bat and squirrel feces [sic]) used as medicine.
Image 1. The bear bile entry in the 1986 version of Materia Medica by Bensky et al. The entry in the latest edition (3rd ed. 2004) has been moved to “Obsolete Substances.” Image used with the explicit permission of Eastland Press.
The globalization of TCM has lead to a dramatic increase in the demand for bear bile along with other traditional remedies. Bear bile is sold in Asian apothecaries throughout the world in the form of powder, solution or pills. It is likewise the key ingredient in many Asian “patent medicines” used for tapeworm, childhood nutritional impairment, hangovers, colds, and even cancer. Bear bile is even found in Chinese throat lozenges, shampoo, wine, and tea.
Image 2. Raw bear bile in both liquid and powder forms. Photo: Kathleen E. McLaughlin, the Chronicle Foreign Service correspondent in Beijing
Overall, the worldwide trade in bear parts, including bile, is estimated to be a $2 billion industry. Research in August 2007 by the animal rights group Animals Asia shows its staggering profitability: while the wholesale price of bile powder is around US$410 per kg in China, the retail price increases exponentially to 25 to 50 fold in South Korea, and to 80 fold in Japan (US$33,000 per kg)!
While the trade in bear products is prohibited under the Convention on International Trade in Endangered Species (CITES), and the importation and trade of bear bile products to North America is illegal under both US and Canadian law, many products are still openly offered for sale in Chinese stores. Back in 2001, when the World Society for the Protection of Animals conducted a probe of Asian shops in Canada and four US cities — Chicago, New York, Washington, and San Francisco — it found that 91% of the shops surveyed sold some form of bear part, including farmed bile powder, bile medicines, and whole gallbladders, which the merchants claimed originated from wild bears in China. When WildAid, an animal rights group based in San Francisco, sent an undercover investigator into Chinatown in 2004, two shopkeepers readily produced vials in velvet-lined boxes with pictures of a bears on the lid.
Bear bile is obtained through surgically implanting a tube in the animal, in a process called “milking,” that produces an average 15 ml (.5 oz) of bile each time. The Humane Society of the United States reports that the process of milking is so painful for the bears that they moan and often chew their paws during the procedure. In order to make access to the animals easier, the farmers often break the bears’ teeth and pull out their claws, sometimes brutally removing whole digits. If the bears stop producing bile, they are left to die, or are killed for their gallbladder and paws (considered a delicacy in China).
According to Jeanette McDermott, the founder of Ursa Freedom Project, bear farming in Asia increased during the 1980s in response to the dwindling supply of bear parts obtained from bears hunted in the wild. Tragically, the situation grew out of control, and by the early 1990s, there were over 400 bear farms in operation, containing more that 10,000 bears. Plans were in place to increase the number of bears in farms to 40,000 by the year 2000.
Today, China produces 7,000 kilos of bear bile annually, much of which is illegally exported to Japan, Korea, Australia, Canada, and the US. Whole bear gallbladders are also exported: the Humane Society of the United States says smugglers have been caught with gallbladders packed in coffee to conceal their smell, or dipped in chocolate to disguise them as chocolate-covered figs.
Most of the bears used in bile farming are Himalayan black bears (Ursus thibetanus), also known as “Asiatic black bears” or “Moon bears,” due to the cream-colored crescent moon shape on their chests. As their population has decreased by almost 40 percent over the past few decades, they have been listed (since 2000) as among the most critically endangered species on the International Union on Conservation of Nature’s Red List of Threatened Species.
A number of the bears in bile farms are captured illegally in the wild as cubs. Poachers either wait to capture new-born cubs until the mother leaves the den in search of food , or sometimes they simply kill her to get to the babies. Some of the cubs are born in captivity — but in either case, bear cubs rarely survive to adulthood — and those who do often grow into the bars of their cages as their bodies mature.
Image 3. Is this traditional medicine or savagery and barbarism? Photo: Cornelius Maarselar/Animals Asia
Animal activists posing as potential clients report that the caged bears moan, writhe in pain, and clutch their stomachs as the bile drains from their bodies. Sometimes the bears try to pull out the catheters. Those that succeed are immobilized in an iron corset. Under-nourished and highly stressed from horrific pain and unnatural confinement, the bears lie in agony, in their own filth.
According to Jeanette McDermott, bile is not the farmers’ only source of profit from the bears. Some farmers amputate one or two paws from live bears to sell to restaurants. When bears are no longer able to secrete bile, they are left to die from sickness or starvation. Bears might endure this torture for up to 25 years, making their lifetime a reality of suffering and pain in the name of “natural” and “traditional” medicine.
Image 4. This metal clamp is placed around bears who might struggle or move around excessively in order to ensure they remain still through the painful bile extraction. Photo: Animals Asia
There are a number of extremely painful techniques used for milking bear bile. Image 4, above, illustrates the common extraction technique that relies on plastic or metal catheters, and often necessitates a metal jacket in order to restrain the bears (the chilling details can be found at the Animals Asia website). Some farms rely on an ultrasound machine to guide a catheter connected to a medicinal pump. In this method, the bears are sedated — usually with ketamine — restrained with ropes, and have their abdomens jabbed repeatedly with four-inch needles until the gallbladder is located. Animals Asia suspects that this process leads to dangerous leakages of bile into the body, and to a slow and agonizing death from peritonitis.
In recent years, China has introduced a new, “humane,” free-dripping extraction method, which does away with the need for catheters. Free-dripping involves carving a permanent hole, or fistula, into the bear’s abdomen and gall bladder, from which bile drips out freely. The damage caused by the bile’s leaking back into the abdomen, together with infection from the permanently open puncture, is even worse than the catheters method, and results in a high mortality rate. Often, the bears’ livers and gallbladders become severely diseased through this process, and the collected bile is contaminated with pus, blood, urine and feces.
Image 5. Sometimes a hollow steel stick is pushed through the bear’s abdomen, and the bile runs into a basin under the cage. In this case, about half of the bears die from infections or other complications. Photo: Animals Asia
Image 6. Ultrasound bile extraction from a bear in Vietnam. Photo: Asia Wild Life
A healthy bear’s bile is as fluid as water, and ranges in color from bright yellow-orange to green. However, Animals Asia’s vets have described bile leaking from the gallbladders of farmed bears as “black sludge.” Eminent Chinese and Vietnamese pathologists have warned the public not to use bile taken from sick bears.
The active substance in bile (of bear and all other mammals) is ursodeoxycholic acid (UDCA), also known as Ursodiol, which is easily synthesized, and has been available for several decades. It is estimated that 100,000 kilos of synthetic UDCA are already being used each year in China, Japan, and South Korea, and that the total world consumption may double this figure.
Despite the availability and affordability of synthetic UDCA and suitable herbal alternatives, some practitioners obstinately continue to prescribe bear bile, which in turn drives up the market demand, and pressures the Chinese government to continue to allow the practice of bear farming.
The world’s appetite for bear bile and other parts has also led to the hunting and killing of wild bears in the North America. The media reports that the poaching of bear gallbladder for its use in TCM is on the rise in the US. The Los Angles Times, of August 22, 2008, writes that Fish and Game Wardens in California (CA) often report finding dead black bear carcasses that have been skinned and dismembered. The gallbladder is by far the most often stolen part (see the Los Angeles Times of November 29, 2010). The CA animal safety group, BEAR League, reports that since the beginning of 2007, as many as 87 dead bears have been found near state roadsides. On occasion, they report the bears’ heads or paws are cut off, but they also report finding bear carcasses with the gallbladder missing.
Image 7. This California black bear was struck and killed on State Highway 89 near Lake Tahoe in August 2008. State wildlife officials say the gallbladder was removed. Photo: BEAR League
The appalling impact of TCM on endangered species goes well beyond bears though. It affects the world’s most precious and protected animals, such as Bengal tigers, American bears and African rhinos. A worldwide interest in alternative medicine and the ease of international commerce now put dozens of species worldwide at risk. And while most of traditional Chinese medicines rely on herbs, the demand for products made at the expense of threatened animals continues to grow. In reality, many of the current claims associated with the medicinal value of animal products are spurious; but reality hasn’t stopped the rising demand for these illegal substances, and the profits to be made by poachers and smugglers rise.2
While the use of some animal products was perhaps justifiable in the past — when there were no alternatives available, the extent of demand was limited, and the particular species were plentiful in their natural habitat — it is no longer sustainable, or justifiable, given our modern, globalized, and technically-advanced world. Today, with other approved therapeutic alternatives available, there is little justification for the use of endangered species such as the black bear.3
The belief advanced by the Counterculture of the 1960s and the New Age movement — that “natural” curatives are better than their synthetic equivalents — contributes enormously to TCM’s popularity in North America today. These groups originally objected to the growing over-consumption and over-reliance on synthetically-produced medicines, over natural alternatives. And while these concerns should be considered serious, the apologists of TCM and other types of traditional medicines fail to recognize that at present, their massive demand for “natural” products has made crime against animals commonplace. TCM has behind it a powerful, moneyed group of consumers whose “needs” now drive a whole black market economy — one that supports poachers, bear bile farmers, and all types of heinous torture.
As I wrote his article, I was overwhelmed with rage, and repulsed not only by the horrific images of the animal holocaust in Asia, but also by the enormous hypocrisy of the proponents of TCM, who effectively claim that pus-infested bear bile, and the by-products of animals tortured, disfigured, and dismembered in the name of the“natural” are better, safer, and “gentler” than synthetic pharmaceuticals.
With many thanks to Sara Pegarella, JD, and Kristin Koster, PhD, for their valuable comments.
The above mentioned animal rights advocacy groups (Animals Asia, Asia Wild Life, etc.) were not interviewed for this piece and any information attributable to them was taken from their websites. I encourage you to visit these sites to become more informed and involved.
REFERENCES
- Bensky D, Gamble A, Kaptchuck T. Chinese Herbal Medicine: Materia Medica. Revised Edition. Eastland Press. 1986. Return to text
- Ellis R. Tiger Bone & Rhino Horn: The Destruction of Wildlife for Traditional Chinese Medicine. Island Press; 1 edition. 2005. Return to text
- Still J. Use of animal products in traditional Chinese medicine: environmental impact and health hazards. Complement Ther Med. 2003 Jun;11(2):118-22. Return to text
CAM and Evidenced-Based Medicine
Mark Tonelli, MD has problems with evidence-based medicine (EBM). He has published a few articles detailing his issues, and he makes some legitimate points. We at science-based medicine (SBM) have a few issues with the execution of EBM as well, so I am sympathetic to constructive criticism.
In an article titled: Integrating evidence into clinical practice: an alternative to evidence-based approaches. The abstract states:
Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient.
I certainly agree that clinical evidence (what he he referring to by “empirical” evidence above) is not, and should not be, the sole type of knowledge that is incorporated into clinical decision-making. However, I think this criticism is a bit of a straw man, at least with regard to items 2, 4, and 5. The goals and values of the patient are definitely part of clinical decision-making, even in a rigorously evidence-based practice. We are, after all, treating people, not diseases. When I was in medical school this was called the biopsychosocial model of medicine. Now it is also not uncommon for quality of life measures and overall satisfaction to be incorporated as outcome measures in clinical trials, blurring the lines between empiricism and personal goals and values.
So while I agree that patient values and goals absolutely need to be taken into consideration when practicing medicine, I don’t see this as a new idea or one that is at odds with EBM, nor entirely distinct from empiricism. By including this as he does, however, there is the implication that EBM excludes such considerations, and I do not believe that is fair.
Where we likely mostly agree is on number 3 – pathophysiological rationale. I could expand this to include all of basic science – medical practices should be plausible. I also think he has a legitimate point in that EBM gives too much emphasis to clinical science and shortchanges basic science. But it is interesting to note that the EBM grading system for recommendations do allow for extrapolation (i.e grade B=.consistent level 2 or 3 studies or extrapolations from level 1 studies). Extrapolation involves considering pathophysiology and mechanism of action. While extrapolation (rather than direct evidence) downgrades the recommendation by one category (which is appropriate) it does not exclude it altogether.
Further, I think the real problem with failing to consider pathophysiology is not for support of a plausible treatment, but to be extra cautious about an implausible treatment. When the basic science dictates that a proposed treatment is highly implausible, the bar for clinical evidence should be raised proportionately. I don’t think this is what Tonelli had in mind, however, as we will see.
Item #2- Experiential evidence, is highly problematic. While experience is great for some things, like recognizing diagnoses, being sensitive to the subtleties of history taking, and interfacing with patients – it is highly misleading when it comes to determining safety and efficacy. The simple fact is that personal experience is too limited, quirky, and uncontrolled, and is overwhelmingly likely to simply confirm our biases than actually lead us in the direction of truth.
In another related article (actually published in 2001, earlier than the 2006 paper above), Tonelli clarifies:
Empirical evidence, when it exists, is viewed as the “best” evidence on which to make a clinical decision, superseding clinical experience and physiologic rationale. But these latter forms of medical knowledge differ in kind, not degree, from empirical evidence and do not belong on a graded hierarchy.
He is partly correct here – these other forms of evidence are not necessarily below, but are tangential to, empirical evidence. But I think Tonelli is missing the context of EBM. EBM is not a method for solely determining clinical practice (clinical decision-making) but for determining safety and efficacy, which is one factor that informs practice. Values, the system, and the human side of medicine also go into clinical practice, but they should not be used to determine efficacy. So it seems his criticism is based upon a straw man constructed of his own confusion.
I might have been inclined to give Tonelli some benefit of the doubt, were it not for this:
The methods for obtaining knowledge in a healing art must be coherent with that art’s underlying understanding and theory of illness. Thus, the method of EBM and the knowledge gained from population-based studies may not be the best way to assess certain CAM practices, which view illness and healing within the context of a particular individual only. In addition, many alternative approaches center on the notion of non-measurable but perceptible aspects of illness and health (e.g., Qi) that preclude study within the current framework of controlled clinical trials. Still, the methods of developing knowledge within CAM currently have limitations and are subject to bias and varied interpretation. CAM must develop and defend a rational and coherent method for assessing causality and efficacy, though not necessarily one based on the results of controlled clinical trials. Orthodox medicine should consider abandoning demands that CAM become evidence-based, at least as “evidence” is currently narrowly defined, but insist instead upon a more complete and coherent description and defense of the alternative epistemic methods and tools of these disciplines.
This casts a new light on all of Tonelli’s other publications. It seems he is making an elaborate argument for the inclusion of other kinds of evidence (other than rigorous, controlled, clinical studies) as support for fanciful but ideologically appealing treatments.
This is a refrain that is becoming common in the CAM community - that we need to redefine “evidence”, not restrict ourselves to narrow definitions of evidence, and that CAM modalities cannot be properly studied by traditional scientific methods. There is always a flavor that CAM must free itself from the tyranny of scientific evidence.
What is it, exactly, about scientific methods that they feel is incompatible with CAM methods – being thorough, counting all the data, controlling for variables, minimizing the effects of bias, carefully defining terms and outcomes, or being statistically rigorous? Even individualized treatments can be studied rigorously – so that is an insufficient excuse. In the end, the call to expand the definition of evidence is just a deceptive way of asking for sloppy methods of research, because CAM modalities generally do not hold up under rigorous standards.
We don’t need to redefine or expand the methods of science – we need to return common sense to medicine.
Join Trine Tsouderos for a web chat with Dr. Paul Offit
Here’s something for you all to check out. Trine Tsouderos, the journalist from The Chicago Tribune who’s distinguished herself as being one of the few reporters who “gets it” when it comes to quackery and the anti-vaccine movement (just put her name in the search box of this blog for some examples) will be hosting a web chat about vaccines featuring none other than Dr. Paul Offit, one of the gutsiest (if not the gutsiest) defender of vaccine science out there. The chat will occur here at noon CDT today. Questions can be submitted in advance to Tsouderos at ttsouderos@tribune.com.
Head on over, everyone. The anti-vaccine movement is clearly out in force in the comments. Although the usual intrepid defenders of science are there, reinforcements are always welcome.
