Gill Stannard

Monday, June 05, 2006

where science and naturopathy meet

The following musings are intended as a discussion paper, not an academic document. This covers some of the questions I have about medical science, from my perspective as a naturopath with a background in the sciences. By no means do I dispute that medical research has given us many gains and I eagerly keep up with the latest studies. However I do have some concerns about the limitations of science generally and as it is applied to another paradigm.
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Where science and art meet

As a student of natural therapies in the ‘80’s the buzzwords to describe naturopathy was as an “art and a science”. The course had recently been rebadged, from a naturopathic diploma, to one of applied science. Strong debate raged within the profession between what was considered the ‘old’ traditional ways and the modern world of science.

Almost 20 years down the track, the profession still straddles both worlds. The course has been upgraded to an applied science degree and ‘evidence based medicine’ can be heard being uttered like a mantra by some in the profession. But the most significant change in this time is the interest that orthodox medicine has developed in what was once ‘alternative’, now ‘complementary’, medicine.

The most rapid time of change in Australia occurred in the 1990’s while Kerryn Phelps was at the helm of the AMA. At the beginning of her term she carried on the party line that natural medicines (and those who prescribed them) were unproven and either ineffective or potentially dangerous. By the end of her presidency Phelps had declared that the Association was aware that the public wanted complementary medicine and that if anyone was going to deliver this, the people best suited to the job were medical doctors. Since leaving the helm of the AMA Phelps has made a career out of spruiking evidence based complementary medicine to her peers. With no prior training in complementary medicines, she had suddenly been transformed into an expert.

With greater interest in herbs and nutrients in particular from orthodox medicine has come a greater focus on scientific testing of such products, but not necessarily the massive amount of funding needed to do so. Unless ‘proven’ both effective and safe by modern science, individual medicines have been tainted with suspicion. But there are many issues around applying current scientific methods to naturopathic practice.

1. Treating the individual

Perhaps the most significant difference between orthodox and naturopathic medicine is the philosophy underpinning its use. The basis of naturopathy is the treatment of the individual rather than a disease, while western medicine remains disease focused. While the local GP may now recommend the occasional vitamin or herb, it is usually still within a framework of a herb-drug replacement. A naturopath believes that the body can in many cases heal itself and that medicines are prescribed according to the specific symptoms the client presents with at the time of the consultation. Crudely put – there is no universal herb to treat a cough, but many variations depending on what preceded the persons current illness, their constitution and the symptoms they have developed. Replacing a drug with a natural panacea is to most naturopaths like prescribing with your eyes shut.

Beyond actual medicines, lifestyle and diet are absolutely crucial and give many clues as to how and why a condition has developed. This information is vital to treat and further prevent a recurrence of a condition, or manage a chronic complaint. It would be unusual for a well educated naturopath to prescribe only a pill or a potion, without working with the client to make fundamental changes in the way that they live.

2. Body, mind and spirit

Scientific research still remains primarily body focused, even more so it clings onto the ‘pathogen cause of disease’ philosophy. Traditional naturopathy believes there is interplay between the mind, the spirit and the body. Spiritual health can be both individual and nebulous. What gladdens the spirits of one person may have the opposite effect on another. Just like the huge divide in personal taste when it comes to music, what is ‘ good medicine’ for one may have the opposite effect on another

3. Time and placebo

To gain such in depth information about a patient’s wellbeing, more than the standard 5-15 minute medical consult is needed. An initial consultation with a naturopath usually takes a good hour and this is just to get the health history of the individual. A strange argument as to the effectiveness of naturopathic treatment has been something like ‘if doctors had the time to spend that long with a client, they’d get better results’. Once again, how can you treat accurately with not just your eyes shut, but one hand tied behind your back?

The length of consultation has added to the placebo theory. Some have claimed that the human interaction between the naturopath and the patient is the therapeutic agent, not the medicines we prescribe. Far from the medicines being placebo, I would argue the consultation process is a major part of the therapeutic treatment – and this cannot be a bad thing.

4. Introducing Evidence Based Medicine (EBM)

EBM, the current Holy Grail in scientific research, basically means that significant, reproducible research needs to be done to prove that a treatment has any validity. Anecdotal evidence, non-double blinded, placebo controlled trials and one off studies hold little sway and are often discounted from meta analysis. As a result, due to the lack of research into complementary medicines and treatment protocols there may be no “evidence”. Insufficient evidence too often becomes erroneously equated with a belief that the treatment is ineffective.

However, orthodox medicine frequently falls short using this framework yet manages to thrive under the guise of science. While many popular medical protocols have come up with insufficient evidence to recommend them in reviews like Cochrane, under funding for research in the area of naturopathic medicine will often mean they can’t get out of the starting gate. No money for a study (usually because a whole plant cannot be patented and then financially exploited by a company) equals no evidence to support use of the medicine.

As for commonsense, which at times goes awol in the world of EBM, would you willingly jump out of a plane without a parachute? According to the lack of published data within this framework, there is no EBM to support that employing a parachute under such circumstances will actually extend your life. No evidence, so would you wear one any way?

5. Can we test for what we don’t know?

One of the serious limitations to science is we can only test for something we believe may exist. This, for me, is the biggest stumbling block in current medical research.

One of the most significant shifts in these 2 decades has been the acceptance and validation by science, of the role of stress in the development of some diseases. When I was a naturopathic student, this was a largely disabused notion within the medical profession. Now there is money to be made in the treatment of stress and all of a sudden there is the evidence to suggest it can be causative in a variety of health problems.

But conventional thinking and to some degree our technology, still remains in the dark ages. For example, current scientific research has not conclusively proven the link between mobile phone towers and the development of some kinds of brain tumours – but tell that to the 7 staff at RMIT who have unfortunately developed them. Is this just a coincidence or do we need to reassess how we evaluate various forms of radiation?

6. Does medical research go far enough?

Stress as a cause of stomach ulcers was disproven due to the Nobel Prize winning discovery of helicobacter pylori. But why do the investigations end there? Does everyone exposed to h. pylori develop an ulcer? What makes one individual more prone to do so, than another? Maybe stress plays a role after all?

But despite a specific antibiotic therapy being employed in the war against ulcers, the amount of people with ongoing symptoms in need of further lifelong pharmaceutical support continues.

7. Universality

Another issue is that of universality – that results of one study apply across the board in all contexts. Naturopathy takes into account genetic, constitutional and acquired individual predispositions. What makes one person more susceptible to an outside influence may be different from another.

Dosage remains a contentious issue within naturopathy. It is understood that as individuals, one person may require a substantially different therapeutic dose of a natural medicine, than someone else may need. In clinical practice – I might prescribe a single herbal dose of 0.5 mls to one adult, but 15 mls to another. Individulised treatment does not fit easily within the current parameters of medical research.

The notion of universality in conventional science applies the results from studies using one species and extrapolates them to be relevant for another. However, most naturopaths believe the physiology of a rat, rabbit or a monkey does not precisely mimic a human, nor is it ethical to subject such animals to these kinds of experiments.

Even the physiological differences between the genders needs to be taken into account. When the “French Paradox” (a diet high in fats and alcohol that did not increase cardiovascular disease) was applied to women, the same optimistic results did not eventuate. There were also common misunderstandings of the research. Most people read it as “all wine is good for you”, however the reality was the population studied drank the local rough red wine made annually. This turned out to be high in a particular kind of antioxidants. Unfortunately a smooth aged red, or even a young white, does not contain significant amounts of this heart friendly constituent.

8. Let’s not forget the test tube

Even more of a concern for natural medicines is in vitro experiments. This we have found can lead to some irrelevant conclusions. This is especially so when an isolated constituent from a herb or nutrient is used. Not only is the petri dish not a fair representation of a body, but also an isolated ingredient tends to react very differently than the whole plant.

Homoeopathy has been given the thumbs down because an experiment referred to as the “memory of water” was unable to be reproduced. It was thus concluded that as there is no scientific basis to homoeopathy therefore, it is all placebo. As a “homoeopathic prover” (someone who can manifest the symptoms of a remedy, if given the wrong one), I might choose not to be a homoeopath, but I know for sure that when prescribed correctly the medicines can have dramatic effects. Once more, if we don’t know how to accurately test for ‘energetic’ medicines outside the confines of our current scientific techniques, the medicine is considered to be at fault, not the method.

9. Benefit’s of science for the practitioner

In many cases, when put to the test, science has validated commonly used naturopathic medicines. It has also found new uses for old medicines and found biochemical explanations for many traditional uses.

However, when tests come up with negative or inconclusive results a well educated practitioner tends to evaluate the legitimacy of the study with a number of factors in mind. In human studies - quality of the medicine, correct dosage and adequate duration of taking the medicine are supremely important. Nutritionally, sometimes co-factors are required. For example to get the antiinflammatory effect of some oils (including evening primrose oil) other nutrients such as B6 and Vitamin E is required. If a subject has inadequate amounts of these in the diet, an inflammatory reaction can sometimes occur.

10. Complementary Medicine companies and pseudoscience

Some of the worst offenders of scientific mumbo jumbo are those who make and sell complementary medicines. Wild Yam having scientific claims to contain progesterone (hence “natural progesterone”) is a case of bad science that continues to persist. In this instance the herb has a precursor to progesterone that can be manipulated in a lab, but not naturally in the body, to create a form of the hormone.

Sellers of multi level marketing health panaceas sometimes go to a lot of effort to appear scientific. One popular company supplies distributors with copies of what looks like a scientific journal that validates their therapeutic claims. A closer examination of the document reveals some interesting facts. Though the title sounds official, it’s not one on any medical libraries database, cross-referencing information about the company finds that the board of directors are the peer review panel for the journal and in fact all studies are written ‘in house’. Despite using scientific language the studies are all of statistically insignificant sizes, not double blinded and though obviously staged by the company there is no disclosure. This is such bad science it makes you wonder where the so-called scientists got their degrees. But the lesson from this is just because it looks like science, don’t take it on face value.

11. Who benefits from medical research?

The answer is obvious, isn’t it? Surely, we the disease prone public must be the real winners from science. Often we are, but not always. Despite increasing awareness and moves to register studies in order to be published on completion, there is a dark side to science that unfortunately exists in some cases. When we ask who benefits, too often it is capitalism. The majority of medical research funding still originates from big business. Even some government funded studies are influenced by how the outcome will profit the State.

One of the biggest contributors, the pharmaceutical industry has over the years been correctly accused of manipulating research, burying negative research and suppressing research that may show that a non-drug approach is more beneficial.

As for government’s, my first brush with research, as a lowly search assistant opened my eyes to how study parameters can predict outcomes. In this case it was “proving” the use of Agent Orange in Vietnam had no adverse effects on the health of the servicemen who were exposed to it, or to their children. A correlation between the defoliant and health problems or birth defects would clearly put the State at blame and make them liable for millions of dollars of compensation. Yet even with no scientific training behind me at the time, I could see flaws in the studies. While the AVH studies “proved” no detrimental effects, follow up studies, funded by a subsequent government demonstrated otherwise.

Take home message – science has its swings and round-abouts, but I still believe that it shouldn't be placed on a pedistool giving it greater vaulue than traditional knowledge. I use my science training daily in practice, but equally or more so I use empirical wisdom. We need to find a better framework in which this knowledge can be usefully evaluated.

Other refs:

A Canadian scientist who has become a naturopath shares his views on the subject here.

Quackwatch’s thoughts on alternative medicine espouses The other side of the story.

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