IT TASTES AWFUL, BUT DOES IT WORK? A SKEPTICAL PATIENT LOOKS FOR THE RIGHT MEDICINE
“Take one tablet once a day.” The prescription reads like a verdict sentencing me to a life of pharmacy. Tucked away in the top of my backpack hides a tiny pillbox of shame needed to keep me healthy.
“Stop being so melodramatic. Lots of people are hypothyroid; it’s one of the most common hormonal imbalances.” My friend Julia brings me back to reality. In the wake of successful chemotherapy and radiation treatments, my thyroid (a gland in the neck responsible for producing hormones that regulate metabolism) became underactive. It happened so gradually it was hard to perceive a change. Probing questions from my doctor about energy levels or concentration ability were confounded by my erratic student habits (caffeine, all-nighters). However, staring at my irregular blood test results made me question how ‘normal’ I really felt. With an impending Physics Honours thesis deadline, I loathed the idea that my body and mind were not running on all cylinders. Finally I resolved to follow my doctor’s recommendation and begin a daily regiment of thyroid supplements.
Three weeks after beginning the thyroid medication I felt more like ‘myself’ than I had in months. Fearing a return to sloth upon disuse, I religiously take the pill every morning. Am I happy about it? No. Of course I am happy to have my energy back, but I despise my pharmaceutical dependency. According to my oncologist, the radiation damage is likely permanent, and my prescription has infinite refills. Perhaps I should quit my whining and count myself lucky, but I keep hoping to find some way of being healthy without popping pills. Chalk it up to arrogance, or embarrassment.
“If you don’t want to take the thyroid medication, then don’t.” Julia is a beacon of hope. Eventually diagnosed with Candidiasis (an imbalance of flora in the gut), her story is packed with hasty prescriptions for antibiotics and antidepressants that only aggravated her situation. Frustrated with callous doctors, Julia found alternative treatment from a Naturopath who recommended a strict antifungal diet. Two years after beginning this diet, Julia describes herself as “not the same person. I used to get sick 10 times a year. Now I am only ill twice a year at most.” Julia tells me not to blindly accept my doctor’s prognosis, and tempts me with the promise of alternative medicines.
Here lies the crux of my debate: Should I trust my health to Canada’s pharmacy oriented medical system, or seek alternative treatments that promise a drug-free solution? My bias is obvious from the question. But remember, I am the product of over two decades of western education, and my physics degree will not let me abandon the scientific method. The Canadian health-care system is grounded in Evidence-Based Medicine (EBM), a term used to describe the “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” [1]. This approach is juxtaposed with Traditional Chinese Medicine (TCM), a range of practices developed over several thousand years that include herbal medicine, acupuncture, and massage. Although I am highly skeptical of medical theories that operate outside of a scientific paradigm, the dissatisfaction with my current prescription compels me to examine these two systems in search for something better.
Evidence Based Medicine
The term “evidence-based medicine” first appeared in medical literature in 1992 [2], and describes explicit methodologies for determining treatment efficacy. The gold standard of EBM is the systematic review of randomized, double-blind, placebo-controlled trials involving a homogeneous patient population and medical condition. Randomized control trials aim to eliminate bias by allocating treatments to subjects at random, and to establish average efficacy by sampling a large population. Considering the complexity and variety of biological organisms (such as humans), large populations are required for statistical confidence, as well as gauging the most frequent side-effects. EBM places little value on patient testimonials, case reports, and ‘expert’ opinion.
The practice of EBM takes the form of evidence-based guidelines and policies, as well as evidence-based individual decision making by the health care provider. Although evidence-based individual decision making has not been shown to improve health-care [3], increasing evidence supports the efficacy of EBM at the organizational level [4].
Therapeutic strategies derived from EBM are constantly evolving and benefit from the wealth of discoveries made by an army of tireless molecular biologists. These advances typically take the form of a new pharmaceutical agent. For example, elucidation of the role of the bcr-abl tyrosine kinase in Chronic Myelogenous Leukemia led to the development of a new drug called Gleevec (Imatnib) that specifically inhibits this tyrosine kinase. Randomized controlled trials have demonstrated this pharmaceutical to be more effective than previous treatments which non-specifically inhibit rapidly dividing cells. The scientific and cutting-edge nature of EBM gives the patient confidence in their treatment.
Critics of EBM tend to place emphasis on clinical experience and argue that pooled and aggregated population data sets are hard to compare to individual patients [5]. EBM can be subject to publication bias (the tendency to report positive results), as well as conflicts of interest. The expense of large, randomized, controlled trials makes EBM heavily influenced by funding sources. Pharmaceutical companies, wielding millions of dollars in venture capital, have been accused of disease mongering in the pursuit of blockbuster drugs (a drug that can generate more than $1 billion revenue per year) [6].
Pharmaceutical companies also attempt to influence doctors with ‘gifts’ to bias them towards prescribing certain brand medications [6]. Furthermore, the time-frame of randomized controlled trials is often not long enough to determine long-term side-effects of a pharmaceutical agent. This was demonstrated in 2004, when Merck withdrew Vioxx from the market due to concerns of increased risk of heart attack and stroke associated with long-term use. (Note: Over 80 million people have been prescribed Vioxx at some point, and Merck has reserved US $970 million to pay for Vioxx-related legal expenses through 2007. The 2006 sales revenue from Vioxx was US $2.5 billion [7]). The role of the pharmaceutical industry in the practice of EBM is clear from the emphasis on drug prescriptions (e.g. overuse of antibiotics and antidepressants), as opposed to preventative medicine.
Traditional Chinese Medicine
In contrast to EBM, TCM is founded on philosophical theories such as Yin-yang, the Five Elements, body Meridians, and Zang Fu organ theory [8]. One of the key principles is that the human body is in balance (good health) through a constant process of change. Illness results from loss of balance due to stagnation (no change) or too much change. This concept is not dissimilar to western views of homeostasis. TCM uses a holistic (or system-wide) approach to address imbalances.
Diagnosis in TCM tends to be symptom based (as opposed to molecular lab tests), and often involves listening to a patient’s pulse in different positions, physical observation, and talking to the patient about their problem [8]. Treatment commonly takes the form of herbal medicine, acupuncture, and/or food therapy. Although many patients swear by TCM, the efficacy of these treatments continues to be a topic of much debate. Scientific studies have focused on acupuncture, with results suggesting efficacy in recovery from surgery, chemotherapy, and migraines, however a lack of well-conducted clinical trials continues to dog the credibility of this technique [9].
Even less scientific research has been done on Chinese herbal remedies. Proponents of TCM argue that the crucible of time provides evidence for the medicinal properties of these herbs, as only those deemed effective would remain in use. Chinese herbal medicines could provide an excellent starting point when looking for a ‘novel’ pharmaceutical agent. For example, investigation of the Chinese wormwood (qinghao) used in TCM to treat malaria, lead to the discovery of artemisinin [10]. Artemisinin (an isolated compound from qinghao) is now used extensively in Africa and Asia to treat mult-drug resistant strains of malaria [10]. Systematic validation (and elucidation) or debunking of TCM methods by scientific studies could have broad benefits for patients and practitioners of both medical camps. Historically, this pursuit may have been inhibited by antagonizing attitudes of ‘Western’ doctors and scientists towards a TCM system they deemed as ‘quackery’ [11]. However, with increasing interest in TCM within western culture, rigorous studies are required to measure the safety, effectiveness, and regulatory status of TCM methods in order to ensure proper patient care.
Medicine For Me
Now, having familiarized myself with EBM and TCM, it is time to decide upon my next course of action (before I see Julia again). Although I subscribe to the principles of EBM, I am uncomfortable with the level of toxicity and adverse side-effects that are considered acceptable (or remain unknown) when a new pharmaceutical treatment is approved. Fear of unknown complications runs equally (if not more) rampant when I consider the scientific void of TCM. Although my doctor’s prescription for thyroid medication is evidence-based (and the evidence suggests that I will live a happy, thyroid-compensated life), I still feel that prescription drugs are a last resort, and that I have not exhausted my options. I want a treatment that will address the root of my problem—my thyroid gland—not only compensate downstream with supplemental thyroid hormones. I am now the individual: the thorn in the side of the generalized guidelines of EBM. The holistic approach of TCM, and the emphasis on the individual seem increasingly suitable. Indeed, it is with grave trepidation that I decide to foray outside the realm of EBM. In particular, I am hopeful that TCM methods of detoxification (diet and herbal therapy), and physical stimulation (acupuncture, exercises) will rouse my thyroid from its slumber, and return it to normal function. Can I have my cake (health) and eat it (without drugs) too? I am skeptical, but I will try. There is not enough evidence to convince me otherwise.
References
1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996). “Evidence based medicine: what it is and what it isn’t”. BMJ 312 (7023): 71-2.
2. Guyatt G, Cairns J, Churchill D, et al. (1992). “Evidence-based medicine. A new approach to teaching the practice of medicine.” JAMA 268: 2420-5.
3. Coomarasamy A, Khan KS (2004). “What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review”. BMJ 329 (7473): 1017.
4. Yealy DM, Auble TE, Stone RA, et al (2005). “Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial”. Ann. Intern. Med. 143 (12): 881-94.
5. Tonelli, MR (2001). “The limits of evidence-based medicine.” Respir Care 46(12): 1435-40.
6. Ray Moynihan and Alan Cassels (2005). Selling Sickness: How Drug Companies are Turning Us All Into Patients. Allen & Unwin. New York.
7. Reuters. “Merck Sees Slightly Higher 2007 Earnings”, New York Times, 2006-12-07, p. A1.
8. Porkert, Manfred (1974). The Theoretical Foundations of Chinese Medicine MIT Press. Massachusetts.
9. Melchart, D, Linde, K, and Fischer, P et al. (1999). “Acupuncture for recurrent headaches: a systematic review of randomized controlled trials.” Cephalalgia 19(9):779-86.
10. Cumming, JN, Ploypradith, P, Posner, GH (1997). “Antimalarial activity of artemisinin (qinghaosu) and related trioxanes: mechanism(s) of action.” Advances in Pharmacology (San Diego) 37: 253-297.
11. Johnson, T (1999). “MDs skeptical as BC gives stamp of approval to traditional Chinese medicine.” CMAJ 161(11): 1435-1436.