A Trial Of 1000 People Or 1000 Years Of ‘Trial And Error’: Does Evidence Based Medicine Spell the End for Local and Traditional Wisdom?
Alessandro Demaio writes about evidence based medicine versus local wisdom and knowledge.
Evidence Based medicine (EBM) has rapidly become a cornerstone of modern healthcare practice and is seen not only to be the answer to delivering safer, more effective and sustainable medicine but to also please health-economists and governments. Health provision everywhere must now be proven before it will be funded or concreted in policy. Administrators and senior clinicians alike are placing the emphasis on the outcomes from large, complex and commonly drug-driven trials rather than experience, time-tested knowledge and sometimes even common sense.
Simultaneously, the divide in healthcare and population-health between the developed and developing worlds continues to widen. But what about medicine based on human intelligence, local knowledge and generations of “evidence”? When it comes to public health, what role does traditional or indigenous knowledge play? In modern medicine with the growing global burden of disease, are we overlooking an important knowledge resource simply because it is not backed by studies?
In 2006, the World Health Organisation and UNAIDS announced their acknowledgement and support that circumcision had a role in HIV/AIDS prevention. This simple and cheap traditional practice had been recognised by local African communities for many years yet was largely ignored by the scientific and medical communities. Instead, expensive drugs and complex treatments were employed as a reactive measure to address this massive problem whilst cheap and effective interventions were delayed. Clinical trials would not have been impossible to perform and yet, at least in part, this did not quickly occur because it is difficult to patent a circumcision! Despite many drugs entering the market throughout this period with expensive trials to back their use, circumcision remained an untapped intervention, absent from the anti-HIV armament.
This reveals a major weakness of evidence-reliance; clinicians will only perform medicine with an evidence-base, evidence usually equals expensive trials and it takes the financial-backing and promise of monetary returns to bring about these trials. So almost by definition, this current system acts as a disincentive for the global medical community to develop and implement the affordable, simple and universally applicable disease treatments we currently need for diseases such as HIV and TB in the third world.
Another issue with the concept of evidence-based medicine is that it is universally applied and regarded as unmalleable. It is rigid and discourages a clinician from using their own judgement and adapting their healthcare provision for the specific environment. A real life example is from a medical student in remote Australia where the geographical isolation as well as sociocultural needs in this population means that medicine has to be ‘culturally-based’. Supporting an individual who chooses to use traditional healing techniques and “bush” medicines whilst refusing to take western pharmacotherapy goes against the evidence but may be appropriate or even better practice. It is far safer for the patient if the clinician is flexible and accommodating, and understanding and appreciative of the cultural context in which the patient presented. This style of medicine may take more time, thought or consideration, but has better outcomes for the patient and the healthcare system alike.
But one must be fair, maverick medicine is not the answer either and, being purely pragmatic, governing bodies and health administrators need to know an intervention will work before they will be willing to fund it. With limited budgets available, it makes sense to support the strategies that have been proven to work through trials and are supported by clinicians and scientists.
Some would argue that is it not simply a matter of one or the other and that age-old wisdom can be a powerful vector for western health modalities. In a recent interview Funke Bugonjoko, Public Health Officer with the WHO, explained that “we as scientists need to learn, we have the [health] message but need to learn how to reach the people appropriately. Medicines are not the answer, telling is not the answer, trust based on mutual respect and understanding is the answer. Health promoters must appreciate the crucial and profound influence of local knowledge and community gatekeepers on community health. Until you understand and penetrate cultural beliefs you cannot affect health-seeking behaviours.”
Evidence based medicine places a strong emphasis on the strength of evidence and particularly the use of randomised controlled trials in proving therapeutic value. Yet a traditional practice that has been used and refined over many generations may be totally ignored by the medical profession. These trials work well when the intervention is clear and the outcome quantifiable, such as with medications. Though when the intervention is a socio-cultural approach with outcomes that modern science cannot explain, such as with traditional healers, its inability to be rigorously proven through testing makes it redundant to modern medicine. Furthermore, unless there is monetary gain for pharmaceutical companies or demonstrable cost-effectiveness and tax-savings for government investment, it is very difficult to find the support to conduct the trials even if these are possible.
But it is not all doom and gloom, things are being done to address this conflict between scientific and traditional evidence. In Malawi, Hotz and Gibson report on a laboratory that has been established to analyse traditional foods, cooking, preparing techniques in an effort to provide cheap and effective solutions to the growing problems of malnutrition and starvation amongst local communities. Close-by, the African Medical and Research Foundation have been analysing the use of locally trained health workers and their efficacy in delivering appropriate healthcare and screening programs. In other terms, if clinicians and scientists are unwilling to recognise anything without an evidence-base then these few and financially-able traditionalists will prove their potions!
In conclusion, it is crucially important in modern medical practice to encourage clinicians to provide care with an evidence base. But one must be healthily critical of a system that encourages the provision of health only when endorsed by expensive trials, inevitably funded with profits in mind. Evidence-based medicine, like anything, has its limitations and does not negate the need for careful analysis, thought and human judgement. No one endorses rebel medicine of the style of Gregory House, but at the same time, age-old knowledge, techniques and practical, applicable interventions or treatments should not be automatically discounted due to a lack of scientific evidence.
After all, a trial of 1000 people or 1000 years of ‘trial and error’, which is really the evidence base? Something to ponder…
Alessandro Demaio
Overall Chairperson
Asian Medical Students’ Association
African Medical and Research Foundation,
Hotz C and Gibson R. (2007) Traditional Food-Processing and Preparation Practices to Enhance Bioavailability of Micronutrients in Plant-Based Diets.
The Journal of Nutrition. 137, 1097-1100.World Health Organization and United Nations. (13 December, 2006) Press Statement on Kenyan and Ugandan Trial Findings Regarding Male Circumcision and HIV.
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