There has been an ongoing internal debate among those of use promoting science in medicine – how fragile vs robust is the dedication to science in the medical profession? In other words, how much of an existential threat do movements such as “alternative medicine” really present to the culture of science that dominates medical practice?
There are those who think that science has a critical advantage, it actually works, and in the long run it will win out. In the extreme one might think that all we have to do is keep our heads down, do the science, and let pseudoscience whither naturally over time. At the other end of the spectrum is the belief that, if we let it, pseudoscience in all its various forms can completely erode out the center of the medical profession, turning health care providers into virtual witch doctors.
I am somewhere in the middle as both sides have a point, but I think we need to assume that the reality is toward the existential threat end of the spectrum. The other perspective breeds complacency. I also think that if you look around the world you gain a broader perspective, and it becomes clear that dedication to science within the medical profession or anywhere is a fragile cultural construct.
Recent cultural trends in the West also reinforce the “fragile” perspective. Deference to expertise and respect for objective information appear to be on the wane. The democratization of information means that everyone can be their own expert, do their own “research”, and decide reality for themselves, even concerning highly technical areas. At the same time, scientists, scholars, and professionals are insufficiently engaged with the culture and politics to effectively counter these trends. The world is changing around them, and at times I have to wonder if they are even noticing.
The even deeper threat is that as new doctors and scientists replace the old, they will be steeped in the new culture. In a generation no one will be left to question the complete infiltration of quackery into the medical profession. This is what happened in China, with the infiltration of Traditional Chinese Medicine (TCM) by proclamation of Chairman Mao.
Quackery in India
Politicians in India are now attempting to replicate Mao’s transformation of medicine in China, and for the same reason. India has a doctor shortage, lacking about half the health care professionals needed to meet the minimum World Health Organization benchmark. To address this shortage some politicians are proposing a bill to license practitioners of Siddha, Ayurvedic, and homeopathic medicine as health care providers in India. The bill is being proposed by health minister JP Nadda.
The bill would allow such practitioners to prescribe medicine and function as primary care doctors after a brief “bridge” course – basically a crash course in medicine (the exact length of the course has not been determined, but Indian states that have similar laws already license practitioners after a three-month course).
Clause 49 of the Bill calls for a joint sitting of the National Medical Commission, the Central Council of Homoeopathy and the Central Council of Indian Medicine at least once a year ‘to enhance the interface between homoeopathy, Indian Systems of Medicine and modern systems of medicine’.
The joint sitting will also have input into the development of “educational modules or programmes” across all areas of medical education.
Fortunately the Indian Medical Association (IMA) is opposing the bill vigorously (as they should). The association’s president, KK Aggarwal, stated:
The government is giving sanction to quackery. If those doctors make mistakes and people pay with their lives, who is going to be held accountable?
The threat goes beyond individual practitioners making specific mistakes. This gets back to the “robust vs fragile” argument. If this bill is passed it will demonstrate how fragile the dedication to science in medicine can be. Science itself is dependent upon support from society, including specifically from institutions, such as government. Without that support, scientists can believe whatever they want but it won’t matter.
We have seen the same types of things happen in the US, with the licensing of entire professions such as chiropractic and naturopathy that are not dedicated to a scientific basis for health care. Those professions then lobby for greater and greater scope of practice, and push the entire practice of medicine in the direction of pseudoscience. Medical school education is now infiltrated with quackery – producing doctors who will be the next generation of experts to make decisions about further infiltration of quackery.
There is also great harm in the government “giving sanction” to quackery, because it is then interpreted as a mark of legitimacy. Regardless of the initial reasons given for regulations allowing the practice of pseudoscience in medicine, once the regulations exist they will be presented and interpreted generally as an indication that the pseudoscience is legitimate.
Indian regulators may think they are proposing a short term solution to their doctor shortage, one that can be reversed in the future, but they would be wrong. History has shown that once pseudoscience takes hold culturally and institutionally it is very difficult to get rid of. Again, TCM in China is an excellent example. The superstitious notions of chi are so deeply embedded in the culture that it is not going anywhere for the foreseeable future.
China has even exported some of its TCM pseudoscience to the West, specifically acupuncture. Acupuncture (the sticking of needles into imaginary points on the body to influence the life force, chi) is pure pseudoscience. It has no plausible mechanism, and despite thousands of studies has not been shown convincingly to work for anything. And yet it has thoroughly infiltrated medicine in the US, and people generally believe it is legitimate.
Proponents have managed to use poorly designed or executed studies, or misinterpreted negative studies, to push acupuncture into the mainstream. This is the very essence of pseudoscience – using the appearance of science to arrive at a predetermined conclusion. Acupuncture now exists in its own bubble of pseudoscience, apparently immune to any objective and critical assessment. All it took was a less than robust dedication to rigorous standards of science in medicine.
That is what the Indian bill threatens to do. There is already a massive problem of medical pseudoscience in India. This bill would legitimize all of it, give it regulatory and educational power, and set back the cause of science-based medicine in India indefinitely.
This struggle is happening throughout the world. In the last half century the pendulum has unfortunately swung massively in the direction of pseudoscience. There is still a core strength to science that does have a long term advantage, but even if you take the maximally optimistic view, there is still a tremendous amount of harm that pseudoscience will do in the meantime. Anything less than this optimistic view results in the indefinite incorporation of rank pseudoscience into the institutions of medicine.