The one principle guiding Science-Based Medicine (SBM) from the beginning was set forth by our fearless leader in the very first post on this blog over ten years ago:
The philosophy of this blog, at its core, is simple: Safe and effective health care is critical to everyone’s quality of life; so much so that it is generally considered a basic human right. The best method for determining which interventions and health products are safe and effective is, without question, good science. Therefore it is in everyone’s best interest for health care to be systematically evaluated by the best science available.
We strive every day to continue to make the above statements the philosophy of this blog. Contrary to what some critics claim, we do not exempt “conventional” medicine from our skepticism, although we do focus more on pseudoscience and quackery that has been increasingly finding its way into academic and community medicine, mainly because it is a niche that needs to be filled. Unfortunately, promoting rigorous science remains as difficult now, if not more so, as it was in 2008. Scientifically unfounded health scares, antivaccine views, anti-GMO activism, and the increasing respectability of quackery like acupuncture, energy medicine, and the like leave SBM under assault as never before.
Other ways of knowing about medicine
Because so much of what is being “integrated” into medicine as “complementary and alternative medicine” (CAM), “integrative medicine,” “integrative health,” or whatever the next nom du jour will be is either unproven, a distortion of existing SBM, or outright quackery, proponents of integrating pseudoscience into medicine—of course, that is not how they would characterize themselves—can’t win on the science, at least not when it is accurately represented. So instead they use other techniques, and one of the most common tropes to which they resort is the appeal to other ways of knowing. As they say in law, if you have the facts on your side, hammer the facts. If you have the law on your side, hammer the law. If you have neither the facts nor the law, hammer the table. It’s a little different in medicine, where, if you have science on your side, you hammer the science, but if you don’t you hammer anecdotes, sow doubt, or appeal to other ways of knowing.
Regular readers will be familiar with this particular tactic. We’ve seen it used by all manner of quacks, cranks, and charlatans, ranging from homeopaths to Dr. Oz to Deepak Chopra. Basically, when science doesn’t support your argument, an appeal to other ways of knowing takes the form of dismissing the science that refutes your argument by saying something along the lines of “Science doesn’t know everything” (which is, of course, true, but irrelevant) and then appealing to a different “way of knowing” that doesn’t involve rigorous science. The appeal to other ways of knowing is basically a form of special pleading, in which it is claimed that your belief should be exempt from rigorous scientific evaluation.
Unfortunately, there is one form of this special pleading that is gaining some currency, and that’s basically carving out an exception to the requirement for rigorous science for “traditional medicine,” be it Ayurveda, traditional Chinese medicine (TCM), aboriginal medicine, or folk medicine practiced around the world. A while back, I discussed how the World Health Organization (WHO) has included a section of ICD (International Classification of Diseases) codes in the new ICD-11 system for TCM codes. Some of these codes included diagnoses like the bladder meridian pattern, triple energizer meridian pattern, liver qi stagnation pattern, and other “diagnoses” derived from the prescientific vitalistic ideas upon which TCM is based. Of note, ICD-10 (the current version) is the standard that the whole world uses to classify diseases. Government health agencies use it, as do private insurers to determine reimbursement for services. The TCM section (International Classification of Traditional Medicine, or ICTM) in ICD-11 will be optional at first, but I predict that it won’t be too long before it becomes mandatory. In a similar vein, the Chinese government recently passed a law designed to promote the use of TCM and facilitate the export of TCM remedies, in effect lowering the scientific bar for ideology and profit.
Last week, Steve Novella took note of this phenomenon, which was referred to as “Indigenous ways of knowing” (IWK), taking note of a recent article by Josh Dehaas, which is highly critical. I had come across the article as well, but I had also come across a couple of others, one by former MD turned philosopher Paul Biegler (which was a lot more wishy-washy than Dehaas’ article bordering on being an apologia for indigenous ways of knowing), and an article in a CAM journal advocating different standards for regulating TCM and other traditional medicines.
Colonialism as a justification for accepting other ways of knowing about medicine?
Of course, as both articles point out, there is history here. Many of the cultures whose medicine is being promoted have a long history of having suffered predation and oppression under the colonialism of European and American powers. This cannot be denied and is a powerful force making claims for IWK sound more compelling. How? Well, let’s look at what Nadine Ijaz and Heather Boon write in justifying differing standards for regulating TCM. I’ll note that we’ve met Heather Boon before. She’s the Dean for the Leslie Dan Faculty of Pharmacy, University of Toronto, where she’s supported a clinical trial of homeopathy, mischaracterized Steve’s and my position with respect to clinical trials of CAM, and generally shown herself to be a true believer in unscientific alternative medicine. In any event, Ijaz and Boon write:
An important issue that frequently goes unaddressed in scholarly discussions of T&CM [traditional and complementary medicine] pertains to the historical and ongoing impacts of European colonization on traditional medicine systems and practices across the globe. As documented and discussed elsewhere,6–9 traditional medicine treatments and practices have long been subjugated, devalued, co-opted, and in some cases decimated across the globe within the context of European colonization. Still today, many indigenous healthcare systems remain under threat due to colonization’s impacts.10
Biomedicine’s globalized dominance, as Hollenberg and Muzzin have elaborated, is far less the result of biomedical science’s evidenced efficacy than it is a feature of the ongoing sociopolitical subordination of precolonial indigenous knowledge systems and related healthcare practices.11 Traditional medicine continues to be in widespread use, and in many jurisdictions (particularly in the global South) represents the “mainstay of healthcare delivery.”1 However, considerable political, research, economic, and institutional capital continues to sustain biomedicine’s pre-eminence in state healthcare systems worldwide.11,12 Regardless, indigenous systems of medical knowledge remain important resources not only within their specific cultural contexts but also as “critical alternative models for resolving health crises on a global scale where biomedical and technological solutions fall increasingly short.”2
The study and reframing of traditional medicine approaches using biomedical conceptual frameworks and language have been used, for many decades, arguably as a strategy to increase their perceived legitimacy within biomedically dominant healthcare systems.12 This has included the increased adoption of biomedical subject areas in the curricula of institutionalized training programs for codified traditional medicine systems such as Chinese medicine, Ayurveda, and Unani, as well as an increasing body of biomedical-style research conducted on particular traditional medicine therapies.
This is the basic narrative of IWK: “Western” biomedical science is a cultural construct whose dominance is due not to its success in diagnosing, treating, and, in some cases, eradicating disease but rather to past imperialism and colonization by European powers. A corollary to the above claim is that attempts by practitioners and proponents of traditional medicine to achieve scientific legitimacy are not because science is better, but because the biomedical model predominates because of the prior subjugation (and, in some cases, the continued oppression) of indigenous peoples. Add to that an appeal to popularity, namely that many millions of people still use traditional medicine as their primary form of health care, and you have an argument that can seem powerful, both to indigenous people using traditional medicines and to some “Western” scientists or physicians—like Heather Boon.
Indeed, Boon goes even further. First, she points out that nearly a quarter of all modern medicines are derived from natural products, many of which were first used in traditional medicine. While I suspect she exaggerates a bit regarding just how many of these natural products were discovered by traditional practitioners, it is true that some were. Of course, the story is not always that simple, as when TCM advocates claimed that the awarding of the Nobel Prize in medicine to Youyou Tu for her discovery of the anti-malaria compound Artemisinin, which was used in TCM. It turns out that considerable “biomedical science” had to go into isolating and validating the active component. This is the sort of thing that Ijaz and Boon complain about, namely how most traditional herbal medicines have undergone “considerable recomposition en route to pharmaceutical usage,” which they describe as a process that “privileges biomedical epistemology while erasing/negating the remedies’ indigenous cultural origins and epistemic underpinnings.”
See what I mean? By this appeal to IWK, “Western” scientists are damned if they do, damned if they don’t. Science is portrayed as being just another way of knowing whose preeminence in medicine is due more to cultural and national hegemony than to actual effectiveness, and if that “Western” science actually tries to use traditional medicines its application of science to testing and formulating them into safe and reliable forms ends up “erasing” the cultural origins and epistemological basis for their use, or, as Ijaz and Boon characterize one problem with regulating traditional medicine, the “historical circumstances (and resulting evidentiary tensions) that surround traditional medicine’s political subjugation to Western biomedical knowledge systems.”
Biegler, unfortunately, appears to be sympathetic to, if not entirely buying, these sorts of arguments:
Few dispute that traditional cultures should be protected and knowledge preserved. But that is a long way from saying that cultural longevity confers legitimacy on a health treatment. By turning the torch on colonialism are the authors sidestepping the awkward fact that the real threat to traditional medicine comes from science, a discipline that bridges the global North and South?
The back-story is that practitioners of traditional medicine (Ijaz is a medical herbalist and shiatsu therapist) have good reason to see the randomised clinical trial (RCT) as a threat. One criterion of the US Food and Drug Administration (FDA) for approving medicines is that they been shown superior to placebo on two RCTs. It’s a standard that could ring the death knell on some TCM practices, should they be compelled to conform to it.
Which, of course, plays to the authors’ point that the Western model threatens to extinguish many venerable and ancient therapies.
Remember, though, that plenty of Western medicines fall at the very same hurdle. An infamous recent example was researcher Irving Kirsch’s use of Freedom of Information to unearth 47 failed antidepressant trials from the FDA, trials subsequently buried by the parent pharmaceutical companies.
If Western medicine is predatory, then, it also eats its own.
Of course, I can’t help but note that more recent evidence clearly supports the efficacy of antidepressants, although the effect size appears to be smaller than previously thought. I also can’t help but note that, in general, science is self-correcting, while fully conceding that the process of self-correction is often quite messy and takes longer than we wish it would. All those traditional medicines have been used for centuries or millennia based on anecdotal evidence passed down through the generations and are basically never abandoned as ineffective. That’s a big difference. “Western medicine” is indeed predatory, and it does eat its own when later evidence shows a treatment to be ineffective or carry more risk than the severity of the condition being treated warrants taking.
Dehaas describes quite well what IWK really means, illustrating it by quoting a professor at UT who teaches a course on IWK, which is, alarmingly, being increasingly infused into the curricula of universities in Canada:
In an introductory IWK lecture, Paul Restoule, a professor at the University of Toronto’s Ontario Institute for Studies in Education (OISE), starts off by telling his class that “knowledges” are subjective. He also claims that the mere act of defining IWK is “problematic,” since any definitions would use “Western knowledge” as a frame of reference. This is not unusual. I’ve been writing about higher education for a decade, and have investigated the issue of IWK on different campuses. Invariably, my attempts to determine the exact parameters of IWK always meet with this somewhat gauzy, defensive response. Oddly, the most zealous proponents of IWK also are the ones who are the most reluctant to describe what it is.
Restoule claims that, for Indigenous people, “the senses can know more deeply and concretely than knowledge gained through reading and being told.” He asserts that “knowledge is sometimes revealed through dreams, visions and intuitions.” And he offers a Venn diagram with a circle for “Western science”—“limited to evidence and explanation within [the] physical world” and “skepticism,”—overlapping somewhat with a circle for “Indigenous knowledge,” which is described as “holistic,” involving a “metaphysical world linked to moral code” and “trust for inherited wisdom.”
This is, of course, correct. Basically, what IWK, at least with respect to traditional medicines, appears to boil down to is to trust that one’s forbearers got it right all those centuries or millennia ago. It is also based on prescientific, mystical, and/or religious beliefs, as Frances Widdowson, a professor of political science at Mount Royal University in Calgary, is quoted as saying:
Whenever proponents are asked to define IWK, “at some point in the conversation, postmodern relativism begins to enter into it,” she says. When asked to explain the unique “ways of knowing” exhibited by Indigenous peoples, advocates tend to describe either folk knowledge or spiritual beliefs, she adds. These may indeed be described as “alternative” ways of knowing. But their alternative character originates in the fact that they present themselves as exempt from the expectation of rigorous scrutiny that typically is applied to claims made by academics.
Precisely. “Western” scientists who promote IWK are, in essence, saying that we should trust “ancient knowledge” and that such ancient knowledge is just “another way of knowing” that is no worse or better than science, just different, even if the knowledge is based on tradition, religion, and prescientific understanding of how the body functions. I should, however, point out that I prefer the term “other ways of knowing” over “indigenous ways of knowing,” given that it is a more general term that encompasses much more of the special pleading that CAM apologists indulge in to claim their treatments are equivalent to science-based medicine without being so specific to a culture or potentially loaded with the baggage that comes with the long and violent history of colonialism and imperialism. Also, I can’t help but note that two of the most popular traditional medicines, TCM and Ayurveda, came from highly advanced civilizations, which is not captured in a term like “IWK.”
There’s also more than a little bit of a racist tendency that has been called the “cult of the noble savage,” wherein indigenous peoples are romanticized as being “purer,” more in tune with nature. Uncorrupted by modern civilization, the noble savage is good and can possess hidden knowledge that we “civilized” (and therefore corrupted) people do not. It’s a not uncommon trope in literature and the arts. (Think the Lakota tribe in Dances With Wolves or, in a science fiction context, the The Na’vi in Avatar.) Not coincidentally, it’s also a variant of the story of the fall of man in Genesis. Indeed, if you want to know why I use scare quotes when referring to “Western” medicine or science, it’s because dividing science into “Western” (cold, rational, reductionist) as compared to “Eastern” or cultures other than European (which includes nations like the US that started out as European colonies) as more “naturalistic,” mystical, and in tune with nature and ancient knowledge is just a variant of the racist noble savage myth.
Sadly, it’s also an attitude that, thanks to postmodern-like relativism, often infects CAM proponents.
Worse, accepting such IWK with respect to medicine can result in real harm:
Widdowson recounts the story of an Inuit man in northern Quebec who got frostbite so severe that his boots froze to his feet. Instead of going to a doctor or warming up his feet, he turned to an elder, who suggested he pack them in wet snow. Eventually, he was coaxed by the RCMP to a hospital where doctors informed him that his reliance on traditional treatment methods might have cost him his feet.
I also can’t help but recount the case of a First Nations girl in Ontario who suffered from leukemia whose mother wanted to choose “aboriginal medicine” (although in reality what she was choosing was the quackery of a white con man who preyed upon Canadian aboriginal people). The results were tragic. It doesn’t even have to be a different race, either. I’ve recounted the story of an Amish girl with cancer whose parents decided to abandon SBM and treat her with traditional Amish medicines. The concept is the same. The “simple” people know things that we modern people do not.
Distrust of “Western science” and the role of the shaman-healer
Of course, it’s understandable why many indigenous people are distrustful of their former colonial rulers. As I discussed when considering the case of the First Nations child with cancer, Canada has a horrible history of placing children of indigenous people in residential schools, whose express purpose was to remove the children from their own culture and assimilate them into Canadian culture. There, many aboriginal children suffered physical and sexual abuse, and it is estimated that 6,000 died over the 100+ year history of the schools. It’s not surprising that there still exists in Canadian aboriginal communities a great deal of distrust of the government and the medical system that facilitated such cultural imperialism, the same as the native peoples in the US very much distrust the government that drove them off their ancestral lands and onto reservations and as other indigenous peoples distrust their former (and, all too often, continuing) oppressors. It’s very easy for them to view “Western” science as just another tool of oppression that delegitimizes their traditional medicine.
But why do “Western” scientists buy into it? I think it’s far too flippant of Dehaas to say that “most of those who sign on are simply afraid of being called racists,” although there could well be element of that. Another motivation for embracing other ways of knowing related to traditional medicine almost certainly includes an element of a longing to be the shaman-healer, something that no less a personage in the world of CAM than Dr. Mehmet Oz himself has expressed in an interview:
“I would take us all back a thousand years, when our ancestors lived in small villages and there was always a healer in that village—and his job wasn’t to give you heart surgery or medication but to help find a safe place for conversation.”
Oz went on, “Western medicine has a firm belief that studying human beings is like studying bacteria in petri dishes. Doctors do not want questions from their patients; it’s easier to tell them what to do than to listen to what they say. But people are on a serpentine path through life, and that is the way it is supposed to be. All I am trying to do is put a couple of road signs out there. I sit on that set every day, and that is what I am focussing on. The road signs.”
It’s that role, that some doctors crave (and, to some extent, understandably so), that of the healer. It’s a large part of why most doctors went into medicine in the first place. Why? I suspect it’s part of reclaiming something that many perceive as having been lost over the last couple of decades, the physician-patient interaction. As the financial pressures of practicing medicine have grown and patient face time has declined, it’s understandable that some physicians would like to reclaim “the way it was,” whether it ever really was that way or not. They yearn for the days when doctors were “healers” and shamans, the way medicine was for hundreds and hundreds of years before science intruded. Indeed, I’ve lost track of how many times I’ve seen rhetoric from practitioners of “integrative” medicine that basically says just this, usually with the implication that to attain that hallowed role of healer requires the embrace of various prescientific treatments.
Indeed, there still exists in the collective consciousness a concept of the physician along the lines of Dr. Marcus Welby and Dr. James Kildare, kindly, benign figures whose influence and good intent were unquestioned by patients, doctors who in essence functioned as modern day shaman-healers. Doctors also long for a perceived time when the will of the physician was generally unquestioned, and patients did what they were told. Of course it’s all romanticized. Certainly shamans were respected and could have empathetic relations with those whom they treated, but they couldn’t really do much else, given the limited their ability to actually treat serious disease and injury was.
I also can’t help but point out that embracing other ways of knowing about medicine has become a business opportunity:
We also should remember that, however warm and fuzzy the principles of IWK may sound, it also has become a business opportunity. In recent years, the demand for more IWK in curricula has created a niche for those who present themselves as an expert in this vaguely defined area. As with other efforts to expand the influence of other cultures in schools and businesses, IWK draws in educators, consultants and administrators whose job is to help these institutions match action to words. These programs also are sometimes accompanied by demands that those who teach the subject be allowed to do so without the normally required credentials, as is recommended in a recent report prepared for Ryerson University.
Also, in the case of TCM, appealing to other ways of knowing has become an even bigger business, promoted and protected by the power of the Chinese government. Indeed, China’s TCM industry grosses $116 billion a year and represents nearly 30% of China’s entire pharmaceutical industry.
Science, culture, and other ways of knowing
Unlike Steve, I’m not going to say that science necessarily transcends culture, at least not today. It can, however, transcend culture, and Steve is correct that a goal of science is to develop a way of knowing and methods that can work for everyone everywhere, regardless of culture, to investigate how nature works and use that knowledge for the betterment of humankind. There is also no doubt that, in medicine, science has produced the goods, saving more lives and preventing more deaths than any “way of knowing” that came before. No one, least of all I, should claim that science is perfect. Obviously it’s not. Advocates of applying other ways of knowing to medicine (like Boon) might love to trot out examples of SBM’s failures or imperfections as a justification for embracing prescientific methods of treatment, but until the traditional medicine they embrace can do what SBM has done and still does, pointing out SBM’s imperfections does not justify abandoning science and retreating to the past. Yet, that’s what advocates of traditional medicine ask us to do.
None of this is to say that indigenous knowledge should be ignored. As scholars have pointed out, the local knowledge of indigenous peoples can be valuable in studying climate and ecological change. The example of the Nobel Prize for Artemisinin shows that some traditional medicines can be turned into highly effective medicines, although it’s hard not to note that the experience of screening natural products for medicinal properties (i.e. pharmacognosy) suggests a low wheat-to-chaff ratio. Respect for cultural knowledge, however, does not justify exempting ancient claims about medicine from scientific scrutiny or using a lower bar of evidence to use and regulate traditional medicines than we do for SBM.