by Alan Cassels

It was 260 years ago this month (May 20, 1747, to be exact) that a British naval physician began what some have called the world’s first clinical trial. At the time, the biggest scourge of the Royal Navy was not enemy cannon fire from the French or Spanish fleets, but scurvy, a disease that left sailors weak, bleeding and incapacitated, often killing them.
No one knew anything about vitamins then, and even less about vitamin deficiency. A 31-year-old naval surgeon, James Lind, hypothesized that foods high in acid content might help, so he tested 12 sailors suffering from scurvy and divided them into six pairs. In addition to their regular meals, he fed each pair different things, such as garlic, seawater, cider, vinegar, oranges and limes, and within a few weeks it was obvious which worked best: While the orange and lime pair regained their strength and went back to work, the others worsened. This discovery was of no small import; preventing scurvy contributed enormously to the massive strength of the British navy and Britannia would rule the waves for the next almost 200 years.
Lind’s elegant, little nutrition experiment comes to mind when I ponder the debates in Canada over the sustainability of healthcare, the perennial discussions about how much healthcare we can afford and the public’s concern around what is considered “legitimate” healthcare, worthy of public coverage.
Canadians now spend in excess of $20 billion per year on prescription drugs, an amount that is growing at a rate of about $1.5 billion per year. While some argue that this money is a good investment in healthcare, leading to longer and healthier lives, others say that our growing dependence on high-tech pharmaceuticals is leading us in the opposite direction where we get diminishing – and some would say negative – returns for all this new money.
Like human-induced climate change, there are a lot of inconvenient truths around the sustainability of publically-funded medical care. Sadly, the debate is mired in arguments around who should pay (public versus private), as opposed to what we should pay for. Those who have thought deeply about this issue have suggested “integrative solutions” to the current healthcare crises, where we start rethinking the contents of our publically-funded healthcare basket and make some hard choices about paying for effective care.
At the end of May, a conference at the University of Victoria may hold a key to cracking the nut of unsustainable health care. Sponsored by the Association of Complementary and Integrative Physicians of BC (ACIPBC), a group of physicians aiming to shape a healthcare system that draws from both worlds – orthodox medicine and “complementary and alternative” medicine – the Body Heals Conference (www.bodyheals.ca) brings together an array of luminaries in the fields of integrative care. No doubt the conference will, at the very least, provide some grist for the mill as the government continues its public “Conversation on Health” in BC.
BC’s expert in the field of integrative medicine is Dr. Warren Bell, a family physician from Salmon Arm who also happens to be the current president of the ACIPBC. For the past 27 years, Dr. Bell has been a keen observer of the relationship between the pharmaceutical industry and the medical profession and the field of therapeutics in general. He maintains that integrative healthcare chooses from the entire palette of effective options, some of which are orthodox – drugs and surgery – while others are complementary, such as massage therapy, nutrition therapy, naturopathy and herbal treatments.
Critiques of complementary or integrative medicine usually revolve around three main concepts: Evidence, respect and public funding. Many doctors and patients believe that “real” medicine is based on solid, scientific evidence, that it is respected and practised by the medical mainstream and that it is taught in medical school and paid for by public funds. These beliefs neglect to consider that a myriad of political decisions, along the way, determine which therapies are included in the basket and which aren’t. Practitioners of integrative medicine, such as Dr. Bell, are aware of the political and economic issues that influence the basket’s contents. They believe, as I think most of us do, that the value of a therapy should be judged on its therapeutic efficacy, not on politics. Let’s look at the three arguments:

1) Integrative medicine is not evidence-based
In terms of “evidence,” you won’t find many 5,000-patient clinical studies of complementary medicine (unlike patented pharmaceuticals), but that doesn’t mean these therapies aren’t based on good research. Most medical knowledge is not derived from studies of thousands of patients, but physicians can still be guided by careful research, observation and well-controlled, but smaller, studies. How many patients did it take to prove the efficacy of lime juice to prevent and treat scurvy? Twelve. With many big drug studies, the effect sizes are so miniscule that the studies need thousands of patients to prove statistically-significant results. Many experts will tell you that complementary medicine is not evidence-based, but, as Dr. Bell notes, “Those who say that alternative medicine isn’t based on good evidence have resolutely refused to look at the evidence.”

2) The medical mainstream does not respect integrative medicine
Many of us have had the experience of broaching the subject of this herb or that vitamin with our doctors only to be warned that we shouldn’t be taking our chances with “untested” therapies. Why do our doctors dis the alternative or non-drug approaches to treating illness? The answer is complex, but one key culprit is undoubtedly the dominance of the pharmaceutical industry in the education of our physicians; the non-patented alternatives rarely get much air-time. Physicians typically learn about new developments in medicine at medical education seminars, dinner meetings and professional conferences, which are still highly dominated by pharmaceutical industry funding. When pharma is funding our doctors’ education, which, by its very nature tends to ignore or discredit the non-patented alternatives, should we be surprised that those paying the piper are calling the tune?

3) Integrative medicine is not paid for by public funds, therefore must not be worthy of payment
It’s true that if the public pays for something, it is perceived to be valuable, but there are many examples of low-cost, simple therapies that aren’t covered by the public purse. While we spend billions more every year on new drugs, even a fraction of that money could fund interventions to get patients eating better, exercising more and even supplying them with important supplements. What about prescribing a shot of lime juice to prevent patients from getting scurvy? This is not a facetious question; some research has suggested that up to a quarter of the US population may be deficient in vitamin C. Why the vitamin shot treatments are still not covered is a mystery, especially in cases where there is clear evidence that a patient is suffering from a proven vitamin deficiency, and that vitamin supplementation may keep people out of hospitals and save them paying for other costly medical treatments.

The one example that infuriates Warren Bell is the use of hyperbaric oxygen in treating deep infections. Putting a patient in a hyperbaric chamber and using oxygen in a pressurized environment can increase oxygen to injured tissues, reduce swelling, improve healing and help fight infection. And there is very good, randomized, controlled evidence that supports the many benefits of hyperbaric oxygen. While it’s no “miracle cure,” by all accounts, it’s very effective. For people with diabetes, who often get ulcers in the lower extremities, which often require amputation, hyperbaric oxygen therapy might be the best thing going. Bizarrely, in BC there are very few hyperbaric chambers and not nearly enough medical use of the ones that do exist. Of those, only MDs can order their use and approve reimbursement for the patient. If you are a naturopath, tough luck. The government won’t pay for hyperbaric treatments for your patients.

Why don’t we have a health care system that embraces, more thoroughly, the concept of therapeutic efficacy, regardless of whether or not the treatment has a patent? The real problem is not the power of the drug companies, but the power of intellectual property rights (patents), which, Dr. Bell says, effectively “… supplants most other forms of therapy in our country.” We’re no doubt witnessing a world where pharmaceuticals so eclipse the delivery of healthcare that a vast field of non-prescription remedies go unused.
What’s the one thing that integrative medicine practitioners are asking for? A level playing field.

It seems to me that integrative healthcare, as I understand it, is all about taking a central tenet of medicine seriously: “First do no harm.” If there are low-cost, low-tech, unpatented solutions for many of our ills, why wouldn’t we encourage their use?

Integrative medicine may well require a revolution in thinking. It requires that medical education be more open and accepting, and that a medical profession, even one absolutely sold on the drugs‘n’surgery paradigm, understands how something as simple as vitamin therapy could help patients. If alternatives work, put them in the basket along with other forms of medicine.

But be patient because all of this will take time. It took 42 years (and thousands of scurvy deaths) before James Lind’s famous experiment was enacted into policy by the British Admiralty.

Alan Cassels is co-author of Selling Sickness and a drug policy researcher at the University of Victoria. He is also the founder of Media Doctor Canada, which evaluates reporting of medical treatments in Canada’s media. www.mediadoctor.ca
Alan presents the talk Promiscuous Medicine on May 26 (between 10:15-11:15 AM) as part of the Body Heals Conference in Victoria.