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Antiscience-Based Medicine in South Africa

South Africa’s Health Minister, Manto Tshabalala-Msimang, is fighting to protect the traditional healers of her country from having their methods tested scientifically. She warns that, “We cannot use Western models of protocols for research and development,” and that she does not want the incorporation of traditional healing to get “bogged down in clinical trials.” Her arguments are anti-scientific and represent a health tragedy for South Africa. However, such attitudes are not uncommon within the community of sectarian medicine and represent some of the common rhetoric used to disguise anti-scientific positions.

This is also not the first controversial statement made by South Africa’s health minister. In 2006 she advocated using garlic and beetroot to treat HIV infection, prompting outrage from South Africa’s academic community. In response to criticism about delays and funding cuts in providing anti-retroviral drugs to HIV sufferers in South Africa, the Health Minister said, “Garlic is absolutely critical, we need to do research on it. We cannot just ridicule it.” South Africa’s president, Thabo Mbeki, resisted calls for Ms. Tshabalala-Msimang’s resignation.

President Mbeki has a spotty history on this front as well, gaining international infamy when in 2000 he declared that he was unconvinced as to the cause of AIDS and convened a panel to discuss its true causes. Just last year Mbeki came under further criticism when he fired the deputy health minister, Nozizwe Madlala-Routledge, who was an outspoken critic of Mbeki and Tshabalala-Msimang and is credited with reversing many of South Africa’s disastrous HIV and health policies.

This fight over the role of science in public health would likely have escaped world attention were HIV/AIDS not at the center of the controversy in a country that is itself at the epicenter of the African AIDS epidemic. (It is estimated that about 10% of the population may be infected with HIV.) But let us take a look at Tshabalala-Msimang’s statements in the broader context of science-based medicine.

“We cannot use Western models of protocols for research and development.”

The implication behind this statement is that science is somehow a “Western” cultural endeavor, or that there is “Western science” vs “Eastern science” or perhaps in this case “African science.” Such attitudes are simply a way to take a position that is anti-science while providing rhetorical cover.

There is no such thing as “Western science” or any other qualified science. Science is a set of methods for systematically and carefully gathering reliable evidence, for testing ideas by seeing if their predictions can be verified, using valid logic to draw conclusions, and fairly considering all available evidence. What, exactly, about “Western” protocols does Tshabalala-Msimang find objectionable or incompatible with the public health goals of her country? Does she object to using valid logic or to considering all available evidence? Perhaps she objects to the transparency of “Western” research.

“bogged down in clinical trials.”

Her other statement does clarify what she does not like about “Western” protocols – its reliance upon clinical trials. So perhaps she prefers anecdotes to placebo-controlled trials (in other words preferring inferior forms of evidence whose conclusions one likes to superior forms of evidence whose conclusions one does not like). Apparently she feels that taking the time to see if a treatment is safe and effective is a waste of time and only slows the widespread incorporation of the treatment.

We hear this type of thing from promoters of dubious and sectarian methods frequently – they are too busy healing people to take the time to do the research. Of course this is based upon the assumption that their methods work. History has clearly shown that such assumptions are not warranted. The research is necessary to determine if they are helping people and not hurting them.

Medicines used for thousands of years

Tshabalala-Msimang believes that because traditional healing methods have been used for thousands of years they do not need to be subjected to proper scientific study. I call this the argument from antiquity, which is a special case of the argument from authority. It falsely assumes that a treatment modality that has stood the test of time must be safe and effective. History shows this is not always the case. For example, blood letting based upon the humoral philosophy of illness survived for a couple thousand years in Europe and was only abandoned when it was replaced by scientific medicine. Also, the argument from antiquity is just another way of appealing to anecdotal evidence. Large amounts of anecdotal evidence, even spread out over many centuries, is still anecdotal and therefore subject to all the uncertainty and limitations that implies.

This is not to say that collective experience with a treatment is of no value. Uncontrolled observation is capable of detecting very obvious and immediate effects. But it is not reliable enough to detect long term risk or toxicity from treatment, nor to judge if it truly changes the course of an illness.

I will further note that Tshabalala-Msimang is relying upon traditional healing practices to claim that garlic and beetroot are effective in treating HIV/AIDS. It is, of course, not possible that there is thousands of years of experience with such a treatment, since HIV has been recognized for only two and a half decades. She therefore must be extrapolating from more non-specific claims made for these treatments. There simply is no evidence for the efficacy of nutrition in general or garlic and beetroot in particular as first-line therapy for HIV. The Academy of Science of South Africa, after studying the role of nutrition in HIV and TB, made the following statement:

The Study Panel is frankly appalled by the dearth of reliable and truly informative studies of the nutritional influences/interventions on the course and outcomes of the pandemic chronic diseases addressed in this report.

The argument from antiquity, when stripped down, is just another way to argue that poor quality evidence should replace or even trump high quality scientific evidence, or for putting health claims and practice ahead of proper evidence.

Conclusion

Unfortunately it seems that by firing the deputy health minister, while keeping Tshabalala-Msimang on as health minister despite widespread calls for her resignation, President Mbeki is making his intentions clear. Science-based medicine is being denigrated in South Africa as “Western,” tedious, and unnecessary, while implausible health methods are being offered without evidence or adequate justification. This does not bode well for South Africa’s health crisis.

Posted in: Politics and Regulation, Science and Medicine

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43 thoughts on “Antiscience-Based Medicine in South Africa

  1. OwenSwart says:

    Thank you for that analysis, far more eloquent than my own attempt.

    What is so alarming is that these people who remain in positions of considerable power within our government are determined to further their own, personal agendas at the expense of South African lives.

    Any dissent to their opinions within their own ranks is punished by relief from duty. Any questions from outside their ranks is their completely ignored or ridiculed as being “racist” (a curious and unjustifiable accusation, but one that carries a lot of emotional weight, given our troubled past).

    I can only hope that the negative attention focussed upon Manto as a result of this idiotic statement of hers will somehow influence the powers that be, and cause her to lose favour within the ruling party. However I don’t suffer under any delusions that that might actually be the case.

    Thanks again for helping us bring this travesty to the attention of the international community.

  2. esther says:

    This is a very interesting post. I have studied a little about South Africa and have a good friend from that country. I think that you are incorrect concerning the point about “Western medicine.” I agree with you on the scientific aspects and I agree that science is not just a Western thing. However, I think the problems other countries have with Western medicine is that it appears very materialistic and all about bringing in money. Now, I don’t operate under that delusion having worked in health care for a couple years. But I have talked to a lot of people who do. I do not think the scientific aspect is what the South African minister is trying to avoid so much as the idea of cultural changes that might occur. I think it needs to be shown that science as a basis for medicine should be a universal value and I am glad you pointed that out.

  3. Meadon says:

    Good on ya Steve! – Mike, card-carrying South African…

  4. Manto Tshabalala-Msimang was pretty clear – she was not talking about a Western style health care delivery system. She was talking about the need to do clinical trials – about “Western protocols.” She was explicitly arguing that SA does not need to do scientific studies of traditional healing methods.

    But I agree that part of the challenge is in educating the public about what the nature of science really is – and that is as true at home (meaning the US) as abroad.

  5. daedalus2u says:

    My take on this is that the politicians of South Africa are acting like politicians everywhere; they are seeking to do whatever increases their power and authority by appealing to their political “base”. Appeals to authority make absolute perfect sense (if one is that authority). Politicians don’t have the scientific background and understanding to understand issues on a scientific basis, so they go to an “authority”. That authority has a strong incentive to tell them what they want to hear (because politicians control funding). This is how all governments work; this is how politicians feel everything should work. This is no different than US politicians claiming abortion causes breast cancer or that there is no such thing as global warming. Anti-science political policies are an appeal to the anti-science political base that many politicians have.

    There may be the perception that “western” medicine is overly materialistic in the sense that the companies providing those services derive income and profits from doing so. Practitioners of “traditional” medicine derive benefits from their practices too, prestige, power, authority. These are benefits that perhaps cannot be measured so easily as wealth, but benefits that motivate the practitioners to exclude competition via any means available.

  6. BlazingDragon says:

    I don’t think it is just “politics as usual” in South Africa. Thabo Mbeki came into office not believing that HIV causes AIDS and with the idea that Western medicine was somehow “out to get” South Africans (especially black South Africans). He holds weird beliefs and has done everything in his power to perpetuate them. I think the political benefits are just “gravy” to him.

    One day, I hope, the people of South Africa will turn on anti-science idiots like Mbeki, but I don’t see it happening soon. Many “western” companies have very poor track records and have knowingly abused people all over the African continent to make a few extra dollars. This sad fact makes it much easier for idiots like Mbeki to take advantage of the population at large. However, he is not the only African leader to use this same outrageous technique of “distrusting western science.” Anyone remember the tragedies of polio nearly being wiped out, then some leaders declaring the vaccine was a plot to sterilize African Muslim women? Ugh.

    It will take time and building a trusting relationship between “western” agencies and African leaders to undo the damage done by unthinking or greedy people in the past. Unfortunately, there will always be idiots like Mbeki who either use this for political benefit and/or truly believe that “western” powers have bad intentions.

  7. overshoot says:

    Traditional healing methods?

    Do we mean traditional methods like “sex with a virgin will cure you?”

  8. BlazingDragon says:

    Don’t forget overshoot, the local idiots take “sex with a virgin” to mean “get them young,” and some have been having sex with toddlers to “guarantee” a virgin.

    If I had to guess, Mbeki and his cronies won’t defend this particular “cure” for HIV/AIDS, but they are pushing many other “therapies” with as much scientific plausibility as having sex with a virgin…

  9. daedalus2u says:

    It is exactly like politicians in this country playing on xenophobic fears by playing cards of race, religion, politics, immigration, terrorism. Politicians will play on what ever fears resonate with their political base.

    Playing into vaccine fears is not unique to Africa. Measles cases in the UK are up 30% since last year, and the highest they have been since 1995.

    http://scienceblogs.com/insolence/2008/02/the_consequences_of_not_vaccinating.php

  10. BlazingDragon says:

    Some politicians “use the rubes” but are smart enough (and cynical and evil enough) to use complete lunatics to forward their personal aggrandizement … some politicians actually believe some (or all) of the lunacy they spew. I think Mbeki and his awful cohorts fall mostly (or completely) into the latter category.

    We’re having a measles “outbreak” here in San Diego too (5-7 cases locally, last time I checked). Sigh.

    Maybe the measles outbreak and the near-miss on the flu vaccine this year will shake some people out of their complacency and remind them that vaccines exist for a reason… the diseases are far more disabling (or potentially deadly) than the vaccine side effects. Of course, some people, one can never reach.

  11. Egaeus says:

    It is not reasonable to expect every shaman or witch doctor to spend fortunes on clinical trials. Firstly, most of them simply do not have that kind of money. Secondly, even if a shaman had $200 million or so to spend proving that its garlic and beetroot product, say, cured AIDS, they would then neither have marketing exclusivity for the species as a whole….

    Oh, wait, is this the wrong thread?

  12. Meadon says:

    BlazingDragon… A small point: Mbeki is most certainly not an idiot. He has some crazy beliefs and buys way too much into pomo for my taste, but he’s still probably the single most intelligent president the country has ever had (with the possible exception of Smuts). Remember, intelligence does not necessarily protect people from pseudoscience – indeed, I’m guessing Mbeki’s intelligence and independence is what drove him to question the HIV/AIDS link. He was wholly wrong, of course, but he’s no idiot.

  13. Calli Arcale says:

    Egaeus:
    “It is not reasonable to expect every shaman or witch doctor to spend fortunes on clinical trials. Firstly, most of them simply do not have that kind of money. Secondly, even if a shaman had $200 million or so to spend proving that its garlic and beetroot product, say, cured AIDS, they would then neither have marketing exclusivity for the species as a whole….”

    It’s unreasonable to expect a lone shaman to pay for a clinical trial or other research, correct. But what’s stopping universities and governments? For that matter, what’s stopping corporations? You don’t have to have exclusive control over a product to make money off of it. Heck, if you find an inventive new way to administer an old remedy, you may even be able to patent it.

    Of course, it’s cheaper just to stand next to the impoverished practitioners of traditional medicine and say “would you want to bankrupt this man who just wants to help people?” and reap the benefits of the herbal remedy without actually paying much to develop into a proper drug (or even find out if it actually does squat).

    I’m all for spending money on studying things like garlic for AIDS. The only problem is, there’s only so much money to go around. So some things will have to wait. That’s just the way it is. Since anti-retrovirals have a lot more going for them than a few vague “but my brother’s cousin used it and swears he felt better a few weeks ago” type testimonials, it makes sense to devote the money to those before going for the long-shot ideas like garlic.

  14. Egaeus says:

    Calli,

    You need to turn your sarcasm meter sensitivity up, and/or go read the following thread:

    http://www.sciencebasedmedicine.org/?p=50

  15. weing says:

    Is this garlic to be smeared on the genitals 5 minutes before intercourse?

  16. daedalus2u says:

    There is a concept is to use something that will reduce the transmission of HIV and which women can used when their partners refuse to use a condom. This is known as a topical microbicide and there is a very serious research effort to produce products and get them to women so they can protect themselves.

    http://www.microbicide.org/

    I am working on a product to reduce transmission of HIV via this mechanism. The base I plan to use is not garlic, but rather the nitric oxide bacteria I am working with. NO has a number of broad spectrum antimicrobial and antiviral effects, the normal treatment for bacterial vaginosis is metronidazole which is a NO donor, NO also causes apoptosis of infected immune cells (suspected to be a major transmission factor). The major flora of the vagina, the Lactobacilli are quite resistant to NO because they don’t have hemes. The normal pH (~4) is too acid for my bacteria to be very active because at that pH ammonia is present as ammonium ion. However if opportunistic heterotrophic bacteria began hydrolyzing urea, the pH would rise and ammonia oxidizing bacteria could generate NO/NOx and inhibit them.

    There once was a traditional remedy that also used a similar natural base, but precisely what it was used for is unknown because the papyrus that explains the function has a hole in it.

    That would be the use of crocodile dung applied vaginally.

    While crocodile dung pessaries may be contraceptive through a variety of mechanisms, (pH, sperm motility, detergency) and may have encouraged abstinence (!), one wonders as to the experimental program and methodology by which such properties might be discovered, and the marketing program necessary to achieve consumer acceptance. Prevention of conception would not be apparent for a significant period of time, and without modern statistical methods, marginal contraceptive effectiveness would not be easily confirmed. Use of a crocodile dung pessary would not be cryptic, and so presumably was tolerated by the woman’s partner.

    I propose that the described material would be a potent sexual stimulent and broad spectrum anti-microbial agent and that these prompt effects would be sufficient to gain consumer acceptance, irrespective of the contraceptive effectiveness.

    http://www.digitalegypt.ucl.ac.uk/lahun/ucarchivelahun/uc32057page1-2.gif

    For those of you who are rusty with ancient Egyptian, there is a translation:

    http://www.digitalegypt.ucl.ac.uk/med/birthpapyrus.html

    This would be remedy 21.

    21. Column 3, 6
    tm [..] Hs msH wgp Hr HsA awyt txb [...]
    For preventing [..] crocodile dung, chopped over HsA and awyt-liquid, sprinkle [...]

    I have done research using a crocodile dung stimulant. That is the aerobically composted dung of another uricotelic (meaning excretes uric acid in its urine) organism, the chicken. 10 grams of the material (Cockadoodle DOO) produces ~1 nM/min nitric oxide when moistened with water for about an hour. This is a large quantity of NO.

    http://www.purebarnyard.com/cockadoodledoo/

    The exact reasons why ancient Egyptian women used pessaries containing crocodile dung may never be known. However, as a powerful NO source it may be that crocodile dung was used to prevent/treat bacterial vaginosis (similar to the NO donor metronidazole), perhaps to prevent/treat erectile dysfunction or anorgasmia/dysphoria, or perhaps to prevent/treat STDs, similar to the topical microbicides being proposed for HIV prevention.

  17. weing says:

    I still think rubbing garlic on genitals 5 minutes before intercourse would be effective in preventing transmission.

  18. Egaeus says:

    Weing, that is an interesting hypothesis. You should try it and get back to us. Be sure to crush the garlic well to get the maximum effect. While traditionally you would not crush the genitals, I would hypothesize that doing so may also aid in preventing the transmission of disease.

  19. apteryx says:

    In a previous thread, I wrote:

    “It is not reasonable to expect every manufacturer of supplements to spend fortunes on clinical trials. Firstly, most of them, like most small food manufacturers, simply do not have that kind of money. Secondly, even if a company had $200 million or so to spend proving that its elderberry product, say, shortened the duration of colds, they would then neither have marketing exclusivity for the species as a whole (nor should they),”

    and above, Egaeus wrote:

    “It is not reasonable to expect every shaman or witch doctor to spend fortunes on clinical trials. Firstly, most of them simply do not have that kind of money. Secondly, even if a shaman had $200 million or so to spend proving that its garlic and beetroot product, say, cured AIDS, they would then neither have marketing exclusivity for the species as a whole….”

    When I find someone “very sincerely flattering” my own personal words in order to distort and smear the opinions of a larger class of people, I take it as a compliment, and evidence that I am being a successful gadfly. The two cases are not comparable, for several reasons:

    1. Elderberry has been used for respiratory infections for millennia, and I see no reason why us commoners should feel (or be) forced to completely abandon traditional practices the minute some new product in a shiny corporate package turns up. As noted, AIDS is a new disease, so there is no recorded history of people alleviating its symptoms by the use of garlic, beetroot, or anything else.

    2. There is scientific evidence supporting the traditional use of elderberry. Although garlic is a well-documented antiviral, there is no evidence that it affects HIV or AIDS.

    3. Colds and flu are self-limiting. If an elderberry product sold with a TM-based anti-flu claim turned out to have “only” a placebo effect (such as many corporate cold products have), nobody would be harmed, beyond being out a few dollars. A remedy wrongly promoted as a treatment for AIDS can cause harm when conventional treatment is available but might be foregone by CAM users who would benefit from it.

    Tshabalala-Msimang is an idiot and I have no sympathy with her position. That said, malnutrition worsens AIDS symptoms, and improved nutrition improves health in AIDS patients. People who have access to traditional plant foods and herbs containing beneficial phytochemicals will be better off, healthwise, than those who can only afford cornmeal mush, so there is nothing wrong with encouraging AIDS patients to eat well. But it is completely inappropriate to tell people that those plants will have any direct effect on the AIDS virus, unless such has been scientifically demonstrated.

    It is absolutely true that no “witch doctor” can pay for clinical trials. [That is generally considered a racist pejorative these days, BTW] That does not mean that no remedies used by “witch doctors” are useful. They often have plants that will alleviate symptoms such as diarrhea safely and more affordably than Western drugs. I am familiar with an example in which a plant mixture provided by a “witch doctor” has been tried out on AIDS patients by a group of MDs and been observed to provide such conspicuous relief that they are supplying it to many of the patients at a local clinic.

    Another thing you need to understand is that many Africans go to traditional healers because they have little access to Western medicine, or cannot pay for it when it is available. If they are shamed and berated for the fact when they do see the Western clinician, they will be forced to choose sides and use only one or the other. Those who are poor will usually pick the ajuoga or inyanga because THEY HAVE TO. These are people who live in often remote areas with poor services and see a few hundred dollars per year. It’s much better if the MDs and the healers can work together to support public health, as is happening in several successful local programs. Both parties gain knowledge, and the healers are taught, for example, when to provide referrals for AIDS tests and wind up supporting the Western system. But for this to happen, the MDs must be able to treat the healers with respect and listen to them, not just preach at them or against them.

  20. BlazingDragon says:

    Meadon,

    Your comment proves Mbeki is cunning, but he is not necessarily “smart” (and therefore, not an idiot). He may have his pulse on the finger of what people like to hear (making him an excellent politician), but he could still be functionally an idiot (anyone who trusts the idiots pushing these “alternative” therapies for HIV is a gullible fool, almost by definition).

    If he were truly smart, he would have looked at their “evidence” and laughed at them. As it is, he sounds more like a dangerous idiot (“nothing is so dangerous as just a little bit of knowledge”). He THINKS he knows all about HIV/AIDS, but he really doesn’t and he is doing incredible damage to the people he is leading in the process.

  21. daedalus2u says:

    One of the things that works against EBM MDs and traditional healers working together is the placebo effects that the different treatments generate. The largest placebo effect is obtained by the practitioner who has the biggest and the most Mojo. The placebo effect is mediated through the physiology of the patient. Who ever has the patient’s confidence will invoke the placebo effect to the greatest degree (and hence gets credit for that component of healing associated with the placebo effect). Healing due to the placebo effect is going to be pretty much zero sum. What the placebo effect can do is limited, and once the placebo effect is maximally invoked, there is nothing more that any placebo can do.

    Trash-talking traditional medicine and trash-talking EBM treatments will diminish the placebo effect of each of those treatments, and tend to move some of the placebo effect onto the modality that is not trashed.

    This puts EBM practitioners in an ethical bind. The only therapeutic effect of most CAM treatments is via placebo, but if that is made known to the patient, then that placebo effect is diminished. Unless the EBM treatment can provide a placebo effect sufficient to make up for the loss of the CAM placebo effect, the patient may not do as well. EBM ethical guidelines don’t allow lying to the patient even if those lies were therapeutic (by invoking a stronger placebo effect).

    Practitioners of CAM don’t have an ethical bind about lying to themselves and to their subjects. If they did, they would only use evidence based CAM approaches (i.e. they would not lie to themselves about what was effective).

    I think this explains the somewhat contradictory attitudes some physicians have toward CAM. With a physicians focus on the well being of the patient, how the patient receives a placebo effect that improves their health is irrelevant. EBM will provide reliable non-placebo based therapeutic effects. Patients with a strong belief in CAM will have their placebo effect triggered by that CAM. To deny those patients a placebo effect mediated though their CAM of choice would be to worsen their outcome (unless that placebo effect could be produced some other way).

  22. weing says:

    Egaeus,
    I’m not the one prescribing it. Just trying to figure out how it could work.

  23. apteryx says:

    BlazingDragon writes:

    “anyone who trusts the idiots pushing these “alternative” therapies for HIV is a gullible fool, almost by definition”

    What they are is human, which may well be almost the same thing. Please remember that the Africans who are using these products are (a) in immediate need of whatever help they can get, and (b) poor and poorly educated. In some places, most people, especially women, do not get beyond grade school. They have no internet access or local library. All they can do is trust their national and tribal leaders and media to inform them. If those sources fall down on the job, a poor farmer has no possible means of personally re-evaluating the evidence.

    Lest you sneer at Africans for their unscientific beliefs, how many Americans with heartburn have been stampeded by their opinion molders into thinking they absolutely must have Nexium, instead of Prilosec at a quarter the cost, to “Heal Your Esophagus,” when in fact the active ingredients in those two drugs are identical? And the average American finishes high school and has some college, plus readily available internet. Still, he either can’t, won’t, or just doesn’t have time to evaluate every claim he hears on TV. All he does is absorb and believe the claims that are made to sound plausible and that fit the value system he’s already been trained to. And that’s pretty much what the Africans do. They are more ignorant than we are, but what they need to catch up is more access to education, not a label that implies the gap is due to innate personal defects.

  24. daedalus2u says:

    There is quite a good blog about the interaction of an EBM doctor and a Witch Doctor in the African bush, Bush Doctor In The City

    http://babawilly.wordpress.com/

    He hasn’t written anything recently, but I recommend going back into his archives. The Bush Doctor and the Witch Doctor did reach an accommodation of sorts, but I think this was mostly because the Witch Doctor pretty much knew his limits and didn’t try to do things outside his expertise. He referred those cases to the Bush Doctor. Many of the Bush Doctor’s patients would go to the Witch Doctor to get all their bases covered.

    The Bush Doctor did know the culture, and how to work within it. I think both the Bush Doctor and the Witch Doctor were trying to help their patients to the best of their ability, and they each knew the limits of their abilities and the limited resources they had to work with. I don’t think the experience could be transplanted to the west because the culture is so different.

  25. skidoo says:

    “Tshabalala?” LMAO! Sorry, I’m just an easily amused, feeble-minded skeptic. Although, there’s really nothing amusing about this wewe. Except her name.

  26. Egaeus says:

    apteryx,

    The point was to illustrate the fallacy of your argument. I do believe that there are some products in the woo aisle of the local co-op that are effective (elderberry being one, and I’ve yet to see anyone anywhere refute that). However, your argument does nothing to help those, and allow the charlatans to make unsubstantiated claims about their products. The worst offenders are like those in the article. People believe them over established scientific data, and eschew EBM for snake oil and dying as a result, or worse yet spreading their disease. This is CAM at its worst, and unfortunately, the science behind it is about as sound as the science behind intelligent design.

  27. weing says:

    apteryx,
    re prilosec and nexium,
    The active ingredient in a bottle of vodka and a bottle of beer is the same. So if you drink a bottle of either one, you can drive your car with the same safety?

  28. apteryx says:

    Weing-

    No, but if you consume three shots of vodka or three bottles of beer, you’ll have similar alcohol-based physiological effects, if that is your purpose for drinking. Are you suggesting there is some vastly important medical reason why a person with heartburn needs to take 20 mg of Nexium rather than 40 mg of Prilosec?

  29. weing says:

    Same medical reason someone wants to drink a bottle of vodka vs a bottle of beer.

  30. apteryx says:

    I guess my little consumer mind just does not get your point here. In the event that you wanted to get stinking blotto, yes, drinking one bottle of vodka would be a lot easier on your bladder than drinking 30 beers. In theory, Prilosec has 50% less of the active enantiomer, right (although Nexium has not been definitely twice as potent in head-to-head competition at equivalent doses)? The active dose of either will easily fit in one pill, as we know from the fact that Prilosec was heavily marketed in its time as a single pill. So the difference between prescription Prilosec and Nexium will not be noticeable, and the former will be far cheaper since its patent has expired. I imagine an OTC version of Prilosec would be lower-dose, requiring the patient to take two pills. If doing so would save the patient a few bucks with every swallow, or several hundred or more per year, most patients would be happy to take that deal.

    At least, it ought to be the patient’s choice whether the added value, if any, is worth the cost, and that choice has to be based on true information if it is to be meaningful. The consumer is fed the line that he “needs” some bioactivity that can only be found in Nexium. Such can’t possibly exist, since there is nothing in Nexium that isn’t in Prilosec. It should be his doctor’s job to educate him, thereby saving him thousands, but the doctor just got this really nifty Nexium clipboard…

  31. weing says:

    You assume all patients are educable. Sure you have a purer product in Nexium, and the company can have longer patent protection and hopefully spend the profits on bringing new instead of me too treatments into the market. I’ll keep on dreaming.

  32. Harriet Hall says:

    Egaeus,

    You mentioned elderberry. The Natural Medicines Comprehensive Database says elderberry “seems to reduce the symptoms and duration of influenza infection when given within 48 hours of initial symptoms. Significant symptom relief seems to occur within 2 to 4 days of treatment for most patients. On average, elderberry extract seems to reduce the duration of symptoms by about 56%.”
    Unfortunately, the information is based on 2 small trials that need further confirmation, and because of this the NMCD only rates elderberry as “possibly effective.” It also gives it only a “possibly safe” rating because of insufficient information. It also cautions against use by patients with autoimmune diseases.

    If the FDA approved a new prescription medication on the basis of this amount of information, we would hear protests. If the FDA put a medication on the market with this amount of safety data and post-marketing reports of side effects started to come in, we would hear protests. Elderberry may indeed be safe and effective, but to allege that on the basis of current evidence seems to me to indicate a double standard.

  33. Egaeus says:

    Dr. Hall,

    Sorry, I was unclear. Agreeing with its effectiveness is purely based on personal experience after my GP recommended trying it. I know this is anecdotal, but I’ve used it to great effect to accelerate recovery from one full-blown cold, one apparent cold (fever, sore throat, etc.) that didn’t progress after starting the Sambucol, as well as being (literally) the only on in the office who didn’t get the community cold in January, and my immune system is historically sub-par (I can take 2-4 weeks to recover from the average cold).

    If it’s a placebo, then it’s the best placebo ever. It works for colds a heck of a lot better than Prozac, Serzone or Imipramine ever worked on my moderate depression back in college. I was not surprised by the recent headlines at all.

    But having sang its praises, I definitely, absolutely agree that it needs more testing. That has actually been my main point of contention with apteryx. While he(?) believes in a lot more “supplements” than I do, he, for some reason, doesn’t want to force them to be tested further. I personally would like something stronger than what we have now, which is all but unregulated.

    A search on Google Scholar turns up a few more than 2 papers on elderberry and/or Sambucol. They are quite limited based on their summaries, but I haven’t yet found one that suggests it doesn’t work. It’s not yet overwhelming evidence, but it should (hopefully) spur someone to test it more thoroughly.

    I’d think that some university somewhere would have jumped on it by now. It’s a relatively easy trial since the results are unambiguous. There’s no “rate your pain on a scale of 1-10″ types of subjectivity. The effects of cold and flu viruses are well known, obvious, and for the most part objective. The bottom line is that if it works for everyone else like it works for me, then it is literally an effective treatment (if not outright cure) for the common cold. (I have no personal experience with it treating the flu though, and I don’t want any, thanks.)

  34. apteryx says:

    I think that while human use is adequate evidence of some health claims (aspirin was not marketed on the basis of RCTs), commercial products should have to have scientific evidence to back most such claims. The amount of evidence demanded should be enough to be meaningful, but not so great as to be practically impossible. We could use something like Germany’s Commission E to decide which claims have been supported. However, at the moment a supplement is not allowed to make disease claims no matter what the evidence. If manufacturers should be “forced” to do clinical trials, they should also get to brag about the results on the packaging. Also, they should not face the assertion that all manufacturer-funded, non-Big Pharma studies are worthless because they are tainted by manufacturer involvement.

    Most certainly, I do not think that an existing product sold without health claims should be banned simply because it is a botanical, unless it can be shown to cause harm. When you speak of “forcing” small businesses to do this and that, no matter what the cost and regulatory hurdles, it really translates into forcing them to shut their doors. To reiterate, these products have been used continuously for millennia. I could assert that maybe one of the “minor” fruits or vegetables eaten by humans is a health risk. Why, maybe it causes cancer! And that could even be true. But if I have no actual evidence against any of those species, I should not argue for removing them all from the market and telling everyone to shut up and eat their iceberg lettuce.

    Dr. Hall – Other parts of the elder plant are used medicinally, but elderberry is a FOOD. Fruits are used in jams, jellies, and elderberry wine (which also has an anti-cold reputation). You say that the NMCD gives it “only” a possibly safe rating; as I noted in a previous thread, this is also the rating they give to pumpkin seeds, another conventional food that, though not popular among middle-class white Americans, is eaten enough that we need have no fear it is secretly poisonous. The NMCD ratings are extremely conservative. “Possibly safe” requires the agreement of “reputable references” AND human trial data showing safety, plus not a shred of evidence for a lack of safety (because any claim of danger, no matter how silly, gets at least “possibly unsafe”). Will you next argue that chicken soup might be unsafe because its bioactivity is well known in folklore?

  35. Harriet Hall says:

    Yes, elderberries are food and are presumably safe when used as food. We assume foods are safe, but occasionally we get a surprise, like when we discovered that eating a lot of licorice can induce hypertension. Beer is food, and presumably safe; but I needn’t list all the harmful effects on health that we know it can cause. And often the medicinal form and amount is different from typical use as food. I would argue that the NMCD ratings are no less conservative than FDA standards. When a food is used as a medicine, shouldn’t it meet the same safety requirements as other medicines, and shouldn’t it meet the same standard of proof of efficacy?

    For that matter, it is very rare to find a food that has proven value as a medicine, despite the many unsupported claims.

  36. Harriet Hall says:

    Oops. I meant the NMCD ratings are no more conservative than FDA standards.

  37. apteryx says:

    I like the response of Jim Duke, who suggested that the the anti-herb FDA head David Kessler should be asked publicly whether prune juice was a safe and effective laxative — and if he said no, he should be invited to drink a glass and observe the results. I do not think that each company that sells prunes should be required to take them off the market until safety studies are conducted, or indeed that any company should be required to conduct such studies. Nor should manufacturers of prune products be required to conduct very costly efficacy studies, unless they are allowed to and wish to make health claims. Legally, they are foods, and the public’s awareness of their health benefits does not change that. Many of our common herbs, spices, and fruits likewise have scientific evidence for their bioactivity. You can ban them if you like from the herb aisle, but people will still get them in the spice aisle.

    It is true that medicinal doses can be larger than food doses, but they can also be smaller. A spoonful or two of elderberry syrup is not a higher dose than you would get from drinking elderberry wine by the glassful. For herbs and spices, people may use somewhat more medicinally than they would in cooking, but that determination must be based on the species’ food use in other cultures, not just our own, which is dominated by flavor-phobic Anglo-Saxon cuisine. Garlic, ginger, and peppermint are seen by many people as vegetables to be eaten by the forkful. Since culinary plants tend to have very low toxicity, people who consume a little more than the average probably are at little risk. (If you want to dispute that, the first botanical product for which studies should be required is refined wheat flour.) The above may not apply to super-concentrated, few-molecule artificial extracts, such as resveratrol supplements, which really can give you far more of a substance than anyone would normally consume. FDA interprets DSHEA to treat such products as new dietary ingredients, if not grandfathered in, mening that the manufacturer must demonstrate safety.

  38. weing says:

    I’d like to see those who claim that herbals are safe drink a bottle of hemlock or eat a bowl of belladonna berries.

  39. Egaeus says:

    weing, no need for strawmen.

  40. weing says:

    Sssorry.

  41. maydont says:

    Just a follow up – 6months later. Mbeki has been ousted by his own party and so has the health minister Tshabalala-Msimang. The new health minister (Barbara Hogan) seems quite promising, however due to cultural sensitivity it would take a lot to do a u-turn on the “Traditional Medicine” matter.

    One should also understand that if she does get tougher on traditional medicine that the racist card could easily be played. Hogan is white and Tshabalala-Msimang is black. This is important as the lingering odor of apartheid still exists in South Africa. One feels that perhaps politics here will be chosen above science.

    On sadder, but related, matters, 2 weeks ago 13 family members were killed when one of their members, a practitioner of Traditional Medicine used poisonous herbs in a cleansing ritual. The practitioner was just 17.

    http://www.mg.co.za/article/2008-09-22-thirteen-dead-in-apparent-herbal-poisoning

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