There is a great deal of clinical research conducted and vast sums are spent on it, yet what is learned does not necessarily get translated into changes in practice, especially in the field of complementary and alternative medicine. This is unless the research suggests the effects could be down to unexplained and none specific aspects of clinical care. In which case the intervention or therapy under investigation is very readily written off.
The last years have seen homeopathy suffer a staggering amount of scientific and popular derision – when most trials are, from a scientific materialist perspective, simply evaluating sugar pills, and not the skilful care of the homeopathy practitioner, working with years of knowledge and experience, asking questions and offering support in what will inevitably be a highly specific ritualised manner in an iterative treatment process – where clinical decisions at follow up are based on responses to previous treatment. All this clinical care is dismissed as placebo.
Such dismissal of potentially effective clinical care, and lack of curiosity about why patients might experience the care and treatment they recieve from a complementary therapist as so beneficial, is worrying – and it is hard to see how this benefits any of the stakeholder groups whose interests should be at the heart of the research endeavour.
Three main groups of stakeholders need to know, and would like to understand, whether an intervention, or form of support, is effective. These are: those that could benefit from receiving or using it, those that practice it or would be gate keeping access, and those that would potentially fund healthcare -and must decide, with many competing priorities, and limited resources, which forms of support to fund. Each of these stakeholder groups have different questions to ask – although there will be a degree of overlap.
Research questions should address the specific concerns of these stakeholder groups. The reality is that often the same methods that pharmaceutical companies employ to test new drugs are used with complementary medicine, and such clinical trials raise all sorts of concerns. Finding a placebo or sham comparison is not straightforward. Research has shown that some placebos are more effective and powerful than others. This means different forms of comparison need to be carefully thought about – as well as the different types of care to investigate – for what may be an individualised therapy under investigation, which changes at every consultation and requires different optimal durations for different target populations. And there are potential ethical concerns – it is one thing to expect a clinician with limited patient interaction to take part in a trial – but it is another to see healthcare practitioners involve themselves in elaborate and deliberate deceptions with sick patients, over repeated consultations.
Just how helpful is this sort of research? How necessary is it? Patients, practitioners and funders might often prefer to know how the treatment under investigation, possibly already widely used, and already perceived to be helpful, stacks up against existing forms of care, which are accessible and already NHS funded. This was what we found when preliminary research was conducted for the main definitive trial on acupuncture for depression, at the University of York. There is little reason to suppose this situation is different for other health conditions, especially other health problems where there is an ‘effectiveness gap’ – where existing care is only of limited or partial benefit. Furthermore, when existing medical care has a negative impact as well as a positive one, and it is expensive, there is little justification for not conducting research to see if other forms of care can be supportive and beneficial, or assist to reduce the negative impact of a difficult and harmful treatment. Some of the drugs used in chemotherapy or autoimmune conditions can, for example, take a great toll on the body and compromise a person’s immunity. Yet research is rarely done on complementary medicine in such cases.
The way forwards, to address the concerns of stakeholders, is to conduct more pragmatic trials and research the cost effectiveness of the therapy under investigation in comparison with other forms of care. These trials have the advantage of high external validity – meaning they are generalisable to real world scenarios. They need be no less than scientifically robust than any explanatory trial, eith placebo or sham comparisons, which seeks to answer more narrowly focussed questions about the component efficacy of what in reality may be quite a complex ‘package of care’. These pragmatic studies have real value and would be of high interest to stakeholders – but these stakeholders are not, unfortunately, in the driving seat of the research agenda, especially when it comes to complementary medicine. This must change.
Whether positive results of pragmatic trials, answering useful questions for stakeholders about the potential beneficial impact and cost effectiveness of complementary and traditional therapies (as oppose to conventional or mainstream biomedicine), will influence funders and make these treatments more accessible to patients is really down to political factors, medical power structures and social attitudes. The evidence based medicine paradigm is not played out on a level playing field.