A discussion that got a little out-of-hand at my book club prompted me to think about how we make decisions regarding ‘conventional’ and ‘alternative medical’ practices. I should note here that book club discussions getting out-of-hand are not really the norm. Book clubs seem to largely comprise of women and groups of women generally do their very best to keep the social fabric intact. I will therefore blame the ongoing stresses of COVID-19 for this incident!
A variety of comments were made at book club about acupuncture. There was a particularly inflammatory comment that “ACC fund acupuncture so there must be evidence supporting its use”. When last did a government department decision ensure that an item or experience is value for money, or valuable in any way whatsoever? This could start me on a rant about the ongoing, profligate government spending highlighted this week by $11.7M allocated to construct buildings at a ‘Green School’, who largely get their income from international students, at fees of up to $40,000 per annum. The money is touted as supplying work for 200 construction staff (obviously temporary) and generating considerable future income from the students. A business catering to international anything doesn’t seem necessarily the right place for current expansion, as opposed to our public schools, many of whom would love to have a construction project improving their infrastructure. If the school took a year to construct, and 1/3 of building costs was in wages (as is normal), then the 200 workers will be receiving a wage of $15,000 each. They had better work quickly. Or perhaps James Shaw and the Green Party had better back down fast.
Government rant over, let’s return to acupuncture – the primary comment I reacted to was actually someone saying that ‘acupuncture worked for me’ with the apparent implication that acupuncture has definite efficacy, and therefore could work for others. I have looked at articles about acupuncture over many years, wishing for sound clinical trial evidence of it working and, better yet, some sound physiological/cellular rationale for its ability to relieve pain and promote healing. I acknowledge that we take many medicines through the clinical trial process without yet understanding their ‘mode of action’, but understanding mode of action promotes a lot of confidence in a medical treatment. I also feel like It would be so nice for something that hangs around the fringes of medicine to be proven right (though perhaps what I would really like is for it to be proven one way or another).
If we took personal experience as a standard of proof, as people in book club seemed to be suggesting, then if I get a dose of the Russian Sputnik V COVID-19 vaccine and am never subsequently found to have suffered from COVID-19, I could confidently say, “It works”. I could go on to suggest that other people should be injected with Sputnik V, on the basis that it works and I didn’t get sick from having the injection. How does that sound? Would you like to try Sputnik V, given my great experience? A group of New Zealand politicians and businessmen are trying to bring Sputnik V into the country so if Sputnik V sounds appealing you might even have the chance to try it (it is actually highly unlikely that MedSafe will allow it).
Personally, I would prefer to wait for the results of the trialling of Sputnik V on a larger number of people to see if it harms them or prevents infection. Testing on a large number of people is exactly what a normal, pre-commercialisation, Phase III clinical trial encompasses. However, we could also say that as long as Sputnik V (or acupuncture) are not harmful, they might do some good, so why not try them? In the case of Sputnik V we are not yet sure it is safe because it has only been tested on 76 people. But in the case of acupuncture, it has been applied to many millions of people so we should be a lot more certain.
According to a WHO meta-review of the use of acupuncture in China, between 6% and 15% of acupuncture patients have mild adverse effects in the form of local pain and slight bleeding or bruising. In a study of 190,924 patients the incidence of severe adverse effects (hospital transmission, organ trauma or death) was 0.024%. Another study found that 2.2% of 229,230 subjects had adverse effects requiring specific treatment. However, many of the severe adverse effects occurred in rural areas, where it is likely that practitioners were poorly trained, including in sterilisation practices. So perhaps its ok to try acupuncture with an experienced practitioner (although there was additional book club comment that one should best experience it with a ‘real’ old Chinese doctor, rather than a modern trainee). I looked up New Zealand medical sites relating to acupuncture to see what records of harm there were. I liked this line, “Existing symptoms can get worse after treatment (less than 3% of patients). You should tell your acupuncturist about this, but it is usually a good sign.“. I wonder how that is a good sign, a shame they didn’t explain.
It is reasonably likely that you won’t get damaged by acupuncture, but it is very difficult to tell whether it will help you – thousands of ‘real’ medical trials have been carried out, most with inconclusive results. Acupuncture is tricky to trial – the gold standard method used for medicine requires that, for a specific condition, some people get treated, other people don’t get treated (the ‘controls’) and no-one, including the practitioner administering the treatment, knows who has been treated. It is very hard to appear to stick needles in people while not actually doing it. However, ‘sham acupuncture’ has been tried in the interests of proving acupuncture efficacy. A British meta-review of such studies covering 3025 people found that “A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias.” A USA study found that acupuncture has some effect on pain but that there must also be other important factors involved in the relief of pain in these situations. David Colquhoun and Steven Novella argue that there are indeed other factors, which are more important than the needles, in “Acupuncture is Theatrical Placebo“. They suggest that, since it has proved impossible to find consistent evidence for acupuncture after more than 3000 trials, it is time to give up.
‘But does it matter that there is no proof, and what is proof anyway?’, people in book club debated. If one person has a condition supposedly ‘cured’ by acupuncture, should anyone argue against that? One obvious problem with the ‘it worked for me’ argument, is that the individual is rarely telling you about the times when the same intervention didn’t work. If it doesn’t work once does that cancel the time it did work? Or do you need ten examples of failure to cancel one success? Or ten successes to cancel one failure? In the end, if the person is paying the cost of the treatment and there is little evidence of harm, it probably doesn’t matter. But what if ACC is paying for the treatment? ACC doesn’t have an unlimited budget, nor does the government (even if it seems so right now). Therefore acupuncture treatment of some people will mean other people will not be treated for a condition, because money is not unlimited. A plethora of ineffective, or barely effective, treatments, will drain resources from the health system with few health returns.
The telling of ‘It worked for me’, taps into our love of stories and their centrality to our brains and to our behaviours. So ‘it worked for me’ makes sense to us, in a way that isn’t totally sensible. We love a good story and hear it as a plausible explanation. Just like, if we hear that someone who caught COVID-19 was fraternising inappropriately with border staff, we might like to believe and spread that story too because it sounds quite plausible and a good story is fun. We often don’t think of the ancillary damage caused in the process.
Perhaps, in the end, it is the specific delivery of the message that is critical. If Sputnik V doesn’t make me sick, and I don’t get COVID-19, I should say, ‘Sputnik V appeared to work for me ‘. I definitely should not say ‘Sputnik V works’. I should not say ‘You should try Sputnik V’. I could say, ‘I was desperate enough to risk taking Sputnik V and I am very thankful it has turned out OK, but I am really looking forward to seeing the results of large scale trials that will prove its safety, efficacy and the breadth of its effect.’ Oh, to be that considered when making statements at book club!
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