May 14, 2007

The power of nothing

GEOFF WATTS, NEW SCIENTIST, FIRST PUBLISHED MAY 26, 2001

WANT TO devise a new form of alternative medicine? No problem. Here's the recipe.

Be warm, sympathetic, reassuring and enthusiastic. Your treatment should involve physical contact, and each session with your patients should last at least half an hour. Encourage your patients to take an active part in their treatment and understand how their disorders relate to the rest of their lives. Tell them that their own bodies possess the true power to heal. Make them pay you out of their own pockets. Describe your treatment in familiar words, but embroidered with a hint of mysticism: energy fields, energy flows, energy blocks, meridians, forces, auras, rhythms and the like. Refer to the knowledge of an earlier age: wisdom carelessly swept aside by the rise and rise of blind, mechanistic science.

Oh, come off it, you're saying. Something invented off the top of your head couldn't possibly work, could it? Well yes, it could—and often well enough to earn you a living. A good living if you are sufficiently convincing or, better still, really believe in your therapy.

Many illnesses get better on their own, so if you are lucky and administer your treatment at just the right time you'll get the credit. But that's only part of it. Some of the improvement really would be down to you. Not necessarily because you'd recommended ginseng rather than camomile tea or used this crystal as opposed to that pressure point. Nothing so specific. Your healing power would be the outcome of a paradoxical force that conventional medicine recognises but remains oddly ambivalent about: the placebo effect.

Placebos are treatments that have no direct effect on the body, yet still work because the patient has faith in their power to heal. Most often the term refers to a dummy pill, but it applies just as much to any device or procedure, from a sticking plaster to a crystal to an operation. The existence of the placebo effect implies that even quackery may confer real benefits, which is why any mention of placebo is a touchy subject for many practitioners of complementary and alternative medicine (CAM), who are likely to regard it as tantamount to a charge of charlatanism. In fact, the placebo effect is a powerful part of all medical care, orthodox or otherwise, though its role is often neglected and misunderstood.

One of the great strengths of CAM may be its practioners' skill in deploying the placebo effect to accomplish real healing.

"Complementary practitioners are miles better at producing non-specific effects and good therapeutic relationships," says Edzard Ernst, professor of CAM at Exeter University. The question is whether CAM could be integrated into conventional medicine, as some would like, without losing much of this power.

At one level, it should come as no surprise that our state of mind can influence our physiology: anger opens the superficial blood vessels of the face; sadness pumps the tear glands. But exactly how placebos work their medical magic is still largely unknown. Most of the scant research to date has focused on the control of pain, because it's one of the commonest complaints and lends itself to experimental study. Here, attention has turned to the endorphins, natural counterparts of morphine that are known to help control pain. "Any of the neurochemicals involved in transmitting pain impulses or modulating them might also be involved in generating the placebo response," says Don Price, an oral surgeon at the University of Florida who studies the placebo effect in dental pain. "But endorphins are still out in front."

That case has been strengthened by the recent work of Fabrizio Benedetti of the University of Turin, who showed that the placebo effect can be abolished by a drug, naloxone, which blocks the effects of endorphins. Benedetti induced pain in human volunteers by inflating a blood-pressure cuff on the forearm. He did this several times a day for several days, using morphine each time to control the pain. On the final day, without saying anything, he replaced the morphine with a saline solution. This still relieved the subjects' pain: a placebo effect. But when he added naloxone to the saline the pain relief disappeared. Here was direct proof that placebo analgesia is mediated, at least in part, by these natural opiates.

Still, no one knows how belief triggers endorphin release, or why most people can't achieve placebo pain relief simply by willing it. Several labs are now thinking of using brain imaging to study the neurobiology of the placebo effect in more detail. "The brain has already been imaged during drug-induced analgesia," says Price. "There's going to be a race between laboratories to do this experiment first for placebo analgesia."

Though scientists don't know exactly how placebos work, they have accumulated a fair bit of knowledge about how to trigger the effect. A London rheumatologist found, for example, that red dummy capsules made more effective painkillers than blue, green or yellow ones. Research on American students revealed that blue pills make better sedatives than pink, a colour more suitable for stimulants. Even branding can make a difference: if Aspro or Tylenol are what you like to take for a headache, their chemically identical generic equivalents may be less effective.

Special delivery

It matters, too, how the treatment is delivered. Decades ago, when the major tranquilliser chlorpromazine was being introduced, a doctor in Kansas categorised his colleagues according to whether they were keen on it, openly sceptical of its benefits, or took a "let's try and see" attitude (American Journal of Psychiatry, vol 113, p 52). His conclusion: the more enthusiastic the doctor, the better the drug performed. And this year Ernst surveyed published studies that compared doctors' bedside manners (The Lancet, vol 357, p 757). The studies turned up one consistent finding: "Physicians who adopt a warm, friendly and reassuring manner," he reported, "are more effective than those whose consultations are formal and do not offer reassurance."

Warm, friendly and reassuring are precisely CAM's strong suits, of course. Many of the ingredients of that opening recipe—the physical contact, the generous swathes of time, the strong hints of supernormal healing power—are just the kind of thing likely to impress patients. It's hardly surprising, then, that complementary practitioners are generally best at mobilising the placebo effect, says Arthur Kleinman, professor of social anthropology at Harvard University.

"This doesn't go down well in these communities because of the denigrating connotations of placebos. It's very threatening to people in those fields," Kleinman says. "The problem is that biomedicine has an extraordinarily negative view of placebos. They're treated as a nuisance rather than being seen as what they really are." And what they are, according to Kleinman, is part of the complex interaction of physiology, psychology and culture which underlies the process of turning a sick person into a healthy one.

This, needless to say, is a world away from the mechanistic approach of most conventional medicine, which has little to say about what people's experience of illness means to them. As Ernst puts it: "The very popularity of complementary medicine is a criticism of mainstream medicine. In the mainstream we have sharper and sharper tools. But in terms of empathy, time, understanding and touch we are losing out."

But even if many CAM therapies do get much of their power from the placebo effect, it's still important to ask whether there's anything more to them than that. To say—as many a CAM practitioner does—that a treatment "works" begs the question of how well it works. If a mantra-induced placebo effect will ease the pain of my bad back, that's good. But might something else do it even better? A handful of aspirin, for example? If doctors had been content to declare that a treatment works and leave it at that, orthodox medicine would not have got far. We want to know not just what works, but what works best. In answering that question, there's no substitute for clinical trials.

Yet it's not easy to design those trials in a way that both CAM advocates and conventional scientists will agree is fair. To give the clearest possible test of the treatments in question, experimentalists want to randomly assign patients to receive, say, aspirin or mantra therapy while rigorously holding all other conditions constant. But CAM practitioners charge that this cookie-cutter regularity is unfair to CAM therapies because it removes the individualised care that is such a central feature of most of them. "Because I apply orthodox research methods to complementary medicine, I've been accused of stripping it of what makes it work," says Ernst. "They say I'm throwing out the baby with the bath water. I accept that this could be a danger. If a therapy works only as a placebo then maybe one should keep science out of it. On the other hand this is how science advances."

This problem of context extends far beyond the realm of research. It also casts a shadow over attempts to integrate alternative therapies, with their powerful placebo-invoking techniques, into mainstream medicine. In practice this integration would mean, among other things, offering alternative medicine on state systems like Britain's National Health Service. To a limited but growing extent this already happens: the NHS runs a couple of homeopathic hospitals, and increasing numbers of family doctors invite aromatherapists, acupuncturists, herbalists and others into their surgeries. Some doctors even administer these treatments themselves.

But for much of CAM—especially techniques in which the placebo effect accounts for most or perhaps all the benefit—integration might well be counterproductive. After all, the value of CAM depends partly on its unorthodoxy. Price talks of a "clash of cultures". Would your free, state-registered crystal therapist, pressed for time and perhaps wearing a uniform just like other paramedical staff, still be able to mobilise as good a placebo response? Ernst, for one, doubts it, and sees this as a powerful argument against integration. "Although there is little evidence to support the view, one intuitively feels that something exotic has a stronger placebo effect than something bog standard. And some complementary therapies are very exotic," he says.

Integration faces other obstacles, too. Doctors would face serious ethical problems in recommending what they know to be placebo treatments to their patients (see "An ethical dilemma"). And complementary practitioners would likely be disparaged by their conventional counterparts, as they often are today. With the growing emphasis on evidence-based medicine, installing a roomful of radionics boxes or setting aside a clinic for dispensing Bach flower remedies would be hard to justify, however much it might please the customers. Integrated medicine "would have about as much validity as a hybrid of astronomy and astrology", Neville Goodman, an anaesthetist in Bristol, wrote in the April newsletter of HealthWatch.

Healthcare managers, too, may view such moves with some alarm. The addition of a whole raft of new and time-consuming treatments could play havoc with already overstretched budgets. In the long term, though, a few CAM techniques might achieve integration. A study of low back pain by Britain's Medical Research Council, for instance, revealed that chiropractic compares favourably with conventional hospital treatment in terms of cost and effectiveness (British Medical Journal, vol 300, p 1431). It's likely that chiropractic treatment provides specific benefits over and above the placebo effect.

Even CAM techniques that do largely depend on their placebo value could achieve the same cost-effectiveness. Indeed, for most of medicine's history, compassion, attention and tender loving care—all big contributors to the placebo effect—were all that doctors had to offer. The advent of science changed that, but in adopting their new role of body technician, doctors have to a great extent dropped the traditional one of healer: the non-specific but still valuable business of caring. Most doctors would now be faintly embarrassed by the suggestion that "healing" might be part of their job description. It sounds a bit pre-scientific. But that's what most CAM practitioners still offer, and they are certainly not embarrassed by the idea.

A professor of surgery with a confident manner, an expensive suit and an international reputation who sees you privately and guarantees to solve your problem with a costly operation may still be unrivalled as a source of placebo power. But most doctors are beaten hands down by countless alternative practitioners who might not know a lymphocyte from a lump of cheese. What they do know is how to make you feel better. And that's a big part of the battle.
Geoff Watts is a medical and science journalist, and author of Pleasing the Patient, a book on the placebo effect. He is also vice-chairman of the group HealthWatch, which argues the case for reliable information about medicine

From issue 2292 of New Scientist magazine, 26 May 2001, page 34

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May 12, 2007

A visit to the Sambhavna Trust Clinic in Bhopal, April 3rd to 7th 2007

BY DOCTOR BISWANATH GOUDA

I never understood it when people used to say that it's easier to make rational decisions when you are not part of the problem you are trying to understand. Not until April 2004. That summer, after graduating with a Masters in Public Health from Tulane I stumbled upon the AID website and was thus accidentally introduced to AID and its work. Since then I have tried to be an active volunteer given my work and time constraints and supporting the Bhopal campaign has been one of the consistent projects that attracts my attention. To be honest, until 2004 my level of awareness about the Bhopal gas tragedy was very vague. I knew something had happened in the year 1984 while I was in my second/third standard school in Bombay. And I remained as vague for the next 20 years during which I left India and went to study in New Orleans.

When we used to hold events at different temples, garba, dandiya/ poojas or social gatherings in US cities, I used to wonder why a significant part of the Indian community couldn't identify with or support our petitions. But the reason was a similar lack of awareness and proper knowledge of facts/events that occurred in 1984 and the way things have evolved for the communities since. I have encountered two polarized views so far about the Bhopal disaster. One was while helping man a booth in San Diego for AID last year. An American lady came to us inquiring why we were raising the issue after two decades when everything was resolved – hadn't the company compensated the affected people? We weren't surprised to be asked this question and after sharing the facts and telling her about the present condition of the survivors and the reason for our display of posters, she willingly signed the petition and said she hoped those people would get proper compensation. I was glad that she at least signed, unlike some of our own Indian folks who, even after hearing the details and facts, refused to sign because they strongly believed that Bhopal was a lost cause.

The other incident occurred in Bhopal. I was on my way to the Sambhavna Clinic in a rickshaw and casually asked the driver what he thought of the gas-peedith (victims) people and if anything needed to be done for their benefit. First of all, he didn't want to discuss the issue, stating that it was an old story and there was no point going back to the past. He was more interested in describing different tourist destinations in and around Bhopal and the town's new shopping areas and markets – which is understandable given the evident globalization in most cities/towns of India. He seemed aloof from the Bhopal issue although born and living in that same town. I asked myself, what makes me one of those who are supporting that same cause? I am sure he has his reasons for his opinions and I will find mine.

Reaching the Clinic was not much of a problem except the rickshaw driver was surprised to know that such a hospital existed in the interior of the community as opposed to being on a major road or street. I would say the clinic is a 'state of art' piece of architecture, blends very well with the surrounding locality, smartly chosen colors, beautifully landscaped and cross ventilated structure gives it an airy feel in each and every room and hall of the clinic. The structure details of the clinic can be found at: http://www.bhopal.org/sambhavnaclinic.html

I had never been to Bhopal before and hence never visited the Clinic. So this was my first visit to the city as well as to the Clinic. I had planned to be there from Tuesday through Saturday and return back to Mumbai on Sunday. After being accommodated at the volunteers' residence and discussing with Rachna the possible roles I could play during my stay as part of 'shramdaan', I agreed to attend the clinic with Dr Kaisar, who is the sole allopathic physician and offered to provide my services to the clinic patients. Since I enjoyed spending most time in the clinic, my observations below pertain to the allopathic services provided in the clinic.

· The clinic draws a huge patient population that includes not only disaster survivors but also patients from nearby neighborhoods and distant localities. I encountered an elderly women suffering from malnourishment and asthma, who had come to the clinic riding a bus for an hour one way! Around 150-200 patients are seen everyday who come seeking allopathic, ayurvedic, yoga/ massage therapy, diet, pediatric or gynecological services. A warm and friendly person, Dr Kaisar, the sole allopathic (modern medicine) doctor, sees around 60-80 patients regularly in the span of 5 hours.
· The majority of patients suffer from breathing disorders (asthma, bronchitis, lung tuberculosis, restrictive lung disorders), malnourishment, diabetes, heart disease, hypertension, obesity, alcohol and drug abuse related ailments.
· Cancer is also prevalent, mostly lung, esophagus, uterine and cervical cancers. I was astonished to see an operated case of transverse colon cancer, that's more widely found in Western countries where reduced fibre intake is a common cause unlike in India and that too in an interior community of Bhopal.
· Diabetes is a huge problem and it is clubbed with obesity at Sambhavana Clinic. On a regular day, we saw at least 40-45% of the patients who were diabetic, either on multiple oral medicines or on insulin injections.
· The Clinic opens at 8 in the morning and functions till 3 in the afternoon with one-hour lunch break around noon. There is an evident smooth coordination between the staff workers, clinicians, health workers, interns and patients, which is a striking feature of its work.
· The in-house blood work lab and medicine-dispensing facility reflect the farsighted vision of the Clinic and are an added advantage not only to the patients but also for the treating physicians.
· The majority of the patients are Muslim and the staff members and physicians are well versed with their cultural and traditional mores, which helps the Clinic create good rapport and trust with patients.
· An in house kitchen provides food and breakfast at an economic price both to the Clinic staff and patient, thus saving time in seeking afternoon meals from venturing outside the complex.
· The Clinic provides ample space for patient waiting/ registration in the corridors and lawn.
· Housing alternative therapies like ayurveda, yoga, massage and dietician services provides a 'one step destination' for patients who need to seek multiple referrals to cure their ailments.
· The services are offered at a nominal service based fee structure, which is less than any hospital/clinic around Sambhavna.

I have tried to analyze each disorder as a single entity. My recommendations are based on my observations as stated below:

· Lung Disorders: As there is a huge patient population with lung ailments, most of them requiring steam/steroid inhalation with nebuliser, the Clinic needs an additional two nebulisers to meet the need. One should be solely reserved for pediatric patients. The clinic should also stock ample quantities of breathing masks. Pediatric masks should not be used for adults. Best practice would be to identify those patients who seek nebuliser every week and either ask/ provide them with an individual mask to reduce cross infection with other patients.
· Pulmonary function test/ Lung function tests should be done at affordable intervals to assess the improvement of treatment. Since it's a costly test, some sort of collaboration should be made with nearby investigative labs to get the test done at a discounted rate for Sambhavna patients.
· An in house TB-Tuberculosis Center supported by the Central Health Govt. can be proposed to help subjects with tuberculosis. This can reduce the traveling distance for the patients and also would increase the compliance for treatment. Another suggestion would be to collaborate with the nearby Public Health Centers and make sure the patients referred are followed up for complete duration of therapy.
· Patients suffering from lung ailments seemed to be malnourished, more so protein deficient. Dietician should study the local food and commonly obtained food items and formulate a diet intake focusing on increasing protein intake, keeping the cost and culture in mind.
· Obesity: Obesity is a huge problem nationwide and seems more prevalent in Bhopal. As in India obesity is often seen as a sign of economic prosperity, this link needs to be broken by creating awareness of the diseases related to obesity – namely diabetes, high blood pressure, high cholesterol, breathing problems, knee and joint pains and few organ cancers. Physicians and dieticians should stress the importance of ideal weight, weight loss for obese patients and keeping a strict chart of weight, height and waist measurement at each visit for such obese people. Awareness camps/ lectures at the clinic, building educational materials for dissemination and healthy diet marketing should be stressed upon.
· Alcohol/ Drug Abuse: I was shocked to see a 12 year old male child with end stage liver failure due to alcohol intake and another 8 years old male child consuming some sort of whitener for snorting and his elder brother consuming some "white" powders. Dr Kaisar informed me that drug use was an important yet challenging health problem in kids in some localities. Both alcohol and drug use needs a multi pronged effort and cannot be treated in the Clinics unless the community is made aware and the parents are made responsible and aware to the ill effects of these drugs. Here Sambhavna should take a lead in raising community awareness, making local government take severe steps against those who peddle/supply such drugs to children and youngsters. Alcoholics Anonymous group meetings should be promoted in the Clinic campus to help such alcoholic patients.
· Cancer: I was informed that cancer was equally widely seen among the patient population. Incurable cancer patients or terminally ill patients due to cancer should be provided appropriate palliative care more so focusing on reducing pain at such late stages. The clinic staff and members should be educated to be empathetic and various ways to reduce pain in terminally ill cancer subjects. In house cancer registry should be maintained to help provide details of type, trend and history of various cancer for educational and research purpose.
· Diabetes: The clinic draws a huge diabetic population and I think it's the case with any primary health care in India today, as we are heading to be the world's Diabetes Capital in the next 20 years. In Bhopal, diabetes is more seen in the adult group and its mostly type 2 diabetes, which can be controlled with weight loss, diet and oral medicines. But I saw a large number of diabetics who were poorly controlled and overweight and most of them were post prandial (after intake of food) glucose raised. Some had severe form of vascular and foot disorders related to diabetes. The picture was even more complicated in those with high blood pressure and heart disorders with obesity. I suggest that the Clinic should strictly follow "ABC". A: Hba1c should be done every 2 months or at least 4/5 months to see how tightly the glucose is maintained as it's the most important and valid indicator for blood glucose treatment. Tighter and radical steps should be followed to achieve ideal glucose levels and the same should be stressed to the patients during education or dietary class and more so should come from the treating physician. B: A good measure of blood pressure and treating even mild hypertension in diabetics is good. C: Cholesterol check and medicines to reduce raised cholesterol should be promoted in addition to dietary changes. These three steps should be followed in each and every diabetic. Preventive steps to reduce the risk of complications due to diabetes like yearly eye examinations by fundoscope or eye doctor, annual kidney tests and monthly feet examinations to detect changes in sensation or color of feet should be widely promoted.
· Six monthly or annual diabetic special camps should be conducted by inviting a local eye doctor, kidney specialist and cardiologist as a team to assist the in house physicians. One or two days of the week should be named as "diabetes clinic' so that doctor can give better care and attention to diabetic patients.
· A chart recording details about the onset of diabetes, regular weight and waist measurements, blood sugar levels done on various days, and eye examinations should be carried by the patient during each visit – it could be called "My Sugar Book".
· Diabetes education classes should be held either by the health educator or dietician, in the communities and clinic premises to promote education and awareness of complications due to diabetes. Each diabetic patient should be well informed of his disease and should be equally prepared to handle any emergency state due to low/high blood glucose levels.
· Insulin intake/ injection behavior seems to be widely misunderstood. One lady was delighted to have insulin injections after being educated and taught how to take the injection. She had been flatly refusing to get started on insulin as she thought it was going to be painful and cause her more discomfort and she preferred to continue with oral medicines. But her diabetes was not under control, hence she needed to start on insulin. Friendly and proper training about insulin injections should be given at awareness lectures or meetings.
· Support Groups: I think starting support groups among alcoholics, diabetics, asthmatics and cancer patients should be encouraged to infuse a friendly and healthy behavior among such groups.
· The clinic needs a minor surgical room to attend to cuts, bruises, boils or suturing/ dressings, to carry out the physicians' wishes.
· The Clinic is well designed to handle and accommodate volunteers. Volunteers should document interesting cases, form patient charts, and maintain blood sugar/ pressure measurements, height and weight charts and data collection and data input. Attention should be given to take pictures of such interesting cases and archive them in the library for future reference including the therapy.
· I would recommend that the Clinic should try to present their case series, patient data on prevalence of diabetes, problems of residing closer to the Union Carbide factory and similar health outcomes at national/ international meets and medical conferences, write articles and scientific papers to similar journals. This would propel the Clinic and the cause behind it to a wider and different group.

The above recommendations might not seem essential to the Clinic organizers, hence it's totally up to their discretion. I also understand that to implement some of the above recommendations, funds and hiring additional manpower has to be met. But once the above steps are implemented, Sambhavna Clinic would proudly emerge as an 'Ideal Primary health Care Clinic' giving excellent standard of care treatment for chronic disorders like diabetes, hypertension and lung disorders.

I couldn't have completed this visit report without describing my time spent in the company of AID JeevanSaathi, Rachna Dhingra.


Rachna Dhingra:

An individual with immense energy to fight for the rights of the marginalized sections of the community, that includes the Bhopal disaster survivors. She is a dedicated, hard working and never compromising female who is not only supporting the cause but living among the survivors communities. AIDers who have been supporting the Bhopal campaign are very well aware that she was working for Dow Chemicals in US after graduating from Univ. of Michigan and now she is currently self-employed whole heartedly towards the cause. She has definitely set a fine example of sacrifice and selfless service towards a cause that she feels her contribution is worth and without which, she would might not be happy. The few days that I was at Sambhavna, I failed to see a single day where she wasn't actively involved at any second of the time. She was either busy making sure the clinic was running as per the protocol, supervising & cooking for breakfast and lunch in the kitchen, responding to her emails, drafting letters, writing press releases or coordinating with local supporters and guiding the next possible step. I don't feel we would have accomplished to find any other person who would have been so honest and dedicated in supporting Bhopal campaign as Rachna. She has been instrumental in conducting AID wide awareness for Bhopal campaign, coordinating with 'Students for Bhopal' to polarize students from various universities globally, going on indefinite hunger strikes since last two years, walking on feet from Bhopal to Delhi and has also been jailed for her never failing conviction. I would agree with Ravi, co-founder of AID, who has rightly described her as "beacon of AID", in one of his email communications. We, the AID family, are proud having Rachna Dingra as one of our JeevanSaathis and it is apt to honor her as the 'keynote speaker' at the upcoming AID-US conference.

I was inundated with incidents and stories of Mr. Sathyu Sarangi, the force behind the development of Sambhavna, who was traveling overseas during my visit, but plan to meet up with him during my upcoming future visit to Bhopal.

Biswanath Gouda MD, MPH. Born in India, educated in Nair Hospital (Mumbai), graduated majoring in Clinical Epidemiology from Tulane University ( New Orleans, US) and recently completed fellowship in advanced laparoscopic surgery from Scripps Clinic ( San Diego, US). He has been an active AID volunteer since 2004 and was instrumental in starting AID-New Orleans Chapter. He also serves on the Executive Board and is the current Co-Chair on South Asian Public Health Association (SAPHA), a South Asian health advocacy group based in US.

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