by Dawn Garisch
Art is able to illuminate internal facts of impulses and desires both in the artist and in those who experience it – readers and audiences. Powerful art pulls the bandages off our denial, and asks awkward, embarrassing, outrageous questions. It wields the cold, wet fish of reality. Or it can be the ravishing awakening to mystery and beauty, alerting us to things we take for granted every day. Art displayed in public can be a form of witnessing – of our time and its beauty, difficulties and challenges.
The courage, patience and focus of the artist can bring something of true value into being for us all to experience and recognise. The tools employed by the artist are different from those of the scientist, yet there are overlaps, as we shall see.
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17. Tracking the Truth as a Scientist
There are two possible outcomes: If the result confirms the hypothesis, then you've made a measurement. If the result is contrary to the hypothesis, then you've made a discovery.
Enrico Fermi66
Last night at a dinner party, a man held forth about how ancient Arab civilization did not develop any original ideas, but stole them from the Greek and Spanish cultures that they had conquered. No matter what evidence was presented to him, he was unswayed in his belief that Arab culture is inferior.
We all have our beliefs that we have inherited or adopted that seem immune to evidence and logic. The Qur'an advises: ‘You shall not accept any information, unless you verify it for yourself. I have given you the hearing, the eyesight, and the brain, and you are responsible for using them. ’67
The first record of a person employing what we now term ‘scientific method’ dates back to the tenth century AD. Abū ‘Alī al-Hasan ibn al-Hasan ibn al-Haytham (translated as Alhacen or Alhazen in the West), was born in Persia, now Iraq, in 965 AD. The method he proposed has come to form the backbone of contemporary culture, yet it was applied and described for the first time a mere one thousand years ago. During much of the six hundred thousand years prior to this, our species relied mainly on conjecture, association and story to explain life and the universe.
We know from oral traditions and written accounts that humans extrapolate from the evidence, often wildly. We thought that the earth was flat and stationary, the sun moved across the sky, and that illness and drought were punishments for not obeying deities, or were curses invoked by enemies. Strangers who looked, behaved or spoke differently from your tribe were denounced as either stupid and ugly, or they were elevated as the arrival of a god. War was the best method to achieve peace. Character could be determined from the shape of a person's head. Untying thongs and shoes and opening doors allowed labour to progress. The spleen was the seat of emotion. The laying on of hands cast out illness or malevolent spirits. Seizures were evidence of possession. Potions drunk at full moon could make someone fall in love with you.
Beliefs that were once common sense and common-place have frequently been overturned. Scientific method evolved as an attempt to set aside opinion, prejudice, superstition and tradition to uncover the truth. It is the process by which scientists endeavour to construct an accurate – that is, reliable, consistent and non-arbitrary – representation of the world.
However, humans have routinely applied scientific principles for centuries without knowing that that was what they were doing:
• Identifying a problem – how can I prevent this animal I have just killed from going bad before we have time to eat it?
• Testing – cut it into strips, salt it and dry it in the sun.
• Observing – the dried and salted meat does not rot.
• Repeat testing – the procedure works repeatedly.
Ibn al-Haytham formally introduced the importance of observation, testing and measurement to ascertain whether a belief was the truth. His scientific method was very similar to the modern application and consisted of the following:68
• Observation
• Statement of problem
• Formulation of hypothesis
• Testing of hypothesis using experimentation
• Analysis of experimental results
• Interpretation of data and formulation of conclusion
• Publication of findings
By applying these principles, he correctly refuted many long-held beliefs, for example, that the moon does not reflect sunlight like a mirror, that light is not produced by the eye but perceived by it, that the Milky Way is not part of the earth's atmosphere but is very far away, and that vision occurs in the brain, not in the eyes. He also astutely observed that people ‘see’ events in the world according to their experience of them, and not necessarily according to reality.
Therefore, the seeker after the truth is not one who studies the writings of the ancients and, following his natural disposition, puts his trust in them, but rather the one who suspects his faith in them and questions what he gathers from them, the one who submits to argument and demonstration, and not to the sayings of a human being whose nature is fraught with all kinds of imperfection and deficiency. Thus the duty of the man who Investigates the writings of scientists, If learning the truth Is his goal, is to make himself an enemy of all that he reads, and, applying his mind to the core and margins of its content, attack it from every side. He should also suspect himself as he performs his critical examination of It, so that he may avoid falling Into either prejudice or leniency.69
In its ideal form, science does not set out to prove a point.3 But Ibn al-Haytham knew that science, like everything else, including religion, is attached to people, who are attached to their psychologies.
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Although the scientific method has been around for a thousand years, medical science has only relatively recently cottoned on. When I was trained during the years 1975 to 1981 the term ‘evidence-based medicine’ was not in use. We were not taught statistics, nor how to read a journal article critically. These skills are essential to try and interpret the mass of conflicting information that confronts doctors and their patients. Nowadays the medical fraternity no longer supports treatments whose merits have not been thoroughly investigated.
Twenty years before I qualified, H. K. Beecher opened a can of worms by noting in his article, ‘The Powerful Placebo’,70 that a sizeable proportion of people, whom he called placebo-responders, get better when given treatments that have no physiological effects on the body. He pointed out that in order to measure the true effect of any agent, researchers had to correct for this. Beecher therefore suggested that participants be divided into two random groups, and that the treatment and placebo be packaged identically – for example in a green and white capsule. One group would get the capsule containing the substance under study, and the other would get the capsule containing the inert sugar or starch.
Two further problems arose from this recommendation. One concerned ethics: Participants in a trial need to know that this is an experiment, and that what they receive may or may not contain an active ingredient. Indeed they do – researchers explain the trial to the participants in detail before they sign informed consent. As a consequence, the efficacy of the placebo, which appears to depend on trust and faith, is diminished. If you know that the medication you are receiving might be a starch pill, it cuts across the anticipation of cure.
The other problem, researchers noted, was that if the person administering the treatment knows whether or not it contains starch or the medication under study, subtle interactions in the consultation could cue the participant as to which substance she was ingesting. To avoid this pitfall, neither the dispenser nor the patient is allowed to know whether the capsules contain medicine or starch. This aspect of the method is termed ‘double-blind’.
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Patients often ask me whether a treatment works. A friend, they say, has recommended silver ions or kelp extract or vitamin B injections. Word of mouth, or anecdotal experience has been the basis for decisions for aeons. But impressions, subjective experience and anecdote are the very things that the scientific metho
d aims to eliminate.
When a medical researcher wants to examine the effects of a substance, they first set an hypothesis. For example, someone might notice that when he eats nasturtium leaves, the pain of osteoarthritis in his knee goes away. To find out whether that is a coincidence, a researcher will set the hypothesis that nasturtium leaf extract will relieve the pain of osteoarthritis. She then needs to find a large number of osteoarthritic people who agree to take part in a trial. She does this by co-opting rheumatologists to help conduct the study. Once enough patients have signed up, she divides them randomly into two or three groups.
Random grouping of the participants helps to minimise any differences in the two groups. Differences in age, gender, race, health, educational level and income bracket, could affect the outcome of the test, and render the results of an expensive exercise inconclusive or even erroneous.
During the trial, the members of one group receive the extract of nasturtium leaves, and the others from the control group are given a placebo.
A third, randomly-assigned group can be given a substance proven to be effective in relieving osteoarthritic pain, for example an anti-inflammatory. The hypothesis would then state that not only is nasturtium leaf extract effective in relieving pain, but it is at least as effective as anti-inflammatories, with fewer side effects.
At set time intervals the patients involved in the trial report back to the researchers who examine and test them. If there are differences between the groups – say forty-three more people were helped by nasturtium medication than those receiving the placebo – statisticians calculate the difference to see whether it might reflect a natural variation, or whether we can confidently say that nasturtium leaves are in fact medicinal.
Researchers will also look at unwanted effects, for example, whether there is an increase in the incidence of heart attacks in people taking nasturtium leaf extract for arthritis.
The findings, both positive and negative, need to be written up in a standard way, where the hypothesis, method, findings and conclusions are spelt out. The article is submitted to a peer-review journal, where it is published if it is sound. The researchers must store the data generated by the study in such a way that other researchers can access them so that they can repeat the experiment to check the results. Fraudulent studies have been uncovered in this way, as well as studies that have had built-in errors which yielded incorrect conclusions.
This systematic and rigorous approach to uncovering the truth as to whether a substance will heal or harm or do nothing at all is a huge advance over an unscrupulous salesman arriving at your door and convincing you that a bottle of his proverbial snake oil can cure everything from corns to asthma. Yet many people use treatments that have not been verified by scientific method, and claim that they work.
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The jury is still out as to what the placebo effect actually is, and even whether it exists. Some researchers say that measurable improvement while on a placebo could represent the natural course of the illness, where the body tends to get better anyway. Others claim that the effects are so powerful that we should be investigating the placebo rather than drugs. Newman71 has coined the phrase ‘placebo paradox’, in which he points out that it is unethical to use a treatment that has no known effects in the body, but it is also unethical not to use something that heals.
The debate that rages around the placebo effect illustrates an important point. Sometimes our methods of measurement reveal something we can rely on, and sometimes they don't. The world, it seems, does not always obey the tenets of a tape measure.
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3 Interestingly, neither does art. ‘Art’ that sets out to prove a point is called propaganda.
18. Buying Health, Trading in Illness
To say that a man is made up of certain chemical elements is a satisfactory description only for those who intend to use him as a fertilizer.
Hermann Joseph Muller72
Health care has become big business, where many interested parties make enormous profits. Most people get sick or injured many times in their lives, or else have chronic complaints that can be alleviated by medication. In the article ‘Drug Companies & Doctors: A Story of Corruption’, Dr Marcia Angell, who for two decades was an editor of the New England Journal of Medicine, points out that: ‘Even when changes of lifestyle would be more effective, doctors and their patients often believe that for every ailment and discontent there is a drug. ’ She continues: ‘Physicians learn to practice a very drug-intensive style of medicine. ’73
Drug companies that finance research into new medications and drug trials need to make returns on their investments. Angell shows how easy it is for researchers to manipulate data in order to demonstrate that the medicine being tested is superior to the placebo or another medicine used in the same disease.
Angell adds: ‘Physicians are also led to believe that the newest, most expensive brand-name drugs are superior to older drugs or generics, even though there is seldom any evidence to that effect because sponsors do not usually compare their drugs with older drugs at equivalent doses. ’74
Recently, there has been an explosion of new drugs on the market, many of them presenting no major advance on the old tried and trusted medicines. Pharmaceutical companies compete against each other for the position of ‘market leader’. Sometimes drug reps are even made to compete within the same company, marketing the identical product under a different name and in different packaging, all in an effort to claim a bigger slice of the pie.
Doctors are approached daily by drug representatives who arrive in expensive cars bearing ‘gifts’ and food as an incentive for the busy general practitioner to take time out to listen to the sales pitch. These can be as embarrassing as the ‘gift’ of a shampoo and conditioner to illustrate the synergistic action of combination therapy, firelighters to remind the GP about treatment for erectile dysfunction, or a mug with a picture of a caveman dragging a cavewoman along by her hair, illustrating a use for an anti-inflammatory. The drug rep may literally plead with the doctor to support her by prescribing the product she is promoting. Her income depends on it. The ill patient disappears into a theoretical point on a graph where the points plotted may or may not have been manipulated into position.
South African medical practitioners are obliged by law to obtain thirty continuing medical education (CME) points each year to ensure that they stay up to date with developments in the medical field. Drug companies use this as a way to promote their products. They entice doctors, who are tired at the end of a busy day, to attend CME lectures by including meals at expensive restaurants, or even flying doctors to a hotel where they will put them up and fête them for a weekend. The doctor obtains the necessary points, sometimes learns important information, and gets to feel special and cared for. In return for hosting and toasting doctors, the drug company hopes to change their prescribing habits.
Some doctors feel that this wining and dining is a justified perk. A doctor's income, unlike that of a successful businessman, is linked to time on the job. Very few doctors refuse these bribes. I tread a wary compromise, trying not to be influenced by any consideration other than what is best for my patients. I attend the lectures and eat the food, but I pass the ‘gifts’ on to my domestic worker for redistribution. It amuses me to think of designer water bottles, Weber braais, wall clocks, beach towels, blankets, Leatherman tool sets, deck chairs and umbrellas, all sporting the names of pharmaceutical products, finding homes in the townships.
Speakers at CME talks receive huge financial rewards for lecturing, usually on subjects allied to products. Dr Angell points out: ‘After much unfavourable publicity, medical schools and professional organizations are beginning to talk about controlling conflicts of interest, but so far the response has been tepid. They consistently refer to “potential” conflicts of interest as though that were different from the real thing, and about disclosing and “managing” them, not about prohibiting them. In short, there seems to be a desire
to eliminate the smell of corruption, while keeping the money. ’75
These practices have fostered distrust of both science and the medical establishment.
Dr Angell, referring to the book On The Take: How Medicine's Complicity With Big Business Can Endanger Your Health, argues that although the drug companies go to perverse excesses to promote their product, they are mostly within their mandate in the capitalist system. They are required to make as much profit as they can by whatever legal means are at their disposal on behalf of their shareholders. She does, however, cite several cases where drug companies were made to pay huge fines running to millions and even billions of dollars for fraudulent claims. Yet this was an insignificant amount compared with the enormous profits generated by false advertising and the resultant ongoing misperception of the public and doctors.
However, she argues, the medical profession does not have the excuses of business in that we are not answerable to shareholders. A physician's responsibility is to put a patient's wellbeing first. Where this duty has been tainted or subverted by pecuniary considerations, she says, the doctors should be held more accountable for their behaviour than the pharmaceutical companies.
I recently went on one of these extravaganzas in Johannesburg. At least six hundred doctors from all over South Africa attended. I learnt a lot from the lectures, which will benefit my patients, but I was acutely aware that everything, from the plane ticket to the hotel room and banquet with cabaret, comedian and musicians, was paid for by the profits made by selling medication to the sick or to those wanting to ward off illness and disability. On one hand I am grateful to the drug company that hosted an event where in one weekend I earned half a year's worth of CME points, but I felt very queasy. I, too, am culpable.