Minus 10:23 – The little campaign that could

Avogadro

Also known as 'the mole man' to his friends.

On the first weekend of February this year, anti-homeopathy demonstrations were held in twenty-three cities spread across ten countries. Groups of skeptics took to the streets with a simple message for the public – there is nothing in a homeopathy remedy other than a solvent. No active compounds, no medicinal molecules. Nada.

The 10:23 campaign – so-called for the 6.02 x 10^23 particles in a mole of any substance – focused on the chemistry of homeopathy in an effort to provide the public with a grain of science with which to make a better choice. As a means of attracting interest, many participants chose to ingest quantities of homeopathic remedy in order to emphasise their claim that homeopathy was not like a conventional pill, with active components that increased with dosage.

I’ve written before on the tendency for participants to engage in activism without asking whether it is demonstrably effective. And contrary to how it might seem, I’m actually in favour of such activism, in principle. Grassroots movements have the capacity to bring about significant changes in society, and 10:23 has shown success in achieving significant output. The message is simple and consistent, and the campaign carries media appeal.

However, output is but a small factor, and often risks being a misleading one when used to denote success. Therefore the question is; what factors should activists consider in changing the public’s medical behaviour?

Target acquired

Perhaps an even more fundamental consideration is simply ‘why bother at all?’. Why make the effort to change how others see homeopathy? Why engage in activism at all?

Ethically speaking, it would be difficult to justify wanting to change another’s behaviour for any reason other than an altruistic one. Public confusion over herbal remedies and the pseudoscience of homeopathy might offend rationalist values, but unless it carries some form of public risk, it’s hard to sell as anything but bigotry.

There is a clear case for claiming that irrational behaviour can lead to poor decision-making, creating undesired consequences for those responsible. When a person wants good health and chooses medication presenting a poor risk-benefit ratio, sympathy demands some form of intervention.

In regards to homeopathy, the fact that the medication is nothing more than an innocuous solvent presents close to zero risk for a near zero benefit. Instead, the harm is claimed to lie in the possible inaction of the individual in seeking scientifically supported health treatment. Additionally, it is proposed that homeopathy is strongly associated with sociocultural beliefs that lead to further health decisions that are incompatible with scientifically supported medicine.

In other words, homeopathy is harmful when people avoid treatment that might be more helpful as a result of believing they’re already being treated.

Who’s ‘at risk’?

Identifying members of this subpopulation is tricky to do, especially for a globalised event. Use of homeopathy varies significantly between countries. A survey of the German population found just over one in ten had used it as a medication at least once[1], while in Australia it’s only one in twenty[2]. In any case, this is not necessarily the target ‘at risk’ population, but rather those who have used homeopathy for any reason.

In the United States, 4.4 per cent of the population have reported to rely on alternative medicines to the exclusion of conventional treatments[3]. While I was unable to locate the proportion of homeopathic uses in this specific instance, a report[4] by the National Center for Health Statistics (CDC) and the National Center for Complementary and Alternative Medicine concluded 3.6 per cent of alternative medicine use by individuals in the US over the age of 18 was homeopathic.

In rough terms, that amounts to a possible 500 000 people in the United States who could potentially use homeopathy and not much else to treat their ill health. Of that, it’s hard to judge how many would change their mind when treated with a serious illness.

Of course, that’s a significant number of people, and of those there’s still a real risk of serious illness or even death for some individuals. In European countries, this figure could be far higher. The point is not that such a miniscule fraction of the population is insignificant – it’s that it is an extremely narrow demographic to target, if it’s their behaviour a campaign is to change.

Fighting vitalism with science

The campaign relies on presenting a mechanism for homeopathy as unscientific. The fact that there are no chemically active ingredients in a homeopathic solution is promoted in order to demonstrate that the homeopath’s claims are ‘impossible’. While this is true, there is an unstated assumption that this fact will have an influence (either direct or indirect) on the behaviour of a target demographic.

No homeopath would argue that there are chemically active components remaining in their tinctures. There are two significant schools of ‘mechanism’ explaining why the remedy works in spite of this. One is practically materialistic – the solvent’s molecular properties change in the presence of a solute. The other is vitalistic – an essential force or property from the solute remains in the solvent. Neither is scientifically supported, however neither relies on chemistry as it is conventionally understood.

That means for an individual to accept the efficacy of homeopathy, a belief in textbook chemistry and physics must be superseded by alternative evidence. This alternative evidence appears to overwhelmingly take the form of social influences, with values in ‘holistic’ beliefs and a mistrust of conventional medicine[5].

For a person to merely try homeopathy, however, it takes nothing more than curiosity acting upon the social acceptance of the efficacy of this ‘natural’ remedy.

For the message ‘there’s nothing in it’ to create change, it must resonate with a firm appreciation of the laws of chemistry and physics, to the point that there can be no wiggle-room for the possibility of vitalistic or pseudoscientific mechanisms. In other words, the person must prioritise values in science while being ignorant of what homeopathy truly is.

There is no doubt that a sizeable percentage of the general ‘curious’ population falls into this category. And it is this group who might well be persuaded to put that bottle of diluted diluent back on the shelf.

Yet how likely is it that our target group consists of individuals who prioritise chemistry and physics over vitalism and personal, unblinded experience? Chances are slim.

Another target

Of course, it might not be important to directly target those members of the population who are at the greatest risk from their own choices. Some would patronise them by calling them ‘true believers’, claiming they would be beyond change anyway. By changing the behaviours of the ‘casual curious’ users, the culture of alternative medical use might shift, potentially even affecting the market in ways to reduce distribution and maybe even see the culture itself dissolve.

It’s a crafty idea that would work if the culture and the market were indeed supported by people who prioritised science over essentialism or social beliefs.

Unfortunately, while about half of new users of complementary or alternative medicine are those who are merely curious about trying something different, it’s unlikely that dissuading them would have an appreciable impact on alternative medicine culture or marketing. Just as a small percentage of the population are responsible for the majority of visits to conventional healthcare providers, alternative healthcare is buoyed by a minority of users. A study by the American Medical Association ‘suggests that only 8.9% of the population accounted for more than 75% of the 629 million visits estimated to have been made to CAM providers in 1997[6]’ Changing the minds of nine out of ten ‘casual’ or even potential users, in other words, is unlikely to even dent the alternative medicine culture or industry.

10:23 might have reached a lot of people, but it would be misleading to readily assume this is the same as striking at the heart of the problem. Even if it manages to polarise populations and become a popular event, success can’t be measured in nodding heads.

Is all therefore lost?

Not necessarily. The 10:23 campaign demonstrated that through social media it’s possible for passionate people who embrace scientific values to gather in great numbers for an altruistic cause. As a resource, this is a tremendous asset that could potentially save lives.

The question is, what, exactly, is it targeting? The casual user, or the at-risk population? The average casual user is more likely to misunderstand what homeopathy is and be persuaded by scientific values, but is far less likely to abstain from other forms of medical treatment, using it in a ‘complementary’ fashion. In a best-case scenario, success with this demographic could reduce the pharmacy-shelf purchases of homeopathic ‘cold and flu’ remedies who rely on the confusion between ‘herbal’ and ‘homeopathic’.

Yet to have an appreciable impact on the demographic at risk of making decisions that impact on their health, it pays to understand the cause of the problem being addressed and enact a plan in accordance with it. With few exceptions, most investigations into the reasons why people turn to homeopaths (as opposed to merely using over-the-counter remedies) conclude that some form of dissatisfaction with conventional treatments is involved[7]. Whether it is a poor personal experience with a doctor, undesired side effects from medication, failure of medicine to work or a misdiagnosis, conventional medicine is actively rebuffed for homeopathy.

The 10:23 campaign’s ‘overdose’ publicity required little spin for alternative medicine advocates to subvert to their own agenda, playing on fear of conventional medicine by arguing that homeopathy is not only remarkably effective, it is safe.

What of other indicators? Interestingly, education is positively correlated with use of alternative medicine in general, as is poor health status[8]. Far from ignorance on what medicine is, it is more often a combination of illness being combined with a personal, essentialist philosophy that leads people into alternative medical cultures. Knowing what scientists say is not the same as valuing scientific beliefs, hence repeating the facts is not synonymous with winning appeal in such instances.

Correlations also exist with compatible philosophies such as environmentalism or personal ‘spiritual’ growth, indicating that alternative medicine subcultures are far from discrete social groups. Indeed, research warns against treating the demographic as a homogeneous collective. Hence while target opportunities are indicated through certain correlations, such as attitude towards medicine and personal philosophies, it’s too easy to make generalised assumptions that aren’t strongly reflected in the population, such as education level, socioeconomics and ethnicity.

Where to from here?

For activism to be successful in changing public behaviour, it must resonate with pre existing conditions, or ‘opportunities’. The 10:23 campaign could arguably have succeeded with opportunities in the fraction of the public who act out of ignorant curiosity, and as such might affect ‘casual’ homeopathy use. Those same opportunities are unlikely to exist within populations at risk of poor health decision making, however, which is the demographic most often cited as potentially suffering harm from homeopathy.

Is there a way for activism to impact on this group at all? Are they really just ‘true believers’ beyond help, or is that a simplistic dismissal?

Given the opportunities in this case lie in attitudes towards conventional healthcare and personal ‘sympathetic’ philosophies, any effort to really reduce the harm caused by alternative medicine needs to be constructive in improving the perception of science and conventional medicine, rather than destructive and antagonistic towards irrational beliefs. Stunts that ridicule alternative medicine must give way to presentations that put scientists and medical practitioners in an affable light, that demystify medicine and demonstrate not just its effectiveness, but as a sympathetic community.

It would perhaps be a refreshing and positive angle for future campaigns to focus less on antagonistic tactics, and more on reinforcing positive attitudes towards the role of chemistry and physics in medicine. Connecting the public to the strength of science in decision making is a challenge worthy of a mass of passionate people. And just maybe it might mean homeopathy would one day join humour balance and phrenology as a historical curiosity in our medical past.


[1] Bücker, B; Groenewold M, Schoefer Y, Schäfer T, (2008), The use of complementary alternative medicine (CAM) in 1 001 German adults: results of a population-based telephone survey”. Gesundheitswesen, 70 (8-9): e29–36.

[2] MacLennan AH, Wilson DH, Taylor AW, (1996), Prevalence and cost of alternative medicine in Australia, Lancet 347 (9001): 569–573

[3] Astin, J., (1998) Why Patients Use Alternative Medicine Results of a National Study, JAMA (19):1548-1553

[4] Barnes, P.M., Powell-Griner, E., McFann K., Nahin, R.L, (2002) Complementary and Alternative Medicine Use Among Adults: United States, Division of Health Interview Statistics and National Center for Complementary and Alternative Medicine, National Institutes of Health

[5] McIntosh C., Ogunbanjo, G.A., (2008) Why Do Patients Choose to Consult Homeopaths? South African Family Practice, Vol 50, No 3

[6] Wolsko P.M., Eisenberg, D.M., Davis, R.B., Ettner S.L., Phillips, R.S., (2002), Insurance Coverage, Medical Conditions, and Visits to Alternative Medicine Providers – Results of a National Survey, ARCH INTERN MED, Vol 162 pp 281

[7] McIntosh C., Ogunbanjo, G.A., (2008)

[8] Astin, J., (1998)

Published in: on February 12, 2011 at 9:11 am  Comments (2)  
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The placebo protest: under the microscope

Placebo pills

Protesting makes me feel good.

At the end of April last year, I wrote an essay on the rise of protest-based demonstrations as a means of engaging with the public on certain irrational beliefs. While the 10:23 homeopathy campaign and the so-called Boobquake protest were the two references I provided, other examples such as the atheist billboards in the US can be arguably included in the category of what I termed the ‘placebo protest’.

In its simplest terms, protests can be described as any collective’s attempt to coerce others into changing behaviour or taking action, making it a fairly broad category that can include many different forms of public engagement. However, the term also suggests the active opposing of an existing social condition, so is commonly negative or antagonistic in nature. A campaign that promotes the message ‘don’t eat pizza from Joe’s” is a protest, while ‘eat at Joe’s Pizzeria’  is less likely to fall into that category.

While academic literature varies somewhat in the precise boundaries of what constitutes a protest, there is a consensus amongst outreach researchers that any attempt to impact on public behaviour relies on specific environmental conditions (termed ‘opportunities’) to succeed. Identifying these conditions can make the difference between winning people over and wasting resources trying.

A good example of identifying opportunities involves understanding how a target demographic interprets a particular message. Using communication tools that convey subtle variations in meaning between sub-cultures risks losing key messages in translation; using stunts, demonstrations or slogans that mean one thing to the protester (or extend from a culture within that group rather than one understood externally) and another to an audience could make any effort to change behaviour somewhat impotent, or even counter productive.

A significant impediment to identifying opportunities in a demographic is a lack of  – or wide variation in – explicit goals. Terms such as ‘promoting education in…’ and ‘raising awareness of…’ are commonly bandied about without objective qualifiers or even a hint of an observable indicator. Often, the qualities of the target audience might be too broad or be presumed without good evidence. Without clear aims or targets there is an added risk of ad hoc justifications of success, typically relying on output (audience scope and reach) to represent impact (change of behaviour).

For a form of outreach to be a placebo protest, however, there is one last important feature – those engaged have to demonstrate little interest in evaluating the circumstances or effectiveness of their actions. Like placebo medicine, placebo activism is practiced not with a true desire to blind oneself to bias, but simply to feel better on having acted, regardless of the true impact of their efforts.

While I can’t accuse all individuals who are engaged in any single protest campaign of doing so for merely placebo reasons, there is some irony in that a number of people will happily offer explanations for their participation that aren’t unlike the same explanations many users of homeopathy or natural medicine offer; ‘soft science like sociology or psychology is too ineffective to study the effects of what I intuitively already suspect to be true’, ‘it takes all types of action to make a difference’, ‘doing something is better than doing nothing’, and ‘it might not work for all people, but what’s the harm in trying?’

Central to the placebo protest is the apparent assumption that sharing feelings is synonymous with sharing knowledge. An emotional reaction to a wrongdoing leads to encouraging others to see it as silly, immoral or dangerous. That’s not to say this is always ineffective (history is full of examples of fear campaigns that are immensely successful in changing behaviours), however when it comes to rational outreach, should it be the desired approach?

Boobquake was proposed as a scientific study, for example, however was presented more as a satirical exercise poking fun at an Iranian prayer leader’s claim that the exposed skin of females is positively correlated with earthquakes. Either way, it’s unclear as to what – precisely – the point of the exercise was, if not an outlet for indignation. Many people have their own view of the agenda, whether it was to promote scientific values, encourage people to understand more about tectonics, or to simply ridicule a specific view (thereby encouraging an emotional reaction in the population to an emotional claim).

The actual impact, regardless of the intentions, is unknown. Was it antagonistic towards the goals of many feminists? Did it polarise views or change them? Were a significant number of people more aware of the science of earthquakes, or of the importance of statistics in science? It’s not clear. Yet there was still a sense of ‘success’ given it had a large output.

When the sense of success carries more importance than a true understanding, however, science loses out. This is the placebo protest. For a community of people protesting in the name of science, it is a rather bitter hypocrisy.

Likewise, when the association of American Atheists launched a billboard campaign in time for Christmas, 2010, telling people ‘You know it’s a myth!’, it’s hard to know what the real aim was. At face value, it might serve as encouragement for members of the driving public who hold some theistic beliefs to abandon them. How successful was it? Are billboards an effective means for spending such funds, or could they have achieved the same (or better) results by spending it elsewhere? If they’re successful, how did it compete against the reciprocal billboard funded by Catholics stating ‘You know it’s real’?

What of the 10:23 campaign, now in its second year? Interestingly, one individual decided to take a closer look at the 2010 homeopathic ‘suicide’ stunt and seek some evidence of its impact.

As a part of a research project, David Waldock sampled reports from the mainstream and social media and analysed them in relation to the event. Focusing on a single objective of the campaign – ‘To educate the public about the full story of homeopathy, to cause them to question and become opinionated about homeopathy’ – he found that the context of the various forms of media discussion changed from being more scientific and clinical to being more political, tending towards language that reflected regulation rather than the specific mechanics of the practice.

Of course, this lays the foundation for a rather interesting discussion. Given evidence of a discourse that is leaning towards regulation, should this be the goal of future protests? Is it better to influence politics and act top-down, or should activists continue to focus on changing attitudes from the bottom-up? Are resources being well used if this is the response, or should they change?

The important thing is, useful discussion can now progress further on the back of potential evidence than on blind assertions. David’s work is by no means the final word on the matter, but it has at least provided grist for the mill and is a clear attempt at marrying observed consequences with actions.

For activism to be successful, it needs to be done with evidence, experience and expertise. Currently, protests and stunts seem to be performed more as a means of expressing frustration, anger or bigotry than a measured way of encouraging a change of culture. As such, success is measured by how many people know you’re upset.

Yet if we truly wish to combat the poor consequences of irrational thinking, we need to identify what makes outreach effective, and distinguish this from occasions when it is merely a way to placate the irate.

The Others

 

Apothecary

Medicines stupid people use (nb., I'm not one of them).

“How can skeptics have a dialogue with homeopaths?” Michelle asks that modern well of insight and wisdom, ‘Yahoo’. “[W]ithout pointing out the stupidity of their arguments? I’m thinking about the paranoid ramblings about big pharma as well as the ignorance of simple science.”

Ignoring for a moment the framing of Michelle’s query, I was interested to scan through the responses for a solution two centuries of debate on the topic might have overlooked.

“Crucially, homeopaths lack the educational level to understand how their potions can only be water,” says Dave, a top contributor. Another top contributor says, “They only start with the fallacies to avoid providing evidence – so no matter what they crap on about, keep dragging them back to evidence.”

“Never argue with an idiot, they’ll drag you down to their level and beat you with experience,” says Flizbap 2.0.

And on it goes. There are some that advocate avoidance of engagement without resorting to well-poisoning or flippant antagonism, but for the most part the advice involves engaging in a behaviour anthropologists and other social scientists refer to as ‘othering‘.

Regardless of the intentions, the practice involves judgments of inferiority or impeded progress based on observations of contrasting social beliefs, behaviours and values. It is born of ethnocentrism, where observations are made with the assumption that one’s own experiences define what is objectively desirable. The result is a sense that a group of people, ‘them’, is inferior to one’s own company, or ‘us’, on account of differences in beliefs and values.

By the dawn of the 21st century, however, ethnology has had enough of an influence on the developed world that it’s become difficult to ‘other’ non-local cultures without seeming naïve or xenophobic. Most people have come to see that subsistence farming or hunter-gathering is not a mark of inferiority or low intelligence, and limited technological dependence is a socioeconomic issue rather than a cultural or cognitive failing. Openly claiming a village in the Papua New Guinea highland is ignorant, stupid or indulgent in logical fallacies would probably raise eyebrows, leading such discussions on cultural practices to be couched in less derisive terms. While the debate over racial intelligence might continue, it’s harder to find people who justify their beliefs by pointing out contrasting traditions, lifestyles or cultural practices.

However, within national borders, ethnocentrism returns with all of the ignorance of our colonial ancestors. If it’s one habit we can’t seem to shake, it’s that our nationalistic heritage has embedded in us a strong correlation between culture and country, as if by being white and sharing an accent our cultural values must be homogeneous. As a result, othering occurs far easier with those who appear (at least superficially) to share an ethnic background.

What’s missed is that within our own community there are shades of culture and sub culture that pool, ebb and overlap. Healthcare is just one example, yet one that has significant consequences beyond other examples of cultural behaviour such as art or language. Medicine in the context of a scientific product leads many to interpret healthcare as a ‘culture without a culture‘. Science and medicine is typically presented as timeless, truthful and above all, objectively correct. It’s strictly biophysical, with its sociocultural component reduced to a vestigial nub.

As such, it’s far easier to other those who demonstrate contrasting medical behaviours. Lack of intellect or education can be easily held up as reasons for their alternative beliefs without evidence, as it’s assumed that all else must be equal. As such, archaic and empty solutions such as ‘better education’ or legal enforcement is suggested as a way of making people see sense.

In truth, there is a multitude of reasons why people use alternative medicines, few of which (if any) have much of a direct link with a level of education or cognitive deficiencies. Rather, values in what constitutes good evidence, familial traditions, cultural identities and distrust of contrasting sociocultural groups play far greater roles in determining health behaviour than university degrees or brain function. In other words, the very same factors medical anthropologists deal with abroad when studying any other health culture are responsible for the same alternative beliefs in our own community.

The question on how best to address culture change is also just as relevant here as it is elsewhere. It’s all well and good that African or Indigenous communities retain their cultural heritage, but what does one do when it conflicts with treatments for HIV, alcohol abuse or diabetes? This is a question a good friend of mine is currently researching through the Australian National University; as you might expect, the resulting discussion demands more than a simplistic ‘they need better education’ or ‘they’re just stupid’. Yet it’s not a novel dilemma; whether it’s vaccination, water sanitation, nutrition or infant care, the question of how to effectively assist diverse communities in improving and maintaining their health and wellbeing has occupied anthropologists for years, producing rich debate and diverse results.

Ironically, those who propose answers for Michelle seem to identify as individuals who would normally value science as a way of presenting useful solutions to a problem. Why then do few seem to be informed by research? Why are the answers without citations or references, seeming to be based on little more than personal hunches or folk wisdom?

Based on my own experience, few would be inclined to look further as they already assume to be correct. Science works for some things…unless you already think you know, at which point it’s all rhetoric and pedantry. Social science is a soft science, therefore gut feelings and intuition are as useful (if not more so).

Michelle’s question and many of the answers reveal the roadblock we face here in our efforts to address alternative healthcare. Rather than treating it as a legitimate sociological question, where science might provide some insight, the issue is reduced to a dichotomy of smart vs. stupid, of educated vs. naive. When those are the questions we ask, we certainly can’t hope for any productive answers.

The mighty loopholes of the TGA

At first glance, there seems to be a rather effective safeguard preventing Australians from being sold anything that erroneously claims to treat illness or relieves us from discomfort. The Therapeutic Goods Association is the regulatory body responsible for assessing and monitoring therapeutic goods or materials that are marketed in Australia. It covers what can and can’t be said in advertisements, the necessity of clinical trials and the provisions for what can be termed a complimentary or alternative medicine.

For the most part the TGA’s regulations maintain a high level of safety when it comes to the types of medications we have available to us. Thanks to the national customs service, it’s also relatively difficult to procure medications that are deemed to be unsafe or illegal. Yet ever-present loopholes, both semantic and procedural, continue to threaten the health and hip pockets.

One such gap in this medical chain-link fence is both the scourge of scientists and the joy of scientifically illiterate journalists – what I term as the ‘proof paradox’. As far as science philosophy goes, proof is a provisional term. Indeed, certainty is so heavily reliant on context, the word ‘proof’ is typically softened to reflect a sense of probability when it comes to scientific conclusions. Things can be proven logically, yet such solutions are constrained by context of accepted premises.

Scientists consider their ideas as a sliding scale of confidence, approaching absolutes but never committing whole-heartedly. Such philosophical scepticism is useful for scientists, should new evidence ever arise that casts past observations in a completely new light. As such, all conclusions carry a silent caveat that says ‘given that the surrounding scaffold of knowledge continues to hold true’.

Colloquially, this reservation takes on a new weight and substance. The term ‘theory’ grows heavy in the public domain, anchored by doubts scientists would dismiss as merely provisional. All scientific ideas are painted in shades of mights and maybes, where evidence is regarded as subjective regardless of one’s epistemological values. With the caveat dropped, all things are indeed possible. No longer is a statement implicitly ‘false or misleading’ should it say a material ‘might’ treat, cure or alleviate symptoms.

There is no conflict in the eyes of the majority of people, who know of no such footnotes, caveats or hidden contexts. To the average citizen, that ‘might’ carries weight. To the scientifically literate, it is a weasel word that lurks in the shadows beyond abandoned hypotheses and weak p values.

The second gap is less philosophical. When an advertisement is challenged as false, the TGA is currently alerted to it as having broken its regulations. What happens there, according to ABC reporter Steven Cannane in this Lateline report, is something of a mystery.

Short of tightening up science literacy amongst the general public, it’s difficult to address the contrast between the public’s practical view of doubt and science’s provisional scepticism. It’s arguable that the TGA should be given the authority to mediate the use of weasel words such as ‘might’, ‘may’ and ‘could’ when it comes to not-so-subtle suggestions of dubious efficacy, treating even vague suggestions of treatment as if they are making solid claims.

When it comes to the reporting of obvious advertising breaches, however, lets hope changes are in the wind that will see to more forceful actions being engaged over matters of non-compliance. Having a watch-dog that barks but doesn’t bite is about as effective as a placebo authority.

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