WHO's Evidence Anyway? The Extra Careful Mainstreaming Of Alternative Medicine
The World Health Organization has long walked the uneasy tightrope between evidence-based and traditional medicine. It is time to dismantle this unrealistic balance.
The World Health Organization (WHO) held its First Global Summit on Traditional Medicine in August. The event, held in the city of Gandhinagar, India, was preceded by a social media advertising campaign that left scientists and serious science communicators reeling. It presented in a "friendly" way – equivalent to an implicit endorsement – alternative practices that contradict the best scientific evidence, such as homeopathy and naturopathy, and that are in no way “traditional”: the first was invented in Germany 200 years ago and the other in the U.S., a little over a century ago.
Here's an excerpt from WHO's introduction to the subject on the summit's website:
“For centuries, traditional and complementary medicine has been an integral resource for health in households and communities. It has been at the frontiers of medicine and science, laying the foundation for conventional medical texts. Around 40% of pharmaceutical products today have a natural product basis, and landmark drugs derive from traditional medicine, including aspirin, artemisinin, and childhood cancer treatments. New research, including on genomics and artificial intelligence are entering the field, and there are growing industries for herbal medicines, natural products, health, wellness and related travel. ”
At first glance, this paragraph contains two confusions and a riddle. The first confusion occurs between what some philosophers of science call the “context of discovery” and the “context of justification.” The context of discovery is the one from which scientists get their ideas, where they will find the questions they want to answer and the problems they set out to solve. The “justification context” is where scientists perform the heavy work of testing hypotheses, controlling confounding factors, conducting experiments, and producing or seeking evidence – in short, everything that allows a discovery to be called truly scientific.
When it states that “around 40% of current pharmaceutical products are based on natural products, and reference medicines are derived from traditional medicine, including aspirin”, the WHO is saying that traditional medicines are a rich part of the discovery context – which is true.
The fact that tradition is a source of good ideas does not mean that all of the ideas that come from there are good.
But this is just the first step – it is in the context of justification that the wheat from the chaff is separated, and the hypotheses that are nothing more than “brilliant theories” are separated from the ones that really work.
The fact that tradition is an abundant source of good ideas does not mean that all (or even most) of the ideas that come from there are good. And even among the good ideas, not all end up paying off in the real world.
The second confusion is between market power and therapeutic legitimacy. The existence of “growing industries for herbal medicines, natural products, health, wellness and related travel” does not imply the efficacy or safety of these medicines and products (nor do the supposed beneficial effects of travel to water resorts or other “healing places”). It is true that the combined market for traditional medicines in China (which sponsored the report 'WHO Traditional Medicine Strategy 2014-2023') and India (the summit's host country, which has a special ministry just to promote alternative therapies) probably already exceeds 10 billion dollars annually. But commercial success and scientific validity are very different worlds.
The enigma is contained in the brief excerpt 'New research, including on genomics and artificial intelligence are entering the field'. The question is, shouldn't tradition be valuable by itself? Who needs these modernist fads?
“Around 40% of current pharmaceutical products are based on natural products, and reference medicines are derived from traditional medicine."
WHO's Delicate Balancing Act
WHO's introductory text is a balancing act. In six paragraphs, the word “evidence” appears five times. Being part of the UN and, therefore a political but also a technical (or technical but also political) body, the WHO juggles things to impress its sponsors who want to capitalize on “traditions” in the globalized health and wellbeing market, without betraying its commitment to human health.
Sometimes this doesn't work out very well, as seen in the social media campaign for the India summit or the disastrous 2019 decision to include traditional Chinese medicine diagnoses in the International Classification of Diseases. However, the conflict becomes really clear from a careful reading of the most up-to-date material on traditional medicine recently made available by WHO. At the heart of it is that word “evidence”. Consider this paragraph obscured in the FAQs sections the WHO press website (dated August 9, 2023):
“Integration of T&CM [traditional, complementary and integrative medicine] with national health system and the mainstream of health care must be done appropriately, effectively and safely, based on the latest scientific evidence. WHO assists countries that want to embrace traditional medicine practices to do so in a science-based manner to avoid patient harm and ensure safe, effective and quality health care. An evidence-based approach is crucial; even if traditional medicines are derived from longstanding practice and are natural, establishing their efficacy and safety through rigorous clinical trials is critical.”
This is a true statement of principles, and it stands in contrast to the report 'WHO Traditional Medicine Strategy 2014-2023' published 10 years ago. The latter contained vague mentions of “traditional medicine with proven efficacy, safety and quality” (without explaining how were they “proven”, by what criteria, or by whom) and problematic statements such as “although there is much to learn from controlled clinical trials, other evaluation methods are also valuable”.
A woman buying drugs at a pharmacy.
Building A New Bridge
Traditional medicine with efficacy, safety and quality proven by rigorous clinical tests is... just medicine.
This is what happened with aspirin and artemisinin, two drugs originally inspired by traditional uses of plants, but which are now duly incorporated into the arsenal of evidence-based medicine. Read together, the WHO's current statements on the subject seem to push traditional medicines, gently but firmly, into the context of discovery. And with the full intention of leaving them only in that context, which is quite the opposite of what was suggested a decade ago.
The 10 billion-dollar question: Is this stance really serious? Or is it just a rhetorical bone thrown to critics to distract them while some new traditional Chinese medicine CID-sized atrocity is cooked up behind the scenes?
In any case, it is notable that the declaration of principles contained in the FAQ condemns, even if implicitly, public policies already implemented by countries that integrate alternative practices into their health systems.
If taken seriously, the recipe dismantles the current tenuous bridge between the alternative and the mainstream.
In India, the ministry in charge of traditional medicine has, as part of its founding mission, the promotion of homeopathy – which has never been able to prove its merits in the “rigorous clinical trials” that the WHO considers “fundamental” for the integration of therapies to the health system. In Brazil, the National Policy on Integrative and Complementary Practices (PNPIC) not only includes homoeopathy, but defends it with the argument that traditions, especially those associated with oppressed groups, have epistemic value independent of the scientific method. (Never mind that most of the practices present in the PNPIC are of North American or European provenance.)
If taken seriously, the recipe presented in the FAQ dismantles the current tenuous bridge between the alternative and the mainstream. At the same time that it lays the groundwork for a new one, linking the traditional with scientific medicine. If it manages to withstand the bombardment of political, ideological, and economic interests that it will certainly suffer, it could yet be an imposing structure.
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