‘I’ve been standing on this bridge all day selling Dr Carter’s pink pills for pale people.  Guaranteed to purify the blood and make the skin like velvet.  Take on an empty stomach and they won’t roll off.  If the pills don’t work, swallow the box.’ 

 

Did you catch Dr Ben Goldacre’s programmes on Placebos on Radio 4 last Monday and the Monday before?   The messages were uncompromising; the evidence overwhelming.  People who suffer from a variety of illnesses can get better when they are given ‘placebo’ pills that contain an inert sugar or starch compound and no ‘active’ pharmacological agent.  Double the number of placebo pills and the effect increases.  Improve the packaging,  invent a brand name, alter the colour of the pill,  provide a rationale and there are further increments in efficacy.  In other words, it seems that people are not responding to the tablet, they are responding to the idea, the expectation, the belief they have in the treatment. 

 

Placebo controlled trials indicate that for many illnesses, expectation and belief can provide the bulk of the therapeutic effect.  In patients with unexplained illnesses such as the Irritable Bowel Syndrome, as many as 60% of patients respond to the placebo alone, only a few percent short of those who respond to the active drug.  Thousands of patients are required to prove statistically that this effect could not occur by chance alone.  So are drug companies spending billions of dollars to develop new drugs that are only marginally more effective than inert tablets?   And are we paying for the privilege?      

 

But it’s even worse than that.  Evidence-based medicine’s holy grail, the randomised, placebo-controlled trial (RCT) is fallible.  The outcomes of RCTs depend on  the patient being unaware of whether they are being given the active drug or the dummy, but this is rarely tested.  Instead, it is assumed that using capsules or tablets that are identical in shape, size and colour and concealing the true nature of the tablet from the prescribing doctor or nurse must make it impossible for the patient to detect the difference. 

 

That’s not true.  Drugs often taste bitter.  Placebos often taste sweet.  And haven’t we all been trained from childhood that the nasty tasting medicine makes you better?  Even if trial patients don’t detect differences in taste, they almost certainly detect differences in side effects.  Dry mouth, a change in bowel habit, a slight dizziness, drowsiness are all common side effects that would instantly alert the patient that they are taking the active drug. 

 

Ethical practice for therapeutic trials dictates that patients have to be told that they are taking part in an experiment and that although they may receive the active drug, they may equally well receive a pill that has no pharmacological action on the disease process.  Just imagine what that must be like.  You have suffered a painful disease for years and suddenly you get the chance to test a new drug that promises to solve all your problems, but then you are told that you may not get the new wonder drug, you stand just as much chance of getting the blank.  You would feel so worried that you  would just have to find out whether you were getting the active drug or not.  So you would chew the tablet, break open the capsule, become very sensitive to any tell tale side effects, and even to the complicit gleam in the doctor’s eye, but you wouldn’t let on.   In the few studies where patients have been asked whether they could tell whether they were taking the drug or the placebo, most guessed correctly.  This simple fact must invalidate the results of any RCT at a stroke.

 

But there’s more.  Although I know of no study that has formally investigated whether the doctor actually knew the true nature of the medication he was administering,  I was involved in research for long enough to realise that such distortions do take place.   Reputations are fragile and ephemeral; medical researchers,  pharmaceutical research coordinators, even multinational executives will do almost anything to protect them.  Sealed codes can be broken, statistics fudged, inconvenient results omitted, negative studies not sent for publication,  studies left out of systematic reviews.     

 

I’m not intending to blow the whistle on pharmaceutical trials. Many of them, I feel sure, are  conducted meticulously, responsibly according the highest ethical standards.  There are numerous guidelines and safeguards to make sure this is so.  I’m not suggesting that pharmaceutical multinationals are necessarily evil empires that deliberately try to deceive the regulatory authorities.  I am just pointing out the obvious.  Human beings and the organisations they represent are all too – well – human.  And humanity is a broad church.  Politics is about concealment.  Error, distortion, omission and exaggeration all exist in the congregation gathered in the nave of the National Institute for Clinical Excellence.  Indeed, one might be forgiven for asking ‘Excellence in what;  The Arts of Deception?’  

 

What worries me is that health services now exist in such a state of mutual interdependence with the pharmaceutical industry that it is difficult to see how research can always be conducted and reported with absolute objectivity.    

       

Some of the drugs that have been developed are truly miraculous and have made enormous differences to our ability to withstand illness and our quality of life – antibiotics, insulin, diuretics, anti-arrhythmics, chemotherapy,  but so many others are probably little more than super-placebos?   

 

The examples, quoted in Dr Goldacre’s programmes are but a fraction of those that demonstrate the efficacy of placebos.  Human beings are not separated in the neck.  Whatever goes on in our minds has an enormous effect on the ways our bodies work.  Belief can get rid of pain, expectation can cure infections, friendship can cure depression, love can treat tiredness, peace and companionship can prolong life.  Cardiac failure can be treated by a pacemaker that is turned off, angina by an operation in which the skin of the chest wall is opened and closed up again, Parkinson’s disease by an injection of saline,  leprosy by the touch of a King,  epileptic seizures by healers that do little more than place their hands on the heads,  and almost any disease by sipping a solution that is so dilute that the active ingredient cannot possibly exist.    

 

Drugs are prescribed by serious, responsible and authoritative professionals, who have been trained for five years and apprenticed for a further seven years, who believe in the action of the medication and who understand the way the body works.  With that kind of endorsement, how could we ever doubt the efficacy of drugs.  Drugs are what doctors are about.  Indeed, remove drugs and what would doctors do?      

 

The idea of  modern drugs;  the notion that there is a pill that can relieve our pain, rectify the gut that has been wrenched out of kilter,  alleviate the burden of backache, make us breathe more freely,  quieten the troubled heart, bring us sleep, render us potent and make us happy, make us life forever, may be deeply reassuring.  We are not alone. There’s always another pill.  There is even a proposal to make Simvastatin available to everybody over the age of 50 so that we don’t die of heart attacks. But our dependence on drugs has stripped people of their self determination.  If we cannot look after our own health without recourse to drugs, how free can we be?  And if we can’t be free from health anxiety,  how healthy can we be?    

 

I feel sure that our descendants will look back on the millennium as a time when medicine was dominated by pharmaceuticals just as we look back on the ‘enlightenment’ as a time on quack remedies.  The annual UK drug budget is about 7.5 billion pounds.  We urgently need to put our dependany on drugs into perspective.  We must take back responsibility for our own health, realise what living a healthy life means. 

 

Most illnesses are reversible in their early stages.  The body has remarkable resilience. Rest, shelter, food, exercise, companionship and trust can rectify most illnesses.  It’s only when illnesses are truly life threatening or when the deterioration of bodily function has been compromised beyond repair than we need to turn to drugs. They have their place, but that place is not everywhere.        

 

It’s time to trust the body to heal itself and learn to give it the best conditions to do so.

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