Science means that one explores existing practices, further research those that appear to be beneficial and discard/criticise/reject those that are harmful.
Published Sep 08, 2024 | 2:44 PM ⚊ Updated Sep 10, 2024 | 3:30 PM
Ayurvedic medicines. Representational Image. (iStock)
On 13 September, 2023, Dr Cyriac Abby Philips has made a bucket list of “MOST useless supplements in descending order”. It is extremely concerning that many supplements are indiscriminately prescribed more to meet business interests than healthcare ones.
Still @theliverdr fails to do due diligence while locating himself as judge and jury at the top of the chain of ‘EBM practitioners’. It is one thing to say that most of these ingredients are available in food or have been proven to be beneficial, harmful or useless, and quite another to throw everything out as useless.
Anecdotal evidence is obviously not a basis for an intervention. However, case studies and case series (many of which he himself presents), can lead researchers to explore clinical trials in controlled settings. Some of these supplements that he has labelled as useless have undergone systematic reviews. Some have been found useful and others have required further investigation, so at best he can quote from the case-control studies or systematic reviews rather than making sweeping generalisations.
Enhancers and Inhibitors
For instance, glucosamine and chondroitin in combination, have been found to be beneficial in osteoarthritis, so one can only urge individual practitioners to use it based on individual patient condition.
Foods that we consume have ways of interacting with each other either in a beneficial or adverse manner. For instance, the presence of Vitamin C along with the food considerably enhances the absorption of iron (both haem and non-haem). This is of significance in a country with the highest maternal deaths due to iron deficiency anaemia. As the good doctor rightly pointed out, adequate amounts of these are available through food.
Both onion and garlic have been known to increase the absorption of iron and zinc from foods, both of which are documented to be deficient in the Indian population. Normally vegetarian foods have phytates to inhibit the absorption of iron.
Probiotics seem to have been found useful by systematic reviews in improving gut health especially post-strong antibiotics or those with irritable bowel syndrome etc (over placebo). For clinicians, systematic reviews are the benchmark, so if this liver doctor is rejecting some studies because they do not have adequate SR to back them, then he also has to explain why he rejects SRs in other instances.
In the first post, he says (without exception), that Omega 3/fish liver oils are the most useless supplements and in this post, he contradicts himself by saying it is justified in vegans and vegetarians. There are many meat-eaters who consume very little quantities of meat for various reasons and who may also be deficient.
Fish oils are one of the richest sources of pro-vitamin A (retinol) and in a country with concerning Vitamin A deficiency, he should avoid making sweeping generalisations. Excess Vitamin A can lead to toxicity, so obviously if someone has adequate intake through the diet, they should avoid additional supplements of Vitamin A, but there is also a large section of the population who could benefit from it especially as Vitamin A deficiency is the largest cause of preventable blindness in India.
Excessive (ab)use of multivitamins is a cause for concern, but completely dismissing this, especially in those recovering from illnesses, the elderly, children with malnutrition, those with malabsorption related issues, pregnant women and those with acute clinical signs of deficiency of vitamins, minerals etc shows a general lack of concern for detail. A more nuanced and less temperamental approach would be far more useful if one self-proclaims to be ‘evidence-based’.
On 5 September, 2023, Dr. Abby Philips (@theliverdr) says about me on Twitter (now X).
Prototype of “clinician” without sound scientific temperament. Fence-sitters among science-based medical practitioners are WORSE than pseudoscience peddlers themselves.
One, there is no Allopathy in current era. This has been shouted from hill tops time and again, and still “supposed science-trained” medical practitioners still hold on to this derogatory term coined by Homeopaths against medieval crude medicine.
SOUND research in modern medicine and the fruits of it’s labor has come from scientific methodology. In the history of medicine, all plant, animal and other sources of drug discoveries have been made by scientific practitioners and NONE from pseudoscience peddlers or traditional medicine quacks.
Of the examples given, curcumin from turmeric is utter waste. It has no clinical benefits. Penicillin has nothing to do with traditional medicine. Everything else was discovered by practitioners of medical science and none by useless traditional healers.
Traditional medicine is untested, primal observations based, illogical and at present a load of quackery.
Ayurveda is a pseudoscience.
Homeopathy is a f*cking joke.
Siddha is unscientific nonsense.
Acupuncture is a load of BS.
Naturopathy is a state of delusion.
Grow a spine and learn to call a spade a spade. Science based medicine is closest to the truth. You cannot research traditional medicine because it’s pseudoscientific nonsense.
Modern medicine practitioners must stop shagging traditional medicine. It doesn’t orgasm.
This tweet is in response to my tweet as below:
“Allopaths shouldn’t look down too unkindly on traditional medicines.
Of course, sound research is non-negotiable, but some ‘modern’ medicine came from there – morphine, quinine, curcumin, aspirin, digoxin, codeine, pilocarpine, artemisin, atropine, capsacain, penicillin etc.”
A whole bunch of people including doctors have jumped into the fray to lend solidarity with Dr Philips and claim stake on being vanguards of ‘modern’ and ‘evidence based medicine’.
I don’t have the same Twitter space as some of the more influential doctors, so shall put my points here.
Firstly, I am no promoter of Ayurvedic medicine in its current form. It’s intrinsic casteist nature and unscientific government patronage is hard to overlook. In fact, I raised some concerns with the same aforementioned Dr Abby Philips about a patient I saw with a full-blown steroid overdose after being put on a commercially manufactured Ayurvedic preparation.
The use of heavy metals and steroids in a largely unregulated system, that is being given a boost by the government, is a serious cause for concern. Their targeting of Dr Philips is also a cause for concern and I have expressed my solidarity with him on that front too.
Similarly, the practice of giving AYUSH practitioners six months of training and then giving them a licence to practice allopathic medicine is worrying.
Scientists have to maintain objectivity and also a great deal of humility. Righteous anger on behalf of patients who are dying or made sick(er) by unethical and unregulated practitioners should make us all angry, but they should not make us so morally righteous that we lose objectivity.
Dr Philips throws blanket judgements and abrasive posturing, egged on by doctors who can hardly be called practitioners of evidence-based medicine (EBM). Doctors like Dr Philips can become so absorbed in their own haloed positions, that, rather than be objective, they can become rigid and obstinate.
Holding on to positions, refusing to engage in a decent way, and throwing away all contrarian or different opinions as “bullshit and a F***ing joke” is one pointer to this toxic behaviour. His last line to a woman fellow ‘modern medicine practitioner’ is telling and a case in point.
‘Modern medicine practitioners must stop shagging traditional medicine. It doesn’t orgasm.’
Of course, he can justify all of this by saying his concern for patients makes him supra angry and therefore beyond and above normal etiquette of communication, but that is for people to take a call on. Interestingly, fellow doctors were happy with this statement as they see it as a fitting response to what they see as a shame in their haloed medical profession. That is also telling.
There also seems to be some umbrage at the use of the term ‘allopathy’ and that a more befitting term would be to call it ‘modern’ or ‘evidence based medicine’.
That brings us to the question of whether Indian doctors practising after MBBS and MD are indeed practising EBM. It is a sad reality that most medical colleges do not train students AT ALL leave alone in EBM. The business of medical education is too obvious for anyone to feign ignorance of it. In fact, I get regular calls from medical colleges asking to be a ‘faculty on paper’ — ‘give your documents, be present during the MCI inspections, pretend to be a regular staff and get paid either monthly or in lump sums with the amount increasing from Assistant Professor to Professor’!
More importantly, my own doctor friends and colleagues, who readily participate in this ‘side business’, tell me ‘welcome to the real world’, ‘life is not all black and white’ and interestingly “You can always take the money and use it for a good cause!!’
There are several instances of patients in India being subject to unethical practices ranging from cuts and commissions to a nexus with the pharma industry. That apart, the healthcare system, especially the private, is unregulated, exploitative and exorbitant. Even the Covid pandemic failed to make a dent and, in fact, aggravated the burden on patients.
If Dr Philips and his buddies have not called this out and are hiding behind the haloed umbrella of modern medicine practitioners, then it reeks of duplicity (and complicity).
There are always traditional and other practices that one can learn from and that is how EBM has also evolved from. To sit on a moral high chair abrasively refusing to even engage, doesn’t really give a feel of ‘scientific’ to it.
For instance, traditional birth attendants (TBA) have been assisting women in labour in remote places where allopathic doctors refuse to go. The TBA accommodates the woman in a position that she is comfortable with for her to push, using gravity. This doesn’t need rocket science to understand. The so-called practitioners of ‘modern medicine’ have, for years, made women lie on their backs with their legs suspended mid-air and yelled at to ‘push’.
It is only some doctors such as Dr Evita Fernandez who was humble enough to learn from midwives who are changing this practice.
Also, midwives refuse to cut the umbilical cord till the placenta is born and this is now being accepted as an important way to ensure that iron stores in the baby can be increased. Even as medical students, we have been taught to throw the midwives under the bus and blame them for maternal deaths in the country for failing to be hygienic.
Science means that one explores existing practices, further research those that appear to be beneficial and discard/criticise/reject those that are harmful. For instance, the practice of applying cow dung on the umbilical cord of a newborn baby has been the biggest cause of neonatal tetanus in India, so one should reject and actively prevent this practice.
The point is that one should be open to exploring and willing to do further research or wait for some practices to be tested. These can then be incorporated into mainstream practice and into guidelines. For that one has to be humble and willing to state that ‘we don’t know enough and further research is needed’. Locating oneself as judge and jury, throwing judgements, opinions and abuses will hardly allow the practice of medicine to grow.
Dr Philips has also slayed generic medicines and conducted trials (at his own expense) to further establish his position. He has proved that branded medicines are superior to generic medicines. In the process, he has completely missed two crucial points. One is that the so-called branded medicines have a long history of being inadequately regulated and also found to be spurious.
Secondly, the logic behind the demand for generic medicines has completely passed him by. Patients need access to cheap AND good-quality medicines. Neither should be compromised. Pitting branded against generic instead of holding both accountable is the kind of slippery slope that one gets on to if one gets too pontificatory.
Dr Philips does a great service to patients and the country by demanding high-quality evidence in patient care. However, civility in discourse and humility are not negotiable in the interest of a ‘larger good’ and their absence may even become detrimental to the larger good in the long run.
Links
On aspirin, morphine, codeine, quinine, curcumin, digoxin, pilocarpine, artemisin, atropine, capsacain
(The article was first published by the author in her blog. Views expressed are personal. Edited by Muhammed Fazil)
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Editor’s note: The earlier version of this article was published with a few remarks that were considered personal in nature. The oversight is regretted. The article has been updated to retain the subject matter-based rebuttal that it intended to be.
