The FDA maintains a database of clinical trials. They created the database after 20 years of criticism about the murky and often deceptive use to which this research was put in approving drugs and medical technologies. The database is intended to make it possible for researchers and clinicians to access the best evidence in medical care.
In a recent issue of the Journal of the American Medical Association, researchers reported the first systematic analysis of this database. The results are a cause for concern. What kind of concern depends, of course, on your point of view.
The researchers were concerned because most of the studies could not provide practitioners with what they called “high-quality evidence.” This is a problem because, for over two decades, there’s been a drumbeat for evidence-based medicine. Now it turns out that the evidence isn’t so great.
This study is not the only voice from within conventional medicine that has raised the flag of over-confidence in health and medical research.
Of course, it also turns out that conventional practitioners don’t much practice evidence-based medicine, at least not as envisioned by its promoters. Although practitioners pay attention to official guidelines and such, what they principally use as sources of knowledge includes the advise of colleagues, observing colleagues, information from sales representatives of drug companies and medical device manufacturers, and other forms of social knowledge.
One researcher calls the actual practice of evidence-based medicine a new ritual. Other researchers refer to it as marketing-based medicine, referring to the grip that commercial interests hold over research and publication in respectable journals—the place where the evidence of evidence-based medicine is to be found.
The take away message for these folks—trying desperately to maintain social order—is just keep up the good work and the evidence will get better and better.
I offer two other take away messages.
The first is that the clinical trial as the standard for knowledge of health and illness is a false idol. Clinical trials are privileged by a specific ideology of health and medicine—namely, that health effects (whether good or bad) are caused through a linear process that is reducible to specific biochemistry or physiology. In other words, clinical trials are incapable unraveling inherently complex health effects.
The second take away message is that this handwringing over the FDA database reinforces the ideology and institutions of science that count evidence to be valid only when it is of a particular kind. That ideology and those institutions are tightly coupled with specific technologies, which are inevitably manifested in commercial enterprises.
This coupling of science with commerce is obvious in virtually every study I read, where researchers hope that their new knowledge will lead to a better drug or medical device or procedure or what have you.
It’s also true that this coupling of science with commerce is characteristic of what is referred to as natural medicine and natural health. Instead of a better drug, it’s a better nutraceutical or better herb or better something that isn’t a pharmaceutical.
All of this technology for the healing arts should, of course, be common property not commercial property—because our health is common property resource—it is like the air we breathe.
A recent study suggests another approach. In this study, the prevalence of obesity and diabetes was found to be as much about neighborhood as genetics. A neighborhood is common property resource—it is like the air we breathe.
As I said before, what dominates now is science that’s about linear processes reduced to biochemistry and physiology. A good deal of ink is being spilled on how our genome determines all of that. Strange thing, though, is that with greater sophistication in examining the proteins our genes produce—proteins being the biochemicals that do the actual doing—there is great gene variation among peoples, variations that affect health. The variations are closely associated with place of origin.
Put simply, each body has a place that it’s made for. That’s not a reason to abandon finding things to cook up in the lab. It is a reason—a very good reason—to abandon our scientific devotion to an ideology that prevents us from understanding how where we live affects our health and, like where we live, is something we share in common—like the air we breathe.