Evidence-based is not the same as research-based
Meeting the evidence-based standards employing random controlled trials (RCT) has been the only acceptable means to evaluate the effectiveness of all aspects of health interventions. But what is the evidence for the reliability of this ‘gold standard’ and is this the most appropriate tool to evaluate all health-related matters, from drugs, food, nutrition to therapies?
Most people will agree that there is always a need for evidence and this is where evidence issues, disagreements and debates stem from. There is a difference between ‘evidence-based’ and ‘research-based’ (RCT) but, whether by accident or by design, those two terms have become synonymous - a nominalisation. (a good explanation of what nominalisations are and their effects can be found in Griffith-Dickson, G. Struggling for Meaning, Human Givens Journal 2006; 13(2): 15-19). Research is but one tool in the evidence-gathering process.
Providing that some of the human issues are addressed - such as non-disclosure of full data, financial and conflict of interests, to name just a few - research evidence may have a role to play. But this role dramatically decreases in importance when we take into account the variability amongst each individual’s biology and metabolism and once we take a look at some other issues related to this way of gathering evidence:
Presumably every licensed drug has to conform to RCT standards but frequently they are shown to have extremely harmful side-effects including death e.g. COX2 inhibitors such as vioxx and celecoxib;
(Sometimes dubious) findings on certain substances are generalised without taking their differences into account (such as applying results from artificial nutrients to their natural forms e.g. Fairfield and Fletcher, Vitamins for Chronic Disease Prevention in Adults JAMA 2002; 287:3116-3126 and Goran Bjelakovic at al, Antioxidant supplements for prevention of gastrointestinal cancers: a systematic review and meta-analysis, Lancet 2004; 364: 1219-28;
Evaluating effectiveness of therapies by lumping conditions with different pathogenesis and etiologies (such as ‘back pain’) and by lumping different modes of treatment (by calling them ‘manipulation’ for example) notably in meta-analysis e.g. Leon Chaitow, Spinal Manipulation - What are We to Believe? Positive Health 2006; 126:39-40.
For those reasons and a few others, it is illogical that governments and policy makers in general should base 100 per cent of their health policies on research-based evidence depriving millions of people of treatments and facilities that have been shown to be affective by other means of evaluation.
There are many alternatives to gather evidence for all kinds of therapeutic approaches and many alternative ways to promote, deliver and maintain public health. Some of those can be found in the document ‘Evidence and Public Health’ published by the King’s Fund and written by Natasha Gowlman and Anna Coote. As the writers state in that document:
“Too narrow a definition of public health, or of what constitutes evidence, will work against joined-up thinking, and work against the mainstreaming of health improvement. A medically oriented evidence base will mean that evidence about health improvement remains the preserve of mainstream public health practitioners, excluding many others within local government or the voluntary and business sectors who have a significant part to play. A new framework for evidence needs to be based on a clear understanding of these different players and functions“.