This story was originally written in Portuguese, and published to the website of Revista Questão de Ciência. It appears here with permission.
In May, the city government of São Paulo in Brazil published an advertorial to the website of Rio de Janeiro newspaper O Globo, boasting about offering, in the municipal health system, many of the 29 integrative and complementary practices (PICs) approved by the Ministry of Health for use in Brazil’s Unified Health System (SUS). To be clear, this was “paid content” (or, in the current euphemism, “branded content”), published not because the newspaper editor thinks it is important, but because someone bought the space.
We can leave it to political analysts to figure out why São Paulo taxpayers’ money is being used to buy online space in a Rio de Janeiro newspaper. The issue here, after all, is science. The acronym “PICs” serves as an umbrella for a series of therapeutic proposals and medications that have one thing in common: either their risks and benefits have never been properly evaluated by science, or they have been evaluated and ultimately rejected.
The provision of PICs by the government is unethical and uneconomical, an argument that we have made extensively across a series of previous publications in Revista Questão de Ciência (some of which can be found here , here and here ).
The examples cited in São Paulo city government’s advertorial include herbal remedies such as valerian, for which there is some evidence of efficacy, albeit weak and inconclusive, plus some which do not even have a completed clinical trial, such as espinheira-santa, as well as low-impact physical activity modalities, such as yoga and tai-chi, from which it is reasonable to expect some benefit, even if nonspecific. It goes on to cover absurd and unscientific practices, such as auriculotherapy, and others that are clearly placebos, such as acupuncture.
The paid article is exemplary in the sense that it exercises several of the fallacies and contradictions normally used to justify the unjustifiable – the provision of unfounded or dubious therapies by the public service. One of them is the contrast between “treating the symptom” (which is supposedly what science-based medicine does) and “treating the patient as a whole” (supposedly the province of PICs).
This is obviously false; conventional medicine also requires a holistic view. Where it falls short of this goal, it is a flaw that needs to be corrected – it is not reason to turn to nonsense. As British doctor, journalist and researcher Ben Goldacre has pointed out, just because airplanes are uncomfortable and sometimes crash, we are not better off turning to flying carpets.
In this respect, PICs end up acting as an accidental pretext for maintaining the industrial, cold and impersonal nature of typical medical care in the public system and in private health plans: to continue the aeronautical metaphor, instead of improving the seats and the quality of the on-board service, we are offered flying carpets, which may be beautiful and soft but, at the end of the day, go nowhere.
Satisfied customer fallacy
This does not mean that the softness of the carpet does not provide some momentary comfort, and that the beautiful patterns of the fabric do not help the patient to distract themselves and forget that they have not moved. The problems are the lack of objective change – the trip did not happen, and the real illness was not treated; there is intrinsic dishonesty in selling illusions.
Illusions of causality – when the mind ends up accepting as true cause and effect relationships that are, in reality, false – are favoured when there is high “cause density” and high “effect density”.
In the case of health issues, a high effect density means that the disease in question is either chronic – the symptoms come and go – or has a high rate of spontaneous remission. In other words, there are diseases that tend to resolve themselves, or with symptoms that go through cycles of relief. This is why any cold remedy “works,” whether it’s chicken soup, a multivitamin pill, or homeopathy: the cold was going to go away anyway.
High “cause density,” in turn, occurs when the number of people trying the pseudo-cure is high, which increases the chance of “positive results” arising by mere chance. It is overly optimistic to imagine that this mechanism is unsustainable in the long term – that random cures cannot sustain the popularity of an ineffective (or even ineffective and highly dangerous) treatment for years or even centuries. One need only recall the example of bloodletting, popular for three millennia.
The two densities appear very clearly in the publicity material of the São Paulo city government published in O Globo – both, of course, falsely interpreted as real evidence of effectiveness. The text cites huge numbers of attendance:
Auriculotherapy (derived from acupuncture which consists of pressing nerve points on the ear) and acupuncture are the main individual modalities performed. There were, respectively, 192,403 sessions (equivalent to 51% of all services) and 45,417 procedures in the first half of 2023.
And, a few paragraphs later:
From January to November 16, 2023, the municipal administration delivered 13,996,700 herbal medicines to pharmacies in the municipal health network, an increase of 29.78% compared to the same period in 2022. In the last nine years, more than 60 million units were released.
These data are interspersed with testimonials from four satisfied users, two of whom have chronic conditions. Given the extremely high cause density and prevalence of chronic cases, and therefore high effect density, it would probably have been possible to find hundreds or even thousands of positive testimonials. But the same can be said of chloroquine or ivermectin for Covid-19, and for the same reasons: a huge number of patients treated and a condition that, in most cases, tends to resolve itself.
Using the glow of popularity to overshadow the lack of concrete evidence of effectiveness is a common rhetorical strategy in the PIC universe.
How much does it cost?
One piece of information that is notable for its absence from the press release is the amount of spending (or “investment”) involved in offering “more than one million alternative procedures” in “471 Basic Health Units.” We read that the “city government invests in training and updating professionals in this area”, but we are not told how much is invested.
As a matter of principle, any penny of public health funds spent on procedures and therapies of zero or highly dubious effectiveness is a waste; as a practical matter, in times of fiscal tightening and limited funding, any waste is irresponsible.
Direct financial loss, however, is just one of the problems brought about by the endorsement of alternative therapies by the government. Added to this are the very real dangers to citizens’ health and a profound miseducation effect.
The danger exists, either because the risk profile of the practice offered is unknown, since most PICs have never been adequately tested for safety or efficacy, or because the illusion of the flying carpet can mask serious health conditions, or lead the patient to neglect real treatments. The miseducation comes from the false equivalence proposed between scientific knowledge and mythologies such as vital energy and water memory; between Aeronautical Engineering and fairytale magic.
This is sabotage against the most fundamental scientific literacy of the population.
