Tuesday, 2 February 2016

In It For The Money?

One of the more laughable but still understandable claims made for herbalism is that we're in it for the money.  The idea is that we are either deceived or con merchants, and that we are able to make a pretty penny out of it.

The more charitable version of this is that the majority of conditions get better on their own, so if they happen to improve while someone is taking a herbal remedy, that is fallaciously chalked up to success by us lot and we continue to deceive ourselves because of this kind of thing.  If there is a trajectory of health and illness like this:

then the right hand side of that graph is, financially speaking, the herbalist's friend.  The other half might also be fine if you can sell the idea of things getting worse before they're going to get better. In the meantime in this view, we deceive ourselves or others into thinking we're helping our patients.

Just briefly, this is not true, two pieces of evidence being that many patients only come to see a herbalist once they've tried everything else they can think of without success and that measurable findings such as peak flow, degree of cover by skin lesions, resting blood pressure and the like can be seen to improve after treatment.  However, I'm not here to argue for the efficacy of herbalism but to point out how laughable it is that we are in it for the money.

Several years ago, I took the rather brave step of publishing a summary of our accounts year on year in the newsletter for our professional body.  I had suspected for a long time by that point that not many people were making a living this way because of the nature of our figures, but was open to the possibility that it was due to our location in the country or some other factor.  I was rewarded by a prolific response from other herbalists which revealed that we were by no means an isolated exception to the rule.  Very few people make a living from herbalism, by which I mean that they fail to generate much of an income from taking consultations and prescribing medicine.  There are also rather few "pure" herbalists, so those who practice herbalism who are making a living may be doing so from other complementary therapies rather than herbalism itself.  That said, there may be a way of making a living from herbalism by other methods, such as running continuing professional development workshops, writing books or lecturing.  The problem with these, however, is that they take money from other herbalists or potential herbalists - students.  This would also be fine if there was a greater level of income from acquiring new skills and practices which would then increase income and success, but that isn't what happens.  What in fact takes place is that herbalists give other herbalists their money and continue much as before.

This is not necessarily a bad thing.  Herbalism is useful and rewarding, and also fascinating, so in an ideal world there is no reason not to continue with it.  What needs to be borne in mind, however, is that it can only very rarely be a source of sufficient money to live on, and therefore herbalists either have to do something else to support themselves or have a means of support from somewhere else.  I would like to stress that this need not be a bad thing.  If we have no prospect of making enough money to live on, reducing reliance on that source of income means that there is no temptation to treat patients unprofessionally as a way of maximising profits.

A later response to my letter was a Master's thesis on the public profile of herbalists, which involved a survey at an NHS health centre among a randomly selected group of patients.  Something like 2% of the sample were aware of what a herbalist does.  Many people confused it with homeopathy and even those who did know what a herbalist does usually mixed up Western and Chinese herbalists.  When most people think of herbalism, they conceive of it in terms of dried herbs, pills and potions bought from chemists or health food shops and never even imagine there are professional herbalists.  The mark up on the herbs sold to the public over the counter is many times that of the herbs sold by a professional herbalist to the public and the quality is far lower.

It seems to me that the reason people think we're making money hand over fist is that they think it's about the expensive and relatively ineffective remedies sold in shops.  There may also be some confusion with Traditional Chinese Medicine, Ayurveda and the like.  There is a psychological phenomenon known as the Dunning-Kruger Effect where those who are relatively ignorant of a subject think they know a lot more than those who have more knowledge of it.  Education often reveals how little one knows about a subject.  Since the people concerned know little to nothing of herbalism, they suppose they know a lot more than the herbalists.  For instance, and this also occurs in home ed, they presume they know what it is and don't need to be told.  Experts, what do they know, eh?

However, there is more than this and it can be applied more widely than to the alleged snake oil vendors such as myself.  Specifically, there is a tendency to pad out herbalism courses with irrelevant and poorly applicable subject areas and also there is a tendency to over-sell the courses as vocational.  However, this is not a feature specific to herbalism or complementary medicine.  It's actually something which happens across the board.  Performing and fine arts courses are said to be other examples.  There are financially successful results there, yes, but they are often the exception rather than the rule.

Another, again entirely true, allegation made against complementary medicine courses is the secrecy of the course content.  The content and syllabus is not available to the general public.  This is a very common practice.  I tested this by looking at the syllabi of courses such as engineering, physics and psychology from Russell Group universities, and found that there was a similar degree of secrecy.  Some higher ed institutions do publish their entire course content online, for example MIT, but this is because they profit from the likes of good physical facilities, the opportunity to network and good staff-student ratios.  It is an indictment, but not of complementary medicine so much as the profiteering of universities and their ilk.

One thing that bothers me about all this is that the people who make this allegation often see themselves as sceptics.  They are sceptical of what they see as complementary medicine.  They rightly criticise the nature of complementary medicine course content but fail to note that the same criticisms, and they are serious, apply across the board in many universities and many disciplines.  They also assume they are well-informed about something about which they are not, a well-known cognitive bias, and yet they are apparently unaware of that cognitive bias when they are very ready to accuse us of the likes of confirmation bias.  This bias leads them to think we're raking money in from the gullible public when in fact nothing of the kind is taking place.  It's not easy to make a good living out of anything if you haven't already got some kind of fiscal or social capital behind you and the same is true of herbalism as it is of all sorts of other areas.  They also fail to mention the dubious ethics of taking the cash off other people acting in good faith to improve the lot of others in a way which accords more with their conscience.  Moreover, they seem to be completely unaware that they are doing any of these things.

Anyone who is in this for the money is going to be seriously disappointed unless they're extremely lucky.  I am aware that like everyone else I have cognitive biasses, although most of the time I don't know what they are.  People who describe themselves as sceptics seem to be relatively unaware that they too are subject to these limitations.  They are in fact not sceptics.  Sceptics, usually spelt with a K because they are apparently reacting to American religious fundamentalism or copying that reaction in a different cultural context where it's less of an issue and therefore spell it in the American way, are in that narrow sense people who suspect opinion stated as facts.  In the broader sense of people who believe knowledge is rarely possible, I am a sceptic.  It can be a lot easier to perceive the opinions of others as factual than it is to recognise your own opinions are those, not necessarily facts.  Moreover, there is an emotional element to truth which they seem to gloss over entirely.  Suppose your house has burned down.  You might say "I know my house has burned down but I can't believe it", because you don't want to believe it.  These kinds of bias are healthy and part of most people's mental make up, and it doesn't make sense to deny that they exist and form an important part of thought.  Denying them is not intuitively a good thing.

Therefore, no, we are not in it for the money, and the main reason people think we are is that they know nothing about herbalism, don't even know that they know nothing, and don't want to be less ignorant than they currently are.  In the meantime, we have very tough lives which they make even worse by propagandising ignorantly against our good will and honest attempts to improve the lot of our patients.