Narrative based medicine in an evidence based world
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7179.323 (Published 30 January 1999) Cite this as: BMJ 1999;318:323
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EDITOR - Greenhalgh [1] showed that narrative-based reasoning is
inevitable (and effective) in practical medicine. I wish to touch a
closely related topic - that practical value of evidence-based "knowledge"
is often overestimated. Facts accepted as incontrovertible scientific
evidence, after closer and skeptical examination, often occur not an
evidence at all, or even an evidence
for the reverse.
For several years I analyzed evidences for causal role of HIV in
AIDS. (Some skeptics insist that HIV is not the cause of AIDS [2], and
even that existence of HIV has never been proven rigorously [3]).
Proponents of the mainstream paradigm often use the following argument. In
a British funded study [4], it was found that annual mortality in hiv-
seropositive Ugandans at age 13-44 is more than 60
times higher than in hiv-seronegatives (96/1000 against 1.4/1000). At
first sight, this is a persuasive evidence for causal role of HIV in AIDS
and death. But let us look at the facts more closely.
There are several alternative hypotheses which treat hiv-positivty as
a consequence (a non-specific marker) of deteriorated health, not as the
cause. All these hypotheses also predict much higher mortality in hiv-
positives. To decide which view - the mainstream or the dissident
one - is closer to the truth, one has to look at mortality in hiv-
negatives. Really, if HIV were a new pathogen, which causes deaths
independently on other diseases (the main cause of death in young adults
in Uganda), mortality in hiv-negatives would remain at the normal level -
typical to this region in the past. In contrast, if hiv-positivity is only
a marker of diseases, mortality in hiv-negatives should be lower than
normal - because a great proportion of "normal" deaths would be associated
with hiv-positivity. So, the crucial question is whether annual mortality
1.4/1000 is normal for this region or it is lower.
Mortality in Africa always was notoriously high, compared to
developed countries. A great proportion of population die from various
infectious diseases at relatively young age. Is this "narrative"
information compatible with mortality observed in hiv-negative 13-44 old
Ugandans (1.4/1000/year)? Definitely not, because it is even a lower than
mortality in the US population at this age in 1980, before AIDS epidemic.
Narrative information from Africa is that mortality in young adults
increased twice in recent years, not higher. So, normal mortality may be
estimated as half of the overall rate observed in the study (9.3/1000) -
i.e. 4.65/1000.
"Deficit" of deaths in hiv-negatives is 2.3 times the observed number of
deaths - (4.65-1.4)/1.4. These expected but not observed deaths fell into
hiv-positive group. If HIV were a new cause of death - independent on
other death-causing factors, normal deaths would be distributed as 1:9
between hiv-positives and hiv-negatives (as far as
9.6% of the population are hiv-positive in that study). But the actual
ratio is more than 20 (=2.3:1/1:9) times greater. This is a strong
evidence for unorthodox HIV-is-a-marker hypotheses, and against the
conventional vision of causal relations between HIV and lethal diseases.
A general lesson is that narrative-based thinking, accompanied by a
bit of common sense, may often lead to a more adequate vision of reality
than vision imposed by "evidence-based" science. This is the case even in
epidemiology, let alone practical medicine - which deals
with individual human beings, not with "populations" and "samples".
Vladimir Koliadin
162-G Tractorostroiteley Prosp.,
Kv.128
Kharkov 129
Ukraine 310129
References
1. Greenhalgh,T. "Narrative based medicine in an evidence based
world." BMJ 1999; 318:323-5 (30 Jan.)
2. Duesberg, P. "AIDS epidemiology: Inconsistencies with human
immunodeficiency virus and with infectious disease".
Proc.Natl.Acad.Sci.USA 1991, 88:1575-9 (Feb.)
3. Papadopulos-Eleopulos,E., Turner,V.F., Papadimitriou,J.M. and
Causer,D. "Factor VIII, HIV and AIDS in haemophiliacs: an analysis of
their relationship". Genetica 1995; 95:25-50 (March)
4. Mulder, D.W. et al. "Two-year HIV-1-associated mortality in a
Ugandan rural population". Lancet 1994; 343:1021-3 (Apr 23)
Competing interests: No competing interests
Sir
With interest I read the series on narrative based medicine(1) and I
strongly agree with the authors that relying on individual narratives in a
world of valid and generalisable truths has not to be a paradox. This
applies to clinical practice as well as to clinical research. In the
present series, though, the latter is touched with just a few casual
remarks. In mental health research, narratives may generate new hypotheses
about how
people cope with traumatic experiences. The ability to report on these
experiences coherently, regarding the significant aspects and emotions,
supports their psychological integration, contributes to a sense of
identity and may facilitate coping. Adverse life changes are made
sensible, or internally consistent, within a life story that serves to
manage meanings and to preserve a sense of self as coherent and integrated
over time(2). In our ongoing study, psychodynamic analysis of childhood
cancer survivors'
narratives on the course of their illness is used to measure psychological
integration of the cancer experience into personal biography. These
findings will have to be related to standardised measures of psychological
adjustment. With this combined approach new options for helping people
cope
with severe illness and preventing chronic disturbances may be
established. However, narrative analysis in medical research still lacks
expertise. In addition, when analysing individual stories for any purpose,
we have to keep
in mind that our goal should always remain the understanding of the
narrative rather than the defence of a particular method of understanding
it if the latter is at the expense of the former(3).
Alain Di Gallo
Child and adolescent psychiatrist,
University Dept of Child & Adolescent Psychiatry
and University Children's Hospital,
Basel,
Switzerland
1. Greenhalgh T, series ed. Narrative based medicine. BMJ 1999;318:48
-50,117-119,186-188,253-256,323-325.
2. Cohler BJ. The life story and the study of resilience and response to
adversity. Journal of Narrative and Life History 1991;1:169-200.
3. McCabe A. Preface: Structure as a way of understanding. In: McCabe A,
Peterson C, eds. Developing narrative structure. Hillsdale,NJ:Lawrence
Erlbaum Ass.Pub.,1991:XIV.
Competing interests: No competing interests
Re: Narrative based medicine in an evidence based world
Evidence based medicine is science and Narrative is a step beyond, it's the art of medicine.
Narrative medicine is bridging the gaps, the evidence based left - in the context of empathy and most of all possible solutions.
Very well written article.
Competing interests: No competing interests