Green Party Health Policy

There was a thread recently in one of the Facebook groups I’m a member of in which, among other election-related things, the Green Party’s Health Policy was being discussed. It was mentioned that the Green Party had been essentially pro-CAM, at least in the past. As I’d been considering voting for the Greens, this was something I thought I should look into further.

Here’s a link to their Health Policy. My first impressions of this document were quite positive, especially seeing that one of their “Key Principles” seems to echo the mission statement of the Society for Science Based Healthcare where it states that:

Decisions about health services should be based on the strongest possible evidence.

However, I found myself worried that this might just be paying lip service to evidence-based policy. Particularly considering the comments I’d seen regarding past policy, and some other sections of the current Health Policy such as:

The Green Party will… Find ways to integrate complementary therapies that have a sound evidence base into health services.

The Green Party will … Increase resources for physical and mental rehabilitation in… complementary practices.

Of course, complementary therapies that have a sound evidence base should be “integrated” into real medicine. That’s exactly what medicine should be – therapies with a sound evidence base. However, as I said before, I felt worried this mention of evidence may just be lip service, or perhaps that the standard of evidence required might be low (as I’ve typically seen when it comes to the promotion of complementary therapies).

As you’ll have seen if you’ve clicked on the Health Policy link, Kevin Hague is listed as the spokesperson for this policy, as well as the person to contact. So that’s what I did. Below is the email I sent him, and the response I received (much faster than anticipated – within 2 hours):

Hello Mr Hague,

My name is Mark Hanna. I don’t think we’ve met, although we were both at the New Zealand Skeptics conference in Wellington last year. I’m currently considering giving my party vote to the Greens this election but I wanted to email you first to clarify something about one of the policy statements.

I spend a lot of my spare time working with regulatory systems to combat misinformation about health and healthcare in the public sphere. The vast majority of this misinformation comes from sources that promote “complementary therapies”.

To this end, I’ve made dozens of successful complaints to the Advertising Standards Authority and Medsafe, and have recently co-founded the Society for Science Based Healthcare as part of this continued effort. I’ve also written on some aspects of publicly funded healthcare in New Zealand that I find troubling and would very much like to see change, such as ACC’s stance on acupuncture (http://sciblogs.co.nz/honestuniverse/?p=41).

I’ve read the Green Party’s Health Policy (https://home.greens.org.nz/policy/health-policy); I’m glad to see an emphasis on evidence and I strongly support with [sic] party’s focus on equality in healthcare and making it as accessible as possible. However, I’m also wary that I don’t want my party vote to inadvertently support the kind of thing I spend so much of my time fighting against. Most particularly, I am worried about point 7 under the “Whole-of-System Healthcare” section:

“Find ways to integrate complementary therapies that have a sound evidence base into health services.”

As you may be aware, the majority of complementary therapies have a very poor evidence base. Even in cases where there is a large amount of research, in general it is of poor quality, and in very many cases the use of complementary therapies is simply not supported by sound evidence.

Other sections of the Health Policy add to my concern here, such as the 1st point under “9. Post-Acute Care” which says “The Green Party will… Increase resources for physical and mental rehabilitation in… complementary practices”. Before I commit my party vote, I’d appreciate it if you could assuage my fear that the reference to sound evidence may be no more than lip service.

In general terms, what would the Green Party consider the minimum standard of a sound evidence base in this context? Could you describe what the evidence for a treatment that does not meet this standard might look like?

As part of their commitment, will the Green Party also make an effort to prevent the integration of therapies (whether “complementary” or otherwise) into health services where there is not a sound evidence base?

I also note the party has pledged to:

“Support rongoa Māori (traditional Māori healing) practitioners and practices, and develop better linkages with other health services.”

I’m wary that when dealing traditional healing practices such as rongoa Māori and Traditional Chinese Medicine, the complex issues of science- and evidence-based healthcare and cultural sensitivity and inclusiveness can become entangled. Will the Green Party maintain their commitment to basing decisions about health services being based on the strongest possible evidence even when dealing with complex and often difficult issues such as these?

I’m under the impression that other people I know who are also considering giving their party vote to the Greens could also be swayed one way or the other depending on your response. I’d appreciate it if I could have your permission to publicly share any response you send me regarding this.

Sincerely
Mark Hanna

This is the response I received from Kevin Hague:

hi Mark,
I’m an admirer of your work. Thank you for it!

As you probably know, Green Party policy is developed by members, rather than MPs, and the Policy Committee strives for consensus if possible.

if you have compared the current Health policy with its predecessor (and my statements with those of my predecessor in the role) you will have noted substantial change that I think you would be pleased with.

The statement in the principles concerning complementary therapies, is a neat compromise I think (nobody can really argue for the use of public money on something that doesn’t work, but if it does work then it should be integrated), but does give rise to your question of what kind of evidence would be sufficient. In practice it would be me as spokesperson who would interpret the meaning of the policy (this is established practice in the Green Party). My first port of call would be Cochrane. If there is no guidance there, then it’s probably a no, but as someone who used to teach at postgrad level in research methods I would also be in a position to look at any papers that are proposed as providing evidence and make an assessment.

The obverse of this commitment does also apply ie if the state is currently funding therapies with poor or no evidence of effectiveness then it should stop doing so. This applies both to ‘complementary therapies, but also to mainstream treatments (my favourite instructive example being mammary arterial ligation as a treatment for coronary heart disease – it’s worse than ineffective).

In the case of rongoa I think matters actually are more complex. In addition to the cultural sensitivity matters to which you refer there are also Article II Treaty rights, so it’s not simply a matter of evidence. And when it comes to the evidence, far fewer studies have been undertaken. You probably know that there is significant evidence internationally that such indigenous treatment systems may be effective, even though their intervention logic and mechanism are quite different from traditional western approaches (eg Kleinmann in relation to mental illness in Taiwan). It could be that strongly held cultural beliefs may create a substantial placebo effect. Sometimes, even if we know the effect is just placebo, it could be worth having. So on this point I would interpret our policy as supporting the availability of rongoa, even though the evidence base for effectiveness may not be strong. I would also support further research to create a sound evidence base, where this doesn’t currently exist.

Hope that’s useful. Please feel free to share this if you want.

Best,

Kevin

Honestly, I’m quite happy to hear this answer. It sounds to me like the mentions of evidence are more than lip service, and hopefully indicative of a change in direction for the Greens in this area. The fact that Kevin Hague is their spokesperson on Health and ACC gives me hope as well. Especially comparing him to their past Health spokesperson Sue Kedgley, who has some ideas about healthcare that are rather wacky.

I would like to make one more comment regarding the issue of traditional medicine such as rongoa. First off, rongoa is not something I’ve looked into in much depth, I don’t know much about the state of the evidence and don’t mean to discuss it here. I would like to say though, that when I referred to issues like it being “complex and often difficult”, I meant to imply that it is not as simple as it may be in some other cases, where the only important question may be “what does the evidence say?”.

These traditions are often more than just for healing, they’re part of a wider culture and the people that use them are often already part of a disadvantaged group. If we care about what’s best for people, then we also need to care about the repercussions of discouraging or somehow diminishing such a part of their culture. As Kevin mentioned in his response, this is where things like the Treaty of Waitangi become important. There’s also an important distinction to be drawn between treatments for which there is negative evidence and those for which there is no evidence one way or the other.

I certainly wouldn’t claim to have all the answers when it comes to issues like this, and I think it’s a matter on which I would do better to listen than to speak. I do agree with Kevin that it’s not simply a matter of evidence, though, and I’d welcome a discussion on this particular issue if anyone else has anything to add.

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15 thoughts on “Green Party Health Policy

  1. When a complementary treatment becomes evidence-based it is no longer complementary – it is medicine. The “complementary” tag is just short-hand for “non-evidence-based but we like it anyway”. So, if the Greens are serious about the evidence-based criterion, they should drop the term complementary

    1. It’s a nice rhetoric that I’d usually agree with, but using language like “complementary therapies” can still be useful. There are some (few, I’ll readily admit) things that are generally regarded as such despite being supported by evidence.

      As I said in my email to Kevin Hague, it’s their reference to “complementary therapies” that made me concerned their references to evidence might just be lip service. As I said though, I think his response shows the inclusion of evidence in their policy is more indicative of a change in the direction of the party.

      Maybe next time the election comes around the importance of evidence will remain and the reference to “complementary therapies” specifically will go. That would certainly be nice. For now though, I feel pretty satisfied that Kevin Hague can reliably represent my views on this topic as a scientific sceptic.

  2. I’m very comforted by the fact that he used to teach research methods at a post-grad level. This inspires quite a bit more confidence in his understanding of what sufficient evidence and valid evidence is in terms of otherwise “unproven” or “complementary” treatments.

    It makes me quite confident that he would know what he is talking about, provided he is not biased, but again, if he used to teach research methods I am sure he has a far greater handle on bias that a lowly internet commenter like myself would have.

    10/10 would vote again.

  3. Great post! Especially love both your sensitivity and sensibility that surround the issues of biculturalism in New Zealand :) Very encouraging for me to come across. Thanks for sharing this.

  4. Great article – really well laid out argument. I too am passionate about evidence based medicine, and it increases the appeal of the greens tenfold if they are seen to shake their past of anti-scientific stances.

  5. Concerning that there appears to be a paternalistic attitude here about alternative medicine for Maori – as if an exception is required on standards of proof because Maori are not intellectually capable of dealing with challenges to a world view unsupported by rigorous evidence.

    1. Hi Paul, thanks for your comment.

      The attitude you describe is something I’d tried and hoped to avoid, and it’s certainly not something I think or meant to imply, but perhaps I didn’t do a good enough job of that. This is why I thought I needed to say that this is a topic on which I think I would do better to listen than to speak.

      I didn’t mean to imply that a lower standard of evidence should be applied when evaluating rongoa, and indeed in my work with alternative medicine I’ve tried hard to apply a consistent standard of evidence in all cases. How do you think I should approach this issue?

    2. I think Kevin Hague has the right approach to rongoa Maori. It isn’t paternalism because the issue isn’t exclusively about science, or even exclusively about medicine. For a start, what traditional rongoa treatments are is a matter of historical, anthropological, and cultural interest. Then there’s the issue that Maori traditions have historically been harshly suppressed in many ways, and refusing to fund research into rongoa could add to that. If a moderate amount of funding goes to rigorous study of rongoa treatments everyone’s happy. There’s no question of being paternalistic; the fate of Maori and Maori culture depends (practically) entirely on what happens in this country. That isn’t the case with any other group in our society. Even without Treaty obligations that’s sufficient reason for rongoa Maori to be treated differently from, say, traditional Chinese or Indian medicine.

      1. Thanks Nicky, I think you’ve put that well. I think it’s what I was going for, but I also think I didn’t manage it all that well – both in how I worded it and probably in how I was thinking about it too. I’ll try to keep a look out for this sort of attitude in myself in the future so I can do my best to avoid it.

        Paul, thanks for raising this issue. If you have anything else to say about this I’d like to hear it :)

  6. I’m not that impressed myself. They definitely have done some work with the policy, but nowhere in the reply does there seem to be any grasp of how medical treatments should be evaluated and the many issues with shoe-horning in treatments you already know are not evidence based or useful in medical practice. Otherwise, it would be being used. It’s not just about it working and then after that it should be integrated, anyone that has the role of interpreting this should understand there is also effectiveness, safety, cost effectiveness and at least pay some lip service to that we do have a system for licensing and approving drugs and medical devices for use and also for introduction as approved medical therapies for doctors to utilise in care and how they’d work this in with that.

    I’m cringing at the statement that he’d go off to Cochrane, and seems to think that would be any use in evaluating complementary therapies. Cochrane can be useful for medical therapies, but has a massive flaw there with complementary therapies – they do not take into account whether the treatment is plausible so you’ve got them “evaluating” treatments like homeopathy that clearly don’t work. Worse, it’s suggestive that this will be a top down thing, where decisions like this should not rest on personal evaluations or preferences of one minister. It’s very concerning to think this could be imposed on health professionals let alone the tax payer with no real consultation or consideration and nothing is there to suggest otherwise.

    Health care is already costly and considerations need to be made as to the best therapy to use. Yes, you can probably find papers that say homeopathy is great for diarhorreal illnesses, but what would you rather use in a child with this showing significant dehydration? Little drops from bottles of water that cost plenty and only appear on paper to do something or oral rehydration which we know is very cheap and extremely effective in replacing lost fluid? One of things is not like the other and could lead to deaths and injury if poor decisions are made. This is particularly if something needs to be taken out that is in current use to fund this other stuff given there is little flexibility in health care budgets.

    “The obverse of this commitment does also apply ie if the state is currently funding therapies with poor or no evidence of effectiveness then it should stop doing so. This applies both to ‘complementary therapies, but also to mainstream treatments (my favourite instructive example being mammary arterial ligation as a treatment for coronary heart disease – it’s worse than ineffective).”

    Notice something here, that it seems to be talking about a contemporary treatment and the implication there that medicine doesn’t cull anything either? False equivalence for a starter, there is nothing dumped from so-called complementary therapies and the same old things continue to be sold to us as ever there was. Otherwise homeopathy would be a thing of the past already and otherwise they wouldn’t be talking about introducing CAM which clearly won’t and can’t meet the standards that you’d use for medical treatments. The evidence required to use such things is vastly lower, and even multiple studies showing uselessness don’t change behaviour.

    The thing is mammary arterial ligation was dumped back in the late 1950’s, initially it was believed to be effective but later was studied with the development of sham surgery studies which meant that it could be seen whether the treatment was effective or no better than doing nothing as the sham surgery would omit the step thought to be critical to the surgery being studied. If it’s meant to be example of medicine clinging onto something ineffective, well it’s actually the opposite.

    Getting on rongoa I think the current system works fine, patients are expected to receive culturally appropriate care and if someone desires to access a Kaumatua or Tohunga that would be facilitated, with some regard to how this fits with current medical therapies as there may be limitations there or incompatible treatments. So in effect this is available already and balances things fairly well as there is some medical oversight and continuation of current therapies but at the same time patient can be helped to get the full range of care they feel is appropriate for them. Here it is made clear that there will no standard for supporting, expanding or introducing this and they devolve into special pleading about differing “intervention logic and mechanism”. But again, this has to be with regard to the needs of patients but with some consideration as what they’ll be funding because this could lead to some very strange treatments being offered to people and if this is combined with a lack of proper assessment could be rather risky to them. A recent health and disability case shows that a young woman was referred to an Tohunga who “diagnosed” her with entities, took her to a river for dunking and then offered homeopathic treatments – http://www.hdc.org.nz/decisions–case-notes/commissioner%27s-decisions/2014/13hdc00172

    While it is important to support a person in the context of their culture and recognise the importance of such figures as Kaumatua and Tohunga and their roles to that person at the same time consideration needs to be made about what exactly is going to be provided and the appropriateness of funding that.

    1. Thanks for your comment sarineal.

      One thing I’m quite aware that when it comes to voting is that our choices are always going to be limited by the parties available. I’ve had a look through the other parties’ health policies today to see if they had anything to say about evidence in healthcare and/or CAM and there’s really very little. As far as I could tell, only the Labour Party and New Zealand First have anything to say on it.

      Part of Labour’s health policy is that a principle is:

      “Evidence based: We need a health system that is based on evidence about what works – not fixated on manufactured targets or political slogans.”

      New Zealand First had this to say about CAM:

      “New Zealand First will… Consult with the natural health industry and other stakeholders to ensure there is an appropriate regulatory regime for complementary medicines.”

      Given that, in my experience, the natural health industry generally things that an appropriate regulatory regime for complementary medicines is no regulation, I’m rather disappointed with that part of their policy. Users of “natural health” products and services deserve the same protections from health fraud as everyone else.

      I’d be interested to hear if you think any of the other parties might be able to handle this better. Also, if you have improvements you’d like to see in the Greens’ policy, perhaps it could be worth emailing Kevin Hague yourself to suggest them?

      Via a comment on Reddit, I’ve been made aware that they have reviewed their health policy in the past after being prompted about it, so it could be worth a shot.

      1. Just managed to find time to come back, thanks for the reply.

        To address your points, the other parties are not saying as an overt part of their health policy and platform to integrate CAM, which by nature does not have evidence backing it like medicine does so of course it wouldn’t be in their policies. I’d be very surprised if they had to say anything about evidence in medicine, as medicine already has evidence backing it and as I’ve pointed out before we have a system in place for licencing pharmaceuticals and medical devices and also for assessing whether it is cost-effective and beneficial to adopt a new treatment. So unless they want changes there, it’s unnecessary to add any more. As regards the Green’s health policy, we are discussing it as it is and as it is being promoted by them to the public and I’m not here to fix that. I can criticise it though :)

        The other parties are handling it better as they are not making introducing CAM their policy, and I’m not sure why having consultation about appropriate regulatory regimes for CAM would be disappointing? Having them state they’ll look at regulation is a good thing, I also think the Medicines Act also is probably due for an review. The thing being it is typical to have consultation, while I’d agree with you that it is likely some sectors would resist any sort of regulation, that is beside the point. We don’t stop looking regulating other things like preventing contamination of waterways because some people would prefer it otherwise, and it shouldn’t be the case here either. I would say though that last time regulation of this came up some actually supported it, generally larger companies as this was meant to harmonise with Australia’s approval scheme and would have made their products more readily licensed there, and probably ease the process of importation elsewhere as a evidence, quality control and other relevant things would have had to be introduced to comply.

        Cunliffe’s statement is more or less waffle. It is however not saying medical care and treatment in the system is not evidence based but is pointing to political misuses of the same. That’s things like saying “no person will be on the waiting list for hip surgery for more than eighteen months” and then quietly making all the cases that are non-urgent get taken off the list and go back to their GP’s for review and referral to a specialist to get back on the list again despite that it’s highly unlikely their condition has changed and very likely it is getting progressively worse. This sort of thing has actually happened. Sounds fine as a target for the health system, but impractical as targets need to be realistic and take into account real factors like theatre capacity and availability of qualified staff to do the operations not what sounds good to say. I could go on and talk about the meaninglessness of slogans like “closing the gaps”, or funding decisions like with Herceptin a few years back, but that’s another whole other discussion again.

        I still have significant concern that the Green’s will not do proper assessment given those statements, and even more concerned that “sound evidence base” and the introduction of this is stated to based on one person “interpret[ing] the meaning of the policy”. No consultation, no recognition of the issues involved here, and no indication of what they think is “sound” in regards to evidence is stated there. It’s a non-answer really.

        There are considerable issues with the implications of introducing this and foisting this on health professionals and patients who at the end of this, will have to deal with non-evidence based therapies being integrated. I recall that Whanganui DHB had a brief flirtation with a natural therapies clinic which used massage, reiki, colour therapy, traditional Maori healing and prayer. Even at the starting point, this is likely to cause confusion as to what is a medical therapy or not in a context where claims about CAM are often misleading and also grant this stuff unwarranted legitimacy and the impression it’s as good as evidence based medicine. It’s also a waste of limited funds, those sorts of therapies have been tested and consistently failed, but money is going to be spent on them none the less if they are introduced. The thing is, the standards are always vastly less for this stuff, and you can nearly always find something positive as regards evidence to cherry pick if predisposed to do so. If we are concerned about funds and getting the best bang for the health dollar it’s going to be a huge waste if we end up spending $100.00 on four bottles of homeopathic remedy when we could have bought 200 sachets of oral rehydration mix for the same money. Worse, we know definitely one does save lives, the other does not but it would claim it did.

      2. Hi again sarineal, thanks for your reply.

        I’m going to start off this comment by saying I’m coming at this from a certain perspective in that I often see the worst of the worst. While medicine generally is already evidence-based, I’m aware that there are a few lapses when it comes to public funding and approval of healthcare. For example, NZQA accredits a number of courses in “complementary therapies” that appear to be anything but evidence-based, and ACC’s funding of acupuncture seems to similarly not be based on evidence. We at the Society for Science Based Healthcare are trying to tackle these issues, but I’d quite like to see these issues addressed from within parliament instead of only from groups like SBH, which is why I’m happy when I hear a political party say something like “Decisions about health services should be based on the strongest possible evidence”.

        I do see your point about the Greens’ policy including integration of complementary therapies whereas other parties’ policies don’t. That’s a big part of why I emailed Kevin Hague about this, because I saw a conflict between this part of their policy and the evidence-based parts of it, and I don’t want to vote for them only to find their actions fall on the wrong side of that conflict. I hope I haven’t been given the wrong impression, and you can bet that if I do vote for them then later find they’re trying to integrate some complementary therapy that isn’t based on evidence I’m going to do my best to hold them accountable for it. I should probably point out that their health policy isn’t the only (or even the primary) thing I’m considering when it comes to my party vote though, and I don’t mean to argue that I think they necessarily deserve anyone’s vote because of this.

        My comment about being disappointed regarding NZ First wanting to consult with “the natural health industry” regarding regulation of complementary medicines could have done with the added context that I don’t see any reason why any healthcare product or service should be regulated differently because it’s considered “complementary”. I think people who use “natural health products” and the like deserve all the same protections from health fraud and malpractice as those who rely on medicine. Attempts like the Natural Health and Supplementary Products Bill worry me when they make provisions like this (emphasis mine):

        health benefit claims made for natural health and supplementary products should be supported by scientific or traditional evidence.

        Where, in that case, “traditional evidence” is further defined as:

        traditional evidence means evidence of traditional use of a substance based on knowledge, beliefs, or practices passed down from generation to generation
        use, in relation to a product, includes—
        (a)consumption of the product; and
        (b)being administered the product.

        For this reason in particular, I’m quite happy that this bill seems to have dropped off the agenda and hasn’t yet had its 3rd reading, despite the fact that its second reading was 18 months ago.

        When it comes to the Medicines Act being in need of a review, you might be interested to know that some sections the Medicines Amendment Act 2013 has recently come into effect at the start of July, and the rest of it is due to come into effect 3 years later at the latest. I’d be interested to hear what sections of it you think could do with updating.

        I think you’ve made a good point regarding whether or not the Greens’ assessment of the strength of evidence will be accurate, as it’s based on a single person’s assessment of policy. I actually hadn’t thought about the idea of them consulting experts on this, but now that you’ve brought it up that is something I’d rather see them do. I’ll certainly want to keep my eye on them to make sure they don’t use a lower standard of evidence than I think is appropriate. For now their words have made me optimistic about this, but time will tell if their actions live up to my hopes.

  7. My view about cultural placebo is a simpke one. Public money should go to clinically proven health care. However, the department for social/cultural development could fund alternative treatments all they want perhaps? Just separate it from the healthcare system somehow.

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