I’ve recently been reading Sonia Shah’s amazing book on malaria – “The Fever“, but this is not a book review… She discusses some really interesting points about the cultural perception of medical treatments and I wanted to explore how these elements could relate to the placebo effect in the context of global health.

A bitter pill to swallow

“Traditional Chewa people, Helitzer found, judge the efficacy of the medicines they buy based on taste. Because it is chalky tasting, they consider aspirin harmless. Because it is bitter, they see chloroquine – which malaria scientists find to be the very picture of a safe and nontoxic drug – as extremely powerful. If they consider their case of malaria to have derived from some everyday factor – a change in the weather, say, or a hard day’s work – they treat it with only a mild medication, such as aspirin. If they use chloroquine, they use only a tiny bit, because of its perceived great potency.” (p.126)

This excerpt describes how the taste of a treatment can alter how effective the Chewa people expect it to be. Given the role of expectation and the anticipation of remedial effects in the placebo effect, this is an important factor to consider for both global health and the placebo effect.

In the context of global health, it is vitally important to take into account the cultural differences between people, to encourage the patient’s compliance to a treatment plan. In the case of the Chewa people, a simple solution could be to provide a coating for effective treatments to make them taste more bitter. If this is not feasible, it is still beneficial to be aware of this cultural perception and to engage with that as a clinician. Perhaps educational services could be provided to patients and the wider community.

There is a danger, that when approaching poor rural communities from a modern, Western, ‘first world’ perspective, we may see this cultural beliefs as quaint, naive, or even primitive. It is important therefore, that we take the time to consider where these beliefs originate from and to accept that our role is not necessarily to condemn their traditional practices, but in stead to offer them an alternative and to explain its benefits in a culturally sensitive way.

It is likely that this equation of bitterness and efficacy originated from traditional herbal treatments used in the community – perhaps for generations. If these herbal treatments were bitter and effective, that could lead to such a perception. In addition, if this bitter treatment was also highly potent with a high risk of side effects, that could explain the choice to only take small amounts of bitter treatments. It is also worth being aware, that beliefs like this can be deeply ingrained within a culture and attempts to discredit such long-held beliefs can have the opposite effect – causing the culture to perceive conventional medicine as naive and ill-informed.

What can this teach us about the placebo effect? A scientific review from 2008, states that “big, dark-colored, bad-tasting placebos are more effective than small, brightly colored, good tasting ones”. Unfortunately, placebo studies are rarely conducted on a wide range of cultures, so these findings may not be widely applicable, but we do know that the bitter taste is relevant to the expectation of a cure amongst the Chewa people. As expectation is a core component of the placebo effect, it is reasonable to expect that -for the Chewa people – the placebo effect of an intervention could be enhanced if the medicine had a bitter taste. We also learn, that Chewa people believe that bitter medicines are more potent and therefore they prefer to take just a small amount. Therefore, taking a larger amount of a bitter treatment, could potentially enhance the placebo effect and/or produce negative (nocebo) effects such as increased side effects.

Being aware of these beliefs, can help medical practitioners to be culturally sensitive. This could help to build a trusting relationship between clinicians and the communities they serve, potentially also improving any placebo effect associated with the treatment.

The authority of traditional healers

In the previous section, we discussed the benefits of cultural sensitivity when building a relationship with a community. This is an area where traditional healers have the edge. Traditional healers are often rooted within the communities they serve. They know their patient’s and their patient’s families and for this reason, they are often considered more authoritative than conventional medical practitioners. Shockingly, 80% of Africans use traditional medicines for their illnesses. From a modern Western perspective, that seems almost ludicrous, but the traditional healers have earned the trust of their communities in a way that conventional medicine is yet to do.

It is easy to think that perhaps traditional medicine is so popular, because people don’t have a choice over where to get treatment, or perhaps they simply don’t know any better. But this is a simplification, that fails to consider the complexities of the communities and cultures involved. Admittedly, traditional healers are a lot easier to access from rural communities. Often they are within the communities themselves or at least within walking distance. In remote areas, few people have cars or even bicycles, so visiting a medical practice is often a last resort. On the other hand, traditional healers and their remedies can be a lot more expensive than conventional medicine. But, these traditional community healers are trusted by their patients in a way that medical practices simply are not.

But why not? A study of rural villages in Tanzania found that the quality of care in conventional health clinics is considered to be ‘poor’. This is not necessarily an unfair opinion – most rural health clinics are not going to have the same resources available as urban hospitals and modern medical centres. But could the conventional treatment really be so poor, that traditional healers – often armed only with placebos – are a better option? This too, is a more complex issue.

In a study conducted in Senegal… found that local people considered modern clinicians dismissive. They “don’t take time to listen”, Ndoye was told. They always prescribed the same medicine, over and over again, regardless of differences in patients’ temperaments or histories. Because of this perceived rigidity, there was no point in going to see them, Ndoye was told.” (p.128)

This passage shows that there is a problem with communication between clinicians and their patients, and this has a negative effect upon how they are perceived. Conventional medicine usually involves following a set of guidelines. This helps to standardise the treatment process and whilst some individual differences are taken into account, the treatment is often the same for most people with the same condition. From a modern Western perspective, this makes sense, but if you’re used to a more holistic approach, something that takes into account your emotions and recent life events, you may feel that conventional medicine simply doesn’t consider the individual person enough. As the standard conventional treatment for many conditions is not affected my psychological or social factors, these elements are often not taken into account. Therefore, busy clinicians may well ‘not take the time to listen’ and you can see where the negative perceptions come from.

But this gives health care providers something to work on. How can they have a more holistic approach to engage with the individual? How can they build trust? And how can they make sure the patient feels heard? In a resource-poor setting, these questions may be difficult to answer, but that doesn’t mean they’re not worth aiming for. With increased cultural awareness, perhaps these issues could be improved upon, so more patient’s view conventional medicine as the best option for them.

Interestingly, placebo effect research has also found that patients can experience stronger placebo effects when they have a positive and engaged interaction with their doctor. A doctor who takes the time to listen to them and how engages and communicates honestly and positively with the patient can improve placebo effects, hence why this approach is often used in open-label placebo studies. So, not only could this improve the clinician-patient relationship in these settings, it may also help improve patient outcome for those that do seek conventional treatment. Improved outcome is also likely to have reciprocal effects of improving trust in conventional medicine and encouraging more patient’s to use those services.

Conclusion

So that was a quick reflection on some passages from Sonia Shah’s “The Fever”. I believe that this discussion highlights the importance of being aware of the cultural differences that may affect healthcare. Having this awareness could improve clinician-patient relationships, build trust in conventional medicine, encourage patient compliance with treatment plans as well as maximising the placebo effect of treatments. In the future, I’d like to see more studied into the placebo effect and non-Western cultures, so that we can optimise healthcare across the whole world in a way that reflects cultural differences. I also believe that in the West we could learn from how other cultures perceive healthcare. We can identify ways to improve our approach to healthcare to become more person-centred and to build trust with patients. In the wake of increased vaccine skepticism and antibiotic-resistance, it is vital that the trust between doctors and patients is maintained if not strengthened.

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