White coats in far flung lands

No reader of this site would be unaware of the placebo effect (aka the 'white coat effect') which is usually defined as something like: -

The measurable, observable, or felt improvement in health or behavior not attributable to a medication or invasive treatment that has been administered

Your attitude to placebos is probably driven by your overall attitude to health care.  One side of the argument is that that anything that offers a sick person a respite from the effects of his disease has value.  People holding this view are renaming the phenomenon the placebo response; whatever it is that's going on is broadly on our side.  The opposing view is that what's being peddled is fraud and false hope; we're tricking the patient into believing that something substantial is being done and the fact that the patient's own brain is in on the ruse doesn't excuse anyone.

The placebo effect / response is the bete noir of pharmaceutical research.  If you've sunk upwards of half a billion dollars into developing a drug then 'no better than placebo' is not want you want to hear at the end of Phase III trials.  The brutal logic is that there's no point in subjecting the patient to an expensive treatment that is undoubtedly accompanied by a raft of side-effects when with a little encouragement the patient's own body can achieve the same response on its own.

And apparently we're seeing a strange increase in the placebo effect.  A few years ago Wired Magazine ran a great Steve Silbermen article entitled Placebos Are Getting More Effective.  Drugmakers Are Desperate To Know Why.  It tracks the work done by Dr William Potter, a researcher at Eli Lilly, who observed that new antidepressant and antianxiety medications were actually being overtaken by placebos in as many as nine out of ten trials.  Potter questioned two assumptions that are pivotal to clinical trials: -

1. If a trial is managed correctly, a medication will perform as well or badly anywhere in the world
2. The standard tests used to gauge volunteers' improvement in trials yield consistent results

It turns out that part of the problem stems from (surprise, surprise) the pharma industry's habit of scouring the globe for the cheapest option to undertake any necessary work; more and more clinical trials are using centres in Eastern Europe, Russia, China, India and Africa.  Something that's of great concern to the hand-wringing lefties of this week's Guardian: -

Places such as South Africa – where mostly vulnerable poor with low literacy levels are recruited and the culture is to accept authority without question – are fertile land for ethical misconduct

I accept that ethical misconduct of every kind is more likely in the less developed world (viz. Nestle infant formula) but I reject the knee-jerk implication that such exploitation is inevitable.  The irony is that the problem of the spreading placebo effect may be a result of exploitation in the opposite direction: -

A patient's hope of getting better and expectation of expert care—the primary placebo triggers in the brain—are particularly acute in societies where volunteers are clamoring to gain access to the most basic forms of medicine. "The quality of care that placebo patients get in trials is far superior to the best insurance you get in America," says psychiatrist Arif Khan, principal investigator in hundreds of trials for companies like Pfizer and Bristol-Myers Squibb. "It's basically luxury care."

Wired, ibid

When a Big Pharma company grandly states that its mission is to 'improve the lives of people across the world', I strongly doubt that the promotion of the placebo effect is what it has in mind.