How Long Do You Wait for a Therapy to Be Proven Effective (aka, Waiting for Godot)

Waiting for Godot (GOD – oh) is a play written by Irish playwright Samuel Beckett in which two characters named Estragon and Vladimir wait endlessly – and in vain – for the arrival of someone named Godot.*  They talk, they wait, they are understanding, they are patient – and Godot never shows up.  It’s a classic – truly a great play.

“Good things come to those who wait,” is a time-honored saying, and there’s a lot to be said for it.  But at least one of the lessons of Beckett’s play have apparently been lost on some portion of the horse world.  One wonders:  when it comes to therapies, at what point should one run out of patience, and should it start to dawn on folks that nothing is likely to happen?

When it comes to many of the therapies that horse owners have to choose from I think that the time has long since passed.  It’s not rational to wait forever based solely on criteria such as a therapy being “promising” or “new,” or the testimonials of eager purveyors or satisfied customers.

VLADIMIR: A —. What are you insinuating? That we’ve come to the wrong place?

ESTRAGON: He should be here.

VLADIMIR: He didn’t say for sure he’d come.

ESTRAGON: And if he doesn’t come?

VLADIMIR: We’ll come back tomorrow.

ESTRAGON: And then the day after tomorrow.

VLADIMIR: Possibly.

ESTRAGON: And so on.

ASIDE:  Acupuncture is said (falsely) to have been used as a treatment for horses for thousands of years.  However, in all that time, it has failed to show effectiveness as a cure for any single condition of the horse (or any other species, for that matter).

When therapies are truly effective, people usually figure out that they are effective very quickly.  Take penicillin.  Penicillin was based on a really interesting observation that certain fungi produced some substance that killed bacteria.  Scientists worked for a bit more than a decade to isolate and purify that substance.  It was certainly promising.  Then, in desperation, they gave a bit of the purified substance – penicillin – to a woman dying from pneumonia.  The next morning, she was up and hungry.  It worked, it worked for other people and, pretty soon, antibiotics really hit their stride.  All in a bit more than a decade.

ESTRAGON:(coldly.) There are times when I wonder if it wouldn’t be better for us to part.

VLADIMIR: You wouldn’t go far.

ESTRAGON: That would be too bad, really too bad. (Pause.) Wouldn’t it, Didi, be really too bad? (Pause.) When you think of the beauty of the way. (Pause.) And the goodness of the wayfarers. (Pause. Wheedling.) Wouldn’t it, Didi?

VLADIMIR: Calm yourself

ASIDE:  Glucosamine (various salts) and chondroitin sulfate have been sold as joint supplements for decades.  In horses, there’s no established dose an good studies showing that they do anything at all are sorely lacking.

Be suspicious of long-lived therapies if:

1. They have wonderful, but somewhat vague, claims.  Beware of claims like:

• “Comprehensive, multi-faceted joint health management”
• “Formulas designed to provide different levels of support”
• “… high quality, cutting edge supplements that provide support in maintaining the health, performance, and longevity of our horses…”

2. They are not subjected to or have had very little testing for things like effectiveness, content, or purity.
3. They are not subjected to regulation.
4. Their main virtue is in their packaging and promotion.
5. They don’t have to prove that they do what they say they are going to do. (By the way,   2 – 5 apply to almost every supplement, as well as many therapies).

ASIDE:  Chiropractic was first posited in the late 1800’s by a former grocer and magnetic healer.  Spinal bones out of place were said to interfere with the flow of “the innate,” the body’s putative vital force.  Putting those bone back in place was said to be the cure for ALL disease (deafness, soreness, cancer, stomach ache, dandruff – I mean ALL diseases).  While many chiropractors no longer hold to the original tenets, since its inception, chiropractic has not been shown to be effective for the treatment of any objectively demonstrable condition of man or beast, and it has not been shown to be superior to any other treatment, even for human back pain, the condition for which it is most commonly used.

ASIDE:  When therapies are truly effective, people usually figure out that they are effective very quickly.  Take H. pylori, a bacteria associated with gastric ulcers in people.  The bacterium was first discovered in the stomachs of patients with gastritis and ulcers in 1982 by the Australian Drs. Barry Marshall and Robin Warren. At the time, conventional wisdom was that no bacterium could live in the acid environment of the human stomach.  They were initially ridiculed, however, by 2005, after their work had been put to test and was shown to be true, Drs. Marshall and Warren were jointly awarded the Nobel Prize in Medicine for their work.

VLADIMIR: I don’t understand.

ESTRAGON: Use your intelligence, can’t you? Vladimir uses his intelligence.

VLADIMIR: (finally). I remain in the dark.

ASIDE:  Magnets have been tried as therapeutic materials for centuries.  In the late 1700’s, Franz Anton Mesmer held sessions using magnets as healing devices and captivated a certain segment of the upper crust of Paris (none of whom are alive today).  However, magnets – whether they are static or pulsing – have failed to show effectiveness for any of the conditions for which they have been said to help.  However, they’re found in barns everywhere.  The ones that hold paper onto message boards are the most useful (for holding up messages).

When therapies are truly effective, people usually figure out that they are effective very quickly.  In 1976, when German cardiologist Andreas Roland Grüntzig first presented his idea that putting a balloon into the coronary artery might help manage heart disease (as a poster at the annual meeting of the American Heart Association), a world-renowned catheterization specialist said, “It’ll never work.” Grüntzig returned to the American Heart Association one year later and presented his first four cases of angioplasties in humans from the podium. When he finished, he received a standing ovation. Percutaneous transluminal coronary angioplasty (PTCA) is one of the most common procedures performed during US hospital stays.

VLADIMIR: I’m curious to hear what he has to offer. Then we’ll take it or leave it.

ESTRAGON: What exactly did we ask him for?

VLADIMIR: Were you not there?

ESTRAGON: I can’t have been listening.

VLADIMIR: Oh . . . Nothing very definite.

ESTRAGON: A kind of prayer.

VLADIMIR: Precisely.

ESTRAGON: A vague supplication.

VLADIMIR: Exactly.

ESTRAGON: And what did he reply?

VLADIMIR: That he’d see.

ESTRAGON: That he couldn’t promise anything.

ASIDE:  In the 1960’s, “FAX” was just a mispronunciation of things that are said to be true; a “laptop” was where infants were bounced.  The word “nutraceutical” was coined by an MD, Dr. Stephen DeFelice, “While strolling at the Piazza Navona late at night in Rome in the early 80s.”  It’s a combination of the words “nutrition” and “pharmaceutical.”  Dr. DeFelice was instrumental in the formation of this huge industry – sales exceed those of pharmaceuticals.  Interestingly, Dr. DeFelice also has stated that, “The best way to establish the effectiveness of a nutraceutical is in a clinical study.”  Nevertheless, in spite of literally hundreds of studies, and in spite of billions of dollars spent on such glucosamine and chondroitin products (for example), evidence is not accumulating to show that most neutraceuticals do anything but waste people’s money (and plenty of evidence shows that they don’t do anything else).  Otherwise stated, although they have been responsible for considerable economic activity, neutraceuticals have promoted neither horse health nor any real understanding of horse health in the decades since they were invented.

On the other hand, when neurologist Stanley Prusiner insisted that mad cow disease and Creutzfeldt-Jakob disease are caused not by viruses, bacteria, or fungi but by infectious proteins, which he dubbed “prions” in 1982, even he admitted that the idea was “clearly heretical.” Colleagues who had been studying these diseases for their whole careers wouldn’t accept the idea.  In 1996, the first cases of the human form of mad cow disease were reported in Britain. The disease had previously been identified as a prion disease by Prusiner. One year later, in 1997, he won the Nobel Prize.

If a therapy is effective, over time, good evidence will accumulate.  However, just because good evidence doesn’t accumulate doesn’t mean that a therapy will be discarded.  People have long memories.  Hope springs eternal.  Plus, there’s too much money to be made.

People have been aggressively selling stuff to horse owners, especially over the past few decades (but also a long time before).  And they’ve been doing a very good job:  a good job selling, that is.  Take a look at the sponsors of events and classes, or at the ad space in any horse magazines.  Horse owners get pushed hard to buy products and services.  The most effective tools of persuasion are just about anything but evidence.

ESTRAGON:  Nothing to be done.
VLADIMIR:  I’m beginning to come round to that opinion.

Honestly, you’ve got one of two options, when it comes to products and services offered for your horse.  You can read the labels, buy a whim and a prayer, and hope that your horse gets better, or doesn’t get the condition you’re concerned about (due to the promised “support,” no doubt).  Or, you can save your money, and wait for good evidence of effectiveness before you buy into something.  But given how long it’s been, for a whole lot of products and services out there, you might as well wait for Godot.

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* As a service to those of you that are really into theater, you can read the entire play if you CLICK HERE.