Dr David Bender, chairman of HealthWatch, told BBC health correspondent Jane
Dreaper, “The AIDS epidemic in Africa has been massively exacerbated by
a refusal to accept the scientific knowledge about the disease.” [1] The
workshop, which marked World Aids Day, was reportedly attended by about 80 homeopaths
and workers from HIV projects. Its publicity had claimed it would offer “a
fascinating insight into the role of homeopathy in treating HIV/AIDS”
[2] and discussed the work of homeopaths in AIDS clinics in Africa and included
a presentation on remedies with which, the conference was told, “the AIDS
epidemic can be called to a halt”. However Dr Michael Brady, consultant
in genitourinary medicine and HIV at Kings College Hospital and medical director
of The Terrence Higgins Trust, supports HealthWatch’s objections, saying,
“There is no credible evidence that homeopathy is an effective treatment
for HIV. Anti-retroviral therapy is the only treatment that has been clinically
proven to improve immune function, delay disease progression and prevent death
in patients with HIV. It is misleading, irresponsible and potentially dangerous
to suggest otherwise.”3 Dr. Ian Williams, Consultant in Genitourinary
Medicine at University College London agrees, “There is no proven evidence
that homeopathy will treat HIV infection effectively, nor is there a biological
plausibility this may be the case.” [3]
But the people of SubSaharan Africa are desperate and vulnerable: the continent has 22.5million people infected with HIV, accounting for 68% of the global total. As few as one in ten of them are being treated with retroviral drugs, and death rates are high amongst those who cannot get them [4].
Consultant clinical scientist and HealthWatch committee member Les Rose heard Society of Homeopath’s vice chair Jayne Thomas, interviewed on the BBC Today programme on Saturday morning. “She said that the purpose of the conference was to evaluate the evidence,” recalls Les. “But if that was the case, I would like to know if any specialists in clinical evidence attended? Will the proceedings be published in the open literature? Why use a conference to evaluate evidence, instead of submitting papers to rigorous review in the journals?”
Ben Goldacre, the Guardian’s “Bad Science” commentator and last year’s winner of the HealthWatch Award, discussed the conference in a column on “Aids quackery” where he quotes Society of Homeopaths conference speaker Peter Chappell as saying, “Right now, Aids in Africa could be significantly ameliorated by a simple tune played on the radio.” [5]
1. http://news.bbc.co.uk/1/hi/uk/7122370.stm
2. http://www.homeopathy-soh.org/for-homeopaths/documents/
Aidsflyer.pdf
3. Quoted in HealthWatch press release, 30 November 2007.
4. UN Aids. 2007 AIDS epidemic update. View on http://www.unaids.
org/en/HIV_data/2007EpiUpdate/default.asp
5. http://www.guardian.co.uk/commentisfree/2007/dec/01/aids
There is more on this and a link to the interview with Jayne Thomas on David Colqhoun's web site at http://dcscience.net/?p=207 as an mp3 file.
WoW is the strap line for Wellbeing of Women, a UK charity that works in partnership with the Royal College of Obstetricians and Gynaecologists (RCOG) to solve health problems that affect women by funding medical research and training into all aspects of reproductive health (see http://www.wellbeingofwomen.org.uk). They’re good: in the last 40 years they have invested over £27million to fund medical research and training. The charity was formerly known as Birthright and in the 80’s its patron was Diana, Princess of Wales…
Dr Gillian Robinson
Associate Specialist in Sexual and Reproductive Health
St Giles’ Hospital, London
HealthWatch’s 19th Annual General Meeting met on 18th October 2007 at
the Medical Society of London, Chandos Street, London W1. The HealthWatch Award
was presented to Professor Raymond Tallis for his thoughtful promotion of evidence-based
medicine. He has been kind enough to supply us with the text of his presentation
on the curse of the media anecdote. You can read this below.
The 2007 HealthWatch Student Prize for Evaluation of Clinical Research Protocols continues to generate interest in quality research amongst young medical and nursing students. This year’s Medical Student winner was Alison Myers, of the Royal Free and University College Medical School, who received a cheque for £500. Alison has agreed to offer her services to the HealthWatch Committee as a student representative now that her predecessor, Elizabeth Fairfax, has qualified as a doctor. Runner-up medical students were Alexandros Georgiou of Liverpool UMS; Ruth Heseltine of Barts and the London; Philip Jones of Nottingham; Gillian Norrie of Aberdeen and George Peck of Imperial College London. Top prize from the Nursing Students category, with another £500 cheque, went to Sarah Linge of Edinburgh. Lisa Common was a runner-up.
From time to time we would like to be able to contact members between Newsletters with alerts about new activities, important media reports, or to call for action. If you are willing to be contacted by e-mail, please send an e-mail to the membership secretary so that he can add your address to the list. Important: this list will only be used to circulate matters believed to be of genuine interest to HealthWatch members. The list will be confidential to the Membership Secretary and will not be used for marketing activities of any description.
Minutes of the 2007 AGM are now available on-line
To see photographs taken at the AGM, click on "photo galleries" on
the left.
Membership subscriptions to HealthWatch simply do not cover the cost of producing, printing and distributing the Newsletter four times a year, and therefore with regret the meeting agreed that subscription rates should be increased as follows:
I
will start with a quotation from an editorial in the Journal of the American
Medical Association of November 15th 1913 entitled Braughan’s pellagra
remedy: worthless nostrum sold under fraudulent claims. “Nostrum fakers
are damned. It is they who feed carrion-like on the fears of suffering humanity.
To those stricken with a well-nigh incurable disease they hold out the hope
of a sure cure.” This remedy contained quinine and iron salts, which give
a bitter taste, which would suggest to the pellagrin that it was good medicine.
Little seems to have changed over the last century, and HealthWatch seems to
be needed as much as ever.We publish this newsletter four times a year, and occasional position papers (with one revised paper and three new ones published this year), as well as maintaining a website with an archive of all past newsletters. In addition to this we have recently written to organisations such as the Medicines and Healthcare products Regulatory Agency and the Royal College of Obstetrics and Gynaecology concerning their promotion of unproven complementary and alternative therapies, with the aim of publishing our letters and their responses. We also hold the annual student prize for critical appraisal of clinical research protocols, generously supported by a grant form the Ajahma Trust, and make an annual award to an outstanding medical scientist, practitioner or journalist for his or her contribution to better understanding or practice of evidence-based medicine. We provide a source of information and informed comment for press, radio and TV.
The committee has spent much time over the last few months wondering what more we should do. Three areas have emerged:
Our great strength is our independence. Our only sources of income are membership subscriptions and occasional donations, as well as the grant from the Ajahma Trust for the student prize. This does not stop vilification that we are “in the pockets of big Pharma”, despite the fact that we receive no money from industry at all. We maintain friendly relations with Sense About Science; we share many of their aims, but not their more political objectives and we lack their financial and political resources.
We seem to have influence beyond what our small size might suggest. The website has received an average of 53,000 hits per month over the last year. About half of these are from addresses such as .com, .net or of unknown origin; of the half that can be traced to a country, only 16% are from uk addresses, and at least 50 hits in any one month have come from 50 different countries. One third of the hits come from people going directly to the HealthWatch website, and most of the rest come from Google, Yahoo and MSN searches, but a significant number come from Wikipedia –obviously we are considered to be an important, authoritative and independent source of information on health.
The Chairman is only as good as his committee, and I have to thank all members of the HealthWatch committee for their help. I must pay tribute to the late Michael Allen, who was a founder member of HealthWatch and over the years has done all the difficult jobs (treasurer, newsletter editor, secretary, mailing out the newsletter, and as his final gift to HealthWatch, reconciling the membership records held by the membership secretary and treasurer, which had diverged over the years). Anne Raikes now keeps the accounts in order; John Garrow is an indefatiguable vice-Chairman and contributor to the newsletter; Malcolm and Diana Brahams are always ready to offer legal advice, and Malcolm has written a number of solicitor’s letters on our behalf (we probably could not have afforded to pay a solicitor to do so); John Illman, Keith Isaacson, James May, Caroline Richmond and Les Rose are always ready to write for the newsletter; Gillian Robinson and Walli Bounds produced the protocols for the student competition and judged this year’s record entry.
There are four other people we could not do without: Mandy Paine produces this excellent newsletter every quarter; Caroline Addy reads the draft newsletter to check it for libel, pro bono; Joan Gandy undertakes all the work associated with running the student prize, and consistently refuses to accept even a modest honorarium; Kenneth Bodman took over as membership secretary (with the added burden of distributing the newsletter each quarter) in January, in return for a modest honorarium.
David A Bender
Now members can join the lively online discussions that are increasingly taking place between HealthWatch committee members and their colleagues. We have begun a forum site linked to the HealthWatch website. Anyone can view the discussions, but you have to go through the quick registration process in order to start or reply to posts in the forum.
It is expected that the HealthWatch Forum will grow to become a useful resource
for members, a significant source of information, views and links related to
HealthWatch and its aims, and an interesting, thought-provoking browse.
Just click on “Member’s Forum” on the left of the HealthWatch
home page, then just follow the instructions and dive in.
Professor
Raymond Tallis, gerontologist, philosopher, author and poet, was the worthy
recipient of the 2007 HealthWatch Award at the October AGM at the Medical Society
of London. Our members and committee were enthralled and provoked by his talk.The media love anecdotes because those who work in them believe (usually correctly) that their customers do. Anecdotes—about a new miracle cure, a drug that is not being made available on the NHS, or the side effects of treatment, or some environmental hazard—sell product. Data, on the other hand, which take us towards the truth about these things, are less popular. Anecdotes, however multiplied, do not point the way to reliable knowledge. As the aphorism says, “The plural of anecdote is not data”. For an anecdote does not even count as a datum. It may prompt a search for data, as when a chance clinical observation makes someone wonder whether A causes B, or C may have therapeutic benefits in condition D.
These deficiencies count less than they should. For anecdotes, unlike data, have a human face: they are closer to gossip, which is a universal human pastime, and to the things that shape belief formation in everyday life. Scientific data—for all that science is one of the most human, as well as the greatest, of human achievements—lack this human face. Their very strength, in that they are unattached to persons and personalities, is a PR weakness. At best, data belong to “the science community”; worse, to “the scientific establishment”; or, worst of all, when they are adopted by, and guide, those who make policy on our behalf, “the authorities”.
Let me illustrate the accursed power of the anecdote with one of the most potent anecdotes of recent times: …
The full text of Prof Tallis' lecture is available here.
IN
THE DAYS of old, Eminent Professors (EPs) were the ultimate source of clinical
wisdom. They wrote textbooks approving treatments that, in their experience,
were effective. Usually this advice was repeated in successive editions of their
textbooks, even if new data suggested that some of this advice was not optimal.By 1990 the authority of EPs was being supplanted by Data Revolutionaries (DRs), disrespectful young people who dismissed the experience of EPs as “anecdote”, and instead worshipped a new DataGod. The new Holy Scripture was called “Meta-analysis”, and contained the collected wisdom arising from several clinical trials on each clinical condition. This movement to exterminate EPs and replace anecdote with Meta-analysis in textbooks was supported by HealthWatch, which has the charitable objective to promote valid clinical trials.
At first it appeared that DRs would dominate academic medicine. But now it is becoming clear that the Utopian ideal of totally evidence-based medicine will always be difficult to achieve for several reasons.
First, it is impractical to assemble data from clinical trials of good quality for every possible condition, and for every possible patient. Trials typically compare the effect of the treatment (versus not-treatment as a control group) in adults who are healthy except for the condition being studied. It is useful to show that the treatment being tested is best for this selected group of patients, but it does not mean the treatment is best for real-life patients who are older, or younger, than those in the group tested, or who may also have several other conditions.
Second, good quality clinical trials may require massive resources in money and skilled investigators. The 2004 EU directive on clinical trials has so increased this burden that hardly anyone except pharmaceutical giants can afford to meet the new requirements. This means that there are fewer clinical trials for the DRs to meta-analyse, and they are biased in favour of a drug treatment. There may be a very good treatment involving lifestyle changes that never appears in a meta-analysis, because no non-profit sponsor could afford to finance the trial.
Third, editors of peer-reviewed journals want to fill their pages with information that subscribers want to read. It is generally more interesting to read that a treatment works than that it does not. Therefore trials with a negative outcome are less likely to be published either because the editor rejected them or, more often, because the researchers did not write them up and submit them.
Fourth, researchers and DRs (and perhaps even editors of journals!) are not always pure and impartial scientists—they may well have conflicts of interest. The solution to this problem is to have Eminent Editors (EE) who are pure, impartial and ever vigilant to present (as far as possible) a perfect unbiased summary of the evidence of efficacy for every treatment of every condition. So we can all have confidence in the purity of the EE he (or she) must be sponsored by an organisation of irreproachable integrity, and the methods used to reach conclusions must be totally transparent, so that sceptical readers can replicate the process.
Perhaps the nearest we can get to an EE is Dr David I Tovey, editorial director for the British Medical Journal’s Knowledge department, which produces evidence-based products for clinicians and the public. It is therefore worrying that on the BMJ Clinical Evidence website [1] a statement on the current knowledge about effectiveness of treatments suggests the meticulous rules for meta-analyses are not being obeyed:
“Of around 2500 treatments covered 13% are rated as beneficial, 23% likely to be beneficial, 8% as trade off between benefits and harms, 6% unlikely to be beneficial, 4% likely to be ineffective or harmful, and 46%, the largest proportion, of unknown effectiveness.”
Can it be true? The selection of 240 common conditions is arbitrary, but they are listed, so I can replicate that. But when I try to replicate the list of treatments I am baffled [2]. To claim that “46% of around 2500 treatments are of unknown effectiveness” (my italics) makes no sense unless the criteria for selecting which treatments to include and which to leave out are clearly stated. Some people may treat their wrinkles by washing their faces in the dew on May mornings. If the treatment list included that, and all the other innumerable evidence-free folk remedies for every common condition, the treatment list would have thousands of entries of which the percentage “unknown” would approach 100%.
On the other hand the list of treatments analysed could have been limited to those which had been tested by good randomised trials, in which case the “unknown effectiveness” category would shrink to nearly 0%. Without the selection criteria specified, the figure of “46%” is meaningless. Worse, it is even snatched up with glee by the alternative health lobby, who have used it to claim that nearly half of orthodox treatments are of unknown effectiveness [3], when in reality many of the treatments analysed are themselves alternative remedies (and are, not surprisingly, over-represented in the “unknown effectiveness” category).
So, is Dr Tovey really committed to the crucial value of evidence? In a letter
to the BMJ he wrote: “A principle of evidence-based practice is that the
evidence should be only one influence on clinical decision making, alongside
the expertise and perspectives of both patients and clinicians. However uncomfortable
for health system planners, an evidence based service should reflect expressed
patient preference.” [4]
In other words, now the Eminent Professor suggests that “expertise and
perspectives of both patients and clinicians” (what we used to call anecdote)
should have a place on the rostrum along with meta-analyses of clinical trials.
Maybe that will bring some benefits, but if it is a sign that he wishes to hark
back to the days where anecdote supplanted evidence I think Dr Tovey should
reconsider his position as editorial director of Clinical Knowledge.
John Garrow
Emeritus Professor of Human Nutrition, University of London
1. http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp
2. Garrow JS. How much of orthodox medicine is evidence based? BMJ 2007; 335:
951 (10th November).
3. http://www.newscientist.com/article/mg19125630.200-happy-homeopaths.html
4. Tovey DI. Evidence should not be the only consideration. BMJ 2007; 335: 952
(10th November).
Consultant
obstetrician Susan Bewley wrote to express her fury at an article which appeared
in the last issue:Dear Healthwatch Editor,
I note the article entitled “HRT under fire––again” by Michael Henk (retired) in the latest Healthwatch Newsletter (issue 67, October 2007). He writes about a newspaper article by Margaret Cook [1] (haematologist) in the Daily Telegraph that was based on an editorial [2] in a well respected international journal (the Lancet) written by a well respected author (Valerie Beral) about a potentially important topic (whether HRT causes ovarian cancer). I’m not going to get into the rights and wrongs of a complex topic except to say that I was appalled this was accepted for publication:
1. Dr Henk says that “many critical medical scientists would be unimpressed by a relative risk of 1.2 in such a study, whatever the significance level”. Why? Many of us would think that a relative risk of 1.2 of a nasty, though not very common, cancer associated with a medication that a significant minority of postmenopausal women are presently taking might be worthy of note, albeit not proof of causation.
2. Dr Henk notes that there may be confounding factors in an observational study, but is singularly unconvincing when he goes on to say that “some women could have been prescribed HRT for menopausal-type symptoms that were actually caused by incipient ovarian carcinoma, something which I have personally observed in one case” (my emphasis). Oh really? An unpublished n of 1 anecdote is supposed to impress us, the evidence-seeking “critical medical scientists” who belong to Healthwatch (strapline “for treatment that works”)?
3. He describes Cook’s article as “vituperation”. With respect to concerns about HRT he dismisses these with “perhaps there is actually some female prejudice against it” (my emphasis). And lastly, he tells us authoritatively that “the claim that it (HRT) is being promoted by male doctors and the pharmaceutical industry in the interests of commerce is specious”. So that’s alright then! The critical medical scientist (Henk, n of 1) versus vituperative female prejudice (Cook & Beral) and the HRT debate is wiped away.
Surely HealthWatch readers deserve better?
SUSAN BEWLEY
References
1. HRT: kill or cure? Cook, M. The Daily Telegraph; 20 April 2007. (Article
no longer available online).
2. Beral V. Ovarian cancer and hormone replacement therapy in the Million Women
Study. Lancet 2007; 369: 1703–10.
We have just welcomed Dr Susan Bewley onto the HealthWatch committee. More details in the next issue.
Dear HealthWatch Editor,
James May (HealthWatch Newsletter issue
67, October 2007) is rather too kind to post-modernist views on knowledge:
the idea that no understanding of the material world can be relied upon more
than any other is not merely “gullible and naive”—it is also,
frankly, rather childish.
The reason why conventional science is preferable to what is taught in Hogwarts
is that, by and large, science works and Harry Potter-type magic doesn’t.
Does James May’s interlocutor live in a house with electricity, water
and mains drainage? Does she travel by any form of motorised transport? Does
she use sun cream when lying out in the garden in the summer? If she does, she
is using technologies derived from conventional science, because they work.
The conventions, classifications and conclusions used in such science and technology
are not arbitrary, like how you might classify pieces of flotsam and jetsam—they
are derived from a long process of observation, experiment, prediction and further
experiment.
ROGER FISKEN
Dr Fisken’s views are echoed by James May’s fellow HealthWatch committee
member Les Rose, who answers in “last word” below.
But will it be the last word? If you want to join the debate, log onto www.healthwatch-uk.org
and join the discussion forum by clicking “members forum” (last
button on the left-hand panel)
James May is a bit too tolerant of post-modernism (see his article in the HealthWatch Newsletter issue 67, October 2007), although I do see what he is trying to explain. One of the main reasons that science is so often mistrusted is that it is in the business of reducing uncertainty, and less concerned with providing the “yes” or “no” answers that many non-scientists demand.
We have statistics so that we can assess this uncertainty surrounding a piece
of evidence. Thus I really do not see the merit in failing to recognise the
difference between a claim which lacks convincing evidence, because of high
uncertainty, and one for which the uncertainty is low––as post-modernists
seem to do. Neither do I see the utility of living one’s life like this.
By accepting a claim which has good evidence to support it, I run a low risk
of failure. By refusing all claims, however strong the evidence, none of my
decisions will have any value.
Science is also the business of the ‘crash testing of ideas’...
Les Rose
Freelance consultant clinical scientist and HealthWatch committee member
lans for an Independent NHS board with responsibility for allocating the £90 billion a year health service budget and setting national standards of care were unveiled by Andrew Lansley, the shadow home secretary, in November.
Rather like HealthWatch, this board would seek to influence decisions in the
NHS by promoting clinical trials and evidence-based medicine, rooting out treatments
(both orthodox and complementary) whose benefits are unproven, and therefore
saving the country from unnecessary expenditure.
If patients felt the NHS failed to deliver care to the defined standard, they
could complain to a completely new body which would gauge patients’ opinions
and ensure their views were acted upon.