In
a letter to the World Health Organisation in June, a group of young scientists
called on the agency to condemn the promotion of unproven homeopathic treatments
for serious diseases—TB, HIV-AIDS, malaria and childhood diarrhea—in
developing countries. One of the signatories, biochemist and medical writer
Evelyn Harvey (above), has a background in TB research and has worked with Health
and Development Networks, a TB and HIV communications non-governmental organisation.
In India she reported on Community health in the Thar Desert. She writes here
about her experiences exclusively for HealthWatch members.The WHO takes a constructive view towards integrating traditional healers in the drive to improve public health. However, unlike many alternative medical systems, such as Indian Ayurveda, homeopathy is neither ancient nor traditional to the developing countries where it is being promoted—it was invented in 1796 by a German physician. And while herbal remedies contain active substances that affect the body’s chemistry, homeopathic remedies are diluted to the point of containing not a single molecule of the substance on the label. Homeopaths in the West would shy away from claiming their remedies exclusively curative for TB, HIV, malaria and other serious diseases. I have found, sadly, that this is not the case in developing countries.
The dangers of unproven treatments in these regions are compounded by the
hostility that is often shown towards allopathic medicines, demonstrated most
corrosively by the AIDS denialists who advocate vitamins and vegetables as curative
of HIV-AIDS. Third world homeopaths frequently denigrate proven drug treatments
on the basis of side effects or inefficacy. (Homeopathic medicines are indeed
without side effects, a predictable consequence of a remedy containing no active
ingredients.) The dangers are manifold—patients can be persuaded to interrupt
treatment, leaving them vulnerable to drug resistant TB, while someone with
HIV might believe themselves cured and take no precautions against infecting
others.
To me, the homeopathy issue demonstrates that public health programs can make
great improvements to service delivery with the help of two relatively simple,
low-cost interventions: accessible information and psychosocial support.
I believe that unpicking the scientific explanation and opening up the details
of drug action and design in a way that people can readily understand, is the
way to counter misinformation generated by alternative therapists. Merely stating
the opposite will reduce people’s decision to a judgment of trust, and
on this factor homeopaths often win.
Why do people trust homeopaths and believe them but not doctors? Partly due
to lack of understanding—scienctific jargon and complexity can be intimidating,
in contrast with the relatively simplistic explanations offered by homeopaths.
It is also to do with the tendency of alternative practitioners to be more empathic,
and they may have background or community in common with the patients. They
offer, in effect, a from of psychosocial support that medical services would
struggle to provide: a caring, sensitive and encouraging practitioner with time
to talk over life in general, and who explains the disease in understandable
(if incorrect) terms.
An appropriate level of communication is essential. People who have had no formal education are not stupid, but they will be alienated by medical jargon. I recall a medical educator manual, supplied by a western agency for use in Indian village health worker training, which suggested explaining that, “other STIs increase the risk of HIV transmission because lymphocytes are drawn to the inflamed area.” Even the person doing the training didn’t understand it!
Whereas when an open discussion was held on, “you know, THOSE diseases..,”
we got people coming up with good ideas. “So if a man comes to us, we
should send the wife to the doctor too,” for example. People in many cultures
will not indicate when they have no idea what the speaker is talking about,
instead sitting politely and silently through a meaningless session. On the
other hand, once villagers I encountered were engaged and empowered in the discussion,
there was no way to get a word in edgewise.
Cultural sensitivity is also extremely important. Discussing a poster advertising
a yogic cure for HIV-AIDS with a group of Indian villagers, it was clear that
yogis command respect in their communities. So, while getting across the basic
facts of HIV infection, and how to prevent it, I emphasised that although the
yogi was only trying to help, there would come a point when the patient would
need access to drugs and medical care.
Doctors in the developing world, with huge caseloads and limited resources, can’t always educate patients or cultivate personal connections, however much they would like to. However, community led education can be very successful and there’s a need for more operational research on the best strategies in this area. Too often, patient education and psychosocial support are afterthoughts. Yet the costs are minimal when compared to the investment needed to develop and market a new drug, diagnostic or vaccine. It’s fundamental to the success of long-term public health strategy and is also the best defence against health programmes being undermined by proponents of unproven therapies.
Evelyn Harvey
http://www.evelynharveymedicalwriting.com
Further reading
For information about HDNet see http://www.hdnet.org
To read about Voice of Young Science’s letter to WHO see: http://www.senseaboutscience.org.uk/index.php/site/project/331/
Media coverage:
http://
www.guardian.co.uk/science/2009/jun/01/world-health-organisation-homeopathy-hiv
http://
www.timesonline.co.uk/tol/life_and_style/health/article6406213.ece
Iain
Chalmers has agreed to be the seventeenth winner of the HealthWatch Annual Award.
Chalmers, who enjoys descriptions such as “maverick” and “troublemaker”,
has spent the past 30 years trying to ensure that health professionals and patients
have free access to unbiased evidence of the effects of medical interventions.Currently editor of the James Lind Library, which documents the evolution of fair tests for treatments, he was a founder and director of the Cochrane Collaboration which promotes systematic review methods throughout medicine. Chalmers began his mission when, as a clinician in the 1970s, he realised that not everything he’d been taught in medical school had been correct, and patients were suffering and dying for lack of reliable information on the effects of treatment.
Chalmers was knighted in 2000 for services to healthcare. The HealthWatch Award will be presented at the 2009 HealthWatch Annual General Meeting, to be held on Thursday 29th October. Further details will be sent to members in due course.
Reference
Watts G. Iain Chalmers: maverick master of medical evidence The Lancet 2006;
368 (9554): 2203-2203. See: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69879-6/fulltext
A US campaign group is using tragic stories from NHS patients in its TV advertisements as a weapon to attack president Barack Obama’s healthcare reforms…
See the Guardian, 13th May 2009 http://www.guardian.co.uk/world/2009/may/13/advertising-campaign-nhs-us-healthcare-reforms
Charges have been filed against nine French doctors for allegedly failing to disclose their ties to drug manufacturers, says a report by investigative journalist Jeanne Lenzer in the British Medical Journal. All nine are considered authorities in their fields. One, a professor of neurology, had chaired the Alzheimer’s disease working group of the France’s national health authority, which issued guidelines that recommend the use of specific drugs for Alzheimer’s. The charges were filed by the doctors group Formindep (Formation Independante) a French-based non-profit organisation that promotes independent medical information.
BMJ 2009; 338: b2347 Go to http://www.formindep.org/for
more information or to sign Formindep’s charter
Homeopathy cost the NHS £11.89m between 2005 and 2008, according to figures released to More4 News under the Freedom of Information Act for a report that was broadcast in June. During this time there were 68,647 treatment “episodes” at an average cost per episode of £173. This breaks down to £151 for each outpatient treated, and £3066 for each inpatient. The biggest spenders are the London primary care trusts—Camden PCT alone spent £1.86m.
http://www.guardian.co.uk/society/2009/jun/10/
complementary-medicine-nhs-more4
http://www.channel4.com/news/articles/uk/truth+behind+nhss+homeopathy+budget/3204562
In a referendum on 17th May Swiss voters approved
a proposal to promote alternative medicines. Sixty-seven per
cent of the electorate voted in favour of complementary treatments, including
homeopathy, herbal and neural therapies as well as traditional Chinese medicine
being paid for by the compulsory health insurance. However, the Swiss government
says such treatments must be effective, reasonably priced and appropriate to
be included in the list of paid health services. Opponents had unsuccessfully
argued that including these forms of treatment would add to the financial strains
on the health system.
Since
1993, when I was appointed professor of Complementary Medicine, I have researched
chiropractic and have often been critical about aspects of this therapy. For
instance, I have shown that it is associated with considerable risks and that
the evidence for efficacy is frequently negative or unconvincing [1].
Chiropractors often make claims far beyond spinal conditions. One example—asthma—may suffice. During October and November 2008, the following chiropractic organisations were promoting chiropractic as an effective therapy for asthma: American Chiropractic Association, British Chiropractic Association (BCA), Canadian Chiropractic Association, Chiropractic Patients Associations (US) and the International Chiropractors Association.
The three existing studies on this subject [2], however, show quite clearly that chiropractic is not better than sham-treatment…
…Readers who want to help preserve our ability to discuss science and medicine freely can sign the statement “Keep Libel Laws out of Science” on http://www.senseaboutscience.org.uk/index.php/site/project/333
Professor Edzard Ernst
Director, Complementary Medicine
Exeter
References
1. Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35(5):
544–562.
2. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. The Cochrane Database
of Systematic Reviews, Issue 2. Art. No.: CD001002. 2005.
For sceptics with a sense of fun, the Quackometer website is worth a look. It’s simple: you enter any name (it could be a journalist, media personality, or even yourself) and the meter will return with a quackery score—a number of between 0 and 10 “canards” (the more canards scored the dodgier is that person’s online presence). Try it for yourself on http://www.quackometer.net…
Mandy Payne
In practice, it’s almost impossible to measure the success or safety of diets people follow themselves, as we’ve no way of knowing exactly what they’re eating in their own homes. But it can be done in a carefully controlled environment, and the results are not always what patients expect. John Garrow, the University of London’s emeritus professor of human nutrition, explains, “For 17 years (1970–1987) I had the luxury of having complete control over three beds at the end of a ward at Northwick Park Hospital. We admitted obese patients from my outpatient clinic for three week periods, so each week one came in and one went out.
“So we had a closed ward where the patients never went out except when escorted by members of my research team, and everything they ate came from a metabolic kitchen, and whatever they left on the plate was analysed…
Mandy Payne
Editor, HealthWatch Newsletter
Diets
that (probably) won’t work: from A to ZAtkins diet Originally proposed in 1972; a diet in which carbohydrate intake is severely limited (to 20–30 grams per day) but fat and protein are permitted in unlimited amounts, leading to ketosis. It is effective for weight loss, since ketosis reduces appetite, but as a long term strategy for maintaining weight loss it runs counter to all modern advice on a prudent diet. Excessive fat intake results in high blood cholesterol, leading to atherosclerosis and coronary heart disease. There are also suggestions that too much protein may be linked with the development of kidney disease and osteoporosis.
Beverley Hills diet Based on the unfounded belief that enzymes from certain fruits (pineapple, mango, etc) are required to digest foods, and that undigested food in the gastro-intestinal tract leads to obesity.
Blood group diet From another unfounded belief, this time that blood groups evolved at different times, and the diet prevalent at the time a person’s blood group evolved is optimum for health and weight control.
Cabbage soup diet Advocates consumption of large amounts of home-made cabbage soup with a very limited range of other foods; likely to be nutritionally inadequate in many respects.
Detox diet Based on the belief that weight gain is the result of accumulation of toxins in the body, and a period of fasting and strict avoidance of such supposed toxins as caffeine and food additives is beneficial. There is no evidence to support this.
Duvet diet Followed from the observation that sleep deprivation leads to increased secretion of the hormones cortisol and ghrelin (which stimulate appetite) and reduced secretion of leptin (which reduces appetite). By extrapolation it is suggested that increasing the time spent sleeping will reduce appetite and food intake, and so permit weight loss. There is no evidence it works.
Food combining diet A system of eating based on the—again unfounded—concept that carbohydrates and proteins should not be eaten at the same meal. It ignores the fact that almost all carbohydrate-rich foods also contain significant amounts of protein. In any case, in the absence of adequate carbohydrate, protein is oxidized as a metabolic fuel (i.e. to provide energy) and therefore not available for tissue building. Also called food combining or Hay diet.
Hay diet This is a food combining diet (see above).
Macrobiotic diet A system of eating associated with Zen Buddhism; consists of several stages, finally reaching Diet 7 which is restricted to cereals. Cases of severe malnutrition have been reported on this diet. It involves the Chinese concept of yin (female) and yang (male) whereby foods, and even different vitamins (indeed, everything in life) are predominantly one or the other and must be balanced.
pH diet This involves balancing the intake of acid forming and base forming foods, but has little scientific basis.
South Beach diet Uses a high protein and low carbohydrate intake. A variant of the Atkins diet.
Zone diet Based on the belief that each meal should comprise a fixed proportion of macronutrients: 40% carbohydrate, 30% fat and 30% protein. There is no reason why this should be beneficial, let alone result in weight loss.
From A Dictionary of Food and Nutrition by David A Bender. Third edition published 29th January 2009 by Oxford University Press, Oxford. Paperback, 608 pages. Price £11.99 ISBN-10: 0199234876; ISBN-13: 978-0199234875
Any healthcare professional has a duty to their patients to provide treatment which is based on sound scientific research. But how do can you tell whether a given piece of research is reliable? In an attempt to encourage students of Medicine, Nursing and Complementary therapies to acquire the skills to assess research claims Health Watch launched the Student Prize in 2002. Its aim is to encourage students to learn how to read and critically appraise clinical trial protocols so they can assess the validity of research findings…
Gillian Robinson
Associate Specialist in Sexual and Reproductive Health
St Giles Hospital in London
GENERAL
PRACTICE: Choice is everything—isn’t it? It is a largely unquestioned assumption which governs our thought life in the modern world—that choice is always and in all circumstances a good thing. The individual’s freedom to choose has become ultimate reality in a generation charmed by the narcissism of the existential philosophy of Sartre whose axiom, “Man makes himself” is one we all buy into at some level—even if it is as trivial as an obsession with the interior design of our houses.
Thus in medical ethics the ‘principle’ of autonomy (the free choice of the individual) might be seen as trumping all other values where there is conflict. Those of us in General Practice are frequently being reminded that such and such a policy is part of the governments ‘choice agenda’—polyclinics, ‘choose and book’, nurse prescribing, longer opening hours, NHS direct, pharmacy minor ailments schemes and so on ad infinitum.
I was recently privileged to be part of a ‘round table discussion’ as the background to a research project on ‘choice’ in medicine…
James May
HealthWatch Chairman and GP
London
The December 2008 issue of The Biochemist was devoted to ethics: forgery, fakery and fraud in science. In an article entitled The golden age of fraud, Walter Gratzer [1] quotes Charles Babbage “fulminating against the lax standards of probity set by the Royal Society, and the prevalence of intellectual malfeasance in English science generally.” Babbage identified “three sins”: forging, trimming and cooking…
David A Bender
Senior Lecturer in Biochemistry
University College London
References
1. Gratzer W The golden age of fraud. The Biochemist 2008; 30 (6): 8-10 View
at http://www.biochemist.org
( free registration required).
In big blue letters, the e-mail began, “Cancer update from John Hopkins” and explained that women should not drink bottled water that has been left in a car. “The heat causes toxins from the plastic to leak into the water and they have found these toxins in breast tissue...Please,” and here comes the clue, “pass this on to all the women in your life.” That’s right, it’s a hoax…
Mandy Payne
LAST
WORD: New arnica labels make MHRA look silly Most readers will know that the new Medicines for Human Use (National Rules for Homeopathic Products) Regulations 2006 was slid quietly onto the statute book during that year’s summer recess, thus avoiding parliamentary debate, and caused a huge protest from scientific professional bodies (see HealthWatch's position paper for more information [2]). No efficacy data are now required in order for a homeopathic product label to claim to be able to treat a medical condition, and the UK regulatory body (the MHRA) states that it allows these label claims to be based on traditional use only. In fact the MHRA also accepts data on homeopathic ‘provings’. Provings is a practice rooted in tradition and not in science, which has nothing to do with efficacy and is not even carried out on the finished product. Nevertheless, Nelsons’ chairman was reported in the Pharmaceutical Journal as saying, “The fact that therapeutic indications may now be included on the packaging of licensed homoeopathic medicines not only opens the practice of homoeopathy up to new users but also gives it added credibility as a safe and natural complement to conventional medicine.”
Responding in the same article the MHRA refuted Nelsons’ statements, adding that the rules were introduced, “to address the anomalies in regulating homeopathic medicinal products and enable consumers to make an informed choice”. This is a somewhat disingenuous stance, because in its consultation on the proposed rules the MHRA stated that to do nothing would, “inhibit the expansion of the homeopathic industry”. Why should the MHRA be worried about that? The answer may be simple. The MHRA is not funded from taxation, but from fees, mostly from product licenses. Golden eggs and geese perhaps spring to mind. At the time the MHRA argued that it was obliged to introduce the rules by a European Directive, which was not quite correct as the Directive could have been satisfied by sensible legislation. For example, products on the market before 1971 (when the 1968 Medicines Act came into force) have licences of right which carry indications, and these could simply have been phased out and no new indications allowed. But then there would have been no new licence fees.
As it happens the actual clinical evidence for homeopathic arnica is well worth an examination. It is one of the most intensively researched homeopathic remedies, the outcome of which is—nothing. A systematic review of all eight randomised controlled trials of homeopathic arnica concluded as follows: “The claim that homeopathic arnica is efficacious beyond a placebo effect is not supported by rigorous clinical trials” [3]. It can be hardly any clearer that there is no effect. It seems ironic that a therapeutic indication can be awarded in the first instance to perhaps the most clearly ineffective remedy that could have been selected. As the review’s author, Edzard Ernst, professor of complementary medicine at Peninsula Medical School, Exeter, commented to HealthWatch, “This demonstrates just how silly the MHRA’s regulation really is.”
Les Rose
Freelance consultant clinical scientist
References
1. See online report at http://www.pjonline.com/news/homoeopathic_remedy_receives_approval_for_labelling_with_therapeutic_indications
2. http://www.healthwatch-uk.org/Position
homeopathic regulation.pdf
3. Ernst E, Pittler MH. Efficacy of Homeopathic Arnica. A Systematic Review
of Placebo-Controlled Clinical Trials. Arch Surg 1998; 133: 1187–1190.