But risk communication experts have warned that the campaigners are posing a serious threat to the success of vaccination campaigns. Society is facing a "slippery slope of philosophical exemptions," the American Association for the Advancement of Science was told at its annual meeting. "Sooner or later this herd immunity is going to collapse and we're going to have disease back again".
The Advertising Standards Authority (ASA) received complaints about an advert in the UK national press for the childhood measles vaccination campaign, which aims to avoid a predicted epidemic. Urging vaccination, the advert said that measles could cause blindness, brain damage and sometimes death, and likened its possible effects to the results of solvent abuse and traffic accidents.
But the ASA rejected the complaint, saying it was satisfied with the advert's prediction that there could soon be a measles epidemic attacking up to 200,000 people, with 50 deaths. It said that "the risks of the disease greatly outweighed those of the inoculation".
The complaints highlight the activities of a vocal minority that has been campaigning against childhood vaccines, claiming that the side-effects are worse than the disease. Organisations such as 'What Doctors Don't Tell You" have carried articles that do not give a balanced picture about vaccinations. One article, for example, claimed that measles is a "trivial disease". The campaigners also complain that the opportunity to vaccinate children has turned into a "tyranny" and say that herd immunity is an unachievable goal.
These fears contrast starkly with the success of the Government's recent anti-measles campaign. Only six cases of measles were reported in January, one of the lowest figures ever recorded. If routine vaccination levels are maintained, measles could be eliminated as a public health problem, it says.
The measles vaccination campaign is costing the Government £20 million. The avoided cases of measles would have cost £60 million in hospital and GP time, and a third of a million working days would have been lost as parents took time off to look after sick children.
Fears that anti-vaccination campaigners could wreck attempts to eradicate or minimise diseases were highlighted recently at the AAAS meeting in Atlanta, Georgia. Risk specialists said that such campaigners could jeopardise the essential herd immunity that health experts aim for with mass vaccination.
Dr Robert Chen of the US Centers for Disease Control said that vaccinators were victims of their own success. As a greater proportion of children are vaccinated, the risk of contracting the disease goes down. As a result the risks of side-effects from the vaccine may end up higher than the risk of the disease. Thus the individual may find it more advantageous to avoid vaccination and to rely on everyone else being vaccinated in order to hide within the herd immunity. But for society as a whole, vaccination is still by far the better option.
"The problem is that this type of societal risk/benefit, utilitarian ethics always looks bad to a victim-seeking media," Dr Chen told the conference. "There could be loss of confidence in the programme and the return of the disease. This occurred with the pertussis vaccine in several countries in the 1970s where vaccine coverage dropped from 80 per cent to the 30 per cent level and massive pertussis outbreaks came back.
"But how do you present this dynamic process to the average parent when they just see the adverse events and not the disease? Many doctors today have never seen a case of polio or of pertussis or measles. It becomes very difficult to explain the risk of the disease to the parent.
Dr Chen said that another problem was that side effects from vaccinations were much more difficult to monitor than the incidence of the disease itself. This means that it is not possible to tell parents exactly what the risk of a vaccine is. But it also means that parents often wrongly attribute their child's illness to a recent vaccination.
"Within a week or so something wrong happens to the kid and to the parent it becomes very natural to blame the vaccine," he said. "It may be causal, but it may be purely coincidental."
The World Health Organisation hopes to eliminate measles as a significant public health problem by 2000. Around the world, more than a million unvaccinated children die every year from measles.
See also Newsletter no 4
The rules are part of the ASA's first review of its codes since 1988. The authority also says that advertisers should not discourage people from having essential medical treatment: "Medical advice is needed for serious or prolonged ailments and advertisers should not offer medicines or therapies for them".
Other rules for health and beauty adverts include: advertisers must not use fear or anxiety to promote medicines or recovery from illness; and advertisements for medicines should not be addressed to children.
The ASA has also tightened up on slimming adverts, saying that they should not be directed at or appeal to under-18 year olds. Adverts should not suggest that it is desirable to be underweight; advertisers should be able to show that their diet plans are nutritionally well-balanced; and crash diets should not be advertised to dieters unless they are to be used under direct medical supervision.
Just before the codes were launched the ASA also clarified its position on adverts for books that contain unproven facts. Alarming claims in such books formed part of a HealthWatch investigation in 1993. The ASA agrees that there can appear to be a conflict between two of its principles: that advertisers are allowed to give accurate descriptions of the contents of their books, even when the facts quoted are unproven; and that factual claims in adverts must be substantiated.
Regarding unproven theories in books it says: "An advertisement can explain what the book is about but, without substantiation, it cannot claim that the contents are true or that by following the author's advice users might achieve a particular result."
For copies of the code, contact the ASA on: 0171 580 5555.
Although there were 12 deaths of babies born in water in 1992 and 1993, there is no evidence that it was the water birth that caused or contributed to their deaths, according to the report, which was published in the British Medical Journal. The study was based on questionnaires sent to all maternity units in England and Wales. The principal author, Professor Mary Renfrew, of the National Perinatal Epidemiology Unit, found that 8,300 women had gone through labour in a pool but given birth out of the water; 4,500 women gave birth in water.
The researchers found that there were 51 cases of illness and 33 cases of serious problems in the women. Babies' illnesses included respiratory problems and infections while some women had haemorrhaged.
They noted that most health professionals have little experience of labour and birth in - in 1993 only four units had carried out more than 100 births in water. Most had carried out fewer than 20.
A guide to spotting fraudulent faith healers and psychics has been published by two academics.
Guidelines for Testing Psychic Claimants is written by Richard Wiseman, magician and senior lecturer in psychology at the University of Hertfordshire and Robert Morris, professor of parapsychology at the University of Edinburgh.
Dr Wiseman has researched claims of psychic powers in the UK, India and the USA and has found evidence of deception for each one.
Interest in antioxidants increased after the discovery that many major human diseases, such as cancer and heart disease, may involve processes that generate free radicals (highly active molecules). Nutrients which are anti-oxidants may be able to delay or prevent these processes.
But although Vitamin C shows antioxidant behaviour, it may behave as a pro-oxidant at high doses-generating the damaging free radicals that it would destroy at lower doses. And high levels of iron have been associated, in controversial studies, with cancer and cardiovascular disease, according to Barry Halliwell, of the pharmacology group at King’s College, London.
Dr Halliwell was taking part in an effort by the Biochemical Society to examine our knowledge, and its gaps, about antioxidants. Summarising current knowledge in The Biochemist (February/March), he said that Vitamin E is now known to be important as an antioxidant, protecting against hardening of the arteries. The evidence to support Vitamin C is less rigorous, although it is widely thought to be important as an antioxidant: it is good at scavenging free radicals and may help to detoxify inhaled pollutants such as cigarette smoke or ozone. But its pro-oxidant effect at high doses is “well known to food scientists".
Meanwhile, carotenoids such as beta-carotene have not been shown to have beneficial anti-oxidant effects in the body. They are probably important in combating cancer and heart disease but possibly for another reason.
Even less certain are the flavonoids, such as those present in red wine. The possibility that they have a beneficial anti-oxidant effect is still speculation because we do not know how many of the chemicals are absorbed by the gut, said Dr Halliwell.
He said that the possibility that iron may be a damaging pro-oxidant needs to be investigated. Iron speeds up free radical reactions but in the body it is normally harmless because it is safely bound to proteins. But if that iron is released, for example if there is iron overload in the body or if body tissue is injured, the resulting free iron can speed up free radical reactions. Giving vitamin C to patients with iron overload has produced serious and sometimes lethal clinical effects", he said.
But despite their caution the scientists were optimistic about antioxidants. Dr Halliwell said: "If cancer, cardiovascular, lung and neurodegenerative diseases could be delayed by even a few years by dietary changes, the social and economic benefits would be enormous".
A report seeking to “legitimise” complementary medicine both legally and politically, throughout Europe, is being put together by a Belgian member of the European Parliament.
Paul Lannoye's report is the focus of much of the attention of complementary health organisations across Europe, according to the International Journal of Alternative and Complementary Medicine.
One in five X-rays taken is unnecessary and may even be harmful, according to the Audit Commission. It has reported that surplus X-rays cost the NHS at least £20 million and that the extra dose of radiation "carries significant risks to health".
One hospital found that three quarters of X-rays were never even taken out of their envelopes by doctors. X-rays are often taken in order to reassure worried patients or to guard against medical negligence claims, says the report.
X-rays of people with back pain rarely show clinically significant findings; X-rays of sinuses are seldom useful, says the Commission.
The Royal College of Radiologists published guidelines in 1993 which have led to a cut in X-rays by about 30 per cent. More than £600 million a year is spent on radiology services.
Which? Way to Health has called for an end to what it sees as "excessive secrecy in medicine regulation". It wants to see the abolition of section 118 of the Medicines Act (1968), which makes it a criminal offence for officials to reveal any information they receive under the Act's powers.
It also wants to see comprehensive information published after each licensing decision, and consumer representatives included on two committees: the European Committee for Proprietary Medicinal Products, the committee of scientific experts which assesses licence applications from pharmaceutical companies; and the Medicines Control Agency's committees.
Which? Way to Health, February 1995.
The International Journal of Alternative and Complementary Medicine says that complementary medicine is moving into the “new" universities - and this carries the risk that “what is being evaluated may be found wanting".
Editor Leon Chaitow writes:
“We must be prepared to place our clinical work under the glare of detached evaluation. Much of what we do... remains unproven in the absolute sense.
“Of course there are exciting individual anecdotal reports which indicate that one or other form of alternative / complementary therapy 'works' - however this proves nothing except that there was a good outcome which may or may not have had something to do with the treatment which was applied.
"In many instances patients recover despite treatment-and while many would argue that this is probably more true of what happens in orthodox rather than in complementary circles it remains something we should keep in mind.
"Many (most) health problems are self-limiting and as long as the treatment given does no harm (and arguably what complementary health care offers is at the very least less harmful than most of what orthodox care offers) then almost anything will appear to be 'working' when the patient recovers."
HealthWatch welcomes the move of this journal towards more self-criticism and assessment.
“Britain is slipping into mysticism", a Guardian article has warned. It describes the links between the beliefs of well-known alternative therapies and occult healers and mediums from whom they often wish to distance themselves.
"Both tend to agree that the human body, and the environment around it, is seething with unspecified energies," the article says. Herbalists talk of how the 'non-physical energy fields" of plants and humans can fruitfully interact; acupuncturists locate 'energy meridians' running through the body, homeopaths hold that their diluted poisons 'relate more to the body's energy patterns than to its physical characteristics'; aromatherapists believe that their pure essential oils can deliver the 'life force of plants'."
But author Pat Kane concludes:
"However irrational and muddleheaded New Age and occult cultures are. ..the whole movement is centred on the empowerment and enrichment of individuality. And there are perhaps lessons to be learned from occultism's personalist ethic... .The black hole of homo economicus is filled by the ethical interests of homo spiritualitas".
Valerian and skullcap are ingredients in at least 85 over-the-counter remedies, including Kalms, an anti-stress treatment, and Boots' Herbal Stress Remedy.
Scientists at the Edinburgh Royal Infirmary have researched valerian and published their findings in the British Medical Journal. German research has suggested that skullcap may cause liver damage.
But Boots has pointed out that the wording on its remedy has been approved by the Medicines Control Agency. The label says: "side effects are rare”.
And GR Lane, which manufactures Kalms, told The Big Issue magazine that "there is no medical evidence of a link between valerian and liver damage" and pointed out that Kalms has a full product licence.
The warnings follow the Government back-down last December over attempts to force herbal medicine manufacturers to apply for licences similar to those required for orthodox medicines.
The act set up the General Medical Council. Its single object was to enable people who needed medical aid to distinguish between qualified and unqualified practitioners. Until then it had been a free-for-all - a state we seem to be in some danger of slipping back into.
The Act guarded against telling doctors what to do by warning that, should "anybody entitled under the Act to grant qualifications, impose upon any candidate offering himself for examination an obligation to adopt or refrain from adopting, the practice of any particular theory of medicine or surgery", their licence could be withdrawn and their qualifications no longer recognised.
Non-doctors could offend against the Act if they implied that they were registered under it.
During the battle to pass the Act The Lancet railed against "selfish corporations”. including the Royal Colleges, who opposed it because they would lose some of their power to the General Medical Council.
One campaign over what should go in to the act did not succeed: the BMJ wanted to make compulsory "a preliminary examination in general knowledge" so that "medicine should exact from its students at least the same amount of general knowledge as is demanded from gentlemen who intend to study for the church, the bar, the army or even inferior government situations". This was never done.
Several proposed amendments were rejected. One proposed that all that was necessary for a body to be recognised and allowed to hand out qualifications was that it should have 500 members. This caused an outcry in The Times (not the BMJ or Lancet). which said: "Now's your time. walk up herbalists, Coffinites and homeopaths; medical botanists throw up your caps... get what you can in the general scramble. No matter how absurd; no matter how knavish; no matter how dangerous your creed: gather together but 500 of you and you shall have the right of giving diplomas".
According to The Lancet of August 1858, Parliament finally passed the Bill "not because it had any fancy for the subject of medical policy but because it was absolutely nauseated and disgusted with the whole question. It was completely sickened and tired out...".
Thurstan Brewin
Did you know that Pluto is a trigger planet and governs illnesses that either "disrupt the body like cancer - or develop progressively like multiple sclerosis or ME"?
Did you know that "the brain can't operate without Uranus"? Bad news for all higher forms of life on earth should anything happen to Uranus.
Another thing we are told is that when the Moon, Neptune and Saturn get into a particular relationship this "could trigger stomach cancer". Stomach cancer in how many million people, one wonders? Would the whole human race be affected? Or would there just be an outbreak among those Bristol elite who read The Grapevine?
Given the fact that the article is headed "Preventative Medicine" the author is also strangely silent about what his readers can actually do to keep the planets in line and prevent these terrible things happening. No doubt he is working on this for a future article.
The Grapevine is delivered free to 20,000 selected homes and businesses in Bristol.
Carlo Levi, an Italian doctor, in his book Christ Stopped at Eboli, describes the magical cures of the peasants of Lucania, where he lived 60 years ago.
As for orthodox medicine, he says, "the custom of prescribing some medicine for every illness, even when not necessary, is equivalent to magic, especially when the prescription is written, as it once was, in Latin, or in indecipherable handwriting. Most prescriptions would be just as effective if they were not taken to the druggist, but were simply hung on a string around the patient's neck."
In British medicine a virtual industry has sprung up composed of "expert analysts" whose message is that medical practice does not take sufficient account of scientific evidence. The critics have included myself and colleagues from epidemiology and public health as well as health economists, medical sociologists, management experts and statisticians.
But when it comes to reform (or revolution) we must be cautious if we wish to avoid throwing out the baby of good medicine with the bathwater of ineffective practices. There is a big difference between reforming a system that is a failure and improving a system which is a success.
It is easy to show variations between regions, hospitals and individual doctors in what they do and don't do. It is easy to think that they can't all be right. The problem is then to find out who is right and make everyone else do the same.
Another approach is to find out from a survey of the literature (eg. meta analysis) what is considered the consensus on a topic, then find out how long it takes for this to filter through into every doctor's practice. Not surprisingly, some doctors are very slow indeed: why c~ all doctors be as fast as the best, or at least the average?
This is the familiar technique of the Audit Commission, for example.
So, there are problems with medicine-that much is uncontroversial. Unfortunately evidence of problems is taken to mean that the whole system is rotten and deserves to be scrapped and replaced with something Modern, Streamlined and Rational. This new M, S and R system will be run by NHS management who will evaluate the scientific evidence, discover the right thing to do and then make sure that doctors do it. Neat. Simple. And rubbish.
This analysis fails to take into account historical facts. The therapeutic revolution, over a few decades in the middle of this century, revolutionised medical treatment and created almost all of the most effective interventions in use today.
By comparison, and with a few well known exceptions (such as H2 blockers for ulcers) the past 30 years of medical science have made surprisingly little difference to the effectiveness of treatments.
The safety of therapies has improved and their indications for use have been refined - but the pace of useful innovation is much less than it was 50 years ago. The "problem" of introducing new treatments actually isn’t much of a problem because there are so few of them. The real problem is to sort out the wheat (real improvements) from the chaff (false or greatly exaggerated claims of improvements).
This therapeutic revolution was introduced without a bureaucratic apparatus directed by the Department of Health. Indeed, it is a moot point whether it would have happened at all if the process had been controlled by NHS management.
This is not just a snipe at administrators. It is a question of competence: I find it surprising that we should imagine that managers are likely to make better decisions about treatment than doctors in clinical practice. This is not to say that doctors should be allowed to do exactly as they wish. But the ultimate responsibility ought to lie with the person prescribing the treatment rather than with a committee of experts and administrators.
The point is made that just because a treatment has a good track record of success does not mean that the claims made for it are definitely correct. Past experience shows that even the most logical and rational treatment, based upon the best scientific evidence, may still be useless or even harmful. We need randomised controlled trials to check what actually happens.
But the constraints of real life mean that we can't test every treatment. Perhaps, therefore, the most important decision is between treatments which really need such trials and ones which either don’t or are not worth the bother and expense. Examples of the latter might be treatments that are obviously absurd or based upon magical thinking.
Even if we lived in a world of unlimited resources and with infinite time at our disposal. are critics really suggesting that we should take no notice of known science? Are we to regard Bach Flower Remedies as on a par with ACE inhibitors for high blood pressure merely because neither has been properly evaluated in a randomised controlled trial?
It is true that clinical trials are an essential background to a clinical consultation. This statistical information makes up part of the core curriculum which should be hammered home during medical training.
Factual knowledge of group trials, while necessary, is not sufficient for good practice. The facts must be taken into consideration, but on their own they do not tell the doctor what to do. That decision is a matter of judgement. Inculcating the power of good judgement is a very different problem from inculcating factual knowledge.
Mega-trials and epidemiology provide us with a very valuable refinement, but the wellsprings of medical creativity do not seem to lie in the manipulations of statistics.
Dr Charlton is lecturer in public health medicine at the University of Newcastle upon Tyne.
Dear Sir
I have just seen your editorial in HealthWatch Newsletter no 16
To me, as someone who has been subjected to kinesiological testing of the kind mentioned in your first paragraph, muscle weakening is not a matter of belief but of experience. The practice of placing allergy test substances under the tongue (which can obviously produce a biased result) is not, as you seem to imply, the rule.
The practitioners I know of place them on the abdomen where their identity is unknown to the testee.
In short, what you write leads me to suspect that you don't know much about the procedures of kinesiology and have done nothing to check the validity of its claims. In spite of this, you somehow feel at liberty to adopt the derisive, dismissive tone apparent in your opening questions and later in the same article.
I find this hard to distinguish from the bias and lack of scientific rigour which you frequently deplore elsewhere. You may not realise that such an approach tends to devalue what you have to say on other topics.
David Wade, Tunbridge Wells
Alternative Healthcare: a comprehensive guide by Jack Raso, Prometheus Books (UK), Loughton, Essex. 267 pages: ISBN 0-87975-891-0. £23 cloth
Would you like to know what actually happens when you consult a practitioner of acupuncture, herbalism, Qigong, rolfing, polarity therapy, jin shin do, shiatsu, or dozens of other forms of bodywork or spiritual healing? This book will tell you about it. Mr Raso reports the results of years spent investigating forms of treatment based on the idea that there is a supernatural force-God, vital energy, biomagnetic waves, or whatever-which controls our health and well-being. He is passionately opposed to this view, as a result of his religious upbringing and scientific training.
Von Hugel identifies three stages in the religious development of an individual: institutional, critical and mystical. Development can go wrong if it sticks at one stage without progressing to the next, or if what has been learned in the earlier stages is totally discarded on going to a later stage. It appears that Jack Raso was adopted by a devout Roman Catholic family who over-dosed him in childhood with institutional religion. In his critical phase in college, studying dietetics, he revolted against any form of religious dogma or mysticism, and became an angry Atheist.
In particular he read widely and personally investigated an astonishing range of “alternative” treatments, about which this book is an encyclopedia. He loses no opportunity to castigate the therapists on the grounds that they invoke supernatural forces, which he is sure do not exist, so he is sure that they are defrauding their clients.
I suspect that most members of HealthWatch will arrive at a similar conclusion, but perhaps by a different route. As a Christian, and a scientist, I am sorry that he thinks these two designations are mutually incompatible: I find no difficulty in reconciling a belief in the supernatural with the HealthWatch Position Statement on randomised controlled trials.
My objection to healers who invoke biomagnetic waves arises if they are unable to show, by proper trials, that their therapy actually works. On the other hand, if it can be shown to work, they can invoke little green men from Mars for all I care - we can always check at a later stage on the necessity for the little green men.
The accounts of alternative healers at work, and the biographies of the men who invented their therapies, make fascinating reading. Raso classifies them into “spiritual healing”, “pseudonatural healing” and “physical cultism”, but the boundaries between these seem rather blurred, and most therapists use a mixture of types, and maybe even change their methods from one patient to another.
The book ends with a “Glossary of supernaturalistic methods” which lists about 380 therapies, but some are variants of other therapies, and sometimes the same treatment is known by several names. There is also a useful bibliography of publications by proponents or opponents of alternative healthcare.
I think this book is a major contribution to our understanding of what is on offer in alternative healthcare. The examples come from the United States, but no doubt those therapies which have not yet reached our shores will soon do so, and this handy volume will help us know what their exotic designations really signify.
Professor John Garrow MD PhD
In 1993 advertisements in the Daily Mirror promoted a product called 'Autoslim", which (it was claimed) would cause “steady easy weight loss day after day”. As a result of taking this preparation “your body's metabolism will activate and actually start to burn off excess calories and fat". The metabolic situation created was described as a “fat furnace”. Other advertisements in The People promoted “the amazing anti-fat patch” which offered “simple convenient weight reduction for everyone” and was “the amazing alternative aid to slimming reduction”. This effect was said to be obtained by virtue of fucus, an ingredient of seaweed.
Both products were supplied, by mail order only but with a money-back guarantee, from a company called Jacaranda Ltd, of West Walk Buildings, 110 Regent Road, Leicestershire. (The company has since changed its name to Artvent Ltd).
Mr N Cotton, of the Sandwell Consumer Services Section, had the products analysed, and found that the iodine content of the anti-fat patch was lower than the minimum detectable limit of the Public Analyst: it therefore seemed unlikely that significant amounts of iodine (the active ingredient in fucus) would pass through the skin into the customer. He obtained expert advice that even if iodine did enter through the skin this would have no effect on weight loss or metabolism unless the wearer was severely iodine deficient (an unlikely event in the UK), and even in this case the amount in the patch was too little to make any significant difference to iodine status. Autoslim contained trivial amounts of some amino acids, but these were in any case supplied in far greater amount by the normal diet, and would therefore cause no significant change in metabolic rate.
Both products came with a sheet describing “Newton's special diet plan" on which the customer was allowed to eat unlimited amounts of fresh fruit and vegetables, lean meat and fish, but no white bread, cakes, nuts, sugar, sweets, milk, cheese or fat in any form.
A prosecution with 10 alleged offences was therefore brought against Jacaranda (or Artvent) Ltd under the Trade Descriptions Act 1968 Section 1(1)(a) for applying a false trade description, and under Section 1(1)(b) for supplying goods to which a false description was applied.
In addition two alleged offences were brought under Section 23 of the Act that the above offences were due to the act or default of Newtons Traditional Remedies, of 82 Silhill Hall Road, Solihull, West Midlands, who were associated with Jacaranda.
The case was heard in the Sandwell Magistrates Court on 15th December. The counsel for the prosecution was Mr Barry Berlin who told the court that the descriptions were false because the Anti-fat patch or Autoslim had no effect on body weight or weight reduction.
The defence was that the diet advice supplied with the product would cause weight reduction if followed, and the product might motivate customers to keep to the diet.
It was also suggested that the extremely small amount of iodine in the patches might exert an effect as in homeopathy, but this point was not followed up in the final defence submission. In mitigation defence counsel observed that no member of the public had complained about the product, but the case had originated with the Trading Standards Officer, and also that the defendants were not wealthy, and had no previous convictions.
The defendants were found guilty on all of the 12 charges, fined a total of £6000, and ordered to pay the costs of the prosecution, estimated at about £5000.
The case is of importance concerning misleading information about slimming products. Although the claims were misleading, no member of the public in Sandwell had complained to their local Consumer Services Section. If that department had not initiated the inquiry the charges would not have been brought. In this case the court ordered that the costs of the prosecution must be paid by the defendants, but that is not always the situation, so Trading Standards Officers risk spending a substantial amount of their departmental budget on these prosecutions.
If members of HealthWatch see advertisements for healthcare products which they believe are untrue they should notify their local Trading Standards Office. Policies vary locally, but it seems that in some districts no action will be taken unless there is a complaint from a member of the public.