It’s a shame when someone has a good idea but then gets it wrong. Lynne McTaggart is editor of “What doctors don’t tell you”. She wants people to know “facts that the medical establishment and the drug companies would rather you didn’t know”.
Established nearly ten years ago, this view is very much of the moment; the GMC has recently published explicit guidance on informed consent, and under EU legislation patient information leaflets now accompany all prescribed drugs. Patients are demanding more and more information about their diseases and the treatments for them, although it’s an uncomfortable fact that there are patients who do not wish to know this information, or at least not as much information as other people believe is their right.
Celebrating its ten years, “What doctors don’t tell you” published a special 100th issue. “100 ways to live to 100” was their 100 most important tips. It’s available on their website, from which this is a verbatim quote:
“In our view, this advice tends to run counter to what your doctor tells you, but all our tips are backed up by solid medical evidence. These include 50 general tips about diet, supplements, children, your environment and also a final 10 suggestions for your spiritual health. We also included five boxes of 10 tips apiece concerning which medical practices are useless or downright dangerous.”
This is pretty dogmatic stuff. Many of the 100 ways are supported by references to back issues in which the evidence was examined. I could not possibly have wide enough knowledge to judge all 100, and nor was I prepared to read their back issues and make judgements on how comprehensively they had examined the evidence. But my reading is fairly wide, especially on “health scares”. Would I advise a curious patient to look at or subscribe to “What doctors don’t tell you” if they wanted impartial, reliable, medical advice?
Readers have to be sceptical of any claim I make to impartiality, but a quick scan of the 100 tips immediately threw up a contradiction. Tenth of “The 10 useless medical tests” is “Lab tests”, of which “a quarter…produce incorrect results”. Whether this fraction is right or wrong, earlier in the list we are advised to contact two commercial laboratories who will test your “digestive capacity” to check whether you are producing enough stomach acid. We are also advised to “get yourself tested by a knowledgeable nutritionist” before taking vitamin supplements. Why should these tests be any more reliable than other laboratory tests?
Beyond this contradiction, I had a more general concern, encapsulated in that bald heading, “The 10 useless medical tests” and its all-inclusive sub-heading, “Lab tests”. There is a good case for warning patients that medical tests are not infallible. Breast and cervical screening have brought the issues of false positives and false negatives into public scrutiny, and Lynne McTaggart has good advice on both these issues. But screening is not—generally and absolutely—useless, and lumping all laboratory tests together and attaching any figure for overall accuracy is wholly misleading. What is more, the first “useless test” is blood pressure. There might be argument about how to define high blood pressure and what the treatment threshold should be, but it is beyond doubt that excessively high blood pressure kills.
So with what else do I take issue? The 50 general tips include sensible advice on a general and varied diet. There is some advice I would describe as cranky, but it seems otherwise harmless. Then we are told that “Unlike our forebears, we live in a highly processed, polluted, allergic world” and are advised that “it’s almost certain that you have vitamin deficiencies, even on the best diet”. Let’s leave aside that our forebears lived in a far nastier world than we do, in which half of them were dead before they were 40; it is not true that vitamins need to be added to a “best diet”. This “almost certainty” is introduction to 10 suggestions for various dietary supplements, which includes strong advocacy for vitamin C’s ability to stop cancer spreading. This sort of thing enrages me: if vitamin C truly stopped cancer, why does Lynne McTaggart and her co-writers think doctors would not use it? We are not all in thrall to drug companies’wishing us to prescribe expensive chemotherapy, and in aspirin we are happy to prescribe a dirt cheap drug to all sorts of advantage.
The next section is “Your healthy house”, including the risk of leukaemia from power lines, and unnamed risks from other sources of electromagnetic force such as electric blankets and computer batteries. These risks, if they exist at all (see Healthwatch Newsletters issue 27, October 1997; issue 24, February 1997; issue 23, October 1996 and issue 21, April 1996), are tiny.
In the next section, “Your healthy children”, government reassurances about MMR vaccine and autism are dismissed because of research (the most recent of which fails to support the claim of causation) and the large numbers making claims (an argument that takes account only of those who believe they were affected, but tells us nothing of the real incidence). Vaccination levels are falling, and the infections are increasing: an epidemiological research project is in progress. I hope Lynne McTaggart is right: much better not to have to vaccinate if it really is unnecessary, but I fear she will be proved wrong.
One of the “Top 10 medical myths” is that mercury in dental fillings is harmless. We are warned that, “Numerous studies in animals and humans demonstrate that mercury particles and vapours are a timed-release poison…” A recent report (The future of dental amalgam, Stockton Press), which is probably the basis of the Guardian’s report (13 April 1999, G2), concluded that “large-scale studies have found no evidence of health risks” and that the greatest risk is environmental contamination from incorrect disposal of waste amalgam-originally, no doubt, the fillings of the worried well.
So even though “What doctors don’t tell you” advises wariness of steroids, and thinks Prozac is not all it’s cracked up to be, and suggests not going to the doctor with simple fevers, infections or backache, and thinks an exercise programme you enjoy is worthwhile, and believes many hysterectomies and cholecystectomies are unnecessary, and warns that blood transfusion can be dangerous, I cannot recommend it to a curious patient. “What doctors don’t tell you” is a good idea (even if the title makes me uncomfortable). Its implicit message that conventional medicine is wrong and doctors are not to be trusted, but that alternative and natural treatments are right, is just plain wrongheaded. But who am I to judge, when more people visit alternative practitioners than visit GPs? That doesn’t mean they’re right: in my view, it shows merely that you can fool most of the people most of the time.
Dr Neville W Goodman
Consultant Anaesthetist Southmead Hospital Bristol
Michael Allen, a longstanding member of the HealthWatch committee, has been appointed HealthWatch’s press officer and promises a speedy and authoritative response to all media enquiries.
Journalists looking for an expert to interview on subjects related to complementary medicine or the assessment and testing of health therapies may contact Michael Allen by telephone or fax on 020 8789 7813.
A common difficulty with these studies, argue Sloan and coworkers, is that the researchers do not take into account factors other than religious faith that could explain their results. For example, four different studies found that members of religious orders—priests, nuns, and monks—had lower rates of death and disease than lay people. But these men and women, because of the rules of their orders, are less likely than lay people to smoke or drink alcohol: factors that could explain why they tended to be healthier. Another study found that people who went to church regularly were healthier than those who did not, but this study may only prove that healthy people are better able to attend church than those who are ill.
The results of the better-designed studies are inconsistent, say Sloan and colleagues. One study, for example, found that having “religious comfort and strength” seemed to reduce a patient’s risk of death after heart surgery. However, in the same study, other frequently used measures of religiosity, such as church attendance, did not seem to help. Given such inconsistent results, the researchers argue, it is hard to say what effect—if any—religious belief has on health.
Lancet, February 20, 1999
“The Surgery Room” (1–2 November) will examine how developments such as robotics, virtual reality in the operating theatre, tissue engineering for spare part surgery and novel material design for tissue repair, could combine to produce the surgical environment of the future. It will include a presentation by Dr Jim Gimzewski from the IBM Research Laboratory in Switzerland, who led project groups that have created precision instruments such as amplifiers and manipulators on a molecular scale.
Another area that is set to be revolutionised by new technology is diagnostics. New ways to identify the cause of illness, and create and prescribe drugs, will be the subject of “The Diagnostics Centre” (3–4 November). Topics to be covered will include the development of bioprocessor chips for clinical diagnostics and cell therapeutics; the applications of high throughput screening to DNA analysis; and software support for new developments in diagnostics.
The conferences have been prompted by themes from the Royal Academy of Engineering’s white paper, “Medical Engineering—a field with potential”.
For further details contact the Institute of Nanotechnology by telephone on 01786 447520; fax on 01786 447530; visit the Institute of Nanotechnology web site or send an e-mail info@nano.org.uk.
The study, published in the June 3rd issue of the New England Journal of Medicine, found that women who started to use alternative medicine after breast cancer surgery experienced more depression, anxiety, and number and intensity of physical symptoms than did their counterparts not using alternative medicine.
The study was based on surveys of 480 women in Massachusetts diagnosed with early stage breast cancer. Women were asked about their medical treatments, quality of life, and use of alternative medical practices in the year after their breast cancer surgery. The study found that 28% of these women began to use such alternative therapies as herbal medicines, megavitamins, acupuncture, spiritual healing, chiropractic, and homeopathy. These practices were “complementary” to standard medical care, and not treatment “alternatives.”
An important observation was that 71% of patients told their doctors about their use of alternative therapies. In the future, doctors might use the start of alternative therapy as a cue to ask patients about symptoms of anxiety, depression or physical complaints. “As a group, women who started to use alternative therapies reported more distress in the wake of their diagnosis, which suggests to us that alternative medicine might be an important marker for identifying vulnerable patients who need more help,” comments Dr. Harold Burstein, a study co-author and fellow at Dana-Farber.
New England Journal of Medicine 3rd June 1999
The mailing, issued by Prospect House Publishing, claimed the course would teach you “How to earn £100 000 each year from your Hypnotism business”, with a repertoire that could include knowing, “how to hypnotise the ENTIRE audience” and “hypnotising people without their consent”. Healthy applications of hypnotism would also be included in the course, apparently, “The technique…is one of enabling the successful treatment in ONE session, any problem presented to you. From simple habit cessation, to treating terminal cancer.” When challenged by the Advertising Standards Authority, the advertisers did not provide substantiation for any of the claims. They were asked not to repeat them and agreed to take copy advice for future ads.
Yorkshire residents were alarmed recently by a leaflet that fell through their letterboxes, announcing,
“DO YOU DRINK TAP WATER? You Could Be Damaging Yours and You Families (sic) Health!…Did you know that the water you drink straight from the tap could be very dangerous to your health (Channel 4 Dispatches Documentary). A number of people have taken in, possibly through tap water, a parasitic micro organism called cryptosporidium which causes severe stomach problems, in some cases for years, and has been known to cause death. Samples of water in many areas in the UK, Yorkshire being a particularly bad area, have been shown to be contaminated with cryptosporidium cysts which can cause serious health problems and can be drunk unknowingly by you or your children!!!”
The advertisers, EHSP of Harrogate, who were promoting a water purification system, attempted to support their claims with a copy of the Drinking Water Inspectorate’s 1997 Report on Yorkshire Water. The ASA, however, understood that the Report stated that very low levels of cryptosporidium were found at three water treatment sites in 1997 but that there were no associated outbreak of illness in the communities supplied by the works. The ASA considered the leaflet misleading in suggesting that drinking tap water could damage health, and that it appealed unnecessarily to recipients’ sense of fear—EHSP were asked to withdraw the leaflet.
ASA Monthly Report June 1999
Thousands of people, mostly elderly, are admitted to hospital each year with upper gastrointestinal bleeding, the commonest serious adverse effect of non-steroidal inflammatory drugs (NSAIDs).
Dr Herxheimer surveyed product information leaflets for 29 major preparations of NSAID including well-known brands such as Brufen 400, Ponstan and Voltarol.
Only four of the 29 leaflets made it clear that an NSAID only relieves symptoms, leaving the course of the disease unaffected. Thirteen leaflets omitted to mention the need to discontinue taking the drug if stomach symptoms occurred; a further ten only advised stopping in the event of serious bleeding. And none discouraged patients from using higher doses to achieve complete relief rather than accepting alleviation at a safer dose. The Medicines Control Agency and manufacturers should act urgently, says Herxheimer.
Reference: Herxheimer A. Pharmaceutical Journal 1999; 262: 559–561.
Established as a Special Health Authority, NICE has its own corporate and legal identity with direct responsibility to the Secretary of State for Health and Secretary of State for Wales. The aim is to provide health professionals in the NHS with clear and robust advice to allow them to give high-quality clinical care and cost-effective care to their patients. The Institute is chaired by Professor Michael Rawlins, of the Wolfson Unit of Clinical Pharmacology, University of Newcastle, who believes there is abundant evidence that the clinical care given to patients too often departs from best practice.
Its recommendations are not mandatory but there is an expectation that its recommendations on technologies will be universally accepted. NICE is concerned with priorities, that is, the allocation of resources to some categories of individuals before others on the basis of need.
In a recent editorial Richard Horton, editor of the Lancet, commented, “Perhaps the greatest opportunity that NICE presents is to alter the existing balance of information available to patients and doctors in favour of the patient. NICE has all the prospects of being an important and valuable agent for change in the NHS.”
In 1997 Professor Di Bella, an 85-year-old physician, launched an intense campaign to persuade the medical establishment of the efficacy of his cancer treatment, which consists of fixed selection of hormones and vitamins, plus other drugs added according to the individual’s needs. Reports claimed high cure rates, although Di Bella never released detailed results. The Italian Health Minister refused to allow use of this treatment in state hospitals, but public pressure led to the start of controlled (phase II) trials.
As we reported last year, the committee of international cancer experts invited by the Italian Government to test the remedy concluded that (as most doctors might have suspected), the treatment is ineffective and possibly harmful. But what kind of expectations did the patients have for such treatments? Dr Rudolfo Passalacqua of Parma, Italy and his colleagues decided to study patients’ reactions and expectations before the trials started. 1300 patients from cancer centres across Italy were sent questionnaires, 1120 of which were returned and analysed. The key findings were as follows:
The investigators concluded that campaigns for unproven treatments can be harmful to patients’ expectations and have psychological consequences. They also conclude that when making decisions, patients are looking for hope from the treatment and trust in their doctor, both of which depend on effective doctor-patient communication.
In an accompanying Commentary in the same issue of the Lancet, Professor Giuseppe Remuzzi of Bergamo claims that the whole episode reveals how poorly the mass media understand medical matters, and that there is a profound lack of knowledge among the public of how advances in medicine are achieved.
We knew this already, of course. It should not be surprising that people are easily influenced by media reports—after all, the whole point of the media is to communicate to the general public.
It is also hardly surprising that people struggling to cope with a diagnosis of cancer will wish to grasp at any hope offered, however daft the method, and in these cases the patient is more motivated than ever to believe reports that an individual whose perspective is more balanced might dismiss as hype.
The challenge for doctors is, perhaps, to learn how to communicate to their patients as effectively as—though with more medical accuracy than—their patients’ tabloid newspaper and breakfast TV.
Mandy Payne
On September 18, 1895, a janitor who was troubled by his loss of hearing went to consult Daniel David Palmer. Palmer manipulated the man’s spine and his hearing was restored. Further successes with his novel treatment led Palmer to believe that all human ailments are caused by minute maladjustments or “subloxations” of the spine and that by manipulating the blocked segments, health would be restored.
Since those early days chiropractic-or manual manipulation of the spine-has evolved considerably. Palmer’s theory, however, has repeatedly been revised by his followers and the claims of today are less radical.
In this country, the chiropractic profession is now well established, with more than 1,100 practitioners registered. It even has its own Chiropractic Awareness Week and it will soon be governed by statutory regulations.
But can we be sure that chiropractic treatments really work? When seeing a new patient, chiropractors take a medical history and conduct a thorough physical examination. In addition, X-rays of the spine are frequently taken. Treatment can consist of a variety of manual techniques that are broadly categorised into “manipulations” and “mobilisations”. Manipulations consist of high-velocity thrusts to the spine, while mobilisations are more gentle. One important difference between the two is that while the gentler movements still leave the patient in control, the high-velocity thrusts are applied so quickly that the patient has no time to react and so cannot block excessive movement of the spine. The chances of injury are, therefore, considerably greater.
Chiropractic treatments are most frequently used to treat neck pain and tension headache as well as low back pain. Back pain is particularly important: most people suffer from this condition at some time and the costs—both financial and in terms of human suffering—are immense.
The questions that every potential patient wants answered are, of course: is chiropractic an effective treatment and is it safe? This is one area of complementary medicine in which a substantial number of clinical trials have been conducted, but their results have been surprisingly contradictory.
A British Medical Research Council trial produced positive results but, rather than consider a single study, a more objective approach is to base one’s judgment on systematic reviews-on analyses that summarise all clinical trials, whatever their outcome.
Several such systematic reviews have recently been published for chiropractic as a treatment of neck pain and tension headache. None demonstrates beyond reasonable doubt that chiropractic interventions are effective in treating these conditions, and none shows that chiropractic is superior to other treatments—for example, physiotherapy or drugs.
But, while these reviews do not confirm the treatment’s efficacy, neither do they establish that chiropractic is ineffective for these conditions; they merely suggest that, currently, there is insufficient evidence to draw firm conclusions.
As for low back pain, the most authoritative and up-to-date systematic review was published in 1996 by a team of Dutch experts. Most disappointingly, it comes to similarly negative conclusions: “The available randomised clinical trials provided no convincing evidence of the effectiveness of chiropractic for acute or chronic low back pain.” Again, this by no means indicates that chiropractic is not useful for treating low back pain. It does, however, mean that we need more clinical trials to prove or disprove this point.
As for safety: it is essential for any medical treatment—orthodox or complementary—to weigh the potential benefits carefully against the potential risks. Only if the former outweigh the latter does it make sense to employ the proposed therapy.
Many chiropractors try to assure us that their treatments are almost free of risks. Regrettably, little compelling evidence is available at present. Two Scandinavian studies recently published provide some of the best evidence to date. They suggest that about half of the patients seen by chiropractors will, at some stage, experience side effects. These tend to be both transient and mild—for example, temporary increase of pain after treatment.
In addition to these mild side effects, serious complications have repeatedly been reported in medical literature. Two recent overviews summarised 177 reports of severe complications after chiropractic treatments of the cervical spine and 295 serious complications following manipulation of all parts of the spine.
The most frequently reported problems were arterial dissection or spasm-which can result in a stroke or death-and lesions of the brain stem. Others included cerebral injury, spinal cord injury, thrombosis and joint dislocation, hernia and nerve paralyses. In 32 of these cases, the outcome was fatal.
The most serious problems arise almost exclusively with manipulation of the neck; mobilisation is shown to be much safer. The authors of one review go so far as to advise that “referral for spinal manipulation therapy should not be made to practitioners applying rotary cervical manipulation”.
These statistics and reviews might sound alarming, but the figures have to be seen in the right context. Considering the huge number of chiropractic treatments that are performed worldwide every day, the number of cases going badly wrong is small.
Side effects are probably less frequent than those of conventional drugs (for example, painkillers) taken for the same condition. On the other hand, the figures might represent the tip of the iceberg; under-reporting of side effects and complications of chiropractic is believed to be high. The truth is that, at present, the real frequency of such events remains unknown.
All this leads to the inevitable conclusion that the merits of chiropractic cannot, at present, be fairly estimated; our knowledge is still too incomplete.
The burden of proof that their treatment does more good than harm lies clearly on the shoulders of the chiropractics; compelling evidence from them is needed. This, it seems, is the challenge to be remembered at the conclusion of Awareness Week.
Edzard Ernst is professor of Complementary Medicine at the University of Exeter
Dear Sirs Ever since my 37 year old wife’s sudden and unexplained death which I was able to connect to her use of a herbal diet tea sold as a food but which contained herbal laxatives and diuretics, I have become very active in trying to make both the public as well as the medical community here in the US realise that herbal products and dietary supplements sold in this country cannot necessarily be considered safe simply because they are labelled “All natural”. As a result of my efforts, the state of California has enacted an emergency regulation requiring that warnings be placed on these kinds of products. The FDA also did a study and wrote about their findings in the FDA Consumer.
In short, I share your view that the public needs information about these products to make intelligent choices. Unfortunately, in the US there is very little by way of laws that requires that this information be made public. As you may know, the FDA does not test nor does it require any tests before a dietary suplement can be sold. Individuals who sell these products do not need a license or proof that they know anything about the ingredients used in these products.
Recently, for example, I obtained proof that at least one company is adding synthesized ephredrine HCl to its dietary supplement. This same company has received over 3500 consumer complaints that were never reported to anyone.
Yours faithfully CHRIS GRELL
Dear Sirs On Wednesday 3rd February The Times published an article from Hong Kong. Old Hong Kong, it is stated, prospered from its manufacturing industry. Southern China and other parts of South-East Asia now compete, and Hong Kong is looking for new outlets. The article suggests that there are ambitions to launch Chinese traditional medicine as an important new product for Hong Kong.
Let us hope that this will not lead to a large export of ineffective medicines.
Yours faithfully GUS PLAUT
“There’s one born every minute, and two to take their money.”
…attributed to Phineas T. Barnum, founder of the famous circus. Sent by HealthWatch member Caroline Richmond.