HealthWatch has always been concerned that doctors and patients are able to make reasoned decisions about treatments. Whether these treatments come under the heading of conventional, complementary or alternative therapy is unimportant; what has mattered is whether treatments have been properly tested, or improperly promoted. These considerations will always remain important, but in the next months or years may be overtaken by deeper issues.
Many people do not realise that worries about the ability of the National Health Service to cope with demand are not new. Steroids were first used in the early to mid-fifties and there were worries that they would bankrupt the then infant NHS before it had even reached adolescence. Introduced before the modern era of controlled trials and close surveillance for side effects, steroids were lauded as wonder drugs-which was the worry-but their many and sometimes dangerous side effects prevented the feared widespread use. Since then, there have been many other similar soul-searches, and the last few years have seen discussion in the medical journals and media, but not generally by the politicians, of the need for rationing in health care. Then, just a few weeks into the new year and the new millennium the Prime Minister, Mr Tony Blair, admitted in the television programme Frost on Sunday that the NHS was underfunded.
In the following days much was made of whether Mr Blair's extra money was a promise or an aspiration. But we're still in the stage of knee-jerk response, and it is extremely important that influential voices in medicine now take the discussion firmly into the public forum. We need seriously to consider, as dispassionately as possible, what we want our NHS to do for us. Even before Mr Blair's Sunday promise, the Secretary of State for Health, Mr Alan Milburn, was giving us more cancer specialists and cardiac surgeons. This is better than the previous, misplaced, concern with waiting lists, which Labour inherited from the Conservatives but should have had the courage to reject, but it still ignores the important question. It is also a simplistic response to the difficulties faced by those specialties. For a government so keen on stressing the need for evidence (with which HealthWatch has no quarrel), it is illogical to demand a two week target for all people suspected of having cancer to be seen by specialists; and strenuous efforts to reduce the incidence of heart disease might be a better solution than more surgeons to unclog arteries. Asking for several more hundred oncologists and cardiac surgeons presumes that the extra medical students admitted to medical schools in 2005 (or whenever the schools will have the expanded capacity) will want to go into those specialties when they eventually graduate and choose their career paths. The consultants cannot stand alone: oncologists need radiographers, physicists, and chemotherapy nurses; cardiac surgeons need anaesthetists, cardiac pump bypass technicians, and intensive care beds. Both groups need offices and wards.
The same bed crisis that took Mr Blair to David Frost brought the intensive care physicians into the public gaze. The nearest available bed to London was somewhere in the Midlands. Mr Milburn had announced 100 extra ICU beds but the Intensive Care Society, which is a well organised group, could not actually identify these beds. No sooner had the oncologists, cardiac surgeons and intensivists felt their messages had been understood than another group of doctors, the neurosurgeons, started agitating. The Society of British Neurological Surgeons declared that many units do not have enough surgeons, are working beyond safe limits, and do not have enough beds. It was not long before the ophthalmologists complained they had too many cataracts to deal with and the orthopaedic surgeons declared that patients with fractured necks of femur were getting a raw deal.
Is there a specialty that believes itself over-staffed? There is no single, simple reason why the NHS is so over-stretched. The apparent suddenness is an artifact; there is a crisis now because the politicians felt forced into it and the media took it up. In reality, little has changed materially in the NHS over the last few years. The politicians could have declared crisis at any time but chose to ignore it. It was unlikely to go away. It certainly will not do so now, in case the politicians hope that soothing words and distant promises are all that is needed.
Declarations of billions of pounds are all very well, and Chancellor of the Exchequer Gordon Brown's budget is extremely welcome, but we need more than that. Not more money, but deeper thought. More and more older people now live on their own. More and more married women go out to work. How can the sick and the dying stay at home? Where are the convalescent beds that I discharged my patients to when I was a surgical house officer in the 70s? The British Medical Journal has taken up the cudgels for ageism1, and there was a case report in the British Journal of Anaesthesia of a 113-year-old admitted to the ICU. Before the ethicists and the geriatricians persuade us that everyone of whatever age has full medical treatment as a right (accepting that decisions cannot be based solely on chronological age), we need to realise the consequences of ICU beds being filled as soon as they are available.
HealthWatch likes to think that it has been one of the influences towards better appraisal of medical treatments (HealthWatch Newsletter issue 36, Chairman's report). Whenever we get the chance, we must not overlook chances to discuss the wider issue of the purpose of these medical treatments. Otherwise, reasoned decisions from good clinical research will become less and less relevant to an ever more dissatisfied NHS workforce, who are beginning to feel even worse off than the Red Queen. She, by running, was at least able to stay in the same place.
Neville Goodman
Consultant Anaesthetist Southmead Hospital, Bristol
Reference
Tonks A. Medicine must change to serve an ageing society. BMJ 1999; 319:
1450-1451.
We have been pleased to welcome to HealthWatch's growing membership the journalist and former broadcaster John Diamond.
In recent years Diamond has written frankly about his personal experience of the cancer which has robbed him of his ability to speak. An advocate of clinical trials, and of a rational approach to medicine, in his articles he is frequently outspoken in his criticism of the complementary faddists who bombard him with advice.
See John Diamond's address to the 2000 AGM in Newsletter no 40, and the obituary notice in Newsletter no 41
Doctors at the Department of Neurology, Lariboisière Hospital, Paris, France cite the case of a 33 year old airline baggage handler - a fit non-smoker - who sustained an extensive stroke after regularly taking high doses of "energy pills" containing MaHuang extract, caffeine and ephedrine, along with high doses of creatine, to enhance his athletic prowess as a body builder.
MaHuang, say the authors, is taken as an energy supplement in certain countries. Caffeine and ephedrine can have adverse effects on the heart, if taken in large quantities, and creatine may act in concert with preparations that affect the sympathetic nervous system, suggest the authors.
Reference
Journal of Neurology, Neurosurgery and Psychiatry 2000; 68: 11-13.
The Science and Technology Committee of the House of Lords is preparing a report on Complementary and Alternative Medicine,
"addressing in particular the issues of training and regulation, and of provision within the NHS in addition to the private sector."
The Committee will produce a report to the House, with recommendations to the UK Government, in autumn 2000.
A controversial prospective trial showed that patients on the regimen survived three times longer than the standard.
Straus is distinguished for his previous work on, among other things, the virology of chronic fatigue syndrome.
Other NCCAM trials will look at the alternative medicines for which there is already some evidence of efficacy-St John's Wort for depression, Ginkgo biloba extract to prevent dementia in the elderly, and glucosamine and chondroitin for knee osteoarthrosis.
Reference
Nature 2000; 6 (3): 240.
For further details please contact Julie Hutcheon at the Institute of
Nanotechnology
Tel: +44 1786 447520
Fax: +44 1786 447530
email julie@nano.org.uk
website: http://www.nano.org.uk
An anecdote from China dating back to the 5th century tells the story of the governor of the province of Luzhou and his painful shoulder. The problem particularly annoyed him because it interfered with his archery, and the celebrated physician Zhen Quan was summoned.
After examining the governor, the physician told him to face the target with his bow and arrow and take aim. As he did so, Zhen Quan stood behind him and thrust a needle in the acupuncture point on the tip of the shoulder. The response was dramatic and immediate: the arrow flew straight to the bull's-eye and the governor was cured of his pain.
The history of acupuncture is filled with colourful tales of this type-but anecdotes are no longer sufficient to persuade us of the effectiveness of therapeutic interventions. Today, we want evidence-based medicine.
Is there evidence that acupuncture works? The answer is yes. It is probably more effective than most sceptics want to admit, but it is also less so than many enthusiasts realise.
Traditional acupuncturists believe that our bodies are governed by a life energy flowing in channels called meridians. This energy is a balance of opposing characteristics, called yin and yang. Every illness is understood as the expression of an imbalance between yin and yang. One way of re-establishing the balance is to insert needles in acupuncture points located along the meridians.
Instead of needles, other means of stimulation can be used-such as pressure, laser light, electrical currents or heat. Neither the meridians nor the acupuncture points have been identified scientifically and, because the concept of yin and yang is more an ancient philosophy than a fact, critics have always insisted that no sound scientific rationale of acupuncture exists.
In the early 1970s, when President Nixon visited China, this situation began to change. One member of his entourage fell ill and required immediate surgery. His pain during and after the operation was controlled by acupuncture. Back home in America, he publicised his extraordinary experience widely and this sparked off a flurry of research.
As a consequence, we now have a reasonable understanding of how the treatment might work. The theory is that acupuncture activates certain areas in the brain thought to be involved in pain control, releasing transmitter substances that have powerful effects on pain perception.
Such lines of research opened up new ways of thinking about acupuncture and led to the emergence of "Western" or "scientific" acupuncture. There are considerable differences between traditional Chinese treatments and the Western variety. In the former, conventional diagnoses are not normally sought and treatment is usually tailored according to each patient's particular yin/yang imbalance.
Western acupuncturists do not personalise treatment to that extent, but direct it at the conventional diagnosis established beforehand. While traditional acupuncturists tend to view acupuncture as a "cure-all", Western acupuncturists strive to discriminate between those ailments for which it is helpful and those for which there is little positive evidence.
Hundreds of clinical studies have been carried out to determine whether acupuncture works for certain conditions. Studies of this type are fraught with numerous problems.
What, for instance, is an acceptable "placebo" (dummy treatment) for an intervention therapy such as acupuncture? It is hardly surprising that the findings are not uniform.
While it is tempting to pick out those trials that confirm one's beliefs, it is also obvious that this can be grossly misleading. The fairest way to evaluate acupuncture is not by the results of a single clinical trial, but through a detailed summary of all trials published to date, regardless of their results-an exercise scientists call "systematic review". About 20 systematic reviews have been published.
Based on such evidence, we are now reasonably sure that acupuncture is effective for back pain, dental pain, migraine and nausea.
Other systematic reviews have shown inconclusive overall results. Either the findings of reliable studies were contradictory or the majority of the trials were too flawed to be reliable. Ailments for which this is the case include addictions (other than nicotine), asthma, headache, inflammatory rheumatic conditions, neck pain, osteoarthritis and stroke. Finally, two systematic reviews show that for giving up smoking or weight loss, acupuncture is no more effective than a dummy treatment.
It is interesting to compare this evidence with the results of surveys assessing the complaints acupuncturists actually treat.
Traditional acupuncturists in this country see mainly patients with musculoskeletal problems, emotional and psychological problems, arthritis, "low energy" and digestive problems. Western acupuncturists treat musculo-skeletal problems, pain in general, neurological conditions, allergies and addictions, as well as ear, nose and throat conditions.
And what about safety? The public often believes that complementary therapies are inherently risk-free and acupuncture is no exception. Yet there are numerous accounts of minor adverse effects associated with the treatment.
Discomfort or pain during the procedure or slight dizziness and tiredness afterwards are probably the most common complaints. Much more serious complications are also occasionally reported: trauma through needling and infections where non-sterile needles have been used.
These events are most likely to be genuine rarities, but more research needs to be done to be absolutely sure. With proper training of all acupuncturists, the incidence of serious adverse effects could probably be reduced even further.
So, what is the bottom line? Does acupuncture do more good than harm? The best evidence available to date is positive, but it also shows that acupuncture is not a "cure-all". More research is needed to define when it might be dangerous, when it is harmless-but also not helpful-and when it offers more benefits than conventional medicine.
Edzard Ernst
Director of Complementary Medicine
University of Exeter.
Further reading:
Acupuncture: A Scientific Appraisal, A White, E Ernst (Eds)
(Butterworth.Heinemann, 1999).
See also the review of this book in Newsletter no 36
The warning came just weeks after the Irish Medicines Board made St John's Wort a prescription-only drug because of safety fears.
An estimated two million people in the UK have now tried St John's Wort (Hypercium perforatum, sometimes known as "nature's Prozac") for the treatment of mild to moderate depression, and the market is expanding rapidly.
The Committee on Safety of Medicines (CSM) has now advised the public to seek the advice of their doctor or pharmacist before taking St John's Wort with other medications-whether prescribed or bought from a pharmacy. People who are not taking other medicines, however, can take St John's wort safely.
Recent studies have shown that St John's Wort can affect drug metabolism, speeding up the rate at which other medicines are broken down in the liver and reducing their effectiveness. It can also add to the effect that some drugs (for instance, prescribed anti-depressants) can have on the brain, triggering adverse reactions.
Herbal remedies do not need to be licensed, and as such cannot make any claims to be clinically effective, but manufacturers and herbal practitioners say this also stops them from printing adequate advice about products. The Medicines Control Agency is holding discussions with herbal practitioner organisations and trade associations on the information that should be made available with unlicensed herbal remedies containing St John's wort.
Two research letters published in the Lancet in Febuary illustrated the danger of interactions between St John's Wort and the pharmacological processes involved with HIV and heart transplant treatments, respectively.
In one research letter Stephen Piscitelli and colleagues from the US national Institutes of Health, Bethesda, USA, evaluated the effect of St John's wort on plasma concentrations of an HIV-1 protease inhibitor called indinavir and its effect on 8 volunteers who were non-HIV positive.
Their study showed a large reduction in blood plasma indinavir concentrations due to the pharmacological interaction with St John's wort. These results have important clinical implications for HIV-infected patients receiving these two agents since low plasma concentrations of protease inhibitors are a cause of antiretroviral resistance and treatment failure. In a second research letter Frank Ruschitzka and colleagues from University Hospital, Zurich, Switzerland reported acute rejection in two heart transplant patients due to a metabolic interaction of St John's wort and the drug cyclosporine. They observed two patients who had previously undergone heart transplant and were later admitted to hospital three weeks after taking St John's wort to alleviate symptoms of mild depression. St John's wort lowered the plasma cyclosporine levels; subsequent cardiac biopsy revealed acute heart transplant rejection. Withdrawal of St John's wort resulted in a return to normal cyclosporine levels and no further episodes of rejection occurred.
Reference
Lancet 2000; 355: 547-8.
On the other hand, are we to assume that those who sell the various praiseworthy alternative remedies propounded in this book, and indeed those who publish books of this kind, are not motivated by profit, but are pure altruists? At one point we are actually told that the US Food and Drug Administration exists [solely] to protect big pharmaceutical business and giant food technology industries-try telling that to a company seeking regulatory approval for a new drug or food additive.
"The FDA goes cheerfully on its crooked way, ruining decent doctors, holding back decades of progress".
We are told that prescription drugs are a major cause of death, and that orthodox medicine has failed us in health promotion-this latter is something that we can accept to a considerable extent. I cannot accept that the solution is to dynamite medical schools. Nor can I accept that medicines are designed to kill.
Throughout there is what might be praiseworthy scepticism, were it not so obviously against everything that is accepted by the scientific and medical establishment: ischaemic heart disease is not caused by, or even related to, cholesterol; there is no evidence that coronary bypass surgery does anything to help "in the long term" (how long is not stated); AIDS is not caused by HIV-indeed the killer is the drug AZT (manufactured, of course, by a multinational pharmaceutical company), not the virus; psychoanalysis and antidepressant medication are roundly condemned (but megavitamin therapy is praised); antibiotics "should never be taken except in extreme emergency, and not without the protection of plain Lactobacillus acidophilus yoghurt". Vaccination and genetically modified foods are obviously attacked, as are pesticides, monosodium glutamate and aspartame (both "potent neuroexcitatory toxins") and lead-free petrol ("more than half a litre of unleaded fuel is not petrol [but] a brew of aromatics [that are] carcinogens and cause leukaemia").
The conspiracy theory really takes off in the discussion of the ban on tryptophan supplements for treatment of depression and sleep disorders in 1990. We now know that the problem (an apparently auto-immune disease, the eosinophilia-myalgia syndrome) was caused by a trace contaminant in a single batch of tryptophan, manufactured using a different strain of micro-organism from that used previously-here we are told that it was genetically modified tryptophan. Before the cause of the problem was known, FDA (and other regulatory authorities) demanded withdrawal of all tryptophan supplements-but here we are told this was because Prozac was granted a product licence as an antidepressant four days later.
We are told that perfumes are based on petrochemicals, so wearing perfume is equivalent to breathing in traffic fumes all day-would that I was exposed to only the fumes from a few drops of petrochemicals as I cross the road.
Electromagnetic radiation causes brain tumours (but see many articles on this subject in HealthWatch Newsletters, and the December 1999 report from Doll et al that there is no evidence at all of any association) so we are advised to keep the (electric) alarm clock on the other side of the room-good advice if you are a heavy sleeper who, like me, can silence an alarm clock without being woken, unless you have to get out of bed to switch it off. We are told that electricity keeps flowing in the wires and apparently we can buy a "demand switch" which keeps the electricity in the intake board until something is switched on.
Homogenised milk is especially dangerous. The droplets of fat are "small enough to be absorbed", whereas with unhomogenised milk "when the body had taken up all the good stuff. it wanted to, fat particles were too large to be dealt with so they passed harmlessly out. Now the body is faced with another alien substance". However, in a previous chapter we are told how good butter is (in the context of heart disease), and how harmful margarine is. Indeed, we are advised to eat lots of butter. We are also given a recipe for a "safe" infant formula-based on raw milk. Surely the hazards of unpasteurised milk are considerably greater, especially for an infant, than any supposed adverse effect of pasteurisation.
We are told that since we evolved the oxygen in the air has "decline drastically" from 30% down to 19%, which in cities can be reduced to 12% or less, and "oxygen deficiency is a major cause of disease." The answer, apparently, is to take 1-3 drops of 35% hydrogen peroxide in a glass of water (distilled, because no water is fit to drink, and never allowed to come into contact with evil plastic) daily. This will "put the oxygen back in our bodies". By my calculation, an average person consumes 500 litres of oxygen per day, so a few drops of hydrogen peroxide will scarcely be noticeable, even if the remainder of the hypothesis is valid.
If you are concerned about the effects of mercury stored in your body as a result of mercury fillings in your teeth ("and we've all got it if we have four or more fillings") then you are advised to take substantial quantities of vitamin C or N-acetylcysteine, or try intravenous chelation therapy (with EDTA) "which will have the added bonus of cleaning your arteries out at the same time". In an earlier chapter we are told that coronary bypass surgery is useless, and we should undergo chelation therapy to treat the atherosclerosis that is the result of the trans-fatty acids that are [deliberately] put into margarine, and being hard have nowhere to go except the blood vessel walls.
We are told that the artificial sweetener aspartame is 50% phenylalanine (correct) compared with 4% in meat and other proteins (again correct)-but we are not told that we consume only milligrams of aspartame, compared with tens of grams of protein. In any case, this is apparently not the problem-it is the 10% "methyl alcohol" in aspartame that is dangerous. (Aspartame is methyl-aspartyl-phenylalanine). America's "epidemic of multiple sclerosis and systemic lupus" is attributed to this "methyl alcohol" in aspartame, as is Gulf War syndrome (soft drinks were apparently left on pallets in full sunlight, releasing methyl alcohol).
David A Bender
Dept of Biochemistry & Molecular Biology University College London
The symptom began between 9.30 and 10 am on the morning of Friday, August 12th, 1983, during treatment by a Cranial Osteopath. I had consulted him for relief of similar pain that I had had-since 1958!-on the RIGHT side of my head; and he was seeking by manipulation to improve the alignment of the bones of my head and the pulsations of my cerebro-spinal fluid, and even to remove obstructions from my Eustachian tubes! So, at least, he said.
After several months of both left-sided and right-sided pain, my old right-sided pain subsided. But it has since returned. So now, thanks to Cranial Osteopathy, I have not only the original right-sided pain but left-sided pain as well. If there is anyone out there who still thinks that Fringe Therapies have no harmful side-effects, I urge them to think again.
Driven by increasing desperation, I returned in the next four years some twenty times to the Cranial Osteopath who had injured me. He could not undo what he had done. Finally, in despair, I offered him £1000 for as many-or as few-sessions as it would take to cure me. He was happy to accept my offer, but kept me waiting all the afternoon in his consulting room.until I realised that he had scruples about taking my money. I got dressed, went home, and wrote to thank him for what might have been the most generous act-or non-act-of his life.
I also consulted other Cranial Osteopaths and Cranio-Sacral Therapists, and even a Craniopath (the Chiropractic equivalent of a Cranial Osteopath). Some said they knew what was wrong and tried to put it right, unsuccessfully. Others said they could find nothing wrong with me-cranially, at least.
At the same time I complained about my injury to the Register of Osteopaths and to anyone else who would listen. Eventually, for whatever reason, my Cranial Osteopath was struck off the Register. Unfortunately, all that meant was that whereas he had hitherto practised as DO, MRO he thenceforth practised as DO (Diploma in Osteopathy) only. To the best of my knowledge he continued to ply his trade until his death several years ago.
Those are the bare bones of my story. To put flesh on the bones, a bit of context is needed. Before my Therapeutic Adventure with Cranial Osteopathy I had tried a great variety of treatments. Of these, only two were really Orthodox. Dentistry provided me with several appliances intended to improve my occlusion (the way my jaws bit together). Medicine offered me an array of anti-depressants. Neither approach worked; and, in particular, the anti-depressants produced a whole range of unwanted side-effects. Indeed, it was in response to these awful side-effects that I decided to return to Cranial Osteopathy.
I was driven by despair rather than by hope. I didn't really believe that Cranial Osteopathy would work. But I did feel I had to do something. That was my mistake.
In 1962 or 1963 I had the good fortune to consult a young man who, after a brief examination of me, said, "You have Atypical Facial Pain and nothing can be done about it." Some years later I learnt that the young man was one of America's leading neurologists. If only I had had the fortitude to do nothing! I appeal to all readers to consider that therapeutic intervention may be worse-much worse-than useless.
But how to contain the anxiety and despair that a chronic painful condition can produce? My one positive suggestion is that GPs should offer to patients in chronic pain a regular-but infrequent-consultation. Twice a year, perhaps? It would not cost the NHS much; and I for one would certainly look forward to the opportunity to tell my GP how I was faring and learn whether there had been any breakthroughs relevant to my complaint. Knowing my GP would not forget me might have enabled me to stop my ears to the siren song of Fringe Therapy, and given me the strength to do nothing.
Rx, The writer of this article has asked to remain anonymous, but would welcome any correspondence on this issue and can be contacted through the Editor. Please write to: Rx c/o the Editor, HealthWatch Newsletter, HealthWatch, Box BM HealthWatch, London WC1N 3XX or e-mail newsletter@healthwatch-uk.org g iving Rx as the subject.
Any letters will be forwarded to the author in confidence.
See also letter from Richard Pitcairn-Knowles in Newsletter no 38
Sirs, I wonder whether readers of Healthwatch have any comments on the following:
Apparently, some 40 years ago a French ENT specialist, called Alfred Tomatis, "pioneered" a therapy based on auditory stimulation. I never heard of him duri ng my psychiatric training in the UK but recently came accross several websites describing the method of therapy and its indications. References on Tomatis can be found on the Internet at http://www.tomatis.com/index.html.
I don't quite get the gist of the method but it's apparently based on auditory stimulation with various sounds that have been modified electronically. It's claimed to be of use in a variety of conditions, e.g. attention deficit, autism and dyslexia. I would like to find out more about the validity of Tomatis' theoretical claims and clinical results. While I hesitate to be too judgmental, the theoretical basis and therapeutic claims seem somewhat doubtful-however there are apparently quite a number of centres in North America offering treatment with his method.
Dr Karel W de Pauw
Consultant and Senior Clinical Lecturer in Psychiatry
Roundhay Wing
St James's University Hospital
Leeds LS9 7TF
Tel 00 44 113 2065519
Fax 00 44 113 2065803
Email:kwdepauw@talk21.com
But with so much medical information available at the touch of a button how do you tell the authoritative sites from the downright wacky? Crompton gives some helpful tips:
Sites particularly recommended as sources of reliable health information include those run by the UK's large well-known voluntary organisations.
Also worth bookmarking are: