The other week I wrote a piece in one of the papers I write for, about alternative medicine. If any of you have read more than four newspaper pieces with my name attached to them then the chances are that one of them was about the intellectual folly which is alternative medicine. I must have written that piece a hundred times now in various forms and the routine has become pretty standard: the true nature of scientific endeavour, the infallibility of the properly designed controlled experiment, the futility of purely anecdotal evidence-well, you all know how it goes.
This time among the outraged correspondence that these pieces invariably attract was a letter from a man in Liverpool. He'd read my piece and it had upset him. For he was a practitioner in alternative medicine and knew it worked. And what's more, he said, he also knew that orthodox medicine simply didn't work. He didn't say it didn't work as well as doctors thought it did, or as well as patients were suckered into believing it would by the grasping medical establishment. No: he was quite certain. Orthodox medicine is a complete sham. It just doesn't work.
He'd included an e-mail address on the letter and-what can I tell you? I was in front of my computer screen, I was bored with whatever it was I was writing-probably yet another piece on the intellectual folly that is alternative medicine-and I e-mailed him. Getting into e-mail arguments about alternative medicine on the internet is as foolish a waste of time as-well, getting into arguments on the internet about gun control or who killed JFK or any of the other cul de sacs up which internet users regularly disappear. But nonetheless I wrote the message and, fool that I am, pressed the 'send' button.
"If orthodox medicine doesn't work," I wrote, "how come life expectancy since, say, the turn of the century has almost doubled?" In fact I wasn't quite sure of the precise figure, but if my previous arguments with alternative medicine supporters are anything to go by, nor was he. He wrote back what they always write back: the reason life expectancy has increased is because infant mortality has decreased. Take out of the equation all those babies dying before they get to their first birthday, and your average Victorian, with his homoeopathy and naturopathy and Little Liver Pills and Tiger Balm, lived just as long as your 21st century pill-popper.
Up to a point he's right, of course. One of the reasons infant mortality has decreased is because of orthodox medicine. But that's not what I wrote to him. Instead I wrote something like this: yes, infant mortality is down. But life expectancy at 20 is up too. And at 30, 40, 50 and 90. A 50-year old with access to a reasonably sober GP and a branch of Boots has a greater chance of living to 80 or 90 than his father or grandfather did. And these aren't statistics worked out by evil doctors with their axes to grind, but by actuaries who work for life insurance companies and who have to get the figures right or the insurance companies will go bust.
I'll give the man his due. He was, by his lights at least, honest with me, for his next message said "Oh. I didn't know that. Look, let me get back to you. Yes, I thought. A result! For the first time in years of arguing the toss with these people, I've made a conversion.
His next message arrived the next day. He was grudging. He didn't know where I'd got my figures from, but he supposed I must be right. Nonetheless, he was sticking by his original statement: orthodox medicine doesn't work and alternative medicine does.
I, he said, was a case in point. I had cancer. The doctors had tried to cure me and had failed. On the other hand his mother had been diagnosed with cancer a couple of years earlier. She, like me, had been a scoffer, a cynic, an unbeliever and had put her faith in the wretched medical con-artists. But after a while he had persuaded her to take Essiac.
Essiac, some of you will know, is an ancient herbal remedy used by Native Americans in Canada to cure cancer, and was rediscovered by a Canadian nurse some time in the 30s. There's no evidence that cancerous Native Americans lived longer in Canada than anywhere else, but Canadian alternativists rather like having their very own national alternative remedy, and the stuff is now touted all over the place as a miracle cure. I don't have to tell you that it isn't, of course; or that every properly controlled study of Essiac has shown that patients might as well drink Tizer for all the good it does.
But this man had fed his mother Essiac and she had-well, since you ask, she'd died ten months later. And this proved Essiac worked? Yes, he said. Because the doctors had only given his mother two months to live. Now as it happens this is one of the things that alternativists are always telling me about in their success stories: "The doctors said the patient would be dead in two months, or a year or two years," they say, "but he took-insert name of alternative remedy-and lived twice as long". In fact doctors very rarely give a precise sell-by date for cancer. Until the very end is nigh, they can usually only ever give a ball park figure. But when doctors say "I'm sorry, we can't be precise. It might be a year, it might be as soon as a couple of months", what people hear, understandably enough, is "You'll be dead in two months." Believe me, I know. Before I had my last bout of chemotherapy I was forever telling people I had three months to live, because that was the worst-case scenario. That was over a year ago, and here I am talking to you tonight. Well, not talking to you exactly, but you know what I mean.
Anyway, the reason his mother had died wasn't because Essiac didn't work but because she'd taken it the wrong way. She had swigged it and she should have sipped it.
I know: the man sounds mad. But I promise you, I've had this conversation, or one like it, with dozens of people like him who make their livings passing on information like this to anyone who pays them: from people with vague symptoms their GPs have got bored trying to treat, to terminal cancer patients desperate for something, anything, to give them some hope.
And the thing about these people is they tell lies. They may not think they're telling lies, but that's what it comes down to. Those of us who doubt the efficacy of alternative medicine tend not to point this out; after all alternative practitioners are usually kind and gentle people who like to think they have their patients' best interests at heart. Saying a homoeopath tells lies is rather like saying that the tooth fairy sniffs glue. But they do. I keep on getting messages, for instance, from men and women who want me to try one or other of their cures, and who tell me a story which goes like this: "I had a patient/friend/client who had been given two months to live and sent home to die because the doctors said there was nothing they could do about the tumour on her liver/lung/brain. Together, though, we worked out a regime of coffee enemas/organic grape juice/zinc-and-aspirin (and I promise you, all of those cures come straight from my e-mail in-box) and what do you know? The next scan showed the tumour had shrunk by half." Which does, indeed, sound miraculous. But then you say to yourself, hang on: what are the doctors doing scanning the patient if she's been sent home to die? Even the best-equipped hospitals tend not to give expensive scans to patients whose time is up. And so after a bit of gentle prodding it turns out that actually the patient has been sent home, but comes in every day for some radiotherapy. Or is on chemotherapy. And, OK, the doctors didn't actually say that the patient was terminal, but ...
If orthodox doctors tried to get away with that sort of nonsense they'd be kicked out of the business in five minutes flat. But the alternativists do it all the time.
But then it occurred to me. Although my Liverpool correspondent was a resolute and unabashed alternativist and I'm a steely-hearted and over-rational supporter of the orthodoxy, we do share a single belief which is this: we both agree that it's possible, under certain circumstances, to alter the outcome of some illnesses by introducing some sort of specific preparation into the sufferer's system.
That basic agreement established, there are two differences between us. I think that the best way of determining what works and what doesn't is to try it out under controlled conditions. If you give Essiac to 100 patients with the same sort of cancer and they die as quickly as 100 patients not fed Essiac, then you can be pretty certain that Essiac doesn't work. Simple. But he doesn't believe that. His is an act of faith-a faith based on rumour, speculation, misheard anecdotage and all the rest of it.
The other difference is probably more telling. If you were to ask most alternativists they'd probably tell you that one of the big differences between their art and our science is that the medical establishment is so very sure of itself. It's closed minded. It knows it's right. But in fact that's the very opposite of the truth. Although we patients demand certainty of our doctors because we prefer certainty in our lives, medical science is as much about not knowing as it is about knowing. An experiment, by definition, is about what you don't know, about what you want to find out. It's the alternativists who are so certain of their beliefs that so many of them don't think it's necessary to submit them to proper scrutiny. Not that they dismiss experiment out of hand. Look through the alternativist's web sites and they have one thing in common: the slightest hint of experimental success is enough to support a vast body of alternative belief; the slightest hint of experimental failure is enough to demolish an equally vast body of established orthodox belief. To be more specific: I've been told scores of times that the Thalidomide case demonstrates how much nonsense orthodox medicine is (and it's interesting that 30 years after the discovery of Thalidomide's dangers, the alternativists still use it as their prime example of orthodox failure). Because Thalidomide was bad medicine it follows that all orthodox medicine is bad. You then go on to challenge them about homoeopathy and they'll tell you that the meta-research published by the EU last year showed that there are statistically significant results showing that homoeopathy has a benefit for hay fever sufferers and people with sore limbs. And on that tiny shred of evidence they start telling me about the wonders homeopathy can work in cases of cancer and heart disease.
It's nonsense. And much of it is offensive and dangerous nonsense too. And for as long as I can, and as long as I can sweet-talk indulgent editors, I hope I'll get the chance to say so again and again.
All of which is an unforgivably long way round of telling you how very honoured I am by this award, above any of them. Yes, I was grateful and usually pretty surprised to win prizes for my journalism and for the book. But to be told that I've done something to help people-too confused by the welter of nonsense about medicine they read in the papers to approach their illnesses rationally-to help them think twice about the claims made for the untested and the impossible...well as far as I'm concerned, that's something worth doing. Thank you.
John Diamond died on March 2nd 2001 - see the personal tribute and obituary notice in Newsletter no 41
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From May 1999 until October 2000 the HealthWatch Helpline ([+44] 020 8789 7813) handled 62 enquiries, mostly from journalists seeking a balancing view on alternative and complementary medicine claims. In many cases they were directed to appropriate experts. It would be greatly appreciated if members other than these made themselves available to speak to journalists within their speciality. Members wishing to help should contact Michael Allen at BMHealthWatch, London WC1N 3XX or e-mail Michael.E.Allen@btinternet.com.
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The letter, in the 6th December issue, details the work of researchers at the University of Durham. They surveyed heads and teachers from 54 randomly selected primary schools in England (with league tables) and Scotland (without league tables). They found that, compared with Scottish schools, English schools were more likely to concentrate on meeting their targets at the expense of other important objectives, that target setting had a narrowing effect on the curriculum and had increased the "blame culture." The findings should give pause for thought, say the authors, and they warn that careful consideration should be given to the unintended consequences of league tables.
British Medical Journal 2000; 321: 1467.
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From presentation of the data at a conference through to final publication in a medical journal, the process involves data cleaning, writing, widespread consultation with co-authors, submission and often re-submission to journals, and peer-review, before the paper joins a queue of other articles awaiting publication. Then there is the issue of "negative publication bias", where medical journals reject studies if the results were either negative or "unexciting". The editorial suggests that one "fast and dirty" answer could be the electronic preprint, a practice common in scientific fields outside medicine. "This allows a much wider range of people to examine the data, provide feedback and, where appropriate, suggest changes or offer comments. Until someone comes up with a better idea for speeding up the traditional publication process, perhaps clinical trialists should take a closer look at this electronic short-cut".
The Lancet Oncology, November 2000.
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In his commentary accompanying the Lancet's recent publication of two reports on mobile 'phone safety Philip Dendy, formerly Chief Physicist at Addenbrookes Hospital, Cambridge notes that public perception of safety is heavily influenced by the perceived level of benefit from the activity in question. As an extreme example of this, he cites the risk associated with household gas. "This highly explosive substance is piped into millions of homes in the country. Is it safe? Of course not but the amenity value is such that people are prepared to live with the risk. Researchers into the pursuit of safety, of mobile telephones or other features of modern living, would be well advised to take this political element into consideration".
Lancet, 24th November 2000.
A homoeopath's objection to a drug company's ads for vaccination was rejected recently by the Advertising Standards Authority. SmithKline Beecham plc's campaign promoting pre-holiday vaccination for Hepatitis A included the claim, "The holiday shot you'll never regret is a vaccination". The homoeopath objected to this statement because she understood that some people suffered debilitating and painful side effects from the hepatitis A vaccine. The ASA reviewed evidence supporting the advertisers' claim that over 10 million doses of the vaccine had been sold in the UK since its launch, and that independent authoritative sources agreed that hepatitis A vaccines were extremely safe and not associated with debilitating and painful side effects. It considered that the advertisers had shown that hepatitis A vaccines were safe and did not uphold the complaint.
ASA Monthly Report, 6th December 2000.
Traditional Chinese Medicine (TCM), says a recent newspaper report, could hold a cheap and effective cure for Aids. Professor Guang Chongfen of the China Academy of TCM in Beijing told The Independent that his team's trials in Tanzania showed that 14 out of 29 Aids patients responded positively to treatment with zhongyan erhao, a compound of eight different TCM standards, including ginseng. Meanwhile Professor Luo Shide, of the Kunming Plant Research Institute, under the Chinese Academy of Sciences, claims a higher success rate for his compound SH drug. After sifting though over 1,000 medicinal herbs, Professor Luo selected the bark of white mulberry root and four other Chinese plants. His team then tested SH on 28 patients in Thailand-nine showed obvious reductions in viral concentration, while 16 others showed no increase after three months' treatment. It was not clear from the report, however, whether the trials mentioned were placebo-controlled.
The Independent, 9th December 2000.
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Public interest in health issues since October 1999 has continued unabated. The media are awash with information and misinformation. During that time HealthWatch has made its small but influential contribution towards ensuring that information has a degree of accuracy. Our activities have been divided between our regular core activities and a number of individual efforts.
The HealthWatch Newsletter is published four times a year. It contains a mixture of original articles by members and by outside contributors and reproduces articles and news reports from other sources, and we welcome any articles or letters you can contribute. Our Committee includes a number of members with special expertise. The position papers we publish in the Newsletter from time to time allow them to expand on their specialist subjects at greater length that the Newsletter generally permits. They provide a permanent record of HealthWatch's policy on a number of subjects. Examples are papers on cancer, the dangers of dieting, the placebo effect and, central to our philosophy, the design of good clinical trials. They are available on our website.
Helpline The HealthWatch Helpline (020 8789 7813) has been manned by our Press Officer Michael Allen for the past year, providing health journalists and broadcasters with reliable information. Michael answers the queries himself where he can or refers them on to one of our members who specialises in the relevant field.
Thanks to David Bender, almost everything HealthWatch has ever published including the contents of newsletters and position papers is available on our website (http://www.healthwatch-uk.org). Until this year, David arranged the HealthWatch website as part of his personal area on the UCL site. This year we decided to spend a modest part of our resources and pay an annual fee to transfer the site to a dedicated HealthWatch address. It was largely the donation which David's late father Professor Arnold Bender secured from a Swiss charity that made this possible.
In the category of individual efforts, first and foremost this year has been the opportunity for HealthWatch to make submissions to the Science and Technology Committee of the House of Lords who are preparing a report on Complementary Medicine. John Garrow and Thurstan Brewin prepared a written submission encapsulating our stated position that proper clinical trials are needed for all types of treatment. For example, they drew attention to the absence of proper evidence that complementary procedures like iridology and reflexology can diagnose diseases, the extravagant claims made for some food supplements and the need for the public to understand the virtues of evidence based medicine. The Committee responded with questions and John and Thurstan attended the House on 27th June to be cross questioned by its members.
HealthWatch could not have had two better advocates for its cause and whilst we were fortunate to have an opportunity to put our case at the highest level, I think their Lordships were equally fortunate to hear from Thurstan and John.
The teaching function is one which we ought to explore. For some time we have been considering the feasibility of establishing a prize for medical students in a competition to test their skills in appraising the quality of protocols for clinical trials. This would require a lot of effort and, of course, money. Several members of our committee are well qualified to talk about randomised trials and evidence based medicine and are willing to offer their services. We are waiting to hear if University of Westminster would welcome our involvement in their course for medical journalists and also from a professor involved in further education of GPs.
If any members know of any courses where our input would be appreciated, please let one of us know.
Clearly we need to find further sources of finance if we are to continue and expand our activities because the modest membership subscriptions alone are not sufficient. John Garrow took a lot of trouble to apply for a grant from the Committee for the Public Understanding of Science (COPUS) but sadly, there were too many other worthy competitors. Again, your ideas will be welcome and will be considered carefully.
I would like to thank the officers and the other committee members for their help and support. Except for the editor of the newsletter, Mandy Payne, no-one at HealthWatch is paid for their efforts. On the contrary the officers and committee members put in a great deal of their own time without reward. I suspect they do not always ask for their expenses either. Last year, John Garrow concluded his term of office as chairman and went on to introduce our awardwinner Bernard Dixon without any ceremonial handing over of the Chairman's office. This deprived me of the opportunity to acknowledge publicly the enormous contribution John made as chairman and continues to make as secretary of HealthWatch. In all sorts of ways, ranging from his cartoons in the Newsletter to acting as a guinea pig in his own one man trial he has gone beyond the call of duty and always with the good humour and erudition that we have come to expect from him.
My thanks also to John Hanford as Treasurer, Michael Allen as Press Officer, Geoff Watts, as vice chairman and Shirley Churchman as membership secretary all of whom have been of tremendous help and have fulfilled their respective roles quietly and efficiently throughout the year and to Nick Ross for his support and encouragement.
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Dr Edward Bach was an unusual man. He claimed that emotional imbalance is at the root of all illness. "Treat people for their emotional unhappiness-allow them to be happy and they become well", he wrote. Bach was born in 1886 in Mosely, a village near Birmingham. After school he worked in his father's foundry for a while. Later he entered Birmingham University and qualified as a doctor in 1912. Having developed an interest in the role of bacteria as a possible cause for chronic illness and having practised some time as a Harley Street doctor, he eventually joined the Royal London Homoeopathic Hospital as a microbiologist. His later ideas are clearly influenced by homoeopathy although homoeopaths are keen to point out that Bach's ideas are distinct from theirs.
Having left London, Bach spent several years exploring the Welsh countryside that he so loved. "It will take me five years to forget all I have been taught", he wrote then. He became attracted to plants and developed his theory that negative moods were the cause of all illness. He began to believe that the only true healing agents were to be found in plants. Over the next 6 to 7 years, he identified 38 plant-based healing remedies which, according to his belief, corresponded with the 38 negative emotional states that determined health. Bach had found what he longed for: a complete system of emotional healing based on plants that is understandable and affordable by everyone. "Behind all disease", he claimed, "lie our fears, our anxieties, our greed, our likes and our dislikes". Today many more flower remedies are marketed and their sale has become a thriving business.
Flower remedies are commonly divided into "type remedies" which correspond to certain personality types and "mood remedies" which correspond to certain emotional states. They are made by placing freshly picked flowers in a bowl of spring water. The bowl is then left in the sun for several hours. This process is believed to "energise" the water. Subsequently the flower essence is preserved by adding 50% brandy. The mechanism of action of these remedies remains unknown. Proponents claim that flower remedies adjust imbalances within the patient's emotional perceptions. Sceptics argue that the remedies contain nothing except water and brandy and thus have no specific activity at all; any therapeutic response must therefore be due to a placebo effect.
So, are flower remedies pure placebos? Until recently no reliable data existed to answer this question. Anecdotal reports suggested that Bach flower remedies may be effective in treating addiction disorders, agoraphobia, allergies, amnesia, anxiety, asthma, bites and stings, bronchitis, bruxism, bruises, bunions, burns, chronic fatigue syndrome, claustrophobia, common cold, depression, eczema, fatigue, fluid retention, hay fever, headaches, hypotension, hypertension, infertility, insomnia, migraines, various painful conditions including neuralgia, mood swings, panic attacks, post-partum depression, premenstrual syndrome, psoriasis, sciatica, slipped or prolapsed vertebral disks, renal disease, sexual dysfunction, as well as stress and tension. Yet no rigorous trials had been performed to test flower remedies. Considering their popularity and the sales figures associated with them, the lack of evidence is perhaps surprising. Flower remedies are not marketed as medicines, thus there is no obligation for manufacturers to back them up with evidence.
At the University of Exeter, we therefore decided to test the effects of "Five Flower Remedy" on stress, the very condition it is marketed for. With this particular remedy Bach has allegedly saved the life of a sailor. According to Bach, it cures "severe mental stress and tension, a feeling of desperation or a numbed state of mind". The same mixture is also sold as "Rescue Remedy" and is the most widely used of all flower remedies. It is composed of Clematis, Impatients, Rock Rose, Cherry Plum and Star of Bethlehem. We recruited 100 students who took either the real thing or placebos to alleviate their "exam nerves". We made sure that the real treatment was indistinguishable from the placebo. In technical terms, our study was a "randomised, double-blind, placebo-controlled trial" which simply means it was the most rigorous clinical test possible.
Our results show no differences between the "Five Flower Remedy" and placebo. Unfortunately some of our students proved to be unreliable and we therefore could only evaluate 45 of them. Yet we are confident that the results are conclusive: "Five Flower Remedy" is not an effective treatment for examination stress.
Unbeknown to us, scientists from the University of Freiburg in Germany carried out a study that was strikingly similar to ours. They recruited 61 students suffering from exam stress and treated them with "Rescue Remedy" or with placebo. Their results show that students in both groups responded positively but there was no difference between placebo and the real thing. Our German colleagues wryly conclude that "flower remedies are an effective placebo for test-anxiety which do not have a specific effect".
This highlights the surprising power of the placebo. Dummy pills can alleviate pain and, of course, reduce examination stress. And what is wrong with using harmless mixtures like flower remedies in this way? Why should we not maximise the power of belief to the benefit of our health? I suspect there is very little wrong with this-provided one makes sure that people do not suffer harm.
Some would probably say that charging considerable amounts of money to sell placebos already constitutes harm in some way. I would argue that the potential risk of flower remedies lies elsewhere. Placebos are helpful treatments for some conditions but for others they are not. The lay literature often misleads the public into unrealistic expectations regarding complementary therapies. Therefore someone might be induced to try flower remedies for seemingly innocent symptoms. Due to the power of belief her symptoms might improve but after a while they come back. This cycle can repeat itself with further remedies providing further temporary relief. Finally she consults a doctor who diagnoses a serious disease that would have been curable had she only visited earlier! This is where apparently harmless complementary therapies can become a serious threat to health. And this is, I believe, why it is not just a question of scientific honesty to determine which treatments have specific therapeutic effects and which are placebos.
Department of Complementary Medicine
Acknowledgement: Our trial of Flower Remedies was supported by the Pilkington Charitable Trusts.
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The report of the House of Lords Select Committee on Complementary and Alternative medicine (CAM) calls for more regulation of (CAM) and its practitioners, and also suggests that well-regulated and evidence-based CAM therapies should be provided on the National Health Service. The House of Lords report recognises three categories of therapies (see below).
Amongst these, there is a group of therapies - including acupuncture and herbal medicine - considered to have established research into their effectiveness and organised self-regulation of their practitioners; they are increasingly being provided on the NHS. Statutory regulation of practitioners of acupuncture and herbal medicine should be introduced quickly and such regulation may soon become appropriate for homoeopathy.
The committee took note of the submission by the Proprietary Association of Great Britain, that the public has difficulty distinguishing between licensed medicinal products and unlicensed herbal medicines. It asks the Medicines Control Agency to find a way to allow the public to identify licensed products and that the rules against making medicinal claims for unlicensed products should be more strictly enforced.
It suggests that conventional health care practitioners should become familiar with CAM therapies as part of their continuing professional development. Professional and regulatory bodies should develop guidelines on competence and training in CAM therapies for health professionals who wish to provide complementary therapies as part of their practice. Where CAM is provided on the NHS, this should he through referral by a health care professional.
Covering themselves with the weasel words "enthusiasts believe", most writers of these columns fail to point out that there may not be a shred of evidence for many of the beliefs. John Diamond (see front page) was characteristically blunt in the Observer (3 December 2000), and the sub-editors didn't mince his words: "Why I hate alternative medicine" was the signpost - top left on the front page - to his piece.
The broadsheets gave pretty full coverage to the report on 29 November. While the headline writers gave the Guardian's report (Peers say NHS could embrace alternative therapies) a different emphasis from the Independent (Public 'at risk from alternative therapies') and the Times (Lords puncture myths of alternative medicine), the general tenor of all reporting was much the same. The main thrust was the need for regulation and research.
However as John Diamond pointed out, to regulate is to confer respectability, and research means less money for research into orthodox treatments. Regulation-as with regulation of doctors-requires syllabuses, curricula, and recognition of best practice. While everyone acknowledges that orthodox medicine does not get everything right, and sometimes causes great harm, at least it is built on a foundation of verifiable science.
To give an example from the past, asbestos was once sprinkled into the pericardial cavity (the membrane surrounding the heart) to relieve angina. Clinical trials eventually showed this to be useless, but the operation was based on the observation that asbestos increased local blood flow, and it was known that failure of blood flow to heart muscle caused angina. Unfortunately, local blood flow (caused by irritation, much as scratching the skin causes redness) was not muscle blood flow. Alternative therapies generally do not have any similar foundation and often rely on scientifically undemonstratable principles such as "blocked energy channels", so when we are informed that "acupuncture should be subject to statutory regulation", it is not easy to see what form this regulation can take, beyond the obvious need to sterilise the needles.
As the Lords acknowledge, and the media reported, it is public demand that has meant we now have more complementary therapists than general practitioners. A letter writer to the Guardian pointed up the irony, noted by many in the past, that any of these therapies that make it under the NHS umbrella will be stifled by the same underfunding and understaffing that allow GPs only seven minutes per consultation. We shall have to wait and see whether, if the recommendations of the Lords are accepted, the public lose their love affair with the unproven and the fanciful. Sadly, I doubt it. For many diseases and conditions, orthodox medicine is of little or no help, and is not afraid to admit it. Even said gently by the most considerate of doctors, this is not what the worried ill want to hear. The key to any future regulation of therapists outside the proven and the scientifically based is to prevent the rogues selling their useless potions while still allowing the kind, if deluded, to help people feel better, even if not actually making them better. The nature of scientific "proof", and the impossibility of proving that something does not work, will not make the key easy to shape.
Consultant Anaesthetist Southmead Hospital
Reference Complementary and alternative medicine,
House of Lords Select Committee on Science and Technology, 6th report. 1999-2000 (HL123),
The Stationery Office, London (£15.50).
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by Ragnar Levi
Studentlitteratur, Lund, Sweden, 2000
Price: SEK 230 excluding postage and V.A.T.
(V.A.T. number should accompany orders within the EU)
I have never had the slightest intention of writing a guide to medical journalism. But if ever I had been so minded, this is pretty much the book I would like to have written. Ragnar Levi, a Swede with training in medicine and journalism, has clearly thought long and hard about the good, the bad and the intellectually indefensible in both his trades. And while much of the book is concerned with the technicalities of distinguishing the worthwhile stuff from the dross, he's not afraid of the big questions-such as "What is truth, anyway?" This modest query crops up as a subsection of the chapter on telling science fact from science fiction, and embodies the core of Levi's argument. "Faced with an enthusiastic claim...some journalists will simply quote the enthusiastic innovator, and throw in a few critical quotes from an expert who thinks the old methods are better," writes Levi. "This approach is convenient and fulfils the superficial requirements of 'balanced reporting', but it tends to result in word-against-word stories..." Indeed, quoting two parties' opposing views on a topic is often regarded as a hallmark of "objective reporting". Levi, however, expects much more than this from his ideal journalist.
He outlines what he calls "critical medical journalism". Although rooted in journalistic "best practice"-checking the facts, checking the sources, asking the difficult question, remaining sceptical of all with power and authority-for Levi this is no more than a starting point. Medical science has devised an intricate methodology for trying to uncover objective truth, and journalists reporting on medicine should be doing something very similar.
For this reason Levi expects the properly trained reporter to know his RCT from his RRR, to be able to make use of Cochrane data, to understand the importance of meta-analysis, to be confident in asking researchers about "numbers needed to treat", and a great deal more besides. This is, as I am sure Levi would agree, a counsel of perfection. Peer reviewers get weeks to satisfy themselves about such matters; journalists may get days, hours or even a few minutes. So while the practice of evidence-based journalism may be a worthy ideal, doing it for real is not always feasible.
The other problem with his idealistic view is that it bears little relationship to the thought processes by which most people decide what to watch, read and listen to - or, indeed, by which editors choose what to put in and what to leave out. This is hardly surprising; outside of decision-making in science itself, the scientific method barely registers in any area of the conduct of human affairs. A tiny minority of journalists are in a position to bring to the pages of the Daily WayUpMarket the criteria that hold sway in the BMJ or the Lancet. But even they may not choose to do so. Either way, most are not so privileged. Indifference, economics, ratings...all sorts of things interfere with the dissemination of pure truth. If being worthy and truthful grabs the punters, proprietors are all in favour; if it doesn't, trivia and hype are the tempting alternatives.
That said, though, the book is splendid. You don't have to be a professional scribbler to get something out of it. But although Levi is trying to appeal to a wider audience, I imagine that most of his readers will in fact be aspiring medical journalists, or those already established but still prepared to reflect on the probity of what they do. Those outside the business will have no difficulty in reading it-but it would take a committed interest in the topic actually to do so. For students on any of the medical or scientific journalism courses which are cropping up around the country the book should be mandatory.
There is, of course, one other group who would benefit mightily by much of what Levi has to say. They are more numerous than journalists, medical or otherwise, and their decisions are far more fateful. Many of them have an incomplete grasp of the methodology of scientific medicine. A few appear to disregard it. They're called (whisper it!) doctors.
Orders for Medical Journalism-exposing fact, fiction, fraud can be placed by
fax: +46-46-32 04 41
or by e-mail: firstname.lastname@example.org.
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Dear Sirs I would like the opportunity to reply to an article published in the July issue of the HealthWatch Newsletter (issue 38).
Two orthodontic consultants, Mr Isaacson and Mr Reed, criticised a presentation I made on a recent Channel 4 programme in which I stated the opinion that "20% of faces are noticeably damagedby orthodontic treatment and a further 30% slightly damaged. There is no more accurate way of comparing different types of treatment than following the consequences on identical twins. On the evidence of my own published research using twins I feel confident that these figures are, if anything, an underestimate. The opinions on the programme came from the twins themselves, one saying that his face had been elongated and flattened because of the extractions when compared with his own twin brother whose face had been improved by making room for his teeth.
These two consultants clearly resent a "General Practitioner" criticising established techniques but they cannot deny that current treatment is based largely on trial and error and most of it involves the extraction of four or eight perfectly sound teeth. I know of no speciality with a poorer record of long term success as 90% of their results relapse to "an unacceptable" extent within twenty years. The evidence clearly shows that orthodontic treatment tends to increase the downward component of facial growth and as these consultants know this makes the face look less attractive. They call for proper evidence and yet fail to produce it themselves.
Not so long ago David Sackett (1985), Professor of Evidence-based Medicine at Oxford, stated that orthodontic research "was behind such treatment modalities as acupuncture, hypnosis, homoeopathy, and orthomolecular therapy and on a par with scientology". Derek Richards, director at the same centre, recently stated (2000), "The current focus of dental schools leans toward the teaching of technical skills rather than scientific thinking". Bill Shaw Dean at Manchester and an orthodontist says in "Evidence Based Dentistry" (2000), "Sadly it is hard to see this situation change unless the inadequacy of current knowledge is acknowledged by its practitioners".
These are heavyweight opinions and should be listened to.
Yours sincerely, JOHN MEW.
Dr Mew made the above letter available to the authors of July's article issue 38 in advance of publication in this issue. Mr Isaacson responded, taking exception to the suggestion that he might "resent criticism by a General Practitioner", and pointing out, "I think I have done more than probably any other Consultant Orthodontist in the country to encourage general practitioners to be involved in orthodontic treatment".
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For reasons of space, the planned feature on homoeopathy mentioned in our October issue, has had to be postponed until the April issue of the HealthWatch newsletter. Our apologies to members interested in the subject and to the author, Jan Willem Nienhuys.