In one week HealthWatch sadly lost two of its most distinguished members.
Thurstan Brewin who died on 25th February 2001 at the age of 79 was a past Chairman and Secretary of HealthWatch and remained on the Committee as one of its most valuable and knowledgeable members. As recently as June last year, he joined with John Garrow in making oral and written submissions to the Science and Technology Committee of the House of Lords for their report on Complementary Medicine.
Thurstan lost a leg in the Second World War but did not let this inhibit him from a full family life and a distinguished career as a consultant oncologist. He was an unusually skilled communicator as his writings in this Newsletter and the Lancet and other learned journals demonstrate. Following his retirement, he made new friends and contacts and everyone who met him developed a great affection for this quietly spoken, authoritative and genuinely wise man. We will all miss him.
Within seven days HealthWatch and a much wider public lost John Diamond at the age of 47. He died on 2nd March after losing his heroic struggle against throat cancer. He was, of course, the recipient of the HealthWatch award at our last Annual General Meeting in October 2000. It was a great privilege to have met him and to hear Geoff Watts deliver John's brilliant and witty address. His loss of his power of speech did not prevent him engaging in lightning and barbed exchanges with the audience using the overhead equipment to project his comments on the screen behind him, his ripostes often appearing before the questioner had finished speaking. He wrote a heart warming appreciation of the award in his Times column and I think he really valued the award even if he was not sure of the utility of the silver platter we gave him.
So much has been written about John Diamond in the public press by those who knew him well. He demonstrated and explained in his wonderfully expressive and ironic prose that even someone who is facing death at the end of a harrowing and painful illness can still find life rewarding and has much to give and to teach the rest of us.
On behalf of all members of HealthWatch I send our heartfelt and sincere condolences to Thurstan and John's respective families.
Malcolm Brahams
HealthWatch Chairman
There were three editorials, four articles under the heading Education and Debate, some letters, and some less formal items. The general plea was for more merging of orthodox and alternative medicine, with formal introduction of the study of complementary and alternative medicine to the medical school curriculum.
The irony of this acceptance of alternative therapies coming so soon after the publication of John Diamond's article (he described alternative medicine as "offensive and dangerous nonsense") was presumably lost on the BMJ's editor, Richard Smith, who, in his Editor's Choice column asked readers to be open minded and critical. One of Diamond's points had been the paradox that the alternativists (as he termed them) criticise orthodox practitioners for having closed minds, but it is orthodox medicine that conducts clinical trials while the alternativists function by belief.
The idea that medicine has "lost its soul" - Smith's column was headed "Restoring the soul of medicine" - is a common one. I think it is in general true, in that the emphasis of modern medicine tends towards the goal of cure by technological wizardry. This emphasis, though, is promoted more by those same media that condemn doctors for human failings than it is by doctors themselves. And if it is true, then the remedy should be to alter the attitudes of doctors rather than to incorporate unproven, unscientific hearsay into a new discipline of "integrated medicine" (which would have about as much validity as a hybrid of astronomy and astrology). At the simplest level, allowing doctors more time with their patients would be good for the soul.
For the benefit of newsletter readers, here are some of the e-comments made to the e-BMJ in response to the various articles. Their precise sources and authors are not given here, but can be found at http://www.bmj.com, accessed via the various articles in the issue of 20th January, 2001. It will come as no surprise that the correspondence illustrated a failure of meeting of minds: the opinions of the article and letter writers are those of people who have no common ground other than a wish to do the best for their patients. Each believes that the best excludes, to a greater or lesser extent, what the other has to offer. That being said, there were far more e-letters critical of the BMJ than supportive of it. What is more, whereas it was easy to pick cogent extracts from critical letters, it was difficult to do the same from supportive letters, which tended to be less focused and to restate anecdotal evidence for CAM.
"[The BMJ issue shows] subservience to political correctness (commitment to being non-judgemental, non-paternalistic, anti-intellectual, anti-science).
If our politically correct public wish to avail themselves of unproven remedies, we should not stand in their way. But neither should we join their rush into foolishness."
"Given the tide of political correctness [that] seems to have been engulfing the BMJ in recent years I am not surprised by the theme of your current issue. I am, however, appalled: if we get into bed with alternative medicine we are not only betraying our scientific heritage but we are also a short step away from betraying our patients... To suggest that one cannot be a good scientist and a caring, compassionate doctor is utter, drivelling nonsense."
"CAM is a misleading, oxymoronic misnomer, consciously or unconsciously created to give a false impression, get political clout and win undeserved confidence and respect. Although it lacks convincing proof of efficacy, it seeks to win acceptance without meeting the usual criteria demanded of EBM for gaining and deserving the acceptance it seeks. It is not "Complementary" to EBM, but is "Competitive" to it."
"Allegedly, alternative medicine treats people more humanely than standard medicine. If so, the answer lies in making standard medicine more humane; not in accepting humane, unscientific medicine. The popularity of alternative medicine testifies to the gullibility of people who don't understand the superiority of science over other ways of claiming knowledge." A number of critical letters were a plea for research to be done and presented. They contained much that is unfortunately true, despite the belief of many of us (including John Diamond) that the money could be better spent: "Time passes while we refuse to do the research. Meanwhile the quacks are getting their message out to the public."
"For goodness sake, wake up and realise that CAM is not something to be dismissed as quackery like so much black magic; it is here to stay, and the sooner it receives the complete backing of the medical fraternity and appropriate regard in the race for research funding the sooner we can all work in harmony... Let well conducted research provide the evidence for or against the variety of CAM treatments on offer."
A typical reply supporting the BMJ read: "Alternative Medical Systems are fully scientific and no one can charge it as baseless etc. We are not going to discover anything new. It is only going to be the rediscoveries of what is said in the Traditional literatures perhaps in the modern/scientific terminologies. Our ultimate aim is going to be one, i.e., providing a healthier life for all. We (the People of Alternative Medical Systems) only opt for a peaceful, understanding and co-operative working atmosphere... Then we will find a wonderful, natural, innovative and an Eco-friendly Road."
Perhaps a more perceptive view was: "People want to be 'masters of their own destiny'. We make choices, act independently, try things out. We have self-help books, the Internet, distance education, and a growing trend of 'choose your own health care methods'. Feeding this basic human drive for independence and self-control are opportunities to choose amongst multifarious accessible and ostensibly 'proven' (e.g. by testimonials) treatments.
In contrast, feelings of utter dependence are fuelled by prescriptions backed up by realistic but unamazing statistical likelihoods of their effectiveness." Supporters of CAM often refer to the US National Institutes of Health (NIH) Office of Alternative Medicine (OAM). There was a comment about that.
"[Relaxation techniques and massage] may be appropriately used as part of the art of patient care... But procedures linked to belief systems that reject science itself have no place in responsible medicine... Creation of [the OAM] was spearheaded by promoters of questionable cancer therapies who wanted more attention paid to their methods... none of its publications have criticized any method... it remains to be seen whether [their] studies will yield useful results. Even if some do, their benefit is unlikely to outweigh the publicity bonanza given to questionable methods."
An author of one of the BMJ editorials has published books about self-help medicine. A correspondent selected some quotes. Even granted that the quotes are out of context, they are worrying. The correspondent commented about what might be "left of scientific biomedicine should such notions be thoroughly 'integrated' with it. I hope practitioners of science-based medicine reading this issue of BMJ fully understand what they are dealing with.
" 'Proper breathing is a key to good health... Improper breathing is a common cause of ill health... Since leaving the world of allopathic practice, I have witnessed a number of impressive nonallopathic cures of dramatic illnesses, including cancer and life-threatening infections... To the straight mind nonallopathic healing sounds very mystical. Faith healing is held in contempt by most rational people, despite the abundant evidence of cures.' " (The correspondent points out that this evidence is not cited.)
Another opinion of the editorialist is "...I am almost tempted to call psychotics the evolutionary vanguard of our species. They possess the secret of changing reality by changing the mind; if they can learn to use that talent for positive ends, there are no limits to what they can accomplish."
Neville Goodman
Consultant Anaesthetist Southmead Hospital, Bristol
Reference:
Integrated medicine: orthodox meets alternative. BMJ 2001 (20 Jan); 322:
119-182.
The Lancet's report of the study (1) is accompanied by an editorial (2). There are provisos, and the effect is not large, but the editorial concludes: "It is time for the profession to accommodate the possibility that many nutritional products may have valuable therapeutic effects and to gain the credibility of the public at large." This is true. We need more of these studies, and they must be encouraged.
What we do not need is the evidence of benefit for glucosamine in arthritis being taken as evidence that all nutritional supplements work in all circumstances, a chain of illogic that is depressingly common in this field.
The February issue of Which? (3) has done a good job of summarising screening for cancer. In a sensible, unemotional way, the reasons for screening for cancer of the breast and cervix are given; as are the reasons for not screening for lung and testicular cancer and melanoma. The current situations for prostate, colorectal, and ovarian cancer are described, and there is full recognition of the downside of screening. We need more articles such as this, in more magazines.
Neville Goodman
References
A small voluntary organisation started by a group of young New York doctors is initiating a "Drug Free Practitioners" listing. This listing, which will be posted on the No Free Lunch website will be made up of health care providers who have pledged to be "Drug company free", that is, free of drug company money and influence in their clinical practice, teaching, and research.
The listing aims to help patients find health care providers who practice medicine on the basis of evidence, rather than promotion, as well as raising awareness of this issue both among the public and the medical profession, thereby maintaining pressure on the profession to mend its ways, as well as on individual practitioners (or researchers) to mend theirs.
Those taking the pledge will be listed on the website and will receive a certificate certifying them "drug company free" for display in their office.
For more information see the No Free Lunch website at http://www.nofreelunch.org
Adverse events in NHS hospitals cost £1bn a year, says a recent study of London hospitals. Ten per cent of patients admitted to British hospitals experience an adverse event, about half of which are preventable with ordinary standards of care, according to preliminary findings from a pilot study. These events could cost the NHS around £1bn a year in 3 million extra bed days. The figures came from a review of 1,014 medical and nursing records at two acute hospitals in the London area. A third of the adverse events led to moderate or greater disability or death.
BMJ 2001; 322: 517-519.
The popular herbal remedy Ginkgo biloba is no better than a placebo for treating tinnitus (ringing in the ears) according to results of the largest trial of Ginkgo biloba for treatment of this particular condition.
Researchers at the University of Birmingham included 1,121 otherwise healthy tinnitus sufferers in the placebo-controlled 12-week trial. Ginkgo biloba extract has in the past been shown to have therapeutic effects on symptoms of cerebral insufficiency including memory disturbances and cognitive deficits such as tinnitus, but previous studies on tinnitus alone have been inconclusive.
BMJ 2001 322: 73-75.
Doctors who adopt a warm, friendly, and reassuring manner are more effective than those who keep consultations formal and do not offer reassurance, conclude authors of a Lancet review. Throughout history, doctor-patient relationships have been acknowledged as an important therapeutic effect-known as a context effect-irrespective of prescribed treatment. Zelda Di Blasi and colleagues from the University of York, UK, systematically reviewed 25 randomised controlled trials to determine whether the evidence supported the theory. The team concluded that enhancing patients' expectations through positive information about the treatment or the illness, while providing support or reassurance, positively influenced health outcomes.
Lancet 2001; 10: 733.
There is no correlation between the frequency of MMR vaccination and the rapid increase in risk of autism, say researchers from Boston Unversity School of Medicine. Using data from the General Practice Research Database, they estimated that the yearly incidence rate of newly diagnosed autism among under-12's increased seven-fold between 1988 and 1999 to a total of 2.1 per 10,000 person-years. In contrast, MMR vaccine coverage was virtually constant at about 97% for each successive annual birth group. If MMR vaccine were a major cause of the increasing incidence of autism, one would expect that the yearly risk of autism would cease to rise within a few years after the vaccine was in full use, say the authors, whose results suggested that this was not the case. They say the increase in recorded diagnoses could result from increased awareness of autism among parents and general practitioners, changing diagnostic criteria, or to environmental factors not yet identified.
BMJ 2001; 322: 460-463.
Thurstan Brewin died suddenly on 25th February 2001 at the age of 79 years.
He had been badly wounded in the war, which required an above-knee amputation of his right leg. He went to the London Hospital Medical College and qualified MB BS in 1949, and subsequently became a Fellow of the Royal Colleges of Physicians of Glasgow and of London, and also of Radiologists.
He was internationally known as an oncologist who carried out rigorous trials of cancer treatments, but who also put as much emphasis on the problem of supporting the morale of the cancer patients as on attacking their malignant tissue.
It was this combination of clear-sighted realism in the testing of treatments, together with his caring attitude to the whole patient, that made him such an asset to HealthWatch as well as to the other Charities to which he so generously gave his time and talents. He could draw on a rich store of both professional and personal experience when advising the Marie Curie Foundation about the management of patients with cancer, and to the Sue Ryder Foundation about the problems faced by amputees. He rarely complained about his own disability, but on direct questioning would admit that it was rare for a month to pass since the original injury in which he did not suffer discomfort bad enough to require an adjustment to the fitting of his prosthesis.
When HealthWatch was invited to give evidence to the House of Lords Select Committee on Complementary and Alternative Medicine Thurstan was an obvious choice to be our representative. In both speech and writing he explained very clearly the need for proper testing of treatments both in conventional and alternative medicine. Although he never denied the value of the placebo effect in medicine, he could cite many examples where a treatment was accepted on anecdotal evidence, but later proved to be useless or even harmful.
Perhaps his best memorial is a "Personal view" which was published in the 13th January 2001 issue of the British Medical Journal, on page 177. The piece is entitled "Deserted". He deplores the tendency of doctors today not to call on terminally ill patients unless they are called to a crisis: it is so much better for the patient if they know that the doctor will call regularly-say once a week. Many would say that this is the practical, caring attitude that tends to be missing in modern, hectic high-technology medicine. Thurstan was the personification of the caring scientific doctor.
We will miss him sorely.
John Garrow
John Diamond was one of the wittiest and most eloquent opponents of medical quackery. His interest in the subject was involuntary, a side-effect of malignant tumours in his neck and throat, but he swiftly became one of the most astute and scientifically literate commentators on cancer and the vile or foolish people who peddle snake oils in its wake. The disease spread to his tongue whose removal he bore with public fortitude and humour, and eventually to his lungs, "the proper home of cancer", as he put it. That he survived such vigorous cancer for four years after diagnosis is testament to the treatment he received, but John had an extra twinkle in his eye because he knew that his longevity served to confound what he called the "alternativists".
John's column in The Times became a diary of his illness, laying bare for all to see the torment, the hopes and the absurdities inspired by his condition. For many Times subscribers his article was the first thing they would turn to, and his candid, searing, brilliant writing made him well known and very much admired. His autobiography C: Because Cowards Get Cancer Too was adapted into a stage play and then taken up by the BBC, and John was due to play himself in the television version. A few weeks before he died he had agreed to make a television programme with me to expose how vulnerable patients are misled and often preyed upon by the vast alternativist industry and its gullible supporters.
Oncologists and the cancer charities will mourn John's death for he did so much to inform fellow-sufferers and defy the fatalism and awkwardness that tends to accompany the disease. Tobacco lobbyists will rejoice, for although John resumed his heavy smoking when he knew he was dying soon, he was a fierce opponent of the commercial cynicism of the tobacco industry.
It is often said of people that they bore their illness bravely, but John's courage went to the core of him. After being bombarded by offers of potions and pills and all manner of curious cures from well-meaning souls (as well as a few more sinister approaches by conmen) John researched the evidence, was appalled at how much harm was being done because of ignorance, set out to correct misconceptions and, finding himself under attack, struck back robustly, eventually becoming Britain's foremost public champion of evidence-based medicine against peddlers of unreason.
Unable to speak because of surgery to his throat and mouth, John flourished a notebook, rapidly penning his side of a conversation, and he relished e-mails: a simple inquiry would provoke a stream of erudite facts and withering analysis of "complementary medicine" but always tinged with humour and compassion. "Complementary medicine" and "alternative medicine", incidentally, were terms he eschewed: there is, he said, only medicine that works, and medicine that doesn't.
When John accepted HealthWatch's annual award last October his presentation was read out for him by Geoff Watts (reprinted in Newsletter 40, January 2001) and it almost brought the composed membership of HealthWatch to its feet. Thereafter in his column in The Times John wrote that of all his awards the one from HealthWatch was, "the most satisfying of the lot". Given that he was Columnist of the Year in 1997 for What the Papers Say and was shortlisted for the £30,000 Samuel Johnson Prize that was quite a compliment. Three weeks before he died John e-mailed all his friends to say the cancer was back with a vengeance. He had by then had as much radiotherapy as anyone could take, and "surgery would mean cutting out bits of me that I really can't do without". He died aged 47 on 2nd March leaving his wife, the writer Nigella Lawson, and his two children Cosima and Bruno, and leaving the world a slightly less civilised place.
Nick Ross
However, one of our objectives still is to expose healthcare workers (alternative or conventional) who make excessive or unproven claims for their methods for diagnosis or treatment of diseases. Recently public attention has been directed to another type of health fraud, in which medical researchers make excessive claims for the significance of their own research results-in some cases fabricating false data to support their claims.
In early December 2000 the Committee on Publication Ethics (COPE) published their third annual report (1), citing many examples of publication misconduct.
Since COPE was set up in 1997 they have considered 103 cases submitted by journal editors, and consider that there was evidence of misconduct in 80 of these.
Fabrication or falsification was a problem in 23 of these cases, but the commonest sin was redundant publication (29 cases) which some researchers consider a trivial offence.
It is ironic that two of the leading players in COPE, the editors of the BMJ (2) and the Lancet (3) published a similar editorial in their journals dated 16th December drawing attention to the COPE report. Some would say this was an example of redundant publication. The editorials complained that the statutory upholders of ethical medical behaviour-the Royal Colleges and the General Medical Council (GMC) - promised to take firm action to control publication misconduct, but so far have done nothing effective to achieve this objective.
There are two main difficulties. First, there is no consensus about what constitutes misconduct. For example, in an ideal world the results of all technically sound research should be published, but in reality papers which show a positive effect of some treatment are more likely to be published than ones which fail to find a positive effect. This is important, because it means that published reports have a bias that exaggerates the value of treatments, but does it follow that failure to publish negative results is misconduct? If so, is it misconduct by the researchers if they fail to submit the paper, or the sponsors of the research if they suppress the paper, or editors if they fail to accept the paper when it is submitted for publication? I think the problem of defining what constitutes publication misconduct could easily be resolved by separating misdeeds of presentation from misdeeds of fact.
Most of the problems considered by COPE concern presentation: the list of authors does not reflect those who actually did the research; the same data are submitted more than once; plagiarism; abstracts do not accurately represent the findings in the text; or conflicts of interest are not declared. Sometimes these are deliberate, sometimes they are caused by ignorance of the rules, or by the carelessness of the authors. Editors are well placed to insist that these faults are corrected before a paper is acceptable, and have the sanction of withdrawing a published paper, and/or banning an offending author from publication in their journal for (say) two years if the fault is deliberate or repeated. Since the motivation for this misconduct is to inflate the authors' CV this sanction would be simple and effective.
COPE performs a useful role in considering such cases in anonymised form, so that editors are not obliged to base their actions on their own personal whim. If the editor acts unethically he/she can be criticised in the correspondence column of the journal. The more difficult, and more serious, problem arises when the data in the paper may be fabricated or falsified.
Recently a consultant surgeon, Mr Anjan Banerjee, was suspended for a year by the GMC for publishing an article in Gut in 1990 that contained information which "was deliberately falsified" (4). This is a satisfactory outcome, but the ten-year delay between the offence and the punishment is not acceptable.
That the case was heard by the GMC at all is due to the persistence of Dr Peter Wilmshurst, who brought the accusations despite vigorous attempts to cover up by the employers of Mr Banerjee. Editors cannot be expected to detect false data in papers submitted to them, nor do they have adequate sanctions if accusations of fraud are found to be true.
Investigation of such cases is always difficult, especially since the local employers will tend to defend their staff to avert scandal in the institution where they work.
But accusations of fraud should not be too readily accepted, since false accusations may cause gross injustice to innocent researchers and their employers. Whistle-blowers are never popular with the people they accuse, and often are viewed askance by their colleagues and employers, who may wield great political power.
A striking example of punishment by the media of an innocent whistle-blower is provided by Dr Ludwig Gortner (5). He found that the antiseptic used in his intensive care unit for infants had become contaminated by a strain of Klebsiella that was resistant to the disinfectant, and therefore became a medium for causing sepsis. He published this finding in The Lancet as a warning to other doctors, but received unwelcome publicity from the mass media in Germany.
This has led to police investigations, a prosecution is underway, parents of uninfected children have lodged complaints with the hospital, and colleagues involved in joint research projects are unwilling to continue with the collaboration. In summary, I think there are adequate systems for dealing with researchers who excessively blow their own trumpet in the presentation of their findings. We have serious difficulties in adequately nurturing whistle-blowers that expose colleagues who falsify research data, promptly but discreetly investigating their accusations, and punishing those responsible.
However, I see no effective protection for public-spirited auto-whistle-blowers who fall prey to the mass media. In this cultural climate, why should anyone blow their own whistle?
John Garrow
Emeritus Professor of Human Nutrition University of London
References
It has been suggested that homeopathy may or may not be a placebo response.
I would argue that the juxtaposition of these two words is inappropriate in any case. In the first place, the use of the placebo concept is often greatly overrated. A placebo, or "dummy" treatment, is often associated with an apparent clinical effect. While the placebo itself is, by definition, ineffective it is conceivable that something about the way the treatment is given could affect the patient, perhaps by boosting the immune system or lowering blood pressure or increasing endorphins, thereby affect the course of the disease.
It is unlikely that there is a single explanation for pain reduction, recovery from infections, cancers cured or a generally improved sense of well being that may occur after administering a placebo. In experimental settings how could you separate the components? People who seem to be placebo responders in one test aren't in the next test. Carefully planned investigations of the difference between giving a placebo and not doing anything at all are scarce. In fact the placebo effect is-for therapeutic purposes-pretty useless, because you can't count on it anyway.
High "placebo effects" in placebo controlled studies are nothing of the sort. They are an inseparable mix of the natural course of the disease, various errors of judgements, and genuine improvements brought about by the psychosocial effects of the treatment. The rationale for having placebo controls in blinded randomised studies is to control for the whole of this inseparable mix. That's a feature of scientific method, that is, to eliminate as many subjective judgements as possible from your results.
Homeopaths seem often unable to understand this research philosophy. In a recent Dutch court case (1) a producer of a commercially successful liniment containing large amounts of undiluted comfrey presented the results of a clinical investigation. Their 'placebo' was, it seems, the usual white odourless ointment, while their product was yellowish and had an unusual pine needle smell, so patients getting their product quite possibly knew immediately that they were getting the real thing.
Homeopaths often claim that children and animals are insensitive to the placebo effect, because they presumably don't understand explicit verbal 'suggestions'. But both children and animals can be sensitive to the mood of those who care for them, and when those caregivers have to report about the effects of the treatment all the usual distortions can operate when there is no proper blinding.
There have been properly blinded and randomised studies with animals, but not many. J.J. Aulas (2) and L Ôscher (3) have reported on them, and the former's report of a grand total of four publications covering seven experiments shows the sorry state of animal experimentation in this field.
For example, U. Seifert (4) reported in 1987 in his Inaugural Dissertation upon an experiment with mastitis. Sixty-four animals (pigs) were given either a homeopathic treatment (some of it in low potencies) or a "normal" treatment. The homeopathy group had better results. But there was no comparison with ordinarily (non-homeopathically) diluted stuff or a placebo and it was not clear whether the "normal" treatment was in doses likely to be effective (often "normal" treatments for animals like pigs and cows use too small doses for economic reasons). When two years later the Seifert study was repeated with better controls there was no distinction between homeopathy, "normal" medication and placebo (3). There is, to my knowledge, only one well designed large animal study of homeopathy (with almost 5000 pigs), and that yielded clearly negative results.
The other inappropriately used word is 'homeopathy'. Classical homeopathy is supposed to work through administration of a (1) single (2) diluted substance that creates a (3) disease with (4) 'similar' but not equal symptoms in (5) healthy persons. It is supposed to cure a (6) specific constellation of complaints in a specific (7) human individual.
When homeopaths are criticized for using high dilutions, they point out that the succussions between the dilutions are absolutely essential for amplifying or liberating the power of their preparations. This goes back to Hahnemann (5) who quite explicitly linked the life force to magnetic phenomena (iron bars that are hammered or rasped, or just stroked with magnets become magnetized. However, 'homeopathy' covers a wide field of contradictory practices and theories. All the seven principles above are violated in applications and experiments. Homeopathic pharmaceutical companies sell undiluted OTC preparations (mother tinctures) for specific indications, or mixtures of substances that haven't been tested on healthy persons. The lack of theoretical and practical coherence of homeopathy was already the main conclusion of D.K. de Jongh's (6) dissertation back in 1943.
So a test of 'homeopathy' seems impossible or meaningless. What is more, while homeopaths seem happy to overlook studies yielding negative results, when somehow a positive result emerges all the contradictions are forgotten and the theories seem proven beyond doubt in one fell swoop.
Brigo (7) found a very clear result with classical homeopathy for the treatment of migraine. Blinding and randomisation seemed in order and from the publication one could only notice an unusually low rate of improvement of the placebo group. Then Brigo's investigation was very carefully duplicated in Munich (8) and nothing was found.
When Klaus Linde et al (9) did a meta-analysis of homeopathic investigations they found roughly that if you put all homeopathy investigations together there were a tiny bit too many ones with positive outcomes. But they left out the Munich study, even though its design had been published in 1992 and its outcome in the form of a biometric report had been available since December 1994, whereas supposedly the Linde study used anything that had been available before the middle of 1995.
The zeal of homeopaths drives them to organizing RCTs. These trials collectively suggest that 'homeopathy works' and it does: it clouds the minds of the experimenters into making mistakes (or worse) that all go in the same direction, notably carrying on 'research' after the codes are broken.
Jan Willem Nienhuys
References
I must admit I have never liked this kind of title. Nor do I like the scary diagram of a crab on the cover. There's nothing wrong with the subtitle except that "coming to terms with" has become a bit of a cliché. For the authors, however, I have nothing but admiration.
The first half of the book is written by Linda, who developed ovarian cancer soon after her fiftieth birthday, the second half by her husband. They have two young adult children. They are both exceptionally articulate, so it's not surprising that they have given interviews to help "Ovacome", the ovarian cancer charity. They have private health insurance and are not hard up ("a silver and enamelled box for £7,500 was rather tempting", writes Roy when he catches sight of one), but I'm glad they imply that basic care and communication may be just as good in the NHS. I hope this is still as true as it was in my day.
Almost the entire book is written in diary form and in the present tense, which brings it sharply into focus. Inevitably there is a fair amount of overlap when each describes the same episode from their own vantage point.
But both write so honestly, skilfully, and vividly that it doesn't matter.
Both have a scientific background. Alternative medicine hardly gets a mention. Something that would never have been mentioned until fairly recently - yet what could be more natural? - is Linda's entry in her diary, "I'm very nervous about our first post-op sexual activity, but find that a gentle session doesn't cause any problems".
The choice between optimism and pessimism, the doubts, the gnawing fears-and the huge difference it makes when these are handled by medical and nursing staff in a sensible and sensitive way-are all well described. I have known many other couples in the same position who have shown equal courage, but few with the same ability to express it. What comes across is their love of life, their love for each other, their understanding of each other's reactions to the crisis they share-and an absolute minimum of anger, bitterness or self pity.
All this is conveyed not so much in stark or embarrassing terms as by the general impression given by reading between the lines. And, of course, the understanding between them is not perfect. For example, a sudden interesting comment from Roy - "Linda still feels that I inhibit her from letting her emotions run their course".
Many ex-patients, cancer or not (including doctors - some of whom have had quite a lot of experience of being patients) will be reminded of the sort of thing that may have to be endured before a diagnosis is reached. In this case it took three months of consultations and investigations. Would some professionals have got there sooner? Possibly. But ovarian cancer is notoriously hard even to suspect, let alone confirm, from the early symptoms. Anyway, in August 1997 surgery reveals not only the cancer, but extensive abdominal spread. Which is exactly where a sister-in-law of mine (now very well) was 15 years ago with the same kind of cancer, so there is always hope. It's good to read how satisfied this couple were with the care they received. And all HealthWatch members will be particularly pleased to see how readily they agreed to enter a randomised comparison of two kinds of chemotherapy. Like many others, they also found this an easier form of treatment than they had expected.
In February, when it's all over, they go for a five mile walk together, Linda very conscious of the fact that her hair (including eyelashes and eyebrows) has still not fully regrown. In May she is back playing badminton. And as often happens (heaven knows why) her previously straight hair is now curly.
Thurstan Brewin
Dear Sirs
I was extremely interested to read the article, "The Changing Face of Refractive Surgery" in a recent edition of the HealthWatch newsletter (issue 39, July 2000).
I have been extremely shortsighted since the age of seven, and the thought of being able to manage without glasses is attactive. However, ever since surgical correction of shortsightedness has been available, I have asked every single consultant ophthalmologist that I have met whether they would have the surgery performed on themselves. I have now asked well over twenty consultants. I have yet to meet one who would be prepared to have the operation on themselves. This has obviously put me off this surgery, and these responses beg more questions than they answer.
Yours faithfully
David Haslam
Dear Sirs
John Diamond's presentation to the HealthWatch AGM (HealthWatch Newsletter issue 40, January 2001) expresses so much of my own concerns about the very misleading term, "Alternative Medicine" and patients' unquestioning faith in various pills and potions and even my own profession, osteopathy.
After nearly fifty years in osteopathy I have at last seen regulation by the statutory registration incorporated in the Osteopaths Act (1993) but I still crave the research which will prove the widespread belief in its effectiveness as the evidence could still be said to be anecdotal in spite of a vast number of happy patients.
Osteopathy has come in from the fringe, since my student days in 1955, towards acceptance by the government and the medical profession as well as the patients. However, during these near fifty years the proliferation and blind acceptance of so many doubtful, to say the least, methods of treatment-all of them under the umbrella of "Alternative Medicine"-has been as much beyond belief as many of the treatments themselves! Otherwise intelligent people often become unthinking when they become patients-how often have I heard patients say, "I don't mind what you do to me as long as it helps." Where is their caution, why this unnerving trust? However, John Diamond's inference that life expectancy has increased so much due entirely to conventional medicine is probably not true. The underlying improvements since the turn of the last century in housing, sanitation, diet, water supply, clothing, transport and a reduction in poverty have played a very large part in this change.
If as much intense research went into the good and bad effects on health of diet and lifestyle, as into the search for new drugs, and if populations were educated about how to look after their health, lives would probably be longer and healthier than ever and conventional medicine-the drug therapy that is-would be needed less.
Yours faithfully
Richard Pitcairn-Knowles