Dr Peter Wilmshurst has agreed to accept this year’s HealthWatch Award, and his address on the subject of “Obstacles to honesty in medical research” will take place at the 2003 Annual General Meeting on Tuesday 28th October at the Medical Society of London.
Peter Wilmshurst, now a Consultant cardiologist at the Royal Shrewsbury Hospital, first became concerned about dishonest research practices in the early 1980’s when a pharmaceutical company tried to persuade him to alter his own research. When the medical establishment would take no action, he turned to the media and subsequent publicity led to his being approached about other examples of unethical practice. Led by concern about a case in which misconduct was well known by senior doctors and managers who turned a blind eye he brought the case, and the issue of research ethics, to the media’s attention in his frankly titled paper “Institutional corruption in medicine”1.
Those wishing to attend the HealthWatch AGM will find full details published in the July Newsletter.
Reference: Wilmshurst P. Institutional Corruption in Medicine. British Medical Journal 2002; 325: 1232–
The article, an edited summary of the original position paper, argues that the European Commission’s current proposals, which plan to allow DtCA for a limited number of conditions subject to self-regulation, will not be enough to force pharmaceutical companies to act in the public interest. Allen and Ross instead put forward HealthWatch’s five proposals for a framework that will, they believe, liberate patients, physicians and industry.
Michael Allen’s position paper on Direct to Consumer Advertising of Prescription Medicines is available by clicking here. The magazine pH7 can be accessed online at http://www.ph7.epolitix.com
pH7, 26 February 2003, issue 5, vol 1
Products containing combinations of herbs with “nutrients” such as vitamins and minerals should now be permitted, provided such remedies are genuinely traditional; and the required minimum period of traditional medicinal use within the EU is to be reduced from 15 to 10 years. Both amendments are supported by the Medicines Control Agency.
It is predicted that EU member states will need to set up their own product registration schemes by the end of 2004, followed by a five-year transitional period during which manufacturers will be expected to ensure their products comply with the new directive.
Under the new directive, product quality will be considered in relation to safety—manufacturers will have to ensure ingredients’ purity and stability, for example. This contrasts with rules for conventional medicines, which also have to show evidence of efficacy. Pack leaflets will have to be included that comply with requirements laid out in the directive, but manufacturers will also be allowed to make minor medicinal claims for their products.
Pharmaceutical Journal 2003; 270: 201–202.
Professor Garrow was prompted to action by the low number of entries to last year’s competition, which invites undergraduate students of medicine, nursing and alternative therapies to evaluate four hypothetical research protocols. Despite a top prize of £3000, with reminders sent to 91 academic departments, we received only 21 entries. Why so few? Garrow suspects that at least part of the reason was that the examinations which students face are not designed to test their ability to appraise protocols, and that students set a low priority on learning skills that will not be tested in examinations. “This is understandable, but unfortunate,” laments Garrow. “When they graduate and enter clinical practice these students will be expected to maintain the principles of evidence-based medicine, but much of the ‘evidence’ they are shown will be of poor quality. Patients now appear in GP surgeries with material downloaded from the Internet that may give very misleading information about the efficacy of treatments. Surely it must be an important part of medical training to be able to tell the patient if such information is reliable, and if not, why not?”
The 2003 HealthWatch Student Prize, with a new set of protocols, will be launched in April, with a closing date for entries of 31st July.
THE ADVERTISING Standards Authority (ASA) is getting tough with advertisers who make wild claims for sports and muscle supplements such as, “The Bodybuilding Breakthrough that can get you Ultra-ripped in just 72 hours!”. Other products promise to inhibit fat absorption, boost the immune system, increase metabolic rate, raise testosterone levels or suppress appetite. Two advertisers have already been referred to the Director General of Fair Trading with a request for action to be taken against them under the Control of Misleading Advertisements Regulations (1988).
KING’S College London is to host the 11th European Skeptics Congress on September 5–7, 2003, organised by the Association for Skeptical Enquiry (ASKE). Edzard Ernst, Professor of Complementary Medicine at Exeter University will be giving a keynote address at the Congress.
Symposia will be devoted to different areas of interest to sceptics. These will include Science, Health and Medicine, Parapsychology, Anomalistic Psychology, and ‘Scientists on the Defensive’—the last-mentioned may be include a debate and individuals not attending the full congress will be welcome to attend and participate. For further details visit the ASKE website www.aske.org.uk or contact The 11th European Skeptics Congress, ASKE, P.O. Box 5994, Ripley, DE5 3X. E-mail: general@aske.org.uk
FEWER than 20% of heart attack patients who consented to enter a treatment trial had actually read the information sheet given, reports a New Zealand team investigating the consent process. The 78% of patients who had not been educated beyond secondary school said they found the sheet difficult to understand. Informed consent is mandatory for patients entering randomised trials in emergency situations but the team found that in reality consent may not be as well-informed as it should be and recommend that information should be communicated verbally in simple, concise language, supported by written information.
The Lancet, 15 March 2003
THE HEALTH benefits of being married have been demonstrated by a number of studies, and there is some evidence from the US that the use of psychometric marital and pre-marital inventories can result in lower divorce rates. GPs with a counsellor in their surgery or health centre who would like to take part in a study using psychometric inventories are invited to look at the sample statements at http://www.affinities.org.uk and to e-mail nickgulliford@affinities.org.uk for more details.
THE HORMONE melatonin has long been used to prevent and treat jet lag, but in Europe and Australia it cannot be sold because it is not licensed. HealthWatch Committee member Andrew Herxheimer argues in the British Medical Journal that if use of the drug is in the public interest, then public funds should be used to get it adequately tested to be licensed. A recent review found that eight out of ten randomised controlled trials found a clear reduction in the effects of jet lag when melatonin had been taken.
British Medical Journal 2003; 326: 296–7.
THE NATIONAL Institute for Clinical Excellence (NICE) now has a website. Anyone interested in being kept in touch with the agency’s evaluation of medical treatments and technologies can register to receive regular alerts and the monthly e-newsletter on the website http://www.nice.org.uk
THREE Books by the late Petr Skrabenek, a past recipient of the HealthWatch Award, are now available by post. “The Death of Humane Medicine” and “Follies and Fallacies in Medicine” (the latter co-authored with James McCormick) are softback, and the hardback “False Premises, False Promises” is a selection of his papers. All are now available priced at £15 or 23 euro (including postage and packing). Orders accompanied by a cheque made payable to The Skrabanek Foundation should be sent to Dr Maurice Gueret, P.O. Box 5049, Dublin 6W or e-mail: mgueret@iol.ie
HAS ALTERNATIVE medicine become a euphemism for things that can’t be shown to work? A recent Lancet editorial considered the difficulties in evaluating the effectiveness of primary care. “Is its contribution measurable?” it asks, “Or is primary care to be accepted as the homoeopathy of modern medicine—incontestable, irreducible, and, ultimately, irredeemable?”
The Lancet 22 March 2003
The time has come to name and shame those who use celebrity status to promote medical misinformation, says Professor John Garrow
A PRESS conference in May 1989, chaired by Caroline Richmond, officially launched our organisation that was then called The Campaign Against Health Fraud (CAHF), modelled on Quackbusters in the USA. The speakers were our President, Nick Ross, Professor Michael Baum who spoke about fraudulent cancer treatments, and myself about dodgy nutritional claims. By 1990 Malcolm Brahams was seeking for us the status of a Registered Charity, but Charities are not allowed to campaign, so in July 1991 we were registered in the name of HealthWatch. Our objectives then, and now, are set out on the back page of each Newsletter, and summarised in the by-line “Enhancing informed choice through reliable information”.
Over the last decade it has been immensely encouraging to see the organisation grow in strength and influence, while maintaining our absolute independence from any vested interest in the healthcare field. We are still concerned to expose misleading advertising for alternative methods of diagnosis or treatment for which there is no good evidence of efficacy, but increasingly we are seeking to promote good practices in the assessment and testing of treatments, whether “orthodox” or “alternative”. This more positive emphasis is reflected in the recent change of our by-line to “HealthWatch, for treatment that works”.
It was an important development when we decided to make an annual award to a person who had, in the judgement of the executive committee, been outstandingly effective in publishing reliable information about healthcare. Our first award in 1993 was to Geoff Watts, who has been recognised by many organisations as an extraordinarily competent and accurate reporter of healthcare news. Other journalists to receive the award were Annabel Ferriman (1997), Polly Toynbee (1998), Bernard Dixon (1999), John Diamond (2000), and Claire Rayner (2001). We have also honoured the clinical scientists who did the research from which this reliable information was obtained. Professor Edzard Ernst (1994) received the award for his scrupulous analysis of the evidence base of alternative therapies. Professor David Sackett (1995) was recognised for his work at the Cochrane Centre with meta-analysis as a basis for evidence-based orthodox medicine. Professor Sir Richard Doll (1996) is the outstanding contributor to clinical epidemiology, especially the health hazards of cigarette smoking. An award (sadly posthumous) was given to Petr Skrabanek, a witty and outspoken critic of the weaknesses of clinicians.
Last year our award went to Prof Michael Baum, one of our founder members. His concern was that breast screening for cancer was being promoted by the Department of Health as a procedure that saved lives, and therefore was a good idea. However, critical examination of the evidence showed that the claim to save lives was by no means clear, and that there were important disadvantages of breast screening that were not properly acknowledged. These were principally the anxiety and distress caused by the large number of recalls for further investigations in women who did not have cancer, or who had a cancer that might never be a serious threat to health. Also the screening programme involved resources (both in money and staff) that might more profitably be employed elsewhere in the NHS.
It was once a criticism that HealthWatch picked on way-out alternative practitioners offering absurd therapies, rather than tackling the much more important and difficult problem of conventional doctors who mislead their patients about the efficacy of the treatment they offer. This is certainly not true today. Indeed the contribution of Dr Peter Wilmshurst, to whom the 2003 Award will be given, is his courage and tenacity in exposing dishonest research practices in some of the most distinguished medical institutions in the country. The lot of the whistle-blower is not a happy one, especially if this causes offence to the most senior members of the medical profession, but it is essential that medical research is irreproachably honest if the public is not to be misled.
Last year also saw the inauguration of the HealthWatch Prize for students of the healthcare professions (medicine, nursing and alternative medicine). It is no use telling students that they must practice medicine based on evidence from clinical trials if the student cannot tell a good trial from a bad one. Assessment of clinical trial protocols is a skill that is not well learned by many medical graduates, perhaps because it is not part of the final professional examinations. We are therefore offering prizes to students who best show that they have learned to appraise clinical trial design. If more healthcarers were competent to do this it would advance our aim to promote good practices in the assessment and testing of treatments, whether “orthodox” or “alternative”.
So do we need yet another HealthWatch award? I think perhaps we do. I am proud that, looking back over the development of HealthWatch, we have advanced from mere quackbusting to the serious criticism of healthcare procedures, even in the most august institutions of the medical profession. But our aim is to provide reliable healthcare information to the public, and the public obtains information mainly from the broadcast and written media. Sometimes the media provides good information, but sometimes the message is fundamentally flawed. Even the very best journalists, to whom we have given awards, have very frankly explained the pitfalls in the path of a competent and conscientious medical journalist trying to earn a living by reporting current healthcare issues. In her address on acceptance of the 1997 Award Annabel Ferriman observed: “Newspapers are not universities. They don’t pay journalists to research into medical matters, fully inform themselves and then occasionally impart some of their wisdom to the British public.” Their copy must be exciting, comprehensible, ahead of the competition and (as far as possible) true. Under these pressures they are bound to make mistakes from time to time.
However there is a class of medical journalistic malpractice that cannot be excused on the basis of time constraints, and it is becoming ever more prevalent. This is the celebrity endorsement. Those who organise presidential election campaigns are aware how valuable it is to have of the endorsement of a particular candidate by a famous pop musician, or actor in a soap opera. This is a legitimate publicity tactic: the celebrity is as entitled as any other member of the electorate to favour a particular candidate to vote for (or a product to buy, for that matter), and because he/she is a celebrity that view will carry more weight than usual. When it comes to matters of healthcare different rules should apply. For example Dame Barbara Cartland was an extraordinarily prolific romantic novelist, and hence a Celebrity. She had a newspaper column in which she dispensed advice to the readers on matters of romance (on which she may have some claim to expertise) and about the health benefits of nutritional supplements, on which she clearly had very little. It is difficult to assess the effect that Dame Barbara’s pronouncements had on the use of such supplements. She clearly expected them to be taken seriously, and no doubt sometimes they were, which is a pity, because they were unfounded.
The revised Code of Practice (1995) of the Advertising Standards Authority expressly forbids celebrity endorsement in advertisements for medicines, but there are loopholes with this rule. For example the Evening Standard of Tuesday, 25th February carried, in its Health and Fitness section, a feature written by Jenny Seagrove (an actress) entitled “How can they ban the pills that keep me well?” The piece is written to complain that the Brussels bureaucrats want to ban the vitamin and herbal supplements on which she relies for good health, so by next year they would only be available on the black market. No doubt she sincerely believes this is true, but it is not. Celebrities are Opinion Leaders: the public were influenced by Dame Barbara Cartland because she was a rich and famous novelist, and by Jenny Seagrove because she is a well-known actress. Unfortunately their opinions on matters of healthcare are wrong, so they are Celebrity Opinion Misleaders (COM).
I do not suggest that Jenny Seagrove is uniquely misguided, or that the Evening Standard is uniquely to blame for publishing her feature: magazines abound with celebrity endorsements in matters on which the celebrity may or may not be expert. However I do suggest that celebrity endorsement in the field of healthcare is a potent source of misinformation to the public which is, at present, uncontrolled. A letter to the editor setting the record right may or may not be accepted for publication, and even if it is published will have little impact on readers of the newspaper.
I therefore propose that we offer the COM-trick award, to be presented annually to the Celebrity whose views on some aspect of healthcare mislead public opinion. There should be many candidates for such a prize, but the winner in any given year would be the person who was judged to be the greatest celebrity, who has the least knowledge of the aspect of healthcare addressed, and whose views most seriously misled public opinion. The COM-trick award would be appropriate to the winning publication. For example, if Ms Seagrove won she might benefit from a copy of the draft European directive on herbal remedies and the excellent book “Guide to Popular Natural Products” that gives a summary of the known value (determined by controlled trials) and dangers of a wide range of herbal remedies.
John Garrow
Emeritus Professor of Human Nutrition
University of London
IN PSYCHOLOGY there is a condition known as Learned Helplessness. It happens when people have had a series of disappointments and, to them, failures that have led them to believe they are useless and incapable of anything. This can affect patients who have lived with a chronic illness for many years when, having tried different therapies to no avail, they develop a sense of hopelessness and desperation for a treatment that will finally relieve their symptoms.
When the conditions come under the heading of ‘embarrassing illnesses’ then the problems are magnified. People may not seek help from the GP or nurse. They will not talk about the problem with partners. Social avoidance behaviours develop as the sufferer attempts to hide their symptoms from others.
It is perhaps these ailments which are most likely to drive those afflicted to seek recourse from dubious therapies, and in such cases we cannot even guess at the extent of the disappointment, financial cost and doubtless psychological damage that result. Each subsequent failure to find a cure adds to the feeling of helplessness. When the problem has psychological overtones and visible observable behaviours as seen in some forms of social phobias then the feelings of shame and helplessness are particularly high. This is especially true of an extremely common, often painful but only recently recognised problem called Avoidance Paruresis. Its more common, and graphic, labels include Shy Pee and Bashful Bladder.
Imagine walking into a room and feeling anxious. You tell yourself to relax, but your whole body remains tense. Your breathing becomes rapid and you may break out into a sweat. You think that everyone is watching you and noting your every movement. Now imagine the room you are in is a public toilet and that you need to urinate badly. But nothing happens. As you wait the tension becomes worse. You are in pain and frantic to urinate but cannot. Despite your distress you leave the toilet in pain. You suffer physically and emotionally. The failure has reinforced your belief that this is something you can’t cope with. This is Avoidance Paruresis.
The nature of this condition and the reluctance of those affected to seek treatment from family doctors means it is difficult to estimate the numbers of those affected but the UK Paruresis Association (UKPA) estimate there could be millions in the UK. What we do know is that nine out of ten sufferers are men. We also know that, like other social anxiety disorders, this inability to use a public toilet—or even the toilet in their own home when others are present—is a problem that can develop in early childhood or adolescence. So it is clear that some paruretics may have hidden their secret for their entire adult life, with accompanying disruptions to their social life, their work, and family relationships, sometimes even changing jobs to avoid embarrassing situations.
Many GPs are unaware of the extent to which avoidance paruresis can affect quality of life and can be unsympathetic. The UKPA have found that paruretics who do seek help probably see four to six practitioners without result before, if they’re lucky, getting effective treatment. A USA cost analysis estimated that 10 years of ineffective treatment for this type of condition may cost $10–12,000.
In contrast to orthodox medicine, many alternative therapies seem to offer more promising results, but there is little evidence for success. Treatments for social anxiety disorder are also necessarily expensive as most treatment trials are 12 weeks in length. Hypnosis has been tried by many paruretics—with a price tag not uncommonly of £400 to £500 for a course of ten sessions—but this approach seems to be ineffective. Psychological counselling in some form may be offered, even though many therapists with experience of helping paruretics consider that psychodynamic and other traditional psychotherapies probably have no place in the treatment of social anxiety disorder. Talking therapies do not work here without a behavioural component in the treatments to give confidence and feelings of successes. (One approach that is recommended by the International Paruresis Association and which is the basis for the many workshops run internationally is systematic desensitisation. The person is confronted with the worst fears and then is gradually introduced to the source of that fear, reducing the anxiety levels.)
There have been recent reports in the press of claims made for face tapping techniques such as Field Therapies; (emotional field therapy (EFT) or thought field therapy (TFT). There is no research to show that these techniques offer a lasting cure. Others have sought herbal cures. But the evidence here, too, is that the money buys little or no result.
Not surprisingly some paruretics have tried alcohol or even drugs such as ecstasy, marijuana and LSD in the mistaken belief that this might help them relax enough to allow streaming to start. One reported that an LSD trip was so distracting that for him “it effected a complete but regrettably temporary cure”.
To date however there is no real cure, just a long painful battle, sorting out the mind games of many years. But there is progress when people are willing to work at this and day by day break down the steps that lead to failures. In extreme cases the only form of relief is self catheterisation, a procedure which, in the ill informed, may run risks of injury or infection. The registered charity known as The United Kingdom Paruresis Association (UKPA) advise on the kind of treatments that from practical experience are most likely to be successful and where sufferers should go for help. They run a website and organise regional meetings and workshops. Through the UKPA sufferers are advised to seek professional advice through a GP referral to a consultant urologist. An early day motion in the House of Commons recognised this health problem area and called for more advancement of treatments for this condition. Well informed doctors, nurses and other health professionals are essential for progress.
As for many other “embarrassing” and “secret” ailments it is sympathetic and informed treatment of this problem, not promises of quick fixes through dubious alternative treatments, that will help those afflicted to live a normal full life.
Professor Alex Gardner
Member of the advisory panel of the International Paruresis Association
Consultant to the United Kingdom Paruresis Association
Websites: http://www.shybladder.org.uk and http://www.paruresis.org
THE TIME has come to stop wasting scant resources on researching most areas of Complementary/Integratory Health and to focus instead on the few which actually submit to scientific method. Evidence from sources that are not subject to bias by vested interests is in short supply. Yet according to recent reports (HealthWatch Newsletter issue 48, January 2003) the Complementary Medicine (CAM) department at Exeter University may be forced to close because its results are not finding favour with benefactors.
Many areas of CAM such as Acupuncture, Homoeopathy, Radionics, Applied Kinesiology, Iridology are allied more to faith than to science. Scientific research into them will never be sufficiently positive to satisfy the establishment. Edzard Ernst, who heads Exeter’s CAM department, has confirmed this and so potential benefactors have vanished. HealthWatch should perhaps aim for consumers to be made aware of the element of faith that is fundamental to many CAM practices rather than ask its followers to produce “evidence”.
Whilst a vast body of CAM practice defies logic there is at least one area—I refer to my own field, that of nutritional supplementation—which should be capable of scientific evaluation. However, I fear resources are insufficient and vested interests against them may be too great to prove their value to the satisfaction of the medical establishment—which is why the loss of the world’s leading centre for quality independent research into complementary therapies is such a tragedy.
Media stories about the poor quality of the British diet are ever popular. The demand for high fat, high sugar and highly processed foods of relatively low nutrient content, coupled with spiraling obesity levels, support this view.
The industry that produces and markets attractive but nutritionally poor foods could be said to have a vested interest in the status quo and in denigrating the idea that supplements in tablets or capsules can be helpful. That their members might be capable of using deception to protect their market is open to question, but a series of events that took place in 1988 gave cause for concern.
In that year some research [1,2] demonstrated that where children were not eating an adequate diet, quantitative addition of a number of well known discrete diet components had a beneficial effect that could be objectively measured through non-verbal IQ points. For the purposes of the research dietary supplementation was achieved using a pharmaceutically prepared dose form—obviously it would not have been possible to give measured nutrient quantities using oranges for vitamin C, spinach for folic acid etc. The vitamin supplements were supplied to the researchers at their request by my then company, Larkhall Laboratories, a small manufacturer of vitamin supplements. The results suggested that there are indeed people in this country who do not eat a balanced diet, who suffer measurable effects as a result which are reversible with improved nutrition (as, incidentally, does more recent research on antisocial behaviour of prisoners [3]). While pills were the research tool the message that diet was the answer should have been clear. The events that followed showed, however, that it was not.
The research was misreported. A documentary TV programme in January 1988 that investigated the research and its links between children’s diet and IQ put emphasis on diet—yet the tabloid newspapers gave pills the star billing. No particular brand was ever mentioned and shelves were cleared of all vitamin pills by consumers. My old company did not initiate the publicity or the misleading angle although many thought we did. We were very small players in the market.
The same journalists all did a volte face in July 1988 when the negative results of another trial using a different formula pill [4] appeared in the media. The research seemed to have been hurriedly conducted—involving just one month’s trial compared to the nine in the original—and indeed at least one national newspaper was running the story even before the preliminary report had been published. The research department in question was partly funded by the World Sugar Research Organisation—a point which did not surface in press reports and interviews.
The new study used a different formula and method and so should not have stood comparison with the original four trials [2,5,6,7], all of which had been positive. For the sake of the consumer, I believe repeat studies to confirm the results should have been conducted by an independent body, such as Exeter.
Exeter is already taking an interest in nutritional therapies. Supplement products can be made to consistent standards so that clinical investigations can be undertaken on standardised products. If research resources for food supplements are not found then the outlook is bleak for the public because all real resources will be vested in the multinational food and pharmaceutical industries, establishment medicine and Government here and in Brussels. Their agenda is open to question and rightly causing disquiet among informed consumers and some health professionals. The stakes could not be higher.
Robert J Woodward
References
This article was edited for reasons of space. A full version is available by clicking here. Further information is available in The Tandem IQ Story by RJ Woodward, Roberts Publications 1994.
THE DAILY Mail, whose medical stories do not always adhere to principles of which HealthWatch would approve, should be commended for reporting (5 March) a recent review by Jonas et al of homoeopathy [1]. Homoeopathy was invented by Samuel Hahnemann, who in 1796 first explained what Oliver Wendel Holmes described as “his peculiar notions”. Hahnemann’s notion was that like cures like, so a substance that causes a symptom is given as cure. It is given, however, in extreme dilution, and the more the dilution the more effective the compound.
For me, no further criticism of homoeopathy is necessary beyond that of Holmes [2], and homoeopaths freely admit that the dilutions are so great that there may be no molecule of the curative substance in the purchased bottle. Jonas’ overall conclusion was, “There is a lack of conclusive evidence on the effectiveness of homeopathy for most conditions.” I think an opportunity was missed to add that the lack of evidence is not surprising, given the putative mechanism, but instead was added, “Homeopathy deserves an open-minded opportunity to demonstrate its value by using evidence-based principles.” Having seen only the Daily Mail report and the abstract of the paper, I cannot guess the motives for the conciliation. The usual motives in mainstream medical journals that report homoeopathy are the understandable reluctance to upset anyone, and the impossibility of proving a negative.
The Daily Mail’s approach to medicine is in general a populist one: it reports on medicine in a way it expects to appeal to its readers, rather than to educate them. Given the popularity of homoeopathy, the headline “Homeopathic remedies that won’t make you better” under a page-top banner “Patients better off with conventional treatments, says study” with a picture of a pretty woman “Trusting to nature: but there is little evidence homeopathy works” were perhaps a bold move for the Mail. We read newspapers, however, mainly to confirm what we already believe. The article ends with quotes from a spokesman from the British Homoeopathic Association saying, “there is every reason to explore some especially promising areas” and, “homeopathy is steaming ahead because the holistic approach to health… seems to benefit patients”.
When “promising areas” in homoeopathy are explored, believers reject evidence in favour of faith. Arnica is much favoured as a homoeopathic treatment for bruising, but the conclusion of a recent paper [3] was that arnica was no use for bruising or pain after surgery for carpel tunnel syndrome (a minor operation at the wrist to free a trapped nerve). A news report in the British Medical Journal [4] attracted the usual rapid response e-letters complaining that the study had not been done correctly or else responses of the type, “this study might not have worked, but I know arnica worked for my toddler”. The responses were best summarised in the final rapid response, from a Belgian Professor of Family Medicine who wrote, “It is refreshing to learn from homeopaths that they knew all along that their brethren prescribed useless treatments and to see this confirmed by scientific testing. Homeopathic science has taken a giant step forward by confirming one more non-indication. The next step should now be for the researchers to do another trial, taking into account the bluntness of the trauma and avoiding to administer Arnica before the blow is delivered. What if it again shows to be not better than placebo? Will the art of Arnica therapy be adjusted once more, or will they abandon using Arnica, or will the faith prevail?” Sadly, the faith is likely to prevail.
HealthWatch is often criticised for criticising alternative medicine more than it does mainstream treatments, but there is much to criticise in mainstream medicine. More credit is due to the Lancet for publishing David Horrobin’s brilliant Personal Paper [5] about the futility of much research into new drug treatments for cancer. The government is obsessed by cancer treatments, yet many drugs for cancer are expensive, toxic, and of little benefit. Horrobin argues that we need to get away from large, drug company controlled trials, which are looking for small effects in large groups of patients, and look for larger effects in small groups. There are many compounds to test, but the research is unlikely because the administrative costs of research are now too high to test compounds that cannot be patented. Thus, simple compounds that may be novel approaches to treating cancer are ignored in favour of complex expensive compounds. The main thrust of Horrobin’s argument is ethical: he believes—and unfortunately writes from experience—that patients enter cancer trials not out of altruism but because they want to live longer. The current large trials are unethical because there is “the remote chance of a cure… the certainty of toxicity and the near certainty of no useful response”, and he believes most participants in the trials are unaware of this.
Neville Goodman
Consultant Anaesthetist, Southmeads Hospital, Bristol
References
Dr Gus Plaut, retired General Practitioner of Halstead, Essex, writes to defend the practice of male circumcision.
Dear Editor,
THE ARTICLE by Dr Peter Ball on male circumcision: minor surgery or an unforgivable cut? (HealthWatch Newsletter issue 48, January 2003) requires an answer.
I agree with Dr Ball that no operation should be done unless there is a good reason for it. Even minor operations carry a risk and most doctors will have seen an occasional complication following circumcision.
Nevertheless tradition (religious or otherwise) may be a good reason for an operation. In our society very many girls have their ears pierced so that they can wear dangling earrings. I have seen this procedure followed by nasty sepsis. Would Dr Ball advocate a law against this, and indeed against all cosmetic surgery? It is important to consider psychological factors as well as physical factors when advising for or against an operation. Many Jews would be very upset if circumcision was not permitted.
Christians consider the christening at baptism a sign of admission to a Christian Church. In a similar way Jewish parents consider circumcision of their son a sign of admission to their religion.
Genesis 17: 11 states: “And you shall circumcise the flesh of your foreskin: and it shall be a token of the covenant betwixt Me and you (The King James Bible).” Circumcision and study of the Jewish Bible was prohibited by law by Antiochus IV (165 BC) and several times since then, in the 20th century by the Nazis in Germany. Jews continued to be circumcised, often facing a death sentence.
Circumcision was universal in all Middle Eastern countries, except only the Philistines, from antiquity. In early historical times a flint was used for this procedure, suggesting that the tradition dates to the Stone Age.
Circumcision has been claimed as a fertility rite; Moses Maimonides (the great 12th century Jewish philosopher and physician) suggested the opposite namely that it reduced sexual activity to a manageable level. Is there any real evidence that the foreskin enhances sexual enjoyment, as Dr Ball claims?
In modern times in the United States of America circumcision is very commonly advised for “hygienic reasons”. It is claimed that in uncircumcised boys a few drops of urine may be retained under the foreskin, and that these can be a source of an ascending infection and cystitis. Dr Ball, in his article, apparently claims the opposite, namely that the foreskin prevents such infection. I have seen no unbiased statistics to prove either suggestion.
I agree with Dr Ball that the often-quoted statement that Jewish women do not develop cervical cancer is untrue. I had two Jewish patients in my general practice who were found to have early cancer of the cervix.
I support Health Watch in that valid clinical trials are the best way of ensuring protection, but we all accept risks if the benefits are great. In no way do I agree that circumcision should be considered “The most unforgivable cut”.
Yours sincerely
GUS PLAUT
Dear Editor,
MICHAEL Allen’s report on DtCA (HealthWatch Newsletter issue 48, January 2003) is especially relevant over here. I regret that USA is not the only country where DtCA is allowed. As all New Zealand free-to-air TV channels carry advertisements, we cannot escape this bombardment. “Ask your doctor if X is right for you” is the catch phrase; our GP’s are fed up with being bullied and are agitating to ban the practice. Objection from the pharmaceutical and advertising industries is fierce, of course. I intend to draw the attention of our authorities to your Position Paper.
Yours sincerely
BERNARD HOWARD
The NHS “Better Food Programme”, launched in England nearly two years ago along with celebrity chef-developed meals and a new NHS cook book, has moved the issue of hospital catering up the management agenda. When food waste in hospitals costs an estimated £8 million each year this is undoubtedly to be welcomed.
The success of the new programme has stimulated debate on what to do next and, it seems, NHS Estates’ newest projects might include, “introducing protected meal times, giving food the same status as drug rounds, protecting patients from being disturbed and freeing nurses to help feed patients.”
Never mind the celeb chefs, might such measures not have made a sensible starting point for improvements in the first place? Indeed, is it unreasonable to find it completely shocking that they aren’t happening anyway?
Mandy Payne