My topic is my libel trial and some of the battles I’ve had with alternative medicine, alongside my colleague and friend Edzard Ernst.
To start with, I should stress that my background is not in medicine, but in particle physics. And, for most of my career in journalism, I focussed on promoting good science – exciting, interesting, challenging science – the kind of science we used to dream about when we were kids.
For example, a few years ago I heard a song on the radio by Katie Melua, called nine million bicycles, which contained the following verse.
We are 12 billion light years from the edge,
That’s a guess,
No one can ever say it’s true,
But I know that I will always be with you.
It made me a little bit annoyed, because the song implies the universe is 12 billion years old, and it’s not. Then she says, “That’s a guess,” but it’s not a guess - this is science and scientists don’t make guesses, we make careful measurements. Next she says, “no-one can ever say it’s true”. But that’s not right because in science we always try to get closer to the truth. And finally, “I know that I will always be with you”. Well at this point I felt I couldn’t trust a word this woman says. So I wrote an article about this for the Guardian, and at the end I re-wrote the lyrics to make them a bit more accurate.
We are 13.7 billion light years from the edge of the observable universe,
That’s a good estimate with well defined error bars,
Scientists say it’s true, but acknowledge that it may be refined,
And with the available information, I predict that I will always be with you.
The great thing was that Katie Melua actually read the article, she got the joke, and we met up and she re-recorded the song, using my lyrics. Even better, the article about my re-write hit a big mainstream audience, so I was able to convey a bit of cosmology to the general public.
However, about ten years ago, instead of finding ways to communicate mainstream science, I began writing about pseudoscience. I started to get interested in some different kinds of claims that were being made in the name of science, that weren’t very scientific, but which could have serious consequences. For example, I wrote about homeopaths who offered homeopathy pills as protection from malaria. Moreover, I worked on an undercover investigation with Sense About Science and we exposed the dangers of the advice that we found some homeopaths were giving to people travelling to malaria-affected countries.
Back in those days I still didn’t know that much about alternative medicine generally, so I was interested to see a BBC 2 show in 2006 called “Alternative Medicine – The evidence”. It was particularly memorable, because the narrator explained an astonishing clip: “In China this woman is having open heart surgery. But it is unlike anything you will see in the West - she’s still conscious. Because, instead of a general anaesthetic, this 21st Century surgical team are using a 2000-year-old method of controlling pain. Acupuncture.”
I thought, either that’s the most staggering bit of film I’ve seen all year, or there’s something wrong here. I did a bit of digging and I learned that the Royal College of Anaesthetists had written a report for the BBC about that very piece of footage, and it said that the patient didn’t have a general anaesthetic, but she had in fact received sufficiently large doses of sedative and painkilling drugs to make the acupuncture’s role no more than cosmetic.
It was around this time I met Edzard Ernst, Professor of Complementary Medicine at Exeter University. We soon realised that we had overlapping interests, namely an appreciation of the importance of evidence and the desire to communicate research to the general public. In time, we wrote a book together1 to look at the evidence for alternative medicine, to consider what does and doesn’t work, and whether any of it could actually be dangerous. We had chapters about homeopathy, acupuncture and all kinds of other practices, and also we wrote articles in the press, to help people weigh up the risks and benefits of these treatments.
One of the articles I wrote at the time was on the subject of chiropractic and was published in the Guardian on 19 April 2008, with the title "Beware the Spinal Trap". I mentioned the way that many chiropractors go from claiming to treat back problems to being able to treat things like ear infections and asthma, based on this rather odd philosophy that manipulating the spine is able to influence the rest of the body via the nervous system. As a result of writing this article I became the subject of a libel action brought by the British Chiropractic Association (BCA).
The case went on for two years, and I was facing costs of £500,000 were I to lose. Fortunately, the BCA finally backed down, withdrew its lawsuit, and the case ended. It was a miserable time, causing a huge amount of stress and forcing me to dedicate half of my working time on the legal battle. Nevertheless, some good things came out of this. Firstly, it encouraged discussion and the challenge of chiropractic claims. Fiona Godlee, in the British Medical Journal, published a debate between Edzard Ernst and the BCA. She concluded: “Readers can decide for themselves whether or not they are convinced. Edzard Ernst is not. His demolition of the 18 references is, to my mind, complete.”2
Suddenly doctors were becoming more aware of what chiropractors were claiming. There were also campaigns run by people who are not really part of the medical establishment. For example, Simon Perry, Chris French, and Alan and Maria Henness of the Nightingale Collaboration, submitted 600 legitimate complaints about chiropractors to the General Chiropractic Council. Almost overnight, chiropractors reacted and began taking down their websites and withdrawing leaflets in order to avoid prosecution for claims that could not be supported by evidence.
It was around this time that the campaign to reform the English libel law started. There was a general sense that it was too easy to bring a libel case, and that this state of affairs was actually discouraging critical media reporting on matters of serious public interest. The burden of proof was on the writer, there was no public interest defence, and it was possible for companies to sue individuals and land them with high costs, with no risk to the organisation bringing the case.
What is more, a lot of these features were peculiar to English libel law, so if someone anywhere in the world wanted to issue a writ, they would be tempted to issue it here in London. This is what is known as libel tourism. Even the United Nations had condemned the English judges' practice of welcoming rich libel tourists from across the world to their hospitable courts; and following a case in which an English judge ordered the censorship of a New York author's book on terrorism, which had not even been published in Britain, the US Congress began drafting a law which would guarantee that English libel judgments have no validity in America.
My case was not unique. At the time, some of the other people being sued for libel or being threatened included Ben Goldacre, Peter Wilmshurst, David Colquhoun, Andy Lewis, Mumsnet. Even the prestigious journal Nature was sued over an article on cosmology, and that case also lasted for two years and ran up huge costs. What is more, there were many good articles which were never even written because of self-censorship fuelled by a fear of a libel suit – what we call the “chilling effect”.
The Libel Reform Campaign was founded by Sense About Science, English PEN and Index on Censorship, with support from groups ranging from HealthWatch to Skeptics in the Pub, from academic journals to Mumsnet, and there were people all around the world who joined in, because they realised they could also get dragged into London’s Royal Courts of Justice. The Libel Reform campaign at www.libelreform.org received the backing of the editors of BMJ, Nature and New Scientist, and people like Richard Dawkins, Ricky Gervais, Stephen Fry, Penn & Teller, James Randi, Sir Tim Hunt, Sir David King, the UCL Provost and 50,000 others.
After a remarkable grass roots campaign, the Defamation Act received royal assent on 25 April 2013, and became law in England and Wales at start of 2014. This change to the law of defamation aims to strike a fair balance between the right to freedom of expression and the right to reputation. Plaintiffs now have to show that they suffer serious harm before a court will accept the case. There’s protection for website operators, a defence of 'responsible publication on matters of public interest' and new statutory defences of truth and honest opinion.
But there is still work to be done. In Northern Ireland there remains a problem because Belfast’s libel laws have not yet been brought into line with the new Act. So the campaign is still ongoing, and with the backing of HealthWatch and all our other supporters, I am optimistic that Northern Ireland will realise that necessity of bringing its defamation laws into the twenty first century.
1 Singh S and Ernst E. Trick or treatment? Alternative medicine on trial. Corgi Books, London, 2008.
2 Godlee F. Keep libel laws out of science. BMJ 2009;339:b2783. See: http://www.bmj.com/content/339/bmj.b2783.full
Sir Richard Doll receives HealthWatch award
The Fourth Annual HealthWatch Award was presented to Professor Sir Richard Doll OBE MD DSc FRS of the University of Oxford, at the HealthWatch Annual General Meeting on 14th October, in recognition of his 50 years of work at the highest level in clinical epidemiology.
It was Sir Richard who, in the 1950s, led the landmark research study of 34,000 male doctors which showed that people who smoked were significantly more likely to develop lung cancer. He has more recently studied links between vitamin D and the brittle bone condition osteoporosis.
The presentation of the HealthWatch award followed Sir Richard's fascinating talk, "Help and hindrance in epidemiology". The help, he said, came from GP's, who are highly cooperative when invited to give information for epidemiological studies. Patients are similarly willing - out of thousands of patients studied he recalled only one letter which asked how the scientists had obtained their information.
Employers, on the other hand, have a tendency to "lose" records of past employees who may have been exposed to dangerous materials such as asbestos or poison gases. He found that questions asked in the House often prompted renewed searching and the subsequent discovery of missing documents.
Fears about patient confidentiality can also hinder epidemiological research. A study which hoped to investigate the possibility of a link between road traffic accidents and tranquilising medication ran into difficulties when the police questioned the ethics of looking at details of patients' medical prescriptions.
The Department of Health have raised objections to anonymous HIV testing of blood samples routinely taken on hospital admission; and a study of the effect of natural radon emission on lung cancer was interrupted by a non-research-minded committee who insisted that they alone should be responsible for choosing the subjects for the trial.
Sir Richard's talk was beautifully delivered and provided an enjoyable and thought-provoking conclusion to this year's AGM.
The need for evidence-based medicine
At the Annual General Meeting of Health Watch at Regent College, London this year we were delighted to welcome guest speaker Professor David Sackett from the Oxford Radcliffe Hospital. The professor's compelling talk described his team's important work on the need for accurate and up-to-date information in making clinical decisions.
Doctors need new clinical information up to 100 times a week but are unlikely to receive it because their textbooks are out of date, and their journals disorganised. Yet this dearth of accurate information could influence eight important decisions every day. So began Professor David Sackett, visiting professor at the University of Oxford, when he addressed the 7th Annual General Meeting of HealthWatch on 23rd October 1995.
By questioning a group of general practitioners while they saw their patients, Professor Sackett's team identified up to 16 needs for new, clinically-important information in just half a day, of which a quarter were related to diagnosis.
However, only 30% of these information needs were met in the doctor's workplace, and most of these by asking colleagues.
The literature shows that doctors' ability to obtain the information they need is limited by out-of-date textbooks, journals that are too disorganised to be useful, and by simply not having enough time to read. Even the keenest GPs spend only one hour a week reading the medical literature, and this is clearly not enough to keep pace with therapeutic advances.
The net effect of this unfulfilled need for important new information is that it can lead to progressive declines in clinical competency. It has been shown repeatedly that there is a negative correlation between a doctors' knowledge of up to date care and the years that have elapsed since completing formal training. For example, in one study of clinical behaviour, the decision to start antihypertensive drugs was more closely linked to the number of years since medical school graduation in the doctor than to the severity of target organ damage in the patient.
It is clear, said Professor Sackett, that doctors need far readier access to clinically-important information. The problem is to distill the message buried in some 600,000 published randomised controlled trials into a form which was accessible to clinicians when they needed it, and on which they would be able to base their treatment decisions.
Critics of conventional medicine, said the professor, have claimed that fewer than 15% of medical interventions are supported by solid scientific evidence, leaving between 80 and 90% in the realms of quackery. A more reassuring picture emerged when the professor’s team reviewed the diagnoses made and interventions performed upon 121 patients admitted during April 1995 to the John Radcliffe Hospital.
He found that the vast majority - 82% - of interventions were justified on the basis of evidence-based medicine, and in 53% of all cases that evidence came from randomised controlled trials. In only 18% of cases were treatments were performed for which there was not substantial clinical evidence, and Professor Sackett found that these involved mainly non-acute disorders for which there are no known effective treatments.
The professor went on to outline how clinicians can practice evidence-based medicine for themselves as a life-long, self-directed learning process. The discipline involves:
- converting information needs into answerable questions;
- tracking down efficiently the best evidence with which to answer them;
- critically appraising that evidence for its validity and usefulness;
- applying the results and evaluating performance.
Research in Canada has shown that when equipped with these skills, graduates not only made more accurate diagnostic and management decisions, but they retained a high level of clinical competence and stayed more up to date than their traditionally trained peers as long as 15 years after graduation.
After his talk at the HealthWatch 7th Annual General Meeting Mr Nick Ross announced that Professor David Sackett was the unanimous choice of the committee for the Third Annual HealthWatch Award. Professor Sackett was presented with a handsome silver-plate comport-a dish for dessert, raised on a stem-inscribed with these words:
To Professor David Sackett in recognition of his distinguished contributions to medical research, education and the reliable assessment of treatment.
Medical journalism: triumphs and pitfalls
Geoff Watts, presenter of Radio Four's Medicine Now, is the recipient of the first annual HealthWatch Award. Here is a shortened version of the talk he gave to HealthWatch members.
The medium I work in - radio - has strengths and weaknesses. TV relies on pictures: the words are subsidiary. Print journalism does rely on words but they are mostly those of the journalists themselves, fleshed out with quotes from people whose views and ideas are being reported, disputed or analysed. But in radio this 'fleshing out with quotes' actually forms the greater part of what is broadcast. This is both the strength and the weakness of radio journalism.
It is a strength because radio journalists have the authority that comes from using a contributor's own words and voice. It also reduces the likelihood of distortion.
It is a weakness because radio journalists are more reliant on the fluency and articulacy of their interviewees. This can be a problem when dealing with complicated technical matters.
Broadcaster vs. medic
Doctors can't ignore their patients' prejudices or advocate therapies that patients don't want. Nor can broadcasters survive by making programmes that people don't want to watch or listen to. Compromises have to be made by both.
But there is a fundamental difference: doctors don't have to entertain their audiences, which are largely captive. The media do have to entertain -using that word in the sense of 'amuse and intrigue': to hold the attention.
One result is that the media do not necessarily emphasise what doctors think are the most important issues or angles. The 'responsible' journalist tempers the presentation of pure truth with enough entertainment to woo the audience; the less responsible provides nothing but entertainment - from sob stories to horror stories. But, when criticising the serious media, recall that they too have to make themselves attractive to audiences. No audience means, ultimately, no programme.
Doctors and broadcasters can fall out over the question of language, particularly when talking about matters that are technically difficult. Doctors are generally better than scientists at speaking in plain English but there is the danger of patronising the audience with talk of 'germs' and 'tummies.
Are doctors and scientists afraid to talk in ordinary language? Do they fear they won't sound important enough? Some can't seem to get away from the idea that they're talking to their peers. They're not. To talk simply and directly is not to trivialise.
Disasters and triumphs
Developments that would have been impossible without the cooperation of the media include the reduction in cot death following changes in the recommended sleeping position and the spread of knowledge about safe sex. People are now better informed about health.
Things go wrong for many reasons. There is genuine misunderstanding of the facts. Sometimes those providing the facts don't help. There is conflicting propaganda, for example, over the role of animal fats in heart disease.
Journalists occasionally decide their conclusions before they write the story. One TV production company and one particular journalist seek to champion the unorthodox ideas of Stanford University's Peter Duesberg about HIV. Provided no violence is done to the truth, and the competing claims are given a fair hearing, a partisan or unorthodox line of argument presents no problems - but it must be declared as such.
Anecdote is legitimately the basis of much journalism - to rule it out would be absurd. But, unaccompanied by the examination of more objective evidence it results in uncritical coverage of miracle cures and gee-whizz technology and a wide-eyed enthusiasm for every dubious idea dreamed up on the fringe from total allergy syndrome to the health benefits of sitting inside pyramids. It's an area in which journalists' natural scepticism can fall prey to the lure of a good story -and is a regular source of pitfalls.
Changes of points of view inside the medical establishment can lead to stories going wrong. The value of dietary fibre, the health benefits of moderate drinking and the violence induced by lowering blood cholesterol are just a few of the issues on which the research establishment has been, or is in the process of, rethinking its ideas. Changes of understanding can't be avoided - but they do create problems.
Publicity-seeking by individual doctors can generate bogus, dubious or non-stories. Motives range from self-agrandisement to bringing in private work to shroud-waving for an institution.
The practice of medicine is nothing like as international as the science on which it is (supposed to be) based. There are transatlantic differences which can be subtle and create further pitfalls for the unwary.
Finally, should medical reporters working for the lay media try to behave like editors of peer-reviewed journals? This is not practicable or desirable. The periodic failures of journalism are not so much a problem to be solved as a (sometimes unavoidable) phenomenon to be monitored, noted and kept within bounds of acceptability.
Pitfalls of medical journalism
Leading medical journalist Annabel Ferriman, winner of the 1997 HealthWatch Award, entertained members at HealthWatch's ninth Annual General Meeting in October when she explained the factors which can conspire against media reports being quite as accurate as health professionals would like them to be. Her talk is summarised here.
Pitfalls include the pressure to produce, the need to be first, the search for simplicity, the media's dislike of neutrality and commercial and political pressures. I'm going to confess that I have fallen into all of them.
The Pressure to Produce
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. One day a journalist is a general reporter; the next, he or she is medical correspondent. From that day onwards, she's expected to under-stand the most complex issues and translate them into comprehensible language for the lay reader. Moreover; most of the time points are won only for disclosing information and producing copy, not for deciding that a story should not be published because it's without foundation or overblown. Experienced medical journalists who've seen dozens of breakthroughs and scares and who suggest to their news editor that the latest is not worth covering, are likely to be branded negative or stale or lazy.
For me and others who work on weeklies, or who are feature writers rather than daily journalists, the problem comes when you sell an idea to the news editor or features editor that you then cannot "stand up". When you sell it, you have usually only half-researched it and often, on further research, you discover your first impressions were wrong.
An example: I sold the idea to the medical editor of The Independent that it was a scandal that men were not being screened for prostate cancer; but discovered on further research that the issue was rather more complex. I could hardly then sell the idea that it was a good thing that we are not screening everyone for it, because that is a non-story.
This is a well-known phenomenon in journalism known as the 'one 'phone call too many'. That is, you've made a 'phone call that has knocked down your whole story. What do you do? Suppress the knowledge and pretend you never made it? Sometimes that happens. Or include the qualifying statements in paragraph 24, so that it's not too obvious that your whole story is somewhat flimsy.
The need to be first
This can result in dangerous half-truths. I have also been guilty of this: witness my piece on discovering the gene for schizophrenia. A chap at the Middlesex thought he had done so, I wrote it up and, as quite often happens, it was a false dawn. The search for simplicity.
When I first started in medical journalism, I was told by Michael O'Donnell that there were only three medical stories: the major breakthrough, the major scare and the major scandal.
The search for simplicity (usually based on the assumption that your reader has a 50-second attention span) often means that complicated stories are over-simplified to the point of nonsense.
But this need for simplicity has another side to it. Editors and readers love nothing better than the story which suggests a lot of clever scientists have been working away for years to discover the key to a healthy life; or a cure for cancer; or the answer to multiple sclerosis. And then along comes a patient, or alternative medicine practitioner, who discovers that all that scientific research was quite unnecessary, that medics had been overcomplicating things and the answer was quite simple. The media's dislike of neutrality.
Newspapers and television producers love to name the guilty men. Doctors, scientists and drug companies are often cast as the villains; the poor long-suffering patient as the hero or heroine. News editors don't tend to like stories that say: on the one hand this and on the other hand that. I was quite good at those, but they were usually put on page 10, so I didn't get many points for that.
I recently discovered that the Hammersmith were planning to offer pre-implantation diagnosis for couples carrying the breast cancer gene. I tried to write a completely neutral story, but it ended up with the headline, 'Breast cancer embryos may be culled'.
Commercial and time pressures
The fact is that most journalists are inundated with press releases every day, pushing this or that product, drug, cure, book or message. It is very easy, if you are up against a deadline, simply to reproduce a press release that you have been sent, without giving it the scrutiny that you should. I have seen press releases reproduced almost verbatim by journalists, for example a particularly idiosyncratic introduction to a Department of Health release on skin cancer was recently reproduced word for word in the Guardian. In this case, not many people would find it sinister. But it shows how easy it can be to manipulate the press.
Some PR firms spoon-feed journalists and are rewarded by column inches. I had to produce a column very quickly for the Telegraph recently, and there happened to land on my desk a long press briefing about bedwetting. It even had the magic words, 'We have a case study which could be of some interest.' I am slightly ashamed to say that I used a great deal that was in the briefing, inter-viewed the case study and banged out 1,200 words in no time. My only defence is that I had very little time, and that I did include a lot of advice about behavioural ways of tackling bedwetting, as well as the fact that there is now a good pill available.
In the light of the strong pressures working against good medical journalism, it is something of a miracle that medical coverage is as good as it is.