Saturday, August 30, 2008

Britain: Regulating quack medicine makes me feel sick

If alternative remedies are either untested or ineffective, why are we promoting them?

It is fashionable to think things are true for no better reason than you wish it were so. The latest sign of this trend is a report to the Department of Health from Professor Michael Pittilo, Vice-Chancellor of the Robert Gordon University, Aberdeen. His May report - on acupuncture, herbal medicine, traditional Chinese medicine and the like - recommends that these therapies should have statutory regulation run by the Health Professions Council, and that entry for practitioners should "normally be through a bachelor degree with honours". Consultation is supposed to begin around now.

Both of the ideas in the report are disastrous. The first thing you wanted to know about any sort of medical treatment is: "Does it work?" One of the criteria that must be met by groups aspiring to regulation by the HPC is that they "practise based on evidence of efficacy". That evidence does not exist for herbal and Chinese medicine, which remain largely untested. For acupuncture the evidence does exist and it shows very clearly that acupuncture is no more than a theatrical placebo.

Placebos can, it is true, make you feel better; and if there is no better treatment, why not use them? That's fine, but it raises huge ethical questions about how much you can lie to patients, and how much you can lie to students who are training to use the placebos.

New Labour has often said that its policies are guided by the best scientific evidence, but the problem is that the answer you get depends on whom you ask. Pittilo's committee consisted of five acupuncturists, five herbalists and five representatives of traditional Chinese medicine (plus eleven observers). There was not a single scientist or statistician to help in the assessment of evidence. And it shows: the assessment of the evidence in the report was execrable.

Take one example, the use of a herbal preparation, Gingko biloba, for the treatment of dementia. On page 25 of the report we read: "There have been numerous in vitro and in vivo trials on herbal medicine... which have established the benefits of single ingredients such as gingko...for vascular dementia". That is totally out of date. The most prestigious source of reliable summaries of evidence, the Cochrane Collaboration, says: "There is no convincing evidence that Ginkgo biloba is efficacious for dementia and cognitive impairment". The NHS Complementary and Alternative Medicine Specialist Library (compiled by alternative medicine people) says: "The evidence that ginkgo has predictable and clinically significant benefit for people with dementia or cognitive impairment is inconsistent and unconvincing." Since then another large trial, funded by the Alzheimer's Society, concludes: "We found no evidence that a standard dose of high purity Ginkgo biloba confers benefit in mild-moderate dementia over six months."

The Government's answer to the problem is, as always, to set up more expensive quangos to regulate alternative medicine. That might work if the regulation was effective, but experience has shown it isn't. It makes no sense to regulate placebos, especially if you don't admit that is what they are. The Government should be warned by the case of chiropractors about the dangers of granting official recognition before the evidence is available. The General Chiropractic Council already has a status similar to that of the General Medical Council, despite it being based on the quasi-religious idea of "subluxations" that nobody can see or define. Recent research has shown it to be no more effective, and less safe, than conventional treatments that are much cheaper.

The problems that Professor Pittilo's recommendations pose for universities are even worse. You cannot have universities teaching, as science, early 19th-century vitalism, and how sticking needles into (imaginary) meridians rebalances the Qi so the body systems work harmoniously. To advocate that degrades the whole of science.

The vice-chancellors of the 16 or so universities who run such courses presumably do not themselves believe that vitalism is science, or subscribe to the view that "amethysts emit high yin energy", so it is hard to see why they accept taxpayers' money to teach such things. Thankfully, the University of Central Lancashire abandoned its first-year homoeopathy course this week because of low numbers.

Fortunately there is a much simpler, and probably much cheaper, solution than Pittilo's: enforce the laws that already exist. It is already illegal to sell contaminated and poisonous goods to the public. It is already illegal to sell goods that are not as described on the label. And, since May 2008, new European laws make it explicitly illegal to make claims for any sort of treatment when there is no reason to believe the claims are true. At the moment these laws are regularly and openly flouted on every hand. Enforce them and the problem is solved.


BOOK REVIEW of "Trick or Treatment" by Simon Singh and Edzard Ernst


When I was practicing medicine in the Elmhurst section of New York about five years ago, my colleagues and I confronted an epidemic of liver damage among the recently arrived Chinese immigrants who live there. We put these patients through an exhaustive battery of tests for conventional sources of hepatitis, the most likely culprit, but found none. The mysterious illness, we decided, must have been caused by the folk therapies, usually herbal, that our patients often used but rarely disclosed to their doctors. There was little we could do but counsel them to stop. Instead of following our professional advice, though, they usually just added new herbs to their regimen, hoping to solve their liver problems but sometimes making themselves even more ill.

The Elmhurst epidemic was a classic example of the clash -- both cultural and scientific -- between "alternative" and conventional medicine. In this case, the inability of doctors to treat a liver ailment strengthened the false faith of patients in other cures. Usually, alternative medicine is a harmless distraction. And some treatments actually do offer benefits. But going outside modern medical practice also carries dangers.

Luckily, hundreds of studies have examined the purported benefits of various alternative-medicine treatments. In "Trick or Treatment," Simon Singh and Dr. Edzard Ernst report on the results. Ginseng has been proposed as a cure-all for everything from cancer to common colds, but there's no evidence that it does any good. Shiatsu massage appears to be a "waste of effort and expense," the authors say. Many aspects of traditional Chinese medicine, like the use of the herbs aristolochia and liquorice, are potentially harmful. Aromatherapy can relieve stress, but there is not a lick of evidence that it can treat a specific illness. Chelation therapy -- a legitimate method of removing heavy metals such as lead or mercury from the body, but now pitched in alternative-medicine circles as a cure for heart disease and other ailments -- is "disproven, expensive, and dangerous," according to Mr. Singh and Dr. Ernst. They urge patients "not to use this treatment."

Some alternative remedies, it should be said, do appear to have value. There is evidence that St. John's Wort can help mild depression, although probably not as well as conventional antidepressants. Echinacea may be able to help relieve symptoms of the common cold, and perhaps reduce the length of illness, but so can many better understood conventional remedies that are sold over the counter. "It seems bizarre," the authors note, in light of the disappointing results, "that alternative treatments are touted as though they offer marvelous benefits."

Dr. Ernst is not a dispassionate observer. He is a pioneer in the field of complementary medicine -- a branch of the medical profession whose practitioners prescribe selective alternative treatments. But he is also a scourge of too-large claims made for his field. Based at the University of Exeter in England, he leads a research group that has spent 15 years studying alternative remedies, trying to separate snake oil from science. Mr. Singh, his co-author, is a science journalist whose books include "Fermat's Enigma" and "Big Bang." Together they conclude, after cataloging the evidence, that most of the popular forms of alternative medicine are "a throwback to the dark ages." Too many alternative practitioners, they say, are "uninterested in determining the safety and efficacy of their interventions."

And safety is a real concern. "Chiropractors who manipulate the neck can cause a stroke . . . some herbs can cause adverse reactions or can interfere with conventional drugs." The authors are particularly hard on homeopathy, the practice of using ultradilute solutions of common substances. The solutions are so dilute, though, that they are often little more than water. "Homeopathic remedies, which of course contain no active ingredient, can be dangerous if they delay or replace a more orthodox treatment," Mr. Singh and Dr. Ernst write, calling homeopathy "the worst therapy encountered so far -- it is an implausible therapy that has failed to prove itself after two centuries and some 200 clinical studies."

"Trick or Treatment" includes a brisk history of our evidence-based approach to medicine, tracing the development of the modern clinical trial from its earliest days, when scurvy was shown to be caused by insufficient vitamin C and bleeding was debunked as a medical cure. Unfortunately, the evidence of clinical trials is largely ignored when it comes to alternative medicine.

So the treatments persist: Americans spend an astonishing $3 billion annually on chiropractors and about $1.5 billion on homeopathy, not to mention billions more for herbal remedies. Government is complicit: Most states mandate health-insurance coverage for chiropractic visits, and many states direct insurers to cover the cost of acupuncture -- another remedy with far fewer benefits than are commonly claimed for it.

Why is there so much blind faith? Mr. Singh and Dr. Ernst blame media hype, celebrities and even certain doctors -- complementary-medicine doctors for shading facts but also, importantly, conventional doctors whose high-handedness breeds patient frustration, opening the door to the seductions of alternative medicine.

"Alternative medicine is not so much about the treatments we discuss in this book," the authors write, "but about the therapeutic relationship. Many alternative practitioners develop an excellent relationship with their patients that helps to maximize the placebo effect of an otherwise useless treatment." To bring all treatments in line with rigorous science, an "excellent relationship" between doctor and patient is a good place to start.


1 comment:

Garth Godsman said...

Excellent stuff. I've sent this on to everybody I could think of.