MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Dear Professor Robinson,

please forgive me for writing to you in a matter that, you might think, is really none of my business. I have been following the news and discussions about the BLACKMORE CHAIR at your university. Having been a professor of complementary medicine at Exeter for ~20 years and having published more papers on this subject than anyone else on the planet, I am naturally interested and would like to express some concerns, if you allow me to.

With my background, I would probably be the last person to argue that a research chair in alternative medicine is not a good and much-needed thing. However, accepting an endowment from a commercially interested source is, as you are well aware, a highly problematic matter.

I am confident that you intend to keep the sponsor at arm’s length and plan to appoint a true scientist to this post who will not engage in the promotional activities which the alternative medicine scene might be expecting. And I am equally sure that the money will be put to good use resulting in good and fully independent science.

But, even if all of this is the case, there are important problems to consider. By accepting Blackmore’s money, you have, perhaps inadvertently, given credit to a commercially driven business empire. As you probably know, Blackmores have a reputation of being ‘a bit on the cavalier side’ when it comes to rules and regulations. This is evidenced, for instance, by the number of complaints that have been upheld against them by the Australian authorities.

For these reasons, the creation of the new chair is not just a step towards generating research, it could (and almost inevitably will) be seen as a boost for quackery. It is foremost this aspect which might endanger the reputation of your university, I am afraid.

My own experience over the last two decades has taught me to be cautious and sceptical regarding the motives of many involved in the multi-billion alternative medicine business. I have recently published my memoir entitled ‘A SCIENTIST IN WONDERLAND. SEARCHING FOR TRUTH AND FINDING TROUBLE’; it might be a helpful read for you and the new professor.

I hope you take my remarks as they were meant: constructive advice from someone who had to learn it all the hard way. If I can be of further assistance, please do not hesitate to ask me.

Sincerely

Edzard Ernst

22 Responses to The Australian ‘Maurice Blackmore Chair in Integrative Medicine: an open letter to the dean

  • Looks like you were tired when wriiting that; there are a number of typos.

    But seriously: letting Blackmores sponsor a chair? In pseudoscience?

  • Just one small point that may head off people as picky as I: The title of the post is the Maurice Blackmore Chair in Integrative (i.e not “Alternative”) Medicine. (See http://sydney.edu.au/news/84.html?newsstoryid=15028)

    • thanks
      I changed this in the title

    • Your comment comes across as naively pedantic Stephen. Those who know anything about ‘integrative medicine’ will be aware that it’s the latest term for what used to be known as ‘complementary medicine’, and that it uncritically embraces a range of ‘alternative’ practices. It may as well be called a chair in alternative medicine.

      • Robert, thank you for the pompous, unsolicited and unncessary lesson in the functional equivalence of “integrative”, “alternative” & “complementary”.

        However, my intention (which you have contrived to miss completely) was that somebody whom I admire (i.e. Edzard) was not left open to the inevitable taunts of “couldn’t even get the name of the position correct” from the iCAM brigade. Given that the correction has been made, I appear to have been successful in my intent.

        You’re welcome.

        • YES, CORRECTION MADE AND THANKS AGAIN

        • Glad to have gotten up your nose Stephen. Given that my intention was to provoke, I appear to have been successful. Indeed, the ‘lesson’ was useful, because it allows me to point out that the terms ‘integrative’, alternative’ and ‘complementary’ are not functionally equivalent in the present context.

          The proponents for the establishing of this chair are all about raising the profile and legitimacy of a disparate group of medical practitioners who have coalesced under the banner of the ‘Australian Integrative Medicine Association’ (AIMA) over the past 20 years in Australia, and mainly comprise general practitioners seeking to exploit a medical niche in the CAM marketplace. If you check out their website, you’ll see that they have very cleverly exploited all the currently fashionable buzz-words:

          https://www.aima.net.au/what-is-integrative-medicine/

          AIMA has close links (and overlapping membership) with the Australian College of Nutritional and Environmental Medicine (ACNEM), which has murky origins dating back to the Clinical Ecology movement which emerged in N America, the UK and Australia between the late 1960s and early 1990s. At that point, having been soundly discredited within mainstream medicine, the Clinical Ecology Society of Australia morphed into the Australian College of Nutritional and Environmental Medicine, a more orthodox sounding body, fellowship of which gave its medical members the opportunity of putting bogus qualifications (‘FACNEM’) on their letterhead.

          AIMA rose to prominence in parallel during the 1990s, and has gradually acquired more influence amongst doctors who practice on the less orthodox fringes of medicine, probably because it encompasses a wider range of alternative modalities than ACNEM such that its members can compete more effectively with the profusion of non-medical CAM practitioners.

          POST SCRIPT: I have also been an admirer of Edzard Ernst for many years, and may have been partly responsible for stimulating his open letter via the Friends of Science in Medicine. Here is what I wrote to FSM a couple of weeks ago in response to their request for comments on their position paper:

          —————————————————————————————————————————
          “I am appalled by the University’s decision to establish this chair. It would be a body blow to the University’s high standards of academic excellence.

          “My views on this are based on considerable experience. Because of my long-standing interests in food intolerance, food allergies, functional gastrointestinal disorders, CFS, environmental chemical intolerances etc, I have been an invited speaker at many ‘integrative medicine’ conferences (in its various incarnations) over the past 30 years, and have shared many patients & had dealings with many doctors who practice in this field. I have also been a member of several expert panels (NHMRC, RACP, CASA, NSW Health) examining some of the practices concerned and have made submissions to various parliamentary inquiries.

          “Leaving aside the misguided philosophy and the various alternative practices commonly indulged in, the field is rife with pseudoscientific testing methods. In many cases, samples of blood, urine, faeces, hair etc are sent off to unaccredited local or overseas laboratories for testing. Most of these tests have not been subjected to the kind of rigorous validation that we have come to expect of standard diagnostic testing methods. Patients often show me their test results and I have read most of the promotional blurb that goes with them; I’ve trawled through the websites & am familiar with the numerous unsupported claims made; and I’ve heard some of the people who run these services speak at conferences. My impression is that they range from well-intentioned but misguided entrepreneurs to outright charlatans.

          “And let’s not forget the unsuspecting patients who place their trust in the doctor. For them, the un-reimbursed investigations often cost an arm-and-a-leg, not to mention the various unorthodox treatments they are given based on spurious results and/or misinterpretation by the doctor. It’s not overstating the problem by saying that much of what is done in the name of ‘integrative medicine’ is ethically dubious.

          “Having a Chair established by one of our foremost Sandstone Universities will give this pseudo-field of medical practice an unwarranted imprimatur of respectability that will only encourage more patients to wander off into the medical wilderness.

          “Pharmacies have already sold their soul to the devil. Having the Blackmore name attached to a Chair risks putting the University in a similar position.

          “The University should take heed of Edzard Ernst’s experience:

          http://www.theguardian.com/science/2014/oct/19/edzard-ernst-outspoken-professor-of-complementary-medicine.

          “I would suggest they seek his advice before jumping onto this careening bandwagon.

          “The University may as well call it a Chair in “Non-evidence-based Medicine”.
          ————————————————————————————————

          …Here endeth the lesson.

  • You have answered your own question – it is none of your business and you have now been used by a lunaty group called Friends of science in medicine.
    Of course money will have to come from industry, who else will pay for research? Cetainky not the Australian government. Critics say there is no research to support cam medicine and at the same time they argue against a research chair. You can’t have it both way. And the funny thing about your research Edward, is that it has done nothing to improve my clinical herbal practice. So what is the value of your research? Nothing for me. Not once has your reviews helped my patients. We need better research at the practitioner level as this is sadly missing. Don’t criticise what is happening in Australia when you achieved so little in 20 years!

    • …and if they do manage to do some research ‘at the practitioners level’ I hope they find someone who is a little more switched on than the author of this comment!

      • Hi
        Apologies for being rude, but I am really annoyed at your letter to Prof Robinson.

        Let us wait until the Chair has conducted and published some research and let us then attack any poor or biased research.

        I should have mentioned I am only referring to the herbal medicine articles as they are the only ones I focus on.

        You have certainly produce many articles on CAM, however, they either expose the really bad products or claims, or they are reviews.

        I have been treating patients with herbal medicine for 30 years. I know my herbs pretty well.

        The problem I have is that, when it comes to herbal medicines, most of the work I have seen by you are reviews. The problem is that we still need good clinical studies. If 5 out of 6 studies were too bad to include in a review, the review is going to be negative. It doesn’t help me much. It may simply be a problem of lack of good studies, not that the herb doesn’t work.

        I think we can agree that there are really bad products with lots of ridiculous claims and often the promotors are using pseudoscience to promote their products. If you expose those product, I am happy.
        I don’t use macca or horny goat weed for sexual disorders (which was all the retail rage a few years ago). I have never prescribed goji berry, acai, or any other “super food”. I am very happy you expose such products.

        I tend to use practitioner-only products that are not available to patients for self-selection. These products are generally not marketed directly to the public either. They are often not tested clinically, our companies can’t generally afford clinical trials, however, the ingredients are often, if not evidence-based, then evidence-informed or based on traditional usage. We often have great success in our practice but the way we practice or prescribe a formulation made from single liquid extracts is of course hard to study and it is never done.

        Many reviews also lack details. St John’s wort is such an example. The observed drug interactions is due to hyperforin.

        I select my St John’s wort very carefully and use products where the level of hyperforin has not been increased by selecting the dried herb at a different time or using an extract method which will enhance the level of hyperforin. Low hyperforin products do not pose a risk for drug interactions.

        You may have written about this elsewhere but it was not included in the review form 2013. I believe there are at least 9 publication on Pubmed where you have mentioned St John’s wort, not one of them seem to mention this fact about hyperforin. This is another example of why I mentioned ‘at the practitioner level’. I know about hyperforin.

        I understand that for a retail level, warnings may be necessary because such details as the level of hyperforin are not listed, not understood or ignored. But I, as a practitioner, know about these subtleties and prescribe accordingly.

        Some times we are lucky when a extract manufacturer does the research. Examples are Theracurcumin from Japan, or some of the Germany products, eg St John’s wort, horse chestnut etc. Then we can prescribe with greater confidence. I look at the research to find the right clinical dosage, regardless of what the retail label states or what a company may promote the product for.

        • and what has this to do with my open letter?
          you did clearly not understand its purpose, and (more worryingly) you also seem to be unable to understand scientific papers.

          • Actually, I do understand scientific papers. But I do not understand the purpose of your letter. It is no help to anybody, whatsoever, it doesn’t enlighten anybody, it is not helpful.
            Of course we have to worry about industry money in science. We all know this. But where else does the money come from? Pharmaceutical medicine is the same.

            Considering the position you had, you could have done so much better.
            I can only conclude now that you have achieved nothing substantial in 20 years.
            All those reviews have contributed nothing to our understanding of herbal medicine, how to use it, how to make better products, which dosages to use…
            good bye

          • oh dear!
            you are a credit to THE NATIONAL INSTITUE FOR INTEGTATED MEDICINE or what ever name you use to disguise quackery these days.

        • @Michael Thomsen
          Thank you for setting out so clearly everything that’s wrong with herbal medicine.
           
          “I have been treating patients with herbal medicine for 30 years. I know my herbs pretty well.” Argument from personal anecdotal experience. Sorry, but that’s not science, that’s subjective self conviction.
           
          “Practitioner-only products…are often not tested clinically, our companies can’t generally afford clinical trials, however, the ingredients are often, if not evidence-based, then evidence-informed or based on traditional usage.” Companies selling products that people are expected to ingest or apply to their bodies must provide sound evidence for efficacy and safety, or they are behaving unethically. Would you buy a TV from a manufacturer who pleaded they couldn’t afford first to test that it won’t burst into flames when you plug it in? Grandfathering from traditional usage is ridiculous adherence to possible ignorance and is no evidence whatsoever.
           
          “I select my St John’s wort very carefully and use products where the level of hyperforin has not been increased by selecting the dried herb at a different time or using an extract method which will enhance the level of hyperforin. Low hyperforin products do not pose a risk for drug interactions.” Well bully for you. But you’re acknowledging that St John’s wort with high levels of hyperforin is publicly available, and without any control over its production. The main caveat about herbs is the total lack of standardization or production control. That’s why decades of research have already picked out the (many) molecules from herbs that have proven clinical effects. They are manufactured in pure, controlled and regulated form. They are used in the form of medicine that stresses the importance of science and evidence. They do not depend on traditional usage of herbs — traditional usage has failed to produce useful medicines as often as it’s led to genuine discoveries. “I, as a practitioner, know about these subtleties and prescribe accordingly.” Once again, bully for you. What about the hordes of other herbalists who lack your wondrously dependable knowledge?
           
          You complain that most of the blogs on this site deal in reviews — they’re usually systematic reviews of clinical trials, and that’s not the same thing as reviews in general. You acknowledge that most the systematic reviews reject the majority of published clinical trials: “It may simply be a problem of lack of good studies, not that the herb doesn’t work.” That’s quite a problem, and the onus is on the manufacturer of the product to demonstrate efficacy in one or more good studies; otherwise the assumption is that the product doesn’t work.
           
          Suppose I put on the market a product I claim will “help keep your kitchen sink free of harmful germs”. I can’t afford to do any kind of test of the product to prove that it works to remove microbes from kitchen sinks or that splashing it on your skin won’t bring you out in a dreadful rash, but I claim the product “contains a natural ingredient that has been used for thousands of years as a disinfectant by many cultures”. A reasonable person would expect something more robust by way of evidence, and many advertising and product regulators would probably seek to have the product taken off the market. Yet this is exactly analogous to what herbalists do, even though they — like you — are aware of all the problems of batch reproducibility, toxic contamination, and lack of robust evidence demonstrating that the products, in most cases, do anything of clinical benefit whatsoever.
           
          Medicine has moved on massively from vague notions of disease to very precise, fine-scale definitions of individual pathological processes. Treatments nowadays need to specify exactly what condition they can benefit, under what conditions, to what quantitative extent and for how long, and with what side effects. They need to provide good quality evidence in robust, double-blind trials with adequate numbers of patients. Herbal medicine, like all branches of the Big Snakeoil industry, dabbles with obsolete therapeutic approaches, mostly devoid of evidence and — by your own admission — at risk of poisoning its customers. You should be ashamed of what you do.
           
          Any university chair funded by a commercial interest should be looked at askance. Edzard Ernst’s letter to Sydney University is no more than a rational plea for due diligence in a highly dubious example of conflict of interest.

        • When the new appointee starts teaching medical students, the starting position on herbal medicines should be that they consist of:

          An unknown combination, of
          Unknown substances, in
          Unknown amounts, with
          Unknown actions,
          Unknown interactions,
          Unknown side-effects,
          Unknown toxicities, and
          Unknown efficacy…

          …and he/she might go on to add that commercially available herbal preparations are frequently of:

          Unknown quality, and
          Unknown purity, and can be adulterated with
          Unknown medicinal agents.

          There are of course some notable exceptions where the active ingredients have been isolated, characterized and developed into useful drugs, but that’s a small minority.

    • I don’t suppose you are this Michael Thomsen, are you?

      So what is the value of your research? Nothing for me.

      I guess not.

      Not once has your reviews helped my patients.

      If Prof Ernst has managed to highlight the lack of evidence for some herbal products and highlighted the harms, then I think he may well have helped your patients, don’t you?

      • if they insist, we have to allow THE NATIONAL INSTITUTE OF INTEGRATED MEDICINE to discredit themselves.

      • hello Alan, and you are you?

        I replied with my own email. Nothing to do with NIIM.
        My conclusion is still the same, the reviews have not helped my clinical practice. Please do primary research of high quality. That is what I need.
        thank you

        • Yes, I am definitely me. But if you need research to find out whether there is any good evidence for the products/services you sell, who do you think should be doing them? But if that evidence isn’t already there, on what basis are you selling your wares?

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