Herbal medicine is popular. Consumers seem to be attracted by the notion that they are natural – and if it’s natural, it must be safe!!! But do we really know what is in the product that we might be buying? A recently published analytical study aimed to investigate herbal product integrity and authenticity with the goal of protecting consumers from health risks associated with product substitution and contamination.
The researchers used DNA barcoding to conduct a blind test of the authenticity for (i) 44 herbal products representing 12 companies and 30 different species of herbs, and (ii) 50 leaf samples collected from 42 herbal species. They also assembled the first standard reference material (SRM) herbal barcode library from 100 herbal species of known provenance that were used to identify the unknown herbal products and leaf samples.
DNA barcodes from 91% of the herbal products and all leaf samples could be recovered. 59% of the products tested contained DNA barcodes from plant species not listed on the labels. 48% of the products could be authenticated but one-third of these also contained contaminants and or fillers not listed on the label. Product substitution occurred in 30 of the 44 products tested and only 2 of the 12 companies sold products without any substitution, contamination or fillers. Some of the contaminants we found pose serious health risks to consumers.
Based on these findings, the authors drew the following conclusions: Most of the herbal products tested were of poor quality, including considerable product substitution, contamination and use of fillers. These activities dilute the effectiveness of otherwise useful remedies, lowering the perceived value of all related products because of a lack of consumer confidence in them. We suggest that the herbal industry should embrace DNA barcoding for authenticating herbal products through testing of raw materials used in manufacturing products. The use of an SRM DNA herbal barcode library for testing bulk materials could provide a method for ‘best practices’ in the manufacturing of herbal products. This would provide consumers with safe, high quality herbal products.
These findings are fairly alarming. I have previously blogged about the fact that herbal products are far to often adulterated or contaminated. Now it seems that we have to add to this list of dangers the substitution of the herbal ingredient with a presumably less expensive but potentially toxic herb that should not legally be there at all.
The following is a guest post by Preston H. Long. It is an excerpt from his new book entitled ‘Chiropractic Abuse—A Chiropractor’s Lament’. Preston H. Long is a licensed chiropractor from Arizona. His professional career has spanned nearly 30 years. In addition to treating patients, he has testified at about 200 trials, performed more than 10,000 chiropractic case evaluations, and served as a consultant to several law enforcement agencies. He is also an associate professor at Bryan University, where he teaches in the master’s program in applied health informatics. His new book is one of the very few that provides an inside criticism of chiropractic. It is well worth reading, in my view.
Have you ever consulted a chiropractor? Are you thinking about seeing one? Do you care whether your tax and health-care dollars are spent on worthless treatment? If your answer to any of these questions is yes, there are certain things you should know.
1. Chiropractic theory and practice are not based on the body of knowledge related to health, disease, and health care that has been widely accepted by the scientific community.
Most chiropractors believe that spinal problems, which they call “subluxations,” cause ill health and that fixing them by “adjusting” the spine will promote and restore health. The extent of this belief varies from chiropractor to chiropractor. Some believe that subluxations are the primary cause of ill health; others consider them an underlying cause. Only a small percentage (including me) reject these notions and align their beliefs and practices with those of the science-based medical community. The ramifications and consequences of subluxation theory will be discussed in detail throughout this book.
2. Many chiropractors promise too much.
The most common forms of treatment administered by chiropractors are spinal manipulation and passive physiotherapy measures such as heat, ultrasound, massage, and electrical muscle stimulation. These modalities can be useful in managing certain problems of muscles and bones, but they have little, if any, use against the vast majority of diseases. But chiropractors who believe that “subluxations” cause ill health claim that spinal adjustments promote general health and enable patients to recover from a wide range of diseases. The illustrations below reflect these beliefs. The one to the left is part of a poster that promotes the notion that periodic spinal “adjustments” are a cornerstone of good health. The other is a patient handout that improperly relates “subluxations” to a wide range of ailments that spinal adjustments supposedly can help. Some charts of this type have listed more than 100 diseases and conditions, including allergies, appendicitis, anemia, crossed eyes, deafness, gallbladder problems, hernias, and pneumonia.
A 2008 survey found that exaggeration is common among chiropractic Web sites. The researchers looked at the Web sites of 200 chiropractors and 9 chiropractic associations in Australia, Canada, New Zealand, the United Kingdom, and the United States. Each site was examined for claims suggesting that chiropractic treatment was appropriate for asthma, colic, ear infection/earache/otitis media, neck pain, whiplash, headache/migraine, and lower back pain. The study found that 95% of the surveyed sites made unsubstantiated claims for at least one of these conditions and 38% made unsubstantiated claims for all of them.1 False promises can have dire consequences to the unsuspecting.
3. Our education is vastly inferior to that of medical doctors.
I rarely encountered sick patients in my school clinic. Most of my “patients” were friends, students, and an occasional person who presented to the student clinic for inexpensive chiropractic care. Most had nothing really wrong with them. In order to graduate, chiropractic college students are required to treat a minimum number of people. To reach their number, some resort to paying people (including prostitutes) to visit them at the college’s clinic.2
Students also encounter a very narrow range of conditions, most related to aches and pains. Real medical education involves contact with thousands of patients with a wide variety of problems, including many severe enough to require hospitalization. Most chiropractic students see patients during two clinical years in chiropractic college. Medical students also average two clinical years, but they see many more patients and nearly all medical doctors have an additional three to five years of specialty training before they enter practice.
Chiropractic’s minimum educational standards are quite low. In 2007, chiropractic students were required to evaluate and manage only 15 patients in order to graduate. Chiropractic’s accreditation agency ordered this number to increase to 35 by the fall of 2011. However, only 10 of the 35 must be live patients (eight of whom are not students or their family members)! For the remaining cases, students are permitted to “assist, observe, or participate in live, paper-based, computer-based, distance learning, or other reasonable alternative.”3 In contrast, medical students see thousands of patients.
Former National Council Against Health Fraud President William T. Jarvis, Ph.D., has noted that chiropractic school prepares its students to practice “conversational medicine”—where they glibly use medical words but lack the knowledge or experience to deal appropriately with the vast majority of health problems.4 Dr. Stephen Barrett reported a fascinating example of this which occurred when he visited a chiropractor for research purposes. When Barrett mentioned that he was recovering from an attack of vertigo (dizziness), the chiropractor quickly rattled off a textbook-like list of all the possible causes. But instead of obtaining a proper history and conducting tests to pinpoint a diagnosis, he x-rayed Dr. Barrett’s neck and recommended a one-year course of manipulations to make his neck more curved. The medical diagnosis, which had been appropriately made elsewhere, was a viral infection that cleared up spontaneously in about ten days.5
4. Our legitimate scope is actually very narrow.
Appropriate chiropractic treatment is relevant only to a narrow range of ailments, nearly all related to musculoskeletal problems. But some chiropractors assert that they can influence the course of nearly everything. Some even offer adjustments to farm animals and family pets.
5. Very little of what chiropractors do has been studied.
Although chiropractic has been around since 1895, little of what we do meets the scientific standard through solid research. Chiropractic apologists try to sound scientific to counter their detractors, but very little research actually supports what chiropractors do.
6. Unless your diagnosis is obvious, it’s best to get diagnosed elsewhere.
During my work as an independent examiner, I have encountered many patients whose chiropractor missed readily apparent diagnoses and rendered inappropriate treatment for long periods of time. Chiropractors lack the depth of training available to medical doctors. For that reason, except for minor injuries, it is usually better to seek medical diagnosis first.
7. We offer lots of unnecessary services.
Many chiropractors, particularly those who find “subluxations” in everyone, routinely advise patients to come for many months, years, and even for their lifetime. Practice-builders teach how to persuade people they need “maintenance care” long after their original problem has resolved. In line with this, many chiropractors offer “discounts” to patients who pay in advance and sign a contract committing them for 50 to 100 treatments. And “chiropractic pediatric specialists” advise periodic examinations and spinal adjustments from early infancy onward. (This has been aptly described as “womb to tomb” care.) Greed is not the only factor involved in overtreatment. Many who advise periodic adjustments are “true believers.” In chiropractic school, one of my classmates actually adjusted his newborn son while the umbilical cord was still attached. Another student had the school radiology department take seven x-rays of his son’s neck to look for “subluxations” presumably acquired during the birth process. The topic of unnecessary care is discussed further in Chapter 8.
8. “Cracking” of the spine doesn’t mean much.
Spinal manipulation usually produces a “popping” or “cracking” sound similar to what occurs when you crack your knuckles. Both are due to a phenomenon called cavitation, which occurs when there is a sudden decrease in joint pressure brought on by the manipulation. That allows dissolved gasses in the joint fluid to be released into the joint itself. Chiropractors sometimes state that the noise means that something therapeutic has taken place. However, the noise has no health-related significance and does not indicate that anything has been realigned. It simply means that gas was allowed to escape under less pressure than normal. Knuckles do not “go back into place” when you crack them, and neither do spinal bones.
9. If the first few visits don’t help you, more treatment probably won’t help.
I used to tell my patients “three and through.” If we did not see significant objective improvement in three visits, it was time to move on.
10. We take too many x-rays.
No test should be done unless it is likely to provide information that will influence clinical management of the patient. X-ray examinations are appropriate when a fracture, tumor, infection, or neurological defect is suspected. But they are not needed for evaluating simple mechanical-type strains, such as back or neck pain that develops after lifting a heavy object.
The average number of x-rays taken during the first visit by chiropractors whose records I have been asked to review has been about eleven. Those records were sent to me because an insurance company had flagged them for investigation into excessive billing, so this number of x-rays is much higher than average. But many chiropractors take at least a few x-rays of everyone who walks through their door.
There are two main reasons why chiropractors take more x-rays than are medically necessary. One is easy money. It costs about 35¢ to buy an 8- x 10-inch film, for which they typically charge $40. In chiropractic, the spine encompasses five areas: the neck, mid-back, low-back, pelvic, and sacral regions. That means five separate regions to bill for—typically three to seven views of the neck, two to six for the low back, and two for each of the rest. So eleven x-ray films would net the chiropractor over $400 for just few minutes of work. In many accident cases I have reviewed, the fact that patients had adequate x-ray examinations in a hospital emergency department to rule out fractures did not deter the chiropractor from unnecessarily repeating these exams.
Chiropractors also use x-ray examinations inappropriately for marketing purposes. Chiropractors who do this point to various things on the films that they interpret as (a) subluxations, (b) not enough spinal curvature, (c) too much spinal curvature, and/or (d) “spinal decay,” all of which supposedly call for long courses of adjustments with periodic x-ray re-checks to supposedly assess progress. In addition to wasting money, unnecessary x-rays entail unnecessary exposure to the risks of ionizing radiation.
11. Research on spinal manipulation does not reflect what takes place in most chiropractic offices.
Research studies that look at spinal manipulation are generally done under strict protocols that protect patients from harm. The results reflect what happens when manipulation is done on patients who are appropriately screened—usually by medical teams that exclude people with conditions that would make manipulation dangerous. The results do not reflect what typically happens when patients select chiropractors on their own. The chiropractic marketplace is a mess because most chiropractors ignore research findings and subject their patients to procedures that are unnecessary and/or senseless.
12. Neck manipulation is potentially dangerous.
Certain types of chiropractic neck manipulation can damage neck arteries and cause a stroke. Chiropractors claim that the risk is trivial, but they have made no systematic effort to actually measure it. Chapter 9 covers this topic in detail.
13. Most chiropractors don’t know much about nutrition.
Chiropractors learn little about clinical nutrition during their schooling. Many offer what they describe as “nutrition counseling.” But this typically consists of superficial advice about eating less fat and various schemes to sell you supplements that are high-priced and unnecessary.
14. Chiropractors who sell vitamins charge much more than it costs them.
Chiropractors who sell vitamins typically recommend them unnecessarily and charge two to three times what they pay for them. Some chiropractors center their practice around selling vitamins to patients. Their recommendations are based on hair analysis, live blood analysis, applied kinesiology muscle-testing or other quack tests that will be discussed later in this book. Patients who are victimized this way typically pay several dollars a day and are encouraged to stay on the products indefinitely. In one case I investigated, an Arizona chiropractor advised an 80+-year-old grandma to charge more than $10,000 for vitamins to her credit cards to avoid an impending stroke that he had diagnosed by testing a sample of her pubic hair. No hair test can determine that a stroke is imminent or show that dietary supplements are needed. Doctors who evaluated the woman at the Mayo Clinic found no evidence to support the chiropractor’s assessment.
15. Chiropractors have no business treating young children.
The pediatric training chiropractors receive during their schooling is skimpy and based mainly on reading. Students see few children and get little or no experience in diagnosing or following the course of the vast majority of childhood ailments. Moreover, spinal adjustment has no proven effectiveness against childhood diseases. Some adolescents with spinal stiffness might benefit from manipulation, but most will recover without treatment. Chiropractors who claim to practice “chiropractic pediatrics” typically aim to adjust spines from birth onward and are likely to oppose immunization. Some chiropractors claim they can reverse or lessen the spinal curvature of scoliosis, but there is no scientific evidence that spinal manipulation can do this.6
16. The fact that patients swear by us does not mean we are actually helping them.
Satisfaction is not the same thing as effectiveness. Many people who believe they have been helped had conditions that would have resolved without treatment. Some have had treatment for dangers that did not exist but were said by the chiropractor to be imminent. Many chiropractors actually take courses on how to trick patients to believe in them. (See Chapter 8)
17. Insurance companies don’t want to pay for chiropractic care.
Chiropractors love to brag that their services are covered by Medicare and most insurance companies. However, this coverage has been achieved though political action rather than scientific merit. I have never encountered an insurance company that would reimburse for chiropractic if not forced to do so by state laws. The political pressure to mandate chiropractic coverage comes from chiropractors, of course, but it also comes from the patients whom they have brainwashed.
18. Lots of chiropractors do really strange things.
The chiropractic profession seems to attract people who are prone to believe in strange things. One I know of does “aura adjustments” to treat people’s “bruised karma.” Another rents out a large crystal to other chiropractors so they can “recharge” their own (smaller) crystals. Another claims to get advice by “channeling” a 15th Century Scottish physician. Another claimed to “balance a woman’s harmonics” by inserting his thumb into her vagina and his index finger into her anus. Another treated cancer with an orange light that was mounted in a wooden box. Another did rectal exams on all his female patients. Even though such exams are outside the legitimate scope of chiropractic, he also videotaped them so that if his bills for this service were questioned, he could prove that he had actually performed what he billed for.
19. Don’t expect our licensing boards to protect you.
Many chiropractors who serve on chiropractic licensing boards harbor the same misbeliefs that are rampant among their colleagues. This means, for example, that most boards are unlikely to discipline chiropractors for diagnosing and treating imaginary “subluxations.”
20. The media rarely look at what we do wrong.
The media rarely if ever address chiropractic nonsense. Reporting on chiropractic is complicated because chiropractors vary so much in what they do. (In fact, a very astute observer once wrote that “for every chiropractor, there is an equal and opposite chiropractor.”) Consumer Reports published superb exposés in 1975 and 1994, but no other print outlet has done so in the past 35 years. This lack of information is the main reason I have written this book.
1. Ernst E, Gilbey A. Chiropractic claims in the English-speaking world. New Zealand Medical Journal 123:36–44, 2010.
2. Bernet J. Affidavit, April 12, 1996. Posted to Chirobase Web site.
3. Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status. Council on Chiropractic Education, Scottsdale, Arizona, Jan 2007.
4. Jarvis WT. Why becoming a chiropractor may be risky. Chirobase Web site, October 5, 1999.
5. Barrett S. My visit to a “straight” chiropractor. Quackwatch Web site, Oct 10, 2002.
6. Romano M, Negrini S. Manual therapy as a conservative treatment for idiopathic scoliosis: A review. Scoliosis 3:2, 2008.
Having disclosed in my previous post that, on 1 October, I have been in full-time alternative medicine research for exactly 20 years, I thought it might be interesting to briefly reflect on these two decades. One thing I ought to make clear from the beginning: I truly enjoy my work (well, ~90% of it anyway). When I came to Exeter, I never expected it to get so fascinating, and I am surprised to see how it gripped me.
A PERIOD OF TWO HALVES
One could divide these two decades in two periods of roughly equal length. The first half was characterised by defining my aims, assembling a team, getting the infrastructure sorted and doing plenty of research. I had made it very clear from the beginning that I was not going to promote alternative medicine; my aim was to critically evaluate it. Once I realised how controversial and high profile some of our work could become, I made a conscious effort to keep out of any disputes and tried to avoid the limelight. I wanted to first do my ‘homework’, analyse the evidence, produce own results and be quite sure of my own position before I entered into any public controversies. During this time, we therefore almost exclusively published in medical journals, lectured to medical audiences and generally kept as low a public profile as possible.
The second half was characterised by much more research and my increasing willingness to stick my head out and stand up publicly for the findings I had reasons to be confident about. The evidence had reached a point where it was simply no longer possible nor ethical to keep silent. I felt we had a moral duty to speak up and present the evidence clearly; and that often meant going public: after all, alternative medicine is an area where the public often make the therapeutic decisions without consulting a health care professional – so they need accurate and reliable information. Therefore, I began publishing in the daily papers, lecturing to lay audiences more regularly and addressing the public in many other ways.
THE PLEASURE OF SUPPORTING YOUNG SCIENTISTS
One of the most gratifying aspects of directing a research team is to meet and befriend scientists from all over the world. When several independent analyses had shown that our team had grown into the most productive research unit in alternative medicine worldwide, we started receiving numerous requests from young scientists across the globe to join us. Many of those individuals later went back to their home countries to occupy key positions in research. Our concept of critical evaluation thus spread around the world – at least this is what I hope when I feel optimistic about our achievements.
Amongst the ~90 staff who have worked with me during the last 20 years, we had many enthusiastic and gifted scientists. I owe thanks to all of those who advanced our research and helped us to make progress through critical evaluation. Unfortunately, we also had a few co-workers who, despite of our best efforts, proved to be unable of critical thinking, and more than once this created unrest, tension and trouble. When I analyse these cases in retrospect, I realise how quasi-religious belief must inevitably get in the way of good science. If a person is deeply convinced about the value of his/her particular alternative therapy and thus decides to become a researcher in order to prove his/her point, serious problems are unavoidable.
THE THREE MOST IMPORTANT MESSAGES
But generally speaking, my team worked both very well and extremely hard. Perhaps the best evidence for that statement is the fact that we published more than 1000 articles in the peer review literature, including ~30 clinical trials and 300 systematic reviews/meta-analyses. If I had to extract what I consider to be the three the most important messages from these papers, I might make the following points:
- The concepts that underpin alternative treatments are often not plausible and must be assessed critically.
- Most claims made for alternative medicine are unproven and quite a few should be regarded as disproven.
- Very few alternative therapies demonstrably generate more good than harm.
Looking back to those 20 years, I am struck by the frequency with which I encountered intellectual dishonesty and denial of facts and evidence. Medical research, I had previously assumed is a rather dry and unemotional business – not so when it comes to research into alternative medicine! Here it is dominated by people who carry so much emotional baggage that rational analysis becomes the exception rather than the rule.
The disappointment of alternative medicine apologists had been noticeable virtually from the start; they had quickly realised that I was not in the business of promoting quackery. My remit was to test hypotheses, and when you do that, you have to try to falsify them. To those who fail to understand the rules of science – and that is the vast majority of alternative medicine fans – this process can appear like a negative, perhaps even destructive activity. Consequently, some people began to suspect that I was working against their interests. In fact, as a researcher, I had little patience with such people’s petty interests; all I wanted is to do good science, hopefully for the benefit of the patient.
These sentiments grew dramatically during the second decade when I began to go public with the evidence which often failed to confirm the expectations of alternative medicine enthusiasts. To see the truth published in relatively obscure medical journals might have already been tough for them; to see it in the daily papers or hear it on the radio from someone whom they could not easily accuse of incompetence was obviously more than the evangelic believers could take. Their relatively cautious attitude towards our work soon changed into overt aggression, particularly after our book ‘TRICK OR TREATMENT…‘. The second decade was therefore also characterised by numerous attacks, challenges, defamations and conflicts, not least the ‘run ins’ with Prince Charles and his sycophants. Unfortunately, my own University as well as my newly formed Medical School had no stomach for such battles; the top officials of both institutions seemed more concerned about their knighthoods than about defending me against obviously malicious attacks which could only have one aim: to silence me.
But silence they did me not! It is simply not in my character to give up when I know that I have done nothing wrong and fighting ‘the good fight’. On the contrary, each attack merely strengthened my resolve to fight harder for what I knew was right, ethical and necessary. Eventually, my peers became so frustrated with my resilience that they pulled the plug: they stopped all support. This meant my team had to be dismissed and I had to go into early retirement.
Since about a year, I am ‘Emeritus Professor’, a status which has disadvantages (no co-workers to help with the research, no salary) but also important advantages. I can finally speak the truth without fearing that some administrator suffering from acute ‘knighthood starvation syndrome’ is going to try to discipline me for my actions.
This blog, I think, is pretty good evidence for the fact that I continue to enjoy my work in alternative medicine. I cannot promise to do another 20 years but, for the time being, I continue to be research-active and am involved in numerous other activities. Currently I am also writing a book which will provide a full account of those remarkable last 20 years (almost finished but I have no publisher yet) and I am working on the concept of another book that deals with alternative medicine in more general terms. They did not silence me yet, and I do not assume they will soon.
Homeopaths can bear criticism only when it is highly diluted. Any critique from the ‘outside’ is therefore dismissed by insisting that the author fails to understand the subtleties of homeopathy. And criticism from the ‘inside’ does not exist: by definition, a homeopath does not criticise his/her own trade. Through these mechanisms, homeopaths have more or less successfully shielded themselves from all arguments against their activities and have, for the last 200 years, managed to survive in a world of make-belief.
As I will show below, I started my professional life on the side of the homeopaths – I am not proud of this fact, but there is no use denying it. When the evidence told me more and more clearly that I had been wrong, about 10 years ago, I began expressing serious doubts about the plausibility, efficacy and safety of using homeopathic remedies to treat patients in need. Homeopaths reacted not just with anger, they were also at a loss.
Their little trick of saying ‘He does not understand homeopathy and therefore his critique is invalid’ could not possibly work in my case – I had been one of them: I had attended their meetings, chaired some of their sessions, edited a book on homeopathy, accepted an invitation to join the editorial board of the journal ‘HOMEOPATHY‘ as well as a EU-panel investigating homeopathy, conducted trials, systematic reviews and meta-analyses, published over 100 articles on the subject, accepted money from Prince Charles as well as from the ‘ueber-homeopath’ George Vithoulkas for my research, and even contributed to THE INTERNATIONAL DICTIONARY OF HOMEOPATHY. It would have not looked reasonable to suddenly deny my previously accepted expertise. Homeopaths thus found themselves in a pickle: critique from the ‘inside’ is not what they were used to or could easily cope with.
The homeopathic idyll was under threat, and a solution to the problem had to be found with some urgency. And soon enough, it was found. Homeopaths from across the world started claiming that I had been telling porkies about my training/qualifications in homeopathy: “Edzard Ernst has admitted that he has over the years lied or supported a lie about having homeopathic training. In reality he has had none at all! The leading so-called ‘expert’ and critic of homeopathy, Professor Edzard Ernst, has admitted that he has no qualifications in homeopathy. etc. etc. Diluting the truth to the extreme, they almost unanimously insisted that, contrary to my previous assertions, I had no training/qualifications in homeopathy. Thus, they began to argue, that I was an imposter and had insufficient knowledge, expertise and experience after all: Professor Edzard Ernst the leading ‘authority’ on homeopathy, and perhaps its most referenced critic, has no qualifications in homeopathy. William Alderson of HMC21 also claims that Ernst’s book Trick or Treatment? shows Ernst to be unreliable as a researcher into homeopathy. Opposition to homeopathy is based on propaganda, they stated. Others wrote that Edzard Ernst’ failure as a homeopath only proves he lacked some basic qualities essential to become a successful homeopath. He failed as a homeopath, and then turned a skeptic. His failure is only his failure- it does not disprove homeopathy by any way. Once he failed in putting a mark as a successful homeopath or CAM practitioner, he just tried the other way to become famous and respectable- he converted himself into a skeptic, which provided him with ample opportunities to appear on ‘anti-homeopathy’ platforms’ as an ‘authority’, ‘expert’ and ‘ex-homeopath’! Some went even further claiming that I had also lied about my medical qualifications.
These notions has been going around the internet for several years now and conveniently served as a reason to re-categorise me into the camp of the homeopathically unqualified pseudo-experts: ‘We believe that it is time to recognise that opposition to homeopathy is largely based on the opinions of individuals who are unqualified or unwilling to judge the evidence fairly’. I, by contrast, believe it is time that I disclose the full truth about ‘my double-life as a homeopath’. What exactly is my background in this area? Have I really been found out to be a confidence-trickster?
THE HOMEOPATHIC CLINICIAN
I graduated from medical school in Munich in the late 1970s and, looking for a job, I realised that there weren’t any. At the time, Germany had a surplus of doctors and all the posts I wanted were taken. Eventually, I found one in the only hospital that was run almost entirely homoeopathically, the KRANKENHAUS FUER NATURHEILWEISEN in Munich. Within about half a year, I learned how to think like a homeopath, diagnose like a homeopath and treat patients like a homeopath. I never attended formal courses or aspired to get a certificate; as far as I remember, none of the junior doctors working in the homeopathic hospital did that either. We were expected to learn on the job, and so we did.
Our teachers at medical school had hardly ever mentioned homeopathy, but one thing they had nevertheless made abundantly clear to us: homeopathy cannot possibly work; there is nothing in these pills and potions! To my surprise, however, my patients improved, their symptoms subsided and, in general, they were very happy with the treatment we provided. My professors had told me that homeopathy was rubbish, but they had forgotten to teach me a much more important lesson: critical thinking. Therefore, I might be forgiven for proudly assuming that my patients’ improvement was due to my skilful homeopathic prescriptions.
But then came another surprise: the boss of the homeopathic hospital, Dr Zimmermann, took me under his wings, and we had occasional discussions about this and that and, of course, about homeopathy. When I shyly mentioned what I had been told at medical school ( about homeopathy being entirely implausible), he agreed! I was speechless. Crucially, he considered that there were other explanations: “Our patients might improve because we look after them well and we discontinue all the unnecessary medication they come in with; perhaps the homeopathic remedies play only a small part”, he said.
THE INVESTIGATOR OF HOMEOPATHY
This may well have been the first time I started looking critically at homeopathy and my own clinical practice – and this is roughly where I left things as far as homeopathy is concerned until, in 1993, it became my job to research alternative therapies systematically and rigorously. Meanwhile I had done a PhD and tried my best to learn the skills of critical analysis. As I began to investigate homeopathy scientifically, I found that my former boss had been right: patients do indeed improve because of a multitude of factors: placebo-effects, natural history of the disease, regression towards the mean, to mention just three of a multitude of phenomena. At the same time, he had not been entirely correct: homeopathic remedies are pure placebos; they do not play a ‘small part’ in patients’ improvement, they play no part in this process.
As I began to state this more and more clearly, all sorts of ad hominem attacks were hauled in my direction, and recently I was even fired from the editorial board of the journal ‘HOMEOPATHY’ because allegedly I “…smeared homeopathy and other forms of complementary medicine…” I don’t mind any of that – but I do think that the truth about ‘my double-life as a homeopath’ should not be diluted like a homeopathic remedy until it suits those who think they can defame me by claiming I am a liar and do not know what I am talking about.
This rather depressing story shows, I think, that some homeopaths, rather than admitting they are in the wrong, are prepared to dilute the truth until it might be hard for third parties to tell who is right and who is wrong. But however they may deny it, the truth is still the truth: I have been trained as a homeopath.
If my health insurance pays for this treatment, it must be scientifically tested and proven. The ‘appeal to authority’ is powerful indeed, and I imagine that many consumers fall for this argument. But it is a fallacy! Health insurances are misinforming us for commercial benefit.
In 2007, I published an analysis of German health insurance companies’ policies regarding bogus treatments (MMW 2006, 149: 55-56 [the paper is in German and unfortunately not Medline-listed]). For this purpose, I had selected three popular alternative modalities: Bach flower remedies, Schuessler salts, and kinesiology all of which are, of course, not supported by sound evidence nor by biological plausibility. What emerged from this evaluation was shocking: of the 13 companies analysed, 9 paid for Bach flower remedies, 7 for kinesiology and 9 for Schuessler salts.
If you now think ‘ah yes, those Germans are obsessed with alternative medicine’, think again. The situation in most other countries is not much better; health insurances go for alternative medicine as though there is no tomorrow. A review from the US concluded that the number of people using CAM insurance benefits was substantial; the effect on insurance expenditures was modest. Because the long-term trajectory of CAM cost under third-party payment is unknown, utilization of these services should be followed. And apparently this is by no means confined to human health; recently someone tweeted that he had a very hard time finding a pet-insurance which did not offer to cover woo.
A few years after the above-mentioned publication, I was invited to speak at an international meeting of health insurers. I told the delegates in no uncertain terms that most of what they were offering to their clients in terms of alternative medicine was either unproven or disproven. There was stunned silence during the official discussion period, and I asked myself whether I had impolitely embarrassed my hosts. Then came the tea break, and one high-level representative of an insurance company after the other came to me to chat. Essentially, they all said: “We are well aware of the facts and the evidence you reviewed in your lecture; most of these treatments are useless, of course. But we have to offer them to our customers because we need to be competitive.”
In other words, health insurers, who normally are keen to keep their costs down, do not mind to pay for treatments which they know are ineffective simply because they use it as some sort of an advertising gimmick. In doing so they say or imply that these treatments do work. I think this is not just wrong and short-sighted, it is unethical and it significantly contributes to the ‘sea of misinformation’.
It almost goes without saying that alternative practitioners contribute importantly to the ‘sea of misinformation’ about alternative medicine. Again, I could write books about this subject but have to refrain myself and therefore will merely put quick spotlights on several types of practitioners, mostly drawing from my own research on these subjects.
A survey of more than 9000 patients of U.K. non-medically trained acupuncturists showed that a considerable number had received advice from their therapists about prescribed medicines. Since these acupuncturists hold no medical qualifications, they are not qualified to issue such advice. It is therefore clear to me that the advice given is likely to be misleading. In 2000, we directly asked the U.K. acupuncturists’ advice about electro-acupuncture treatment for smoking cessation, a treatment which we previously had identified to be ineffective. The advice we received was frequently not based on current best evidence and some of it also raised serious safety concerns (Schmidt, K., & Ernst, E. Internet advice by acupuncturists—a risk factor for cardiovascular patients? Perfusion,2002, 15: 44-50. Article not Medline-listed).
Many chiropractors from the UK and other countries make unsustainable therapeutic claims on their websites. In 2002, at the height of the ‘‘MMR scare’’ in Britain, we conducted a study revealing that a sizable proportion of U.K. chiropractors advised mothers against having the measles-mumps-rubella (MMR) jab for their children. A survey of the U.K. chiropractors demonstrated that an alarming percentage of the U.K. chiropractors fail to provide advice about the risks of spinal manipulation before commencing treatment. As these risks are, in fact, considerable, this behaviour amounts to misinformation and is an obvious violation of medical ethics.
With osteopaths, it is a very similar story; the main difference is that there are far less investigations than for chiropractors. This may be due to the fact that, in the US, osteopaths are not alternative but conventional clinicians with much the same training and skills as proper doctors. But in Europe, they are strictly alternative and make as many bogus claims as chiropractors. Systematic investigations are rare, but I only need to remind us of my recent blog-post where I pointed out that:
Most osteopaths treat children for a wide range of conditions and claim that their interventions are helpful. They believe that children are prone to structural problems which can be corrected by their interventions. Here is an example from just one of the numerous promotional websites on this topic:
STRUCTURAL PROBLEMS, such as those affecting the proper mobility and function of the body’s framework, can lead to a range of problems. These may include:
- Postural – such as scoliosis
- Respiratory – such as asthma
- Manifestations of brain injury – such as cerebral palsy and spasticity
- Developmental – with delayed physical or intellectual progress, perhaps triggering learning behaviour difficulties
- Infections – such as ear and throat infections or urinary disturbances, which may be recurrent.
OSTEOPATHY can assist in the prevention of health problems, helping children to make a smooth transition into normal, healthy adult life.
Encouraging evidence exists for some specific herbs in the treatment of some specific conditions. Yet, virtually no good evidence exists to suggest that the prescriptions of individualized herbal mixtures by traditional herbalists across the globe generate more good than harm. Despite this lack of evidence, herbalists do not seem to offer this information voluntarily to his or her patients. When we directly asked the UK herbalists for advice on a clinical case, we found that it was ‘‘misleading at best and dangerous at worst’’ . In other words, herbalists misinform their patients and the public about the value of their treatments.
Many non-medically trained homeopaths advise their clients against the immunization of children. Instead, these practitioners often recommend using ‘‘homeopathic vaccinations’’ for which no good evidence exists. For instance, the vice-chair of the board of directors of ‘‘The Society of Homeopaths’’ had a site with the following statements: ‘‘Homeopathic alternatives to children’s immunisation are now available.’’ ‘‘Our clinic offers alternative immunisation programmes for the whole family.’’ Such statements amounts to misinformation which puts children’s health at risk.
Other alternative practitioners
I have chosen the above-listed professions almost at random and could have selected any other type as well. Arguably, all alternative practitioners who employ unproven treatments – and that must be the vast majority – misinform their patients to some extend. The only way to avoid this is to say: ‘look, I am going to give you a therapy for which there is no good evidence – I hope you don’t mind’. If they did that, they would be out of business in a flash. It follows, I think, that being in business is tantamount to misleading patients.
And there is, of course, another way of misinforming patients which is often forgotten yet very important: withholding essential information. In all of health care, informed consent is a ‘sine qua non’. Alternative practitioners very rarely obtain informed consent from their patients. The reason seems obvious (see above). I would argue that not informing people when they should be informed is a form of misinformation.
In this context, it is worth mentioning an investigation we did in 2009: We obtained the ethical codes of the following bodies: Association of Naturopathic Practitioners, Association of Traditional Chinese Medicine (UK), Ayurvedic Practitioners Association, British Acupuncture Council, Complementary and Natural Healthcare Council, European Herbal Practitioners Association, General Chiropractic Council, General Osteopathic Council, General Regulatory Council for Complementary Therapies, National Institute of Medical Herbalists, Register of Chinese Herbal Medicine, Society of Homeopaths, UK Healers, Unified Register of Herbal Practitioners. We then extracted the statements from these codes referring to evidence-based practice (EBP). The results showed that only the General Chiropractic Council, the General Osteopathic Council and the General Regulatory Council for Complementary Therapies oblige their members to adopt EBP.
It seems that misinformation is an alternative practitioner’s daily bread. Without it, alternative therapists would need to confine their practice to the few treatments/conditions for which the evidence is positive. If they ever followed this strategy, they would hardly be able to earn a living.
Where can someone turn to who wants reliable information on alternative medicine? Many consumers and patients who ask themselves this question might already be somewhat weary of the Internet; everybody should by now know that websites can be dangerously misleading and usually commercially driven. What about books then? People still tend to trust books; they are written by experts, published by responsible enterprises, and sold through respectable outlets. Surely we can trust books, or can’t we?
The first thing that strikes you when you look into the subject is the fact that there are thousands of books on alternative medicine. You only need to visit a major book shop in your high street and admire the rows and rows of these volumes. Since many years, I have been evaluating such volumes, for instance, for our journal FACT where we regularly publish reviews of new material. Through this and other work, I have gained the impression, that most of these books are not worth the paper they are printed on and constitute a major contributor to the misinformation bombarding the consumer in this area. But that was just an impression, hard data would be better.
In 1998, we assessed for the first time the quality of books on alternative medicine ( Int J Risk Safety Med 1998, 11: 209-215. [For some reason, this article is not Medline-listed]). We chose a random sample of 6 such books all published in 1997, and we assessed their contents according to pre-defined criteria. The findings were sobering: the advice given in these volumes was frequently misleading, not based on good evidence and often inaccurate. If followed, it would have caused significant harm to patients.
In 2006, we conducted a similar investigation which we then reported in the first and second editions of our book THE DESKTOP GUIDE TO COMPLEMENTARY AND ALTERNATIVE MEDICINE. This time, we selected 7 best-sellers in alternative medicine and scrutinised them in much the same way. What we found was revealing. Almost every treatment seemed to be recommended for almost every condition. There was no agreement between the different books which therapy might be effective for which condition. Some treatments were even named as indications for a certain condition, while, in other books, they were listed as contra-indications for the same problem. A bewildering plethora of treatments was recommended for most conditions, for instance:
- addictions: 120 different treatments
- arthritis: 131 different treatments
- asthma: 119 different treatments
- cancer: 133 different treatments
- etc. etc.
This experience, which we published as a chapter in our book entitled AN EPITAPH TO OPINION-BASED MEDICINE, confirmed our suspicion that books on alternative medicine are a major contributor to the ‘sea of misinformation’ in this area – and, as they are read by many people, a significant risk factor to public health.
Why do publishers allow such rubbish to be printed? Why do so many authors spend their time misleading the public with their dangerous half-knowledge? Why do consumers buy such overtly uncritical nonsense? I do not know the answers, I must admit. But I know that books of this nature do a disservice to everyone involved, including the few respectable aspect of alternative medicine which might actually exist.
Has the situation changed since 2006? We cannot be sure; there is, to the best of my knowledge, no hard data; and nobody has repeated our investigations. But my impression from regularly reviewing new books for FACT and other journals is far from encouraging. I fear that our ‘epitaph to opinion-based medicine’ might have been a little premature.
Imagine: you consult your doctor and he says: “I am so sorry, but I have bad news: the tests have shown that you have cancer”. You go home and feel as though someone has hit you with a sledge hammer. You cry a lot and your thoughts go round in circles. A complete nightmare unfolds; you sometimes think you are dreaming but reality soon catches up with you.
A few days later, you have an appointment with the oncologist who explains the treatment plan. You feel there is no choice and you agree to it. After the first chemotherapy, you lose your hair, your well-being, your dignity, your control and your patience – time to investigate what else there is on offer. There must be an alternative!
By then lots of well-wishers will have mentioned to you that the conventional route is but one of many: there are, in fact, alternatives!!! You go on the internet and find not just a few, you find millions of website promoting hundreds of solutions – anything from diets to herbal remedies, from homeopathy to faith-healing. All are being promoted as cures for your cancer, and all are free of those nasty side-effects which make your life hell at the moment. You think “there is a choice after all”.
Who would not be tempted by these options advertised in the most glorious terms? Who would not begin to distrust the oncologists who kindly but firmly insist that ‘alternative cancer cures’ are bogus? Who would not want to get rid of the cancer and the side-effects in one genial master-stroke?
Cancer patients yearn for hope and are extremely vulnerable to such influences. I do not know a single one who, faced with the diagnosis and all it entails, has not looked at the ‘alternatives’. This is why it would be so very important that the websites informing patients and their carers convey accurate and responsible information. But do they?
One of our research projects at Exeter had been aimed at assessing the quality of the websites advising patients on alternative treatments for cancer. For this purpose, we evaluated a total of 32 sites which cancer patients were most likely to consult according to pre-defined criteria – in other words, we assessed the most frequented websites for cancer.
Our results were shocking: many of these sites were of poor quality and most of them recommended a plethora of unproven treatments for cancer, most frequently herbal remedies, diets and mind-body therapies. In our estimation, at least three of them were outright dangerous and had the potential to harm patients.
The level of misinformation in this area is sickening. Patients are being sold false hope by the truck-load. Yet they deserve better; they deserve impartial information on their illness and the best treatment for it – cancer patients especially so. What they get instead is a total disgrace: commercially driven lies about ‘treatments’ which are not just unproven but which would, if used as instructed, hasten their death. Some alternative therapies have potential for palliative and supporting care, BUT NONE OFFER A CURE OR A REDUCTION OF THE TUMOR BURDEN OR A CHANGE IN THE NATURAL HISTORY OF THE DISEASE.
Colonic irrigation is the alternative therapy of celebrities (and those who like to imitate them): they tend to use it for all sorts of ailments, predominantly for loosing weight. And it works! When they have paid for the session, they are relieved of some cash as well as of about half a kilo of body weight. By the time they wake up the next morning, the money is still gone, but the weight is back. This is a most effective method for getting rid of some £s, but NOT an effective way for shedding a few pounds.
Numerous synonyms for colonic irrigation exist, e.g. colonic treatment, colon cleansing, rectal irrigation, colon therapy, colon hydrotherapy, colonic. The treatment is based on the ancient but obsolete theory of ‘autointoxication’, i.e. the body is assumed to poison itself with, ‘autotoxins’ which, in turn, cause various illnesses. So, it is implausible and there is also no evidence to suggest it is effective. But this does not stop professional organisations to make claims which are good for business.
My analysis of the claims made by professional organisations of practitioners of colonic irrigation across the globe aimed at assessing the therapeutic claims made by these institutions. Six such organisations were identified, and the contents of their websites were studied. The results showed that all of the six organisations make therapeutic claims on their websites. Frequently mentioned themes are ‘detoxification’, normalisation of intestinal functions, treatment of inflammatory bowel diseases and body weight reduction. The claims are mostly confined to symptomatic improvements – but there are exceptions, e.g. prevention of bowel cancer or sorting out Irritable Bowel Syndrome ‘once and for all’ . Other therapeutic claims pertain to asthma, menstrual irregularities, circulatory disorders, skin problems, improvement in energy levels and no longer requiring pharmacotherapy. All these claims represent testable hypotheses.
The question therefore arises whether these hypotheses have been tested and, if so, what the results of such investigations suggest? The use of colonic irrigation by alternative practitioners for any indications is not supported by any sound evidence at all. There are simply no trials to show effectiveness. Even worse is the fact that, although touted as safe, colonic irrigation can lead to serious complications.
The conclusion is therefore simple: colonic irrigation is neither demonstrably effective nor safe, and the information supplied by its professional organisations is therefore a significant contributor to the sea of misinformation in the realm of alternative medicine.
The UK ‘Society of Homeopaths’ (SoH) is the largest professional organisation of UK non-doctor, so-called lay- homeopaths. On their website, the SoH made very specific claims about homeopathy; in particular, they listed conditions for which homeopathy had allegedly been proven to be effective. These claims have now thoroughly been debunked, and the evidence the SoH produced in support of their claims has been shown to be misleading, cherry-picked or misinterpreted.
I have no idea who conducted the above-named investigation and made a youtube video of it, but I think it is essentially correct and well worth watching. My own experiences with the SoH relate mainly to two encounters.
The first was a complaint I made about one of their high-ranking officers, Ralf Jeutter. He had been promotiong homeopathic vaccinations on his website (needless to stress, I think, that there is no evidence to support the notion that homeopathic vaccinations are effective). As I felt that the SoH dragged their feet pursuing my complaint, I had to send several reminders. Eventually, they considered it and concluded that Reuter had done nothing wrong. This, presumably, is the reason why, even today, he can state on his website that Homeopathy is used to help individuals in dealing better with kinds of infections such as leptospirosis, meningitis and cholera. All is fine, it seems as long as a disclaimer is added: Any information obtained here is not to be construed as medical OR legal advice. The decision to vaccinate and how you implement that decision is yours and yours alone. The evidence for the efficacy of homeopathic immunisation is ‘anecdotal’. That means it is based on individuals’ reports past and present.
My second encounter with the SoH relates to my 2010 analysis of the SoH code of ethics and their adherence to it. The code demanded that:
- ‘all speculative theories will be stated as such and clearly distinguished’
- ‘no advertising may be used which expressly or implicitly claims to cure named diseases’
- ‘Advertising shall not be false, fraudulent, misleading, deceptive, extravagant or sensational.’
Encouraged by these assurances, I decided to study the websites of some members of the SoH, and soon discovered numerous and very obvious violations of the above-mentioned imperatives. In an attempt to find the root of these transgressions, I scrutinised the SoH’s own website where I found a multitude violations on all levels of the SoH’s own code of ethics. Many of the violations related to claims which were not supported by evidence. In other words, the largest professional UK organisation of lay- homeopaths misled the public in several rather devious ways:
they pretended to adhere to a code of ethics which forbids members to mislead the public
SoH -members nevertheless did mislead the public in ways that public health at risk
and they did so not least because the SoH followed exactly the same strategy
thus the SoH violated its own code of ethics to the detriment of public health.
My analysis was conducted a while ago, and some might hope that the SoH has stopped systematically misleading the public. This hope, however, is harshly disappointed when you watch the brand-new video entitled TESTING HOMEOPATHY mentioned above. As the SoH is about to celebrate 35 years of wisdom, courage, knowledge and prosperity, I do wonder whether this should not be 35 years of dangerously misleading the public.
What do you think?