George Lewith has died on 17 March, aged 67. He was one of the most productive researchers of alternative medicine in the UK; specifically he was interested in acupuncture. If you search this blog, you find several posts that mention him or are entirely dedicated to his work. Undeniably, my own views and research were often very much at odds with those of Lewith.
Wikipedia informs us that Lewith graduated from Trinity College, Cambridge in medicine and biochemistry. He then went on to Westminster Medical School to complete his clinical studies and began working clinically in 1974. In 1977 Lewith became a member of the Royal College of Physicians. Then, in 1980, he became a member of the Royal College of General Practitioners and, later in 1999, was elected a fellow of the Royal College of Physicians.
He was a Professor of Health Research in the Department of Primary Care at the University of Southampton and a director of the International Society for Complementary Medicine Research. Lewith has obtained a significant number of institutional peer reviewed fellowships at doctoral and post-doctoral level and has been principal investigator or collaborator in research grants totally over £5 million during the last decade.
Between 1980 and 2010, Lewith was a partner at the Centre for Complementary and Integrated Medicine, a private practice providing complementary treatments with clinics in London and Southampton.
A tribute by the British Acupuncture Council is poignant, in my view: “George was a friend not only to all of the acupuncture profession, be it traditional, medical or physiotherapist – he was a member of all three professional bodies – but to the whole of complementary medicine. As well as being a research leader he was also politically savvy, working tirelessly up front and behind the scenes to try to bring acupuncture and CAM further into the mainstream. Nobody did more.”
I find it poignant because it hints at the many differences I (and many others) had with Lewith during the last 25 years that I knew him. George was foremost a proponent of acupuncture. His 1985 book – the first of many – advocated treating many internal diseases with acupuncture!
George did not strike me as someone who had the ability or even the ambition to use science for finding the truth and for falsifying hypotheses; in my view, he employed it to confirm his almost evangelic belief. In the pursuit of this all-important aim he did indeed spend a lot of time and energy pulling strings, including on the political level. George was undoubtedly successful but the question has to be asked to what extent this was due to his tireless work ‘behind the scenes’.
In my view, George was a typical example of someone who first and foremost was an advocate and a researcher second. During my time in Exeter, I have met numerous co-workers who had the same problem. Almost without exception, I found that it is impossible to turn such a person into a decent scientist. The advocacy of alternative medicine always got in the way of objectivity and rationality, qualities that are, of course, essential for good science.
George’s very first publication on acupuncture was a ‘letter to the editor’ published in the BMJ. In it, he announced that he is planning to conduct a trial of acupuncture and stated that “acupuncture will be compared to an equally magical placebo”. Yes, George always had the ability to make me laugh; and this is why I will miss him.
The love-affair of many nurses with complementary medicine is well-known. We have discussed it many times on this blog – see for instance here, here and here. Yet the reasons for it remain somewhat mysterious, I find. Therefore I was interested to see a new paper on the subject.
The aim of this ‘meta-synthesis‘ was to review, critically, appraise and synthesize the existing qualitative research to develop a new, more substantial interpretation of nurses’ attitudes regarding the, use of complementary therapies by patients. Fifteen articles were included in the review.
Five themes emerged from the data relating to nurses’ attitude towards complementary therapies:
- the strengths and weaknesses of conventional medicine;
- complementary therapies as a way to enhance nursing practice;
- patient empowerment and patient-centeredness;
- cultural barriers and enablers to integration;
- structural barriers and enablers to integration.
Nurses’ support for complementary therapies, the authors of this article claim, is not an attempt to challenge mainstream medicine but rather an endeavour to improve the quality of care available to patients. There are, however, a number of barriers to nurses’ support including institutional culture and clinical context, as well as time and knowledge limitations.
The authors concluded that some nurses promote complementary therapies as an opportunity to personalise care and practice in a humanistic way. Yet, nurses have very limited education in this field and a lack of professional frameworks to assist them. The nursing profession needs to consider how to address current deficiencies in meeting the growing use of complementary therapies by patients.
In my view, there are two most remarkable misunderstandings here:
- While it is undoubtedly laudable that nurses “endeavour to improve the quality of care available to patients”, it has to be said that such an endeavour does not require complementary medicine. Are they implying that with conventional medicine the quality of care cannot be improved?
- I fail to understand why the lack of good evidential support for most complementary therapies did not emerge as a prominent theme. Are nurses not concerned about the (lack of) evidence that underpins their actions?
THE HINKLEY TIMES is quickly becoming my favourite newspaper. Yesterday they published an article about my old friend Tredinnick. I cannot resist showing you a few excerpts from it:
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Alternative therapy advocate, David Tredinnick has called for greater self reliance as a way of reducing pressures on the NHS. Speaking on the BBC’s regional Sunday Politics Show he suggested people should take more responsibility for their own health, rather than relying on struggling services. He highlighted homeopathy as a way of treating ailments at home and said self-help could cut unnecessary trips to the GP. He also said people could avoid illness by not being overweight and taking exercise…During debate on the show about the current ‘crisis’ in health and social care he said: “There are systems such as homeopathic remedies. Try it yourself before going to the doctor.”
Mr Tredinnick has always stood by his personal preferences for traditional therapies despite others disparaging his views. His recent remarks have sparked a response from Lib Dem Parliamentary spokesman Michael Mullaney. He said in the wake of the NHS facing cuts and closures, Mr Tredinnick was yet again showing he was out of touch. He added: “It’s dangerous for Mr Tredinnick, who is not properly medically trained, to use his platform as an MP to tell ill people to treat themselves with homeopathy, a treatment for which there is no medical proof that it works. He should stop talking about his quack theories and do his job representing the people of Hinckley and Bosworth, or otherwise he should resign as MP for he is totally failing to do his job of representing local people.”
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Yes, there is no doubt in my mind: if the public would ever take Tredinnick seriously when he talks about quackery, our health would be in danger. Therefore, it must be seen as most fortunate that hardly anyone does take him seriously. And here are a few reasons why this is so:
Personally, I would very much regret if he resigned – there would be so much less to laugh about in the realm of alternative medicine!
On 13 March, the UK Charity Commission published the following announcement:
This consultation is about the Commission’s approach to deciding whether an organisation which uses or promotes CAM therapies is a charity. For an organisation to be charitable, its purposes must be exclusively charitable. Some purposes relate to health and to relieve the needs of the elderly and disabled.
We are seeking views on:
- the level and nature of evidence to support CAM
- conflicting and inconsistent evidence
- alternative therapies and the risk of harm
- palliative alternative therapy
Last year, lawyers wrote to the Charity Commission on behalf of the Good Thinking Society suggesting that, if the commission refused to revoke the charitable status of organisations that promote homeopathy, it could be subject to a judicial review. The commission responded by announcing their review which will be completed by 1 July 2017.
Charities must meet a “public benefit test”. This means that they must be able to provide evidence that the work they do benefits the public as a whole. Therefore the consultation will have to determine what nature of evidence is required to demonstrate that a CAM-promoting charity provides this benefit.
In a press release, the Charity Commission stated that it will consider what to do in the face of “conflicting or inconsistent” evidence of a treatment’s effectiveness, and whether it should approach “complementary” treatments, intended to work alongside conventional medicine, differently from “alternative” treatments intended to replace it. In my view, however, this distinction is problematic and often impossible. Depending on the clinical situation, almost any given alternative therapy can be used both as a complementary and as an alternative treatment. Some advocates seem to cleverly promote their therapy as complementary (because this is seen as more acceptable), but clearly employ it as an alternative. The dividing line is often far too blurred for this distinction to be practical, and I have therefore long given up making it.
John Maton, the commission’s head of charitable status, said “Our consultation is not about whether complementary and alternative therapies and medicines are ‘good’ or ‘bad’, but about what level of evidence we should require when making assessments about an organisation’s charitable status.” Personally, I am not sure what this means. It sounds suspiciously soft and opens all sorts of escape routes for even the most outright quackery, I fear.
Michael Marshall of the Good Thinking Society said “We are pleased to see the Charity Commission making progress on their review. Too often we have seen little effective action to protect the public from charities whose very purpose is the promotion of potentially dangerous quackery. However, the real progress will come when the commission considers the clear evidence that complementary and alternative medicine organisations currently afforded charitable status often offer therapies that are completely ineffective or even potentially harm the public. We hope that this review leads to a policy to remove such misleading charities from the register.”
On this blog, I have occasionally reported about charities promoting quackery (for instance here, here and here) and pointed out that such activities cannot ever benefit the public. On the contrary, they are a danger to public health and bring many good charities into disrepute. I would therefore encourage everyone to use this unique occasion to write to the Charity Commission and make their views felt.
‘Country News’ just published an article about our heir to the throne. Here is an excerpt:
The Prince of Wales has revealed he uses homeopathic treatments for animals on his organic farm at Highgrove to help reduce reliance on antibiotics, the article stated. He said his methods of farming tried wherever possible to ‘‘go with the grain of nature’’ to avoid dependency on antibiotics, pesticides and other forms of chemical intervention.
The prince made these comments to experts at a summit at the Royal Society in London as part of a global battle against the growing threat of antibiotic resistance. ‘‘In fact, it was one of the reasons I converted my farming operation to an organic, or agro-ecological, system over 30 years ago, and why incidentally we have been successfully using homeopathic — yes, homeopathic — treatments for my cattle and sheep as part of a program to reduce the use of antibiotics,’’ Prince Charles said. Calling for ‘‘urgent and coherent’’ global action, he said antibiotics were being overused. ‘‘It must be incredibly frustrating to witness the fact that, as has been pointed out by many authorities, antibiotics have too often simply acted as a substitute for basic hygiene, or as it would seem, as a way of placating a patient who has a viral infection or who actually needs little more than patience to allow a minor bacterial infection to resolve itself.’’
The prince continued: ‘‘I find it difficult to understand how we can continue to allow most of the antibiotics in farming, many of which are also used in human medicine, to be administered to healthy animals… Could we not devise more effective systems where we reserve antibiotics for treating animals where the use is fully justified by the seriousness of the illness?’’
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Charles seems to have a few reasonable points her. Sadly he then spoils it all by not being able to resist his passion for quackery.
- Yes, we have over-used antibiotics both in human and in veterinary medicine.
- Yes, this has now gone so far that it now endangers our health.
- Yes, it is a scandal that so little has happened in this respect, despite us knowing about the problem for many years.
- No, homeopathy is not the solution to any of the above!!!
The Prince claims he has been ‘successfully using homeopathy’. This is nonsense, and he should know it. Highly diluted homeopathic remedies are pure placebos, and to use placebos for sick animals cannot be a good idea. For those who need the evidence for these (all too obvious) statements, here it is:
A recent systematic review assessed the efficacy of homeopathy in cattle, pigs and poultry. Only peer-reviewed publications dealing with homeopathic remedies, which could possibly replace or prevent the use of antibiotics in the case of infective diseases or growth promotion in livestock were included. Search results revealed a total number of 52 trials performed within 48 publications fulfilling the predefined criteria. Twenty-eight trials were in favour of homeopathy, with 26 trials showing a significantly higher efficacy in comparison to a control group, whereas 22 showed no medicinal effect. Cure rates for the treatments with antibiotics, homeopathy or placebo varied to a high degree, while the remedy used did not seem to make a big difference. No study had been repeated under comparable conditions. Consequently, the use of homeopathy cannot claim to have sufficient prognostic validity where efficacy is concerned. When striving for high therapeutic success in treatment, the potential of homeopathy in replacing or reducing antibiotics can only be validated if evidence of efficacy is confirmed by randomised controlled trials under modified conditions.
If we want to reduce antibiotics, we need to stop using them for situations where they are not necessary, and we must improve husbandry such that antibiotics are not required for disease prevention. To a large extent this is a question of educating those who are responsible for administering antibiotics. Education has to be rational and evidence-based. Homeopathy is irrational and believe-based.
Yet again, Prince Charles’ views turn out to be a hindrance to progress.
God save the Queen!
We use too many opioids; some experts even speak of an epidemic of opioid over-use. This is a serious problem not least because opioids are addictive and have other serious adverse-effects. But what can be done about it? Currently many experts are trying to answer this very questions.
It must be clear to any observer of the ‘alternative medicine scene’ that charlatans of all types would sooner or later try to jump on the ‘opioid band-waggon’. And indeed exactly this has already happened!
In particular, chiropractors have been busy in this respect. For instance, Alison Dantas, CEO, Canadian Chiropractic Association (CCA) has been quoted in a press-release by the CCA stating that “Chiropractic services are an important alternative to opioid prescribing… We are committed to working collaboratively to develop referral tools and guidelines for prescribing professions that can help to prioritize non-pharmacological approaches for pain management and reduce the pressure to prescribe… We are looking to build an understanding of how to better integrate care that is already available in communities across Canada… Integrating chiropractors into interprofessional care teams has been shown to reduce the use of pharmacotherapies and improve overall health outcomes. This effort is even more important now because the new draft Canadian prescribing guidelines strongly discourage first use of opioids.”
I find it hard to call this by any other name than ‘CHIROPRACTIC MEGALOMANIA’.
Do chiropractors really believe that their spinal manipulations can serve as an ‘alternative to opioid prescribing’?
Do they not know that there is considerable doubt over the efficacy of chiropractic manipulation for back pain?
Do they not know that, for all other indications, the evidence is even worse or non-existent?
Do they really think they are in a position to ‘develop referral tools and guidelines for prescribing professions’?
Do they forget that their profession has never had prescribing rights, understands almost nothing about pharmacology, and is staunchly against drugs of all kinds?
Do they really believe there is good evidence showing that ‘integrating chiropractors into interprofessional care teams… reduce(s) the use of pharmacotherapies and improve overall health outcomes’?
Personally, I cannot imagine so.
Personally, I fear that, if they do believe all this, they suffer from megalomania.
Personally, I think, however, that their posturing is little more than yet another attempt to increase their cash-flow.
Personally, I get the impression that they rate their income too far above public health.
According to our friend Dana Ullman, “homeopathy has had a long tradition within Russia. Even though it was not officially recognized during the Communist regime, it was tolerated. And perhaps in part because it did not receive governmental sanction, the Russian people developed a trust in homeopathy. Due to the fact that homeopathic physicians worked outside of governmental medicine, homeopathy was a part of Russia’s “new economy”. People had to pay for homeopathic care, rather than receive it for free.
Homeopathy is still the minority practice. I was told that there are approximately one million medical doctors in Russia and its surrounding republics, with 15,000 medical doctors who use homeopathic medicines regularly, and about 3,000 medical doctors who specialize in classical homeopathy.”
It has just been reported that the Russian Academy of Sciences (RAS) has labelled homeopathic medicine a health hazard. The organization is now petitioning Russia’s Ministry of Health to abandon the use of homeopathic medicine in the country’s state hospitals, the RBC news outlet reported Monday.
A RAS committee warns that some patients were rejecting standard medicine for serious conditions in favour of homeopathic remedies, a move that almost inevitably puts their lives in danger. The committee also noted that, because of sloppy quality control during the manufacturing processes, some unlicensed homeopathic remedies contain toxic substances which harm patients in a direct fashion.
“The principles of homeopathy contradict known chemical, physical and biological laws and persuasive scientific trials proving its effectiveness are not available,” the committee stated in its report.
The move forms part of a growing backlash against homeopathy in Russia. Last month, students at the First Moscow State Medical University filed a petition to ban homeopathic principles from being taught in medical schools. Russia’s Federal Customs Service also introduced new rules in November 2016, forcing manufacturers to prove the effectiveness of any homeopathic products that they wish to sell.
To this, I have little to add; perhaps just this: ABOUT TIME TOO!
The Committees of Advertising Practice (CAP) write and maintain the UK Advertising Codes, which are administered by the Advertising Standards Authority. On their website, the CAP recently published an updated advertising code for naturopathy. As we have regularly discussed the fact that the public is being frequently misled in this area, I consider the code important in the context of this blog. I therefore take the liberty of repeating it here – not least in the hope that this helps preventing misinformation in the future [the numbers in square brackets refer to me footnotes below].
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What is Naturopathy?
Naturopathy is a holistic  approach to healthcare that uses a combination of one or more different disciplines (for example herbal medicine or hydrotherapy) and a healthy lifestyle  in order to gain and maintain a healthy body .
What claims are likely to be acceptable?
The promotion of a healthy  lifestyle is likely to acceptable as are claims that go no further than those commonly accepted for healthy  eating, sleeping well, taking exercise and the like.
What claims are likely to be problematic?
The ASA and CAP have not yet been provided with evidence which demonstrates that Naturopathy can be used to treat medical conditions (Rule 12.1). Therefore, any claims that go beyond accepted claims for a healthy  lifestyle are likely to be problematic  unless they are supported by a robust body of evidence. In 2013, the ASA ruled against claims on a marketer’s website which said that Naturopathy could be used to treat acute and chronic illness and disease because the marketer had not provided any evidence in support of their claims (CNM The College of Naturopathic Medicine Ltd, 13 March 2013).
What about serious medical conditions?
Claims to offer treatment on conditions for which medical supervision should be sought  are likely to be considered to discourage essential treatment unless that treatment is carried out under the supervision of a suitably qualified health professional (Rule 12.2).
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Naturopathy has been the subject of my posts before – see for instance here, here, here, here and here. Naturopathy can be dangerous to the point where it can kill the patient – see for instance here and here. Therefore it is important that advertising gets regulated. To make it very clear: the above statement by the CAP is, in my view, a step in the right direction, and I encourage alternative practitioners to look up the equivalent CAP documents for their specific therapy.
Having said that, I still feel the need to make a few comments:
- It is misleading to call naturopathy ‘holistic’. This is often factually incorrect and also gives the impression that conventional medicine is not holistic – see also here.
- Are we sure that all lifestyles promoted by naturopaths are, in fact, healthy?
- Maintaining a healthy body is naturopathy speak for DISEASE PREVENTION. Who decides what is effective prevention? On what evidence? How come many naturopaths are against the most effective means of prevention of all times – vaccination?
- Who decides what is ‘healthy’? On what evidence?
- Why ‘problematic’? Are they not wrong or bogus or false or fraudulent or criminal?
- Are there conditions for which medical supervision should not be sought? Which are they?
The ‘CHRONICLE OF CHIROPRACTIC’ recently reported on the relentless battle within the chiropractic profession about the issue of ‘subluxation’. Here is (slightly abbreviated) what this publication had to say:
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Calling subluxation based chiropractors “unacceptable creatures” chiropractic researcher Keith H Charlton DC, MPhil, MPainMed, PhD, FICC, recently stated “. . . that it is no longer scientifically acceptable for any responsible chiropractic clinician to ever use the word subluxation except as theory . . .” Charlton made the comment to members of the Chiropractic Research Alliance a group of subluxation deniers who routinely disparage the concept of subluxation.
Charlton is a well known “Subluxation Denier” and frequently attacks subluxation based chiropractors in his peer reviewed research papers and on Facebook groups. According to Charlton in a paper published in the journal Chiropractic and Osteopathy: “The dogma of subluxation is perhaps the greatest single barrier to professional development for chiropractors. It skews the practice of the art in directions that bring ridicule from the scientific community and uncertainty among the public.”
On January 5, 2017 Charlton further stated: “We need NOW in 2017 and beyond to get rid of the quacks that do us so much harm. They need to be treated personally and professionally as utterly unacceptable creatures to be shunned and opposed at every turn. Time to get going on cleaning out the trash. And that includes all signs, websites, literature, handouts and speech of staff and chiropractors.”
…Charlton has testified against subluxation based chiropractors in regulatory board actions and appears to revel in it.
In his most recent pronouncement Charlton states that he is okay with subluxation as a “regional spine shape distortion” and asserts that this is a CBP subluxation. This contention is common with subluxation deniers who are willing to accept an orthopedic definition of subluxation absent the neurological component.
…Charlton states he uses the following techniques on his website:
- Applied Kinesiology
- Motion Palpation
- Sacro-Occipital Technique
- Logan Basic
When this self-declared scientist was confronted with his use of Applied Kinesiology and these other techniques his response was essentially that he is engaging in a “bait and switch” and that he just has those on his website to get patients who are looking for those things. Charlton lists 21 “research papers” on his curriculum vitae though they are all simply commentaries or reviews not original clinical research. The majority of these opinion pieces are attacks on subluxation and the chiropractors who focus on it.
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What does this tell us?
- It seems to me that the ‘anti-subluxation’ movement with in the chiropractic profession is by no means winning the battle against the ‘hard-core subluxationists’.
- Chiropractors cannot resist the temptation to use ad hominem attacks instead of factual arguments. I suppose this is because the latter are in short supply.
- The ‘anti-subluxationists’ present themselves as the evidence-based side of the chiropractic spectrum. This impression might well be erroneous. Giving up the myth of subluxation obviously does not necessarily mean abandoning other forms of quackery.
Homeopaths have, since about 200 years, insisted that their remedies are efficacious treatments for infectious diseases. As evidence for this notion, they often produce epidemiological data showing that a group of infected patients treated homeopathically had better results than another group treated conventionally. While potentially interesting, such findings never constitute proof, because the two groups might not have been comparable and many other factors could have determined the observed outcome. In fact, these stories are prime examples for the need of rigorously controlled trials when testing the efficacy of medical treatments.
Homeopaths are invariably unable to provide more compelling evidence for their claims. Instead, they repeat, since 200 years, their assumptions over and over again. Are they not aware, I ask myself, that the repetition of a lie does not create a truth?
What their repetition of lies sometimes does create, unfortunately, is some impact on a political level. This website explains it fairly well:
The Public Health Ministry (of Thailand) is thinking of implementing alternative therapy homeopathy in all districts of Sing Buri this year, after a report that it could boost the human’s body immunity to fight dengue fever, an inspector-general at the ministry said.
Homeopathic medicines had been given to Sing Buri volunteer students from kindergarten to lower-secondary level in a 2012-13 trial and it yielded satisfactory results, said Dr Jakkriss Bhumisawasdi, director of the Inspector-General Region for Bureau of Inspection and Evaluation.
The number of dengue fever cases in Sing Buri have gone down, taking its rankings from No 67 in the country (with one death) in 2011 to No 76 in 2012. As there was a nationwide dengue fever outbreak in 2013, Sing Buri reported the country’s lowest prevalence at 44.95 per 100,000 population.
Jakkriss said “homeopathy” was safe and low-cost and had been used in various countries including the United Kingdom, France, Italy, Switzerland, Belgium, the United States, Australia, India and Malaysia.
Next, the system of medicine would be implemented in Region 4 Bureau’s seven other provinces: Nakhon Nayok, Nonthaburi, Pathum Thani, Ayutthaya, Lop Buri, Sara Buri and Ang Thong. If this one district per province pilot project went well, they would consider implementing it across the country, he said.
Sing Buri Hospital paediatrician Dr Wali Suwatthika said the preparation involved dissolving Eupatorium herbal pills in drinking water. Each child would be given 3cc of this tasteless water every three months. The trial, which began in July 2012, covered 4,250 children in Muang district and only four of them developed mild dengue fever in one year, while seven out of the district’s 2,856 remaining kids who didn’t get the medicine had dengue fever, in a more severe condition.
Thailand reported 150,934 dengue fever patients last year, double the previous year’s number, and 133 deaths. As there is no vaccine for dengue fever, the Public Health Ministry used a combination of several measures, including the eradication of mosquito larva incubation grounds and a campaign for people to install mosquito nets.
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So, where is the evidence that homeopathy does anything at all for Dengue patients? The 2012-13 trial referred to above has, as far as I can see, not been published. This probably means that it was not a publishable study at all. The only study available on Medline is this one:
A double-blind, placebo-controlled randomized trial of a homeopathic combination medication for dengue fever was carried out in municipal health clinics in Honduras. Sixty patients who met the case definition of dengue (fever plus two ancillary symptoms) were randomized to receive the homeopathic medication or placebo for 1 week, along with standard conventional analgesic treatment for dengue. The results showed no difference in outcomes between the two groups, including the number of days of fever and pain as well as analgesic use and complication rates. Only three subjects had laboratory confirmed dengue. An interesting sinusoidal curve in reported pain scores was seen in the verum group that might suggest a homeopathic aggravation or a proving. The small sample size makes conclusions difficult, but the results of this study do not suggest that this combination homeopathic remedy is effective for the symptoms that are characteristic of dengue fever.
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The bottom line is simple and depressing: the totality of the best available evidence fails to show that homeopathy is efficacious for Dengue fever (or any other infectious disease). It is irresponsible to claim otherwise.