MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

quackery

It was 20 years ago today that I started my job as ‘Professor of Complementary Medicine’ at the University of Exeter and became a full-time researcher of all matters related to alternative medicine. One issue that was discussed endlessly during these early days was the question whether alternative medicine can be investigated scientifically. There were many vociferous proponents of the view that it was too subtle, too individualised, too special for that and that it defied science in principle. Alternative medicine, they claimed, needed an alternative to science to be validated. I spent my time arguing the opposite, of course, and today there finally seems to be a consensus that alternative medicine can and should be submitted to scientific tests much like any other branch of health care.

Looking back at those debates, I think it is rather obvious why apologists of alternative medicine were so vehement about opposing scientific investigations: they suspected, perhaps even knew, that the results of such research would be mostly negative. Once the anti-scientists saw that they were fighting a lost battle, they changed their tune and adopted science – well sort of: they became pseudo-scientists (‘if you cannot beat them, join them’). Their aim was to prevent disaster, namely the documentation of alternative medicine’s uselessness by scientists. Meanwhile many of these ‘anti-scientists turned pseudo-scientists’ have made rather surprising careers out of their cunning role-change; professorships at respectable universities have mushroomed. Yes, pseudo-scientists have splendid prospects these days in the realm of alternative medicine.

The term ‘pseudo-scientist’ as I understand it describes a person who thinks he/she knows the truth about his/her subject well before he/she has done the actual research. A pseudo-scientist is keen to understand the rules of science in order to corrupt science; he/she aims at using the tools of science not to test his/her assumptions and hypotheses, but to prove that his/her preconceived ideas were correct.

So, how does one become a top pseudo-scientist? During the last 20 years, I have observed some of the careers with interest and think I know how it is done. Here are nine lessons which, if followed rigorously, will lead to success (… oh yes, in case I again have someone thick enough to complain about me misleading my readers: THIS POST IS SLIGHTLY TONGUE IN CHEEK).

  1. Throw yourself into qualitative research. For instance, focus groups are a safe bet. This type of pseudo-research is not really difficult to do: you assemble about 5 -10 people, let them express their opinions, record them, extract from the diversity of views what you recognise as your own opinion and call it a ‘common theme’, write the whole thing up, and – BINGO! – you have a publication. The beauty of this approach is manifold: 1) you can repeat this exercise ad nauseam until your publication list is of respectable length; there are plenty of alternative medicine journals who will hurry to publish your pseudo-research; 2) you can manipulate your findings at will, for instance, by selecting your sample (if you recruit people outside a health food shop, for instance, and direct your group wisely, you will find everything alternative medicine journals love to print); 3) you will never produce a paper that displeases the likes of Prince Charles (this is more important than you may think: even pseudo-science needs a sponsor [or would that be a pseudo-sponsor?]).
  2. Conduct surveys. These are very popular and highly respected/publishable projects in alternative medicine – and they are almost as quick and easy as focus groups. Do not get deterred by the fact that thousands of very similar investigations are already available. If, for instance, there already is one describing the alternative medicine usage by leg-amputated police-men in North Devon, and you nevertheless feel the urge of going into this area, you can safely follow your instinct: do a survey of leg-amputated police men in North Devon with a medical history of diabetes. There are no limits, and as long as you conclude that your participants used a lot of alternative medicine, were very satisfied with it, did not experience any adverse effects, thought it was value for money, and would recommend it to their neighbour, you have secured another publication in an alternative medicine journal.
  3. If, for some reason, this should not appeal to you, how about taking a sociological, anthropological or psychological approach? How about studying, for example, the differences in worldviews, the different belief systems, the different ways of knowing, the different concepts about illness, the different expectations, the unique spiritual dimensions, the amazing views on holism – all in different cultures, settings or countries? Invariably, you will, of course, conclude that one truth is at least as good as the next. This will make you popular with all the post-modernists who use alternative medicine as a playground for getting a few publications out. This approach will allow you to travel extensively and generally have a good time. Your papers might not win you a Nobel prize, but one cannot have everything.
  4. It could well be that, at one stage, your boss has a serious talk with you demanding that you start doing what (in his narrow mind) constitutes ‘real science’. He might be keen to get some brownie-points at the next RAE and could thus want you to actually test alternative treatments in terms of their safety and efficacy. Do not despair! Even then, there are plenty of possibilities to remain true to your pseudo-scientific principles. By now you are good at running surveys, and you could, for instance, take up your boss’ suggestion of studying the safety of your favourite alternative medicine with a survey of its users. You simply evaluate their experiences and opinions regarding adverse effects. But be careful, you are on somewhat thinner ice here; you don’t want to upset anyone by generating alarming findings. Make sure your sample is small enough for a false negative result, and that all participants are well-pleased with their alternative medicine. This might be merely a question of selecting your patients cleverly. The main thing is that your conclusion is positive. If you want to go the extra pseudo-scientific mile, mention in the discussion of your paper that your participants all felt that conventional drugs were very harmful.
  5. If your boss insists you tackle the daunting issue of therapeutic efficacy, there is no reason to give up pseudo-science either. You can always find patients who happened to have recovered spectacularly well from a life-threatening disease after receiving your favourite form of alternative medicine. Once you have identified such a person, you write up her experience in much detail and call it a ‘case report’. It requires a little skill to brush over the fact that the patient also had lots of conventional treatments, or that her diagnosis was assumed but never properly verified. As a pseudo-scientist, you will have to learn how to discretely make such irritating details vanish so that, in the final paper, they are no longer recognisable. Once you are familiar with this methodology, you can try to find a couple more such cases and publish them as a ‘best case series’ – I can guarantee that you will be all other pseudo-scientists’ hero!
  6. Your boss might point out, after you have published half a dozen such articles, that single cases are not really very conclusive. The antidote to this argument is simple: you do a large case series along the same lines. Here you can even show off your excellent statistical skills by calculating the statistical significance of the difference between the severity of the condition before the treatment and the one after it. As long as you show marked improvements, ignore all the many other factors involved in the outcome and conclude that these changes are undeniably the result of the treatment, you will be able to publish your paper without problems.
  7. As your boss seems to be obsessed with the RAE and all that, he might one day insist you conduct what he narrow-mindedly calls a ‘proper’ study; in other words, you might be forced to bite the bullet and learn how to plan and run an RCT. As your particular alternative therapy is not really effective, this could lead to serious embarrassment in form of a negative result, something that must be avoided at all cost. I therefore recommend you join for a few months a research group that has a proven track record in doing RCTs of utterly useless treatments without ever failing to conclude that it is highly effective. There are several of those units both in the UK and elsewhere, and their expertise is remarkable. They will teach you how to incorporate all the right design features into your study without there being the slightest risk of generating a negative result. A particularly popular solution is to conduct what they call a ‘pragmatic’ trial, I suggest you focus on this splendid innovation that never fails to produce anything but cheerfully positive findings.
  8. It is hardly possible that this strategy fails – but once every blue moon, all precautions turn out to be in vain, and even the most cunningly designed study of your bogus therapy might deliver a negative result. This is a challenge to any pseudo-scientist, but you can master it, provided you don’t lose your head. In such a rare case I recommend to run as many different statistical tests as you can find; chances are that one of them will nevertheless produce something vaguely positive. If even this method fails (and it hardly ever does), you can always home in on the fact that, in your efficacy study of your bogus treatment, not a single patient died. Who would be able to doubt that this is a positive outcome? Stress it clearly, select it as the main feature of your conclusions, and thus make the more disappointing findings disappear.
  9. Now that you are a fully-fledged pseudo-scientist who has produced one misleading or false positive result after the next, you may want a ‘proper’ confirmatory study of your pet-therapy. For this purpose run the same RCT over again, and again, and again. Eventually you want a meta-analysis of all RCTs ever published. As you are the only person who ever conducted studies on the bogus treatment in question, this should be quite easy: you pool the data of all your trials and, bob’s your uncle: a nice little summary of the totality of the data that shows beyond doubt that your therapy works. Now even your narrow-minded boss will be impressed.

These nine lessons can and should be modified to suit your particular situation, of course. Nothing here is written in stone. The one skill any pseudo-scientist must have is flexibility.

Every now and then, some smart arse is bound to attack you and claim that this is not rigorous science, that independent replications are required, that you are biased etc. etc. blah, blah, blah. Do not panic: either you ignore that person completely, or (in case there is a whole gang of nasty sceptics after you) you might just point out that:

  • your work follows a new paradigm; the one of your critics is now obsolete,
  • your detractors fail to understand the complexity of the subject and their comments merely reveal their ridiculous incompetence,
  • your critics are less than impartial, in fact, most are bought by BIG PHARMA,
  • you have a paper ‘in press’ that fully deals with all the criticism and explains how inappropriate it really is.

In closing, allow me a final word about publishing. There are hundreds of alternative medicine journals out there to chose from. They will love your papers because they are uncompromising promotional. These journals all have one thing in common: they are run by apologists of alternative medicine who abhor to read anything negative about alternative medicine. Consequently hardly a critical word about alternative medicine will ever appear in these journals. If you want to make double sure that your paper does not get criticised during the peer-review process (this would require a revision, and you don’t need extra work of that nature), you can suggest a friend for peer-reviewing it. In turn, you can offer to him/her that you do the same to him/her the next time he/she has an article to submit. This is how pseudo-scientists make sure that the body of pseudo-evidence for their pseudo-treatments is growing at a steady pace.

It is time, I think, to call an end to this series of articles on ‘drowning in a sea of misinformation’. Not that I have covered every contributor to and aspect of it. On the contrary, I could have carried on for another couple of weeks writing a post every day as I did during the last 15 days. But it was getting a bit boring – at least for me. So, for the last post, I have decided to briefly discuss politicians. In my view, they are crucially important in this context, as they create the general atmosphere and framework in which all the other mis-informers can thrive.

Peter Hain (Labour) is a campaigner for homeopathy and wants to see it widely used on the NHS. He was quoted as saying: “I first came to know about homeopathy through my son who as a baby suffered from eczema. He had it a couple of years but with conventional treatment the eczema was getting progressively worse and at the age of four he also developed asthma. We turned to homeopathy out of desperation and were stunned with the positive results. Since then I have used homeopathy for a wide variety of illnesses, but I rely on arnica as it’s excellent for treating the everyday bruises and shocks to the system we face. My view is that homeopathy and conventional medicines must remain side by side under the NHS to offer the best to patients”

Politicians who put anecdote before evidence do worry me quite a bit, I have to admit; by doing this, they provide us with strong evidence that they would be wise to keep their mouth shut when it comes to matters of science and medicine. But Hain is in good company: Jeremy Hunt (conservative), the current Secretary for Health, signed the following Early Day Motion in 2007: That this House welcomes the positive contribution made to the health of the nation by the NHS homeopathic hospitals; notes that some six million people use complementary treatments each year; believes that complementary medicine has the potential to offer clinically-effective and cost-effective solutions to common health problems faced by NHS patients, including chronic difficult to treat conditions such as musculoskeletal and other chronic pain, eczema, depression, anxiety and insomnia, allergy, chronic fatigue and irritable bowel syndrome; expresses concern that NHS cuts are threatening the future of these hospitals; and calls on the Government actively to support these valuable national assets.

The wording here is remarkable, I think: “…believes that complementary medicine has the potential to offer clinically-effective and cost-effective solutions to common health problems faced by NHS patients…” What is this supposed to mean? Health politics based on believe??? What it, in fact, implies is that there is merely belief but no evidence. Bravo! This looks like an own-goal to me.

And there are many, many more politicians who seem to prefer belief over evidence – not just in the UK but in virtually every country; our US friends would probably want me to mention Senator Tom Harkin who is responsible for spending billions of tax-payers’ dollars on researching implausible concepts with flawed studies. To make things worse, it is not just individual politicians who promote woo, as far as I can see, most political parties have a group of members promoting pseudo-science.

But why? Why do so many politicians misinform their voters about the values of unproven and disproven treatments? And I do not mean those members of parliament who nobody seems to be able to take seriously, like David Tredenick; I mean otherwise respectable politicians with real influence. Should they not be the first to insist on reliable evidence? Do they not have a mandate and an ethical/moral obligation to do so?

Call me cynical, but I have come to the conclusion that the answer is actually quite simple. Politicians need to be (re-)elected, and therefore they have to run with whatever subject is popular – and, like it or not, alternative medicine is popular. Politicians rarely take a reasonably long view on health care (in fact, very few understand the first thing about science or medicine); their perspective has exactly the same length as the current legislative period. They usually do not even attach much importance to alternative medicine; after all, it only amounts to a tiny fraction of the total health care budget.

Tony Blair (Labour) is as good an example as any other politician; in relation to homeopathy, he is quoted saying: I think that most people today have a rational view about science and my advice to the scientific community would be fight the battles you need to fight. I wouldn’t bother fighting a great battle over homeopathy – there are people who use it, people who don’t use it, it is not going to determine the future of the world, frankly. What will determine the future of the world however, is the scientific community explaining for example the science of genetics and how it develops, or the issue to do with climate change and so on.

Sounds reasonable? Almost, but not quite. Firstly, if people employ homeopathy to protect themselves from infectious diseases like malaria, typhus, TB, AIDS etc., or if people believe those charlatans who promote it as an effective cure for life-threatening conditions, we do have a serious public health issue at hand. Secondly, why should the vast majority of health care professionals bend over backwards to do their very best implementing the concepts of EBM, if homeopathy is being given a free ride to continue existing in a virtual universe of belief-based medicine? Thirdly, how on earth can scientists possibly explain “the science of genetics and how it develops, or the issue to do with climate change”, if they lack the skill, courage, power or honesty to adequately respond to harmful quackery masquerading as medicine?

It is not difficult to criticise politicians but what might be the way forward and out of this mess? Because of the central role they play in all this, I think that it would be important that those politicians who take up posts in science-based areas be adequately educated and trained in science. I know this may sound naïve, but I think it would be an essential step towards avoiding politicians regularly making fools of themselves, misinforming the public and misguiding important decisions which might affect all of us.

I have said it so often that I hesitate to state it again: an uncritical researcher is a contradiction in terms. This begs the question as to how critical the researchers of alternative medicine truly are. In my experience, most tend to be uncritical in the extreme. But how would one go about providing evidence for this view? In a previous blog-post, I have suggested a fairly simple method: to calculate an index of negative conclusions drawn in the articles published by a specific researcher. This is what I wrote:

If we calculated the percentage of a researcher’s papers arriving at positive conclusions and divided this by the percentage of his papers drawing negative conclusions, we might have a useful measure. A realistic example might be the case of a clinical researcher who has published a total of 100 original articles. If 50% had positive and 50% negative conclusions about the efficacy of the therapy tested, his trustworthiness index (TI) would be 1.

Depending on what area of clinical medicine this person is working in, 1 might be a figure that is just about acceptable in terms of the trustworthiness of the author. If the TI goes beyond 1, we might get concerned; if it reaches 4 or more, we should get worried.

An example would be a researcher who has published 100 papers of which 80 are positive and 20 arrive at negative conclusions. His TI would consequently amount to 4. Most of us equipped with a healthy scepticism would consider this figure highly suspect.

So how would alternative medicine researchers do, if we applied this method for assessing their trustworthiness? Very poorly, I fear – but that is speculation! Let’s see some data. Let’s look at one prominent alternative medicine researcher and see. As an example, I have chosen Professor George Lewith (because his name is unique which avoids confusion with researchers), did a quick Medline search to identify the abstracts of his articles on alternative medicine, and extracted the crucial sentence from the conclusions of the most recent ones:

  1.  The study design of registered TCM trials has improved in estimating sample size, use of blinding and placebos
  2.  Real treatment was significantly different from sham demonstrating a moderate specific effect of PKP
  3. These findings highlight the importance of helping patients develop coherent illness representations about their LBP before trying to engage them in treatment-decisions, uptake, or adherence
  4. Existing theories of how context influences health outcomes could be expanded to better reflect the psychological components identified here, such as hope, desire, optimism and open-mindedness
  5. …mainstream science has moved on from the intellectual sterility and ad hominem attacks that characterise the sceptics’ movement
  6. Trustworthy and appropriate information about practitioners (e.g. from professional regulatory bodies) could empower patients to make confident choices when seeking individual complementary practitioners to consult
  7. Comparative effectiveness research is an emerging field and its development and impact must be reflected in future research strategies within complementary and integrative medicine
  8. The I-CAM-Q has low face validity and low acceptability, and is likely to produce biased estimates of CAM use if applied in England, Romania, Italy, The Netherlands or Spain
  9.  Our main finding was of beta power decreases in primary somatosensory cortex and SFG, which opens up a line of future investigation regarding whether this contributes toward an underlying mechanism of acupuncture.
  10. …physiotherapy was appraised more negatively in the National Health Service than the private sector but osteopathy was appraised similarly within both health-care sectors

This is a bit tedious, I agree, so I stop after just 10 articles. But even this short list does clearly indicate the absence of negative conclusions. In fact, I see none at all – arguably a few neutral ones, but nothing negative. All is positive in the realm of alternative medicine research then? In case you don’t agree with that assumption, you might prefer to postulate that this particular alternative medicine researcher somehow avoids negative conclusions. And if you believe that, you are not far from considering that we are being misinformed.

Alternative medicine is not really a field where one might reasonably expect that rigorous research generates nothing but positive results; even to expect 50 or 40% of such findings would be quite optimistic. It follows, I think, that if researchers only find positives, something must be amiss. I have recently demonstrated that the most active research homeopathic group (Professor Witt from the Charite in Berlin) has published nothing but positive findings; even if the results were not quite positive, they managed to formulate a positive conclusion. Does anyone doubt that this amounts to misinformation?

So, I do have produced at least some tentative evidence for my suspicion that some alternative medicine researchers misinform us. But how precisely do they do it? I can think of several methods for avoiding publishing a negative result or conclusion, and I fear that all of them are popular with alternative medicine researchers:

  • design the study in such a way that it cannot possibly give a negative result
  • manipulate the data
  • be inventive when it comes to statistics
  • home in on to the one positive aspect your generally negative data might show
  • do not write up your study; like this nobody will ever see your negative results

And why do they do it? My impression is that they use science not for testing their interventions but for proving them. Critical thinking is a skill that alternative medicine researchers do not seem to cultivate. Often they manage to hide this fact quite cleverly and for good reasons: no respectable funding body would give money for such an abuse of science! Nevertheless, the end-result is plain to see: no negative conclusions are being published!

There are at least two further implications of the fact that alternative medicine researchers misinform the public. The first concerns the academic centres in which these researchers are organised. If a prestigious university accommodates a research unit of alternative medicine, it gives considerable credence to alternative medicine itself. If the research that comes out of the unit is promotional pseudo-science, the result, in my view, amounts to misleading the public about the value of alternative medicine.

The second implication relates to the journals in which researchers of alternative medicine prefer to publish their articles. Today, there are several hundred journals specialised in alternative medicine. We have shown over and over again that these journals publish next to nothing in terms of negative results. In my view, this too amounts to systematic misinformation.

My conclusion from all this is depressing: the type of research that currently dominates alternative medicine is, in fact, pseudo-research aimed not at rigorously falsifying hypotheses but at promoting bogus treatments. In other words alternative medicine researchers crucially contribute to the ‘sea of misinformation’ in this area.

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.

Acupuncturists

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).

Chiropractors

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.

Osteopaths

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.

Herbalists

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.

Homeopaths

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.

Conclusion

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.

To include conventional health care professionals amongst those who significantly contribute to the ‘sea of misinformation’ on alternative medicine might come as a surprise. But sadly, they do deserve quite a prominent place in the list of contributors. In fact, I could write one entire book about each of the various professions’ ways to mislead patients about alternative medicine.

There are, of course, considerable national differences and other peculiarities which render each specific profession quite complex to evaluate. The material is huge – far to big to fit in a short comment. All I will therefore try to do with this post is to throw a quick spotlight on some of the mainstream professions mentioning just one or two relevant aspects in each instant.

Nurses

Particularly in North America, many nurses seem to be besotted with ‘Therapeutic Touch’, an implausible and unproven ‘energy-therapy’. For instance, the College of Nurses of Ontario includes Therapeutic Touch as a therapy permitted for its members. In other regions, other alternative treatments might be more popular with nurses but, in general, many seem to have a weakness for this sector. Researchers from Aberdeen  recently conducted a survey to establish the use of alternative medicine by registered nurses, as well as their knowledge-base and attitudes towards it. They sent a questionnaire to 621 nurses and achieved a remarkable response rate of 86%. Eighty per cent of the responders admitted to employ alternative medicine and 41% were using it currently. Only five nurses believed that alternative medicine was not effective and 74% would recommend it to others. In other words, there is a strong likelihood of patients being misinformed by nurses.

Midwives

A recent article in the UK journal THE PRACTISING MIDWIFE (Sept 2013) by Valerie Smith (not Medline-listed) claimed that the Royal College of Midwives supports the use of homeopathic remedies during childbirth. This does come to no surprise to those who know that several surveys have suggested that midwives are particularly fond of un- or dis-proven therapies and that they employ them often without the knowledge of obstetricians. We investigated this question by conducting a systematic review of all surveys of alternative medicine use by midwives. In total,19 surveys met our inclusion criteria. Most were recent and many originated from the US. Prevalence data varied but were usually high, often close to 100%. Much of this practice was not supported by sound evidence for efficacy and some of the treatments employed had the potential to put patients at risk. It seems obvious that, in order to employ unproven treatment, midwives first need to misinform their patients.

Physiotherapists

Some physiotherapists promote and practise a range of unproven treatments, e.g. craniosacral therapy. I am not aware of statistics on this, but it is not difficult to find evidence on the Internet: One website boldly states that Physiotherapy & Craniosacral Therapy available with Charetred Physiotherapist with 20 years of experience in the NHS. Another one proudly announces:  Our main methods of treatment are through Physiotherapy and Craniosacral Therapy. A third site claims that Craniosacral Therapy is attracting increasing interest for its gentle yet effective approach, working directly with the body’s natural capacity for self-repair to treat a wide range of conditions. And a final example: Catherine is a registered Cranio-Sacral Therapist, a Physiotherapist, and is a tutor at the London College of Cranio-Sacral Therapy.  She is also qualified in acupuncture for pain relief and a member of the Craniosacral Therapy Association, the Chartered Society of Physiotherapy and Acupuncture Association for Chartered Physiotherapists.

Pharmacists

If you go into any pharmacy in the UK, you do not need to search for long to find shelves full of homeopathic remedies, Bach flower remedies, aromatherapy-oils or useless herbal slimming aids, to mention just 4 of the many different bogus treatments on offer. If you do the same in Germany, France, Switzerland or other countries, the amount of bogus remedies and devices for sale might even be greater. Pharmacists, it seems to me, have long settled to be shopkeepers who have few scruples misleading their customers into believing that these useless products are worth buying. Their code of ethics invariably forbids them such promotion and trade, but most pharmacists seem to pay no or very little attention. The concern for profit has clearly won over the concern for customers or patients.

Doctors

I have left my own profession for last – not because they are the least contributors to the ‘sea of misinformation, but because, in some respects, they are the most important ones. The general attitude amongst doctors today seems to be ‘I don’t care how it works, as long as it helps my patients’. I have dedicated a previous post on explaining that this is misleading nonsense; therefore there is no reason to not repeat myself. Instead, I might just mention how many doctors practice homeopathy thus misleading patients into believing that it is an effective therapy. Alternatively, I could refer to those charlatans with a medical degree who promote bogus cancer cures. In my view, misinformation by doctors is the most serious form of misinformation of them all: physicians involved in such activities violate their ethical code and betray patients who frequently trust doctors almost blindly.

Conclusion

It would be a misunderstanding to assume that, with this post, I am accusing all conventional health care professionals of misinforming us about alternative medicine. But some clearly do; and when they do abuse their positions of trust in this way, they do a serious disservice to us all. I hope that exposing this problem will contribute to conventional health care professionals behaving more responsibly in future.

Presumably we all agree that journalists can have a considerable influence over consumers’ behaviour. They seem obsessed with alternative medicine – no, I don’t mean extraordinary specimens of the journalist-tribe, like the one who pocketed money from five homeopathic manufacturers to defame me. I mean the middle of the road, respectable journalist writing for middle of the road respectable papers. Hardly a day goes past without the subject attracting their attention. Such coverage is surely going to influence the usage of alternative medicine. But are there any hard data to back up this assumption?
In 2000, we conduced a study to determine the frequency and tone of reporting on medical topics in daily newspapers in the UK and Germany. Eight major daily newspapers (4 German and 4 British) were scanned for medical articles on eight randomly chosen working days in the summer of 1999. All articles relating to medical topics were extracted and categorised according to subject, length, and tone of article (critical, positive, or neutral).

A total of 256 newspaper articles were evaluated. We identified 80 articles in the German papers and 176 in the British; thus, the British reported on medical topics more than twice as often as German broadsheets. Articles in German papers were on average considerably longer and took a positive attitude more often than British ones. We identified 4 articles on alternative medicine in the German and 26 in the UK newspapers. The tone of the UK articles was unanimously positive (100%) whereas most 75% of the German articles on alternative medicine were critical.

This analysis, we concluded, suggested that, compared with German newspapers, British newspapers report more frequently on medical matters and generally have a more critical attitude. The proportion of articles on alternative medicine seems to be considerably larger in the UK (15% v 5%), and, in contrast to articles on medical matters in general, reporting on alternative medicine in the UK was overwhelmingly positive.

That was 13 years ago, and things may well have changed since then. My impression is that more critical coverage of alternative medicine has finally and thankfully begun to emerge. But, even if this is true, we still cannot be sure how misleading it is. In 2006, we therefore conducted another investigation aimed at assessing UK newspapers’ coverage of alternative medicine, this time specifically for cancer.

We searched the “Lexis Nexis” database for 3-month periods in 2002, 2003 and 2004 to retrieve all relevant articles. A total of 310 articles were thus found: 117 came from national and 193 originated from local newspapers. The UK press showed an increasing interest towards alternative medicine for cancer (in 2002, 81 articles; in 2003, 82 articles and in 2004, 147 articles). The most frequently mentioned alternative therapies were diets and supplements (17.7%). Articles mainly focused on alternative medicine as possible cancer treatments (44.8%), and 53.4% of all treatments mentioned were not backed up by evidence. The tone of the articles was generally positive towards alternative medicine. Promotional articles increased over the years, especially for cancer centres and clinics.

Our conclusion: UK national newspapers frequently publish articles on alternative medicine for cancer. Much of this information seems to be uncritical with a potential for misleading patients.

There is no doubt that, in recent months, some journalists have produced excellent articles on alternative medicine. Let me use this occasion to congratulate them for this achievement. Yet, at the same time, it is indisputably true that misleading journalism continues to cause harm on a daily basis. Vulnerable people are thus led to make wrong therapeutic decisions; in some cases, this will only cost money, in other instances, it may well cost lives. Today, I would therefore formulate a much more constructive conclusion: it is time, I think that, when writing about health and medicine, journalists constantly remind themselves that they have a responsibility towards public health and stop giving bogus treatments a free ride.

And finally, to make this more fun, I invite you the reader of this post to report the most misleading newspaper article about alternative medicine you have come across (and, if possible provide a link to it). I will try to be a shining example and start with my choice: I’ve seen herbal remedy make tumours disappear, says respected cancer doctor (THE DAILY TELEGRAPH 20 SEPT 2004) The sub-headline that followed was: Since I have been putting people on Carctol I have seen miracles. Carctol, it turns out, once we do some research, is a herbal mixture heavily promoted as an alternative cancer cure, which is not supported by any reliable evidence at all. I do wonder how many lives have been shortened by this article!

Numerous charities in the UK, US and elsewhere abuse their charitable status to misinform the pubic about alternative medicine. As the BMJ today published an article on one this organisation, I have chosen HOMEOPATHS WITHOUT BORDERS as an example – from a disturbingly vast choice, I hasten to add.

Sounds good, doesn’t it? HOMEOPATHS WITHOUT BORDERS (HWB). Unless, of course, you happen to know that this organisation has nothing whatsoever to do with the much-admired ‘Medicine without Borders’. HWB and its numerous national branches promote the use of homeopathic remedies worldwide, particularly in disaster-stricken and extremely poor areas.  On their website, they state: When disaster strikes or in times of crisis, homeopathy can provide effective treatment for acute anxiety and  the after effects of shock and trauma. No, no, no! Homeopathy is a placebo-therapy; it is not effective for anxiety or anything else, crisis or no crisis.

To get an impression about their activities, here are HWB’s projects for 2013:

  • We plan to train as many as 40 additional Homeopathe Communautaires in 2013.
  • We’ll support the Homeopathe Communautaires as they grow with study groups and ongoing clinical support provided by our volunteer homeopaths.
  • The 2012 graduates of the Fundamentals program will become teachers, moving HWB toward achieving our vision of Haitians teaching Haitians.
  • We hope to bring continuing homeopathic medical care to the people of Haiti, reaching nearly three times as many people as we did in 2012.
  • We plan to initiate a training program in 2013 for Haitian midwives and birth attendants for homeopathic therapeutics in pregnancy, delivery and postpartum care.

All of this looks to me as though HWB should be re-named into HOMEOPATHS WITHOUT SCRUPLES! Under the guise of some humanitarian activity, they seem to promote misinformation about a disproven treatment for some of the most vulnerable people in the world. I cannot imagine many things that are more despicable than that.

David Shaw, senior research fellow, Institute for Biomedical Ethics, University of Basel, Switzerland, has just published the above-mentioned BMJ-article on HWB. He discloses their activities as deeply unethical and concludes: Despite Homeopaths Without Borders’ claims to the contrary, “homeopathic humanitarian help” is a contradiction in terms. Although providing food, water, and solace to people in areas affected by wars and natural disasters certainly constitutes valuable humanitarian work, any homeopathic treatment deceives patients into thinking they are receiving real treatment when they are not. Furthermore, training local people as homeopaths in affected areas amounts to exploiting vulnerable people to increase the reach of homeopathy. Much as an opportunistic infection can take hold when a person’s immune system is weakened, so Homeopaths Without Borders strikes when a country is weakened by a disaster. However, infections are expunged once the immune system recovers but Homeopaths Without Borders’ methods ensure that homeopathy persists in these countries long after the initial catastrophe has passed. Homeopathy is neither helpful nor humanitarian, and to claim otherwise to the victims of disasters amounts to exploitation of those in need of genuine aid.

I strongly recommend reading the article in full.

And lastly: can I encourage readers to post their experience with and knowledge of other woo-infested charities, please?

 

 

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.

 

 

 

Can anyone think of celebrities promoting conventional treatments? Jane Fonda advertising blood pressure control?  Brad Pit advocating early intervention after stroke? Boris Johnson making sure that diabetics check their metabolic control? Angelina Jollie suggesting that we all immunise our kids?  Well, I cannot – not many anyway. But I certainly could list numerous VIPs doing their very best to promote quackery and anti-vaccination propaganda.

We may smile about such vain attempts to catch the lime-light, but the influence of celebrities on consumers’ behaviour might be huge and detrimental. It is difficult to estimate, and I am not aware of much reliable research data in this area. But my instinct tells me that, in the realm of alternative medicine, the ‘celebrity-factor’ is a very strong determinant of alternative medicine usage, and one that significantly contributes to the ‘sea of misinformation’ in this area.

With one of our research projects at Exeter, we wanted to identify reports on celebrities’ use of alternative medicine. We searched our department’s extensive data files, the Internet via the Google search engine, and the UK popular press via LexisNexis using the search terms “celebrity”, “alternative medicine” and “complementary medicine”. We considered articles published during 2005 and 2006 for inclusion in our study.

Using this strategy, we identified 38 celebrities using a wide range of alternative medicine interventions. Homeopathy, acupuncture and Ayurveda were the most popular modalities. The conclusion we drew from this investigation was that there may be many reasons why consumers use alternative medicine, and wanting to imitate their idols is one of them.

Some pro-alternative sites even boast with the fact that celebrities use quackery: Oprah is into it; so are Madonna, Uma and Gwyneth. No, it’s not a club for high-profile women with unique names. It’s alternative medicine. As ABC News describes, alternative medicine remains an option outside of “standard care” practices that physicians employ. But it has had a sweeping effect on the country, and celebrities have played a role in its popularity.

This, I think, indicates that celebrities are being used as a marketing tool for the alternative medicine industry. Both seem to feed of each other: the industry turns the celebrity endorsements into profit, and the celebrities turn the interest of the press into the all-important fame needed for remaining a celebrity. If a star displays her shapely back in a low-cut dress, nobody bats an eyelash; if, however, her back is covered with marks from today’s cupping-therapy, the press goes crazy – and, as a consequence, cupping therapy experiences a boost. The fact that there is no good evidence for this treatment becomes entirely irrelevant, and so is the fact that thousands of people will hence forward waste their money on ineffective treatments, some of them possibly even losing valuable time for curing a life-threatening disease.

Who wants such a pedestrian thing as evidence? We are in the realm of the high-fliers who cannot be bothered with such trivialities – unless, of course, they are really ill, in which case they will not consult their local quack but use the best conventional medicine on offer. Has anyone heard of a member of the Royal family being rushed to a homeopathic hospital when acutely ill?

In my experience, a VIP’s conviction in promoting quackery is inversely correlated to his expertise and intelligence. Prince Charles seems to want the entire British nation to be force-fed on quackery – anything from Gerson diet to homeopathy. He knows virtually nothing about medicine, but makes up for this deficit through a strong and quasi-religious belief in quackery. Scientists tend to laugh about his quest and might say with a slightly pitiful smile “but he is full of good will!”. Yet I am not sure that it is all that funny, nor am I convinced that good will is enough. Misleading the public about matters of health care is not amusing. And good will and conviction render quacks not less but more dangerous.

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