We have repeatedly discussed on this blog the fact that many alternative practitioners are advising their patients against vaccinations, e. g.:
- Governments take action to prevent vaccination-rates from falling
- Use of alternative medicine is associated with low vaccination rates
- Integrative medicine physicians tend to harbour anti-vaccination views
- Vaccination: chiropractors “espouse views which aren’t evidence based”
- Faith-healing as an alternative to vaccination?
- Recommending homeoprophylaxis is unethical, irresponsible and possibly even criminal
- Chiropractors are undermining public health
- CAM use is risk factor for the failure to immunise children
- Let’s be blunt: homeopathy is bogus – but homeoprophylaxis is worse, much worse!
- Are mothers being taught by homeopaths to become anti-vaxers?
- Some naturopaths are clearly a danger to public health
There is little doubt that this phenomenon contributes to low immunisation rates. This, in turn, is a contributing factor to outbreaks of measles and other infectious diseases. The website of the European Centre for Disease Prevention and Control has recently published data on measles outbreaks in Europe:
Bulgaria: There is an increase by three cases since 21 July 2017. Since the beginning of 2017 and as of 16 July, Bulgaria reported 166 cases. During the same time period in 2016 Bulgaria reported one case.
France: On 27 July 2017 media quoting the French Minister of Health reported the death of a 16-year-old unvaccinated girl. She had fallen sick in Nice and died on 27 June 2017 in Marseille.
Germany: There is an increase by four cases since the last report on 21 July 2017. Since the beginning of 2017 and as of 26 July, Germany reported 801 cases. During the same time period in 2016 Germany reported 187 cases.
Italy: There is an increase by 170 cases since 21 July 2017. Since the beginning of 2017 and as of 25 July, Italy reported 3 842 cases, including three deaths. Among the cases, 271 are healthcare workers. The median age is 27 years, 89% of the cases were not vaccinated and 6% received only one dose of vaccine.
Romania: There is an increase by 229 cases, including one additional death, since 21 July 2017. Since 1 January 2016 and as of 21 July 2017, Romania reported 8 246 cases, including 32 deaths. Cases are either laboratory-confirmed or have an epidemiological link to a laboratory-confirmed case. Infants and young children are the most affected groups. Timis, in the western part of the country closest to the border with Serbia, is the most affected district with 1 215 cases. Vaccination activities are ongoing in order to cover communities with suboptimal vaccination coverage.
Spain: There is an increase by seven cases since 14 July 2017. Since the beginning of 2017 and as of 25 July, Spain reported 145 measles cases.
United Kingdom: Public Health Wales reported two additional cases related to the outbreak in Newport and Torfaen, bringing the total to ten cases related to this outbreak. In England and Wales there is an increase by 76 cases since 21 July 2017. Since the beginning of 2017 and as of 23 July 2017, England and Wales reported 922 cases. In the same time period in 2016, they reported 946 cases.
In addition to the updates listed above ECDC produces a monthly measles and rubella monitoring report with surveillance data provided by the member states through TESSy. The last report was published on 11 July 2017 with data up to 31 May 2017.
Measles outbreaks continue to occur in EU/EEA countries. There is a risk of spread and sustained transmission in areas with susceptible populations. The national vaccination coverage remains less than 95% for the second dose of MMR in the majority of EU/EEA countries. The progress towards elimination of measles in the WHO European Region is assessed by the European Regional Verification Commission for Measles and Rubella Elimination (RVC). Member States of the WHO European Region are making steady progress towards the elimination of measles. At the fifth meeting of the RVC for Measles and Rubella in October 2016, of 53 countries in the WHO European Region, 24 (15 of which are in the EU/EEA) were declared to have reached the elimination goal for measles, and 13 countries (nine in the EU/EEA) were deemed to have interrupted endemic transmission for between 12 and 36 months, meaning they are on their way to achieving the elimination goal. However, six EU/EEA countries were judged to still have endemic transmission: Belgium, France, Germany, Italy, Poland and Romania. More information on strain sequences would allow further insight into the epidemiological investigation.
All EU/EEA countries report measles cases on a monthly basis to ECDC and these data are published every month. Since 10 March 2017, ECDC has been reporting measles outbreaks in Europe on a weekly basis and monitoring worldwide outbreaks on a monthly basis through epidemic intelligence activities. ECDC published a rapid risk assessment on 6 March.
END OF QUOTE
Personally, I believe that it is high time to stop the rhetoric and actions of the anti-vaccination movements. This includes educating alternative practitioners and their patients. If necessary, we need regulation that prohibits their dangerous and unethical activities.
On this blog, we have often discussed the risks of spinal manipulation. As I see it, the information we have at present suggests that
- mild to moderate adverse effects are extremely frequent and occur in about half of all patients;
- serious adverse effects are being reported regularly;
- the occur usually with chiropractic manipulations of the neck (which are not of proven efficacy for any condition) and often relate to vascular accidents;
- the consequences can be permanent neurological deficits and even deaths;
- under-reporting of such cases might be considerable and therefore precise incidence figures are not available;
- there is no system to accurately monitor the risks;
- chiropractors are in denial of these problems.
Considering the seriousness of these issues, it is important to do more rigorous research. Therefore, any new paper published on this subject is welcome. A recent article might shed new light on the topic.
The objective of this systematic review was to identify characteristics of 1) patients, 2) practitioners, 3) treatment process and 4) adverse events (AE) occurring after cervical spinal manipulation (CSM) or cervical mobilization. A systematic searches were performed in 6 electronic databases up to December 2014. Of the initial 1043 articles thus located, 144 were included, containing 227 cases. 117 cases described male patients with a mean age of 45 and a mean age of 39 for females. Most patients were treated by chiropractors (66%). Manipulation was reported in 95% of the cases, and neck pain was the most frequent indication for the treatment. Cervical arterial dissection (CAD) was reported in 57% of the cases and 45.8% had immediate onset symptoms. The overall distribution of gender for CAD was 55% for female. Patient characteristics were described poorly. No clear patient profile, related to the risk of AE after CSM, could be extracted, except that women seemed more at risk for CAD. The authors of this review concluded that there seems to be under-reporting of cases. Further research should focus on a more uniform and complete registration of AE using standardized terminology.
This article provides little new information; but it does confirm what I have been saying since many years: NECK MANIPULATIONS ARE ASSOCIATED WITH SERIOUS RISKS AND SHOULD THEREFORE BE AVOIDED.
In my previous post, I reported that the NHS has included homeopathy and herbal medicine on the list of medications that might no longer get reimbursed. The news was reported by most newspapers in the UK. All of the papers correctly quote NHS England giving their reasons for black-listing homeopathy and herbal remedies. Some papers also quote critics of homeopathy providing short ‘sound bites’ and opinions. None of the articles bother to explain in any detail why homeopathy is so ridiculously implausible or how strong the evidence against it has become. In this post, I intend to analyse some of this press coverage by copying those excerpts from the newspaper articles which I find odd or misleading and by adding short comments by myself.
THE DAILY MAIL claimed that homeopathic remedies are treatments using heavily diluted forms of plants, herbs and minerals. This is factually incorrect; think of remedies like X-ray! The Mail also quoted Don Redding, director of policy at National Voices, stating: ‘Whilst some treatments are available to purchase over the counter, that does not mean that everyone can afford them. There will be distinct categories of people who rely on NHS funding for prescriptions of remedies that are otherwise available over the counter. Stopping such prescriptions would break with the principle of an NHS “free at the point of use” and would create a system where access to treatments is based on a person’s ability to pay.’ This argument might apply to medicines that are proven to work; it does, however, not apply to homeopathy.
THE INDEPENDENT cited Professor Helen Stokes-Lampard, chair of the Royal College of GPs, who said: “If patients are in a position that they can afford to buy over the counter medicines and products, then we would encourage them to do so rather than request a prescription – but imposing blanket policies on GPs, that don’t take into account demographic differences across the country, or that don’t allow for flexibility for a patient’s individual circumstances, risks alienating the most vulnerable in society.” Again, this argument might apply to medicines that are proven to work; it does, however, not apply to homeopathy.
THE DAILY TELEGRAPH also reported the quote from Don Redding, Director of Policy at National Voices which I cited above.
THE DAILY MIRROR quoted The Royal Pharmaceutical Society claiming that such a move raised “serious concerns” for poorer Brits. RPS England Board Chair Sandra Gidley said: “A blanket ban on prescribing of items available to buy will not improve individual quality of life or health outcomes in England. “Those on low incomes will be disproportionately affected.” THE MIRROR also reported what had to say and added that the NHS constitution states that: “Access to NHS services is based on clinical need, not an individual’s ability to pay; NHS services are free of charge, except in limited circumstances sanctioned by parliament.”
THE NEWS & STAR repeated the above quote from The Royal Pharmaceutical Society.
THE GUERNSEY PRESS repeated what RPS England board chair Sandra Gidley said: “We would encourage people with minor health problems to self-care with the support of a pharmacist and to buy medicines where appropriate and affordable to the individual. However, expecting everyone to pay for medicines for common conditions will further increase health inequalities and worsen the health of patients who cannot afford them. A blanket ban on prescribing of items available to buy will not improve individual quality of life or health outcomes in England. Those on low incomes will be disproportionately affected. They should not be denied treatment because of an inability to pay.”
THE TIMES also quoted the RPS and Don Redding misleadingly (see above and below) and concluded their article by citing Cristal Summer, chief executive of the British Homeopathic Association saying: Patients will be prescribed more expensive conventional drugs in place of homeopathy, which defeats the object of the exercise. The NHS also claims it wants to reduce the amount of prescription drugs patients take, then stops offering complementary therapies which can help achieve this. This clearly ignores the fact that ‘the object of the exercise’ for any health service must be to provide effective treatments and avoid placebo therapies like homeopathy.
THE SUN quoted The Royal Pharmaceutical Society saying such a move raised “serious concerns” for poorer Brits. But it said banning NHS-funded homeopathy was long overdue. THE SUN continued by citing John O’Connell, Chief Executive of the TaxPayers’ Alliance: “The NHS are absolutely right to look at removing homeopathy from their approved prescription list and it’s astonishing that it hasn’t happened sooner.”
METRO pointed out that actress Gwyneth Paltrow, ex-Beatle Paul McCartney and world record sprinter Usain Bolt are all known to swear by homeopathic remedies.
Generally speaking, the newspaper coverage was not bad, in my view. The exception evidently is THE TIMES (see above). Several other articles also have a slight whiff of false balance, introducing seemingly rational counter-arguments where none exist. Even though the headlines invariably focus on homeopathy, some of the quotes used by the papers are clearly about other medicines black-listed. This seems particularly obvious with the quotes by the RPS. Many readers might thus be misled into thinking that there is opposition by reputable organisations to the ban on homeopathy. None of the articles that I read quoted a homeopath at the end saying something like WE KNOW OF MANY PATIENTS WHOSE LIVES WERE SAVED BY HOMEOPATHY. JUST BECAUSE WE DON’T UNDERSTAND HOW IT WORKS DOES NOT MEAN IT DOES NOT WORK. A BAN WOULD PUT PUBLIC HEALTH AT RISK.
Only a few years ago, this type of conclusion to an article on homeopathy would have been inevitable! Could it be that UK journalists (with the exception of those at THE TIMES?) are slowly learning?
Dr Gabriella Day is a GP in England who describes herself and her beliefs as follows: “I began training in homeopathy as it is clear that for many conditions conventional treatment options are not effective and can have unwanted side effects. It seemed to me that there must be another way to help people suffering from symptoms such as these… I believe in whole person medicine. No illness exists in isolation. The human body is immensely sophisticated and complicated and we do not understand it fully. Therefore the illness cannot be separated from the person suffering the disease. This may be as simple as stress impairing the immune system to far more complex interactions. Homeopathic treatment seeks to match the underlying disturbance in the system and stimulate the body to correct itself.”
I do not know Dr Day, but she caught my attention recently when she published an article in THE HIPPOCRATIC POST (I had never heard of this publication before!). It is, I think, sufficiently noteworthy to show you some excerpts (the references [in square brackets] were added by me, and they refer to my comments below):
START OF QUOTES
…Homeopathy can be helpful for pretty much any condition , whether as the main treatment , as a complement to a conventional treatment  to speed up the healing process , or to lessen the side-effects of a pharmacological medication . It can be helpful in the treatment of emotional problems , physical problems  and for multi-morbidity patients . I find it an invaluable tool in my GP’s toolbox and regularly see the benefits of homeopathy in the patients I treat …
There are many conditions for which I have found homeopathy to be effective … There are, however, a multitude of symptomatic treatments available to suppress symptoms, both on prescription and over-the-counter. Most symptoms experienced by patients in this context result from the body’s attempt to eliminate the infection. Our immune systems have spent thousands of years refining this response; therefore it seems counter-intuitive to suppress it .
For these types of acute conditions homeopathy can work with the body to support it . For instance, homeopathic Arsenicum album (arsenic) is a classic remedy for diarrhoea and vomiting that can be taken alongside essential oral rehydration . And in influenza I’ve found Eupatorium perfoliatum (ague or feverwort) to be very helpful if the patient is suffering with bony pain .
…Unless it is clinically imperative for a pharmacological intervention, I will always consider homeopathy first  and have successfully prescribed the homeopathic remedy Nux vomica (strychnine) for women suffering from morning sickness . Problems associated with breastfeeding such as mastitis have also responded well to the classic remedies Belladonna (deadly nightshade) and Phytolacca (pokeweed), while I have found Urtica urens (dog nettle) effective in switching off the milk supply to prevent engorgement when the mother stops breastfeeding .
…“heart sink” patients are clearly suffering from pain and discomfort, which is blighting their lives. This is understandably frustrating for them, for they know full well something is awry but there is no medical evidence for this… Homeopathy affords me another approach in trying to help these patients [1,3]. It doesn’t work for them all, but I’m frequently surprised at how many it does help .
The beauty of homeopathy is that it combines mental and emotional symptoms with physical symptoms . When the right remedy is found it appears to stimulate the body to recognise how it is being dysfunctional and corrects this, with no suppression, just a correction of the underlying disturbance . Thus homeopathy not only eliminates unwanted symptoms , it dramatically improves a patient’s overall well-being .
…homeopathy… enables me to reduce the number of painkillers and other drugs I’m prescribing [1,3]. This is particularly true for older multi-morbidity, polypharmacy patients  who are often taking huge amounts of medication.
Contrary to what most homeopaths will tell you, I believe homeopathic treatment does have side-effects – positive side-effects!  It fosters an enhanced doctor patient relationship . The process of eliciting the relevant information to select a remedy enables me to better understand the patient’s condition and helps me to get to know them better . And the patient, seeing that the doctor is interested in the idiosyncrasies and detail of their disease, finds themselves heard and understood . In short, since training in homeopathy I enjoy my job as a GP and my relationship with patients so much more .
Dr Gabriella Day BSc, MBBS, MRCP, DCH, MRCGP, MFHom
END OF QUOTES
- statement without good evidence,
- Hahnemann was vehemently against combining homeopathy with other treatments and called clinicians who disregarded this ‘traitors’,
- statement of belief,
- wrong assumption,
- questionable ethics.
I have recently attempted to slip into the brain of lay-homeopaths and shown how illogical, misguided and wrong the arguments of such enthusiasts really are. Surely, the logic of a doctor homeopath must be better, I then thought. Once you have studied medicine, you have learnt an awful lot of things about the body, disease, therapy, etc., etc., I felt.
Judging from the above article, I might have been wrong.
Alternative medicine differs from conventional medicine in numerous ways. One important difference is that patients often opt to try this or that product without consulting any healthcare professional at all. In such cases, the pharmacist might be the ONLY professional who can advise the patient who is about to purchase such a product.
This is why the role of the pharmacist in alternative medicine is crucial, arguably more so than in conventional medicine. And this is why I am banging on about pharmacists who far too often behave like shop-keepers and not like ethical healthcare professionals. A new review addresses these issues and provides relevant information.
Pharmacists from the University of Macau in Macau, China conducted a literature review to extract publications from 2000 to 2015 that related pharmacist to alternative medicine products. 41 publications which reported findings from exploratory studies or discussed pharmacists’ responsibilities towards such products were selected for inclusion.
Seven major responsibilities emerged:
- to acknowledge the use of alternative medicine products;
- to be knowledgeable about such products;
- to ensure safe use of such products;
- to document the use of such products;
- to report ADRs related to such products;
- to educate about such products;
- to collaborate with other health care professionals in respect to such products.
One point that is not directly covered here is the duty of pharmacists to comply with their own ethical codes. As I have pointed out ad nauseam, this would mean in many instances to not sell alternative medicine products at all, because there is no good evidence to show that they are generating more good than harm and thus are potentially harmful as well as wasteful.
Some pharmacists have realised that there is a problem. Some pharmacists are trying to initiate discussions about these issues within their profession. Some pharmacists are urging to change things. Some pharmacists are well-aware that healthcare ethics are being violated on a daily basis.
All this has been going on now for well over a decade.
And has there been any noticeable change?
Not as far as I can see!
Perhaps it is time to realise that not merely the sale of bogus medicines by pharmacists is unethical, but so is dragging one’s feet in initiating improvements.
According to Wikipedia, “the Bundesverband der Pharmazeutischen Industrie (BPI) with headquarters in Berlin is an Eingetragener Verein and the German industry association/trade group for the pharmaceutical industry. It represents 240 German pharmaceutical and Biotech companies in with altogether approximately 70,000 employees. BPI has an office in Brussels. The focus of the BPI is on political consulting and public relations on the EU-level.”
The BPI has recently published a remarkable press-release about homeopathy. As it is in German, I will translate it for you (and append the original text for those who can read German).
HERE WE GO:
Homeopathy is a recognised and proven therapy for patients in Germany . This is demonstrated by a new, BPI-sponsored survey . About half of all questioned had experience with homeopathic remedies . More than 70% of those people are satisfied or very satisfied with their effectiveness and safety .
“Homeopathic remedies are important for many patients in Germany”, says Dr. Norbert Gerbsch, deputy chair of the BPI. ” If therapists and patients use them correctly, they can support the therapeutic success . Therefore, they should be recognised by conventional medicine as an integrative medicine  – that is what patients in Germany clearly want .”
Two thirds of the people surveyed think it is important or very important, that therapies like anthroposophical medicine and homeopathy are supported politically next to conventional medicine . More than 70% find it personally important or very important that health insurances pay for selected anthroposophical and homeopathic services . More than 80% said they would favour this. Thus, the majority is for keeping homeopathy amongst the services that can be chosen by the insurances for reimbursement .
Dr. Norbert Gerbsch: “The survey proves that very many individuals integrate, use and treasure homeopathy as an additional and usually safe therapy . Those who aim at curtailing therapeutic freedom patronise numerous patients in Germany who can benefit from it . There are numerous diseases for which homeopathy can be used as an integrative therapeutic option . Thus, many conventional physicians employ homeopathic and anthroposophic remedies in parallel to guideline-orientated medicine [3, 11].”
(Homöopathie ist eine anerkannte und bewährte Therapieform für Patienten in Deutschland. Das belegt eine neue, vom BPI beauftragte Forsa-Umfrage. Rund die Hälfte der Befragten hat demnach bereits Erfahrung mit homöopathischen Arzneimitteln. Über 70 Prozent von ihnen sind zufrieden oder sehr zufrieden mit der Wirksamkeit und Verträglichkeit.
„Homöopathische Arzneimittel haben für viele Patienten in Deutschland einen hohen Stellenwert“, sagt Dr. Norbert Gerbsch, stellvertretender BPI-Hauptgeschäftsführer. „Wenn Behandler und Patienten sie richtig und verantwortungsvoll einsetzen, kann sie den Therapieerfolg unterstützen. Sie sollte insofern als wichtige Ergänzung der Schulmedizin im Sinne einer Integrativen Medizin anerkannt werden – das wünschen sich die Patienten in Deutschland eindeutig.“
Fast zwei Drittel der von Forsa Befragten finden es wichtig bis sehr wichtig, dass sich die Politik neben schulmedizinischen Behandlungsmethoden auch aktiv für Heilmethoden wie etwa Homöopathie oder Anthroposophische Medizin einsetzt. Über 70 Prozent finden es persönlich wichtig bis sehr wichtig, dass Krankenkassen ihren Versicherten auch die Kosten für ausgewählte Leistungen aus dem Bereich der homöopathischen Medizin erstatten. Mit über 80 Prozent überdurchschnittlich häufig plädieren Befragte mit Homöopathie-Erfahrung für die Kostenübernahme ausgewählter Leistungen durch die Krankenkassen. Damit stimmt die Mehrheit für den Erhalt der Homöopathie im Rahmen von sogenannten Satzungsleistungen, die von den Krankenkassen individuell festgelegt werden können.
Dr. Norbert Gerbsch: „Die Umfrage belegt, dass sehr viele Menschen Homöopathie als ergänzende und in der Regel nebenwirkungsarme Therapieoption in die Behandlung integrieren, sie nutzen und achten. Wer die Therapiefreiheit und -vielfalt beschneiden will, bevormundet zahlreiche Patienten in Deutschland, die davon profitieren können. Es gibt eine Vielzahl an Erkrankungen, bei denen homöopathische Arzneimittel als integraler Bestandteil von Therapien einsetzbar sind. So nutzen viele Schulmediziner neben dem gesamten Spektrum der leitlinienorientierten Medizin gleichzeitig die integrativen Angebote der Homöopathie und Anthroposophischen Medizin.“)
I DO APPOLOGISE FOR MY POOR TRANSLATION; I HAVE ALWAYS FOUND THAT IT IS VERY HARD TO TRANSLATE SOMETHING THAT SIMPLY DOES NOT MAKE SENSE!
I have rarely seen such an unscientific, irrational, nonsensical and promotional comment from an organisation and an individual that should know better. Mr. Gerbsch studied biotechnology and graduated in 1997 in bioprocess engineering. He headed a scientific team following his promotion to director of a trans-departmental research topic with 13 professorships at the Technical University of Berlin. He later took on responsibilities as commissioner, officer and director of various companies. Since 2006, Mr. Gerbsch works as department manager of biotechnology / research & development at BPI and is responsible for the biotechnology department and innovation & research committee.
Here are just a few short points of criticism referring to the numbers I have added in my translation:
- Homeopathy is recognised and proven to be a pure placebo-therapy.
- A survey of this nature can at best gauge the current opinion.
- Fallacy: appeal to popularity.
- Perceived effectiveness/safety is not the same as true effectiveness/safety.
- There is no good evidence for this statement.
- What patients want might be interesting, but it cannot determine what they need; medicine is not a supermarket!
- I suspect this is the result of a leading question.
- This is where the BPI discloses the aim of the survey and their comment about it: they want the German health insurances to continue paying for homeopathic and anthroposophical placebos because some of their member companies earn their money selling them. In other words, the BPI actively hinder progress.
- No, those who advocate not paying for placebos want to encourage progress in healthcare for the benefit of patients and society.
- “Can be used” is an interesting phraseology! It is true, one can use homeopathy – but one cannot use it effectively because it has no effect beyond placebo.
- Yes, many physicians are sadly more focussed on their own cash-flow than on the best interest of their patients. Not all that different from the BPI, it seems.
It is beyond me how an organisation like the BPI can produce such shamefully misleading, dangerous and unethical drivel. Not one word about the fact that all international bodies have condemned homeopathy as being a useless and dangerous placebo-therapy! Who ever thought that the BPI was an independent organisation (homeopathy manufacturers belong to its membership) has been proven wrong by the above press-release.
The BPI clearly needs reminding of their duty to inform the public responsibly. I recommend that the leading heads of this organisation urgently attend one course on critical thinking followed by another on medical ethics.
Since more than 20 years, I have been writing about the risks of alternative therapies. One of my first papers on this issue was published in 1995 and focussed on acupuncture. Here is its abstract:
My reason for banging on about the potential harms (direct and indirect risks) of alternative medicine is fairly obvious: I want to alert healthcare professionals and consumers to the fact that these treatments may not be as harmless as they are usually advertised to be. Yet, I have often be called an alarmist fear-monger. In my view, nothing could be further from the truth.
Thinking about fear-mongering, I began to ask myself whether those who regularly accuse me are the ones guilty of the deed. Are alternative practitioners fear-mongers? Surely not all of them, but some clearly are. Here are a few of the strategies they use for their fear-mongering.
Perhaps the most obvious way to instil fear into people is to tell them that they are affected by a disease or condition they do not have. Many alternative practitioners do exactly that!
- A chiropractor might tell you that you have a subluxation in your spine.
- A naturopath would inform you that your body is full of toxins.
- An acupuncturist will tell you that your life energy is blocked.
- A homeopath might warn you that your vital force is too low.
These diagnoses have one thing in common: they do not exist. They are figments of the therapist’s imagination. And they have another thing in common: the abnormalities need to be corrected, and – surprise, surprise – the very therapy that the practitioner specialises in happens to be just the ticket for that purpose.
- The chiropractor will tell you that a simple spinal adjustment will solve the problem.
- The naturopath will inform you that a bit of detox will eliminate the toxins.
- The acupuncturist will tell you that his needles will de-block your chi.
- The homeopath will persuade you that he can find the exact remedy to revive your vital force.
And there we have the third thing these diagnoses have in common: they are all treatable, will all result in a nice bill, and will all improve the cash-flow of the therapist.
But often, it is not even necessary for an alternative therapist to completely invent a diagnosis. Patients usually consult an alternative practitioner with some sort of symptom – frequently with what one might call a medical triviality that does not need any treatment at all but can be dealt with differently, for instance, by issuing some life-style advice or just simple re-assurance that nothing major is amiss. But for the fear-monger, this is not enough. He feels the need to administer his therapy, and for that purpose he needs to medicalize trivialities :
- A low mood thus becomes a clinical depression.
- A sore back is turned into a nasty lumbago.
- A tummy upset morphs into a dangerous gastritis.
- Abdominal unrest is diagnosed to be a leaky gut syndrome.
- A food aversion turns into a food intolerance, etc., etc.
The common denominator is again the fact that fear is instilled into the patient. And again, a useless therapy is administered, if at all possible in the form of a lengthy series of treatments. This, of course, generates significant benefit – not therapeutic, but financial!
DEMONIZING CONVENTIONAL MEDICINE
But there is always the risk that the patient is wiser than expected. She might be so scared learning of her condition that she decides to see her doctor. That would mean a loss of income which has to be avoided! The trick to achieve this is usually not difficult: conventional healthcare professionals must be demonized.
- They are not treating the root cause of the problem.
- They are in the pocket of BIG PHARMA.
- They prescribe medicines with terrible side-effects.
- They have no idea about holism.
- They never have enough time to listen, etc., etc.
I know, some of these criticisms are not entirely incorrect (for instance, many conventional medicines do have serious side-effects but, as I try to point out ad nauseam, we need to consider their risk/benefit balance). But that is hardly the point here; the point is to scare the patient off conventional medicine. Only a person who is convinced that the ‘medical mafia’ is out to get her, will prove to be a loyal customer of all things alternative.
And a loyal customer is someone who comes not just once or twice but regularly, ideally from cradle to grave. The way to achieve this ultimate stimulus of the practitioners cash flow is to convince the patient that she needs regular treatments, even when she feels perfectly alright. The magic word here is PREVENTION! The masters here are the chiropractors, I guess; they promote what they call ‘maintenance care’, i.e. the regular treatment of healthy individuals to keep their spines subluxation-free. It goes without saying that maintenance care is a money-making scam.
The strategy requires two little lies, but that’s forgivable considering the good cause, boosting the income of the practitioner:
- Conventional doctors don’t do prevention.
- The alternative treatment is an effective preventative.
The first statement can be shown to be an obvious lie. All we know about effective disease prevention today comes from conventional medicine and science; nothing originates from the realm of alternative medicine. Remarkably, the most efficacious preventative measure of all times, immunisation, is frequently defamed and neglected by alternative practitioners.
The second statement is a necessary lie; how else would a patient agree to pay regularly for the practitioner’s services? I am not aware of any alternative therapy that can effectively prevent any disease.
- Some alternative practitioners regularly instil fear into consumers.
- Several strategies are being used for this purpose.
- They have the aim of maximising the therapists’ income.
- Fear-mongering is unethical and despicable.
- Pointing out that a certain therapy might fail to generate more good than harm is not fear-mongering.
In 2006, the World Health Organization and UNICEF created the ‘Global Immunization Vision and Strategy’, a 10-year strategy with 4 main goals:
- to immunize more people against more diseases,
- to introduce a range of newly available vaccines and technologies,
- to integrate other critical health interventions with immunization,
- to manage vaccination programmes within the context of global interdependence.
More than a decade later, we have to realise that this vision has been frustrated, not least by fans of alternative medicine (FAMs). They are almost by definition more negative about the value and achievements of conventional medicine and science. This shows in all sorts of ways; the clearest this phenomenon is documented must be the FAMs’ attitude towards immunisations. Few rational thinkers would doubt that vaccinations are amongst the most important achievement in the history of medicine.
Yet FAMs are not impressed by such statements and often refuse to have their kids vaccinated according to the recommended schedule. This trend has significantly contributed to vaccination rates that, in some parts of the world, are now dropping so low that our ‘herd immunity’ is jeopardised.
One such place is Germany, and the German government is now making a controversial move against parents who choose to refrain from vaccinating their children. Germany is presently passing a law that will force kindergartens to inform the authorities, if parents don’t provide evidence that they have gotten advice from their doctor on vaccinations for their children.
This study tested chondroitin sulfate 800 mg/day (CS) pharmaceutical-grade in the management of symptomatic knee osteoarthritis. It was designed as a prospective, randomised, 6-month, 3-arm, double-blind, double-dummy, placebo and celecoxib (200 mg/day)-controlled trial. The primary endpoints were changes in pain on a Visual Analogue Scale (VAS) and in the Lequesne Index (LI). Minimal-Clinically Important Improvement (MCII), Patient-Acceptable Symptoms State (PASS) were used as secondary endpoints.
A total of 604 patients, diagnosed according to American College of Rheumalogy (ACR) criteria, were recruited in five European countries and followed for 182 days. CS and celecoxib showed a greater significant reduction in pain and LI than placebo. In the intention-to-treat (ITT) population, pain reduction in VAS at day 182 in the CS group (−42.6 mm) and in celecoxib group (−39.5 mm) was significantly greater than the placebo group (−33.3 mm) (p=0.001 for CS and p=0.009 for celecoxib). No difference observed between CS and celecoxib. Similar trend for the LI, as reduction in this metric in the CS group (−4.7) and celecoxib group (−4.6) was significantly greater than the placebo group (−3.7) (p=0.023 for CS and p=0.015 for celecoxib). Again, no difference was observed between CS and celecoxib. Both secondary endpoints (MCII and PASS) at day 182 improved significantly in the CS and celecoxib groups. All treatments demonstrated excellent safety profiles.
The authors concluded that a 800 mg/day pharmaceutical-grade CS is superior to placebo and similar to celecoxib in reducing pain and improving function over 6 months in symptomatic knee osteoarthritis (OA) patients. This formulation of CS should be considered a first-line treatment in the medical management of knee OA.
In my view, this is a good study with clear and useful results: CS seems to be efficacious and safe. Another recent study confirmed the superiority of CS over celecoxib at reducing cartilage volume loss in knee OA patients.
The current Cochrane review does not yet account for the new data; it concluded cautiously positive: A review of randomized trials of mostly low quality reveals that chondroitin (alone or in combination with glucosamine) was better than placebo in improving pain in participants with osteoarthritis in short-term studies. The benefit was small to moderate with an 8 point greater improvement in pain (range 0 to 100) and a 2 point greater improvement in Lequesne’s index (range 0 to 24), both seeming clinically meaningful. These differences persisted in some sensitivity analyses and not others. Chondroitin had a lower risk of serious adverse events compared with control. More high-quality studies are needed to explore the role of chondroitin in the treatment of osteoarthritis. The combination of some efficacy and low risk associated with chondroitin may explain its popularity among patients as an over-the-counter supplement.
The call for more high quality trials was justified but has now been answered. In my view, CS can be considered an evidence-based option in the management of OA.
The new guidelines by the American College of Physicians entitled ‘Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians’ have already been the subject of the previous post. Today, I want to have a closer look at a small section of these guidelines which, I think, is crucial. It is entitled ‘HARMS OF NONPHARMACOLOGIC THERAPIES’. I have taken the liberty of copying it below:
“Evidence on adverse events from the included RCTs and systematic reviews was limited, and the quality of evidence for all available harms data is low. Harms were poorly reported (if they were reported at all) for most of the interventions.
Low-quality evidence showed no reported harms or serious adverse events associated with tai chi, psychological interventions, multidisciplinary rehabilitation, ultrasound, acupuncture, lumbar support, or traction (9,95,150,170–174). Low-quality evidence showed that when harms were reported for exercise, they were often related to muscle soreness and increased pain, and no serious harms were reported. All reported harms associated with yoga were mild to moderate (119). Low-quality evidence showed that none of the RCTs reported any serious adverse events with massage, although 2 RCTs reported soreness during or after massage therapy (175,176). Adverse events associated with spinal manipulation included muscle soreness or transient increases in pain (134). There were few adverse events reported and no clear differences between MCE and controls. Transcutaneous electrical nerve stimulation was associated with an increased risk for skin site reaction but not serious adverse events (177). Two RCTs (178,179) showed an increased risk for skin flushing with heat compared with no heat or placebo, and no serious adverse events were reported. There were no data on cold therapy. Evidence was insufficient to determine harms of electrical muscle stimulation, LLLT, percutaneous electrical nerve stimulation, interferential therapy, short-wave diathermy, and taping.”
The first thing that strikes me is the brevity of the section. Surely, guidelines of this nature must include a full discussion of the risks of the treatments in question!
The second thing that is noteworthy is the fact that the authors confirm the fact I have been banging on about for years: clinical trials of alternative therapies far too often fail to mention adverse effects. I have often pointed out that the failure to report adverse effects in clinical trials is an unacceptable violation of medical ethics. By contrast, the guideline authors seem not to feel strongly about this omission.
The third thing that is noteworthy is that the guidelines evaluate the harms of the treatments purely on the basis of the adverse effects reported in the clinical trials and systematic reviews included in their efficacy assessments. This is nonsensical for at least two reasons:
- The guideline authors themselves are aware that the trials very often fail to mention adverse effects.
- For any assessment of harm, one has to go far beyond the evidence of clinical trials, because trials tend to be too small to pick up rare adverse effects, and because they are always conducted under optimally controlled conditions where adverse effects are less likely to occur than in real life.
Together, these features of the assessment of harms explain why the guideline authors arrive at conclusions which are oddly misguided; I would even feel that they resemble a white-wash. Here are two of the most overt misjudgements:
- no harms associated with acupuncture,
- only trivial harm associated with spinal manipulations.
The best evidence we have today shows that acupuncture leads to mild adverse effects in about 10% of all cases and is also associated with very severe complications (e.g. pneumothorax, cardiac tamponade, infections, deaths) in an unknown number of patients. More details can be found for instance here, here, here and here.
And the best evidence available shows that spinal manipulation leads to moderately severe adverse effects in ~50% of all cases. In addition, we know of hundreds of cases of very severe complications resulting in stroke, permanent neurological deficits or deaths. More details can be found for instance here, here, here and here.
In the introduction, I stated that this small section of the guidelines is crucial.
The reason is simple: any responsible therapeutic decision has to be based not just on the efficacy of the treatment in question but on its risk/benefit balance. The evidence shows that the risks of some alternative therapies can be considerable, a fact that is almost totally neglected in the guidelines. Therefore, the recommendations of the new guidelines by the American College of Physicians entitled ‘Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians’ are in several aspects not entirely correct and need to be reconsidered.