Edzard Ernst

MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Yesterday, I received a ‘LETTER FROM DR JONAS’ (the capital lettering was his) – actually, it was an email, and not a very personal one at that. Therefore I feel it might be permissible to share some of it here (you do remember Jonas, don’t you? I did mention him in a recent post: “Considering the prominence and experience of Wayne Jonas, the 1st author of this paper, such obvious transgression is more than a little disappointing – I would argue that is amounts to overt scientific misconduct.”)

Here we go:

As part of my book tour, I spent last month visiting hospitals and medical schools, talking to the doctors, nurses and students. I tell them to think of a chronically ill patient, and I ask:

“What matters most for this patient? What is the person’s lifestyle like – their nutrition, movement and sleep? How does that patient manage their stress? Does that patient have a good support system at home? What supplements does that patient take? Has your patient seen any CAM practitioners to cope with their condition? Why do they want to get well?”

Most can’t answer these questions. Providers may know the diagnosis and treatments a patient gets, but few know their primary determinants of health. They know ‘what’s the matter’, but not ‘what matters.’ …

END OF QUOTE

Let’s have a closer look at those items of which Jonas thinks they matter:

  1. What is the person’s lifestyle like – their nutrition, movement and sleep? Depending on the condition of the patient, these issues might indeed matter. And if they do, any good doctor will consider them. There is nothing new about this; it is stuff I learnt in medical school all those years ago.
  2. How does that patient manage their stress? The question supposes that all patients suffer from stress. I know it is fashionable to ‘have stress’, but not every patient suffers from it. If the patient does suffer, it goes without saying that a good doctor would consider it.
  3. Does that patient have a good support system at home? Elementary, my dear Watson! If a doctor does not know about this, (s)he has slept through medical school (where did you go to medical school Wayne, and what did you do during these 6 years?).
  4. What supplements does that patient take? That’s a good one. I suppose Jonas would ask it to see what further nonsense he might recommend. Most rational doctors would ask this question to see what (s)he must advise the patient to discontinue.
  5. Has your patient seen any CAM practitioners to cope with their condition? As above.
  6. Why do they want to get well? Most patients would assume we are pulling their leg, if we really asked this. Instead of a response, they might return a question: Why do you ask, do you think being ill is fun?

So, doctor Jonas’ questions might do well during lectures to a self-selected audience, but in reality they turn out to be a mixture of embarrassing re-discoveries from conventional medicine, platitudes and outright nonsense. “My goal is for integrative healthcare to become the standard of care…” says Jonas towards the end of his ‘LETTER’. I suppose, this explains it!

Thus Jonas’ ‘LETTER’ turns out to be yet another indication to suggest that the reality of ‘integrative medicine’ consists of little more than re-discoveries from conventional medicine, platitudes and outright nonsense.

The authors of this review aimed to present an overview of the literature on physicochemical research performed on homeopathic preparations with respect to publication quality and methods used. They searched major scientific databases to find relevant publications from its origin to the end of 2015. Publications were assessed using a scoring scheme, the Manuscript Information Score (MIS). Information regarding country of origin of the research and experimental techniques used was extracted.

The authors identified 183 publications. The rate of publication in the field was 2 per year from the 1970s until 2000. Afterward, it increased to over 5.5 publications per year. The quality of publications was seen to increase sharply from 2000 onward: before 2000, only 12 (13%) publications were rated as ‘‘high quality’’ (MIS ‡7.5); 44 (48%) publications were rated as ‘‘high quality’’ after 2000.

Countries with most publications were Germany (n=42, 23%), France (n=29, 16%), India (n=27, 15%), and Italy (n=26, 14%). Techniques most frequently used were electrical impedance (26%), analytical methods (20%), spectroscopy (20%), and nuclear magnetic resonance (19%).

The authors concluded that physicochemical research into homeopathic preparations is increasing both in terms of quantity and quality of the publications.

They also announce that there will be a further paper on the subject: In part 2, we aim to identify the most interesting experimental techniques. With this, we aim to be in a position to generate meaningful hypotheses regarding a possible mode of action of homeopathic preparations.

It might be relevant to ask who the authors are and where they come from. They are Klein SD, Würtenberger S, Wolf U, Baumgartner S, and Tournier A. And their affiliations are:

  • Institute of Complementary Medicine, University of Bern, Switzerland.
  • Scientific & Regulatory Affairs, Hevert-Arzneimittel GmbH & Co. KG, Germany.
  • Society for Cancer Research, Arlesheim, Switzerland.
  • Institute of Integrative Medicine, University of Witten/Herdecke, Germany.
  • Homeopathy Research Institute (HRI), London, United Kingdom.

In other words, they are without exception proponents of homeopathy, some burdened with considerable conflicts of interest in the subject. Personally, I think it unlikely that anything meaningful will ever come of this research. But unsurprisingly, the enthusiasts beg to differ: on facebook, the HRI claimed that this new systematic review is a major step towards developing clear and testable hypotheses regarding the mode of action of homeopathy.

In a previous blog-post I have tried to explain my reservations in some detail; please allow me to repeat them here:

… homeopaths have been keen to find more rational support for their theories. Thus they have developed several ‘sciency’ concepts to explain the mode of action of their highly diluted homeopathic remedies. For instance they postulated that water can form secondary structures that hold some information of the original substance (stock), even if it has long been diluted out of the remedy. Alternatively, they claimed that the shaking of the remedy generates nano-particles or silicone-particles which, in turn, are the cause of the clinical effects.

Today, I want to assume for a minute, that one of these theories is correct – they cannot all be right, of course. Homeopaths regularly show us investigations that seem to support them, even though it only needs a real expert in the particular field of science to cast serious doubt on them. I will nevertheless assume that, after potentisation, the diluent retains information via nano-particles or some other phenomenon. For the purpose of this mind-experiment, I grant homeopaths that, in this respect, they are correct. In other words, let’s for a moment assume that the ‘memory of water’ theory is correct.

As I have been more than generous, I want homeopaths to return the favour and consider what this would really mean: information has been transferred from the stock to the diluent. Does that prove anything? Does it show that homeopathy is valid?

Could the homeopaths who make this assumption be equally generous and answer the following questions, please?

  1. How does a nano-particle of coffee, for instance, affect the sleep centre in the brain to make the patient sleep? Or how does a nano-particle of the Berlin Wall or a duck liver affect anything at all in the human body? The claim that information has been retained by the diluent is no where near to an explanation of a rational mode of action, isn’t it?
  2. Most homeopathic remedies are consumed not as liquids but as ‘globuli’, i. e.  tiny little pills made of lactose. They are prepared by dropping the liquid remedy on to them. The liquid subsequently evaporates. How is it that the information retained in the liquid does not evaporate with the diluent?
  3. The diluent usually is a water-alcohol mixture which inevitably contains impurities. In fact, a liquid C12 remedy most certainly contains dimensions more impurities than stock. These impurities have, of course, also been vigorously shaken, i. e. potentised. How can we explain that their ‘potency’ has not been beefed up at each dilution step? Would this not necessitate a process where only some molecules in the diluent are agitated, while all the rest remain absolutely still? How can we explain this fantastic concept?
  4. Some stock used in homeopathy is insoluble (for instance Berlin Wall). Such stock is not diluted but its concentration in the remedy is initially lowered by a process called ‘trituration’, a process which consists in grinding the source material in another solid material, usually lactose. I have granted you that potentisation works in the way you think. But how is information transferred from one solid material to another?
  5. Everything we drink is based on water containing molecules that have been inadvertently potentised in nature a million times and therefore should have hugely powerful effects on our bodies. How is it that we experience none of these effects each time we drink?

Now, homeopaths, let me propose a deal.

If you can answer these questions satisfactorily, I will no longer doubt your memory of water theory. If you cannot do this, I think you ought to admit that all your ‘sciency’ theories about the mode of action of highly diluted homeopathic remedies are really quite silly – more silly even than Hahnemann’s idea of a ‘spirit-like’ effect.

HELLO HOMEOPATHS OF THIS WORLD…

SO FAR NOBODY HAS TAKEN UP MY OFFER.

BUT IT STILL STANDS!

HOW ABOUT IT?

You might remember: I have been badly misquoted in an article in THE DAILY TELEGRAPH. Based on a newly published scientific paper, the Telegraph article was about herbal medicines and their potential to interact with synthetic drugs. Towards its end, it cited me stating this:

Emeritus Professor Edzard Ernst, Britain’s first professor of complementary medicine at Exeter University said that doctors should make it clear to patients that they could not be taking herbal remedies alongside drugs.

Prof Ernst said there was no good evidence that they work and that doctors were ‘contributing to disinformation’ by turning a blind eye to the practice.

Not only did this not make any sense (I felt, it made me look like an idiot), but crucially I had never stated this nor had I even commented to a Telegraph journalist about this scientific paper. This was (27/1) when I wrote my blog-post about it.

Several friends persuaded me to file an official complaint – which I somewhat reluctantly did. Subsequently, I received an email from the paper’s ‘editorial compliance executive’ asking me to supply more details about my grievances. I complied with the request by pointing out that:

The following things are wrong with this passage:

1) I never said this.

2) I have not even been interviewed by your journalist and do not know where this quote is supposed to come from.

3) As far as I am aware, I also never stated anything like this anywhere else.

4) It is not and never has been my view that there is no good evidence that herbal remedies can never be combined with drugs.

5) It is not and never has been my opinion that there is no good evidence to suggest that herbal remedies work.

6) It is not and never has been my view that doctors were contributing to disinformation by turning a blind eye to the use of herbal remedies.

The response came swiftly:

The quoted words were recorded at a briefing at the SMC to launch your new book, More Harm than Good? The Moral Maze of Complementary and Alternative Medicine on 17th January 2018. 

We are aware that you have had correspondence with our Science Editor, Sarah Knapton who has since amended the online article to make this clear. 

We do however accept that one sentence was mistakenly attributed to you. We have therefore amended the online article and added a footnote to explain what has been updated.

This was most bizarre, I thought, because I did NOT  have a correspondence with Sarah Knapton, the author of the Telegraph article. On the plus-side, the Telegraph had indeed changed the passage in question; it now read (and did so until yesterday):

Emeritus Professor Edzard Ernst, Britain’s first professor of complementary medicine at Exeter University said there was a ‘potential for harm’.

“It’s a lazy way out of the problem,” he said at a briefing to launch his new book More Harm than Good? The Moral Maze of Complementary and Alternative Medicine. “In medicine you give treatment for a reason and if there is no reason for the homeopathic remedy why should you support it for the placebo treatment.

“As a good doctor you should be able to transmit a placebo effect any case. I just don’t see a reason, I see the potential for harm.” 

The research was published in the British Journal of Clinical Pharmacology.

CORRECTION: This article originally stated that Professor Edzard Ernst said there was no good evidence that herbal remedies work and that doctors were ‘contributing to disinformation’ by turning a blind eye to their usage. In fact, this was not said by Professor Ernst. The article has been amended.

I felt that this was a correction of one mistake by another mistake and pointed out that the briefing had been about homeopathy and NOT about herbal medicine or herb/drug interactions. Therefore I replied to the ‘editorial compliance executive’ insisting on further corrections and pointing out that such an utterly nonsensical comment might harm my reputation as an expert. I also posted a comment under the Telegraph article explainig that homeopathy is not herbal medicine.

Sadly, nothing happened.

So, a few days later, I sent a reminder to the ‘editorial compliance executive’.

And again nothing happened.

… until yesterday.

I had almost given up and was contemplating what to do next, when I received an email. It was not from the  ‘editorial compliance executive’, but from THE TELEGRAPH’s ‘Head of Editorial Compliance’. He wrote that he had listened to the tapes of the original briefing and realised that my comments were indeed made in a different context. Therefore, they had now erased all of the nonsensical stuff and replaced it with this text:

CORRECTION: This article originally stated​ ​that Professor Edzard Ernst​,​ professor of complementary medicine at Exeter Universit​y, ​had said there​ was​ ‘potential for harm’ ​in herbal remedies and ​that doctors were ‘contributing to disinformation’ by turning a blind eye to ​this.​ These comments did not in fact relate to ​interactions between herbal remedies​ and prescribed medication, and they have been removed. We apologise to the Professor for the error.   

I am pleased!

And I gratefully accept the apology.


This might be a long, convoluted and somewhat boring story, but I think it has at least two important elements to it:

  1. It may seem petty to complain, and complain, and send reminders when the complaint seems to be getting ignored (I certainly did not feel sure that I was doing the right thing). But occasionally, it is worth the effort – not because of the personal satisfaction (nice but not essential), but because the truth has a high value which should be respected.
  2. Wondering how all this mess came about, I am asking myself: Does the author of the Telegraph article perhaps genuinely not know the difference between herbal and homeopathic remedies? Obviously, I don’t know the answer to this question, but it would explain the mess she got herself (and me) into. And it would also suggest that it might be necessary to educate journalists about alternative medicine in general and homeopathy in particular (In case there is any interest, I offer to give a few informative lectures with opportunities to ask questions to London-based health writers and science journalists).

Many hard-nosed sceptics might claim that there is no herbal treatment for upper respiratory infections that makes the slightest difference difference. But is this assumption really correct?

According to my own research of 2004, it is not. Here is the abstract of our systematic review:

Acute respiratory infections represent a significant cause of over-prescription of antibiotics and are one of the major reasons for absence from work. The leaves of Andrographis paniculata (Burm. f.) Wall ex Nees (Acanthaceae) are used as a medicinal herb in the treatment of infectious diseases. Systematic literature searches were conducted in six computerised databases and the reference lists of all papers located were checked for further relevant publications. Information was also requested from manufacturers, the spontaneous reporting schemes of the World Health Organisation and national drug safety bodies. No language restrictions were imposed. Seven double-blind, controlled trials (n = 896) met the inclusion criteria for evaluation of efficacy. All trials scored at least three, out of a maximum of five, for methodological quality on the Jadad scale. Collectively, the data suggest that A. paniculata is superior to placebo in alleviating the subjective symptoms of uncomplicated upper respiratory tract infection. There is also preliminary evidence of a preventative effect. Adverse events reported following administration of A. paniculata were generally mild and infrequent. There were few spontaneous reports of adverse events. A. paniculata may be a safe and efficacious treatment for the relief of symptoms of uncomplicated upper respiratory tract infection; more research is warranted.

A. Paniculata (Burm.f.) Wall ex Nees (Acanthaceae family), also known as nemone chinensi, Chuān Xīn Lián, has traditionally been used in Indian and Chinese herbal medicine mostly as an antipyretic for relieving and reducing the severity and duration of symptoms of common colds and alleviating fever, cough and sore throats, or as a tonic to aid convalescence after uncomplicated respiratory tract infections. The active constituents of A. paniculata include the diterpene, lactones commonly known as the andrographolides which have shown anti-inflammatory, antiviral, anti-allergic, and immune-stimulatory activities. A. Paniculata has also been shown, in vitro, to be effective against avian influenza A (H9N2 and H5N1) and human influenza A H1N1 viruses, possibly through blocking the binding of viral hemagglutinin to cells, or by inhibiting H1N1 virus-induced cell death.

But our systematic review was published 14 years ago!

We need more up-to-date information!

And I am pleased to report that a recent paper provided exactly that.

This systematic review included published and unpublished RCTs. Quasi-RCTs, crossover trials, controlled before and after studies, interrupted time series (ITS) studies, and non-experimental studies were not included due to their potential high risk of bias.

Thirty-three trials involving 7175 patients with ARTIs were included. Their methodological quality was restricted as randomisation was not well documented; 73% of the trials included were not blinded; where ITT analysis were performed, loss to follow-up data were counted as no effect; and most trials were published without a protocol available.

Findings suggested limited but consistent evidence that A. Paniculata improved cough and sore throat when compared with placebo. A. Paniculata (alone or plus usual care) had a statistically significant effect in improving overall symptoms of ARTIs when compared to placebo, usual care, and other herbal therapies. A. Paniculata in pillule tended to be more effective in improving overall symptoms over A. Paniculata in tablet. Evidence also suggested that A. Paniculata (alone or plus usual care) shortens the duration of cough, sore throat and sick leave/time to resolution when compared versus usual care. Reduction in antibiotic usage was seldom evaluated in the included trials.

The authors concluded that A. Paniculata appears beneficial and safe for relieving ARTI symptoms and shortening time to symptom resolution. However, these findings should be interpreted cautiously owing to poor study quality and heterogeneity. Well-designed trials evaluating the effectiveness and potential to reduce antibiotic use of A. Paniculata are warranted.

In case you wonder about conflicts of interest: there were none with my 2004 paper, and the authors of the new review state that this paper presents independent research funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR). The views expressed are those of the author(s) and not necessarily those of the NIHR, the NHS or the Department of Health.

Yes, the RCTs are not all of top quality.

And yes, the effect size is not huge.

But maybe – just maybe – we do have here an alternative therapy that does help against a condition for which conventional drugs are fairly useless!?!

Virologists have discovered the very virus that is threatening the survival of the UK. It is a Coxsackie virus, to be precise, a mutation of the one responsible for HAND FOOT AND MOUTH DISEASE. In contrast to the Coxsackie A 16, the new ‘Coxsackie Brexit Strong’ (‘Coxsackie BS’ for short) seems to attack mostly adult Brits. By no means everybody is affected, and the scientists have already identified important risk factors:

  • being English,
  • being a nationalist,
  • white colour,
  • male gender,
  • age 60 and older,
  • low intelligence,
  • affluence,
  • cronyism,
  • aversion to Frogs,
  • dislike of Huns,
  • unusual dress-sense,
  • propensity of fill own pockets,
  • urge to invest in tax-heavens.

The infected individuals display a wide range of symptoms, including the compulsory repetition of slogans such as:

  • Brexit is Brexit!
  • We want our country back!!
  • The will of the people!!!
  • Get over it!!!!
  • Strong and stable!!!!!
  • The treasury are fiddling the figures!!!!!!

The disease is dangerously progressive, and its victims show increasing breakdown of reason, critical thinking, insight into facts, common sense, understanding of economics, ability to consider the views of experts, as well as further cognitive functions. Other significant symptoms, particularly of the later stages of the condition, is the urge to become the laughing-stock of other nations, galloping jingoism, and depicting uninfected individuals as ‘Remoaners’.

The danger for the UK arises from the fact that victims are eager to take over high places, for instance in politics. As the disease progresses, they become more and more ruthless in pursuing their aim to ‘MAKE BRITAIN GERAT AGAIN’. They tend to make false promises, lie in Parliament, avoid questions, withhold information, engage in intrigues, attempt to turn the BBC into a propaganda machine in the style of Josef Goebbels etc. … and, when confronted with the truth, shrug it off with an imbecilic smile.

The virus, it is assumed, affects the brain’s newly discovered ‘honesty-centre’ and turns it into a malignant ‘xenophobia centre’. The victim feels no pain; instead (s)he is taken over by an ever-increasing sense of righteousness and an urge to behave like a ‘little Englander’. In some badly affected individuals, this phenomenon shows itself in a bizarre dress-sense (e. g. ‘Victorian undertaker’).

Several concerned scientists have issues a nation-wide alert stating: ‘This is a national emergency! If the virus remains unchecked, the UK will go straight back into the Dark Ages.’

Virologists are currently working tirelessly trying to find a cure; experts say that it will take months to make meaningful progress. “We are working flat out, but our immunisation might come too late – not least because, due to insufficient funding, we have to work on a shoestring”, said one desperate scientist.

By contrast, enthusiasts from the alternative medicine scene claim to have found the solution: homeopathy!

Researchers at ‘British Science in Homeopathy’ (or ‘BS Homeopathy’) have re-analysed Hahnemann’s Organon in full detail and extrapolated that, based on the guru’s words, they can produce an effective remedy in a timely fashion. In fact, they already have exposed distilled water to the sound of recorded speeches by Hitler, Mussolini, the KKK and Trump. According to homeopathy’s ‘dislike cures dislikes’ principle, this procedure generates a novel ‘mother tincture’, fittingly called ‘Brexit Solution’, or BS for short.

Currently, the homeopaths are potentising this remedy and are organising its large-scale production. However, a fly has been discovered in the homeopathic ointment: a heated debate has erupted amongst these experts whether to employ ‘BS C30’ or ‘BS C200’ for the planned nation-wide emergency immunisation programme. Proponents of the ‘BS C200’ solution insist that such a dramatically high potency is needed in our present acute emergency, while members of the ‘C30 camp’ caution that it might cause a severe homeopathic aggravation which would lead to an outbreak of open hostilities in Europe. “After 70 years of peace, it would be foolish to risk it”, one senior homeopath has been quoted saying.

This is a question most clinicians must have asked themselves. The interest of patients in this area is enormous, and many do seek advice from their doctor, nurse, pharmacist, midwife etc. In a typical scenario, a patient might plug up her courage (yes, for many it does take courage) and ask:

What about therapy xy for my condition? My friend suffers from the same problem, and she says the treatment works very well.

The way I see it, there are essentially 4 options for formulating a reply:

1.       Uncompromisingly negative

2.       Evidence-based

3.       Open-minded

4.       Uncritically promotional

Let me explain and address these 4 options in turn.

1.       Uncompromisingly negative

I know that it can be tempting to be wholly dismissive and simply state that all alternative medicine is rubbish; if it were any good, it would have been adopted by conventional medicine. Therefore, alternative medicine is never an alternative; it is by definition implausible, ineffective and often dangerous.

Even if all of this were true, the uncompromisingly negative approach is not helpful, in my experience. Patients need and deserve some empathy and understanding of their position. If we brusque them, they feel insulted and go elsewhere. Not only would we then lose a patient, but we would run a high risk of exposing her to a practitioner who promotes quackery. The disservice seems obvious.

2.       Evidence-based

Clinicians might consider their patient’s question and reply to it by explaining what the current best available evidence tells us about the therapy in question. This can be done with empathy and compassion. For instance (if that is true), the clinician can explain that the treatment in question lacks a scientific basis, that it has nevertheless been tested in clinical trials which sadly do not show that it works. Crucially, the clinician should subsequently explain what effective treatments do exist and discuss a viable treatment plan with the patient.

The problem with this approach is that many, if not most conventional clinicians are fairly clueless about the evidence as it relates to the plethora of alternative therapies. Therefore, an honest discussion around the current best evidence is often difficult or impossible.

3.       Open-minded

This is the approach many clinicians today use as a default position. They basically tell their patient that there is not a lot of evidence for the treatment in question. However, it seems harmless, and therefore – if the patient is really keen on going down this route – why not? This type of response is, I fear, given regardless of the therapy in question and it largely ignores the evidence – some alternative treatments do work, some don’t, some are fairly safe, some aren’t.

Condoning alternative medicine in this way gives the impression of being ‘open-minded’ and ‘patient-centred’. It has the considerable advantage that it does not require any hard work, such as informing oneself about the current best evidence. It’s disadvantage is that it neither correct nor ethical.

4.       Uncritically promotional

Many clinicians go even one decisive step further. Under the banner of ‘integrative medicine’, they openly recommend using ‘the best of both worlds’ as being ‘holistic’, ’empathetic’, ‘patient-centred’, etc. By this, they usually mean employing as many unproven or disproven treatments as alternative medicine has to offer.

This approach gives the impression of being ‘modern’ and in tune with the wishes of patients. Its disadvantages are, however, obvious. Introducing bogus treatments into clinical routine can only render it less effective, more expensive, and less safe. Integrative medicine is therefore not in the best interest of patients and arguably unethical.

Conclusion

So, how should we advise patients on alternative medicine? I know what I would say and probably most of my readers can guess. But I do not want to prejudge the issue; I prefer to hear your views, please.

If you ask me, the field of alternative medicine is plagued with surveys; too many are published and most are complete, meaningless rubbish which serve merely the purpose of being misinterpreted as a means of popularising bogus treatments. Yet, every now and then, a decent and informative article appears – like this survey from Canada.

It yields a number of fascinating findings:

  • More than three-quarters of Canadians (79%) had used at least one from of CAM sometime in their lives in 2016 (74% in 2006 and 73% in 1997). British Columbians were most likely to have used an alternative therapy during their lifetime (89%), followed by Albertans (84%) and Ontarians (81%).
  • More than half (56%) of Canadians had used at least one CAM therapy in the year prior to the 2016 survey, compared to 54% in 2006 and 50% in 1997.
  • In 2016, massage was the most common type of therapy that Canadians used over their lifetime with 44 percent having tried it, followed by chiropractic care (42%), yoga (27%), relaxation techniques (25%), and acupuncture (22%).
  • The most rapidly expanding therapies over the past two decades were massage, yoga, acupuncture, chiropractic care, osteopathy, and naturopathy.
  • High dose/mega vitamins, herbal therapies, and folk remedies were in declining use over that same time period.
  • The most likely users of CAM over the past 12 months in 2016 were from the 35- to 44-year-old age group (61%). The use of CAM diminished with age, and generally rose with both income and education. These trends are similar to those observed in 2006 and 1997.
  • The majority of people choosing to use CAM in the 12 months preceding the 2016 survey did so for “wellness”.
  • Canadians spent an estimated $8.8 billion on CAM in the last 12 months ($8.0 billion in 2005/06 and $6.3 billion in 1996/97.
  • Of the $8.8 billion spent in 2016, more than $6.5 billion was spent on providers of CAM, while another $2.3 billion was spent on herbs, vitamins, special diet programs, books, classes, and equipment.
  • The majority of Canadians believe that CAM should be paid for privately and not by provincial health.

The strengths of this survey are that it is methodologically rigorous, and that it provides longitudinal data (this is in sharp contrast to the plethora of CAM surveys published recently). Many of its findings confirm what has already been known. Yet some results are new and noteworthy.

To many readers of this blog, the high CAM-usage will be disturbing. However, I am mildly encouraged by the results of this survey.

  • Firstly, the choice of CAM by Canadians seems rather more reasonable than that by other nations. Canadians seem to avoid the more ridiculous types of CAM, such as homeopathy or para-normal healing.
  • Secondly, many Canadians seem to view CAM not as medicine, but as a sort of luxurious pampering that they use to relax and feel well. Consequently, most are not pushing to get it reimbursed which I find more sensible than consumers’ attitudes in many other countries.

I have recently moved to Cambridge. Once I had unpacked my boxes etc., I decided to have a look at what Cambridge offers in terms of homeopathy. My hope was that, being a town dominated by higher education and top science, Cambridge would be free (or almost free) of quackery.

This hope was sadly disappointed. The first website I came across was this one:

Homeopathy can be used to treat a wide range of complaints…

  • mental and emotional states (eg OCD, depression, anxiety, panic attacks, irritability, etc)
  • respiratory tract disorders (eg asthma, bronchitis, laryngitis, rhinitis, sinusitis, hayfever, etc)
  • digestive problems (eg IBS, IBD, heartburn, colic, constipation, candidiasis, etc)
  • skin conditions (eg eczema, psoriasis, acne, warts, molluscum, urticaria, herpes etc)
  • musculo-skeletal complaints (eg rheumatoid arthritis, osteoarthritis, fibromyalgia, etc)
  • hormonal problems (eg thyroid disorders, menstrual and menopausal complaints,  etc)
  • male and female reproductive issues (eg PCOS, infertility, endometriosis, fibroids, etc)
  • sex related issues (eg physical and psychological issues,  diminished libido, etc)
  • complaints of pregnancy (eg nausea, fatigue, emotional upset, etc)
  • complaints of babies and children (including behavioural issues)
  • acute and/or recurring illnesses (eg ear infections, tonsillitis, cystitis, childhood diseases, etc)
  • disorders affecting the immune system (eg autoimmune disorders, allergies, etc)
  • side effects of conventional drugs (eg nausea of chemotherapy, skin burns of radiotherapy, etc)
  • and many more (eg ME,  chronic fatigue,  glandular fever, migraines, headaches, insomnia, etc)…

You would be forgiven for finding this list worrying – I certainly do. But there was an assurance:

Each homeopath at the Centre holds a Licentiate qualification from a respected homeopathic college and has many years experience. All are registered with at least one professional body, whose code of ethics and conduct they adhere to.

It seems that the code of ethics of these professional bodies has nothing against making bogus therapeutic claims.

Cambridge also offers training and education in homeopathy – even homeopathic first aid courses for lay people:

Courses typically cover the following topics:

  • The principles of homeopathic first aid
  • How to choose the right remedy
  • Understanding homeopathic potency
  • How to treat conditions such as colds, flu, fever
  • How to treat conditions such as insect bites, bee and wasp stings
  • How to treat food poisoning and other digestive ailments, acute tendon inflammations caused by overuse of parts of the body (tennis elbow, frozen shoulder, ‘keyboard’ wrist) and exam nerves…

Whether you are looking after yourself or looking after your family, knowledge of homeopathic first aid equips you with safe, simple and proven treatments for many common ailments and conditions…

The course fee is £90 and includes a booklet and refreshments. Fees are payable in two instalments.

A choice of homeopathic first aid kits is available on the course…

And there is more!

Take this website, for instance:

The healing process using clinical homeopathy, shortly explained

The homeopathic case-taking will assess a patient in respect to the position of the symptoms and vitality on the two charts above.

When faced with disease and symptoms, the body does not heal in a haphazard, accidental way, but according to a deep biological intelligence. A true healing process will mirror the body’s own healing strategies. It will not be about a specific herb or remedy but about understanding and helping the way our mind and body heal themselves.

The healing process can broadly be divided into five stages. For some cases, the focus is only needed in one or two stages, but in others, the healing process will require all five. Depending on the individual and the situation, each stage will be best done one-by-one but sometimes several stages can be achieved simultaneously.

1. Symptom Relief

What drives most patients to a health practitioner is relief from some kind of pain, discomfort or lack of freedom on a physical or psychological level. All systems of medicine are involved with alleviating these symptoms. While, this is the primary focus of conventional medicine, holistic treatment such as homeopathy will also seek to unravel deeper causes and promote lasting changes in your level of health.

2. Revitalisation

As the body has devoted parts of its energy to eliminate an illness, there is usually a loss in vitality and internal resources suffered by the individual. In order to have an effective response, it is important to ensure that the body has the right nutrients and resources to promote health. This is often overlooked by conventional medicine and also many holistic practitioners. Providing nutrients and support to a sick body will help with the recovery.

3. Detoxification

Very often, the body cannot function properly if there are high levels of damaging toxins or free radicals within the lymphatic system or at a tissue or cellular level. Toxins are often found at an area where disease occurs or has occurred. Toxins can be external (virus, metals, chemicals) or internal accumulations of the body’s own by-products. These wastes slowly and inexorably weaken the organism on all levels, generating both chronic disease states and acute illness. Clearing debris from cells, tissues and organs relieves the body of a tremendous burden and allow the body to work as it should…

But the proverbial biscuit is taken by another Cambridge institution, The Quantum Medicine of our Time:

LOOKING-GLASS MEDICINE is pioneering work in Homeopathy energy healing, and particularly in medicine. It possesses the capacity to heal the mental, emotional, and physical illnesses (refer to Case Studies under the title “Publication”). This energy form of medicine culminated a synthesis of the healing laws and principles of Homeopathy and Jungian psychology of the archetypes, and of which also incorporates the human energy system (the chakras) in both theories and practice. Counselling is an integral part of this healing process for one to achieve deep healing.

My working and researching, over the years, in how individuals whose life/psyche impacted severely by trauma can be healed has given rise to Looking-Glass Medicine’s sound theoretical foundation in terms of congruence and consistency in its healing system and healing outcome. It is this unique three-dimensional energy healing system’s capacity to heal from the personal unconscious that these patients’ healing outcome is INNER TRANSFORMATION that shifts their negative/harmful behaviour patterns into life affirming ones. Particularly, many of them were severely traumatised…

Einstein says, “The field is the sole governing agency of the particle.” Particle is matter, which is determined ultimately by the field as in how things manifest. Our body in disease and health is influenced and impacted by the individual energy field, the vibratory frequencies, 


in our evolution of consciousness…

——————————————————————————————

There would be much more but, at this point, I stopped my searches and asked myself, HOW IS IT THAT A MAJOR CENTRE OF EDUCATION AND SCIENCE IS ALSO HOME TO SOME OF THE WORST QUACKERY?

Is it that excellence in science always attracts an excess in pseudo-science?

I am not sure.

Perhaps there is a much simpler explanation: Cambridge is a fairly wealthy town, and quackery always thrives where there is money to be earned with it.

 

PS

I will soon give a talk in Cambridge about homeopathy. If you are a Cambridge homeopath, please reserve the date. This could be fun!

Traditional Chinese Medicine (TCM) is popular, not least because it is heavily marketed and thus often perceived as natural and safe. But is this assumption true?

This study analysed  liver tests before and following treatment with herbal Traditional Chinese Medicine (TCM) in order to evaluate the risk of liver injury. Patients with normal values of alanine aminotransferase (ALT) as a diagnostic marker for ruling out pre-existing liver disease were enrolled in a prospective study of a safety program carried out at the First German Hospital of TCM from 1994 to 2015. All patients received herbal products, and their ALT values were reassessed 1-3 d prior to discharge. To evaluate causality for suspected TCM herbs, the Roussel Uclaf Causality Assessment Method (RUCAM) was used.

The report presents data of 21470 patients. ALT ranged from 1 × to < 5 × upper limit normal (ULN) in 844 patients (3.93%) and suggested mild or moderate liver adaptive abnormalities. A total of 26 patients (0.12%) experienced higher ALT values of ≥ 5 × ULN (300.0 ± 172.9 U/L, mean ± SD). Causality for TCM herbs was estimated to be probable in 8/26 patients, possible in 16/26, and excluded in 2/26 cases.

Compared with the large TCM study cohort, patients in the liver injury study cohort were older and contained a higher percentage of women, whereas the duration of the hospital stay was similar in both cohorts. The TCM herbs were rarely applied mostly as mixtures consisting of several herbs adding up to 35 different drugs during the patients’ four-week stay. The daily dosage was 95 ± 30 g and thus slightly higher than in the TCM study cohort. Among the many herbal TCM used by the 26 patients in the liver injury cohort, Bupleuri radix and Scuterllariae radix were the two TCM herbs most frequently implicated in liver injury, with variable RUCAM-based causality gradings. Most of the patients received one to six TCM drugs that were associated with potential liver injury as evidenced from the scientific literature, e.g., one patient (case 8) received six potentially hepatotoxic herbal TCM drugs during their hospital stay.

The authors concluded that in 26 (0.12%) of 21470 patients treated with herbal TCM, liver injury with ALT values of ≥ 5 × ULN was found, which normalized shortly following treatment cessation, also substantiating causality.

In the discussion section of the paper, the authors comment that the use of TCM is widely considered less risky as compared with synthetic drugs, although data on direct comparisons are not available in support of this view. Populations using herbal TCM, drugs, either alone, or combined experience more drug-induced liver injury (DILI) than herb-induced liver injury (HILI), possibly due to a higher use of drugs. Valid data of incidence and prevalence of HILI caused by TCM herbs are lacking, and respective data cannot be derived from the present study.

This study is most valuable, in my view. Its strength is clearly the huge sample size. Top marks for the authors for publishing it!

Having said that, we need to take the incidence figures with a pinch of salt, I think. In reality they could be much higher because:

  • other settings will not be as tightly supervised as the unusual hospital setting;
  • in most other situations the quality of the Chinese herbs might be less controlled;
  • there could be adulteration;
  • there could be contamination.

The ‘elephant in the room’ obviously is the inevitable question about benefit. Like any other treatment, TCM cannot be judged on the basis of its risk but must be evaluated according to its risk/benefit balance. I realise that this was not the subject of the present study, but it is nevertheless crucial: do the benefits of TCM outweigh its risks?

I am not aware that this is the case (but more than willing to consider any sound evidence readers might supply). More importantly, I am not aware of good evidence to show that, for any condition, TCM would be superior in terms of risk/benefit balance than conventional options. This is not a trivial issue: clinicians have the ethical obligation to apply the best (the one with the most positive risk/benefit balance) treatment to their patients.

If I am right, then TCM should not be used in therapeutic routine in or outside hospitals.

If I am right, the ‘First German Hospital of TCM‘ should close asap; it would be violating fundamental ethical principles.

If I am right, the debate about the risks of TCM is almost irrelevant because we simply should not use it.

Or did I misunderstand something here?

What do you think?

 

Some of you will remember the saga of the British Chiropractic Association suing my friend and co-author Simon Singh (eventually losing the case, lots of money and all respect). One of the ‘hot potatoes’ in this case was the question whether chiropractic is effective for infant colic. This question is settled, I thought: IT HAS NOT BEEN SHOWN TO WORK BETTER THAN A PLACEBO.

Yet manipulators have not forgotten the defeat and are still plotting, it seems, to overturn it. Hence a new systematic review assessed the effect of manual therapy interventions for healthy but unsettled, distressed and excessively crying infants.

The authors reviewed published peer-reviewed primary research articles in the last 26 years from nine databases (Medline Ovid, Embase, Web of Science, Physiotherapy Evidence Database, Osteopathic Medicine Digital Repository , Cochrane (all databases), Index of Chiropractic Literature, Open Access Theses and Dissertations and Cumulative Index to Nursing and Allied Health Literature). The inclusion criteria were: manual therapy (by regulated or registered professionals) of unsettled, distressed and excessively crying infants who were otherwise healthy and treated in a primary care setting. Outcomes of interest were: crying, feeding, sleep, parent-child relations, parent experience/satisfaction and parent-reported global change. The authors included the following types of peer-reviewed studies in our search: RCTs, prospective cohort studies, observational studies, case–control studies, case series, questionnaire surveys and qualitative studies.

Nineteen studies were selected for full review: seven randomised controlled trials, seven case series, three cohort studies, one service evaluation study and one qualitative study. Only 5 studies were rated as high quality: four RCTs (low risk of bias) and a qualitative study.

The authors found moderate strength evidence for the effectiveness of manual therapy on: reduction in crying time (favourable: -1.27 hours per day (95% CI -2.19 to -0.36)), sleep (inconclusive), parent-child relations (inconclusive) and global improvement (no effect).

Reduction in crying: RCTs mean difference.

The risk of reported adverse events was low (only 8 studies mentioned adverse effects at all, meaning that the rest were in breach of research and publication ethics): seven non-serious events per 1000 infants exposed to manual therapy (n=1308) and 110 per 1000 in those not exposed.

The authors concluded that some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action. Manual therapy appears relatively safe.

For several reasons, I find this review, although technically sound, quite odd.

Why review uncontrolled data when RCTs are available?

How can a qualitative study be rated as high quality for assessing the effectiveness of a therapy?

How can the authors categorically conclude that there were benefits when there were only 4 RCTs of high quality?

Why do they not explain the implications of none of the RCTs being placebo-controlled?

How can anyone pool the results of all types of manual therapies which, as most of us know, are highly diverse?

How can the authors conclude about the safety of manual therapies when most trials failed to report on this issue?

Why do they not point out that this is unethical?

My greatest general concern about this review is the overt lack of critical input. A systematic review is not a means of promoting an intervention but of critically assessing its value. This void of critical thinking is palpable throughout the paper. In the discussion section, for instance, the authors state that “previous systematic reviews from 2012 and 2014 concluded there was favourable but inconclusive and weak evidence for manual therapy for infantile colic. They mention two reviews to back up this claim. They conveniently forget my own review of 2009 (the first on this subject). Why? Perhaps because it did not fit their preconceived ideas? Here is my abstract:

Some chiropractors claim that spinal manipulation is an effective treatment for infant colic. This systematic review was aimed at evaluating the evidence for this claim. Four databases were searched and three randomised clinical trials met all the inclusion criteria. The totality of this evidence fails to demonstrate the effectiveness of this treatment. It is concluded that the above claim is not based on convincing data from rigorous clinical trials.

Towards the end of their paper, the authors state that “this was a comprehensive and rigorously conducted review…” I beg to differ; it turned out to be uncritical and biased, in my view. And at the very end of the article, we learn a possible reason for this phenomenon: “CM had financial support from the National Council for Osteopathic Research from crowd-funded donations.”

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