MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

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About 7 months ago, I contacted a German journalist who I knew and trusted to tell her about the incredible quackery-promotion performed by Germany’s institutes of adult education, the ‘Volkshochschulen‘ (VHSs). After I had been invited to give a few lectures for the VHSs, I had conducted some preliminary research and realised that, nationwide, they run hundreds of courses promoting the worst types of quackery.

My journalist friend, Veronika Hackenbroch, who works for DER SPIEGEL liked the idea of conducting an in-depth investigation into the matter. What it revealed became the centre-piece of a theme issue published today. Here is its title page:

In a nutshell, the key finding is that every 5th course offered by the VHSs in the area of healthcare is steeped in woo. Considering that their funding comes mainly from the public purse, this is intolerable. When asked why they offer so much quackery, some heads of local VHSs said that they are not competent to evaluate the science; they simply assume that, if doctors in Germany use these treatments – specifically homeopathy – and if the public wants to learn about them, they have to offer them.

When I first heard this argument, it made me speechless. It has some undeniable logic behind it. The heads of VHSs are not medical experts. Thus, they cannot do their own research or evaluations. To just follow what the doctors must therefore seem reasonable to them.

So, where is the crux of the problem?

I think, it lies in the vicious circle that inevitable unfolds such a situation:

  • some people like homeopathy (or other bogus treatments),
  • therefore, they ask their doctors to provide it,
  • therefore, some doctors offer it,
  • therefore, the VHSs feel they can promote if,
  • therefore, people like homeopathy (or other bogus treatments).

This circle has no beginning and no end; it just turns and turns. And it is difficult to stop, not least because it is driven by the relentless promotion of interested parties, such as the manufacturers of woo. Yet, if we want to make progress and are serious about improving healthcare, we have to try stopping it!

But how?

Through providing information and fighting misinformation (of course, some rules and regulations would help as well).

That’s exactly what we tried to do – thank you Veronika Hackenbroch!

We probably have all heard of predatory journals. The phenomenon of ‘predatory conferences’ seems to be less-well appreciated. Hardly a day goes by that I do not receive emails like the one below:

________________________________________________________

Dear Dr. E Ernst ,

Good day!

After the success of Traditional Medicine-2018 in Rome, Italy, on behalf of the Organizing committee, we are delighted to invite you to be a speaker at our upcoming “3rd World Congress and Expo on Traditional and Alternative Medicine” (Traditional Medicine-2019) which will be held during June 06-08, 2019 in Berlin, Germany.

Traditional Medicine-2019 will focus on the theme “Natural and Scientific Approach for Treatment and Rehabilitation”…

_________________________________________________________

I have chosen this particular one because it refers to the success of a recent conference in Rome. This is a conference where I was a member of  the organising committee and have been listed as a keynote speaker. Here is the original entry from the programme:

Keynote Forum 09:15-09:55

Title: Integrative Medicine: Hype or Hope? Ernst Edzard, University of Exeter, United Kingdom

And here is the strange tale how it all came about:

After receiving a barrage of similar invitations and having ignored them for months, I thought that maybe I am unnecessarily suspicious – perhaps these conferences are not as dodgy as they appear to be. So, I responded to one email and stated the usual things:

  • I do not insist on a fee,
  • I want my expensed paid,
  • I need a topic that I feel comfortable with,
  • I need to know who else is speaking,
  • I must know who is sponsoring the event,
  • the whole thing must fit into my time-table.

I got an enthusiastic response and, even though not all my questions were answered, they agreed to fund my travel and hotel costs with a lump sum of 300 Euro. They asked me to act as chair of the entire meeting and as ‘signing authority for the conference’ (I don’t know what this means) but I declined. Yet I wanted to see how the whole thing would play out. So, I accepted a keynote lecture, agreed to be a member of the organising/scientific committee, and send them my abstract.

Then I did not hear anything for a long time (normally, I would, as a member of the organising/scientific committee, have expected to receive abstract submissions for review and other material). When someone sent me an email about it, I noted that the organisers were advertising the conference with my name and photo. I was irritated by that, but decided to play along so that I could get to the bottom of all this. Then, about 6 weeks before the event came this email from the organisers:

Dear Dr. Ernst ,

Greetings of the day!!

We are glad to have your presence at Traditional Medicine 2018.

Hope this mail finds you in good spirits.

Kindly find the attached final program for the Conference.

Could you please confirm us your check in & check out dates.

Revert back to me for further queries…

I replied as follows:

I will look at the possibilities of trains, flights etc., once you send me the promised funds for buying my tickets.

e ernst

________________________________________________________

And the rest was silence!

I did not hear a word from them after telling them that they need to send me the money before I commit myself into buying flight tickets etc. Nor did I expect to hear from them after that.

The run-up to the conference was too bizarre, in my view, for a credible conference:

  • The organisers seemed to know next to nothing about the topic of the conference.
  • They signed with English names and had a London address, but their language skills seem to be limited.
  • They had few of the features that are typical for a serious conference.
  • Almost all of their emails seemed strangely vague.
  • I got the impression that the entire organisation is not run by a thinking person but by a computer.
  • They seemed to organise dozens of conferences at any one time.
  • All their conferences were in towns that might seem attractive to visit.
  • None were associated with a leading scientist’s place of work.
  • They wanted my commitments but never committed themselves to anything tangible.

In a word, they seemed phony!

Of course, in the end, I did not fly to Rome and did not deliver my keynote lecture. Evidently, this did not stop them to email me soon after stating “After the success of Traditional Medicine-2018in Rome, Italy, on behalf of the Organizing committee…”

The reason for writing this is to warn you: there are obviously quite a few (not so) clever people out there who want to get hold of your cash by tempting you to attend an apparently interesting conference in an attractive town which, once you participate, turns out to be a waste of time, money and effort.

Vis a vis the overwhelming evidence to the contrary, why are there so many clinicians (doctors as well as lay practitioners) who still believe that homeopathy is working? And why are there so many patients who still believe that homeopathy is working?

These are questions that puzzle me quite a bit.

Of course, there is no simple, single answer; there are probably dozens. But one reason must be that there are only three possible outcomes after homeopathic treatments, all of which are favourable for homeopathy (at least in the interpretation of proponents of homeopathy). Seen in this light, there simply is no better therapy!

Let me explain:

If a patient consults a homeopath who prescribes a highly diluted homeopathic remedy, she might subsequently:

  1. get better,
  2. get worse,
  3. or experience no change at all.

Analysing these three possibilities, we quickly see that, from the point of view of a convinced homeopath, all are a proof for homeopathy’s effectiveness, and none suggests that the scientific evidence is correct in claiming that highly diluted homeopathic remedies are pure placebos.

SCENARIO 1

In this situation, it is easy to assume that the remedy was the cause for the clinical improvement. Most clinicians of any discipline fall into this trap, and most patients follow them willingly. Yet, we all know that a temporal relationship is not the same as a causal one (the crowing of a cock before dawn is not the cause of the sun rising). Of course, it is conceivable that the treatment was the cause, but there are several other possibilities as well; just think of the placebo effect, regression towards the mean, and the natural history of the disease. In our case, these non-specific effects are most certainly the cause of our patient’s improvement.

SCENARIO 2

Most clinicians in this situation would start wondering whether they have employed the correct therapy for this patient’s condition – not so the homeopath! He would triumphantly exclaim: “excellent, you are experiencing a ‘homeopathic aggravation’. This is a sure sign that I have given you the optimal remedy. Things will get better soon.” A homeopathic aggravation occurs, according to homeopathic logic, because homeopathy follows the ‘like cures like’ principle. The homeopath prescribes the remedy that would normally cause the symptoms from which his patient is suffering. This means it must also cause these symptoms in every patient. Usually these aggravations are not strong enough to be noticed, but when they are, it is interpreted by homeopaths as a triumph of homeopathy.

SCENARIO 3

In this situation, the homeopath has several options. He can claim “but without my remedy you would be much worse by now. The fact that you are not, shows how very effective homeopathy really is. A more humble homeopaths might explain that the optimal remedy is not always easy to find straight away, and he would therefore proceed in prescribing another one. In both cases, the patient is kept paying for more and homeopathy is presented as an effective therapy.

These three scenarios clearly show that there is no conceivable outcome where any homeopathy-fan would need to consider that scientists are correct in stating that homeopathy is ineffective. And this is one of the reasons why the myth of homeopathy’s effectiveness persists.

Hold on … the patient might be dead!

Yes, that is a rather unfortunate situation for any clinician – except for a homeopath, of course. He would simply point out that the patient must have forgotten to take her medicine. A conventional practitioner might get in trouble, if he tried that excuse; one could easily measure blood levels of the prescribed drug and verify the claim. Not so in homeopathy! Because they contain not a single active molecule, homeopathic remedies are undetectable!

We can easily see that there is no better treatment than homeopathy – at least for the homeopath!

 

 

Chiropractors will never cease to amuse and amaze me. Today, I received this comment to a recent post of mine; its author is a chiropractor by the name of SD White (I never met the man [surely it’s a man] and don’t know where he’s from):

Someone is suffering from a love of credentials (small penis?) and a sour disposition who has zero actual information about a profession of which he is not a member. So this is how you choose to spend your days? What a royal disappointment you must be to family, friends, and others with your extremely disjointed and disgruntled opinions. Which no one requested. Rating: 1/10

This type of hilarity encouraged me to write a post about chiropractic which fulfils some of SD White’s criteria: no one requested it, and it has zero actual information. But I hope it adds to the hilarity chiropractic so often creates.

The article it refers to is entitled ‘Chiropractic in global health and well being’.  When I read such a headline, my BS-detectors starts running amok, and my BS-corrector automatically springs into action.

In the following, I will show you some excerpts from this paper – first in its original version and subsequently in the version altered by my BS-corrector.

ENJOY

_______________________________________________________________________________________________________ 

 

The abstract:

The World Federation of Chiropractic supports the involvement of chiropractors in public health initiatives, particularly as it relates to musculoskeletal health. Three topics within public health have been identified that call for a renewed professional focus. These include healthy ageing; opioid misuse; and women’s, children’s, and adolescents’ health. The World Federation of Chiropractic aims to enable chiropractors to proactively participate in health promotion and prevention activities in these areas, through information dissemination and coordinated partnerships. Importantly, this work will align the chiropractic profession with the priorities of the World Health Organization. Successful engagement will support the role of chiropractors as valued partners within the broader healthcare system and contribute to the health and wellbeing of the communities they serve.

Passage from the paper:

The WFC’s Public Health Committee has committed to an expanded agenda that focuses on three new priority areas of public health: healthy ageing; opioid overuse and misuse; and women’s, children’s, and adolescents’ health. These were chosen for their alignment with WHO priorities, and the chiropractic profession’s ability to uniquely contribute to each through the lens of musculoskeletal health. The goal is to enhance the ability for chiropractors to actively engage in health promotion activities in alignment with WHO priority areas and pursue collaborative work to increase global attention on these important public health issues. As a first step, the WFC will focus on providing key strategies that chiropractors in primary care settings can focus on bridging their work in primary care and population health. The WFC has developed position statements and proposed public health strategies for each priority area, as described below.

The conclusion

The WFC commits to promoting and facilitating public health strategies for chiropractors to implement in practice. Healthy ageing, opioid misuse, and supporting women’s, children’s and adolescents’ health are priority areas of initial focus. This work builds on the shared goal of primary care and population health, through the prevention of illness, promoting health, improving patient care, and addressing contextual factors in a collaborative and evidence-based manner. Future work in public health for the chiropractic profession should also focus on broader roles such as community engagement and the creation of sustainable systems, engaging key stakeholders locally and globally.

______________________________________________________________________________

VERISON BY BS-CORRECTOR

The abstract:

The World Federation of Chiropractic supports the involvement of chiropractors in fleecing the public, particularly as it relates to musculoskeletal health. Three topics within chiropractic wealth have been identified that call for a boost in our cash flow. These include healthy ageing; opioid misuse; and women’s, children’s, and adolescents’ health. The World Federation of Chiropractic aims to enable chiropractors to proactively participate in misinforming the public in these areas, through coordinated partnerships with anyone who can be fooled. Importantly, this work will be camouflaged such that it seemingly aligns the chiropractic profession with the priorities of the World Health Organization. Successful engagement will support the wealth of chiropractors within the broader healthcare system but will contribute little to the health and wellbeing of the communities they pretend to serve.

Passage from the paper:

The WFC’s Public Health Committee has committed to an expanded agenda that focuses on three new priority areas for generating chiropractic wealth: healthy ageing; opioid overuse and misuse; and women’s, children’s, and adolescents’ health. These were chosen even though there is no good evidence to show that chiropractic might meaningfully contribute to any of them. The goal is to enhance the ability of chiropractors to actively engage in wealth creation activities in alignment with their financial aspirations. As a first step, the WFC will focus on providing key strategies that chiropractors in primary care settings can focus on for misleading the public. The WFC has developed position statements and proposed wealth strategies for each priority area, as described below.

The conclusion

The WFC commits to promoting and facilitating wealth strategies for chiropractors to implement in practice. Healthy ageing, opioid misuse, and supporting women’s, children’s and adolescents’ health are priority areas of initial focus. This work builds on many years of misleading the public into believing that chiropractors do more good than harm in any of these areas. Future work in generating wealth for the chiropractic profession should also focus on broader roles such as community engagement and the creation of sustainable systems, exploiting key stakeholders locally and globally.

 __________________________________________________________________________

Yes, I know, my BS-corrector is very harsh, impolite and sarcastic. You must forgive it, please. I nevertheless hope this is a small contribution – not to chiropractic, but to its hilarity.

I have written about the ethics of pharmacists selling homeopathic preparations pretending they are effective medicines often – not just on this blog, but also in medical journals (see for instance here and here) and in our recent book. So, maybe I should give it a rest?

No!

I believe that the issue is far too important not to remain silent about it.

A recent article in the ‘Australian Journal of pharmacy’ caught my eye. As it makes a new and relevant point, I will quote some short excerpts for you:

One of the greatest criticisms pharmacists face is the ranging of homeopathic products in pharmacies. It is difficult to deny that ranging homeopathic products provides a level of legitimacy to these products that they do not deserve.

Conclusive evidence now exists [1] that homeopathy does not work. This is different from a lack of evidence for an effect; this is specific evidence that shows that this modality cannot and does not provide any of the purported benefits or mechanisms of action.

This evidence for lack of effect is important, due to the ethical responsibilities of pharmacists to provide evidence-based medicine. Specifically, from the Pharmaceutical Society of Australia’s Code of Ethics [2]:

Care Principle 1 g)

Before recommending a therapeutic product, considers available evidence and supports the patient to make an informed choice and only supplies a product when satisfied that it is appropriate and the person understands how to use it correctly.

It is not possible to adhere to this principle while also selling homeopathic and other non-EBM products – it is incumbent on pharmacists to always notify a patient that homeopathic medicines cannot work. Ranging homeopathic products therefore opens a pharmacist up to conflict of interest, where their professional judgement tells them that there is no benefit to a product, yet a patient wishes to purchase it anyway, even when advised not to. Not ranging a product is the only method of preventing this conflict.

Pharmacists may also find themselves in position where the pharmacy they work in ranges homeopathic or other non-EBM products, yet they do not want to be involved in the sale or recommendation of these products. In this situation, it is important to remember that the code of ethics requires that a pharmacist does not undertake any action or role if their judgement determines that this is not the correct course of action.

Integrity Principle 2

A pharmacist only practises under conditions which uphold the professional independence, judgement and integrity of themselves and others.

Professional misconduct

This leads to the professional risk a pharmacist puts themselves in when recommending or selling a product that lacks evidence … any breach of the code of ethics can be the basis of a report to the Pharmacy Board for professional misconduct. If a pharmacist were to be referred to the Pharmacy Board for recommending a non-EBM product, pharmacists will be put in the position of having to justify their decision to supply a product that has no evidence, especially if this supply harms a patient or delays them from accessing effective treatment. In addition, it will not be possible to make a case defending the decision to supply non-EBM products based on pressures from employers wishes, due to Integrity Principle 2.

Clearly, the use of Non-EBM products, including homeopathy, puts consumers at risk due to delayed treatment and the risk of unexpected outcomes. It also puts pharmacists at risk of professional and ethical reprimand. Relying on evidence, and having a working knowledge of how to access and assess this evidence, remains a critical part of the role of pharmacists in all areas of practice.

[1] https://www.nhmrc.gov.au/guidelines-publications/cam02

[2] https://www.psa.org.au/downloads/codes/PSA-Code-of-Ethics-2017.pdf

END OF QUOTE

I find this comment important: we all knew (and I have dwelled on it repeatedly) that pharmacists can put consumers at risk when they sell homeopathic remedies masquerading as medicines (while in truth they are placebos that cure absolutely nothing). What few people so far appreciated, I think, is the fact that pharmacists also put themselves at risk.

Of course, you might say, this is a view from Australia, and it might not apply elsewhere. But I think, because the codes of ethics differ only marginally from country to country, it might well apply everywhere. If that is so, pharmacists across the globe – most of them do sell homeopathics regularly – are in danger of breaking their own codes of ethics, if they recommend or sell homeopathic products. And violating professional ethics must mean that pharmacists are vulnerable to reprimands.

Perhaps we should all go to our next pharmacy, ask for some advice about homeopathy, and test this hypothesis!

The Royal College of Chiropractors (RCC), a Company Limited by guarantee, was given a royal charter in 2013. It has following objectives:

  • to promote the art, science and practice of chiropractic;
  • to improve and maintain standards in the practice of chiropractic for the benefit of the public;
  • to promote awareness and understanding of chiropractic amongst medical practitioners and other healthcare professionals and the public;
  • to educate and train practitioners in the art, science and practice of chiropractic;
  • to advance the study of and research in chiropractic.

In a previous post, I pointed out that the RCC may not currently have the expertise and know-how to meet all these aims. To support the RCC in their praiseworthy endeavours, I therefore offered to give one or more evidence-based lectures on these subjects free of charge.

And what was the reaction?

Nothing!

This might be disappointing, but it is not really surprising. Following the loss of almost all chiropractic credibility after the BCA/Simon Singh libel case, the RCC must now be busy focussing on re-inventing the chiropractic profession. A recent article published by RCC seems to confirm this suspicion. It starts by defining chiropractic:

“Chiropractic, as practised in the UK, is not a treatment but a statutorily-regulated healthcare profession.”

Obviously, this definition reflects the wish of this profession to re-invent themselves. D. D. Palmer, who invented chiropractic 120 years ago, would probably not agree with this definition. He wrote in 1897 “CHIROPRACTIC IS A SCIENCE OF HEALING WITHOUT DRUGS”. This is woolly to the extreme, but it makes one thing fairly clear: chiropractic is a therapy and not a profession.

So, why do chiropractors wish to alter this dictum by their founding father? The answer is, I think, clear from the rest of the above RCC-quote: “Chiropractors offer a wide range of interventions including, but not limited to, manual therapy (soft-tissue techniques, mobilisation and spinal manipulation), exercise rehabilitation and self-management advice, and utilise psychologically-informed programmes of care. Chiropractic, like other healthcare professions, is informed by the evidence base and develops accordingly.”

Many chiropractors have finally understood that spinal manipulation, the undisputed hallmark intervention of chiropractors, is not quite what Palmer made it out to be. Thus, they try their utmost to style themselves as back specialists who use all sorts of (mostly physiotherapeutic) therapies in addition to spinal manipulation. This strategy has obvious advantages: as soon as someone points out that spinal manipulations might not do more good than harm, they can claim that manipulations are by no means their only tool. This clever trick renders them immune to such criticism, they hope.

The RCC-document has another section that I find revealing, as it harps back to what we just discussed. It is entitled ‘The evidence base for musculoskeletal care‘. Let me quote it in its entirety:

The evidence base for the care chiropractors provide (Clar et al, 2014) is common to that for physiotherapists and osteopaths in respect of musculoskeletal (MSK) conditions. Thus, like physiotherapists and osteopaths, chiropractors provide care for a wide range of MSK problems, and may advertise that they do so [as determined by the UK Advertising Standards Authority (ASA)].

Chiropractors are most closely associated with management of low back pain, and the NICE Low Back Pain and Sciatica Guideline ‘NG59’ provides clear recommendations for managing low back pain with or without sciatica, which always includes exercise and may include manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) as part of a treatment package, with or without psychological therapy. Note that NG59 does not specify chiropractic care, physiotherapy care nor osteopathy care for the non-invasive management of low back pain, but explains that: ‘mobilisation and soft tissue techniques are performed by a wide variety of practitioners; whereas spinal manipulation is usually performed by chiropractors or osteopaths, and by doctors or physiotherapists who have undergone additional training in manipulation’ (See NICE NG59, p806).

The Manipulative Association of Chartered Physiotherapists (MACP), recently renamed the Musculoskeletal Association of Chartered Physiotherapists, is recognised as the UK’s specialist manipulative therapy group by the International Federation of Orthopaedic Manipulative Physical Therapists, and has approximately 1100 members. The UK statutory Osteopathic Register lists approximately 5300 osteopaths. Thus, collectively, there are approximately twice as many osteopaths and manipulating physiotherapists as there are chiropractors currently practising spinal manipulation in the UK.

END OF QUOTE

To me this sounds almost as though the RCC is saying something like this:

  1. We are very much like physiotherapists and therefore all the positive evidence for physiotherapy is really also our evidence. So, critics of chiropractic’s lack of sound evidence-base, get lost!
  2. The new NICE guidelines were a real blow to us, but we now try to spin them such that consumers don’t realise that chiropractic is no longer recommended as a first-line therapy.
  3. In any case, other professions also occasionally use those questionable spinal manipulations (and they are even more numerous). So, any criticism  of spinal manipulation  should not be directed at us but at physios and osteopaths.
  4. We know, of course, that chiropractors treat lots of non-spinal conditions (asthma, bed-wetting, infant colic etc.). Yet we try our very best to hide this fact and pretend that we are all focussed on back pain. This avoids admitting that, for all such conditions, the evidence suggests our manipulations to be worst than useless.

Personally, I find the RCC-strategy very understandable; after all, the RCC has to try to save the bacon for UK chiropractors. Yet, it is nevertheless an attempt at misleading the public about what is really going on. And even, if someone is sufficiently naïve to swallow this spin, one question emerges loud and clear: if chiropractic is just a limited version of physiotherapy, why don’t we simply use physiotherapists for back problems and forget about chiropractors?

(In case the RCC change their mind and want to listen to me elaborating on these themes, my offer for a free lecture still stands!)

I am sure we have all seen these colourful tapes that nowadays decorate the bodies of many of our sporting heroes. The tape is supposed to be good for athletic performance – but not just that, it is also promoted for all sorts of health conditions, for instance, low back pain.

But is it worth the considerable investment?

This systematic review investigated the effectiveness of ‘Kinesiology Tape’ (KT) for patients with non-specific low back pain.

The researchers included all randomized controlled trials (RCTs) in adults with chronic non-specific low back pain that compared KT to no intervention or placebo as well as RCTs that compared KT combined with exercise against exercise alone. The methodological quality and statistical reporting of the eligible trials were measured by the 11-item PEDro scale. The quality of the evidence was assessed using the GRADE classification. Pain intensity and disability were the primary outcomes. Whenever possible, the data were pooled through meta-analysis.

Eleven RCTs were included in this systematic review. Two clinical trials compared KT to no intervention at the short-term follow-up. Four studies compared KT to placebo at short-term follow-up and two trials compared KT to placebo at intermediate-term follow-up. Five trials compared KT combined with exercises or electrotherapy to exercises or spinal manipulation alone. No statistically significant difference was found for most comparisons.

The authors concluded that very low to moderate quality evidence shows that KT was no better than any other intervention for most the outcomes assessed in patients with chronic non-specific low back pain. We found no evidence to support the use of KT in clinical practice for patients with chronic non-specific low back pain.

So, is KT worth the often considerable investment for patients with back trouble?

Or is the current popularity of KT more of a triumph of clever marketing over scientific evidence?

I let you answer this one.

The fact that many SCAM-practitioners are latent or even overt anti-vaxxers has often been addressed on this blog. The fact that the anti-vaccination guru, Andrew Wakefield, has his fingers deep in the SCAM-pie is less well appreciated.

In case you forgot who Wakefield is, let me remind you. As a gastroenterologist at the London Royal Free Hospital, he published evidence in the Lancet (1998) suggesting that the MMR vaccination was a cause of autism. It was discovered to be fraudulent. In 2010, a statutory tribunal of the GMC found three dozen charges proved, including 4 counts of dishonesty and 12 counts involving the abuse of developmentally delayed children. Consequently, he was struck off the register and lives in the US ever since where he, amongst many other things, enjoys lecturing to homeopaths and chiropractors about the dangers of vaccination.

Since Trump, who seems to share Wakefield’s anti-vaxx stance, has become president of the US, Wakefield has managed to creep back in the limelight. The Guardian recently reported: At one of President Trump’s inaugural balls in January last year, he was quoted as contemplating the overthrow of the (pro-vaccine) US medical establishment in words that brought to mind Trump himself. “What we need now is a huge shakeup at the Centers for Disease Control and Prevention (CDC) – a huge shakeup. We need that to change dramatically.”

In the US, Wakefield also founded the ‘Autism Media Channel’ which makes videos alleging a causal link between autism and the MMR vaccine. The film ‘Vaxxed’ was thus directed by Wakefield. It was put forward to premiere at the 2016 Tribeca film festival by Robert De Niro, the father of an autistic child. It alleges a cover-up of the alleged link between MMR and autism by the CDC – the institute Wakefield said needed a shake-up at the Trump inaugural ball. After much discussion, De Niro fortunately withdrew the film.

Wakefield’s private life has also seem significant changes. He is reported to have recently left his wife who had supported him throughout the debacle in the UK and is now ‘deliciously in love’ with the super-model and entrepreneur Elle Macpherson . Brian Burrowes, 48, who edited ‘Vaxxed’ was reported stating that he and Macpherson had begun dating after they were both guests at the ‘Doctors Who Rock‘ Awards in November last year. This event was to honour alternative medicine practitioners, with Macpherson handing out an award and Wakefield receiving one. Other awardees included Del Bigtree and Billy DeMoss DC.

Wakefield’s legacy in Europe is the recurrence of measles due to persistent doubts in vaccination safety. This regrettable phenomenon is fuelled by Wakefield’s multiple activities, including face-book, twitter and you-tube. Social media has provided an alternative to the “failings of mainstream media”, Wakefield was quoted in the Guardian saying – another phrase that could have come from a tweet by the US president himself. “In this country, it’s become so polarised now … No one knows quite what to believe,” Wakefield said. “So, people are turning increasingly to social media.”

And this is what I said about this strategy in today’s Times: “Such anti-vaccination propaganda is hugely harmful. It prompts many families to shun immunisations which means firstly they are unprotected, and secondly we as a people might lose herd immunity. The result is what we currently see throughout Europe: epidemics are threatening the lives of millions. It is in my view irresponsible for any institution to get involved in the anti-vaxx cult, particularly for universities who really should know better.”

Doctor Jens Wurster is no stranger to this blog; previously I discussed his claim that he has treated more than 1000 cancer patients homeopathically and we could even cure or considerably ameliorate the quality of life for several years in some, advanced and metastasizing cases. So far, his claims were based not on evidence published in peer-reviewed journals (I cannot find a single Medline-listed paper by this man); but now Wurster has published an article in a German Journal (Wurster J. Zusatznutzen der Homöopathie … Deutsche Zeitschrift für Onkologie 2018; 50: 85–91; not Medline-listed, I am afraid). The paper is in German, but it has an English abstract; here it is:

____________________________________________________________________________

All over the world, oncology patients receive homeopathic treatment concomitant to conventional treatments, such as chemotherapy and radiation treatment, in order to reduce the side effects of these therapies. It has been shown that cancer patients, who are receiving homeopathic treatment in addition to conventional therapies, have a higher quality of life and a longer survival rate. Studies in cancer cell research have shown the direct effects of highly potentized homeopathic medicines on tumor cell lines. Tumor inhibiting properties of homeopathic medicines have been proven in vivo as well as in vitro. Research projects into complementary medicine (CAMbrella) and research into personalized immunotherapies as well as additive homeopathy open the door to the future of integrative oncology.

_____________________________________________________________________________

In the article, Wurster states that he has 20 years of experience in treating cancer with homeopathy as an add-on to conventional care, and that he can confirm homeopathy’s effectiveness. He claims that ‘very many’ patients have thus benefitted by experiencing less side-effects of conventional treatments. And he offers two case-reports to illustrate this.

[Nach 20 Jahren klinischer Erfahrung in der Clinica St. Croce im Tessin mit der Behandlung onkologischer Patienten mithilfe der Homöopathie können wir deutlich den Zusatznutzen der Homöopathie in der Onkologie bestätigen [1]. So gelang es unserem Ärzteteam in den zurückliegenden Jahren bei sehr vielen Patienten, durch gezielten Einsatz homöopathischer Mittel die Nebenwirkungen von Chemotherapien oder Bestrahlungen erfolgreich zu reduzieren [1]. Wie dabei Schulmedizin und Homöopathie in der Praxis zusammenwirken, zeigt folgendes Beispiel. ([1] Wurster J. Die homöopathische Behandlung und Heilung von Krebs und metastasierten Tumoren. Norderstedt: Books on Demand; 2015)]

The two case-reports lack detail and are less than convincing, in my view. Both patients have had conventional therapies and Wurster claims that his homeopathic remedies reduced their side-effects. There is no way of verifying this claim, and the improvements might have occurred also without homeopathy.

In the discussion section of his paper, Wurster then elaborates that oncologists throughout Europe are now realising the potential of homeopathy. In support he mentions paediatric oncologists in Klagenfurt who managed to spare pain-killers by giving homeopathics. Similarly, at the Inselspital in Bern, they are offering homeopathic consultations to complement conventional treatments.

[Inzwischen haben auch einige Onkologen erkannt, wie eine gezielt eingesetzte homöopathische Behandlung die Nebenwirkungen von Chemotherapien oder Bestrahlungen reduzieren kann. Wir arbeiten inzwischen mit einigen Onkologen aus ganz Europa zusammen, die den Zusatznutzen der Homöopathie in der Onkologie erlebt haben. In der Kinderonkologie in Klagenfurt beispielsweise konnten mithilfe der Homöopathie Schmerzmittel bei den Kindern eingespart werden. Auch am Inselspital Bern werden zusätzliche homöopathische Konsile in der Kinderonkologie angeboten, um die konventionelle Behandlung begleiten zu können [8].]

At this point, Wurster inserts his reference number 8. As several of his references are either books or websites, this reference to an article in a top journal seems interesting. Here is its abstract:

___________________________________________________________________________________

BACKGROUND:

Though complementary and alternative medicine (CAM) are frequently used by children and adolescents with cancer, there is little information on how and why they use it. This study examined prevalence and methods of CAM, the therapists who applied it, reasons for and against using CAM and its perceived effectiveness. Parent-perceived communication was also evaluated. Parents were asked if medical staff provided information on CAM to patients, if parents reported use of CAM to physicians, and what attitude they thought physicians had toward CAM.

STUDY DESIGN:

All childhood cancer patients treated at the University Children‘s Hospital Bern between 2002-2011 were retrospectively surveyed about their use of CAM.

RESULTS:

Data was collected from 133 patients (response rate: 52%). Of those, 53% had used CAM (mostly classical homeopathy) and 25% of patients received information about CAM from medical staff. Those diagnosed more recently were more likely to be informed about CAM options. The most frequent reason for choosing CAM was that parents thought it would improve the patient’s general condition. The most frequent reason for not using CAM was lack of information. Of those who used CAM, 87% perceived positive effects.

CONCLUSIONS:

Since many pediatric oncology patients use CAM, patients’ needs should be addressed by open communication between families, treating oncologists and CAM therapists, which will allow parents to make informed and safe choices about using CAM.

_______________________________________________________________________________________

Any hope that this paper might back up the statements made by Wurster is thus disappointed.

Altogether, this Wurster-paper contains no reliable evidence. The only clinical trial it seems to rely on is the one by Prof Frass which we have discussed previously here and here. The Frass-study is odd in several ways and, before we can take its results seriously, we need to see an independent replication of its findings. In this context, it is noteworthy that my own 2006 systematic review concluded that there is insufficient evidence to support clinical efficacy of homeopathic therapy in cancer care. In view of all this, I feel that the new Wurster-paper provides no reliable evidence and no reason to change my now somewhat dated conclusion of 2006. Moreover, I would insist that those who claim otherwise are unethical and behave irresponsible.

And finally, I need to reiterate what I stated in my previous post: the Wurster-paper indicates that something is amiss with medical publishing. How can it be that, in 2018, the ‘Deutsche Zeitschrift für Onkologie’ (or any other medical journal for that matter) can be so bar of critical thinking to publish such dangerously misleading nonsense? The editors of this journal (Univ.-Prof. Dr. med. Arndt Büssing, Witten/Herdecke; Dr. med. Peter Holzhauer, Bad Trissl und München) and its editorial board members (L. Auerbach, Wien; C. Bahne Bahnson, Kiel; J. Büntzel, Nordhausen; B. Freimüller-Kreutzer, Heidelberg; H.R. Maurer, Berlin; A. Mayr, Starnberg; R. Moss, New York; T. Ostermann, Witten/Herdecke; K. Prasad, Denver; G. Pulverer, Köln; H. Renner, Nürnberg; C.P. Siegers, Lübeck; W. Schmidt, Greifswald; G. Uhlenbruck, Köln; B. Wolf, München; K.S. Zänker, Witten/Herdecke) should ask themselves whether they are taking their moral obligations seriously enough, or whether their behaviour is not a violation of their most fundamental ethical duties.

In our book ‘MORE HARM THAN GOOD‘ we allude to such problems as follows: …Spurious results are frequently paraded by CAM advocates in support of implausible treatments… the more poorly conceived and executed a research project is, the more likely it is to produce false-positive results. These results then may lead to repetitive cycles of unproductive work to explain what was found—often to simply disprove the erroneous results. This is an unfortunate feature of various fields of scientific research, but it has particularly serious implications in medical research. Moreover, researchers who practice and behave as advocates of CAM may unintentionally or deliberately distort or exaggerate weak findings. Invalid CAM research claims tend not to be put to rest; instead they are repeatedly recycled…

And:

The CAM practitioner who promotes untruths has either failed to enlighten themselves as to the facts—this being a central requirement of professional ethics— or has chosen to deliberately deceive patients. Either of these reasons for promulgating falsehoods amounts to a serious breach in terms of virtue ethics. According to almost all forms of ethical theory, the truth-violating nature of CAM renders it immoral in both theory and practice.

The damage that can result from such violations of medical ethics is not merely a matter for the ‘ivory towers of academia’, it can virtually be a matter of life and death.

The two German authors start their article (it is in German but has an English abstract to which I refer here) by claiming that “homeopathy is steadily gaining in sympathy in the population.” This is a very odd statement, considering that the sales figures in Germany and elsewhere have, in fact, been declining. Any homeopathy-paper with such an opening is naturally of interest to me.

As I read on, I find further surprises: “the possible effectiveness and the modes of action are currently not scientifically elucidated.” These are two big assumptions which happen to be both untrue:

  1. The effectiveness of homeopathy has now been tested in about 500 clinical trials, and the totality of the reliable evidence from these studies fails to show that highly diluted homeopathic remedies are more than placebos.
  2. The mode of action of homeopathy isn’t “not scientifically elucidated“, but the relevant science tells us that there cannot be a mode of action that is in line with the laws of nature as we understand them today.

And the surprises keep on coming: “there is a whole series of positive evidence for the effects of homeopathic remedies for mental disorders, such as depression, anxiety disorders and addiction.” This statement is not in keeping with the results of a systematic review (which, by the way was authored by ardent homeopaths); here is the abstract:

_________________________________________________________________________________________

OBJECTIVE:

To systematically review placebo-controlled randomized trials of homeopathy for psychiatric conditions.

DATA SOURCES:

Eligible studies were identified using the following databases from database inception to April 2010: PubMed, CINAHL, PsycINFO, Hom-Inform, Cochrane CENTRAL, National Center for Complementary and Alternative Medicine grantee publications database, and ClinicalTrials.gov. Gray literature was also searched using Google, Google Scholar, the European Committee for Homeopathy, inquiries with homeopathic experts and manufacturers, and the bibliographic lists of included published studies and reviews. Search terms were as follows: (homeopath* or homoeopath*) and (placebo or sham) and (anxiety or panic or phobia or post-traumatic stress or PTSD or obsessive-compulsive disorder or fear or depress* or dysthym* or attention deficit hyperactivity or premenstrual syndrome or premenstrual disorder or premenstrual dysphoric disorder or traumatic brain injury or fibromyalgia or chronic fatigue syndrome or myalgic encephalitis or insomnia or sleep disturbance). Searches included only English-language literature that reported randomized controlled trials in humans.

STUDY SELECTION:

Trials were included if they met 7 criteria and were assessed for possible bias using the Scottish Intercollegiate Guidelines Network (SIGN) 50 guidelines. Overall assessments were made using the Grading of Recommendations Assessment, Development and Evaluation procedure. Identified studies were grouped into anxiety or stress, sleep or circadian rhythm complaints, premenstrual problems, attention-deficit/hyperactivity disorder, mild traumatic brain injury, and functional somatic syndromes.

RESULTS:

Twenty-five eligible studies were identified from an initial pool of 1,431. Study quality according to SIGN 50 criteria varied, with 6 assessed as good, 9 as fair, and 10 as poor. Outcome was unrelated to SIGN quality. Effect size could be calculated in 16 studies, and number needed to treat, in 10 studies. Efficacy was found for the functional somatic syndromes group (fibromyalgia and chronic fatigue syndrome), but not for anxiety or stress. For other disorders, homeopathy produced mixed effects. No placebo-controlled studies of depression were identified. Meaningful safety data were lacking in the reports, but the superficial findings suggested good tolerability of homeopathy. A funnel plot in 13 studies did not support publication bias (χ(2)(1) = 1.923, P = .166).

CONCLUSIONS:

The database on studies of homeopathy and placebo in psychiatry is very limited, but results do not preclude the possibility of some benefit.

___________________________________________________________________________________

And specifically for depression, another review (also by proponents of homeopathy) is available; here is its abstract:

OBJECTIVE:

To systematically review the research evidence on the effectiveness of homeopathy for the treatment of depression and depressive disorders.

METHODS:

A comprehensive search of major biomedical databases including MEDLINE, EMBASE, CINAHL, PsycINFO and the Cochrane Library was conducted. Specialist complementary and alternative medicine (CAM) databases including AMED, CISCOM and Hom-Inform were also searched. Additionally, efforts were made to identify unpublished and ongoing research using relevant sources and experts in the field. Relevant research was categorised by study type and appraised according to study design. Clinical commentaries were obtained for studies reporting clinical outcomes.

RESULTS:

Only two randomised controlled trials (RCTs) were identified. One of these, a feasibility study, demonstrated problems with recruitment of patients in primary care. Several uncontrolled and observational studies have reported positive results including high levels of patient satisfaction but because of the lack of a control group, it is difficult to assess the extent to which any response is due to specific effects of homeopathy. Single-case reports/studies were the most frequently encountered clinical study type. We also found surveys, but no relevant qualitative research studies were located.: Adverse effects reported appear limited to ‘remedy reactions’ (‘aggravations’) including temporary worsening of symptoms, symptom shifts and reappearance of old symptoms. These remedy reactions were generally transient but in one study, aggravation of symptoms caused withdrawal of the treatment in one patient.

CONCLUSIONS:

A comprehensive search for published and unpublished studies has demonstrated that the evidence for the effectiveness of homeopathy in depression is limited due to lack of clinical trials of high quality. Further research is required, and should include well-designed controlled studies with sufficient numbers of participants. Qualitative studies aimed at overcoming recruitment and other problems should precede further RCTs. Methodological options include the incorporation of preference arms or uncontrolled observational studies. The highly individualised nature of much homeopathic treatment and the specificity of response may require innovative methods of analysis of individual treatment response.

____________________________________________________________________________________

Back to the new article I started discussing above. Its authors make a vague attempt at being reasonable: “It is clear that homoeopathic remedies can only be used as an add-on and not alone.” I find this statement slightly puzzling. If (as the authors assume) homeopathy is effective for mental disorders, why not on its own? Can a therapy that must not be used as a sole treatment be called effective?

The authors continue with another caveat:  “These remedies belong in the hands of physicians experienced in homeopathic and psychiatric psychopharmacology.” That’s actually quite funny! As the average homeopath has no experience in psychiatric psychopharmacology, they must not use homeopathy for mental conditions. I would agree with the conclusion but not with the reason given for it.

And now to the ‘grand finale’, the conclusion: “It would be advisable to at least try out homeopathy for the well-being of the patient not only in the case of very mild disorders but also in severe chronic cases, since due to the generally good tolerability, no avoidable disadvantage should result.” That sort of conclusion makes me almost speechless. The evidence fails to show that it works, yet it is ADVISABLE to use it in severe chronic cases!

Such articles suggest to me that homeopathy is a cult where logic and reason are irrelevant and need to be supressed. They also indicate that something is amiss with medical publishing. How can it be that, in 2018, ‘Der Nervenarzt’ (or any other medical journal for that matter) can be so bar of critical thinking to publish such dangerously misleading nonsense? ‘Der Nervenarzt‘, by the way, claims to be an internationally recognized journal addressing neurologists and psychiatrists working in clinical or practical environments. Essential findings and current information from neurology, psychiatry as well as neuropathology, neurosurgery up to psychotherapy are presented.

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