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

evidence

The only time we discussed gua sha, it led to one of the most prolonged discussions we ever had on this blog (536 comments so far). It seems to be a topic that excites many. But what precisely is it?

Gua sha, sometimes referred to as “scraping”, “spooning” or “coining”, is a traditional Chinese treatment that has spread to several other Asian countries. It has long been popular in Vietnam and is now also becoming well-known in the West. The treatment consists of scraping the skin with a smooth edge placed against the pre-oiled skin surface, pressed down firmly, and then moved downwards along muscles or meridians. According to its proponents, gua sha stimulates the flow of the vital energy ‘chi’ and releases unhealthy bodily matter from blood stasis within sore, tired, stiff or injured muscle areas.

The technique is practised by TCM practitioners, acupuncturists, massage therapists, physical therapists, physicians and nurses. Practitioners claim that it stimulates blood flow to the treated areas, thus promoting cell metabolism, regeneration and healing. They also assume that it has anti-inflammatory effects and stimulates the immune system.

These effects are said to last for days or weeks after a single treatment. The treatment causes microvascular injuries which are visible as subcutaneous bleeding and redness. Gua sha practitioners make far-reaching therapeutic claims, including that the therapy alleviates pain, prevents infections, treats asthma, detoxifies the body, cures liver problems, reduces stress, and contributes to overall health.

Gua sha is mildly painful, almost invariably leads to unsightly blemishes on the skin which occasionally can become infected and might even be mistaken for physical abuse.

There is little research of gua sha, and the few trials that exist tend to be published in Chinese. But recently, a new paper has emerged that is written in English. The goal of this systematic review was to evaluate the available evidence from randomized controlled trials (RCTs) of gua sha for the treatment of patients with perimenopausal syndrome.

A total of 6 RCTs met the inclusion criteria. Most were of low methodological quality. When compared with Western medicine therapy alone, meta-analysis of 5 RCTs indicated favorable statistically significant effects of gua sha plus Western medicine. Moreover, study participants who received Gua Sha therapy plus Western medicine therapy showed significantly greater improvements in serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH) compared to participants in the Western medicine therapy group.

The authors concluded that preliminary evidence supported the hypothesis that Gua Sha therapy effectively improved the treatment efficacy in patients with perimenopausal syndrome. Additional studies will be required to elucidate optimal frequency and dosage of Gua Sha.

This sounds as though gua sha is a reasonable therapy.

Yet, I think this notion is worth being critically analysed. Here are some caveats that spring into my mind:

  • Gua sha lacks biological plausibility.
  • The reviewed trials are too flawed to allow any firm conclusions.
  • As most are published in Chinese, non-Chinese speakers have no possibility to evaluate them.
  • The studies originate from China where close to 100% of TCM trials report positive results.
  • In my view, this means they are less than trustworthy.
  • The authors of the above-cited review are all from China and might not be willing, able or allowed to publish a critical paper on this subject.
  • The review was published in , a journal not known for its high scientific standards or critical stance towards TCM.

So, is gua sha a reasonable therapy?

I let you make this judgement.

Is homeopathy effective for specific conditions? The FACULTY OF HOMEOPATHY (FoH, the professional organisation of UK doctor homeopaths) say YES. In support of this bold statement, they cite a total of 35 systematic reviews of homeopathy with a focus on specific clinical areas. “Nine of these 35 reviews presented conclusions that were positive for homeopathy”, they claim. Here they are:

Allergies and upper respiratory tract infections 8,9
Childhood diarrhoea 10
Post-operative ileus 11
Rheumatic diseases 12
Seasonal allergic rhinitis (hay fever) 13–15
Vertigo 16

And here are the references (I took the liberty of adding my comments in blod):

8. Bornhöft G, Wolf U, Ammon K, et al. Effectiveness, safety and cost-effectiveness of homeopathy in general practice – summarized health technology assessment. Forschende Komplementärmedizin, 2006; 13 Suppl 2: 19–29.

This is the infamous ‘Swiss report‘ which, nowadays, only homeopaths take seriously.

9. Bellavite P, Ortolani R, Pontarollo F, et al. Immunology and homeopathy. 4. Clinical studies – Part 1. Evidence-based Complementary and Alternative Medicine: eCAM, 2006; 3: 293–301.

This is not a systematic review as it lacks any critical assessment of the primary data and includes observational studies and even case series.

10. Jacobs J, Jonas WB, Jimenez-Perez M, Crothers D. Homeopathy for childhood diarrhea: combined results and metaanalysis from three randomized, controlled clinical trials. Pediatric Infectious Disease Journal, 2003; 22: 229–234.

This is a meta-analysis by Jennifer Jacobs (who recently featured on this blog) of 3 studies by Jennifer Jacobs; hardly convincing I’d say.

11. Barnes J, Resch K-L, Ernst E. Homeopathy for postoperative ileus? A meta-analysis. Journal of Clinical Gastroenterology, 1997; 25: 628–633.

This is my own paper! It concluded that “several caveats preclude a definitive judgment.”

12. Jonas WB, Linde K, Ramirez G. Homeopathy and rheumatic disease. Rheumatic Disease Clinics of North America, 2000; 26: 117–123.

This is not a systematic review; here is the (unabridged) abstract:

Despite a growing interest in uncovering the basic mechanisms of arthritis, medical treatment remains symptomatic. Current medical treatments do not consistently halt the long-term progression of these diseases, and surgery may still be needed to restore mechanical function in large joints. Patients with rheumatic syndromes often seek alternative therapies, with homeopathy being one of the most frequent. Homeopathy is one of the most frequently used complementary therapies worldwide.

Proper systematic reviews fail to show that homeopathy is an effective treatment for rheumatic conditions (see for instance here and here).

13. Wiesenauer M, Lüdtke R. A meta-analysis of the homeopathic treatment of pollinosis with Galphimia glauca. Forschende Komplementärmedizin und Klassische Naturheilkunde, 1996; 3: 230–236.

This is a meta-analysis by Wiesenauer of trials conducted by Wiesenauer.

My own, more recent analysis of these data arrived at a considerably less favourable conclusion: “… three of the four currently available placebo-controlled RCTs of homeopathic Galphimia glauca (GG) suggest this therapy is an effective symptomatic treatment for hay fever. There are, however, important caveats. Most essentially, independent replication would be required before GG can be considered for the routine treatment of hay fever. (Focus on Alternative and Complementary Therapies September 2011 16(3))

14. Taylor MA, Reilly D, Llewellyn-Jones RH, et al. Randomised controlled trials of homoeopathy versus placebo in perennial allergic rhinitis with overview of four trial series. British Medical Journal, 2000; 321: 471–476.

This is a meta-analysis by David Reilly of 4 RCTs which were all conducted by David Reilly. This attracted heavy criticism; see here and here, for instance.

15. Bellavite P, Ortolani R, Pontarollo F, et al. Immunology and homeopathy. 4. Clinical studies – Part 2. Evidence-based Complementary and Alternative Medicine: eCAM, 2006; 3: 397–409.

This is not a systematic review as it lacks any critical assessment of the primary data and includes observational studies and even case series.

16. Schneider B, Klein P, Weiser M. Treatment of vertigo with a homeopathic complex remedy compared with usual treatments: a meta-analysis of clinical trials. Arzneimittelforschung, 2005; 55: 23–29.

This is a meta-analysis of 2 (!) RCTs and 2 observational studies of ‘Vertigoheel’, a preparation which is not a homeopathic but a homotoxicologic remedy (it does not follow the ‘like cures like’ assumption of homeopathy) . Moreover, this product contains pharmacologically active substances (and nobody doubts that active substances can have effects).

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So, positive evidence from 9 systematic reviews in 6 specific clinical areas?

I let you answer this question.

The ‘Pharmaceutical Journal’ just published a ‘pro/contra’ piece discussing whether UK community pharmacists should be selling homeopathic remedies to the public. Here are the essential parts of both arguments:

PRO

… I do not believe there is good scientific evidence to validate homeopathic remedies as medicines, but it is important to provide patients with choice in an informed environment — pharmacists and pharmacy teams are able to provide this expertise.

It is better for the public to buy these products from a reputable source where the community pharmacist — the expert on medicines — can provide professional advice, which is not available from unregulated online suppliers or other non-healthcare outlets…

So, I’m not here to argue the science: I argue that some people can benefit from homeopathy.

We ought to explore homeopathy’s placebo effect. Placebos are often dismissed as fakes, but they seem to act on the same brain pathways that are targeted by ‘real’ treatments. I wonder whether, through the placebo effect, homeopathy has a role to play in mental health treatment and pain relief. Whether for anxiety, mild-to-moderate depression, sleeplessness or stress, taking a little white tablet may benefit the patient, have fewer side effects than conventional medication, cause no harm, and is better than an excess of alcohol or illegal drugs.

Of course, homeopathy should not replace conventional medicines, and people should continue to be vaccinated, should use their inhalers and take their insulin. Homeopathy should not be funded on the NHS, but we do not live in a nanny state.

The clinical efficacy of many other products sold in the pharmacy is also questionable, but we still provide them. One example is guaifenesin for chesty coughs, which, at over-the-counter strength, provides a suboptimal dose. Many people are sceptical of the benefits of vitamin and mineral supplements. Bach flower remedies claim to tackle stress. We drink herbal tea for its ‘health’ benefits or buy fortified cereals because they are ‘better for you’, but these benefits are not clinically proven.

If the public finds comfort in a complementary therapy — whether it is acupuncture, reflexology, vitamins or homeopathy — I am happy to offer that choice, as long as the chosen therapies do no harm, and people continue to take their prescribed medicines.

If the patient wants my professional advice, I will explain that homeopathic medicines are not clinically proven but they may help certain conditions. I will probably recommend a different product, but at least I am there to do so.

You will not find a pharmacist in a health shop or on the internet, but in the community pharmacy you will find a highly qualified medicines expert, who will advise and inform, and who truly cares about the public’s health.

 

CONTRA

… given pharmacy’s heavy promotion of homeopathy, I feared that the profession was in danger of losing science as its bedrock.

… in 2009, a London-based pharmacy was supplying homeopathic ‘swine flu formula’. This was a dangerous practice but government agencies failed to regulate it effectively or to close it down.

In 2010, the then professional standards director at Boots, Paul Bennett (now chief executive, Royal Pharmaceutical Society), appeared before the Science and Technology Committee in its discussion of homeopathy’s availability on the NHS. Bennett stood by the sale of homeopathic remedies in Boots’ stores: “It is about consumer choice for us,” he said. I disagree with this argument.

Like the sale of cigarettes in US pharmacies, homeopathy threatens to fatally damage the reputation of community pharmacy. Pharmacies that sell homeopathic remedies give them unjustified credibility. Informed patient choice should be king; if pharmacists, pharmacy staff and shelf-barkers fail to clearly inform customers that homeopathic remedies are no more effective than placebo, we have acted unethically.

Yet Boots, perhaps alarmed by the number of subsequent protests against homeopathy outside its stores, got the message. Its website now reflects a more scientific approach: the homeopathic remedies it supplies state that they are “without approved therapeutic indications”. Boots also seems to have modified its range and offering of homeopathic remedies. So there is hope for community pharmacy.

Homeopathic remedies are still sold in pharmacies only because they make a profit. Sales in pharmacy are nonsense because, as most homeopathic practitioners claim, it is not possible to sell homeopathic remedies in isolation of a homeopathic consultation. The consultation determines the remedy. Off-the-shelf homeopathy is a relatively recent phenomenon.

The remedies are no more effective compared with placebo, anyway. Systematic reviews from the Cochrane Library — the gold standard of medical science — have considered homeopathy in the treatment of dementia, asthma and attention deficit hyperactivity disorder, all of which have confirmed the placebo effect. Irritatingly, supporters of homeopathy will always, in any debate, quote a bunkum study that shows some possible efficacy. Some might argue that placebo, or suggestion, is effective therapy, so why not use it? We must question the ethics of this approach.

Pharmacists act immorally when they sell the products without making clients aware that homeopathy does not work.

… I find that most pharmacists, when asked, appreciate that homeopathy has no scientific basis and provides merely a placebo effect. I sincerely hope that with this insight, pharmacy will finally clear its shelves of this expensive hocus pocus for good.

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I find both pieces quite weak and poorly argued. In fact, the ‘pro’ – arguments are quite laughable and could easily be used for teaching students the meaning and use of logical fallacies. In my view, all that needs to be pointed out here is this:

  1. Homeopathy is based on implausible assumptions.
  2. Despite 200 years of research and around 500 clinical trials, there is still no proof that highly diluted homeopathic remedies have effects beyond placebo.
  3. Therefore, selling them to the naïve public, while pretending they are real medicines, is dishonest, arguably fraudulent and certainly not the behaviour one would expect of a healthcare professional.
  4. Pharmacists who nevertheless sell these remedies as medicines are in breach of their very own regulations.

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Strangely enough, when trying to find the relevant passage from the code of ethics for UK pharmacists, I struggled. The General Pharmaceutical Council’s ‘Standards fro Pharmacy Professionals‘ merely states this:

People receive safe and effective care when pharmacy professionals reflect on the application of their knowledge and skills and keep them up-to-date, including using evidence in their decision making. A pharmacy professional’s knowledge and skills must develop over the course of their career to reflect the changing nature of healthcare, the population they provide care to and the roles they carry out. There are a number of ways to meet this standard and below are examples of the attitudes and behaviours expected.

People receive safe and effective care when pharmacy professionals:

  • recognise and work within the limits of their knowledge and skills, and refer to others when needed
  • use their skills and knowledge, including up-to-date evidence, to deliver care and improve the quality of care they provide
  • carry out a range of continuing professional development (CPD) activities relevant to their practice
  • record their development activities to demonstrate that their knowledge and skills are up to date
  • use a variety of methods to regularly monitor and reflect on their practice, skills and knowledge

This, I admit, is not as clear as I had hoped (if my memory serves me right, this used to be much more explicit; in case anyone knows of a more suitable section in the code of ethics, please let me know); but it does preclude selling placebos, while pretending they are effective medicines.

I have been alerted to this website; it is truly remarkable! Here is but one example, the section with advice on ‘reducing the risk of vaccine damage’:

START OF QUOTE

1. Give vitamin A before the measles vaccine (MMR).Vitamin A has been shown to reduce death in measles sufferers by 50% so will support the body in its dealing with the measles vaccine. The WHO is now giving out Vitamin A pills along with the vaccine! Consider high doses (5,000 IU or more) the day before, on the day and the day after vaccination.

2. Give increased vitamin C before and after all vaccines. Vitamin C is known to help eliminate heavy metals. Consider high doses (3,000-5,000 mg per day) the day before, day of, and day after.

3. Consider detox programs after vaccination. These include homeopathy (before and after each vaccination), supplements, especially vitamin C, probiotics etc. It can take up to a year to detox the system but it is worth the investment (Autistic children are usually highly toxic – See Treating Autism).

4. Reconsider the routine use of Calpol or similar before or after vaccination. A rise in body temperature is the immune systems healthy response to any attack. Suppressing this reaction will impair its’ ability to deal with the load imposed upon it by the vaccine. Links have been made with the use of Calpol etc after the MMR and autism because the body needs to raise a high temperature to deal with measles. Complications can arise if temperature is bought down too early in cases of measles. See ‘Dealing with Fever Naturally’ under the Health section of this site.

5. Avoid antibiotic use where possible.

Delay vaccines, especially the MMR, within up to 6 months of antibiotics.

The strength of the gut is compromised and the gut is 70% of the immune system. Autistic children often have Gut and Bowel disorders. Antibiotics during pregnancy & breast feeding can also compromise the child’s immune system.

Try not to use antibiotics, as there are links with increased asthma in the vaccinated and also with the overuse of antibiotics in children. Asthma kills 1,300 people a year in the UK and rates have doubled in the last 40 years. This is far higher than the mortality rates as a result of contracting contagious diseases before the vaccines! In the years leading up to the vaccination program between 30-50 people died of measles, for example. Nearly 200 children under 14 years now die of Asthma. Asthma UK puts this this condition down to lack of childhood infections! For most children, as they recover from illness, their immune system is strengthened. The UK, US, New Zealand, Cuba and Australia lead the world with Asthma (Vaccinated populations). Asthma UK says that ‘the goal would be to find a suitable vaccine to provide the beneficial effects of early life infection’!!!

6. Use Probiotics to strengthen the gut, in capsule form rather than from a drinking yogurt product which usually contains sugar and other additives.

7. Consider giving long term Vit B6 as “One of the components of the MMR is Neomycin. This is an antibacterial drug that is used to suppress gastrointestinal bacteria before surgery to avoid infection. …This antibiotic interferes with the absorption of Vitamin B6. An error in the uptake of Vitamin B6 can cause a rare form of epilepsy and children become mentally retarded. Vitamin B6 is the major vitamin for processingamino acids, which are the building blocks of all proteins and a few hormones. There are studies around which support the theory of treating autistic children with Vitamin B6.”

END OF QUOTE

Let me briefly comment on these 7 points.

  1. I am not aware of good evidence supporting this claim.
  2. I am not aware of good evidence supporting this claim.
  3. I am not aware of good evidence supporting this claim.
  4. I am not aware of good evidence supporting this claim.
  5. I am not aware of good evidence supporting this claim.
  6. I am not aware of good evidence supporting this claim.
  7. I am not aware of good evidence supporting this claim.

Of course, I may have missed some important evidence; if that is the case, I would appreciate someone showing it to me in the comments section below, so that we can all benefit from it.

The above advice is from the ‘ARNICA’ group (as the name suggests, they are close to or even led by homeopaths). They believe that the non-vaccinated child is potentially healthier than the vaccinated child.  

They also claim they  want to reduce the fear often felt by parents with their young children on health issues, whether that is to learn how to look after children when they have a fever, or to suggest ways to reduce the adverse reactions from vaccines.

I respectfully suggest that they are dismally failing in their aims. In fact, they seem to promote fear and issue bogus advice.

The HRI is an innovative international charity created to address the need for high quality scientific research in homeopathy… HRI is dedicated to promoting cutting research in homeopathy, using the most rigorous methods available, and communicating the results of such work beyond the usual academic circles… HRI aims to bring academically reliable information to a wide international audience, in an easy to understand form. This audience includes the general public, scientists, healthcare providers, healthcare policy makers, government and the media.

This sounds absolutely brilliant!

I should be a member of the HRI!

For years, I have pursued similar aims!

Hold on, perhaps not?

This article makes me wonder:

START OF QUOTE

… By the end of 2014, 189 randomised controlled trials of homeopathy on 100 different medical conditions had been published in peer-reviewed journals. Of these, 104 papers were placebo-controlled and were eligible for detailed review:
41% were positive (43 trials) – finding that homeopathy was effective
5% were negative (5 trials) – finding that homeopathy was ineffective
54% were inconclusive (56 trials)

How does this compare with evidence for conventional medicine?

An analysis of 1016 systematic reviews of RCTs of conventional medicine had strikingly similar findings2:
44% were positive – the treatments were likely to be beneficial
7% were negative – the treatments were likely to be harmful
49% were inconclusive – the evidence did not support either benefit or harm.

END OF QUOTE

The implication here is that the evidence base for homeopathy is strikingly similar to that of real medicine.

Nice try! But sadly it has nothing to do with ‘reliable information’!!!

In fact, it is grossly (and I suspect deliberately) misleading.

Regular readers of this blog will have spotted the reason, because we discussed (part of) it before. Let me remind you:

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A clinical trial is a research tool for testing hypotheses; strictly speaking, it tests the ‘null-hypothesis’: “the experimental treatment generates the same outcomes as the treatment of the control group”. If the trial shows no difference between the outcomes of the two groups, the null-hypothesis is confirmed. In this case, we commonly speak of a negative result. If the experimental treatment was better than the control treatment, the null-hypothesis is rejected, and we commonly speak of a positive result. In other words, clinical trials can only generate positive or negative results, because the null-hypothesis must either be confirmed or rejected – there are no grey tones between the black of a negative and the white of a positive study.

For enthusiasts of alternative medicine, this can create a dilemma, particularly if there are lots of published studies with negative results. In this case, the totality of the available trial evidence is negative which means the treatment in question cannot be characterised as effective. It goes without saying that such an overall conclusion rubs the proponents of that therapy the wrong way. Consequently, they might look for ways to avoid this scenario.

One fairly obvious way of achieving this aim is to simply re-categorise the results. What, if we invented a new category? What, if we called some of the negative studies by a different name? What about INCONCLUSIVE?

That would be brilliant, wouldn’t it. We might end up with a simple statistic where the majority of the evidence is, after all, positive. And this, of course, would give the impression that the ineffective treatment in question is effective!

How exactly do we do this? We continue to call positive studies POSITIVE; we then call studies where the experimental treatment generated worst results than the control treatment (usually a placebo) NEGATIVE; and finally we call those studies where the experimental treatment created outcomes which were not different from placebo INCONCLUSIVE.

In the realm of alternative medicine, this ‘non-conclusive result’ method has recently become incredibly popular . Take homeopathy, for instance. The Faculty of Homeopathy proudly claim the following about clinical trials of homeopathy: Up to the end of 2011, there have been 164 peer-reviewed papers reporting randomised controlled trials (RCTs) in homeopathy. This represents research in 89 different medical conditions. Of those 164 RCT papers, 71 (43%) were positive, 9 (6%) negative and 80 (49%) non-conclusive.

This misleading nonsense was, of course, warmly received by homeopaths. The British Homeopathic Association, like many other organisations and individuals with an axe to grind lapped up the message and promptly repeated it: The body of evidence that exists shows that much more investigation is required – 43% of all the randomised controlled trials carried out have been positive, 6% negative and 49% inconclusive.

Let’s be clear what has happened here: the true percentage figures seem to show that 43% of studies (mostly of poor quality) suggest a positive result for homeopathy, while 57% of them (on average the ones of better quality) were negative. In other words, the majority of this evidence is negative. If we conducted a proper systematic review of this body of evidence, we would, of course, have to account for the quality of each study, and in this case we would have to conclude that homeopathy is not supported by sound evidence of effectiveness.

The little trick of applying the ‘INCONCLUSIVE’ method has thus turned this overall result upside down: black has become white! No wonder that it is so popular with proponents of all sorts of bogus treatments.

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But one trick is not enough for the HRI! For thoroughly misinforming the public they have a second one up their sleeve.

And that is ‘comparing apples with pears’  – RCTs with systematic reviews, in their case.

In contrast to RCTs, systematic reviews can be (and often are) INCONCLUSIVE. As they evaluate the totality of all RCTs on a given subject, it is possible that some RCTs are positive, while others are negative. When, for example, the number of high-quality, positive studies included in a systematic review is similar to the number of high-quality, negative trials, the overall result of that review would be INCONCLUSIVE. And this is one of the reasons why the findings of systematic reviews cannot be compared in this way to those of RCTs.

I suspect that the people at the HRI know all this. They are not daft! In fact, they are quite clever. But unfortunately, they seem to employ their cleverness not for informing but for misleading their ‘wide international audience’.

When NHS England announced several months ago that they plan to stop the reimbursement of homeopathy, UK homeopaths were understandably upset and decided to launch a legal challenge to this decision. Yesterday, the result of this challenge has been published in a NHS press-release:

START OF QUOTE

NHS chief Simon Stevens has today welcomed the High Court’s decisive rejection of a legal challenge by the British Homeopathic Association to overturn plans to no longer routinely fund homeopathy on the NHS.

As part of action to clamp down on waste, over the last two years NHS England has taken action to curb prescriptions for medicines that can be bought over the counter or are of low value.

At the end of last year NHS England published guidance to curb prescriptions for 18 ineffective, unsafe or low clinical priority treatments, such as coproxamol, some dietary supplements, herbal treatments and homeopathy, saving up to £141 million a year. Earlier this year NHS England published a further list of 35 minor, short-term conditions for which over the counter medicines should not routinely be prescribed, saving around a further £100 million a year.

Savings form a key building block of the NHS’s 10 point efficiency plan contained in the Next Steps on the NHS Five Year Forward View, published in March 2017.

NHS chief, Simon Stevens said: “There is no robust evidence to support homeopathy which is at best a placebo and a misuse of scarce NHS funds.

“So we strongly welcome the High Court’s clear cut decision to kick out this costly and spurious legal challenge.”

Guidance on items which should not be routinely prescribed in primary care is available on the NHS England website.

END OF QUOTE

The reaction of UK homeopaths was as swift and deluded as it was predictable. The British Homeopathy Association, for instance, commented thus:

… The charity’s main claims against NHS England were that the consultation misrepresented homeopathy and therefore was unfair; and a report used in the consultation to inform the public was so complicated it would deter rather than encourage people to respond. Although the judge found there were sufficient grounds for a judicial review, after four days of lengthy legal arguments he dismissed the claims. Margaret Wyllie, BHA Chair, said the case highlighted how health bosses were unfairly manipulating the consultation process and making decisions about healthcare services without genuine patient engagement. “That NHS England attracted fewer than 3,000 responses from patients to a national consultation that ran for three months highlights its failure to genuinely engage with the public on important decisions about healthcare provision. Although 18 medicines were under review the only negative statement in NHS England’s press release promoting its public consultation was about homeopathy. The statement was so prejudicial it was widely reported in the media that the decision to deny patients homeopathic medicines had already been taken. How the judge failed to recognise that this was a deliberate attempt by NHS England to unfairly influence the public is astonishing,” said Mrs Wyllie.

In The Telegraph, Wyllie is quoted saying: It appears NHS England can fail to engage with patients properly on removing services and get away with it. That is not good enough, for it is important to remember that the real losers in this case are the patients who are now being refused a treatment on which they have come to depend.”

One can only marvel at the lack of insight and self-criticism. I should to add that the BHA is a charity; with this court case, they have wasted significant amounts of public money for their own, hopelessly misguided interests. To me, this indicates that they no longer deserve a charitable status.

Personally, I had very little doubt that the court would decide as it did. The evidence was simply overwhelming and indisputable. In the written judgement, the judge stated that “I am satisfied that NHSE was rigorous in the discharge of the duty to have “due regard” to relevant matters, and that it was entitled, on the evidence before it, to conclude that the Guidance would not have an adverse impact on the statutory equality objectives, but rather, as the Analysis found, “would [enable] patients to have access to the most effective medications to achieve the best outcomes”.

 

In all this, the open questions, in my view, were whether

  1. Prince Charles, the prime defender of quackery in the UK, would intervene,
  2. and whether his intervention might change anything.

So, did he try to intervene?

I do not know. It could be that, after all the hoo-ha about his spider memos, he now is a little more cautions about meddling in health politics. It could also be that, as he is getting ready to become king, he wants to keep a low profile about his more bizarre ideas. Lastly, it could be that his opinion does not weigh as heavily as I had feared.

In any case, The High Court ruling is most welcome and unquestionably just, progressive, and long-overdue. I applaud all who have worked hard to bring it about, and am sure that (most of) my readers agree.

Personally, I find our good friend Dana Ullman truly priceless. There are several reasons for that; one is that he is often so exemplarily wrong that it helps me to explain fundamental things more clearly. With a bit of luck, this might enable me to better inform people who might be thinking a bit like Dana. In this sense, our good friend Dana has significant educational value.

Recently, he made this comment:

According to present and former editors of THE LANCET and the NEW ENGLAND JOURNAL OF MEDICINE, “evidence based medicine” can no longer be trusted. There is obviously no irony in Ernst and his ilk “banking” on “evidence” that has no firm footing except their personal belief systems: https://medium.com/@drjasonfung/the-corruption-of-evidence-based-medicine-killing-for-profit-41f2812b8704

Ernst is a fundamentalist whose God is reductionistic science, a 20th century model that has little real meaning today…but this won’t stop the new attacks on me personally…

END OF COMMENT

Where to begin?

Let’s start with some definitions.

  • Evidence is the body of facts that leads to a given conclusion. Because the outcomes of treatments such as homeopathy depend on a multitude of factors, the evidence for or against their effectiveness is best based not on experience but on clinical trials and systematic reviews of clinical trials (this is copied from my book).
  • EBM is the integration of best research evidence with clinical expertise and patient values. It thus rests on three pillars: external evidence, ideally from systematic reviews, the clinician’s experience, and the patient’s preferences (and this is from another book).

Few people would argue that EBM, as it is applied currently, is without fault. Certainly I would not suggest that; I even used to give lectures about the limitations of EBM, and many experts (who are much wiser than I) have written about the many problems with EBM. It is important to note that such criticism demonstrates the strength of modern medicine and not its weakness, as Dana seems to think: it is a sign of a healthy debate aimed at generating progress. And it is noteworthy that internal criticism of this nature is largely absent in alternative medicine.

The criticism of EBM is often focussed on the unreliability of the what I called above the ‘best research evidence’. Let me therefore repeat what I wrote about it on this blog in 2012:

… The multifactorial nature of any clinical response requires controlling for all the factors that might determine the outcome other than the treatment per se. Ideally, we would need to create a situation or an experiment where two groups of patients are exposed to the full range of factors, and the only difference is that one group does receive the treatment, while the other one does not. And this is precisely the model of a controlled clinical trial.

Such studies are designed to minimise all possible sources of bias and confounding. By definition, they have a control group which means that we can, at the end of the treatment period, compare the effects of the treatment in question with those of another intervention, a placebo or no treatment at all.

Many different variations of the controlled trial exist so that the exact design can be adapted to the requirements of the particular treatment and the specific research question at hand. The over-riding principle is, however, always the same: we want to make sure that we can reliably determine whether or not the treatment was the cause of the clinical outcome.

Causality is the key in all of this; and here lies the crucial difference between clinical experience and scientific evidence. What clinician witness in their routine practice can have a myriad of causes; what scientists observe in a well-designed efficacy trial is, in all likelihood, caused by the treatment. The latter is evidence, while the former is not.

Don’t get me wrong; clinical trials are not perfect. They can have many flaws and have rightly been criticised for a myriad of inherent limitations. But it is important to realise that, despite all their short-comings, they are far superior than any other method for determining the efficacy of medical interventions.

There are lots of reasons why a trial can generate an incorrect, i.e. a false positive or a false negative result. We therefore should avoid relying on the findings of a single study. Independent replications are usually required before we can be reasonably sure.

Unfortunately, the findings of these replications do not always confirm the results of the previous study. Whenever we are faced with conflicting results, it is tempting to cherry-pick those studies which seem to confirm our prior belief – tempting but very wrong. In order to arrive at the most reliable conclusion about the efficacy of any treatment, we need to consider the totality of the reliable evidence. This goal is best achieved by conducting a systematic review.

In a systematic review, we assess the quality and quantity of the available evidence, try to synthesise the findings and arrive at an overall verdict about the efficacy of the treatment in question. Technically speaking, this process minimises selection and random biases. Systematic reviews and meta-analyses [these are systematic reviews that pool the data of individual studies] therefore constitute, according to a consensus of most experts, the best available evidence for or against the efficacy of any treatment.

END OF QUOTE

Other criticism is aimed at the way EBM is currently used (and abused). This criticism is often justified and necessary, and it is again the expression of our efforts to generate progress. EBM is practised by humans; and humans are far from perfect. They can be corrupt, misguided, dishonest, sloppy, negligent, stupid, etc., etc. Sadly, that means that the practice of EBM can have all of these qualities as well. All we can do is to keep on criticising malpractice, educate people, and hope that this might prevent the worst abuses in future.

Dana and many of his fellow SCAMers have a different strategy; they claim that EBM “can no longer be trusted” (interestingly they never tell us what system might be better; eminence-based medicine? experience-based medicine? random-based medicine? Dana-based medicine?).

The claim that EBM can no longer be trusted is clearly not true, counter-productive and unethical; and I suspect they know it.

Why then do they make it?

Because they feel that it entitles them to argue that homeopathy (or any other form of SCAM) cannot be held to EBM-standards. If EBM is unreliable, surely, nobody can ask the ‘Danas of this world’ to provide anything like sound data!!! And that, of course, would be just dandy for business, wouldn’t it?

So, let’s not be deterred  or misled by these deliberately destructive people. Their motives are transparent and their arguments are nonsensical. EBM is not flawless, but with our continued efforts it will improve. Or, to repeat something that I have said many times before: EBM is the worst form of healthcare, except for all other known options.

“This utter hokum is symptomatic of the crass stupidity of the vacuous classes before the lumpen mob rebelled and chopped off their useless heads. Where, oh where, is our mob?”

No, I am not calling for a British re-run of the French revolution. This is a comment that made me chuckle. I found it under an article in the SUNDAY TIMES. As it is about acupuncture, I thought I mention it here and show you a few experts:

_________________________________________________________________________________

… Prince Harry and Meghan Markle had regular appointments with an acupuncturist in the lead-up to their wedding. They were treated by Ross Barr, acupuncturist to the stars, who has been described as “divertingly handsome” by many of his enthusiastic fans and whose treatments have been lauded as “better than Botox”. Beauty experts say his appointments “go faster than Glastonbury tickets”.

Barr, whose treatments deal with anything from infertility to hair loss and relationship problems, is understood to have been regularly treating the couple since Meghan moved to London last year. The treatments are said to have been so successful that Barr and his wife, the actress Eva Birthistle, were invited to the wedding alongside celebrities including Oprah Winfrey, who had acupuncture live on her television show…

Harry, 33, has spoken of his struggles with anxiety and depression after the death of his mother, Diana, Princess of Wales in 1997. In an interview with The Sunday Times in 2016 he also admitted “my body . . . has basically been ruined over the last 10 years of army service”. His father, the Prince of Wales, is renowned for championing alternative and complementary therapies such as homeopathy and acupuncture…

It is thought Harry was keen to try acupuncture as part of a recent health drive to prepare for his wedding. He is reported to have reduced his alcohol consumption and is now regularly seen exercising at the exclusive KX gym in Chelsea, west London. Meghan, 36, is likely to be a fan of Barr’s “anti-wrinkle acupressure facial”, which aims to smooth fine lines and may have contributed to the American former actress’s radiant complexion on her wedding day…

Both Kensington Palace and Barr declined to comment yesterday.

_________________________________________________________________________________

Well, let me offer a few comments then:

  1. The article is recklessly promotional and, in my view, very poor journalism.
  2. It does not even include the usual attempt at ‘balance’ where an expert warns at the end of the article that acupuncture is unscientific rubbish.
  3. There is no good evidence that acupuncture works for any of the conditions mentioned in the article.
  4. Critical thinking, journalistic ethics, or objective analysis do not seem to be the forte of the author of this regrettable drivel.

Yes, I know … this is not very important. It is merely a little innocent story about some VIPs for gullible consumers.

Innocent?

Perhaps!

But misleading the public about healthcare can also be seen as short-sighted, counter-productive, unethical, and stupid.

The Internet is full of complete nonsense about alternative medicine, as we all know. Much of it could be funny – if it was not so extremely dangerous. Misinformation on health can (and I am afraid does) kill people. One of the worst BS I have seen for a long time is this article entitled ‘Here’s What Oncologists Won’t Tell You About Essential Oils’.

A few excerpts might be of interest:

START OF QUOTES

…The human body resonates at a frequency of 62-78 MHz and scientists believe that diseases start at 58 MHz. Many studies have shown that negative thoughts can reduce our frequency by 12 MHz, while positive thinking raises it by 10.

This means that there are many things that can affect our health in ways we can’t imagine.

According to the latest studies, essential oils can fight cancer thanks to their antibacterial properties and their ability to change the frequency we resonate at.

One of the scientists involved in the study, Bruce Tainio, developed a special Calibrated Frequency Monitor that measures the frequency of essential oils and how they affect us. M. Suhail, an immunologist, says that cancer develops when the DNA in our cells’ nucleus is corrupted.

Essential oils can correct this and repair the code, effectively improving our chances against the terrible disease…

In his book “The Body Electric”, R. O. Becker said that our bodies’ electronic frequency determines our health.

Even Nikola Tesla said that removing outside frequencies can make us more resistant against ailments, while Dr. Otto Warburg discovered over a century ago that our cells have a specific electrical voltage that can drop due to a various factors and trigger diseases such as cancer.

However, science has now discovered that essential oils with higher frequencies can destroy diseases with lower frequencies.

Here’s a list of some of the oils used in the research and their electrical frequencies:

  • Juniper – 98 Mhz
  • Angelica – 85 Mhz
  • Frankincense – 147 MHz
  • Rose – 320 Mhz.
  • Sandalwood – 96 Mhz
  • Helichrysum – 181 MHz
  • Peppermint – 78 Mhz
  • Lavender – 118 Mhz

In the study, cinnamon, thyme, jasmine and chamomile oils had the best results when put up against breast cancer cells. Chamomile destroyed 93% of the cells in vitro, while thyme destroyed 97% of the cells…

11 oils were examined in total including bitter and sweet fennel, winter savory, peppermint, sage, lavender, chamomile and thyme.

Frankincense oil

According to Suhail, frankincense oil can divide the nucleus of cancer cells from the cytoplasm and prevent it from reproducing. The oil works thanks to the presence of the so-called monoterpenes which have the ability to kill cancer cells.

Frankincense oil works in all stages of cancer and is cytotoxic, meaning it doesn’t destroy healthy cells.

End-stage liver cancer patient

In the study, a patient with end-stage liver cancer was given only a few months left to live. The tumor was inoperable due to the large size, so having nothing to lose, the man decided to try frankincense oil.

He applied a bit under his tongue and topically on the area of the liver, and on his next doctor visit, the tumor has already reduced in size. The patient continued using frankincense oil, and it eventually reduced just enough to be operable. His tumor was later removed and the man is now happily enjoying his life free of cancer.

A child with brain cancer

One of the toughest cases among all the patients in the study was a little girl aged 5 with brain cancer. After exhausting all other options, the parents decided to give the girl a mixture of frankincense and sandalwood oil.

They rubbed the mixture on her feet while also rubbing a bit of lavender on her wrist. After a few months, the cancer was completely defeated!

Bladder cancer patient

Jackie Hogan is a woman suffering from bladder cancer who needed to undergo a surgery for bladder removal due to the cancer.

However, she decided to try using essential oils in her condition and after a few months of applying a mixture of sandalwood and frankincense oil topically on the area, she is cancer-free.

Stage-4 cancer patient

One woman in the research was diagnosed with stage-4 lung cancer which has already spread to other organs in her body.

Instead of agreeing to chemo and surgery, the woman started applying a bit of frankincense oil topically on the affected areas of her body every 2-3 hours and she was completely healthy in 7 months.

Breast cancer patient

A woman diagnosed with advanced breast cancer used a mixture of frankincense and lemongrass oil (topically and under the tongue) to defeat the disease in only a few months.

Cervical cancer patient

A woman with cervical cancer was given only a few months left to live, but thanks to the powers of frankincense oil, she managed to defeat the diseases in a couple of months.

There are many more patients who have managed to defeat different types of cancer using the remarkable powers of various essential oils…

_________________________________________________________________________

END OF QUOTES

Unspeakable nonsense!

I managed to find 4 of the studies this article seems to refer to:

__________________________________________________________________________

Differential effects of selective frankincense (Ru Xiang) essential oil versus non-selective sandalwood (Tan Xiang) essential oil on cultured bladder cancer cells: a microarray and bioinformatics study.

Dozmorov MG, Yang Q, Wu W, Wren J, Suhail MM, Woolley CL, Young DG, Fung KM, Lin HK.

Chin Med. 2014 Jul 2;9:18. doi: 10.1186/1749-8546-9-18. eCollection 2014.

2.

Frankincense essential oil prepared from hydrodistillation of Boswellia sacra gum resins induces human pancreatic cancer cell death in cultures and in a xenograft murine model.

Ni X, Suhail MM, Yang Q, Cao A, Fung KM, Postier RG, Woolley C, Young G, Zhang J, Lin HK.

BMC Complement Altern Med. 2012 Dec 13;12:253. doi: 10.1186/1472-6882-12-253.

3.

Chemical differentiation of Boswellia sacra and Boswellia carterii essential oils by gas chromatography and chiral gas chromatography-mass spectrometry.

Woolley CL, Suhail MM, Smith BL, Boren KE, Taylor LC, Schreuder MF, Chai JK, Casabianca H, Haq S, Lin HK, Al-Shahri AA, Al-Hatmi S, Young DG.

J Chromatogr A. 2012 Oct 26;1261:158-63. doi: 10.1016/j.chroma.2012.06.073. Epub 2012 Jun 28.

PMID:
22835693
4.

Boswellia sacra essential oil induces tumor cell-specific apoptosis and suppresses tumor aggressiveness in cultured human breast cancer cells.

Suhail MM, Wu W, Cao A, Mondalek FG, Fung KM, Shih PT, Fang YT, Woolley C, Young G, Lin HK.

BMC Complement Altern Med. 2011 Dec 15;11:129. doi: 10.1186/1472-6882-11-129.

PMID:
22171782

Free PMC Article

____________________________________________________________________________

I do not think that these papers actually show what is claimed above. Specifically, none of the 4 articles refers to clinical effects of essential oil on cancer patients. In fact, according to a 2014 review, and a 2013 paper (the most recent summaries I found) there are no clinical trials of essential oil as a cure for cancer.

The conclusion therefore must be this: Essential oils might be an interesting area of research, yet one has to tell consumers and patients very clearly:

there is no evidence to suggest that using essential oils will change the natural history of any type of cancer. 

Canadian naturopaths are reported to be under investigation for practising and promoting ‘CEASE’. It might be worth therefore, to explain what this treatment amounts to.

The name ‘CEASE’ is the abbreviation of Complete Elimination of Autistic Spectrum Expression. Here are 7 points that are, I think, relevant:

  1. CEASE therapy was developed by Dr Tinus Smits (1946-2010) in the Netherlands. Smits had practised as a lay-homeopath for many years before he decided to study medicine.
  2. Smits became convinced that autism is caused by a child’s exposure to an accumulation of toxic substances and published several books about his theory.
  3. In his experience (as far as I can see, Smits never published a single scientific paper in the peer-reviewed literature) autism is caused by an accumulation of different toxins. About 70% is due to vaccines, 25% to toxic medication and other toxic substances, 5% to some diseases.
  4. According to the ‘like cures like’ principle of homeopathy, Smits claimed that autism must be cured by applying homeopathic doses of the substances which caused autism. Step by step all assumed causative factors (vaccines, regular medication, environmental toxic exposures, effects of illness, etc.) are detoxified with the homeopathically prepared substances that has been administered prior to the onset of autism. Smits and his followers believe that this procedure clears out the “energetic field of the patient from the imprint of toxic substances or diseases”.
  5. One problem with this concept is that it flies in the face of science. There is no reason to believe that autism is caused by the exposure to toxins. In fact, CEASE turns out to be a layered monster of bogus assumption. The first layer is a false theory of the pathogenesis of autism; the second is the ‘like cures like’ myth of homeopathy; the third is the notion that ‘potentisation’ (dilution for you and me) renders substances not less but more potent; the fourth is the nonsensical concept of detoxification.
  6. Another, perhaps even more important problem is that there is no evidence that the CEASE therapy is clinically effective.
  7. Despite all this, many homeopaths and naturopaths have enthusiastically adopted the CEASE therapy, and some have discovered that there is money in running courses and awarding diplomas. Alerted to this abuse by concerned consumers, the UK Professional Standards Authority recently forced the UK ‘Society of Homeopaths’ to issue a statement saying: A number of Society members have been trained in CEASE and make reference to it in their marketing. While this is acceptable, members should be aware the title, meaning ‘Complete Elimination of Autistic Spectrum Expression’ is misleading. RSHoms must not suggest that they are capable of a complete cure of autism as this would be unethical and in breach of the Code of Ethics. The Society does not endorse any aspects of CEASE therapy contrary to NHS guidance and nor should RSHoms. In particular on vaccination, homeopathic prophylaxis, and the use of dietary supplements. It is beyond standard homeopathic practice to provide advice on the use of supplements and therefore any guidance given should be in line with the NHS Guidelines. The Society expects its members to comply with its Code of Ethics and statements on vaccination and homeopathic prophylaxis at all times, and any breaches may be treated as disciplinary matters. In order to ensure patient safety and In line with our guidelines, we will check the websites and marketing of all our members on a regular basis to ensure they are adhering to this statement. (Personally I find it astonishing that the SoH seems to declare CEASE ‘acceptable’.)

PS

In case you are interested to consider the arguments from a proponent (one of the Canadian naturopaths who are currently under investigation for practising CEASE), read this article: https://www.drzimmermann.org/blog-vaccines-homeopathy-autism-cease-therapy/cease-therapy-misconceptions-and-truths

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