Today, Prince Charles celebrates his 65th birthday. He is one of the world’s most tenacious, outspoken and influential proponent of alternative medicine and attacker of science – sufficient reason, I think, to join the birthday-celebrations by outlining a chronology of his love affair with quackery. The following post highlights just a few events (there are so many more!) which I happen to find interesting. As I was personally involved in several of them, I have tried to stay as close as possible to the text published by journalists at the time (with links to the originals); this, I thought, was fairer than providing my own, possibly biased interpretations.
The origins Charles’ passion for all things alternative are not difficult to trace. The Royal family is famous for using homeopathy and other doubtful treatments while they are healthy, and for employing the very best conventional medicine has to offer as soon as they are ill. This pattern also applied to Charles’ childhood, and it is more than likely that this is how his weakness for alternative medicine and charlatans first started.
The young Prince Charles went on a journey of ‘spiritual discovery’ into the wilderness of northern Kenya. His guru and guide was Laurens van der Post (who was later discovered to be a fraud and compulsive fantasist and to have fathered a child with a 14-year old girl entrusted to him during a sea voyage). Van der Post wanted to awake Charles’ young intuitive mind and attune it to the ideas of Carl Jung’s ‘collective unconscious’ which allegedly unites us all through a common vital force. It is this belief in vitalism (long obsolete in medicine and science) that provides the crucial link to alternative medicine: virtually every form of the otherwise highly diverse range of alternative therapies is based on the assumption that some sort of vital force or energy exists. Charles was so taken by van der Post that, after his death, he established an annual lecture in his honour.
Throughout the 1980s, Charles seems to have lobbied for the statutory regulation of chiropractors and osteopaths in the UK. In 1993, it finally became reality.
Osteopathy has strong Royal links: Prince Charles is the President of the GOsC; Princess Diana was the President of the GCRO; and Princess Anne is the patron of the British School of Osteopathy (statement dated 2011).
In 1982, Prince Charles was elected as President of the British Medical Association (BMA) and promptly challenged the medical orthodoxy by advocating alternative medicine. In a speech at his inaugural dinner as President, the Prince lectured the medics: ‘Through the centuries healing has been practised by folk healers who are guided by traditional wisdom which sees illness as a disorder of the whole person, involving not only the patient’s body, but his mind, his self-image, his dependence on the physical and social environment, as well as his relation to the cosmos.’ The BMA-officials were impressed – so much so that they ordered a full report on alternative medicine which promptly condemned this area as utter nonsense.
In 1993, Charles founded his often re-named lobby group that ended up being called the ‘Foundation for Integrated Health’ (FIH). It was closed down in 2010 amidst allegations of money laundering and fraud. Its chief executive, George Gray, was later convicted and went to jail. The FIH had repeatedly been economical with the truth. For instance, when it published a DoH-sponsored ‘patient guide’ that was entirely devoid of evidence, arguably the most important feature of such a document. They claimed evidence was never meant to be included. But I had seen a draft where it had been part of it, and friends have seen the contract with the DoH where “evidence” was an important element.
In 2000, Charles wrote an open letter to The Times (citing my work twice!!!) stating that…It makes good sense to evaluate complementary and alternative therapies. For one thing, since an estimated £1.6 billion is spent each year on them, then we want value for our money. The very popularity of the non-conventional approaches suggests that people are either dissatisfied with their orthodox treatment, or they find genuine relief in such therapies. Whatever the case, if they are proved to work, they should be made more widely available on the NHS…But there remains the cry from the medical establishment of “where’s the proof?” — and clinical trials of the calibre that science demands cost money…The truth is that funding in the UK for research into complementary medicine is pitiful…So where can funding come from?…Figures from the department of complementary medicine at the University of Exeter show that less than 8p out of every £100 of NHS funds for medical research was spent on complementary medicine. In 1998-99 the Medical Research Council spent no money on it at all, and in 1999 only 0.05 per cent of the total research budget of UK medical charities went to this area…
In 2001, Charles was working on plans to help build a model hospital that would tap into the power of alternative therapy. It was to train doctors to combine conventional medicine and alternative treatments, such as homeopathy, Ayurvedic medicine and acupuncture, and was to have have up to 100 beds. The prince’s intervention marked the culmination of years of campaigning by him for the NHS to assign a greater role to alternative medicine. In a speech he had urged the NHS not to dismiss it as a “woolly cul-de-sac”. Groups interested in alternative medicine were delighted at the news. Teresa Hale, founder of the Hale Clinic in London, said: “Twenty-five years ago people said we were quacks. Now several branches, including homeopathy, acupuncture and osteopathy, have gained official recognition.” The proposed hospital, which was due to open in London in 2003 or early 2004, was to be overseen by Mosaraf Ali, who runs the Integrated Medical Centre (IMC) in London. He was also responsible for raising finance for its construction.
To the best of my knowledge, this hospital never materialised. This might be due to Mosaraf Ali falling in disrepute: Raj Bathija, 69 and from India, went for a massage at the clinic of Dr Mosaraf Ali and his brother Imran in 2005 after suffering from two strokes. However, he claims that shortly after the treatment, his legs became pale and discoloured. Four days afterwards, Mr Bathija was admitted to hospital, where he had to have both legs amputated below the knee due to a shortage of blood. According to Mr Bathija, Dr Ali and his brother were negligent in that they failed to diagnose his condition and neglected to advise him to go to hospital.
His daughter Shibani said: “My father was in a wheelchair but was making progress with his walking. He hoped he might become a bit more independent. With the amputations, that’s all gone.”
In 2003, Prince Charles’ Prince of Wales’ FIH has launched a five-year plan which outlined how to improve access to therapies.
In 2004, Charles publicly supported the Gerson diet as a treatment for cancer and Prof Baum, one of the UK’s most eminent oncologists, was invited to respond in an open letter to the British Medical Journal: …Over the past 20 years I have treated thousands of patients with cancer and lost some dear friends and relatives to this dreaded disease…The power of my authority comes with knowledge built on 40 years of study and 25 years of active involvement in cancer research. Your power and authority rest on an accident of birth. I don’t begrudge you that authority but I do beg you to exercise your power with extreme caution when advising patients with life-threatening diseases to embrace unproven therapies.
In 2005, the ‘Smallwood-Report’ was published, commissioned by Charles and paid for by Dame Shirley Porter, specifically to inform health ministers. It stated that up to 480 million pounds could be saved if one in 10 family doctors offered homeopathy as an alternative to standard drugs. Savings of up to 3.5 billion pounds could be achieved by offering spinal manipulation rather than drugs to people with back pain. Because I had commented on this report, Prince Charles’ first private secretary asked my vice chancellor to investigate my activities; even though I was found to be not guilty of any wrong-doing, specifically of violating confidentiality, all local support stopped which led to my early retirement. ITV later used this incident in a film entitled THE MEDDLING PRINCE.
In a 2006 speech Prince Charles told the World Health Organisation in Geneva that alternative medicine should have a more prominent place in health care. The Prince urged every country to come up with a plan to integrate conventional and alternative medicine into the mainstream. But British science struck back. Anticipating Prince Charles’s sermon in Geneva, thirteen of Britain’s most eminent physicians and scientists issued a widely quoted “Open Letter: Use of ‘Alternative’ Medicine in the NHS”. The letter expressed concern over “ways in which unproven or disproved treatments are being encouraged for general use in Britain’s National Health Service.” The signatories, who included three Fellows of the Royal Society, one Nobel Laureate (Sir James Black, FRS) and the son of another (Professor Gustav Born, FRS), cited the overt promotion of homeopathy by the NHS, including its official website. The Open Letter warned that “it would be highly irresponsible to embrace any medicine as though it were a matter of principle.”
In 2008, The Times published my letter asking the FIH to recall two guides promoting “alternative medicine”, saying: “the majority of alternative therapies appear to be clinically ineffective, and many are downright dangerous.” A speaker for the FIH countered the criticism by stating: “We entirely reject the accusation that our online publication Complementary Healthcare: A Guide contains any misleading or inaccurate claims about the benefits of complementary therapies. On the contrary, it treats people as adults and takes a responsible approach by encouraging people to look at reliable sources of information… so that they can make informed decisions. The foundation does not promote complementary therapies.”
In 2009, the Prince held talks with the health Secretary to persuade him to introduce safeguards amid a crackdown by the EU that could prevent anyone who is not a registered health practitioner from selling remedies. This, it seems, was yet another example of Charles’ disregard of his constitutional role. In the same year, Charles urged government to protect alternative medicine medicine because “we fear that we will see a black market in herbal products”, as Dr Michael Dixon, medical director of Charles’ FIH, put it.
In 2009, Charles seemed to have promised that his London-based ‘College of Integrated Medicine’ (the name was only later changed to ‘College of Medicine’, see below) was to have a second base in India. An Indian spokesman commented: “The second campus of the Royal College will be in Bangalore. We have already proposed the setting up of an All India Institute of Integrated Medicine to the Union health ministry. At a meeting in London last week with Prince Charles, we finalized the project which will kick off in July 2010”.
In 2010, Charles publicly stated that he was proud to be perceived as ‘an enemy of the enlightenment’.
In 2010, ‘Republic’ filed an official complaint about FIH alleging that its trustees allowed the foundation’s staff to pursue a public “vendetta” against a prominent critic of the prince’s support for complementary medicines, Edzard Ernst. It also suggests the imminent closure of Ernst’s department may be partly down to the charity’s official complaint about him after he publicly attacked its draft guide to complementary medicines as “outrageous and deeply flawed”.
In 2010, former fellows of Charles’ disgraced FIH launched a new organisation, The College of Medicine’ supporting the use of integrated treatments in the NHS. One director of the college is Michael Dixon, a GP in Cullompton, Devon, who was formerly medical director of the Foundation for Integrated Health. The others are George Lewith, who runs a complementary medicine unit at Southampton University; David Peters, the chairman of the British Holistic Medical Association; and Christine Glover, a holistic health consultant. All are former fellows of the prince’s charity. My own analysis of the activities of the new college leaves little doubt that it is promoting quackery.
In 2010, Charles published his book HARMONY which is full of praise for even the most absurd forms of quackery.
In 2011, after the launch of his very own range of herbal tinctures Charles was harshly criticised. Consequently, a public row was re-ignited with Clarence House by branding the Prince of Wales a “snake oil salesman”. I had the audacity to criticise the heir to the throne for lending his support to homeopathic remedies and for selling the Duchy Herbals detox tincture.
In 2011, Charles forged a link between ‘The College of Medicine’ and an Indian holistic health centre. The collaboration has been reported to include clinical training to European and Western doctors in ayurveda and homoeopathy and traditional forms of medicine to integrate them in their practice. The foundation stone for the extended campus of the Royal College known as the International Institution for Holistic and Integrated Medicine was laid by Dr Michael Dixon in collaboration with the Royal College of Medicine.
In 2012, Charles was nominated for ‘THE GOLDEN DUCK AWARD’ for his achievements in promoting quackery; Andrew Wakefield beat him to it, but Charles was a well-deserved runner-up.
In 2013, Charles called for society to embrace a broader and more complex concept of health. In his article he described a vision of health that includes the physical and social environment, education, agriculture and architecture. Emphasising that his point is not to confront accepted medical wisdom, HRH suggests reasons for encouraging a wider perspective on health. Rather than simply treating the symptoms of disease, The Prince advocates a health service that puts patients at the heart of the process by incorporating the core human elements of mind, body and spirit. Explaining that symptoms may often be a metaphor for underlying disease and unhappiness, he calls for a scientific and therapeutic approach that understands, values and uses patient perspective and belief rather than seeking to exclude them.
In 2013, Charles’ Highgrove enterprise offered ‘baby-hampers’ for sale at £195 a piece and made a range of medicinal claims for the products it contained. As these claims were not supported by evidence, there is no way to classify them other than quackery.
By 2013, the ‘Association of Osteomyologists’ are seeking to become regulated in statute, with the help of Prince Charles as their patron. An Osteomyologist will treat both the symptoms and the root cause of a condition with the aim of alleviating symptoms and preventing reoccurrence whenever possible. Osteomyology encourages the skilled use of techniques including Cranial and Cranio-Sacral therapy.
In November 2013, Charles invited alternative medicine proponents from across the world, including Dean Michael Ornish, Sausalito, California, Michael Dixon, chair of College of Medicine, UK and Issac Mathai of Soukya Foundation, Bangalore, to India for a ‘brain storm’ and a subsequent conference on alternative medicine. The prince wanted the experts to collaborate and explore the possibilities of integrating different systems of medicines and to better the healthcare delivery globally, one of the organisers said.
I am sure that, in the future, we will hear much more about Charles’ indulgence in quackery; and, of course, we will hear more criticism of it. But I doubt that anyone can put it better that the late Christopher Hitchens who repeatedly wrote about Charles’ passion for anti-science:
“Once the hard-won principles of reason and science have been discredited, the world will not pass into the hands of credulous herbivores who keep crystals by their sides and swoon over the poems of Khalil Gibran. The “vacuum” will be invaded instead by determined fundamentalists of every stripe who already know the truth by means of revelation and who actually seek real and serious power in the here and now. One thinks of the painstaking, cloud-dispelling labour of British scientists from Isaac Newton to Joseph Priestley to Charles Darwin to Ernest Rutherford to Alan Turing and Francis Crick, much of it built upon the shoulders of Galileo and Copernicus, only to see it causally slandered by a moral and intellectual weakling from the usurping House of Hanover.”
And perhaps even better here:
We have known for a long time that Prince Charles’ empty sails are so rigged as to be swelled by any passing waft or breeze of crankiness and cant. He fell for the fake anthropologist Laurens van der Post. He was bowled over by the charms of homeopathic medicine. He has been believably reported as saying that plants do better if you talk to them in a soothing and encouraging way. But this latest departure promotes him from an advocate of harmless nonsense to positively sinister nonsense….The heir to the throne seems to possess the ability to surround himself—perhaps by some mysterious ultramagnetic force?—with every moon-faced spoon-bender, shrub-flatterer, and water-diviner within range.
Some sceptics are convinced that, in alternative medicine, there is no evidence. This assumption is wrong, I am afraid, and statements of this nature can actually play into the hands of apologists of bogus treatments: they can then easily demonstrate the sceptics to be mistaken or “biased”, as they would probably say. The truth is that there is plenty of evidence – and lots of it is positive, at least at first glance.
Alternative medicine researchers have been very industrious during the last two decades to build up a sizable body of ‘evidence’. Consequently, one often finds data even for the most bizarre and implausible treatments. Take, for instance, the claim that homeopathy is an effective treatment for cancer. Those who promote this assumption have no difficulties in locating some weird in-vitro study that seems to support their opinion. When sceptics subsequently counter that in-vitro experiments tell us nothing about the clinical situation, apologists quickly unearth what they consider to be sound clinical evidence.
An example is this prospective observational 2011 study of cancer patients from two differently treated cohorts: one cohort with patients under complementary homeopathic treatment (HG; n = 259), and one cohort with conventionally treated cancer patients (CG; n = 380). Its main outcome measures were the change of quality life after 3 months, after one year and impairment by fatigue, anxiety or depression. The results of this study show significant improvements in most of these endpoints, and the authors concluded that we observed an improvement of quality of life as well as a tendency of fatigue symptoms to decrease in cancer patients under complementary homeopathic treatment.
Another, in some ways even better example is this 2005 observational study of 6544 consecutive patients from the Bristol Homeopathic Hospital. Every patient attending the hospital outpatient unit for a follow-up appointment was included, commencing with their first follow-up attendance. Of these patients 70.7% (n = 4627) reported positive health changes, with 50.7% (n = 3318) recording their improvement as better or much better. The authors concluded that homeopathic intervention offered positive health changes to a substantial proportion of a large cohort of patients with a wide range of chronic diseases.
The principle that is being followed here is simple:
- believers in a bogus therapy conduct a clinical trial which is designed to generate an apparently positive finding;
- the fact that the study cannot tell us anything about cause and effect is cleverly hidden or belittled;
- they publish their findings in one of the many journals that specialise in this sort of nonsense;
- they make sure that advocates across the world learn about their results;
- the community of apologists of this treatment picks up the information without the slightest critical analysis;
- the researchers conduct more and more of such pseudo-research;
- nobody attempts to do some real science: the believers do not truly want to falsify their hypotheses, and the real scientists find it unreasonable to conduct research on utterly implausible interventions;
- thus the body of false or misleading ‘evidence’ grows and grows;
- proponents start publishing systematic reviews and meta-analyses of their studies which are devoid of critical input;
- too few critics point out that these reviews are fatally flawed – ‘rubbish in, rubbish out’!
- eventually politicians, journalists, health care professionals and other people who did not necessarily start out as believers in the bogus therapy are convinced that the body of evidence is impressive and justifies implementation;
- important health care decisions are thus based on data which are false and misleading.
So, what can be done to prevent that such pseudo-evidence is mistaken as solid proof which might eventually mislead many into believing that bogus treatments are based on reasonably sound data? I think the following measures would be helpful:
- authors should abstain from publishing over-enthusiastic conclusions which can all too easily be misinterpreted (given that the authors are believers in the therapy, this is not a realistic option);
- editors might consider rejecting studies which contribute next to nothing to our current knowledge (given that these studies are usually published in journals that are in the business of promoting alternative medicine at any cost, this option is also not realistic);
- if researchers report highly preliminary findings, there should be an obligation to do further studies in order to confirm or refute the initial results (not realistic either, I am afraid);
- in case this does not happen, editors should consider retracting the paper reporting unconfirmed preliminary findings (utterly unrealistic).
What then can REALISTICALLY be done? I wish I knew the answer! All I can think of is that sceptics should educate the rest of the population to think and analyse such ‘evidence’ critically…but how realistic is that?
HRH, The Prince of Wales has supported quackery on uncounted occasions. Several years ago, Charles even began selling his very own line of snake-oil. Now he surprises the British public with a brand new product: the ‘Baby Organic Hamper’. It is being sold for £195 under Prince Charles’ Highgrove-label and advertised with the following words:
A limited edition, hand-numbered hamper box packed with our new gentle organic bath and body products and a Highgrove Baby Bear. An ideal gift for new babies and parents. The blend of organic Roman chamomile and mandarin has been developed to be calm and gentle on delicate skin.
Roman chamomile has been known for centuries for its calming and relaxing benefits and also acts as an anti-inflammatory. Mandarin, known as ‘happy-oil’, has been chosen for its antiseptic properties and ability to boost immunity. Combined, this blend of ingredients produces a calming, protective barrier helping babies to relax. The exclusive, fully jointed Highgrove Baby Bear in antique mohair is made by Merrythought.
Provenance The unique bath and body collection has been created with Daniel Galvin Jr. in collaboration with Alexandra Soveral. Daniel Galvin Jr. has pioneered and developed organic products for hair and beauty over the last decade and Alexandra Soveral is a renowned and highly respected aromatherapist and facialist.
This new collection has been formulated in accordance with The Soil Association’s standards for health and beauty products, ensuring the purity of the range. Hamper Contents Body Lotion 100ml. Bath and Massage Oil 100ml. Flower Water 100ml. Bath and Body Wash 100ml. Balm 50ml. Highgrove Baby Bear.
Terms like relaxing benefits … anti-inflammatory … antiseptic properties … ability to boost immunity … protective barrier … helping babies to relax do undoubtedly amount to medical/therapeutic claims which, by definition (and by English law), need to be supported by evidence. I fail to see any sound evidence that either chamomile or mandarin oil or their combination have any of these effects on babies when applied as a body lotion, bath oil, massage oil, flower water, body wash.
The only RCT for mandarin-oil I could find concluded that results do not support a benefit of ‘M’ technique massage with or without mandarin oil in these young postoperative patients. Several reasons may account for this: massage given too soon after general anaesthesia, young patients’ fear of strangers touching them, patients not used to massage. For Roman Chamomile, I also identified just one relevant study; its results do not seem to suggest that the oil is the decisive factor in producing relaxation: Massage with or without essential oils appears to reduce levels of anxiety. Neither of these trials were done with babies, and crucially, no clinical trial at all seems to exist of the combination of the two oils as used in the Charles’ products.
As Charles and his team are clearly not scientists or health care experts, they took advice from people who might know about such matters: Daniel Galvin Jr. in collaboration with Alexandra Soveral. Daniel Galvin Jr. has pioneered and developed organic products for hair and beauty over the last decade and Alexandra Soveral is a renowned and highly respected aromatherapist and facialist.
This might look responsible at first glance; at closer scrutiny, Daniel Galvin turns out to be more an expert in cosmetics than in medicine; his own website explains: Born into the country’s most influential hairdressing dynasty, Daniel Galvin Jr, has been instrumental in the growth of the organic beauty market for the past 12 years and has been in the industry for 27 years. As a salon owner and creator of natural, organic professional haircare, he is at the forefront of colour expertise, with a client list including a ‘who’s who’ of TV personalities, British actors, royalty and London’s most beautiful socialites.
Alexandra Soveral might have once worked as an aromatherapist, but today she is the co-owner of a firm marketing natural beauty products; her website explains: We use rare & organic ingredients of the highest quality to create products that work in synergy with nature. We work towards a synthetic chemical free world. The scents from our essential oils evoke mind, body and soul reactions that promote well-being. We aim to continue our journey by always ensuring we source out new ways to improve our products and be kind to the planet.
At this point, two questions emerge in my mind: 1) is this just foolish nonsense or is it more sinister than that? 2) Why on earth does Charles venture into this sort of thing?
I would be inclined to file Charles’ baby-hamper under the category of ‘foolish nonsense’. Ok, it exploits the love of parents for their new-borns – £195 per item is not exactly cheap (even considering that it is HAND-NUMBERED!) – but the type of customer who might buy this product is probably not on the brink of financial hardship. The ‘foolish nonsense’ does, however, acquire a more sinister significance through the fact that the heir to the throne, who arguably should be an example to us all, yet again is responsible for unsubstantiated therapeutic claims. So, on balance, I think this is more than just foolish nonsense; in fact, it is yet another example of Charles misguiding the public through his passion for quackery.
Why does he do it? Does Charles need the money? No, unlike other quacks, he is not motivated by commercial interests. Is it for boosting his public image? Charles has certainly had an alternative bee under his royal bonnet for a very long time; in his quest to spread his abstruse notions of integrated health care, he has aquired an image to live up to. This new foray into quackery seems nevertheless baffling, in my view, because it is so obviously and cynically disregarding the law, regulations and evidence.
The way I see it, there are only two explanations for all this: either Charles is less aware of reality than one might have hoped, or he delegates trivial matters of this nature to one of his many sycophants without caring about the embarrassing details. Both of these possibilities are neither flattering for him nor reassuring for us…GOD SAVE THE QUEEN!
A most excellent comment by Donald Marcus on what many now call ‘quackademia‘ (the disgraceful practice of teaching quackery (alternology) such as homoeopathy, acupuncture or chiropractic at universities as if they were legitimate medical professions) has recently been published in the BMJ.
Please allow me to quote extensively from it:
A detailed review of curriculums created by 15 institutions that received educational grants from the National Center for Complementary and Alternative Medicine (NCCAM) showed that they failed to conform to the principles of evidence based medicine. In brief, they cited many poor quality clinical trials that supported the efficacy of alternative therapies and omitted negative clinical trials; they had not been updated for 6-7 years; and they omitted reports of serious adverse events associated with CAM therapies, especially with chiropractic manipulation and with non-vitamin, non-mineral dietary supplements such as herbal remedies. Representation of the curriculums as “evidence based” was inaccurate and unjustified. Similar defects were present in the curriculums of other integrative medicine programs that did not receive educational grants….
A re-examination of the integrative medicine curriculums reviewed previously showed that they were essentially unchanged since their creation in 2002-03…Why do academic centers that are committed to evidence based medicine and to comparative effectiveness analysis of treatments endorse CAM? One factor may be a concern about jeopardizing income from grants from NCCAM, from CAM clinical practice, and from private foundations that donate large amounts of money to integrative medicine centers. Additional factors may be concern about antagonizing faculty colleagues who advocate and practice CAM, and inadequate oversight of curriculums.
By contrast to the inattention of US academics and professional societies to CAM education, biomedical scientists in Great Britain and Australia have taken action. At the beginning of 2007, 16 British universities offered 45 bachelor of science degrees in alternative practices. As the result of a campaign to expose the lack of evidence supporting those practices, most courses in alternative therapies offered by public universities in Britain have been discontinued. Scientists, physicians, and consumer advocates in Australia have formed an organization, Friends of Science in Medicine, to counter the growth of pseudoscience in medicine.
The CAM curriculums violate every tenet of evidence based medicine, and they are a disservice to learners and to the public. It could be argued that, in the name of academic freedom, faculty who believe in the benefits of CAM have a right to present their views. However, as educators and role models they should adhere to the principles of medical professionalism, including “a duty to uphold scientific standards.” Faculty at health profession schools should urge administrators to appoint independent committees to review integrative medicine curriculums, and to consider whether provision of CAM clinical services is consistent with a commitment to scholarship and to evidence based healthcare.
One of the first who openly opposed science degrees without science was David Colquhoun; in an influential article published in Nature, he wrote:
The least that one can expect of a bachelor of science (BSc) honours degree is that the subject of the degree is science. Yet in December 2006 the UK Universities and Colleges Admissions Service advertised 61 courses for complementary medicine, of which 45 are BSc honours degrees. Most complementary and alternative medicine (CAM) is not science because the vast majority of it is not based on empirical evidence. Homeopathy, for example, has barely changed since the beginning of the nineteenth century. It is much more like religion than science. Worse still, many of the doctrines of CAM, and quite a lot of its practitioners, are openly anti-science.
More recently, Louise Lubetkin wrote in her post ‘Quackademia‘ that alternative medicine and mainstream medicine are absolutely not equivalent, nor are they by any means interchangeable, and to speak about them the way one might when debating whether to take the bus or the subway to work – both will get you there reliably – constitutes an assault on truth.
I think ‘quackademia’ is most definitely an assault on truth – and I certainly know what I am talking about. When, in 1993, I was appointed as Professor of Complementary Medicine at Exeter, I became the director of a pre-existing team of apologists teaching a BSc-course in alternative medicine to evangelic believers. I was horrified and had to use skill, diplomacy and even money to divorce myself from this unit, an experience which I will not forget in a hurry. In fact, I am currently writing it up for a book I hope to publish soon which covers not only this story but many similarly bizarre encounters I had while researching alternative medicine during the last two decades.
Acupressure is a treatment-variation of acupuncture; instead of sticking needles into the skin, pressure is applied over ‘acupuncture points’ which is supposed to provide a stimulus similar to needling. Therefore the effects of both treatments should theoretically be similar.
Acupressure could have several advantages over acupuncture:
- it can be used for self-treatment
- it is suitable for people with needle-phobia
- it is painless
- it is not invasive
- it has less risks
- it could be cheaper
But is acupressure really effective? What do the trial data tell us? Our own systematic review concluded that the effectiveness of acupressure is currently not well documented for any condition. But now there is a new study which might change this negative verdict.
The primary objective of this 3-armed RCT was to assess the effectiveness and cost-effectiveness of self-acupressure using wristbands compared with sham acupressure wristbands and standard care alone in the management of chemotherapy-induced nausea. 500 patients from outpatient chemotherapy clinics in three regions in the UK involving 14 different cancer units/centres were randomised to the wristband arm, the sham wristband arm and the standard care only arm. Participants were chemotherapy-naive cancer patients receiving chemotherapy of low, moderate and high emetogenic risk. The experimental group were given acupressure wristbands pressing the P6 point (anterior surface of the forearm). The Rhodes Index for Nausea/Vomiting, the Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool and the Functional Assessment of Cancer Therapy General (FACT-G) served as outcome measures. At baseline, participants completed measures of anxiety/depression, nausea/vomiting expectation and expectations from using the wristbands.
Data were available for 361 participants for the primary outcome. The primary outcome analysis (nausea in cycle 1) revealed no statistically significant differences between the three arms. The median nausea experience in patients using wristbands (both real and sham ones) was somewhat lower than that in the anti-emetics only group (median nausea experience scores for the four cycles: standard care arm 1.43, 1.71, 1.14, 1.14; sham acupressure arm 0.57, 0.71, 0.71, 0.43; acupressure arm 1.00, 0.93, 0.43, 0). Women responded more favourably to the use of sham acupressure wristbands than men (odds ratio 0.35 for men and 2.02 for women in the sham acupressure group; 1.27 for men and 1.17 for women in the acupressure group). No significant differences were detected in relation to vomiting outcomes, anxiety and quality of life. Some transient adverse effects were reported, including tightness in the area of the wristbands, feeling uncomfortable when wearing them and minor swelling in the wristband area (n = 6). There were no statistically significant differences in the costs associated with the use of real acupressure band.
26 subjects took part in qualitative interviews. Participants perceived the wristbands (both real and sham) as effective and helpful in managing their nausea during chemotherapy.
The authors concluded that there were no statistically significant differences between the three arms in terms of nausea, vomiting and quality of life, although apparent resource use was less in both the real acupressure arm and the sham acupressure arm compared with standard care only; therefore; no clear conclusions can be drawn about the use of acupressure wristbands in the management of chemotherapy-related nausea and vomiting. However, the study provided encouraging evidence in relation to an improved nausea experience and some indications of possible cost savings to warrant further consideration of acupressure both in practice and in further clinical trials.
I could argue about several of the methodological details of this study. But I resist the temptation in order to focus on just one single point which I find important and which has implications beyond the realm of acupressure.
Why on earth do the authors conclude that no clear conclusions can be drawn about the use of acupressure wristbands in the management of chemotherapy-related nausea and vomiting? The stated aim of this RCT was to assess the effectiveness and cost-effectiveness of self-acupressure using wristbands compared with sham acupressure wristbands and standard care. The results failed to show significant differences of the primary outcome measures, consequently the conclusion cannot be “unclear”, it has to be that ACUPRESSURE WRIST BANDS ARE NOT MORE EFFECTIVE THAN SHAM ACUPRESSURE WRIST BANDS AS AN ADJUNCT TO ANTI-EMETIC DRUG TREATMENT (or something to that extent).
As long as RCTs of alternative therapies are run by evangelic believers in the respective therapy, we are bound to regularly encounter this lamentable phenomenon of white-washing negative findings with an inadequate conclusion. In my view, this is not research or science, it is pseudo-research or pseudo-science. And it is much more than a nuisance or a trivial matter; it is a waste of research funds, a waste of patients’ good will that has reached a point where people will lose trust in alternative medicine research. Someone should really do a systematic study to identify those research teams that regularly commit such scientific misconduct and ensure that they are cut off public funding and support.
A recent article by a South African homeopath promoted the concept of homeopaths taking over the role of primary care practitioners. His argument essentially was that, in South Africa, homeopaths are well trained and thus adequately equipped to do this job responsibly. Responsibly, really? You find that hard to believe? Here are the essentials of his arguments including all his references in full. I think they are worth reading.
Currently, the Durban University of Technology (DUT) and the University of Johannesburg (UJ) offer degree’s in homoeopathy. This involves a 5-year full-time theoretical and practical training course, followed by a Master’s level research project. After fulfilment of these criteria, a Master’s Degree in Technology (Homoeopathy) is awarded. The course comprises of a strong core of medical subjects, such as the basic sciences of Anatomy, Physiology, Medical Microbiology, Biochemistry and Epidemiology, and the clinical sciences of Pathology and Diagnostics. This is complemented with subjects in Classical, Clinical and Modern Homoeopathy and Homoeopharmaceutics4,5…
By law, any person practicing homoeopathy in South Africa must be registered with the Allied Health Professions Council of South Africa (AHPCSA). This is essential, as the Council ensures both medical and homoeopathic competency of practitioners, and that the activities of registered practitioners are closely monitored by the Professional Board. The purpose of the AHPCSA is to ensure that only those with legitimate qualifications of a high enough standard are registered and allowed to practice in South Africa, thus protecting the public against any fraudulent behaviour and illegal practitioners. Therefore, in order to ensure effective homoeopathic treatment, it is essential that any person wishing to prescribe homoeopathic medicine or practice homoeopathy in South Africa must be registered as a Homoeopathic Practitioner with the Allied Health Professions Council of South Africa. This includes conventional Medical Practitioners (dual registration is allowed for Medical Practitioners with both the Health Professions Council and AHPCSA)6, as homoeopathy requires several years of training in order to apply effectively in clinical practice…
Registration with the Council affords medico-legal rights similar to those of a medical professional, where treatment is limited to the scope of homoeopathic practice. Thus a homoeopath is firstly a trained diagnostician, and with successful registration with the Council, obtains the title Doctor. A homoeopath is trained and legally obliged to conduct a full medical history, a comprehensive clinical examination, and request further medical investigations, such as blood tests and X-rays, in order to fully assess patients. This is coupled with the ability to consult with specialist pathologists and other medical specialists when necessary, and refer a patient to the appropriate practitioner if the condition falls outside the scope of homoeopathic practice. A homoeopath may also legally issue a certificate of dispensation (‘Doctor’s note’) with appropriate evidence and within reason, and is deemed responsible for the diagnosis and treatment of patients under their care6. A homoeopath is not trained or licensed in any form of surgery, specialist diagnostics (e.g. colonoscopy or angiograms), cannot prescribe prescription medication and is not lawfully allowed to conduct intra-venous treatment of any kind. However, a registered homoeopath is licensed to use intra-muscular homoeopathic injectables in the treatment of various local or systemic complaints when necessary.
Conventional (allopathic) medicine generally targets specific biochemical processes with mostly chemically synthesised medication, in an attempt to suppress a symptom. However, in doing so, this usually negatively affects other biochemical reactions which results in an imbalance within the system. Homoeopathy, by contrast, seeks to re-establish a balance within the natural functioning of the body, restore proper function and results in the reduction or cessation of symptoms. Homoeopathy therefore enables the body to self-regulate and self-heal, a process known as homeostasis that is intrinsic to every living organism.
Conventional medical treatment is by no means risk free. Iatrogenic (medically induced) deaths in the United States are estimated at 786 000 per year, deaths which are considered avoidable by medical doctors7,8. These figures put annual iatrogenic death in the American medical system above that of cardiovascular disease and cancer as the leading cause of death in that country9, a fact that is not widely reported! South African figures are not easily available, but it is likely that we have similar rates. Although conventional medications have a vital role, are sometimes necessary and can of-course be life-saving, all too often too many patients are put on chronic medication when there are numerous effective, natural, safe and scientifically substantiated options available….
According to the World Health Organisation (WHO), homeopathy is the second largest system of medicine in the world, and world-wide use continues to grow in developed and developing nations10. Homoeopathy is widely considered to be safe and effective, with both clinical and laboratory research providing evidence for the efficacy of homoeopathy11. As the range of potential conditions that homoeopathy can treat is almost limitless, and that treatment is not associated with adverse reactions, homoeopathy should be considered a first-line therapy for all ages. As homoeopaths in South Africa are considered primary health care practitioners, if a conventional approach is deemed necessary, and further diagnostics are required, your practitioner will not hesitate to refer you to the appropriate health care practitioner. Homeopathy is also used alongside conventional medicine and any other form of therapy, and should be seen as ‘complementary’ medicine and not ‘alternative’ medicine.
Homoeopathy is an approach that is widely considered to be safe, and when utilised correctly, can be effective for a wide range of conditions. As a primary health care practitioner, a homoeopath is able to handle all aspects of general practice and family health care, including diagnostics, case management and referral to other practitioners or medical specialists. A registered homoeopath is legally responsible to ensure the adequate treatment of their patients, and is accountable for all clinical decisions and advice. A registered homoeopath understands the role of conventional medicine, and will refer to the appropriate specialist in cases that fall outside the legal scope of practice.
1. http://homeopathyresource.wordpress.com/what-is-homeopathy (accessed 31 March 2010)
2. Bloch R, Lewis B. Homoeopathy for the home. Cape Town, South Africa: Struik Publishers: 2003
3. http://www.dut.ac.za/site/awdep.asp?depnum=22609 (accessed 1 April 2010)
4. http://dutweb.dut.ac.za/handbooks/HEALTH%20Homoeopathy.pdf (accessed 1 April 2010)
5. http://www.uj.ac.za/EN/Faculties/health/departments/homeopathy/coursesandprogrammes/undergraduate/Pages/default.aspx (accessed 1 April 2010)
6. http://www.ahpcsa.co.za/pb_pbhnp_homoeopathy.htm (accessed 6 April 2010)
7. Starfield, B. Is US Health Really the Best in the World? JAMA 2000; 284(4).
8. Null G, Dean C, et al. Death by Medicine. Nutrition Institute of America 2003. 9. http://www4.dr-rath-foundation.org/features/death_by_medicine.html (accessed 7 April 2010)
10. http://ukiahcommunityblog.wordpress.com/2010/03/04/worldwide-popularity-grows-for-homeopathy-alternative-medicine/#comments (accessed 7 April 2010)
11. http://liga.iwmh.net/dokumente/upload/556c7_SCIEN_FRA_2009_final_approved.pdf (accessed 7 April 2010)
I found this article extremely revealing and scary. It gives us an important glimpse into the way some or perhaps even most homeopaths think. They clearly believe that:
1) Their training is sufficient for them to become competent primary care professionals, i.e. clinicians who are the first port of call for sick people to be diagnosed and treated effectively.
2) Homeopathy is scientifically proven to be efficacious for an ‘almost limitless’ range of conditions. Interestingly, not a single reference is provided to support this claim. Nevertheless, homeopath believe it, and that seems to be enough.
3) Homeopaths seem convinced that they perfectly understand real medicine; yet all they really do is to denounce it as one of the biggest killer of mankind.
4) The fact that homeopaths cannot prescribe real medicine is not seen as a hindrance to their role as primary care practitioner; if anything, homeopaths consider this to be an advantage.
5) Homeopaths view registration with some sort of governing body as the ultimate legitimation of their trade. Once such regulatory measures are in place, the need to support any of their claims with evidence is nil and void.
This article did remind me of the wry statement that ‘HOMEOPATHY IS TO MEDICINE WHAT THE CARPET INDUSTRY IS TO AVIATION’. Homeopaths truly live on a different planet, a planet where belief is everything and responsibility is an alien concept. I certainly hope that they will not take over planet earth in a hurry. If I imagine a world where homeopaths dominate primary care in the way it is suggested in this article, I start having nightmares. It seems to me that people who harbour ideas of this type are not just deluded to the point of madness but they are a danger to public health.
This post will probably work best, if you have read the previous one describing how the parallel universe of acupuncture research insists on going in circles in order to avoid admitting that their treatment might not be as effective as they pretend. The way they achieve this is fairly simple: they conduct trials that are designed in such a way that they cannot possibly produce a negative result.
A brand-new investigation which was recently vociferously touted via press releases etc. as a major advance in proving the effectiveness of acupuncture is an excellent case in point. According to its authors, the aim of this study was to evaluate acupuncture versus usual care and counselling versus usual care for patients who continue to experience depression in primary care. This sounds alright, but wait!
755 patients with depression were randomised to one of three arms to 1)acupuncture, 2)counselling, and 3)usual care alone. The primary outcome was the difference in mean Patient Health Questionnaire (PHQ-9) scores at 3 months with secondary analyses over 12 months follow-up. Analysis was by intention-to-treat. PHQ-9 data were available for 614 patients at 3 months and 572 patients at 12 months. Patients attended a mean of 10 sessions for acupuncture and 9 sessions for counselling. Compared to usual care, there was a statistically significant reduction in mean PHQ-9 depression scores at 3 and 12 months for acupuncture and counselling.
From this, the authors conclude that both interventions were associated with significantly reduced depression at 3 months when compared to usual care alone.
Acupuncture for depression? Really? Our own systematic review with co-authors who are the most ardent apologists of acupuncture I have come across showed that the evidence is inconsistent on whether manual acupuncture is superior to sham… Therefore, I thought it might be a good idea to have a closer look at this new study.
One needs to search this article very closely indeed to find out that the authors did not actually evaluate acupuncture versus usual care and counselling versus usual care at all, and that comparisons were not made between acupuncture, counselling, and usual care (hints like the use of the word “alone” are all we get to guess that the authors’ text is outrageously misleading). Not even the methods section informs us what really happened in this trial. You find this hard to believe? Here is the unabbreviated part of the article that describes the interventions applied:
Patients allocated to the acupuncture and counselling groups were offered up to 12 sessions usually on a weekly basis. Participating acupuncturists were registered with the British Acupuncture Council with at least 3 years post-qualification experience. An acupuncture treatment protocol was developed and subsequently refined in consultation with participating acupuncturists. It allowed for customised treatments within a standardised theory-driven framework. Counselling was provided by members of the British Association for Counselling and Psychotherapy who were accredited or were eligible for accreditation having completed 400 supervised hours post-qualification. A manualised protocol, using a humanistic approach, was based on competences independently developed for Skills for Health. Practitioners recorded in logbooks the number and length of sessions, treatment provided, and adverse events. Further details of the two interventions are presented in Tables S2 and S3. Usual care, both NHS and private, was available according to need and monitored for all patients in all three groups for the purposes of comparison.
It is only in the results tables that we can determine what treatments were actually given; and these were:
1) Acupuncture PLUS usual care (i.e. medication)
2) Counselling PLUS usual care
3) Usual care
Its almost a ‘no-brainer’ that, if you compare A+B to B (or in this three-armed study A+B vs C+B vs B), you find that the former is more than the latter – unless A is a negative, of course. As acupuncture has significant placebo-effects, it never can be a negative, and thus this trial is an entirely foregone conclusion. As, in alternative medicine, one seems to need experimental proof even for ‘no-brainers’, we have some time ago demonstrated that this common sense theory is correct by conducting a systematic review of all acupuncture trials with such a design. We concluded that the ‘A + B versus B’ design is prone to false positive results…What makes this whole thing even worse is the fact that I once presented our review in a lecture where the lead author of the new trial was in the audience; so there can be no excuse of not being aware of the ‘no-brainer’.
Some might argue that this is a pragmatic trial, that it would have been unethical to not give anti-depressants to depressed patients and that therefore it was not possible to design this study differently. However, none of these arguments are convincing, if you analyse them closely (I might leave that to the comment section, if there is interest in such aspects). At the very minimum, the authors should have explained in full detail what interventions were given; and that means disclosing these essentials even in the abstract (and press release) – the part of the publication that is most widely read and quoted.
It is arguably unethical to ask patients’ co-operation, use research funds etc. for a study, the results of which were known even before the first patient had been recruited. And it is surely dishonest to hide the true nature of the design so very sneakily in the final report.
In my view, this trial begs at least 5 questions:
1) How on earth did it pass the peer review process of one of the most highly reputed medical journals?
2) How did the protocol get ethics approval?
3) How did it get funding?
4) Does the scientific community really allow itself to be fooled by such pseudo-research?
5) What do I do to not get depressed by studies of acupuncture for depression?
Has it ever occurred to you that much of the discussion about cause and effect in alternative medicine goes in circles without ever making progress? I have come to the conclusion that it does. Here I try to illustrate this point using the example of acupuncture, more precisely the endless discussion about how to best test acupuncture for efficacy. For those readers who like to misunderstand me I should explain that the sceptics’ view is in capital letters.
At the beginning there was the experience. Unaware of anatomy, physiology, pathology etc., people started sticking needles in other people’s skin, some 2000 years ago, and observed that they experienced relief of all sorts of symptoms.When an American journalist reported about this phenomenon in the 1970s, acupuncture became all the rage in the West. Acupuncture-fans then claimed that a 2000-year history is ample proof that acupuncture does work.
BUT ANECDOTES ARE NOTORIOUSLY UNRELIABLE!
Even the most enthusiastic advocates conceded that this is probably true. So they documented detailed case-series of lots of patients, calculated the average difference between the pre- and post-treatment severity of symptoms, submitted it to statistical tests, and published the notion that the effects of acupuncture are not just anecdotal; in fact, they are statistically significant, they said.
BUT THIS EFFECT COULD BE DUE TO THE NATURAL HISTORY OF THE CONDITION!
“True enough”, grumbled the acupuncture-fans and conducted the very first controlled clinical trials. Essentially they treated one group of patients with acupuncture while another group received conventional treatments as usual. When they analysed the results, they found that the acupuncture group had improved significantly more. “Now do you believe us?”, they asked triumphantly, “acupuncture is clearly effective”.
NO! THIS OUTCOME MIGHT BE DUE TO SELECTION BIAS. SUCH A STUDY-DESIGN CANNOT ESTABLISH CAUSE AND EFFECT.
The acupuncturists felt slightly embarrassed because they had not thought of that. They had allocated their patients to the treatment according to patients’ choice. Thus the expectation of the patients (or the clinician) to get relief from acupuncture might have been the reason for the difference in outcome. So they consulted an expert in trial-design and were advised to allocate not by choice but by chance. In other words, they repeated the previous study but randomised patients to the two groups. Amazingly, their RCT still found a significant difference favouring acupuncture over treatment as usual.
BUT THIS DIFFERENCE COULD BE CAUSED BY A PLACEBO-EFFECT!
Now the acupuncturists were in a bit of a pickle; as far as they could see, there was no good placebo for acupuncture! Eventually some methodologist-chap came up with the idea that, in order to mimic a placebo, they could simply stick needles into non-acupuncture points. When the acupuncturists tried that method, they found that there were improvements in both groups but the difference between real acupuncture and placebo was tiny and usually neither statistically significant nor clinically relevant.
NOW DO YOU CONCEDE THAT ACUPUNCTURE IS NOT AN EFFECTIVE TREATMENT?
Absolutely not! The results merely show that needling non-acupuncture points is not an adequate placebo. Obviously this intervention also sends a powerful signal to the brain which clearly makes it an effective intervention. What do you expect when you compare two effective treatments?
IF YOU REALLY THINK SO, YOU NEED TO PROVE IT AND DESIGN A PLACEBO THAT IS INERT.
At that stage, the acupuncturists came up with a placebo-needle that did not actually penetrate the skin; it worked like a mini stage dagger that telescopes into itself while giving the impression that it penetrated the skin just like the real thing. Surely this was an adequate placebo! The acupuncturists repeated their studies but, to their utter dismay, they found again that both groups improved and the difference in outcome between their new placebo and true acupuncture was minimal.
WE TOLD YOU THAT ACUPUNCTURE WAS NOT EFFECTIVE! DO YOU FINALLY AGREE?
Certainly not, they replied. We have thought long and hard about these intriguing findings and believe that they can be explained just like the last set of results: the non-penetrating needles touch the skin; this touch provides a stimulus powerful enough to have an effect on the brain; the non-penetrating placebo-needles are not inert and therefore the results merely depict a comparison of two effective treatments.
YOU MUST BE JOKING! HOW ARE YOU GOING TO PROVE THAT BIZARRE HYPOTHESIS?
We had many discussions and consensus meeting amongst the most brilliant brains in acupuncture about this issue and have arrived at the conclusion that your obsession with placebo, cause and effect etc. is ridiculous and entirely misplaced. In real life, we don’t use placebos. So, let’s instead address the ‘real life’ question: is acupuncture better than usual treatment? We have conducted pragmatic studies where one group of patients gets treatment as usual and the other group receives acupuncture in addition. These studies show that acupuncture is effective. This is all the evidence we need. Why can you not believe us?
NOW WE HAVE ARRIVED EXACTLY AT THE POINT WHERE WE HAVE BEEN A LONG TIME AGO. SUCH A STUDY-DESIGN CANNOT ESTABLISH CAUSE AND EFFECT. YOU OBVIOUSLY CANNOT DEMONSTRATE THAT ACUPUNCTURE CAUSES CLINICAL IMPROVEMENT. THEREFORE YOU OPT TO PRETEND THAT CAUSE AND EFFECT ARE IRRELEVANT. YOU USE SOME IMITATION OF SCIENCE TO ‘PROVE’ THAT YOUR PRECONCEIVED IDEAS ARE CORRECT. YOU DO NOT SEEM TO BE INTERESTED IN THE TRUTH ABOUT ACUPUNCTURE AT ALL.
The following is a guest post by Preston H. Long. It is an excerpt from his new book entitled ‘Chiropractic Abuse—A Chiropractor’s Lament’. Preston H. Long is a licensed chiropractor from Arizona. His professional career has spanned nearly 30 years. In addition to treating patients, he has testified at about 200 trials, performed more than 10,000 chiropractic case evaluations, and served as a consultant to several law enforcement agencies. He is also an associate professor at Bryan University, where he teaches in the master’s program in applied health informatics. His new book is one of the very few that provides an inside criticism of chiropractic. It is well worth reading, in my view.
Have you ever consulted a chiropractor? Are you thinking about seeing one? Do you care whether your tax and health-care dollars are spent on worthless treatment? If your answer to any of these questions is yes, there are certain things you should know.
1. Chiropractic theory and practice are not based on the body of knowledge related to health, disease, and health care that has been widely accepted by the scientific community.
Most chiropractors believe that spinal problems, which they call “subluxations,” cause ill health and that fixing them by “adjusting” the spine will promote and restore health. The extent of this belief varies from chiropractor to chiropractor. Some believe that subluxations are the primary cause of ill health; others consider them an underlying cause. Only a small percentage (including me) reject these notions and align their beliefs and practices with those of the science-based medical community. The ramifications and consequences of subluxation theory will be discussed in detail throughout this book.
2. Many chiropractors promise too much.
The most common forms of treatment administered by chiropractors are spinal manipulation and passive physiotherapy measures such as heat, ultrasound, massage, and electrical muscle stimulation. These modalities can be useful in managing certain problems of muscles and bones, but they have little, if any, use against the vast majority of diseases. But chiropractors who believe that “subluxations” cause ill health claim that spinal adjustments promote general health and enable patients to recover from a wide range of diseases. The illustrations below reflect these beliefs. The one to the left is part of a poster that promotes the notion that periodic spinal “adjustments” are a cornerstone of good health. The other is a patient handout that improperly relates “subluxations” to a wide range of ailments that spinal adjustments supposedly can help. Some charts of this type have listed more than 100 diseases and conditions, including allergies, appendicitis, anemia, crossed eyes, deafness, gallbladder problems, hernias, and pneumonia.
A 2008 survey found that exaggeration is common among chiropractic Web sites. The researchers looked at the Web sites of 200 chiropractors and 9 chiropractic associations in Australia, Canada, New Zealand, the United Kingdom, and the United States. Each site was examined for claims suggesting that chiropractic treatment was appropriate for asthma, colic, ear infection/earache/otitis media, neck pain, whiplash, headache/migraine, and lower back pain. The study found that 95% of the surveyed sites made unsubstantiated claims for at least one of these conditions and 38% made unsubstantiated claims for all of them.1 False promises can have dire consequences to the unsuspecting.
3. Our education is vastly inferior to that of medical doctors.
I rarely encountered sick patients in my school clinic. Most of my “patients” were friends, students, and an occasional person who presented to the student clinic for inexpensive chiropractic care. Most had nothing really wrong with them. In order to graduate, chiropractic college students are required to treat a minimum number of people. To reach their number, some resort to paying people (including prostitutes) to visit them at the college’s clinic.2
Students also encounter a very narrow range of conditions, most related to aches and pains. Real medical education involves contact with thousands of patients with a wide variety of problems, including many severe enough to require hospitalization. Most chiropractic students see patients during two clinical years in chiropractic college. Medical students also average two clinical years, but they see many more patients and nearly all medical doctors have an additional three to five years of specialty training before they enter practice.
Chiropractic’s minimum educational standards are quite low. In 2007, chiropractic students were required to evaluate and manage only 15 patients in order to graduate. Chiropractic’s accreditation agency ordered this number to increase to 35 by the fall of 2011. However, only 10 of the 35 must be live patients (eight of whom are not students or their family members)! For the remaining cases, students are permitted to “assist, observe, or participate in live, paper-based, computer-based, distance learning, or other reasonable alternative.”3 In contrast, medical students see thousands of patients.
Former National Council Against Health Fraud President William T. Jarvis, Ph.D., has noted that chiropractic school prepares its students to practice “conversational medicine”—where they glibly use medical words but lack the knowledge or experience to deal appropriately with the vast majority of health problems.4 Dr. Stephen Barrett reported a fascinating example of this which occurred when he visited a chiropractor for research purposes. When Barrett mentioned that he was recovering from an attack of vertigo (dizziness), the chiropractor quickly rattled off a textbook-like list of all the possible causes. But instead of obtaining a proper history and conducting tests to pinpoint a diagnosis, he x-rayed Dr. Barrett’s neck and recommended a one-year course of manipulations to make his neck more curved. The medical diagnosis, which had been appropriately made elsewhere, was a viral infection that cleared up spontaneously in about ten days.5
4. Our legitimate scope is actually very narrow.
Appropriate chiropractic treatment is relevant only to a narrow range of ailments, nearly all related to musculoskeletal problems. But some chiropractors assert that they can influence the course of nearly everything. Some even offer adjustments to farm animals and family pets.
5. Very little of what chiropractors do has been studied.
Although chiropractic has been around since 1895, little of what we do meets the scientific standard through solid research. Chiropractic apologists try to sound scientific to counter their detractors, but very little research actually supports what chiropractors do.
6. Unless your diagnosis is obvious, it’s best to get diagnosed elsewhere.
During my work as an independent examiner, I have encountered many patients whose chiropractor missed readily apparent diagnoses and rendered inappropriate treatment for long periods of time. Chiropractors lack the depth of training available to medical doctors. For that reason, except for minor injuries, it is usually better to seek medical diagnosis first.
7. We offer lots of unnecessary services.
Many chiropractors, particularly those who find “subluxations” in everyone, routinely advise patients to come for many months, years, and even for their lifetime. Practice-builders teach how to persuade people they need “maintenance care” long after their original problem has resolved. In line with this, many chiropractors offer “discounts” to patients who pay in advance and sign a contract committing them for 50 to 100 treatments. And “chiropractic pediatric specialists” advise periodic examinations and spinal adjustments from early infancy onward. (This has been aptly described as “womb to tomb” care.) Greed is not the only factor involved in overtreatment. Many who advise periodic adjustments are “true believers.” In chiropractic school, one of my classmates actually adjusted his newborn son while the umbilical cord was still attached. Another student had the school radiology department take seven x-rays of his son’s neck to look for “subluxations” presumably acquired during the birth process. The topic of unnecessary care is discussed further in Chapter 8.
8. “Cracking” of the spine doesn’t mean much.
Spinal manipulation usually produces a “popping” or “cracking” sound similar to what occurs when you crack your knuckles. Both are due to a phenomenon called cavitation, which occurs when there is a sudden decrease in joint pressure brought on by the manipulation. That allows dissolved gasses in the joint fluid to be released into the joint itself. Chiropractors sometimes state that the noise means that something therapeutic has taken place. However, the noise has no health-related significance and does not indicate that anything has been realigned. It simply means that gas was allowed to escape under less pressure than normal. Knuckles do not “go back into place” when you crack them, and neither do spinal bones.
9. If the first few visits don’t help you, more treatment probably won’t help.
I used to tell my patients “three and through.” If we did not see significant objective improvement in three visits, it was time to move on.
10. We take too many x-rays.
No test should be done unless it is likely to provide information that will influence clinical management of the patient. X-ray examinations are appropriate when a fracture, tumor, infection, or neurological defect is suspected. But they are not needed for evaluating simple mechanical-type strains, such as back or neck pain that develops after lifting a heavy object.
The average number of x-rays taken during the first visit by chiropractors whose records I have been asked to review has been about eleven. Those records were sent to me because an insurance company had flagged them for investigation into excessive billing, so this number of x-rays is much higher than average. But many chiropractors take at least a few x-rays of everyone who walks through their door.
There are two main reasons why chiropractors take more x-rays than are medically necessary. One is easy money. It costs about 35¢ to buy an 8- x 10-inch film, for which they typically charge $40. In chiropractic, the spine encompasses five areas: the neck, mid-back, low-back, pelvic, and sacral regions. That means five separate regions to bill for—typically three to seven views of the neck, two to six for the low back, and two for each of the rest. So eleven x-ray films would net the chiropractor over $400 for just few minutes of work. In many accident cases I have reviewed, the fact that patients had adequate x-ray examinations in a hospital emergency department to rule out fractures did not deter the chiropractor from unnecessarily repeating these exams.
Chiropractors also use x-ray examinations inappropriately for marketing purposes. Chiropractors who do this point to various things on the films that they interpret as (a) subluxations, (b) not enough spinal curvature, (c) too much spinal curvature, and/or (d) “spinal decay,” all of which supposedly call for long courses of adjustments with periodic x-ray re-checks to supposedly assess progress. In addition to wasting money, unnecessary x-rays entail unnecessary exposure to the risks of ionizing radiation.
11. Research on spinal manipulation does not reflect what takes place in most chiropractic offices.
Research studies that look at spinal manipulation are generally done under strict protocols that protect patients from harm. The results reflect what happens when manipulation is done on patients who are appropriately screened—usually by medical teams that exclude people with conditions that would make manipulation dangerous. The results do not reflect what typically happens when patients select chiropractors on their own. The chiropractic marketplace is a mess because most chiropractors ignore research findings and subject their patients to procedures that are unnecessary and/or senseless.
12. Neck manipulation is potentially dangerous.
Certain types of chiropractic neck manipulation can damage neck arteries and cause a stroke. Chiropractors claim that the risk is trivial, but they have made no systematic effort to actually measure it. Chapter 9 covers this topic in detail.
13. Most chiropractors don’t know much about nutrition.
Chiropractors learn little about clinical nutrition during their schooling. Many offer what they describe as “nutrition counseling.” But this typically consists of superficial advice about eating less fat and various schemes to sell you supplements that are high-priced and unnecessary.
14. Chiropractors who sell vitamins charge much more than it costs them.
Chiropractors who sell vitamins typically recommend them unnecessarily and charge two to three times what they pay for them. Some chiropractors center their practice around selling vitamins to patients. Their recommendations are based on hair analysis, live blood analysis, applied kinesiology muscle-testing or other quack tests that will be discussed later in this book. Patients who are victimized this way typically pay several dollars a day and are encouraged to stay on the products indefinitely. In one case I investigated, an Arizona chiropractor advised an 80+-year-old grandma to charge more than $10,000 for vitamins to her credit cards to avoid an impending stroke that he had diagnosed by testing a sample of her pubic hair. No hair test can determine that a stroke is imminent or show that dietary supplements are needed. Doctors who evaluated the woman at the Mayo Clinic found no evidence to support the chiropractor’s assessment.
15. Chiropractors have no business treating young children.
The pediatric training chiropractors receive during their schooling is skimpy and based mainly on reading. Students see few children and get little or no experience in diagnosing or following the course of the vast majority of childhood ailments. Moreover, spinal adjustment has no proven effectiveness against childhood diseases. Some adolescents with spinal stiffness might benefit from manipulation, but most will recover without treatment. Chiropractors who claim to practice “chiropractic pediatrics” typically aim to adjust spines from birth onward and are likely to oppose immunization. Some chiropractors claim they can reverse or lessen the spinal curvature of scoliosis, but there is no scientific evidence that spinal manipulation can do this.6
16. The fact that patients swear by us does not mean we are actually helping them.
Satisfaction is not the same thing as effectiveness. Many people who believe they have been helped had conditions that would have resolved without treatment. Some have had treatment for dangers that did not exist but were said by the chiropractor to be imminent. Many chiropractors actually take courses on how to trick patients to believe in them. (See Chapter 8)
17. Insurance companies don’t want to pay for chiropractic care.
Chiropractors love to brag that their services are covered by Medicare and most insurance companies. However, this coverage has been achieved though political action rather than scientific merit. I have never encountered an insurance company that would reimburse for chiropractic if not forced to do so by state laws. The political pressure to mandate chiropractic coverage comes from chiropractors, of course, but it also comes from the patients whom they have brainwashed.
18. Lots of chiropractors do really strange things.
The chiropractic profession seems to attract people who are prone to believe in strange things. One I know of does “aura adjustments” to treat people’s “bruised karma.” Another rents out a large crystal to other chiropractors so they can “recharge” their own (smaller) crystals. Another claims to get advice by “channeling” a 15th Century Scottish physician. Another claimed to “balance a woman’s harmonics” by inserting his thumb into her vagina and his index finger into her anus. Another treated cancer with an orange light that was mounted in a wooden box. Another did rectal exams on all his female patients. Even though such exams are outside the legitimate scope of chiropractic, he also videotaped them so that if his bills for this service were questioned, he could prove that he had actually performed what he billed for.
19. Don’t expect our licensing boards to protect you.
Many chiropractors who serve on chiropractic licensing boards harbor the same misbeliefs that are rampant among their colleagues. This means, for example, that most boards are unlikely to discipline chiropractors for diagnosing and treating imaginary “subluxations.”
20. The media rarely look at what we do wrong.
The media rarely if ever address chiropractic nonsense. Reporting on chiropractic is complicated because chiropractors vary so much in what they do. (In fact, a very astute observer once wrote that “for every chiropractor, there is an equal and opposite chiropractor.”) Consumer Reports published superb exposés in 1975 and 1994, but no other print outlet has done so in the past 35 years. This lack of information is the main reason I have written this book.
1. Ernst E, Gilbey A. Chiropractic claims in the English-speaking world. New Zealand Medical Journal 123:36–44, 2010.
2. Bernet J. Affidavit, April 12, 1996. Posted to Chirobase Web site.
3. Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status. Council on Chiropractic Education, Scottsdale, Arizona, Jan 2007.
4. Jarvis WT. Why becoming a chiropractor may be risky. Chirobase Web site, October 5, 1999.
5. Barrett S. My visit to a “straight” chiropractor. Quackwatch Web site, Oct 10, 2002.
6. Romano M, Negrini S. Manual therapy as a conservative treatment for idiopathic scoliosis: A review. Scoliosis 3:2, 2008.
As I write these words, I am travelling back from a medical conference. The organisers had invited me to give a lecture which I concluded saying: “anyone in medicine not believing in evidence-based health care is in the wrong business”. This statement was meant to stimulate the discussion and provoke the audience who were perhaps just a little on the side of those who are not all that taken by science.
I may well have been right, because, in the coffee break, several doctors disputed my point; to paraphrase their arguments: “You don’t believe in the value of experience, you think that science is the way to know everything. But you are wrong! Philosophers and other people, who are a lot cleverer than you, tell us that science is not the way to real knowledge; and in some forms of medicine we have a wealth of experience which we cannot ignore. This is at least as important as scientific knowledge. Take TCM, for instance, thousands of years of tradition must mean something; in fact it tells us more than science will ever be able to. Qi-energy, for instance, is a concept based on experience, and science is useless at verifying it.”
I disagreed, of course. But I am afraid that I did not convince my colleagues. The appeal to tradition is amazingly powerful, so much so that even well-seasoned physicians fall for it. Yet it nevertheless is a fallacy, I am sure.
So what does experience tell us, how is it generated and why should it be unreliable?
On the level of the individual, experience emerges when a clinician makes similar observations several times in a row. This is so persuasive that few doctors are immune to the phenomenon. Let’s assume the experience is about acupuncture, more precisely about acupuncture for smoking cessation. The acupuncturist presumably has learnt during his training that his therapy works for that indication via stimulating the flow of Qi, and promptly tries it on several patients. Some of them come back for more and report that they find it easier to give up cigarettes after consulting him. This happens repeatedly, and our clinician forthwith is convinced – in fact, he knows – that acupuncture is effective for smoking cessation.
If we critically analyse this scenario, what does it tell us? It tells us very little of relevance, I am afraid. The scenario is entirely compatible with a whole host of explanations which have nothing to do with the effects of acupuncture per se:
- Those patients who did not manage to stop smoking might not have returned. Only seeing his successes without his failures, the acupuncturist would have got the wrong end of the stick.
- Human memory is selective such that the few patients who did come back and reported failure might easily get forgotten by the clinician. We all remember the good things and forget the disappointments, particularly if we are clinicians.
- The placebo-effect might have played a dirty trick on the experience of our acupuncturist.
- Some patients might have used nicotine patches that helped him to stop smoking without disclosing this fact to the acupuncturist who then, of course, attributed the benefit to his needling.
- The acupuncturist – being a very kind and empathetic clinician – might have involuntarily induced some of his patients to show kindness in return and thus tell porkies about their smoking habits which would have created a false positive impression about the effectiveness of his treatment.
- Being so empathetic, the acupuncturists would have provided lots of encouragement to stop smoking which, in some patients, might have been sufficient to kick the habit.
The long and short of all this is that our acupuncturist gradually got convinced by this interplay of factors that Qi exists and that acupuncture is an ineffective treatment. Hence forth he would bet his last shirt that he is right about this – after all, he has seen it with his own eyes, not just once but many times. And he will doubt anyone who shows him evidence that says otherwise. In fact, he is likely become very sceptical about scientific evidence in general – just like the doctors who talked to me after my lecture.
On a population level, such experience will be prevalent in not just one but most acupuncturists. Our clinician’s experience is certainly not unique; others will have made it too. In fact, as an acupuncturist, it is hard not to make it. Acupuncturists would have told everyone else about it, perhaps reported it on conferences or published it in articles or books. Experience of this nature is passed on from generation to generation, and soon someone will be able to demonstrate that acupuncture has been used ’effectively’ for smoking cessation since decades or centuries. The creation of a myth out of unreliable experience is thus complete.
Am I saying that experience of this nature is always and necessarily wrong or useless? No, I am not. It can be and often is correct. But, at the same time, it is frequently incorrect. It can serve as a valuable indicator but not more. Experience is not a tool for reliably informing us about the effectiveness of medical interventions. Experience based-medicine is an obsolete pseudo-medicine burdened with concepts that are counter-productive to optimal health care.
Philosophers and other people who are much cleverer than I am have been trying for some time to separate good from bad science and evidence from experience. Most recently, two philosophers, MASSIMO PIGLIUCCI and MAARTEN BOUDRY, commented specifically on this problem in relation to TCM. I leave you with some extensive quotes from what they wrote.
… pointing out that some traditional Chinese remedies (like drinking fresh turtle blood to alleviate cold symptoms) may in fact work, and therefore should not be dismissed as pseudoscience… risks confusing the possible effectiveness of folk remedies with the arbitrary theoretical-metaphysical baggage attached to it. There is no question that some folk remedies do work. The active ingredient of aspirin, for example, is derived from willow bark…
… claims about the existence of “Qi” energy, channeled through the human body by way of “meridians,” though, is a different matter. This sounds scientific, because it uses arcane jargon that gives the impression of articulating explanatory principles. But there is no way to test the existence of Qi and associated meridians, or to establish a viable research program based on those concepts, for the simple reason that talk of Qi and meridians only looks substantive, but it isn’t even in the ballpark of an empirically verifiable theory.
…the notion of Qi only mimics scientific notions such as enzyme actions on lipid compounds. This is a standard modus operandi of pseudoscience: it adopts the external trappings of science, but without the substance.
…The notion of Qi, again, is not really a theory in any meaningful sense of the word. It is just an evocative word to label a mysterious force of which we do not know and we are not told how to find out anything at all.
Still, one may reasonably object, what’s the harm in believing in Qi and related notions, if in fact the proposed remedies seem to help? Well, setting aside the obvious objections that the slaughtering of turtles might raise on ethical grounds, there are several issues to consider. To begin with, we can incorporate whatever serendipitous discoveries from folk medicine into modern scientific practice, as in the case of the willow bark turned aspirin. In this sense, there is no such thing as “alternative” medicine, there’s only stuff that works and stuff that doesn’t.
Second, if we are positing Qi and similar concepts, we are attempting to provide explanations for why some things work and others don’t. If these explanations are wrong, or unfounded as in the case of vacuous concepts like Qi, then we ought to correct or abandon them. Most importantly, pseudo-medical treatments often do not work, or are even positively harmful. If you take folk herbal “remedies,” for instance, while your body is fighting a serious infection, you may suffer severe, even fatal, consequences.
…Indulging in a bit of pseudoscience in some instances may be relatively innocuous, but the problem is that doing so lowers your defenses against more dangerous delusions that are based on similar confusions and fallacies. For instance, you may expose yourself and your loved ones to harm because your pseudoscientific proclivities lead you to accept notions that have been scientifically disproved, like the increasingly (and worryingly) popular idea that vaccines cause autism.
Philosophers nowadays recognize that there is no sharp line dividing sense from nonsense, and moreover that doctrines starting out in one camp may over time evolve into the other. For example, alchemy was a (somewhat) legitimate science in the times of Newton and Boyle, but it is now firmly pseudoscientific (movements in the opposite direction, from full-blown pseudoscience to genuine science, are notably rare)….
The borderlines between genuine science and pseudoscience may be fuzzy, but this should be even more of a call for careful distinctions, based on systematic facts and sound reasoning. To try a modicum of turtle blood here and a little aspirin there is not the hallmark of wisdom and even-mindedness. It is a dangerous gateway to superstition and irrationality