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

risk

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So-called alternative medicine (SCAM) is, as we all know, an umbrella term. Under this umbrella, we find hundreds of different modalities that have little in common with each other. Here I often focus on:

  • homeopathy,
  • chiropractic,
  • acupuncture,
  • herbal medicine.

There are uncounted others, and in my recent book, I published critical evaluations 150 of them. But for the moment, let’s keep to the 4 SCAMs listed above.

What strikes me regularly is that many SCAM enthusiasts do seem to appreciate my critical assessments of SCAM; for instance:

  • When I point out that the assumptions of homeopathy fly in the face of science, most SCAM enthusiasts agree.
  • When I point out that chiropractic spinal manipulations might not be safe, most SCAM enthusiasts agree.
  • When I point out that acupuncture is not a panacea, most SCAM enthusiasts agree.
  • When I point out that herbal remedies can interact with prescribed drugs, most SCAM enthusiasts agree.

Most but not all!

  • Those who find my criticism of homeopathy unfair are the homeopaths and their proponents.
  • Those who find my criticism of chiropractic unfair are the chiropractors and their proponents.
  • Those who find my criticism of acupuncture unfair are the acupuncturists and their proponents.
  • Those who find my criticism of herbal medicine unfair are the herbalists and their proponents.

Hardly ever does a herbalist defend homeopathy’s weird assumptions; rarely does an acupuncturist tell me that I am too harsh with the chiropractors; never have I heard a chiropractor complain that my criticism of acupuncture is unjustified.

Entirely obvious?

Perhaps!

But I find it nevertheless curious, because my critical stance is always the same. I do not change it for this or that form of SCAM (I would also not change it for conventional medicine, but I leave it to those who have more specific expertise to do the criticising). I have no axe to grind against any particular SCAM. All I do is point out flaws in their logic, limitations in their studies, gaps in the evidence. All I do is provide my honest interpretation of the evidence.

It really seems to me that everyone appreciates my honesty, until I start being honest with them.

And this is why I find it curious. Homeopaths, chiropractors, acupuncturists, herbalists and all the other types of SCAM practitioners like to be seen on the side of science, evidence, critical thinking and progress. This, I suppose, is good for the (self) image; it might even help the delusion that they are all evidence-based. But as soon as someone applies science, evidence, critical thinking and progress to their very own little niche within SCAM, they stop liking it and start aggressing the critic.

I suppose this is entirely obvious as well?

Perhaps!

But it also exposes the double standard that is so deeply ingrained in SCAM.

I was criticised for not referencing this article in a recent post on adverse effects of spinal manipulation. In fact the commentator wrote: Shame on you Prof. Ernst. You get an “E” for effort and I hope you can do better next time. The paper was published in a third-class journal, but I will nevertheless quote the ‘key messages’ from this paper, because they are in many ways remarkable.

  • Adverse events from manual therapy are few, mild, and transient. Common AEs include local tenderness, tiredness, and headache. Other moderate and severe adverse events (AEs) are rare, while serious AEs are very rare.
  • Serious AEs can include spinal cord injuries with severe neurological consequences and cervical artery dissection (CAD), but the rarity of such events makes the provision of epidemiological evidence challenging.
  • Sports-related practice is often time sensitive; thus, the manual therapist needs to be aware of common and rare AEs specifically associated with spinal manipulative therapy (SMT) to fully evaluate the risk-benefit ratio.

The author of this paper is Aleksander Chaibi, PT, DC, PhD who holds several positions in the Norwegian Chiropractors’ Association, and currently holds a position as an expert advisor in the field of biomedical brain research for the Brain Foundation of the Netherlands. I feel that he might benefit from reading some more critical texts on the subject. In fact, I recommend my own 2020 book. Here are a few passages dealing with the safety of SMT:

Relatively minor AEs after SMT are extremely common. Our own systematic review of 2002 found that they occur in approximately half of all patients receiving SMT. A more recent study of 771 Finish patients having chiropractic SMT showed an even higher rate; AEs were reported in 81% of women and 66% of men, and a total of 178 AEs were rated as moderate to severe. Two further studies reported that such AEs occur in 61% and 30% of patients. Local or radiating pain, headache, and tiredness are the most frequent adverse effects…

A 2017 systematic review identified the characteristics of AEs occurring after cervical spinal manipulation or cervical mobilization. A total of 227 cases were found; 66% of them had been treated by chiropractors. Manipulation was reported in 95% of the cases, and neck pain was the most frequent indication for the treatment. Cervical arterial dissection (CAD) was reported in 57%, and 46% had immediate onset symptoms. The authors of this review concluded that there seems to be under-reporting of cases. Further research should focus on a more uniform and complete registration of AEs using standardized terminology…

In 2005, I published a systematic review of ophthalmic AEs after SMT. At the time, there were 14 published case reports. Clinical symptoms and signs included:

  • central retinal artery occlusion,
  • nystagmus,
  • Wallenberg syndrome,
  • ptosis,
  • loss of vision,
  • ophthalmoplegia,
  • diplopia,
  • Horner’s syndrome…

Vascular accidents are the most frequent serious AEs after chiropractic SMT, but they are certainly not the only complications that have been reported. Other AEs include:

  • atlantoaxial dislocation,
  • cauda equina syndrome,
  • cervical radiculopathy,
  • diaphragmatic paralysis,
  • disrupted fracture healing,
  • dural sleeve injury,
  • haematoma,
  • haematothorax,
  • haemorrhagic cysts,
  • muscle abscess,
  • muscle abscess,
  • myelopathy,
  • neurologic compromise,
  • oesophageal rupture
  • pneumothorax,
  • pseudoaneurysm,
  • soft tissue trauma,
  • spinal cord injury,
  • vertebral disc herniation,
  • vertebral fracture…

In 2010, I reviewed all the reports of deaths after chiropractic treatments published in the medical literature. My article covered 26 fatalities but it is important to stress that many more might have remained unpublished. The cause usually was a vascular accident involving the dissection of a vertebral artery (see above). The review also makes the following important points:

  • … numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death. Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely. Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition. Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive.
  • Reliable estimates of the frequency of vascular accidents are prevented by the fact that underreporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%. Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome. Incomplete reporting of outcomes might therefore further increase the true number of fatalities.
  • This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to a osteopath. A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors. This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy. The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.

Another review summarised published cases of injuries associated with cervical manipulation in China. A total of 156 cases were found. They included the following problems:

  • syncope (45 cases),
  • mild spinal cord injury or compression (34 cases),
  • nerve root injury (24 cases),
  • ineffective treatment/symptom increased (11 cases),
  • cervical spine fracture (11 cases),
  • dislocation or semi-luxation (6 cases),
  • soft tissue injury (3 cases),
  • serious accident (22 cases) including paralysis, deaths and cerebrovascular accidents.

Manipulation including rotation was involved in 42% of all cases. In total, 5 patients died…

To sum up … chiropractic SMT can cause a wide range of very serious complications which occasionally can even be fatal. As there is no AE reporting system of such events, we nobody can be sure how frequently they occur.

[references from my text can be found in the book]

2020 was certainly a difficult year (please note, I am trying a British understatement here). From the point of view of running this blog, it was sad to lose James Randi (1928 – 2020) who had been the hero of so many sceptics worldwide, and to learn of the passing of Frank Odds (1945-2020) who was a regular, thoughtful commentator here.

Reviewing the topics we tackled, I could mention dozens. But let me pick out just a few themes that I feel might be important.

HOMEOPATHY

Homeopathy continued to have a rough time; the German medical profession has finally realised that homeopathy is treatment with placebos and the German Green Party no longer backs homeopathy. In India, the Supreme Court ruled: Homeopathy must not be sold as a cure of Covid-19, and in the US improved labeling on homeopathic products were introduced. To make matters worse I issued A CHALLENGE FOR ALL HOMEOPATHS OF THE WORLD.

NOVEL SCAMs

On this blog, I like to write about new so-called alternative medicines (SCAMs) that I come accross. Blood letting is not exactly new, but Oh look! Bloodletting is back! Many other ‘innovations’ were equally noteworthy. Here is merely a very short selection of modalities that were new to me:

COVID-19

Unquestionably the BIG subject (not just) in SCAM was – is and will be for a while – the pandemic. It prompted quacks of any type to crawl out of the woodwork misleading the public about their offerings. On 24 January, I wrote for the first time about it: Coronavirus epidemic: Why don’t they ask the homeopaths for help? Thereafter, every charlatan seemed to jump on the COVID bandwaggon, even Trump: Trump seems to think that UV might be the answer to the corona-pandemic – could he mean “ultraviolet blood irradiation”?  It became difficult to decide who was making a greater fool of themselves, Trump or the homeopaths (Is this the crown of the Corona-idiocy? Nosodes In Prevention And Management Of COVID -19). Few SCAM entrepreneurs (Eight new products aimed at mitigating COVID-19. But do they really work?) were able to resist the opportunity. Snakeoil salesmen were out in force and view COVID-19 as an ‘opportunity’. It is impossible to calculate what impact all this COVID-quackery had, but I fear that many people lost their lives at least in part because of it.

VACCINATION

The unavoidable consequence of the pandemic was that the anti-vaxx brigade sensed that their moment had arrived. Ex-doctor Andrew Wakefield: “Better to die as a free man than live as a slave” (and get vaccinated against Covid-19). Again the ‘charlatan in chief’ made his influence felt through the ‘Trump-Effect’ on vaccination attitudes. Unsurprisingly, the UK ‘Society of Homeopath’ turned out to be an anti-vaxx hub that endangers public health. And where there is anti-vaxx, chiropractors are seldom far: Ever wondered why so many chiropractors are profoundly anti-vax?. All this could be just amusing, but sadly it has the potential to cost lives through Vaccine hesitancy due to so-called alternative medicine (SCAM).

ETHICS

I happen to believe that ethics in SCAM are an important, yet much neglected topic. It is easy to understand why this should be so: adhering to the rules of medical ethics would all but put an end to SCAM. This applies to chiropractic (The lack of chiropractic ethics: “valid consent was not obtained in a single case”), to homeopaths (Ethical homeopathy) and to most other SCAM professions. If I had a wish for the next year(s), it would be that funding agencies focus on research into the many ethical problems posed by the current popularity of SCAM.

CONCLUSION

If I had another wish, it would be that critical thinking becomes a key subject in schools, universities and adult education. Why do so many people make irrational choices? One answer to this question is, because we fail to give this subject the importance it demands. The lack of critical thinking is the reason why we elect leaders who are compulsory lyers, make wrong choices about healthcare, and continue to destroy the planet as though there is no tomorrow. It is high time that we, as a society, realise how fundamentally important critical thinking truly is.

OUTLOOK

Yes, 2020 was difficult: Brexit, COVID-19, anti-vaxx, etc. But it was not all bad (certainly not for me personally), and there is good reason for hope: the globally malign influence of Trump is about to disappear, and we now have several effective vaccines. Common sense, decency and science might triumph after all.

HEALTHY NEW YEAR EVERYONE!

I often hear that my ambitions to inform the public and inspire critical thinking are hopeless: there are simply too many quacks trumpeting nonsense, and their collective influence is surely bigger than mine. This can be depressing, of course. And because I often feel that I am fighting an unwinnable battle, stories like this are so importand and up-lifting.

Denby Royal was a ‘holistic nutritionist’, then she became a critic of so-called alternative medicine (SCAM). Here is the story about her transformation:

… I had gone to holistic nutrition school. I was running my own nutrition consulting business. And suddenly I didn’t believe in any of it anymore. How did this flip flop come to pass?

… As a holistic nutritionist, I was an active participant in what I now consider alternative medicine tomfoolery, specifically pushing supplements on a clientele of the “worried well” who often mistook wellness enthusiasts like me for medical experts. I want to be clear that I wasn’t knowingly deceiving anyone—I really did believe in the solutions I was offering my clients… To holistic nutrition enthusiasts and people who believe in a certain kind of alt wellness, these “natural” and “holistic” products seem more trustworthy than what mainstream medicine offers. The truth is, they often lack sufficient, peer-reviewed, reliable scientific evidence of their supposed effectiveness.

Did I have rock-solid evidence that these products would do what their labels promised they would do? Not really. Sure, I read studies here and there that found specific health benefits for some of the products. But I rarely mentioned the fine print (if I knew it at all)—that the sample sizes of many of these studies often were so small that the results couldn’t be generalized to a larger population, that the studies’ authors sometimes noted that more research was needed to support any findings on the effects they found, or that systematic reviews later found that many studies were poorly constructed or at risk for bias, making their findings even less compelling than they seemed initially. And in some cases, study authors themselves note that their findings are merely jumping off points, and that more long-term studies are needed in order to draw more solid conclusions…

Was I relying on strong, valid evidence? Nah, not really. But at the time, I thought what I had was better than strong evidence: Faith in a lifestyle and a dogmatic belief that all things traditional and mainstream were unhealthy or harmful, and therefore, that all things unconventional and alternative were curative and would bring about “wellness.”

In an effort to expand my product knowledge I researched a lot of the different supplements available. I was using all the best bias-confirming websites where other homeopathic medicine enthusiasts evangelized their favorite remedies, their enthusiasm and insistence, and anecdotal evidence standing in for what typically shows us that a product is safe and effective—clinical trials and FDA approval.

When their arguments and reasoning started to sink in, I realized that my faith in the healing powers of supplements may have been overzealous at best, unfounded at worst. My world crumbled like a piece of raw gluten-free paleo cheesecake. It started to sink in: Where there was a morsel of convincing medical information blended with enough compelling nonsense and communicated with enough conviction, I believed it, hook, line, and sinker.

When I started to notice the holes in the fabric of holistic nutrition, the fabric looked, well, pretty threadbare. I subsequently disconnected from social media and distanced myself from the entire culture. I took a good look at how I was personally and publicly communicating my relationships with food and wellness. After spending my twenties experimenting with all kinds of specialty diets, I was left feeling exhausted, anxious, underweight, overweight, and fed-up.

And so that last domino fell when I took away the thing that was propping it up for me: social media. Instagram is a playground for wellness influencers, including, at the time, me. My Instagram account was the best way to advertise my nutrition consulting business, so maintaining a certain persona there felt completely crucial to my success, and eventually, my identity. It was a world full of beautifully curated accounts of thin yogis gathering wild herbs in nature or making raw desserts with ingredients that cost more than my entire monthly food budget. I started to feel like the alternative wellness community I was part of—myself included—was an echo chamber, where we stockpiled likes and positive comments to build a wall that would keep out ideas that challenged our status quo. In fact, the more reassurance I received from my online community, the harder I believed in our gospel.

As I was disentangling my beliefs from everything I was learning by looking at the actual evidence, I realized that my education to become a holistic nutritionist hadn’t prepared me to understand health and wellness as completely and comprehensively as I’d once thought. Sure, I’d spent a some time studying the pathology of disease, and a little longer learning about how each bodily system works to get your human suit from point A to point B, but I am only slightly closer to being a medical professional than I am to becoming a professional cricket player. First of all, in total, my entire formal education as a holistic nutritionist was 10 months long. Second of all, that education was intended to complement—not replace—traditional medical treatment. But as soon as I finished the program, I could immediately start taking on clients. And lots of potential clients out there are just like the way I used to be—wishing they looked or felt different and in search of the panacea, willing (if not eager) to defer to an expert.

There may have been many people willing to look to me as an expert, but here’s the thing: in my school, there were no residency or clinical hours required to prepare us for the real world or to take on clients—unlike dietitians here in Canada, who must obtain a bachelor’s degree in Nutritional and Food Sciences, qualify to complete a rigorous post-degree internship program and register with a provincial dietetics organization, or get a master’s degree. We received a certificate, and that was that. It was a credential that wholeheartedly fell short of resembling anything close to making me an authority on the subject of health as it relates to food and diet. But most people in the general public can’t be expected to understand the ins and outs of how experts are credentialed and licensed—many of us assume that someone calling themselves something that we associate with authority is, in fact, an authority we can trust.

The brief education that I received to become a holistic nutritionist did provide me with valuable stepping stones and a general understanding of how the body works. My program discouraged students from saying “treat,” “heal,” “prevent,” or “cure.” Generally speaking holistic nutrition programs don’t provide the training and medical education that registered dietitians receive, which enables them to give sound, ethical medical nutrition advice, nor are they required by law, the way dietitian programs are, to provide it. In fact, in 2015 graduates of the Canadian School of Natural Nutrition were barred from identifying as Registered Holistic Nutritionists, and since then must use the title “Holistic Nutritional Consultant.”

… With what I do have from my classroom education, I can analyze a lifestyle that needs some fine-tuning and provide guidance on how to structure a solid meal plan. That’s about it. After years of self-diagnosis and hashtagging all my fad-diet escapades (for this, I greatly apologize to all those I have alienated with my profuse self-righteousness), I can at least say I have a deep appreciation for those who are actually on the front lines in the fight against unproven medical remedies and the potential damage it may do to those who use it to the exclusion of traditional medicine.

The influence of these remedies is not harmless, and I have seen firsthand in many different examples and situations how it can lure people away from real, evidence-based help in their times of need. I am fortunate enough that within my practice I had enough foresight to turn away individuals who required more guidance than I was capable of giving. But along the way I made many embarrassing and conjectural recommendations. Like I said, I was far from knowingly deceiving anyone. I firmly held the belief that alternative medicine, no matter the cost, was an investment in a healthful future. My own medicine cabinet, an arsenal full of supplements, tincture, and powders, was a personal testament to how deeply I was devoted to holistic nutrition.

This essay is a firm farewell from a world I disconnected from long ago. The person that over years I let myself become through naiveté, not doing my own research, and a misguided desire to be different. So here I am now, officially having left the church of woo, bidding the world of alternative health adieu.

_________________________________

Reading Denby’s account, I was reminded of many themes we have previously discussed on this blog. One issue that perhaps needs more focus is this notion:

I was far from knowingly deceiving anyone.”

I have not yet met a SCAM practitioner who says:

“I am in the business of  deceiving my patients.”

The reasons for this are simple:

  1. if they knowingly deceive, they would not tell us,
  2. and if they don’t know that they are deciving their patients, they cannot possibly admit to it.

The way Denby repeatedly assures us that she was far from knowingly deceiving anyone sounds charmingly naive and is, in my experience, very typical for SCAM practitioners. It depicts them as honorable people. Yet, in actual fact, it is neither charming nor honorable. It merely demonstrates the fact that they were perhaps not ruthlessly dishonest but all the more dangerous.

Let me explain this with a deliberately extreme example:

  • A man with a chronic condition – say type 2 diabetes – consults a SCAM practitioner who is knowingly deceiving him claiming that her SCAM effectively treats his condition. The patient follows the advice but, since he is not totally convinced (deception is rarely perfect), consults his doctor who puts him straight. This patient will therefore survive.
  • The same chap consults a SCAM practitioner who is deeply convinced of the effectiveness of her SCAM and thus not knowingly deceiving her patient when she claims that it is effective for his diabetes. Her conviction is so strong that the patient blindly believes her. Thus he stops his conventional medication and hopes for the best. This patient could easily die.

In a nutshell:

‘Honest’ conviction might render a quack more socially acceptable but also more dangerous to her patients.

 

On this blog we have seen just about every variation of misdemeanors by practitioners of so-called alternative medicine (SCAM). Today, I will propose a scale and rank order of these lamentable behaviours. As we regularly discuss chiropractic and homeopathy here, I decided to use these two professions as examples (but I could, of course, have chosen almost any other SCAM).

  1. Treating conditions which are not indicated: SCAM practitioners of all types are often asked by their patients to treat conditions which their particular SCAM cannot not affect. Instead of honestly saying so, they frequently apply their SCAM, wait for the natural history of the condition to do its bit, and subsequently claim that their SCAM was effective.
  2. Over-charging: asking too much money for services or goods is common (not just) in SCAM. It raises the question, what is the right price? There is, of course, no easy answer to it. Over-charging is therefore mostly a judgement call and not something absolute.
  3. Misleading a patient: there are numerous ways in which patients can be misled by their SCAM practitioners. A chiropractor who uses the Dr title, without explaining that it is not a medical title, is misleading his/her patients. A homeopath who implies that the remedy he/she is selling is a proven treatment is also misleading his/her patients.
  4. Being economical with the truth: the line between lying (see below) and being economical with the truth is often blurred. In my view, a chiropractor who does not volunteer the information that acute back pain, in most cases, resolves within a few days regardless of whether he/she mapipulates the patient’s spine or not, is economical with the truth. Similarly, a homeopath who does not explain up front that the remedy he/she prescribes does not contain a single active molecule is economical with the truth.
  5. Employing unreasonably long series of therapy: A chiropractor or homeopath, who treats a patient for months without any improvement in the patient’s condition, should suggest to call it a day. Patients should be given a treatment plan at the first consultation which includes the information when it would be reasonable to stop the SCAM.
  6. Failing to refer: A chiropractor or homeopath, who treats a patient for months without any improvement in the patient’s condition should refer the patient to another, better suited healthcare provider. Failing to do so is a serious disservice to the patient.
  7. Unethical behaviour: there are numerous ways SCAM practitioners regularly violate healthcare ethics. The most obvious one, as discussed often before on this blog, is to cut corners around informed consent. A chiropractor might, for instance, not tell his/her patient before sarting the treatment that spinal manipulation is not supported by sound evidence for efficacy or safety. A homeopathy might not explain that homeopathy is generally considered to be implausible and not evidence-based.
  8. Neglect: medical neglect occurs when patients are harmed or placed at significant risk of harm by gaps in their medical care. If a chiropractor or a homeopath, for instance, claim to be able to effectively treat asthma and fail to insist that all prescribed asthma medications must nevertheless be continued – as both often do – they are guilty of neglect, in my view. Medical neglect can be a reason for starting legal proceedings.
  9. Lying: knowingly not telling the truth can also be a serious legal issue. An example would be a chiropractor who, after beeing asked by a patient whether neck manipulation can cause harm, answers that it is an entirely safe procedure which has never injured anyone. Similarly, if a homeopaths informs his/her patient that the remedy he/she is prescribing has been extensively tested and found to be effective for the patient’s condition, he must be lying. If these practitioners believe what they tell the patient to be true, they might not technically be lying, but they would be neglecting their ethical duty to be adequately informed and they would therefore present an even greater danger to thier patients.
  10. Abuse: means to use something for the wrong purpose in a way that is harmful or morally wrong. A chiropractor who tells the mother of a healty child that they need maintenance care in order to prevent them falling ill in the future is abusing her and the child, in my view. Equally, I think that a homeopath, who homeopathically treats a disease that would otherwise be curable with conventional treatments, abuses his patient.
  11. Fraud: fraud is a legal term referring to dishonest acts that intentionally use deception to illegally deprive another person or entity of money, property, or legal rights. It relies on the use of intentional misrepresentation of fact to accomplish the taking. Arguably, most of the examples listed above are fraud by this definition.
  12. Sexual misconduct: the term refers to any behaviour which is sexual in nature and which is unwelcome and engaged in without consent. It ranges from unwanted groping to rape. There is, for instance, evidence that sexual misconduct is not a rarety in the realm of chiropractic. I have personally served once as an expert witness against a SCAM practitioner is a court case at the Exeter Crown Court.

The 12 categories listed above are not nearly as clearly defined as one would wish, and there is plenty of overlap. I am not claiming that my suggested ‘scale of misdemeanors by SCAM practitioners‘ or the proposed rank order are as yet optimal or even adequate. I am, however, hoping that readers will help me with their suggestions to improve them. Perhaps your input might then generate a scale of practical use for the future.

The authors of this review wanted to determine similarities and differences in the reasons for using or not using so-called alternative medicine (SCAM) amongst general and condition-specific populations, and amongst populations in each region of the globe.

Quantitative or qualitative original articles in English, published between 2003 and 2018 were reviewed. Conference proceedings, pilot studies, protocols, letters, and reviews were excluded. Papers were appraised using valid tools and a ‘risk of bias’ assessment was also performed. Thematic analysis was conducted. Reasons were coded in each paper, then codes were grouped into categories. If several categories reported similar reasons, these were combined into a theme. Themes were then analysed using χ2 tests to identify the main factors related to reasons for CAM usage.

A total of 231 publications were included. Reasons for SCAM use amongst general and condition-specific populations were similar. The top three reasons were:

  • (1) having an expectation of benefits of SCAM (84% of publications),
  • (2) dissatisfaction with conventional medicine (37%),
  • (3) the perceived safety of SCAM (37%).

Internal health locus of control as an influencing factor was more likely to be reported in Western populations, whereas the social networks was a common factor amongst Asian populations (p < 0.05). Affordability, easy access to SCAM and tradition were significant factors amongst African populations (p < 0.05). Negative attitudes towards SCAM and satisfaction with conventional medicine were the main reasons for non-use (p < 0.05).

The authors concluded that dissatisfaction with conventional medicine and positive attitudes toward SCAM, motivate people to use SCAM. In contrast, satisfaction with conventional medicine and negative attitudes towards SCAM are the main reasons for non-use.

At this point, I thought: so what? This is all very obvious and does not necessitate an extensive review of the published literature. What it actually shows is that the realm of SCAM is obsessed with conducting largely useless surveys, a phenomenon, I once called ‘survey mania‘. But a closer look at the review does reveal some potentially interesting findings.

In less developed parts of the world, like Africa, SCAM use seems to be determined by affordability, accessibility and tradition. This makes sense and ties in with my impression that consumers in such countries would give up SCAM as soon as they can afford proper medicine.

This notion seems to be further supported by the reasons for not using SCAM. Asian consumers claim overwhelmingly that this is because they consider SCAM ineffective and unsafe.

In our review of 2011 (not cited in the new review), we looked at some of the issues from a slightly different angle and evaluated the expectations of SCAM users. Seventy-three articles met our inclusion criteria of our review. A wide range of expectations emerged. In order of prevalence, they included:

  • the hope to influence the natural history of the disease;
  • the desire to prevent disease and promote health/general well-being;
  • the hope of fewer side effects;
  • the wish to be in control over one’s health;
  • the hope for symptom relief;
  • the ambition to boost the immune system;
  • the hope to receive emotional support;
  • the wish to receive holistic care;
  • the hope to improve quality of life;
  • the expectation to relief of side effects of conventional medicine;
  • the desire for a good therapeutic relationship;
  • the hope to obtain information;
  • the hope of coping better with illness;
  • the expectation of supporting the natural healing process;
  • the availability of SCAM.

All of these aspects, issues and notions might be interesting, even fascinating to some, but we should not forget three important caveats:

  • Firstly, SCAM is such a diverse area that any of the above generalisations are highly problematic; the reasons and expectations of someone trying acupuncture may be entirely different from those of someone using homeopathy, for instance.
  • Secondly (and more importantly), the ‘survey mania’ of SCAM researchers has not generated the most reliable data; in fact, most of the papers are hardly worth the paper they were printed on.
  • Thirdly (and even more importantly, in my view), why should any of this matter? We have known about some of these issues for at least 3 decades. Has this line of research changed anything? Has it prevented consumers getting exploited by scrupulous SCAM entrepreneurs? Has it made consumers, politicians or anyone else more aware of the risks associated with SCAM? Has it saved many lives? I doubt it!

It has been reported that Karnataka’s Deputy Chief Minister, Dr CN Ashwathnarayan, has launched eight products, several of which fall in the category of so-called alternative medicine (SCAM), aimed at mitigating COVID-19, developed by various start-ups at Bangalore Bioinnovation Centre (BBC). Dr CN Ashwathnarayan said the launch of the products shows that Karnataka has emerged as a leading state in developing solutions to fight the COVID 19 pandemic.

Here are short descriptions of the innovations:

  • Padma Vitals +: Developed by Innovator start-up Dr. Madan Gopal of Cardiac Design labs,Padma Vitals + is a  centralized monitoring system for ECG, respiration, Spo2 and body temperature, which can measure the vitals continuously and the analysis sent through telemetry, with an alerting system embedded in it. The device is much needed for contactless monitoring of patients during COVID 19 Pandemic. The product has been validated at Narayana Hrudayalaya.
  • Malli’s Cordytea: Developed by Dr. Moushmi Mondal from Mallipatra Neutraceuticals, this product is an Immunity booster tea prepared from medicinal mushroom – Cordyceps. The mushroom variety grown under laboratory conditions is developed by the Innovator. Cordicepin, an active ingredient is known to have anti-viral properties too. In the COVID 19 times, it will be helpful in boosting the immunity levels. The product has been patented and is approved by FSSAI.
  • CD4 Shield : Developed by Dr. Vijay Lanka and his team from Stabicon, this product is a chewable tablet containing curcumin and Vitamin B12. Both the ingredients fight inflammation and infection. The product ensures activation of innate immunity by activating CD4+, CD8+ and IFN 1 to virus specific effect and has immunomodulatory properties. It also reduces cytokine storm in response to viral infection. The product is approved by FSSAI.
  • BeamRoti : Developed by Dr. Srinivas from Aspartika, the product is an immunity booster chapati having mixture of herbs recommended by AYUSH ministry. The ingredients have been prepared using supercritical fluid extraction technology to ensure optimum concentration of herbal extract reaches the body. The chapatis are easy to store with good shelf life and Patent application has been filed. The product is approved by FSSAI.
  • Immune booster daily drops: Developed by Dr. Srinivas from Aspartika, the product is an immunity booster drop having mixture of herbs recommended by AYUSH ministry. The ingredients have been prepared using supercritical fluid extraction technology to ensure optimum concentration of herbal extract reaches the body by mixing just one drop of the product in a glass of hot water. The product is approved by FSSAI.
  • VegPhal – Fruit and Vegetable Sanitizer: Developed by Deepak Bhajantri from Krimmi Biotech, this fruit and vegetable sanitizer is prepared using edible ingredients effective against microbes and removal of pesticides. It is chorine and alcohol free.
  • Water Sanitizer – Kitchen Tap: The product is developed by Ravi Kumar from Biofi and is a miniaturized version of UV purifier that can be attached to a water tap and kill 99% of microbes including viruses such as phages.
  • nti-Micobial HVAC module: The product is developed by Ravi Kumar from Biofi and is a module that can be fitted to HVAC system to ensure circulating air is sanitized. This is especially useful during COVID 19 times as many enclosed spaces in which AC circulated air may be contaminated. Based on UV-silver titanium dioxide technology, the product is patented and has been validated.

Karnataka is of course a state in the south western region of India. The region has so far about one million COVID-19 cases, while almost 12 000 people have died. One would therefore very much hope that the newly launched innovations can make a difference.

But will they?

As far as the SCAM-related products (e.g. ‘immune boosters’) are concerned, I see no convincing evidence to assume that they are effective. If anyone has information to the contrary, please let me know.

But why not? They can’t do any harm!

Sadly, I am am not so sure. I see the potential for considerable harm from all the useless SCAMs that are being promoted left right and centre for protecting the public against COVID-19. Firstly, there is the financial harm of paying for products that are useless. Secondly, ineffective effords might distract from finding and adhering to efforts that are effective. Thirdly, believing in a SCAM that does not work will create a sense of false security which, in turn, renders consumers more vulnerable to catch the virus.

As always in healthcare, even harmless interventions that do not work can become dangerous, as they lead to neglecting effective measures. I shudder to think of how many deaths have been caused by the many SCAM merchants who see the current pandemic as an opportunity.

In 2012, we published a systematic review of adverse effects of homeopathy. Here is its abstract:

Aim: The aim of this systematic review was to critically evaluate the evidence regarding the adverse effects (AEs) of homeopathy.

Method: Five electronic databases were searched to identify all relevant case reports and case series.

Results: In total, 38 primary reports met our inclusion criteria. Of those, 30 pertained to direct AEs of homeopathic remedies; and eight were related to AEs caused by the substitution of conventional medicine with homeopathy. The total number of patients who experienced AEs of homeopathy amounted to 1159. Overall, AEs ranged from mild-to-severe and included four fatalities. The most common AEs were allergic reactions and intoxications. Rhus toxidendron was the most frequently implicated homeopathic remedy.

Conclusion: Homeopathy has the potential to harm patients and consumers in both direct and indirect ways. Clinicians should be aware of its risks and advise their patients accordingly.

The paper prompted a number of angry reactions from proponents of homeopathy who claimed, for instance, that homeopathic remedies are highly diluted and thus safe. We responded that homeopaths can nevertheless be dangerous to patients through neglect and bad advice by homeopaths, and that not all homeopathic remedies are highly diluted, and that some might be toxic because of poor quality control of the manufacturing process.

Now, a different group of researchers have looked at the problem from a slightly different angle and with different methodologies. This systematic review and meta-analysis by researchers from NAFKAM focused on observational studies, as a substantial amount of the research base for homeopathy are observational.

Eight electronic databases, central webpages and journals were searched for eligible studies, and a total of 1,169 studies were identified, 41 were included in this review. Eighteen studies were included in a meta-analysis that made an overall comparison between homeopathy and control (conventional medicine and herbs).

Eighty-seven percent (n = 35) of the studies reported adverse effects. They were graded as CTCAE 1, 2 or 3 and equally distributed between the intervention and control groups. Homeopathic aggravations (homeopaths believe that, when the optimal remedy is given, patients will experience an aggravation of their presenting symptoms) were reported in 22,5% (n = 9) of the studies and graded as CTCAE 1 or 2. The frequency of adverse effects for control versus homeopathy was statistically significant (P < 0.0001). Analysis of sub-groups indicated that, compared to homeopathy, the number of adverse effects was significantly higher for conventional medicine (P = 0.0001), as well as other complementary therapies (P = 0.05).

The authors concluded that adverse effects of homeopathic remedies are consistently reported in observational studies, while homeopathic aggravations are less documented. This meta-analysis revealed that the proportion of patients experiencing adverse effects was significantly higher when receiving conventional medicine and herbs, compared to patients receiving homeopathy. Nonetheless, the development and implementation of a standardized reporting system of adverse effects in homeopathic studies is warranted in order to facilitate future risk assessments.

While these results are interesting, they have to be taken with a pinch of salt and beg a number of questions:

  • Is there proof that aggravations exist at all?
  • How can one differentiate them from adverse effects?
  • As even placebos are known to cause adverse effects (nocebo effects), how can one be sure that the adverse effects of homeopathy are not nocebo effects?
  • Is it a good reason to focus on largely inconclusive observational studies, because a substantial amount of the research base for homeopathy are observational?
  • Can one produce conclusive results by meta-analysing inconclusive studies?

For me, the most impressive findings of this review is that in total 86 studies had to be excluded by the authors because they reported no adverse effects or aggravations. I think this renders the interpretation of the evidence from the 41 studies they did include even more flimsy. In fact, I don’t see how any meaningful conclusion can be drawn at all – except of course that many researchers of homeopathy violate the rules of research ethics by not reporting adverse effects in their studies.

As to aggravations, we clearly need to rely on placebo controlled studies, if we want to find out whether they exist at all. This we have done in our 2003 paper:

Homeopathic aggravations have often been described anecdotally. However, few attempts have been made to scientifically verify their existence. This systematic review aimed at comparing the frequency of homeopathic aggravations in the placebo and verum groups of double-blind, randomised clinical trials. Eight independent literature searches were carried out to identify all such trials mentioning either adverse effects or aggravations. All studies thus found were validated and data were extracted by both authors. Twenty-four trials could be included. The average number of aggravations was low. In total, 50 aggravations were attributed to patients treated with placebo and 63 to patients treated with homoeopathically diluted remedies. We conclude that this systematic review does not provide clear evidence that the phenomenon of homeopathic aggravations exists.

What is interesting, from my perspective, is the fact that the NAFKAM authors chose to ignore our 2012 paper completely (even though it is highly relevant to their paper and was not published in an obscure journal) and elected to completely misinterpret the findings of our 2003 paper (stating this about it: Grabia and Ernst reported a total of 103 cases of homeopathic aggravations in 3437 participants (3%), while, in fact, our paper demonstrated that aggravations are a homeopathic figment of imagination).

I wonder why.

In the past, NAFKAM did not have the reputation of doing research that was overtly biased towards homeopathy. Recently, the head of the team retired and was replaced by Miek C. Jong who is a co-author of the present review (plus head of CAMcancer, an organisation of which I am a founding member and which did, I think, some good work in the past). She happens to have a long history as a homeopath or homeopathic researcher and is co-author of many papers in this area. Here are three of her conclusions:

Could it be that, within NAFKAM, the attitude towards homeopathy has changed?

This systematic review and meta-analysis was aimed at investigating the effect and safety of acupuncture for the treatment of chronic spinal pain.

The authors included 22 randomized controlled trials (RCTs) involving patients with chronic spinal pain treated by acupuncture versus sham acupuncture, no treatment, or another treatment were included. Chronic spinal pain was defined as:

  • chronic neck pain,
  • chronic low back pain,
  • or sciatica for more than 3 months.

Fourteen studies had a high risk of bias, 5 studies had a low risk of bias, and 5 studies had an unclear risk of bias. Pooled analysis revealed that:

  • acupuncture can reduce chronic spinal pain compared to sham acupuncture (weighted mean difference [WMD]  -12.05, 95% confidence interval [CI] -15.86 to -8.24),
  • acupuncture can reduce chronic spinal pain compared to mediation control (WMD -18.27, 95% CI -28.18 to -8.37),
  • acupuncture can reduce chronic spinal pain compared to usual care control (WMD -9.57, 95% CI -13.48 to -9.44),
  • acupuncture can reduce chronic spinal pain compared to no treatment control (WMD -17.10, 95% CI -24.83 to -9.37).

In terms of functional disability, acupuncture can improve physical function at

  • immediate-term follow-up (standardized mean difference [SMD] -1.74, 95% CI -2.04 to -1.44),
  • short-term follow-up (SMD -0.89, 95% CI -1.15 to -0.62),
  • long-term follow-up (SMD -1.25, 95% CI -1.48 to -1.03).

Trials assessed as having a high risk of bias (WMD −13.45, 95% CI −17.23 to −9.66, I 2 96.2%, moderate-quality evidence, including 14 studies and 1379 patients) found greater effects of acupuncture treatment than trials assessed as having a low risk of bias (WMD −11.99, 95% CI −13.94 to −10.03, I 2 44.6%, high-quality evidence, including 4 studies and 432 patients), but smaller effects than trials assessed as having an unclear risk of bias (WMD −14.51, 95% CI −17.25 to −11.78, I 2 0%, high-quality evidence, including 3 studies and 190 patients).

Only 6 trials provided information on adverse events. No trial reported data on serious adverse events during acupuncture treatment. The most frequent adverse events were temporarily worsened pain and needle pain at the acupuncture site, which can decrease quickly after a short period of rest.

The authors concluded that compared to no treatment, sham acupuncture, or conventional therapy such as medication, massage, and physical exercise, acupuncture has a significantly superior effect on the reduction in chronic spinal pain and function improvement. Acupuncture might be an effective treatment for patients with chronic spinal pain and it is a safe therapy.

I think this is a thorough review which produced interesting findings. I agree with most of what the authors report, except with their conclusions which I find too optimistic. In view of the facts that

  • only 5 RCTs had a low risk of bias,
  • collectively, the rigorous trials reported smaller effect sizes,
  • the majority of trials failed to mention adverse effects which, in my view, casts considerable doubt on their quality and ethical standard,

I would have phrased the conclusion differently: compared to no treatment, sham acupuncture, or conventional therapies, acupuncture seems to have a significantly superior effect on pain and function. Due to the lack rigour of most studies, these effects are less certain than one would have wished. Many trials fail to report adverse effects which reflects poorly on their quality and ethics and prevents conclusions about the safety of acupuncture. In essence, this means that the effectiveness and safety of acupuncture as a treatment of chronic spinal pain remains uncertain.

Acupuncture-moxibustion therapy (AMT) is a so-called alternative medicine (SCAM) that has been used for centuries in treatment of numerous diseases. Some enthusiasts even seem to advocate it for chemotherapy-induced leukopenia (CIL)  The purpose of this review was to evaluate the efficacy and safety of acupuncture-moxibustion therapy in treating CIL.

Relevant studies were searched in 9 databases up to September 19, 2020. Two reviewers independently screened the studies for eligibility, extracted data, and assessed the methodological quality of selected studies. Meta-analysis of the pooled mean difference (MD) and risk ratio (RR) with their respective 95% confidence intervals (CI) were calculated.

Seventeen studies (1206 patients) were included, and the overall quality of the included studies was moderate. In comparison with medical therapy, AMT has a better clinical efficacy for CIL (RR, 1.24; 95% CI, 1.17-1.32; P < 0.00001) and presents advantages in increasing leukocyte count (MD, 1.10; 95% CI, 0.67-1.53; P < 0.00001). Also, the statistical results show that AMT performs better in improving the CIL patients’ Karnofsky performance score (MD, 5.92; 95% CI, 3.03-8.81; P < 0.00001).

The authors concluded that this systematic review and meta-analysis provides updated evidence that AMT is a safe and effective alternative for the patients who suffered from CIL.

A CIL is a serious complication. If I ever were afflicted by it, I would swiftly send any acupuncturist approaching my sickbed packing.

But this is not an evidence-based attitude!!!, I hear some TCM-fans mutter. What more do you want that a systematic review showing it works?

I beg to differ. Why? Because the ‘evidence’ is hardly what critical thinkers can accept as evidence. Have a look at the list of the primary studies included in this review:

  1. Lin Z. T., Wang Q., Yu Y. N., Lu J. S. Clinical observation of post-chemotherapy-leukopenia treated with ShenMai injectionon ST36. World Journal of Integrated Traditional and Western Medicine2010;5(10):873–876. []
  2. Wang H. Clinical Observation of Acupoint Moxibustion on Leukopenia Caused by Chemotherapy. Beijing, China: Beijing University of Chinese Medicine; 2011. []
  3. Fan J. Y. Coupling of Yin and Yang between Ginger Moxibustion Improve the Clinical Effect of the Treatment of Chemotherapy Adverse Reaction. Henan, China: Henan University of Chinese Medicine; 2013. []
  4. Lu D. R., Lu D. X., Wei M., et al. Acupoint injection with addie injection for patients of nausea and vomiting with cisplatin induced by chemotherapy. Journal of Clinical Acupuncture and Moxibustion2013;29(10):33–38. []
  5. Yang J. E. The Clinical Observation on Treatment of Leukopenia after Chemotherapy with Needle Warming Moxibustion. Hubei, China: Hubei University of Chinese Medicine; 2013. []
  6. Fu Y. H., Chi C. Y., Zhang C. Y. Clinical effect of acupuncture and moxibustion on leukopenia after chemotherapy of malignant tumor. Guide of China Medicine2014;12(12) []
  7. Wang J. N., Zhang W. X., Gu Q. H., Jiao J. P., Liu L., Wei P. K. Protection of herb-partitioned moxibustion on bone marrow suppression of gastric cancer patients in chemotherapy period. Chinese Archives of Traditional Chinese Medicine2014;32(12):110–113. []
  8. Zhang J. The Clinical Research on Myelosuppression and Quality of Life after Chemotherapy Treated by Grain-Sized Moxibustion. Nanjing, China: Nanjing University of Chinese Medicine; 2014. []
  9. Tian H., Lin H., Zhang L., Fan Z. N., Zhang Z. L. Effective research on treating leukopenia following chemotherapy by moxibustion. Clinical Journal of Chinese Medicine2015;7(10):35–38. []
  10. Hu G. W., Wang J. D., Zhao C. Y. Effect of acupuncture on the first WBC reduction after chemotherapy for breast cancer. Beijing Journal of Traditional Chinese Medicine2016;35(8):777–779. []
  11. Zhu D. L., Lu H. Y., Lu Y. Y., Wu L. J. Clinical observation of Qi-blood-supplementing needling for leukopenia after chemotherapy for breast cancer. Shanghai Journal of Acupuncture and Moxibustion2016;35(8):964–966. []
  12. Chen L, Xu G. Y. Observation on the prevention and treatment of chemotherapy-induced leukopenia by moxibustion therapy. Zhejiang Journal of Traditional Chinese Medicine2016;51(8):p. 600. []
  13. Mo T., Tian H., Yue S. B., Fan Z. N., Zhang Z. L. Clinical observation of acupoint moxibustion on leukocytopenia caused by tumor chemotherapy. World Chinese Medicine2016;11(10):2120–2122. []
  14. Nie C. M. Nursing observation of acupoint moxibustion in the treatment of leucopenia after chemotherapy. Today Nurse2017;4:93–95. []
  15. Wang D. Y. Clinical Research on Post-chemotherapy-leukopenia with Spleen-Kidney Yang Deficiency in Colorectal Cancer Treated with Point-Injection. Yunnan, China: Yunnan University of Chinese Medicine; 2017. []
  16. Gong Y. Q, Zhang M. Q, Zhang B. C. Prevention and treatment of leucocytopenia after chemotherapy in patients with malignant tumor with ginger partitioned moxibustion. Chinese Medicine Modern Distance Education of China2018;16(21):135–137. []
  17. Li Z. C., Lian M. J., Miao F. G. Clinical observation of fuzheng moxibustion combined with wenyang shengbai decoction in the treatment of 80 cases of leukopenia after chemotherapy. Hunan Journal of Traditional Chinese Medicine2019;35(3):64–66. []

Notice anything peculiar?

  • The studies are all from China where data fabrication was reported to be rife.
  • They are mostly unavailable for checking (why the published adds links that go nowhere is beyond me).
  • Many do not look at all like randomised clinical trials (which, according to the authors, was an inclusion criterion).
  • Many do not look as though their primary endpoint was the leukocyte count (which, according to the authors, was another inclusion criterion).

Intriguingly, the authors conclude that AMT is not just effective but also ‘safe’. How do they know? According to their own data extraction table, most studies failed to mention adverse effects. And how exactly is acupuncture supposed to increase my leukocyte count? Here is what the authors offer as a mode of action:

Based on the theory of traditional Chinese medicine (TCM), CIL belongs to the category of consumptive disease, owing to the exhaustion of genuine qi in the zang-fu viscera and the insufficiency of kidney essence and qi-blood. Researchers believe that there is an intimate association between the occurrence of malignant tumors and the deficiency of genuine qi. During attacking the cancer cells, chemotherapeutics also damaged the function of zang-fu viscera and qi-blood, leading to CIL. According to the theory of TCM and meridian, acupuncture-moxibustion is an ancient therapeutic modality that may be traced back more than 3500 years in China. Through meridian conduction, acupuncture-moxibustion therapy stimulates acupoints to strengthen the condition of zang-fu viscera and immune function, supporting genuine qi to improve symptoms of consumption.

I think it is high time that we stop tolerating that the medical literature gets polluted with such nonsense (helped, of course, by journals that are beyond the pale) – someone might actually believe it, in which case it would surely hasten the death of vulnerable patients.

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