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

Simon Singh

My new book has just been published. Allow me to try and whet your appetite by showing you the book’s introduction:

“There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking.” These words of Fontanarosa and Lundberg were published 22 years ago.[1] Today, they are as relevant as ever, particularly to the type of healthcare I often call ‘so-called alternative medicine’ (SCAM)[2], and they certainly are relevant to chiropractic.

Invented more than 120 years ago by the magnetic healer DD Palmer, chiropractic has had a colourful history. It has now grown into one of the most popular of all SCAMs. Its general acceptance might give the impression that chiropractic, the art of adjusting by hand all subluxations of the three hundred articulations of the human skeletal frame[3], is solidly based on evidence. It is therefore easy to forget that a plethora of fundamental questions about chiropractic remain unanswered.

I wrote this book because I feel that the amount of misinformation on chiropractic is scandalous and demands a critical evaluation of the evidence. The book deals with many questions that consumers often ask:

  • How well-established is chiropractic?
  • What treatments do chiropractors use?
  • What conditions do they treat?
  • What claims do they make?
  • Are their assumptions reasonable?
  • Are chiropractic spinal manipulations effective?
  • Are these manipulations safe?
  • Do chiropractors behave professionally and ethically?

Am I up to this task, and can you trust my assessments? These are justified questions; let me try to answer them by giving you a brief summary of my professional background.

I grew up in Germany where SCAM is hugely popular. I studied medicine and, as a young doctor, was enthusiastic about SCAM. After several years in basic research, I returned to clinical medicine, became professor of rehabilitation medicine first in Hanover, Germany, and then in Vienna, Austria. In 1993, I was appointed as Chair in Complementary Medicine at the University of Exeter. In this capacity, I built up a multidisciplinary team of scientists conducting research into all sorts of SCAM with one focus on chiropractic. I retired in 2012 and am now an emeritus professor. I have published many peer-reviewed articles on the subject, and I have no conflicts of interest. If my long career has taught me anything, it is this: in the best interest of consumers and patients, we must insist on sound evidence; not opinion, not wishful thinking; evidence.

In critically assessing the issues related to chiropractic, I am guided by the most reliable and up-to-date scientific evidence. The conclusions I reach often suggest that chiropractic is not what it is often cracked up to be. Hundreds of books have been published that disagree. If you are in doubt who to trust, the promoter or the critic of chiropractic, I suggest you ask yourself a simple question: who is more likely to provide impartial information, the chiropractor who makes a living by his trade, or the academic who has researched the subject for the last 30 years?

This book offers an easy to understand, concise and dependable evaluation of chiropractic. It enables you to make up your own mind. I want you to take therapeutic decisions that are reasonable and based on solid evidence. My book should empower you to do just that.

[1] https://pubmed.ncbi.nlm.nih.gov/9820267

[2] https://www.amazon.co.uk/SCAM-So-Called-Alternative-Medicine-Societas/dp/1845409701/ref=pd_rhf_dp_p_img_2?_encoding=UTF8&psc=1&refRID=449PJJDXNTY60Y418S5J

[3] https://www.amazon.co.uk/Text-Book-Philosophy-Chiropractic-Chiropractors-Adjuster/dp/1635617243/ref=sr_1_1?keywords=DD+Palmer&qid=1581002156&sr=8-1

Yesterday, I received a tweet from a guy called Bart Huisman (“teacher beekeeping, nature, biology, classical homeopathy, agriculture, health science, social science”). I don’t know him and cannot remember whether I had previous contact with him. His tweet read as follows:

“Why should anyone believe what Professor Edzard Ernst says, after he put his name to a BBC programme, he now describes as “deception”.”

This refers to a story that I had almost forgotten. It’s a nice one with a ‘happy ending’, so let me recount it here briefly.

In 2005, the BBC had hired me as an advisor for their 4-part TV series on alternative medicine.

The first part of the series was on acupuncture, and Prof Kathy Sykes presented the opening scene taking place in a Chinese operation theatre. In it a Chinese women was having open heart surgery with the aid of acupuncture. Kathy’s was visibly impressed and said on camera that the patient was having the surgery “with only needles to control the pain.”  However, the images clearly revealed that the patient was receiving all sorts of other treatments given through intra-venous lines. So, Prof Sykes was telling the UK public a bunch of porkies. This was bound to confuse many viewers.

One of them was Simon Singh. At the time, I did not know Simon (to be honest, I did not even know of him) and was surprised to receive a phone call from him. He politely asked me to confirm that I had been the adviser of the BBC on this production. I was happy to confirm this fact. Then he asked why I had missed such a grave error. I replied that I could not possibly have spotted it, because all I had been asked to do was to review and correct the text of the programme which the BBC had sent to me by email. Before it was broadcast, I had not seen a single passage of the film.

Correcting the text had already led to several problems (not so much regarding the acupuncture part but mostly the other sections), because the BBC was reluctant to change several of the mistakes I had identified. When I told them that, in this case, I would quit, they finally found a way to alter them. But the cooperation had been far from easy. I explained all this to Simon and eventually he asked me whether I would be willing to support the official complaint he was about to file with the BBC. I agreed. This is probably where I used the term ‘deception’ that Mr Huisman mentioned in his tweet.

So, Simon submitted his complaint and eventually won the case.

But this is not the happy ending I was referring to.

During the course of the complaint, Simon and I realised that we were thinking alike and were getting on well. A few months later, he suggested that the two of us write a book together about alternative medicine. At first, I was hesitant. Simon said, “let’s try just one chapter, and see how it works out.” So we did. It turned out to be fun and instructive for both of us. So we did the other chapters as well. The book was published in 2008 and is called TRICK OR TREATMENT. It was published in about 20 different languages and the German version became ‘science book of the year in 2011 (I think).

And that’s not the happy ending either (in fact, it caused a lot of hardship for Simon who was sued by the BCA; luckily, he won that case too).

The real happy ending is the fact that Simon and I became friends for life.

Thank you Bart Huisman for reminding me of this rather lovely story.

 

A few days ago, I reported that the German homeopathy manufacturer Hevert has taken legal action against German critics of homeopathy. This caused a storm of protests on twitter, in the press and even on TV. Hevert has remained silent in all this, but now a spokesperson and part owner of the firm, Mr Mathias Hevert, has given an interview to ‘Pharma Relations’ in an attempt to explain and justify Hevert’s position.

The interview does not tell us much, except for one particular passage:

Frau Grams hat sich meines Wissens nach gar nicht konkret auf die Produkte der Firma Hevert bezogen. Warum fühlten Sie sich dennoch aufgerufen, sozusagen stellvertretend für die Branche juristische Schritte einzuleiten?

Da homöopathische Arzneimittel neben pflanzlichen und schulmedizinischen Präparaten einen wichtigen Teil des breiten Hevert-Sortiments darstellen, fühlen wir uns bereits seit der Firmengründung 1956 eng mit der durch Pastor Emanuel Felke begründeten Komplexmittel-Homöopathie verbunden. Seit Monaten beobachten wir, wie die Homöopathie von Meinungsbildnern in den Sozialen Medien, der Presse und dem Fernsehen undifferenziert und ohne wissenschaftliche Grundlage denunziert wird. In Großbritannien wurden bereits einflussreiche Lobbygruppen aktiv, um die Homöopathie als Ganzes und ohne differenzierte Betrachtung der Datenlage zu verunglimpfen. Mit ihren Bemühungen schafften sie es sogar, die Politik zu gesetzlichen Einschränkungen des Feldes zu drängen. Um ähnliches in Deutschland – dem Mutterland der Homöopathie – zu verhindern, geht Hevert entschlossen gegen ungerechtfertigte und nicht fundierte Diskreditierungen der Homöopathie durch Lobbygruppen und andere Meinungsbildner vor.

Here is my translation of the bit that concerns me:

Q: Frau Grams has, as far as I know, not even concretely referred to the products of Hevert. Why do you still feel compelled to start legal procedures, so to speak for the sector?

A: … We observe since months how homeopathy is being denounced in an undifferentiated manner and without a scientific basis by opinion leaders in social media, the press, an on TV. In England, influential lobby groups have been active to denigrate homeopathy as a whole and without differentiated consideration of the data. Through their efforts, they have even managed to force politicians to implement legal restrictions in this area…

_________________________________________________________

I must admit, I find this response quite extraordinary!

I am not aware of anyone or any group in England denigrating homeopathy without differentiated consideration of the data. All we did was to point out what the best available evidence tells us, exercise our critical thinking abilities, and report facts. And I do strongly object anyone claiming otherwise. In fact, I ask myself whether the above remarks by a representative of a manufacturer of homeopathics are not libellous and thus actionable.

What do you think?

PS

But perhaps I have misunderstood something; in this case, could Mr Hevert please name the UK critics he had in mind when he made these comments?

The following announcement was made by the NHS on 7 August 2018:

The Governing Body of Bristol, North Somerset and South Gloucestershire (BNSSG) Clinical Commissioning Group (CCG) today approved changes that mean NHS funded homeopathy will only be available in exceptional circumstances in the area. The changes will mean the CCG’s Individual Funding Request (IFR) Panel would need a clinician to set out why the patient is clinically exceptional before treatment could be provided.

The decision comes after the publication of a report, which took evidence from local people, clinicians, patient groups, providers of homeopathic treatments and national guidelines.

CCG Clinical Chair Dr Jonathan Hayes said, “We are working hard to become an evidence-informed organisation because we need to make the best use of all resources to offer treatment and care to the widest range of people. The decision on homeopathy funding today is a step towards this and brings us in line with national guidelines.”

It is estimated that 41 patients receiving NHS funded homeopathic consultations in the area cost the local NHS £109,476 in the 2017/2018 financial year.

END OF QUOTE

R.I.P. NHS #homeopathy 5 July 1948 - 7 August 2018

The move is the result of 4 years of excellent work by the GOOD THINKING SOCIETY, a charity dedicate to the promotion of rational thinking.

Michael Marshall, its Project Director, said: “We are very pleased to see the Bristol CCGs take this decision to cease funding for homeopathy – every other CCG across the country has made it clear that homeopathic remedies are no better than placebo and such there is simply no place for homeopathy on the NHS.

“With the end to homeopathy funding in Bristol, the region joins NHS bodies across the rest the country in recognising that homeopathy is not a valid use of limited NHS resources. There is now no CCG in England where homeopathic pills or consultations can be routinely funded with NHS money – instead, funding can be directed towards treatments that have been shown to actually work.”

Does that not call for a knighthood for Mr Marshall?

One would have thought so!

Who will tell Prince Charles to get the ball rolling?

And while we are all waiting for the big event, you might as well donate a few £s to this truly splendid charity.

Please be generous!!!

Yesterday, I saw a Tweet stating:

Homeopath in Cornwall specialising in Women’s Health #fertility #naturalconception #pcos #pms

It was followed by a list of specific indications:

  • Pregnancy
  • Infertility
  • PCOS
  • PMS
  • Fibroids
  • Depression
  • Anxiety and much more…

I responded to this Tweet by tweeting:

Homeopath in Cornwall specialising in misleading women

Minutes later I received a response from a homeopathy-fan:

That could be called libel Edzard. I would be careful.

So, should I be careful, and if so why?

Reading the thinly veiled threat, I wasn’t exactly shaking in my boots with fear (I was deeply involved in helping Simon Singh in his defence against the BCA’s libel action), but I nevertheless wanted to be sure of my position and conducted some ‘rough and ready’ searches for recent evidence to suggesting that homeopathy is effective for any of the conditions mentioned above. Here is what I found:

  • Pregnancy. Yes, there is an RCT! It concluded that “homeopathy does not appear to prevent excessive body mass gain in pregnant women…” And another one concluding that “neither Pentazocine, or Chamomilla recutita offer substantial analgesia during labor.”
  • Infertility. No RCT or other sound evidence.
  • PCOS. Nothing
  • PMS. No clinical trials.
  • Fibroids. No clinical trials
  • Depression. Even leading homeopaths seem to agree that there is no good evidence.
  • Anxiety. Again, I could not find any sound evidence.

Don’t get me wrong, these statements are not based on full systematic reviews; that would take a while and hardly seems worth it. (If you want a good systematic review, I recommend this one; it concluded: “Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner. Those who use homeopathy should tell their health practitioner and should keep taking any prescribed treatments.“) But my quick glance at the evidence is enough, I think, to justify my statement that the above claims by a homeopath are misleading. In fact, I believe that I could have used much stronger terminology without the slightest risk of being sued.

PERHAPS NEXT TIME!

Today is ‘World Bedwetting Day’!

No, don’t laugh; the event is initiated and supported by the World Bedwetting Day Steering Committee, which consists of the International Children’s Continence Society (ICCS) and the European Society for Paediatric Urology (ESPU) along with professional groups across the globe (see website for details).

A good day to remember that the British Chiropractic Association once sued my friend Simon Singh because he had disclosed that they were happily claiming that chiropractic was an effective therapy for bedwetting (and a few other childhood problems). An equally good day to remind ourselves that most alternative therapies are highly effective for this condition. At least this is what practitioners will tell you. For instance:

“Stop, stop! This blog is about evidence!!!” I hear you shout impatiently.

Alright, here is a full and unabbreviated list of all alternative therapies that have been scientifically proven to work for bedwetting:

 

HAPPY BEDWETTING DAY EVERYBODY!

If you start reading the literature on chiropractic, you are bound to have surprises. The paucity of rigorous and meaningful research is one of them. I am constantly on the look-out for such papers but am regularly frustrated. Over the years, I got the impression that chiropractors tend to view research as an exercise in promotion – that is promotion of their very own trade.

Take this article, for instance. It seems to be a systematic review of chiropractic for breastfeeding. This is an interesting indication; remember: in 1998, Simon Singh wrote in the Guardian this comment “The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.” As a consequence, he got sued for libel; he won, of course, but ever since, chiropractors across the world are trying to pretend that there is some evidence for their treatments after all.

The authors of the new review searched Pubmed [1966-2013], Manual, Alternative and Natural Therapy Index System (MANTIS) [1964-2013] and Index to Chiropractic Literature [1984-2013] for the relevant literature. The search terms utilized “breastfeeding”, “breast feeding”, “breastfeeding difficulties”, “breastfeeding difficulty”, “TMJ dysfunction”, “temporomandibular joint”, “birth trauma” and “infants”, in the appropriate Boolean combinations. They also examined non-peer-reviewed articles as revealed by Index to Chiropractic Literature and conducted a secondary analysis of references. Inclusion criteria for their review included all papers on breastfeeding difficulties regardless of peer-review. Articles were excluded if they were not written in the English language.

The following articles met the inclusion criteria: 8 case reports, 2 case series, 3 cohort studies and 6 manuscripts (5 case reports and a case series) that involved breastfeeding difficulties as a secondary complaint. The findings revealed a “theoretical and clinical framework based on the detection of spinal and extraspinal subluxations involving the cervico-cranio-mandibular complex and assessment of the infant while breastfeeding.”

Based on these results, the authors concluded that chiropractors care of infants with breastfeeding difficulties by addressing spinal and extraspinal subluxations involving the cervico-cranio-mandibular complex.

Have I promised too much?

I had thought that chiropractors had abandoned the subluxation nonsense! Not really, it seems.

I had thought that systematic reviews are about evidence of therapeutic effectiveness! Not in the weird world of chiropractic.

I would have thought that we all knew that ‘chiropractors care of infants with breastfeeding difficulties’ and do not need a review to confirm it! Yes, but what is good for business deserves another meaningless paper.

I would have thought that the conclusions of scientific articles need to be appropriate and based on the data provided! It seems that, in the realm of chiropractic, these rules do not apply.

An appropriate conclusion should have stated something like THERE IS NO GOOD EVIDENCE THAT CHIROPRACTIC CARE AIDS BREASTFEEDING. But that would have been entirely inappropriate from the chiropractic point of view because it is not a conclusion that promotes the sort of quackery most chiropractors rely upon for a living. And the concern over income is surely more important than telling the truth!

The chiropractic profession have been reminded time and times again that their claim to be able to effectively treat paediatric conditions is bogus. Many experts have asked them to produce some compelling evidence or stop this dangerous nonsense. Yet most of them seem to remain in denial, famously documented by the British Chiropractic Association suing Simon Singh for libel after he disclosed that they happily promote bogus treatments.

Some chiropractors now say that things have changed and that chiropractors are finally getting their act together. If that is true, progress must be painfully slow – so slow, in fact, that it is hard to see it at all. There are still far too many chiropractors who carry on just as before. There are hundreds, if not thousands of articles promoting chiropractic for childhood conditions; a very basic Google search for ‘chiropractic for children’ returns more than 7 million hits many of which advertise this sort of approach. Take this website, for instance; it makes its bogus claims entirely unabashed:

Even as an infant your child may have spinal nerve stress, known as subluxations. Although subluxations may not be painful, they can pose serious threats to your child’s development. If your baby was in a difficult position in the womb, or experienced a traumatic birth they may have developed subluxations. A common condition attributed to subluxations in children is known as Blocked Atlantal Nerve Syndrome. This condition may be the primary cause of ear and upper respiratory infections, and chronic tonsillitis.

Even regular childhood activities such as tumbles taken while learning to walk and run, bike riding, and participation in sports can also cause stress on your child’s body. Emotional stress and trauma may also be a cause of subluxations. Unless they are corrected they can affect future nerve function and the development of your child’s nervous system. They can also cause problems as your child grows and develops into adulthood.

With regular chiropractic care your child may be at less risk for common childhood disease such as colds and fevers. Some children show a marked improvement in asthma symptoms with regular chiropractic care and nutritional counselling. While chiropractors do no treat disease or sickness, they can identify and remove subluxations which interfere with your child’s natural ability to heal. By removing this stress from your child’s spinal system their immune system may function more efficiently and your child may have a better defense to disease. Their overall health may improve as their natural healing power is released. Children who receive regular chiropractic care may also be able to handle emotional and physical stress better and this care may contribute to their natural development.

Your child is never too young to start chiropractic care. Well-child care starts are early as the first month of life. Doctors use a very gentle pressure to treat children (no more pressure than picking up a tomato in the grocery store) and their treatments are very soothing to your child. After their first visit it is recommended that they receive treatments every three months up to age three, and then every six to 12 month after that. You may also want to visit your chiropractor after major milestones in your child’s life such as learning to sit up, crawl, and walk. They should also be seen if they experience any falls or trauma, and if you notice any balance issues they may be experiencing. These may include head tilting and limping.

Pediatric chiropractic care has many benefits. Children as young as infants may see an improvement in their development and overall health with regular care. Doctors of chiropractic take a proactive approach to health by striving to return and maintain your body’s natural balance. If you are looking for an alternative or supplement to traditional medical care, look into chiropractic care for your entire family.

Just a few rotten apples!… the apologists would probably say. But this is clearly not true. I find it even hard to locate the non-rotten apples in this decomposing and disgusting mess. More importantly, if it were true that things were now changing, one would expect that the progressive sections of the chiropractic profession protest regularly, sharply and effectively to shame the many charlatans amongst their midst. Crucially, one would expect the chiropractic professional organisations  to oust their bogus members systematically and swiftly.

The sad truth, however, is that none of this is really happening – certainly not in the US or the UK. On the contrary, organisations like THE INTERNATIONAL PEDIATRIC ASSOCIATION, books entitled CHIROPRACTIC PEDIATRICS, and periodicals like the JOURNAL OF PEDIATRIC, MATERNAL AND FAMILY CHIROPRACTIC remain popular and respected within the chiropractic profession. A few lip-services here and there, yes. But truly effective action? No!

The tolerance of quackery, I would argue, must be one of the most important hallmarks of a quack profession.

The question whether infant colic can be effectively treated with manipulative therapies might seem rather trivial – after all, this is a benign condition which the infant quickly grows out of. However, the issue becomes a little more tricky, if we consider that it was one of the 6 paediatric illnesses which were at the centre of the famous libel case of the BCA against my friend and co-author Simon Singh. At the time, Simon had claimed that there was ‘not a jot of evidence’ for claiming that chiropractic was an effective treatment of infant colic, and my systematic review of the evidence strongly supported his statement. The BCA eventually lost their libel case and with it the reputation of chiropractic. Now a new article on this intriguing topic has become available; do we have to reverse our judgements?

The aim of this new systematic review was to evaluate the efficacy or effectiveness of manipulative therapies for infantile colic. Six RCTs of chiropractic, osteopathy or cranial osteopathy alone or in conjunction with other interventions were included with a total of 325 infants. Of the 6 included studies, 5 were “suggestive of a beneficial effect” and one found no evidence of benefit. Combining all the RCTs suggested that manipulative therapies had a significant effect. The average crying time was reduced by an average of 72 minutes per day. This effect was sustained for studies with a low risk of selection bias and attrition bias. When analysing only those studies with a low risk of performance bias (i.e. parental blinding) the improvement in daily crying hours was no longer statistically significant.

The quality of the studies was variable. There was a generally low risk of selection bias but a high risk of performance bias. Only one of the studies recorded adverse events and none were encountered.

From these data, the authors drew the following conclusion: Parents of infants receiving manipulative therapies reported fewer hours crying per day than parents whose infants did not and this difference was statistically significant. Most studies had a high risk of performance bias due to the fact that the assessors (parents) were not blind to who had received the intervention. When combining only those trials with a low risk of such performance bias the results did not reach statistical significance.

Does that mean that chiropractic does work for infant colic? No, it does not!

The first thing to point out is that the new systematic review included not just RCTs of chiropractic but also osteopathy and cranio-sacral therapy.

The second important issue is that the effects disappear, once performance bias is being accounted for which clearly shows that the result is false positive.

The third relevant fact is that the majority of the RCTs were of poor quality. The methodologically best studies were negative.

And the fourth thing to note is that only one study mentioned adverse effects, which means that the other 5 trials were in breach of one of rather elementary research ethics.

What makes all of this even more fascinating is the fact that the senior author of the new publication, George Lewith, is the very expert who advised the BCA in their libel case against Simon Singh. He seems so fond of his work that he even decided to re-publish it using even more misleading language than before. It is, of course, far from me to suggest that his review was an attempt to white-wash the issue of chiropractic ‘bogus’ claims. However, based on the available evidence, I would have formulated conclusions which are more than just a little different from his; something like this perhaps:

The current best evidence suggests that the small effects that emerge when we pool the data from mostly unreliable studies are due to bias and therefore not real. This systematic review therefore fails to show that manipulative therapies are effective. It furthermore points to a serious breach of research ethics by the majority of researchers in this field.

The dismal state of chiropractic research is no secret. But is anything being done about it? One important step would be to come up with a research strategy to fill the many embarrassing gaps in our knowledge about the validity of the concepts underlying chiropractic.

A brand-new article might be a step in the right direction. The aim of this survey was to identify chiropractors’ priorities for future research in order to best channel the available resources and facilitate advancement of the profession. The researchers recruited 60 academic and clinician chiropractors who had attended any of the annual European Chiropractors’ Union/European Academy of Chiropractic Researchers’ Day meetings since 2008. A Delphi process was used to identify a list of potential research priorities. Initially, 70 research priorities were identified, and 19 of them reached consensus as priorities for future research. The following three items were thought to be most important:

  1.  cost-effectiveness/economic evaluations,
  2.  identification of subgroups likely to respond to treatment,
  3.  initiation and promotion of collaborative research activities.

The authors state that this is the first formal and systematic attempt to develop a research agenda for the chiropractic profession in Europe. Future discussion and study is necessary to determine whether the themes identified in this survey should be broadly implemented.

Am I the only one who finds these findings extraordinary?

The chiropractic profession only recently lost the libel case against Simon Singh who had disclosed that chiropractors HAPPILY PROMOTE BOGUS TREATMENTS. One would have thought that this debacle might prompt the need for rigorous research testing the many unsubstantiated claims chiropractors still make. Alas, the collective chiropractic wisdom does not consider such research as a priority!

Similarly, I would have hoped that chiropractors perceive an urgency to investigate the safety of their treatments. Serious complications after spinal manipulation are well documented, and I would have thought that any responsible health care profession would consider it essential to generate reliable evidence on the incidence of such events.

The fact that these two areas are not considered to be priorities is revealing. In my view, it suggests that chiropractic is still very far from becoming a mature and responsible profession. It seems that chiropractors have not learned the most important lessons from recent events; on the contrary, they continue to bury their heads in the sand and carry on seeing research as a tool for marketing.

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