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

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I hear this notion regularly and I have repeatedly published about it (even on this blog).

In Germany, people often express it succinctly  WER HEILT HAT RECHT! The argument is so prevalent that I feel like addressing it yet again by publishing a revised version of my Lancet Oncology paper of 2005.

At first glance, the argument seems disarmingly obvious and ethical – above everything else, clinicians must have the welfare of their patients in their minds. All other concerns are secondary.

However, on closer inspection and reflection the argument is not convincing. For the purpose of this discussion, I shall use healing as an example of a SCAM that fulfils the following three criteria:

  • it is associated with perceived benefit to some patients;
  • it is apparently without harm;
  • it is not supported by convincing evidence of efficacy.

Thus, spiritual healing could be replaced, for instance, by homeopathy, Bach Flower Remedies, craniosacral therapy, shark cartilage, etc.

It is obvious that the above argument can apply only, if the treatment in question does not entail meaningful risks. But how do we know it doesn’t? The fact that we are unaware of risks does not mean that none exist. Indeed, none of the above-named treatments are entirely free of adverse effects. Even healing has been associated with unwanted effects. They may be relatively mild and rare, but in the absence of any reporting schemes, this fact is less than conclusive: absence of evidence is not evidence of absence of an (adverse) effect.

The above argument can also be viewed as an endorsement for use of SCAM. If widespread, such endorsements could lead to many patients trusting the many unsubstantiated claims made about SCAM. This would mislead patients into using such therapies as alternatives to conventional treatments—the promotion of alternative cancer cures is rife with recommendations for abandoning conventional cancer therapy, and the effects have repeatedly been shown to be disastrous. Used as an alternative, even the most harmless treatment can become positively life-threatening.

The above argument clearly presupposes that the treatment in question works. But what is meant by this phraseology? Certainly there is no convincing trial evidence that spiritual healing works for cancer or indeed any other condition. “It works” therefore could mean that the treatment helps some patients via a placebo response. There is, of course, nothing wrong with patients benefiting from placebo effects. But do we need placebo treatments to generate a placebo response? The answer is no; even effective therapies will evoke a placebo response. In other words, patients don’t need healing or any other such treatment to profit from a placebo effect. It follows that administering pure placebos to sick patients means cheating them out of an essential element of an effective therapy.

If patients feel better after consulting a healer, they most likely respond to factors like empathy, sympathy, and time provided to them by that therapist. Again, there is absolutely nothing wrong with such a response. To the contrary, responsible orthodox healthcare professionals should cultivate the attitudes that generate it. By directly or indirectly sending our patients to healers to benefit from empathy, etc, we effectively delegate these core qualities of a good therapeutic relationship to others. But delegating empathy to SCAM practitioners would be a most serious mistake for modern medicine to make.

Healers often charge £100 or more per session. Because a placebo response is a free add-on to any well-administered treatment, this seems an unjustifiably high amount of money. Financial exploitation is a subject not much talked about in SCAM – in our recent new book, we included a whole chapter on this issue. We all should think twice before endorsing exploitation.

Perhaps the most detrimental effect of the above argument is outside the realm of medicine. Spiritual healing, like astrology, clairvoyance, mind-reading, etc, is not merely implausible it is mystical nonsense based on ideas that are demonstrably incorrect. Promotion of such nonsense undermines rationality and supports the growth of anti-science and superstition in our society at large. Arguments like that above therefore amount to an endorsement of anti-science. They might sound liberal, tolerant and politically correct but, in truth, they undermine the foundation of rational thinking, hinder progress and lead us back to the Dark Ages.

I have previously mentioned some of the background but, somehow, I seem to have omitted to draw your attention to the actual paper. Yes, I am talking of the review of cervical manipulation prepared for the Manitoba Health Professions Advisory Council. It is an important and well-researched document; even though it is already a few months old, I feel I must correct my omission.

Here is the abstract:

Neck manipulation or adjustment is a manual treatment where a vertebral joint in the cervical spine—comprised of the 7 vertebrae C1 to C7—is moved by using high-velocity, low-amplitude (HVLA) thrusts that cannot be resisted by the patient. These HVLA thrusts are applied over an individual, restricted joint beyond its physiological limit of motion but within its anatomical limit. The goal of neck manipulation, referred to throughout this report as cervical spine manipulation (CSM), is to restore optimal motion, function, and/or reduce pain. CSM is occasionally utilized by physiotherapists, massage therapists, naturopaths, osteopaths, and physicians, and is the hallmark treatment of chiropractors; however the use of CSM is controversial. This paper aims to thoroughly synthesize evidence from the academic literature regarding the potential risks and benefits of cervical spine manipulation utilizing a rapid literature review method.

METHODS Individual peer-reviewed articles published between January 1990 and November 2016 concerning the safety and efficacy of cervical spine manipulation were identified through MEDLINE (PubMed), EMBASE, and the Cochrane Library.

KEY FINDINGS

  • A total of 159 references were identified and cited in this review: 86 case reports/ case series, 37 reviews of the literature, 9 randomized controlled trials, 6 surveys/qualitative studies, 5 case-control studies, 2 retrospective studies, 2 prospective studies and 12 others.
  • Serious adverse events following CSM seem to be rare, whereas minor adverse events occur frequently.
  • Minor adverse events can include transient neurological symptoms, increased neck pain or stiffness, headache, tiredness and fatigue, dizziness or imbalance, extremity weakness, ringing in the ears, depression or anxiety, nausea or vomiting, blurred or impaired vision, and confusion or disorientation.
  • Serious adverse events following CSM can include the following: cerebrovascular injury such as cervical artery dissection, ischemic stroke, or transient ischemic attacks; neurological injury such as damage to nerves or spinal cord (including the dura mater); and musculoskeletal injury including injury to cervical vertebral discs (including herniation, protrusion, or prolapse), vertebrae fracture or subluxation (dislocation), spinal edema, or issues with the paravertebral muscles.
  • Rates of incidence of all serious adverse events following CSM range from 1 in 10,000 to 1 in several million cervical spine manipulations, however the literature generally agrees that serious adverse events are likely underreported.
  • The best available estimate of incidence of vertebral artery dissection of occlusion attributable to CSM is approximately 1.3 cases for every 100,000 persons <45 years of age receiving CSM within 1 week of manipulative therapy. The current best incidence estimate for vertebral dissection-caused stroke associated with CSM is 0.97 residents per 100,000.
  • While CSM is used by manual therapists for a large variety of indications including neck, upper back, and shoulder/arm pain, as well as headaches, the evidence seems to support CSM as a treatment of headache and neck pain only. However, whether CSM provides more benefit than spinal mobilization is still contentious.
  • A number of factors may make certain types of patients at higher risk for experiencing an adverse cerebrovascular event after CSM, including vertebral artery abnormalities or insufficiency, atherosclerotic or other vascular disease, hypertension, connective tissue disorders, receiving multiple manipulations in the last 4 weeks, receiving a first CSM treatment, visiting a primary care physician, and younger age. Patients whom have experience prior cervical trauma or neck pain may be at particularly higher risk of experiencing an adverse cerebrovascular event after CSM.

CONCLUSION The current debate around CSM is notably polarized. Many authors stated that the risk of CSM does not outweigh the benefit, while others maintained that CSM is safe—especially in comparison to conventional treatments—and effective for treating certain conditions, particularly neck pain and headache. Because the current state of the literature may not yet be robust enough to inform definitive prohibitory or permissive policies around the application of CSM, an interim approach that balances both perspectives may involve the implementation of a harm-reduction strategy to mitigate potential harms of CSM until the evidence is more concrete. As noted by authors in the literature, approaches might include ensuring manual therapists are providing informed consent before treatment; that patients are provided with resources to aid in early recognition of a serious adverse event; and that regulatory bodies ensure the establishment of consistent definitions of adverse events for effective reporting and surveillance, institute rigorous protocol for identifying high-risk patients, and create detailed guidelines for appropriate application and contraindications of CSM. Most authors indicated that manipulation of the upper cervical spine should be reserved for carefully selected musculoskeletal conditions and that CSM should not be utilized in circumstances where there has not yet been sufficient evidence to establish benefit.

___________________________________________________________________

I think this is a balanced review, not least because the authors stress that further research is required to strengthen evidence for efficacy of CSM for treatment of neck pain and headache, as well as for other indications where evidence currently does not exist (i.e., upper back and shoulder/arm pain, high blood pressure, etc.).

The review expresses many of the concerns and cautions that I have repeatedly tried to voice on this blog. I have no means of telling who the authors of this document are, but I applaud their thorough research, their clear language, and their courage to publish. For all who have a deeper interest in upper neck manipulation, I strongly recommend to study the report in full detail.

Hahnemann spent his last years in Paris where he and his young French wife became what we today might call fashionable gurus. Ever since, homeopathy has been almost as popular in France as it is in Germany. The world’s largest producer of homeopathic products, Boiron, is based in France, and about 10% of the French population, particularly young children and women, receive at least one homeopathic preparation per year.

For a long time, homeopathy existed almost entirely unchallenged in France. This odd ‘status quo’ has changed only in recent months. But now even the French Academies of Medicine and Pharmacy have published a short document entitled L’homéopathie en France : position de l’Académie nationale de médecine et de l’Académie nationale de pharmacie. It stated this:

L’homéopathie a été introduite à la fin du XVIIIe siècle, par Samuel Hahnemann, postulant deux hypothèses : celle des similitudes (soigner le mal par le mal) et celle des hautes dilutions. L’état des données scientifiques ne permet de vérifier à ce jour aucune de ces hypothèses. Les méta-analyses rigoureuses n’ont pas permis de démontrer une efficacité des préparations homéopathiques.

[My translation: Homeopathy was introduced by Samuel Hahnemann at the end of the 18th century; he postulated two hypotheses: like cures like and high dilution. The scientific evidence does not confirm either of them. Rigorous meta-analyses fail to show the effectiveness of homeopathic remedies.]

The academies concluded that no French university should offer degrees in homeopathy, and that homeopathy should no longer be funded by the public purse: “no homeopathic preparation should be reimbursed by Assurance Maladie [France’s health insurance] until the demonstration of sufficient medical benefit has been provided. No university degree in homeopathy should be issued by medical or pharmaceutical faculties ... The reimbursing of these products by the social security seems aberrant at a time when, for economic reasons, we are not reimbursing many classic medicines because they are more or less considered to not work well enough …

Already last year, the Collège National des Généralistes Engseignants, the national association for teaching doctors, had pointed out that there was no rational justification for the reimbursement of homeopathics nor for the teaching of homeopathy in medical schools: It is necessary to abandon these esoteric methods, which belong in the history books. Simultaneously, 124 doctors published an open letter criticising SCAM (including homeopathy) as dangerous and fantasist … practised by charlatans of all kinds.

Also in 2018, the University of Lille announced its decision to stop its course on homeopathy. The faculty of medicine’s dean, Didier Gosset, stated: It has to be said that we teach medicine based on proof – we insist on absolute scientific rigour – and it has to be said that homeopathy has not evolved in the same direction, that it is a doctrine that has remained on the margins of the scientific movement, that studies on homeopathy are rare, that they are not very substantial. Continuing to teach it would be to endorse it.

Agnès Buzyn, the health minister, said in April 2018: there is a continuous evaluation of the medicines we call complementary. A working group at the head office of my department checks that all these practices are not dangerous. If a therapy continues to be beneficial without being harmful, it continues to be reimbursed… The French are very attached [to homeopathy]; it’s probably a placebo effect. If it can prevent the use of toxic medicine, I think that we all win. I does not hurt. Shortly after, she asked France’s medical council, the Haute Autorité de Santé (HAS), to evaluate the efficacy of homeopathy and the basis for it being reimbursed. The HAS will publish its findings in June.

It seems that we will soon know whether the minister, the officials of HAS and the Academies, as well as a growing group of French sceptics have all joined the infamous KKK – in an interview, Christian Boiron pointed out not long ago that “Il y a un Ku Klux Klan contre l’homéopathie” THERE IS A KU KLUX KLAN AGAINST HOMEOPATHY.

The Horse‘ is not a publication I often read. But I was alerted to an article in this magazine that fascinated me. Allow me to show you a few short quotes:

In essence, holistic medicine falls under the realm of what we now refer to as, “complementary, alternative, and integrative veterinary medicine,” or CAIVM. The American Veterinary Medical Association (AVMA) describes CAIVM as “a heterogeneous group of preventive, diagnostic, and therapeutic philosophies and practices that are not considered part of conventional (Western) medicine as practiced by most veterinarians.”

… Joyce Harman, DVM, owner of ­Harmany Equine Ltd., in Flint Hill, Virginia, is one veterinarian committed to the practice of CAIVM. She’s certified in acupuncture and chiropractic and has completed advanced training in veterinary homeopathy, nutrition, and herbal medicine. “If you’re looking for a local practitioner, find one with extensive training in the modality you’re interested in,” she says…

Let’s have a look at the actual evidence for or against these treatments. Here are (again) the most up-to-date systematic reviews for acupuncture, chiropractic and homeopathy in veterinary medicine:

ACUPUNCTURE

Acupuncture is a popular complementary treatment option in human medicine. Increasingly, owners also seek acupuncture for their animals. The aim of the systematic review reported here was to summarize and assess the clinical evidence for or against the effectiveness of acupuncture in veterinary medicine. Systematic searches were conducted on Medline, Embase, Amed, Cinahl, Japana Centra Revuo Medicina and Chikusan Bunken Kensaku. Hand-searches included conference proceedings, bibliographies, and contact with experts and veterinary acupuncture associations. There were no restrictions regarding the language of publication. All controlled clinical trials testing acupuncture in any condition of domestic animals were included. Studies using laboratory animals were excluded. Titles and abstracts of identified articles were read, and hard copies were obtained. Inclusion and exclusion of studies, data extraction, and validation were performed independently by two reviewers. Methodologic quality was evaluated by means of the Jadad score. Fourteen randomized controlled trials and 17 nonrandomized controlled trials met our criteria and were, therefore, included. The methodologic quality of these trials was variable but, on average, was low. For cutaneous pain and diarrhea, encouraging evidence exists that warrants further investigation in rigorous trials. Single studies reported some positive intergroup differences for spinal cord injury, Cushing’s syndrome, lung function, hepatitis, and rumen acidosis. These trials require independent replication. On the basis of the findings of this systematic review, there is no compelling evidence to recommend or reject acupuncture for any condition in domestic animals. Some encouraging data do exist that warrant further investigation in independent rigorous trials.

CHIROPRACTIC

There are no studies of chiropractic for animals and hence no systematic review. However, I did publish a blog-post about veterinary chiropractic. It arrived at this conclusion: chiropractors treating animals and those treating humans have one important characteristic in common. THEY HAPPILY PROMOTE BOGUS TREATMENTS.

HOMEOPATHY

Meta-analysis of randomised controlled trials (RCTs) of veterinary homeopathy has not previously been undertaken. For all medical conditions and species collectively, we tested the hypothesis that the outcome of homeopathic intervention (treatment and/or prophylaxis, individualised and/or non-individualised) is distinguishable from corresponding intervention using placebos.

All facets of the review, including literature search strategy, study eligibility, data extraction and assessment of risk of bias, were described in an earlier paper. A trial was judged to comprise reliable evidence if its risk of bias was low or was unclear in specific domains of assessment. Effect size was reported as odds ratio (OR). A trial was judged free of vested interest if it was not funded by a homeopathic pharmacy. Meta-analysis was conducted using the random-effects model, with hypothesis-driven sensitivity analysis based on risk of bias.

Nine of 15 trials with extractable data displayed high risk of bias; low or unclear risk of bias was attributed to each of the remaining six trials, only two of which comprised reliable evidence without overt vested interest. For all N = 15 trials, pooled OR = 1.69 [95% confidence interval (CI), 1.12 to 2.56]; P = 0.01. For the N = 2 trials with suitably reliable evidence, pooled OR = 2.62 [95% CI, 1.13 to 6.05]; P = 0.02).

Meta-analysis provides some very limited evidence that clinical intervention in animals using homeopathic medicines is distinguishable from corresponding intervention using placebos. The low number and quality of the trials hinders a more decisive conclusion.

So, what shall we make of ‘holistic horse care’ in view of this evidence?

I think I let you answer this question.

This ‘nationwide, population-based ‘cohort study’ was meant to investigate the probable effect of TCM to decrease the fracture rate. Its authors identified cases with osteoporosis and selected a comparison group that was frequency-matched according to sex, age (per 5 years), diagnosis year of osteoporosis, and index year. The difference between the two groups in the development of fracture was estimated using the Kaplan-Meier method and the log-rank test.

After inserting age, gender, urbanization level, and comorbidities into the Cox’s proportional hazard model, patients who used TCM had a lower hazard ratio (HR) of fracture compared to the non-TCM user group. The Kaplan-Meier curves showed that osteoporosis patients who used TCM had a lower incidence of fracture events than those who did not. Our study also demonstrated that the longer the TCM use, the lesser the fracture rate.

The authors concluded that their study showed that TCM might have a positive impact on the prevention of osteoporotic fracture.

The authors also mention three weaknesses of their study:

  • Firstly, we were unable to include medicines taken at the patient’s own expense. According to the specification of the NHI program, Western medicine for osteoporosis can only be applied after a fracture occurred. It is possible that the patients source such medicines at their own expense when they were diagnosed with osteoporosis before a fracture happens.
  • Secondly, some data related to fractures, such as a patient’s exercise, lifestyle, BMI, alcohol, and cigarette use is not available from the NHI program.
  • Thirdly, the Kaplan–Meier curve might be influenced by economic levels and patient severity. However, we can conclude that TCM might have a positive impact on the prevention of osteoporotic fracture…

Disregarding these limitations, they nevertheless state that their study not only reveals the preventative value of TCM use for patients with osteoporosis in the clinical setting, but also provides valuable information regarding the most common prescriptions provided to osteoporotic patients.

So, is there a causal link between TCM and osteoporosis?

Yes, it is possible.

But is it proven?

No!

Is it likely?

No!

By far the most plausible explanation of the findings is that the two groups that were compared here were not comparable in many ways that affect the osteoporosis-risk.

Major risk factors of osteoporosis include:

  • Inadequate nutritional absorption
  • Lack of physical activity or fall risk
  • Weight loss
  • Cigarette smoking
  • Alcohol consumption
  • Air pollution
  • Stress

I suggest therefore that this study shows that the two populations differed regarding these risk factors.

I also suggest that researchers of SCAM might benefit from a minimum of critical thinking.

I furthermore suggest that, if SCAM-fans want to test whether causal effects exist, they use controlled clinical trials rather than cohort or case-control studies

Lastly, I suggest that authors, journal editors, reviewers and funders (this study was funded by the ‘Taiwan Ministry of Health and Welfare Clinical Trial Center’) remind themselves that they have a responsibility and thus avoid misleading the public.

The discussion about the value of homeopathy has recently become highly acute in Germany. Once again, it seems that German homeopaths fight for survival with all means imaginable. This can perhaps be better understood in the light of what has happened during the Third Reich. In 1995, I published a paper about this intriguing bit of homeopathic history (British Homoeopathic Journal October 1995, Vol. 84, p. 229). As it has miraculously disappeared from Medline, I take the liberty of re-publishing it here in full and without further comment:

In the early part of the 20th century, there was a strong lay movement of ‘natural health’ in Germany. It is estimated that, when the Nazis took over in 1933, the number of lay practitioners equalled that of physicians. The Nazis jumped on this bandwagon and created the Neue Deutsche Heilkunde (new German medicine)–forced integration of health care to a single body under strict political control [1].

A systematic attempt was orchestrated to scrutinize homoeopathy. The motivation was probably threefold: it fitted the Neue Deutsche Heilkunde concept, it was put forward as a ‘pure German’ line of medicine, and homoeopathy was also seen as potentially a cheap way of keeping the nation healthy, freeing resources for preparatory war efforts. The results have never been published and may be lost for ever. However, an eye- witness report was written after the war by Dr Donner, a homoeopathic physician of high standing. His report, probably not entirely objective, makes fascinating reading [2].

Dr Donner joined the Stuttgart Homoeopathic Hospital in the mid 1930s. He became involved in the German Ministry of Health’s initiatives to scrutinize homoeopathy. Following a detailed study of the literature he expressed profound doubts as to the validity of homoeopathic provings. Experiments to replicate such provings in 1939 showed the importance of the placebo phenomenon and subject/evaluator blinding. His and his colleagues’ results gave no evidence of validity.

A concept by which homoeopathy was to be scrutinized emerged. It foresaw the tests to be supervised by conventional physicians with sufficient knowledge of homoeopathy. About 60 university institutions were to participate. Each team included homoeopaths, toxicologists, pharmacologists and internists. The tests protocols were to be adapted to the special needs of homoeopathy—e.g, freedom of homoeopathic prescription. Donner argues that never before did homoeopathy have such ideal conditions for evaluation. He reports on about 300 planning meetings with staff from the ministry.

Experts were perfectly aware of problems such as the placebo effect and spontaneous remissions and therefore planned large, placebo-controlled trials. These were to be performed on patients with tuberculosis, pernicious anaemia, gonorrhoea and other diseases where homeopaths had claimed to treat successfully.

On the occasion of the 1937 Homoeopathic World Congress in Berlin, Nazi officials decided to start the trials on homoeopathy on a large scale. ‘Hundreds of millions’ of Reichsmark were available. Donner describes several provings and clinical trials in some detail. Without exception, their results yielded no indication for the validity of homoeopathy.

Although there had been previous agreement to the contrary amongst all participants, it was agreed that these negative findings should not be published at this stage, but a new experimental beginning should be sought. Further experiments were planned which could not be concluded due to the outbreak of war.

In 1947, the subject was again discussed by those who were initially involved. The original documents seem to have survived the war. They had not yet been published and are not likely to have been lost or destroyed.

Dr Donner finishes his report by urging the reader to draw the right conclusions. The ‘fiasco’, he maintains, must be blamed not on the individuals involved in these experiments but on the situation inside German homoeopathy. Future evaluations of homoeopathy should be performed to a high scientific standard and without illusions.

Dr Donner’s report is presently being published for the first time [2]. As it is in German, the above summary might be helpful for an international readership.

References

1 Ernst E. Naturheilkunde im Dritten Reich. Dtsch. Arzteblatt 1994 (accepted for publication).

2 Donner. Report to be published in issues 1 5 of Perfusion. Pia Verlag, Nuernberg.

Guest post by Richard Rawlins

It is 18 years since Health Secretary Alan Milburn launched a scheme for family doctors to prescribe exercise, aerobics, swimming, and yoga for those who are overweight and at risk of strokes, heart disease or suffering from osteoporosis, diabetes or stress. Splendid! But have any benefits resulted? We do not know.

In 2015, Simon Stevens, CEO NHS England, emphasised the importance of NHS staff being cared for: “NHS staff have some of the most critical but demanding jobs in the country. When it comes to supporting the health of our own workforce, frankly the NHS needs to put its own house in order.” He identified “ten leading NHS employers to spearhead a comprehensive initiative to boost NHS staff health at work by committing to ‘six key actions’, including “by establishing and promoting a local physical activity ‘offer’ to staff, such as running, yoga classes, Zumba classes, or competitive sports teams…”

Mr Stevens pointed out that his proposals would cost £5m, but would “help solve the problem of the NHS bill for staff sickness” – then standing at £2.4bn a year.

Good idea. I like to keep fit, and yoga may well help – but is there any evidence it does? Has there been any evaluation of Mr Stevens’ initiative? Has it worked – by any criterion?

More recently, Mr Stevens has climbed aboard the ‘Social Prescribing’ band wagon and declared he would like to see patients provided with yoga, paid for by the NHS.

In January, Health Secretary Matt Hancock announced the need to support a “growing elderly population to stay healthy and independent for longer” with “more social prescribing, empowering people to take greater control and responsibility over their own health through prevention”. And at a ‘Yoga in Healthcare Conference’ in February, Mr Duncan Selbie, chief executive of Public Health England, spoke of extra money promised under the government’s NHS Long Term Plan to fund yoga classes.

Mr Selbie, told doctors and yoga practitioners at the conference: “The evidence is clear … yoga is an evidenced intervention and a strengthening activity that we know works.”

The problem is, Mr Selbie did not provide any evidence in support of his assertions. It is likely there is none. Do not take my word for it – that is the opinion of the US National Center for Complementary and Integrated Health – an institution founded and dedicated to establishing evidence of any benefit from complementary and alternative treatment modalities, and funded to the tune of $164 million p.a.

Promotion for the conference suggested that “The Yoga in Healthcare Alliance (YIHA), the College of Medicine and Integrated Health (CoMIH) and the University of Westminster is collaborating to bridge the worlds of yoga and healthcare with the first ever Yoga in Healthcare Conference.” The YIHA claims it is “working with the NHS to provide yoga to patients.” Its Yoga4Health programme is a 10-week yoga course commissioned by the West London Clinical Commissioning Group, for patients registered at a GP in West London.

In a statement, the YIHA said: “There is significant robust evidence for yoga as an effective ‘mind-body’ medicine that can both prevent and manage chronic health issues and it also delivers significant cost savings to healthcare providers…The College of Medicine will be offering a certificate of attendance to all delegates that can be used towards CPD points.”

On the face of it, that all seems rational and reasonable, but consider, the conference opened with a speech from Dr. Manjunath Nagendra, Chair of the Indian Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy. AYUSH is an “Indian governmental body purposed with developing, education and research in the field of alternative medicines.”

Now it is one thing to cover the background and history of a therapeutic modality at a conference on yoga, but quite another to give respectful house room to a promoter of anachronistic concepts based on vitalism and having no basis in reality. Good luck to those who believe in vitalism, but why is NHS England involved? Is NHS England content to promote alternative medicine? We should be told – perhaps we should all climb on that bandwagon.

Amongst an array of speakers, most with an interest in having alternative medicine paid for by the NHS, Dr Michael Dixon of the CoMIH, spoke on ‘Social Prescribing and Yoga’ and Drs. Patricia Gerbarg and Richard Brown on “The Therapeutic Power of Breath, a Key Public Health Intervention.”

Inevitably, another enjoying a trip on the bandwagon, is the Prince of Wales. In a written address to the conference he advised: “The ancient practice of yoga has proven beneficial effects on both body and mind…For thousands of years, millions of people have experienced yoga’s ability to improve their lives … The development of therapeutic, evidence-based yoga is, I believe, an excellent example of how yoga can contribute to health and healing. This not only benefits the individual, but also conserves precious and expensive health resources for others where and when they are most needed…I will watch the development of therapeutic yoga in the UK with great interest and very much look forward to hearing about the outcomes from your conference.” The Prince claimed yoga classes had “tremendous social benefits and builds discipline, self-reliance and self-care”, which, he said. contributed to improved general health.

The Prince supplied no evidence to support those assertions. No scientific evidence, no economic evidence such as cost-benefit analyses.

The Prince was “delighted” to discover that the conference was examining the health benefits of yoga and claimed it was “the first of its kind in the UK”. Hardly – there have been many conferences on yoga and health, but the semanticists will hide behind the phrase: “…of its kind” – that is, this was the first UK conference involving the ‘College of Medicine and Integrated Health’ together with representatives of NHS institutions. Semantic sophistry.

Originating in India, the principles and practices of yoga developed as one of the six branches of the Vedas – a Hindu spiritual and ascetic discipline, a part of which, including breath control, simple meditation, and the adoption of specific bodily postures, is now more widely practised for health and relaxation. The word yoga comes from the Sanskrit ‘yug’, meaning to yoke or unite. Not fingers touching toes or noses reaching knees, nor the union of mind and body, although, this is a sense commonly applied within the yoga community. The union that the word yoga is referring to is that of uniting individual consciousness and experience of reality with Divine consciousness – a spiritual state perceived when we quiet our five senses and reconnect with the Supreme Self within. That requires faith.

The concept of yoga is inevitably on the agenda of those who perceive a need to foster ‘integration’ and ‘harmony’ – but as oncological surgeon Dr Mark Crislip has pointed out: “If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie it does not make the cow pie taste better, it makes the apple pie worse.”

Back to reality. Academics from Northumbria University have begun a £1.4m four-year study exploring the impact of yoga on older people with multiple long-term health conditions. In the UK, two-thirds of people aged 65+ have multimorbidity – defined as having two or more long-term health conditions such as diabetes and heart disease.

“Treatments for long-term health conditions account for 70 per cent of NHS expenditure, so researchers want to look at the effectiveness clinically and cost-wise of an adapted yoga programme for older adults with multimorbidity, to reduce reliance on medication.”

Excellent. But for now – the jury is out. Until we do have evidence of the anticipated benefit, we should all bear in mind the view of the Director of the US NICCIH. Commenting on “Yoga for Wellness” Dr Helene Langevin says:

“In a national survey, 94 percent of adults who practiced yoga reported that they did so for wellness-related reasons—such as general wellness and disease prevention or to improve energy – and a large proportion of them perceived benefits from its use. For example, 86 percent said yoga reduced stress, 67 percent said they felt better emotionally, 63 percent said yoga motivated them to exercise more regularly, and 43 percent said yoga motivated them to eat better.”

But what does the science say? Does yoga actually have benefits for wellness? The NCCIH tells us:

“Only a small amount of research has looked at this topic. Not all of the studies have been of high quality, and findings have not been completely consistent. Nevertheless, some preliminary research results suggest that practicing yoga may help people manage stress, improve balance, improve positive aspects of mental health, and adopt healthy eating and physical activity habits.”

“May help” does not mean “it does help”. And whilst TLC is always lovely, and virtually all interventions “may help relieve stress and improve positive aspects of mental health”, the jury is out as to whether yoga actually does have such benefits. And the NCCIH cites “preliminary research…”. “Preliminary” – after some thousands of years?

Shorn of esoteric metaphysical mishmash, yoga may well assist many patients come to terms with their ailments, but the association of NHS institutions with the CoMIH suggest an agenda to have a wider variety of un-evidenced alternative modalities smuggled into the NHS, contrary to policy that NHS healthcare should be based on evidence. Surely that is to be deprecated. NHS England should explain its endorsement for conferences such as this lest all those who are struggling to advance health care on a rational scientific base pack their bags and go home.

Homeopathy has been criticised since it first emerged 200 years ago. First, people mocked its utter implausibility. More recently, critics have pointed out that, despite 200 years of research, there is no good evidence that highly diluted remedies are anything other than placebos. In some countries, this has led to a ban of the public reimbursement of homeopathy.

In its homeland, Germany, homeopathy had a relatively long free ride. Vocal opposition only emerged a few years ago. But now it has become effective, sales figures (in excess of half a billion Euros) have started to drop and understandably, the German homeopathy-lobby is on high alert. Their latest attempt to sway public opinion is most revealing (if you read German, I highly recommend reading it in full).

A group of pro-homeopathy organisations and individuals make a series of accusations that seem like the frantic nonsense uttered in pure desperation and panic. The aim is no longer to attempt informing the public; the aim has now degenerated into a vile defamation of the critics. Amongst other claims, the lobbyists defame the critics by claiming that:

  • the current criticism of homeopathy is an expression of ‘ignorance’;
  • critics are wilfully misleading the public by dishonestly publishing wrong information;
  • critics monopolise their paradigm and that this amounts totalitarianism;
  • critics are not prepared to enter into a productive discussion;
  • critics merely follow a currently fashionable trend of arguing against homeopathy;
  • critics misrepresent scientific facts;
  • all of Prof Ernst’s homeopathy research is fraudulent (‘unserioes’);
  • critics are dogmatic ideologists and totalitarians.

The lobbyists further claim that:

  • leading universities in the US and elsewhere are on the side of homeopathy;
  • homeopathy is not in conflict with the principles of evidence-based medicine;
  • German law is on the side of homeopathy;
  • medical pluralism which includes homeopathy is in the interest of the patient;
  • only homeopaths are able to generate unbiased assessments of homeopathy;
  • homeopathy is an important part of integrated medicine for the benefit of the patient;
  • the Swiss example is something Germany should aim for;
  • Robert Hahn’s analysis invalidated the research of critics;
  • the Australian NHMRC-report is invalid;
  • homeopathy is fully dedicated to science;
  • placebos (such as homeopathic remedies?) are helpful interventions;
  • across the globe, the view is now accepted that integrative medicine must become the basis for good healthcare;
  • the German law forbids the authorities to regulate against homeopathy.

The arguments voiced here are by no means new; they have been voiced in every other country that has or is/was about to limit or abolish the public reimbursement of homeopathy. All they amount to, in fact, is a well-rehearsed, often-repeated and equally often refuted pack of lies and misleading statements. One has the impression of listening to a broken record.

Yet, many people will consider seriously what clearly is the last line of the defence of the indefensible, and they might ask themselves: who can we believe? For non-experts the confusion must be profound.

In all such cases, my advice is this: ask yourself who might be less motivated to mislead you, independent academics and sceptics with no ties to any industry, or the clinicians, their lobbyists and associations who all make their living via the multi-million industry of the SCAM in question?

 

By Guest Blogger Carlos Orsi, Instituto Questão de Ciência – Brazil

Elizabeth spent her whole adult life on yoga, follows a raw vegetable diet full of detox juices, studies acupuncture, and all of a sudden, in spite of this super healthy New age lifestyle, she is diagnosed with bowel and liver cancer, stage 4. After one course of chemotherapy and one of radiotherapy, both the main tumour and the metastasis vanished! She considers herself fully healed. A victory for Science, of course! Or isn’t it?

Not accordingly to the interpretation of “Heal”, Netflix’s recent documentary.

Even after Elizabeth’s doctor suggested that maybe the quick and relatively simple remission might be due to a misdiagnosis made at the beginning, that overestimated the severity of the tumour, the film insists that the actual reason for Elizabeth’s recovery was the release of negative emotions and energy. Those, they say, had accumulated for decades, ever since the day when the patient, still a small child, was humiliated by her kindergarten mates for bringing a pack of crackers for Show and Tell.

Produced, directed, written, and hosted by Kelly Noonan Gores (American actor that can be seen on the episode “Sex, Lies and Silicone” from the series CSI, New York), “Heal” tells the stories of two women struggling with disease. While Elizabeth deals with her cancer, Eva suffers from a mysterious type of rash, undiagnosed by doctors. Eva, of course, is also searching for a cure.

The documentary features both women -either talking about their ailments or consulting with alternative doctors and practitioners – and interviews with authors of mystical self-help best-sellers, such as Deepak Chopra, Bruce Lypton and Kelly Turner.

For those not familiar with these celebrities, Chopra is the one who claims that the human body is a “field of energy and awareness”, and that it is possible to stop the process of aging, and even reverse it, using meditation, physical exercise and plain strong will. There is a parody twitter account, @WisdomOfChopra, that produces nonsense phrases, indistinguishable from the pseudo-sayings of this mighty guru. There is even a scientific paper (http://journal.sjdm.org/15/15923a/jdm15923a.html) showing clearly that everything Chopra says is actually identical to random nonsense.

Lypton, on the other hand, believes that since gene regulation – the study of which genes are active and which are not within the cells on a given moment – depends partly on environmental signals, then it obviously should be possible to turn genes on and off by sheer will and power of the mind. Kelly Turner has travelled the world interviewing cancer survivors who faced the worst prognoses, asking them how they assessed their own healing process. It makes sense of course, if you consider it wise asking lottery winners how they pick the numbers!

More self-help celebrities lend their grace to “Heal”. Rob Wergin, the “Divine conduit”, who claims to channel healing energy directly from God to the patients, and the so-called “medical medium” Anthony Williams, both show up in the documentary and even John of God, the famous Brazilian medium healer, features a small part. Heal was filmed in 2017, before John of God was tried and arrested for the sexual harassment and rape of over 400 women. Too bad no fortune-teller or tarot reader predicted this and warned the producer beforehand…

Quantum Physics, Buddha and Epigenetics

One guru/coach/master/whatever in the film cites the phrase “each men and women are the architects of their own health”, and attributes it to Buddha. That is false, Sidarta Gautama, the Buddha who taught in India around 500 BCE probably never said that. The statement, however, immersed in an atmosphere of profound “wisdom” and absolute certainty, is the hallmark of the documentary as a whole: every mention of science, epigenetics, physics or placebo effect is either false, twisted or out of context.

Let’s start with Physics: all the practitioners in the film seem to believe that the Matter and Energy equivalence, as described in the Theory of Relativity, together with certain aspects of Quantum Physics, somehow validate a kind of dualism in the world, where matter and soul would be separate entities. These scientific theories, in the film’s assessment, would also validate the predominant role of spirit over mundane things: if everything is about energy, then the physical world is nothing but an illusion, easily manipulated by sheer will.

No need to mention just how wrong this line of thinking is. Energy, in Quantum Physics, is a physical property of the world. It can be measured and manipulated with the appropriate tools, and it does not represent any kind of abstract or divine power.

Both in logic and rhetoric, this misuse of words is called “equivocation”: using the same word in the same argument several times, but with different meanings, pretending not to notice the change.

The stars of the film seem fascinated by examples that some mental states correlate with physiological states, but do not seem to realise that this does not mean mind rules over matter, but rather that the mind is also subject to physiological changes.

More scientific concepts are twisted during the show: epigenetics and the placebo effect are hyped all the way to the moon and back. Epigenetics – which deals with the cellular mechanisms responsible for turning genes on and off – is pictured as the key to positive thinking in cellular biology: “If I change my perception, my mind changes my beliefs about life, I change the signals that are going in and adjusting the functions of the cell”, says Bruce Lypton, author of “Biology of Belief”, looking straight into the camera.

Lypton jumps to the conclusion that if different hormones can make identical stem cells differentiate in different organs, by turning genes on and off, then surely thoughts can have the exact same effect, in any kind of cell! Of course, if there was any truth to this, it should be possible to differentiate an ear from a finger, or regenerate a lost member, just by wishful thinking.

A similar explanation is given by the author of “You are the placebo”. Joe Dispenza argues that if the placebo effect, generated by a combination of classic conditioning and self-suggestion, can make the body produce opioid-like molecules for pain, then surely faith and belief can make the body produce virtually anything necessary to heal. The writer claims to have healed himself of a severe spinal injury, using nothing but visualizations and positive thinking.

To sum up

Heal’s leading claims state that all illnesses are self-inflicted, result from emotional stress (bad emotions create “density” which weakens the immune system and causes cancer), and are as such, self-healing. And of course, we know that because of Quantum Physics, Epigenetics and blah-blah-blah.

There is a slight attempt – very slight indeed – not to blame the patients. It is mentioned at a certain point that the patients are not to blame for their own diseases; it is the modern lifestyle that poisons us all. The overall message, however, is very clear: everything happens for a reason, and it is all in your head. Noonan Gores tries to sell the documentary as a message of hope. Sadly, it is but a message of despair and guilt.

Perhaps the most naïve demonstration of this message is Kelly Turner’s idea -as stated in her book Radical Remission – that people who recover from malignant tumours have “found the cure to their own cancer”. Collecting and cataloguing these survivors’ “habits” makes no sense unless you compare them to a control group: a group pf people who shared the same habits and lifestyle, and did not recover.

The film also shows a man who presents himself as a brain cancer patient. He takes part in a very emotional sequence, where he shares a “mystical moment” in Rob Wergin’s arms. Everyone in the room looks really moved, and it is clear that the patient believes himself cured. But was he? The film conveniently stops right there.

Eva, the second protagonist, with the mysterious rash, has no closure either, and finishes the documentary exactly at the same place where she began: no diagnosis nor treatment – or so they say. One doctor put her on steroids, another gave her antibiotics. The holistic therapist that helped her go through childhood issues and release negative emotion did not seem to help either.

The main – and only – cure shown in “Heal” is Elizabeth’s, who treated her cancer with chemotherapy and radiotherapy. The producer, however, refuses to connect the dots and give credit to “Western medicine”. Western medicine is after all, an aggressive monster, and full credit is given to alternative medicine alone. The reality of course, lies on the other end: the adoption of alternative therapies actually increases the risk of death in cancer patients (https://jamanetwork.com/journals/jamaoncology/article-abstract/2687972 ).

The true “power of the mind”, it seems, lies in ignoring the obvious and falling desperately in love with a pseudoscientific fantasy. A cruel fantasy for those who fall, a very lucrative one for those who sell.

I am indebted to my good friend and long-term admirer Dana Ullman for alerting me to this new (2019) paper. It reports a study aimed to test whether homeopathic medication administration to COPD patients during the influenza-exposure period may help to reduce the frequency of common URTIs.

This prospective, observational, multicenter study was carried out in Cantabria, Spain. Patients with COPD were divided into two groups: group 1 received conventional treatment + homeopathic medication (diluted and dynamized extract of duck liver and heart; Boiron) (OG); group 2 received conventional treatment only (CG). The primary endpoint was the number of URTIs between the 4-5 months follow up (mean 4.72 ± 0.96) from basal to last visit. Secondary endpoints included the duration of URTIs, number and duration of COPD exacerbations, use of COPD drugs, changes in quality of life (QoL), compliance, and adverse events (AEs).

219 patients were analyzed (OG = 109, CG = 110). There was a significant reduction in mean number of URTIs during the follow-up period in OG compared to CG (0.514 ± 0.722 vs. 1.037 ± 1.519, respectively; p = 0.014). Logistic regression analysis showed a 3.3-times higher probability of suffering ≥2 URTI episodes in CG (p = 0.003, n = 72). OG patients having ≥1 URTI also had a significant reduction in mean URTI duration per episode (3.57 ± 2.44 days OG vs. 5.22 ± 4.17 days CG; p = 0.012). There was no significant difference in mean number of exacerbations, mean duration of exacerbations, or QoL between OG and CG. There was a greater decrease in proportion of patients using corticosteroids for exacerbations between baseline and visit 2 in OG compared to CG (22.1% vs. 7.5% fewer respectively, p = 0.005). Exacerbator phenotype patients had a significant decrease in number of URTIs (0.54 ± 0.72 vs. 1.31 ± 1.81; p = 0.011), and fewer COPD exacerbations (0.9 ± 1.3 vs. 1.5 ± 1.7; p = 0.037) in OG vs. CG, respectively.

The authors concluded that homeopathic medication use during the influenza-exposure period may have a beneficial impact at reducing URTIs’ number and duration in COPD patients and at reducing the number of COPD exacerbations in patients with the exacerbator phenotype. Further studies are needed to confirm the effects observed in this study.

Evidently, Dana thinks highly of this new evidence for Boiron’s duck diluted out of existence, markeded as Oscillococcinum. Do we now have to eat out words? Does homeopathy work after all? Has Dana been right all along?

‘fraid not!

Here are just a few of the most obvious flaws of this trial:

  1. It was not an observational study as I understand it.
  2. It followed the infamous A+B versus B design (which never generates a negative result).
  3. As such it did not control for placebo effects.
  4. It cannot achieve its stated aim.
  5. Its statistical analysis seems faulty.
  6. It lacks randomisation which means the 2 groups differed in many undetected ways.
  7. The primary endpoints were assessed by an undisclosed method.

But there is more, much more.

Conflicts of interest:

J.L. Garcia-Rivero has received speaker’s fees from Boiron Laboratories. G. Diaz Saez (the senior author of the trial) was the Medical Director of Boiron Laboratories when the study was carried out and continued to collaborate in the study after leaving this post. A. Viejo Casas has received speaker’s fees from Boiron Laboratories. All authors of this study, except for G. Diaz, received fees for including patients.

Funding:

This work was supported by Boiron Laboratories.

I REST MY CASE

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