Read Trick or Treatment Online
Authors: Simon Singh,Edzard Ernst M.D.
Today, the balance of evidence clearly goes against the possibility of divine healing via prayer. This means that the original power of prayer study, which gave a shockingly positive result, probably contained serious errors in the way it was conducted. In fact there are several reasons to be suspicious about that particular trial.
First, after the research was published, it became apparent that the study was conducted without informed consent. To be more specific, the women involved had no idea that their photographs were being sent to the prayer groups. Bearing in mind that infertility is a personal and sensitive issue, this is a major breach of protocol. Dr Bruce Flamm, who has investigated the study, pointed out:
Furthermore, because the study was conducted in Korea, where the majority of the population is Buddhist, Shamanist, or nonreligious, many study patients might have objected to Christian prayers as unwanted, blasphemous, or antithetical to their personal beliefs. But since the study was conducted without their knowledge or permission, the study subjects had no way to voice their objections or to opt out of the study.
Per se, this lack of consent did not invalidate the results of the trial, but it prompted one of the three researchers to reveal another worrying issue. Rogerio Lobo, who brought credibility to the research because of his position as chairman of a department at Columbia University, admitted that he had not been involved in conducting the actual research and instead merely helped to edit and publish the research paper. Dr Lobo has now removed his name from the paper, implying that he no longer believes it to be a respectable piece of research and prefers not to be associated with it.
Daniel Wirth, who was the second author, still seems to believe that the research is credible, but his own integrity has been questioned ever since 2004 when he pleaded guilty to criminal fraud and to using numerous fake identities to commit felonies. He was sentenced to five years in federal prison. The third author of the prayer-infertility paper was Dr Kwang Cha – he holds the unique position of both remaining loyal to the research and not being a convicted felon.
There is clearly a risk that patients might be aware of this particular prayer study, without knowing about its dubious background or the existence of all the other studies that contradict its conclusion. This, in turn, could leave patients with an unjustified confidence in the power of prayer, thereby tempting them to pay for and rely on spiritual healers.
This brief history of prayer-fertility research illustrates a general point about alternative medicine. Before deciding whether or not to invest time, money and hope in an alternative treatment, it is important for patients to know about the overall conclusion from all the research conducted into that particular treatment. That is why we have devoted four chapters to examining the evidence with respect to the four main alternative therapies. In our appendix, we have applied the same approach to analysing over thirty more alternative therapies – our conclusions are much more concise, but they are equally rigorous.
As you have probably realized by now, with some important exceptions our conclusions about alternative medicine are largely negative. Over and over again, we are forced to use words such as ‘disproven’, ‘unproven’, or even ‘dangerous’. This is what the balance of evidence tells us, and we have done our level best to explain how we have arrived at our conclusions and why you should take them seriously. There is, however, one reason why you still might be reluctant to accept our conclusions, and why instead you might be willing to give alternative medicine the benefit of the doubt. We will cover this reason, which is both compelling and misleading, in the final section of this chapter.
Seeing is believing
For many patients, scientific evidence is not the deciding factor in whether or not they adopt a particular alternative therapy. Even if they are aware that the overall conclusion based on all the research is negative, patients are still likely to adopt a therapy if they have personally witnessed its benefits with their own eyes. After all, seeing is believing. This reaction is quite natural and wholly understandable, yet it exposes patients to the risk of ineffective and possibly dangerous treatments.
If we take homeopathy as an example, then millions of people are convinced that it is effective because of their own personal experience – they suffer various ailments, they consume homeopathic remedies and they feel better, so it is perfectly natural to assume that the homeopathic remedy was responsible for their recovery. The fact that the scientific evidence indicates that homeopathy is wholly ineffective, as discussed in Chapter 3, carries very little weight for most people in this sort of situation.
How do we resolve this conflict between personal experience and scientific research? Two hundred years of scientific testing is unlikely to be wrong, so let us assume (for the time being, at least) that homeopathy is ineffective. This would mean that our personal experiences are somehow misleading us – but how?
The central problem is that we are tempted to assume that two events that happen one after the other must be connected. If recovery from illness takes place after taking some homeopathic pills, then isn’t it obvious that the homeopathic pills caused the recovery? If there is a correlation between two events, then isn’t it common sense that one event caused the other? The answer is ‘No’.
We can see why a correlation should not be confused with causation if we look at a neat example invented by Bobby Henderson, author of
The Gospel of the Flying Spaghetti Monster
. He spotted a very interesting correlation between the increase in global temperature over the last two centuries and the decline in the number of pirates. If correlation is synonymous with cause and effect, then he speculated that the decline in pirates is causing global warming. Henderson therefore suggested that political leaders should encourage more pirates to take to the seas in an effort to combat global warming. This might seem ridiculous, but Henderson backed up his causal link between pirates and global warming with further evidence. For example, many people dress up as pirates for Halloween, and the months following 31 October are generally cooler than those that precede it.
Henderson’s absurd pirate–climate example should be enough to show that two events happening at the same time are not necessarily linked. Hence, it is certainly conceivable that homeopathic remedies are not causing the recoveries with which they are associated. This, however, poses a new problem – how and why are patients feeling better? We can only reject homeopathy as the causal agent if we can find more reasonable explanations for why patients report improvements soon after taking homeopathic pills. As it happens, finding such explanations is relatively straightforward.
For example, the patient might be taking conventional medicine that might coincidentally take effect around the time that he or she resorts to homeopathic pills. Although it is the conventional pill that is active, the patient might credit the homeopathic pill. Another explanation is that the patient might be benefiting thanks to other recommendations from the homeopath, such as advice on relaxation, diet or exercise. These lifestyle changes can positively influence a whole range of conditions, and the benefits can easily be misattributed to homeopathic pills that are being taken at the time. We also have to consider the possibility that the homeopathic remedy is contaminated, perhaps with steroids or other conventional pharmaceuticals. In each of these cases, it is not the homeopathic pill that is helping the patient, but rather the contaminant, the homeopath’s advice or the parallel conventional treatment.
Other explanations for why homeopathy seems to work rely on changes that are occurring in the patient’s own body. For example, it is quite natural for symptoms to fluctuate, and it might be that the taking of a homeopathic pill coincides with an upswing in the patient’s condition. Indeed, when a patient feels particularly awful, perhaps during a bout of influenza, then it might be tempting to turn to homeopathy, but at that point the only way is up. This is known as
regression to the mean
: a patient who is feeling particularly ill has probably hit rock-bottom and is very likely to start returning to their average (or mean) state.
It is also worth bearing in mind that many conditions have a limited natural duration, which means that the body heals itself given time. Unexplained lower back pain significantly improves within six weeks for roughly 90 per cent of patients who receive no treatment, so any homeopath who can retain a patient for a couple of months is highly likely to see some sort of recovery within this period. This natural recovery is likely to be inappropriately claimed as a success for alternative medicine.
Some of these explanations rely heavily on coincidence. Remarkable coincidences are rare, such as the one spotted by puzzle expert Cory Calhoun, who noticed that the letters of ‘To be or not to be: that is the question; whether ’tis nobler in the mind to suffer the slings and arrows of outrageous fortune…’ from Shakespeare’s
Hamlet
can be rearranged into the highly appropriate ‘In one of the Bard’s best-thought-of tragedies our insistent hero, Hamlet, queries on two fronts about how life turns rotten.’ On the other hand, more mundane coincidences are commonplace. With millions of people catching colds and so many of them trying alternative remedies, it is inevitable that a significant number will coincidentally experience an improvement in their condition soon after taking the remedy.
Fortunately for alternative therapists, they are in an ideal position to exploit the vagaries of coincidence and thereby take false credit for the body’s own healing powers. They often treat patients with chronic conditions, which have fluctuating symptoms, providing numerous opportunities coincidentally to catch the condition on an upswing. Back pain, fatigue, headaches, insomnia, asthma, anxiety and irritable bowel syndrome are all conditions that go through unpredictable cycles of improvements and deterioration. A herbal or homeopathic pill taken when the patient is at their worst, or an acupuncture session when the patient was in any case beginning to improve, will all be perceived as the agent of change.
Even if the start of the treatment coincides with a decline in the patient’s condition, then this can be excused by the so-called ‘healing crisis’ or ‘aggravation’, already discussed in Chapter 4. This is claimed to be an inherent part of many alternative therapies, whereby the patient’s health is almost expected to worsen before it improves, supposedly because toxins are being ejected. In reality, this ploy merely buys the therapist more time. Eventually, when recovery actually begins, for whatever reason, the alternative therapist is still in a position to take the credit.
Many of the coincidences described so far are particularly likely to impress those patients who already have a strong belief in alternative medicine. This is because believers are vulnerable to
confirmation bias
, which is the tendency to interpret events in a way that confirms preconceptions. In other words, believers will focus on information that supports prior beliefs and ignore information that contradicts those beliefs. Practitioners are highly prone to confirmation bias, because they have vested interests, both emotional and financial, in seeing the therapy work. This sort of confirmation bias is sometimes referred to as Tolstoy syndrome, after an observation made by Leo Tolstoy:
I know that most men, including those at ease with problems of the greatest complexity, can seldom accept the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have proudly taught to others, and which they have woven, thread by thread, into the fabrics of their life.
There is one more good reason to explain why so many people experience some form of recovery soon after taking an alternative treatment, even when the scientific evidence suggests that the treatment is entirely ineffective. It is an explanation that you may already be expecting, because it was discussed in detail in Chapter 2 – it is the placebo effect. Remember, this is the phenomenon whereby a patient responds positively to a treatment simply because of a sincere belief that the treatment is effective. The placebo effect is a very real phenomenon, so much so that doctors have probably been aware of it since ancient times, and it has been scientifically studied for over half a century. It is potentially very powerful, providing everything from pain relief to boosting a patient’s immune system.
The evidence outlined so far in this book suggests that the majority of alternative therapies in most cases have very little to offer aside from the placebo effect. Consequently, it would be tempting to condemn all these therapies as being worthless – but this is too simplistic, as it ignores the genuine relief that can emerge as a result of the placebo effect.
This revives an issue that was briefly mentioned at the end of Chapter 2, and which is one of the most important and controversial questions concerning alternative medicine. Even if alternative medicine relies largely on the placebo effect, why shouldn’t alternative therapists exploit placebo to help the sick, particularly when we know it can be so powerful? In the final chapter of this book we will outline our response to this question.
6 Does the Truth Matter?
‘It makes good sense to evaluate complementary and alternative therapies. For one thing, since an estimated £1.6 billion is spent each year on them, then we want value for our money.’
His Royal Highness The Prince of Wales
IF YOU HAVE BEEN A PARTICULARLY ATTENTIVE READER
,
THEN YOU MAY
have noticed that on frontmatter we dedicated this book to His Royal Highness The Prince of Wales. We took this decision because the Prince has a long-standing interest in alternative medicine. In fact, as early as 1993 he established the Foundation for Integrated Health, which exists in order ‘to encourage greater collaboration between conventional and complementary health practitioners and to facilitate the development of integrated healthcare.’
The Prince of Wales has spoken positively about alternative medicine on numerous occasions, whether visiting hospitals, or addressing GPs, or at the World Health Organization. He has also written several articles on the subject of alternative medicine, including one that was published in reaction to a report by the House of Lords Select Committee on Science and Technology in 2000. The Committee had concluded that many forms of alternative medicine were poorly understood because they had not been adequately tested, neither in terms of efficacy nor of safety. Responding in
The Times
, Prince Charles accepted that this was indeed the case, but he strongly emphasized another aspect of the Committee’s report, namely the need for more research into alternative medicine in order to address the issues of efficacy and safety.
Under the heading ‘Alternative medicine needs – and deserves – more research funding’, the Prince pointed out that he had been advocating an evidence-based approach to alternative medicine for some time:
Are these therapies as good as orthodox medicine, or even in some instances better? If so, which therapies and for which conditions? In 1997 the Foundation for Integrated Medicine, of which I am the president and founder, identified research and development based on rigorous scientific evidence as one of the keys to the medical establishment’s acceptance of non-conventional approaches.
Although the tone of Prince Charles’s article was strongly optimistic, implying that greater evaluation would lead to greater acceptance of alternative therapies, many medical researchers were more sceptical. Either way, there was general agreement that further research was the way forward.
Since 2000, there have been some 4,000 research studies into alternative medicine published worldwide, and to a large extent this book has been written in order to answer Prince Charles’s questions. He wanted more research to find out which therapies work and which do not: now that the research is on the table, we are in a position to identify those therapies that genuinely help patients, those that are pure quackery and those that lie somewhere in the middle.
The previous chapters examined the four main alternative therapies, and their conclusions reveal that these alternative treatments offer a disappointing level of benefit. At the more positive end of the scale, herbal medicine can claim a few successes, but the majority of herbs appear to be overhyped. Chiropractic therapy might offer some marginal benefit, but only for back pain – all its other claims are unsubstantiated. Similarly, acupuncturists might be able to offer some marginal benefit in terms of relieving some sorts of pain and nausea, but the effect is so borderline that there is also the strong possibility that acupuncture is worthless. And it is certain that acupuncturists are guilty of offering unproven treatments for a range of conditions, including diabetes, heart disease and infertility. Homeopathy is the worst therapy encountered so far – it is an implausible therapy that has failed to prove itself after two centuries and some 200 clinical studies.
The bottom line is that none of the above treatments is backed by the sort of evidence that would be considered impressive by the current standards of medical research. Those benefits that might exist are simply too small, too inconsistent and too contentious. Moreover, none of these alternative treatments (apart from a few herbal medicines) compare well against the conventional options for the same conditions. This dismal pattern is repeated in the appendix, where we examine many more alternative therapies.
If you find the previous paragraph somewhat blunt and disparaging, please remember that it is based on an analysis of the scientific information, which is exactly what both the House of Lords and the Prince of Wales advocated. As outlined in Chapter 1 (and indeed reiterated throughout the book), it is clear that scientific trials, observations and experiments are the fairest and best ways to establish the truth in medicine, so our conclusions cannot easily be dismissed.
In light of such disappointing results, it seems bizarre that alternative treatments are touted as though they offer marvellous benefits. In fact, not only are such treatments unproven, but over and over again we have seen that alternative medicine is also potentially dangerous. Remember, chiropractors who manipulate the neck can cause a stroke, which can be fatal. Similarly, some herbs can cause adverse reactions or can interfere with conventional drugs, thereby leading to serious harm. Acupuncture practised by an expert is probably safe, but minor bleeding is common for many patients and more serious problems include infection from re-used needles and the puncturing of major organs. Even homeopathic remedies, which of course contain no active ingredient, can be dangerous if they delay or replace a more orthodox treatment. In fact, any ineffective alternative treatment jeopardizes the health of a patient if it replaces an effective conventional treatment. This problem was clearly demonstrated by the tragic death of a Dutch comedienne called Sylvia Millecam.
Millecam shot to fame in Holland when she starred in her own TV show in the 1990s. However, in 1999 her GP noticed a small lump in her breast. He referred her to a radiologist for more tests, but the results were inconclusive. Then, instead of visiting a surgeon for further investigation, she underwent electro-acupuncture. Even when it was absolutely clear that she had breast cancer, Millecam rejected conventional medicine and visited a total of twenty-eight alternative practitioners over the course of two years. The pointless treatments that she received included homeopathy, food supplements, cell-specific cancer treatment, salt therapy and psychic healing, and her diagnoses relied on bizarre techniques such as electromagnetic and vega testing. Gradually the cancer spread and Millecam was admitted to hospital in August 2001, but it was too late. She died four days later, aged forty-five. This is appalling: if Millecam’s breast cancer had been treated quickly, then she would probably still be alive. An expert medical panel looked into the case of Sylvia Millecam and concluded that she had received ‘unfounded methods of treatment’ and that her alternative therapists had denied her ‘a reasonable chance of recovery’ and caused her ‘unnecessary suffering’.
And, not only do alternative therapists offer us often ineffective and sometimes dangerous treatments, they also charge us heavily for these services and products. The issue of money is problematic at every level. Parents on a limited budget might waste money on alternative medicine in a misguided attempt to improve their child’s health. At the other end of the scale, national governments have much larger budgets, but these are also limited, and they also risk wasting money on alternative medicine in a similarly misguided attempt to improve the health of their nations.
Acupuncture sessions, chiropractic manipulations and homeopathic consultations can all cost upwards of £50 each and are often more than double this price. Other alternative therapists, such as spiritual healers, charge similar amounts for a session, and a full course of alternative treatment for an individual can cost hundreds or thousands of pounds. At the start of this chapter, the Prince of Wales quoted an annual UK spend of £1.6 billion in 2000, but even this is likely to be an underestimate. Surveys of the money spent on alternative medicine can give conflicting results, but the general trend has been inexorably upwards, and a recent extrapolation estimated that Britons currently spend £5 billion on alternative treatments – £4.5 billion spent by the public and the remaining £500 million being spent by the National Health Service. And, remember, the annual global spend on alternative medicine is estimated to be £40 billion.
One might argue that every individual has the right to spend money according to his or her own wishes, but if alternative practitioners are making unproven, disproven or vastly exaggerated claims, and if their treatments carry risks, then we are being swindled at the expense of our own good health.
In terms of UK government spending, the alternative lobby might defend the £500 million bill by pointing out that it represents less than 1 per cent of the National Health Service budget, but £500 million spent on unproven or disproven therapies could instead pay for 20,000 more nurses. Another way to grasp the impact of government spending on alternative medicine is to consider the recent refurbishment of the Royal Homoeopathic Hospital in London, which cost £20 million. The hospital is part of the University College London Hospitals NHS Foundation Trust, which had to announce a deficit of £17.4 million at the end of 2005. In other words, the overspend could have been easily avoided if so much money had not been spent on refurbishing a hospital that practises and promotes a bogus form of medicine.
Professor David Colqhuoun, a pharmacologist at University College, has been one of the most vocal critics of the money invested in the Royal Homoeopathic Hospital:
It is striking that the deficit seems to be comparable with the costs of the Royal London Homoeopathic Hospital. It is true that the amount spent by the NHS on complementary medicine is not huge when compared to the entire NHS budget, but to spend anything at the same time that different parts of the trust are dismissing nurses is quite wrong.
Despite the fact that many scientists consider much of alternative medicine to be a waste of money, the Prince of Wales remains enthusiastic about its potential role within government health provision. To add weight to his views, His Royal Highness commissioned a report ‘to examine evidence relating first to the effectiveness and then to the associated costs of mainstream complementary therapies’. The mainstream complementary therapies were identified as acupuncture, homeopathy, herbal medicine, chiropractic therapy and osteopathy, and the report was conducted by the economist Christopher Smallwood. When it was published in 2005, one of the main conclusions of the Smallwood Report surprised medical experts:
Despite the fragmentary nature of the evidence, there seems good reason to believe that a number of CAM (Complementary and Alternative Medicine) treatments offer the possibility of significant savings in direct health costs, whilst others, perhaps just as expensive as their conventional counterparts, can nonetheless deliver additional benefits to patients in a cost-effective way. In addition, the benefits to the economy of a wider application of successful complementary therapies in the key areas could run into hundreds of millions of pounds.
In light of all the negative evidence contained in our book, Smallwood’s conclusion seems utterly absurd, so how did a respected economist come to such a distorted and rose-tinted view of alternative medicine? Smallwood himself admitted that he and his team had no specialist expertise in healthcare economics, and they were naïve about the research data concerning alternative medicine. This resulted in a report that contained numerous fundamental errors. For example, Smallwood maintained that homeopathy is a cost-effective treatment for asthma, even though a Cochrane review indicates that its effectiveness has not been established. Hence, it is not so surprising that the report mistakenly claimed that £190 million would be saved if 4 per cent of British GPs were to offer homoeopathy as a front-line approach to treatment.
The Smallwood Report’s conclusions were not only incorrect, but also highly dangerous. For example, if homeopathy were to be used to treat asthma, then the consequences could be disastrous, as pointed out by Richard Horton, editor of the
Lancet
:
About 1,400 people die from asthma every year in the UK. It is a life-threatening condition that can be controlled by the effective use of drugs. The idea that homeopathy can replace conventional treatment, as the Prince’s report suggests, is absolutely wrong. Not one shred of reliable evidence exists to support this incredibly misjudged claim.
Possibly more than any previous member of the Royal Family, the Prince of Wales has been outspoken on a number of issues, from architecture to opportunities for young people, from the environment to, of course, alternative medicine. In many cases, he has been a force for good, highlighting important causes and bringing them to public attention. In other cases, such as alternative medicine, he has steered the debate into sterile territory and made statements that have flown in the face of all the best expert opinion. For instance, speaking at a healthcare conference in 2004, the Prince endorsed Gerson therapy, which is based on a severe diet regime and coffee enemas. The Prince said:
I know of one patient who turned to Gerson Therapy having been told she was suffering from terminal cancer and would not survive another course of chemotherapy. Happily, seven years later, she is alive and well. So it is vital that, rather than dismissing such experiences, we should further investigate the beneficial nature of these treatments.
The Prince was thus promoting a therapy that has been discredited and which is known to be potentially harmful. Gerson therapy starves already malnourished patients, depriving them of vital nutrients. Moreover, adopting Gerson therapy often means that patients abandon their conventional treatment, thereby jeopardizing their main hope for recovery. Although the Gerson Institute has an office in California, it runs its main clinic in Tijuana, Mexico, where it claims it can cure cancer – this geographical dislocation is necessary because the US forbids doctors to practise Gerson therapy.