Read Trick or Treatment Online
Authors: Simon Singh,Edzard Ernst M.D.
These inordinate costs were cited in the journal
Scientific American
in 2000, so they have probably increased significantly in the last few years. Moreover, only a third of those drugs that enter Phase I trials reach the stage of New Drug Application, which allows a drug to be marketed to the public.
In short, conventional medicines have to leap over extraordinarily high hurdles, which requires a vast amount of money and time, but this level of testing is essential if the public is to be protected from harmful and ineffective drugs. Such rigorous testing should bring reassurance to patients, and it would not be unreasonable to demand similar levels of testing and regulation for alternative medicine.
There is, however, an argument that suggests that the sequence of testing for alternative medicines should be reversed. This is for the simple reason that these treatments are already widely available, whereas the pharmacological approach outlined above was developed for entirely new drugs. If millions of people are already using treatments such as herbal remedies and acupuncture, then it seems most sensible to assess the safety of these treatments based on the experiences of patients. For instance, practitioners could be asked to note the details of any adverse reactions and post them to a central database. The next priority would be to submit alternative therapies to clinical trials in order to find out for what (if any) conditions they are effective. Finally, if these tests were positive for a particular alternative therapy, scientists might investigate the mechanism behind the therapy and conduct the preclinical research.
This reversed approach puts patient safety first, because the consumer is already being exposed to alternative medicine, but it ultimately demands the same level of scientific rigour. Conducting such rigorous testing would be expensive, but remember that alternative medicine is a billion-dollar global industry, so it would not be unfair for it to devote part of its vast profits towards properly testing the products that it sells to the public. Moreover, governments already have funds for medical research, and they could act in a coordinated manner to devote a fraction of this money towards high quality clinical trials focused on the biggest selling products and the most popular therapies.
The reversed testing procedure, like the normal procedure, would take several years to complete. In the meantime, while awaiting the results, governments could require alternative remedies to carry labels and compel therapists to make disclosures that accurately reflect the existing evidence. Dylan Evans suggested exactly this idea in his book
Placebo
. For homeopathic remedies, he suggested the following label:
Homeopathy
Warning: this product is a placebo. It will work only if you believe in homeopathy, and only for certain conditions such as pain and depression. Even then, it is not likely to be as powerful as orthodox drugs. You may get fewer side-effects from this treatment than from a drug, but you will probably also get less benefit.
We believe that Evans’s idea has some merit, because such open, honest and accurate summaries would certainly help patients. For alternative treatments supported by evidence, the summaries would contain the sort of helpful advice that we see on conventional pharmaceuticals. For other alternative treatments, the summaries would read more like a statutory health warning, akin to those found on cigarette packets.
As we approach the final few pages of the final chapter, it is interesting to see what happens if we apply Evans’s idea to a selection of alternative therapies discussed elsewhere in this book. In some cases, the Evans-style summaries would appear on boxes of tablets, while in other cases they might appear on websites or in leaflets distributed in a clinic. And in every case, the summaries would help patients to be more aware of the evidence relating to any particular therapy.
Acupuncture
Warning: this treatment has shown only very limited evidence that it can treat some types of pain and nausea. If it is effective for these conditions, then its benefits appear to be short-lived and minor. It is more expensive than conventional treatments, and very likely to be less effective. It is likely that its major impact is as a placebo in treating pain and nausea. In the treatment of all other conditions, acupuncture either has no effect other than a placebo effect. It is a largely safe treatment when practised by a trained acupuncturist.
Chiropractic
Warning: this treatment carries the risk of stroke and death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo.
Herbal Medicine – Evening Primrose Oil
Warning: this product is a placebo. It will work only if you believe in it, and only for certain conditions which respond to placebo treatments. Even then, the placebo effect is unpredictable and it is not likely to be as powerful as orthodox drugs. You may get fewer adverse side-effects from this treatment than from a drug, but you will probably also receive less benefit.
Herbal Medicine – St John’s Wort
Warning: this product can interact with other drugs – consult your GP before taking St John’s wort. There is evidence that it is effective in the treatment of mild and moderate depression. Conventional drugs are available for these conditions, and are similarly effective.
These summaries reflect the broad range and complexity of alternative therapies, which includes treatments that are untested, or unproven, or disproven, or unsafe, or placebos, or only marginally beneficial, or almost certainly beneficial. Of all the above treatments, St John’s wort has the most positive summary. Indeed, the clinical trials for St John’s wort are so positive that GPs and scientists would endorse its use. Conventional medicine has no prejudice against any alternative treatment that can prove its worth, both in terms of safey and efficacy.
Fish oil is another excellent example of an alternative treatment that has been embraced by conventional medicine. Fish oil, available in capsules, comes under the heading of food supplements, and such supplements are discussed in the appendix. The trigger for detailed research into the possible benefits of fish oil was the observation that Inuits have very low rates of heart disease. This gave rise to further epidemiological investigations in other populations and eventually to clinical trials that have been uniformly positive. Ultimately, this has led to reassurances that fish oil is both safe and effective as a long-term preventative treatment for coronary heart disease. Detailed evaluation has also suggested that daily fish-oil capsules can extend life by one year on average. For those who do not eat oily fish on a regular basis, fish-oil capsules offer a clear benefit. Fish oil may also help control inflammation, which would be beneficial for people with arthritis or a range of skin problems.
Fish oil and St John’s wort are marvellous examples of treatments that have emerged from traditional roots, which were then promoted within alternative medicine, and which have now been accepted by conventional medicine. Fish oil, in particular, is so utterly mainstream that it is no longer considered alternative by most conventional doctors, and St John’s wort should be heading in the same direction. The appendix includes several other alternative therapies that conventional doctors would also endorse, particularly those that increase general wellbeing by relaxation or stress reduction – for instance, meditation and massage therapy.
This brings us to an interesting situation: any provably safe and effective alternative medicine is not really an alternative medicine at all, but rather it becomes a conventional medicine. Therefore, alternative medicine, by definition, seems to consist of treatments that are untested, or unproven, or disproven, or unsafe, or placebos, or only marginally beneficial.
Yet, alternative therapists continue to wear the name ‘alternative’ as a badge of honour, using it to give their substandard treatments an undeserved level of dignity. They use the term ‘alternative’ to promote the notion that they somehow exploit alternative aspects of science. The truth, however, is that there is no such thing as alternative science, just as there is no alternative biology, alternative anatomy, alternative testing, or alternative evidence.
Science, as we demonstrated in Chapter 1, is a universal approach for establishing the value of any medical intervention. The results of science are never complete and perfect, but step by step they bring us closer to the truth. The term ‘alternative’ is merely an attempt to escape from this truth by replacing the knowledge derived from science by hunches derived from other sources. This includes intuition, anecdote and tradition, which means that alternative medicine is based on personal opinions, the opinions of others and the opinions of our forefathers. However, in our introduction we pointed out:
‘
There are, in fact, two things, science and opinion;the former begets knowledge, the latter irgnorance.
’
Even though Hippocrates wrote these words more than 2,000 years ago, it took us a phenomenally long time to really take this message seriously. When we finally did, about 150 years ago, medicine began to move rapidly out of the Dark Ages and doctors abandoned treatments such as bloodletting, which were more dangerous than the conditions they claimed to cure. Since then, progress has been immense and continuous. Immunization has eradicated killer infections; formerly fatal diseases affecting millions, like diabetes, appendicitis and many others, are now treatable; childhood mortality is only a fraction of what it once was, pain can be effectively controlled in most cases; and generally we live longer and enjoy a better quality of life. All of this is thanks to applying rational scientific thought to healthcare and medicine.
By contrast, the concept of an alternative type of medicine is a throwback to the Dark Ages. Too many alternative therapists remain uninterested in determining the safety and efficacy of their interventions. These practitioners also fail to see the importance of rigorous clinical trials in establishing proper evidence for or against their treatments. And where evidence already exists that treatments are ineffective or unsafe, alternative therapists will carry on regardless with their hands firmly over their ears.
Despite this disturbing situation, the market for alternative treatments is booming and the public is being misled over and over again, often by misguided therapists, sometimes by exploitative charlatans.
We argue that it is now time for the tricks to stop, and for the real treatments to take priority. In the name of honesty, progress and good healthcare, we call for scientific standards, evaluation and regulation to be applied to all types of medicine, so that patients can be confident that they are receiving treatments that demonstrably generate more harm than good.
If such standards are not applied to the alternative medicine sector, then homeopaths, acupuncturists, chiropractors, herbalists and other alternative therapists will continue to prey on the most desperate and vulnerable in society, raiding their wallets, offering false hope, and endangering their health.
Appendix: Rapid Guide to Alternative Therapies
THE CORE OF OUR BOOK HAS FOCUSED ON ONLY FOUR OF THE MAIN ALTERNATIVE
therapies (acupuncture, homeopathy, chiropractic therapy and herbal medicine), but we have also evaluated many other therapies, which will be discussed in this section. We have devoted a page to each one, in which we address key issues, such as how did the therapy start, what does it involve, is it effective and is it safe? Despite the brevity of the sections, we have rigorously examined the scientific evidence for and against each therapy in order to reach our conclusions. You can also find more information about each alternative therapy in
The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach
, a detailed reference book edited by Edzard Ernst, Max H. Pittler, Barbara Wider and Kate Boddy. This book also contains references to all the research that leads to the conclusions in this appendix.
Anybody considering alternative medicine as a mode of treatment, including all the therapies that follow, should take into account five pieces of advice. First, if you are thinking of using any form of alternative therapy for a particular condition, then we strongly recommend that you first consult and inform your GP – the treatment that you have chosen might interfere with any ongoing conventional therapies. Second, do not stop your conventional treatment unless your doctor advises that this is sensible. Third, bear in mind that alternative therapies can be expensive, particularly if they involve long-term consultations, so make sure that there is evidence to support the efficacy of a therapy before investing significant sums of money in its claimed benefits. Fourth, all therapies can generate placebo effects, but this alone is not enough to justify their use. Fifth, remember that every treatment carries risks, so make sure that the risks are outweighed by the benefits.
Included in this section are our evaluations of: