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The publication of Gilbey’s paper and my editorial in the New Zealand Medical Journal (NZMJ) led to a threat of legal action by the NZ Chiropractors’ Association Inc for alleged defamation.  After publishing a defiant editorial, the editor of the NZMJ offered chiropractors the chance to put their case.

In the last issue of NZMJ (22 Aug 2008) three letters appeared. One was from Brian Kelly, (President, New Zealand College of Chiropractic) [download letter]. One was from Karl Bale (CEO/Registrar, Chiropractic Board New Zealand) [download letter], and one was from Simon Roughan (Registered Chiropractor and Acting President of the New Zealand Chiropractors’ Association) [download letter].

The wars within chiropractic

Although the chiropractors seem to be rather upset by the criticisms that have been levelled against them, the most interesting war is not between chiropractors and people who think that medicine should not be based on metaphysics.  It’s the war within chiropractic itself.

The internecine wars within chiropractic have been going almost from the day it was invented.  The (ex-)insider’s view gives us a rare insight into what chiropractic schools actually do.   Now support has come from a rather unexpected quarter.  An article by five chiropractors has just appeared by Murphy et al. (Chiropractic & Osteopathy, 2008, 16:10).

Although the authors declare that they have “a financial interest in the success” of chiropractic, the changes that they propose are so drastic that, if implemented, tthey would leave little left to distinguish chiropractic from, say, physiotherapy. The authors ask the very pertinent question, ‘why is it that podiatry (chiropody in the UK) is well accepted and chiropractic remains on the controversial fringe of medicine?..   Here are some quotations.

“It is also vital that those chiropractors who dogmatically oppose common public health practices, such as immunization [15] and public water fluoridation, cease such unfounded activity.”

“We are concerned that the common perception (which is well supported, in our experience) that chiropractors are only interested in “selling” a lifetime of chiropractic visits may be one of the primary factors behind our low standing in the minds of members of the public [2].”

“One of the problems that we encounter frequently in our interaction with chiropractic  educational institutions is the perpetuation of dogma and unfounded claims. Examples include the concept of spinal subluxation as the cause of a variety of internal diseases and the metaphysical, pseudo-religious idea of “innate intelligence” flowing through spinal nerves, with spinal subluxations impeding this flow. These concepts are lacking in a scientific foundation [27] [28] [29] and should not be permitted to be taught at our chiropractic institutions as part of the standard curriculum. Much of what is passed off as “chiropractic philosophy” is simply dogma [30], or untested (and, in some cases, untestable) theories [27] which have no place in an institution of higher learning, except perhaps in an historical context.”

“The Council on Chiropractic Education requirement of 250 adjustments forces interns to use manipulation on patients whether they need it or not, and the radiographic requirement forces interns to take radiographs on patients whether they need them or not.”

“They [podiatrists] did not invent a “lesion” and a “philosophy” and try to force it on the public. They certainly did not claim that all disease arose from the foot, without any evidence to support this notion. The podiatric medical profession simply did what credible and authoritative professions do [32] – they provided society with services that people actually wanted and needed.”

“In the beginning, DD Palmer invented a lesion, and a theory behind this lesion, and developed a profession of individuals who would become champions of that lesion. This is not what credible professions do.”

“In the interim it [chiropractic] has seen its market share dwindle from 10% of the population [4] to 7.5% [3] [42]. Even amongst patients with back pain, the proportion of patients seeing chiropractors dropped significantly between 1987 and 1997, a period of time in which the proportion seeing both medical doctors and physical therapists increased [43].”

“When an individual consults a member of any of the medical professions, it is reasonably expected that the advice and treatment that he or she receives is based in science, not metaphysics or pseudoscience.”

“The chiropractic profession has an obligation to actively divorce itself from metaphysical explanations of health and disease as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are more rampant in our profession than in other healthcare professions [46].”

“Podiatric medicine is a science-based profession dedicated to the diagnosis and treatment of foot disorders. Foot reflexology is a metaphysically-based group consisting of non-physicians who believe that many physical disorders arise from the foot. Podiatrists have rejected foot reflexology as an unproven and unscientific practice, and do not consider it part of mainstream podiatric practice.”

“We must finally come to the painful realization that the chiropractic concept of spinal subluxation as the cause of “dis-ease” within the human body is an untested hypothesis [27]. It is an albatross around our collective necks that impedes progress.”

All this, remember, comes from five chiropractors. That looks like all out war between their view of chiropractic and that taught in New Zealand College of Chiropractic, and, in the UK by the three chiropractic colleges in the UK.

Follow-up

A report in the New Zealand Herald (18 September 2008) is rather relevant to all this.

Chiropractor to apologise after patient has stroke

A chiropractor has been recommended to apologise to a woman patient who suffered a stroke after he treated her.

After the announcement that the University of Central Lancashire (Uclan) was suspending its homeopathy “BSc” course, it seems that their vice chancellor has listened to the pressure, both internal and external, to stop bringing his university into disrepute.

An internal review of all their courses in alternative medicine was announced shortly after the course  closure.   Congratulations to Malcolm McVicar for grasping the nettle at last.  Let’s hope other universities follow his example soon.

I have acquired, indirectly, a copy of the announcement of the welcome news.

 Homeopathy, Herbalism and cupuncture Concern has been expressed by some colleagues as to whether the University should offer courses in homeopathy, Herbalism and Acupuncture. Therefore, to facilitate proper discussion on this matter I have set up a working party to review the issues. I have asked Eileen Martin, Pro Vice-Chancellor and Dean of the Faculty of Health, to lead this working party and report to me as soon as possible. Whilst the review is taking place, we need to recognise that there are students and staff studying and teaching on these courses which have satisfied the University’s quality assurance procedures and been duly validated. I would therefore ask that colleagues would refrain from comment or speculation which would cause concern to these students and staff. Staff who wish to express their views on this issue should direct these to Eileen Martin, by the end of September. Regards Malcolm McVicar Vice-Chancellor

Times Higher Education today reports

“The University of Central Lancashire is to review all its courses in homoeopathy, herbalism and acupuncture after some staff said it should not be offering degrees in “quackery”, Times Higher Education has learnt.

A university spokesman said: “As a university we value and practise transparency and tolerance and welcome all academic viewpoints.”

(Later, an almost identical version of the story ran on the Times Online.)

So far, so good.   But of course the outcome of a committee depends entirely on who is appointed to it.  Quite often such committees do no more than provide an internal whitewash.

It does seem a bit odd to appoint as chair the dean of the faculty where all these course are run, and presumably generate income.  Eileen Martin has often appeared to be proud of them in the past. Furthermore, the whole investigation will (or should) turn on the assessment of evidence.  It needs some knowledge of the design of clinical trials and their statistical analysis, As far as I can see, Ms Martin has essentially no research publications whatsoever.

I also worry about a bit about “satisfied the University’s quality assurance procedures and been duly validated”.  One point of the investigation should be recognise frankly that the validation process is entirely circular, and consequently worth next to nothing.  It must be hard for a vice-chancellor to admit that, but it will be an essential step in restoring confidence in Uclan.

Let’s not prejudge though. If there are enough good scientists on the committee, the result will be good.

I hope that transparency extends to letting us know who will be doing the judging.  Everything depends on that.

Follow-up

Well well, there’s a coincidence, Once again, the week after a there is an announcement about degrees in witchcraft, what should pop up again in the column of the inimitable Laurie Taylor in THE. The University of Poppleton’s own Department of Palmistry.

 Letter to the editor Dear Sir I was shocked to see yet another scurrilous attack upon the work of my department in The Poppletonian. Although Palmistry is in its early days as an academic discipline it cannot hope to progress while there are people like your correspondent who insist on referring to it as “a load of superstitious nonsense which doesn’t deserve a place on the end of the pier let alone in a university”. A large number of people claim to have derived considerable benefit from learning about life lines, head lines and heart lines and the role of the six major mounts in predicting their future. All of us in the Palmistry Department believe it vitally important that these claims are rigorously examined. How else can science advance? Yours sincerely, Janet Petulengro (Doctor)

The Times today has given s good showing for my comment piece. It gives the case against following the advice of the Pittilo report. It simply makes no sense to have government regulation of acupuncture, herbal medicine, traditional Chinese medicine until such time as there is evidence that they work. It makes even less sense to have BSc degrees in them. The Department of Health should have more sense that to use the Prince of Wales as its scientific advisor.

Let’s hope that the recent example set by the University of Central Lancashire is the start of trend for vice-chancellors to appreciate that running such degrees brings their universities into disrepute.

I can only apologise for the dreadful title that The Times’ sub-editors put on the piece, My original title was

A bad report for the vice chancellor

The Pittilo report to the Department of Health will endanger the public and corrupt universities. There is a better way.

I like that much better than “Regulate quack nedicine? I feel sick”.

But, oh dear, the picture that I sent them is on the left, but what appeared is on the right. Spot the difference.

Well now, at least, I can feel I have something in common with Isambard Kingdom Brunel.

Follow-up

It so happens that Professor Pittilo wrote a letter to Times Higher Education this week. I fear that it provided a yet more evidence that he hasn’t really quite got the hang of evidence.

The Lancashire Evening Post catches up with the UCLan story, two days after you read it here.

This response to the op-ed of 29th August appeared as a letter
in the Times
on Sept 2.

 Public health needs protection Regulation of acupuncture and herbal medicine has been subject to much scrutiny Sir, Professor Colquhoun’s campaign to discredit our report (“Regulate quack medicine? I feel sick,” Aug 29) is in danger of placing public health at risk. He is entitled to challenge existing evidence for the effectiveness of complementary and alternative medicine (CAM) but fails to acknowledge the key recommendation from the steering group on the essential need to demonstrate efficacy, safety and quality assurance as a prerequisite for NHS funding. Professor Colquhoun dismisses CAM because of the absence of a rigorous scientific foundation and he asserts that to teach and practise it is unethical. Survey data consistently demonstrates very high demand for CAM with one report estimating that 22 million visits involving 10.6 per cent of the population in England alone occurred in 2008. This demand is one reason why his alternative model of trade law enforcement will not work. He may argue that these people are uncritical recipients of nonsense, but data from the Medicines and Healthcare products Regulatory Agency confirm that they are at significant risk from poor practice. It is essential that we protect the public by implementing statutory regulation alongside demanding evidence of efficacy. Professor Colquhoun’s resistance to the teaching of science to CAM practitioners will do little to help them to critically evaluate effectiveness. Professor Michael Pittilo Chair of the Department of Health Steering Group

And Pittilo wrote in similar vein to Times Higher Education.

Science vital to health study

28 August 2008

Your feature on some members of staff at the University of Central Lancashire attacking science degrees in complementary and alternative medicine (“Staff attack science degrees in alternative health”, 7 August) raises a number of concerns.

It is up to any university, taking account of the expert views of staff and external peer review, to determine the appropriate title and award for any degree. It is encouraging to note from the feature that new courses
in acupuncture and Chinese herbal medicine “contain significant elements of science”.

The recent report to Ministers from the Department of Health Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and other Traditional Medicine
Systems Practised in the UK recognises the significant challenges in developing a strong research and evidence base for complementary and alternative medicine (CAM). It also states that the need to demonstrate
benefit is essential if National Health Service resources are to be made available to fund these therapies.

There is no doubt that courses that provide a solid scientific foundation will greatly assist CAM practitioners in establishing evidence-based practice. It would be most unfortunate if the reported resistance to degree titles led to those wishing to practise acupuncture or herbal medicine receiving less hard science than they might have.

To say that acupuncture and herbal medicine degrees have no academic justification appears arrogant in the extreme. Although it is certainly true that some content may not be scientific, this does not invalidate the legitimacy of these courses at degree level, a fact borne out by their successful validation in a number of universities.

R. Michael Pittilo, Principal and vice-chancellor, The Robert Gordon University.

This one got excellent responses from Kevin Smith (University of Abertay, Dundee), and from Peter J. Brophy (Professor of veterinary anatomy and cell biology University of Edinburgh). This was  my comment to THE

 There are a few very obvious responses to Professor Pittilo’s letter (1) “It is encouraging to note from the feature that new courses in acupuncture and Chinese Herbal medicine “contain significant elements of science”. For many alternative therapies the “philosophy” is simply incompatible with science. One obvious example is homeopathy. On Mondays and Wednesdays (science days) the students will be required to learn that response increases with dose. On Tuesdays and Thursdays will be taught the opposite. But for the exam they must reproduce only the latter (nonsensical) idea because their aim is to get a job as a homeopath. That makes nonsense of the idea of a university. (2) His report “recognises the significant challenges in developing a strong research and evidence base for complementary and alternative medicine (CAM)”. This seems to constitute a recognition that the evidence is still very inadequate. The time to start degrees, and the time to give official government recognition, is after the evidence is in, not before. What happens if you start degrees and then find that the subject is so much nonsense? Well, that has already happened in several areas of course. But the people who accredit the course and who act as external examiners just happen to be fervent believers in that nonsense, so all appears to be well (to bean counters anyway). (3) “It would be most unfortunate if the reported resistance to degree titles led to those wishing to practise acupuncture or herbal medicine receiving less hard science than they might have.” There is, as it happens, a great deal of evidence now about acupuncture, but the authors of the report do not seem to be aware of it. I recommend Barker Bausell’s book on the topic. If students are educated science, like what constitutes evidence, and our current understanding of words like “energy”, they would have to disavow the subject that there are supposed to training to practise (4) “To say that acupuncture and herbal medicine degrees have no academic justification appears arrogant in the extreme.” No, it is not a matter of arrogance, just a matter of careful attention to the evidence. Attention to evidence was notably absent in Prof Pittilo’s report, perhaps because his committee consisted entirely of people who earn their living from the subjects they were supposed to be assessing. (5) “ . . a fact borne out by their successful validation in a number of universities”. I have had the misfortune to have waded through a mound of such validation documents. The one thing they never consider is whether the treatment works. Sad to say, these validations are not worth the paper they are written on.

The first major victory in the battle for the integrity of universities seems to have been won. This email was sent by Kate Chatfield who is module leader for the “BSc” in homeopathic medicine at the University of Central Lancashire (UCLAN).

 from Kate Chatfield… Dear All, It’s a sad day for us here at UCLan because we have taken the decision not to run a first year this year due to low recruitment. The course will be put ‘on hold’ for this year and next until we see what happens with the general climate. Fortunately our masters course is thriving and we have been asked to focus upon this area and homeopathy research for the time being. Of late UCLan has been the subject of many attacks by the anti-homeopathy league. Colquhoun et al have kept the university lawyers and us quite fruitlessly busy by making claims for very detailed course information under the Freedom of Information Act. The latest demand is for 32 identified lesson plans with teaching notes, power points, handouts etc. The relentless attacks have taken their toll and it appears that they have won this small victory. The university has been very clear that this decision has been taken solely on the grounds of poor educational experience and is nothing to do with the current furore. They continue to be supportive of us and our efforts. Best wishes Kate and Jean

There is some background here. In July 2006 I made a request to UCLAN under the Freedom of Information Act 2000, in which I asked to see some of their teaching materials. I appealed to UCLAN but Professor Patrick McGhee, Deputy Vice-Chancellor (Academic), also turned down two appeals. A letter sent directly to Professor Malcolm McVicar, vice-chancellor and president of UCLAN, failed to elicit the courtesy of a reply (standard practice I’m afraid, when a vice chancellor is faced with a difficult question). (Ironically, McVicar lists one of his interests as “health policy”.) So then I appealed to the Office of the Information Commissioner, in November 2006. Recently the case got to the top of the pile, and a judgment is expected any moment now.

Kate Chatfield’s letter to her colleagues is interesting. She describes a request ro see some of her teaching materials as an “attack”. If someone asks to see my teaching materials, I am rather flattered, and I send them. Is she not proud of what she teaches? Why all the secrecy? After all, you, the taxpayer, are paying for this stuff to be taught, so why should you not be able see it? Or is the problem that she feels that the “alternative reality” in which homeopaths live is just too complicated for mortals to grasp? Perhaps this attitude should be interpreted as flattering to the general public, because somewhere deep down she knows that the public will be able to spot gobbledygook when they see it. The revelation that the University of Westminster teaches first year undergraduates the “amethysts emit high yin energy” didn’t help their academic reputation much either.

Much credit for this decision must go also to the pressure from the many good academics at UCLAN. When it was revealed recently that UCLAN intended to open yet more courses in forms of medicine that are disproved or unproven, they naturally felt that their university was being brought into disrepute. Opposition to plans to introduce new “degrees” in acupuncture and Chinese herbal medicine were exposed in Times Higher Education recently. It particular, great credit must go to Dr Michael Eslea from UCLAN’s Psychology department. His open letter to his vice-chancellor is an example of scientific integrity in action.

The abandonment of this degree in medicines that contain no medicine is a small victory for common sense, for science and for the integrity of universities. Sadly, there is still a long way to go.

It is my understanding that ‘bringing the university into disrepute’ is a serious offence. Please note, vice-chancellor.

A few more judgments like that to suspend your homeopathy degree could work wonders for your reputation.

The follow-up

Watch this space.

The Guardian was quick off the mark -this story appeared on their education web site within 3 hours of my posting it “Homeopathy degrees suspended after criticism” by Anthea Lipsett. My comment there disappeared for a while because the Guardian legal people misunderstood the meaning of the last sentence. It’s back now, with blame allocated unambiguously to the vice-chancellors of the 16 or so universities who run this sort of course.

UCLAN’s web site seems to need some updating. The “BSc” in homeopathic medicine is still advertised there. as of 28 August.

UCLAN’s best ally. Dr Michael Eslea, has had some publicity for his attempts to rescue his university’s reputation. The story appeared in the “High Principals” column of Private Eye (Issue 1217, Aug 22, 2008). It also appeared in his local paper, the Lancashire Evening Post.

The Lancashire Evening Post catches up with homeopathy suspension story, two days after you read it here. But the UCLAN web site still advertises it.

My original piece on Integrative Baloney@Yale was posted on May 16th, after I got back from a visit there. The talk I gave there included a short video. My movie, Integrative baloney@Yale, was made entirely from clips taken from Yale’s own YouTube movies which showed something approaching three hours of its “1st Annual Scientific [sic] symposium”, entitled “Complementary and Alternative Medicine: Evidence for Integration”. I had merely interspersed a few titles to show the worst scientific absurdities of that rather pathetic event. YouTube removed the movie last week.

It should soon reappear on YouTube (actually it took over a month and several reminders, but eventually  they kept their word in the end).

Yale’s lawyers had written to YouTube, to have my movie removed. I guess if you have no evidence, all you can do is resort to law to suppress the views of those who have the temerity to point out that the emperor is naked. Last week it was New Zealand Chiropractors’ Association Inc. This week the rather more substantial Yale University. We live in interesting times.

This is what I got on 15th August.

 Dear Member This is to notify you that we have removed or disabled access to the following material as a result of a third-party notification by Yale University, Yale School of Medicine (CME) claiming that this material is infringing: Integrative baloney@Yale: http://uk.youtube.com/watch?v=HEl2fhfGBdI Please Note: Repeated incidents of copyright infringement will result in the deletion of your account and all videos uploaded to that account. In order to prevent this from happening

If you clicked on the link you saw

“This video is no longer available due to a copyright claim by Yale University, Yale School of Medicine (CME)”

It seems that Yale’s Continuing Medical Education (CME) department was responsible.

Of course Yale is correct. I expect they own the copyright of their original movies, but they are not what I posted. I would argue that selecting 6 minutes from a 3 hour original amounts to “fair quotation”, no different from when one cites a short passage from somebody else’s book or paper. Perhaps Yale was just a bit jealous that my movie was getting viewed a lot more times than theirs. Or perhaps they were a bit peeved that a Google search for “Yale Integrative Medicine” produced my movie as #2 (add the word movie and I was #1).

My movie seems to me to be fair comment from someone who is a pharmacologist by trade. Apparently it didn’t seem that way to the apparatchiks of Yale Medical School, who seem to think that academic arguments should be settled by paying lawyers to suppress views they don’t like, rather than by rational discussion.

It’s interesting that the three hours of Yale’s own movie have also vanished from YouTube. Could that be because they realise that the remarks made at the meeting are so embarrassing intellectually that it would be better not to make them public? Actually, no.

What does Yale CME say?

Rather than publishing this straight away, I thought it better to delve a bit further into what had happened. I lodged an appeal with YouTube and I wrote to Ronald J. Vender, MD (Associate Dean, YSM Clinical Affairs, CMO, Yale Medical Group, Medical Director, Yale CME ). The outcome was rather interesting.

First, it turned out that the original posting of the three hours of the symposium proceedings on YouTube was itself unauthorised, which is why it suffered the same fate as my movie.

Dr Vender told me that he is new to the job, and didn’t know about the incident. What’s more surprising, he said he “did not know an Integrative Program even existed at Yale”. That does seem a bit odd indeed for an Associate Dean of Clinical Affairs.

However, Dr Vender turned out to be a very reasonable man,.After some amiable correspondence over the weekend, it took him only a day and a half to sort the matter out. After talking to Yale’s attorney, he wrote on 19th August, thus

“The University attorney believes that there is in fact a difference between the initial unauthorized filming of an entire conference as opposed to quoting from that conference. Therefore, she has agreed to withdraw the injunction that has been imposed on your use of the material. YouTube will be contacted.”

That’s good for me, but it isn’t the main thing. The movie would doubtless have been seen by more people if Yale had tried to maintain the ban. Much more impressively, Dr Vender also said

“As for this particular program, I will be speaking with Dr Belitsky and the program directors to encourage them to adopt a more critical view of the scientific basis for claims made by proponents of CAM. They will also be encouraged to develop a future program that includes faculty who have opposing points of view.”

It remains to be seen what actually happens, but so far, so good.

What next?

The removal of the original videos of the meeting is understandable because they were pretty embarrassing to Yale. But can that be the real reason? I was told that it is simply because their posting was “unauthorised”. But Yale Continuing Medical Education still boasts about the meeting on their own web site. They describe the meeting as “successful”, but if they are so proud of it, why remove the video from YouTube whether it was authorised or not? We are told

“The symposium, accredited for 7.5 AMA PRA Category 1 Credits, began what is hoped to be a long tradition at the Yale School of Medicine.”

They give credits for such miseducation?

Dr Katz’s phrase “we need a more fluid concept of evidence” now gets about 148 hits in Google, since I first helped him to publicise it.

Two of the six “learning objectives” that Yale CME lists for this symposium are particularly revealing.

• Describe therapeutic benefits and recent scientific evidence supporting a wide range of safe and practical complementary treatments, including acupuncture, massage, yoga, meditation, nutrition and exercise
• Identify and discuss barriers to CAM use, practice and research, as well as propose ways of overcoming these barriers

‘Describe the evidence supporting complementary treatments’? But don’t on any account describe the much more substantial evidence that does not support them? A question (or “learning objective”) put in this loaded way is the very antithesis of education.

Equally the second ‘learning objective’ carries with it the assumption that CAM works, otherwise why would anyone want to overcome the barriers to it?

This is indoctrination, not education. It betrays everything that a university should stand for.

Let’s hope the new head of CME, the admirable Dr Vender, succeeds in doing something about it

Follow-up

Success!. Well I think it is success. On 26 November 2008, the admirable Dr Vender wrote to me as follows.

“I do not know if another CAM/Integrative Medicine program is planned at Yale. However, based on the new ACCME standards, this program does not fulfil the standards for receiving CME accreditation (by my interpretation of the standards). At least one of last year’s program directors has been notified already.”

Samuel Hahnemann (1755 – 1843) was the originator of homeopathy. He was clearly a well-intentioned man.. There is good reason to believe that he thought dilution could not go on for ever, but he died 22 years before it became possible to calculate that his favourite 30C dilution already contained nothing at all.

 The bible of homeopaths is Hahnemann’s Organon der rationellen Heilkunde, “Organon of the Medical Art”. His views on dosage, as expressed in the six editions of this book are almost as self-contradictory as the other bible. Hahnemann’s writing about ‘vital spirits’ sounds very silly now, but it is language that was quite common at the end of the 18th century, before much was known about medicine or physiology. But his interest in chemistry was entirely sensible.

Before 1800 Hahnemann started out with the very high doses that were conventional at the time. Unlike most of his contemporaries, he was smart enough to realise that giving 50 g of antimony was killing people so he kept reducing the dose until it was no longer toxic. Unfortunately he (like almost everyone else at the time) didn’t know about controls so he mistook lack of toxicity (because the dose was zero) for a beneficial effect. Nonetheless, for most of his life he did not advocate the extreme dilutions that many modern homeopaths use routinely.

In The Life and Letters of Dr Samuel Hahnemann by Thomas Lindsley Bradford, M.D.(or see Google books edition of the Organon), there is an interesting passage. According to the edition here pp. 237 – 238), this was a note attached to para. #283 in the first edition of the Organon.

 ” The doctrine of the divisibility of matter teaches us that we cannot make a part so small that it shall cease to be something, and that it shall not share all the properties of the whole.”

Here Hahnemann refers to the doctrine of divisibility, but appears to be saying that dilution can go on for ever. But he also says something that directly contradicts this view (Organon, Dudgeon’s translation see also here, page 239 ). The emphasis is mine.

 “I must say that these procedures seem to show chiefly how high one can go with the potentized attenuation of medicines without their action on the human health becoming nil.“

Although this claims that you can dilute a lot, it also admits that if the dilution goes too far the effect would eventually vanish, contrary to the usual homeopathic “principle” that it should keep getting stronger and stronger. and contrary to Hahnemann’s suggestions in other places that he thought matter was infinitely divisible.

This passage shows quite clearly that Hahnemann did not believe that his medicines would work if they were diluted so much that that there were no molecules left. That he believed this is confirmed by a letter that Hahnemann wrote in a letter to a Dr Schreter dated September 13th, 1829. This letter reprimanded Schreter for advocating extremely high dilutions.

 “there must be some limit to the thing. It cannot go on to infinity” The original German version was “Es muss ein Ende geben, es kann nicht bis ins Unendliche weitergehen”

This confirms that Hahnemann was aware of, and accepted, that matter was not infinitely divisible and his medicines would not work if they contained nothing of the original material.

This attitude is actually not at all surprising, because Hahnemann was an educated man and he had a particular interest in chemistry. He cannot have failed to be aware of Dalton’s atomic theory, which was published between 1805 – 1810, while Hahnemann was writing the first edition of the Organon.

Peter Morrell, in Hahnemann and Homeopathy, says

“These were obviously developments that Hahnemann could not have failed to know about and indeed, was thoroughly excited about, It is clear from many of his asides that he regarded chemistry as the most important science.”

What is astonishing is that I can find no example of Hahnemann ever having mentioned Dalton or Avogadro. Perhaps he was a bit scared by the implications of their suggestions that molecules could not be divided without changing their nature.

The first edition of the Organon was published in 1810. but in the 5th edition appeared 1833, ten years before his death, These dates turn out to be important.

John Dalton (1776 – 1844) was able to estimate relative atomic masses of various molecules, the smallest unit that a chemical can exist in without losing irs identity. His values were soon improved by Amadeo
(1776 – 1856), in 1811. Avogadro made the very important proposal that the volume of a gas (strictly, of an ideal gas ) is proportional to the number of atoms or molecules that are present. More precisely, the relationship between the masses of the same volume of different gases (at the same temperature and pressure) corresponds to the relationship between their respective molecular weights. Hence, the relative molecular mass of a gas can be calculated from the mass of a sample of known volume.

BUT neither Avogadro nor Dalton knew how many molecules there were in a given mass of a substance

This is absolutely crucial because it means that, although Hahnemann realised that there was a limit to the dilutions that could be used, he had no way of knowing what that limit was,

The answer to that question was discovered only in 1865, 22 years after the death of Hahnemann.  It was discovered not by Avogadro, but by Johann Josef Loschmidt (1821 – 1895). It is Loschmidt, not Avogadro, who discovered the crucial numerical value of ‘Avogadro’s number‘, and in the German literature it is known, properly, as Loschmidt’sche Zahl.

This number is 6.022 x 1023 molecules per mole. One mole of a pure compound is its molecular mass in grams. The molecular mass of carbon (relative to hydrogen) is 12, so 12 grams of carbon contain 6.022 x 1023 carbon atoms. The molecular mass of of strychnine is 334.4 so 334.4 grams of strychnine contain 6.022 x 1023 strychnine molecules.

Armed with the numerical value of Avogadro’s number, it is easy to calculate that a 30 C homeopathic dilution contains nothing whatsoever. More precisely, it would contain, on average, a single molecule in spherical pill with a diameter equal to the distance from the earth to the sun.

But Hahnemann could not have known that. If had lived another 25 years he would almost certainly have renounced the idea of using 30 C dilutions.

He had a good excuse for getting it wrong. He was dead before the knowledge existed to do the calculation

But modern homeopaths have no excuse whatsoever for believing the impossible.

Hahnemann would have thought they were nuts, I suspect. He was too intelligent to believe that medicines that contain no medicine could be effective. In his words, “It cannot go on to infinity”.

Acknowledgement

I very grateful to ‘ Lindy’ for help in checking the references that are cited here, and for helpful discussions.

The article below is an editorial that I was asked to write for the New Zealand Medical Journal, as a comment on article in today’s edition about the misuse of the title ‘doctor’ by chiropractors [download pdf]. Titles are not the only form of deception used by chiropractors, so the article looks at some of the others too.  For a good collection of articles that reveal chiropractic for what it is, look at Chirobase

THE NEW ZEALAND
MEDICAL JOURNAL

Journal of the New Zealand Medical Association

NZMJ 25 July 2008, Vol 121 No 1278; ISSN 1175 8716

Doctor Who?
Inappropriate use of titles by some alternative “medicine” practitioners

David Colquhoun

Who should use the title ‘doctor’? The title is widely abused as shown by Gilbey1 in this issue of the NZMJ in an article entitled Use of inappropriate titles by New Zealand practitioners of acupuncture, chiropractic, and osteopathy. Meanwhile, Evans and colleagues 2, also in this issue, discuss usage and attitudes to alternative treatments.

Gilbey finds that the abuse of the title doctor is widespread and that chiropractors are the main culprits. An amazing 82% of 146 chiropractics used the title Doctor, andL most of them used the title to imply falsely that they were registered medical practitioners.

Although it is illegal in New Zealand to do that, it seems clear that the law is not being enforced and it is widely flouted. This is perhaps not surprising given the history of chiropractic. It has had a strong element of ruthless salesmanship since it was started in Davenport, Iowa by D.D. Palmer (1845–1913). His son, B.J. Palmer, said that their chiropractic school was founded on “a business, not a professional basis. We manufacture chiropractors. We teach them the idea and then we show them how to sell” (Shapiro 2008)3 It is the same now. You can buy advice on how to build “build high-volume, subluxation-based, cash-driven, lifetime family wellness practices”

In her recent book3 , Rose Shapiro comments on the founder of chiropractic as follows.

“By the 1890s Palmer had established a magnetic healing practice in Davenport, Iowa, and was styling himself “doctor”. Not everyone was convinced, as a piece about him in an 1894 edition of the local paper, the Davenport Leader, shows.

A crank on magnetism has a crazy notion hat he can cure the sick and crippled with his magnetic hands. His victims are the weak-minded, ignorant and superstitious,those foolish people who have been sick for years and have become tired of the regular physician and want health by the short-cut method he has certainly profited by the ignorance of his victim. His increase in business shows what can be done in Davenport, even by a quack.”

D.D. Palmer was a curious mixture: grocer, spiritual healer, magnetic therapist, fairground huckster, religious cult leader—and above all, a salesman. He finally found a way to get rich by removing entirely imaginary “subluxations”.

Over 100 years later, it seems that the “weak-minded, ignorant, and superstitious” include the UK’s Department of Health, who have given chiropractics a similar status to the General Medical Council.

The intellectual standards of a 19th Century Mid-Western provincial newspaper journalist are rather better than the intellectual standards of the UK’s Department of Health, and of several university vice-chancellors in 2007.

Do the treatments work?

Neither Gilbey nor Evans et al. really grasp the nettle of judging efficacy. The first thing one wants to know about any treatment —alternative or otherwise — is whether it works. Until that is decided, all talk of qualifications, regulation, and so on is just vacuous bureaucratese. No policy can be framed sensibly until the question of efficacy has been addressed honestly.

It is one good effect of the upsurge of interest in alternative treatments that there are now quite a lot of good trials of the most popular forms of treatments (as well as many more bad trials). Some good summaries of the results are now available too. Cochrane reviews set the standard for good assessment of evidence. New Zealand’s Ministry of Health commissioned the Complementary and Alternative Medicine
website to assess the evidence, and that seems to have done a good job too. Their assessment of chiropractic treatment of low back pain is as follows:

There appears to be some evidence from one systematic review and four other studies, although not conclusive, that chiropractic treatment is as effective as other therapies but this may be due to chance. There is very little evidence that chiropractic is more effective than other therapies.

And two excellent summaries have been published as books this year. Both are by people who have had direct experience of alternative treatments, but who have no financial interest in the outcome of their assessment of evidence. The book by Singh and Ernst4 summarises the evidence on all the major alternative treatments, and the book by Bausell5 concentrates particularly on acupuncture, because the author was for 5 years involved in research in that area, Both of these books come to much the same conclusion about chiropractic. It is now really very well-established that chiropractic is (at best) no more effective than conventional treatment. But it has the disadvantage of being surrounded by gobbledygook about “subluxations” and, more importantly, it kills the occasional patient.

Long (2004)7 said “the public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45.

The chiropractors of Alberta (Canada) and the Alberta Government are now facing a class-action lawsuit8. The lead plaintiff is Sandra Nette. Formerly she was a fit 41 year old. Now she is tetraplegic. Immediately
after neck manipulation by a chiropractor she had a massive stroke as a result of a torn vertebral artery.

Acupuncture comes out of the assessments equally badly. Bausell (2007) concludes that it is no more than a theatrical placebo.

Are the qualifications even real?

It is a curious aspect of the alternative medicine industry that they often are keen to reject conventional science, yet they long for academic respectability. One aspect of this is claiming academic titles on the flimsiest of grounds. You can still be held to have misled the public into thinking you are a medical
practitioner, even if you have a real doctorate. But often pays to look into where the qualifications come from.

A celebrated case in the UK concerned the ‘lifestyle nutritionist’, TV celebrity and multi-millionaire, Dr Gillian McKeith, PhD. A reader of Ben Goldacre’s excellent blog, badscience.net did a little investigation. The results appeared in Goldacre’s Bad Science column in the Guardian9.

She claimed that her PhD came from the American College of Nutrition, but it turned out to come from a correspondence course from a non-accredited US ‘college’. McKeith also boasted of having “professional membership” of the American Association of Nutritional Consultants, for which she provided proof of her degree and three professional references.

The value of this qualification can be judged by the fact that Goldacre sent an application and $60 and as a result “My dead cat Hettie is also a “certified professional member” of the AANC. I have the certificate hanging in my loo”. Is the solution government regulation? In New Zealand the law about misleading the public into believing you are a medical practitioner already exists. The immediate problem would be solved if that law were taken seriously, but it seems that it is not. It is common in both the UK and in New Zealand to suggest that some sort of official government regulation is the answer. That solution is proposed in this issue of NZMJ by Evans et al2. A similar thing has been proposed recently in the UK by a committee headed by Michael Pittilo, vice-chancellor of Robert Gordon’s University, Aberdeen. I have written about the latter under the heading A very bad report. The Pittilo report recommends both government regulation and more degrees in alternative medicine. Given that we now know that most alternative medicine doesn’t work, the idea of giving degrees in such subjects must be quite ludicrous to any thinking person. The magazine Nature7 recently investigated the 16 UK universities who run such degrees. In the UK, first-year students at the University of Westminster are taught that “amethysts emit high yin energy” . Their vice chancellor, Professor Geoffrey Petts, describes himself a s a geomorphologist, but he cannot be tempted to express an opinion about the curative power of amethysts. There has been a tendency to a form of grade inflation in universities—higher degrees for less work gets bums on seats. For most of us, getting a doctorate involves at least 3 years of hard experimental research in a university. But in the USA and Canada you can get a ‘doctor of chiropractic’ degree and most chiropractic (mis)education is not even in a university but in separate colleges. Florida State University famously turned down a large donation to start a chiropractic school because they saw, quite rightly, that to do so would damage their intellectual reputation. This map, now widely distributed on the Internet, was produced by one of their chemistry professors, and it did the trick. Other universities have been less principled. The New Zealand College of Chiropractic [whose President styles himself “Dr Brian Kelly”,though his only qualification is B. App Sci (chiro)] is accredited by the New Zealand Qualifications Authority (NZQA). Presumably they, like their UK equivalent (the QAA), are not allowed to take into account whether what is being taught is nonsense or not. Nonsense courses are accredited by experts in nonsense. That is why much accreditation is not worth the paper it’s written on. Of course the public needs some protection from dangerous or fraudulent practices, but that can be done better (and more cheaply) by simply enforcing existing legislation on unfair trade practices, and on false advertising. Recent changes in the law on unfair trading in the UK have made it easier to take legal action against people who make health claims that cannot be justified by evidence, and that seems the best way to regulate medical charlatans. Conclusion For most forms of alternative medicine—including chiropractic and acupuncture—the evidence is now in. There is now better reason than ever before to believe that they are mostly elaborate placebos and, at best, no better than conventional treatments. It is about time that universities and governments recognised the evidence and stopped talking about regulation and accreditation. Indeed, “falsely claiming that a product is able to cure illnesses, dysfunction, or malformations” is illegal in Europe10. Making unjustified health claims is a particularly cruel form of unfair trading practice. It calls for prosecutions, not accreditation. Competing interests: None. NZMJ 25 July 2008, Vol 121 No 1278; ISSN 1175 8716 URL: http://www.nzma.org.nz/journal/121-1278/3158/ ©NZMA Author information: David Colquhoun, Research Fellow, Dept of Pharmacology, University College London, United Kingdom (http://www.ucl.ac.uk/Pharmacology/dc.html) Correspondence: Professor D Colquhoun, Dept of Pharmacology, University College London, Gower Street, London WC1E 6BT, United Kingdom. Fax: +44(0)20 76797298; email: d.colquhoun@ucl.ac.uk References: 1. Gilbey A. Use of inappropriate titles by New Zealand practitioners of acupuncture, chiropractic, and osteopathy. N Z Med J. 2008;121(1278). [pdf] 2. Evans A, Duncan B, McHugh P, et al. Inpatients’ use, understanding, and attitudes towards traditional, complementary and alternative therapies at a provincial New Zealand hospital. N Z Med J. 2008;121(1278). 3 Shapiro. Rose. Suckers. How Alternative Medicine Makes Fools of Us All Random House, London 2008. (reviewed here) 4. Singh S, Ernst E. Trick or Treatment. Bantam Press; 2008 (reviewed here) 5. Bausell RB. Snake Oil Science. The Truth about Complementary and Alternative Medicine. (reviewed here) Oxford University Press; 2007 6. Colquhoun D. Science degrees without the Science, Nature 2007;446:373–4. See also here. 7. Long PH. Stroke and spinal manipulation. J Quality Health Care. 2004;3:8–10. 8. Libin K. Chiropractors called to court. Canadian National Post; June21, 2008. 9. Goldacre B. A menace to science. London: Guardian; February 12, 2007/ 10. Department for Business Enterprise & Regulatory Reform (BERR). Consumer Protection from Unfair Trading Regulations 2008. UK: Office of Fair Trading. This, I fear, is pure plagiarism, Robert Shrimsley’s piece in today’s Financial Times was so funny that it just begged to be quoted. Here it is.  Surely this is a call to action. The news that Radovan Karadzic has been hiding out as some kind of homeopath has confirmed all prejudices about alternative medicine. I have had my doubts about this vicious breed ever since we were gulled into giving the kids valerian and hops to calm them down on an overnight flight and they went absolutely wild. Talk about a crime against humanity. Incidentally old Rad is not exactly an advert for homeopathy if this week’s photographs are anything to go by. Before he got into all this complementary healing, he was a sprightly, globally-feared warlord and international criminal. Now, after a decade of mixing his own marjoram, he is a strangely bearded hippy, blathering on about the need to nurture your inner self. Of course with hindsight health shops of the world were an obvious hiding place for genocidal maniacs. Remember all that talk of cleansing impurities? Well, I think we now know what that was all about. Some of you may be thinking that Karadzic was an aberration in an otherwise harmless community. But I ask you, how likely is it that the butcher of Belgrade could have kept up the pretence for so long without ever giving himself away. Were no suspicions aroused by the publication of his first book Radovan’s Remedies . Did no one notice that his patented treatment for stress prescribed ground echinacea root, essence of basil and the blood of a thousand Bosnians. Anyway, now that these collected homeopaths, herbologists and healers have finally been exposed as nothing more than a front organisation for the world’s most wanted, we will doubtless see swift action. How long can it be until the National Security Agency, operating undercover in Greenwich Village, finally pinpoints the precise location of Osama bin Laden’s reiki parlour? Crack teams of CIA operatives will surely be rounding up reflexologists in their search for Ratko Mladic. We can be confident that even now special rendition flights, crammed full of ayurvedic surgeons are en route to Guantánamo, where skilled interrogators will rearrange their chakras at no extra charge. Homeopaths will be forced to take two Disprins every four hours until they crack. US authorities have, however, pledged not to use the cruel practice of water-boarding – except perhaps on hydrotherapists. Of course we may snare a few, genuinely innocent aromatherapists on the way but as they say in the trade, you can’t make a poultice without grinding some ginger. Jump to follow-up During the last year, there has been a very welcome flurry of good and informative books about alternative medicine. They are all written in a style that requires little scientific background, even the one that is intended for medical students. I’ll start with the bad one, which has not been mentioned on this blog before. Complementary and Alternative medicine. An illustrated text. by Allan D. Cumming, Karen R. Simpson and David Brown (and 12 others). 94 pages, Churchill Livingstone; 1 edition (8 Dec 2006).  The authors of this book sound impressive Allan Cumming, BSc(Hons), MBChB, MD, FRCP(E), Professor of Medical Education and Director of Undergraduate Learning and Teaching, and Honorary Consultant Physician, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK; Karen Simpson, BA(Hons), RN, RNT, Fellow in Medical Education, College of Medicine and Veterinary Medicine David Brown, MBChB, DRCOG, General Practitioner, The Murrayfield Medical Centre, and Honorary Clinical Tutor, University of Edinburgh Sadly, this is a book so utterly stifled by political correctness that it ends up saying nothing useful at all. The slim volume is, I have to say, quite remarkably devoid of useful information. Partly that is a result of out-of-date and selective references (specially in the chapters written by alternative practitioners), But the lack of information goes beyond the usual distortions and wishful thinking. I get the strong impression is that it results not so much for a strong commitment to alternative medicine (at least by Cumming) as from the fact that the first two authors are involved with medical education. It seems that they belong to that singularly barmy fringe of educationalists who hold that the teacher must not give information to s student for fear of imparting bias. Rather the student must be told how to find out the information themselves. There is just one little problem with this view. It would take about 200 years to graduate in medicine. There is something that worries me about medical education specialists. Just look at the welcome given by Yale’s Dean of Medical Education, Richard Belitsky, to Yale’s own division of “fluid concepts of evidence”, as described at Integrative baloney @ Yale, and as featured on YouTube. There are a lot of cryptic allusions to alternative forms of evidence in Cumming’s book too, but nothing in enough detail to be useful to the reader. What should a book about Alternative medicine tell you? My list would look something like this. • Why people are so keen to deceive themselves about the efficacy of a treatment • Why it is that are so often deceived into thinking that something works when it doesn’t • How to tell whether a medicine works better than placebo or not, • Summaries of the evidence concerning the efficacy and safety of the main types of alternative treatments. The Cumming book contains chapters with titles like these. It asks most of the right questions, but fails to answer any of them. There is, time and time again, the usual pious talk about the importance of evidence, but then very little attempt to tell you what the evidence says. When an attempt is made to mention evidence, it is usually partial and out of date. Nowhere are you told clearly about the hazards that will be encountered when trying to find out whether a treatment works.  The usual silly reflexology diagram is reproduced in Cumming’s introductory chapter, but with no comment at all, The fact that it is obviously total baloney is carefully hidden from the reader.. What is the poor medical student meant to think when they perceive that it is totally incompatible with all the physiology they have learned? No guidance is offered.  You will look in vain for a decent account of how to do a good randomised controlled trial, though you do get a rather puerile cartoon, The chapter about evidence is written by a librarian. Since the question of evidence is crucial, this is a fatal omission. Despite the lack of presentation of evidence that any of it works, there seems to be an assumption throughout the book that is is desirable to integrate alternative medicine into clinical practice. In Cumming’s chapter (page 6) we see Since it would not be in the interests of patients to integrate treatments that don’t work with treatments that do work, I see only two ways to explain this attitude. Either the authors have assumed than most alternative methods work (in which case they haven’t read the evidence), or they think integration is a good idea even if the treatment doesn’t work. Neither case strikes me as good medical education. The early chapters are merely vague and uninformative. Some of the later chapters are simply a disgrace. Most obviously the chapter on homeopathy is highly selective and inaccurate, That is hardly surprising because it is was written by Thomas Whitmarsh, a consultant physician at Glasgow Homeopathic Hospital (one that has still survived). It has all the usual religious zeal of the homeopath. I honestly don’t know whether people like Whitmarsh are incapable of understanding what constitutes evidence, or are simply too blinded by faith to even try. Since the only other possibility is that they are dishonest, I suppose it must be one of the former. The chapter on “Nutritional therapy” is also written by a convert and is equally misleading piece of special pleading. The same is true of the chapter on Prayer and Faith Healing. This chapter reproduces the header of the Cochrane Review on “Intercessory prayer for the alleviation of Ill Health”, but then proceeds to ignore entirely its conclusion “Most of the studies show no real differences”). If you want to know about alternative medicine, don’t buy this book. Although this book was written for medical students, you will learn a great deal more from any of the following books, all of which were written for the general public. Trick or Treatment by Simon Singh and Edzard Ernst, Bantam Press, 2008  Simon Singh is the author of many well-known science books, like Fermat’s Last Theorem. Edzard Ernst is the UK’s first professor of complementary and alternative medicine. Ernst, unlike Cumming et. al is a real expert in alternative medicine. He practised it at an early stage in his career and has now devoted all his efforts to careful, fair and honest assessment of the evidence. That is what this book is about. It is a very good account of the subject and it should be read by everyone, and certainly by every medical student. Singh and Ernst follow the sensible pattern laid out above, The first chapter goes in detail into how you distinguish truth from fiction (a little detail often forgotten in this area). The authors argue, very convincingly, that the development of medicine during the 19th and 20th century depended very clearly on the acceptance of evidence not anecdote. There is a fascinating history of clinical trials, from James Lind (lemons and scurvy), John Snow and the Broad Street pump, Florence Nightingale’s contribution not just to hygiene, but also to the statistical analysis that was needed to demonstrate the strength of her conclusions (she became the first female member of the Royal Statistical Society, and had studied under Cayley and Sylvester, pioneers of matrix algebra). There are detailed assessments of the evidence for acupuncture, homeopathy, chiropractic and herbalism, and shorter synopses for dozens of others. The assessments are fair, even generous in marginal cases. Acupunture. Like the other good books (but not Cumming’s), it is pointed out that acupuncture in the West is not so much the product of ancient wisdom (which is usually wrong anyway), but rather a product of Chinese nationalist propaganda engineered by Mao Tse-tung after 1949. It spread to the West after Nixon’s visit Their fabricated demonstrations of open heart surgery under acupuncture have been known since the 70s but quite recently they managed again to deceive the BBC It was Singh who revealed the deception. The conclusion is ” . . . this chapter demonstrates that acupuncture is very likely to be acting as nothing more than a placebo . . . ” Homeopathy. “hundreds of trials have failed to deliver significant or convincing evidence to support the use of homeopathy for the treatment of any particular ailment. On the contrary, it would be to say that there is a mountain of evidence to suggest that homeopathic remedies simply do not work”. Chiropractic. Like the other good books (but not Cumming’s) there is a good account of the origins of chiropractic (see, especially, Suckers). D.D. Palmer, grocer, spiritual healer, magnetic therapist and fairground quack, finally found a way to get rich by removing entirely imaginary ‘subluxations’. They point out the dangers of chiropractic (the subject of court action), and they point out that physiotherapy is just as effective and safer. Herbalism. There is a useful table that summarises the evidence. They conclude that a few work and most don’t Unlike homeopathy, there is nothing absurd about herbalism, but the evidence that most of them do any good is very thin indeed.  “We argue that it is now the 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.” Snake Oil Science, The Truth about Complementary and Alternative Medicine. R. Barker Bausell, Oxford University Press, 2007 Another wonderful book from someone who has been involved himself in acupuncture research, Bausell is a statistician and experimental designer who was Research Director of a Complementary and Alternative Medicine Specialised Research Center at the University of Maryland. This book gives a superb account of how you find out the truth about medicines, and of how easy it is to be deceived about their efficacy. I can’t do better than quote the review by Robert Park of the American Physical Society (his own book, Voodoo Science, is also excellent)  “Hang up your lantern, Diogenes, an honest man has been found. Barker Bausell, a biostatistician, has stepped out of the shadows to give us an insider’s look at how clinical evidence is manipulated to package and market the placebo effect. Labeled as ‘Complementary and Alternative Medicine’, the placebo effect is being sold, not just to a gullible public, but to an increasing number of health professionals as well. Bausell knows every trick and explains each one in clear language” Bausell’s conclusion is stronger than that of Singh and Ernst. “There is no compelling, credible scientific evidence to suggest that any CAM therapy benefits any medical condition or reduces any medical symptom (pain or otherwise) better than a placebo”. Here are two quotations from Bausell that I love. [Page 22] ” seriously doubt, however, that there is a traditional Chinese medicine practitioner anywhere who ever stopped performing acupuncture on an afflicted body in the presence of similarly definitive negative evidence. CAM therapists simply do not value (and most cases, in my experience, do not understand) the scientific process” And even better, [Page39] “But why should nonscientists care one iota about something as esoteric as causal inference? I believe that the answer to this question is because the making of causal inferences is part of our job description as Homo Sapiens.” Testing Treatments: Better Research for Better Healthcare by Imogen Evans, Hazel Thornton, Iain Chalmers, British Library, 15 May 2006 You don’t even need to pay for this excellent book (but buy it anyway, eg from Amazon). If you can’t afford, £15 then download it from the James Lind Library.  This book is a unlike all the others, because it is barely mentions alternative medicine. What it does, and does very well, is to describe he harm that can be done to patients when they are treated on the basis of guesswork or ideology, rather than on the basis of proper tests. This, of course, is true whether or not the treatment is labelled ‘alternative’. It is worth noting that one of the authors of this book is someone who has devoted much of his life to the honest assessement of evidence, Sir Iain Chalmers, one of the founders of the Cochrane Collaboration , and Editor of the James Lind Library . A central theme is that randomised double blind trial are essentially the only way to be sure you have the right answer. One of the examples that the authors use to illustrate this is Hormone Replacement Therapy (HRT). For over 20 years, women were told that HRT would reduce their risk of heart attacks and strokes. But when, eventually, proper randomised trials were done, it was found that precisely the opposite was true. The lives of many women were cut short because the RCT had not been done, The reason why the observational studies gave the wrong answer is pretty obvious. HRT was used predominantly by the wealthier and better-educated women. Income is just about the best predictor of longevity. The samples were biassed, and when a proper RCT was done it was revealed that the people who used HRT voluntarily lived longer despite the HRT, not because of it. It is worth remembering that there are very few RCTs that test the effects of diet. And diet differs a lot between rich and poor people. That, no doubt, is why there are so many conflicting recommendations about diet. And that is why “nutritional therapy” is little more than quackery. Sadly, the media just love crap epidemiology. One of the best discussions of this topics was in Radio 4 Programme. “The Rise of the Lifestyle Nutritionists“, by Ben Goldacre. One of the big problems in all assessment is the influence of money, in other words corruption, The alternative industry is entirely corrupt of course, but the pharmaceutical industry has been increasingly bad. Testing Treatments reproduces this trenchant comment. Suckers. How Alternative Medicine Makes Fools of Us All Rose Shapiro, Random House, London 2008  I love this book. It is well-researched, feisty and a thoroughly good read. It was put well in the review by George Monbiot. “A fascinating and excoriating book; witty, shocking and utterly convincing” The chapters on osteopathy and chiropractic are particularly fascinating. This passage describes the founder of the chiropractic religion. “By the 1890s Palmer had established a magnetic healing practice in Davenport, Iowa, and was styling himself ‘doctor’. Not everyone was convinced as a piece about him in an 1894 edition of the local paper, the Davenport Leader, shows.” A crank on magnetism has a crazy notion hat he can cure the sick and crippled with his magnetic hands. His victims are the eak-minded, ignorant and superstitious, those foolish people who have been sick for years and have become tired of the regular physician and want health by the short-cut method . . . he has certainly profited by the ignorance of his victims . . . His increase in business shows what can be done in Davenport, even by a quack” Over 100 years later, it seems that the “weak-minded, ignorant and superstitious” include the UK’s Department of Health, who have given these quacks a similar status to the General Medical Council. The intellectual standards of a 19th Century mid-western provincial newspaper leader writer are rather better than the intellectual standards of the Department of Health, and of several university vice-chancellors in 2007. Healing Hype or Harm Edited by Imprint Academic (1 Jun 2008) Download the contents page My own chapter in this compilation of essays, “Alternative medicine in UK Universities” is an extended version of what was published in Nature last year (I don’t use the term CAM because I don’t believe anything can be labelled ‘complementary’ until it has been shown to work). Download a copy if the corrected proof of this chapter (pdf).  Perhaps the best two chapters, though, are “CAM and Politics” by Rose and Ernst, and “CAM in Court” by John Garrow. CAM and politics gives us some horrifiying examples of the total ignorance of almost all politicians and civil servants about the scientific method (and their refusal to listen to anyone who does understand it). CAM in Court has some fascinating examples of prosecutions for defrauding the public. Recent changes in the law mean we may be seeing a lot more of these soon. Rational argument doesn’t work well very well with irrational people. But a few homeopaths in jail for killing people with malaria would probably be rather effective. Follow-up Healing, Hype or Harm has had some nice reviews, That isn’t so surprising from the excellent Harriet Hall at Science-Based Medicine. The introduction to my chapter was a fable about the replacemment of the Department of Physics and Astronomy by the new Department of Alternative Physics and Astrology. It was an unashamedly based on Laurie Taylor’e University of Poppleton column. Hall refers to it as “Crislip-style”, a new term to me. I guess the incomparable Laurie Taylor is not well-known in the USA, Luckily Hall gives a link to Mark Crislip’s lovely article, Alternative Flight, “Americans want choice. Americans are increasingly using alternative aviation. A recent government study suggests that 75% of Americans have attempted some form of alternative flight, which includes everything from ultralights to falling, tripping and use of bungee cords.” “Current airplane design is based upon a white male Western European model of what powered flight should look like. Long metal tubes with wings are a phallic design that insults the sensibilities of women, who have an alternative, more natural, emotional, way of understanding airplane design. In the one size fits all design of allopathic airlines, alternative designs are ignored and airplane design utilizing the ideas and esthetics of indigenous peoples and ancient flying traditions are derided as primitive and unscientific, despite centuries of successful use.” Metapsychology Online Reviews doesn’t sound like a promising title for a good review of Healing, Hype or Harm, but in fact their review by Kevin Purday is very sympathetic. I like the ending. “One may not agree with everything that is written in this book but it is wonderful that academic honesty is still alive and well.” Jump to follow up The extent to which irrationality has become established in US Medicine is truly alarming I wrote about Quackademics in the USA and Canada on my last trip to the USA, and on my May trip I visited Yale, where I decided to try a full frontal attack. [download the poster] Several US blogs have written about this phenomenon. For example the incomparable Orac at the The Academic Woo Aggregator , and Dr RW (R.W. Donnell) , see particularly his articles on How did pseudoscience get admitted to medical school? and What is happening to our medical schools? Abraham Flexner is turning over in his grave. Excellent US stuff too at Science-based Medicine (try this and this). There is also a good analysis of what’s happening at Yale by Sandy Szwarc at Junkfood Science. Remember that the terms ‘integrative’ and ‘complementary’ are euphemisms coined by quacks to make their wares sound more respectable, There is no point integrating treatments that don’t work with treatments that do work. ‘Integrative Medicine’ at Yale says, like all the others on the roll of shame, says “we aim to improve awareness and access to the best in evidence-based, comprehensive medical care available worldwide”. They all pay lip service to being “evidence based”, but there is just one snag. It is untrue. In almost all cases, the evidence is either negative or absent. But this does not put them off for a moment. The whole process is simply dishonest. The evidence The evidence has been summarised in several books recently, The following books are particularly interesting because they are all ‘views from the inside. Edzard Ernst is the UK’s first Professor of Complementary Medicine. Barker Bausell was research director of an NIH funded Complementary and Alternative Medicine Specialized Research Center at the University of Maryland. The first two books go through the evidence fairly and carefully. They show no bias against alternative treatments (if anything, I’d say they are rather generous in cases of doubt). For a first class US account try Barker Bausell’s Snake Oil Science  Bausell’s book gives an excellent account of how to test treatments properly, and of all the ways you can be fooled into thinking something works when it doesn’t. Bausell concludes “There is no compelling, credible scientific evidence to suggest that any CAM therapy benefits any medical condition or reduces any medical symptom (pain or otherwise) better than a placebo”.  For an excellent account of how to find the truth, try Testing Treatments (Evans. Thornton and Chalmers). One of the authors, Iain Chalmers, is a founder of the Cochrane library and a world authotity on how to separate medical fact from medical myth. It can now be said with some certainty that the number of alternative treatments that have been shown to work better than placebo is very small, and quite possibly zero, With that settled, what’s going on at Yale (and many others on the roll of shame)? David L. Katz, MD, MPH, FACPM, FACP, is founder and director of the Integrative Medicine Center (IMC) at Griffin Hospital in Derby, Connecticut. He is also an associate professor, adjunct, of Public Health and director of the Prevention Research Center (PRC) at the Yale University School of Medicine in New Haven, Connecticut. That sounds pretty respectable. But he is into not just good nutrition, exercise, relaxation and massage, but also utterly barmy and disproved things like homeopathy and ‘therapeutic touch’.  Watch the movie It so happens that Yale recently held an “Integrative Medicine Scientific Symposium”. Can we find the much vaunted evidence base there? That is easy to answer because three hours of this symposium have appeared on YouTube. So this is the public face of Yale medical school. There’s some interesting history and a great deal of bunkum and double-speak. To save you time, I’ve cut out about 6 minutes from the movies. View or download the movie here > [18.5 Mb, flv file]. Dean of education Richard Belitsky and Dr David Katz Pretty remarble uh? Dr Katz goes through several different trials, all of which come out negative. And what is his conclusion? You guessed. His conclusion is not that the treatments don’t work but that we need a “more fluid concept of evidence” . It’s equally bizarre to hear Richard Belitsky, Dean of Medical Education at Yale saying he is “very proud” of this betrayal of enlightenment values. If this is what Yale now considers to be education, it might be better to go somewhere else. This is not science. It isn’t even common sense. It is a retreat to the dark ages of medicine when a physician felt free to guess the answer. In fact it’s worse. In the old days there was no evidence to assess. Now there is a fair amount of evidence, but Dr Katz feels free to ignore it and guess anyway. He refers to teaching about evidence as ‘indoctrination’, a pretty graphic illustration of his deeply anti-scientific approach to knowledge. And he makes a joke about having diverted a$1m grant from CDC, for much needed systematic reviews, into something that fits his aims better.

Katz asks, as one must, what should we do if there is no treatment that is known to help a patient. That is only too frequent a problem. The reasonable thing to say is “there is no treatment that is known to help”. But Dr Katz thinks it’s better to guess an answer. There is nothing wrong with placebo effects but there is everything wrong with trying to pretend that you are doing more than give placebos. Perhaps he should consider the dilemmas of alternative medicine.

You can read about more about Yale’s activities here and in interviews here. Dr Katz says “The founding approach—and I think Andrew Weil, MD, gets the lion’s share of credit for establishing the concept —is training conventional practitioners in complementary disciplines”. Let’s take a look at this hero. Try, for example, Arnold Relman’s “A trip to Stonesville“.

“According to Weil, many of his basic insights about the causes of disease and the nature of healing come from what he calls “stoned thinking,” that is, thoughts experienced while under the influence of psychedelic agents or during other states of “altered consciousness” induced by trances, ritual, magic, hypnosis, meditation, and the like.”

“To the best of my knowledge, Weil himself has published nothing in the peer-reviewed medical literature to document objectively his personal experiences with allegedly cured patients or to verify his claims for the effectiveness of any of the unorthodox remedies he uses.”

Not only does this yet again propagate the great antioxidant myth, but a few moments with Google show that it is riddled with vested interests, as already pointed out on Quackademics in USA and Canada.

What has brought medical schools down to this level?

That isn’t hard to see, The main thing is simply money. Very few university administrators have the intellectual integrity to turn down money, whatever the level of dishonesty that is required by its acceptance. You can buy a lot of silence for $100m The US Taxpayer has given almost a billion dollars, via NIH. Wallace Sampson, MD says of NCCAM “. . it has not proved effectiveness for any ‘alternative’ method. It has added evidence of ineffectiveness of some methods that we knew did not work before NCCAM was formed” “Its major accomplishment has been to ensure the positions of medical school faculty who might become otherwise employed in more productive pursuits.” “Special commercial interests and irrational, wishful thinking created NCCAM. It is the only entity in the NIH devoted to an ideological approach to health.” NCCAM has given money from some very dubious trials too, Both Orac on Respectful Insolence and Dr RW (R.W. Donnell) have written recently about the NCCAM-funded trial of “chelation therapy”, as first exposed in a devastating article by Kimball C. Atwood IV, MD; Elizabeth Woeckner, AB, MA; Robert S. Baratz, MD, DDS, PhD; Wallace I. Sampson, MD on Medscape Today. This is a$30 million, 5-year, phase 3 Trial to Assess Chelation Therapy (TACT) for coronary artery disease.

“But how did such a crappy study ever come to be, much less be funded by the NIH to the tune of $30 million? The answer, not surprisingly, involves one of the foremost promoters of quackery in the federal government, Representative Dan Burton (R-IN).” We conclude that the TACT is unethical, dangerous, pointless, and wasteful. It should be abandoned.” Orac comments “TACT is not the only example of an unethical and scientifically worthless trial being funded not because the science is compelling but because powerful lobbies and legislators who are true believers in woo applied pressure to the NIH to do them” The Bravewell Collaboration is the other major source of money. Forbes Business says “Bravewell is not some flaky New Age group”. Well dead wrong there, That is precisely what it is.  This group of ultra-rich people, according to its boss, Christy Mack, has a ” . . common goal —fast-tracking integrative medicine into mainstream medicine” So Bravewell is corrupting the search for real knowledge and real cures with big bucks. You can buy a lot of hokum for$100m.

The money comes from Morgan Stanley,

 “John Mack earned the nickname “Mack the Knife” during his ascension to the top of the company [Morgan Stanley] ladder, known for his aggressive cost cutting and consolidation, managerial efficiency, yelling matches, and brutal treatment of others.” “From 2002 until July 2004, Mack was Co-CEO of Credit Suisse, where he eliminated about 10,000 jobs, cut costs by about \$3 billion, and turned the company around to post a huge profit. Accused by SEC of insider trading in 2001, but escaped despite pressure from Senate Finance Committee Chairman Charles Grassley in 2006. Returned as CEO of Morgan Stanley in 2005.”

Bravewell is run by his wife, Christy Mack (Mack-the-wife?) Vice-President, The C.J. Mack Foundation, Member, Board of Directors, The Bravewell Collaborative.

The Flexner report.

The story of Bravewell stands in chilling contrast to another case of philanthropy. Andrew Carnegie’s foundation financed the report by Abraham Flexner, “Medical Education in the United States and Canada” (1910) [download, 15 Mb] . That report was responsible for dragging medical education out of the dark ages
almost a century ago. It resulted in creation of some of the best medical schools anywhere (including Yale).

“By educational patriotism I mean this: a university has a mission greater than the formation of a large student body or the attainment of institutional completeness, namely, the duty of loyalty to the standards of common honesty, of intellectual sincerity, of scientific accuracy.”

“The tendency to build a system out of a few partially apprehended facts, deductive inference filling in the rest, has not indeed been limited to medicine, but it has nowhere else had more calamitous consequences.”

Flexner (1910).

Now another philanthropist is using big bucks to reverse the process and push medicine back into the 19th century.

Flexner would have thought it quite inconceivable that in 2007 medical schools would be offering Continuing Medical Education in homeopathy.

Perhaps they don’t even know it’s happening. If they say firmly that they don’t want it, it will go,

It’s been done before

Florida State University, allegedly under political pressure, proposed to set up a school of Chiropractic. That would have made it Florida State school of snake-oil salesmanship. What a sad fate. [ Science magazine comment] [comment form Paul Lee] [Comment in St Petersburg Times]

But the academics stopped it. An FSU professor, Albert Stiegman, predicted the future campus map.

According to FSUnews

“The Florida Board of Governors voted 10-3 Thursday to deny Florida State University’s request to build a chiropractic school.”

“However, the passage of the bill for the chiropractic school by the Legislature seemingly bypassed the Board of Governors.”

In the end, reason won. Let’s hope that Yale follows their example.

The problem of Yale has been taken up with great eloquence by some US commentators

Dr RW (R.W, Donnell): “Quackademic Medicine at Yale

“By the way, where’s the AAMC in all this? Aren’t they supposed to be guardians of integrity and professionalism in medical education? Are they asleep at the switch or is money silencing them too?”

Orac (Respectful Insolence): “Integrative” medicine at Yale: A more “fluid” concept of evidence?

“after the Dean of the Yale School Medicine embarrassed himself in the introduction by saying he’s proud of how far this nonsense has come, Dr. Katz takes the stage and demonstrates the sort of hostile attitude towards science that, if allowed to take root will be the death of scientific medicine in any meaningful form at U.S. medical schools”

Junkfood Science. Sandy Szwarc on “Quote of the day: ;We need a more fluid concept of evidence’

“Will healthcare professionals and consumers . . . . speak out against these wellness programs being enacted by government agencies, insurers and employers? Or is the money too good?”

Science-based Medicine. Steven Novella writes on “Changing the rules of evidence“. When alternative medicine people do not like the evidence, they change the rules to get the outcome that they want, as seen so graphically in this post. They have always done this, but it is only recently that this sort of behaviour has been endorsed by places like Yale.

The Macho Response, another US blog, comments bluntly, in “Yale wants a more fluid concept of evidence

This is beyond embarrassing – it’s a fucking crime – and it’s happening at Yale University and many others.

If you’re in the medical profession (and I know many of my readers are) you need to go here – now.

Kiosque Médias writes as follows

Pour ceux qui s’intéressent à la médecine et à la santé, le blog de David Colquhoun vaut probablement le détour. Ce professeur-chercheur au département de neurosciences, de physiologie et de pharmacologie de l’University College London y décrypte les résultats d’études médicales, en mettant l’accent sur les médecines alternatives. Et il est rarement tendre!

James Randi Newsletter. The hit rate soars after a recommendation this piece by the amazing Randi.

Hokum-Balderdash Assay. Edwardson writes

“Yale University is going to the ducks. It now has an Integrative Medicine program and in April held its first annual Integrative Medicine Scientific Symposium. I think there must’ve been a typo there. They must’ve meant “Ist Annual I.M. Pseudoscientific Symposium.” There! Now we’ve done away with the oxymoron.”

Why is Yale so secretive about its quackery department?,

Most universities are only to keen to boast about their grant income. Not in this case though. When I asked how they funded their quackery, all I got was a letter that had very obviously been drafted by a lawyer.

“As a private institution, Yale University is not generally subject to the U.S. Freedom of Information Act. We therefore respectfully decline to compile and provide the information you have requested.”

So pretty clear signs of guiltiness there.

Dr David Katz, yes, he of the “fluid concept of evidence”, has posted an article, Health Hazards of rhe Blogoshere. If it quacks like a duck . . .

It seems that he has been a bit alarmed by the reaction of the bloggers. It starts, rather pompously, thus.

“Being well educated does not guarantee you’ll always be right, and it certainly doesn’t guarantee everyone will agree with you. But it still matters. Or at least it used to “

But the rest if it reads less like a defence than as an admission of guilt, thus prompting the next item.

Paul Hutchinson’s blog

 A quack who admits it picks out a quotation from Dr Katz’s response and turned into a cartoon, released to the public domain, So here it is.

Respectful Insolence.

Orac comments too, in “Fluid evidence” strikes back: Dr. Katz versus the skeptical blogsophere”. He does a terrific job in taking apart the response from the hapless Dr Katz.

“No, Dr. Katz does not like his first encounter with the medical blogosphere at all. Indeed, he is so unhappy that apparently a few weeks ago he tried t answer the bloggers who had raked him over the coals for blatantly advocating “integrating” unscientific woo like homeopathy with scientific medicine. Unfortunately for him, he did not do a particularly good job of it. Indeed, what most stood out as I read his rejoinder was that he does not answer a single substantive criticism leveled at his comments. Not one. Instead, he does what pretty much all woo-meisters do when criticized for shifting goalposts and appealing to other ways of knowing besides science as a means of “proving” that their preferred fairy dust works; he wraps himself in the mantle of the brave iconoclast willing to challenge accepted dogma and whines about the peons who criticized him, heaping contempt on the bloggers who had the temerity to criticize his advocacy for pseudoscience because to him they have not earned the right to criticize his (at least in his opinion, apparently) greatness in comparison to him.”

After writing the recent post Boots reaches new level of dishonesty with CoQ10 promotion, I sent a complaint about the dishonesty of the advertisements to the Advertising Standards Authority. I got a surprsingly fast response. On April 22 I got

“it appears you have a valid point and, with a view to acting quickly, have asked Boots to change their ad. We have asked them to remove the claims that CoQ1 0 can create “a spring in your step” and “boost energy levels”. Provided we get an assurance from the advertisers that they will change their ad, we will close the case.”

Then on 1 May, the ASA said

“We have now received a response from Boots and they have given us an assurance that they will not repeat the problematic claims for this product. We have therefore closed our file on that basis.”

Boots agreed to this request, so no full investigation will appear. That’s a win for reason, up to a point, but it also shows how toothless the rules about advertising are. Boots launch a big promotion with advertisements that are simply not true. The promotion is over and they got clean away with it. All they get is a little publicised rap on the knuckles and no doubt they’ll do the same again next time.

This blog, along with many others, has had plenty to say about the Prince of Wales’ unconstitutional meddling in public affairs. The lovely description, Quacktitioner Royal, was coined by NHS Blog doctor.

The Times published a letter from Edzard Ernst and Simon Singh on April 16th. In their forthcoming book, Trick or Treatment? Alternative Medicine on Trial, they go carefully through all the evidence for all sorts of ‘alternative’ treatments. They find some evidence that a handful of them work. For most the answer is ‘not enough evidence’, and for a number there is good evidence that many of them don’t work to any useful extent.

“Sir, For over two decades the Prince of Wales has been actively promoting alternative medicine and his Foundation for Integrated Health continues to encourage the use of treatments such as homoeopathy or reflexology.””In light of this “rigorous scientific evidence”, we strongly advise that the Prince of Wales and the Foundation for Integrated Health withdraw the publications Complementary Health Care: A Guide for Patients and the Smallwood report. They both contain numerous misleading and inaccurate claims concerning the supposed benefits of alternative medicine. The nation cannot be served by promoting ineffective and sometimes dangerous alternative treatments.”

Thank heavens that someone has the courage to say it as it is.

If only the ineffectual and ill-educated people in the Department of Health wouold do the same. But no, instead they gave £37 000 to the Prince of Wales Foundation to write their make-believe guides. And £900 000 to write nonsense for the Complementary and Natural Healthcare Council (also known as Ofquack), and Skills for Health,

The next day The Times ran an article by their science editor, Mark Henderson, Prince of Wales’s guide to alternative medicine ‘inaccurate’. Natasha Finlayson, of the Prince’s Foundation for Integrated Health, is quoted as saying “The foundation does not promote complementary therapies.”. That takes some beating for sheer bare-faced dishonesty.

Edzard Ernst appeared on the Today Program on 18th April. He was interveiwed by the formidable John Humphrys, along with Kim Lavely, Chief Executive, The Prince’s Foundation for Integrated Health (FIH). Ernst points out that the FIH guide suggests that chiropractic is effective in asthma, and that acupuncture is good for addiction, whereas the evidence says the opposite. Lavely retorts, rather lamely (OK I’m biassed).

Lavely: ” . . . we didn’t attempt to give detailed evidence on every therapy”. “We think they [the public] have the right to know and what doesn’t”

Humphrys: “Well isn’t that the whole point? the professor is saying here is that these things do not work, at least in terms of the claims that are made for them, such as homeopathy and chiropractic . . . ”

Lavely: “There are no claims made in this guide for what works and what doesn’t. What we have said is that some therapies are used for some things but we aren’t saying they are effective for those things . . . “

So, one might ask, what on earth is the use of a guide is it that offers no indication of effectiveness? Lavely’s second quotation contradicts directly her first. A pretty pathetic performance.
Listen to the interview [mp3 file]

The Sunday Times, on April 20th, pblished a pretty good review of Trick of Treatment?. “Their case against the folly, vanity and damage of HRH et al. is hard to argue with.”

Of course, the letters column drew the expected response from the quacks, most verging on the hilarious.

Another blow for the alternative industry came in the same week, The authoratitve Cochrane review confirmed earlier reports that vitamin supplements not only do not help you but some actually increase mortality. The antioxidant myth nevertheless rumbles on, and on, and on. There is too much money in it for it to die easily.

Predictably enough, the conclusions were denied by the Health Food Manufacturers’ Association (HFMA). They wheeled out several pop singers to say how wonderful their products are. Read about that pathetic defence on Holfordwatch.

Who is behind HFMA? Incidentally, HFMA are strangely reticent about the identity of their 120 members. They will not reveal who they are. Does anybody out there know the answer? I’ll buy a good dinner for anyone who can root this out.  If it is anything like the ‘Health Supplements Information Service‘ it is likely to be backedby the very big pharmaceutical companies that the alternative industry loves to hate.

Take the test

Prince of Wales Guide

“Reflexologists work with a wide range of conditions including certain types of pain, particularly back and neck pain, migraine and headaches, chronic fatigue, sinusitis, arthritis, insomnia, digestive problems such as irritable bowel syndrome, and constipation, stress-related disorders and menopausal symptoms.”

Singh & Ernst

“The notion that reflexology can be used to diagnose health problems has been disproved and there is no convincing evidence that it is effective for any condition.”

This is a fuller version, with links, of the comment piece published in Times Higher Education on 10 April 2008. Download newspaper version here.

If you still have any doubt about the problems of directed research, look at the trenchant editorial in Nature (3 April, 2008. Look also at the editorial in Science by Bruce Alberts. The UK’s establishment is busy pushing an agenda that is already fading in the USA.

Since this went to press, more sense about “Brain Gym” has appeared. First Jeremy Paxman had a good go on Newsnight. Skeptobot has posted links to the videos of the broadcast, which have now appeared on YouTube.

 Then, in the Education Guardian, Charlie Brooker started his article about “Brain Gym” thus “Man the lifeboats. The idiots are winning. Last week I watched, open-mouthed, a Newsnight piece on the spread of “Brain Gym” in British schools “ Dr Aust’s cogent comments are at “Brain Gym” loses its trousers.

The Times Higher’s subeditor removed my snappy title and substituted this.

So here it is.

“HR is like many parts of modern businesses: a simple expense, and a burden on the backs of the productive workers”, “They don’t sell or produce: they consume. They are the amorphous support services” .

So wrote Luke Johnson recently in the Financial Times. He went on, “Training advisers are employed to distract everyone from doing their job with pointless courses”. Luke Johnson is no woolly-minded professor. He is in the Times’ Power 100 list, he organised the acquisition of PizzaExpress before he turned 30 and he now runs Channel 4 TV.

Why is it that Human Resources (you know, the folks we used to call Personnel) have acquired such a bad public image? It is not only in universities that this has happened. It seems to be universal, and worldwide. Well here are a few reasons.

Like most groups of people, HR is intent on expanding its power and status. That is precisely why they changed their name from Personnel to HR. As Personnel Managers they were seen as a service, and even, heaven forbid, on the side of the employees. As Human Resources they become part of the senior management team, and see themselves not as providing a service, but as managing people. My concern is the effect that change is having on science, but it seems that the effects on pizza sales are not greatly different.

The problem with having HR people (or lawyers, or any other non-scientists) managing science is simple. They have no idea how it works. They seem to think that every activity
can be run as though it was Wal-Mart That idea is old-fashioned even in management circles. Good employers have hit on the bright idea that people work best when they are not constantly harassed and when they feel that they are assessed fairly. If the best people don’t feel that, they just leave at the first opportunity. That is why the culture of managerialism and audit. though rampant, will do harm in the end to any university that embraces it.

As it happens, there was a good example this week of the damage that can be inflicted on intellectual standards by the HR mentality. As a research assistant, I was sent the Human Resources Division Staff Development and Training booklet. Some of the courses they run are quite reasonable. Others amount to little more than the promotion of quackery. Here are three examples. We are offered a courses in “Self-hypnosis”, in “Innovations for Researchers” and in “Communication and Learning: Recent Theories and Methodologies”. What’s wrong with them?

“Self-hypnosis” seems to be nothing more than a pretentious word for relaxation. The person who is teaching researchers to innovate left science straight after his PhD and then did courses in “neurolinguistic programming” and life-coaching (the Carole Caplin of academia perhaps?). How that qualifies him to teach scientists to be innovative in research may not be obvious.

The third course teaches, among other things, the “core principles” of neurolinguistic programming, the Sedona method (“Your key to lasting happiness, success, peace and well-being”), and, wait for it, Brain Gym. This booklet arrived within a day or two of Ben
Goldacre’s spectacular demolition of Brain Gym “Nonsense dressed up as neuroscience”

“Brain Gym is a set of perfectly good fun exercise break ideas for kids, which costs a packet and comes attached to a bizarre and entirely bogus pseudoscientific explanatory framework”

“This ridiculousness comes at very great cost, paid for by you, the taxpayer, in thousands of state schools. It is peddled directly to your children by their credulous and apparently moronic teachers”

And now, it seems, peddled to your researchers by your credulous and
moronic HR department.

Neurolinguistic programming is an equally discredited form of psycho-babble, the dubious status of which was highlighted in a Beyerstein’s 1995 review, from Simon Fraser University.

“ Pop-psychology. The human potential movement and the fringe areas of psychotherapy also harbor a number of other scientifically questionable panaceas. Among these are Scientology, Neurolinguistic Programming, Re-birthing and Primal Scream Therapy which have never provided a scientifically acceptable rationale or evidence to support their therapeutic claims.”

The intellectual standards for many of the training courses that are inflicted on young researchers seem to be roughly on a par with the self-help pages of a downmarket women’s magazine. It is the Norman Vincent Peale approach to education. Uhuh, sorry, not education, but training. Michael O’Donnell defined Education as “Elitist activity. Cost ineffective. Unpopular with Grey Suits . Now largely replaced by Training .”

In the UK most good universities have stayed fairly free of quackery (the exceptions being the sixteen post-1992 universities that give BSc degrees in things like homeopathy). But now it is creeping in though the back door of credulous HR departments. Admittedly UCL Hospitals Trust recently advertised for spiritual healers, but that is the NHS not a university. The job specification form for spiritual healers was, it’s true, a pretty good example of the HR box-ticking mentality. You are in as long as you could tick the box to say that you have a “Full National Federation of Spiritual Healer certificate. or a full Reiki Master qualification, and two years post certificate experience”. To the HR mentality, it doesn’t matter a damn if you have a certificate in balderdash, as long as you have the piece of paper. How would they know the difference?

A lot of the pressure for this sort of nonsense comes, sadly, from a government that is obsessed with measuring the unmeasurable. Again, real management people have already worked this out. The management editor of the Guardian, said

“What happens when bad measures drive out good is strikingly described in an article in the current Economic Journal. Investigating the effects of competition in the NHS, Carol Propper and her colleagues made an extraordinary discovery. Under competition, hospitals improved their patient waiting times. At the same time, the death-rate e emergency heart-attack admissions substantially increased.”

Two new government initiatives provide beautiful examples of the HR mentality in action, They are Skills for Health, and the recently-created Complementary and Natural Healthcare Council.(already dubbed OfQuack).

The purpose of the Natural Healthcare Council .seems to be to implement a box-ticking exercise that will have the effect of giving a government stamp of approval to treatments that don’t work. Polly Toynbee summed it up when she wrote about “ Quackery
and superstition – available soon on the NHS
“ . The advertisement for its CEO has already appeared, It says that main function of the new body will be to enhance public protection and confidence in the use of complementary therapists. Shouldn’t it be decreasing confidence in quacks, not increasing it? But, disgracefully, they will pay no attention at all to whether the treatments work. And the advertisement refers you to
the Prince of Wales’ Foundation for Integrated Health for more information (hang on, aren’t we supposed to have a constitutional monarchy?).

Skills for Health, or rather that unofficial branch of government, the Prince of Wales’ Foundation, had been busy making ‘competences’ for distant healing, with a helpful bulletted list.

“This workforce competence is applicable to:

• healing in the presence of the client
• distant healing in contact with the client
• distant healing not in contact with the client”

And they have done the same for homeopathy and its kindred delusions. The one thing they never consider is whether they are writing ‘competences’ in talking gobbledygook. When I phoned them to try to find out who was writing this stuff (they wouldn’t say), I made a passing joke about writing competences in talking to trees. The answer came back, in all seriousness,

“You’d have to talk to LANTRA, the land-based organisation for that”,
“LANTRA which is the sector council for the land-based industries uh, sector, not with us sorry . . . areas such as horticulture etc.”.

Anyone for competences in sense of humour studies?

The “unrepentant capitalist” Luke Johnson, in the FT, said

“I have radically downsized HR in several companies I have run, and business has gone all the better for it.”

Now there’s a thought.

The follow-up

The provost’s newletter for 24th June 2008 could just be a delayed reaction to this piece? For no obvious reason, it starts thus.

Human resources often gets a bad name in universities, because as academics we seem to sense instinctively that management isn’t for us. We are autonomous lone scholars who work hours well beyond those expected, inspired more by intellectual curiosity than by objectives and targets. Yet a world-class institution like UCL obviously requires high quality management, a theme that I reflect on whenever I chair the Human Resources Policy Committee, or speak at one of the regular meetings to welcome new staff to UCL. The competition is tough, and resources are scarce, so they need to be efficiently used. The drive for better management isn’t simply a preoccupation of some distant UCL bureaucracy, but an important responsibility for all of us. UCL is a single institution, not a series of fiefdoms; each of us contributes to the academic mission and good management permeates everything we do. I despair at times when quite unnecessary functional breakdowns are brought to my attention, sometimes even leading to proceedings in the Employment Tribunal, when it is clear that early and professional management could have stopped the rot from setting in years before. UCL has long been a leader in providing all newly appointed heads of department with special training in management, and the results have been impressive. There is, to say the least, a close correlation between high performing departments and the quality of their academic leadership. At its best, the ethos of UCL lies in working hard but also in working smart; in understanding that UCL is a world-class institution and not the place for a comfortable existence free from stretch and challenge; yet also a good place for highly-motivated people who are also smart about getting the work-life balance right.”

I don’t know quite what to make of this. Is it really a defence of the Brain Gym mentality?

Of course everyone wants good management. That’s obvious, and we really don’t need a condescending lecture about it. The interesting question is whether we are getting it.

There is nothing one can really object to in this lecture, apart from the stunning post hoc ergo propter hoc fallacy implicit in “UCL has long been a leader in providing all newly appointed heads of department with special training in management, and the results have been impressive.”. That’s worthy of a nutritional therapist.

Before I started writing this response at 08.25 I had already got an email from a talented and hard-working senior postdoc. “Let’s start our beautiful working day with this charging thought of the week:”.

He was obviously rather insulted at the suggestion that it was necessary to lecture academics with words like ” not the place for a comfortable existence free from stretch and challenge; yet also a good place for highly-motivated people who are also smart about getting the work-life balance right.”. I suppose nobody had thought of that until HR wrote it down in a “competence”?

To provoke this sort of reaction in our most talented young scientists could, arguably, be regarded as unfortunate.

I don’t blame the postdoc for feeling a bit insulted by this little homily.

So do I.

Now back to science.

In a wonderful demonstration of common sense, the BBC has removed all the alternative medicine pages from BBC Health web site. I expect that it was helped in making that decision by the many complaints it had received about statements on these pages that were simply not true, The existence of these pages was just not compatible with the BBC’s commitment to accuracy.

 Needless to say, this decision was greeted with howls of rage from the alternative world. Some wrote to the BBC to complain (and I wrote to congratulate them). Until today I haven’t been able to find any BBC statement on the matter. This one appeared on Healthypages, one of the zaniest sites on the net. Nothing is too barmy for them. This is the picture they used to show how wrong the BBC is Picture from Healthypages

A recent offer on Healthypages, not to be missed, comes from “Innerjoy”.

“I do a range of spiritual healing practices and can offer an energetic healing session including techniques from the Order of Melchizedek and about 10 forms of Reiki in exchange for a Theta Healing session.”

And just in case you don’t know about the Melchidezek method, here is a picture of a poster in the window of my local “health food” shop.

The explanation says

“Using ancient holographic technology, the basis of the techniques presented is the activation of the Merkaba, a rotating lightfield awakening your spherical consciousness. This raises one’s quotient of light vibration within the human atomic cell structure. Once activated. the merkaba assists us in accessing our naturally ascended consciousness state: the healing capabilities are enhanced a hundred-fold. The Hologram of Love has the ability to heal and rejuvenate any form of creation as it is the living conscious holographic pattern of God Source vibration.”

There, and I’ll bet you thought holography was a recent invention. As an example of sciencey-sounding words used in random order, this one takes a bit of beating. It really is an insult to human intellect.

Anyway, back to the BBC. This is their diplomatic response (what they should have said really was, ‘those pages were nonsense so we removed them’).

BBC issued the following statement, dated 22 Feb 2008:

 Complaint We received complaints about the Complementary section of the BBC Health website being disbanded The BBC’s response The decision to remove the complementary medicine area of the health website was taken as part of a wider review of all the health content in order to enable the BBC to focus its efforts on creating new and exciting content. In order to release resources for this redevelopment work, we’re reviewing existing content from an editorial and value-for-money perspective.The complementary health section was incomplete and, therefore, not of a satisfactory editorial standard. It also represented a small proportion of traffic to the site but was disproportionately time-consuming.Therefore, the decision to take it down was based on a combination of factors: how much work it needed to maintain to a high editorial standard, how much this cost and how popular it was with site users.We have already removed other sections of the health site and plan to reduce or remove others. We appreciate people are disappointed this area of the site has been removed and apologise if the decision has appeared abrupt to site users or inconvenienced other sites linking to BBC Health. The BBC will continue to cover complementary health in other areas of its output, such as TV, radio and news programmes, and may reassess its complementary health content in future.

The news of the BBC’s return to honesty was greeted with consternation in CAM magazine too. The March 2008 issue notes that there used to be over 40 pages of alternative medicine on the BBC, now all gone, They quote an email from ‘Mardi’, thus,

” . . . However the site has in recent months been targetted by the self-appointed ‘quackbusters’ ( . . . such as David Colquhoun), who sent a deluge of letters and emails claiming that complementary therapies such as homeopathy and cranial osteopathy were ‘unscientific’ and should be removed.”

Well thanks for the credit, but sorry, there was no deluge. I wrote no more than a couple of times myself, and I suspect that a handful of friends did the same. I didn’t even ask them to remove the whole lot, merely to correct particular statements that were not true,

‘Mardi’ goes on

“Rather than taking a reasoned view and considering the evidence from good research studies on complementary medicine, these individuals seem simply hell bent on trying to stamp out complementary medicine”

That really is a bit rich. Suddenly the alternative industry are invoking evidence from good research studies. It is precisely the other way round. It is because that evidence is almost all negative that the BBC have decided to remove their coverage.

Of course it may have helped that the BBC had to spend a lot of time defending itself against criticism of the BBC 2 TV series on Alternative Medicine from February 2006. After initially rejecting complaints, an appeal to the highest level, the Board of Trustees, two of the most serious complaints were upheld against these programmes.

Boots the Chemists have proved themselves dishonest before, over their promotion of homeopathy and of B Vitamins “for vitality”

In a press release dated 12 March 2008, they have hit a new low in ethical standards

 Boots help boost the nation’s energy levels in just one week “Health and beauty expert Boots has launched an exclusive energising vitamin supplement that helps boost depleted energy levels and maintain vitality. It is the first time that this exclusive form of CoQ10 has been made available on the high street.” ” . . .supplementation can help to supply higher levels of CoQ10 than are available in the diet. Boots Energy Super Strength CoQ10 containing natural Kaneka CoQ10 is a way of boosting energy levels that can help people who lack energy to see results in a week”

This is as bad a bit of nutribollocks as I’ve ever seen. It is based on the confusion between two totally different meanings of the word “energy”. I see only two interpretations. Either the people who wrote and checked the promotional material are utterly ignorant about biochemistry and psychology. Or it is a deliberate attempt to mislead the public in order to shift the product.

You decide.

Last year there was an equally misleading press release about CoQ10 from Solgar/Boots Herbal. That one was headed “Need More Energy – Solgar’s Nutri Nano™ Uses Nanotechnology to Deliver Unprecedented Bioavailability of CoQ10”. Not only is the word ‘energy’ misused but notice that the trendy term ‘nanotechnology’ is worked in for extra sciencey effect. It turns out that all this means is that the preparation contains micelles. So nothing new there either. Micelles have been known for almost 100 years.

In contrast, the Boots online store is noticeably more restrained. Could that be because the Advertising Standards People can’t touch press releases, just as they can’t control what Boots Expert Team tell you face to face in the shop?

Boots PR contact is given as: Carrie Eames, PR Manager, Boots The Chemists, D90W WG14, Thane Road, Nottingham NG90 1BS. I’m not sure how Ms Eames sleeps at night. Perhaps you should write to her and let her know what you think.

You might point out to her Boots (anti) Social Corporate (ir)Responsibility Page. It says

 “So it’s part of our heritage to treat our customers fairly and act with integrity in everything we do, rather than seizing on the quickest and easiest way to turn a profit.”

CoQ10 and “energy”

Coenzyme Q10 (also known as ubiquinone) is a relatively small molecule. It cooperates with cytochrome enzymes (big proteins) to synthesize a molecule called ATP. This is a chemical form of energy that can be used to do work, such as making a muscle fibre contract.

The word “energy ” here is used in the sense that a physicist would use it. It is measured in joules or in calories. The meaning of the word ‘energy‘ is described nicely in the Wikipedia entry. For example, when an electric current passes through a resistor (like a kettle) the electrical energy is converted to heat energy, and the energy used is potential difference (volts) X current (amps) X time. In other words energy is power (in watts) times time. So another unit for energy is kilowatt-hours (one kilowatt-hour is about 3.6 megajoules).

Energy in this sense has nothing whatsoever to do with the everyday use of ‘energy’ to indicate your vitality, or how lively you feel.

Furthermore there is not the slightest empirical reason to think that CoQ10 makes you feel more lively. None. The press release cites a sciencey-sounding reference (Ernster L, Dallner G. Biochemical, physiological and medical aspects of ubiquinone function. Biochim Biophys Acta. 1995 May 24;1271(1):195-204.). But this paper is just a review of the biochemistry, nothing whatsoever to do with feeling good.

There is nothing new in this big push by Boots. CoQ10 has been a staple of supplement business for a long time now. All sorts of medical claims have been made for it. Everything from migraine, to Parkinson’s disease to cancer has been raised as possible benefits of the magic drug, oops, I mean ‘supplement’. This is quite improper of course, since it is being sold as a food not as a medicine, but it is standard practice among supplement hucksters, and so far they have been allowed to get away with it.

What’s interesting though is that until Boots PR machine swung into action, one thing that hadn’t been claimed much is that it made you feel more lively. That’s one they just invented.

CoQ10 and the press

It’s standard technique to get free advertising by hoping that journalists will dash off an article on the basis of a press release, with the hope that they will be in too much hurry to check the spin. Too often it works.

The Daily Mail has big coverage of the press release, under the title “Can a 60p pill from the chemist really add years to your life?“. This was written by Anna Hodgekiss and it’s not bad. It starts with a nice note of scepticism

“Forget vitamins C, E or even B12. The real wonder supplement is Coenzyme Q10 or CoQ10. That’s what Boots would have you believe, anyway. ”

“So should we all be taking this supplement?

Not according to David Colquhoun, professor of pharmacology at University College London, who says Boots’ claims are “deliberately misleading customers”.

“Yes, CoQ10 helps the body convert glucose into energy, but it’s not the psychological get-up-and-go energy you feel day to day.

“The type of energy it does produce powers our muscles and cells – physical energy. They have confused the two here to promote a product that I’m not convinced would make any difference to how you actually feel at all.”

The article goes on

Among the other sceptics is Scott Marsden, a senior dietician at The London Clinic.

“There haven’t been enough trials to warrant us all taking CoQ10,” he says.

“It sounds boring, but if you are healthy and eating a balanced diet, you will get all the nutrients you need and shouldn’t have to take supplements.

“Not only could you be spending money unnecessarily, you could also be putting your health at risk. Buy some wholesome food instead.” “

Dr Clare Gerada, vice chairman of the Royal College of General Practitioners, is more forthright.

“While there is some evidence to suggest CoQ10 supplements may help patients with heart failure or severe respiratory disorders, more work is needed,” she says.

“This is just another example of normal health being medicalised, and it’s an issue that worries me.

“The human body is an amazing machine, and we have never been in better health. The fact that more people are living well into their 80s and 90s is proof.

“People need to stop looking for a wonder pill in their quest to live for ever.”

But guess who comes out fighting for Boots? None other than my old friend Dr Ann Walker. Little wonder then that my Nutriprofile result recommended a co Q10 supplement, because she is involved in that too.

Ann Walker’s colleague on the Nutriprofile project, Dr Sarah Brewer comments on CoQ10 on the Healthspan site, thus.

“As CoQ10 is vital for energy production in muscle cells, lack of CoQ10 is linked with lack of energy, physical fatigues, muscle aches and pains . . .”

It seems that she also can’t distinguish between energy in joules and energy as vitality,

Female First and Marie Claire also carry a story “Boots Sell ‘Life Extending’ Pill

“A new pill that claims to add years to our lives is due to hit shelves in Boots stores this week but scientists say the drug is misleading.”

“Despite these claims Professor David Colquhoun told Marie Clare that he believes the drug is ‘deliberately misleading customers’: “Yes, CoQ10 helps the body convert glucose into energy, but it’s not the psychological get-up-and-go energy you feel day to day,” he said.”

(Funny, I never consciously spoke to Marie Claire but the quotation is OK.)

The Times, in contrast, carries an appalling column by their Dr Thomas Stuttaford, “A natural solution to tiredness“. There isn’t even a question mark in the title, and the content is totally uncritical. Private Eye has nicknamed the author ‘Dr Thomas Utterfraud’. How very cruel.

See also, excellent articles on CoQ10 by Ben Goldacre in the Guardian, and at badscience.net, and at Holfordwatch and Dr Aust’s Spleen

This appeared in the Guardian on 18 March, and I’m told it was in the Mail too.

The small print says

“The new Boots Energy supplement contains Kaneka Q10 to help boost your energy levels throughout the day”

Here is what I just sent to the Advertising Standard Authority, or email new.complaints@asa.org.uk . Why not have a go yourself?

 “The words “boost your energy levels” and “still lacking energy” constitute a (presumably deliberate) confusion beteen ‘energy’ measured in joules and the everyday use of the word ‘energy’ to mean vitality. The former usage would be justified in viewof the role of Coenzyme Q10 in ATP production. There is neither theoretical justification nor any empirical evidence that CoQ10 helps your vitality or ‘energy’ in the latter sense.”