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Today brings a small setback for those  of us interested in spreading sensible ideas about science.  According to a press release

“The BMJ Group is to begin publishing a medical journal on acupuncture from next year, it was announced today (Tuesday 11 November 2008).

This will be the first complementary medicine title that the BMJ Group has published.”

And they are proud of that? What one earth is going on?   The BMJ group is a publishing company which says, of itself,

“Our brand stands for medical credibility.   We are one of the world’s best known and most respected medical publishers.”

Well perhaps it used to be.

They have certainly picked a very bad moment for this venture.  In the last year there have been at least five good books that assess the evidence carefully and honestly.  Of these, the ones that are perhaps the best on the subject of acupuncture are Singh & Ernst’s Trick or Treatment and Barker Bausell’s Snake Oil Science.  Both Ernst and Bausell have first hand experience of acupuncture research.  And crucially, none of these authors has any financial interest in whether the judgement goes for acupuncture or against it.

Here are quotations from Singh & Ernst’s conclusions

“Reliable conclusions from systematic reviews make it clear that acupuncture does not work for a whole range of conditions, except as a placebo.”

“There are some high quality trials that support the use of acupuncture for some types of pain and nausea, but there are also high quality trials that contradict this conclusion.  In short, the evidence is neither consistent nor convincing – it is borderline.”

The House of Lords’ report in 2000 tended to give acupuncture the benefit of the (very considerable) doubt that existed at the time the report was written.  Since that time there have been a lot of very well-designed trials of acupuncture.

Now it is quite clear that,  for most (and quite possibly all) conditions, acupuncture is no more than a particularly theatrical placebo.  Perhaps that is not surprising insofar as the modern western practice of acupuncture owes more to Chinese nationalistic propaganda that started in the time of Mao-Tse Tung than it owes to ancient wisdom (which often turns out to be bunk anyway).

The BMJ Group has decided to endorse acupuncture at a time when it is emerging that the evidence for any specific effect is very thin indeed.  Well done.

The journal in question is this.

Acupuncture in Medicine is a quarterly title, which aims to build the evidence base for acupuncture. It is currently self-published by the British Medical Acupuncture Society (BMAS).

One good thing can be said about the Society and the Journal. That is that they don’t espouse all the mumbo-jumbo about ‘meridians’ and ‘Qi’. This, of course, puts them at odds with the vast majority of acupuncture teaching.  This sort of internecine warfare between competing sects is characteristic of all sorts of alternative medicine.  But that is just ideology.  What matters is whether or not sticking needles in you is actually anything more than a placebo.

British Medical Acupuncture Society (BMAS)

The British Medical Acupuncture Society (BMAS). is “a registered charity established to encourage the use and scientific understanding of acupuncture within medicine for the public benefit.”.   The phrase “encourage the use” suggests that they do not even envisage the possibility that it might not work.  Their web site includes these claims.

Acupuncture can help in a variety of conditions:

  • Pain relief for a wide range of painful conditions
  • Nausea, especially postoperative nausea and vomiting
  • Overactive bladder, also known as bladder detrusor instability
  • Menstrual and menopausal problems, eg period pains and hot flushes
  • Allergies such as hay fever and some types of allergic rashes
  • Some other skin problems such as ulcers, itching and localised rashes
  • Sinus problems and more

Presumably the word “help” is chosen carefully to fall just short of “cure”.  The claims are vaguely worded, but let’s see what we can find about them from systematic reviews.  It appears that the BMAS is being rather optimistic about the evidence.

BMJ Clinical Evidence is considered reliable and is particular interesting because it is owned by the BMJ Publishing Group.

Low Back Pain (chronic) Acupuncture is listed as being of “unknown effectiveness”.

Dysmenorrhoea Acupuncture is listed as being of “unknown effectiveness”.

Osteoarthritis of the knee.  Acupuncture is listed as being of “unknown effectiveness”.

Psoriasis (chronic plaque) Acupuncture is listed as being of “unknown effectiveness”.

Neck pain “Acupuncture may be more effective than some types of sham treatment (not further defined) or inactive treatment (not further defined) at improving pain relief at the end of treatment or in the short term (less than 3 months), but not in the intermediate term (not defined) or in the long term (not defined)”

Headache (chronic tension-type) Acupuncture is listed as being of “unknown effectiveness”.

What about the greatest authority, the Cochrane Reviews?

Cochrane Reviews

Low back pain The data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back pain. For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and “alternative” treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain. Because most of the studies were of lower methodological quality, there certainly is a further need for higher quality trials in this area.

Chronic asthma.  There is not enough evidence to make recommendations about the value of acupuncture in asthma treatment. Further research needs to consider the complexities and different types of acupuncture.

But most of the vaguely-worded claims made by BMAS have not been the subject of Cochrane reviews.  The obvious interpretation of that is that there is not enough evidence to make it worth writing a review.  In which case, why does BMAS claim that acupuncture can “help”?

Bandolier is another excellent source of high quality information, This was their view in September 2006

“Large, high-quality randomised trials of acupuncture have been published since the reviews. In fibromyalgia, chemotherapy-induced nausea and vomiting, breech presentation, tension headache, and migraine, all were negative compared with sham acupuncture. One in osteoarthritis of the knee, had statistical improvement over sham acupuncture at three months, but not later. Both large trials and this review of reviews come to the same general conclusion; that over a whole range of conditions and outcomes acupuncture cannot yet be shown to be effective.”

After thousands of years of acupuncture (or at least almost 40 years in the West) there seems to be very little to show for it.

The journal: Acupuncture in Medicine

What about the journal in question?  Like all journals devoted to alternative medicine, it claims to be evidence-based.  And like all journals devoted to alternative medicine it suffers from a fatal conflict of interest.  If this journal were ever to conclude that acupuncture is a placebo, it would destroy the journal and the livelihoods of many of the people who write for it.

Scanning the first three issues of 2008 shows that it is very much like other alternative medicine journals.  Most of the papers don’t address the critical question, is it a placebo.  And most papers end up rather limply, with a statement along the lines “acupuncture may be useful for ***.  More research is needed.”

The editor in chief of the journal is Dr Adrian White, and its editor  is Michael Cummings.  White is quoted by Ernst in the Guardian in 2004.

“We need to provide hard evidence to support what we all see in our clinics every day: that the modern approach to acupuncture works, and is highly relevant to the new,  patient-centred NHS.” .

That means the answer is assumed in advance. That just isn’t science.. ‘We know the answer, all we have to do now is get some evidence’.

Why should the BMJ Group want to do a thing like this?

The press release says

Commenting on the move, BMJ and BMJ Journals Publishing Director, Peter Ashman, said “The journal is a good complement for our existing portfolio of journals and we’re certain that the Society’s members and other subscribers will appreciate the benefits of the decision the BMAS has made on their behalf.”

He continued: “The BMAS is ambitious for its journal to grow and flourish and we’re looking forward to working with the Society to develop an editorial and commercial strategy which will achieve the aims of BMAS and those of its members, while reaching out to the wider global community interested in this fascinating area of medicine.”

Yes, you got it.  Money.  The same motive that causes some vice-chancellors to bring their university into disrepute by awarding BSc degrees in subjects that are not only not science, but which are oftenly openly anti-science.

Conscience doesn’t seem to bother these people, so let’s put the problem in purely cash terms.

Both the BMJ Group and the vice-chancellors will have to decide whether the cash they gain is sufficient to counterbalance the corrosive effects of their actions on their own reputations.

Follow-up

Only a couple of days later, two new trials show acupuncture is no different from sham controls for helping IVF pregnancy rates. James Randerson in the Guardian writes thus.

“Acupuncture aimed at improving IVF success rates is widely offered by fertility clinics in the UK. In the first of the studies, researchers in Hong Kong split 370 women receiving IVF into two groups. One group received real acupuncture before and after having an IVF embryo implanted into their uterus. The other had the same procedure, except the treatment used retractable needles that did not penetrate the skin.”

“Of the 185 who received the sham treatment, 91 achieved a clinical pregnancy (foetal heartbeat identified using ultrasound) and 71 had a successful delivery. This compared with 72 clinical pregnancies in the true acupuncture group and 55 live births. The differences between the groups were not statistically significant.”

“In a second study, researchers in Chicago used a similar design in which 124 women received true or sham acupuncture. The control group had their skin punctured by real acupuncture needles, but not at genuine “Qi-lines” on the body.   In the true acupuncture group, 43.9% achieved a clinical pregnancy, compared with 55.2% of the women given the sham treatment. “

The original paper for the first study can be seen here.

Jump to the homeopathy debate

Jump to follow-up: Brian Kaplan

Obama wins! Bush and Blair have gone. Could this mark the beginning of the end of the fashion for believing things that aren’t true?

Trinity College Dublin: the Phil. “Creationism is a valid world view”

This is the 324th year of the Trinity College Philosophical Society (known locally as the ‘Phil’).  Its former members include Bishop Berkeley,  Dean Jonathan Swift, Oscar Wilde, Bram Stoker, Samuel Beckett, and E.T.S. Walton .  It was founded for “discourse of philosophy, mathematics, and other polite literature ”, and is now a debating society.

Click to enlarge

The motion was Creationism is a Valid World view.  At the dinner before the debate, the students all dutifully stood as one of them recited long graces in Latin both before and after eating.  All very Oxbridge.  So I wasn’t optimistic.  However I hadn’t taken into account the conformist tendencies of undergraduates.   Notwithstanding the Latin graces, the result of the debate was very clear indeed.

Result. The Creationists were totally wiped out. Almost the only vote for the motion was a young born-again student, who made a desperately sincere speech.

I don’t need to give the details of what happened, because the opposer of the motion, Bob Bloomfield (of the Natural History Museum) has given an excellent account (The Discovery Institute send big guns to Ireland but only manage to fire blanks) on the Beagle project blog.  Two of the proposers were Americans, from the Discovery Institute, and they said what you’d expect: nothing that would impress anyone with any education.    I’ll settle for Bloomfield’s description of me as “charmingly irascible”. Irascible, moi? Well it would make anyone mildly irritated to have to spend time arguing about creationism in 2008.

Religion, all religion, seems to me to be boring and not a thing worth wasting good time on thinking about, but the rise of barmy fundamentalism has made it essential, if only so that genetics can be taught without  accusations of racism,   I’m entirely with Dawkins,  I can’t prove that there is no god, and I can’t guarantee
that the bottom of my garden is free of fairies.  Both questions merit about the same amount of time, though if pressed, I’d go for the fairies. They are, allegedly, rather better behaved than gods.

The 24th president of the USA said, when asked for his thoughts on evolution, said

“of course like every other man of intelligence and education I do believe in organic evolution. It surprises me that at this late date such questions should be raised”.

Woodrow Wilson, 1922

That, of course, was from a president who has been described as ” leading intellectual of the Progressive Era”.

How things have changed in the time of Tony Blair, George Bush and Sarah Palin. Very few people had such barmy beliefs in 1960, never mind 1922. My thesis is much the same as that of Francis Wheen in “How mumbo-jumbo conquered the world” Sometime around 1980, with the conjunction of Thatcher, Reagan and Khomeini it came into fashion to believe things that aren’t true, just because you wished they were (actually I’d put it a bit earlier than Wheen: arguably it started when the Beatles went to that guru), It was after that when suddenly people started to believe in magic medicine, religious fundamentalism. weapons of mass destruction, and, ahem,  that the market would make us rich if only we would remove all the regulations.

Tony Blair defended in parliament the Emmanuel School which is run by a young earth creationist and used car dealer, Peter Vardy.  The head of the school, Nigel McQuoid, features strongly on the web site of the Christian Institute, This curious organisation seems to be devoted largely to creationism, homophobia and the virtue of beating children (a search of the site for “corporal punishment” gives 43 hits).  An essay by Burns & McQuoid says

“There are those who argue that Science and Christianity can be harmoniously reconciled .  ; ;. We cannot subscribe to this view”

The former head of science (yes, of science) at McQuoid’s school, Steven Layfield, had an article on the Christian Institute web site. It vanished as soon as it got some publicity but you can read it at http://www.darwinwars.com/lunatic/liars/layfield.html.
Try this quotation.

“Note every occasion when an evolutionary/old-earth paradigm (millions or billions of years) is explicitly mentioned or implied by a text-book, examination question or visitor and courteously point out the fallibility of the statement. Wherever possible, we must give the alternative (always better) Biblical explanation of the same data.”

These guys are really at the fruit-cake end of the religious spectrum.  In contrast, the young anglican chaplain of Trinity, Darren McCallig, spoke against creationism, eloquently and sensibly.  His religiousness did seem at times to be diluted almost to homeopathic extremes, but all the better for that. He seems to have a sense of humour too, judging by the poster for his services.
click to enlarge

There is, of course, a very healthy opposition to creationists in the USA too,  I like particularly Gerald Weissman’s article “The facts of evolution: fighting the Endarkenment” (it may have been the first time that I saw the wonderful word endarkenment, which describes so well the last 30 years). It starts thus.

“Those of us who practice experimental science are living in the best of times and the worst of times, and I’m not talking about A Tale of Two Cities, but a tale of two cultures. “

Here are a couple of pictures of the meeting.

Chris Stillman (geologist)

Berlinski (left) Luke Ryder (speaking), Bloomfield, DC, Stillman (right)

And some pictures of Dublin here

James Joyce, TCD quadrangle and Molly Malone. Click to view

UCL homeopathy debate

This was organised by the UCL students’ debating society.  The Darwin Lecture theatre was surprisingly full for this debate, but they weren’t all students. As usual on these occasions, the homeopaths tried to pack the audience, but this time they failed.  That tactic is fair enough I suppose, but it means that the vote failed to tell us anything much about the opinion of students, beyond the fact that not many of them opposed the motion.

There are a few though. To the horror of some of our pharmacology and neuroscience undergraduates, a student society devoted to medicines that don’t work has been started at UCL, for the first time ever.  Luckily, it seems to be a rather small society.  I was fascinated to see that they are going to hear about the evidence base for complementary therapies, from George Lewith. I had occasion a while ago to look at Dr Lewith’s attitude to evidence: see Lewith’s private clinic has curious standards.

The proposers were Simon Singh and me. Simon is author of, among other things, Fermat’s Last Theorem and Trick or Treatment.  I thought he did an excellent job.




Singh pointed out that, contrary to the view propagated by quacks, science likes wacky ideas, as long as you can produce the evidence for them  He cited dark matter as an example.

The main opposer was my old friend Peter Fisher, homeopathic physician to the Queen.  It was a pleasure to show the video of Fisher agreeing with me that there is not enough science in homeopathy to justify a BSc degree in it.  Fisher, in his papers, strikes me as one of the most honest of homeopaths.  He was “very angry” when homeopaths were caught out recommending their sugar pills to prevent malaria.  But is his speech, he struck me as less than honest. He cherry-picked the evidence quite shamelessly as usual.  And his suggestion that there was an analogy between the ‘memory of water’ and a DVD was disposed of ably by a physics student who spoke from the floor.

The results were too close for comfort, 65 for, 53 against and an amazing 37 abstentions,

Sadly we’ll never know how the students voted, because of the imported homeopaths.

Dr Brian Kaplan was there.  He had given the meeting some advance publicity, in a web posting that also kindly gave publicity to our 2006 letter to the Times. He didn’t like the letter, which is unsurprising given that it turned out to be more effective than we could ever have hoped (see also here).



On the second row, getting very excited, was homeopath Grace Da Silva-Hill and her husband,  She runs the ‘Healing with Grace’ business.  On her web site she makes the ludicrous claim that

“Homeopathy will treat the cause of your health problem, not just alleviate your symptom”

She also says, inter alia, that

“Homeopathy is effective in treating a wide range of conditions such as: asthma, . . . “

In contrast, the Cochrane review says

“There is not enough evidence to reliably assess the possible role of homeopathy in asthma. “

I have been sent her account of the debate (a reply to a query from the ubiquitous Dana Ullman).

“Hello Dana, The debate, on monday 20th Oct., organised by UCL debating society, was poorly managed, and biased, attended mostly by students, who appear to have gone there to practice their debating skills. The motion was lost by 12 (65 for and 53 against), with 37 abstentions. Peter Fisher put on a good show, and so did his second, in comparison with the rather stale and poor presentation of Simon and Qulquoun (sorry, can never spell this). My husband Ken did a rather
good caricature of him, unfortunately can’t share it here. Pity there were not more  homeopaths/supporters there. Kind regards,”

Uhuh. Well, I guess she would say that.

You can judge the critical faculties of Mrs Da Silva-Hill from a comment she left on a piece in the Daily Telegraph, ‘Homeopathy putting lives at risk with claims’. I quote from it verbatim.

“The public does not care about the research available, the public care about having their health problem sorted, where conv. medicine has failed,”

(I apologise for attributing to Mrs Da Silva in the original post a quotation from the Telegraph that appeared above her name but was actually written by somebody else. I apologise also for using a picture of her without permission.)

On the way out of the debate, I walked back to Euston Road with another homeopath, William Alderson, who had come all the way from Kings Lynn to cast his vote.  He was earnest and sincere, the conversation was amicable but his idea of evidence was so different from mine that no progress was made. You can read more about Alderson on Dr Aust’s blog.

It’s fascinating stuff.

Follow-up

Dr Brian Kaplan has posted some splenetic comments on this post. I suppose the paranoid tone is an indication that we are winning, but I do wish he’d be a bit more careful about the facts. Let me correct some of them.

(1)Neither the letter of May 2006, nor its follow up in May 2007, was written under the NHS letterhead. The follow-up letter of May 2007 contained the words

“If you have not already reviewed your own trust’s provision, you might find it useful to consider, in conjunction with your Director of Public Health, the paper that we have enclosed which, while not a full review of the scientific position, has been used by other trusts to promote evidence based commissioning.”

The enclosed form was a sample commissioning letter which reproduced the NHS logo with a notice saying “insert your NHS logo here”. The accompanying letter made it perfectly clear that the enclosed form was simply an example to help those who wanted to save money and not an official NHS communication.

(2) Kaplan says I accuse him of lying to his patients, but his reference is to (an old version of) my Dilemmas at the heart of alternative medicine. It says nothing of the sort. I have said many times that I believe homeopaths are perfectly sincere, but they are just deluded. The reference to lying in the ‘dilemmas’ concerns how to get the maximum placebo effect when you know it is a placebo. Homeopaths have not reached that stage yet.

All this information has been available since May 2007.  He should have checked.

Jump to follow-up

It seems that validation committees often don’t look beyond the official documents. As a result, the validations may not be worth the paper they are written on. Try this one.

One of the best bits of news recently was the downfall of Matthias Rath.  He’s the man who peddled vitamin pills for AIDS in Africa, and encouraged the AIDS denialists in the South African government.  Thabo Mbeki and his Health Minister, Mrs Beetroot, have gone now, thank heavens.

Rath was one of the best illustrations of the murderous effect of selling ineffective treatments.  The fact that nobody in the “nutritional therapy” industry has uttered a word of condemnation for this man illustrates better than anything one can imagine the corrupt state of “nutritional therapy”.  The people who kept silent include the British Association of Nutritional Therapists (BANT).

It might be surprising, then, to find the Northern College of Acupuncture proudly adding a course in alternative nutrition to its courses in acupuncture (now known to be a theatrical placebo) and Chinese herbal medicine (largely untested and sometimes toxic).  It might be even more surprising to find the boast that the course is validated by the University of Wales.  It seemed a good idea to find out a bit more about how this came about.  Thanks to the Freedom of Information Act, some interesting things can be discovered.

Polly Toynbee’s superb article, Quackery and superstition – available soon on the NHS,  written in January 2008, mentioned diplomas and degrees in complementary therapies offered by, among others, the University of Wales.  This elicited a letter of protest to Toynbee from the Vice-Chancellor of the University of Wales, Professor Marc Clement BSc, PhD, MInstP, CEng,CPhys,FIET.   He invited her to visit the university to see their “validation and monitoring procedures (including the University’s very specific guidelines on health studies disciplines”.

So let’s take a look at these validation procedures and guidelines.

The validation process

The Northern College of Acupuncture submitted a 148 page proposal for the course in October 2007.   The document has all the usual edu-bollocks jargon, but of course doesn’t say much about clinical trials, though it does boast about an unblinded trial of acupuncture published in 2006 which, because of lack of appropriate controls, served only to muddy the waters.  : This submission was considered by the University’s validation committee last December.


Panel of Assessors:

Professor Nigel Palastanga (Chair), Cardiff University

Dr Celia Bell (School of Health and Social Sciences Middlesex University)

Dr John Fish (Moderator designate) (Institute of Biological Sciences University of Wales, Aberystwyth)

Ms Rhiannon Harris (Centre for Nutrition & Dietetics University of Wales Institute,
Cardiff (UWIC))

Ms Felicity Moir (School of Integrated Health University of Westminster)

The whole validation document is only four pages long [download it]. The most interesting thing about it is that the words ‘evidence’ or ‘critical’ do not occur in it a single time.  It has all the usual bureaucratic jargon of such documents but misses entirely the central point.

Does that mean that the University of Wales doesn’t care about evidence or critical thinking?  Well, not on paper. Two years previously a short document called Health Studies Guidelines had been written by Dr Brian Spriggs (Health Studies Validation Consultant, since retired) for the Health Studies Committee, and it was approved on 21 April 2005.  It starts well.

“Degrees in the Health Studies field are expected to promote an understanding of the  importance of the scientific method and an evidence-base to underpin therapeutic interventions and of research to expand that base.”

It even goes on to say that a BSc degree in homeopathy is “unacceptable”.  Don’t get too excited though, because it also says that acupuncture and Chinese herbal  stuff is quite OK.  How anyone can imagine they live up to the  opening sentence beats me.   And it gets worse. It says that all sorts of rather advanced forms of battiness are OK if they form only part of another degree.  They include Homeopathy, Crystal therapy. Dowsing, Iridology; Kinesiology, Radionics, Reflexology, Shiatsu, Healing, and Maharishi Ayurvedic Medicine.

Dowsing? Crystal therapy?  Just let me remind you. We are living in 2008. It is easy to forget that when ploughing through all this new age junk.

The Validation Handbook of Quality Assurance: Health Studies (2007) runs to an astonishing 256 pages [download the whole thing]. On page 12 we find the extent of the problem.

“The University of Wales validates a number of schemes in the Health Studies field. At the current time we have undergraduate and/or postgraduate degree schemes in Acupuncture, Animal Manipulation, Chiropractic, Herbal Medicine, Integrative Psychotherapy, Osteopathy, Osteopathic Studies, Traditional Chinese Medicine and Regulatory Affairs, both in the UK and overseas.”

That sounds pretty shocking.   Further down on page 12, though, we find this.

“Degrees in the Health Studies field are expected to promote an understanding of the importance of the scientific method and an evidence-base to underpin therapeutic interventions and of research to expand that base. The mission is to promote and require the critical evaluation of the practices, doctrines, beliefs, theories and hypotheses that underlie the taught therapeutic measures of the discipline.”

They are indeed fine words. The problem is that I can detect no sign in the submission, nor in its consideration by the validation committee, that any attempt whatsoever was made to ensure that the course complied with these requirements.

The only sign of concern I could detect of any concern about the quality of what was being taught came in a minute to a meeting of the Health Studies Committee meeting on 24th April 2008.

“Members received a copy of an article entitled Quackery and superstition available soon on the NHS which appeared in The Guardian newspaper in January 2008, and a copy of the Vice- Chancellors response. Members agreed that this article was now historical but felt that if/when the issue were to arise again; the key matter of scientific rigour should be stressed. The Committee agreed that this was the most critical element of all degree schemes in the University of Wales portfolio of health studies schemes. It was felt it would be timely to re-examine the schemes within the portfolio as well as the guidelines for consideration of Health Studies schemes at the next meeting. The Committee might also decide that Institutions would be required to include literature reviews (as part of their validation submission) to provide evidence for their particular profession/philosophy. It was agreed that the guidelines would be a vital document in the consideration of new schemes and during preliminary visits to prospective Institutions. “

The Press Office had passed Polly Toynbee’s article to them.  Curiously the Health Studies Committee dismissed it as “historical”, simply because it was written three months earlier.  That is presumably “historical” in the sense that the public will have forgotten about it, rather than in the sense that the facts of the matter have changed since January.  So, at least for the nutrition degree, Toynbee’s comments  were simply brushed under the carpet.

After a few cosmetic changes of wording the validation was completed on 16th January 2008. For example the word “diagnosis” was removed in 43 places and “rewritten in terms of evaluation and assessment”.  There was, needless to say, no indication that the change in wording would change anything in what was taught to students.

You may think that I am being a bit too harsh. Perhaps the course is just fine after all? The problem is that the submission and the reaction of the validation committee tell you next to nothing about what actually matters, and that is what is taught. There is only a vague outline of that in the submission (and part of it was redacted on the grounds that if it were made public somebody might copy ;it.  Heaven forbid).

That is why I have to say, yet again, that this sort of validation exercise is not worth the paper it’s written on.

How can we find out a bit more? Very easily as it happens. Just Google. What matters is not so much formal course outlines but who teaches them.

The nutrition course

The title of the course is just “Nutrition”, not ‘Nutritional Therapy’ or ‘Alternative Nutrition’.  That sounds quite respectable but a glance at the prospectus shows immediately that it is full-blown alternative medicine.

Already in July 2007, the glowing press releases for the course had attracted attention from the wonderfully investigative web site HolfordWatch.   I see no sign that the validation committee was aware of this. But if not, why not? I would describe is as dereliction of academic duty.

“This pioneering course is unique in that it is firmly rooted in both Western nutritional science and naturopathic medicine and also covers concepts of nutrition within traditional Chinese, Japanese, Tibetan and Ayurvedic medicine.

This means that graduates will gain comprehensive understanding of both modern scientific knowledge and ancient wisdom concerning nutrition and dietetics.”

Ancient wisdom, of course, means something that your are supposed to believe though there is no good reason to think it’s true.  In the end, though, almost the only thing that really matters about any course is who is running it.  The brochure shows that all of the people are heavily into every form of alternative nuttiness.

Course Director and Tutor: Jacqueline Young nutritionist, naturopath, clinical psychologist and Oriental medical practitioner

Nutrition Tutors:

Elaine Aldred  (qualified as a chiropractor with the Anglo European Chiropractic College, as an acupuncturist with the British College of Acupuncture and as a Western Medical Herbalist with the College of Phytotherapy. She recently also qualified in Chinese herbal medicine with the Northern College of Acupuncture.)

Sue Russell (3 year diploma in nutritional therapy at the Institute of Optimum Nutrition. She currently practises as a nutritional therapist and also works part-time as a manager at the Northern College of Homeopathic Medicine.)

Anuradha Sharma (graduated as a dietician from Leeds Metropolitan University in 2002 and subsequently completed a Naturopathy certificate and a post-graduate diploma in acupuncture).

Guest Lecturers include : Dr John Briffa, Professor Jane Plant, M.B.E. (a geochemist turned quack), and, most revealingly, none other than the UK’s most notorious media celebrity and pill peddler, Patrick Holford.

So much has been written about Holford’s appalling abuse of science, one would have thought that not even a validation committee could have missed it.

“The course has been created by Jacqueline Young“, so let’s look a bit further at her track record.

Jacqueline Young has written a book, ‘Complementary Medicine for Dummies’ [Ed: ahem shouldn’t that be Dummies for Complementary Medicine?].  You can see parts of it on Google Books. Did the validation committee bother to look at it?  As far as I can tell, the words ‘randomised’ or ‘clinical trial’ occur nowhere in the book.

The chapter on Tibetan medicine is not very helpful when it comes to evidence but for research we are referred to the Tibetan Medical and Astrology Institute.  Guess what? That site gives no evidence either. So far not a single university has endorsed Astrology (there is a profitable niche there for some vice-chancellor).

Here are few samples from the book. The advice seems to vary from the undocumented optimism of this

Well researched?  No. Safe? Nobody knows.  Or this

Mandarin peel prevents colds and flu?  Old wive’s tale.  Then there are things that verge on the weird, like this one

or the deeply bizarre like this

The problem of Jacqueline Young’s fantasy approach to facts was pointed out at least as far back as 2004, by Ray Girvan., who wrote about it again in May 2005. The problems were brought to wider attention when Ben Goldacre wrote two articles in his Badscience column, Imploding Researchers (September 2005), and the following week, Tangled Webs.

“we were pondering the ethics and wisdom of Jacqueline Young dishing out preposterous, made-up, pseudoscientific nonsense as if it was authoritative BBC fact, with phrases such as: “Implosion researchers have found that if water is put through a spiral its electrical field changes and it then appears to have a potent, restorative effect on cells.” “

and later

“Take this from her article on cranial osteopathy, riddled with half truths: “Sutherland found that the cranial bones (the skull bones encasing the brain) weren’t fused in adulthood, as was widely believed, but actually had a cycle of slight involuntary movement.” In fact the cranial bones do fuse in adulthood.

She goes on: “This movement was influenced by the rhythmic flow of cerebrospinal fluid (the nourishing and protective fluid that circulates through the spinal canal and brain) and could become blocked.” There have now been five studies on whether “cranial osteopaths” can indeed feel these movements, as they claim, and it’s an easy experiment to do: ask a couple of cranial osteopaths to write down the frequency of the rhythmic pulses on the same person’s skull, and see if they give the same answer. They don’t. A rather crucial well-replicated finding to leave out of your story.

That was in 2005 and since then all of Young’s “preposterous, made-up, pseudoscientific nonsense” (along with most of the other stuff about junk medicine) has vanished from the BBC’s web site, after some people with a bit of common sense pointed out what nonsense it was.  But now we see them resurfacing in a course validated by a serious university.  The BBC had some excuse (after all, it is run largely by arts graduates). I can see no excuses for the University of Wales.

Incidentally,  thanks to web archive you can still read Young’s nonsense,  long after the BBC removed it.  Here is a quotation.

“Implosion researchers have found that if water is put through a spiral its ,field changes and it then appears to have a potent, restorative effect on cells. In one study, seedlings watered with spiralised water grew significantly faster, higher and stronger than those given ordinary water.”

The vice-chancellor of the University of Wales, Marc Clement, is a physicist (Department of Electrical and Electronic Engineering), so can he perhaps explain the meaning of this?

Selection committees for jobs (especially senior jobs) and validation committees for courses, might make fewer mistakes if they didn’t rely so much on formal documents and did a little more investigation themselves. That sort of thing is why the managerial culture not only takes a lot more time, but also gives a worse result.

It would have taken 10 minutes with Google to find out about Young’s track record, but they didn’t bother. As a result they have spent a long time producing a validation that isn’t worth the paper it’s written on. That makes the University of Wales a bit of a laughing stock. Worse still, it brings science itself into disrepute.

Follow-up

What does the University of Wales say? So far, nothing.   Last week I sent brief and polite emails to Professor Palastanga and to Professor Clement to try to discover whether it is true that the validation process had indeed missed the fact that the course organiser’s writings had been described as “preposterous, made-up, pseudoscientific nonsense” in the Guardian.

So far I have had no reply from the vice-chancellor, but on .26 October I did get an answer from Prof Palastaga.

As regards the two people you asked questions about – J.Young – I personally am not familiar with her book and nobody on the validation panel raised any concerns about it. As for P.Holford similarly there were no concerns expressed about him or his work. In both cases we would have considered their CV’s as presented in the documentation as part of the teaching team. In my experience of conducting degree validations at over 16 UK Universities this is the normal practice of a validation panel.


I have to say this reply confirms my worst fears. Validation committees such as this one simply don’t do their duty. They don’t show the curiosity that is needed to discover the facts about the things that they are meant to be judging. How could they not have looked at the book by the very person that they are validating? After all that has been written about Patrick Holford, it is simply mind-boggling that the committee seems to have been quite unaware of any of it.

It is yet another example of the harm done to science by an unthinking, box-ticking approach.

Pharmacology. A Handbook for Complementary Healthcare Professionals

Elsevier were kind enough to send me an inspection copy of this book, which is written by one of the nutrition course tutors, Elaine Aldred. She admits that pharmacology is “considered by most students to be nothing more that a ‘hoop-jumping’ exercise in the process of becoming qualified”.  She also says. disarmingly. that “I was certainly not the most adept scientist at school and found my university course a trial”.

The book has all the feel of a cut and paste job. It is mostly very simple (if not simplistic). though for no obvious reason it starts with a long (and very amateur) discussion of chemical bonding  Then molecules are admitted to be indivisible (but, guess what, the subject of homeopathy is avoided).  There is a very short section on ion channels, though, bizarrely, it appears under the heading “How do drugs get into cells?”. Since the author is clearly not able to make the distinction between volts and coulombs, the discussion is more likely to confuse the reader than to help.

Then a long section on plants. It starts of by asserting that “approximately a quarter of prescription drugs contain at least one chemical that was originally isolated and extracted from a plant”.. This cannot be even remotely correct.  There are vast tables showing complicated chemical structures, but the usual inadequate
list of their alleged actions  This is followed by a quick gallop through some classes of conventional drugs, illustrated again mainly by chemical structures not data.  Hormone replacement therapy is mentioned, but the chance to point out that it is one of the best illustrations of the need for RCTs is missed.

The one thing that one would really like to see in such a book is a good account of how you tell whether or not a drug works in man. This is relegated to five pages at the end of the book, and it is, frankly, pathetic.  It
is utterly uncritical in the one area that matters more than any other for people who purport to treat patients. All you get is a list of unexplained bullet points.

If this book is the source of the “scientific content” of the nutrition course, things are as bad as we feared.




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Alfred Joseph Clark FRS held the established chair of Pharmacology at UCL from 1919 to 1926, when he left for Edinburgh.  In the 1920s and 30s, Clark was a great pioneer in the application of quantitative physical ideas to pharmacology.   As well as his classic scientific works, like The Mode of Action of Drugs on Cells (1933) he wrote, and felt strongly, about the fraud perpetrated on the public by patent medicine salesmen.  In 1938 (while in Edinburgh) he published a slim volume called Patent Medicines.  The parallels with today are astonishing.


Alfred Joseph Clark FRS (1885 – 1941)

I was lucky to be given a copy of this book by David Clark, A.J. Clark’s eldest son, who is now 88. I visited him in Cambridge on 17 September 2008, because he thought that, as holder of the A.J. Clark chair at UCL from 1985 to 2004, I’d be a good person to look after this and several other books from his father’s library. They would have gone to the Department of Pharmacology if we still had one, but that has been swept away by mindless administrators with little understanding of how to get good science.

Quotations from the book are in italic, and are interspersed with comments from me.

The book starts with a quotation from the House of Commons Select Committee report on Patent Medicines. The report was submitted to the House on 4 August 1914, so there is no need to explain why it had little effect. The report differs from recent ones in that it is not stifled by the sort of political correctness that makes politicians refer to fraudsters as “professions”.


The problem

“2.2 The situation, therefore, as regards the sale and advertisement of proprietary medicines and articles may be summarised as follows:

For all practical purposes British law is powerless to prevent any person from procuring any drug, or making any mixture, whether patent or without any therapeutical activity whatever (as long as it does not contain a scheduled poison), advertising it in any decent terms as a cure for any disease or ailment, recommending it by bogus testimonials and the invented opinions and facsimile signatures of fictitious physicians, and selling it under any name he chooses, on payment of a small stamp duty. For any price he can persuade a credulous public to pay.”

Select Committee on Patent Medicines. 1914

“The writer has endeavoured in the present article to analyse the reasons for the amazing immunity of patent medicines form all attempts to curb their activity, to estimate the results and to suggest the obvious measures of reform that are needed.”

Clark, writing in 1938, was surprised that so little had changed since 1914.  What would he have thought if he had known that now, almost 100 years after the 1914 report, the fraudsters are still getting away with it?


Chapter 2 starts thus.

THE LAW

The Select Committee appointed by the House of Commons in 1914 ‘to consider and inquire into the question of the sale of Patent and Proprietary Medicines’ stated its opinion in 28 pages of terse and uncompromising invective. Its general conclusions were as follows:

That the trade in secret remedies constituted a grave and widespread public evil.

That the existing law was chaotic and had proved inoperative and that consequently the traffic in secret remedies was practically uncontrolled.

In particular it concluded ‘”that this is an intolerable state of things and that new legislation to deal with it, rather than merely the amendment of existing laws, is urgently needed in the public interest.”

The “widespread public evil”continues almost unabated, and rather than introduce sensible legislation to cope with it, the government has instead given a stamp of approval for quackery by introducing utterly ineffective voluntary “self-regulation”.

Another Bill to deal with patent medicines was introduced in 1931, without success, and finally in 1936, a Medical and Surgical Appliances (Advertisement) Bill was introduced. This Bill had a very limited scope. Its purpose was to alleviate some of the worst abuses of the quack medicine trade by prohibiting the advertisement of cures for certain diseases such as blindness, Bright’s disease [nephritis] , cancer, consumption [tuberculosis], epilepsy, fits, locomotor ataxy, fits, lupus or paralysis.

The agreement of many interests was secured for this measure. The president of the Advertising Association stated that the proposed Bill would not affect adversely any legitimate trade interest. Opposition to the Bill was, however, whipped up amongst psychic healers, anti-vivisectionists and other opponents of medicine and at the second reading in March 1936, the Bill was opposed and the House was counted out during the ensuing debate. The immediate reason for this fate was that the Bill came up for second reading on the day of the Grand National! This is only one example of the remarkable luck that has attended the patent medicine vendors.
(Page 14).

The “remarkable luck” of patent medicine vendors continues to this day, Although, in principle, advertisement of cures for venereal diseases was banned in 1917, and for cancer in 1939, it takes only a few minutes with Google to find that these laws are regularly flouted by quacks,  In practice quacks get away with selling vitamin pills for AIDS, sugar pills for malaria and homeopathic pills for rabies, polio anthrax and just about anything else you can think of.  Most of these advertisements are contrary to the published codes of ethics of the organisations to which the quack in question belongs but nothing ever happens.
Self-regulation simply does not work, and there is still no effective enforcement even of existing laws..

“It has already been stated that British law allows the advertiser of a secret remedy to tell any lie or make any claim that he fancies will sell his goods and the completeness of this licence is best illustrated by the consideration of a few specific points.

Advertisements for secret remedies very frequently contain a list of testimonials from medical men, which usually are in an anonymous form, stating that ………….. M.D., F.R.C.S., has found the remedy infallible. Occasionally, however, the name and address of a doctor is given and anyone unaware of the vagaries of English law would imagine that such use of a doctor’s name and professional reputation could not be made with impunity without his consent. In 1899, however, the Sallyco Mineral Water Company advertised that ‘Dr. Morgan Dochrill, physician to St. John’s Hospital, London and many of the leading physicians are presenting ‘Sallyco’ as an habitual drink. Dr. Dochrill says nothing has done his gout so much good.
Dr. Dochrill, whose name and title were correctly stated above, sued the company but failed in his case. ”

“The statement that the law does not prevent the recommending of a secret remedy by the use of bogus testimonials and facsimile signatures of fictitious physicians is obviously an understatement since it is doubtful how far it interferes with the use of bogus testimonials from real physicians.”

Dodgy testimonials are still a mainstay of dodgy salesman.  One is reminded of the unauthorised citation of testimonials from Dr John Marks and Professor Jonathan Waxman by Patrick Holford to aid his sales of unnecessary vitamin supplements. There is more on this at Holfordwatch.

The man in the street knows that the merits of any article are usually exaggerated in advertisements and is in the habit of discounting a large proportion of such claims, but, outside the realm of secret remedies, the law is fairly strict as regards definite misstatements concerning goods offered for sale and hence the everyday experience of the man in the street does not prepare him for dealing with advertisements which are not merely exaggerations but plain straightforward lies from beginning to end.

Scientific training is undoubtedly a handicap in estimating popular gullibility as regards nostrums. One imagines that no one today would be willing to spend money on pills guaranteed to prevent earthquakes but yet the claims of many of the remedies offered appear equally absurd to anyone with an elementary
knowledge of physiology or even of chemistry. A study of the successes and failures suggests that success depends chiefly on not over-rating the public intelligence. (Page 34)

This may have changed a bit since A.J. Clark was writing in 1938. Now the main clients of quacks seem to be the well-off “worried-well”. But it remains as true as ever that “Scientific training is undoubtedly a handicap in estimating popular gullibility as regards nostrums.” In 2008, it is perhaps more a problem of Ben Goldacre’s dictum ““My basic hypothesis is this: the people who run the media are humanities graduates with little understanding of science, who wear their ignorance as a badge of honour.”

Clark refers (page 36) to a successful conviction for fraud in the USA in 1917.  The subject was a widely advertised ‘get fat quick’ pill that contained lecithin, proteins and sugar.  The BMA analysis (in 1912)
suggested that the cost of the ingredients in a box of 30 tablets sold for 4/6 was 1 1/4 d. [4/6 meant 4 shillings and six pence, or 22.5 pence since 1971, and 1 1/4 old pence, a penny farthing, is 0.52 new pence]. He comments thus.

The trial revealed many interesting facts. The formula was devised after a short consultation with the expert of one of the largest drug manufacturers in the U.S.A. This firm manufactured the tablets and sold them to the proprietary medicine company at about 3/- per 1000, whilst they were retailed to the public at the rate of £7 10s. per 1000. The firm is estimated to have made a profit of about $3,000,000.

These trials in the U.S.A. revealed the fact that in a considerable proportion of cases the ‘private formula’ department of the large and well known drug firm already mentioned had first provided the formula for the nostrum and subsequently had prepared it wholesale.

Nothing much has changed here either. The alternative medicine industry (and it is a very big industry) is fond of denouncing the evils of the pharmaceutical industry, and sadly, occasionally they are right.  One of the less honest practices of the pharmaceutical industry (though one never mentioned by quacks) is buying heavily into alternative medicine. Goldacre points out

“there is little difference between the vitamin and pharmaceutical industries. Key players in both include multinationals such as Roche and Aventis; BioCare, the vitamin pill producer that media nutritionist Patrick Holford works for, is part-owned by Elder Pharmaceuticals.”

And then. of course, there is the deeply dishonest promotion by Boots the Chemists of homeopathic miseducation, of vitamins and of CoQ10 supplements.

The manner in which secret remedies can survive repeated exposure is shown by the following summary of the life history of a vendor of a consumption [tuberculosis] cure.

1904, 1906: Convicted of violating the law in South Africa.

1908:            Exposed in British Medical Association report and also attacked by Truth.

1910:            Sued by a widow. The judge stated: ‘I think this is an intentional and well-considered fraud. It is a scandalous thing that poor people should be imposed upon and led to part with their money, and to hope that those dear to them would be cured by those  processes which were nothing but quack remedies and had not the slightest value of any kind.’

1914:             A libel action against the British Medical Association was lost.

1915              The cure was introduced into the United States.

1919               The cure was sold in Canada.

1924                Articles by men with medical qualifications appeared in the Swiss medical journal boosting
the cure.

Secret remedies have a vitality that resembles that of the more noxious weeds and the examples mentioned suggest that nothing can do them any serious harm.

Most of the time, quacks get away with claims every bit as outrageous today.   But Clark does give one example of a successful prosecution.  It resulted from an exposé in the newspapers -wait for it -in the Daily Mail.

There is, however, one example which proves that a proprietary remedy can be squashed by exposure if this is accompanied by adequate publicity.

The preparation Yadil was introduced as an antiseptic and was at first advertised to the medical profession. The proprietor claimed that the remedy was not secret and that the active principle was ‘tri-methenal allylic carbide’. The drug acquired popularity in the influenza epidemic of 1918 and the proprietor became more and more ambitious in his therapeutic claims. The special virtue claimed for Yadil was that it would kill any harmful organism that had invaded the body. A more specific claim was that consumption in the first stage was cured with two or three pints whilst advanced cases might require a little more.  Other advertisements suggested that it was a cure for most known diseases from cancer downwards.

These claims were supported by an extraordinarily intense advertising campaign.  Most papers, and even magazines circulating amongst the wealthier classes,  carried full page and even double page advertisements. The Daily Mail refused these advertisements and in 1924 published a three column article by Sir William Pope, professor of Chemistry in the University of Cambridge. He stated that
the name ‘tri-methenal allylic carbide’ was meaningless gibberish and was not the chemical definition of any known substance. He concluded that Yadil consisted of :

‘About one per cent of the chemical compound formaldehyde.

About four per cent of glycerine.

About ninety-five per cent of water and, lastly, a smell.

He calculated that the materials contained in a gallon cost about 1/6, whilst the mixture was sold at £4 10s. per gallon.

This exposure was completely successful and the matter is of historic interest in that it is the only example of the career of a proprietary medicine being arrested by the action of the Press.

Clark goes on to talk of the law of libel.


“On the other hand the quack medicine vendor can pursue his advertising campaigns in the happy assurance that, whatever lies he tells, he need fear nothing from the interference of British law. The law does much to protect the quack medicine vendor because the laws of slander and libel are so severe.”

The law of libel to this day remains a serious risk to freedom of speech of both individuals and the media. Its use by rogues to suppress fair comment is routine.  My first encounter was when a couple of herbalists
threatened to sue UCL
because I said that the term ‘blood cleanser’ is gobbledygook.  The fact that the statement was obviously true didn’t deter them for a moment.  The herbalists were bluffing no doubt, but they caused enough nuisance that I was asked to take my pages off UCL’s server.  A week later I was invited back but by then I’d set up a much better blog and the publicity resulted in an enormous increase in readership, so the outcome was good for me (but bad for herbalists).

It was also good in the end for Andy Lewis when his immortal page “The gentle art of homoeopathic killing” (about the great malaria scandal) was suppressed.   The Society of Homeopaths’ lawyers didn’t go for him personally but for his ISP who gave in shamefully and removed the page.  As a result the missing page reappeared in dozens of web sites round the world and shot to the top in a Google search.

Chiropractors are perhaps the group most likely to try to suppress contrary opinions by law not argument.  The only lawyers’ letter that has been sent to me personally, alleged defamation in an editorial that I wrote for the New Zealand Medical Journal.  That was a little scary, but the journal stuck up for its right to speak and the threat went away after  chiropractors were allowed right of reply (but we got the last word).

Simon Singh, one of the best science communicators we have, has not been so lucky. He is going to have to defend in court an action brought by the British Chiropractic Association because of innocent opinions expressed in the Guardian.

Chapter 6 is about “The harm done by patent medicines”. It starts thus.

“The trade in secret remedies obviously represents a ridiculous waste of money but some may argue that, since we are a free country and it pleases people to waste their money in this particular way, there is no call for any legislative interference. The trade in quack medicines cannot, however, be regarded as a harmless one. The Poisons Acts fortunately prevent the sale of a large number of dangerous drugs, but there are numerous other ways in which injury can be produced by these remedies.”

The most serious harm, he thought, resulted from self-medication, and he doesn’t mince his words.

“The most serious objection to quack medicines is however that their advertisements encourage self-medication as a substitute for adequate treatment and they probably do more harm in this than in any other manner.

The nature of the problem can best be illustrated by considering a simple example such as diabetes. In this case no actual cure is known to medicine but, on the other hand, if a patient is treated adequately by insulin combined with appropriate diet, he can be maintained in practically normal health, in spite of his disability, for an indefinite period. The expectation of life of the majority of intelligent diabetics, who make no mistakes in their regime, is not much less than that of normal persons. The regime is both irksome and unpleasant, but anyone who persuades diabetics to abandon it, is committing manslaughter as certainly as if he fired a machine gun into a crowded street.

As regards serious chronic disease the influence of secret remedies may be said to range from murderous to merely harmful.

‘Cures’ for consumption, cancer and diabetes may fairly be classed as murderous, since they are likely to cause the death of anyone who is unfortunate enough to believe in their efficacy and thus delay adequate treatment until too late.

The phrase “‘Cures for consumption, cancer and diabetes may fairly be classed as murderous” made Clark himself the victim of suppression of freedom of speech by lawyers. His son, David Clark, wrote of his father in “Alfred Joseph Clark, A Memoir” (C. & J. Clark Ltd 1985 ISBN 0-9510401-0-3)

“Although tolerant of many human foibles, A. J. had always disapproved fiercely of quacks, particularly the charlatans who sold fraudulent medicines.  During his visits to London he met Raymond Postgate, then a crusading left wing journalist, who persuaded A.J. to write a pamphlet which was published in an ephemeral series called ‘Fact‘ in March 1938. It was a lively polemical piece. . To A.J.’s surprise and dismay he was sued for libel by a notorious
rogue who peddled a quack cure for for tuberculosis. This man said that A.J.’s remarks (such as “‘Cures’ for consumption, cancer and diabetes may fairly be classed as murderous”) were libellous and would damage his business.  A.J. was determined to fight, and he and Trixie decided to put their savings at stake if necessary. The B.M.A. and the Medical Defence Union agreed to support him and they all went to lawyers. He was shocked when they advised him that he would be bound to lose for he had damaged the man’s livelihood!   Finally, after much heart searching, he made an apology, saying that he had not meant that particular man’s nostrum”

Talk about déjà vu!

On page 68 there is another very familiar story. It could have been written today.

“The fact that the public is acquiring more knowledge of health matters and is becoming more suspicious of the cruder forms of lies is also helping to weed out the worst types of patent medicine advertisements. For example, in 1751 a bottle of oil was advertised as a cure for scurvy, leprosy and consumption but today such claims would not be effective in promoting the sale of a remedy. The modern advertiser would probably claim that the oil was rich in all the vitamins and the elements essential for life and would confine his claims to a statement that it would alleviate all minor forms of physical or mental ill-health.

The average patent medicine advertised today makes plausible rather than absurd claims and in general the advertisements have changed to conform with a change in the level of the public’s knowledge.

It is somewhat misleading, however, to speak of this as an improvement, since the law has not altered and hence the change only means that the public is being swindled in a somewhat more skilful manner.

The ideal method of obtaining an adequate vitamin supply is to select a diet containing an abundant supply of fresh foods, but unfortunately the populace is accustomed to live very largely on preserved or partially purified food stuffs and such processes usually remove most of the vitamins.”

The first part of the passage above is reminiscent of something that A.J Clark wrote in  the BMJ in 1927.  Nowadays it is almost unquotable and I was told by a journal editor that it was unacceptable even with asterisks.  That seems to me a bit silly. Words had different connotations in 1927.

“The less intelligent revert to the oldest form of belief and seek someone who will make strong magic for them and defeat the evil spirits by some potent charm. This is the feeling to which the quack appeals; he claims to be above the laws of science and to possess some charm for defeating disease of any variety.

The nature of the charm changes with the growth of education. A naked n****r howling to the beat of a tom-tom does not impress a European, and most modern Europeans would be either amused or disgusted by the Black mass that was popular in the seventeenth century. Today some travesty of physical science appears to be the most popular form of incantation.”

A.J. Clark (1927) The historical aspect of quackery, BMJ October 1st 1927

Apart from some of the vocabulary, what better description could one have of the tendency of homeopaths to harp on meaninglessly about quantum theory or the “scienciness” and “referenciness” of
modern books on nutritional therapy?

So has anything changed?

Thus far, the outcome might be thought gloomy. Judging by Clark’s account, remarkably little has changed since 1938, or even since 1914. The libel law in the UK is as bad now as it was then. Recently the United Nations Human Rights Committee said UK laws block matters of public interest and encourage libel tourism (report here, see also here).   It is unfit for a free society and it should be changed.

But there are positive sides too. Firstly the advent of scientific bloggers has begun to have some real influence. People are no longer reliant on journalists to interpret (or, often, misinterpret) results for them. They can now get real experts and links to original sources.  Just one of these, Ben Goldacre’s badscience.net, and his weekly column in the Guardian has worked wonders in educating the public and improving journalism.  Young people can, and do, contribute to the debate because they can blog anonymously if they are frightened that their employer might object.

Perhaps still more important, the law changed this year. Now, at last, it may be possible to prosecute successfully those who make fraudulent health claims. Sad to say, this was not an initiative of the UK government, which remains as devoted as ever to supporting quacks.  Remember that, quite  shamefully, the only reason given by the Medicines and Health Regulatory Authority (MHRA) gave for allowing false labelling of homeopathic pills was to support the “homeopathic industry”. They suggested (falsely) that the EU required them to take this irresponsible step, which was condemned by just about every scientific organisation. But the new unfair trading regulations did come from the EU. After almost 100 years since the 1914 report, we have at last some decent legislation. Let’s hope it’s enforced.

Postcript

The back cover of the series of ‘Fact‘ books in which A.J. Clark’s article appeared is reproduced below, simply because of the historical portrait of the 1930s that it gives.


Follow-up

This post got a lot of hits from Ben Goldacre’s miniblog which read

Jump to follow-up

Today is a good day for anyone who deplores dangerous confidence tricksters. In particular it is a good day for Ben Goldacre, and for the Guardian which defended him at potentially enormous expense.

Matthias Rath, the Dutch (or is it German) vitamin salesman has dropped his libel action against the  Guardian. He is the man who is, without doubt, responsible for many deaths form AIDS in Africa, as a result of peddling vitamin pills as cures.  The action was taken after Goldacre said, in the Guardian, that Rath  aggressively sells his message to Aids victims in South Africa that Rath vitamin pills are better than medication”.

Here is some of what has appeared already today

Fall of the doctor who said his vitamins would cure Aids – from The Guardian, with a video of the villain.

Goldacre’s Badscience blog article on his victory .

Leader from The Guardian .

Profile of Zackie Achmat – from The Guardian, Mr Achmat is the founder of the Treatment Action Campaign , instrumental in exposing Rath.

Extract from witness statements from the defence in the trial .

And a lot of publicity from Gimpyblog (“Ben Goldacre and The Guardian triumph over murderous Matthias Rath”), Holfordwatch , Quackometer and jdc325 blogs.

Then more in the Guardian the next day, Chris McGreal investigates the Rath Foundation

Nutritional therapist?

Let’s be clear about what the words mean.  Nutritional therapists are not like dietitians, and they are not like nutritionists.  Nutritional therapists are solidly in the camp of alternative medicine practitioners,  Don’t
take my word for it. They say so themselves.

“For nutritional therapists (who practise Complementary and Alternative Medicine) optimum nutrition encompasses individual prescriptions for diet and lifestyle in order to alleviate or prevent ailments and to promote optimal gene expression through all life stages. Recommendations may include guidance on natural detoxification, procedures to promote colon health, methods to support digestion and absorption, the avoidance of toxins or allergens and the appropriate use of supplementary nutrients, including phytonutrients.”

They love to use imaginary words like “detoxification”, and, much more dangerously, they love to pretend that they can cure diseases by changes in diet. As long as you buy from them a stack of expensive “supplement” pills, of course. That means they are selling medicines, but by pretending they are selling food supplements they manage to evade the law that requires medicines to be safe and effective.  That will not be so easy under new legislation though, and we can look forward to a few prosecutions soon.

Guess who runs an “Honours BSc degree” in Nutritional Therapy. No prizes for realising it is the UK’s leading university purveyor of woo.

The University of Westminster

On their web site we learn that the Course Leader is Heather Rosa, and the Deputy Course Leader is Val Harvey.  Harvey qualified in the subject at the Institute  of Optimum Nutrition, the private college run by none other than the famous pill-peddler, Patrick Holford, about whom so very much has been written (try Holfordwatch, or the masterly chapter in Goldacre’s Bad Science)

We don’t know much about what is taught on the Nutritional Therapy course because the University of Westminster has refused repeated requests to say (but watch this space).. One can only assume that,  whatever it is, they are not very proud of it.  It seems a little unlikely that they will go as far as Matthias Rath and claim to cure AIDS -we’ll just have to wait and see.  Meanwhile we can get an inkling by looking elsewhere.

Course leader, Heather Rosa, pops up for example, on the expert panel of a web site called Supplements Compared.com. “Supplements Compared is designed to help you find the best dietary supplement product for your health needs.”   And what sort of advice do you find there?  Try the page that compares 10 brands of CoQ10 (that is the stuff I wrote about recently, in “Boots reaches new level of dishonesty with CoQ10 promotion” – their advertising was deemed improper by the ASA ).  It isn’t a recommended treatment for anything at all, but you certainly wouldn’t guess that from what is written by the ‘expert panel’.  The winners are, according to the ‘expert panel’, Boots’ CoQ10 and Holland and Barrett’s CoQ10.   Winners?   Perhaps the explanation for that comes elsewhere, under “How are we funded?”.   “Manufacturers who are awarded “best product” and “worth a look” are given the opportunity to promote this fact throughout the site for an additional fee.”. Well well.

Deputy Course leader, Val Harvey has her own web site and business (I do hope thar Westminster does not pay these people a full time salary too). What can we glean from there? It has the usual scare tactics “Why
you are at risk?
“. Never fear; buy enough vitamin pills and you’ll be saved.

Her home page makes some pretty drastic claims.

“Potential health benefits of your nutritional programme

An appropriate Nutritional Programme can benefit many conditions including:

Allergies

Arthritis

Asthma

Bloating, indigestion

Chronic degenerative diseases

Chronic fatigue, ME

Constipation, diarrhoea

Cystitis

Depression, mood swings

Digestive or bowel problems

Eczema, psoriasis, other skin problems

Food sensitivities

Frequent infections

Hormone imbalance
Hypertension or elevated cholesterol

Irritable bowel syndrome

Low energy

Menopausal symptoms

Migraines, headaches

Parasitic and fungal infections

Pre-conceptual issues

Premenstrual syndrome (PMS)

Sinus congestion

Stress

Thrush

Weight problems

and many others ….



These are just some of the wide range of health problems that may be helped by nutritional therapy. Even those who consider themselves well and healthy may be able to enhance their physical and mental health, as well as their performance, including athletic performance, by improving their nutrition.”

There is, in my view, not the slightest bit of good evidence that swallowing vitamin pills can benefit most of these conditions.

But at least the list doesn’t contain AIDS, so is all this really relevant to the case of Matthias Rath?

Yes, I believe it is. The University of Westminster may well not support the views of Matthias Rath (they won’t say), but we have heard no choruses of protests about him from any nutritional therapists, as far as I’m aware. There is no mention of him at all on the web site of the British Association of Nutritional Therapists (BANT), the UK club for these people.  BANT, by the way, has a rather curious code of ethics. It allows its members to take undisclosed financial kickbacks for the pills they prescribe to patients. If doctors were caught doing that they’d be struck off the register.

It is the existence of degrees in subjects like “nutritional therapy” that gives the subject a spurious air of respectability which allows seriously dangerous people like Rath to flourish with very little criticism.  In an indirect way, the vice-chancellors who allow it to flourish (and Universities UK who do nothing about it) must bear some small part of the responsibility for the deaths of thousands of people from AIDS.

It is about time they did something about it.

Follow-up

ANH. The first reaction from the supplement-peddling industry comes from the Alliance for Natural Health on 16th September. It contains not one word of condemnation for Rath’s murderous activities. It’s hard to believe how low they will sink.

The Prince’s Foundation for Integrated Health remains totally silent about Rath. HRH’s concern for health seems to dry up if things don’t suit his views.

The British Association of Nutritional Therapists shows it’s total irresponsibility after a letter was sent to them to ask about their reaction. Their answer , on jdc325’s weblog was “The association has no opinion to offer on Dr Raths vitamin trials.”.


There have been some really excellent books about quackery this year.  This isn’t one of them, because

Nice dedication uh?



it is about a lot more than quackery  It is about the scientific method in general. and in particular about how often it is misunderstood by journalists.  Abuse of evidence by the pharmaceutical industry is treated just as harshly as abuse of evidence by homeopaths and you get the low-down on both.

Buy it here.

“More importantly, you will also see how a health myth can be created, fostered and maintained by the alternative medicine industry using all the same tricks on you, the public, which big pharma uses on doctors. This is about something much bigger than homeopathy.” (p.28)

Sir Iain Chalmers, a founder of the Cochrane Collaboration , co-author of the best lay text on evidence says: “Bad Science introduces the basic scientific principles to help everyone become a more effective bullshit detector”.  And there is no more invaluable skill than being a bullshit detector.

Chalmers says also “Ben Goldacre has succeeded where the ‘public engagement in science’ organisations have so signally failed.” That is exactly right. ‘Public engagement’ has rapidly become bureaucratised, and at its worst, is no better than a branch of the university’s marketing department.  This sort of public engagement corrupts as much as it enlightens. Goldacre enlightens, and he also makes you laugh.

In the introduction, Goldacre says

“You cannot reason people out of positions that they didn’t reason themselves into.” (p xii)

It’s a nice point, but the rest of the book makes a magnificent attempt to do just that.

There is quite a lot about medicine, of course, that’s his job, after all.  But it isn’t all quackery by a long chalk  Quackery is merely a good hook to hang the arguments on about how you distinguish what’s true from what isn’t.  That’s partly because quacks make every mistake known to mankind (sometimes through ignorance, sometimes just to boost  sales), and partly just because it is a topic that interests people, and with which they are bombarded every day   I  feel exactly the same.  If I were to talk about the statistics of single ion channels, nobody would read it (big mistake -it’s fascinating), but if one can use the case of honey versus cough medicine to explain the analysis of variance, there is a chance that someone might find it interesting.

As much as anything, Goldacre’s book is about C.P. Snow’s two cultures.  The chapters on the distortion and trivialisation of science in the media are just terrific.

“My basic hypothesis is this: the people who run the media are humanities graduates with little understanding of science, who wear their ignorance as a badge of honour.  Secretly, deep down, perhaps they resent the fact that they have denied themselves access to the most significant  developments in the history of Western thought from the past two hundred years.” Chapter 11, p. 207

“.. . . here is the information I would like from a newspaper to help me make decisions about my health, when reporting on a risk: I want to know who you’re talking about (e.g. men in their fifties): I want to know what the baseline risk is (e.g. four men out of a hundred  will have a heart attack over ten years);  and I want to know what the increase in risk is , as a natural frequency [not as relative risk] (two extra men out of that hundred will have a heart attack over ten years). I also want to know exactly what’s causing that increase in risk -an occasional headache pill or a daily tub full of pain-relieving medication for arthritis.  Then I will consider reading your newspapers again, instead of blogs which are written by people who understand research , and which link reliably back to the original academic paper, so that I can double check their précis when I wish. ” (p. 242)

I detect some ambiguity in references to things that aren’t true. Sometimes there is magnanimity.   At other times he is a grade one kick-ass ninja. For example

I can very happily view posh cosmetics -and other forms of quackery -as a special,  self-administered, voluntary tax on people who don’t understand science properly (p. 26)

Of course nobody wants to ban cosmetics, or even homeopathy.  But a lot of bad consequences flow from  being over-tolerant of lies if you take it too far (he doesn’t).  The lying dilemma and the training dilemma are among them. Some unthinking doctors will refer troublesome patients to a reflexologist.  That gets the worried-well out of their surgery but neglects the inevitable consequence that Human Resources box-ticking zombies will then insist on having  courses that teach the big toe is connected to the kidney (or whatever) so that reflexologists can have an official qualification in mystical mumbo-jumbo.

Is there anything missing from the book?  Well inevitably.  There are plenty of villains among the peddlers of nutri-bollocks, and in the media.   But there isn’t much about the people who seem to me to be in some ways even worse.  What about the black-suited men and women in the Ministry of Health and in some vice-chancellors’ chairs who betray their institutions and betray the public through some unfathomable
mixture of political correctness, scientific ignorance and greed?   What about the ludicrous behaviour of quangos like Skills for Health? You have to wait right to the end of the book to hear about universities. But when it comes, it is well worth the wait.

“I’m not surprised that there are people with odd ideas about medicine, or that they sell those ideas. But I am spectacularly, supremely, incandescently unimpressed when a a university starts to offer BSc science courses in them.” (p. 317)

It’s almost worth buying Ben Goldacre’s book for that sentence alone.

This book is a romp through the folly, greed and above all the ignorance of much in our society.  It’s deeply educational.  And it makes you laugh.  What more could you want?

Jump to follow-up

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].

In the current issue (5 September 2008) Gilbey, Ernst and I responded.{download Gilbey response] [download Ernst response].

Here’s mine. The printed version differs in minor ways [download pdf]

I’m grateful for the opportunity to reply to the defences of chiropractic from Kelly1, Roughan2 and Bale3 in your last issue.

I’d like first to deal with the minor matter of titles, before getting on to the more important question of  vidence. I notice that Brian Kelly signs his letter “Dr Brian Kelly B App Sci (Chiro)” in his letter to NZMJ. He seems to be a bit less careful in his use of titles on his own school’s web site where his president’s welcome4 is signed simply “Dr Brian Kelly”, a title he adopts in at least three other places. Karl Bale3 (CEO/Registrar, Chiropractic Board New Zealand) points out that “Failure to qualify the use of the title ‘Doctor’ may contravene the provisions of the Medical Practitioners Act 1995”. One wonders whether Bale has done anything to stop Kelly’s apparent breaches of this rule?

This example makes on wonder whether the Chiropractic Board take its responsibilities seriously? It seems often to be the case that ‘voluntary self-regulation’ doesn’t work, because there are too many vested interests. Karl Bale points out that some ruthless sales methods characteristic of chiropractic are also contrary to the Chiropractic Board’s code of ethics. One would hope their well-known antipathy to vaccination and to medicine as a whole were also considered unethical. These practices seem to continue so the the code of ethics
seems not to be enforced. Much the same is true in other forms of alternative medicine too5.

It seems to me quite remarkable that none of the letters mentions the ‘subluxation’ that lies at the heart of their subject6. Could that be because they are reluctant to admit openly that it is a mere metaphysical concept, that no one can see or define? It is sad that so many patients are subjected to X-rays in search of this  phantom idea. It is this metaphysical nature of chiropractic that separates it quite clearly from science.

Brian Kelly says “How can any reader take seriously, anything suggested by a writer who opines that a 19th Century journalist possessed superior “intellectual standards” to “the UK’s Department of Health” and “several university vice chancellors”. The views of the Davenport Leader on chiropractic were mild compared with those of the great H.L. Mencken (1924)7 who wrote “This preposterous quackery flourishes lushly in the back reaches of the Republic, and begins to conquer the less civilized folk of the big cities….” The problem is that the Department of Health is full of arts graduates who may be very good at classics but can’t understand the nature of evidence. And the UK has one vice-chancellor, a geomorphologist, who defends a course in his university that teaches that “amethysts emit high yin energy”8 I’ll admit, though, that perhaps ‘intellect’ is not what’s deficient in this case, but rather honesty.

Your correspondents seem to confuse the duration of a course with its intellectual content. You can study homeopathy for years too, but after all that they are still treating sick people with medicines that contain no medicine. Anyone who works in a university knows that you can easily get accreditation for anything whatsoever if you choose the right people to sit on the committee. I have seen only too many of these worthless pieces of paper. “Amethysts emit high yin energy”8 was part of an accredited course (at the University of Westminster) too. Need I say more?

Now to the real heart of the problem, namely the question of evidence. Brian Kelly says that the book by Singh and Ernst9 shows “extreme bias”, but what that book actually shows is an extremely scrupulous regard for evidence, Ernst is in a better position to do this than just about anyone else. He has qualified and practised both regular and alternative medicine, and he was appointed to his present position, as professor of complementary and alternative medicine to assess the evidence. Perhaps most importantly of all, his position allows him to do that assessment with complete lack of bias because, unlike Kelly, his livelihood does not depend on any particular outcome of the assessment. I’m afraid that what Kelly describes as “extreme bias” is simply a display of pique because it has turned out that when all the evidence is examined dispassionately, the outcome is not what chiropractors hoped.

The fact of the matter is that when you look at all of the evidence, as Singh & Ernst do, it is perfectly clear that chiropractic is at best no better than conventional treatments even for back pain. For all other conditions its benefits fail to outweigh its risks – contrary to the many claims by chiropractors. Both the New Zealand and the UK governments have got themselves into an impossible position by giving official recognition to chiropractic before the evidence was in. Since the conventional manipulative treatments are cheaper, and may be well be safer, and because they involve no quasi-religious ideas like “subluxation” or “innate intelligence”, the only reasonable conclusion is that there is no need for chiropractic to exist at all. They do nothing they do that could not be done as well by medical practitioners and physiotherapists. What will governments do about that, I wonder?

David Colquhoun

1. Kelly, B. New Zealand College of Chiropractic response to
“Dr Who?” editorial.
NZMJ 22 August 2008, Vol 121 No 1280

2. Roughan, S. Setting the record straight: New Zealand Chiropractors’ Association response letter. NZMJ 22
August 2008, Vol 121 No 1280

3. Bale,
K. Chiropractic Board New Zealand response to “Dr Who?” editorial.
NZMJ 22
August 2008, Vol 121 No 1280.

4. http://www.nzchiro.co.nz/about_president.php

5. http://dcscience.net/?p=24

6. http://www.chirobase.org/01General/chirosub.html

7. http://www.geocities.com/healthbase/mencken_chiro.html

8. http://dcscience.net/?p=227

9. Singh S, Ernst E. Trick or Treatment. Bantam Press; 2008

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.

The case report is here.

The Advertising Standards Authority has had a bit to say about chiropractors too.


Jump to follow-up

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)


Jump to follow-up

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.

Jump to follow-up

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.

You can download the movie here [15.8 Mb, wmv file].

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
Avogadro
(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

URL: http://www.nzma.org.nz/journal/121-1278/3158/ ©NZMA

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.

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.

CAM, Cumming | Trick or Treatment | Snake Oil Science |
Testing treatments | Suckers | Healing, Hype or Harm

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

A report has appeared on Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine. The report is written by people all of whom have vested interests in spreading quackery. It shows an execrable ability to assess evidence, and it advocates degrees in antiscience It would fail any examination. Sorry, Prof Pittilo, but it’s gamma minus.[Download the report]

Alice Miles put it well in The Times, today.

“This week came the publication of the “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”. Otherwise known as twaddle.” . . .

“Regulate the practitioners – for safety, note, not for efficacy, as that is impossible to prove – and you give them official recognition. From recognition it is but a short hop to demand and then prescription: packet of Prozac, bit of yoga and a bag of dodgy herbs for you, sir.” . . .

“The Government responded on Monday – with a three-month consultation. So join in. Write to the Health Minister Ben Bradshaw at Richmond House, 79 Whitehall, SW1A 2NS. Write, on behalf of the NHS: “What I want for my 60th birthday is… the chance to provide medical, dental, and nursing care to all. And absolutely nothing else.”

Judging by Ben Bradshaw’s speech to the Prince’s Foundation, there may be a problem in conveying to him the evidence, but one can and must try.

Why is it that a health joutnalist can do so much better than a university head? Yes, the chair of the steering group is Professor R. Michael Pittilo BSc PhD CBiol FIBiol FIBMS FRSH FLS FRSA, Principal and Vice-Chancellor of The Robert Gordon University, Aberdeen. Despite all those impressive-lookin initials after his name, I believe that this is a very bad report.

Here is something about Prof Pittilo from his university’s web site (the emphasis is mine).

Professor Michael Pittilo joined The Robert Gordon University, Aberdeen, as Principal and Vice-Chancellor on 5th September, 2005.

After postdoctoral research on arterial disease at the University of London, he was appointed to Kingston University where he became Head of Life Sciences. In 1995 he became Foundation Dean of the Faculty of Health and Social Care Sciences at Kingston University and St George’s Medical School (University of London). He was appointed Pro Vice Chancellor at the University of Hertfordshire in 2001.

Professor Pittilo has held a number of additional roles, including chairing Department of Health working groups, and as a trustee for the Prince of Wales’s Foundation for Integrated Health.

Notice that Prof Pittilo is a Trustee of the Prince’s Foundation for Integrated Health, source of some of the least reliable information about alternative medicine to be found anywhere.

This steering group is, as so often, a nest of vested interests. It does not seem to have on it any regular medical or clinical scientist whatsoever. Why not? They just might produce some embarrassing facts perhaps? Like most government committees its members seem to have been chosen to produce the desired outcome.

For a start, the university run by Prof Pittilo, Robert Gordon’s University, is itself involved in a few antiscientific courses. Since his report recommends that degrees in quackery should become mandatory, I expect he’d welcome the chance to run more. Amazingly, Robert Gordon’s University runs an Introduction to Homeopathy, just about the daftest of all the common sorts of magic medicine.

Most of the the members of the steering group represent vested interests, though strangely this is not made clear in the list of members. An earlier report, in 2006, from the steering group was more open about this. Twelve of the members of the group represent Herbal Medicine, Chinese Medicine and Acupuncture (four from each). Most of the rest are lay members or bureaucrats. With membership like that it is, I suppose, not surprising that the assessment of evidence is, to put it kindly, grossly distorted and woefully inadequate.

The report starts badly by failing to mention that the House of Lords report (2000), and the government’s response to it, set the following priorities. Both state clearly

“… we recommend that three important questions should be addressed in the following order . .

  • (1) does the treatment offer therapeutic benefits greater than placebo?
  • (2) is the treatment safe?
  • (3) how does it compare, in medical outcome and cost-effectiveness, with other forms of treatment?

The word ‘placebo’ does not occur a single time in the main report (and only twice in the text of the seven appendices). But they do say (page 11):

“We recommend that public funding from the NHS should be used to fund CAM therapies where there is evidence of efficacy, safety and quality assurance.”

The evidence

The problem is that the assessment of the evidence for efficacy in the report is pathetically poor. The report, sad to say, consists essentially of 161 pages of special pleading by the alternative medicine industry, served up with the usual large dose of HR gobbledygook.

There is really no excuse for this utterly incompetent assessment. There have been plenty of books this year alone that make excellent summaries of the evidence, mostly written for the lay public. They should, therefore, be understandable by any university vice-chancellor (president). The one benefit of the upsurge in public interest in magic medicine is that there are now quite a lot of good clinical trials, and when the trials are done properly, they mostly confirm what we thought before: in most cases the effects are no more than placebo.

Here is one example. Annexe1 concerns “Developing Research and Providing an Evidence Base for Acupuncture and Herbal/Traditional Medicine Treatment”. The wording of the title itself suggests, rightly, that this evidence base does not exist, in which case why on earth are we talking about them as “professions”? The discussion of the evidence in Annexe 1 is nothing if not partial. But what do you expect if you ask herbalists to assess herbal medicine? An honest assessment would put them out of business. The eternal mantra of the alternative industry appears as usual, “Absence of evidence is, of course, not evidence of absence”. True of course, but utterly irrelevant. Annexe 1 says

“Acupuncture is a complex intervention and lack of a suitable placebo control has hindered efforts to evaluate efficacy”

This is simply untrue, In recent years enormous efforts have been put into devising controls for assessment of acupuncture, but they are entirely ignored here. One thing that has been established quite clearly is that it makes no difference where you put the needles, so all the talk of Qi and meridians is obvious mumbo-jumbo.

Have the authors of Annexe 1, and Professor Pittilo, not read the relevant studies? Two books this year have dealt with the question of evidence with great care. They are both by people who have been involved personally with acupuncture research, Prof Edzard Ernst and Dr Barker Bausell. 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.

Singh and Ernst discuss thoroughly the question of controls and assess all the evidence carefully. Their conclusions include the following.

  • The traditional principles of acupuncture are deeply flawed, as there is no evidence at all to demonstrate the existence of Ch’i [Qi] or meridians.
  • By focussing on the increasing number of high-quality research papers, reliable conclusions from systematic reviews make it clear that acupuncture does not work for a whole range of conditions, except as a placebo.
  • In short, the evidence is neither consistent nor convincing. It is borderline.

Barker Bausell was himself involved in designing and analysing trialsof acupuncture. His conclusions are even less positive.

“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”.

These are serious authors with direct experience in CAM research, which is more than can be said of anyone on the steering group. Why are their conclusions ignored entirely? That is sheer incompetence.

Degrees in anti-science

One conclusion of the report is that

“The threshold entry route to the register will normally be through a Bachelor degree with Honours”

This is utter nonsense. It is quite obvious surely that you can’t award honours degrees until after you have the evidence. You can read on page 55 of the report

3a: Registrant acupuncturists must:

understand the following aspects and concepts for traditional East-Asian acupuncture:

– yin/yang, /5 elements/phases, eight principles, cyclical rhythms, qi ,blood and body fluids, different levels of qi, pathogenic factors, 12 zang fu and 6 extraordinary fu, jing luo/ meridians, the major acupuncture points, East-Asian medicine disease categorisation, the three burners, the 4 stages/levels and 6 divisions

– causes of disharmony/disease causation

– the four traditional diagnostic methods: questioning, palpation, listening and observing”

This is utter baloney. Anyone who advocates giving honours degrees in such nonsense deserves to be fired for bringing his university into disrepute (and, in the process, bringing all universities and science itself into disrepute).

That includes also degrees that teach that “amethysts emit high yin energy“.

So what should be done?

If making peole do degrees in mumbo-jumbo is not the answer, what is? Clearly it would be far too draconian to try to ban quackery (and it would only increase its popularity anyway).

The answer seems to me to be quite simple. All that needs to done is to enforce existing laws. It is already illegal to sell contaminated and poisonous goods to the public. It is already illegal to make fraudulent advertisemants and to sell goods that are not as described on the label.

The only problem is that the agencies that enforce these rules are toothless and that there are a lot of loopholes and exceptions that work in favour of quackery. I have tried myself to complain about mislabelling of homeopathic pills to the Office of Fair Trading on the grounds that are labelled Arnica 30C but contain no Arnica. They solemnly bought a bottle and sent it to an analyst and of course they found no arnica, But nothing happened, because an exception to the usual law applies to homeopathic pills.

The Advertising Standards Authority is good as far as it goes. They quickly told Boots Pharmacies to withdraw advertisements that claimed CoQ10 “increased vitality”. But they can exact no penalties and they can’t deal with lies that are told to you orally, or with anything at all on the web.

The Health Professions Council (HPC) says that one of the criteria for registering new professions is aspirant groups must “Practise based on evidence of efficacy”. If that were actually applied, none of this process would occur anyway. No doubt the HPC will fail to apply its own criteria. On past form, it can be expected to adopt a “fluid concept of evidence“.,

One more thing, New European legislation was described recently in the BMJ

“Consumers in the United Kingdom are to receive stronger legal safeguards against products that claim, without any identifiable scientific evidence, to provide physical and mental health benefits such as tackling obesity or depression.”

“The scope of the legislation is deliberately wide and is the biggest shake up in consumer law for decades. It targets any unfair selling to consumers by any business.”

Politicians seem to be immune to rational argument when it comes to quackery. But a few legal actions under these laws could bring the house of cards tumbling so fast that this gamma-minus report would become rapidly irrelevant. There will be no shortage of people to bring the actions. I can’t wait.

Follow up

Dominic Lawson, 24 June 2008. An excellent column appeared today in the Independent. Dominic Lawson writes about the Pittilo report: “So now we will have degrees in quackery. What, really, is the difference between acupuncture and psychic surgery?“. The reference to that well known conjuring trick, “psychic surgery” as a “profession”, revealed here, causes Lawson to say

“It makes it clear that the lunatics have taken over the asylum. For a start, how could Philip Hunt, previously director of the National Association of Health Authorities and Trusts, possibly have thought that “psychic healing” constituted a “profession” – let alone one which would “develop its own system of voluntary self-regulation?”

“One can see how this might fit in with the Government’s “never mind the quality, feel the width” approach to university education. One can also see how established practitioners of such therapies might see this as a future source of income – how pleasant it might be to become Visiting Professor of Vibrational Medicine at the University of Westminster.

Thus garlanded with the laurels of academic pseudo-science, the newly professionalised practitioners of “alternative medicine” can look down on such riff-raff as the “psychic surgeons”

Once again I have to ask, how is it that we have to rely on journalists to prevent vice-chancellors eroding academic standards; indeed eroding simple common sense? I guess it is just another sign of the delusional thinking engendered by the culture of managerialism that grips universities.

Jump to follow up

We have often had cause to criticise Boots Alliance, the biggest retail pharmacist in the UK, because of its deeply unethical approach to junk medicine. Click here to read the shameful litany. The problem of Boots was raised recently also by Edzard Ernst at the Hay Literary Festival. He said

“The population at large trusts Boots more than any other pharmacy, but when you look behind the smokescreen, when it comes to alternative medicines, that trust is not justified.”

Ernst accused Boots of breaching ethical guidelines drawn up by the Royal Pharmaceutical Society of Great Britain, by failing to tell customers that its homeopathic medicines contain no active ingredients and are ineffective in clinical trials.

Another chain, Lloyds Pharmacy, are just as bad. Many smaller pharmacies are no more honest when it comes to selling medicines that are known to be ineffective.

Pharmacists are fond of referring to themselves as “professionals” who are regulated by a professional body, the Royal Pharmaceutical Society of Great Britain (RPSGB). It’s natural to ask where their regulatory body stands on the question of junk medicine. So I asked them, and this is what I found.

17 April, 2008

I am writing an article about the role of pharmacists in giving advice about (a) alternative medicines and (b) nutritional supplements.

I can find no clear statements about these topics on the RPSGB web site.

Please can you give me a statement on the position of the Royal Pharmaceutical Society on these two topics.

In particular, have you offered guidance to pharmacists about how to deal with the conflict of interest that arises when they can make money by selling something that they know to have no good evidence for efficacy? This question has had some publicity recently in connection with Boots’ promotion of CCoQ10 to give you “energy”, and only yesterday when the bad effects of some nutritional supplements were in the news.

Here are some extracts from the first reply that I got from the RPSGB’s Legal and Ethical Advisory Service (emphasis is mine).

28 April 2008

Pharmacists must comply with the Code of Ethics and its supporting documents. Principle 5 of the Code of Ethics requires pharmacists to develop their professional knowledge and competence whilst Principle 6 requires pharmacists to be honest and trustworthy.

The Code states:

5. DEVELOP YOUR PROFESSIONAL KNOWLEDGE AND COMPETENCE

At all stages of your professional working life you must ensure that your knowledge, skills and performance are of a high quality, up to date and relevant to your field of practice. You must:

5.1 Maintain and improve the quality of your work by keeping your knowledge and skills up to date, evidence-based and relevant to your role and responsibilities.

5.2 Apply your knowledge and skills appropriately to your professional responsibilities.

5.3 Recognise the limits of your professional competence; practise only in those areas in which you are competent to do so and refer to others where necessary.

5.4 Undertake and maintain up-to-date evidence of continuing professional development relevant to your field of practice.

6. BE HONEST AND TRUSTWORTHY

Patients, colleagues and the public at large place their trust in you as a pharmacy professional. You must behave in a way that justifies this trust and maintains the reputation of your profession. You must:
6.1 Uphold public trust and confidence in your profession by acting with honesty and integrity.

6.2 Ensure you do not abuse your professional position or exploit the vulnerability or lack of knowledge of others.

6.3 Avoid conflicts of interest and declare any personal or professional interests to those who may be affected. Do not ask for or accept gifts, inducements, hospitality or referrals that may affect, or be perceived to affect, your professional judgement.

6.4 Be accurate and impartial when teaching others and when providing or publishing information to ensure that you do not mislead others or make claims that cannot be justified.

And, on over-the counter prescribing

In addition the “Professional Standards and Guidance for the Sale and Supply of Medicines” document which supports the Code of Ethics states:

“2. SUPPLY OF OVER THE COUNTER (OTC) MEDICINES

STANDARDS

When purchasing medicines from pharmacies patients expect to be provided with high quality, relevant information in a manner they can easily understand. You must ensure that:

2.1 procedures for sales of OTC medicines enable intervention and professional advice to be given whenever this can assist the safe and effective use of medicines. Pharmacy medicines must not be accessible to the public by self-selection.

Evidence-based? Accurate and impartial? High quality information? Effective use?

These words don’t seem to accord with Boots’ mendacious advertisements for CoQ10 (which were condemned by the ASA).

Neither does it accord with the appalling advice that I got from a Boots pharmacist about Vitamin B for vitality.

Or their bad advice on childhood diarrhoea.

Or the unspeakable nonsense of the Boots (mis)-education web site.

Then we get to the nub. This is what I was told by the RPSGB about alternative medicine (the emphasis is mine).

8. COMPLEMENTARY THERAPIES AND MEDICINES

STANDARDS

You must ensure that you are competent in any area in which you offer advice on treatment or medicines. If you sell or supply homoeopathic or herbal medicines, or other complementary therapies, you must:

8.1 assist patients in making informed decisions by providing them with necessary and relevant information.

8.2 ensure any stock is obtained from a reputable source.

8.3 recommend a remedy only where you can be satisfied of its safety and quality, taking into account the Medicines and Healthcare products Regulatory Agency registration schemes for homoeopathic and herbal remedies.”

Therefore pharmacists are required to keep their knowledge and skills up to date and provide accurate and impartial information to ensure that you do not mislead others or make claims that cannot be justified.

It does seem very odd that “accurate and impartial information” about homeopathic pills does not include mentioning that they contain no trace of the ingredient on the label. and have been shown in clinical trials to be ineffective. These rather important bits of information are missing from both advertisements and from (in my experience) the advice given by pharmacists in the shop.

If you look carefully, though, the wording is a bit sneaky. Referring to over-the-counter medicines, the code refers to “safe and effective use of medicines”, but when it comes to alternative medicines, all mention of ‘effectiveness’ has mysteriously vanished.

So I wrote again to get clarification.

29 April, 2008

Thanks for that information. I’d appreciate clarification of two matters in what you sent.

(1) Apropros of complementary and alternative medicine, the code says

8.3 recommend a remedy only where you can be satisfied of its safety and quality

I notice that this paragraph mentions safety and quality but does not mention efficacy. Does this mean that it is considered ethical to recommend a medicine when there is no evidence of its efficacy? Apparently it does. This gets to the heart of my question and I’d appreciate a clear answer.

This enquiry was followed by a long silence. Despite several reminders by email and by telephone nothing happened until eventually got a phone call over a month later (May 3) from David Pruce, Director of Practice & Quality Improvement, Royal Pharmaceutical Society of Great Britain. The question may be simple, but the RPSGB evidently it hard, or more likely embarrassing, to answer.

When I asked Pruce why para 8.3 does not mention effectiveness, his reply, after some circumlocution, was as follows.

Pruce: “You must assist patients in making informed decisions by providing necessary and relevant information . . . we would apply this to any medicine, the pharmacist needs to help the patient assess the risks and benefits.”

DC: “and would that include saying it doesn’t work better than placebo?”

Pruce “if there is good evidence to show that it ???????? ????? ????????may, but it depends on what the evidence is, what the level of evidence is, and the pharmacist’s assessment of the evidence”

DC “What’s your assessment of the evidence?”

Pruce, “I don’t think my personal assessment is relevant. I wouldn’t want to be drawn on my personal assessment”. “If a pharmacist is selling homeopathic medicines they have to assist the patient in making informed decisions”

“I don’t think we specifically talk about the efficacy of any other medicine” [DC: not true, see para 2.1, above]

We would expect pharmacists to be making sure that what they are providing to a patient is safe and efficacious

DC “So why doesn’t it mention efficacious in para 8.3”

Pruce “What we are trying to do with the Code of Ethics is not go down to the nth degree of detail ” . . . “there are large areas of medicine where there is an absence of data”

DC “Yes, actually homeopathy isn’t one of them. It used to be.”

Pruce. “uh, that’s again a debatable point”

DC I don’t think it’s debatable at all, if you’ve read the literature

Pruce. “well many people would debate that point” “This [homeopathy] is a controversial area where opinions are divided on it”

DC “Not informed opinions”

Pruce “Well . . . there are also a large number of people that do believe in it. We haven’t come out with a categorical statement either way.”

I came away from this deeply unsatisfactory conversation with a strong impression that the RPSGB’s Director of Practice & Quality Improvement was either not familiar with the evidence, or had been told not to say anything about it, in the absence of any official statement about alternative medicine.

I do hope that the RPSGB does not really believe that “there are also a large number of people that do believe in it” constitutes any sort of evidence.

It is high time that the RPSGB followed its own code of ethics and required, as it does for over-the-counter sales, that accurate advice should be given about “the safe and effective use of medicines”.

“The scientist on the High Street”

The RPS publishes a series of factsheets for their “Scientist in the High Street” campaign. One of these “factsheets” concerns homeopathy, [download pdf from the RPSGB]. Perhaps we can get an answer there?

Well not much. For the most part the “factsheet” just mouths the vacuous gobbledygook of homeopaths. It does recover a bit towards the end, when it says

“The methodologically “best” trials showed no effect greater than that of placebo”.

But there is no hint that this means pharmacists should not be selling homeopathic pills to sick people..

That is perhaps not surprising, because the Science Committee of the RPSGB copped out of their responsibility by getting the factsheet written by a Glasgow veterinary homeopath, Steven Kayne. You can judge his critical attitude by a paper (Isbell & Kayne, 1997) which asks whether the idea that shaking a solution increases its potency. The paper is a masterpiece of prevarication, it quotes only homeopaths and fails to come to the obvious conclusion. And it is the same Steven Kayne who wrote in Health and Homeopathy (2001)

“Homeopathy is not very good for treating bacterial infections directly, apart from cystitis that often responds to a number of medicines, including Berberis or Cantharis”.

So there is a bacterial infection that can be cured by pills that contain no medicine? Is this dangerous nonsense what the RPSGB really believes?

More unreliable advice

While waiting for the train to Cardiff on April 16th (to give a seminar at the Welsh School of Pharmacy), I amused myself by dropping into the Boots store on Paddington station.

DC I’ve seen your advertisements for CoQ10. Can you tell me more? Will they really make me more energetic?

Boots: Yes they will, but you may have to take them for several weeks.

DC. Several weeks? Boots: yes the effect develops only slowly

Peers at the label and reads it out to me

DC I see. Can you tell me whether there have been any trials that show it works?

Boots. I don’t know. I’d have to ask. But there must be or they wouldn’t be allowed to sell it.

DC. Actually there are no trials, you know

Boots. Really? I didn’t think that was allowed. But people have told me that they feel better after taking it.

DC You are a pharmacist?

Boots. Yes

Sadly, this abysmal performance is only too typical in my experience, Try it yourself.

The malaria question

After it was revealed that pharmacists were recommending, or tolerating recommendations, of homeopathic treatment of malaria, the RPSGB did, at last. speak out. It was this episode that caused Quackometer to write his now famous piece on ‘The gentle art of homeopathic killing‘ (it shot to fame when the Society of Homeopaths tried to take legal action to ban it) Recommending pills that contain no medicine for the treatment or prevention or treatment of malaria is dangerous. If it is not criminal it ought to be [watch the Neals Yard video]. .

The RPSGB says it is investigating the role of pharmacists in the Newsnight sting (see the follow-up here). That was in July 2006, but they are stlll unwilling to say if any action will be taken. Anyone want to bet that it will be swept under the carpet?

The statement issued by the RPSGB, 5 months after the malaria sting is just about the only example that I can find of them speaking out against dangerous and fraudulent homeopathic practices. Even in this case, it is pretty mild and restricted narrowly to malaria prevention.

The RPSGB and the Quacktioner Royal

The RPSGB submitted a response to the ‘consultation’ held by the Prince’s Foundation for Integrated Health, about their Complementary Healthcare; a guide for patients.

Response by the Royal Pharmaceutical Society of Great Britain
Dr John Clements, Science Secretary

“We believe that more emphasis should be given to the need for members of the public who are purchasing products (as opposed to services) to ask for advice about the product. Pharmacists are trained as experts on medicines and the public, when making purchases in pharmacies, would expect to seek advice from pharmacists”

So plenty of puffery for the role of pharmacists. But there is not a word of criticism about the many barmy treatments that are included in the “Guide for Patients”. Not just homeopathy and herbalism, but also Craniosacral therapy, Laying on of Hands, chiropractic, Reiki, Shiatsu –every form of barminess under the sun drew no comment from the RPS.

I can’t see how a response like this is consistent with the RPS’s own code of ethics.

A recent president of the RPSGB was a homeopath

Christine Glover provides perhaps the most dramatic reason of all for thinking thst, despite all the fine words, the RPSGB cares little for evidence and truth The NHS Blogdoctor published “Letter from an angry pharmacist”.

Mrs Glover was president of the RPSGB from 1999 to 2001, vice-president in 1997-98, and a member of the RPSGB Council until May 2005. She is not just a member, but a Fellow. (Oddly, her own web site says President from 1998 – 2001.)

So it is relevant to ask how the RPSGB’s own ex-president obeys their code of ethics. Here are some examples on how Ms Glover helps to assist the safe and effective use of medicines. . Much of her own web site seems to have vanished (I wonder why) so I’ll have to quote the “Letter from an angry pharmacist”., as revealed by NHS Blogdoctor,

“What has Christine got to offer?

  • “We offer a wide range of Homeopathic remedies (over 3000 different remedies and potencies) as well as Bach flower remedies, Vitamins, Supplements, some herbal products and Essential Oils.”
  • Jetlag Tablets highly recommended in ‘Wanderlust’ travel magazine. Suitable for all ages.
  • Wind Remedy useful for wind particularly in babies. In can be supplied in powder form for very small babies. Granules or as liquid potency.
  • Udder Care 100ml £80.00 One capful in sprayer filled with water. Two jets to be squirted on inner vulva twice daily for up to 4 days until clots reduced. Discard remainder. Same dose for high cell-counting cows detected.

Udder Care? Oh! I forgot to say, “Glover’s Integrated Healthcare” does cows as well as people. Dr Crippen would not suggest to a woman with sore breasts that she sprayed something on her inner vulva. But women are women and cows are cows and Dr Crippen is not an expert on bovine anatomy and physiology. But, were he a farmer, he would need some persuasion to spend £80.00 on 100 mls of a liquid to squirt on a cow’s vulva. Sorry, inner vulva.”

Nothing shows more clearly that the RPSGB will tolerate almost any quackery than the fact that they think Glover is an appropriate person to be president. Every item on the quotation above seems to me to be in flagrant breach of the RPSGB’s Code of Ethics. Just like the Society of Homeopaths, the code seems to be there merely for show, at least in the case of advice about junk medicine..

A greater role for pharmacists?

This problem has become more important now that the government proposes to give pharmacists a greater role in prescribing. Needless to say the RPSGB is gloating about their proposed new role. Other people are much less sure it is anything but a money–saving gimmick and crypto-privatisation.

I have known pharmacists who have a detailed knowledge of the actions of drugs, and I have met many more who haven’t. The main objection, though, is that pharmacists have a direct financial interest in their prescribing. Conflicts of interest are already rife in medicine, and we can’t afford them.

Conclusion

The Royal Pharmaceutical Society is desperately evasive about a matter that is central to their very existence, giving good advice to patients about which medicines work and which don’t. Pharmacists should be in the front line in education of the public, about medicines, the ‘scientist on the High Street’. Some of them are, but their professional organisation is letting them down badly.

Until such time as the RPSGB decides to take notice of evidence, and clears up some of the things described here, it is hard to see how they can earn the respect of pharmacists, or of anyone else.

Follow-up

Stavros Isaiadis’ blog, Burning Mind, has done a good piece on “More on Quack Medicine in High Street Shops“.

The Chemist and Druggist reports that the RPSGB is worried about the marketing of placebo pills (‘obecalp’ -geddit?). It does seem very odd that the RPSGB should condemn honest placebos, but be so very tolerant about dishonest placebos. You couldn’t make it up.

A complaint to the RPSGB is rejected

Just to see what happened, I made a complaint to thr RPSGB about branches of their own Code of Ethics at Boots in Hexham and in Evesham. Both of them supported Homeopathy Awareness Week These events had been publicised in those particularly unpleasent local ‘newspapers’ that carry paid advertising disguised as editorial material. In this case it was the Evesham Journal and the Hexham Courant.

Guess what? The RPSGB replied thus

“Your complaint has been reviewed bt Mrs Jill Williams and Mr David Slater who are both Regional Lead Inspectors. Having carried out a review they have concluded that support of homeopathic awareness week does not constitute a breach of the Society’s Code of Ethics or Professional Standards.”

In case you have forgotten, the Professional Standards say

2.1 procedures for sales of OTC medicines enable intervention and professional advice to be given whenever this can assist the safe and effective use of medicines.

The RPSGB has some very quaint ideas on how to interpret their own code of ethics