The General Pharmaceutical Council (GPhC) has been the statutory body responsible for the regulation of pharmacy since 2010. It’s status is similar to that of the GMC and. heaven help us, the GCC. Before that the regulator was the same as the professional body, the Royal Pharmaceutical Society of Great Britain (RPS). The RPS proved to be as useless as most other regulators, as documented in detail in my 2008 post, At around the time it stopped being a regulator, the RPS started to condemn quackery more effectively, but by then it had lost the power to do much about it (I hope the latter wasn’t the cause of the former). The body that could do something, the GPhC has done essentially nothing. as described in this post.
I did a 2 year apprenticeship in Timothy White’s and Taylor’s Homeopathic (yes, really) Chemists in the 1950s.
My first degree was in pharmacy. I got my interest in pharmacology from reading Martindale’s Extra Pharmacopoeia in the shop. I soon decided that I didn’t really want to spend the rest of my life selling lipstick and Durex. The latter was quite a big seller because the Boots across the road didn’t sell contraceptives (they changed their minds in the 1960s).
In those days, we spent quite a lot of time making up (almost entirely ineffective) ‘tonics’ and ‘cough mixtures’. Now the job consists largely of counting pills. This has exacerbated the ‘chip on the shoulder’ attitude that was present even in the 1950s. For a long time now, pharmacists have wanted to become the a ‘third tier’ in the NHS, alongside GP practices and hospitals., after hospitals and doctors". . Here are a few comments on this proposition.
First let me say that I’ve met some very good and ethical pharmacists. I did a vacation job in a hospital pharmacy where the boss had an encyclopaedic knowledge of the effects and side effects of drugs, and of their dosage. His advice was often sought by doctors, and rightly so. He had no way of knowing at the time that his advice to replace barbiturates with thalidomide would lead to such a tragedy, because the evidence had been concealed by the manufacturer. Some of the problems alluded to here have already been highlighted by two excellent pharmacists, Anthony Cox and @SparkleWildfire, neither of whom work in pharmacists shops. They are absolutely spot on but they seem to be in a minority among pharmacists.
The problems seem to lie mostly in retail shops. Their shelves are laden with ineffective pills and potions. And the pharmacist has every incentive to sell them. His/her income depends on it directly if it’s a privately owned pharmacy. And his/her standing with head office depends on it in chain store pharmacies. This conflict of financial interest is the prime reason why pharmacists are not qualified to form a third tier of healthcare. The avoidance of conflicts of interest among doctors was one of the great accomplishments of the NHS. In the USA there are huge scandals when, as happens repeatedly, doctors order expensive and unnecessary treatments from which they profit. It’s no consolation that such problems are creeping back in the UK as a result of the government’s vigorous efforts to sell it off.
Here are few examples of things that have gone wrong, and who is to blame. Then I’ll consider what can be done.
In any pharmacy you can see ineffective ‘tonics’ and ‘cough medicines’, unnecessary supplements with dishonest claims and even, heaven help us, the ultimate scam, homeopathic pills.
What’s worse, if you ask a pharmacist for advice, it’s quite likely that they’ll recommend you to buy them.
I was amazed to discover that a number of old-fashioned ‘tonics’ and ‘cough medicines’ still have full marketing authorisation. That’s the fault of the Medicines and Healthcare Regulatory Auhority (MHRA) who are supposed to assess efficacy and totally failed to do so, Read about that in “Some medicines that don’t work. Why doesn’t the MHRA tell us honestly?” . It’s hard to blame a pharmacist for the bad advice given by the MHRA, but a good one would tell patients to save their money.
Big corporate pharmacies
Companies like Boots seem to have no interest whatsoever in ethical behaviour. All that matters is sales. They provide “(mis)educational” materials that promote nonsense They advertise ridiculous made-up claims in the newspapers, which get shot down regularly by the Advertising Standards Authority, but by that time the promotion is over so they don’t give a damn. See for example, CoQ10 scam and the ASA verdict on it. And "Lactium: more rubbish from Boots the Chemists. And a more serious problem". And "The Vitamin B scam. Don’t trust Boots"
Recently the consumer magazine Which? checked 122 High Street pharmacies. They got unsatisfactory advice from 43% of them, a disastrously bad performance for people who want to be the third tier of healthcare.
Even that’s probably better than my own experience. Recently, when I asked a Sainsbury’s pharmacist about a herbal treatment for prostate problems, he pointed to the MHRA’s kite mark and said it must work because the MHRA approved it -he was quite unaware that you get the THR kite mark without having to present any evidence at all about efficacy.
Of course that is partly the fault of the MHRA for allowing misleading labels, but nevertheless, he should have known. See “Why does the MHRA refuse to label herbal products honestly? Kent Woods and Richard Woodfield tell me” for more on how the MHRA has betrayed its own standards.
When I’ve asked Boots’ pharmacists advice about persistent diarrhoea in an infant, saying I wanted a natural remedy, I’ve usually been guided to the homeopathic display. Only once was I told firmly that I should use rehydration not homeopathy (something every good parent knows) and when I asked that good pharmacist where she’d been educated, she said in Germany (mildly surprising given the amount of junk available in German pharmacies)
Anthony Cox, a pharmacist who has been consistently on the side of right, says
"This is something that needs to be dealt with at a regulatory and professional body by the whole profession, and I am certain we have the majority of the UK pharmacy profession on side."
But the regulator has done nothing, and it isn’t even clear that there is a majority on his side.
At a 2009 meeting of Branch Representatives of the RPS a motion was proposed:
“…registration as a pharmacist and practice as a homeopath are not compatible, and that premises registered with the Society should not be used for the promotion of homeopathy”
Although that is obviously sensible to most people, the proposal was followed by a speaker from Leicester who thought it right to keep an open mind about Avogadro’s number and the motion was defeated. So much for the "scientists on the High Street" aspiration.
There have been two major scandals surrounding homeopathy recently. Both were revealed first by bloggers, and both came to wide notice through television programs. None were noticed by the regulators, and when they were brought to the attention of the regulator, nothing effective was done.
The malaria scandal
A lot has been wriitten about this here and on other blogs e.g. here and here. The idea that sugar pills can prevent or cure malaria is so mind-bogglingly dangerous that it was condemned by the Queen’s Homeopathic Physician, Peter Fisher. It was exposed on a BBC Newsnight programme in 2006. Watch the video.
The Gentle Art of Homeopathic Killing was an article that originally appeared on the excellent Quackometer blog produced by Andy Lewis. "The Society of Homeopaths were so outraged about one of their members flouting the code of ethics so blatantly that they took immediate action. That action was, as expected, not to do anything about the ethics breach but to threaten Andy and his hosting ISP with legal action for defamation. The article is reproduced here as a public service".
Some of the people involved in this bad advice were pharmacists, Very properly they were referred to the RPS in 2006 qnd 2009, the regulator at that time. They sat on the complaint so long that eventually the RPS was replaced by the GPhC as regulator. Nothing much has happened.
The GPhC did precisely nothing. Read their pathetic response.
Homeopathy for meningitis
An equally murderous fraud, "homeopathic vaccines" by Ainsworth’s has long been targeted by bloggers. In January 2013, Samantha Smith made an excellent BBC South West programme about it. Watch it and get angry.
Anthony Pinkus, pharmacist at Ainsworths, has been referred to the then regulator, the RPS, in 2006 and 2009. It’s said that he took "remedial action", though there is little obvious change judged by the video above. No doubt some of the most incriminating stuff has been removed from his web site to hide it from the ASA. It’s safer to mislead people by word of mouth. Since the last video more complaints have been made to the GPhC. So far, nothing but silence.
Why doesn’t the regulator regulate?
This pamphlet is reproduced from the July 2011 Quackometer post, “Ainsworths Pharmacy: Casual Disregard for the Law“
It’s almost as though those royal warrants, enlarged on right, acted as a talisman that puts this dangerous company outside the grasp of regulators. I hope that the GPhC Council , and Duncan Rudkin (its chief executive and registrar), are not so worried about their knighthoods that they won’t risk upsetting the royal family, just to save patients from malaria and meningitis. Their CEO, Robert Nicholls is only a CBE so far.
Another reason for their inaction might be that the GPhC Council members, and Duncan Rudkin (its chief executive and registrar), lack critical faculties. Perhaps they have not been very well educated? Many of them aren’t even pharmacists, but that curious breed of professional administrators who inhabit the vast number of quangos, tick their boxes and do harm. Or perhaps they are just more interested in protecting the income of pharmacists than in protecting their customers?
The solution to most problems is education. But there is no real knowledge of how many pharmacists in the UK are educated in the critical assessment of evidence. A recent paper from the USA did not give cause for optimism. It’s discussed by the excellent US pharmacist, Scott Gavura, at Science-based medicine. The results are truly horrifying.
“Few students disagreed with any CAM therapy. There was the greatest support for vitamins and minerals (94%, mean 4.29) which could include the science-based use these products. But there was strong support for demonstrably ineffective treatments like acupuncture, with 64% agreeing it was acceptable. Even homeopathy, which any pharmacy student with basic medicinal chemistry skills ought to know is absurd, was supported by over 40% of students.”
If the numbers are similar in the UK, the results of the Which? magazine survey are not so surprising. And if they are held by the GPhC Council. their inaction is to be expected. We just don’t know, and perhaps someone should find out.
I suspect that sympathy for quackery may sometimes creep in through that old-fashioned discipline known as pharmacognosy. It is about the botany of medicinal plants, and it’s still taught, despite the fact that very few drugs are now extracted from plants. At times, it gets dangerously close to herbalism. For example, at the School of Pharmacy (now part of UCL) a book is used Fundamentals of Pharmacognosy and Phytotherapy by Michael Heinrich, Joanne Barnes, Simon Gibbons and Elizabeth M. Williamson, ot the Centre for Pharmacognosy and Phytotherapy at the School of Pharmacy. The introductory chapter says.
“TRADITIONAL CHINESE MEDICINE (TCM) The study of TCM is a mixture of myth and fact, stretching back well over 5000 years. At the time, none of the knowledge was written down, apart from primitive inscriptions of prayers for the sick on pieces of tortoise carapace and animal bones, so a mixture of superstition, symbolism and fact was passed down by word of mouth for centuries. TCM still contains very many remedies, which were selected by their symbolic significance rather than proven effects; however, this does not necessarily mean that they are all ‘quack’ remedies!”
Well, not necessarily. But as in most such books, there are good descriptions of the botany, more or less good accounts of the chemical constituents followed by uncritical lists of things that the herb might (or might not) do. The fact that even the US National Institutes of Health quackery branch, NCCAM, doesn’t claim that a single herbal treatment is useful tells you all you need to know.
Joanna Barnes is Associate Professor in Herbal Medicines, School of Pharmacy, University of Auckland, New Zealand. She has written a book, Herbal Medicines (“A useful book for learning holistic medicine”) that is desperately uncritical about the alleged theraputic effectiveness of plants. ("Simon Gibbons is on the editorial board of The Chinese Journal of Natural Medicine. Elizabeth Williamson is editor of the Journal of Phytotherapy Research, a journal that has a strong flavour of herbalism (take the infamous snoring remedy). These people aren’t quacks but they are dangerously tolerant of quacks.
The warning is in the title. "Phytotherapy" is the current euphemism for herbalism. It’s one of those red light words that tells you that what follows is unlikely to be critical. Exeter’s fantasy herbalist, Simon Mills, now describes himself as a phytotherapist. What more warning could you need?
Perhaps this explains why so many pharmacists are unworried by selling things that don’t work. Pharmacy education seems not to include much about the critical assessment of evidence. It should do.
Chemist and Druggist magazine certainly doesn’t help. It continually reinforces the idea that there is a debate about homepathy. There isn’t. And in one of its CPD modules Katherine Gascoigne says
"Homeopathic remedies are available, but are best prescribed by a homeopath"
Ms Gascoigne must be living on another planet.
The main conclusion from all of this is that the General Pharmaceutical Council is almost criminally negligent. It continues to allow pharmacists, Anthony Pinkus among them, to endanger lives. It fails to apply its own declared principles. The members of its Council, and Duncan Rudkin (its chief executive and registrar), are not doing their job.
Individual pharmacists vary a lot, from the superb to those who believe in quackery. Some, perhaps many, are embarrassed by the fact that their employer compels them to sell rubbish. It’s too much to expect that they’ll endanger their mortgage payments by speaking out about it, but the best ones will take you aside and explain that they can’t recommend it.
The GPhC itself is regulated by the Professional Standards Authority, the subject of my last post. We can’t expect anything sensible from them.
In the USA there is a shocking number of pharmacists who seem to believe in quackery. In the UK. nobody knows, though judging by their failure to vote against the daftest of all scams, homeopathy, there is no cause for complacency here.
It seems that there will have to be big improvements in pharmacy education before you can have much confidence in the quality of the advice that you get in a pharmacy.
Yesterday a talk was given at the School of Pharmacy, organised by the “The Centre for Homeopathic Education” (an oxymoron if there ever was one). The flyer had all the usual nonsense. Its mention of “Remedies & Tonics for Cancer Recovery” might well have breached the Cancer Act (1939). When I asked whether the amount received in room rental was sufficient to offest the damage to the reputation of the School of Pharmacy resulting from hosting a nutty (and possible illegal) event, I had the greatest difficulty in extracting any sort of response from the school’s director, Duncan Craig. I’m told that he considers “the policy on space rental to be a UCL management issue, rather than a matter of discussion on scientific ethics with a colleague”. Oh dear.
I hate to be forced to return to the world’s most boring delusion, homeopathy. It is boring because the battle to inform people how daft it is has been almost won. Now not a single Bachelors degree in homeopathy appears in UCAS, compared with at least five in 2007. But the battle is not quite won with the UK Government. This post is not so much about homeopathy as about the failures of the Government and the MHRA.
The Medicines and Health Regulatory Authority (MHRA), has just launched yet another consultation and I have felt obliged to waste an entire Sunday writing a response to it, I can’t imagine that any scientist would disagree much with what I have written, but most of them have far better ways to spend their time than bothering about the lunatic fringes of medicine. No doubt most of the responses will come from people who make money from homeopathy, Not just the homeopaths on the High Street, but also the very rich companies like Boiron and Weleda who make enormous profits from selling pills that contain nothing but a bit of sugar.
The consultation concerns what should be done, about homeopathy in the wake of the scarifying report of the House of Commons Select Committee [get pdf], and the governments response to that report [get pdf].
The MHRA’s request for consultation is here. Download the consultation document. You can download my full response [get pdf], Please write your own response and send it to email@example.com before February 17th. Feel free to plagiarise anything you find here.
Another good response is from Healthwatch, [download pdf]
And an excellent response by Prof John C. McLachlan [download pdf].
Now I’ll filll in some of the background and outline why I think the MHRA still hasn’t understood.
The Medicines Act 1968 and PLRs
The Medicines Act (1968) was passed in the wake of the thalidomide disaster. It required evidence that medicines work and that they are safe. It was not possible to check all existing medicines by the time the Act was implemented in 1971, so, as a temporary measure, many medicines, including homeopathic stuff, were give a "public licence of right" (PLR). Forty years later they have mostly vanished. But not for homeopathy. The PLR is the licence that allows homeopaths to break all the rules. They still exist.
MHRA cocked it up in 2006
The story starts with the National Regulation Scheme for homeopathic junk that was introduced by the MHRA in 2006. This allowed, for the first time, indications to be put on the labels of the bottles of sugar pills. There were howls of outrage from just about every scientific organisation (the medical establishment was, as usual, more pusillanimous, with some honourable exceptions). The history is related here in the following posts.
The MHRA breaks its founding principle: it is an intellectual disgrace
The Royal Society speaks out on CAM
Learned Societies speak out against CAM, and the MHRA
The MHRA loses the plot: it allows mislabelling of Arnica gel
House of Lords slams homeopathy and the MHRA
MHRA admits herbal medicines unproven
The Science and Technology Select Committee report
This was an admirable effort, It extracted, with some difficulty, admissions from Boots’ professional standards director that the sold pills while knowing that they didn’t work. It also squeezed out of the then Health Minister, Mike O’Brien an admission that they don’t work, Less surprisingly, the head of the MHRA agreed that they don’t work. So it is unanimous (apart, of course, from those who make money from selling things that don’t work).
If you want to know more about Boots’ Professional standards, take a look at Mis-education at Boots the Chemist, or The Vitamin B scam. Don’t trust Boots, or Boots reaches new level of dishonesty with CoQ10 promotion, to name but a few. The oral sessions of the committee were notable for the squirming evasiveness of most of the answers to simple questions. An account can be found in Comedy gold in parliament and tragedy from Prince of Wales: editorial in British Medical Journal
The Government’s response to the report was mostly as truly pathetic bit of official waffle, like those letters you get when you write to your Member of Parliament. But it did contain one good thing."In order for the public to make informed choices, it is therefore vitally important that the scientific evidence base for homeopathy is clearly explained and available." (though even that statement is attributed to John Beddington, the Government’s Chief Scientific advisor, rather than something the Government thinks essential).
"“The MHRA will review the labelling requirements under the NRS to ensure that these deliver clarity as to the status of products and their composition."
The proposals in the MHRA Consultation document’
There are a couple of good things in the proposals. The MHRA proposes to end PLRs (decades overdue, but nonetheless welcome).
The MHRA proposes to stop ‘regulating’ (ho ho) “Bach Flower Remedies” as medicines (but seems happy to classify them as food Supplements, another weasel description to evade sensible regulation). That’s sensible because they aren’t medicines. Homeopathic pills most certainly aren’t medicines either but the MHRA seems to have difficulty grasping that, and wants to treat them quite differently from “Flower remedies”
More honest labelling was about the only sensible thing recommended by the Government’s response. On this topic the MHRA proposals verge on the laughable
At present the labelling allowed under the NRS includes
“A homeopathic medicinal product used within the homeopathic tradition for the symptomatic relief of ….”
It is proposed to change this to
“A homeopathic medicinal product licensed only on the basis of safety, quality and use within the homeopathic tradition”
“A homeopathic medicinal product used within the homeopathic tradition for the symptomatic relief of……”
Spot the difference!
The is utterly inadequate. In fact it verges on the pathetic (and on the dishonest). Here is an extract from my full response.
"Sad to say these proposals to remedy the labelling problem are wholly inadequate. They are almost as deceptive as the originals. These labels don‘t come anywhere near to fulfilling the requirement in the government‘s response which said
In order for the public to make informed choices, it is therefore vitally important that the scientific evidence base for homeopathy is clearly explained and available
Why, oh why, cannot the MHRA bring itself to simply tell the truth? It seems to be so stifled by some perversion of political correctness that it is unable to do what it must know is right.
Nothing indicates more clearly the ludicrous state of the NRS than the label approved for Arnica 30C pills.
The approved label says
Each pill contains 30C Arnica Montana
Also contains: lactose and sucrose"
The MHRA must decide whether or not it believes Avogadro‘s number or not.
How many people in the general public realise the ―Each pill contains 30C Arnica Montana‖ means that the ―pills contain no Arnica whatsoever‖? The very mention of the words ―active ingredient‖ will suggest to most people that there is an active ingredient when there is not. This wording alone is both dishonest and deceptive.
The rest of the approved label consists largely of make-believe too.
"If you are pregnant or breastfeeding consult your doctor before use"
What is your doctor meant to advise you about the dangers of taking a few mg of sugar when you are pregnant?
"If you take too much of the product (overdose) speak to a doctor / pharmacist and take this label with you,."
Unless the MHRA has disavowed Avogadro‘s number, an overdose is impossible. To allow a label like this makes the MHRA a laughing stock
Labels should tell the truth in plain language. For example they should say
This product contains no Arnica
There is no evidence that it works for any condition, other than as a placebo
Some comments on regulation of magic medicine
Governments like to regulate things. They should have regulated the banks a bit more. The problem arises when you try to regulate things that are myths. Like homeopathy.
Andy Lewis has recently written a superb account of the problems on his Quackometer blog, When the Regulator Believes in Fairies, Who Protects the Public?
The government appears to believe that "training" will solve all the problems. Training people to believe things that aren’t true can never solve problems. On the contrary, it creates problems. Organisations like the Complementary and Natural Health Care Council (CNHC)do nothing to protect the public, They endanger the public (see Why the CNHC can’t succeed). Their excuse for rejecting complaints that members were making false claims was not to deny that the claims were false, but to say that it didn’t matter because that is what they had been trained to say. That is make-believe regulation.
.This is Andy Lewis’s version of an honest label. It looks quite accurate to me.
27 January 2011
News today makes one despair of the morality of governments. Remember those obviously fraudulent bomb detectors, no more than a dowsing rod? Although they are now the subject of a fraud investigation, they are still being sold. The government has banned their export to Iraq and Afghanistan, but NOT to anywhere else, This suggests not only that the government is (or at least was) quite happy to believe in dowsing. It also implies that even when they realise that it’s fraud they take the view that that business is far more important than even the most basic morality. No doubt they will allow fraudulent labelling of medicines in order to protect the homeopathic industry
Does politics have to be quite so disgusting?
28 January 2011. An excellent post on a similar topic is that referred to in a comment below. The MHRA and the non-regulation of homeopathy explains the European background better that I have done.
11 February 2011. Here is a characteristically beautiful response to the consultation by Prof John C. McLachlan, who has allowed me to post it here [download pdf].
I don’t know about you, but I’m bored stiff with homeopathy. There are a lot more important things. Nevertheless, it remains a gross insult to reason, and there has been such enormous success in combating it over the last five years so, this is not the moment to stop.
Hats off to the Merseyside Skeptics Society. I admit that when I first heard about the 10:23 campaign, it seemed to be a bit of a gimmick, but in fact it turned out to be an enormous success., not just in the UK but also in Canada, Australia and New Zealand
The campaign was focussed on Boots, the UK’s biggest pharmacy chain, In particular the fact that Boots sell homeopathic pills. and regularly gives appallingly bad advice about all forms of quackery that they stock.
I’ve been criticising Boots for years now, starting with Mis-education at Boots the Chemist in May 2006. was largely about homeopathy, but Boots’ quackery is not restricted to homeopathy, In November 2007, Don’t Trust Boots described Boots’ promotion of vitamin pills that were
advertised by Boots to increase your energy, and also the appallingly bad advice given by shop staff on this product.
In March 2008, Boots did it again, with a big promotion written up as Boots reaches new level of dishonesty with CoQ10 promotion. The strategy seems clear by now. Launch an enormous publicity effort, and rely on journalists to parrot the press release. Put mendacious advertisements in every newspaper. Eventually the advertisements are found to be inaccurate by the Advertising Standards Authority. Boots are told to stop using the advertisement, but suffer no penalty at all. By that time the advertising campaign is over anyway, and they can rely now on inaccurate advice from "Boots expert team"; face to face in the store, to continue the promotion in a way that evades all regulation.
Boots is deeply involved too in the great ‘detox’ scam, as recounted, for example, in “Detox”: nonsense for the gullible, along with the Prince of Wales. And, most recently, Lactium: more rubbish from Boots the Chemists. And a more serious problem.
The nauseating hypocrisy of Boots’ Corporate Social Responsibility statement beggars belief. The same stuff is repeated on the current Alliance Boots site.
“Trust – The essence of the way we do business. We are trusted because we deliver on our promises.”
You must be joking.
Who owns Boots?
Boots started in 1849 as a single shop in Nottingham. Within my lifetime, they were rather ethical pharmacies (my recollection is that they didn’t sell homeopathic pills). They were also an ethical pharmaceutical company. They developed ibuprofen, which was launched in 1969. But since then the company was involved in a complicated series of acquisitions. Now it is a supranational conglomerate with presence in 20 countries, and almost beyond the reach of the law. Boots’ executive chairman is Stefano Pessina, who, with private equity firm Kohlberg Kravis Roberts in a £11.1 billion deal last year, took the firm private in 2007. In 2008 they announced a 20% increase in profits, to £771 million In 2008 they moved their headquarters out of the UK, to Geneva, partly, it seems, so they can be closer to other giants of Big Pharma, and partly, no doubt, to put pressure on the UK government not to tax them too much, On the other hand, tax may not be a big consideration because, according to The Times, the ultimate owners of Boots are based in Gibralter
The disgraced head of HBOS, Andy Hornby, was appointed as chief executive of Alliance Boots in June 2009. Before playing his part in ruining the UK economy he used to work for grocery chain, Asda. I’d guess that he has limited interest in pharmacology.
The economics of such organisations are beyond most people. a bit like the two cow economics joke perhaps.
"VENTURE CAPITALISM – AN ICELANDIC CORPORATION
You have two cows.
You sell three of them to your publicly listed company, using letters of credit opened by your brother-in-law at the bank, then execute a debt/equity swap with an associated general offer so that you get all four cows back, with a tax exemption for five cows. The milk rights of the six cows are transferred via an intermediary to a Cayman Island Company secretly owned by the majority shareholder who sells the rights to all seven cows back to your listed company. The annual report says the company owns eight cows, with an option on one more. You sell one cow to buy a new president of the United States, leaving you with nine cows. No balance sheet provided with the release. The public then buys your bull."
Clearly there is not the slightest chance of an organisation like this will have any sort of conscience about selling useless pills, The only way that they can be influenced is by public mockery of their outrageous behaviour. If the publicity harms their image enough they may decide to cut their losses, because it pays, not because it is right.
10:23 a great success
The campaign was a success because it got good coverage in the newspapers, radio and TV. Boots, rather like vice-chancellors, seems to be uninterested in reason or morals, but will certainly be sensitive about its public image, There is a partial list of coverage at the 10.23 site.
Laura Donnelly had a good account in the Telegraph, "Homeopathy: medicine that’s hard to swallow?". And Hadley Freeman in the Guardian showed that fashion journalists can spot nonsense too, in "Me and my homeopathic overdose. How I knocked back a bottle of homeopathic ‘medicine’ and lived to tell the tale"
The spoof published on the NewsArse site (despite the name, it is excellent) hit the nail on the head, because it uses exactly the naive sort of post ho ergo propter hoc argument that homoeopaths love.,
Homeopathy proven to work after overdosing protesters eventually fall asleep
Homeopathic practitioners are today claiming victory for the efficacy of their remedies, after a protest by the 10:23 group who overdosed on homeopathic sleeping pills, left each participant asleep within just 36 hours of taking the remedy.
Funniest of all though, was the bleating by homeopaths themselves. Try, for example, Homeopathy Heals. Like all the others it alleges a conspiracy by big Pharma: “it seems to be driven by those working for Pharma behind the scenes”. It seems to have escaped the attention of these conspiritorialists that the demonstration was aimed at Boots and Boots IS Big Pharma. The two are inextricably linked and both use the same tactics to increase sales.
My small contribution
Apart form contributing to Laura Donnelly’s piece in the Telegraph, "Homeopathy: medicine that’s hard to swallow?"., I had a few more calls.
Mary English, homeopath and astrologer
The most interesting was a talk show on Radio 5 live, where I was was pitted against a homeopath, Mary English [play the mp3 file, 4.4
Mb]. Having come across Mary English before, I was well-prepared to talk about her record not only in homeopathy, but also in astrology. The presenter didn’t give me time to raise these points but he did a pretty good job himself in asking her the relevant questions.
Mary English’s website is a delight. "Homeopathy and Astrology can heal you".
" If you eat a whole bottle of them it wouldn’t make any difference because it’s the dose that you have, not the quantity of the tablets"
"It’s the frequency of dose . . .because it’s vibrational medicine"
The host asked "what’s vibrational medicine?"
"it works with your bodies systems as opposed to against it"
No doubt Mary English is quite sincere, She just, like so many homeopaths, seems to be quite unaware that these words don’t mean anything at all. Just pure gobbeldygook.
Some of her claims are bizarre, even by the standards of homeopaths. She has researched the birth charts of Indigo Children, and written a book, "How to survive a Pisces" Her claim to homeopathic fame is that she has done "provings" of "remedies" including thunderstorm, and shipwreck and Stanton Drew Stone Circle, and Old Wardour Castle. Ahem, suddenly Arnica 30C sounds quite sane.
Less excusably, Mary English went on to claim that there is good evidence that homeopathy works. She just hasn’t read, or hasn’t understood the evidence. But since she earns her living as a homeopath
and astrologer, she hasn’t got much incentive to read the evidence. if she did, her income would dry up.
The presenter put directly to Mary English the recommendation of homeopathy for malaria prevention. "You wouldn’t condone that would you?". Quite disgracefully that question was avoided. She
changed the subject without answering the question. The quackometer’s classic post on The Gentle Art of Homeopathic Killing came to mind (see also here for links to full text)
Some herbal stuff
Herbal medicine rather than homeopathy was the topic of the other two weekend gigs. That arose from the Pittilo proposals for statutory regulation of herbalists and Chinese medicine.
The BBC TV interview, together with a herbalist, Rhona Edmonds, is now in YouTube. A Welsh member of the European parliament, Jill Evans (Plaid Cymru) , has been backing herbalists on the grounds that they are a “well-respected profession”. Oh yes? The Prince of Wales has also had support from another MEP. Mike Nattrass (UKIP). It seems that our fringe parties have even more trouble with science than the Labour and Conservative parties (and, tragically, that includes the Green party too).
There was also an early morning talk show interview on Sunday 31 January, against the same herbalist [play mp3 file] She claims "we treat all sorts of conditions",. Yes indeed, that’s the problem. "If we were recognised it would give the public even more confidence". And that is the problem too. They don’t deserve that confidence.
The analogy between alternative medicine and religion is often striking. Both involve blind faith, and both are characterised by tendency to split into sects that war with each other even more viciously than they war with unbelievers. All the discussions of herbalism ignore the fact that an enormous number of herbalists (2536 as of 4th February) have signed a petition opposing the idea of statutory regulation, even in the ineffective form that is being proposed.
The Prince of Wales declares war on . . . the Enlightenment
That was the headline of an article in The Times (February 4th, 2010). There can be no more high profile propagandist for every form of magic medicine than the Prince of Wales. Nothing seems to stretch his credulity. But even I was taken aback by his latest pronouncement. It seems he’s been called an enemy of the enlightenment (yes, by me among many others).
“I was accused once of being the enemy of the Enlightenment,” “I felt proud of that.”
“We cannot go on like this, just imagining that the principles of the Enlightenment still apply now. I don’t believe they do. But if you challenge people who hold the Enlightenment as the ultimate answer to everything, you do really upset them.”
So it seems he wants to return medicine not just to 1800, but to 1500, the dark ages. Can he really think that life in 1500 was some sort of utopia? Of course one suspects that his disapproval of the enlightenment is restricted to medical matters. He hasn’t been seen to reject other products of the enlightenment, like cars, aircraft, telephones, radio, TV and the internet.
I suspect that the Prince of Wales needs a history lesson.
Thanks to a colleague for pointing out an excellent sketch from the Newsjack show on BBC Radio 7, broadcast on 4th February 2009. [play mp3 file, 2.4 Mb]. I quote.
“Last weekend, people up and down rhe country engaged in a mass anti-homeopathy protest, swallowing whole bottles of remedies outside Boots.”
“It’s very easy to sneer at homeopathy but we at Newsjack believe it’s important to listen to both sides of the debate. So to put the case for homeopathy we have invited on a ridiculous charlatan who extorts money from innocent people while providing no services of any actual value.”
“Will you please welcome His Royal Highness, the Prince of Wales”
Snow on December 18th Roaring fire
Lindy contributes acute comments regularly here. She is also an accomplished musician. She has kindly allowed me to post here four of her re-written carols.
Adam lay ybounden | Hark the Herald | Holly and the Ivy | Merry Gentlemen
Adam lay ybounden
The Middle English dialect is not easy to follow. In fact Wikipedia reveals that it is oit even standard Middle English, but Macaronic English. The original words are reproduced in the right hand column. The original, sung by choir of King’s College Chapel, is on YouTube.
|Atoms lay y’bounden
In primordial soup;
Six billion years did pass
A’fore they could regroup.
For first had bin a big bang
The universe was shook;
Though through milennia
For god it was mistook.
Then particles of light did shine, ema-
-nating from the sun.
Out of soup arose archaea
And so life was begun.
Thanks be to the man
This mystery did solve;
Through him we celebrate how we
Did from the bugs evolve.
Adam lay ybounden,
Bounden in a bond:
Four thousand winter
Thought he not too long.
And all was for an apple,
An appil that he took,
As clerkè finden
Written in their book.
Ne had the apple taken been,
The appil taken been,
Ne had never our lady
Abeen heavenè queen.
Blessèd be the time
That appil taken was,
Therefore we moun singen,
Hark the Herald Angels sing.
This version is for Simon Singh. If you haven’t yet signed the new peition, please do it here.
Mark this very dang’rous thing,
Story is of Simon Singh.
He got chiropractors riled,
“Sod it! We have been defiled!
Ployful all ye woosters rise,
Join us to defend our lies,
With us loudly please proclaim,
Subluxations are our game”
Christ, they all with one accord
Took young Simon off to court.
“We’ll put you before a judge,
Since we always bear a grudge
‘Gainst all those who say our modus
Operandi is all bogus;
Mark the words of justice Eady,
Gave his ruling oh so speedy.
Mark the case of Simon Singh
With support the web does ring.
Ditch draconian libel laws,
Without which they’d have no cause
To sue those who would speak freely,
Truth, opinion-and reason really
Should prevail o’er all such things,
Surely he his case must win.
The Holly and the Ivy
Dedicated to the Prince of Wales, certain vice-chancellors and other champions of the endarkenment.
The folly and the lies, see
How they’ve become full-blown;
The braying of th’quackti’tioner Roy-
Al, th’enlightenment has flown.
Refrain: For deriding all the data
(Such stunning stuff we hear)!
The displaying of such cherry pick-
-Ing, beats bringing in Chi square.
The folly hears no critics
It makes you quite struck dumb,
Just put a poison substance in,
And dilute to kingdom come.
For deriding all the data etc.
The folly so does blossom,
Beguiles you with its charm,
Just make some movements with your wrist
And it will do no harm.
For deriding all the data etc.
The folly’s given credence
If you are qualified
With a BSc in pseudosci-
-Ence, th’endarkenment is nigh!
For deriding all the data etc.
The folly bears a burden
Now it has fallen down;
F.O.I requests and publicity
Have giv’n D.C. the crown.
For deriding all the data etc.
The folly is so fickle,
How did they have the gall
To tell us how their remedies
Were here to treat us all?
For deriding all the data etc.
The folly and the lies, see
How they must surely fail
We’ll drink a toast to good evidence
And let real science prevail!
Oh the rising of the Reiki,
Of acupuncture too,
All Rolfering* and Tuina-ish,
They all amount to woo.
*The names Rolf and Roger seem remarkably similar in some circumstances so I get a little confused.
Here is Lindy’s version of "god rest ye merry gentleman", composed in the wake of the admission by the Professional Standards director of Boots the Chemists that they sell homeopathic pills despite being aware of the fact that there is no reason to think they work.
I arrest you merry gentlemen,
Please kindly step this way.
For you are selling sugar pills
For which the people pay;
We’re from the Trading Standards and through courts we’ll find a way
To stop your profit-making ploy, Profiting ploy,
We’ll stop your profiteering ploy”!
The chemists calmly did defend
Themselves though they were riled;
“The people do demand these pills
Because they’re not defiled
With molecules (nor ‘owt at all), despite the claims so wild;
We’ll continue our profiteering ploy, Profiting ploy,
We’ll continue our profiteering ploy”.
So Trading Standards did respond
“We understand your aim
To make more money, though if you
Persist with bogus claim
To cure disease with sugar pills,
We’ll put you all to shame!
We are stopping your profiteering ploy, Profiting ploy,
We are stopping your profiteering ploy”.
“You breach the regulations by selling pills, you see,
Which claim to contain ‘aqua’ (dilute to 30C),
Or ‘dolphin song’ or ‘canine testes’ – even ‘ATP’!
So you’ll stop all this profiteering ploy, profiting ploy,
So you’ll stop all this profiteering ploy”.
The Dept of Health bangs on and on
About a patient’s choice,
But all good people must condemn
These lies with one great voice.
We dream of days when fibs are gone and we can all rejoice
‘Cos they’ve stopped all their profiteering ploy, Profiting ploy,
‘Cos they’ve stopped all their profiteering ploy
We have listed many reasons hear why you should never trust Boots. Here are the previous ones.
Can you trust Boots?
Don’t Trust Boots
Boots reaches new level of dishonesty with CoQ10 promotion
This post is about a "functional food". That is about something a bit more serious than homeopathy, though I’ll return to that standing joke in the follow-up, because of Boots’ latest shocking admission..
Alternative medicine advocates love to blame Big Pharma for every criticism of magic medicine. In contrast, people like me, Ben Goldacre and a host of others have often pointed out that the differences seem to get ever smaller between the huge Alternative industry (about $60 billion per year), and the even huger regular pharmaceutical industry (around $600 billion per year),
Boots are as good an example as any. While representing themselves as ethical pharmacists, they seem to have no compunction at all in highly deceptive advertising of medicines and supplements which are utterly useless rip-offs.
The easiest way to make money is to sell something that is alleged to cure a common, but ill-defined problem, that has a lot of spontaneous variability.. Like stress, for example.
The Times carried a piece Is Boots’s new Lactium pill the solution to stress?. Needless to say the question wasn’t answered. It was more like an infomercial than serious journalism. Here is what Boots say.
What does it do?
This product contains Lactium, a unique ingredient which is proven to help with the stresses of every day life, helping you through a stressful day. Also contains B vitamins, magnesium and vitamin C, which help to support a healthy immune system and energy levels.
Why is it different?
This one a day supplement contains the patented ingredient Lactium. All Boots vitamins and suppliers are checked to ensure they meet our high quality and safety standards.
So what is this "unique ingredient", Lactium? It is a produced by digestion of cow’s milk with trypsin. It was patented in 1995 by the French company, Ingredia, It is now distributed in the USA and Canada by Pharmachem. which describes itself as “a leader in the nutraceutical industry.” Drink a glass of milk and your digestive system will make it for you. Free. Boots charge you £4.99 for only seven capsules.
What’s the evidence?
The search doesn’t start well. A search of the medical literature with Pubmed for "lactium" produces no results at all. Search for "casein hydrolysate" gives quite a lot, but "casein hydrolysate AND stress" gives only seven, of which only one looks at effects in man, Messaoudi M, Lefranc-Millot C, Desor D, Demagny B, Bourdon L. Eur J Nutr. 2005.
There is a list of nineteen "studies" on the Pharmachem web site That is where Boots sent me when I asked about evidence, so let’s take a look.
Of the nineteen studies, most are just advertising slide shows or unpublished stuff. Two appear to be duplicated. There are only two proper published papers worth looking at, and one of these is in
rats not man. The human paper first.
Paper 1 Effects of a Bovine Alpha S1-Casein Tryptic Hydrolysate (CTH) on Sleep Disorder in Japanese General Population, Zara de Saint-Hilaire, Michaël Messaoudi, Didier Desor and Toshinori Kobayashi [reprint here] The authors come from France, Switzerland and Japan.
This paper was published in The Open Sleep Journal, 2009, 2, 26-32, one of 200 or so open access journals published by Bentham Science Publishers.
It has to be one of the worst clinical trials that I’ve encountered. It was conducted on 32 subjects, healthy Japanese men and women aged 25-40 and had reported sleeping disorders. It was double blind and placebo controlled, so apart from the fact that only 12 of the 32 subjects were in the control group, what went wrong?
The results were assessed as subjective sleep quality using the Japanese Pittsburg Sleep Quality Index (PSQI-J). This gave a total .score and seven component scores: sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction.
In the results section we read, for total PSQI score
"As shown in Table 2, the Mann-Whitney U-test did not show significant differences between CTH [casein tryptic hydrolysate] and Placebo groups in PSQI-J total scores at D0 (U=85; NS), D14 (U=86.5; NS), D28 (U=98.5; NS) and D35 (U=99.5; NS)."
Then we read exactly similar statements for the seven component scores. For example,. for Sleep Quality
As shown in Table 3, the Mann-Whitney U-test did not show significant differences between the sleep quality scores of CTH and Placebo groups at D0 (U=110.5; NS), D14 (U=108.5; NS), D28 (U=110; NS) and D35 (U=108.5; NS).
The discussion states
"The comparisons between the two groups with the test of Mann-Whitney did not show significant differences, probably because of the control product’s placebo effect. Despite everything, the paired comparisons with the test of Wilcoxon show interesting effects of CTH on sleep disorders of the treated subjects. "
Aha, so those pesky controls are to blame! But despite this negative result the abstract of the paper says
"CTH significantly improves the PSQI total score of the treated subjects. It particularly improves the sleep quality after two weeks of treatment, decreases the sleep latency and the daytime dysfunction after four weeks of treatment.
Given the antistress properties of CTH, it seems possible to relate the detected improvement of sleep aspects to a reduction of stress following its’ chronic administration."
So there seems to be a direct contradiction between the actual results and the announced outcome of the trial. How could this happen? The way that the results are presented make it hard to
tell. As far as I can tell, the answer is that, having failed to find evidence of real differences between CTH and placebo, the authors gave up on the placebo control and looked simply at the change
from the day 0 basleine values within the CTH group and, separately, within the placebo group. Some of these differences did pass statistical significance but if you analyse it
that way. there is no point in having a control group at all.
How on earth did such a poor paper get published in a peer-reviewed journal? One answer is that there are now so many peer-reviewed journals, that just about any paper, however poor, can get published
in some journal that describes itself as ‘peer-reviewed’. At the lower end of the status hierarchy, the system is simply broken.
Bentham Science Publishers are the publishers of the The Open Sleep Journal. (pity they saw fit to hijack the name of UCL’s spiritual founder, Jeremy Bentham). They publish 92 online and print journals, 200 plus open access journals, and related print/online book series. This publsher has a less than perfect reputation. There can be no scientist of any age or reputation who hasn’t had dozens of emails begging them to become editors of one or other of their journals or to write something for them. They have been described as a "pyramid scheme” for open access. It seems that every Tom, Dick and Harry has been asked. They have been described under the heading Black sheep among Open Access Journals and Publishers. More background can be found at Open Access News..
Most telling of all, a spoof paper was sent to a Bentham journal, The Open Information Science Journal. . There is a good account of the episode the New Scientist, under the title “CRAP paper accepted by journal”. It was the initiative if a graduate student at Cornell University. After getting emails from Bentham, he said “”It really painted a picture of vanity publishing”. The spoof paper was computer-generated rubbish, but it was accepted anyway, without comment. Not only did it appear that is was never reviewed but the editors even failed to notice that the authors said the paper came from the "Center for Research in Applied Phrenology", or CRAP. .The publication fee was $800, to be sent to a PO Box in the United Arab Emirates. Having made the point, the authors withdrew the paper.
Paper 5 in the list of nineteen stidies is also worth a look. It’s about rats not humans but it is in a respectable journal The FASEB Journal Express Article doi:10.1096/fj.00-0685fje (Published online June 8, 2001) [reprint here].
Characterization of α-casozepine, a tryptic peptide from bovine αs1-casein with benzodiazepine-like activity. Laurent Miclo et al.
This paper provides the basis for the claim that digested milk has an action like the benzodiazepine class of drugs, which includes diazepam (Valium). The milk hydrolysate, lactium was tested in rats and found to have some activity in tests that are alleged to measure effects on anxiety (I haven’t looked closely at the data, since the claims relate to humans).. The milk protein, bovine αS1 casein contains 214 amino acids. One of the many products of its digestion is a 10-amino-acid fragment (residues 91 -100) known as α-casozepine and this is the only product that was found to have an affinity for the γ-amino-butyric acid (GABA) type A receptors, which is where benzodiazepines are thought to act. There are a few snags with this idea.
- The affinity of α-casozepine peptide had 10,000-fold lower affinity for the benzodiazepine site of the GABAA than did diazepam, whereas allegedly the peptide was 10-fold more potent than diazepam in one of the rat tests.
- The is no statement anywhere of how much of the α-casozepine peptide is present in the stuff sold my Boots, or whether it can be absorbed
- And if digested milk did act like diazepam, it should clearly be callled a drug not a food.
What’s the conclusion about lactium?
Here is what I make of it.
Does it relieve stress? The evidence that it works any better than drinking a glass of milk is negligible. Tha advertising is grossly misleading and the price is extortionate.
Corruption of science. There is a more interesting aspect than that though. The case of lactium isn’t quite like the regular sort of alternative medicine scam. It isn’t inherently absurd, like homeopathy. The science isn’t the sort of ridiculous pseudo-scientific ramblings of magic medicine advocates who pretend it is all quantum theory The papers cited here are real papers, using real instruments and published in real journals,
What is interesting about that is that they show very clearly the corruption of real science that occurs at its fringes, This is science in the service of the dairy industry and in the service of the vast supplements industry. These are people who want to sell you a supplement for everything.
Medical claims are made for supplements, yet loopholes in the law are exploited to maintain that they are foods not drugs. The law and the companies that exploit it are deeply dishonest. That’s bad enough. but the real tragedy is when science itself is corrupted in the service of sales.
Big Pharma and the alternative industry. Nowhere is the slose alliance between Big Pharma and the alternative medicine industry more obvious than in the supplement and nutriceutical markets. Often the same companies run both. Their aim is to sell you thinks that you don’t need, for conditions that you may well not have, and to lighten your wallet in the process. Don’t believe for a moment that the dark-suited executives give a bugger about your health. You are a market to be exploited.
If you doubt that, look from time to time at one of the nutraceutical industry web sites, like nutraingredients.com. They even have a bit to say about lactium. They are particularly amusing at the moment because the European Food Safety Authority (EFSA) has had the temerity to demand that when health claims are made for foods, there is actually some small element of truth in the claims. The level of righteous indignation caused in the young food industry executives at the thought that they might have to tell the truth is everywhere to see. For example, try Life in a European health claims wasteland. Or, more relevant to Lactium, Opportunity remains in dairy bioactives despite departures. Here’s
a quotation from that one.
“Tage Affertsholt, managing partner at 3A Business Consulting, told NutraIngredients.com that the feedback from industry is that the very restrictive approach to health claims adopted by the European Food Safety Authority (EFSA) will hamper growth potential.”
“Affertsholt said: “Some companies are giving up and leaving the game to concentrate on more traditional dairy ingredients.”
Science and government policy
It may not have escaped your notice that the sort of low grade, corrupted, fringe science described here, is precisely the sort that is being encouraged by government policies. You are expected to get lots of publications, so never mind the details, just churn ’em out; The hundreds of new journals that have been created will allow you to get as meny peer-reviwed publications as you want without too much fuss, and you can very easily put an editorship of one of them on your CV when you fill in that bit about indicators of esteem. The box tickers in HR will never know that it’s a mickey mouse journal.
Boots own up to selling crap
Although this post was nothing to do with joke subjects like homeopathy, it isn’t possible to write about Boots without mentioning the performance of their professional standards director, Paul Bennett, when he appeared before the Parliamentary Select Committee for Science and Technology.. This committee was holding an “evidence check” session on homeopathy (it’s nothing short of surreal that this should be happening in 2009, uh?). The video can be seen here, and an uncorrected transcript. It is quite fun in places. You can also read the written evidence that was submitted.
Even the Daily Mail didn’t misss this one. Fioana Macrae wrote Boots boss admits they sell homeopathic remedies ‘because they’re popular, not because they work’
“It could go down as a Boot in Mouth moment.
Yesterday, the company that boasts shelf upon shelf of arnica, St John’s wort, flower remedies and calendula cream admitted that homeopathy doesn’t necessarily work.
But it does sell. Which according to Paul Bennett, the man from Boots, is why the pharmacy chain stocks such products in the first place.
Mr Bennett, professional standards director for Boots, told a committee of MPs that there was no medical evidence that homeopathic pills and potions work.
‘There is certainly a consumer demand for these products,’ he said. ‘I have no evidence to suggest they are efficacious.
‘It is about consumer choice for us and a large number of our customers believe they are efficacious.’
His declaration recalls Gerald Ratner’s infamous admission in 1991 that one of the gifts sold by his chain of jewellers was ‘total crap’.”
The Times noticed too, with Boots ‘labels homeopathy as effective despite lack of evidence‘.
Now you know that you can’t trust Boots. You heard it from the mouth of their professional standards director.
A commentary on the meeting by a clinical scientist summed up Bennett’s contribution thus
"Paul Bennett from Boots had to admit that there was no evidence, but regaled the committee with the mealy-mouthed flannel about customer choice that we have come to expect from his amoral employer."
The third session of the Scitech evidence check can be seen here, and the uncorrected transcript is here. It is, in a grim way, pure comedy gold, More of that later.
It’s only a matter of weeks since a lot of young scientists produced a rather fine pamphlet pointing out that the “detox” industry is simply fraud. They concluded
“There is little or no proof that these products work, except to part people from their cash.”
With impeccable timing, Duchy Originals has just launched a “detox” product.
Duchy Originals is a company that was launched in 1990 by the Prince of Wales, Up to now, it has limited itself to selling overpriced and not particularly healthy stuff like Chocolate Butterscotch Biscuits and Sandringham Strawberry Preserve. Pretty yummy if you can afford them.
The move of HRH into herbal concoctions was first noted in the blogosphere (as usual) in December, by Quackometer. It was reported recently in the Daily Telegraph (23rd January).
Expect a media storm.
Aha so it is a “food supplement” not a drug. Perhaps Duchy Originals have not noticed that there are now rather strict regulations about making health claims for foods?
And guess who’s selling it? Yes our old friend, for which no deception is too gross, Boots the Chemists.
That’s £10 for 50 ml. Or £200 per litre.
And what’s in it?
Problem 1. The word detox has no agreed meaning. It is a marketing word, designed to separate the gullible from their money
Problem 2. There isn’t the slightest reason to think that either artichoke or dandelion will help with anything at all. Neither appears at all in the Cochrane reviews. So let’s check two sources that are both compiled by CAM sympathisers (just so I can’t be accused of prejudice).
National Electronic Library of CAM (NELCAM) reveals nothing useful.
- There is no good evidence that artichoke leaf extract works for lowering cholesterol. No other indications are mentioned.
- Dandelion doesn’t get any mention at all.
The US National Center for Complementary and Alternative Medicine (NCCAM) has spent almost $1 billion on testing alternative treatments So far they have produced no good new remedies (see also Integrative baloney @ Yale).They publish a database of knowledge about herbs. This is what they say.
- Dandelion. There is no compelling scientific evidence for using dandelion as a treatment for any medical condition.
- Artichoke isn’t even mentioned anywhere.
If “detox” is meant to be a euphemism for hangover cure, then look at the review by Pittler et al (2005), ‘Interventions for preventing or treating alcohol hangover: systematic review of randomised controlled trials’.
“Conclusion No compelling evidence exists to suggest that any conventional or complementary intervention is effective for preventing or treating alcohol hangover. The most effective way to avoid the symptoms of alcohol induced hangover is to practise abstinence or moderation.”
Problem 3. The claim that the product is “cleansing and purifying” is either meaningless or false. Insofar as it is meaningless, it is marketing jargon that is designed to deceive. The claim that it supports “the body’s natural elimination and detoxification processes, and helps maintain healthy digestion” is baseless. It is a false health claim that, prima facie, is contrary to the Unfair Trading law, and/or European regulation on nutrition and health claims made on food, ref 1924/2006 , and which therefore should result in prosecution.
Two more Duchy herbals
Duchy are selling also Echinacea and Hypericum (St John’s Wort).
The evidence that Echinacea helps with colds is, to put it mildly, very marginal.
Of St John’s Wort, NCCAM says
“There is some scientific evidence that St. John’s wort is useful for treating mild to moderate depression. However, two large studies, one sponsored by NCCAM, showed that the herb was no more effective than placebo in treating major depression of moderate severity.”
As well as having dubious effectiveness it is well known that St John’s Wort can interact with many other drugs, a hazard that is not mentioned by Duchy Originals
These two are slightly different because they appear to have the blessing of the MHRA.
The behaviour of the MHRA in ignoring the little question of whether the treatment works or not has been condemned widely. But at least the MHRA are quite explicit. This is what the MHRA says of St. John’s Wort (my emphasis).
“This registration is based exclusively upon evidence of traditional use of Hypericum perforatum L. as a herbal medicine and not upon data generated from clinical trials.. There is no requirement under the Traditional Herbal Registration scheme to prove scientifically that the product works.“
But that bit about “There is no requirement under the Traditional Herbal Registration scheme to prove scientifically that the product works” does not appear in the Duchy Originals advertisement. On the contrary, this is what they say.
Yes, they claim that “the two tinctures [echinacea and hypericum] -in terms of their safety, quality and efficacy -by the UK regulatory authorities”
That is simply not true.
On the contrary, anyone without specialist knowledge would interpret bits like these as claims that there will be a health benefit.
That is claim to benefit your health. So are these.
Who makes them?
Michael McIntyre is certainly a high profile herbalist.
He was founder president of the European Herbal Practitioners Association and a trustee of the Prince of Wales’s Foundation for Integrated Medicine. It seems that he a great believer in the myth of “detox”, judging by his appearance on the Firefly tonics web site. They will sell you
“Natural healthy energy” in a drink
That’s what we wanted…
A Wake up for that drowsy afternoon… Detox for a dodgy Friday morning…
Sharpen up for that interminable meeting.
We left the herbs to our wonderful herbalists.
Their De-tox contains lemon, lime, ginger, sarsparilla and angelica. I expect it tastes nice. All the rest is pure marketing rubbish. It does not speak very well of Michael McIntyre that he should lend his name to such promotions.
Nelsons, who actually make the stuff, is better known as a big player in the great homeopathic fraud business. They will sell you 30C pills of common salt at £4.60 for 84. Their main health-giving virtue is that they’re salt free.
If you want to know what use they are, you are referred here, where it is claimed that it is “used to treat watery colds, headaches, anaemia, constipation, and backache”. Needless to say there isn’t a smidgeon of reason to believe it does the slightest good for them.
And remember what Nelson’s advisor at their London pharmacy told BBC TV while recommending sugar pills to prevent malaria?
“They make it so your energy doesn’t have a malaria-shaped hole in it so the malarial mosquitos won’t come along and fill that in.”
You couldn’t make it up.
The Prince of Wales has some sensible things to say in other areas, such as the world’s over-reliance on fossil fuels. Even his ideas about medicine are, no doubt, well-intentioned. It does seem a shame that he just can’t get the hang of the need for evidence. Wishful thinking just isn’t enough.
Some more interesting reading about the Prince of Wales.
Michael Baum’s An open letter to the Prince of Wales: with respect, your highness, you’ve got it wrong”
Gerald Weissman’s essay Homeopathy: Holmes, Hogwarts, and the Prince of Wales.
Channel 4 TV documentary HRH “meddling in politics”
11 March 2009 The MHRA have censured Duchy Originals for the claims made for these products. and in May 2009, two complaints to the Advertising Standards Authority were upheld.
Sense about Science have just produced a rather good pamphlet that exposes, yet again. the meaningless marketing slogan “detox”. You can download the pamphlet from their web site.
The pamphlet goes through the claims of eleven products. Needless to say, the claims are either meaningless, or simply untrue.
- Garnier Clean Detox Anti-Dullness Foaming Gel
“Detoxifies by cleansing the skin’s surface”
- MG Detox Shampoo Trevor Sorbie
“Deep cleansing and clarifying shampoo”
- Boots Detox Body Brush
“Ritualistic body brushing helps expel toxins through the skin”
- Innocent Natural Detox Smoothie
“Helps neutralise nasty free radicals which can cause damage to your body’s cells”
- Vitabiotics Detoxil 15 day support
“Helps the body cleanse itself of toxins and pollutants caused by the excesses of a busy life”
- V-Water Detox
“Cleanse your system and whisk away the polluting nasties”
- 4321 Shape Up and Detox
“To drain off water and toxins” and “purify the body”
- Boots Detox 5 Day Plan
Works “in harmony with your body to flush away toxins”
- Farmacia Spa Therapy Detox range
To “rid your body of these damaging toxins”
- Crystal Spring Detox patches
“I’m the easy way to detox, just put me on one foot at night and take me off in the morning”
- Fushi Holistic and Health Solutions Total Detox Patch
“it acts as a toxin sink and absorbs impurities through your feet”
One nice thing about the pamphlet is that each item is written by a young scientist (including my close neighbour, Daniella Muallem). They are all people at an early stage in their career, but they care enough to spend time dissecting the rubbish spread by companies in order to part you from your money.
Garnier, it’s true, is a cosmetics company, so one expects nothing but lies You won’t be disappointed on that score.
That least ethical of pharmaceutical companies, Boots, appears twice The Boots Detox Body Brush is reviewed by a young chemist, Tom Wells. It turns out (there’s a surprise) to be nothing more than an ordinary stiff brush. It seems that Boots’ definition of “detox”, for this purpose, is “removing dead skin cells” A totally shameless con, in other words.
The Boots Detox 5 day plan consists if 5 phials of apple or strawberry flavoured goo containing two vitamins and one mineral, mixed with glycerol. In this case the young investigator, Evelyn Harvey, elicited a quite remarkable response from Boots.
Well, have you tested the effects of that diet, with or without the detox product? Does the ‘goo’ stuff [the drink which forms part of the plan] add anything extra?
Well, it’s meant to kick start it.
But has is been tested like that?
Ok, I’m thinking I’ll just try a healthy diet for a week, a bit more exercise, and not bother with buying the detox.
Yes, that sounds like a better idea, to be honest I’d never do this myself.
The media coverage
The Radio 4 Today programme interviewed Ben Goldacre and the managing director of yet another product “Detox in a box” (following their usual policy of equal time for the Flat Earth Society). Listen to the mp3. When Ben Goldacre asked the MD for evidence for the claim made on the web site of Detox in a box, that their diet could remove cadmium from the body, it was denied explicitly that any such claim had been made.
But by 10.02 the site had already changed
So no apology for the mistake. Just a sneaky removal of a few words.
That seems to be the only change though. All the rest of the nutribollocks is still there. For example
There isn’t the slightest reason to believe that it will “improve our immune function”.
There isn’t the slightest reason to think that scavenging free radicals would do you any good, even if it happened.
There isn’t the slightest reason to think it will strengthen body’s fight against cancer cells (that looks like a breach of the Cancer Act to me).
“Cleansing mucous” doesn’t mean much, but whatever it is there isn’t any reason to think its true.
“Purify our blood”. Total meaningless bollocks. The words mean nothing at all. I’ve been here before.
Ben Goldacre’s own account is here “The barefaced cheek of these characters will never cease to amaze and delight me.”
The BBC web site does a good job too.
The Guardian gives an excellent account (James Randerson).
The Daily Mail writes “Detox diets to kick-start the New Year are a ‘total waste of money’ “.
Medical News Today write “Debunking The Detox Myth“.
The Daily Telegraph disgraces itself by not only failing to carry a decent account of the item, but it does run an article on “Detox holidays: New year, new you“. Mega-expensive holidays for the mega-stupid (not to mention the capital letter after the colon).
The Daily Mash provides a bit of cognate fun with “BRITAIN SIGNS UP FOR VORDERMAN’S 28-DAY PISS-DRINK DETOX“. That alludes to “Carol Vorderman’s 28-Day Detox Diet”. A woman who got an enormous salary for playing a parlour game on TV, and has done some good for maths education, is reduced to promoting nonsense for yet more money.
As Clive James pointed out, it’s a but like watching George Clooney advertising coffee for, of all unethical companies, Nestlé. They really look very silly.
Evening Standard 6th January. Nick Cohen writes “Give up detox – it’s bad for your health”
“Giving up on detox should not be painful, however. On the contrary, it should e a life-enhancing pleasure.”
The Times. rather later (January 18th) had a lovely one, “Detox
Debunked“, by the inimitable Ben Goldacre, His account of /detox; as a quasi-religious ‘cleansing ritual’, is spot on.
It may be only post-1992 universities that run degrees in nonsense, but you can find plenty even in the highest places. Like St Bartholomew’s (founded in 1123). That well known source of misleading medical advice, The Prince’s Foundation for Integrated Health (FiH), published last March, “Teaching integrated health at Barts and the London“. This consists of an interview with two members of staff from what is now known as the Barts and The London School of Medicine and Dentistry (SMD)..
|Dr Mark Carroll BSc (Hons), PhD, FHEA is Associate Dean (Education Quality) in the Centre for Medical Education (SMD), specialising in all aspects of quality assurance in the SMD|
|Prof Chris Fowler BSc MA MS FRCP FRCS(Urol) FEBU is Dean of Education|
They say they are dubious about alternative medicine, but rather keen on integrated medicine. Seems odd, since the latter is really just a euphemism for the former.
After seeing the FiH posting, I wrote to Carroll and Fowler to get more information.
From Carroll 20 March
We are at an early stage in the planning process for the “Integrated Health & Wellbeing” strand in our new MBBS curriculum. I can send you our ideas (attached). Much will depend on whether we can make a new appointment of someone who can lead on the planning
From Fowler 25 March 2008
Our discussions with the PFIH [Prince’s Foundation for Integrated Health] have only progressed to the stage of indicating an indicative curriculum for integrated health. We don’t have the sort of detail that you are asking for at present. We are hoping that they will work with us to get someone to champion the development.
. . .
Your views would be welcome
So I sent them some views on 26 March (read them here). I also said “I find it quite astonishing that a respectable medical school should feel it appropriate to have parts of its curriculum in the hands of the Prince of Wales.”. It seems, though, that only one sort of view was wanted. On 27 March. Fowler wrote
“I find your insinuation unnecessary and insulting. We have been working on a serious response to the GMC’s requirement that we teach medical students about the range of options available to patients. It is fatuous to suggest that the Prince of Wales is personally involved in any practical sense. The Prince’s Foundation for Integrated Health is an important stakeholder and I think that it entirely reasonable both to talk to them and to seek funding to help us to develop an area that is deficient in our current provision.”
Uhuh, not a very nice response to a rather moderate letter. Lesson 1: never trust anyone who uses the word “stakeholder”.
It does seem very odd that a medical school like Barts should turn to the Prince of Wales’ Foundation for advice on medicine. After all, the bad advice given by the “Patients Guide” is rather well documented (see also here). If messrs Fowler and Carroll were really unaware of that, I’d argue that they aren’t doing their job properly.
It seems that Barts, like Edinburgh, has over-reacted to pressure from the General Medical Council (GMC). Actually all that the GMC require is that
“They must be aware that many patients are interested in and choose to use a range of alternative and complementary therapies. Graduates must be aware of the existence and range of such therapies, why some patients use them, and how these might affect other types of treatment that patients are receiving.” (from Tomorrow’s Doctors, GMC)
There is nothing there about saying that they work. Certainly medical students need to be familiar with alternative medicine, given the number of theit patients that use it. That is a job I have done myself, both at UCL and at Kings College London. I’d argue that I am marginally better qualified to assess the evidence than the Prince of Wales.
Oddly enough, the bad education in Edinburgh came also from a Professor of Medical Education and Director of Undergraduate Learning and Teaching,
The result is manifested in two ways. Barts has a “Science in Medicine” course that has resulted in medical students being placed with homeopaths. And it has a Special Studies Module in Ayurvedic Medicine. Let’s take a look at them.
An Introduction to Ayurvedic Medicine
|The aims of this Special Study Module are “To introduce the concepts and principles which underpin Ayurvedic medicine. To introduce Year 1 and 2 medical students to the Ayurvedic approach to patient assessment, diagnosis and treatment”, and to “Critically evaluate the evidence base for Ayurvedic treatments and yoga therapy”. Just one small snag there. There is next to no evidence base to be assessed.||
Click to enlarge
The module is given by Professor Shrikala Warrier, who is Dean of MAYUR: The Ayurvedic University of Europe. That sounds quite grand. But the web site of The Ayurvedic University of Europe is rather unusual for a university. It lists two courses but has no list of staff. Could it be that Professor Shrikala Warrier is the staff? Neither is it clear where Professor Warrier’s professorial title comes from. Her own private university perhaps?
The two courses it offers are B.Sc.(Hons) Ayurveda and B.Sc.(Hons) Yoga. It says that the course the “BA(Hons)Ayurvedic Studies is a three year programme of study developed in collaboration with Thames Valley University in London”. That’s odd too, because there is no mention of it on the Thames Valley University web site (and TVU is not in London, it’s in Slough). Elsewhere it is stated that the “programme has been validated by MAHE, which is also the degree awarding body”. MAHE is not explained but it appears to refer to the Manipal Academy of Higher Education, in Goa, India. That looks like a pretty good place. It does not offer degrees in Ayurveda, though there is a small Department of Ayurvedic medicine within the otherwise entirely conventional Kasturba Medical College-Manipal. Their first year physiology exam would tax our students.
Elsewhere we see the same address, 81 Wimpole Street, listed as The Manipal Ayurvedic University of Europe (a joint venture between The Manipal University and the Ayurvedic Company of Great Britain) Prof. S. Warrier, B.A.(Hons), M.A., Ph.D., MILT, Dean of Academic Planning.
If one checks Mayur Ltd at Companies House, one finds that it has two directors, Lady Sarah Morritt and Professor Shrikala Warrier. The company report shows that no accounts have been filed up to now and their 2008 accounts are overdue.
The business history of ayurveda is nothing if not tortuous. The London Gazette (May 2008) notifies us that
AYURVEDA HOLDINGS LIMITED (chairman Lady Sarah Morritt) was passed a Special Resolution: “That the company be wound up voluntarily.”
If you email the Ayurvedic University of Europe, the reply comes not from a University address but from unififiedherbal.com. That seems to be some sort of marketing company, at the same address, 81 Wimpole Street. But efforts to find out more about it from Companies House show that UnifiedHerbal.com was dissolved on 3 October 2006.
Several of the links are broken on the web site of Ayurvedic University of Europe, but one that does work is ‘products’. That takes you to the sales pages of http://www.drwarrier.co.uk/. That doesn’t look much like a university, but no prizes for guessing the address. Yes, it’s 81 Wimpole Street again. They will sell you all sorts of cosmetics, though Companies House lists Dr Warrier Limited, and tells us
Last Accounts Made Up To : 31/08/2007 (DORMANT) and
Next Return Due : 26/09/2008 OVERDUE. Their registered office is
at Harold House, Waltham Cross EN8 7AF.
From drwarrier.co.uk you can buy, for example,
The most commonly prescribed Ayurvedic formula. Triphala is an effective blood purifier that detoxifies the liver, helps digestion and assimilation, and reduces serum cholesterol and lipid levels.
Blood purifier? Detox? Where have we seen this sort of utter gobbledygook before? Or perhaps she can sell you some
Traditionally used for obesity and overweight, and reducing and preventing accumulation of cholesterol (LDL). Its anti-inflammatory and detoxifying actions help reduce arthritic pain and swelling.
There isn’t the slightest evidence for these effects in man. Hence, no doubt, the usual weasel words. “traditionally used for . . . ”
The sales department alone casts rather a large doubt on Prof Warrier’s ability to teach medical students how to “critically evaluate the evidence base for Ayurvedic treatments”.
It does seem a bit surprising that a top flight medical school should think that this is an appropriate place to educate its students.
Medicine in Society
The syllabus at Barts includes something called Medicine and Society. Page 5 of the second year Tutor Guide mentions “complementary therapies” as part of the course. There is little hint about what that means in practice.
It turns out that the alt med placements are at the Greenwich Natural Health Centre. Nothing is too barmy for them Acupuncture. Cranial Osteopathy, Craniosacral Therapy, Herbal Therapy, Homeopathy, Hot Stone Therapy and Nutritional therapy to name but a few of the preposterous make-believe stuff that is on offer.
Medical students are having to spend their time listing to stuff like this, on ‘hot stone therapy’.
“Hot stone therapy / massage is a kind of massage that uses treated volcanic rocks such as basalt and basinite that are believed to promote relaxation as well as eliminating negative energy within the client’s body, mind and soul.”
“These stones are carefully gathered and handcrafted for various sizes, shapes and weights according to what part of the body it will be use on.”
Or this, on ‘nutritional therapy’.
“Many of us lack the basic raw materials (from food and drink) to function at our best. Intensive farming, pollution, stress, stimulants and an over-reliance on processed foods are just some of the reasons for us being deficient in vital nutrients. As a result, we may develop serious degenerative diseases like cancer or arthritis.”
“Some clients may experience reactions like headaches, skin eruptions or bad breath during the first stage of treatment. These are quite normal and are due to detoxification, which is usually followed by a sense of well-being and increased energy.”
That must be about as close as you can get to claiming you can prevent cancer by taking vitamin pills. It is wrong and it is dangerous,
Sigh. What century are we living in?
According to Barts’ second year Tutor Guide, “Placement tutors are responsible for student assessment”.
What sort of grade will the student get if they tell their tutor in homeopathy or ‘Nutritional therapy’ that they are talking nonsense?
What do the students think?
Could the Ayurvedic course be the very same course that is referred to by a second year medical student on the Unprotected Text blog?
“When I found out my friend had been attached to a “doctor” in Ayurvedic “medicine” for the year I was horrified, as was she, and the school would not allow her to change claiming that the point is not to learn the medicine but its role in the multidisciplinary healthcare team.
I don’t believe that there is such a role.
The very fact that a student is forced to put up with this as a part of their education is appalling.”
A comment left on Unprotected Text by someone writing as ‘Barts Medic’ said
“I was HORRIFIED to hear that some of my friends have their medsoc placements
at such RUBBISH places too!
last week, they were forced into a room one by room to be touched up (‘massaged’)
by the ‘doctor-person’ to HEAL them. she rubbed them all over, and CHANTED! WTF.
if i was given a CRAPPY placement like that, i wouldnt turn up either”.
And there is an excellent statement about “holistic medicine” on Unprotected Text. Better, perhaps, than you’d get from the GMC.
“Holistic medicine is in fact a world away from homeopathy, although the two are often confused predominantly by homeopaths trying to validate their branch of “medicine”. Much of what is taught in medical school is in fact, holistic, and so it should be. The importance of mentality, or spirituality in medicine should not be used to excuse homeopathy.”
“That doesn’t seem to add up” is another blog that relates the experiences of another student who has been exposed to “Enforced quackery Day 1, “, “Enforced quackery Day 2“, “Enforced quackery Days 3 and 4“. He says
“. . .by the end of day 3 the students *still* hadn’t seen any patients and that, when confronted with this fact the person in charge is reported to have said that this was because she was scared of what the students might say to the patients… Apart from this being a massive insult to the professionalism of the students, it is at least an encouraging sign that they have not been very effectively indoctrinated.”
It seems that we shall soon have some more documentary evidence. It is truly impressive to find that Barts’ medical students are so bright and that they have the courage to speak up about it.
So there is one good thing. We have some very perspicacious medical students in London.
Pity that one can’t say the same thing of their teachers.
I have it on good authority that the unhappy students who were placed at the Greenwich Natural Health Centre were presented with one of the more absurd documents ever to be produced by homeopaths, “An Overview of positive homeopathy research and surveys“.
There is no need to argue about whether homeopaths cherry-pick the evidence. The selective use of evidence is announced proudly, right there in the title.
What excuse can Bart’s have for exposing medical students to such profoundly anti-educational stuff as this?
Later there appeared on the That doesn’t seem to add up blog, Enforced
Quackery – the literature. The unfortunate students who were pushed into a homeopathic placement were give a print out of a page from Sue Young’s homeopathic web site. It is merely a bit of phony history that attempts to link Pasteur with homeopathy.
Sue Young, incidentally, is a homeopath who has consistently breached the Code of Ethicsof the Society of Homeopaths by claiming to treat serious diseases, though needless to say the Society did nothing about it. She is also the person who wrote a wholly inaccurate account of the reasons why my blog left the UCL server (see alse here and here). She didn’t, needless to say, ask me, but luckily she was soon corrected on quackometer and in the Guardian.
Incidentally, the Unprotected Text blog continues to provide a fascinating student view on medical education. Students show more sense than their teachers not only about alternative nonsense but also about other gimmicks like ‘problem based learning’.
Shortly after I published my editorial in the New Zealand Medical Journal, Dr Who?, I was delighted to get a letter from someone who had trained in chiropractic and seen it all from the inside.
Sadly this wonderful letter had to be removed within a few weeks of posting it because its author was threatened and bullied by chiropractors. Its author is too young and too vulnerable to risk his future career. As a result of this shameful and vindictive treatment, I was asked to remove the letter and did so immediately. Other copies on the web have now vanished too.
The experiences described in the letter justified much of what I said in the editorial, and in some ways went further. This letter doubtless contributed to dropping of the threatened legal action by chiropractors against the Journal and against me. The letter was posted originally on 21 August 2008, with the permission of its author. See also the follow-up in Chiropractic wars. Part 3: internecine conflict.
Now I have been sent a much more anonymous version, and it is a great pleasure to post this inside information.
I must begin by stating my background in relation to chiropractic. I am a graduate of a chiropractic college and have practiced for several years. I have elected not to register or practice again and have returned to study to begin a new career. Prior to studying chiropractic, I gained undergraduate and postgraduate qualifications in science.
First I would like to address your comment about the validity of a qualification from a private chiropractic college, especially in relation to the difference between studying there and studying at a university.
A major difference is the education and experience of faculty. At the time I was there, most of the faculty at my college had only undergraduate qualifications (I would suggest that the American DC degree is of undergraduate level as it is the primary qualifying degree for chiropractic in the US and Canada -it is not the equivalent of a doctorate in a British or Australasian university) and have not published in peer-reviewed journals. This is quite different to my experience of universities where the all of the faculty usually have at least a PhD and are actively involved in research.
The content of the chiropractic curriculum was voluminous. It included basic sciences, chiropractic subjects and social sciences. The college I attended did not have any laboratory facilities so the experience of learning science from a textbook was quite different to the way I had been taught at university, where each subject had a significant laboratory program that had to be passed separately to pass the subject.
As chiropractic is a clinical discipline, the course contained subjects in common with a medical degree. Sadly, the attitude towards medicine and the medical profession was not always the most constructive. For example, I can recall a noticeboard where newspaper clippings of media reports of medical misadventure and adverse effects of pharmaceuticals were posted regularly.
Clinical experience was gained by a 2 year internship in the school health centre concurrent with the last 2 years of academic study; so it was not a full-time internship. The requirements for passing this component of the course were complex but centred around seeing a number of patients, a number of visits, performing a number of various kinds of x-rays and reading a number of x-ray films. Every student was responsible for finding all of their own patients to meet the requirements. The result of this was a clinical experience that was quite narrow for most people. This would seem to be quite different to the hospital internship of a medical degree, the clinical internship of a dental degree or the range of placements in a physiotherapy degree in terms of the breadth of experience of different kinds of patients of different ages and states of health.
For people who are not aware, there are a range of ideas within chiropractic about what it is and what it is for. The “wellness”, subluxation-based kind of chiropractic is taught by a minority of schools and is what chiropractors call a “philosophical view”. It advocates that chiropractic care be independent from symptoms or treatment and be a regular part of peoples’ lives. The expectation is that healthy, asymptomatic people will be “adjusted” on a regular basis to keep them free from “vertebral subluxation”. To that end, the training at schools that teach this approach is adequate (and probably even excessive).
The issue that you wrote about related to the use of the title “doctor” by chiropractors in New Zealand. In licensing chiropractors and allowing them the use of the title “Dr” in front of their names (provided that the title is qualified by the word “chiropractor”) governments have awarded chiropractors with recognition and prestige that has usually been associated with a level of academic achievement or with a medical qualification. It indicates that the bearer of the title can be trusted to give credible advice within their area of expertise.
The issue may seem benign, but in allowing chiropractors to use the title, people who would not normally feel safe to submit to the treatment of an alternative health practitioner, choose to try chiropractic. I make this point because at its core, chiropractic is quite different to medicine, dentistry and physiotherapy.
A chiropractic office often looks like a lot like a doctor’s surgery. The layout is similar (with waiting rooms and consultation rooms; there are things like stethoscopes and x-ray machines and there are often informative and education posters and brochures. In many cases, the title “doctor” is used in
I have found that some people believe chiropractors are medical doctors. Some even believe that chiropractic is a kind of medical speciality. I have seen patients who choose chiropractic as their primary health care and come to a chiropractic office as their first port of call when they are unwell. I
Two practices are of particular concern in some chiropractic offices and in my view; these alone should be sufficient reason to prevent chiropractors from calling themselves “doctor”. The first is the systematic and deliberate erosion of a person’s confidence in the medical system. Many offices have anti medical literature in their libraries. Chiropractors are sometimes taught practices to subvert medical credibility. See http://chirobase.org/20PB/top7.html for an example.
The second is a subset of the first but is particularly damaging. It is active opposition to vaccination. At chiropractic school, I was taught anti-vaccination information in my paediatrics course. I have seen books written by chiropractors opposing vaccination and I have seen many offices with anti vaccination leaflets and books in abundance. Now I am all for informed choice but this type of material is rarely accurate or balanced. People are being encouraged not to vaccinate their children by professionals who they believe to be a reliable and prestigious source of information.
Although it may sound paternalistic to people who have not had the privilege of clinical practice (albeit in a profession I no longer agree with), it made me realise several things. The first is that people who are unwell are vulnerable. The second is that there are people who trust “medical” advice unquestioningly.
I believe we should be very careful about who we title as a credible source of advice about health care. Legislation treads a fine line between limiting personal freedom and protecting people from harm.
Aside from the qualification being inconsistent with the academic level that is usually required to use the title “Doctor”, the greatest danger, in my opinion, is that the legal recognition and permission to use the title has allowed chiropractors to assume the mantle of a doctor. In the guise of this respectability, some chiropractors are deliberately eroding confidence in doctors and denying children (and possibly populations) the protection of vaccination.
David, thank you for having the courage to question the use of the title “doctor” by chiropractors. Historically (and in your case), chiropractors fight their battles through litigation so it takes personal courage and integrity to do so.
All I can say is, don’t thank me. It doesn’t take much courage at my age. It takes a lot at yours and the world should be grateful to you.
Replies from chiropractors in the NZMJ
The New Zealand Medical Journal, very properly, allowed right of reply to chiropractore. This week’s issue contains three letters, one of which is from Paul Kelly. It is signed “Dr Brian Kelly B App Sci (Chiro), President, New Zealand College of Chiropractic”. This is not quite the same as appears on his College’s web site which shows the president’s welcome.
It seems that Kelly has not been quite so careful about use of his title on the web site because (as of 21 August) the signature on his address looks like this.
“Dr Brian Kelly, President”. That does seem a bit careless, given that his usage of “Dr” was pointed out in my original editorial, published on 25th July.
Replies to these letters appeared in the September 5th issue of NZMJ.
It was a great delight to visit Amsterdam on 25 October to speak at a meeting off the Vereniging tegen de Kwakzalverij (Society against quackery). Unfortunately their excellent web site is in Dutch, so the best you can do at the moment is to use the Google translation, with its frequently hilarious renderings. Better translations coming soon, I hope.
Niet-reguliere geneeswijzen in de 21ste eeuw in internationaal perspectief
Non-mainstream medicine in the 21st century in an international perspective
The Dutch society has 1800 members and is the oldest and biggest such society in the world. I very much hope that their web site will soon have an English version. That is only appropriate since the origin of the word quack is from the Dutch Kwakzalver. (Kwak=Chatterer, salesman, zalf = salve, ointment). (In contrast the noise made by a duck is simply described by the OED as being “imitative”, though the great Michael Quinion thinks the two usages may be connected.
De Kwakzalver, Jan Steen (1626-1679) Rijksmuseum Amsterdam. Click to enlarge
The Quack doctor, Jan Steen (1626-1679). Click to enlarge
Translations of some key parts will be posted here soon. My talk was about Support for alternative medicine in government and universities in the U.K
The meeting started with the announcement of the winner of the Meester Kackadorisprijs.
The Master Kackodoris prize
The Meester Kackadorisprijs is awarded to individuals or institutions who promote quackery and who should know better (the quacks themselves are never nominated). The short list for the 2008 prize included the vice chancellor of the Free University of Amsterdam
|Prof. dr. Lex Bouter, rector magnificus Vrije Universiteit
The vice-chancellor was on the short-list for the prize because of his part in a recent paper, “Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis.” (Manheimer E, Zhang G, Udoff L, Haramati A, Langenberg P, Berman BM, Bouter LM, Brit Med J 336, 545-9) [Available free]
This paper has been cited all over the world, but it seems not to have been very good. See for example the magnificent analysis of it in “Yawn, still one more overhyped acupuncture study: Does acupuncture help infertile women conceive?” . See also the Cochrane review (it could all be placebo). The fact that the vice-chancellor appears to have been only a ‘guest author’ anyway does not count as an excuse. The large number of citations received by this paper should, incidentally, be seen as another nail in the coffin of attempts to measure quality by citation rates.
In the event, vice-chancellor Bouter did not win the Kackodoris prize this year. In a speech at the start of the symposium, it emerged that he had been narrowly beaten by the Dutch Christian Radio Association for its assiduous promotion of quackery.
The chair of the Dutch society, Cees Rencken, is doing a great job. I hope that it will soon be better known outside the Netherlands.
And it’s time we had a UK equivalent of the Kackadoris prize. There will be no shortage of worthy candidates.
Frits Van Dam (Secretary) and Cees Renckens (Chair) of VtdK
(photo: Sofie van de Calseijde)
Some pictures of Amsterdam
(meetings photos: Sofie van de Calseijde)
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.
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.
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
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?
The Times today has given s good showing for my comment piece. It gives the case against following the advice of the Pittilo report. It simply makes no sense to have government regulation of acupuncture, herbal medicine, traditional Chinese medicine until such time as there is evidence that they work. It makes even less sense to have BSc degrees in them. The Department of Health should have more sense that to use the Prince of Wales as its scientific advisor.
Let’s hope that the recent example set by the University of Central Lancashire is the start of trend for vice-chancellors to appreciate that running such degrees brings their universities into disrepute.
I can only apologise for the dreadful title that The Times’ sub-editors put on the piece, My original title was
A bad report for the vice chancellor
The Pittilo report to the Department of Health will endanger the public and corrupt universities. There is a better way.
I like that much better than “Regulate quack nedicine? I feel sick”.
But, oh dear, the picture that I sent them is on the left, but what appeared is on the right. Spot the difference.
Well now, at least, I can feel I have something in common with Isambard Kingdom Brunel.
It so happens that Professor Pittilo wrote a letter to Times Higher Education this week. I fear that it provided a yet more evidence that he hasn’t really quite got the hang of evidence.
The Lancashire Evening Post catches up with the UCLan story, two days after you read it here.
A reply from Professor Pittilo
This response to the op-ed of 29th August appeared as a letter
in the Times on Sept 2.
|Public health needs protection
Regulation of acupuncture and herbal medicine has been subject to much scrutiny
Sir, Professor Colquhoun’s campaign to discredit our report (“Regulate quack medicine? I feel sick,” Aug 29) is in danger of placing public health at risk. He is entitled to challenge existing evidence for the effectiveness of complementary and alternative medicine (CAM) but fails to acknowledge the key recommendation from the steering group on the essential need to demonstrate efficacy, safety and quality assurance as a prerequisite for NHS funding.
Professor Colquhoun dismisses CAM because of the absence of a rigorous scientific foundation and he asserts that to teach and practise it is unethical. Survey data consistently demonstrates very high demand for CAM with one report estimating that 22 million visits involving 10.6 per cent of the population in England alone occurred in 2008. This demand is one reason why his alternative model of trade law enforcement will not work. He may argue that these people are uncritical recipients of nonsense, but data from the Medicines and Healthcare products Regulatory Agency confirm that they are at significant risk from poor practice. It is essential that we protect the public by implementing statutory regulation alongside demanding evidence of efficacy. Professor Colquhoun’s resistance to the teaching of science to CAM practitioners will do little to help them to critically evaluate effectiveness.
Professor Michael Pittilo
Chair of the Department of Health Steering Group
And Pittilo wrote in similar vein to Times Higher Education.
Science vital to health study
28 August 2008
Your feature on some members of staff at the University of Central Lancashire attacking science degrees in complementary and alternative medicine (“Staff attack science degrees in alternative health”, 7 August) raises a number of concerns.
It is up to any university, taking account of the expert views of staff and external peer review, to determine the appropriate title and award for any degree. It is encouraging to note from the feature that new courses
The recent report to Ministers from the Department of Health Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and other Traditional Medicine
There is no doubt that courses that provide a solid scientific foundation will greatly assist CAM practitioners in establishing evidence-based practice. It would be most unfortunate if the reported resistance to degree titles led to those wishing to practise acupuncture or herbal medicine receiving less hard science than they might have.
To say that acupuncture and herbal medicine degrees have no academic justification appears arrogant in the extreme. Although it is certainly true that some content may not be scientific, this does not invalidate the legitimacy of these courses at degree level, a fact borne out by their successful validation in a number of universities.
R. Michael Pittilo, Principal and vice-chancellor, The Robert Gordon University.
This one got excellent responses from Kevin Smith (University of Abertay, Dundee), and from Peter J. Brophy (Professor of veterinary anatomy and cell biology University of Edinburgh). This was my comment to THE
|There are a few very obvious responses to Professor Pittilo’s letter
For many alternative therapies the “philosophy” is simply incompatible with science. One obvious example is homeopathy. On Mondays and Wednesdays (science days) the students will be required to learn that response increases with dose. On Tuesdays and Thursdays will be taught the opposite. But for the exam they must reproduce only the latter (nonsensical) idea because their aim is to get a job as a homeopath. That makes nonsense of the idea of a university.
This seems to constitute a recognition that the evidence is still very inadequate. The time to start degrees, and the time to give official government recognition, is after the evidence is in, not before. What happens if you start degrees and then find that the subject is so much nonsense? Well, that has already happened in several areas of course. But the people who accredit the course and who act as external examiners just happen to be fervent believers in that nonsense, so all appears to be well (to bean counters anyway).
There is, as it happens, a great deal of evidence now about acupuncture, but the authors of the report do not seem to be aware of it. I recommend Barker Bausell’s book on the topic. If students are educated science, like what constitutes evidence, and our current understanding of words like “energy”, they would have to disavow the subject that there are supposed to training to practise
No, it is not a matter of arrogance, just a matter of careful attention to the evidence. Attention to evidence was notably absent in Prof Pittilo’s report, perhaps because his committee consisted entirely of people who earn their living from the subjects they were supposed to be assessing.
I have had the misfortune to have waded through a mound of such validation documents. The one thing they never consider is whether the treatment works. Sad to say, these validations are not worth the paper they are written on.
This post is written in part as a distraction from a plague of lawyers, in New Zealand, here in the UK, and now in the USA (my movie, Integratative baloney@Yale, has recently been removed from YouTube. More on that coming soon).
The duty of an advocate is to take fees, and in return for those fees to display to the utmost advantage whatsoever falshoods the solicitor has put into his brief.
[ Bentham, Jeremy , The Elements of the art of packing as applied to special juries , 1821]
The letter below comes from a much-copied piece of paper that I unearthed in my office during its decennial clearout. It was typed on a manual typewriter and I have no idea where it came from or whether it is genuine. Its origin has been discussed on the internet, with no firm conclusion. This post is a miscellany of thought that followed its rediscovery.
The alleged quotation shows that there is nothing new about the cult of managerialism, at least in Whitehall. It took longer to reach universities, which are now suffering an acute case of this sad condition,
|MESSAGE FROM THE DUKE OF WELLINGTON TO THE BRITISH FOREIGN OFFICE IN LONDON–
written from Central Spain, August 1812
Whilst marching from Portugal to a position which commands the approach to Madrid and the French forces, my officers have been diligently complying with your requests which have been sent by H.M. ship from London to Lisbon and thence by dispatch to our headquarters.
We have enumerated our saddles, bridles, tents and tent poles, and all manner of sundry items for which His Majesty’s Government holds me accountable. I have dispatched reports on the character, wit, and spleen of
Unfortunately the sum of one shilling and ninepence remains unaccounted for in one infantry battalion’s petty cash and there has been a hideous confusion as to the number of jars of raspberry jam issued to one cavalry
This brings me to my present purpose, which is to request elucidation of my instructions from His Majesty’s Government so that I may better understand why I am dragging an army over these barren plains. I construe that perforce it must be one of two alternative duties, as given below. I shall pursue either one with the best of my ability, but I cannot do both:
Your most obedient servant,
Substitute the options
“I shall pursue either one with the best of my ability, but I cannot do both:
- To spend my days in endless meetings and form-filling for the benefit of the accountants and copy-boys in central administration, or perchance
- To do some original science.”
It seems a bit odd to be citing approvingly Arthur Wellesley, 1st Duke of Wellington. As a politician he was a high Tory and arch-opponent of parliamentary reform. He became prime minister in 1828, two years after
the foundation of UCL, the ‘godless institution of Gower Street”, and he was instrumental in the foundation of the traditionally religious rival to UCL, King’s College London.
Wellington’s government fell in 1830, and a Whig goverment was formed with Earl Grey as prime minister. In 1832, after many struggles, Lord John Russell managed to get the Great Reform Act passed (properly known as the Representation of the People Act 1832). This was an enormously important reform. It could be said to mark the beginning of true democracy in the UK.
The Whigs had been out of power for most of the time since the 1770s. But there were riots in the country and the Whigs advocated political reform as the best response to the unrest. Wellington, on the other hand, ignored the riots and continued with the Tory policy of opposition all reform and to any expansion of the franchise. He got the nickname “the iron duke” not because of his military prowess but because of the iron shutters he had to put on his London home, Apsley House, as protection against rioters. He lost a vote of no confidence on 15 November 1830, and was replaced as Prime Minister by Earl Grey, who put the passage of the Reform Bill in the hands of Lord John Russell
Lord John Russell was the grandfather of Bertrand Russell, whose 1935 essay, On the Value of Scepticism, had an enormous influence on me. This following quotation I find just beautiful, both the ideas, the wonderfully simple prose in which he conveys the ideas, and the Voltaire-like pure mischiefness.
|I wish to propose for the reader’s favourable consideration a doctrine which may, I fear, appear wildly paradoxical and subversive. The doctrine in question is this: that it is undesirable to believe a proposition when there is no ground whatever for supposing it true. I must, of course, admit that if such an opinion became common it would completely transform our social life and our political system: since both are at present faultless, this must weigh against it. I am also aware (what is more serious) that it would tend to diminish the incomes of clairvoyants, bookmakers, bishops and others who live on the irrational hopes of those who have done nothing to deserve good fortune here or hereafter. In spite of these grave arguments, I maintain that a case can be made out for my paradox, and I shall try to set it forth.
Bertrand Russell, 1935. On the Value of Scepticism
Bertrand Russell was brought up by his grandfather, Lord John Russell in Pembroke Lodge at the edge of Richmond Park (I’ve been there often, but only because it became a tea room, a welcome break from marathon training in the park). I saw Russell in the distance, speaking in Trafalgar Square at a CND rally in about 1963. It is the most striking example I know of the the very short time than there has been any real democracy in the UK. I was one step away from the passing of the Reform Act, the founding of UCL and medical reforms.
The medical connections.
Adrian Desmond’s fascinating book, The Politics of Evolution. described what was happening in medicine and biology at around the same time as Wellington was deposed, and the Reform Bill was passed. There was equal turmoil in the medical world. Radicals in London agitated for removal of the hegemony of the Royal Colleges and of Oxford and Cambridge, so proper medical schools could be established in London. That is the atmosphere in which UCL’s medical school was born.
Many of the first staff there came from Scotland. Robert Grant, UCL’s first professor of comparative anatomy, came from Edinburgh and brought to UCL the new French ideas about evolution, especially those of Geoffroy. His influence was enormous, not least because Charles Darwin was one of his students.
The same period saw the foundation in 1823 of Thomas Wakley’s “ribald and radical” medical journal, The Lancet. The Wikipedia entry gives us a taste of Wakley’s style,
“[We deplore the] “state of society which allows various sets of mercenary, goose-brained monopolists and charlatans to usurp the highest privileges…. This is the canker-worm which eats into the heart of the medical body.” Wakley, The Lancet 1838-9, 1,
“The Council of the College of Surgeons remains an irresponsible, unreformed monstrosity in the midst of English institutions – an antediluvian relic of all… that is most despotic and revolting, iniquitous and insulting, on the face of the Earth.” Wakley, The Lancet 1841-2,
He was especially severe on whomever he regarded as quacks. The English Homeopathic Association were “an audacious set of quacks” and its supporters “noodles and knaves, the noodles forming the majority, and the knaves using them as tools”.  “
Plus ça change, plus c’est la même chose.
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
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
Inappropriate use of titles by some alternative “medicine” practitioners
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.
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: firstname.lastname@example.org
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.
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:
6.2 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
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
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 itmay, 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?
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.
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.
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