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Integrated Health – DC's Improbable Science

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

Alice Miles put it well in The Times, today.

“This week came the publication of the “Report to Ministers from the Department of Health Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and Other Traditional Medicine Systems Practised in the UK”. Otherwise known as twaddle.” . . .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The evidence

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

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

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

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

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

Have the authors of Annexe 1, and Professor Pittilo, not read the relevant studies? Two books this year have dealt with the question of evidence with great care. They are both by people who have been involved personally with acupuncture research, Prof Edzard Ernst and Dr Barker Bausell. Edzard Ernst is the UK’s first Professor of Complementary Medicine. Barker Bausell was research director of an NIH-funded Complementary and Alternative Medicine Specialized Research Center at the University of Maryland.

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

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

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

“There is no compelling, credible scientific evidence to suggest that any CAM therapy benefits any medical condition or reduces any medical symptom (pain or otherwise) better than a placebo”.

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

Degrees in anti-science

One conclusion of the report is that

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

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

3a: Registrant acupuncturists must:

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

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

– causes of disharmony/disease causation

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

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

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

So what should be done?

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

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

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

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

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

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

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

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

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

Follow up

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

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

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

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

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