Download Lectures on Biostatistics (1971). Corrected and searchable version of Google books edition
Download review of Lectures on Biostatistics (THES, 1973).
Two days ago I wrote NICE falls for Bait and Switch by acupuncturists and chiropractors: it has let down the public and itself
Now the official ‘guidance’ is out, and it is indeed quite as bad as the draft.
The relevant bits now read thus.
- Offer one of the following treatment options, taking into account patient preference: an exercise programme, a course of manual therapy or a course of acupuncture. Consider offering another of these options if the chosen treatment does not result in satisfactory improvement.
- Consider offering a structured exercise programme tailored to the person:
- This should comprise of up to a maximum of 8 sessions over a period of up to 12 weeks.
- Offer a group supervised exercise programme, in a group of up to 10 people.
- A one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.
- Consider offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks
- Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of up to 12 weeks.
The summary guidance still doesn’t mention chiropractic explicitly, just a coy reference to “spinal manipulation”. At a time when the British Chiropractic Association is busy trying to suppress free speech via the law courts, I guess it isn’t surprising that they don’t like to use the word.
The bias in the recommendations is perhaps not surprising because the guidance development group had a heavy representation from alternative medicine advocates, and of people with a record of what, is, in my view, excessive tolerance of mumbo-jumbo.
Royal College of General Practitioners (RCGP) played a large part in writing the guidance. That is an organisation thar has steadfastly refused to make any sort of sensible statement of policy about magic medicine. It isn’t long since I was told by a senior person at the RCGP that there was nothing odd about neuro-linguistic programming. That does not bode well.
Professor Martin Underwood, Professor of Primary Care Research Warwick Medical School, University of Warwick. Underwood chaired the guidance development group. Martin Underwood is also a GP in Coventry See also the British Osteopathic Association. Underwood was lead author of the BEAM trial (download reprint). It is well worth reading the comments on this trial too. It was a randomised trial (though not, of course, blind).
|
Our main aim was to estimate, for patients consulting their general practitioner with back pain, the effectiveness of adding the following to best care in general practice: a class based exercise programme (“back to fitness”), a package of treatment by a spinal manipulator (chiropractor, osteopath, or physiotherapist), or manipulation followed by exercise Conclusions |
In other words, none of them worked very well. The paper failed to distinguish between manipulation by physiotherapists, chiropractors and osteopaths and so missed a valuable chance to find out whether there is an advantage to employing people from alternative medicine (the very problem that this NICE guidance should have dealt with)
Steve Vogel, another member of the guidance development group, is an osteopath. Osteopathy has cast off its shady origins better than chiropractic, but it remains a largely evidence-free zone, and is still usually classified as alternative medicine.
Peter Dixon DC FCC FBCA is chairman of the General Chiropractic Council and founder of Peter Dixon Associates. They run six chiropractic clinics. The claims made by these clinics on their web site are mostly related to musculo-skeletal conditions (not, all spine-related however). But they also include
“Chiropractic is also suitable for relieving the symptoms of stress, and optimizing the way the body works is one of the best ways of enhancing health and wellbeing.”
I wonder how they could justify that claim? Then we get
A chiropractor is always willing to discuss individual conditions or answer questions in order to assess whether chiropractic may be of benefit.
Thanks for the invitation. I accepted it. After the first two phone calls, I had learned all I needed.
The first of Peter Dixon’s clinics that I called, was asked about my son who was suffeiing from perpetual colic. I asked for advice. I was put through to the chiropractor. Here are some extracts from the conversation.
“I think now it’s termed irritable baby syndrome. . . . . We’ve found chiropractic is very effective for colic . . . . £50 up to 3/4 hour which would involve taking a case history, examining the baby, with regard to seeing how the joints in the spine work because often colic is down to, er um, faulty movement patterns in the spine. We deal with an awful lot of things to do with the frame -how the spine moves -and it’s often problems with the way that the bones of the spine move in infants and babies that is the underlying cause in colicky symptoms. . . usually on the whole, I’ve shot myself in the foot by saying this in the past, if there are -um when I say back problems they’re usually temporary issues -when they are there the response for most babies is quite quick . . . it depends on how it’s related to what’s gone on in the birth process -there is usually some traumatic cause and it usually sets up a problem in the upper neck or the mid-back and that will drive those colic symptoms. . . . Yes it’s quite a straightforward thing we just check the baby’s spine and see if it’s problem we can deal with or not.”
Yes, I think you just shot yourself in the foot again. I have no idea in what fraction of cases a chiropractor would fail to claim that it was a case that they could deal with. At least that possibility was envisaged. But when I asked where he’d refer me to in such case I was told it might be a result of bottle feeding -“what they consume”. So I expect it would have been sent to some sort of “nutritional therapist” who would have used one of their usual battery of unreliable tests for food allergies.
I tried a second clinic in Peter Dixon’s empire and asked if chiropractic could help with asthma.”It can do, depending on what type of asthma you have". After some questions I was asked
“Do you have any general aches and pains otherwise, any tension .problems round the rib cage or thoracic spine . . . There are two things we’d look as chiropractors as to whether we could help or not and that would include the tension round the rib cage -in any type of asthma you’ll become tight round the rib cage and merely by keeping that area loose you’d help to stop the asthma from becoming quite as bad. And the second part is we’d look at the neck area with you to see if there is any restriction there -which houses the nerve supply to the lungs which can be indicated in some asthma cases also.”
I was invited to come for a free screen, so I asked if it usually worked quickly, “It depends what the problem is but you’d need a course I suspect”. £45 for the first appointment then £28 per session. “In most cases you’d need to look at a six to eight session course”.
Would anyone with experience of crying babies or of asthma like to comment on these proposed treatments? They are not my idea of evidence-based treatments and I find it quite surprising that someone who sponsors them is thought appropriate to write guidance for NICE.
This sort of ‘sting’ always makes me feel a bit uneasy, but it seems to be the only way to find out what actually goes on. And what goes on has all the appearance of classic bait and switch. You go in for your backache, and before you know where you are you are being sold a course of treatment to stop your baby crying.
Media follow-up after the NICE announcement
Sadly, I heard that the Today programme (my favourite news programme) was pretty wet. if only their science reporting was as good as their politics reporting.
The 27th May was certainly pretty busy for me, Apart from a couple of local paper interviews, this is what happened,
Sky News TV. Richard Suchet and two cameraman came to UCL and filmed a lot of stuff out of which a 20 second clip was used. And then they grumble that they don’t make money.
BBC TV 6 o’clock News. Similar, but at least only two people this time. Both TV stations spent ages showing pictures of people having needles pushed into them and very little time discussing the problems. A pathetically bad attempt at science reporting. Radio, on the whole, did much better
BBC Three Counties Radio (09.20) Host Ronnie Barbour, The daytime talk shows may be appalling to some of us, but the hosts did a far better job of airing the problems than TV [download the mp3].
Radio 5 Live Victoria Derbyshire [download the mp3]
BBC Radio Sheffield (12.05) was the best talk show by far. First speaker was Steve Vogel, the osteopath from the guidance development group. Although invited by the rather sensible host, Rony, to respond to the idea that a secondary consequence of the guidance would be to introduce hocus-pocus, he steadfastly refused to answer the question. At the end a rather sensible GP summed up the view from the coalface. [play the mp3]
Radio 4 PM programme This excellent early evening news programme is run by Eddie Mair. It was the best interview yet. The other side was put by Martin Underwood, chair of the guidance development group [play the mp3]
Underwood said “the evidence shows that it [acupuncture] works”. I disagree. The evidence shows that acupuncture, in a non-blind comparison with no acupuncture shows a small, variable additional effect that doesn’t last and is of marginal clinical significance, That is not what I call “works”. Underwood then indulges in the subgroup analysis fallacy by asserting that a few people get a large benefit from acupuncture. Or perhaps a few people just happen to get better that day. I was not convinced.
More 4 News TV 20.20 was an interview, with the other side being put by my old friend, George Lewith.
During the introduction, an acupuncturist. Lisa Sherman, ‘explained’ acupuncture in the usual sort of utterly meaningless words that illustrate perfectly the problem.
George Lewith said that “we don’t have a good pretend form of acupuncture”. “We don’t have a good placebo and we can demonstrate that acupuncture is literally twice as effective as conventional care”. The first is simply nonsense: huge efforts have gone into developing good controls in acupuncture studies (see, for example, Barker Bausell’s book, Snake Oil Science). And I hope that George will send the references for his “twice as effective” claim. It seems to me to be nothing short of preposterous.
My conclusions
So what went wrong?
One problem could be regarded as medical arrogance. The fact is that the problem of low back pain has not been solved, either by drugs or anything else. It is a failure of medicine (and of pharmacology). That should be the premise of all discussions, and it smacks of arrogance not to tell people straight out. Of course there are some cases when causes can be identified, and perhaps remedied, usually by surgery, but these are the exceptions not the rule.
One consequence of the inability of medicine to help much is that patients get desperate, and willing to try anything. And of course if they happen to have a remission, that is attributed to the treatment, however preposterous that treatment may have been. Conditions like back pain that come and go unpredictable are a gift for quacks.
Another consequence, for researchers rather than patients, is to clutch at straws. Even small and inconsistent effects are seized on as ‘successes’. This phenomenon seems to be part of the reason for the NICE guidance. Another reason is, almost certainly, the grinding of axes by some of the people who wrote it.
What should be done now?
Professor Sir Michael Rawlins is a sensible chap. He cares about evidence, But it does seem that in this case, he might have taken his eye off the ball, for once. In my opinion, he should restore the reputation of NICE by withdrawing this guidance and starting again.
Follow-up
An interesting document has come my way. It shows the responses of the guidance group to the consultation on the draft guidance. Many people made comments not unlike mone, but they were all brushed aside in a way that looks to me rather partisan. The document appears to have vanished from NICE’s web site, but you can download it here.
Friday 29th May. The Times prints a letter from two consultants in pain medicine, Joan Hestor and Stephen Ward. It says, inter alia
“As experienced pain specialists we feel that NICE has lost its way in publishing these guidelines.”
“We are saddened that NICE has chosen to ignore our important role and promote seemingly unworkable and for the most part clinically ineffective treatments”
Friday 29th May. NICE has had a good reputation in the USA for its important, and usually high-quality, attempts to assess what works and what doesn’t. That makes it all the sadder to see it condemned already from the USA for its latest effort. The excellent Yale neurologist, Steven Novella, has written about it on his Neurologica blog.
Friday 29th May. A correspondent points out that the costings of the guidance can be found on the NICE web site. Table 1 has a strong air of make-believe.
The Daily Mail (29 May 2009). Their article quotes serious criticisms of NICE.
Dr Ron Cooper, past chairman of the group and a consultant pain specialist in Northern Ireland, said: ‘I have never known so many pain medicine specialists to be so furious. More patients will end up having more expensive surgery, which is unnecessary, risky and has worse results.
‘NICE made it difficult for us to submit evidence to a committee on which there was not one experienced pain physician.
‘The guidelines will make us the laughing stock of Europe, Australia and the U.S. where pain specialists will continue to have full access to a wide range of treatments.’
Chirowatch suspended. 30 May 2009. The invaluable chiro-watch site, http://www.chirowatch.com, run by Dr Canadian physician, Dr Tom Polevoy, has been “suspended”. In fact the whole of his domain, healthwatcher.net, has been disabled. It seems that this was the result of a legal threat to his ISP, not by chiropractors this time, but by William O’Neill of the Canadian Cancer Research Group, which is far from being what the respectable-sounding title suggests, according to Dr Stephen Barrett. The site will be back soon, I’m told. Meanwhile you can read the suspended page here, and the only result of their hamfisted bullying will be to vastly increase the number of people who read it. You can read lots more at Quackwatch’s chirobase and at ebm-first.
A new blog, Not as NICE as you think appeared on May 30th. It is written by a pain physician, Stephen Ward. and is devoted to pointing out the serious problems raised by NICE’s guidance. It starts with the (very critical) World Institute of Pain Press Release.
British Medical Journal has more flak for the NICE guidelines
And the BMJ has published a letter signed by 50 consultants in pain medicine, NICE guidelines on low back pain are flawed.(this will probably appear as a letter in the print edition of the BMJ).
First the MHRA lets down the public by allowing deceptive labelling of sugar pills (see here, and this this blog). Now it is the turn of NICE to betray its own principles.
The National Institute for Health and Clinical Excellence (NICE) describes its job thus
“NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health.”
Its Guidance document on Low Back Pain will be published on Wednesday 27 May 2009, but the newspapers have already started to comment, presumably on the assumption that it will have changed little from the Draft Guidance of September 2008. These comments may have to be changed as soon as the final version becomes available.
The draft guidance, though mostly sensible, has two recommendations that I believe to be wrong and dangerous. The recommendations include (page 7) these three.
- Consider offering a course of manual therapy including spinal manipulation of up to 9 sessions over up to 12 weeks.
- Consider offering a course of acupuncture needling comprising up to 10 sessions over a period of up to 12 weeks.
- Consider offering a structured exercise programme tailored to the individual.
All three of this options are accompanied by a footnote that reads thus.
“A choice of any of these therapies may be offered, taking into account patient preference.”
On the face if it, this might seem quite reasonable. All three choices seem to be about as effective (or ineffective) as each other, so why not let patients choose between them?
Actually there are very good reasons, but NICE does not seem to have thought about them. In the past I have had a high opinion of NICE but it seems that even they are now getting bogged down in the morass of political correctness and officialdom that is the curse of the Department of Health. It is yet another example of DC’s rule number one.
Never trust anyone who uses the word ‘stakeholder’.
They do use it, often.
So what is so wrong?
For a start, I take it that the reference to “spinal manipulation” in the first recommendation is a rather cowardly allusion to chiropractic. Why not say so, if that’s whar you mean? Chiropractic is mentioned in the rest of the report but the word doesn’t seem to occur in the recommendations. Is NICE perhaps nervous that it would reduce the credibility of the report if the word chiropractic were said out loud?
Well, they have a point, I suppose. It would.
That aside, here’s what’s wrong.
The Evidence
I take as my premise that the evidence says that no manipulative therapy has any great advantage over the others. They are all more or less equally effective. Perhaps I should say, more or less equally ineffective, because anyone who claims to have the answer to low back pain is clearly deluded (and I should know: nobody has fixed mine yet). So for effectiveness there are no good grounds to choose between exercise, physiotherapy, acupuncture or chiropractic. There is, though, an enormous cultural difference. Acupuncture and chiropractic are firmly in the realm of alternative medicine. They both invoke all sorts of new-age nonsense for which there isn’t the slightest good evidence. That may not poison your body, but it certainly poisons your mind.
Acupuncturists talk about about “Qi”, “meridians”, “energy flows”. The fact that “sham” and “real” acupuncture consistently come out indistinguishable is surely all the evidence one needs to dismiss such nonsense. Indeed there is a small group of medical acupuncturists who do dismiss it. Most don’t. As always in irrational subjects, acupuncture is riven by internecine strife between groups who differ in the extent of their mystical tendencies,
Chiropractors talk of “subluxations”, an entirely imaginary phenomenon (but a cause of much unnecessary exposure to X-rays). Many talk of quasi-religious things like “innate energy”. And Chiropractic is even more riven by competing factions than acupuncture. See, for example, Chiropractic wars Part 3: internecine conflict.
The bait and switch trick
This is the basic trick used by ‘alternative therapists’ to gain respectability.
There is a superb essay on it by the excellent Yale neurologist Steven Novella: The Bait and Switch of Unscientific Medicine. The trick is to offer some limited and reasonable treatment (like back manipulation for low back pain). This, it seems, is sufficient to satisfy NICE. But then, once you are in the showroom, you can be exposed to all sorts of other nonsense about “subluxations” or “Qi”. Still worse, you will also be exposed to the claims of many chiropractors and acupuncturists to be able to cure all manner of conditions other than back pain. But don’t even dare to suggest that manipulation of the spine is not a cure for colic or asthma or you may find yourself sued for defamation. The shameful legal action of the British Chiropractic Association against Simon Singh (follow it here) led to an addition to DC’s Patients’ Guide to Magic Medicine.
(In the face of such tragic behaviour, one has to be able to laugh).
Libel: A very expensive remedy, to be used only when you have no evidence. Appeals to alternative practitioners because truth is irrelevant.
NICE seems to have fallen for the bait and switch trick, hook line and sinker.
The neglected consequences
Once again, we see the consequences of paying insufficient attention to the Dilemmas of Alternative Medicine.
The lying dilemma
If acupuncture is recommended we will have acupuncturists telling patients about utterly imaginary things like “Qi” and “meridians”. And we will have chiropractors telling them about subluxations and innate energy. It is my opinion that these things are simply make-believe (and that is also the view of a minority of acupuncturist and chiropractors). That means that you have to decide whether the supposed benefits of the manipulation are sufficient to counterbalance the deception of patients.
Some people might think that it was worth it (though not me). What is unforgivable is not to consider even the question. The NICE guidance says not a word about this dilemma. Why not?
The training dilemma
The training dilemma is even more serious. Once some form of alternative medicine has successfully worked the Bait and Switch trick and gained a toehold in the NHS, there will be an army of box-ticking HR zombies employed to ensure that they have been properly trained in “subluxations” or “Qi”. There will be quangos set up to issue National Occupational Standards in “subluxations” or “Qi”. Skills for Health will issue “competences” in “subluxations” or “Qi” (actually they already do). There will be courses set up to teach about “subluxations” or “Qi”, some even in ‘universities’ (there already are).
The respectability problem
But worst of all, it will become possible for aupuncturists and chiropractors to claim that they now have official government endorsement from a prestigious evidence-based organisation like NICE for “subluxations” or “Qi”. Of course this isn’t true. In fact the words “subluxations” or “Qi” are not even mentioned in the draft report. That is the root of the problem. They should have been. But omitting stuff like that is how the Bait and Switch trick works.
Alternative medicine advocates crave, above all, respectability and acceptance. It is sad that NICE seems to have given them more credibility and acceptance without having considered properly the secondary consequences of doing so,
How did this failure of NICE happen?
It seems to have been a combination of political correctness, failure to consider secondary consequences, and excessive influence of the people who stand to make money from the acceptance of alternative medicine.
Take, for example, the opinion of the British Pain Society. This organisation encompasses not just doctors. It
includes “doctors, nurses, physiotherapists, scientists, psychologists, occupational therapists and other healthcare professionals actively engaged in the diagnosis and treatment of pain and in pain research for the benefit of patients”. Nevertheless, their response to the draft guidelines pointed out that the manipulative therapies as a whole were over-represented.
|
Manipulation The guidelines assess 9 large groups of interventions of which manual therapies are only one part. The full GDG members panel of 13 individuals included two proponents of spinal manipulation/mobilisation (P Dixon and S Vogel). In addition, the chair of the panel (M Underwood) is the lead author of the UKBEAM trial on which the positive recommendation for |
It seems that the Pain Society were quite right.
LBC 97.3 Breakfast Show (25 May 2009) had a quick discussion on acupuncture (play mp3 file). After I had my say, the other side was put by Rosey Grandage. She has (among other jobs) a private acupuncture practice so she is not quite as unbiassed as me). As usual, she misrepresents the evidence by failing to distinguish between blind and non-blind studies. She also misrepresented what I said by implying that I was advocating drugs. That was not my point and I did not mention drugs (they, like all treatments, have pretty limited effectiveness, and they have side effects too). She said “there is very good evidence to show they (‘Qi’ and ‘meridians’] exist”. That is simply untrue.
There can’t be a better demonstration of the consequences of falling for bait and switch than the defence mounted by Rosey Grandage. NICE may not mention “Qi” and “meridians”; but the people they want to allow into the NHS have no such compunctions.
I first came across Rosey Grandage when I discovered her contribution to the Open University/BBC course K221. That has been dealt with elsewhere. A lot more information about acupuncture has appeared since then. She doesn’t seem to have noticed it. Has she not seen the Nordic Cochrane Centre report? Nor read Barker Bausell, or Singh & Ernst? Has she any interest in evidence that might reduce her income? Probably not.
Where to find out more
An excellent review of chiropractic can be found at the Layscience site. It was written by the indefatigable ‘Blue Wode’ who has provided enormous amounts of information at the admirable ebm-first site (I am authorised to reveal that ‘Blue Wode’ is the author of that site). There you will also find much fascinating information about both acupuncture and about chiropractic.
I’m grateful to ‘Blue Wode’ for some of the references used here.
Follow-up
| The Prince of Wales’ Foundation for Integrated Health (FiH) is a propaganda organisation that aims to persuade people, and politicians, that the Prince’s somewhat bizarre views about alternative medicine should form the basis of government health policy.
His attempts are often successful, but they are regarded by many people as being clearly unconstitutional. |
 |
The FiH’s 2009 AnnualConferen ce conference was held at The King’s Fund, London 13 – 14 May 2009. It was, as always, an almost totally one-sided affair devoted to misrepresentation of evidence and the promotion of magic medicine. But according to the FiH, at least, it was a great success. The opening speech by the Quacktitioner Royal can be read here. It has already been analysed by somebody who knows rather more about medicine than HRH. He concludes
“It is a shocking perversion of the real issues driven by one man; unelected, unqualified and utterly misguided”.
We are promised some movie clips of the meeting. They might even make a nice UK equivalent of “Integrative baloney @ Yale“.
This post is intended to provide some background information about the speakers at the symposium. But let’s start with what seems to me to be the real problem. The duplicitous use of the word “integrated” to mean two quite different things.
The problem of euphemisms: spin and obfuscation
One of the problems of meetings like this is the harm done by use of euphemisms. After looking at the programme, it becomes obvious that there is a rather ingenious bit of PR trickery going on. It confuses (purposely?) the many different definitions of the word “integrative” . One definition of “Integrative medicine” is this (my emphasis).
” . . . orienting the health care process to engage patients and caregivers in the full range of physical, psychological, social, preventive, and therapeutic factors known to be effective and necessary for the achievement of optimal health.”
That is a thoroughly admirable aim. And that, I imagine, is the sense in which several of the speakers (Marmot, Chantler etc) used the term. Of course the definition is rather too vague to be very helpful in practice, but nobody would dream of objecting to it.
But another definition of the same term ‘integrative medicine’ is as a PR-friendly synonym for ‘alternative medicine’, and that is clearly the sense in which it is used by the Prince of Wales’ Foundation for Integrated Health (FIH), as is immediately obvious from their web site.
The guide to the main therapies supports everything from homeopathy to chiropractic to naturopathy, in a totally uncritical way. Integrated service refers explicitly to integration of ‘complementary’ medicine, and that itself is largely a euphemism for alternative medicine. For example, the FIH’s guide to homeopathy says
“What is homeopathy commonly used for?
Homeopathy is most often used to treat chronic conditions such as asthma; eczema; arthritis; fatigue disorders like ME; headache and migraine; menstrual and menopausal problems; irritable bowel syndrome; Crohn’s disease; allergies; repeated ear, nose, throat and chest infections or urine infections; depression and anxiety.”
But there is not a word about the evidence, and perhaps that isn’t surprising because the evidence that it works in any of these conditions is essentially zero.
The FIH document Complementary Health Care: A Guide for Patients appears to have vanished from the web after its inaccuracy received a very bad press, e.g. in the Times, and also here. It is also interesting that the equally widely criticised Smallwood report (also sponsored by the Prince of Wales) seems to have vanished too).
The programme for the meeting can be seen here, for Day 1, and Day 2
Conference chair Dr Phil Hammond, GP, comedian and health service writer. Hammond asked the FIH if I could speak at the meeting to provide a bit of balance. Guess what? They didn’t want balance.
09:30 Opening session
Dr Michael Dixon OBE
09:30 Introduction: a new direction for The Prince’s Foundation for Integrated Health and new opportunities in integrated health and care. Dr Michael Dixon, Medical Director, FIH
Michael Dixon is devoted to just about every form of alternative medicine. As well as being medical director of the Prince’s Foundation he also runs the NHS Alliance. Despite its name, the NHS Alliance is nothing to do with the NHS and acts, among other things, as an advocate of alternative medicine on the NHS, about which it has published a lot.
Dr Dixon is also a GP at College Surgery, Cullompton, Devon, where his “integrated practice” includes dozens of alternative practitioners. They include not only disproven things like homeopathy and acupuncture, but also even more bizarre practitioners in ‘Thought Field Therapy‘ and ‘Frequencies of Brilliance‘.
To take only one of these, ‘Frequencies of Brilliance’ is bizarre beyond belief. One need only quote its founder and chief salesperson.
“Frequencies of Brilliance is a unique energy healing technique that involves the activation of energetic doorways on both the front and back of the body.”
“These doorways are opened through a series of light touches. This activation introduces high-level Frequencies into the emotional and physical bodies. It works within all the cells and with the entire nervous system which activates new areas of the brain.”
“Frequencies of Brilliance is a 4th /5th dimensional work. The process is that of activating doorways by lightly touching the body or working just above the body.”
“Each doorway holds the highest aspect of the human being and is complete in itself. This means that there is a perfect potential to be accessed and activated throughout the doorways in the body.”
Best of all, it can all be done at a distance (that must help sales a lot). One is reminded of the Skills for Health “competence” in distant healing (inserted on a government web site at the behest (you guessed it) of the Prince’s Foundation, as related here)
“The intent of a long distance Frequencies of Brilliance (FOB) session is to enable a practitioner to facilitate a session in one geographical location while the client is in another.
A practitioner of FOB that has successfully completed a Stage 5 Frequency workshop has the ability to create and hold a stable energetic space in order to work with a person that is not physically present in the same room.
The space that is consciously created in the Frequencies of Brilliance work is known as the “Gap”. It is a space of nonlinear time. It contains ”no time and no space” or respectively “all time and all space”. Within this “Gap” a clear transfer of the energies takes place and is transmitted to an individual at a time and location consciously intended. Since this dimensional space is in non-linear time the work can be performed and sent backward or forward in time as well as to any location.
The Frequencies of Brilliance work cuts through the limitations of our physical existence and allows us to experience ourselves in other dimensional spaces. Therefore people living in other geographic locations than a practitioner have an opportunity to receive and experience the work.
The awareness of this dimensional space is spoken about in many indigenous traditions, meditation practices, and in the world of quantum physics. It is referred to by other names such as the void, or vacuum space, etc.”
This is, of course, preposterous gobbledygook. It, and other things in Dr Dixon’s treatment guide, seem to be very curious things to impose on patients in the 21st century.
Latest news. The Mid-Devon Star announces yet more homeopathy in Dr Dixon’s Cullompton practice. This time it comes in the form of a clinic run from the Bristol Homeopathic Hospital. I guess they must be suffering from reduced commissioning like all the other homeopathic hospitals, but Dr Dixon seems to have come to their rescue. The connection seems to be with Bristol’s homeopathic consultant, Dr Elizabeth A Thompson. On 11 December 2007 I wrote to Dr Thompson, thus
|
In March 2006, a press release http://www.ubht.nhs.uk/press/view.asp?257 announced a randomised trial for homeopathic treatment of asthma in children. This was reported also on the BBC http://news.bbc.co.uk/1/hi/england/bristol/4971050.stm . I’d be very grateful if you could let me know when results from this trial will become available. Yours sincerely David Colquhoun |
The reply, dated 11 December 2007, was unsympathetic
|
I have just submitted the funders report today and we have set ourselves the deadline to publish two inter-related papers by March 1st 2007. Can I ask why you are asking and what authority you have to gain this information. I shall expect a reply to my questions, |
I answered this question politely on the same day but nevertheless my innocent enquiry drew forth a rather vitriolic complaint from Dr Thompson to the Provost of UCL (dated 14 December 2007). In this case, the Provost came up trumps. On 14 January 2008 he replied to Thompson: “I have looked at the email that you copied to me, and I must say that it seems an entirely proper and reasonable request. It is not clear to me why Professor Colquhoun should require some special authority to make such direct enquiries”. Dr Thompson seems to be very sensitive. We have yet to see the results of her trial in which I’m still interested.
Not surprisingly, Dr Dixon has had some severe criticism for his views, not least from the UK’s foremost expert on the evidence for efficacy, Prof Edzard Ernst. Accounts of this can be found in Pulse,
and on Andrew Lewis’s blog.
Dixon is now (in)famous in the USA too. The excellent Yale neurologist, Steven Novella, has written an analysis of his views on Science Based Medicine. He describes Dr. Michael Dixon as “A Pyromaniac In a Field of (Integrative) Straw Men”
Peter Hain
09:40 Politics and people: can integrated health and care take centre stage in 2009/2010? Rt Hon Peter Hain MP
It seems that Peter Hain was converted to alternative medicine when his first baby, Sam, was born with eczema. After (though possibly not because of) homeopathic treatment and a change in diet, the eczema got better. This caused Hain, while Northern Ireland Secretary to spend £200,000 of taxpayers’ money to set up a totally uninformative customer satisfaction survey, which is being touted elsewhere in this meeting as though it were evidence (see below). I have written about this episode before: see Peter Hain and Get Well UK: pseudoscience and privatisation in Northern Ireland.
I find it very sad that a hero of my youth (for his work in the anti-apartheid movement) should have sunk to promoting junk science, and even sadder that he does so at my expense.
There has been a report on Hain’s contribution in Wales Online.
09:55 Why does the Health Service need a new perspective on health and healing? Sir Cyril Chantler, Chair, King’s Fund, previous Dean, Guy’s Hospital and Great Ormond Street
Cyril Chantler is a distinguished medical administrator. He also likes to talk and we have discussed the quackery problem several times. He kindly sent me the slides that he used. Slide 18 says that in order to do some good we “need to demonstrate that the treatment is clinically effective and cost effective for NHS use”. That’s impeccable, but throughout the rest of the slides he talks of integrating with complementary” therapies, the effectiveness of which is either already disproved or simply not known.
I remain utterly baffled by the reluctance of some quite sensible people to grasp the nettle of deciding what works. Chantler fails to grasp the nettle, as does the Department of Health. Until they do so, I don’t see how they can be taken seriously.
10.05 Panel discussion
The Awards
10:20 Integrated Health Awards 2009 Introduction: a review of the short-listed applications
10:45 Presentations to the Award winners by the special guest speaker
11:00 Keynote address by special guest speaker
Getting integrated
Dr David Peters
12:00 Integration, long term disease and creating a sustainable NHS. Professor David Peters, Clinical Director and Professor of Integrated Healthcare, University of Westminster
I first met David Peters after Nature ran my article, Science Degrees without the Science. .One of the many media follow-ups of that article was on Material World (BBC Radio 4). This excellent science programme, presented by Quentin Cooper, had a discussion between me and David Peters ( listen to the mp3 file).
There was helpful intervention from Michael Marmot who had talked, in the first half of the programme, about his longitudinal population studies.
Marmot stressed the need for proper testing. In the case of
homeopathy and acupuncture, that proper testing has largely been done. The tests were failed.
The University of Westminster has, of course, gained considerable notoriety as the university that runs more degree programmes in anti-scientific forms of medicine than any other. Their lecture on vibrational medicine teaches students that amethysts “emit high Yin energy so transmuting lower energies and clearing and aligning energy disturbances at all levels of being”. So far their vice-chancellor, Professor Geoffrey Petts, has declined to answer enquiries about whether he thinks such gobbledygook is appropriate for a BSc degree.
But he did set up an internal enquiry into the future of their alternative activities. Sadly that enquiry seems to have come to the nonsensical conclusion that the problem can be solved by injection of good science into the courses, as reported here and in the Guardian.
It seems obvious that if you inject good science into their BSc in homeopathy the subject will simply vanish in a puff of smoke.
In 2007, the University of Westminster did respond to earlier criticism in Times Higher Education, but their response seemed to me to serve only to dig themselves deeper into a hole.
Nevertheless, Westminster has now closed down its homeopathy degree (the last in the country to go) and there is intense internal discussion going on there. I have the impression that Dr Peters’ job is in danger. The revelation of more slides from their courses on homeopathy, naturopathy and Chinese herbal medicine shows that these courses are not only barmy, but also sometimes dangerous.
Professor Chris Fowler
12:10 Educating tomorrow’s integrated doctors. Professor Chris Fowler, Dean for Education, Barts and The London School of Medicine and Dentistry
I first came across Dr Fowler when I noticed him being praised for his teaching of alternative medicine to students at Barts and the London Medical School on the web site of the Prince’s Foundation. I wrote him a polite letter to ask if he really thought that the Prince of Wales was the right person to consult about the education of medical students. The response I got was, ahem, unsympathetic. But a little while later I noticed that two different Barts students had set up public blogs that criticised strongly the nonsense that was being inflicted on them.
At that point, I felt it was necessary to support the students who, it seemed to me, knew more about medical education than Professor Fowler. It didn’t take long to uncover the nonsense that was being inflicted on the students: read about it here.
There is a follow-up to this story here. Fortunately, Barts’ Director of Research, and, I’m told, the Warden of Barts, appear to agree with my view of the harm that this sort of thing can do to the reputation of Barts, so things may change soon,
Dame Donna Kinnair
12:30 Educating tomorrow’s integrated nurses.
Dame Donna Kinnair, Director of Nursing, Southwark PCT
As far as I can see, Donna Kinnair has no interest in alternative medicine. She is director of nursing at Southwark primary care trust and was an adviser to Lord Laming throughout his inquiry into the death of Victoria Climbié. I suspect that her interest is in integrating child care services (they need it, judging by the recent death of ‘Baby P’). Perhaps her presence shows the danger of using euphemisms like ‘integrated medicine’ when what you really mean is the introduction of unproven or disproved forms of medicine.
Michael Dooley
12:40 Integrating the care of women: an example of the new paradigm. Michael Dooley, Consultant Obstetrician and Gynecologist
DC’s rule 2. Never trust anyone who uses the word ‘paradigm’. It is a sure-fire sign of pseudoscience. In this case, the ‘new paradigm’ seems to be the introduction of disproven treatment. Dooley is a gynaecologist and Medical Director of the Poundbury Clinic. His clinic offers a whole range of unproven and disproved treatments. These include acupuncture as an aid to conception in IVF. This is not recommended by the Cochrane review, and one report suggests that it hinders conception rather than helps.
12.40 Discussion
13.00 – 14.00 Lunch and Exhibition
15.30 Tea
Boo Armstrong and Get Well UK
16.00 Integrated services in action: The Northern
Ireland experience: what has it shown us and what are its implications?
Boo Armstrong of Get Well UK with a team from the NI study
I expect that much will be made of this “study”, which, of course, tells you absolutely nothing whatsoever about the effectiveness of the alternative treatments that were used in it. This does not appear to be the view of Boo Armstrong, On the basis of the “study”, her company’s web site proclaims boldly
“Complementary Medicine Works
Get Well UK ran the first government-backed complementary therapy project in the UK, from February 2007 to February 2008″
This claim appears, prima facie, to breach the Unfair Trading Regulations of May 2008. The legality of the claim is, at the moment, being judged by a Trading Standards Officer. In any case, the “study” was not backed by the government as a whole, but just by Peter Hain’s office. It is not even clear that it had ethical approval.
The study consisted merely of asking people who had seen an alternative medicine practitioner whether they felt better or worse. There was no control group; no sort of comparison was made. It is surely obvious to the most naive person that a study like this cannot even tell you if the treatment has a placebo effect, never mind that it has any genuine effects of its own. To claim that it does so seems to be simply dishonest. There is no reason at all to think that the patients would not have got better anyway.
It is not only Get Well UK who misrepresent the evidence. The Prince’s
Foundation itself says
“Now a new, year long trial supported by the Northern Ireland health service has . . . demonstrated that integrating complementary and conventional medicine brings measurable benefits to patients’ health.”
That is simply not true. It is either dishonest or stupid. Don’t ask me which, I have no idea.
This study is no more informative than the infamous Spence (2005) ‘study’ of the same type, which seems to be the only thing that homeopaths can produce to support their case.
There is an excellent analysis of the Northern Ireland ‘study’ by Andy Lewis, The Northern Ireland NHS Alternative Medicine ‘Trial’. He explains patiently, yet again, what constitutes evidence and why studies like this are useless.
His analogy starts
” . . . the Apple Marketing Board approach the NHS and ask for £200,000 to do a study to show the truth behind the statement ‘An apple a day keeps the doctor away’. The Minister, being particularly fond of apples, agrees and the study begins.”
16.30 Social enterprise and whole systems integrated care. Dee Kyne, Sandwell PCT and a GP. Developing an integrated service in secondary care
Dee Kyne appears to be CEO of KeepmWell Ltd (a financial interest that is not mentioned).
Peter Mackereth, Clinical Lead, Supportive Services, Christie Hospital NHS Foundation Trust
I had some correspondence with Mackereth when the Times (7 Feb 2007) published a picture of the Prince of Wales inspecting an “anti-MRSA aromatherapy inhaler” in his department at the Christie. It turned out that the trial they were doing was not blind No result has been announced anyway, and on enquiry, I find that the trial has not even started yet. Surprising, then to find that the FIH is running the First Clinical Aromatherapy Conference at the Christie Hospital, What will there be to talk about?
Much of what they do at the Christie is straightforward massage, but they also promote the nonsensical principles of “reflexology” and acupuncture.
The former is untested. The latter is disproven.
Parallel Sessions
Developing a PCT funded musculoskeletal service Dr Roy Welford, Glastonbury Health Centre
Roy Welford is a Fellow of the Faculty of Homeopathy, and so promotes disproven therapies. The Glastonbury practice also advertises acupuncture (disproven), osteopathy and herbal medicine (largely untested so most of it consists of giving patients an unknown dose of an ill-defined drug, of unknown effectiveness and unknown safety).
Making the best of herbal self-prescription in integrated practice: key remedies and principles. Simon Mills, Project Lead: Integrated Self Care in Family Practice, Culm Valley Integrated Centre for Health, Devon
Simon Mills is a herbalist who now describes himself as a “phytotherapist” (it sounds posher, but the evidence, or lack of it, is not changed by the fancy name). Mills likes to say things like “there are herbs for heating and drying”, “hot and cold” remedies, and to use meaningless terms like “blood cleanser”, but he appears to be immune to the need for good evidence that herbs work before you give them to sick people. He says, at the end of a talk, “The hot and the cold remain the trade secret of traditional medicine”. And this is the 21st Century.
Practical ways in which complementary approaches can improve the treatment of cancer. Professor Jane Plant, Author of “Your life in your hands” and Chief Scientist, British Geological Society and Professor Karol Sikora, Medical Director, Cancer Partners UK
Jane Plant is a geologist who, through her own unfortunate encounter with breast cancer, became obsessed with the idea that a dairy-free diet cured her. Sadly there is no good evidence for that idea, according to the World Cancer Research Fund Report, led by Professor Sir Michael Marmot. No doubt her book on the subject sells well, but it could be held that it is irresponsible to hold out false hopes to desperate people. She is a supporter of the very dubious CancerActive organisation (also supported by Michael Dixon OBE –see above) as well as the notorious pill salesman, Patrick Holford (see also here).
Karol Sikora, formerly an oncologist at the Hammersmith Hospital, is now Dean of Medicine at the University of Buckingham (the UK’s only private university). He is also medical director at CancerPartners UK, a private cancer company.
He recently shot to fame when he appeared in a commercial in the USA sponsored by “Conservatives for Patients’ Rights”, to pour scorn on the NHS, and to act as an advocate for the USA’s present health system. A very curious performance. Very curious indeed.
His attitude to quackery is a mystery wrapped in an enigma. One was somewhat alarmed to see him sponsoring a course at what was, at first, called the British College of Integrated Medicine, and has now been renamed the Faculty of Integrated Medicine That grand title makes it sound like part of a university. It isn’t.
The alarm was as result of the alliance with Dr Rosy Daniel (who promotes an untested herbal conconction, Carctol, for ‘healing’ cancer) and Dr Mark Atkinson (a supplement salesman who has also promoted the Qlink pendant. The Qlink pendant is a simple and obvious fraud designed to exploit paranoia about WiFi killing you.
The first list of speakers on the proposed diploma in Integrated Medicine was an unholy alliance of outright quacks and commercial interests. It turned out that, although Karol Sikora is sponsoring the course, he knew nothing about the speakers. I did and when I pointed this out to Terence Kealey, vice-chancellor of Buckingham, he immediately removed Rosy Daniel from directing the Diploma. At the moment the course is being revamped entirely by Andrew Miles. There is hope that he’ll do a better job. It has not yet been validated by the University of Buckingham. Watch this space for developments.
Stop press It is reported in the Guardian that Professor Sikora has been describing his previous job at Imperial College with less than perfect accuracy. Oh dear. More developments in the follow-up.
The role of happy chickens in healing: farms as producers of health as well as food – the Care Farm Initiative Jonathan Dover, Project Manager, Care Farming, West Midlands.
“Care farming is a partnership between farmers, participants and health & social care providers. It combines the care of the land with the care of people, reconnecting people with nature and their communities.”
Sounds lovely, I wonder how well it works?
What can the Brits learn from the Yanks when it comes to integrated health? Jack Lord, Chief Executive Humana Europe
It is worth noticing that the advisory board of Humana Europe includes Micheal Dixon OBE, a well known advocate of alternative medicine (see
above). Humana Europe is a private company, a wholly owned subsidiary of Humana Inc., a health benefits company with 11 million members and 22,000 employees and headquarters in Louisville, Kentucky. In 2005 it entered into a business partnership with Virgin Group. Humana was mentioned in the BBC Panorama programme “NHS for Sale”. The company later asked that it be pointed out that they provide commissioning services, not clinical services [Ed. well not yet anyway].
Humana’s document “Humana uses computer games to help people lead healthier lives” is decidedly bizarre. Hang on, it was only a moment ago that we were being told that computer games rewired your brain.
Day 2 Integrated health in action
09.00 Health, epidemics and the search for new solutions. Sir Michael Marmot, Professor of Epidemiology and Public Health, Royal Free and University College Medical School
It is a mystery to me that a distinguished epidemiologist should be willing to keep such dubious company. Sadly I don’t know what he said, but judging my his publications and his appearence on Natural World, I can’t imagine he’d have much time for homeopaths.
9.25 Improving health in the workplace. Dame Carol Black, National Director, Health and Work, Department of Health
This is not the first time that Dame Carol has been comtroversial.
9.45 Integrated health in focus: defeating obesity. Professor Chris Drinkwater, President, NHS Alliance.
The NHS Alliance was mentioned above. Enough said.
10.00 Integrated healthcare in focus: new approaches to managing asthma, eczema and allergy. Professor Stephen Holgate, Professor of Immunopharmacology, University of Southampton
10.15 Using the natural environment to increase activity. The Natural England Project: the results from year one. Dr William Bird and Ruth Tucker, Natural England.
10.30 Panel discussion
10.45 Coffee
Self help in action
11.10 Your health, your way: supporting self care through care planning and the use of personal budgets. Angela Hawley, Self Care Lead, Department of Health
11.25 NHS Life Check: providing the signposts to
integrated health. Roy Lambley, Project Director, NHS LifeCheck Programme
This programme was developed with the University of Westminster’s “Health and Well-being Network”. This group, with one exception, is separate from Westminster’s extensive alternative medicine branch (it’s mostly psychologists).
11.45 The agony and the ecstasy of helping patients to help themselves: tips for clinicians, practices and PCTs. Professor
Ruth Chambers, FIH Foundation Fellow.
11.55 Providing self help in practice: Department of Health Integrated Self Help Information Project. Simon Mills, Project Lead: Integrated Self Care in Family Practice, Culm Valley Integrated Centre for Health, Devon and Dr Sam Everington, GP, Bromley by Bow.
The Culm Valley Integrated Centre for health is part of the College Surgery Partnership, associated with Michael Dixon OBE (yes, again!).
Simon Mills is the herbalist who says “The hot and the cold remain the trade secret of traditional medicine” .
Sam Everington, in contrast, seems to be interested in ‘integration’ in the real sense of the word, rather than quackery.
Integrated health in action
How to make sense of the evidence on complementary approaches: what works? What might work? What doesn’t work?
Dr Hugh MacPherson, Senior Research Fellow in Health Sciences, York University and Dr Catherine Zollman, Bravewell Fellow
Hugh MacPherson‘s main interest is in acupuncture and he publishes in alternative medicine journals. Since the recent analysis in the BMJ from the Nordic Cochrane Centre (Madsen et al., 2009) it seems that acupuncture is finally dead. Even its placebo effect is too small to be useful. Catherine Zollman is a Bristol GP who is into homeopathy as well as acupuncture. She is closely connected with the Prince’s Foundation via the Bravewell Fellowship. That fellowship is funded by the Bravewell Collaboration, which is run by Christie Mack, wife of John Mack (‘Mack the Knife’), head of Morgan Stanley (amazingly, they still seem to have money). This is the group which, by sheer wealth, has persuaded so many otherwise respectable US universities to embrace every sort of quackery (see, for example, Integrative baloney @ Yale)
The funding of integrated services
14.15 How to get a PCT or practice- based commissioner to fund your integrated service. A PCT Chief Executive and a Practice-Based Commissioning lead.
14.30 How I succeeded: funding an integrated service. Dr John Ribchester, Whitstable
14.45 How we created an acupuncture service in St Albans and Harpenden PBC group. Mo Girach, Chief Executive, STAHCOM
Uhuh Acupunture again. Have these people never read Bausell’s
book? Have they not read the BMJ? Acupuncture is now ell-established to be based on fraudulent principles, and not even to have a worthwhile placeobo effect. STAHCOM seem to be more interested in money than in what works.
Dragon’s Den. Four pitchers lay out their stall for the commissioning dragons
And at this stage there is no prize for guessing that all four are devoted to trying to get funds for discredited treatments
- An acupuncture service for long-term pain. Mike Cummings Chair, Medical Acupuncture Association
- Manipulation for the treatment of back pain Simon Fielding, Founder Chairman of the General Osteopathic Council
- Nigel Clarke, Senior Partner, Learned Lion Partners Homeopathy for long term conditions
- Peter Fisher, Director, Royal Homeopathic Hospital
Sadly it is not stated who the dragons are. One hopes they will be more interested in evidence than the supplicants.
Mike Cummings at least doesn’t believe the nonsense about meridians and Qi. It’s a pity he doesn’t look at the real evidence though.
You can read something about him and his journal at BMJ Group promotes acupuncture: pure greed.
Osteopathy sounds a bit more respectable than the others, but in fact it has never shaken off its cult-like origins. Still many osteopaths make absurd claims to cure all sorts of diseases. Offshoots of osteopathy like ‘cranial osteopathy’ are obvious nonsense. There is no reason to think that osteopathy is any better than any other manipulative therapy and it is clear that all manipulative therapies should be grouped into one.
Osteopathy and chiropractic provide the best ever examples of the folly of giving official government recognition to a branch of alternative medicine before the evidence is in.
Learned Lion Partners is a new one on me. It seems it is
part of Madsen Gornall Ashe Chambers (‘MGA Chambers’) “a grouping of top level, independent specialists who provide a broad range of management consultancy advice to the marketing community”. It’s a management consultant and marketing outfit. So don’t expect too much when it comes to truth and evidence. The company web site says nothing about alternative medicine, but only that Nigel Clarke
“. . . has very wide experience of public affairs issues and campaigns, having worked with clients in many sectors in Europe, North America and the Far East. He has particular expertise in financial, competition and healthcare issues. “
However, all is revealed when we see that he is a Trustee of the Prince’s Foundation where his entry says
“Nigel Clarke is senior partner of Learned Lion Partners. He is a director of Vidapulse Ltd, Really Easy Ltd, Newscounter Ltd and Advanced Transport Systems Ltd. He has worked on the interfaces of public policy for 25 years. He has been chair of the General Osteopathic Council since May 2001, having been a lay member since it was formed. He is now a member of the Council for Healthcare Regulatory Excellence”
The Council for Healthcare Regulatory Excellence is yet another quango that ticks boxes and fails absolutely to grasp the one important point, does it work?. I came across them at the Westminster Forum, and they seemed a pretty pathetic way to spend £2m per year.
Peter Fisher is the last supplicant to the Dragons. He is clinical director of the Royal London Homeopathic Hospital (RLHH), and Queen’s homeopathic physician, It was through him that I got an active interest in quackery. The TV programme QED asked me to check the statistics in a paper of his that claimed that homeopathy was good for fibrositis (there was an elementary mistake and no evidence for an effect). Peter Fisher is also remarkable because he agreed with me that BSc degrees in homeopathy were not justified (on TV –see the movie). And he condemned homeopaths who were caught out recommending their sugar pills for malaria. To that extent Fisher represents the saner end of the homeopathic spectrum. Nevertheless he still maintains that sugar pills work and have effects of their own, and tries to justify the ‘memory of water’ by making analogies with a memory stick or CD. This is so obviously silly that no more comment is needed.
Given Fisher’s sensible condemnation of the malaria fiasco, I was rather surprised to see that he appeared on the programme of a conference at the University of Middlesex, talking about “A Strategy To Research The Potential Of Homeopathy In Pandemic Flu”. The title of the conference was Developing Research Strategies in CAM. A colleague, after seeing the programme, thought it was more like “a right tossers’ ball”.
Much of the homeopathy has now vanished from the RLHH as a result of greatly reduced commissioning by PCTs (read about it in Fisher’s own words). And the last homeopathy degree in the UK has closed down. It seems an odd moment for the FIH to be pushing it so hard.
Follow-up
Stop press It is reported in the Guardian (22 May 2009) that Professor Sikora has been describing his previous job at Imperial College with less than perfect accuracy. Oh dear, oh dear.
This fascinating fact seems to have been unearthed first by the admirable NHS Blog Doctor, in his post ‘Imperial College confirm that Karol Sikora does not work for them and does not speak on their behalf‘.
This article has been reposted on The Winnower, and now has a digital object identifier DOI: 10.15200/winn.142934.47856
This post is not about quackery, nor university politics. It is about inference, How do we know what we should eat? The question interests everyone, but what do we actually know? Not as much as you might think from the number of column-inches devoted to the topic. The discussion below is a synopsis of parts of an article called “In praise of randomisation”, written as a contribution to a forthcoming book, Evidence, Inference and Enquiry.
About a year ago just about every newspaper carried a story much like this one in the Daily Telegraph,
|
Sausage a day can increase bowel cancer risk By Rebecca Smith, Medical Editor Last Updated: 1:55AM BST 31/03/2008
|
||||
What, I wondered, was the evidence behind these dire warnings. They did not come from a lifestyle guru, a diet faddist or a supplement salesman. This is nothing to do with quackery. The numbers come from the 2007 report of the World Cancer Research Fund and American Institute for Cancer Research, with the title ‘Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective‘. This is a 537 page report with over 4,400 references. Its panel was chaired by Professor Sir Michael Marmot, UCL’s professor of Epidemiology and Public Health. He is a distinguished epidemiologist, renowned for his work on the relation between poverty and health.
Nevertheless there has never been a randomised trial to test the carcinogenicity of bacon, so it seems reasonable to ask how strong is the evidence that you shouldn’t eat it? It turns out to be surprisingly flimsy.
In praise of randomisation
Everyone knows about the problem of causality in principle. Post hoc ergo propter hoc; confusion of sequence and consequence; confusion of correlation and cause. This is not a trivial problem. It is probably the main reason why ineffective treatments often appear to work. It is traded on by the vast and unscrupulous alternative medicine industry. It is, very probably, the reason why we are bombarded every day with conflicting advice on what to eat. This is a bad thing, for two reasons. First, we end up confused about what we should eat. But worse still, the conflicting nature of the advice gives science as a whole a bad reputation. Every time a white-coated scientist appears in the media to tell us that a glass of wine per day is good/bad for us (delete according to the phase of the moon) the general public just laugh.
In the case of sausages and bacon, suppose that there is a correlation between eating them and developing colorectal cancer. How do we know that it was eating the bacon that caused the cancer – that the relationship is causal? The answer is that there is no way to be sure if we have simply observed the association. It could always be that the sort of people who eat bacon are also the sort of people who get colorectal cancer. But the question of causality is absolutely crucial, because if it is not causal, then stopping eating bacon won’t reduce your risk of cancer. The recommendation to avoid all processed meat in the WCRF report (2007) is sensible only if the relationship is causal. Barker Bausell said:
[Page39] “But why should nonscientists care one iota about something as esoteric as causal inference? I believe that the answer to this question is because the making of causal inferences is part of our job description as Homo Sapiens.”
That should be the mantra of every health journalist, and every newspaper reader.
|
The essential basis for causal inference was established over 70 years ago by that giant of statistics Ronald Fisher, and that basis is randomisation. Its first popular exposition was in Fisher’s famous book, The Design of Experiments (1935). The Lady Tasting Tea has become the classical example of how to design an experiment. . |
|
Briefly, a lady claims to be able to tell whether the milk was put in the cup before or after the tea was poured. Fisher points out that to test this you need to present the lady with an equal number of cups that are ‘milk first’ or ‘tea first’ (but otherwise indistinguishable) in random order, and count how many she gets right. There is a beautiful analysis of it in Stephen Senn’s book, Dicing with Death: Chance, Risk and Health. As it happens, Google books has the whole of the relevant section Fisher’s tea test (geddit?), but buy the book anyway. Such is the fame of this example that it was used as the title of a book, The Lady Tasting Tea was published by David Salsburg (my review of it is here)
Most studies of diet and health fall into one of three types, case-control studies, cohort (or prospective) studies, or randomised controlled trials (RCTs). Case-control studies are the least satisfactory: they look at people who already have the disease and look back to see how they differ from similar people who don’t have the disease. They are retrospective. Cohort studies are better because they are prospective: a large group of people is followed for a long period and their health and diet is recorded and later their disease and death is recorded. But in both sorts of studies,each person decides for him/herself what to eat or what drugs to take. Such studies can never demonstrate causality, though if the effect is really big (like cigarette-smoking and lung cancer) they can give a very good indication. The difference in an RCT is that each person does not choose what to eat, but their diet is allocated randomly to them by someone else. This means that, on average, all other factors that might influence the response are balanced equally between the two groups. Only RCTs can demonstrate causality.
Randomisation is a rather beautiful idea. It allows one to remove, in a statistical sense, bias that might result from all the sources that you hadn’t realised were there. If you are aware of a source of bias, then measure it. The danger arises from the things you don’t know about, or can’t measure (Senn, 2004; Senn, 2003). Although it guarantees freedom from bias only in a long run statistical sense, that is the best that can be done. Everything else is worse.
Ben Goldacre has referred memorably to the newspapers’ ongoing “Sisyphean task of dividing all the inanimate objects in the world into the ones that either cause or cure cancer” (Goldacre, 2008). This has even given rise to a blog. “The Daily Mail Oncological Ontology Project“. The problem arises in assessing causality.
It wouldn’t be so bad if the problem were restricted to the media. It is much more worrying that the problem of establishing causality often seems to be underestimated by the authors of papers themselves. It is a matter of speculation why this happens. Part of the reason is, no doubt, a genuine wish to discover something that will benefit mankind. But it is hard not to think that hubris and self-promotion may also play a role. Anything whatsoever that purports to relate diet to health is guaranteed to get uncritical newspaper headlines.
At the heart of the problem lies the great difficulty in doing randomised studies of the effect of diet and health. There can be no better illustration of the vital importance of randomisation than in this field. And, notwithstanding the generally uncritical reporting of stories about diet and health, one of the best accounts of the need for randomisation was written by a journalist, Gary Taubes, and it appeared in the New York Times (Taubes, 2007).
The case of hormone replacement therapy
In the 1990s hormone replacement therapy (HRT) was recommended not only to relieve the unpleasant symptoms of the menopause, but also because cohort studies suggested that HRT would reduce heart disease and osteoporosis in older women. For these reasons, by 2001, 15 million US women (perhaps 5 million older women) were taking HRT (Taubes, 2007). These recommendations were based largely on the Harvard Nurses’ Study. This was a prospective cohort study in which 122,000 nurses were followed over time, starting in 1976 (these are the ones who responded out of the 170,000 requests sent out). In 1994, it was said (Manson, 1994) that nearly all of the more than 30 observational studies suggested a reduced risk of coronary heart disease (CHD) among women receiving oestrogen therapy. A meta-analysis gave an estimated 44% reduction of CHD. Although warnings were given about the lack of randomised studies, the results were nevertheless acted upon as though they were true. But they were wrong. When proper randomised studies were done, not only did it turn out that CHD was not reduced: it was actually increased.
The Women’s Health Initiative Study (Rossouw et al., 2002) was a randomized double blind trial on 16,608 postmenopausal women aged 50-79 years and its results contradicted the conclusions from all the earlier cohort studies. HRT increased risks of heart disease, stroke, blood clots, breast cancer (though possibly helped with osteoporosis and perhaps colorectal cancer). After an average 5.2 years of follow-up, the trial was stopped because of the apparent increase in breast cancer in the HRT group. The relative risk (HRT relative to placebo) of CHD was 1.29 (95% confidence interval 1.02 to 1.63) (286 cases altogether) and for breast cancer 1.26 (1.00 -1.59) (290 cases). Rather than there being a 44% reduction of risk, it seems that there was actually a 30% increase in risk. Notice that these are actually quite small risks, and on the margin of statistical significance. For the purposes of communicating the nature of the risk to an individual person it is usually better to specify the absolute risk rather than relative risk. The absolute number of CHD cases per 10,000 person-years is about 29 on placebo and 36 on HRT, so the increased risk of any individual is quite small. Multiplied over the whole population though, the number is no longer small.
Several plausible reasons for these contradictory results are discussed by Taubes,(2007): it seems that women who choose to take HRT are healthier than those who don’t. In fact the story has become a bit more complicated since then: the effect of HRT depends on when it is started and on how long it is taken (Vandenbroucke, 2009).
This is perhaps one of the most dramatic illustrations of the value of randomised controlled trials (RCTs). Reliance on observations of correlations suggested a 44% reduction in CHD, the randomised trial gave a 30% increase in CHD. Insistence on randomisation is not just pedantry. It is essential if you want to get the right answer.
Having dealt with the cautionary tale of HRT, we can now get back to the ‘Sisyphean task of dividing all the inanimate objects in the world into the ones that either cause or cure cancer’.
The case of processed meat
The WCRF report (2007) makes some pretty firm recommendations.
- Don’t get overweight
- Be moderately physically active, equivalent to brisk walking for at least 30 minutes every day
- Consume energy-dense foods sparingly. Avoid sugary drinks. Consume ‘fast foods’ sparingly, if at all
- Eat at least five portions/servings (at least 400 g or 14 oz) of a variety of non-starchy vegetables and of fruits every day. Eat relatively unprocessed cereals (grains) and/or pulses (legumes) with every meal. Limit refined starchy foods
- People who eat red meat to consume less than 500 g (18 oz) a week, very little if any to be processed.
- If alcoholic drinks are consumed, limit consumption to no more than two drinks a day for men and one drink a day for women.
- Avoid salt-preserved, salted, or salty foods; preserve foods without using salt. Limit consumption of processed foods with added salt to ensure an intake of less than 6 g (2.4 g sodium) a day.
- Dietary supplements are not recommended for cancer prevention.
These all sound pretty sensible but they are very prescriptive. And of course the recommendations make sense only insofar as the various dietary factors cause cancer. If the association is not causal, changing your diet won’t help. Note that dietary supplements are NOT recommended. I’ll concentrate on the evidence that lies behind “People who . . . very little if any to be processed.”
The problem of establishing causality is dicussed in the report in detail. In section 3.4 the report says
” . . . causal relationships between food and nutrition, and physical activity can be confidently inferred when epidemiological evidence, and experimental and other biological findings, are consistent, unbiased, strong, graded, coherent, repeated, and plausible.”
The case of processed meat is dealt with in chapter 4.3 (p. 148) of the report.
“Processed meats” include sausages and frankfurters, and ‘hot dogs’, to which nitrates/nitrites or other preservatives are added, are also processed meats. Minced meats sometimes, but not always, fall inside this definition if they are preserved chemically. The same point applies to ‘hamburgers’.
The evidence for harmfulness of processed meat was described as “convincing”, and this is the highest level of confidence in the report, though this conclusion has been challenged (Truswell, 2009) .
How well does the evidence obey the criteria for the relationship being causal?
Twelve prospective cohort studies showed increased risk for the highest intake group when compared to the lowest, though this was statistically significant in only three of them. One study reported non-significant decreased risk and one study reported that there was no effect on risk. These results are summarised in this forest plot (see also Lewis & Clark, 2001)
Each line represents a separate study. The size of the square represents the precision (weight) for each. The horizontal bars show the 95% confidence intervals. If it were possible to repeat the observations many times on the same population, the 95% CL would be different on each repeat experiment, but 19 out of 20 (95%) of the intervals would contain the true value (and 1 in 20 would not contain the true value). If the bar does not overlap the vertical line at relative risk = 1 (i.e. no effect) this is equivalent to saying that there is a statistically significant difference from 1 with P < 0.05. That means, very roughly, that there is a 1 in 20 chance of making a fool of yourself if you claim that the association is real, rather than being a result of chance (more detail here),
There is certainly a tendency for the relative risks to be above one, though not by much, Pooling the results sounds like a good idea. The method for doing this is called meta-analysis .
Meta-analysis was possible on five studies, shown below. The outcome is shown by the red diamond at the bottom, labelled “summary effect”, and the width of the diamond indicates the 95% confidence interval. In this case the final result for association between processed meat intake and colorectal cancer was a relative risk of 1.21 (95% CI 1.04–1.42) per 50 g/day. This is presumably where the headline value of a 20% increase in risk came from.
Support came from a meta-analysis of 14 cohort studies, which reported a relative risk for processed meat of 1.09 (95% CI 1.05 – 1.13) per 30 g/day (Larsson & Wolk, 2006). Since then another study has come up with similar numbers (Sinha etal. , 2009). This consistency suggests a real association, but it cannot be taken as evidence for causality. Observational studies on HRT were just as consistent, but they were wrong.
The accompanying editorial (Popkin, 2009) points out that there are rather more important reasons to limit meat consumption, like the environmental footprint of most meat production, water supply, deforestation and so on.
So the outcome from vast numbers of observations is an association that only just reaches the P = 0.05 level of statistical significance. But even if the association is real, not a result of chance sampling error, that doesn’t help in the least in establishing causality.
There are two more criteria that might help, a good relationship between dose and response, and a plausible mechanism.
Dose – response relationship
|
It is quite possible to observe a very convincing relationship between dose and response in epidemiological studies, The relationship between number of cigarettes smoked per day and the incidence of lung cancer is one example. Indeed it is almost the only example. |
 Doll & Peto, 1978 |
There have been six studies that relate consumption of processed meat to incidence of colorectal cancer. All six dose-response relationships are shown in the WCRG report. Here they are.
This Figure was later revised to
This is the point where my credulity begins to get strained. Dose – response curves are part of the stock in trade of pharmacologists. The technical description of these six curves is, roughly, ‘bloody horizontal’. The report says “A dose-response relationship was also apparent from cohort studies that measured consumption in times/day”. I simply cannot agree that any relationship whatsoever is “apparent”.
They are certainly the least convincing dose-response relationships I have ever seen. Nevertheless a meta-analysis came up with a slope for response curve that just reached the 5% level of statistical significance.
The conclusion of the report for processed meat and colorectal cancer was as follows.
“There is a substantial amount of evidence, with a dose-response relationship apparent from cohort studies. There is strong evidence for plausible mechanisms operating in humans. Processed meat is a convincing cause of colorectal cancer.”
But the dose-response curves look appalling, and it is reasonable to ask whether public policy should be based on a 1 in 20 chance of being quite wrong (1 in 20 at best –see Senn, 2008). I certainly wouldn’t want to risk my reputation on odds like that, never mind use it as a basis for public policy.
So we are left with plausibility as the remaining bit of evidence for causality. Anyone who has done much experimental work knows that it is possible to dream up a plausible explanation of any result whatsoever. Most are wrong and so plausibility is a pretty weak argument. Much play is made of the fact that cured meats contain nitrates and nitrites, but there is no real evidence that the amount they contain is harmful.
The main source of nitrates in the diet is not from meat but from vegetables (especially green leafy vegetables like lettuce and spinach) which contribute 70 – 90% of total intake. The maximum legal content in processed meat is 10 – 25 mg/100g, but lettuce contains around 100 – 400 mg/100g with a legal limit of 200 – 400 mg/100g. Dietary nitrate intake was not associated with risk for colorectal cancer in two cohort studies.(Food Standards Agency, 2004; International Agency for Research on Cancer, 2006).
To add further to the confusion, another cohort study on over 60,000 people compared vegetarians and meat-eaters. Mortality from circulatory diseases and mortality from all causes were not detectably different between vegetarians and meat eaters (Key et al., 2009a). Still more confusingly, although the incidence of all cancers combined was lower among vegetarians than among meat eaters, the exception was colorectal cancer which had a higher incidence in vegetarians than in meat eaters (Key et al., 2009b).
Mente et al. (2009) compared cohort studies and RCTs for effects of diet on risk of coronary heart disease. “Strong evidence” for protective effects was found for intake of vegetables, nuts, and “Mediterranean diet”, and harmful effects of intake of trans–fatty acids and foods with a high glycaemic index. There was also a bit less strong evidence for effects of mono-unsaturated fatty acids and for intake of fish, marine ω-3 fatty acids, folate, whole grains, dietary vitamins E and C, beta carotene, alcohol, fruit, and fibre. But RCTs showed evidence only for “Mediterranean diet”, and for none of the others.
As a final nail in the coffin of case control studies, consider pizza. According to La Vecchia & Bosetti (2006), data from a series of case control studies in northern Italy lead to: “An inverse association was found between regular pizza consumption (at least one portion of pizza per week) and the risk of cancers of the digestive tract, with relative risks of 0.66 for oral and pharyngeal cancers, 0.41 for oesophageal, 0.82 for laryngeal, 0.74 for colon and 0.93 for rectal cancers.”
What on earth is one meant to make of this? Pizza should be prescribable on the National Health Service to produce a 60% reduction in oesophageal cancer? As the authors say “pizza may simply represent a general and aspecific indicator of a favourable Mediterranean diet.” It is observations like this that seem to make a mockery of making causal inferences from non-randomised studies. They are simply uninterpretable.
Is the observed association even real?
The most noticeable thing about the effects of red meat and processed meat is not only that they are small but also that they only just reach the 5 percent level of statistical significance. It has been explained clearly why, in these circumstances, real associations are likely to be exaggerated in size (Ioannidis, 2008a; Ioannidis, 2008b; Senn, 2008). Worse still, there as some good reasons to think that many (perhaps even most) of the effects that are claimed in this sort of study are not real anyway (Ioannidis, 2005). The inflation of the strength of associations is expected to be bigger in small studies, so it is noteworthy that the large meta-analysis by Larsson & Wolk, 2006 comments “In the present meta-analysis, the magnitude of the relationship of processed meat consumption with colorectal cancer risk was weaker than in the earlier meta-analyses”.
This is all consistent with the well known tendency of randomized clinical trials to show initially a good effect of treatment but subsequent trials tend to show smaller effects. The reasons, and the cures, for this worrying problem are discussed by Chalmers (Chalmers, 2006; Chalmers & Matthews, 2006; Garattini & Chalmers, 2009)
What do randomized studies tell us?
The only form of reliable evidence for causality comes from randomised controlled trials. The difficulties in allocating people to diets over long periods of time are obvious and that is no doubt one reason why there are far fewer RCTs than there are observational studies. But when they have been done the results often contradict those from cohort studies. The RCTs of hormone replacement therapy mentioned above contradicted the cohort studies and reversed the advice given to women about HRT.
Three more illustrations of how plausible suggestions about diet can be refuted by RCTs concern nutritional supplements and weight-loss diets
Many RCTs have shown that various forms of nutritional supplement do no good and may even do harm (see Cochrane reviews). At least we now know that anti-oxidants per se do you no good. The idea that anti-oxidants might be good for you was never more than a plausible hypothesis, and like so many plausible hypotheses it has turned out to be a myth. The word anti-oxidant is now no more than a marketing term, though it remains very profitable for unscrupulous salesmen.
The randomised Women’s Health Initiative Dietary Modification Trial (Prentice et al., 2007; Prentice, 2007) showed minimal effects of dietary fat on cancer, though the conclusion has been challenged on the basis of the possible inaccuracy of reported diet (Yngve et al., 2006).
Contrary to much dogma about weight loss (Sacks et al., 2009) found no differences in weight loss over two years between four very different diets. They assigned randomly 811 overweight adults to one of four diets. The percentages of energy derived from fat, protein, and carbohydrates in the four diets were 20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; and 40, 25, and 35%. No difference could be detected between the different diets: all that mattered for weight loss was the total number of calories. It should be added, though, that there were some reasons to think that the participants may not have stuck to their diets very well (Katan, 2009).
The impression one gets from RCTs is that the details of diet are not anything like as important as has been inferred from non-randomised observational studies.
So does processed meat give you cancer?
After all this, we can return to the original question. Do sausages or bacon give you colorectal cancer? The answer, sadly, is that nobody really knows. I do know that, on the basis of the evidence, it seems to me to be an exaggeration to assert that “The evidence is convincing that processed meat is a cause of bowel cancer”.
In the UK there were around 5 cases of colorectal cancer per 10,000 population in 2005, so a 20% increase, even if it were real, and genuinely causative. would result in 6 rather than 5 cases per 10,000 people, annually. That makes the risk sound trivial for any individual. On the other hand there were 36,766 cases of colorectal cancer in the UK in 2005. A 20% increase would mean, if the association were causal, about 7000 extra cases as a result of eating processed meat, but no extra cases if the association were not causal.
For the purposes of public health policy about diet, the question of causality is crucial. One has sympathy for the difficult decisions that they have to make, because they are forced to decide on the basis of inadequate evidence.
If it were not already obvious, the examples discussed above make it very clear that the only sound guide to causality is a properly randomised trial. The only exceptions to that are when effects are really big. The relative risk of lung cancer for a heavy cigarette smoker is 20 times that of a non-smoker and there is a very clear relationship between dose (cigarettes per day) and response (lung cancer incidence), as shown above. That is a 2000% increase in risk, very different from the 20% found for processed meat (and many other dietary effects). Nobody could doubt seriously the causality in that case.
The decision about whether to eat bacon and sausages has to be a personal one. It depends on your attitude to the precautionary principle. The observations do not, in my view, constitute strong evidence for causality, but they are certainly compatible with causality. It could be true so if you want to be on the safe side then avoid bacon. Of course life would not be much fun if your actions were based on things that just could be true.
My own inclination would be to ignore any relative risk based on observational data if it was less than about 2. The National Cancer Institute (Nelson, 2002) advises that relative risks less than 2 should be “viewed with caution”, but fails to explain what “viewing with caution” means in practice, so the advice isn’t very useful.
In fact hardly any of the relative risks reported in the WCRF report (2007) reach this level. Almost all relative risks are less than 1.3 (or greater than 0.7 for alleged protective effects). Perhaps it is best to stop worrying and get on with your life. At some point it becomes counterproductive to try to micromanage `people’s diet on the basis of dubious data. There is a price to pay for being too precautionary. It runs the risk of making people ignore information that has got a sound basis. It runs the risk of excessive medicalisation of everyday life. And it brings science itself into disrepute when people laugh at the contradictory findings of observational epidemiology.
The question of how diet and other ‘lifestyle interventions’ affect health is fascinating to everyone. There is compelling reason to think that it matters. For example one study demonstrated that breast cancer incidence increased almost threefold in first-generation Japanese women who migrated to Hawaii, and up to fivefold in the second generation (Kolonel, 1980). Since then enormous effort has been put into finding out why. The first great success was cigarette smoking but that is almost the only major success. Very few similar magic bullets have come to light after decades of searching (asbestos and mesothelioma, or UV radiation and skin cancer count as successes).
The WCRF report (2007) has 537 pages and over 4400 references and we still don’t know.
Sometimes I think we should say “I don’t know” rather more often.
More material
-
Listen to Ben Goldacre’s Radio 4 programmes. The Rise of the Lifetsyle Nutritionists. Part 1 and Part 2 (mp3 files), and at badscience.net.
-
Risk The Science and Politics of Fear, Dan Gardner. Virgin
Books, 2008 -
Some bookmarks about diet and supplements
Follow up
Dan Gardner, the author of Risk, seems to like the last line at least, according to his blog.
Report of the update, 2010
The 2010 report has been updated in WCRF/AICR Systematic Literature Review Continuous Update Project Report [big pdf file]. This includes studies up to May/June 2010.
The result of addition of the new data was to reduce slightly the apparent risk from eating processed meat from 1.21 (95% CI = 1.04-1.42) in the original study to 1.18 (95% CI = 1.10-1.28) in the update. The change is too small to mean much, though it is in direction expected for false correlations. More importantly, the new data confirm that the dose-response curves are pathetic. The evidence for causality is weakened somewhat by addition of the new data.
Dose-response graph of processed meat and colorectal cancer
|
It seems that bits of good news don’t come singly. First honours degrees in acupuncture vanish, Now a big chain of shops selling Chinese herbs and acupuncture has gone into administration. It seems that, at last, people are getting fed up with being conned out of their hard-earned money |
 Herbmedic Barking |
A local newspaper, The North Herts Comet reported thus.
Customers of Herbmedic, which trades under the name Herbs and Acupuncture, on Queensway in Stevenage have been left counting the cost after shelling out hundreds of pounds for treatment they never received.
The company, which has practices across the country, is now in the hands of receivers, Macintyre Hudson.
Sandra Emery, of The Paddocks in Stevenage, paid £350 for 10 treatment sessions, but only received one before the practice closed.
She said: “A standard course of treatment is 10 sessions, so most customers will have bought this package.
Claudia Gois, of Walden End in Stevenage, paid £240 for 12 treatment sessions but only received four before the practice closed.
She said: “I went there on Friday and it was closed. There was no warning or anything.
“I got in touch with head office and they said it’s very unlikely I will get money back.
This report was on 1st April, The company’s web site shows no sign of any problems, In fact they are still advertising jobs. So was this an April Fool joke?
No it wasn’t. A visit to Companies House soon settled the matter. The whole company is insolvent, as of 27 March 2009..
Download the whole administration notice and the company report.
Criticisms of Herbmedic
This chain of shops was investigated by the BBC’s
Inside Out programme. (September 25th 2006).
“We sent an undercover reporter to branches of the Herbmedic chain in southern England.
On each occasion, the reporter claimed to be suffering from tiredness and was prescribed herbal remedies after a consultation lasting less than five minutes.
The herbalists, who describe themselves as “doctors”, didn’t ask any questions about the patient’s medical history or take any notes.”
This is so bad that even Andrew Fowler, a past President of the Register of Chinese Herbal Medicine, described it as “malpractice”.
“Herbmedic has been investigated by the authorities in the past.
In 2002, trading standards officers prosecuted the branch in Southampton for selling herbal remedies with 26 times the permitted legal limit of lead.
And in October 2003, the Advertising Standards Authority banned Herbmedic from describing its practitioners as “doctors”.
Despite the ban, all three of the stores visited by Inside Out referred to the herbalist as the doctor.”
See also the BBC report Herbalists’ customers ‘at risk’, and a report in the Sunday Times, Herbmedic accused of high-pressure selling.
Read the Advertising Standards report. Seven different complaints against Herbmedic were upheld.
This is entirely consistent with my own experience. I went into one of their shops and asked about a cure for diabetes (hoping the be able to refer them to Trading Standards, but the young lady behind the counter had such a poor grasp of English that her reply was incomprehensible. She just kept trying to push me into having a consultation with “the doctor” who appeared to speak no English at all. I left.
The chequered history of Herbmedic
The company that his just gone into administration is Herbmedic Centre Ltd. It has been in existence for only two years. Its predecessor, known simply as Herbmedic, was dissolved on 13 March 2007, Companies House said
Company Filing History Type Date Description Order GAZ2(A) 13/03/2007 FINAL GAZETTE: DISSOLVED VIA VOLUNTARY STRIKE-OFF GAZ1(A) 28/11/2006 FIRST GAZETTE NOTICE FOR VOLUNTARY STRIKE-OFF 652a 16/10/2006 APPLICATION FOR STRIKING-OFF
Another Chinese medicine chain seems to be having a few problems too
Harmony Medical Distribution Ltd (“specialists in acupuncture and holistic medicine”) seems to be still in business(web site here), but several very similar companies have been dissolved, Harmomy Medics Ltd (dissolved 19 Sep 2006) ,, Harmony Medical Services (UK ) Ltd. (dissolved 6 May 2008) and Harmony Medical Services Ltd (dissolved 17 Oct 2008)
Given this history of companies that dissolve every couple of years and then mysteriously reincarnate with a slightly different name, one wonders if this really is the end of herbmedic, or it is just a device for shedding bad debts. Is this just another “pre-pack administration“?
Watch this space for more.
What’s the latest evidence on acupuncture anyway?
A correspondent drew my attention to the 2009 Annual Evidence Update on acupuncture complied by the NHS Complementary and Alternative Medicine Specialist Library. This includes no fewer than 56 systematic reviews and meta-analyses. Although the reviews are complied by alternative medicine sympathisers, they seem mostly to be pretty fair. Well apart form one thing.
Almost all of the reviews fail to come up with any positive evidence that acupuncture works well enough to be clinically useful. Only two come close, and they are the two singled out as “editor’s picks”. Perhaps that’s not entirely surprising given that the editor is Dr Mike Cummings.
Again and again, the results are inconclusive: #8 is pretty typical
Acupuncture for tension-type headache: a meta-analysis of randomized, controlled trials.
This meta-analysis suggests that acupuncture compared with sham for tension-type headache has limited efficacy for the reduction of headache frequency. There exists a lack of standardization of acupuncture point selection and treatment course among randomized, controlled trials. More research is needed to investigate the treatment of specific tension-type headache subtypes.
Vast effort and a lot of money is being put into trials, yet there are very few (if any) positive results. Very often there are no results at whatsoever. All we hear, again and again, is “more research is needed”.
At some point someone will have to decide it is all a charade and start to spend time and money on investigating things that are more promising.
Follow-up
A correspondent checked with Companies House to discover more about two of the directors of Herbmedic, Mr. Li Mao and Mr Xiao Xuan Chen. They have a chequered history indeed. [download the complete list]
Mr. Li Mao is, or has been, on the board of 31 different companies. Of these 6 are active, 5 are in administration, 14 were dissolved, 4 were liquidated and 2 are active with proposal to strike off. Not only is Her Medic centre Ltd in administration, but so is Dr China (UK) Ltd, and Great Chinese Herbal Medicine Ltd
With record like that, my correspondent wonders whether they should be disqualified.
The Nutrition Society is the interim professional body for nutrition. It seems that, unlike so many ‘regulatory bodies’, it may actually take its responsibilities seriously. The following announcement has appeared on their web site.
|
The UK Voluntary Register of Nutritionists acts to protect the public and the reputation the nutrition profession On March 4th 2009, a Fitness to Practice Panel was convened to consider an allegation against a registrant, Dr Ann Walker, that her fitness to practise was impaired. The panel considered whether the registrant, in advocating the use of a web based personal nutritional profiling service had complied with the Code of Ethics’ clause 3: This expects all registered nutritionists to “maintain the highest standards of professionalism and scientific integrity”. In particular, the panel considered whether the registrant showed “knowledge, skills and performance of high quality, up-to-date, and relevant to their field of practice”, in keeping with the Statement of Professional Conduct (para 9). The Panel accepted the allegation of impaired fitness to practice. Mindful of its duty to protect the public, it recommended that Dr Walker be removed from the register. Dr Walker has a right of appeal. |
Well. well, this must be none other than the Dr Ann Walker who caused UCL,and me, such trouble a few years ago. And just because I described her use of the word “blood cleanser” as gobbledygook. She has appeared a few times on this blog.
- Nutribollocks: antioxidants useless, some are dangerous
- Red clover, herbal spin and vested interests
- The fallout from DC’s de-excommunication
- So what is a “blood cleanser”? Quinion speaks.
- Herbal medicines fail test
- Nutriprofile: useful aid or sales scam?
- She even gets a brief mention at Boots reaches new level of dishonesty with CoQ10 promotion
Presumably the “web-based personal nutritional profiling service” that is referred to is Nutriprofile, on which, with the help of a dietition, we had a bit of fun a while ago. However ideal your diet it still recommended at the end of the questionnaire that you should buy some expensive supplements. Read about it at Nutriprofile: useful aid or sales scam?
I have no idea who lodged the complaint (but it wasn’t me).
It is interesting to compare the high standards of the Nutrition Society with the quite different standards of BANT (the British Association for Applied Nutrition and Nutritional Therapy). They bill themselves as the “Professional Body for Nutritional Therapists”. Nutritional therapists are those fantasists who believe you can cure any ill by buying some supplement pills. Their standards can be judged by, for example, BANT ethics code: BANT nutritional therapists are allowed to earn commission from selling pills and tests.
It seems Dr Ann Walker may have joined the wrong society.
Follow-up
On 24 July 2006, I sent a request to the University of Central Lancashire (UCLAN), under the Freedom of Information Act (2000) I asked to see the teaching materials that were used on their BSc Homeopathy course. The request was refused, citing the exemption under section 43(2) of the Act (Commercial Interests).
Two internal reviews were then held. These reviews upheld and the original refusal on the grounds of commercial interests, Section 43(3), and additionally claimed exemption under Section 21 “that is reasonably accessible to applicants by other means (upon the payment of a fee)….i.e. by enrolling on the course….”
In 21 October 2006 I appealed to the Office of the Information commisioner. (The”public authority” means UCLAN, and “the complainant” is me.)
|
“The complainant specifically asked the Commissioner to consider the application of section 43(2) to the course materials he had requested. The main thrust of his argument in this regard was that the public authority could not be considered a ‘commercial organisation’ for the purposes of the Act, and that the public authority had confused ‘commercial interests’ with ‘financial interests’. He however added that if the Commissioner decided section 43(2) was correctly engaged, then it was in the public interest to order disclosure.” |
In May 2008, my appeal got to the top of the pile, and on 30th March 2009 a judgement was delivered. In all respects but one trivial one, the appeal was upheld. In future universities will not be able to refuse requests for teaching materials.
The Decision Notice is on the web site of the Office of the Information Commissioner, [or download pdf file].
This whole thing has taken so long that the course at which it was aimed has already closed its doors last August (and blamed that, in part, on the problems caused by the Freedom of Information Act). UCLAN also announced a review of all its alternative medicine activities (and asked me to give evidence to it). That review is due to report its findings any time now.
Tha particular course that prompted the request is no longer the point. What matters is that all the usual exemptions claimed by universities have been ruled invalid. Here are a few details
What the decision notice says (the short version)
The full text of the Act is here.
The following three exemptions were judged NOT to apply the requests for university teaching materials. I’ll quote some bits from the Decision Notice.
Section 21 provides that –
“Information which is reasonably accessible to the applicant otherwise than under section 1 is exempt information.”
|
34. The public authority’s argument suggests that the requested information is reasonably accessible to the complainant if he enrols as a student on the course, and is therefore not accessible to him by any other means outside the Act unless he decides to make a total payment of £9,345 as a combined payment of three years tuition fees. 40. The Commissioner therefore finds that the public authority incorrectly applied the exemption contained at section 21 of the Act. |
Section 42(2) provides that –
“Information is exempt information if its disclosure under this Act would, or would be likely to, prejudice the commercial interests of any person (including the public authority holding it).”
|
71. The Commissioner therefore finds that the section 43(2) was incorrectly engaged by virtue of the fact that the public authority’s ability to recruit students is not a commercial interest within the contemplation of section 43(2). 76. In addition to his finding on commercial interests the Commissioner finds that section 43(2) would in any case not be engaged as the likelihood of prejudice to the public authority’s ability to recruit students as a result of disclosure under the Act is no more than the likelihood of prejudice resulting from the availability of the course materials to students already enrolled on the course. |
Section 36(2)C provides that –
“Information to which this section applies is exempt information if, in the reasonable opinion of a qualified person, disclosure of the information under this Act-
(c) would otherwise prejudice, or would be likely otherwise to prejudice, the effective conduct of public affairs
| 98. For the reasons set out above, the Commissioner finds that section 36(2)(c) is not engaged as he does not accept the opinion of the qualified person is an objectively reasonable one. He does not find that disclosure would be likely to prejudice the effective conduct of public affairs. |
Section 41(1) provides that –
“Information is exempt information if-
(a) it was obtained by the public authority from any other person (including another public authority), and
(b) the disclosure of the information to the public (otherwise than under this Act) by the public authority holding it would constitute a breach of confidence actionable by that or any other person.”
| 56. The Commissioner therefore finds the public authority correctly applied the exemption contained at section 41 to the case studies listed in Annex A. In the Commissioner’s view, even though the patients would not be identifiable if the case studies were disclosed, this disclosure would still be actionable by the patients. |
The Decision
|
99. The Commissioner finds that section 41 is engaged 100. He however finds that the exemptions at sections 21, 43(2), and 36(2)(c) are not engaged. 101. The Commissioner therefore finds the public authority in breach of; • Sections 1(1)(b) and 10(1), because it failed to disclose the remainder of the course materials (i.e. excluding the case studies) to the complainant within 20 working days. • Section 17(1), because it did not specify in its refusal notice that it was also relying on sections 41 and 36(2)(c). |
Steps required
|
103. The Commissioner requires the public authority to take the following steps to ensure compliance with the Act: • Disclose all the course materials for the BSc (Hons) in Homeopathy apart from the case studies listed in Annex A of this Notice. 104. The public authority must take the steps required by this notice within 35 calendar days of the date of this notice. |
Follow-up
In March 2007 I wrote a piece in Nature on Science degrees without the science. At that time there were five “BSc” degrees in homeopathy. A couple of weeks ago I checked the UCAS site for start in 2009, and found there was only one full “BSc (hons)” left and that was at Westminster University.
Today I checked again and NOW THERE ARE NONE.
A phone call to the University of Westminster tonight confirmed that they have suspended entry to their BSc (Hons) homeopathy degree.
They say that they have done so because of “poor recruitment”. It was a purely financial decision. Nothing to do with embarrasment. Gratifying though it is that recruits for the course are vanishing, that statement is actually pretty appalling It says that the University of Westminster doesn’t care whether it’s nonsense, but only about whether it makes money.
Nevertheless the first part of this post is not entirely outdated before it even appeared, because homeopathy will still be taught as part of Complementary Therapies. And Naturopathy and “Nutritional Therapy” are still there..
According to their ‘School of Integrated Health‘, “The University of Westminster has a vision of health care for the 21st Century”. Yes, but it is what most people would call a vision of health care in the 18th century.
The revelation that the University of Westminster teaches that Amethysts emit high Yin energy caused something of a scandal.
Since then I have acquired from several sources quite a lot more of their teaching material, despite the fact that the university has refused to comply with the Freedom of Information Act.
In view of the rather silly internal review conducted by Westminster’s Vice-Chancellor, Professor Geoffrey Petts, this seems like a good moment to make a bit more of it public,
I think that revelation of the material is justified because it is in the
public interest to know how the University if Westminster is spending taxpayers’ money. Another motive is to defend the reputation of the post-1992 universities. I have every sympathy with the ex-polytechnics in their efforts to convert themselves into universities. In many ways they have succeeded. That effort
is impeded by teaching mystical versions of medicine.
If the University of Westminster is being brought into disrepute, blame its vice-chancellor, not me.
Homeopathic spiders
Here are a few slides from a lecture on how good spider venom is for you. It is from Course 3CTH502 Homeopathic Materia Medica II. No need to worry though, because they are talking about homeopathic spider venom, so there is nothing but sugar in the pills. The involvement of spiders is pure imagination. No more than mystical gobbledygook.
You are in hurry, or play with your fingers? You need spider venom pills (that contain no spider venom).
You break furniture? Time goes too fast for you? Try the tarantula-free tarantula pills.
You are preoccupied with sex? You play with ropes? What you need is Mygale (which contains no Mygale)
Much more seriously, the same sugar pills are recommended for serious conditions, chorea, ‘dim sight’, gonorrhoea, syphilis and burning hot urine.
This isn’t just preposterous made-up stuff. It is dangerous.
There is a whole lot more fantasy stuff in the handouts for Homeopathy Materia Medica II (3CTH502). Here are a couple of examples.
Aurum metallicum (metallic gold) [Download the whole handout]
Affinities MIND, VASCULAR SYSTEM, Nerves, Heart, Bones, Glands, Liver, Kidneys, RIGHT SIDE, Left side.
Causations Emotions. Ailments from disappointed love and grief, offence or unusual responsibility, abuse of mercury or allopathic drugs.
Aurum belongs to the syphilitic miasm but has elements of sycosis (Aur-Mur).
Potassium salts are the subject of some fine fantasy, in “The Kali’s” [sic]. (there is much more serious stuff to worry about here than a few misplaced apostrophes.). [Download the whole handout]
“The radioactive element of potassium emits negative electrons from the atom nucleus and is thought to be significant in the sphere of cell processes especially in relation to functions relating to automatism and rhythmicity.”
“Kali people are very conscientious with strong principles. They have their rules and they stick to them, ‘a man of his word’.”
“Potassium acts in a parasympathetic way, tending towards depression”
“They [“Kali people=] are not melancholic like the Natrum’s but rather optimistic.”
Radioactive potassium is involved in automaticity? Total nonsense.
Where is the science?
Yes, it is true that the students get a bit of real science. There isn’t the slightest trace that I can find of any attempt to resolve the obvious fact that what they are taught in the science bits contradict directly what they are told in the other bits. Sounds like a recipe for stress to me.
They even get a bit of incredibly elementary statistics. But they can’t even get that right. This slide is from PPP – Res Quant data analysis.
“Involves parameters and/or distributions”. This has no useful meaning whatsoever, that I can detect.
“Tests hypotheses when population distributions are skewed”. Well yes, though nothing there about forms of non-Gaussian properties other than skew, nothing about normalising transformations, and nothing about the Central Limit theorem.
“Ranks data rather than the actual data itself”. This is plain wrong. Randomisation tests on the original data are generally the best (uniformly most powerful) sort of non-parametric test. It seems to have escaped the attention of the tutor that ranking is a short-cut approximation that allowed tables to be constructed, before we had computers.
The students are told about randomised controlled trials. But amazingly in the lecture PPP-RCTs, the little matter of blinding is barely mantioned. And the teacher’s ideas about randomisation are a bit odd too.
Sorry, but if you fiddle the randomisation, no amount of “careful scrutiny” will rescue you from bias.
An Introduction to Naturopathic Philosophy
Naturopathy is just about as barmy as homeopathy. You can see something about it at the University of Wales. How about this slide from Westminster’s An Introduction to Naturopathic Philosophy.
So if you get tuberculosis, it isn’t caused by Mycobacterium tuberculosis? And the symptoms are “constructive”? So you don;t need to do anything. It’s all for the best really.
This isn’t just nonsense. It’s dangerous nonsense.
Traditional Chinese Medicine
Ever wondered what the mysterious “Qi” is? Worry no more. All is explained on this slide.
It means breath, air, vapour, gas, energy, vitalism. Or perhaps prana? Is that quite clear now?
What can we make of this one? Anyone can see that the description is barely written in English and that vital information is missing (such as the age of the woman). And it’s nonsense to suggest that “invasion of cold” (during keyhole surgery!) would cause prolonged constriction of blood vessels (never mind that it would “consume yang qi”). Not being a clinician, I showed it to an oncologist friend. He said that it was impossible to tell from the description whether the problem was serious or not, but that any abdominal pain should be investigated properly. There isn’t anything here about referral for proper investigation. Just a lot of stuff about ginger and cinnamon. Anyone who was taught in this way could be a real danger to the public. It isn’t harmless nonsense It’s potentially harmful nonsense.
And finally, it’s DETOX
Surely everyone knows by now that ‘detox’ is no more than a marketing word? Well not at the University of Westminster. They have a long handout that tells you all the usual myths and a few new ones.
It is written by Jennifer Harper-Deacon, who describes herself modestly, thus.
Jennifer Harper-Deacon is a qualified and registered Naturopath and acupuncturist who holds a PhD in Natural Health and MSc in Complementary Therapies. She is a gifted healer and Reiki Master who runs her own clinic in Surrey where she believes in treating the ‘whole’ person by using a combination of Chinese medicine and naturopathic techniques that she has qualified in, including nutritional medicine, Chinese and Western herbalism, homoeopathy, applied kinesiology, reflexology, therapeutic massage, aromatherapy and flower remedies.
It seems that there is no limit on the number of (mutually incompatible) forms of nuttiness that she believes. Here are a few quotations from her handout for Westminster students.
“Detoxification is the single most powerful tool used by natural health professionals to prevent and reverse disease”
What? To “prevent and reverse” malaria? tuberculosis? Parkinson’s disease? AIDS? cancer?
“When you go on to a raw food only diet, especially fruit, the stored toxins are brought up from the deep organs such as the liver and kidneys, to the superficial systems of elimination.”;
Very odd. I always though that kidneys were a system of elimination.
“The over-use and mis-use of antibiotics has weakened the body’s ability to attack and destroy new strains of resistant bacteria, virulent viruses, which have led to our immune system becoming compromised.”
Certainly over-use and mis-use are problems. But I always thought it was the bacteria that became resistant.
“The beauty about detoxification therapy is that it addresses the very causative issues of health problems”
That is another dangerous and silly myth. Tuberculosis is not caused by mythical and un-named “toxins”. It is caused by Mycobacterium tuberculosis.
“Naturopathy follows the logic of cause and effect therefore believes that we simply need pure food and water, sunshine, air, adequate rest and sleep coupled with the right amount of exercise for health.”
Try telling that to someone with AIDS.
“Colon cleansing is one of the most important parts of any detoxification programme.”
The strange obsession with enemas in the alternative world is always baffling.
“Frankincense: holds the capacity to physically strengthen our defence system and can rebuild energy levels when our immune system is weak. Revered as a herb of protection, frankincense can also strengthen our spiritual defences when our Wei qi is low, making us more susceptible to negative energies. This calming oil has the ability to deepen the breath, helping us to let go of stale air and emotions, making it ideal oil to use inhale prior to meditating.”
This is so much hot air. There is a bit of evidence that frankincense might have some anti-inflammatory action and that’s it.
But this has to be my favourite.
“Remember when shopping to favour fruits and vegetables which are in season and locally grown (and ideally organic) as they are more vibrationally compatible with the body.”
Locally grown vegetables are “more vibrationally compatible with the body”? Pure mystical gobbledygook. Words fail me.
OK there’s a whole lot more, but that will do for now.
It’s good that Westminster is shutting down its Homeopathy BSc, but it seems they have a bit further to go.
The Health Professions Council (HPC) is yet another regulatory quango.
The HPC’s strapline is
|
 |
At present the HPC regulates; Arts therapists, biomedical scientists, chiropodists/podiatrists, clinical scientists, dietitians, occupational therapists, operating department practitioners, orthoptists, paramedics, physiotherapists, prosthetists/orthotists, radiographers and speech & language therapists.
These are thirteen very respectable jobs. With the possible exception of art therapists, nobody would doubt for a moment that they are scientific jobs, based on evidence. Dietitians, for example, are the real experts on nutrition (in contrast to “nutritional therapists” and the like, who are part of the alternative industry). That is just as well because the ten criteria for registration with the HPC say that aspirant groups must have
“Practise based on evidence of efficacy”
But then came the Pittilo report, about which I wrote a commentary in the Times, and here, A very bad report: gamma minus for the vice-chancellor, and here.
Both the Pittilo report, the HPC, and indeed the Department of Health itself (watch this space), seem quite unable to grasp the obvious fact that you cannot come up with any sensible form of regulation until after you have decided whether the ‘therapy’ works or whether it is so much nonsense.
In no sense can “the public be protected” by setting educational standards for nonsense. But this obvioua fact seems to be beyond the intellectual grasp of the quangoid box-ticking mentality.
That report recommended that the HPC should regulate also Medical Herbalists, Acupuncturists and Traditional Chinese Medicine Practitioners. Even more absurdly, it recommended degrees in these subjects, just at the moment that those universities who run them are beginning to realise that they are anti-scientific subjects and closing down degrees in them.
How could these three branches of the alternative medicine industry possibly be eligible to register with the HPC when one of the criteria for registration is that there must be “practise based on evidence of efficacy”?
Impossible, I hear you say. But if you said that, I fear you may have underestimated the capacity of the official mind for pure double-speak.
The HPC published a report on 11 September 2008, Regulation of Medical Herbalists, Acupuncturists and Traditional Chinese Medicine Practitioners.
The report says
1. Medical herbalists, acupuncturists and traditional Chinese medicine practitioners should be statutorily regulated in the public interest and for public safety reasons.
2. The Health Professions Council is appropriate as the regulator for these professions.
3. The accepted evidence of efficacy overall for these professions is limited, but regulation should proceed because it is in the public interest.
But the last conclusion contradicts directly the requirement for “practise based on evidence of efficacy”. I was curious about how this contradiction
could be resolved so I sent a list of questions. The full letter is here.
The letter was addressed to the president of the HPC, Anna van der Gaag, but with the customary discourtesy of such organisations, it was not answered by her but by Michael Guthrie, Head of Policy and Standards He said
“Our Council considered the report at its meeting in July 2008 and decided that the regulation of these groups was necessary on the grounds of public protection. The Council decided to make a recommendation to the Secretary of State for Health that these groups be regulated.
http://www.hpc-uk.org/assets/documents/100023FEcouncil_20080911_enclosure07.pdf “.
This, of course, doesn’t answer any of my questions. It does not explain how the public is protected by insisting on formal qualifications, if the qualifications
happen to teach mythical nonsense. Later the reply got into deeper water.
“I would additionally add that the new professions criteria are more focused on the process and structures of regulation, rather than the underlying rationale for regulation – the protection of members of the public. The Council considered the group’s report in light of a scoring against the criteria. The criteria on efficacy was one that was scored part met. As you have outlined in your email (and as discussed in the report itself) the evidence of efficacy (at least to western standards) is limited overall, particularly in the areas of herbal medicines and traditional Chinese medicine. However, the evidence base is growing and there was a recognition in the report that the individualised approach to practice in these areas did not lend themselves to traditional RCT research designs.”
Yes, based on process and structures (without engaging the brain it seems). Rather reminiscent of the great scandal in UK Social Services. It is right in one respect though.
The evidence base is indeed growing, But it is almost all negative evidence. Does the HPC not realise that? And what about “at least by Western standards”? Surely the HPC is not suggesting that UK health policy should be determined by the standards of evidence of Chinese herbalists? Actually it is doing exactly that since its assessment of evidence was based on the Pittilo report in which the evidence was assessed (very badly) by herbalists.
One despairs too about the statement that
“there was a recognition in the report that the individualised approach to practice in these areas did not lend themselves to traditional RCT research designs”
Yes of course the Pittilo report said that, because it was written by herbalists! Had the HPC bothered to read Ben Goldacre’s column in the Guardian they would have realised that there is no barrier at all to doing proper tests. It isn’t rocket science, though it seems that it is beyond the comprehension of the HPC.
So I followed the link to try again to find out why the HPC had reached the decision to breach its own rules. Page 10 of the HPC Council report says
3. The occupation must practise based on evidence of efficacy This criterion covers how a profession practises. The Council recognizes the centrality of evidence-based practice to modern health care and will assess applicant occupations for evidence that demonstrates that:
- Their practice is subject to research into its effectiveness. Suitable evidence would include publication in journals that are accepted as
learned by the health sciences and/or social care communities- There is an established scientific and measurable basis for measuring outcomes of their practice. This is a minimum—the Council welcomes
evidence of there being a scientific basis for other aspects of practice and the body of knowledge of an applicant occupation- It subscribes to the ethos of evidence-based practice, including being open to changing treatment strategies when the evidence is in favour
of doing so.
So that sounds fine. Except that research is rarely published in “journals that are accepted as learned by the health sciences”. And of course most of the good evidence is negative anyway. Nobody with the slightest knowledge of the literature could possibly think that these criteria are satisfied by Medical Herbalists, Acupuncturists and Traditional Chinese Medicine Practitioners.
So what does the HPC make of the evidence? Appendix 2 tells us. It goes through the criteria for HPS registration.
“Defined body of knowledge: There is a defined body of knowledge, although approaches to practice can vary within each area.”
There is no mention that the “body of knowledge” is, in many cases, nonsensical gobbledygook and, astonishingly this criterion was deemed to be “met”!.
This shows once again the sheer silliness of trying to apply a list of criteria without first judging whether the subject is based in reality,
Evidence of efficacy. There is limited widely accepted evidence of efficacy, although this could be partly explained by the nature of the professions in offering bespoke treatments to individual patients. This criterion is scored part met overall.
Sadly we are not told who deemed this criterion to be “part met”. But it does say that “This scoring has been undertaken based on the information outlined in the [Pittilo] report”. Since the assessment of evidence in that report was execrably bad (having been made by people who would lose their jobs if
they said anything negative). it is no wonder that the judgement is overoptimistic!
Did the HPC not notice the quality of the evidence presented in the Pittilo report? Apparently not. That is sheer incompetence.
Nevertheless the criterion was not “met”, so they can’t join HPC, right? Not at all. The Council simply decided to ignore its own rules.
On page 5 of the Council’s report we see this.
The Steering Group [Pittilo] argues that a lack of evidence of efficacy should not prevent regulation but that the professions should be encouraged and funded to strengthen the evidence base (p.11, p. 32, p.34).
This question can be a controversial area and the evidence base of these professions was the focus of some press attention following the report’s publication. An often raised argument against regulation in such circumstances is that it would give credibility in the public’s eyes to treatments that are not proven to be safe or efficacious.
This second point is dead right, but it is ignored. The Council then goes on to say
In terms of the HPC’s existing processes, a lack of ‘accepted’ evidence of efficacy is not a barrier to producing standards of proficiency or making decisions about fitness to practise cases.
This strikes me as ludicrous, incompetent, and at heart, dishonest.
There will be no sense in policy in this area until the question of efficacy is referred to NICE. Why didn’t the HPC recommend that? Why has it not been done?
One possible reason is that I discovered recently that, although there are two scientific advisers in the Department of Health,. both of them claim that it is “not their role” to give scientific advice in this area. So the questions get referred instead to the Prince of Wales Foundation. That is no way to run a ship.
The fact of the matter is that the HPC, like so many other regulatory agencies, fails utterly to protect the public from fraudulent and incompetent practitioners. In fact it actually protects them, in the same way that the financial ‘regulators’ protected fraudulent bankers. They all seem to think that ticking boxes and passing exams is an effective process. Even if the exams require you to memorise that amethysts “emit high Yin energy so transmuting lower energies and clearing and aligning energy disturbance as all levels of being”.
Recently I wrote a piece for the National Health Executive (“the Independent Journal for Senior Health Service Managers”), with the title Medicines that contain no medicine and other follies
In the interests of what journalists call balance (but might better be called equal time for the Flat Earth Society), an article appeared straight after mine, Integrating Homeopathy into Primary Care. It was by Rachel Roberts “Research consultant for the Society of Homeopaths”.
This defence was so appalling that I sent them a response (after first doing a bit of checking on its author). To my surprise, they published the response in full [download pdf of printed version]. Their title was
As always, the first step is to Google the author, to find out a bit more. It seems that Rachel Roberts runs a business Integrated Homeopathic Training. (a financial interest that was not mentioned in her article). She will sell you flash cards (‘Matmedcards’) for £70 (+£9 p&p) for 120 cards (yes, seriously). The card for Conium maculatum is remarkable. It says on the reverse side
Yes, it says (my emphasis)
“The poison used to execute Socrates. No 1 remedy for scirrhous breast cancer. Esp after blow to the breast”
No doubt she would claim that the word “remedy” was a special weasel word of homeopaths that did not imply any therapeutic efficacy. But its use in this context seems to me to be cruel deception, even murderous. It also appears to breach the Cancer Act 1939, as well as the Unfair Trading laws.
I asked the Bristol Trading Standards Office, and got a reply remarkably quickly. It ended thus.
“. . . . the use of the card for “hemlock” as an example amounts to advice in connection with the treatment (of cancer)”. I will initially write to IHT and require that they remove this, and any other, reference to cancer treatment from their website.
When I checked again a couple of weeks later, the hemlock sample card had been been replaced by one about chamomile (it is described as the opium of homeopathy. Luckily the pills contain no opium (and no chamomile either) or that would be breaking another law. Bafflingly, it is not (yet) against the law to sell pills that contain no trace of the ingredient on the label, if they are labelled ‘homeopathic’.
Presumably the packs still contain a claim to cure cancer. And what is said in the privacy of the consulting room will never be known.
Political correctness is a curious thing. I felt slightly guilty when I reported this breach of the Cancer Act. It felt almost sneaky. The feeling didn’t last long though. We are talking about sick people here.
It isn’t hard to imagine a desperate woman suffering from cancer reading that Ms Roberts knows the “No 1 remedy for scirrhous breast cancer”. She might actually believe it. She might buy some hemlock pills that contain no hemlock (or anything else). She might die as a result. It is not a joke. It is, literally, deadly serious.
It is also deadly serious that the Department of Health and some NHS managers are so stifled by political correctness that they refer to homeopaths as “professionals” and pay them money.
Ms Roberts, in her article, is at pains to point out that
|
 |
Well it is already well known that the the Code of Ethics of the Society of Homeopaths is something of a joke. This is just one more example.
The Code of Ethics, para 72 says homeopaths have a legal obligation
“To avoid making claims (whether explicit or implied; orally or in writing) implying cure of any named disease.”
Like, perhaps, claiming to have the “No 1 remedy for scirrhous breast cancer”?
Obviously voluntary self-regulation isn’t worth the paper it’s written on.
You don’t need to go to her web site to find “claims . . . implying cure of any named disease”. In her article she says
“Conditions which responded well to homeopathy included childhood eczema and asthma, migraine, menopausal problems, inflammatory bowel disease, irritable bowel syndrome, arthritis, depression and chronic fatigue syndrome.”
No doubt they will say that the claim that asthma and migraine “responded well” to their sugar pills carries no suggestion that they can cure a named disease. And if you believe that, you’ll believe anything.
I have to say that I find Ms Robert’s article exceedingly puzzling. It comes with 29 references, so it looks, to use Goldacre’s word, ‘sciencey’. If you read the references, and more importantly, know about all the work that isn’t referred to, you see it is the very opposite of science. I see only two options.
Either it is deliberate deception designed to make money, or it shows, to a mind-boggling extent, an inability to understand what constitutes evidence.
The latter, more charitable, view is supported by the fact that Ms Roberts trots out, yet again, the infamous 2005 Spence paper, as though it constituted evidence for anything at all. In this paper 6544 patients at the Bristol Homeopathic Hospital were asked if the felt better after attending the out-patient department. Half of them reported that the felt ‘better’ or ‘much better’. Another 20% said they were ‘slightly better’ (but that is what you say to be nice to the doctor). The patients were not compared with any other group at all. What could be less surprising than that half of the relatively minor complaints that get referred for homeopathy get ‘better or much better’ on their own?
This sort of study can’t even tell you if homeopathic treatment has a placebo effect, never mind that it has a real effect of its own. It is a sign of the desperation of homeopaths that they keep citing this work.
Whatever the reason, the conclusion is clear. Never seek advice from someone who has a financial interest in the outcome. Ms Roberts makes her living from homeopathy. If she were to come to the same conclusion as the rest of the world, that it is a placebo and a fraud, her income would vanish. It is asking too much of anyone to do that.
| This is the mistake made time and time again by the Department of Health and by the NHS. The Pittilo report does the same thing The execrably bad assessment of evidence in that report is, one suspects, not unrelated to the fact that it was done entirely by people who would lose their jobs if they were to come to any conclusion other than their treatments work. |  |
At present , the regulation of alternative medicine is chaotic because the government and the dozen or so different quangos involved are trying to regulate while avoiding the single most important question – do the treatments work?
They should now grasp that nettle and refer the question to NICE.
Follow-up
BSc courses in homeopathy are closing. Is it a victory for campaigners, or just the end of the Blair/Bush era?
The Guardian carries a nice article by Anthea Lipsett, The Opposite of Science (or download pdf of print version).
Dr Peter Davies, dean of Westminster’s school of integrated health, says
“he welcomes the debate but it isn’t as open as he would like.”
Well you can say that again. The University of Westminster has refused to send me anything much, and has used flimsy excuses to avoid complying with the Freedom of Information Act. Nevertheless a great deal has leaked out. Not just amethysts emit hig Yin energy, but a whole lot more (watch this space). Given what is already in the public, arena, how can they possibly say things like this?
“Those teaching the courses insist they are academically rigorous and scientific.”
There’s another remark from an unlikely source that I can agree with too. George Lewith, of Southampton University and Upper Harley Street, is quoted as saying
“The quality of degrees is an open joke . . . ”
Whatever next? [Note: Lewith told me later that he was quoted out of context by the Guardian, so it seems that after all he is happy with the courses. So sadly I have to withdraw the credit that I was giving him].
The article emphasises nicely the view that universities that run BSc degrees in things that are fundamentally the opposite of science are deceiving young people and corrupting science itself.
Professor Petts of Westminster seems to think that the problem can be solved by putting more science into the courses The rest of the world realises that as soon as you apply science to homeopathy or naturopathy, the whole subject vanishes in a puff of smoke, I fear that Professor Petts will have to do better,
“He [DC] believes the climate is starting to change after the Bush/Blair era where people believed in things because they wished they were true. “This has been going on for a generation and it’s about time for a swing in the other direction,” he suggests.”
Well, one can always hope.
Follow-up
It is almost six months now since I posted Quackery creeps into good universities too -but through Human Resources. One example given there was the University of Leicester. This is an excellent university. It does first class research and it was the alma mater of the incomparable David Attenborough who has done more than anyone to show us the true beauty and wonder of the natural world.
Nevertheless, their well-meaning occupational health department had a section about “complementary therapies” that contained a lot of statements that were demonstrably untrue. They even recommended the utterly outrageous SCENAR device. So I pointed this out to them, and I had a quick and sympathetic response from their HR director.
But three months later, nothing had changed. Every now and then, I’d send a polite reminder, but it seemed the occupational health staff were very wedded to their quackery. The last reminder went on 6th February, but this time I copied it to Leicester’s vice-chancellor. This time it worked. There is still a link to Complementary Therapies on the Wellbeing site, but if you click on it, this is what you see.
Complementary therapiesSome employees may have an interest in complementary therapies such as acupuncture, yoga, Indian head massage, Reiki, sports & remedial massage, reflexology and hypnotherapy. If you have an interest in any of these, Staff Counselling can happily provide details of practitioners in the local area. Some of these practitioners offer discounts from their normal rates for University of Leicester staff. However, the University of Leicester cannot vouch for, or recommend any of these therapies to staff as being effective. We would urge members of staff who believe that such therapies might be effective to contact their GP prior to undertaking any of them. Further, the University of Leicester shall not be liable for any damage of any kind arising out of or related to the services of any complementary therapists or treatments listed here. If you would like further information, please contact Chris Wilson at: staffcounsel&welfare@le.ac.uk or telephone 1702. |
That’s not bad. Pity it doesn’t say alternative, rather than complementary though. Euphemisms aren’t really helpful.
In fact I have a bit of a problem with “wellbeing” too. It is a harmless word that has been highjacked so that its use now makes one think of mud baths provided by expensive hotels for their rich and gullible customers.
Leicester’s HR director wrote
“Unfortunately an instruction I had given previously had not been fully complied with. I spoke to the manager of the Staff Counselling team on Friday and gave clear instructions as to the content of this site. I had been assured that the offending information had been removed, but found that it had not.
I have now checked the site for myself and can say, with confidence, that all claims for the efficacy of complimentary [sic] therapies have been removed including SCENAR.”
The similarity between quack treatments and religion is intriguing. It seems that the devotion of the occupational health people to their baloney was so great that they wouldn’t take it down even when told to do so. The more irrational the belief, the greater the fervour with which it is defended,
What’s the lesson from this minor saga? It seems that most VCs and many HR people are too sensible to believe in alternative baloney, but that they are a bit too ready to tolerate it, perhaps on grounds of political correctness. Tolerance is a virtue, but lies about health are not in the least virtuous. If you point out that people are saying things for which there isn’t the slightest evidence, they will often respond. Just be prepared to send a few reminders.
It may also be useful to point out that some of the claims made are almost certainly illegal. Even people who care little about evidence of efficacy are impressed by the idea that they might be prosecuted by Trading Standards officers.
Who needs mystical medicine when you have real wonders like these.
(Click the google video logo for a bigger version)
Or try the pitcher plant video, or the Bird of paradise, or the Bower Bird, or the giant Amazon lilies.
Follow-up
From time to time, Private Eye Magazine takes a look at university vice-chancellors (aka presidents/rectors/principals) in its High Principals column.
The current issue (No, 1239, 20, Feb – 5 Mar, 2009) features Professor Geoffrey Petts, vice-chancellor of the University of Westminster,
Well well. Who’d have thought such things were possible?
Follow-up
Notice
I heard, in January 2011, that Barts has a new Dean of Education, and no longer teaches about alternative medicine in the way that has caused so much criticism in the last two years. That’s good news.
What on earth has gone wrong at the Barts and The London School of Medicine and Dentistry (SMD)?
It is not so long ago that I discovered that the very sensible medical students at Barts were protesting vigourously about being forced to mix with various quacks. A bit of investigation soon showed that the students were dead right: see St Bartholomew’s teaches antiscience, but students revolt.
Now it seems that these excellent students have not yet succeeded in educating their own Dr Mark Carroll who, ironically, has the title Associate Dean (Education Quality) in the Centre for Medical Education (SMD), specialising in all aspects of quality assurance in the SMD,
Recently this letter was sent to all medical students. They are so indignant at the way they are being treated, it didn’t take long for a copy of the letter to reach me via a plain brown email.
| Does any medical student have a particular interest in Complementary Medicine? If so, a group at Westminster University would like to contact you (see email message below) with a view to some collaborative work. Further details from Dr Mark Carroll ( m.carroll@qmul.ac.uk ).
|
A student of naturopathy? Does Mark Carroll have the slightest idea what naturopathy is (or pretends to be)? If so, why is he promoting it? If not, he clearly hasn’t done his homework.
You can get a taste of naturopathy in Another worthless validation: the University of Wales and nutritional therapy, or in Nutritional Fairy Tales from Thames Valley University.
It is a branch of quackery that is so barmy that it’s actually banned in some US states. A pharmacist was fined $1 miilion for practising it. But Barts encourages it.
Or read here about the College of Natural Nutrition: bizarre teaching revealed. They claim to cure thyroid cancer with castor oil compresses, and a holder of their diploma was fined £800 000 for causing brain damage to a patient.
I removed the name of the hapless naturopathy student, I have no wish for her to get abusive mail. It isn’t her fault that she has been misled by people who should know better. If you feel angry about this sort of thing then that should be directed to the people who mislead them. The poor student has been misled in to taking courses that teach amethysts emit high yin energy by the University of Westminster’s Vice-chancellor, Professor Geoffrey Petts, But note that Professor Petts has recently set up a review of the teaching of what he must know to be nonsense (though it hasn’t got far yet). In contrast, Dr Carroll appears to be quite unrepentant. He is the person you to whom you should write if you feel indignant.
He claims Barts is "ahead of the game". Which game? Apparently the game of leading medicine back to the dark ages and the High Street quack shop. But, Dr Carroll, it isn’t a game. Sick people are involved.
Dr Carroll is the Associate Dean (Education Quality) in the Centre for Medical Education (SMD), specialising in all aspects of quality assurance in the SMD. This has to be the ultimate irony. It’s true that the Prince of Wales approach to medicine has penetrated slightly into other, otherwise good, medical schools (for example, Edinburgh) but I’m not aware of any other that has gone so far down the road of irrationality as at Barts.
Dr Carroll, I suggest you listen to your students a bit more closely.
You might also listen to President Obama. He has just allocated $1.1 billion “to compare drugs, medical devices, surgery and other ways of treating specific conditions“. This has infuriated the drug industry and far-right talk show host Rush Limbaugh. Doubtless it will infuriate quacks too, if any of it is spent on testing their treatments properly.
Follow-up
This classic was published in issue 1692 of New Scientist magazine, 25 November 1989. Frank Watt was head of the Scanning Proton Microprobe Unit in the Department of Physics at Oxford University. He wrote for the New Scientist an article on Microscopes with proton power.
In the light of yesterday’s fuss about research funding, Modest revolt to save research from red tape , this seemed like a good time to revive Watt’s article. It was written near to the end of the reign of Margaret Thatcher, about a year before she was deposed by her own party. It shows how little has changed.
It is now the fashion for grant awarding agencies to ask what percentage of your time will be spent on the project. I recently reviewed a grant in which the applicants had specified this to four significant figures, They’d
pretended they knew, a year before starting the work that they could say how much time they’d spend with an accuracy better than three hours. Stupid questions evoke stupid answers.
The article gave rise to some political follow-up in New Scientist, here and here.
Playing the game – The art of getting money for research
WELL, that’s it,’ thought the Captain. ‘We have the best ship in the world, the most experienced crew, and navigators par excellence. All we need now is a couple of tons of ship’s biscuits and it’s off to the ends of the world.’ NRC (Nautical Research Council) grant application no MOD2154, September 1761. Applicant: J. Cook. Aim: To explore the world. Requirements: Supplies for a three-year voyage. Total cost: Pounds sterling 21 7s 6d. January 1762: Application MOD2154,rejected by the Tall Ships subcommittee Reasons for rejection: ‘Damn,’ thought the Captain, ‘that’s nailed our vitals to the plank good and NRC grant application no MOD2279, April 1762. Applicant J. Cook. Aim: To explore the world beyond Africa in a clockwise direction and discover a large continent positioned between New Guinea and the South Pole. Requirements: Supplies for a three-year voyage. Total cost: Pounds sterling 21 7s 7d (adjusted for inflation). September 1762: Application MOD2279 rejected by the Castle and Moats subcommittee Reasons for rejection. (a) Why discover a large continent when there are hundreds of castles in Britain. (b) It is highly unlikely that Cook’s ship will fit into the average moat. ‘Damn,’ thought the Captain, ‘shiver me timbers, the application has gone to the wrong committee.’ ‘Come back in six months,’ he told his sturdy crew. Dear NRC, Why did our application MOD2279 go to the Castle and Moats subcommittee instead of the Tall Ships committee? Yours sincerely, James Cook. Dear Mr Cock, The Tall Ships subcommittee has been rationalised, and has been replaced by the Castle and Moats subcommittee and the Law and Order subcommittee. Yours sincerely, NRC. ‘Damn,’ thought the Captain, ‘rummage me topsail, we’ll never get off the ground like this. I had better read up on this new chaos theory.’ In fact the Captain did not do this, but instead took advice from an old sea dog who had just been awarded a grant of Pounds sterling 2 million from the emergency drawbridge fund to research the theory of gravity. NRC Application no MOD2391, January 1763 (to be considered by the Law and Order subcommittee). Applicant J. Cook. Aim: Feasibility study for the transportation of rascals, rogues and vagabonds to a remote continent on the other side of the world. Initial pilot studies involve a three-year return journey to a yet undiscovered land mass called Australia . Requirements: Supplies for a three-year voyage. Total cost: Pounds sterling 21 7s 8d (again adjusted for inflation). Dear Mr Coko, We are pleased to inform you that your application MOD2391 has been successful. Unfortunately, due to the financial crisis at the moment, the subcommittee has recommended that funding for your three-year round trip to Australia be cut to 18 months. Yours sincerely, NRC. |
Follow-up
A letter to Mr Darwin A correspondent draws my attention to another lovely piece from the EMBO Reports Journal )Vol 10, 2009), by Frank Gannon. [Download the pdf.]
Dear Dr Darwin
” . . . . In a further comment, referee three decries your descriptive approach, which leaves the task of explaining the ‘how’ to others. His/her view is that any publications resulting from your work will inevitably be acceptable only to lowimpact specialist journals; even worse, they might be publishable only as a monograph. As our agency is judged by the quality of the work that we support—measured by the average impact factor of the papers that result from our funding—this is a strongly negative comment”
Rather sadly, this excellent editorial had to accompanied by a pusillanimous disclaimer
This Editorial represents the personal views of Frank Gannon and not those of Science Foundation Ireland or the European Molecular Biology Organization.
Recent Comments