Trick or Treatment – review

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I’ve just finished reading Simon Singh and Edzard Ernst’s book on alternative medicine entitled ‘Trick or Treatment’.

Written by a best selling science author Singh, who boasts a PhD in particle physics, and Ernst, a professor in complementary therapy, and subtitled ‘alternative medicine on trial’ Singh and Ernst clearly hope to set a standard in the genre.  They set out their stall early, first by dedicating the book to the Prince of Wales, whose sympathetic views on alternative medicine are well known, and then by quoting Hippocrates as providing their guiding path:

‘There are, in fact, two things, science and opinion; the former begets knowledge, the latter ignorance.’

They themselves are not modest:

‘Although there are plenty of books that claim to tell you the truth about alternative medicine, we are confident that ours offers an unparalleled  level of rigour, authority and independence’

Any treatment which cannot stand up to the rigours of scientific enquiry, by which Singh and Ernst mean a well conducted controlled clinical trial, has no place calling itself medicine and is simply hocus-pocus with good PR.  At best such therapy is simply no better than placebo, at worse it is positively dangerous.  But even if it is harmless, it is far from costless, as the annual global spend on alternative medicine is in the region of £40 billion, money that could be spent on more fruitfully, should alternative therapies prove to be ineffective.

The authors say that the key theme running through their book is ‘truth’.  And not in any post-modern sense, but instead in the sense of the fundamental question: ‘is alternative medicine effective for treating disease?’.  With this in mind, the first chapter of the book is about how science establishes whether medical interventions are effective or not; that is, how the ‘evidence’ is put into ‘evidence-based medicine’.

To explain this, Singh and Ernst take a historical approach, building the notion of the clinical trial as the gold standard for evaluating medical interventions.  They start by telling us of one of the casualties of the ancien regime; on December 13 1799 former President George Washington awoke with the symptoms of a cold.  He thought nothing of it, but by the following night he was gasping for air.  Serious, but potentially survivable, until bloodletters drained Washington of half his blood in less than a day.  These men weren’t witchdoctors, but Washington’s personal physicians.  They thought that they were working in the great man’s best interests, but alas the medical profession had yet to work out how to distinguish interventions that worked from those that didn’t.

Typically, it was a British man who first came up with the randomized control trial, even more typically he then totally failed to capitalize upon his insight. The man was a naval surgeon called James Lind;  Britain at this time was the world’s greatest seafaring nation, but any journey lasting more than a few weeks was blighted by scurvy, a disease we now know is caused by a deficit in vitamin C. Lind split twelve scurvy sufferers into six pairs, and gave each a different treatment.  He also observed another group of sailors who received no treatment; these acted as a control.  As a shot in the dark, to one pair he gave oranges and lemons; this group made a miraculous recovery.  Alas, in part due to Lind’s diffidence, his findings remained almost totally ignored for 33 years.

Just as interesting, Singh and Ernst tell us about Florence Nightingale and her penchant for statistics.  Feeling a divine calling to become a nurse, Nightingale decided to work in the hospitals of the Crimean war, having read reports of the large numbers of soldiers dying there from cholera and malaria.  Upon her arrival at her chosen hospital she embarked on the mother of all spring cleans and within one week removed 215 handcarts of filth, had flushed the sewers nineteen times and buried the carcasses of two horses, a cow and four dogs all of which were found in the hospital grounds (I think that she had some help).  But, amazing to us now, the officers and doctors who were previously in charge felt that these changes were an insult to their professionalism.  Fortunately Nightingale also had a statistical education and used this to demonstrate that soldiers under her new order fared much better than those hospitalized in less salubrious conditions. By telling us of this Ernst and Singh also seek to demonstrate that, quite opposite to what alternative practitioners believe, scientists are willing to accept ideas which run contrary to the current received wisdom.  The clinical trail is such a strong instrument that it forces them to do so.

In the next four chapters of their book, the authors take four of the main branches of alternative medicine to task: Acupuncture, Homeopathy, Chiropractic therapy and Herbal Medicine.  They take us through the history of each approach, its theory of action and assess the evidence for its efficacy.

Acupuncture, is an ancient treatment, whereby the body’s ‘Ch’i', its vital energy or life force flows through our bodies in channels called meridans.  Illnesses are due to imbalances or blockages in the flow of Ch’i and the goal of acupuncture is to tap into the meridans at key points to rebalance or unblock the Ch’i.  Ernst and Singh cite the experience of James Reston, who was reporting on Nixon’s 1973 Chinese visit as key for acupuncture’s introduction into the west.  Whilst in China he suffered from appendicitis and was treated by acupuncture, bringing news of his treatment and recovery home. Unlike Reston, Ernst and Singh are unconvinced.  They demolish positive papers published by the WHO as having included too many trials, some of which used poor methodology, and conclude that the science behind acupuncture is implausible and totally without evidence.  They finish by saying that Acupuncture has inconsistent evidence to suggest that it has a use in pain and nausea control.

If acupuncture gets une point, then Homeopathy, gets null.   This was the work of a German physician Samuel Hahnemann at the end of the 18th century.  Hahnemann correctly realised that he and his medical colleagues knew nothing about how to treat people, but he then moved away from the then conventional medicine and contrived to establish his own brand of treatment.  Having taken quinine one morning he found himself having the same symptoms as if he had malaria.  From this he extrapolated a universal principle ‘that which can produce a set of symptoms in a healthy individual can treat a sick individual who is manifesting a similar set of symptoms’.  Even better, he went on to say that the potency of a cure could be greatly enhanced by diluting them.  Not just a little bit either; some homeopathic remedies are at the sort of concentration you might expect from putting a teabag in lake Superior.  Singh and Ernst find this all highly improbable, and put any positive effects attributed to this brand of alternative medicine down, amongst other things, to the body’s ability to heal itself.

The founders of chiropractic therapy argue that ill health in the body is due to subluxations, slight misalignments of vertebrae in the spine.  These subluxations interfere with the flow of innate intelligence (a bit like Ch’i).  They are corrected by spinal manipulation, whereby the practitioner flexes of extends the neck beyond its normal range of movement.  There are some chiropractors called ‘mixers’, who are basically back specialists, however their ‘straight’ colleagues believe that their techniques can cure the body of ills seemingly unconnected with the bony structures.

My attitude to all this would be: not to my neck you don’t buddy.  And according to Ernst and Singh rightly so.  There is some evidence that chiropractors have a place in treating back pain.  This is something with which conventional medicine has struggled.  However in its treatment, chiropractors and conventional medicine come out as a dead heat, and a pack of ibuprofen is 35p in Sainsburys whereas a course of Chiropractic treatment costs a great deal more than this.  As worrying is that it is reported in the book that it is not unusual for chiropractors to spinally manipulate patients without their consent on their first appointment, and furthermore that this spinal manipulation has lead to vertebral artery dissections and death in patients.

Before their finger pointing and conclusions and an interesting section entitled ‘Why do smart people believe such odd things?’ Singh and Ernst take as their fourth case study Herbal Medicine.  This is a more tricky area for them, as unlike their previous three methodologies, some herbal remedies, for example St John’s Wort, actually work.  Here the problems are more subtle.  Imagine this:  in order to get onto the shelf in your pharmacy a mainstream medicine has been exhaustively evaluated in a process costing millions of pounds and will have been produced in a sophisticated process whereby a manufacturer will be sure exactly of the contents of the drug they are selling you.  With a herbal remedy on the other hand, you may be getting something, covered in dirt, from someone’s back garden and they probably didn’t even wash their hands as they picked it.  There’s worse too, as herbal remedies can interact with conventional drugs with unpredictable consequences and if they are taken in preference to conventional medicines they won’t get you very far, as the authors tell us was discovered by several unfortunate, but trusting, cancer victims.  And beware, some herbal remedies are effective because they actually contain conventional medicines.

So whose fault is this?  Ernst and Singh propose that most alternative remedies trade on being more natural, traditional and holistic, three ideas they quickly dispatch.  Uranium is natural, bloodletting was traditional, and holistic medicine is not a preserve of alternative practitioners – GPs regularly give lifestyle advice. They go onto blame celebrities for endorsing alternative treatments, universities for providing alternative medicine courses to make money and thus legitimizing alternative approaches, the media for inaccurately reporting the benefits of alternative therapies and many doctors for prescribing alternative medicine to get difficult patients out of their consulting rooms.

There should be warning messages on alternative medical treatments like cigarettes they say, accurately reflecting the current evidence.  For Homeopathy this would read

Warning: this product is a placebo.  It will work only if you believe in homeopathy and only for certain conditions, such as pain and depression.  Even then it is not likely to be as powerful as orthodox drugs.  You may get fewer side effects, from this treatment, than from a drug, but you will probably get less benefit.

At the end of their book a further 36 alternative therapies are critiqued including colonic irrigation and ear candles – the latter of which I could tell you is bollocks just from the name.

So, having written a much longer review than I initially intended, is this book any good?  It’s certainly pretty thorough.  The first chapter about scientific method is very interesting, but the next four chapters wherein the authors examine acupuncture, Homeopathy, Chiropractic therapy and Herbal Medicine are interesting in a lot of places, but often come across as a bit dry.  This book may attempt too much aiming to be both an entertaining popular science book and one offering balanced medical advice to those seeking treatment.

Mark Bostridge has written a new biography of Florence Nightingale:

Florence Nightingale: a woman and her legend

Guardian review

8 Responses to “Trick or Treatment – review”

  1. give me the beans and I'll count them says:

    How well do psychological treatments REALLY come out in Randomised Controlled Trials? This article doesn’t make any great claims for an evidence base for current treatments, and yet NICE et al are happy to say that there ARE evidence based treatments available. http://www3.interscience.wiley.com/journal/110472689/abstract?CRETRY=1&SRETRY=0

  2. TheShrink says:

    I’m not enthusiastic about complementary medicine as an alternative to appropriate medical care.

    Equally I’m not so grandiose as to presume that nothing ‘cept what I learnt at medical school is useful in promoting, improving or maintaining health.

    But, although fairly open minded, I am cautious about the explicit intervention. Look it in the eye and tell me what it is. We know from aromatherapy studies that the type of oil is irrelevant. Maybe the studies were wrong, but the take home message to me was it’s the process not the active agents that give benefit.

    Crystal therapy, colour therapy, there’s all sorts of presentations of stuff that I’ve sat through which really has bemused me.

    Acupuncture, as you say, scores points. It can work. It has little in the way of treatment emergent adverse events. It is fairly cost efficient (locally there are over 600 folk having acupuncture on the NHS regularly, i.e. at fixed regular intervals forever) and this investment in indefinite longditudinal care has contained them (with no other input from other services now necessary). Prior to this, frequent ‘phone calls to GP surgeries and trips to A&E and repeat Consultant referrals were the norm. None of these are mental health patients, so in mainstream health provision I would see acupuncture as having some utility in affording both better patient care (with helpful symptom reduction) and meaningful impact.

  3. Frontier Psychiatrist says:

    Of course we should be open to things which we weren’t taught at medical school, but the position of the book is that anything that works and can be shown to do so in a properly conducted clinical trial is no longer actually alternative medicine, and anything which cannot pass these rigorous tests should be treated with great suspicion.

    The authors feel that we as doctors should be more forthright ambassadors for conventional medicine. They blame doctors for colluding with alternative medicine out of ignorance and also expedience – we wish to use the ‘harmless placebo’.

    Your position on acupuncture appears to be quite close to this harmless placebo argument, whereby alternative therapies are provided for a difficult to treat conditions as a way of keeping our customers satisfied. (The authors consider acupuncture to be ineffective in all but analgesia and nausea and even then to be no better than conventional treatments and with weak evidence). Singh and Edzard consider the harmless placebo approach to be ‘paternalistic and inevitably involves deception’. It is discussed on page 244 onwards (hardback).

  4. Frontier Psychiatrist says:

    give me the beans – the above link doesn’t work – can you post the reference (title, authors, journal etc)?

  5. give me the beans and I'll count them says:

    oops – it doesn’t work for me either.

    It’s an article by Professor Christopher Fairbairn submitted in September 2004 (and thus possibly out of date) to the International Journal of Eating Disorders published by Wiley Interscience on 25th April 2005. The title is Evidence Based treatment of Anorexia Nervosa. I found it here http://www3.interscience.wiley.com/aboutus/topics/eating_disorders_evidence_base.html – hope that link works better

    The abstract reads “This paper addresses the question Is evidence-based treatment of anorexia nervosa possible? Barely is the conclusion drawn. New forms of treatment are needed for adults with anorexia nervosa, and the true value of family-based treatment for adolescents has yet to be established. © 2005 by Wiley Periodicals, Inc.” and the article appears (at least to me as a simple bean counter without a clinical qualification to her name) to be arguing that there isn’t yet any overwhelming evidence for the so called evidence based treatments for Anorexia Nervosa cited in the NICE guidelines

  6. I’m not a big proponent of alternatives to medical care, but I’m not completely closed-minded about it. A good example would be acupuncture. Prior to being introduced to this treatment, I always dismissed anything that’s not western medicine-related. I didn’t think that anything that wasn’t FDA approved was a valid course of action. I was mistaken when after having my 1st acupuncture treatment to aid with an injury I received on my lower back (a freak accident when I slipped on a banana peel outside and fell down a flight of stairs…I know, cliche!) about 8 years ago. I remember the alleviation of pain I felt when I first stood up after that 1st treatment and I thought I was walking on clouds. It wasn’t an instant fix because a good portion of the pain was still there, but I could tell that it wasn’t completely in vain. I continued to go 3 times/week for a month and see if this ailment can be completely taken care of. I was surprised to see that I was nearly 100% by the end of that month. Mind you, I also had anti-inflammatory medication and a small vial of pain pills as well, but the acupuncture was a God-send. These days, I’m still not big on the whole genre of herbal alternative medicines, but if something works for me personally, I’ll stand by it throughout my life. Acupuncture is one of those coupled by a good deep-tissue massage does the trick without a doubt in my book.

  7. Julie says:

    Re’ acupuncture: Singh notes that research shows sham acupuncture working just as well as ‘true’ acupuncture. The placebo effect can account for the relief.

    I found the book a very easy read but completely comprehensive and thorough in the research of each of the therapies. The explanations as to how the therapies began is helpful, in understanding how they gained footholds, as well.

    As we’ve all heard before, the plural of anecdote is not data. I prefer to trust the scientific method to discover which treatment is helpful – or not.

    :)

  8. Fernando says:

    If the authors say: Any treatment which cannot stand up to the rigours of scientific enquiry, by which Singh and Ernst mean a well conducted controlled clinical trial, has no place calling itself medicine and is simply hocus-pocus with good PR,
    then their book is nothing but hocus-pocus.
    I must point out some inaccuracies in the book that do not stand up to any serious research.
    On page 326 the authors talk about shiatsu, and they don’t seem to know what they are talking about.
    They mention Tokujiro Namikoshi as the creator or developer of shiatsu, which is correct, and a bit later they say that shiatsu is based on yin/yang concepts.
    For your their information, Mr Namikoshi NEVER mentioned yin/yang in all his life or in his writings.
    That was done by one of his students, 50 years after he had opened his first shiatsu school, when they followed seaprate ways.

    They also say that shiatsu might be dangerous for people who are at risk of suffering a stroke.
    This is absolutely true. ANY type of massage – or even going for a run – might trigger the stroke.
    However, the implication in the book is that Western Massage is not dangerous, which again is totally untrue.

    They claim that shiatsu can hurt people with osteoporosis.
    I wrote to Dr Singh asking where they got that information from.
    Any scientific studies? Someone mentioned it? Or did they just make it up?
    I didn’t get a reply. I didn’t expect one either. After all, who am I?

    And finally, they also mention that there aren’t enough clinical trials of shiatsu.
    I agreed, but explained that this is because hospitals and research centres don’t let us do them.
    I challenged them to set up a clinical trial with shiatsu for people with osteoporosis.
    I’d gladly participate in such a trial.

    This is only from one page in the book. I wonder how many other things they have made up and not researched properly.
    Scientific book? Hardly.

    But the worse is seeing some reviews that accept that the book is scientific because it’s written by scientists.
    I thought science was about proof (at least statistically speaking) and not about scientists’ opinion.

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