Download Lectures on Biostatistics (1971). Corrected and searchable version of Google books edition
Download review of Lectures on Biostatistics (THES, 1973).
chiropractor
| One of the most extraordinary bits of journalism I’ve read for a long time appeared as an editorial in the Sri Lankan newspaper, the Sunday Leader, on Sunday January 11th 2009 It was reproduced in the Guardian on 13th January, and in The Times. It was written by Lasantha Wickrematunge, editor of the Sunday Leader, and it was the last thing he wrote. Days after writing it he was assassinated. |  |
It is a plea for freedom of speech. In particular, for the freedom of journalists to tell the truth, It is deeply moving and it is also written in more beautiful English than many native speakers can manage. The second person to leave a comment in the Guardian said
“Extraordinary, humbling and deeply moving.
Cif Eds, please leave this at the top of the page for about a week, and then nail copies it to every available surface at Guardian HQ.”
Writing blogs like this one (and a thousand others) need some of the skills of investigative journalism. Those skills are not so different from those you need in science, Curiosity, a willingness to look under stones, a preference for truth over myth, some skill with Google and a good deal of tenacity. You also need to be resilient to abuse and defamation by people who disagree with you. But you do not risk your life. It does not take much courage. That isn’t true in large parts of the world.
Read it all. Here are a few quotations to persuade you it’s worth the time.
“No other profession calls on its practitioners to lay down their lives for their art save the armed forces – and, in Sri
Lanka , journalism. In the course of the last few years, the independent media have increasingly come under attack. Electronic and print institutions have been burned, bombed, sealed and coerced. Countless journalists have been harassed, threatened and killed. It has been my honour to belong to all those categories, and now especially the last.”“The Sunday Leader has been a controversial newspaper because we say it like we see it: whether it be a spade, a thief or a murderer, we call it by that name. We do not hide behind euphemism. The investigative articles we print
are supported by documentary evidence thanks to the public-spiritedness of citizens who at great risk to themselves pass on this material to us. We have exposed scandal after scandal, and never once in these 15 years has anyone proved us wrong or successfully prosecuted us.”“The free media serve as a mirror in which the public can see itself sans mascara and styling gel. From us you learn the state of your nation, and especially its management by the people you elected to give your children a better future.”
“It is well known that I was on two occasions brutally assaulted, while on another my house was sprayed with machine-gun fire. Despite the government’s sanctimonious assurances, there was never a serious police inquiry into the perpetrators of these attacks, and the attackers were never apprehended.
In all these cases, I have reason to believe the attacks were inspired by the government. When finally I am killed, it will be the government that kills me.”
“In the wake of my death I know you will make all the usual sanctimonious noises and call upon the police to hold a swift and thorough inquiry.
But like all the inquiries you have ordered in the past, nothing will come of this one, too. For truth be told, we both know who will be behind my death, but dare not call his name. Not just my life but yours too depends on it.
As for me, I have the satisfaction of knowing that I walked tall and bowed to no man. And I have not travelled this journey alone. Fellow journalists in other branches of the media walked with me: most are now dead, imprisoned
without trial or exiled in far-off lands.”“People often ask me why I take such risks and tell me it is a matter of time before I am bumped off. Of course I know that: it is inevitable. But if we do not speak out now, there will be no one left to speak for those who cannot,
whether they be ethnic minorities, the disadvantaged or the persecuted. An example that has inspired me throughout my career in journalism has been that of the German theologian, Martin Niemöller. In his youth he was an antisemite and an admirer of Hitler. As nazism took hold of Germany, however, he saw nazism for what it was. It was not just the Jews Hitler sought to extirpate, it was just about anyone with an alternate point of view. Niemöller spoke out, and for his trouble was incarcerated in the Sachsenhausen and Dachau concentration camps from 1937 to 1945, and very nearly executed. While incarcerated, he wrote a poem that, from the first time I read it in my teenage years, stuck hauntingly in my mind:
First they came for the Jews
and I did not speak out because I was not a Jew.Then they came for the Communists
and I did not speak out because I was not a Communist.Then they came for the trade unionists
and I did not speak out because I was not a trade unionist.Then they came for me and there was no one left to speak out for me.
If you remember nothing else, let it be this: the Leader is there for you, be you Sinhalese, Tamil, Muslim, low-caste, homosexual, dissident or disabled.”
This man puts to shame the those who won’t speak out in the safety of the West, despite the fact that they have nothing to lose but their ministerial jobs or their knighthoods. Or running the risk of being sued by chiropractors.
How about some nominations for Western journalists who live up to these ideals? I’d start with Seymour Hersh and Paul Krugman in the USA, and our own Ben Goldacre. It’s interesting though, that two of these three are not full time journalists. Blogs do rather better than most newspapers. They have become an important force for freedom of speech. That more than counterbalances the use of the web for promoting junk. It is a lot harder to keep a secret than it used to be.
There is an obituary of Lasantha Wickrematunge in the Sunday Leader, and a report from Amnesty International.
Shortly after I published my editorial in the New Zealand Medical Journal, Dr Who?, I was delighted to get a letter from someone who had trained in chiropractic and seen it all from the inside.
Sadly this wonderful letter had to be removed within a few weeks of posting it because its author was threatened and bullied by chiropractors. Its author is too young and too vulnerable to risk his future career. As a result of this shameful and vindictive treatment, I was asked to remove the letter and did so immediately. Other copies on the web have now vanished too.
The experiences described in the letter justified much of what I said in the editorial, and in some ways went further. This letter doubtless contributed to dropping of the threatened legal action by chiropractors against the Journal and against me. The letter was posted originally on 21 August 2008, with the permission of its author. See also the follow-up in Chiropractic wars. Part 3: internecine conflict.
Now I have been sent a much more anonymous version, and it is a great pleasure to post this inside information.
| David
I must begin by stating my background in relation to chiropractic. I am a graduate of a chiropractic college and have practiced for several years. I have elected not to register or practice again and have returned to study to begin a new career. Prior to studying chiropractic, I gained undergraduate and postgraduate qualifications in science. First I would like to address your comment about the validity of a qualification from a private chiropractic college, especially in relation to the difference between studying there and studying at a university. A major difference is the education and experience of faculty. At the time I was there, most of the faculty at my college had only undergraduate qualifications (I would suggest that the American DC degree is of undergraduate level as it is the primary qualifying degree for chiropractic in the US and Canada -it is not the equivalent of a doctorate in a British or Australasian university) and have not published in peer-reviewed journals. This is quite different to my experience of universities where the all of the faculty usually have at least a PhD and are actively involved in research. The content of the chiropractic curriculum was voluminous. It included basic sciences, chiropractic subjects and social sciences. The college I attended did not have any laboratory facilities so the experience of learning science from a textbook was quite different to the way I had been taught at university, where each subject had a significant laboratory program that had to be passed separately to pass the subject. As chiropractic is a clinical discipline, the course contained subjects in common with a medical degree. Sadly, the attitude towards medicine and the medical profession was not always the most constructive. For example, I can recall a noticeboard where newspaper clippings of media reports of medical misadventure and adverse effects of pharmaceuticals were posted regularly. Clinical experience was gained by a 2 year internship in the school health centre concurrent with the last 2 years of academic study; so it was not a full-time internship. The requirements for passing this component of the course were complex but centred around seeing a number of patients, a number of visits, performing a number of various kinds of x-rays and reading a number of x-ray films. Every student was responsible for finding all of their own patients to meet the requirements. The result of this was a clinical experience that was quite narrow for most people. This would seem to be quite different to the hospital internship of a medical degree, the clinical internship of a dental degree or the range of placements in a physiotherapy degree in terms of the breadth of experience of different kinds of patients of different ages and states of health. For people who are not aware, there are a range of ideas within chiropractic about what it is and what it is for. The “wellness”, subluxation-based kind of chiropractic is taught by a minority of schools and is what chiropractors call a “philosophical view”. It advocates that chiropractic care be independent from symptoms or treatment and be a regular part of peoples’ lives. The expectation is that healthy, asymptomatic people will be “adjusted” on a regular basis to keep them free from “vertebral subluxation”. To that end, the training at schools that teach this approach is adequate (and probably even excessive). The issue that you wrote about related to the use of the title “doctor” by chiropractors in New Zealand. In licensing chiropractors and allowing them the use of the title “Dr” in front of their names (provided that the title is qualified by the word “chiropractor”) governments have awarded chiropractors with recognition and prestige that has usually been associated with a level of academic achievement or with a medical qualification. It indicates that the bearer of the title can be trusted to give credible advice within their area of expertise. The issue may seem benign, but in allowing chiropractors to use the title, people who would not normally feel safe to submit to the treatment of an alternative health practitioner, choose to try chiropractic. I make this point because at its core, chiropractic is quite different to medicine, dentistry and physiotherapy. A chiropractic office often looks like a lot like a doctor’s surgery. The layout is similar (with waiting rooms and consultation rooms; there are things like stethoscopes and x-ray machines and there are often informative and education posters and brochures. In many cases, the title “doctor” is used in I have found that some people believe chiropractors are medical doctors. Some even believe that chiropractic is a kind of medical speciality. I have seen patients who choose chiropractic as their primary health care and come to a chiropractic office as their first port of call when they are unwell. I Two practices are of particular concern in some chiropractic offices and in my view; these alone should be sufficient reason to prevent chiropractors from calling themselves “doctor”. The first is the systematic and deliberate erosion of a person’s confidence in the medical system. Many offices have anti medical literature in their libraries. Chiropractors are sometimes taught practices to subvert medical credibility. See http://chirobase.org/20PB/top7.html for an example. The second is a subset of the first but is particularly damaging. It is active opposition to vaccination. At chiropractic school, I was taught anti-vaccination information in my paediatrics course. I have seen books written by chiropractors opposing vaccination and I have seen many offices with anti vaccination leaflets and books in abundance. Now I am all for informed choice but this type of material is rarely accurate or balanced. People are being encouraged not to vaccinate their children by professionals who they believe to be a reliable and prestigious source of information. Although it may sound paternalistic to people who have not had the privilege of clinical practice (albeit in a profession I no longer agree with), it made me realise several things. The first is that people who are unwell are vulnerable. The second is that there are people who trust “medical” advice unquestioningly. I believe we should be very careful about who we title as a credible source of advice about health care. Legislation treads a fine line between limiting personal freedom and protecting people from harm. Aside from the qualification being inconsistent with the academic level that is usually required to use the title “Doctor”, the greatest danger, in my opinion, is that the legal recognition and permission to use the title has allowed chiropractors to assume the mantle of a doctor. In the guise of this respectability, some chiropractors are deliberately eroding confidence in doctors and denying children (and possibly populations) the protection of vaccination. David, thank you for having the courage to question the use of the title “doctor” by chiropractors. Historically (and in your case), chiropractors fight their battles through litigation so it takes personal courage and integrity to do so. |
All I can say is, don’t thank me. It doesn’t take much courage at my age. It takes a lot at yours and the world should be grateful to you.
Replies from chiropractors in the NZMJ
The New Zealand Medical Journal, very properly, allowed right of reply to chiropractore. This week’s issue contains three letters, one of which is from Paul Kelly. It is signed “Dr Brian Kelly B App Sci (Chiro), President, New Zealand College of Chiropractic”. This is not quite the same as appears on his College’s web site which shows the president’s welcome.
It seems that Kelly has not been quite so careful about use of his title on the web site because (as of 21 August) the signature on his address looks like this.
“Dr Brian Kelly, President”. That does seem a bit careless, given that his usage of “Dr” was pointed out in my original editorial, published on 25th July.
Replies to these letters appeared in the September 5th issue of NZMJ.
Alfred Joseph Clark FRS held the established chair of Pharmacology at UCL from 1919 to 1926, when he left for Edinburgh. In the 1920s and 30s, Clark was a great pioneer in the application of quantitative physical ideas to pharmacology. As well as his classic scientific works, like The Mode of Action of Drugs on Cells (1933) he wrote, and felt strongly, about the fraud perpetrated on the public by patent medicine salesmen. In 1938 (while in Edinburgh) he published a slim volume called Patent Medicines. The parallels with today are astonishing.
 
Alfred Joseph Clark FRS (1885 – 1941) |
 |
I was lucky to be given a copy of this book by David Clark, A.J. Clark’s eldest son, who is now 88. I visited him in Cambridge on 17 September 2008, because he thought that, as holder of the A.J. Clark chair at UCL from 1985 to 2004, I’d be a good person to look after this and several other books from his father’s library. They would have gone to the Department of Pharmacology if we still had one, but that has been swept away by mindless administrators with little understanding of how to get good science.
Quotations from the book are in italic, and are interspersed with comments from me.
The book starts with a quotation from the House of Commons Select Committee report on Patent Medicines. The report was submitted to the House on 4 August 1914, so there is no need to explain why it had little effect. The report differs from recent ones in that it is not stifled by the sort of political correctness that makes politicians refer to fraudsters as “professions”.
The problem
“2.2 The situation, therefore, as regards the sale and advertisement of proprietary medicines and articles may be summarised as follows:
For all practical purposes British law is powerless to prevent any person from procuring any drug, or making any mixture, whether patent or without any therapeutical activity whatever (as long as it does not contain a scheduled poison), advertising it in any decent terms as a cure for any disease or ailment, recommending it by bogus testimonials and the invented opinions and facsimile signatures of fictitious physicians, and selling it under any name he chooses, on payment of a small stamp duty. For any price he can persuade a credulous public to pay.”
Select Committee on Patent Medicines. 1914
“The writer has endeavoured in the present article to analyse the reasons for the amazing immunity of patent medicines form all attempts to curb their activity, to estimate the results and to suggest the obvious measures of reform that are needed.”
| Clark, writing in 1938, was surprised that so little had changed since 1914. What would he have thought if he had known that now, almost 100 years after the 1914 report, the fraudsters are still getting away with it? Chapter 2 starts thus. |
 |
THE LAW
The Select Committee appointed by the House of Commons in 1914 ‘to consider and inquire into the question of the sale of Patent and Proprietary Medicines’ stated its opinion in 28 pages of terse and uncompromising invective. Its general conclusions were as follows:
That the trade in secret remedies constituted a grave and widespread public evil.
That the existing law was chaotic and had proved inoperative and that consequently the traffic in secret remedies was practically uncontrolled.
In particular it concluded ‘”that this is an intolerable state of things and that new legislation to deal with it, rather than merely the amendment of existing laws, is urgently needed in the public interest.”
The “widespread public evil”continues almost unabated, and rather than introduce sensible legislation to cope with it, the government has instead given a stamp of approval for quackery by introducing utterly ineffective voluntary “self-regulation”.
Another Bill to deal with patent medicines was introduced in 1931, without success, and finally in 1936, a Medical and Surgical Appliances (Advertisement) Bill was introduced. This Bill had a very limited scope. Its purpose was to alleviate some of the worst abuses of the quack medicine trade by prohibiting the advertisement of cures for certain diseases such as blindness, Bright’s disease [nephritis] , cancer, consumption [tuberculosis], epilepsy, fits, locomotor ataxy, fits, lupus or paralysis.
The agreement of many interests was secured for this measure. The president of the Advertising Association stated that the proposed Bill would not affect adversely any legitimate trade interest. Opposition to the Bill was, however, whipped up amongst psychic healers, anti-vivisectionists and other opponents of medicine and at the second reading in March 1936, the Bill was opposed and the House was counted out during the ensuing debate. The immediate reason for this fate was that the Bill came up for second reading on the day of the Grand National! This is only one example of the remarkable luck that has attended the patent medicine vendors.
(Page 14).
The “remarkable luck” of patent medicine vendors continues to this day, Although, in principle, advertisement of cures for venereal diseases was banned in 1917, and for cancer in 1939, it takes only a few minutes with Google to find that these laws are regularly flouted by quacks, In practice quacks get away with selling vitamin pills for AIDS, sugar pills for malaria and homeopathic pills for rabies, polio anthrax and just about anything else you can think of. Most of these advertisements are contrary to the published codes of ethics of the organisations to which the quack in question belongs but nothing ever happens.
Self-regulation simply does not work, and there is still no effective enforcement even of existing laws..
“It has already been stated that British law allows the advertiser of a secret remedy to tell any lie or make any claim that he fancies will sell his goods and the completeness of this licence is best illustrated by the consideration of a few specific points.
Advertisements for secret remedies very frequently contain a list of testimonials from medical men, which usually are in an anonymous form, stating that ………….. M.D., F.R.C.S., has found the remedy infallible. Occasionally, however, the name and address of a doctor is given and anyone unaware of the vagaries of English law would imagine that such use of a doctor’s name and professional reputation could not be made with impunity without his consent. In 1899, however, the Sallyco Mineral Water Company advertised that ‘Dr. Morgan Dochrill, physician to St. John’s Hospital, London and many of the leading physicians are presenting ‘Sallyco’ as an habitual drink. Dr. Dochrill says nothing has done his gout so much good.
Dr. Dochrill, whose name and title were correctly stated above, sued the company but failed in his case. ”
“The statement that the law does not prevent the recommending of a secret remedy by the use of bogus testimonials and facsimile signatures of fictitious physicians is obviously an understatement since it is doubtful how far it interferes with the use of bogus testimonials from real physicians.”
Dodgy testimonials are still a mainstay of dodgy salesman. One is reminded of the unauthorised citation of testimonials from Dr John Marks and Professor Jonathan Waxman by Patrick Holford to aid his sales of unnecessary vitamin supplements. There is more on this at Holfordwatch.
The man in the street knows that the merits of any article are usually exaggerated in advertisements and is in the habit of discounting a large proportion of such claims, but, outside the realm of secret remedies, the law is fairly strict as regards definite misstatements concerning goods offered for sale and hence the everyday experience of the man in the street does not prepare him for dealing with advertisements which are not merely exaggerations but plain straightforward lies from beginning to end.
Scientific training is undoubtedly a handicap in estimating popular gullibility as regards nostrums. One imagines that no one today would be willing to spend money on pills guaranteed to prevent earthquakes but yet the claims of many of the remedies offered appear equally absurd to anyone with an elementary
knowledge of physiology or even of chemistry. A study of the successes and failures suggests that success depends chiefly on not over-rating the public intelligence. (Page 34)
This may have changed a bit since A.J. Clark was writing in 1938. Now the main clients of quacks seem to be the well-off “worried-well”. But it remains as true as ever that “Scientific training is undoubtedly a handicap in estimating popular gullibility as regards nostrums.” In 2008, it is perhaps more a problem of Ben Goldacre’s dictum ““My basic hypothesis is this: the people who run the media are humanities graduates with little understanding of science, who wear their ignorance as a badge of honour.”
Clark refers (page 36) to a successful conviction for fraud in the USA in 1917. The subject was a widely advertised ‘get fat quick’ pill that contained lecithin, proteins and sugar. The BMA analysis (in 1912)
suggested that the cost of the ingredients in a box of 30 tablets sold for 4/6 was 1 1/4 d. [4/6 meant 4 shillings and six pence, or 22.5 pence since 1971, and 1 1/4 old pence, a penny farthing, is 0.52 new pence]. He comments thus.
The trial revealed many interesting facts. The formula was devised after a short consultation with the expert of one of the largest drug manufacturers in the U.S.A. This firm manufactured the tablets and sold them to the proprietary medicine company at about 3/- per 1000, whilst they were retailed to the public at the rate of £7 10s. per 1000. The firm is estimated to have made a profit of about $3,000,000.
These trials in the U.S.A. revealed the fact that in a considerable proportion of cases the ‘private formula’ department of the large and well known drug firm already mentioned had first provided the formula for the nostrum and subsequently had prepared it wholesale.
Nothing much has changed here either. The alternative medicine industry (and it is a very big industry) is fond of denouncing the evils of the pharmaceutical industry, and sadly, occasionally they are right. One of the less honest practices of the pharmaceutical industry (though one never mentioned by quacks) is buying heavily into alternative medicine. Goldacre points out
“there is little difference between the vitamin and pharmaceutical industries. Key players in both include multinationals such as Roche and Aventis; BioCare, the vitamin pill producer that media nutritionist Patrick Holford works for, is part-owned by Elder Pharmaceuticals.”
And then. of course, there is the deeply dishonest promotion by Boots the Chemists of homeopathic miseducation, of vitamins and of CoQ10 supplements.
The manner in which secret remedies can survive repeated exposure is shown by the following summary of the life history of a vendor of a consumption [tuberculosis] cure.
1904, 1906: Convicted of violating the law in South Africa.
1908: Exposed in British Medical Association report and also attacked by Truth.
1910: Sued by a widow. The judge stated: ‘I think this is an intentional and well-considered fraud. It is a scandalous thing that poor people should be imposed upon and led to part with their money, and to hope that those dear to them would be cured by those processes which were nothing but quack remedies and had not the slightest value of any kind.’
1914: A libel action against the British Medical Association was lost.
1915 The cure was introduced into the United States.
1919 The cure was sold in Canada.
1924 Articles by men with medical qualifications appeared in the Swiss medical journal boosting
the cure.
Secret remedies have a vitality that resembles that of the more noxious weeds and the examples mentioned suggest that nothing can do them any serious harm.
Most of the time, quacks get away with claims every bit as outrageous today. But Clark does give one example of a successful prosecution. It resulted from an exposé in the newspapers -wait for it -in the Daily Mail.
There is, however, one example which proves that a proprietary remedy can be squashed by exposure if this is accompanied by adequate publicity.
The preparation Yadil was introduced as an antiseptic and was at first advertised to the medical profession. The proprietor claimed that the remedy was not secret and that the active principle was ‘tri-methenal allylic carbide’. The drug acquired popularity in the influenza epidemic of 1918 and the proprietor became more and more ambitious in his therapeutic claims. The special virtue claimed for Yadil was that it would kill any harmful organism that had invaded the body. A more specific claim was that consumption in the first stage was cured with two or three pints whilst advanced cases might require a little more. Other advertisements suggested that it was a cure for most known diseases from cancer downwards.
These claims were supported by an extraordinarily intense advertising campaign. Most papers, and even magazines circulating amongst the wealthier classes, carried full page and even double page advertisements. The Daily Mail refused these advertisements and in 1924 published a three column article by Sir William Pope, professor of Chemistry in the University of Cambridge. He stated that
the name ‘tri-methenal allylic carbide’ was meaningless gibberish and was not the chemical definition of any known substance. He concluded that Yadil consisted of :
‘About one per cent of the chemical compound formaldehyde.
About four per cent of glycerine.
About ninety-five per cent of water and, lastly, a smell.
He calculated that the materials contained in a gallon cost about 1/6, whilst the mixture was sold at £4 10s. per gallon.
This exposure was completely successful and the matter is of historic interest in that it is the only example of the career of a proprietary medicine being arrested by the action of the Press.
Clark goes on to talk of the law of libel.
“On the other hand the quack medicine vendor can pursue his advertising campaigns in the happy assurance that, whatever lies he tells, he need fear nothing from the interference of British law. The law does much to protect the quack medicine vendor because the laws of slander and libel are so severe.”
The law of libel to this day remains a serious risk to freedom of speech of both individuals and the media. Its use by rogues to suppress fair comment is routine. My first encounter was when a couple of herbalists
threatened to sue UCL because I said that the term ‘blood cleanser’ is gobbledygook. The fact that the statement was obviously true didn’t deter them for a moment. The herbalists were bluffing no doubt, but they caused enough nuisance that I was asked to take my pages off UCL’s server. A week later I was invited back but by then I’d set up a much better blog and the publicity resulted in an enormous increase in readership, so the outcome was good for me (but bad for herbalists).
It was also good in the end for Andy Lewis when his immortal page “The gentle art of homoeopathic killing” (about the great malaria scandal) was suppressed. The Society of Homeopaths’ lawyers didn’t go for him personally but for his ISP who gave in shamefully and removed the page. As a result the missing page reappeared in dozens of web sites round the world and shot to the top in a Google search.
Chiropractors are perhaps the group most likely to try to suppress contrary opinions by law not argument. The only lawyers’ letter that has been sent to me personally, alleged defamation in an editorial that I wrote for the New Zealand Medical Journal. That was a little scary, but the journal stuck up for its right to speak and the threat went away after chiropractors were allowed right of reply (but we got the last word).
Simon Singh, one of the best science communicators we have, has not been so lucky. He is going to have to defend in court an action brought by the British Chiropractic Association because of innocent opinions expressed in the Guardian.
Chapter 6 is about “The harm done by patent medicines”. It starts thus.
“The trade in secret remedies obviously represents a ridiculous waste of money but some may argue that, since we are a free country and it pleases people to waste their money in this particular way, there is no call for any legislative interference. The trade in quack medicines cannot, however, be regarded as a harmless one. The Poisons Acts fortunately prevent the sale of a large number of dangerous drugs, but there are numerous other ways in which injury can be produced by these remedies.”
The most serious harm, he thought, resulted from self-medication, and he doesn’t mince his words.
“The most serious objection to quack medicines is however that their advertisements encourage self-medication as a substitute for adequate treatment and they probably do more harm in this than in any other manner.
The nature of the problem can best be illustrated by considering a simple example such as diabetes. In this case no actual cure is known to medicine but, on the other hand, if a patient is treated adequately by insulin combined with appropriate diet, he can be maintained in practically normal health, in spite of his disability, for an indefinite period. The expectation of life of the majority of intelligent diabetics, who make no mistakes in their regime, is not much less than that of normal persons. The regime is both irksome and unpleasant, but anyone who persuades diabetics to abandon it, is committing manslaughter as certainly as if he fired a machine gun into a crowded street.
As regards serious chronic disease the influence of secret remedies may be said to range from murderous to merely harmful.
‘Cures’ for consumption, cancer and diabetes may fairly be classed as murderous, since they are likely to cause the death of anyone who is unfortunate enough to believe in their efficacy and thus delay adequate treatment until too late.
The phrase “‘Cures for consumption, cancer and diabetes may fairly be classed as murderous” made Clark himself the victim of suppression of freedom of speech by lawyers. His son, David Clark, wrote of his father in “Alfred Joseph Clark, A Memoir” (C. & J. Clark Ltd 1985 ISBN 0-9510401-0-3)
“Although tolerant of many human foibles, A. J. had always disapproved fiercely of quacks, particularly the charlatans who sold fraudulent medicines. During his visits to London he met Raymond Postgate, then a crusading left wing journalist, who persuaded A.J. to write a pamphlet which was published in an ephemeral series called ‘Fact‘ in March 1938. It was a lively polemical piece. . To A.J.’s surprise and dismay he was sued for libel by a notorious
rogue who peddled a quack cure for for tuberculosis. This man said that A.J.’s remarks (such as “‘Cures’ for consumption, cancer and diabetes may fairly be classed as murderous”) were libellous and would damage his business. A.J. was determined to fight, and he and Trixie decided to put their savings at stake if necessary. The B.M.A. and the Medical Defence Union agreed to support him and they all went to lawyers. He was shocked when they advised him that he would be bound to lose for he had damaged the man’s livelihood! Finally, after much heart searching, he made an apology, saying that he had not meant that particular man’s nostrum”
Talk about déjà vu!
On page 68 there is another very familiar story. It could have been written today.
“The fact that the public is acquiring more knowledge of health matters and is becoming more suspicious of the cruder forms of lies is also helping to weed out the worst types of patent medicine advertisements. For example, in 1751 a bottle of oil was advertised as a cure for scurvy, leprosy and consumption but today such claims would not be effective in promoting the sale of a remedy. The modern advertiser would probably claim that the oil was rich in all the vitamins and the elements essential for life and would confine his claims to a statement that it would alleviate all minor forms of physical or mental ill-health.
The average patent medicine advertised today makes plausible rather than absurd claims and in general the advertisements have changed to conform with a change in the level of the public’s knowledge.
It is somewhat misleading, however, to speak of this as an improvement, since the law has not altered and hence the change only means that the public is being swindled in a somewhat more skilful manner.
The ideal method of obtaining an adequate vitamin supply is to select a diet containing an abundant supply of fresh foods, but unfortunately the populace is accustomed to live very largely on preserved or partially purified food stuffs and such processes usually remove most of the vitamins.”
The first part of the passage above is reminiscent of something that A.J Clark wrote in the BMJ in 1927. Nowadays it is almost unquotable and I was told by a journal editor that it was unacceptable even with asterisks. That seems to me a bit silly. Words had different connotations in 1927.
“The less intelligent revert to the oldest form of belief and seek someone who will make strong magic for them and defeat the evil spirits by some potent charm. This is the feeling to which the quack appeals; he claims to be above the laws of science and to possess some charm for defeating disease of any variety.
The nature of the charm changes with the growth of education. A naked n****r howling to the beat of a tom-tom does not impress a European, and most modern Europeans would be either amused or disgusted by the Black mass that was popular in the seventeenth century. Today some travesty of physical science appears to be the most popular form of incantation.”
A.J. Clark (1927) The historical aspect of quackery, BMJ October 1st 1927
Apart from some of the vocabulary, what better description could one have of the tendency of homeopaths to harp on meaninglessly about quantum theory or the “scienciness” and “referenciness” of
modern books on nutritional therapy?
So has anything changed?
Thus far, the outcome might be thought gloomy. Judging by Clark’s account, remarkably little has changed since 1938, or even since 1914. The libel law in the UK is as bad now as it was then. Recently the United Nations Human Rights Committee said UK laws block matters of public interest and encourage libel tourism (report here, see also here). It is unfit for a free society and it should be changed.
But there are positive sides too. Firstly the advent of scientific bloggers has begun to have some real influence. People are no longer reliant on journalists to interpret (or, often, misinterpret) results for them. They can now get real experts and links to original sources. Just one of these, Ben Goldacre’s badscience.net, and his weekly column in the Guardian has worked wonders in educating the public and improving journalism. Young people can, and do, contribute to the debate because they can blog anonymously if they are frightened that their employer might object.
Perhaps still more important, the law changed this year. Now, at last, it may be possible to prosecute successfully those who make fraudulent health claims. Sad to say, this was not an initiative of the UK government, which remains as devoted as ever to supporting quacks. Remember that, quite shamefully, the only reason given by the Medicines and Health Regulatory Authority (MHRA) gave for allowing false labelling of homeopathic pills was to support the “homeopathic industry”. They suggested (falsely) that the EU required them to take this irresponsible step, which was condemned by just about every scientific organisation. But the new unfair trading regulations did come from the EU. After almost 100 years since the 1914 report, we have at last some decent legislation. Let’s hope it’s enforced.
Postcript
The back cover of the series of ‘Fact‘ books in which A.J. Clark’s article appeared is reproduced below, simply because of the historical portrait of the 1930s that it gives.
Follow-up
This post got a lot of hits from Ben Goldacre’s miniblog which read
- Prof David Colquhoun gets into a time machine and meets himself
A truly classic DC post.
Thanks, Ben.
The publication of Gilbey’s paper and my editorial in the New Zealand Medical Journal (NZMJ) led to a threat of legal action by the NZ Chiropractors’ Association Inc for alleged defamation. After publishing a defiant editorial, the editor of the NZMJ offered chiropractors the chance to put their case.
In the last issue of NZMJ (22 Aug 2008) three letters appeared. One was from Brian Kelly, (President, New Zealand College of Chiropractic) [download letter]. One was from Karl Bale (CEO/Registrar, Chiropractic Board New Zealand) [download letter], and one was from Simon Roughan (Registered Chiropractor and Acting President of the New Zealand Chiropractors’ Association) [download letter].
In the current issue (5 September 2008) Gilbey, Ernst and I responded.{download Gilbey response] [download Ernst response].
Here’s mine. The printed version differs in minor ways [download pdf]
| I’m grateful for the opportunity to reply to the defences of chiropractic from Kelly1, Roughan2 and Bale3 in your last issue.
I’d like first to deal with the minor matter of titles, before getting on to the more important question of vidence. I notice that Brian Kelly signs his letter “Dr Brian Kelly B App Sci (Chiro)” in his letter to NZMJ. He seems to be a bit less careful in his use of titles on his own school’s web site where his president’s welcome4 is signed simply “Dr Brian Kelly”, a title he adopts in at least three other places. Karl Bale3 (CEO/Registrar, Chiropractic Board New Zealand) points out that “Failure to qualify the use of the title ‘Doctor’ may contravene the provisions of the Medical Practitioners Act 1995”. One wonders whether Bale has done anything to stop Kelly’s apparent breaches of this rule? This example makes on wonder whether the Chiropractic Board take its responsibilities seriously? It seems often to be the case that ‘voluntary self-regulation’ doesn’t work, because there are too many vested interests. Karl Bale points out that some ruthless sales methods characteristic of chiropractic are also contrary to the Chiropractic Board’s code of ethics. One would hope their well-known antipathy to vaccination and to medicine as a whole were also considered unethical. These practices seem to continue so the the code of ethics It seems to me quite remarkable that none of the letters mentions the ‘subluxation’ that lies at the heart of their subject6. Could that be because they are reluctant to admit openly that it is a mere metaphysical concept, that no one can see or define? It is sad that so many patients are subjected to X-rays in search of this phantom idea. It is this metaphysical nature of chiropractic that separates it quite clearly from science. Brian Kelly says “How can any reader take seriously, anything suggested by a writer who opines that a 19th Century journalist possessed superior “intellectual standards” to “the UK’s Department of Health” and “several university vice chancellors”. The views of the Davenport Leader on chiropractic were mild compared with those of the great H.L. Mencken (1924)7 who wrote “This preposterous quackery flourishes lushly in the back reaches of the Republic, and begins to conquer the less civilized folk of the big cities….” The problem is that the Department of Health is full of arts graduates who may be very good at classics but can’t understand the nature of evidence. And the UK has one vice-chancellor, a geomorphologist, who defends a course in his university that teaches that “amethysts emit high yin energy”8 I’ll admit, though, that perhaps ‘intellect’ is not what’s deficient in this case, but rather honesty. Your correspondents seem to confuse the duration of a course with its intellectual content. You can study homeopathy for years too, but after all that they are still treating sick people with medicines that contain no medicine. Anyone who works in a university knows that you can easily get accreditation for anything whatsoever if you choose the right people to sit on the committee. I have seen only too many of these worthless pieces of paper. “Amethysts emit high yin energy”8 was part of an accredited course (at the University of Westminster) too. Need I say more? Now to the real heart of the problem, namely the question of evidence. Brian Kelly says that the book by Singh and Ernst9 shows “extreme bias”, but what that book actually shows is an extremely scrupulous regard for evidence, Ernst is in a better position to do this than just about anyone else. He has qualified and practised both regular and alternative medicine, and he was appointed to his present position, as professor of complementary and alternative medicine to assess the evidence. Perhaps most importantly of all, his position allows him to do that assessment with complete lack of bias because, unlike Kelly, his livelihood does not depend on any particular outcome of the assessment. I’m afraid that what Kelly describes as “extreme bias” is simply a display of pique because it has turned out that when all the evidence is examined dispassionately, the outcome is not what chiropractors hoped. The fact of the matter is that when you look at all of the evidence, as Singh & Ernst do, it is perfectly clear that chiropractic is at best no better than conventional treatments even for back pain. For all other conditions its benefits fail to outweigh its risks – contrary to the many claims by chiropractors. Both the New Zealand and the UK governments have got themselves into an impossible position by giving official recognition to chiropractic before the evidence was in. Since the conventional manipulative treatments are cheaper, and may be well be safer, and because they involve no quasi-religious ideas like “subluxation” or “innate intelligence”, the only reasonable conclusion is that there is no need for chiropractic to exist at all. They do nothing they do that could not be done as well by medical practitioners and physiotherapists. What will governments do about that, I wonder? David Colquhoun 1. Kelly, B. New Zealand College of Chiropractic response to 2. Roughan, S. Setting the record straight: New Zealand Chiropractors’ Association response letter. NZMJ 22 3. Bale, 4. http://www.nzchiro.co.nz/about_president.php 6. http://www.chirobase.org/01General/chirosub.html 7. http://www.geocities.com/healthbase/mencken_chiro.html 8. http://dcscience.net/?p=227 9. Singh S, Ernst E. Trick or Treatment. Bantam Press; 2008 |
The wars within chiropractic
Although the chiropractors seem to be rather upset by the criticisms that have been levelled against them, the most interesting war is not between chiropractors and people who think that medicine should not be based on metaphysics. It’s the war within chiropractic itself.
The internecine wars within chiropractic have been going almost from the day it was invented. The (ex-)insider’s view gives us a rare insight into what chiropractic schools actually do. Now support has come from a rather unexpected quarter. An article by five chiropractors has just appeared by Murphy et al. (Chiropractic & Osteopathy, 2008, 16:10).
Although the authors declare that they have “a financial interest in the success” of chiropractic, the changes that they propose are so drastic that, if implemented, tthey would leave little left to distinguish chiropractic from, say, physiotherapy. The authors ask the very pertinent question, ‘why is it that podiatry (chiropody in the UK) is well accepted and chiropractic remains on the controversial fringe of medicine?.. Here are some quotations.
“It is also vital that those chiropractors who dogmatically oppose common public health practices, such as immunization [15] and public water fluoridation, cease such unfounded activity.”
“We are concerned that the common perception (which is well supported, in our experience) that chiropractors are only interested in “selling” a lifetime of chiropractic visits may be one of the primary factors behind our low standing in the minds of members of the public [2].”
“One of the problems that we encounter frequently in our interaction with chiropractic educational institutions is the perpetuation of dogma and unfounded claims. Examples include the concept of spinal subluxation as the cause of a variety of internal diseases and the metaphysical, pseudo-religious idea of “innate intelligence” flowing through spinal nerves, with spinal subluxations impeding this flow. These concepts are lacking in a scientific foundation [27] [28] [29] and should not be permitted to be taught at our chiropractic institutions as part of the standard curriculum. Much of what is passed off as “chiropractic philosophy” is simply dogma [30], or untested (and, in some cases, untestable) theories [27] which have no place in an institution of higher learning, except perhaps in an historical context.”
“The Council on Chiropractic Education requirement of 250 adjustments forces interns to use manipulation on patients whether they need it or not, and the radiographic requirement forces interns to take radiographs on patients whether they need them or not.”
“They [podiatrists] did not invent a “lesion” and a “philosophy” and try to force it on the public. They certainly did not claim that all disease arose from the foot, without any evidence to support this notion. The podiatric medical profession simply did what credible and authoritative professions do [32] – they provided society with services that people actually wanted and needed.”
“In the beginning, DD Palmer invented a lesion, and a theory behind this lesion, and developed a profession of individuals who would become champions of that lesion. This is not what credible professions do.”
“In the interim it [chiropractic] has seen its market share dwindle from 10% of the population [4] to 7.5% [3] [42]. Even amongst patients with back pain, the proportion of patients seeing chiropractors dropped significantly between 1987 and 1997, a period of time in which the proportion seeing both medical doctors and physical therapists increased [43].”
“When an individual consults a member of any of the medical professions, it is reasonably expected that the advice and treatment that he or she receives is based in science, not metaphysics or pseudoscience.”
“The chiropractic profession has an obligation to actively divorce itself from metaphysical explanations of health and disease as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are more rampant in our profession than in other healthcare professions [46].”
“Podiatric medicine is a science-based profession dedicated to the diagnosis and treatment of foot disorders. Foot reflexology is a metaphysically-based group consisting of non-physicians who believe that many physical disorders arise from the foot. Podiatrists have rejected foot reflexology as an unproven and unscientific practice, and do not consider it part of mainstream podiatric practice.”
“We must finally come to the painful realization that the chiropractic concept of spinal subluxation as the cause of “dis-ease” within the human body is an untested hypothesis [27]. It is an albatross around our collective necks that impedes progress.”
All this, remember, comes from five chiropractors. That looks like all out war between their view of chiropractic and that taught in New Zealand College of Chiropractic, and, in the UK by the three chiropractic colleges in the UK.
Follow-up
A report in the New Zealand Herald (18 September 2008) is rather relevant to all this.
Chiropractor to apologise after patient has stroke
A chiropractor has been recommended to apologise to a woman patient who suffered a stroke after he treated her.
The case report is here.
The Advertising Standards Authority has had a bit to say about chiropractors too.
An editorial in today’s issue of the New Zealand Medical Journal prints in full a letter sent to the Journal by Paul Radich, a lawyer who acts for the New Zealand Chiropractors’ Association Inc and its members. The letter alleges defamation by Andrew Gilbey’s article, and by my editorial which sets the wider context of his paper. The articles in question are here.
Here are some quotations from the Editorial by the Journal’s editor, Professor Frank A Frizelle, Department of Surgery, Christchurch Hospital, NZ. [Download the whole editorial].
| In the article by Gilbey, data is provided about use of inappropriate titles by New Zealand practitioners of acupuncture, chiropractic, and osteopathy while the greater context is provided by Colquhoun. The comments made by Paul Radich are entirely consistent with the response as expressed by Professor Edzard Ernst (Editor-in-Chief of Focus on Alternative and Complementary Medicine (FACT) and Chair in Complementary Medicine at the University of Exeter) in his humorous article In praise of the data-free discussion. Towards a new paradigm5 when he states “data can be frightfully intimidating and non-egalitarian”. . . . The Journal has a responsibility to deal with all issues and not to steer clear of those issues that are difficult or contentious or carry legal threats. Let the debate continue in the evidence-based tone set by Colquhoun and others. I encourage, as we have done previously, the chiropractors and others to join in, let’s hear your evidence not your legal muscle. |
My article said nothing that has not been said many times before. I regard it as fair scientific comment, and I believe that expression of those opinions is in the public interest, The reaction of the Journal is thoroughly admirable.
The outcome of legal bullying can be very counterproductive, as the UK’s Society of Homeopaths found recently to their cost.
The lawyers’ letter demanded a response by 11th August, but in the advice of a lawyer I have decided to ignore for now this rather crude attempt to stifle discussion.
For further developments, watch this space.
The story was picked up within hours, It seems that a storm may be brewing round the world for New Zealand Chiropractors. Here are some of them.
Silence Dissent Ben Goldacre’s badscience,net
HolfordWatch Professor Frizelle’s Instant Classic: Let’s hear your evidence not your legal muscle
The first New Zealand site.
More Legal Chill -from spine-cracking chiropractors on jdc325’s blog
And A beginners guide to chiropractic, on the same site.
Andy Lewis’s Quackometer takes a sharp look too, in They are bone doctors aren’t they?
Support from a NZ blog, Evidence-based thought NZ Chiropractors vs NZ Medical Journal
And another New Zealand blog, Chiropractors attack NZ Medical Journal on SillyBeliefs.com
and another: Evidence should trump “legal muscle”, on “Open Parachute. The mind doesn’t work if it’s closed”
New Zealand Doctor magazine. “Kiwi-practors legal wrangle” in the Nature world news blog, The Great Beyond.
“Self-destructing chiropractors” on Jonathan Hearsay’s blog is particularly interesting because he is a (sceptical) osteopath. He says “Chiropractors are seemingly hell-bent on destroying themselves as a therapy”.
There are now so many allusions on the web to the behaviour of the New Zealand Chiropractors’ Association Inc that I’ll give up trying to list all of them. Their action seems tp have done much to damage their own reputation.
Shortly after this came the news that the British Chiropractic Association is to sue one of out best science communicators, Simon Singh, because he had the temerity to inspect the evidence and give his opinion about it in the Guardian. His original article has gone (for now) from the Guardian web site, but as always happens with attempts at bullying and intimidation, it is more easily available then ever, For example here, and here.
Chiropractic in the UK is analysed by Andy Lewis on Quackometer,
The article below is an editorial that I was asked to write for the New Zealand Medical Journal, as a comment on article in today’s edition about the misuse of the title ‘doctor’ by chiropractors [download pdf]. Titles are not the only form of deception used by chiropractors, so the article looks at some of the others too. For a good collection of articles that reveal chiropractic for what it is, look at Chirobase
THE NEW ZEALAND
MEDICAL JOURNAL
Journal of the New Zealand Medical Association
NZMJ 25 July 2008, Vol 121 No 1278; ISSN 1175 8716
URL: http://www.nzma.org.nz/journal/121-1278/3158/ ©NZMA
Doctor Who?
Inappropriate use of titles by some alternative “medicine” practitioners
David Colquhoun
Who should use the title ‘doctor’? The title is widely abused as shown by Gilbey1 in this issue of the NZMJ in an article entitled Use of inappropriate titles by New Zealand practitioners of acupuncture, chiropractic, and osteopathy. Meanwhile, Evans and colleagues 2, also in this issue, discuss usage and attitudes to alternative treatments.
Gilbey finds that the abuse of the title doctor is widespread and that chiropractors are the main culprits. An amazing 82% of 146 chiropractics used the title Doctor, andL most of them used the title to imply falsely that they were registered medical practitioners.
Although it is illegal in New Zealand to do that, it seems clear that the law is not being enforced and it is widely flouted. This is perhaps not surprising given the history of chiropractic. It has had a strong element of ruthless salesmanship since it was started in Davenport, Iowa by D.D. Palmer (1845–1913). His son, B.J. Palmer, said that their chiropractic school was founded on “a business, not a professional basis. We manufacture chiropractors. We teach them the idea and then we show them how to sell” (Shapiro 2008)3 It is the same now. You can buy advice on how to build “build high-volume, subluxation-based, cash-driven, lifetime family wellness practices”
In her recent book3 , Rose Shapiro comments on the founder of chiropractic as follows.
“By the 1890s Palmer had established a magnetic healing practice in Davenport, Iowa, and was styling himself “doctor”. Not everyone was convinced, as a piece about him in an 1894 edition of the local paper, the Davenport Leader, shows.
A crank on magnetism has a crazy notion hat he can cure the sick and crippled with his magnetic hands. His victims are the weak-minded, ignorant and superstitious,those foolish people who have been sick for years and have become tired of the regular physician and want health by the short-cut method he has certainly profited by the ignorance of his victim. His increase in business shows what can be done in Davenport, even by a quack.”
D.D. Palmer was a curious mixture: grocer, spiritual healer, magnetic therapist, fairground huckster, religious cult leader—and above all, a salesman. He finally found a way to get rich by removing entirely imaginary “subluxations”.
Over 100 years later, it seems that the “weak-minded, ignorant, and superstitious” include the UK’s Department of Health, who have given chiropractics a similar status to the General Medical Council.
The intellectual standards of a 19th Century Mid-Western provincial newspaper journalist are rather better than the intellectual standards of the UK’s Department of Health, and of several university vice-chancellors in 2007.
Do the treatments work?
Neither Gilbey nor Evans et al. really grasp the nettle of judging efficacy. The first thing one wants to know about any treatment —alternative or otherwise — is whether it works. Until that is decided, all talk of qualifications, regulation, and so on is just vacuous bureaucratese. No policy can be framed sensibly until the question of efficacy has been addressed honestly.
It is one good effect of the upsurge of interest in alternative treatments that there are now quite a lot of good trials of the most popular forms of treatments (as well as many more bad trials). Some good summaries of the results are now available too. Cochrane reviews set the standard for good assessment of evidence. New Zealand’s Ministry of Health commissioned the Complementary and Alternative Medicine
website to assess the evidence, and that seems to have done a good job too. Their assessment of chiropractic treatment of low back pain is as follows:
There appears to be some evidence from one systematic review and four other studies, although not conclusive, that chiropractic treatment is as effective as other therapies but this may be due to chance. There is very little evidence that chiropractic is more effective than other therapies.
And two excellent summaries have been published as books this year. Both are by people who have had direct experience of alternative treatments, but who have no financial interest in the outcome of their assessment of evidence. The book by Singh and Ernst4 summarises the evidence on all the major alternative treatments, and the book by Bausell5 concentrates particularly on acupuncture, because the author was for 5 years involved in research in that area, Both of these books come to much the same conclusion about chiropractic. It is now really very well-established that chiropractic is (at best) no more effective than conventional treatment. But it has the disadvantage of being surrounded by gobbledygook about “subluxations” and, more importantly, it kills the occasional patient.
Long (2004)7 said “the public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45.”
The chiropractors of Alberta (Canada) and the Alberta Government are now facing a class-action lawsuit8. The lead plaintiff is Sandra Nette. Formerly she was a fit 41 year old. Now she is tetraplegic. Immediately
after neck manipulation by a chiropractor she had a massive stroke as a result of a torn vertebral artery.
Acupuncture comes out of the assessments equally badly. Bausell (2007) concludes that it is no more than a theatrical placebo.
Are the qualifications even real?
It is a curious aspect of the alternative medicine industry that they often are keen to reject conventional science, yet they long for academic respectability. One aspect of this is claiming academic titles on the flimsiest of grounds. You can still be held to have misled the public into thinking you are a medical
practitioner, even if you have a real doctorate. But often pays to look into where the qualifications come from.
A celebrated case in the UK concerned the ‘lifestyle nutritionist’, TV celebrity and multi-millionaire, Dr Gillian McKeith, PhD. A reader of Ben Goldacre’s excellent blog, badscience.net did a little investigation. The results appeared in Goldacre’s Bad Science column in the Guardian9.
She claimed that her PhD came from the American College of Nutrition, but it turned out to come from a correspondence course from a non-accredited US ‘college’. McKeith also boasted of having “professional membership” of the American Association of Nutritional Consultants, for which she provided proof of her degree and three professional references.
The value of this qualification can be judged by the fact that Goldacre sent an application and $60 and as a result “My dead cat Hettie is also a “certified professional member” of the AANC. I have the certificate hanging in my loo”.
Is the solution government regulation?
In New Zealand the law about misleading the public into believing you are a medical practitioner already exists. The immediate problem would be solved if that law were taken seriously, but it seems that it is not.
It is common in both the UK and in New Zealand to suggest that some sort of official government regulation is the answer. That solution is proposed in this issue of NZMJ by Evans et al2. A similar thing has been proposed recently in the UK by a committee headed by Michael Pittilo, vice-chancellor of Robert Gordon’s University, Aberdeen.
I have written about the latter under the heading A very bad report. The Pittilo report recommends both government regulation and more degrees in alternative medicine. Given that we now know that most alternative medicine doesn’t work, the idea of giving degrees in such subjects must be quite ludicrous to any thinking person.
The magazine Nature7 recently investigated the 16 UK universities who run such degrees. In the UK, first-year students at the University of Westminster are taught that “amethysts emit high yin energy” . Their vice chancellor, Professor Geoffrey Petts, describes himself a s a geomorphologist, but he cannot be tempted to express an opinion about the curative power of amethysts.
There has been a tendency to a form of grade inflation in universities—higher degrees for less work gets bums on seats. For most of us, getting a doctorate involves at least 3 years of hard experimental research in a university. But in the USA and Canada you can get a ‘doctor of chiropractic’ degree and most chiropractic (mis)education is not even in a university but in separate colleges.
Florida State University famously turned down a large donation to start a chiropractic school because they saw, quite rightly, that to do so would damage their intellectual reputation. This map, now widely distributed on the Internet, was produced by one of their chemistry professors, and it did the trick.
Other universities have been less principled. The New Zealand College of Chiropractic [whose President styles himself “Dr Brian Kelly”,though his only qualification is B. App Sci (chiro)] is accredited by the New Zealand Qualifications Authority (NZQA). Presumably they, like their UK equivalent (the QAA), are not allowed to take into account whether what is being taught is nonsense or not. Nonsense courses are accredited by experts in nonsense. That is why much accreditation is not worth the paper it’s written on.
Of course the public needs some protection from dangerous or fraudulent practices, but that can be done better (and more cheaply) by simply enforcing existing legislation on unfair trade practices, and on false advertising. Recent changes in the law on unfair trading in the UK have made it easier to take legal action against people who make health claims that cannot be justified by evidence, and that seems the best
way to regulate medical charlatans.
Conclusion
For most forms of alternative medicine—including chiropractic and acupuncture—the evidence is now in. There is now better reason than ever before to believe that they are mostly elaborate placebos and, at best, no better than conventional treatments. It is about time that universities and governments recognised the evidence and stopped talking about regulation and accreditation.
Indeed, “falsely claiming that a product is able to cure illnesses, dysfunction, or malformations” is illegal in Europe10.
Making unjustified health claims is a particularly cruel form of unfair trading practice. It calls for prosecutions, not accreditation.
Competing interests: None.
NZMJ 25 July 2008, Vol 121 No 1278; ISSN 1175 8716
URL: http://www.nzma.org.nz/journal/121-1278/3158/ ©NZMA
Author information: David Colquhoun, Research Fellow, Dept of Pharmacology, University College London, United Kingdom (http://www.ucl.ac.uk/Pharmacology/dc.html)
Correspondence: Professor D Colquhoun, Dept of Pharmacology, University College London, Gower Street, London WC1E 6BT, United Kingdom. Fax: +44(0)20 76797298; email: d.colquhoun@ucl.ac.uk
References:
1. Gilbey A. Use of inappropriate titles by New Zealand practitioners of acupuncture, chiropractic, and osteopathy. N Z Med J. 2008;121(1278). [pdf]
2. Evans A, Duncan B, McHugh P, et al. Inpatients’ use, understanding, and attitudes towards traditional, complementary and alternative therapies at a provincial New Zealand hospital. N Z Med J. 2008;121(1278).
3 Shapiro. Rose. Suckers. How Alternative Medicine Makes Fools of Us All Random House, London 2008. (reviewed here)
4. Singh S, Ernst E. Trick or Treatment. Bantam Press; 2008 (reviewed here)
5. Bausell RB. Snake Oil Science. The Truth about Complementary and Alternative Medicine. (reviewed here)
Oxford University Press; 2007
6. Colquhoun D. Science degrees without the Science, Nature 2007;446:373–4. See also here.
7. Long PH. Stroke and spinal manipulation. J Quality Health Care. 2004;3:8–10.
8. Libin K. Chiropractors called to court. Canadian National Post; June21, 2008.
9. Goldacre B. A menace to science. London: Guardian; February 12, 2007/
10. Department for Business Enterprise & Regulatory Reform (BERR). Consumer Protection from Unfair Trading Regulations 2008. UK: Office of Fair Trading.