Download Lectures on Biostatistics (1971). Corrected and searchable version of Google books edition
Download review of Lectures on Biostatistics (THES, 1973).
General Chiropractic Council
It makes a nice change to be able to compliment an official government report.
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Ever since the House of Lords report in 2000, the government has been vacillating about what should be done about herbalists. At the moment both western herbalists and traditional Chinese medicine (TCM) are essentially unregulated. Many (but not all) herbalists have been pushing for statutory regulation, which they see as government endorsement. It would give them a status like the General Medical Council. |
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A new report has ruled out this possibility, for very good reasons [download local copy].
Back story (abridged!)
My involvement began with the publication in 2008 of a report on the Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine . That led to my post, A very bad report: gamma minus for the vice-chancellor. The report was chaired by the late Professor Michael Pittilo BSc PhD CBiol FIBiol FIBMS FRSH FLS FRSA, Principal and Vice-Chancellor of The Robert Gordon University, Aberdeen. The membership of the group consisted entirely of quacks and the vice -chancellor’s university ran a course in homeopathy (now closed).
The Pittilo report recommended statutory regulation and "The threshold entry route to the register will normally be through a Bachelor degree with Honours". It ignored entirely the little problem that you can’t run a BSc degree in a subject that’s almost entirely devoid of evidence. It said, for example that acupuncturists must understand " yin/yang, 5 elements/phases, eight principles, cyclical rhythms, qi ,blood and body fluids". But of course there is nothing to "understand"! They are all pre-scientific myths. This “training dilemma” was pointed out in one of my earliest posts, You’d think it was obvious, but nonetheless the then Labour government seemed to take this absurd report seriously.
In 2009 a consultation was held on the Pittilo report. I and many of my friends spent a lot of time pointing out the obvious. Eventually the problem was again kicked into the long grass.
The THR scheme
Meanwhile European regulations caused the creation of the Traditional Herbal Registration (THR) scheme. It’s run by the Medicines and Healthcare products Regulatory Authority (MHRA). This makes it legal to put totally misleading claims on labels of herbal concoctions, as long as they are registered with THR, They also get an impressive-looking certification mark. All that’s needed to get THR registration is that the ‘medicines’ are not obviously toxic and they have been in use for 30 years. There is no need to supply any information whatsoever about whether they work or not. This appears to contradict directly the MHRA’s brief:
"”We enhance and safeguard the health of the public by ensuring that medicines and medical devices work and are acceptably safe."
After much effort, I elicited an admission from the MHRA that there was no reason to think that any herbal concoctions were effective, and that there was nothing to prevent them from adding a statement to say so on the label. They just chose not to do so. That’s totally irresponsible in my opinion. See Why does the MHRA refuse to label herbal products honestly? Kent Woods and Richard Woodfield tell me. Over 300 herbal products have been registered under the THR scheme (a small percentage of the number of products being used). So far only one product of Tibetan medicine and one traditional Chinese medicine have been registered under THR. These are the only ones that can be sold legally now, because no herbs whatsoever have achieved full marketing authorisation -that requires good evidence of efficacy and that doesn’t exist for any herb.
The current report
Eventually, in early 2014, the Tory-led government set up yet another body, "Herbal Medicines and Practitioners Working Group " (HMPWG). My heart sank when I saw its membership (Annex A.2). The vice-chair was none other that the notorious David Tredinnick MP (Con, Bosworth). It was stuffed with people who had vested interests. I wrote to the chair and to the few members with scientific credentials to put my views to them.
But my fears were unfounded, because the report of the HMPWG was not written by the group, but by its chair only. David Walker is deputy chief medical officer and he had clearly listened. Here are some quotations.
The good thing about the European laws is that
"This legislation effectively banned the importation and sale of large-scale manufactured herbal medicine products. This step severely limited the scope of some herbal practitioners to continue practising, particularly those from the Traditional Chinese Medicine (TCM) and Ayurvedic traditions."
The biggest loophole is that
"At present under UK law it is permitted for a herbal practitioner to see individual patients, offer diagnoses and prepare herbal treatments on their own premises, as long as these preparations do not contain banned or restricted substances. This is unchanged by the Traditional Herbal Medicinal Products Directive. "
Walker recognised frankly that there is essentially no good evidence that any herb, western or Chinese, works well enough to make an acceptable treatment. And importantly he, unlike Pittilo, realised that this precludes statutory regulation.
"There are a small number of studies indicating benefit from herbal medicine in a limited range of conditions but the majority of herbal medicine practice is not supported by good quality evidence. A great deal of international, primary research is of poor quality. "
"ts. Herbal medicine practice is therefore currently based upon traditional practice rather than science. It is difficult to differentiate good practice from poor practice on the basis of this evidence in a way that could establish standards for statutory regulation"
The second problem was the harms done by herbs. Herbalists, western and Chinese, have no satisfactory way of reporting side effects
" . . . there is very limited understanding of the risks to patient safety from herbal medicines and herbal practice. A review of safety data was commissioned from HMAC as part of this review. This review identified many anecdotal reports and case studies but little systematically collected data. Most herbal medicine products have not been through the rigorous licensing process that is required of conventional pharmaceutical products to establish their safety and efficacy. Indeed, only a small proportion have even been subject to the less rigorous Traditional Herbal Registration (THR) process. "
"The anecdotal evidence of risk to patients from herbal products in the safety review highlighted the prominence of manufactured herbal medicines in the high profile serious incidents which have been reported in recent years. Many of these reports relate to harm thought to be caused by industrially manufactured herbal products which contained either dangerous herbs, the wrong constituents, toxic contaminants or adulterants. All such industrially manufactured products are now only available under European regulations if their safety is assured through MHRA licensing or THR
accreditation; and specific dangerous herbs have been banned under UK law. This has weakened the case for introduction of statutory regulation as a further safety measure. "
Then Walker identified correctly the training dilemma. Although it seems obvious, this is a big advance for a government document. Degrees that teach nonsense are not good training: they are miseducation.
"The third issue is the identification of educational standards for training practitioners and the benchmarking of standards for accrediting practitioners. With no good data on efficacy or safety, it is difficult for practitioners and patients to understand or quantify the potential benefits and risks of a proposed therapeutic intervention. Training programmes could accredit knowledge and skills in some areas including pharmacology and physiology, professional ethics and infection control but without a credible evidence base relating to the safety and effectiveness of herbal medicine it is hard to see how they could form the basis of accreditation in this field of practice.
There are a number of educational university programmes offering courses in herbal medicine although the number has declined in recent years. Some of these courses are accredited by practitioner organisations which is a potential governance risk as the accreditation may be based on benchmarks established by tradition and custom rather than science.
"
"The herbal medicine sector is in a dilemma" is Walker’s conclusion.
"Some practitioners would like to continue to practise as
they do now, with no further regulation, and accept that their practice is based on tradition and personal experience rather than empirical science. The logical consequence of adopting this form of practice is that we should take a precautionary approach in order to ensure public safety. The public should be protected through consumer legislation to prevent false claims, restricting the use of herbal products which are known to be hazardous to health"
The problem with this is, if course, is that although there is plenty of law, it’s rarely enforced : see Most alternative medicine is illegal Trading Standards very rarely enforce the Consumer Protection Regulations (2008) but Walker is too diplomatic to mention that fact.
"The herbals sector must recognise that its overall approach (including the rationale for use of products and methods of treatment, education and training, and interaction with the NHS) needs to be more science and evidence based if in order to be established as a profession on the same basis as other groups that are statutorily regulated."
So what happens next?
In the short term nothing will happen.
The main mistake has been avoided: there wil be no statutory regulation.
The other options are (a) do nothing, or (b) go for accreditation of a voluntary register (AR) by the Professional Standards Authority for Health and Social Care (PSA). Walker ends up recommending the latter, but only after a lot more work (see pages 28-29 of report). Of particular interest is recommendation 5.
"As a first step it would be helpful for the sector organisations to develop an umbrella voluntary register that could support the development of standards and begin to collaborate on the collection of safety data and the establishment of an academic infrastructure to develop training and research. This voluntary register could in due course seek accreditation from the Professional Standards Authority for Health and Social Care (PSA)."
So it looks as though nothing will happen for a long time, and herbalists and TCM may end up with the utterly ineffectual PSA. After all, the PSA have accredited voluntary registers of homeopaths, so clearly nothing is too delusional for them. It’s very obvious that, unlike Walker, the PSA are quite happy to ignore the training dilemma.
Omissions from the report
Good though this report is, by Department of Health standards, it omits some important points.
Endangered species and animal cruelty aren’t mentioned in the report. Traditional Chinese medicine, and its variants, are responsible for the near-extinction of rhinoceros, tiger and other species because of the superstitious belief that they have medicinal value. It’s not uncommon to find animal parts in Chinese medicines sold in the UK despite it being illegal
And the unspeakably cruel practice of farming bears to collect bile is a direct consequence of TCM.
A bile bear in a “crush cage” on Huizhou Farm, China (Wikipedia)
Statutory regulation of Chiropractors
The same arguments used in Walker’s report to deny statutory regulation of herbalism, would undoubtedly lead to denial of statutory regulation of chiropractors. The General Chiropractic Council was established in 1994, and has a status that’s the same as the General Medical Council. That was a bad mistake. The GCC has not protected the public, in fact it has acted as an advertising agency for chiropractic quackery.
Perhaps Prof. Walker should be asked to review the matter.
Follow-up
You can also read minutes of the HMPWG meetings (and here). But, as usual, all the interesting controversies have been sanitised.
Edzard Ernst has also commented on this topic: Once again: the regulation of nonsense will generate nonsense – the case of UK herbalists.
This article has appeared, in nearly identical form, on the UK Conversation . You can leave comments there or here.
A constitutional monarch is purely ceremonial and plays no part in politics. Well actually in the UK it isn’t quite as simple as that. The first problem is that we have no constitution. Things haven’t changed much since the 19th century when Walter Bagehot said "the Sovereign has, under a constitutional monarchy… three rights—the right to be consulted, the right to encourage, the right to warn."
These are not inconsiderable powers in a country which is meant to be run by elected representatives. But nobody knows how these powers are used: it is all done in secret. Well, almost all. Charles, Prince of Wales, has been unusually public in expressing his views. He told a conference at St James’s Palace “I was accused once of being the enemy of the Enlightenment” “I felt proud of that.” That’s a remarkable point of view for someone who, if he succeeds, will become the patron of that product of the age of enlightenment, the Royal Society.
I have no doubt that Prince Charles means well. He can’t be blamed for his lack of education. But his views on medicine date from a few centuries ago, and he has lost no opportunity to exploit his privileged position to proclaim them.
Euphemisms for quackery
He set up the Prince’s Foundation for Integrated Health (PFIH) to promote his views. ( “Integrated”, in this context, is, of course, just the latest euphemism for “alternative” or “quack”.) When the Foundation collapsed because of a financial scandal in 2010, it was replaced by the “College of Medicine”. The name changed, but not the people behind it. Initially this phoenix was to be named the “College of Integrated Health”, but by this time the prince’s views on medicine had become sufficiently discredited that the word “integrated” was quickly dropped. This might be thought less than frank, but it is just employment of the classic bait and switch technique, beloved by used car salesmen.
His views were well publicised in a PFIH publication, “Complementary Healthcare: a Guide for Patients”. That volume either omitted or misrepresented the evidence about the one question that matters most to patients – does the treatment work or not? It caused me to write a much shorter, but more accurate, version, the Patients’ Guide to Magic Medicine. The PFIH guide was arguably a danger to public health. When, very properly, it was criticised by Edzard Ernst, a letter was sent from from the prince’s private secretary to Ernst’s vice-chancellor, Steve Smith. Instead of defending Ernst’s public spirited action, Smith instituted disciplinary proceedings against Ernst that lasted for a year. The prince had intervened directly in the affairs of the university. Steve Smith was rewarded with a knighthood in 2011.
None of this criticism has dimmed the prince’s enthusiasm for barmy medical ideas. He is well known to write many letters to government ministers to try to persuade them to adopt his ideas in a whole range of areas. In July 2013, the Minister of Health, Jeremy Hunt, visited the prince at Clarence House. The visit was reported to be to persuade the minister to defend homeopathy, though it was more likely to have been to press the case to confer a government stamp of approval on herbalists and traditional Chinese Medicine practitioners by giving them statutory regulation. This is a matter that was recently raised again in parliament by Charles’ greatest ally, David Tredinnick MP (Con, Bosworth) who got into trouble for charging astrology software to expenses. We shall never know what pressure was applied. A ruling of the Information Commissioner judged, reasonably enough, that there was public interest in knowing what influences were being brought to bear on public policy. But the Attorney General overruled the judgement on the grounds that “Disclosure of the correspondence could damage The Prince of Wales’ ability to perform his duties when he becomes King.” That, of course, is exactly what we are worried about.
Influence on politics
The prince’s influence seems to be big in the Department of Health (DH). He was given £37,000 of taxpayers’ money to produce his guide, and an astonishing £900,000 to prepare the ground for the setting up of the hapless self-regulator, the Complementary and Natural Healthcare Council (CNHC, also known as Ofquack). When NHS Choices (itself set up by DH to assess evidence) tried to rewrite its web page about that most discredited of all forms of quackery, homeopathy, officials in DH referred the new advice to Michael Dixon, the medical director of the Prince’s Foundation and, were it not for the Freedom of Information act, the DH would have caused inaccurate information to be provided. The DH has a chief medical officer and two scientific advisors, but prefers to take the advice of the Prince of Wales.
The Prince of Wales’ business, Duchy Originals, has been condemned by the Daily Mail, (of all places) for selling unhealthy foods. And when his business branched into selling quack “detox” and herbal nonsense he found himself censured by both the MHRA and the Advertising Standards Authority (ASA) for making unjustifiable medical claims for these products.
Ainsworth’s homeopathic pharmacy is endorsed by both Prince Charles and the Queen: it has two Royal Warrants. They sell “homeopathic vaccines” for meningitis, measles, rubella and whooping cough. These “vaccines” contain nothing whatsoever so they are obviously a real danger to public health. Despite the fact that Ainsworth’s had already been censured by the ASA in 2011 for selling similar products, Ainsworth’s continued to recommend them with a “casual disregard for the law”. The regulator (the MHRA) failed to step in to stop them until it was eventually stirred into action by a young BBC reporter, Sam Smith, made a programme for BBC South West. Then, at last, the somnolent regulator was stirred into action. The MHRA “told Ainsworths to stop advertising a number of products” (but apparently not to stop making them or selling them). They still sell Polonium metal 30C and Swine Meningitis 36C, and a booklet that recommends homeopathic “vaccination”. Ainsworth’s sales are no doubt helped by the Royal Warrants. The consequence is that people may die of meningitis. In 2011, the MHRA Chief Executive Professor Kent Woods, was knighted.
It runs in the family
The Prince of Wales is not the only member of the royal family to be obsessed with bizarre forms of medicine. The first homeopath to the British royal family, Frederick Quin, was a son of the Duchess of Devonshire (1765-1824). Queen Mary (1865-1953), wife of King George V, headed the fundraising efforts to move and expand the London Homeopathic Hospital.
King George VI was so enthusiastic that in 1948 conferred the royal title on the London Homeopathic Hospital. The Queen Mother loved homeopathy too (there is no way to tell whether this contributed to her need for a colostomy in the 1960s).
The present Queen’s homeopathic physician is Peter Fisher, who is medical director of what, until recently was called the Royal London Homeopathic Hospital (RLHH). In 2010 that hospital was rebranded as the Royal London Hospital for Integrated Medicine (RLHIM) in another unsubtle bait and switch move.
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The RLHIM is a great embarrassment to the otherwise excellent UCLH Trust. It has been repeatedly condemned by the Advertising Standards Authority for making false claims. As a consequence, it has been forced to withdraw all of its patient information. The patron of the RLHIM is the Queen, not the Prince of Wales. It is hard to imagine that this anachronistic institution would still exist if it were not for the influence, spoken or unspoken, of the Queen. Needless to say we will never be told. |
 The Queen and Peter Fisher Observer 8 April 2007 |
The attorney general, while trying to justify the secrecy of Charles’ letters, said
“It is a matter of the highest importance within our constitutional framework that the Monarch is a politically neutral figure”.
Questions about health policy are undoubtedly political, and the highly partisan interventions of the prince in the political process make his behaviour unconstitutional. They endanger the monarchy itself. Whether that matters depends on how much you value tradition and how much you value the tourist business generated by the Gilbert & Sullivan flummery at which royals excel.
The least that one can ask of the royal family is that they should not endanger the health of the nation. If I wanted to know the winner of the 2.30 at Ascot, I’d ask a royal. For any question concerning science or medicine I’d ask someone with more education.
Here is some more interesting reading
Michael Baum’s “An open letter to the Prince of Wales: with respect, your highness, you’ve got it wrong”
Gerald Weissman’s essay Homeopathy: Holmes, Hogwarts, and the Prince of Wales.
Channel 4 TV documentary HRH “meddling in politics”
Observer April 2007 "Royals’ favoured hospital at risk as homeopathy backlash gathers pace. The Queen loves it. But alternative medicine centre’s future looks uncertain as more NHS trusts axe funding"
Follow-up
The Scottish Universities Medical Journal asked me to write about the regulation of alternative medicine. It’s an interesting topic and not easy to follow because of the veritable maze of more than twenty overlapping regulators and quangos which fail utterly to protect the public against health fraud. In fact they mostly promote health fraud. The paper is now published, and here is a version with embedded links (and some small updates).
We are witnessing an increasing commercialisation of medicine. It’s really taken off since the passage of the Health and Social Security Bill into law. Not only does that mean having NHS hospitals run by private companies, but it means that “any qualified provider” can bid for just about any service. The problem lies, of course, in what you consider “qualified” to mean. Any qualified homeopath or herbalist will, no doubt, be eligible. University College London Hospital advertised for a spiritual healer. The "person specification" specified a "quallfication", but only HR people think that a paper qualification means that spiritual healing is anything but a delusion.
The vocabulary of bait and switch
First, a bit of vocabulary. Alternative medicine is a term that is used for medical treatments that don’t work (or at least haven’t been shown to work). If they worked, they’d be called “medicine”. The anti-malarial, artemesinin, came originally from a Chinese herb, but once it had been purified and properly tested, it was no longer alternative. But the word alternative is not favoured by quacks. They prefer their nostrums to be described as “complementary” –it sounds more respectable. So CAM (complementary and alternative medicine became the politically-correct euphemism. Now it has gone a stage further, and the euphemism in vogue with quacks at the moment is “integrated” or “integrative” medicine. That means, very often, integrating things that don’t work with things that do. But it sounds fashionable. In reality it is designed to confuse politicians who ask for, say, integrated services for old people.
Put another way, the salespeople of quackery have become rather good at bait and switch. The wikepedia definition is as good as any.
Bait-and-switch is a form of fraud, most commonly used in retail sales but also applicable to other contexts. First, customers are “baited” by advertising for a product or service at a low price; second, the customers discover that the advertised good is not available and are “switched” to a costlier product.
As applied to the alternative medicine industry, the bait is usually in the form of some nice touchy-feely stuff which barely mentions the mystical nonsense. But when you’ve bought into it you get the whole panoply of nonsense. Steven Novella has written eloquently about the use of bait and switch in the USA to sell chiropractic, acupuncture, homeopathy and herbal medicine: "The bait is that CAM offers legitimate alternatives, the switch is that it primarily promotes treatments that don’t work or are at best untested and highly implausible.".
The "College of Medicine" provides a near-perfect example of bait and switch. It is the direct successor of the Prince of Wales’ Foundation for Integrated Health. The Prince’s Foundation was a consistent purveyor of dangerous medical myths. When it collapsed in 2010 because of a financial scandal, a company was formed called "The College for Integrated Health". A slide show, not meant for public consumption, said "The College represents a new strategy to take forward the vision of HRH Prince Charles". But it seems that too many people have now tumbled to the idea that "integrated", in this context, means barmpottery. Within less than a month, the new institution was renamed "The College of Medicine". That might be a deceptive name, but it’s a much better bait. That’s why I described the College as a fraud and delusion.
Not only did the directors, all of them quacks, devise a respectable sounding name, but they also succeeded in recruiting some respectable-sounding people to act as figureheads for the new organisation. The president of the College is Professor Sir Graham Catto, emeritus professor of medicine at the University of Aberdeen. Names like his make the bait sound even more plausible. He claims not to believe that homeopathy works, but seems quite happy to have a homeopathic pharmacist, Christine Glover, on the governing council of his college. At least half of the governing Council can safely be classified as quacks.
So the bait is clear. What about the switch? The first thing to notice is that the whole outfit is skewed towards private medicine: see The College of Medicine is in the pocket of Crapita Capita. The founder, and presumably the main provider of funds (they won’t say how much) is the huge outsourcing company, Capita. This is company known in Private Eye as Crapita. Their inefficiency is legendary. They are the folks who messed up the NHS computer system and the courts computer system. After swallowing large amounts of taxpayers’ money, they failed to deliver anything that worked. Their latest failure is the court translation service.. The president (Catto), the vice president (Harry Brunjes) and the CEO (Mark Ratnarajah) are all employees of Capita.
The second thing to notice is that their conferences and courses are a bizarre mixture of real medicine and pure quackery. Their 2012 conference had some very good speakers, but then it had a "herbal workshop" with Simon Mills (see a video) and David Peters (the man who tolerates dowsing as a way to diagnose which herb to give you). The other speaker was Dick Middleton, who represents the huge herbal company, Schwabe (I debated with him on BBC Breakfast), In fact the College’s Faculty of Self-care appears to resemble a marketing device for Schwabe.
Why regulation isn’t working, and can’t work
There are various levels of regulation. The "highest" level is the statutory regulation of osteopathy and chiropractic. The General Chiropractic Council (GCC) has exactly the same legal status as the General Medical Council (GMC). This ludicrous state of affairs arose because nobody in John Major’s government had enough scientific knowledge to realise that chiropractic, and some parts of osteopathy, are pure quackery,
The problem is that organisations like the GCC function more to promote chiropractic than to regulate them. This became very obvious when the British Chiropractic Association (BCA) decided to sue Simon Singh for defamation, after he described some of their treatments as “bogus”, “without a jot of evidence”.
In order to support Singh, several bloggers assessed the "plethora of evidence" which the BCA said could be used to justify their claims. When, 15 months later, the BCA produced its "plethora" it was shown within 24 hours that the evidence was pathetic. The demolition was summarised by lawyer, David Allen Green, in The BCA’s Worst Day.
In the wake of this, over 600 complaints were made to the GCC about unjustified claims made by chiropractors, thanks in large part to heroic work by two people, Simon Perry and Allan Henness. Simon Perry’s Fishbarrel (browser plugin) allows complaints to be made quickly and easily -try it). The majority of these complaints were rejected by the GCC, apparently on the grounds that chiropractors could not be blamed because the false claims had been endorsed by the GCC itself.
My own complaint was based on phone calls to two chiropractors, I was told such nonsense as "colic is down to, er um, faulty movement patterns in the spine". But my complaint never reached the Conduct and Competence committee because it had been judged by a preliminary investigating committee that there was no case to answer. The impression one got from this (very costly) exercise was that the GCC was there to protect chiropractors, not to protect the public.
The outcome was a disaster for chiropractors, wno emerged totally discredited. It was also a disaster for the GCC which was forced to admit that it hadn’t properly advised chiropractors about what they could and couldn’t claim. The recantation culminated in the GCC declaring, in August 2010, that the mythical "subluxation" is a "historical concept " "It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease.". Subluxation was a product of the fevered imagination of the founder of the chiropractic cult, D.D. Palmer. It referred to an imaginary spinal lesion that he claimed to be the cause of most diseases. .Since ‘subluxation’ is the only thing that’s distinguished chiropractic from any other sort of manipulation, the admission by the GCC that it does not exist, after a century of pretending that it does, is quite an admission.
The President of the BCA himself admitted in November 2011
“The BCA sued Simon Singh personally for libel. In doing so, the BCA began one of the darkest periods in its history; one that was ultimately to cost it financially,”
As a result of all this, the deficiencies of chiropractic, and the deficiencies of its regulator were revealed, and advertisements for chiropractic are somewhat less misleading. But this change for the better was brought about entirely by the unpaid efforts of bloggers and a few journalists, and not at all by the official regulator, the GCC. which was part of the problem. not the solution. And it was certainly not helped by the organisation that is meant to regulate the GCC, the Council for Health Regulatory Excellence (CHRE) which did nothing whatsoever to stop the farce.
At the other end of the regulatory spectrum, voluntary self-regulation, is an even worse farce than the GCC. They all have grand sounding "Codes of Practice" which, in practice, the ignore totally.
The Society of Homeopaths is just a joke. When homeopaths were caught out recommending sugar pills for prevention of malaria, they did nothing (arguably such homicidal advice deserves a jail sentence).
The Complementary and Natural Healthcare Council (CNHC) is widely know in the blogosphere as Ofquack. I know about them from the inside, having been a member of their Conduct and Competence Committee, It was set up with the help of a £900,000 grant from the Department of Health to the Prince of Wales, to oversee voluntary self-regulation. It fails utterly to do anything useful.. The CNHC code of practice, paragraph 15 , states
“Any advertising you undertake in relation to your professional activities must be accurate. Advertisements must not be misleading, false, unfair or exaggerated”.
When Simon Perry made a complaint to the CNHC about claims being made by a CNHC-registered reflexologist, the Investigating Committee upheld all 15 complaints. But it then went on to say that there was no case to answer because the unjustified claims were what the person had been taught, and were made in good faith.
This is precisely the ludicrous situation which will occur again and again if reflexologists (and many other alternative therapies) are “accredited”. The CNHC said, correctly, that the reflexologist had been taught things that were not true, but then did nothing whatsoever about it apart from toning down the advertisements a bit. They still register reflexologists who make outrageously false claims.
Once again we see that no sensible regulation is possible for subjects that are pure make-believe.
The first two examples deal (or rather, fail to deal) with regulation of outright quackery. But there are dozens of other quangos that sound a lot more respectable.
European Food Standards Agency (EFSA). One of the common scams is to have have your favourite quack treatment classified as a food not as a medicine. The laws about what you can claim have been a lot laxer for foods. But the EFSA has done a pretty good job in stopping unjustified claims for health benefits from foods. Dozens of claims made by makers of probiotics have been banned. The food industry, needless to say, objects very strongly to be being forced to tell the truth. In my view, the ESFA has not gone far enough. They recently issued a directive about claims that could legally be made. Some of these betray the previously high standards of the EFSA. For example you are allowed to say that "Vitamin C contributes to the reduction of tiredness and fatigue" (as long as the product contains above a specified amount of Vitamin C. I’m not aware of any trials that show vitamin C has the slightest effect on tiredness or fatigue, Although these laws do not come into effect until December 2012, they have already been invoked by the ASA has a reason not to uphold a complaint about a multivitamin pill which claimed that it “Includes 8 nutrients that can contribute to the reduction in tiredness and fatigue”
The Advertising Standards Authority (ASA). This is almost the only organisation that has done a good job on false health claims. Their Guidance on Health Therapies & Evidence says
"Whether you use the words ‘treatment’, ‘treat’ or ‘cure’, all are likely to be seen by members of the public as claims to alleviate effectively a condition or symptom. We would advise that they are not used"
"Before and after’ studies with little or no control, studies without human subjects, self-assessment studies and anecdotal evidence are unlikely to be considered acceptable"
"Before and after’ studies with little or no control, studies without human subjects, self-assessment studies and anecdotal evidence are unlikely to be considered acceptable"
They are spot on.
The ASA’s Guidance for Advertisers of Homeopathic Services is wonderful.
"In the simplest terms, you should avoid using efficacy claims, whether implied or direct,"
"To date, the ASA has have not seen persuasive evidence to support claims that homeopathy can treat, cure or relieve specific conditions or symptoms."
That seems to condemn the (mis)labelling allowed by the MHRA as breaking the rules.. Sadly, though, the ASA has no powers to enforce its decisions and only too often they are ignored. The Nightingale collaboration has produced an excellent letter that you can hand to any pharmacist who breaks the rules
The ASA has also judged against claims made by "Craniosacral therapists" (that’s the lunatic fringe of osteopathy). They will presumably uphold complaints about similar claims made (I’m ashamed to say) by UCLH Hospitals.
The private examination company Edexcel sets exams in antiscientific subjects, so miseducating children. The teaching of quackery to 16 year-olds has been approved by a maze of quangos, none of which will take responsibility, or justify their actions. So far I’ve located no fewer than eight of them. The Office of the Qualifications and Examinations Regulator (OfQual), Edexcel, the Qualifications and Curriculum Authority (QCA), Skills for Health, Skills for Care, National Occupational Standards (NOS), private exam company VTCT and the schools inspectorate, Ofsted.. Asking any of these people why they approve of examinations in imaginary subjects meets with blank incomprehension. They fail totally to protect tha public from utter nonsense.
The Department of Education has failed to do anything about the miseducation of children in quackery. In fact it has encouraged it by, for the first time, giving taxpayers’ money to a Steiner (Waldorf) school (at Frome, in Somerset). Steiner schools are run by a secretive and cult-like body of people (read about it). They teach about reincarnation, karma, gnomes, and all manner of nonsense, sometimes with unpleasant racial overtones. The teachers are trained in Steiner’s Anthroposophy, so if your child gets ill at school they’ll probably get homeopathic sugar pills. They might well get measles or mumps too, since Steiner people don’t believe in vaccination.
Incredibly, the University of Aberdeen came perilously close to appointing a chair in anthroposophical medicine. This disaster was aborted by bloggers, and a last minute intervention from journalists. Neither the university’s regulatory mechanisms. nor any others, seemed to realise that a chair in mystical barmpottery was a bad idea.
Trading Standards offices and the Office of Fair Trading.
It is the statutory duty of Trading Standards to enforce the Consumer Protection Regulations (2008) This European legislation is pretty good. it caused a lawyer to write " Has The UK Quietly Outlawed “Alternative” Medicine?". Unfortunately Trading Standards people have consistently refused to enforce these laws. The whole organisation is a mess. Its local office arrangement fails totally to deal with the age of the internet. The situation is so bad that a group of us decided to put them to the test. The results were published in the Medico-Legal Journal, Rose et al., 2012. "Spurious Claims for Health-care Products: An Experimental Approach to Evaluating Current UK Legislation and its Implementation". They concluded "EU directive 2005/29/EC is
largely ineffective in preventing misleading health claims for consumer products in
the UK"
Skills for Health is an enormous quango which produces HR style "competences" for everything under the son. They are mostly quite useless. But those concerned with alternative medicine are not just useless. They are positively harmful. Totally barmy. There are competences and National Occupational Standards for every lunatic made-up therapy under the sun. When I phoned them to discover who’d written them, I learned that the had been drafted by the Prince of Wales’ Foundation for Magic Medicine. And when I joked by asking if they had a competence for talking to trees, I was told, perfectly seriously, “You’d have to talk to LANTRA, the land-based organisation for that.”
That was in January 2008. A lot of correspondence with the head of Skills for Health got nowhere at all. She understood nothing and it hasn’t improved a jot.
This organisation costs a lot of taxpayers’ money and it should have been consigned to the "bonfire of the quangos" (but of course there was no such bonfire in reality). It is a disgrace.
The Quality Assurance Agency (QAA) is supposed to ensure the quality of university courses. In fact it endorses courses in nonsense alternative medicine and so does more harm than good. The worst recent failure of the QAA was in the case of the University of Wales: see Scandal of the University of Wales and the Quality Assurance Agency. The university was making money by validating thousands of external degrees in everything from fundamentalist theology to Chinese Medicine. These validations were revealed as utterly incompetent by bloggers, and later by BBC Wales journalist Ciaran Jenkins (now working for Channel 4).
The mainstream media eventually caught up with bloggers. In 2010, BBC1 TV (Wales) produced an excellent TV programme that exposed the enormous degree validation scam run by the University of Wales. The programme can be seen on YouTube (Part 1, and Part 2). The programme also exposed, incidentally, the uselessness of the Quality Assurance Agency (QAA) which did nothing until the scam was exposed by TV and blogs. Eventually the QAA sent nine people to Malaysia to investigate a dodgy college that had been revealed by the BBC. The trip cost £91,000. It could have been done for nothing if anyone at the QAA knew how to use Google.
The outcome was that the University of Wales stopped endorsing external courses, and it was soon shut down altogether (though bafflingly, its vice-chancellor, Marc Clement was promoted). The credit for this lies entirely with bloggers and the BBC. The QAA did nothing to help until the very last moment.
Throughout this saga Universities UK (UUK), has maintained its usual total passivity. They have done nothing whatsoever about their members who give BSc degrees in anti-scientific subjects. (UUK used to known as the Committee of Vice-Chancellors and Principals).
Council for Health Regulatory Excellence (CHRE), soon to become the PSAHSC,
Back now to the CHRE, the people who failed so signally to sort out the GCC. They are being reorganised. Their consultation document says
"The Health and Social Care Act 20122 confers a new function on the Professional Standards Authority for Health and Social Care (the renamed Council for Healthcare Regulatory Excellence). From November 2012 we will set standards for organisations that hold voluntary registers for people working in health and social care occupations and we will accredit the register if they meet those standards. It will then be known as an ‘Accredited Register’. "
They are trying to decide what the criteria should be for "accreditation" of a regulatory body. The list of those interested has some perfectly respectable organisations, like the British Psychological Society. It also contains a large number of crackpot organisations, like Crystal and Healing International, as well as joke regulators like the CNHC.
They already oversee the Health Professions Council (HPC) which is due to take over Herbal medicine and Traditional Chinese Medicine, with predictably disastrous consequences.
Two of the proposed criteria for "accreditation" appear to be directly contradictory.
Para 2.5 makes the whole accreditation pointless from the point of view of patients
2.5 It will not be an endorsement of the therapeutic validity or effectiveness of any particular discipline or treatment.
Since the only thing that matters to the patient is whether the therapy works (and is safe), accrediting of organisations that ignore this will merely give the appearance of official approval of crystal healing etc etc. This appears to contradict directly
A.7 The organisation can demonstrate that there either is a sound knowledge base underpinning the profession or it is developing one and makes that explicit to the public.
A "sound knowledge base", if it is to mean anything useful at all, means knowledge that the treatment is effective. If it doesn’t mean that, what does it mean?
It seems that the official mind has still not grasped the obvious fact that there can be no sensible regulation of subjects that are untrue nonsense. If it is nonsense, the only form of regulation that makes any sense is the law.
Please fill in the consultation. My completed return can be downloaded as an example, if you wish.
Medicines and Healthcare products Regulatory Agency (MHRA) should be a top level defender of truth. Its strapline is
"We enhance and safeguard the health of the public by ensuring that medicines and medical devices work and are acceptably safe."
The MHRA did something (they won’t tell me exactly what) about one of the most cruel scams that I’ve ever encountered, Esperanza Homeopathic Neuropeptide, peddled for multiple sclerosis, at an outrageous price ( £6,759 for 12 month’s supply). Needless to say there was not a jot of evidence that it worked (and it wasn’t actually homeopathic).
Astoundingly, Trading Standards officers refused to do anything about it.
The MHRA admit (when pushed really hard) that there is precious little evidence that any of the herbs work, and that homeopathy is nothing more than sugar pills. Their answer to that is to forget that bit about "ensuring that medicines … work"
Here’s the MHRA’s Traditional Herbal Registration Certificate for devils claw tablets.
The wording "based on traditional use only" has to be included because of European legislation. Shockingly, the MHRA have allowed them to relegate that to small print, with all the emphasis on the alleged indications. The pro-CAM agency NCCAM rates devil’s claw as "possibly effective" or "insufficient evidence" for all these indications, but that doesn’t matter because the MHRA requires no evidence whatsoever that the tablets do anything. They should, of course, added a statement to this effect to the label. They have failed in their duty to protect and inform the public by allowing this labelling.
But it gets worse. Here is the MHRA’s homeopathic marketing authorisation for the homeopathic medicinal product Arnicare Arnica 30c pillules
It is nothing short of surreal.
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Since the pills contain nothing at all, they don’t have the slightest effect on sprains, muscular aches or bruising. The wording on the label is exceedingly misleading.
If you "pregnant or breastfeeding" there is no need to waste you doctor’s time before swallowing a few sugar pills.
"Do not take a double dose to make up for a missed one". Since the pills contain nothing, it doesn’t matter a damn.
"If you overdose . . " it won’t have the slightest effect because there is nothing in them
And it gets worse. The MHRA-approved label specifies ACTIVE INGREDIENT. Each pillule contains 30c Arnica Montana
No, they contain no arnica whatsoever.
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It truly boggles the mind that men with dark suits and lots of letters after their names have sat for hours only to produce dishonest and misleading labels like these.
When this mislabeling was first allowed, it was condemned by just about every scientific society, but the MHRA did nothing.
The Nightingale Collaboration.
This is an excellent organisation, set up by two very smart skeptics, Alan Henness and Maria MacLachlan. Visit their site regularly, sign up for their newsletter Help with their campaigns. Make a difference.
Conclusions
The regulation of alternative medicine in the UK is a farce. It is utterly ineffective in preventing deception of patients.
Such improvements as have occurred have resulted from the activity of bloggers, and sometime the mainstream media. All the official regulators have, to varying extents, made things worse.
The CHRE proposals promise to make matters still worse by offering "accreditation" to organisations that promote nonsensical quackery. None of the official regulators seem to be able to grasp the obvious fact that is impossible to have any sensible regulation of people who promote nonsensical untruths. One gets the impression that politicians are more concerned to protect the homeopathic (etc, etc) industry than they are to protect patients.
Deception by advocates of alternative medicine harms patients. There are adequate laws that make such deception illegal, but they are not being enforced. The CHRE and its successor should restrict themselves to real medicine. The money that they spend on pseudo-regulation of quacks should be transferred to the MHRA or a reformed Trading Standards organisation so they can afford to investigate and prosecute breaches of the law. That is the only form of regulation that makes sense.
Follow-up
The shocking case of the continuing sale of “homeopathic vaccines” for meningitis, rubella, pertussis etc was highlighted in an excellent TV programme by BBC South West. The failure of the MHRA and the GPC do take any effective action is a yet another illustration of the failure of regulators to do their job. I have to agree with Andy Lewis when he concludes
“Children will die. And the fault must lie with Professor Sir Kent Woods, chairman of the regulator.”
In July 2008 I wrote an editorial in the New Zealand Medical Journal (NZMJ), at the request of its editor.
The title was Dr Who? deception by chiropractors. It was not very flattering and it resulted in a letter from lawyers representing the New Zealand Chiropractic Association. Luckily the editor of the NZMJ, Frank Frizelle, is a man of principle, and the legal action was averted. It also resulted in some interesting discussions with disillusioned chiropractors that confirmed one’s worst fears. Not to mention revealing the internecine warfare between one chiropractor and another.
This all occurred before the British Chiropractic Association sued Simon Singh for defamation. The strength of the reaction to that foolhardy action now has chiropractors wondering if they can survive at all. The baselessness of most of their claims has been exposed as never before. No wonder they are running scared. The whole basis of their business is imploding.
Needless to say chiropractors were very cross indeed. Then in February 2009 I had a polite email from a New Zealand chiropractor, David Owen, asking for help to find one of the references in the editorial. I’d quoted Preston Long as saying
"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.”
And I’d given the reference as
7. Long PH. Stroke and spinal manipulation. J Quality Health Care. 2004;3:8–10
I’d found the quotation, and the reference, in Ernst’s 2005 article, The value of Chiropractic, but at the time I couldn’t find the Journal of Quality Healthcare. I did find the same article on the web. At least the article had the same title, the same author and the same quotation. But after finding, and reading, the article, I neglected to change the reference from J Quality Health Care to http://skepticreport.com/sr/?p=88. I should have done so and for that I apologise.
When I asked Ernst about the Journal of Quality Healthcare, he couldn’t find his copy of the Journal either, but he and his secretary embarked on a hunt for it, and eventually it was found.
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It turns out that Journal of Quality Healthcare shut down in 2004, without leaving a trace on the web, or even in the British Library. It was replaced by a different journal, Patient Safety and Quality Healthcare (PSQH) A reprint was obtained from them. It is indeed the same as the web version that I’d read, and it highlighted the quotation in question. The reprint of the original article, which proved so hard to find, can be downloaded here. |
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The full quotation is this
"Sixty-two clinical neurologists from across Canada, all certified members of the Royal College of Physicians and Surgeons, issued a warning to the Canadian public, which was reported by Brad Stewart, MD. The warning was entitled Canadian Neurologists Warn Against Neck Manipulation. The final conclusion was that endless non-scientific claims are being made as to the uses of neck manipulation(Stewart, 2003). They need to be stopped. The public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45."
I have often condemned the practice of citing papers without reading them (it is, of course, distressingly common), so I feel bad about this, though I had in fact read the paper in question in its web version. I’m writing about it because I feel one should be open about mistakes, even small ones.
I’m also writing about it because one small section of the magic medicine community seems to think they have nailed me because of it. David Owen, the New Zealand chiropractor, wrote to the editor of the NZMJ, thus.
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The quote [in question] is the public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45. Long PH. Stroke and Manipulation. J Quality Health Care. 2004:3:8-10 This quote actually comes from the following blog article http://www.skepticreport.com/medicalquackery/strokespinal.htm [DC the URL is now http://skepticreport.com/sr/?p=88] I have attached all my personal communications with Colquhoun. They demonstrate this is not a citation error. Prof Colquhoun believes the origin of the quote doesn’t matter because Long was quoting from a Canadian Neurologists’ report (this is also incorrect). As you can see he fails to provide any evidence at all to support the existance [sic] of the “J Quality Health Care.” Colquhoun ‘s belief that my forwarding this complaint is me “resorting to threats” is the final nail in the coffin. If he had any leg to stand on where is the threat? This may seem pedantic but it surely reflects a serious ethical breach. Is it acceptable to make up a reference to try and slip any unsupported statement into a “scientific” argument and thereby give it some degree of credibility? Incidentally, at the end of the article, conflicts of interest are listed as none. As Colquhoun is a Professor of Pharmacology and much of his research funding no doubt comes from the pharmaceutical industry how can he have no conflict of interest with therapies that do not advocate the use of drugs and compete directly against the billions spent on pain medications each year? If I may quote Colquhoun himself in his defence of his article (Journal of the New Zealand Medical Association, 05-September-2008, Vol 121 No 1281) I’ll admit, though, that perhaps ‘intellect’ is not what’s deficient in this case, but rather honesty. David Owen |
Financial interests
Well, here is a threat: I’m exposed as a shill of Big Pharma. ". . . much of his funding no doubt comes from the pharmaceutical industry". I can’t count how many times this accusation has been thrown at me by advocates of magic medicine. Oddly enough none of them has actually taken the trouble to find out where my research funding has come from. None of them even knows enough about the business to realise the extreme improbability that the Pharmaceutical Industry would be interested in funding basic work on the stochastic properties of single molecules. They fund only clinicians who can help to improve their profits,
The matter of funding is already on record, but I’ll repeat it now. The media ‘nutritional therapist’, Patrick Holford, said, in the British Medical Journal
“I notice that Professor David Colquhoun has so far not felt it relevant to mention his own competing interests and financial involvements with the pharmaceutical industry “
To which my reply was
” Oh dear, Patrick Holford really should check before saying things like “I notice that Professor David Colquhoun has so far not felt it relevant to mention his own competing interests and financial involvements with the pharmaceutical industry”. Unlike Holford, when I said “no competing interests”, I meant it. My research has never been funded by the drug industry, but always by the Medical Research Council or by the Wellcome Trust. Neither have I accepted hospitality or travel to conferences from them. That is because I would never want to run the risk of judgements being clouded by money. The only time I have ever taken money from industry is in the form of modest fees that I got for giving a series of lectures on the basic mathematical principles of drug-receptor interaction, a few years ago.”
I spend a lot of my spare time, and a bit of my own money, in an attempt to bring some sense into the arguments. The alternative medicine gurus make their livings (in some cases large fortunes) out of their wares.
So who has the vested interest?
Does chiropractic actually cause stroke?
As in the case of drugs and diet, it is remarkably difficult to be sure about causality. A patient suffers a vertebral artery dissection shortly after visiting a chiropractor, but did the neck manipulation cause the stroke? Or did it precipitate the stroke in somebody predisposed to one? Or is the timing just coincidence and the stroke would have happened anyway? There has been a lot of discussion about this and a forthcoming analysis will tackle the problem of causality head-on,
My assessment at the moment, for what it’s worth, is that there are some pretty good reasons to suspect that neck manipulation can be dangerous, but it seems that serious damage is rare.
In a sense, it really doesn’t matter much anyway, because it is now apparent that chiropractic is pretty well discredited without having to resort to arguments about rare (though serious) effects. There is real doubt about whether it is even any good for back pain (see Cochrane review), and good reason to think that the very common claims of chiropractors to be able to cure infant colic, asthma and so on are entirely, ahem, bogus. (See also Steven Novella, ebm-first, and innumerable other recent analyses.)
Chiropractic is entirely discredited, whether or not it may occasionally kill people.
Complaint sent to UCL
I had an enquiry about this problem also from my old friend George Lewith. I told him what had happened. Soon after this, a complaint was sent to Tim Perry and Jason Clarke, UCL’s Director and Deputy Director of Academic Services. The letter came not from Lewith or Owen, but from Lionel Milgom. Milgrom is well known in the magic medicine community for writing papers about how homeopathy can be “explained” by quantum entanglement. Unfortunately for him, his papers have been read by some real physicists and they are no more than rather pretentious metaphors. See, for example, Danny Chrastina’s analysis, and shpalman, here. Not to mention Lewis, AP Gaylard and Orac.
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Dear Mr Perry and Mr Clark, I would like to bring to your attention an editorial (below) that appeared in the most recent issue of the New Zealand Medical Journal. In it, one of your Emeritus Professors, David Colquhoun, is accused of a serious ethical breach, and I quote – “Is it acceptable to make up a reference to try and slip any unsupported statement into a “scientific” argument and thereby give it some degree of credibility?” Professor Colquhoun is well-known for writing extensively and publicly excoriating many forms of complementary and alternative medicine, particularly with regard to the alleged unscientific nature and unethical behaviour of its practitioners. Professor Colquhoun is also a voluble champion for keeping the libel laws out of science. While such activities are doubtlessly in accord with the venerable Benthamite liberal traditions of UCL, I am quite certain hypocrisy is not. And though Professor Colquhoun has owned up to his error, as the NZMJ’s editor implies, it leaves a question mark over his credibility. As custodians of the college’s academic quality therefore, you might care to consider the possible damage to UCL’s reputation of perceived professorial cant; emeritus or otherwise. Yours Sincerely Dr Lionel R Milgrom |
So, as we have seen, the quotation was correct, the reference was correct, and I’d read the article from which it came I made a mistake in citing the original paper rather than the web version of the same paper..
I leave it to the reader to judge whether this constitutes a "serious ethical breach", whether I’d slipped in an "unsupported statement", and whether it constitutes "hypocrisy"
Follow-up
It so happens that no sooner was this posted than there appeared Part 2 of the devastating refutation of Lionel Milgrom’s attempt to defend homeopathy, written by AP Gaylard. Thanks to Mojo (comment #2) for pointing this out.
Today, 29 July 2009, a large number of magazines and blogs will publish simultaneously Simon Singh’s article. The Guardian was forced to withdraw it, but what he said must be heard (even if the word ‘bogus’ is now missing).
This is an edited version if the article in the Guardian that resulted in the decision of the British Chiropractic Association to sue Singh for libel. That decision was bad for Singh, though its effects could yet be good for the rest of the world, Firstly the decision to use law rather than rational argument stands a good chance of destroying chiropractic entirely because its claims have now come under scrutiny as never before, and they have been found wanting. Secondly, the support for Singh has been so enormous that there must now be a good chance of getting the UK’s iniquitous laws about defamation changed.
I’d rather have reproduced the original article in its entirety, but this bowdlerised version still presents the case very strongly (and the unedited version appears here and here).
Beware the spinal trapSome practitioners claim it is a cure-all, but the research suggests chiropractic therapy has mixed results – and can even be lethal, says Simon Singh. You might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that “99% of all diseases are caused by displaced vertebrae”. In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body. In fact, Palmer’s first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra. You might think that modern chiropractors restrict themselves to treating back problems, but in fact some still possess quite wacky ideas. The fundamentalists argue that they can cure anything, including helping treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying – even though there is not a jot of evidence. I can confidently label these assertions as utter nonsense because I have co-authored a book about alternative medicine with the world’s first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions. But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic. In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors. More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures. Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection. Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: “Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck.” This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Edzard Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher. If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market. Simon Singh is a science writer in London and the co-author, with Edzard Ernst, of Trick or Treatment? Alternative Medicine on Trial. This is an edited version of an article published in The Guardian for which Singh is being personally sued for libel by the British Chiropractic Association. |
That’s a great account of the evidence. Notice the conclusion,
“If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market“.
It is the job of NICE to evaluate critically that sort of thing, which makes it all the odder that the NICE guidance group, very unusually, failed to assess properly the evidence for chiropractic.
If you aren’t one of the 15,000 people who have already signed Singh’s statement, please do it now
Follow-up
Resignation of Pain Society president. While we are on the topic of chiropractic, my comment, The hidden cost of endorsing voodoo, appeared at last on the BMJ article about NICE’s low back pain guidance. The thread came back to life after the British Pain Society voted out its president, Paul Watson, a physiotherapist who was a member of the group that wrote the guidance.
Some of the links Links to some of the many repostings of Singh’s article today are aggregated at Sense about Science. There where over 200 in a single day. The British Chiropractic Association tried to suppress criticism, but they clearly don’t understand the web.
“An intrepid, ragged band of bloggers. Chiropractors may regret choosing to sue Simon Singh, springing online scientists into action”. Ben Goldacre has summed up the reaction of the blogosphere with characteristically fine style in the Guardian. Ragged? Moi? The blog version (with links) is here.
It’s good to see the BMJ joining the campaign for free speech (only a month or two behind the blogs). The suing of Simon Singh for defamation by the British Chiropractic Association has stirred up a hornet’s nest that could (one hopes) change the law of the land, and destroy chiropractic altogether. The BMJ’s editor, Fiona Godlee, has a fine editorial, Keep the libel laws out of science. She starts “I hope all readers of the BMJ are signed up to organised scepticism” and says
“Weak science sheltered from criticism by officious laws means bad medicine. Singh is determined to fight the lawsuit rather than apologise for an article he believes to be sound. He and his supporters have in their sights not only the defence of this case but the reform of England’s libel laws.”
Godlee refers to equally fine articles by the BMJ’s Deputy Editor, Tony Delamothe, Thinking about Charles II“, and by Editor in Chief, Harvey Marcovitch, “Libel law in the UK“.
The comments on Godlee’s editorial, show strong support, (apart from one from the infamous quantum fantasist, Lionel Milgrom). But there was one that slighlty surprised me, from Tricia Greenhalgh, author of the superb book, “How to read a paper”. She comments
“the use of the term ‘bogus’ seems both unprofessional and unscholarly. The argument would be stronger if expressed in more reserved terms”
That set me thinking, not for the first time, about the difference between journalism and scholarship. I can’t imagine ever using a word like ‘bogus’ in a paper about single ion channels. But Singh was writing in a newspaper, not in a scientific paper. Even more to the point, his comments were aimed at people who are not scholars and who, quite explicitly reject the normal standards of science and evidence. The scholarly approach has been tried for centuries, and it just doesn’t work with such people. I’d defend Singh’s language. It is the only way to have any effect. That is why I sent the following comment.
The ultimate irony is that the comment was held up by the BMJ’s lawyers, and has still to appear.
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Thanks for an excellent editorial. I doubt that it’s worth replying to Lionel Milgrom whose fantasy physics has been totally demolished by real physicists. Trisha Greenhalgh is, though, someone whose views I’d take very seriously. She raises an interesting question when she says “bogus” is an unprofessional word to use. Two things seem relevant. First, there is little point in writing rational scholarly articles for a group of people who do not accept the ordinary rules of evidence or scholarship. We are dealing with fantasists. Worse still, we are dealing with fantasists whose income depends on defending their fantasies. You can point out to your heart’s content that “subluxations” are figment of the chiropractors’ imagination, but they don’t give a damn. They aren’t interested in what’s true and what isn’t. Throughout my lifetime, pharmacologists and others have been writing scholarly articles about how homeopathy and other sorts of alternative medicine are bogus. All this effort had little effect. What made the difference was blogs and investigative journalism. When it became possible to reveal leaked teaching materials that taught students that “amethysts emit high yin energy“, and name and shame the vice-chancellors who allow that sort of thing to happen (in this case Prof Geoffrey Petts of Westminster University), things started to happen. In the last few years all five “BSc” degrees in homeopathy have closed and that is undoubtedly a consequence of the activities of bloggers and can assess evidence but who work more like investigative journalists. When the BCA released, 15 months after the event, its “plethora of evidence” a semi-organised effort by a group of bloggers produced, in less than 24 hours, thoroughly scholarly analyses of all of them (there is a summary here). As the editorial says, they didn’t amount to a hill of beans, They also pointed out the evidence that was omitted by the BCA. The conventional press just followed the bloggers. I find it really rather beautiful that a group of people who have other jobs to do, spent a lot of time doing these analyses, unpaid, in their own time, simply to support Singh, because they believed it is the right thing to do. Simon Singh has analysed the data coolly in his book. But In the case that gave rise to the lawsuit he was writing in a newspaper. It was perfectly clear from the context what ‘bogus’ meant. but Mr Justice Eady (aided by a disastrous law) chose to ignore entirely the context and the question of truth. The description ‘bogus’. as used by Singh, seems to be entirely appropriate for a newspaper article. To criticise him for using “unprofessional” language is inappropriate because we are not dealing with professionals. At the heart of the problem is the sort of stifling political correctness that has resulted in quacks being referred to as “professions” rather than fantasists and fraudsters [of course I use the word fraudster with no implication that it necessarily implies conscious lying]. At least there are some laughs to be had from the whole sorry affair. Prompted by that prince among lawyers known as Jack of Kent there was a new addition to my ‘Patients’ Guide to Magic Medicine‘, as featured in the Financial Times.
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It is, perhaps, misplaced political correctness that lies at the heart of the problem. Who can forget the letter from Lord Hunt, while he was at the Department of Health, in which he described “psychic surgery” (one of the best known fraudulent conjuring tricks) as a “profession”.
Follow-up
Two days later, the comment has appeared in the BMJ at last. But it has been altered a bit.
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Unprofessional language is appropriate when dealing with unprofessional people Thanks for an excellent editorial. I doubt that it’s worth replying to Lionel Milgrom whose fantasy physics has been totally demolished by real physicists. Trisha Greenhalgh is, though, someone whose views I’d take very seriously. She raises an interesting question when she says “bogus” is an unprofessional word to use. Two things seem relevant. First, there is little point in writing rational scholarly articles for a group of people who do not seem to accept the ordinary rules of evidence or scholarship. You can point out to your heart’s content that “subluxations” are figment of the chiropractors’ imagination, but they don’t give a damn. Throughout my lifetime, pharmacologists and others have been writing scholarly articles about how homeopathy and other sorts of alternative medicine are bogus. All this effort had little effect. What made the difference was blogs and investigative journalism. When it became possible to reveal leaked teaching materials that taught students that “amethysts emit high yin energy”, and name and shame the vice-chancellors who allow that sort of thing to happen (in this case Prof Geoffrey Petts of Westminster University), things started to happen. In the last few years all five “BSc” degrees in homeopathy have closed and that is undoubtedly a consequence of the activities of bloggers and can assess evidence but who work more like investigative journalists. When the BCA released, 15 months after the event, its “plethora of evidence” a semi-organised effort by a group of bloggers produced, in less than 24 hours, thoroughly scholarly analyses of all of them (there is a summary here). As the editorial says, they didn’t amount to a hill of beans, They also pointed out the evidence that was omitted by the BCA. The conventional press just followed the bloggers. I find it really rather beautiful that a group of people who have other jobs to do, spent a lot of time doing these analyses, unpaid, in their own time, simply to support Singh, because they believed it is the right thing to do. Simon Singh has analysed the data coolly in his book. But In the case that gave rise to the lawsuit he was writing in a newspaper. It was perfectly clear from the context what ‘bogus’ meant. but Mr Justice Eady (aided by a disastrous law) chose to ignore entirely the context. The description ‘bogus’. as used by Singh, seems to be entirely appropriate for a newspaper article. To criticise him for using “unprofessional” language is inappropriate because we are not dealing with professionals. At least there are some laughs to be had from the whole sorry affair. Prompted by that prince among lawyers known as Jack of Kent there was a new addition to my ‘Patients’ Guide to Magic Medicine’, as featured in the Financial Times.
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Here are the changes that were made. Hmm.very interesting.
Here is a short break from the astonishing festival of chiropractic that has followed the British Chiropractic Association (BCA) v Simon Singh defamation case, and the absurd NICE guidance on low back pain.
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Singh’s statement already has over 10000 signatories, many very distinguished, Sign it now if you haven’t already. And getting on for 600 separate complaints about exaggerated and false claims by chiropractors have been lodged with the General Chiropractic Council and with Trading Standards offices. |
Click to sign |
The BCA has exposed the baselessness of most of chiropractic’s claims more effectively than any sceptic could have done.
The University of Westminster is seeing the light?
It is only recently that the University of Westminster suspended entry to degrees in homeopathy and remedial massage and neuromuscular therapy. Luckily for science, they have a new Dean who knows bullshit when she sees it. I suspect than she has been instrumental in starting to restore Westminster’s reputation. The job isn’t finished yet though. According to the UCAS site Westminster still offers
- Chinese Medicine: Acupuncture with Foundation (B341) 4FT Hon BSc
- Health Sciences: Complementary Ther with Foundn (B300) 4FT Hon BSc
- Health Sciences: Complementary Therapies (B255) 3FT Hon BSc
- Health Sciences: Herbal Medicine (B342) 3FT Hon BSc
- Health Sciences: Herbal Medicine with Foundation (B340) 4FT Hon BSc
- Health Sciences: Naturopathy (B391) 3FT Hon BSc
- Health Sciences: Naturopathy with Foundation (B392) 4FT Hon BSc
- Health Sciences: Nutritional Therapy (B400) 3FT Hon BSc
- Health Sciences: Nutritional Therapy with Foundn (B402) 4FT Hon BSc
With the possible exception of herbal medicine, which could be taught scientifically. all the rest is as delusional as homeopathy.
Rumour has it that Naturopathy may be next for the chop, so it seems appropriate to help the dean by showing a bit more of what the hapless students get taught. Remember that, according to Westminster, this is a bachelor of science degree!
Psychotherapeutic Approaches in Naturopathy 3CMW606
“This module is a core subject for BSc (Hons) Health Sciences: Naturopathy and option for BSc (Hons) Health Sciences: Complementary Therapies; BSc (Hons) Health Sciences: Therapeutic Bodywork; Graduate Diploma in Therapeutic Bodywork.”
Lectures 3 – 5 of this course are about the Theory and Application of EmoTrance.
EMOTRANCE? No I had never heard of it either. But it takes only two minutes with Google to discover that it yet another product of the enormous navel-gazing self-help industry. A new variant is born almost every day, and no doubt they make buckets of money for their inventors. You can download a primer from http://emotrance.com/. The web site announces.
“EmoTrance REAL energy healing for the 21st Century”
Here are three quotations from the primer.
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And then I thought of the lady in the supermarket whose husband had died, and I spend the following time sending her my best wishes, and my best space time quantum healing efforts for her void. It doesn’t matter how “bad”; something is or how old, it is ONLY AN ENERGY and energy can be moved with consciousness in quantum time, easily, and just for the asking. Is EmoTrance a Science? |
Now back to Westminster
Here are a few slides about EmoTrance
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So it is pure vitalistic psycho-babble. The usual undefined use of impressive sounding words like “energy” and “quantum” with no defined meaning. Just preposterous made-up gobbledygook.
Before getting to EmoTrance, the course Psychotherapeutic Approaches in Naturopathy (3CMW606) had a lecture on Flower Essences. The evidence says, not surprisingly, that the effects of flower essences is not distinguishable from placebo “The hypothesis that flower remedies are associated with effects beyond a placebo response is not supported by data from rigorous clinical trials.” (See Ernst Wien. Klin. Wochenschr. 2002 114(23-24):963-6). Here are two of the slides.
This last slide departs from the simply silly to the totally mad. Dowsing? Kinesiology?
Pendulums I’m told from more than one source that the use of pendulums is not uncommon. both in teaching and by students in the Westminster University polyclinic Apparently they provide an excellent way to choose a ‘remedy’ or make a diagnosis (well, I expect they are as good as the alternatives). If in doubt, guess.
Of course pendulums were popular with Cherie Blair who is reported to have taken her son Leo to a pendulum waver, Jack Temple, rather than have him vaccinated with MMR. At least her delusions affected fewer people than those of her husband (the latest Iraq body count is about 100,000).
Kinesiology was originally a word that applied to the perfectly sensible science of human movement. But Applied Kinesiology more often refers now to a fraudulent and totally ineffective diagnostic method invented by (you guessed) a chiropractor. It has been widely used by alternative medicine to misdiagnose food allergies. It does not work (Garrow, 1988: download reprint).
General Chiropractic Council It is a mind-boggling sign of the incompetence of the General Chiropractic Council that they manage to include kinesiology within their definition of “evidence based care”. Their definition is clearly sufficiently flexible to include anything whatsoever. The incompetence of the GCC is documented in superb detail on jdc325’s blog (James Cole).
Council for Healthcare Regulatory Excellence (CHRE) is yet another example of the network of ineffective and incompetent quangos that plague us.. It is meant to ensure that regulation is effective but utterly fails to do so. The CHRE is quoted as saying “[The GCC] takes its role seriously and aspires to, and often maintains, excellence.”. Like endorsing kinesiology and ‘craniosacral therapy’ perhaps? Quangos like the CHRE not only fail to ensure regulatory excellence, they actually endorse rubbish. They do more harm than good.
The reading list for the course includes the following books. I guess the vibrational medicine (whatever that means) was covered already in the now infamous ‘amethysts emit high yin energy‘ lectures.
Reading List
Essential:
Hartman S (2003) Oceans of Energy: The Patterns and Techniques of EmoTrance: Vol 1.DragonRising. ISBN: 1873483732.
Lynch V and Lynch P (2001) Emotional Healing in Minutes. Thorsons: London. ISBN: 0007112580Recommended:
Gerber R (2001) Vibrational Medicine for the 21st Century. Piatkus Publishers: London.
Gurudas (1989) Flower Essences and Vibrational Medicine. Cassandra Press: California, USA
Hartman S (2000) Adventures in EFT: The Essential Field Guide to Emotional Freedom Techniques. DragonRising. ISBN: 1873483635.
Hartman S (2004) Living Energy: The Patterns and Techniques of EmoTrance: Vol 2. DragonRising.ISBN: 1873483740.
Hartman S (2006) Energy Magic: The Patterns and Techniques of EmoTrance: Vol 3. Dragon Rising.ISBN: 1873483767.
Real magic.
Sylvia Hartman’s books seem to feature heavily in the reading list. I just got news of her latest effort
Welcome to a special update to the June 2009 newsletter to announce Silvia Hartmann’s latest book “Magic, Spells & Potions” is now available to pre-order from our site. The eBook edition will be released this Sunday, the most magical day of the year.
http://DragonRising.com/store/magic_spells_and_potions/?r=DR0609MSAP
If you do pre-order this exciting new book, not only will you be amongst the first to receive your copy, but you will also be entered into an exciting competition for Silvia Hartmann’s handmade copal amber magic pendant. Each paperback book pre-ordered will also be signed by the author and contain a unique blessing for the reader.
Because this is a serious book on real magic, potions and fortune telling if you are a beginner Silvia has provided ample sample spells and potions for you to practice working with before you start covering the advanced material.
What? No honestly, I didn’t invent that.
The idea that stuff of this sort is appropriate for a bachelor of science degree is simply ludicrous. I have no doubt that Westminster’s new dean can see that as well as anyone else. She has the delicate diplomatic job of extirpating the nonsense, I wish her well.
Follow-up
A flood of complaints against chiropractors has arrived at the General Chiropractic Council (GCC) in the wake of the British Chiropractic Association (BCA) v Singh affair. It is really rather beautiful that people have put some such enormous effort into writing complaints for no gain to themselves.
My own paltry two complaints to the GCC produced an interesting reaction. Yesterday I was told by the GCC
“Under the provisions of the General Chiropractic Council (Investigating Committee) Rules
2000 (“the Rules”), the Committee is required to invite you to make a statement of evidence in relation to your complaint by way of statutory declaration or affidavit. If you wish to, you can discuss your complaint with a solicitor who acts on behalf of the Committee who could help you draft a statement of evidence that meets the requirements of the Rules. The General Chiropractic Council will pay for the Investigating Committee solicitor’s costs and will reimburse you for any fee you subsequently pay for having your witness statement sworn at a location convenient to you.”
Naturally I shall take up this offer. If the same offer is made to everyone who complained (must be approaching 600), the legal fees incurred by the GCC would presumably be enough to bankrupt them. No wonder they are wriggling.
Here is a letter sent by the GCC’s Chief Executive and Registrar, Margaret Coats, a couple of days ago. It reached me by more than one route, but it is already on the web anyway, on Richard Lanigan’s site, Told you the General Chiropractic Council would find a way to dismiss the complaints. “Protecting the public” my arse! Protecting themselves more like it.. (The GCC has been under attack from within for some time, though mainly because some chiropractors think it regulates too much, not too little)
The bit that is especially interesting is para 2
In quangos like the GCC, complaints don’t necessarily get considered at all. First they go to an investigating committee (IC) which has to decide if there is a ‘case to answer’. Now the GCC wants that criterion to be changed to ‘realistic prospect of success’. Given the GCC’s attitude to evidence it is hard to imagine that any complaint will have a ‘realistic prospect of success’.
The second idea is even more grotesque. The GCC want to be able to dismiss without consideration rafts of complaints where in their opinion, referral to the Professional Conduct Committee (PCC) ‘is not required in the public interest. Or, more likely, not required in the interests of the GCC.
Will the Privy Council acquiesce in this disgraceful attempt to evade complaints? Wel, until January 2008, Graham Donald was a senior civil Servant at the Privy Council bit he now works for the GCC. That must help.
The GCC has been contacted by several Trading Standards Offices too, after complaints made to them about chiropractors. . A response was sent by the GCC on 5 June [download the whole response]. It includes
“It is important to emphasise that the GCC doesn’t claim that chiropractors ‘treat’ asthma, headaches (including migraine) and infant colic. It is possible that chiropractic care may help to alleviate the symptoms of some of these conditions.”
What on earth is that meant to mean?
One hopes that Trading Standards officers are too smart to be taken in by weasel words like that.
The attitude of the GCC to evidence is amply illustrated by the fact that they have said that the rather crude myths known as craniosacral therapy and applied kinesiology fall within their definition of evidence-based care.
Any organisation that can say that is clearly incompetent.
Follow-up
Peter Dixon is a chiropractor. He is chair of the General Chiropractic Council (GCC). He was also a member of the hotly-disputed NICE low back pain guidance group that endorsed (you guessed it) the use of chiropractic, a decision that has led to enormous criticism of the standards of the National Institute of health and Clinical Excellence (NICE).
As a consequence largely of the decision of the British Chiropractic Association (BCA) to sue Simon Singh for defamation, there has been an unprecedented interest taken in the claims made by chiropractors in general.
Peter Dixon has a problem because something like 600 individual complaints about unjustified health claims have been sent to the GCC. Even when a web site does not claim to be able to benefit things like asthma and colic, a phone call may reveal that claims are made in private (one of the many complaints to the GCC concerns such behaviour by two practices belonging to, ahem, Peter Dixon Associates).
The crucial question is, as always, one of evidence. The BCA claim to have a plethora of evidence for their claims, but they have been strangely reluctant to produce it. In fact evidence is cited on the “Your first visit” page on Dixon’s site.
At the bottom we see “How effective is Chiropractic?”.
That sounds very impressive indeed: . ” . . . patients who received chiropractic treatment improved by 70% more than those given hospital out-patient.”
But hang on. If we look at the paper, Meade et al., 1990 [download reprint], we see that Figure 2 looks like this.
Several things jump out. First, the Oswestry disability index scale runs for 0 to 100, but scores are plotted only from 0 to 35, so the size of the effects are exaggerated. Second, there are no error bars on the points. Third there is essentially no advantage for chiropractic at all when all patients are taken together (top graph). Fourth, and most important, the patients who were followed up for two years (bottom graph) seem to show a slight advantage for chiropractic but on average, the effect is 7 percent (on the 100 point scale, NOT 70 percent as claimed on the web site of Peter Dixon Associates.
What sort of mistake was made?
The abstract of the paper itself says “A benefit of about 7% points on the Oswestry scale was seen at two years.” How did this become “improved by 70% more”?
It could have been simple a typographical error, but that seems unlikely, Who’d boast about a 7% improvement?
Perhaps it is a question of relative versus absolute change. The Figure does not show the actual scores on the 100 point scale, but rather the change in score, relative to a questionnaire given just before starting treatment. If we look at the lower part of the Figure, restricted to those patients who stayed with the trail for 2 years (by this time 28% of the patients had dropped out), we see that there is a reduction in score (improvement) of about 10 points on the 100 point scale with hospital treatment (not a very impressive response). The improvement with those sent to private chiropractic clinics was about seven points bigger. So a change from 10 to 17 is a 70 percent change. What’s wrong with that?
What’s wrong is that it is highly misleading, as relative changes often are. Imagine that the hospital number had been 7 points and the chiropractic number had been 14 (both out of 100). That would mean that both treatments had provided very modest benefits to the patients. Would it then be fair to describe the chiropractic patients as have improved by 100 percent more than the hospital patients, when in fact neither got much benefit? Of course it would not. To present the results in this way would be highly deceptive.
Put another way, a 70% increase in a trivial effect is still pretty trivial.
That isn’t all either. The paper has been analysed in some detail on the ebm-first site. The seven point difference on a 100 point scale, though it may be real, is too small to be ‘clinically significant’ In other words the patient would scarcely notice such a small change. Another problem lies in the nature of the comparison. Patients were, quite properly, allocated at random to chiropractic or to to hospital treatment. BUT the comparion was very from blind. one group was treated in hospital. The other group was sent to private chiropractic clinics. The trivial 7 point difference could easily be as much to do with the thickness of the carpets rather than any effect of spinal manipulation.
What this paper really tells you is that neither treatment is very effective and that there is little to choose between them.
It is really most unfortunate that the chairman of the GCC should show himself to be so careless about evidence at a time when the evidence for the claims of chiropractors is under inspection as never before. It does not add to their case for criticising Simon Singh and it does not add to one’s confidence in the judgement of the NICE guidance group.
Follow-up
The Pain Society revolt. A letter has been sent from several distinguished members of the British Pain Society to its President and Council.
“We, the undersigned, call upon the President of the British Pain Society to issue a statement to NICE and to the press condemning outright the conclusions of the recent UK National Institute for Health and Clinical Excellence (NICE) guidelines . . .”
The sigificance of this letter is that the present president of the British Pain Society is Professor Paul Watson who was a member of the NICE guidance group that produced the recommendations which have engendered such criticism. He was clinical advisor to the guidance group. There is a video of Paul Watson talking about back pain, that seems to me to illustrate very well the problem with the guidance. He says it is a huge problem (everyone knows that) and that something must be done, but he doesn’t say what. There is no admission that, in very many cases, nobody knows what to do. It is exactly this sort of hubris that that makes the NICE report so bad,
One caustic comment on the letter says
“We are led by a physiotherapist! A Professor who cannot even interpret straight forward evidence when it is presented to him on a plate.
Who’s going to be the next BPS President? A Hospital Porter?”
That isn’t my title. It is the title of a post by Richard Lanigan, with whom I’ve been corresponding. He has a major grudge against the General Chiropractic Council. And in particular he is disaffected about the GCC’s chair, Peter Dixon, about whom he has written a lot, I can’t judge the details of his complaints, but they are laid out in detail on his blog, http://chiropracticlive.com/
Particular interest attaches to his recent revelation of a letter that was sent on July 8th to its members by the McTimoney Chiropractic Association. The McTimoney sect of chiropractic are the ‘true believers’ in the most mystical codswallop aspects of the subject. Oddly enough their College has been validated by the University of Wales, I’ve put in a Freedom of Information Act reguest to the University of Wales to see how that happened. Watch this space.
My interpretation of this letter is that it is as near as you can get to an admission, by chiropractors themselves, that many chiropractors make claims that are against the law. And worse still, that the McTimoney Chiropractic Assocation is well aware of that.
News travels fasts in the blogosphere. This item has already appeared today on The Quackometer, The Lay Scientist and Gimpy and on Zeno’s blog. Let’s hope that the news spreads far and wide.
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Date: 8 June 2009 09:12:18 BDT Subject: FURTHER URGENT ACTION REQUIRED! Dear Member If you are reading this, we assume you have also read the urgent email we sent you last Friday. If you did not read it, READ IT VERY CAREFULLY NOW and – this is most important – ACT ON IT. This is not scaremongering. We judge this to be a real threat to you and your practice. Because of what we consider to be a witch hunt against chiropractors, we are now issuing the following advice: The target of the campaigners is now any claims for treatment that cannot be substantiated with chiropractic research. The safest thing for everyone to do is as follows.
When you have done that, please let us know preferably by email or by phone. This will save our valuable time chasing you to see whether it has been done.
CHECK ALL ENTRIES CAREFULLY AND IF IN DOUBT, CONTACT THE RELEVANT PROVIDER TO REMOVE YOUR INFORMATION. CHECK OUR PREVIOUS EMAILS FOR SPECIFIC ADVICE AND KEY WORDS TO AVOID. KEEP A LOG OF YOUR ACTIONS.
5. Be wary of ‘mystery shopper’ phone calls and ‘drop ins’ to your practice, especially if they start asking about your care of children, or whiplash, or your evidence base for practice. IF YOU DO NOT FOLLOW THIS ADVICE, YOU MAY BE AT RISK FROM PROSECUTION. IF YOU DO NOT FOLLOW THIS ADVICE, THE MCA MAY NOT BE ABLE TO ASSIST YOU WITH ANY PROCEEDINGS. Although this advice may seem extreme or alarmist, its purpose is to protect you. The campaigners have a target of making a complaint against every chiropractor in the UK who they perceive to be in breach of the GCC’s CoP, the Advertising Standards Code and/or Trading Standards. We have discovered that complaints against more than 500 individual chiropractors have been sent to the GCC in the last 24 hours. Whatever you do, do not ignore this email and make yourself one of the victims. Some of our members have not followed our earlier advice and now have complaints made against them. We do not want that to happen to you. Even if you do not have a website, you are still at risk. Our latest information suggests that this group are now going through Yellow Pages entries. Be in no doubt, their intention is to scrutinise every single chiropractor in the UK. The MCA Executive has worked tirelessly over the last week keeping abreast of development and contacting at risk members. We have decided that this is our best course of action to protect you and the Association at this time of heightened tension. This advice is given to you solely to protect you from what we believe is a concerted campaign, and does not imply any wrongdoing on your part or the part of the Association. We believe that our best course of action is simply to withdraw from the battleground until this latest wave of targeting is over. Finally, we strongly suggest you do NOT discuss this with others, especially patients, Firstly it would not be ethical to burden patients with this, though if they ask we hope you now have information with which you can respond. Most importantly, this email and all correspondence from the MCA is confidential advice to MCA members alone, and should not be shared with anyone else. Please be aware that the office phone lines are likely to be busy, so, if you need our help, please send an email to the office and we will get back to you as soon as we can. Yours, Berni Martin MCA Chair. Best wishes, Nicki Nicki Choules-Rowe Administrative Officer – Executive Liaison McTimoney Chiropractic Association Crowmarsh Gifford Wallingford OX10 8DJ Tel : 01491 829494 |
Follow-up
The deleted pages are here. Thanks again to quackometer, here is where you can see the pages that might have been taken down as a result of McTimoney’s letter. I hope they won’t grumble. Really, they sjould never have put them up if they weren’t true, should they?.
The first post was NICE falls for Bait and Switch by acupuncturists and chiropractors: it has let down the public and itself.
That was followed by NICE fiasco, part 2. Rawlins should withdraw guidance and start again.
Since then, something of a maelstrom has engulfed NICE, so it’s time for an update.
It isn’t only those who are appalled that NHS should endorse voodoo medicine on the basis of very slim evidence who are asking NICE to rethink their guidance on low back pain. Pain specialists are up in arms too, and have even started a blog, ‘Not Nearly as NICE as you think …‘, to express their views. Equally adverse opinions are being expressed in the Britsh Medical Journal. A letter there is signed by over 50 specialists in pain medicine. It ends thus
“Because of these new guidelines patients will continue to experience unnecessary pain and suffering and their rights to appropriately individually tailored treatment have been removed on the basis of a flawed analysis of available evidence. We believe the guidelines do not reflect best practice, remove patient choice and are not in our patients’ best interests.”
In a contribution headed “NICE misguidance”. Dr Michel Vagg ends
It seems to me that this guideline has been used as a propaganda vehicle to allow cherry-picked evidence to be enshrined as doctrine. This is an abuse of the guideline development process . . . ”
I have to say, though, that it seems to me that some of these people are promoting their own interests as much as chiropractors and acupuncturists. The evidence that spinal injections produce worthwhile benefits seems to be as thin as the evidence that chiropractic and acupuncture produce worthwhile benefits. But no doubt the injections are good for the budgets of PCTs or private practice doctors.. Could it perhaps be the case that some of the clinicians’ anger is being generated by doctors who are rushing to defend their own favourite ineffective treatment?
Why, oh why, can’t either NICE or the pain consultants bring themselves to state the obvious, that nothing works very well. The only thing that can be said for most of the regular treatments is that although they may not be much more effective than acupuncture or chiropractic, at least they don’t come with the intellectually-offensive hokum that accompanies the latter. Very sensible attempts have been made to identify the cause of low back pain [reviewed here], Occasionally they succeed. Mostly they don’t.
One clinician’s letter deserves special attention because it goes into the evidence, and the costs, in some detail. Its conclusions are very different from those in the NICE guidance.
The letter, a Review of NICE guidance, is from Dr C.J.D. Wells [download the whole letter]. He is a pain relief consultant from Liverpool.
Let’s look at some highlights.
Wells points out the absurdity of the cost estimates
“In the pricing section, they estimate that this will require an increase of facilities so that 3,500 patients can be treated instead of 1,000 at present (again see comments on pricing). This is not many treatments for the 20 million sufferers, of whom we can estimate that at least 2 million will have significant long-term disability and psychological distress”
And that is without even costing all the secondary costs of miseducating a new generation of students in fables about “Qi”, meridians, energy flow, subluxations and innate intelligence.
“The abysmal ignorance of the committee is reflected in the poor overall advice. So if you have a committee with special interests in Exercise, Manipulation, PMP’s, and Surgery, and you call an expert on Acupuncture, you get advice to use Exercise, Manipulation, Acupuncture, PMP’s and Surgery. Amazing.”
Another pain consutant, Charles Guaci, says in a comment in the Daily Mail.
I am a Pain Consultant of 30 years experience, have published two books (one translated into different languages).
NICE never asked me for my opinion.
This is the most ridicuculous pseudo-scientific document I have ever seen.
The panel consisted of a surgeon, psychologist, osteopath, acupuncturist a physiotherapist and an academic; not one pain consultant! The conclusions are simply a means of increasing the employment of their friends!
All evidence submitted to NICE was ignored.
It is almost certain than unless NICE rethink their ideas that Pain Consultants will be seeking a judicial review as well as full disclosure of how the panel arrived at their bizarre findings under the Freedom of information act.
Patients should realise that they are being taken for a ride.
Despite the outcry from opponents of magic medicine and from pain specialists, the assessment by the normally excellent NHS Choices site was disappointing. It made no mention at all of the secondary consequences of recommending CAM and described the assertions of the guidance group quite uncritically.
The reputation of NICE
NICE has been criticised before, though usually unjustly. In the past I have often supported them. For example. when NICE said that treatment of dementia with anticholinesterase drugs like galantamine was ineffective, there was a great outcry, but NICE were quite right. There is little or no rationale for such treatments, and more importantly, very little evidence that they work. But patients, especially when they are desperate, have greater faith in drug treatments than most pharmacologists, They want to clutch at straws. A bit like the NICE guidance committee, faced with a bunch of treatments most of which are almost ineffective, clutched at the straws of acupuncture and chiropractic. But this time it isn’t only the patients who are cross. It is most of the medical and scientific world too.
One interpretation of these bizarre events is that they represent a case of medical/scientific arrogance. Ben Goldacre wrote of another aspect of the same problem thus week, in Dodgy academic PR [download the paper on which this is based].
The first job of a scientist is to say openly when the answer to a question is not known. But scientists are under constant pressure to exaggerate the importance of their results. Last year we published an article which I feel may, if verified, turn out to be the second most important that I have ever been an author on. Because it happened to be published in Nature (not because of its quality), a press release was written (by an arts graduate!). It took some argument to prevent the distorted and exaggerated account being imposed on the public. This is typical of the sort of thing reported in Goldacre’s column. I reported a similar case a while ago, Why honey isn’t a wonder cough cure: more academic spin.
If NICE does not reconsider this guidance, it is hard to see how it can be taken seriously in the future. I hope that when NICE’s director, Professor Sir Michael Rawlins, returns from his trips abroad, he will find time to look at the case himself.
Indirectly, then, it can be argued that NICE’s bizarre guidance is just another manifestation of the management of science being passed from the hands of scientists into the hands of administrators and spin experts. It is yet another example of DC’s rule
Never trust anyone who uses the word ‘stakeholder’
Some bone-headed bureaucrat decides that any charlatan or quack is a ‘stakeholder’ in the provision of NHS care and gives them a quite disproportionate say in how taxpayers’ money is spent. The bureaucrats are so busy following processes and procedures, ticking boxes, and so deficient in scientific education, that they failed to notice that they’ve been caught out by the old trick of used car salesmen, bait and switch.
The consequences
The expected consequences have already started to materialise. The Prince of Wales’ Foundation for Magic Medicine is jubilant about having been endorsed by NICE. And I’m told that “The chiropractors have now just written letters to all health boards in Scotland asking for contracts for their services to deal with back pain”.
There could hardly have been a worse time for NICE to endorse chiropractic. We are in the middle of a storm about free speech because of the disgraceful action of the British Chiropractic Associaton in suing one of our best science writers, Simon Singh, for defamation because he had the temerity to express an opinion, Of course, even if the BCA wins in court, it will be the overall loser, because chiropractic claims are now being scrutinised as never before (just look at what they told me).
Follow-up
A much-cited paper. The paper that is most often cited by chiropractors who claim to be able to cure colic by spinal manipulation is Klougart N, Nilsson N and Jacobsen J (1989) Infantile Colic Treated by Chiropractors: A Prospective Study of 316 Cases, J Manip Physiol Ther,12:281-288. This is not easy to get hold of but Steve Vogel has sent me s scanned copy which you can download here. As evidence it is about as useless as the infamous Spence study so beloved of homeopaths. There was no control group at all. It simply follows 316 babies and found that most of them eventually got better. Well, they do, don’t they? It is a sign of the pathetic standard of reaearch in chiropractic that anyone should think this paper worth mentioning at all.
June 6 2009. More flak for NICE from the Royal College of Anaesthetists, and more adverse comment in the BMJ. And of course the blogs. for example, “If this is “evidence based medicine” I want my old job back“.
“Acupuncture on the NHS: a dangerous precedent”: a good analysis at counterknowledge.com.
June 6 2009, Comment sent to the BMJ. The comment was submitted, as below, early on Friday 5th June. The BMJ said it was a “sensitive issue” and for the next five days lawyers pondered over it.
Underwood and Littlejohns describe their guidance as being a “landmark”. I can only agree with that description. It is the first time that NICE has ever endorsed alternative medicine in the face of all the evidence. The guidance group could hardly have picked a worse moment to endorse chiropractic. Chiropractors find it so hard to find evidence for their practices that, when one of our finest science writers, Simon Singh, asked to see the evidence they sued him for defamation. I suggest that the guidance group should look at the formidable list of people who are supporting Singh, after his brave decision to appeal against this iniquitous persecution.
Of course I’m sure this bizarre decision has nothing to do with the presence on the guidance group of Peter Dixon, chair of the General Chiropractic Council. Nevertheless, I am curious to know why it is that when I telephoned two of the practices belonging to Peter Dixon Associates, I was told that they could probably treat infantile colic and asthma. Such claims have just been condemned by the Advertising Standards Authority.
The low back pain guidance stands a good chance of destroying NICE’s previously excellent reputation for dispassionate assessment of benefits and costs. Yes, that is indeed a landmark of sorts.
If NICE is ever to recover its reputation, I think that it will have to start again. Next time it will have to admit openly that none of the treatments work very well in most cases. And it will have to recognise properly the disastrous cultural consequences of giving endorsement to people who, when asked to produce evidence, resort to legal intimidation.
Eventually, on Wednesday 10 June the comment appeared in the BMJ, and it wasn’t greatly changed. Nevertheless if is yet another example of legal chill. This is the final version.
Underwood and Littlejohns describe their guidance as being a “landmark”. I can only agree with that description. It is the first time that NICE has ever endorsed alternative medicine in the face of all the evidence. The guidance group could hardly have picked a worse moment to endorse chiropractic. Chiropractors are so sensitive about criticisms of their practices that, when one of our finest science writers, Simon Singh, queried the evidence-base for their therapeutic claims they sued him for defamation. I suggest that the guidance group should look at the formidable list of people who are supporting Singh, after his brave decision to appeal against an illiberal court ruling in this iniquitous persecution.
One wonders whether this bizarre decision by NICE has anything to do with the presence on the guidance group of Peter Dixon, chair of the General Chiropractic Council. I am also curious to know why it is that when I telephoned two of the practices belonging to Peter Dixon Associates, I was told that chiropractic could be effective in the treatment of infantile colic and asthma. Similar claims about treating colic have just been condemned by the Advertising Standards Authority.
The low back pain guidance stands a good chance of destroying NICE’s previously excellent reputation for dispassionate assessment of benefits and costs. Yes, that is indeed a landmark of sorts.
If NICE is ever to recover its reputation, I think that it will have to start again. Next time it will have to admit openly that none of the treatments works very well in most cases. And it will have to recognise properly the disastrous cultural consequences of giving endorsement to people who, instead of engaging in scientific debate, resort to legal intimidation.
Bait and switch. Oh dear, oh dear. Just look at this. British Chiropractic Association tell their members to hide their sins from prying eyes.
Excellent round-up of the recent outburst of writing about “chiroquacktic” (Tut, tut, is there no respect?).
Dr Crippen writes “NICE recommends a cure for all known disease” [Ed some exaggeration, surely]