Sunday, March 22, 2009

alternative medicine

I don't want this blog to turn into Monbiot Watch or anything, but he's said summat again that makes me go 'hang on'.

He points out that many environmentalists are meticulous about their climate science yet get laughably superstitious about things like homeopathy. In doing so, he sweepingly decries 'alternative medicine,' a term too broad to have much meaning.

It's remarkable how agribusiness has us using the term 'conventional farming' for practices that are barely fifty years old and even now only used in certain parts of the world. All other methods are, by implication, unconventional - a bit weird, dippy and/or ineffective, they should be abandoned or catch up.

By the same token, if it's not pharmaceutical-surgical, it's 'alternative' medicine, batty and useless hippy nonsense, unlike the real thing. This attitude prevails even when big chunks of pharmaceutical medicine are seemingly based on shonky foundations.

Prozac, the bestselling antidepressant taken by 40 million people worldwide, does not work and nor do similar drugs in the same class, according to a major review released today.


The term 'alternative medicine' is used to describe a vast jumble of practices. Some of them we have no evidence for and nobody uses, like leeches; these are lumped in with popular yet still evidence-free stuff like crystals and homeopathy, together with ones that do indeed have some real evidence of their effectiveness like acupuncture and herbal medicine.

Herbal medicine is complementary to 'conventional' medicine. If you turn up at a herbalist's with something very serious, they refer you to a doctor. Herbalists can treat a wide range of minor conditions, but as a sole prescription it's clearly for eczema and depression rather than rampant cancer or open heart surgery.

It is so complementary that it overlaps to a sizeable degree. The development of new pharmaceutical medicines is often just isolating the active part of a plant already used in herbal medicine.

Acupuncture can also be complementary to Western medicine. I recently spoke to a GP who refers patients and says that it not only works on minor conditions in a less sledghammery way but can actually cure one or two conditions such as chronic back pain that pharmaceutical medicine often cannot treat, only mask.

Homeopaths, on the other hand, tend to distrust modern knowledge of physiology and believe their medicine can treat anything.

The theory is that the more you dilute the active ingredient, the stronger the medicine becomes. Many pills are so diluted that they would need to be bigger than your entire body to contain a single molecule of the active ingredient. Some would need to be bigger than the earth.

One person I know who studied homeopathy was told by her lecturer that if you cannot get the active ingredient then just write the name of it on a piece of paper and use that instead. Not only can water retain more power of a drug the less it contains, but it can read any language in any handwriting too.

Homeopathy defies all scientific reasoning, and indeed it defies the results of proper trials. There's no real evidence homeopathy works. Despite this, homeopaths will tell you they can treat anything and will happily send you into a malaria zone inoculated with tiny sugar pills.

Clearly the scientific methods used to discern what works should apply to all medicinal disciplines, but when it costs hundreds of thousands of pounds to get a medicine on the EU approval list, you're only going to shell out if you own the patent rather than someone growing valerian root.

This is why so many things from the pills and potions aisle in Holland and Barrett make no claims for themselves and only say they 'should not be used as a substitute for a varied diet'. Some of these substances work, others probably do not, and we don't know which are which or what a real effective dosing regime should be.

Perhaps where there's considerable anecdotal evidence for a non-patent treatment the EU itself should pay to have it properly evaluated. Given how much we spend on health care, and how much we'll save by having cheaper non-patented treatments available, it would likely be a comparatively small sum of money soundly invested.

21 comments:

Derek Wall said...

The pharmaceutical corporations patent medicine and earn huge abnormal profits in the process...they are killing machines but can pay for lots of lovely pr to justify their monopoly

Gyrus said...

I think the best comment I heard on the topic was from one of the apparently most anti-alternative people: Richard Dawkins. He said, "there is no alternative medicine. There is only medicine that works and medicine that doesn't work."

I'm not sure how this works as a critique of alternative medicine; presumably he's implying that everything that gets habitually tagged with that label doesn't work (which of course isn't true).

There's a wider issue of what "working" actually involves. Herbal remedies with deep traditional histories usually have these histories precisely because they work. A set of lab trials conducted over a few years or decades is hardly a replacement for untold generations of actual use.

People attacking "pseudoscience" and defending "conventional" science often seem reluctant to discuss the corporation factor. I'm just reading Pinker's The Blank Slate. Essential reading in many ways, but in discussing GM foods, he never mentions Monsanto - only analyzes our (supposed) bias against "artificial" things.

Dunc said...

People attacking "pseudoscience" and defending "conventional" science often seem reluctant to discuss the corporation factor.

Umm, who do you think is making all those "alternative treatments", and how much money do you think they're making? It's not the fairies, and they're not doing it pro-bono, I'll tell you that...

The fantastic profit ratios of the quacks give the lie to many of the IP arguments. They may not be patenting anything, but they're coining it in hand over fist anyway.

Gyrus said...

Dunc, highlighting any corporate corruption of "conventional" medicine doesn't prevent you from highlighting commercial corruption elsewhere. There's medicine that works and medicine that doesn't; and there's people ripping you off and people not ripping you off. Let's look at what's what and admit to the greatest threats in each instance.

My comment was trying to highlight the fact that "anti-alternative" voices often tactically ignore the vast threats in what they're implicitly defending, not calling for ignorance about the real (if smaller-scale) threats in what they're attacking.

The other point is that much conventional medicine inherently relies on commercial structures, whereas many "alternative" treatments can be "home-grown". Even if some companies are raking it in disproportionately, there's at least more scope for less alienated, less commercially-bound approaches.

Dunc said...

My comment was trying to highlight the fact that "anti-alternative" voices often tactically ignore the vast threats in what they're implicitly defending, not calling for ignorance about the real (if smaller-scale) threats in what they're attacking.

Most of the bloggers I read who focus on these issues (such as Ben Goldacre and Orac of ScienceBlogs) are quite happy to also tackle corruption and conflicts of interest in "conventional" medicine. I'll grant that they may not a representative sample.

Even if some companies are raking it in disproportionately, there's at least more scope for less alienated, less commercially-bound approaches.

Well, that's where I disagree - my impression is that the growth of "alternative" medicine in recent decades has been primarily driven by the profit motive and clever advertising, and that in many cases it's purely commercial, completely untainted by any concern for actual clinical outcomes.

Gyrus said...

I said "there's at least more scope" for less commercial approaches. The fact that the current manifestation of "alternative" medicine is primarily driven by profit is no surprise in a culture primarily driven by profit!

merrick said...

Gyrus, whilst I agree with the sentiment of Dawkins', it comes apart when we try to define 'work'.

As Ben Goldacre describes, the placebo effect is a strange and mysterious thing.

Red pills don't work as well for anxiety ads green ones. Two sugar pills are more effective than one. a saltwater injection is more effective still.

Weirder, a proven effective medicine, Cimetidine, decreased in power when a new medicine came on the market for the same condition.

Perhaps weirdest of all, patients who are explcitly told that they are being given sugar pills with no medicine in still respond better than ones given no treatment.

With 'alternative' treatments, patients are given a lot more time than the six minutes that GPs give us on average.

As Goldacre says elsewhere, it seems quite likely that "theatrical ceremony, reassurance, the thought of someone doing something useful, and a chat with someone nice helps" in a real medical sense.

That being so, any intrinsically ineffective thing prescribed in that ritual will 'work', in the most side-effect free manner imaginable.

Unfortunately, it also leads to a belief in the healing powers of non-effective substances and entire disciplines.

I know what you're getting at when you say

A set of lab trials conducted over a few years or decades is hardly a replacement for untold generations of actual use

But in some cases frankly it is. Dangling a key on a string over the belly has no effect on the foetus inside, despite generations of belief in it.

Indeed, it's only a short jump to using your line of thought as a defence for monotheism.

Gyrus said...

My comment about lab trials vs. tradition was indeed woefully lacking in qualification. Clearly we need attention to both.

I stand by Dawkins' comment, but I think the placebo and related effects only undo "work" for Dawkins. As a long-time student of magic, incredulity and befuddlement over "the placebo effect" is a little odd to me!

Matt Hodgkinson said...

Monbiot was quite right to make this call. He might have unfairly lumped in some effective therapies in "alternative medicine", but as said above, if a medicine works, it isn't "alternative", it's just medicine.

Environmentalists need to stop giving unthinking support to any CAM therapy that comes along, and equally they need to stop jumping on every scare bandwagon that goes past. For instance, I've seen a tendency to believe all stories attributing cancer to mobile phones, without ever actually reading the (ambiguous) scientific literature on the topic.

Yes, pharmaceutical therapies have problems, which are so legion I won't go into them here. But I will reply to this quote: "Prozac, the bestselling antidepressant taken by 40 million people worldwide, does not work".

That review in PLoS Medicine was poorly done. The authors' interpretation of their results was flawed. See http://medicine.plosjournals.org/perlserv/?request=read-response&doi=10.1371/journal.pmed.0050045

Matt Hodgkinson said...

More on the effectiveness of anti-depressants, and more explanation of the flaws in Kirsch et al. here.

studentmedic said...

Good article but I agree with Matt. There are many alternative therapies which have been evaluated and don't have evidence to back them up and yet are still touted. Too often some greens argue against anything which makes it harder for these to jump through the regulatory hoops, but the reality is that these hoops are hard to get through for a reason: to protect the health of others. If this favours bigger corporations, so be it. but please let's note that there are plenty of alternative medicine advocates who make a small packet by aiming their 'treatments' at naieve people.

If something has real evidence, it should no longer be 'alternative'. Yes, plenty of things previously classed as alternative would now be seen as complimentary or conventional, but that is how life is. Until we have evidence, it is stupid to suggest something which we have no real reason will work in the hope that it will...

punkscience said...

Unfortunately, Merrick, I think all you've succeeded in doing here is pointing out that medicine is incredibly complex. However, I think even you have underestimated quite how much. Yes, big pharma is clearly an enemy of society, ignoring the simple, common ailments that could save millions of lives in the developing world and investing millions developing fractionally different cures for a handful of common, Western ailments that are profitable. But do you know how much money must be invested to prove a drug's clinical safety and efficacy before it can be licensed on the market? Its a very, very big figure. The sort of money that only big pharma and governments can throw around and therefore, unless you want to see the black financial hole that is the NHS grow a little bit bigger and deeper your options really are limited when it comes to pharmaceutical R&D.

As for herbs, acupuncture and all that jazz, I am with David Colquhoun: ALternative medicine that has been demonstrated to work is just called "medicine". The "alternative" tag simply means that there's no evidence to demonstrate that it functions to produce the effect described. Your examples of placebo pills is a good one. Effect but no functional link.

http://dcscience.net/


As for your doctor who prescribes acupuncture, the reason he is doing that is because appropriate, double-blind, placebo-controlled trials are revealing which conditions the treatment works for, and- most importantly- why.

EG.
http://www.nature.com/aja/journal/v11/n2/abs/aja20084a.html

punkscience said...

Sorry to double-post but reading the other comments here, I'm reminded of how different this evidence-based dialogue is from the fluffy shite you get from typical "Greens". Let me link to an example which really made my blood boil and my mouth froth:

http://ruscombegreen.blogspot.com/2008/12/stop-compulsory-vaccinations.html

The comments relate a saga of ignorance and endarkenment. Sadly, the last laugh went to the chakra-channellers and spiritual healers as the government sided with them against the massive weight of evidence and the opinion of the British Medical Association. Little surprise there.

merrick said...

MattHodgkinson and punkscience,

I think we're in basic agreement here. I certainly agree with you (and Monbiot) that there's a tendency for Greens to believe any scare story about not just modern medicine but, as you point out Matt, technology too.

a medicine works, it isn't "alternative", it's just medicine.

That may be your definition but the point I'm trying to make is that, in much of its usage, the term means anything not pharmaceutical-surgical. You can certainly find many instancres to call acupuncture 'alternative mediciine', and I'll gladly wager that a serious percentage of the population would call it that.

Studentmedic,

If something has real evidence, it should no longer be 'alternative'.

My point is that it is kept 'alternative' by the lack of any attempt to find real evidence. As Punkscience says,

But do you know how much money must be invested to prove a drug's clinical safety and efficacy before it can be licensed on the market? Its a very, very big figure.

I totally agree with you that

Until we have evidence, it is stupid to suggest something which we have no real reason will work in the hope that it will.

The problem is that because of the difficulty in getting older, non-patented effective things properly tested, they are on the health shop shelves alongside a shitload of useless junk. This means the junk gets credibility it doesn't deserve from believers, and the effective stuff gets dismissed by non-beleivers.

My point is that where there is stuff that we DO have real reason to believe will work, we should test it at public expense. This would bring the effective ones into a clearer light and allow us to marginalise the ineffective junk.

Punkscience, I don't agree that such testing would necesarily see 'the black financial hole that is the NHS grow a little bit bigger'. By bringing cheap, non-prescription medicines on to the market this would surely result in less pharmaceutical prescriptions, less GP time, (and quite likely conditions caught earlier because people haven't wasted time on quackery, too).

Annwen said...

I agree, this has highlighted a very complex issue, the idea that we can simply find something that works universally to make us all healthy will never happen.

I get very angry though when a blanket term like 'alternative medicine' is used dismissively as that encompasses so many different things, it even seems that something as basic to health as nutrition is alternative when many doctors know little about it and never discuss it with patients. I can’t comment about homeopathy as I have neither the information, experience nor the leap of faith required to believe in it. Plant based medicine is what I do know about. Most conventional drugs are derived originally from plant constituents and for the majority of people on earth plant medicines are the norm and not the exception.

Evidence is a complex area and so it’s not as easy as asking “what works?” centuries of documented successful and widespread use is not considered objective enough (perhaps rightly). I would love to see more evidence base in herbal medicine but sadly the research budgets are lacking and much of what is carried out is of poor quality with a surprising amount of studies using inappropriate doses, wrong form/mode of delivery leading to spurious results and erroneous conclusions as researches don’t have an understanding of how herbal medicine is practiced (e.g. a trial concluded that Echinacea was not effective after a week based on trials lasting 5 days!). Herbal medicine in practice treats each patient with a unique prescription based on their entire health picture rather than single symptoms, changes the prescription as the treatment progresses and depends in part for its efficacy on the patients willingness to adopt dietary and lifestyle changes, this approach can not easily be tested by randomised controlled trials without a degree of meticulousness and understanding of the subject that I’ve not seen in many of the research papers I’ve read.
Herbal medicine as an arm of the supplements industry is much more conventional in approach, in that it’s often marketed as popping a pill to cure a single ailment. Holland and Barrat ‘sweepings off the factory floor’ type quality of product often have little or no active constituents, and I’ve read many studies that are testing such over the counter remedies rather than good quality extracts. I think that not being legally allowed to make claims for a products efficacy on the label contributes to companies getting away with stuff that is highly unlikely to be any good at all, sometimes even the wrong part of the plant altogether…they don’t have to say it’ll do anything anyway.
Other studies test single chemical constituents from a plant, which obviously has some relevance but doesn’t give us the whole picture, e.g. many of the issues regarding the safety of St John’s wort are based on a constituent that doesn’t extract in alcohol and so wouldn’t be present in a tincture. A plant is a complex mix of constituents and how they work together is often unknown, which is why taken out of the plant context they can behave very differently. Some plants contain constituents that balance out ‘side’ effects of others e.g. diuretics deplete the body of potassium (so people taking conventional diuretics have to take a potassium supplement) many herbs that have a diuretic effect also have high potassium content and so don’t deplete the body in the same way.

However, my main point is not about the relative efficacy of conventional drugs versus plant drugs it is about how western medicine (conventional and often so called alternative too) is not concerned with making us healthy just with a quick fix fast buck solution. Looking at the overall picture of a person’s health means looking at how an infection can be better dealt with if immune systems are strengthened or how a skin condition will clear up if diet and digestive function are improved, conventional or herbal anti-bacterials should only be a part of the solution – this isn’t some mad theory or random quackery it’s just common sense, it involves striving for health rather than simply the absence of disease, but this isn’t how conventional medicine is practiced. Western medicine is obsessed with the tiny organisms that cause disease and finding chemicals to kill each one, it pays little attention to how different people get ill to a varying degree when they’re all exposed to the same bugs, why is that not researched more? why haven’t they come up with an immune system boosting jab? It’s that nobody makes any money from making us healthy and the modern doctor doesn’t have the time for it.

Gyrus said...

punkscience:

The "alternative" tag simply means that there's no evidence to demonstrate that it functions to produce the effect described. Your examples of placebo pills is a good one. Effect but no functional link.

This sums up my reservations about scientific reservations about placebo effects. "Effect but no functional link" seems to mean "It works but we don't know how". Where you go from that "don't know how" is crucial. Do you allow scientific unease with mystery to subtly (or not so subtly) smother the "it works" bit? Why?

This is why I went with Dawkins' "there's medicine that works and medicine that doesn't" - if pursued honestly, it validates any practically effective medicine, even if the functioning of the treatment defies contemporary theory.

Wiktionary defines placebo thus:

A dummy medicine containing no active ingredients; an inert treatment; Anything of no real benefit which nevertheless makes people feel better.

Discussion of the "placebo effect" (which is demonstrable) is tainted, I think, with the base meaning of "inert treatment". It's like saying, "It works but it doesn't".

I mean, look at the second part of the definition: "Anything of no real benefit which nevertheless makes people feel better." That's just nonsense. And - without shifting personal responsibility for spouting crap - I think this kind of nonsense generates a certain amount of the anti-science nonsense we're discussing. We need to get past the idea that "feeling better" is a frivolous effect. It's not a cure-all, but it should be part of any humane and holistically effective treatment.

punkscience said...

Annwen, you made a great point in your closing paragraph about preventative medicine. I.E. that it is worth many times its value in curative medicine. I don't think 'curative' is really a word but you get my point.

Gyrus, you should look up psychoneuroimmunology if you want to understand the placebo effect. Immune function can be heavily influenced by moods. Its well established that people with positive outlooks heal more quickly. "Laughter is the best medicine" isn't just a saying either. You have to understand that science still has much work to do before we can understand these phenomenon, particularly when they are so hard to define when compared to cancer or AIDS.

Merrick, re: the NHS, I don’t agree that bringing “cheap and non-prescription drugs onto the market” would reduce prescriptions and GP visits. Over-the-counter medicines are already widely available and do little to treat common ailments. I remember a NewScientist article relating how even aspirin only worked effectively on 1/3 of people and paracetamol was even less. Big pharma makes untold billions from cold and flu “remedies” that are, essentially, menthol and eucalyptus oil and sugary water. I find GPs to be pretty useless. The only reason I visit them is to get prescriptions for stuff that’s a bit cheaper that way than buying meds over the counter (hayfever treatments for example) or- before I worked in science- to get sick notes. The reason GPs have to prescribe stuff is because a lot of medicines are dangerous if abused. There’s no easy way around that and its unrelated to the pharma industry. I wasn’t endorsing the current state of the industry- I think big pharma is disgusting and should be broken up. The abuse of patents for profit is a classic example of this. But if you are to test drugs exhaustively in order to protect the public then either you place responsibility for it in the hands of a body like NICE or you leave it in the hands of big pharma. I’ve obviously been a twat by suggesting that the NHS is inferior to big pharma; clearly I had my head up my arse when I wrote that but the NHS, like many UK national institutions, is being assaulted from all sides and is hardly the bastion of public service it should be. If I was being idealistic I would advocate an independent body of experts, analogous to the judiciary's role in law, to oversee and adjudicate in matters of science. Such a body could endorse legitimate “alternative” treatments where there is good evidence to support their efficacy. All a big pipe dream but I thought I ought to straighten my position out a bit.

Word.

George Monbiot said...

you make a very good point about the use of language in farming (and the same could apply to many things - eg the disastrous experiment called conventional child-rearing from about 1840-1970). But I think the alt med category does apply, as meaning those treatments not supported by peer-reviewed trials.

Now this might seem unfair for two reasons:

1. Much that was alternative has become conventional through testing and adoption

2. many of the trials are unfair/biased/fraudulent as a result of drug company meddling, undisclosed interests etc. (Criticising alt med doesn't
imply endorsement of all conventional medicine.)

What this means is that alt med is the rump left behind after the good stuff has been nicked. Not all acupuncture is alt med, for example, but that which is confined only to alt med is probably kooky.

Herbal medicines work, but the doses aren't nearly as accurate as those in the conventional medicine extracts.

merrick said...

George

you say alt med is the rump left behind after the good stuff has been nicked

but yet you define it as those treatments not supported by peer-reviewed trials.

The implication is that all the good stuff has passed peer-reviewed trials, and anything that hasn't passed them or hasn't had them isn't 'the good stuff'.

Failing a test is very different to never having had the opportunity to pass it.

We have strong anecdotal evidence on some alternative medicines, but its in nobody's financial interest to cough up for proper trials and getting it listed when it passes.

You're right about the inaccuracy of dosing in herbal medicines. This, as Annwen points out, is made worse by the way any part of the plant (including the useless bits) can be sold (including in forms that would be ineffective).

This situation is made worse by the fact that effective and ineffective herbal medicines aren't allowed to make any claims for themselves.

The position that I'm arriving at is this: there should be a body that finds 'alternative' medicines with strong anecdotal evidence and they tested using public funds.

The effective stuff can then be labelled as stuff. We then separate the good stuff from the crap. Preferably by putting cigarette packet style warnings on untested stuff saying 'WARNING: There is no evidence that this works at all'.

Then you would get a clear gulf and there would be - to use your buttocky phrasing - a rump left behind.

Matt Hodgkinson said...

"We have strong anecdotal evidence on some alternative medicines, but its in nobody's financial interest to cough up for proper trials and getting it listed when it passes".

The idea that CAM therapies are not being studied is a myth.

There are a lot of trials done on alternative medicines. Many of them are poor quality trials conducted by those with a financial interest in showing that the therapy works (the same sponsor bias exists with testing pharmaceutical drugs), but they're certainly being done. One solution is that CAM practitioners need to learn how to properly conduct clinical trials; another is that more experienced triallists need to do trials of CAM medicines.

Search PubMed and you'll find a lot of studies, with conclusions such as:
"The evidence from rigorous clinical trials of any type of therapeutic or preventive intervention testing homeopathy for childhood and adolescence ailments is not convincing enough for recommendations in any condition" or
"The findings cast doubt on the validity of traditional acupuncture theories about point locations and indications. Scientific rationales for acupuncture trials are needed to define valid controls, and the theoretical basis for traditional acupuncture practice needs to be re-evaluated".

In particular, look for Cochrane reviews. Try this search in PubMed:
Cochrane Database Syst Rev[jo] AND (complementary OR "alternative medicine" OR homeopathy OR "chinese medicine" OR herbal OR acupuncture OR massage OR reflexology OR kinesiology)

merrick said...

Matt, once again I think we're closer to agreement than might first appear.

I concede that I was generalising and that some trials of alternative medicines do take place.

But unfortunately, as you yourself rightly say, these are often done badly in scientific terms (as Annwen pointed out), and/or in terms of wanting a predetermined outcome.

What I'm advocating - and I think this still holds - is that there be proper independent publicly funded trials of alternative medicines that have strong anecdotal evidence.

Or, as you say, more experienced traillists should do the trials.

The stuff that works will come clear, the quackery should have to be labelled as such like cigarete warnings.