New Under the Sun:
October - December 2008
Volume 7, Issue 4
Trick or Treatment
In past issues of AnthroHealth News, I discussed the problems associated with alternative therapies. This month I review a book published this year that details the results of years of scientific research on these therapies and the conclusions to be drawn from this research. The book is Trick or Treatment: The Undeniable Facts about Alternative Medicine by Simon Singh and Edzard Ernst, MD. The conclusions they present will not make believers in and practitioners of alternative therapies happy. However, the long history of alternative therapies is unlikely to end even in the face of such outstanding evidence. As noted by Mark Kurlansky in his fascinating book Cod: A Biography of the Fish that Changed the World, “Ideas are not easily conquered by facts.” In the case of alternative therapies, which primarily “succeed” through the placebo effect, imagination does appear to conquer fact.
Trick or Treatment goes beyond a simple list of therapies and the results of research on that therapy. It is in many ways a history of medicine text, but one written to appeal to a broad audience. We like to think of medicine as a very scientific, rigorous enterprise. But, in fact, for most of its history, physicians did more harm than good. George Washington, our first president, died of a cold in large part because his physicians thought it wise, when their first medicinal preparations failed to relieve an obstruction in his throat, to bleed him. They, in effect, bled him to death. And these were the best physician’s available to the former president.
Of course, there were extremely competent individuals throughout history who did more good than harm. These tended to be physicians who used what we now recognize as the gold standard: evidence-based medicine. As noted in Trick or Treatment, this standard was recognized over 2000 years ago by none other than Hippocrates who stated that, “There are, in fact, two things, science and opinion; the former begets knowledge, the latter ignorance.” Unfortunately, the evidence marshaled by these more scientific physicians was frequently not put into practice until decades after it was first presented. James Lind did a controlled study of scurvy in 1747, finding that citrus fruit prevented the malady. However, it was not until 1795 that the inclusion of lemon juice in the daily rations of sailors was mandated in Britain. Another case of early evidence-based medicine not discussed in this book (as it is unrelated to alternative therapies) was that of Ignaz Semmelweis who found in 1847, after rigorous analysis, that cases of puerperal fever, common in obstetric clinics after women had given birth, could be drastically reduced if the attending medical personnel would just wash their hands between patients. Unfortunately, instead of being lauded, he was ridiculed, and women continued to die needlessly for many more decades.
Fortunately for patients, evidence-based medicine supported by clinical trials is now the accepted practice for providing physicians with the best knowledge about the efficacy of various treatments. Unfortunately for those with a belief in or a stake in alternative therapies, this more rigorous look at treatment modalities has, in most cases, failed to support their claims.
Singh and Ernst carefully discuss the history of and analyze the primary alternative therapy treatments: acupuncture, homeopathy, chiropractic therapy, and herbal medicine. I do not have the space here to go into detail on each of these therapies. If the reader is particularly interested in how the authors came to their conclusions, I urge you to read their book. What I will do here is present their conclusions for each of the therapies.
In the case of acupuncture, Singh and Ernst concluded that the evidence is that acupuncture is primarily a placebo therapy. It may provide some relief for pain and nausea, but the evidence is equivocal. In all other cases, there is no evidence that acupuncture provides any benefit beyond that of the placebo effect.
As for homeopathy, “…it would be fair to say that there is a mountain of evidence to suggest that homeopathic remedies simply do not work. This should not be such a surprising conclusion when we recall that they typically do not contain a single molecule of any active ingredient.” Again the placebo effect is at work. The packaging of many homeopathic remedies even states that they are sugar pills (“…0.85 grams of sucrose and 0.15 grams of lactose…”).
Singh and Ernst strongly caution the reader to avoid chiropractors for anything more the lower back pain. And even then, they state that it must be made clear to the chiropractor that he/she is not allowed to manipulate anywhere near the neck. Many patients of chiropractors have been injured or even killed by mishandled and totally unnecessary neck manipulations. There is no evidence that chiropractic treatment can help anything other than lower back pain. The authors recommend a physical therapist as a safer choice.
Herbal medicine is the one therapy where for some herbal remedies, there has been some evidence to support their efficacy. However, for most commonly used herbal treatments, there is little or equivocal evidence that they work and, in some cases, evidence that they harm. The list of herbal medicines is long; therefore, I recommend reading the book to obtain a complete picture.
The authors also include an appendix that covers an additional 36 alternative therapies. Over and over they conclude that there is little if any benefit to a treatment and, in many cases, there is harm.
Singh and Ernst conclude Trick or Treatment by the following statements:
Trick or Treatment is a heavily-researched, scientifically-supported plea for truth and honesty in the treatment of patients. It also requires that patients abandon imaginative ideas and focus on the facts. Anyone who has an interest in alternative therapies should read this book and discover the facts for themselves. Interestingly, discovering the facts for himself is exactly what Edzard Ernst, the co-author of this book did. In addition to being a MD, Ernst also practiced homeopathy and was interested in acupuncture. However, as a science-based physician, he began to have questions. Careful research and analysis led him to conclude that there was no there there. The alternative therapies were not treatments; they were tricks. If Dr. Ernst can face facts, can we do any less?
Recently, the British Medical Journal (10/23/08) reported a study of American physicians that found that around 50% of those surveyed prescribed placebos for their patients. Singh and Ernst argued in their book against this practice since the physician is, in effect, lying to the patient. However, the surveyed physicians believe that since the placebo effect is real, there is no harm in offering the “treatment” (generally pain relievers or vitamins) as something that “might help” the patient feel better.
If a significant portion of physicians educated in evidence-based medicine are willing to ignore the evidence to prescribe placebo treatments for their patients, perhaps we should not be surprised that the general public so whole-heartedly embraces alternative therapies. Are humans predisposed to accept belief over reason?