Who’s confused about alternative medicine?

Even during my studies I pursued other things like massage therapy and acupuncture….As a young doctor I had an appointment in a homoeopathic hospital, and I was very impressed with its success rate. My boss told me that much of this success came from discontinuing mainstream medication. This made a big impression on me.’ (BMJ Career Focus 2003; 327:166; doi:10.1136/bmj.327.7425.s166).

Here we see Ernst responding as a clinician working in the field of alternative medicine – and also as a consumer, like the millions of Daily Mail readers who have remained passionate about this form of healthcare. The question is: why is there so much controversy over these non-pharmaceutical therapies? Why is it that users keep coming back to food supplements, herbal remedies, homoeopathy and all the therapies medics refer to as “complementary”, while a relatively small group of doctors attack such therapies as if they were some form of illicit witchcraft?

The answer may lie in the cloudy world of the scientific method, which is perhaps not as objective as many of the alternative medicine sceptics might claim. Being a skeptic (let us not forget that Ernst gave the keynote address to the 11th European Skeptics Congress on September 5-7, 2003) might suggest less than an open mind.  The divergence in views might also have something to do with the variable and often positive experiences of users of these therapies.

After his early support for homoeopathy, Professor Ernst has now become, de facto, one of its main opponents. Robin McKie, science editor for The Observer (December 18, 2005) reported Ernst as saying, ‘Homeopathic remedies don’t work. Study after study has shown it is simply the purest form of placebo. You may as well take a glass of water than a homeopathic medicine.’ Ernst, having done the proverbial 180 degree turn, has decided to stand firmly shoulder to shoulder with a number of other leading assailants of non-pharmaceutical therapies, such as Professors Michael Baum and Jonathan Waxman. On 22 May 2006, Baum and twelve other mainly retired surgeons, including Ernst himself, bandied together and co-signed an open letter, published in The Times, which condemned the NHS decision to include increasing numbers of complementary therapies.

Six months on, Professor Waxman, in an article in the British Medical Journal (BMJ), said on 24 November 2006 that he wanted peddlers of food supplements consigned to “the cobra filled dustbin of oblivion”. I have to say, I’m not sure that such an attitude towards human life is particularly compliant with the Hippocratic Oath, but Professor Waxman has made it clear he feels very strongly about this issue. In the BMJ’s Rapid Responses to the same article, my colleague Dr Damien Downing and my responses reminded Waxman that orthodox medicine was not well known for its spectacular curative properties. We cited, by example, a recent study of the effectiveness of chemotherapy in Australia and the USA which showed it contributed less than 5% to the 5-year survival rate (Clin Oncol (R Coll Radiol) 2004; 16(8): 549-60).

As high profile as the Ernsts, Baums and Waxmans of this world might be – their views are not unanimous across the orthodox medical profession. Some of these contrary views were expressed just last Sunday in The Sunday Times (Lost in the cancer maze, 10 December 2006). The author of the article, Robert Randall, is a cancer sufferer himself. He claims to be a consumer of services offered by both sides of the divide and it is interesting that from this consumer’s perspective, we receive a much more balanced debate. The concept of orthodox medicine relying on the evidence-based gold standard of the randomized controlled trial (RCT) is now wearing thin when it comes to understanding the relevance of this methodology to many forms of alternative medicine. Let’s take nutrition, for example. Is it really scientifically valid to condemn the potential role of supplementary nutrients like vitamin E and carotenoids (from carrots, peppers and other brightly coloured fruits and vegetables) because, when delivered in their synthetic, pharmaceutical forms, they have failed to generate strong beneficial effects in RCTs aiming to investigate their role in reducing chronic diseases like cancer and heart disease? Is it fair to do this when copious evidence from epidemiological and observational studies – which are often less prejudiced by bias and confounding factors – have consistently demonstrated strong associations for the natural, dietary forms of these nutrients? I think not – and, as a scientist, I am far from alone.

Natural products work within the human body in a different manner to pharmacologically-active drugs. They often work as complex mixtures in which the components interact with each other synergistically, or they interact with factors in the diet or the body. These sorts of variables are omitted from the pharma-friendly gold standard that Ernst and his colleagues seem to worship. I have no issue with using the evidence base – but I have a big problem with how selective you are being when you view the available evidence.

The real loser in open battles between warring factions in healthcare could be the consumer. Imagine how schizophrenic you could become after reading any one of the many newspapers that contains both pro-natural therapy articles and stinging attacks like that found in this week’s Daily Mail.

But then again, we may misjudge the consumer who is well known for his or her ability to vote with the feet – regardless. The consumer, just like Robert Sandall, and the millions around the world who continue to indulge in complementary therapies, will ultimately make choices that work for them. ‘Survival of the fittest’ could provide an explanation for why hostile attacks from the orthodox medical community, the media and over-zealous regulators have not dented the steady increase in the popularity of alternative medicine.

Although we live in a technocratic age where we’ve handed so much decision making to the specialists, perhaps this is one area where the might of the individual will reign. Maybe the disillusionment many feel for pharmaceutically-biased healthcare is beginning to kick in…. Perhaps the dictates from the white coats will be overruled by the ever-powerful survival instinct and our need to stay in touch with nature, from which we’ve evolved.