- Email: [email protected]
Keynote comment: dumbing down of complementary medicine
Reflection and Reaction
Keynote comment: dumbing down of complementary medicine For a while, complementary medicine was maturing into a respectable branch of clinical investigation, and the subject was widely thought to deserve serious study.1 Research funds were increasing, and as a result, more and more high-quality trials were being done.2 Yet, recent events have reduced such optimism. Instead of tackling efficacy and safety,1 investigators of complementary medicine seem to do mainly surveys or interview-based projects such as focus groups. On average, one survey is published every other day. No other medical specialty publishes results at this frequency. Most of the projects are of such poor quality that they tell us little worth knowing, and the data are often overinterpreted. For instance, if the investigators think that use of complementary treatments and patient satisfaction is sufficiently high, they press for wholesale integration of complementary medicine into routine healthcare.3 Investigators think that this approach provides solutions to health-care delivery issues, and suggests the direction for a new health service in the 21st century that is focused on the needs of consumers by use of a new model of integrated healthcare.3 Thus, so-called integrated medicine is promoted with little thought. Whereas evidence-based
Natural products often used in complementary medicine
442
medicine first defines which treatments work and subsequently judges them for routine use, integrated medicine tends to bypass crucial assessment— integration today and assessment later. Are scientific rigour and common sense being sacrificed on the altar of political correctness? After a report from the UK House of Lords recommended scientific assessment,1 the UK Department of Health dedicated about £2 million for research into complementary medicine. The recommendation made by The House of Lords to prioritise research according to efficacy and safety was, however, ignored. Instead, more survey data will now add to the already large, convoluted, but in terms of improving healthcare, inconsequential, body of evidence on questions such as why do patients use complementary treatments? Who uses complementary medicine? How might people use this approach? Complementary medicine, it seems, is being turned into complementary sociology, and research priorities that are based on patients’ medical needs are all but forgotten. A disturbing new development is that a document entitled Complementary healthcare: a guide for patients3 was distributed widely throughout the UK. It follows in the footsteps of a guide for primary-care trusts, which had much the same defects. The UK Department of Health, the Welsh Assembly, and the Scottish Executive have all given substantial amounts of money to The Prince of Wales’s Foundation for Integrated Health to develop the new guide. The booklet is very misleading and does not contain the most essential component of any patient guide—reliable and detailed information on efficacy and safety. Instead, it informs patients that “the laying on of hands…is used for a wide variety of physical and emotional conditions…[including] healing of wounds… migraine, irritable-bowel syndrome, reducing side-effects of chemotherapy and radiotherapy for people with cancer…[and] pain relief”.3 Both the Prince of Wales’s Foundation for Integrated Health and the UK Department of Health insist that the guide was never meant to include information on efficacy, but correspondence obtained under the Freedom of http://oncology.thelancet.com Vol 6 July 2005
Reflection and Reaction
Information Act clearly shows otherwise. The Foundation has now embarked on its next two projects. One is aimed at the production of national guidelines for the use of complementary healthcare in mental-health services,3 the other is aimed at the establishment of a cost effective way to integrate complementary medicine. Is tax-payers’ money being used to produce promotional literature devoid of crucial thinking? But the dangers of this erosion of science are much greater than the economical consequences. The postmodernist notion that science is no better or worse than other forms of knowledge has already claimed victims on a large scale. Tabo Mbeki, President of South Africa, embraced postmodernist pseudoscience, attacking western science as colonialist, and adopted the ideas of Peter Duesberg who proclaims that AIDS is not caused by an infection but by poverty.4 Manto Tshabala-Msimang, South Africa’s Health Minister, recommends raw garlic and lemon skin in the fight against AIDS.5 South Africa has the highest prevalence of HIV infection in the world and every year more than 70 000 children who are HIV positive are born there. In India, the fundamentalist government promoted Vedic science between 1998 and 2004. This idea states that all
knowledge can be found in the old Hindu religious texts. As a result, India’s earthquake-prediction systems and tuberculosis or AIDS research changed from being science orientated to being founded in Vedic science. Some forms of complementary medicine have a lot to offer.2 Others are not effective, some are even dangerous, and most are too under-researched to be sure either way.2 Turning complementary medicine into a commodity such as a beauty therapy, or allowing pseudoscience to take over will do no favours—neither to the patient nor, in the long term, to complementary medicine itself. E Ernst Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter EX2 4NT, UK [email protected] I declare no conflicts of interest. 1
2 3 4 5
House of Lords Select Committee on Science and Technology. Complementary and alternative medicine. 6th report. Session 1999–2000. (HL123) ISBN 0 10 483 1006. London: The Stationery Office. 2000. Ernst E, Pittler MH, Stevinson C, White AR. The desktop guide to complementary and alternative medicine. Edinburgh: Mosby. 2001. Anon. The Prince of Wales’s Foundation for Integrated Health. http://www.fihealth.org.uk (accessed April 18, 2005). Hari J. The Independent (London) May 25, 2005. Clayton J. The Times (London) May 7, 2005.
Alcohol and cancer: benefits in addition to risks? Drinking of alcohol entails an increased risk of cancer. The evidence is strongest for squamous-cell carcinoma of the oral cavity, pharynx, larynx, and oesophagus.1 In addition, alcohol drinking is strongly associated with the risk of primary liver cancer; the mechanism of which, however, might be mainly or solely via the development of liver cirrhosis, implying that light or moderate drinking could have little effect on risk.2 An increased risk of colorectal cancer has also been noted in many populations, although a causal association has not been shown.3 Strong evidence of a role of alcohol drinking in breast carcinogenesis has been provided by a pooled analysis of 53 cohort and casecontrol studies.4 Although the excess risk is probably not large, the association is of great importance because of the apparent lack of a threshold, the large number of women drinking small amounts of alcohol, and the high incidence of the disease. Indeed, alcohol drinking has been attributed with more cases of http://oncology.thelancet.com Vol 6 July 2005
breast cancer than of any other cancer in women in developed countries.5 The Article by Morton and colleagues in this issue of The Lancet Oncology6 provides evidence of a protective effect of alcohol drinking against a human cancer. Previous studies on this issue were limited by small numbers and imprecise assessment of exposure. If real, such an effect would add a new dimension to our view of alcohol-related carcinogenesis, since potential benefits should also be taken into account together with the risks entailed by the habit when considering the overall effect of alcohol drinking on health. Besides its effect on cancer risk, alcohol drinking increases the risk of various types of injuries, and its use during pregnancy has a detrimental effect on the development of the fetus and its CNS, often resulting in malformations, behavioural disorders, and cognitive deficits in the postnatal period.7 On the other hand, there is strong evidence for a J-shaped pattern of risk of total mortality and cardiovascular disease
See Articles page 469 for results of a pooled analysis of the effect of alcohol consumption on risk of non-Hodgkin lymphoma
443
Keynote comment: dumbing down of complementary medicine For a while, complementary medicine was maturing into a respectable branch of clinical investigation, and the subject was widely thought to deserve serious study.1 Research funds were increasing, and as a result, more and more high-quality trials were being done.2 Yet, recent events have reduced such optimism. Instead of tackling efficacy and safety,1 investigators of complementary medicine seem to do mainly surveys or interview-based projects such as focus groups. On average, one survey is published every other day. No other medical specialty publishes results at this frequency. Most of the projects are of such poor quality that they tell us little worth knowing, and the data are often overinterpreted. For instance, if the investigators think that use of complementary treatments and patient satisfaction is sufficiently high, they press for wholesale integration of complementary medicine into routine healthcare.3 Investigators think that this approach provides solutions to health-care delivery issues, and suggests the direction for a new health service in the 21st century that is focused on the needs of consumers by use of a new model of integrated healthcare.3 Thus, so-called integrated medicine is promoted with little thought. Whereas evidence-based
Natural products often used in complementary medicine
442
medicine first defines which treatments work and subsequently judges them for routine use, integrated medicine tends to bypass crucial assessment— integration today and assessment later. Are scientific rigour and common sense being sacrificed on the altar of political correctness? After a report from the UK House of Lords recommended scientific assessment,1 the UK Department of Health dedicated about £2 million for research into complementary medicine. The recommendation made by The House of Lords to prioritise research according to efficacy and safety was, however, ignored. Instead, more survey data will now add to the already large, convoluted, but in terms of improving healthcare, inconsequential, body of evidence on questions such as why do patients use complementary treatments? Who uses complementary medicine? How might people use this approach? Complementary medicine, it seems, is being turned into complementary sociology, and research priorities that are based on patients’ medical needs are all but forgotten. A disturbing new development is that a document entitled Complementary healthcare: a guide for patients3 was distributed widely throughout the UK. It follows in the footsteps of a guide for primary-care trusts, which had much the same defects. The UK Department of Health, the Welsh Assembly, and the Scottish Executive have all given substantial amounts of money to The Prince of Wales’s Foundation for Integrated Health to develop the new guide. The booklet is very misleading and does not contain the most essential component of any patient guide—reliable and detailed information on efficacy and safety. Instead, it informs patients that “the laying on of hands…is used for a wide variety of physical and emotional conditions…[including] healing of wounds… migraine, irritable-bowel syndrome, reducing side-effects of chemotherapy and radiotherapy for people with cancer…[and] pain relief”.3 Both the Prince of Wales’s Foundation for Integrated Health and the UK Department of Health insist that the guide was never meant to include information on efficacy, but correspondence obtained under the Freedom of http://oncology.thelancet.com Vol 6 July 2005
Reflection and Reaction
Information Act clearly shows otherwise. The Foundation has now embarked on its next two projects. One is aimed at the production of national guidelines for the use of complementary healthcare in mental-health services,3 the other is aimed at the establishment of a cost effective way to integrate complementary medicine. Is tax-payers’ money being used to produce promotional literature devoid of crucial thinking? But the dangers of this erosion of science are much greater than the economical consequences. The postmodernist notion that science is no better or worse than other forms of knowledge has already claimed victims on a large scale. Tabo Mbeki, President of South Africa, embraced postmodernist pseudoscience, attacking western science as colonialist, and adopted the ideas of Peter Duesberg who proclaims that AIDS is not caused by an infection but by poverty.4 Manto Tshabala-Msimang, South Africa’s Health Minister, recommends raw garlic and lemon skin in the fight against AIDS.5 South Africa has the highest prevalence of HIV infection in the world and every year more than 70 000 children who are HIV positive are born there. In India, the fundamentalist government promoted Vedic science between 1998 and 2004. This idea states that all
knowledge can be found in the old Hindu religious texts. As a result, India’s earthquake-prediction systems and tuberculosis or AIDS research changed from being science orientated to being founded in Vedic science. Some forms of complementary medicine have a lot to offer.2 Others are not effective, some are even dangerous, and most are too under-researched to be sure either way.2 Turning complementary medicine into a commodity such as a beauty therapy, or allowing pseudoscience to take over will do no favours—neither to the patient nor, in the long term, to complementary medicine itself. E Ernst Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter EX2 4NT, UK [email protected] I declare no conflicts of interest. 1
2 3 4 5
House of Lords Select Committee on Science and Technology. Complementary and alternative medicine. 6th report. Session 1999–2000. (HL123) ISBN 0 10 483 1006. London: The Stationery Office. 2000. Ernst E, Pittler MH, Stevinson C, White AR. The desktop guide to complementary and alternative medicine. Edinburgh: Mosby. 2001. Anon. The Prince of Wales’s Foundation for Integrated Health. http://www.fihealth.org.uk (accessed April 18, 2005). Hari J. The Independent (London) May 25, 2005. Clayton J. The Times (London) May 7, 2005.
Alcohol and cancer: benefits in addition to risks? Drinking of alcohol entails an increased risk of cancer. The evidence is strongest for squamous-cell carcinoma of the oral cavity, pharynx, larynx, and oesophagus.1 In addition, alcohol drinking is strongly associated with the risk of primary liver cancer; the mechanism of which, however, might be mainly or solely via the development of liver cirrhosis, implying that light or moderate drinking could have little effect on risk.2 An increased risk of colorectal cancer has also been noted in many populations, although a causal association has not been shown.3 Strong evidence of a role of alcohol drinking in breast carcinogenesis has been provided by a pooled analysis of 53 cohort and casecontrol studies.4 Although the excess risk is probably not large, the association is of great importance because of the apparent lack of a threshold, the large number of women drinking small amounts of alcohol, and the high incidence of the disease. Indeed, alcohol drinking has been attributed with more cases of http://oncology.thelancet.com Vol 6 July 2005
breast cancer than of any other cancer in women in developed countries.5 The Article by Morton and colleagues in this issue of The Lancet Oncology6 provides evidence of a protective effect of alcohol drinking against a human cancer. Previous studies on this issue were limited by small numbers and imprecise assessment of exposure. If real, such an effect would add a new dimension to our view of alcohol-related carcinogenesis, since potential benefits should also be taken into account together with the risks entailed by the habit when considering the overall effect of alcohol drinking on health. Besides its effect on cancer risk, alcohol drinking increases the risk of various types of injuries, and its use during pregnancy has a detrimental effect on the development of the fetus and its CNS, often resulting in malformations, behavioural disorders, and cognitive deficits in the postnatal period.7 On the other hand, there is strong evidence for a J-shaped pattern of risk of total mortality and cardiovascular disease
See Articles page 469 for results of a pooled analysis of the effect of alcohol consumption on risk of non-Hodgkin lymphoma
443