Saturday, 30 January 2010

Trick or Treatment?

You know what they call alternative medicine that's been proved to work?
- Tim Minchin, "Storm"

Which rather encapsulates my problem with so-called complementary and alternative medicine. It is, at least in principle, not that hard to test whether a given medical treatment works or not, and anything that falls into the "alternative" camp has generally either not been tested at all, or if it has, has tended to fail the test. My view is that, if you're going to make medical claims you really ought to be able to back them up. And that's really the bottom line.

For instance, I see no particular reason why herbal medicines, for instance, shouldn't work. But they really ought to be tested to check exactly what they do (and what side effects they have, if any) and should only be sold and advertised based on what the evidence actually says. As a professional healthcare worker, this is something I do regard as important. Because the danger is that someone might take an inert treatment for a serious condition, and delay real treatment that might genuinely help them. There should be no double standards. (And that, incidentally goes for any malfeasance that the regular pharmaceutical companies might engage in).

So, anyway, I was obviously going to be interested in the latest event to be held by CFI London at Conway Hall. The "Trick or Treatment?" was a series of three talks on the subject of alternative medicine, and was well up the usual standard.

As it so happened, this was the same day selected by the 10:23 campaign to conduct a mass overdose to protest the selling of homoeopathic remedies by Boots the Chemist as if they were real remedies. Boots have been singled out here because, on 25th November 2009, Paul Bennett, the Professional Standards Director of the company testified before the House of Commons Science and Technology Committee that he did not personally believe homoeopathy worked, but that he was happy to sell it if people wanted to buy it. This strikes me as a pretty irresponsible attitude.

The overdosing had nothing to do with the event at Conway Hall, although some of the campaigners were outside. [Video of short discussion here]. But it does illustrate where this sort of thing can be useful. It's not going to convince the homoeopaths to change their mind, or anything like that. Nor any of their customers who have already made an informed decision (albeit, in my view, an erroneous one). But one has to wonder how many users know what homoeopathy really is. Do they, perhaps, think, that a homoeopathic preparation labelled, say, "Belladonna", actually contains any... well, Belladonna? Once they realise that, in all but the "weaker" preparations, it actually doesn't, then they might be in a better position to make that informed choice. And then it's up to them.

Anyway, the actual event opened with Simon Singh talking about acupuncture, chiropractice, and, of course, libel law. Acupuncture, as I probably don't need to explain, is the hypothesis that the human body contains channels, or "meridians" of magical energy called "Chi", and that by altering this flow by inserting needles into specific points along the meridians, it is possible to alleviate pain, and maybe also cure disease.

It's interesting to note, as a later speaker did, that this method may not be quite as ancient as commonly thought. Earlier references to the method apparently actually refer to cutting into patients with flint knives, which isn't quite what we think of today. Although, in fairness, the underlying concept is much the same. Some forms of acupuncture are even more modern. "Auricular acupuncture" only dates from the 1950s, when it was realised that the human ear looks quite like a foetus - and that it therefore obviously followed that, if you stuck needles in the parts of the ear that corresponded to where the meridian points would be if it were a whole body, the therapeutic effects should be the same.

Uh huh.

That aside, it has to be said that an interesting problem arises when we look at testing acupuncture to see how effective it is. To rule out the possibility of a placebo effect, with any proposed treatment it's important to test two groups of patients: one actually receiving the treatment, and another who think they are, but actually aren't. That's easy enough with a pill, but most people can tell if you've stuck a needle into them or not.

The problem isn't completely intractable however. The meridian lines are supposed to be quite deep, so you could just make a very shallow puncture, and see if that makes a difference. Or you could use fake needles, rather like stage daggers, that appear to stick into you, but, in fact, just retract. Or you could just put the needles in the wrong place - if acupuncture theory says they should go into the hand, put them into the feet, for instance. (Obviously this last one doesn't work if the patient knows enough about acupuncture to realise what you're up to).

And, guess what - when you do these sorts of studies, the "fake" treatments work pretty much as well as the real acupuncture. Which isn't to say that they don't work at all, just that acupuncture appears to be a fairly effective way of harnessing the placebo effect, and that all the stuff about Qi and meridians has no bearing on that.

Chiropractice was originally based on the theory that the body maintains its health by channelling vital energy through the spinal nerves. Virtually all disease, claimed its founder, Daniel David Palmer, was due to misalignments, or "subluxations" of the spine, blocking the passage of this vital energy to the relevant body parts. Now, not all chiropractors today necessarily believe that, but some it seems, still do, and claim that manipulating the spine can cure, for example, ear infections. One would have thought there was quite enough money in curing just back pain, but there you go.

In fact, it's probably worth mentioning that, regardless of what it might do for ear infections and the like, there does seem to be some reasonable evidence that chiropractice can help to relieve back pain. Perhaps surprisingly, it's not terribly good at doing even this - but in fairness, neither is anything else (such as, say, mainstream physiotherapy). In this particular respect, I'm not aware of any clear evidence that it's any different from the various alternatives, and at least some of the time, it does seem to work.

This brings me back to the point I made earlier about informed knowledge. Many people, it seems, are unaware that chiropractors aren't MDs, and that, at least when it comes to conditions other than back pain, there really isn't an awful lot of evidence that the technique works.

Given that my verbosity has once again got the better of me, I'll move onto the other two speakers at a later time.

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