My skeptical comrades down under have been kicking A and taking names. They demonstrate that skeptical activism can have concrete positive effects. Most recently they issued a complaint to the Therapeutic Goods Administration (the Australian equivalent of the FDA) about the claims being made on two homeopathy websites (“Homeopathy Plus!” and “www.d-n-h.org”). Specifically the cites claimed that homeopathic immunization (there is no such thing) was as effective as real immunization for the prevention of infectious diseases. They report:

Dr Ken Harvey, a lecturer at Latrobe University School of Public Health, who authored the complaint, objected to claims on the website that “homeopathic immunisation is effective against poliomyelitis, chicken pox, meningococcal disease, hepatitis (all types), Japanese encephalitis, HiB, influenza, measles, pnuemococcal disease, smallpox, typhoid, cholera, typhus whooping cough, rubella, mumps, diptheria, malaria, tetanus, yellow fever, dysentery and many other epidemic diseases”.

To support these claims the research of Isaac Golden was referenced, but the study referenced was in fact negative – without statistically significant results.

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The complementary and alternative (CAM) or integrative medicine phenomenon that has arisen over the last couple of decades primarily involves the creation of a separate subculture within medicine. The primary defining characteristic of the CAM subculture is a lack of dedication to a culture of science-based practice.

The strength of mainstream medicine, which should strive for the ideals of science-based medicine, is that it mostly does. There is a culture of ultimate respect for the scientific evidence. The application, of course, is imperfect – but the ideal is there. If you bring enough high quality evidence to bear, you can change the standard of care, how everyone else is practicing medicine.

Like freedom and democracy, science-based medicine is messy in all the ways that human cultures are messy, and it requires vigilance and constant self-examination. Right now the systems of quality control and self-correction within medicine are straining to keep up with the rapid advances in medical knowledge and technology. We are, in some ways, victims of our own success. The evidence-based medicine (EBM) movement is primarily about codifying strategies for keeping up with the exploding evidence.

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A skeptical theme that crops up very frequently is the fact that there is a huge disconnect between popular beliefs and the findings of science. There is a tendency for people to overestimate their own knowledge even when they have no basis for their confidence (even skeptics – we all do this). Often this amounts to just making up answers because they feel right and then assuming they are correct. We all do this – believers and skeptics alike. This is the default mode of human thinking. It takes discipline to insert the critical thinking filter – “is this really true? what does the evidence actually say?”

The specific topic at hand is attitudes toward so-called complementary and alternative medicine (CAM) – how popular is it, and what is the basis for its popularity? I have dealt before with the former question. Here’s the summary: most surveys that site huge numbers of people using CAM are grossly inflating the numbers by including things such as exercise, prayer, or taking a multivitamin. I exercise, so by some measures I am a CAM user. This, of course, reflects the confusion caused by the dubious category of CAM itself – it is a pseudo-category, containing a wide variety of modalities, some mutually exclusive, with very fuzzy boundaries.

It is more meaningful to consider individual claims and practices, and to use somewhat tighter categories (such as energy-medicine). If we consider the “hard-core” CAM practices – like homeopathy, acupuncture, and energy medicine – we find that their use is still in the tiny minority – single digits. And these numbers are not significantly changing over time. The popularity of CAM is overblown.

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So-called complementary and alternative medicine (CAM) – or what I think is best characterized as non-science-based medicine, is a common subject for the lay press. It’s counter-cultural, controversial, and can easily incorporate elements of fear and self-empowerment – all themes the media loves.

Articles on CAM often contain the same “facts”, whether quoted from some perceived expert or just asserted by the author, that in fact are wrong or grossly misleading. In an interview with the SGU, Christopher Hitchens commented that lazy journalists simply tell the story that is being told and then they build the “facts” around that story – rather than investigating to determine what the story actually is. This is very true in the world of CAM reporting.

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After a decade of research, and 2.5 billion dollars of taxpayer money, government funded research into so-called “alternative” medicine has little to show for it. The AP has put out a fairly insightful review of this research, which echos many of the points I have been making over the years.

They report:

Echinacea for colds. Ginkgo biloba for memory. Glucosamine and chondroitin for arthritis. Black cohosh for menopausal hot flashes. Saw palmetto for prostate problems. Shark cartilage for cancer. All proved no better than dummy pills in big studies funded by the National Center for Complementary and Alternative Medicine. The lone exception: ginger capsules may help chemotherapy nausea.

As for therapies, acupuncture has been shown to help certain conditions, and yoga, massage, meditation and other relaxation methods may relieve symptoms like pain, anxiety and fatigue.

And to reinforce that point:

(Dr. Josephine Briggs) conceded there were no big wins from its first decade, other than a study that found acupuncture helped knee arthritis. That finding was called into question when a later, larger study found that sham treatment worked just as well.

Dr. Briggs is the current director of the National Center for Complementary and Alternative Medicine (NCCAM) – the NIH center that funds this research.

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The National Institute for Health and Clinical Excellence (NICE) is an independent UK organization that provides advice on which treatments and medical practices are likely to promote health. In other words, they comment on what they think is or should be the standard of care. This is a very important function, and the NICE is generally taken seriously.

That is why it was very disturbing to find that in their latest guidelines for low back pain they include recommendations for both spinal manipulation (wihout explicity naming chiropractic) and acupuncture.

The spinal manipulation recommendation is at least semi-reasonable, in that there is some evidence for modest benefit for spinal manipulation for acute uncomplicated low back pain. However there are still problems that derive from the bait and switch tactic employed by many practitioners of spinal manipulation.

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I am covering the in-patient service this month and so I am more busy than usual. I am trying to keep my blogging schedule without change, but it’s challenging, so forgive me if I occasionally miss a post or I am late.

For that reason, for my post today I am simply going to respond to a comment on my recent post on acupuncture and migraines. In response to this, frequent commenter, Sonic, wrote:

The conclusion that acupuncture does not work does not coincide with the evidence presented.

From the 2009 Cocrane review:

“Four trials compared acupuncture to proven prophylactic drug treatment. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment.”

This implies that acupuncture is a safe and effective treatment compared to the “proven” prophylactic drug treatment.

A drug company could go to the FDA with a study that showed their treatment to be better than the existing proven treatment and get approval based on that fact.

The conclusion that it is possible that the exact placement of the needles may not be as important as thought, does not invalidate the therapy.

Just because there might be a mistake in exactly how something works does not invalidate that it does work. The studies quoted would indicate that acupuncture works as well as or better than any other current therapy.

There is nothing in the evidence to indicate that the therapy did not work better than any existing therapy and better than doing nothing.

The fact that something works better than the proven therapy means that it works.

To conclude otherwise is to misread the evidence as presented.

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It must be tough being a highly visible politician – specifically taking questions from the public. You can get hit with highly technical questions in any area, often posed by someone with a narrow agenda and a great deal of information with which they can plan rhetorical mines. I don’t expect politicians to have all the technical details for any such issue at their fingertips. Experienced politicians, however, have learned how to handle such situations – the first rule of which is not to pull facts out of your butt.

George Bush’s most famous such gaffe, in my opinion, is when he said that the “jury is still out” on the question of evolution. Right – only greater than 98% of all scientists agree that evolution is a scientific fact, but we’re still waiting on the other 1% or so of hold outs.

Obama is not likely to get tripped up on the evolution issue, but he is vulnerable when it comes to science and medicine. Unscientific medical modalities and practitioners have found allies on both sides of the political aisle. The impending health care reform has also mobilized the CAM (complementary and alternative medicine) troops who are trying to twist the health care agenda to serve pseudoscience.

At a recent town meeting Obama received the following question and gave the following answer:

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Those who advocate for strict scientific standards in medicine are often asked, “what’s the harm” of someone pursuing unconventional medicine? If people want to engage in a little hope, even if it’s a false hope, it might make them feel better and it won’t cause any harm.

Often the questioner assumes that the unscientific remedies are themselves harmless. This is not always a reasonable assumption. Some unscientific treatments are directly harmful, or carry a non-trivial risk. But that is not the limit to the harm that can be caused by pursuing such remedies.

For me the biggest harm of unscientific medicine is that it fosters a distruct of science-based medicine and practitioners and faith in bizarre notions of health and illness and in treatments that do not work. Someone who feels that acupuncture helpe their back pain may then rely upon it when they get cancer.

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The Cochrane Collaboration, an organization dedicated to evidence-based medicine, has published a review of studies of homeopathic treatments for side effects of radiation therapy and chemotherapy for cancer.  The results are unimpressive – consistent with the null-hypothesis that homeopathic remedies have no effect. And yet the review is being distorted to promote a very misleading bottom-line to the press – that homeopathic remedies have a role to play in cancer therapy.

One point has been made clear – the treatments under study are not for cancer itself, but for the side effects of standard cancer therapies: radiation and chemotherapy. However, the results are being presented as if they support the efficacy of homeopathic remedies, when they do not.

Homeopathy

Some quick background on homeopathy: This is a pre-scientific philosophy of medicine invented by Samuel Hahnemann around 1792. The principles of homeopathy are akin to sympathetic magical rituals. They include the notion that like cures like, or that a small amount of a substance that causes a symptom can be used to cure it. However, he then combined this principle with his “law of infinitessimals” which states that substances will become more potent as they are diluted, even if they are diluted beyond there point where any active ingredient remains. And finally he came up with the notion of succussion – that homeopathic remedies are given their power by shaking them 10 times in each spacial plane.

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