Open University - perspectives on complementary and alternative medicine (k221)

Introduction:

At the time of writing it is the end of September 2009 and I have just completed the Open University (OU) faculty of health and social care course number K221 "Perspectives on Complementary and Alternative Medicine (CAM)" (Open University, 2009a). It is a 10 month long course and I have greatly enjoyed the experience although it wasn't quite what I was expecting for a number of reasons.

For those not familiar with the OU it is a well respected, UK establishment started in the 1960's which facilitates university level study at home by means of good quality, structured course materials using communications technology, originally television and the postal service but nowadays computer based (Open University, 2009b). By studying written material, supported by the internet, email, audio-visual aids, interractive forums, a locally based tutor and the occasional face to face tutorial or Summer school students can study a number of modules which can be put together to count for a degree such as batchelor of arts or science. Alternatively anyone can pick a single module and study it for pure interest as I have done in this case. It is a British institution and we're very proud of it!

The course is very well structured, based around a number of texts. The 'Learning Guide' breaks the course down into twenty manageable sections, each one of which should take about a week to complete. The learning guide takes students through the two core texts; book one is entitled "Perspectives on Complementary and Alternative Medicine" and book two is "Complementary and Alternative Medicine: Structures and Safeguards". The books' editors are Geraldine Lee-Treweek, Tom Heller, Hilary MacQueen, Julie Stone, Jeanne Katz, and Sue Spurr. There are also contributions from Mike Saks, Lorraine Williams, Phil Nicholls, Sheena Murdoch, Andrew Vikers, Dick Heller, Gavin Yamey, Elaine Weatherley-Jones and Dione Hills. The learning guide, both core texts and a set of five CD-roms containing audio and video clips are provided as part of the course fee but it is necessary to buy "Perspectives on Complementary and Alternative Medicine: A Reader" separately. This 'reader' is a collection of short essays on CAM from a variety of authors which the learning guide directs the student to at various points. Both core texts and the learning guide are also available to students for download as pdf files which makes searching for information in them much easier.

As the course progresses the student has to submit 4 tutor marked assessments (TMA's) of 1,500 words and a final end of course assessment (ECA) of 3,000 words. It is these that the student is assessed on. One of the challenges for me in doing the course was being obliged to look at CAM from a different perspective from the one I am used to, social, ethical, regulatory and so forth rather than from a purely scientific perspective. The essay titles required me to try to see things from the point of view of CAM proponents as well as my own, sceptical perspective. So, while this was an interesting discipline, it was also infuriating at times when I felt I was being constrained from making certain points because of the need to stick to fairly narrow topics. Hence, having finished my coursework, I am writing this essay, as a slightly indulgent personal critique of the course from a balanced but sceptical perspective - it is something I need to "get off my chest"!

Development:

My first surprise was that the 'Perpecives' the course title referred to were actually mainly social, regulatory and ethical perspectives. There was a small section on evidence towards the end of the course which was mainly delivered from a CAM point of view and wasn't included in any of the course assessments, so students were never challenged to think critically about it or to develop the ideas in that section. Right from the opening chapters, the major impression was of "putting the cart before the horse", i.e. considering all the mechanics of CAM provision and integration without actually ever asking whether it is effective or not. As someone who is used to verifying the effectiveness of all sorts of veterinary interventions on a daily basis this was a cause of considerable frustration to me.

The tone for the whole course is set right from the first chapter of the first book where the impression is given that CAM is like an empowering, comforting bubble bath waiting to envelop users and bring health and well being to all, if only it was given the chance. The very first paragraph states that CAM is just one of many "sets of knowledge and ideas about the world" offering a "vast array of choices in dealing with health and wellbeing"; no mention is made of the relative validity of these choices. The reader is invited to "consider CAM in a critical way" but also to "see what it can offer to society". CAM is presented enthusiastically as "a fascinating and fast changing area of social life", the only concession to the controversy behind the subject being the statement that the issue of what CAM is "can be considered contentious and open to debate". So, from the outset CAM is presented in a positive light, as equivalent to other types of healthcare and the only debate is to be about what is meant by CAM, not its effectiveness.

There follows a largely uncritical account of how CAM is defined - natural, traditional, "holistic", energy based which then moves on to an account of CAM in modern, consumerist society with consumer choice and medical pluralism, self expression and empowerment all presented as reasons for the popularity of CAM. This "pick and mix" version of healthcare is illustrated, bizarrely, by food and restaurant metaphors, as if scienced based medicine was just another lifestyle-menu choice to be selected or rejected depending on the tastes of the diner. The admirable idea that patients should be included in medical decisions which concern them is extrapolated to the point where patients should have the right to choose whatever type of healthcare they wish in a 'healthcare market', regardless of the fact that it is later recognised that CAM ethics and provision are chaotic with public safeguards, outside criminal law, being very limited.

Such criticisms as there are are presented non-judgementally, often in the form of questions for the reader to consider - does "traditional" mean safe or effective; safety and efficacy must be "borne in mind" for instance, although it is acknowledged that the subject of CAM is contentious. The only section where there is any hint of real criticism is the section covering so called "new health experts" where the author is critical about the claims of people who set themselves up as experts in the "new health" and points out that they inevitably have something to sell by doing so. This criticism however is presented against the background of the "healthcare market" generally, which provides choice and is portrayed as a good thing.

Later, various models of healthcare are discussed briefly starting with the "Biomedical model" at one end which allegedly represents orthodox medicine. This section is opened with a photograph of a group of doctors having a discussion among themselves at the bottom of a patient's hospital bed which is supposed to illustrate how orthodox medicine leaves patients isolated. The term biomedical is often used synonymously with science based medicine in the course material so it is worth exploring how this model is portrayed by the authors. Using quotes from references it is reported that "Biomedicine (which is also known as allopathy, conventional medicine or modern western scientific medicine) is relatively new, unlike some ancient healing systems which have been practised for several thousand years", it has "contributed to a narrowing of medical vision – to the reductionism, mind–body dualism and objectification of body so characteristic today of the disease perspective". The main function of the biomedical provider (that's "doctor" to you and me) is to "get people back to productive labour". Then, as if it is a minor consideration compared with its many offences against post-modernist equivalency, it is mentioned that "Biomedicine provides effective treatment for many serious illnesses – for example, bypass surgery for heart conditions – which in the past may have resulted in death or long-term disability".

Several other healthcare models are discussed ranging from prescriptive, paternalistic models where the domineering physician decides what the patient needs (that's conventional medicine again, inevitably) to the touchy-feely, caring, holistic or alternative model (no prizes for guessing where CAM practitioners fit on this spectrum). This last model is described in woolly terms such as "CAM therapists explore and treat underlying causes, not merely control symptoms" and in CAM "Self-healing is paramount, working with, not against, symptoms". Well, one of the "big five" group of CAM practices is homeopathy and its core texts are almost entirely given over to great lists of symptoms which must be addressed by the correct "similmum". This methodology is entirely directed towards the symptoms of disease, any "underlying causes" from the homeopaths' point of view being largely fictitious, consisting of "imbalances", "obstructions to cure" and miasmas (a concept which has been outdated since the 1700's).

The statement that "self healing is paramount" is so obvious as to be almost unworthy of further consideration - no health system, including science based medicine could function without "self-healing", yet CAM practitioners feel they have a monopoly on it. Working "with" symptoms is a meaningless platitude (how can you "work with" spots for instance?) derived from the homeopathic term for orthodox medicine practiced two centuries ago which included purging and blood-letting in an attempt to counterract symptoms such as a flushed skin (which was believed to indicate excessive amounts of blood). This so called "allopathic" medicine was supposed to work against symptoms but now, two centuries later, rational medicine does what it takes to treat disease - correcting deficiencies, repairing damaged tissue, helping the body fight disease causing organisms and so forth. There is no single dogma which can describe science based medicine yet CAM critics fail to recognise this in their desire for easy targets with which to promote their own beliefs.

Early in the course we are introduced to the "Political and historical perspectives" of CAM. This section was one I found particularly interesting but even more frustrating as this section was mainly a list of excuses about why CAM wasn't in the mainstream. Everything, including political, financial and professional prejudices, vested interests and racial and sexual discrimination was, we are told, responsible for keeping CAM on the margins of healthcare - everything but the possibility that it simply didn't work. The main difference between CAM and orthodox medicine, states author Mike Saks, "lies in its legitimation by the state".

This was one of the least balanced section of the course with the authors apparently convinced that the attitudes which prevailed at the inception of the Medical Registration Act of 1858 when, arguably, CAM first came into existence still remain today. In 1858, it is claimed, the medical establishment (physicians, surgeons and apothecaries) managed to use political and financial clout to get its foot in the door of state orthodoxy at the expense of equally deserving disciplines such as herbalists and homeopaths and that's pretty much how things remain today. The fact that orthodox medicine has, in the last 150 years, managed to rid itself of practices which were then regarded as mainstream such as bleeding, purging and treatment with heavy metals and managed to include new, initially unpopular disciplines such as antisepsis, vaccination, psychiatry, midwifery and palliative care to name but a few isn't even mentioned.

The rather large "elephant in the room" is that medicine incorporates things that have proven themselves effective, even things for which it is difficult or impossible to conduct scientific trials on. The reason that, say, palliative care is now accepted by mainstream practitioners whereas homeopathy isn't when both were treated with suspicion to start with is that palliative care (after 40 years) now has a proven track record whereas homeopathy (after 250 years) doesn't.

Regarding political power and influence homeopathy in particular has always had the backing of significant influential figures. At the time of the 1858 act homeopathy was the darling of the aristocracy at a period in British history when aristocratic and Royal patronage were a major influence in politics. The chief advocate of homeopathy in Britain at that time was Dr F. Quin, the physician of Prince Leopold of Saxe-Coburg, a close relative of the British Royal family and himself a possible illegitimate son of Lady Elizabeth Cavendish, the Duchess of Devonshire and Sir Valentine Richard Quin, 1st Earl of Dunraven whose families ranked among the five richest in the country. In those days members of aristocratic families made up the majority of parliament and further supporters of homeopathy with the power to influence legislation included William Cowper, president of the General Board of Health & sponsor of the 1858 act (Roberts, 2009), Lord Ebury (formerly Lord Grosvenor), Lord Elcho and the Dukes of Edinburgh and Beaufort. Dr Quin was also one of the regular dining partners of Edward, Prince of Wales, son of the reigning Queen Victoria and future King (Classic Encyclopaedia, 1911; Morrell, 2008; Winston, 2009).

Such aritsocratic and political influence has continued right up to the present day with homeopathy being used by royalty up to and including the present Queen Elizabeth, her son and heir Prince Charles and his late wife Princess Diana. Former Prime Minister Tony Blair and his wife Cherie were advocates of all things alternative during Mr Blair's period of office (Scott, 2008).

So homeopathy at least, has political influence in spades yet it is still not mainstream. The conclusion must be therefore that patronage makes no long term difference to what is or is not mainstream medicine; science, on the other hand, does.

Integration is the new buzz word in CAM, some sceptics would say integration was just CAM reinventing itself as it has done so often in order to present a more acceptible face (Ernst, 2009). There is however a schizophrenic atttiude to integration among CAM practitioners, many of whom are determined to remain firmly rooted in a fundamental "otherness" - "for some groups of CAM practitioners, the growth of 'integrative medicine' represents an undermining of counter-cultural values" we are told in the introduction to book one. Clearly for some CAM practitioners philosophy is more important than the practicalities. On the other hand many CAM practitioners are keen to work with mainstream medicine, particularly the state sector, and benefit from the enhanced credibility and financial stability such a move would confer. It seems to me entirely reasonable that if CAM seeks the benefits of state patronage it should submit to the same levels of scrutiny that conventional medicine does.

Despite a desire to cling to "counter-cultural values" rather than simply demonstrating effectiveness there are still complaints that CAM is marginalised and ignored (it can be reasonably argued that the definition of CAM is one of exclusion - albeit for good reason). So it comes as a surprise, when conventional medicine appears to be adopting a more inclusive attitude to new approaches, it is crtiticised for trying to 'colonise' new territories; pharmaceutical companies moving into CAM areas are accused of simply wanting to exploit new markets. So while CAM complains about being ignored any attempts at integration by conventional medicine are derided as 'colonisation' or 'exploitation' - damned if you do and damned if you don't!

In the course material there are complaints that integration would still leave doctors in control and deprive CAM of its unique perspective yet later it is acknowledged that the ethics of CAM are rudimentary, CAM provision is variable and fragmented and training is often inadequate. The thought of a Reiki practitioner practicing part-time to earn a bit of extra cash having control of serious medical decisions is horrifying yet that is what the idea of the 'new-expert' suggests - all "expertise" is equal, no matter whether that expertise has solid foundations or fictitious ones.

Later in the course there are several chapters which go into considerable detail about how CAM is used in specific areas, namely mental health and palliative care for cancer patients. There are genuinely moving accounts from patients with serious health problems in praise of centres and individuals offering CAM which provides great comfort, companionship and reassurance for conditions which are difficult to discuss with friends and family. The problem is however that the types of CAM in the case studies are being used purely as ways of providing comfort to the patients and, beneficial as it is, there is no alternative system involved. Reflexology and aromatherapy are presented simply as types of massage, no mention is made of the alternative claims of both these practices. Bowen therapy and Reiki, despite talk of "energy" flowing in various directions, seem to be mainly a way of the patients getting a little relaxation and time out - no attempt is made to explore the claims of either therapy in treating specific diseases. We are, yet again, being shown a sanitised, whitewashed version of CAM, completely glossing over its many nonsensical claims and its tendency to denigrate real medicine.

The theme of CAM providing comfort is developed as CAM as a "holistic" therapy is discussed, particularly in the section on the therapeutic relationship. There are claims that CAM exploits the placebo effect, promotes self healing by working with the patient and that real medicine should "look at the broader context" rather than simply concern itself with facts and figures. Scientific research in particular comes in for criticism, concerned as it is with data collection and end points. We are told that controlled trials are not appropriate to study CAM as they are specifically designed to correct for variables such as bedside manner, physicial empathy and the placebo effect in order to study the specific effects of the treatment under study. If a study fails to show that acupuncture is effective for the treatment of, say asthma then trial designers should disregard their original end points and look for other aspects which have improved such as enhanced well being perhaps, or patients getting on better with their families after the trial. This technique is known as "data dredging" and is recognised as bad practice, as researchers cherry pick results to try to obtain the outcomes they want rather than analysing the evidence they have. It is typical of the way that CAM proponents insist on double standards in research. The authors even quote Edzard Ernst out of context and make it sound as if he is in favour of a different standard of research for CAM compared with everything else; a simple email confirmed that this view is the diametric opposite to the one he actually holds.

Finally, just a quick word about factual errors and unsubstantiated claims. The OU makes great efforts to correctly reference claims throughout the course work and students are rightly required to reference correctly in submitted work. So, when claims are made in the course books which are not referenced it has to be asked "why not?". For instance early on, among a lengthy complaint about some of the more negative terms used to describe CAM, we are told, "...CAM can be used as a treatment for serious conditions (for example homoeopathy to treat acute asthma or acute infection, and acupuncture to treat addiction and help recovery from stroke)". This statement is not backed with references but simply presented as a fact; there is no hint of the massive controversy underlying these bold, and erroneous, claims. In book two, the chapter on homeopathy, after stating that scientific knowledge is a mere social construct fabricated by a conspiracy of scientists, moves on to give a highly biassed account of the infamous "memory of water" experiments of Jacques Benveniste. The follow-up investigation by a team from the Nature journal is portrayed as a personal attack on Benveniste himself and an attempt to suggest that his team used "trickery" to obtain their results rather than what it actually was, namely a straightforward replication of the original experiment using more stringent controls and involving people who didn't have a vested interest in the results.

Later, in the same chapter, there is an account of the BBC Horizon programme's investigation of the memory of water (BBC, 2009) which is simply factually wrong. The OU author states that in the investigation homeopathic remedies and placebos were given to participants suffering illness and the results analysed. In fact the test was another replication of the Benveniste experiment done with stringent blinding and controls (unlike the original work) and, what's more was entirely 'in-vitro', involving no human subjects at any stage. Yet this catalogue of errors is used as a justification for the belief that science and scientists are inherently prejudiced against CAM.

Conclusion:

One of the first exercises in the K221 course required the student to think of a few words which, to them, best described CAM. My words were; wellmeaning, misguided, institutionally delusional and non-scientific. Having now finished the course I can find no reason to change any of them really. I have to give CAM practitioners the benefit of the doubt and assume that most are well meaning and do what they do in an effort to help their patients. Many such practitioners have limited scientific training however so, to them, if a patient says they feel better then that is all the evidence they need. On the other hand many CAM proponents are qualified doctors, veterinary surgeons and scientists who know very well the importance of scientific rigour and how meaningless the phrase "it got better so it works" is. This group knows about the lack of rigorous evidence behind much of CAM, it knows that CAM practitioners are given to denigrating real medicine and turning patients away from treatments which could really help and it knows all the reasons why many medical conditions appear to improve following an inneffective treatment and, furthermore, why some relapse fatally later if left untreated. It is this group - people who should know better, that I have trouble with. As long as people with a scientific grounding, such as the K221 authors continue to perpetuate the myth that there is "something out there", magical forces we cannot detect but at the same time are able to manipulate, and continue to promote populist, consumer driven medicine then others will follow.

I have to agree with David Colquhoun (2007) that a reader who knew little about CAM coming to this course would risk coming away with the false impression that CAM was a fully functional, effective health care system that was deeper, broader and more patient centred than OM and the only reason it isn't mainstream today is because of establishment bias. This impression is conveyed by first failing to address the real controversies around CAM, namely lack of effectiveness, excessive claims and the denigration of real medicine and second, by insisting on a spurious 'balance' throughout the texts; treating CAM as if it were the equal of science based medicine; discussing 'Chi' or the 'vital force' as if they were as real as the blood stream or lymphatic system.

This account is my own, it is inevitably subjective and imperfect; everyone will get different things from this course. I took some comfort from a couple of fellow students who were relatively pro-CAM prior to starting but, by the end, were much more questioning of it. One student found the material biased and patronising, much as I did; another said that after completing the course she wouldn't trust CAM to treat any serious conditions. My tutour on the other hand, a very pleasant acupuncturist who did a first class job of staying calm in the face of my scepticism, felt the course material was strongly biased against CAM. So there is a lot to this course, it is deeply flawed in the ways mentioned above (and others time hasn't permitted me to mention) but it has got me thinking, and that is always a good thing. It has 'demystified' certain aspects of CAM for me and helped put a personal face on it by meeting fellow students. It has helped me understand some of the real benefits some patients derive from CAM and has cast a light on the faulty reasoning and perspectives of many of those who claim to be experts in the subject. So, all in all, I am glad I have done the course, for all its imperfections I have learned a lot and seen things from other points of view. On balance I would recommend it to anyone with an interest in the subject but make sure your critical skills are turned to high!

References:

BBC (2009) Homeopathy: The Test - transcript, Horizon - Science and Nature [online transcript] http://www.bbc.co.uk/science/horizon/2002/homeopathytrans.shtml [accessed 21/10/09]

Classic Encyclopaedia (1911), [online] http://www.1911encyclopedia.org/Homoeopathy [accessed 20/10/09]

Colquhoun, D., (2007) The Open University now teaches quackery, [online] http://www.dcscience.net/improbable.html#ou1 [accessed 20/10/09]

Ernst, E., (2009) 'A shabby smokescreen for unproven treatments' , BBC News online http://news.bbc.co.uk/1/hi/health/7960689.stm [accessed 21/10/09]

Morrell, P., (2008), A History of Homeopathy in Britain, HomeopathyHome.com [online] http://www.homeopathyhome.com/reference/articles/ukhomhistory.shtml [accessed 20/10/09]

Open University (2009a), Perspectives on complementary and alternative medicine [online] http://www3.open.ac.uk/study/undergraduate/course/k221.htm [accessed 20/10/09]

Open Universtiy (2009b), About the OU: History of the OU [online] http://www.open.ac.uk/about/ou/p3.shtml [accessed 20/10/09]

Roberts, M J D., (2009) The Politics of Professionalization: MPs, Medical Men, and the 1858 Medical Act, Med Hist. 2009 January; 53(1): 37–56 www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2629176 [accessed 19/3/09]

Winston, J., (2009), Homeopathy in England, Whole Health Now [online] http://www.wholehealthnow.com/homeopathy_pro/england.html [accessed 20/10/09]

Scott, P., (2008) Revenge, money... what's really driving Cherie Blair, Mail Online [online] http://www.dailymail.co.uk/news/article-565822/Revenge-money--whats-really-driving-Cherie-Blair.html [accessed 20/10/09]

Notes on the course books:
Throughout the essay I have referred extensively to the course books for K221. These books can be seen at Amazon by clicking these links - Book one: Perspectives on Complementary and Alternative Medicine; book two: Complementary and Alternative Medicine: Structures and Safeguards; and Perspectives on Complementary and Alternative Medicine: A Reader. The first and second books are also available in preview form from Google books.

Review of "Alternative Medicine? A History", by Roberta Bivins

I have to say, despite the promise of its title, this book was a disappointing read. Although the first chapter harks back as far as the 17th century and there is a nod to 20th century in the closing chapter the bulk of this work is an account of the challenges to the Western medicine of the 18th and 19th centuries from medical systems introduced from other parts of the world. The alternative medical systems addressed are mainly moxibustion and acupuncture but also include Traditional Chinese Medicine, Ayurveda, Unani Tibb, mesmerism and homeopathy (Europe's 'home grown' alternative medicine).

The history covered in the work is worthwhile, if limited. It is interesting to learn for example about the introduction of acupuncture into Europe and the reaction of the medical establishment to it in the 1700's or even earlier and how, as a practice it was confused by western doctors with a method of bleeding and so condemned as ineffective; similarly moxibustion was confused with cautery. It is interesting to hear that moxibustion as a treatment for the ubiquitous gout of the 18th century was highly praised in certain circles, not least because it avoided the brutal, painful and occasionally life threatening medical practices then current.

Following this however, no attempt is made to bring the subject up to date and discuss how scientific advances have allowed modern medicine to emerge from and leave behind earlier "mainstream" practices including bleeding, cupping, scarification, puking and purging which by and large made no more rational sense than the alternative practices under discussion. Instead, the author choses to portray the current medical establishment as if it were still of the dogmatic mind set of its predeccessors of 200 years ago. This approach provides a false, straw man, construct which will give encouragement and ammunition to those who currently practice and promote non-scientific medicine but has no basis in reality.

So, this book appears to be yet another work by an author versed in social sciences to conflate 19th century so called "heroic" medicine with modern science based medicine and, with a postmodern bent, present any and all alternative systems of medicine as simply "other ways of knowing" and allegedly equally as valid and effective as science based medicine. Very early in the work the tone becomes increasingly partisan and, turning against scienctific medicine, borders on the polemic at times with claims that orthodox medicine was "forged in the furnace of fear and loathing of homeopathy", Ether was promoted to combat Mesmerism and that anatomical study is a way of excluding women and non whites from "the franchise" (none of these claims are referenced so the reader is left guessing about their veracity).

Scientific medicine (or "biomedicine") is dismissed, without supporting evidence as impersonal and driven by the needs of the laboratory and technology and the "medical-industrial complex". Modern doctors are accused of being concerned only with dispassionate observation and measurement and of ignoring patient self reporting. The author is apparently unaware of the enormous part played in the conventional therapeutic relationship by history taking and has perhaps forgotten how often a doctor will open a consultation with the words, "how do you feel?".

From the outset, as the reader is told of the author's childhood, growing up alternately in various isolated African communities and urban New England, to the closing sentence when people are urged to see other cultures first hand and "judge for themselves if qi or prana are more or less credible, comprehensible, and intellectually attractive than neurotransmitters or the Krebbs cycle" this book is characterised by an apparent lack of understanding of science and of the importance of simply being able to decide whether a medical procedure works or not, something science alone, not tradition, not intuitive "ways of knowing", can tell us. Neurotransmitters and the Krebs cycle exist, whether Western intellects find them attractive or not is simply missing the point.

Dem bones! - The pseudoscience of “raw feeding”

The subject which has been exercising my ‘little grey cells’ of late is the raw feeding of pets. Now you might think (as I did a few months ago before getting embroiled in an especially acrimonious debate with raw food proponents) that feeding dogs and cats ought to be fairly straight forward - go to shop, buy bag/tin of food, feed to pet - job done, easy.

Like most vets and animal lovers I was aware that some people preferred to feed their pets non-commercially produced diets. I had heard of groups such as “Bones And Raw Food” (BARF for short) and “Raw Meaty Bones” (RMB) to name but two and I thought, basically live and let live really, so long as the animal appears happy. I had some concerns about bones doing damage to the gut, or food poisoning from raw meat possibly but I had no idea of the actual level of risk.

For some people however that’s simply not good enough. The raw food brigade, I now know, despise the convenience and peace of mind obtained from feeding a ready prepared diet and feel that we must suffer for the cause by wrestling with great slabs of tripe, disembowelling wildlife and dismembering chicken carcasses to present to our animal companions.

Furthermore, and this is where it gets silly, they are also convinced, like the true believers they are, that any one who doesn’t share their devotion to all things raw is a heretic who deserves to be castigated roundly for their sins. Well, I am exaggerating slightly but the evangelical tone of such groups is quite disturbing at times and they are most intolerant of opposing views.

Their actual arguments vary but the one thing they seem to have in common is a lack of good quality evidence. Raw proponents seem to feel that if they deliver anecdotal evidence loudly, frequently and aggressively enough then that should be enough. This disregard for evidence and condemnation of anyone who doesn’t accept their dogma is what, in my opinion, puts much of raw feeding firmly into the realm of veterinary pseudoscience.

Some anecdotes are more equal than others:

The case for feeding raw is heavily dependant on anecdotal evidence, "my dog’s coat is glossier/teeth are shinier/flatulence has gone since starting to feed raw..." , that sort of thing. On the other hand though when vets and pet owners submit that they also know long lived animals with good teeth, good coats and excellent bowel function which are fed on a commercial diet these claims are dismissed as fanciful or simply wrong. Even if they are true we are told, the animal in question is bound to be harbouring hidden problems which will only come to light years down the line.

Some of the claims for raw feeding, particularly the dental benefits are not unreasonable and it is clear from anecdotal evidence presented that many owners who feed raw are happy with such a diet - fair enough. The whole debate takes a far less convincing turn however with the multitude of additional claims which are considerably more far fetched. Commercial diets are bad, it is claimed because they contain grains which, when fed to dogs, cause stunting of the intestinal villi leading to celiac disease and this phenomenon is actually the cause of death in many elderly, debilitated wild canids as well as commercially fed pets. Yet despite the fact that postmortem evidence for this very specific claim should be easy and cheap for any raw feeding veterinary surgeon to obtain no proof has ever been forthcoming.

Then there’s “argument by revulsion” - advocates of raw feeding reel in horror at the mention of ingredients such as "rice, animal fats, maize gluten, maize flour, wheat gluten, vegetable fibres, minerals, poultry proteins, hydrolysed animal proteins" (technical sounding terms for meat, vegetables and grain), yet would have everyone else feeding their pets deceased wildlife scraped from the tarmac of our highways and byways following road traffic accidents. This appeal to emotion cuts both ways.

Raw feeding is claimed to repel parasites both internal and external, reduce obesity, improve bowel function, improve animal behaviour (to the extent that it has been suggested that feeding kibble could put children at risk of attack by pet dogs), reduce the incidence of hormone problems and arthritis and even improve owners' own immune systems by making them more happy about feeding their pets. There is very little in the way of health problems infact that raw diets will not help with if its proponents are to be believed. The only problem is that not one of these claims is backed by anything other than speculation and anecdote.

What is wrong with anecdotes you might ask - if someone feeding raw food to their dog tells us its coat is in better condition then so be it, raw diets must be good for dogs’ coats. Unfortunately though, it’s not as simple as that. I have no reason to doubt stories of this nature that abound in raw feeding literature but we need to consider other things too. There are very many people feeding their pets on commercial diets who also feel that their pets’ health, coat condition and so forth is also extremely good. In the course of my daily work I hear from many owners how they have changed from commercial brand A to commercial brand B and who also report the exact same improvements as raw feeders claim - but to raw feeders somehow these accounts are less believable than theirs. Like true evangelists they just know that their way is the right way.

To achieve a balanced view, we need to consider not just the alleged benefits of a raw diet but also any potential risks. There are several published papers (LeJeune, 2001; Morley, 2006; Strohmeyer, 2006) which clearly demonstrate the fact that raw food can be a source of various food poisoning organisms such as salmonella, yersinia and campylobacter. Thus householders feeding raw would certainly be likely to be exposed to infection, not just from the raw meat itself but from contaminated furnishings and bedding and contact with the mouth and lips of raw fed dogs. To be fair, what with media scares and super-bug panics we are all probably over concerned with the risks of exposure to bacteria generally, in most cases our immune systems are more than capable of handling such challenges. In other cases however we cannot cope, often with serious consequences. Many cases of food poisoning are reported every year with problems varying from a simple gastroenteritis to, in rare cases, death. Rare yes, we should not be paranoid about this, but it cannot be denied that there are potential risks; this is not, as one raw feeding proponent claimed dismissively, “sensationalist nonsense”.

There are also risks to the pets being fed raw. A recent survey of owners committed to feeding raw (which might reasonably be expected to have a pro-raw bias) was found, with refreshing honesty, to concede potential problems in pets such as food poisoning and obstruction of the bowel attributable to feeding raw (Raw Fit Pet Survey, 2009). Such problems were observed in 11% of cases, a rate vastly higher than any similar complications from feeding commercial diets. Needless to say this section of the survey is discounted by raw feeding proponents who nevertheless are quite happy to accept other sections of the results which suggest positive results.

The Nature Cure:

Proponents of raw food will trot out the mantra, so beloved by all devotees of all things alternative, “nature is best” (usually in capital letters of course, just so we know they’re REALLY SERIOUS!). They maintain that since the dog’s closest wild relative is the wolf then they should be fed the same diet. The observation that the lives of most wolves in the wild are brutal and short, spent mostly fighting, breeding and trekking over hundreds of miles of frozen wastes in search of extremely agile prey seems to have escaped raw food evangelists who see things through somewhat more rose-tinted glasses than most, and believe that a plucked and gutted chicken carcase from the freezer is the same as a freshly killed Caribou. The fact that wolf dentition is pretty much identical to that of dogs is presented as sure evidence that a dog is a pure carnivore. The fact that the slightly less closely related fox also has identical dentition yet exists quite happily on a varied, omnivorous diet is quietly ignored - dentition is not an accurate way to judge whether an animal is a pure carnivore or not.

Much as raw feeders would prefer to believe otherwise dogs are a species in their own right, with their own behaviours and dietary needs, they are not simply “wolf-lite”. Recent genetic studies suggest that dogs have been evolving alongside humans for up to 100,000 years during which time considerable selection pressure has given rise to a unique species which is well adapted to live on a varied omnivorous diet of scraps and pickings from human settlements (Wayne, 1999) and has more friendly, human adapted behaviour (Gacsi, 2005; Gacsi 2009). These selection pressures have been described by one author as “Living in the human niche” (Bleed, 2006).

So, after months of personal abuse from raw diet proponents, who are less than polite (to put it mildly) about anyone who ventures to disagree with their point of view I have concluded that many of their arguments belong firmly in the pseudoscience camp. I am personally still a bit of a "fence sitter" on such matters, there are beyond doubt very many people feeding raw who are delighted with the results, just as there are people feeding commercial diets without problems, I certainly wouldn't condemn an owner for feeding either type of diet. Where the difficulty lies for anyone with a scientific bone in their body though is the extreme rhetoric, excessive claims and verbal abuse employed by raw advocates, all based on flimsy, anecdotal evidence alone. When it is suggested that firmer, scientific evidence is what is required to substantiate the claims that believers feel so strongly about this is dismissed as an attack on the integrity of proponents - the benefits are obvious to raw feeders, they should be obvious to everyone.

The sad thing is that Raw Food Evangelists are their own worst enemies, their abrasive style of debate and their assertions that veterinary surgeons are either too stupid or too corrupt to be able to make an objective decision about feeding pets only serve to alienate people even further. And if their diet is half as wonderful as they claim then the only losers as a result are the animals.

For further reading, have a look at Steve Crane's excellent article "BARF diet mythology" which addresses the subject of raw diets for pets in more depth.

References:

Bleed, P., (2006) Living in the Human Niche, Evolutionary Anthropology 15:8 –10

LeJeune, J.T., and Dale D. Hancock, D.D., (2001) Public health concerns associated with feeding raw meat diets to dogs Journal of the American Veterinary Medical Association, 219, (9), [Accessed 21/9/09]

Morley, P.S., Strohmeyer, R.A., Tankson, J.D., Hyatt, D.R., Dargatz, D.A., Paula J. Fedorka-Cray, P.J., (2006) Evaluation of the association between feeding raw meat and Salmonella enterica infections at a Greyhound breeding facility Journal of the American Veterinary Medical Association, 228:1524–1532 [Accessed 21/9/09]

Raw Fit Pet Survey (2009) [online] http://www.rawfitpet.com/pb/wp_fa7e8251/wp_fa7e8251.html [Accessed 21/9/09]

Strohmeyer, RA, Morley, PS, Hyatt, DR, Dargatz, DA, Scorza, AV, Lappin, MR, (2006) Evaluation of bacterial and protozoal contamination of commercially available raw meat diets for dogs, Journal of the American Veterinary Medical Association, 228, (4) 537-542 [Accessed 21/9/09]

Wayne, R.K., and Ostrander, E.A., (1999) Origin, genetic diversity,and genome structure of the domestic dog, Genes and Genomes BioEssays 21:247–257

Gácsi M, Gyori B, Miklósi A, Virányi Z, Kubinyi E, Topál J, Csányi V (2005) Species-specific differences and similarities in the behavior of hand-raised dog and wolf pups in social situations with humans Developmental Psychobiology.47(2):111-22

Gácsi, M., Gyoöri, B., Virányi, Z., Kubinyi, E., Range, F., Belényi, B., Miklósi, A., (2009) Explaining Dog Wolf Differences in Utilizing Human Pointing Gestures: Selection for Synergistic Shifts in the Development of Some Social Skills PLoS ONE 4(8): e6584. doi:10.1371/journal.pone.0006584

Harriett Hall at her eloquent best

A fantastic article by Harriett Hall (aka skepdoc) about scaremongering about swine flu vaccination - I just love her style!

 

Claim: Mercola says “Injecting organisms into your body to provoke immunity is contrary to nature.”

Fact: Nature kills people. Doing something contrary to nature is what medicine is all about. It’s a good thing.

and...

Mercola’s advice for preventing flu: Eliminate sugar and processed foods from your diet, take a high quality source of animal-based omega 3 fats like Krill Oil, exercise, optimize your vitamin D levels, get plenty of sleep, deal with stress, and wash your hands.

Fact: Washing your hands is a good idea

Mercola claims: “Vitamin D deficiency is the likely cause of seasonal flu viruses.”

Fact: Now really! Vitamin D deficiency in a human body can no more “cause a virus” than it could “cause a cat.” ...

Brilliant.

http://www.skeptic.com/eskeptic/09-09-23#feature

 

Read it immediately!

Over the Hills and far, far away

Have a look at these quotes from a recent trial of homeopathy in dogs and try to guess which journal they have come from.
We have all the usual tactics and excuses:

1/ Cherry picking of data: “To date, comprehensive meta-analyses of placebo-controlled trials in human medicine have, in general, suggested that homeopathy is superior to placebo"
2/ Homeopathy is too sophisticated to be assayed by mere science: “One obstacle to the performance of clinical trials to investigate veterinary homeopathy is the holistic approach taken by homeopathic practitioners, in which the whole patient is treated on the basis of the individual signs and constitutional characteristics, rather than just a specific disease.”
3/ Any study which suggests homeopathy is anything less than completely effective is plainly wrong: “... a previous single-blinded, placebo-controlled study was conducted... to determine the efficacy of a commercial homeopathic remedy in the treatment of canine atopic dermatitis. Although no beneficial effects were seen, the study design was widely criticised by homeopathic practitioners who wrote to the journal in which the study was reported, claiming that the requirement for individualisation of remedies had been completely misunderstood and ignored by the authors...”
4/ There’s no such thing as real medicine, it’s just homeopathy’s evil twin, “allopathy”: “a novel, two-stage study design was tested in order to allow adherence to both homeopathic and allopathic principles.”
5/ Anyone who doesn’t believe in homeopathy is an idiot: “Conventional clinicians who are sceptical about homeopathy might interpret the results differently, and attribute the responses to chance and ‘wishful thinking’ on behalf of the owners."
6/ Anyone who doesn’t believe in homeopathy is a complete idiot: “... the chances of a sudden resolution occurring coincidentally after the remedies had been administered would be small.”
... and finally,
7/ Bugger the results, that’s not what we want to hear, let’s hear some heart-warming anecdotes instead: “The owners of the five dogs were in no doubt that the improvements seen in their dogs’ signs were a result of the homeopathic remedies.

Well, despite what you may think from the quotes they’re not from some partisan, pro-homeopathic journal which treats magic on a par with science. Sadly for the veterinary profession it’s from our dearly beloved premier journal, The Veterinary Record. To be precise, Hill, P. B., Hoare, J., Lau-Gillard, P., Rybnicek, J., and Mathie, R.T. Pilot study of the effect of individualised homeopathy on the pruritis associated with atopic dermatitis in dogs, Veterinary Record 164:364-370

This paper was designed as a pilot study of homeopathy as a treatment for pruritis (itching) in dogs suffering from allergic skin disease. To give you a bit of background, this condition, known as atopy, is a terrible one which causes an irresistible compulsion on the part of the suffering dog to continuously itch and scratch itself so badly that sometimes its skin ends up looking like raw meat and oozes blood and serum. It is caused by an allergy to inhaled substances such as pollen, house-dust mites and fungal spores and there is no cure. In the early stages is starts insidiously, often only obvious at a certain time of year, it is what is described as “seasonal”, so it is worse when, say, the pollen of a particular plant is plentiful in the environment. Later on, as the dog grows older the season lasts longer and longer until the affliction appears almost permanent. Nevertheless it is still prone to periods of waxing and waning; it’s not equally as bad all the time. For whatever reason there are good periods and bad periods which result in the condition ameliorating for variable lengths of time, up to several weeks or months. Environmental conditions such as a cool spell, changes in diet, routine or even washing powder will all impact on the severity and conspire to change its presentation at different times.

In this trial the authors took twenty dogs suffering from atopy and put them on homeopathy for a while. After a while five of them improved (or, rather, as the authors chose to describe it, “responded”). Now normally, at this point many trials would have had a placebo group, which is to say a similar group of dogs who were given identical looking blank tablets to see if they responded any differently. This allows the authors to compare the numbers of dogs who might have improved for any reason other than homeopathy with the numbers who improved in the group actually having the homeopathy. In this case though the design of the test didn’t include a placebo group so we are left guessing how many of the subjects would have improved anyway, regardless of treatment. In fact in this pilot stage of the trial all the owners knew that they were giving homeopathy to their dogs.

Once the pilot stage was over the five dogs which had improved were put forward to the next stage, a blinded trial (where owners wouldn’t know whether they were giving homeopathy or a blank placebo). Before this was started however one of the dogs’ symptoms improved so much it couldn’t participate and sadly, one of them was put to sleep as a result of epilepsy. So that left the authors with three dogs out of a total of twenty to do the most important phase of the trial. Now I’m not the world’s greatest statistician but even I can tell that any trial involving three participants is not going to be worth the paper it is written on. Much, much larger numbers are needed to show any sort of effect, especially when most previous homeopathic trials of any quality have been unable to distinguish homeopathy from placebo. If the difference is so small (some would say non-existent) you have to work very hard to test it and a trial involving three dogs is no where near the mark. OK, it might have made an interesting letter but a six page paper in the UK’s top Veterinary Journal; I don’t think so.

The tone of the paper is strange and rather out of keeping with the usual detached language of such works. The authors seem to embrace, without question, the language and assumptions of homeopathy. It reads exactly the same way that one would expect a paper in a homeopathic journal to sound. There is an enormous section on homeopathic type signs (or “rubrics” as they’re called in homeo-speak) - one dog is described as ‘clairvoyant’, another is described as suffering from ‘vaccinosis’ (a condition entirely fabricated by purveyors of alternative medicine with no place in a scientific journal), yet another has an ‘aversion to onions’ while another is ‘very jealous but does not console owner’. All these descriptions are given straight-faced without rationale or explanation as to their significance or bearing on atopy. At a point sometime after the trial the authors, perhaps unhappy with homeopathy’s poor showing, decided to telephone the owners of one of the dogs from the first phase of the trial and ask how things were progressing. Even though this dog did not improve well enough to meet the study’s criteria for inclusion in the blinded phase the authors, for reasons known only to themselves, deemed it necessary to discuss the fact that the owner felt there had, after all, been a good ‘response’ and actually the dog had also ‘responded’ to some more homeopathy (nothing to do with the trial) six months later - well big deal!

The conclusion is awash with contradictions, almost as if several contributors have been working on different sections independently of one another. There is this statement of fact, “The success rate was lower than the 60 to 70 per cent predicted by the homeopath at the outset of the study”. Fair enough you might think, but it is immediately followed by a whole list of excuses as if the authors already know homeopathy works, but here are the reasons it didn’t in this case. Then, incredibly, we are told, “the authors consider that the overall success or failure rate in this study is somewhat irrelevant” Well, this trial certainly didn’t demonstrate any success for homeopathy so they must mean that failure is irrelevant - so why bother to do the trial if the outcome didn’t matter?

Despite the incredibly low power of the trial the authors actually claim, with no justification, to have shown that “even with a cautious interpretation” the results support the view that homeopathic remedies are beneficial in treating atopy (this is from three dogs remember). Then, a few lines further on, the whole piece finishes with the non-sequitur last line, “There is no justification for using the findings reported here to substantiate or repudiate the overall efficacy of homeopathy in either veterinary or human medicine”.

All very strange and, I fear, a sad day for our profession.

Aillas

Veterinary Voodoo Society gets a relaunch

Well, here's a bit of good news, the high priestess of Veterinary Voodoo has decided to give the organisation's web-site a bit of a wash and brush-up; as a fellow sceptoid said, "about bloody time!".  For those not already in the know, the satirical British Veterinary Voodoo Society (BVVS) came into existence some decades ago at a meeting where it was proposed that veterinary homeopaths should become a specialist division of the Royal College of Veterinary Surgeons.  This definition carries considerable weight and would have given homeopaths special status alongside cardiologists, opthalmologists, orthopaedic surgeons and other people who practice real veterinary medicine at a more exalted level that us mere mortals.

 

Such a proposal was anathema to one of the more rational members of the meeting who, in a flash of inspiration, immediately proposed that Veterinary Voodoo should also be granted specialist status on the basis that this ancient, spiritual and traditional modality had exactly the same amount of good quality evidence supporting its use as homeopathy did (which is to say none whatsoever of course).  Thus the BVVS was born and the homeopathic menace vanquished (well, as a specialist division anyway).

 

It was given a firmer footing and its own website a few years ago as a consequence of a flurry of pro-homeopathy letters in the veterinary press at the time (the whole discussion is available on the BVVS site) but little has been added in the years since.  The BVVS had the distinction of being reported to the veterinary governing body in the UK, the Royal College of Veterinary Surgeons (RCVS) by well known homeopath John 'Jack' Hoare with the allegation that its views were "bringing the profession into disrepute".  An action was brought against BVVS office holders and the case was considered by the preliminary complaints committee of the RCVS.  The charges could have seriously affected the careers of those involved, there was even a risk of suspension of the right to practice should they have been upheld - such is the homeopaths' respect for free speech.  Fortunately for the embattled ranks of voodooists the complaint was dismissed and after a very minor change to a couple of links the web-site was re-opened.

 

John 'Jack' Hoare BVSc VetMFHom CertIAVH MRCVS is (amongst other things) the author of this children's guide to the homeopathic care of smaller pets.  In it he offers advice including the use of homeopathic aconite if your small furry is squashed in the door.  He goes on to describe homeopathy in easy to undertand ways which will appeal to children, using pithy soundbites such as, "Hahnemann, in Aphorism 3 of the Organon instructs us, when treating disease, to 'know the obstacles to cure and how to remove them, so that recovery is permanent'", and, "If bad food is suspected, the stools are foul-smelling and brown in colour", which are bound to appeal to the inquiring young mind.  Awww, sweet.

UK government science advisor criticised over stance on homeopathy

UK government science advisor Professor John Beddington has been criticised by MP's over his stance on homeopathy. Should someone in his position be advising that, "there may be more to government policy on homeopathy than science" or should he be leaving politics to the politicians and just sticking to the science? Hmm, that's a tricky one... how should the science advisor be advising... the science advisor... hang on - the SCIENCE advisor!!!??? Oh drat, the clue was in the name all along.

The Grauniad covers the story as does the BMJ and healthcare republic and the Times. Oh, and in the interests of balance someone is making a load of dodgy claims about homeopathic research, also at healthcare republic.