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.