My Final Post on Vet CAM Commonsense

Well, I am sorry to say this will be the last post on Vet CAM Commonsense.

No, no, it's ok, there's no need to be downhearted - dry those tears and turn up those corners! Because the blog will continue... just not here (although all the old posts will remain, naturally). I have decided to consolidate my ramblings about sceptical and CAM matters so in future the main website will be found at the brand-new RationalVetMed.net site, which will also host the new blog.

There, that's better!

My original RationalVetMed.org web site will continue although I will be moving most of the articles to the new site to simplify it and allow it to become a straightforward repository for the various CAM references which is the original reason it was set up in the first place and is really the thing it does best.

So, hop over to RationalVetMed.net and have a look, sign up and leave comments - the campaign continues!

And on a related matter, if you have enjoyed what you have read here make sure and keep an eye out for the forthcoming 'No Way to Treat a Friend', a book jointly authored by me and fellow veterinary surgeon and sceptic, Alex Gough, which will lift the lid on the dubious claims of complementary and alternative veterinary medicine in a way that is hopefully entertaining and informative at the same time. It is due to be published by 5M publishers in the autumn. For updates on its progress check out the RationalVetMed blog.

So, fare thee well for now, I'll see you on the other side!

Pet Insurance and Magical Thinking

In a letter in the latest Veterinary Times, veterinary surgeon Alison Price has spotted that a pet insurance company (Direct Line) while on the one hand correctly declining to pay out if a claim arises when an unvaccinated animal is affected by a disease preventible by vaccination will, on the other hand, accept the use of nosodes (so-called homeopathic vaccines) as evidence the animal is protected. [1]

Nosodes, strictly speaking a form of isopathy but very much homeopathic in principle, have long been discredited as being of any use in protecting animals against disease. The Faculty of Homeopathy itself even advises they cannot be relied on to protect in this way and recommend vaccination instead:

‘Nosodes are sometimes offered as alternatives to conventional vaccines, in both the human and veterinary fields. The Faculty is of the opinion that there is currently insufficient evidence for it to promote this methodology. The Faculty follows the Department of Health guidelines on immunisation and recommends that immunisation be carried out in the normal way unless there are medical contra-indications.’

They also advise:

‘Those patients who seek to use nosodes in place of conventional travel vaccinations and malaria prevention, should note that this method is currently unlikely to be acceptable to insurance providers. Likewise, in veterinary applications, they will currently not fulfil ‘pet passport’, equine competition or official kennel requirements.’

Yet it seems some pet insurance companies—unlike travel insurers, boarding kennels and the Department for Environment, Food & Rural Affairs (DEFRA) who supervise pet passports—will accept the validity of the use of nosodes simply, according to their spokesperson, on the recommendation of a qualified vet. Direct Line were quoted as saying, ‘As an insurer, we are not in a position to advise on the vet's clinical judgement’.

When that judgement is flawed and so unbalanced as to represent a danger to our animal patients though, perhaps they should reconsider their position. Simply denying responsibility isn’t good enough. Then again, who can blame them when the Royal College of Veterinary Surgeons, the governing body for UK profession, tacitly endorses the use of pseudoscience and magical thinking in veterinary medicine  because, according to then president, Bradley Viner, there is a ‘public demand’ for it and ‘there are strong views about these issues on both sides of the argument’. [2]

Well, there used to be a ‘public demand’ for the docking of dogs’ tails, bull baiting and cock fighting, but you don’t hear much from the RCVS about ‘both sides of the argument’ for them.

References:

1] Price, A (2017) ‘Concern at insurance policies allowing nosodes’, Veterinary Times,  vol. 47, no. 8, p. 35.

2] Viner, B. (2016) 'Homeopathy and Cancer' (letter), Veterinary Record, vol. 179, no. 3, p. 79. [doi:10.1136/vr.i3862]

A Victory for Common-Sense

A long long time ago, UK veterinary surgeon Phil Hyde came across the website of fellow UK veterinary surgeon, Roger Meacock. What he found there depressed him.

On his website, Mr Meacock starts by pointing out he is a ‘fully qualified veterinary surgeon who has established an international reputation for treating animals using a wide range of cutting-edge healing technologies and products.’ After that things start to go steadily down-hill as we discover the ‘cutting-edge healing technologies and products’ on sale are not what you might think and that, although Mr Meacock obviously believes passionately in them, some of his ideas are a little silly. In fact, this web site seems to be something of a Grand Central Station of Silly, where there is an uncritical acceptance of a wide range of nonscience-based concepts, regardless of scientific merit, proper evidence or plain common-sense.

For instance Mr Meacock tells us the Russians can change DNA using only words and language, to restore group consciousness and clairvoyance. Readers are advised that ten drops of ‘Aerobic Oxygen’ in a glass of water will increase its oxygen levels by over 400% and drinking it will boost the oxygen concentration of animals’ blood (clearly drinking oxygen is much more efficient than breathing it). Then there is Quinton Marine Plasma, which harnesses ‘the [unspecified] healing power of seawater’ and the Silent Healing CD, a recording of (you guessed it) complete silence, apparently useful for ‘space clearing and for group healing.’

The ‘Russian Healing Blanket’ we are told, in a glorious riot of technobabble, is a ‘new informo-bioenergetic therapeutic tool which uses the patient's own reflected infra-red and extra-high frequency emissions... [and] more evenly distributes the surface electrical charge density [of the body], thus providing a reservoir of energy that is drawn into the body through deficient biologically active points... of the body surface to rebalance the meridians and body energy systems.’

Phil felt strongly these sorts of evidence-free and patently ridiculous claims might be both damaging the reputation of the profession and, more importantly, harmful to animals. He initially brought his concerns to the attention of prospective candidates for positions in the council of the of the Royal College of Veterinary Surgeons (RCVS - the governing body for the UK profession) during an election debate at the forum Vetsurgeon.org in 2013. His pleas fell on deaf ears.

Shortly afterwards he lodged a formal complaint about Mr Meacock and his website with the RCVS’s Preliminary Investigation Committee (PIC). The complaint was first made in December 2014 and I was pleased to be asked at that time to help. Phil received a copy of Mr Meacock’s response to the complaint from the RCVS, which, though heavy on personal attack, was extremely light on the actual evidence Phil had asked for. Instead of arguing his case, Mr Meacock instead brought a charge against Phil himself, for bullying, a complaint which was later dismissed by the RCVS.

The RCVS is no different from any other large bureaucracy and has a lot on its plate. Inevitably there were many false starts and adjournments. Feeling he was getting nowhere Phil contacted Arlo Guthrie, the editor of www.Vetsurgeon.org, one of the largest and most active veterinary forums in the UK, for advice.

Arlo’s first instinct was to get together a group of like minded veterinary surgeons to offer advice and to widen the field to make the strength of feeling among the profession clearer to the RCVS. This group initially got together in August 2015 and thus was born the Campaign for Rational Veterinary Medicine (CfRVM), with the aim of responding to the false claims of veterinary alternative practitioners in the media, to publicise the real risks to animal welfare and the ethical concerns over veterinary homeopathy and to get this message across to the RCVS in order to convince the authorities this wasn’t a lone voice, but a united front. This was done in the form of direct submissions and a petition in support of reforming the (to date) laissez faire attitude of the RCVS.

Finally, nearly 2 years after the initial complaint, Mr Meacock was presented, by the RCVS, with a list of charges and advised the accusation was one of ‘conduct disgraceful in a professional respect’ and that he was to face ‘six charges relating to matters asserted on his website which the College alleged were misleading and/or inaccurate to the point of bringing the veterinary profession into disrepute’.[1] The hearing date was set for Tuesday 18 October 2016. Phil and other members of the CfRVM headed for London.

The day of the hearing involved a lot of waiting around in court where more knitting than legal debate took place. But finally an announcement was made. The Disciplinary Committee hearing into Roger Sidney Meacock MRCVS was being adjourned as he had voluntarily agreed to ‘amend his website in order to make it compliant with his professional responsibilities’. While this was not entirely what had been expected, it was nevertheless a victory, and a step forward for professional standards in the UK veterinary profession.

Mr Meacock and the far-fetched claims on his website were the catalyst that brought the members of the Campaign for Rational Veterinary Medicine together, and our work continues. We care about the rational and scientific basis for the UK veterinary profession and will continue to question the irrational ideas and treatments promoted by a small but vocal section of the profession to the detriment of our patients. Only with a real world foundation for the treatments we use and the advice we give can we be certain the animals which trust us to do our best for them are treated fairly and with respect and their owners and caregivers are not misled into believing certain treatments are effective when they are most certainly not.

So thanks, Roger, we owe it all to you.

References: 

1] Royal College of Veterinary Surgeons RCVS (2016) Disciplinary hearing for Staffordshire-based vet adjourned following undertakings [Online]. Available at http://www.rcvs.org.uk/news-and-events/news/disciplinary-hearing-for-derbyshire-based-vet-adjourned/ (Accessed 16 February 2017).

Real Secrets of Alternative Medicine - A Review

Rawlins, R. (2016) Real Secrets of Alternative Medicine: An Exposé, Dartmouth, Placedo Publishing.

A Review (February 2017)

This is a book on an epic scale by an extremely knowledgeable author. In its three main sections Dr Richard Rawlins, practicing magician, hypnotist, medical practitioner and specialist surgeon takes the reader on a detailed journey through what lies behind complementary and alternative medicine (CAM) by exploring both the macroscopic—from the big-bang to human evolution—and the microscopic—from Steiner schools, cognitive dissonance and the ingredients of the Queen’s coronation oil, to those members of the society of apothecaries who apply cold water behind the ears to refresh themselves during meetings.

The first section covers the background to science and how it has developed alongside faith and religion, it looks at some of the ways CAM may appear to work and some of the semantic tricks and ‘sleights of mind’ employed by its practitioners as they ply their trade. The second section gives a more conventional narrative, covering many of the principle practices and personalities of CAM—chiropractic, homeopathy, acupuncture and so forth while the final section addresses the ways CAM may actually work, with a detailed consideration of one of the central themes of the book—the ethical use of the placebo in medical practice and a few suggestions as to how the scientific and medical world can constructively regard and even engage with CAM.

Using his theatrical experience, both surgical and stage, Dr Rawlins is ideally placed to see the devices and artifice of the CAM practitioner for what they are and point out the contrasts between those who make a career out of deception—honestly in the case of the stage magician, less so in the case of those who profit by CAM. The author’s love of words and language shines throughout the book. He is at pains to enlighten the reader with the roots and origins of words, many of which the non-linguist may have taken for granted. Who knew for instance what the origin of the term ‘clinical’ was, or where the word ‘electron’ or even simply ‘drug’ came from?

This passion for words extends to indignation that CAM has got all the catchy ones—traditional, holistic, complementary and so forth, and is disingenuously misusing others—the homeopaths’ mistranslation of ‘Prüfung’ for one. So, in response, Rawlins has devised a novel lexicon of his own, in which, for example, a practitioner of CAM becomes a ‘camist’ and a patient is a ‘camee’ while ‘placedo’ (as practised by ‘placebists’) is the consideration of the path to a better understanding of placebo effects. Critics of science-based medicine talk of ‘big-pharma’, Rawlins describes the CAM industry as ‘big-charma’ while CAM practices themselves are referred to, not as ‘complementary’, but ‘condimentary’—producing flavour and pleasurable feelings but with ‘no substantial effect on any pathological or physical process’. The phrase ‘Traditional Western Medicine’ (TWM) comes as a surprise to the reader, but when considered carefully is found to be true—modern, science-based doctors do indeed practice TWM which has evolved from the ancient practices of the western classical world and has as much right to the label ‘traditional’ as has ‘modern’ Traditional Chinese Medicine (TCM). My favourite Rawlinism is ‘wudo’—the path of nothingness, as followed by those who employ CAM.

Dr Rawlins explores much of his subject using detailed biographical information on some of the more prominent characters, ancient and modern, from both sides of the debate and in this way his work is, apart from anything else, a superb reference book to turn to when detailed information regarding CAM, the history and development of science and medicine or any of its personalities is needed. So I hope I can be forgiven for one small criticism of an otherwise excellent volume—an index would have been nice—perhaps something to consider for the second edition.

All in all, Real Secrets of Alternative Medicine is an enjoyable and original insight into the subject matter from an author whose familiarity with illusion and medicine has given him a unique perspective on human nature. It deserves a place in the library of anyone who wishes to understand and learn from, rather than simply ridicule, complementary and alternative medicine and discover some of the reasons why, despite firm evidence of its lack of efficacy, it continues to thrive. I would recommend anyone interested in a serious exploration of CAM to buy a copy but of course, to use one of Dr Rawlins’s preferred phrases, you must be the judge!

Now, about gluten intolerance in dogs...

Gluten - 'the new evil'

An excellent article, examining the literature on nutrition in the Veterinary Times this week from Marge Chandler with a comprehensive, well referenced, diplomatic and well reasoned put down of those who claim gluten sensitivity and coeliac disease in particular is a raging epidemic in the pet dog population of the UK and elsewhere.

It turns out even in humans the true incidence is only 0.2 to 0.5 percent, despite all those food-faddists claiming to have (self-diagnosed) gluten intolerance, and the incidence in dog is minimal to extremely tiny. Despite the wails of the raw feeding lobby as represented by BARF and RMB, true (as opposed to imaginary) gluten intolerance is not a disease that is a problem in real-world veterinary practice. If the raw food lobby are so convinced it is though, it would be extremely easy for them to take a few samples and prove their case. I'm sure permission would be easy to obtain from similarly convinced dog owners and costs would be minimal, particularly for a pilot study. It remains a mystery why such work has not yet been carried out.

Dr Chandler also takes time to discuss various supplements and their claims to aid canine health. Turmeric (curcumin) apparently, while performing minor miracles in cell cultures in laboratory glassware does nothing to help actual dogs with actual arthritis.

The aminosaccharides chondroitin sulphate and glucosamine, although they have been used for many years to treat arthritis in dogs and seem to give a subjective improvement when assessed by caregivers, are found to have no effect when assessed objectively using force-plate analysis. Although no adverse reports were recorded from these studies a seperate case of fatal acute hepatotoxicity was reported following overdose, so we are advised to use these supplements with care.

Fish oils (Omega-3s) fare somewhat better with both subjective and objective improvements in joint function being recorded in dogs following administration and an improvement in the wellbeing and activity levels of cats. And finally it is confirmed that commercial renal diets are the most important, effective tools you can get in the control of chronic kidney disease in cats and the earlier in the disease process you start, the better the long-term effect. Used alongside the symmetric dimethylargenine (SDMA) test, allowing earlier detection of kidney disease than ever before, this means we have the means to really help in these difficult and distressing cases.

Reference:

Chandler, M. (2017) 'Small animal nutrition: latest updates and developments', Veterinary Times, vol. 17, no. 02, (1 February).

If Jesus was a Homeopath

If there was ever a patron saint of critical-thinking it would have to be St Thomas the Doubter.

At my old Church of Scotland Sunday School in a little village by the Firth of the Tay I always loved the bible stories which were read to us. But even in those days I always felt Thomas got a rough deal. All he had done was to ask for evidence, he never said anyone wasn't being truthful, he just asked for proof and he's been reviled by history for the past 2,000 years or so.

Recently I looked up the actual story in my old bible and reminded myself of the rhythm and beauty of the words of the King James version.

St. John chpt 20, vs 24-29

But Thomas, one of the twelve, called Didymus, was not with them when Jesus came. The other disciples therefore said unto him, We have seen the Lord. But he said unto them, Except I shall see in his hands the print of the nails and put my finger into the print of the nails, and thrust my hand into his side I will not believe.

And after eight days again his disciples were within, and Thomas with them. Then came Jesus, the doors being shut, and stood in the midst, and said, Peace be unto you. Then saith he to Thomas, Reach hither thy finger, and behold my hands; and reach hither thy hand and thrust it into my side: and be not faithless, but believing. And Thomas answered and said unto him, my Lord and my God. And Jesus saith unto him, Thomas, because thou hast seen me, thou hast believed: blessed are they that have not seen, and yet have believed.

The names Thomas and Didymus both mean ‘twin’ by the way.

Apparently theologists see this as an example of Jesus, not castigating Thomas but being prepared willingly to present proof when it was requested. I like this idea. It sounds like Thomas was giving Jesus a chance to shine and to demonstrate how not to take offence when questioned about a claim.

And I thought how refreshing that attitude to evidence was and I began to imagine how the scene might have gone if Jesus had been a homeopath; a group notoriously reluctant to provide anything approaching reasonable quality proof:

But Thomas, one of the twelve, called Didymus, was not with them when Jesus came. The other disciples therefore said unto him, We have seen the Lord. But he said unto them, Except I shall see in his hands the print of the nails and put my finger into the print of the nails, and thrust my hand into his side I will not believe.

And after eight days again his disciples were within, and Thomas with them. Then came Jesus, the doors being shut, and stood in the midst, and said, Peace be unto you. Then saith he to Thomas, Reach hither thy finger, and behold, my garment is rent where the spear has passed through and behold, my hands are pretty sore, I can tell you. And Thomas answered and said unto him, But I would behold thine wounds with mine own eyes. And Jesus spake unto Thomas saying, Art thou calling me a liar?

Thomas's heart was heavy and he was sorely grieved. He spake saying, No Rabbi, yet I wouldst see the marks, how about I reach thither my hand and thrust it into thy side? And Jesus was angered and said unto Thomas, No way, that's gross. Look Sonny-Jim I've got a sheaf of parchments here from people who swear they have seen the marks, what other proof dost thou need?

And Thomas read the words which were given him and afterwards he reached out to move the garments of Jesus to one side that he might better see the mark. And, he beheld there was no mark and neither were there the prints of the nails in his hands. This Thomas told unto Jesus and asked why it was so.

And the anger of Jesus increased and he said unto Thomas, It's quantum, mate. Obviously you can't actually see them; if you look at them they disappear; it's quantum. Hast thou been reading that apostate Newton again? Stick to Einstein, he was a good Jewish boy, he knew a thing or two about quantum; quantum's great, what would you know – have you even studied medicine? Anyway, why dost thou touch my person? And, turning to the disciples Jesus said unto them, You lot saw that, that's technically assault, why doest these sceptics get so aggressive?

And yea at his command the sky darkened and the heavens opened and the wrath of God descended upon them with fire and hail and a great clashing of cymbals, verily the room wherein the disciples were was filled with the Holy Spirit burning like bright flame unto the very walls and timbers and the sound of His rage was heard throughout the land and the mountains shook and the ground trembled.

At this the disciples were sore afraid and cast themselves to the ground in their misery. And Thomas was among their number and thought unto himself, I wonder if it's too late to be a Zoroastrian instead?

Doesn’t have quite the same ring really, does it!

Homeopathic hypocracy and vivisection

What do you think of when you consider homeopathy - holistic, safe, trusted? Well, what about vivisection?

Even I, as someone highly sceptical of homeopathy, didn’t consider laboratory animals would be used to test homeopathic remedies. Surely that would be anathema to a practice which preaches gentleness and holism. For years I believed the British Homeopathic Association (BHA) when they proudly declared in their journal “Homeopathic medicines are NOT tested on animals and our Memorandum of Association clearly sets out that we may only ‘undertake and finance research into the problems of medicine WITHOUT vivisection’ 3(E)” [emphasis in the original].

Well, I was wrong – it appears their veterinary colleagues didn’t get the memo.

The magic of homeopathy: getting the public to believe anything

In 2014 the Honorary Secretary of the British Association of Homeopathic Veterinary Surgeons (BAHVS) stated in a letter in the veterinary press (1) “If one is bringing data, it should be the truth” and suggested the truth regarding homeopathy might be found in a series of “more than 800 veterinary papers” published on a homeopathy website owned by veterinary homeopath Mark Elliott (2).

Since first entering the debate surrounding veterinary homeopathy one of my preoccupations has been studying the evidence presented by homeopaths in support of their practice. I have gone as far as to devote a website to this activity which now contains critiques of some 200 articles and scientific papers on the subject of complementary and alternative veterinary medicine, none of which provides any evidence for the effectiveness of homeopathy – veterinary or otherwise. I had begun to despair of ever finding the proof of which homeopaths talked with such glib confidence and consequently told myself there would be little point in making a close study of the much heralded “800 papers”.

However, the question of evidence for homeopathy has always been central to the debate. So, somewhat against my better judgement, I turned my attention to the list in question. Perhaps this would be where the convincing proof homeopathy was all it was claimed to be would finally be found. I began by reading the first section, with authors whose names started with 'A'.

First impressions weren't promising - a jumble of languages, odd fonts, strange formatting and broken links greeted me as I scrolled down. Undeterred, I pressed on to discover there were thirty-nine papers in 'A' section, although after removing papers which had been published twice in different locations the number dropped to thirty-six.

Despite the claim these were all “peer reviewed papers” I found a multitude of symposia proceedings, article reviews and case reports - there was even a book review! Closer scrutiny revealed a number of studies didn't actually involve homeopathy at all; three being concerned with isopathy, and two with herbal medicine. Three others found homeopathy to be ineffective.

The potential for bias was rife, with some trials sponsored by the manufacturers of the substance under test and nineteen published in pro-homeopathic journals. Not one of the papers was double-blinded and only a handful claimed even to be single-blinded. Some dated back to the 1970's, so old no references were to be found online.

The most shocking aspect of the list though wasn’t the misleading promise of ‘truth’ from the BAHVS, it was the scale of the vivisection involved. In the name of the gentle art of homeopathy, hundreds of laboratory mammals were variously burned with lasers, scalded, incised, crushed, irradiated, had their jaw and leg bones fractured, were poisoned with strychnine, injected with formaldehyde, dry-cleaning fluid and cancer cells, and infected with sleeping-sickness. One experiment in a later section measured the effect of homeopathy in mice on “writhing induced by intraperitoneal acetic acid”. And it wasn't just mammals. One paper involved a group of unfortunate snails having their equivalent of a central nervous system dissected out for study.

And yet, even after all that, not a single one of these studies was fit for purpose. Inadequate methodologies, publication bias, vested interest and small group sizes ensured the mass sacrifice had been in vain. We still hadn’t come anywhere near proving homeopathy as a viable system of medicine.

It seems the homeopathic definition of ‘truth’ is different from that used by everyone else. It is apparently so elastic as to allow a mere book review to be transformed into a peer-reviewed paper; studies of herbal remedies to be proof homeopathy is effective; and to allow a single paper to be presented as two separate pieces of evidence. Homeopaths must think we’ll believe anything, on the one hand promising remedies are "NOT tested on animals" yet at the same time using exactly this type of evidence in support of their cause. The only explanation I can possibly think of is the authors of the “800 papers” must simply have hoped noone would read them and in this way they could completely pull the wool over our eyes. Perhaps this then, is the real magic of homeopathy.

I am trying to resist, but now my gaze is starting to drift down the page and I notice the first paper in the ‘B’ section also has nothing to do with homeopathy, being concerned instead with testing a herbal remedy. This doesn’t bode well.

References:
1 - Marston (2014) - Truth, evidence and marketing of drugs (letter) - Veterinary Times 7 April, vol 44 no 14 
2 - Anon (2014) Veterinary Papers Peer Reviewed: Animal/Lab Studies by Name of Lead Author, A Research Database and Information for Homeopathy and its use in Veterinary Medicine [online: www.homeopathicvet.org/Veterinary_Research_into_Homeopathy/Veterinary_Papers_Peer_Reviewed_files/Animal%20Studies%20by%20Name%20of%20Lead%20Author.pdf]  [accessed 23/12/15]

Homeopathy and Phrenology - kindred spirits

Few Veterinary Surgeons or Nurses would be convinced if we were told that it was possible to diagnose disease by feeling for lumps and bumps on our patients’ skulls. Yet 100 years ago many people believed just that. Phrenology, as it was called, was practiced by many prominent public figures of the day, including Royalty all of whom were convinced of its merits. It was even practiced on animals. The subject was debated at length by scholars and intellectuals and was supported by masses of detailed text books and articles in specialist journals. Nowadays Phrenology is defunct and discredited and the only sign that it ever existed is the occasional porcelean head marked with impressively named bumps usually found in curio shops.

The reason that these days few people have even heard of Phrenology is simply that real evidence for its effectiveness was found wanting. While in selected cases Phrenology apparently produced miraculous results, when the totality of cases was looked at, no clinical effect was found. Science proved what common sense should have told people all along; that there is no reason why bumps on heads should reflect anything other than... well, bumps on heads. Phrenology owed its existence solely to the blind faith of its practitioners and their willingness to rely only on favourable data whilst ignoring the rest.

Now consider something that is still used widely in human and veterinary medicine today, also by worthy and intelligent people but which has an even more unlikely basis than Phrenology. Homeopathy is a treatment invented two centuries ago at a time when purging and bleeding were common-place in the treatment of disease but which, unlike its more violent contemporaries has remained unaltered since. In homeopathy, remedies are made by taking basic ingredients such as Peregrine falcon, condoms, or the Berlin wall (these are genuine examples) and diluting them to such levels that a quantity of remedy equivalent to all the atoms in the known universe wouldn’t contain even a single molecule of the original. Yet even though there is no trace of anything other than water in their remedies homeopaths claim incredible results in the treatment of any condition you care to name including SARS, AIDS and cancer. Despite the fact that this underlying principle defies both common sense and scientific rationale, critics of homeopathy are dismissed as being out of harmony with today’s holistic New Age in the same way that critics of Phrenology were once called out of touch with the progressive Victorian Age.

When we look at the research we find that, like Phrenology, almost all supporting evidence for homeopathy is found within specialist journals and texts written by homeopaths themselves.  Much of this literature is questionable, suffering as it does from publication bias and is incapable of being replicated by independent researchers. Other, more objective studies have combined the results of multiple trials and in no case has any firm evidence been found in favour of homeopathy.

In conclusion homeopathy, like Phrenology before it, has many supporters, all of whom are convinced that it works; yet it has no basis in science and should have no place in the Veterinary profession founded as it is on rational principles.  Like Phrenology, homeopathy is an illusion sustained only by the faith of its followers and their selective use of evidence.

In the story of the Emperor’s new clothes, people are unwilling to admit what is obvious for fear of being ridiculed by others. Well, it’s about time we admitted that if our homeopathic Emperor appears to be wearing no clothes then, no matter what excuses he tries to come up with, the Emperor really is making a spectacle of himself.

(This was originally published in the letters pages of the Veterinary Nursing Times)

Homeopaths' bogus arguments - No. 12

Homeopathy is a different way of knowing and works perfectly well within its own frame of reference – it cannot be judged by science.

This ‘everything is subjective’ line is a well worn trope heard from many practitioners of CAVM – how can science ‘prove itself’, much less disprove anything which operates oustide its purview? Such commentators though want it both ways as we will see.

The point hinges on the very philosophy of science itself and disingenuous homeopaths as well as well-meaning but naïve scientists will suggest that any scientific argument against homeopathy is, at its root, prejudice. Homeopathy, it is claimed, is merely one of many ways of looking at the world and understanding it. As such, although different from science, it is deserving of equal respect. Good scientists, critics say, recognise this and should always have doubt. Well, that last point is certainly true, but it doesn’t mean doubt can be filled in with any old far-fetched nonsense which springs to mind.

To be clear, the core philosophy of science has little to do with the way medical trials are conducted or the usefulness evidence-based medicine. Certainly, medicine employs scientific tools – the double blind placebo controlled trial, confidence intervals, metanalyses and so forth but medicine (and by extension EBM) is no more a science than engineering is, both use science but that does not make them science; they are technologies.

One of the best illustrations of scientific principles is simply if something is going to claim scientific credentials then those credentials must be able to be tested by science. That’s it really, nothing more – 'Put up or shut up' in other words. Science isn't even about finding answers, being far more concerned with asking questions.

Philosophers of a post-modern bent (and possibly a few who like to sound clever!) will argue science is just 'another way of knowing' and that all healing (and other) modalities are equal but different. While this makes for interesting debate it is meaningless in practical terms in the real world. We know much of how the universe works. Consequently we know if a culture believes it is possible for humans to fly unaided while it might be polite of us not to directly contradict or otherwise disrespect members of that particular culture, even a homeopath would be ill advised to take politeness so far as to step out of a high window on their say-so. You can't have one set of facts, or truths for one group and a different set for another.

Critics are regularly castigated by its adherents for describing homeopathy as unscientific. Quite the opposite we are told, loudly and with vigour, homeopathy does indeed work by scientific principles (inevitably quantum physics as a rule), non-homeopaths are just too feeble-minded to see it. Yet, when the paucity of their ‘scientific’ evidence is pointed out to them, instead of doing the scientific thing by upping the ante and performing better tests homeopaths instead accuse critics of prejudice and bigotry while at the same time doing a volte face and hiding behind the skirts of New-Age philosophising. From this refuge they will claim they’ve changed their mind and actually homeopathy can't be tested by science afterall (that is until the next poorly performed trial comes along which claims even the smallest of effects from homeopathy, at which point all the mental gymnastics and philosophical navel-gazing get quietly shelved!). This really is wanting to have one’s cake and eat it, but that isn't how science works.

Homeopathy craves all the kudos and credibility science brings but will not accept the scientific process and the discipline that comes with it – mainly the discipline of discarding cherished beliefs in the face of contradictory evidence. It is homeopaths who are attempting to prove homeopathy by science, not scientists. If they were content to present themselves as practitioners of a mystic, unexplainable and untestable philosophy this whole debate would have a very different tone.

Homeopaths' bogus arguments - No. 11

"But we don't even know why mainstream drugs work, why pick on homeopathy - what about anaesthetics!"

This particular argument runs along the lines that since, allegedly, we don’t know how many conventional drugs work we should basically cut homeopathy some slack and give it the benefit of the doubt. A favourite example is anaesthetics with claims that we have no idea how they work and no information as to their safety or cost-effectiveness, the implication being that if anaesthetics (which obviously do work) have no known mechanism of action then homeopathy also must work even though it also has no known mechanism of action.

This is simply another tu quoque argument – flawed and designed to mislead. There are several problems with it, not least of which is that even if we really did have no idea how pharmaceutical drugs worked it still wouldn't mean it was ok to go on using homeopathy. We don't have to worry about that though because not only is this argument illogical, it is based on a falsehood, presumably put about in the hope that readers won’t bother to check the far-fetched claims being made in the defence of homeopathy.

In fact we have a very good idea of how pharmaceuticals work, including anaesthetics. Take Alfaxan (alfaxalone) for example, a popular veterinary anaesthetic agent. Alfaxalone binds to specific binding sites on the gamma animo butyric acid (GABA) sub-type A receptors on the cells of the Central Nervous System. GABA is a major inhibitory neurotransmitter. When GABA binds to the GABA-A receptors this results in opening of chloride channels into the cells and an influx of chloride ions, resulting in hyperpolarisation of the cells and inhibition of neural impulse transmission. Alfaxalone enhances the effects of GABA at the GABA-A receptors, so causing greater inhibition of neural impulse transmission and, thereby, unconsciousness. This information, along with safety and cost data is widely available in textbooks and via the internet. Why anyone would want to pretend we don't know how anaesthetics work when it is so clear we do is a mystery, but possibly reflects the limited grasp medical and veterinary homeopaths have of proper medicine.

Even if we didn’t know exactly how anaesthetics and other pharmaceuticals worked we do know they have recognised, analysable, physical content. We know exactly what they are. Their mode of action, even where not known precisely, will involve a number of pre-existing mechanisms, all firmly grounded in the known facts of neurology, physiology and biochemistry. All pharmaceuticals, including anaesthetics, follow predictible, rational patterns – if I dilute an anaesthetic it will have a reduced effect, if I use a stronger concentration it will have a more profound effect. And anaesthetics actually work. If I get the dose correct and use the proper delivery route my patients will go to sleep – every single time.

The rational basis of real drugs means if someone makes the claim that a particular pharmaceutical doesn’t work, or has unacceptible consequences that claim can be investigate using proven scientific principles and, depending on the results, the drug will either be withdrawn from use or have its safety profile enhanced. To take extreme examples of both – thalidomide was withdrawn from use in the middle of the 20th century after investigation showed it was causing an unacceptible level of deformities in new-born babies whereas claims the MMR vaccine caused autism in children were discovered to be without foundation once the research was carried out, consequently the MMR vaccine is now one of the safest, most widely researched drugs on the market.

Homeopathy on the other hand has no rational basis and no content other than sugar or water, its ‘mode of action’ is a pure fiction. Infact several pure fictions, depending on what you believe – quantum, nano-bubbles, spallation, cavitation, the life-force etc… You’ll find a different ‘mode of action’ at every website you care to visit on the subject. Unlike real drugs, homeopathy follows no rational or predictable pattern – behind the closed doors of the consulting room it is reported to have profound effects yet when looked at objectively those effects vanish to the margins of statistical significance. When homeopathy declines to perform when tested by science homeopaths, instead of upping the ante and doing better research, simply make excuses; the energy has been ‘antidoted’ (by pretty much any substance you care to mention), or it’s being tested by people who don’t ‘understand’, or it’s the ‘wrong type’ of homeopathy – not individualised, or isopathy – or we’re looking at the ‘wrong results’. Yet all those excuses go out of the window if the results look even vaguely like they support the idea homeopathy works. Homeopaths’ view of a well-conducted trial is one that proves, not tests homeopathy, and that's not how proper science works.

Finally, with homeopathy if you dilute it, it supposedly gets stronger, not weaker. And no theory of homeopathy’s ‘mode of action’ has ever managed to explain that one. Why homeopathy should get more quantum activity, nano-particles, energy signatures, micro-clusters or whatever the more dilute it is, remains a total mystery, even to the most imaginitive of those practitioners and multi-national corporations who profit by it.

The Campaign for Rational Veterinary Medicine

By complete coincidence two separate campaigns concerning veterinary homeopathy have been launched in the last few weeks. Both campaigns raise concerns about the ethics of veterinary surgeons using irrational, unscientific and ineffective remedies to treat ill animals or in place of conventional treatments and vaccinations.

The first was organised by Danny Chambers who feels so strongly about the subject he is pressing for a complete ban on UK veterinary surgeons practicing homeopathy. This is the 'change.org' campaign and the petition is open for signatures from anyone who cares to support Danny's aims.

The second campaign, organised by a concerned group of UK Veterinary Surgeons, is the official Campaign for Rational Veterinary Medicine and calls for the governing body of the UK veterinary profession (the Royal College of Veterinary Surgeons (RCVS)) to come off the fence and issue a position statement concerning veterinary homeopathy. It also calls for veterinary homeopaths to require animal owners to sign a consent form before embarking on homeopathic treatment which will inform them exactly what homeopathy is and that it has been proven to be no more effective than placebo.

The CfRVM has a website here and a petition which veterinary surgeons are asked to sign here.

For more information have a look at the press release here.

It is high time the RCVS came into line with the bulk of the profession, the UK's NHS and countless other medical and veterinary bodies around the world and admits that homeopathy is utterly ineffective and no vet should have the right to practice it under the banner of their professional qualifications unless they have obtained fully informed consent beforehand.

BSAVA position statement on Complementary and Alternative Medicine

The British Small Animal Veterinary Society have issued a position statement on CAVM. It can be found here.

It's pretty diplomatic stuff really (as you'd expect in this day and age) but there is a thread of hard truth running through it, for example:

"Health claims for many complementary and alternative therapies are far in excess of the available scientific data, and sometimes in frank contradiction to scientific evidence."

Very refreshing - it's a pity truth and logic have never been greatly valued by the multi-billion pound CAVM industry. 

Contaminated herbal products

Herbal products are often contaminated, study finds

"Herbal medicines are frequently contaminated or contain plant species that are a substitute for the plants listed on the label or contain other species that may be a filler, a DNA analysis has found.

"Some of the herbal medicines analysed were contaminated with plants that have known toxicity or can interact with other supplements or medications, the study reported… "

http://www.bmj.com/content/347/bmj.f6138?etoc=

and...

http://www.biomedcentral.com/1741-7015/11/222 [full text, original article]

So much for "Nature is Best"!

Time for a Reality Check

OK, time for a reality check. What exactly is this thing called homeopathy that everyone is going on about? Here is a summary, most of this stuff is available in other forms elsewhere but I just felt a review might be called for.

It's magic you know:
Homeopathy was made up, apropos of nothing at all, around 200 years ago by a German doctor called Hahnemann. Like many of the treatments of the time it had no rational basis and was more akin to sympathetic magic than anything we would call science today.

Other similar contemporary practices included humoural medicine, where practitioners would use for instance firing, purging and bleeding to restore “balance”. Herbalists believed that the form or location of a plant would give it magical properties so dock leaves, since they grow close to nettles would alleviate the nettle's sting; the leaves of the dandelion were taken, by virtue of their resemblance to the claws of the lion, to confer strength and liverwort, because of its resemblance to the lobes of the human liver, was used to treat liver conditions. In other societies it was thought that rhino horn would bring potency by virtue of its shape and eating the heart of a lion would bring courage.

In the same way homeopaths believe in their first "Law of Similars" where remedies are believed to “cancel out” disease by employing ingredients reported to cause symptoms in healthy patients similar to the those caused by a disease in ill patients. So, we read that healthy patients taking (proving) a remedy based on the Peregrine falcon (1) experience an urge to drive very quickly, can’t get off roundabouts when driving as they feel an urge to whirl around in the way a soaring raptor does and also have dreams about raw meat. Healthy volunteers taking a remedy based on the light of the planet Venus (2) can expect to feel, among other things “floaty and aware of the universe around [them]”. On the other hand portions of the Berlin wall (3) when given to anxious patients will promote agreement and peace. Dinosaur bones or calcium will supposedly help in the treatment of tumours which produce boney proliferation. Onions cause runny eyes and noses so they are used to treat people with a head cold as they have runny eyes and noses.

There is no reason for the choice of onion, peregrine falcon, anti-matter, condoms, thunderstorms, dead bees or any of the other base ingredients used in homeopathic remedies other than the belief that some of their 'power’ will be transferred to the patient. This isn't medical thinking, it's magical thinking with no more scientific credibility than selling warts or trying to tell the sex of an unborn baby by dangling a wedding ring on a bit of string over an expectant mother.

Water, water everywhere (oh, and some sugar):
The second principal of homeopathy, invented to avoid 'provers' poisoning themselves while testing new remedies, is the law of infinitesimals where the base remedy, having been selected, is then diluted to astronomical levels. The degree of dilution can be read on the labels of homeopathic remedies so for example 20X means the original base has been diluted by a tenth (the X) and this dilution has itself been diluted to the same degree 20 times. 30C means the base has been diluted (in water or alcohol) 100 fold (the C) and this has been repeated 30 times. It is known that, by virtue of Avogadro's rule any remedy diluted further than 12C will have no trace of the base material in the solution - after that you’re diluting water. The most extreme dilutions (200C for example) would require an amount of water equivalent to the total number of all molecules in the known universe to give a chance of there being even a single molecule of the base solution within it.

Then, as if this wasn’t all credibility-stretching enough, homeopaths go on to claim that the more dilute the remedy, the stronger the "potency". So ironically remedies of 12C or below which could actually contain an active ingredient are held to be weak and ineffective whereas remedies containing nothing but water are considered so powerful by the homeopathic cognisenti they could do permanent harm in the wrong hands.

Thanks for the memory:
Homeopathic proponents maintain that water must have some sort of memory and can somehow retain an imprint of the base material throughout these serial dilutions while at the same time conveniently managing to forget about all the unavoidable contaminants present even in the purest of water samples. Even a single molecule of silica from the glass vials used in the process would count as massive contamination on the scale of dilutions homeopaths work with. This memory is supposedly promoted by "sucussion", the bashing or vigorous shaking of the solution between dilutions. Hahnemann felt a leather bound bible was most effective for this purpose he gives no explanation or information about how he came to this conclusion, he just seems to have decided this was the best way.

Speculation about possible mechanisms for this 'memory' have, over the years included a spiritual force, electricity, molecular 'holes', molecular vibrations, the clumping of water molecules (a genuine phenomenon but one which last for nanoseconds only), “spallation”, so called "nano-bubbles", chaos theory and most recently quantum physics. Some even claim to have isolated this memory signal and encapsulated it so that it can be transmitted to the patient by telephone or email or can be incorporated into preposterous machines such as the Voice Programmed Remedy Maker (4) or the E-lybra machine (5) where you put a bit of the patient in one part of the machine, press a button and take your magically potentised pillules out of another.
No evidence has ever been found for any sort of memory of water despite years of research and numerous false claims from enthusiasts. Even if such evidence were forthcoming though there would still be a problem. Often homeopaths will not use water (or alcohol) based remedies directly but will transfer the remedy to sugar tablets. This is done by simply putting a drop of potentised water into a pot of pills. The properties of the liquid are then supposed to transmit to the solid tablets by an unexplained process known as grafting. In some cases homeopaths will go further and claim to be able to potentise a whole bottle of ordinary sugar tablets by dropping a single potentised tablet into the pot. No one so far has even broached the subject of the memory of sugar.

The evidence Watson:
The fundamental principles of homeopathy are nonsensical. Homeopathic remedies are mere water or sugar or alcohol - nothing else. There is no potency, no magic energy, no ‘life force’ possessed by any remedy. It is impossible to distinguish between different remedies by any known means of analysis other than reading the label. If homeopathy is found to work it will mean that there is a major property of water in its liquid state which has so far been missed by every observer and researcher since the time of Aristotle; a major gap in physics itself which homeopaths alone are able to see.

That is the reason homeopathy has such a credibility gap and why it is so important to scrutinise papers which claim efficacy for homeopathy carefully. There is just too much vested interests among homeopaths to prove their modality works that they will quote trials which time and again are found to be sub-standard with poor methodology, inadequate blinding and inadequate statistical strength. Highlighting these shortcomings makes no difference and the same papers will be recycled time and again regardless. Homeopaths will always quote positive evidence, regardless of its quality, so long as it supports their preconceptions that their modality works.

The truth is, when the big picture is considered and the poor quality trials separated out from the relatively few good ones the blindingly obvious conclusion is that there is no evidence that homeopathic sugar tablets perform any better than ordinary sugar tablets. The latest in a long line of quality meta analyses disproving homeopathy (6) concludes,  

"Our study powerfully illustrates the interplay and cumulative effect of different sources of bias. We acknowledge that to prove a negative is impossible, but we have shown that the effects seen in placebo controlled trials of homoeopathy are compatible with the placebo hypothesis" and "This finding is compatible with the notion that the clinical effects of homoeopathy are placebo effects".

Many sources of good quality evidence refuting homeopathy are available but you don’t have to take my word for it. Have a look at the report of the UK parliamentary committee on science and technology (7) which spent days looking at all the available evidence on homeopathy and taking lengthy submissions from representatives of homeopathic bodies, industry and science. The committee concluded, "To maintain patient trust, choice and safety, the Government should not endorse the use of placebo treatments, including homeopathy. Homeopathy should not be funded on the NHS and the MHRA should stop licensing homeopathic products". Furthermore the witnesses for homeopathy were accused by scientists and the committee of misrepresenting the evidence and submitting trials which were negative for homeopathy or whose authors didn’t make the conclusions that the homeopaths claimed they did (8).

This delibarate misrepresentation is a well worn homeopathic chestnut, as we have seen in this very blog (9) and from our own home grown veterinary homeopaths (10). Unfortunately for the British Homeopathic Association you can't get away with the old "post-some-impressive-references-then-hope-no-one-actually-reads-them" ploy in every case and submitting evidence to parliamentary sub-committees isn't the same as doing a drive by posting to someone's blog and keeping your fingers crossed that no one will notice.
Many call this approach disingenuous, others might call it lying. As for me, well, I couldn't possibly comment.
Come on homeopaths, time to wake up and smell the Coffea Tosta!

Aillas

1 - http://www.hominf.org/articles/posheal.htm [accessed 24-8-10]
2 - http://www.btinternet.com/~wellmother/venusprover.htm [accessed 24-8-10]
3 - http://www.biolumanetics.net/tantalus/Cases/BerlinWall.htm [accessed 24-8-10]
4 - http://www.remedydevices.com/ [accessed 24-8-10]
5 - http://www.bio-resonance.com/elybra.htm [accessed 24-8-10]
6 - Shang et al 2005, Are the clinical effects of homoeopathy placebo effects Lancet; 366; 726-32 available online http://www.sld.cu/galerias/pdf/sitios/revsalud/are_the_clinical-effects-of-homoeopathy_placebo-effects.pdf [accessed 24-8-10]
7 - http://www.publications.parliament.uk/pa/cm200910/cmselect/cmsctech/45/4507.htm [accessed 24-8-10]
8 - http://www.guardian.co.uk/science/blog/2010/feb/04/homeopathic-association-evidence-commons-committee [accessed 24-8-10]
9 - http://tiny.cc/awutm [accessed 24-8-10]
10 - http://vetpath.co.uk/voodoo/vettimes4.html#taylor5 [accessed 24-8-10]

More on NHS Tayside

An interesting development with the NHS Tayside advertisment for a homeopathic doctor.

While re-visiting the web-page featuring the advert in order to find out where to send my application I found that every contact detail apart from the address of the recruiting agency involved has been removed!  I'm pretty certain they were all there as you'd expect when I first viewed the site a few days ago but now there is zilch, nada, nowt.  No address for Ninewells hospital or for NHS Tayside, no emails, no phone numbers, no fax numbers.

I wonder why?  Could it be that they prefer not to hear the howls of protest from those with enough common sense to see that it is inappropriate for the NHS to sell sugar and water to patients suffering from real diseases.
 

We can but hope.
 

Aillas

NHS Tayside wants a homeopathic doctor

Incredibly, in these times of austerity, having already made 500 redundancies in conventional care NHS Tayside is advertising the post of "Homeopathic Doctor" to work 2 days a week for the princely sum of over £68,000 per annum. This is so insensitive on so many levels it is almost obscene. Let me rephrase - that's nearly £70,000 per year to dispense sugar tablets while at the same time hospital beds are being closed and staff laid off. These people want their heads examined.
Still, what can you do. So, in a spirit of 'if you can't beat them, join them' I decided, reluctantly to offer my meagre talents. After all, I was born and raised in Tayside so I must have a 'harmonic resonance' with the area - that's got to count for something, surely?
Here's my contribution:

Dear Sir or Madam,
I am writing following your advertsement on the NHS Scotland web-site for a homeopathic doctor. I would like to apply for the post as I feel I have a number of attributes which make me uniquely qualified.
While taking your point about preferring a qualified doctor, as a veterinary surgeon I am not subject to inconvenient pressure from groups such as the BMA and parliamentary sub-committees on the subject of alternative medicine and I hope I might be considered should a suitable medically qualified candidate not be found.
Although my expertise is primarily as a practitioner of Voodoo (I am a member of the British Veterinary Voodoo Society (BVVS)) there are many similarities between Voodoo and its younger cousin Homeopathy as I hope to explain. Apart from anything else there are precisely equal amounts of convincing, scientific evidence for the efficacy and safety of both disciplines.
Although the Voodoo concept of the application of needles to specific points in patient-matched dolls in order to treat medical conditions is no less plausible than the idea that homeopaths can treat patients by the administration of water or sugar it is known that many so called experts, mired in the scientific paradigm, regard both these underlying principles with unjustified suspicion and scepticism. This is in spite of the overwhelming evidence from satisfaction surveys where patients, when asked if they feel better after treament, will invariably respond positively. What further proof is needed for the effectiveness of both modalities. As I often say, if Voodoo doesn't work, why do so many of my patients keep coming back?
Voodoo, like homeopathy is a form of vibrational medicine which relies on the manipulation of a fundamental energy within the body (Voodoo has the ‘Loa’, homeopathy has the ‘vital-force’). The inability of science to be able to demonstrate either of these fundamental forces only serves to underline the need for a more enlightened approach to the “new-health”.
Voodoo practitioners believe that dolls, if carefully prepared using samples of hair, nail clippings etc, will take on many of the energetic properties of the patient under treatment. Similarly homeopaths believe that their remedies are able to transfer energy from the base ingredients (for example dust from the Berlin Wall, dead bees or a feather from the Peregrine Falcon) to the patient via potentised water or sugar thus cancelling out the symptoms of disease. What could be more logical?
I hope the above examples are enough to convince you of the similarities between both these highly respected and most ancient modalities. To demonstrate my commitment to homeopathy I have been researching the subject and I gather that sugar is a fundamental ingredient in many remedies. Once again I am uniquely qualified to advise on local supply issues here, as I was born and raised just across the Tay from Dundee and my mother grew up in Dundee itself.
My mother tells me of a first class confectioners which she used to frequent in Lorimer Street owned by a Mrs Crawford; failing that there was an equally helpful ice cream shop owned by Joe Nolli in nearby Strathmore Avenue. By my recollection there was also an excellent sweetie shop in the Bay Road in Newport-on-Tay when I was a boy. In more recent times my favoured supplier has been the Moffat Toffee Shop (while based outside the Tayside region their Soor Plooms are second to none). I’m sure any one of these establisments could be approached to tender for supply to the NHS. If distance to Moffat is a problem, as a stop gap I have a very good recipe for Abernethy biscuits which have a lot of sugar in them (Maw Broon’s Cookbook, DC Thomson and co ltd 2007 p146).
The above may serve to give you a flavour of what I can bring to this position and I hope you will consider my application favourably. I would like to congratulate you on your enlightened attitude at this difficult time in our economy. When so many others are making cutbacks in conventional care, based as it is on mundane, western concepts of "disease" and so called "evidence", NHS Tayside is to be commended for its forward thinking attitude to energy based medical modalities. After all, if we can't give the public what it wants where would we be.

Yours,

Aillas MRCVS, FFVVS

I think it's in the bag!

If you think you can do better, why not apply yourself. Click here and wait for the comforting 'ker-ching' as the money starts flowing in - http://www.jobs.scot.nhs.uk/ApplySearch/VacancyDetails.aspx?vacNo=348347

Two sides to every story - the Truth vs Andrew Wakefield

So, Dr Andrew Wakefield has finally got his comeuppance from the General Medical Council (GMC) - on what will probably become known as "Wakefield day" one of the the longest and most complex hearings ever held by the GMC has given its conclusions - he has behaved unethically and acted with "callous disregard for the distress and pain the children might suffer".

Wakefield was found to have conducted invasive, risky and unnecessary tests (lumbar punctures, colonoscopies and barium meals) on children for research purposes rather than in their clinical interests. His initial paper, involving just 12 children, was conducted without ethical approval and although the paper reported that no firm conclusions about vaccination protocols could be drawn from the results Wakefield himself told a press conference shortly afterwards that single dose vaccines should be used instead of a combined dose as in MMR.

What he failed to disclose to the press, his colleagues or the journal which published the paper at the time was that he had just patented a single shot measles vaccine which he now makes a healthy living selling in the US. Furthermore, the fact that for the 2 years prior to the "trial" he had been paid £250.00 per hour plus an initial payment of £55,000 by a legal firm to provide evidence against MMR for their attempts to sue manufacturers on behalf of the parents of two thirds of the children in the "trial" also seems to have slipped his mind.

While he was trying to establish his patent on his single shot measles vaccine he founded a pharmaceutical company (Immunospecifics Biotechnologies Ltd, whose managing director was the father of one of the affected children) and tested his vaccine on children without permission or approval and without including it in their medical records or telling the children's doctors.

He was also found to have unethically arranged for his son's friends to have blood samples taken from them during a birthday party - for which he paid them £5.

In a second trial for which he received only provisional approval he was found again to have conducted the same potentially dangerous, unnecessary and unapproved tests on children and to have breached the terms of the ethics committee.

Since his original, extremely small, study others have repeated the work and done research on other aspects of the MMR vaccine until it is now one of the most thoroughly researched medicines in history and no one has ever discovered a causative link between MMR and either bowel disease or autism.

I am not unaware of the irony of Wakefield now being villified by the very press that were lauding him as a leading light and a victim of establishment opression but the Guardian was one of the few papers to maintain a degree of integrity on the affair and their take on the story can be read here: http://www.guardian.co.uk/society/2010/jan/28/andrew-wakefield-mmr-vaccine with Ben Goldacre's comments here: http://www.guardian.co.uk/science/2010/jan/28/mmr-vaccine-ben-goldacre. You can also have a look at the excellent work by journalist Brian Deer who, along with Ben Goldacre, has done fantastic work exposing Wakefields misdemeanours - http://briandeer.com/mmr/lancet-summary.htm

Andrew Wakefield is a bad man - really bad. He isn't a lone maverick, bravely fighting the establishment; he *is* the establishment - he *is* "Big Pharma". He has lied, distorted results, taken undeclared payments and put children's health at risk in order to sell his company's measles vaccine and to make a substantial income from the anti-MMR industry by promoting his own, highly questionable personal agenda. He has plenty of highly vocal followers admittedly but then so do many dubious characters from David Icke to Uri Geller, that tells us nothing about the validity of his work.

There may indeed be two sides to every story but in this case Wakefield's side is just plain wrong. The real victims in this story are the children who have died or been disabled as a result of contracting measles, the unborn children suffering a similar fate as a result of their mothers contracting Rubella, the parents of autistic children driven to distraction by completely unfounded feelings of guilt for having consented to MMR and genuine autism research whose advocates have had to stand by while millions of pounds was wasted fruitlessly refuting the word of someone who the GMC declared today was a "dishonest and irresponsible doctor" who had "flouted the rules in pursuit of his theory - and profit".

If you are reading this (thank you by the way) and you have been affected by autism or are worried about the now discredited link with MMR, possibly feeling guilty that choices you made to protect your children against serious diseases may have caused them harm then please don't. You have no reason to reproach yorself, there is no causal link between MMR vaccination and the development of autism. Wakefield has manipulated the scientific establishment and you into believing his story for reasons of personal gain - please believe me; you have done nothing wrong, he has lied to you. And if you don't believe me then that's ok, but have a chat with these people - the charity SENSE, established by mothers of children made deaf-blind by Rubella infection, really does have something to be worried about by the MMR "scare".

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.