Funding for CAM
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39388.425799.1F (Published 08 November 2007) Cite this as: BMJ 2007;335:951All rapid responses
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Dear sir,
If I was head scratchingly bemused at Dr Vagg's first reponse, I was
hilariously gobsmacked at his second. For a moment, I thought I had
ventured onto a site containing Monty Python scripts:
>>>>Anecdotes, cultural appropriateness and small
unblinded trials are not the stuff of which a credible treatment is made.
Arguments from popularity or authority are also not scientific and
rational, as even the wisest authority can be mistaken on any particular
issue.<<<<
Sure he doth jest?
What is evidence? Is it the word of the patient who goes to a doctor
and says "I have this big lump here...." thereby the doctor makes a
diagnosis?
Is evidence the word of a medical practitioner who says "I think this
might work, so lets see if we can prove my opinion?
Was it the "anecdote" that set William Pickering on the trail of
Digitalis? Though his 1775 paper is today considered a classic, anyone
familiar with medical history of the time is familiar with the expressed
fear of his colleagues who considered his protocols outrageous, far too
toxic, and who publicly condemned him as a potential murderer or menace.
Even if you fast forward to the 1900's medical literature you see
absolute anecdotal classics passed off as wonderful medical advances, such
as:
"Preparation of [autologous]diphtheria vaccine", Dr A. Cowan Guthrie,
BMJ Sept 28, 1935 pg 602. In Monty Python vein, this could be described
as your 'every doctor's guide as to how to make a vaccine for your patient
in your kitchen."
Or how about the Lancet, March 23, 1935, Page 703, where Dr W.H.
Palmer described how there is no doubt that his "kitchen" vaccine made
from daffodil stalks, to prevent lily rash, works a treat.
Those of us who make a habit of looking at "evidence" cannot
understand why it is, when you go to a site like www.clinicaltrials.gov
and stick in any of the new vaccine trials, you see such a comprehensive
list of exlusionary criteria, which have always applied in the past and we
have no doubt will apply in the future.
This list usually applies through all phase trials, and yet, when it
is declared "safe", parents are then told the vaccine is safe for their
perhaps immunosuppressed child who needs it even more than healthy
children! Yet said type of child (and many other "fragile" children) never
even made the cut for any phase trials whatsoever!
So then, when you look at evidence, what is evidence?
Where is the proof? How much of what is done today is, as
Professor Silverman* said in his instructive comments, the "lets try it
and see" approach:
>>>>The impatient let's-try-it-and-see approach in the
burgeoning field of neonatal medicine has resulted in therapeutic disaster
after disaster. It is extremely difficult, I've learned over the years, to
convince physicians about the importance of a hard-won modern lesson (the
amazing sulfisoxazole incident was the most indelible and instructive
example).
Since knowledge in medicine is never complete, the use of concurrent
controls in clinical trials of proposed interventions cannot prevent all
therapeutic catastrophes. But the precaution can always bring about a
substantial reduction in the number of patients maimed and killed as the
result of inevitable surprises!<<<<<<
One of the biggest problems in medicine today, is that doctors who
only reach for the Merck Manual, behave is if they know it all. And when
a patient comes with anecdote and says "Hey, Jeeves, this
acupuncture/homeopathy/herbal worked a treat!" they are told "That's not
evidence!"
When you look at ALL the treatments available in your doctor's
waiting room, how many of them are based on evidence which fulfills the
criteria Dr Vagg would have Dr Heptonstall produce?
For those who have had a long hard look into the cupboard on locked
away medical history, it looks to us as if "anecdote" can be manipulated
to mean "evidence" when it suits a doctor, or a vaccine trial to make it
appear so.
Isn't it odd that when it comes to the views of their patients, or
any potential treatment protocol which might fall outside technocentric
pharmacology, that the standards of 'evidence' required by the Vagg's of
this world, from the Heptonstalls of the world, appear not to be the
standards of evidence to which, in practice, the Vaggs would adhere
themselves!
Which has got to be very strange, don't you think?
Hilary Butler.
* Silverman WA (2003). Personal reflections on lessons learned from
randomized trials involving newborn infants, 1951 to 1967. James Lind
Library (www.jameslindlibrary.org).
Accessed Friday 23 November 2007.
http://www.jameslindlibrary.org/essays/cautionary/silverman.html
Competing interests:
None declared
Competing interests: No competing interests
Rather than detail here for Mr Vagg a necessarily large quantity of
examples from an enormous number of studies that inform chronologically on
TCM research, practices and principles and generate the scientific
evidence that proves the existence of, and many characteristics of, TCM
phenomena such as meridians, acupoints and Qi, that Vagg has probably
never read, I will now place that data at
www.morleyacupunctureclinic.co.uk under ‘Research and General Information
on TCM’ article 2 on research developments in China from 70s to 90s for
easy access.
To help inform Mr Vagg in this medium I will begin by quoting WANG
Xuetai of the Chinese Academy of Traditional Chinese Medicine, Beijing, in
his “The Exploration on the Tendency of the Development of Acupuncture-
Moxibustion from its History” World Journal of Acupuncture &
Moxibustion, Vol 3, No 4, December 1993 and “The Current Situation and
Prospects of Acupuncture”, World Journal of Acupuncture & Moxibustion,
Vol 7, No 4, December 1997 – comments already 10 years old.
“Since the seventies our researchers have observed the propagated
sensation, paresthesia and skin diseases along meridians, transmission of
sound information, isotopes, weak illuminance phenomena along meridians,
and there has been a new progress in research on the correlation between
internal organs and points on the meridians, and the electric
characteristics of skin along the meridians. Thus the objective existence
of the meridian phenomenon, its specific properties and conditions of
appearance have been demonstrated and mastered preliminarily by
thoroughgoing investigation…by means of various kinds of new measurements
of detection such as the infrared radiometry, energy spectrometry,
detection of magnetic information, effect of pressure and electric field
and the electrostatic concentration etc. scientific researchers have
proved ‘the external Qi’ put out by the master of Qigong, and also
observed its influence on living beings and microbio-organisms. The above
progress of research indicates that, in the process of exploring life
phenomena scientists are making a break through the limitation of
experimental methods of reductive analysis in western medicine and
introducing directly the newest scientific method, especially the
detective measurements of information, into the field of human body
science…In the time of flourishing science, people have already recognised
that there are three important elements, information, energy and matter,
which constitute the universe. Thus the human body can undoubtedly be
manifested comprehensively by these three elements. We can not help being
sorry to indicate that the human science has been limited much more in the
structure and function only with less investigation on the information of
the human body up to now…(In 1997 paper he added new advances of the early
90s including…) distribution of Ca ions ++ along meridians and its
formative mechanisms, appearance of liquid crystal substance along
meridians, relationship between extracellular matrix and meridians etc…and
some results from acupuncture clinics and meridian studies have shown the
possible close relation of connective tissue with the essence of
meridians”.
Ten years ago, by 1997, researchers had also reported numerous
studies using electron microscopy of the ‘ultrastructures’ affected and
effected by acupuncture, whilst a team at Xian Medical University Research
Laboratory of Meridians reported discoveries of neuromastocytic junctions,
a junction specifically established between the expanded axon terminal and
certain mast cell belonging to type A junction (already reported by ZHANG
in 1985), axons approaching the junction run in the direction of the
meridian and a link with Substance P activity also strongly suggested
association with the meridian phenomenon. A multidisciplinary team in
Beijing from the Institute of Biophysics, Hospital of Qinyang, Hospital of
TCM, Union Medical College and Institute of Aeronautics and Astronautics,
studied the low impedance nature of meridian lines on the epidermis and
stratum corneum and its morphology etc. They evidenced the existence of
meridian lines/channels, that the Chinese have long known as conduits for
Qi, blood and other substances.
The lines/meridians involve cellular structures, including nerve and
mast cells and others, communicating energetically at specific frequencies
throughout the whole body maintaining equilibrium through feedback from
and to every point of consciousness. The meridian lines are characterised
by low electrical resistance therefore higher conductivity to facilitate
this communication, are generally fixed anatomically, have the ability to
override and reroute signals during damage or inhibition of communication
at local sites. Each acupoint has its own ‘sound’ identification 'code'
for ease of communication with control structures, and meridians that
connect with and pertain to certain internal organs were shown to be
capable of communication with those organs.
Qi refers to vital energy, energy that is associated with life. In
western medical terms energy has a much more limited meaning, ATP is one
form understood by medical research chemists looking at the human body.
According to TCM there are many forms of Qi, many forms of energy (just
like the general physics concept of energy), for example energy derived by
through respiration, food and drink, plus that derived at birth from
parents, a universality of the concept Qi includes every form known (and
as yet unknown) to man.
Meridian energy is characterised by weak bioluminescence identified
in Chinese research during the 70s and 80s which evidences electromagnetic
signals travelling between cells along meridians; magnetic and electrical
signals have been identified along meridian lines, Russian biophysicists
identified radiation emission spectra from human cells intracellular
structures such as mitochondria and nuclei many decades ago including
visible light in HeNe wavelengths, ultra violet, infrared and plasma
emissions from various intracellular structures – emissions suggestive of
potential for universal intercellular electromagnetic communication.
TCM is founded on empirically derived, well tried and tested, proven
research and practices thus illustrating how much safer, and in many cases
more powerful, are its forms of intervention than western medicine (WM).
It carries an infinitesimal risk of serious injury as compared to WM which
is statistically proven to be the most injurious, in terms of mortality
and morbidity, cause known to man. For that reason alone one ought to
question the protocols and ‘science’ that underpin practices and
principles fundamental to WM research that result in such potentially
dangerous interventions; one can learn from the Chinese and their
evolution of TCM. Every western medical physician ought to become aware of
the effectiveness, efficacy, safety and range of disorders treatable
successfully by TCM modalities and the enormous wealth of scientific data
that underpins TCM. The public deserves no less from those assuming the
task of promoting health.
John H.
Competing interests:
Traditional Chinese Medicine Specialist
Competing interests: No competing interests
I am happy to address John Hepponstall's query to clarify that the
basis for acupuncture in TCM is the flow of Chi/Qi through meridians.
There is no anatomical or physiological evidence for the existence of
these meridians despite much research. The literature on acupuncture's
effectiveness has the overall pattern of a non-effective treatment, ie
small trials are promising but the higher quality the study, the smaller
the treatment effect, with the most rigorous studies being negative. My
comment was intended to highlight the logical fallacies used in defence of
acupuncture and other such treatments. Anecdotes, cultural appropriateness
and small unblinded trials are not the stuff of which a credible treatment
is made. Arguments from popularity or authority are also not scientific
and rational, as even the wisest authority can be mistaken on any
particular issue. Practitoners of TCM cannot simply retreat into their
practices whenever negative evidence emerges if they wish to be taken
seriously. If they don't wish to follow scientific method like the rest of
us, discussions such as this are essentially meaningless.
Competing interests:
None declared
Competing interests: No competing interests
Could Michael F Vagg qualify his statement "acupuncture (for which
there is no rational scientific basis......)" as it is at odds with
multitudinous published research, global demonstrations and anecdote
amongst billions of peoples, empirically derived (and recorded in
classical texts) evidence over millennia, and World Health Organisation
assessments and subsequent recommendations for more than 30 years?
Regards
John H.
Competing interests:
Traditional Chinese Medicine Specialist
Competing interests: No competing interests
Michael Vagg's comments including these statements...:
>>>Homeopathy, chiropractic and herbalism to name but three
adhere to received doctrines which have not changed despite at least a
century of evidence that they are ineffective.<<<
... shows me several things, but first a digression.
Along with millions of people, I have used my own herbs with
considerable success. I have a raft of herbals that work very well with
the flu for instance. Doctors say that what is needed to stop the flu is
a vaccine and when that doesn't work, miserable people are prescribed
paracetamol, tamiflu, a cough suppressant, as well as antibiotics, for
those secondary infections that might come along.
I've had minimal usage of homeopathy, but when I have, it too has
been successful. A chiropractor got rid of a headache that neither the
doctor, physio or paracetamol would budge.
These MILLIONS of people who prefer CAM would stop using it if it
wasn't working.
What has been notable to me is that when I went to the doctor with
various issues, first line "solutions" to problems were expensive
prescription drugs, or a steroidal cream, one of the now banned Cox-3
inhibitors, all items designed to remove a wodge out of my wallet.
I declined them all, decided to use CAM and on the back of "negative
evidence" got better. Either because of, or in spite of.
I'd say this state of affairs might apply to MILLIONS of other people
as well.
If "negative evidence" helps so many people better, what is the
rationale for the wholesale prescriptions of potentially toxic, very
expensive drugs etc, for conditions, which Dr Vagg will maintain that CAM
didn't fix at all? If all I needed was to sit and wait or be given a
placebo, why then prescribe unnecessary expensive, potentially toxic
drugs?
Is arguing against funding CAM more a cover for making sure that the
"just in case" pharmaceutical profits are kept as high as possible, for
perhaps "no good reason"?
Vagg says: >>>The history of the enlightenment would suggest
that old knowledge should be discarded in the light of new evidence.
<<< Yes, I notice that so many people talk about how much safer
and preferable caesarians are these days....
Maybe some lessons can be learned by doctors from the realisation
that some people are done with the first line "best practice" of being
vaccinated, drugged etc, and being expected to comply like automatons for
something that feels like supporting a doctor/pharmaceutical partnership.
Maybe there is more to "medicine" than that, and just perhaps, CAM
sometimes supplies it.
Hilary Butler.
Competing interests:
None declared
Competing interests: No competing interests
Lewith's assertion that 'CAM' treatments are used in pain clinics is
based on a confusion between 'mind body treatments' and legitimate
cognitive-behavioural therapy, which has consistently proven effective in
self-management of chronic pain. Similarly, he may be confusing
acupuncture (for which there is no rational scientific basis) with dry
needling techniques for myofascial pain (for which there is a rationale
and in vivo experimental evidence of benefit ).
His assertion that 'Much of our current conventional pharmacopoeia is
derived from herbals' is mostly true but irrelevant in the context of the
topic under discussion. Is Lewith suggesting that we should use ground
fungus instead of cyclosporin ?
The history of the enlightenment would suggest that old knowledge
should be discarded in the light of new evidence. Homeopathy, chiropractic
and herbalism to name but three adhere to received doctrines which have
not changed despite at least a century of evidence that they are
ineffective. A sensible approach to the acquisition of knowledge should
include a preparedness to accept negative evidence when it is presented .
Competing interests:
None declared
Competing interests: No competing interests
Re: Re: Reply
If these tests are so accurate, and meridians and qi do exist. Why
is it when
studies with extremely good methodology (i.e using control groups along
with people thinking they are receiving real acupuncture even though it is
sham acupuncture, or the study where there was a sheath around the needle
and the needle never even pierced the skin) that it always turns out that
either acupuncture shows no efficacy or shows the same efficacy as fake
acupuncture.
Fake acupuncture is defined as randomly placing needles in the skin,
not
deep enough to touch the meridians.
Seeing as how this is the case, it could be argued that there is some
mechanism that helps us by the mere simple act of sticking needles in your
skin, but that means that we should all save ourselves some money because
paying for the expertise doesn't make a difference. Just stick yourself
with
needles at home.
Also, if you did it at home, it would most likely be MORE hygienic as
subscribers to the acupuncture dogma typically don't accept the
concept of germ theory (I could be generalizing but this is based off my
anecdotal evidence combined with the core beliefs of acupuncture) , so why
be hygienic?
Also, do not take in to account studies that group acupuncture in
with the
practice where they stick needles in your body and send an electric
current
through the needles. this artificially skews the results because:
A) it is NOT acupuncture
B) electricity already has proven efficacy when it comes to pain.
In short, you hurt somewhere, run electricity through it, it will hurt
less. But
again, this is NOT acupuncture.
It is important to look into the methodology of studies that come out
and not
rely on their conclusion. A very common pattern for treatments that do
not
work is that when tests are small, or done poorly with bad methodology, it
shows promise. But as the tests become more thorough and have better
methodology the effectiveness slowly disappears. This is the case with
acupuncture, do not be fooled, it is a sham.
National Council Against Health Fraud : NCAHF Position Paper on
Acupuncture http://www.ncahf.org/pp/acu.html.
Acupuncture and Knee Osteoarthritis A Three-Armed Randomized Trial
Hanns-Peter Scharf, MD; Ulrich Mansmann, PhD; Konrad Streitberger, MD;
Steffen Witte, PhD; Ju ̈ rgen Kra ̈ mer, MD; Christoph Maier,
MD;
Hans-Joachim Trampisch, PhD; and Norbert Victor, PhD
Ann Intern Med. 2006;145:12-20. www.annals.org. Never letting data get in
the way of conclusions.
Meta-Analysis: Acupuncture for Low Back Pain Eric Manheimer, MS;
Adrian
White, MD, BM, BCh; Brian Berman, MD; Kelly Forys, MA; and Edzard Ernst,
MD, PhD Intern Med. 2005;142:651-663. www.annals.org. More intellectual
dishonesty from what was once a trusted source of medical information.
Competing interests:
None declared
Competing interests: No competing interests