Dara O’Briain is an Irish comedian who often takes a skeptical view of things. This brief video offers a refreshingly frank take on homeopathy and nutritional woo. Be warned, though, that it also contains a good bit of profanity.
The World Health Organization is, like most UN entities, is a highly political creature. It tries to promote health in a bewildering variety of political, economic, and physical environments, and I give it full credit for what it manages to accomplish in the face of such challenges. Unfortunately, it has generally been forced by political and cultural considerations into an unfortunately weak stance on alternative medicine (or as WHO prefers to call it, “traditional,” as inaccurate as that term is for most CAM therapies).
While the official statements of the organization on traditional medicine usually include some reference to the need for validation by scientific evidence, they also tend to take a “more study is needed” approach even to the ridiculous and clearly disproven varieties of CAM. Here is an example of the usual WHO posture:
WHO and its Member States cooperate to promote the use of traditional medicine for health care. The collaboration aims to:
However, it is nice to see that WHO can be more assertive when the dangers of CAM are especially clear. A number of researcher scientists and doctors associated with Sense About Science issued a statement in June asking WHO to condemn the use of homeopathy in treatment of HIV, TB, malaria, influenza, and infant diarrhea. These serious disease sicken and kill millions, especially in poor nations with limited health care resources, and the statement articulates what should be obvious; that offering clearly ineffective treatments for life-threatening diseases, especially when proven medical therapies exist and resources are limited, is unethical, impedes control of these diseases, and causes a great deal of unnecessary suffering.
In response, a number of WHO officials have issued responses clearly acknowledging that homeopathy is useless, and even potentially harmful, when used in serious diseases.:
Dr Mario Raviglione, Director, Stop TB Department, WHO: “Our evidence-based WHO TB treatment/management guidelines, as well as the International Standards of Tuberculosis Care (ISTC) do not recommend use of homeopathy.”
Dr Mukund Uplekar, TB Strategy and Health Systems, WHO: “WHO’s evidence-based guidelines on treatment of tuberculosis…have no place for homeopathic medicines.”
Dr Teguest Guerma, Director Ad Interim, HIV/AIDS Department, WHO: “The WHO Dept. of HIV/AIDS invests considerable human and financial resources […] to ensure access to evidence-based medical information and to clinically proven, efficacious, and safe treatment for HIV… Let me end by congratulating the young clinicians and researchers of Sense About Science for their efforts to ensure evidence-based approaches to treating and caring for people living with HIV.”
Dr Sergio Spinaci, Associate Director, Global Malaria Programme, WHO: “Thanks for the amazing documentation and for whistle blowing on this issue… The Global Malaria programme recommends that malaria is treated following the WHO Guidelines for the Treatment of Malaria.”
Joe Martines, on behalf of Dr Elizabeth Mason, Director, Department of Child and Adolescent Health and Development, WHO: “We have found no evidence to date that homeopathy would bring any benefit to the treatment of diarrhoea in children…Homeopathy does not focus on the treatment and prevention of dehydration – in total contradiction with the scientific basis and our recommendations for the management of diarrhoea.”
Certainly, we might hope for more global and definitive statements on the importance of employing strictly evidence-based, scientific medicine in world public health efforts, but it is at least encouraging that when the consequences of a politic, but ultimately irrational, stance are high enough, even such a political organization has to openly acknowledge that science offers a far better hope for reducing human suffering than faith-based approaches such as homeopathy.
I’ve often thought that the following two maxims apply to American culture generally, but especially to medicine in the US:
1. It is never appropriate to say, “There is nothing that can be done.”
2. Nothing is ever Nobody’s Fault.
The latter, along with simple venality, explains the excessive litigation that helps make human health care so exorbitantly expensive here, though it is far less damaging to veterinary medicine, at least for now. The former, I believe, plays a large role in the popularity of alternative medicine.
While some few people reject science entirely, and turn to alternative approaches for ideological reasons, most people accept and eagerly take advantage of mainstream scientific medicine when possible. However, the epistemological and ethical nature of science is such that those of us who practice scientific medicine are obliged to admit to what we don’t know, and we are obliged to tell patients or clients when science has no answers nor effective diagnostic or therapeutic options. Alternative approaches based on faith, intuition, mysterious and undetectable forces, and so on are under no such obligation. So many people turn to CAM at the point where science has nothing satisfactory to offer them.
Accepting the inevitability or intractability of disease and death with only comfort measures to ease the passage is not an option for many people raised in the can-do, American culture. We are accustomed by our history and national temperament to subduing nature and continually improving our condition. Ironically, the successes of scientific medicine have contributed greatly to the expectation that there will always be an answer and a cure. And, of course, the natural drive to live impels us to reject any acceptance of dying as long as we can maintain the illusion that there is real hope.
All of this informs not only why people turn to CAM, but also how we handle people who have made such a choice out of desperation. One school of thought is that any comfort possible should be given those for whom no real meaningful therapy is available. If they feel better, despite the lack of any real, measurable change in their condition, that has real value. This is part of the argument for taking advantage of the placebo effect, and it has some merit, at least in human medicine. I have serious doubts, however, about the ethics of this approach in veterinary medicine, where the comfort obtains only for the owner, while the patient continues to suffer.
We must realize that allowing the comfort of false belief is not without risks. What’s the Harm is full of stories of people who died with much unnecessary suffering because accepting the palliative care scientific medicine had to offer was an acknowledgement of the inevitability of death, and so they chose the false hope of CAM treatments. Some alternative therapies have known risks, and because they are not adequately studied others may have risks we are unaware of. There is even some evidence that cancer patients who use CAM have worse outcomes than those who do not, possibly because they take less full advantage of scientific therapies or because of the deleterious effects of CAM therapies.
Nevertheless, we also have to acknowledge and have compassion for the fear and suffering that leads people to choose unproven therapies as a last resort. Discussions about the inevitability of death and the limits of human knowledge and technology are hard to have in our culture, but I don’t think they need be off limits for health care providers. Certainly, it is not appropriate or useful to challenge someone’s philosophical or metaphysical beliefs in a health care setting, but when we tell someone that the CAM straw they are grasping at is unlikely to help and has the potential to harm, I think it helps to acknowledge the feelings that lie behind the grasping and to offer the same kind of simple human comfort that CAM providers often give, without the concomitant false hope.
I recently met a smart, clever man living with diabetes who had written a very funny song about the Placebo Effect. He has spent much time and energy looking at the best way to manage his disease, and he has done his best to rationally evaluate the recommendations both of his doctors and of the friends, family, and strangers who promote alternative approaches. This has engendered a certain frustration and a bit of pessimism about the ability of human beings to understand and manage the complexities of living organisms and their diseases.
While we didn’t agree entirely on the reliability of scientific knowledge or the meaningful differences between CAM and scientific medicine, I was impressed by his intelligent and thoughtful approach to epistemological questions which had a sharply personal significance for him. Our conversation helped me to better understand the psychology behind people reaching for what seem to me to be clearly useless, irrational therapies. Contrary to the mythology CAM providers often promote, science-based medicine providers do care about the whole patient and the totality of their well-being, and this compassionate “holistic” attitude must always be at the center of our attempts to provide the best care and educate our clients/patients about the difference between science-based and faith-based medicine. If we understand and acknowledge the legitimacy of the needs that lead people to unproven therapies, perhaps we can better steer them to those approaches that are the most likely to benefit them.
I was recently asked to comment on an advertising card for Evolution Diet. There are a number of claims made, and because they are vague and wildly inflammatory, it is difficult to address them in an evidence-based manner, but I’ll do my best.
1. “Up to 30% Longer Life Expectancy”. This is in large, colored type adjacent to the name of the diet and a picture of a puppy and kitten. No evidence is presented on the card or the various websites associated with the company or the CEO Eric Weisman. Much is made of a couple of studies linking calorie restriction to some increase in life expectancy in various experimental animal studies. This is an interesting area of research, but it has no connection to the implied benefits of feeding this diet.
2. According to this advertisement, the pet food industry “provides a convenient way for the disposal of slaughterhouse toxic wastes unfit for human consumption” “hard to digest, nutrient deficient toxic ingredients include: intestines, udders, stomachs, lungs, heads…drugs and pharmaceuticals (antibiotics, hormones)…euthanized pets.”
A wild string of fallacies, nonsense, and outright lies. It is true that some parts of animals that people think of as icky are used to make pet food. But if lungs, intestines, stomachs, eyeballs and so on are all toxic, then why aren’t they poisoning all those cats who hunt rodents and birds, or for that matter every other carnivore that eats them routinely in the wild? Of course, Mr. Weisman would say they are, but the logic behind claiming that an obligate carnivore like a cat or ferret is healthiest if fed a vegan diet is bizarre and indefensible.
Antibiotics and drugs used in agricultural animals (which are then used to make pet food) are regulated very tightly because we eat the meat from these animals, and there isn’t any more of these things in the pet food that isn’t also in the steak we eat, which is to say little to none under normal circumstances. There are some real and serious issues about what we feed to animals intended for consumption, but these have little to do with the claims Evolution Diets makes.
The pentobarbital thing I addressed in my previous discussion of nutritional myths, and you can find the details on the FDA web site. In short, miniscule amounts were found in some (not “all”) foods tested, but no traces of dog or cat DNA were found in these foods, and there are separate companies and facilities involved in rendering companion animals and agricultural animals used to make pet food, so it’s pretty darned unlikely there are regularly pets in pet food. No one is sure where the pentobarbital comes from, but it’s possible a euthanized horse occasionally makes it into a rendering plant that provides ingredients for pet food. This is obviously not desirable, but it has also not been shown to represent a real health risk.
Is the amount of pentobarbital in some pet foods toxic? Pretty unlikely. The FDA calculated the maximum exposure and determined it was far too low to represent a danger. And contrary to what purveyors of the naturalistic fallacy generally think, dose matters in toxicology. Enough oxygen or water can kill you, though these are essential for life, and we all get tiny amounts of “natural” and synthetic substances in eating, drinking, and breathing all the time and always have. Common herbs and spices used in cooking have been linked to cancer, as long as they are fed in obscene amounts to rats. Does that mean we’re all going to die of oregano poisoning? It’s a big leap from saying tiny amounts of possibly toxic things are present to showing that there are health consequences to this, and this hasn’t been shown here.
3. “…millions of Dogs and Cats suffer and die each year from cancers, kidney/liver failure, heart disease, etc” and “scientific studies demonstrate that there are nutrient deficiencies for immune system, cardio-vascular and urinary tract precursor proteins in all basic meat, poultry, and fish-based pet foods.” I’d love to take a look at these studies, as I’m sure would all the veterinary nutritionists who don’t seem to be aware of them. AAFCO sets standards which all major manufacturers follow for nutrient content in foods, and I’m not aware of any evidence that every dog food made except this company’s is nutrient deficient and causes disease. The advertisement states the food is “complete and balanced for all life stages,” which at least claims compliance with AAFCO guidelines, just like every other commercial pet food.
As for the implication that cancer, kidney failure, liver failure, and heart disease in pets are somehow due to toxic ingredients or nutritional deficiencies in foods, well they just made that up. It is the most egregious kind of unfounded fear mongering with no evidence provided to support it.
4. “Literally, all major commercial pet food brands and suppliers, including most brand names, have been involved in major pet food recalls that have sickened and killed millions of Dogs and Cats in the U.S.” “Never a Recall!”
I’m not sure it’s possible to check the accuracy of these claims. Certainly, many pet foods have been recalled at one time or another, but I think it would be hard to show that all foods except this one have been. And the implication that this implies the foods are killing dogs and cats is nonsense. Most recalls are precautionary and no actual harm is ever found. And in those cases where some contaminate is actually present, a recall is an example of a responsible action that saves lives. The melamine incident, which I suspect is being referred to, involved a non-animal ingredient (what was supposed to be wheat protein but got adulterated with the melamine). Wheat and corn gluten meal are the first two ingredients on several of the Evolution Diets, and while I don’t know where they get these, the issue of contamination is just as likely to come up for this company as any other.
Interestingly, in 2003 a recall of Go! Natural pet food was conducted due to a number of cases of acute liver failure associated with the food. The underlying cause was never found, but the company manufacturing the food continues to tout it as healthier based on claims about “good” and “bad” ingredients very similar to those made on the Evolution Diet site. Simply claiming something is healthy and natural provides no assurance that it is safe or healthy.
Finally, if you check out the web site for the company producing this diet, you might get a hint of the ideology behind this product from the CEO’s diatribe on the evils of mainstream medicine, and the reason why we could all stop getting sick and dying if we just followed the messianic vision of the CEO of this company, Eris Weisman. Here’s a sample:
“One of the most important reasons why many veterinarians do not like Evolution Diet Pet Foods is because people using them have much healthier pets. When pets become healthier, they become much less dependent on veterinary services and vets make much less money. Sadly, most medical doctors and veterinarians are more concerned about their income then your health or the health of your pet(s) respectively.”
What do you think? Sound like the vets you know? So, once again, it’s the small visionary against the evil establishment, who are all crooked and deluded. He talks at length about how his vision would save humans as well as pets from our toxic environment, and the increase in health and longevity brought about by science and medicine in the last 150 years appears to have escaped him. A messianic version of the David and Goliath complex.
Mr. Weisman is an interesting character. He claims a number of academic credentials, including “2 Diplomats[sic] and a Doctorate in post-graduate Health Sciences at Northwestern Health Sciences University in Minnesota…[and] a National Board Diplomat[sic] for his Post Graduate Work in Health Sciences.” The university he refers to is a college of chiropractic, acupuncture, and oriental medicine, and while I can find no reference to the graduate programs Mr. Weisman claim to have completed, it is possible they are offered there. Likewise, I can find no sign of a National Board of Health Sciences for him to be a diplomate of, but I suppose it might exist. He also claims to have been “a physician in private practice using Vitamin, Botanical, Nutraceutical & Nutrition Therapy for Humans” and makes references to time in medical school, but he doesn’t use M.D. and he recommends Naturopathy, so it is impossible to tell whether he was a true physician or a Naturopath.
In any case, despite offering these credentials, Mr. Weisman disdains formal academic training and the medical profession generally. He says:
“I was not a great student until my later years in post graduate school. Part of the problem I faced in the schools I attended was my constant need to question why things were being taught and if they were true in the first place.
It took me decades to realize that many of the courses taught in schools are based on misinformation and half truths much like television and newspapaer[sic] news. It wasn’t because the teaching staff suddenly decided to inform me, it was because I studied alternate books with different information that opposed what I was being taught in various schools, colleges and universities.”
He clearly likes to portray himself as a misunderstood visionary, as is so often the case for people selling quackery. He begins his essay on the “VETERINARY & HUMAN MEDICINE IN CRISIS and How I Have Extended and Improved Quality Of Life in Cats, Ferrets, Dogs and Humans with Supplements & Nutrition” with a dedication to a number of famous vegetarians, including Max Gerson, originator of the infamous Gerson cancer therapy which, along with its offspring the Gonzalez Protocol, is a shining example of abusing the desperation of cancer patients and torturing them with uncomfortable and irrational diet, coffee enemas, and other nonsense that only magnifies their suffering without treating their disease. He frequently reminds us that most doctors are either simple greedy liars or brainwashed by the media, since we all know “Television and Radio are very powerful influences that easily manipulate most human minds: Except for people like myself.”
Mr. Weisman is clearly driven by the quasi-religious belief that he has a unique insight into the conspiracy of government and industry that exists to keep people and animals ill for profit and to keep them under control. He refers to painful experiences in his own past, including his mother’s mental illness, which he attributes to electroconvulsive therapy experiments performed on her by the CIA and the Canadian Psyschiatric Association*, and the death of his father from heart disease which he attributes to eating meat, fish, and poultry and to the deliberate refusal of doctors to properly resuscitate him from the last of his many heart attacks.* *
Like all of us, he has suffered painful losses of loved ones and had to watch suffering and disease that could not be prevented or cured. But his reaction to this is to reject science, to blame his pain on the deliberate evil and lack of vision of the rest of the world, and then to invent his own reality in which he has simple answers that will make the pain go away. That may be understandable for him as a human being, but it is not justification for selling that private, and false vision to others through hysterical scare tactics and fear mongering, as well as defamation of the medical profession and outright lies. The diets he sells may or may not be perfectly adequate, acceptable pet foods, but they are not the key to preventing or curing death and disease that he claims. And the rest of the pet food industry, of which he is a part despite his protestations, may not be any better than any other collection of people or companies, but it is not the sinister conspiracy deliberately marketing death and disease that he portrays.
I would like to think the Evolution Diet marketing strategy sufficiently absurd on the face of it that it would fail, but clearly this isn’t the case. Smart, well-intentioned pet owners can be fooled and frightened by the unfounded claims and accusations Mr. Weisman makes. Hopefully, demonstrating the lack of evidence, and the bizarre agenda and worldview behind his statements will help people make their own, sound decisions about how to best care for their animal companions.
*”When a child, I dreamt that I could one day free my mother from her long term illness that was caused by an experimental “medical” study procedure (she was made a subject without her permission). I hoped that the knowledge I would accrue from different colleges and universities would help me achieve this goal.
I only found out that my mother was a forced participant in a series of electro-convulsive shock experiments at a Canadian Hospital after I saw an extensive film documentary on CIA studies that resulted in litigation. The litigation was a result of unsuspecting hospital patients being used as subjects for various forms of torture and abuse at three Canadian Hospitals. I went back into my mother’s medical file to find out that she was at the same hospital at the same time refered to in the documentary. In the files were references to a series of electro convulsive shock treatments she recieved at that Hospital over a two month period.
According to the documentary, the CIA and Canadian Psychiatric Association conducted interogation and brain washing experiments on unwitting patients at the same Canadian Hospital my mother went to for a mild case of post partum depression. After my father brought her to that hospital, she was treated with high doses of electro-convulsive shock for her simple problem of unhappy mood linked to increased responsibility with my sister’s birth. During her two months of treatment, she developed a permanent form of advancing dementia from which she never recovered and increased as she aged.
From the bright, intelligent, pretty and generous woman she was, I remember how sick and dull her personality seemed after she came back from her long stay at that hospital. I remember that she was never the same bright person she was before she went in, but I had no complete understanding of why until the summer of 1993 after watching that televison CIA law suit documentary and delving into my mother’s medical records. As I watched the documentery in awe, I did not know then that my mother was going to die from some of the related injuries she sustained in that study just three years later (1996).”
**”It was a cool, wet and dark October Morning in Toronto at about 1:00 AM in 2004. I pulled my father’s car into the Sunnybrook Hospital Parking lot ramp near the front Emergency Entrance and stopped next to a concrete parking wall. I turned off the engine and looked at my pretty twenty-three year old neice Angela and said, “I don’t think he made it.” I was preparing myself for the worst.
Angela was crying “They’re doing all they can to resusitate him, aren’t they?”
Tears had welled up in my eyes. “It looks like a Dog and Pony Show to me. The doctors told me that they did not think he was a good candidate for resusitation. The On Call Doctor told me he did not want to resusitate him. He said that Dad would not make it, but I promised Dad I would have it done. It was the last thing he asked me to do. The doctor told me that Dad has so many forms of organ failure…his heart especially: He has little chance of making it. Just the way they put him on that table in the resusitation room tells me it’s over. That had him lying in a fully recombant position even though he has pneumonia. With all that fluid in his lungs, how can he even breath or be resusitated in a fully recumbant position. I don’t think they were really giving him a chance to make it.”
Angela jutted her head forward and cocked it to the left, looking straight into my eyes, “You think that they would just let him die and make it look like they were going to help him?”
“I think they do this kind of thing every day in hospitals throughout the US and Canada…
I said, “I hope you are going to change your diet. This might be your last chance Dad. I really mean it Dad. I don’t think you are going to make it next time. You’ve got to change your diet for real this time. I can tell by the way you have been forgetting things that you are in trouble…and you haven’t been answering my pahone calls. You just got out of the hospital for heart failure. Don’t you know that everytime you eat meat, poultry, fish or dairy products that you progressively block all of your arteries. It’s very serious because the most important arteries that are being blocked are in your heart and brain. Dad you’ve got to stop eating that stuff…you’ve had five heart attacks and it’s animal fat and animal cholesterol that have caused each one. I don’t want you to die. That’s why we came to visit you. Lynn and I want you to change your diet now. You’ve got to stop blocking your arteries with animal fat and cholesterol…
Flash forward to that cool, wet, dark October Morning. My niece and I entered the special resusitation room and looked at my Dad’s still warm, but lifeless body. He still had a large ortho-pharyngeal tube poking out of his motionless mouth. He looked so still. It was so unlike him. He was a man that lived life to the fullest. If he would have only taken meat, poultry and fish out of his diet when I had spoken to him six months earlier. I knew that he would still be here. Animal fat and cholesterol are what progressively killed his organs by blocking his arteries.”
*
I recently read a commentary by Dominic Lawson, in the Times of London Sunday edition, entitled “Organic Food is Just a Tax on the Gullible.He was referring to a couple of systematic reviews (health benefits and nutritional content) that suggest there are no measurable health benefits an no meaningful nutritional superiority associated with organically produced food . The studies and the commentary add some useful detail to my previous comments about nutrition myths, and they illustrate nicely the seldom-appreciated complexity of making sound decisions about producing food, whether for animals or humans.
Now I’ll admit to a certain sympathy with organic food production, particularly as it seems likely to be less harmful to the environment than conventional industrial agriculture. And I have no doubt that the economic incentives of the agriculture industry lead to just as much malfeasance as those in the pharmaceutical game, or really any other area of economic activity. I believe we now produce more food, of better quality, more efficiently in terms of calories per acre that ever before, and that is itself a good thing, at least for our health as individuals and as a species. However, this increased production comes at a cost, and the use of fossil fuels and pesticides has consequences we must be mindful of.
Nevertheless, I believe in applying the same standards of evidence to all scientific claims, including those I personally find appealing. And I have been skeptical in the past of the nutritional and health claims of organic food proponents, which seem to be based more of the naturalistic fallacy than on any evidence I’m aware of. A reader here suggested I had missed this evidence: “there are increasing numbers of studies documenting that (certified) organic food is more nutritious than conventional (non-certified organic food). They find significantly more minerals, vitamins, antioxidants in most all foods researcher look at.” Unfortunately, the person never responded to my subsequent request for details on these studies.
The first of the reviews Lawson comments on examined the literature from 1958-2008 and found only 11 studies that addressed the question of health benefits from organically produced foods or specific food ingredients. Of these, only 3 studies met the a priori defined criteria for methodological quality. The authors concluded, ” because of the limited and highly variable data available, and concerns over the reliability of some reported findings, there is currently no evidence of a health benefit from consuming organic compared to conventionally produced foodstuffs.” Clearly, this study does not definitively show that there are no health benefits to organically produced foods. But it does show that there is no high quality evidence for such benefits in the literature, which leaves the burden of proof squarely on those who make claims for the health benefits of eating organic foods.
The second study reviewed the literature for the same period, and did slightly better in terms of finding high quality studies. Of over 3000 studies examined, 55 met the quality standards. Based on these, the authors concluded:
“No evidence of a difference in content of nutrients and other substances between organically and conventionally produced crops and livestock products was detected for the majority of nutrients assessed in this review suggesting that organically and conventionally produced crops and livestock products are broadly comparable in their nutrient content. The differences detected in content of nutrients and other substances between organically and conventionally produced crops and livestock products are biologically plausible and most likely relate to differences in crop or animal management, and soil quality. It should be noted that these conclusions relate to the evidence base currently available, which contains limitations in the design and in the comparability of studies. There is no good evidence that increased dietary intake, of the nutrients identified in this review to be present in larger amounts in organically than in conventionally produced crops and livestock products, would be of benefit to individuals consuming a normal varied diet, and it is therefore unlikely that these differences in nutrient content are relevant to consumer health.”
These two reviews have been criticized, not surprisingly, by organic food producers, primarily for their exclusion of studies which support the producers’ claims. Ben Goldacre has already responded to the substance of these criticisms. Clearly, these two reviews cannot not be the final word on the subject. They strongly suggest that when the scientific literature does not support the claims that organically produced food is healthier or more nutritious than conventionally produced foods, but they also show that the evidence is sparse and of poor quality, so we must keep an open mind on the subject. And, of course, none of this bears on the other potential benefits of organic agriculture, including decreased environmental harm and subjective benefits such as better tasting food. These are themselves issues which ought to be investigated in a rigorous way.
Finally, Lawson’s commentary made what I thought was a critical point, nicely illustrate by an anecdote that is humorous, rather than tragic, only because it ended happily. I’ll let him tell it:
“A few years ago my wife decided we should have an entirely organic vegetable garden. To this end she refused all man-made fertilisers [sic] and ordered a truckload of pigeon droppings. What could be more natural? Neither was there anything unnatural in the germs I inhaled through the spores of our organic manure, thereby contracting psittacosis. This developed into “atypical” pneumonia, which was of course resistant to all standard antibiotics. Had a hospital doctor not guessed the cause and put me on a drip with the appropriate drugs – ooh, chemicals! – I could have become a fatal casualty of the organic movement. Obviously my wife might have ordered cow manure rather than pigeon poo[p]; then I could have been felled by E coli instead.”
This is a powerful illustration of a concept promoters of CAM often ignore; every choice has an array of costs and benefits that have to be evaluated and balanced. Vaccines do sometimes cause harm, but to a far lesser degree than the harm of not using them appropriately. And there may be benefits to reducing the use of chemical fertilizers, but one cannot just blithely follow the naturalistic fallacy and assume that organic fertilizers are always better. This sort of cost benefit analysis is always difficult, tedious, and fraught with uncertainty, and it lacks the appeal of simplicity, but it is a crucial part of making the best decisions about medicine, agriculture, or any other complex endeavor.
What is it?
Dr. Edward Bach was a physician and homeopath in England in the late 19th and early 20th centuries. He eventually gave up his medical practice to focus full-time on developing a system of treatment based on elements of homeopathy and his own ideas about health and disease. He believed that all disease was primarily spiritual in origin and due to negative emotions. These emotions are the manifestation of a conflict between the divine energy of the spirit and the limitations and weaknesses of the physical body and the mind. He became convinced that certain flowers posses unique energetic resonances that can help dispel negative feelings and re-establish balance between body and spirit.
Dr. Bach identified the healing properties of specific flowers intuitively, by touching a flower or putting a petal on his tongue and then observing changes in his own feelings. He compiled an extensive list of specific flowers and combinations indicated for specific emotions and situations. The most popular Bach remedy currently is Rescue Remedy®, a mixture of five flower essences purported to be calming during sudden emotional crises.
Dr. Bach initially treated people with dew from flowers, which he believed absorbed the signature energy of the plant, but because of the limited quantity of dew which could be produced he began instead to soak flowers in water and then collect this. The water was then mixed 1:1 with brandy and this stock solution dispensed to patients. The patient generally would take several drops of the stock solution directly or mixed into a beverage. The Dr. Edward Bach Centre continues to produce flower essences by these methods and holds the rights to the term Bach Flower Essence, though other manufacturers make products produced in the same manner under other brand names.
Due to the extreme dilution of the remedies, flower essences contain only very small quantities of alcohol, and they are unlikely to contain much in the way of residual chemicals from the plants used in their preparation. Though they are widely available as an over-the-counter product, Bach flower essences are often dispensed by alternative medicine providers, such as homeopaths, or by Bach Flower Remedy Practitioners (BFRP), who have taken an educational course offered by the Bach Centre. The Centre also promotes the veterinary use of flower remedies, and these products are sometimes given to animals by owners, veterinarians, or alternative medicine practitioners.
Does It Work?
There is no evidence for the reality of Dr. Bach’s model of health and disease. By their nature, emotions are subjective and individual and so difficult to study scientifically. And the concept of divine spiritual energies is a religious, rather than a scientific concept.
It is possible, however, to study whether patients respond differently when taking a flower remedy or a placebo substance not thought to have any healing properties. Several such studies have been conducted with Bach flower essences, and the results clearly demonstrate that humans report positive changes in their feelings when they are given either treatment, with no difference between a flower remedy and a placebo.
For humans, such placebo effects may provide some comfort even if the remedy is nothing but water and has no actual activity. If a person believes their unpleasant emotions will improve when they take such a remedy, this belief may itself be enough to change how they feel. However, since the substance has no actual activity in the body, any physical illness the patient has will remain unchanged.
For veterinary patients, who cannot reflect on and express their own feelings, it is difficult to see how one would choose which remedy to apply. However, some Bach flower practitioners have adapted Dr. Bach’s list of emotions and the corresponding flowers for veterinary use. There have been no controlled studies of these remedies in animals, however in general placebo effects that require a belief or expectation of improvement do not benefit veterinary patients. Such effects based on belief or expectation can, however, influence the owner’s and the practitioner’s interpretation of the pet’s behavior, leading to an impression of improvement where none has actually occurred.
Is It Safe?
Because Bach flower essences are greatly diluted, they generally contain only water and very small traces of brandy or substances leeched out of the flowers. It is unlikely, then, that they would cause any direct harm. However, because they have no actual effect on physical disease, their use can cause indirect harm if it leads to a delay in appropriate diagnosis and treatment for any underlying illness.
Summary
*There is no evidence to support the notion that disease is caused primarily by spiritual and emotional imbalances or that flowers contain any mysterious energy that can correct these imbalances and improve health or treat illness.
*Clinical studies have shown that Bach flower remedies are no different from inert placebo substances in their effects on the emotions of humans using them. While the belief that they will help may itself change a person’s feelings, the remedies have no actual effect on mood or physical illness.
*No objective research on the effect of flower essences has been conducted in animals. Because their effects in humans relies on belief and expectation, it is unlikely that they would have benefit for veterinary patients. However, because owners and others providing care to animals are influenced but beliefs and expectations, they perceive a benefit for an animal given a flower remedy even if no real change has occurred.
References and More Information
Armstrong, NC, Ernst, E. A randomized, double-blind, placebo-controlled trial of Bach flower Remedy. Perfusion 1999;11:440-446.
Bach, E, Wheeler, FJ, The Bach Flower Remedies, Rev. ed. New Canaan, CT. Keats Publishing; 1997.
Ernst, E. “Flower remedies:” a systematic review of the clinical evidence. Wiener Klinische Wochenschrift 2002;114:963-966.
Ernst, E, Pittler, M, Wider, B. eds. The Desktop Guide to Complementary and Alternative Medicine 2nd Ed. Philadelphia, PA: Mosby Elsevier; 2006: 306-308.
Pintov, S, Hochman, M, Livne, A, Heyman, E, Lahat, E. Bach flower remedies used for attention deficit hyperactivity disorder in children-a prospective, double-blind, controlled study. European J Paediatric Neurol 2005;9:395-398.
Thaler, K. et al. Bach Flower Remedies for psychological problems and pain: a systematic review. BMC Comp Alt Med. 2009;26:9-16.
Walach, H, Rilling, C, Engelke, U. Efficacy of Bach flower remedies in test anxiety: a double-blind, placebo-controlled, randomized trial with partial crossover. Anxiety Disord 2001;15:359-366.
© Brennen McKenzie, 2009
http://www.skeptvet.com
In addition to substantive arguments about evidence, clinical studies, and underlying biological or physical rationale, many arguments between supporters and skeptics of veterinary CAM involve myths, stereotypes, logical fallacies, and other rhetorical devices or conceptual errors unrelated to the actual merits of the case being made. The recent discussion in response to Narda Robinson’s article on the Pet Connection Blog has revealed some of the archetypical forms of these, and I thought I’d offer a few possible responses.
1. Argument from Faith-
This, of course, underlies much CAM. Supporters “know” things work because of their firsthand experiences or they have faith in the wisdom of tradition or individual gurus. Apart from the cognitive errors that make anecdote and firsthand experience rather unreliable, the propensity for self-validating belief is a problem in itself. Faith is, by its very nature, self-reinforcing. Belief begets belief, and humans are notoriously loath to give up beliefs regardless of evidence. We hate to have to accept the ambiguity and uncertainty of knowing our personal impressions are less reliable than the objective and impersonal process of science. There is a powerful psychological incentive to reject evidence-based medicine because it takes away our illusions. Supporters of CAVM can claim that because they have believed and practiced these methods, because they have “seen for themselves,” that their wisdom and position of authority must be respected. Sadly, their intelligence and passion and conviction may make them convincing to others, but they don’t make them right. Only well-designed and conducted research which take the biases of passion and conviction out of the evaluation process can prove their case, and they often disdain such because it seems to them beside the point, a mere frill to “prove” what they already “know.”
The emotional intensity of true faith also contributes to the tendency of CAM supporters to perceive disagreement as disrespect, or to act as if respect ought to be a substitute for evidence, but such is the nature of faith-based medicine.
While we should be free to disagree about facts, I find CAM proponents often identify disagreement with suppression of the truth, ignorance, or some sort of political conspiracy. This is part of the David and Goliath Myth I’ve written about before. I try to take their belief in the benefits of the methods they espouse in good faith, and I believe they have their patients’ best interests at heart. Mature and respectful disagreement requires that they treat dissenting opinions likewise because their belief is often a matter of personal faith, they can be quick to dismiss other opinions as disingenuous or motivated by something other than the best interests of our patients.
There are several versions of the “you too” argument. One is that mainstream medicine is itself not evidence or science based and so CAM has an equal claim to legitimacy and efficacy. The specific citation that “only 15% of allopathic medical treatments were based on scientific studies” has been well-debunked.
There is a grain of truth to this assertion. Many mainstream practices have been “grandfathered in” (as, I might add, has the US Homeopathic Pharmacopeia, which was automatically exempted from proving safety and efficacy when food and drug safety laws were instituted in the U.S.). These practices do not have the level of evidence behind them they would require if newly discovered today. However, the level of evidence behind mainstream medical practices is far higher than for alternative practices. And the underlying principles are not grossly inconsistent with established principles of the biological or physical sciences, as is often the case for CAM methods. And rather than considering centuries or millennia of unquestioned use to be a point in favor of a therapy, as does the CAVM community, scientific medicine holds all practices as open to criticism based on logic, reason, general scientific principles, and of course clinical evidence.
Another fallacious form of this argument says that because mainstream scientific medicine makes mistakes and there are bad doctors in scientific as well as alternative medicine, that this is somehow evidence in support of homeopathy, TCM, or other alternative therapies. There is no connection. Scientific medicine makes mistakes, but science is always changing and improving and these mistakes eventually get corrected. Scientists are imperfect human beings, but the scientific method applied over time but many individuals compensates for our flaws. Therapies based on unwavering respect for ancient traditions and validated primarily by personal experience and belief, on the other hand, have no reason to seek and correct mistakes. If Palmer and Hahnemann and the ancient Chinese physicians had it right, then our duty is to follow their advice and not question or challenge it. Western mainstream medicine made this mistake in canonizing Galen and the other Greek physicians and accepting without question both what they were right about and what they were wrong about. And medicine stagnated in a miserable state for centuries. The scientific method changed that and made active questioning and critique a virtue. I know some CAM proponents will disagree and say that we are all drowning in toxins and disease and that the pre-scientific age was a Golden Age, but the history of the succeeding couple hundred years suggests to me that the scientific approach works much better.
In any case, the lack of perfection in scientific medicine is not an argument that no progress has been made or that the method doesn’t work. And it’s certainly not an argument that the exact opposite philosophy is the better alternative.
3. Health Care Choice
A popular defense of CAM in the U.S. these days if the argument that consumers (not “patients”) should be free to choose what kind of health care they want, apparently regardless of whether it works or not. The “free choice” argument is a popular strategy as it plays into the general cultural suspicion of government and the respect for individual freedom. But the “choice” between methods which help and those which do nothing or even harm a patient is not a truly free choice. If one accepts that the government has any role at all in protecting public health, than one has to accept that establishing some reliable and objective standards of safety and efficacy is an appropriate government activity. If, of course, you believe government should stay out of everybody’s business altogether, than you won’t accept this, but that’s really a political not a scientific debate. There is a segment of the libertarian movement that aggressively supports CAM for clearly political reasons, though thankfully there are also many solidly skeptical libertarians as well.
History suggests to me, that the methods of science are better at determining safety and efficacy than tradition and personal experiences. For a thousand years doctors and patients believed bloodletting, purging, cupping, casting out demons, and lots of other non-scientific method of treatment were helpful. Those people were just as smart as we are, but they had the same flaws and cognitive vulnerabilities. We now live longer and healthier lives and eschew those methods because we have developed a better way to determine what works and what doesn’t. This is not cultural chauvinism, it’s just a pragmatic evaluation of reality. And if this is true, then a caveat emptor approach to health care where we are “free” to choose whatever snake oil is sold to us, and the salesmen are free to claim whatever they like without reasonable proof, seems a step backwards and a guarantee of much unnecessary suffering.
The history of government regulation of food and drugs shows some real benefits to limiting the medical therapies that can be made available to those which have some reasonable, scientific plausibility, and the weakening of such laws through legislation such as the 1994 Dietary Supplement and Health Education Act have clearly led to harm, and this argues against the benefits of so-called “health care freedom.”
This is an insightful essay illustrating the ultimately faith-based nature of much CAM. Statements about safety and efficacy and the indications of a treatment are determined by tradition, appeal to authority, or instinct and then justified by anecdote without any objective supporting evidence. What I find as informative as the essay are the voluminous comments, including from the legendary CAVM guru Dr. Pitcairn, illustrating how passionate people become when you suggest that their intuition and personal experience, their faith, may not be a sufficient justification for medical recommendations that don’t have any other evidentiary basis. Enjoy!
It is widely understood that the 1994 Dietary Supplement Health and Education Act has created a wide open and lucrative market for herbal remedies and dietary supplements that don’t have to pass even minimal standards of evidence that they are safe or effective. The act was introduced by Tom Harkin and Orrin Hatch, apparently true believers in CAM and certainly recipients of a great deal of campaign money from the supplement industry. Though some have hoped the new respect paid to objective science by the current administration might lead to reconsideration of this disastrous act, it hasn’t seemed very likely. But there is at least a glimmer of hope.
A report prepared by the General Accounting Office (GAO) evaluating the FDA’s ability to safeguard the public from untested dietary supplements and has concluded that the agency should “request additional authority to oversee dietary supplements, issue guidance on new dietary ingredients, and take steps to improve consumer understanding of dietary supplements.” The report further states that “without a clear understanding of the safety, efficacy, and labeling of dietary supplements, consumers may be exposed to greater risks.” and adds that the “FDA generally agreed with GAO’s recommendations.
Undoubtedly, such reports are generated and molder unheeded in the halls of government all the time. But official recognition from outside the FDA that the current law is inadequate to protect consumers is welcome, and hopefully a sign of things to come.
Many proponents of Complementary and Alternative Medicine (CAM) reject the very idea of scientific evaluation of their methods. If scientists say they can find no trace of Ch’i or vertebral subluxations or water memory, well that shows that science doesn’t know everything, right? These are the easiest CAM believers to deal with because there is nothing to be done except agree to disagree. If mystical and undetectable entities can only be seen and understood by those who have faith in them, then there’s no foundation for productive debate.
More challenging are those promoters of alternative medicine who seek to claim legitimacy through scientific credentials or research. Of course, who could object to scientific training for CAM providers or proper research into their claims? Well….
The first problem is that the general public sometimes imagines scientific credentials to be validation in and of themselves for the scientific claims one may make. Sadly, this is not true. Linus Pauling was a brilliant scientist who happened to be dead wrong about the value of megadoses of Vitamin C. Andrew Weil may have an M.D., but he is much more a priest of New Age mysticism than a doctor of scientific medicine. Scientists, intelligent or not, are not much less susceptible to the errors that lead to false beliefs in medicine than non-scientists. We experience non-specific (aka “placebo”) effects, we fall prey to availability bias, confirmation bias, and all the other cognitive traps that the method of science is designed to help us avoid. If we don’t follow the method, we’re just as likely to be wrong as the next guy.
And just as scientific credentials are often erroneously interpreted as evidence for one’s claims, scientific publications are frequently granted more respect than they deserve. For many different reasons, simply being able to produce citations in a journal does not constitute a QED for a medical claim. For starters, publication bias leads to the publication of positive findings and the quiet lonely demise of negative findings often enough to make conclusions based on published literature less reliable than we’d all like. This is more of a problem in some countries than others. In China and Russia, for example, nearly 100% of the clinical trials published show positive results. Perhaps the scientists in these countries are smarter and better at their work than those in Europe and the U.S.? Or, perhaps there is a cultural stigma to publishing negative results? In any case, no one is immune from the pressure to report positive and dramatic results from one’s research, to justify not only the publication but the time and money spent on the research, as well as to show oneself to be a smart and productive scientist, and this reduces the reliability of published research results.
Judging the credibility of published research requires looking at how the research was conducted. There is a hierarchy of reliability for clinical evidence, from the easiest to find and least reliable, personal anecdote and clinical experience, to the most rigorous controlled clinical trial. And though we open ourselves to charges of cultural or institutional bias by saying so, there is a hierarchy of reliability for the journals in which clinical trials are published. Even excluding countries in which negative results simply aren’t published, there is a meaningful difference in reliability between a study that appears in the New England Journal of Medicine or the Lancet versus one that appears in the Journal of Complementary and Alternative Medicine or The Chiropractic Journal. Journals that exist solely for the purpose of publishing research that does not meet the publication standards of established high-quality journals are clearly going to be more ideological, less evidence-based, and less reliable as a guide to the truth about clinical therapies.
Sadly, the scientific literature in veterinary medicine is not only sparser than for human medicine, it is frequently of inferior quality. As a simple function of resources, trials are smaller and less well-designed, and they are often funded by pharmaceutical companies, commercial firms, or others with a vested interest in the outcome, which has been clearly shown to affect the outcome of research studies. A review of published studies in veterinary dermatology recently found widespread misuse and misinterpretation of basic statistics and data presentation methods.
So with cognitive biases, ideological biases, publication bias, the influence of funding source, and all the other factors that limit the reliability of published research, how are we to decide which therapies work and which don’t, what are the risks and the benefits of various therapies, and all the other question that we need to answer to provide good care?
To start with, we should follow the principles of science-based medicine, which differs in a small but highly significant way from evidence-based medicine in considering the plausibility of the underlying physiologic rationale as a key component in evaluating a therapy. Running a hundred clinical trials, with all the errors to which they are prone, in order to test the efficacy of manipulating mysterious energy fields that can only be real if everything science has shown us is all wrong makes no sense. As one bloger described it, this is Tooth Fairy Science. You can conduct a well-designed study to evaluate how much money the tooth fairy leaves for each different type of tooth, age of child, etc. You can even do statistical analyses on the findings. None of this means the Tooth Fairy exists.
Next, we can educate ourselves about the source of information. A study of chiropractic funded by chiropractors, conducted by chiropractors, and published in an all-chiropractic journal isn’t automatically wrong, but it’s a good bit less reliable and more susceptible to bias than an independent study published in the New England Journal of Medicine. A journal that follows the principles of the CONSORT statement, that requires registration of trials with stated primary endpoints in advance and full disclosure of funding and potential conflicts of interest is more likely to be reliable than one that does not.
Finally, we can read each study in a critical and thoughtful way. Not just the abstract and the discussion section. I’m am frequently amazed at how often those parts of a paper do not present an accurate interpretation of the actual data reported. Looking at studies critically also means recognizing the limitations of different kinds of evidence. A small case series is less reliable than a retrospective cohort study, which is less reliable than a prospective randomized controlled double-blinded study, and so on. This means more work for the individual clinician, of course, but that is a price worth paying for better medicine.
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