The Madness of Complementary & Alternative Medicine
Dr Mike Eslea
 Complementary and alternative medicine (CAM) has never been more popular. According to Rose Shapiro's terrific recent book Suckers, the UK market for CAM remedies is worth something like £2.3 billion per year. Half the adult population have tried one form or another, but it is most popular among wealthy, well-educated women aged 35-55. Much CAM use is by the "worried well" who use it for general wellbeing and to prevent illness, but it is also used to treat serious diseases. The available range of CAMs is mind-boggling. Simon Singh & Edzard Ernst's book Trick or Treatment? examines 40 different therapies, including colonic irrigation, ear candling, reflexology and crystal healing. Does any of it actually work? The short answer is "No". Scientific evaluation of CAMs almost always finds the effects to be negligible or non-existent. If a CAM was properly tested and found to be effective, it would cease to be "alternative" and would become part of mainstream medicine, as has happened with some plant-based drugs such as digitalis or aspirin. Alternative medicine is therefore, by definition, that which is either untested or which has failed the tests. In the modern era of evidence-based medicine, such use of untried therapies seems rather foolish. However, that does not mean that all CAMs are equally improbable. In fact, CAMs exist along a spectrum of lunacy ranging from the lightly dotty to the full-blown barking.
 At the lightly dotty end we find herbalism. I don't have a major problem with herbalism in theory: of course plants have evolved all sorts of interesting compounds to help them attract pollinators, repel parasites etc, and it makes perfect sense to study these compounds and their effects on humans. I do have some problems with herbalism in practice, however. A tiny proportion of the herbals in the materia medica have been properly tested for safety, let alone effectiveness, and a lot of herbalism seems based on signatures (like the Euphrasia that looks like bloodshot eyes and so is used for eye problems) rather than data. People seem to think that "natural" is necessarily good or harmless, and are therefore much more cavalier about dosage and multiple treatments. People taking herbals such as St John's wort do not think of it as a "drug" and so don't mention it to their doctors, even though it can interact dangerously with anti-depressants or the contraceptive pill. There are also big problems with the purity and concentration of the herbal remedies on sale in shops. Tests have found that the actual proportions of the stated ingredients vary from none at all to ten times the amount on the label, and that all sorts of contaminants are usually present. It seems to me that once you have discovered that, say, willow bark can cure headaches, the sensible thing to do is study the bark, identify the active ingredient(s), learn how to synthesise it, and make it available in carefully controlled doses. If I was in pain I would much rather take two aspirins than head down to the park to chew on a willow!
 In the middle of our spectrum of silliness we find therapies whose underlying theory is nonsense, but for which there is a plausible mode of action and some evidence of effectiveness. Acupuncture is based on the bogus idea that "Chi" or "Qi" energy flows through "meridians" in the body, but it is not unreasonable to expect that sticking needles into people will have some kind of effect upon them. It probably does this by stimulating the release of endorphins, which can have painkilling or intoxicating effects in the brain. However, it matters not a jot where the needles are stuck: study after study has found that needling the traditional pressure points has no more effect than random needling. Furthermore, all but the most recent research has been hampered by the difficulty of carrying out double-blind trials (it is very hard to fake sticking needles into someone, and even when it has been possible to use dummy needles to fool the patients, those administering the needles would certainly have known whether they were actually being inserted). In recent years, some more convincing dummy needles have been developed that do allow some double-blinding, and studies using them suggest that the effects of needling are at best negligible and may be zero. If you want to stimulate your endorphins, you would do better to take a brisk walk.
A little further along the silliness spectrum, we find Chiropractic. This too has a bogus theory, that illnesses are caused by spinal irregularities known as "subluxations" and can be cured by the appropriate spinal manipulations. There is some evidence that chiropractic can help for low back pain, but no evidence at all that it helps with other ailments. Worse, there are significant risks associated with the "high-velocity low-amplitude thrusts" used by chiropractors, which can severely damage the neck and which have caused "chiropractic strokes" in patients whose blood supply to the brain has been disrupted. There is an excellent chapter on chiropractic in Trick or Treatment, but when Simon Singh reprised this argument in the Guardian he was promptly sued for defamation by the British Chiropractic Association. My view is that this is quite revealing: rather than responding with evidence, they chose to try to silence a critic through legal means. Would you submit to a dangerous procedure at the hands of such people? Madness!
Now we reach the far end of the spectrum: therapies of underpants-on-the-head-and-pencils-up-the-nose lunacy. In some ways, the worst of these is probably Breatharianism. The breatharians are an odd sect led by "Jasmuheen" of the Cosmic Internet Academy. Jasmuheen never eats or drinks anything (she claims), but subsists instead on a diet of "Prana", or light, which comes from "the Divine One Within". The breatharians claim to be "Knights of Camelot" who can cure all famine and hunger (and even anorexia) by teaching people to live on Prana. Unfortunately, press reports suggest that several of Jasmuheen's followers have already died from starvation and dehydration. How, then, can she have survived since 1993 without sustenance? Perhaps she gives the game away when she reveals that although technically she never eats, she does have occasional meals purely for the "pleasures of taste and social interaction". Marvellous! Fortunately, breatharians are few in number, and their madness is so obvious that I cannot put them top of my list. That honour goes to a therapy of utter mad-as-a-lorry silliness that has somehow nevertheless become widely accepted across the world. In the UK we spend millions on it, both directly as individuals, and indirectly as taxpayers who fund special NHS hospitals devoted to it. It is taught - as science! - in several British Universities. I am talking about homeopathy [Nature article PDF, and reaction].
 The probability that a homeopathic medicine could have any effect (other than placebo) is vanishingly small. I can say this with confidence because homeopathy contradicts at least two of the most solidly-established principles in biology and chemistry. The first is that larger amounts of a drug or toxin have larger effects. This is called the dose-response relationship, and it is an iron law of biomedicine. Ten paracetomols are more dangerous than two, just as ten pints of ale will get you drunker than two. There are no exceptions, except in the topsy-turvy world of the homeopath, where lower dilutions such as 3X can be bought over the counter and given to babies (e.g. for teething) whereas extremely high dilutions such as 200C are thought to be far too dangerous for this, and should only be prescribed by a trained practitioner.
For readers unfamiliar with homeopathic notation I will explain these dilutions. The "X" means that the original essence has been diluted one part in ten, and the number tells you how many times the dilution has been repeated. So 3X means that a one in ten dilution has been repeated three times, leaving a final concentration of one in a thousand, or 1x103. A "C" dilution is one in a hundred, so a 200C preparation would have a concentration of one in 1x10400 (forgive me for not writing out the full number: a one followed by 400 zeroes). This brings me to the second basic principle that homeopathy flaunts: the Avogadro limit. Once the dilution process has passed 24X or 12C we can be pretty sure that no molecules of the original substance remain. According to the standard molecular model of Chemistry it is impossible for these dilutions to have any effect. At the lower dilutions yes, a 3X dilution will still contain a fair dose of the original essence, but most homeopathic preparations are taken way beyond the Avogadro limit: 30X and 30C are probably the most commonly used. To visualise a 30C dilution, imagine one molecule of an active ingredient being added to 1060 molecules of diluent. What would this look like? We are not talking drop-in-a-swimming-pool or even drop-in-the-ocean here. 1060 water molecules would make a sphere twenty-eight billion times larger than planet Earth.
At dilution levels beyond the Avogadro limit it makes no difference what the original essence was, but it is still worth spending a few moments considering the range of ingredients that homeopaths use. This provides another reason to be sceptical about the claims of homeopathy: the jaw-dropping silliness of the so-called remedies. One common misconception about homeopathy is that it uses only natural substances, such as herbal essences and plant products like coffee or onions. Indeed, there are homeopaths who choose to specialise in such remedies, but for most practitioners the herbals are only a small part of their armoury. Another very important group of remedies are based on minerals, especially salts such as sodium chloride, magnesium phosphate and silicon dioxide, which you can buy in combination as a hayfever remedy. A third group of remedies are based on animal parts or products, such as duck liver, snake venom and even dog excrement. Fourthly, there are remedies known as "nosodes", which are made from human disease products, such as pus, mucus, blood, faeces and scraps of tissue. Finally, there is a group of remedies known as "imponderables", made from such things as electricity, thunderstorms or sunlight.
Homeopaths select these "remedies" according to a principle known as the Law of Similars. In 1790, the German physician Samuel Hahnemann noticed that cinchona bark, which contains quinine and had long been used as a malaria remedy, actually produced some of the symptoms of malaria when taken by a healthy person (namely himself). Unfortunately for homeopaths, it may be that Hahnemann's reaction to the cinchona was in fact simply the result of an undiagnosed allergy. Nevertheless, it led him to wonder if a general principle of similarity could be used to discover new remedies, and to classify the chaotic muddle of herbal and mineral preparations that constituted the materia medica of the day. He therefore embarked on a series of experiments upon himself and others, to test for the pathological effects of various substances, including mercury, belladonna, tobacco and nux vomica (strychnine). Family, friends, students and colleagues submitted themselves to these "provings", and by 1796 he was convinced that homeopathy ("similar suffering") was indeed the answer: a substance that causes particular symptoms in a healthy person can be used to cure those symptoms in a sick person. A few examples of the current uses of well-known substances should suffice to give the general idea: onions irritate the eyes and nose, and so may be given as a treatment for colds; coffee is a stimulant, and so can be used to treat insomnia; arsenic causes sickness and diarrhoea, and so is used for food poisoning, and so on.
Hahnemann intended his work on similars to be a refutation of the doctrine of signatures, which provided the basis for much of the medicine of the time. For Hahnemann, similarity was solely a matter of the effects a substance had, not (as in the doctrine of signatures) anything to do with its physical appearance or provenance. However, it is immediately clear from considering the range of substances described above that the doctrine of signatures quickly re-asserted itself, and that a major flaw in the method used in Hahnemann's provings allowed this to happen (and has been perpetuated in subsequent provings by others): his experiments were not done blind. In other words, he always knew exactly what his guinea pigs were taking, and probably they knew it too, and so his and their perceptions of any symptoms would inevitably have been coloured by the nature of the test and their existing knowledge of the substance. It is not therefore surprising that many ancient herbals resurfaced in homeopathy with similar functions based on appearance. Euphrasia, for example, re-appears as a homeopathic remedy for eye problems, just as it did under the doctrine of signatures owing to its supposed resemblance to a bloodshot eye. So as we have seen, nowadays virtually anything can be (and is) used as a homeopathic remedy, often based on nothing more that superficial resemblances or associations.
Supporters of homeopathy often claim that at least it does no harm. This may be true in one sense: since the medicine has no effects whatsoever, it cannot have side effects. However, it is clearly untrue in another sense: if people are diverted from real medicine by their homeopaths, the results can be dangerous and even fatal. Notoriously, all ten homeopaths approached by an undercover BBC Newsnight reporter recommended homeopathic malaria prevention and advised against real antimalarial drugs. Other homeopaths have been caught out telling patients to give up their asthma inhalers or epipens in favour of worthless homeopathic alternatives. People who follow such advice put themselves in serious danger. And for what? Sugar pills. That is why homeopathy sits proudly at the maddest end of my madness spectrum.
Dr Mike Eslea
is a Senior Lecturer in Psychology at the University of Central Lancashire [home page].
A punk rock fan, his Punk Psychologist blog prides itself on "gobbing in the face of pseudoscience".
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