HealthManagement, Volume 19 - Issue 1, 2019

The essential truth

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Critical evaluation of complementary and alternative medicine


Due to a reverence for scientific truth in an area of healthcare that is hazardously left uncontrolled, Professor Edzard Ernst left his position as chair of physical and rehabilitation medicine at the Medical Faculty of Vienna to become the world’s first chair in complementary and alternative medicine (CAM). That was in 1993; for 25 years he has been refuting pseudoscience and violation of medical ethics, raising awareness and encouraging action from the authorities, journalists, physicians and schools. He speaks to HealthManagement.org about his findings and the changes he believes are urgently needed.


Moving over to CAM research


You left your post as chair of physical and rehabilitation medicine at the Medical Faculty of the University of Vienna. Why were you convinced that there was enough medicinal value in complementary and alternative therapies to dedicate your working life to it?

I wasn’t convinced! This is why I insisted that my remit would be entirely research-based. There were and still are many open questions in CAM, and I thought it would be rewarding trying to answer some of them. 


You became the first and only professor of CAM in the UK. How did doctors and medical researchers respond to this? Are there many such professors of complementary medicine around the world? 

The reaction was mixed; some thought it was a waste of a promising career, and others felt it was worth doing. At the time, in 1993, there was no other such professorship anywhere; now there are several, but none has a particular focus on ‘critical’ evaluation of CAM. 

How did CAM practitioners take it? 

Once I started publishing, they were aghast. They had expected the first professor to be a promoter of CAM and did not understand why I insisted on critical assessments. 

Do CAM practitioners appreciate that by putting therapies and treatments under rigorous scrutiny, you will open the field to the discovery of evidence which could render their treatments (if effective) more respected by doctors and medical boards? 
No. Most of them do not see any point in research at all; those who do seem to view research more as a marketing tool than a means of finding the truth. 

Performance of CAM therapies 


Your research spans acupuncture to herbs to reflexology. In which area are you finding most evidence of positive performance? 

Apart from some mind-body therapies such as relaxation techniques and some manual treatments such as massage, the best evidence by far comes from herbal medicine. This is hardly surprising because many herbs contain pharmacologically active ingredients.

In your reports on the efficacy of CAM treatments and therapies, you express that most of the findings are negative or inconclusive. What do you consider to be your most important findings since you moved your focus to CAM research?

Firstly, that many CAMs are not nearly as safe as the public is led to believe. Secondly, that most of the therapeutic claims for efficacy made by CAM proponents are demonstrably false.

Some herbal treatments are illegal in the UK, despite evidence of positive medicinal value. Kava kava proved effective in relieving anxiety, yet it was banned following some studies that linked it to liver damage (although mixed research data exists about its liver toxicity). Do you believe that authorities commonly address risks in isolation and neglect the efficacy side of some treatments?

By and large, the authorities act responsibly. Sadly, they often are slow because they have little manpower and do rarely consider CAM a priority.

Do you think that more research into CAM treatments could lead to healthcare system savings throughout the world?

There have been several cost-effectiveness analyses of CAM. Their findings are sobering. As a rule of thumb, it is fair to say that where there is no effectiveness, there can also be no cost-effectiveness.

Homeopathy


You express that homeopathy as a treatment is scientifically implausible, yet in centres you’ve worked at, people have got better. What do you put this down to? 

Patients tend to get better because of the placebo effect and—more importantly—because of the natural history of the condition. Homeopaths are specialists in treating self-limiting conditions and subsequently taking the credit for any improvement that would also have occurred without any treatment at all.

Do any randomised controlled trials (RCTs) for homeopathy treatment indicate its efficacy?

There are hundreds of such RCTs. This means that pure chance, plus publication bias, plus flawed methodology, plus wishful thinking all add up to the fact that some studies come out positive. However, the relevant point is that the totality of the reliable data fails to show that highly diluted homeopathic remedies are more than placebos.

Chiropractic


Do you think visiting a chiropractor is dangerous?

Potentially yes; chiropractic spinal manipulations can lead to stroke and even death. About 500 such cases are on record, and that figure is probably just the tip of an iceberg because there is no reporting system that could monitor such events.

Chiropractic is a widely respected profession; they are regulated, and in the UK we have the Royal College and General Chiropractic Council. This suggests transparency. Is this not the case? 
I cannot find the lack of an adverse event reporting system very transparent.

Do you believe recent literature has raised awareness of the dangers of chiropractic and that it can contribute more problems?

When the British Chiropractic Association (BCA) sued my friend and co-author Simon Singh for libel because he had stated that “they happily promote bogus treatments,” they shot a huge own goal. Their behaviour caused huge reputational damage, and people became aware that chiropractic is not what it’s often made out to be.

Research methods, analysis and clinical competence


Do you believe that your rigorous scrutiny of the CAM field has reduced the amount of unethical research and unethical assertions taking place? Are CAM researchers conducting more RCTs and sticking to better protocol and ethical procedures?
Sorry, but I do not believe that there is rigorous scrutiny of the CAM field. Practitioners continue to do more or less what they want and violate medical ethics on a daily basis. Their collective research output is close to zero, and the few studies that do emerge tend to be of deplorable quality.


Do you think your publications, articles and interviews will encourage people to be more sceptical, educate them on how to choose a therapy, and make the most dangerous therapies commonly known in the mainstream?
On a good day, yes, I do hope my work has an effect. There is now a growing group of active sceptics in the UK. But when I see the amount of nonsense that is still out there, I sometimes despair. 


Is there increasing literature on malpractice in alternative medicine?
No, by and large CAM practitioners continue to have a free ride. The UK Government seems to not care very much, and it is up to a relatively small group of highly motivated sceptics to try and prevent the worst.

What more could be done to educate the public?
About a million things! For starters, we urgently need better science education in schools. And then we require many more politicians to have a minimum understanding of science. Their ignorance is often frightening, in my view. The same sadly applies to many journalists. 

What controls are in place to regulate clinical competence in conducting CAM therapies?
Regulation is still very lax. Regulation should foremost protect consumers. However, in CAM it is mostly seen as giving practitioners a veneer of credibility.

What do you believe to be the gravest area of malpractice in CAM?
Where to start? Perhaps the lack of proper informed consent is one of the gravest problems. It is almost completely missing in CAM which basically means that the current practice of CAM is unethical.



pseudoscience, Complementary and alternative medicine, medical ethics Prof. Edzard Ernst speaks about his critical evaluation of CAM, including uncontrolled pseudoscience and violation of medical ethics. He highlights where change is urgently needed.

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