Programme 2. How do we know if they work?
There’s
no shortage of people who’ll tell you that CAM works for them. But anecdote is not
the same as the sort of evidence that comes from testing new pharmaceuticals in rigorous
clinical trials. And in today’s cash-strapped NHS, value for money is crucial. How
should we establish whether CAM therapies “work”, and is the scientific trial
the only reliable method?
We
visit one of the new research institutes in the UK which have been set up to throw some
light on the effectiveness of CAM. We follow the progress of some examples of CAM therapy
trials, shedding light on the challenges of this sort of “test”. Despite a
shortage of research funding, there is a growing body of rigorous, published, scientific
evidence on CAM. We hear from Dr Richard Horton, editor of The Lancet, who
has published several CAM trials recently, including a review of homeopathy which suggests
it works better than would be expected from the placebo effect alone. Why, for someone
like Dr Horton, is the randomised controlled trial (RCT), published in a peer-reviewed
journal, the gold standard of evidence?
Several
new journals are now devoted exclusively to “alternative” medicine – why is
there a need for these sorts of journals? Are the CAM researchers, such as Professor
Edzard Ernst at Exeter or George Lewith at Southampton, equally convinced that RCT’s
are the bottom line? Is there any truth in the assertion by some therapists that CAM is
simply not suitable for testing in controlled trials? From the evidence we have, we assess
how some CAM therapies measure up against the accepted scientific yard stick- it’s a
mixed picture.
Many
therapists and CAM users argue that there are other, more appropriate, ways to measure the
effectiveness of their therapies. NHS researchers are now assessing therapies as they are
really delivered, in their normal settings. For example, Kate Thomas has spent nearly 20
years researching complementary therapies and is now deputy director of the Medical Care
Research Unit at the University of Sheffield. In her research, she is asking a different
sort of question from the usual controlled trial: “Do patients who have access to
acupuncture for their back pain do better than those who don’t?” We explore a
range of possible approaches to CAM research, and ask how CAM research is likely to
develop in future.
Programme 3. Does it matter how it works?
Are
therapies like homeopathy or aromatherapy nothing more than elaborate placebos? If they
work by some other mechanisms, what are they? And if they do work, does it really matter
how they work?
In
the scientific world, mechanism does matter. Without a plausible, testable mechanism,
scientists are not impressed. That is why so many scientists are not convinced by
homeopathy (where treatments are often so dilute that they are nothing more than water),
or acupuncture (where there is no anatomical or physiological evidence for the
“energy channels” on which the therapy depends). We hear from scientists and
therapists who have tried to establish mechanisms for these therapies in formal
experiments, and from practitioners who explain the importance – or otherwise –
of understanding the “mechanisms”. Is there room for “alternative
sciences”, such as those proposed by Lynn McTaggart, to explain the basis for CAM?
Dr
Peter Fisher, president of the Faculty of Homeopathy, explains how homeopathy works in
terms of an analogy - solutions hold a memory of the active substance just as video tapes
hold pictures, so scientists analysing tape would only see iron particles, not images. Is
it important, even if the effect is a type of placebo, for patients to have some image or
concept in their mind of how the therapy is working? Why do some mainstream doctors, and
others in the scientific community, get so worked up about mechanisms?
When
doctors test a new treatment, they conclude that it works only when patients who receive
it fare significantly better than those given a dummy treatment, or placebo. That’s
because many patients feel better, no matter which one they receive. But having once
written off the placebo effect as “no effect”, scientists are now discovering
that the placebo effect can be very powerful indeed. Whatever the placebo effect really
is, could it hold the secret mechanism for some complementary therapies? And if CAM is a
sort of placebo, how do we explain the evidence that it can work in animals? We talk to
one of the many vets who use CAM to treat their animal patients. And how do doctors who
dismiss homeopathic remedies as “just water” explain the fact that trials show
patients can often develop side effects?
We explore some of the latest biological theories which
try to explain the placebo effect. Sir Ian Chalmers, past Director of the
Cochrane Centre, explains that the size of the effect is determined by the
way a patient and doctor interact, how a patient feels about their care, and
what he or she is expecting from a therapy. And whether it’s conventional
or alternative therapy, it’s now clear that patients and therapists need
to believe that it will work. We also know that the more elaborate the
therapy, the greater the effect. So with longer consultations and a more
patient-centred, holistic approach, could it be that CAM therapies are
simply tapping into this powerful placebo effect in a much more effective
way than conventional medicine? And does that necessarily devalue it in some
way? We ask patients, therapists, and sceptical physician Dr Roger Fisken,
for their opinions.
Programme 4. First,
do no harm
Hippocrates’
golden rule for healers was to “first, do no harm”. “Natural”
doesn’t always mean safe – after all, opium, belladonna and digitalis are all
“natural” poisons. We often hear about the dangers of CAM therapies – but
are they really so dangerous? What’s being done to protect patients?
We’ve
all heard the horror stories: 6-month old Cameron Ayres, who died of a treatable disease
because his parents insisted on continuing with homeopathy, despite advice from their
therapist to seek urgent medical attention, or the patient with eczema who developed
serious liver failure following a course of Chinese herbal medicine. Many alternative
therapies are not tested in the same way as pharmaceuticals, and are regulated as food
supplements rather than medicines. But how dangerous are they really – how do they
compare with orthodox pharmaceuticals? There is certainly very little evidence that many
CAMs such as acupuncture, osteopathy or homeopathy are dangerous. To what extent are
scares and warnings about CAMs a political weapon used by those with a vested interest to
discredit the alternative market? Can doctors really claim that they are unsafe?
We
hear from experts at the Committee on the Safety of Medicines about how they monitor the
safety of herbal remedies, despite poor reporting systems for adverse effects, and the
variable quality of products with the same name. What are the main dangers of CAM
therapies – and how can people avoid them? The World Health Organisation Department
of Drugs and Policy is so alarmed about the dangers for the public that they are now
monitoring safety of CAM following several deaths. There have been calls for much clearer
labelling of herbal remedies to allow patients to distinguish between licensed and
unlicensed products. We hear practical advice from therapists about side effects,
interactions with conventional drugs, and from Professor Michael Baum from UCL about the
indirect dangers of homeopathy resulting in delayed diagnoses of, for example, breast
cancer. But, as we hear, CAM does not have a monopoly on delayed diagnoses…in the NHS
they account for nearly a third of all complaints.
Programme 5. Fit to
practise
Could
the problems of delayed diagnosis or dangerous advice be avoided with tighter regulation
and better training in CAM? Could this stop vulnerable or desperate people being relieved
of their cash by charlatans and quacks? How can patients find out who to trust?
Can
anyone call themselves a homeopath or an osteopath? (Osteopathy was the first CAM to be
properly regulated, and only those practitioners who have attained a prescribed level of
training can call themselves osteopaths). What about crystal therapists? Doctors can go on
day courses and call themselves acupuncturists, whereas traditional practitioners of
Chinese medicine see their training as a lifelong project.
How
does regulation in the CAM world compare with the “conventional” medical world?
How have internal political power struggles within CAM slowed progress in this area? The
House of Lords Select Committee report recommends that each therapy should have a single
regulatory authority with clear guidelines on competency and training – how likely is
that, and what are the hurdles? At the moment, most practitioners are free to practise as
they like after they are qualified – should CAM therapists be subject to the same
sort of five-yearly revalidation that doctors now have to undergo?
We speak to students of CAM at various stages of their
training – comparing, say, the four year or longer training in osteopathy
with a two day course in aromatherapy massage. Given that many therapies
incorporate a considerable element of diagnosis, some have argued that
therapists should do more basic medical science training (in anatomy,
physiology, biochemistry and pharmacology). Is this another example of
medical colonialism?
Programme 6. A marriage made in heaven?
“This
isn't a question of orthodox medicine taking over or of complementary and alternative
medicine diluting the intellectual rigour of orthodoxy; it is about reaching across the
disciplines to help and to learn from one another for the ultimate benefit of the patients
that you all serve” - Prince Charles, Founder of the Foundation for Integrated
Medicine.
Sometimes
known as “the Prince Charles approach” or “why don’t we all just work
together”, the new move to integrate CAM therapies into the mainstream NHS may be
attractive, but will it all end in tears?
“I
couldn’t work without complementary therapies now,” says Dr Sue Morrison, one of
the general practitioners at the Marylebone Health Centre. “Bodywork, and massage in
particular, reaches everyone and is a wonderful comfort and healing thing to offer. We
have a big multi-ethnic group of patients, and it can help break through language barriers
and help those with emotional, as well as physical problems, in a very short time.”
The Marylebone Health Centre was a pioneer in the collaboration between orthodox and other
therapies, when it was founded in 1987. It’s a shining example of how CAM and
orthodox health care can work along side each other. We hear the patient’s experience
of properly integrated care, and Dr Bob Leckridge, GP and Homeopath explains how he sees
the visit to a doctor for back pain in ten years’ time: “Well, I hope the guy
with the back pain comes in, and he meets his GP, and his GP's well trained, got good
skills and understands the person as a whole person, helps the patient to understand why
they've got back pain, how it's come about and to make a proper diagnosis and then get him
treatment from one of the CAM therapists on the team”. We visit a hospital in China
to see how western and traditional Chinese medicine can work side by side. In many
hospitals there will be both types of approach readily available often just across the
corridor from each other.
But who wears the trousers in this professional partnership – is CAM
doomed to be subservient to the orthodox? Would only certain types of CAM
(perhaps the “Big Five”) be acceptable to the medical mainstream – and
why? To what extent are resource shortages always going to stand in the way
of CAM? If CAM were fully integrated into the NHS, would it simply become
mainstream medicine and therefore lose some of its unique attraction? Is it
time to question the entire basis upon which our medical care is organised?
Some therapists, such as energy healer Kim Hutchison, think the two worlds
could never be integrated: “The orthodox reductionist view is drug centred
and its viewpoint is molecular - that the physical body is detached from the
mind and the soul. Well, we're far more complex than a bunch of molecules in
a Petri dish. Until we understand that our minds and bodies are directly
affected by our consciousness, we will not be able to help our patients to
experience true healing. We need to integrate the healers, not the
methods”. We explore some of the tensions and political struggles that
have surfaced as a result of the push towards integration.
