Complementary therapies: The big con?
We spend billions on complementary therapies. But after 15 years of research, one man has found that most of them don't work. Jeremy Laurance reports
Mischief is what Professor Edzard Ernst most enjoys. You can see it in his face, twinkling eyes peering over rimless glasses. You can see it, too, on the first page of his new book, Trick or Treatment, published today, which promises readers the truth about alternative medicine – what works, what doesn't and what is dangerous.
The book is dedicated to the Prince of Wales. Casual readers may take this as the admiration of the foreigner – Ernst was born and brought up in Germany – for British royalty. In fact, it is a jibe at the foremost celebrity supporter of alternative medicine, whom Ernst accuses of promoting therapies and misleading the public.
Their dispute, which has been simmering for years, erupted again last week when Ernst and his co-author, the science writer Simon Singh, wrote to The Times attacking two guides published by the Prince's Foundation for Integrated Health, for being "misleading". The letter elicited a pained response from the foundation, which accused the authors of whipping up controversy to promote their book. Ernst must have been rubbing his hands with glee.
It is 15 years since he was appointed as the world's first professor of complementary medicine, at the University of Exeter, supported with a £1m grant from Maurice Laing, the builder – and he has been causing trouble ever since. Laing, who died earlier this year, had become an enthusiast after his wife had been helped by alternative medicine during a serious illness, and decided it needed a university chair and proper scientific investigation.
The alternative medicine establishment initially rejoiced at the prospect of academic recognition by a leading university, with a department devoted to research. Its joy did not last long. To the dismay of many, Professor Ernst quickly became the scourge of alternative medicine.
It was not what might have been expected, given his background. The son of a doctor, Ernst followed his father into the profession and spent half his career working his way up to become professor of rehabilitation medicine at the University of Vienna, with a staff of 120. Like many German doctors, he dabbled in alternative medicine and claims to be trained in acupuncture, homoeopathy, massage therapy and herbal medicine.
Exactly what happened then is not clear. Perhaps he got bored, or rehabilitative medicine did not offer sufficient opportunities for mischief-making or, as he says, he grew tired of running a large department. But when he saw the advertisement for the alternative medicine professorship at Exeter, he applied, and got it. In his mid-forties, he and his French wife, a librarian whom he met in London, started a new life.
Initially, the plan was to run clinical trials of alternative therapies in the "laboratory" in the basement of the large Victorian house where his department is based. One of the first was of spiritual healing. Ernst describes it as "the most interesting study I have ever been involved in". His idea was to compare healers with actors, and to compare a healer placed behind a door, out of sight of the patient, with the effect when there was no one behind the door (a tape recording of someone breathing and shifting in their chair created the illusion that the healer was present).
All the patients in the double-blind, randomised trial reported feelings of warmth and tingling, suggesting they were experiencing the effects of healing, even when it was delivered by an actor – or a tape recorder. More remarkably, among the patients, there were five in wheelchairs, four of whom found the effect so powerful that they were able to get up and walk.
Ernst recalls going home and telling his wife how he was going to be mocked by his scientific colleagues as the man who worked miracle cures. Instead, it emerged that the four patients who had got up and walked were equally distributed between the four arms of the trial. In other words, the results were an early lesson in the power of placebo.
But it was also a lesson in something else – the resistance of alternative therapists to evidence that does not suit them. "The healers had pestered us to do this trial. But when they got the results, only one was so disappointed that he gave up healing. The others reached the standard conclusion – if my healing art is not shown to work then it must be the fault of the trial."
That clash of philosophies set the scene for the battles that Ernst has waged ever since. Alternative therapists think he is out to destroy them. But he denies he is a "quackbuster". "I don't see myself as that at all. When the evidence is positive, I say so. When it is negative, I say so. The alternative is to tell lies, which I will not do. It is a disentangling exercise – lots of [alternative medicine] is rubbish, but a few things are to be encouraged."
Why is it so popular, then? Ernst blames the providers, customers and the doctors whose neglect, he says, has created the opening into which alternative therapists have stepped. "People are told lies. There are 40 million websites and 39.9 million tell lies, sometimes outrageous lies. They mislead cancer patients, who are encouraged not only to pay their last penny but to be treated with something that shortens their lives. "At the same time, people are gullible. It needs gullibility for the industry to succeed. It doesn't make me popular with the public, but it's the truth.
"Mainstream medicine is pretty awful, too. Doctors lack empathy and time. There is plenty of evidence that people using alternative medicine don't even expect effective treatment – they are just looking for a therapeutic relationship. They are not getting it from their GP, so they look for it elsewhere."
Ernst is an expert communicator who delights in upsetting professional apple carts. "People think natural equals safe. That's the appeal of herbal medicine. But there is no receptor in humans that can tell this comes from plants and this comes from a factory."
Isn't he a bit of a killjoy? Lots of people claim to benefit from alternative medicine and what harm can a homoeopath do, if his remedies contain nothing but water? "The remedy may be safe, but the homoeopaths aren't necessarily. Think of their attitude to immunisation. Even the least harmful treatment becomes life-threatening if it is used as an alternative treatment for a life threatening condition."
His mission has been to bring the discipline of the randomised controlled trial to alternative medicine. Critics claim this is to misunderstand the nature of the beast – alternative medicine does not lend itself to objective tests, because it relies for its effect on human contact. Ernst is unimpressed.
"I would challenge anyone to name me one treatment that is not susceptible to a randomised controlled trial. When I give lectures, I take along a bottle of wine and make this offer to the audience. I always bring it back."
Despite the difficulty of raising funds for research – his own institute abandoned clinical trials long ago and now confines itself to reviews and meta-analyses – there is still plenty going on around the world, and the amount of evidence has grown substantially.
What does it show? Not a lot. In a paper in last month's British Journal of General Practice, Ernst listed the treatments that "demonstrably generate more good than harm". Most are plant extracts such as St John's Wort (for depression), hawthorn (congestive heart failure) and guar gum (diabetes). Only six therapies are included: acupuncture for nausea and osteoarthritis, aromatherapy as a palliative treatment for cancer, hypnosis for labour pain and massage, music therapy and relaxation therapy for anxiety and insomnia.
Is this an unduly negative conclusion? "What people describe as negative is actually positive. I can tell patients, don't use it, you are wasting your money. That is a positive benefit. It is only negative if you trying to protect that little cult. That is the big misunderstanding. My allegiance is not with the homoeopaths and the acupuncturists, but with patients. In that sense, it cannot be negative."
Perhaps not. But the truth can hurt.
'Trick or treatment? Alternative Medicine on Trial' by Simon Singh and Edzard Ernst, Bantam Press, £16.99. To buy for £15.29 (inc P&P), call Independent Books Direct on 0870 079 8897 or go to www.independentbooksdirect.co.uk
Alternative cures: the verdict
After hundreds of trials, one of the most thoroughly researched therapies. Despite this research effort, there is little evidence that the treatment, involving placing needles in the skin, is effective, except as a placebo. Trials have shown it can reduce some types of pain, including back pain, pelvic pain and headaches. It also helps reduce nausea and vomiting.
Based on the principle of like cures like, patients are given highly dilute solutions of substances believed to cause, in a healthy person, the same symptoms, to stimulate the body's natural defences. In some cases the remedies are so dilute they are unlikely to contain a single molecule of the original substance, but are said to retain a memory of the substance. Here, too, there has been a large body of research, but it has failed to show the remedies act as anything other than a placebo.
Scented oils are rubbed into the skin with gentle massage to soothe and relax. The plant essences used to scent the oils – which can also be added to a bath or suffused in the air – are claimed to have different effects. There is no evidence that aromatherapy can treat specific diseases, but trials show it does produce short-term relaxation and is comforting as a palliative treatment for people with cancer and those suffering anxiety and tension headaches or chronic pain.
Chiropractic therapy and osteopathy
These are different forms of manual therapy. Chiropractic involves manipulating the spine to realign it and restore mobility and osteopathy uses massage to loosen muscles and joints as well as manipulation. Both are effective for back pain, but no more so than pain killers, gentle exercise and physiotherapy. There is no evidence they are good for other disorders. There is a risk with chiropractic that manipulating the neck can cause neurological problems and even stroke.
Hypnosis is used to treat a range of conditions, including pain, addictions and anxiety. Dozens of trials show that it is effective in reducing pain, anxiety and symptoms of irritable bowel syndrome. However, though it is advertised as an aid to stopping smoking, there is no evidence that it helps smokers quit.
A technique for improving posture through gentle exercise. Little research has been done, but there is some evidence that the technique can improve chronic back pain. There are also indications it can improve breathing and reduce anxiety.
Many drugs are refined and concentrated versions of substances found in plants. Practitioners of herbal medicine use the whole plant rather than just the active ingredient. While some herbal remedies have been shown in randomised clinical trials to be effective – St John's Wort for mild to moderate depression, for example – most lack good evidence.