April 16, 2008. Yesterday, the Daily Mail published an article by Simon Singh and Edzard Ernst entitled "Does alternative medicine generate more good than harm?" The authors are described as "leading scientists" who  "give their verdict." Singh and Ernst are the authors of Trick or Treatment: Alternative Medicine on Trial. That's the title in the U.K. In the U.S., where the book will be available next August, the subtitle is The Undeniable Facts about Alternative Medicine. I guess the marketing department at W. W. Norton figures that we Americans are more likely to go for a book that doesn't require the reader to do any thinking. You don't need to think about undeniable facts because those are no-brainers, matters of common sense, and things only an idiot would question. A trial might force the reader to evaluate the evidence, a very tedious process that might interfere with time better spent getting an acupuncture facial or taking your dog to the homeopath.

I was impressed with the authors' claim that:

The journal Hepatology documented how 35 out of 366 patients contracted hepatitis B from an acupuncture clinic in America.

The infection was caused by re-using needles that have not been properly sterilised, and part of the problem may be due to the Chinese tradition of storing needles in alcohol solutions, which is not sufficient to protect against hepatitis viruses.

The second is that needles might puncture a major nerve or organ.

For example, needling at the base of the skull can lead to brain damage, and there are more than 60 reported cases of punctured lungs.

Most worrying of all, there is a report of an acupuncturist inserting a needle in the chest of an Austrian patient which pierced her heart and killed her.

Normally, needling at this point is entirely safe because the sternum protects the heart, but one in 20 people have a hole in that bone which cannot be felt or seen.

Although acupuncture carries some common and serious risks, it is important to stress that the common risks are not at all serious and the serious risks are not at all common - they need to be seen in the context of the millions of treatments given each year.

Moreover, the serious risks can be minimised by visiting a medically trained acupuncturist who has a full knowledge of anatomy and uses disposable needles.

On the other hand, the evidence for the efficacy of acupuncture ranges from zero for a range of conditions to borderline for some types of pain relief and nausea.

Hence, it's only worth considering for pain relief and nausea - and only then if you feel the supposed benefits outweigh the small risks.

I was impressed, that is, until I did a little research and a little thinking. I couldn't find anything in Hepatology about acupuncture and hepatitis B. That is probably because the report didn't appear in that journal.

In 1988, the American Journal of Epidemiology documented 35 cases of acupuncture patients who contracted hepatitis B from a single clinic in Rhode Island during 1984. The clinic had 366 patients that were seen by an acupuncturist. Another outbreak of hepatitis B caused by acupuncture with improperly sterilized needles occurred in Israel in 1986. So, more than twenty years ago there were instances in two clinics. It looks like Singh and Ernst exaggerated the undeniable facts to maximize the fear factor. However, it seems that the real undeniable fact is that:

acupuncture has not been demonstrated to be a significant risk factor in population studies of hepatitis B. A large population-based study of Chinese men in Singapore showed an odds ratio of 0.88 (95% CI: 0.71,1.11 ) for the association between acupuncture and hepatitis B surface antigenemia. This study confirmed the lack of association between acupuncture and hepatitis B infection in a population with a high prevalence of both. Concordantly, this lack of association had also been previously demonstrated in another study in Taiwan (9). These large population-based studies suggested that although breaches in acupuncture technique may lead to an outbreak of infection with a bloodborne virus, such outbreaks should be quite rare, even for non-physician traditional practitioners.*

Furthermore, it would be an easy matter to find undeniable facts that would arouse fear of scientific medicine. For example, it was recently reported in Pediatrics that 11.1% of hospitalized children were harmed by an adverse drug reaction and about one-fifth of these were deemed preventable. A few years ago, it was reported that about one million Americans are injured each year by medical mistakes. Not all the injuries are as serious as hepatitis B. The errors range from giving a patient a twice-daily dose of a laxative instead of twice a week, to amputating the wrong limb, to killing the patient. The point is, we can find examples from any branch of scientific medicine that would arouse fear of treatment in most people. In the case of acupuncture, however, the authors recognize that the appeal to fear isn't needed. As they note, the scientific evidence for acupuncture being an effective treatment for anything is about nil. However, the authors probably recognize that citing undeniable facts is probably useless in motivating people to avoid acupuncture. Why? Isn't it true that a rational person would not waste time and money on services or products that have been repeatedly shown to be worthless or no more effective than a placebo? Maybe, but most of us aren't rational when it comes to decisions regarding our health. One anecdote or story on Oprah or from the lady in the next hairdresser chair trumps a thousand well-designed RCTs (randomized control studies).

The bottom line is, as the authors state, that there is a very small risk that comes with acupuncture. (They claim that 10% of those getting acupuncture have an adverse reaction. I have no idea how they arrived at that figure.) In any case, it probably does not matter what the percentage of adverse reactions is. Those who are thinking about going to an acupuncturist are very unlikely to do a cost-benefit or statistical analysis of potential for good versus potential for harm before making their decision. They've never heard of an acupuncturist maiming someone for life or accidentally killing their patients. Those kinds of scary stories are reserved for practitioners of scientific medicine and chiropractors. (update, May 9, 2008: Wrong again! A BBC story today chronicles the woes of a lady who drove home with an acupuncture needle stuck in her back!)

Last week, the Mail published part one of Singh and Ernst's article. They had this to say about chiropractic:

Neck manipulation has been linked to neurological complications such as strokes - in 1998, a 20-year-old Canadian woman died after neck manipulation caused a blood clot which led to stroke. We would strongly recommend physiotherapy exercises and osteopathy ahead of chiropractic therapy because they are at least effective and much safer.

If you do decide to visit a chiropractor despite our concerns and warnings, we very strongly recommend you confirm your chiropractor won't manipulate your neck. The dangers of chiropractic therapy to children are particularly worrying because a chiropractor would be manipulating an immature spine.

Most of the other therapies considered in the article are described as useless or no more effective than a placebo. Besides osteopathy, mentioned in the previous quote, Singh and Ernst also have good things to say for hypnotherapy as a pain-reducer. My own take on hypnosis is that it is the poster child for placebo therapy. It works by suggestion, compliance, belief, motivation, and trust. In some cases, classical conditioning can also be at work. I don't think it has anything to do with trances or tapping into the subconscious. As for osteopathy....the best thing I can say about it is that it is probably less likely to be harmful than chiropractic, but I wouldn't recommend it over physical therapy or massage.

The authors point out that the main dangers from things like magnet therapy, homeopathy, aromatherapy, and Bach flower essence therapy is that they might prevent a person from seeking science-based medical help for conditions that are highly treatable. Because of not seeking proper treatment, many patients suffer unnecessarily.

I don't think fear of harm is going to motivate too many people to avoid alternative therapies. Unfortunately, the knowledge that most of these therapies are placebos is probably not going to motivate too many people to avoid them, either. Belief in these alternatives is often part of a larger network of beliefs that constitute a worldview filled with fantasy notions about spirits, energies, angels, or forces that sustain and nurture the believers. A little logic and a few thousand undeniable facts from science-based medicine are unlikely to have much effect in cracking through that network of beliefs.

further reading

--BBC sees the light: removes Alternative Medicine Pages

--Prince of Wales's guide to alternative medicine ‘inaccurate’

 Skeptimedia archives

* AmeriCares *