Alternative medicine: a phrase that is heavy with connotations, emotions and frankly, a great deal of confusion. Whichever side of the debate you find yourself on, the opinions are usually strong, stubbornly held, and generally backed up with too few facts for any kind of meaningful discussion. It is for these reasons that I usually try to avoid the topic entirely. But avoiding the issue gets us nowhere. So lets do it properly, if we’re going to do it at all. Over the last year I have read no less than 144 scientific papers on seven different so-called “alternative medicines”, in search of the truth behind the hype. From acupuncture to homeopathy, from reiki to hypnotism, I’ve searched high and low to find out what really works, what doesn’t work, what is helpful and what is potentially harmful. This series will explain what I’ve found in a fair and scientific way. It is not meant to offend anybody, merely to arm us all with the facts, so that we can make our own informed decisions.
Alternative Medicine that has been Proved to Work
“Do you know what Alternative Medicine that has been proved to work is called?”
– Tim Minchin
In the four centuries since the advent of the modern scientific method*, many traditional medicines, herbal remedies, folk treatments and holistic therapies, have been proved to work. Scientific testing revealed not only the effectiveness of these treatments, but also how they worked, and the active ingredients or medicinal components of these remedies were identified and eventually distilled into their most effective form. Today, we know these treatments as medicine. Many more treatments and medicines have since been developed or discovered (often based on ingredients found in nature), and together this arsenal of treatments forms what we know as modern medicine. Those remedies that remain, that we now often categorise as ‘alternative medicine’ or ‘holistic therapy’, are simply those that have not yet been proved to work, or have been proved not to work**.
* The Modern Scientific Method
Just to clarify, what I mean by the scientific method is the process of systematic observation, measurement and experiment that enables the formulation, statistical testing and subsequent modification of hypotheses.
** To again, quote Tim Minchin
My point is, the perceived void between alternative medicine and medicine does not have to be an ideological one. Any particular cure or treatment can happily jump across the divide, from one side to the other, simply through rigorous scientific testing. It’s possible that some alternative medicines simply haven’t been tested thoroughly enough yet. Perhaps this is why they remain in the ‘alternative’ category today. However, we must accept the possibility that many of these remedies remain alternative because scientific testing has been unable to prove their effectiveness – because they genuinely don’t work. If that is the case, though, why do so many people continue to use, and report positive results from these alternative treatments?
The Value of Care
Complementary and alternative medicine (CAM) is incredibly popular in both the US and the UK, with around 40 – 50% of people using CAMs of some kind. The most popular forms are herbal medicine, homeopathy, massage and reflexology, chiropractic and osteopathic care and meditation. Among users, satisfaction rates are high. In fact, many people anecdotally report better results from alternative medicine than modern medicine. For example, one survey of over 3000 adults in Switzerland found greater patient satisfaction and fewer reported side effects from homeopathic care than conventional medicine. And in the US visits to CAM practitioners may exceed those to physicians. So, if alternative medicines are treating and even curing illnesses, and apparently performing better than treatments offered by GPs and hospitals, then the treatments must work, surely?
Well, not necessarily. I suppose ultimately it depends on your definition of ‘work’. When we test medicines scientifically, they are considered to work if they produce a measurable benefit that is greater than the placebo effect. The placebo effect is a bizarre phenomenon which we’ll cover in more detail a bit later, but suffice to say that it is the medicinal (or otherwise) effect of simply knowing you’ve taken medicine or received treatment – the mind is a powerful thing! So, even a treatment that doesn’t actually work in the scientific sense can have a beneficial outcome; it can be better than doing nothing at all.
But then why would some people report better results from alternative medicine than hospitals? Well, alternative medicine often offers a much higher standard of patient care. Holistic therapists often have more time to spend with each patient, and can provide a higher standard of care because they are privately funded (and often very expensive!!). One study investigated the influence of different components of the placebo effect on sufferers of irritable bowel syndrome and found that the assessment (diagnosis), the treatment itself, and a warm patient-practitioner relationship, combined additively to produce the reported placebo effect.
Further, alternative medicine can also offer diagnosis and treatment for many ailments that we cannot treat with conventional medicine. For example, by far the most common use of CAM is to treat back pain, an ailment that is notoriously difficult to diagnose and treat. It has been shown that just simply receiving a diagnosis can trigger beneficial placebo effects. Patients who might have been forced through a battery of testing in conventional hospitals, only to find themselves without a satisfactory diagnosis for their problem, let alone treatment, might find answers in the world of alternative medicine. For sufferers of IBS, aiagnosis alone was enough to provide relief from symptoms for 28% of participants! Actually receiving the placebo treatment (in this case acupuncture) increased this number to 44%, and doing it all with a friendly practitioner increased relief to 62%! It’s easy to see why holistic therapies may end up with higher patient satisfaction.
What is the Placebo Effect?
The placebo effect is a truly mind-boggling phenomenon that continues to astound and amaze me the more I learn about it. The placebo effect refers to the fact that physical, biochemical and psychological changes can be achieved simply as a result of a person expecting those changes to occur. This is why sugar pills labelled as medicine can still illicit a physiological response, why people can act drunk when they’ve drunk non-alcoholic drinks that they believe are alcoholic, and why packaging can determine how effective that aspirin you just took will be.
Countless experiments have confirmed the existence of the placebo effect, although we do not currently understand well the mechanisms that underlie it*. Its power is truly mind blowing. The placebo effect can cause measurable physiological factors such as blood pressure, heart rate and brain chemistry to change. It can reverse the effects of a particular drug depending on colour. The placebo can even generate side effects, if we expect them to occur (this is known as the nocebo effect).
* That is not to say that the mechanisms are not understandable, but merely that science has only just begun to investigate the placebo effect, and testing is likely to be slow given the myriad ethical and logistical issues that surround testing the placebo effect.
The placebo effect blurs the line between perception and reality. It means that a “drug” with no physical or chemical effect on the body could elicit a response, were the taker expecting to experience one. It is this that makes clinical testing of medicine and alternative medicine alike more difficult. But knowing that the placebo effect exists allows us to take measures when designing experiments to ensure we can detect an effect over and above the placebo effect. Because although it might get results, the placebo effect isn’t really a drug working, is it?
The Meaning of Significance
The biggest problem with trying to find out whether a particular treatment is or isn’t effective over and above the placebo effect, is that there is an overwhelming body of scientific literature out there and (most importantly) that body of literature is extremely variable in terms of quality. There are many, many studies that report significant benefits of different alternative remedies, but very few of them are good enough quality to offer meaningful data. What are the necessary components of a scientific study to make it trustworthy? Here’s my quick rundown:
- A fair comparison
As I discussed earlier, when we’re testing a medicine scientifically, we are interested in whether or not it creates a greater beneficial effect than the placebo alone. Therefore, it is important that we test our medicine against the placebo. It isn’t enough to say that patients who received this treatment were better off than patients who received no treatment at all. We need a suitable placebo control treatment to compare with. This is easy for some treatments such as homeopathy, which I discuss in detail in part I, where treatments are often given in pills or capsules. In tablet form, it is easy to produce nearly identical treatments, one of which contains none of the active ingredient. In contrast, chiropractor would have a much harder time providing a ‘sham’ treatment! Of course, it’s crucial that the patient doesn’t know whether they have received a treatment or the placebo – in a single-blind study, the patients are given a treatment but are kept in the dark about what it really contains.
- Nobody Knows
It isn’t just important to control for what the patient knows, but also what the doctor or therapist treating them knows. A doctor giving a patient the placebo treatment can unconsciously reveal this fact to the patient just through what they say and do. Double-blind studies, therefore, conceal the type of treatment from both the patient and the doctor providing the treatment, although again this is easier for some types of alternative medicine than others. While it is easy to provide unlabelled tablets to doctors and patients, it is much more difficult to conceal from an acupuncturist whether they are providing the real or sham treatment. Wherever possible, double-blind studies should be used to ensure that the placebo effect has been controlled for.
- Size Matters
Another important component of significance is the number of people involved in the study. If you test only a few people, it is much easier to find a statistically significant result when in fact there is no real effect. Imagine flipping a coin five times. On average, you would expect to get 2.5 heads and 2.5 tails, but on this occasion you throw five heads in a row. From this sample alone, you might be compelled to suggest the coin was biased, but in fact, even an unbiased coin will throw five heads in a row roughly 3% of the time. This is small enough to be considered statistically significant by the scientific community, but it is still fairly common. Consider, however, a sample of fifty coin flips. The chances of getting all heads is infinitesimally small now, and were you to throw fifty heads in a row you would feel certain that the coin was biased. And rightly so. The cut off for a study to claim statistical significance is relatively high (5%) and for studies with small samples this result can easily be biased. It is also good to check how balanced the treatment groups were – it’s all very well and good having a sample of 500 people, but if 450 of them were given one treatment and only 50 the other, your data is still relatively useless. When it comes to sample size – the bigger (and more evenly distributed) the better. When it comes to statistics, however, very small probabilities (p-values) are far more trustworthy – the smaller the better!
The Problem With Alternatives
I’ll admit, I have a few concerns about alternative medicine. In some ways, these concerns seem to be mutually contradictory, but I will try briefly to explain. The belief* in alternative medicine seems to come in three general forms –
- people who believe that alternative medicine works in way that science cannot possibly comprehend – ‘magic’ believers;
- people who believe that alternative medicine can be explained by untested or untestable theories – ‘pseudoscience believers’;
- people who believe in alternative medicine because they have seen or experienced it’s positive effects – ‘anecdotal believers’
* I say belief here, because many of those who use or endorse alternative medicine (or at least of those that I have encountered either personally or through the media), seem to treat the topic as faith – in the sense that faith is “confidence or trust based on no scientific, plausible, testable, demonstrable evidence whatsoever”. In contrast, science will change its stance in light of new evidence. Present me with sound, rigorous evidence that a particular alternative therapy works and I will happily endorse it.
My concern about type I, magic believers, is that this type of thinking hampers scientific curiosity; it is ready to simply accept what we do not understand as magic and go on with life. For example, in part V I discuss Reiki, based around the principles of chakras, meridians and auras, which are often explained away as being undetectable and untestable by modern science. Magic believers also include those who use alternative therapies due to superstitions and religious traditions, such as herbal medicine. To discard our curiosity is a great loss both to our wellbeing and our economic prosperity. Scientific curiosity drives new ideas, new ways of thinking about the world, and ultimately new technologies, new medicines and a deeper understanding of our place in the universe. Therefore, my feelings about type I are primarily intellectual. I suppose it’s harmless enough to look at the world this way, I never really liked GPS or penicillin or mobile phones anyway.
Type II, pseudoscience believers, are often guilty of creating bizarre, scientific-sounding explanations that bamboozle unsuspecting clients – on the surface the explanations sound compelling, but upon close inspection they either make no sense, or are totally untested or even untestable. For example, in part V I discuss crystal healing, which is often explained through ‘vibrational frequencies’ and ‘resonances’ of certain rocks and minerals – this pseudoscientific explanation actually makes no sense at all. Similarly, the claim by homeopaths that water has ‘memory’ is untested pseudoscience, and if taken to its logical conclusion, really quite disgusting!
In this case, people are either naïvely perpetuating pseudoscience they have picked up from someone else, or they are being deliberately deceitful. But it seems to me that we would all be far better off if we knew how these treatments really work, so that we could harness this functionality, increase effectiveness and even reduce side effects. If we can distil the medicinal parts of a therapy out, then we can make an even more effective treatment. But only if we understand how it works. So, much like my dislike of Type I thinking, I object to Type II thinking on the basis that it hampers scientific enquiry and slows our progress in improving healthcare.
My concern about type III, anecdotal believers, is that this way of thinking demonstrates a fundamental misunderstanding of the roles of chance and probability and the meaning and function of statistics. Our experience is irreparably biased. Our memories are not perfect mirror images of our past, but a murky watercolour of how our brains understood and interpreted each moment as it came. Our memories are like water colour paintings, but paintings that you’ve spilled a big glass of water over so half of the painting is now lost, smudged and smeared across the canvas. Our experience is also a continual feedback loop interacting with our hopes and expectations; the placebo effect is a consequence of this loop.
Finally, our brains are not adept at weighing up probability fairly – the classic illustration of this being the birthday problem. It goes like this. How many people do you need to gather in a room so that it is probable (greater than 50% chance) that at least two of them will share the same birthday? Many people answer very high numbers for this – 300 or more – but the truth is that with just 23 people in a room, you have a 50% chance that two of them will share a birthday. Any more than 23 and the odds just keep going up. By the time you’ve got 70 people in a room together, there’s a 99.9% chance that two of them share a birthday. This paradox occurs because our brains are not very good at estimating probability. In general, we tend to expect things to be less probable than they really are, causing us to be surprised and impressed when they happen despite the odds. What I’m getting at is that our own meandering experiences, memories, intuitions and estimates are not a good basis on which to make medical decisions. That’s why we need science to empirically test our ideas about the world so that we can see what is real and what is imagined.
What Works For You
That being said, if it works for you – then great! In that respect, experience is a good basis for our decisions. And frankly, whether it’s the placebo effect or a real medicinal one, who cares? As long as it works, what difference does it make? And to some extent, I agree, I would happily take a placebo if it cured my ailment. The exception to this comes, of course, when the placebo has side effects. Surely we can design placebo treatments that don’t have side effects? Several of the alternative treatments I will discuss come with some fairly serious side effects, for example chiropractic care has been linked to an increased risk of strokes*, many herbal remedies contain harmful toxins, and ear candles can be associated with (sometimes serious) ear injuries. Which leads me back to my previous point – we need to thoroughly, rigorously and fairly test alternative medicines and holistic therapies to understand if they work, how they work and how any side effects can be reduced or eliminated.
* See Part Two: Body Manipulation – Osteopathy and Chiropractic Care for a full and empirical discussion of this issue.
This is not a call to arms. This is a call to pipettes. A call for more research, better research and more rigorous scientific enquiry. And it is a call for everybody to try to be better informed about the medicines (both conventional and alternative) that they use. Science doesn’t have all the answers, but it possesses the methods that will allow us to reach the answers. Ultimately, a more open, honest, and research-driven discussion of alternative therapies has the power to improve medical care and patient quality of life for millions (perhaps even billions?) of people the world over.
Articles in this Series:
- Part One: The Ultimate Dilute – Homeopathy
- Part Two: Body Manipulation – Osteopathy and Chiropractic Care
- Part Three: Poking Holes in Things – Acupuncture [Coming May 2015]
- Part Four: Mental Manipulation – Hypnosis [Coming June 2015]
- Part Five: Good Vibrations – Reiki and Crystal Healing [Coming July 2015]
Want to Know More?
- Posadzki et al (2013) Prevalance of use of complementary and alternative medicine (CAM) by patients / consumers in the UK: A systematic review of surveys Clinical Medicine
- Kaptchuk (2008) Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome BMJ
- Marian et al (2008) Patient satisfaction and side effects in primary care: An observational study comparing homeopathy and conventional medicine BMC Complementary and Alternative Medicine
- Harris and Rees (2000) The prevalence of complementary and alternative medicine use among the general population: a systematic review of the literature Complementary Therapies in Medicine
- Eisenberg et al (1998) Trends in Alternative Medicine Use in the United States, 1990 – 1997 JAMA
- Astin (1998) Why patients use alternative medicine JAMA
- de Craen et al (1996) Effect of colour of drugs: systematic review of perceived effect of drugs and of their effectiveness BMJ