Examination of Witnesses (Questions 502-519
PROFESSOR JONATHAN
BROSTOFF, MS
KATE CHATFIELD,
PROFESSOR CHRIS
CORRIGAN AND
PROFESSOR EDZARD
ERNST
21 FEBRUARY 2007
Q502 Chairman: Can I start by thanking you very
much for coming today to give evidence to our Committee? I am
Lady Finlay. I chair this select committee of science and technology
sub-committee inquiring into allergy. Can I also welcome those
who have come to listen in to the session, who are seated in the
public gallery? There was an information note produced and that
has the declaration of interests of all members of the Committee
so we will not be restating those as we go through with our questions.
We have a lot of questions and I would therefore ask you if you
could please be precise and concise with your answers to enable
other people to make a comment and to make sure that we get through
the questions. Can I ask each of you to introduce yourselves?
Professor Ernst: My name is Professor Ernst.
I am professor of complementary medicine at the Peninsula Medical
School Universities of Exeter and Plymouth.
Professor Corrigan: I am Professor Chris Corrigan,
a professor of asthma, allergy and respiratory science at King's
College, London School of Medicine, Guy's and St Thomas's Hospitals.
Ms Chatfield: I am Kate Chatfield. I am here
to represent the Society of Homeopaths and I am a senior lecturer
in homeopathy at the University of Central Lancashire.
Professor Brostoff: I am Jonathan Brostoff,
professor of allergy and environmental health at King's College,
London.
Q503 Chairman: Ms Chatfield, could I
just clarify your professional background? Is that in nursing?
Ms Chatfield: No. I am trained as a homeopath.
Q504 Chairman: Specifically?
Ms Chatfield: Yes.
Q505 Chairman: I wonder if I can start
by asking all of you which techniques allied to complementary
and alternative medicine are currently used in the UK for the
diagnosis and the treatment of allergic diseases?
Professor Ernst: It is a difficult question
because we are dealing with a flavour of the month type of therapy
and they come and go quite frequently. A little while ago, we
tried to assess this systematically by looking at seven leading
lay books in complementary medicine and for allergies we found
57 different treatment modalities. It is big.
Q506 Chairman: Would you be able to provide
us with a list of those after the session?
Professor Ernst: Not offhand but if you give
me a little time, yes.
Professor Corrigan: The four commonest ones
used for the treatment of asthma and allergy are acupuncture,
herbalism or phytotherapy, homeopathy and various physical techniques,
spinal manipulation and the like. Some of these techniques claim
to diagnose as well as treat allergy. For example, homeopaths
and herbalists diagnose. Others take the diagnosis as read and
work from there. There are lots of tests available on the Internet,
by post and in shops that are claimed to diagnose allergy including
leukocytotoxic testing, electrodermal testing or Vega testing,
kinesiology, pulse testing and various other miscellaneous ones
including iridology.
Ms Chatfield: In homeopathy we have a very different
definition of diagnosis. It is not diagnosing a specific allergy
according to a specific allergen. A homeopathic diagnosis for
us literally means finding the right remedy for the person, so
it is not a conventional diagnosis in that sense.
Professor Brostoff: Some of the so-called scientific
tests for diagnosing allergy and in particular food allergy that
are marketed have dubious clinical validity, even when put to
double blind studies. That is one aspect, even if the techniques
used in the laboratory are robust but the interpretation, I am
afraid, is fallacious. In terms of the allergy patients that I
see, many have used herbal treatments and I think we did the first
double blind placebo controlled trial of Chinese herbs in eczema
in the early nineties which showed it to be remarkably successful,
but we were careful to exclude toxic elements in the herbs. As
the Chinese have been doing it for about 1,500 years, I think
we might have a lot to learn from them!
Q507 Chairman: That is an example as
to my second question which is whether there are certain types
of complementary medicine that are more suited to particular allergic
diseases than others. You have cited one, Professor Brostoff.
I wonder if others would like to comment?
Professor Corrigan: There is a vast body of
literature that suggests that there is no net clinical benefit
from many of these procedures, including acupuncture, homeopathy
and various physical techniques. Some physical techniques have
been shown to improve the quality of life for some patients—for
example, asthmatics—probably by teaching them how to breathe
properly but there is no evidence that they improve the disease.
With herbalism you have to be careful. We must not forget that
many of the drugs we use today have been derived from plants.
It is likely that there are still a few more to be discovered.
The problem with herbalism as it is applied currently is that
the preparations are not standardised. The active ingredients
are not known. The prescription of these substances is rather
ad hoc and, because the whole process is unregulated, there is
the problem of poisoning. There are well documented cases of toxins
such as organophosphorous pesticides in herbal remedies and other
toxic agents. Whilst there is scope for looking at allergy treatments
derived from plants, this research should be organised more systematically
and the active ingredients should be isolated and their properties
characterised. With the one exception of herbalism, I do not believe
there is any good evidence that any other form of alternative
medicine produces a tangible benefit in asthma. There are many
studies and summaries of studies to back this statement up.
Ms Chatfield: In homeopathy, as far as I am
aware, we do not have any significant evidence from randomised
controlled trials for the treatment of asthma but we do for allergic
rhinitis and hay fever and a lot of clinical of evidence suggests
that homeopathy could be of great benefit in eczema, particularly
with the kinds of patients that we get. We have a very high percentage
of children coming with eczema and related allergies. [1]
Results of a six-year study at Bristol Homeopathic
Hospital, published 2005, show that over 70 per cent of patients
with chronic diseases reported positive health changes after homeopathic
treatment. The most marked improvements were seen in children.
89 per cent of under 16 year olds with asthma reported improvement
and 75 per cent felt "better" or "much better",
as did 68 per cent of eczema patients under 16.
Professor Ernst: There are virtually dozens
of complementary therapies that have been submitted to clinical
trials. We have summarised them in a book which I have here and
which I am happy to donate to the Committee. This material is
systematically and transparently summarised. I agree with my colleague.
For no treatment modality is there good evidence that it is clinically
effective in asthma, atopic eczema or hayfever. These are the
three conditions that we have included in our systematic review.
Q508 Chairman: I just wonder whether
you might be able to comment on the term "holistic allergy
therapy". Professor Corrigan, I also wondered what you feel
the evidence is for the role of physiotherapy in breathing techniques
in patients with asthma.
Ms Chatfield: I have no idea what holistic allergy
therapy is. I have never heard of it.
Professor Corrigan: There are various breathing
techniques which can strengthen the respiratory muscles and these
are of proven benefit in some patients with asthma and indeed
chronic obstructive airways disease. Anxiety plays a natural role
in many of the symptoms of asthma and teaching patients to calm
and control breathing, techniques allied to physiotherapy, have
been shown to improve asthmatics' quality of life, presumably
because they help them to calm down and breathe more naturally.
There is no evidence these techniques improve the severity or
the natural history of the disease.
Professor Brostoff: Because allergy services
in the UK are minimal for the number of people who complain of
allergy, patients will be forced to go and see people who might
use Vega machines or apply kinesiology. Anecdotally, many of these
patients improve. Whether that is placebo or due specifically
to the technique, or it is a subgroup of patients who respond,
it would take very little to produce a clinical study of sufficient
power to show that the Vega or applied kinesiology in controlled
conditions was effective, either globally in groups of patients
or in a subgroup. I think it is very sad that effort is not put
into this but it is quite understandable. Private practitioners
are not going to pay for clinical studies.
Q509 Lord Colwyn: May we assume that
none of you has a problem with the efficacy of the placebo effect?
Professor Brostoff: I wish I could treat every
patient with the placebo effect. It would be much less contentious
and have far fewer side effects.
Professor Ernst: I have absolutely no problem
with placebo effects. In fact, as a clinician, I used to try to
maximise them but I would like to point out that you do not need
a placebo in order to generate a placebo effect.
Q510 Lord Taverne: Professor Ernst said
that his clinical testing of alternative remedies and treatments
did not show any effect. Could he comment on what Professor Brostoff
has said about the use of Chinese herbs?
Professor Ernst: This is very complex because
Chinese herbs are a whole world in themselves. There are very
few people who understand them and I am probably not one of them.
They are usually given as individualised treatments so if you
all have asthma and I am a Chinese herbalist I would take your
pulse, look at your tongue and your constitution and so forth
and give you all different herbal mixtures, often containing a
dozen or more herbal ingredients and plants. The potential for
interaction, for instance, is huge there. This approach has not
been submitted to a clinical test. It can be tested, this individualised
approach, but it has not been. What my colleague spoke of was
a standardised formula of certain herbs targeted for eczema in
this case and there were indeed some positive results. Later on
there were some negatives as well with that particular formula.
That is a different way of dealing with herbalism. There is the
standardised herbalism where you buy a pill in Boots, or whatever,
and there is the individualised herbalism. The individualised
herbalism is the one that has been practised in this country by
all herbalists and it has not been submitted to clinical tests
in relation to allergy. For some other conditions it has and the
results have been negative.
Professor Corrigan: There are herbs that have
been shown to be efficacious in isolated studies because they
contain known, active, pharmacological medicines. For example,
butterbur is a herb which impairs the immune system and may treat
asthma very much along the same lines as conventional steroids.
Coleus is another herb which contains forskolin which is a bronchodilator.
There are many drugs in some herbs which may be effective but
what I deplore is the ad hoc use of these unpurified medicines
which may not be safe in an unsystematised and untried fashion.
Q511 Lord Rea: Could we go back to Vega
testing and kinesiology which have been mentioned briefly? Could
you remind the Committee exactly what these techniques consist
of and how are they used to diagnose allergic disease?
Professor Corrigan: A Vega test or an electrodermal
test is based on a couple of wires being connected to a small
galvanometer or battery which generates a small voltage. The machines
look very impressive. They have lots of knobs, switches and dials.
They impress the customers. There are various variations but the
basic technique is that the subject holds one wire in one hand;
the other wire is placed in various areas of the skin or other
parts of the body which are deemed to be of diagnostic importance.
Sometimes there is a plate in the circuit containing a vial of
allergen which looks very impressive to the customer. The only
galvanometer readings that are generated by this process are caused
by flow of electrical current across the skin and depend on how
sweaty the patient is or where exactly you put the electrodes.
From these measurements, typically a list of substances is produced
and given to the subject and they are told that they are allergic
to these substances. These lists are entirely ad hoc and random.
There is no evidence that this technique can diagnose allergy.
Applied kinesiology is the science where practitioners claim to
be able to diagnose allergy from the tension in the muscles of
the outstretched arm. They will ask a patient to outstretch an
arm and apparently, with years of training and experience, when
the patient holds a vial typically of allergen in the other hand
they can detect changes in the weakness of the muscle of the opposite
arm and thereby diagnose whether or not the patient is or is not
allergic to the vial of allergen that is being held in the opposite
hand. This can be practised with surrogates. In other words, if
you have an uncooperative child, the kinesiologist can hold the
adult's hand and hold the adult's hand again when they are holding
the child's hand. Again, they claim to be able to diagnose what
that child is allergic to. This is all completely bizarre and,
I am afraid, utter nonsense. There is no scientific evidence or
mechanistic base to suggest that these tests could be remotely
effective.
Q512 Lord Rea: Is the diagnostic part
of these techniques the same as treatment—as the therapeutic
effect—or once the diagnosis has been made is a different
treatment applied?
Professor Corrigan: These diagnostic tests do
not necessarily proceed to treatment. Often, the patient is just
presented with a list of substances to which they are putatively
allergic and then they are just allowed to walk away with it.
They are not the basis for specific therapeutic regimens.
Ms Chatfield: They are then told to avoid those
substances.
Professor Corrigan: Yes, typically they are
and typically they do to their detriment.
Q513 Lord Broers: Presumably this leads
to a positive placebo effect anyway, does it? The very fact that
people have been treated with an elaborate machine must—
Professor Corrigan: Of course. It is the fact
that they have been treated with an elaborate machine and that
they have often paid a large sum to do so which gives them the
firm impression that the diagnosis must be right, which is appalling.
Q514 Lord Rea: Have we any evidence at
all about the efficacy of these techniques and could you give
us an idea about how much a typical treatment would cost?
Professor Ernst: Both these techniques have
been submitted to proper scientific tests. Some of these tests
have been of high methodological quality. When they have, they
have resulted in negative findings. In other words, there is no
validity to either of these two tests. I cannot comment on the
costs. I believe it is around £50 per go.
Q515 Lord Rea: Would it be possible to
suggest that the efficacy is related to the skills and experience
of the practitioner rather than the complicated techniques and
equipment that they use?
Professor Ernst: In these tests, obviously the
practitioners were experienced and, yes, there was no reproducibility,
specificity et cetera, which you require from a diagnostic test
to be valuable.
Professor Corrigan: It is difficult to define
what an experienced practitioner is in these cases. One can define
an experienced practitioner of physiotherapy because there is
a set training course but, with these procedures, there is no
standard training manual written down. There are sets of instructions
with the individual kits but it is difficult to know how somebody
does become professional in these techniques.
Q516 Lord Rea: I was thinking, rather
than skill or training, of the personality of the practitioner.
Professor Corrigan: I suspect that has a very
great deal to do with it, yes, somebody who looks knowledgeable,
authoritative and presents you with a piece of paper in a solemn
tone which you take as gospel.
Q517 Lord Taverne: My question is really
addressed to Ms Chatfield. What is the difference between homeopathy
and isopathy and how do these therapies, do you argue, compare
with more conventional treatments in efficacy and cost?
Ms Chatfield: As Professor Ernst was pointing
out, with herbal practitioners there are different ways of applying
and prescribing herbal medicines, but it is the same with homeopathy.
A homeopathic prescription is based on the symptom picture that
the patient presents with. The remedy is prescribed according
to the symptoms that the patient presents with. With isopathy,
the remedy is not individualised according to the symptoms but
according to the specific or primary allergen that has been identified.
For example, in the case of a birch allergy, it would be betula
that was used as the remedy to treat that if it was an isopathic
prescription. The remedies would still be highly diluted as they
are with homeopathic remedies. That is the difference between
isopathy and homeopathy. Generally speaking, I think homeopaths
would consider homeopathy more effective than isopathy but I do
not think we have any evidence to show that.
Q518 Lord Taverne: I was asking about
the comparison with conventional treatment.
Ms Chatfield: If you look at the outcome studies
we have, obviously they do not involve the placebo question but
we have various high levels of improvement in large scale outcome
studies all over the world with this kind of treatment. In terms
of cost effectiveness, we do not have enough information on that
either. What I would specifically like to see would be research
trials which compare the conventional treatment directly with
homeopathic treatment in terms of efficacy and cost.
Q519 Lord Taverne: In a recent debate
in the House of Lords, the president of the Royal Society said
that if medicines can really work even if only a single molecule
is left this would entail some fundamentally new scientific principle
with amazingly broad ramifications and fundamental implications
for experiment over the whole of science. Could you explain how
the mechanism is supposed to work that achieves these astonishing
results?
Ms Chatfield: I think you know very well that
I will not be able to because we have not discovered that yet.
I am of the opinion—and I think a lot of homeopaths are
who were initially sceptical when they came in and, for a number
of reasons, are convinced by the evidence—that science is
not a static thing. It changes all the time and just because we
do not have an explanation currently we do have a lot of people
proposing different theories about how it may work. Just because
we cannot explain it now does not mean it does not work. Yes,
it will mean that science is revolutionised and I do not see that
as a bad thing.
Professor Ernst: There is a fundamental difference
in saying we have not discovered the mechanism yet. 50 years ago,
we did not know exactly how Aspirin worked but we always knew
that there would be a mechanism there because it is pharmacology.
With homeopathy, this is fundamentally different. Science tells
us that there is no mechanism by which it can work and that is
an important difference. If we find the mechanism then we have
to rewrite our textbooks of physics, pharmacology and chemistry.
Professor Brostoff: I do not think there is
a problem with rewriting any textbook if new facts arise. The
critical data is: has homeopathy in a sense been shown in model
systems in the laboratory. The answer is very likely to be yes,
both in the haematological system recently and also a long series
of experiments in Paris. I know there was controversy over those.
The fact that the clinical trials in the homeopathic hospital
in Scotland, David O'Reilley's studies, in three separate studies
showed that these were statistically significant in terms of active
versus placebo suggests that whatever the mechanism is it does
bear thinking about.
1 Out of a total of 11 randomised controlled trials
investigating the efficacy of homeopathy in the treatment of seasonal
allergic rhinitis, eight demonstrate a significant positive effect. Back
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