Examination of Witnesses (Questions 520-539
PROFESSOR JONATHAN
BROSTOFF, MS
KATE CHATFIELD,
PROFESSOR CHRIS
CORRIGAN AND
PROFESSOR EDZARD
ERNST
21 FEBRUARY 2007
Q520 Lord Taverne: A Lancet
paper recently compared 110 homeopathy trials with 110 conventional
medicine trials and found there was no evidence whatsoever that
homeopathy performed better than placebos.
Ms Chatfield: The conclusions the authors came
to were based on eight trials of homeopathy, not 110. What they
did was single out what they called the high quality homeopathy
trials and narrowed them down to eight trials of homeopathy, none
of which were reflective of homeopathy as it practised in the
real world. These trials involved a combination of isopathy, and
therapeutic prescribing, not individualised homeopathy. It was
unbelievable that they could draw that conclusion from eight trials
that homeopaths would not even consider homeopathy.[2]
Professor Ernst: Unbelievable or not, the importance
of this Lancet paper that you quote lies not in that it
may be the only paper questioning the efficacy of homeopathy.
There are to my knowledge well over a dozen such systematic reviews
published in the peer reviewed literature which all show the same
thing, so the importance lies in yet another confirmation of something
that has been shown a dozen times before.
Professor Brostoff: The fact that there may
be a meta analysis showing that many trials are negative does
not negate, for example, three positive trials that David O'Reilley
did in the homeopathic hospital in Glasgow. The fact that you
have lots of negatives does not deny a positive.
Professor Corrigan: On a statistical basis,
one would expect one trial in 10 to be positive purely at random.
Ms Chatfield: A major problem with meta analyses
and homeopathy is that they incorporate lots of different kinds
of prescribing and it would be prescribing for the whole person,
prescribing for the disease, using isopathy, comparing them all,
lumping them all in together as if they are one thing when they
are not. We do know that some of the older trials of homeopathy
were not robust in terms of the way that they were designed and
carried out.[3]
Q521Lord Colwyn: I am sure the panel would agree
that, despite the criticism, there is no doubt that these techniques—we
can go back to kinesiology and Vega testing and also homeopathy—have
successes. I have referred patients to a kinesiologist for 30
years and I do not think he has ever got one wrong.
Professor Corrigan: I am afraid that is the
sort of anecdotal report we have to be very careful of. Such observations
mean nothing outside a properly controlled trial. Anybody can
convince themselves they have benefited, particularly the person
who recommended them, but I am afraid that does not constitute
scientific evidence.
Q522 Lord Colwyn: It constitutes a grateful
patient usually.
Professor Corrigan: We are all in the business
of making patients happy. If that is all we are doing, maybe there
is room for that but if we are talking about real science that
is a different matter.
Q523 Lord Broers: Professor Corrigan,
would you agree that homeopathy at least does not suffer from
the dangers of herbalism in that if there are toxins they are
diluted beyond action?
Professor Corrigan: Yes, absolutely. It is hard
to see how they would be toxic but I do not agree that they are
necessarily harmless because they may delay accurate, valid and
pressing diagnosis.
Q524 Baroness Platt of Writtle: There
is some concern that seeking help from complementary medical practitioners
may delay the diagnosis of allergic diseases by more evidence
based therapies or even lead to misdiagnosis, which could have
potentially fatal consequences. How would you respond to this
suggestion?
Ms Chatfield: In homeopathy we do not pretend
to diagnose in the way that conventional medics do. Most of the
patients that come to see us have already tried everything else.
Then they try homeopathy. It is a last resort kind of treatment
for most people. We also have a strict code of ethics and practice
which our practitioners are bound by and within our code of ethics
and practice practitioners are told that they should always point
out to their patients the necessity to visit a GP. We have never
had a complaint of that nature in the 29 years of the Society
of Homeopaths being in existence.
Professor Brostoff: The fact that allergy is
taught at a remarkably low level in medical school, the fact that
there are probably under five trainees in allergy for the whole
of the United Kingdom and the fact that several allergy clinics
have now been shut means that patients are not getting a fair
crack of the whip in standard allergy clinics. To take the questioners
point, I have seen patients who have been to two or three allergy
clinics where a very important and significant medical condition
has been missed, potentially fatal in one case, but the boot is
sometimes on the other foot. If we train enough allergists of
a high quality, I do not think this question would be worth considering,
but sadly we do not.
Q525 Baroness Perry of Southwark: My
question is about the standard of proof that the Medicines and
Healthcare Products Regulatory Agency uses. As you will all well
know, it registered its first herbal medicine last November and,
as I understand it, a herbal medicine gets onto the register only
if its maker can prove that the substance has been used in traditional
medicine for many years. They do not have to prove that it is
efficacious. Do you think this is an appropriate standard of proof
or should complementary medicines have to prove their efficacy
to the same extent as more conventional medicines?
Professor Corrigan: I am afraid this is appalling
nonsense. We have been campaigning as allergists to get allergen
immunotherapy licensed by the MHRA for years. This is a very scientifically
validated treatment which is of great benefit to thousands of
sufferers with hay fever and still the MHRA turned us down because
some patients have reactions to the injections. It is very frustrating
that they then condone the use of these untried, uncharacterised
and untested concoctions on the basis of no evidence at all. It
is completely impossible to understand and very frustrating for
the practise of proper, scientifically conducted allergy.
Ms Chatfield: Of course, I do not think it should
be taken in isolation as a form of evidence but it is still a
kind of evidence.[4]
I think the Chinese would be horrified by what you have just said,
that because their medicine has not been scientifically proven
it should not be used.
Professor Ernst: I agree with Professor Corrigan.
It is a nonsense and it is very regrettable because it sets a
double standard for the first time in medicine regulation and,
for me as a researcher, it is particularly detrimental because
it just puts any impetus to do any further efficacy research down
to the level of zero. We are freezing our knowledge of potentially
beneficial herbal treatments if we do not ask for proof of efficacy.
Q526 Baroness Platt of Writtle: Professor
Ernst, you did say earlier that private practitioners clearly
are not concerned with funding research into the efficacy of what
they do, but is there a need for real research into efficacy and
are there any charities or other bodies that are funding research
of this kind?
Professor Ernst: Research funding is the most
difficult thing in my life to obtain. It is nearly impossible
and it has become even more impossible over the last few years
because regulation of clinical trials is now such that it is very
expensive, mostly geared up to large pharmaceutical trials, and
to conduct a trial of homeopathy or herbal medicine under these
circumstances would be very difficult indeed. Public funds are
by and large not available. The science select committee seven
years ago recommended large funds to be made available. That has
not happened. Industry funds are non-existent so we are reliant
on charitable funds which are very scarce indeed.
Q527 Lord Colwyn: It has been about 10
years since I visited you in Exeter. What is your level of research
staff at the moment? Do you have a number of DHS fellowships and
PhDs there?
Professor Ernst: We have about 10 research staff
in Exeter which makes us by far the largest unit of that nature
in Great Britain. We have no government funding at all. We did
not get any despite various attempts. Basically, we live on charitable
funds, the most important of which is the Laing Foundation.
Q528 Chairman: How many prospective comparative
studies do you have under way at the moment?
Professor Ernst: Zero. It is not out of ambition;
that is my expertise and I cannot fund them any more so we have
shifted our emphasis towards meta analysis of clinical trials,
not because we particularly think they are important. We think
they are important but clinical trials would be more important.
It is simply by default.
Q529 Chairman: I wonder if you could
explain to us the difference between immunotherapy and enzyme
potentiated desensitisation and any dangers of adverse reactions
with either?
Professor Brostoff: Classic immunotherapy as
practised in the NHS and in the UK is incremental immunotherapy.
That is, for the most part, it starts at a low dose and builds
up. It is allergen specific based on skin testing and serology.
Many studies are done on that. We did the first study of sublingual
immunotherapy which is a little more comfortable for the patient
and that has now been accepted by the European Academy of Allergy
as a validated treatment for inhalant allergy—that is, hay
fever and sometimes asthma. There are other variations on this
form of immunotherapy using titrated doses. EPD is enzyme potentiated
desensitisation which contains enzymes and a low level of allergen.
This has been used for almost 40 years. It has had one study published
in the BMJ on hay fever which showed no difference between
active and placebo. I understand there were significant problems
with that study. Anecdotally, the side effects are minimal and
anecdotally many patients respond well to it.
Q530 Lord Haskel: If we could move on
to the provision of complementary and alternative medicines, some
seven years ago this Committee produced a report and one of the
proposals was that they should introduce statutory regulation
for practitioners of herbal medicine and acupuncture. The government
decided to act on this in 2005. What progress has been made towards
implementing these proposals?
Professor Corrigan: I am afraid I cannot answer
in a professional sense but you only have to walk down the high
street to see that there is a great deal of deregulation still
in existence. So far as I am aware, any practitioner can put up
a brass plate and sell herbal medicines. Is that not the case?
Certainly you can walk into any high street shop and have a Vega
test. I do not see any regulation at all as a lay person and a
consumer. I cannot answer you professionally because I am not
involved in the licensing of alternative practices.
Professor Ernst: I am also not involved in these
regulatory issues but I know that chiropractors and osteopaths
are regulated, as we all know, and acupuncturists and herbalists
are well on the way to being regulated as professionals. I believe
there is an initiative to bring all the other complementary therapies
under one regulatory umbrella. How far this has succeeded or advanced
I am not aware of but I think a regulatory process is well on
its way. I am not sure that this is entirely a good thing because,
as I pointed out, if you regulate traditional herbalists and there
is no shred of positive evidence for their individualised approach,
you regulate in my view nonsense and that will result in nonsense.
Ms Chatfield: I would like to reiterate what
Professor Ernst has said. My understanding is that they are well
on the way to regulation. They are in the last stages. There have
been many things that they have had to sort out about who would
be allowed to go on the register in terms of the qualifications
and kind of practice they have, how they practise. They are managing
at the moment to sort all those out and move on.
Q531 Lord Haskel: The Committee was quite
impressed with the regulation of the osteopaths and chiropractors
and also with the work that they did for continuing professional
development. Is there any guidance for the general public to help
them choose a reputable practitioner and how could this be improved?
Ms Chatfield: Certainly I think regulation is
the way to go and in homeopathy we would like to go for statutory
regulation ultimately ourselves. At the moment, we are in the
process of voluntary regulation and putting together one register
for all the homeopathy professionals. For all of the forms of
complementary medicine, we need some kind of professional body
with clear guidelines, a code of conduct, clear complaints procedures—all
of these things we need in place.
Professor Ernst: We have recently published
a little piece of research where we have shown that chiropractors,
after having been regulated in the United Kingdom, have totally
fallen asleep as to research. That proves the point that I have
tried to make previously, that regulation is seen as a substitute
for evidence. Once we are regulated, we do not need to show the
world any more that what we are doing is any good. That seems
to be happening on a major scale and therefore I am happy for
regulation as it safeguards consumer issues and so forth but,
if it is used as a substitute for efficacy or safety research
it worries me.
Professor Corrigan: Regulation does not mean
the treatment is effective. At best, it may protect some patients
from being poisoned and it may protect some patients from charlatans.
Once you do license them, they are under less obligation then
to show that what they do is of any benefit, which is counterproductive.
Q532 Lord Haskel: Is there any useful
guidance for the general public?
Professor Corrigan: Not that I know of.
Ms Chatfield: It is not something I have seen,
that there is a decreased interest in research. That has not been
my observation at all. The decrease in research is due to the
drying up of any funding. That is the primary factor that affects
the level of research. Certainly within the professions there
is still the drive to carry out the kind of research that improves
practice. It is not just about proving efficacy but trialling
different techniques.
Q533 Lord Taverne: On the question of
guidance, I know that opinion on the panel will be divided but
would it not be useful guidance to issue a health warning when
so many people do resort to alternative therapies?
Professor Brostoff: It might be interesting
to issue a health warning about going into hospitals these days.
If you take malpractice, if you take 10 per cent of hospital admissions
being due to drug reactions plus MRSA, plus clostridium dificile,
that would be more appropriate at the moment and it is also a
much larger problem.
Professor Ernst: From my perspective, guidance
against complementary, alternative therapies is nonsensical. Guidance
against unproven or disproven treatments, yes. Many treatments
in complementary medicine are unproven or disproven, but not all.
Some have very good evidence, not in the area of allergy, I am
afraid. In these cases, guidance should favour the usage of these
treatments. It is not about a label, complementary versus mainstream;
it is about proof of efficacy and safety.
Q534 Viscount Simon: It seems that allergy
sufferers feel as if they are driven to try complementary medicines
and therapies because the conventional treatments do not appear
to be there. Is this right?
Professor Ernst: I think all the evidence points
to the fact that it is used in addition, as a complement to, rather
than because it is not there and therefore we have to use the
other type of medicine. The reasons why people seek it out are
obviously complex. A level of understanding, empathy and even
time which medicine at present does not afford within the NHS
is, in my view, a very strong motivator for patients to turn towards
complementary practitioners.
Professor Brostoff: There is a frustration with
the availability in the allergy field and the provision in the
National Health Service is so limited. My particular interest
is food intolerance. If patients do go to conventional allergy
clinics, the conventionally trained allergist is often not very
interested or involved in food intolerance. For brittle asthma,
for example, John Ayres's study in Birmingham was of 60 patients
put on an extremely rigid diet. He found that in about a third
of the patients their asthma improved very significantly when
specific foods were eliminated, and of note these are patients
where skin tests and blood tests are negative, so it is a completely
different mechanism. I of course would put in a plea for more
interest in food intolerance.
Professor Corrigan: I agree with Professor Ernst.
A lot of patients use complementary medicine more as an adjunct
to existing therapy than anything else. A lot of it is peer pressure,
pressure from the media: I have tried this and it has worked for
me for 10 years, these sorts of statements. Interestingly, if
you look at studies, whereas many patients use these complementary
therapies, a lot of them do not think they are particularly effective.
It is almost a thing one does these days, rather like getting
a new car. I would also endorse the principle that many patients
in this country do not have an allergist to consult and that is
a very important factor in people seeking help. One will seek
help from anywhere if one is desperate enough. I think we can
all understand that sort of sentiment. That has played a role
but largely I think it is also peer pressure and modern society
that force people to look at these medicines.
Ms Chatfield: What you call "peer pressure"
I would call word of mouth and stories of successful treatment.
Certainly that is where most of our patients have come from when
we have looked at the motivation for coming. They have heard stories
from other people who have been successfully treated. That is
why they come. I cannot call that peer pressure. When we are looking
at particularly children with allergies, their parents most often
bring them because they do not want to use conventional treatment
or, if they have used conventional treatment, they are worried
about the side effects and the long term usage of that. That is
one of the main motivators for parents who bring their children.
Q535 Viscount Simon: Would I be right
in thinking that if more allergy specialists were around the place
the demand for alternative medicines might reduce?
Professor Corrigan: In my view, dramatically,
yes.
Q536 Viscount Simon: Professor Brostoff,
is there a role for complementary and alternative medicine in
severe brittle asthma?
Professor Brostoff: What I am interested in,
which is food intolerance and aspects of nutrition, I would not
call complementary medicine. I would call it mainstream medicine
and my brittle asthmatics all go on diets. If I get one in three
better, I think that is an enormous yield. Keeping somebody out
of hospital six times a year, to me, is not a little matter.
Q537 Earl of Selborne: There are currently
five NHS homeopathic hospitals which offer homeopathic and other
complementary treatments such as acupuncture. Should we have more
on the National Health Service and should the range of treatments
alongside conventional treatments be extended to such therapies
as Vega testing and kinesiology on the National Health Service?
Ms Chatfield: I do not really want to comment
on Vega testing and kinesiology. I think that is a separate issue
but certainly with homeopathic hospitals we would welcome far
more provision of homeopathy on the NHS because at the moment
there is very little provision available and it remains the preserve
of the people who can afford to pay for it in most instances.
We would welcome any opportunity to increase provision.
Professor Corrigan: I think it is sad that we
consider such an option when the conventional and professional
allergy services that are available on the NHS currently are so
few and so limited. It is possibly a question of priorities, but
that should be regarded as a secondary issue. We are all in the
business of making people feel better. If people do feel better,
even if there is no tangible benefit, one might argue that that
might be a suitable alternative to spending more than two minutes
with your GP discussing your problems, or even your priest or
your mentor. I could not condone expansion of homeopathic hospitals
or any other alternative therapy to the detriment of setting up
a well accessible, conventional allergy service within the NHS.
Q538 Lord Broers: I have a simple, technical
question about homeopathy and drugs. Is it possible to distinguish
between homeopathic drugs after they have been diluted? Is there
any means of distinguishing one from the other?
Ms Chatfield: Only by the label.
Q539 Lord Taverne: The question was about
possibly expanding and financing more hospitals. Do you think,
as an alternative to this that, given the shortage of funds in
the health service, the present expenditure on these five homeopathic
hospitals is justified or can be justified? Ms Chatfield obviously
would say it is justified.
Ms Chatfield: Of course it is justified. I think
you will find when you look at the cost effectiveness of homeopathy
and what the provision costs, it is a very small proportion of
the NHS budget. When you look at putting money into that kind
of provision, you will ultimately save money in other areas.
Professor Ernst: I cannot think of a logical
justification for treatments which are disproven or unproven.
In as much as these hospitals use proven treatments, they are
justified. In as much as they do not, they are not justified.
Professor Corrigan: I would agree with that
and if we are talking about cost effectiveness do not forget that
it costs the NHS £100 million a year to treat asthma and
allergy, not to mention the socio and economic losses from loss
of time at work or school and poor performance in exams. The cost
effectiveness of an effective allergy service in this country
would be overwhelmingly positive.
Professor Brostoff: If you take general surgery
or most surgical operations, probably 90 per cent have not been
put to a true double blind clinical study and we are using empirical
methods which sometimes work better than others. If homeopathy
is satisfactory to the patient and adds something to their quality
of life and keeps them away from the NHS, I would support it fully.
2 In the same paper the authors established that a
far higher percentage of homeopathy trials (21 per cent), than
conventional drug trials (8 per cent), were of highest quality.
This does beg the question as to how we are ever able to trust
the conclusions of conventional drug trials. Back
3
It is misleading of Professor Ernst to quote results from systematic
reviews of homeopathy as if they are all negative. In actual fact
most systematic reviews and meta-analyses are positive, and this
includes comprehensive reviews and those focussed on specific
conditions including influenza, arthritis and allergic rhinitis. Back
4
Although it is not in the form of randomised trials, surely well-documented
use in real life cases over hundreds of years holds some value. Back
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