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A new 6-part series about complementary medicine. |
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Every year, one in five of us tries some sort of complementary or alternative medicine (CAM) - what's the attraction? And what do we get out of it?
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| Presenter: Anna Ford |
 ÌýListen again to Programme 3: Does it matter how it works?
BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
THE OTHER MEDICINE 3.
RADIO 4
TUESDAY 05/10/04 2100-2130
PRESENTER:
ANNA FORD
CONTRIBUTORS:
DAVID REILLY
THOMAS MARSHALL MANIFOLD
GEORGE LEWITH
DYLAN EVANS
KATHERINE ARMITAGE
PETER FISHER
PHILLIP BALL
PRODUCER:
RAMI TZABAR
NOT CHECKED AS BROADCAST
MUSIC
REILLY
I knew this was going to have to be a great study, I knew it was going to have to be watertight science. And of course we chose one of these extreme dilutions which definitely shouldn't work as it were. And out of that we began to get the sequence of positive results. And the editor of the Lancet, once the peer review process was over, I said to him: "Listen …" - it was the first time we'd spoke - I said, "I want to thank you for having the courage to take this paper." He said: "I want to thank you for recognising it took courage," he said, "we absolutely sweated over this paper, we went through it as we don't go through papers with the finest of combs and we concluded this is science, good science and this is good data and we have to publish this." I did this as a personal inquiry along with my co-workers because I wanted to know the answer and the answer that came back to me was that this was working.
FORD
The impassioned voice of Dr David Reilly, who in 1986 was one of the first scientists to publish credible, well-regarded clinical studies of homeopathy. While the battle still rages about how effective it and other complementary medicines are, some scientists are attempting to unravel a deeper mystery about how they work and ultimately about what's underlying the healing process. In this programme we'll find out if such answers exist.
ACTUALITY - THOMAS MARSHALL MANIFOLD'S CLINIC
What we're looking at there are 12 pathways on either side of the body and we're going to measure the end point of each of the lines. So the supposition is that if the activity of the point is high then the activity in the pathway is high.
Right well I'll give you my hand to start with.
Raise the hand - so the first thing we do is we need a reference electrode …
FORD
Tom Marshall Manifold runs the Wimbledon Clinic of Natural Medicine. Over 20 years, he's become a one-stop treatment centre offering chiropractic, acupuncture, herbal medicine and other therapies as well. Unusually for a practitioner of natural medicine, he's an avid enthusiast of modern technology, including a device developed by the Russian space programme, called the Prognos - a diagnostic test based on electronically measuring acupuncture points on the fingers and toes.
ACTUALITY - THOMAS MARSHALL MANIFOLD'S CLINIC
If we take the first line, which is the lung line, so it's ears, nose and throat and lungs.
And that's on my thumb.
That's on the thumb. Then we move to the index finger, which is the colon line. Then the next line is circulation on the next finger. And the hormone line is the ring finger.
Do you offer treatments to your patients or cures? Do you ever talk about a cure?
No I don't think I would ever - I wouldn't turn round and say that because I can't because none of us, no matter what field of medicine you're in, can offer a cure. What you can say is you have a condition that is evident in your health system being imbalanced and if we can bring a balance round and strengthen things then your ability to get better will be improved.
So how important to you is the functioning say of the immune system in the body?
It's got to be A1. It's absolutely got to be A1. But you've got to - in order to get your immune system back it's not a matter of you take things for your immune system, you must find out what's hindering the immune system, what's going on in somebody's life that's not allowing them to be better, what is it that has weakened this immune system over a period of time, is it going back to childhood, is it going back to teens when they spent five or six years having glandular infections? So that's why the whole concept has got to be - it's got to be a holistic approach.
PATIENT
He has become the sort of first port of call when you're feeling just - whatever ailment you have and there's a sense and he has a great sort of calmness and authority about him and so if you're feeling run down or if I have a sore throat rather than going to a GP and get antibiotics I'll come in here and get some tablets or phone up and he'll say you've probably got that in the cupboard take 12 of them for two days and you feel better and you feel physically better and you feel better, I think, because you've done it in a natural way. And to be honest I look at him sometimes and I think you're crazy, what are you doing, you can't possibly tell how I am feeling by putting an electrode on my baby finger. But the thing is that what he then gives you works, it makes you feel better. And I'm sure there's an element of you want it to and there's an element of believability in there and it seems to work.
FORD
Now you clearly have a very strong almost paternalistic relationship with your patients, all the patients we've talked to really believe in you, they believe you're going to make them better. How much of their getting better is related to that belief rather than anything you might be giving them?
MARSHALL MANIFOLD
The placebo effect and the faith somebody has in me can only enhance whatever I'm doing.
PATIENT
I just felt like somebody could understand what I was going through and at that point, when I was coming to see the people here, I was at my wit's end and I was prepared to accept anything and I remember speaking with my family who were slightly sceptical and were saying that - do you know what it is you're taking? And at that point I said - I'm prepared to do anything - because I felt so at the end of the road. And I think once you put your trust in a cure and it works for you then you don't need to question it quite so much.
FORD
In spite of the technology and his multi-disciplined approach, part of Tom Marshall Manifold's strength lies in a rather un-fancy old fashioned concept: 'bedside manner'. He's devoted to his clients and they seem to place a faith in his healing powers that any stressed NHS GP would envy.
And it's this sort of relationship which is starting to attract researchers aiming to understand how CAM - indeed how all medicine - works.
LEWITH
There are two aspects to any therapy. If we take depression as an example, if we look at the overall effectiveness of antidepressants they work. But if when we do the placebo controlled trials we find that probably only 15 or 20% of their effect is because of the actual chemical we're prescribing. So perhaps 70 or 85% of the effect may be due to caring for the patient, putting them into a clinical trial, saying I recognise you have a problem, oh dear you have a very low mood for whatever reason or maybe this is a chemical imbalance. And so a lot of the effect that the GP will gain from the prescription is because of the process of consulting and prescribing. Now the same is very possibly true of complementary medicine - that a lot of the effect that we gain is because of the process of receiving treatment.
FORD
George Lewith, former GP and now a CAM practitioner and researcher in Southampton. He's trying to separate out these two aspects of treatment - the specific effect of the therapy (the needle, the herb, or the drug) and the non-specific effect of talking and being listened to.
LEWITH
We have some trials currently underway that separate the process of consultation from giving of the therapy, because we can give some therapies without consultation or we can make some consultations involving a lot of chat and discussion and very caring consultations and we can actually also consent people to have acupuncture consultations where apriori - a the beginning they'll consent to just have somebody come in, define the tender points and put the needles in and not have much conservation, deliberately and specifically just the process. So we can begin to separate out time and caring.
REILLY
When I first saw homeopathy I was quite confident that that was the total explanation and that the bottles and so on and that the rituals surrounding that would prove to be placebo.
FORD
Dr David Reilly runs the Glasgow Â鶹ԼÅÄopathic Hospital. It's the only in-patient homeopathic unit in the country, which despite its name, treats patients with a range of different therapies. Reilly's ground-breaking studies surprised everyone, including himself.
REILLY
I was profoundly sceptical before conducting these studies. I was respectful of homeopathy and of the care of patients and the results it was getting but I was really quite sceptical that the medicines would show any activity. After all by current orthodox models it's an absurdity, would be the only logical way to approach that.
FORD
The therapeutic relationship isn't an interesting aside in the story of healing says Reilly, it's central. And studies are starting to show this.
REILLY
What the research is showing is if you engage with a patient in a discourteous way, in a way which that isn't effective - let's call it join up, actual blocking together, deep effective communication in a safe emotional environment, conscious of the depth that the words are penetrating to in such a charged situation, one, you're doing damage without knowing it and two, you're missing opportunity. And I again would say what complementary medicine has been screaming out over this last two decades is the fact that these holistic factors of engagement are critically important, are of central importance.
LEWITH
I believe that the homeopathic process works because I've used homeopathy and been amazed by its effects. I'm not actually certain that it's the remedy that's working.
FORD
But you still use it, you're happy to give it to your patients?
LEWITH
I'm happy to give homeopathy to my patients, yes because I think the process of coming to see me and having a homeopathic remedy prescribed is really beneficial.
FORD
But you might as well give them a cup of tea.
LEWITH
No I don't think so because that's where the thinking model comes in. Because when I see a person and I want to prescribe a homeopathic remedy for them I want to take a very careful homeopathic history, I want to find out what the whole process is that's going on with them and it may be the process of taking the history which is effective.
FORD
So why go through the process - you could still ask them all those questions and give them a cup of tea at the end, why do you have to give them the homeopathic medicine?
LEWITH
My personal view is that I like to prescribe, I feel it's important to prescribe, I think it's perhaps a symbolic act that's part of the process.
FORD
So when you're treating people as a homeopath you don't believe that it's working according to the principles of homeopathy, you just believe in the process - you with the patient?
LEWITH
Well that's not quite true, I believe that homeopathy is effective. And effective contains a specific effect and a non-specific effect that you might call placebo. And I don't know how much of that effect is specific. Very often in medicine, even in conventional medicine, we use very powerful treatments, the effect of which we don't understand completely - like general anaesthesia - yet we're very happy to use them because they have positive effects in certain specific situations.
FORD
You can call it 'the process', you can call it 'the non-specific effect' but some might also called it 'placebo'.
Dylan Evans is a senior researcher from the University of the West England and author of Placebo: the Belief Effect. Placebos, says Evans, can act powerfully - the effect on pain can be as powerful an analgesic, as morphine. Relatively little research exists on how placebos might work, but the growing interest in so-called mind-body medicine points to our innate immune system being activated or deactivated in some way.
EVANS
We have two arms, if you like, of our immune system - the innate immune system and the acquired immune system. The acquired immune system is the part of the immune system that is most complex and which we've probably all heard about, which involves things like antibodies, B cells and T cells. The innate immune system is much simpler, it's much more primitive, it's evolutionarily much older than the acquired immune system. A lot of attention has been refocused on the importance of the innate immune system since it seems that it does play a very important role in the initial phases of fighting infection and dealing with injury. So the innate system - what the innate immune system does is to provide a very rough and ready first line of defence against infection and it does that through a number of mechanisms, such as making the sight of infection or injury more painful so that we tend to guard it and protect it against further damage, it does it by raising our body temperature in the form of fever. The innate immune system also causes local inflammation - swelling, redness, heat and local pain. And so it has a wide range of systemic effects - local effects - and they all - all of those signs, the typical signs of infection, having a cold for example, all of those symptoms are in fact not the direct result of the infectious agent, if you like, but rather defences that are produced by the body itself to fight the infection. Now my theory is that sometimes this period of acute response to infection produced by the innate immune system can get out of hand, it can become chronic, and then it's a very good idea to be able to suppress it and that's exactly what placebos do - placebos work by suppressing some of the body's own natural defences to infection and sometimes that's a bad thing and sometimes it's a good thing.
FORD
The body healing itself? When put like that, it doesn't sound too far off the notion trumpeted by many CAM practitioners. David Reilly confirms this revaluation of the role of the placebo which is now being seen in the lab, though he's still not keen on the word.
REILLY
What had been buried in the placebo literature was not as irrelevant as we thought. That actually all along it had been desperately trying to tell us that these drugs were interacting with the innate healing systems of the body. Medicine hasn't even woken up to this, that the individual that sits down in front of us in pain and distress and sadness can be helped to begin to spark these changes within themselves without medicalising them and making them dependent on orthodox or complementary therapies.
FORD
Placebo aside, what about the treatments themselves? Patients go to practitioners for a specific therapy. So has science got anywhere in understanding them? How might an acupuncture needle reduce your pain? Does the body really contain energy that can heal? And is there a mechanism working within the extreme dilutions of classical homeopathy?
Well, science has barely begun to explore these questions yet. Acupuncture is probably closest. It's thought that the needles activate the body's own painkiller - endorphin. This at least gives scientists a site of action and a plausible theory to build on.
Â鶹ԼÅÄopathy is another matter. Whilst clinical trials show patients improving, attempts to repeat the results in the lab have become notorious, and have led to some widely publicised, though bogus results.
Â鶹ԼÅÄopathy is based on the principle "similia similibus curentur" meaning "let like be treated by like". Its inventor was Samuel Hahnemann, an 18th Century orthodox doctor, horrified at the ever-more barbaric practices of his profession. He created a gentler form of medicine which takes as its basis for treatment, the presenting complaint.
ARMITAGE
I'm Katherine Armitage, I work as a homeopath from Health Foods, Fulham Road. I use flower essences and homeopathy as my main therapies. I also work as a healer. A lady from up the road was getting very bad hot flushes and last week she came in and I suggested a remedy to her - apis mel - which is honey bee sting in potency. She's a very busy lady, always rushing around, not very much time for herself and busy like a busy bee flying around. And apis has helped her enormously with her hot flushes, it's also a very good remedy for water retention and she's now going to try and take it for a further week - morning and evening - and she's going to come back and report her results.
People think that homeopathic remedies, because they have less matter in them, are less strong than something like an orthodox medicine, let's say Imodium for diarrhoea, Imodium will literally immobilise the system. We might as a homeopathic remedy give arsenicum, which is arsenic in potency, which actually causes diarrhoea but it's diluted and shaken, diluted and shaken to such a degree that you're just getting the energy of the arsenic and as homeopathy works with the law of similars you're giving - you're matching the energy of the body and you're giving it a stimulus to say something needs rebalancing here, something needs correcting.
FISHER
My own interest in complementary medicine goes back a long way when I was still a medical student and we went to China, and this was in the summer of 1972, and I can tell you the precise moment at which the scales fell from my eyes - we were standing in the operating theatre of a small Chinese provincial town, there was a woman on the operating table, entire abdomen open, conscious, talking to the anaesthetist with three needles attached to a little electrical box - three needles in her left ear. And I thought this doesn't happen, they certainly didn't tell us about this in medical school. So that was I think what opened my eyes to the fact that there is more to medicine than the orthodoxy.
FORD
Dr Peter Fisher is the head of the Royal London Â鶹ԼÅÄopathic Hospital and homeopath to her Majesty the Queen. Earlier this year, a respected research journal published the results of several studies that seemed to show that the extreme dilutions of homeopathic remedies could nevertheless have a direct effect on cells in culture. This is, Fisher argues, objective, repeatable evidence that something which science says shouldn't work, does. And it begs the question: how?
FISHER
There is a surprisingly large number of clinical trials of homeopathy, over 200 clinical trials of homeopathy and everybody who's looked at them, everybody you can do something called mesh analysis where you get all the results and pool them using a statistical technique called metanalysis. Everybody who's done that concludes that the evidence says homeopathy really does work compared to placebo, it is not a placebo effect. And the question is well how on earth, people are sceptical about that because they cannot understand how these very high dilutions could possibly have an effect that isn't a placebo effect. But again I think even in that area we're starting to make progress, there are now test tube laboratory research that says these very high dilutions do something, in a model of allergic response in the test tube you can show that very consistently - that there really is an effect. So the next question is - well how is that effect mediated? And I think we don't have the answers to that, we certainly don't have all the answers to that. It may be that what we're talking about is a structural effect in water, that's the water is carrying or the water alcohol mixture that homeopathic medicines are made up in is carrying a message. We talk about floppy disks, if you take a homeopathic medicine to an analytical chemist and say what's in here, they'll say well water, alcohol and sugar, the medicine's made up in water and alcohol and then put on sugar pills. But of course if you took that same chemist a floppy disk and said what's in here, he'll say vinyl ferric oxide. For all he knows it could have a Shakespeare play or a virus or it might be a blank disk, you simply don't know what the information content is from the chemical point of view, it's a physical phenomenon, there is some physical structuring phenomenon going on in the water and that is how it works.
BALL
You can find throughout history the idea that water has miraculous properties and miraculous properties that will somehow be to our benefit, that will somehow act as a saviour, that it will provide a fuel or that it will provide a marvellous medicine or that it will purify and cleanse - this is a cultural - a very strong cultural myth.
FORD
Phillip Ball is a science writer by profession, but was educated as a chemist and later as a physicist. He's taken a keen interest in efforts by others to discover a mechanism for homeopathy. In his book, H20: a Biography of Water, he examined the most commonly held belief, that homeopathic dilutions, with no active molecules of the medicine left in them, might be working through something called "the memory of water".
BALL
It's an idea that is supposed to convey the suggestion that water can retain, if you like, an imprint of molecules that have been in it and then have been effectively taken out by diluting the water. So the idea is that somehow once the water has been exposed to these substances it is able to mimic their behaviour, it's able to remember their - perhaps their shape or their function. It's never really made very clear how people think this memory is being retained, whether it simply is the sort of template effect or whether it's something else, that's never really specified. Water - liquid water is a bit like a crowd of people who are holding hands, okay, because the molecules are bound to each other by these weak bonds between molecules, called hydrogen bonds, and those are constantly forming and reforming all the time, so this crowd they're holding hands but they're always letting go and then joining up with a new partner. And that happens, on average, a hydrogen bond lasts for just a billionth of a second before it breaks and then the molecule reforms one to another molecule. So there's this constant making and breaking of this so-called hydrogen bonded network throughout the liquid and that's something that makes water different from just about every other liquid that we know about, the fact that it has this continuous three dimensional network of hydrogen bonds.
I don't think you can simply sweep away the question of how this could be working when the phenomenon seems so strongly to contradict fundamental properties of matter - fundamental principles of science. I think it's kind of incumbent on any serious scientist to in that situation to be thinking well how on earth can I explain this, or perhaps to be thinking well what have I done wrong. And to continue asking that question until you can't ask it anymore, it's not clear that that's really the approach that's been taken. So I think if people were seriously interested in explaining what was going on then they would start to think about these sorts of experiments of how you can simplify this, how you can - if you think that it's happening because of this phenomenon how can you test that in a much more direct way?
REILLY
Surely we have to realise that when we look back three hundred years from now back to now we will see ourselves in the dark ages to a measure, just as much as we see those of three or four hundred years ago. I certainly don't hold a world model that we've somehow cracked it and have an understanding of the forces of nature, never mind of healing, which is even more complicated at one level because it involves a whole living organism to some level. We were dealing with everyday phenomenon like gravity, like light, like magnetism - all the basic forces of nature - and then the scientific inquiry, long before we had any inkling whatsoever of the mechanism. So I personally find that a naïve critique.
FORD
Whether or not we think it's of value to explore the mechanisms underlying complementary medicine, there's little doubt many mechanisms will eventually be understood. Some practitioners might one day have to face up to irrefutable evidence that their therapies are solely based on belief and placebo. Or, the scientific community might have to accept that water has a memory. Meanwhile perhaps for the time being, what really lies at the heart of this debate is the simple question of whether or not patients get better, rather than why. For Dylan Evans as for others, like George Lewith, the arguments about mechanism point to a need to explore and understand a new way of healing, that may reflect as much about our minds as about our bodies.
EVANS
The existence of the placebo effect could lead to a much more sophisticated understanding of the body's own abilities and a respect for the body's own abilities to manage its own healing system because one thing that medicine - Western medicine - has been guilty of in the last 30, 40 years is to assume that it's always best to aggressively intervene and treat things and in fact the body turns out to be a lot wiser than we were previously aware of.
LEWITH
I think it will ask questions about the way we practise medicine, as both practitioners and patients and I think those questions are very important. There's a very big spirit to human beings and it overcomes lots of difficulties and lots of things. I mean people survived terrible hardships on the D-Day beaches in the war in Central Europe, in the camps, in all sorts of situations and they survived when they really shouldn't have survived because of what was going on in the head.
MUSIC
ÌýListen again to Programme 3: Does it matter how it works?
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