Edzard Ernst assigns a grade to 150 alternative medicine modalities, evaluating plausibility, efficacy, safety, cost, and risk/benefit balance. A very useful reference.
Edzard Ernst has written another book, and it’s a real tour de force: Alternative Medicine: A Critical Assessment of 150 Modalities. He probably knows more about alternative medicine than anyone else alive, and he has distilled his lifetime of knowledge into a handy, practical, easily accessible reference. He has managed to find a clever way to systematically evaluate, compare, and provide a simple grade to each of 150 areas of alternative medicine.
As he reminds us in the Preface, it was 1998 when Angel and Kassirer pointed out that there cannot be two kinds of medicine; there can only be medicine that has been adequately tested and proven to work and medicine that has not. They called for the scientific community to stop giving alternative medicine a free ride. Now, over two decades later, “assertions, speculation, and testimonials still substitute for evidence.” He wrote this book for confused consumers who have been inundated with conflicting information, for those who “are looking for the facts, trust in science, and prefer critical assessment to commercial promotion”. He has done them a great service.
No one is more qualified to write about alternative medicine. Ernst experienced it as a patient, practiced it as a clinician, and researched it as a scientist. He holds both an MD and a PhD, was the world’s first professor of complementary medicine, and he has published more peer-reviewed articles on the subject than anyone else on the planet. He has written many previous books on alternative medicine, each with a somewhat different focus. A partial list:
- Trick or Treatment: Alternative Medicine on Trial (with Simon Singh)
- Homeopathy: A Critical Appraisal (with Eckhart Hahn)
- More Harm than Good? The Moral Maze of Complementary and Alternative Medicine(with Kevin Smith)
- SCAM: So-called Alternative Medicine
He is not biased against alternative medicine but he is biased against claims not supported by evidence. He is as fair as anyone could possibly be. In this book, he says “My aim was to be consistently critical but not dismissive.” When he finds evidence that supports alternative medicine, he says so. He has identified alternative therapies that work but says he has never come across an alternative therapy that clearly and demonstrably outperforms conventional medicine.
For readers who are not knowledgeable about science, the first section of the book is a discussion of evidence and critical thinking, why experience alone is not enough, why controlled studies are needed, and when evidence can be considered sufficient. He covers the attractions of alternative medicine and the fallacies involved. He explains that the idea that alternative medicine tackles the root causes of illness is a falsehood. He covers the pseudoscience and poor-quality studies that alternative medicine wants to call “evidence”. He shows that alternative medicine’s claim to be strong on prevention is a lie. He covers ethics and health freedom.
The highlight of this section is a fictional but all-too-typical vignette about Tom, whose wife is a devotee of alternative medicine. When Tom develops persistent pain in his shoulder and arm, she refuses to let him consult his GP, dosing him with her Rescue Remedy instead. When that doesn’t work, her chiropractor diagnoses Tom with subluxations and treats him with spinal manipulation, and he feels a little better but the pain returns. Then her Spiritual Healer treats Tom for a problem with his vital energy. He feels a little better for a while, but the pain returns. The wife has him evaluated by her reflexologist and acupuncturist, who diagnose energy blockages and chi deficiency. After transient improvements, the pain returns. A naturopath diagnoses auto-intoxication and prescribes a full program of detox. The pain returns. At this point, Tom is fed up. Valuing his health over peace in his marriage, he consults his GP, who correctly diagnoses his pain as caused by coronary artery disease. He dies while awaiting surgery for a stent. A tragic story, but I had to laugh as I recognized the common pattern: patient feels a little better with an alternative medicine treatment, enthusiastically embraces it, relapses, and continues to try one modality after another, each with initial enthusiasm but eventual disappointment.
The 150 modalities
Ernst’s choice of subjects was guided largely by popularity, with a few exotic and interesting additions. They are divided into these categories:
- Diagnostic techniques (10 of them) from dowsing to live blood analysis
- Medicines and oral treatments (46 of them) including diets, homeopathic Berlin wall, Essiac, oil pulling, colloidal silver, and many others
- Physical therapies (39) such as acupuncture, chiropractic, moxibustion, massage, tai chi, and slapping therapy (yes, that’s a thing!)
- Other therapies (28) from coffee enemas to meditation
- Umbrella terms (28) including alternative cancer treatments, Ayurveda, detox, energy healing, naturopathy, and slimming aids
His rating system
He summarizes each modality with seven short points about facts and evidence and provides references to the most relevant research articles. He evaluates each modality for these five criteria:
- Risk/benefit balance
And he uses color-coded thumb signals to rate each of these as positive, debatable, or negative.
For instance, iridology not surprisingly gets a red thumbs-down for each of the five criteria. Aloe vera gets a green thumbs-up for plausibility and a yellow “debatable” for cost, with red thumbs-down for efficacy, safety, and risk/benefit balance. Antioxidants are rated green for plausibility and cost, yellow for efficacy, safety, and risk/benefit balance. Berlin wall rates green for safety, yellow for cost, and red for the other three. For chondroitin, all the criteria are rated green except red for cost. Feverfew gets all green except yellow for safety. Garlic gets all green thumbs-up. Homeopathy is rated red for plausibility, efficacy and risk/benefit ratio, but green for cost and yellow for safety. Kava gets 3 greens and 2 yellows (for safety and risk/benefit). Laetrile gets five reds. St. John’s Wort gets all greens except yellow for cost. Chiropractic gets 5 red thumbs-down. Cupping is rated yellow for plausibility, efficacy, and risk/benefit and green for cost and safety. Moxibustion is rated red for everything but cost. Hypnotherapy is rated yellow in all 5 categories. Guided imagery, mindfulness, and laughter therapy each get 5 greens. Anti-aging therapies are all red except yellow for safety. Apitherapy (bees!) gets all yellows. Integrative medicine gets all reds except yellow for plausibility. Naturopathy gets all yellows.
And so it goes.
Conclusion: room for disagreement, but a very useful book
You will probably not agree with all of his ratings; there is certainly room for debate. Even good science is often plagued by uncertainty. Patients want answers, and they should find it helpful to have a book (by a scientist rather than a salesman) that gives clear yes/no/maybe answers to help them decide whether to try a given modality. It can’t have been easy for Ernst to decide on these summaries and ratings, and I applaud his courage and commitment. I might have given some of the modalities a different rating, but I might be wrong. I have the highest respect for Ernst’s knowledge and judgment and am always willing to re-evaluate my thinking. If nothing else, this book should start a lot of fruitful discussions among other critics of alternative medicine. And if it steers even a handful of readers away from nonsense like iridology or homeopathy, Ernst will have done his readers an invaluable service. Ausgezeichnet, Edzard! I wonder what you will do for your next act.
This article was originally published in the Science-Based Medicine Blog.