Singh on alternative therapies

Simon Singh, author, science journalist and Imperial alumnus, speaks to Felix’s Science Editor about his new book

Simon Singh recently got in touch with Felix, mentioning he'd got a new book out, "Trick or Treatment? Al­ternative Medicine on Trial", which he'd co-authored with Edzard Ernst, and asking if we wanted an interview. Naturally, we leapt at the chance, which resulted in the following conversation, outside a Richmond pub on a sunny af­ternoon last week.

It's very informative - I've picked up a lot of things I'd not twigged, such as chiropractice being completely different from what chiropodists do...

I think that's an important point: I sat in on a lecture for some trainee GPs - I surveyed them before the lecture, and it was quite clear that half of them had no real idea what homeopathy was ­they thought it was to do with herbal medicine - they didn't realise it was just sugar pills. On the one hand, GPs shouldn't hand out homeopathy, but on the other, they will encounter pa­tients who will say "Oh, I'm thinking about this - what do you think about this': You say you learned a lot read­ing this book, I think GPs could too, because alternative medicine, like it or not, is an area they'll come across again and again.

How did this book come about ­when did you meet Edzard Ernst, and where did your personal interest come from?

Although I started off as a physicist, I then went off to become a TV journal­ist and an author and so I skip about all over the place - from pure maths in Fermat's Last Theorem to cosmol­ogy in the Big Bang to cryptography in The Code Book. So in a way it's not surprising that I skip over to alterna­tive medicine, except that it's very dif­ferent from maths and physics.

The way it started was that I'd heard of people using homeopathy to prevent malaria, and I thought this cannot re­ally be true. I know for a fact that ho­meopathy's just sugar pills and that of all the alternative therapies it's the one that we know just doesn't work - both from a theoretical and an experimental basis. I think an important point of the book is that we're not anti alternative medicine, we're just pro-evidence, and sometimes we'll embrace an alterna­tive treatment, and in other cases we won't; homeopathy's one we abso­lutely reject. Having heard these sto­ries about malaria, I thought it would be good to do a bit of a survey, and so I worked with a young graduate, who went to ten different homeopaths - it's one of the stories we tell in the book. Because I'm not a specialist, I collabo­rated with some tropical medicine spe­cialists. They said you should say this woman's going to West Africa, where the most serious cases are. I double­ checked with Edzard, as I knew he was the world's first Professor of Alterna­tive Medicine, to check if there was any evidence homeopathy could be used to avoid malaria. That's when I first met Edzard, and when I first became aware of how scandalous what's going on is - that ten out of ten homeopaths were willing to treat this young lady, sending her off to West Africa unprotected.

That's when I thought: hang on ­there's something here that needs to be written; for the public. Even people close to me - members of my fam­ily - have used homeopathy. They're good parents, smart people, and if they're turning to homeopathy, there's clearly a public education thing going on here, as well as a fascinating history as to how homeopathy emerged, how it grew, and what's going on in the minds of people who are spending money and investing hope in therapies which don't work. That's when it all came together, during the homeopathy study, meet­ing Edzard and realising he's spent 15 years studying this and writing a hun­dred academic papers, but wondering whether his message was getting out to a wider audience.

Though you've worked in many different areas as a science journalist, this was your first book-length piece in this sort of area. How was the process of collaborating?

It worked incredibly well, much better than I could have hoped for. There are nightmare scenarios where authors fall out with each other. But this was ut­terly painless, for a variety of reasons. One of them is that Edzard's a good writer - he's written columns, articles for the public - so there were sections where I'd say 'Can you have a go at this: so he'd send me the material, and I might go away and reshape it, reword it, and shorten it a bit but he always gave me stuff that was already read­able. And in other cases, I'd say 'I want to write a section on herbal medicine and I'm particularly interested in the safety aspect. Can you send me some material?' And he'd send me essentially a dossier of all the most important ma­terial. I'd read outside that too, but he would give a good starting point.

And perhaps the most important thing is that we always said our conclu­sions about particular therapies would always be based on the scientific evi­dence - we're not writing a book about what food we like - we're looking at-------­whether or not a treatment works, and the way you do that is through a scientific trial. Science is never as cut-and­-dried as people might think it is - it's always open to slight interpretation, but at the end of the day it's quite clear whether or not acupuncture is effec­tive for eczema, or is there adequate evidence that it's effective.

I think the only area where we could have had disagreements, and it's a real­ly interesting area, is on the placebo ef­fect. We could have said "Homeopathy has no pharmacological effect in and of itself, so why does it work, why do people think it works?" Well there are various reasons - one is they take them when they're at their worst, so they can only get better; they take them when they're already taking conventional drugs, which may help them, yet they credit the homeopathy; they think it works because of misleading things they read in the press. And the body heals itself. So if you have a cold, with homeopathy you'll get better in 7 days, without it you'll get better in a week, but again you'll credit homeopathy.

But one of the reasons is the placebo effect - the sheer thought of taking a remedy which you think will help you will have some positive effect. We ex­plain the placebo effect is incredibly powerful, and clearly of benefit to pa­tients. So even if homeopathy is just a placebo, if a placebo is generally bene­ficial, what's wrong with homeopathy? That's a very powerful question we can get to. The problem in the debate is getting homeopaths to agree it's just a placebo in the first place! If we can get that far there's an interesting debate as to whether or not we should use placebos. Some people would say we should - it provides an instant benefit at relatively cheap cost for people who have otherwise untreatable conditions like chronic back pain. But Edzard and I agreed that we would not want to go down that route.

They're interesting, the reasons you raise as to why you think this is unethical, that the ends don't justify the means. You say it devalues medicine...

Yes, it encourages irrationality; it's a gateway to people who think well if ho­meopathy works for my cold, maybe it will h elp for my malaria protection. Also, it encourages a culture of lying ­if homeopaths are allowed to lie to us, are big drug companies? Who else is allowed to lie to us?

And why on earth would you have just a placebo when you can have a real medicine plus a placebo: if you have a back pain Ibuprofen has a real effect as well as the placebo.

And the more we run down conven­tional drugs (which admittedly aren't perfect) the more we remove their pla­cebo effect, and stop their real effect.

This raises a few issues - as you point out, alternative medicine is attractive to many because of its individual approach, which maximises the "therapeutic relationship", has this effect been investigated?

Yes, studies have shown that if a doctor gives you medicine personally, rather than a prescription, this enhances the placebo effect. There are prob­ably things conventional medicine can learn from alternative therapists. But one of the ways you elicit the placebo effect is purely through time. I had my first acupuncture session recently - a photo for an interview. I've deliberately avoided all alternative therapies be­cause I shouldn't base the conclusions in a book from my own personal expe­riences - how arrogant would that be of me to say acupuncture worked for me, so everyone should use it? So it was my first session, and it was an hour long ­someone talked to me, held my hand, and seemed to do some level of diagnoses. For half an hour, I had acupuncture, for 20 minutes of that I lay down in a quiet room, with music playing gently, for the last 10 minutes I had a head massage. It's an hour long procedure, which probably cost around £50. Now if you can invest that kind of money, you're bound to get a placebo effect, but unfortunately money's always go­ing to be limited, which is why, I'm very happy to say, we can't waste money on unproven therapies.

Is alternative medicine on the rise?

Yes, undoubtedly, increasingly there are all sorts of weird and wonderful things on almost every high street ­why is this? One reason is we're an af­fluent society, we have money to pam­per ourselves and give ourselves the illusion we're helping ourselves. When people have a real crisis - breaking a leg - they go to A&E. Alternative medicine caters for these diseases which annoy us, where people get frus­trated with mainstream medicine, say colds or back pain, where mainstream medicine has nothing to offer. And it's partly about mainstream medicine's lack of sensitivity to the public, and the way a minority of doctors treat their patients.

But I think the main driving force is the mainstream media - in any Sunday supplement you'll see articles about the benefits of crystal therapy, or "My Reiki guru': And if you're reading that you've got to think there's something in. it. And you look across the street, and Boots is selling homeopathy. Boots sells medicines that help me, surely there­fore homeopathy must help me, other­wise why would they be allowed to sell it. Neal's Yard, just last week, were very heavily criticised by the MHRA for selling a homeopathic remedy which claimed it could treat malaria. So all of this stuff is going on around us, so it's not surprising the public thinks there's something in it.

You promote an idea of Dylan Evan's, suggesting alternative medicines and therapies should come with disclaimer labels; that this £40 billion industry should regulated. How easy do you think it would be to impose this regulation?

I don't know - it's a funny one - if I want to fit a gas meter in my house, whoever does it has to be CORGI reg­istered. If someone wants to give me a check-up, it could be anyone. You could go home tonight and put up an advert calling yourself a homeopath, and nobody could stop us. You have to be trained to install a gas meter, but you don't have to be to treat someone else. This is where the regulation falls apart - the really bizarre thing is that although I can treat anyone who wants to see me and pay me, I can't treat any animals - to treat animals you need to be a fully trained vet. Animals have more protection than us!

Say you suffered from something, say irritable bowel syndrome, which hasn't responded well to, conventional treatment. You then come across an alternative ther­apy, which as a scientist sounds plausible and useful. How would you go about investigating it?

I'd get a copy of my book and I'd look it up! We look at the 30 most popular herbal remedies, which have been the most investigated, and say what they're effective for. If it was mild depression, and it was St John's Wort, which really does seem to be effective (though it does have some side effects) then I'd go and speak to my GP. I was recently giv­en some pills by a herbalist, of which I was supposed to take 30 a day, and I said I'd like to talk to my GP first. Their response was "There's no point telling your GP, they're not a herbalist, they won't know what this is." That's the level of irresponsibility and huckster­ism that's out there. I'm shocked - the sort of things we talk about in the book - if a GP did that, they'd be struck off!

Should this be a criminal offence?

About 180 MPs signed an early-day motion in support of homeopathy. It's the most extreme example of political cowardice I can imagine - they're be­ing asked to endorse a form of medi­cine most doctors don't seem to sup­port. If they campaigned to get rid of it, they know about 15-20% of their constituency, who maybe use home­opathy, would say "how dare you try to deprive me of this medicine, or cut it at Westminster had the guts to stand up and say ''I'm a biochemist here and I care about what we stand for, and I don't want to be in a university where, in one part, we teach that the more dose you give someone, the bigger the effect, and in that little bit, they teach the opposite”.

One interesting thing here, to go back to your earlier question, is that I love physics, and maths and the pure sci­ence side, still more than anything else. The direction here is not just a shift in subject matter, it's also shifting to an is­sue which faces society and which just makes me angry and frustrated. I think it's a role for young scientist~ and un­dergraduates, to get involved.

In what way?

Say going to pharmacists and asking "You're selling this stuff, do you be­lieve in it? How does it work?" I think there's a level of involvement, becom­ing active. There's an organisation, the Voice of Young Scientists (VOYS), and they're great - there's a cosmetic, which is supposed to block radiation, and they've just rung up the company which makes it, and asked "How does it work? Sounds fantastic!" They've basically been causing a little bit of mischief, and forcing people to justify what it is they're selling. And I think the more that scientists can confront these issues, and talk about them, and cause trouble with the people that sell them, and try and talk to other people who may be less aware of how sc ience works, the better!

And so what now - any ideas for the next project? I imagine you'll be sticking with this one for a while.

These things do roll on for a while - I'll be going to America in August, to talk about the book there. It's a fascinating process, writing a book, but it's also ex­hausting - for two years I've not read a novel or any other non-fiction. It's lovely to think that this summer I'll be able to sit down and read a book. And I might read one which triggers my next project - these things fall into your lap in a way which you never expect! Now I'm writing about things which appal and anger me. I've got involved in the debate on some of the bad and ludi­crous anti-science which tries to ex­plain global warming isn't serious, isn't caused by humans. I'm a firm believer there's a scientific consensus that global warming's real, and that we need to I act - so maybe my next book will also be this angry sort too!