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A new 6-part series about complementary medicine.
Tuesdays from  21 September 2004 9.00-9.30pm

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?

Anna Ford
Presenter: Anna Ford

Listen again Listen again to Programme 4: First, do no harm





TUESDAY 12/10/04 2100-2130






So far I've had no bad experiences with herbal medicine at all.

Hospitals are filled with patients suffering from adverse reactions from conventional interventions. We get 2,000 deaths per annum from non-steroidal anti-inflammatories.

There's an elderly woman who had breast cancer which was being treated with carrot juice and she was bright orange. I think she'd reached the point where she thought she ought to abandon alternative medicine.

Complementary and alternative medicine, or CAM is often marketed by practitioners as the safe and natural option. Patients have told me "well if it doesn't do you any good, it won't do you any harm." But is this true? Can CAM be said to have fewer side-effects and less incidents of toxicity than conventional medicine? In this programme, we'll explore the possibility of harm in complementary medicines, from the advice practitioners give to some of the remedies themselves.

[Knock, knock]
Take a seat please.

At the Traditional Acupuncture Centre in London, which also offers herbal treatments, Elisabeth has made an appointment to see Dr Guang Xu, a practitioner of traditional Chinese medicine about a skin problem.

So I get red - sore red areas here between the eyebrows and on my cheeks. And they're like little spots that move around, they almost - it sort of moves around. And I think it's hormonal because it's always worse before my period.

Why don't you try antibiotics as well, why do you want to have herbal treatment?

I did go to the doctor and I got something called MetroGel, which is an antibiotic I believe. And I used that for four days and it just seemed to get worse - it got worse and worse and really angry looking and it became very, very itchy and I couldn't stop scratching my face.

In China it takes five or six years full-time to train as a doctor who can prescribe herbal medicine. So we have to know every single herbs, how much dose we could use and then in the prescription we would use 5, 10, sometimes up to 30 different ingredients in it and which herbs can be mixed together and which herbs are not allowed to mix together and which herbs can reduce the other herbs side effect. We also should check the patients on a regular basis, so if there's any sign of side effect we would pick up on time and before it gets too bad.

Traditional Chinese medicine has become incredibly popular in Britain over the last decade, as more non-Chinese patients have sought it out to treat conditions that Western medicine hasn't touched. However, government agencies are concerned about the quality and safety of the largely untested ingredients in Chinese medicine, which can include not just plants but minerals and even animal extracts.

A lot of ingredients go into the preparations and I've no idea what they are, they look strange, they smell strange and they're pretty disgusting but because I've been recommended them I'm prepared to give them a go. So far I've had no bad experiences with herbal medicine at all.

Traditional Chinese medicine, like many forms of CAM, is based on such ancient and natural practices that most patients assume they are safe. But is that really the case?

Not only do people perceive it as less risky but it definitely is less risky, absolutely.

Edzard Ernst is Professor of Complementary Medicine in the Peninsular Medical School at the Universities of Exeter and Plymouth. Compared to CAM, he says, orthodox medicine has a poor safety record - thousands die in our hospitals every year from drug overdoses, MRSA and surgical complications. But is this a fair comparison?

Very few people die on the table of an acupuncturist or chiropractor and quite a few people die on the table of the surgeon. But the absolute risks are a very unfair comparison. What we really should compare is the risk benefit ratio. Now if something has no benefit then even a slight risk weighs very heavily and some other therapeutic intervention has the potential to save your life then enormous risks are acceptable.

How do you know that CAMs - complementary medicines - aren't dangerous given that there's so little research about it?

That's a very good question. How do we actually know that people aren't dying from batch flour remedies? If they were we would hear about it. But some other therapies are associated with risk - sticking a needle into a patient certainly carries a risk and manipulating the neck of a patient definitely does. So I think we have to distinguish between some complementary therapies which are plausibly, even though we don't have the evidence, plausibly almost entirely safe and other therapies, like chiropractic herbalism, where we feel it is perhaps associated with risk and it is predominantly, in my view, these therapies that we should investigate systematically.

It's true that acupuncture and chiropractic do have the potential to cause harm. But are patients aware of this? Hugh MacPherson trained in acupuncture in London and China and has worked at the York Clinic of Complementary Medicine for more than 20 years. He surveyed his own patients and was surprised by the results.

My experience of patients coming to see me is they tend to be very trusting and don't expect acupuncture to be unsafe, they don't expect risks, they don't expect cross-infection and they assume, for example, that all acupuncturists use disposable needles, once and once only, and so forth. So there's a sense - an assumption that because it's alternative - and it's involving natural medicine where there's nothing added to the body or taken away as there would be say with drugs and surgery - then acupuncture has to be very safe. That's their assumption. I think the conclusion increasingly has come in that competent hands acupuncture is safe, if people aren't properly trained then it is not safe, there are dangerous conditions - dangerous situations that can be caused by acupuncture, for instance a pneumothorax - if someone's inappropriately needling they can puncture the lungs. Now that is definitely bad practice and anyone who has a decent training would never ever allow that to happen.

Many people think that because something is natural it's safe. But if you stop and think quite a lot of the most poisonous things we know actually come from natural sources, there are obviously things like the venoms from snakes and spiders, but even from plants there's things like strychnine, which many people would know as a poison, many of the fungi produce poisonous substances and of course bacteria produce nasty toxins like botulin.

So just as nature's poisons can in tiny doses be made into some of our most effective medicines, for Peter Houghton, Professor of Pharmacognosy in the Department of Pharmacy at King's College in London, natural treatments using some herbal preparations remain an area of concern.

There are three main reasons why they can be harmful. Because they are medicines you've got the same problems of overdosing in some circumstances with some patients as any ordinary medicine would have. The second problem is that you sometimes get contamination or complete substitution with a more dangerous substance. The third area, which we're only just beginning to explore, is where they interact with ordinary medicines, either to exaggerate the effect - so you might get toxicity - or they go against the effects so you don't get the effect you want.

One of the more adverse interactions is found with the plant St John's Wort. Commonly prescribed for mild depression by herbalists and bought over the counter by thousands of consumers, with Warfarin, a blood thinning agent, the interaction can be deadly, and it can render the contraceptive pill ineffective.

We're in my dispensary, herbal dispensary, and here we have rows of bottles in tincture form - tincture is a solution of a dried herb in a mixture of alcohol and water, it keeps it - preserves it - for many months and is a very convenient way of dispensing it. We have Echinacea, a herb widely used by the public in the shops, from the pharmacies and so on, as a support for immune defences, as protection against respiratory and other infections. We need to do quite a lot more research and see what it's real potential is.

Simon Mills is a herbalist and co-founder of the Complementary Health Studies Unit at the Universities of Exeter and Plymouth. One of the important issues in herbal medicine, apart from toxicity, is quality control. With a UK market worth in excess of £100 million a year, making sure remedies contain what they're supposed to is getting harder.

These plants are derived from all over the world in different circumstances. In the past there have been fairly rigorous quality control measures, simply because the people in the market were experts at it and they needed to buy the right quality of stuff for their customers, their clients, who were conventional drug manufacturers very often. Nowadays it's a bit more open and we are concerned about the quality of some of the material that reaches the market. For example, in the United States where it's a very wide open market over half of the herbs found in studies, in surveys, have been found to be of poor quality. Now that means that at very least you're not buying what's on the label but at worst it could mean you're getting a substitution or you're getting something that might even harm or hinder your healthcare.

Increased regulation of herbal medicines, particularly those used by traditional Chinese practitioners, is one way to ensure better quality and safety. The body charged with drawing up guidelines: the Medicines and Healthcare Products Regulatory Agency continues to be concerned over these issues and recently reminded herbal practitioners that they will "not hesitate to take enforcement action including prosecution where products pose a risk to public health".

But whilst the quality of medicine is important, so too is the quality of advice given by CAM practitioners. The majority of therapists belong to associations or societies which lay out codes of practice. However, at the moment, there's no legal requirement for them to follow these codes and on certain issues, a considerable number don't.

Researcher Katja Schmidt from the Department of Complementary Medicine at the Universities of Exeter and Plymouth discovered this when she sent out an e-mail to GPs, homeopaths and chiropractors asking them for advice about immunisation.

We contacted those people in which a mother asked for advice regarding the MMR vaccination for her one year old child. And altogether we contacted 168 homeopaths of whom 72% responded and we also contacted 63 chiropractors, of whom 44% responded. I have to point out that not a single general practitioner responded to our query. And what we found really is that only a few professional homeopaths and about a quarter of the chiropractors that we contacted and that responded advised in favour of the MMR vaccination and almost half of the homeopaths and nearly a fifth of the chiropractors advised against MMR vaccination. So really what we can say is that some providers of complementary medicine are advising people against government policy and general practitioners, on the other hand, seem not to respond at all to patients' e-mails on this very delicate matter.

The fact is that increasing numbers of parents are exploring alternative ways of protecting their children from infectious diseases. Acupuncturist Nancy Holroyd Downing believes an alternative way of viewing health doesn't necessarily fit with the conventional view of immunisation.

This remains a highly debated issue both within CAM but also between CAM and orthodox medicine. But are practitioners like Nancy right to offer advice?

What I try to do, because this is a fractious argument and this is something that is not only a source of a lot of anger but it's a source of a lot of soul searching on the parts of parents and I don't …

And guilt as well.

And guilt and I do not want to contribute to the bad stuff there. What I say to people is that there are a number of ways to look at the whole notion of childhood illnesses and there are a number of ways to treat those illnesses either preventively or after the fact. Measles is not bubonic plague, people do and did survive - I survived measles …

Yes so did I and my brothers as well.

And I think the public health issue is relevant here. I think if a parent chooses to have their child immunised it's a perfectly reasonable decision to make.

Because measles does have potentially very large numbers of complications doesn't it.

Yes it does.

And some children, very few, might become seriously ill. Now if we didn't have vaccination and we only used Chinese medicine do you think we could protect as many children as we do by vaccinating them?

I don't know quite honestly the answer to that question. I don't think we can say that if there was not measles vaccine we would have - I don't think, I mean I'm willing to be proved wrong here - I don't think we would have scores of children dropping dead.

We'll that's one view and we'll examine what the professional bodies governing different CAM practices have to say on this and other issues in more detail next week when I'll look at the regulation of CAM. But Dr Peter Fisher, Head of the Royal Homeopathic Hospital in London is adamant that immunisation is an advance in child health care.

One of the things that annoys me particularly when you hear people who are not members of health professions denouncing immunisation - it's what I call the spoilt brat school of medicine, they've never seen diphtheria or polio, they assumed it didn't exist - it never existed or those things weren't the terrible diseases that they are. The fact is the reason they've never seen them is that immunisation is an extremely effective treatment and kids don't get paralysed from polio, they don't die of diphtheria anymore and it's entirely down to immunisation.

One of the illnesses that causes the greatest anxiety and fear today, is cancer. And here CAM has much to offer, but here also is where it runs up against vehement opposition from the orthodoxy. So what are the issues over harm and advice when people, confronted by that dreaded diagnosis, attempt to find help and support?

In Bristol, I met Michelle who was diagnosed with breast cancer nearly four years ago.

I first discovered I had a lump in my armpit and eventually went to the doctor to have this investigated. And it was discovered some weeks later that it was actually breast cancer that had spread to lymph nodes underneath my arm, so the decision then was taken to go very quickly to chemotherapy - the danger being that the cancer had spread to other parts of my body.

Hello there.

Hi, hi Carol, hi Anna.

This is Anna Ford.


As well as using conventional treatments such as chemotherapy and surgery, Michelle, feels very fortunate to have come here - to the Bristol Cancer Help Centre. It offers a range of supportive therapies through various residential courses, designed to give what its late co-founder Penny Brohn called "care for the mind, the spirit, the emotions, the heart and the soul". The sort of care that the medical profession rarely provided in the past.

Director of Therapy is Helen Cook.

People are wanting to think of lifestyle issues and what they can do to help themselves. Somebody said to me recently - Well how come if I was a cardiac patient, if I'd had a heart attack, I'd be given this whole rehabilitation regime, I'd be told maybe I needed to change my diet, I'd be given an exercise regime, why is it that after a diagnosis of something as kind of - as crucial as cancer that I'm not told to make any changes to my life? People come here in a great state of distress, sometimes trying to make very difficult choices, an experience I'll give you - I saw a woman, not very long ago, who was 41, she was single, she didn't actually have a great support network, she'd been told by her surgeon that she needed a mastectomy and was absolutely terrified about that idea and needed somebody to talk to about that. But meanwhile also she'd been to see a herbalist and I must say the majority of herbalists - I've never heard make such claims but this herbalist said - Well, don't worry I can - don't go for your surgery just yet I'll give you some herbs and maybe you won't even need to go for your mastectomy. The other difficult thing is she'd been talking to some of her family about it and been given 15 books, this is in one week, since she'd seen her surgeon. So she'd been to see a herbalist, been to see a surgeon, been given 15 - and came to us absolutely kind of on her knees trying to think of the most sensible and rational way forward. And of course we all know when we're in stress we don't make very rational or wise choices. So we were able to sort of sit down with her and go through with her the different options and give - just give her some of the kind of right information for her to make that kind of balanced choice that was right for her.

The first day was just so incredible - just to be with other people who have no kind of judgement to be made of you or just being in a supportive atmosphere where you could learn from other people.

Which treatments do you think helped you most?

It's difficult to isolate them because they all came as a kind of package. But the issue around the diet I think is a very important one.

Did it change the way you ate a lot?

Absolutely, absolutely. I read very quickly the issues about the move towards a more sort of whole food diet, move away from things that might hinder your recovery - things like dairy food, things like all the saturated fats, all that kind of thing. But that was the first step. From there I had a whole number of things, one particular sort of massage course - Shiatsu - which I found just incredibly powerful and very, very healing and very, very kind of centring in myself, helping me to feel just stronger and feel kind of able to - when you're going through chemotherapy you just are so weak and just wiped out, to have somebody helping you to perhaps amass the energy that you do have and make you feel better was just incredible.

How long ago now is it that you were first told that you'd got cancer?

It was in the October of 2000 - so it's coming up for four years. I think you're sort of considered to be cured after five years so well on the way.

In my long career I have seen some of the most awful things.

Cancer specialist Professor Michael Baum has seen first hand the horror of what accepting advice which can lead to avoiding orthodox treatment can do.

The worst, which I cannot - I still have nightmare visions of this was a youngish, in her thirties, African girl who came in moribund with advanced breast cancer. Her breasts had rotted away and was a stinking bleeding mess. She had also been adopting certain African traditional remedies as well, and she died within about 24, 36 hours of being admitted to hospital. And I saw on her body the stigma of what breast cancer must have been like in the days before there was any surgery. I saw another case, which was very rewarding in a way, it was an elderly woman who had a very indolent type of breast cancer which was being treated with carrot juice - a very popular high intake of carrot juice. And she was bright orange. I think she'd reached the point where she thought she ought to abandon alternative medicine. We stopped the carrot juice and I put her on tamoxifen and she was lucky and she - if you talk about miracles, this looked like a miracle.

Professor Baum voices the concerns of others involved in cancer care who fear that patients faced with a desperate diagnosis will search for alternatives hoping for a miracle. Today one of the first places they turn to is the internet. Earlier this year Katja Schmidt and Professor Edzard Ernst, published a study of websites offering cancer advice to patients and found that a significant number were promoting bogus cures or advising patients to avoid medical treatments like chemotherapy.

Of the anti-cancer products being offered - 118 of them across 32 websites - most had little or no direct clinical research behind them but were being offered as preventative or in some cases even curative treatments.

For instance people were very much advising things like the Gerson diet, let's say, or various herbal products as well and different mind body therapies as well. Most of the websites are citing studies that are at a pre-clinical stage, at an early stage, and haven't really been tested on humans at all. And they overtly discourage patients from using conventional cancer therapies. We found quotes such as: "Chemotherapy and radiation though known to be a total failure in the so-called war against cancer remain as the only therapies which enjoy federal mandate." Now if I read a statement like that it sounds very, very off putting and as a patient I would think they're talking here about conventional therapies equals failure and I won't be able to get any sort of cure out of them and I then I might look for on that website well what alternatives do they offer me. And we really think that is dangerous.

Not all websites came under fire from the report but one that was singled out was the "", which the authors said was making "ridiculous promises and claims" about cancer treatments. It's founder, Dr George Georgiou, a practitioner of natural medicine based in Cyprus, says he's just giving the 40,000 visitors a month he gets, honest information.

When you look at the information that is on the website there is nothing categorical. Firstly, I haven't written all the information on the website because we also get papers donated from other practitioners - medical practitioners as well as CAM practitioners - from all over the world. These are vetted by myself or other scientific advisors. One of the papers was talking about the dangers of using radiation and chemotherapy for the treatment of cancer and there is a lot of evidence to suggest that that is the case and this was actually written by a medical doctor who had experience in this field and we felt that this was his opinion and this went up. I believe strongly that at the end of the day it is the patient that makes the final decision what type of treatment they want to follow and there are many cancer patients that have chosen natural remedies and have been cured and these are well documented in the literature.

Any sort of user of a health website should be looking for who owns the website, what sort of qualifications do they have and people make claims in there, do they cite - do they reference those claims - is there any book source or article source at the end of the article? Also is the website current and up-to-date? And how easy is it to navigate between different sites and how well is the balance really on that website - do they only talk in very negative terms, do they use very extreme language? And finally I would like to point out that there are things - so-called seals of approval - for instance the Health on the Net Code of Conduct which means that other - a group of medics have looked at that website and have approved of their content and that's certainly something to look out for.

So the advice, as ever when using the internet, is 'patient beware'.

Over the last decade, research has shown that many therapies are not just safe but used alongside conventional treatments particularly with serious illness, can vastly improve the patient's well being. Perhaps even, their condition. What's needed is more research, further collaboration and less antagonistic divisions between CAM and medical profession. For Exeter herbalist Simon Mills, this means encouraging more openness between patient, CAM practitioner and doctor but also more honesty about the nature of medical advice and the limitations of treatments - complementary or otherwise.

CAM, complementary medicine, does have to prove itself. Where a treatment might be less safe or where it is done outside conventional healthcare in a way that might threaten, for example, a life saving treatment then clearly complementary medicine does need to be checked. Bringing it together so that the complementary and conventional professional can work together as a team is to me the most obvious way of doing this, so that everyone is aware of what's going on. The main problem, by far the main problem with complementary medicine at the moment is that patients are often living double lives - they will tell doctor one thing and ignore the fact that they're taking complementary healthcare. The doctor therefore doesn't know that this is happening. If only the patient was reassured that the doctor would not mark down their card, if the patient admitted to taking complementary medicine which is what they fear, if doctors were open to this and invited patients to tell them what was going on, and ideally then communicated with the CAM professional, then we would have integrated healthcare, that is the real goal.

Next week I'll be looking at the present state and the future regulation of CAM, and asking if patients are adequately protected from bad practice.


Listen again Listen again to Programme 4: First, do no harm

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