In my last article I stated that alternative treatments are therapies that either have not been proven to work or have been proven not to work. Like so many quips, this sentence expresses a complex matter succinctly but simplistically.
A similar statement is attributed to Tim Michin: what do we call an alternative medicine that works? We call it medicine! It suggests that all alternative therapies are ineffective. Once an alternative treatment has been proven to work, it swiftly becomes part of conventional medicine. This sounds obvious to many sceptics — but is it really true?
Another witticism contradicts this notion by stating that, in medicine, we make progress ‘from funeral to funeral’. This implies that progress in healthcare is rarely swift and that the old generation of opinion leaders has to retire before a novel approach (such as an effective alternative therapy) will be accepted. To the many fans of alternative medicine, this notion highlights the closed-mindedness of ‘the establishment’. But this assumption might be simplistic too.
Reality hardly ever mimics the little clichés or prejudices we tend to create in order to make sense of the world around us. None of the above bon mots are entirely true, nor are they entirely false; and none of them tell the full story. Let me try to explain this using three alternative treatments as examples.
The first one is tai chi; this meditative exercise regimen has long been used by the elderly in China and now has also become popular in the West. But does it work?
This is, of course, a silly question — work for what? Aspirin works very well, but not for everything. It might reduce my headache but does not cure my baldness. Yet, in alternative medicine, we often encounter claims that this or that therapy cures everything. This is dangerous nonsense; a cure-all is just as implausible as a perpetuum mobile.
Therefore, we need to ask: does tai chi work for a specific condition? Does it, for instance, prevent falls in the elderly? Some might sneer at this question; it is not on the scale of curing cancer, but it is nevertheless hugely important. Many old people fall, break a hip and subsequently need weeks of medical care and attention; some even die in the course of it.
The answer to the above question is crystal clear: tai chi reduces the risk of falling. This is not my opinion; it is the verbatim conclusion of a Cochrane review on the subject which evaluated six tai chi trials. In other words, we have identified our first alternative therapy that works for at least one purpose.
And has this alternative medicine become medicine? No! Why not? Because there is a snag.
You will appreciate it, once you read the full conclusions from the Cochrane review: ‘Group and home-based exercise programmes, and home safety interventions reduce rate of falls and risk of falling. Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; tai chi reduces risk of falling. Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.’ This means that tai chi works but other, more conventional treatments might be more suitable, cheaper or more available.
My second example originated from the plant kingdom and is equally exotic: kava (or Piper methysticum, if you insist). This is a herbal medicine that, about 10 years ago, used to be very popular for managing anxiety. It originates from the South Sea where it has been used as a recreational drug for centuries.
Does kava work for anxiety? The answer is yes. In 2003, we published a Cochrane review of all rigorous studies testing the efficacy of kava as a treatment of anxiety. We were able to include 11 randomised, placebo-controlled trials and concluded that ‘compared with placebo, kava extract appears to be an effective symptomatic treatment option for anxiety. The data available from the reviewed studies suggest that kava is relatively safe for short-term treatment (one to 24 weeks), although more information is required. Further rigorous investigations, particularly into the long-term safety profile of kava, are warranted’.
Great! We have identified another alternative therapy that clearly works. Alas, again there is a problem. For a while, many of us thought that kava was safe and effective. When the first reports of side effects emerged, we were not particularly worried — which medication is totally free of them? But then a flurry of reports was published suggestive of severe liver damage after kava intake. At this stage, many national regulators became seriously concerned and started to investigate. The results seemed to indicate that the commercial kava preparations on the market were indeed liver-toxic. Consequently, kava was banned in many countries.
My third example is garlic. We all know it as a spice, of course. Its medicinal properties are less well appreciated, but nevertheless well documented. For instance, regular intake of garlic supplements has been shown to lower cholesterol level and to normalise elevated blood pressure. Both effects could be highly desirable for preventing cardiovascular disease.
If that is so, why do doctors rarely prescribe garlic supplements for their patients at risk of cardiovascular disease? The reason is simple: both effects are statistically significant but not necessarily clinically all that relevant; in fact, they are relatively small, and we have plenty of much more effective drugs that can achieve both aims reliably, safely and cheaply. In other words, garlic may work, but it works less well than conventional medicines.
What do these three examples tell us?
They show, I think, that some alternative therapies do indeed work. And yet, they have not become part of mainstream medicine. The reasons for this can be complex and varied. In the case of tai chi, they have to do with the fact that there might be other options that are easier to access. In the case of kava, they are based on concerns about the safety of the treatment. In the case of garlic, they relate to the fact that more effective medicines are available. In none of these instances, they include the closed-mindedness of doctors.
So yes, some alternative medicines do work in the sense that they are better than a placebo. But this fact does not necessarily mean that they are the best option currently on offer. I have been in this business for a very long time now, I have published more papers on alternative medicine than any other researcher on this planet — and yet, I have never come across an alternative therapy that clearly and demonstrably out-performs conventional medicine. And in that sense, the bon mot that ‘alternative treatments are therapies that either have not been proven to work or have been proven not to work’ does make sense after all.