Saturday, August 30, 2008

Regulating quack medicine makes me feel sick

If alternative remedies are either untested or ineffective, why are we promoting them?

It is fashionable to think things are true for no better reason than you wish it were so. The latest sign of this trend is a report to the Department of Health from Professor Michael Pittilo, Vice-Chancellor of the Robert Gordon University, Aberdeen. His May report - on acupuncture, herbal medicine, traditional Chinese medicine and the like - recommends that these therapies should have statutory regulation run by the Health Professions Council, and that entry for practitioners should "normally be through a bachelor degree with honours". Consultation is supposed to begin around now.

Both of the ideas in the report are disastrous. The first thing you wanted to know about any sort of medical treatment is: "Does it work?" One of the criteria that must be met by groups aspiring to regulation by the HPC is that they "practise based on evidence of efficacy". That evidence does not exist for herbal and Chinese medicine, which remain largely untested. For acupuncture the evidence does exist and it shows very clearly that acupuncture is no more than a theatrical placebo.

Placebos can, it is true, make you feel better; and if there is no better treatment, why not use them? That's fine, but it raises huge ethical questions about how much you can lie to patients, and how much you can lie to students who are training to use the placebos.

New Labour has often said that its policies are guided by the best scientific evidence, but the problem is that the answer you get depends on whom you ask. Pittilo's committee consisted of five acupuncturists, five herbalists and five representatives of traditional Chinese medicine (plus eleven observers). There was not a single scientist or statistician to help in the assessment of evidence. And it shows: the assessment of the evidence in the report was execrable.

Take one example, the use of a herbal preparation, Gingko biloba, for the treatment of dementia. On page 25 of the report we read: "There have been numerous in vitro and in vivo trials on herbal medicine... which have established the benefits of single ingredients such as gingko...for vascular dementia". That is totally out of date. The most prestigious source of reliable summaries of evidence, the Cochrane Collaboration, says: "There is no convincing evidence that Ginkgo biloba is efficacious for dementia and cognitive impairment". The NHS Complementary and Alternative Medicine Specialist Library (compiled by alternative medicine people) says: "The evidence that ginkgo has predictable and clinically significant benefit for people with dementia or cognitive impairment is inconsistent and unconvincing." Since then another large trial, funded by the Alzheimer's Society, concludes: "We found no evidence that a standard dose of high purity Ginkgo biloba confers benefit in mild-moderate dementia over six months."

The Government's answer to the problem is, as always, to set up more expensive quangos to regulate alternative medicine. That might work if the regulation was effective, but experience has shown it isn't. It makes no sense to regulate placebos, especially if you don't admit that is what they are. The Government should be warned by the case of chiropractors about the dangers of granting official recognition before the evidence is available. The General Chiropractic Council already has a status similar to that of the General Medical Council, despite it being based on the quasi-religious idea of "subluxations" that nobody can see or define. Recent research has shown it to be no more effective, and less safe, than conventional treatments that are much cheaper.

The problems that Professor Pittilo's recommendations pose for universities are even worse. You cannot have universities teaching, as science, early 19th-century vitalism, and how sticking needles into (imaginary) meridians rebalances the Qi so the body systems work harmoniously. To advocate that degrades the whole of science.

The vice-chancellors of the 16 or so universities who run such courses presumably do not themselves believe that vitalism is science, or subscribe to the view that "amethysts emit high yin energy", so it is hard to see why they accept taxpayers' money to teach such things. Thankfully, the University of Central Lancashire abandoned its first-year homoeopathy course this week because of low numbers.

Fortunately there is a much simpler, and probably much cheaper, solution than Pittilo's: enforce the laws that already exist. It is already illegal to sell contaminated and poisonous goods to the public. It is already illegal to sell goods that are not as described on the label. And, since May 2008, new European laws make it explicitly illegal to make claims for any sort of treatment when there is no reason to believe the claims are true. At the moment these laws are regularly and openly flouted on every hand. Enforce them and the problem is solved.


Britain: Deaths linked to hospital infection Clostridium difficile double in two years

The number of deaths linked to the hospital infection Clostridium difficile has more than doubled in the last two years, official figures show. Last year in England and Wales 8,324 people died either from C. diff or were infected with it when they died from other causes - this is a rise of 28 per cent in just one year. The infection which particularly affects elderly people has increased four times over since 2001 when 1,804 deaths were linked to the superbug, data from the Office of National Statistics shows.

Deaths linked to MRSA rose steadily between 2003 and 2005 but have levelled off. In the last year there has been a slight drop of 3.6 per cent in deaths either directly from MRSA or linked to it to reach 1,593.

Andrew Lansley, the shadow health secretary, said the 'vast majority' of these deaths could have been avoided with better prescribing of antibiotics and proper isolation of infected patients. Critics say Labour's waiting list targets have encouraged hospitals to rush through patients leaving wards overcrowded with time for cleaning patient areas between cases.

The data is collected from death certificates where doctors note down one underlying cause of death and can mention any number of other factors that may have contributed. In recent years doctors have been encouraged by Sir Liam Donaldson, the Chief Medical Officer, to mention hospital infections on death certificates where patients have them even if it was not the underlying cause of death. The figures show of the 8,324 death certificates that mentioned C.diff, around half noted it as the underlying cause of death.

C.diff is mainly a disease that affects the elderly who have been in hospital for other reasons and who have received broad spectrum antibiotics. These drugs cut the natural flora in the stomach allowing C.diff to multiply and produce a toxin which causes diarrhoea. The ONS figures there was one death per million people aged under 45 but 2,000 deaths per million people aged 85 and over. The number of actual cases of reported cases of C difficile in the over-65s - the main age group affected - fell by nine per cent from 55,635 in 2006 to 50,392 in 2007.

The Clostridium difficile bacteria is a major cause of antibiotic-associated diarrhoea and the intenstinal infection colitis. In most cases the infection is mild and a full recovery is made. Although elderly and vulnerable patients may become seriously ill through dehydration caused by severe diarrhoea. The more serious symptoms include ulceration and intenstinal bleeding and it can be life-threatening.


The tragedies that prompted `our massive wake-up call'

Bacteria will be present in hospitals as long as people are, but vital lessons in infection control have been learnt since outbreaks of Clostridium difficile caused the death of at least 90 patients at Maidstone and Tunbridge Wells NHS Trust in Kent.

Sara Mumford, formerly of the Health Protection Agency, the watchdog for infectious diseases, helped to bring attention to how much bad hygiene and poor staffing had contributed to hundreds of infections during the outbreaks of 2005 and 2006, which were later the subject of a high-profile investigation by the Healthcare Commission.

Now the director of infection control at the trust, Dr Mumford has an array of tools and procedures to keep superbugs at bay, she told The Times yesterday. "Unlike MRSA, there is no way of screening for C. difficile, so the most important thing to get right is cleanliness," she said. "Patients, staff and visitors can carry the bacteria into a hospital without knowing it, or become infected in the community. That's why handwashing is so important."

After an infection had been identified, soap and water were not enough, she said. "We use chlorine-based cleaners and have antimicrobial disposable curtains that we remove after an infected patient has been in a ward. During the `deep clean' we evacuated every ward and subjected everything to ultra-sonic baths or other cleaning. "It was so thorough that afterwards the wheels on the beds seized up - they would not run properly because they'd been cleaned of oil. "The most important thing when you suspect an infection is to isolate the patient quickly - even before you get the test results back from the lab," she said.

The isolation facility at Maidstone - introduced only after the notorious outbreaks - is a dedicated 12-bed ward. Dr Mumford said it helped recovery if patients with the same condition could talk to each other. Patients with a C. difficile infection required specialist nursing and treatment, she said, because other factors could also cause avoidable illness. "Antibiotic use in particular is really, really important," Dr Mumford said. "If you give patients broad-spectrum antibiotics designed to kill all bacteria, they get rid of even the types that help keep C. difficile at bay."

The three hospitals run by Maidstone and Tunbridge Wells Trust are now reporting rates of C. difficile that are below the national average. "Maidstone has had a tragic wake-up call and had to undertake a crash-course in infection control, but some trusts still have work to do - it's something that they ignore at their peril," Dr Mumford said.


Britain's Polish experience

SUPERMARKET aisles offer amateur ethnographers rich opportunities for fieldwork. American pockets in London can be identified by the Thanksgiving displays in November; sour cherry juice suggests that Turks are close at hand. Now great rows of tinned borscht announce a newer arrival. Recent immigration from eastern Europe has been on a truly grand scale: Tesco, Britain's biggest retailer, now runs a groceries website in Polish.

Just over a million people have so far come to Britain from the eight central and east European countries that joined the European Union in 2004. John Salt, a geographer at University College London, reckons it is the biggest influx in British history, at least in gross terms (immigration by French Huguenots in the 17th century may have been bigger relative to the population at the time). Poles, who have made up about two-thirds of the newcomers, are now the largest group of foreign nationals in Britain, up from 13th place five years ago.

They might not be for much longer. The insatiable job market that sucked them in is beginning to tire. Work in hospitality and construction is becoming scarcer in Britain, while Poland's economy is growing by over 5% a year. And earnings do not translate as well as they did: the pound, which bought seven zlotys at the beginning of 2004, now fetches four (see article).

Last quarter saw the lowest number of east Europeans registering for work since 2004 (see chart), even though summer months tend to be the busiest. And as arrivals fall, departures seem to be increasing. There is no reliable official count of the numbers leaving Britain, but in April a think-tank, the Institute for Public Policy Research (IPPR), carried out its own "poll of Poles" and found that about half of the newcomers had already gone home. It predicts that departures will start to outweigh arrivals within a year.

This is bad news for borscht lovers, as well as for the Catholic church, which reckons its numbers have been swelled by some 10% in the past two years, in large part by Poles. But east European migration will leave lasting marks, however brief an episode it turns out to be.

Most noticeably, it has gone some way to decoupling the issue of immigration from that of race. Since the 1950s large-scale immigration to Britain has mainly been from Africa, the Caribbean and South Asia, meaning that arguments about immigration have been racially charged (indeed, plenty of politicians have deliberately conflated the issues). Now, with the arrival of a million white, mainly poor, foreigners, immigration is being analysed in more purely economic terms.

There is a sensible argument to be had about immigration and population (see article), and whether this wave of low-paid workers has put pressure on wages. David Cameron, the Tory leader, has shaken off his brief reluctance to discuss the subject and now casts it in terms of demography. Labour has toughened up too: last year Gordon Brown, the prime minister, called for more "British jobs for British workers," a rallying cry that once only the far right used. Some critics still touch on the old ugly themes: this month the Daily Mail agreed to remove some negative articles from its website following a complaint from the Federation of Poles in Great Britain. But even when the east Europeans have departed, debating the merits of immigration will no longer be off-limits in polite society.

The brevity of the east Europeans' spell in Britain-if such it proves to be-is the second distinctive thing about it. Past waves of immigrants have nearly always stayed put, or at least aimed to. Unencumbered by visas because their countries belong to the EU, east Europeans do not have to stick around once they are in. Cheap airlines enable some even to split their time between Britain and their home country. This flexibility should give Britain a softer landing if the economy slows further, since migrants can head home rather than swell the unemployment figures. But it has also changed the way that Britons think about immigrants. Once seen as a charge on the state (especially when asylum applications were high, at the start of the decade) they are now more likely to be considered a threat to jobs. Laura Chappell of IPPR has spotted that people tend to describe east Europeans as "migrants", whereas non-European settlers are called "immigrants".

Finally, east Europeans have fanned out across the country far more than earlier arrivals, manning Lake District retirement homes, East Anglian farms, Scottish fish-processing plants and Channel Island guest houses. In all, 21% live in London, compared with 41% of other foreign nationals resident in Britain. Their arrival in areas that had little prior experience of migration-Boston, Northampton, Peterborough and others-has exposed problems with how money is disbursed by the central government, and is prompting reform. Funding for public services such as health, police and fire services relies on population estimates, which undercount short-term visitors and those who live at business addresses, such as hotel staff. The government is setting up a (mainly symbolic) pot of about œ15m ($28m) a year, funded by a levy on visas, to bail out councils that fall short, and it has promised to improve its counting. More tweaks may follow.

As the Poles pack their bags, those who came to rely on them to paint their walls or fix their computers are feeling the loss. Reinforcements could be on the way: Romanians and Bulgarians will be able to work freely in Britain from 2013 and could come earlier if the economy picks up. But Ms Chappell points out that those countries have strong links with Italy and Spain, and other western European countries have more open labour markets than they did in 2004. Britain may not look as attractive a destination a second time around.


Stupid do-gooder learns about reality the hard way: "A British woman has been raped by a gang of asylum seekers in Calais, it has been alleged. The journalism student wanted to highlight the plight of migrants who sleep rough in a squalid camp at the French port before trying to sneak into Britain. She was subjected to a horrific attack by six Afghan men she intended to write about, it was claimed. French riot police rounded up 200 migrants for questioning. Ten remained in custody tonight and police said it was possible all had been involved in the rape, which detectives described as 'extremely brutal'. Police said the 31-year-old victim, who cannot be named for legal reasons, was a London student who had travelled to France 'to highlight problems surrounding clandestine immigration'... The victim remains in Calais, with police hoping she will be able to identify her attackers. Tonight she was described as 'utterly traumatised and receiving counselling'."

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